The American Journal of Cardiology

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.

Background: Clinical genetic evaluation for patients with dilated cardiomyopathy (DCM) is minimally implemented and models of care are not defined. To understand current genetics care for DCM, a systematic needs assessment was conducted. Methods: Principal Investigators (PIs) of the DCM Consortium convened at the Summer Scientific Symposium in July 2025. An electronic needs assessment was collected from the 24 PIs in advance to define current care models by evaluating which Heart Failure Society of America-recommended genetic evaluation components are conducted, by whom, and time required. Descriptive statistics were generated to characterize model features. Focus group discussions explored barriers and facilitators to implementing genetic services. Results: Four care models emerged from the PI responses: 1 -- Traditional-Synchronous (25%, n=6, requiring the most time per patient), 2 -- Traditional-Asynchronous (33%, n=8), 3 -- Externally Sourced (17%, n=4), and 4 -- Physician/Advanced Practice Provider Conducted (25%, n=6, requiring the least time per patient). All models used genetic testing, whereas other components were implemented variably or not at all. Models 1 (15.7{+/-}4.1) and 2 (15.4{+/-}3.0) were rated more acceptable than Model 4 (9.8{+/-}2.9, 1 vs 4: p=0.027; 2 vs 4, p=0.023). Notably, 88% of PIs used genetic information for treatment decisions, including ICD placement (83%; n=20) or cardiac transplant (63%; n=15). Major facilitator themes from focus group discussions included having a genetic counselor on the HF team and developing authoritative standards directing provision of DCM genetic services. Barrier themes included operational challenges, limited personnel, clinician under-recognition, need for new service delivery models, and billing/reimbursement. Conclusions: DCM genetic care models and components were highly variable across the 24 sites of the DCM Consortium, even though all sites discussed similar factors that enable or hinder implementing genetic services for DCM. Understanding the basis of practice model variability may provide insight to yield more scalable care approaches.

BackgroundThe prevalence of severe symptomatic aortic stenosis (sSAS) continues to rise, yet women remain significantly less likely to receive timely intervention. Evidence indicates a 36% lower likelihood of diagnosis and a 20% lower likelihood of undergoing aortic valve replacement (AVR) compared with men. The purpose of this study was to examine the perspectives of interventional cardiologists and cardiothoracic surgeons who treat AS about late diagnosis and undertreatment of women with sSAS. MethodsA cross-sectional, web-based survey was distributed to interventional cardiologists and cardiothoracic surgeons across the United States. Participants completed a 10-item open-ended questionnaire developed from published literature. Responses were analyzed using descriptive statistics and qualitative content analysis to identify key issues related to diagnostic practices, referral patterns, and provider perceptions. ResultsNineteen physicians completed the survey (15% response rate). While most participants believed women receive timely AVR consistent with guidelines, they acknowledged delays due to multifactorial causes, including under-recognition of symptoms, diagnostic variability in community echocardiography practices, limited awareness of sex-specific guideline gaps, and socioeconomic barriers such as financial constraints, caregiver burden, and access to care. Although some respondents denied overt gender bias, others described subtle or unconscious bias influencing referral timing and symptom interpretation. ConclusionsSurvey respondents recognized complex clinical and systemic factors contributing to delayed diagnosis and undertreatment of women with sSAS. Enhanced provider education, improved access to diagnostic testing, and revision of sex-specific clinical guidelines are needed to promote equitable care and timely intervention for female patients.

BackgroundCoronary artery tortuosity (CAT) is often viewed as a benign angiographic finding; however, emerging evidence suggests its potential hemodynamic significance, particularly in non-atherosclerotic cardiomyopathies such as Takotsubo syndrome (TS). ObjectivesThis study aimed to investigate the prevalence and hemodynamic implications of CAT in patients diagnosed with Takotsubo cardiomyopathy (TCM) and to evaluate the association between the severity of tortuosity and myocardial injury markers, recovery of ventricular function, and other clinical variables. MethodsA retrospective review of 100 patients with TCM from the Baptist Memorial Hospital network (2015-2025) was conducted. Tortuosity severity was quantified using angiographic criteria per Eleid et al. (2014). Associations between CAT and biochemical or echocardiographic parameters were evaluated using multiple linear regression and non-parametric tests. ResultsCAT was highly prevalent (85.1%) in this TCM cohort, with a mean tortuosity index of 3.26--significantly higher than in general angiography populations. No significant correlations were found between tortuosity severity and peak troponin levels (p = .588) or ejection fraction (EF) at presentation (p = .820). Full EF recovery (55-65%) at [&ge;]3 months occurred in 70.7% of patients and was not significantly associated with prior cardiomyopathy, coronary artery tortuosity index or baseline troponin levels. ConclusionsCAT appears markedly more prevalent among patients with TCM, although its severity does not correlate with biomarker elevation or EF recovery. These findings suggest that coronary tortuosity may contribute to the hemodynamic environment predisposing to TS, without directly determining the extent of myocardial dysfunction or recovery.

