Transcatheter aortic valve replacement (TAVR) is an established therapy for severe aortic stenosis, yet dynamic left ventricular outflow tract obstruction (LVOTO) remains an uncommon but critical complication. We reviewed published reports of LVOTO after TAVR to delineate clinical patterns, imaging features, and management strategies. LVOTO may be pre-existing and worsen with TAVR or arise de novo after relief of valvular afterload. Emerging data suggests that septal hypertrophy, small left ventricular cavity size, and adverse mitral-septal geometry may identify patients at risk. Management is individualised and includes medical optimisation, atrioventricular pacing, alcohol septal ablation, and transcatheter edge-to-edge mitral repair. An imaging-guided approach may support earlier recognition, risk stratification and management of this rare but severe post-TAVR complication.
BACKGROUND & AIMS:Despite atrial fibrillation ablation showing promise, recent studies have described the potential induction of haemolysis and onset of acute kidney injury (AKI) caused by pulsed field ablation (PFA) raising safety concerns. This study aimed to evaluate the changes in haemolysis and renal function biomarker following the ablation. METHODS:We systematically searched PubMed, ScienceDirect, and Cochrane Library for observational and randomised controlled trials up to 16 July 2025. We calculated the changes using the difference between pre- and post-ablation biomarker levels. Generic inverse variance was used with 95% confidence interval (CI). Data measures were mean difference (MD) and pooled using a random effects model. RESULTS:Ten observational studies with 1,292 patients were included. PFA is associated with haemolysis reflected on significant increase in lactate dehydrogenase (MD -123.63, 95% CI -194.54 to -52.71), bilirubin (MD -0.82, 95% CI -1.44 to -0.20), and free plasma haemoglobin (MD -47.50, 95% CI -62.36 to -32.65) together with a reduction of haptoglobin (MD 0.58, 95% CI 0.23 - 0.94) following the ablation resulting reduced red blood cell (MD 0.19, 95% CI 0.03 to 0.35), haemoglobin (MD 0.99, 95% CI 0.62 to 1.36), and haematocrit (MD 2.79, 95% CI 1.10 to 4.49). However, there were no difference in urea (MD -0.20, 95% CI -1.17 to 0.77), creatinine (MD -0.07, 95% CI -0.14 to 0.00), and estimated glomerular filtration rate (MD -2.63, 95% CI -6.65 to 1.39). CONCLUSIONS:Despite significant haemolysis-related biomarker changes after PFA, no clinically meaningful anaemia occurred, and AKI was rare and transient. Renal risk appears to depend on application and baseline renal vulnerability, while post-ablation hydration may serve as a preventive strategy against AKI. Further optimisation of PFA and peri-procedural management is needed to enhance safety.
Background Transradial access (TRA) for invasive coronary angiography (ICA) can injure the radial artery (RA). We investigated the distribution of injury to propose injury-mitigation strategies to maximise RA conduit availability for coronary artery bypass grafting (CABG). Method This was a single-centre study including 24 patients who underwent CABG with both the left and right RA after TRA for ICA. Four tissue samples were acquired from each patient: the proximal (subjected to wires and catheters during the ICA) and distal (subjected to the sheath during ICA) instrumented and non-instrumented RAs. Histological analyses assessed regional differences in injury to the instrumented as compared to the non-instrumented RA. Results The distal instrumented RA intima-to-media ratio was higher compared to both the proximal instrumented RA (p=0.009) and the proximal non-instrumented RA (p=0.005). No difference was seen in the density of fibrosis in the media (beta regression: χ2=3.459; p=0.33). There were no statistically significant differences in the presence or absence of inflammation, fibrosis, intimal thickening, calcification, disruption or duplication of the internal elastic lamina, or intimal injury and erosion (Pearson’s chi-squared: χ2=10.572, df=15; p=0.78). Visual inspection of the correlation plot of the residuals suggested a higher-than-expected count of inflammation in the instrumented RA, and a higher-than-expected rate of fibrosis in the proximal instrumented RA. Conclusions Instrumented RA conduit deemed suitable for grafting has histological changes induced by TRA. Although the injury pattern varies, the intima-to-media ratio differences suggest intimal proliferation is greatest in the sheath-exposed distal RA, while the qualitative findings suggest reactive changes are more apparent in the instrumented RA as a whole. The findings suggest the smallest possible sheath and catheters should be considered during ICA, particularly in patients with a high index of suspicion of needing CABG, to help maximise RA conduit availability.
