Search Results (474)

Background/Objectives: Heart failure (HF) in patients with conventional right ventricular pacing with significant pacing percentages is still a subject of concern, and management of HF in this population has historically been difficult; however, novel HF pillar medications, such as SGLT2 inhibitors (SGLT2i) and angiotensin receptor/neprilysin inhibitors (ARNi), have fundamentally transformed contemporary pharmacological HF management. The aim of this study was to assess left ventricular (LV) function after current guideline-directed medical therapy (GDMT) in patients with chronic right ventricular (RV) pacing and HF. Methods: Patients with a lifetime ventricular pacing percentage > 20% (Vp > 20%) and HF diagnosed according to ESC guideline criteria were included. Device interrogation and transthoracic echocardiography (TTE), including assessment of left ventricular ejection fraction (LVEF) and mitral annular plane systolic excursion (MAPSE), were performed at GDMT initiation and during subsequent follow-up. Changes in LVEF and MAPSE were assessed overall and according to baseline HF phenotype. Multivariable linear regression analyses were performed to identify independent predictors of changes in LVEF and MAPSE. Results: Among 550 conventionally paced patients screened for HF, 127 (23.1%) met the inclusion criteria and underwent GDMT initiation. Mean age was 68.2 ± 12.1 years, and mean follow-up duration was 10.2 ± 6.3 months. Baseline LVEF and MAPSE were 48.7 ± 6.3% and 12.0 ± 2.4 mm, respectively. All patients received SGLT2i therapy, while 24 (18.9%) received ARNi. Overall, LVEF increased by 1.94 ± 2.47% and MAPSE by 0.84 ± 0.96 mm (both p < 0.001). Patients with HFrEF (n = 25) showed an increase in LVEF of 5.84 ± 2.53% and MAPSE of 1.72 ± 1.21 mm. In patients with HFmrEF, LVEF increased by 2.50 ± 1.54% and MAPSE by 0.83 ± 0.92 mm, whereas in HFpEF, LVEF increased by 0.67 ± 0.78% and MAPSE by 0.58 ± 0.71 mm. NYHA functional class improved by at least one class in 100 patients (78.7%). In multivariable analysis, ARNi use was independently associated with greater improvement in LVEF and MAPSE, while lower baseline LV function was associated with greater subsequent improvement. Conclusions: In patients with HF and chronic RV pacing, GDMT was associated with modest but statistically significant improvements in LV systolic function, assessed by LVEF and MAPSE, across the HF spectrum. The greatest improvements were observed in patients with HFrEF. However, given the observational design, absence of a control group, and universal use of SGLT2i, these findings do not establish a causal treatment effect or demonstrate superiority of any specific GDMT combination. Prospective controlled studies are warranted to determine the clinical significance of these changes and the independent contribution of individual therapies. Full article

Background/Objectives: This study evaluated automated magnetic resonance imaging (MRI) volumetry for characterizing structural brain changes in Alzheimer’s disease (AD), mild cognitive impairment (MCI), and cognitively healthy controls (HC), and examined its association with cognitive performance. Methods: This retrospective observational study included consecutively enrolled individuals aged ≥65 years. AD dementia and MCI were diagnosed according to the 2011 National Institute on Aging–Alzheimer’s Association (NIA-AA) clinical criteria. Automated volumetric analysis of structural MRI was used to obtain the total intracranial volume-normalized cortical and subcortical volumes, cerebrospinal fluid (CSF) compartments, and hemispheric asymmetry indices. Between-group comparisons were corrected using the Benjamini–Hochberg false discovery rate. Prespecified volumetric markers were evaluated using receiver operating characteristic analysis and internally validated logistic regression models. Results: The study included 102 participants (34 per group). Compared with HC, the AD group showed lower total cerebrum, right hippocampal, and anterior cingulate gyrus (ACgG) volumes and higher CSF volumes. Compared with MCI, the AD group exhibited lower thalamic and caudate volumes. CSF volume showed the highest individual discriminative performance for differentiating AD from HC (AUC = 0.837), whereas the combined hippocampal–ACgG–CSF model showed the best performance for differentiating MCI from HC (AUC = 0.826). After adjustment for diagnostic group, cognitive performance remained positively associated with hippocampal volume and negatively with CSF and lateral ventricular volumes. Conclusions: Automated MRI volumetry may support the quantitative assessment of neurodegeneration in clinically defined AD and MCI. Combined volumetric markers improved discrimination between MCI and HC, although these findings require external validation in larger, longitudinal, biomarker-characterized cohorts. Full article

