Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 24 appraisals
Critical care explorations
Drug Clearance and Dosing During CytoSorb Hemoadsorption: A Systematic Review
OBJECTIVE: CytoSorb (CS) hemoadsorption is increasingly used in critical care and cardiac surgery to remove inflammatory mediators and select drugs. This systematic review aimed to summarize available evidence on intentional drug removal as well as unintentional drug removal during CS therapy. DATA SOURCES: PubMed, congress abstracts, and CytoSorbents online literature database. STUDY SELECTION: Eligible studies included benchtop, animal, and human pharmacokinetic investigations of drug removal during CS therapy as well as clinical reports describing CS use for drug overdose. DATA EXTRACTION: Data from the eligible studies were extracted independently by two authors into Microsoft Excel. DATA SYNTHESIS: Data were identified for drugs across multiple therapeutic classes, including analgesics, antiarrhythmics, anticonvulsants, antidepressants, antihypertensives, anti-infectives, antithrombotics, anxiolytics, and immunosuppressants. Drugs were categorized into low (< 30%), moderate (30-60%), or high (> 60%) removal rate, or by the relative increase in clearance attributable to CS: negligible (< 25%), low (25-100%), moderate (100-400%), or high (> 400%). Based on the assembled data and considering drug-, patient-, and circuit-specific factors, general dosing recommendations for concomitant medications were developed. CONCLUSIONS: CS therapy can alter drug concentrations for select agents with variable clinical relevance. CS can reduce perioperative bleeding risk through antithrombotic removal and treat certain drug overdoses. Unintentional drug removal during CS therapy may occur and practical guidance is provided for drugs with known susceptibility to removal.
16 July 2026
Read appraisal →Neurological sciences : official journal of the Italian Neurological Society and of the Italian Society of Clinical Neurophysiology
Topography and functional connectivity analysis of heart surgery-associated brain lesions: a literature review
BACKGROUND: Cardiac surgery is a major therapeutic advancement but remains associated with neurological complications, including ischemic stroke and postoperative cognitive decline. Compared with stroke of other etiologies, ischemic brain injury following cardiac surgery may involve distinct vascular territories and functional networks, potentially influencing its characteristic cognitive profile. METHODS: We performed a systematic review of case reports describing ischemic brain lesions occurring after cardiac surgery in adults with available neuroimaging data. Lesions were manually traced onto a standard brain atlas and compared with ischemic stroke lesions from the ATLAS database, matched for hemispheric involvement. Lesion topography was analyzed at the arterial territory and voxel levels. Lesion network mapping was conducted using normative resting-state functional connectivity data to identify patterns of functional disconnection. Permutation-based statistical analyses were applied, with correction for multiple comparisons and lesion volume included as a covariate. RESULTS: Nineteen articles met the inclusion criteria, yielding 20 cases of post-cardiac surgery ischemic lesions. Compared with stroke controls, these lesions more frequently involved posterior arterial territories, particularly the occipital branches of the posterior cerebral arteries and posterior thalamic regions. Lesion network mapping revealed a distinct pattern of functional disconnection in the occipital lobes, posterior thalamus (including the pulvinar), and medial frontal cortex. CONCLUSIONS: Our results suggest that ischemia associated with cardiac surgery may preferentially involve posterior arterial territories and be associated with distinct patterns of functional disconnection involving the occipital lobe, the pulvinar, and the medial frontal cortex.
6 July 2026
Read appraisal →The American journal of cardiology
Transcatheter Chordal Repair for Degenerative Mitral Regurgitation: Systematic Review and Meta-analysis
Transcatheter chordal repair enables off-pump, echocardiography-guided treatment of degenerative mitral regurgitation, but real-world outcomes remain variably reported. We performed a systematic review and meta-analysis of studies evaluating outcomes after transcatheter chordal repair in adults with primary degenerative mitral regurgitation. Pooled event rates were calculated using random-effects models. Seventeen studies (n = 3,787) were included. Mitral regurgitation ≤ mild was achieved in 93.9% of patients at discharge and 82.5% at 30 days, while moderate mitral regurgitation occurred in 5.0% and 17.5%, respectively. Procedural success was 96.2%, although small-study effects were suggested. Early adverse events were infrequent, with 30-day mortality of 1.2%, stroke of 0.7%, and myocardial infarction of 1.2%. Reintervention occurred in 4.5%. In conclusion, transcatheter chordal repair demonstrates high technical success and favorable early safety; however, early mitral regurgitation recurrence and heterogeneity highlight the need for anatomy-guided patient selection and cautious interpretation given single-arm study limitations.
15 June 2026
Read appraisal →BMC cardiovascular disorders
Trends in cardiac implantable electronic device infections: 2015 to 2019
BACKGROUND: Cardiovascular implantable electronic devices (CIEDs) improve survival in patients with cardiac rhythm disorders but carry risks of complications, most notably major infections. Reported infection rates vary internationally, and contemporary large-scale data from Germany are scarce. We aimed to determine nationwide rates of CIED infection-related hospitalizations and associated mortality over a five-year period. METHODS: We analyzed administrative claims from Germany's largest statutory health insurer covering more than 27 million beneficiaries. All CIED procedures performed between January 2015 and December 2019 were identified, including initial implantations, upgrades or downgrades, generator replacements, early revisions, and device extractions. Major infections were detected using International Classification of Diseases (ICD-10-GM) and procedural codes, and stratified as generator pocket infections or lead-associated endocarditis. In-hospital mortality was determined from discharge records. RESULTS: Among 282,205 patients (57.7% male) undergoing CIED procedures, 6,577 individuals (2.33%) experienced 7,704 major infections within three months. Generator pocket infections occurred in 5,396 cases (1.91%), lead-associated endocarditis in 2,308 (0.82%), and combined infections in 1,127 patients (0.39%) within the acute 90-day observation period. CIED infections substantially increased healthcare utilization: Infected patients required substantially more procedures than non-infected patients, despite correct treatment. In-hospital mortality reached 8.36% for pocket infections and 15.0% for endocarditis. Extended follow-up in the 2015 cohort revealed a 4.33% infection-related procedure rate over five years. CONCLUSIONS: Nationwide German data reveal higher acute CIED infection rates than previously reported, with considerable mortality and procedural burden. These findings highlight an urgent need for improved prevention and management strategies.
