BACKGROUND:Tricuspid regurgitation (TR) leads to systemic venous congestion and congestive hepatopathy, but conventional TR imaging parameters incompletely capture systemic consequences. Hepatic extracellular volume fraction (ECV) on cardiac magnetic resonance T1 mapping may reflect hepatic tissue remodeling and provide prognostic information beyond conventional risk markers. METHODS:Consecutive patients with moderate or greater TR who underwent cardiac magnetic resonance with hepatic T1 mapping were studied. Hepatic ECV was calculated using pre- and postcontrast T1 values and hematocrit. Patients were stratified by hepatic ECV tertiles. The primary end point was all-cause mortality. RESULTS:Among 234 patients (mean age, 65.6±15.8 years; 46.2% men), mean hepatic ECV was 37.7±9.0%, with tertile cutoffs at 32.5% and 41.3%. Higher hepatic ECV tertiles were associated with worse biventricular function and greater TR severity. Right ventricular ejection fraction decreased across tertiles (48.2% versus 48.5% versus 40.3%, P<0.001), while right ventricular end-diastolic volume index increased (107.4 versus 105.4 versus 127.4 mL/m², P<0.001). The prevalence of severe TR (regurgitant fraction ≥50%) increased from 10.9% (mean) across tertiles 1 and 2 to 29.5% in tertile 3 (P<0.001). During a mean follow-up of 2.2 years, 43 (18.4%) deaths occurred. Mortality increased across hepatic ECV tertiles: 12.8% versus 11.5% versus 30.8% (P=0.002 for trend). Kaplan-Meier analysis showed 3-year survival rates of 88%, 89%, and 57% across tertiles 1, 2, and 3, respectively. In multivariable Cox regression adjusting for age, right ventricular dysfunction, and severe TR, hepatic ECV tertiles remained independently predictive of mortality (hazard ratio, 1.62 [95% CI, 1.06-2.48]; P=0.027). Forward stepwise analysis yielded significant incremental prognostic value beyond traditional TR risk factors, improving model discrimination from χ²=24.4 to 30.1 (P=0.02). CONCLUSIONS:Hepatic ECV is a novel prognostic marker that provides incremental risk stratification in TR and has potential to impact therapeutic decision-making in the era of expanded treatment options for TR.

BACKGROUND:Right atrioventricular coupling index (RACI), defined as the ratio of right atrial (RA) to right ventricular (RV) end-diastolic volume on cardiac magnetic resonance, is a novel parameter that reflects RA-RV hemodynamic interplay. Its prognostic value in functional tricuspid regurgitation (TR) is unknown. METHODS:This study included 633 consecutive patients with moderate or greater functional TR undergoing cardiac magnetic resonance. Patients were stratified into 2 groups based on the optimal cutoff by the Youden index (normal: RACI<0.62 versus high: RACI≥0.62). The primary outcome was all-cause mortality. RESULTS:Patients with high RACI (n=147) were older (74.1±10.7 years versus 60.6±16.1 years, P<0.001) with larger RA volumes (RA end-systolic volume index: 96.7 [interquartile range, 77.5-121.2] mL/m2 versus 55.4 [interquartile range, 42.6-69.0] mL/m2; P<0.001), smaller RV size (RV end-diastolic volume index: 106.2±33.5 versus 114.8±37.2 mL/m2; P=0.012), and no difference in RV function (RV ejection fraction: 46.3±9.8% versus 45.4±12.7%; P=0.43). Over a median follow-up of 2.9 years (interquartile range, 0.7-6.9), a high RACI was associated with increased mortality risk (25% versus 15%; hazard ratio, 2.06 [95% CI, 1.47-2.90]; P<0.001). In multivariable Cox regression analysis adjusting for age, right and left heart size and function, and clinical markers of right-sided congestion (glomerular filtration rate <30, total bilirubin), RACI remained an independent predictor of all-cause mortality (adjusted hazard ratio, 1.16 per 0.10 increase, 95% CI, 1.03-1.32, P=0.014). In addition, RACI provided incremental prognostic value for predicting the primary outcome over conventional right heart indices (RA and RV volumes, RV ejection fraction, TR severity), improving model performance (χ2 increased from 28.5 to 37.6; P=0.003). CONCLUSIONS:RACI is a novel parameter that effectively integrates RA and RV remodeling, and independently predicts all-cause mortality in functional TR. Incorporating RACI into clinical assessment may help with improving risk stratification and guiding the timing of intervention in patients with functional TR.

