Abstract Background ST-elevation myocardial infarction (STEMI) remains a major cause of global mortality. While troponin is the gold-standard biomarker for myocardial injury, a subset of patients presents with troponin levels below the clinical “rule-in” threshold upon hospital admission. The long-term prognostic significance of these initial “low-troponin” presentations in a large-scale population remains insufficiently characterized. Methods We conducted a retrospective multicenter cohort study using the “KINERET” database, analyzing 8,394 patients diagnosed with STEMI who underwent percutaneous coronary intervention (PCI) at four academic medical centers in Israel between 2016 and 2023. Patients were stratified into two groups based on ESC rule-in criteria for high-sensitivity cardiac troponin (hs-cTn) at admission: a High trop group (above rule-in cutoff) and a Low trop group (below rule-in cutoff). The primary outcome was all-cause mortality at 5 years. Results Of the 8,394 patients (mean age 68.3±13.3 years; 76% male), 36.5% (n=3,064) presented with troponin levels below the rule-in cutoff. Patients in the High trop group were older and had a higher prevalence of comorbidities, including heart failure (46.7% vs. 28.7%) and chronic kidney disease (13.9% vs. 9%). The Low trop group demonstrated significantly higher survival rates at both 1 year (92.9% vs. 84.0%, p<0.001) and 5 years (85.7% vs. 75.0%, p<0.001). After adjusting for age, sex, and comorbidities in a multivariate Cox regression model, initially elevated troponin remained a robust independent predictor of 5-year mortality (HR 1.15, 95% CI 1.14-1.16, p<0.001), alongside age >75, female sex, and chronic kidney disease. Conclusions STEMI patients presenting with initial troponin levels below the diagnostic rule-in threshold have a significantly better short- and long-term prognosis compared to those with early troponin elevation. Moreover, admission troponin levels serve as a powerful predictor of 5-year mortality and may be used as an independent prognostic factor following STEMI.

Background/Objectives: Obesity and diabetes mellitus coexist, but the association of obesity with invasive management and in-hospital outcomes in acute myocardial infarction (AMI) complicated by cardiogenic shock is uncertain. We evaluated these associations among adults with diabetes mellitus. Methods: We performed a retrospective discharge-level analysis of the National Inpatient Sample for 2016–2021. Obesity was identified from ICD-10-CM codes. Survey-design logistic regression accounted for weights, strata, hospital clusters, and prespecified covariates. Results: The cohort comprised 19,399 discharges, representing 96,995 hospitalizations; 24.1% had obesity. Angiography and coronary artery bypass grafting (CABG) were more frequent with obesity, whereas percutaneous coronary intervention (PCI) was less frequent. After adjustment, obesity was associated with higher odds of angiography (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.03–1.21) and CABG (aOR 1.49, 95% CI 1.35–1.63), lower odds of PCI (aOR 0.90, 95% CI 0.84–0.97), and similar odds of circulatory support (aOR 1.00, 95% CI 0.93–1.07). Adjusted odds were lower for major adverse cardiovascular and cerebrovascular events (aOR 0.88, 95% CI 0.82–0.95), in-hospital mortality (aOR 0.90, 95% CI 0.83–0.98), acute ischemic stroke (aOR 0.78, 95% CI 0.64–0.95), and major bleeding (aOR 0.86, 95% CI 0.76–0.98). Procedure adjustment attenuated mortality and major bleeding. Conclusions: Obesity was associated with a different invasive-management pattern and lower adjusted odds of several short-term outcomes, consistent with an apparent in-hospital obesity paradox in this high-risk population.

