Transcatheter aortic valve implantation (TAVI) has become the leading technique for aortic valve replacement in symptomatic patients with severe aortic stenosis with conventional surgical aortic valve replacement (SAVR) now limited to patients younger than 65–75 years due to a combination of unsuitable anatomies (calcified raphae in bicuspid valves, coexistent aneurysm of the ascending aorta) and concerns on the absence of long-term data on TAVI durability. This incredible rise is linked to technological evolutions combined with increased operator experience, which led to procedural refinements and, accordingly, to better outcomes. The article describes the main and newest technical improvements, allowing an extension of the indications (valve-in-valve procedures, intravascular lithotripsy for severely calcified iliac vessels), and a reduction of complications (stroke, pacemaker implantation, aortic regurgitation).

Drug-coated balloons (DCBs) are increasingly used in percutaneous coronary intervention (PCI). Their application for chronic total occlusions (CTOs) is a promising option to limit stent length in diffuse disease and avoid stent underexpansion and malapposition in negatively remodeled distal vessel segments. The aim of this study was to analyze CTO PCI procedures recorded in ERCTO (European Registry of Chronic Total Occlusion) to investigate frequency of use, patient and lesion characteristics, and in-hospital outcomes of DCBs. CTO cases entered into the database from 2016 to 2023 were examined and categorized according to DCB use. DCB-treated patients were further divided into 2 groups: DCBs only and DCBs in association with drug-eluting stents. To minimize the potential impact of confounding factors, 1:1 propensity score matching was applied. Of 40,449 CTO PCIs performed at 184 centers, DCBs were used in 2,506 (6.2%), increasing from 3.4% (n = 185 of 5,498) in 2016 to 14.9% (n = 705 of 4,722) in 2023. In-hospital complications were infrequent, but DCB-treated CTOs had significantly lower rates of pericardial tamponade (0.1% [n = 2 of 2,506] vs 0.4% [n = 169 of 37,943]; P = 0.006). After propensity score matching, DCB use led to reduced drug-eluting stent length (44.2 ± 36.9 mm [95% CI: 42.7-45.7 mm] vs 58.1 ± 35.9 mm [95% CI: 56.7-59.5] mm; P < 0.001). Contrast volume was lower in the DCB-treated patients (202.4 ± 109.8 mL [95% CI: 198.1-206.7 mL] vs 211.6 ± 123 mL [95% CI: 206.8-216.4 mL]; P = 0.005). The use of DCBs in CTO recanalization is increasing and is associated with a reduction in the length of stents implanted, as well as a decrease in contrast volume and a lower rate of pericardial tamponade.

(1) Background: This single-center retrospective study aimed to evaluate whether sodium–glucose cotransporter-2 inhibitors (SGLT2-i) therapy may have a nephroprotective effect to prevent contrast-induced acute kidney injury (CI-AKI) in patients with heart failure (HF) undergoing iodinated contrast medium (ICM) invasive procedures. (2) Methods: The population was stratified into SGLT2-i users and SGLT2-i non-users according to the chronic treatment with gliflozins. The primary endpoint was CI-AKI incidence during hospitalization. Secondary endpoints were all-cause mortality and the need for continuous renal replacement therapy (CRRT). (3) Results: In total, 86 patients on SGLT2-i and 179 patients not on SGLT2-i were enrolled. The incidence of CI-AKI in the gliflozin group was lower than in the non-user group (9.3 vs. 27.3%, p < 0.001), and these results were confirmed after propensity matching analysis. Multivariable logistic regression showed that only SGLT2-i treatment was an independent preventive factor for CI-AKI (OR: 0.41, 95% CI: 0.16–0.90, p = 0.045). The need for CRRT was reported only in five patients in the non-SGLT2-i-user group compared to zero patients in the gliflozin group (p = 0.05). (4) Conclusions: SGLT2-i therapy was associated with a lower risk of CI-AKI in patients with HF undergoing ICM invasive procedures.

Drug-coated balloons (DCBs) offer an attractive therapeutic option to avoid long stent implantation in diffuse disease, especially for small vessels. We report this first observation with high-frequency intravascular ultrasound (HF-IVUS) of effective delivery of paclitaxel together with urea excipient. A 76-year-old hypertensive and diabetic gentleman with exertional angina underwent coronary computed tomography angiography (Panel 1) showing total occlusion of the mid-segment of the left anterior descending artery, shorter than the occluded segment at selective coronary angiography, performed three months later (Panel 2, Supplemental Video 1). We antegradely crossed the lesion with a Fielder XT-R guidewire supported by a Corsair Pro XS microcatheter (both Asahi Intecc, Japan). After balloon pre-dilatation (Panel 3), HF-IVUS (Opticross™HD 60 MHz, Boston Scientific, USA) showed a subocclusive lesion with positive remodelling in the proximal occluded segment and diffuse subcritical disease in the distal occluded segment (Panel 3A–D, Supplemental Video 3). We elected to limit stent implantation to a 3.0 × 15 mm sirolimus-eluting stent in the proximal occlusion and treat the distal disease with prolonged inflation (up to 5 min) of three paclitaxel urea DCB (Prevail, Medtronic, USA), 3.0 × 30 mm, 2.75 × 25 mm and 2.5 × 20 mm, respectively (Panel 4, Supplemental Video 2). The final HF-IVUS (Panel 4A–D, Supplemental Video 4) documented a continuous intimal hyperechoic layer throughout the entire segment treated with DCB (arrows, Panel 4B–C), with similar echogenicity to the stent struts (arrowheads, Panel 4A) and not present before DCB deployment or distally (Panel 4D). We believe that this phenomenon is the result of the intimal deposition of the DCB coating. Further IVUS studies will reveal how long this pattern persists and whether its visualization is associated with better drug response and lower risk of restenosis over time.

The authors describe a transcatheter mitral valve-in-valve-in-valve (VIVIV) for the correction of a degenerated transcatheter in a surgical bioprosthesis, a challenging interventional scenario that will be increasingly frequent in the near future. The key steps taken were as follows: preprocedural planning integrating data from transesophageal echocardiogram, cardiac computed tomography, and 3mensio reconstruction (Pie Medical Imaging); transfemoral transseptal VIVIV performed with EchoNavigator system (Philips) guidance; Sapien Ultra 3 26-mm valve (Edwards Lifesciences) delivered with buddy balloon maneuvers to uncage the valve from the atrial struts of the previously implanted valve; and atrial septal defect occlusion with the Amplatzer ASO 24 mm (Abbott Cardiovascular). The inability to advance the prosthesis into the ventricle, irreversible hemodynamic collapse, residual high transmitral mean gradient because of impingment of the 3 valves, residual paravalvular leaks, and left ventricular outflow tract obstruction. Mitral VIVIV procedures represent a viable option for patients with prohibitive surgical risk and a degenerated transcatheter in surgical bioprostheses. Success hinges on adequate preprocedural planning and a thorough understanding of bailout techniques to minimize failure and prevent major complications.