OBJECTIVES:The SELUTION SLR 014 In-stent Restenosis (SELUTION4ISR) trial showed noninferiority of DCB for the outcome of target lesion failure (TLF) when compared with standard of care (80% DES and 20% POBA). It was notable that in the DCB vs DES subgroup analysis there was a numerically higher rate of TLF with DCB (15.3% vs 7.1%). The authors aimed to re-evaluate the outcomes of drug-eluting stent (DES), drug-coated balloon (DCB), or plain old balloon angioplasty (POBA) in patients with coronary in-stent restenosis (ISR). METHODS:The authors searched PubMed and EMBASE databases for randomized clinical trials (RCTs) that compared these 3 percutaneous revascularization strategies for ISR until March 15, 2026. Outcomes included major adverse cardiovascular events (MACE), target lesion revascularization, all-cause mortality, cardiovascular mortality, and stent thrombosis. RESULTS:From 19 RCTs that randomized 4238 patients with ISR at mean follow-up of 19.6 months, there was a significant reduction in MACE and TLR with both DCB (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.28; 95% CI, 0.16-0.49, respectively) and DES (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.22; 95% CI, 0.12-0.42, respectively) when compared with POBA. There were no significant differences in clinical outcomes between DCB and DES. CONCLUSIONS:In patients with ISR, DCB reduced MACE/TLR when compared with POBA. There were no clinical differences between DCB and DES even after inclusion of the SELUTION4ISR trial, thus suggesting that DCB are reasonable alternative to repeat stenting in patients presenting with ISR.

BACKGROUND:In patients with intermediate-risk pulmonary embolism (PE), there are limited tools to assess therapeutic response following catheter-based intervention. This study evaluates pulmonary vascular resistance (PVR), an invasive marker of right ventricular (RV) afterload, and its prognostic significance in acute PE. METHODS:This single-center retrospective study included patients from October 2020-May 2025 with intermediate-high risk PE undergoing large bore mechanical thrombectomy (LBMT) with pulmonary artery catheter-derived hemodynamic indices obtained pre- and post-procedure. The primary objective was to evaluate the effect of LBMT on PVR. Secondary objective was to evaluate the predictors of post procedure elevated PVR (defined as PVR >2 Wood units, WU) and its effect on clinical composite outcome (PE mortality, resuscitated cardiac arrest, hemodynamic instability and 90-day hospital readmission) and hospital length of stay (LOS). RESULTS:A total of 131 patients were included. Following LBMT, median PVR decreased significantly from 2.9 to 1.8 WU (p < 0.001), with greater reduction in patients with higher baseline PVR (baseline PVR tertile 3 to 1: 50% vs. 40% vs. 20%; p < 0.001). Persistently elevated post procedure PVR (>2 WU) was seen in 43.6% of patients. However, the incidence of post-procedure severe PVR >5 WU was extremely low (11.5% pre-procedure, 0.8% post-procedure). Multivariable predictors of elevated post-procedural PVR were pre-procedural mean pulmonary artery pressure (OR: 1.07, 95% CI 1.01-1.14, p = 0.026) and pre-procedural PVR (OR 2.20, 95% CI: 1.20-4.04, p = 0.011). In an age and sex adjusted model, elevated post-procedure PVR was associated with a longer in-hospital LOS of 4.2 days (95% CI: 0.60-7.88; p = 0.023) and a 4-fold higher risk of the composite outcome (20.7% vs 5.3%, adjusted hazard ratio: 4.02, 95% CI: 1.28-12.61, p = 0.017). CONCLUSIONS:In patients with intermediate-high risk PE, LBMT significantly reduced PVR and may be a valuable hemodynamic marker of disease severity and treatment response. Elevated post-procedural PVR identified patients at increased risk of adverse outcomes.

