Stefano Sasso

Artificial intelligence (AI) is being developed to analyze intracoronary optical coherence tomography (OCT) and intravascular ultrasound (IVUS) images. This narrative review examines applications in vessel segmentation, plaque and calcium characterization, plaque phenotyping, physiological assessment, and percutaneous coronary intervention (PCI) planning. OCT provides high-resolution assessment of superficial plaque and stent structures, whereas IVUS provides deeper vessel-wall information. Automated segmentation and quantitative measurements show promising technical performance, although results vary by model, imaging feature, and validation setting. Evidence for physiological inference and prognostic assessment remains largely observational, and diagnostic agreement or association with events does not establish that AI-guided care improves clinical outcomes. These tools may support individualized lesion assessment and procedural planning, but their clinical value requires prospective evaluation. At present, AI should be used as clinician-supervised decision support, with attention to image quality, uncertainty, and model limitations.

Percutaneous left atrial appendage occlusion (LAAO) has become an established alternative to long-term oral anticoagulation for stroke prevention in patients with atrial fibrillation, with expanding indications beyond those with absolute contraindications to anticoagulation. Alongside its broader adoption, device-related thrombus (DRT) has emerged as a clinically relevant complication that directly compromises the protective intent of LAAO. This comprehensive narrative review synthesizes contemporary evidence on the incidence, mechanisms, predictors, clinical impact, and management of DRT. DRT is a multifactorial phenomenon that carries an annual incidence ranging from 1.75% to almost 5%, resulting from the interplay between post-implant flow dynamics, device engineering, endothelialization processes, procedural factors, and patient-specific prothrombotic features. Accumulating data from observational registries links DRT to increased risks of ischemic stroke, systemic embolism, major adverse cardiovascular events (MACE), and mortality. Although evidence is growing, optimal management regimens for both the prevention and treatment of DRT remain undefined. Moreover, a lack of standardization also affects diagnosis and imaging surveillance, mainly performed by transesophageal echocardiography or cardiac computed tomography. By integrating mechanistic insights, clinical predictors, device-specific considerations, and therapeutic evidence, this review highlights current knowledge gaps and proposes practical considerations to inform individualized risk stratification, surveillance, and management of DRT in contemporary LAAO practice.

Drug‐coated balloon (DCB) angioplasty represents a unique drug‐delivery paradigm in which all therapeutic efficacy depends on the first seconds of device‐tissue interaction. Unlike drug‐eluting stents (DES), DCBs must achieve meaningful drug transfer, penetration, and retention during a single, brief inflation. This review provides a mechanistic, bench‐to‐bedside framework linking drug physicochemistry, excipient chemistry, coating engineering, balloon mechanics, and tissue pharmacokinetics to angiographic and clinical outcomes. Paclitaxel‐based DCBs consistently outperform sirolimus‐coated platforms in early drug uptake, intracellular retention, transmural distribution, and late lumen loss. These advantages derive from paclitaxel's extreme lipophilicity, particulate deposition, and high‐affinity microtubule binding, which enable durable antiproliferative activity despite modest absolute transfer. Sirolimus, by contrast, requires an engineered delivery system—crystalline matrices, PLGA micro‐reservoirs, nanoparticle carriers, or pressure‐driven infusion—to compensate for its lower membrane permeability and reversible intracellular binding. Integrating preclinical modeling, coating‐stability studies, optical coherence tomography (OCT) remodeling signatures, randomized trials, and recent meta‐analyses, this review demonstrates that DCB therapy is not a drug‐class effect: technology, not drug load, determines biological behavior. Early transfer efficiency, tissue retention kinetics, depth of penetration, and platform‐specific dissection response fully explain the divergent angiographic patterns observed across devices. Understanding these mechanistic principles is essential for rational device selection and for guiding the next generation of DCB technologies capable of achieving consistent and durable clinical performance.

Background/Objectives: Polymer-free drug-eluting stents (PF-DESs) aim to mitigate long-term adverse effects associated with polymer-based platforms. However, clinical comparisons with biodegradable polymer DESs (BP-DESs) remain limited. The objective of this review is to assess the efficacy and safety of PF-DESs versus thin-struts (2 > 50%). Results: Nine RCTs (n = 9597) were included. At 12 months, no significant differences were found between PF-DESs and BP-DESs for TLR (RR 1.51; 95% CI: 0.83–2.75), MI, or stent thrombosis. At 24 months, MI and all-cause death were similar between groups. A subgroup analysis showed lower cardiac death with the BioFreedom stent (RR 0.57; 95% CI: 0.35–0.90), not observed in non-BioFreedom devices. No significant differences were detected in angiographic or OCT outcomes, though heterogeneity was high. Conclusions: PF-DESs and BP-DESs demonstrated comparable clinical performance. The observed benefit in cardiac death with BioFreedom may reflect device-specific effects and merits further investigation.

Drug-coated balloons (DCBs) have emerged as a promising alternative therapeutic strategy to traditional drug-eluting stent (DES) implantation in various coronary artery lesion scenarios, aiming to minimize complications associated with permanent metallic scaffolds, such as chronic inflammation, delayed vessel healing, and stent thrombosis. This review systematically evaluates the current clinical evidence supporting the use of DCBs across diverse anatomical and clinical contexts, including small-vessel disease, in-stent restenosis, bifurcation lesions, diffuse coronary lesions, acute coronary syndromes, and chronic total occlusions, as well as in special patient populations such as individuals with diabetes mellitus or at high bleeding risk. The literature analysis incorporated recent randomized controlled trials, observational studies, and real-world registries, highlighting the clinical efficacy, safety profiles, and specific advantages of DCB angioplasty. The findings consistently demonstrated non-inferior clinical outcomes of DCBs compared to DESs across multiple lesion types, with particular benefits observed in special populations, including reduced restenosis rates and comparable major adverse cardiac events (MACEs). Nevertheless, clinical data gaps remain, emphasizing the need for larger, longer-term randomized trials to refine patient selection and procedural techniques. In conclusion, DCB angioplasty represents a viable and effective alternative to conventional stenting, particularly advantageous in complex lesions and specific patient subsets, pending further definitive evidence.

Cardioneuroablation (CNA) is now recognized as a safe and effective method in patients with cardioinhibitory neurocardiogenic syncope (CNCS), especially in young patients in order to avoid or prolong, as much as possible, the timing of definitive cardiac pacing. Several investigations have shown beneficial and very satisfactory results with a standard non-extensive endocardial ablation, aimed at identifying high-amplitude fragmented signals in the right and left atria. Despite this, the current scientific debate is focused about a proposal on an ablative method, even more individualized than CNA (at least as a first approach), considering that a standardized approach, especially in the left atrium, could expose CNCS patients with a good prognosis to an excessive risk of complications. These findings, moving from the concept of CNA to a new concept of ‘cardioneuromodulation’, opened a new era, aimed at a non-extensive and individualized treatment of different clinical CNCS scenarios or vagally-mediated atrioventricular block or sinus-atrial node dysfunction.