International Journal of Cardiology

Background Donation after circulatory death (DCD) is an increasingly accepted strategy to expand the adult heart donor pool, but its use in children remains limited and incompletely characterized. We compared national characteristics and post-transplant outcomes of pediatric DCD versus donation after brain death (DBD) heart transplantation. Methods We performed a retrospective cohort study of the Organ Procurement and Transplantation Network (OPTN) registry, including patients younger than 18 years who underwent primary isolated heart transplantation between January 1993 and March 2025. Recipients were stratified by donor type (DCD vs DBD). Continuous variables were compared with the Mann Whitney U test and categorical variables with the Fisher exact test. Survival was estimated by the Kaplan Meier method and compared using the log-rank test and Cox proportional hazards regression. Results Of 10,671 pediatric heart transplant recipients, 33 (approximately 0.3%) received DCD allografts. The first DCD transplant was recorded in 2004, with a marked increase in 2023 to 2024. Compared with DBD recipients, DCD recipients were more frequently infants (<1 year, 51.5% vs 28.4%) and more often had congenital heart disease (69.7% vs 47.6%; P=0.033); DCD donors were younger (median 0 vs 6 years; P=0.038) and more frequently died of anoxia (72.7% vs 37.0%; P<0.001). Donor and recipient left ventricular mass were lower in the DCD group (P<0.05), but predicted left ventricular mass matching was similar. DCD recipients had longer hospital stays (median 31.5 vs 19 days; P=0.023); rates of treated rejection, dialysis, stroke, and pacemaker implantation were comparable. Early survival did not differ (30-day, 90-day, and 1-year), and Kaplan Meier survival through 5 years was not significantly different (hazard ratio 1.17; 95% CI 0.49 to 2.81; log-rank P=0.73). More than 90% of DCD transplants were performed in four UNOS regions (11, 4, 5, and 8). Conclusions In this national analysis, pediatric DCD heart transplantation was uncommon but expanding rapidly, concentrated in a few regions, and used preferentially in infants and children with congenital heart disease. Early post-transplant outcomes were not significantly different from DBD, supporting cautious expansion of DCD as a means of enlarging the pediatric donor pool. The small number of DCD recipients and limited followup warrant confirmation in larger, longer-term studies. Keywords: pediatric heart transplantation; donation after circulatory death; donor pool; congenital heart disease; OPTN registry; organ allocation.

Introduction Percutaneous coronary intervention (PCI) is a widely adopted strategy for managing coronary artery disease (CAD), leading to improved survival rates, particularly in developing countries. However, the increased survival of these patients imposes a substantial burden on long-term management, especially at the primary healthcare level. Recently, the hemoglobin-to-red cell distribution width ratio (HRR) has emerged as a potentially valuable prognostic biomarker for post-PCI patients. Despite its accessibility and cost-effectiveness, HRR has not been extensively investigated in resource-limited settings. Aim This study aimed to evaluate the prognostic value of the HRR in predicting 3-year major adverse cardiovascular events (MACE) among patients undergoing PCI who were managed at the primary healthcare level. Methods We conducted a multicenter prospective cohort study in Vietnam. A total of 626 post-PCI patients were ultimately included in the final analysis. The study commenced in October 2019 and concluded in October 2025. The association between HRR and 3-year MACE was evaluated using Cox proportional hazards regression models. Results The MACE incidence decreased progressively across the ascending HRR quartiles (p < 0.001). According to the unadjusted Cox model, each unit increase in HRR was associated with a lower risk of MACE (HR = 0.756; 95% CI, 0.703-0.814; p < 0.001). This association persisted after adjustment for age, sex, comorbidities (Model I: HR = 0.810; 95%CI: 0.750-0.878; p < 0.001). HRR outperformed its individual components, hemoglobin and red cell distribution width. Subgroup analyses confirmed the consistency of the association across clinically relevant strata. Calibration and decision-curve analyses further suggested acceptable risk estimation and potential clinical utility of HRR for 3-year MACE risk stratification. In the discriminative analysis for predicting 3-year MACE, the HRR had the highest area under the curve outperforming other inflammation-based indices. Conclusion A lower HRR was independently associated with a greater 3-year MACE risk in post-PCI patients. HRR outperforms commonly used leukocyte- and platelet-derived indices, highlighting its potential utility as a simple, cost-effective prognostic marker in resource-constrained healthcare settings.

