Search Results (40)

Background: Interpretation of intermediate computed tomography-derived fractional flow reserve (CT-FFR) remains uncertain. We evaluated whether Coronary Artery Disease Reporting and Data System (CAD-RADS) severity modifies the association between CT-FFR and downstream management in patients with CT-FFR 0.71–0.80. Methods: This retrospective study included 973 symptomatic patients stratified by index-vessel CAD-RADS category and CT-FFR 0.71–0.75 versus 0.76–0.80. Planned revascularization within 90 days was the primary outcome. Multivariable logistic regression assessed CT-FFR associations and interaction with CAD-RADS; major adverse cardiac and cerebrovascular events (MACCE) were exploratory. Results: Planned revascularization occurred in 39.8% versus 19.3% of patients with CT-FFR 0.71–0.75 versus 0.76–0.80 (adjusted odds ratio [OR], 2.38; 95% confidence interval [CI], 1.72–3.29; p < 0.001). Each 0.01 decrease in CT-FFR was associated with higher odds of revascularization (adjusted OR, 1.23; 95% CI, 1.15–1.32; p < 0.001). The association differed by CAD-RADS category (interaction p = 0.011), with a more pronounced association observed in CAD-RADS 3 (adjusted OR per 0.01 decrease, 1.39; 95% CI, 1.25–1.54). During a median follow-up of 384 days, 31 patients (3.2%) experienced MACCE, with no significant adjusted association with CT-FFR. Conclusions: Among patients with intermediate CT-FFR, lower values were associated with a higher likelihood of planned revascularization, and the magnitude of this association differed across CAD-RADS categories. Full article

Cardiovascular disease (CVD) prevention depends on accurate risk stratification before symptoms develop. Standard tools such as the Pooled Cohort Equations, QRISK3, and SCORE2 require laboratory data and are less informative in borderline-risk individuals, creating a role for accessible adjuncts. Retinal imaging directly visualizes the systemic microvasculature, and deep-learning oculomics may provide complementary risk information. Reti-CVD generates a three-tier classification from a retinal photograph and is among the more extensively validated retinal-AI tools. This narrative review evaluates its clinical positioning and implementation as an exemplar rather than a product endorsement, organizing evidence by cohort, comparing the approach with established scores and subclinical atherosclerosis markers, and considering implementation, regulation, and equity. RetiCAC was trained using coronary artery calcium as a surrogate label; subsequent Reti-CVD studies included UK Biobank, Singapore SEED, and CMERC-HI. Reported discrimination was approximately 0.75 by the Harrell C-index, with modest reclassification improvement, particularly in borderline-risk groups. As the commercial product DrNoon for CVD, the tool holds marketing authorization from Korea’s Ministry of Food and Drug Safety (MFDS) and, according to the manufacturer, CE certification under the EU Medical Device Regulation (MDR); in Korea it entered outpatient practice through a time-limited non-covered (out-of-pocket) assessment-deferral pathway, and it has not yet received US FDA authorization. Most evidence originates from one research group and one commercial algorithm, and no randomized or outcome-based study has shown that Reti-CVD-guided care improves clinical outcomes. These observational findings remain hypothesis-generating rather than evidence of established clinical utility. Reti-CVD is therefore best regarded as a non-invasive risk enhancer for borderline/intermediate-risk reclassification, not as a tool of established clinical utility; independent validation, intervention trials, and cost-effectiveness and reimbursement evidence are needed before broad integration. Full article

Background: Intravascular lithotripsy (IVL) has emerged as a safe and effective modality for treating severely calcified coronary lesions. While the Shockwave™ system is well-established, clinical data on newer IVL platforms such as the Shunmei ShockFast™ system remain limited. Objectives: To evaluate the safety, feasibility, and procedural outcomes of the ShockFast IVL device in patients with heavily calcified de novo coronary artery disease. Methods: We conducted a prospective, single-center case series of 16 patients undergoing percutaneous coronary intervention (PCI) with the ShockFast IVL system between June and December 2025. Inclusion required angiographic or optical coherence tomography (OCT) evidence of severe coronary calcification. The primary efficacy endpoint was acute procedural success and absence of in-hospital MACE. Secondary endpoints included, among others, device deliverability, presence of calcium fracture and post-stent expansion metrics. Results: All patients underwent successful lithotripsy delivery with the ShockFast IVL system. Acute procedural success was 100%, with no intraprocedural complications, abrupt closure, or in-hospital MACE. OCT was performed in 50% of cases and demonstrated calcium fractures in all imaged lesions, with ≥2 fractures in 63% of cases. Median stent expansion was 90% [IQR 9], with no major malapposition or edge dissections. Quantitative coronary analysis showed a median acute lumen gain of 1.86 mm [0.62]. Conclusions: The ShockFast IVL system showed excellent safety and procedural performance in this first-in-center experience. Outcomes were encouraging and consistent with those reported in early-stage studies of other IVL platforms. These findings support the clinical feasibility of ShockFast as a novel tool for calcium modification in complex PCI. Full article

