BACKGROUND:The prognostic relevance of the Academic Research Consortium-High Bleeding Risk (ARC-HBR) criteria in chronic total occlusion (CTO) percutaneous coronary intervention (PCI) is unknown. OBJECTIVES:To assess the ARC-HBR criteria for predicting bleeding and adverse outcomes after CTO PCI. METHODS:The authors retrospectively included all patients who underwent CTO PCI at a tertiary referral center from January 2019 to December 2024. Patients were stratified by ARC-HBR status. Outcomes were in-hospital and 1-year all-cause death, major adverse cardiac and cerebrovascular events (MACCE), and in-hospital Bleeding Academic Research Consortium (BARC) 3-5 bleeding. Multivariable and inverse probability of treatment weighting analyses were performed. RESULTS:Among 2,082 patients, 749 (36.0%) met ARC-HBR criteria. Compared to non-HBR patients, HBR patients had higher in-hospital BARC 3-5 bleeding (15.1% vs 5.9%; p<0.001) and all-cause death (3.7% vs 0.8%; p<0.001). After IPTW adjustment, HBR remained associated with in-hospital BARC 3-5 bleeding (adjusted odds ratio [aOR] 2.44, 95% CI 1.78-3.34; p<0.001) and in-hospital death (aOR 1.77, 95% CI 1.15-2.57; p=0.005), but not in-hospital MACCE (p>0.05). At 1-year follow-up, HBR was associated with all-cause death (adjusted hazard ratio [aHR] 1.45, 95% CI 1.02-2.10; p=0.044) and MACCE (aHR 2.07, 95% CI 1.69-2.51; p<0.001). Among index admission survivors, in-hospital BARC 3-5 bleeding was associated with post-discharge 1-year mortality (aHR 1.72, 95% CI 1.07-2.75; p=0.025), independent of HBR status. CONCLUSIONS:ARC-HBR criteria may identify a vulnerable CTO PCI phenotype at increased bleeding and mortality risk.
Currently, surgery and fibrinolysis are the two class-I recommendations to manage obstructive mechanical mitral valve thrombosis (OMMVT). Percutaneous transcatheter release of a stuck mechanical valve (PETROS) with cerebral embolic protection (CEP) for OMMVT is suggested when neither of the above treatment options can be offered. This study estimated the 1-year clinical outcomes of the PETROS and fibrinolysis. The primary outcome was 1-year all-cause death. The secondary outcomes included technical success and the 1-year stroke, recurrence and redosurgery. Between January 2019 and April 2024, 123 consecutive patients with OMMVT were evaluated. Out of them, 32 underwent PETROS, and 70 received fibrinolysis. All patients were followed up for one year. In the PETROS group, 1-year survival was 87.50% (95%CI: 70% - 95.10%, and technical success was achieved 93.75% of patients. The cumulative incidence of 1year stroke, recurrence, and redo surgery was 6.25% (95% CI: 1.10%-18.10%), 20% (95% CI: 8.10%-35.60%), and 6.25% (95% CI: 1.10%-18.10%), respectively. In the Fibrinolysis group, 1-year survival was 79.60% (95%CI: 68% - 87.40%, and technical success was achieved in 54.28%. The cumulative incidence of 1year stroke, recurrence, and redo surgery was 10.19% (95% CI: 4.50%-18.70%), 24.68%(95% CI: 12.30%-39.40%), and 10.39% (95% CI: 4.60%-19%), respectively. In conclusion, PETROS with CEP appears to be a promising treatment option for selected high-risk patients with OMMVT in whom surgery and fibrinolysis are contraindicated or after failed fibrinolysis, with high technical success and acceptable 1-year clinical outcomes.
