Heart

Background: Atrial high-rate episodes (AHRE) detected by cardiac implantable electronic devices (CIEDs) are associated with increased thromboembolic risk, yet their clinical significance and optimal anticoagulation strategy remain uncertain, particularly in the absence of electrocardiogram (ECG)-confirmed atrial fibrillation. Methods: We conducted a nationwide cross-sectional survey of UK clinicians involved in CIED follow-up. The survey assessed anticoagulation decision-making in AHRE, including episode-duration thresholds, cumulative burden, CHA2DS2-VA use, additional ECG monitoring, and anticoagulant choice. Only responses from UK-based consultant clinicians were included and analysed descriptively. Results: A total of 51 responses were received; 38 met the inclusion criteria and were analysed. Most respondents (86.8%) reported having reviewed AHRE alerts within the preceding six months, indicating that AHRE are commonly encountered in clinical practice. A [≥]24-hour episode was the most common threshold for anticoagulation (44.7%), although many clinicians reported lower thresholds or individualised approaches. Nearly half (44.7%) did not consider cumulative AHRE burden in decision-making. CHA2DS2-VA thresholds also varied, most commonly [≥]2 or [≥]1. Additional ECG monitoring was infrequently performed. Direct oral anticoagulants were universally preferred, with apixaban the most commonly selected agent (73.7%). Conclusion: There is substantial variation in UK clinical practice regarding anticoagulation for AHRE, reflecting ongoing uncertainty and lack of clear guidance. These findings highlight the need for evidence-based thresholds to support consistent and informed clinical decision-making.

Background Non-vitamin K antagonist oral anticoagulants (NOACs) are the guideline-recommended standard for stroke prevention in atrial fibrillation (AF), yet bleeding risks limit real-world adherence. Percutaneous left atrial appendage closure (LAAC) offers a mechanical alternative without definitive comparative synthesis. Objectives To evaluate percutaneous LAAC versus NOAC therapy by synthesizing all contemporary NOAC-era randomized controlled trials (RCTs). Methods Five databases and registries (PubMed, MEDLINE, Embase, Cochrane CENTRAL, ClinicalTrials.gov) were searched from inception to 8 May 2026 for RCTs comparing percutaneous LAAC against NOACs in adults with non-valvular AF. Risk of bias was assessed using Cochrane RoB 2. Ischemic stroke was pooled using a random-effects DerSimonian-Laird model; primary efficacy composite and non-procedural bleeding were evaluated via pre-specified narrative synthesis. Results Four RCTs (CHAMPION-AF, OPTION, PRAGUE-17, CLOSURE-AF) comprising 5,890 patients were included. LAAC achieved noninferiority for the primary efficacy composite in three trials and demonstrated a statistically significant 45-56% reduction in non-procedural bleeding across the three moderate-risk trials. CLOSURE-AF did not meet noninferiority but retained a directionally consistent bleeding reduction. Pooled ischemic stroke analysis (HR 1.31; 95% CI 0.96-1.80; I^2=0%) showed no statistically significant increase in stroke risk, though a consistent directional trend toward more ischemic events was observed. Conclusions LAAC significantly reduces non-procedural bleeding in moderate-risk AF patients, though this benefit attenuates in very high-risk populations. A consistent, statistically nonsignificant ischemic stroke trend and population-dependent efficacy establish LAAC as a shared decision-making alternative to NOACs rather than a universal replacement, pending 5-year CHAMPION-AF data.

Objectives To assess agreement between Cardio-HART (CHART) and echocardiography for left ventricular ejection fraction (LVEF) estimation and heart failure (HF) classification in a real-world predominantly ischaemic cohort, while examining whether a point-of-care structural and functional assessment tool could reveal a broader workflow gap between the nominal availability of echocardiography and timely cardiac assessment in routine care. Design Prospective single-centre cohort study. Setting Secondary-care cardiology service at Cascais Hospital, Lisbon, Portugal. Participants Forty-seven adults referred for cardiology evaluation with suspected HF or followed in a hospital HF clinic. Primary and secondary outcome measures Agreement between CHART-derived and echocardiographic LVEF by Bland-Altman analysis; diagnostic performance for HF phenotypes; comparison with the Teichholz method. Results Mean age was 65.6+-15.9 years; 78.7% of participants had HF and 43.2% of HF cases were ischaemic. CHART showed a mean LVEF bias of +1.92% versus echocardiography, with 95% limits of agreement from -14.6% to +18.4% and a mean absolute error of 6.09%. Agreement was strongest in HF with reduced ejection fraction (HFrEF) and HF with mildly reduced ejection fraction (HFmrEF), and lower in HF with preserved ejection fraction (HFpEF). Diagnostic area under the curve for HFrEF classification was 0.89. Compared with the Teichholz method, CHART showed a lower root mean square error relative to Simpson's biplane LVEF. Conclusions CHART showed clinically credible performance for LVEF estimation and HF stratification, particularly in reduced-EF phenotypes. However, the most important finding of this study was not agreement alone. By performing credibly in a cardiology-based real-world setting, CHART exposed a previously under-recognised workflow gap between the nominal availability of echocardiography and timely access to structural cardiac assessment in routine care. The study therefore suggests that the value of CHART lies not only in diagnostic performance, but in making visible, and potentially narrowing, a hidden but consequential gap in cardiac assessment pathways. Larger studies are warranted, particularly for HFpEF and across broader clinical workflows.

