International Journal of Cardiology

BackgroundDespite improvements in PCI techniques and equipment, there are still cases where traditional PCI is insufficient to manage complex and high-risk lesions. Patients with these lesions have increased rates of major adverse cardiac events, including myocardial infarction, cardiogenic shock, and death. In recent years, the use of extracorporeal membrane oxygenation (ECMO) during PCI has emerged as a potential solution to managing complex and high-risk lesions. MethodsThis retrospective study included patients who underwent elective complex and high-risk percutaneous coronary interventions with hemodynamic support provided by Veno-Arterial external membrane oxygenation (VA-ECMO) from 2018 to 2022. Complications related to VA-ECMO rates, Complications related to PCI, death, and major cardiovascular, cerebral events (MACCE) during hospitalization and after one-year follow-up were analyzed. ResultsThis retrospective study overall included 81 patients in which Males (N=60, 74.1%) and females (N=21, 25.9%) having (Average age: 62.74 {+/-}10.807 years) underwent complex and high-risk percutaneous coronary intervention assisted ECMO. The VA-ECMO support was provided for an average of 21.0 hours (With a range of 1-312). Intra-aortic Balloon Pump IABP support was done in 32.1% of patients. The pre-and post-PCI SYNTAX scores of the patients were 39.92 {+/-} (6.4) and 6.04 {+/-} (9.25) respectively. (P <0.001). Most of the patients had triple vessel coronary disease which was the common coronary lesion (47%). Interoperated complications include Cardiac Tamponade (N=1,1.2%), Acute Myocardial Infarction (N=6,7.2%), Cardiogenic Shock (N=2,2.4%), Cardiac Arrest (N=2,2.4%), Arrhythmias malignant in nature which required electro cardioversion (2,2.4%), Ventricular tachycardia (N=1,1.2%), Non-infectious multiple organ failure MODS(N=1,1.2%), Aortic Dissection Type-A (N=1,1.2%). Blood hemoglobin Pre-CHIP assisted VA-ECMO PCI and Post-procedure were 136.17 {+/-} 21.479 g/L and 106.67 {+/-} 19.103 g/L respectively P<0.001). eGFR pre and post-PCI were 67.22 {+/-} 26.85 and 60.09 {+/-} 27.78 respectively (<0.002), Pre and Post PCI EF were 38.69 {+/-} 13.65 and 43.55 {+/-} 13.72 respectively (<0.001), During hospitalization the outcomes for the CHIP assisted by ECMO procedure include Death(N=16,19.8%), Inguinal Hematoma (N=2,2.5%), Bleeding from the punctured site (N=2,2.5%), Peudoaneurysm (N=1,1.2%), Cerebral Infarction(N=1,1.2%), Subarachnoid hemorrhage (N=1,1.2%), No lower limb ischemia, No acute renal injury, Bacteremia, were noted in any of the hospitalization. Patient Hb decline requiring blood transfusion therapy was (N=59, 72.8%). Survival at discharge (Healthy) was (N=65, 80.2%). After one year of post-operation death (N=6, 7.2%) ConclusionIn conclusion, ECMO-assisted high-risk PCI proves to be a safe and effective strategy for complex procedures in patients who are not candidates for Coronary artery bypass grafting (CABG). The use of VA-ECMO resulted in minimal complications and low rates of MACCE during hospitalization and one-year follow-up. Further research is needed to determine the optimal timing for VA-ECMO initiation.

Heart failure that has a lower ejection fraction (HFrEF) is a major cause of morbidity and mortality in the world. Left bundle branch area pacing (LBBAP) has become a viable option compared to conventional cardiac resynchronization therapy (CRT) to patients with conduction system abnormalities, including left bundle block (LBBB). Yet, there is a group of patients that are not responsive to LBBAP. Predictors of non-response identification is the key to maximizing patient selection and therapy outcomes.This multicenter cohort study was conducted in patients with HFrEF (LVEF 35 % or less) and who had LBBAP implantation. Baseline clinical, electrophysiological and imaging data were taken. Response was considered as an absolute improvement in left ventricular ejection fraction (LVEF) 5% and decrease in left ventricular end-systolic volume (LVESV) 15% 6 months. The predictors of non-response were found using multivariate logistic regression.:Sixty percent of the patients were responders and 30 percent were non-responders at 6-month follow-up. Ischemic heart disease (OR 2.3, p = 0.010), LVEDD > 60 mm (OR 3.2, p = 0.001), QRS duration > 170 ms (OR 2.1, p = 0.022) and presence of myocardial scar (OR 1.8, p = 0.047) were significant predictors of non-response. LVEF and LVESV improved greatly in the responders and did not improve in non-respondents.:LBBAP is useful in the treatment of most patients with HFrEF, although non-response is more frequent in patients with ischemic heart disease, increased LVEDD, longer QRS, and myocardial scarring. These are the factors that should be taken into consideration when choosing the candidates to be recruited in LBBAP, and other strategies might be required in the case of patients at high risk.

