In many countries, patients’ access to transcatheter aortic valve implantation (TAVI) is limited by reimbursement issues or delayed admission to heart valve centers, thus increasing the risk of adverse events in wait-listed patients. The TAVI AT HOME (TAH) is a single-arm, multicenter study aiming to evaluate the safety and efficacy of transfemoral TAVI performed at centers without on-site cardiac surgery by expert operators. The primary endpoint is 30-day all-cause mortality. This study focuses on the run-in phase of the registry, which was required by the ethics committee to perform an interim safety analysis. The outcome of 20 TAH patients enrolled at three Italian centers from May 2023 to May 2024 was compared to 41 TAVI cases included in the permanent local registry, matching the TAH inclusion/exclusion criteria. The two groups had similar baseline characteristics. Significantly more patients in the TAH group were deemed at prohibitive risk (85.0% vs. 56.1%; p = 0.026) but had similar surgical risk scores. A self-expanding device was used in most cases (60.7%). Technical success did not differ between groups (95.0% in the TAH vs. 85.4%, p = 0.409). No deaths at 30 days (primary endpoint) were observed. The 1-year survival rate did not differ between groups. After interim data analysis, the ethics committee authorized the completion of the TAH enrollment and extension to other centers. The TAH approach might represent an alternative model to allow timely access to TAVI without compromising safety and effectiveness.

Transcatheter structural heart procedures have become standard therapy for elderly patients with high surgical risk. Over time, these procedures have significantly increased worldwide, accompanied by a concomitant reduction of major complications, including those requiring emergent cardiac surgery (ECS). This marked decline in ECS is due to technological advancements, improved patient selection and procedural techniques, and increased institutional and operators expertize. Moreover, most major structural complications after transcatheter structural heart procedures are now managed percutaneously, with only a small proportion requiring ECS. It is important to note that outcomes for patients requiring ECS remain unfavorable, even in the optimal setting. Currently, ECS after percutaneous structural interventions is very rare, less than 0.5%, as reported in multicenter available studies. However, fragmented data exist in the literature on the need of ECS. Indeed, low incidence, different definitions, and lack of recent reports make it difficult to have a precise and up-to-date overview of bailout surgery for treatment of procedural complications. This is the first comprehensive analysis focusing on ECS following the major frequent percutaneous structural procedures, that is, transcatheter aortic valve replacement, mitral valve repair/replacement, and left atrial appendage occlusion. More in general, a collaborative approach among Heart Team members, along with thorough procedural planning guided by advanced imaging techniques, is essential for ensuring high-quality interventions thus minimizing the risk of adverse events.

Transcatheter aortic valve implantation (TAVI) has become the standard of care for elderly patients with aortic stenosis. International guidelines recommend that TAVI should be performed only in centers with on-site cardiac surgery (CS). However, rapidly evolving TAVI technology and increasing operator expertise have significantly reduced peri-procedural complications, including those requiring rescue surgery, which occur in less than 0.5% of cases. Furthermore, only a minority of major complications are treated with CS, and the outcomes remain unfavorable. TAVI in centers without CS could represent a solution to reduce waiting times and ensure continuity of care for fragile patients. “TAVI at Home” is a single-arm prospective interventional study. According to sample size calculations based on literature data, the study aims to enroll a total of 200 patients, beginning with a run-in phase of 20 patients to establish safety. The primary endpoint is 30-day all-cause mortality. Secondary endpoints include technical success and the evaluation of single complications 30 days after the procedure. Hospitals without CS that are eligible to perform TAVI must have a high volume of coronary percutaneous interventions, operators with established TAVI experience, collaboration with vascular surgeons, and regular Heart Team meetings to ensure rigorous patient selection.

Postpartum electrical storm due to torsade de pointes is a rare but life-threatening condition. The uniqueness of this case lies in the use of cabergoline to suppress postpartum ventricular arrhythmias in absence of heart disease. Timely multidisciplinary management is crucial to achieve final diagnosis, deliver proper treatment and improve prognosis.

BACKGROUND:There is little data on the outcome of balloon aortic valvuloplasty (BAV) in relation to valve dimensions and calcification patterns. The procedure is not standardized, particularly the choice of balloon size. METHODS:This retrospective multicenter study focused on BAV efficacy and safety by analyzing the relationship between balloon size, annulus geometry (i.e., diameters, perimeter, and area), and calcification patterns (total burden and calcium distribution over each individual leaflet). From March 2018 to March 2023, all consecutive patients who underwent clinically indicated BAV and ECG-gated multidetector computed tomography of the aorta were included, except those with a bicuspid valve. Calcium score was calculated on contrast-enhanced images based on a luminal attenuation threshold of +100 HU. RESULTS:One hundred and fifteen patients were included. Procedural success was 82.6 %. The balloon-to-annulus ratio (BAR) relative to diameter, perimeter, and area was higher in patients with successful BAV. Patients with unsuccessful BAV had a significantly higher aortic valve calcium burden. The complication rate was 4.3 % and there was no association with valve geometry or calcium burden. A trend towards a reduced complication rate was found as calcium asymmetry increased. BAR minimum annulus diameter was the best parameter in predicting procedural success, with a cut-off at 0.85. CONCLUSIONS:BAV efficacy is correlated directly with balloon size in relation to annulus dimension and inversely with total calcium burden. The minimum diameter of the valve may be adopted as a reference for balloon sizing.

