Management of asymptomatic severe aortic stenosis: A critical review of guidelines and clinical outcomes

BACKGROUND

Asymptomatic severe aortic stenosis (AS) poses a clinical challenge with variations in recommendations for management.

OBJECTIVES

We sought to compare contemporary guidelines focusing on asymptomatic AS management and present a summary of contemporary studies on early intervention in these patients.

METHODS

Systematic search of electronic databases was conducted with guidelines analyzed using a comparative matrix. A pooled random-effects meta-analysis of randomized controlled trial (RCT) data comparing intervention versus clinical surveillance in asymptomatic severe AS was also performed.

RESULTS

Four guidelines from ACC/AHA, ESC/EACTS, JCS/JSCS/JATS/JSVS, and NICE were included encompassing 108 recommendations. Consensus was found for intervention thresholds including left ventricular dysfunction and very severe AS while discrepancies existed in the utility of biomarkers, myocardial fibrosis, exercise stress testing and choice of intervention. Despite variation in study inclusion criteria, current RCTs on the management of asymptomatic AS indicated a significant reduction in rates of major adverse cardiovascular events when comparing early intervention to clinical surveillance (hazard ratio [HR] 0.52 [0.42, 0.63]), driven primarily by reductions in unplanned hospitalizations (HR 0.41 [0.32, 0.52]).

CONCLUSION

While there is broad consensus on classic indicators of severity such as left ventricular dysfunction as indication for intervention, guidelines diverge on other high-risk features warranting intervention. Early studies indicate the overall safety of early intervention, although further work is needed to identify whether it can reduce the risk of hard clinical endpoints. This underscores the need for further research and updated guidelines to clarify the optimal thresholds for intervention and harmonize treatment pathways for the growing number of patients with asymptomatic AS.

Gender differences in the presentation and management of patients with severe aortic stenosis at specialist versus primary/secondary care centres: A sub-analysis of the IMPULSE enhanced registry

BACKGROUND

Management and treatment of severe aortic stenosis (AS) may differ considerably in European countries. To investigate these differences in France, Germany, and the UK, the IMPULSE enhanced registry was established. Previous data revealed differences in how patients were managed in specialist (hub) versus primary/secondary care (satellite) centres.

METHODS

The IMPULSE enhanced registry sub-analysis aimed to determine if there were gender-specific differences for patients with severe AS at centres with and without access to intervention.

RESULTS

Among the 790 patients, 594 and 196 were recruited at hub and satellite centres, respectively; 44 % of patients were female. In both settings, women were older than men (hubs: 78.7 vs. 76.2, p = 0.007; satellites: 79.8 vs. 75.1, p = 0.002). Symptoms at the presentation were comparable. Males had more often undergone previous cardiac surgery. Females had a smaller left ventricular (LV) outflow tract, smaller LV cavities, and, more often, a preserved ejection fraction (>50 %). There was no gender-based difference in time to intervention. At one year, the cumulative incidence of aortic valve replacement in females was higher than in males in hubs (p = 0.012) but not in satellites (p = 0.600); surgical AVR was more common in males in hubs only (p = 0.008), while transcatheter aortic valve implantation was more common in females in both settings (hubs: p < 0.001; satellites: p = 0.022). One-year survival was comparable in both genders, regardless of setting.

CONCLUSIONS

A better understanding of gender-specific differences in patients with severe AS, according to the diagnostic setting, could improve patient stratification and earlier diagnosis.

Atrial arrhythmias following lung transplantation: A state of the art review

Lung transplantation (LT) is now an accepted therapy for end stage lung disease in appropriate patients. Atrial arrhythmias (AA) can occur after LT. Early AA after LT are most often atrial fibrillation, whereas late arrhythmias which occur many months or years after LT are often atrial tachycardia. The causes of AA are multifactorial. The review begins with a brief history of LT and AA. This review further describes the pathophysiology of the AA. The risk factors, incidence, recipient characteristics including intra-operative factors are elaborated on. Since there are no clear and specific guidelines on the management of atrial arrhythmia following LT, the recommended guidelines on the management of AA in general are often extrapolated and used in the setting of post LT arrhythmia. The strategy of rate control vs rhythm control is discussed. The pros and cons of various drug regimen, need for direct current cardioversion and catheter ablation therapies are considered. Possible methods to prevent or reduce the incidence of AA after LT are considered. The impact of AA on the short-term and long-term outcomes following LT is discussed.

Foundation versus domain-specific models for left ventricular segmentation on cardiac ultrasound

The Segment Anything Model (SAM) was fine-tuned on the EchoNet-Dynamic dataset and evaluated on external transthoracic echocardiography (TTE) and Point-of-Care Ultrasound (POCUS) datasets from CAMUS (University Hospital of St Etienne) and Mayo Clinic (99 patients: 58 TTE, 41 POCUS). Fine-tuned SAM was superior or comparable to MedSAM. The fine-tuned SAM also outperformed EchoNet and U-Net models, demonstrating strong generalization, especially on apical 2-chamber (A2C) images (fine-tuned SAM vs. EchoNet: CAMUS-A2C: DSC 0.891 ± 0.040 vs. 0.752 ± 0.196, p < 0.0001) and POCUS (DSC 0.857 ± 0.047 vs. 0.667 ± 0.279, p < 0.0001). Additionally, SAM-enhanced workflow reduced annotation time by 50% (11.6 ± 4.5 sec vs. 5.7 ± 1.7 sec, p < 0.0001) while maintaining segmentation quality. We demonstrated an effective strategy for fine-tuning a vision foundation model for enhancing clinical workflow efficiency and supporting human-AI collaboration.

The HALP score predicts no-reflow phenomenon and long-term prognosis in patients with ST-segment elevation myocardial infarction after primary percutaneous coronary intervention

INTRODUCTION AND OBJECTIVE

Despite recent advances in the management of ST-segment elevation myocardial infarction (STEMI), the clinical outcome of some patients is still unsatisfactory. Therefore, early evaluation to identify high-risk individuals in STEMI patients is essential. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score, as a new indicator that can reflect both nutritional status and inflammatory state of the body, can provide prognostic information. In this context, the present study was designed to investigate the relationship between HALP scores assessed at admission and no-reflow as well as long-term outcomes in patients with STEMI.

MATERIAL AND METHODS

A total of 1040 consecutive STEMI patients undergoing primary PCI were enrolled in this retrospective study. According to the best cutoff value of HALP score of 40.11, the study samples were divided into two groups. The long-term prognosis was followed up by telephone.

RESULTS

Long-term mortality was significantly higher in patients with HALP scores lower than 40.11 than in those higher than 40.11. The optimal cutoff value of HALP score for predicting no-reflow was 41.38, the area under the curve (AUC) was 0.727. The best cutoff value of HALP score for predicting major adverse cardiovascular events (MACE) was 40.11, the AUC was 0.763. The incidence of MACE and all-cause mortality was higher in the HALP score <40.11 group.

CONCLUSION

HALP score can independently predict the development of no-reflow and long-term mortality in STEMI patients undergoing PCI.

Clinical factors associated with severe coronary stenosis in patients undergoing cardiac surgery

BACKGROUND

Many cardiovascular patients undergoing valve surgeries require coronary angiography (CAG). Positive results may lead to bypass surgery, while negative results require no treatment. Although informative, CAG is costly and exposes patients to significant radiation. This study aimed to develop a model to reduce unnecessary procedures.

METHODS

A retrospective cohort study was conducted on 5,086 patients who underwent valve repair/replacement or other cardiac surgeries at Zhongshan Hospital between 2016 and 2021 and received CAG. Patients treated between 2016 and 2020 formed the training set, while those treated in 2021 constituted the validation set. Severe coronary stenosis was defined as a ≥ 50% reduction in luminal diameter. Logistic regression analysis identified independent predictors in the training set, and a scoring system (Coronary Angiography Positivity Prediction Score) was constructed based on the β-coefficients of each variable. The model was evaluated for discrimination and calibration.

RESULTS

Among 4,049 patients, 536 (13.2%) had severe coronary stenosis. Independent predictors included age ≥ 60 years, male sex, hypertension, diabetes, hyperlipidemia, and left ventricular ejection fraction ≤ 58%. The scoring system ranged from 0 to 11 points and demonstrated good discrimination, with an area under the receiver operating characteristic curve of 0.715 (95% confidence interval: 0.694-0.740) in the training set. In the high-risk group (≥ 6 points), the probability of severe coronary stenosis was 23.1%, compared to 8% in the low-risk group (< 6 points). The scoring system also performed well in the validation set with the curve of 0.740 (95% CI, 0.695-0.784).

CONCLUSION

We developed and validated a scoring system based on six clinical variables to predict severe coronary stenosis in patients undergoing valve surgeries. This tool may help optimize individual treatment strategies and reduce unnecessary CAG procedures.