Background Pulmonary embolism (PE) is a leading cause of morbidity among cancer patients. The COVID-19 pandemic introduced new challenges to healthcare delivery. This study aimed to evaluate the impact of the COVID-19 pandemic on PE-related hospitalizations, treatment, and in-hospital outcomes in patients with active cancer. Methods We conducted a retrospective analysis using the National Inpatient Sample database from 2016 to 2021. Patients with active cancer and a primary diagnosis of acute PE were categorized into three groups: pre-COVID-19 (2016–2019), peak COVID-19 (2020), and ongoing COVID-19 (2021). We compared baseline characteristics, in-hospital procedures, and clinical outcomes among these groups. Multivariable logistic regression was employed to assess associations between COVID-19 periods and outcomes. Results Among 170,630 patients with PE and cancer, admission rates decreased during the pandemic. Patients hospitalized during the COVID-19 pandemic more frequently presented with severe PE phenotypes, including saddle PE (9.7% and 9.4% vs. 7.5%, p<0.001) and acute cor pulmonale (8.4% and 8.9% vs. 5.9%, p<0.001). Thrombolysis-based therapies increased during the pandemic, whereas adjusted odds of catheter-directed embolectomy were lower. Despite more severe presentations, in-hospital mortality remained relatively stable (6.0% pre-COVID-19, 6.0% peak, 5.5% ongoing; p=0.004). Conclusion The COVID-19 pandemic led to decreased PE-related hospitalizations among cancer patients but was associated with more severe presentations and shifts in therapeutic strategies. Notably, in-hospital mortality remained stable, which may be consistent with maintained PE care pathways during the pandemic. These findings highlight the need for robust, adaptable healthcare systems to ensure continuity of care for high-risk populations during global health crises.

Background:Artificial intelligence-based fractional flow reserve (AI-FFR) incorporates a machine learning-based algorithm to derive FFR directly from angiography. Its accuracy compared with invasive FFR has not been assessed. Methods:AI-FFR was compared with wire-based FFR in patients with a single intermediate lesion (diameter stenosis ≥40% to <70%) at 5 centers in the United States and Israel. AI-FFR assessments were performed by core laboratory analysts blinded to invasive FFR results. Diagnostic performance metrics were calculated using an FFR threshold of ≤0.80. Results:A total of 504 vessels from 496 patients were analyzed. AI-FFR computation time was 36.1 ± 7.7 seconds. Lesion detection was fully automatic in 371 of 504 (73.6%) vessels, whereas semiautomated analysis with manual marking was performed in 133 of 504 (26.4%) vessels. Mean wire-based FFR was 0.85 ± 0.07 and mean AI-FFR was 0.85 ± 0.08 (mean difference, 0.00 ± 0.08; 95% CI, -0.15 to 0.15; P = .41). AI-FFR showed a sensitivity of 90.2%, specificity of 94.9%, positive predictive value of 83.5%, negative predictive value of 97.1%, and overall diagnostic accuracy of 93.8%. The area under the receiver operating characteristic curve (AUC) was 0.93 (95% CI, 0.89-0.96). Among 151 lesions with wire-based FFR values in the borderline "gray zone" (0.75-0.85), AI-FFR demonstrated a diagnostic accuracy of 91.4% and an AUC of 0.91 (95% CI, 0.86-0.96). AI-FFR demonstrated high diagnostic accuracy across vessel types and lesion locations in men and women and between the US and Israeli cohorts. Conclusions:AI-FFR, an automated, machine learning-based tool, demonstrated high diagnostic accuracy compared with wire-based FFR. Its speed, simplicity, and independence from complex procedural steps may facilitate broader adoption during coronary angiography.

BACKGROUND:Prior studies demonstrated that lung impedance (LI)-guided therapy reduces heart failure (HF) hospitalizations in patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS:In this proof-of-concept, single-blind, single-center randomized controlled trial (NCT02661841), 150 HFpEF patients (NYHA class I-IV, LVEF >50%, elevated NT-proBNP, prior HF hospitalization) were randomized 1:1 to LI-guided management or usual care. LI was measured noninvasively at monthly outpatient visits using the FDA-approved CardioSet device. The primary endpoint was recurrent HF hospitalization. Mean follow-up was 38.4±22.8 months. HF hospitalizations were significantly reduced in the LI-guided group (HR 0.26; 95% CI 0.14-0.49; p<0.001; 20 vs 95 events). All-cause mortality (HR 0.40; 95% CI 0.18-0.87; p=0.02) and HF-specific mortality (HR 0.26; 95% CI 0.08-0.80; p=0.02) were also significantly lower. The Lung Impedance Ratio (LIR), reflecting each patient's degree of pulmonary congestion relative to their individual normal dry state, was used as a real-time fluid index to assess fluid status and guide diuretic titration at each visit. LI-guided patients spent significantly more time within the therapeutic LIR range, median 97% vs 49%; p<0.001, achieved through earlier treatment escalation (median LIR -20.8% vs -35.4%; p<0.01) and more conservative de-escalation (-13.7% vs -2.3%; p<0.01). Diuretic adjustment efficacy was similar between groups (LIR improvement +1.01% vs +1.36%; p=0.63), confirming benefit derived from precision timing rather than superior drug response. CONCLUSIONS:In this proof-of-concept randomized trial, LI-guided management significantly reduced HF hospitalizations, all-cause mortality, and HF-specific mortality in HFpEF through precision timing of decongestion.

