Transcatheter Aortic-Valve Replacement for Asymptomatic Severe Aortic Stenosis

BACKGROUND

For patients with asymptomatic severe aortic stenosis and preserved left ventricular ejection fraction, current guidelines recommend routine clinical surveillance every 6 to 12 months. Data from randomized trials examining whether early intervention with transcatheter aortic-valve replacement (TAVR) will improve outcomes in these patients are lacking.

METHODS

At 75 centers in the United States and Canada, we randomly assigned, in a 1:1 ratio, patients with asymptomatic severe aortic stenosis to undergo early TAVR with transfemoral placement of a balloon-expandable valve or clinical surveillance. The primary end point was a composite of death, stroke, or unplanned hospitalization for cardiovascular causes. Superiority testing was performed in the intention-to-treat population.

RESULTS

A total of 901 patients underwent randomization; 455 patients were assigned to TAVR and 446 to clinical surveillance. The mean age of the patients was 75.8 years, the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 1.8% (on a scale from 0 to 100%, with higher scores indicating a greater risk of death within 30 days after surgery), and 83.6% of patients were at low surgical risk. A primary end-point event occurred in 122 patients (26.8%) in the TAVR group and in 202 patients (45.3%) in the clinical surveillance group (hazard ratio, 0.50; 95% confidence interval, 0.40 to 0.63; P<0.001). Death occurred in 8.4% of the patients assigned to TAVR and in 9.2% of the patients assigned to clinical surveillance, stroke occurred in 4.2% and 6.7%, respectively, and unplanned hospitalization for cardiovascular causes occurred in 20.9% and 41.7%. During a median follow-up of 3.8 years, 87.0% of patients in the clinical surveillance group underwent aortic-valve replacement. There were no apparent differences in procedure-related adverse events between patients in the TAVR group and those in the clinical surveillance group who underwent aortic-valve replacement.

CONCLUSIONS

Among patients with asymptomatic severe aortic stenosis, a strategy of early TAVR was superior to clinical surveillance in reducing the incidence of death, stroke, or unplanned hospitalization for cardiovascular causes. (Funded by Edwards Lifesciences; EARLY TAVR ClinicalTrials.gov number, NCT03042104.).

Accuracy of Three-Dimensional Neo Left Ventricular Outflow Tract Simulations With Transcatheter Mitral Valve Replacement in Different Mitral Phenotypes

BACKGROUND

Transcatheter mitral valve replacement (TMVR) is emerging in the context of annular calcification (valve-in-MAC; ViMAC), failing surgical mitral annuloplasty (mitral-valve-in-ring; MViR) and failing mitral bioprosthesis (mitral-valve-in-valve; MViV). A notorious risk of TMVR is neo left ventricular outflow tract (neo-LVOT) obstruction. Three-dimensional computational models (3DCM) are derived from multi-slice computed tomography (MSCT) and aim to predict neo-LVOT area after TMVR. Little is known about the accuracy of these neo-LVOT predictions for various mitral phenotypes.

METHODS

Preprocedural 3DCMs were created for ViMAC, MViR and MViV cases. Throughout the cardiac cycle, neo-LVOT dimensions were semi-automatically calculated on the 3DCMs. We compared the predicted neo-LVOT area on the preprocedural 3DCM with the actual neo-LVOT as measured on the post-procedural MSCT.

RESULTS

Across 12 TMVR cases and examining 20%-70% of the cardiac phase, the mean difference between predicted and post-TMVR neo-LVOT area was -23 ± 28 mm2 for MViR, -21 ± 34 mm2 for MViV and -73 ± 61 mm2 for ViMAC. The mean intra-class correlation coefficient for absolute agreement between predicted and post-procedural neo-LVOT area (throughout the whole cardiac cycle) was 0.89 (95% CI 0.82-0.94, p < 0.001) for MViR, 0.81 (95% CI 0.62-0.89, p < 0.001) for MViV, and 0.41 (95% CI 0.12-0.58, p = 0.002) for ViMAC.

CONCLUSIONS

Three-dimensional computational models accurately predict neo-LVOT dimensions post TMVR in MViR and MViV but not in ViMAC. Further research should incorporate device host interactions and the effect of changing hemodynamics in these simulations to enhance accuracy in all mitral phenotypes.

CardiacField: computational echocardiography for automated heart function estimation using two-dimensional echocardiography probes

Aims

Accurate heart function estimation is vital for detecting and monitoring cardiovascular diseases. While two-dimensional echocardiography (2DE) is widely accessible and used, it requires specialized training, is prone to inter-observer variability, and lacks comprehensive three-dimensional (3D) information. We introduce CardiacField, a computational echocardiography system using a 2DE probe for precise, automated left ventricular (LV) and right ventricular (RV) ejection fraction (EF) estimations, which is especially easy to use for non-cardiovascular healthcare practitioners. We assess the system's usability among novice users and evaluate its performance against expert interpretations and advanced deep learning (DL) tools.

Methods and results

We developed an implicit neural representation network to reconstruct a 3D cardiac volume from sequential multi-view 2DE images, followed by automatic segmentation of LV and RV areas to calculate volume sizes and EF values. Our study involved 127 patients to assess EF estimation accuracy against expert readings and two-dimensional (2D) video-based DL models. A subset of 56 patients was utilized to evaluate image quality and 3D accuracy and another 50 to test usability by novice users and across various ultrasound machines. CardiacField generated a 3D heart from 2D echocardiograms with <2 min processing time. The LVEF predicted by our method had a mean absolute error (MAE) of 2.48 % , while the RVEF had an MAE of 2.65 % .

Conclusion

Employing a straightforward apical ring scan with a cost-effective 2DE probe, our method achieves a level of EF accuracy for assessing LV and RV function that is comparable to that of three-dimensional echocardiography probes.

Use of artificial intelligence to predict outcomes in mild aortic valve stenosis

Aims

Aortic stenosis (AS) is a common and progressive disease, which, if left untreated, results in increased morbidity and mortality. Monitoring and follow-up care can be challenging due to significant variability in disease progression. This study aimed to develop machine learning models to predict the risks of disease progression and mortality in patients with mild AS.

Methods and results

A comprehensive database including 9611 patients with serial transthoracic echocardiograms was collected from a single institution across three clinical sites. The data set included parameters from echocardiograms, electrocardiograms, laboratory values, and diagnosis codes. Data from a single clinical site were preserved as an independent test group. Machine learning models were trained to identify progression to severe stenosis and all-cause mortality and tested in their performance for endpoints at 2 and 5 years. In the independent test group, the AS progression model differentiated those with progression to severe AS within 2 and 5 years with an area under the curve (AUC) of 0.86 for both. The feature of greatest importance was aortic valve mean gradient, followed by other valve haemodynamic measurements including valve area and dimensionless index. The mortality model identified those with mortality within 2 and 5 years with an AUC of 0.84 and 0.87, respectively. Smaller reduced-input validation models had similarly robust findings.

Conclusion

Machine learning models can be used in patients with mild AS to identify those at high risk of disease progression and mortality. Implementation of such models may facilitate real-time, patient-specific follow-up recommendations.

Clot lysis time and thrombin generation in patients undergoing transcatheter aortic valve implantation

BACKGROUND

Aortic valve stenosis (AS) is the most prevalent valvular heart disease and is associated with a significant increase in mortality. AS has been shown to be linked with numerous coagulation system abnormalities, including increased fibrin deposition on the stenotic aortic valves. Transcatheter aortic valve implantation (TAVI) is the primary treatment method for patients at high surgical risk.

OBJECTIVES

The aim of the study was to assess the impact of treating severe AS with TAVI on thrombin generation and clot lysis time (CLT).

METHODS

We studied 135 symptomatic AS patients recommended for TAVI by the local Heart Team. All measurements were performed before and 5-7 days after TAVI. Alongside clinical assessment and echocardiographic analysis, we assessed clot lysis time (CLT) and thrombin generation parameters, including lag time, peak thrombin generation, time to peak thrombin generation (ttPeak), and endogenous thrombin potential (ETP).

RESULTS

70 patients were included in the final analysis. After TAVI, there was a significant 9% reduction in CLT despite a 12% increase in fibrinogen concentration. We observed significant increase in lag time and ttPeak (20% and 12%, respectively), and 13% decrease in peak thrombin concentration compared to pre-procedural levels. Multivariable linear regression analysis demonstrated that baseline CLT and C-reactive protein (CRP) levels were independent predictors of significant reduction in mean aortic gradient, defined as TAVI procedure success.

CONCLUSIONS

CLT and peak thrombin concentration decreased, while Lag time and ttPeak increased significantly after TAVI. Multivariable linear regression analysis demonstrated CLT and CRP levels as independent predictors of achieving a reduction in mean aortic gradient, defining TAVI procedure success.

Latest evidence on assessment and invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in the older population

INTRODUCTION

Invasive management of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) should be considered regardless of age, but a key challenge is deciding which patients are most likely to benefit from an invasive approach in the older population. In addition to assessment of the clinical signs and symptoms, a holistic assessment of geriatric syndromes such as frailty, multimorbidity and cognitive impairment is of increasing importance. Recent trials have validated the roles of physiological assessment and intracoronary imaging to guide revascularisation.

AREAS COVERED

This review focuses on the comparison between invasive and conservative management in the older population with NSTE-ACS, the clinical characteristics of the older population with NSTE-ACS, and the role of physiological assessment and intracoronary imaging to guide revascularisation in this cohort.

EXPERT OPINION

Invasive management in the older population with NSTE-ACS may not improve mortality but reduces the risk of non-fatal myocardial infarction and repeat revascularisation. Decisions surrounding invasive versus conservative management should be individualized to each patient, depending on patient preference, clinical features, comorbidities and frailty. In patients where invasive management is indicated, a combination of physiological assessment and intracoronary imaging is likely to improve revascularisation outcomes, especially in the context of complex anatomical characteristics like multivessel disease.

