Objective: Prosthesis–patient mismatch (PPM) occurs after aortic valve replacement (AVR) when the effective orifice area of the implanted prosthetic valve is small relative to the patient’s body surface area. Beyond simply elevating transvalvular gradient, PPM profoundly affects cardiac remodeling, coronary physiology, and ultimately patient survival. This comprehensive review synthesizes current evidence regarding PPM pathophysiology, clinical consequences, and therapeutic strategies. Methods: We conducted a narrative review of PPM in surgical (SAVR) and transcatheter (TAVR) aortic valve replacement. PubMed and Embase were systematically searched using terms related to AVR and PPM and reference lists of key studies and reviews were screened. Studies addressing PPM prevalence, hemodynamic impact, clinical outcomes, and mitigation strategies were included. Results: PPM, defined as an iEOA ≤ 0.85 cm²/m² (moderate) or ≤0.65 cm²/m² (severe), demonstrates variable prevalence across studies, typically ranging from 5 to 30% after SAVR and 2–35% after TAVR. It is associated with increased transvalvular gradients, reduced left ventricular mass regression, persistent coronary flow abnormalities, higher rates of heart failure, and both early and late mortality. Supra-annular self-expanding transcatheter aortic valve replacement (TAVR) devices and newer generation stentless or bovine pericardial surgical valves exhibit lower PPM rates than older stented or porcine valves. Valve-in-valve (ViV) TAVR and bioprosthetic valve fracture (BVF) can improve outcomes in failed surgical valves but are less effective in small annuli. TAVR-in-TAVR procedures are limited by anatomic and technical constraints, especially in maintaining coronary access and minimizing residual gradients. Conclusions: PPM remains a common and clinically consequential complication of AVR that compromises long-term outcomes. It is largely preventable through accurate preoperative imaging, valve sizing, and consideration of annular enlargement. Optimal outcomes require matching valve characteristics to individual patient anatomy and physiology. In an era of expanding TAVR use, preventing PPM during the index procedure is critical to optimizing survival and preserving future reintervention options.

Neuroprotective strategies in coronary artery interventions are essential due to the rising number of high-risk patients undergoing procedures like coronary artery bypass grafting (CABG), totally endoscopic coronary artery bypass (TECAB), and hybrid revascularization. In this review article, we summarize the neurological complications associated with coronary artery disease intervention and the risk mitigation strategies. CABG carries significant risks, including ischemic stroke, encephalopathy, seizures, and peripheral nerve injuries. Risk factors include advanced age, hypertension, diabetes, and atherosclerosis. Off-pump CABG minimizes stroke risk by avoiding aortic manipulation and CPB. TECAB and hybrid revascularization have fewer reported neurological complications but still pose risks of stroke and cranial nerve injuries. Pharmacological neuroprotection includes agents such as barbiturates, volatile anesthetics, lidocaine, NMDA receptor antagonists, magnesium, nimodipine, corticosteroids, and aprotinin. Deep hypothermic circulatory arrest (DHCA) is reserved for complex aortic cases requiring a bloodless surgical field. Intraoperative strategies involve cerebral perfusion monitoring, embolic protection devices, and therapeutic hypothermia. Preoperative optimization targets risk factors, arrhythmia prevention, and antiplatelet therapy management. Postoperatively, timely antiplatelet administration, glucose control, hemodynamic stabilization, and cognitive monitoring are critical. Comprehensive neuroprotective approaches, spanning pre- to postoperative phases, aim to reduce neurological complications and enhance outcomes in coronary interventions.

Objectives: Several measurement techniques have been proposed to address the non-circular geometry of the aortic root. The Laplace diameter metric incorporates the cloverleaf anatomy of the aortic root and is derived via measurement of sinus-to-commissure lengths with subsequent doubling of the largest radius from the center. This study compares the conventional sinus-to-sinus with the novel Laplace method for sizing the aortic root and quantifying its implication on surgical decision-making. Methods: Patients undergoing surveillance at a high-volume aortic center were categorized by aortic root morphology as nondilated, non-syndromic dilated, bicuspid aortic valve and Marfan syndrome. Aortic root diameters by sinus-to-sinus and Laplace diameter methods were measured on computed tomography, compared using paired t-tests, and correlated using Spearman rank coefficients. Results: Of the 1297 patients assessed, 530 were included in the final analysis (nondilated n = 113, non-syndromic dilated n = 347, bicuspid aortic valve n = 50, Marfan syndrome n = 17). Aortic root diameters were significantly larger by Laplace than sinus-to-sinus diameter across all groups (sinus-to-sinus: 1.9 ± 5.5 mm; Laplace: 44.9 ± 7.0 mm; 95% confidence interval 2.72–3.34; p < 0.0001). Although Laplace and sinus-to-sinus diameter were correlated (Spearman r = 0.6789, 95% CI 0.6–0.7; p < 0.0001), the relationship was non-linear (R² = 0.492). Laplace diameter increased the proportion of patients meeting surgical thresholds (2022 AHA/ACC guidelines) versus sinus-to-sinus: nondilated 0% vs. 1.77%, non-syndromic dilated 4.9% vs. 25.1%, bicuspid aortic valve 10.0% vs. 26.0%, and Marfan syndrome 23.5% vs. 52.9%. Conclusions: On average, Laplace diameter exceeded sinus-to-sinus diameter by 3 mm and would extend surgical eligibility to an additional 21% of patients under current guidelines.

