Transit-time flow measurement (TTFM) is used during coronary artery bypass grafting (CABG), but outcome-linked thresholds for low left internal mammary artery-left anterior descending artery (LIMA-LAD) mean graft flow (MGF) and preoperative low-flow predictors remain limited. This single-center retrospective study included 282 patients undergoing elective off-pump CABG with LIMA-LAD grafting. Restricted cubic spline and segmented regression examined the association between MGF and peak high-sensitivity cardiac troponin I (hs-cTnI) within 48 hours, and logistic regression evaluated associations with in-hospital major adverse cardiac and cerebrovascular events (MACCE) and developed a preoperative low-flow prediction model. LIMA-LAD MGF showed a nonlinear association with peak hs-cTnI, with an inflection point at 31 mL/min. Flow <31 mL/min was associated with higher hs-cTnI levels and higher adjusted in-hospital MACCE risk in the main model (34 events; adjusted odds ratio [OR] 2.53, 95% confidence interval [CI] 1.21-5.44; P = 0.014). In a sensitivity model additionally adjusted for obtuse marginal/left circumflex-territory grafting, the association was attenuated but remained directionally consistent (OR 2.10, 95% CI 0.99-4.46; P = 0.053). Higher LAD quantitative flow ratio (QFR) and smaller distal vessel diameter independently predicted low flow. In conclusion, a LIMA-LAD MGF threshold of 31 mL/min was associated with greater perioperative myocardial injury and higher in-hospital event risk, and a QFR-based model may support perioperative risk stratification pending external validation with standardized 30-day outcomes.

New-onset atrial fibrillation (AF) is common among acutely hospitalized patients and is associated with increased risks of stroke and mortality. However, anticoagulation in this setting involves a temporal tradeoff between early bleeding during recovery and potential long-term stroke prevention, and data guiding direct oral anticoagulant (DOAC) initiation at discharge remain limited. We conducted a retrospective cohort study of adults with newly diagnosed AF identified between 3 days before hospital admission and hospital discharge within the Baylor Scott & White Health system (July 2020-June 2024), comparing patients initiated on DOAC therapy at discharge with those who were not. Outcomes included major adverse cardiovascular events (MACE: all-cause death, non-fatal myocardial infarction, or ischemic stroke/transient ischemic attack) and net adverse clinical events (NACE: MACE or major bleeding) at 30 days and 3 years. Cox proportional hazards models were used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs), and landmark cumulative incidence analyses assessed temporal trends after discharge. Among 16,641 patients (mean age 75.1 years; 41.8% women), 7,181 (43.2%) were discharged on a DOAC. In adjusted analyses, DOAC use was associated with lower risk of 3-year MACE (HR 0.61; 95% CI 0.58-0.65; p<0.001) and NACE (HR 0.64; 95% CI 0.61-0.68; p<0.001) compared with those not receiving DOAC therapy. Landmark analyses showed consistent reductions in MACE at both 30 days (HR 0.61; 95% CI 0.57-0.65) and 3 years (HR 0.68; 95% CI 0.62-0.74). Patients treated with DOACs had a lower risk of NACE at both 30 days (HR 0.65; 95% CI 0.61-0.69) and 3 years (HR 0.67; 95% CI 0.62-0.73). Overall, DOAC initiation at discharge in patients with newly diagnosed AF identified between 3 days before hospital admission and hospital discharge was associated with lower early and long-term ischemic risk, with lower rates of both MACE and NACE observed at 30 days and 3 years, underscoring the need for individualized decision-making regarding anticoagulation during acute hospitalization.

Low-flow states are associated with adverse outcomes in AS, but the prognostic value of Transvalvular Flow Rate (TFR) has not been consistently established across studies. This study is a systematic review and meta-analysis of reconstructed time-to-event data was performed in accordance with PRISMA. PubMed/MEDLINE, EMBASE, and Cochrane Library were searched for studies (published by November 14, 2025) comparing low versus normal TFR in AS. Data were collected from Kaplan-Meier curves. The primary endpoint was all-cause mortality. Survival was assessed using pooled Kaplan-Meier curves, Cox regression, flexible parametric survival models, and restricted mean survival time (RMST) analysis. A total of nine studies including 6,494 patients were analyzed; 2,575 (39.7%) had low TFR. At 8 years of follow-up, estimated survival was 34.1% (95% CI: 24.7%-47.0%) in the low-TFR group and 63.0% (95% CI: 58.9%-67.4%) in the normal-TFR group. Low TFR was associated with higher all-cause mortality (HR 1.59; 95%CI 1.45-1.74; P<0.001). We observed a progressively greater hazard over time, with the HR approaching 1.9 by 8 years. At 8 years, RMST in the normal-TFR group was 7.37 years (95% CI: 7.21-7.53 years) versus 5.07 years (95%CI 4.91-5.23 years) in the low-TFR group, representing a lifetime loss of 2.3 years in the low TFR group (ΔRMST -2.30 years; 95%CI -2.53 to -2.07 years; P<0.001). In patients with AS, low TFR is associated with significantly higher mortality and lifetime loss. These findings support TFR as a clinically meaningful marker for risk stratification in AS.