Risk-Based Primary Prevention of Heart Failure: A Scientific Statement From the American Heart Association

The growing morbidity, mortality, and health care costs related to heart failure (HF) underscore the urgent need to prioritize its primary prevention. Whereas a risk-based approach for HF prevention remains in its infancy, several key opportunities exist to actualize this paradigm in clinical practice. First, the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guidelines provided recommendations, for the first time, on the clinical utility of multivariable risk equations to estimate risk of incident HF. Second, the American Heart Association recently developed the PREVENT (Predicting Risk of Cardiovascular Disease Events) equations, which not only enable prediction of incident HF separately, but also include HF in the prediction of total cardiovascular disease. Third, the predominant phenotype of HF risk has emerged as the cardiovascular-kidney-metabolic syndrome. Fourth, the emergence of novel therapies that prevent incident HF (eg, sodium-glucose cotransporter-2 inhibitors) and target multiple cardiovascular-kidney-metabolic axes demonstrate growing potential for risk-based interventions. Whereas the concept of risk-based prevention has been established for decades, it has only been operationalized for atherosclerotic cardiovascular disease prevention to date. Translating these opportunities into a conceptual framework of risk-based primary prevention of HF requires implementation of PREVENT-HF (Predicting Risk of Cardiovascular Disease Events-Heart Failure) equations, targeted use of cardiac biomarkers (eg, natriuretic peptides) and echocardiography for risk reclassification and earlier detection of pre-HF, and definition of therapy-specific risk thresholds that incorporate net benefit and cost-effectiveness. This scientific statement reviews the current evidence for accurate risk prediction, defines strategies for equitable prevention, and proposes potential strategies for the successful implementation of risk-based primary prevention of HF.

Effect of dapagliflozin on the no-reflow phenomenon in patients with acute myocardial infarction and type II diabetes mellitus

OBJECTIVE

This study aimed to assess the effect of dapagliflozin on the no-reflow phenomenon in patients with type II diabetes mellitus (T2DM) and acute myocardial infarction (AMI) who underwent percutaneous coronary intervention (PCI).

METHODS

This single-center, observational cohort study included a total of 829 consecutive T2DM patients who were diagnosed with AMI and underwent PCI within 24 h of the onset of symptoms. Only patients using dapagliflozin (10 mg per day) for more than one year were considered as patients using dapagliflozin. The no-reflow phenomenon was defined as inadequate myocardial perfusion within a segment of the coronary circulation without angiographic evidence of mechanical vessel obstruction, dissection, or residual stenosis after PCI.

RESULTS

Four hundred and thirty-four patients were diagnosed with ST-segment elevation myocardial infarction (STEMI), and 395 patients were diagnosed with non-ST-segment elevation myocardial infarction (NSTEMI). Forward conditional logistic regression analysis demonstrated that the estimated glomerular filtration rate (OR = 0.940, 95% CI: 0.900 to 0.982, p = 0.006), SYNTAX score I (OR = 1.338, 95% CI: 1.179 to 1.520, p < 0.001), and dapagliflozin use (OR = 0.030, 95% CI: 0.004 to 0.228, p = 0.001) were independent predictors of the no-reflow phenomenon in STEMI. However, dapagliflozin use (OR = 0.112, 95% CI: 0.013 to 0.933, p = 0.043) was the only independent predictor of the no-reflow phenomenon in NSTEMI.

CONCLUSION

Lower rates of the no-reflow phenomenon were observed in T2DM patients taking dapagliflozin, diagnosed with AMI, and underwent PCI. However, this finding requires further investigation.

Head-to-head comparison of cardiac magnetic resonance imaging and transthoracic echocardiography in the general population (MATCH)

BACKGROUND

Comparing transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR) is crucial for cardiac assessment. This study aims to clarify their comparability in a large population sample.

METHODS

CMR and two- (2D) and three-dimensional (3D) TTE were used to quantify left and right heart dimensions in participants of the Hamburg City Health Study. Intertechnique agreement was evaluated using Bland-Altman analyses, Pearson correlation coefficients, and Cohen's Kappa.

RESULTS

Data from 2126 participants (median age 67 [IQR: 59-72] years, 897 (42.2%) female) were analyzed. Left ventricular (LV) diastolic volumes were similar (CMR: 117.0 [96.2, 138.0] ml, 2D-TTE: 111.8 [93.6, 134.3] ml, r = 0.7, p < 0.001), while systolic volumes were lower with CMR (CMR: 36.0 [26.9, 46.0] ml, 2D-TTE: 46.7 [37.9, 57.5] ml, r = 0.67, p < 0.001). CMR LV ejection fraction (LVEF) was 10% higher than 2D-TTE (CMR = 69.0 [64.0, 74.0]%, 2D-TTE = 58.3 [55.5, 61.7]%, p < 0.001; r = 0.40, p < 0.001). Left atrial volumes correlated moderately with low bias (CMR: 53.0 [40.0, 68.0] ml, 2D-TTE: 51.6 [41.5, 64.0] ml, r = 0.63, p < 0.001). LV mass showed good correlation but was higher using 2D-TTE (r = 0.74, p < 0.001). Right ventricular (RV) volumes showed the largest differences, with CMR demonstrating lower interobserver variability (ICC = 0.97 vs. 0.61 for 2D-TTE) and markedly larger volumes (RVEDV mean bias = 74.8 ml, r = 0.50, p < 0.001).

CONCLUSION

In a large general population, CMR quantifies cardiac function and dimensions more reliably than TTE. Both modalities provide significantly different absolute values, limiting intertechnique transferability.

TRIAL REGISTRATION

Retrospectively registered at ClinicalTrial.gov, registration number: NCT03934957, registration date: 04/01/2019, https://clinicaltrials.gov/study/NCT03934957 .

Native QRS duration and outcomes in heart failure with mildly reduced ejection fraction: results from a large-scaled registry

OBJECTIVE

The study investigates the prognostic impact of the native QRS duration in patients with heart failure and mildly reduced ejection fraction (HFmrEF).

BACKGROUND

The prognostic impact of QRS duration in HFmrEF has rarely been investigated.

METHODS

Consecutive patients with HFmrEF and available 12-lead electrocardiogram were retrospectively included at one institution from 2016 to 2022. Patients with QRS duration ≥ 120 ms were compared to patients with QRS duration < 120 ms, further risk stratification was performed comparing patients with left and right bundle branch block (LBBB vs. RBBB). The primary endpoint was all-cause mortality at 30 months, secondary endpoints comprised the risk of HF-related rehospitalization.

RESULTS

In total, 1627 patients with HFmrEF were included with a median QRS duration of 90 ms (i.e., QRS duration ≥ 120 ms: 15%). Although the risk of long-term all-cause mortality was not affected by a prolonged QRS duration (35.1% vs. 28.7%; p = 0.057; HR = 1.254; 95% CI 0.993-1.583), patients with QRS duration ≥ 120 ms had a higher risk of HF-related rehospitalization (18.2% vs. 11.9%; p = 0.008; HR = 1.574; 95% CI 1.124-2.204). A QRS duration ≥ 120 ms was associated with long-term HF-related rehospitalization even after multivariable adjustment (HR 1.420, 95% CI 1.008-2.002, p = 0.045). Finally, the risks of long-term all-cause mortality and HF-related rehospitalization did not differ among patients with LBBB and RBBB.

CONCLUSION

A prolonged native QRS duration is independently associated with a higher risk of HF-related rehospitalization in HFmrEF, but not long-term all-cause mortality.

Evidence of bioprosthetic valve dysfunction during three-year follow-up following TAVR

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) has increased significantly in younger patients and patients at lower surgical risk. In this retrospective multicenter study, we aimed to assess for bioprosthetic valve dysfunction (BVD) during three-year follow-up (FU) and potential differences between self-expandable (SEV) and balloon-expandable valves (BEV) under real-world conditions.

METHODS

Endpoints were defined according to VARC-3 criteria, including VARC composite endpoints during three-year FU.

RESULTS

A total of 1233 patients with tricuspid aortic valve stenosis, who underwent TAVR with contemporary transcatheter heart valve (THV) devices from three different tertiary care centers were included. One-fifth of the study population showed BVD at three-year FU (BVD[-]: n = 957;77.6%; BVD[+]: n = 276;22.4%). Non-structural valve deterioration (NSVD) was the most represented category (8.5%) followed by structural valve deterioration (SVD, 5.3%). BVD was more common in association with BEV as compared with SEV (60.9% vs 39.1%; p < 0.001) owing to higher rates of SVD (13.5% vs 9.5%; p = 0.028) and NSVD (17.9% vs. 13.8%; p = 0.048). Subclinical leaflet thrombosis was only documented in BEV (1.7%, p < 0.001). At three years, all-cause mortality was higher in BVD+ patients (BVD[-] vs. BVD[+]: 13.2% vs. 22.5%; HR: 1.99; 95%-CI: 1.39-2.85; p < 0.001*) but did not differ between THV platform.

CONCLUSION

BVD after TAVR is common and associated with higher all-cause mortality. Despite a preponderance of BVD in association with balloon-expandable valves, mortality rates remain similar between THV platforms.

CLINICAL TRIAL REGISTRATION

NCT01805739.

Aortic Valve Calcium: A Narrative Review of its Role in the Assessment of Aortic Stenosis and as a Predictor of Post-transcatheter Aortic Valve Implantation Outcomes

Degenerative aortic valve disease is the third most common cause of heart disease in the developed world. Calcific deposits accrue in the valve endothelium causing progressive stenosis of the orifice. Increasingly, transcatheter aortic valve implantation is being used in place of surgery as treatment for aortic stenosis, particularly for patients who are considered high surgical risk. Although echocardiography remains the gold standard for the diagnosis and grading of aortic valve stenosis, there is an increasing interest in the role that aortic valve calcification scoring may play in these areas. In this review, the authors evaluate the current evidence for aortic valve calcium scoring as an adjunct to echocardiography in grading, and as a prognostic marker in challenging cases. They also explore the ability of calcium scoring to predict outcomes following transcatheter aortic valve implantation.

