Decompression Illness in Divers With or Without Patent Foramen Ovale : A Cohort Study.

BACKGROUND: In previous studies, the prevalence of patent foramen ovale (PFO) has been reported to be higher in scuba divers who experienced decompression illness (DCI) than in those who did not. OBJECTIVE: To assess the association between PFO and DCI in scuba divers. DESIGN: Prospective cohort study. SETTING: Tertiary cardiac center in South Korea. PARTICIPANTS: One hundred experienced divers from 13 diving organizations who did more than 50 dives per year. MEASUREMENTS: Participants had transesophageal echocardiography with a saline bubble test to determine the presence of a PFO and were subsequently divided into high- and low-risk groups. They were followed using a self-reported questionnaire while blinded to their PFO status. All of the reported symptoms were adjudicated in a blinded manner. The primary end point of this study was PFO-related DCI. Logistic regression analysis was done to determine the odds ratio of PFO-related DCI. RESULTS: Patent foramen ovale was seen in 68 divers (37 at high risk and 31 at low risk). Patent foramen ovale-related DCI occurred in 12 divers in the PFO group (non-PFO vs. high-risk PFO vs. low-risk PFO: 0 vs. 8.4 vs. 2.0 incidences per 10 000 person-dives; P = 0.001) during a mean follow-up of 28.7 months. Multivariable analysis showed that high-risk PFO was independently associated with an increased risk for PFO-related DCI (odds ratio, 9.34 [95% CI, 1.95 to 44.88]). LIMITATION: The sample size was insufficient to assess the association between low-risk PFO and DCI. CONCLUSION: High-risk PFO was associated with an increased risk for DCI in scuba divers. This finding indicates that divers with high-risk PFO are more susceptible to DCI than what has been previously reported and should consider either refraining from diving or adhering to a conservative diving protocol. PRIMARY FUNDING SOURCE: Sejong Medical Research Institute.

Efficacy and Safety of 3 Versus 6 Months of Dual-Antiplatelet Therapy in Patients Implanted With a Coroflex ISAR Stents: A Prospective, Multicenter, Randomized Clinical Trial.

BACKGROUND: The optimal duration of dual-antiplatelet therapy (DAPT) after implantation of a drug-eluting stent (DES), especially recently developed polymer-free DESs, is unknown. This study examined the efficacy and safety of 3- versus 6-month DAPT in patients implanted with Coroflex ISAR polymer-free DESs. METHODS: Between May 2015 and August 2020, 488 patients who underwent Coroflex ISAR stent implantation were enrolled in the study and randomly assigned to the 3-month (n=244) or 6-month (n=244) DAPT group. RESULTS: At 1 year, the primary endpoint (composite of cardiovascular death, myocardial infarction, target vessel revascularization, and Bleeding Academic Research Consortium [BARC] type 2-5 bleeding) occurred in 9 (3.7%) patients in the 3-month DAPT group and in 7 (2.9%) patients in the 6-month DAPT group (hazard ratio 1.31; P=.60). There was no difference between the 3- and 6-month DAPT groups in either BARC type 2-5 bleeding (1.6% vs 0.8%; hazard ratio 2.00; P=.42) or any bleeding (2.9% vs 3.3%; hazard ratio 0.87; P=.80). CONCLUSION: Compared with 6 months of DAPT, 3 months of DAPT did not increase the risk of primary endpoint 1 year after Coroflex ISAR stent implantation, although it should be noted that the trial has limited power to see differences due to low event rate and low recruitment rate.

Effects of deferred versus immediate stenting on left ventricular function in patients with ST elevation myocardial infarction.

