Transcatheter aortic valve implantation (TAVI) has expanded from a treatment for inoperable and high-risk aortic stenosis to an established therapeutic option for selected patients at low surgical risk. This review focuses on the outcomes of major trials comparing TAVI to traditional surgical aortic valve replacement (SAVR), highlighting outcomes and potential complications when considering lifetime valve management as we move into the younger population. A literature search of PubMed using terms such as 'transcatheter aortic valve replacement' and 'low surgical risk' was used to identify relevant publications from within the last 10 years. Recent randomized trials and follow-up studies suggest that, in appropriately selected low-risk patients, TAVI and SAVR provide broadly comparable mid-term outcomes for cardiovascular mortality, stroke, and valve re-intervention. However, important differences remain. TAVI is consistently associated with lower rates of new-onset atrial fibrillation but higher rates of permanent pacemaker implantation and paravalvular aortic regurgitation. As TAVI moves into younger and asymptomatic populations, unresolved questions remain around valve durability, coronary access, redo strategies, and lifetime valve management, highlighting the central role of multidisciplinary heart-team assessment in selecting the optimal lifetime therapeutic strategy.
INTRODUCTION:Revascularization post myocardial infarction is a complex interplay of patient and anatomical factors. There is a growing number of interventional tools providing both physiological and anatomical delineation of disease burden which can help determine the method and extent of revascularization. A tailored approach is required taking into consideration shared decision making, co-morbidities, and evolving treatment options. AREAS COVERED:This review article explores the wide array of revascularization techniques of both the culprit lesion and non-culprit lesions in the setting of acute myocardial infarction. A scoping literature review was undertaken of the PubMed database using keywordshighlighted below. EXPERT OPINION:Prompt and durable revascularization of the infarct-related coronary artery remains the cornerstone of treatment for acute myocardial infarction. Specifically, timely restoration of normal flow and implantation of a DES during the index procedure remains the gold standard; however, deferred treatment and novel devices such as DCB may have an emerging role. Despite much evidence, complete revascularization of non-culprit coronary artery disease in acute myocardial infarction is still the subject of contention.
INTRODUCTION:Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF). Despite major technological advances, arrhythmia recurrence remains common because of pulmonary vein reconnection caused by non-durable lesions. Achieving durable PVI requires balancing effective lesion formation with the prevention of collateral injury. AREAS COVERED:This review examines the biophysical determinants of lesion formation, mechanisms responsible for lesion inconsistency, and strategies to improve lesion durability while minimizing collateral injury. The literature was identified through a structured review of major clinical trials, observational studies, mechanistic investigations, and contemporary guideline documents focusing on radiofrequency, cryoballoon, laser balloon, and pulsed field ablation technologies, together with emerging approaches for lesion assessment and procedural optimization. EXPERT OPINION:Durable PVI depends not only on the energy source but also on precise control of catheter-tissue interaction, lesion contiguity, and individualized energy delivery. Pulsed field ablation has substantially improved procedural safety by reducing collateral thermal injury; however, durable lesion formation remains dependent on adequate tissue contact and appropriate energy delivery. Future progress will be driven less by the development of new energy sources than by technologies capable of providing real-time lesion verification and patient-specific ablation strategies.
INTRODUCTION:Stress echocardiography (SE) is a widely used noninvasive imaging method to detect myocardial ischemia and assess prognosis in patients with suspected or established coronary artery disease (CAD). However, its results may challenge clinical interpretation and individualized management when technical performance is inadequate. AREAS COVERED:This review summarizes key diagnostic issues regarding SE that affect interpretation and clinical decision pathways for coronary intervention, including: discordance between SE and coronary angiography findings (positive studies with non-obstructive coronaries and negative studies with anatomically significant stenoses), limited myocardial ischemia, and normal wall-motion response with ischemic ECG changes or chest pain. In addition to that, this review discusses issues in specific patient groups like those with small LV cavity/LV hypertrophy, left bundle branch block, extensive baseline wall-motion abnormalities, and atrial fibrillation/arrhythmias. Moreover, we have mentioned recent technological advances like three-dimesion SE and speckle tracking analysis, which have shown promising preliminary results. An extensive literature search was performed in Pubmed and Embase platforms using the appropriate keywords. Unfortunately, the available data are limited and clinical practice is based on operators' experience. EXPERT OPINION:SE remains an operator-dependent technique. In order to improve the objectivity of each study, several steps have been proposed like stress workload adequacy, use of contrast agents, coronary microvascular evaluation commitment, and advocacy of adjunctive methods (atropine infusion, hand-grip).