Practical application of multimodality imaging for cardio-oncology in Latin America

Latin America (LA) is one of the regions in the world with the highest levels of overweight, dyslipidemia, and diabetes mellitus, which, together with smoking and high blood pressure, are common risk factors for cardiovascular and oncological diseases. Chemotherapy (CT) and Radiotherapy (RT) have become two of the mainstays of treatment for several types of cancer. One of the most worrisome side effects generated by CT and RT is cardiotoxicity. There are several imaging techniques in cardiology that can inform the presence of underlying disease, but they differ in their availability and access to the masses, their accuracy and repeatability, all of which are important determinants of the applicability of these techniques in routine clinical practice. Thus, it is mandatory to promote a clinically effective and a cost-effective multimodality approach for risk stratification, diagnosis and management of cardiovascular diseases in oncologic patients. The purpose of this review is to inform cardiologists, oncologists, cardio-oncologists and imaging cardiologists on the cardiac imaging modalities that can be applied in patients with cancer, the differences among imaging techniques and recommendations on how to apply them in LA.

Prior hospitalizations as a predictor of prognosis in heart failure with mildly reduced ejection fraction

OBJECTIVE

This study aims to investigate the prognostic impact of the presence and type of prior hospitalizations in patients with heart failure with mildly reduced ejection fraction (HFmrEF).

BACKGROUND

Data investigating the prognostic impact of the present and type of previous all-cause hospitalizations in HFmrEF is limited.

METHODS

Consecutive patients hospitalized with HFmrEF at a single medical center were retrospectively included from 2016 to 2022. The prognosis of patients with a prior hospitalization < 12 months was compared to patients without. The primary endpoint was all-cause mortality at 30 months (median follow-up), the key secondary endpoint was heart failure (HF)-related rehospitalization at 30 months.

RESULTS

Two thousand one hundred eighty four patients with HFmrEF were included, 34.8% had a previous hospitalization < 12 months (admission to internal medicine and geriatrics: 60.8%, surgical department: 23.5%). The presence of a previous hospitalization was associated with an increased risk of all-cause mortality (38.6% vs. 27.4%; HR = 1.51; 95% CI 1.30-1.76; p = 0.01) and HF-related rehospitalization at 30 months (21.2% vs. 9.1%; HR = 2.48; 95% CI 1.96-3.14; p = 0.01), even after multivariable adjustments. However, the department of previous hospitalization (internal medicine vs. surgical) did not significantly affect the risk of 30-months all-cause mortality (37.1% vs. 43.2%; HR = 0.82, 95% CI 0.63-1.08; p = 0.16) or HF-related rehospitalization (24.0% vs. 16.8%; HR = 1.47, 95% CI 0.98-2.24; p = 0.07). Finally, the type of previous admission (i.e., elective, emergency vs. HF-related admission) (log-rank p = 0.29) did not affect the risk of 30-months all-cause mortality.

CONCLUSION

Prior hospitalizations within 12 months were independently associated with impaired long-term mortality in patients with HFmrEF, irrespective of the department or type of prior admission.

Temporal Trends in Etiology of Aortic Valvular Diseases for Patients Undergoing Surgical Valve Replacement: A Report From 40 Years Pathological Experience

Although aortic valvular disease has various etiologies, recently, calcific aortic valve stenosis has been increasing. We analyzed the trends in the pathological characteristics of aortic valvular disease in the past four decades in Japan. The pathology department data for aortic valvular disease operated in our hospital documented 4508 patients from 1978 to 2022. Subsequently, trend analyses were performed over four periods: Period 1, 1978-1989 (618 cases); Period 2, 1990-1999 (903 cases); Period 3, 2000-2010 (1179 cases); and Period 4, 2011-2022 (1808 cases). We reviewed the pathological characterization of the resected aortic valves and categorized them based on the representative etiology of aortic valvular disease as congenital bicuspid, chronic rheumatic change, infective endocarditis, degenerative calcific change, and myxoid change. Our pathologic analysis revealed a significant decrease in the proportion of chronic rheumatic disease from 47% to 14%, an increase in the congenital bicuspid valve from 8% to 24%, and a rise of the degenerative calcific change of the aortic valve from 4% to 27% (p < 0.001), especially significant increases in aortic stenosis. Calcification of the aortic valve may result from an active process similar to atherosclerosis, leading to aortic stenosis with increasing dyslipidemia in Japanese patients in 40 years.

Risk Factors and Prevention of Cancer and CVDs: A Chicken and Egg Situation

Cardiovascular diseases and cancer are the two primary causes of mortality worldwide. Although traditionally regarded as distinct pathologies, they share numerous pathophysiological mechanisms and risk factors, including chronic inflammation, insulin resistance, obesity, and metabolic dysregulation. Notably, several cancers have been identified as closely linked to cardiovascular diseases, including lung, breast, prostate, and colorectal cancers, as well as hematological malignancies, such as leukemia and lymphoma. Additionally, renal and pancreatic cancers exhibit a significant association with cardiovascular complications, partly due to shared risk factors and the cardiotoxic effects of cancer therapies. Addressing the overlapping risk factors through lifestyle modifications-such as regular physical activity, a balanced diet, and cessation of smoking and alcohol-has proven effective in reducing both CV and oncological morbidity and mortality. Furthermore, even in patients with established cancer, structured interventions targeting physical activity, nutritional optimization, and smoking cessation have been associated with improved outcomes. Beyond lifestyle modifications, pharmacological strategies play a crucial role in the prevention of both diseases. Several cardiovascular medications, including statins, aspirin, beta-blockers, and metformin, exhibit pleiotropic effects that extend beyond their primary indications, demonstrating potential anti-neoplastic properties in preclinical and observational studies. Recently, novel therapeutic agents have garnered attention for their possible cardioprotective and metabolic benefits. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is), initially developed for managing type 2 diabetes, have shown CV and renal protective effects, alongside emerging evidence of their role in modulating cancer-related metabolic pathways. Inclisiran, a small interfering RNA targeting PCSK9, effectively lowers LDL cholesterol and may contribute to reducing CV risk, with potential implications for tumor biology. Additionally, sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor, has revolutionized heart failure management by improving hemodynamic parameters and exerting anti-inflammatory effects that may have broader implications for chronic disease prevention. Given the intricate interplay between CVD and cancer, further research is essential to clarify the exact mechanisms linking these conditions and assessing the potential of CV therapies in cancer prevention. This review aims to examine shared risk factors, consider the role of pharmacological and lifestyle interventions, and emphasize crucial epidemiological and mechanistic insights into the intersection of CV and oncological health.

Effects of a Cloud-Based Synchronous Telehealth Program on Valvular Regurgitation Regression: Retrospective Study

BACKGROUND

Telemedicine has been associated with better cardiovascular outcomes, but its effects on the regression of mitral regurgitation (MR) and tricuspid regurgitation (TR) remain unknown.

OBJECTIVE

This study aimed to evaluate whether telemedicine could facilitate the regression of MR and TR compared to usual care and whether it was associated with better survival.

METHODS

This retrospective cohort study enrolled consecutive patients with moderate or greater MR or TR from 2010 through 2020, excluding those with concomitant aortic stenosis, aortic regurgitation, or mitral stenosis greater than mild severity. All patients underwent follow-up transthoracic echocardiography (TTE) at least 3 months apart. Patients receiving telehealth services for at least two weeks within 90 days of baseline TTE were categorized as the telehealth group; the remainder constituted the nontelehealth group. Telemedicine participants transmitted daily biometric data-blood pressure, pulse rate, blood glucose, electrocardiogram, and oxygen saturation-to a cloud-based platform for timely monitoring. Experienced case managers regularly contacted patients and initiated immediate action for concerning measurements. The primary endpoint was MR or TR regression from ≥moderate to

RESULTS

The MR cohorts consisted of 264 patients (mean age 67 years), including 97 regressors and 74 telehealth participants. Telehealth participation (hazard ratio 2.20, 95% CI 1.35-3.58; P=.001) was robustly associated with MR regression; MR regressors were linked to reverse cardiac remodeling, indicated by improved left ventricular ejection fraction (LVEF), and reduced left ventricular (LV) and left atrial (LA) dimensions (all P≤.005). Determinants of ACD were age (P<.001), LVEF (P<.001), percutaneous coronary intervention (P<.001), and MR regressors (P=.02). The TR cohort consisted of 245 patients (mean age 68 years), including 87 TR regressors and 61 telehealth participants. Telehealth (P=.05) was one of the univariable determinants of TR regression, while beta-blocker use (P=.048) and baseline TR severity (P=.01) remained strong predictors of TR regression in multivariable analysis.

CONCLUSIONS

Patients in the telehealth group were 2.2 times more likely to experience MR regression. Moreover, MR regressors had better survival and reverse cardiac remodeling compared to nonregressors. These findings may have important implications for future guidelines.