BACKGROUND: Previous studies have shown conflicting results on the benefits of deferred stenting (DS) in infarct size and the incidence of microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, effect of DS on left ventricular (LV) function was not known. We aimed to evaluate whether DS improve LV function and relevant clinical outcomes after STEMI, using follow-up data from the INNOVATION study (NCT02324348). METHODS: In total, 114 patients were randomly assigned to DS group or immediate stenting (IS) group at a 1:1 ratio. LV functional remodeling indices and MACE (major adverse cardiac events: a composite of death, non-fatal MI, unplanned target vessel revascularization, or hospitalization due to heart failure) were compared between DS and IS groups. RESULTS: Serial echocardiographic analyses were completed in 89 subjects (78%). There were no significant changes in LV volume in either group. While LV ejection fraction and wall motion score index (WMSI) improved in both groups during follow-up, the increments were not statistically different between the 2 groups (4.3 ±â€Š8.2 vs 3.2 ±â€Š7.1, P = .504 for ΔLV ejection fraction; -0.16 ±â€Š0.25 vs -0.16 ±â€Š0.25, P = .99 for ΔWMSI). However, E/e'' was decreased and e' was increased only in the DS group (-3.31 ±â€Š5.60 vs -0.46 ±â€Š3.10, P = .005 for ΔE/e'; 0.77 ±â€Š1.71 vs -0.22 ±â€Š1.64, P = .009 for Δe'). The incidence of major adverse cardiac events was numerically lower in the DS group than in the IS group without a statistical significance at 1-year follow-up. CONCLUSIONS: Routine DS improved LV diastolic function but not systolic function compared with IS in patients with STEMI.

Percutaneous Left Atrial Appendage Occlusion Yields Favorable Neurological Outcomes in Patients with Non-Valvular Atrial Fibrillation.

BACKGROUND AND OBJECTIVES: Prior studies have shown that stroke patients treated with percutaneous left atrial appendage occlusion (LAAO) for non-valvular atrial fibrillation (NVAF) experience better outcomes than similar patients treated with warfarin. We investigated the impact of percutaneous left atrial appendage closure on post-stroke neurological outcomes in NVAF patients, compared with non-vitamin K antagonist oral anticoagulant (NOAC) therapy. METHODS: Medical records for 1,427 patients in multiple registries and for 1,792 consecutive patients at 6 Korean hospitals were reviewed with respect to LAAO or NOAC treatment. Stroke severity in patients who experienced ischemic stroke or transient ischemic attack after either treatment was assessed with modified Rankin Scale (mRS) scoring at hospital discharge and at 3 and 12 months post-stroke. RESULTS: mRS scores were significantly lower in LAAO patients at 3 (p<0.01) and 12 months (p<0.01) post-stroke, despite no significant differences in scores before the ischemic cerebrovascular event (p=0.22). The occurrences of disabling ischemic stroke in the LAAO and NOAC groups were 36.7% and 44.2% at discharge (p=0.47), 23.3% and 44.2% at 3 months post-stroke (p=0.04), and 13.3% and 43.0% at 12 months post-stroke (p=0.01), respectively. Recovery rates for disabling ischemic stroke at discharge to 12 months post-stroke were significantly higher for LAAO patients (50.0%) than for NOAC patients (5.6%) (p<0.01). CONCLUSIONS: Percutaneous LAAO was associated with more favorable neurological outcomes after ischemic cerebrovascular event than NOAC treatment.

Comparison of clinical outcomes between multiple antithrombotic therapy versus left atrial appendage occlusion with dual antiplatelet therapy in patients with atrial fibrillation undergoing drug-eluting stent implantation.

BACKGROUND: Complex antithrombotic regimens are recommended for patients with atrial fibrillation (AF) undergoing drug-eluting stent (DES) implantation but carry high bleeding risk. HYPOTHESIS: We aimed to evaluate whether left atrial appendage occlusion (LAAO) with dual antiplatelet therapy (DAPT) improve clinical outcomes when compared with multiple antithrombotic therapy (MAT) in patients with AF undergoing DES implantation. METHODS: Among 475 AF patients who underwent DES, 41 patients treated by LAAO with DAPT and 434 patients on MAT were compared. MAT was defined as any combination of warfarin-based antithrombotic therapy. Among the MAT group, 34.8% were on triple antithrombotic therapy. The primary endpoint was a net adverse clinical event (NACE), a composite of cerebrovascular accident (CVA) and major bleeding. Secondary endpoints were CVA, major bleeding, major adverse cardiac and cerebral event (MACCE), MI, cardiovascular death, and all-cause death. Additional analysis between the new oral anticoagulant (NOAC)-based antithrombotic therapy group (n = 45) and the LAAO group was performed for the same endpoints. To adjust the confounding factors, inverse probability of treatment weighting (IPTW) was applied during the endpoint analysis. RESULTS: The LAAO group showed higher incidences of diabetes mellitus, prior CVA, higher CHA2DS2-VASc score (4.56±1.55 vs. 2.96±1.60; P<0.0001), and higher HAS-BLED score (3.24±1.20 vs. 2.13±0.75; P<0.0001). NACE occurred less frequently in the LAAO group than the MAT group at 24 months (9.4% vs. 15.3%; hazard ratio 0.274; 95% confidence interval 0.136 - 0.553; P = 0.0003), mainly driven by the reduction in major bleeding (2.4% vs. 9.3%; hazard ratio 0.119; 95% confidence interval 0.032 - 0.438; P = 0.001). The LAAO group with greater thrombotic and hemorrhagic risks showed comparable primary/secondary outcomes with the NOAC-based anti-thrombotic therapy group. CONCLUSIONS: Among patients with AF who underwent DES implantation, the LAAO group had better net clinical outcomes for preventing CVA and major bleeding than the MAT group. Further large-scale trials including comparisons with NOACs are warranted.