BackgroundNew-onset permanent pacemaker implantation (PPMI) is still a common complication after transcatheter aortic valve implantation (TAVI) with adverse clinical outcomes. This study aims to investigate whether left bundle branch area pacing (LBBAP) improves long-term clinical results compared to traditional right ventricular pacing (RVP) in patients requiring PPMI following TAVI. MethodsA total of 237 consecutive patients undergoing RVP (N=117) or LBBAP (N=120) following TAVI were retrospectively included. Long-term outcomes including all-cause death, heart failure rehospitalization (HFH) and left ventricular ejection fraction (LVEF) change compared to baseline were obtained until 5 years post-TAVI. ResultsThe mean age of the overall population was 74 years with a mean surgical risk score as 4.4%. The paced QRS duration was significantly shorter in LBBAP group compared to RVP group (151 {+/-} 18 vs. 122 {+/-}12 ms, P<0.001). There was no difference between two groups in all-cause death (13.7% vs. 13.3%, adjusted HR: 0.76; 95% CI: 0.37 to 1.58; P=0.466) or the composite endpoint of death and HFH (29.9% vs. 19.2%, adjusted HR: 1.22; 95% CI: 0.70 to 2.13; P=0.476), however, the risk of HFH was significantly reduced in LBBAP group compared to RVP at 5 years after TAVI (21.4% vs. 7.5%, adjusted HR: 2.26; 95% CI: 1.01 to 5.08; P=0.048). There was a more marked evolution of LVEF over time in LBBAP group (P=0.046 for LVEF changes over time between groups). ConclusionsLBBAP improved long-term clinical outcomes compared to RVP in patients undergoing PPMI after TAVI in terms of less HFH and better LVEF improvement.

BackgroundCoronary chronic total occlusions (CTOs) are considered to increase the risk of adverse clinical outcomes. The purpose of this study was to evaluate whether long-term clinical outcomes could be improved by successful percutaneous coronary intervention (PCI) over optimal medical therapy (OMT) in CTO patients. Methods258 consecutive patients with CTO lesions undergoing PCI at the First Affiliated Hospital of Nanjing Medical University from January 2011 to December 2017 were enrolled. After 25 were excluded due to CABG surgery, a total of 233 patients who met the enrollment criteria were divided into successful CTO-PCI group (n=187) and CTO-OMT group (n=46) based on the treatment received. The study primary endpoint was major adverse cardiac cerebrovascular events (MACCE), including cardiac death, recurrent myocardial infarction, unplanned revascularization, and stroke. The secondary endpoint was all-cause death. ResultsDuring a median follow-up of 78 months, PCI treatment significantly improved MACCE incidence survival probability compared with OMT (29.55% vs 21.95% p=0.028). There was no difference between these two groups in secondary endpoint (p=0.93). There was also no significant difference in MACCE between single vessel CTO lesions and single vessel CTO combined with multiple vessel lesions(p=0.54). The cumulative survival of LAD is the highest among different branch lesion groups(p=0.044). Elderly patients ([&ge;]65 years) in PCI group showed a significant decrease of MACCE incidence compared with OMT (35.00% vs 21.33% p=0.001). ConclusionsSuccessful PCI in CTO patients is associated with a significant decrease of MACCE compared with OMT.

ObjectiveTo analyze the current situation of reperfusion strategies of ST-segment elevation myocardial infarction (STEMI) in China and evaluate the efficacy and safety of different reperfusion strategies, especially pharmaco-invasive percutaneous coronary intervention (PI-PCI). MethodsThe CCC-ACS (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) project is a joint study between the American Heart Association and Chinese Society of Cardiology (CSC). STEMI patients who were recruited to the CCC-ACS project between November 2014 and December 2019 and admitted within 48 hours after symptom onset and treated by thrombolysis or percutaneous coronary intervention (PCI) were included in this cohort study. The primary efficacy outcomes were major adverse cardiac cerebrovascular events (MACCEs) that occurred during hospitalization. The primary safety outcomes were Thrombolysis in Myocardial Infarction (TIMI) major or minor bleedings criteria during hospitalization. Univariate regression logistic analysis, multivariable logistic regression analysis, propensity score-matched analysis, and inverse probability of treatment weighting analysis were performed to evaluate the efficacy and safety of different reperfusion strategies. ResultsOf 37733 STEMI patients, 35019 patients received primary percutaneous coronary intervention (PPCI), 999 patients received thrombolysis and 1715 patients received PI-PCI. Compared with PPCI, the thrombolysis group had higher incidence of all cause death (1.6% vs 2.8%, P =0.003), MACCEs (2.0% vs 3.6%, P < 0.001), and TIMI major bleedings (1.2% vs 2.2%, P=0.007). In the PI-PCI group, the incidence of MACCEs (2.0% vs 0.8%, P =0.001), all cause death (1.6% vs 0.4%, P =0.001), and cardiac death (1.5% vs 0.4%, P =0.001) were significantly lower than PPCI group; and the same conclusion was found in the subgroup of in time from first medical contact(FMC) to reperfusion [&ge;] 3h. However, the risk of TIMI minor bleedings (5.1% vs 6.7%, P=0.008) was higher in the PI-PCI group in the subgroup of in time from FMC to reperfusion [&ge;] 3h. Compared with timely PPCI group, the incidence of all cause death was significantly lower and the incidence of heart failure was higher in the scheduled PCI group. Compared with late PPCI group, the incidence of all cause death, MACCEs were significantly lower in scheduled PCI group. Compared with timely PPCI, the ratio of heart failure was statistically significant higher in the rescue PCI group. There was no significant difference in all outcomes in all models between rescue PCI group and late PPCI group. Moreover, compared with scheduled PCI [&le;] 24h group, the scheduled PCI during 24h to 7d group had lower risk of TIMI major or minor bleedings and the scheduled PCI >7d group had the similar risk of bleedings; the scheduled PCI >7d group had lower risk of heart failure. ConclusionsThis study demonstrates that in STEMI patients who could not perform timely PPCI, PI-PCI is feasible, including rescue PCI,which can reduce the rate of MACCEs and mortality during hospitalization.But the increased risk of bleedings also should be noted.In scheduled PCI after successful thrombolysis, appropriate extension the time window of scheduled PCI can be considered under stable clinical conditions.

