International Journal of Cardiology

Background: Primary graft dysfunction (PGD) remains one of the leading causes of early mortality after pediatric heart transplant (HT). While neurodevelopmental impacts of congenital heart disease (CHD) are well-characterized, the effect of PGD on long-term neurodevelopmental outcomes in pediatric HT recipients remains unknown. We sought to determine the association between PGD and neurodevelopmental outcomes in this population. Methods: We performed a retrospective cohort study using the United Network for Organ Sharing (UNOS) database. All pediatric (age <18 years) isolated heart transplant recipients from 2010-2025 were included. The most recent pre- and post-transplant neurodevelopmental outcomes including cognitive delay, motor development, academic progress, and function status (stratified by age) were compared between PGD (n=434) and non- PGD groups (n=6956). Results: PGD patients had significantly worse pre-transplant functional status and motor development. Post-transplant, PGD was associated with worse motor development (18.8% vs. 13.0% definite motor delay; p=0.01) and functional status in younger children (39.5% vs. 57.8% able to keep up with peers; p<0.001). Post-transplant stroke occurred 3.5 times more frequently in PGD patients (11.5% vs. 3.3%; p<0.001). Cognitive development (p=0.94) and academic progress (p=0.096) did not differ significantly. Thirty-day (7.8% vs. 1.9%) and 1-year mortality (20.3% vs. 6.4%) were significantly higher in PGD patients (both p<0.001). Conclusions: This is the first study to characterize neurodevelopmental outcomes in pediatric patients undergoing HT with PGD. PGD is associated with significantly worse motor development and functional status independent of pre-transplant baseline. There is a 3.5-fold higher stroke rate providing a plausible neurological mechanism. The findings support targeted developmental surveillance recommendations and early intervention for this high-risk population.

Background: Antibody-mediated rejection (AMR) after heart transplant (HT) is associated with increased risk of mortality and graft loss. Contemporary studies delineating AMR presentation, management, and response to treatment are lacking, especially for patients who do not have typical immunohistological evidence of rejection (biopsy-negative, BN-AMR). In this study, we sought to describe the prevalence and clinical course of BN-AMR compared to biopsy-positive (BP-AMR) patients in a multicenter HT population. Methods: We conducted a retrospective analysis of all adult HT recipients at 2 academic medical centers. AMR was further divided into BP-AMR and BN-AMR, depending on their endomyocardial biopsy findings. The primary outcome was death and secondary outcome was a composite of death, retransplant, and new International Society of Heart and Lung Transplant grade 2 or 3 coronary artery vasculopathy. Results: A total of 742 patients were included in this study. We found that AMR occurred in 10% of HT recipients and was associated with worse overall survival compared to those with only cellular rejection or no rejection. BN-AMR accounted for 33% of AMR cases. Compared to BP-AMR, BN-AMR was diagnosed later, less aggressively treated, and associated with high morbidity and mortality. The long-term outcomes between BP-AMR and BN-AMR were similarly poor, with 5-year mortality approaching 50% after diagnosis. Conclusions: AMR after HT is associated with poor clinical outcomes and BN-AMR is common. Future studies should focus on incorporating novel tools for earlier detection of AMR and investigating AMR sub-phenotypes and optimal modes of treatment.

BackgroundST-elevation myocardial infarction (STEMI) is reported to be a leading cause of mortality worldwide. While cardiac troponins are the gold standard for myocardial injury detection but creatine kinase-MB (CK-MB) and total creatine phosphokinase (CPK) retain prognostic use in resource-limited settings. ObjectiveTo evaluate the prognostic significance of admission CK-MB and CPK levels in STEMI patients and to assess their association with hematological parameters for integrated risk stratification. MethodsThis cross-sectional study enrolled 15 consecutive STEMI patients from the Punjab Institute of Cardiology, Lahore, during January 2024. Comprehensive laboratory analysis including cardiac biomarkers (CK-MB, CPK, troponin-I, LDH), complete blood count, renal function, serum electrolytes, and metabolic parameters, was performed on admission. Pearson correlation and comparative statistical analyses were also conducted to assess the relationships between cardiac biomarkers and hematological indices. ResultsThe cohort includes 15 patients (mean age 50.1 {+/-} 12.2 years; 73.3% male). Cardiac biomarker elevation was prevalent: CK-MB was elevated in 12/15 (80%), CPK was elevated in 12/15 (80%), with concordant elevation in 11/15 (73.3%), which indicates extensive myocardial necrosis. Troponin-I showed the highest elevation rate at 13/15 (86.7%). Hematological abnormalities included anemia (60%), WBC elevation (53.3%), and RBC reduction (40%). Random glucose averaged 150.80 {+/-} 63.55 mg/dL, with 66.7% highlighted the hyperglycemia. Remarkably, electrolyte balance was preserved in all of the patients (0% sodium, potassium, and bicarbonate abnormalities), indicating maintained homeostasis. Pearson correlation analysis revealed a significant correlation between CK-MB and CPK (r = 0.615, p = 0.0126), while correlations between cardiac biomarkers and hematological parameters were weak (p > 0.05). Risk stratification identified 53.3% of patients as high-risk who required intensive management. ConclusionsCK-MB and CPK demonstrate significant concordance and retain prognostic value in STEMI patients, particularly in resource-limited settings where troponin access may be constrained. While troponin-I remains the most sensitive biomarker, combined assessment of conventional cardiac enzymes supports reliable evaluation of myocardial injury. Hematological parameters reflect systemic response but show limited correlation with cardiac biomarkers.

