Ariel Roguin

Background/Objectives: Acute pulmonary embolism (PE) can be life-threatening, and outcomes vary considerably between patients. Frailty reflects reduced physiologic reserve and may help describe vulnerability during an acute illness. We examined the association between the Hospital Frailty Risk Score (HFRS) and in-hospital outcomes among adults admitted with acute PE. Methods: We analyzed adult hospitalizations for acute PE recorded in the U.S. National Inpatient Sample between 2016 and 2021. HFRS was reconstructed from 109 three-character ICD-10 categories, with each category counted once per hospitalization and grouped as low (15). Survey-weighted logistic regression used NIS discharge weights, year-specific strata, and year-specific hospital clusters. Additional analyses were limited to patients aged ≥65 and ≥75 years, adjusted for available PE-severity markers and repeated with a modified HFRS that excluded potentially acute components. Results: The study included 220,455 unweighted hospitalizations, representing an estimated 1,102,274 U.S. hospitalizations. Low, intermediate, and high HFRS categories accounted for 67.1%, 31.5%, and 1.5%, respectively. In-hospital mortality was 1.2%, 7.1%, and 9.7% across these groups. Mechanical ventilation occurred in 0.9%, 7.9%, and 16.2%, acute ischemic stroke in 0.2%, 1.3%, and 6.4%, and major bleeding in 1.2%, 4.8%, and 9.3%, respectively. Compared with low HFRS, high HFRS was associated with higher odds of mortality (aOR 8.30, 95% CI 7.24–9.52), mechanical ventilation (aOR 27.74, 95% CI 24.59–31.31), circulatory support (aOR 19.18, 95% CI 11.83–31.11), acute ischemic stroke (aOR 37.61, 95% CI 30.45–46.46), and major bleeding (aOR 7.65, 95% CI 6.68–8.76). Associations persisted in age-restricted and severity-adjusted analyses but were substantially attenuated when potentially acute HFRS components were excluded. Conclusions: Higher HFRS categories were associated with worse in-hospital outcomes in acute PE. Associations were weaker after removing HFRS components that may reflect acute conditions, suggesting that same-admission coding may explain part of the association. Further prospective studies are needed before HFRS is used for treatment decisions or as an additional prognostic tool in acute PE.

Background/Objectives: Obesity and diabetes mellitus coexist, but the association of obesity with invasive management and in-hospital outcomes in acute myocardial infarction (AMI) complicated by cardiogenic shock is uncertain. We evaluated these associations among adults with diabetes mellitus. Methods: We performed a retrospective discharge-level analysis of the National Inpatient Sample for 2016–2021. Obesity was identified from ICD-10-CM codes. Survey-design logistic regression accounted for weights, strata, hospital clusters, and prespecified covariates. Results: The cohort comprised 19,399 discharges, representing 96,995 hospitalizations; 24.1% had obesity. Angiography and coronary artery bypass grafting (CABG) were more frequent with obesity, whereas percutaneous coronary intervention (PCI) was less frequent. After adjustment, obesity was associated with higher odds of angiography (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.03–1.21) and CABG (aOR 1.49, 95% CI 1.35–1.63), lower odds of PCI (aOR 0.90, 95% CI 0.84–0.97), and similar odds of circulatory support (aOR 1.00, 95% CI 0.93–1.07). Adjusted odds were lower for major adverse cardiovascular and cerebrovascular events (aOR 0.88, 95% CI 0.82–0.95), in-hospital mortality (aOR 0.90, 95% CI 0.83–0.98), acute ischemic stroke (aOR 0.78, 95% CI 0.64–0.95), and major bleeding (aOR 0.86, 95% CI 0.76–0.98). Procedure adjustment attenuated mortality and major bleeding. Conclusions: Obesity was associated with a different invasive-management pattern and lower adjusted odds of several short-term outcomes, consistent with an apparent in-hospital obesity paradox in this high-risk population.

