Background: Heavy calcifications in severe aortic stenosis (AS) pose a major challenge in patients undergoing transcatheter aortic valve replacement (TAVR). Only a few studies have addressed the performance of different transcatheter heart valves (THV) in this subgroup of patients. Objectives: We aimed to investigate the outcomes of the self-expanding Medtronic CoreValve Evolut valve frame and the balloon-expandable Edwards SAPIEN-3/3 Ultra THV in this challenging patient population. Materials and methods: This was a multicenter registry including a total of 1513 patients with heavily calcified AS undergoing TAVR. The primary endpoint was the incidence and degree of paravalvular leak (PVL) after TAVR. Secondary endpoints were post-implant hemodynamics as well as clinical endpoints according to the VARC-3 definitions. Results: The CoreValve Evolut R but not the Evolut PRO showed significantly higher rates of PVL compared to the SAPIEN-3/3 Ultra (44.8% vs. 29.5% for mild PVL, p < 0.001), while there was no significant difference in ≥ moderate PVL between both groups (p = 0.399). The CoreValve Evolut R and Evolut PRO showed superior THV hemodynamics compared to the SAPIEN-3/3 Ultra group. These findings were confirmed in a propensity score-matched analysis. There were no significant differences regarding short-term outcomes including permanent pacemaker implantation and all-cause mortality between the three groups. Conclusion: In patients with severely calcified AS, both CoreValve Evolut PRO and SAPIEN-3/3 Ultra THV showed lower rates of PVL than the CoreValve Evolut R. The self-expanding CoreValve platform had superior post-implant hemodynamics than the SAPIEN-3/3 Ultra system. Graphical

Background: Valve-in-Valve (VIV) transcatheter aortic valve replacement (TAVR) is a potential solution for malfunctioning surgical aortic valve prostheses, though limited data exist for its use in Perceval valves. Methods: searches were performed on PubMed and Scopus up to 31 July 2023, focusing on case reports and series addressing VIV replacement for degenerated Perceval bioprostheses. Results: Our analysis included 57 patients from 27 case reports and 6 case series. Most patients (68.4%) were women, with a mean age of 76 ± 4.4 years and a mean STS score of 6.1 ± 4.3%. Follow-up averaged 9.8 ± 8.9 months, the mean gradient reduction was 15 ± 5.9 mmHg at discharge and 13 ± 4.2 mmHg at follow-up. Complications occurred in 15.7% of patients, including atrioventricular block III in four patients (7%), major bleeding or vascular complications in two patients (3.5%), an annular rupture in two patients (3.5%), and mortality in two patients (3.5%). No coronary obstruction was reported. Balloon-expanding valves were used in 61.4% of patients, predominantly the Sapien model. In the self-expanding group (38.6%), no valve migration occurred, with a permanent pacemaker implantation rate of 9%, compared to 5.7% for balloon-expanding valves. Conclusions: VIV-TAVR using both balloon-expanding and self-expanding technologies is feasible after the implantation of Perceval valves; however, it should be performed by experienced operators with experience both in TAVR and VIV procedures.

Background: Postoperative patients are at risk of pulmonary embolism. They typically exhibit multiple contributing factors such as comorbidities, immobility, blood loss, increased hematocrit, dehydration, long hospital stays, and a higher bleeding risk. PE management in this vulnerable group is challenging. Although current guidelines provide differing recommendations, many clinical questions remain unanswered. Decisions regarding periprocedural anticoagulation management must balance the thromboembolic and procedural higher bleeding risks. In addition, a recent major surgery is an absolute contraindication to systemic thrombolysis. Small doses of local lytics or a mechanical percutaneous embolectomy in the era of catheter-based therapy may be a safer option. However, the safety and efficacy of CDT have not been evaluated in this particular PE-vulnerable population. Methods: We performed a retrospective study of 35 postoperative patients with intermediate–high-risk PE treated with the EkoSonic Endovascular System. Operative bleeding risk, different management modalities, and post-PE-therapy presumptive complications were assessed before PE treatment. Results: Procedural success was achieved in 100% of cases. We observed a marked improvement in clinical and PE hemodynamics. One major bleeding, defined as life-threatening, required surgical intervention; four moderate bleedings, defined as bleeding without hemodynamic compromise, required intervention such as drainage. Minor bleeding was managed conservatively. Conclusions: Catheter-directed therapies may be an alternative to systemic reperfusion therapies for selected postoperative intermediate–high-risk PE-vulnerable populations.

Background: The optimal choice of antiplatelet monotherapy after dual antiplatelet therapy (DAPT) among patients undergoing PCI remains debatable. While aspirin has long been the default choice, clopidogrel has emerged as a potential alternative due to its lower bleeding risk and possible superior ischemic protection. This meta-analysis sought to investigate the recent findings comparing the use of aspirin against clopidogrel after different durations of DAPT in patients who underwent PCI. Methods: We searched for randomized controlled trials and cohort studies comparing long-term aspirin and clopidogrel monotherapy after DAPT post-PCI. The primary outcome was major adverse cardiovascular events (MACE). Secondary outcomes included major and minor bleeding, gastrointestinal (GI) bleeding, stroke, myocardial infarction (MI), target vessel revascularization, and stent thrombosis. Results: Six studies comprising 14,992 patients were included. Clopidogrel monotherapy was associated with a significantly lower risk of MACE than aspirin (risk ratio [RR]: 1.24; 95% CI: 1.09–1.42; P = .001). Aspirin monotherapy resulted in a higher risk of minor bleeding (RR: 1.57; 95% CI: 1.06–2.34; P = .03) and GI bleeding (RR: 1.19; 95% CI: 1.04–1.37; P = .01). However, aspirin monotherapy was associated with a higher risk of stroke, including both ischemic (RR: 1.56; 95% CI: 1.03–2.38; P = .04) and hemorrhagic stroke (RR: 2.06; 95% CI: 1.06–3.98; P = .03). Conclusion: Clopidogrel monotherapy appears to be a superior alternative to aspirin for long-term secondary prevention after PCI, offering a lower risk of MACE and stroke without increasing major bleeding or mortality. However, individual factors such as genetic variability, GI bleeding risk, and cost should guide therapy selection.

The superior septal approach (SSA) was developed to improve mitral valve exposure during surgery, particularly in patients with complex anatomy. However, c