Background: ST-elevation myocardial infarction (STEMI) remains a major cause of global mortality. While troponin is the gold-standard biomarker for myocardial injury, a subset of patients presents with troponin levels below the clinical "rule-in" threshold upon hospital admission. The long-term prognostic significance of these initial "low-troponin" presentations in a large-scale population remains insufficiently characterized. Methods: We conducted a retrospective multicenter cohort study using the "KINERET" database, analyzing 8,394 patients diagnosed with STEMI who underwent percutaneous coronary intervention (PCI) at four academic medical centers in Israel between 2016 and 2023. Patients were stratified into two groups based on ESC rule-in criteria for high-sensitivity cardiac troponin (hs-cTn) at admission: a High trop group (above rule-in cutoff) and a Low trop group (below rule-in cutoff). The primary outcome was all-cause mortality at 5 years. Results: Of the 8,394 patients (mean age 68.3{+/-}13.3 years; 76% male), 36.5% (n=3,064) presented with troponin levels below the rule-in cutoff. Patients in the High trop group were older and had a higher prevalence of comorbidities, including heart failure (46.7% vs. 28.7%) and chronic kidney disease (13.9% vs. 9%). The Low trop group demonstrated significantly higher survival rates at both 1 year (92.9% vs. 84.0%, p<0.001) and 5 years (85.7% vs. 75.0%, p<0.001). After adjusting for age, sex, and comorbidities in a multivariate Cox regression model, initially elevated troponin remained a robust independent predictor of 5-year mortality (HR 1.15, 95% CI 1.14-1.16, p<0.001), alongside age >75, female sex, and chronic kidney disease. Conclusions: STEMI patients presenting with initial troponin levels below the diagnostic rule-in threshold have a significantly better short- and long-term prognosis compared to those with early troponin elevation. Moreover, admission troponin levels serve as a powerful predictor of 5-year mortality and may be used as an independent prognostic factor following STEMI.

Introduction Whartons jelly-derived mesenchymal stem cells (WJ-MSCs) have emerged as a promising regenerative strategy for ischemic heart disease because of their immunomodulatory, angiogenic, and antifibrotic properties. This pilot randomized trial evaluated the safety, feasibility, and exploratory efficacy of intramyocardial WJ-MSC administration combined with an extracellular matrix (ECM) patch in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG). Methods In this randomized, controlled pilot trial, 28 patients with ischemic cardiomyopathy, left ventricular ejection fraction (LVEF) <40%, and viable myocardium on cardiac magnetic resonance imaging (MRI) were assigned to receive intramyocardial WJ-MSC injections plus an extracellular matrix (ECM) patch or a placebo patch. Patients were followed for 12 months with echocardiography, cardiac MRI, Holter monitoring, functional assessment, and quality-of-life evaluation. Results Among 44 screened patients, 28 were randomized (16 to WJ-MSC and 12 to control). At 12 months, echocardiography showed a greater improvement in LVEF in the WJ-MSC group than in the control group (8% vs. 0%, p=0.045). Myocardial fibrosis decreased by 32% in both groups. Cardiac MRI demonstrated improvement in both groups, with numerically greater gains in LVEF and larger reductions in fibrosis in the WJ-MSC arm, although between-group differences were not statistically significant. No significant between-group differences were observed in ventricular arrhythmias or serious adverse events. Two non-cardiac postoperative deaths occurred in the WJ-MSC group. Conclusions Intramyocardial WJ-MSC administration combined with an ECM patch during CABG appears feasible and safe, with signals of functional improvement. Larger, adequately powered trials are needed to confirm efficacy and long-term safety.

BACKGROUND The optimal antiplatelet regimen in patients with acute coronary syndrome (ACS) and multivessel disease undergoing drug-coated balloon (DCB) angioplasty remains unclear. METHODS This was a prespecified subgroup analysis of the REC-CAGEFREE II trial, which was conducted at 41 sites in China and randomized 1948 exclusively DCB-treated participants with ACS to stepwise dual antiplatelet therapy (DAPT) de-escalation or standard DAPT. The primary endpoint was net adverse clinical events (NACE; including all-cause death, stroke, myocardial infarction, revascularization, and BARC type 3 or 5 bleeding) at 12 months. Participants were stratified into multivessel and single-vessel subgroups according to angiographic characteristics. RESULTS Overall, 720/1948 (37.0%) patients had multivessel disease. The multivessel subgroup was associated with a significantly higher risk of NACE compared with the single-vessel subgroup (12.5% versus 6.7%, HR IPTW:1.84, 95%CI:1.35-2.51, P<0.001). No significant interaction was observed between vessel status (multivessel or single-vessel) and treatment allocation with respect to NACE (Pinteraction=0.542). In the multivessel subgroup, NACE occurred in 44/368 (12.1%) and 45/352 (12.9%) in the stepwise de-escalation and standard DAPT groups (HR IPTW:0.95, 95%CI:0.62-1.75, P=0.818), respectively. In the single-vessel subgroup, NACE occurred in 43/607 (7.1%) and 39/621 (6.3%) in the stepwise de-escalation and standard groups (HR IPTW:1.12, 95%CI:0.72-1.70, P=0.611), respectively. For the prespecified hierarchical secondary endpoint, win ratio analyses yielded more wins for stepwise de-escalation in both subgroups. CONCLUSIONS Among patients with ACS undergoing DCB-only angioplasty, those with multivessel disease were associated with a higher risk of NACE than those with single-vessel disease. Stepwise DAPT de-escalation and standard DAPT exhibited similar risk-benefit profiles in both subgroups.