Cardiogenic shock (CS) is associated with high short-term mortality and the use of temporary mechanical circulatory support (tMCS) devices, especially left-sided microaxial flow pumps (Impella, Abiomed), has increased in recent years. However, few studies have investigated tMCS's effect on right ventricular-pulmonary artery (RV-PA) hemodynamics and its impact on clinical outcomes. We retrospectively analyzed all adult patients implanted with Impella 5.5 at our institution with acute myocardial infarction or acute decompensated heart failure-induced CS between 2019 to 2023. We found that Impella 5.5 led to an early improvement in RV-PA hemodynamics, even in patients with poor baseline RV function. In addition, we found that RV function itself did not predict death, post-heart transplant right ventricular-primary graft dysfunction, or post-left ventricular assist device severe RV failure. However, an increase in right atrial:pulmonary capillary wedge pressure ratio (RA/PCWP) despite tMCS support was a powerful prognosticator. Our study sheds important insight into anticipated hemodynamic changes after Impella 5.5 placement, supports the use of early tMCS even in patients with marginal RV function in the setting of left heart disease, and highlights the importance of serial assessment of RA/PCWP as a key determinant of CS outcomes.

Heart transplantation (HT) is the durable therapy for end-stage heart failure (HF). Despite advances in immunosuppression, cardiac allograft vasculopathy (CAV) remains a leading cause of late graft failure and mortality in the modern era. Prior studies have established donor age and immunological phenomena, such as acute cellular rejection (ACR), antibody-mediated rejection (AMR), and development of donor-specific antibodies (DSAs) as risk factors for CAV. However, it remains unclear whether acute rejection (AR) that occurs early post-HT, when individuals experience the highest degree of immunosuppression, reflects higher baseline immune activity and confers a higher risk of future CAV compared to later AR, when immunosuppression is minimized. We therefore examined whether AR occurring during pre-specified early and intermediate intervals compared to those who did not experience AR in the first post-HT year was associated with future CAV among recipients without CAV at 1 year.

Background: Atrial Fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide, representing the primary cardiac etiology of stroke. In recent years, direct oral anticoagulants (DOACs) have shown favorable results in terms of efficacy and safety in the prevention of thromboembolism in patients with AF. TROMBIX-DZ study investigated the safety and efficacy of rivaroxaban in routine clinical settings in response to the need for real-world evidence on the use of DOACs. Methods: We carried a national, multicenter, prospective, observational cohort study to evaluate the safety and efficacy of rivaroxaban in Algerian patients with atrial fibrillation. Patients were followed-up at 3 months intervals for 1 year. The primary outcome of this study was to evaluate the safety of rivaroxaban, reported as the frequency of treatment-emergent serious adverse events (SAEs); Secondary outcomes assessed the frequency of thromboembolic events, adverse events (AEs), and treatment persistence. Results: TROMBIX-DZ enrolled 398 eligible patients with AF from 19 specialized public and private cardiology centers across different regions in Algeria. The mean age was 70.5 {+/-} 11.94. 71.9% of patients received once daily rivaroxaban 20mg, and 28.1% received the 15mg dose. The most common comorbidities included, hypertension (77.1%), diabetes (28.6%) and heart failure (25.4%), prior strokes and TIA (8.8%), and prior major bleeding (3.1%). The mean CHA2DS2-VASc score was 3.147 {+/-} 1.3, and the mean HAS-BLED score was 1.682 {+/-} 1.198; 14.06% of patients had Creatinine clearance < 50 ml/min. A total of 5.77% had treatment-emergent AE, and 1.76% had treatment-emergent SAE. The incidence rate (events per 100 patient-years) of treatment-emergent major bleeding events, treatment-emergent thromboembolic events and all-cause death during the study period were 2.1, 0.9, and 4.18, respectively. Treatment persistence was 75.88% at the end of the study. Conclusion: TROMBIX-DZ study, the first cohort in the Maghreb region, provides important insights into the safety and efficacy of rivaroxaban in Algerian population with atrial fibrillation receiving standard medical care. Rates of major bleeding and stroke were low and broadly consistent with previous international real-world registries. Trial registration number: Clinicaltrial.gov: (NCT06184204). Keywords: Direct oral anticoagulants, Rivaroxaban, Atrial fibrillation, Major bleeding, Stroke, Thromboembolism, The Maghreb region, Real-world.