IntroductionTimely reperfusion within 120 minutes is strongly recommended in patients presenting with non-ST segment myocardial infarction (NSTEMI) with very high-risk features. Evidence regarding the use of high sensitivity cardiac troponin (hs-cTn) concentration upon admission for the risk-stratification of patients presenting with NSTEMI in order to expedite percutaneous coronary intervention (PCI) and thus potentially improve outcomes is limited. MethodsAll patients admitted to a tertiary care center intensive cardiac care unit (ICCU) between July 2019 - July 2022 were included and were followed for up to 3 years. Hs-cTnI level on presentation was recorded and patients were divided into four quartiles according to their hs-cTnI level on admission. Association between the initial hs-cTnI level and all-cause mortality during the follow-up period was examined. ResultsA total of 544 NSTEMI patients with a median age of 67 were included. There was no difference between the initial hs-cTnI level groups regarding age and comorbidities. A higher mortality rate was observed in the highest hs-cTnI quartile as compared with the lowest hs-cTnI quartile (16.2% vs. 7.35%, p=0.03) with Hazard ratio (HR) for mortality of 2.6 (CI: 1.23-5.4; p=0.012). ConclusionsPatients presenting with NSTEMI and higher Hs-cTnI levels on admission were at higher risk for mortality during follow-up. This finding supports further prospective studies to examine the impact of early reperfusion strategy on mortality in patients presenting with NSTEMI according to degree of troponin elevation on admission.

Meta-analysis exploring outcomes beyond 5-years of trials comparing coronary artery bypass graft (CABG) with percutaneous coronary intervention (PCI) utilizing drug-eluting stents in patients with coronary artery disease (CAD), are missing. We conducted a meta-analysis to compare very long-term outcomes, between the two interventions. Using electronic databases, we retrieved 4 trials, between January, 2010 and January, 2023. The primary endpoint was all-cause mortality. Kaplan-Meier curves of endpoint was reconstructed. Comparisons were made by Cox-linear regression frailty model and by landmark analysis. A flexible parametric model for survival analysis was used to obtain the time-dependent hazard-ratio. A random-effect method was applied. 5180 patients were included and randomized to CABG (n=2586) or PCI with DES (n=2594). During 10-year follow-up, PCI showed an overall higher incidence of all-cause mortality [hazard ratio (HR) 1.19; 95% confidence interval (CI), 1.104-1.32; p=0.008)]. At landmark analysis, PCI showed higher risk of the endpoint within 5-years (HR 1.2; 95% CI, 1.06-1.53; p=0.008) while no difference was found at 5-10-year period (HR,1.03; 95%CI, 0.84-1.26; p=0.76). The time-varying HR analysis of PCI versus CABG was consistent with the results of the landmark analysis. There was no long-term difference between the two interventions for myocardial infarction (MI) (OR,1.42; 95%CI, 0.92-2.18; p=0.11), composite of all-cause mortality, stroke or MI (OR,1.07; 95%CI, 0.84-1.36; p=0.57), stroke (OR,0.97; 95%CI, 0.59-1.59; p=0.91) and cardiovascular death (OR,1.02; 95%CI, 0.75-1.40; p=0.90), while PCI was associated with an increased risk for repeat revascularization (OR,2.11; 95%CI, 1.58-2.81; p<0.001) and major adverse cardiac and cerebrovascular events (OR,1.41; 95%CI, 1.13-1.75; p<0.0001). In conclusion, in patients with CAD, there was a significantly overall higher incidence of all-cause mortality after PCI compared to CABG beyond 5-year follow-up. Specifically, CABG is still favorable beyond 5 years and maintains its gold standard role for the CAD treatment; PCI has an evident higher mortality during the first 5 years and a comparable outcome beyond 5 years.