Background: Coronary artery calcium score (CACS) is a well-established marker of coronary atherosclerotic burden and cardiovascular risk. While its association with left ventricular dysfunction has been extensively investigated, the relationship between CACS and right ventricular (RV) function remains insufficiently explored. This study aimed to evaluate the association between CACS and echocardiographic RV function parameters and to explore the discriminatory ability of CACS for identifying patients meeting predefined echocardiographic thresholds of RV dysfunction in patients with suspected stable coronary artery disease (CAD). Methods: This retrospective observational study included 96 patients who underwent coronary computed tomography angiography and transthoracic echocardiography within a 3-month interval. CACS was calculated using the Agatston method. RV function was assessed using tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV-FAC), and tissue Doppler-derived systolic velocity (S′). Correlation analyses, subgroup comparisons, multivariable linear regression, receiver operating characteristic (ROC) analyses, decision curve analysis (DCA), and calibration analyses were performed. Results: CACS demonstrated significant inverse correlations with TAPSE (r = −0.42, p < 0.001), RV-FAC (r = −0.36, p = 0.002), and S′ (r = −0.31, p = 0.006). Patients with higher CACS values exhibited progressively impaired RV systolic function. In multivariable regression analyses, higher CACS remained associated with lower TAPSE, RV-FAC, and S′ after adjustment for age, hypertension, and diabetes mellitus. Exploratory ROC analyses demonstrated moderate discriminatory performance, with AUC values ranging from 0.70 to 0.76. DCA suggested a potential net benefit across a range of threshold probabilities, while bootstrap calibration analysis demonstrated acceptable agreement between predicted and observed outcomes. Conclusions: In this retrospective single-center cohort, higher CACS values were associated with lower conventional echocardiographic measures of right ventricular systolic function. However, given the selected study population, relatively small sample size, limited clinical and instrumental characterization, potential residual confounding, and absence of external validation, these findings should be considered exploratory. The present data do not establish CACS as a clinical predictor of right ventricular dysfunction or support its use for clinical decision-making. Full article

Background: Right-to-left shunting through a patent foramen ovale (PFO) is an underrecognized yet potentially reversible cause of refractory hypoxemia, particularly in patients with right ventricular dysfunction. This case report describes heart-rate-dependent right-to-left shunting through a PFO causing refractory hypoxemia in a patient with inflammatory cardiomyopathy and severe right ventricular dysfunction, presumably arising from biventricular output mismatch. Case Presentation: We report the case of a 41-year-old male with inflammatory cardiomyopathy and a recently implanted single-chamber pacemaker (VVI mode, lower rate limit 50 bpm), admitted for decompensated heart failure. After initial clinical improvement with guideline-directed therapy, the patient’s intrinsic heart rate declined, and ventricular pacing at 50 bpm became the dominant rhythm. He subsequently developed refractory hypoxemia unresponsive to mechanical ventilation. Systematic hemodynamic assessment was performed using transthoracic echocardiography and thoracic electrical bioimpedance (TEB) monitoring at different pacing rates. Results: Echocardiographic evaluation revealed dynamic interatrial shunting through a PFO with the following characteristics: left-to-right at a pacing rate of 80 bpm and right-to-left at 50 bpm. Hemodynamic and echocardiographic data suggested that bradycardia induced biventricular output mismatch—left ventricular outflow tract velocity–time integral (VTI) increased by approximately 38% (from 17.5 cm to 24.1 cm), whereas right ventricular outflow tract VTI increased by only approximately 4% (13.3 cm vs. 13.8 cm). This mismatch likely resulted in relative elevation of right atrial pressure, thereby driving right-to-left shunting through the PFO. Increasing the pacing rate to 80 bpm reversed the shunt direction, normalized oxygenation, and facilitated successful extubation. Conclusions: This case suggests that in patients with severe right ventricular dysfunction, bradycardia may induce biventricular output mismatch with substantially greater left than right ventricular stroke volume augmentation, and presumably relative elevation of right atrial pressure, potentially leading to dynamic right-to-left shunting through a PFO. For such patients with unexplained hypoxemia, the possibility of dynamic PFO shunting should be considered. Appropriately increasing the pacing rate may help restore biventricular output matching, reverse shunt direction, and improve oxygenation; individualized heart rate management strategies warrant clinical consideration. Full article