Impact of pulmonary hypertension on short-term outcomes in patients undergoing surgical aortic valve replacement for severe aortic valve stenosis

OBJECTIVES

In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center.

METHODS

In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data.

RESULTS

Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR.

CONCLUSION

In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.

Degenerative mitral stenosis by echocardiography: presentation and outcome

AIMS

Degenerative mitral stenosis (DMS) is due to degenerative mitral annular calcification (MAC) and valvular calcification. However, DMS impacts on the outcome, and therefore, potential treatment needs are poorly known. We aimed at evaluating survival after DMS diagnosis by Doppler echocardiography in routine practice.

METHODS AND RESULTS

A cohort of 2937 (75 ± 12 years, 67% women) consecutive patients were diagnosed between 2003 and 2014 with DMS (diastolic mean gradient ≥ 5 mmHg), with analysis of short- and long-term survival. All patients had overt mitral annular/valvular degenerative calcification without rheumatic involvement. Mean gradient was 6.5 ± 2.4 mmHg, and DMS was considered mild in 50%, moderate in 44%, and severe in 6%. DMS was associated with left atrial enlargement (52 ± 23 mL/m2) and elevated pulmonary pressure (49 ± 16 mmHg) despite generally normal ejection fraction (61 ± 13%). DMS was associated with frequent comorbid conditions (74% hypertension, 58% coronary disease, and 52% heart failure) and humoural alterations (haemoglobin 11.3 ± 1.8 g/dL and creatinine 1.5 ± 1.4 mg/dL). One-year mortality was 22%, most strongly related to older age, higher comorbidity, and abnormal haemoglobin/creatinine but only weakly to DMS severity (with anaemia 42% irrespective of DMS severity, P = 0.99; without anaemia 18, 23, and 28% with mild, moderate, and severe DMS, respectively, P < 0.0004). Long-term mortality was high (56% at 5 years) also mostly linked to aging and weakly to DMS severity [with anaemia P = 0.90; without anaemia: adjusted-hazard ratio: 1.30 (1.19-1.42), P < 0.0001, for moderate vs. mild DMS and 1.63 (1.34-1.98), P < 0.0001, for severe vs. mild DMS].

CONCLUSION

DMS is a condition of the elderly potentially resulting in severe mitral obstruction and haemodynamic alterations. However, DMS is frequently associated with severe comorbidities imparting considerable mortality following diagnosis, whereas DMS severity is a weak (albeit independent) determinant of mortality. Hence, patients with DMS should be carefully evaluated and interventional/surgical treatment prudently considered in those with limited comorbidity burden, particularly without anaemia. Keywords: Degenerative Mitral Stenosis; Outcome; Natural history; Ecocardiography; Mitral Stenosis.

A Machine Learning Model for the Prediction of No-Reflow Phenomenon in Acute Myocardial Infarction Using the CALLY Index

BACKGROUND

Acute myocardial infarction (AMI) constitutes a major health problem with high mortality rates worldwide. In patients with ST-segment elevation myocardial infarction (STEMI), no-reflow phenomenon is a condition that adversely affects response to therapy. Previous studies have demonstrated that the CALLY index, calculated using C-reactive protein (CRP), albumin, and lymphocytes, is a reliable indicator of mortality in patients with non-cardiac diseases. The objective of this study is to investigate the potential utility of the CALLY index in detecting no-reflow patients and to determine the predictability of this phenomenon using machine learning (ML) methods.

METHODS

This study included 1785 STEMI patients admitted to the clinic between January 2020 and June 2024 who underwent percutaneous coronary intervention (PCI). Patients were in no-reflow status, and other clinical data were analyzed. The CALLY index was calculated using data on patients' inflammatory status. The Extreme Gradient Boosting (XGBoost) ML algorithm was used for no-reflow prediction.

RESULTS

No-reflow was detected in a proportion of patients participating in this study. The model obtained with the XGBoost algorithm showed high accuracy rates in predicting no-reflow status. The role of the CALLY index in predicting no-reflow status was clearly demonstrated.

CONCLUSIONS

The CALLY index has emerged as a valuable tool for predicting no-reflow status in STEMI patients. This study demonstrates how machine learning methods can be effective in clinical applications and paves the way for innovative approaches for the management of no-reflow phenomenon. Future research needs to confirm and extend these findings with larger sample sizes.

The emerging challenge of Enterococcus faecalis endocarditis after transcatheter aortic valve implantation: time for innovative treatment approaches

SUMMARYInfective endocarditis (IE) is a life-threatening infection that has nearly doubled in prevalence over the last two decades due to the increase in implantable cardiac devices. Transcatheter aortic valve implantation (TAVI) is currently one of the most common cardiac procedures. TAVI usage continues to exponentially rise, inevitability increasing TAVI-IE. Patients with TAVI are frequently nonsurgical candidates, and TAVI-IE 1-year mortality rates can be as high as 74% without valve or bacterial biofilm removal. Enterococcus faecalis, a historically less common IE pathogen, is the primary cause of TAVI-IE. Treatment options are limited due to enterococcal intrinsic resistance and biofilm formation. Novel approaches are warranted to tackle current therapeutic gaps. We describe the existing challenges in treating TAVI-IE and how available treatment discovery approaches can be combined with an in silico "Living Heart" model to create solutions for the future.

Comprehensive Analysis of Cardiovascular Diseases: Symptoms, Diagnosis, and AI Innovations

Cardiovascular diseases are some of the underlying reasons contributing to the relentless rise in mortality rates across the globe. In this regard, there is a genuine need to integrate advanced technologies into the medical realm to detect such diseases accurately. Moreover, numerous academic studies have been published using AI-based methodologies because of their enhanced accuracy in detecting heart conditions. This research extensively delineates the different heart conditions, e.g., coronary artery disease, arrhythmia, atherosclerosis, mitral valve prolapse/mitral regurgitation, and myocardial infarction, and their underlying reasons and symptoms and subsequently introduces AI-based detection methodologies for precisely classifying such diseases. The review shows that the incorporation of artificial intelligence in detecting heart diseases exhibits enhanced accuracies along with a plethora of other benefits, like improved diagnostic accuracy, early detection and prevention, reduction in diagnostic errors, faster diagnosis, personalized treatment schedules, optimized monitoring and predictive analysis, improved efficiency, and scalability. Furthermore, the review also indicates the conspicuous disparities between the results generated by previous algorithms and the latest ones, paving the way for medical researchers to ascertain the accuracy of these results through comparative analysis with the practical conditions of patients. In conclusion, AI in heart disease detection holds paramount significance and transformative potential to greatly enhance patient outcomes, mitigate healthcare expenditure, and amplify the speed of diagnosis.

The Impact of the Coexistence of Frailty Syndrome and Cognitive Impairment on Early and Midterm Complications in Older Patients with Acute Coronary Syndromes

Background/Objectives: The ageing population has heightened interest in the prognostic role of geriatric conditions, notably frailty syndrome (FS) and cognitive impairment (CI). Evidence indicates a significant link between cardiovascular disease, FS, and CI. However, limited research has explored the impact of impaired functional and cognitive performance on outcomes in acute coronary syndrome (ACS) patients. This study aimed to evaluate the effect of coexisting FS and CI (FSxCI) on early and 6-month complications in older adults with ACS. Methods: This study included 196 ACS patients (119 men) aged 65 and over (mean = 74.7 years), with 90.8% undergoing invasive treatment (PCI in 81.6%, CABG in 9.2%). FS and CI were assessed on the third hospital day using the Tilburg Frailty Indicator (TFI) and Mini Mental State Examination (MMSE). Early (in-hospital) complications included major bleeding, ventricular arrhythmia (VT), conduction disturbances, cardiac arrest, stent thrombosis, acute heart failure (Killip-Kimball class III/IV), stroke, prolonged stay, and in-hospital death. Six-month follow-up recorded major adverse cardiovascular and cerebrovascular events (MACCEs). Results: Patients with FSxCI (n = 107, 54.6%) were older and had higher hypertension prevalence and lower nicotine dependence. FSxCI patients faced over twice the risk of prolonged hospital stays (OR 2.39; p = 0.01) and nearly three times the risk of early complications (OR 2.73; p < 0.001). At 6 months, FSxCI tripled the risk of MACCEs (OR 2.8; p = 0.007). Kaplan-Meier analysis confirmed a worse 6-month prognosis for FSxCI patients. Conclusions: Elderly patients with ACS and concomitant FSxCI had significantly higher rates of early (in-hospital) and 6-month complications. FSxCI was associated with a worse 6-month prognosis. This highlights its significance for clinical decision-making, as identifying FSxCI in ACS patients can help prioritize high-risk individuals for tailored interventions, optimize resource allocation, and improve outcomes.

Sex differences in long-term heart failure prognosis: a comprehensive meta-analysis

AIMS

Sex differences in the long-term prognosis of heart failure (HF) remain controversial, and there is a lack of comprehensive pooling of the sex differences in outcomes of HF. This study aims to characterize the sex differences in the long-term prognosis of HF and explore whether these differences vary by age, HF course, left ventricular ejection fraction, region, period of study, study design, and follow-up duration.

