OBJECTIVE: Patients with severe tricuspid regurgitation (TR) are at risk for significant morbidity and mortality. Transcatheter tricuspid valve interventions (TTVI) may offer patients less invasive treatment alternatives to surgery. This review evaluates the most common class of device currently used worldwide to treat TR, tricuspid transcatheter edge-to-edge repair (T-TEER) and orthotopic transcatheter tricuspid valve replacement (TTVR), both of which are now approved in the USA and Europe.
RESULTS: The first pivotal randomized clinical trial, TRILUMINATE, demonstrated that T-TEER can safely reduce TR and is associated with improved health status outcomes. However, results of this trial have raised questions about whether this device can provide sufficient TR reduction to impact clinical outcomes. Orthotopic TTVR has recently gained attention with initial data suggesting near-complete TR elimination. The current review examines the technical features and anatomic limitations of the most commonly used devices for T-TEER and orthotopic TTVR, discusses the current clinical data for these devices, and offers a theoretical construct for device selection.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of myocardial infarction that most frequently affects younger women, making it an important cause of morbidity and mortality within these demographics. The evolution of intracoronary imaging, improved diagnosis with coronary angiography, and ongoing research efforts and attention via social media, has led to increasing recognition of this previously underdiagnosed condition. In this review, we provide a summary of the current body of knowledge, as well as focused updates on the pathogenesis of SCAD, insights on genetic susceptibility, contemporary diagnostic tools, and immediate, short- and long-term management.

BACKGROUND: Patients with a small aortic annulus (SAA) undergoing aortic valve replacement are at increased risk of patient-prosthesis mismatch (PPM), which adversely affects outcomes. Transcatheter aortic valve replacement (TAVR) has shown promise in mitigating PPM compared to surgical aortic valve replacement (SAVR).
METHODS: We conducted a systematic review and meta-analysis following PRISMA guidelines to compare clinical outcomes, mortality, and PPM between SAA patients undergoing TAVR and SAVR. Eligible studies were identified through comprehensive literature searches and assessed for quality and relevance.
RESULTS: Nine studies with a total of 2476 patients were included. TAVR demonstrated similar 30-day and 2-year mortality, myocardial infarction, and stroke rates compared to SAVR. However, TAVR showed significant advantages in reducing moderate survival post SAVR, the observed hemodynamic outcomes may potentially contribute to substantial survival variations between TAVR and SAVR during extended follow-up periods.22 Furthermore, previous studies found comparable 30-day and 2-year mortality rates between TAVR and SAVR, with no significant differences across annulus sizes.22, 23 Stroke and myocardial infarction incidences and severe PPM and lowering rates of major bleeding at both 30 days and 2 years. Conversely, SAVR had better outcomes in 30-day permanent pacemaker implantation. Echocardiographic outcomes were comparable between the two interventions.
CONCLUSIONS: Our findings suggest that both TAVR and SAVR are viable options for treating AS in patients with a small aortic annulus. TAVR offers advantages in reducing PPM and major bleeding, while SAVR performs better in terms of pacemaker implantation. Future studies should focus on comparing newer generation TAVR techniques and devices with SAVR. Consideration of patient characteristics is crucial in selecting the optimal treatment approach for AS.

BACKGROUND: Aortic valve stenosis is a common cardiac condition that requires intervention for symptomatic and/or prognostic reasons. The two most common interventions are surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). The ratio of TAVI:SAVR has increased twofold over the past few years and is now being considered in intermediate-risk patients as well. One of the significant benefits of TAVI is that it is less invasive; however, one of the drawbacks is a high paravalvular leaks (PVLs) rate compared to SAVR. To assess the impact of PVLs on survival, progression of heart failure, and the need for re-intervention.
METHODS: We conducted a comprehensive systematic literature search from the conception of TAVI 2002 until December 2022 through Embase (Ovid), MEDLINE (Ovid), Science Direct, and CENTRAL (Wiley). We followed PRISMA guidelines and checklists. Review protocol registration ID in PROSPERO: CRD42023393742.
RESULTS: We identified 28 studies that met our eligibility criteria, and only 24 studies were suitable for pooling in a meta-analysis (including their hazard ratio with a confidence interval of 95%) assessing our primary outcome (all-cause mortality). The remaining four studies were narratively synthesised. RevMan V5.4 (Version 5.4. Cochrane Collaboration, 2020) was utilised to pool meta-analysis data to assess effect estimates of PVLs in both intervention arms, using a random effect model for calculation (hazard ratio 1.14 confidence interval 95% 1.08-1.21 [p<0.0001]), with a follow-up duration between 30 days to 5 years.
CONCLUSIONS: Patients with mild or higher degrees of PVLs in both intervention arms incurred unfavourable outcomes. The incidence of PVLs was significantly higher with TAVI; even a mild degree led to poor quality of life and increased all-cause mortality on long-term follow-up.

