Aortic valve repair (AVr) has evolved into a reproducible surgical strategy for selected patients with aortic regurgitation (AR), offering preservation of native tissue, avoidance of prosthesis-related complications, and favorable long-term outcomes when performed at expert centers. This narrative review summarizes contemporary concepts, indications, preoperative imaging work-up, and procedure selection for AVr in tricuspid (TAV) and bicuspid (BAV) aortic valves, with an emphasis on functional mechanisms and standardized annular and root stabilization. Recent international guidelines and key surgical series and registries addressing aortic valve repair, valve-sparing root replacement (VSRR), annuloplasty strategies, and bicuspid repair techniques were reviewed. Modern AVr is anchored in mechanism-based diagnosis of AR, systematic correction of cusp pathology, and stabilization of the functional aortic annulus (FAA), including the virtual basal ring, sinotubular junction, and aortic root. Current guideline recommendations support aortic valve repair in selected patients with severe AR at experienced centers when durable results are expected and recommend valve-sparing root replacement in young patients with aortic root dilation. Quantitative intraoperative quality control, including effective height targets, and durable annular stabilization are key determinants of repair longevity. AVr and VSRR represent mature surgical options for carefully selected patients with AR, particularly younger individuals with good cusp tissue and access to high-volume repair expertise. A mechanism-driven algorithm, including BAV-specific geometry restoration approaches such as the 180-degree reimplantation technique, may clarify the optimal procedure for each clinical scenario.

BACKGROUND:Renal dysfunction increases thromboembolic risk but is not consistently included in standard risk scores. AIMS:To compare the prevalence of left atrial thrombus (LAT) in atrial fibrillation (AF)/atrial flutter (AFl) patients based on renal function and oral anticoagulant (OAC) regimens. METHODS:Consecutive AF/AFl patients undergoing transesophageal echocardiography before cardioversion or ablation were included. RESULTS:Among 2790 patients with creatinine clearance (CrCl) data, 89% had CrCl ≥50 ml/min, 9.6% had CrCl 30-49 ml/min, and 1.5% had CrCl <30 ml/min. LAT prevalence was 6.7%, 16%, and 19%, respectively (P = 0.008). CrCl <50 ml/min was an independent predictor of LAT (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.25-2.64). Of 2028 patients treated with non-vitamin K antagonist OACs (NOACs), 17% received reduced doses, with 56% of these reductions deemed inappropriate. LAT prevalence was higher with reduced NOAC doses (12%) compared to standard doses (4.6%; P <0.001). Patients with no indication for dose reduction but receiving reduced doses had a higher LAT risk (12% vs. 4.2%; P <0.001). Among those with an indication for reduced doses, LAT prevalence was similar (11%) regardless of dose appropriateness. There were no significant differences in LAT prevalence among different NOACs. Inappropriate NOAC dosing increased LAT risk (OR, 1.74; 95% CI, 1.11-2.73). Inappropriate dose reductions, especially with apixaban and rivaroxaban, were the main issue in inappropriate NOAC prescribing, likely influenced by age, bleeding risk, anemia, low CrCl, and antiplatelet use. CONCLUSIONS:AF patients with CrCl <50 ml/min face a doubled LAT risk despite OAC therapy. Inappropriate NOAC dosing, particularly with apixaban and rivaroxaban, leads to double LAT risk.

BACKGROUND AND AIMS:Severe tricuspid regurgitation (TR) is associated with increased mortality and hospitalizations for heart failure (HF). Aetiologies of TR include: secondary (atrial or ventricular), primary and cardiac implantable electronic device (CIED)-related. The aim of the study was to assess the prevalence of different TR aetiologies, as well as characteristics and treatment of patients with severe TR in a real-life setting. METHODS:This was a prospective, observational study of patients with severe TR, conducted in 18 cardiology centres. Consecutive adult patients with severe TR were included, regardless of the presence of TR symptoms and the cause of hospital admission. RESULTS:A total of 1295 patients with severe TR were enrolled (median age 76 years, 53% women). The most common reason for admission was HF decompensation (40%). Single TR aetiology was identified in 79% patients. The most frequent overlap between aetiologies included secondary ventricular and atrial TR, and was found in 11% of patients. The most common TR aetiology was secondary atrial (37%), followed by secondary ventricular (25%). Primary and CIED-related TR accounted for 10% and 15%, respectively. In 2.4% TR aetiology was not determined. Patients with secondary atrial and CIED-related TR were the oldest (79 and 78 years, respectively), and those with primary TR the youngest (68 years). Patients with CIED-related and secondary ventricular TR were more often hospitalized for HF decompensation, had more advanced HF symptoms, worse left- and right-ventricular function, worse kidney and liver function, and higher in-hospital mortality. Only 40% of patients underwent evaluation by the Heart Team and 21% were qualified for TR interventions. CONCLUSIONS:In real life, unequivocal identification of TR aetiology remains challenging. Secondary atrial TR is the most common aetiology. There are significant differences in characteristics and outcomes depending on TR aetiology. Too few patients with severe TR undergo evaluation by the Heart Team.