BACKGROUND:Despite advancements in catheter ablation (CA) technique and expertise, success rates of atrial fibrillation (AF) ablation have not substantially improved in recent years. Treating patients with advanced age and higher comorbidities may limit success rates while increasing complications. OBJECTIVE:To evaluate trends in comorbidity burden and its association with in-hospital outcomes following inpatient CA procedures for AF. METHODS:Using the National Inpatient Sample database, an estimated total of 64,995 CA procedures for AF between 2016 and 2021 in the United States were analyzed. Each patient's comorbidities were identified, and their comorbidity burden was evaluated using a standardized comorbidity index. In-hospital outcomes were compared between patients with high and low comorbidity burdens. Annual trends in the rates of patients with high comorbidity burden were calculated. RESULTS:A total of 11,685 (18.0%) patients had high comorbidity burden. The annual trend in CA procedures for patients with high comorbidity burden gradually increased from 11.7% in 2016 to 22.1% in 2021 (p < 0.001). A higher rate of total complications was observed in patients with high comorbidity burden (14.2% vs. 7.8%, p < 0.001), driven by vascular, infectious, and respiratory complications, but not by cardiac complications. In-hospital mortality was significantly higher among those with a high comorbidity burden (1.5% vs. 0.2%, p < 0.001). CONCLUSION:In recent years, inpatient CA for AF has increasingly been performed in patients with higher comorbidity burden. A careful preprocedural risk-benefit assessment would be prudent in patients with high comorbidity burden to improve outcomes.

Background: Cardiovascular-kidney-metabolic (CKM) syndrome, recently defined by the American Heart Association, encompasses the interplay between obesity, diabetes, chronic kidney disease, and cardiovascular disease. This study aimed to investigate the impact of CKM syndrome severity on outcomes in patients with acute myocardial infarction (AMI). Methods: A retrospective analysis was conducted using the National Inpatient Sample database from 2016 to 2019. Adult patients hospitalized with AMI were stratified into CKM Stages 0-4 based on ICD-10 codes. Multivariable logistic regression models were used to examine associations between CKM stages and in-hospital procedures and outcomes. Results: The study analyzed 2,768,154 AMI cases. Advanced CKM stages were associated with older age and a higher proportion of males. Patients with severe CKM were more likely to undergo invasive procedures. Coronary angiography showed the strongest association in CKM Stage 4A (aOR: 6.86, 95% CI: 6.73-6.99, p-value < 0.001) and Stage 4B (aOR: 3.87, 95% CI: 3.80-3.95, p-value < 0.001). Similarly, the likelihood of PCI was highest in Stage 4A (aOR: 5.93, 95% CI: 5.79-6.08, p-value < 0.001) and Stage 4B (aOR: 4.14, 95% CI: 4.04-4.24, p-value < 0.001). Notably, patients with CKM Stage 0 demonstrated higher odds of adverse outcomes compared to other stages. Conclusions: This study reveals a complex relationship between CKM syndrome severity and AMI outcomes. Patients with advanced CKM stages were more likely to undergo invasive procedures, and those without CKM risk factors unexpectedly showed worse outcomes. Among Stages 1-4B, no consistently graded association emerged between the CKM stage and adverse outcomes. These findings warrant further investigation into underlying mechanisms and long-term prognosis.

