Michelle Demetres

OBJECTIVES: Atrial functional mitral regurgitation (MR) lacks well-defined treatment guidelines. Medical therapy alone is insufficient, and either TEER (transcatheter edge-to-edge) or surgery is recommended. Short- and long-term comparative outcomes remain unclear. We aim to address this gap using available data. METHODS: We performed a meta-analysis of studies examining the outcomes of surgery and/or transcatheter edge-to-edge. MEDLINE, EMBASE, and the Cochrane Library were assessed. The incidence rate of late severe MR was the primary outcome. A random model was performed. Leave-one-out, subgroup, and meta-regression analyses were conducted. RESULTS: Thirty-two studies (1923 patients); 20 in surgery (1166) vs 12 in TEER (757), were selected. TEER patients were, on average, 10 years older, with twice the rate of New York Heart Association Classification (NYHA) III/IV symptoms and more than double the Society of Thoracic Surgeons Risk (STS) score. At a weighted mean follow-up of 3.2 years, compared to isolated transcatheter, surgery was associated with decreased incidence of late severe MR (2.53 vs 6.66 events per 100 person-years, P-interaction = .03), late all-cause mortality (3.00 vs 8.84, P-interaction = .024), late heart failure hospitalization (4.44 vs 17.03, P-interaction < .01), and late NYHA III/IV (2.98 vs 22.47, P-interaction < .01). However, significantly better long-term outcomes associated with surgery showed high heterogeneity. There were no differences in early all-cause mortality, early cardiac-specific mortality, late cardiac-specific mortality, postprocedural morbidities, or atrial diameter. On meta-regression, preprocedural heart failure (β = 0.0224, P < .01) and coronary artery disease (β = 0.0294, P < .00001) were linked to increased late severe MR. Older age, hypertension, mitral valve replacement, and associated aortic valve surgery were linked to increased late all-cause mortality. CONCLUSIONS: Surgery and isolated transcatheter edge-to-edge repair showed comparable short-term outcomes, with surgery appearing more effective long-term; however, due to study limitations and heterogeneity, these findings are hypothesis-generating and require validation through prospective studies. CLINICAL REGISTRATION NUMBER: PROSPERO website: CRD42024504022.

Background: This review evaluates the current evidence for the role of venoactive drugs (VADs) for venous origin chronic pelvic pain (VO-CPP) and provide insights to inform the design of an ideal randomized controlled trial (RCT) for future research. Methods: A search was performed in the following databases: Ovid MEDLINE, Ovid EMBASE, Cochrane Library, and Scopus. Studies retrieved were screened for eligibility using Covidence software following PRISMA reviews’ methodology. The quality of RCTs and cross-over RCTs was assessed using the Cochrane review tools. Studies were reviewed by 3 physicians, with discrepancies resolved by consensus. A narrative review of the studies was conducted to identify and synthesize clinical outcomes and safety profile of VADs. Results: Eleven studies (n = 748) were identified: 3 RCTs and 8 open-label prospective studies. Most participants were reproductive-age women with confirmed VO-CPP, diagnosed via imaging or laparoscopy. Micronized Purified Flavonoid Fraction (MPFF) was the most studied VAD. Pain assessment with VAS scores was the primary endpoint in all studies, with significant benefit in patients consistently demonstrated. Other endpoints included Pelvic Venous Clinical Severity Score (PVCSS) and Pelvic Varicose Vein Questionnaire (PVVQ), with improved symptoms and quality of life. Quantitative outcomes were also reported (reduced pelvic vein diameter; better venous hemodynamics). MPFF was safe, with few adverse events reported. Three RCTs had methodological limitations, with two judged high-risk for bias. Conclusions: While many identified studies appear to be of low quality, the consistent beneficial effect on VO-CPP scores and the safety profile observed across all reviewed studies suggest that flavonoids have a positive role in the conservative management of pelvic venous disease (PeVD). Future well-designed RCTs are needed to confirm these findings. In the meantime, flavonoids should be considered a therapeutic option for symptomatic patients with PeVD who are not qualified for, not wishing, or are awaiting intervention.

