Periprocedural Risk Research Articles

Role of Routine Electrophysiological Study Performed During Transcatheter Aortic Valve Replacement to Predict AV Block.

Periprocedural electrophysiological (EP) testing may be useful to predict high degree atrioventricular block (HAVB) risk in patients undergoing transcatheter aortic valve replacement (TAVR). To determine whether pre- and immediate post-TAVR ECG and HV interval findings are predictive of HAVB. Consecutive TAVR patients without prior pacemaker (PM) implantation underwent ECG and standardized HV interval measurements pre- and post-TAVR using the quadripolar catheter for rapid pacing. The primary outcome was HAVB >24 h after TAVR or ventricular pacing need RESULTS: Out of 97 included patients, 8 experienced the primary outcome (7 with HAVB and 1 with PM need). On univariate analysis, pre- and post-TAVR PR, post-TAVR HV, and Delta-HV intervals were predictors of the primary outcome. A Delta-HV interval ≥18ms predicted HAVB with sensitivity = 50% and specificity = 90% (AUC = 0.708, PPV = 31%), while an HV interval ≥60ms after TAVR had sensitivity = 63% and specificity = 79% (AUC = 0.681, PPV = 21%). None of the patients with a PR interval ≤180ms post-TAVR experienced the primary outcome. Among patients with new-onset LBBB, an HV interval post-TAVR >65ms was the only predictor of HAVB (AUC = 0.776, PPV = 33%, and NPV = 97%). The yield of periprocedural EP assessment during TAVR is limited considering that about half of the at-risk patients fail to be identified. However, early periprocedural risk stratification may be more useful in the subset of patients with new-onset LBBB. Among ECG findings, a post-TAVR PR interval ≤180ms identifies a subgroup at very low risk, independently of QRS interval and morphology.

Abstract TMP76: Inadequate Pre-Procedure Antiplatelet Medication Use May Explain the Higher Risk of Peri-Procedural Stroke and/or Death with Carotid Stent Placement within First 7 Days after Qualifying Ischemic Event

Background and Purpose: In randomized trials, carotid artery stent (CAS) may have higher risk of periprocedural risk compared with carotid endarterectomy (CEA) if performed within the first 7 days after the onset of symptoms. Methods: We analyzed the data from Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). The time interval between the most recent qualifying ischemic event and CAS/CEA procedure was divided in four strata: 1-7 days, 8-14 days, 15-30 days and >30 days. We analyzed the effect of time interval strata between most recent qualifying ischemic event and procedure and procedure type (CEA versus CAS) on peri-procedural stroke and/or death after adjusting for age, gender, symptomatic status and initial severity of stenosis (≥70% versus <70%). Results: The rate of periprocedural stroke and/or death was significantly higher in patients who underwent CAS compared with CEA at 7 days or less after the qualifying event (5.4% versus 0%, p=0.031) but not significantly different in patients who underwent CAS compared with CEA at 8-14 days (3.8%versus 2.0%, p=0.68), at 15-30 days (5.1% versus 1.8%, p=0.26) days and >30 days (CAS 7.8% versus CAE 4.3%, p=0.12), after the most recent qualifying event. In the multivariate analysis, patients who underwent CAS had higher rate of peri-procedural stroke and/or death (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.25- 4.66) but timing of procedure were not associated with higher rate of peri-procedural stroke and/or death after adjustment for potential confounders. The interaction between procedure type and timing of procedure was not significant. The rate of peri-procedural stroke and/or death was significantly higher in CAS patients who received clopidogrel bolus (without 48-hour maintenance dose) among patients treated 7 days or less after the qualifying event compared with those undergoing CEA (6.6% versus 0%, p=0.012) but was not different between CAS patients who received 48 hours of clopidogrel maintenance and those undergoing CEA (0% versus 0%). Conclusions: The higher rate of peri-procedural stroke and/or death seen with CAS (compared with CEA) within the first 7 days may be attributed to factors such as inadequate pre-procedure antiplatelet medication use. The results of CAS and CEA may become comparable within the first 7 days after the qualifying ischemic event with use of newer generation P2Y12 platelet inhibitors that achieve rapid antiplatelet inhibition.