METHODS AND RESULTS

A systematic review was conducted using Medline, Embase, Web of Science, and the Cochrane Library, from 1 January 1990 to 31 March 2024. The primary outcome was all-cause mortality (ACM), and the secondary outcomes included cardiovascular mortality (CVM), hospitalization for HF (HHF), all-cause hospitalization, a composite of ACM and HHF, and a composite of CVM and HHF. Pooled hazard ratios (HRs) with corresponding 95% confidence intervals (CIs) were calculated using random-effects meta-analysis. Ninety-four studies (comprising 96 cohorts) were included in the meta-analysis, representing 706,247 participants (56.5% were men; the mean age was 71.0 years). Female HF patients had a lower risk of ACM (HR 0.83; 95% CI 0.80, 0.85; I2 = 84.9%), CVM (HR 0.84; 95% CI 0.79, 0.89; I2 = 70.7%), HHF (HR 0.94; 95% CI 0.89, 0.98; I2 = 84.0%), and composite endpoints (ACM + HHF: HR 0.89; 95% CI 0.83, 0.95; I2 = 80.0%; CVM + HHF: HR 0.85; 95% CI 0.77, 0.93; I2 = 87.9%) compared with males. Subgroup analysis revealed that the lower risk of mortality observed in women was more pronounced among individuals with long-course HF (i.e. chronic HF, follow-up duration > 2 years) or recruited in the randomized controlled trials (P for interaction < 0.05).

CONCLUSION

Female HF patients had a better prognosis compared with males, with lower risks of ACM, CVM, HHF, and composite endpoints. Despite the underrepresentation of female populations in HF clinical trials, their mortality benefits tended to be lower than in real-world settings.

REGISTRATION

PROSPERO: CRD42024526100.

Acute Ventricular Dysfunction After Doxorubicin-Based Induction Therapy for Pediatric Acute Lymphoblastic Leukemia

Background Doxorubicin is an important drug used in the treatment of children with acute leukemia, and cardiotoxicity is the most serious complication due to its use. The cardiac dysfunction due to doxorubicin can be acute, early, or late. Echocardiography is a non-invasive tool and can be employed to detect clinical and subclinical cardiac dysfunction and plan treatment strategies accordingly. Materials and methods Twenty-eight children with acute lymphoblastic leukemia were enrolled. Echocardiography was done at baseline and 72 h after induction dose of doxorubicin. Conventional and tissue Doppler imaging parameters were obtained and compared. Results After the induction dose of doxorubicin, both ventricles developed systolic and diastolic dysfunction. Tricuspid annular plane systolic excursion significantly decreased after doxorubicin (20.0±4.95 mm vs. 19.40±4.90 mm). Right ventricular myocardial performance index and isovolumetric relaxation times increased after doxorubicin (0.38±0.08 vs. 0.41±0.08 and 41.4±1.8 ms vs. 43.1±12.6 ms, p<0.05, respectively). Tricuspid E velocity decreased (62.3±8.35 cm/s vs. 60.1±7.34 cm/s, p<0.01) as well as tricuspid E/A ratio after doxorubicin (1.54±0.26 vs. 1.40±0.23, p<0.01). The left ventricular fractional shortening and ejection fraction decreased after doxorubicin (32.1±2.26% vs. 31.4±2.27% and 64.60±4.69% vs. 63.10±4.63%, respectively). Left ventricular myocardial performance index and isovolumetric relaxation times were increased after doxorubicin (0.44±0.05 vs. 0.46±0.06 and 58.6±8.75 ms vs. 60.3±10.1 ms, respectively). Mitral E velocity is reduced (85.6±11.3 cm/s vs. 83±11.9 cm/s) and tricuspid E/A ratio is also reduced after doxorubicin (1.78±0.43 vs. 1.63±0.39). Conclusion Both systolic and diastolic dysfunctions are seen after doxorubicin. Echocardiography should be employed for early diagnosis of clinical and subclinical cardiac dysfunction and timely initiation of management to prevent progression.

Sex differences in the impact of frailty on patients with heart failure: A retrospective cohort study

AIMS

Limited literature shows the existence of sex differences in the long-term prognosis of heart failure (HF) patients with frailty. In this study, whether sex differences exist in the impact of frailty on death from cardiovascular causes in patients with HF was investigated by conducting a retrospective cohort study.

METHODS AND RESULTS

Data from the National Health and Nutrition Examination Survey (NHANES) study (2009-2018) were used to conduct a retrospective cohort study of 958 participants with HF. Patients were grouped based on sex and frailty index (FI). The relationship between death from cardiovascular causes and baseline frailty was assessed by Cox proportional hazard analysis and the Kaplan-Meier (K-M) plot. The study population had an age of 67.3 ± 12.3. Among them, around 54.5% were male. A median follow-up of 3.6 years was performed. After that, females who died from cardiovascular causes exhibited higher baseline FI values, while males did not show this trend (P < 0.05; P = 0.1253). Cox regression analysis demonstrated a significant association between FI and cardiovascular mortality in females (most frail: hazard ratio (HR) = 3.65, 95% confidence interval (CI): 1.07 ~ 12.39, P < 0.05; per 1-unit increase in FI: HR = 1.78, 95% CI: 1.33 ~ 2.39, P < 0.001). A dose-response association between FI and cardiovascular mortality was presented by restricted cubic splines.

CONCLUSIONS

Frailty is related to an increased risk of cardiovascular mortality in HF patients, particularly female patients.

Impact and limitations of 3D computational modelling in transcatheter mitral valve replacement-a two-centre Dutch experience

BACKGROUND

Transcatheter mitral valve replacement (TMVR) has emerged as a minimally invasive alternative to mitral valve surgery for patients at high or prohibitive operative risk. Prospective studies reported favourable outcomes in patients with annulus calcification (valve-in-mitral annulus calcification; ViMAC), failed annuloplasty ring (mitral valve-in-ring; MViR), and bioprosthetic mitral valve dysfunction (mitral valve-in-valve; MViV). Multi-slice computed tomography (MSCT)-derived 3D-modelling and simulations may provide complementary anatomical perspectives for TMVR planning.

AIMS

We aimed to illustrate the implementation of MSCT-derived modelling and simulations in the workup of TMVR for ViMAC, MViR, and MViV.

METHODS

For this retrospective study, we included all consecutive patients screened for TMVR and compared MSCT data, echocardiographic outcomes and clinical outcomes.

RESULTS

Sixteen out of 41 patients were treated with TMVR (ViMAC n = 9, MViR n = 3, MViV n = 4). Eleven patients were excluded for inappropriate sizing, 4 for anchoring issues and 10 for an unacceptable risk of left ventricular outflow tract obstruction (LVOTO) based on 3D modelling. There were 3 procedure-related deaths and 1 non-procedure-related cardiovascular death during 30 days of follow-up. LVOTO occurred in 3 ViMAC patients and 1 MViR patient, due to deeper valve implantation than planned in 3 patients, and anterior mitral leaflet displacement with recurrent basal septum thickening in 1 patient. TMVR significantly reduced mitral mean gradients as compared with baseline measurements (median mean gradient 9.5 (9.0-11.5) mm Hg before TMVR versus 5.0 (4.5-6.0) mm Hg after TMVR, p = 0.03). There was no residual mitral regurgitation at 30 days.

CONCLUSION

MSCT-derived 3D modelling and simulation provide valuable anatomical insights for TMVR with transcatheter balloon expandable valves in ViMAC, MViR and MViV. Further planning iterations should target the persistent risk for neo-LVOTO.

Exploring the Prognostic Role of Red Blood Cell Distribution Width in Aortic Valve Calcification Evaluations via Multi-Slice Computed Tomography

Background

Previous reports have indicated an association between red blood cell distribution width (RDW) and cardiovascular disease. However, few relevant studies exist on the relationship between RDW and aortic valve calcification (AVC). Explore the correlation and predictive value of RDW concerning the occurrence and severity of aortic valve calcification.

Methods

Blood examination results were analyzed from 1720 hospitalized patients at the Second Affiliated Hospital of Soochow University. Logistic regression analysis and the Cox proportional hazards model examined the relationship between RDW and the incidence and severity of AVC.

Results

The RDW value in cases with AVC was significantly higher than in the control group. Red cell distribution width-standard deviation (RDW-SD) and red cell distribution width-coefficient of variation (RDW-CV) increased with calcification severity. Both RDW-SD and RDW-CV demonstrated high predictive values for the occurrence of aortic valve calcification.

Conclusions

Red blood cell distribution width significantly correlated with the occurrence and severity of aortic valve calcification.

SimLVSeg: Simplifying Left Ventricular Segmentation in 2-D+Time Echocardiograms With Self- and Weakly Supervised Learning

OBJECTIVE

Achieving reliable automatic left ventricle (LV) segmentation from echocardiograms is challenging due to the inherent sparsity of annotations in the dataset, as clinicians typically only annotate two specific frames for diagnostic purposes. Here we aim to address this challenge by introducing simplified LV segmentation (SimLVSeg), a novel paradigm that enables video-based networks for consistent LV segmentation from sparsely annotated echocardiogram videos.

METHODS

SimLVSeg consists of two training stages: (i) self-supervised pre-training with temporal masking, which involves pre-training a video segmentation network by capturing the cyclic patterns of echocardiograms from largely unannotated echocardiogram frames, and (ii) weakly supervised learning tailored for LV segmentation from sparse annotations.

RESULTS

We extensively evaluated SimLVSeg using EchoNet-Dynamic, the largest echocardiography dataset. SimLVSeg outperformed state-of-the-art solutions by achieving a 93.32% (95% confidence interval: 93.21-93.43%) dice score while being more efficient. We further conducted an out-of-distribution test to showcase SimLVSeg's generalizability on distribution shifts (CAM US dataset).

CONCLUSION

Our findings show that SimLVSeg exhibits excellent performance on LV segmentation with a relatively cheaper computational cost. This suggests that adopting video-based networks for LV segmentation is a promising research direction to achieve reliable LV segmentation. Our code is publicly available at https://github.com/BioMedIA-MBZUAI/SimLVSeg.