BACKGROUND: Machine learning (ML) models have been used to evaluate one-year post-transplant mortality in donor-recipient pairs. Previous modeling utilizing noninterpretable ML methods (deep neural networks [DNN] and XGBoost) showed modest gains in area under the receiver operating curve (AUC) beyond logistic regression, but suffered a significant drop in predictive AUC applied to the subsequent years' data and lacked statistical significance in validating previously identified risk factors. METHODS: Using balanced SRTR datasets, we evaluated non-interpretable models against interpretable ML models (adaptive logistic regression with interaction terms [aLR], Classification and Regression tree [CART], and conditional inference tree [CIT]) for one-year mortality, including comprehensive clinician-supervised data curation and inclusion of variables describing pre- and post-2018 listing status changes. Models were trained/tested using rolling-window validation across years and further analyzed with repeated ten-fold crossvalidation. Interaction terms were obtained via Adaptive Best-Subset Selection (ABESS). RESULTS: Predictive validation before the listing policy change in 2018 showed similar AUCs between DNN (0.579), aLR (0.642), CART (0.579), and CIT (0.584), with XGBoost having a higher (0.763) AUC. However, in the post-2018 predictive analysis, aLR outperformed XGBoost (AUC 0.613 vs. 0.586). The interpretable ML models confirm the significance of previously reported risk factors (recipient bilirubin and creatinine) and identify risk factors not previously reported (donor pH, potential recipient distance, and recipient transfusion), as well as clinically relevant interaction terms. CONCLUSIONS: Carefully developed interpretable ML models of one-year transplant mortality have similar predictive performance to black-box models, while identifying novel risk factors, and showing improved performance after recent listing policy changes. With appropriate validation and additional data, interpretable ML modeling may allow real-time data-driven donor selection.

Aims Polymer-free drug-eluting stents were developed to enhance vascular biocompatibility and safety while maintaining antirestenotic efficacy. The TRANSEVER registry evaluated 12-month clinical outcomes of the polymer-free everolimus-eluting ISAR SUMMIT stent in a large, real-world population undergoing percutaneous coronary intervention. Methods This prospective, multicentre study enrolled patients with coronary artery disease undergoing PCI with the ISAR SUMMIT stent across 33 centres in India. The primary endpoint was target-lesion failure (TLF) at 12 months, a composite of cardiac death, target vessel myocardial infarction, or clinically driven target lesion revascularisation. Secondary endpoints included the patient-oriented composite endpoint (POCE) of all-cause death, any myocardial infarction, stroke, revascularization, and definite/probable stent thrombosis. Results A total of 1,000 patients were enrolled, of whom 996 completed 12-month follow-up. The cohort presented with a high-risk profile, including an acute coronary syndrome (ACS) in 89.8% of the cases and diabetes mellitus in 44.4% of them. Procedural outcomes were excellent in terms of device success and final TIMI 3 flow (achieved in all treated lesions). At 12 months, TLF occurred in 15 patients (1.5%). Definite or probable stent thrombosis was observed in 8 patients (0.8%). POCE was observed in only 21 patients (2.1%). Conclusions In this large, contemporary real-world population with a very high proportion of patients presenting with ACS, the polymer-free everolimus-eluting ISAR SUMMIT stent demonstrated favourable 12-month clinical outcomes, with low rates of target lesion failure and stent thrombosis. These results suggest that this novel device is both safe and effective for routine clinical use.