Time is aorta in uncomplicated type B aortic dissection.

While cardiovascular control optimization through best medical therapy (BMT) remains the gold standard of treatment for uncomplicated type B aortic dissection (uTBAD) according to international guidelines, thoracic endovascular aortic repair (TEVAR) has increasingly emerged as a viable and appealing treatment option due to its potential to induce favourable aortic remodelling and improve long-term outcomes. However, the optimal timing of TEVAR in uTBAD remains debatable. This narrative review aims to evaluate the safety, efficacy, and outcomes of TEVAR at different time points in the disease history. We conducted a comprehensive literature review across multiple electronic databases, including PUBMED and Scopus, to synthesize research evidence on the timing of TEVAR in uncomplicated type B aortic dissection. Hyperacute-phase TEVAR (<24 hours) is associated with prohibitive periprocedural risks and is thus discouraged. Acute-phase TEVAR (1-14 days) may provide benefits in aortic remodelling, but it is burdened by relatively elevated rates of early complications and reinterventions. The subacute phase (14-90 days) is consistently identified as the optimal therapeutic window, balancing procedural safety and efficacy, with studies reporting superior mortality, complications, and aortic remodelling outcomes. Chronic-phase TEVAR (>90 days), although sometimes necessary in cases of disease progression, is associated with poorer outcomes, including higher rates of reintervention, complications, and limited aortic remodelling for the subacute phase. The consistent findings across the studies indicate that the subacute phase offers the best combination of reduced procedural risks and favourable long-term outcomes. However, ,more substantial evidence is needed to refine timing strategies.

Straining to predict mortality in low flow low gradient aortic stenosis patients undergoing TAVR: can GLS and myocardial work parameters improve outcomes?

Abstract Background Classic low flow low gradient aortic stenosis (LFLG-AS) represents 5-10% of the Aortic Stenosis (AS) population and is associated with poorer clinical outcomes when compared to other AS subtypes. The survival rate of these patients is low (40–60% at 2-yrs) with conservative management. The TOPAS study found a transfemoral Transcatheter Aortic Valve Replacement (TAVR) adjusted hazard ratio (HR) of 0.23 and Surgical Aortic Valve Repair adjusted HR of 0.36. However, mortality within 2-yrs of TAVR can still be as high as 30%-50%. Currently there are no pre-TAVR echocardiographic markers that reliably predict post-TAVR outcomes. Global longitudinal strain (GLS), a load-dependent measurement, in conjunction with the recently emerging load-independent measurements, global myocardial work index (GWI) and global myocardial work efficiency (GWE), have the potential to improve peri-procedural risk stratification. Purpose This study sought to establish the sensitivity and specificity of using GLS, GWI, GWE, Contractile Reserve, and Left Ventricle Ejection Fraction (LVEF) in predicting mortality for LFLG AS patients undergoing TAVR. Methods We measured baseline GLS, GWI, GWE, Contractile Reserve, and LVEF, using GE Echo Pac AFI software (ver. 203) in patients with LFLG AS (n=29, age 79 ± 8 yrs, 69% males) that underwent low dose Dobutamine Stress Echocardiography (DSE) pre-TAVR (2017 to 2023). Contractile flow reserve (defined as &amp;gt;20% increase in LV stroke volume (SV) during DSE was recorded. LVEF was re-measured by a single operator. Receiver operating curves (ROC) were created to predict mortality using SPSS. Results Baseline LVEF was 37.6 ± 9.3% with mean AV gradient of 30 ± 10 mmHg prior to TAVR. 59% (17) had contractile reserve (25 ± 19% increase in SV). There was -0.3 ± 15.7% change in LVEF and 24% (10) patients had ≥10% improvement in LVEF at 1-yr Total mortality was 21% (6) and heart failure admission was 34% (10) at 1-yr Post TAVR, GLS (AUC 0.82, p=0.017), GWI (AUC 0.688, p=0.209) and GWE (AUC 0.82, p=0.001) can predict 1-yr mortality compared to baseline LVEF (AUC 0.536, p=0.83), and contractile reserve (AUC 0.551, p=0.132) (Figure 1). Baseline GLS of ≥ -7.5% (83% sensitivity, 83% specificity), GWI ≤ 817 mmHg% (83% sensitivity, 67% specificity) and GWE ≤74% (83% sensitivity, 67% specificity) can predict 1-yr mortality. Conclusion This study demonstrates that GLS, GWI, and GWE possess superior predictive capabilities for predicting mortality within 1-yr post-TAVR compared to baseline LVEF and contractile reserve. A baseline GLS of ≥ -7.5%, GWI ≤ 817 mmHg%, and GWE ≤ 74% were identified as thresholds with high sensitivity and specificity. This study has notable limitations, being a single-center retrospective study with a small sample size, however, the findings justify replication of this study in a larger, multicenter cohort, in an effort to improve risk stratification in the patients with LFLG-AS being considered for TAVR.