Background Right ventricular ejection fraction (RVEF) is a known predictor of adverse outcomes; however, its prognostic value diminishes in tricuspid regurgitation (TR). Objectives This study aims to assess whether effective right ventricular ejection fraction (eRVEF) offers a more physiologic assessment of RV function and improves risk stratification in patients with TR. Methods The derivation cohort comprised 453 consecutive patients with at least moderate functional TR (regurgitant fraction ≥30% or volume ≥30 mL) on cardiac magnetic resonance (CMR). eRVEF was calculated as the ratio of forward volume to RV end-diastolic volume. The eRVEF threshold (≤25%) was derived based on all-cause mortality data. Clinical data were collected from standardized questionnaires at the time of CMR and supplemented with electronic health records; the primary outcome was all-cause mortality. External validation was performed in 2 independent cohorts, totaling 316 patients using identical inclusion criteria. Results In the derivation cohort, impaired eRVEF was associated with more advanced biventricular remodeling, worse biventricular function, and greater burden of late gadolinium enhancement (P < 0.05 for all), which was paralleled by higher TR volume and fraction (both P < 0.05). Over a median follow-up period of 2.7 years (Q1-Q3: 0.6-6.6 years), 20% of the patients died; mortality was higher in patients with impaired versus preserved eRVEF (28% vs 12%; HR: 1.72 [95% CI: 1.16-2.54]; P = 0.007). After adjusting for known TR risk markers including age, RV size, TR severity, conventional RVEF, and clinical markers of right-sided congestion, eRVEF remained independently predictive of mortality (HR: 0.49 [95% CI: 0.24-0.97]; P = 0.042). Adding eRVEF to a model inclusive of RVEF improved mortality prediction (chi-square from 30.6 to 37.0; P = 0.011) whereas adding RVEF to eRVEF did not (chi-square from 35.4 to 37.0; P = 0.199). External validation confirmed the prognostic significance of eRVEF ≤25% in both cohorts (HR: 2.66-2.86; both P < 0.05). Conclusions eRVEF independently predicts mortality in TR and provides incremental prognostic value over conventional prognostic markers.

Clot-in-transit (CIT) is associated with high mortality, and optimal treatment strategies remain uncertain. This study compares the efficacy of catheter-based thrombectomy (CBT) with other treatments for CIT, including anticoagulation, systemic thrombolytic (ST) therapy, and surgical thrombectomy. We conducted a retrospective analysis of patients with CIT documented on echocardiography between January 2020 and May 2024, managed with urgent upfront CBT. We compared the all-cause mortality rates of the CBT cohort to performance goal rates for anticoagulation, ST, and surgical thrombectomy from a published meta-analysis. Our cohort included 26 patients who underwent CBT (mean age 59.3 +/- 17.9 years, 42.3% women, 57.7% Black). Compared to 463 patients from the meta-analysis receiving alternative treatments, the CBT group's short-term mortality was significantly lower (7.7% vs 32.4% for anticoagulation, 13.8% for ST, and 23.2% for surgical thrombectomy). CBT demonstrated noninferiority to anticoagulation (P < .001), ST (P = .031) and surgical thrombectomy (P < .001), and was superior to anticoagulation (P = .0056) and surgical thrombectomy (P = .036). This study suggests CBT is a promising treatment for CIT. Further prospective studies are warranted to validate these findings.

It is crucial to acknowledge that both percutaneous and surgical coronary revascularizations remain vital for treating acute coronary syndromes and angina with or without heart failure. However, the incremental efficacy of PCI (or for that matter CABG) over modern medical therapy in patients with stable CAD and HF, specifically to diminish the risk of death and heart failure hospitalizations, remains unconfirmed. Current guidelines only recommend surgical coronary revascularization to potentially improve mortality in HF for a select group of patients. The effectiveness of pretreatment evaluation of myocardial viability and hibernation in guiding treatment for myocardial revascularization remains inconclusive. Undoubtedly, additional trials are necessary to deliver more definitive answers on identifying patients who could benefit from coronary revascularization and determining the optimal approach to revascularization. Remarkably, as of 2024, the cardiology field still seeks clear answers to these critical questions, reflecting the complexities at the intersection of the discipline's most pressing challenges.