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Key Words

• cardiac remodeling
• mitral regurgitation
• telehealth
• telemedicine
• tricuspid regurgitation

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MESH Headings

• Humans
• Retrospective Studies
• Male
• Telemedicine
• Female
• Aged
• Mitral Valve Insufficiency/therapy
• Mitral Valve Insufficiency/mortality
• Cloud Computing
• Middle Aged
• Tricuspid Valve Insufficiency/therapy
• Tricuspid Valve Insufficiency/mortality
• Echocardiography

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Affiliation(s)

Li-Tan Yang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Han Wu Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Jen-Kuang Lee Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Wei-Jyun Wang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Ying-Hsien Chen Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Ching-Chang Huang Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Chi-Sheng Hung Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Kuang-Chien Chiang Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
Yi-Lwun Ho Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan
Hui-Wen Wu Telehealth Center, National Taiwan University Hospital, Taipei, Taiwan

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The use of left ventricular ejection fraction in the diagnosis and management of heart failure. A clinical consensus statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

Rare Earth Elements in Human Calcified Aortic Valves and Epicardial Adipose Tissue

Background/Objectives: Rare earth elements (REEs) are emerging environmental pollutants, with human exposure increasing due to recent industrial and technological activities. While most studies have focused on detecting REEs in human fluids, their presence in tissues remains understudied. Aortic valve degeneration is known to facilitate the adsorption of various chemical elements; however, the occurrence of REEs in human valves has not yet been investigated. This exploratory study aimed to determine the presence of REEs in the aortic valves of patients with aortic stenosis undergoing surgical valve replacement. It also analyzed potential correlations between REE levels in the valves, epicardial adipose tissue, serum, and selected disease markers. Methods: Samples of aortic valve, epicardial adipose tissue, and serum were collected from 20 adult patients undergoing elective aortic valve replacement. The concentrations of 14 REEs in these samples were measured using inductively coupled plasma mass spectrometry. Biochemical and clinical parameters of the patients were also considered to explore potential associations with the determined REE levels. Results: Total REEs, heavy REEs, and light REEs in aortic valves, epicardial fat, and serum were not intercorrelated. Moreover, for any sample type, they were not significantly related to the patient's demographics (age and sex), clinical characteristics (body mass index, heart failure severity, and systolic pressure gradients), kidney function (estimated glomerular filtration rate), and biochemical markers (creatinine, lipoprotein(a), total cholesterol, HDL, LDL, and fibrinogen). Smoking was the only factor influencing REE burden in studied patients, with active smokers revealing 61% higher serum REE concentrations and past smokers exhibiting 133% higher REE valvular deposition. Conclusions: The findings suggest that REE accumulation in aortic valve tissues occurs independently of systemic and clinical parameters but may be promoted by smoking, highlighting the need to investigate the underlying mechanisms of REE deposition. Given the small sample size and the cross-sectional, hypothesis-generating design, these observations should be interpreted with caution and treated as preliminary. Larger, longitudinal studies are needed to validate these results and explore potential causal relationships. Further research should also include the tissue originating from individuals without aortic stenosis for comparison. A deeper understanding of the pathways and health risks associated with REEs in cardiovascular tissues may offer valuable insights into their broader implications for human health.

Outcomes and Left Ventricular Ejection Fraction in Cardiac Magnetic Resonance: Challenging the "Higher Is Better"

BACKGROUND

Contradictory evidence exists regarding the correlation between supranormal left ventricular ejection fraction (LVEF) and adverse outcomes. This study aimed to elucidate the prognostic value of supranormal LVEF.

METHODS

This retrospective cohort study analyzed patients referred for cardiac magnetic resonance imaging to assess myocardial ischemia or viability. Subjects were stratified into eig8ht LVEF groups: <20%, 20% to 30%, 30% to 40%, 40% to 50%, 50% to 60%, 60% to 70%, 70% to 80%, and ≥80%. Primary outcomes included cardiovascular death, heart failure, myocardial infarction, and stroke. The extracellular volume fraction was measured.

RESULTS

The study cohort comprised 3279 patients (mean age 68.0±12.7 years; 64.0% female). The group with 60% to 70% LVEF had the lowest risk and was used as the reference group. The median follow-up was 41.4 months (interquartile range, 33.9-49.7 months). The group with LVEF <20% exhibited the highest composite outcome risk (unadjusted hazard ratio [HR], 6.77 [95% CI, 3.81-12.03]; P<0.001; adjusted HR, 2.68 [95% CI, 1.28-5.62]; P<0.001). The groups with LVEF 70% to 80% and ≥80% showed increased risk (adjusted HR, 1.96 [95% CI, 1.23-3.08]; P=0.004; 2.16 [95% CI, 1.33-3.52]; P=0.002, respectively). A greater extracellular volume fraction was associated with an LVEF of 70% to 80% and ≥80% (adjusted odds ratios, 1.34 [95% CI, 1.03-1.74]; P=0.027; and 1.74 [95% CI, 1.30-2.34]; P<0.001, respectively).

CONCLUSIONS

LVEF >70% demonstrated increased event rates compared with an LVEF of 60% to 70%. The supranormal LVEF warrants further investigation into its pathogenesis and management.

Methylations in dilated cardiomyopathy and heart failure

Dilated cardiomyopathy (DCM) is characterized by impaired expansion or contraction of the left or both ventricles in the absence of abnormal load conditions (such as primary valve disease) or severe coronary artery disease that can lead to ventricular remodeling. Genetic mutations, infections, inflammation, autoimmune diseases, exposure to toxins, and endocrine or neuromuscular factors have all been implicated in the causation of DCM. Cardiomyopathy, particularly DCM, often has genetic underpinnings, with established or suspected genetic origins. Up to 40% of DCM cases involve probable or confirmed genetic variations. The significance of RNA modification in the pathogenesis of hypertension, cardiac hypertrophy, and atherosclerosis is well-established. Of late, RNA methylation has garnered attention for its involvement in DCM. This review examines the biological mechanisms and effects of RNA methylation in DCM and heart failure.

The use of Left Ventricular Ejection Fraction in the Diagnosis and Management of Heart Failure. A Clinical Consensus Statement of the Heart Failure Association (HFA) of the ESC, the Heart Failure Society of America (HFSA), and the Japanese Heart Failure Society (JHFS)

This clinical consensus statement revisits the role of left ventricular ejection fraction (LVEF) as a measurement of cardiac function, a prognostic marker and a major criterion to classify patients with heart failure, and gives new advice for clinical practice. Heart failure is traditionally classified on the basis of LVEF thresholds and this has major implications for treatment recommendations. However, the reproducibility of LVEF measurement is poor and its prognostic and diagnostic value lessens when it is above 45%, with no relationship with the severity of either cardiac dysfunction or outcomes at higher values. These limitations dictate the need for a more comprehensive approach to classify and assess heart failure focusing more on the trajectory of LVEF rather than to its absolute value. Furthermore, the assessment of LVEF is not required for the initiation of treatments like sodium-glucose cotransporter 2 inhibitors, mineralocorticoid receptor antagonists and diuretics in patients with suspected de novo heart failure and elevated N-terminal pro-B-type natriuretic peptide levels. Future research utilizing advanced imaging techniques and biomarkers which can better characterize myocardial structure, metabolism and performance may facilitate the identification of alternative therapeutic targets and better ways to monitor heart failure therapies across the entire spectrum of LVEF.

The value of handheld ultrasound in point-of-care or at home EF prediction

In this paper, AI-enabled handheld ultrasound is used in point-of-care or at home, and evaluate the accuracy of it for left ventricular ejection fraction (LVEF) evaluation. It provides a simple, convenient, and practical tool for the patients with heart disease, especially those with heart failure. The AI model used for this AI-enabled handheld ultrasound is a machine learning model trained with tens of thousands of ultrasound four-chamber cardiograms. The LVEF evaluation accuracy of the AI model was compared by the experts performing ultrasound four-chamber cardiogram detection in 100 patients on high-end ultrasound in the hospital. In the 100 clinical trials, the sensitivity, specificity, and accuracy of the AI model were 91%, 95%, and 98%, respectively. Then 10 cases were used to compare the LVEF results of hospital tests with the predicted results of the AI model. The difference between the two is less than 10%. Finally, over the course of one month, the AI-enabled handheld ultrasound was employed to conduct regular evaluations of left LVEF for point-of-care purposes on a group of 10 patients diagnosed with heart failure. The LVEF evaluation accuracy of AI-enabled handheld ultrasound is more than 96%, which was higher than that of experts in high-end ultrasound in hospitals. The easy-to-use AI-enabled handheld ultrasound can evaluate the LVEF in the point of care or at home and get the same accuracy as the high-end ultrasound equipment in the hospital. It may play an important role in monitoring cardiac function at home for the ambulatory heart failure patients.

Alcohol Septal Ablation for Left Ventricle Outflow Tract Obstruction Prevention Before Transcatheter Mitral Valve Replacement Procedure: Computed Tomography Analysis Series

BACKGROUND

Left ventricle outflow tract obstruction (LVOTO) is the main limitation of transcatheter mitral valve replacement (TMVR) procedure occurring in 7%-9% of cases and responsible of 25% TMVR screen failures.

AIMS

We aim to assess the alcohol septal ablation (ASA) effect on LVOTO risk before TMVR by multistage cardiac computed tomography (CT).

METHODS

Patients indicated for TMVR procedure using Sapiens 3 Prosthesis with high LVOTO risk were enrolled in the study. ASA was the first choice technique to reduce this risk based on multiple and staged cardiac CT screening.

RESULTS

Out of 29 consecutive TMVR procedures conducted in our center between March 2021 and April 2023, nine patients presented high LVOTO risk and were enrolled in our study. The main risk factor retained was a reduced predicted NeoLVOT surface 89 mm2 [66-135] (< 170 mm2). Most procedures were valve in MAC and all patients underwent at least one ASA. CT control showed a significant increase by 95% in the predicted NeoLVOT surface: 174 mm2 [121-240]; p = 0.012 compared to the baseline value. There were no significant paraprosthesis leakage or LVOTO found on TTE according to the MVARC criteria. Cardiac CT showed a larger than predicted final NeoLVOT surface: 215 mm2 [175-317]; p = 0.018. One patient died after ASA, and two others during the first year of follow-up. Survivors had significant symptom relief (p = 0.046) and a decreased PASP (38 mmHg [32-47] vs. 54 mmHg [46-62.5]; p = 0.028).

CONCLUSIONS

Multistage CT analysis shows that ASA is effective in high LVOTO-risk patients undergoing TMVR.