Structured AbstractO_ST_ABSBackgroundC_ST_ABSVericiguat and sacubitril/valsartan both modulate the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate signaling pathway and may improve myocardial function in patients with heart failure. ObjectivesTo compare the effects of vericiguat, sacubitril/valsartan, and their combination on left ventricular function and clinical outcomes in heart failure with nonpreserved ejection fraction patients. MethodsIn this retrospective real-world study, patients were classified into three groups: vericiguat added to guideline-directed medical therapy (vericiguat group), sacubitril/valsartan-based therapy (sacubitril/valsartan group), and combined sacubitril/valsartan plus vericiguat therapy (add-vericiguat group). Changes in left ventricular ejection fraction ({Delta}LVEF), in stroke volume ({Delta}SV), and in log-transformed N-terminal pro-B-type natriuretic peptide ({Delta}Log10 NT-pro BNP) from baseline to 1 year were evaluated. Clinical outcomes were also assessed. ResultsAt 1 year, LVEF significantly improved in both the vericiguat group (p = 0.02) and the sacubitril/valsartan group (p < 0.001). There was no significant difference in {Delta}LVEF between these two groups (p = 0.25). In contrast, the add-vericiguat group demonstrated a significantly greater improvement in {Delta}LVEF compared with the vericiguat group alone (p = 0.01). ConclusionsIn a real-world setting, vericiguat was associated with improvements in left ventricular function comparable to those of sacubitril/valsartan, and combination therapy provided incremental benefits. Vericiguat may serve as an alternative or adjunctive treatment option, particularly in patients unable to tolerate or maintain angiotensin receptor-neprilysin inhibitor therapy.

Background | Angina with nonobstructive coronary arteries (ANOCA) is a heterogeneous condition encompassing distinct endotypes representing different underlying pathophysiological mechanisms. Endothelial dysfunction is considered a central hallmark of ANOCA. However, studying patient-derived endothelial cells (ECs) remains challenging due to the limited availability of disease-specific endothelial samples. We therefore aimed to assess the feasibility of isolating and culturing ECs from catheterization material obtained during routine coronary function testing in ANOCA patients. Methods | Catheterization material was collected from 79 ANOCA patients (84% female, age 58{+/-}10 years) undergoing coronary function testing. ECs were isolated, expanded and characterized using immunostaining, flow cytometry, gene expression profiling and functional assays. Results | EC isolation was successful in 43% of cases and resulted in 34 primary EC cultures that were expanded up to passage 10. Isolation success was independent of clinical or procedural characteristics. Isolated cells exhibited typical EC morphology and expressed EC markers confirmed by immunostaining, flow cytometry and gene expression analyses. EC marker gene expression remained largely stable over passages. However, stress- and defense-related gene expression programs increased over time, while proliferation-related processes decreased. Functional assays demonstrated that the coronary catheterization-derived ECs showed typical properties of wound healing, angiogenesis, activation responses upon stimuli and monocyte adhesion. Conclusions | This study demonstrates the feasibility of isolating and expanding ECs directly from catheterization material collected during routine coronary function testing in ANOCA patients. These patient-derived ECs retain characteristic endothelial features and functionality. This approach offers primary EC cultures to study the mechanisms underlying endothelial dysfunction in ANOCA.