INTRODUCTION:Takotsubo syndrome is an acute, transient ventricular dysfunction that frequently mimics acute coronary syndrome. Patients with cancer may be particularly vulnerable because malignancy-related stress and cancer therapies converge with cardiovascular susceptibility. AREAS COVERED:This narrative review examines sex-related susceptibility and acuity, cancer-related stressors, implicated therapy classes, diagnostic differentiation, management, and treatment rechallenge. PubMed/MEDLINE was searched from January 2000 through June 2026 using combinations of terms for Takotsubo syndrome, cancer, cardio-oncology, sex, specific antineoplastic agents, imaging, outcomes, and rechallenge; reference lists of relevant consensus statements and reviews were also screened. Evidence is predominantly derived from registries, retrospective cohorts, case series, and case reports. EXPERT OPINION:Sex should be treated as a risk modifier rather than a stand-alone determinant. A cumulative vulnerability framework integrating patient susceptibility, cancer-related stress burden, and treatment exposure may support earlier recognition and multidisciplinary decisions, but prospective validation and standardized sex-stratified reporting are required.
INTRODUCTION:Cardiovascular disease (CVD) remains the leading global cause of mortality. To improve prevention, the American Heart Association introduced Life's Simple 7 (LS7) in 2010 and updated it to Life's Essential 8 (LE8) in 2022. This review summarizes the development, scientific rationale, predictive validity, and clinical applications of LE8 across diverse populations. AREAS COVERED:A comprehensive search of PubMed, EMBASE, and Scopus through December 2025 identified studies evaluating LS7 and LE8 in U.S. and international cohorts. Evidence from prospective studies, registries, and validation analyses was synthesized to assess prognostic performance. LE8 includes diet, physical activity, nicotine exposure, sleep health, body mass index, blood lipids, blood glucose, and blood pressure, each scored on a 0-100 scale. Higher LE8 scores consistently correlate with lower risks of cardiovascular disease, stroke, heart failure, cognitive decline, chronic kidney disease, and all-cause mortality. Findings from NHANES, ARIC, CARDIA, and REGARDS demonstrate strong prognostic validity, while international studies support reproducibility. EXPERT OPINION:LE8 provides a practical framework for cardiovascular health assessment, risk communication, and prevention. Broader implementation may improve population health, although challenges remain, including reliance on self-reported measures and limited integration of psychosocial and environmental determinants of health.
BACKGROUND:Sex differences may influence outcomes of dual antiplatelet therapy after acute ischemic stroke or transient ischemic attack (TIA). We evaluated whether treatment effects of clopidogrel plus aspirin differ by sex in patients with mild ischemic stroke or high-risk TIA. . RESEARCH DESIGN AND METHODS:This prespecified subgroup analysis used data from the INSPIRES trial, a multicenter, double-blind, placebo-controlled randomized trial conducted in China. Patients aged 35-80 years enrolled within 72 hours of symptom onset were randomized to clopidogrel plus aspirin or aspirin alone. The primary efficacy outcome was new stroke within 90 days, and the primary safety outcome was moderate-to-severe bleeding. Sex-by-treatment interaction was assessed. RESULTS:Among 6,100 patients (female 35.8%), new stroke occurred in 7.9% of females and 6.95% of males in the clopidogrel plus aspirin group, compared with 9.9% and 8.71% in the aspirin group, respectively. No significant sex-by-treatment interaction was observed for stroke prevention. Rates of moderate-to-severe bleeding were low and similar between females and males, with no evidence of interaction. CONCLUSIONS:In this prespecified subgroup analysis, clopidogrel plus aspirin showed no sex-based differences in efficacy or safety. These findings do not support sex-specific treatment effects. . TRIAL REGISTRATION:ClinicalTrials.gov (NCT03635749).
