Orazio Strazzieri

BACKGROUND: The best management of coronary artery disease in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI) is debated. We investigated the clinical impact of the residual extent of myocardium at risk in patients undergoing TAVI. METHODS: Patients enrolled in the REVASC-TAVI (Management of Myocardial Revascularization in Patients Undergoing TAVI With Coronary Artery Disease) international multicenter registry were stratified according to the myocardium jeopardized by coronary artery disease using the British Cardiovascular Intervention Society Jeopardy Score (BCIS-JS) after a planned coronary revascularization. A planned revascularization included percutaneous coronary interventions performed before TAVI, during TAVI, or within 1 month after TAVI. The study population was divided according to the residual BCIS-JS (rBCIS-JS): patients with extensive residual myocardial at risk (rBCIS-JS >4 group) and patients without extensive residual myocardial at risk (rBCIS-JS ≤4 group). The primary study end point was the composite of all-cause death, nonfatal myocardial infarction, nonfatal stroke, and rehospitalization for heart failure at 2 years. RESULTS: Among the 2407 patients enrolled, 294 pairs of patients were selected by propensity matching and compared. At 2-year follow-up, the incidence of the primary end point was higher in patients with rBCIS-JS >4 compared with patients with rBCIS-JS ≤4 (37.5% versus 23.0%, P =0.004). A significantly lower rate of myocardial infarction was reported in patients with BCIS-JS ≤4 (8.2% versus 2.6%, P =0.011). At multivariate analysis, rBCIS-JS >4 (hazard ratio, 1.43 [95% CI, 1.11–1.84]; P =0.005) independently predicted 2-year major adverse cardiac and cerebrovascular events. CONCLUSIONS: In patients with concomitant coronary artery disease and severe aortic stenosis, the residual myocardial risk significantly affects TAVI outcomes. In particular, a rBCIS-JS >4 is associated with higher rates of major adverse cardiac and cerebrovascular events at 2 years.

The progressive aging of the atrial fibrillation (AF) population, frequently characterized by high ischemic and bleeding risks, has led to a substantial increase in referrals for left atrial appendage occlusion (LAAO). The expansion of indications and the high procedural success rate of LAAO have further contributed to rising procedural volumes. However, this growth introduces important challenges: LAAO candidates are often elderly and frail, with increased anesthesia-related risks, and high-volume catheterization laboratories may face logistical constraints, particularly in centers without dedicated anesthesiology support. The current gold standard approach, transesophageal echocardiography (TEE) under general anesthesia (GA), ensures optimal imaging and procedural control but may increase procedural complexity and perioperative risks. In response, minimalist strategies are increasingly explored, targeting either the anesthetic protocol or the imaging modality. Conscious sedation (CS) protocols have been adopted to reduce anesthesia-related burden while maintaining TEE guidance. Alternatively, imaging-based strategies aim to replace TEE with less invasive modalities, including intracardiac echocardiography (ICE), transesophageal–intracardiac echocardiography (TE-ICE), and MicroTEE. Each approach presents specific advantages and limitations regarding safety, feasibility, operator expertise, and institutional resources. Taken together, these findings support a patient-centered approach to LAAO, whether traditional or minimalist, in which the choice of anesthetic strategy and echocardiographic guidance is driven by institutional resources, operator expertise, and individual patient characteristics rather than by expected differences in procedural or clinical efficacy. This review summarizes current evidence on minimalist LAAO pathways and discusses their role in achieving a tailored, resource-conscious procedural model.

The use of excimer laser atherectomy (ELA) has significantly evolved from the mid-1990s to the present, showing substantial improvements in both coronary and peripheral artery interventions. Initially associated with suboptimal outcomes due to low-energy settings and limited techniques, advancements such as high-energy delivery, improved catheter designs, contrast injection protocols, and refined procedural approaches have greatly enhanced clinical efficacy. In coronary applications, ELA has become an established technique for treating intracoronary thrombus, under-expanded stents, in-stent restenosis, and heavily calcified lesions, offering favorable procedural and clinical outcomes with low complication rates. The excimer laser operates through photochemical, photothermal, and photomechanical mechanisms, enabling precise plaque ablation with minimal collateral damage. In peripheral interventions, especially in critical limb ischemia (CLI), ELA has emerged as a viable option for complex, non-crossable lesions and in-stent restenosis, demonstrating high technical success, improved patency, and promising limb salvage rates. Multiple clinical trials and registries support the safety and effectiveness of ELA, particularly in high-risk patient populations. This narrative review summarizes current evidence and practical considerations on the use of excimer laser atherectomy in coronary and peripheral interventions.