Machine-learning versus traditional methods for prediction of all-cause mortality after transcatheter aortic valve implantation: a systematic review and meta-analysis

BackgroundAccurate mortality prediction following transcatheter aortic valve implantation (TAVI) is essential for mitigating risk, shared decision-making and periprocedural planning. Surgical risk models have demonstrated modest discriminative value for patients undergoing...

Risk Factors for Coronary Events After Robotic Hybrid Off-Pump Coronary Revascularization.

The impact of long-term complications after robotic hybrid coronary revascularization (HCR), including persistent angina, repeat revascularization, and myocardial infarction (MI), remains limited. This study aims to determine the risk factors for coronary events after robotic HCR and their time-varying effects on outcomes. We identified all consecutive patients who underwent robotic HCR at our institution. Baseline characteristics were explored as possible risk factors for angina, MI, and repeat revascularization with stents at any time during the follow-up. A total of 875 patients (mean age 71.1 ± 11.1 years) were included. After a median follow-up of 3.32 years (IQR 1.18-6.34 years), angina occurred in 134 patients (15.3%), repeat revascularization with stents in 139 patients (15.8%), and MI in 36 patients (4.1%). The hazard rates for all outcomes increased with follow-up time, with a notable early rise around two years of follow-up for angina and, to a lesser extent, repeat revascularization. The risk factors were the lack of radial artery graft use, black race, diabetes, obesity, chronic obstructive pulmonary disease, low ejection fraction <50%, severe left main coronary artery stenosis (>50%), and more than three-vessel disease. Optimization of modifiable periprocedural risk factors may positively impact long-term prognosis in patients undergoing robotic HCR.

Myocardial Revascularization – Where Do We Stand Through The Guidelines Window

What is new in ESC and ACC revascularization guidelines. Why we need to embrace it in everyday practice. When we can use different antiplatelet therapeutic options in those patients. How can we implement mode of artificial intelligence after primary PCI. When and What is the right new definition of ACS. ESC 2023. new guideliness and urge for complete revascularization. ACC 2021. Main pathways Why and how to assess High Bleeding Risk (HBR), seen in about 20% of ACS patients. Can we measure periprocedural risk in ACS and what types of de-escalation antiplatelet therapy can be used. CCS – Chronic coronary sydrom (stable angina) ESC 2019. guidelines. ACC 2023. What are patient risk profiles number 1, 2 and 3. Why we should use Guideline Directed Medical Therapy, the proven benefit in CCS. Different types of revascularization therapies, OMT (Optimal Medical Therapy) vs PCI vs CABG (Coronary Artery By Pass). What is OPTIMUM Registry and who are the patients ineligible for surgical revascularization. The role and definition of Prehabilitation. All those new aspects through intertwined evidence based cardiology facts concerning revascularization, across both side of the ocean.