14 June 2026
Read appraisal →The New England journal of medicine
Stem-Cell-Derived Biologic Ventricular Assist Tissue in Heart Failure
BACKGROUND: Biologic ventricular assist tissue (BioVAT) is formulated from engineered heart muscle composed of cardiomyocytes and stromal cells derived from allogeneic induced pluripotent stem cells for cardiac remuscularization in patients with heart failure and a reduced left ventricular ejection fraction. METHODS: We conducted an open-label, phase 1-2 study of tissue-engineered heart repair by means of BioVAT transplantation. Patients with heart failure and a left ventricular ejection fraction of 35% or less and at least one hypokinetic or dyskinetic left ventricular segment were treated with BioVAT allografts, which consisted of 5, 10, or 20 engineered-heart-muscle units. All the patients received immunosuppression. Safety was assessed as adverse events related to the procedure. The primary efficacy end points were the change from baseline in the target heart-wall thickness, the left ventricular ejection fraction, and the Kansas City Cardiomyopathy Questionnaire-Overall Summary Score (KCCQ-OSS). RESULTS: A total of 20 patients were treated in the study. Three patients died during the study (1 each from vasoplegia, coronavirus disease 2019, and aortic dissection). One patient underwent heart transplantation. Immunosuppression was discontinued in 4 patients because of implantation of a left ventricular assist device (in 2 patients), renal failure (in 1 patient), and urothelial carcinoma (in 1 patient). Of the 16 patients who were treated with the safe maximal dose (20 engineered-heart-muscle units), 12 patients completed the prespecified 3-month interim follow-up. The least-squares mean increase in the target-wall thickness was 4.5 mm (90% confidence interval [CI], 3.7 to 5.4; P<0.001), the increase in the left ventricular ejection fraction was 3.9 percentage points (90% CI, 0.9 to 6.8; P = 0.04), and the increase in the KCCQ-OSS was 6.7 points (90% CI, 1.0 to 12.5; P = 0.06). All the patients had at least one adverse event. CONCLUSIONS: In this interim analysis, cardiac remuscularization with BioVAT was associated with an increase in the target heart-wall thickness, left ventricular ejection fraction, and KCCQ-OSS at 3 months; all the patients had at least one adverse event. Longer-term follow-up and further clinical investigation are warranted. (Funded by the German Center for Cardiovascular Research and Repairon; BioVAT-HF ClinicalTrials.gov number, NCT04396899.).
30 May 2026
Read appraisal →JMIR formative research
An In-Hospital Mortality Risk Model for Patients Undergoing Coronary Artery Bypass Grafting Based on Machine Learning: Cohort Study
BACKGROUND: Ischemic heart disease remains the leading cause of death worldwide. Coronary artery bypass grafting (CABG) remains the primary surgical treatment for ischemic heart disease. There is currently a lack of highly accurate and widely applicable models for assessing the risk of postoperative mortality following CABG. OBJECTIVE: This study aimed to develop and validate an in-hospital mortality risk prediction system for patients undergoing coronary artery bypass grafting (CABG) by using machine learning algorithms and to compare its performance with the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II) and Sino System for Coronary Operative Risk Evaluation (SinoSCORE). METHODS: Between January 2017 and December 2020, 21,443 patients undergoing CABG in the Chinese Cardiac Surgery Registry were included. Patients were randomly divided into training (n=17,753) and test (n=3690) cohorts. We addressed class imbalance using the synthetic minority oversampling technique (SMOTE) and optimized hyperparameters via grid search. Fifteen machine learning algorithms were developed to predict in-hospital mortality. Performance was evaluated using the area under the receiver operating characteristic curve (AUC), calibration metrics (Brier score), and decision curve analysis, and was compared against EuroSCORE II and SinoSCORE. RESULTS: A total of 21,443 patients were included. Overall, in-hospital mortality was 2.1% (n=450). The Extreme Gradient Boosting (XGBoost) model achieved the best performance with an AUC of 0.850 in the training cohort and 0.782 in the independent test cohort (this cohort was independent and not involved in model construction). While EuroSCORE II showed an AUC of 0.722 and SinoSCORE showed an AUC of 0.726 in the test cohort, the XGBoost model demonstrated superior discrimination and calibration (P<.05). CONCLUSIONS: Our study developed and validated a machine learning-based risk prediction model for in-hospital mortality after CABG by using a large-scale Chinese multicenter registry. Among the algorithms tested, the XGBoost model demonstrated superior discrimination and calibration compared with the traditional EuroSCORE II and SinoSCORE, suggesting that locally calibrated models may better capture the risk profile of Chinese patients. The derived 7-variable web calculator may serve as an exploratory auxiliary tool to provide a preliminary reference for bedside risk stratification, though its direct impact on surgical decision-making requires further prospective validation. Future research should focus on independent test cohorts across diverse hospital tiers to ensure broad generalizability.