Background: Adult congenital heart disease (ACHD) patients are prone to HLA-antibody formation from multiple surgeries, transfusions, and prosthetic surgical material. Females with ACHD may accrue additional, non-surgical alloantigen exposure. Whether sex modifies the impact of allosensitization on heart transplant (HT) access and outcomes in ACHD remains unknown. Methods: We retrospectively analyzed the OPTN/UNOS registry of adults with ACHD listed for first-time HT (2018-2025). Sensitization was defined by calculated panel reactive antibodies (cPRA) at listing. We tested the sex x sensitization (highly sensitized, cPRA >50%) interaction on transplant access using Fine-Gray competing-risks regression, treating transplantation as the event of interest and death or removal from the waitlist as competing events, and on post-transplant survival using multivariable Cox proportional-hazards regression, both adjusted for age at listing, mechanical support at listing, and the number of distinct prior cardiac surgery categories. Results: Among 856 candidates (38% female), females were more often highly sensitized than males (23% vs 14%; age-adjusted OR 1.81, 95% CI 1.26-2.61), even after adjusting for surgical burden. Sensitization reduced transplant access in females (84% to 71%; median wait 60 to 110 days, p < 0.001) but not males (79% vs 79%, median wait 88 vs 98 days). In adjusted Fine-Gray models, the subdistribution hazard for transplant was reduced in sensitized females (sHR 0.54, 95% CI 0.41-0.72) with no effect in males (sHR 0.96, 95% CI 0.73-1.26), and the sex x sensitization interaction was significant (interaction sHR 0.64, 95% CI 0.44-0.94, p = 0.02). Post-transplant mortality was numerically higher in sensitized than non-sensitized candidates in both sexes and the sex x sensitization interaction on 1-year mortality was not significant. The sex-asymmetric effect persisted and was more pronounced in the multiorgan candidates. Conclusions: Allosensitization is not a sex-neutral barrier to transplant in HT candidates with ACHD. Females are more sensitized and have reduced transplant access without differences in 1-year mortality. The female excess in sensitization is not accounted for by surgical burden, and the exposures responsible remain to be defined. These findings warrant a sex-aware listing strategy and further studies.

Background: The PREVENT (Predicting Risk of CVD EVENTs) equations estimate the risk of incident cardiovascular disease (CVD) in primary prevention patients. We hypothesized that risk factors incorporated in the equations may be relevant to prognosis in heart failure (HF) and investigated the association between estimated CVD risk and clinical outcomes in patients with preserved ejection fraction (HFpEF). Methods: We estimated the 10-year CVD risk using the PREVENT equations in 278 patients hospitalized for acutely decompensated HFpEF (median 75 years, 51.4% male). We divided them into four groups according to the quartiles of estimated CVD risk and followed them to observe major adverse cardiovascular events (MACE), a composite of all-cause death, HF hospitalization, and stroke. Results: MACE occurred in 125 patients (45.0%) over a median follow-up of 1,050 days. The estimated CVD risk classification was an independent predictor for MACE (p=0.02) in the multivariable Cox proportional hazard model. There was a difference in MACE-free survival across the four quartile groups (p<0.001 by log-rank test), and the lowest CVD risk group had significantly lower MACE incidence than other groups. The estimated CVD risk provided incremental prognostic value beyond N-terminal pro-B type natriuretic peptide (C-index: 0.626 vs, P=0.009). The predictive value of the estimated CVD risk for MACE at 1 year was comparable to that of the MAGGIC score (AUC 0.676 vs. 0.639, p=0.42). Conclusions: The 10-year CVD risk estimated by the PREVENT equations had a moderate predictive value for MACE in patients hospitalized for HFpEF.

Background: Clinical outcomes of switching versus continuing direct oral anticoagulant (DOAC) among atrial fibrillation (AF) patients who experienced an ischemic stroke despite receiving DOAC therapy are uncertain. Methods: We included patients with AF who were hospitalized for ischemic stroke (index stroke) between January 1, 2016, and June 30, 2022, while receiving DOAC therapy and who resumed DOAC within 90 days after discharge in the Merative MarketScan Commercial and Medicare databases. Patients were classified as DOAC-switched or DOAC-continued according to whether the DOAC agent changed or remained the same after the index stroke; secondary analyses considered individual DOACs. The primary outcome was recurrent ischemic stroke; secondary outcomes included major bleeding and a composite outcome (bleeding or ischemic stroke). Propensity score-based overlap weighting and weighted Cox models were used to estimate adjusted hazard ratios (aHRs). Results: A total of 1175 patients were eligible for the study, of whom 970 (82.6%) continued and 205 (17.4%) switched DOAC therapy. Comparing DOAC-switched to DOAC-continued was not significantly associated with recurrent ischemic stroke (aHR, 1.20; 95% CI, 0.63-2.30), major bleeding (aHR, 0.60; 95% CI, 0.21-1.72), or the composite outcome (aHR, 0.98; 95% CI, 0.56-1.70). However, among patients who received apixaban before stroke, switching to rivaroxaban was associated with a higher risk of recurrent ischemic stroke (aHR, 2.70; 95% CI, 1.05-6.95). Conclusions: Overall, switching DOAC therapy after ischemic stroke was not associated with improved clinical outcomes. Switching from apixaban to rivaroxaban, however, could increase risk of recurrent ischemic stroke.