Aortic Stenosis and Coronary Artery Disease: Decision-Making Between Surgical and Transcatheter Management.

Aortic stenosis (AS) and coronary artery disease (CAD) frequently coexist and share pathophysiological mechanisms. The proportion of patients with AS and CAD requiring revascularization varies widely because of uncertainty about best clinical practices. Although combined surgical aortic valve replacement and coronary artery bypass grafting has been the standard of care, management options in patients with AS and CAD requiring revascularization have expanded with the advent of transcatheter aortic valve replacement (TAVR). Potential alternative treatment pathways include revascularization before TAVR, concomitant TAVR and percutaneous coronary intervention, percutaneous coronary intervention after TAVR and deferred percutaneous coronary intervention or hybrid procedures. Selection depends on underlying disease severity, antithrombotic treatment strategies, clinical presentation, and symptom evolution after TAVR. In patients undergoing surgical aortic valve replacement, the addition of coronary artery bypass grafting has been associated with improved long-term mortality, especially if CAD is complex. although it is associated with higher periprocedural risk. The therapeutic impact of percutaneous coronary intervention in patients with TAVR is less well-established. The multitude of clinical permutations and remaining uncertainties do not support a uniform treatment strategy for patients with AS and CAD. Therefore, to provide the best possible care for each individual patient, heart teams need to be familiar with the available data on AS and CAD. Herein, we provide an in-depth review of the evidence supporting the decision-making process between transcatheter and surgical approaches and the key elements of treatment selection in patients with AS and CAD.

Periprocedural Risks Associated With GLP-1 Receptor Agonists

Periprocedural Risks Associated With GLP-1 Receptor Agonists

The Bleeding Edge: Managing Coagulation and Bleeding Risk in Patients with Cirrhosis Undergoing Interventional Procedures.

This review addresses the peri-procedural bleeding risks in patients with cirrhosis, emphasizing the need for careful coagulation assessment and targeted correction strategies. Liver disease presents a unique hemostatic challenge, where traditional coagulation tests may not accurately predict bleeding risk, complicating the management of procedures like paracentesis, endoscopic therapy, and various interventional procedures. As such, this paper aims to provide a comprehensive analysis of current data, guidelines, and practices for managing coagulation in cirrhotic patients, with a focus on minimizing bleeding risk while avoiding unnecessary correction with blood products. The objectives of this review are threefold: first, to outline the existing evidence on bleeding risks associated with common invasive procedures in cirrhotic patients; second, to evaluate the efficacy and limitations of standard and advanced coagulation tests in predicting procedural bleeding; and third, to examine the role of blood product transfusions and other hemostatic interventions, considering potential risks and benefits in this delicate population. In doing so, this review highlights patient-specific and procedure-specific factors that influence bleeding risk and informs best practices to optimize patient outcomes. This review progresses through key procedures often performed in cirrhotic patients. The discussion begins with paracentesis, a low-risk procedure, followed by endoscopic therapy for varices, and concludes with high-risk interventions requiring advanced hemostatic considerations. Each chapter addresses procedural techniques, bleeding risk assessment, and evidence-based correction approaches. This comprehensive structure aims to guide clinicians in making informed, evidence-backed decisions in managing coagulation in cirrhosis, ultimately reducing procedural complications and improving care quality for this high-risk population.

Minimally Invasive Aortic Valve Replacement for High-Risk Populations: Transaxillary Access Enhances Survival in Patients with Obesity.