Background: A growing burden of cardiovascular risk factors has raised cardiovascular disease-related mortality in Sub-Saharan Africa (SSA), driving higher prevalence of heart failure with reduced ejection fraction (HFrEF) and its complication with atrial fibrillation (AF). No prospective study has examined AF's clinical impact on HFrEF in SSA. Aim: To determine AF prevalence in HFrEF, describe HFrEF-AF clinical characteristics, and determine AF's impact on mortality. Methods: In this prospective observational study at a tertiary hospital in Johannesburg, 136 HFrEF patients were enrolled and categorised as HFrEF- SR (sinus rhythm) or HFrEF-AF. Baseline clinical characteristics and biochemistry were recorded. Comprehensive echocardiography including left atrial strain by 2D speckle-tracking was performed. Median follow-up was 30.6 months. Results: AF was present in 28 patients (21%). The mean age was 58.7 {+/-} 14.9 years (52.9% male) and differed between groups (p < 0.001). Hypertensive heart disease was the leading cause of HFrEF (36%). Compared with SR, HFrEF-AF patients had poorer health status (KCCQ 27 [16-43] vs 45 [32-60], p < 0.001) and lower left atrial strain (26.2 {+/-} 11.3%, p < 0.001). Guideline-directed medical therapy was suboptimal in the AF group: anticoagulation use was higher than SR (60% vs 9.5%, p < 0.001) but overall inadequate; HFrEF-AF patients received lower median doses of carvedilol (15.6 mg vs 25 mg, p = 0.002) and enalapril (10 mg vs 20 mg, p = 0.004), and fewer received spironolactone (50% vs 75.3%, p = 0.013). Survival was significantly lower in HFrEF-AF (0.41 [0.22-0.61]) versus SR (0.73 [0.61-0.82], p < 0.001). Independent predictors of mortality included prior stroke, lower TAPSE and KCCQ, and higher E/e' and heart rate. Conclusion: AF is common among HFrEF patients in this SSA cohort (though lower than in high-income countries) and associates with worse clinical status, suboptimal therapy, and higher mortality.

Background: Higher METS-IR has been shown to be associated with a higher risk of major adverse cardiovascular events, but data are lacking regarding cardiac arrhythmias. Objectives: The aim of this study was to assess the association between METS-IR and atrial fibrillation/flutter, ventricular arrhythmia and bradyarrhythmia. Methods: Data from the Atherosclerosis Risk in Communities study spanning 1987 to 2013 was utilized for this analysis. METS-IR scores were assessed at baseline (1987-1989) and arrhythmia episodes were identified using ICD-9 codes. Multivariate-adjusted Cox proportional hazard models were constructed to evaluate the relationship between METS-IR and arrhythmia risk, with dose-response analyses conducted. In addition, we analyzed the predictive value of METS-IR for arrhythmias. Results: Over a mean follow-up of 21.9 years, 2493 cases of AF, 688 cases of bradyarrhythmia, and 1315 cases of ventricular arrhythmia were recorded. Each interquartile range increase in METS-IR was associated with a 49% higher risk of atrial fibrillation(P<0.001), 29% higher risk of bradyarrhythmia(P<0.001), and 42% higher risk of ventricular arrhythmia(P<0.001). After correction for relevant confounders, the METS-IR index was significantly and positively associated with the risk of new-onset atrial fibrillation, bradyarrhythmia, and ventricular arrhythmia (P overall<0.05, P for non-linearity>0.05). Most of the results of the subgroup analyses were not significantly different. The inclusion of METS-IR in the base model improves the predictive value of the risk of arrhythmogenesis. Conclusions: There is a significant association between METS-IR and increased risk of arrhythmias.