BackgroundAnomalous aortic origin of a coronary artery (AAOCA) can cause myocardial ischemia and sudden cardiac death. The optimal stress-testing strategy and impact of coronary morphology on ischemia remain unclear. We assessed the effect of coronary morphology on stress-test completion and results across multiple test modalities. MethodsThis retrospective cohort study included 531 adults with AAOCA at our institution (7/2015 - 3/2023). Coronary morphology was characterized by the anomalous coronary (right [RCA], left main [LMCA], left anterior descending [LAD], left circumflex) and the course type (intramural, interarterial-only, transseptal, and other [prepulmonic and retroaortic]). Exercise and pharmacologic stress tests were positive if ischemia included the territory of the anomalous coronary. A mixed-effect logistic regression modeled the odds of a positive test based on morphology, comorbidities, and modality. A random forest regression analyzed the stress iFR as a continuous outcome. ResultsStress test results were available for 396 (75%) of patients (age 50 {+/-} 17 years; 42% female). Stress testing included 699 ECGs, 198 echocardiograms, 288 SPECTs, 133 PETs, and 103 dobutamine iFR studies. Completion of invasive dobutamine iFR (versus noninvasive-only) stress testing was associated with high-risk coronary morphology, p<0.001. Coronary morphology that trended toward higher adjusted odds of ischemia included the anomalous LMCA (OR: 2.1, p=0.054) and intramural course (OR: 1.9, p=0.14). Compared to ECG, iFR had higher adjusted odds of a positive result (OR: 27, p<0.001), followed by PET (OR: 9.0, p<0.001). In the random forest regression, stress iFR value was lowest for LAD (0.75) compared to LMCA (0.83) and RCA (0.84). For course type, transseptal (strongly correlated with the anomalous LAD) had the lowest stress iFR (0.77), followed by intramural (0.83), and interarterial (0.88). ConclusionsIn our adult AAOCA cohort, high-risk coronary morphology demonstrated a borderline association with ischemia on stress testing, whereas stress test modality was the strongest determinant of ischemia detection. Invasive stress testing was reserved for higher-risk coronary morphology. These findings underscore that effective risk stratification in AAOCA integrates clinical symptoms, coronary morphology, and stress test modality. Long-term follow-up is needed to determine the optimal strategy for ischemia evaluation. Clinical PerspectivesO_ST_ABSWhat is new?C_ST_ABSO_LIIn this single-center registry of adults with anomalous aortic origin of a coronary artery (AAOCA), 75% of patients had stress testing, enabling the largest analysis of how anomalous coronary morphology impacts stress testing practices and the presence of ischemia. C_LIO_LIConsistent with published data in younger AAOCA cohorts, our adult population (mean age >50 years) trended toward increased risk of ischemia with an anomalous left coronary and intramural course. C_LIO_LIComparing various stress test modalities for AAOCA, instantaneous wave-free, followed by positron emission tomography and single-photon emission computed tomography, have higher odds of being positive for ischemia than electrocardiogram and echocardiograms. C_LI What are the clinical implications?O_LIAdults with AAOCA remain at risk for ischemia and require careful risk stratification, with coronary morphology and clinical symptoms informing stress test selection and result interpretation. C_LIO_LIFor higher risk morphologic variants of AAOCA, consider further risk stratification with invasive coronary provocative studies to detect inducible ischemia. C_LI

BackgroundBoth acute myocardial infarction (AMI) and acute myocarditis are characterised by cardiac troponin release as a marker of cardiomyocyte injury. While peak troponin is widely accepted as a surrogate marker for infarct size in AMI, its relationship with myocardial injury in acute myocarditis is unclear. This study aimed to quantify and compare the association between peak high-sensitivity cardiac troponin and cardiovascular magnetic resonance (CMR) late gadolinium enhancement (LGE) extent in patients with AMI versus acute myocarditis. MethodsPatients undergoing CMR imaging and measurement of high-sensitivity cardiac troponin I during hospital admission were retrospectively included. LGE extent was quantified in grams using the semi-automated expectation-maximization weighted intensity algorithm (EWA). ResultsCompared to patients with acute myocarditis (n=47), patients with AMI (n=49) had higher peak troponin levels (median [interquartile range] 32,470 [3,109-104,699] vs 7,295 [1,857-22,550] ng/L, p=0.002), larger LGE extent (25 [13-56] vs 10 [6-17] g, p<0.001), and lower left ventricular ejection fraction (45 [36- 52] vs 55 [49-58] %, p<0.001). Peak troponin was moderately positively correlated with LGE extent in both AMI (rho=0.56, p<0.001) and acute myocarditis (rho=0.58, p<0.001). However, the ratio of peak troponin to LGE mass was higher in AMI compared to acute myocarditis (1,299 [419-3233] vs 909 [310-1446] ng/L/g, p=0.02). ConclusionsPeak cardiac troponin correlates positively with LGE extent in both AMI and acute myocarditis, but the magnitude of LGE and LV systolic dysfunction is greater in AMI. Also, AMI typically has an approximately 40% greater amount of troponin release per unit LGE mass compared to acute myocarditis. This suggest that troponin-based estimates of myocardial injury size estimated by LGE are not directly interchangeable between ischaemic and inflammatory myocardial diseases.