BACKGROUND:This study evaluates the prognostic utility of the RV/LV diameter ratio in predicting low cardiac index (CI) in patients with acute intermediate-risk PE. METHODS:We conducted a retrospective analysis of 112 patients with acute PE who underwent catheter-based therapies. The RV/LV diameter ratio was measured from standard axial views on computed tomography pulmonary angiogram (CTPA). Multivariable regression models were used to assess the relationship between the RV/LV diameter ratio and invasive hemodynamic parameters. RESULTS:A total of 63 patients (56.3 %) had a low CI (≤2.2 L/min/m2). The optimal cut-off for the RV/LV ratio to predict low cardiac index was 1.0 (area under the curve: 0.64). In a multivariable model, the RV/LV ratio (every 0.1 increase) was a significant predictor of low CI (OR: 1.11, 95 % CI 1.01-1.23, p = 0.03). Patients with a high RV/LV ratio (>1.0) had a lower pre-procedure cardiac index (2.0 [IQR 1.7, 2.6] vs 2.7 [IQR 2.4, 3.0] L/min/m2, p < 0.001), higher pre-procedure mPAP (34.0 [IQR 27.0, 41.0] mm Hg vs 28.0 [IQR 20.0, 35.0] mm Hg, p = 0.015), and were more likely to have a low cardiac index (65 % vs 3 %, p = 0.001). Every 0.1 increase in the ratio was associated with a 0.5 mm Hg increase in mPAP (p < 0.001) and a 0.05 L/min/m2 lower cardiac index (p = 0.002). The RV/LV ratio demonstrated moderate sensitivity (64.5 %) and high specificity (84.2 %) for predicting low cardiac index. CONCLUSION:The RV/LV diameter ratio offers real-time risk stratification and is a predictor of low cardiac index in patients with acute PE.

BACKGROUND:Right ventricular (RV) performance impacts clinical outcomes across pulmonary hypertension (PH), yet noninvasive tools for early detection and risk stratification are limited. Cardiac MRI (CMR) derived RV to left ventricular (LV) volume ratio (RV/LVvol ratio) provides a relative assessment of RV size by normalizing chamber size to the LV. However, its prognostic utility remains underexplored. In the present study, we investigate the association between the RV/LVvol ratio and outcomes in patients with PH. METHODS:This prospective study included patients with PH (pulmonary arterial systolic pressure > 35 mmHg by echocardiography or mean pulmonary artery pressure > 20 mmHg on invasive right heart catheterization), who underwent CMR. Abnormal RV/LVvol ratio cutoff (≥1.27) was applied and further tested using established gradation thresholds. The primary outcome was a composite of all-cause mortality and heart failure hospitalizations. RESULTS:Of 135 patients, 56 (41.5 %) had an abnormal RV/LVvol ratio. After a mean follow-up of 1.9 ± 1.3 years, 75 patients experienced the primary outcome. Patients with an abnormal RV/LVvol ratio had higher rates of the primary outcome (64.3 % vs 50.0 %, p = 0.02). After multivariable analysis adjusting for age and CMR indices, abnormal RV/LVvol ratio was independently associated with the primary outcome (HR 1.81 [95 % CI 1.06-2.97]; p = 0.003). RV/LVvol ratio added incremental prognostic value over age and traditional RV indices (global χ2 value increasing from 6.7 to 17.4, p = 0.006). CONCLUSIONS:The RV/LVvol ratio is a simple clinical tool associated with an increased risk of adverse outcomes in PH patients, offering prognostic information beyond traditional RV parameters.