Objectives: To assess the diagnostic accuracy of a deep learning (DL)-based algorithm for non-invasive computation of fractional flow reserve (FFR-CT) from coronary computed tomography angiography (CCTA) and to evaluate the model’s ability to automatically assign cardiovascular risk categories according to the Coronary Artery Disease–Reporting and Data System (CAD-RADS). Materials and Methods: Sixty patients with suspected coronary artery disease who underwent both CCTA and invasive coronary angiography (ICA) were retrospectively included in this multicenter study. Curved multiplanar reconstructions derived from CCTA were analyzed by the deep learning-based model to estimate FFR-CT values and to automatically assign CAD-RADS risk categories. The diagnostic performance of the software for the identification of hemodynamically significant coronary stenoses was evaluated using ICA as the reference standard. Receiver operating characteristic (ROC) curve analysis was performed to determine the area under the curve (AUC), sensitivity, and specificity on both a per-patient and per-vessel basis. Finally, agreement between CAD-RADS risk categories assigned by the DL algorithm and those determined by an expert radiologist was assessed. Results: FFR-CT demonstrated high diagnostic accuracy, with AUC of 0.935, sensitivity of 93.2%, specificity of 93.7%, and excellent agreement with reference standard (k = 0.836) on a per-patient level. Per-vessel diagnostic performance was consistently high across all major coronary arteries, with the left anterior descending artery (LAD) showing the highest accuracy (AUC = 0.932). Automated CAD-RADS classifications generated by the software showed good agreement with those assigned by human (k = 0.765). Conclusions: The DL-based model demonstrated high diagnostic accuracy and represents a promising noninvasive approach for ischemia assessment and cardiovascular risk stratification. Full article

Epicardial adipose tissue (EAT) has previously been associated with coronary artery calcium scores, an increased burden of coronary artery disease (CAD), and features of plaque instability. These associations are likely mediated by endocrine and paracrine signaling from bioactive molecules secreted by EAT, which may contribute to coronary atherosclerosis. EAT can be non-invasively quantified on images obtained during coronary computed tomography angiography (CCTA). This study aimed to evaluate the potential association between EAT and non-calcified coronary plaques with severe stenosis using radiomic methodology. Materials and Methods: A total of 128 consecutive patients undergoing CCTA—both with and without contrast—for known or suspected CAD were retrospectively analyzed. EAT features were extracted from contrast scans. Coronary artery plaque features were evaluated using Coronary Artery Disease-Reporting and Data System (CAD-RADS). Results: EAT features showed a statistically significant positive correlation with non-calcified coronary plaques with severe grades of stenosis (CAD-RADS > 4). The Ensemble Machine Learning (EML) model combined with coronary plaque data showed a sensitivity of 1.00 and a specificity of 0.93, with a negative predictive value of 1.00 and a positive predictive value of 0.85, and an accuracy of 0.95 (95% CI: 0.9221–1) in internal validation. Conclusions: EAT may represent a novel imaging biomarker associated with the presence of actionable coronary plaques. Radiomic texture analysis of EAT could enhance the non-invasive prediction of coronary stenoses. These preliminary findings support the clinical utility of EAT evaluation via CCTA in patients with low to intermediate cardiovascular risk. Full article