Background: Frail patients undergoing AF ablation face elevated periprocedural risks. However, prior studies often examined composite or long-term outcomes and did not stratify acute complication risks by frailty severity. Objective: The objective of this study was to assess the impact of frailty, measured by the Hospital Frailty Risk Score (HFRS) on in-hospital outcomes after AF ablation, and to delineate the risk of specific acute complications across frailty levels. Methods: We analyzed a national inpatient cohort of AF ablation hospitalizations (2016-2021). Patients were stratified into low-, intermediate-, and high-frailty groups by HFRS. In-hospital mortality and major complications (stroke, respiratory failure, sepsis, acute dialysis, cardiac arrest, cardiogenic shock) were compared across frailty groups, and multivariable logistic regression identified independent predictors of these outcomes. Results: Among an estimated 42,830 AF ablation admissions, 80.0% were low-frailty, 15.0% intermediate, and 5.0% high-frailty. High-frailty patients had markedly higher complication rates than low-frailty patients. In-hospital mortality was 6.1% in high frailty vs. 1.0% in low frailty, and stroke occurred in 4.0% vs. 0.3%, respectively. Rates of respiratory failure (18.0% vs. 3.5%), sepsis (8.0% vs. 1.2%), and acute dialysis (4.0% vs. 0.5%) were also significantly higher in the high-frailty group (all p < 0.001). In multivariate analyses, frailty remained a strong independent predictor of complications; high frailty conferred over four-fold higher odds of in-hospital mortality and five-fold higher odds of stroke compared to low frailty. Conclusions: Frailty is a powerful predictor of periprocedural complications and mortality in AF ablation patients. Even after accounting for age and comorbidities, patients with higher frailty scores experienced substantially worse in-hospital outcomes. These findings highlight the importance of frailty assessment to identify high-risk patients and inform clinical decision-making for AF ablation.

Background:Pulmonary embolism (PE) is a life-threatening cardiovascular condition with increasing global incidence. Obesity is a significant risk factor for PE, although its reported relationship with outcomes is inconsistent. This study aimed to investigate the impact of obesity on clinical outcomes in patients with high-risk PE. Methods:We conducted a retrospective analysis of US adult patients hospitalized with high-risk PE from 2016 to 2019 using the National Inpatient Sample database. Patients were categorized into three groups based on BMI: non-obese, obese (30 to < 40 kg/m2), and severely obese (≥40 kg/m2). We compared baseline characteristics, in-hospital procedures, and outcomes among these groups. Multivariable logistic regression models assessed the relationship between obesity levels and in-hospital outcomes. Results:Of 752,660 patients with PE, 29,610 (3.9 %) were classified as high-risk. The distribution among BMI categories was: non-obese (77.1 %), obese (8.8 %), and severely obese (14.1 %). Severely obese patients were younger (mean age 55.7 vs. 66.1 years for non-obese, p < 0.001) and more likely to be female (63.2 % vs. 51.4 % for non-obese, p < 0.001). After adjustment, obese and severely obese patients had lower odds of in-hospital mortality (obese: aOR 0.50, p < 0.001; severely obese: aOR 0.69, p < 0.001) and major adverse cardiovascular and cerebrovascular events (obese: aOR 0.50, p < 0.001; severely obese: aOR 0.72, p < 0.001). Conclusion:Our study revealed an "obesity paradox" in high-risk PE patients, with obese and severely obese individuals showing lower mortality and fewer complications despite higher comorbidity rates. These findings emphasize the need for tailored risk assessment and treatment strategies in obese patients with high-risk PE.

