Mohamed, Ahmed

ABSTRACT Background In patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF), atrioventricular node ablation (AVNA) and permanent pacing are often pursued when rhythm control is not pursued. Biventricular pacing (BiVP) has demonstrated benefits over right ventricular pacing, while conduction system pacing (CSP) has emerged as an alternative. However, evidence directly comparing CSP with BiVP in this high‐risk population remains inconsistent. Objective To compare CSP versus BiVP in patients with AF and HFrEF undergoing AVNA, focusing on cardiac function, clinical outcomes, and procedural metrics. Methods Following PRISMA guidelines, we searched PubMed, Scopus, and Web of Science through February 2026 for studies comparing CSP and BiVP in adults with AF and HFrEF undergoing AVNA. Outcomes included all‐cause mortality, heart failure hospitalization (HFH), changes in left ventricular ejection fraction (LVEF), QRS duration, New York Heart Association (NYHA) class, pacing threshold, procedure duration, and fluoroscopy duration. A random‐effects model was used to pool mean differences (MDs) or risk ratios (RRs) with 95% confidence intervals (CIs). Results Six studies (one randomized crossover trial and five observational studies; N = 766 patients: CSP = 356, BiVP = 410) were included. All‐cause mortality was significantly reduced in favor of CSP (RR 0.64 [CI: 0.44 to 0.94], p = 0.02, I 2 = 0%). There was also a trend towards lower HFH, but it marginally missed statistical significance (RR 0.77 [CI: 0.58 to 1.03], p = 0.08; I 2 = 0%). Additionally, CSP decreased NYHA class (MD ‐0.64 [CI: −1.18 to −0.10], p = 0.02; I 2 = 85%) and significantly reduced QRS duration (MD −33.56 ms [CI: −52.36 to −14.76], p = 0.0005; I 2 = 97%). LVEF improvement did not significantly differ between groups (MD 4.51% [95% CI: −1.50 to 10.52], p = 0.14; I 2 = 98%). Procedure duration and fluoroscopy times did not show statistically significant difference between the two groups (MD −11.54 min [CI: −50.05 to 26.97], p = 0.56, I 2 = 96%), and (MD −5.75 min [CI: −13.13 to 1.63], p = 0.13, I 2 = 88%), respectively. Overall pacing thresholds did not significantly differ between CSP and BiVP; however, modality‐specific subgroup analysis showed comparable thresholds between HBP and BiVP, whereas LBBP was associated with significantly lower pacing thresholds than BiVP. Conclusions Among patients with AF and HFrEF undergoing AVNA, CSP may offer symptomatic and electrocardiographic advantages over BiVP, with a possible signal toward improved major clinical outcomes that requires confirmation in larger randomized studies.

ABSTRACT Observational studies comparing Impella and venoarterial extracorporeal membrane oxygenation (VA‐ECMO) in cardiogenic shock have reported inconsistent findings. We performed an updated systematic review and meta‐analysis, with exploratory matched‐cohort analyses where directly reportable propensity score–matched event‐level data were available. We searched PubMed, Scopus, Web of Science, and the Cochrane Library from inception through March 2026 for observational studies comparing Impella versus VA‐ECMO in adult patients with cardiogenic shock. The primary outcome was in‐hospital mortality. Secondary outcomes included all‐cause mortality, ICU outcomes, access site bleeding requiring transfusion, peripheral vascular complications, renal outcomes, and stroke. Random‐effects models using restricted maximum likelihood were applied. Fifteen observational studies including 22,618 patients were analyzed. In the primary crude analysis, Impella was not associated with a statistically significant difference in in‐hospital mortality (RR 0.84, 95% CI 0.66−1.07; p = 0.15) with substantial heterogeneity ( I ² = 92.9%). However, leave‐one‐out analysis identified an influential registry study; its exclusion markedly reduced heterogeneity and favored Impella ( p < 0.01). In exploratory propensity score‐matched analysis, Impella was also associated with lower in‐hospital mortality (RR 0.69, 95% CI 0.56−0.85, p < 0.01). Thirty‐day and 6‐month all‐cause mortality were neutral, whereas 12‐month mortality modestly favored Impella ( p = 0.048). Sensitivity analyses similarly resolved heterogeneity and favored Impella for selected secondary outcomes, including 6‐month mortality, acute kidney injury, and ischemic stroke. ICU mortality was neutral, while ICU length of stay was shorter with Impella ( p = 0.01). Impella was also associated with lower access site bleeding requiring transfusion ( p < 0.01), peripheral vascular complications ( p < 0.01), and hemorrhagic stroke ( p < 0.01). In this updated meta‐analysis of observational studies, the primary crude analysis of in‐hospital mortality was neutral overall but highly heterogeneous, whereas sensitivity and exploratory matched‐cohort analyses showed a more consistent association favoring Impella. Impella was also associated with lower bleeding and vascular complications and shorter ICU length of stay, although several outcomes remained sensitive to study‐level influence. These findings should be interpreted cautiously given the observational design, predominance of serious risk of bias, and strong potential for confounding by indication.