Differential clinical impact of chronic total occlusion revascularization based on left ventricular systolic function.

BACKGROUND: The effect of chronic total occlusion (CTO) revascularization on survival remains controversial. Furthermore, data regarding outcome differences for CTO revascularization based on left ventricular systolic function (LVSF) are limited. The differential outcomes from CTO revascularization in patients with preserved LVSF (PLVSF) versus reduced LVSF (RLVSF) were assessed. METHODS: A total of 2,173 CTO patients were divided into either a PLVSF (n = 1661, Ejection fraction ≥ 50%) or RLVSF (n = 512, < 50%) group. Clinical outcomes were compared between successful CTO revascularization (SCR) versus optimal medical therapy (OMT) within each group. The primary endpoint was a composite of all-cause death or non-fatal myocardial infarction. Inverse probability of treatment weighting for endpoint analysis and a contrast test for comparison of survival probability differences according to LVSF were used. RESULTS: Patients with RLVSF had a mean 37% ejection fraction (EF) and 19% had EF < 30%. The median follow-up duration was 1,138 days. Regardless of LVSF, the primary endpoint incidence was significantly lower in patients treated with SCR [RLVSF: 29.7% vs. 49.7%, hazard ratio (HR) = 0.46, 95% confidence interval (CI): 0.36-0.62, p < 0.0001; PLVSF 7.3% vs. 16.9%, HR = 0.68, 95% CI: 0.54-0.93, p = 0.0019], which was mainly driven by a reduction in cardiac death. The difference in survival probability was greater and became more pronounced over time in patients with RLVSF than with PLVSF (1-year, p = 0.197; 3-years, p = 0.048; 5-years, p = 0.036). CONCLUSIONS: SCR was associated with better survival benefit than OMT regardless of LVSF. The benefit was greater and became more significant over time in patients with RLVSF versus PLVSF.

Optimal strategy for side branch treatment in patients with left main coronary bifurcation lesions.

INTRODUCTION AND OBJECTIVES: There are no guidelines regarding the most appropriate approach for provisional side branch (SB) intervention in left main (LM) bifurcation lesions. METHODS: The present prospective, randomized, open-label, multicenter trial compared conservative vs aggressive strategies for provisional SB intervention during LM bifurcation treatment. Although the trial was designed to enroll 700 patients, it was prematurely terminated due to slow enrollment. For 160 non-true bifurcation lesions, a 1-stent technique without kissing balloon inflation was applied in the conservative strategy, whereas a 1-stent technique with mandatory kissing balloon inflation was applied in the aggressive strategy. For 46 true bifurcation lesions, a stepwise approach was applied in the conservative strategy (after main vessel stenting, SB ballooning when residual stenosis> 75%; then, SB stenting if residual stenosis> 50% or there was a dissection). An elective 2-stent technique was applied in the aggressive strategy. The primary outcome was a 1-year target lesion failure (TLF) composite of cardiac death, myocardial infarction, or target lesion revascularization. RESULTS: Among non-true bifurcation lesions, the conservative strategy group used a smaller amount of contrast dye than the aggressive strategy group. There were no significant differences in 1-year TLF between the 2 strategies among non-true bifurcation lesions (6.5% vs 4.9%; HR, 1.31; 95%CI, 0.35-4.88; P=.687) and true bifurcation lesions (17.6% vs 21.7%; HR, 0.76; 95%CI, 0.20-2.83; P=.683). CONCLUSIONS: In patients with a LM bifurcation lesion, conservative and aggressive strategies for a provisional SB approach have similar 1-year TLF rates.

