Background: Acute coronary syndromes (ACSs) remain a leading cause of death and disability. Since the publication of the 2023 ESC ACS guidelines, multiple studies and an ESC/EAS dyslipidaemia update have refined how clinicians diagnose, revascularize, and treat ACS across the care continuum. Content: This state-of-the-art review synthesizes advances from 2023 to 2025 across five domains. Diagnosis: High-sensitivity troponin-based accelerated pathways remain foundational; GRACE 3.0 improves calibration for early vs. delayed angiography, while selective use of CCTA and routine use of intracoronary imaging/physiology help define the mechanism and optimize PCI. Revascularization: complete revascularization continues to underpin care in multivessel disease, with recent data favouring culprit-only PCI acutely and staged non-culprit treatment during the index stay in most STEMI presentations, particularly with heart-failure physiology. Antithrombotic therapy: Aspirin remains critical early after ACS-PCI; emerging evidence supports shorter DAPT and aspirin withdrawal after 1 month in carefully selected, low-ischaemic-risk patients, whereas day-0 aspirin-free strategies in unselected ACS are not non-inferior. Secondary prevention: A “strike early and strong” approach to LDL-cholesterol—often with combination therapy in hospital—is emphasized, alongside nuanced roles for SGLT2 inhibitors and GLP-1 receptor agonists. Special populations and implementation: Sex- and age-aware tailoring (including MINOCA/SCAD evaluation), pragmatic bleeding-risk mitigation, digitally enabled cardiac rehabilitation, and registry-driven quality improvement translate evidence into practice. Summary: Contemporary ACS care is moving from uniform protocols toward risk-stratified, mechanism-informed pathways. We offer practical algorithms and checklists to align interventional timing, antithrombotic intensity/duration, and secondary prevention with individual patient risk—bridging new evidence to bedside decisions.

Background: The Valve Academic Research Consortium (VARC) has updated criteria for periprocedural bleeding after transcatheter aortic valve replacement. However, clinical validation of the VARC‐3 bleeding definition is scarce. The aim of this study was to evaluate incidence, associated variables, and clinical impact of VARC‐3 bleeding. Methods: The study included 2227 patients with severe aortic stenosis undergoing transcatheter aortic valve replacement between 2018 and 2023 at the University Hospital Cologne. VARC‐3 bleeding during the index hospitalization were analyzed. Incidence, variables associated with bleeding, and impact on 30‐day mortality were evaluated by comparison to the VARC‐2 criteria. All data were prospectively collected. Results: VARC‐3 bleeding was 2.5 times more prevalent than VARC‐2 (13.9% versus 34.4%), as VARC‐3 includes nonattributable blood loss >3 g/dL as a bleeding event. Chronic kidney disease, thoracotomy access, dual antiplatelet therapy ( P <0.001 for all), and female sex ( P =0.023) were variables associated with VARC‐3 bleedings. Type 3 bleeding (VARC‐3) was associated with an increased 30‐day mortality (hazard ratio [HR], 2.89 [95% CI, 1.35–6.19], P =0.006). VARC‐2 major and life‐threatening bleeding events were associated with increased 30‐day mortality as well (HR, 2.74 [95% CI, 1.26–5.95], P =0.011 and HR, 29.60 [95% CI, 17.42–50.30], P <0.001). Conclusions: The VARC‐3 criteria present a refined classification for bleeding with prognostic relevance. However, the VARC‐2 criteria demonstrate precision and clear correlation with increasing mortality risk proportional to the severity of bleeding too, showing even greater predictive accuracy in the transfemoral cohort. These findings require further validation with similar or even larger patient cohorts.

Background: The frozen elephant trunk (FET) technique as a hybrid combining surgical and endovascular repair is an emerging concept to treat complex aortic dissection. Early experience showed technical feasibility and promising clinical outcomes. However, unsuspected complications still arise. Case summary: A 25-year-old male presented to the emergency department with a 2-day history of chest pain. After exclusion of acute coronary syndrome, a computed tomography angiography (CTA) revealed Type A (DeBakey Type I) aortic dissection. The patient underwent median stenotomy for complete replacement of the ascending aorta, the aortic arch, and FET. Early after rewarming, the patient became unstable due to severe left ventricular dysfunction. Soon veno-arterial extracorporal membrane oxygenation (VA-ECMO) was required for circulatory support. The cause of deterioration remained unclear until repeated CTA showed acute obstruction of the FET. Invasive exploration confirmed a trans-FET gradient of 100 mmHg, successfully managed by repeated balloon inflation with resolution of both obstruction and gradient. The patient recovered completely without any sequela. Discussion: While the mechanism of acute obstruction after FET remains subject to speculation, the rescue intervention of ballooning the obliteration on VA-ECMO was life-saving. Intraoperative ultrasound and videoscopic inspection may be instrumental before chest closure to avoid such critical events.