Background: Atrial stiffness can be estimated non-invasively using speckle-tracking echocardiography (STE) and has recently emerged as an outcome predictor. We aimed to assess left atrial (LA) and right atrial (RA) phasic function; the LA stiffness index (LASI), the RA stiffness index (RASI) and their sum; and the biatrial stiffness index (BASI) in dilated cardiomyopathy (DCM), and to test whether combining the two atria adds prognostic information over either index alone. Methods: A total of 121 patients with non-ischaemic DCM in sinus rhythm were followed prospectively for a composite endpoint of all-cause death, non-fatal cardiac arrest, or hospitalisation for heart failure decompensation. LASI was defined as the mitral E/e′ ratio divided by LA reservoir strain, RASI as the tricuspid Et/e′t ratio divided by RA reservoir strain, and BASI as the sum of the two. Cox models were adjusted for NYHA class, LV ejection fraction (LVEF), maximal LA volume (LAVmax) and pulmonary artery systolic pressure (PASP). Results: After 19 ± 11 months, 55 patients reached the endpoint. LA reservoir and contraction strain, all three components of RA strain and all three stiffness indices were significantly impaired in patients with events. All stiffness indices were independent outcome predictors in multivariable Cox regression (HR 2.79 [95% CI, 1.35–5.75], p = 0.006 for LASI, HR 1.84 [95% CI, 1.02–3.29], p = 0.04 for RASI and HR 2.74 [95% CI, 1.36–5.51], p = 0.005 for BASI). BASI showed the greatest increase in risk prediction (Δ likelihood ratio χ² test = 10.3, p = 0.001) over NYHA class, left ventricular ejection fraction, LA maximal volume and pulmonary artery systolic pressure. BASI showed the highest discrimination (AUC = 0.73); however, it was not significantly better than LASI or RASI alone. Conclusions: Left and right atrial stiffness are both associated with adverse outcome in DCM and add prognostic information to an LV-centred risk model. Their unweighted sum performs at least as well as either component and offers a single parsimonious measure, whose incremental clinical value remains to be established in larger, externally validated cohorts. Full article

Background: Catheter ablation (CA) with pulmonary vein isolation is an established treatment for atrial fibrillation (AF). Epicardial adipose tissue (EAT) has been implicated in AF pathophysiology, but data on periatrial EAT and cardiac structural changes after CA in patients with heart failure with preserved ejection fraction (HFpEF) remain limited. Methods: We prospectively included 43 patients with paroxysmal AF and HFpEF undergoing radiofrequency CA. Cardiac magnetic resonance (CMR) was performed before ablation and after 6 months to quantify periatrial EAT volume and left ventricular mass (LVM) as prespecified primary endpoints, alongside secondary exploratory structural and functional parameters. Results: The study included 43 patients (74.4% male; mean age 60.5 ± 10.4 years). At 6-month follow-up, both primary endpoints improved significantly: periatrial EAT volume decreased from 28.8 ± 6.3 to 20.3 ± 5.9 mL (p < 0.001), and LVM decreased from 102 (95–115) to 97 (89–104) g/m² (p = 0.003). Exploratory analyses demonstrated favorable reverse cardiac remodeling, including reductions in left atrial area (LAA), left ventricular end-diastolic and end-systolic volumes, right ventricular end-systolic volume, and an increase in left ventricular stroke volume. Greater reduction in periatrial EAT volume correlated with more pronounced reverse cardiac remodeling, particularly with reductions in LVM (ρ = 0.48; p < 0.001) and LAA (ρ = 0.44; p = 0.003), with similar associations observed across other left ventricular remodeling parameters. Conclusions: In patients with paroxysmal AF and HFpEF, CA was associated with significant reductions in periatrial EAT volume and LVM, accompanied by favorable structural changes on CMR. These findings are consistent with reverse cardiac remodeling following CA and support further investigation of its structural effects in this patient population. Full article