Background: Lipoprotein(a) (Lp(a)) is a genetically determined lipid particle associated with atherosclerotic cardiovascular disease. Despite growing evidence supporting the clinical relevance of Lp(a) in cardiovascular risk stratification and the emergence of potential therapies targeting elevated Lp(a) levels, Lp(a) testing remains underutilized, with reported rates below 20–30%. This study aims to explore Lp(a) levels in the Lebanese population and their association with the vascular and metabolic burden of diseases. Methods: We conducted a retrospective observational study of patients who underwent Lp(a) level testing at the American University of Beirut Medical Center between 2010 and 2023. Data were extracted using the EPIC electronic medical record system, and statistical analyses were performed using IBM SPSS Statistics Version 28. Results: This study included 456 patients; the mean age was 50 ± 13, and the mean Lp(a) level was 25 ± 28 mg/dL. Mean Lp(a) was higher in females than in males (28 ± 32 mg/dL versus 23 ± 25 mg/dL), and 25.9%, 12.9%, and 7.6% of the population had Lp(a) levels ≥ 30, ≥50, and ≥70 mg/dL respectively. Logistic regression analysis showed no significant association between Lp(a) levels and cardiovascular factors including dyslipidemia, hypertension, coronary artery disease, previous coronary artery bypass graft, and previous myocardial infarction. Similarly, no significant correlation was found between Lp(a) and LDL, HDL, total cholesterol, triglyceride, and HbA1c. Subgroup analysis showed a significant relationship between Lp(a) levels > 50 mg/dL and atrial fibrillation. Conclusions: This study explores the distribution of Lp(a) levels in a Middle Eastern tertiary-care population and provides population-specific descriptive data, addressing an important gap in the existing literature. Full article

Background/Objectives: Atrial fibrillation (AF) is associated with increased epicardial adipose tissue (EAT), atrial dilation, and coronary inflammation, though causality remains unclear. Cardiac computed tomography (CCT) allows for precise quantification of EAT volume and the left atrial volume index (LAVI), along with the calculation of the fat attenuation index (FAI), indicating coronary inflammation. Combined with the Coronary Artery Disease-Reporting and Data System (CAD-RADS), these imaging markers may improve AF risk stratification. This study evaluates the association between peri-atrial EAT volumes, LAVI, CAD-RADS, and FAI scores in AF patients using advanced AI platforms. Methods: This retrospective study analyzed 122 patients presenting with angina-type pain and a low-to-intermediate likelihood of CAD, who underwent CCT. Patients were divided into two groups based on rhythm status: 42 with AF and 80 without AF. Total EAT, left atrial (LA-EAT), and bi-atrial EAT (BA-EAT) volumes were assessed, along with LAV, CAD-RADS classification, and FAI scores measured using CaRi-Heart^® and syngo.via Frontier^®. Results: AF patients exhibited significantly higher EAT volumes (total EAT: 231.8 ± 45.85 vs. 153.2 ± 54.14 mL, p < 0.0001; LA-EAT: 23.55 ± 6.44 vs. 15.54 ± 8.49 mL, p < 0.0001; BA-EAT: 50.24 ± 12.69 vs. 39.84 ± 15.70 mL, p = 0.0002) and elevated LAVI values (57.7 ± 11.44 vs. 45.9 ± 12.58 mL/m², p < 0.0001). ROC analyses confirmed strong diagnostic performance of total EAT (AUC = 0.869), LA-EAT (AUC = 0.776), BA-EAT (AUC = 0.703), and the LAVI (AUC = 0.756). Higher CAD-RADS categories (2–5) were more frequent in AF, although significant differences were observed only in the lowest category (0–1; 26.2% AF vs. 47.8% non-AF, p = 0.032). Total FAI scores were also higher in AF patients (14.83 ± 10.16 vs. 12.37 ± 7.89, p = 0.044). Conclusions: Increased EAT volumes, an elevated LAVI, and higher FAI scores are significantly associated with AF, suggesting a combined structural and inflammatory substrate. EAT, the LAVI, the FAI, and CAD-RADS collectively represent valuable non-invasive imaging biomarkers for early AF risk assessment. Full article

Coronary artery disease (CAD) is the third leading cause of disability and death globally. Intravascular ultrasound (IVUS) is the most commonly used imaging modality for the characterization of vulnerable plaques. The development of novel intravascular imaging and therapy devices requires dedicated open systems (e.g., for pulse sequences for imaging or thrombolysis), which are not currently available. This paper presents the development of a novel multifunctional FPGA-based pulser/receiver system for intravascular ultrasound imaging and therapy research. The open platform consists of a host PC with a Matlab-based software interface, an FPGA board, and a proprietary analog front-end board with state-of-the-art electronics for highly flexible transmission and reception schemes. The main features of the system include the capability to convert arbitrary waveforms into tristate bipolar pulses by using the PWM technique and by the direct acquisition of raw radiofrequency (RF) echo data. The results of a multicycle excitation pulse applied to a custom 550 kHz therapy transducer for acoustic characterization and a pulse-echo experiment conducted with a high-voltage, short-pulse excitation for a 19.48 MHz transducer are reported. Testing results show that the proposed system can be easily controlled to match the frequency and bandwidth required for different IVUS transducers across a broad class of applications. Full article

