International Journal of Cardiology

BackgroundHeart transplant (HT) has a high in-hospital mortality of around 5%. Risk prediction in-hospital mortality can be informative for transplant candidacy and post-HT prognosis. Elixhauser Comorbidity Index (ECI) is an ICD diagnostic code-based comorbidity measurement tool that can predict in-hospital mortality. While it has been validated in the large in-patient population, the accuracy of the mortality prediction has not been assessed in HT. MethodsThis study assessed the in-hospital mortality risk prediction by ECI as well as demographic variables in HT patients in the National Inpatient Sample (NIS) database. Demographic information was included in the multivariable ECI with demographics (ECID) model to assess in-hospital mortality. Moreover, ECI and age were used to develop a single index adjusted ECI (aECI) for mortality prediction. ResultsAge best predicts (c-statistic = 0.673, 95% CI = 0.638-0.709) in-hospital mortality, followed by ECI (c-statistic = 0.638, 95% CI = 0.598-0.678), race (c-statistic = 0.571, 95% CI = 0.533-0.609). Sex did not have predictive power (c-statistic = 0.501, 95% CI = 0.467-0.535) for in-hospital mortality. The predictive power of ECI was improved (c-statistic = 0.753, 95% CI = 0.720-0.785) in the ECID model. The single measure aECI had comparable discriminative power (c-statistic = 0.763, 95% CI = 0.731-0.794) to ECID in predicting in-hospital mortality. ConclusionThis study showed that ECI was an effective measure to predict post-HT in-hospital mortality. The improved measure aECI can be easily derived from ECI as a quick reference to assess post-HT in-hospital mortality in both the clinic and health administration.

BackgroundThe United Network for Organ Sharing (UNOS) adopted new criteria for the heart allocation score on 10/18/2018 to reflect changing trends of candidates mortality while awaiting transplant. We examined the impact of these policy changes on rates of left ventricular assist device (LVAD) implantation and outcomes posttransplant from a relatively newer UNOS database. MethodsThe UNOS registry was used to identify first-time adult heart recipients with LVAD at listing or transplant who underwent transplantation between 1/1/2016 and 3/10/2020. Survival data was collected through 3/30/2023. Those listed prior to 10/18/2018 but transplanted after were excluded. Patients were divided into before or after change groups. Demographics and clinical parameters were compared. Survival was analyzed with Kaplan-Meier curves and log-rank tests. A p<0.05 was considered significant. ResultsWe identified 4599 heart recipients with LVAD in the before (N=3767) and after (N=832) score change eras. The after group had a lower rate of LVAD implantation while listed compared to the before group (19.4% vs 34.5%, p<0.0001), younger average age (53.1 {+/-} 12.2 vs 54.1 {+/-} 11.9, p=0.0350) and more likely to be female (24.9% vs 19.6%, p=0.0007); in both groups, most recipients (62%) were white. There was significantly farther distance from the donor hospital to transplant center in the after group (259.5 {+/-} 246.8 NM vs 143.2 {+/-} 182.1 NM, p<0.0001) and decreased waitlist days (83.5 {+/-} 103.5 vs 369.0 {+/-} 458.5, p<0.0001). Recipients in the after group were more likely to receive a CDC increased-risk donor organ (37.5% vs 30.2%, p=0.0002). Survival at 5-years was significantly reduced in the after group (60.5% vs 78.9%, p<0.0001). ConclusionsThe allocation score change in 2018 yielded considerable changes in mechanical circulatory support device implantation strategy and survival. The rate of LVAD implantation decreased with profoundly worse 5-year survival, showing further divergence from prior short-term post-transplant data.

