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).

In the setting of patients with indication to receive dual antiplatelet therapy undergoing surgery or invasive procedures, the risk of perioperative cardiac ischemic events, particularly stent thrombosis, is high, because surgery has a prothrombotic effect and antiplatelet therapy is withdrawn in order to avoid bleeding complications. Cangrelor, an intravenous P2Y₁₂ receptor antagonist, has been tested in a randomized trial as a “bridge” to cardiac surgery from discontinuation of oral P2Y₁₂ receptor antagonists. Thus, a consensus document extended its off-label use in this setting and before non-cardiac surgery. Currently, despite the implementation of a standardized bridging protocol with cangrelor, a residual risk of adverse outcome mainly due to bleeding events, still persist during the perioperative phase. Accordingly, a personalized management driven by platelet reactivity serial measurements and careful assessment of ischemic and bleeding risks has potential to optimize outcomes and costs as compared to a standardized bridging protocol, based on average pharmacodynamic data of oral P2Y₁₂ inhibitors. While specific indications for bridging have been extensively addressed in the aforementioned consensus statement, the aim of the present document is the proposal of a “tailored” clinical decision-making algorithm inspired to the principle of personalized medicine dealing with complex clinical scenarios.

The appropriate use of dual antiplatelet therapy (DAPT) in elderly patients with acute coronary syndrome (ACS) is largely debated. Due to the "demographic transition" in western countries, the elderly represent a growing percentage of patients admitted to hospitals for ACS, and among this high risk setting population most of early and late adverse outcomes occur. The presence of several concomitant "comorbidities" complicates the management strategy of both medical or invasive treatment and the clinical decision-making process is challenging. Moreover, elderly people are constantly underrepresented in clinical trials and studies. As a result, there is no specific evidence about the optimal antithrombotic therapy in elderly and no specific recommendations are mentioned in the current ACS guidelines. Currently, the best practice for old people is still rudimentary and principally extrapolated from general cardiovascular guidelines. The management of elderly patients should be based on the evaluation of ischemic and hemorrhagic risk, life expectancy, comorbidities and parameters that are not included in the scores recommended by the current guidelines such as frailty and disability. In the era of "precision medicine", the evaluation of bleeding and ischemic risk in elderly patients must be a dynamic process because of the risk changing over time. A "tailored therapy by individualized medicine" is the key of management strategy.

The EchoNavigator^® (Philips Healthcare) is a recently introduced system able to integrate real-time information from transoesophageal echocardiography (TOE) and fluoroscopy in the same anatomical alignment, and its use has been associated with the reduction of radiation exposure and fluoroscopy time. ^{1, 2} The present case illustrates the advantages resulting from the use of intraprocedural guidance with the Echonavigator system (EN), in particular, the possibility to avoid any contrast dye. A 50-year-old hypertensive gentleman with a history of mitral and coronary artery disease, previous treated surgically, was referred for percutaneous left atrial appendage (LAA) occlusion because of permanent atrial fibrillation and a history of severe not-correctable gastrointestinal bleeding while on oral anticoagulant therapy. The patient also suffers from chronic kidney disease, and the estimated glomerular filtration rate was 40 mL/min/1.73 m². Hence, pre-procedural planning with TOE was carried out showing a thrombus-free LAA with a landing zone of 21 mm. The LAA occlusion procedure was performed under general anaesthesia and TOE guidance, using fluoroscopic-echocardiographic fusion imaging from the EN software (Philips Healthcare, Amsterdam, Netherlands). At the beginning of the procedure, we placed fixed markers on the left circumflex artery and the tip of the Marshall band ( Figure 1A) that highlighted the LAA ostium and guided the subsequent catheter and device positioning in relation to relevant cardiac structures. EN provided significant advantages during the transseptal puncture ( Figure 1B, Video 1) and guided the hardware and device orientation during the implantation ( Figure 1C). A 25-mm Amplatzer Amulet (Abbott, Chicago, IL, USA) occluder device was chosen. Good stability of the implanted device ( Figure 1D), no interference with the mitral valve apparatus ( Video 2), and the correct final position were assessed by TOE ( Figure 1E, Video 3). The patient was discharged home the day after and dual antiplatelet therapy was recommended for 1 month.