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Background: Mixed venous oxygen saturation (SVO2), a direct marker of circulatory adequacy measured in the pulmonary artery, has been proposed as a more immediate reflection of perfusion compared to serum lactate, which can be delayed due to clearance variability and lab turnaround. While central venous oxygen saturation (ScVO2) is commonly used in shock management, data on the prognostic value of SVO2 remains inconsistent. This study evaluates whether trends in SVO2 and lactic acid over 72 hours are associated with ICU mortality, and whether monitoring SVO2 offers clinical benefit. Methods: From the MIMIC-IV ICU database (n=34,222), 3,149 patients with SVO2 measurements were included. Patients were stratified into four groups based on SVO2 and lactate trends from ICU admission to 72 hours: SVO2 Groups: BB: Below–Below: SVO2 <55% at both timepoints (q1: 51%, q3: 60%) BA: Below–Above: SVO2 <55% initially, improved to >65% (q1: 58%, q3: 68%) AA: Above–Above: SVO2 ≥65% consistently (q1: 72%, q3: 79%) AB: Above–Below: SVO2 >65% initially, dropped to <55% (q1: 62%, q3: 72%) Lactic Acid Groups: BB: Below–Below: <2 mmol/L throughout (q1: 1, q3: 1.6) BA: Below–Above: <2 initially, rose to >2 (q1: 1.5, q3: 2.8) AA: Above–Above: >2 consistently (q1: 2.6, q3: 5.4) AB: Above–Below: >2 initially, fell to <2 (q1: 1.6, q3: 2.9) We then constructed a heat map to compare %mortality at 30 days in these groups. Results: The highest mortality (100%) occurred in patients with persistently elevated lactate (>2 mmol/L) and low SVO2 (<55%) (group 3a). The second-highest mortality (75%) was observed in those with persistently elevated lactate but improved SVO2(3c). Notably, among patients with improved lactate, mortality was similar regardless of whether SVO2 improved or remained low ($a vs 4c). This suggests that lactic acid trends may be a more reliable prognostic marker than SVO2. Conclusion: Improvement in SVO2 over 72 hours does not necessarily correlate with improved ICU survival. Persistent hyperlactatemia remains a stronger predictor of mortality. These findings question the clinical utility and cost-effectiveness of routine SVO2 monitoring in ICU settings.

Background: Cardiac amyloidosis (CA) patients with reduced left ventricular ejection fraction (EF) are at increased risk for mortality. The benefit of cardiac resynchronization therapy (CRT) in terms of mortality reduction has not been established in this population. Aim: To evaluate the survival benefit of CRT, either CRT-D or CRT-P, in a large cohort of patients with cardiac amyloidosis and reduced EF. Methods: We retrospectively analyzed patients with confirmed CA and reduced EF (<40%) between 2009 and 2023 across Mayo Clinic sites. Patients were stratified into three groups: no device, CRT with pacemaker function (CRT-P), and CRT with defibrillator function (CRT-D). CRT devices were indicated for low ejection fraction less than 40% and patients who had chronic heart failure with a wide QRS. Kaplan-Meier survival estimates were generated, and log-rank tests were used for comparison. A secondary analysis was conducted combining CRT-P and CRT-D versus no device (EF <40%), and a tertiary analysis compared CRT-P versus CRT-D. Results: Among 184 patients [36 AL (20%), 148 ATTR (80%)], 38 (19%) had no cardiac device and EF <40%, 20 (11%) received CRT-P, and 116 (63%) received CRT-D. The median follow-up was 3.4 years (1.7, 5.0). The probability of survival was significantly higher in the CRT group compared to the no device-EF<40 group (Log Rank p=0.013; figure B). Among patients receiving CRT, there was no significant difference in all-cause mortality between those receiving CRT-P and those receiving CRT-D (Log Rank p=0.5; figure C). Conclusion: In patients with cardiac amyloidosis and reduced EF, CRT is associated with significantly improved survival compared to no device. No mortality difference was observed between CRT-P and CRT-D. Prospective studies are warranted.

