Mohammad Alkhalil

Background/Objectives: Although still considered off-label, there are accumulating data demonstrating that intravascular lithotripsy (IVL) is safe and effective in treating patients with stent failure (SF). Diabetes (DM) is an independent predictor of recurrent SF. Whether IVL has a differential treatment effect depending on the diabetic status of SF patients undergoing IVL has never been studied. Therefore, we aimed to compare IVL outcomes in patients with SF and concomitant DM versus non-DM counterparts. Methods: This is a pre-specified subgroup analysis of the COIL registry (coronary intravascular lithotripsy in patients with stent failure), which included patients who underwent IVL for SF, divided according to the patients’ diabetic status. Procedural and clinical outcomes were compared between DM and non-DM patients. The primary clinical endpoint was major adverse clinical event (MACE) defined as the composite of cardiovascular death, spontaneous myocardial infarction, or target vessel revascularization (TVR) at one-year follow-up. Results: There were 102 patients enrolled in the coronary intravascular lithotripsy in patients with stent failure (COIL) registry, of whom 47 (46.1%) had DM. Most baseline clinical characteristics were similar between the groups, although patients with DM had higher rates of hypertension and hypercholesterolemia. The use of intracoronary imaging (53% and 56%, respectively, p = 0.75) and the procedural success rate (77% vs. 80%, p = 0.68) were similar in DM and non-DM patients. No difference was observed in the incidence of in-hospital (2.1% vs. 1.8%, p = 0.91) and one-year MACE (12.8% vs. 18.2%, p = 0.45). Conclusions: In patients undergoing IVL for the treatment of SF, procedural and one-year clinical outcomes did not differ significantly between DM and non-DM patients, although the limited sample size should be acknowledged.

Background: Inaccurate measurement of lesion length during percutaneous coronary intervention (PCI) increases the risk of restenosis and poor clinical outcomes. Methods: Two interventional cardiologists evaluated angiographic images and made visual estimates of target lesion length and stent length selection. A 2 mm stent overlap of both the proximal and distal lesion edges was considered to be optimal. The target lesion was also assessed for lesion length using the millimetre controls of the CorPath®GRX system (Siemens Healthineers AG, formerly Corindus). Measurements for 10 lesions (randomly selected) were repeated to assess inter-observer variability. The primary endpoint was longitudinal geographic miss (LGM), defined as an absolute difference of 2 mm or more between visual and vascular robotics measurements. Results: A total of 21 lesions in 19 patients were evaluated. LGM was detected in 16/21 lesions. Visual lesion length measurements were short for 15 (71%), long for one lesion (5%) and appropriate for five (24%). Stent or drug-coated balloon length selections were short for 15 lesions and appropriate for six. Conclusion: The CorPath GRX robotic PCI system increases the accuracy of lesion length evaluation and stent length selection compared with visual estimation.

Background: Patients undergoing urgent transcatheter aortic valve implantation (TAVI) represent a clinically high-risk population with increased peri-procedural morbidity. Whether an early discharge strategy is feasible and safe remains unclear. We evaluated the feasibility of early discharge in patients undergoing urgent transcatheter aortic valve implantation. Methods: This single-centre observational cohort study included 279 consecutive patients undergoing urgent TAVI (mean age 81 ± 7 years; 155 [56%] male). Patients were stratified according to post-TAVI length of stay into next-day discharge or prolonged hospitalisation (>1 day). Data were prospectively collected and the primary end point was 30-day all-cause mortality. Results: Among 279 urgent TAVI patients, 62 (22%) were discharged the next day and 217 (78%) had prolonged hospitalisation. Baseline clinical and echocardiographic characteristics were similar between the two groups. Among the 279 patients surviving to discharge assessment, 30-day mortality was 0.4%, with no significant difference between the next-day and longer-stay groups. Patients in the short hospital stay group had an 11% complication rate compared to 30% in the long stay one. Unlike stroke or pacemaker implantation, vascular complication was an independent predictor of extended in-hospital length of stay [Beta coefficient 3.41, 95% CI (0.98 to 5.85), p = 0.006]. Conclusions: Next-day discharge appears feasible in carefully selected patients undergoing urgent TAVI and was not associated with excess 30-day mortality in this observational cohort. Prospective multi-centre studies are required to validate these findings and establish standardised discharge criteria.