BACKGROUND:Patients with intermediate-risk pulmonary embolism (PE) have outcomes worse than uncomplicated ST elevation myocardial infarction. Yet, no large-scale study has compared the outcomes of large-bore mechanical thrombectomy (LBMT) with anticoagulation alone (AC). The aim of this study was to compare the clinical outcomes among patients receiving LBMT vs AC alone. METHODS:This was a two-center retrospective study that included patients with intermediate-risk PE from October 2016 - October 2023 from the institution's Pulmonary Embolism Response Team (PERT) database. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest or hemodynamic decompensation. Inverse probability of treatment weighting (IPTW) was used to balance covariates; Kaplan Meir curves and IPTW multivariable Cox regression were used to assess the relationship between treatment groups and outcomes. RESULTS:Of the 273 patients included in the analysis, 192 (70 %) patients received AC alone and 81 (30 %) patients received LBMT and AC. A total of 30 (10.9 %) patients experienced the primary composite outcome over a median follow-up of 30 days. The primary composite outcome was significantly lower in the group that received LBMT compared to those on AC alone (1.2 % vs 15.1 %, log-rank p < 0.001; adjusted HR: 0.02; 95 % CI: 0.002-0.17, p < 0.001) driven by a lower rate of 30-day all-cause mortality (0 % vs 7.3 %, log-rank p = 0.01), resuscitated cardiac arrest (0 % vs 6.8 %, log-rank p = 0.016) and new or worsening hemodynamic instability (4 % vs 11.1 %, log-rank p = 0.007). CONCLUSION:In this largest cohort to date comparing LBMT versus AC alone in acute intermediate-risk PE, LBMT had a significantly lower rate of the primary composite outcome including a lower rate of all-cause mortality when compared to AC alone. Ongoing randomized trials will test these associations.

BACKGROUND:Tricuspid regurgitation (TR) is associated with right ventricular (RV) remodeling; however, conventional RV metrics may not fully reflect the interplay between the right and left ventricles. OBJECTIVES:The aim of the study was to examine the prognostic value of the right ventricular-to-left ventricular volume ratio (RV/LVvol) ratio in TR. METHODS:A retrospective analysis was conducted on 949 patients with ≥moderate TR who underwent cardiac magnetic resonance imaging between 2005 and 2024. The RV/LVvol ratio was assessed as a dichotomous variable (normal: <1.27, abnormal: ≥1.27) and by severity strata. Follow-up data, including all-cause mortality, were collected using the Social Security Death Index and electronic medical records. RESULTS:Of the 949 patients, 43.6% had an abnormal RV/LVvol ratio. Among 528 patients with a normal RV end-diastolic volume index, 178 (33.7%) had an abnormal RV/LVvol ratio. Over a mean follow-up of 4.8 ± 4.5 years, 236 patients died. An abnormal RV/LVvol ratio was independently associated with increased mortality after adjusting for covariates (adjusted HR: 1.47, 95% CI: 1.01 to 2.14, P = 0.043). Mortality risk increased with RV/LVvol ratio severity, with severe ratios conferring the highest risk (adjusted HR: 2.20, 95% CI: 1.31-4.76, P = 0.045). The RV/LVvol ratio provided significant incremental prognostic value over conventional RV indices, improving global chi-square from 24.7 (age/sex) to 47.1 with RV ejection fraction, 59.3 with RV end-diastolic volume index, and 68.3 with the addition of RV/LVvol ratio (P = 0.005). CONCLUSIONS:The RV/LVvol ratio is a strong predictor of mortality in advanced TR, capturing ventricular remodeling not identified by conventional metrics.

BACKGROUND:Among patients with intermediate-risk pulmonary embolism undergoing mechanical thrombectomy, the mean change in cardiac index (CI) is modest. We sought to identify variables associated with a hemodynamic super-response or a CI increase of ≥25% postthrombectomy. METHODS:This was a single-center retrospective study including patients with intermediate-risk pulmonary embolism undergoing mechanical thrombectomy with pulmonary artery catheter-derived hemodynamic indices obtained preprocedure and postprocedure. RESULTS:Overall, 105 intermediate-risk patients had complete hemodynamic profiles, with 41 patients (39%) classified as super-responders. Super-responders had a lower baseline CI (1.9±0.7 versus 2.3±0.6 L/min per m2). The mean change in CI postthrombectomy was 0.8±0.4 L/min per m2 among super-responders versus 0.1±0.4 L/min per m2 among non-super-responders. Several established indices of poor right ventricular function were associated with a significant increase in the CI in a univariable model. A left ventricular outflow tract velocity-time integral ≤15 cm, tricuspid annular plane systolic excursion/pulmonary artery systolic pressure ≤0.34 mm/mm Hg, and substantial inferior vena cava contrast reflux were associated with a hemodynamic super-response with an odds ratio of 16.19 (95% CI, 1.97-133.24,), 6.5 (95% CI, 2.13-19.83), and 2.53 (95% CI, 1.09-5.88), respectively. In a multivariable model, a preprocedure CI ≤2.2 L/min per m2 was associated with a hemodynamic super-response (odds ratio, 3.76 [95% CI, 1.09-13.0]). CONCLUSIONS:Patients with intermediate-risk pulmonary embolism with the more severe hemodynamic derangements had the greatest improvement in CI post thrombectomy. This group can be identified with commonly available noninvasive indices of right ventricular dysfunction.