Background: Aspirin-free P2Y12-inhibitor monotherapy after percutaneous coronary intervention (PCI) is an alternative to dual antiplatelet therapy (DAPT), but the evidence rests largely on full-dose ticagrelor in acute coronary syndrome and on designs retaining a DAPT run-in; East-Asian patients may not require the same antithrombotic intensity. We compared standard DAPT, DAPT with half-dose ticagrelor, and aspirin-free half-dose ticagrelor monotherapy initiated on the day of PCI in chronic coronary syndrome (CCS). Methods: Sixty-one East-Asian patients with CCS scheduled for elective PCI were randomized 1:1:1 to Control (aspirin plus clopidogrel), Experimental A (aspirin plus ticagrelor 45 mg twice daily), or Experimental B (ticagrelor 45 mg monotherapy, aspirin discontinued at day 2). DAPT arms continued for six months; Experimental B continued indefinitely. P2Y12 reaction units (PRU) were measured at baseline and at a median of 17 days. Results: PRU reduction was three-fold greater in both ticagrelor arms than in Control ({Delta}PRU -188 and -181 versus -60.5; P<0.001), with no difference between ticagrelor arms (P=0.772). At 12 months, major adverse cardiovascular events (MACE) and clinically relevant bleeding each occurred in 1 of 17 Experimental B patients (5.9%) and in neither other arm. One Experimental A patient crossed over for ticagrelor-induced dyspnea; no stent thrombosis or cardiac death occurred. Conclusions: In East-Asian patients with CCS, half-dose ticagrelor produced markedly greater platelet inhibition than standard DAPT, with an identical effect whether given with or without aspirin. It merits evaluation in an adequately powered randomized trial. Clinical Trial Registration. URL: https://www.clinicaltrials.gov; Unique Identifier: NCT07622056

Background: Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is an infiltrative cardiomyopathy and an increasingly recognized cause of heart failure. With improved survival from disease-modifying therapies, an increasing number of patients are presenting for surgery and may be at increased risk of adverse postoperative outcomes. This study reports outcomes of ATTR-CM patients undergoing surgery and evaluates the utility of the Revised Cardiac Risk Index (RCRI), a perioperative risk tool. Methods: A total of 145 ATTR-CM patients were included, among which 51 patients underwent at least one eligible surgical procedure. Preoperative risk was assessed using the RCRI, analyzed both as a categorical and as a dichotomized ({greater than or equal to}3 vs <3) variable. Postoperative outcomes included unplanned hospital admission, length of stay (LOS), prolonged hospitalization (>48 hours), and major adverse cardiac events. Models were adjusted for frailty (Clinical Frailty Scale {greater than or equal to}5) and major surgery, using multivariable, ordinal, and Firth penalized logistic regression analyses. Results: Patients were predominantly male (86%) with a mean age of 76 {plus minus} 9 years, and 61% were frail. Higher RCRI scores were associated with unplanned postoperative hospital admission (RCRI {greater than or equal to}3: adjusted OR 48.9, 95% CI 4.8-502.2) and longer LOS (RCRI {greater than or equal to}3: adjusted OR 40.7, 95% CI 4.3-382.8). RCRI {greater than or equal to}3 was also associated with prolonged hospitalization (>48 hours) in Firth penalized logistic regression, whereas frailty was not independently associated. Conclusions: In a real-world ATTR-CM cohort undergoing major non-cardiac surgery, the overall risk of adverse outcomes was low, and higher RCRI scores were associated with increased postoperative hospital admission and longer LOS, including hospitalization exceeding 48 hours. The RCRI retains prognostic utility in this high-risk cohort and may support peri-operative risk stratification.