26 May 2026
Read appraisal →Journal of medical economics
A systematic review of acute and long-term outcomes in patients with non-transvenous implantable cardioverter-defibrillators
BACKGROUND: Non-transvenous implantable cardioverter-defibrillator (ICD) systems have been developed to address limitations of transvenous ICDs. This systematic literature review aimed to summarize periprocedural and long-term outcomes of non-transvenous ICD systems in adult patients with guideline-based indications for ICD therapy. METHODS: A systematic review was conducted in accordance with PRISMA guidelines (PROSPERO: CRD420261327618). Eligible studies enrolled adults (≥18 years) receiving a non-transvenous ICD for primary or secondary prevention. Outcomes included periprocedural and long-term endpoints and were summarized descriptively. The Newcastle-Ottawa Scale (NOS) and Joanna Briggs Institute (JBI) checklist for case series were used to assess risk of bias. RESULTS: Twenty-five publications representing 18 unique studies and 4,633 patients were included. Most studies were single-arm (n = 13), while 2 were randomized controlled trials and 3 were nonrandomized comparative studies. Procedural success ranged from 81%-100%, with rates ≥94% of patients in all but one early-phase study; defibrillation threshold testing success ranged from 89%-100% (≥96% in studies with n ≥ 100). Periprocedural complications were reported in 0%-5% of patients in most studies. Long-term complication rates ranged from 0%-8% at 0.5-1.5 years of follow-up and 1%-14% beyond 1.5 years. All-cause mortality ranged from 1%-5% within 6 months and increased to 16%-26% at 4-8 years. Clinical defibrillation success was consistently high (95%-100%). Incidence of inappropriate shock generally ranged from 7%-13% at 1 year and 2%-18% at later timepoints. Appropriate shock incidence ranged from 2% to 9% within 1 year and increased with longer follow-up. Risk of bias was predominantly moderate, with limited variation using NOS and greater discrimination observed with JBI. CONCLUSIONS: Non-transvenous ICD systems demonstrate favorable safety and effectiveness profiles, with high procedural and defibrillation success and acceptable complication and inappropriate shock rates across studies. Overall, the available evidence supports their use in appropriately selected adult patients with standard ICD indications. Non-transvenous implantable cardioverter-defibrillators (ICDs) are devices placed outside the blood vessels and heart, designed to treat life-threatening heart rhythm problems while avoiding complications related to transvenous ICDs.This review summarized results from 25 published studies including 4,600 patients to understand how safe and effective these devices are.Across studies, non-transvenous ICDs showed high implant procedure success, effective therapy delivery, and had generally low rates of short- and long-term complications.
23 May 2026
Read appraisal →Journal of the American Heart Association
Residual Angina Following Complete Revascularization in the ISCHEMIA Trial: Frequency, Clinical Characteristics, Health Status, and Cardiovascular Outcomes
BACKGROUND: The frequency of residual angina and its impact on health status and death following anatomic complete revascularization in symptomatic patients with chronic coronary disease are unknown. METHODS: Data were analyzed from ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial participants randomized to invasive management with baseline angina (Seattle Angina Questionnaire Angina Frequency score <100), no prior coronary artery bypass graft surgery, and anatomic complete revascularization within 90 days of randomization. The primary outcome was frequency of residual angina after revascularization, defined as a Seattle Angina Questionnaire Angina Frequency score <100 within 6 months of randomization. Secondary outcomes included 6-month health status and medication use and 5-year all-cause and cardiovascular death. RESULTS: Among 2588 participants randomized to invasive management, 1442 (56%) had baseline angina and no prior coronary artery bypass graft surgery; 1034 underwent revascularization within 90 days, and 436 achieved anatomic complete revascularization. Of these, 184 (42.2%) had residual angina within 6 months. Baseline characteristics were similar between those with and without residual angina. Percutaneous coronary intervention was more common than coronary artery bypass graft surgery in those with residual angina (88% versus 80%, P=0.03). At 6 months, residual angina participants reported lower quality of life (Seattle Angina Questionnaire Quality of Life: 70±20 versus 83±20, P<0.001), greater physical limitation (Seattle Angina Questionnaire Physical Limitation: 84±20 versus 95±11, P<0.001), more dyspnea (Rose Dyspnea Scale score: 1±1.3 versus 0.4±0.8, P<0.001), and more antianginal medication use (P=0.006). Five-year all-cause and cardiovascular death did not differ significantly between groups. CONCLUSIONS: Residual angina is common (>40%) following anatomic complete revascularization for chronic coronary disease and is associated with reduced quality of life and greater antianginal medication use but no increase in death. REGISTRATION: Unique Identifier: NCT01471522.
20 May 2026
Read appraisal →European heart journal
Mitral transcatheter edge-to-edge repair and outcomes according to baseline health status: the RESHAPE-HF2 trial
BACKGROUND AND AIMS: Mitral transcatheter edge-to-edge repair (M-TEER) using the MitraClip device improves clinical outcomes in patients with moderate-to-severe ventricular secondary mitral regurgitation (vSMR) and heart failure (HF). This study evaluated whether the effects of M-TEER on clinical outcomes vary by baseline health status, as measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ), and assessed the impact of M-TEER on health status post-randomization. METHODS: The RESHAPE-HF2 trial included patients with symptomatic HF and moderate-to-severe vSMR (mean effective regurgitant orifice area .25 cm2; 14% >.40 cm2, 23% <.20 cm2). The impact of baseline KCCQ-clinical summary score (CSS) on the effect of M-TEER on clinical outcomes was assessed using Cox proportional hazards models. Changes post-randomization in health status and responder analyses were performed to assess the odds ratio (OR) of improvement and deterioration in KCCQ scores. RESULTS: Among 505 patients, M-TEER reduced cardiovascular death or HF hospitalization risk [hazard ratio (HR): .71 (.48-1.05), .50 (.29-.85), and .73 (.38-1.41)] across KCCQ-CSS tertiles of <38.9, 38.9-66.1, and >66.1, respectively (P-trend = .53). Similar results were seen for total HF hospitalization (P-trend = .48). M-TEER improved KCCQ-CSS, total symptom score, and overall summary score at 1, 6, 12, and 24 months compared to medical therapy alone (P < .05 at all time points). More patients in the M-TEER arm experienced a ≥5-point [OR 3.38 (2.09-5.45)], ≥10-point [OR 3.12 (1.93-5.02)], and ≥15-point [OR 3.25 (1.94-5.45)] improvement, and less patients had a ≥5-point deterioration [OR .34 (.19-.57)] in KCCQ-CSS at 6 months. Similar results were seen across other KCCQ domains and all time points. CONCLUSIONS: In patients with HF and moderate-to-severe vSMR, M-TEER showed a consistent trend towards a lower risk of HF hospitalization, with or without cardiovascular death, across all KCCQ-CSS tertiles and improved health status over time.