Additional postdilatation using noncompliant balloons after everolimus-eluting stent implantation: Results of the PRESS trial.

BACKGROUND: There are limited data on the clinical value of routine postdilatation using noncompliant balloons after contemporary drug-eluting stent implantation. HYPOTHESIS: Additional postdilatation using noncompliant balloons after everolimus-eluting stent implantation could provide better clinical outcomes. METHODS: We randomly assigned 1774 patients with coronary artery disease to undergo additional high-pressure postdilatation using noncompliant balloons and moderate-pressure dilatation using stent balloons after everolimus-eluting stent implantation. The primary endpoint was a composite of death, myocardial infarction (MI), stent thrombosis, and target vessel revascularization (TVR) 2 years after randomization. RESULTS: The study was discontinued early owing to slow enrollment. In total, 810 patients (406 patients in the high pressure group and 404 in the moderate pressure group) were finally enrolled. At 2 years, the primary endpoint occurred in 3.6% of patients in the high pressure group and in 4.4% of those in the moderate pressure group (P = .537). In addition, no significant differences were observed between the two groups in the occurrence of an individual end point of death (0.8% in the high pressure group vs 1.5% in the moderate group, P = .304), MI (0.2% vs 0.5%, P = .554), stent thrombosis (0% vs 0.2%, P = .316), or TVR (2.8% vs 2.6%, P = .880). CONCLUSIONS: The strategy of routine postdilatation using noncompliant balloons after everolimus-eluting stent implantation did not provide incremental clinical benefits.

Complications of veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock or cardiac arrest.

BACKGROUND: The frequency of using veno-arterial extracorporeal membrane oxygenation increased, especially in patients with refractory cardiogenic shock or cardiac arrest. However, data of complications of veno-arterial extracorporeal membrane oxygenation are lacking. This study sought to investigate the incidence of veno-arterial extracorporeal membrane oxygenation complications for acute myocardial infarction patients with refractory cardiogenic shock or cardiac arrest and its relationship with patient survival. METHODS: This study included 151 consecutive patients who underwent veno-arterial extracorporeal membrane oxygenation between 2006 and 2018 at a single referral center. We divided the patients into those who survived for 30 days after veno-arterial extracorporeal membrane oxygenation (n = 57, 38%; group 1) and those who died within 30 days after veno-arterial extracorporeal membrane oxygenation support (n = 94, 62%; group 2). The major adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation were defined as first occurrence of infection, major bleeding, and stroke. RESULTS: Adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation occurred in 34 (59.6%) and 56 (59.6%) patients in groups 1 and 2, respectively. Group 2 had more patients who underwent new renal replacement therapy (21.1% vs 37.2%, p = 0.037). After multivariable analysis, cardiac arrest was independently associated with 30-day mortality (odds ratio = 3.6; 95% confidence interval = 1.7-7.63; p = 0.001). After excluding patients who died within 48 h after undergoing veno-arterial extracorporeal membrane oxygenation, new renal replacement therapy (odds ratio = 4.47; 95% confidence interval = 1.58-12.61; p = 0.005) and major adverse clinical events (odds ratio = 2.66; 95% confidence interval = 1.01-7.03; p = 0.049) were independently associated with 30-day mortality. CONCLUSION: Although veno-arterial extracorporeal membrane oxygenation can improve the survival, it is associated with morbidity. Therefore, risk-benefit analysis for veno-arterial extracorporeal membrane oxygenation and prevention of complications are important to improve prognosis.

A comparison of procedural success rate and long-term clinical outcomes between in-stent restenosis chronic total occlusion and de novo chronic total occlusion using multicenter registry data.

