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.

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.