Aim: To analyze the feasibility and procedural outcome of percutaneous coronary intervention (PCI) using rotational atherectomy (RA), performed via transradial sheathless guiding catheter, as compared to a standard radial and femoral vascular approach. Methods: All consecutive patients undergoing RA at two high-volume PCI centers from May 2011 to May 2023 were included. Comparisons were made between the two transradial approaches and between the three types of vascular access. Results: Two hundred twenty-three patients were enrolled. Baseline characteristics were similar, with the exception of gender. We observed, in percentages, fewer cases of failure for sheathless than standard transradial attempts (7.5% vs. 11.5%, respectively), whereas all trans-femoral attempts were successful. Transfemoral procedures were longer and more frequently performed under mechanical circulatory support. There was no difference in procedural success between the three vascular approaches. A trend towards a higher rate of vascular and bleeding complications was found in the femoral group. Conclusion: Sheathless transradial vascular access is a viable option when performing RA during complex PCI procedures, tending to result in fewer failures than the standard transradial approach and reduced bleeding and vascular complications compared to the femoral method.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Dall’Ara G, Compagnone M, Grotti S, Tarantino F. Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2022;18(3):189-191. doi:10.5114/aic.2022.123298. APA Dall’Ara, G., Compagnone, M., Grotti, S., & Tarantino, F. (2022). Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 18(3), 189-191. https://doi.org/10.5114/aic.2022.123298 Chicago Dall’Ara, Gianni, Miriam Compagnone, Simone Grotti, and Fabio Tarantino. 2022. "Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going". Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej 18 (3): 189-191. doi:10.5114/aic.2022.123298. Harvard Dall’Ara, G., Compagnone, M., Grotti, S., and Tarantino, F. (2022). Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, 18(3), pp.189-191. https://doi.org/10.5114/aic.2022.123298 MLA Dall’Ara, Gianni et al. "Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going." Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej, vol. 18, no. 3, 2022, pp. 189-191. doi:10.5114/aic.2022.123298. Vancouver Dall’Ara G, Compagnone M, Grotti S, Tarantino F. Balloon aortic valvuloplasty in high-risk patients: when the going gets tough, the tough get going. Advances in Interventional Cardiology/Postępy w Kardiologii Interwencyjnej. 2022;18(3):189-191. doi:10.5114/aic.2022.123298.

Introduction: Balloon aortic valvuloplasty (BAV) improves hemodynamic and clinical status of patients with severe aortic stenosis (AS) for a limited period of 6-12 months. However, there is a high number of procedures performed worldwide and an upward trend over the last decades. Areas covered: Epidemiology of AS and the advent of transcatheter aortic valve implantation (TAVI) contribute to the extensive referral of patients. The expansion of recommendations for TAVI has occasionally led to financial reimbursement-related problems that do not exist for BAV. BAV is indicated as a bridge to valve replacement, to decision in complex cases, and to extracardiac surgery. BAV may play a role in preparing for TAVI and optimizing procedural results. The minimalist approach and reduced complication rate make it applicable in fragile patients. Expert opinion: In the near future, BAV will continue to be a useful asset in managing patients with AS given the multiple indications, broad applicability, safety profile, low cost, and repeatability. Specific studies are necessary to explore technical solutions, stronger indications, the finest technique, and to standardize the procedural result. Pending the development of potential competitive devices, the role that BAV plays will remain closely intertwined with the one played by TAVI.

Left main coronary artery percutaneous coronary intervention is particularly complex when stenting across the distal bifurcation is required in the presence of a diameter mismatch between the proximal main and distal branches. A suboptimal procedural result increases the risk of thrombosis and restenosis. Considering the paucity of data published on this topic, our objective was to provide technical solutions to deal with this complex anatomy. We described four cases showing the use of devices and techniques which allowed us to overcome a diameter discrepancy between adjacent coronary segments: (1) self-expanding nitinol stent; (2) stent platform with noteworthy expansion capacity; (3) the 'extended skirt' technique; (4) the 'trouser-leg' technique. In conclusion, the use of specific strategies and devices allows a safe and effective approach to be used to perform treatment that respects the coronary anatomy, and to optimize percutaneous coronary intervention results in complex scenarios.

