Cardiology

Midwall fibrosis predicts risk but does not select patients who benefit more from early AVR in asymptomatic severe AS

In asymptomatic severe aortic stenosis with CMR-detected midwall fibrosis (n=224, median follow-up 42 months), higher fibrosis burden predicted the composite of death or unplanned AS hospitalization. Each 1% increase in fibrosis was associated with higher risk of the primary endpoint and AS-related hospitalization but not clearly with all-cause mortality alone. Among patients with fibrosis above the median, early AVR reduced AS-related hospitalizations versus conservative care but did not clearly lower mortality. There was no interaction between fibrosis burden and randomized strategy for primary or secondary outcomes, including in high-fibrosis patients. 1

Sirolimus-eluting balloon noninferior to usual care overall but inferior to repeat DES for single-layer ISR

In SELUTION4ISR (418 randomized; 390 per protocol), a sirolimus drug-eluting balloon was noninferior to usual care for 1-year target lesion failure (TLF). TLF occurred in 16.2% with the sirolimus balloon versus 14.5% with operator-selected usual care, satisfying the prespecified noninferiority margin. In single-layer ISR, the sirolimus balloon failed noninferiority versus DES, with higher TLF than repeat DES. Operator-selected analyses showed higher TLF with the balloon than DES but lower TLF versus plain balloon angioplasty. 2

Real-world TTVR delivers high success, near-complete TR elimination, and rapid symptomatic improvement

In 1,034 attempted TTVR procedures from the STS/ACC TVT Registry, implantation succeeded in 98.4% of patients with severe symptomatic TR. Mild-or-less TR was achieved in 98.4% post procedure and remained in 97.7% at 30 days, indicating durable early hemodynamic benefit. At 30 days, all-cause mortality was 3.1%, stroke 0.2%, major bleeding 7.9%, and heart failure hospitalization 3.1%. Functional status improved substantially, with 82.7% in NYHA class I/II and mean KCCQ-OS score increasing by 22.4 points at 30 days. 3

PCSK9 monoclonal antibodies lower 5-year MACE and mortality in ASCVD without prior ischemic events

This observational study included 19,670 ASCVD patients without prior ischemic events, comparing 6,545 PCSK9 inhibitor initiators with 13,125 matched non-initiators. Over 5 years, the composite of nonfatal MI, nonfatal ischemic stroke, or all-cause mortality was 17.5% with PCSK9 therapy versus 25.4% without. This corresponded to a 30.9% relative and 7.8% absolute risk reduction using intention-to-treat analysis with the parametric G-formula. Relative risk reductions for MI, ischemic stroke, and all-cause mortality were all around 25% to 30%, favoring PCSK9 initiation. 4