An understanding of the numerous ways in which the mitral valve supports left ventricle (LV) function is important to clinicians who evaluate interventions on the mitral valve. Knowledge of the relative contributions to LV function provided by the various support mechanisms allows clinicians to balance the benefits against the adverse effects of mitral interventions. Although much of the research into the valvular-ventricular interaction has been undertaken in animals with normal hearts, the known mechanics of the interaction can be logically translated to human cardiomyopathic hearts. The systolic force applied through the marginal chordae of the anterior mitral leaflet (AML) is the dominant mechanism supporting LV function, and any intervention that inhibits AML closure (immobilisation, splitting, partial resection, etc.) sacrifices some level of LV contractility. Such interventions might provide limited overall benefit in cardiomyopathic hearts that poorly tolerate further LV impairment. This narrative review presents a summary of the existing evidence on the relative contributions of the various valvular-ventricular support mechanisms and their clinical application.
BACKGROUND:This study aims to compare the clinical characteristics and outcomes of Māori and Pacific people receiving implantable cardioverter defibrillators (ICD) compared with other ethnicities. METHOD:All patients who received an ICD in Aotearoa New Zealand between 2016 to 2020 were identified from a national registry for cardiac implantable electronic devices. Patients with infiltrative cardiomyopathies, congenital heart disease and channelopathies were excluded. The primary outcome was all-cause mortality. Secondary outcomes were cardiovascular disease (CVD) mortality, non-CVD mortality, heart failure (HF) hospitalisation and ventricular arrhythmia (VA) hospitalisation. Log-rank tests on Kaplan-Meier (KM) curves and 4-year KM event rates were reported. Multivariable Cox regression models were performed to determine the hazard ratio (HR) of all-cause mortality in ethnic subgroups groups compared to European/other. RESULTS:There were 1,990 patients with a mean follow-up of 4.0±1.5 years. Compared to other ethnicities, Māori and Pacific patients were younger (Māori: 59 years, Pacific: 56 years, Asian: 60 years, European/other: 65 years; p<0.001), more likely to live in socioeconomically deprived areas, had more comorbidities, history of HF, New York Heart Association class III-IV, left ventricular ejection fraction ≤35% and chronic renal impairment. At 4 years, Māori and Pacific patients had higher all-cause mortality (Māori: 23.1%, Pacific: 18.6%, Asian: 5.3%, European/other: 12.0%; p<0.0001); CVD mortality (Māori: 17.4%, Pacific: 10.9%, Asian: 4.3%, European/other: 7.6%; p<0.0001), non-CVD mortality (Māori: 6.9%, Pacific: 8.7%, Asian: 1.1%, European/other: 4.8%; p=0.02), HF hospitalisation (Māori: 34.9%, Pacific: 30.9%, Asian: 19.5%, European/other: 20.8%; p<0.0001) and VA hospitalisation (Māori: 23.8%, Pacific: 29.5%, Asian: 11.0%, European/other: 20.3%; p=0.02) compared to other ethnicities. After adjustment for demographics, comorbidities, New York Heart Association class and left ventricular ejection fraction, the all-cause mortality in Māori remained elevated (HR 1.88 [1.41-2.50]), with a trend towards increased all-cause mortality in Pacific patients (HR 1.51 [0.97-2.33]) compared with European/other. CONCLUSIONS:In Aotearoa New Zealand ICD recipients, all-cause mortality and HF and VA hospitalisation was substantially higher in Māori and Pacific compared to other ethnicities. Urgent efforts are needed to improve the health and healthcare of Māori and Pacific people to achieve more equitable clinical outcomes.
