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Background: Current guidelines for aortic valve replacement (AVR) lack consensus on prosthesis selection in middle-aged patients. This study aimed to provide a comprehensive comparison of long-term outcomes following AVR with mechanical versus biological prostheses among middle-aged patients in an Asian population.

Methods: This retrospective cohort study used Taiwan's national claims database, including patients aged 45-64 years who underwent AVR between 2006 and 2021 across 46 hospitals. Propensity score matching was applied to achieve covariate balance. Risks of all-cause mortality and major adverse prosthesis-related events (major bleeding, ischaemic stroke, aortic valve reoperation, endocarditis and sudden cardiac death) were compared using restricted mean survival time (RMST) and subdistribution HRs (sHRs) to account for competing risks. Subgroup analyses were performed for patients aged 45-54 and 55-64 years.

Results: A total of 1136 matched pairs of patients with biological or mechanical prostheses were included, with follow-up of up to 17 years. In the overall cohort, all-cause mortality did not significantly differ between prosthesis groups. However, patients with biological prostheses experienced fewer major adverse prosthesis-related events (10-year RMST difference: 0.68 years; 95% CI: 0.38 to 0.98; sHR: 0.69; 95% CI: 0.59 to 0.81). In age-stratified analyses, outcomes were comparable between types in patients aged 45-54, whereas biological prostheses were associated with similar survival but fewer adverse events in those aged 55-64.

Conclusions: Among middle-aged Asian patients undergoing AVR, biological and mechanical prostheses yield similar long-term survival, yet biological prostheses carry a lower risk of major adverse events, especially in those aged 55-64. Opting for biological prostheses at a younger age, potentially starting at age 55, may offer advantages in improving long-term outcomes.

Obesity is an independent driver of cardiovascular disease (CVD), mediated through adverse haemodynamic loading, insulin resistance, systemic inflammation, endothelial dysfunction and prothrombotic pathways. Contemporary obesity therapies show cardiovascular (CV) benefits beyond improvements in traditional risk factors. Across large CV outcome trials, glucagon-like peptide 1 receptor agonists consistently reduce three-point major adverse CV events (MACE) in patients with overweight, obesity and established CVD with and without diabetes. In obesity-related heart failure of preserved ejection fraction, semaglutide and tirzepatide improve symptoms and functional capacity and reduce worsening heart failure events, while effects on CV mortality remain uncertain. In contrast, evidence for metabolic bariatric surgery is dominated by large observational cohorts and meta-analyses, which are associated with durable weight loss and lower observed rates of MACE, heart failure and all-cause mortality compared with non-surgical care, though causal inference is constrained by residual confounding. Data support that sustained weight loss of at least 10% is more likely to translate into CVD event reduction, alongside other organ specific mechanisms that impact CV health independent from weight reduction. Obesity treatments offer a safe and effective method to lose weight with varying CV benefits, with current evidence still in early stages to establish robust clinical recommendations.

Background: QT interval prolongation is associated with incident stroke in the general population. Whether QT prolongation predicts recurrent stroke is unknown.

Methods: The Atrial Cardiopathy and Antithrombotic Drugs in Prevention After Cryptogenic Stroke trial was conducted in North America from 2018 to 2023 and randomised patients with cryptogenic stroke and atrial cardiopathy to apixaban versus aspirin to assess the prevention of recurrent strokes. In this secondary analysis, we excluded patients with missing ECG data and those with prolonged QRS (≥120 ms). The poststroke QT interval was corrected for heart rate (QTc) using a cohort-specific correction formula and the Framingham, Hodges, Bazett and Fridericia formulae. Multivariable Cox proportional hazards models were used to assess the association between QTc and recurrent stroke of any type.

Results: Among 881 included patients, 139 (15.8%) had a prolonged cohort-specific QTc. Over a mean of 1.8 years, 62 patients had recurrent strokes of any type (crude rate 7.0%, annualised rate 3.9% per year). After multivariable adjustment, prolongation of cohort-specific QTc was associated with decreased risk of recurrent stroke (HR (95% CI)=0.72 (0.54 to 0.95) per SD and 0.16 (0.04 to 0.64) for prolonged vs normal QTc). These findings were consistent across methods of QT interval correction. Accounting for the timing of baseline ECG, QRS duration, incident atrial fibrillation and the competing risk of death did not change the results.

Conclusions: Among patients with recent cryptogenic stroke and atrial cardiopathy, QTc prolongation was associated with a reduced risk of recurrent stroke. These findings contrast with the association observed between QTc prolongation and first stroke in the general population, which may reflect the unique characteristics of this selected population. If confirmed in broader populations, these findings suggest that electrocardiographic markers such as QTc may have distinct implications for risk stratification in terms of first versus recurrent stroke.

Trial registration number: NCT03192215.

Background: Recurrent mitral regurgitation (MR) remains a major limitation of mitral valve (MV) repair in patients with advanced degenerative MR (asDMR) and left ventricular (LV) enlargement. We investigated whether the disproportion between LV size and prosthetic annulus dimension predicts long-term MR recurrence and adverse LV remodelling after restrictive annuloplasty.

Methods: This retrospective study included 445 patients with asDMR (stages C2-D) who underwent MV repair with either the Medtronic CG Future or Edwards Physio II annuloplasty prosthesis between 2005 and 2019. The ratio of LV end-systolic diameter (LVESD) to prosthetic orifice area (POA) quantified LV-annulus mismatch. Recurrent MR (≥grade 2) was the primary endpoint, with death treated as a competing risk. The optimal LVESD/POA threshold was derived using maximally selected rank statistics. Propensity-score matching (1:1) adjusted for baseline differences and longitudinal LV changes were analysed by generalised least-squares modelling.

