الأبحاث والمنشورات

Objectives Acute intermediate–high-risk pulmonary embolism (PE) is associated with right-ventricular (RV) dysfunction, biomarker elevation, and risk of early clinical deterioration. Ultrasound-assisted catheter-directed thrombolysis (USAT) using the Eko Sonic Endovascular System (EKOS) system is increasingly used in selected patients; however, real-world data on physiological response and clinically relevant in-hospital outcomes remain limited. Methods We conducted a retrospective single-centre analysis of 128 consecutive patients with acute intermediate–high-risk PE treated with EKOS-guided USAT within a structured Pulmonary Embolism Response Team (PERT) pathway between August 2017 and December 2023. Changes in RV/LV ratio, B-type natriuretic peptide (BNP), and cardiac troponin before and after intervention were assessed. A composite end-point of death, extracorporeal membrane oxygenation (ECMO), renal replacement therapy, or invasive mechanical ventilation captured clinically meaningful deterioration. Multivariable logistic regression identified determinants of the composite end-point. Results RV/LV ratio and biomarkers improved significantly after intervention. Median RV/LV ratio decreased from 1.6 to 1.0, and BNP declined from 2365 to 877 pg/mL (both P < .001). Clinically meaningful in-hospital deterioration requiring escalation of organ support occurred in a subset of patients and was predominantly associated with baseline disease severity. Short-term survival remained favourable (60-day probability 96.9%). Conclusions In this real-world, PERT-guided cohort, EKOS was associated with rapid physiological improvement and favourable short-term survival in patients with intermediate–high-risk PE. These findings should be interpreted as descriptive single-centre experience.

Background Sex-related differences in outcomes after left ventricular assist device (LVAD) implantation are recognized, yet the structural mechanisms remain incompletely defined. We evaluated sex-specific remodeling patterns and the prognostic value of ventricular geometry and non-invasive myocardial work (MW). Methods We performed a retrospective analysis of 103 adults (85 men, 18 women) undergoing durable LVAD implantation. Primary endpoints were changes in left ventricular sphericity index (LVSI) and RV pressure–dimension index (PDI) from baseline to 6 months. Adjusted models (ANCOVA with robust standard errors) and quantile regression were used to assess sex effects, with robustness examined by a 1:2 propensity score matching analysis (matching on age, BMI, clinical profile, and device). Predictors of mortality and postoperative right heart failure (RHF) were assessed using Cox and logistic regression models, respectively. Results Baseline geometry and myocardial work were similar between sexes. Post-implantation, men exhibited adverse sphericalization (median ΔLVSI +0.045, p  = 0.001) and a significant decline in PDI (median Δ −1.475, p  < 0.001). In contrast, women demonstrated a pattern of “geometric resistance” [defined descriptively as stable left ventricular sphericity index (ΔLVSI p  = 0.766) and a non-significant change in RV pressure-dimension index (median ΔPDI −0.922, p  = 0.130)], while maintaining higher absolute PDI at 6 months ( p  = 0.041). While statistical significance was attenuated after 1:2 propensity-score matching, the matched-cohort estimates remained directionally consistent but imprecise: adjusted 6-month LVSI difference −0.060 (95% CI −0.189 to 0.069; p  = 0.342), adjusted mean PDI difference +0.276 (95% CI −0.589 to 1.140; p  = 0.510), and adjusted median PDI difference +0.828 (95% CI −0.150 to 1.806; p  = 0.095). Preoperative LVSI was independently associated with mortality (HR 1.47 per SD, p  = 0.034). Furthermore, preoperative global work index (GWI) was a robust independent predictor of both mortality (HR 0.14 per SD, p  < 0.001) and postoperative right heart failure (OR 0.41 per SD, p  = 0.022), with larger effect sizes than sex in adjusted models. Conclusion In this exploratory cohort, women showed preserved LV geometry and PDI after LVAD implantation, but findings require cautious interpretation due to small sample size and attenuation after matching. LVSI and myocardial work may support future risk stratification studies.

Whether women do worse than men after cardiac surgery is contested, largely because women tend to present with higher baseline risk, making raw comparisons unreliable. This analysis addressed that by matching rather than comparing crude groups.

Using data from the SUSTAIN-CSX trial (1,386 patients with complete data), women were matched 1:1 to men by age and EuroSCORE II, with exact matching on surgical category, producing 327 matched pairs.

Survival at 180 days did not differ significantly between women and men. Women had numerically longer intensive care and hospital stays, and after adjustment for residual imbalance — frailty, haemoglobin, renal disease, ejection fraction, previous infarction, preoperative medication and creatinine — female sex remained associated with longer intensive care stay (adjusted IRR 1.8) and hospital stay (adjusted IRR 1.4). Major complications were similar.

The paper is careful about what it does not show: the mortality estimates changed depending on the statistical model used, so they are reported as inconclusive rather than positive. The defensible finding is a longer recovery trajectory in women, not a difference in death.

Women have smaller aortic roots than men, so a valve that performs adequately in a man may be functionally too small in a woman — prosthesis–patient mismatch, which impairs recovery of the left ventricle. Sutureless valves offer a larger effective orifice for a given annulus, and this study asked whether that closes the gap.

We retrospectively analysed 139 patients (68 men, 71 women) undergoing Perceval sutureless aortic valve replacement between 2016 and 2020, grading mismatch by indexed effective orifice area under VARC-3 criteria and stratifying by body mass index.

Mismatch occurred in 74.6% of women against 22.1% of men, and the gap persisted among non-obese patients (47.9% versus 16.2%). Women received smaller valves and had lower indexed orifice areas despite comparable gradients; postoperatively they had lower indexed orifice area but higher ejection fraction. Early clinical outcomes were similar, and most mismatch was moderate.