Bleeding events have been reported as a complication of percutaneous left ventricular assist devices (pLVAD). While chronic kidney disease (CKD) independently increases bleeding risk, the impact of worsening CKD stages on bleeding outcomes following pLVAD implantation remains poorly characterized. Therefore, we sought to evaluate the impact of CKD severity gradient on major bleeding and in-hospital mortality among adults undergoing pLVAD implantation. The National Inpatient Sample was queried from 2016 to 2021. Adults undergoing pLVAD implantation were stratified into six cohorts: no CKD, CKD stages 1-2, stage 3, stage 4, stage 5, and end-stage renal disease (ESRD). Multivariable logistic regression was used to estimate adjusted odds ratios (aORs) of major bleeding, in-hospital mortality, and secondary outcomes. A cohort of 130,620 pLVAD hospitalizations was identified, of which 72.9% had no CKD, 2.0% had CKD stages 1-2, 14.1% had CKD stage 3, 3.0% had CKD stage 4, 0.4% had CKD stage 5, and 7.6% had ESRD. Following adjustment, CKD stages 1-5 showed no significant association with major bleeding. In contrast, ESRD was independently associated with increased odds of mortality (aOR 1.25; 95% CI 1.63-2.25, p <0.001), major bleeding (aOR, 1.45; 95% CI 1.23-1.65; p <0.001) and specific bleeding types including gastrointestinal bleeding (aOR 1.92; 95% CI 1.63-2.25) and intra-abdominal bleeding (aOR 1.81; 95% CI 1.18-2.78). In conclusion, ESRD represents a high-risk phenotype characterized by significantly increased major bleeding and in-hospital mortality. Major bleeding is driven by site-specific hemorrhage, including gastrointestinal, intra-abdominal, and pericardial bleeding. Risk stratification and targeted anticoagulation strategies are necessary for this vulnerable population.

Coronary artery disease is common in patients undergoing transcatheter aortic valve implantation (TAVI), but the optimal pre-procedural coronary assessment strategy is uncertain. We compared long-term outcomes of a computed tomography angiography (CTA)-first versus an invasive coronary angiography (ICA)-first strategy in 307 consecutive patients undergoing TAVI at a single center (ICA-first, n=150; CTA-first, n=157). The primary outcome was all-cause mortality. Over a median follow-up of 61.7 months, mortality did not differ between strategies (unadjusted HR 0.88, 95% CI 0.66-1.16), and assessment strategy was not an independent predictor of death after adjustment (HR 0.95, 95% CI 0.67-1.34). A CTA-first strategy avoided invasive angiography in 73% of patients, with a non-significant trend toward more late post-TAVI catheterization (HR 2.47, 95% CI 0.94-6.45). Pre-TAVI percutaneous coronary intervention was not associated with lower mortality, although coronary artery disease itself identified a higher-risk phenotype. In conclusion, a CTA-first strategy yielded equivalent long-term survival while sparing most patients invasive angiography, supporting its use as the default pre-TAVI coronary assessment strategy.

The impact of chronic kidney disease (CKD) stage on outcomes after percutaneous coronary intervention (PCI) for left main (LM) coronary artery disease remains unclear. We investigated the impact of CKD stage on long-term outcomes after contemporary LM-PCI. We analyzed 756 consecutive patients who underwent LM-PCI for de novo lesion under intracoronary imaging-guidance across 19 hospitals. Patients were categorized by CKD stage: I/II (n=360), IIIa (n=212), IIIb (n=105), IV (n=40), and V (n=39). Three-year major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, clinically driven revascularization, myocardial infarction, and cerebrovascular events, were evaluated. Patients with CKD stage IIIb or worse had higher comorbidity burdens than those with CKD I/II, including high age, hypertension, peripheral artery disease, and reduced left ventricular ejection fraction. Patients with CKD-IIIb and -IV presented more acute coronary syndrome and required mechanical circulatory support, whereas these frequencies in CKD-V were similar as in CKD-I/II. In contrast, CKD V patients exhibited greater lesion complexity, with more true bifurcation lesion and calcified lesions needing atherectomy. MACCE rates were significantly higher in CKD IV and V (CKD-I/II: 28.9%, IIIa: 31.3%, IIIb: 35.7%, IV: 45.8%, V: 48.7%). All-cause mortality rose stepwise with worsening CKD (CKD-I/II: 8.4%, IIIa: 14.9%, IIIb: 24.2%, IV: 34.9%, V: 34.6%). Clinically driven revascularization rates did not increase with advancing CKD stage. In conclusion, advanced CKD was associated with progressively worse clinical outcomes after contemporary LM-PCI, primarily driven by increased mortality, whereas clinically driven revascularization did not increase with CKD severity despite greater lesion complexity.