Mechanical circulatory support for high-risk surgical aortic valve and ascending aortic replacement in severe bicuspid aortic valve stenosis: a case series

Background

Bicuspid aortic valve (BAV) is the most common congenital heart defect (reported incidence of 0.5%-2%) and is commonly associated with proximal aortic dilation. Patients with severe aortic stenosis (AS) of BAV have been shown to have worse pre-operative left ventricular (LV) function as well as a higher incidence of post-operative heart failure hospitalization when compared with analogous patients with tri-leaflet aortic valve disease. While surgical aortic valve replacement (SAVR) may be favoured over transcatheter aortic valve implantation (TAVI) due to anatomical factors or concomitant aortopathy and coronary artery disease, surgical candidacy is often limited by prohibitive operative risk.

Case summary

We report on three cases of severe AS in BAV with concomitant aortopathy and severe left ventricular dysfunction in whom we proceeded with SAVR with a priori planned venoarterial extracorporeal membrane oxygenation (VA-ECMO) support and inotrope-assisted wean. All patients had severe LV dysfunction (ejection fraction < 25%) at baseline with gradual substantial improvement or normalization after successful SAVR.

Discussion

These cases demonstrate the utility of planned VA-ECMO with SAVR and aortic root replacement as an integral component of the operative strategy for high surgical risk patients with severe BAV AS not amenable to TAVI. Appropriate pre-operative planning and consent for VA-ECMO as well as a multi-disciplinary approach involving anaesthesia, intensive care, and heart failure cardiology are the key to offering this option as an alternative to palliative medical therapy to a selected group of patients.

Migration Spurs Changes in the Human Microbiome: a Review

International migration often results in major changes in living environments and lifestyles, and these changes may lead to the observed increases in obesity and diabetes among foreign-born people after resettling in higher-income countries. A possible mechanism linking changes in living environments to the onset of health conditions may be changes in the microbiome. Previous research has shown that unfavorable changes in the composition of the microbiome can increase disposition to diseases such as diabetes, obesity, kidney disease, and inflammatory bowel disease. We investigated the relationship between human migration and microbiome composition through a review using microbiome- and migration-related search terms in PubMed and Web of Science. We included articles examining the gut, oral, or oropharyngeal microbiome in people who migrated internationally. Nine articles met eligibility criteria. All but one examined migration from a non-Western to a Western country. Four of these found a difference in the microbiome of migrants compared with non-migrating residents of their country of birth, seven found differences in the microbiome of migrants compared with the native-born population in the country of resettlement, and five found microbiome differences associated with duration of stay in the country of resettlement. Microbiome composition varies with country of birth, age at migration, time since immigration, and country of resettlement. The results suggest that migration may lead to changes in the microbiome; thus, microbiome characteristics are a plausible pathway to examine changes in health after resettlement in a new country.

Time to Treatment Delay and Clinical Indicators in Patients with ST-Segment Elevation Myocardial Infarction: A Descriptive Cross-sectional Study

Introduction

ST-segment elevation myocardial infarction (STEMI) continues to be a significant global health issue, necessitating ongoing monitoring of care processes to enhance quality. This study aimed to examine time to treatment delay and clinical indicators in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI).

Methods

This descriptive cross-sectional study was conducted with the recruitment of 313 patients with STEMI treated with PPCI Tabriz (Iran) in 2023. Data were analyzed using descriptive statistics, the Mann-Whitney U test, the Kruskal-Wallis test, the chi-square test, and regression analysis in SPSS v.13 software.

Results

Most of the patients were men and half of them were 60 years old or younger. The median door-to-balloon time [IQR] was 80 [49-140] minutes. The pre-PCI center delay time and treatment delay time were 191 and 310 minutes, respectively. There was a statistically significant association between the patient's place of residence, the admission type in the PCI center, and the pre-PCI center delay time. In addition, there was a statistically significant association between treatment delay time, left ventricular ejection fraction (LVEF), baseline troponin I level, angioplasty outcome, and receiving acute coronary syndrome (ACS) drugs at the pre-PCI center.

Conclusion

The longer pre-PCI center delay time resulted in a longer total treatment delay. To reduce delays, it is proposed to improve the logistics surrounding these procedures for patients with STEMI and to provide appropriate education about the STEMI management program to all stockholders.

Sex-Related Differences in Heart Failure Development in Patients After First Myocardial Infarction: The Role of Galectin-3

Backgrounds: Galectin-3 (gal-3) is upregulated in remodeling, and failing myocardium and gal-3 levels are increased in hypertrophy, fibrosis and inflammation. The aim of this study was to investigate the potential role of sex-related differences in the following: risk factors, left ventricular (LV) structural and functional changes, coronary angiography, expression of the gal-3 encoding gene LGALS-3 and plasma gal-3 levels in heart failure (HF). Materials and Methods: This prospective study included 137 men and 44 women with first MI who underwent Doppler echocardiography within 2-4 days of MI and after 6 months. Relative LGALS-3 mRNA expression in peripheral blood mononuclear cells (PBMCs) was detected using TaqMan® technology. Plasma gal-3 concentration was determined by ELISA method. Results: In the acute phase of MI, LV end-diastolic and end-systolic volume indexes (LVEDVI and LVESVI) were significantly lower in women compared to men (58.2 ± 13.1 vs. 46.3 ± 11.1, p < 0.001; 33.7 ± 9.5 vs. 27.0 ± 9.2, p < 0.001, respectively). The incidence of LV hypertrophy (LVH) and HF was significantly higher in women compared to men (70.0% vs. 44.6%, p = 0.03; 37.5% vs.19.5%, p = 0.02, respectively). There was a significant correlation between the grade of LV diastolic dysfunction (LVDD) and plasma gal-3 levels (p < 0.001). The relative expression of LGALS-3 mRNA in PBMCs was higher in females (fold induction = 1.326, S.E. range = 0.748-2.587, p = 0.007). Plasma gal-3 levels were higher in women compared to men (44.66 ± 28.04 vs. 16.30 ± 12.68, p < 0.001) and higher in patients with HF than in patients without HF (31.14 ± 27.09 vs.21.39 ± 18.17, p = 0.025). Conclusions: Gender-specific factors such as LVH, LVDD, LGALS-3 mRNA expression and plasma gal-3 levels may explain the increased incidence of HF in women. The differences in the model and determinants of HF between men and women may be relevant for further therapeutic strategies including the inhibition of gal-3.

Successful Management of Intraoperative Cardiac Arrest in a Patient With Undiagnosed Hypertrophic Cardiomyopathy

Intraoperative cardiac arrest presents a significant challenge in surgical settings, particularly in patients with undiagnosed cardiac conditions. This report details the case of a 62-year-old male patient who experienced cardiac arrest during elective laparoscopic cholecystectomy, attributed to previously undiagnosed hypertrophic cardiomyopathy (HCM). The patient exhibited no prior cardiac symptoms and was assessed as low risk preoperatively. Following prompt cardiopulmonary resuscitation (CPR) and defibrillation, return of spontaneous circulation (ROSC) was achieved after approximately 10 minutes. Post-resuscitation, echocardiography confirmed significant left ventricular hypertrophy, leading to a new diagnosis of HCM. This case emphasizes the necessity of thorough cardiovascular evaluation in high-risk surgical patients and outlines effective management strategies for intraoperative emergencies.

Medical Therapy to Prevent or Slow Progression of Aortic Stenosis: Current Evidence and Future Directions

Degenerative aortic stenosis is a growing clinical problem owing to the high incidence in an aging population and its significant morbidity and mortality. Currently, aortic valve replacement remains the only treatment. Despite promising observational data, pharmacological management to slow or halt progression of aortic stenosis has remained elusive. Nevertheless, with a greater understanding of the mechanisms which underpin aortic stenosis, research has begun to explore novel treatment strategies. This review will explore the historical agents used to manage aortic stenosis and the emerging agents that are currently under investigation.

Heterogeneous treatment effects of coronary artery bypass grafting in ischemic cardiomyopathy: A machine learning causal forest analysis

OBJECTIVES

We aim to evaluate the heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy and to identify a group of patients to have greater benefits from coronary artery bypass grafting compared with medical therapy alone.

METHODS

Machine learning causal forest modeling was performed to identify the heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy from the Surgical Treatment for Ischemic Heart Failure trial. The risks of death from any cause and death from cardiovascular causes between coronary artery bypass grafting and medical therapy alone were assessed in the identified subgroups.

RESULTS

Among 1212 patients enrolled in the Surgical Treatment for Ischemic Heart Failure trial, left ventricular end-systolic volume index, serum creatinine, and age were identified by the machine learning algorithm to distinguish patients with heterogeneous treatment effects. Among patients with left ventricular end-systolic volume index greater than 84 mL/m2 and age 60.27 years or less, coronary artery bypass grafting was associated with a significantly lower risk of death from any cause (adjusted hazard ratio, 0.61; 95% CI, 0.45-0.84) and death from cardiovascular causes (adjusted hazard ratio, 0.63; 95% CI, 0.45-0.89). By contrast, the survival benefits of coronary artery bypass grafting no longer exist in patients with left ventricular end-systolic volume index 84 mL/m2 or less and serum creatinine 1.04 mg/dL or less, or patients with left ventricular end-systolic volume index greater than 84 mL/m2 and age more than 60.27 years.

CONCLUSIONS

The current post hoc analysis of the Surgical Treatment for Ischemic Heart Failure trial identified heterogeneous treatment effects of coronary artery bypass grafting in patients with ischemic cardiomyopathy. Younger patients with severe left ventricular enlargement were more likely to derive greater survival benefits from coronary artery bypass grafting.