Background: The increasing use of routine oncological imaging has led to more frequent detection of incidental pulmonary embolism (PE), potentially modifying the contemporary clinical presentation of cancer-associated pulmonary embolism (CAPE). Methods: We performed a retrospective cohort study including 381 consecutive patients hospitalized with acute PE, of whom 58 had active cancer and 323 had no active malignancy. The primary endpoint was a Severe Hemodynamic Presentation Composite Endpoint (SHPCE), defined as shock, systolic blood pressure < 90 mmHg, and/or high-risk PE according to European Society of Cardiology criteria. Clinical characteristics, severity markers, management strategies, and in-hospital outcomes were compared between patients with CAPE and non-cancer PE (NCPE). Multivariable logistic regression analyses were performed to evaluate factors associated with SHPCE and incidental PE. Results: The patients with CAPE had higher PESI (129.8 ± 29.3 vs. 110.1 ± 32.3; p < 0.001) and sPESI scores (3.03 ± 0.56 vs. 2.68 ± 0.81; p < 0.001), and lower hemoglobin levels (11.7 ± 1.9 vs. 13.2 ± 1.8 g/dL; p < 0.001). Incidental PE was more frequent in CAPE than NCPE cases (13.8% vs. 1.9%; OR 8.45, 95% CI 2.81–25.39; p < 0.001). Despite their higher baseline risk scores, patients with CAPE and NCPE showed similar rates of SHPCE (12.1% vs. 17.6%; p = 0.295), ICU admission (10.3% vs. 11.5%; p = 1.000), and in-hospital mortality (10.3% vs. 11.1%; p = 0.858). In multivariable analyses, right ventricular dysfunction (RVD) showed the strongest association with SHPCE (adjusted OR 10.21, 95% CI 5.34–19.52; p < 0.001), whereas active cancer was not associated with severe presentation. Conclusions: Active cancer was associated with higher clinical risk scores and a greater prevalence of incidental PE but not with increased hemodynamic severity or adverse in-hospital outcomes. Acute PE severity appeared to be more closely related to right ventricular involvement than to cancer status, supporting a severity-based rather than cancer-based approach to risk assessment. Full article

Background: Minimally invasive approaches for combined aortic valve and ascending aortic surgery remain challenging. We report a case of utilizing a transaxillary approach (TAX) in combination with the RAM^® system. Methods: A 65-year-old male presented with exertional angina and palpitations. He reported a one-year history of dizziness. Diagnostics revealed severe aortic regurgitation due to a calcified bicuspid aortic valve and an ascending aortic aneurysm measuring 57 × 54 mm. Left ventricular ejection fraction was reduced to 42%. Coronary artery disease was excluded. Surgery was performed via a right transaxillary mini-thoracotomy (3rd intercostal space) using endoscopic visualization. Cardiopulmonary bypass was established through femoral cannulation. After aortic cross-clamping and cardioplegic arrest, the bicuspid valve was excised and replaced with a bioprosthesis. A supracoronary ascending aortic replacement was performed using a Dacron graft. The RAM^® system was used for annular suturing and proximal anastomosis, with automated fastener fixation. Results: The patient was extubated on postoperative day 1 and transferred to intermediate care on day 2. Postoperative recovery was uneventful, with no neurological deficits, bleeding, or other complications. Discharge occurred on postoperative day 9 in stable condition. Conclusions: This case highlights the feasibility and safety of a minimally invasive transaxillary approach for combined aortic valve and ascending aortic replacement using the RAM^® system. This technique may expand the surgical armamentarium for complex aortic pathology while avoiding sternotomy. Further studies are required to evaluate reproducibility, long-term outcomes, and broader applicability. Full article