Results: During a median follow-up of 6.0 years, 15.5% of patients developed recurrent MR and 10.6% died. LVESD/POA was independently associated with recurrence (adjusted subdistribution HR 1.95, 95% CI 1.65 to 2.30; p<0.001). A threshold of 12.25 mm/cm² identified a 'mismatch' cohort with higher 5-year cumulative MR recurrence (30% vs 14%, p=0.02) and faster postoperative LV re-enlargement compared with the non-mismatch group. These findings were consistent after propensity matching. Mortality did not differ between groups.

Conclusions: In patients with asDMR, a larger LVESD-to-POA ratio identifies those at elevated risk of recurrent regurgitation and progressive LV remodelling after repair. Preoperative echocardiographic assessment of LV-annulus proportionality may help optimise prosthesis sizing and improve long-term durability of MV repair. Prospective multicentre validation is warranted.

Trial registration number: Chinese Clinical Trial Registry (ChiCTR2400088114).

Background: Coronary microvascular dysfunction (CMD) is associated with a poor prognosis but is difficult to diagnose non-invasively. In a recent paper, ST-segment depression on exercise-ECG was found to have a very high positive predictive value (PPV) for CMD in a highly selected group of patients.

Objectives: In the present study of chest pain patients, we used myocardial perfusion single photon emission CT (MPS) to rule out ischaemia due to epicardial coronary stenosis. In the remaining patients with suspected CMD, we studied the prognostic value of ex-ECG findings.

Methods: A single-centre observational study of 1021 consecutive patients examined with MPS and ex-ECG. Follow-up data were acquired from national registries. Major adverse cardiac events (MACE) were defined as cardiovascular death, myocardial infarction, unstable angina and unplanned revascularisation. A total of 113 patients were excluded due to inconclusive ex-ECG findings or missing data, and 148 due to ischaemia on MPS.

Results: In the final study cohort (n=760) with a mean age of 63 years and 55% female, ex-ECG was abnormal in 126 patients (17%). During a mean follow-up of 8.5 years, MACE occurred in 31 (25%) patients with abnormal ex-ECG and 103 (16%) patients with normal ex-ECG. The Kaplan-Meier curves for cumulative events separated significantly (log-rank p=0.01), but when adjusting for age, sex, comorbidities and exercise capacity, abnormal ex-ECG was no longer significantly associated with MACE (HR 1.1, CI 0.7 to 1.7, p=0.6). The prognostic PPV of an abnormal ex-ECG was only 25% (31/126) and this decreased to 17% (11/66) when excluding patients with known coronary artery disease (n=323).

Conclusions: In patients with suspected CMD, ischaemic ST-segment changes are of limited prognostic value, showing poor sensitivity and low PPV for the occurrence of MACE. However, reduced exercise capacity was an independent risk factor and, therefore, ex-ECG testing could be considered if a functional assessment of patients is warranted.

Background: Myeloperoxidase (MPO), a neutrophil-derived enzyme, is associated with oxidative stress and inflammation, which contribute to the pathophysiology of heart failure with preserved ejection fraction (HFpEF). Bioactive MPO causes vascular dysfunction and accumulation of serum uric acid (SUA). We investigated the association of plasma MPO and SUA with echocardiographic variables in a populational setting.

Methods: This was a cross-sectional analysis of the fourth visit of the STANISLAS cohort (N=1677 participants, age 49±14 years, 48% male), a population of initially healthy individuals. Participants were divided into four groups according to median plasma MPO and SUA levels. Adjusted linear regression models were used to assess the relationship of plasma MPO and SUA with echocardiographic markers.

Results: Participants with high MPO and high SUA were older, had more diabetes, a higher body mass index, lower estimated glomerular filtration rate and higher systolic blood pressure. In multivariable regression analyses, compared with patients with low MPO and low SUA, they had decreased left atrial reservoir strain (mean±SE=-1.43±0.62, p=0.022), decreased mitral annular e' velocity (mean±SE=-0.60±0.16, p<0.001) and more impaired left ventricular systolic global longitudinal strain (mean±SE=0.50±0.23, p=0.029). In contrast, high MPO with low SUA was not associated with impaired diastolic function.

Conclusions: In a population setting, high MPO and SUA, indicative of high bioactive MPO, were associated with early markers of diastolic dysfunction, suggesting a potential role of the MPO pathway in the early development of HFpEF.

Artificial intelligence (AI) is rapidly transforming cardiovascular imaging by automating tasks such as image segmentation, feature extraction, and risk prediction - leading to significant improvements in diagnostic precision and efficiency. However, the integration of AI into clinical workflows comes with critical risks that must be addressed to ensure safe and reliable patient care.This review explores the technical, clinical, and ethical challenges of AI in cardiovascular imaging, particularly highlighting the risks of model errors, data drift and inappropriate usage. We also examine concerns about explainability, the potential for deskilling of healthcare professionals, generalisability across diverse populations, and accountability in AI implementation.We present real-world examples of where these risks have been realised, along with attempts at mitigations, including the adoption of explainable AI techniques, rigorous validation frameworks to ensure fairness and broad applicability, continuous performance monitoring, and transparency at every stage of model development and deployment.The successful adoption of AI in cardiovascular imaging relies on striking a balance between innovation and the need for ethical and legal safeguards. Achieving this requires collaborative efforts between clinicians, data scientists, patients and regulators.Evaluating and addressing these challenges is essential for responsible AI implementation and advancing patient care while maintaining high safety standards.