Introduction Patients hospitalized with heart failure who do not speak English as their primary language face communication barriers, however the impact on documented History of Present Illness (HPI) and Review of Systems (ROS) has not been reported. Methods This retrospective cohort study was based on MIMIC-IV, an anonymized clinical database. Adult patients admitted to general medicine or cardiology services with heart failure (by DRG) were identified. Multivariable linear regression was used to assess for an association between language (English vs. non-English) and word counts for HPI+ROS and HPI word counts. Qualitative differences in texts were also analyzed using Claude Opus 4.6. Results In a cohort of 552 patients, non-English language (N = 81) was associated with a shorter HPI+ROS (coef. -33.387, 95% CI [-62.076, -4.697], p = 0.023) controlling for age (coef. -1.023, 95% CI [-1.817, -0.230], p = 0.012) and Elixhauser score (coef. 10.391, 95% CI [7.078, 13.705], p<0.001). Similar associations were found for HPI alone. Qualitative differences included less discussion of symptoms and timing of onset. Discussion HPI+ROS and HPI were more abbreviated when the primary documented language was not English. This has important implications for equitable care and the development of emerging translation and documentation technologies.

IntroductionWith improved life expectancy, mitral annular calcification and calcific mitral stenosis (CMS) are increasing in prevalence. Echocardiographic evaluation of CMS is challenging due to acoustic shadowing and lack of CMS specific data on assessment of severity and outcomes. MethodsWe retrospectively identified patients with isolated CMS between the years 1/1/2010 and 4/5/2022. Severe CMS was defined as MVAcont [&le;]1.5 cm2. The primary outcome was a composite of all-cause mortality, mitral valve replacement (MVR) and ischemic stroke. Outcomes were collected through electronic health records with follow up through 8/15/2025. ResultsOur cohort included a total of n=717 patients with CMS of which n=140 had severe CMS. The mean age was 74{+/-}13 years and cohort was predominantly female. We found that MVAPHT consistently overestimates the MVA and is a poor predictor of severe CMS. Mean gradient >5 mm Hg had 81% specificity and 57% sensitivity for severe CMS. Over a median follow up of 36 (IQR 10.5-49.7) months, a total of n=331 (46.2%) patients died, and the primary composite outcome occurred in n=370 (51.6%). Although MVAcont [&le;]1.5 cm2 [aHR 1.3 (95% CI 0.9-1.8),p=0.29] was not an independent predictor of the primary outcome we found that mTMG was a significant independent predictor primary outcome [aHR 1.5 (95% CI 1.1-2), p<0.01]. Patients with MVAcont [&le;]1.5 cm2 and mean gradient [&ge;] 5 mmHg had the highest risk for the primary outcome [aHR 2 (95% CI 1.1-3.7),p=.02]. ConclusionPatients with severe CMS are older, female with a high burden of comorbidities and carry an overall poor prognosis. mTMG is an independent prognostic marker in these patients. Patients with MVA [&le;]1.5 cm2 and mTMG [&ge;]5 mmHg have the worst prognosis.

Background. Peripheral artery disease (PAD) may amplify procedural risk during atrial fibrillation (AF) catheter ablation, but dedicated evidence is lacking. We aimed to evaluate the association between PAD and in-hospital outcomes among adults undergoing AF ablation in the National Inpatient Sample (NIS). Methods. We identified inpatient AF ablation hospitalizations in the 2016 through 2020 National Inpatient Sample using ICD-10-PCS procedure codes and a concurrent AF diagnosis. PAD was identified from ICD-10-CM diagnosis codes used in prior claims-based PAD studies. Stabilized inverse probability of treatment weighting based on the propensity score was used to balance baseline differences. The primary outcome was in-hospital mortality. Fourteen secondary outcomes and 2 composite end points were prespecified. Results. Among 22,166 AF ablation hospitalizations, 899 (4.06%) involved patients with PAD. Compared with patients without PAD, those with PAD were older and had a substantially greater cardiovascular, renal, and smoking/tobacco comorbidity burden. In-hospital mortality did not differ significantly (1.39% vs 1.06%; aOR, 1.32; 95% CI, 0.66 - 2.64; P= 0.44). PAD was associated with higher odds of major bleeding (aOR, 1.62; 95% CI, 1.17 - 2.24; P = 0.004), vascular or access-site complications (aOR, 1.80; 95% CI, 1.04 - 3.12; P = 0.04), acute kidney injury (aOR, 1.31; 95% CI, 1.05 - 1.64; P = 0.02), and composite major adverse hospital events (aOR, 1.29; 95% CI, 1.05 - 1.59; P = 0.02). Total hospital charges were 13% higher (charge ratio, 1.13; 95% CI, 1.04 - 1.22; P = 0.003). Major bleeding, vascular/access-site complications, cardiac arrest, and composite major adverse in-hospital events remained elevated in sensitivity analysis. Conclusion. PAD was independently associated with higher bleeding risk, vascular or access-site complications, acute kidney injury, and composite major adverse hospital event during AF ablation, identifying a clinically relevant subgroup with elevated periprocedural risk.

