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High-dose ASA therapy and clopidogrel treatment for at least 6 months were associated with a reduced incidence of ischemic events, without affecting the risk of hemorrhagic events.

IntroductionMechanical thrombectomy (MT) is increasingly used for large-vessel occlusions (LVO), but randomized clinical trial (RCT) level data with regard to differences in clinical outcomes of MT devices are limited. We conducted a network meta-analysis (NMA) that enables comparison of modern MT devices (Trevo, Solitaire, Aspiration) and strategies (stent retriever vs aspiration) across trials.MethodsRelevant RCTs were identified by a systematic review. The efficacy outcome was 90-day functional independence (modified Rankin Scale (mRS) score 0–2). Safety outcomes were 90-day catastrophic outcome (mRS 5–6) and symptomatic intracranial hemorrhage (sICH). Fixed-effect Bayesian NMA was performed to calculate risk estimates and the rank probabilities.ResultsIn a NMA of six relevant RCTs (SWIFT, TREVO2, EXTEND-IA, SWIFT-PRIME, REVASCAT, THERAPY; total of 871 patients, 472 Solitaire vs medical-only, 108 Aspiration vs medical-only, 178 Trevo vs Merci, and 113 Solitaire vs Merci) with medical-only arm as the reference, Trevo had the greatest functional independence (OR 4.14, 95% credible interval (CrI) 1.41–11.80; top rank probability 92%) followed by Solitaire (OR 2.55, 95% CrI 1.75–3.74; top rank probability 72%). Solitaire and Aspiration devices had the greatest top rank probability with respect to low sICH and catastrophic outcomes (76% and 91%, respectively), but without significant differences between each other. In a separate network of seven RCTs (MR-CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, REVASCAT, THERAPY, ASTER; 1737 patients), first-line stent retriever was associated with a higher top rank probability of functional independence than aspiration (95% vs 54%), with comparable safety outcomes.ConclusionsThese findings suggest that Trevo and Solitaire devices are associated with a greater likelihood of functional independence whereas Solitaire and Aspiration devices appear to be safer.

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a safe, effective alternative to redo aortic valve surgery in high-risk patients with degenerated surgical bioprosthetic valves. However, ViV-TAVR has been associated high postprocedural valvular gradients, compared with TAVR for native-valve aortic stenosis.Methods: We performed a retrospective study of all patients who underwent ViV-TAVR for a degenerated aortic valve bioprosthesis between January 1, 2013 and March 31, 2019 at our center. The primary outcome was postprocedural mean aortic valve gradient. Outcomes were compared across surgical valve type (stented versus stentless), surgical valve internal diameter (≤19 versus >19 mm), and transcatheter aortic valve type (self-expanding vs. balloon-expandable).Results: Overall, 89 patients underwent ViV-TAVR. Mean age was 69.0±12.6 years, 61% were male, and median Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.4 [interquartile range, 3.2-8.5].Bioprosthesis mode of failure was stenotic (58% of patients), regurgitant (24%), or mixed (18%). The surgical valve was stented in 75% of patients and stentless in 25%. The surgical valve's internal diameter was ≤19 mm in 45% of cases. A balloon-expandable transcatheter valve was used in 53% of procedures. Baseline aortic valve area and mean gradients were 0.87±0.31 cm 2 and 36±18 mmHg, respectively. These improved after ViV-TAVR to 1.38±0.55 cm 2 and 18±11 mmHg at a median outpatient follow-up of 331 days.Higher postprocedural mean gradients were associated with surgical valves having an internal diameter ≤19 mm (24±13 versus 16±8, P=0.002) and with stented surgical valves (22±11 versus 12±6, P<0.001). Conclusions: ViV-TAVR is an effective option for treating degenerated surgical aortic bioprostheses, with acceptable hemodynamic outcomes. Small surgical valves and stented surgical valves are associated with higher postprocedural gradients.

We read with great interest the article by Pouletty et al reporting 16 paediatric patients presenting with Kawa-COVID-19, an inflammatory syndrome similar to Kawasaki disease (KD) associated with SARS-CoV-2 infection. 1 All 16 patients met criteria for complete or incomplete KD. Severe cases in children involving systemic inflammation and multiorgan involvement related to COVID-19 are increasingly being reported. These cases, named multisystem inflammatory syndrome in children (MIS-C) in the USA and pediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 in the UK, share features of both KD and macrophage activation syndrome. 2-6 In contrast to children, few adults with KD-like cases have been reported. 7 8 Herein, we describe an adult who presented with KD-like illness similar to children in the Kawa-COVID-19 cohort 4 weeks following a documented SARS-CoV-2 infection. A 38-year-old Hispanic woman developed fever, dyspnoea, cough, anosmia, myalgias and polyarthralgias of the hands, wrists, elbows and knees 4 weeks prior to admission. At that time, nasopharyngeal SARS-CoV-2 PCR was positive. Her symptoms completely resolved within 2 weeks. Five days prior to admission, she developed fevers up to 39.4°C, dyspnoea and polyarthralgias. Additionally, she described occipital headaches, conjunctival injection, lip peeling, odynophagia, vomiting and a maculopapular rash on her chest and arms (figure 1A). The conjunctival injection and rash resolved within a week, but arthralgias, dyspnoea and fevers persisted. On admission, vitals showed temperature 39.1°C, pulse 114 beats/min, blood pressure 114/67 mm Hg and 97% oxygen saturation. Physical examination revealed clear conjunctiva, erythematous tongue, lip peeling, clear lung fields and a normal cardiac