Background/Objectives: Minimally invasive cardiac surgery is often avoided in patients with obesity due to exposure and surgical access concerns. Nonetheless, these patients have elevated periprocedural risks. Minimally invasive transaxillary aortic valve surgery offers a sternum-sparing "nearly no visible scar" alternative to the traditional full sternotomy. This study evaluated the clinical outcomes of patients with obesity compared to a propensity score-matched full sternotomy cohort. Methods: This retrospective cohort study included 1086 patients with obesity (body mass index [BMI] of >30 kg/m2) undergoing isolated aortic valve replacement from 2014 to 2023. Two hundred consecutive patients who received transaxillary minimally invasive cardiac lateral surgery (MICLAT-S) served as a treatment group, while a control group was generated via 1:1 propensity score matching from 886 patients who underwent full sternotomy. The final sample comprised 400 patients in both groups. Outcomes included major adverse cardio-cerebral events, mortality, and postoperative complications. Results: After matching, the clinical baselines were comparable. The mean BMI was 34.4 ± 4.0 kg/m2 (median: 33.9, range: 31.0-64.0). Despite the significantly longer skin-to-skin time (135.0 ± 37.7 vs. 119.0 ± 33.8 min; p ≤ 0.001), cardiopulmonary bypass time (69.1 ± 19.1 vs. 56.1 ± 21.4 min; p ≤ 0.001), and aortic cross-clamp time (44.0 ± 13.4 vs. 41.9 ± 13.3 min; p = 0.044), the MICLAT-S group showed a shorter hospital stay (9.71 ± 6.19 vs. 12.4 ± 7.13 days; p ≤ 0.001), lower transfusion requirements (0.54 ± 1.67 vs. 5.17 ± 9.38 units; p ≤ 0.001), reduced postoperative wound healing issues (5.0% vs. 12.0%; p = 0.012), and a lower 30-day mortality rate (1.5% vs. 6.0%; p = 0.031). Conclusions: MICLAT-S is safe and effective. Compared to traditional sternotomy in patients with obesity, MICLAT-S improves survival, reduces postoperative morbidity, and shortens hospital stays.

Comparison of machine learning and traditional methods for prediction of adverse clinical events after percutaneous coronary intervention

Abstract Background Accurate prediction of clinical outcomes following percutaneous coronary intervention (PCI) is essential for mitigating risk and periprocedural planning. Traditional risk models have demonstrated modest predictive value. Machine learning (ML) models offer an alternative risk stratification that may provide improved predictive accuracy. We performed a systematic review and meta-analysis comparing ML models and traditional risk scores for prediction of clinical outcomes after PCI. Methods This study was reported according to PRISMA guidelines. PubMed, EMBASE, Web of Science and Cochrane databases were searched until 1st November, 2023 for studies comparing ML models with traditional statistical methods for event prediction after PCI. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals between ML models and traditional methods in estimating the risk of all-cause mortality, major bleeding and the composite outcome major adverse cardiovascular events (MACE). Results Thirty-four models were included across 13 observational studies (4105916 patients). The summary C-statistic all ML models across all clinical endpoints was 0.81 (95% CI, 0.78-0.85), compared to traditional methods 0.79 (95% CI, 0.74-0.85). The difference in C-statistic was 0.02 (95% CI, 0.002-0.04, p=0.56). Of included studies, only 1 model was externally validated and 10 models were calibrated. Conclusion ML models did not outperform traditional risk scores in the discrimination of all-cause mortality, major bleeding or MACE following PCI. While integration of ML algorithms into electronic healthcare systems may improve periprocedural risk stratification, immediate implementation in the clinical setting remains uncertain. Further research is required to overcome methodological and validation limitations.

Predictive value of the systemic immune-inflammation index for periprocedural complications in flow diverter treatment for patients with intracranial aneurysms.

