Canadian Journal of Cardiology最新文献

Background: High-risk pulmonary embolism (HR-PE) includes a heterogeneous population ranging from cardiac arrest to obstructive shock or hypotension, with high early mortality. While systemic thrombolysis (ST) remains the standard of care, its use is limited by contraindications and bleeding risk. Catheter-directed therapies (CDT) have emerged as alternatives, though data in HR-PE is limited. This study aimed to assess clinical characteristics, management, and outcomes across three HR-PE clinical phenotypes.

Methods: We analysed 137 consecutive HR-PE patients consulted by two Polish PERT centres. Based on presentation, patients were stratified into three groups: Cardiac Arrest, Shock, and Hypotension, according to the European Society of Cardiology HR-PE criteria. Reperfusion strategies included ST and CDT. The primary outcome was in-hospital mortality. Logistic regression was used to identify predictors of survival.

Results: In-hospital mortality differed significantly across phenotypes (Cardiac Arrest: 40.0%, Shock: 21.1%, Hypotension: 8.7%; p=0.01). CDT was associated with lower mortality than ST (6.7% vs. 41.1%, p<0.001), especially in the Shock (6.3% vs. 38.1%, p=0.009) and Hypotension groups (0% vs. 25.0%, p=0.04). CDT was also linked to fewer major bleeding events and lower therapy failure. Management at expert PE centre was associated with improved survival, particularly among Cardiac Arrest patients, while the use of CDT determined survival in HR-PE patients with Shock or Hypotension.

Conclusions: HR-PE presented phenotype-specific differences in prognosis and treatment response. Our findings support a phenotype-driven approach and timely referral to expert PE centres, where CDT may be a safer and more effective alternative to systemic thrombolysis particularly in non-Cardiac-Arrest PE patients.

Background: Pre-existing right bundle branch block (RBBB) is the leading predictor of permanent pacemaker implantation (PPI) following transcatheter aortic valve implantation (TAVI). The applicability of conventional PPI predictors in this high-risk subgroup remains unclear. This review evaluates PPI incidence and associated predictors in TAVI patients with pre-existing RBBB.

Methods: A systematic review of PubMed, Scopus, Embase, and Web of Science identified studies reporting PPI incidence and predictors in RBBB patients undergoing TAVI. Studies not addressing RBBB-specific factors were excluded. Pooled PPI incidence was calculated, and a qualitative narrative synthesis of predictors was performed.

Results: Of 2,269 identified references, 22 studies with 429,342 patients met inclusion criteria. Within the RBBB cohort, the mean age was 81.6 ± 7.4 years, with 64.2% male, and 23.7% having atrial fibrillation. Balloon-expandable valves were used in 69.8% of cases, and the transfemoral approach in 88.6%. The pooled PPI incidence was 37% across 17 studies. Substantial interstudy heterogeneity necessitated further analysis amongst 13 studies reporting consistent 30-day follow-up, which yielded 39% incidence. PPI predictors in the RBBB cohort encompassed demographic, anatomical, electrophysiological, and procedural domains.

Conclusion: Patients with baseline RBBB have significantly higher post-TAVI PPI rates. Identifying RBBB specific predictors could facilitate individualised procedural planning and risk stratification. This review reinforces how both traditional (e.g. implantation depth) and non-traditional (e.g. female sex, myocardial fibrosis, calcium volume and distribution) factors have an amplified role in predicting PPI risk, emphasising the need for further research in this subgroup to improve risk stratification and reduce PPI incidence.