19 May 2026
Read appraisal →BMJ paediatrics open
Prevalence of dysglycemia following paediatric cardiac surgery: a systematic review and meta-analysis
BACKGROUND: Postoperative dysglycemia is a common but under-recognised complication in paediatric cardiac surgery, driven by physiologic stress, hormonal changes and cardiopulmonary bypass. Reported prevalence varies widely, and no meta-analysis has synthesised the evidence. Therefore, this study aimed to estimate the pooled prevalence of postoperative dysglycaemia and describe associated postoperative outcomes, such as intensive care unit (ICU) stay and mechanical ventilation duration. METHODS: We conducted a systematic review and meta-analysis following PRISMA 2020 guidelines and the Joanna Briggs Institute (JBI) methodology for prevalence studies. Eligible studies included paediatric patients (≤18 years) undergoing cardiac surgery reporting postoperative dysglycaemia (hyperglycaemia or hypoglycaemia). A random-effects model was used to calculate pooled prevalence and 95%CIs, with logit transformation applied to prevalence proportions and heterogeneity assessed using I² statistics. Subgroup analyses were performed by region/continent, study design, age group and glycaemic threshold. All included studies were critically appraised using the Newcastle-Ottawa Scale for observational studies and the Cochrane Risk of Bias 2 tool for randomised trials. The protocol was registered with PROSPERO (CRD420251161893). RESULTS: 22 studies involving 3864 patients were included. The pooled prevalence of postoperative dysglycemia was 68.6% (95% CI 52.8 to 81.0), with hyperglycaemia accounting for most cases (71.2%) and hypoglycaemia observed in 8.1%. Prevalence was higher in Asia and North America (~75%) than in Europe (45.2%), though not statistically significant. Studies using lower hyperglycaemia thresholds (126-139 mg/dL) reported significantly the highest prevalence (82.3%, p<0.032). The pooled mean ICU stay among dysglycemic patients was 180.3 hours (95% CI 82.3 to 279.3), and mean mechanical ventilation duration was 94.6 hours (95% CI 5.2 to 184.1). Sensitivity analyses showed that no single study disproportionately influenced the overall pooled estimates, and no publication bias was detected. The certainty of evidence assessed using the GRADE approach was moderate for overall dysglycemia prevalence. CONCLUSION: Dysglycaemia is highly prevalent following paediatric cardiac surgery, particularly hyperglycaemia, with prolonged ICU and mechanical ventilation times observed among affected patients. These findings underscore the need for vigilant perioperative glucose monitoring, standardised definitions of dysglycaemia, and evidence-based glycaemic management protocols. Future multicentre studies are warranted to establish optimal glycaemic thresholds and evaluate targeted interventions to improve postoperative outcomes in this vulnerable population.
15 May 2026
Read appraisal →The New England journal of medicine
Left Ventricular Unloading in High-Risk Percutaneous Coronary Intervention
BACKGROUND: Complex percutaneous coronary intervention (PCI) in patients with severely impaired left ventricular function carries a high risk of death and complications. Whether percutaneous left ventricular unloading improves outcomes remains unclear. METHODS: We randomly assigned 300 patients with severe left ventricular dysfunction and extensive coronary artery disease in a 1:1 ratio to a strategy of elective unloading with a microaxial flow pump or to standard care during planned complex PCI. The primary outcome was a hierarchical composite that included death from any cause, disabling stroke, spontaneous myocardial infarction, hospitalization for cardiovascular causes, or periprocedural myocardial injury at a minimum of 12 months, as analyzed according to a win ratio. RESULTS: A total of 148 patients were assigned to receive a microaxial flow pump and 152 to receive standard care. At a median of 22 months (interquartile range, 16 to 30), 36.6% of pairwise comparisons favored the microaxial flow pump, and 43.0% favored standard care (win ratio, 0.85; 95% confidence interval [CI], 0.63 to 1.15; difference, -6.4 percentage points; P = 0.30). Death from any cause occurred in 47 patients in the microaxial-flow-pump group and 33 in the standard-care group (hazard ratio, 1.54; 95% CI, 0.99 to 2.41). There was no material between-group difference in the risk of bleeding or vascular complications. CONCLUSIONS: Among patients with severely impaired left ventricular function undergoing complex PCI, elective left ventricular unloading with a microaxial flow pump did not reduce the risk of major adverse clinical outcomes at a minimum of 12 months. (Funded by the U.K. National Institute for Health and Care Research; CHIP-BCIS3 ClinicalTrials.gov number, NCT05003817.).
12 May 2026
Read appraisal →European heart journal
Tricuspid valve replacement outcomes by baseline tricuspid regurgitation severity: the TRISCEND II trial
BACKGROUND AND AIMS: The TRISCEND II trial demonstrated superior clinical benefits for patients with ≥severe tricuspid regurgitation (TR) treated with the EVOQUE transcatheter tricuspid valve replacement (TTVR) system plus medical therapy vs medical therapy alone. This work reports 1-year and 18-month outcomes in patients stratified by baseline TR severity. METHODS: The multicentre, prospective TRISCEND II trial enrolled 400 patients with symptomatic, ≥severe TR, and randomized 2:1 to TTVR (n = 267) or control (n = 133). In a post hoc analysis, patients were stratified into severe TR (n = 172) and massive/torrential TR (n = 220) cohorts. Clinical and quality-of-life outcomes were reported at 1 year, with Kaplan-Meier estimates for all-cause mortality and heart failure (HF) hospitalization assessed at 18 months. Study oversight included an independent echocardiographic core laboratory, clinical events committee, and data safety monitoring board. RESULTS: One year after TTVR, TR was ≤mild in 95.2% of severe TR and 95.3% of massive/torrential TR patients. The primary safety and effectiveness endpoint (win ratio) favoured TTVR over control regardless of baseline TR severity: severe {1.64 [95% confidence interval (CI): 1.11, 2.43]} and massive/torrential [2.20 (1.55, 3.14)]. At 18 months, TTVR patients had similar mortality to controls [rate difference: severe 0.2% (-11.6, 11.9), massive/torrential -5.8% (-17.6, 6.0)], whereas HF hospitalization rates favoured TTVR in the massive/torrential cohort [vs control, severe 9.8% (-3.0, 22.7), massive/torrential -15.2% (-28.9, -1.5)]. CONCLUSIONS: Patients with ≥severe TR benefit from TTVR, experiencing improvements in TR severity, functional capacity, and quality of life regardless of baseline TR severity, with a signal for greater benefit in patients with more advanced disease.