Background: Aortic insufficiency (AI) during long-term left ventricular assist device (LVAD) support creates a maladaptive recirculatory loop that impairs forward flow, increases left ventricular filling pressures, leading to progressive congestion, and accelerates right ventricular dysfunction. Surgical correction carries high risk, making transcatheter aortic valve implantation (TAVI) an alternative strategy, although outcomes are challenged by complex annular geometry and the absence of calcific anchoring. Methods: We performed a retrospective single-center analysis of consecutive LVAD-supported patients undergoing TAVI for native AI. Annular sizing was area-based with a predefined oversizing strategy of approximately 15–30%, adjusted to annular geometry. Balloon-expandable valves were implanted using controlled deployment under rapid pacing and temporary LVAD flow reduction. Outcomes were assessed according to VARC-3 definitions. Results: Fourteen patients underwent TAVI. The cohort demonstrated high anatomical complexity, including annular eccentricity (median 0.21 [IQR 0.19–0.23]), horizontal aorta (42.9%), and flared left ventricular outflow tract (LVOT) morphology (50%). Median annular area was 528 mm² (IQR 487–574), with area-derived diameter 25.9 mm (IQR 24.9–27.0). Mean oversizing was 21.9% (median 20.0%; range 15.1–30.3%). Technical and VARC-3 device success were achieved in 71.4%. Second valve implantation occurred in 28.6%. Procedural mortality was 0%. In-hospital mortality (21.4%) was related to low cardiac output and multi-organ dysfunction rather than device failure. No survivor had moderate or greater residual AI at discharge. Conclusions: In anatomically complex LVAD patients, an anatomy-driven balloon-expandable TAVI strategy achieved elimination of clinically significant AI with zero procedural mortality. In our interpretation, mortality reflected the advanced stage of heart failure at the time of intervention rather than acute device-related failure. Full article

Background/Objectives: Right ventricular dysfunction (RVD) is a major determinant of adverse outcomes in patients with acute pulmonary embolism (PE). Several laboratory-derived composite indices reflecting metabolic, inflammatory, thrombotic, and nutritional status have been proposed as prognostic markers in cardiovascular diseases; however, their relationship with imaging-defined RVD in acute PE remains insufficiently investigated. This study aimed to evaluate the association between metabolic, inflammatory, thrombotic, and nutritional indices and RVD in patients with acute PE. Methods: This retrospective observational cohort study included 270 patients with acute PE treated at a tertiary referral center between January 2024 and March 2026. Patients were categorized according to the presence or absence of RVD determined by echocardiographic and/or computed tomography pulmonary angiography criteria. The triglyceride–glucose (TyG) index, triglyceride/high-density lipoprotein cholesterol ratio (TG/HDL-C), blood urea nitrogen-to-albumin ratio (BAR), C-reactive protein-to-albumin ratio (CAR), lactate-to-albumin ratio (LAR), D-dimer-to-albumin ratio (DAR), fibrinogen-to-albumin ratio (FAR), and prognostic nutritional index (PNI) were calculated from admission laboratory data. Logistic regression, receiver operating characteristic (ROC), DeLong, and correlation analyses were performed. Results: Among the 270 patients, 118 (43.7%) had RVD and 152 (56.3%) did not. Patients with RVD demonstrated significantly higher thromboembolic burden, more severe imaging findings, and worse clinical outcomes. All investigated composite indices differed significantly between groups (all p < 0.001). In multivariable logistic regression analyses, TyG index (OR: 1.63, 95% CI: 1.01–2.63), BAR (OR: 1.15, 95% CI: 1.05–1.26), CAR (OR: 1.03, 95% CI: 1.01–1.06), LAR (OR: 2.04, 95% CI: 1.12–3.72), DAR (OR: 1.18, 95% CI: 1.04–1.34), and PNI (OR: 0.93, 95% CI: 0.88–0.98) remained independently associated with RVD. ROC analysis demonstrated that DAR yielded the numerically highest AUC (AUC: 0.858, 95% CI: 0.812–0.904), but was not statistically superior to CAR (AUC: 0.846), PNI (AUC: 0.837), and LAR (AUC: 0.823). Correlation analysis revealed that DAR exhibited the strongest association among the composite indices with both RV/LV ratio on computed tomography pulmonary angiography (r = 0.612, p < 0.001) and tricuspid annular plane systolic excursion (r = −0.551, p < 0.001). Conclusions: Several metabolic, inflammatory, thrombotic, and nutritional indices were associated with imaging-defined RVD in acute PE. DAR yielded the numerically highest AUC and the strongest correlations among the composite indices but was not statistically superior to CAR, PNI, or LAR. These exploratory findings do not establish incremental value beyond D-dimer, cardiac biomarkers, established risk scores, or imaging. Full article

