Severe aortic stenosis represents a significant prognostic burden, particularly in symptomatic patients. The advent of transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of patients previously considered ineligible for surgical aortic valve replacement (SAVR). TAVR provides a relatively safe intervention that leads to improvements in survival, symptoms, and functional status within months of implantation. A major complication following TAVR is the occurrence of paravalvular leaks (PVLs), which have been associated with increased mortality and higher rates of heart failure-related hospitalizations. PVLs refer to abnormal blood flow between the implanted valve and the aortic wall, which can compromise the functionality of the device. Careful pre-procedural planning enables the identification of patients at higher risk for PVL development. Although the incidence of PVLs has decreased with the introduction of newer-generation transcatheter valves, the condition remains clinically relevant. Due to the complex anatomy of the aortic valve apparatus and interference from the prosthetic frame, accurate evaluation of PVLs requires a multimodal diagnostic approach. Current evidence on PVL management is limited. In most cases, a conservative approach is adopted, while interventional strategies (such as pre- and post-dilatation, percutaneous PVL closure, and TAVR-in-TAVR) are reserved for selected patients. We performed a systematic literature review to summarize the incidence, predictors, diagnostic techniques, and management strategies of PVLs following TAVR.

Background: The ageing population has led to an increased prevalence of chronic diseases, posing challenges for the management of critically ill cardiac patients with multiple comorbidities. The Palliative Performance Scale (PPS), initially developed for terminally ill cancer patients, has shown prognostic value in various medical settings but remains understudied in cardiac intensive care units (CICUs). This study evaluates the PPS as a prognostic tool for in-hospital and 1-year all-cause mortality in CICU patients. Methods: We conducted a single-centre, prospective, observational study at the Maggiore Hospital in Bologna, including 1131 patients admitted to the CICU between August 2022 and November 2023. Patients were stratified into two groups based on their PPS at admission (≤70 and >70). Multivariable regression models were used to assess predictors of mortality, and Kaplan-Meier survival curves were generated. Model accuracy and calibration were evaluated using receiver operating characteristic curves and the Hosmer-Lemeshow test. Results: Patients with PPS ≤70 had significantly higher 1-year all-cause mortality (37.0% vs 9.8%, p<0.001) and in-hospital all-cause mortality (17.7% vs 3.3%, p<0.001). In the multivariable regression models, PPS emerged as an independent predictor of both 1-year and in-hospital all-cause mortality, along with age and Sequential Organ Failure Assessment score. The models demonstrated good discriminatory performance (area under the curve of 0.841 for 1-year mortality, 0.862 for in-hospital mortality) and acceptable calibration. Conclusions: The PPS is a reliable and independent predictor of mortality in CICU patients. Incorporating PPS into clinical practice may enhance risk stratification, guide decision-making and optimise resource allocation in this high-risk population.

Non-obstructive coronary artery disease (NOCAD) encompasses a heterogeneous group of conditions in which patients present with angina, ischemia or myocardial infarction despite the absence of obstructive epicardial stenoses. This spectrum includes myocardial infarction with non-obstructive coronary arteries (MINOCA) and angina or ischemia with non-obstructive coronary arteries (ANOCA/INOCA), entities increasingly recognized as clinically significant and associated with adverse outcomes. Advances in cardiac computed tomography (CT) have expanded the diagnostic capabilities beyond the exclusion of obstructive coronary artery disease, enabling comprehensive anatomical, functional and tissue-level assessment relevant to NOCAD. CT allows precise identification of non-obstructive atherosclerosis, high-risk plaque features, myocardial bridging and structural vascular remodelling. Quantitative and qualitative characterization of plaque burden correlates with ischemic risk and provides prognostic information that complements traditional stenosis-based evaluation. Emerging CT-derived biomarkers, such as pericoronary fat attenuation index and epicardial adipose tissue metrics, offer insight into vascular inflammation and microvascular dysfunction, key mechanisms in NOCAD. Functional CT techniques, such as CT-derived fractional flow reserve and CT perfusion imaging, enable non-invasive assessment of hemodynamic significance and microvascular impairment, although their routine use is limited by methodological variability and evolving clinical evidence. Beyond coronary evaluation, CT also provides myocardial tissue characterization, detects extracardiac causes of symptoms and contributes to comprehensive differential diagnosis. Despite its strengths, cardiac CT remains limited by spatial resolution, radiation exposure and its inability to directly visualize the microcirculation. Nevertheless, ongoing technological refinement and integration of computational modelling are likely to enhance its diagnostic and prognostic role.

Background: The number of older patients admitted with myocardial infarction (MI) is increasing, and their clinical profiles range from very fit to frail and functionally impaired. Objectives: To evaluate whether the benefits of complete revascularization are consistent across subpopulations of older MI patients stratified by the Clinical Frailty Scale (CFS). Methods: In the FIRE trial, 1445 patients aged ≥75 years with MI and multivessel disease were randomized to either complete or culprit-only revascularization. Overall, 1010 patients (70%) were stratified according to CFS (scores 1–3 non-frail, 4 pre-frail, 5–9 frail). The primary endpoint was a 3-year composite of death, MI, stroke, or ischemia-driven revascularization. Results: Of the stratified cohort, 523 (52%) were non-frail, 304 (30%) pre-frail, and 183 (18%) frail. Increasing frailty was significantly associated with a higher risk of the primary endpoint (HR 1.62, 95% CI 1.19–2.20; P = .002). Complete revascularization reduced the primary endpoint with no significant interaction between revascularization strategy and CFS category (p for interaction = 0.769). The benefit of complete versus culprit-only revascularization remained consistent across the full range of CFS scores. Similar findings were observed for secondary endpoints, and no significant interaction emerged for safety outcomes. Conclusions: Frailty, as assessed by the CFS, was independently associated with adverse outcomes. Complete revascularization was effective regardless of frailty status and should be considered in all older MI patients with multivessel disease undergoing an invasive strategy. Trial Registration: ClinicalTrials.gov Identifier: NCT03772743.

Atrial strain assessment, both by speckle-tracking echocardiography and feature tracking cardiac magnetic resonance (CMR), represents a useful tool in all the spectrum of cardiomyopathies. The most robust evidence available in the literature concerns cardiomyopathies with a hypertrophic phenotype, in which left atrial strain (LAS) has demonstrated to be able to differentiate each phenotype, with cardiac amyloidosis (CA) having the lowest LAS values compared to hypertrophic cardiomyopathy (HCM), Fabry cardiomyopathy (FD), and hypertensive heart disease. LAS is also able to predict the occurrence of atrial arrhythmias, in particular atrial fibrillation in CA and HCM, and major adverse cardiac event (MACE) in all the phenotypes. Interestingly, both in HCM and FD, improvement in LAS values has been detected during disease-modifying therapy. In cardiomyopathies with a dilated phenotype as well, LAS, which has been more extensively evaluated through CMR compared to other cardiomyopathies, appears to have prognostic value with respect to left ventricular reverse remodeling and the occurrence of MACE and can help to differentiate dilated cardiomyopathy from ischemic heart disease with left ventricular dilatation. Finally, in arrhythmogenic right ventricular cardiomyopathy, right atrial strain has also demonstrated prognostic power, particularly for the occurrence of both atrial and ventricular arrhythmic events. Interestingly, impaired values of right atrial strain have been detected even in the absence of dilatation of the right atrium, suggesting an earlier involvement by fibro-fatty replacement and fibrosis.