Open Heart最新文献

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.

Background: There is a lack of contemporary data describing patients with left ventricular (LV) systolic dysfunction post myocardial infarction (MI) in terms of symptom burden and secondary prevention measures. The aim of this study was to describe patients with various degrees of LV systolic dysfunction after a first MI, their symptom burden, quality of life and adherence to recommended secondary prevention measures in a nationwide patient material.

Methods: Patients (n=49 564) registered in the Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease registry between 2011 and 2018, diagnosed with a first acute MI, discharged alive and with no previous heart failure, were stratified by degree of LV systolic dysfunction.

Results: Compared with patients with normal ejection fraction (EF≥50%), patients with a reduced EF (<30%) more often experienced shortness of breath (32.3% vs 5.6%, adjusted OR (95% CI): 7.45 (6.22 to 8.92)), had more often been readmitted (48.1% vs 31.2%, 1.87 (1.61 to 2.19)) and were more often on sick leave (26.6% vs 9.5%, 3.35 (2.45 to 4.58)), whereas there were no significant differences regarding chest pain and quality of life at the follow-up visit after 11-13 months. Patients with EF <30% had participated in education programme (44.9% vs 55.5%, 0.70 (0.60 to 0.81)) and physical therapy (11.3% vs 14.9%, 0.68 (0.58 to 0.79)) and have been physically active at least 30 min per day for at least 5 days per week (35.5% vs 40.2%, 0.86 (0.73 to 1.01)) to a lesser extent.

Conclusion: Contemporary representative data show that LV systolic dysfunction after MI is associated with a very high symptom burden and worse secondary prevention after 11-13 months.

Objectives: To evaluate if an intervention to improve health literacy, using the risk communication tool 'Your Heart Forecast' and informative e-mails, can lower patients' blood pressure (BP) and total cholesterol to high-density lipoprotein ratio (TC/HDL).

Design: A cluster randomised controlled trial.

Setting: The intervention took place in 17 Danish general practice clinics randomised to either control or intervention at clinic level after invitation of each 25 hypertensive patients by birthdate.

Participants: Men and women were eligible for inclusion if 35-75 years old, without prior cardiovascular disease (CVD). The final population consisted of 255 patients, 142 intervention and 113 control. The 146 men and 109 women were included between April 2019 and May 2021. The trial ended in March 2022.

Intervention: The intervention consisted of the CVD-risk communication tool 'Your Heart Forecast' at the annual BP consultations plus 1 monthly educational e-mail on lifestyle for 12 months. The control group received the usual care, defined as the annual CVD risk management consultation.Main outcome measures, BP and TC/HDL, were measured at baseline and follow-up after 10-18 months. Patients were divided into groups based on baseline levels and a paired t-test was performed on a pseudorandomised dataset by a blinded statistician.

Results: Both groups' most dysregulated patients decreased their BP (p<0.0001, p=0.0002), and the BP decrease in the intervention group was larger. Additionally, the intervention patients with moderately raised BP also decreased their BP significantly (p=0.0133). Both groups saw an increase in BP in the most well-regulated patients. TC/HDL decreased only for the intervention patients with the highest baseline levels (p<0.0001) and increased for all with the lowest ratio (p<0.0001).

Conclusion: The intervention lowered BP and TC/HDL in comparison to usual care for patients with dysregulated BP and/or TC/HDL above 4.

Trial registration number: NCT04058847; Clinicaltrials.gov, registered on 16 August 2019.

Background: The benefits of minimally invasive mitral valve surgery (MIMVS) compared with conventional approaches (CMVS, conventional mitral valve surgery) remain controversial. We conducted a systematic review and meta-analysis to evaluate the short-term benefits between these approaches.

Objective: To evaluate the short-term benefits of MIMVS versus CMVS in adults.

Methods: We searched PubMed/MEDLINE, EMBASE, Cochrane Library, LILACS, SciELO, clinical trial registries and grey literature using MeSH terms, without date or language restrictions. Randomised clinical trials (RCTs) comparing MIMVS and CMVS in adults (≥18 years) were included. Robotic, endovascular and redo procedures were excluded. Two reviewers independently extracted data following Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Risk of bias was assessed with the Cochrane tool, and certainty of evidence with Grading of Recommendations, Assessment, Development and Evaluation. Meta-analyses used random-effects models. Primary outcomes were mortality, acute kidney injury (AKI) and wound infection.

Results: Nine studies (1248 patients) from eight RCTs were included (686 CMVS, 562 MIMVS). MIMVS showed no significant difference in mortality or AKI compared with CMVS. There was a trend towards fewer wound infections (risk ratio=0.47; 95% CI=0.22 to 1.00) and shorter intensive care unit (ICU) stay (mean difference=-0.71 days; 95% CI=-1.47 to 0.04). MIMVS reduced reoperation for bleeding (RR=0.24; 95% CI=0.06 to 0.92) and hospital stay (mean difference=-1.83 days; 95% CI=-3.03 to -0.64). Operative times were longer with MIMVS, but without clinical impact. Stroke, myocardial infarction, mechanical ventilation time and transfusion rates were similar. Most studies had low risk of bias, with moderate to high certainty of evidence. No heterogeneity was detected for primary outcomes.

Conclusion: MIMVS enhances postoperative recovery through shorter hospital stays, fewer reoperations for bleeding and a trend towards fewer wound infections and shorter ICU stays compared with CMVS. Despite longer operative times, key safety is comparable between techniques. The overall certainty of evidence is high for most outcomes, supporting strong clinical recommendations in favour of MIMVS.

Prospero registration number: CRD42022321939.