Background: Postoperative atrial fibrillation (POAF) is a frequent complication following coronary artery bypass grafting (CABG) and is associated with increased acute morbidity and resource utilization. However, its independent role in driving post-discharge adverse events in contemporary practice remains debated. Objective: To evaluate the association between POAF and short-term outcomes after CABG, and to utilize empirical Bayesian risk updating to stratify 90-day post-discharge vulnerabilities. Methods: A retrospective cohort analysis of 4,684 adult patients who underwent isolated CABG in Florida between January 1, 2021, and June 30, 2024, was conducted, excluding those with documented preoperative AFib. We employed multivariable negative binomial and logistic regression models to assess length of stay (LOS), discharge disposition, 90-day readmission, and 90-day composite complications. Additionally, a Bayesian Beta-Binomial conjugate model with an objective Jeffreys Prior was utilized to estimate the posterior probabilities of adverse outcomes across key clinical phenotypes. Results: POAF occurred in 355 patients (7.58%). Multivariable analysis demonstrated a 30% relative increase in expected LOS (IRR 1.30, 95% CI [1.23 - 1.36], P < .001) and 33% higher odds of facility discharge (OR 1.33, 95% CI [1.03 - 1.72], P = .030) for patients with POAF. However, POAF was not independently associated with 90-day readmission (OR 1.25, P = .063) or composite complications (OR 1.20, P = .118). Chronic heart failure (CHF) emerged as the dominant predictor. Bayesian risk updating revealed that while the baseline posterior probability for a 90-day complication was 27.2%, the synergistic presence of both POAF and CHF radically shifted this posterior risk to 42.6% (Probability of Direction > 0.999 vs. baseline). Conclusions: POAF prolongs hospitalization and drives non-home discharges, but it does not independently dictate 90-day morbidity. Bayesian stratification demonstrates that post-discharge outcomes are predominantly driven by underlying chronic conditions. Effective reduction of readmissions requires robust transition-of-care frameworks, empowering primary care clinicians to aggressively optimize heart failure and metabolic disease rather than focusing solely on the acute surgical arrhythmic event.

Background: Approximately 40 million individuals in the US have diabetes, and 6.5 million are also afflicted with congestive heart failure (CHF). This paper outlines the natural history of CHF in T2DM and compares CHF outcomes between patients with and without T2DM. Methods: We performed a retrospective analysis of prospectively collected data from 2,008 patients hospitalized for CHF exacerbation between December 2016 and June 2019. Propensity score matching was used to match diabetics and nondiabetics. Outcomes included survival and readmission rates at 28 d, 3 mo and 6 mo, as well as comparison of echocardiographic findings. Results: A total of 2,008 patients were included. After matching, 492 patients were included, with 244 diabetics and 248 nondiabetics. After matching, readmission rates within 28 days (p=0.625) were not different, but there was a trend for higher readmission rates among diabetics at 3 months (29.3% vs. 21.5%, p=0.049) and 6 months (44.3% vs 35.8%, p=0.053). Echocardiographic characteristics, including LVEF (p=0.135), LV EDV (p=0.707), maximum velocity of mitral valve E wave (p=0.407), maximum velocity of mitral valve A wave (p=0.050), E/A ratio (p=0.501) and tricuspid valve regurgitation pressure (p=0.668) were not different in the two groups. However, tricuspid valve regurgitation velocity was higher in diabetics (3.1 vs 2.9, p=0.003). Conclusions: Although diabetes poses an additional burden for patients with CHF, survival is similar in diabetics and nondiabetics. Nonetheless, readmission rates may be higher among diabetics. Tricuspid return velocity is higher in diabetics, suggesting early pulmonary vasculature remodeling.

BACKGROUND: The revised 2018 AHA/ACC guidelines introduced the Adult Congenital Heart Disease Anatomic and Physiologic classification (ACHD-AP) to better categorize disease severity and prognosis in the ACHD population. The ACHD-AP has not been rigorously studied as a perioperative prediction tool. OBJECTIVE: We aimed to assess the accuracy of the ACHD-AP classification in predicting perioperative morbidity and mortality. METHODS: This retrospective cohort study included 295 ACHD patients at a single academic institution between 2018 to 2022. Patients were identified by the STS congenital surgery registry and had undergone a congenital surgical procedure. The primary outcome was overall mortality. Secondary outcomes included short-term post-operative morbidity and comparison of the ACHD-AP score to other existing surgical mortality risk scores. Kaplan-Meier and area under the curve (AUC) of Receiver Operating Characteristic curves were used to evaluate mortality. Logistic regression was used to compare short-term morbidity. RESULTS: A total of 295 patients were included with a median age of 30 years (interquartile range 21-41 years) and 52% were female. There was a total of 14 deaths with 5 (2%) early post-operative deaths and 9 (3%) long-term deaths. By increasing anatomy complexity, overall mortality was 0%, 4% (n=10), and 8% (n=4), respectively. By increasing physiologic severity, overall mortality was 0%, 3% (n=2), 4% (n=7), and 14% (n=5). Moderate and complex anatomy trended towards increased mortality but were not statistically significant (p-value > 0.9). More severe physiology scores predicted increased mortality (p-value = 0.02). Higher physiologic or anatomic complexity scores were associated with longer post-operative length of stay (>5 days). The ACHD-AP AUC was 0.711 for mortality, which was comparable to the Adult Congenital Heart Surgery (ACHS) score (AUC 0.798) and better than the PEACH score (AUC 0.575). CONCLUSION: The ACHD-AP score revealed comparable or better predictive power to existing risk models. Worsening physiologic and anatomy scores were associated with worse post-operative outcomes. Further prospective studies are needed to validate the ACHD-AP score as a prognostic factor for patients undergoing ACHD surgery.