Background: Two-thirds of Dutch cardiovascular risk management (CVRM) for patients at risk of cardiovascular disease is delivered in primary care practices. While individual risk scores are increasingly used during consultation, a population-level structure for risk-based patient outreach is not currently available. We therefore developed the PROSPERA programme, a multilevel intervention comprising population-level risk stratification and individual-level support tools. Aim: To assess anticipated and experienced barriers and facilitators among healthcare professionals (HCPs) to inform implementation in primary care. Methods: We conducted four focus groups and six interviews with nine primary care HCPs to explore anticipated and experienced barriers and facilitators. Inductive codes were thematically analysed and assigned to corresponding domains of the Theoretical Domains Framework (TDF) and the related Capability, Opportunity, Motivation model of Behaviour. Results: Barriers and facilitators were identified in 11 TDF domains. Population-level barriers included altered professional roles and limitations in technological infrastructure. Individual-level barriers were limited skills in interpreting risk calculations and difficulty integrating tools into clinical routine. Facilitators were related to beliefs on the importance of providing proactive care (population level), the use of U-Prevent for risk communication (individual level) and positive patient responses to the Lifestylecheck questionnaire (individual level). Conclusion: Addressing barriers and facilitators identified at both the population and individual levels can support implementation of the PROSPERA programme. Opportunities exist in education and training of HCPs in risk communication, as well as support in restructuring the physical and digital environment.

Background: Response to cardiac resynchronization therapy (CRT) is heterogeneous in patients with non-left bundle branch block (non-LBBB) heart failure. Whether pre-implant substrate or procedural characteristics provide the more stable framework for predicting 1-year echocardiographic response remains uncertain. Methods: We retrospectively analyzed 120 non-LBBB patients undergoing CRT. The primary logistic model included left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction (LVEF), left atrial diameter, log-transformed NT-proBNP, baseline QRS duration, fragmented QRS burden across V1?V6 leads, and pulmonary artery pressure. Missing predictor data were handled using multiple imputation with 20 datasets. Model performance was assessed using bootstrap internal validation and recalibration. A prespecified procedural extension added pacing strategy, posterolateral biventricular left ventricular lead location, left ventricular pacing threshold, and right ventricular lead position. Exploratory phenotyping and sensitivity analyses were performed. Results: Echocardiographic response occurred in 51 patients (42.5%). LVEDD (OR, 0.899 [95% CI, 0.826?0.978]; P=0.013) and LVEF (OR, 1.068 [95% CI, 1.000?1.140]; P=0.050) were the most informative predictors. The primary model showed apparent AUC 0.811 and Brier score 0.173, with optimism-corrected AUC 0.766 and calibration slope 0.765. Procedural extension showed no retained incremental value after validation. Exploratory phenotyping identified three response patterns with moderate stability. Conclusions: In non-LBBB CRT, baseline structural, biomarker, and electrocardiographic substrate provided the most stable framework for predicting 1-year echocardiographic response. Procedural variables added limited retained value, suggesting that pacing strategy should be interpreted alongside baseline substrate.

Background: Postoperative atrial fibrillation (POAF) affects up to 50% of cardiac surgery patients and is linked to higher morbidity, longer hospital stays and increased thromboembolic risk. Early identification of at-risk patients remains challenging. Calcitonin (CT), a hormone with anti-fibrotic effects, may serve as a novel biomarker. Methods: In 491 patients undergoing elective cardiac surgery, baseline serum CT was measured preoperatively using CT-specific enzyme-linked immunosorbent assay (ELISA). Patients with pre-existing AF were excluded. Associations between CT levels and POAF incidence and onset were evaluated using logistic regression, Cox proportional hazards models, and Kaplan-Meier analysis. Results: Among 248 patients with detectable CT levels, 88 patients developed POAF. Higher baseline CT was independently associated with lower risk of POAF (OR 0.68 per 5 pg/ml increase; 95% CI 0.51-0.89; P = 0.009) and delayed arrhythmia onset (adjusted HR 0.941; 95% CI 0.898-0.980, P = 0.0026) after adjusting for covariates. Kaplan-Meier analysis demonstrated a graded relationship between increasing CT levels and reduced cumulative incidence of POAF. In this cohort, baseline CT showed greater discriminative ability than CRP and BNP, although overall model performance remained moderate. Conclusion. Higher preoperative circulating CT levels are associated with reduced risk and delayed onset of POAF following cardiac surgery. These findings suggest that calcitonin may have the potential as a biomarker for perioperative risk stratification in POAF. Given the observational design and single-centre setting, further validation in independent cohorts and studies integrating mechanistic insights are warranted.