Left ventricular thrombus (LVT) remains a clinically significant complication following acute myocardial infarction (MI). Although its incidence has declined in the era of primary percutaneous coronary interventions (PCIs), the best treatment remains unclear. For decades, vitamin K antagonists (VKAs) such as warfarin have been the mainstay of therapy, supported by guidelines recommendations. However, the limitations of warfarin, including a narrow therapeutic range, the need for frequent monitoring, and food/drug interactions, have spurred interest in direct oral anticoagulants (DOACs). This review summarizes the available evidence on anticoagulation strategies for LVT after MI, focusing on observational studies and recent randomized controlled trials. A total of 12 studies were included in this review: 9 retrospective cohorts and 3 randomized controlled trials. Patient populations ranged from small single-center cohorts to large multicenter registries. DOACs, compared with warfarin, were associated with a higher rate of thrombus resolution, a lower rate of stroke and systemic embolism, and a similar mortality. The usage of DOACs marginally reduced the rate of major bleeding compared with warfarin. The current evidence indicates that DOACs may offer comparable efficacy and potentially improved safety relative to warfarin, although most randomized trials remain small and underpowered for definitive conclusions. Larger, adequately powered studies are still required before DOACs can be routinely considered equivalent alternatives. The RIVAWAR randomized trial provides the strongest evidence to date regarding the use of DOACs in LVT after MI, but further large-scale randomized studies are required to establish definitive guidance. Until then, anticoagulation therapy including DOACs should be individualized, balancing the thromboembolic risk, bleeding risk, and practical considerations of anticoagulant use.

Fluoroscopy-guided medical procedures require medical personnel to wear lead aprons (typically 0.5-mm Pb), which weigh up to 7 kg and can cause significant occupational injuries. A novel robotic radiation-blocking system, Radiaction, reduces full-body scattered radiation by 92

This clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions was developed in association with the European Society of Cardiology Working Group on Cardiovascular Surgery. It aims to define procedural and contemporary technical requirements that may improve the efficacy and safety of percutaneous coronary intervention (PCI), both in the acute phase and at long-term follow-up, in a high-risk cohort of patients on optimal medical therapy when clinical and anatomical high-risk criteria are present that entail unacceptable surgical risks, precluding the feasibility of coronary artery bypass grafting (CABG). This document pertains to patients with surgical contraindication according to the Heart Team, in whom medical therapy has failed (e.g., residual symptoms), and for whom the Heart Team estimates that revascularisation may have a prognostic benefit (e.g., left main, last remaining vessel, multivessel disease with large areas of ischaemia); however, there is a lack of data regarding the size of this patient population. This document aims to guide interventional cardiologists on how to proceed with PCI in such high-risk patients with reduced left ventricular ejection fraction after the decision of the Heart Team is made that CABG - which overall is the guideline-recommended option for revascularisation in these patients - is not an option and that PCI may be beneficial for the patient. Importantly, when a high-risk PCI is planned, a multidisciplinary decision by interventional cardiologists, cardiac surgeons, anaesthetists and noninvasive physicians with expertise in heart failure management and intensive care should be agreed upon after careful consideration of the possible undesirable consequences of PCI, including futility, similar to the approach for structural interventions.

Significant mitral regurgitation (MR), is associated with unfavorable perioperative and periprocedural outcomes in patients undergoing cardiac and noncardiac interventions. This may be especially important in left atrial procedures. However, information regarding its impact on percutaneous left atrial appendage closure (LAAC) procedures is scarce. We utilized the National Inpatient Sample (NIS) database to identify patients who underwent percutaneous LAAC and had an MR diagnosis between the years 2016 and 2021 in the US, using ICD-10 codes. Clinical and sociodemographic data, in-hospital procedures and outcomes were collected. Baseline characteristics and outcomes were compared between patients with and without MR. Multivariable logistic regression models were used to identify predictors of in-hospital complications. An estimated total of 123,785 patients underwent percutaneous LAAC between 2016 and 2021 in the US. Of them, 7,325 (5.9