Objective: This study aimed to assess the relationship between excess epicardial fat and the patterns of perioperative myocardial remodeling in patients undergoing surgical correction of mitral valve (MV) disease. Methods: A total of 148 patients with acquired non-infectious MV disease scheduled for surgical correction under cardiopulmonary bypass were screened in this prospective observational non-randomized study. Preoperative computed tomography (CT) of the heart was performed to assess epicardial adipose tissue (EAT) volume. Transthoracic echocardiography (Echo), including evaluation of left ventricular (LV) global longitudinal strain (GLS), right ventricular (RV) free-wall longitudinal strain, and RV systolic function (3D Echo), was conducted preoperatively, as well as postoperatively during one year after surgery. Analysis of postoperative myocardial remodeling and complications within one year after surgery was performed. Patients were divided into groups before surgical correction of MV based on the (1) EAT volume, associated with atrial fibrillation (AF) presence (EAT volume less than or > 115.1 cm³ by CT), and (2) EAT volume, associated with the presence of at least three metabolic factors (EAT volume less than or ≥100.6 cm³). Results: Prior to MV correction, Echo showed that patients with EAT volume > 115.1 cm³ exhibited larger left and right atrial (LA/RA) volumes and more pronounced RV systolic dysfunction. An EAT volume of >115.1 cm³ was associated with a 4.6-fold increase in the odds of detecting a preoperative TAPSE value < 1.7 cm (OR: 4.6 [95% CI: 1.2543; 16.7481]; p = 0.02). In the early postoperative period, patients with EAT volume > 115.1 cm³ exhibited larger RA dimensions and higher RV end-systolic volumes, as well as impaired RV–pulmonary artery coupling. At the one-year follow-up, patients with EAT volume > 115.1 cm³ exhibited larger indexed atrial volumes and basal RV dimensions. By the one-year follow-up, the group with EAT volume ≤ 115.1 cm³ was characterized by dynamic improvements, including a 10.7% increase in LV GLS (p = 0.02), a 33.6% reduction in the indexed LA volume (p = 0.004), a 28% reduction in the LV mass index (p = 0.003), and a 10.3% reduction in the LV end-diastolic dimension (p = 0.01). Furthermore, this group exhibited a 15% increase in LV stroke volume (p = 0.009), a 17.6% increase in TAPSE (p = 0.02), and a 6.5% increase in RV ejection fraction (p = 0.04) (3D Echo), none of which were observed in the group with EAT volume > 115.1 cm³. Patients with EAT volume ≥100.6 cm³ had more pronounced impairment of LV GLS before and one month after surgery compared with those with EAT < 100.6 cm³ (p = 0.046; p = 0.045). One month after surgery, worsening of RV GLS was observed specifically in the group with EAT ≥ 100.6 cm³ (p = 0.031). By the one-year follow-up, significant improvement in RV systolic function was observed only in the group with EAT volume < 100.6 cm³. Conclusions: The presence of excess epicardial fat (verified by cardiac CT) in cardiac surgery patients with acquired MV disease is associated with less favorable preoperative remodeling of both the left and right cardiac chambers and impaired reverse myocardial remodeling within one year post-surgery. Further studies in larger, independent cohorts are needed to confirm the prognostic and clinical relevance of the EAT cut-off in patients with mitral valve disease. Full article