UNASSIGNED: Hypersensitivity reactions to iodinated contrast media (ICM) are frequently encountered in clinical practice. Severe manifestations, despite being infrequent, can be life-threatening and represent an issue when re-administration of ICM is required. Clear recommendations on prevention and management of relapses are still lacking.
UNASSIGNED: We present the cases of two patients presenting with acute coronary syndrome requiring urgent coronary angiography, with an anamnesis of ICM-induced drug reaction with eosinophilia and systemic symptoms syndrome. Both patients safely underwent a coronary angiography with the use of a different ICM (iobitridol) to the one linked to hypersensitivity manifestations, after premedication with corticosteroids and H1 antagonists.
UNASSIGNED: Our experience highlights that in clinical situations in which the use of ICM is urgently needed, premedication with corticosteroids and H1 antagonists together with the choice of an alternative contrast agent (when the culprit is known) represents an effective strategy to perform a potentially life-saving procedure while avoiding serious systemic allergic reactions.

BACKGROUND: Percutaneous coronary intervention (PCI) on severely calcified coronary lesions is challenging. Coronary calcified nodule (CN) refers to an eccentric and protruding coronary calcification associated with plaque vulnerability and adverse clinical events. This study aims to conduct an extensive review of CNs, focusing on its prognostic impact in comparison with nonnodular coronary calcification (N-CN).
METHODS: A systematic literature review on PubMed, MEDLINE, and EMBASE databases was conducted for relevant articles. Observational studies or randomized controlled trials comparing CNs and N-CNs were included.
RESULTS: Five studies comparing CNs and N-CNs were pertinent for inclusion. The total number of individuals across these studies was 1456. There were no significant differences in the baseline demographic, clinical, and angiographic data between the CN and N-CN groups. Intracoronary imaging was always utilized. At follow-up, CNs were associated with significantly increased, target vessel revascularization [odds ratio (OR) 2.16; 95% confidence interval (CI): 1.39-3.36, P-value < 0.01, I2 = 0%] and stent thrombosis (OR 9.29; 95% CI: 1.67-51.79, P-value = 0.01, I2 = 0%) compared with N-CN. A trend for greater cardiac death was also assessed in the CN group (OR 1.75; 95% CI: 0.98-3.13, P-value = 0.06, I2 = 0%).
CONCLUSIONS: CN has a significantly negative impact on outcomes when compared with N-CN.