BackgroundScreening for atherosclerosis focuses on identifying Standard Modifiable Risk Factors (SMuRFs), including diabetes, hypertension, hyperlipidaemia, and smoking. PurposeTo compare the extracardiac thoracoabdominal atherosclerotic plaque burden, as measured by computed tomography angiography (CTA), among heart transplant candidates with ischemic or non-ischemic cardiomyopathy (ICM, NICM), and evaluate potential associations between plaque burden and SMuRFs. MethodsThis retrospective study identified heart transplant candidates with ICM or NICM matched for age and sex, undergoing thoracoabdominal CTA. Patients were classified as with SMuRFs or SMuRF-less. Extracardiac thoracoabdominal non-calcified and calcified atherosclerotic plaque was classified as present or absent across 78 arterial segments per patient. ResultsAmong included patients (n=167, median [interquartile range] age 58 [53-63] years, 16% female, 51% NICM), 40 patients (24%) were SMuRF-less (ICM: 16/82 (20%), NICM: 24/85 (28%), age 56 [50-67] years). Overall, out of 13,026 arterial segments analysed, 1,746 (13%) were affected by atherosclerotic plaque (9 [4-15] segments per patient). ICM had a higher total plaque burden than NICM (11 [7-18] vs 6 [3-11] segments per patient, p<0.001). SMuRF-less patients showed no difference in non-calcified, calcified, or total plaque burden compared to patients with SMuRFs, among all patients (ICM+NICM, p>0.17) and within the ICM and NICM groups, respectively (p>0.30). ConclusionsThe burden of extracardiac thoracoabdominal atherosclerotic plaque is higher among heart transplant candidates with ICM. However, it does not differ between SMuRF-less or those with SMuRFs, regardless of underlying ICM or NICM. The prevalence of SMuRFs is not an effective marker to determine the need to screen for extracardiac atherosclerotic plaque among heart transplant candidates. GRAPHICAL ABSTRACT O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=134 SRC="FIGDIR/small/26347056v1_ufig1.gif" ALT="Figure 1"> View larger version (51K): org.highwire.dtl.DTLVardef@1aff6b1org.highwire.dtl.DTLVardef@16cfb07org.highwire.dtl.DTLVardef@1d4894corg.highwire.dtl.DTLVardef@81e9d3_HPS_FORMAT_FIGEXP M_FIG C_FIG

BackgroundAn elevated calcium-phosphate product (CPP), defined as a product of serum calcium and serum phosphate, is a hallmark of CKD-mineral and bone disorder and has been implicated in accelerated coronary artery calcification, arterial stiffness, and left ventricular hypertrophy. These pathological changes contribute to adverse cardiovascular outcomes. While prior studies have shown worse percutaneous coronary outcomes (PCI) outcomes in CKD patients overall, the prognostic impact of CPP levels remains underexplored. The objective is to evaluate post-PCI outcomes in CKD patients with and without hypercalcemia and hyperphosphatemia. MethodsA retrospective cohort analysis was conducted using the TriNetX U.S. Collaborative Network, focusing on adult patients with CKD undergoing PCI. Patients were grouped based on serum calcium and phosphorus levels, with those having hypercalcemia and hyperphosphatemia compared to those without. Diagnoses and procedures were identified using ICD-10 and CPT codes. Propensity score matching was applied to account for differences between groups. Post PCI outcomes were analyzed. Primary outcome was all-cause mortality. Secondary outcomes encompass coronary artery bypass grafting (CABG), myocardial infarction (MI), in-stent re-stenosis [redo PCI] and target vessel revascularization, heart failure (HF) exacerbations, and peri-/ post-procedural complications were assessed within a 5-year follow-up period. Kaplan-Meier analysis with log-rank was used for statistical comparisons, with significance set at p<0.05. ResultsThe elevated CPP group was significantly associated with increased post-PCI all-cause mortality [hazard ratio (HR) 1.428], in-stent restenosis [HR 1.589], heart failure exacerbations [HR 1.492], and recurrent angina or MI [HR 1.396]. No significant differences were found in rates of post PCI CABG, periprocedural complications (postprocedural cardiac insufficiency, postprocedural cardiac arrest, postprocedural heart failure, intraoperative cerebrovascular infarction, postprocedural cerebrovascular infarction, and intraoperative cardiac arrest), or redo PCI. ConclusionIn this propensity score-matched analysis, elevated CPP in CKD patients undergoing PCI was independently associated with worse outcomes, including higher mortality and cardiovascular event rates. These findings highlight the prognostic value of CPP and the need for closer metabolic monitoring and individualized risk stratification. O_FIG O_LINKSMALLFIG WIDTH=177 HEIGHT=200 SRC="FIGDIR/small/26347359v1_ufig1.gif" ALT="Figure 1"> View larger version (50K): org.highwire.dtl.DTLVardef@198df1forg.highwire.dtl.DTLVardef@160722borg.highwire.dtl.DTLVardef@e796fforg.highwire.dtl.DTLVardef@6a40d6_HPS_FORMAT_FIGEXP M_FIG C_FIG

