Dimitrios Afendoulis

Cancer activity may modify bleeding and ischemic risk after percutaneous coronary intervention (PCI), but available reports differ in cancer definitions, antiplatelet exposure and follow-up. We reassessed a PROSPERO-registered systematic review (CRD420261350515), originally comprising five observational studies, and undertook targeted verification of related primary literature. Five further potentially eligible reports were identified, providing ten source-verified reports for an expanded, non-exhaustive evidence audit. Active cancer, recent diagnosis or ongoing therapy were frequently associated with bleeding, although ischemic findings were less consistent. One large Veterans Affairs cohort examined observational associations between dual antiplatetet therapy (DAPT) discontinuation and longer-term outcomes by cancer activity; this was not a randomized strategy comparison. Definitions and follow-up precluded pooling of activity-specific bleeding risk ratios. The evidence does not establish a cancer-specific DAPT duration or preferred P2Y12 inhibitor. Prospective studies should integrate serial oncologic, hematologic, procedural and antiplatelet information.

Late saphenous vein graft (SVG) pseudoaneurysm is a rare but life-threatening complication of coronary artery bypass graft surgery. An 80-year-old man presented with dyspnea and chest pain two decades after CABG (LIMA-LAD, SVG-RCA). Coronary angiography revealed SVG occlusion with contrast extravasation and mass formation adjacent to the right heart chambers. CT angiography confirmed a 39 mm mediastinal pseudoaneurysm from proximal SVG rupture, compressing the right heart chambers and lung, with consequent left ventricular dysfunction (EF 45%), elevated pulmonary pressures, and orthostatic hypotension. Following Heart Team discussion, the patient underwent successful pseudoaneurysm resection with right coronary artery revascularization using a left radial artery graft. Symptoms and cardiac function improved at one-month follow-up. This case highlights the importance of clinical suspicion for SVG pseudoaneurysm in patients with prior CABG, and the central role of CT angiography and multidisciplinary decision-making in management.

We report a rare case of fulminant myocarditis caused by Rickettsia conorii infection in a 31-year-old previously healthy male from rural Greece. The patient presented with acute chest pain, fever, and an insect bite eschar. Initial electrocardiography (ECG) demonstrated inferior ST-segment elevation, and coronary angiography excluded obstructive coronary artery disease. Within 24 hours, the patient deteriorated to hemodynamic collapse, with left ventricular ejection fraction (LVEF) declining to 20–25%. Management included doxycycline, empirical broad-spectrum antibiotics, intravenous corticosteroids, and aggressive diuresis. Serological confirmation of R. conorii infection (IgM titer 1:64) directed targeted antibiotic monotherapy. Cardiac magnetic resonance (CMR) imaging performed two days post-discharge confirmed acute myocarditis per the 2018 Updated Lake Louise Criteria, with extensive late gadolinium enhancement (LGE) involving 28% of LV mass. LVEF recovered to 56% within weeks. This case highlights the potential for R. conorii to precipitate fulminant myocarditis even in immunocompetent young patients, underscoring the importance of clinical suspicion in endemic regions.

Traditional cardiovascular assessment has historically focused on the isolated evaluation of either atrial or ventricular structure and function. However, the left atrioventricular coupling index (LACI) represents a paradigm shift by moving beyond single-chamber metrics to quantify the dynamic interaction between the left atrium and left ventricle. Defined as the ratio of left atrial end-diastolic volume to left ventricular end-diastolic volume, LACI integrates structural and functional aspects of cardiac performance. This comprehensive review examines the physiological basis of how the left atrium and ventricle operate as an integrated hemodynamic unit. We detail current measurement methodologies, including two- and three-dimensional echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, which serves as the reference standard. Furthermore, the review explores the pathophysiological mechanisms driving atrioventricular uncoupling, specifically mechanical dysfunction, electromechanical desynchrony, and hemodynamic alterations. Extensive clinical evidence demonstrates LACI’s robust independent prognostic value across diverse cardiovascular conditions, such as heart failure, myocardial infarction, cardiomyopathies, and atrial fibrillation. Observational data suggest that LACI provides a promising prognostic value beyond established risk assessment tools by combining the assessment of both chambers’ interdependence. Finally, we outline future directions for clinical translation, highlighting the necessity for standardized measurement protocols, the integration of artificial intelligence, and the potential of LACI as a target for personalized therapeutic strategies.