Background: Heterotopic caval valve implantation using the TricValve(R) (OrbusNeich P&F) is a unique interventional approach for treatment of severe Tricuspid Regurgitation in patients who are deemed ineligible for surgery. Given the complexity and novelty of TricValve(R) implantation, there is a pressing need for robust clinical data to evaluate its safety, efficacy, and long-term outcomes. Our study assesses the clinical results of patients followed up for 1 year from our center. Methods: Retrospective, single center registry involving patients who have undergone TricValve(R) Transcatheter Bicaval Valves System (OrbusNeich P&F) implantation for the treatment of severe tricuspid regurgitation. Results: Fourteen patients were included. The mean age was 67.5 {+/-} 8.7 years, with high surgical risk (mean EuroSCORE II 6.1 {+/-} 3.7). Procedural success was achieved in thirteen patients, with no reported in-hospital mortality or stroke among all fourteen patients. At 1-year, significant improvements were observed in New York Heart Association (NYHA) functional class (86% Class III at baseline to 0% Class III at 1 year, P=0.002) and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) scores (mean 32.0 {+/-} 7.4 to 42.4 {+/-} 12.0, P=0.015). TR Regurgitant Volume significantly decreased (65.5 {+/-} 16.9 ml to 38.2 {+/-} 13.6 ml, P=0.005). No deaths or strokes occurred during follow-up. Rehospitalization due to heart failure occurred in 14% (2 out of 14) of patients. Conclusion: In this single-center registry of high-risk patients, TricValve(R) implantation was associated with a favorable safety profile, significant reduction in tricuspid regurgitant volume, and meaningful improvements in functional status and quality of life at 1 year follow-up.

Background: In severe aortic stenosis patients undergoing TAVR, whether coexisting coronary disease prompts revascularization and its optimal timing remain unclear. Aim: To evaluate the efficacy and safety of PCI before TAVR compared to deferred PCI in patients with severe aortic stenosis and concomitant coronary artery disease. Methods: We performed a meta-analysis of RCTs. PubMed, Embase, Scopus, CENTRAL, and Web of Science were searched for RCTs comparing PCI before TAVR versus no PCI. HRs with 95% CIs were pooled using random-effects models. Results: Three RCTs (ACTIVATION, NOTION 3, PRO-TAVI) enrolling 1,156 patients (579 PCI, 577 no PCI) were included. Routine PCI before TAVR did not reduce all-cause mortality (HR 0.88, 95% CI 0.67 to 1.17; p=0.38) or cardiovascular death (HR 0.77, 95% CI 0.49 to 1.19; p=0.23). PCI significantly reduced any revascularization (HR 0.24, 95% CI 0.06 to 0.86; p=0.029), and urgent revascularization (HR 0.33, 95% CI 0.12 to 0.87; p=0.025). MI was not significantly reduced with PCI (HR 0.84, 95% CI 0.44 to 1.59; p = 0.59). Stroke showed a borderline trend favoring PCI (HR 0.69, 95% CI 0.46 to 1.04; p=0.073). PCI significantly increased any bleeding (HR 1.96, 95% CI 1.28 to 3.0; p=0.002) and major bleeding (HR 1.88, 95% CI 1.07 to 3.31, p=0.027). Neither AKI nor rehospitalization differed significantly between groups. Leave-one-out sensitivity analyses confirmed the stability of mortality, stroke, and bleeding estimates. Conclusions: Routine PCI before TAVR does not reduce mortality. It lowers urgent revascularization and trends toward less stroke but nearly doubles bleeding. Findings support selective, individualized PCI rather than routine revascularization before TAVR.

