Background: The best management of stable coronary artery disease (CAD) in patients undergoing transcatheter aortic valve implantation (TAVI) is still unclear due to the marked inconsistency of the available evidence. Methods: The REVASC-TAVI registry (Management of Myocardial Revascularization in Patients Undergoing Transcatheter Aortic Valve Implantation With Coronary Artery Disease) collected data from 30 centers worldwide on patients undergoing TAVI who had significant, stable CAD at preprocedural work-up. For the purposes of this analysis, patients with either complete or incomplete myocardial revascularization were compared in a propensity score matched analysis, to take into account of baseline confounders. The primary and co-primary outcomes were all-cause death and the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure, respectively, at 2 years. Results: Among 2407 patients enrolled, 675 pairs of patients achieving complete or incomplete myocardial revascularization were matched. The primary (21.6% versus 18.2%, hazard ratio‚ 0.88 [95% CI, 0.66–1.18]; P =0.38) and co-primary composite (29.0% versus 27.1%, hazard ratio‚ 0.97 [95% CI, 0.76–1.24]; P =0.83) outcome did not differ between patients achieving complete or incomplete myocardial revascularization, respectively. These results were consistent across different prespecified subgroups of patients (< or >75 years of age, Society of Thoracic Surgeons score > or or 0.10). Conclusions: The present analysis of the REVASC-TAVI registry showed that, among TAVI patients with significant stable CAD found during the TAVI work-up, completeness of myocardial revascularization achieved either staged or concomitantly with TAVI was similar to a strategy of incomplete revascularization in reducing the risk of all cause death, as well as the risk of death, stroke, myocardial infarction, and rehospitalization for heart failure at 2 years, regardless of the clinical and anatomical situations.

Background: An increased degree of aortic angulation (AA) represents a challenging feature for bioprosthesis positioning. Whether AA has an impact on procedural outcomes of contemporary self-expanding valves remains unsettled. The aim of this study was to evaluate the impact of AA on procedural outcomes of transcatheter aortic valve replacement with contemporary self-expanding valves. Methods: The HORSE (Horizontal Aorta in Transcatheter Self-Expanding Valves) is an international, retrospective registry including 3862 consecutive patients undergoing transcatheter aortic valve replacement with either Evolut R/PRO (n=1959) or ACURATE neo (n=1903) devices. Patients undergoing Evolut R 34 mm implantation were excluded as no comparable prosthesis size for ACURATE neo is available. AA was evaluated with preprocedural computed tomography, and its impact on device success was evaluated. Results: In the overall population, AA did not have any impact upon device success, also when adjusting for in-study outcome predictors (odds ratio for 1° increment, 0.99 [95% CI, 0.98–1.01], P =0.306). However, increased AA was associated with lower device success with use of the Evolut R/PRO valves (odds ratio, 0.97 [95% CI, 0.95–0.99]; P =0.004), but not the ACURATE neo valves (odds ratio, 1.00 [95% CI, 0.98–1.03], P =0.304). The best AA cutoff value predicting device success was 49° (47% of the study cohort). Among patients with AA≥49°, Evolut R/PRO valves were associated with lower device success as compared to the ACURATE neo valve (inverse probability weighting odds ratio, 0.62 [95% CI, 0.46–0.83]; P =0.002). Conclusions: Horizontal aorta, as defined by an AA ≥49°, is a common feature among transcatheter aortic valve replacement candidates and predicts device failure of the Evolut R/PRO valves, but not of the ACURATE neo valve. AA may be an effect modifier of the association between self-expanding valve type and device success.