BackgroundThe efficacy of intravenous steroids (IS) in patients with fulminant myocarditis presentation (FMP) remains controversial. We aimed to compare the clinical outcomes between patients with FMP who received IS (IS(+)) and not received IS (IS(-)). MethodsFrom the Japanese Registry of Fulminant Myocarditis, we extracted the data of patients requiring catecholamines or mechanical support, with histologically confirmed FMP. The primary outcome was a composite of mortality and heart transplantation within 90 days. We assessed the impact of IS on outcomes using the Kaplan-Meier method, log-rank test, and Cox regression analysis. Patients were categorized according to the number of prognostic factors (age [&ge;]55 years, non-sinus rhythm, left ventricular ejection fraction [LVEF] <40% at admission, ventricular tachycardia/fibrillation on the first day, and the presence of giant cell myocarditis); the relationship between the 90-day prognosis and IS use within these categories. ResultsOf 344 patients (median age: 54 years; 40% female), 98 died within 90 days and 16 died after 90 days. IS was administered in 195 patients. The proportion of patients with lymphocytic myocarditis and LVEF were lower in the IS(+) group than in the IS(-) group. Intra-aortic balloon pumping, extracorporeal membrane oxygenation, and intravenous immunoglobulin administration were more common in the IS(+) group than in the IS(-) group. Analysis of the entire cohort indicated worse 90-day outcomes in the IS(+) group than in the IS(-) group (36.3% vs. 19.2%, P=0.0021); however, there was no substantial difference after propensity score matching (PSM; 26.2% vs. 24.2%; P=0.95). On unadjusted Cox regression, IS use was associated with worse 90-day outcomes (hazard ratio, 1.95 [95% confidence interval, 1.26-3.04]; P=0.0026). However, after PSM, this association was no longer significant (1.02 [0.56-1.87], P=0.95). Similar results were observed among patients with lymphocytic myocarditis. The prognosis was notably worse with IS administration than without IS administration among low-risk patients (P=0.001). ConclusionsIS may not provide prognostic advantages for patients with FMP. The adverse effects of IS might be more pronounced in low-risk patients. RegistrationURL: https://www.umin.ac.jp/ctr; Unique identifier: UMIN000039763. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIIntravenous steroids were commonly administered in more severe cases, particularly in patients diagnosed with eosinophilic myocarditis or giant cell myocarditis. C_LIO_LIWhile the prognosis was poorer in patients who received intravenous steroids than in those who did not, the outcomes were similar when comparing cohorts matched on patient background factors. C_LIO_LINotably, prognosis was worse in low-risk patients who were administered intravenous steroids. C_LI What Are the Clinical Implications?O_LIAdministering intravenous steroids might not yield any prognostic advantage for patients with fulminant myocarditis. Further, the potential negative effects of intravenous steroids appear to be more pronounced in low-risk patients. C_LIO_LIThus, clinicians should be cautious about administering intravenous steroids, especially in those identified as low-risk. C_LI

IntroductionDegenerative mitral valve disease (DMR) is a common valvular disorder, and flail leaflet due to ruptured chordae represents an extreme variation of this pathology. Ruptured chordae can present as acute heart failure which requires urgent intervention. Mitral valve surgery is the preferred mode of intervention; however, some patients represent as a significant surgical risk and are often deemed to be inoperable. We aim to characterize patients with ruptured chordae undergoing urgent transcatheter edge-to-edge repair (TEER), and to analyze their clinical and echocardiographic outcomes. MethodsAt a referral center for several hospitals across Israel, we screened all patients who underwent TEER. We included patients with DMR with flail leaflet due to ruptured chordae, and categorized them into elective and critically ill groups. We evaluated the echocardiographic, hemodynamic and clinical outcomes of these patients. ResultsThe cohort included 49 patients with DMR due to ruptured chordae and flail leaflet, who underwent TEER. Seventeen patients (35%) underwent urgent intervention and 32 patients (65%) underwent an elective procedure. In the urgent group, the average age of the patient was 80.3, with 41.8% being female. Fourteen (82%) received noninvasive ventilation, while three patients (18%) required invasive mechanical ventilation. One patient died due to tamponade, while the other 16 patients all had successful reduction of [&ge;]2 in the MR grade. Left atrial V wave decreased from 41.6 mmHg to 17.9 mmHg (p<0.001), and pulmonic vein flow pattern changed from reversal (68.8%) to a systolic dominant flow in all patients (p=0.001). After the procedure, 78.5% of patients were in New York Heart Association (NYHA) class I or II (p<0.001). There was no significant difference in the overall mortality between the urgent and elective groups, with similar survival rates of 6 months for each group. ConclusionTEER can be safe and feasible with favorable hemodynamic, echocardiographic and clinical outcomes in patients undergoing urgent intervention for flail mitral valve disease. Clinical PerspectivesO_LIMitral transcatheter edge-to-edge repair (TEER) is a proven therapy for patients with chronic mitral regurgitation, however data on patients with acute mitral regurgitation limited. This article focuses on acute TEER intervention and provides further information on the safety, feasibility and effectiveness of TEER in critically ill patients due to flail leaflet. C_LIO_LIThe clinical finding supports the role of acute TEER intervention in acutely ill patients with acute mitral regurgitation due to ruptured chordae and flail leaflet. C_LI