BackgroundDelirium, a common and multifactorial complication after cardiac surgery, is influenced by several factors including inflammation, metabolic disturbances, and cerebral hypoperfusion. Because these factors can be reflected in an elevated anion gap (AG), we hypothesized that a higher preoperative albumin corrected anion gap (ACAG) is associated with increased risk of delirium and 1-year mortality after cardiac surgery. MethodsWe examined a retrospective cohort of adult patients within our healthcare system who underwent cardiac surgery between 2014 and 2022 and had a recorded Confusion Assessment Method for the ICU (CAM-ICU) evaluation. Patients were excluded if they had documented preoperative delirium during the index hospital admission or a history of dementia. The final cohort included 4,482 patients. Preoperative laboratory values were collected, using the most recent results obtained within 48 hours prior to surgery. The primary outcome was delirium after cardiac surgery (DACS), defined as delirium occurring within postoperative days 1 through 5. The secondary outcome was all-cause 1-year mortality. ResultsThe incidence of DACS and 1-year mortality were 9.5% and 4.8%, respectively. A multivariable logistic regression model adjusting for baseline characteristics showed that higher ACAG was significantly associated with higher risk of DACS (adjusted odds ratio (AOR) = 1.56, 95% Confidence Interval (CI) = 1.40-1.74, p < 0.001). Other predictors of DACS included increasing age (AOR = 1.31, CI = 1.16-1.48, p < 0.001), surgery duration (AOR = 1.35, CI = 1.22-1.49, p < 0.001), and history of delirium (AOR = 1.70, CI = 1.29-2.24, p < 0.001). Moreover, increasing ACAG was also associated with 1-year mortality (AOR = 1.35, CI = 1.16-1.56, p < 0.001). Finally, receiver operating characteristic (ROC) analysis demonstrated that ACAG exhibited superior predictive performance compared with AG and anion gap to bicarbonate ratio (AGBR) for both DACS and 1-year mortality outcomes. ConclusionsHigher preoperative ACAG was associated with elevated risk for DACS and 1-year mortality. Preoperative ACAG is an accessible and cost-efficient biomarker that may improve risk stratification for cardiac surgery patients.

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: Pediatric dilated cardiomyopathy (DCM) is a leading cause of heart failure and transplantation, with variable prognosis and high early mortality. This study developed and validated a nomogram predicting short-term mortality risk to guide clinical decisions. Methods: The data were sourced from the Pediatric Cardiomyopathy Database at Shandong Provincial Hospital. Cox regression analysis was conducted to determine outcome-associated factors, and a nomogram was developed to estimate 1, 3, and 5year mortality risks for children with DCM. Model effectiveness was assessed through the concordance index (C-index) and area under the receiver operating characteristic curve (AUC). Additionally, calibration curves and decision curve analysis (DCA) were employed to evaluate the model's predictive accuracy and clinical relevance. Results: A cohort of 106 children diagnosed with primary DCM and who underwent genetic analysis was studied, with a median diagnostic age of 10 months (ranging from 5 to 84 months), comprising 50 girls (47.2%). The rate of detecting genetic mutations was 28.3%, uncovering 14 gene variants linked to DCM, with TTN mutations being the most common. Both univariate and multivariate Cox regression analyses indicated that both sex and NT-proBNP levels had a significant impact on survival rates among pediatric DCM patients.The model exhibited strong discriminative performance, calibration, and clinical net benefit, as assessed by the C-index, calibration plots, and decision curve analysis (DCA). Conclusions: The prediction model created in this research shows strong accuracy in forecasting survival rates at 1, 3, and 5 years for children with DCM, highlighting its significant relevance in clinical settings.