11 May 2026
Read appraisal →Asian journal of psychiatry
Machine learning prediction model for delirium after heart valve replacement with cardiopulmonary bypass: A large-scale cohort study
OBJECTIVE: Postoperative delirium (POD) is a common and severe complication following heart valve replacement (HVR) with cardiopulmonary bypass (CPB), associated with poor outcomes. Accurate early prediction is crucial for targeted prevention. This study aimed to develop and externally validate machine learning (ML) models for predicting POD in this high-risk population. METHODS: We conducted a retrospective cohort study involving 1076 adult patients who underwent HVR with CPB between January 2018 and December 2022. POD was assessed using the CAM-ICU. Perioperative factors were analyzed to develop a traditional logistic regression-based nomogram and four ML models. The best-performing model was then tested on an independent external validation cohort of 281 patients. RESULTS: The incidence of POD was 25.1% (270/1076) and was associated with significantly increased mortality (11.9% vs. 0.2%, P < 0.001) and prolonged hospitalization. In the internal test set, the Random Forest (RF) model demonstrated the highest predictive performance with an AUROC of 0.854 (95% CI, 0.764-0.945), outperforming the traditional nomogram (AUROC: 0.754). The RF model maintained robust performance in the external validation cohort, achieving an AUROC of 0.793. Model interpretation using SHAP analysis identified postoperative awakening time (PAT), postoperative mechanical ventilation time (PMVT), and postoperative reintubation (POR) as the most influential predictors. CONCLUSIONS: Machine learning models, particularly Random Forest, provide a robust and generalizable tool for the early prediction of POD after HVR. These models outperform traditional statistical approaches and offer interpretable insights, highlighting PAT as a critical, modifiable target for perioperative management to mitigate POD risk.
9 May 2026
Read appraisal →Polish archives of internal medicine
Systematic review and meta-analysis of the safety and efficacy of transvenous lead extraction in octogenarian patients
INTRODUCTION: As the global population ages and the use of cardiac implantable electronic devices (CIEDs) increases, transvenous lead extraction (TLE) is being performed more frequently in elderly patients. Concerns remain regarding its safety and efficacy in octogenarians, and age‑specific recommendations are limited. OBJECTIVES: We aimed to assess procedural success, complication rates, and mortality associated with TLE in patients aged 80 years or older in comparison with younger individuals. PATIENTS AND METHODS: A systematic search of PubMed, Cochrane CENTRAL, SciELO, and ScienceDirect was conducted up to December 2024. Studies reporting TLE outcomes in octogenarians and younger patients were included according to predefined criteria. A meta‑analysis was performed to compare procedural success, complications, and mortality between the age groups. RESULTS: Seventeen studies including 15 984 patients were analyzed. Complete lead extraction success was 96.7% in octogenarians and 96.2% in the patients aged below 80 years. No significant differences were observed in major or minor procedural complications. In‑hospital mortality was low and comparable between the groups. Although long‑term mortality was higher in the octogenarians, this reflected greater baseline comorbidity and frailty rather than increased procedural risk. None of the included studies demonstrated higher periprocedural danger of TLE in elderly patients. CONCLUSIONS: TLE is safe and effective in patients aged 80 years and older, with outcomes comparable to younger individuals. Advanced age alone should not preclude referral for lead extraction.
3 May 2026
Read appraisal →Journal of the American College of Cardiology
Intravascular Imaging- vs Angiography-Guided Complex PCI: 5-Year Outcomes From a Randomized Trial
BACKGROUND: Data regarding long-term outcomes of intravascular imaging-guided percutaneous coronary intervention (PCI) for complex coronary artery lesions, compared with angiography-guided PCI, remain limited. OBJECTIVES: The authors sought to present long-term clinical outcomes of intravascular imaging-guided PCI compared with angiography-guided PCI in patients with complex coronary artery lesions. METHODS: Eligible patients with complex coronary artery lesions were randomly assigned 2:1 to undergo intravascular imaging-guided PCI or angiography-guided PCI in this prospective multicenter open-label superiority trial performed in South Korea. The primary endpoint was a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization. RESULTS: A total of 1,639 patients underwent randomization with 1,092 assigned to imaging-guided PCI and 547 assigned to angiography-guided PCI. At a median follow-up of 5.3 years (Q1-Q3: 4.4-6.2 years), the primary endpoint occurred in 109 of 1,092 patients (10.5%) in the intravascular imaging-guided PCI group and 78 of 547 patients (14.9%) in the angiography-guided PCI group (HR: 0.68; 95% CI: 0.51-0.91; P = 0.009). Cardiac death or target vessel-related myocardial infarction occurred in 78 patients (7.6%) in the intravascular imaging-guided PCI group and in 56 patients (10.7%) in the angiography-guided PCI group, clinically driven target vessel revascularization in 45 (4.4%) and 32 (6.2%), and definite stent thrombosis in 1 (0.1%) and 4 (0.7%), respectively. There were no apparent differences in procedure-related safety events between the groups. CONCLUSIONS: In patients with complex coronary artery lesions undergoing PCI, intravascular imaging guidance reduced the risk of a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization at median follow-up of 5.3 years, compared to angiography guidance. (Intravascular Imaging- Versus Angiography-Guided Percutaneous Coronary Intervention for Complex Coronary Artery Disease [RENOVATE-COMPLEX-PCI]; NCT03381872).