IntroductionChanges in tricuspid regurgitation (TR), mitral regurgitation (MR) and left ventricular ejection fraction (LVEF) are frequently noted after conventional pacemaker implantation but prior studies evaluating whether left bundle branch area (LBBA) or leadless pacemakers modify those observed changes are limited. This study aims to compare changes in TR, MR and LVEF after implantation of conventional right ventricular (RV), leadless, and LBBA pacemakers. MethodsInclusion criteria were first-time pacemaker implantation and pre- and post-implant echocardiography. Change in TR, MR and LVEF were analyzed using post-hoc adjusted Kruskal-Wallis and chi-squared testing, and multivariable ordinal logistic regression. ResultsAmong 400 consecutive patients (RV, n=228; LBBA, n=136; leadless, n=36), the change in TR grade differed between pacemaker types (median [interquartile range] grade change: LBBA 0[0,0], leadless 0[0,1], RV 0[0,1]; p<0.01). The prevalence of severe TR was similar between pacemaker groups before implant (p=0.93), but more frequent following implant of RV and leadless pacemakers compared to LBBA pacemakers (p=0.02). In multivariable ordinal logistic regression, leadless (OR 2.26, p=0.03) and RV pacemakers (OR 1.66, p=0.03) both predicted TR worsening compared to LBBA. The change in MR grade differed between pacemaker types (grade change: LBBA 0[-1,0], leadless 0[0,1], RV 0[0,0]; p<0.01). The change in LVEF differed between pacemaker types (LVEF change: LBBA 0[- 5,7]%, leadless -5[-14,1]%, RV -3[-9,2]%; p<0.01). ConclusionChange in TR, MR grade and LVEF following pacemaker implant varied by pacemaker type. Compared to leadless and RV, LBBA pacemaker implant was associated with more favorable changes in valvular and ventricular function. Graphical Abstract O_FIG O_LINKSMALLFIG WIDTH=191 HEIGHT=200 SRC="FIGDIR/small/25327288v1_ufig1.gif" ALT="Figure 1"> View larger version (63K): org.highwire.dtl.DTLVardef@1995106org.highwire.dtl.DTLVardef@967746org.highwire.dtl.DTLVardef@70c52dorg.highwire.dtl.DTLVardef@1a142ec_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundCardiac Allograft vasculopathy (CAV) is a significant cause of late transplant failure. Using a large database, the studys objective was to assess traditional and infectious risk factors linked to the occurrence and severity of CAV. MethodUsing the large inpatient sample database (NIS), we evaluated any association between CAV and risk factors and infectious viral agents. Additionally, we assessed the severity of CAV based on the occurrence of revascularizations. ResultsA total of 78,330 heart transplant recipients were identified. CAV was diagnosed in 1,015 patients overall. Patients with CAV had a higher mortality rate (4.4% vs 2.1%, OR: 2.09 CI 1.08-4.03 p=0.03). All known traditional risk factors and baseline characteristics, including gender, race, hypertension, hyperlipidemia, diabetes mellitus, and smoking, were not linked to the existence of CAV, except for being younger (mean age 56 vs 59 years). Furthermore, a history of infectious mononucleosis strongly correlated with CAV (OR:8.9 CI 2.68-29.6 p<0.001). Being younger not only increases the possibility of the development of CAV but also increases the probability of undergoing coronary bypass surgery after a heart transplant. Influenza and other forms of viral infections, such as Cytomegalovirus, did not correlate with the presence of CAV. ConclusionYounger age was associated with CAV but no other traditional risk factors. Infectious mononucleosis, the only infectious agent correlating with CAV, had a very high association with CAV, warranting further investigation.

BackgroundImpella and intra-aortic balloon pumps (IABP) are commonly utilized in patients with cardiogenic shock. However, the effect on mortality remains controversial. The goal of this study was to evaluate the effect of Impella and IABP on mortality and complications in patients with cardiogenic shock. MethodThe large Nationwide Inpatient Sample (NIS) database was utilized to study any association between the use of IABP or Impella on mortality and complications in adults with a diagnosis of cardiogenic shocks. ResultsICD-10 codes for Impella, IABP, and cardiogenic shock for available years 2016-2020 were utilized. A total of 844,020 patients had a diagnosis of cardiogenic shock. 101,870 were treated with IABP and 39,645 with an Impella. Total inpatient mortality without any device was 34.2% vs only 25.1% with IABP use (OR=0.65, CI 0.62-0.67) but was highest at 40.7% with Impella utilization (OR=1.32, CI 1.26-1.39). Using multivariate analysis adjusting for 47 variables such as age, gender, race, lactose acidosis, three-vessel intervention, left main myocardial infarction, cardiomyopathy, systolic heart failure, acute ST-elevation myocardial infarction, peripheral vascular disease, chronic renal disease, etc., Impella utilization remained associated with the highest mortality (OR: 1.33, CI 1.25-1.41, p<0.001) whereas IABP remained associated with the lowest mortality (OR: 0.69, CI 0.66-0.72, p<0.001). Separating rural vs teaching hospitals revealed similar findings. ConclusionIn patients with cardiogenic shock, the use of Impella was associated with the highest whereas the utilization of IABP was associated with the lowest in hospital mortality regardless of comorbid condition, high-risk futures, or type of hospital.