Background: The prevalence of heart failure (HF) is increasing worldwide, and rehospitalizations due to exacerbations remain a major clinical and economic burden. Beyond medical triggers, insufficient patient understanding and inadequate self-management often contribute to recurrent admissions. The Kurume-HEARTS program was developed to provide regular planned hospitalizations incorporating structured education, cardiac rehabilitation, and medication adjustment for patients with recurrent HF. Objective: To retrospectively evaluate the clinical and economic impact of the Kurume-HEARTS program. Methods: We enrolled consecutive patients with recurrent HF hospitalizations who underwent the program at Kurume University Hospital between January 2020 and October 2025. Outcomes compared planned versus unplanned hospitalizations within the same patients. Co-primary endpoints were total hospitalization cost and total length of stay per person-year. Secondary endpoints included per-hospitalization cost, length of stay, unplanned and planned admission frequency, and NT-proBNP levels at admission. Results: Of 31 screened patients, 20 with recurrent heart failure were included. During a median follow-up of 27.1 months, 135 hospitalizations occurred (69 unplanned and 66 program-based). Total hospitalization cost per person-year was significantly lower during the Kurume-HEARTS program than during unplanned hospitalizations, while length of stay per person-year tended to be shorter. Per-admission cost and length of stay were significantly lower with the program, without differences in admission frequency. NT-proBNP levels at admission were higher during unplanned hospitalizations, indicating greater clinical instability. Conclusions: The Kurume-HEARTS program can help reduce the cost and hospitalization length of unplanned admissions by enabling earlier intervention and structured inpatient management.

BackgroundGuideline-directed medical therapy (GDMT) has been shown to improve mortality and/or symptoms in heart failure with reduced ejection fraction (HFrEF). Medical devices also play an important role in improved quality of life and overall symptom relief for HFrEF patients. Baroreflex Activation Therapy (BAT) increases parasympathetic nervous system activity by stimulating the carotid baroreceptors, thereby reducing symptoms. Herein, we analyzed the effects of BAT on hospitalization, atrial arrhythmia (AA), and ventricular arrhythmia (VA) rates. MethodsA retrospective cohort study was conducted consisting of HFrEF patients treated with BAT at Keck Hospital of USC between 11/2014 and 11/2022. We compared median pre-BAT hospitalization, AA, and VA rates to post-BAT rates at both 6- and 12-months using Wilcoxon Signed Rank tests. ResultsAmong 31 patients on BAT, 38.7% met criteria for receiving all four GDMT classes for at least 12 months prior to BAT. Among these, 91.7% had an implantable cardioverter defibrillator (ICD) implanted for [&ge;]12 months pre- and post-BAT. Average pre- vs. post-BAT all-cause hospitalization rates were significantly different only at 12 months [1.3 {+/-} 1.4 vs 0.3 {+/-} 0.9, respectively (p=0.05)]. Borderline significant pre-post comparisons were noted including decreased VA rate at both 6 and 12 months and increased AA rate at 12-months (p=0.06 for all). ConclusionIn HFrEF patients on full GDMT, BAT was associated with a significant reduction in hospitalization rates at 12 months. There were no significant changes in AA or VA rates.

BACKGROUNDDilated cardiomyopathy (DCM) presents a highly heterogeneous spectrum, including a familial subset with elevated arrhythmic risk. Traditional demographic and imaging markers, such as late gadolinium enhancement, have been inadequate for identifying high-risk patients before arrhythmic events. Remodelling of the interventricular septum--central to ventricular mechanics and conduction--may offer improved risk stratification. OBJECTIVESTo identify differences in left ventricular (LV) morphology between arrhythmic and idiopathic dilated cardiomyopathy (aDCM vs iDCM), and to identify LV remodeling patterns that link to adverse outcomes. METHODSThree-dimensional LV shape models were constructed from end diastolic cardiovascular magnetic resonance images of 102 individuals subdivided by their idiopathic or arrhythmic subgroup allocation. A statistical shape model was built using principal component analysis. A linear discriminant analysis determined shape features of the arrhythmic subgroup and increased composite arrhythmic outcome of sudden cardiac death, aborted sudden cardiac death, and sustained ventricular tachycardia. RESULTSThe idiopathic DCM group displayed larger mass, length, diameter, mass to volume ratio, and a mild spiral pattern of thicker septal walls (p=0.004). The arrhythmic DCM group displayed a more conical (wider basal and mid wall to apical diameter) LV, and the lack of the spiral septal morphology was the most significant feature (p=0.006) to identify subjects that had the composite arrhythmic outcome. CONCLUSIONThe LV morphology derived suggests a differentiation of arrhythmic DCM patients beyond size, function and LGE presence. This was distinctive and captured shape features that suggest alternate mechanisms for arrhythmic risk linked to a pattern of remodeling. Graphical AbstractAssessing LV morphology signature of arrhythmic DCM phenotype O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=114 SRC="FIGDIR/small/26346514v1_ufig1.gif" ALT="Figure 1"> View larger version (39K): org.highwire.dtl.DTLVardef@1f47f7aorg.highwire.dtl.DTLVardef@dd5d08org.highwire.dtl.DTLVardef@106ef07org.highwire.dtl.DTLVardef@36eb76_HPS_FORMAT_FIGEXP M_FIG C_FIG