Background: Improved survival of adolescents with congenital heart disease has shifted the focus to examine health-related quality of life and address challenges in transition to adult care. We aim to describe how congenital heart disease complexity, gender, number of interventions, and Fontan circulation may affect the health-related quality of life and transition readiness of adolescents with congenital heart disease. Methods: We conducted a single-center cross-sectional study involving 536 patients aged 14 to 18 years old who attended a nurse-led, pediatric to adult care cardiac transition clinic, from 2020 to 2024. health-related quality of life was evaluated using the PedsQLTM 4.0 Generic Core Scales and the PedsQLTM 3.0 Cardiac Module. Patients were screened for anxiety and depression using the PHQ-9 and GAD-7. Transition readiness was assessed using the Transition-Q score. Results: The median age of patients was 16 years old and 44% self-identified as female. PedsQLTM 4.0 Generic had a median overall score of 77 (IQR 67?87), with no significant difference according to congenital heart disease severity. Female patients had significantly lower overall PedsQLTM 4.0 score (p=0.028) and lower physical and emotional functioning scores (p=0.005, p<0.001, respectively) when compared to males. Physical functioning scores were lower amongst patients with Fontan circulation compared to non-Fontan patients (p=0.003), although overall PedsQLTM 4.0 score and transition readiness scores were similar to those with complex biventricular congenital heart disease. Number of previous interventions were inversely associated with overall PedsQLTM 4.0 score (p=0.036). Moderate to severe symptoms of depression or anxiety were reported in 30% of screened patients and were associated with 2 significantly lower PedsQLTM 4.0 scores (p<0.001). Transition readiness was significantly lower in patients with moderate and complex compared to those with simple congenital heart disease (p<0.001). Transition readiness improved with repeat transition clinic visits (p=0.004) whereas PedsQLTM 4.0 score did not change significantly. Conclusion: In this large cohort of adolescents with congenital heart disease, health-related quality of life was lower than population norms. Female gender, higher interventional burden, and anxiety or depressive symptoms are associated with lower health-related quality of life scores rather than anatomical severity or Fontan physiology. Transition readiness was lower in complex disease; it has improved with a structured, nurse-led transition clinic, demonstrating modifiability. Consequently, adolescent congenital heart disease care requires a multidisciplinary approach including psychosocial screening, especially for high-risk groups, and structured transition planning to improve long-term outcomes.

Background. Adults with congenital heart disease (CHD) are a growing population and face unique challenges as they age. Unlike acquired diseases that disrupt a previously healthy baseline, CHD is developmentally embedded. Allostatic load, the multi-system biological "wear and tear" exacted by the continuous cost of coping, offers a framework for indexing this lifelong psychophysiological stress. Methods. We analyzed 14,469 adults from the All of Us Research Program: non-syndromic CHD (n = 6,810), acquired heart disease (AHD; n = 2,264), non-cardiac chronic illness (n = 4,331), and a general population comparison cohort (GP; n = 1,064). Using a standardized operationalization, allostatic load was scored across five biomarker domains (AL5, range 0-5). A pre-specified primary test compared adjusted AL5 between CHD and GP. Exploratory analyses examined clinical predictor of this gap and whether baseline subjective health predicted prospective AL5 change, utilizing strictly matched biomarkers across timepoints to prevent substitution artifacts. Results. Adults with CHD carried significantly higher allostatic load than the general population comparison cohort (adjusted difference +0.30 AL5 units, 95% CI 0.24-0.37, p < .001). Cumulative comorbidity and cardiac medication burden explained most of this gap. Congenital anatomical complexity did not independently predict this burden. In a prospective subsample (n = 8,031, mean follow-up 2.7 years), worse baseline mental health predicted increases in allostatic load over time in CHD. Baseline physical health showed no such prospective association. The general population and acquired heart disease cohorts demonstrated the inverse dissociation: subjective physical health predicted these longitudinal physiological changes. Conclusions. Adults with CHD carry an elevated allostatic burden dictated by the cumulative cost of acquired medical and treatment intensity. The original congenital anatomy does not predict this accumulation. Furthermore, subjective mental health prospectively tracks future increases in allostatic load in CHD. This dissociation is absent in adult-onset acquired heart disease, suggesting that the mental aspects of coping with CHD may impact outcomes above and beyond those with acquired heart disease. These findings position psychological care as a potentially physiologically consequential intervention.