3 May 2026
Read appraisal →Heart (British Cardiac Society)
Variation in mechanical circulatory support use for acute myocardial infarction cardiogenic shock
BACKGROUND: Cardiogenic shock (CS) is a leading cause of mortality following acute myocardial infarction (AMI). Some patients may require intra-aortic balloon pump (IABP) or percutaneous ventricular assist device (PVAD) placement; however, there is a paucity of standardised algorithms to guide the deployment of each device. The present study evaluated interhospital variation in the use of IABP and PVAD for AMI CS and identified institutional factors associated with hospital-level device preference. METHODS: All non-elective adult hospitalisations entailing AMI and CS were identified within the 2019 Nationwide Readmissions Database. Patients were grouped into IABP, PVAD and non-mechanical circulatory support cohorts. The primary aim was to quantify the degree of interhospital variation in the use of IABP and PVAD. Escalation to extracorporeal membrane oxygenation (ECMO), left ventricular assist device (LVAD) implantation, length of stay and hospitalisation costs were secondarily assessed. Hospital factors, such as percutaneous coronary intervention (PCI) volume and safety net status, were also analysed. RESULTS: Among 53 903 patients, 23.4% received IABP, and 12.5% received PVAD. After adjustment for patient factors, approximately 13% (11-14%) of variation in IABP use and 18% (15-20%) of PVAD use were attributable to centre-level differences. High-PVAD hospitals had higher annual PCI volume (257 (185-369) vs 204 (148-276) cases/year, p=0.032) and were more commonly safety net institutions (27.4% vs 11.3%, p=0.023), compared to high-IABP hospitals. Patients treated at high-IABP and high-PVAD hospitals faced similar length of stay (β -0.16, 95% CI -1.82 to 1.49) and costs (β -$3500, 95% CI -16 600 to 9600). Those at high-PVAD hospitals had lower adjusted risk of escalation to ECMO (0.52, 95% CI 0.29 to 0.95) and LVAD implantation (0.28, 95% CI 0.08 to 0.94). CONCLUSIONS: The present study identified wide interhospital variation in the use of IABP and PVAD for AMI CS. Although the likelihood of escalation to ECMO or LVAD differed between hospital types, resource utilisation was similar.
27 Apr 2026
Read appraisal →BMJ open
Effect of early antiplatelet therapy on 30-day mortality after coronary artery bypass grafting: a retrospective target trial emulation using the MIMIC-IV database
OBJECTIVES: The effect of early antiplatelet therapy on 30-day mortality after coronary artery bypass grafting (CABG) remains uncertain. This study aimed to evaluate the association between early antiplatelet therapy initiation and clinical outcomes in post-CABG patients. DESIGN: A retrospective target trial emulation. SETTING: Single academic medical centre in Boston, Massachusetts, USA. PARTICIPANTS: We included adult patients who underwent CABG and were admitted to the intensive care unit at Beth Israel Deaconess Medical Center between 2008 and 2022. METHODS: Patients were classified into the treatment group if they initiated antiplatelet therapy within 24 hours postoperatively; otherwise, they were assigned to the control group. To address immortal-time bias for the primary outcome of 30-day mortality, we used clone-censor-weighting. For the exploratory outcome of 30-day acute kidney injury (AKI) incidence, we employed inverse probability of treatment weighting to balance baseline covariates. RESULTS: The analysis for 30-day mortality included 6887 patients. The mortality was 2.35% in the control group versus 1.44% in the treatment group, yielding an absolute risk difference of 0.90% (control group minus treatment group, 95% CI 0.09% to 1.72%). The difference in restricted mean time lost was 0.19 days (control group minus treatment group, 95% CI 0.03 to 0.36). For AKI incidence, 5543 patients were analysed. The incidence was 78.61% in the control group and 69.13% in the treatment group, with an absolute difference of 9.48% (control group minus treatment group, 95% CI 6.40% to 12.50%; p<0.001). CONCLUSIONS: In this target trial emulation, early antiplatelet therapy initiated within 24 hours after CABG was associated with lower 30-day mortality and a reduced incidence of postoperative AKI. These findings warrant confirmation in prospective randomised controlled trials.
24 Apr 2026
Read appraisal →Lancet (London, England)
Deferral of percutaneous coronary intervention in patients undergoing transcatheter aortic valve implantation (PRO-TAVI): an investigator-initiated, multicentre, open-label, non-inferiority, randomised controlled trial
BACKGROUND: Coronary artery disease is common in patients undergoing transcatheter aortic valve implantation (TAVI). We aimed to assess whether deferral of percutaneous coronary intervention (PCI) is non-inferior to routine PCI before TAVI in patients with coronary artery disease. METHODS: In this investigator-initiated, open-label, randomised controlled trial, done at 12 hospitals in the Netherlands, TAVI patients with coronary artery disease were randomly assigned in a 1:1 ratio to deferral of PCI or PCI before TAVI. Randomisation was done by use of a web-based system with random block sizes of 2 and 4, and stratification by presence of coronary artery disease involving proximal left anterior descending artery. The primary endpoint was a composite of all-cause mortality, myocardial infarction, stroke, and major bleeding at 1 year. Non-inferiority testing was done in the intention-to-treat population against the prespecified margin of 11 percentage points. The study is registered with ClinicalTrials.gov (NCT05078619) and long-term follow-up is ongoing. FINDINGS: Between Oct 7, 2021, and Nov 19, 2024, 466 patients were enrolled: 233 were assigned to deferral of PCI and 233 to PCI before TAVI. Median age was 81 years (IQR 78-84), and 166 (36%) of 466 patients were female. The primary endpoint occurred in 56 (24%) of 233 patients in the deferral group as compared with 60 (26%) of 233 patients in the PCI group (rate difference -1·7% [95% CI -9·5 to 6·2]; hazard ratio 0·89 [95% CI 0·62-1·28]; p=0·0008 for non-inferiority; p=0·68 for superiority). INTERPRETATION: In patients with coronary artery disease undergoing TAVI, deferral of PCI was non-inferior to PCI before TAVI for the 1-year composite of all-cause mortality, myocardial infarction, stroke, and major bleeding. These findings suggest that an initial conservative strategy can be appropriate in selected patients, although patient-tailored treatment decisions remain essential. FUNDING: ZonMw.