Prevalence and prognostic value of ventricular conduction delay in heart failure with preserved ejection fraction

Background

The pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF) is heterogeneous and incompletely understood. This study evaluated the presence of a ventricular conduction delay (VCD) phenotype in HFpEF through QRS duration and vectorcardiographic QRS area, and their relation to adverse outcomes.

Methods

This study included consecutive ambulatory HFpEF patients. Baseline QRS duration was obtained from an electrocardiogram (ECG). QRS area was derived from vectorcardiographic analyses of the ECG. QRS duration and area were assessed and analysed as categorical (<100 ms, 100-119 ms, ≥120 ms; ≤ 43.1 µVs, >43.1 µVs) and continuous variables to determine the relation to the composite outcome of HF hospitalisation and all-cause mortality.

Results

349 HFpEF patients were included of whom 70 % had a QRS duration < 100 ms compared to 21 % with QRS duration 100-119 ms and 9 % with QRS duration ≥120 ms. 87 (25 %) patients had QRS area >43.1 µVs. Only 4 % had a QRS area ≥69µVs, indicating delayed lateral wall activation. After a median of 3 years follow-up, 30 % of the patients had an adverse outcome. Longer QRS duration but not larger QRS area was associated with more adverse outcomes on both categorical and continuous scales (HR per 5 ms increase = 1.06, P = 0.033). This prognostic association was mainly present in males.

Conclusion

HFpEF patients have a low prevalence of a VCD phenotype(9 % QRS duration ≥120 ms;4 % a QRS area ≥69 µVs). However, QRS duration >100 ms was present in 30 % and was an independent predictor for adverse outcomes. Future efforts are needed to understand the mechanisms underlying the association of QRS duration and adverse outcomes, and to determine its clinical implications.

Impact of Exercise on Atrial Functional Mitral Regurgitation and Its Determinants: An Exercise Echocardiographic Study

Atrial functional mitral regurgitation (AFMR) is a distinct form of mitral regurgitation in patients with atrial fibrillation and heart failure with preserved ejection fraction. Its pathophysiology remains elusive, and data on exercise-related AFMR are scarce. We sought to investigate the impact of acute exercise on AFMR severity and to identify its determinants. In total, 47 patients with heart failure with preserved ejection fraction (n = 39) and/or atrial fibrillation (n = 22) were enrolled. We assessed AFMR severity, mitral annular dimensions, left atrial size, AFMR severity, and parameters of systolic and diastolic function at rest and during maximal exercise by echocardiography. An increase in AFMR severity of ≥1 grade was observed in 20 patients (43%) during exercise and was associated with impaired progression of peak mitral annulus systolic velocity and increased systolic mitral annular diameter during exercise, whereas the systolic annular diameter decreased in patients without AFMR progression. Furthermore, patients with ≥ moderate AFMR during exercise (n = 19, 40%) had lower peak mitral annulus systolic velocity, greater systolic mitral annular diameters, reduced tricuspid annular plane systolic excursion, and more severe tricuspid regurgitation than patients with ≤ mild MR during exercise. In conclusion, AFMR is a dynamic condition which may worsen during exercise. Deterioration of AFMR during exercise was associated with impaired longitudinal left ventricular contractile reserve and greater mitral annular dimensions. Because impaired left ventricular longitudinal function may influence mitral annular dynamics, this attributes to the hypothesis that AFMR results from mitral annulus area/leaflet area imbalance caused by annular dilation and impaired mitral annular dynamics.

Survival Outcomes After Multiple vs Single Arterial Grafting Among Patients With Reduced Ejection Fraction

Importance

Multiarterial coronary bypass procedures offer improved clinical outcomes compared with single arterial grafting with supplementary saphenous vein grafts. However, the survival advantage of multiarterial grafting across varying levels of left ventricular impairment remains uncertain.

Objective

To compare long-term survival outcomes of patients undergoing multiple vs single arterial grafting, stratified by preoperative ejection fraction.

Design, Setting, and Participants

A complete-case retrospective cohort study was conducted using data from a multicenter population-based cardiac registry established by the Australian & New Zealand Society of Cardiac & Thoracic Surgeons with linkage to the National Death Index. Participants were individuals who underwent primary isolated coronary bypass surgery between June 1, 2001, and January 31, 2020. Exclusion criteria were nonadults, reoperations, concomitant or previous cardiac surgical procedures, single-graft procedure, and cases without any arterial grafts. Statistical analyses were conducted in September 2024.

Exposures

Patients underwent either multiple or single arterial grafting, stratified by their preoperative left ventricular ejection fraction.

Main Outcomes and Measures

Long-term all-cause mortality.

Results

The study included 59 641 patients (mean [SD] age at the time of surgery, 65.8 [10.2] years; 48 321 men [81.0%]). The median follow-up duration was 5.0 years (IQR, 2.3-8.6 years). Multiarterial grafting was associated with a 19.0% relative reduction in all-cause mortality compared with single arterial grafting among patients with a normal left ventricular ejection fraction (hazard ratio [HR], 0.81; 95% CI, 0.75-0.87; P < .001). Similar survival benefits were observed among patients with mild (HR, 0.83; 95% CI, 0.77-0.90; P < .001), moderate (HR, 0.82; 95% CI, 0.74-0.90; P < .001), and severe left ventricular impairment (HR, 0.82; 95% CI, 0.71-0.96; P = .01). A multivariable Cox proportional hazards regression interaction-term analysis indicated no significant differences in the multiarterial survival benefit by ejection fraction stratification (P = .75). Multiarterial grafting with exclusively arterial conduits was associated with enhanced survival benefits compared with other multiarterial procedures with saphenous vein grafts, except when the left ventricular ejection fraction was below 30% (HR, 0.87; 95% CI, 0.67-1.13; P = .30).

Conclusions and Relevance

In this retrospective cohort study using data from a binational database, multiarterial procedures were associated with reduced long-term mortality risk compared with single arterial grafting across the spectrum of preoperative left ventricular ejection fractions. Total arterial revascularization was associated with incrementally improved survival, particularly among patients with preserved ejection fraction. Because most coronary surgery practice continues to use single arterial grafting, consideration to alter grafting strategy to multiarterial procedures may be indicated.

Demographic Factors and Aortic Stenosis-Related Death Locations: A Cross-Sectional Analysis

Background: Aortic stenosis (AS) imposes a significant mortality burden. Understanding demographic influences on the location of AS-related death is crucial for advancing equitable end-of-life care. Therefore, we investigated how demographic factors influence the location of death among AS patients in the United States. Methods: We completed a cross-sectional study utilizing US mortality data from the CDC's WONDER database for 2019. All files related to decedents with AS identified as the primary cause of death were obtained, including demographic information and death locations (i.e., inpatient facilities, outpatient/ER facilities, home, or hospice/nursing facilities). Associations between demographic factors (age, sex, race/ethnicity, marital status, and education) and place of death were assessed using multivariable logistic regression models, yielding odds ratios (ORs). Results: In 2019, most AS-related deaths occurred in inpatient facilities (38.3%, n = 5062), home (29.2%, n = 3859), or hospice/nursing facilities (28.6%, n = 3775). Higher odds of inpatient death were observed among Black (OR 1.67, p < 0.001) and Hispanic individuals (OR 1.91, p < 0.001) compared to White decedents. Those aged >85 years were more likely to die at home (OR 1.76, p < 0.001) or in hospice/nursing facilities (OR 7.80, p < 0.001). Males had increased odds of inpatient death (OR 1.09, p = 0.044) but decreased odds of hospice/nursing facility death (OR 0.87, p = 0.003). Higher education levels were associated with increased odds of home death (OR 1.33, p = 0.023) and decreased odds of hospice/nursing facility death (OR 0.71, p = 0.015). Conclusions: Demographic factors significantly influence the location of death among AS patients, emphasizing the need for culturally and socioeconomically tailored interventions to promote equitable end-of-life care.

Aortic Valve Replacement vs Clinical Surveillance in Asymptomatic Severe Aortic Stenosis: A Systematic Review and Meta-Analysis

BACKGROUND

Current guidelines recommend a strategy of clinical surveillance (CS) for patients with asymptomatic severe aortic stenosis (AS) and a normal left ventricular ejection fraction.

OBJECTIVES

The aim of this study was to conduct a study-level meta-analysis of randomized controlled trials (RCTs) evaluating the effect of early aortic valve replacement (AVR) compared with CS in patients with asymptomatic severe AS.

METHODS

Studies were quantitatively assessed in a meta-analysis using random-effects modeling. Prespecified outcomes included all-cause and cardiovascular mortality, unplanned cardiovascular or heart failure (HF) hospitalization, and stroke. The meta-analysis is registered at the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY202490002).

RESULTS

Four RCTs were identified, including a total of 1,427 patients (719 in the early AVR group and 708 in the CS group). At an average follow-up time of 4.1 years, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization (pooled rate 14.6% vs 31.9%; HR: 0.40; 95% CI: 0.30-0.53; I2 = 4%; P < 0.01) and stroke (pooled rate 4.5% vs 7.2%; HR: 0.62; 95% CI: 0.40-0.97; I2 = 0%; P = 0.03). No differences in all-cause mortality (pooled rate 9.7% vs 13.7%; HR: 0.68; 95% CI: 0.40-1.17; I2 = 61%; P = 0.17) and cardiovascular mortality (pooled rate 5.1% vs 8.3%; HR: 0.67; 95% CI: 0.35-1.29; I2 = 50%; P = 0.23) were observed with early AVR compared with CS, although there was a high degree of heterogeneity among studies.

CONCLUSIONS

In this meta-analysis of 4 RCTs, early AVR was associated with a significant reduction in unplanned cardiovascular or HF hospitalization and stroke and no differences in all-cause and cardiovascular mortality compared with CS.

