Journal of Cardiovascular Development and Disease

Mitral annular calcification makes conventional mitral valve surgery extremely challenging and has led to growing interest in less invasive alternatives such as transcatheter mitral valve replacement. Alongside percutaneous approaches, some centers have explored open transatrial implantation of transcatheter heart valves in patients with heavily calcified annuli. This systematic review examines the current evidence on this hybrid “valve-in-MAC” technique, tracing its clinical evolution, technological refinements, patient outcomes, and ongoing debates. Key themes emerging from the literature include the adaptation of existing balloon-expandable and mitral-specific devices to the complex anatomy of calcified mitral annuli, the open transatrial approach as a safer alternative to extensive surgical debridement, and advances in imaging and device design aimed at reducing left ventricular outflow tract obstruction and paravalvular leak. Persistent uncertainties remain, particularly regarding patient selection, long-term valve performance, and comparisons with conventional surgical repair or replacement. Although open transatrial implantation appears technically feasible and provides favorable hemodynamic results compared with fully percutaneous procedures, reported 30-day mortality remains high (approximately 19–27%). This reflects the advanced age, frailty, and multiple comorbidities typical of this patient group rather than procedural shortcomings. Current evidence is limited, with few comparative studies and little data on valve durability. Future work should prioritize multicenter prospective registries and well-designed comparative studies to better define the role of this emerging salvage strategy.

Pocket hematoma is a common complication following cardiac implantable electronic device (CIED) implantation, traditionally perceived as a manageable local issue. Accumulating evidence, however, indicates that clinically significant pocket hematoma (CSH) is strongly associated with increased infection rates, elevated healthcare costs, and heightened mortality. Key risk factors include advanced age, low body mass index (BMI), chronic kidney disease, complex procedures (device upgrades/replacements) and periprocedural antithrombotic management, particularly uninterrupted dual antiplatelet therapy (DAPT) and heparin/low-molecular-weight heparin (LMWH) bridging strategies, which significantly elevate bleeding risk compared to continued vitamin K antagonist (VKA) therapy or direct oral anticoagulant (DOAC) protocols. Novel compression devices and topical hemostatic agents show promise for prevention, while standardized definitions and risk stratification tools are urgently needed. This review synthesizes current evidence on multifactorial pathogenesis, adverse outcomes, and evolving preventive strategies for pocket hematoma, emphasizing its underappreciated clinical significance and the critical need for optimized periprocedural management in high-risk patients.

Cardiogenic shock (CS) is a heterogeneous pathophysiological state with high mortality, despite the development of cardiac intensive care units (CICUs) and the advanced treatments applied. The cornerstones of therapy that have been proposed in many algorithms are intravenous (i.v.) pressors and devices for mechanical circulatory support (MCS), depending on the CS profile (left, right, or biventricular involvement), etiology (acute myocardial infarction, heart failure, or other) and SCAI stage (A to E, with MCS generally recommended for Stages C–E). There are many gaps in the evidence regarding i.v. medications and devices, with the existing data being controversial. Moreover, there are differences in the devices’ availability and, as a result, a lack of experience in many centers. In this review article, an algorithm for the management of CS is proposed, and the gaps in every step are presented. Early clinical suspicion that leads to prompt diagnosis, health system organization, large-scale trials, and the configuration of national or regional shock centers could bridge the current therapeutic gaps and balance disparities in the management of CS in order to improve outcomes.