Obstetric anesthesia considerations in pregnancy-associated myocardial infarction: a focused review

Pregnancy-associated myocardial infarction (PAMI) is a rare but serious complication that can occur either during pregnancy or postpartum. The etiologies of PAMI are atherosclerosis, spontaneous coronary artery dissection, coronary thrombosis, coronary embolism, and coronary vasospasm. Therapy of acute PAMI depends largely on the ECG presentation, hemodynamic stability, and suspected etiology of myocardial infarction. Anesthetic management during delivery in patients with PAMI should consist of early and carefully titrated neuraxial analgesia and anesthesia, maintenance of normal sinus rhythm, preservation of afterload, and monitoring for and avoiding myocardial ischemia. To improve the care of women with PAMI, a multidisciplinary team of cardiologists, maternal fetal medicine specialists, obstetric providers, neonatologists, and anesthesiologists must work collectively to manage these complex patients.

The Cost of Waiting for a Transcatheter Aortic Valve Replacement in Medicare Beneficiaries With Severe Aortic Stenosis

Background

Aortic stenosis (AS) is a prevalent valvular disorder necessitating timely intervention, particularly when symptomatic. Aortic valve replacement (AVR) is the recommended treatment, but delays in access to AVR are common and linked to adverse outcomes and increased health care costs. This study aims to assess the health care cost burden associated with delaying transcatheter AVR (TAVR) in Medicare Advantage beneficiaries with clinically significant AS.

Methods and Results

This retrospective database study utilized the Optum de-identified U.S. claims database, encompassing Medicare Advantage enrollees. Patients aged 65 years or older were identified as having AS based on medical billing codes and were required to have a record of syncope, dyspnea, fatigue, chest pain/angina, or heart failure prior to, on or within 30 days of their incident AS diagnosis. Total health care costs were analyzed over a 2-year period, regressed against the delay in receiving TAVR, and adjusted for covariates. In the 4105 patients meeting study inclusion criteria, delays in TAVR were associated with a significant increase in health care costs, translating to those waiting 12 months for TAVR incurring an additional cost of $10,080 compared to those receiving TAVR promptly. Non-TAVR related costs largely drove this increase.

Conclusions

Delaying TAVR in clinically significant AS patients is associated with higher health care costs, emphasizing the need for timely interventions. Addressing delays in TAVR access and optimizing pre-TAVR workup can potentially improve patient outcomes and reduce health care expenditure.

Contemporary review of the evolution of various treatment modalities for mitral regurgitation

INTRODUCTION

Mitral regurgitation is one of the most common forms of valvular heart diseases for which there have been several innovative treatment strategies that have developed over the last several decades. We describe the various treatment modalities that have been used for the last several decades. All articles in PubMed, Cochrane, and Embase were screened from inception to August 2024 for the following - 'Mitral valve regurgitation' 'Mitral valve repair' 'Mitral valve replacement' 'Robotic mitral surgery' 'Transcatheter mitral valve repair.'

AREAS COVERED

Mitral regurgitation (MR) is classified into primary and secondary MR. Causes of primary MR include degenerative disease, rheumatic heart disease, and infective endocarditis. Secondary MR is observed in the setting of left ventricle (LV) pathology, including ischemic or dilated cardiomyopathy. In secondary MR, annular dilation, papillary muscle displacement, tethering of chordae tendineae and/or mitral valve (MV) leaflets result in leaflet restriction and malcoaptation.

EXPERT OPINION

In this review, we discuss various modalities for the treatment of mitral regurgitation, as well as newer treatment options for MR including robotic MV repair and other minimally invasive procedures. Several ongoing randomized controlled trials in this topic will help shed more light and provide guidance to deliver the optimal care for our patients.

Evaluating cardiac electrophysiological markers for predicting arrhythmic risk in hypothyroid patients

OBJECTIVES

This study aimed to evaluate the impact of hypothyroidism and levothyroxine (LT4) treatment on arrhythmic risk by concurrently analyzing multiple electrocardiogram (ECG) parameters such as the Index of Cardio-Electrophysiological Balance (iCEB), frontal QRS-T angle, Tpeak-Tend (Tp-e) interval/QT interval ratio, and QT dispersion (QTd).

METHODS

This cross-sectional study included 132 adult patients with primary hypothyroidism who had been receiving LT4 treatment, and 132 demographically matched healthy controls. The hypothyroid group was also stratified by thyroid-stimulating hormone (TSH) levels (subclinical <4.5 and overt ≥ 4.5). Participants underwent a series of thyroid function and ECG measurements.

RESULTS

The hypothyroid and healthy control groups were matched for age and gender (p = 0.080; p = 0.176). Participants with hypothyroidism had higher Tp-e/QT ratios, iCEB, median frontal QRS-T angle, and corrected QT dispersion (cQTd) than healthy controls (p = 0.004; p = 0.025; p = 0.004; p = 0.004, respectively). In the overt group, the Tp-e/QT ratio, iCEB, and median frontal QRS-T angles were all higher (p = 0.012, p = 0.037, and p = 0.016, respectively). Logistic regression analysis indicated that a higher iCEB score (β = 0.60, p = 0.003) was significant for the detection of arrhythmia risk. ROC analysis showed that iCEB had the highest sensitivity (0.80), moderate specificity (0.60), and AUC 0.70.

CONCLUSION

Patients with hypothyroidism have a higher risk of arrhythmia. To assess this risk, it is important to analyze the Tp-e interval, iCEB, frontal QRS-T angle, and QTd. Differentiating between patients with subclinical and overt hypothyroidism can help minimize the risk of arrhythmia. iCEB is the most effective method for identifying arrhythmic risk. Using all these parameters can improve the accuracy of arrhythmic risk detection in patients with hypothyroidism.

Clinical profile and outcomes in patients with moderate to severe aortic stenosis with or without concomitant chronic kidney disease

INTRODUCTION

Management of aortic stenosis (AS) in patients with chronic kidney disease (CKD) may often be overlooked, and this could confer poorer outcomes.

METHODS

Consecutive patients ( n = 727) with index echocardiographic diagnosis of moderate to severe AS (aortic valve area <1.5 cm 2 ) were examined. They were divided into those with CKD (estimated glomerular filtration rate < 60 mL/min) and those without. Baseline clinical and echocardiographic parameters were compared, and a multivariate Cox regression model was constructed. Clinical outcomes were compared using Kaplan-Meier curves.

RESULTS

There were 270 (37.1%) patients with concomitant CKD. The CKD group was older (78.0 ± 10.3 vs. 72.1 ± 12.9 years, P < 0.001), with a higher prevalence of hypertension, diabetes mellitus, hyperlipidaemia and ischaemic heart disease. AS severity did not differ significantly, but left ventricular (LV) mass index (119.4 ± 43.7 vs. 112.3 ± 40.6 g/m 2 , P = 0.027) and Doppler mitral inflow E to annular tissue Doppler e' ratio (E: e' 21.5 ± 14.6 vs. 17.8 ± 12.2, P = 0.001) were higher in the CKD group. There was higher mortality (log-rank 51.5, P < 0.001) and more frequent admissions for cardiac failure (log-rank 25.9, P < 0.001) in the CKD group, with a lower incidence of aortic valve replacement (log-rank 7.12, P = 0.008). On multivariate analyses, after adjusting for aortic valve area, age, left ventricular ejection fraction and clinical comorbidities, CKD remained independently associated with mortality (hazard ratio 1.96, 95% confidence interval 1.50-2.57, P < 0.001).

CONCLUSION

Concomitant CKD in patients with moderate to severe AS was associated with increased mortality, more frequent admissions for cardiac failure and a lower incidence of aortic valve replacement.

A Robust and Data-Efficient Deep Learning Modelfor Cardiac Assessment without Segmentation

Video-based deep learning (DL) algorithms often rely on segmentation models to detect clinically important features in transthoracic echocardiograms (TTEs). While effective, these algorithms can be too data hungry for practice and may be sensitive to common data quality issues. To overcome these concerns, we present a data-efficient DL algorithm, Scaled Gumbel Softmax (SGS) EchoNet, that is robust to these common data quality issues and, importantly, requires no ventricular segmentation model. In lieu of a segmentation model, we decompose and transform the output of an R(2+1)D convolutional encoder to estimate frame-level weights associated with the cardiac cycle, that are then used to obtain a video representation that can be used for estimation. We find that our transformation obviates the need for a segmentation model while improving the ability of the predictive model to handle noisy inputs. We show that our model achieves comparable performance to the state of the art, while demonstrating robustness to noise on an independent (external) validation set.

The role of Cardiotrophin-1 and echocardiography in early detection of subclinical diabetic cardiomyopathy in children and adolescents with type 1 diabetes mellitus

OBJECTIVES

To assess the role of Cardiotrophin-1 (CT-1) and echocardiography in early detection of subclinical Diabetic Cardiomyopathy (DCM) in children with type 1 Diabetes Mellitus (T1D).

METHODS

This case-control study included two groups of children and adolescents aged between 7 and 18. Group (1) included forty patients with T1D (duration > 5 years) regularly followed at the children's hospital of Cairo University, and Group (2) included forty age and sex-matched healthy subjects as a control group. The serum level of CT-1 was measured, and conventional echocardiography, tissue Doppler imaging (TDI), and 2D speckle tracking echocardiography were performed.