Natural history of initially asymptomatic severe aortic stenosis: a one-stage meta-analysis

BACKGROUND

Current guidelines on the management strategy for patients with asymptomatic severe aortic stenosis (AS) remain unclear. This uncertainty stems from the lack of data regarding the natural history of these patients. To address this gap, we performed a systematic review and meta-analysis examining the natural history of asymptomatic severe AS patients receiving conservative treatment.

METHODS

The PubMed, Cochrane, and Embase databases were searched from inception to 24 January 2024 using the keywords "asymptomatic" AND "aortic" AND "stenosis". We included studies examining patients with asymptomatic severe AS. In interventional trials, only data from conservatively managed arms were collected. A one-stage meta-analysis was conducted using individual patient data reconstructed from published Kaplan-Meier curves. Sensitivity analysis was performed for major adverse cardiovascular outcomes in patients who remained asymptomatic throughout follow-up.

RESULTS

A total of 46 studies were included (n = 9545). The median time to the development of symptoms was 1.11 years (95% CI 0.90-1.53). 49.36% (40.85-58.59) of patients who were asymptomatic had suffered a major adverse cardiovascular event by 5 years. The median event-free time for heart failure hospitalization (HFH) was 5.50 years (95% CI 5.14-5.91) with 36.34% (95% CI 33.34-39.41) of patients experiencing an HFH by year 5. By 5 years, 79.81% (95% CI 69.26-88.58) of patients developed symptoms (angina, dyspnoea, syncope and others) and 12.36% (95% CI 10.01-15.22) of patients died of cardiovascular causes. For all-cause mortality, the median survival time was 9.15 years (95% CI 8.50-9.96) with 39.43% (CI 33.41-36.40) of patients dying by 5 years. The median time to AVR was 4.77 years (95% CI 4.39-5.17), with 52.64% (95% CI 49.85-55.48) of patients requiring an AVR by 5 years.

CONCLUSION

Our results reveal poor cardiovascular outcomes for patients with asymptomatic severe AS on conservative treatment. A significant proportion eventually requires an AVR. Further research is needed to determine if early intervention with AVR is more effective than conservative treatment.

Valve cells are crucial for efficient cardiac performance in Drosophila

Blood flow in metazoans is regulated by the activity of the heart. The open circulatory system of insects consists of relatively few structural elements that determine cardiac performance via their coordinated interplay. One of these elements is the intracardiac valve between the aorta and the ventricle. In Drosophila, it is built by only two cells, whose unique histology represents an evolutionary novelty. While the development and differentiation of these highly specialised cells have been elucidated previously, their physiological impact on heart performance is still unsolved. The present study investigated the physiological consequences of cardiac valve malformation in Drosophila. We show that cardiac performance is reduced if valves are malformed or damaged. Less blood is transported through the heart proper, resulting in a decreased overall transport capacity. A reduced luminal opening was identified as a main reason for the decreased heart performance in the absence of functional valves. Intracardiac hemolymph flow was visualised at the valve region by microparticle injection and revealed characteristic similarities to valve blood flow in vertebrates. Based on our data, we propose a model on how the Drosophila intracardiac valves support proper hemolymph flow and distribution, thereby optimising general heart performance.

Sacubitril-Valsartan Lowers Atrial Fibrillation Recurrence and Left Atrial Volume Post-catheter Ablation: Systematic Review and Meta-Analysis

INTRODUCTION

In patients with atrial fibrillation (AF) who have undergone catheter ablation, the comparative effectiveness of sacubitril-valsartan (SV) versus ACE inhibitors (ACEi) or angiotensin-receptor blockers (ARB) in preventing AF recurrence remains unclear. The purpose of the present systematic review and meta-analysis is to determine whether SV offers superior outcomes in this clinical setting.

METHODS

This study systematically reviewed PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating SV's efficacy in preventing AF recurrence after catheter ablation. Outcomes included AF recurrence and structural remodeling assessed via left ventricular ejection fraction (LVEF) and left atrial volume index (LAVi), with statistical analyses performed using Review Manager 5.1.7 and heterogeneity assessed via I2 statistics.

RESULTS

The analysis comprised 642 patients from three RCTs and one PMC (319 SV-treated). SV significantly reduced AF recurrence [risk ratios (RR) 0.54; 95% confidence intervals (CI) 0.41-0.70; p < 0.00001; I2 = 0%), a trend also observed when considering RCTs exclusively (RR 0.58; 95% CI 0.41-0.84; p = 0.004; I2 = 0%). Moreover, SV demonstrated a notable reduction in LAVi [mean deviation (MD) -5.34 mL/m2; 95% CI -8.77 to -1.91; p = 0.002; I2 = 57%] compared with ARB, alongside a significant improvement in LVEF (MD 1.83%; 95% CI 1.35-2.32; p < 0.00001; I2 = 0%). Subgroup analyses among patients with hypertension and LVEF < 50% also indicated lower AF recurrence with SV.

CONCLUSION

SV therapy exhibited superior efficacy in reducing AF recurrence compared with ACEi or ARB and demonstrated superior outcomes in attenuating atrial structural remodeling after catheter ablation. These findings underscore the potential of SV as a therapeutic option for patients with AF undergoing catheter ablation, highlighting its efficacy in mitigating AF recurrence and structural remodeling.

REGISTRATION

PROSPERO identifier number CRD42024497958.

A Case of Immediate Reduction of Severe Mitral Regurgitation After the Ablation of Atrial Flutter

Mitral regurgitation (MR) is a common valvular dysfunction often classified as primary or secondary, with the latter typically associated with left ventricular dysfunction or mitral annular dilation. A subset of MR is termed atrial functional MR, related to atrial fibrillation, but the relationship between atrial flutter and MR remains underexplored. This report describes the case of a 71-year-old man with severe MR and atrial flutter who experienced rapid improvement in MR severity following successful atrial flutter ablation and restoration of sinus rhythm. Initial echocardiography revealed severe left atrial dilation, moderate to severe eccentric MR, and moderate tricuspid regurgitation. Following ablation, MR severity significantly improved despite persistent left atrial dilation, with sustained improvement observed over two years alongside reverse remodeling of the left atrium. This case highlights the independent effect of atrial flutter on MR severity, separate from structural remodeling, and emphasizes the potential for rhythm control strategies to improve MR and avoid invasive valve interventions. It also raises important questions about the interplay between atrial arrhythmias and MR, underscoring the need for further studies to better understand atrial functional MR and its management.

Diagnosis and Management of Mitral Valve Disease in the Elderly

Calcific mitral stenosis, commonly seen in the elderly in developed countries, occurs primarily due to mitral annular calcification, and its prevalence is increasing secondary to an aging population. Mitral regurgitation, commonly seen across all age groups, occurs primarily due to anatomical or functional impairment of one or more components of the mitral apparatus or the left ventricle that are necessary for normal valve function, and its prevalence is increasing secondary to an increasing number of patients with heart failure. The current review discusses the diagnosis of and treatment options (medical, surgical, and transcatheter) for mitral valve disease, including the associated challenges, specifically in the elderly.

The HbA1c/C-Peptide Ratio is Associated With the No-Reflow Phenomenon in Patients With ST-Elevation Myocardial Infarction

Currently, the gold standard treatment for ST-elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (pPCI), but even after successful pPCI, a perfusion disorder in the epicardial coronary arteries, termed no-reflow phenomenon (NR), can develop, resulting in short- and long-term adverse events. The present study assessed the relationship between NR and HbA1c/C-peptide ratio (HCR) in 1834 consecutive patients who underwent pPCI due to STEMI. Participants were divided into two groups according to NR status and the demographic, clinical and periprocedural characteristics of the groups were compared. NR developed in 352 (19.1%) of the patients in the study. While C-peptide levels were significantly lower in the NR group, HbA1c and HCR were significantly higher (P < .001, for all). In multivariable analysis, C-peptide, HbA1c, and HCR, were determined as independent predictors for NR (P < .05, for all). In Receiver Operating Characteristic (ROC) analysis, HCR predicted the NR with 80% specificity and 77% sensitivity. In STEMI patients, combining HbA1c and C-peptide in a single fraction has a predictive value for NR independent of diabetes. This ratio may contribute to risk stratification of STEMI patients.

AI-echocardiography: Current status and future direction

Echocardiography, which provides detailed evaluations of cardiac structure and pathology, is central to cardiac imaging. Traditionally, the assessment of disease severity, treatment effectiveness, and prognosis prediction relied on detailed parameters obtained by trained sonographers and the expertise of specialists, which can limit access and availability. Recent advancements in deep learning and large-scale computing have enabled the automatic acquisition of parameters in a short time using vast amounts of historical training data. These technologies have been shown to predict the presence of diseases and future cardiovascular events with or without relying on quantitative parameters. Additionally, with the advent of large-scale language models, zero-shot prediction that does not require human labeling and automatic echocardiography report generation are also expected. The field of AI-enhanced echocardiography is poised for further development, with the potential for more widespread use in routine clinical practice. This review discusses the capabilities of deep learning models developed using echocardiography, their limitations, current applications, and research utilizing generative artificial intelligence technologies.