INTRODUCTION:Transcatheter aortic valve replacement (TAVR) has transformed the management of severe aortic stenosis across all surgical risk strata. As its use expands to younger, lower-risk patients, the durability of transcatheter heart valves and the clinical consequences of prosthetic failure have become critically important. Despite a growing literature on reintervention strategies, systematic prevention of TAVR failure remains comparatively underemphasized. AREAS COVERED:We searched PubMed and the Cochrane Library (2000-2026, English language) for studies on TAVR failure and its prevention. This review examines the mechanisms of TAVR failure, including structural valve deterioration, paravalvular leak, prosthesis-patient mismatch, subclinical leaflet thrombosis, valve endocarditis, and device migration; appraises current management, including valve-in-valve TAVR, redo surgical aortic valve replacement, and medical therapy; and reviews prevention strategies spanning patient selection, procedural optimization, antithrombotic management, structural surveillance, coronary access preservation, and lifetime planning. EXPERT OPINION:The evidence base has focused disproportionately on reintervention rather than prevention. Greater emphasis on structured lifetime management planning at index TAVR, individualized antithrombotic strategies, and evidence-based surveillance is needed. Several proposed measures, however, including routine anticoagulation for subclinical leaflet thrombosis and routine CT or artificial-intelligence-based surveillance, are not yet supported by outcome data and require prospective validation.
INTRODUCTION:Despite foundational quadruple guideline-directed medical therapy (GDMT), patients with heart failure with reduced ejection fraction (HFrEF) face substantial residual risk. Vericiguat, a novel soluble guanylate cyclase (sGC) stimulator, provides a crucial therapeutic option by directly targeting the impaired NO-sGC-cGMP signaling pathway to mitigate this risk. AREAS COVERED:This review synthesizes current literature tracking vericiguat's trajectory from pivotal clinical trials (VICTORIA, VELOCITY, and VICTOR) to its emerging real-world implementation. We examine its efficacy, hemodynamic and renal tolerability, and safety profile across the HFrEF spectrum. Additionally, we provide a framework for clinical decision-making, addressing optimal patient selection, initiation timing, and the navigation of polypharmacy. EXPERT OPINION:Current evidence suggests that vericiguat may represent a valuable adjunctive therapy for selected high-risk patients with HFrEF, with a generally favorable hemodynamic and renal tolerability profile that appears not to substantially exacerbate hypotension or hyperkalemia when integrated with contemporary guideline-directed medical therapy. To maximize its real-world implementation, clinicians must overcome clinical inertia and embrace the purposeful deprescribing of non-essential symptomatic medications. Future research should prioritize advanced renal disease cohorts and biomarker-guided phenotyping, ultimately shifting vericiguat from a reactive post-decompensation therapy to an earlier, proactive intervention within a personalized treatment strategy.
INTRODUCTION:Autonomic neuropathy is increasingly recognized as an early consequence of glucose dysregulation that may precede type 2 diabetes and contribute to cardiovascular risk. AREAS COVERED:This narrative review summarizes current evidence on autonomic dysfunction in prediabetes, including its epidemiology, pathophysiology, clinical significance, and therapeutic implications. A literature search was conducted in PubMed/MEDLINE, Scopus, and Web of Science for studies published between 2010 and 2026. Evidence indicates that alterations in heart rate variability, impaired baroreflex sensitivity, endothelial dysfunction, and chronic low-grade inflammation contribute to autonomic imbalance and increased cardiovascular risk in individuals with impaired fasting glucose or impaired glucose tolerance. EXPERT OPINION:Autonomic dysfunction should be considered an early manifestation of cardiometabolic disease rather than a late complication of diabetes. Although accumulating evidence supports its prognostic relevance, routine screening remains limited by the absence of standardized diagnostic criteria and clear guideline recommendations. Incorporating autonomic assessment into risk stratification may facilitate earlier identification of high-risk individuals and support targeted preventive strategies. Future studies should focus on validating diagnostic thresholds and determining whether early intervention improves long-term cardiovascular outcomes.