RESULTS

The level of CT-1 in the cases ranged from 11 to 1039.4 pg/ml with a median (IQR) of 19.4 (16.60-25.7) pg/ml, while its level in the control group ranged from 10.8 to 162.6 pg/ml with a median (IQR) of 20.2 (16.2-24.8) pg/ml. CT-1 levels showed no statistically significant difference between cases and controls. Patients had significantly higher mean left ventricle E/E' ratio (p<0.001), lower mean 2D global longitudinal strain (GLS) of the left ventricle (LV) (p<0.001), and lower mean GLS of the right ventricle (RV) (p<0.001) compared to controls. Ofpatients with diabetes, 75 % had LV diastolic dysfunction, 85 % had RV diastolic dysfunction, 97.5 % had LV systolic dysfunction, and 100 % had RV systolic dysfunction.

CONCLUSIONS

Non-conventional echocardiography is important for early perception of subclinical DCM in patients with T1D. CT-1 was not specific for early detection of DCM.

Sex-Related Differences in the Pathophysiology, Cardiac Imaging, and Clinical Outcomes of Aortic Stenosis: A Narrative Review

Aortic stenosis (AS) is the most common valvular heart disease in developed countries, and its prevalence is higher in older patients. Clinical studies have shown gender disparity in the pathogenesis and the progression of aortic stenosis. This disparity has led to several overwhelming questions regarding its impact on the clinical outcomes and treatment of the disease and the requirement of personalized sex-specific approaches for its management. Indeed, aortic stenosis differs in the pathophysiological response to pressure overload created by the stenosis in women compared to men, which would translate into differences in cardiac remodeling and clinical outcomes. Several studies have focused on understanding the differences regarding disease progression according to biological gender and have found that sex hormones play a crucial role. Sex hormones affect many metabolic processes, thus activating crucial cell signaling and energy metabolism through mitochondrial activity. Yet, there is still a significant gap in knowledge on how biological sex influences the pathophysiology of AS. In this review, we have discussed studies that point to the role of sex-related physiological differences in the molecular pathways and the clinical presentation of the disease and outcome in women and men. We used the format of narrative review to review and summarize the body of literature without being systematic but with taking great care of considering the most impactful data available to date on the topic, especially randomized trials, metanalyses, and prospective studies and registries when available, as well as experimental studies with rigorous methodological approaches regarding the basic mechanisms and pathophysiology of the disease in women compared to men. The opinion of the authors on a particular issue or finding was expressed when appropriate for clarification.

Meta-analysis of improved mitral regurgitation after aortic valve replacement

BACKGROUND

This meta-analysis aimed to compare survival outcomes among patients experiencing improvement in untreated significant mitral regurgitation (MR) following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) for severe aortic stenosis, in contrast to those without improvement.

METHODS

We conducted a comprehensive search through February 2024. Pooled hazard ratios (HR) with 95% confidence intervals (CI) were computed. Kaplan-Meier curves depicting all-cause mortality were reconstructed using individual patient data derived from the included studies.

RESULTS

A systematic review identified twelve non-randomized studies encompassing 4040 patients. The pooled all-cause mortality of the meta-analysis demonstrated a significant reduction in patients whose MR improved compared to those with persistent MR after aortic valve replacement (AVR) (HR [95% CI] = 0.55 [0.47-0.64], p < .01). The hazard ratio, derived from reconstructed time-to-event data, indicated lower all-cause mortality in patients with improved MR after AVR relative to the other cohort (HR [95% CI] = 0.50 [0.40-0.62], p < .01 in all patients, 0.48 [0.34-0.68], p < .01 in patients undergoing SAVR, and 0.58 [0.42-0.80], p < .01 in those receiving TAVR).

CONCLUSION

In conclusion, this meta-analysis revealed that improved MR after AVR, whether surgically or by transcatheter approach, correlates with superior survival. The benefits of simultaneous or staged intervention on the mitral valve in individuals undergoing AVR warrant validation in future investigations.

Nanomedicine marvels: crafting the future of cancer therapy with innovative statin nano-formulation strategies

Statins, traditionally used for managing hyperlipidemia and cardiovascular diseases, have garnered significant interest for their potential anti-cancer properties. Research indicates that statins can inhibit critical processes in cancer development, such as apoptosis, angiogenesis, and metastasis. Despite their promising anti-cancer effects, the clinical application of statins in oncology has been hampered by their inherent low solubility and bioavailability. These pharmacokinetic challenges can be effectively addressed through the use of nano-based drug delivery systems. Nano-formulations enhance the delivery and therapeutic efficacy of statins by improving their solubility, stability, and targeting ability, thus maximizing their concentration within the tumor microenvironment and minimizing systemic side effects. This review delves into the potential of nanoparticles as carriers for statins in cancer therapy. It explores the mechanisms by which statins exert their anti-cancer effects, such as through the inhibition of the mevalonate pathway, modulation of immune responses, and induction of apoptosis. Furthermore, the review examines the development of various statin-loaded nano-formulations, highlighting their advantages over conventional formulations. The novelty of this review lies in its focus on recent advancements in nanoformulations that enhance statin delivery to the tumor microenvironment. By discussing the current advancements and prospects of statin nano-formulations, this review aims to provide a comprehensive understanding of how these innovative strategies can improve cancer treatment outcomes and enhance the quality of life for patients. The integration of nanotechnology with statin therapy offers a novel approach to overcoming existing therapeutic limitations and paving the way for more effective and safer cancer treatments.

Segmentation-Free Estimation of Left Ventricular Ejection Fraction Using 3D CNN Is Reliable and Improves as Multiple Cardiac MRI Cine Orientations Are Combined

OBJECTIVES

We aimed to study classical, publicly available convolutional neural networks (3D-CNNs) using a combination of several cine-MR orientation planes for the estimation of left ventricular ejection fraction (LVEF) without contour tracing.

METHODS

Cine-MR examinations carried out on 1082 patients from our institution were analysed by comparing the LVEF provided by the CVI42 software (V5.9.3) with the estimation resulting from different 3D-CNN models and various combinations of long- and short-axis orientation planes.

RESULTS

The 3D-Resnet18 architecture appeared to be the most favourable, and the results gradually and significantly improved as several long-axis and short-axis planes were combined. Simply pasting multiple orientation views into composite frames increased performance. Optimal results were obtained by pasting two long-axis views and six short-axis views. The best configuration provided an R2 = 0.83, a mean absolute error (MAE) = 4.97, and a root mean square error (RMSE) = 6.29; the area under the ROC curve (AUC) for the classification of LVEF < 40% was 0.99, and for the classification of LVEF > 60%, the AUC was 0.97. Internal validation performed on 149 additional patients after model training provided very similar results (MAE 4.98). External validation carried out on 62 patients from another institution showed an MAE of 6.59. Our results in this area are among the most promising obtained to date using CNNs with cardiac magnetic resonance.

CONCLUSION

(1) The use of traditional 3D-CNNs and a combination of multiple orientation planes is capable of estimating LVEF from cine-MRI data without segmenting ventricular contours, with a reliability similar to that of traditional methods. (2) Performance significantly improves as the number of orientation planes increases, providing a more complete view of the left ventricle.

The contemporary management and coronary angioplasty outcomes in young patients with ST-Elevation myocardial infarction (STEMI) age < 40 years old: the insight from nationwide Thai PCI registry

BACKGROUND

Cardiovascular disease (CVD) remains one of the major causes of death around the world in which ST elevation MI (STEMI) is in the lead. Although the mortality rate from STEMI seems to decline, this result might not be demonstrated in young adults who basically have different baseline characteristics and outcomes compared with older patients.

METHODS

Data of the STEMI patients aged 18 years or older who underwent PCI during May 2018 to August 2019 from Thai PCI Registry, a prospective, multi-center, nationwide study, was included and aimed to investigate the predisposing factors and short-term outcomes of patients aged < 40 years compared with age 41-60, and > 61 years.

RESULTS

Data of 5,479 STEMI patients were collected. The patients' mean age was 62.6 (SD = 12.6) years, and 73.6% were males. There were 204, 2,154, and 3,121 patients in the youngest, middle, and oldest groups. The young patients were mainly male gender (89.2% vs. 82.4% and 66.6%; p < 0.001), were current smokers (70.6%, 57.7%, 34.1%; p < 0.001), had BMI ≥ 25 kg/m2 more frequently (60.8%, 44.1%, 26.1%; p < 0.001), and had greater family history of premature CAD (6.9%, 7.2%, 2.9%; p < 0.001). The diseased vessel in the young STEMI patients was more often single vessel disease with the highest percentage of proximal LAD stenosis involvement. Interestingly, there were trends of higher events of procedural failure (2.9%, 2.1%, 3.3%; p = 0.028) and procedural complications (8.8%, 5.8%, 9.4%; p < 0.001) in both youngest and oldest groups compared to the middle-aged group. In-hospital death was found in 3.4% in the youngest group compared to 3.3% in the middle-aged patients and 9.2% in the older patients (p < 0.001).

CONCLUSIONS

Despite experiencing higher rates of procedural failure and complications during treatment compared to middle-aged and older patients, young STEMI individuals demonstrate a significantly lower risk of death during hospitalization and within one year of the event. Younger patients might have a more robust physiological reserve or benefit from more aggressive post-procedure management. However, the higher prevalence of modifiable risk factors like smoking and obesity in younger individuals underscores the need for preventative measures. Encouraging smoking cessation and weight control in this demographic is crucial not only to prevent STEMI but also to potentially improve their long-term survival prospects.

Comparison of Myocardial Blood Flow Quantification Models for Double ECG Gating Arterial Spin Labeling MRI: Reproducibility Assessment

BACKGROUND

Arterial spin labeling (ASL) allows non-invasive quantification of myocardial blood flow (MBF). Double-ECG gating (DG) ASL is more robust to heart rate variability than single-ECG gating (SG), but its reproducibility requires further investigation. Moreover, the existence of multiple quantification models hinders its application. Frequency-offset-corrected-inversion (FOCI) pulses provide sharper edge profiles than hyperbolic-secant (HS), which could benefit myocardial ASL.