BACKGROUND: There have been little data about outcomes of percutaneous coronary intervention (PCI) for in-stent restenosis (ISR) chronic total occlusion (CTO) in the drug eluting stent (DES) era. This study aimed to compare the procedural success rate and long-term clinical outcomes of ISR CTO and de novo CTO. METHODS AND RESULTS: Patients who underwent PCI for ISR CTO (n = 164) versus de novo CTO (n = 1208) were enrolled from three centers in Korea between January 2008 and December 2014. Among a total of ISR CTO, a proportion of DES ISR CTO was 79.3% (n = 130). The primary outcome was major adverse cardiac events (MACEs); a composite of all-cause death, non-fatal myocardial infarction (MI), or target lesion revascularization (TLR). Following propensity score-matching (1:3), the ISR CTO group (n = 156) had a higher success rate (84.6% vs. 76.0%, p = 0.035), mainly driven by high success rate of PCI for DES ISR CTO (88.6%), but showed a higher incidence of MACEs [hazard ratio (HR): 2.06; 95% confidence interval (CI) 1.37-3.09; p < 0.001], mainly driven by higher prevalence of MI [HR: 9.71; 95% CI 2.06-45.81; p = 0.004] and TLR [HR: 3.04; 95% CI 1.59-5.81; p = 0.001], during 5 years of follow-up after successful revascularization, as compared to the de novo CTO group (n = 408). CONCLUSION: The procedural success rate was higher in the ISR CTO than the de novo CTO, especially in DES ISR CTO. However, irrespective of successful revascularization, the long-term clinical outcomes for the ISR CTO were significantly worse than those for the de novo CTO, in terms of MI and TLR.

Comparing the performance of artificial intelligence and conventional diagnosis criteria for detecting left ventricular hypertrophy using electrocardiography.

AIMS: Although left ventricular hypertrophy (LVH) has a high incidence and clinical importance, the conventional diagnosis criteria for detecting LVH using electrocardiography (ECG) has not been satisfied. We aimed to develop an artificial intelligence (AI) algorithm for detecting LVH. METHODS AND RESULTS: This retrospective cohort study involved the review of 21 286 patients who were admitted to two hospitals between October 2016 and July 2018 and underwent 12-lead ECG and echocardiography within 4 weeks. The patients in one hospital were divided into a derivation and internal validation dataset, while the patients in the other hospital were included in only an external validation dataset. An AI algorithm based on an ensemble neural network (ENN) combining convolutional and deep neural network was developed using the derivation dataset. And we visualized the ECG area that the AI algorithm used to make the decision. The area under the receiver operating characteristic curve of the AI algorithm based on ENN was 0.880 (95% confidence interval 0.877-0.883) and 0.868 (0.865-0.871) during the internal and external validations. These results significantly outperformed the cardiologist's clinical assessment with Romhilt-Estes point system and Cornell voltage criteria, Sokolov-Lyon criteria, and interpretation of ECG machine. At the same specificity, the AI algorithm based on ENN achieved 159.9%, 177.7%, and 143.8% higher sensitivities than those of the cardiologist's assessment, Sokolov-Lyon criteria, and interpretation of ECG machine. CONCLUSION: An AI algorithm based on ENN was highly able to detect LVH and outperformed cardiologists, conventional methods, and other machine learning techniques.

Deep-learning-based risk stratification for mortality of patients with acute myocardial infarction.

OBJECTIVE: Conventional risk stratification models for mortality of acute myocardial infarction (AMI) have potential limitations. This study aimed to develop and validate deep-learning-based risk stratification for the mortality of patients with AMI (DAMI). METHODS: The data of 22,875 AMI patients from the Korean working group of the myocardial infarction (KorMI) registry were exclusively divided into 12,152 derivation data of 36 hospitals and 10,723 validation data of 23 hospitals. The predictor variables were the initial demographic and laboratory data. The endpoints were in-hospital mortality and 12-months mortality. We compared the DAMI performance with the global registry of acute coronary event (GRACE) score, acute coronary treatment and intervention outcomes network (ACTION) score, and the thrombolysis in myocardial infarction (TIMI) score using the validation data. RESULTS: In-hospital mortality for the study subjects was 4.4% and 6-month mortality after survival upon discharge was 2.2%. The areas under the receiver operating characteristic curves (AUCs) of the DAMI were 0.905 [95% confidence interval 0.902-0.909] and 0.870 [0.865-0.876] for the ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI) patients, respectively; these results significantly outperformed those of the GRACE (0.851 [0.846-0.856], 0.810 [0.803-0.819]), ACTION (0.852 [0.847-0.857], 0.806 [0.799-0.814] and TIMI score (0.781 [0.775-0.787], 0.593[0.585-0.603]). DAMI predicted 30.9% of patients more accurately than the GRACE score. As secondary outcome, during the 6-month follow-up, the high risk group, defined by the DAMI, has a significantly higher mortality rate than the low risk group (17.1% vs. 0.5%, p < 0.001). CONCLUSIONS: The DAMI predicted in-hospital mortality and 12-month mortality of AMI patients more accurately than the existing risk scores and other machine-learning methods.