BackgroundThe 2018 heart transplant allocation policy has changed the profile of patients receiving heart transplant, with an increased use of acute mechanical support and decreased use of durable left ventricular assist devices. We investigated the use of extracorporeal membrane oxygenation (ECMO) use pre- and post-allocation change. MethodsUsing the UNOS database, we identified adult patients who underwent heart transplant from January, 2006 - June, 2022. The study time period was divided into pre- and post-allocation change. We divided ECMO patients by region and analyzed change in the rate of ECMO use by region between eras. Differences between groups and survival comparison were analyzed. ResultsA total of 41,636 recipients were found, of which 891 (2.1%) were on ECMO at the time of transplant. Overall ECMO use increased from 231 (0.8%) to 660 (5.5%) between eras (p<0.001). There was significant regional variation in the rate of ECMO usage (p<0.001) and significant differences in postoperative dialysis (p=0.014) and acute rejection episodes (p<0.001). There was no significant difference in pacemaker rate (p=0.172), stroke (p=0.212), treatment for rejection within 1 year (p=0.358), or post-transplant survival in the current era between regions for patients on ECMO at the time of transplant (p=0.444). ConclusionThere is increased utilization of ECMO following implementation of an allocation system which prioritizes ECMO recipients on the waitlist and there is a differential increase in the use of ECMO in various regions. Further granular studies are needed to see which patients may benefit more from ECMO and what can be done to reduce post-transplant mortality from ECMO to transplant as it remains high before and after allocation change.

ObjectiveThis study evaluated patterns of utilization, complications, and costs of endomyocardial biopsies (EMB) in heart transplant patients. MethodsThe IBM(R) Treatment Pathways(R) tool was used to analyze claims data selected from the IBM(R)s MarketScan(R) de-identified, HIPAA-compliant dataset. Differences in EMB paid amounts and utilization patterns were assessed for commercial payers and Medicare for years 2016 to 2019. Type, frequency, and overall cost of complications of the EMB procedure in these patients were also evaluated. ResultsA total of 8,170 records (6,385 commercial payers and 1,785 Medicare) of heart transplant patients with evidence of EMB procedures performed between 2016 and 2019 were identified in the database. In 2019, the median paid amount for an outpatient EMB in a heart transplant patient was US $7,918 (commercial) and US $2,980 (Medicare). Heart transplant patients received between 4.6 and 6.8 (median; Medicare, commercial) EMBs the first year after the transplant. Approximately 25% of EMB procedures were associated with complications. In 2019 the total cost of EMB complications per patient was US $9,049. DiscussionAnalysis showed that the paid amount for the EMB procedure increased by almost 25% from 2016 to 2019 for commercial payers. Given the high frequency of complications after the EMB procedure and the associated cost of the complications it is estimated that the median paid amounts are closer to US $10,000 per patient per EMB. Given the number of EMBs provided, the associated risks, and the paid amount trends, non-invasive alternatives to EMB should be considered for the surveillance of heart transplant patients.

BackgroundThe current United States donor heart allocation system prioritizes patients receiving temporary mechanical circulatory support over those with durable left ventricular assist devices (d-LVADs), but the impact on post-transplant survival remains unclear. ObjectivesTo evaluate post-transplant outcomes in patients bridged with d-LVAD versus t-LVAD before and after the 2018 United Network for Organ Sharing (UNOS) allocation policy change. MethodsUsing the UNOS database, we analyzed 24,795 adult first-time HT recipients from 2011-2023, stratified by device type at transplant: d-LVAD (43.3%), t-LVAD (6.4%), or no LVAD. Outcomes included survival at 30 days, 90 days, 1 year, and 2 years. Risk-adjusted analyses were performed using Cox proportional hazards models. Subgroup analysis examined time on LVAD and the impact of organ preservation on outcomes. ResultsCompared to t-LVAD and no-LVAD recipients, d-LVAD recipients had significantly higher adjusted mortality rates at all time points (hazard ratios ranged from 1.44 at 30 days to 1.18 at 2 years; p < 0.001). The mortality gap was more pronounced under the current allocation era. In patients with device duration data, [&ge;]2 years on LVAD was associated with a 39% higher 1-year mortality risk (HR 1.39, 95% CI 1.15-1.68). No significant differences in 1-year mortality were observed between DCD donor and machine-perfused donor transplant subgroups by LVAD status. ConclusionsPost-transplant survival is worse with d-LVAD bridging, particularly under current allocation rules, and prolonged LVAD support further elevates risk. These findings underscore the need to reevaluate LVAD strategy and transplant prioritization, considering evolving allocation policies. Condensed AbstractIn a UNOS analysis of 24,795 heart transplants (2011-2023), patients bridged with durable LVADs (43.3%) consistently experienced worse post-transplant survival than those with temporary LVADs (6.4%) or no device. Adjusted mortality was higher at all time points (HR 1.44 at 30 days to 1.18 at 2 years; p<0.001), with disparities becoming more pronounced after the 2018 allocation change. Prolonged LVAD use ([&ge;]2 years) further increased the risk. These findings highlight the need to reevaluate durable LVAD strategies and transplant prioritization. Preprint ServerNone