Vericiguat reduces cardiovascular death and heart failure (HF) hospitalization in high-risk patients with HF and reduced ejection fraction (HFrEF), but its non-invasive haemodynamic and remodelling effects in real-world practice remain incompletely characterized. We aimed to evaluate changes in non-invasive hemodynamic surrogates and cardiac remodeling parameters 6 months after vericiguat initiation in patients with HFrEF. We conducted a prospective, single-center study of consecutive patients with chronic HFrEF initiating vericiguat while receiving stable, optimized guideline-directed medical therapy (GDMT). Co-primary endpoints were paired 6-month changes in LVEF and LV outflow tract (LVOT) velocity-time integral (VTI). Echocardiograms were analyzed blinded to subsequent clinical outcomes. An exploratory "responder" phenotype was defined by improvement in ≥1 of: LVEF (increase > 2%), LVOT VTI (increase > 1.0 cm), or E/e' (reduction > 1.0), without deterioration in the remaining indices. Clinical events were assessed using a 6-month landmark analysis. Among 113 patients (age 64±11; median NT-proBNP 1433 pg/mL; baseline LVEF 28.0±7.5%, average use of 4 pillars of GDMT 94%), LVEF increased from 28.0±7.5% to 29.8±8.0% (p=0.002); LVOT VTI from 16.0±3.4 to 16.8±4.1 cm (p=0.009) at 6 months. E/e' decreased from 13.3±5.3 to 11.9±5.1 (exploratory; p=0.036), and NT-proBNP levels declined (p<0.001). Responder patients experienced fewer clinical events after the 6-month landmark (p=0.013). In conclusion, among real-world optimally treated patients with HFrEF, vericiguat initiation was associated with modest but statistically significant improvements in LVEF and LVOT VTI at 6 months. Favorable echocardiographic hemodynamic response appeared associated with improved subsequent clinical outcomes, supporting the role of non-invasive hemodynamic phenotyping to characterize response to soluble guanylate cyclase stimulation.
PURPOSE:The aim of this study was to examine the incremental value of three-dimensional transesophageal echocardiography (3DTEE) versus two-dimensional transesophageal echocardiography (2DTEE) in the detection of prosthetic valve endocarditis (PVE), its prognostic value, and its peculiar diagnostic features compared to native valve endocarditis (NVE). METHODS:One hundred and twenty-nine patients with infective endocarditis (64 PVE and 65 NVE), selected from a population of one hundred and ninety-five patients with suspected PVE or NVE, were studied using 3DTEE and 2DTEE. Presence, location and size of vegetations, new or progressive valve regurgitation, perivalvular extension, and new dehiscence of valve prosthesis were assessed. RESULTS:A definite diagnosis of infective endocarditis was obtained by using 2023 Duke-ESC criteria. Significant improvement in global χ2 value was noted with the addition of 3DTEE parameters compared with 2DTEE alone for PVE detection (from 81.7 to 92.3, p=0.002) and for prediction of in-hospital mortality (from 79.3 to 86.7, p=0.01). In patients with prosthetic valves and surgical confirmation of the diagnosis, 2DTEE and 3DTEE showed a sensitivity of 84.8% and 90.1%, a specificity of 74.2% and 84.3% (p=0.001), a positive predictive value of 89.6% and 93.4%, and a negative predictive value of 76.3% and 85.6% (p=0.003) for PVE detection. Regarding the detection of PVE- and NVE-related valvular and perivalvular lesions according to surgery findings, Receiver Operating Characteristic (ROC) curve analysis showed similar diagnostic performance of three-dimensional transesophageal echocardiography (3DTEE) for valvular complications (AUC = 0.727 vs. 0.897, p = 0.704) and superior diagnostic performance for perivalvular complications, both in mechanical and biological prostheses (AUC = 0.831 vs. 0.516, p = 0.012, and AUC = 0.836 vs. 0.697, p = 0.026, respectively). These results were particularly marked in early PVE compared to late PVE (AUC = 0.883 vs. 0.478, p = 0.001). CONCLUSIONS:Our results suggest that 3DTEE provides additional diagnostic and prognostic information for patients with PVE and higher diagnostic performance for perivalvular complications compared to NVE.