Acute coronary syndrome (ACS) remains a major contributor to cardiovascular mortality despite advances in emergency cardiovascular intervention and coronary revascularization strategies. This retrospective cohort study evaluated the association between early hemodynamic instability and major adverse cardiovascular events (MACE) among 1,248 ACS patients admitted between January 2023 and December 2025. Patients were categorized into stable and unstable groups based on early emergency department hemodynamic assessment including blood pressure, lactate level, Killip classification, vasopressor requirement, and cardiac output estimation. The primary outcome consisted of 30-day MACE including cardiovascular mortality, recurrent myocardial infarction, cardiogenic shock, ventricular arrhythmia, and urgent revascularization. A total of 372 patients (29.8%) demonstrated early hemodynamic instability and experienced significantly higher rates of cardiogenic shock, ventricular arrhythmia, mechanical ventilation, ICU admission, and 30-day mortality compared with stable patients. Multivariable regression analysis identified serum lactate >4 mmol/L (adjusted OR 3.42; 95% CI 2.10-5.11), systolic blood pressure <90 mmHg (adjusted OR 2.96; 95% CI 1.88-4.47), and left ventricular ejection fraction <35% (adjusted OR 2.71; 95% CI 1.77-4.09) as independent predictors of MACE. Early hemodynamic instability was strongly associated with poor short-term cardiovascular outcomes, suggesting that integrated emergency hemodynamic profiling may improve early risk stratification and facilitate timely cardiovascular intervention.

Introduction Stroke is a leading cause of disability and death in adults with type 2 diabetes (T2D). We evaluated the comparative stroke risk in Veterans with T2D initiated on either of two glucose-lowering medications: GLP-1 receptor agonists (GLP-1RA) or SGLT-2 inhibitors (SGLT2i). Patients and Methods We conducted a retrospective cohort study on diabetic Veterans aged 40 and older with no prior history of stroke or transient ischemic attack, who started on a GLP-1RA or SGLT2i between 2014 and 2021. Patients with contraindications or prior exposure to medication were excluded. Using national Veteran health data, we identified 195,072 [SS1.1]eligible individuals and followed them from treatment initiation until stroke, death, loss to follow up, or end of follow up, whichever came first. Primary outcome was incident stroke, and secondary outcomes included ischemic and hemorrhagic stroke. We applied Kaplan-Meier methods and Cox proportional hazards models. Adjusted associations were estimated using inverse probability weighting. Results Both unadjusted and adjusted analyses suggest GLP-1RA users have reduced stroke incidence compared SGLT-2i users[HS2.1] (HR = 0.[HS3.1]67, 95% CI 0.64-0.69; HR = 0.72, 95% CI 0.69-0.75). Similar results were found in secondary outcome and stratified analyses, with GLP-1RA users having reduced stroke risk compared to SGLT2i users for all age groups, chronic kidney disease stages, and hemoglobin A1c levels. Discussion and Conclusion GLP-1RA treatment was associated with a lower risk of stroke compared with SGLT2i treatment in Veterans with T2D. These findings were consistent for ischemic and hemorrhagic strokes, suggesting potential differences in stroke risk between the treatments.

Background: Chronic total occlusions (CTOs) are a common manifestation of coronary artery disease (CAD) and are associated with increased long-term mortality. While successful CTO revascularization improves symptoms and quality of life, a consistent mortality benefit has not been demonstrated in randomized trials. Outpatient cardiac rehabilitation (CR) has proven benefits in improving functional status, exercise capacity, and quality of life in patients with CAD, yet its impact on CTO patients has not been well studied. Objective: To evaluate the association between CR and long-term outcomes in CTO patients. Methods: Using the TriNetX Research Network, we analyzed de-identified patient data from 75 healthcare organizations using ICD codes. The study population included patients with CTO who started CR within 3 months of diagnosis vs patients with CTO who did not engage in CR. A secondary analysis was also conducted, which excluded patients with other indications for CR, including prior coronary artery bypass grafting (CABG) and prior or concurrent percutaneous coronary interventions (PCI). Results: Of 167,176 CTO patients, 10,021 enrolled in CR, including 1,608 without another CR indication. Patients were propensity-matched for independent risk factors for mortality. After 5 years, CR participation was associated with a significant reduction in mortality (HR 0.68; 95% CI, 0.61-0.75; p < 0.0001). This benefit was preserved even after excluding prior revascularization (HR 0.81; 95% CI, 0.67-0.99; p < 0.036). Conclusion: This study demonstrates that cardiac rehabilitation is associated with improved long-term survival in patients with CTOs.