14 Apr 2026
Read appraisal →Heart (British Cardiac Society)
Parsimonious machine learning model to predict 1-year mortality and procedural futility after transcatheter aortic valve replacement
BACKGROUND: Current risk scores inadequately predict long-term mortality after transcatheter aortic valve replacement (TAVR), limiting their ability to guide decisions around procedural futility. We aimed to develop and externally validate a machine learning (ML) model using only preprocedural variables to predict 1-year all-cause mortality. METHODS: An ML model was trained on a retrospective cohort of 1025 TAVR patients using 52 clinical and echocardiographic variables. Feature selection and model tuning were performed via a multiobjective evolutionary algorithm to optimise predictive performance and model simplicity. The final model used 13 preprocedural variables and was externally validated in an independent cohort of 270 patients. Performance was compared with European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), FRANCE-2 and TAVI2-SCORE using the area under the curve (AUC), calibration and net reclassification improvement (NRI). RESULTS: The ML model demonstrated excellent discrimination, with AUCs of 0.81 in the discovery cohort and 0.84 in the external validation cohort. This exceeded the performance of EuroSCORE II (AUC: 0.61 and 0.70), FRANCE-2 (0.52 and 0.58) and TAVI2-SCORE (0.56 and 0.64). Calibration plots showed strong agreement between predicted and observed risks. NRI in the test set compared with FRANCE-2 was 0.62 (95% CI: 0.49 to 0.75); compared with TAVI2-SCORE, it was 0.36 (95% CI: 0.14 to 0.61). The final model incorporated age, atrial fibrillation, creatinine, haemoglobin, pulmonary function, frailty markers (Katz Index, poor mobility) and tricuspid regurgitation. Misclassification analysis revealed that most errors were clustered near the decision threshold, with no evidence of systematic bias. Performance was consistent across subgroups and robust to temporal and institutional variation. CONCLUSION: This externally validated ML model, using 13 routinely available variables, significantly outperforms existing risk scores in predicting 1-year mortality post-TAVR. Its simplicity and generalisability support its potential use in real-world clinical decision-making to identify patients at high risk of procedural futility.
12 Apr 2026
Read appraisal →EuroIntervention : journal of EuroPCR in collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology
Ischaemic and bleeding events after complex versus non-complex PCI: a systematic review and meta-analysis
BACKGROUND: Complex percutaneous coronary intervention (PCI) is increasingly performed among patients undergoing myocardial revascularisation. AIMS: We conducted a systematic review and meta-analysis to evaluate the association between complex PCI and the risk of ischaemic and bleeding outcomes. METHODS: Hazard ratios (HRs) were pooled using a random-effects model within a Bayesian framework. The primary analysis was restricted to studies providing adjusted risk estimates, whereas the secondary analysis included unadjusted risk estimates. The primary outcomes were myocardial infarction and major bleeding. The secondary outcomes were all-cause death, stent thrombosis, cardiovascular death, target lesion or vessel revascularisation, and stroke. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework for prognostic studies was used to determine the level of certainty in the association between complex PCI and the risk of events. RESULTS: We included 290,039 patients, of whom 94,633 (33%) underwent complex PCI. Compared with non-complex PCI, patients undergoing complex PCI had a higher risk of myocardial infarction (adjusted HR 1.71, 95% credible interval [CrI]: 1.49-1.96), major bleeding (adjusted HR 1.24, 95% CrI: 1.14-1.35), all-cause death (adjusted HR 1.21, 95% CrI: 1.12-1.32), cardiovascular death (adjusted HR 1.29, 95% CrI: 1.15-1.46), stent thrombosis (adjusted HR 1.76, 95% CrI: 1.49-2.14), target lesion or vessel revascularisation (adjusted HR 1.99, 95% CrI: 1.58-2.50), and stroke (adjusted HR 1.21, 95% CrI: 1.03-1.42). The posterior probability of a higher risk associated with complex versus non-complex PCI was >99% for all study outcomes. Except for stroke (which was low certainty), the certainty of evidence was moderate to high for all other outcomes. Secondary analysis, including unadjusted risk estimates, provided consistent results. CONCLUSIONS: Patients undergoing complex PCI have an increased risk of both ischaemic and bleeding events compared with patients undergoing non-complex PCI (PROSPERO: CRD420250656254).
8 Apr 2026
Read appraisal →Lancet (London, England)
Percutaneous coronary intervention versus coronary artery bypass grafting for unprotected left main stenosis: 10-year final results from the randomised, open-label, non-inferiority NOBLE trial
BACKGROUND: Coronary artery bypass grafting (CABG) is recommended over percutaneous coronary intervention (PCI) for patients with significant unprotected left main coronary artery disease. We aim to provide long-term outcome data comparing PCI with newer generation drug-eluting stents and CABG, which are scarce. METHODS: This previously published, prospective, randomised, open-label, non-inferiority trial enrolled patients with unprotected left main coronary artery stenosis at 36 hospitals in Denmark, Estonia, Finland, Germany, Latvia, Lithuania, Norway, Sweden, and the UK. Eligibility was determined by a multidisciplinary heart team and defined by clinical criteria (chronic or acute coronary syndrome and a life expectancy of >1 year) and angiographic criteria (left main coronary artery diameter stenosis ≥50% or fractional flow reserve ≤0·80 in the left main ostium, mid-shaft, or bifurcation). Patients with ST elevation myocardial infarction within 24 h or considered at too high risk for CABG or PCI were excluded. Patients with angiographically confirmed significant left main coronary artery disease were randomly assigned (1:1) to PCI or CABG using an online system and stratified by site, sex, distal left main coronary artery bifurcation lesions, and diabetes. The primary outcome was the difference in 10-year all-cause mortality in the intention-to-treat (ITT) population, which was analysed using Kaplan-Meier estimates and unadjusted Cox regression. Patients were censored at the date of death, emigration, withdrawal, or loss to follow-up. Variation in all-cause mortality was assessed in prespecified subgroups. The trial is registered with ClinicalTrials.gov, NCT01496651 (active, not recruiting). FINDINGS: From Dec 9, 2008, to Jan 21, 2015, 1201 patients were randomly assigned to PCI (n=598) or CABG (n=603). 17 patients were lost to follow-up before 1 year. 592 patients in each group were included in the ITT population. Mean age was 66·2 years (SD 9·9) in the PCI group and 66·2 years (9·4) in the CABG group. 256 (22%) of 1184 participants were female and 928 (78%) were male. There was no difference in all-cause mortality at 10 years (136 [23%] of 592 in the PCI group and 145 [25%] of 592 in the CABG group; hazard ratio 0·93 [95% CI 0·74-1·18]; p=0·56). No significant difference in all-cause mortality with SYNTAX score was identified. INTERPRETATION: There was no significant difference in all-cause mortality at 10 years between PCI and CABG for patients with unprotected left main coronary artery disease and no additional complex lesions, indicating that PCI is equally as safe as CABG in patients eligible for both treatments. These results will aid heart teams in developing an individualised patient-centred strategy. FUNDING: Biosensors and Aarhus University Hospital.
