Open Heart最新文献

Background: Guidelines permit up to 360 J for synchronised biphasic electrical cardioversion (ECV) in atrial fibrillation (AF) lasting >48 hours. The CHESS randomised trial reported higher first-shock success with fixed 360 J versus a low-escalation 125-150-200 J sequence. Much of this evidence used adhesive pads without manual pressure and anterior-posterior positioning. We evaluated a 200 J-first, fixed-escalation biphasic ECV protocol delivered with a standardised technique in an emergency department (ED).

Methods: Single-centre retrospective observational study of consecutive adults undergoing elective ECV for symptomatic AF >48 hours (2019-2021). Procedures used hand-held paddles with firm chest pressure in the anterolateral (AL) position under deep sedation. The predefined sequence was 200→300→360 J if needed. The primary outcome was restoration of sinus rhythm (SR) documented on a 12-lead ECG within 120 min. Secondary outcomes were first shock success at 200 J, cumulative efficacy, SR to discharge without post-ECV antiarrhythmics, adverse events and subgroup efficacy. Results were contrasted descriptively with 360 J-first cohorts (CHESS).

Results: Of 451 ECV procedures identified, 374 were eligible. The primary outcome was achieved in 97.3% (364/374; 95% CI 95.5 to 98.7). First-shock success with 200 J was 88.0% (329/374; 95% CI 84.3 to 90.9). Escalation to 300 J and 360 J was required in 44 and 15 patients. SR was maintained to discharge in converted patients. Two minor adverse events occurred (2/374, 0.5%) and no serious adverse events were recorded.

Conclusions: A 200 J-first, fixed-escalation biphasic protocol with a standardised technique (manual paddles, firm pressure, AL placement) achieved high first-shock and excellent cumulative efficacy for AF>48 hours in real-world ED care without routine pharmacologic adjuncts. Findings support considering a 200 J-first approach and motivate pragmatic multicentre randomised controlled trials directly comparing 200 J-first versus 360 J-first under harmonised technique with objective safety endpoints.

Background: Persistent atrial fibrillation (AF) remains challenging to treat with catheter ablation. The left atrial posterior wall (PW) may represent an important non-pulmonary vein (PV) substrate; however, randomised trials have not demonstrated improved outcomes with adjunctive PW isolation (PWI), potentially reflecting technical limitations of thermal ablation rather than a lack of mechanistic relevance. Pulsed-field ablation (PFA) is a non-thermal ablation modality that selectively targets myocardial tissue and may enable safer and more consistent PWI. We compared real-world outcomes of PFA and radiofrequency ablation (RFA) for combined PV isolation and PWI in patients with persistent AF.

Methods: 200 consecutive patients (100 PFA and 100 RFA) undergoing combined PVI and PWI were retrospectively followed for up to 12 months. Baseline characteristics were broadly similar; however, PFA patients had lower left ventricular ejection fraction (LVEF) (43.5% (35.5-55.5%) vs 47% (40-58), p=0.01) and higher CHA₂DS₂-VA risk score (3 (2-4) vs 2 (1-3), p=0.01). Primary outcomes were acute procedural success and freedom from recurrent atrial tachyarrhythmia (AT) at 6 and 12 months.

Results: PFA achieved near-universal PWI compared with RFA (99% vs RFA: 65%, p<0.005), with shorter procedure duration (106 vs 143.5 min, p<0.005), reduced left atrial dwell time (62 vs 98 min, p<0.005), and faster time to PVI and PWI (all p<0.005). Major non-vascular complications were uncommon (1.5%) and similar between groups. At 12 months, freedom from recurrent AT was higher with PFA (70% vs RFA 54%, p=0.03), with lower odds of first detected AT recurrence in adjusted time-to-event analysis (OR 0.46 (0.26-0.82), p=0.009).

Conclusions: In this real-world cohort, PFA was associated with a higher rate of acute PWI and greater freedom from AT compared with RFA, without a signal of increased complications. Prospective randomised studies are needed to define the role of PWI delivered with PFA in patients with persistent AF, including those with reduced LVEF.

Background: International guidelines recommend percutaneous coronary intervention within 120 min for high-risk acute coronary syndrome. In Indonesia, a sprawling archipelago with a rising cardiovascular burden, the ministry of health is expanding catheterisation laboratory (cath lab) infrastructure. This study aims to evaluate the current distribution, population coverage and 'effective access' to cath labs to inform equitable infrastructure planning.