CD3xCD20 bispecific antibody (BsAb) therapy and CD19-directed chimeric antigen receptor T-cell therapy (CAR T) are novel immunotherapies that have shown impressive efficacy in B-cell lymphomas, but also come with significant morbidity and mortality, including infections. This meta-analysis compares rates of infections between commercially approved CAR T and BsAb therapy in patients with B-cell non-Hodgkin lymphoma (B-NHL). We conducted a systematic review for prospective trials assessing commercially approved CAR T and BsAbs in patients with B-NHL. Twenty-five studies comprising 3202 patients were included in the analysis. We used random effects models to evaluate all-grade infections, grade 3+ infections, and infection-related mortality, calculating both pooled rates per patient and per patient-month. While CAR T and BsAbs had similar rates of all-grade infections per patient (0.44 vs 0.54; P = .18), BsAbs had a higher rate of infection per patient-month (0.0397 vs 0.0167; P = .0012). Similarly, CAR T and BsAbs had similar rates of grade 3+ infections per patient (0.16 vs 0.22; P = .08), while BsAbs had a higher rate of grade 3+ infections per patient-month (0.0165 vs 0.0069; P = .0003). CAR T and BsAb products had similar rates of infection-related mortality per patient (0.04 vs 0.03; P = .26) and per patient-month (0.0023 vs 0.0022; P = .96). Our findings point to the potential increased burden of infections over time in patients receiving BsAb therapy, particularly for patients on indefinite therapy.

Objectives: The no-touch (NT) technique for saphenous vein (SV) harvesting in coronary artery bypass surgery preserves perivascular tissue and has been proposed to improve vein graft patency compared to conventional (CON) harvesting. However, recent large randomized clinical trials (RCTs) have reported conflicting results. We performed a meta-analysis of all available RCTs comparing graft patency and clinical outcomes between NT-SV and CON-SV harvesting techniques. Methods: A systematic review was conducted through May 9, 2025 to identify RCTs with systematic imaging follow-up comparing the NT-SV and CON-SV. The primary outcome was graft failure. Secondary outcomes included mortality, major adverse cardiac events (MACE; composite of mortality, myocardial infarction, or repeat revascularization), and leg wound complications. Outcomes were pooled using inverse variance random and fixed effects models. Results: Eight RCTs involving 4286 patients (NT-SV: 2155; CON-SV: 2131) were analysed. NT-SV was associated with a significantly lower incidence of graft failure than CON-SV (incidence rate ratio [IRR], 0.70; 95% confidence interval [CI] 0.60-0.82; P < .001) at a weighted mean follow-up of 3.7 years; this result was solid in multiple sensitivity analyses. Mortality (IRR, 1.03; 95% CI, 0.72-1.47, P = .87) and MACE (IRR, 0.89; 95% CI, 0.67-1.18; P = .42) were similar between groups. NT-SV was associated with a higher incidence of leg wound complications (IRR, 1.73; 95% CI, 1.32-2.27; P < .001). Conclusions: The NT-SV harvesting technique was associated with a significant reduction in graft failure and an increased risk of wound complications compared to the CON-SV. Further research is warranted to evaluate clinical NT-SV outcomes, and strategies are needed to mitigate NT-SV harvest-site complications.

Climate change has amplified the effects of extreme heat events (EHEs), exacerbating heat-related morbidity and mortality, particularly in cities due to the urban heat island effect. While a long-term solution to mitigating heat exists via urban greening, less is known about how to implement an urban greening plan co-designed by community members that addresses heat-related health outcomes. To examine the current state of urban greening interventions focused on communities and heat mitigation, we conducted a scoping review of papers at the nexus of urban greening/forestry, heat-related health outcomes, and community engagement. We then evaluated 46 eligible papers using a conceptual framework informed by the literature with the following criteria: (1) identification of urban green space/trees for climate change-amplified heat mitigation with quantifiable benefits; (2) association between objective heat-related health outcomes/health equity and urban greening intervention design; and (3) sustainable and ongoing community engagement and/or community co-creation. We found multiple differences between study methods. Most papers lacked objective heat-related health outcomes data and instead focused on subjective thermal comfort/heat stress measures. Additionally, almost all papers utilized one-time community engagement methods such as surveys or interviews to inform urban greening recommendations or study findings. Our findings have useful implications for urban greening decision-making, further emphasizing the importance of transdisciplinary cooperation and long-term community engagement, so an equitable, context-dependent urban greening and health intervention can be effectively co-produced by city planners, public health officials, and community members.