Background Women with atrial fibrillation (AF) have historically been considered to have higher thromboembolic risk than men. The CHA 2 DS 2 -VASc score treated female sex as an independent risk factor. Recent guidelines recommend CHA 2 DS 2 -VA score, redefining female sex as a risk modifier. Aims This study aimed to assess the prevalence of left atrial appendage thrombus (LAAT) by sex and identify independent predictive factors for LAAT. Methods This analysis used data from the multicenter, prospective Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry, including 3,109 patients with AF. All patients underwent preprocedural transesophageal echocardiography to assess LAAT. Results Women constituted 36.5% of the study population. They were older, had more comorbidities, higher CHA 2 DS 2 -VA scores compared with men (median 3 vs. 2, p < 0.001). Among 3034 patients, LAAT was detected in 7.7% of cases, without significant difference between sexes (8% vs. 7.2%, p = 0.42). In multivariable logistic regression, paroxysmal AF was associated with lower odds of LAAT (OR 0.35), smoking (OR 1.71), reduced left ventricular ejection fraction (LVEF) <50% (OR 1.94), DOAC use (OR 0.42), and LAAV (per 1 cm/s increase; OR 0.92) were independent predictors of LAAT in men. In women only LAAV (per 1 cm/s increase; OR 0.91) remained significant ( p < 0.001). No sex-related effect modification was observed ( p > 0.05). Conclusions Although women with AF present a more adverse clinical profile, sex itself was not an independent predictor of LAAT.

BACKGROUND:Coronary computed tomography angiography (CCTA) reported with Coronary Artery Disease Reporting and Data System (CAD-RADS) 2.0 is increasingly used in chronic coronary syndromes, but real-world adherence to the recommended downstream pathways is poorly characterized. AIMS:To describe the population referred for CCTA in a Polish tertiary center, the distribution of CAD-RADS 2.0 categories by sex and age, and adherence to guideline-recommended downstream pathways. METHODS:We retrospectively analyzed 10 005 consecutive patients who underwent CCTA between July 1, 2022 and December 31, 2024. Downstream procedures were identified in the National Health Fund registry. A pre-specified multivariable logistic regression model (CAD-RADS category, age, sex) described referral for invasive coronary angiography (ICA); discrimination was quantified as the area under the receiver-operating-characteristic curve (AUC). RESULTS:Women constituted 57.8% of the cohort and were older than men (mean 66.4 vs. 64.1 years; P < 0.001). The distribution of categories differed by sex (P < 0.001). Among patients with CAD-RADS 0-2, 18.5% underwent at least one additional test. Among patients with CAD-RADS 3, 41.8% proceeded directly to ICA without prior functional testing and 17.7% followed a functional-testing-first pathway. Among patients with CAD-RADS 4-5, 26.0% did not undergo ICA and 17.8% had no further testing. CAD-RADS category dominated referral for ICA (full model AUC 0.886; 95% confidence interval, 0.877-0.894; CAD-RADS alone 0.883; age and sex alone 0.677). CONCLUSIONS:Divergence between observed and guideline-recommended pathways was evident across all CAD-RADS categories, indicating a need for structured implementation of CAD-RADS-guided care pathways.