Background and aimsIn Chinese patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS), it is essential to evaluate the net clinical benefit (NCB) of fondaparinux compared to low molecular weight heparin (LMWH) in NSTE-ACS patients with varying bleeding and ischemic risks. MethodsThis multicenter, prospective, open-label, real-world study enrolled 8066 adult patients undergoing non-emergency percutaneous coronary intervention (PCI) at 88 hospitals from July 2019 to July 2021. Patients received fondaparinux (2.5 mg/d) or LMWH (1 mg/kg, twice/day) were followed up within 6 months. The GRACE and CRUSADE scores were used to stratify the included patients. The primary outcome was the incidence of NCB event (all-cause death, reinfarction, nonfatal stroke, or BARC[&ge;] type 2 bleeding) at 30 days. ResultsA total of 5430 patients received fondaparinux and 2636 received LMWH. The NCB outcome occurred in 136 patients (2.5%) receiving fondaparinux and in 110 patients (4.2%) receiving LMWH [HR=0.594 (95% CI: 0.462, 0.764), p<0.001]. The 30-day incidence of BARC[&ge;]2 bleeding was significantly lower in the fondaparinux group compared with the LMWH group [68 (1.3%) vs. 66 (2.5%), HR=0.498 (95% CI: 0.355, 0.699), p<0.001].Among patients with lower risk, defined by GRACE score[&le;]140 and CRUSADE scores[&le;]40, fondaparinux significantly reduced the incidence of MACE and BARC [&ge;] 2 bleeding. Fondaparinux decreased the risk of BARC[&ge;]2 bleeding across different risk groups, with absolute risk reductions (ARD) of -0.9% for CRUSADE score[&le;]40, -3.0% for CRUSADE score>40, -1.2% for GRACE score[&le;]140, and -1.7% for GRACE score>140, indicating a more pronounced protective effect in individuals at high bleeding risk. ConclusionsIn Chinese patients with NSTE-ACS, fondaparinux effectively diminished the incidence of the NCB event of 30 days compared with LMWH. Additionally, fondaparinux exhibited superior safety than LMWH in patients with high bleeding risk, consistently outperformed LMWH in terms of efficacy and safety in the low-risk group as well.

Refractory postoperative vasoplegia following cardiac surgery and left ventricular assist device (LVAD) implantation predicts poor outcomes. We aimed to investigate outcomes and predictors of postoperative vasoplegia. We retrospectively reviewed a single-center cohort of 190 patients who received LVADs from January 2015 through March 2022 at The Ohio State Wexner Medical Center. Primary outcomes included duration of ICU stay, development of right heart failure (RHF), and mortality. Secondary outcomes included pre-implant medications and post-implant blood products. Vasoplegia was defined as physician documentation of vasoplegia with patients requiring [&ge;]1 intravenous vasopressors within 48-hours following LVAD implantation to maintain a mean arterial pressure >65 mmHg for >24 hours. Overall, 55 (29%) patients developed vasoplegia following LVAD implantation. Our sample was stratified into two cohorts: patients with vasoplegia and without vasoplegia. Baseline characteristics, LVAD indication, creatinine clearance, and comorbidities did not vary significantly between cohorts. Patients without vasoplegia were more likely to have prior implantable cardiac defibrillators (p = 0.02) and were more commonly prescribed pre-operative inotropes (p = 0.03). Blood-product administration within the first 48-hours postoperatively did not differ. While patients with vasoplegia required a longer ICU stay post-op (5 vs 7 days, p = 0.03), there were no significant differences in development of RHF (39% vs 44%), 30-day (7% vs 13%), 1-year (31% vs 29%), and 2-year mortality (39% vs 33%) in patients without and with vasoplegia, respectively. Overall, our vasoplegia rates were consistent with previous literature (29%) and vasoplegia did not confer inferior outcomes for mortality or developing RHF.

BackgroundDespite extensive research on coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) outcome differences, current literature lacks representation of short-term in-hospital outcomes in patients with existing medical conditions. This study aimed to compare perioperative outcomes of these two revascularization procedures in diabetes mellitus (DM) patients. MethodsThe National Inpatient Sample (NIS) was used to extract patients who received CABG or PCI surgery between the last quarter of 2015 to 2020 based on ICD10-PCS. Patients of age<40 were excluded for congenital heart defects. Preoperative differences were noted and adjusted using multivariable logistic regression. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were estimated between PCI and CAGB groups. ResultsA total number of 90,662 CABG and 173,725 PCI cases of patients with DM were identified in NIS. Compared to CABG, patients who underwent PCI had increased mortality (2.75% vs 2.00%, aOR 1.266, p<0.0001), myocardial infarction (1.5% vs 1.17%, aOR 1.223, p<0.0001), and were less likely to experience respiratory events (0.38% vs 6.33%, aOR 0.055, p<0.0001), stroke (0.03% vs 0.06%, aOR 0.385, p<0.0001), acute kidney injury (20.37% vs 25.37%, aOR 0.727, p<0.0001), sepsis (0.01% vs 0.05%, aOR 0.172, p<0.0001), shock (0.11% vs 0.74%, aOR 0.139, p<0.0001). ConclusionsThe NIS database collects enormous records from nationwide providers, offering great statistical power. PCI was associated with a markedly higher in-hospital mortality rate but a lower morbidity rate in patients with DM as compared to CABG. Therefore, physicians should weigh both mortality and morbidity when considering surgical treatment to DM patients.