The conclusion is that favourable sutureless haemodynamics do not overcome anatomical sex differences. Tailored strategies — aortic root enlargement, and sex-specific orifice-area thresholds — may improve valve selection for women.

Left ventricular assist devices keep patients alive in advanced heart failure, but their long-term problems are dominated by how the pump interacts with blood — pump thrombosis, ischaemic stroke and major bleeding. This multicentre study compared three generations of device in ordinary clinical practice rather than trial conditions.

We followed 327 adult recipients: 112 HeartWare (HVAD), 142 HeartMate II, and 73 HeartMate 3. Survival was analysed by Kaplan–Meier and Cox models, and blood-compatibility events were assessed with competing-risk methods that treat death as a competing event rather than ignoring it.

The third-generation centrifugal HeartMate 3 showed better long-term survival than both the axial-flow HeartMate II and the centrifugal HVAD, together with a lower burden of haemocompatibility-related adverse events across follow-up.

The finding supports the shift toward fully magnetically levitated pump design, and illustrates why competing-risk analysis matters in this population: patients who die cannot go on to have a stroke, and conventional methods overstate event rates if that is not accounted for.

Women have smaller aortic roots than men, so a replacement valve that performs well in a man can still be functionally too small in a woman — a problem called prosthesis–patient mismatch, which holds back recovery of the left ventricle. Sutureless valves give a larger opening area for a given annulus size, and this study asked whether that advantage is enough to close the gap between the sexes.

We reviewed 139 patients (68 men, 71 women) who received a Perceval sutureless aortic valve between 2016 and 2020, grading mismatch by indexed effective orifice area under VARC-3 criteria.

Mismatch was far more common in women than men (74.6% versus 22.1%). The difference persisted in non-obese patients, where body size cannot explain it away (47.9% versus 16.2%). Women received smaller valves and had consistently lower indexed orifice areas despite similar pressure gradients. Early clinical outcomes were nonetheless comparable between the sexes, and most mismatch was moderate rather than severe.

The practical message is that a sutureless valve does not by itself solve the anatomical problem. Planning for women may need to include root enlargement, and the thresholds used to define mismatch may themselves need to be sex-specific.

Mitral valve replacement has traditionally required splitting the breastbone. This randomised trial tested whether a thoracoscopic approach through a small right-sided incision gives comparable results.

One hundred patients with isolated mitral valve disease were randomly allocated to either video-assisted right anterolateral mini-thoracotomy or conventional median sternotomy.

The minimally invasive operation took significantly longer (291 versus 228 minutes). Every recovery measure, however, favoured it: intensive care stay fell from 3.8 to 2.1 days, time to extubation from 8.5 to 4.2 hours, postoperative blood loss from 449 to 272 mL, and hospital stay from 11.2 to 7.2 days. Pain scores were markedly lower, at 3.8 versus 7.6 on a visual analogue scale.

The trade-off is explicit: longer time in theatre buys a shorter, less painful recovery. For suitable patients, the thoracoscopic approach is a safe and effective alternative to sternotomy.

This study repeated the question of sex and prosthesis–patient mismatch using a different valve — the Edwards Intuity rapid-deployment prosthesis — to see whether the pattern held.

We included 256 patients (196 men, 60 women) who received isolated or combined rapid-deployment aortic valve replacement between 2018 and 2023, defining mismatch by indexed effective orifice area under VARC-3 criteria.

Mismatch was again substantially more common in women. Among patients with a body mass index below 30, it occurred in 55% of women compared with 13.3% of men; above that threshold, in 11.7% versus 2.0%. Severe mismatch occurred in 16.7% of non-obese women and in no men in that group. In-hospital mortality did not differ between the sexes, and multivariate regression identified no independent predictor of mismatch.

Taken with the sutureless valve findings, the pattern looks like anatomy rather than a property of any one prosthesis. The paper argues that because left ventricular geometry and function differ in women, the orifice-area thresholds used to define mismatch may need to be different for men and women rather than shared.

Right ventricular dysfunction is common after cardiac surgery and predicts poor outcomes. One suggested cause is simple and mechanical: the pericardium normally supports the thin-walled right ventricle, and it is routinely left open at the end of an operation. This study asked whether closing it again protects early right ventricular function.

We compared patients whose pericardium was closed against those left open, measuring right ventricular longitudinal function early after surgery by TAPSE and tricuspid annular systolic velocity. Because the two groups differed at baseline, comparisons were adjusted for baseline function, left ventricular strain, ejection fraction, ventricular volume, sex, procedure, and bypass and cross-clamp times, with correction for testing two primary endpoints.

Pericardial closure was independently associated with better early right ventricular function — TAPSE higher by 1.53 mm and tricuspid annular systolic velocity by 1.69 cm/s. Mixed-effects sensitivity analyses agreed.

This is a retrospective, adjusted finding rather than proof of cause, but it supports considering closure as a low-cost step to protect right ventricular performance, and it makes the case for a prospective trial.

Empyema necessitans is an uncommon and serious complication of pleural infection, in which pus tracks out of the pleural cavity through the chest wall and collects under the skin. It is rare in children, which is exactly why it is missed.

We report a one-year-old boy who presented with the condition, with Escherichia coli identified as the causative organism — an unusual pathogen in this setting. Treatment combined targeted antibiotics with drainage of the pleural collection, and the outcome was successful.

The clinical lesson is a simple one worth remembering: in a young child with an enlarging chest wall swelling, empyema necessitans belongs in the differential diagnosis. Early recognition and drainage, with paediatricians, thoracic surgeons, infectious disease specialists and interventional radiologists working together, is what determines the outcome.