We aimed to analyze whether national level stressful events were associated with an increase the incidence of Takotsubo syndrome. Takotsubo syndrome is an acute reversible heart failure, characterized by transient regional wall abnormality in the absence of a culprit coronary disease, usually caused by acute stressful etiologies. The terror attack of October 7th 2023 and the subsequent war had an enormous impact on the society in Israel. This was a multi-center, observational, analytic, retrospective, case-control study. To examine our hypothesis, we compared the incidence of Takotsubo syndrome in 7 medical centers in Israel during the period of October-December 2023 ("during war") to the period of October-December 2022 ("before war"), both as an absolute number and as a percentage of all admissions in these 7 medical centers. During the period before the war, 20 patients (0.54 % of all admissions to the cardiology departments) were hospitalized with a proven diagnosis of Takotsubo syndrome, compared with 39 patients (1.07 % of all admissions to the cardiology departments) during the war, accounting for a 95 % increase in the absolute number, and 98 % increase in the percentage of all admissions (p = 0.01, OR = 1.98). Most of the demographic and clinical characteristics, laboratory results, ECG, echocardiogram and angiographic findings were similar between the two groups. Our study showed a significant increase in the incidence of Takotsubo syndrome in Israel during the first three months of the war, suggesting the October 7th terror attack and the consequent war was a traumatic event for the society of Israel.

Background Pulmonary embolism (PE) is a life-threatening condition with significant morbidity and mortality. The relationship between psychiatric disorders and PE outcomes is complex and not well understood. This study aimed to determine the impact of psychiatric disorders on PE outcomes by comparing patients with and without these conditions.Methods Using the National Inpatient Sample database, we analysed 725 725 adult patients hospitalised with PE between 2016 and 2019. Patients were stratified based on the presence or absence of psychiatric disorders. Multivariable logistic regression models were used to examine associations between psychiatric disorders and in-hospital outcomes, adjusting for baseline differences.Results Of the patients studied, 26.6% had psychiatric disorders. These patients were younger (59.80 vs 63.91 years, p<0.001), more likely to be female (60.7% vs 48.8%, p<0.001), and had higher rates of smoking and obesity but lower rates of diabetes and atrial fibrillation. After adjustment, patients with psychiatric disorders were less likely to undergo systemic thrombolysis (adjusted OR (aOR) 0.83, 95% CI: 0.80 to 0.85, p<0.001), catheter-directed interventions and placement of inferior vena cava filters (aOR 0.90, 95% CI: 0.88 to 0.92, p<0.001). These patients had lower odds of all-cause mortality (aOR 0.81, 95% CI: 0.78 to 0.84, p<0.001) and major adverse cardiovascular and cerebrovascular events (aOR 0.87, 95% CI: 0.85 to 0.89, p<0.001), with no significant difference in major bleeding risk (aOR 1.01, 95% CI: 0.98 to 1.05, p=0.553).Conclusions Psychiatric disorders are associated with distinct management and outcomes in PE. Recognising these unique characteristics may help optimise care for this population; further research is needed to clarify the best management strategies.

Catheter ablation is an established important treatment for symptomatic atrial fibrillation (AF), and is increasingly being used as a strategy for rhythm control, even among patients that are more difficult to recruit to randomized trials comparing treatment methods in AF. We aimed to assess the utilization trends of AF catheter ablation among patients with physical disabilities, and to evaluate the acute safety of ablation is this population. Using the National Inpatient Sample (NIS) database, patients who underwent AF ablation in the US between 2012 and 2019 were identified using ICD 9/10 codes. Sociodemographic, clinical data, in-hospital procedures and outcomes and length-of-stay (LOS) were collected. Physical disabilities were defined as hearing, visual and speech disabilities along with musculoskeletal disabilities as coded in the registry. Baseline characteristics and in-hospital outcomes were compared between patients with and without physical disabilities. An estimated total of 78,190 admissions for AF ablations were performed during the study period. Patients with physical disabilities underwent 1745 AF ablation procedures (2.2%). These patients were older and had more comorbidities, with the exception of diabetes and hypertension. The utilization of AF ablation in physical disability patients increased during the study period from 1.3% of ablations in 2012 and 2013, to over 3% of all AF ablations in 2019. In-hospital complications occurred in 5350 AF procedures, however patients with a disability diagnosis had a higher rates of total in-hospital complications (13.8% vs 6.7%;p<0.001), driven by cardiac complications, stroke (3.4% vs 0.1%;<0.001), vascular and infectious complications (1.4% vs. 0.8%;p=0.007). In-hospital mortality was rare in both groups. Average LOS was nearly a day longer in patients with physical disabilities. AF ablation is increasingly utilized in patients with physical disabilities in a nationwide, all-comer registry. This increased trend of ablation procedures, results in a significantly higher complication rates, albeit no change of in-hospital mortality rates. Precautions should be taken to reduce complications in this vulnerable population.AF Ablation annual trend

