Symptomatic severe aortic stenosis has an extremely high risk of death, ranging from 60 to 90% at five years if left untreated. This has informed the recommendation for urgent intervention upon diagnosis, especially when symptoms develop. Asymptomatic severe aortic stenosis has a four-year mortality between 30 and 50% if left untreated, which is similar to some metastatic cancers. Conservative management for patients with severe asymptomatic aortic stenosis was previously advocated, likely owing to the relative invasiveness of surgical aortic valve replacement. The advent of low-risk transcatheter aortic valve implantation with good medium-term durability has prioritized the need for a paradigm shift in the treatment of asymptomatic severe aortic stenosis towards a more proactive strategy of early intervention to reduce significant adverse events. This article provides a state-of-the-art overview of the contemporary management of patients with asymptomatic severe aortic stenosis.

Background: Direct transcatheter aortic valve implantation (TAVI) approach is feasible and safe compared to predilatation‐TAVI. Certain clinical and computerized tomography (CT)‐based characteristics might indicate the need for balloon aortic valvuloplasty (BAV) before TAVI, especially with self‐expanding valves. Aims: We aimed to identify patients who require predilatation before TAVI. Methods and Results: We performed a retrospective, single‐center study between 2020 and 2024, enrolling 315 patients (predilatation = 158 vs. direct = 157) aged 81 ± 6 years, 43.5% male, with EuroSCORE II of 3.7 ± 2.9. The rate of predilatation increased over the study period and was performed more often in patients with higher velocity and pressure gradients on echocardiography, higher aortic valve calcium score on CT, bicuspid morphology, bigger aortic annulus anatomy, severe aortic cusp calcification, tortuous descending aorta (bend > 60 ° ), and horizontal ascending aorta (angle > 50 ° ). Direct implantation was performed more frequently in patients with permanent pacemaker, ischemic heart disease, concomitant significant aortic regurgitation, or alternative‐access TAVI. Regression analysis demonstrated that only the horizontal aorta was an independent predictor of predilatation ( p = 0.037). The rates of valve recapture, embolization, contrast use, procedure duration, hospital stay, inpatient death, stroke, significant paravalvular leak on postprocedural echocardiography, and new pacemaker implantation were not different between the groups. The rate of BARC ≥ 3 bleeding, mainly due to access‐site complications, was more frequent with direct‐TAVI compared to predilatation (6.4% vs. 0.6%; p = 0.005). Conclusions: Both predilatation and direct‐TAVI approaches can be safely performed in routine practice. Upfront selection of either approach based on the patient characteristics, echocardiography gradients, and CT anatomical features is recommended.

Ventricular free wall rupture is a rare but devastating complication. We report right ventricular free wall rupture complicating anterior ST-segment elevation myocardial infarction caused by a wrap-around left anterior descending coronary artery. In acute cardiac tamponade, a rapid and systematic evaluation of the likely source of bleeding is paramount to prevent disastrous outcomes. (Level of Difficulty: Advanced.)

Background:Undeflatable coronary balloons during percutaneous coronary intervention (PCI) are rare but particularly hazardous because persistent intracoronary inflation can cause abrupt coronary occlusion, ischaemia, and haemodynamic collapse. We aimed to synthesise the published experience to define mechanistic patterns, identify recurring predisposing factors, and propose a practical bailout algorithm.Methods and Results:We performed a case-based review of PubMed, the Cochrane Library, and EBSCO from inception to February 2026. Eligible reports described balloons that could not be deflated while positioned in a coronary artery. A total of 15 coronary cases (2011–2025) met the inclusion criteria. Events occurred most often during post-dilatation or after stent deployment in complex anatomy, frequently involving severe calcification, aorto-ostial segments, chronic total occlusion-like lesions, and settings with limited guide engagement. Mechanistic patterns clustered into (i) intact-system non-deflation, where restoration of an exit pathway (system checks, sustained negative suction, and contrast dilution), followed by controlled decompression (wire puncture or mechanical- or energy-assisted disruption), was feasible; (ii) shaft-compromised events (fracture or detachment), where management shifted from decompression to mechanical retrieval, with surgery reserved for percutaneous failure.Conclusion:Undeflatable coronary balloons represent distinct failure modes with different viable rescue options. Outcomes appear to be driven by rapid restoration of perfusion and early recognition of shaft integrity. A structured escalation approach prioritising stabilisation, low-risk troubleshooting, controlled decompression, and decisive transition to retrieval, exclusion, or surgery when decompression is impossible could reduce secondary iatrogenic harm.

Background: Diabetic patients tend to have complex coronary artery disease (CAD). Understanding their procedural risk may help to guide treatment strategies. SYNTAX and the British Cardiovascular Intervention Society Jeopardy Score (BCIS-JS) have been used to define complex CAD, but their use has not been compared in diabetic patients. Methods: This is a retrospective analysis of prospectively collected data of consecutive patients who underwent complex percutaneous coronary intervention (PCI) and were deemed unsuitable for surgical revascularization. Both SYNTAX and BCIS-JS were calculated by experienced operators who were blinded to patient’s outcome. The primary endpoint was all-cause mortality at 12 months. Results: Of 452 patients included in the study, diabetes was present in 35% patients. There was a modest relationship between BCIS-JS and SYNTAX score (Spearman r = 0.44, p < 0.001) and this relationship was even weaker in patients with diabetes (Spearman r = 0.32, p < 0.001). The primary endpoint was comparable in the non-diabetic group, irrespective of the score system (SYNTAX or BCIS-JS) used to define complex CAD. In contrast, there was a differential prognostic outcome in the diabetic group, whereby the primary endpoint was more frequently reported in diabetic patients with high versus low SYNTAX scores [HR 4.96, 95% CI (1.44–17.03), p = 0.011] but not when BCIS-JS was used. Conclusions: There was a modest relationship between BCIS-JS and SYNTAX score. Unlike BCIS-JS, the SYNTAX score identified those who are at increased risk of death among diabetic patients. Both scoring systems did not effectively differentiate mortality risk in non-diabetic patients. Future research is needed to confirm this study’s findings.

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