Methods: We conducted a cross-sectional geospatial analysis using a primary hospital survey (January-June 2024) to identify 335 functional cath labs. Travel times were estimated from the midpoints of all inhabited subdistricts (kecamatan) to the nearest facility using road network modelling. Primary outcomes included cath lab density per million population and the proportion of the population within successive 30 min travel thresholds. Secondary outcomes assessed 'effective coverage' by adjusting for National Health Insurance (BPJS) credentialing.

Results: Nationally, cath lab density is 1.23 per million population, with a median travel time of 54 min. While 73.0% of the total population can reach a facility within 120 min, stark disparities exist: 95% of urban residents have 2-hour access compared with 66.9% in rural areas. Regionally, Java (92.3%) and Bali (91.5%) show high coverage, while Papua and Maluku face critical gaps, with >80% of the population requiring more than 3 hours of travel. 46.3% of cath labs are covered by BPJS, and only 5.1% offer documented 24/7 service. When accounting for insurance status, national 2-hour coverage drops from 73.0% to 63.5%.

Conclusion: Although geographical access appears moderate at a national level, Indonesia's cardiovascular infrastructure is highly inequitable and operationally constrained. Many provinces meet density benchmarks but lack geographical coverage or financial/operational readiness. Beyond Indonesia, this approach offers a practical tool for other low- and middle-income countries to align scarce cardiac care resources with population need.

Background: Early graft failure within 90 postoperative days is the leading cause of mortality after heart transplantation. Existing risk scores, based on linear regression, often struggle to capture the complex, multifactorial biological interactions necessary for personalised donor-recipient matching. This study utilised explainable machine learning (ML) to identify robust predictors of 90-day graft failure and developed a clinically interpretable, ML-informed nomogram designed specifically for cross-population generalisability.

Methods: Using the UNOS registry (2008-2020; n=25 200), XGBoost/Random Forest models identified 90-day graft failure predictors from 32 donor-recipient variables. Explainable AI (SHapley Additive exPlanations) analysis revealed key predictors and their non-linear interactions, which were translated into a clinically applicable nomogram. External validation was performed on a large, single-centre Chinese cohort (Wuhan Union Hospital ; 2018-2023; n=563), assessing performance via area under the curve (AUC), calibration and decision curve analysis (DCA).

Findings: The final model incorporated eight predictors: recipient factors (prior cardiac surgery, age, bilirubin, body mass index (BMI)), donor factors (age, gender, BMI) and cold ischaemia time. The XGBoost-derived nomogram demonstrated consistent discrimination (AUC 0.67, 95% CI 0.64 to 0.70) and calibration. Patients stratified into the high-risk group (top quantile by nomogram score) had a 2.4-fold increased hazard of graft failure (HR 2.42, 95% CI 2.11 to 2.78). DCA confirmed the model's clinical utility across a wide range of risk thresholds (0.0-0.4). External validation in the Chinese cohort affirmed its generalisability (AUC 0.67).

Conclusion: This study introduces an ML-informed nomogram for 90-day graft failure, validated across USA and Chinese populations. By translating ML insights into a clinically interpretable tool using routinely available pretransplant variables, it bridges a key translational gap in transplant risk prediction. This tool can aid in optimising donor-recipient matching and personalising post-transplant management, with the potential to help address geographic disparities in heart transplant outcomes.

Background: To compare the efficacy and safety of off-label low-dose versus standard-dose antiplatelet agents in coronary heart disease (CHD) patients, focusing on the evidence gap in comparisons of low-dose versus standard-dose ticagrelor and prasugrel.

Methods: PubMed, Embase, the Cochrane Library, ClinicalTrials.gov, China National Knowledge Infrastructure and Wanfang databases were searched up to 11 May 2025 for randomised controlled trials. Study quality was assessed using the Cochrane Risk of Bias 2.0 tool. A meta-analysis was performed, with relative risk (RR) and 95% CI as the effect estimates. Subgroup analyses were performed stratified by antiplatelet agent type, ethnic region, treatment duration and CHD subtype.