Introduction. Extracorporeal cardiopulmonary resuscitation (ECPR) can support patients who fail to respond to standard resuscitation for out-of-hospital cardiac arrest (OHCA) allowing further time for critical interventions and patient recovery. Although the majority of patients with refractory OHCA have coronary artery disease, the role of emergent percutaneous coronary intervention (PCI) is not clear. We evaluated the effect of PCI on survival to hospital discharge (SHD) in a contemporary cohort of patients with OHCA receiving ECPR. Methods. We performed a retrospective study using data from the Extracorporeal Life Support Organization (ELSO) registry. We included patients ?18 years with OHCA due to a presumed cardiac etiology or an initial shockable rhythm who received ECPR from January 2020 to December 2023. Our primary outcome was SHD. We used inverse probability weighted matching to estimate the average treatment effect of PCI on SHD. We also performed a sensitivity analysis of patients most likely to benefit from PCI (witnessed arrest and no return of spontaneous circulation after five minutes of cardiopulmonary resuscitation. Results. Of 1336 OHCA patients receiving ECPR, 1131 were included in the final analysis after exclusions for age (n=31) and presumed non-cardiac or initial non-shockable rhythm (n=174). The median age was 55 years (IQR 44-62) and most patients were male (n=901, 80%). Twenty-one percent (n=243) received PCI; those patients who received PCI were slightly older (58 [IQR 48-63] vs 53 [IQR 42-62]) and more often male (n=212 [87%] vs n=689 [78%]). In the primary analysis, we found no significant difference in SHD for patients who received PCI compared to those who did not receive PCI (-3.56%, 95% CI -10.31 to 3.19; p-value 0.301). In our sensitivity analysis, we also did not find a significant difference in SHD for patients who received PCI compared to those who did not receive PCI (-4.52%, 95% CI -12.42 to 2.46; p-value 0.246). Conclusion. In our registry-based study of refractory OHCA patients receiving ECPR, emergent PCI was not associated with a significant improvement in SHD.

Background: Digoxin use after the Norwood procedure has been associated with improved interstage survival in hypoplastic left heart syndrome and related conditions. Whether this benefit translates into improved longer-term outcomes through staged palliation remains unknown. We aimed to determine the association of digoxin use at Norwood discharge with transplant-free survival and Fontan completion. Methods: We conducted a retrospective cohort study using the Pediatric Heart Network (PHN) Single Ventricle Reconstruction trial public dataset, including 549 infants enrolled at 15 North American centers between 2005 and 2008. Competing risk analysis was used to evaluate Fontan completion and Cox regression to assess death or transplantation within 6 years after the Norwood procedure. Mixed-effects models compared pre-Fontan hemodynamic and echocardiographic right ventricular indices between patients treated with and without digoxin after accounting for center clustering and adjustment for sex, shunt type, heart failure medications at Norwood discharge, and census block poverty level. Results: The 6-year cumulative incidence of Fontan completion was higher among patients discharged on digoxin than among those not receiving digoxin (82% vs 71%; p = 0.013). Competing-risk analysis accounting for death and transplant demonstrated a greater likelihood of Fontan completion among digoxin users (aHR 1.31; 95%CI 1.09-1.58; p = 0.005), without significant difference in the hazard of death or transplant (aHR 0.78; 95%CI 0.53-1.15; p = 0.208). No significant differences in pre-Fontan hemodynamic or echocardiographic indices were observed between groups. Initiation of digoxin post Stage II procedure was not associated with improved survival or likelihood to complete Fontan. Conclusion: Digoxin use at the time of Norwood discharge was associated with a 30% greater likelihood of Fontan completion by 6 years, without accompanying improvement in transplant-free survival. These findings extend prior observations of improved interstage outcomes associated with digoxin use and suggest that treatment may facilitate progression through staged palliation.