Tricuspid regurgitation and pulmonary artery systolic pressure may contribute to post-operative morbidity and mortality in liver transplantation. Previous studies suggest that a high Model for End-Stage Liver Disease score may influence the relationship between tricuspid regurgitation and post-operative mortality. Adult patients undergoing liver transplantation workup between 2010 and 2023 were included in this retrospective observational cohort study. Patients with significant portopulmonary hypertension were excluded. Transthoracic echocardiograms were completed pre-transplant and patients were followed up for one year post-operatively. 1031 patients (median MELD score 17, IQR 12-23) underwent transthoracic echocardiography for liver transplantation workup, of whom 708 underwent successful transplantation. Mild or greater tricuspid regurgitation did not predict 1-year mortality in the overall population (HR 1.79 (95% CI 0.78-4.11), p=0.19). Among patients with MELD scores [&ge;]20, mild or greater tricuspid regurgitation was a significant predictor of 1-year mortality (7 (12.7%) vs 9 (3.8%), p=0.01) (HR 3.46 (1.30-10.32), p=0.02). Tricuspid regurgitation in patients with high MELD scores was associated with a trend towards an increased risk of 30-day major adverse cardiovascular events (9 (16.4)% vs 46 (8.1%), p=0.06), driven predominantly by rates of post-operative heart failure (12.7% vs 3.8%, HR 3.66 (95%CI 1.30-10.32), p=0.01). Elevated pulmonary artery systolic pressure was associated with prolonged hospital stay (30 days (14-46) vs 15 days (11-29), p=0.01). Our study confirms that mild or greater tricuspid regurgitation is a significant predictor of 1-year mortality in patients with high MELD scores undergoing liver transplantation. Tricuspid regurgitation severity should be considered during pre-liver transplantation risk stratification.

BackgroundLeft atrial appendage closure (LAAC) and direct oral anticoagulants (DOACs) have emerged as alternatives to warfarin for stroke prevention in atrial fibrillation (AF). However, recent trials have shown variable results igniting the debate on this topic. MethodsWe performed a systematic review and network meta-analysis (NMA) of RCTs comparing LAAC, DOACs, and warfarin in patients with AF. The primary efficacy outcome was ischemic stroke or systemic embolism (IS/SE) and the primary bleeding outcome was hemorrhagic stroke (HS). Secondary outcomes included net adverse clinical events (NACE) and major or clinically relevant bleeding (MCRB). Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were estimated using a random-effects model. ResultsTen RCTs (LAAC: 6 trials; DOAC: 8 trials; warfarin: 6 trials) enrolling 78,594 patients fulfilled the inclusion criteria. There were no significant differences for the primary efficacy outcome of IS/SE among the 3 strategies. However, when compared with warfarin, both DOACs (OR 0{middle dot}43, 95% CI 0{middle dot}34-0{middle dot}54) and LAAC (OR 0{middle dot}34, 95% CI 0{middle dot}18-0{middle dot}63) reduced the primary safety outcome of HS, with no significant difference between them (OR 0{middle dot}79, 95% CI 0{middle dot}44-1{middle dot}3). For NACE, both DOACs (OR 0{middle dot}87, 95% CI 0{middle dot}83-0{middle dot}91) and LAAC (OR 0{middle dot}85, 95% CI 0{middle dot}73-0{middle dot}99) were superior to warfarin, with similar performance between them (OR 0{middle dot}98, 95% CI 0{middle dot}84-1{middle dot}13). For MCRB, DOACs were superior to warfarin (OR 0{middle dot}79, 95% CI 0{middle dot}63-0{middle dot}99), while LAAC showed a non-significant trend towards benefit. ConclusionIn this meta-analysis of RCTs with data from over 78,000 patients, LAAC and DOACs significantly reduced NACE driven by lower hemorrhagic stroke and provided equivalent IS/SE protection compared with warfarin, making LAAC a potential viable alternative to oral anticoagulation in appropriately selected AF patients. FundingNone.