Results: A total of 22 randomised controlled trials, involving 7486 patients, met the study criteria. Among them, 92.09% were Asian, and 63.63% of the included studies exclusively enrolled acute coronary syndrome patients. All patients received the dual antiplatelet therapy (aspirin combined with a low or standard dose of P2Y12 receptor antagonist), mainly with low-dose prasugrel and ticagrelor. Off-label low-dose antiplatelet agents significantly reduced myocardial infarction (MI) (RR 0.75, 95% CI 0.58 to 0.97) and minimal bleeding risks (RR 0.64, 95% CI 0.50 to 0.82) compared with standard doses, with comparable risks for other ischaemic and bleeding events. Compared with standard-dose clopidogrel, they significantly reduced MI risk (RR 0.71, 95% CI 0.54 to 0.93) but increased overall (RR 1.40, 95% CI 1.11 to 1.77) and minor bleeding risks (RR 1.86, 95% CI 1.02 to 3.38). Compared with standard-dose prasugrel or ticagrelor, they demonstrated comparable ischaemic risks and significantly reduced overall and minimal bleeding risks. All other subgroup analyses were consistent with the overall findings.

Conclusion: Off-label low-dose antiplatelet therapy reduces the risks of MI and minimal bleeding. It surpassed standard-dose clopidogrel and offered lower bleeding risks than prasugrel or ticagrelor, thus representing an effective secondary prevention strategy for Asian CHD.

Prospero registration number: CRD42023438376.

Background: Low socioeconomic status (SES) is linked to increased cardiovascular risk, but its association with carotid atherosclerosis in the general population is less well studied. We examined associations between individual-level and area-level SES and carotid plaque burden and explored potential sex differences.

Methods: In this cross-sectional analysis from the Akershus Cardiac Examination 1950 Study, individual-level SES was defined by educational attainment, and area-level SES by urban versus rural residence and median household income of municipality. Carotid ultrasound was used to quantify plaque burden with a plaque score (0-3 per segment; maximum 24), where >3 indicates elevated cardiovascular risk. Associations between SES and plaque score were estimated using Poisson regression in crude and adjusted models.

Results: We included 3673 participants (48.8% women; mean age 63.9 years). The prevalence of elevated plaque score (>3) was 23.3% in tertiary, 28.2% in secondary and 31.4% in primary education groups (p for trend <0.001). Women and men with primary education had 32% and 24% higher plaque scores than those with tertiary education (p<0.001). After adjustment for cardiovascular risk factors, excess atherosclerotic burden remained 22% in women and 12% in men (p<0.001). No significant associations were observed for area-level SES, and no sex interactions were detected.

Conclusion: Lower educational attainment is associated with higher carotid atherosclerotic burden in both sexes, independent of cardiovascular risk factors, while area-level SES shows no clear association. These findings suggest that educational disparities contribute to atherosclerotic disease burden and merit further investigation in longitudinal studies.

Introduction: Persistent atrial fibrillation (PersAF) presents a significant clinical and economic burden and is associated with poorer outcomes after catheter ablation compared with paroxysmal atrial fibrillation (AF). Pulsed field ablation (PFA) has emerged as a new form of energy modality for AF treatment. Sphere-9 is a novel dual-energy large-focal lattice tip (LFLT) catheter that is also capable of high-density mapping. The study aims to evaluate the cost-effectiveness of Sphere-9 catheter versus conventional radiofrequency (RF ablation for the treatment of PersAF in the English National Health Service (NHS) setting.

Methods: Individual patient data from the SPHERE Per-AF randomised controlled trial were used to estimate efficacy, safety and resource utilisation parameters in symptomatic PersAF patients. The cost-effectiveness model consisted of a hybrid decision tree (1-year time horizon) and a Markov model with 3-month cycle length (lifetime time horizon, 40 years) and was developed from the perspective of the English NHS. Unit costs were derived from the National Institute for Health and Care Excellence (NICE) clinical guideline for AF diagnosis and management (NG196) and NHS national cost collection data. Health benefits were expressed in quality-adjusted life years (QALYs), and all benefits and costs were discounted at 3.5% per year in line with NICE requirements.

Results: LFLT ablation was found to be dominant compared with RF, since it was less costly and it produced greater health outcomes. LFLT was associated with an average cost of £15 433 and 8.26 QALYs per patient, compared with £20 861 and 8.20 QALYs for RF ablation. Results remained robust across all sensitivity and scenario analyses.

Discussion: The Sphere-9 catheter is a cost-saving strategy for treating patients with PersAF compared with conventional RF ablation. Given the growing burden of AF and limited healthcare resources, Sphere-9 presents a valuable option for improving patient outcomes while optimising NHS resource allocation.

Background: Mechanical compression from the ascending aorta on the left atrial anterior wall (LAAW) can cause low voltage areas (LVAs), which are associated with a higher risk of atrial fibrillation (AF) recurrence after catheter ablation. This study investigates the AF recurrence rate post-LAAW complex fractionated atrial electrograms (CFAE) ablation or LAAW linear ablation in AF patients with aortic encroachment.