Background: Coronary heart disease (CHD) remains the most prevalent pathology within the circulatory system. Among its chronic complications, ischemic mitral valve regurgitation (IMR) is observed in approximately 15% of patients with sustained myocardial ischemia. The presence of this complex valvular defect significantly increases both overall mortality and the incidence of adverse cardiovascular events. Notably, the presence of moderate to severe mitral regurgitation in patients undergoing surgical revascularization has been shown to double the risk of death. Despite the well-established etiology of IMR, data regarding the efficacy of surgical interventions and the determinants of postoperative outcomes remain inconclusive. Methods: The objective of the present study was to evaluate both early and long-term outcomes of surgical treatment of mitral regurgitation in patients undergoing coronary artery bypass grafting (CABG) due to ischemic heart disease. Particular attention was given to the influence of the severity of regurgitation, left ventricular ejection fraction (LVEF), and the dimensions of the left atrium (LA) and left ventricle (LV) on the postoperative prognosis. An additional aim was to identify preoperative risk factors associated with increased postoperative mortality and morbidity. A retrospective analysis was conducted on 421 patients diagnosed with ischemic mitral regurgitation who underwent concomitant mitral valve surgery and CABG. Exclusion criteria included emergent and urgent procedures as well as non-ischemic etiologies of mitral valve dysfunction. Results: The study cohort comprised 34.9% women and 65.1% men, with the mean age of 65.7 years (±7.57). A substantial proportion (76.7%) of patients were aged over 60 years. More than half (51.5%) presented with severe heart failure symptoms, classified as NYHA class III or IV, while over 70% were categorized as CCS class II or III. Among the surgical procedures performed, 344 patients underwent mitral valve repair, and 77 patients required mitral valve replacement. Additionally, 119 individuals underwent concomitant tricuspid valve repair. Short-term survival was significantly affected by the presence of hypertension, prior cerebrovascular events, and chronic kidney disease. In contrast, hypertension and chronic obstructive pulmonary disease were identified as significant predictors of adverse late-term outcomes. Conclusions: Interestingly, neither the preoperative severity of mitral regurgitation nor the echocardiographic measurements of LA and LV dimensions were found to significantly influence surgical outcomes. The perioperative risk, as assessed by the EuroSCORE II (average score: 10.0%), corresponded closely with observed mortality rates following mitral valve repair (9.9%) and replacement (10.4%). Notably, the need for concomitant tricuspid valve surgery was associated with an elevated mortality rate (12.4%). Furthermore, the preoperative echocardiographic evaluation of LA regurgitation severity, as well as LA and LV dimensions, did not exhibit a statistically significant impact on either early or long-term surgical outcomes. However, a reduced LVEF was correlated with increased long-term mortality. The presence of advanced clinical symptoms and the necessity for tricuspid valve repair were independently associated with a poorer late-term prognosis. Importantly, the annual mortality rate observed in the late-term follow-up of patients who underwent surgical treatment of ischemic mitral regurgitation was lower than rates reported in the literature for patients managed conservatively. The EuroSCORE II scale proved to be a reliable and precise tool in predicting surgical risk and outcomes in this patient population. Full article

