American Journal of Cardiology最新文献

Limited data exist on outcomes for patients with mitral stenosis (MS) who have previously undergone percutaneous mitral commissurotomy (PMC) and later require surgical mitral valve replacement (MVR). This study evaluates the impact of prior PMC on clinical outcomes in rheumatic MS patients undergoing surgical MVR. We retrospectively compared rheumatic MS patients with and without a history of PMC who underwent surgical MVR between 2010 and 2020. The primary outcome was 5-year all-cause mortality, while secondary outcomes included mitral reintervention, rehospitalization for heart failure (HHF), stroke/transient ischemic attack (TIA), and major bleeding over 5 years. Among 1,137 patients with rheumatic MS undergoing surgical MVR, 77 (6.8%) had a history of prior PMC. Compared with patients without prior PMC, patients with prior PMC were more often female and presented with a lower baseline mitral valve pressure gradient. No significant difference in 5-year mortality was observed between patients with and without prior PMC (20.5% vs 17.6%; log-rank p = 0.614). Multivariate analysis confirmed no association between prior PMC and mortality risk (HR: 1.42; 95% CI: 0.82-2.46; p = 0.212). Secondary outcomes of HHF and major bleeding were not different between the 2 groups, although rates of mitral reintervention and stroke/TIA were higher in the prior PMC group (3.9% vs 0.8%; p = 0.014 and 5.2% vs 0.9%; p = 0.002, respectively). In conclusion, in patients with rheumatic MS undergoing surgical MVR, prior PMC did not increase long-term mortality, indicating its safety as an initial treatment. However, the increased risk of mitral reintervention and stroke/TIA suggests the need for long-term monitoring.

Patients with atrial fibrillation and malignancy have increased risks of thromboembolism and bleeding. Evidence comparing apixaban and warfarin in this group remains limited. We aimed to compare effectiveness and safety of apixaban versus warfarin in patients with atrial fibrillation and active malignancy using real-world data from a large multinational cohort. This retrospective cohort study used the TriNetX Global Collaborative Network, de-identified records from 146 healthcare organizations between December 1, 2012, and May 1, 2025. Atrial fibrillation patients with malignancy receiving apixaban or warfarin were matched 1:1 using propensity scores across 74 clinical variables. Outcomes were assessed at 3 months, 6 months, 1 year, and 5 years. Primary endpoints included all-cause mortality, stroke, pulmonary embolism, deep vein thrombosis, gastrointestinal bleeding and intracranial hemorrhage. In this 12.5-year period, 41,764 matched pairs of patients were analyzed. Compared to the warfarin cohort, the apixaban cohort demonstrated lower all-cause mortality at 3 months (OR: 1.05, 95% CI: 1.00-1.10), 6 months (OR: 1.05, 95% CI: 1.01-1.09), 1 year (OR: 1.06, 95% CI: 1.03-1.10), and 5 years (OR: 1.17, 95% CI: 1.13-1.20; all p <0.05). Stroke rates were comparable between groups, while pulmonary embolism, deep vein thrombosis, gastrointestinal bleeding and intracranial hemorrhage were noted less frequent with apixaban. Kaplan-Meier analyses showed early and sustained differences in survival and bleeding outcomes. In conclusion, in atrial fibrillation patients with cancer, apixaban was associated with lower mortality and major bleeding without increasing stroke risk compared to warfarin.