Background:Pulmonary embolism (PE) is a life-threatening condition with high morbidity and mortality rates. Cardiovascular-Kidney-Metabolic (CKM) syndrome, representing a complex interplay of cardiovascular disease, kidney dysfunction, and metabolic disorders, may significantly impact PE outcomes. This study investigates the influence of CKM syndrome staging on clinical outcomes and management strategies in acute PE patients. Methods:This retrospective study analyzed 725,725 adult patients hospitalized with a primary diagnosis of PE between 2016 and 2019 using the National Inpatient Sample database. Patients were categorized into five CKM groups (0,1,2/3,4a, 4b) based on staging criteria. Multivariable logistic regression models were used to assess the relationship between in-hospital outcomes and CKM stages. Results:As CKM stages advanced, patients exhibited distinct profiles characterized by older age, male predominance and a higher prevalence of comorbidities. Multivariate analysis revealed that advanced CKM stages were less likely to receive invasive treatments (systemic thrombolysis: aOR 0.86, 95 % CI 0.81-0.92, p < 0.001) but had higher odds of adverse outcomes, including MACCE (aOR 1.53, 95 % CI 1.45-1.60, p < 0.001), mortality (aOR 1.33, 95 % CI 1.25-1.41, p < 0.001), and major bleeding (aOR 1.15, 95 % CI 1.08-1.23, p < 0.001). All odds ratios were computed using CKM stage 0 as the reference group. Conclusion:CKM syndrome staging significantly impacts clinical outcomes and management strategies in patients with PE. Advanced CKM stages are associated with higher risks of adverse events, including increased mortality and major bleeding complications. Paradoxically, these high-risk patients were less likely to receive invasive treatments, highlighting a critical gap in care.

Background: Atrial fibrillation (AF) is frequently observed in cancer patients, driven by mutual comorbidities and increasing the risk of thromboembolic events. Impediments can hinder the utilization of anticoagulants among patients with malignancy—drug interactions with chemotherapy, renal dysfunction, drug intolerance, and increased bleeding risk. Left atrial appendage occlusion (LAAO) is an effective and safe non-pharmacological approach to prevent thromboembolic complications when anticoagulants are not suitable. Cancer patients were generally excluded from the original LAAO trials, and current safety and efficacy in cancer patients remain uncertain. Methods: This retrospective study utilized the National Inpatient Sample (NIS) database to analyze in-hospital outcomes of LAAO in US patients with and without cancer between 2016 and 2019. Patient demographics, comorbidities, procedures, and in-hospital outcomes were extracted using ICD-10-CM codes. Results: Among 12,273 hospitalizations for LAAO across the US representing an estimated 61,365 LAAO procedures, 2.2% (1365 cases) were performed in cancer patients. Older age, male gender, chronic kidney disease, prior stroke, and anemia were more prevalent in the cancer group, with 785 (58%) having a solid malignancy and 580 (42%) having a hematologic malignancy. Compared to non-cancer patients, cancer patients exhibited a higher rate of in-hospital complications (8.8% vs. 5.7%; p < 0.001), primarily driven by acute kidney injury (4.4% vs. 2.4%; p = 0.002), acute heart failure (3.7% vs. 2.6%; p = 0.012), and cardiac tamponade (1.5% vs. 0.8%; p = 0.006). No significant differences were observed in vascular complications, periprocedural stroke, or in-hospital mortality. Average length of stay (LOS) was longer in cancer patients (1.4 ± 2.7 days vs. 1.8 ± 2.5 days; p < 0.001). Conclusions: This nationwide study found that cancer patients undergoing LAAO had an increased rate of in-hospital complications, particularly acute kidney injury, heart failure, and tamponade, but no increase in in-hospital mortality was observed. Further research is needed to evaluate the long-term safety and efficacy of LAAO for managing embolic prevention in this complex patient population.