BACKGROUND:Pulmonary arterial hypertension (PAH) is a progressive disease characterised by increased pulmonary vascular resistance, leading to right heart failure and premature death. Although classically linked to idiopathic and autoimmune disorders, infectious diseases are increasingly recognised as contributors to PAH pathogenesis. METHOD:This scoping review mapped current evidence on associations between infectious diseases and PAH, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. PubMed, Scopus, and Web of Science were searched for studies addressing epidemiology, mechanisms and clinical implications. RESULTS:Evidence shows robust associations for human immunodeficiency virus and schistosomiasis (Tier 1); hepatitis C virus and hepatitis B virus (Tier 2); and coronavirus disease 2019 (Tier 3). Common mechanisms include chronic inflammation, endothelial dysfunction and vascular remodelling. CONCLUSIONS:Infection-associated PAH remains underrecognised in diagnostic frameworks and clinical practice, particularly in low- and middle-income countries where these infections are endemic. Integrating PAH screening and management into existing infectious disease programs could improve early diagnosis and outcomes. Addressing this neglected interface is crucial to reducing morbidity and advancing health equity for affected populations worldwide.
BACKGROUND:Few clinical studies have assessed cardiovascular events and associated symptoms following coronavirus disease 2019 (COVID-19). METHOD:This was a multicentre study of patients with previous severe acute respiratory syndrome coronavirus 2 infection followed at university and hospital clinics, with collection of both retrospective and prospective data. Demographics, comorbidities, severity and timing of acute COVID-19, subjective functional status, and presence of 30 symptoms were collected. New diagnoses following COVID-19 were classified as cardiovascular or non-cardiovascular. The associations between clinical and demographic covariates and occurrence of new diagnoses were assessed in multivariable logistic regression models. RESULTS:New diagnoses were made in 40.5% of 1,734 adult patients (non-cardiovascular, 35.1%; cardiovascular, 10.9%; both types, 5.4%). The most common new cardiovascular diagnoses were arrhythmias (3.0%), pulmonary embolism (2.6%), hypertension (2.4%), and pericarditis (2.0%), followed by heart failure and venous thrombosis (both at 1.3%), myocarditis (0.6%), and ischaemic heart disease (0.3%). In the multivariable analyses, new cardiovascular diagnoses were associated with age >65 years (adjusted odds ratio 1.64; 95% confidence interval 1.15-2.33), admission to the intensive care unit during acute infection (1.85; 1.08-3.17), and chronic pulmonary disease (1.76; 1.02-3.06). After a mean follow-up of 7 months, patients with new cardiovascular diagnoses had a significantly higher mean number of symptoms, significantly higher prevalence of several individual symptoms, and worse functional status compared with pre-infection. CONCLUSIONS:The findings suggest that new cardiovascular diagnoses following COVID-19 significantly affect subsequent wellbeing. Preventing their occurrence may reduce not only acute and post-acute cardiovascular morbidity, but also the persistence, breadth, and burden of post-COVID-19 symptoms, and may avert a significant decline in functional status.
BACKGROUND:Aortic stenosis (AS) and heart failure with preserved ejection fraction (HFpEF) share common pathophysiologic features and comorbidities and often co-exist, but their combined prognostic impact is unclear. We aimed to assess HFpEF probability among patients with AS undergoing transcatheter aortic valve implantation (TAVI) and evaluate its impact on clinical presentation and outcomes. METHOD:In this retrospective cohort study, consecutive patients with severe AS and preserved left ventricular EF undergoing TAVI were stratified into low (<25%), intermediate (25%-74%) and high (≥75%) HFpEF probability groups using the HFpEF-ABA score (incorporating age, body mass index, and atrial fibrillation history). Demographics, echocardiographic parameters, functional status, quality of life, and outcomes were compared. RESULTS:Among 2,175 patients (median age 82 years; interquartile range 78-86; 44.7% female), 2 (0.1%) had low, 735 (36.1%) intermediate, and 1,388 (63.8%) high HFpEF probability. Patients with high HFpEF probability were older, had more typical HFpEF-related comorbidities, and exhibited poorer quality of life, more severe dyspnoea, and increased cardiac remodelling (higher left ventricular mass and dimensions, pulmonary hypertension, and mitral regurgitation), despite less severe traditional markers of AS. Post-TAVI, both groups had similar improvements in valve haemodynamics, and there was no significant difference in the primary composite end point of 12-month HF hospitalisation or mortality between the high and low-intermediate probability groups (odds ratio 1.32; 95% confidence interval 0.92-1.88; p=0.13). However, high HFpEF probability was associated with increased permanent pacemaker implantation, worse post-TAVI functional status, lower quality of life, and a greater risk of 12-month HF hospitalisation. CONCLUSIONS:The HFpEF-ABA score identifies a high-risk phenotype of AS patients undergoing TAVI, characterised by adverse cardiac remodelling, poorer functional status, and increased post-TAVI complications. Further studies are required to determine whether HFpEF-specific therapies would benefit this population.