Background Disparities between sexes in mortality and morbidity after coronary artery bypass grafting remain incompletely understood. Multi-arterial grafting demonstrates superior outcome compared to single arterial grafting, although the optimal type of a second arterial graft and possible sex-dependent differences in grafting strategy have not been elucidated. We aim to determine whether the right internal thoracic artery or the radial artery is the optimal second arterial graft. Methods We analyzed data from 14,196 patients undergoing primary isolated coronary artery bypass grafting with the left internal thoracic artery and either right internal thoracic artery or radial artery between 2013 and 2022 from the Netherlands Heart Registration. Patients were stratified by sex and type of second arterial graft. Inverse probability treatment weighting was used to balance baseline characteristics. The primary outcome was long-term mortality. Secondary outcomes included short-term complications and repeat revascularization. Results In both sexes, the choice of second arterial graft did not significantly impact long-term survival. Postoperative arrhythmias were more prevalent in both sexes following right internal thoracic artery use (p<0.001). The radial artery was associated with higher rate of repeat revascularization in men (p=0.044 at 5 years follow-up) and more cerebrovascular accidents in women (0.9% vs 0.2%, p=0.028). Conclusion The choice of second arterial graft did not affect long-term survival in either sex. The radial artery was associated with an increased risk of repeat revascularization in men and more cerebrovascular accidents in women. These results underscore the need for further research in the field of sex-specific considerations in operative strategy.

BackgroundChagas cardiomyopathy remains a major cause of heart failure (HF) in endemic regions and is increasingly recognized globally, yet data on in-hospital outcomes are limited. Objective: To assess whether Chagas disease is associated with higher in-hospital mortality among patients hospitalized with HF. MethodsWe analyzed a nationwide administrative database from the Brazilian Unified Health System (DATASUS/SIHSUS), including adults hospitalized with HF between April 2017 and August 2021. HF was identified using ICD-10 code I50.x and Chagas disease using B57.x. The primary outcome was in-hospital mortality, evaluated using multivariable Cox models. Results: Among 910,128 HF hospitalizations, 1,082 (0.12%) were associated with Chagas disease. Patients with Chagas were younger but had a more complex clinical profile and higher resource use. In-hospital mortality was higher in the Chagas group (25% vs 12%; p<0.001). After adjustment, Chagas disease remained independently associated with mortality (HR 1.54; 95% CI 1.35-1.75; p<0.001). ConclusionsIn this large real-world cohort, Chagas disease was associated with higher in-hospital mortality and greater healthcare utilization. These findings reinforce the high-risk nature of Chagas cardiomyopathy and point to the need for more targeted treatment strategies. What is the clinical question being addressed?Chagas cardiomyopathy is a major cause of heart failure in endemic regions and an emerging global health problem, yet real-world data on in-hospital outcomes remain limited. Is Chagas disease associated with higher in-hospital mortality? What is the main finding?Chagas disease was independently associated with a 54% higher risk of in-hospital mortality in a large real-world cohort.

Background: Coronary artery bypass grafting (CABG) to physiologically non-significant coronary artery stenosis may result in graft failure due to competitive native flow. We evaluated whether an instantaneous wave-free ratio (iFR)-guided revascularization strategy improves graft patency and clinical outcomes compared to conventional angiography-guided CABG. Methods: In this prospective, randomized, single-blinded trial, patients with multivessel disease and at least one angiographically intermediate stenosis (50%-75%) were randomized to either CABG guided by angiography alone or angiography supplemented with iFR assessment groups. The primary endpoint was graft patency (occlusion or hypoperfusion of the graft) evaluated by coronary computed tomography angiography (CCTA) at 2, 12, and 36 months. Results: At 36 months, 78% of the patients completed follow-up. Left internal mammary artery (LIMA)-to-left anterior descending (LAD) artery graft patency was significantly higher in the iFR-guided group than in the angiography-guided group (80.5% vs. 56.8%; absolute risk difference, 23.7% [95% CI, 3.7%-43.8%]; RR, 1.42 [95% CI, 1.03-1.95]; P = 0.03). Saphenous vein graft patency also improved with iFR guidance (90.2% vs. 70.3%; P = 0.046). Major adverse cardiac and cerebrovascular events (MACCE) were similar between groups (28% vs. 20%; RR, 1.40 [95% CI, 0.69-2.85]; P = 0.48). Conclusions: iFR-guided CABG advocates significantly improved mid-term graft patency compared with angiography-guided CABG by optimizing surgical target selection and reducing competitive flow.