BackgroundTemporal trends in the management of acute coronary syndrome (ACS) complicated with cardiogenic shock (CS) after the revision of the guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella require further investigation as their impact remains uncertain. MethodsUsing the Japanese Percutaneous Coronary Intervention (J-PCI) registry database from 2019 to 2021 (734,379 patients from 1,190 hospitals), we extracted 24,516 patients undergoing PCI for ACS complicated with CS. Of those, 12,171 patients (49.6%) used mechanical circulatory support (MCS) during the procedure. The patients were stratified into three groups: (i) IABP alone, (ii) Impella, and (iii) venoarterial extracorporeal membrane oxygenation (VA-ECMO); the VA-ECMO group was further stratified into (iiia) VA-ECMO alone, (iiib) VA-ECMO in combination with the IABP, and (iiic) VA-ECMO in combination with the Impella (ECPella). The quarterly prevalence and outcomes were reported. ResultsDuring the study period, there were notable changes in the prevalence of different MCS modalities and their associated outcomes. The use of an IABP alone and VA-ECMO decreased significantly from 63.5% and 34.4% in the first quarter of 2019 to 58.3% and 33.0% in the fourth quarter of 2021, respectively (P for trend = 0.01 and 0.02, respectively). Among the subset of patients who required VA-ECMO (n = 4,245), the use of VA-ECMO in combination with the IABP decreased significantly from 78.7% to 67.3%, whereas the use of ECPella increased significantly from 4.2% to 17.0% (P for trend <0.001 for both). There was no significant change in the use of VA-ECMO alone. In-hospital mortality decreased significantly over time in both the overall population of patients requiring MCS and those requiring VA-ECMO (P for trend = 0.004 and <0.001, respectively). ConclusionsIn conclusion, our study revealed significant changes in the use of different MCS modalities and associated outcomes in ACS complicated with CS, highlighting the evolving patterns of MCS utilization during the study period.

IntroductionProsthetic valve endocarditis (PVE) is a known complication of prosthetic valve implantation (PVI). The incidence of selective native valve endocarditis without concurrent PVE, or isolated native valve endocarditis (INVE), is much lower and largely unheard of in literature. MethodsWe examine here the specific circumstances in which INVE manifests as well as management and complications of this rare form of endocarditis. A systematic review of four major databases was carried out to identify INVE and PVE cases after various PVIs. INVE was compared to PVE across categories such as patient demographics, method and type of PVI prior to endocarditis, pathogen type, management, and outcomes. ResultsINVE comprised 18.2 % of valvular endocarditis cases after transcatheter aortic valve implantation (TAVI) and 6.5 % of valvular endocarditis cases after surgical aortic valve implantation (SAVI). In the TAVI group, mean age of the INVE cohort was 79.5 +- 5 years and it was observed more frequently among males. Prior to most INVE cases, TAVI had been performed by transfemoral route. INVE was more closely linked to diabetes (DM) and chronic obstructive pulmonary disease (COPD) than TAVIE (transcatheter aortic valve implant endocarditis). INVE was less closely linked to chronic kidney disease (CKD) than TAVIE. Gram positive infection rates were similar between the groups. Surgery was done less frequently after INVE than TAVIE. Compared to TAVIE, INVE mortalities were more likely to occur at follow up and were linked to heart failure, renal failure, and septic shock. Total long term mortalities were similar between the two groups. ConclusionINVE makes up a measurable proportion of endocarditis cases after TAVI and shares characteristics, predictors, pathogens, and outcomes linked to TAVIE. Compared to TAVIE, INVE is more closely linked to DM and COPD and less to CKD. It manifests more on mitral valves than right heart valves and presents higher rates of delayed mortality. Given INVEs long term mortality and ability to manifest on different valves, thorough cardiac evaluation and close long term follow up should be considered if endocarditis is suspected after TAVI. Non-mitral INVE and surgical implant based INVE are less frequently reported on and warrant further investigation. Key PointsO_ST_ABSQuestionC_ST_ABSWhat are the incidence, associations, predictors, implicated causes, and outcomes of selectiveand isolated native valve endocarditis following prosthetic valve implantation? FindingsThis systematic review found that isolated native valve endocarditis was reported most frequently after transcatheter aortic valve implants and particularly in mitral valves. Infrequently, isolated native endocarditis has also been reported in right heart valves and after surgical aortic valve implants. Diabetes and pulmonary disease are associated with isolated native endocarditis after transcatheter implants. MeaningThe development of isolated native mitral valve endocarditis should be closely screened for in diabetic and pulmonary patients with transcatheter aortic valve implants. This phenomenon needs further study in non-aortic, non-transcatheter, and non-mitral endocarditis populations. Moreover, patients with this rare endocarditis require close long term follow up as mortalities after hospitalization are significantly higher than in hospital.

IntroductionHeart failure (HF) is a leading cause of mortality worldwide, and heart transplantation remains the gold standard treatment. However, due to the scarcity of donor organs, Left Ventricular Assist Devices (LVADs) have emerged as a critical alternative for patients with advanced HF. LVADs can serve as a bridge to transplantation or a long-term solution for that ineligible for a transplant. This systematic review and meta-analysis aims to evaluate the effectiveness and safety of LVADs, focusing on survival outcomes, adverse events, and quality of life. MethodsA comprehensive literature search was conducted across Cochrane Library, PubMed, and Google Scholar from 2000 to August 2025, adhering to PRISMA guidelines. The studies included were randomized controlled trials, cohort studies, and observational studies evaluating LVAD outcomes in patients with end-stage heart failure. Data on survival rates, adverse events, and quality of life were extracted and pooled for statistical analysis using the Restricted Maximum Likelihood (REML) model in Stata 18.0. ResultsThe pooled analysis showed that LVAD implantation improved survival and functional outcomes. Survival at 1 month post-implantation showed no significant improvement (odds-ratio [OR] = 0.06, 95% CI [-0.12, 0.23]), with low heterogeneity (I{superscript 2} = 0%, {tau}{superscript 2} = 0.00). At 2 months, the pooled OR was 0.09 (95% CI [-0.16, 0.34]) indicating no significant effect on survival. After 6 months, survival outcomes remained non-significant (OR = 0.12, 95% CI [-0.09, 0.33]). However, LVADs significantly improved functional capacity, with a 6-minute walk test (6MWT) showing a 74 {+/-} 141 meter improvement (Starling et al., 2017). Adverse events, including bleeding,neurological issues, and thrombosis, were common. The risk of bleeding was significantly increased (risk-ratio [RR] = 1.87, 95% CI [0.94, 2.80]). ConclusionLVADs are a valuable intervention for end-stage heart failure, offering substantial improvements in functional capacity and quality of life. While survival benefits were modest, the devices significantly enhance the well-being of patients ineligible for heart transplantation. However, the risks of adverse events remain, highlighting the need for careful management. Future advancements in LVAD technology are essential to optimize long-term outcomes and reduce complications, ensuring that LVADs remain a viable treatment option for patients with advanced heart failure.