High Incidence and Mortality of Out-of-Hospital Cardiac Arrest on Traditional Holiday in South Korea.

BACKGROUND AND OBJECTIVES: This study aimed to confirm the effects of traditional holidays on the incidence and outcomes of out-of-hospital cardiac arrest (OHCA) in South Korea. METHODS: We studied 95,066 OHCAs of cardiac cause from a nationwide, prospective study from the Korea OHCA Registry from January 2012 to December 2016. We compared the incidence of OHCA, in-hospital mortality, and neurologic outcomes between traditional holidays, Seollal (Lunar New Year's Day) and Chuseok (Korean Thanksgiving Day), and other day types (weekday, weekend, and public holiday). RESULTS: OHCA occurred more frequently on traditional holidays than on the other days. The median OHCA incidence were 51.0 (interquartile range [IQR], 44.0-58.0), 53.0 (IQR, 46.0-60.5), 52.5 (IQR, 45.3-59.8), and 60.0 (IQR, 52.0-69.0) cases/day on weekday, weekend, public holiday, and traditional holiday, respectively (p<0.001). The OHCA occurred more often at home rather than in public place, lesser bystander cardiopulmonary resuscitation (CPR) was performed, and the rate of cessation of CPR within 20 minutes without recovery of spontaneous circulation was higher on traditional holiday. After multivariable adjustment, traditional holiday was associated with higher in-hospital mortality (adjusted hazard ratio [HR], 1.339; 95% confidence interval [CI], 1.058-1.704; p=0.016) but better neurologic outcomes (adjusted HR, 0.503; 95% CI, 0.281-0.894; p=0.020) than weekdays. CONCLUSIONS: The incidence of OHCAs was associated with day types in a year. It occurred more frequently on traditional holidays than on other day types. It was associated with higher in-hospital mortality and favorable neurologic outcomes than weekday.

Gender differences of in-hospital outcomes in patients undergoing percutaneous coronary intervention in the drug-eluting stent era.

Most studies on gender difference of the in-hospital outcome of percutaneous coronary intervention (PCI) were performed in the pre-drug-eluting stents (DES) era. This study was performed to investigate whether gender influences the in-hospital outcome of PCI in the DES era.A total of 44,967 PCI procedure between January and December of 2014 from the nationwide PCI registry database in Korea were analyzed. The study population was male predominant (70.2%). We examined the association of gender with unadjusted and adjusted in-hospital mortality and composite events of PCI, including mortality, nonfatal myocardial infarction, stent thrombosis, stroke, urgent repeat PCI and bleeding requiring transfusion.Most of the study patients (91.3%) received DES. The incidence rates of in-hospital mortality (2.95% vs 1.99%, P <.001) and composite events (7.01% vs 5.48%, P <.001) were significantly higher in women compared to men. Unadjusted analyses showed that women had a 1.49 times higher risk of in-hospital mortality and a 1.30 times higher risk of composite events than men (P <.001 for each). After adjustment for potential confounders, female gender was not a risk factor for mortality (P = .258), but the risk of composite events remained 1.20 times higher in women than in men (P = .008).Among patients undergoing PCI in the contemporary DES era, female gender was associated with an increased risk of in-hospital composite events, but not in-hospital mortality. More careful attention should be emphasized to minimize procedure-related risks and to improve prognosis in women undergoing PCI.

Development and Validation of Deep-Learning Algorithm for Electrocardiography-Based Heart Failure Identification.