6 Apr 2026
Read appraisal →Open heart
Periprocedural evaluation of patients with BAV stenosis undergoing TAVR: a machine learning-based study
BACKGROUND: Transcatheter aortic valve replacement (TAVR) has increasingly emerged as one of the primary treatments for patients with severe bicuspid aortic valve (BAV) stenosis. Nevertheless, these patients encounter multiple procedural challenges. OBJECTIVE: To develop a machine learning (ML) model for assessing the risk of periprocedural adverse events (PAEs) in TAVR population with BAV. METHODS: This multicentre study retrospectively enrolled 1266 patients with BAV stenosis. Clinical characteristics and imaging data of the patients were collected, and an ML prediction model was developed. PAE was collectively defined as all-cause death, disabling stroke, life-threatening haemorrhage, acute kidney injury (≥stage 3), major vascular complications, valve-related dysfunction necessitating reoperation and other major complications that occurred prior to discharge. RESULTS: The average age was 72.6±6.3 years, and 58.3% (n=738) of male. In the derivation dataset, five predictive factors were identified: Type 0 BAV, aortic root calcification volume, horizontal aorta, annular ellipticity and previous atrial fibrillation. A robust risk scoring model was thereby established (area under the curve=0.801 95% CI 0.768 to 0.832). A graded relationship was observed between the quartiles of the score and PAE (0.6%, 1.7%, 3.2% and 9.6%; overall p<0.001). A nomogram was constructed to enable calculation of individual scores and the corresponding PAE probabilities. Additionally, similar results were observed in the validation dataset. CONCLUSIONS: The ML model developed in this study could predict the PAEs occurrence of TAVR in patients with BAV stenosis. This is conducive to individualised procedural planning and in-hospital management.
5 Apr 2026
Read appraisal →J Am Coll Cardiol
Contemporary Diagnosis and Treatment of Aortic Regurgitation: A State-of-the-Art Review
Aortic regurgitation (AR) is progressive and frequently under-recognized; without timely intervention it drives adverse left-ventricular remodeling and heart failure. Despite Class I guideline indications, many patients-especially older, frail individuals with multimorbidity-remain untreated. Advancements in high-fidelity multimodality imaging-including cardiac magnetic resonance, 4-dimensional flow, and speckle-tracking echocardiography-have enabled earlier detection of remodeling and more accurate quantification of regurgitant burden. These techniques are redefining thresholds for treatment and may enable biomarker-imaging composite staging of disease. Surgery remains the gold standard of therapy for native AR. Contemporary surgical management is tailored to age, anatomy, and root pathology. Although surgical aortic valve replacement remains the predominant therapy for most candidates, valve-sparing root procedures, the Ross operation, and aortic valve neocuspidization are increasingly offered at experienced centers for carefully selected lower-risk patients. Transcatheter aortic valve replacement is expanding rapidly as a viable option that helps bridge the treatment gap for those at prohibitive or high risk for surgery. Yet, devices optimized for calcific aortic stenosis encounter technical obstacles in native AR-including large, noncalcified annuli, elliptical root geometry, and high stroke volumes-leading to suboptimal anchoring, residual paravalvular regurgitation, and device embolization. Purpose-built AR systems with leaflet-engaging anchoring and enhanced sealing have shown encouraging outcomes in feasibility and pivotal studies and have obtained commercial approval in Europe, and U.S. authorization is anticipated. This state-of-the-art review synthesizes current insights into AR pathophysiology, diagnostic advances, and therapeutic innovations in surgical and transcatheter techniques, highlighting knowledge gaps and proposing research priorities to accelerate access to care for this historically undertreated population.
1 Feb 2026
Read appraisal →Eur Heart J
Coronary revascularization: a long-term perspective.
This paper will forecast advancements in coronary revascularization by 2040, drawing on historical trends and recent breakthroughs. Having forecasted in 2000 the impact of innovations like drug-eluting stents, coronary computed tomography angiography, and bioresorbable scaffolds, the authors examine the evolving landscape of coronary artery disease treatment emphasizing artificial intelligence and omics sciences. Imagenomics-the integration of imaging and omics-will be a transformative tool with artificial intelligence enabling more personalized decisions between pharmacological and mechanical revascularization. The shift towards minimally invasive, image-guided procedures is discussed along with the potential obsolescence of current antiplatelet and anticoagulant therapies with novel biomimetic peptides like CD31-covalently bound to metallic or polymeric devices. Advances in photon-counting computed tomography and Fibre Optic Real Shape promise high-resolution imaging with lower radiation, enhancing procedural safety and diagnostic accuracy. It is anticipated that robotics and 3D holograms in percutaneous and surgical revascularization will improve precision and the resulting outcomes. Additionally, the need for mechanical revascularization for younger patients may decline due to effective plaque regression therapies and novel potent anti-atherogenic biologics. However, the aging population will drive demand for mechanical interventions, with advancements in atherectomy and lithotripsy techniques improving outcomes in complex, calcified lesions. This comprehensive analysis outlines a future where myocardial revascularization becomes increasingly personalized, with technology-driven interventions redefining cardiovascular medicine.
1 Feb 2026
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