Methods: We retrospectively analysed AF patients who underwent first-time ablation between 2019 and 2023 in our department and had preablation cardiac CT scans. The impact of LAAW-LVAs and different LAAW ablation strategies on AF recurrence within 1-year postprocedure was evaluated.

Results: In total, 267 patients had both aortic encroachment and LAAW-LVAs. In the absence of LAAW ablation, patients with aortic encroachment had a significantly higher risk of AF recurrence compared with those without (adjusted HR (aHR): 2.29, 95% CI: 1.27 to 4.15, p=0.006). Patients receiving LAAW CFAE ablation had a higher recurrence rate than those receiving LAAW linear ablation (aHR: 3.29, 95% CI 1.42 to 7.63, p=0.006). Multivariable analysis identified that LAAW linear ablation was a strong independent predictor of reduced AF recurrence (HR: 0.13, 95% CI 0.06 to 0.28, p<0.001).

Conclusions: Aortic encroachment is a common and significant risk factor for AF recurrence after ablation. When LAAW-LVAs are present, performing LAAW linear ablation might be a highly effective strategy to reduce postablation AF recurrence.

Objective: Multidisciplinary team (MDT) meetings are central to treatment decisions in aortic stenosis (AS), particularly for borderline or high-risk patients. This study evaluates long-term, real-world outcomes according to MDT-selected management strategy within routine clinical practice in this clinically important patient group.

Methods: We conducted a retrospective cohort study of all patients with severe AS discussed at a transcatheter aortic valve implantation (TAVI) MDT at a tertiary UK centre between January 2014 and December 2016. Patients were categorised as TAVI or non-TAVI (conservatively managed). Demographic, clinical and frailty data were collected, including Charlson Comorbidity Index, Clinical Frailty Scale (CFS) and number of prescribed medications. Survival was analysed using Kaplan-Meier estimates and Cox proportional hazards modelling adjusted for age, sex, frailty, comorbidity burden and medication count.

Results: A total of 373 patients were included (TAVI=178; non-TAVI=195). Patients undergoing TAVI were younger (81.3 years vs 83.5 years; p=0.01) and less frail (CFS 3.9 vs 4.9; p<0.01). Survival at 1 year, 2 years and 5 years was significantly higher following TAVI (87.6%, 74.7%, 44.9%) compared with conservative management (60.8%, 44.2%, 12.1%; p<0.001). Median survival was 53 months after TAVI versus 20 months without intervention. On multivariable analysis, TAVI was independently associated with reduced mortality (HR 0.38, 95% CI 0.28 to 0.50; p<0.001).

Conclusions: In patients with severe AS discussed at MDT, TAVI was associated with a substantial and durable survival advantage compared with conservative management. These findings highlight the poor prognosis of untreated severe AS and support systematic inclusion of conservatively managed patients in interventional registries to better inform MDT deliberation and shared decision-making.

Aims: The obesity paradox has been described in different cardiovascular conditions. Data on the association between obesity and outcomes in patients with Takotsubo syndrome (TTS) are lacking. The aim of this study was to determine the relationship between body weight and mortality in TTS patients.

Methods: Patients enrolled in the International Takotsubo Registry from January 2011 to July 2021 and with available data on body mass index (BMI) were included in the analysis. Patients were stratified according to BMI (underweight, <18.5 kg/m²; normal weight, 18.5-24.9 kg/m²; overweight, 25.0-29.9 kg/m²; obese, 30.0-34.9 kg/m²; and very obese, ≥35.0 kg/m²). The primary endpoint was mortality at 1 year.

Results: Of the 2707 patients, 222 (8.2%) were underweight, 1340 (49.5%) of normal weight, 759 (28.0%) overweight, 268 (9.9%) obese and 118 (4.4%) very obese (p=0.02). Rates of mortality at 1 year were 11.3%, 6.9%, 5.5%, 4.9% and 9.3% in underweight, normal weight, overweight, obese and very obese patients (p=0.02). Being overweight or obese was significantly associated with a lower mortality rate at 1 year (HR 0.70, 95% CI 0.51 to 0.96, p=0.03), and this association remained significant after multivariable adjustments (adjusted HR 0.67, 95% CI 0.46 to 0.97, p=0.03).

Conclusion: A U-shaped mortality curve across BMI categories was observed in TTS patients, with the highest mortality rates observed in underweight and the lowest rates observed in obese patients. These observations provide the first evidence for the existence of the obesity paradox in TTS.

Trial registration number: NCT01947621.