Flow-diverter devices (FDs) are effective in treating intracranial aneurysms (IAs) but carry substantial periprocedural risks, particularly ischemic complications. This study aimed to determine if elevated Systemic Immune-Inflammation Index (SII) can independently predict these risks and assess the impact of age and dual antiplatelet therapy on this association. We conducted a retrospective analysis of patients treated with FDs between February 2016 and August 2023, using blood samples taken within six days before surgery to calculate SII. Logistic regression and decision tree analyses assessed the link between SII and periprocedural complications, with subgroups exploring influencing factors. Multivariable analysis identified high SII as an independent predictor of periprocedural complications (OR = 5.306, 95% CI: 1.367-18.455; P = 0.009). The decision tree model confirmed SII > 0.437 as a critical threshold. Subgroup analysis showed a pronounced association of SII with periprocedural complications in patients ≥ 65 years (OR = 36.979, 95% CI: 2.103-650.134; P = 0.014) and in those on clopidogrel plus aspirin therapy (OR = 16.921, 95% CI: 2.733-104.746; P = 0.002). An elevated Systemic Immune-Inflammation Index (SII) > 0.437 significantly correlates with increased periprocedural complications (6.5% vs. 1.8%, P = 0.017). Although not statistically significant, higher SII is associated with a greater rate of ischemic events (3.9% vs. 0.9%). Elevated preoperative SII independently predicts periprocedural complications, particularly ischemic events, in patients undergoing FDs treatment for intracranial aneurysms. This association is particularly pronounced in older patients (> 65 years) and those receiving dual therapy with clopidogrel plus aspirin. Trial Registration: ClinicalTrials.gov (NCT06446778). Registered on May 22, 2024.

Machine learning approaches for risk prediction after percutaneous coronary intervention: a systematic review and meta-analysis.

Accurate prediction of clinical outcomes following percutaneous coronary intervention (PCI) is essential for mitigating risk and peri-procedural planning. Traditional risk models have demonstrated a modest predictive value. Machine learning (ML) models offer an alternative risk stratification that may provide improved predictive accuracy. This study was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies and Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis guidelines. PubMed, EMBASE, Web of Science, and Cochrane databases were searched until 1 November 2023 for studies comparing ML models with traditional statistical methods for event prediction after PCI. The primary outcome was comparative discrimination measured by C-statistics with 95% confidence intervals (CIs) between ML models and traditional methods in estimating the risk of all-cause mortality, major bleeding, and the composite outcome major adverse cardiovascular events (MACE). Thirty-four models were included across 13 observational studies (4 105 916 patients). For all-cause mortality, the pooled C-statistic for top-performing ML models was 0.89 (95%CI, 0.84-0.91), compared with 0.86 (95% CI, 0.80-0.93) for traditional methods (P = 0.54). For major bleeding, the pooled C-statistic for ML models was 0.80 (95% CI, 0.77-0.84), compared with 0.78 (95% CI, 0.77-0.79) for traditional methods (P = 0.02). For MACE, the C-statistic for ML models was 0.83 (95% CI, 0.75-0.91), compared with 0.71 (95% CI, 0.69-0.74) for traditional methods (P = 0.007). Out of all included models, only one model was externally validated. Calibration was inconsistently reported across all models. Prediction Model Risk of Bias Assessment Tool demonstrated a high risk of bias across all studies. Machine learning models marginally outperformed traditional risk scores in the discrimination of MACE and major bleeding following PCI. While integration of ML algorithms into electronic healthcare systems has been hypothesized to improve peri-procedural risk stratification, immediate implementation in the clinical setting remains uncertain. Further research is required to overcome methodological and validation limitations.