ABSTRACT Background The optimal long‐term antithrombotic strategy after apparently successful catheter ablation of atrial fibrillation (AF) remains uncertain, particularly in patients who meet conventional guideline thresholds for oral anticoagulation (OAC). Objectives To compare continuation versus cessation strategies of long‐term OAC after successful AF ablation and to quantify net clinical benefit (NCB) integrating thromboembolic and bleeding outcomes. Methods We searched PubMed, Cochrane CENTRAL, and Embase from inception through February 2026 for randomized and comparative observational studies evaluating long‐term OAC continuation versus cessation (no OAC and/or switch to aspirin) after successful AF ablation. Risk of bias was assessed using RoB2 for randomized trials and a modified Newcastle–Ottawa Scale (NOS) for observational studies. Random‐effects meta‐analyses used a restricted maximum likelihood estimator with Hartung–Knapp adjustment. NCB was calculated as: thromboembolic event rate − (1.5 × major bleeding rate). Results Six studies met the inclusion criteria (four randomized trials and two observational cohorts). Stroke/transient ischemic attack (TIA) events were reported in six studies and were not significantly different between OAC continuation and cessation strategies (OR 0.69; 95% CI 0.24–1.99; p = 0.49). Systemic embolism (three studies) did not differ between groups ( p = 0.12). Major bleeding (five studies) was numerically higher with continued OAC but not statistically significant (OR 2.07; 95% CI 0.88–4.86; p = 0.09). In NCB analysis, continued OAC yielded more negative or near‐neutral NCB values, whereas, the cessation strategies were less negative or marginally positive; the fixed‐effect risk difference in NCB (continued OAC vs cessation) was +0.00067 (95% CI −0.00279 to +0.00413). Conclusion This meta‐analysis suggests that after successful AF ablation, continuing OAC does not significantly reduce stroke risk compared to cessation or switching to aspirin, but it may increase major bleeding. While NCB trends favor cessation, the low absolute event rates and the risk of silent AF recurrence necessitate caution.

Introduction: Chronic total occlusion (CTO) is commonly encountered in patients with coronary artery disease and is associated with adverse outcomes, including increased short- and long-term mortality. While percutaneous coronary intervention (PCI) has shown potential clinical benefits in CTO patients, its comparative effectiveness against optimal medical therapy (OMT) remains debated. This meta-analysis aims to evaluate the impact of CTO-PCI versus OMT on key cardiovascular outcomes. Methods: We conducted a comprehensive search of Pubmed, Scopus, Web of science and Cochrane. We assessed outcomes including all-cause mortality, cardiac death, myocardial reinfarction, major adverse cardiac events (MACE), stroke, and repeat revascularization. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were calculated using a random-effects model. Statistical significance was defined as p<0.05. Results: 25 studies with a total of 22102 patients were included. Compared to OMT alone, CTO-PCI was associated with a significant reduction in the overall all-cause mortality (RR: 0.66; 95% CI: 0.53–0.82; p=0.0002), cardiovascular mortality (RR: 0.65; 95% CI: 0.52–0.82; p=0.0003) and MACE (RR: 0.84; 95% CI: 0.71–0.98; p=0.03). No statistically significant differences were observed between CTO-PCI and OMT in rates of Stroke (RR: 1.01; 95% CI: 0.68–1.50; p=0.96), Subsequent PCI/CABG (revascularization) (RR: 1.01; 95% CI: 0.78–1.29; p=0.97) or Heart Failure Hospitalization (RR: 0.77; 95% CI: 0.37–1.59; p=0.48) Conclusion: This is the largest and most updated systematic review meta analysis for CTO-PCI vs OMT. Our findings show that CTO-PCI is associated with significantly lower all-cause and cardiovascular mortality compared to OMT. However, no significant differences were observed between the two strategies in the incidence of stroke, need for subsequent revascularization (PCI/CABG), or heart failure hospitalization.

ABSTRACT Background Pulmonary vein isolation is a standard therapy for paroxysmal atrial fibrillation (AF). Pulsed field ablation (PFA) has emerged as a novel approach aiming to improve efficacy and safety over conventional thermal ablation (CTA) (radiofrequency and cryoballoon). This meta‐analysis evaluated outcomes of PFA versus thermal ablation in paroxysmal AF. Methods Electronic databases were searched through May 2025 for randomized controlled trials (RCTs) and observational studies that compared the efficacy and safety of PFA versus CTA. The primary outcome was AF recurrence. Summary estimates were conducted using random effects. Results A total of six studies, involving 1928 patients, were included. The incidence of AF recurrence was significantly lower among patients treated with PFA (risk ratio [RR] 0.67; 95% confidence interval [CI] 0.53–0.85). PFA was associated with a lower incidence of any atrial arrhythmia recurrence (RR 0.78, 95% CI: 0.61–0.99). The total procedure duration was significantly shorter with PFA (mean difference −21.46 min (95% CI: −26.04 to −16.88)), but there was no difference in fluoroscopy time. The rates of esophageal injury and phrenic nerve palsy were lower with PFA. However, the data were limited for these two outcomes, and a meta‐analysis was not conducted for them. There was no difference between the two groups in the incidence of stroke or pericardial tamponade. Conclusion Among patients with paroxysmal AF undergoing catheter ablation, PFA is associated with favorable outcomes, including lower recurrence and shorter procedure time compared to conventional ablation modalities.