Outcomes with isolated right ventricular assist devices (iRVAD) using pumps designed for the left ventricle are not well described. This study compares the clinical characteristics and outcomes of iRVAD patients to those patients treated with left ventricular assist device (LVAD) and biventricular assist devices (BiVAD). This study consisted of patients who received iRVAD from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) registry (2006-2017). The primary outcome was 2-year survival. Of 20,789 patients, 26 (0.13%) received iRVAD, 17 with pulsatile flow and 9 with continuous-flow devices. Device strategy was bridge to recovery/rescue therapy in 9 (35%), bridge to transplant/decision in 14 (52%), and destination therapy in 3 (12%). Twelve (46%) patients were INTERMACS profile 1, 5 patients (19%) required extracorporeal membrane oxygenation, and 13 (50%) needed mechanical ventilation. Two-year survival for patients with iRVAD (41.3%) was similar to BiVAD (45.2%) and significantly lower than LVAD (69.0%). In patients with isolated right-sided failure, long-term iRVAD support is feasible.

BACKGROUND: The aim of this study was to examine the impact of early versus delayed catheter-based therapies (CBTs) on clinical outcomes in patients with acute intermediate-risk pulmonary embolism (PE). METHODS: This retrospective cohort study analyzed data from 2 academic centers involving patients with intermediate-risk PE from January 2020 to January 2024. Patients were divided into early (<12 hours) and delayed CBT (≥12 hours) groups. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest, hemodynamic instability, and 90-day readmission. Secondary outcomes included a composite of 30-day mortality, resuscitated cardiac arrest, and hemodynamic instability. Inverse probability of treatment weighting was used to balance covariates. RESULTS: A total of 133 patients were included (mean age, 58.3 years; 44% women; 29% catheter-directed thrombolysis; 68% mechanical thrombectomy; and 3% both). The median time to intervention was 6.1 hours in the early group and 20.8 hours in the delayed group ( P <0.001). A total of 16 patients (12% of patients) experienced the primary composite outcome. Early CBT was associated with a significantly lower rate of the primary composite outcome (4% versus 18%; log-rank P <0.001; inverse probability of treatment weighting [hazard ratio, 0.13 (95% CI, 0.03–0.58); P =0.007]) and secondary composite outcome (0% versus 9%; log-rank P =0.02). The early CBT group also had lower intensive care unit (3.0 versus 3.4 days; P =0.01) and hospital length of stay (5.0 versus 6.1 days; P =0.046). When patients were stratified by timing of CBT (early/late) and the composite PE shock score (high ≥3; low <3), all 16 patients who experienced the primary composite outcome had a high composite PE shock score, with 14/16 (87.5%) having a high composite PE shock score and delayed intervention. CONCLUSIONS: Early CBT was associated with improved clinical outcomes in patients with acute intermediate-risk PE. The composite PE shock score may help identify patients who will benefit from early CBT. Further prospective studies are needed to validate these findings.

Therapeutic anticoagulation is the mainstay therapy in acute pulmonary embolism (PE), however, select patients benefit from emergent reperfusion to prevent or rescue acute right ventricular failure and haemodynamic collapse. Compared to other leading causes of cardiovascular mortality such as myocardial infarction and stroke, there is a substantial paucity of literature informing on advanced therapies in PE. Recent years have seen significant evolution in the armamentarium available for PE care with the uptake of several endovascular treatment modalities and increased use of mechanical circulatory support. While several ongoing randomised controlled trials may alter the therapeutic landscape and approach to PE management, at present, we are left with multiple selections with limited guidance. In this review, we discuss the latest therapeutic options available for acute PE and offer an approach to their implementation.