Background: Patients with systemic right ventricle (sRV), including congenitally corrected transposition of great arteries (cc-TGA) and dextro-transposition of great arteries (d-TGA) post-atrial switch procedure are at risk of sudden cardiac death due to ventricular arrhythmias (VA). While programmed ventricular stimulation (PVS) can help with risk stratification in certain patients with congenital heart disease, its role in sRV is unknown. Objective: To study the diagnostic value of electrophysiology study (EPS) in predicting VAs in patients with sRV. Methods: EPS was performed in 53 patients with sRV at Mayo Clinic from 1994 to 2021. Patients with a history of sustained VA or cardiac arrest were excluded (n=19). The incidence of sustained VA (sudden cardiac death, sustained ventricular tachycardia [VT] or appropriate implantable cardioverter-defibrillator [ICD] therapy) was evaluated in the remaining 34 patients. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of EPS in predicting VAs is reported. Results: The mean age at EPS was 36.2±11.6 years, 21 (61.8%) were male, 21 (61.8%) had d-TGA and mean sRV ejection fraction was 31.3±10.8%. Indication for EPS was supraventricular tachycardias (n=15, 44.1%), syncope/palpitations (n=9, 26.5%) and non-sustained VT (n=6, 17.6%). 13/34 (38.2%) patients had inducible sustained VA, (5 [38.5%] with monomorphic VT and 8 [61.5%] with polymorphic VT/VF). Treatments included ICD implantation in all 13 patients and ablation in one patient. During a mean follow-up of 8±5.4 years, one patient with a positive PVS (inducible polymorphic VT) experienced sustained VT secondary to atrial flutter with 1:1 conduction. The sensitivity of PVS was 100%, specificity was 63.6%, PPV 7.7%, and NPV 100%. Conclusion: In this retrospective cohort of patients with sRV, polymorphic VT was the most commonly observed VA during PVS. The predictive value of a positive PVS was low in this cohort, and larger studies are needed to better define the role of EPS in risk stratification. Patients with negative EPS did not have future VAs recognizing that the overall event rate is low. Further multicenter research with a larger sample is required to develop predictive models to identify those at risk of VAs.

Background: Stroke is a devastating complication of transcatheter aortic valve replacement (TAVR). Cerebral embolic protection devices (CEPD) have been introduced to reduce TAVR-related stroke by capturing or deflecting debris during the procedure. While these devices can capture embolic material, their clinical benefit in preventing stroke remains uncertain. We aimed to determine whether the use of CEPD during TAVR reduces the incidence of periprocedural stroke. Methods: We performed a systematic review and meta-analysis of studies comparing TAVR with versus without CEPD. We searched PubMed, Embase, and ClinicalTrials.gov for RCTs (randomized controlled trials) comparing CEPDs to no protection in TAVR patients from 2011 to May 2025. Nine RCTs involving a total of 11,608 patients (CEPD group n=5,953; control n=5,655) were included. Stroke outcomes were defined according to Valve Academic Research Consortium-2 (VARC-2) criteria and categorized as- all stroke, disabling stroke, or non-disabling stroke. Risk ratios (RR) with 95% confidence intervals (CI) were calculated using a fixed-effects model. Heterogeneity also was measured. Results: Stroke rates were low and did not differ significantly between the CEPD (n=343) and control (n=319) groups. The incidence of all strokes was 1.96% with CEPD vs 1.88% without CEPD (RR 0.97, 95% CI 0.75–1.15; p=0.50). Disabling stroke occurred in 0.79% of CEPD patients vs 0.95% of controls (RR 0.79, 95% CI 0.57-1.10; p=0.16). Non-disabling stroke occurred in 1.26% of patients in both groups (RR 1.06, 95% CI 0.8 -1.40; p=0.64). There was no significant heterogeneity across trials is (0) for all endpoints. Notably, the largest trial in the analysis (BHF PROTECT-TAVI, n=7,635) showed no difference in stroke rates with CEPD, aligning with the overall results. Subgroup analyses revealed a trend toward fewer disabling strokes with CEPD use, but this trend was not statistically significant. Conclusion: We found no significant stroke risk reduction with the use of CEPDs during TAVR. While a trend toward fewer disabling strokes was observed, it was not statistically significant. Routine use of CEPDs is not supported, and selective use in high-risk patients warrants further large RCTs.