Background and Objectives: Acute heart failure (AHF) has heterogeneous clinical profiles and considerable short-term mortality. Bedside evaluation of congestion and peripheral perfusion may help identify clinically relevant risk groups. This study aimed to evaluate the relationship between a non-invasive congestion–perfusion classification and in-hospital mortality in patients hospitalized with AHF and to explore the prognostic relevance of clinical, biological, and right-heart variables within the phenotypes. Materials and Methods: We performed an observational study that analyzed 790 patients hospitalized with AHF. Patients were classified at presentation into four predefined congestion–perfusion phenotypes: non-congested/preserved perfusion, congested/preserved perfusion, non-congested/impaired perfusion, and congested/impaired perfusion. Congestion was defined using pulmonary and systemic markers, whereas impaired perfusion was defined by the presence of at least two predefined criteria of hypoperfusion. Clinical, biological, and echocardiographic parameters were analyzed according to phenotype and in-hospital mortality. Discriminative performance was evaluated using ROC curve analysis, and logistic regression models were constructed within the congestive phenotypes to investigate the prognostic value of combined clinical and biological markers, with bootstrap internal validation in the combined models. Results: 78 patients died during hospitalization, with different rates across phenotypes; 2.9% in non-congested/preserved perfusion, 3.0% in non-congested/impaired perfusion, 8.0% in congested/preserved perfusion, and 19.5% in congested/impaired perfusion. In congestive phenotypes, several adverse markers were identified. Exploratory combined models demonstrated discriminatory performance in the congested/preserved perfusion phenotype (AUC 0.731) and in the congested/impaired perfusion phenotype (AUC 0.838); bootstrap optimism-corrected AUCs were 0.693 and 0.785, respectively. Right ventricular parameters were more strongly associated with mortality in the congested/impaired perfusion phenotype. LVEF showed limited discrimination within individual phenotypes. Conclusions: The highest in-hospital mortality was observed in the congestive/impaired perfusion phenotype, with a more adverse clinical, biological, and echocardiographic profile. Within the congestive phenotypes, exploratory prognostic marker patterns were partially overlapping, while LVEF showed limited discrimination. Full article

Background: Intermediate-risk acute pulmonary embolism (PE) is clinically heterogeneous, and early deterioration may occur despite initial normotension. The Endothelial Activation and Stress Index (EASIX) is a readily available laboratory index reflecting endothelial activation, cellular injury, renal-perfusion stress, and platelet-related thromboinflammatory burden. We investigated whether admission EASIX and echocardiographic right ventricular-pulmonary arterial (RV-PA) coupling assessed by the TAPSE/PASP ratio identify intermediate-risk PE patients at increased risk for an early adverse clinical outcome (EACO). Methods: This retrospective cohort study included 900 consecutive intermediate-risk acute PE patients admitted between 1 January 2020 and 10 June 2025. EASIX was calculated as LDH (U/L) × creatinine (mg/dL)/platelet count (10⁹/L). The primary endpoint was EACO within the first seven days after PE diagnosis during the index hospitalization, including hemodynamic decompensation, vasopressor/inotrope requirement, intensive care unit transfer, rescue reperfusion therapy, ventilatory support, cardiac arrest, or PE-related death. Hierarchical logistic regression, ROC analysis, calibration assessment, bootstrap internal validation, and 10-fold cross-validation were performed. Results: EACO occurred in 110 patients (12.2%). Patients with EACO had higher EASIX (2.28 [1.52–3.27] vs. 1.27 [0.86–2.00], p < 0.001) and lower TAPSE/PASP ratio (0.29 [0.23–0.36] vs. 0.42 [0.33–0.57], p < 0.001). log2-EASIX correlated inversely with TAPSE/PASP (Spearman rho = −0.30, p < 0.001). In the final combined model, log2-EASIX (OR 1.55 per doubling, 95% CI 1.14–2.10, p = 0.005) and TAPSE/PASP per 0.1-unit decrease (OR 1.36, 95% CI 1.10–1.68, p = 0.004) remained independently associated with EACO after adjustment for clinical variables, troponin, lactate, D-dimer, and C-reactive protein-to-albumin ratio. The final model showed higher discrimination than the clinical-laboratory model, although the absolute AUC increment was modest (AUC 0.920 vs. 0.904). Bootstrap optimism-corrected AUC was 0.910 and 10-fold cross-validated AUC was 0.904. Conclusions: Admission EASIX and impaired RV-PA coupling may provide complementary prognostic information for early risk stratification in intermediate-risk acute PE. Because this was a retrospective single-center study without external validation, these findings should be considered hypothesis-generating and should not be used as definitive treatment-escalation triggers before independent external validation. Full article