Multimodality Imaging in the Diagnosis of Coronary Microvascular Disease: An Update

Coronary microvascular dysfunction (CMD) is characterized by structural and functional abnormalities in the coronary microvasculature which can lead to ischaemia and angina and is increasingly recognized as a major contributor to adverse cardiovascular outcomes. Despite its clinical importance, the diagnosis of CMD remains limited compared with traditional atherosclerotic coronary artery disease. Furthermore, the historical lack of non-invasive methods for detecting and quantifying CMD has hindered progress in understanding its pathophysiology and clinical implications. This review explores advancements in non-invasive cardiac imaging that have enabled the detection and quantification of CMD. It evaluates the clinical utility, strengths and limitation of these imaging modalities in diagnosing and managing CMD. Having improved our understanding of CMD pathophysiology, cardiac imaging can provide insights into its prognosis and enhance diagnostic accuracy. Continued innovation in imaging technologies is essential for advancing knowledge about CMD, leading to improved cardiovascular outcomes and patient care.

Assessing the Vulnerability of Splenectomized Patients to Severe COVID-19 Outcomes: A Systematic Review and Meta-Analysis

BACKGROUND

Splenectomized/asplenic individuals are at a heightened risk for severe infections due to compromised immune function. However, the impact of splenectomy/asplenia on COVID-19 outcomes remains underexplored. This study aims to systematically review and meta-analyze the association between splenectomy/asplenia and severe COVID-19 outcomes.

METHODS

Following the PRISMA guidelines, databases including Scopus, MEDLINE/PubMed, and Web of Knowledge were searched for relevant articles published between January 2020 and June 2024. Odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for severe COVID-19 outcomes, with a random-effects model being used to account for heterogeneity. Out of 749 identified studies, 4 met the inclusion criteria.

RESULTS

The meta-analysis revealed a significant association between splenectomy/asplenia and overall severe COVID-19 outcomes (OR = 1.92; 95% CI = 1.06-3.47). Specifically, splenectomy/asplenia was significantly associated with increased COVID-19-related hospitalization (OR = 2.06; 95% CI = 1.21-3.49), while the association with COVID-19-related death was not statistically significant (OR = 1.52; 95% CI = 0.78-2.99). COVID-19 vaccination is strongly recommended for these patients.

CONCLUSIONS

Splenectomy/asplenia significantly increases the risk of severe COVID-19 outcomes, particularly hospitalization. The findings underscore the need for vigilant clinical management and targeted interventions for this vulnerable population. Further research is warranted to fully understand the risks and to develop effective guidelines for the protection of splenectomized individuals against COVID-19.

Evaluation of Hematological and Biochemical Parameters that Predict the No-reflow Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention

Acute coronary syndromes (ACS) are one of the most common causes of morbidity and mortality worldwide. Primary percutaneous coronary intervention (pPCI) is the main treatment strategy to restore myocardial perfusion. However, the no-reflow phenomenon (NRP) may block coronary flow. The present study focused on assessing and contrasting predictive parameters for NRP in ACS patients. Our research is a retrospective analysis. We assessed the parameters significantly associated with NRP using Cox regression and Receiver operating characteristic (ROC) Curve analysis. The study included 5122 patients who met the criteria. The average age of the patients was 63.9 + 13.2, and 74.4% were male. It was observed that NRP developed in 1.8% of all patients. Age, hemoglobin (Hb), white blood cell (WBC), glucose and low density lipoprotein cholesterol (LDL-C) were determined to be independent predictors of NRP. The power of these parameters to predict NRP was similar, and WBC was the most predictive (Area Under Curve (AUC): 0.605 95% CI: 0.539-0.671, P = .001). We believe that the use of these simple, practical, and routinely used hematological and biochemical parameters will help us predict the risk of developing NRP before pPCI. This information should improve management.

Sex-related differences in outcomes and prognosis of severe calcific mitral stenosis due to mitral annular calcification: A propensity-score matched cohort study

BACKGROUND

The prevalence of severe calcific mitral stenosis (MS) is higher in female patients. The aim of the study was to assess the sex-related differences in clinical characteristics and prognosis in patients with severe calcific MS.

METHODS

Among 7154 adult patients with MS due to mitral annular calcification who underwent echocardiography between October 2010 and August 2020, 287 patients with severe MS were retrospectively analyzed. The endpoint was all-cause mortality. We calculated a propensity score matched analysis with 22 potential confounding covariates including clinical characteristics and medication usage.

RESULTS

In the entire cohort, there was a predominance of female patients (66 %), and the mean age was 72 ± 11 years. While 97 patients (34 %) underwent MV intervention, 190 patients (66 %) were conservatively managed. During a median follow-up of 12 months (25th -75th percentile: 3-29 months), 102 patients (36 %) died. The cumulative survival rate of female patients was lower compared with male patients in conservative treatment group (p = 0.012), while the cumulative survival rate was comparable between the sexes in MV intervention group (p = 0.63). Even after propensity score matching in 170 patients (85 females and 85 males), similar results were obtained (p = 0.012 for conservative treatment group, p = 0.61 for MV intervention group).

CONCLUSIONS

Female sex predominated in patients with severe calcific MS. Female patients with severe calcific MS had worse prognosis than male patients when treated conservatively, while in patients undergoing MV intervention, prognosis was similar between the sexes.

Invasive versus conservative strategies for non-ST-elevation acute coronary syndrome in the elderly: an updated systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Advances in managing non-ST-elevation acute coronary syndrome (NSTE-ACS) have yet to clarify the optimal treatment for elderly patients, whose complex health profiles and underrepresentation in trials add challenges to decision-making.

METHODS

We systematically searched PubMed, Embase, Web of Science, and Scopus for randomized controlled trials comparing invasive versus conservative strategies in elderly patients (≥ 70 years) with NSTE-ACS through October 2024. Co-primary outcomes were all-cause and cardiovascular mortalities, with secondary outcomes including myocardial infarction (MI), revascularization, stroke, decompensated heart failure, and bleeding events. Outcomes were analyzed using both risk ratios (RR) and hazard ratios (HR).

RESULTS

Analysis of 11 trials (4,114 patients) showed no significant differences in all-cause mortality (RR: 1.04, 95% CI: 0.98-1.11; HR: 1.10, 95% CI: 0.94-1.29) or cardiovascular mortality (RR: 0.98, 95% CI: 0.85-1.12; HR: 0.94, 95% CI: 0.73-1.20) between strategies. The invasive approach significantly reduced subsequent revascularization (RR: 0.41, 95% CI: 0.27-0.62; HR: 0.30, 95% CI: 0.19- 0.47; p < 0.01 in both analyses) and MI risk (RR: 0.75, 95% CI: 0.57-0.99, p = 0.04; HR: 0.64, 95% CI: 0.49-0.83, p < 0.01), though with some levels of heterogeneity in sensitivity analyses for MI. Stroke and heart failure outcomes were comparable between strategies. However, it significantly increased the risk of both composite major and minor bleeding risk (RR: 1.50, 95% CI: 1.02-2.20, p = 0.04) and major bleeding alone (RR: 1.92, 95% CI: 1.04-3.56, p = 0.04).

CONCLUSION

In elderly patients with NSTE-ACS, an invasive strategy reduces revascularization needs and, potentially, MI risk without impacting survival, but at the cost of increased bleeding risk. This supports individualized treatment decisions based on patient-specific characteristics, particularly bleeding risk and geriatric factors.

Use of signal detection methods to identify associations between prenatal medication exposure and subsequent childhood cancers: a Nordic hypothesis-generating registry-based study

BACKGROUND

Childhood cancer is an important contributor to childhood mortality in high-income countries. Information on associations between childhood cancer and in-utero exposure is absent or limited for most medications. Signal detection methods identify medications where research should be focused but have not been applied to datasets containing prenatal medication exposures and childhood cancers.

RESEARCH DESIGN AND METHODS

The aim of this study was to apply and evaluate four signal detection methods - odds ratios (OR), the information component (IC), sequential probability ratio testing (SPRT), and Bayesian hierarchical models (BHM) - for identification of associations between medications dispensed during pregnancy and subsequent, incident diagnosis of childhood cancer <10 years, using linked Nordic registry data. Signal detection results were compared to propensity score adjusted odds ratios from generalized linear models.

RESULTS

Analysis was performed for 117 medication-cancer pairs with 5 or more observations. The OR had the greatest sensitivity (0.75). The IC had a greater specificity (0.98) than the OR (0.95).

CONCLUSIONS

The IC may be the most appropriate method for identifying signals within this type of data. Reported signals should not be considered sufficient evidence of causal association and must be followed-up by tailored investigations that consider confounding by indication.

Echocardiographic Findings in Jordanian Atrial Fibrillation Patients: Analysis from Jo-Fib Study

Background and Objectives: Atrial fibrillation (AF) carries a huge socioeconomic burden as it is the most encountered cardiac arrhythmia with a significant morbidity. Echocardiographic (Echo) imaging is of monumental value in providing insight into assessing the cardiac function and anatomy, etiology, and risk stratification of AF patients, which will ultimately lead to the best management plan. Materials and Methods: A total of 2160 adult patients diagnosed with AF in 18 hospitals and 30 out-patient cardiology clinics in Jordan and 1 hospital in the Palestinian Territories were enrolled in this study from May 2019 to January 2021. Ultimately, 1776 patients were included in the analysis after going through the exclusion criteria. Results: The majority of our participants were found to have normal EF at the time of enrollment, with only 31.6% exhibiting a decreased EF. Only 40% of overall patients had Echo evidence of left ventricular hypertrophy (LVH). These patients were older (70.27 ± 10.1 vs. 66.0 ± 14.3, p < 0.001), more obese (45.2% vs. 37.3%, p-value < 0.001), and had a more frequent occurrence of HTN (89.0% vs. 65.6%, p < 0.001) and DM (49.2% vs. 40.1%, p < 0.001) when compared to patients without LVH. A proportion of 84.2% of female patients had abnormal left atrial (LA) size (>3.8 cm), in contrast to only 53.4% of males (LA > 4.2 cm). Pulmonary hypertension (PH) was only observed in 27.9% of our patients, and when comparing patients with PH vs. patients without PH, decreased EF (<50%) (36.9% vs. 20.6%, p = 0.001), a higher prevalence of OSA (6.7% vs. 3.8%, p = 0.009), female predominance (60.3% vs. 39.7%, p < 0.001), and older age (70.2 ± 10.7 vs. 66.7 ± 13.6, p < 0.001) were observed in patients with PH. Conclusion: This study provides the first reported insights on the atrial fibrillation-related echocardiographic findings in a Middle Eastern population. Notably, our study demonstrates that the majority of the studied population have no evidence of LVH and have preserved EF on baseline. However, LA enlargement was extremely frequent among females but not in males, warranting further evaluation to determine the factors contributing to such a difference.