IntroductionAfter the 2018 allocation policy change, the rate of listings and transplants with durable LVADs has decreased significantly in favor of bridging patients from temporary mechanical circulatory support to heart transplant. The Organ Procurement and Transplantation Network (OPTN) recently approved a policy, to be implemented in September 2026, stipulating that patients supported by durable LVADs for 6 and 8 years will obtain statuses 3 and 2, respectively. MethodsUsing OPTN data, we identified all adult heart transplant candidates with a durable LVAD implanted between October 18, 2018 and May 31, 2025. We estimated the cumulative incidence of status upgrades and durable LVAD-related complications, treating transplantation and waitlist removal before experiencing complications as competing events. We also assessed how the composition of the adult heart transplant waitlist on June 1, 2025 would have changed based on the upcoming policy change. ResultsDuring the study period, 3,881 adult patients were listed for heart transplant with a durable LVAD. 3,182 (82.0%) of the durable LVADs were Abbott HeartMate 3, 568 (14.6%) were Medtronic Heartware HVAD, and 91 (2.3%) were Abbott HeartMate II. Transplant centers submitted a total of 6,924 justifications for status upgrades due to LVAD-related complications (6.3% status 1, 34.3% status 2, and 59.4% status 3) for 1,500 (38.6%) of these patients, with a median of 3 per patient. The cumulative incidence of complications or status upgrades was 38.6% [95% CI (37.1%, 40.2%)]. Nearly all of the 2,381 patients who did not experience any complication or status upgrade during listing were removed from the waitlist by 6 years. Had the upcoming OPTN policy change been implemented on June 1, 2025, the proportion of the waitlist that would have achieved higher priority status instantaneously was 0.06%. ConclusionsThe cumulative incidence of status upgrades and complications among heart transplant candidates with durable LVADs was nearly 40% within 6 years of device implantation. The upcoming OPTN policy to escalate patients to statuses 3 and 2 after 6 and 8 years of durable LVAD support, respectively, is unlikely to make a meaningful impact on waitlist priority status.

BackgroundAcute coronary syndrome (ACS) carries significant risks of recurrent cardiovascular (CV) events and bleeding complications. In particular, Asian patients have higher rates of bleeding complications due to genetic and physiological factors. Bleeding complications are associated with an increased risk of subsequent thrombotic events, and the impact of such complications on long-term outcomes must therefore be investigated. This study compared long-term outcomes and clinical characteristics between ACS patients who experienced a single ACS event and those who experienced multiple CV events. MethodsUtilizing data from Taiwans National Health Insurance Research Database, this retrospective cohort study categorized patients into single-event and multiple-event groups based on the occurrence of major adverse CV events within 2 years after the index ACS event. In this cohort study, 28,535 patients were included. After matching by age, sex, and the interval between the first and second CV events at a 1:2 ratio, 8,720 patients were included in the multiple-event group and 17,368 in the single-event group. ResultsThe multiple-event group had higher rates of comorbidities, including hypertension, prior coronary artery disease, heart failure, stroke, and chronic kidney disease. Over a 5-year period, the multiple-event group exhibited higher all-cause mortality (34.1% vs. 24.6%, p < 0.0001) and CV mortality (11.4% vs. 6.2%, p < 0.0001) than the single-event group. The rates of major bleeding events (7.8% vs. 1.6%, p < 0.0001) and minor bleeding events (34.4% vs. 7.2%, p < 0.0001) were also higher in the multiple-event group than in the single-event group. Compared with the single-event group, which showed a significant reduction in major bleeding events 1 month after the index ACS event, the multiple-event group continued to have a higher rate of major bleeding events within 3 months following the index ACS event. In the multiple-event group, patients who experienced a major bleeding event had an earlier onset of subsequent CV events than patients who did not experience a major bleeding event. Specifically, every 1-day earlier occurrence of major bleeding was associated with a 1.0044-day earlier occurrence of a subsequent CV event. ConclusionACS patients with multiple CV events have higher rates of all-cause mortality, CV mortality, and major bleeding than ACS patients with a single CV event. However, major bleeding may be associated with the risk of subsequent CV events, highlighting the importance of implementing a tailored antiplatelet strategy in Asian populations.