BACKGROUND:Patients with femoropopliteal (FP) chronic total occlusions (CTOs) presenting with intermittent claudication (IC) and chronic limb threatening ischemia (CLTI) differ in disease severity and lesion complexity. We performed a subgroup analysis of the prospective, multicenter RESTOR-1 trial to evaluate the safety and effectiveness of the Santreva™-ATK Endovascular Revascularization Catheter in these patient populations. OBJECTIVES:Compare procedural and short-term clinical course outcomes of the Santreva™-ATK catheter in patients with IC and CLTI enrolled in RESTOR-1 pivotal trial. METHODS:74 patients with Rutherford class (RC) 2-5 peripheral artery disease and de novo FP CTOs were stratified into IC (RC 2-3, n=48) and CLTI (RC 4-5, n=26). The primary endpoint was clinical success, defined as successful device-facilitated guidewire placement into the distal true lumen without device-related major adverse events (MAEs). Secondary endpoints included procedural success, intravascular (IVUS)-determined crossing trajectory, and 30-day clinical outcomes. RESULTS:Clinical success was achieved in 89.6% of patients with IC and 84.6% of patients with CLTI, with similarly high technical and procedural success rates between groups. IVUS evaluation was performed in 85.4% (41/48) of patients with IC and 76.9% (20/26) of patients with CLTI. Among patients with documented crossing trajectory, 86.9% (53/61) demonstrated intraplaque crossing and 13.1% (8/61) demonstrated extraplaque crossing. Although patients with CLTI had a numerically higher prevalence of diabetes mellitus and heavily calcified lesions, these differences were not statistically significant, and crossing performance remained comparable between groups. CONCLUSION:Santreva™-ATK catheter demonstrated high clinical success and an excellent safety profile across the spectrum of FP CTO disease, supporting its use in both IC and CLTI patients.
Survivors of acute myocardial infarction (AMI) face high risk of recurrent atherosclerotic cardiovascular disease (ASCVD) events within the first year after discharge, yet real-world achievement of guideline-recommended low-density lipoprotein cholesterol (LDL-C) targets <55 mg/dL remains limited. We conducted a retrospective cohort study of 12,815 adults hospitalized with type 1 AMI between January 1, 2015, and December 31, 2024, within the Rush University Health System in Chicago, Illinois, to evaluate the association between LDL-C <55 mg/dL attainment at approximately 6 months post-discharge and recurrent ASCVD events within 12 months. The primary outcome was a composite of non-fatal MI, unstable angina hospitalization, ischemic stroke, or unplanned coronary revascularization. Among 12,810 patients with available follow-up LDL-C data, 999 (7.8%) achieved the <55 mg/dL target. A total of 4,692 patients (36.6%) experienced a recurrent composite event within 12 months, and all-cause mortality at 12 months was 11.8%. The elevated event rate is attributable to the inclusive composite definition and to administrative coding practices in which hospital readmissions are frequently assigned AMI ICD-10 codes in patients with recent MI history, rather than reflecting true adjudicated MI recurrence. In unadjusted analyses, LDL-C goal attainment was paradoxically associated with higher odds of recurrent events (odds ratio [OR] 1.81; 95% confidence interval [CI] 1.59-2.06; p <0.001), consistent with confounding by indication: patients receiving the most intensive lipid-lowering therapy had the highest underlying cardiovascular risk. After multivariable adjustment for age, comorbidities, statin use, and admitting hospital, LDL-C <55 mg/dL attainment was associated with lower odds of recurrent events (adjusted OR 0.84; 95% CI 0.75-0.97; p = 0.007). LDL-C goal attainment was not significantly associated with all-cause mortality at 12 months (adjusted OR 0.91; 95% CI 0.73-1.14; p = 0.41), consistent with published literature requiring longer follow-up to demonstrate a mortality signal. These findings highlight persistent underattainment of guideline-recommended lipid targets and underscore substantial clinical inertia in post-AMI lipid management, with first LDL-C reassessment occurring at a mean of 85 days post-discharge while recurrent events occurred a mean of 49 days after admission. In conclusion, achievement of LDL-C <55 mg/dL within 6 months after AMI is independently associated with a meaningful reduction in recurrent ASCVD events in real-world practice, and the temporal mismatch between early post-discharge risk and delayed lipid assessment underscores the need for proactive, multidisciplinary care models to close this implementation gap.