Background: Transradial access has become a preferred strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) because of lower access site complication rates and increasing feasibility for complex CTO techniques using large-bore slender or sheathless systems. However, long-term outcomes after successful transradial CTO recanalization and their predictors remain incompletely defined. We aimed to identify long-term clinical and procedural predictors of major adverse cerebrovascular and cardiac events (MACCEs) after successful transradial CTO PCI. Methods: We performed a prospective dual-center cohort study including 227 consecutive patients who underwent successful transradial CTO PCI at two high-volume catheterization laboratories with dedicated CTO programs. A total of 405 CTO PCI procedures were screened; all femoral access cases were excluded and only transradial cases were eligible. Baseline clinical characteristics, left ventricular ejection fraction (LVEF), lesion complexity including J-CTO score, coronary disease extent, and procedural variables were prospectively collected and/or verified from institutional databases. The primary endpoint was MACCEs, defined as a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization, and stroke/transient ischemic attack. Event rates were estimated using Kaplan–Meier methods. Predictors were explored using Cox proportional hazards regression with clinically relevant covariates and procedural characteristics entered into multivariable models. Results: Among 227 patients with successful transradial CTO recanalization and complete 5-year follow-up among survivors, cumulative MACCEs and all-cause mortality were 44.0% and 21.5%, respectively. In multivariable Cox analysis, prior myocardial infarction, right coronary artery target vessel, and a higher number of implanted stents were independently associated with increased MACCE risk, whereas previous PCI and preserved LVEF (≥40%) were associated with lower MACCE risk. For all-cause mortality, preserved LVEF was independently protective, while right coronary artery target vessel intervention was associated with increased mortality risk; severe chronic kidney disease showed a significant univariable association and remained a strong signal after multivariable adjustment. Conclusions: After successful transradial CTO PCI, long-term MACCEs appear to be driven primarily by baseline comorbidity and coronary disease burden. No deaths were related to access site bleeding, and vascular access was not associated with fatal complications. These findings contribute to personalized cardiovascular medicine by identifying readily available clinical, anatomical, and procedural factors that enable individualized long-term risk stratification following successful transradial CTO recanalization. Integrating these predictors into post-procedural assessment may support tailored secondary prevention, follow-up strategies, and patient management according to individual risk profiles. Full article

Background/Objectives: Severe mitral regurgitation (MR) is associated with chronic atrial stretch, chamber enlargement, pulmonary pressure elevation, and atrial fibrosis, yet the relationship between tissue inflammatory/profibrotic signaling, histologically quantified fibrosis, and echocardiographic remodeling remains incompletely characterized. This study aimed to compare biatrial tissue remodeling in patients with severe MR undergoing mitral valve surgery with a practical non-valvular surgical comparator group undergoing isolated coronary artery bypass grafting (CABG). Methods: This single-center, observational, cross-sectional comparative study included 36 elective cardiac-surgery patients: 22 with severe MR and 14 undergoing isolated CABG without significant valvular disease. Left- and right-atrial tissue samples were collected intraoperatively. IL-6, TNF-α, and TGF-β expression was assessed by quantitative real-time PCR using pooled atrial samples stratified by atrial side and study group, whereas atrial fibrosis was quantified histologically on individual tissue specimens using Masson’s trichrome staining and digital image analysis. Clinical, laboratory, and echocardiographic parameters were compared between groups, and exploratory associations were assessed with cautious interpretation. Results: Compared with the CABG comparator group, patients with severe MR showed a pooled molecular profile compatible with higher aggregate atrial expression of IL-6, TNF-α, and TGF-β; because qPCR was performed on pooled tissue preparations, these molecular findings were interpreted descriptively and were not used for patient-level inferential statistics. Histologically quantified fibrosis was significantly increased in severe MR in both the left atrium (29.69 ± 12.26% vs. 12.17 ± 4.56%, p < 0.0001) and the right atrium (25.25 ± 11.33% vs. 9.01 ± 4.46%, p < 0.0001). The MR group also showed more pronounced echocardiographic remodeling, including larger estimated left atrial volume, higher pulmonary artery systolic pressure, and greater right ventricular diameter. Exploratory individual-level analyses were restricted to histological fibrosis and echocardiographic variables. Conclusions: Severe MR was associated with marked echocardiographic remodeling and significantly greater histologically quantified biatrial fibrosis compared with a CABG surgical comparator group. Pooled qPCR findings support an aggregate inflammatory/profibrotic signal, but they should be interpreted descriptively because individual-level molecular variability could not be assessed. These findings are hypothesis-generating and do not establish causality. Full article