BackgroundWhile left ventricular (LV) venting reduces LV distension in cardiogenic shock patients on venoarterial extracorporeal membrane oxygenation (VA-ECMO), it may also amplify risk of acute brain injury (ABI). We investigated the hypothesis that LV venting is associated with increased risk of ABI. We also compared ABI risk of the two most common LV venting strategies, percutaneous microaxial flow pump (mAFP) and intra-aortic balloon pump (IABP). MethodsThe Extracorporeal Life Support Organization registry was queried for patients on peripheral VA-ECMO for cardiogenic shock (2013-2024). ABI was defined as hypoxic-ischemic brain injury, ischemic stroke, or intracranial hemorrhage. Secondary outcome was hospital mortality. We compared no LV venting with 1) LV venting, 2) mAFP, and 3) IABP using multivariable logistic regression. To compare ABI risk of mAFP vs. IABP, propensity score matching was performed. ResultsOf 13,276 patients (median age=58.2, 69.9% male), 1,456 (11.0%) received LV venting (65.5% mAFP and 29.9% IABP), and 525 (4.0%) had ABI. After multivariable regression, LV-vented patients had increased odds of ABI (adjusted odds ratio (aOR)=1.76, 95% CI=1.29, 2.37, p<0.001) but no difference in mortality (aOR=1.08, 95% CI=0.91-1.28, p=0.39) compared to non-LV-vented patients. In the propensity- matched cohort of IABP (n=231) vs. mAFP (n=231) patients, there was no significant difference in odds of ABI (aOR=1.35, 95%CI=0.69-2.71, p=0.39) or mortality (aOR=0.88, 95%CI=0.58-1.31, p=0.52). ConclusionsLV venting was associated with increased odds of ABI but not mortality in patients receiving peripheral VA-ECMO for cardiogenic shock. There was no difference in odds of ABI or mortality for IABP vs. mAFP patients. Clinical PerspectiveIn patients receiving peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock, left ventricular venting is associated with increased odds of acute brain injury (ABI) but not mortality. However, mode of venting--intra-aortic balloon pump (IABP) or percutaneous microaxial flow pump (mAFP)--does not appear to impact either odds of ABI or mortality. These findings highlight a link between venting strategies and neurological outcomes in this high-risk population. Clinicians must weigh the benefits of venting against ABI risk when managing neurocritically ill patients, though our findings provide reassurance clinicians that both IABP and mAFP may offer comparable neurologic safety profiles.

BackgroundAt least 12-month dual antiplatelet therapy (DAPT) is one of the standards of care following Percutaneous Coronary Intervention (PCI) in patients with acute coronary syndrome. However, study on prolonged DAPT for acute myocardial infarction (AMI) patients without revascularization is limited. MethodsWe studied 1744 AMI patients without revascularization from the China Acute Myocardial Infarction registry between January 2013 and September 2014. These patients were on DAPT and did not experience AMI, stroke, or bleeding events at 12-month follow-up. We divided them into two groups: 12-month DAPT group (DAPT for at least 12 months but less than 18 months) and 18-month DAPT group (DAPT for at least 18 months). The primary outcome is 24-month all-cause death. ResultsOverall, 1221 (70.0%) patients took DAPT for [&ge;]12 months but <18 months, while 523 (30.0%) patients took DAPT for [&ge;]18 months. The two groups had comparable proportions with high ischemic risk (27.0% vs. 25.6%, P = 0.5418), as well as high bleeding risk (29.0% vs. 28.5%, P = 0.8316). At 24 months, the all-cause mortality rate of 18-month DAPT group was significantly lower than that for 12-month DAPT group (3.7% vs 5.9%, P = 0.0471). Adjusted hazard ratio for all-cause death also showed statistical significance (0.59, 95% CI: 0.35-0.99, P = 0.0444). ConclusionsDAPT for at least 18 months was associated with lower 24-month mortality for non-revascularization AMI patients without events within 12 months after onset.