Background: Single-access transfemoral transcatheter aortic valve implantation (TAVI) reduces the need for multiple vascular access and therefore, the related risk of related complications. However, the impact of patient age on its clinical outcomes remains uncertain. Methods: This is a secondary analysis of previously reported propensity score matched study comparing clinical outcomes of single- versus dual-access transfemoral TAVI using SAPIEN-3-Ultra. We examined the relation between patient age, access strategy and outcomes—specifically, 30-day safety endpoint according to the Valve Academic Research Consortium 3 (VARC-3) and major adverse cardiovascular events (MACE), defined as death, permanent pacemaker, neurological or vascular complications—using logistic regression interaction analyses, and restricted cubic spline modelling. Results: A total of 204 patients (propensity score-matched cohort) were included in the study. The elderly group were more likely to have hypertension, peripheral vascular disease or stroke. The use of single access was comparable. The elderly cohort demonstrated a tendency toward longer fluoroscopy and procedural times compared with the non-elderly group. This pattern likely reflects the greater technical complexity and heightened procedural caution often associated with older patients, including more challenging vascular anatomy and the need for careful device handling. Although not statistically significant, these findings remain clinically meaningful and are consistent with the notion that procedures in elderly patients frequently require more meticulous planning and execution. There was a significant interaction between access strategy and age in reducing MACE, but not in VARC-3 safety outcomes. Single access was associated with a significant reduction in MACE (5.4% vs. 26.7%, p = 0.015) with comparable technical and safety outcomes when compared with elderly patients who underwent dual-access TAVI. Conclusions: Single-access TAVI was linked to favourable early outcomes, maintained procedural success, and suggested a possible age-dependent pattern in the occurrence of MACE. Our findings support the need for randomised studies to demonstrate superiority of single- versus dual-access TAVI, particularly in the elderly population.

Paravalvular leak (PVL) remains an important limitation of transcatheter aortic valve implantation (TAVI), despite major advances in prosthesis design, imaging guidance, and implantation technique. Although the incidence of moderate and severe PVL has substantially declined with newer-generation valves, mild PVL continues to be frequently observed in contemporary practice and is increasingly recognised as clinically relevant. Multiple studies have demonstrated an association between even mild PVL and adverse outcomes, particularly heart failure (HF) hospitalisation, suggesting that conventional grading systems may underestimate its true haemodynamic burden. Beyond simple regurgitant volume, PVL is characterised by eccentric high-velocity flow, turbulence, impaired pressure recovery, and reduced haemodynamic efficiency. These effects may be particularly important in vulnerable phenotypes such as patients with heart failure with preserved ejection fraction (HFpEF), concentric left ventricular hypertrophy, or low-flow states, in whom small regurgitant volumes can result in disproportionate increases in filling pressures and symptomatic deterioration. This review summarises contemporary evidence regarding the prevalence, diagnosis, haemodynamic impact, and clinical consequences of PVL after TAVI. Differences across valve platforms, predictors of PVL, and current management strategies are also discussed. Particular emphasis is placed on the limitations of pressure-based assessment and the need for a patient-specific, flow-oriented approach aligned with contemporary endpoint definitions such as those proposed by VARC-3.

Background/Objectives: People with non-ST-segment elevation myocardial infarction (NSTEMI) with an occluded culprit vessel represent a unique subset of patients; however, their long-term outcomes remain unclear. This study aimed to compare 5-year mortality between NSTEMI patients treated with percutaneous coronary intervention (PCI) based on TIMI flow states in the culprit vessel on presentation (TIMI 0-1 compared to TIMI 2-3). Methods: A retrospective analysis of prospectively collected data of all NSTEMI patients who underwent PCI from 2012 to 2019 at a tertiary cardiac center (The Freeman Hospital, Newcastle-Upon-Tyne, UK) with follow up for 5 years until January 2024. Patients were identified from the database and categorized based on pre-procedural TIMI flow in the culprit vessel. A propensity score was used to pair TIMI 0-1 patients with a matched cohort of TIMI 2-3 patients. The primary outcome was 5-year all-cause mortality. Results: A total of 775 patients with TIMI 0-1 flow were matched with 750 patients who had TIMI 2-3 flow. Patients with TIMI 0-1 flow were more likely to have transient ST elevation (24% vs. 18%, p < 0.001) or Q waves (4% vs. 1%, p < 0.001) compared with patients who had TIMI 2-3 flow. They were also more likely to have moderately to severely impaired left ventricular systolic function compared with patients with TIMI 2-3 flow (21% vs. 16%, p = 0.01). In-hospital mortality (1.2% vs. 1.2%, p = NS), 1-year mortality (5% vs. 6.9%, p = NS), and 5-year mortality (16% vs. 18%, p = 0.34) were not significantly different between the two groups. The use of glycoprotein IIb/IIIa antagonists was associated with lower mortality, HR 0.64 (0.46 to 0.87). Conclusions: NSTEMI patients with occluded culprit vessels who underwent PCI had similar in-hospital and long-term outcomes to patients with patent culprit vessels. The use of glycoprotein IIb/IIIa inhibitors appears to be associated with lower mortality.