BACKGROUND:The COAPT risk score, developed based on the COAPT trial, is a tool to predict the risk of death or hospitalization for heart failure (HFH) within two years after transcatheter edge-to-edge repair (TEER) of mitral regurgitation using a MitraClip device. We aimed to validate the Score in a Polish population. METHODS:Patients with severe mitral regurgitation who underwent TEER with MitraClip at three cardiology centers in Poland between November 2015 and February 2023 were included. Patients were divided into two groups based on the COAPT trail criteria: COAPT eligible and COAPT non-eligible. Clinical data were collected from medical records and the COAPT risk score was calculated for each patient. Outcomes were collected during the two-year follow-up period. The primary endpoint was a composite of all-cause mortality and HFH at two-year follow-up and evaluated in the overall cohort and separately for COAPT-eligible and -non-eligible patients. RESULTS:A total of 225 patients were included in the study: 134 COAPT eligible (60%) and 91 COAPT non-eligible (40%). Higher COAPT risk score was associated with increased risk of primary endpoint in the overall population and in COAPT-eligible patients. The score demonstrated moderate discrimination (area under curve [AUC] = 0.581) and poor calibration (Hosmer-Lemeshow [HL] p = 0.085) in the overall population, whereas it showed moderate discrimination (AUC = 0.600) and good calibration (HL p = 0.308) in COAPT-eligible patients. CONCLUSIONS:In Polish patients fulfilling COAPT criteria, the COAPT risk score has moderate predictive value for post-procedural outcomes. In COAPT non-eligible patients, novel tools are required to predict outcomes.

Background Atrial flutter (AFL) and atrial fibrillation (AF) are believed to carry the same risk of systemic thromboembolism. However, there is a paucity of data concerning such risk in patients with AFL in comparison to AF. Objective The aim of the study was to evaluate the prevalence of left atrial thrombus (LAT) on transesophageal echocardiography in patients with AFL in comparison to AF according to anticoagulation status. Methods The study is the subanalysis of a multicenter, prospective Left Atrial Thrombus on Transesophageal Echocardiography (LATTEE) registry, which enrolled AF and AFL patients referred for ablation or electrical cardioversion regardless of oral anticoagulation (OAC) use. All patients underwent preprocedural transesophageal echocardiography to assess the primary end point of LAT presence. Results A total of 3109 patients (AF, n = 2577; AFL, n = 532) were included in the study. Therapeutic OAC, defined as anticoagulation lasting at least 3 weeks, was used by 89.8% of patients in the AF subgroup and 82.5% in the AFL subgroup (P < .001). LAT was present in 8.3% of patients with AF and 6.8% with AFL, regardless of therapeutic OAC use (P = .235). In patients receiving therapeutic OAC, LAT was present in 7.6% in the AF subgroup and 5.7% in the AFL subgroup (P = .167); in patients without therapeutic OAC, LAT was present in 14.9% in the AF subgroup and 11.8% in the AFL subgroup (P = .459). Conclusion The risk of thrombus formation in AFL seems to be similar to that in AF, supporting similar recommendations concerning OAC use.

Mitral annular disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point associated with mitral valve prolapse (MVP) and ventricular arrhythmias. Our study's purpose was to check whether two-dimensional (2D) echocardiography using speckle tracking (STE) and myocardial work (MW) analysis may allow us to detect patients at the highest risk of ventricular arrhythmias. Sixty-two patients with MAD detected in cardiac magnetic resonance (CMR) enrolled in the study and had performed echocardiography with STE assessment. Patients with any other than MVP structural heart diseases and more than moderate mitral regurgitation were excluded. The primary end-point (EP) was defined as complex ventricular arrhythmias (frequent ventricular premature beats (more than 5%), non-sustained and sustained ventricular tachycardia, and ventricular fibrillation). EP was noticed in 13 (21%) patients. MVP presented in 38 (61%) patients; however, it did not predict the EP. Patients with EP did not differ regarding clinical parameters or standard echocardiographic measures but more often were treated with beta-blockers and had significantly worse left ventricular ejection fraction (LVEF): 55 (51 – 56)% for EP + group in comparison to 58 (54 – 61)% for EP- group (p=0.031). LVEF, global longitudinal strain (GLS), and global constructive work (GCW) were accurate predictors of the arrhythmic end-points with pre-specified cut-off values of 59%, -21% and 2265 mmHg% respectively with odds ratio (OR) 11.4 (1.35 – 96.36) for LVEF (p=0.009), 5.73 (1.46 – 22.51) for GLS (p=0.019), and 7.19 (1.38-37.31) for GCW (p=0.019). The highest predictive value of the end-point occurrence was reached for a combination of all these parameters: OR 55.71 (2.73 – 1137.52), p<0.001 (Figure). 2D echocardiography using STE and MW assessment could be valuable for assessing arrhythmic risk in MAD patients regardless of MVP presence. GLS and GCW measures, in addition to LVEF, could help reveal the patients at the highest risk of ventricular arrhythmias.