Background: In 2020, the first pre-assembled bioprosthetic aortic valved conduit (AVC) was approved in the United States. This study compares its anatomic and functional outcomes to traditional hand-sewn composite conduits in patients undergoing aortic root replacement. Methods: This retrospective study compared 118 patients receiving the pre-assembled AVC (2021–2023) versus 66 patients with hand-sewn conduits (2012–2020) after elective bio-Bentall procedures. Primary outcomes were post-operative mortality and complication rates. Secondary outcomes included anatomic and hemodynamic changes. Graft dimensions were obtained from post-operative computed tomography (CT). Echocardiographic parameters were collected at early and late follow-up. Between-group differences and longitudinal changes were assessed using linear mixed-effects models. Results: Groups were comparable in age (pre-assembled 63 ± 11 vs. hand-sewn 64 ± 11 years) and predominantly male. Despite significantly higher concomitant hemiarch rates in pre-assembled conduits (91.5% vs. 28.8%, p < 0.001), 30-day mortality, stroke, and reoperation for bleeding were comparable between groups. Pre-assembled conduits demonstrated superior hemodynamics with lower baseline peak gradients (Δ 9.1 mmHg, p < 0.001), lower mean gradients (Δ 5.3 mmHg, p < 0.001), and larger indexed effective orifice area (Δ 0.27 cm²/m², p = 0.018). Annual rates of hemodynamic and dimensional change were minimal and comparable between groups. Kaplan–Meier analysis showed no survival difference at 3 years. Conclusions: The pre-assembled AVC demonstrates equivalent safety and superior early hemodynamic performance compared to hand-sewn conduits, with stable mid-term anatomic and functional outcomes.

Background: Mechanical circulatory support (MCS) has revolutionized advanced heart failure and cardiogenic shock management, yet randomized controlled trials have failed to demonstrate consistent mortality benefits with temporary devices, and outcomes remain highly variable across institutions. Methods: This narrative review examines contemporary MCS devices, analyzing their hemodynamic principles, clinical outcomes, complications, and selection strategies. The published literature addressing MCS clinical applications and outcomes was reviewed, with reference lists examined to identify additional sources. Results: Temporary MCS devices demonstrate a persistent hemodynamic-survival paradox where improved hemodynamics fail to translate into mortality benefits in randomized trials. This disconnect reflects delayed intervention after irreversible organ damage, device complications offsetting hemodynamic gains, heterogeneous patient selection without phenotyping, timing challenges, and inadequate statistical power. Landmark trials provide definitive evidence against routine early VA-ECMO use, showing no survival advantage while significantly increasing complications. Optimal device selection requires integrating hemodynamic phenotyping with shock stage to match devices to pathophysiology, while biventricular failure presents the greatest challenge with substantially lower survival. For durable devices, third-generation systems demonstrate superior outcomes with dramatically reduced pump thrombosis and improved survival. Critically, multidisciplinary shock teams employing standardized protocols significantly reduce mortality beyond what devices alone achieve, with structured programs showing substantially improved survival compared to trials using similar devices without organized care systems. Conclusions: Mechanical circulatory support has transformed heart failure management, but optimal outcomes require integrating devices within structured care delivery systems. Success depends on comprehensive hemodynamic assessment, multidisciplinary team activation, protocolized device selection, standardized escalation and weaning strategies, and regionalized networks. The future lies in shifting focus from device innovation to implementation science, establishing quality metrics, developing precision medicine approaches, and conducting trials in phenotype-selected populations with protocolized care. This systems-of-care paradigm offers the most promising path toward translating technological advances into sustained mortality reduction.