Evaluation and management of aortic stenosis in chronic kidney disease

The combination of aortic stenosis (AS) and chronic kidney disease (CKD) represents a formidable clinical challenge commonly encountered in practice. Specific guidelines addressing the management of AS in CKD/end-stage kidney disease (ESKD) patients are lacking. This review addresses the unique epidemiological features, caveats relevant to diagnostic modalities and specific management considerations pertinent for AS in patients with CKD/ESKD. Transthoracic echocardiography remains the imaging modality of choice for establishing an accurate diagnosis and assessing severity of AS in this population. However, the presence of anatomical and hemodynamic alterations along with co-prevalent valve disease often necessitates complementary imaging including dobutamine stress echocardiography, cardiac computed tomography and magnetic resonance imaging. Management includes blood pressure control, addressing CKD-related metabolic bone disease, and the selection of optimal dialysis modality. For aortic valve replacement (AVR), the choice between mechanical versus biological prosthesis, as well as between surgical versus transcatheter approaches requires careful consideration of patient-specific factors, including life expectancy, bleeding risk, risk of acute kidney injury; as well as prosthesis specific considerations including durability and need for long-term anticoagulation. Patients with CKD/ESKD encounter higher periprocedural risks as well as worse long-term outcomes; yet AVR is associated with improved survival compared to conservative management. Shared-decision making with the patient is essential regarding choice of prosthesis. A multidisciplinary heart-kidney team is recommended for optimizing perioperative planning, hemodynamic/volume status and preventing acute kidney injury to ensure a balanced and comprehensive patient-centered strategy for managing AS in the context of CKD/ESKD.

Comorbidity burden and outcomes of endoscopic ultrasound-guided treatment of pancreatic fluid collections:Multicenter study with nationwide data-based validation.

The appropriate holistic management is mandatory for successful endoscopic ultrasound (EUS)-guided treatment of pancreatic fluid collections (PFCs). However, comorbidity status has not been fully examined in relation to clinical outcomes of this treatment. Using a multi-institutional cohort of 406 patients receiving EUS-guided treatment of PFCs in 2010-2020, we examined the associations of Charlson Comorbidity Index (CCI) with in-hospital mortality and other clinical outcomes. Multivariable logistic regression analysis was conducted with adjustment for potential confounders. The findings were validated using a Japanese nationwide inpatient database including 4053 patients treated at 486 hospitals in 2010-2020. In the clinical multi-institutional cohort, CCI was positively associated with the risk of in-hospital mortality (Ptrend < 0.001). Compared to patients with CCI = 0, patients with CCI of 1-2, 3-5, and ≥6 had adjusted odds ratios (95% confidence intervals) of 0.76 (0.22-2.54), 5.39 (1.74-16.7), and 8.77 (2.36-32.6), respectively. In the nationwide validation cohort, a similar positive association was observed; the corresponding odds ratios (95% confidence interval) were 1.21 (0.90-1.64), 1.52 (0.92-2.49), and 4.84 (2.63-8.88), respectively (Ptrend < 0.001). The association of higher CCI with longer length of stay was observed in the nationwide cohort (Ptrend < 0.001), but not in the clinical cohort (Ptrend = 0.18). CCI was not associated with the risk of procedure-related adverse events. Higher levels of CCI were associated with a higher risk of in-hospital mortality among patients receiving EUS-guided treatment of PFCs, suggesting the potential of CCI in stratifying the periprocedural mortality risk. The research based on the clinical data from the WONDERFULcohort was registered with UMIN-CTR (registration number UMIN000044130).

The role of computed tomography angiography and digital subtraction angiography in the diagnosis and management of gunshot wounds to the head

Introduction: Traumatic intracranial pseudoaneurysms (TICAs) and penetrating cerebrovascular injuries (PCVI) complicate gunshot wounds to the head (GSWH) and other forms of penetrating traumatic brain injury (pTBI). Recent developments in neuroimaging have allowed early detection of these lesions in the minutes and hours following the initial injury. CT angiography (CTA) and digitally subtracted angiography (DSA) have different sensitivity, periprocedural risks, and logistical limitations. Growing evidence is defining their role in clinical practice. Methods: A systematic review of the literature was performed for published articles treating the use of CTA and DSA to diagnose PCVI and TICAs after pTBI and GSWH. Four series, three retrospective and one prospective, were selected for this review. Results: In three retrospective and one prospective series (with a sensitivity of ~70% in the former studies vs 36% in the latter), DSA emerges as the modality of choice to study the intracranial vasculature of patients that suffered pTBI. Nonetheless, the use of CTA in the first hours after the injury can provide a wealth of information in emergent scenarios where TICAs and PCVIs can significantly affect surgical management and risk. Further, a significantly higher incidence of TICAs was reported in the first hours after civilian GSWH via CTA. Conclusions: DSA and CTA emerged as two complementary techniques in the study and management of PCVI and TICA related to pTBI and GSWH. Their integration can provide a safe approach to the emergent surgical management of vascular lesions via CTA, allowing for delayed DSA characterization after neurological and hemodynamical stabilization.