BackgroundLittle is known about the impact of the downgrade of guideline recommendations for intra-aortic balloon pump (IABP) use and the approval of the Impella in Japan, where IABPs have been enthusiastically used. This study aimed to describe the annual trends in the mechanical circulatory support (MCS) use and outcomes in patients with cardiogenic shock (CS) requiring MCS. MethodsUsing the Japanese Diagnosis Procedure Combination database from July 2010 to March 2021, we identified inpatients with CS requiring MCS. The patients were stratified into three groups: (i) IABP alone, (ii) Impella alone, and (iii) extracorporeal membrane oxygenation (ECMO) regardless of IABP or Impella use. The patient characteristics and outcomes were reported by the fiscal year. ResultsOf the 160,559 eligible patients, 117,599 (73.2%) used IABP alone, 1,465 (0.9%) Impella alone, and 41,495 (25.8%) ECMO. The prevalence of an IABP alone significantly decreased from 80.5% in 2010 to 65.3% in 2020 (P for trend <0.001), whereas the prevalence of an Impella alone significantly increased from 0.0% to 5.0% as well as ECMO from 19.5% to 29.6% (P for trend <0.001 for both). In-hospital mortality significantly increased from 29.3% in 2010 to 32.6% in 2020 in the overall patients with CS requiring MCS, but significantly decreased in those requiring ECMO from 73.7% to 64.1% (P for trend <0.001 for both). ConclusionsThere were significant annual changes in the patterns of MCS use and clinical outcomes in patients with CS requiring MCS.

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.

BackgroundDual antiplatelet therapy (DAPT), combining acetylsalicylic acid (aspirin) and a P2Y12 inhibitor, is recommended for patients with non-ST segment elevation myocardial infarction (NSTEMI) undergoing coronary artery bypass grafting (CABG). However, real-world adoption and effectiveness of DAPT in this context has not been adequately evaluated. MethodsWe conducted a retrospective propensity-matched cohort analysis using data from the TriNetX research network, which includes electronic health records from over 70 healthcare organizations across the United States. The study included patients aged >18 years diagnosed with NSTEMI who underwent CABG within one month of presentation from January 2015 to January 2024. Outcomes for patients on DAPT were compared with those on aspirin monotherapy using standardized mean differences, risk ratios, and Cox proportional hazard models for survival analysis. ResultsFrom a cohort of 21,092 NSTEMI patients eligible for DAPT post-CABG, 55.28% received DAPT predominantly consisting of aspirin and clopidogrel. After propensity score matching, DAPT was associated with significantly reduced all-cause mortality at 1-year (8.1% vs 5.5%, OR: 1.52) and 5-year (14.4% vs 10.6%, OR: 1.41) follow-ups compared to aspirin monotherapy. There were no significant differences in rates of major bleeding, ischemic strokes, or repeat revascularization between the two groups. ConclusionThe underutilization of DAPT in real-world settings, despite guideline recommendations, reflects a potential gap between clinical practice and evidence-based guidelines. Our findings support the effectiveness of DAPT in reducing mortality without increasing major bleeding risks, underscoring the need for more widespread adoption and potentially more robust clinical trials to confirm these observational findings.

ObjectivesWe evaluated the clinical impact of residual non-culprit left main coronary artery disease (LMCAD) on prognosis in patients undergoing emergent percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). MethodsA total of 429 patients who underwent PCI for AMI complicated by CS was enrolled from 12 centers in the Republic of Korea. The patients were divided into two groups according to presence of non-culprit LMCAD or not: the LMCAD non-culprit group (n = 43) and the no LMCAD group (n = 386). Primary outcome was major adverse cardiac event (MACE, defined as a composite of cardiac death, myocardial infarction, or repeat revascularization). Propensity score matching analysis was performed to reduce selection bias and potential confounding factors. ResultsDuring a 12-month follow-up, a total of 168 MACEs occurred (LMCAD non-culprit group, 17 [39.5%] vs. no LMCAD group, 151 [39.1%]). Multivariate analysis revealed no significant difference in the incidence of MACE at 12 months between the LMCAD non-culprit and no LMCAD groups (adjusted hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.56 to 1.58, p = 0.817). After propensity score matching, the incidence of MACE was still similar between the two groups(HR 1.07; 95% CI 0.49 to 2.36; p = 0.857). The similarity of MACEs between the two groups was consistent across a variety of subgroups. ConclusionsAfter adjusting for baseline differences, residual non-culprit LMCAD does not appear to increase the risk of MACEs at 12 months in patients undergoing emergent PCI for AMI complicated by CS.