PurposeDespite strong evidence, real-world adoption of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains suboptimal. The Get With The Guidelines-Heart Failure (GWTG-HF) program was designed to close gaps in care. We evaluated whether hospital participation in GWTG-HF is associated with greater GDMT intensity and improved outcomes. MethodsWe conducted a retrospective analysis (2013-2021) of Medicare beneficiaries with Part A and Part D hospitalized with HFrEF. Using a multiple baseline time series design, we compared changes in GDMT prescribing and outcomes at hospitals before and after GWTG-HF enrollment with hospitals that never participated. The primary outcome was a 90-day post-discharge prescription-fill GDMT score summarizing use and dose of beta blockers, renin-angiotensin system inhibitors (RASI; ACE inhibitor/ARB/ARNI), and mineralocorticoid receptor antagonists (MRA). Secondary outcomes included class-specific medication fills, achievement of [&ge;]50% target doses, and 30-day, 90-day, and 1-year all-cause and HF readmission and mortality. We adjusted for baseline hospital performance, patient characteristics, and temporal trends. ResultsAmong 1,274,863 Medicare beneficiaries hospitalized for HFrEF, 53.5% were treated at hospitals that never participated in GWTG-HF and 9.6% at hospitals that joined GWTG-HF before hospitalization. Unadjusted median GDMT scores increased from 3.0 in both groups to 4.0 in non-participating hospitals and 4.5 in GWTG-HF hospitals at 90 days (p<0.001). Hospital enrollment was associated with a higher 90-day GDMT score (+0.15 points; 95% CI 0.12-0.18; p<0.001), and greater use of beta blockers, RASI, and MRA, but not ARNI. HF readmission did not differ significantly; however, GWTG-HF participation was associated with lower all-cause mortality at 30 days (OR 0.95; 95% CI:0.92-0.98), 90 days (OR: 0.97; 95% CI: 0.95-0.99), and 1 year (0.97; 95% CI: 0.95-.0.99; all p<0.05). ConclusionHospital participation in GWTG-HF was associated with higher GDMT intensity and lower mortality, supporting structured quality programs to improve HFrEF care.

Background: Detection of disease progression is key to personalize treatment strategies in transthyretin cardiomyopathy (ATTR-CM), particularly with emerging therapies. Echocardiography can detect subtle longitudinal changes but is limited by operator dependence. This study evaluates agreement and reproducibility of fully automated, AI-assisted echocardiographic measurements under real-world conditions. Methods: This retrospective study included 62 patients with ATTR-CM undergoing 178 serial annual echocardiograms assessed by a reference cardiologist, a second cardiologist, a novice reader, and a fully automated AI algorithm (Us2.ai). Interrater agreement was assessed using Bland-Altman analysis and intraclass correlation coefficients (ICCs). Intrarater variability for human readers was derived from repeated blinded measurements, with limits of agreement (LoA = mean difference +/- 1.96 x SD) defining the smallest detectable change. AI repeatability was assessed using within-study pairwise differences. Results: AI showed moderate agreement with the reference cardiologist for IVSd and LVEDV (ICC 0.65 and 0.51), with biases of -1.9 mm and -39 mL, respectively. Interrater agreement between cardiologists was good (ICC 0.79 and 0.84) with minimal bias (-0.2 mm and +3 mL). Intrarater variability was moderate to excellent for both cardiologists (LoA 3.0 mm and 43 mL for the reference cardiologist; 2.7 mm and 31 mL for the second cardiologist). AI demonstrated comparable repeatability (LoA 3.6 mm and 37 mL), while the novice showed higher variability (5.1 mm and 61 mL). Conclusion: AI-based measurements demonstrated repeatability comparable to experienced cardiologists. Despite moderate agreement and systematic differences in volumetric assessments, their reproducibility supports automated analysis for longitudinal echocardiographic monitoring.