Background: Diabetic patients tend to have complex coronary artery disease (CAD). Understanding their procedural risk may help to guide treatment strategies. SYNTAX and the British Cardiovascular Intervention Society Jeopardy Score (BCIS-JS) have been used to define complex CAD, but their use has not been compared in diabetic patients. Methods: This is a retrospective analysis of prospectively collected data of consecutive patients who underwent complex percutaneous coronary intervention (PCI) and were deemed unsuitable for surgical revascularization. Both SYNTAX and BCIS-JS were calculated by experienced operators who were blinded to patient’s outcome. The primary endpoint was all-cause mortality at 12 months. Results: Of 452 patients included in the study, diabetes was present in 35% patients. There was a modest relationship between BCIS-JS and SYNTAX score (Spearman r = 0.44, p < 0.001) and this relationship was even weaker in patients with diabetes (Spearman r = 0.32, p < 0.001). The primary endpoint was comparable in the non-diabetic group, irrespective of the score system (SYNTAX or BCIS-JS) used to define complex CAD. In contrast, there was a differential prognostic outcome in the diabetic group, whereby the primary endpoint was more frequently reported in diabetic patients with high versus low SYNTAX scores [HR 4.96, 95% CI (1.44–17.03), p = 0.011] but not when BCIS-JS was used. Conclusions: There was a modest relationship between BCIS-JS and SYNTAX score. Unlike BCIS-JS, the SYNTAX score identified those who are at increased risk of death among diabetic patients. Both scoring systems did not effectively differentiate mortality risk in non-diabetic patients. Future research is needed to confirm this study’s findings. Full article

Objectives: Our study aims to investigate the correlation between epicardial adipose tissue (EAT) volume assessed with non-contrast cardiac CT (NCCCT) and sex, age, coronary artery disease reporting and data system (CAD-RADS 2.0) categories, and coronary artery calcification (CAC) extent. The secondary aim is to establish the average values of EAT in a population considered healthy for coronary artery disease (CAD). Materials and Methods: We retrospectively analyzed patients who underwent coronary computed tomography angiography (CCTA) at our institution from January 2023 to August 2024. The CAD-RADS 2.0 scoring system was applied to assess the extent of CAD; CAC extent was quantified according to the Agatston score. EAT was segmented semi-automatically in NCCCT images, and its volume was subsequently measured. Correlation analyses between EAT volume, sex, patient age, CAC, and CAD-RADS categories were conducted. Results: A total of 489 consecutive patients met the inclusion criteria (63.96 ± 12.18 years; 214 females). The mean EAT volume ± SD in those categorized as CAD-RADS 0 (57.25 ± 15.45 years, 120 patients) was 117.43 ± 50.30 cm³: values were higher in men (121.07 ± 53.31 cm³) than in women (114.54 ± 47.98 cm³). EAT volumes positively correlated with age, male sex, CAD severity, and CAC scores. Conclusions: According to our results, males in all CAD-RADS categories have a greater amount of EAT than females. A positive correlation between the volume of EAT and factors such as age (p = 0.003), CAD-RADS categories (p: 0.004), and coronary calcium score (p = 0.0001) with a strong influence exerted by sex was demonstrated. Our results reinforce the observation that higher EAT volumes are associated with a more severe coronary artery disease. Full article

Objective: To investigate the association between sarcopenia, as appraised with CT-derived muscle metrics, and cardiovascular status, as assessed via coronary CT angiography (CCTA) using the Coronary Artery Disease-Reporting and Data System (CAD-RADS) and with pericoronary adipose tissue (pCAT) metrics. Methods: A retrospective observational study conducted on patients who underwent CCTA. The cross-sectional area (CSA) and attenuation values of the paravertebral muscles at the T8 level and the pectoralis major muscles at the T6 level were measured. The patient height was employed for the normalization of the skeletal muscle CSA. The pCAT attenuation around the coronary arteries was assessed, and the CAD severity was graded using the CAD-RADS reporting system. Regression analyses were performed to assess the impact of demographics, clinical factors, and CT variables on the CAD-RADS and pCAT. Results: A total of 220 patients were included (132 males, median age 65 years). Regression analyses showed the associations of CAD with age and sex (p < 0.001). Familiarity with CAD was related to the left anterior descending artery pCAT (p = 0.002) and circumflex artery pCAT (p = 0.018), whereas age was related to the left anterior descending artery pCAT (p = 0.032). Weak positive correlations were found between the lower muscle density and lower pCAT attenuation (ρ = 0.144–0.240, p < 0.039). Conclusions: This study demonstrated weak associations between the sarcopenia indicators and the cardiovascular risk, as assessed by the CAD severity and pCAT inflammation. However, these correlations were not strong predictors of CAD severity, as age and traditional cardiovascular risk factors overshadowed the impact of sarcopenia in the cardiovascular risk assessment. Full article