Background: Older adults with severe aortic stenosis (AS) are at high risk of mortality unless treated by aortic valve replacement (AVR). The Society of Thoracic Surgery (STS) score is primarily used clinically to determine mortality risk from surgical AVR. Due to geriatric comorbidities unique to older adults, traditional methods of risk stratification with STS may have significant shortcomings. Administratively derived risk scores that have prognostic significance in the geriatric population may prove valuable. Methods: We reviewed patients at our hospital system with AS undergoing AVR (surgical and transcatheter) and administratively derived an Elder Risk Assessment (ERA) score from the health record. The ERA score is a composite of age, marital status, number of hospitalized days in previous 2 years, and comorbidities (diabetes, coronary artery disease (CAD), heart failure, stroke, pulmonary disease, cancer, and dementia). Kaplan-Meier method was used to estimate survival by ERA score tertile. Cox regression was used to determine association between ERA and survival after accounting for STS predicted risk. Results: There were a total of 228 patients that underwent AVR (TAVR: 59 (26.1 %); SAVR 167 (73.9%) and had ERA scores derived. The average age was 79.6 (SD 7.6) years) and there were 93 (40.8%) women. Patients were stratified by ERA score tertiles: low (≤6), mid (6-13), or high (≥14). Over a mean follow up of 5.8 (SD 3.1) years, lower ERA scores were associated with better long-term survival (p<0.001). After accounting for age, sex, and STS score, mid ERA (HR 1.61; 95% CI 1.00-2.59; p<0.001) and high (HR 2.90; 95% CI 1.79-4.69; p<0.001) were associated with mortality (reference: low ERA). For every 10-point increase in the ERA, there was a 2-fold increase in adjusted mortality risk (HR 2.14; 95% CI 1.58-2.90; p<0.001). Conclusions: Older adults undergoing AVR for severe AS have specific geriatric comorbidities that may be better characterized using the ERA score. This administratively derived score was independently associated with survival after accounting for the widely used STS risk score.

Backround: Atrial fibrillation (AF) is a common complication following veno-venous extracorporeal membrane oxygenation (VV-ECMO), leading to further complications from anticoagulation or stroke. The Artificial Intelligence AF Prediction Dashboard developed at Mayo Clinic generates two predictive outputs: (1) a continuous probability score and (2) a binary threshold-based signal to predict the likelihood of AF at an individual level after 12-lead electrocardiogram (ECG) is obtained. Using both continuous risk (%) and binary (yes/no) likelihood, we present a novel method to understand AF risk after VV-ECMO cannulation based on pre-ECMO 12-lead ECG. Methods: We reviewed a total of 147 patients on ECMO between 2018 and 2024, from which 85 VV-ECMO patients with complete data were included. AI Dashboard outputs were quantified as binary (1/0) or percent likelihood for AF. R was utilized for statistical analysis. Results: 85 patients met our inclusion criteria from which AF after cannulation occurred in 31 (36%). 17 patients had a history of AF prior to VV-ECMO initiation. The mean age of our cohort was 49 years with a mean BMI of 29.3. Baseline AI Dashboard continuous assessment identified 39 patients (46%) compared to the binary assessment identifying 31 patients (36%). Logistic regression in the binary assessment demonstrated an odds ratio of 1.08 (95% CI 1.04 – 1.12) with a p value of <0.001. The binary AF Prediction yielded a 58% sensitivity, 76% specificity, 58% PPV, and 76% NPV, with an accuracy of 67%. The continuous AF Probability score achieved 72% balanced accuracy with sensitivity 74%, specificity 70%, PPV 59% and NPV 83%, indicating fair overall performance and suggesting good utility for ruling out AF in low-risk patients. Although both outputs provided moderate predictive accuracy, the continuous score reported before ECMO cannulation demonstrated stronger overall performance with fewer false negatives and higher rule-out value. Conclusions: We demonstrate the novel use of an AI predictive model in the VV-ECMO population for the prediction of AF risk with both continuous and binary risk cutoffs from baseline ECG. This data highlights the need for further development in ECMO-specific AI models to help mitigate risk after the onset of atrial arrhythmias. As AI-driven tools become increasingly integrated into care, their performance must be continuously validated and recalibrated for specific populations to ensure their safe and effective use.