BackgroundNeutrophil to lymphocyte ratio (NLR) has emerged as a new inflammation marker, which plays a major role in plaque instability, rupture, and erosion, and facilitates its progression, leading to acute myocardial infarction. The study aims to explore the role of NLR in predicting spontaneous reperfusion (SR) and prognosis in patients with ST-segment elevation myocardial infarction (STEMI). MethodsThis was a retrospective analysis including 506 STEMI patients undergoing primary percutaneous coronary intervention treatment, who were divided into two groups according to the thrombolysis in myocardial infarction (TIMI) flow: SR group (69 patients, initial TIMI flow 3) and No-SR group (437 patients, initial TIMI flow 0-2). ResultsThe incidence of SR was 13.6%. SR group was associated with a remarkably lower level of NLR [5.14 (2.97, 7.02) vs. 8.03 (4.54, 10.92), P<0.001], more proportions of final TIMI 3 flow (98.6% vs. 91.5%, P < 0.05), lower incidence of congestive heart failure (8.7% vs. 18.5%, P < 0.05), and significantly better outcomes. Using multivariate logistic regression analysis, NLR (OR: 0.799, 95% CI: 0.730-0.874, P < 0.001) and fasting blood glucose were the independent predictors of SR. On multivariate Cox regression analysis, NLR (HR: 1.035, 95% CI: 1.001-1.071, P < 0.05) was the independent predictor of MACEs during follow-up. ConclusionsNLR had the ability in predicting SR in STEMI patients and SR flow was associated with a favorable outcome. We also revealed an association between NLR and increased risk of MACEs during follow-up. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIThe incidence of spontaneous reperfusion was 13.6%. Patients with spontaneous reperfusion had a remarkably low level of NLR [5.14 (2.97, 7.02) versus 8.03 (4.54, 10.92), P<0.001], more proportions of final TIMI 3 flow (98.6% versus 91.5%, P < 0.05), lower incidence of congestive heart failure (8.7% versus 18.5%, P < 0.05), and favorable outcomes. C_LIO_LINLR was not only an independent predictor of spontaneous reperfusion, but also was the independent predictor of major adverse cardiac events during follow-up (HR: 1.035, 95% CI: 1.001-1.071, P < 0.05) in patients with ST-segment elevation myocardial infarction. C_LI What Are the Clinical Implications?O_LIThe level of neutrophil to lymphocyte ratio in patients with ST-segment elevation myocardial infarction is associated with low occurrence of spontaneous reperfusion and adverse outcomes, although, the patients received primary percutaneous coronary intervention. C_LIO_LINeutrophil to lymphocyte ratio the plays a major role in the risk classification of patients with ST-segment elevation myocardial infarction. C_LI

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.

Clonal hematopoiesis (CH) promotes inflammation and is associated with the development of cardiovascular disease. Previous studies assessing CH mutations in orthotopic heart transplant (OHT) recipients have revealed inconsistent findings, likely due to small sample size and differing sample collection time. In this study, we investigated the association between CH and post-transplant outcomes with a more consistent sample collection window. This retrospective study included 209 patients who underwent OHT between 2015 and 2022. Targeted sequencing detected CH mutations from samples obtained within a window of six months before or after transplantation. Clinical data were collected from the electronic medical record. Patients undergoing OHT had a median age of 53 years, and 27% were female. CH-associated mutations with a variant allele frequency (VAF) greater than 2% were detected in 29 patients (13.9%). The commonly mutated genes included DNMT3A, TET2, and ASXL1. CH mutations were associated with an increased risk of antibody-mediated rejection (AMR) (HR 2.42, 95% CI 1.07-5.47, p=0.033), but without detected differences in mortality or cardiac allograft vasculopathy (CAV). CH mutations detected at the time of transplant were associated with clinically significant AMR. Sample analysis at the time of transplant provides the clearest association between CH mutations and outcomes in OHT.