The aim of this paper is to demonstrate the difference in usefulness of the coronary artery calcium score (CACS) and the full assessment of the severity of coronary artery disease in coronary computed tomography angiography (CCTA) studies. The difference between the population risk of coronary artery disease (CAD) assessed by the CACS and the severity of CAD was demonstrated in images from two CCTA studies. The first image is from a patient with a CACS of 0 and significant coronary artery stenosis. In the native phase of CCTA examination, no calcified changes were detected in the topography of the coronary arteries. In the middle section of the left descending artery (LAD), at the level of the second diagonal branch (Dg2), a large non-calcified atherosclerotic plaque was visible. Mid-LAD stenosis was estimated to be approximately 70%. The second image features a patient with a high CACS but no significant coronary artery stenosis. The calcium score of individual coronary arteries calculated using the Agatston method was as follows: left main (LM) 0, LAD 403, left circumflex (LCx) 207.7, right coronary artery (RCA) 12. CACS was 622.7, representing a significant population risk of significant CAD. In the proximal and middle sections of the LAD, numerous calcified and mixed atherosclerotic plaques with positive remodeling were visible, causing stenosis of 25–50%. Similarly, in the proximal and middle sections of the LCx, numerous calcified and mixed atherosclerotic plaques with positive remodeling were visualized, causing stenoses of 25–50%. Calcified atherosclerotic plaques were found in the RCA, causing stenosis <25%. The entire CCTA image met CAD-RADS 2 (coronary artery disease reporting and data system) criteria. In summary, CACS may be applicable in population-based studies to assess the risk of significant CAD. In the evaluation of individual patients, a comprehensive assessment of CAD severity based on the angiographic phase of the CCTA examination should be used. Full article

The intracavitary coronary arteries (ICCA) course is a rare phenomenon, where the segments of the coronary artery go through the atria or ventricles of the heart. In the past, these changes were incidentally detected during invasive diagnostic procedures for other reasons, as well as during postmortem examinations. As the use of multidetector computed tomography angiography (CTA) becomes more widespread, it has emerged that the incidence of ICCA has been underestimated. We present images from two coronary computed tomography angiography cases, which document the existence of ICCA in patients with non-specific chest pain. In the first case, in a 66-year-old woman, in addition to confirming coronary artery disease without significant stenosis (CAD-RADS 2-category 2 in the coronary-artery-disease-reporting and data system), the course of the middle section of the right coronary artery (RCA) in the lumen of the right atrium was demonstrated. In the second case, in a 47-year-old man in whom the presence of atherosclerotic lesions in the coronary arteries was excluded (CAD-RADS 0), the course of the distal segment of the left anterior descending (LAD) was found in the lumen of the apical layers of the right ventricle. To sum up, it should be stated that coronary CTA is a non-invasive diagnostic method that allows for visualization of the ICCA. In coronary CTA performed for indications consistent with the guidelines of scientific societies, attention should also be paid to the possible intracavitary course of the coronary arteries. The identification of such a course of the coronary arteries may be useful when preparing the patient for potential future invasive procedures involving the cardiac cavities. Full article

Background: Infective endocarditis (IE) management is challenging, usually requiring multidisciplinary collaboration from cardiologists, infectious disease specialists, interventional cardiologists, and cardiovascular surgeons, as more than half of the cases will require surgical procedures. Therefore, it is essential for all healthcare providers involved in managing IE to understand the disease’s characteristics, potential complications, and treatment options. While systemic embolization is one of the most frequent complications of IE, the coronary localization of emboli causing acute myocardial infarction (AMI) is less common, with an incidence ranging from 1% to 10% of cases, but it has a much higher rate of morbidity and mortality. There are no guidelines for this type of AMI management in IE. Methods: This narrative review summarizes the current knowledge regarding septic coronary embolization in patients with IE. Additionally, this paper highlights the diagnosis and management challenges in such cases, particularly due to the lack of protocols or consensus in the field. Results: Data extracted from case reports indicate that septic coronary embolization often occurs within the first two weeks of the disease. The aortic valve is most commonly involved with vegetation, and the occluded vessel is frequently the left anterior descending artery. Broad-spectrum antibiotic therapy followed by targeted antibiotic therapy for infection control is essential, and surgical treatment offers promising results through surgical embolectomy, concomitant with valve replacement or aspiration thrombectomy, with or without subsequent stent insertion. Thrombolytics are to be avoided due to the increased risk of bleeding. Conclusions: All these aspects should constitute future lines of research, allowing the integration of all current knowledge from multidisciplinary team studies on larger patient cohorts and, subsequently, creating a consensus for assessing the risk and guiding the management of this potentially fatal complication. Full article