Background and Objectives: Recent studies have focused on evaluating the hemodynamic results in patients undergoing transcatheter aortic valve implantation (TAVI) with small aortic annuli. There is limited data on the incidence, clinical characteristics, and mortality of prosthesis–patient mismatch (PPM) in patients undergoing TAVI with large aortic annuli. Materials and Methods: This is a retrospective analysis of consecutive patients with severe aortic stenosis and large annuli who underwent TAVI at a single UK center. PPM was defined according to the Valve Academic Research Consortium (VARC-3) criteria and identified using echocardiography within 4–6 weeks following TAVI. Measurements were analyzed by an experienced operator who was blinded to the type of valve platform and clinical outcomes. Results: A total of 447 patients were screened, of whom 353 patients were included in the analysis. The incidence of any PPM or severe PPM was 38% and 15% of patients, respectively. Patients with severe PPM were younger, had larger body surface area, and were more likely to receive a balloon-expandable valve (BEV). At a mean follow-up of 35 months, mortality was numerically higher in patients with severe PPM (46% vs. 36%, p = 0.20) but this did not reach statistical significance. Similar mortality rates were observed among patients with or without severe PPM in those who received SEV as well as BEV. There was a differential role of body surface area in mortality in patients who developed severe PPM versus non-severe PPM. Conclusions: Severe PPM was evident in patients with large aortic annuli undergoing TAVI, particularly those who received BEV. Nonetheless, severe PPM did not impact mortality rate at three-year follow-up. Longer-term follow-up may be required to assess the impact of severe PPM on mortality.

Background: Concomitant aortic stenosis and chronic kidney disease (CKD) represent management challenges. Transcatheter aortic valve implantation (TAVI) is an established treatment for patients with symptomatic severe aortic stenosis but requires the use of contrast media, particularly in patients undergoing self-expanding platform implantation. Therefore, patients with CKD remain at an increased risk of developing worsening renal impairment post TAVI. Case summary: Herein, we present a 62-year-old male patient who was admitted with progressive dyspnoea. His transthoracic echocardiogram revealed severe aortic stenosis and impaired left ventricular systolic function (an estimated ejection fraction of 35%). He has a background of porcelain aorta and CKD. Despite low-dose contrast CT, the patient’s renal function significantly deteriorated. He was successfully treated with trans-catheter aortic valve implantation using a self-expanding valve (Evolut) without the need for contrast media. The procedure was guided by catheter positioning in the non-coronary cusp and the wire back-up technique in the left coronary cusp. Conclusion: This case demonstrated the feasibility of implanting a self-expanding trans-catheter heart valve using the Evolut platform without the need for the use of contrast media in a patient at high risk of worsening renal impairment. The current approach requires good procedural planning and additional vascular access and should be used only in highly selected cases.

Background: Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis. The two most widely used platforms are either balloon-expandable intra-annular valve (BEV, Edwards) or self-expanding supra-annular valve (SEV) from Medtronic. Comparative data related to clinical and sub-clinical valve thrombosis are limited. The aim of this study-level meta-analysis is to evaluate its incidence and whether this translates into any difference in clinical outcomes. Methods: Electronic databases were searched from inception through to October 2025 to identify randomised clinical trials of patients receiving either platform. Rates of clinical and subclinical valve thrombosis were identified and compared between the two groups. Results: In five randomized controlled trials including 1877 patients, the risk of clinical and sub-clinical valve thrombosis was relatively low in both groups. There was a significant 81% reduction in clinical valve thrombosis in patients undergoing SEV compared to BEV [0.4% vs. 2.1%; rate ratio (RR) 0.19, 95% confidence interval (CI) (0.04 to 0.86), p = 0.03]. Similarly, the risk of sub-clinical valve thrombosis was significantly lower in the SEV group [0.6% vs. 3.6%; RR 0.22, 95% CI (0.07 to 0.65), p = 0.006]. This difference was not translated into increased risk of stroke, valve re-intervention, or death. Conclusion: Patients undergoing TAVI using SEV compared to BEV have a lower risk of clinical and sub-clinical valve thrombosis in randomized trials, which is largely influenced by small annulus anatomy. Larger studies with longer term follow-up or using a dedicated imaging protocol may provide better insights into the clinical sequelae of this phenomenon.

Background: Current guidelines acknowledge that early discharge is not associated with late mortality and that in-hospital length of stay (LOS) of 48–72 h should be considered following successful primary percutaneous coronary intervention (PPCI) in low-risk patients. Recent studies have highlighted the safety of very early discharge after PPCI in highly selected low-risk patients; however, objective tools to guide discharge timing remain limited. The Index of Microcirculatory Resistance (IMR) offers a quantitative assessment of microvascular function and may help identify patients suitable for very early discharge. We aimed to evaluate the feasibility of using IMR to guide very early discharge in patients who underwent uncomplicated PPCI. Study design and objectives: The Safety of Early Discharge Using Index Microcirculatory Resistance in Patients with Acute Myocardial Infarction (SECURE) study is designed to assess the feasibility of using IMR, measured immediately following successful PPCI, to guide early discharge from hospital within 24 h. The SECURE study is a prospective, proof-of-concept, functional non-inferiority, single-centre, randomised, open-label trial to determine if patients with low IMR can be safely discharged when compared to standard discharge policy. The SECURE study will recruit 82 patients with low IMR following successful PPCI. Participants will be 1:1 randomised to either standard discharge timing or very early discharge (within 24 h). The left ventricle ejection fraction will be assessed using cardiac magnetic resonance imaging. A telephone follow-up at 3 months will be arranged. Clinical events are collected as secondary and exploratory safety endpoints. Conclusions: The SECURE study will provide proof-of-concept data about the feasibility of using IMR to guide very early discharge following PPCI. If successful, this study will provide data to plan for a larger study to determine the safety of this personalised approach.