Hypertension is a major driver of cardiovascular disease with a prevalence of 32–34% in adults worldwide. This poses a formidable unmet challenge for healthcare systems, highlighting the need for enhanced treatment strategies. Since 2017, eight major sham-controlled randomised controlled trials have examined the effectiveness and safety of renal denervation (RDN) as therapy for BP control. Although most trials demonstrated a reduction in systolic 24-hour/daytime ambulatory BP compared to control groups, open to discussion is whether major adverse cardiovascular events (MACE)-driven RDN trials are necessary or whether the proof of BP reduction as a surrogate for better cardiovascular outcomes is sufficient. We conducted an analysis of the statistical methods used in various trials to assess endpoint definitions and determine the necessity for MACE-driven outcome data. Such comprehensive analysis provides further evidence to confidently conclude that RDN significantly reduces blood pressure compared to sham controls. Importantly, this enables the interpolation of RDN trial endpoints with other studies that report on outcome data, such as pharmacological trials which demonstrate a significant reduction in MACE risk with a decrease in BP. Moreover, limitations associated with directly evaluating outcome data further support the use of BP as a surrogate endpoint. For example, conducting lengthier trials with larger numbers of participants to ensure robust statistical power presents a substantial challenge to evaluating outcome data. Thus, in light of the crucial need to tackle hypertension, there are notable advantages of considering BP as a surrogate for outcome data.

The sympathetic division of the autonomic nervous system plays a crucial role in maintaining homeostasis, but its overactivity is implicated in various pathological conditions, including hypertension, hyperglycaemia, heart failure, and rheumatoid arthritis. Traditional pharmacotherapies often face limitations such as side effects and poor patient adherence, thus prompting the exploration of device-based multi-organ denervation as a therapeutic strategy. Crucially, this procedure can potentially offer therapeutic benefits throughout the 24 h circadian cycle, described as an “always-on” effect independent of medication compliance and pharmacokinetics. In this comprehensive review, we evaluate the evidence behind targeted multi-organ sympathetic denervation by considering the anatomy and function of the autonomic nervous system, examining the evidence linking sympathetic nervous system overactivity to various cardiometabolic and inflammatory conditions and exploring denervation studies within the literature. So far, renal denervation, developed in 2010, has shown promise in reducing blood pressure and may have broader applications for conditions including arrhythmias, glucose metabolism disorders, heart failure, chronic kidney disease and obstructive sleep apnoea. We review the existing literature surrounding the denervation of other organ systems including the hepatic and splenic arteries, as well as the pulmonary artery and carotid body, which may provide additional physiological benefits and enhance therapeutic effects if carried out simultaneously. Furthermore, we highlight the challenges and future directions for implementing multi-organ sympathetic ablation, emphasising the need for further clinical trials to establish optimal procedural technique, efficacy and safety.

Rotational atherectomy (RA) is an important interventional technique to facilitate effective percutaneous coronary intervention of severely calcified lesions. Despite the improved probability of better procedural outcomes during angioplasty, the use of RA is associated with an inherent risk of complications. Here, we present a case of a woman in her mid-90s with severe aortic stenosis (AS) who underwent RA facilitated angioplasty of the right coronary artery (RCA), with the procedure complicated by the Kokeshi phenomenon. Manual traction to retrieve the burr resulted in dehiscence of an aortic plaque near the ostium of the RCA. Unfortunately, the patient’s risk profile precluded surgery. After a multidisciplinary discussion, a self-expanding Core Valve Evolut R prosthesis (Medtronic, Minneapolis, Minnesota, USA) was successfully implanted, with improvement in the AS and stabilisation of the aortic plaque. This is the first reported case of successful non-operative management of a mobile-aortic plaque caused by RA with a transcatheter prosthesis.

Objectives: Paravalvular leak (PVL) is a clinically significant complication following prosthetic valve replacement. Our aim was to compare the safety and efficacy of transcatheter versus surgical repair for PVL through an updated systematic review and meta-analysis of comparative studies. Methods: We conducted a systematic search of MEDLINE, Embase, CINAHL, and AMED from inception to the date of the final search. Comparative double-arm studies evaluating transcatheter repair (including closure and valve-in-valve procedures) versus open surgical repair were included. Primary outcomes were 30-day and one-year all-cause mortality, stroke or transient ischemic attack (TIA), and major bleeding. Secondary outcomes included acute kidney injury (AKI), vascular complications, residual PVL, heart failure readmission, symptomatic improvement, pacemaker insertion, and conversion to surgery. Results: Ten retrospective comparative studies comprising 1,616 patients (721 transcatheter; 895 surgical) were included. Transcatheter repair was associated with significantly lower 30-day mortality (3.6% vs 11.5%; OR 0.31, 95% CI 0.19–0.49), lower 30-day stroke/TIA (2.1% vs 5.8%; OR 0.36, 95% CI 0.20–0.67), and reduced AKI (3.2% vs 13.3%; OR 0.24, 95% CI 0.11–0.54). However, transcatheter intervention demonstrated higher rates of immediate residual PVL (26.7% vs 12.5%; OR 2.58, 95% CI 1.07–6.22), vascular complications (6.2% vs 2.3%; OR 2.54, 95% CI 1.15–5.63), and one-year heart failure readmission (25.5% vs 3.4%; OR 9.62, 95% CI 3.73–24.81). One-year mortality and long-term symptomatic improvement were comparable between groups. Overall certainty of evidence ranged from low to very low. Conclusions: Transcatheter PVL repair offers a favourable short-term safety profile compared with surgical repair but is associated with lower procedural success and higher rates of heart failure readmission. While transcatheter intervention represents a reasonable alternative for appropriately selected high-risk patients, further prospective comparative studies with standardised outcome definitions are required to clarify long-term durability and optimal patient selection.

Background: Adults with congenital heart disease (ACHD) have an increased risk of infective endocarditis (IE), associated with significant morbidity and mortality. This risk is compounded by patient-related factors, including lack of awareness of IE and the presence of a learning disability (LD). Our study sought to evaluate patients' understanding of the risks and symptoms of IE and to identify patients who could benefit from targeted education. Methods: Patients attending the outpatient department of a tertiary ACHD referral centre completed a questionnaire that assessed their knowledge, attitudes and behaviours towards IE. Baseline demographics and clinical data were collected from electronic patient records. Results: A total of 132 ACHD patients completed the questionnaires (age 41.7 +/- 16.4 years, 50 % male, 11 % with an LD). Only 37.1 % of patients accurately defined IE, none of whom had an LD. Most patients chose pyrexia (47 %) and tiredness (39.4 %) as potential symptoms of IE, however, none correctly identified all symptoms. Only 19.7 % were aware of the requirement for prolonged antibiotic treatment for IE. A third of all patients reported that they would have made lifestyle changes had they been aware of the complications of IE. There was a statistically significant association between learning disability and poor level of awareness in the questionnaire. Conclusions: Our study demonstrates awareness issues regarding IE among ACHD patients, highlighting the need to invest further on patient education. This should start at the time of transition from paediatric to adult services and continue lifelong, with emphasis on patients with a learning disability.