PURPOSE

To assess the performance of MBF quantification models for DG compared to SG ASL, to evaluate their reproducibility and to compare the effects of HS and FOCI pulses.

STUDY TYPE

Prospective.

SUBJECTS

Sixteen subjects (27 ± 8 years).

FIELD STRENGTH/SEQUENCE

1.5 T/DG and SG flow-sensitive alternating inversion recovery ASL.

ASSESSMENT

Three models for DG MBF quantification were compared using Monte Carlo simulations and in vivo experiments. Two models used a fitting approach (one using only a single label and control image pair per fit, the other using all available image pairs), while the third model used a T1 correction approach. Slice profile simulations were conducted for HS and FOCI pulses with varying B0 and B1. Temporal signal-to-noise ratio (tSNR) was computed for different acquisition/quantification strategies and inversion pulses. The number of images that minimized MBF error was investigated in the model with highest tSNR. Intra and intersession reproducibility were assessed in 10 subjects.

STATISTICAL TESTS

Within-subject coefficient of variation, analysis of variance. P-value <0.05 was considered significant.

RESULTS

MBF was not different across acquisition/quantification strategies (P = 0.27) nor pulses (P = 0.9). DG MBF quantification models exhibited significantly higher tSNR and superior reproducibility, particularly for the fitting model using multiple images (tSNR was 3.46 ± 2.18 in vivo and 3.32 ± 1.16 in simulations, respectively; wsCV = 16%). Reducing the number of ASL pairs to 13/15 did not increase MBF error (minimum = 0.22 mL/g/min).

DATA CONCLUSION

Reproducibility of MBF was better for DG than SG acquisitions, especially when employing a fitting model.

LEVEL OF EVIDENCE

2 TECHNICAL EFFICACY: Stage 1.

Routine Protamine Administration for Bleeding in Transcatheter Aortic Valve Implantation: The ACE-PROTAVI Randomized Clinical Trial

Importance

Vascular complications after transfemoral transcatheter aortic valve implantation (TAVI) remain an important cause of procedure-related morbidity. Routine reversal of anticoagulation with protamine at the conclusion of transfemoral TAVI could reduce complications, but data remain scarce.

Objective

To evaluate the efficacy and safety of routine protamine administration after transfemoral TAVI.

Design, Setting, and Participants

The ACE-PROTAVI trial was an investigator-initiated, double-blind, placebo-controlled randomized clinical trial performed at 3 Australian hospitals between December 2021 and June 2023 with a 1-year follow-up period. All patients accepted for transfemoral TAVI by a multidisciplinary heart team were eligible for enrollment.

Interventions

Eligible patients were randomized 1:1 between routine protamine administration and placebo.

Main Outcomes and Measures

The coprimary outcomes were the rate of hemostasis success and time to hemostasis (TTH), presented as categorical variables and compared with a χ2 test or as continuous variables as mean (SD) or median (IQR), depending on distribution. The major secondary outcome was a composite of all-cause death, major and minor bleeding complications, and major and minor vascular complications after 30 days, reported in odds ratios (ORs) with 95% CIs and P values.

Results

The study population consisted of 410 patients: 199 patients in the protamine group and 211 in the placebo group. The median (IQR) patient age in the protamine group was 82 (77-85) years, and 68 of 199 patients receiving protamine (34.2%) were female. The median (IQR) patient age in the placebo group was 80 (75-85) years, and 89 of 211 patients receiving the placebo (42.2%) were female. Patients receiving up-front protamine administration had a higher rate of hemostasis success (188 of 192 patients [97.9%]) than patients in the placebo group (186 of 203 patients [91.6%]; absolute risk difference, 6.3%; 95% CI, 2.0%-10.6%; P = .006); in addition, patients receiving up-front protamine had a shorter median (IQR) TTH (181 [120-420] seconds vs 279 [122-600] seconds; P = .002). Routine protamine administration resulted in a reduced risk of the composite outcome in the protamine group (10 of 192 [5.2%]) vs the placebo group (26 of 203 [12.8%]; OR, 0.37; 95% CI, 0.1-0.8; P = .01). This difference was predominantly driven by the difference in the prevalence of minor vascular complications. There were no adverse events associated with protamine use.

Conclusions and Relevance

In the ACE-PROTAVI randomized clinical trial, routine administration of protamine increased the rate of hemostasis success and decreased TTH. The beneficial effect of protamine was reflected in a reduction in minor vascular complications, procedural time, and postprocedural hospital stay duration in patients receiving routine protamine compared with patients receiving placebo.

Trial Registration

anzctr.org.au Identifier: ACTRN12621001261808.

Impact of sex on clinical and laboratory parameters in patients with heart failure: insights from the Colombian Heart Failure Registry (RECOLFACA)

INTRODUCTION

Heart failure (HF) is one of the leading causes of morbidity and mortality worldwide. This study aimed to assess the impact of sex on sociodemographic, clinical, and laboratory parameters in patients with HF who were included in the Colombian Heart Failure Registry (RECOLFACA).

METHODS

This was a cross-sectional analytical research. All 2528 patients included in RECOLFACA were analysed. The Mann-Whitney U test was used to compare median values as well as first and third quartiles (Q1-Q3). The age-related trend of NT-proBNP levels for both men and women groups was statistically evaluated.

RESULTS

The study included 2528 patients with HF (1072 women and 1456 men). The echocardiographic evidence showed that men presented reduced left ventricular ejection fraction (LVEF) (79.63 vs. 69.75%, respectively; p < 0.001) more often than women, which had a significantly higher proportion of preserved LVEF (20.46 vs.11.24%, respectively; p < 0.001). Women displayed a higher value of systolic blood pressure (p < 0.001) and heart rate (p = 0.014) compared to men. Haemoglobin, creatinine, and sodium levels were significantly higher in men. Men had a considerably lower glomerular filtration rate value, with the median reaching a G3a value for chronic renal failure. According to age, the levels of NT-proBNP in each sex increased equivalently with age.

CONCLUSION

Sex differences presented in this study are comparable to those discovered in other nations. However, certain variations show that these sex differences may differ by geographical area, which should encourage further investigations to describe them.

Accurate fully automated assessment of left ventricle, left atrium, and left atrial appendage function from computed tomography using deep learning

Aims

Assessment of cardiac function is essential for diagnosis and treatment planning in cardiovascular disease. Volume of cardiac regions and the derived measures of stroke volume (SV) and ejection fraction (EF) are most accurately calculated from imaging. This study aims to develop a fully automatic deep learning approach for calculation of cardiac function from computed tomography (CT).

Methods and results

Time-resolved CT data sets from 39 patients were used to train segmentation models for the left side of the heart including the left ventricle (LV), left atrium (LA), and left atrial appendage (LAA). We compared nnU-Net, 3D TransUNet, and UNETR. Dice Similarity Scores (DSS) were similar between nnU-Net (average DSS = 0.91) and 3D TransUNet (DSS = 0.89) while UNETR performed less well (DSS = 0.69). Intra-class correlation analysis showed nnU-Net and 3D TransUNet both accurately estimated LVSV (ICCnnU-Net = 0.95; ICC3DTransUNet = 0.94), LVEF (ICCnnU-Net = 1.00; ICC3DTransUNet = 1.00), LASV (ICCnnU-Net = 0.91; ICC3DTransUNet = 0.80), LAEF (ICCnnU-Net = 0.95; ICC3DTransUNet = 0.81), and LAASV (ICCnnU-Net = 0.79; ICC3DTransUNet = 0.81). Only nnU-Net significantly predicted LAAEF (ICCnnU-Net = 0.68). UNETR was not able to accurately estimate cardiac function. Time to convergence during training and time needed for inference were both faster for 3D TransUNet than for nnU-Net.

Conclusion

nnU-Net outperformed two different vision transformer architectures for the segmentation and calculation of function parameters for the LV, LA, and LAA. Fully automatic calculation of cardiac function parameters from CT using deep learning is fast and reliable.

Electronic physician notification to facilitate the recognition and management of severe aortic stenosis: Rationale, design, and methods of the randomized controlled DETECT AS trial

BACKGROUND

Symptomatic severe aortic stenosis causes substantial morbidity and mortality when left untreated, yet recent data suggest its undertreatment.

OBJECTIVE

To evaluate the efficacy of electronic physician notification to facilitate the guideline-directed management of patients with severe aortic stenosis.

HYPOTHESIS

We hypothesize that patients with severe aortic stenosis who are in the care of physicians who receive the notification are more likely to undergo aortic valve replacement within one year.

METHODS/DESIGN

The Electronic Physician Notification to Facilitate the Recognition and Management of Severe Aortic Stenosis (DETECT AS) trial is a randomized controlled trial and quality improvement initiative designed to evaluate the efficacy of electronic provider notification versus usual clinical care in the management of patients with severe aortic stenosis. Providers ordering an echocardiogram with findings potentially indicative of severe aortic stenosis are randomized to receive electronic notification with customized guideline recommendations for the management of severe aortic stenosis or usual care (no notification). Randomization continues until 940 patients are enrolled.

SETTING

Multicentered, academic health system.

OUTCOMES

The primary endpoint is the proportion of patients with severe aortic stenosis receiving an aortic valve replacement within one year of the index echocardiogram. Secondary endpoints include mortality, heart failure hospitalization, transthoracic echocardiogram utilization, aortic stenosis billing code, and cardiology/Valve Team referral.

CONCLUSION

The DETECT AS trial will provide insight into whether electronic notification of providers on the presence of severe aortic stenosis and associated clinical guideline recommendations will facilitate recognition and guideline-directed management of severe aortic stenosis.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05230225, https://clinicaltrials.gov/ct2/show/NCT05230225.