IntroductionDrug-coated balloon (DCB) is an established treatment option for in-stent restenosis and small vessel, de novo, coronary artery disease (CAD). Although the use of this tool is increasing in everyday practice, little is known about its performance in the treatment of de novo, large vessel CAD (LV-CAD). A systematic review and meta-analysis were conducted to evaluate the efficacy and safety of DCB versus drug-eluting stent (DES) in this setting. MethodsA comprehensive literature search was performed including Medline, Embase and Cochrane electronic databases up to October 24th 2023, for studies which compared efficacy and safety of DCB versus DES in the treatment of de novo lesions in large vessels ([&ge;] 2.5 mm), reporting at least one clinical outcome of interest (PROSPERO ID: CRD42023470417). The outcomes analysed were cardiovascular death (CVD), myocardial infarction (MI), target lesion revascularization (TLR), all cause death (ACD) and late lumen loss (LLL) at follow-up. The effect size was estimated using a random-effect model as risk ratio (RR) and mean difference (MD) and relative 95% confidence interval (CI). ResultsA total of 13 studies (6 randomized controlled trials and 7 observational studies) involving 2,888 patients (DCB n=1,334; DES n=1,533) with de novo LV-CAD were included in this meta-analysis following our inclusion criteria. A DCB-only strategy was non inferior to percutaneous coronary intervention (PCI) with DES in terms of CVD (RR 0.49; 95% CI [0.23 - 1.03]; p=0.06), MI (RR 0.48; 95% CI [0.16 - 1.45]; p=0.89), TLR (RR 0.73; 95% CI [0.40 - 1.34]; p=0.32), ACD (RR 0.78; 95% CI [0.57 - 1.07]; p=0.12) and LLL (MD -0.14; 95% CI [-0.30 - 0.02]; p=0.18) at follow-up. ConclusionOur meta-analysis showed that DCB PCI might provide a promising option for the management of selected, de novo LV-CAD compared to DES. However, more focused RCTs are needed to further prove the benefits of a "metal free" strategy in this subset of CAD.

BackgroundThe adaptive cardiac resynchronization therapy (aCRT) algorithm enables synchronized left ventricular pacing (sLVP) to produce fusion with intrinsic right ventricular activation in normal atrioventricular (AV) conduction. Although sLVP presents benefits over biventricular pacing (BVP), the adequate sLVP rate for better clinical outcomes remains unclear. This study aimed to assess the association between sLVP rates and clinical outcomes. MethodsAmong our cohort of 271 consecutive patients who underwent CRT implantation between April 2016 and August 2021, we evaluated 63 patients who underwent CRT without considerably prolonged AV conduction and applied the aCRT algorithm (48 men, mean age: 64 {+/-} 14 years; median follow-up period: 316 days [interquartile range: 212-809 days]). ResultsAt the 6-month follow-up after CRT implantation, the frequency of CRT responders was 71% (n = 45). The sLVP rate was significantly higher in responders than in non-responders (75 {+/-} 30 vs. 47 {+/-} 40 %, p = 0.003). Receiver operating characteristics (ROC) curve analysis revealed that the optimal cut-off value during the sLVP rate was 59.4% for prediction of CRT responders (area under the curve, 0.70; sensitivity, 80%; specificity, 61%; positive predictive value, 84%; and negative predictive value, 55%). Kaplan-Meier analysis demonstrated that the higher sLVP group (sLVP [&ge;]59.4%, n = 43) had better prognosis (cardiac death and heart failure hospitalization) than the lower sLVP group (sLVP <59.4%, n = 20) (log-rank p<0.001), and multivariate Cox hazard analysis revealed that a higher sLVP rate was associated with good prognosis (p<0.001). ConclusionsLVP was associated with CRT response, and higher sLVP rate ([&ge;]59.4%) is important for good prognosis in patients with aCRT. CLINICAL PERSPECTIVEO_ST_ABSWhat Is New?C_ST_ABSO_LISynchronized left ventricular pacing(sLVP) >59.4% was a significant predictor of cardiac resynchronization therapy(CRT) responders and better clinical outcomes, evidenced by the results of the multivariate analysis. C_LIO_LIIn this study, which included patients with moderately prolonged PR intervals, high sLVP rates were associated with better clinical outcomes. C_LI What Are the Clinical Implications?O_LIsLVP rate was associated with the improvement of cardiac function after CRT implantation. C_LIO_LIA higher sLVP rate was associated with a lower risk of cardiac death and heart failure hospitalization. C_LI