Background & Aim Transcatheter edge-to-edge repair (TEER) has expanded options for high-risk patients with severe mitral regurgitation (MR), however its longer-term performance relative to surgical mitral valve repair (SMVR) remains uncertain. This systematic review and meta-analysis compares the clinical outcomes of TEER versus SMVR in adults with MR. Methods We performed a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses)-guided systematic review and random-effects meta-analysis of randomised and comparative observational studies including adults with primary or secondary MR treated with TEER (MitraClip therapy) or SMVR. Primary outcomes were mortality, reintervention and recurrent ≥3+ MR; secondary outcomes included stroke, acute kidney injury (AKI) and permanent pacemaker implantation. Subgroup analyses explored modification by MR aetiology, study design and surgical strategy. Results Twenty-one studies (70,641 patients; 24,820 TEER, 45,821 SMVR) met the inclusion criteria. TEER recipients were older, more comorbid and had higher baseline risk. In-hospital and 30-day mortality were similar between strategies. At 1 year, mortality was significantly higher after TEER (risk ratio [RR] 1.58, 95% confidence interval [CI] 1.10–2.28). Within 1 year, reintervention was almost three-fold more frequent after TEER (RR 2.98, 95% CI 2.14–4.14), and recurrent ≥3+ MR was substantially higher both at approximately 1 year (RR 4.80, 95% CI 1.97–11.72) and 3 years (RR 6.51, 95% CI 2.60–16.29). TEER was associated with a lower 1-year stroke risk, while pooled AKI and pacemaker outcomes did not differ significantly. Conclusions TEER is a short-term alternative for high-risk patients but demonstrates higher long-term recurrence and reintervention. SMVR remains superior for durability and survival. Further studies are needed to evaluate TEER in high-risk surgical cohorts.
BACKGROUND:We aimed to evaluate the risks and outcomes of coronary artery bypass grafting in patients aged ≥80 years in Australia. METHOD:We conducted a retrospective cohort study of 96,849 patients who underwent isolated coronary artery bypass surgery between 1 January 2001 and 31 December 2022, using data from the Australian and New Zealand Society of Cardiac and Thoracic Surgeons cardiac surgery database. Patients were stratified into octogenarians and non-octogenarians. Primary outcomes included operative mortality (30-day or in-hospital death) and long-term survival. Kaplan-Meier estimates were used to analyse survival, logistic regression to identify predictors of early mortality, and Cox proportional hazards to identify predictors of late mortality. Survival in the octogenarian cohort was compared with an age- and sex-matched Australian population. RESULTS:Operative mortality was 2.8% in octogenarians vs 1.0% in non-octogenarians. The median follow-up was 3.4 years, with Kaplan-Meier estimated survival rates of 93%, 72%, 37% and 14% at 1, 5, 10, and 15 years. Median survival was 8.0 years in octogenarians, compared to 6.7 years in an age- and sex-matched general Australian population. The standardised mortality ratio was 0.78 (95% confidence interval 0.75-0.82; p<0.001). CONCLUSIONS:Although octogenarians undergoing coronary artery bypass have a higher operative risk than younger patients, mortality rates are lower than previously reported. Surgery in this population may be associated with favourable long-term survival compared to the general population. These findings support careful patient selection and shared decision-making when considering surgical revascularisation in the elderly.
