In the past two decades, transcatheter aortic valve replacement (TAVR) has transformed the management of aortic stenosis and has become the standard of care regardless of surgical risk levels. Advances in transcatheter valve design across newer generations, improved imaging, greater operator expertise, and technical enhancements have collectively contributed to increased safety and a decline in procedural complications over this timeframe. The application of TAVR has progressively expanded to include younger patients with lower risks, who have longer life expectancies. This article offers an up-to-date review of the latest innovations in transcatheter delivery systems, devices, and its possible future indications.

BACKGROUND: Redo-transcatheter aortic valve replacement (TAVR) can pin the index transcatheter heart valve leaflets open leading to sinus sequestration and restricting coronary access. The impact of initial implant depth and commissural alignment on redo-TAVR feasibility is unclear. We sought to determine the feasibility of redo-TAVR and coronary access after SAPIEN 3 (S3) TAVR stratified by implant depth and commissural alignment. METHODS: Consecutive patients with native valve aortic stenosis were evaluated using multidetector computed tomography. S3 TAVR simulations were done at 3 implant depths, sizing per manufacturer recommendation and assuming nominal expansion in all cases. Redo-TAVR was deemed unfeasible based on valve-to-sinotubular junction distance and valve-to-sinus height <2 mm, while the neoskirt plane of the S3 transcatheter heart valve estimated coronary access feasibility. RESULTS: Overall, 1900 patients (mean age, 80.2±8 years; STS-PROM [Society of Thoracic Surgeons Predicted Risk of Operative Mortality], 3.4%) were included. Redo-TAVR feasibility reduced significantly at shallower initial S3 implant depths (2.3% at 80:20 versus 27.5% at 100:0, P <0.001). Larger S3 sizes reduced redo-TAVR feasibility, but only in patients with a 100:0 implant ( P <0.001). Commissural alignment would render redo-TAVR feasible in all patients, assuming the utilization of leaflet modification techniques to reduce the neoskirt height. Coronary access following TAV-in-TAV was affected by both index S3 implant depth and size. CONCLUSIONS: This study highlights the critical impact of implant depth, commissural alignment, and transcatheter heart valve size in predicting redo-TAVR feasibility. These findings highlight the necessity for individualized preprocedural planning, considering both immediate results and long-term prospects for reintervention as TAVR is increasingly utilized in younger patients with aortic stenosis.

Background: Patients may prefer percutaneous coronary intervention (PCI) over coronary artery bypass graft (CABG) surgery, despite heart team recommendations. The outcomes in such patients have not been examined. We sought to examine the results of PCI in patients who were recommended for but declined CABG. Methods and Results: Consecutive patients with stable ischemic heart disease and unprotected left main or 3‐vessel disease or Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery score >22 who underwent PCI after heart team review between 2013 and 2020 were included. Patients were categorized into 3 groups according to heart team recommendations on the basis of appropriate use criteria: (1) PCI‐recommended; (2) CABG‐eligible but refused CABG (CABG‐refusal); and (3) CABG‐ineligible. The primary end point was the composite of death, myocardial infarction, or stroke at 1 year. The study included 3687 patients undergoing PCI (PCI‐recommended, n=1718 [46.6%]), CABG‐refusal (n=1595 [43.3%]), and CABG‐ineligible (n=374 [10.1%]). Clinical and procedural risk increased across the 3 groups, with the highest comorbidity burden in CABG‐ineligible patients. Composite events within 1 year after PCI occurred in 55 (4.1%), 91 (7.0%), and 41 (14.8%) of patients in the PCI‐recommended, CABG‐refusal, and CABG‐ineligible groups, respectively. After multivariable adjustment, the risk of the primary composite outcome was significantly higher in the CABG‐refusal (hazard ratio [HR], 1.67 [95% CI, 1.08–3.56]; P =0.02) and CABG‐ineligible patients (HR, 3.26 [95% CI, 1.28–3.65]; P =0.004) groups compared with the reference PCI‐recommended group, driven by increased death and stroke. Conclusions: Cardiovascular event rates after PCI were significantly higher in patients with multivessel disease who declined or were ineligible for CABG. Our findings provide real‐world data to inform shared decision‐making discussions.

The “RotaTripsy” technique offers a potentially synergistic calcium-modification strategy that can treat luminal and abluminal calcification.

Acute pulmonary thromboembolism is associated with high mortality, similar to that of myocardial infarction and stroke. We studied the clinical presentation and management of pulmonary thromboembolism in the Indian population. An analysis of 140 patients who presented with acute pulmonary thromboembolism at a large volume center in India from June 2015 through December 2018 was performed. The mean age of our study population was 50 years with 59% being male. Comorbidities including deep vein thrombosis, diabetes mellitus, hypertension, and chronic obstructive pulmonary disease were present in 52.9%, 40%, 35.7% and 7.14% of patients, respectively. Out of 140 patients, 40 (28.6%) patients had massive pulmonary thromboembolism, 36 (25.7%) sub‐massive pulmonary thromboembolism, and 64 (45.7%) had low‐risk pulmonary thromboembolism. Overall, in‐hospital mortality was 25.7%. Multivariate regression analysis found chronic kidney disease and pulmonary thromboembolism severity to be the only independent risk factors. Thrombolysis was performed in 62.5% of patients with a massive pulmonary thromboembolism and 63.9% of patients with a sub‐massive pulmonary thromboembolism. In the massive pulmonary thromboembolism group, patients receiving thrombolytic therapy had lower mortality compared with patients who did not receive therapy (p=0.022), whereas this difference was not observed in patients in the sub‐massive pulmonary thromboembolism group. We conclude that patients with acute pulmonary thromboembolism in India presented more than a decade earlier than our western counterparts, and it was associated with poor clinical outcomes. Thrombolysis was associated with significantly reduced in‐hospital mortality in patients with massive pulmonary thromboembolism.

Aims: Remnant cholesterol (RC), as the cholesterol content of remnant lipoproteins, has been associated with cardiovascular outcomes. However, studies investigating the impact of RC in stable patients undergoing percutaneous coronary intervention (PCI) are scarce. The present study aimed to evaluate the impact of RC on outcomes in patients undergoing PCI for a non-myocardial infarction (MI). Methods and results: Patients undergoing PCI from 2012 to 2023 at a tertiary centre were analysed. Subgroups according to calculated RC percentiles [<50th (reference), 50th to <75th, 75th to <90th, ≥ 90th] were created. The primary outcome of interest was a composite major adverse cardiovascular event (MACE) endpoint, including all-cause mortality, spontaneous myocardial infarction and stroke 1 year after PCI. Overall, 19 289 patients were included in the current analysis. Patients in higher RC percentiles were younger, less often white, had a higher BMI, and had more comorbidities. Rates for the composite MACE endpoint did not differ significantly according to RC concentrations. However, a significantly increased risk for incident MI in the highest RC percentile subgroup (≥90th percentile—adjusted hazard ratio: 1.54, 95% confidence interval: 1.07–2.22; trend P-value = 0.010) in comparison to the <50th percentile was noted. Conclusion: While RC did not associate with the composite MACE endpoint, higher concentrations of this subtype of triglyceride-rich lipoproteins were a marker for incident ischaemic endpoints such as MI in patients undergoing PCI for a non-MI.