A 65 year old male with a history of paroxysmal atrial fibrillation and sinus node dysfunction underwent dual chamber pacemaker implantation 4 years ago. He presented to the emergency department with acute onset dysarthria and left facial droop. Although non contrast computed tomography (CT) of the head was unremarkable for acute changes, magnetic resonance imaging of the brain revealed multiple small acute and chronic infarcts in the midline superior cerebellum, posterior right parietal and right midfrontal lobes. The patient had been on apixaban for secondary prevention of stroke but had recurrent strokes. With the multifocal distribution of cerebral infarcts, cardioembolic source was suspected. Further evaluation was pursued to determine the underlying etiology.

Elite athletes develop physiological cardiac remodeling, involving both ventricular and atrial chambers, as well as wall thickening. We propose a Global Athletic Heart Index (GAHI) which integrates both ventricular and atrial changes, aiming to define with a simplified marker the physiologic cardiac remodeling and its relationship with aerobic performance in athletes. 641 healthy Olympic athletes (mean age 25.5±5.3 years; 51% male) underwent transthoracic echocardiography and cardiopulmonary exercise testing (CPET). GAHI was calculated as the mean ratio of each chamber dimension to its sex-specific upper limit of normal. Athletes were classified as GAHI >1 (global cardiac remodeling) or ≤1. VO2 max >85% of predicted was considered and indicator of preserved aerobic capacity. Sensitivity, specificity, and predictive values of GAHI >1 for identifying preserved VO2 max were evaluated. Linear regression analyses assessed the association of GAHI with peak VO2 and O2 pulse. Overall, 155 athletes (24.2%) had GAHI >1. Endurance athletes were overrepresented in this group (51% vs. 13%, p<0.0001). GAHI >1 was associated with larger LV and RV dimensions, higher LV mass, balanced biatrial enlargement, and preserved systolic and diastolic function. CPET revealed higher peak VO2, O2 pulse, and workload (all p<0.0001). Linear regression analyses demonstrated significant positive associations between GAHI and peak VO2 (R[2]=0.24, p<0.0001) and O2 pulse (R[2]=0.20, p<0.0001). Using a dichotomous threshold, GAHI >1 identified athletes with VO2 max>85% with 25.7% sensitivity, 93.9% specificity, 98.1% positive predictive value, and 9.5% negative predictive value. GAHI is an integrative marker of balanced cardiac remodeling closely associated with aerobic performance. A GAHI >1 reliably identifies athletes with balanced structural adaptations and preserved exercise capacity. GAHI may serve as a practical tool for athlete screening and individualized cardiovascular assessment.

There is limited data on whether the presence of downstream arterial disease influences outcomes following endovascular revascularization of common femoral artery (CFA). Herein, we aim to compare outcomes of endovascular intervention for symptomatic peripheral artery disease in patients with isolated CFA versus patients with multilevel disease involving the CFA and other infrainguinal arteries. A total of 334 patients were retrospectively analyzed from the XLPAD Registry (NCT01904851) from 2016 to 2024. Primary outcome was 1-year major adverse limb event (MALE). Of the 334 patients, 143 (42.8%) underwent endovascular intervention for isolated CFA lesions and 191 (57.2%) for multilevel disease. Mean age was 69.0 ± 10.5 years with 35.6% females. Chronic total occlusion (21.0% vs. 42.9%; p<0.001), diffuse lesion (19.6% vs. 31.9%; p=0.011), and severe calcification (18.9% vs. 33.0%; p=0.004) were more common in the multilevel disease group. Procedure time was shorter in the isolated CFA group (82.2 ± 39.6 vs. 124.1 ± 69.6 minutes; p<0.001). Technical success (93.0%) and procedural success (91.2%) were similarly high in both groups with overall low peri-procedural complications (2.4%). At 1-year, there was no significant differences in all-cause mortality (4.2% vs. 5.2%; p=0.7) or bleeding events (1.4% vs. 2.1%, p> 0.9). The multilevel disease group had a trend toward a higher rate of 1-year MALE compared to isolated CFA (plog rank= 0.07). In conclusion, infrainguinal disease is common in patients undergoing CFA treatment, indicates greater atherosclerotic burden, and is associated with a trend toward worse limb outcomes, suggesting that treatment success depends on the extent of downstream disease.