Background: Concomitant arrhythmogenic right ventricular cardiomyopathy (ARVC) and mitral valve prolapse (MVP) has only been described in case reports. Little is known about genetic and phenotypic characteristics of these patients. Objective: To describe the prevalence, genetics, and imaging characteristics of MVP in ARVC patients. Methods: We identified 111 definite ARVC cases through medical record review, arrhythmia/cardiomyopathy targeted gene panels, and contrast cardiac magnetic resonance data. MVP was diagnosed on echocardiography as mitral leaflet displacement greater than 2 mm above the annular plane in systole, with borderline MVP defined as less than or equal to 2 mm. Results: We found MVP/borderline MVP in 14% of ARVC patients. Cardiac arrest occurred in 20% of those with MVP/borderline MVP compared to 16% without valve abnormalities. Among 69 ARVC patients with identified genetic variants, PKP2 mutations were highly prevalent (64%), particularly in those with MVP (83%). Most MVPs had posterior prolapse (73%) and trace/mild mitral regurgitation (87%). None had mitral annular disjunction. ARVCs with MVP had higher LV mass (93 vs. 75 g/m2, p = 0.02) and a higher prevalence of LV wall motion abnormalities (27% vs. 5%, p = 0.02) compared to ARVCs without valve abnormalities. Conclusions: MVP is prevalent in ARVC and characterized by PKP2 variants in most cases. Typical features of arrhythmic MVP like bileaflet involvement and annular disjunction are rare in ARVC with MVP; features of arrhythmogenic left-sided cardiomyopathy (increased LV mass index and wall motion abnormalities) are more common. Further studies are needed to understand the role of MVP in arrhythmic risk stratification of ARVC.

Rheumatic heart disease (RHD) is a leading preventable cause of cardiac death in children in low and middle-income countries. Nepals epidemiological data come mainly from auscultation surveys that miss subclinical disease, and no echocardiographic screening study had been conducted in Dhanusha district, a densely populated, low-income region in southern Nepal. We aimed to determine the prevalence of borderline and definite RHD among school children (6-16 years) in Dhanusha using the 2012 World Heart Federation (WHF) echocardiographic criteria, identify independent predictors, and quantify school-level clustering via the intraclass correlation coefficient (ICC). In a cross-sectional study (January 2023-December 2024), we screened 4,536 children from 8 public schools selected by four-stage cluster sampling. RHD was classified by WHF 2012 criteria; predictors were identified using random-effects logistic regression with school as random intercept. Ethical approval was from the Nepal Health Research Council (Protocol No. 155/2023). Overall prevalence of borderline or definite RHD was 18.7 per 1,000 (95% CI 15.1-23.0); definite RHD was 6.8 per 1,000 (95% CI 4.7-9.7) and borderline RHD 11.9 per 1,000 (95% CI 9.0-15.5). Prevalence was higher in girls (23.3 per 1,000) than boys (13.6 per 1,000; P=0.02), with the peak in girls aged 10-14 years (26.0 per 1,000). Subclinical disease accounted for 64.7% of cases; auscultation sensitivity was 35.3%. Mitral valve involvement predominated. Female sex was the sole independent predictor (OR 1.60, 95% CI 1.02-2.53; P=0.043). The school-level ICC was 0.19 (95% CI 0.07-0.44; P<0.001), giving a design effect of {approx}109. The echocardiographic RHD burden in Dhanusha (18.7 per 1,000) is the highest documented in Nepal. Two-thirds of cases are subclinical. Female sex and school attended explain a similar amount of variance in RHD risk, supporting school-targeted screening and informing sample size planning for future cluster-based surveillance.

Background The use of Assisted Reproductive Technology (ART) is increasing worldwide. These treatments involve ovarian stimulation to enable multiple follicle recruitment, hence inducing supraphysiological estrogen levels. While most long-term follow-up of women undergoing ART has concerned cancer incidence, the long-term safety regarding cardiovascular and metabolic diseases remains under-explored. This study was performed to assess the risk of acute myocardial infarction, cerebral ischemic conditions, intracranial hemorrhage, type 2 diabetes mellitus, heart failure, aortic aneurysm or dissection, and chronic kidney disease in women that conceived with ART, and to investigate the role of the underlying infertility and its risk factors. Methods and Findings Swedish national registers allowed us to follow a nationwide cohort of 380,756 women from their first birth between 1992 and 2002 until the end of 2023. The safety of ART was evaluated by comparing women with infertility who conceived with and without ART, while adjusting for baseline differences in age, body mass index, country of origin, socioeconomic factors, pre-existing comorbidity, smoking and year. The role of infertility was additionally explored by comparing all women with and without infertility adjusting for age, as well as the aforementioned baseline characteristics. Cumulative risks were plotted using inverse-probability weighted Kaplan-Meier curves. To facilitate the comparison of groups we also estimated risk differences and ratios at 10-, 20-, and 30-years of follow-up. Use of ART was not associated with cardiovascular disease except for an excess risk of cerebral ischemic conditions, with a 30 year risk ratio of 1.43 (1.09; 1.89). With the exception of cerebral ischemic conditions, intracranial hemorrhage, aortic dissection, and chronic kidney disease, women with a history of infertility exhibited consistently higher risk of all outcomes, adjustment for differences in baseline characteristics explained some but not all of these elevated risks. Conclusions With the exception of ischemic cerebral conditions, the findings provide reassurance regarding the long-term cardiometabolic safety of ART use, while adding to the growing literature suggesting that infertility can act as a marker of womens cardiovascular and metabolic disease.