Background: Gaps in care (GIC) among patients with congenital heart disease (CHD) are associated with adverse outcomes, yet the specific social and healthcare-related factors contributing to GIC and the clinical consequences of delayed re-engagement in care remain poorly characterized. Large electronic medical record datasets often cannot distinguish true GIC from clinically appropriate care patterns or capture the patient-level factors contributing to GIC. Methods: We conducted a retrospective cohort study, combining large data with manual chart review, of 1,746 patients of all ages with surgically repaired CHD between 2003 and 2020 at a tertiary care center serving four states. GIC was defined as more than 3 years and 3 months between cardiology visits and exceeding the physician recommended follow-up interval. Results: Of the cohort, 916 patients (52%) met criteria for potential GIC. Following a structured manual chart review, a substantial subset was reclassified as having appropriate care, leaving 275 patients (15.7%) with true GIC. After multivariable adjustment, older age and simple anatomic CHD complexity were independently associated with GIC. Among patients with GIC, 17.8% had a documented contributor, most commonly insurance instability or social factors. Of those 41.5% returned to care (RTC), and many were asymptomatic but had significant disease progression. Thirteen percent of patients who RTC required cardiac intervention, including semi-urgent or urgent procedures, and 26.7% of those requiring intervention experienced significant morbidity or mortality, including stroke, infective endocarditis, urgent transplant referral, or death. These outcomes occurred across all levels of CHD complexity, including patients with simple CHD. Conclusions: GIC remain prevalent in patients with surgically repaired CHD and are associated with significant morbidity and mortality across the full spectrum of anatomic complexity. They are most often driven by insurance instability and social vulnerability rather than clinical factors, and many adverse outcomes may be preventable with consistent longitudinal care. These findings support a shift toward proactive care models that integrate standardized follow-up pathways, systematic assessment of patient-level needs, and emerging analytic tools to identify at-risk patients before GIC occur.

Background Totally endoscopic aortic root (AR) surgery via right anterior minithoracotomy (RAMT) may reduce surgical trauma and accelerate recovery compared with full sternotomy (FS). However, the approach is technically demanding due to limited access and anatomical complexity. This study compares early clinical outcomes and quality of life (QoL) after RAMT versus FS to evaluate the feasibility and safety of the totally endoscopic approach. Methods This single-center, retrospective study included 149 patients underwent AR surgery via RAMT (n=74) or FS (n=75) between January 2021 and March 2026. Patients with aortic dissection, infective endocarditis, redo surgery, concomitant procedures, or arch replacement were excluded. Operative outcomes, postoperative recovery, 30-day and 1-year mortality were analyzed. QoL was assessed using the Short Form-8 (SF-8) questionnaire. Results The median age was 60.0 years, and 79.9% of patients were male. Bentall procedure was performed in 84.6% of patients, 15.4% underwent a David procedure. Compared with FS-AR, RAMT-AR was associated with shorter median operative time (147.0 vs. 178.0 min; p<0.001), lower median chest drainage volume (650.0 vs. 850.0 mL; p<0.001), and shorter median ICU stay (24.0 vs. 25.0 h; p=0.008) and hospital stay (6.0 vs. 8.0 days; p=0.028). Overall, 30-day and 1-year mortality was 0.7%. SF-8 analysis demonstrated significantly higher physical and mental component scores in RAMT-AR patients. Conclusion In specialized centers, totally endoscopic AR surgery via RAMT is a safe and feasible minimally invasive approach associated with favorable early outcomes and a potential benefit in postoperative physical and mental QoL by reducing surgical trauma.

BACKGROUND: Chronic coronary syndromes (CCS) remain under-characterized in Latin America, where clinical profiles may differ from high-income countries. OBJECTIVE: We aim to characterize the clinical presentation, coronary anatomic profile, and pharmacologic treatment patterns of adults living with CCS using data from the Mexican Chronic Coronary Syndrome Registry (RESINCCRO). METHODS: RESINCCRO is an observational, multicenter, cross-sectional registry conducted across ~50 centers in five regions from Mexico. We included adults ([&ge;]18 years) enrolled between September 2024 and March 2025 who met 2019 ESC CCS criteria. Coronary imaging data was collected from medical records into a standardized electronic case report form. RESULTS: We enrolled 3,029 adults (men [72.5%]; mean age 67.2 {+/-} 10.7 years). Cardiometabolic comorbidities were frequent: overweight/obesity (76%), arterial hypertension (69.0%), type 2 diabetes (44.0%), and chronic kidney disease (24.2%). Persistent angina/equivalents occurred in (23.9%), of which most had Canadian Cardiovascular Society class I - II (91.2%). The mean LVEF was of 53.7 {+/-} 12.0. Cardiac rehabilitation participation was (6.2%). Median LDL-C was 70 mg/dL (IQR 51 - 95) and LDL <55 mg/dL was only 26.1%, despite high prescription of lipid-lowering therapies, including statins (93.2%), ezetimibe (24.6%), and PCSK9 inhibitors (2.4%). 60.3% had obstructive epicardial disease. CONCLUSIONS: Mexican adults with CCS exhibit high cardiometabolic burden, frequent symptoms, suboptimal LDL-C goal attainment, low rehabilitation uptake, and a substantial obstructive phenotype. These findings highlight opportunities to intensify secondary prevention, adopt mechanism-directed evaluation and therapy, and expand cardiac rehabilitation to improve CCS care in Mexico.