Introduction: Peripheral Arterial Disease (PAD) is a prevalent condition associated with considerable morbidity and mortality, a burden that is further intensified by the frequent co-occurrence of hypertension. The coexistence of these conditions not only amplifies cardiovascular risks but also complicates clinical management, thereby contributing to elevated mortality rates. Although their correlation is well understood, mortality trends in United States have not been studied. Methods: This study utilized International Classification of Diseases, 10th Revision (ICD-10) codes to extract age-adjusted mortality data for individuals with PAD and hypertension from the CDC WONDER (Center for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) cohort. The overall sample and subgroups defined by demographics (age, sex, race/ethnicity) and region (state, census and urban-rural status) were analyzed. Trends in mortality were quantified by computing associated annual percentage changes (APC) using Joinpoint Regression Program Version 4.9.0.0 trend analysis software. Results: A total of 540954 deaths were observed, of which 260517 were men (48.2%). Overall, the age-adjusted mortality rates (AAMR) exhibited a sharp increase from 1999 to 2001 (APC:25.3; 95% CI: -0.36,56.2), followed by a sustained decrease until 2017 (APC: -2.16; 95% CI: -11.1, -1.52), after which a notable upward trend was observed (APC:9.38; 95% CI: -0.38,24.1). A similar AAMR trend was seen on gender-based subgroup analysis with male patients showing the highest AAMR 13.5 (95% CI: 13.1,13.7) in 2020. Amongst all racial groups, Black or African American showed the highest 14.9 (95% CI: 14.8-15) while Asian or Pacific Islander showed the lowest 5.8 (95% CI: 5.7-5.9) AAMR over 2 decades. The West region had the highest overall age-adjusted mortality rate (AAMR) of 10.2 (95% CI: 10.2-10.3). Among individual states, Vermont displayed the highest AAMR, reaching 15.8 (95% CI: 15.1-16.5). Conclusion: Healthcare disparities are evident. The unprecedented recent increase in mortality rates, following years of successful decline, necessitates a thorough evaluation of healthcare policies and PAD treatment advancements to identify the causative factors behind this trend reversal.

Background: Sepsis survivors experience substantial long-term cardiovascular (CV) morbidity and mortality. The pooled-cohort atherosclerotic cardiovascular disease (ASCVD) score estimates 10-year risk in the general population, but its accuracy soon after sepsis is unknown. Objectives: (1) Describe the absolute five-year incidence of major adverse cardiovascular events (MACE) after sepsis hospitalization. (2) Evaluate the discrimination and calibration of the 10-year ASCVD score for predicting five-year MACE in this setting. Research Questions: The ASCVD score would underpredict five-year MACE in sepsis survivors, reflecting their heightened risk. Methods: We performed a retrospective closed-cohort study using electronic health records from Mayo Clinic hospitals (USA). Adults aged 40–75 years hospitalized for sepsis between 2018 and 2020 were eligible if follow-up was ≥5 years; the age criterion matched the derivation range of the ASCVD score. The primary outcome was five-year MACE—myocardial infarction (MI), ischemic or hemorrhagic stroke, or CV death. Secondly we evaluated the predictive performance of ASCVD score for five-year MACE. Discrimination was assessed with the area under the receiver-operating curve (AUROC); calibration with Calibration-in-the-Large (CITL, ideal = 0) and slope (ideal = 1). Performance metrics were calculated in patients with complete ASCVD variables. Results: A total of 6306 sepsis admissions were screened. 2424 patients were excluded for age outside 40–75 years and 879 for <5 year follow-up, leaving 2718 patients for incidence analyses. Median age was 65 years (IQR 56–70); 55 % were male, 38 % required ICU care, and 91 % were White. Median body-mass index was 28.2 kg/m2 (IQR 23.7-34.7). During follow-up, 125 patients (4.6 %) had MI, 219 (8.1 %) experienced stroke, and 303 (11.1 %) died of CV causes; overall, 1573 patients (57.9 %) met the composite MACE outcome. Complete ASCVD data were available for 409 patients. In this subset, discrimination was moderate (AUROC 0.65; 95 % CI 0.59–0.71). Calibration showed CITL +0.34 (95 % CI 0.09–0.59) and slope 0.50 (95 % CI 0.28–0.72), indicating systematic infra-prediction and over-fitting, respectively. Conclusion: Five-year MACE incidence after sepsis is high. The 10-year ASCVD score moderately discriminates but underestimates five-year CV risk in this population, highlighting the need for sepsis-specific predictive models or recalibration to guide targeted post-sepsis cardiovascular prevention.