Background: Exercise training is generally discouraged in patients with severe symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) due to safety concerns. However, whole-body vibration (WBV) exercise could offer a novel approach to improve exercise capacity and quality of life, though its effects remain unclear in this population. Methods: Thirty patients with AS scheduled for TAVI were prospectively and randomly assigned to either the WBV group (12 sessions, 30 min each over 4 weeks) or a control group. Assessments of cardiopulmonary exercise testing (CPET), 6-min walking distance (6MWD) and health-related quality of life (HRQoL) questionnaires were conducted at baseline (V1), one day before TAVI (V2) and at short-term follow-up (V3). WBV was conducted between V1 and V2. Results: For the analysis at V1 and V2 16 patients in the WBV group and 14 in the control group were included. Mean age was 79.7 ± 5.22 years, with a mean aortic valve area of 0.75 ± 0.21 cm². Peak V’O₂ increased by 0.3 mL*min^-1*kg^-1 in the WBV group versus a decrease of − 1.4 mL*min^-1*kg^-1 in the control group (difference, 1.7 mL*min^-1*kg^-1; 95% CI, [0.2 to 3.2], p = 0.03). Peak power improved by 5.1 W in the WBV group compared to a decline of − 4.5 W in the control group (difference, 9.6 W; 95% CI, [2.1 to 17.1], p = 0.01). The WBV group also showed a non-significant improvement in 6MWD (34 m vs. − 8 m in the control group; difference, 42 m; 95% CI, [-10 to 93], p = 0.11). No serious adverse events occurred in the WBV group. Conclusion: This pilot study demonstrated that a WBV exercise program is feasible, safe, and showed potential to preserve exercise capacity as well as physical performance in AS patients scheduled for TAVI. Graphical

Background: Mitral transcatheter edge-to-edge repair (M-TEER) has been established as a treatment for severe mitral regurgitation (MR). However, recurrent MR may occur after successful primary M-TEER. Repeat M-TEER procedures are challenging or even anatomically unfeasible. Therefore, novel techniques like electrosurgical laceration from the anterior leaflet and stabilization (ELASTA) of M-TEER devices are important. Case summary: An 85-year-old male presented with recurrent cardiac decompensations and relevant dyspnoea [New York Heart Association (NYHA) functional Class III–IV] caused by severe MR and heart failure. Four years earlier, the patient underwent M-TEER with two PASCAL devices due to severe primary MR. Echocardiography revealed two significant regurgitation jets, representing severe recurrent MR. Repeated M-TEER was prohibitive due to an elevated mean transvalvular gradient (6.2 mmHg) and surgery was deemed unfeasible. A computed tomography (CT) was performed using software based on artificial intelligence (AI) for automatic analysis of the mitral valve anatomy. The heart team then decided to perform an ELASTA of the two PASCAL devices with subsequent transapical transcatheter mitral valve implantation (TMVI). The procedure was performed without complications and achieved optimal haemodynamic outcomes. Discussion: The frequency of M-TEER procedures will rise, leading to a corresponding increase of recurrent MR requiring treatment. However, additional edge-to-edge repair is often not feasible due to space limitations, elevated inflow gradients, or progressive calcification of valve leaflets. Emerging electrosurgical techniques, such as ELASTA, combined with subsequent TMVI, offer promising solutions for recurrent MR. Computed tomography imaging plays a critical role in procedural planning, and AI-driven programs have the potential to significantly improve and optimize these analyses.

Embolization of a left atrial appendage occluder (LAAO) is associated with significant complications and mortality. Retrieval of an embolized device often necessitates surgical intervention, as a standardized percutaneous approach is not yet established. An 83-year-old patient presented with progressive dyspnea six months post LAAO-implantation. Echocardiography revealed embolization of the occluder into the left ventricular outflow tract, where it became entrapped in a biological valve prosthesis, causing severe aortic stenosis. Percutaneous retrieval of the LAAO was performed using the novel ŌNŌ retrieval basket. This case represents the first European application of the ŌNŌ retrieval basket, demonstrating its feasibility and safety.