Background: ST-elevation myocardial infarction (STEMI) remains a major cause of global mortality. While troponin is the gold-standard biomarker for myocardial injury, a subset of patients presents with troponin levels below the clinical “rule-in” threshold upon hospital admission. The long-term prognostic significance of these initial “low-troponin” presentations in a large-scale population remains insufficiently characterized. Methods: We conducted a retrospective multicenter cohort study using the “KINERET” database, analyzing 8,394 patients diagnosed with STEMI who underwent percutaneous coronary intervention (PCI) at four academic medical centers in Israel between 2016 and 2023. Patients were stratified into two groups based on ESC rule-in criteria for high-sensitivity cardiac troponin (hs-cTn) at admission: a High trop group (above rule-in cutoff) and a Low trop group (below rule-in cutoff). The primary outcome was all-cause mortality at 5 years. Results: Of the 8,394 patients (mean age 68.3±13.3 years; 76% male), 36.5% (n=3,064) presented with troponin levels below the rule-in cutoff. Patients in the High trop group were older and had a higher prevalence of comorbidities, including heart failure (46.7% vs. 28.7%) and chronic kidney disease (13.9% vs. 9%). The Low trop group demonstrated significantly higher survival rates at both 1 year (92.9% vs. 84.0%, p<0.001) and 5 years (85.7% vs. 75.0%, p<0.001). After adjusting for age, sex, and comorbidities in a multivariate Cox regression model, initially elevated troponin remained a robust independent predictor of 5-year mortality (HR 1.15, 95% CI 1.14-1.16, p75, female sex, and chronic kidney disease. Conclusions: STEMI patients presenting with initial troponin levels below the diagnostic rule-in threshold have a significantly better short- and long-term prognosis compared to those with early troponin elevation. Moreover, admission troponin levels serve as a powerful predictor of 5-year mortality and may be used as an independent prognostic factor following STEMI.

Background: Frail patients undergoing AF ablation face elevated periprocedural risks. However, prior studies often examined composite or long-term outcomes and did not stratify acute complication risks by frailty severity. Objective: The objective of this study was to assess the impact of frailty, measured by the Hospital Frailty Risk Score (HFRS) on in-hospital outcomes after AF ablation, and to delineate the risk of specific acute complications across frailty levels. Methods: We analyzed a national inpatient cohort of AF ablation hospitalizations (2016–2021). Patients were stratified into low-, intermediate-, and high-frailty groups by HFRS. In-hospital mortality and major complications (stroke, respiratory failure, sepsis, acute dialysis, cardiac arrest, cardiogenic shock) were compared across frailty groups, and multivariable logistic regression identified independent predictors of these outcomes. Results: Among an estimated 42,830 AF ablation admissions, 80.0% were low-frailty, 15.0% intermediate, and 5.0% high-frailty. High-frailty patients had markedly higher complication rates than low-frailty patients. In-hospital mortality was 6.1% in high frailty vs. 1.0% in low frailty, and stroke occurred in 4.0% vs. 0.3%, respectively. Rates of respiratory failure (18.0% vs. 3.5%), sepsis (8.0% vs. 1.2%), and acute dialysis (4.0% vs. 0.5%) were also significantly higher in the high-frailty group (all p < 0.001). In multivariate analyses, frailty remained a strong independent predictor of complications; high frailty conferred over four-fold higher odds of in-hospital mortality and five-fold higher odds of stroke compared to low frailty. Conclusions: Frailty is a powerful predictor of periprocedural complications and mortality in AF ablation patients. Even after accounting for age and comorbidities, patients with higher frailty scores experienced substantially worse in-hospital outcomes. These findings highlight the importance of frailty assessment to identify high-risk patients and inform clinical decision-making for AF ablation.

Left ventricular thrombus (LVT) remains a clinically significant complication following acute myocardial infarction (MI). Although its incidence has declined in the era of primary percutaneous coronary interventions (PCIs), the best treatment remains unclear. For decades, vitamin K antagonists (VKAs) such as warfarin have been the mainstay of therapy, supported by guidelines recommendations. However, the limitations of warfarin, including a narrow therapeutic range, the need for frequent monitoring, and food/drug interactions, have spurred interest in direct oral anticoagulants (DOACs). This review summarizes the available evidence on anticoagulation strategies for LVT after MI, focusing on observational studies and recent randomized controlled trials. A total of 12 studies were included in this review: 9 retrospective cohorts and 3 randomized controlled trials. Patient populations ranged from small single-center cohorts to large multicenter registries. DOACs, compared with warfarin, were associated with a higher rate of thrombus resolution, a lower rate of stroke and systemic embolism, and a similar mortality. The usage of DOACs marginally reduced the rate of major bleeding compared with warfarin. The current evidence indicates that DOACs may offer comparable efficacy and potentially improved safety relative to warfarin, although most randomized trials remain small and underpowered for definitive conclusions. Larger, adequately powered studies are still required before DOACs can be routinely considered equivalent alternatives. The RIVAWAR randomized trial provides the strongest evidence to date regarding the use of DOACs in LVT after MI, but further large-scale randomized studies are required to establish definitive guidance. Until then, anticoagulation therapy including DOACs should be individualized, balancing the thromboembolic risk, bleeding risk, and practical considerations of anticoagulant use.