Background: Pathogenesis of aortic stenosis (AS) involves lipid infiltration, inflammation, and oxidative stress, which drive calcification of the aortic valve and progression to heart failure (HF). Fatty acids (FAs) play a crucial role in these processes. A treatment option for severe symptomatic AS in elderly and high-risk patients is transcatheter aortic valve implantation (TAVI). Objective: To investigate the change in FA profiles in patients undergoing TAVI. Methods: This single-center prospective study included 25 patients with severe AS qualified for TAVI procedure. Blood samples were collected before TAVI and after six months. FA profiles were analyzed by gas chromatography-electron ionization mass spectrometry. Results: Notable changes were identified in FA profiles, including a reduction in docosahexaenoic acid (DHA) levels (117 ± 48.0 µM vs. 141 ± 53.0 µM, p = 0.001) and an increase in alpha-linolenic acid (ALA) concentration (32.8 ± 12.3 µM vs. 19.9 ± 6.40 µM, p = 0.003) six months post-TAVI. Additionally, significant elevations were noted in specific medium-chain FAs (C12) and branched-chain fatty acids (iso C16, iso C17 and anteiso C15, anteiso C17) at six months after TAVI. However, total n-3 polyunsaturated fatty acids (n3 PUFA) levels decreased (p = 0.039), while n-6 polyunsaturated fatty acids (n6 PUFA) levels exhibited no significant overall change at this time point. Decrease in mean pressure gradient (PG) was negatively correlated with eicosapentaenoic acid (EPA), DHA, n-3 docosapentaenoic acid (DPA n3) and n3 PUFA levels in a six-month observation. Conclusions: Our results underscore the complex interplay between cardiac intervention and FA changes, providing novel insights into the metabolic impact of TAVI on FAs serum profile.

Introduction:We aimed to assess the usefulness of lipoprotein(a) [Lp(a)] and LDL-C levels as potential predictors of coronary lesions' complexity in patients with premature coronary artery disease (pCAD). Methods:This study enrolled 162 consecutive patients with pCAD undergoing coronary angiography. The SYNTAX score (SS) was used to assess coronary lesions' complexity. Linear discriminant analysis (LDA) was employed to construct a multivariate classification model enabling the prediction of coronary lesions' complexity in SS. Results:The Lp(a) levels among patients with SS ≥ 23 and with SS 1-22 were significantly higher than those with SS = 0 (p = 0.021 and p = 0.027, respectively). The cut-off point for the Lp(a) level of 63.5 mg/dl discriminated subjects with SS ≥ 23 from those with SS ≤ 22 (sensitivity 0.546, specificity 0.780; AUC 0.620; p = 0.027). An LDA-based model involving the Lp(a) level, age, sex and LDL-C provided improved discrimination performance (sensitivity 0.727, specificity 0.733, AUC 0.800; p = 0.0001). Conclusions:Lp(a) levels in pCAD patients are associated with the advancement of coronary artery lesions in SS patients. An Lp(a) level of 63.5 mg/dl can be the cut-off point for the identification of subjects with SS ≥ 23. LDA-based modelling using Lp(a), LDL-C, age and gender may be an applicable tool for the preliminary identification of patients at risk of more complex coronary artery lesions.