To determine the association of intraoperative pulmonary artery catheter (PAC) use with in-hospital outcomes in cardiac surgical patients. MEDLINE, Embase, and Cochrane Library (Wiley) databases were screened for studies that compared cardiac surgical patients receiving intraoperative PAC with controls and reporting in-hospital mortality. Secondary outcomes included intensive care unit length of stay, cost of hospitalization, fluid volume administered, intubation time, inotropes use, acute kidney injury (AKI), stroke, myocardial infarction (MI), and infections. Seven studies (25 853 patients, 88.6% undergoing coronary artery bypass graft surgery) were included. In-hospital mortality was significantly increased with PAC use [odds ratio (OR) 1.57; 95% confidence interval (CI) 1.12–2.20, P = 0.04]; PAC use was also associated with greater intraoperative inotrope use (OR 2.61; 95% CI 1.54–4.41) and costs [standardized mean difference (SMD) = 0.20; 95% CI 0.16–0.23], longer intensive care unit stay (SMD = 0.29; 95% CI 0.25–0.33), and longer intubation time (SMD = 0.44; 95% CI 0.12–0.76). PAC use is associated with significantly increased odds of in-hospital mortality, but the amount and quality of the available evidence is limited. Prospective randomized trials testing the effect of PAC on the outcomes of cardiac surgical patients are urgently needed.

Background: Postoperative bleeding requiring re-exploration is a serious complication that occurs in 2.8–4.6% of patients undergoing cardiac surgery. Re-exploration has previously been associated with a higher risk of short-term mortality. However, a comprehensive analysis of long-term outcomes after re-exploration for bleeding has not been published. Materials and methods: The authors performed a systematic, three databases search to identify studies reporting long-term outcomes in patients who required re-exploration for bleeding after cardiac surgery compared to patients who did not, with at least 1-year of follow-up. Long-term survival was the primary outcome. Secondary outcomes were operative mortality, myocardial infarction, stroke, renal and respiratory complications, and hospital length of stay. Random-effects models was used. Individual patient survival data was extracted from available survival curves and reconstructed using restricted mean survival time. Results: Six studies totaling 135 456 patients were included. The average follow-up was 5.5 years. In the individual patient data, patients who required re-exploration had a significantly higher risk of death compared with patients who did not [hazard ratio (HR): 1.21; 95% CI: 1.14–1.27; PPPPPPPP=0.0007). Conclusion: Postoperative bleeding requiring re-exploration is associated with lower long-term survival and increased risk of short-term adverse events including operative mortality, stroke, renal and respiratory complications, and longer hospital length of stay. To improve both short-term and long-term outcomes, strategies to prevent the need for re-exploration are necessary.

Midline sternotomy is the main surgical access for cardiac surgeries. The most prominent complication of sternotomy is sternal wound infection (SWI). The use of a thorax support vest (TSV) that limits thorax movement and ensures sternal stability has been suggested to prevent postoperative SWI. We performed a meta-analysis to evaluate differences in clinical outcomes with and without the use of TSV after cardiac surgery in randomized trials. The primary outcome was deep SWI (DSWI). Secondary outcomes were superficial SWI, sternal wound dehiscence, and hospital length of stay (LOS). A trial sequential analysis was performed. Fixed (F) and random effects (R) models were calculated. A total of 4 studies (3820 patients) were included. Patients who wore the TSV had lower incidence of DSWI [odds ratio (OR) = F: 0.24, 95% confidence interval (CI), 0.13–0.43, P < 0.01; R: 0.24, 0.04–1.59, P = 0.08], sternal wound dehiscence (OR = F: 0.08, 95% CI, 0.02–0.27, P < 0.01; R: 0.10, 0.00–2.20, P = 0.08) and shorter hospital LOS (standardized mean difference = F: −0.30, −0.37 to −0.24, P < 0.01; R: −0.63, −1.29 to 0.02, P = 0.15). There was no difference regarding the incidence of superficial SWI (OR = F: 0.71, 95% CI, 0.34–1.47, P = 0.35; R: 0.64, 0.10, 4.26, P = 0.42). The trial sequential analysis, however, showed that the observed decrease in DSWI in the TSV arm cannot be considered conclusive based on the existing evidence. This meta-analysis suggests that the use of a TSV after cardiac surgery could potentially be associated with a reduction in sternal wound complications. However, despite the significant treatment effect in the available studies, the evidence is not solid enough to provide strong practice recommendations.