Abstract Background Cardiogenic shock (CS) is a heterogeneous syndrome with diverse etiologies, treatment pathways, and outcomes. Prior studies of sex differences in CS have largely focused on acute myocardial infarction-related CS or evaluated CS as a single entity. Whether sex-based differences in outcomes and treatment utilization vary across distinct CS phenotypes remains incompletely defined. Methods We performed a retrospective cohort study using the National Inpatient Sample, a nationally representative all-payer database of United States hospitalizations. Adult hospitalizations with CS were identified using ICD-10-CM code R57.0 and categorized into clinically relevant phenotypes, including acute myocardial infarction (AMI), heart failure (HF), arrhythmia-related shock, myocarditis/Takotsubo, valvular disease, and other etiologies. Survey-weighted analyses accounting for the complex sampling design were used for primary analyses. The primary outcome was in-hospital mortality. Secondary outcomes included use of mechanical circulatory support (MCS) and mechanical ventilation. Propensity score-matched analyses were performed as sensitivity analyses. Results Among 254,691 weighted CS hospitalizations, 158,747 (62.3%) occurred in men and 95,896 (37.7%) in women. In survey-weighted analyses, women had higher in-hospital mortality in AMI-related CS (36.1% versus 31.3%; OR, 1.24; 95% CI, 1.19-1.28), HF-related CS (30.5% versus 25.8%; OR, 1.27; 95% CI, 1.23-1.30), and arrhythmia-related CS (37.3% versus 31.6%; OR, 1.28; 95% CI, 1.20-1.38). Women were less likely to receive ECMO (2.4% versus 2.9%), IABP/Impella (13.1% versus 18.9%), or any MCS (14.6% versus 20.4%), but were more likely to receive mechanical ventilation (44.9% versus 42.9%). In propensity-matched analyses, mortality differences were attenuated but persisted in AMI-related, HF-related, and valvular CS. Conclusions Sex differences in CS outcomes and treatment utilization are strongly phenotype dependent. Women experienced higher mortality in major CS phenotypes while receiving less advanced mechanical circulatory support. These findings support early recognition, rapid phenotype classification, and sex-conscious but non-delayed escalation strategies for women with CS.

BackgroundThere is no consensus on a risk threshold for sudden cardiac death (SCD) that could be used in practical design and evaluation of prediction models and decisions regarding implantable cardioverter-defibrillator (ICD) therapy. MethodsBaseline assumptions for a simulation framework were derived from previous randomized controlled trials (n=18) to identify minimal SCD risk threshold that would translate to mortality benefit by ICD therapy also considering the effect of competing non-sudden mortality. ICD efficacy to prevent SCDs and other data for simulations were estimated using inverse-variance weighted meta-analysis of included trials. Number needed to treat (NNT) was evaluated over a five-year horizon ([&le;]21 defined as clinically relevant). ResultsCorrelation analysis confirmed annual SCD incidence in trial populations as the key factor associating with ICD therapy effectiveness to reduce mortality (Pearsons r=0.653, p<0.01). In a simulation assuming 5% annual non-sudden mortality (pooled estimate of included RCTs) and a 56% (48-62%) efficacy for ICDs to reduce SCDs or similar events, 3% annual SCD risk ({approx}12% over five years) emerged as the lowest practical threshold even after controlling for excess (overlapping) mortality among those saved successfully from SCD by ICD therapy. The theoretical minimum threshold for annual SCD risk is 2.0%, 2.5% and 3.5% for populations with the annual incidence of non-sudden deaths 2%, 5% and 10% (assuming no overlapping mortality). ConclusionsEven under substantial competing risk, a 3% annual SCD threshold appears an optimal minimum threshold for identifying patients most likely to benefit from ICD therapy if severe mortality overlap is not observed. Key QuestionsWhat is the minimal risk threshold after which ICD therapy will likely lead to meaningful reduction in overall mortality. This information is needed in practical design of clinical trials and evaluation and development of prediction models Key FindingAnalysis of the data extracted from previous randomized controlled trials revealed that annual SCD risk should be at least 3% in most scenarios (with the annual incidence of non-sudden mortality [&le;]5%) for ICD therapy to be effective. Take-home MessagePrimary prevention SCD and risk models targeted to identify high-risk individual should aim for identifying patients with 3% or higher annual risk for SCD.

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.