Mitral regurgitation (MR) is one of the most common valvular pathologies worldwide, contributing to the morbidity and mortality of several cardiovascular pathologies, including heart failure (HF). Novel transcatheter treatment for MR has given the opportunity for a safe and feasible alternative, to surgery, in order to repair the valve and improve patient outcomes. However, after the results of early transcatheter edge-to-edge repair (TEER) trials, it has become evident that subcategorizing the mitral regurgitation etiology and the left ventricular function, in patients due to undergo TEER, is of the essence, in order to predict responsiveness to treatment and select the most appropriate patient phenotype. Thus, a novel MR phenotype, atrial functional MR (AFMR), has been recently recognized as a distinct pathophysiological entity, where the etiology of the regurgitation is secondary to annular dilatation, in a diseased left atrium, with preserved left ventricular function. Recent studies have evaluated and compared the outcomes of TEER in AFMR with ventricular functional MR (VFMR), with the results favoring the AFMR. In specific, TEER in this patient substrate has better echocardiographic and long-term outcomes. Thus, our review will provide a comprehensive pathogenesis and mechanistic overview of AFMR, insights into the echocardiographic approach of such patients and pre-procedural planning, discuss the most recent clinical trials and their implications for future treatment directions, as well as highlight future frontiers of research in the setting of TEER and transcatheter mitral valve replacement (TMVR) in AFMR patients.

Lipid lowering, with the use of statins after an acute coronary syndrome (ACS), is a cornerstone, well-established strategy for the secondary prevention of ischemic events in this high-risk cohort. In addition to the positive effect on lipid levels, statins have also been linked to improved atherosclerotic plaque characteristics, such as plaque regression and inflammation reduction, associated with the extent of reduction in LDL-C. The recent emergence of PCSK9 inhibitors for the management of dyslipidemia and the more extensive lipid lowering provided by these agents may provide better prevention for ACS patients when initiated after the ACS event. Several trials have evaluated the immediate post-ACS initiation of PCSK9 inhibitors, which has shown, to date, beneficial results. Furthermore, PCSK9 inhibitors have been linked with positive plaque remodeling and associated mortality benefits, which makes their use in the initial management strategy of such patients appealing. Therefore, in this review, we will analyze the rationale behind immediate lipid lowering after an ACS, report the evidence of PCSK9 inhibition immediately after the ACS event and the available data on plaque stabilization, and discuss treatment algorithms and clinical perspectives for the use of these agents in this clinical setting.

CT angiography has become, in recent years, a main evaluating modality for patients with coronary artery disease (CAD). Recent advancements in the field have allowed us to identity not only the presence of obstructive disease but also the characteristics of identified lesions. High-risk coronary atherosclerotic plaques are identified in CT angiographies via a number of specific characteristics and may provide prognostic and therapeutic implications, aiming to prevent future ischemic events via optimizing medical treatment or providing coronary interventions. In light of new evidence evaluating the safety and efficacy of intervening in high-risk plaques, even in non-flow-limiting disease, we aim to provide a comprehensive review of the diagnostic algorithms and implications of plaque vulnerability in CT angiography, identify any differences with invasive imaging, analyze prognostic factors and potential future therapeutic options in such patients, as well as discuss new frontiers, including intervening in non-flow-limiting stenoses and the role of CT angiography in patient stratification.

Background: Patients with severe mitral regurgitation and cardiogenic shock demonstrate a poor prognosis. Mitral transcatheter edge‐to‐edge repair could alter patient management. Methods and Results: We systematically reviewed PubMed/Medline, Scopus, and Cochrane Library until January 2023, including studies assessing transcatheter edge‐to‐edge repair in patients with severe mitral regurgitation and cardiogenic shock. Studies with <5 patients were excluded. The primary outcome was device success and all‐cause death, while secondary outcomes included myocardial infarction, stroke, and heart failure hospitalization rates at 30‐day and intermediate‐term follow‐up. A fixed‐effects meta‐analysis was used to estimate pooled rates. Risk of bias was assessed with the Newcastle–Ottawa Scale. A total of 24 studies and 5428 patients were included, with a mean age of 71.2±3.3 years and a high mean Society of Thoracic Surgery score (15.2±8.9). Device success was achieved in 86% (95% CI, 85%–87%) and mitral regurgitation ≤2+ in 89% (95% CI: 88%–90%). The 30‐day all‐cause mortality rate was 14% (95% CI, 13%–15%). Stroke, myocardial infarction, and heart failure hospitalization rates were 2% (95% CI, 1%–2%), 15% (95% CI, 13%–18%), and 9% (95% CI, 8%–10%), respectively. Patients with acute myocardial infarction had similar device success (81% [95% CI, 74%–87%]), a 30‐day mortality rate of 20% (95% CI, 16%–25%), and intermediate‐term mortality rate of 14% (95% CI, 9%–19%). In non–myocardial infarction populations, the 30‐day mortality rate was 13% (95% CI, 13%–14%), and the intermediate‐term mortality rate was 35% (95% CI, 34%–36%). Conclusions: In patients with mitral regurgitation and cardiogenic shock, transcatheter edge‐to‐edge repair is associated with favorable 30‐day and intermediate‐term outcomes. Limitations, including the observational design of included studies and considerable heterogeneity, necessitate further research in this setting.

Background: Intracardiac echocardiography (ICE) appears to be a potential alternative for percutaneous left atrial appendage occlusion (LAAO) to transesophageal echocardiography (TEE). Thus, a meta-analysis was performed comparing ICE vs. TEE for LAAO guidance. Methods: A comprehensive literature search was performed using MEDLINE, Scopus and Web of Science electronic databases from their inception to November 2023. Results: 18 studies (124,230 patients) were included. Technical success was higher in ICE- compared to TEE-guidance (OR: 1.36, 95% CI 1.14 to 1.63, p = 0.006) and fewer devices employed (SMD: -0.22, 95% CI -0.43 to -0.01, p = 0.04, I2 = 62%). ICE guidance related with more pericardial effusion/tamponade and iatrogenic residual shunts (logRR: 0.62, 95% CI 0.36 to 0.89, p < 0.001 and RR: 1.53, 95% CI 1.12 to 2.09, p = 0.02, I2 = 1%, respectively). More vascular complications were noted in ICE group (logRR: 0.45, 95% CI 0.11 to 0.78, p = 0.009). Conclusion: ICE-guided imaging is an effective alternative to TEE in LAAO, as it shows better efficacy than TEE, considering technical success. However, the higher rates of adverse events should be carefully considered.