INTRODUCTION:Aortic stenosis (AS) is the most common and the deadliest valvular disease. The treatment of asymptomatic patients with severe AS remains a subject of investigation. Recently, ESC/EACTS guidelines for valvular diseases introduced a new indication for the treatment of asymptomatic low-risk patients with isolated high-gradient severe AS, as an alternative to clinical surveillance. AREA COVERED:This paper attempts to provide a rational, clinically oriented and evidence-based approach to the treatment of asymptomatic patients with high-gradient severe AS without additional adverse factors such as decrease in left ventricular systolic function or increase in natriuretic peptides. We searched for original and review papers through the PubMed database using the keywords: aortic stenosis, asymptomatic, risk stratification and intervention, without limiting the time period of the analyzed papers. EXPERT OPINION:The latest ESC/EACTS recommendations for the treatment of asymptomatic AS should be considered adequate. Considering differences in patient characteristics and heterogeneous treatment modalities, as well as differences in institutional-level outcomes, the optimal intervention strategy still needs clarification. Ongoing trials in asymptomatic patients with severe AS should provide significant new evidence. The diverse array of therapeutic options emphasizes the need for TAVI vs. SAVR randomized trial in middle-aged asymptomatic patients.
BACKGROUND:Information about integrated care for patients with atrial fibrillation (AF) in low- and middle-income countries is scarce. METHODS:We analyzed multicentre data from 699 patients with AF treated in São Paulo, Brazil. ABC compliance was defined as (1) adequate anticoagulation ('A' component); (2) controlled AF symptoms ('B' component); and (3) comorbidities treatment ('C' component). We built logistic regression models to identify characteristics associated with ABC compliance. RESULTS:Mean age was 69.4 ± 14.4 years (45.8% women; 57.4% from private healthcare). Compliance with ABC pathway, and with the 'A,' 'B' and 'C' components occurred in 20.9%, 42.3%, 81.7% and 50.1% of the participants, respectively. Lack of ABC compliance was associated with female sex (adjusted odds ratio [aOR]: 1.66; p = 0.015), intermediate (aOR: 3.37; p < 0.001) and high (aOR: 9.17; p < 0.001) bleeding risk. Patients with AF treated in public units had worse performance for the 'A' component (aOR: 2.50; p < 0.001) and better performance for the 'C' component (aOR: 0.49; p < 0.001) compared to those using private healthcare. CONCLUSIONS:Compliance with the ABC pathway in São Paulo, Brazil was low. Lack of ABC compliance was more common in women and individuals with high bleeding risk. We found a mixed pattern of ABC compliance in public and private units.
INTRODUCTION:PCI for severely calcified lesions is still challenging. Calcified lesions are associated with suboptimal results and increased risks of adverse cardiovascular events after PCI. Therefore, optimized strategies for the treatment of calcified lesions are clinically needed. AREAS COVERED:This review summarizes the current evidence on PCI for calcified lesions. It covers pathological features of calcified lesions, the role of intravascular imaging, and the applicability of a variety of lesion preparation devices. In addition, this review discusses the efficacy and limitations of pharmacological therapies for calcified lesions. EXPERT OPINION:A broad range of calcified plaque modification devices is currently available, and high-resolution intravascular imaging has enabled detailed assessment of calcified plaque morphology in vivo. The combination of appropriate devices and intravascular imaging will further improve not only acute procedural success but clinical outcomes after PCI for calcified lesions. However, important challenges remain, including limited calcified lesion-specific evidence, the lack of universally validated optimization criteria, and the absence of a standardized treatment algorithm. Further investigation is warranted to establish practical and evidence-based therapeutic approaches for calcified lesions.
