Atherosclerosis is a multifactorial systemic disease that affects the entire arterial tree, although some areas are more prone to lipid deposits than others. Moreover, the histopathological composition of the plaques differs, and the clinical manifestations are also different, depending on the location and structure of the atherosclerotic plaque. Some arterial systems are correlated with each other more than in that they simply share a common atherosclerotic risk. The aim of this perspective review is to discuss this heterogeneity of atherosclerotic impairment in different arterial districts and to investigate the current evidence that resulted from studies of the topographical interrelations of atherosclerosis.

Background: Inflammation plays a significant role in the pathogenesis of aortic stenosis. This study aimed to investigate the prognostic value of the monocyte-HDL cholesterol ratio (MHR), a new inflammatory marker, in severe aortic stenosis (AS) patients who underwent transcatheter aortic valve replacement (TAVR). Methods: A total of 125 patients with severe AS who underwent TAVR were assessed. Clinical, echocardiographic and laboratory data relevant to the research were retrospectively obtained from the patients’ records. The MHR was determined by dividing the absolute monocyte count by the HDL-C value. The primary endpoints were overall and cardiovascular mortality. Results: During a median follow-up time of 39 months, primary endpoints were developed in 51 (40.8%) patients (overall mortality) and 21 (16.8%) patients (cardiovascular mortality). A receiver operating characteristic (ROC) analysis showed that by using a cut-off level of 16.16, the MHR predicted the all-cause mortality with a sensitivity of 50.9% and specificity of 89.1%. In predicting cardiovascular mortality, the MHR exhibited a sensitivity of 80.9% and specificity of 70.1% when a cut-off level of 13.56 was used. In the multivariate analysis, the MHR (p < 0.0001; 95% CI: 1.06–1.15) and atrial fibrillation (p = 0.018; 95% CI: 1.11–3.38) were found to be significant predictors of overall mortality. Conclusions: This study showed a significant elevation in the MHR among patients who experienced all-cause and cardiovascular mortality and this ratio emerged as an independent predictor of all-cause death in patients with severe AS undergoing TAVR.

Background: Stent enhancement techniques allow adequate visualization of stent deformation or incomplete stent expansion at the ostium of the side branch. Measuring the stent enhancement side branch length (SESBL) could reflect procedural success in terms of optimal stent expansion and apposition with better long-term outcomes. A longer SESBL may reflect a better stent apposition at the polygon of confluence and at the side branch (SB) ostium. Methods: We evaluated 162 patients receiving the left main (LM) provisional one-stent technique and measured the SESBL, dividing them into two groups: SESBL≤ 2.0 mm and SESBL > 2.0 mm. Results: The mean SESBL was 2.0 ± 1.2 mm. More than half of the bifurcations had both main and side branch lesions (Medina 1-1-1) (84 patients, 51.9%) and the length of the SB disease was 5.2 ±1.8 mm. Kissing balloon inflation (KBI) was performed in 49 patients (30.2%). During follow-up (12 months), there was a significantly higher rate of cardiac death in the SESBL ≤ 2.0 mm group (p = 0.02) but no significant difference in all major adverse cardiovascular events (MACEs) (p = 0.7). KBI did not influence the outcomes (p = 0.3). Conclusion: Suboptimal SESBL is positively correlated with worse outcomes and SB compromise. This novel sign could aid the LM operator to assess the level of stent expansion at the ostium of the SB in the absence of intracoronary imaging.

Background: Hemodynamically significant unprotected left main (LM) coronary artery disease is a high-risk clinical condition because of the large area of myocardium at risk, and it requires prompt revascularization. Percutaneous coronary intervention (PCI) is an appropriate alternative to coronary artery bypass grafting (CABG) for revascularization of unprotected LM disease in patients with low-to-intermediate anatomic complexity or when the patient refuses CABG after adequate counseling by the heart team. Methods: We retrospectively evaluated 201 patients receiving left main (LM) provisional one-stent or two-stent procedures, and we assessed the clinical characteristics and outcomes of patients undergoing unprotected LM PCI. Results: The mean age was 66.5 ± 9.9 years, and 72% were male. The majority of the subjects presented several cardiovascular risk factors, among which arterial hypertension (179 patients, 89.5%) and dyslipidemia (173 patients, 86.5%) were the most frequent. Out of all patients, 162 (81.8%) underwent revascularization by using the one-stent technique, while the two-stent technique was used in 36 patients (18.2%). The median value of fractional flow reserve (FFR) of the side branch was 0.9 [0.85–0.95], and 135 patients (67.1%) showed a value of FFR > 0.8. One hundred nine patients (54.2%) had a stent enhancement side branch length (SESBL) > 2, with median values of 2.5 mm² [2.1–3]. Regarding angiographic parameters, the LM area as assessed by intravascular ultrasound (IVUS) or optical coherence tomography (OCT) and the grade of stenosis as assessed by quantitative coronary angiography (QCA) were similar between groups. However, patients who required revascularization by using the two-stent technique presented more frequently with intermediate rather than low SYNTAX scores (69.4% vs. 28.4%, p < 0.0001). Also, the same group required kissing balloon inflation (KBI) more frequently (69.4% vs. 30%, p < 0.001). There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique. FFR was able to predict a SESBL > 2 mm. The cut-off value for FFR to afford the highest degree of sensitivity (74.5%) and specificity (47%) for a SESBL > 2 was >0.86, indicating a moderate accuracy (AUC = 0.61, 95% CI 0.525–0.690, p = 0.036). Conclusions: Unprotected left main PCI is a safe and effective revascularization option amongst a complex and morbid population. There were no differences regarding the success of revascularization between the use of the one-stent or two-stent technique, and there was no significant impact of KBI on side branch FFR measurements but lower side branch FFR values were correlated with angiographic side branch compromise.

Although most commonly diagnosed in the elderly population, aortic stenosis can affect younger patients, being the most frequent valvular disease requiring replacement interventions, either through surgical procedures (SAVR = surgical aortic valve replacement) or through transcatheter aortic valve implantation (TAVI). In young patients, aortic stenosis generally occurs due to congenital malformations, such as bicuspid aortic valves (BAVs), or to rheumatic valve disease, both of which present specific anatomical characteristics. There is an upward trend among young patients regarding TAVI, due to the possibility of avoiding the complications of open-heart surgery while offering a faster recovery, although it is important to note that complications, such as conduction disturbances, paravalvular leaks (PVL), or strokes, can arise. Because of the current lack of long-term data, the implications of these complications among young patients are not well established. Moreover, an important issue among young patients is the durability of the prosthesis, as patient survival is expected to exceed the device’s lifespan. The purpose of this review is to assess the current data on the most common causes of aortic stenosis and outcomes of TAVI in young patients, focusing on subgroups of patients with bicuspid aortic stenosis or rheumatic aortic stenosis, while emphasizing the potential complications, the durability of the aortic prosthesis, and reintervention possibilities.