Supersaturated Oxygen Therapy as a Treatment for No Reflow

No reflow, an interruption in epicardial and microvascular blood flow, during percutaneous coronary intervention (PCI) is associated with adverse outcomes but continues to have limited therapeutic options. We present a case of a patient with multiple comorbidities, multivessel disease and reduced left ventricular function with calcified left anterior descending stenosis who was treated with rotational atherectomy, complicated by slow flow after balloon dilatation. Infusion of supersaturated oxygen (SSO2) into the left main was instituted as an adjunct to PCI, along with pharmacologic vasodilators. Subsequently, there was resolution of the patient's symptoms and improvement in ejection fraction postprocedurally. The potential role of SSO2 in treating patients with intraoperative no reflow is intriguing, given no reflow's current limited treatment options and known increased risk of adverse events (major adverse cardiovascular events, cardiogenic shock, and so on). SSO2 may be a promising therapy for PCI complicated by no reflow.

Valvular Heart Disease-A New Evolving Paradigm

Valvular heart disease is one of the most common cardiovascular diseases today and may result in severe limiting symptoms, a shortened lifespan, and, in some cases, sudden death. It is important to identify significant valve disease because intervention can restore quality of life and in many instances increase longevity. In most patients, the diagnosis of significant valvular heart disease can be made on the basis of a physical examination, yet nearly half of the patients who could benefit from interventions are not being recognized or referred. There have been major improvements in both the diagnosis and treatment of patients with valvular heart disease, with noninvasive echocardiography available to confirm the presence and severity of valve disease, better and more durable surgical procedures, and the advent of catheter-based therapies. There are now national guidelines to aid clinicians in the optimal timing of the intervention, which are presented. However, it is now recognized that the long-standing volume or pressure overload from valve disease can result in incipient ventricular dysfunction even before the onset of symptoms or a drop in ejection fraction; therefore, there is an impetus to recognize and to treat these patients earlier and earlier in the disease natural history. A shared decision-making process should play a key role in the final decision for therapy, outlining the goals and risks of possible intervention coupled with the patient's own needs and expectations.

Impact of Baseline Left Ventricular Ejection Fraction on Midterm Outcomes in Women Undergoing Transcatheter Aortic Valve Implantation: Insight from the WIN-TAVI Registry

Limited evidence exists concerning the prognostic impact of baseline left ventricular ejection fraction (LVEF) on outcomes among women undergoing transcatheter aortic valve implantation (TAVI), which we aimed to investigate in the present analysis. Patients from the Women's International Transcatheter Aortic Valve Implantation (WIN-TAVI) registry were categorized according to baseline LVEF into 3 groups: reduced (LVEF ≤40%), mildly reduced (LVEF between 41% and 49%), and preserved (LVEF ≥50%) LVEF. The primary (Valve Academic Research Consortium 2 [VARC-2]) efficacy point was defined as a composite of mortality, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure, or valve-related dysfunction at 1 year. The primary (VARC-2) safety end point included all-cause mortality, stroke, major vascular complication, life-threatening bleeding, stage 2 to 3 acute kidney injury, coronary artery obstruction requiring intervention, or valve-related dysfunction requiring repeated procedures. A Cox regression model was performed using the preserved LVEF group as the reference. Among the 944 patients included, 764 (80.9%) exhibited preserved, 80 (8.5%) had mildly reduced, and 100 (10.6%) had reduced LVEF. The 1-year incidence of VARC-2 efficacy end point was numerically higher in patients with reduced LVEF, albeit not resulting in a significant risk difference. Notably, reduced LVEF was associated with a higher risk of the 1-year VARC-2 safety end point, still significant after adjustment (28.0% vs 19.6%, Hazard Ratio 1.78, 95% Confidence Interval 1.12- 2.82, p = 0.014). These differences were primarily driven by trends toward increased rates of all-cause mortality, cardiovascular mortality, and major vascular complications. Clinical outcomes were similar between patients with mildly reduced and preserved LVEF. In conclusion, when performed in women with reduced LVEF, TAVI was associated with a worse (VARC-2) safety profile at 1-year follow-up. In contrast, patients with mildly reduced LVEF appeared to align more closely with outcomes observed in the preserved LVEF group than with the reduced LVEF group.

Long-term outcomes of women compared to men after off-pump coronary artery bypass grafting-a propensity-matched analysis

Background

Literature is not clear whether women experience increased mortality and adverse events after coronary artery bypass grafting (CABG). Studies have shown that women had comparative outcomes to men in off-pump CABG (OPCAB). Hence, we undertook this study to understand the short- and long-term outcomes of women compared to men after OPCAB.

Methods

Two thousand two hundred patients who underwent OPCAB from November 2014 to December 2021 were included in the study. Median follow-up period was 4.8 years. We performed propensity matching to match 404 women to 404 men.

Results

In the unmatched cohort, women had increased cardiovascular mortality and inferior major adverse cardiovascular and cerebral event (MACCE)-free survival. In the matched cohorts, there was no difference in the 30-day mortality, long-term survival, MACCE-free survival, and cardiovascular mortality between the sexes. Cox proportional hazard showed post-operative renal failure (p-value < 0.001; hazard ratio (HR) 11.469) (confidence interval (CI) 2.911-45.180), post-operative stroke (p-value 0.023, HR 6.473) (CI 1.295-32.356), EuroSCORE II > 6 (p-value 0.022, HR 3.561) (1.204-10.531), emergency surgery (p-value 0.022, HR 3.498) (CI 1.202-10.177), and ventilation hours (p-value 0.004, HR 3.327) (CI 1.455-7.607) were the risk factors associated with long-term mortality in women.

Conclusion

Our study showed that the increased risk profile of women was the reason for inferior MACCE-free survival and increased cardiovascular mortality in women in the long term after OPCAB. When the risk factors were matched, women had comparable outcomes to men.

Graphical Abstract

Prognostic Value of Multiple Complete Blood Count-Derived Indices in Intermediate Coronary Lesions

Complete blood count (CBC)-derived indices have been proposed as reliable inflammatory biomarkers to predict outcomes in the context of coronary artery disease. These indices have yet to be thoroughly validated in patients with intermediate coronary stenosis. Our study included 1527 patients only with intermediate coronary stenosis. The examined variables were neutrophil-lymphocyte ratio (NLR), derived NLR, monocyte-lymphocyte ratio (MLR), platelet-lymphocyte ratio (PLR), systemic immune inflammation index (SII), system inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI). The primary endpoint was the composite of major adverse cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, and unplanned revascularization. Over a follow-up of 6.11 (5.73-6.55) years, MACEs occurred in 189 patients. Receiver operator characteristic curve analysis showed that SIRI outperformed other indices with the most significant area under the curve. In the multivariable analysis, SIRI (hazard ratio [HR] 1.588, 95% confidence interval [CI] 1.138-2.212) and AISI (HR 1.673, 95% CI 1.217-2.300) were the most important prognostic factors among all the indices. The discrimination ability of each index was strengthened in patients with less burden of modifiable cardiovascular risk factors. SIRI also exhibited the best incremental value beyond the traditional cardiovascular risk model.

Pregnancy-Associated Myocardial Infarction in Alberta: A Population-Based Study

Background

Cardiac disease is the leading cause of maternal mortality in developed countries, and myocardial infarction (MI) is an important cause of pregnancy-associated morbidity and mortality. These infrequent, but very serious, events are not optimally described in the medical literature.

Objectives

This study describes a 15-year consecutive, retrospective cohort of confirmed pregnancy-associated MIs (PAMIs) identified in Alberta, Canada (2003-2017).

Methods

Utilizing a provincial administrative database, a cohort of women with PAMI were identified using a validated algorithm. Additional cases were identified by reviewing provincial maternal mortality records. Medical record review was conducted on each case with further details obtained via linkage with a provincial coronary heart disease registry. Available angiographic images were also reviewed.

Results

Forty-three cases of PAMI were identified in Alberta between 2003 and 2017, providing a crude incidence of ∼5.64/100,000 births. Rates of PAMI increased over the study period. Of the identified MIs, 16.3% occurred antepartum (mean gestational age of 18 weeks), while 30.2% were peripartum and 53.4% occurred within 6 months postpartum (at a mean of 7.8 weeks after delivery). The most common mechanism of PAMI was spontaneous coronary artery dissection (44.2%) and this mechanism predominated postpartum. Coronary artery disease was a frequent antepartum cause of MI, whereas demand ischemia was the leading cause of peripartum MI. Maternal mortality was approximately 9%.

Conclusions

PAMI is an increasing cause of maternal morbidity and mortality in Alberta. Clinicians should have a high index of suspicion for PAMI and ensure optimal management of this dangerous complication of pregnancy.