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery. We enrolled 107 patients with a median age of 64.9 (57.7–73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Even if un to improve long-term prognosis, balloon aortic valvuloplasty (BAV) may be useful in selected patients with symptomatic severe aortic stenosis either as a bridge to surgical or transcatheter valve replacement (aortic valve replacement [AVR] or transcatheter aortic valve implantation [TAVI]) or as a triage strategy for patients with uncertain indications. International guidelines recommend BAV as: a "bridge" to AVR/TAVI, a "trial" in patients with undetermined symptoms, or a "bridge-to-decision" in case of comorbidities. However, in clinical practice, BAV is also used as a palliative measure to improve hemodynamics and quality of life in many patients who are excluded from AVR/TAVI. Finally, BAV is often performed during TAVI to facilitate prosthesis delivery, optimize frame expansion, or for bioprosthetic valve fracture in selected valve-in-valve procedures. Technical innovations, which allow for a mini-invasive approach via transradial access and pacing delivered through the wire, have led to a decrease in complications over time. This review focuses on contemporary BAV with a specific emphasis on new indications, innovative techniques, and specific complex patient subgroups.

Le procedure di angioplastica coronarica su lesioni severamente calcifiche sono gravate da rilevanti difficoltà tecniche e da un maggior tasso di complicanze. La litotrissia intravascolare (IVL) rappresenta ad oggi un sistema sicuro ed efficace per il trattamento di stenosi coronariche calcifiche prima del rilascio dello stent. In questo articolo riportiamo tre casi clinicamente o angiograficamente complessi in cui l’utilizzo della litotrissia coronarica non è ancora codificato. Nello specifico abbiamo mostrato l’applicazione di IVL in un caso di stent ipoespanso dopo angioplastica primaria, un caso di infarto miocardico acuto complicato da shock cardiogeno dovuto ad una lesione subocclusiva del tronco comune, ed un caso di stenosi severamente calcifica di un bypass in vena safena degenerato. In questi tre scenari l’uso della IVL si è dimostrato fondamentale per assicurare un ottimale risultato procedurale, in assenza di eventi clinici avversi.

Recurrent gastrointestinal bleeding is the main manifesta-tion of Heyde ’ s syndrome (HS), comprising aortic valve stenosis (AVS), acquired von Willebrand ’ s syndrome (AVWS)

In patients with severe calcified coronary lesions, angioplasty procedures are associated with significant technical problems and a higher rate of complications. Nowadays, intravascular lithotripsy represents a safe and effective system for the treatment of calcified coronary stenosis before stent deployment. In this article, we report three complex clinical or angiographic cases in which the use of coronary lithotripsy is not yet codified. Specifically, we discuss a case of stent underexpansion after primary angioplasty, a case of acute myocardial infarction due to left main subocclusive stenosis complicated by cardiogenic shock and a case of severely calcified plaque in a venous bypass graft. In these three cases, the use of shockwave was essential to ensure an optimal procedural result, in the absence of significant adverse clinical events.

Delirium is a common cognitive behavioral disorder, with acute onset, frequent in elderly hospitalized patients. This condition has long been the subject of research in the critical area, with the development of targeted prevention and management protocols. In the cardiology field, however, awareness of delirium is poor. The problem of delirium has recently begun to involve practitioners since the publication of first studies showing the increase of adverse events in patients with this condition. The pathophysiology of delirium is unclear and the risk factors are based on clinical conditions and factors related to patient's care itself that need to be readily identified. Thus, delirium is a clinical manifestation that can easily be confused with other conditions. Notwithstanding, delirium can be prevented and treated when clinically evident, with a number of non-pharmacological interventions based on a multidisciplinary approach. Pharmacological therapy, due to its unclear effectiveness, should be reserved to patients with severe agitation or at risk of injuring themselves and others. The purpose of this review is to increase the awareness in healthcare professionals about the recent data on etiology, prevention, treatment and prognosis of delirium and to put the basis for a protocol that could be used in Cardiology departments.

A 89-year-old male presented with severe untreatable pain and ischemic non-healing ulcer in the left forefoot. The pre-procedural angiograms showed multiple stenosis of the superficial femoral and popliteal arteries, occlusion of anterior tibial artery, tibio-peroneal trunk (TTP) and distal posterior tibial artery (PTA), stenosis of the peroneal artery, and the patency of the medial plantar artery (MPA) as a single pedal artery, with very poor perfusion of the lateral aspect of the forefoot. The TTP and PTA were recanalized, and balloon angioplasty of superficial femoral artery and popliteal artery and peroneal artery was carried out. After unsuccessful antegrade attempts, the lateral plantar artery (LPA) was retrogradely recanalized performing the medial-to-lateral plantar loop, navigating from the deep branch of MPA to the plantar arch and reentering back in the common plantar artery through the LPA. Balloon angioplasty of LPA was performed though the retrograde and antegrade route. When the MPA is the single pedal artery, and the antegrade recanalization of the dorsalis pedis artery (DPA) and the LPA is not possible, the medial-to-lateral plantar loop is a feasible technique to recanalize the LPA retrogradely through the plantar arch.