The Official Journal of EuroPCR and the European Association of Percutaneous Cardiovascular Interventions (EAPCI)

Systematic Severe aortic stenosis (AS) is a progressive disease and one of the most common valvular heart diseases in developed countries. The management of asymptomatic severe AS remains challenging and requires a tailored, patient-specific approach. Optimal timing of intervention in asymptomatic patients continues to be a matter of ongoing debate. In individuals with severe AS and reduced left ventricular ejection fraction (LVEF), both the ESC/EACTS and ACC/AHA guidelines recommend aortic valve replacement (AVR), regardless of symptom status. In contrast, for patients with preserved LVEF (≥50%), the decision to proceed with AVR must be individualized and based on a comprehensive risk assessment. Risk stratification plays a central role in guiding early intervention strategies and should incorporate clinical findings, echocardiographic parameters, biomarkers, and advanced imaging techniques such as cardiac magnetic resonance and computed tomography. Recent randomized controlled trials have yielded mixed results regarding the mortality benefit of early AVR but have consistently demonstrated a reduction in heart failure-related hospitalizations. Timely intervention in carefully selected high-risk patients may improve long-term outcomes, while avoiding unnecessary procedures in lower-risk individuals remains equally important.

Background/Objectives: To date, data regarding the characteristics and management of obstructive, stable coronary artery disease (CAD) encountered in patients undergoing transcatheter aortic valve implantation (TAVI) are sparse. The aim of the study was to analyze granular details, treatment, and outcomes of patients undergoing TAVI with obstructive, stable CAD from real-world practice. Methods: REVASC-TAVI (Management of myocardial REVASCularization in patients undergoing Transcatheter Aortic Valve Implantation with coronary artery disease) is an investigator-initiated, multicenter registry, which collected data from patients undergoing TAVI with obstructive stable CAD found during the pre-TAVI work-up. Results: A total of 2025 patients from 30 centers worldwide with complete follow-up were included in the registry. Most patients had single-vessel CAD (56.1%). An involvement of proximal coronary tracts was detected in 62.5% of cases, with 12.0% of patients having CAD in left main (LM). Most patients received percutaneous coronary intervention (PCI) (n = 1617, 79.9%), especially those with proximal CAD (90.4%). At 2 years, the rates of all-cause death [Kaplan–Meier (KM) estimates 20.1% vs. 18.8%, p_log-rank = 0.86] and of the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure (KM estimates 29.7% vs. 27.5%, p_log-rank = 0.82) did not differ between patients undergoing PCI and those who were not. Conclusions: Patients undergoing TAVI with obstructive CAD more commonly had a single-vessel disease and an involvement of proximal coronary tracts. They were commonly treated with PCI, with similar outcomes compared to those treated conservatively.

The progressive aging of the atrial fibrillation (AF) population, frequently characterized by high ischemic and bleeding risks, has led to a substantial increase in referrals for left atrial appendage occlusion (LAAO). The expansion of indications and the high procedural success rate of LAAO have further contributed to rising procedural volumes. However, this growth introduces important challenges: LAAO candidates are often elderly and frail, with increased anesthesia-related risks, and high-volume catheterization laboratories may face logistical constraints, particularly in centers without dedicated anesthesiology support. The current gold standard approach, transesophageal echocardiography (TEE) under general anesthesia (GA), ensures optimal imaging and procedural control but may increase procedural complexity and perioperative risks. In response, minimalist strategies are increasingly explored, targeting either the anesthetic protocol or the imaging modality. Conscious sedation (CS) protocols have been adopted to reduce anesthesia-related burden while maintaining TEE guidance. Alternatively, imaging-based strategies aim to replace TEE with less invasive modalities, including intracardiac echocardiography (ICE), transesophageal–intracardiac echocardiography (TE-ICE), and MicroTEE. Each approach presents specific advantages and limitations regarding safety, feasibility, operator expertise, and institutional resources. Taken together, these findings support a patient-centered approach to LAAO, whether traditional or minimalist, in which the choice of anesthetic strategy and echocardiographic guidance is driven by institutional resources, operator expertise, and individual patient characteristics rather than by expected differences in procedural or clinical efficacy. This review summarizes current evidence on minimalist LAAO pathways and discusses their role in achieving a tailored, resource-conscious procedural model.