BACKGROUND: Significant changes in tricuspid regurgitation (TR) and mitral regurgitation (MR) post-cardiac implantable electronic devices (CIED) are increasingly recognized. However, uncertainty remains as to whether risk of CIED-associated TR and MR differs with right ventricular pacing (RVP) via CIED with trans-tricuspid RV leads, compared to cardiac resynchronization therapy (CRT), conduction system pacing (CSP), and leadless pacing (LP).
OBJECTIVE: Synthesize extant data on risk and prognosis of significant post-CIED TR and MR across pacing strategies.
METHODS: We searched PubMed, EMBASE, and Cochrane Library databases published until October 31st, 2023. Significant post-CIED TR and MR were defined as ≥ moderate.
RESULTS: Fifty-seven TR studies (N=13,723 patients) and 90 MR studies (N =14,387 patients) were included. For all CIED, risk of post-CIED TR increased (pooled odds ratio (OR)=2.46 and 95% CI=1.88-3.22), while risk of post-CIED MR reduced (OR=0.74, 95% CI=0.58-0.94) after 12 and 6 months of median follow-up respectively. RVP via CIED with trans-tricuspid RV leads was associated with increased risk of post-CIED TR (OR=4.54, 95% CI=3.14-6.57) and post-CIED MR (OR=2.24, 95% CI=1.18-4.26). Binarily, CSP did not alter TR risk (OR=0.37, 95% CI=0.13-1.02), but significantly reduced MR (OR =0.15, 95% CI=0.03-0.62). CRT did not significantly change TR risk (OR=1.09, 95% CI=0.55-2.17), but significantly reduced MR with prevalence pre-CRT of 43%, decreasing post-CRT to 22% (OR =0.49, 95% CI=0.40-0.61). There was no significant association of LP with post-CIED TR (OR=1.15, 95% CI=0.83-1.59) or MR (OR=1.31, 95% CI=0.72-2.39). CIED-associated TR was independently predictive of all-cause mortality (pooled hazard ratio (HR)=1.64, 95% CI=1.40-1.90) after median of 53 months. MR persisting post-CRT independently predicted all-cause mortality (HR=2.00, 95% CI=1.57-2.55) after 38 months.
CONCLUSIONS: Our findings suggest that, when possible, adoption of pacing strategies which avoid isolated trans-tricuspid RV leads may be beneficial in preventing incident or deteriorating atrioventricular valvular regurgitation and might reduce mortality.

BACKGROUND: Acute coronary syndrome due to coronary artery embolism in the setting of ascending aortic thrombus is an uncommon condition, even rarer when there is no aortic pathology such as aneurysm, severe atherosclerosis, aortic dissection, or thrombophilia (whether inherited or acquired).
METHODS: We report a case of a 58-year-old male presented with acute chest pain, electrocardiogram showing non-ST-elevation acute coronary syndrome. The computed tomography angiography of coronary artery revealed a mural thrombus in the proximal part of ascending aorta, located above the left coronary artery ostium, without any aortic pathologies. With the exception of hypertension and cigarette smoking, no other risk factors were identified in this patient that may increase the risk of thrombosis. Given the life-threatening risk of interventional therapy and surgery, the patient determinedly opted for anticoagulant and dual antiplatelet therapy. Then he experienced the reoccurrence of chest pain after 6-day treatment, progressed to anterior and inferior ST-segment elevation myocardial infarction. Coronary artery embolism originating from the ascending aortic thrombus was suspected. Considering the hemodynamic instability of the patient, the medical treatment was continued and bridged to warfarin and aspirin after discharge. Follow-up computed tomography angiography at 6 months showed no obstruction in coronary artery and complete resolution of the thrombus. No thromboembolic events occurred henceforward.
CONCLUSIONS: Acute coronary syndrome could be a manifestation of secondary coronary embolism due to ascending aortic thrombus. Currently, there is no standardized guideline for the treatment of aortic mural thrombus, individualized treatment is recommended. When surgical therapy is not applicable for the patient, anticoagulation and dual antiplatelet treatment are alternative treatments that may successfully lead to the resolution of the aortic thrombus.

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UNASSIGNED: Arterial rupture is one of the rare but known and devastating complications of the angiogram, which can ultimately lead to loss of limb and life. Therefore, it is recommended that this complication be included in the consent form and that the operator and the logistics team be prepared for this scenario. Moreover, categorizing the patients based on risk factors to be more cautious during the procedure for high-risk patients can be considered a reasonable strategy.
UNASSIGNED: One of the rare but lethal complications of femoral artery catheterization for coronary angiography is arterial rupture, which can cause a range of negligible to massive retroperitoneal hemorrhage. This case presents a woman with unstable angina who underwent coronary catheterization. After arterial sheath placement, extravasation of blood from the right common iliac and lateral sacral arteries was seen, a diagnosis that has been reported rarely before. The bleeding was controlled with balloon inflation in the lateral sacral artery and a stent graft implantation in the right common iliac artery. The patient remained asymptomatic during the procedure and the short- and long-term follow-up. Interventional cardiologists and radiologists who access the femoral artery for any procedure should be aware of this possible event. Sometimes, this situation manifests with nonspecific symptoms such as weakness, lethargy, and pallor. Moreover, more logistical preparation and training are needed to overcome these unexpected conditions.