Background Cardioplegic arrest during complex aortic arch repair imposes prolonged global myocardial ischaemia, which may contribute to postoperative low cardiac output syndrome (LCOS) and mortality. Whether cardioplegic arrest can be entirely avoided -- performing the complete procedure on a continuously perfused, beating heart -- has not previously been evaluated in a clinical series. Methods and Results Between November 2017 and January 2026, 29 consecutive patients underwent total beating-heart aortic arch repair without any cardioplegic arrest at a single centre. Continuous antegrade myocardial perfusion (warm blood, 34{degrees}C, 300-400 mL/min, perfusion pressure 60-80 mmHg) was delivered via an aortic root needle vent throughout each procedure. Two variants were employed: axillary cannulation with selective antegrade cerebral perfusion (n = 24, 82.8%), and direct aortic cannulation with extra-anatomical left carotid bypass for distal Zone 2 pathology (n = 5, 17.2%). Mean age was 55.4 {+/-} 13.6 years; 41.4% presented with aortic dissection (B/non-A-non-B). No patient required conversion to cardioplegic arrest. Perioperative myocardial infarction and LCOS occurred in none of the patients. Median peak CK-MB was 44.0 U/L. Thirty-day mortality was 10.3% (n = 3); all deaths were due to respiratory failure or visceral ischaemia complicating acute type B dissection. Conclusions Total beating-heart aortic arch repair without cardioplegic arrest is technically feasible and clinically safe in appropriately selected patients and is associated with the complete absence of perioperative myocardial infarction and LCOS across a heterogeneous, high-risk cohort. These findings support prospective, multicentre evaluation of no-arrest myocardial protection as a strategy to reduce the cardiac morbidity of complex arch surgery.

Catheter ablation is an established rhythm-control strategy for atrial fibrillation, but outcomes in persistent atrial fibrillation (PsAF) remain heterogeneous across evolving strategies and energy modalities. An updated synthesis is needed to define current effectiveness and adverse-event profiles in the modern ablation era. We conducted a systematic review and meta-analysis of prospective clinical trials of catheter ablation for PsAF published from 2010 through December 2025. We included randomized and nonrandomized prospective interventional studies reporting effectiveness and adverse events, and pooled outcomes using random-effects models. Prespecified subgroup analyses evaluated ablation strategy (pulmonary vein isolation [PVI] vs PVI with adjunctive lesion sets [PVI+]), ablation modality (radiofrequency [RF], cryoballoon [CRYO], and pulsed field [PF]), and endpoint definition (recurrence-only vs composite measures). Thirty-two studies (9,194 patients) met inclusion criteria; 28 (7,948 patients) contributed to effectiveness analyses. The pooled 12-month arrhythmia-free proportion was 0.65 (95% CI, 0.61-0.68), with substantial heterogeneity. Effectiveness was numerically higher with PVI+ than PVI-only (0.66 [0.60-0.72] vs 0.63 [0.59-0.67]), similar for PF (0.65 [0.57-0.72]) and RF (0.65 [0.61-0.69]), and slightly lower for CRYO (0.64 [0.54-0.74]). Recurrence-only endpoints yielded higher effectiveness than composite endpoints (0.67 [0.63-0.71] vs 0.60 [0.55-0.64]). Safety analyses included 32 studies (9,002 patients). Adverse events were low but heterogeneous (0%-14.56%); pooled vascular access and pericardial complication incidences were each 1%, while thromboembolic events, accessory organ injury, and mortality were rare (pooled 0%). PF ablation showed numerically lower overall complication incidences than RF and CRYO. In contemporary trials, catheter ablation for PsAF shows moderate effectiveness and low overall adverse-event risk. Adjunctive strategies and PF ablation are promising, but no approach is consistently superior. These findings support tailored, patient-specific ablation selection in PsAF.