Background: We conducted an updated meta-analysis of the routine use of cerebral embolic protection (CEP) devices in Transcathter Aortic Valve Replacement (TAVR). This analysis follows the recent BHF PROTECTED TAVI trial which is the largest randomized controlled trial to date. Methods: Electronic databases were searched through April 2025 for eligible randomized controlled trials (RCTs). The primary outcome was overall incidence of stroke, disabling stroke and non-disabling stroke all reported at 2-5 days and 30 days were primary outcomes for our analyses. Results: 8 RCTs with a total of 11,692 patients were included. No statistically significant difference was found between CEP group and the control group in overall stroke incidence at 2-5 days and 30 days as the following (RR=0.95, 95%CI: [0.75,1.19], p=0.64) and (RR=0.93, 95%CI: [0.57,1.53], p=0.79). Similarly, the pooled analysis revealed no statistically significant difference between the two groups in terms of disabling stroke at 2-5 days (RR=0.70, 95%CI: [0.41,1.18], p=0.18), and at 30 days (RR=1.18, 95%CI: [0.36,3.87], p=0.78). CEP group and control group didn’t show statistically significant difference in non- disabling stroke at 2-5 days and 30 days as the results showed: (RR=1.17, 95%CI: [0.84,1.63], p=0.36) and (RR=0.86, 95%CI: [0.49,1.51], P=0.61) respectively. Conclusion: Our meta-analysis found no statistically significant evidence that cerebral embolic protection (CEP) devices reduce the incidence of stroke—disabling or non-disabling in the 2-5 days following TAVR or after 30 days. Major bleeding, major vascular complication and AKI showed no statistically significant results indicating a neutral safety profile.

Introduction: Language barriers represent an often-overlooked determinant of health equity. This study evaluates the impact of limited English proficiency (LEP) on major adverse cardiac events (MACE) and mortality in patients undergoing cardiovascular surgery. We hypothesized that patients with LEP have a higher incidence of adverse outcomes compared to English proficient patients. Methods: We conducted a retrospective cohort study using Cosmos, a longitudinal national electronic health record dataset. Patients were classified as having LEP if their record indicated a preferred language other than English. Adult patients aged 18-95 years who underwent coronary artery bypass grafting, valvular surgery, or thoracic aorta surgery in the United States (January 2016 - February 2025) were included. Exclusion criteria were missing language data, first in-person encounter <1 year prior to surgery, history of metastatic cancer or dialysis, and nursing home residence within 90 days of surgery. The primary outcome was MACE, a composite of stroke, revascularization, and hospitalization for myocardial infarction or heart failure. The secondary outcome was all-cause mortality. The cumulative incidence of MACE was estimated via a competing risk framework, while the cumulative incidence of mortality was estimated with the Kaplan-Meier method. Multivariate Cox proportional hazard regressions were fitted for all outcomes. Results: The cohort included 12,706 LEP patients (28.8% female) and 393,612 English-proficient patients (33.2% female). Differences in baseline characteristics included age, race, and comorbidity burden. The unadjusted cumulative incidence of MACE was higher in LEP patients, but all-cause mortality was lower (Figure 1). Over the follow-up period, the incidence rate of MACE for English proficient patients vs LEP was 185 vs 219 per 1000 patient years and 39 vs 36 per 1000 patient years for mortality. The adjusted hazard ratio for MACE was 0.97 (95% CI: 0.94 - 1.01, p = 0.19) and 0.89 (95% CI: 0.83 - 0.95, p <0.001) for mortality. Conclusions: LEP was associated with higher unadjusted cumulative incidence of MACE and lower mortality, but only the association with mortality persisted after regression analysis. Our findings highlight the need for further research into the impact of language proficiency on outcomes after cardiac surgery and the potential benefit of targeted interventions to address language-related disparities.