Background/Objectives: Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis. The accurate post-procedural assessment of transvalvular gradients is essential for evaluating procedural success and long-term prognosis. However, significant discrepancies have been reported between gradients measured invasively and those derived by Doppler echocardiography. This systematic review aims to summarize the current evidence comparing invasive and echocardiographic gradient measurements after TAVI. Methods: A comprehensive literature search was conducted of the PubMed database from inception to 8 November 2025 using the keywords: “TAVI/TAVR,” “invasive versus echocardiographic gradient,” and related terms. Studies were included if they compared invasive and Doppler-derived aortic valve gradients following TAVI. Out of 44 identified articles, 12 studies met the inclusion criteria and were analyzed. Results: Across all the included studies, the echocardiography-derived mean gradients were consistently 4–7 mmHg higher than those obtained invasively, reflecting physiologic rather than procedural discordance. The difference was more pronounced in balloon-expandable and small-diameter valves and in patients with high-flow states. Invasive gradients were independently associated with mortality and major adverse cardiovascular events (MACEs) in multiple studies. An invasive mean gradient ≤ 10 mmHg immediately post-TAVI was repeatedly identified as the threshold for optimal procedural success and improved long-term outcomes. Conclusions: Doppler echocardiography systematically overestimates transvalvular gradients after TAVI. While both modalities remain valuable, an invasive hemodynamic assessment provides the most reliable evaluation of immediate procedural success and long-term prognosis. Echocardiographic gradients should be interpreted relative to the baseline invasive measurement to avoid overdiagnosis of prosthetic dysfunction and ensure appropriate clinical management.

Diabetic patients with small‐vessel coronary artery disease represent a challenging population in interventional cardiology. Conventional drug‐eluting stents (DES) show limited efficacy due to enhanced neointimal proliferation, microvascular dysfunction, and impaired endothelial healing. This narrative review synthesizes contemporary evidence on drug‐coated balloon (DCB) angioplasty efficacy, safety, and procedural strategies in diabetic small vessel disease (SVD). A comprehensive literature search of PubMed, Scopus, and Web of Science was conducted through October 2025, focusing on randomized controlled trials, meta‐analyses, registries, and physiological studies comparing DCBs and DES in diabetic SVD. Recent trials (BELLO, Dissolve‐SVD, BASKET‐SMALL 2, PICCOLETO II) and meta‐analyses indicate DCBs achieve non‐inferior or superior angiographic outcomes versus DES in diabetic SVD, particularly regarding late lumen loss, restenosis, and vessel thrombosis. Procedural advantages include endothelial function preservation, reduced inflammation, and significantly shorter dual antiplatelet therapy duration—crucial for high‐bleeding‐risk diabetic populations. DCB angioplasty represents a promising “leave‐nothing‐behind” revascularization strategy for diabetic small vessels, combining efficacy with enhanced vascular healing and safety. Ongoing sirolimus‐coated technology developments and future diabetes‐focused trials are expected to refine its interventional role.

Background: Cardiac amyloidosis (CA) is characterized by progressive myocardial infiltration leading to restrictive cardiomyopathy and heart failure. While left ventricular assessment has traditionally dominated prognostic evaluation, right ventricular (RV) dysfunction and RV–pulmonary artery (PA) coupling have emerged as critical determinants of outcomes. Objectives: This review synthesizes current evidence on RV–PA coupling as a prognostic marker in cardiac amyloidosis, examining measurement methodologies, prognostic significance, pathophysiological mechanisms, and clinical applications. Methods: We comprehensively reviewed the recent literature on RV–PA coupling in CA, focusing on studies published from 2020 to 2025, including both AL and ATTR subtypes. We analyzed data from multicenter cohorts, prospective registries, and validation studies examining the relationship between RV–PA coupling indices and clinical outcomes. Results: RV–PA coupling, most commonly assessed using the tricuspid annular plane systolic excursion to pulmonary artery systolic pressure (TAPSE/PASP) ratio, consistently demonstrates strong independent prognostic value for mortality and heart failure outcomes in CA patients. Impaired coupling (TAPSE/PASP < 0.45 mm/mmHg) identifies high-risk patients with hazard ratios ranging from 1.98 to 4.17 for adverse outcomes. In a multicenter cohort of 283 patients, TAPSE/PASP < 0.45 mm/mmHg was independently associated with death or heart failure hospitalization (HR 1.98, 95% CI 1.32–2.96, p = 0.001) and significantly improved risk reclassification (NRI 0.46–0.49). In ATTR-specific populations receiving disease-modifying therapy, impaired coupling (TAPSE/PASP ≤ 0.382 mm/mmHg) predicted three-year mortality with an adjusted HR of 2.99. The coupling index provides incremental value over individual RV parameters by accounting for afterload conditions and demonstrates consistent prognostic performance across both AL and ATTR subtypes. Conclusions: RV–PA coupling represents a robust, easily obtainable prognostic marker that should be routinely assessed in CA patients for risk stratification and clinical decision-making. The TAPSE/PASP ratio can be calculated from standard echocardiographic examinations without additional cost or time, making it practical for widespread implementation. Future research should focus on standardizing measurement protocols, establishing disease-specific thresholds, evaluating coupling trajectories with novel therapies, and integrating coupling assessment into staging systems and management algorithms. The strong prognostic signal, pathophysiological relevance, and ease of measurement position RV–PA coupling as an essential component of comprehensive cardiac amyloidosis evaluation.