Unlocking Success: Strategies for Preventing and Managing Complications in Chronic Total Occlusion Percutaneous Coronary Intervention Procedures

Complications in percutaneous coronary intervention (PCI), particularly in chronic total occlusion (CTO) cases, pose notable challenges, with a mortality rate of approximately 0.4% during hospitalization, mainly due to issues like perforation and tamponade. While risk assessment tools can aid in evaluating periprocedural complication risk, prevention and preparedness take precedence. Guided by the "3 Ps" framework—prevention, preparedness, and planning—we navigate the complexities of managing complications in CTO PCI procedures. This emphasizes the importance of comprehensive patient discussions, adherence to appropriateness use criteria, and ensuring a well-trained team equipped with standardized equipment. Furthermore, it is crucial to extract valuable insights from encountered complications, turning potential setbacks into invaluable learning opportunities. This positive approach not only fosters individual growth but also contributes to the advancement of CTO PCI practices. Various complications specific to CTO PCI are addressed, including donor vessel injury, equipment loss/entrapment, radiation injury and coronary perforation.

Efficacy and safety of atrial fibrillation ablation in patients with aged 80 years or older.

Atrial fibrillation (AF) is the most common cardiac arrhythmia observed in the elderly. Its prevalence rises with age, particularly in individuals over 80 years old. While catheter ablation has emerged as a first line therapy for the patients with symptomatic AF, evidence on its application in elderly patients remains controversial. This study aimed to assess safety and efficacy outcomes of AF ablation in patients aged ≥ 80 years.Consecutive 1327 patients who underwent a first pulmonary vein isolation (PVI) for AF were retrospectively analyzed. Patients aged ≥ 80 years (elderly group, n = 107) were compared with patients aged < 80 years (younger group, n = 1220). At 1-year follow-up, there was no significant difference in AF free rate between the elderly and the younger group (72.0% vs. 73.9%, P = 0.786). Regarding major complications, the elderly patients had a greater incidence of periprocedural stroke (1.9% vs. 0.1%, P = 0.018). The rates of cardiac tamponade, phrenic palsy, and vascular complications were not significantly different between the 2 groups.PVI for AF is effective in patients aged ≥ 80 years with a similar success rate, but periprocedural stoke risk was higher compared to the younger population.

Coagulation disorders in liver cirrhosis - Diagnostics and management

Patients with liver cirrhosis often exhibit complex alterations in their hemostatic system that can be associated with both bleeding and thrombotic complications. While prophylactic correction of abnormal coagulation parameters should be avoided, an individualized approach is recommended prior to invasive procedures, whereby specific preventive measures to stabilize hemostasis should be based on the periprocedural bleeding risk. While the haemostatic system of patients with compensated cirrhosis is often in a rebalanced haemostatic state due to a parallel decline in both pro- and anti-haemostatic factors, a decompensation of liver cirrhosis can lead to destabilization of this fragile equilibrium. Since conventional coagulation tests do not adequately capture the complex changes in the hemostatic system in cirrhosis, functional analysis methods such as viscoelastic tests or thrombin generation assays can be used for evaluating the coagulation status. This review describes the underlying pathophysiological changes in the hemostatic system in liver cirrhosis, provides an overview of diagnostic methods and discusses therapeutic measures in case of bleeding and thrombotic complications.