Background: Atrial fibrillation (AF) is frequently observed in cancer patients, driven by mutual comorbidities and increasing the risk of thromboembolic events. Impediments can hinder the utilization of anticoagulants among patients with malignancy—drug interactions with chemotherapy, renal dysfunction, drug intolerance, and increased bleeding risk. Left atrial appendage occlusion (LAAO) is an effective and safe non-pharmacological approach to prevent thromboembolic complications when anticoagulants are not suitable. Cancer patients were generally excluded from the original LAAO trials, and current safety and efficacy in cancer patients remain uncertain. Methods: This retrospective study utilized the National Inpatient Sample (NIS) database to analyze in-hospital outcomes of LAAO in US patients with and without cancer between 2016 and 2019. Patient demographics, comorbidities, procedures, and in-hospital outcomes were extracted using ICD-10-CM codes. Results: Among 12,273 hospitalizations for LAAO across the US representing an estimated 61,365 LAAO procedures, 2.2% (1365 cases) were performed in cancer patients. Older age, male gender, chronic kidney disease, prior stroke, and anemia were more prevalent in the cancer group, with 785 (58%) having a solid malignancy and 580 (42%) having a hematologic malignancy. Compared to non-cancer patients, cancer patients exhibited a higher rate of in-hospital complications (8.8% vs. 5.7%; p < 0.001), primarily driven by acute kidney injury (4.4% vs. 2.4%; p = 0.002), acute heart failure (3.7% vs. 2.6%; p = 0.012), and cardiac tamponade (1.5% vs. 0.8%; p = 0.006). No significant differences were observed in vascular complications, periprocedural stroke, or in-hospital mortality. Average length of stay (LOS) was longer in cancer patients (1.4 ± 2.7 days vs. 1.8 ± 2.5 days; p < 0.001). Conclusions: This nationwide study found that cancer patients undergoing LAAO had an increased rate of in-hospital complications, particularly acute kidney injury, heart failure, and tamponade, but no increase in in-hospital mortality was observed. Further research is needed to evaluate the long-term safety and efficacy of LAAO for managing embolic prevention in this complex patient population.

Background: Cardiovascular–kidney–metabolic (CKM) syndrome, recently defined by the American Heart Association, encompasses the interplay between obesity, diabetes, chronic kidney disease, and cardiovascular disease. This study aimed to investigate the impact of CKM syndrome severity on outcomes in patients with acute myocardial infarction (AMI). Methods: A retrospective analysis was conducted using the National Inpatient Sample database from 2016 to 2019. Adult patients hospitalized with AMI were stratified into CKM Stages 0–4 based on ICD-10 codes. Multivariable logistic regression models were used to examine associations between CKM stages and in-hospital procedures and outcomes. Results: The study analyzed 2,768,154 AMI cases. Advanced CKM stages were associated with older age and a higher proportion of males. Patients with severe CKM were more likely to undergo invasive procedures. Coronary angiography showed the strongest association in CKM Stage 4A (aOR: 6.86, 95% CI: 6.73–6.99, p-value < 0.001) and Stage 4B (aOR: 3.87, 95% CI: 3.80–3.95, p-value < 0.001). Similarly, the likelihood of PCI was highest in Stage 4A (aOR: 5.93, 95% CI: 5.79–6.08, p-value < 0.001) and Stage 4B (aOR: 4.14, 95% CI: 4.04–4.24, p-value < 0.001). Notably, patients with CKM Stage 0 demonstrated higher odds of adverse outcomes compared to other stages. Conclusions: This study reveals a complex relationship between CKM syndrome severity and AMI outcomes. Patients with advanced CKM stages were more likely to undergo invasive procedures, and those without CKM risk factors unexpectedly showed worse outcomes. Among Stages 1–4B, no consistently graded association emerged between the CKM stage and adverse outcomes. These findings warrant further investigation into underlying mechanisms and long-term prognosis.