Aortic valve stenosis (AVS) is the most common valvular disease in developed countries, and no pharmacological therapy is currently available. Increasing evidence identifies lipoprotein(a) [Lp(a)] as a causal factor linking lipid metabolism, inflammation, and valve calcification. Lp(a) levels are largely genetically determined and remain stable throughout life, making them a potential therapeutic target. This review summarizes the current evidence on Lp(a) and AVS pathophysiology, the diagnostic and prognostic role of Lp(a), and the therapeutic potential of Lp(a)-lowering agents. Emerging Lp(a)-targeted therapies, including antisense oligonucleotides and siRNA-based agents, could reshape AVS management by providing the first pharmacological option to slow disease progression in selected high-risk patients.

Systematic Severe aortic stenosis (AS) is a progressive disease and one of the most common valvular heart diseases in developed countries. The management of asymptomatic severe AS remains challenging and requires a tailored, patient-specific approach. Optimal timing of intervention in asymptomatic patients continues to be a matter of ongoing debate. In individuals with severe AS and reduced left ventricular ejection fraction (LVEF), both the ESC/EACTS and ACC/AHA guidelines recommend aortic valve replacement (AVR), regardless of symptom status. In contrast, for patients with preserved LVEF (≥50%), the decision to proceed with AVR must be individualized and based on a comprehensive risk assessment. Risk stratification plays a central role in guiding early intervention strategies and should incorporate clinical findings, echocardiographic parameters, biomarkers, and advanced imaging techniques such as cardiac magnetic resonance and computed tomography. Recent randomized controlled trials have yielded mixed results regarding the mortality benefit of early AVR but have consistently demonstrated a reduction in heart failure-related hospitalizations. Timely intervention in carefully selected high-risk patients may improve long-term outcomes, while avoiding unnecessary procedures in lower-risk individuals remains equally important.

Aortic valve stenosis (AVS) is the most prevalent valvular heart disease in developed countries, with incidence expected to rise due to aging populations. While surgical aor-tic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) re-main the only definitive treatments for symptomatic disease, no pharmacological therapy has been proven to halt AVS progression. In recent years, lipoprotein(a) [Lp(a)] has emerged as a causal risk factor for cardiovascular disease, including coro-nary artery disease (CAD), aortic valve calcification, and AVS. Epidemiological studies and Mendelian randomization analyses have demonstrated a strong link between ele-vated Lp(a) concentrations and both the development and progression of calcific AVS. This review summarizes the biochemical structure and metabolism of Lp(a), its path-ogenetic role in aortic valve degeneration, and the clinical evidence supporting its as-sociation with AVS. We also discuss challenges in measuring Lp(a), current guideline recommendations, and the impact of commonly used lipid-lowering agents on Lp(a) levels. Finally, we highlight emerging Lp(a)-specific therapies, including antisense oli-gonucleotides and small interfering RNAs, which are currently being evaluated in large-scale clinical trials. While most ongoing studies focus on atherosclerotic out-comes, dedicated investigations into AVS progression are underway and may reshape future therapeutic strategies. By integrating mechanistic insights, clinical evidence, and novel pharmacological ap-proaches, this review underscores the potential of Lp(a)-targeted therapies to address an unmet clinical need in AVS management.

Background/Objectives: To date, data regarding the characteristics and management of obstructive, stable coronary artery disease (CAD) encountered in patients undergoing transcatheter aortic valve implantation (TAVI) are sparse. The aim of the study was to analyze granular details, treatment, and outcomes of patients undergoing TAVI with obstructive, stable CAD from real-world practice. Methods: REVASC-TAVI (Management of myocardial REVASCularization in patients undergoing Transcatheter Aortic Valve Implantation with coronary artery disease) is an investigator-initiated, multicenter registry, which collected data from patients undergoing TAVI with obstructive stable CAD found during the pre-TAVI work-up. Results: A total of 2025 patients from 30 centers worldwide with complete follow-up were included in the registry. Most patients had single-vessel CAD (56.1%). An involvement of proximal coronary tracts was detected in 62.5% of cases, with 12.0% of patients having CAD in left main (LM). Most patients received percutaneous coronary intervention (PCI) (n = 1617, 79.9%), especially those with proximal CAD (90.4%). At 2 years, the rates of all-cause death [Kaplan–Meier (KM) estimates 20.1% vs. 18.8%, p_log-rank = 0.86] and of the composite of all-cause death, stroke, myocardial infarction, and rehospitalization for heart failure (KM estimates 29.7% vs. 27.5%, p_log-rank = 0.82) did not differ between patients undergoing PCI and those who were not. Conclusions: Patients undergoing TAVI with obstructive CAD more commonly had a single-vessel disease and an involvement of proximal coronary tracts. They were commonly treated with PCI, with similar outcomes compared to those treated conservatively.