Cardiac amyloidosis is not a single disease: a multiparametric comparison between the light chain and transthyretin forms

AIMS

Systemic amyloidosis represents a heterogeneous group of diseases resulting from amyloid fibre deposition. The purpose of this study is to establish a differential diagnosis algorithm targeted towards the two most frequent subtypes of CA.

METHODS AND RESULTS

We prospectively included all consecutive patients with ATTR and AL evaluated between 2018 and 2022 in two centres in a score derivation cohort and a different validation sample. All patients had a complete clinical, biomarker, electrocardiographic, and imaging evaluation. Confirmation of the final diagnosis with amyloid typing was performed according to the current international recommendations. The study population included 81 patients divided into two groups: ATTR (group 1, n = 32: 28 variant and 4 wild type) and AL (group 2, n = 49). ATTR patients were younger (50.7 ± 13.9 vs. 60.2 ± 7.3 years, P = 0.0001), and significantly different in terms of NT-proBNP [ATTR: 1472.5 ng/L (97-4218.5) vs. AL 8024 ng/L (3058-14 069) P = 0.001], hs-cTn I [ATTR: 10 ng/L (4-20) vs. AL 78 ng/L (32-240), P = 0.0002], GFR [ATTR 95.4 mL/min (73.8-105.3) vs. AL: 68.4 mL/min (47.8-87.4) P = 0.003]. At similar left ventricular (LV) wall thickness and ejection fraction, the ATTR group had less frequently pericardial effusion (ATTR: 15% vs. AL: 33% P = 0.0027), better LV global longitudinal strain (ATTR: -13.1% ± 3.5 vs. AL: -9.1% ± 4.3 P = 0.04), RV strain (ATTR: -21.9% ± 6.2 vs. AL: -16.8% ± 6 P = 0.03) and better reservoir function of the LA strain (ATTR: 22% ± 12 vs. AL: 13.6% ± 7.8 P = 0.02). Cut-off points were calculated based on the Youden method. We attributed to 2 points for parameters having an AUC > 0.75 (NT-proBNP AUC 0.799; hs-cTnI AUC 0.87) and 1 point for GFR (AUC 0.749) and TTE parameters (GLS AUC 0.666; RV FWS AUC 0.649, LASr AUC 0.643). A score of equal or more than 4 points has been able to differentiate between AL and ATTR (sensitivity 80%, specificity 62%, AUC = 0.798). The differential diagnosis score system was applied to the validation cohort of 52 CA patients showing a sensitivity of 81% with specificity of 77%.

CONCLUSIONS

CA is a complex entity and requires extensive testing for a positive diagnosis. This study highlights a series of non-invasive checkpoints, which can be useful in guiding the decision-making process towards a more accurate and rapid differential diagnosis.

Association between haemoglobin decline and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention

OBJECTIVE

To explore the association between in-hospital haemoglobin decline and long-term mortality and major adverse cardiovascular and cerebrovascular events (MACCE) among ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PCI).

METHODS

This retrospective analysis included adult patients who underwent primary PCI for STEMI. Haemoglobin levels were recorded at admission and 48-72 h later. Patients were divided into two groups based on the extent of haemoglobin decline: low (<3 g/dl or no decline) and high (≥3 g/dl). The primary endpoint was all-cause mortality at long-term follow-up. The secondary endpoint was MACCE.

RESULTS

Patients were divided into two groups: low group (n = 665) and high group (n = 111). The mortality rate was significantly higher in the high group (72 of 111 patients; 65%) than in the low group (185 of 655 patients; 28%). Propensity score matching confirmed this association, with higher mortality (41 of 79 patients [52%] versus 25 of 79 patients [32%]) and MACCE rates (56 of 79 patients [71%] versus 41 of 79 patients [52%]) in the high group compared with the low group, respectively.

CONCLUSION

There was a significant association between in-hospital haemoglobin decline, even without visible bleeding, and increased long-term mortality and MACCE in STEMI patients undergoing primary PCI.

Adverse effects of COVID-19 vaccine in the paediatric population: a focus on the cardiovascular system

The COVID-19 pandemic had an unprecedented impact on healthcare systems and exists globally. To control pandemic progression, COVID-19 vaccines were developed and licensed for use in the adult population in early 2021 and became available in paediatric cohorts several months later. Since then, several studies have reported adverse events and severe adverse events in the adult and paediatric cohorts. The question remains whether there exists a significant risk to paediatric COVID-19 vaccination. This study reviews the classification and presentation of severe adverse events and discusses relevant reports in the literature. An emphasis is put on cardiovascular severe adverse events and adverse events. This paper also provides current and future perspectives relative to the pandemic, its control, and the future of vaccine immunology.

The role of systemic inflammatory indices in predicting atrial fibrillation and its complications: a narrative review

Atrial fibrillation (AF) is associated with increased morbidity and mortality. Inflammation and oxidative stress play critical roles in AF occurrence and its complications. Therefore, evaluating the circulating levels of inflammatory and oxidative stress biomarkers and their possible applications in AF diagnosis and management have been the focus of many efforts. The monocyte-to-high-density lipoprotein cholesterol ratio (MHR) and neutrophil-to-lymphocyte ratio (NLR) are two non-invasive, available, and established markers that serve as indicators of inflammation and oxidative stress. This review summarizes the current literature regarding alterations in the NLR, MHR, and other composite markers of systemic inflammation in AF patients. Moreover, this review discusses the clinical performance of these markers in predicting AF occurrence, recurrence, and disease outcomes. The PubMed, Scopus, and ScienceDirect online databases were searched for relevant studies using appropriate keywords, including "atrial fibrillation", "monocyte to high-density lipoprotein cholesterol ratio", and "neutrophil to lymphocyte ratio". The results of this review revealed the association of elevated levels of systemic inflammatory markers, specifically the NLR and MHR with AF and its complications. This finding indicates the potential role of subclinical inflammation in the development of AF, emphasizing its consideration in both the prevention and treatment of AF and associated complications. Despite these promising findings, the utilization of these markers in routine clinical settings faces challenges, including low specificity and sensitivity and varying cut-off values across different studies.

Transcatheter Procedure Versus Surgical Interventions for Severe Aortic Stenosis: A Contemporary Evaluation Against Conservative Management

For Aortic valve replacement (AVR), both transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) serve as a pivotal therapeutic approach for severe aortic stenosis (AS). While both modalities show advantages over conservative management, the long-term mortality benefits post AVR, especially when comparing TAVR with SAVR, remain uncertain. A comprehensive meta-analysis was conducted through a systematic search of electronic databases up to December 7, 2023. Individual patient data extracted from Kaplan-Meier plots underwent pooling and modeling with stratification by surgical risk. The primary endpoint was all-cause mortality at five years. The study included 11 randomized controlled trials (RCTs) and 12 non-RCTs, encompassing 4,215 patients undergoing TAVR, 4,017 undergoing SAVR, and comparing 11,285 AVR patients with 23,358 receiving conservative management. Transcatheter aortic valve replacement exhibited significantly lower all-cause mortality at six months (hazard ratio (HR) 0.62, 95% CI: 0.52-0.74) compared to SAVR, with no significant difference beyond 6 months (HR 1.08, 95% CI: 0.98-1.19). There were no significant differences in cardiovascular mortality (HR 0.98, 95% CI: 0.83-1.16), stroke (HR 1.02, 95% CI: 0.75-1.38), or valvular hemodynamics between TAVR and SAVR. Aortic valve replacement markedly reduced all-cause mortality compared to medical therapy (P < 0.001), with five-year crude mortality rates of 31.6% versus 49.3% and a difference in restricted mean survival time of 8.9 months. Similar outcomes were observed across high, intermediate, and low surgical risk categories. While TAVR demonstrated early mortality reduction compared to SAVR, no distinctions emerged in the overall five-year follow-up, regardless of surgical risk. Aortic valve replacement notably improved survival over conservative therapy. This study advocates for the preference of TAVR or SAVR in severe AS patients when feasible.

Increased risk of pulmonary embolism and deep vein thrombosis with COVID-19 pneumonia in comparison to influenza pneumonia: insights from the National Inpatient Sample database

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), primarily a respiratory virus causing coronavirus disease 2019 (COVID-19) pneumonia, induces a hypercoagulable state. Previous studies comparing the prevalence of venous thromboembolism (VTE) in patients with COVID-19 pneumonia and those with influenza pneumonia revealed a higher risk of pulmonary embolism (PE) and deep vein thrombosis (DVT) associated with COVID-19 pneumonia. However, these studies have not adequately accounted for the severity and acuity of the presenting viral pneumonia.

Methods

In this retrospective study, we rigorously adjusted for critical illness using a nationally representative dataset to investigate whether COVID-19 pneumonia is independently linked to a higher risk of PE and DVT.

Results

After comprehensive multivariate adjustment, our findings demonstrated that patients with COVID-19 pneumonia maintained significantly higher odds of developing acute inpatient PE [adjusted odds ratio (aOR): 2.48; 95% confidence interval (CI): 2.16-2.86; P<0.01] and DVT (aOR: 1.66; 95% CI: 1.41-1.96; P<0.01) during the early pandemic compared to patients with influenza pneumonia. Furthermore, we identified congenital heart disease and malnutrition as novel risk factors for acute PE in COVID-19 patients.

Conclusions

Our study suggests that the higher prevalence of acute inpatient PE over DVT in patients with COVID-19 pneumonia may support a "thrombus in situ" mechanism of SARS-CoV-2-mediated pulmonary thrombosis. Consequently, clinicians should maintain a high index of suspicion for PE, even in the absence of DVT, among patients with COVID-19 pneumonia and should follow evidence-based guidelines for diagnosis and management.