Vertebral body cement augmentation (Kyphoplasty / Vertebroplasty) for treatment of pathological vertebral fracture is a common procedure. Cement leakage to the venous system is a rare complication. We present a case of cement embolization to the right atrium and right ventricle, resulting in tricuspid valve involvement, and right heart failure. A 59-year-old woman was hospitalized due to dyspnea with pulmonary edema, ascites, severe signs of peripheral edema and liver fibrosis. Echocardiography showed a foreign body attached to the right ventricle, prolapsing into the right atrium and causing severe tricuspid valve regurgitation. CT and CMR showed a foreign body attached to the right ventricle, crossing into the right atrium. She was treated with diuretics and heart failure medications and improved clinically. Six years prior, she had a history of kyphoplasty due to multiple osteoporotic collapsed vertebrae at the age of 53. Spine CT at the time of cement injection was otherwise normal. In retrospect, a CT done two years later at the age of 55, showed a foreign body in the heart, however at that time she was asymptomatic. Her leg edema developed slowly as well as her liver dysfunction. The foreign body was surgically removed, and the tricuspid valve was replaced with a biological valve. The foreign body measured almost 10 cm, crossed the tricuspid valve and was embedded within the right ventricular wall. In pathology it resembled bone (appearance on pathology, not histologically confirmed). In conclusion, intra cardiac cement embolism following percutaneous kyphoplasty is a rare but life-threatening complication. Although often occurring immediately after the procedure, embolisms can also present as a late complication, years after the initial treatment. We present a case of severe tricuspid valve regurgitation caused by the long-term presence of an intra-cardiac foreign body - a cement embolus.

BACKGROUND: An interatrial shunt may provide an autoregulatory mechanism to decrease left atrial pressure and improve heart failure (HF) symptoms and prognosis. METHODS: Patients with symptomatic HF with any left ventricular ejection fraction (LVEF) were randomized 1:1 to transcatheter shunt implantation versus a placebo procedure, stratified by reduced (≤40%) versus preserved (>40%) LVEF. The primary safety outcome was a composite of device-related or procedure-related major adverse cardiovascular or neurological events at 30 days compared with a prespecified performance goal of 11%. The primary effectiveness outcome was the hierarchical composite ranking of all-cause death, cardiac transplantation or left ventricular assist device implantation, HF hospitalization, outpatient worsening HF events, and change in quality of life from baseline measured by the Kansas City Cardiomyopathy Questionnaire overall summary score through maximum 2-year follow-up, assessed when the last enrolled patient reached 1-year follow-up, expressed as the win ratio. Prespecified hypothesis-generating analyses were performed in patients with reduced and preserved LVEF. RESULTS: Between October 24, 2018, and October 19, 2022, 508 patients were randomized at 94 sites in 11 countries to interatrial shunt treatment (n=250) or a placebo procedure (n=258). Median (25th and 75th percentiles) age was 73.0 years (66.0, 79.0), and 189 patients (37.2%) were women. Median LVEF was reduced (≤40%) in 206 patients (40.6%) and preserved (>40%) in 302 patients (59.4%). No primary safety events occurred after shunt implantation (upper 97.5% confidence limit, 1.5%; P P =0.20). However, patients with reduced LVEF had fewer adverse cardiovascular events with shunt treatment versus placebo (annualized rate 49.0% versus 88.6%; relative risk, 0.55 [95% CI, 0.42–0.73]; P P =0.0001; P _interaction <0.0001). There were no between-group differences in change in Kansas City Cardiomyopathy Questionnaire overall summary score during follow-up in all patients or in those with reduced or preserved LVEF. CONCLUSIONS: Transcatheter interatrial shunt implantation was safe but did not improve outcomes in patients with HF. However, the results from a prespecified exploratory analysis in stratified randomized groups suggest that shunt implantation is beneficial in patients with reduced LVEF and harmful in patients with preserved LVEF. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03499236.