BackgroundCardiovascular disease (CVD) is the leading cause of pregnancy-related morbidity and mortality in the United States. Several studies have evaluated readmission rates in the general HF population, but in patients with pregnancy-related HF, readmissions have been understudied. This study aims to characterize the 30-day HF readmission patterns in pregnancy-related admissions to identify vulnerable patient populations. MethodsThe National Readmission Database from 2016 to 2021 was used to identify women aged 13-49 with an index hospitalization in which HF was coded as either the primary or secondary diagnosis during a pregnancy-related antepartum, delivery, or postpartum admission, identified by diagnosis-related group (DRG) codes and ICD-10 codes. The primary outcome was 30-day all-cause readmission. We performed descriptive and comparative analyses to describe the differences in patient characteristics and readmission patterns between groups. ResultsThe overall 30-day all-cause readmission rate was 13% when readmissions for delivery were excluded. The readmission rate increased with age, peaking at 15.1% in the 38-49yr age group. Higher readmission rates were also associated with combined (systolic and diastolic) HF (16.1%), systolic HF (14.8%), lower socioeconomic status (15.3%), substance use disorder (17.2%), and alcohol use (18.6%). Patients whose index hospitalization was for delivery had the highest absolute risk of 30-day readmission at 19.3%. Readmissions peaked between days 6 and 8 post discharge, with more than 50% of all readmissions occurring within the first two weeks post-discharge ConclusionsIn our study, the highest risk of readmission occurred after an index hospitalization for delivery, and most readmissions occurred in the first 2 weeks post-discharge. Our findings suggest that a post-discharge follow up within 7 days of admission complicated by HF should be extended to patients with pregnancy-related HF and effective readmission reduction strategies must include a better understanding of heart failure phenotypes, and a proactive approach to addressing social risk factors.

Aims: Dynamic left ventricular outflow tract obstruction (LVOTO) is a hemodynamically significant complication following transcatheter aortic valve replacement (TAVR) that remains difficult to predict with conventional transthoracic echocardiography (TTE). We examined whether a deep learning (DL) model developed for LVOTO detection in hypertrophic cardiomyopathy (HCM) could predict post-TAVR LVOTO from pre-TAVR TTE in patients with severe aortic stenosis (AS). Methods and Results: In this retrospective study of 302 consecutive patients undergoing TAVR for severe AS, a pre-trained DL model was applied to pre-TAVR TTE to generate a patient-level DL index of LVOTO (DLi-LVOTO; range 0-100). Post-TAVR LVOTO was defined as a peak pressure gradient [&ge;]30 mmHg on follow-up TTE. Logistic regression and receiver operating characteristic analyses assessed the association and discriminative performance of DLi-LVOTO. Pre-TAVR LVOTO was present in 32 patients (10.6%) and post-TAVR LVOTO in 35 (11.6%). Follow-up TTE was performed at a median of 47 days (IQR 37-63) after TAVR, with the majority of TTE (216 of 302, 71.5%) performed within 2 months. DLi-LVOTO was significantly higher in patients with LVOTO at both pre- and post-TAVR TTE (all p<0.001). In multivariable analysis, DLi-LVOTO remained independently associated with post-TAVR LVOTO even after adjusting for conventional TTE parameters and pre-TAVR LVOTO (adjusted OR 1.29, 95% CI 1.06-1.56 per 10-score increase, p=0.011), with an AUROC of 0.78 (95% CI 0.72-0.85). Among patients without pre-TAVR LVOTO, DLi-LVOTO retained independent predictive value (adjusted OR 1.56, 95% CI 1.19-2.06, p=0.001; AUROC 0.84, 95% CI 0.77-0.91). Conclusion: A DL model originally trained in HCM patients independently predicts post-TAVR LVOTO from pre-TAVR TTE, including in patients without pre-existing LVOTO, suggesting it captures hemodynamic features beyond conventional echocardiographic assessment.