Sex differences in the outcomes of bifurcation percutaneous coronary intervention (PCI) have received limited study. We compared procedural characteristics and outcomes between women and men in bifurcation PCI. 2,431 patients who underwent bifurcation PCI at 7 centers between 2013 and 2025 from the Prospective Global Registry for the Study of Bifurcation Lesion Interventions (PROGRESS-BIFURCATION) were studied. Of the study population, 25.3% (n=615) were women. Women were older (68.2 ± 11.9 vs 65.6 ± 16.3 years; p<0.001), had higher prevalence of diabetes mellitus (48.8% vs 33.5%; p<0.001), hypertension (84.2% vs 76.9%; p<0.001), and higher rates of moderate or severe proximal main vessel calcification (40.2% vs 32.4%; p<0.001) compared with men. Use of provisional stenting (63.2% vs 64.0%, p=0.694) and two-stent techniques (31.3% vs 30.3%, p=0.653) was similar between groups. Technical success was comparable (93.7% vs 95.4%; p=0.075), but women had lower procedural success (88.5% vs 93.2%; p<0.001) due to higher in-hospital major adverse cardiovascular events (MACE) (6.0% vs 2.7%; p<0.001), including in-hospital mortality (2.8% vs 1.0%; p=0.001), stroke (1.3% vs 0.2%; p=0.003), and procedural bleeding (1.0% vs 0.2%; p=0.010). On multivariable analysis, female sex was independently associated with higher in-hospital MACE (odds ratio 2.99; 95% confidence intervals [CI] 1.69-5.29; p<0.001). During a median follow-up of 2.6 years, female sex was independently associated with long-term MACE (adjusted hazard ratio 1.32; 95% CI 1.04-1.67; p=0.011). In conclusion, compared with men, bifurcation PCI in women is associated with similar technical success but higher in-hospital and follow-up MACE.

Frequent premature ventricular complexes (PVCs) are well known to impair left ventricular systolic function. However, most patients with frequent PVCs do not develop cardiomyopathy. We review the various predictors and mechanisms of PVCs that lead to cardiomyopathy, with an emphasis on right ventricular outflow tract PVC-induced left ventricular dyssynchrony and diastolic dysfunction. The variable myocardial susceptibility to PVCs may be due to an undiagnosed subclinical cardiomyopathy. Advanced imaging modalities and genetic screening may help identify primary cardiomyopathic processes. Radiofrequency ablation to reduce PVC burden can not only improve both systolic and diastolic function but also reverse left ventricular remodeling and enhance quality of life.

Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with lower rates of bleeding and vascular complications than transfemoral access. However, it remains uncertain whether radial (including distal) access fully mitigates these established sex-based disparities in PCI outcomes. We performed a systematic review and meta-analysis to evaluate sex-specific procedural, access-site, and clinical outcomes following radial and distal radial PCI. PubMed, Embase, and Cochrane databases were searched from inception through October 2025 for randomized controlled trials and observational studies reporting PCI outcomes stratified by sex in patients undergoing radial or distal radial access. Outcomes were categorized as procedural, access-site safety, and clinical endpoints. Pooled mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using random-effects models. Study quality was assessed using the ROBINS-I tool. Nine studies comprising 214,638 patients (52,486 women and 162,152 men) were included. Compared with men, women had higher rates of access-site crossover (RR 1.87, 95% CI 1.58-2.22) and slightly lower procedural success (RR 0.98, 95% CI 0.97-0.99), despite shorter procedure duration (MD -3.62 minutes, 95% CI -7.21 to -0.04). Women experienced significantly higher rates of access-site bleeding (RR 1.84, 95% CI 1.23-2.75), hematoma (RR 1.70, 95% CI 1.00-2.91), and radial artery spasm (RR 3.40, 95% CI 1.30-8.87), while radial artery perforation did not differ by sex. Clinically, women had higher cardiovascular mortality (RR 1.75, 95% CI 1.14-2.69) and major bleeding (RR 1.51, 95% CI 1.24-1.84), but unexpectedly lower target vessel revascularization (RR 0.59, 95% CI 0.36-0.95). Rates of all-cause mortality, myocardial infarction, stroke, and major adverse cardiac events were similar between sexes. In conclusion, women undergoing PCI via radial or distal radial access experienced higher rates of access-site complications, major bleeding, and cardiovascular mortality than men, whereas ischemic outcomes were generally similar between sexes. These findings suggest that sex-related differences may persist despite the widespread use of radial access. However, the contribution of vascular access itself to these differences remains uncertain, as other clinical and procedural factors may also influence outcomes.