Mitral annular calcification (MAC) is recognized as a marker of cardiovascular risk. However, the structural and hemodynamic predictors of its presence and severity remain insufficiently defined. We analyzed a large, consecutive cohort of 49,093 individuals undergoing echocardiography at our tertiary medical center, classifying them into three groups: normal annulus (79.5%), MAC (17.3%), or severe MAC (3.2%). Clinical and echocardiographic multivariable logistic regression models were used to identify independent predictors of MAC presence and severity. Age was a significant predictor of MAC and was characterized by a marked age-by-sex interaction, with the prevalence diverging after age 60. Severe MAC was twice as frequent in women aged ≥70 years. Diabetes, hypertension, renal dysfunction, obesity and heart failure with preserved ejection fraction (HFPEF) were significant independent predictors of MAC. After incorporation of structural variables, concentric remodeling and diastolic parameters emerged as significant determinants. Increased absolute and relative wall thickness, smaller left ventricular end diastolic dimension (LVEDD), higher E/e', left atrial enlargement, and elevated pulmonary pressures were significant predictors of the presence of MAC. Among individuals with MAC, severity was associated with age, sex, diabetes, HFPEF, smaller LVEDD, and elevated filling pressures. During 1,786 days of median follow-up, MAC was an independent predictor of mortality (severe MAC: HR 1.29, 95% CI 1.12-1.48, p<0.001). In conclusion, MAC is age and sex-related and is significantly associated with structural features of a diastolic impairment profile. Severe MAC serves as an indicator of cardiac remodeling and may warrant focused management of diastolic dysfunction and systemic metabolic risk.
Atrial fibrillation (AF) frequently coexists with tricuspid regurgitation (TR), a combination associated with poor clinical outcomes. Although catheter ablation improves outcomes in select AF populations, its comparative effectiveness versus antiarrhythmic drug (AAD) therapy in patients with concurrent TR remains unclear. We conducted a retrospective cohort study using the TriNetX Global Collaborative Network. Adults with AF and TR were stratified by treatment with catheter ablation plus AAD or AAD therapy alone. 1:1 propensity score matching was performed, yielding 13,293 patients per group. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes were stroke, incident heart failure, and right heart strain. Time-to-event analyses were performed using Kaplan-Meier methods with Cox regression as sensitivity analyses. Competing-risk analyses were performed using Fine-Gray models. Over a mean follow-up of 2.60 years, catheter ablation with background AAD use was associated with a 24.8% reduction in MACE (HR 0.752 [0.701, 0.808]), along with reductions in stroke (HR 0.848 [0.788, 0.913]), heart failure (HR 0.803 [0.757, 0.852]), and right heart strain (HR 0.812 [0.761, 0.867]) compared with sole AAD therapy (all p<0.001). Findings were consistent across Cox sensitivity analyses and competing-risk models. In conclusion, among patients with AF and concomitant TR, catheter ablation with background AAD therapy was associated with lower risks of cardiovascular outcomes and survival compared with sole AAD therapy. These findings support catheter ablation as a favorable rhythm-control strategy in this high-risk population.
Chronic coronary syndrome (CCS) is associated with reduced stress perfusion, a predictor of adverse cardiovascular outcome. To what extent myocardial perfusion is related to cardiorespiratory fitness is not completely known. The aim was to investigate if change in myocardial perfusion correlates to change in aerobic capacity after revascularization. Sixty-two patients with suspected or established CCS underwent cardiopulmonary exercise testing (CPET) and [13N]NH3 positron emission tomography (PET) before and after elective invasive coronary angiography. Thirty-six patients were revascularized and 26 were not. The angiographer was blinded to the results from CPET and PET. Myocardial perfusion was defined as decreased when below 2 ml/min/g and as myocardial perfusion reserve (MPR) < 2. Change in oxygen uptake at submaximal effort (VO2 at AT) correlated positively to change in MPR in revascularized patients (r=0.36, p=0.04), but not in conservatively treated patients (r=0.03, p=0.90). Change in VO2peak, however, did not correlate to change in myocardial perfusion in any of the groups. Myocardial perfusion at stress and MPR increased significantly after revascularization, when baseline perfusion was decreased (P=0.01 stress and P=0.001 MPR, respectively). Furthermore, the number of patients with exercise-induced angina decreased significantly for the revascularized patients (42% (14/33) at baseline vs 3% (1/33) at follow-up, p<0.001) whereas half of the conservatively treated patients still had exercise-induced angina at follow-up (42% (10/24) at baseline vs 21% (5/24) at follow-up, p=0.12). In conclusion, change in myocardial perfusion correlates with change in submaximal aerobic capacity after revascularization and revascularization reduces exercise-induced angina.