Structured AbstractO_ST_ABSBackgroundC_ST_ABSGuideline recommendations for infective endocarditis (IE) prophylaxis have narrowed significantly over the past decade. However, these recommendations are derived from adult data and may not adequately account for the unique risk factors for IE in pediatric and congenital heart disease (CHD) patients with cardiac implantable electronic devices (CIEDs). ObjectiveTo characterize contemporary IE cases and prophylaxis practices among members of the Pediatric and Congenital Electrophysiology Society (PACES) and assess how these practices align with or diverge from current international guidelines or practice recommendations. MethodsA cross-sectional, web-based survey was distributed to PACES members worldwide. Questions addressed prophylaxis practices for CIED implantation, reinterventions, and bacteremia-inducing procedures, as well as clinician experience with IE in patients with CIED. Responses were analyzed descriptively. ResultsSubstantial practice heterogeneity was identified across multiple clinical scenarios. Although most clinicians aligned with guideline recommendations for patients with structurally normal hearts, nearly all respondents (92.3%) reported recommending lifelong prophylaxis for patients with complex or repaired CHD. Among 35 reported IE cases, 97% occurred in transvenous systems, 77% occurred >6 months post-implantation, and 90% lacked a clear procedural or infectious trigger. Despite successful device extraction in 77% of cases, significant morbidity and mortality were observed. ConclusionCurrent practice patterns among pediatric and congenital electrophysiologists reflect uncertainty regarding the applicability of adult-derived IE prophylaxis guidelines to younger patients with CIEDs. High observed morbidity, long-term device exposure, and distinct anatomic considerations highlight the need for pediatric-specific risk stratification and updated guidance.

Background Exercise capacity varies among individuals with a Fontan circulation. Percent predicted peak oxygen consumption (%pVO2) may be influenced by ventricular morphology, Fontan subtype, and conduit characteristics, but data explaining variability in exercise capacity are limited. This study examined whether anatomical and surgical factors are associated with %pVO2 later in life. Methods Participants enrolled in the multicenter Single Ventricle Outcomes Network (SV-ONE) database who had cardiopulmonary exercise testing (CPET) data were included. Published reference equations were used to estimate %pVO2. Multivariable regression models evaluated associations between anthropometric, anatomical (diagnosis and dominant ventricle), and surgical (Fontan subtype, conduit size, and surgical era) factors and %pVO2. Restricted spline analyses assessed nonlinearity. Results 561 individuals with a Fontan circulation were included in the analysis; age 20 {+/-} 8 years, 54% male, mean %pVO2 was 63 {+/-} 16%. Sex and exercise modality were the strongest predictors of %pVO2, with females being 12% higher than males and treadmill 4.6% higher than a cycle. Age at CPET was a predictor of exercise capacity with %pVO2 decreasing by 0.8% per year. Ventricular morphology, diagnosis, and Fontan subtype did not have a statistical association with the primary outcome. In models restricted to patients with an extracardiac conduit (n = 330), conduit diameter and area were not associated with %pVO2, even after indexing to body surface area. Univariable nonlinear spline analyses suggested an optimal conduit size of 18 mm for %pVO2, but this was not significant after body size adjustments. Conclusion In this large multicenter cohort, surgical and anatomical features were not as important as sex, age, and body size as determinants of exercise performance in patients with a Fontan circulation. Reduced exercise capacity in this population appears to reflect progressive pathophysiological changes of the Fontan circulation rather than specific characteristics such as conduit size, ventricular morphology, or anatomy.

PurposeObstructive sleep apnea (OSA) is a common comorbidity in heart failure (HF) patients with prevalence increasing as HF severity worsens. While CPAP/BiPAP has been shown to reduce disease burden and mortality in the general HF population, it is unclear whether these benefits extend to patients with left ventricular assist devices (LVADs). We sought to determine whether OSA affects long-term survival in newly implanted LVAD patients and whether CPAP/BiPAP treatment confers mortality benefits. MethodsThis single-center retrospective study included patients who underwent LVAD implantation between January 2007 and February 2022. Recipients were stratified by OSA status (OSA vs No-OSA), and those with OSA were further categorized based on CPAP/BiPAP compliance. Comparative statistics and Kaplan-Meier survival analyses were performed, with log-rank tests used to compare groups and assess survival differences. A Cox proportional hazards model was conducted to evaluate the association between risk factors and survival among patients with OSA and No-OSA. ResultsBefore LVAD implantation, patients with OSA had higher body mass index, hypertension, and a higher rate of implantable cardioverter-defibrillator placement than those without OSA. OSA was not associated with increased postoperative complications. Although survival did not differ significantly between OSA and No-OSA patients (p=0.33), CPAP/BiPAP-compliant OSA patients had significantly better survival than noncompliant patients (p=0.0099). ConclusionsLVAD patients with OSA who consistently use CPAP/BiPAP have better survival than those who do not. CPAP/BiPAP is a simple, low-risk treatment that can reduce mortality in this population. Therefore, increased perioperative screening for OSA should be considered for patients receiving LVADs. Multicenter studies are needed to confirm our findings further.