Atrial fibrillation (AF) is a very common arrhythmia that mainly affects older individuals. The mechanism of atrial fibrillation is complex and is related to the pathogenesis of trigger activation and the perpetuation of arrhythmia. The pulmonary veins in the left atrium arei confirm that onfirm the most common triggers due to their distinct anatomical and electrophysiological properties. As a result, their electrical isolation by ablation is the cornerstone of invasive AF treatment. Multiple factors and comorbidities affect the atrial tissue and lead to myocardial stretch. Several neurohormonal and structural changes occur, leading to inflammation and oxidative stress and, consequently, a fibrotic substrate created by myofibroblasts, which encourages AF perpetuation. Several mechanisms are implemented into daily clinical practice in both interventions in and the medical treatment of atrial fibrillation.

Atherosclerotic plaque development constitutes the primary substrate of coronary artery disease (CAD) and is the outcome of an intricate process involving endothelial damage, inflammation, and lipid retention. The clinical efficacy of many lipid-lowering therapies in patients with CAD has been well established. Over the past few decades, a substantial and significant advance regarding the use of invasive and non-invasive imaging modalities has been observed. Numerous studies have been conducted using these imaging techniques and have investigated the changes in morphology (e.g., atheroma volume) and composition (e.g., lipid burden, fibrous cap thickness, macrophage accumulation) at the plaque level that explain the improved clinical outcomes by various pharmacological interventions. Lipid-lowering agents, such as statins and proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, demonstrate direct effects on plaque volume and composition that enhance plaque stabilization and/or regression beyond the reduction of low-density lipoproteins. An increasing amount of clinical research is also focused on the role of inflammation in plaque vulnerability and future adverse cardiac events. Consequently, there is a pressing need to explore therapeutic strategies that are capable of disrupting the inflammatory response as well as reducing atheroma burden and modifying high-risk plaque characteristics. This review provides a comprehensive analysis of the current evidence regarding the effects of traditional and novel therapeutic strategies targeting modification of the lipid profile and inflammatory processes on reversing plaque growth and attenuating vulnerable features, thereby promoting plaque stabilization and passivation.

Cardiac resynchronization therapy (CRT) using biventricular (BiV) pacing is the standard treatment for heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) and electrical dyssynchrony. However, one in three patients remains a non-responder. Left bundle branch area pacing (LBBAP) could represent a more physiological alternative, but its effectiveness is limited in cases of atypical left bundle branch block (LBBB) or intraventricular conduction delay (IVCD). Left Bundle Branch Pacing Optimized cardiac resynchronization therapy (LOT-CRT) integrates LBBAP with coronary sinus (CS) lead pacing to improve electrical synchrony and clinical outcomes. This review evaluates the feasibility, advantages, disadvantages, and clinical outcomes of LOT-CRT. Additionally, we describe our center’s experience and propose an evidence-based implantation algorithm. A review of published studies investigating LOT-CRT was conducted, comparing its effectiveness with BiV-CRT and LBBAP alone using QRS narrowing, LVEF improvement, left ventricular remodeling, New York Heart Association (NYHA) class changes and NT-proBNP levels. It was found that LOT-CRT outperforms BiV-CRT or LBBAP alone in selected populations, at the cost of higher clinical skills, longer procedural times, and specific device setups. Randomized trials are underway to further define its role in clinical practice.

(1) Background: Ultrasound-guided axillary (USAX) vein puncture is a relatively new method to obtain venous access for the implantation of cardiac implantable electronic devices (CIED). However, its use is limited as most of the operators are not familiar with this technique. Our aim was to investigate the safety and efficacy of the USAX compared with the traditional cephalic vein dissection for venous access in CIED implantation. (2) Methods: This was a single-center, randomized, controlled, superiority trial. A total of 114 patients were randomized (1:1 ratio) to either USAX (u/s axillary group; 59 patients) or cephalic vein access (cephalic group; 55 patients). The primary study endpoint was defined as successful placement of all leads via the chosen access. Secondary study endpoints included time from local anesthetic injection to lead advancement in the SVC, total procedure time (skin to skin), procedure-related complications and pain perception. (3) Results: USAX was superior to cephalic access in terms of primary endpoint (OR: 4.3, 95% CI: 1.3, 14.0; p = 0.012). Total procedure duration was higher in the cephalic group (55.15 ± 16.62 vs. 48.35 ± 12.81 min, p = 0.017) but there was neither a significant difference in fluoroscopy time (p = 0.872) nor in total radiation dose (p = 0.815). The level of pain was higher in the cephalic group (p = 0.016), while the rates of complications were similar in both groups (p > 0.05). (4) Conclusion: USAX was superior to cephalic access regarding success rate, total procedure duration and level of pain, while having no difference in complication rates.

Intravascular imaging (IVI) has emerged as a pivotal tool in percutaneous coronary intervention (PCI), offering superior visualization of coronary anatomy compared with conventional angiography. This literature review synthesizes the latest evidence from randomized trials and meta-analyses published since 2022, assessing the comparative efficacy of IVI modalities—including intravascular ultrasound (IVUS) and optical coherence tomography (OCT)—in complex coronary lesions. Multiple landmark trials, such as RENOVATE-COMPLEX PCI, ILUMIEN IV, OCTOBER, and OCTIVUS, demonstrated that IVI-guided PCI significantly improves procedural outcomes, stent optimization, and clinical endpoints such as target-vessel failure, myocardial infarction, and stent thrombosis. OCT was shown to be particularly beneficial in bifurcation and left main interventions, while IVUS consistently improved outcomes in long lesions and complex anatomies. Despite some trials not meeting their primary clinical endpoints, substudy findings and pooled analyses support a shift toward routine IVI use in anatomically complex cases. Consequently, updated guidelines now recommend IVI as a Class I indication in select patient populations. These findings underscore the need for broader clinical adoption and training in IVI techniques to enhance PCI outcomes.

Wire-free fractional flow reserve (FFR) methods derived from coronary angiography offer a less invasive alternative to pressure-wire physiology assessment of intermediate coronary stenoses. During the last decade, several methodological approaches have shown strong correlation and high diagnostic accuracy compared to FFR values. However, clinical outcome studies are limited and widespread use of the wire-FFR computational methods is still lacking in routine patient management. In this review, we summarize the main technical characteristics of the available methodologies and focus on the clinical applications presenting the diagnostic performance according to various patient and anatomic subsets.