BACKGROUND AND OBJECTIVES: Screening and early diagnosis for heart failure (HF) are critical. However, conventional screening diagnostic methods have limitations, and electrocardiography (ECG)-based HF identification may be helpful. This study aimed to develop and validate a deep-learning algorithm for ECG-based HF identification (DEHF). METHODS: The study involved 2 hospitals and 55,163 ECGs of 22,765 patients who performed echocardiography within 4 weeks were study subjects. ECGs were divided into derivation and validation data. Demographic and ECG features were used as predictive variables. The primary endpoint was detection of HF with reduced ejection fraction (HFrEF; ejection fraction [EF]≤40%), and the secondary endpoint was HF with mid-range to reduced EF (≤50%). We developed the DEHF using derivation data and the algorithm representing the risk of HF between 0 and 1. We confirmed accuracy and compared logistic regression (LR) and random forest (RF) analyses using validation data. RESULTS: The area under the receiver operating characteristic curves (AUROCs) of DEHF for identification of HFrEF were 0.843 (95% confidence interval, 0.840-0.845) and 0.889 (0.887-0.891) for internal and external validation, respectively, and these results significantly outperformed those of LR (0.800 [0.797-0.803], 0.847 [0.844-0.850]) and RF (0.807 [0.804-0.810], 0.853 [0.850-0.855]) analyses. The AUROCs of deep learning for identification of the secondary endpoint was 0.821 (0.819-0.823) and 0.850 (0.848-0.852) for internal and external validation, respectively, and these results significantly outperformed those of LR and RF. CONCLUSIONS: The deep-learning algorithm accurately identified HF using ECG features and outperformed other machine-learning methods.

Deep-learning-based out-of-hospital cardiac arrest prognostic system to predict clinical outcomes.

AIM: Out-of-hospital cardiac arrest (OHCA) is a major healthcare burden, and prognosis is critical in decision-making for treatment and the withdrawal of life-sustaining therapy. This study aimed to develop and validate a deep-learning-based out-of-hospital cardiac arrest prognostic system (DCAPS) for predicting neurologic recovery and survival to discharge. METHODS: The study subjects were patients from the Korea OHCA registry who experienced return of spontaneous circulation (ROSC) after OHCA. A total of 36,190 patients were exclusively divided into a set of 28,045 subjects for derivation data and 8,145 subjects for validation data. We used information available for the time of ROSC as predictor variables, and the endpoints were neurologic recovery (cerebral performance category 1 or 2) and survival to discharge. The DCAPS was developed using the derivation data and represented the favorability of prognosis with a score between 0 and 100. RESULTS: The area under the receiver operating characteristic curve (AUROC) of DCAPS for predicting neurologic recovery for the validation data was 0.953 [95% confidence interval 0.952-0.954]; these results significantly outperformed those of logistic regression (0.947 [0.943-0.948]), random forest (0.943 [0.942-0.945]), support vector machine (0.930 [0.929-0.932]), and conventional methods of a previous study (0.817 [0.815-0.820]). The AUROC of the DCAPS for survival to discharge was 0.901 [0.900-0.903], and this result significantly outperformed those of other models as well. CONCLUSIONS: The DCAPS predicted neurologic recovery and survival to discharge of OHCA patients accurately and outperformed the conventional method and other machine-learning methods.

Efficacy of postprocedural anticoagulation after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A post-hoc analysis of the randomized INNOVATION trial.

There exists controversy on whether and for how long anticoagulation is necessary after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).We aimed to study the impact of prolonged (>24 h) or brief (<24 h) postprocedural anticoagulation on infarct size assessed by cardiac magnetic resonance (CMR) after 30 days as well as on left ventricular ejection fraction (LVEF) and left ventricular (LV) remodeling evaluated by 2D-echocardiography after 9 months from the INNOVATION trial (Clinical Trial Registration: NCT02324348).Of the 114 patients (mean age: 59.5 years) enrolled, 76 (66.7%) received prolonged anticoagulation therapy (median duration: 72.6 h) and 38 (33.3%) patients received brief anticoagulation therapy (median duration: 5 h) after primary PCI. There was no significant difference in infarct size (mean size: 15.6% after prolonged anticoagulation versus 19.8% after brief anticoagulation, P = .100) and the incidence of microvascular obstruction (50.7% versus 52.9%, P = .830) between the groups. Even after adjusting, prolonged anticoagulation therapy could not reduce larger infarct (defined as >75 percentile of infarct size; 19.7% versus 35.3%; adjusted odd ratio [OR]: 0.435; 95% confidence interval [CI]: 0.120-1.57; P = .204). Similar results were observed in subanalyses of major high-risk subgroups. Moreover, follow-up LVEF <35% (3.2% versus 7.4%; adjusted OR: 0.383; 95% CI: 0.051-2.884; P = .352) and LV remodeling (defined as >20% increase in LV end-diastolic volume; 37.1% versus 18.5%; adjusted OR: 2.249; 95% CI: 0.593-8.535; P = .234) were similar between groups.These data suggest that prolonged postprocedural anticoagulation may not provide much benefit after successful primary PCI in patients with STEMI. However, further studies are needed.