A 63-year-old woman presented with fever, cough, and recurrent presyncope following a lower respiratory tract infection. Initial telemetry demonstrated intermittent complete atrioventricular block with ventricular premature complexes. Despite correction of electrolyte abnormalities and withdrawal of QT-prolonging medications (prescribed for cough), she developed repetitive episodes of polymorphic ventricular tachycardia triggered by R-on-T phenomena, requiring electrical cardioversion and suppression with overdrive pacing after magnesium and phenytoin proved ineffective. A nasopharyngeal bio fire panel identified Mycoplasma pneumoniae, prompting initiation of targeted antibiotic therapy along with propranolol. Cardiac magnetic resonance imaging demonstrated myocardial edema with biventricular dysfunction, consistent with acute myocarditis. With clinical stabilization, resolution of infection, and restoration of sinus rhythm following 2 weeks of antibiotic therapy, atrioventricular conduction improved; however, the QTc remained persistently prolonged on serial electrocardiograms. This persistent QT prolongation beyond the acute inflammatory phase prompted genetic testing, which revealed an autosomal dominant loss-of-function mutation in KCNH2, consistent with long QT syndrome type 2. Following further stabilization, a dual-chamber permanent pacemaker was implanted to prevent bradycardia-mediated arrhythmogenic triggers. The patient has remained free of recurrent ventricular arrhythmias at 1-year follow-up. In conclusion, this case illustrates a rare convergence of infectious, structural, and genetic substrates producing a potent arrhythmogenic milieu, in which Mycoplasma myocarditis unmasked an underlying severe long QT syndrome 2 (LQT2) phenotype and precipitated malignant polymorphic ventricular tachycardia.

Hospital-wide strategies improve outcomes in STEMI, yet their impact on patients with nonsystem delays (NSD) to primary PCI remains unknown. This study evaluated the effect of a 4-step comprehensive STEMI protocol (CSP) on outcomes in this high-risk population. This observational cohort analysis included STEMI patients with NSD as defined by the ACC National Cardiovascular Data Registry CathPCI Registry v5.0 criteria, which included difficult vascular access, difficulty crossing the culprit lesion, cardiac arrest and/or need for intubation before PCI, patient delays in providing consent for PCI, emergent placement of left-ventricular support device before PCI, and other reasons. Process and outcome metrics were compared before (January, 2011-July, 2014; n = 163) and after (July, 2014-July, 2019; n = 196) CSP implementation. The CSP comprised: (1) emergency department catheterization-laboratory activation; (2) STEMI Safe Handoff Checklist; (3) immediate transfer to an available laboratory; and (4) radial-first PCI. Among 359 patients with NSD, CSP implementation increased pre-PCI guideline-directed medical therapy (57.1%-79.6%, p <0.001) and radial access (16.6%-55.6%, p <0.001), and reduced median door-to-balloon time (132-101 minutes, p = 0.001). Post-CSP patients experienced lower rates of bleeding (22.7%-10.2%, p = 0.002), cardiac arrest (36.2%-23.5%, p = 0.01), circulatory shock (39.9%-24.5%, p = 0.003), and acute kidney injury (30.7%-19.9%, p = 0.03), with more frequent discharge to home (65.0%-78.6%, p = 0.006). In-hospital mortality was similar (14.1% vs 9.2%, p = 0.20). In conclusion, a 4-step CSP improved process and clinical outcomes among STEMI patients with NSD, challenging the notion that NSD are unmodifiable and underscoring the importance of system-based interventions in this high-risk cohort.

Transcatheter tricuspid valve replacement (TTVR) has shown therapeutic promise for patients with severe tricuspid regurgitation (TR). However, some patients may not be eligible due to anatomic limitations. We sought to describe the outcomes of patients who were referred for transcatheter tricuspid valve intervention (TTVI) and were ineligible for TTVR. This was a single-center, retrospective study of 251 patients referred for TTVI from February 2024 to August 2025. All patients were considered by a multidisciplinary heart team and assessed for feasibility of commercial tricuspid valve repair or replacement, with a strategy to proceed with replacement if anatomically feasible. Data on demographics, clinical characteristics, and outcomes were collected from medical records. Of 251 patients evaluated, 43 (17.1%) were unsuitable for TTVR. Compared with suitable patients, unsuitable patients were more frequently male (67.4% vs 33.2%, p <0.01) and more likely to have implanted electronic device (53.5% vs 32.2%, p = 0.01) or prior tricuspid interventions (7.9% vs 1.6%, p = 0.03). The leading reason for unsuitability was large annular dimensions (60.5%), followed by leaflet tethering (14.0%) and small annular size (11.6%). Of the unsuitable cohort, 10 patients (23.3%) underwent T-TEER and 33 (76.7%) received medical therapy alone. T-TEER resulted in significant reduction in TR severity (p = 0.034), though 80% had residual moderate or greater TR. In conclusion, this commercial experience, rates of TTVR ineligibility were lower than previously described with large annular dimensions serving as the most frequent exclusion criterion. For those ineligible, T-TEER may provide a feasible approach in appropriately selected patients.