IntroductionFor heart transplantation, optimal donor-recipient matching is an important factor in the ongoing development of the United Network for Organ Sharing (UNOS) continuous distribution framework. Donor-recipient sex-mismatch has decreased since the 1990s, but this may be related to the risk posed by size mismatching, particularly when donor hearts are undersized. Thus, the impact of sex-mismatching, controlling for other factors including size mismatch, is uncertain. MethodsAdult first-time, isolated heart transplant patients from the UNOS database between October 1, 1987 and December 31, 2022 were analyzed. Cohorts were separated into male and female recipients. Propensity score matching on known preoperative risk factors was performed. Equivalence testing via Two One-Sided Testing (TOST) was performed to assess between-arm equivalence in postoperative outcomes. Survival differences were measured by the between-arm ratio of Restricted Mean Survival Time and binary outcome differences by the Odds Ratio (OR). ResultsIn the propensity matched cohort, we found significant equivalence between arms in both male (TOST P<0.001) and female (TOST P<0.001) recipients for overall survival at all temporal endpoints, postoperative treatment for rejection within one year, and pre-discharge dialysis. ConclusionsSex-mismatch in isolated heart transplantation confers no additional risk to postoperative outcomes when controlling for other factors, including size mismatch. Consequently, sex-mismatch should not factor into individual assessments of organ acceptance or be incorporated into any national organ allocation policy. Increasing the acceptance of sex-mismatched donors has the potential to expand the donor pool and increase female donor utilization.

BackgroundThe impact of the COVID-19 pandemic on potential racial disparities in acute myocardial infarction (AMI) management and outcomes is unclear. We examined AMI patient management and outcomes during the pandemics initial nine months, comparing COVID-19 and non-COVID-19 cases. MethodsWe identified all patients hospitalized for AMI in 2020 using the National Inpatient Sample (NIS), identifying those with or without concurrent COVID-19. Logistic and linear regression was used for analyses of associations, with adjustment for potential confounders. ResultsPatients with both AMI and COVID-19 had higher in-hospital mortality rates (aOR 3.19, 95% CI 2.63-3.88), mechanical ventilation (aOR 1.90, 95% CI 1.54-2.33), and hemodialysis (aOR 1.38, 95% CI 1.05-1.89) compared to those without COVID-19. Black and Asian/Pacific Islander patients had higher in-hospital mortality than White patients, (aOR 2.13, 95% CI 1.35-3.59) and (aOR 3.41, 95% CI 1.5-8.37). Moreover, Black, Hispanic, and Asian/Pacific Islander patients had higher odds of initiating hemodialysis, (aOR 5.48, 95% CI 2.13-14.1), (aOR 2.99, 95% CI 1.13-7.97), and (aOR 7.84, 95% CI 1.55-39.5) and were less likely to receive PCI for AMI, (aOR 0.71, 95% CI 0.67-0.74), (aOR 0.81, 95% CI 0.77-0.86), and (aOR 0.82, 95% CI 0.75-0.90). Additionally, Black patients had a lower likelihood of undergoing CABG surgery for AMI (aOR 0.55, 95% CI 0.49-0.61). ConclusionOur study revealed increased mortality and complications in COVID-19 patients with AMI, highlighting significant racial disparities. Urgent measures addressing healthcare disparities, such as enhancing access and promoting culturally sensitive care, are needed to improve health equity.

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.

BackgroundDrug coated balloon (DCB) is an emerging treatment technology for percutaneous coronary intervention (PCI). However, the prognostic factors of PCI with DCB remain fully determined. Chronic kidney disease (CKD) is an independent predictor of adverse outcomes in patients with coronary artery disease (CAD) who underwent PCI. The aim of the present study was to clarify the impact of CKD on prognosis in CAD patients who underwent PCI with DCB. MethodsWe enrolled 252 consecutive patients with CAD who underwent PCI with DCB from 2015 to 2023. The endpoints of this study were composite events including all-cause death, myocardial infarction, target vessel revascularization, stroke, and major bleeding. ResultsThe prevalence rate of CKD was 48%. Patients with CKD were older and had higher prevalence of hypertension and diabetes mellitus than those without. Kaplan-Meier analysis revealed a significantly higher composite event rate in patients with CKD (log-rank test, P = 0.003). In the multivariate Cox proportional hazards analysis, CKD was independently associated with composite events after adjusting for confounding factors (adjusted hazard ratio 1.920, 95% confidence intervals 1.154-3.197, P = 0.012), mainly driven by all-cause deaths. ConclusionCKD was associated with unfavorable outcomes in CAD patients who underwent PCI with DCB.