The safety of complex percutaneous coronary intervention (PCI) at hospitals without on-site cardiac surgical backup (Non-SOS) has been broadly established, but data specifically addressing elective coronary atherectomy in this setting remain limited. To evaluate whether on-site cardiac surgical backup status influences clinical outcomes of elective coronary atherectomy procedures using contemporary nationwide data. A retrospective cohort study was conducted using the National Inpatient Sample (NIS) from 2016 to 2023. Elective hospitalizations involving coronary atherectomy were identified using ICD-10-PCS codes. Facilities were stratified by on site coronary artery bypass grafting capability. The primary outcome was in hospital mortality. Inverse probability treatment weighting was utilized to adjust for baseline differences. A separate adjusted analysis evaluated annual hospital atherectomy volume and mortality using Firth's penalized logistic regression. We identified 21,595 weighted elective coronary atherectomy procedures (93.4% at SOS hospitals). After Inverse probability treatment weighting adjustment, in-hospital mortality, although numerically higher, did not differ significantly between SOS and Non-SOS centers (OR 0.503; 95% CI 0.203 to 1.249; p = 0.139). Emergency coronary artery bypass grafting was performed in 1.4% of SOS patients, with a 14.0% mortality rate. Emergent transfer rates were higher at Non SOS hospitals (1.8% vs 0.6%; p = 0.026). Annual hospital atherectomy volume ≥30 procedures was independently associated with lower mortality (Firth-adjusted OR 0.06; 95% CI 0.01 to 0.21; p <0.001). Elective coronary atherectomy was performed with comparable in hospital mortality regardless of on-site surgical backup status. Hospital atherectomy volume was the strongest institutional predictor of mortality.
Valvular heart disease (VHD) contributes substantially to cardiovascular mortality. We evaluated long-term VHD mortality trends among older adults to inform healthcare planning. CDC WONDER mortality data (1999 to 2023) were analyzed for adults aged ≥65 years to calculate age-adjusted mortality rates (AAMRs). Joinpoint regression identified temporal trends, alongside a subtype analysis stratifying AAMRs by nonrheumatic aortic (ICD-10 I35), mitral (ICD-10 I34), tricuspid (ICD-10 I36), and chronic rheumatic (ICD-10 I05 to I09) valve disorders. Age-period-cohort modeling assessed generational effects, and ARIMA models projected mortality rates through 2040. Among 1,204,490 VHD deaths, the AAMR declined from 1999 to 2018 (annual percent change [APC] -0.87) but significantly increased from 2018 to 2023 (APC 1.52). Nonrheumatic aortic valve disorders accounted for the vast majority of deaths, demonstrating a continuous decline (APC -0.20). Tricuspid valve disorders showed a sustained rise (APC 7.30), mitral valve disorders exhibited a biphasic pattern reversing after 2012, and chronic rheumatic diseases showed a post-2017 resurgence. Mortality was highest among non-Hispanic White individuals, men, nonmetropolitan residents, and in the West. Age-period-cohort analysis demonstrated generational divergence: recent cohorts experienced lower mortality at ages 65 to 69, whereas adults aged ≥85 years faced progressively higher risks. Forecasting models project the recent resurgence will transition into a sustained plateau, stabilizing at 109.2 deaths per 100,000 population through 2040. Ultimately, after 2 decades of decline, the VHD mortality trend reversed course and is projected to remain stably elevated. This disproportionate impact among the oldest-old and rural populations underscores the need for targeted strategies to mitigate widening disparities.
