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Since its introduction in 2002, the number of transcatheter aortic valve implantation (TAVI) procedures has grown exponentially. Although technical advances have been made in valve technology and its implantation system, conduction disturbances (CD) remain the most common complication of the procedure. CD have a negative impact on the prognosis of patients for reasons such as the worsening of left ventricular ejection fraction, the need for a pacemaker or the increased risk of sudden cardiac death. Several factors have been associated with higher risk of CD, including prior right bundle-branch block, valve type and deep valve placement inside the left ventricular outflow tract. Whilst CD are the most common complications of TAVI, there is still no general agreement on the optimal strategy to minimize its incidence. In this review we will approach the current evidence for the pathophysiology, incidence, clinical implications and management of CD in TAVI. Resumen Desde su introduccion en 2002, el numero de implantes percutaneos de valvula aortica (TAVI) implantados ha crecido exponencialmente. A pesar de los avances en las valvulas y su sistema de implantacion, las alteraciones de la conduccion (AC) siguen siendo la complicacion mas frecuente. Tienen un impacto negativo en el pronostico de los pacientes (empeoramiento de la fraccion de eyeccion, necesidad de marcapasos o riesgo aumentado de muerte subita). Varios factores se han asociado con mayor riesgo de AC, incluyendo bloqueo de rama derecha previo, el tipo de valvula utilizado y el nivel de implantacion en el tracto de salida del ventriculo izquierdo. A pesar de ser la principal complicacion tras el TAVI, no existe un consenso general en la estrategia optima para minimizar la incidencia de AC. En esta revision se repasara la evidencia disponible en cuanto a la fisiopatologia, incidencia, implicaciones clinicas y manejo de las alteraciones de la conduccion tras el TAVI.

Background Sympathetic activity (SA) is increased in patients with heart failure and reduced ejection fraction (HFrEF) and is associated with poor outcomes. However, its clinical implications are less understood in HF with mid-range (HFmrEF) and preserved ejection fraction (HFpEF). We aimed to study SA across left ventricle ejection fraction (LVEF) groups and its association with clinical outcomes. Methods and Results SA estimated by norepinephrine (NE) levels was determined in 742 consecutive outpatients with chronic HF: 348 (47%) with HFrEF, 116 (16%) HFmrEF, and 278 (37%) HFpEF. After a mean follow-up of 15 months, 17% died. Adjusted analyses showed that patients with HFpEF and HFmrEF had lower estimated marginal means of NE levels compared to HFrEF (278 and 116 pg/mL, respectively, vs. 348 pg/mL; p-value=0.005). Adjusted Cox regression analyses showed that high norepinephrine levels independently predicted all-cause mortality (ACM) in all 3 groups. The strongest associations between high NE levels and cardiovascular mortality (CVM) were observed in HFmrEF (HR: 4.7 [1.33–16.68]), while the weakest association was in HFpEF (HR: 2.62 [1.08–6.35]). Conclusions Adjusted analyses showed that HFpEF and HFmrEF were associated with lower SA compared to HFrEF. Nevertheless, increasing NE levels were independently associated with ACM and CVM in all three LVEF groups. The strongest association between high NE levels and CVM was present in HFmrEF patients, while the weakest was seen in HFpEF. These findings could explain why the response to neurohormonal therapies in patients with HFmrEF is similar to that of patients with HFrEF rather than with HFpEF.

Background In-stent restenosis is a difficult percutaneous scenario if calcific neoatherosclerosis is the underlying aetiology. Case summary A 69-year-old diabetic woman with a previous percutaneous coronary intervention on the left anterior descending coronary artery was readmitted for non-ST-elevation myocardial infarction. In-stent restenosis due to calcific neoatherosclerosis was observed by intracoronary imaging during the intervention. Intravascular lithotripsy was used successfully to fracture the underlying calcific plaque. However, the balloon ruptured during treatment although this did not damage the artery. Discussion Intravascular lithotripsy is a promising tool for the treatment of extremely calcified lesions including calcific neoatherosclerosis of in-stent restenosis. Balloon rupture is a complication of this new percutaneous treatment that has not previously been described.

The absence of polymer in DES systems may reduce the dual anti-platelet therapy (DAPT) period and the occurrence of late stent thrombosis. However, the sequential changes of stent strut endothelial coverage in the extremely early period have never been reported. This study aimed to assess by optical