Cardiovascular disease (CVD) remains a leading cause of maternal mortality in the United States, comprising 26.5% of pregnancy-related deaths. We sought to evaluate trends in CVD during pregnancy and maternal, obstetric, and fetal outcomes in pregnant women with CVD in the Kaiser Permanente Northern California (KPNC) integrated healthcare system. This retrospective cohort study included adult KPNC members with moderate or greater valvular heart disease, cardiomyopathy, congenital heart disease, or ischemic heart disease during pregnancy from 2010 to 2021. Bivariate analyses and multivariable logistic regression were used to evaluate associations between demographic and clinical risk factors and maternal outcomes in pregnant patients with CVD. Of 320,902 pregnancies, 763 (0.24%) were identified with clinically significant CVD. The prevalence of CVD increased from 0.19% to 0.34% over the decade, predominantly due to an increase in prevalence of women with congenital heart disease. Mean gestational age at delivery was 36.7 weeks with 19.5% experiencing preterm delivery. Cesarean section, pre-eclampsia or eclampsia, and postpartum hemorrhage rates were 29.5%, 20.8%, and 9.7%, respectively. Fetal loss beyond the first trimester occurred in 7.1% pregnancies. Adverse maternal cardiac outcomes occurred in 55 (7.2%) of patients, predominantly driven by congestive heart failure hospitalizations. There were 4 deaths (0.5%) during pregnancy or within 1 year postpartum. Pre-existing CVD (aOR 0.20, p = 0.002) and cardiac medication use (aOR 4.13, p <0.001) were significant predictors of adverse maternal outcomes. Higher left ventricular ejection fraction (aOR 0.95, p = 0.018) was associated with lower odds of adverse maternal outcomes. In conclusion, understanding risk factors for adverse pregnancy outcomes in a diverse, contemporary population of patients with CVD can help refine cardio-obstetric risk assessment and preconception counseling.

Thrombolytic therapy (TT) using low-dose, slow, and ultra-slow infusions of tissue-type plasminogen activator (tPA) has become an established first-line treatment for prosthetic valve thrombosis (PVT). However, PVT with stuck valves represents a distinct clinical entity requiring tailored management. This study aimed to evaluate the effectiveness and safety of sequentially combining different TT regimens in patients with PVT and stuck valves. We enrolled 52 patients with PVT and stuck valves [female: 34 (65.4%), mean age: 47.5 ± 12.4 years] who underwent TT with sequential administration of slow (25 mg/6 h) and ultra-slow (25 mg/25 h) low-dose tPA regimens, based primarily on New York Heart Association (NYHA) functional class. All patients were assessed with cinefluoroscopy, transthoracic echocardiography, and transesophageal echocardiography. TT was successful in 46 patients (88.4%), with a median cumulative tPA dose of 120 mg (96-175). Major complications occurred in 3 patients (5.7%), including 1 cerebrovascular accident, 1 intracranial hemorrhage, and 1 gastrointestinal bleed requiring transfusion, while 6 patients (11.5%) experienced minor complications. One in-hospital death occurred (1.9%). Increased thrombus area was the only independent predictor of both failed TT and adverse events. A moderate positive correlation was observed between thrombus area and total tPA dose (r = 0.479; p < 0.001). In conclusion sequential use of slow and ultra-slow low-dose tPA infusion appears to be a safe and effective strategy for managing PVT with stuck valves. Nevertheless, patients with larger thrombus burden remain at increased risk for treatment failure and complications.