The bicuspid aortic valve (BAV) is commonly associated with the early degeneration of the aortic valve. Up to 45% of BAV patients over the age of 50 develop aortic stenosis (AS). Although published data indicate a robust interplay between lipids and calcific AS in tricuspid aortic valve patients, the studies on the BAV population are lacking. We aimed to evaluate the association between selected lipid markers and the occurrence of AS in BAV patients. Methods: The study included 76 adults (21 female) with a BAV diagnosed by echocardiography, divided by age and AS diagnosis. Biochemical parameters concentrations in serum were measured: high density lipoprotein cholesterol (HDL-C) levels by standard enzymatic colorimetric tests, low density lipoprotein cholesterol (LDL-C) levels by the Friedewald formula, apolipoprotein A-I (Apo AI) and apolipoprotein B (Apo B) serum concentration by the nephelometric method, and paraoxonase-1 activity (PON-1 ASE) and arylesterase activity (PON-1 ARE) based on paraoxon and phenyl acetate hydrolysis. Results: A total of 54 patients (15 female) were more than 45 years old and 22 (6 female) were 45 or less years old. BAV patients with AS aged ≤45 had higher levels of Apo B, compared to those without AS [110.5 (102–132) vs. 95.6 (77–101) mg/d; p 0.044]. Similarly, Apo B/Apo AI ratio was higher in BAV patients with AS aged ≤45, compared to those without AS [(0.8 (0.7–1) vs. 0.6 (0.5–0.7); p 0.029]. In the group aged ≤45, Apo B showed a positive correlation with the aortic valve peak transvalvular velocity (AV Vmax) measurement (R Spearman 0.6, p 0.004). We found also that, among young BAV patients, those with AS had a lower level of PON-1 ARE compared to the cohort without AS [63.4 (52–80) vs. 85.3 (70–102); p 0.012]. We did not find any differences in lipid parameters in patients aged >45. Conclusions The metabolic link between Apo B level and Apo B/AI ratio with AS presence in BAV patients under 45 years of age suggests a significant impact of these parameters on the earlier development of AS in the BAV population. Molecules associated with high density lipoprotein and its antioxidant function, such as PON1, are valuable markers for AS development, compared to HDL-C and LDL-C levels.

Current guidelines highlight limited evidence on optimal anticoagulation for atrial fibrillation/flutter (AF/AFl) patients with left atrial thrombus (LAT). This study aimed to assess changes in anticoagulation and their association with LAT resolution in AF/AFl patients. Consecutive patients with AF/AFl undergoing transoesophageal echocardiography (TEE) before direct current cardioversion or ablation at 13 cardiology centres were included. Of 3109 patients enrolled, 8.0% (n = 250) had LAT on TEE, with 46% (n = 116) undergoing follow-up TEE, among whom LAT resolved in 55% (n = 64). No statistically significant predictors of LAT resolution were identified. Baseline characteristics were similar across anticoagulation groups, except for higher prevalence of heart failure in dabigatran users. Switching from vitamin K antagonists (VKAs) to non-VKA oral anticoagulants (NOACs) was associated with lower LAT prevalence (15%) compared to remaining on VKA (50%) or switching to low-molecular-weight heparin (75%, p = 0.022). All patients who continued apixaban had persistent LAT at follow-up, while none who switched from apixaban to another NOAC showed LAT (p = 0.033). Other switching strategies showed no statistically significant differences in LAT prevalence during follow-up. In conclusion, LAT resolved in over half of patients who underwent follow-up. LAT resolution may be associated with changes in anticoagulation, but confirmation in randomized trials is needed.

The Cardiovascular Outcomes Assessment for Heart Failure Patients with Functional Mitral Regurgitation (COAPT) risk score predicts the risk of death or hospitalization for heart failure within 2 years after transcatheter edge-to-edge repair (TEER) of mitral regurgitation (MR) using the MitraClip device. We performed an international validation of the score in patients who underwent TEER in Italian and Polish cardiology centers. Patients with severe functional MR who underwent TEER with MitraClip between March 2012 and July 2023 were included. Patients were categorized as COAPT-eligible or -noneligible based on the COAPT trial criteria. Clinical data were collected from medical records and the COAPT risk score was calculated for each patient. The primary end point was a composite of all-cause mortality and hospitalization for heart failure at the 2-year follow-up. Of 344 patients, 218 were COAPT-eligible (63%) and 126 were COAPT-noneligible (37%). A higher COAPT score correlated to increased risk of primary end point in the overall population (p <0.001) and COAPT-eligible (p = 0.020) and COAPT-noneligible groups (p = 0.042). The COAPT score had a poor predictive value for the primary end point in every group (area under the curve [AUC] ≤0.61 for all). It performed better in lower-risk patients (<4 points) than higher-risk patients (≥4 points) (AUC 0.658 vs AUC 0.523). The COAPT score was independently associated with an increased risk of primary end point in patients with <4 points (adjusted hazard ratio 1.338, 95% confidence interval 1.031 to 1.737, p = 0.028) but not those with higher score values. In conclusion, the COAPT risk score has a poor performance in COAPT-eligible and -noneligible patients with severe functional MR. The score performance depends on the patient baseline risk, with better accuracy in lower-risk patients.