Safety and Efficacy of Biodegradable Polymer-biolimus-eluting Stents (BP-BES) Compared with Durable Polymer-everolimus-eluting Stents (DP-EES) in Patients Undergoing Complex Percutaneous Coronary Intervention.

BACKGROUND AND OBJECTIVES: There are no data comparing clinical outcomes of complex percutaneous coronary intervention (PCI) between biodegradable polymer-biolimus-eluting stents (BP-BES) and durable polymer-everolimus-eluting stents (DP-EES). We sought to evaluate the safety and efficacy of BP-BES compared with DP-EES in patients undergoing complex PCI. METHODS: Patients enrolled in the SMART-DESK registry were stratified into 2 categories based on the complexity of PCI. Complex PCI was defined as having at least one of the following features: unprotected left main lesion, ≥2 lesions treated, total stent length >40 mm, minimal stent diameter ≤2.5 mm, or bifurcation as target lesion. The primary outcome was target lesion failure (TLF), defined as a composite of cardiac death, target vessel-related myocardial infarction (TV-MI), or target lesion revascularization (TLR) at 2 years of follow-up. RESULTS: Of 1,999 patients, 1,145 (57.3%) underwent complex PCI: 521 patients were treated with BP-BES and 624 with DP-EES. In propensity-score matching analysis (481 pairs), the risks of TLF (3.8% vs. 5.2%, adjusted hazard ratio [HR], 0.578; 95% confidence interval [CI], 0.246-1.359; p=0.209), cardiac death (2.5% vs. 2.5%, adjusted HR, 0.787; 95% CI, 0.244-2.539; p=0.689), TV-MI (0.5% vs. 0.4%, adjusted HR, 1.128; 95% CI, 0.157-8.093; p=0.905), and TLR (1.1% vs. 2.9%, adjusted HR, 0.390; 95% CI, 0.139-1.095; p=0.074) did not differ between 2 stent groups after complex PCI. CONCLUSIONS: Clinical outcomes of BP-BES were comparable to those of DP-EES at 2 years after complex PCI. Our data suggest that use of BP-BES is acceptable, even for complex PCI.

Favorable neurological outcome after ischemic cerebrovascular events in patients treated with percutaneous left atrial appendage occlusion compared with warfarin.

OBJECTIVES: This study sought to investigate neurological disability after ischemic cerebrovascular events in patients treated with left atrial appendage (LAA) occlusion compared with those on warfarin. BACKGROUND: Prior studies demonstrated that cerebrovascular events after LAA occlusion in patients with nonvalvular atrial fibrillation (NVAF) is largely nondisabling. METHODS: From the 1,189 patients in the Korean LAA Occlusion and European Amplatzer Cardiac Plug Multi-Center Registry, 24 patients who experienced ischemic cerebrovascular events after LAA occlusion were enrolled. The neurological outcomes were compared with those in 68 patients who experienced an ischemic cerebrovascular event while on warfarin (Yonsei Stroke Registry). A modified Rankin scale (mRS) score of 3-6 categorized the cerebrovascular event as disabling. The mRS at discharge and at 3 and 12 months postcerebrovascular event in the two groups was compared. RESULTS: The percentages of disabling cerebrovascular events were 37.5% and 58.8% at discharge (P = 0.07), 20.8% and 42.6% at 3 months (P = 0.08), and 12.5% and 39.7% at 12 months (P = 0.02) in the LAA occlusion and warfarin groups, respectively. The mRS was significantly lower in the LAA occlusion group at discharge and at 3 months (P < 0.01) and 12 months (P < 0.01) postcerebrovascular event despite no significant difference in mRS before cerebrovascular events (P = 0.98). Patients in the LAA occlusion group demonstrated a significant reduction in mRS between discharge and 12 months (P < 0.01), unlike patients in the warfarin group (P = 0.10). CONCLUSIONS: Ischemic cerebrovascular events in patients who previously underwent percutaneous LAA occlusion for NVAF were more favorable than in patients on warfarin.