Search Results (1,162)

Coronary artery bypass grafting (CABG) remains one of the most effective treatments for advanced coronary artery disease; however, substantial variability persists in both perioperative and long-term outcomes despite advances in surgical technique, myocardial protection, and risk stratification. Oxidative stress is a central mediator of tissue injury during cardiac surgery, contributing to ischemia–reperfusion injury, endothelial dysfunction, systemic inflammation, and postoperative organ complications. At the same time, chronic exposure to ambient air pollution has emerged as an important environmental determinant of cardiovascular disease through mechanisms that converge on many of the same redox-sensitive pathways. We propose the concept of environmental oxidative priming, whereby long-term exposure to particulate matter, nitrogen oxides, ozone, and other pollutants establishes a persistent state of endothelial dysfunction, mitochondrial impairment, chronic inflammation, nitric oxide depletion, and reduced antioxidant reserve before surgery. Within this framework, CABG represents a second oxidative challenge superimposed on a pre-existing environmentally conditioned phenotype. We discuss the mechanistic overlap between air pollution-induced cardiovascular injury and cardiac surgical stress and examine how this interaction may contribute to postoperative complications, graft adaptation, major adverse cardiovascular events, and long-term survival. Recognition of air pollution as a modifier of biological resilience provides a novel framework for understanding outcome heterogeneity after CABG and may support future precision-based risk stratification and preventive strategies. Full article

Background: ST-elevation myocardial infarction (STEMI) complications are widespread and have a direct effect on the length of stay (LOS) and mortality of patients. Reperfusion therapy via Percutaneous Coronary Intervention mainly impacts outcomes within the first few hours. Consequently, delaying this procedure is a key concern in STEMI management. The door-to-balloon (D2B) time is a crucial predictor of clinical outcomes. This study investigates whether D2B time can predict post-STEMI complications and length of hospital stay, accounting for sociodemographic and clinical variables. Methods: This prospective observational study involved 536 patients with confirmed STEMI, recruited consecutively from 8 hospitals in Amman, Jordan. Patients were classified as delayed if their D2B time was ≥2 h. Logistic regression analyzed the impact of delay on complications, while multiple regression assessed how delay time affected LoS. Results: The median D2B time was 108 min (IQR 65–395). The delayed group and patients with a previous AMI had 2.22- and 1.41-times higher risks of complications, respectively, compared to their counterparts. Patients with a history of HTN and DM faced 1.24- and 1.18-times higher risks of complications versus their respective groups. Each additional hour of door-to-balloon delay was associated with an increase of 0.294 days in hospital length of stay. Conclusions: D2B ≥ 2 h is linked to increased complications and longer LoS. Timely management can reduce complications, shorten LoS, and lower hospital resource use. Full article

Background/Objectives: Robotic-assisted percutaneous coronary intervention (R-PCI) reduces occupational hazards, may enhance procedural precision and has demonstrated comparable efficacy to manually performed PCI (M-PCI). However, the switch from M-PCI to R-PCI represents a unique challenge and learning curve, which remains undefined. The purpose of this study was to evaluate patients’ profile and procedural outcomes over time after starting an R-PCI programme at a tertiary cardiac centre. Methods: All consecutive patients who underwent R-PCI with the second-generation CorPath GRX R-PCI system at our centre between March 2021 and January 2024 were included. The study cohort was divided into two equal groups representing the early and late experience. Clinical profile, lesion characteristics and procedural outcomes were compared between both groups. Angiographic success was defined as TIMI 3 flow and less than 30% stenosis, and R-PCI technical success as angiographic success without any unplanned manual input. Results: For 102 patients (mean age 68 years, 73% male) who underwent R-PCI, the angiographic success rate was 100%, and the R-PCI technical success rate was 83.33%, with 16.67% of patients requiring unplanned manual input. In the late (n = 51) versus early (n = 51) group, more bifurcations (52.94% vs. 33.33%, p = 0.046) and ACC/AHA (American College of Cardiology/American Heart Association) type C lesions (45.10% vs. 25.49%, p = 0.038) were treated with no significant differences in contrast volume, radiation dose, procedural time or peri-procedural complications between the two groups. Conclusions: R-PCI appears feasible with acceptable short-term results. In our experience, after ~50 cases, increasing complexity of lesions can be treated without significantly impacting procedural outcomes or safety. Full article

Background: Aorto–atrial fistula is a rare pathological communication associated with diagnostic difficulties, progressive hemodynamic consequences, and potential infective complications. Methods and Results: We present a 53-year-old woman with a long-standing congenital non-coronary sinus of Valsalva–to–right atrial fistula that had been followed for nine years under the working diagnosis of a Gerbode defect. The communication was first detected at the age of 44 years during pregnancy and was managed conservatively while the patient remained largely asymptomatic. At the age of 53 years, recurrent exertional dyspnea prompted definitive reassessment. Right heart catheterization demonstrated a hemodynamically significant left-to-right shunt at the right atrial level, with a pulmonary-to-systemic blood flow (Qp/Qs) ratio of 2.1. Intraoperatively, the communication was shown to originate immediately above the non-coronary cusp and drain into the right atrium, establishing the diagnosis of a congenital aorto–right atrial fistula. A granulomatous, windsock-like endocardial lesion was identified at its right atrial opening, and Staphylococcus capitis was isolated from surgically obtained tissue. Histopathology showed nonspecific regressive changes without specific features of active infective endocarditis. The fistula was closed with an autologous pericardial patch, and intravenous flucloxacillin was administered because of probable localized infective involvement. Conclusions: This case illustrates the diagnostic difficulty of distinguishing an aorto–atrial fistula from a Gerbode defect and supports careful multimodality evaluation of the anatomical origin and flow characteristics of intracardiac shunts. Persistent high-velocity flow may contribute to endocardial injury and create a substrate for subsequent bacterial colonization, although causality cannot be established from a single case. Isolation of a low-virulence skin commensal from pathological cardiac tissue should be interpreted in the complete clinical, operative, microbiological, and histopathological context rather than automatically classified as contamination. Full article

Bleeding is one of the most common and feared complications after coronary angiography and percutaneous coronary intervention (PCI). It is associated with longer hospital stays, higher mortality, and worse clinical outcomes. As the number of patients at high bleeding risk (HBR) continues to grow, preventing bleeding has become an important part of PCI management. This practical review summarizes current evidence on how to assess bleeding risk and reduce bleeding before, during, and after PCI. Several tools, including the BARC classification, ARC-HBR criteria, PRECISE-DAPT, and DAPT scores, help identify patients who may benefit from tailored treatment. Current strategies include the use of radial access, optimized anticoagulation, appropriate selection of antiplatelet therapy, newer-generation drug-eluting stents, and shorter durations of dual antiplatelet therapy in selected HBR patients. We also discuss the management of patients with atrial fibrillation requiring oral anticoagulation, as well as those with anemia or thrombocytopenia. Although significant progress has been made, several questions remain unanswered, particularly regarding transfusion thresholds, antithrombotic therapy in complex patients, and the best balance between bleeding and ischemic risks. Ongoing clinical trials are expected to provide further evidence and help improve the management of patients undergoing PCI. Full article

Background and Clinical Significance: Iatrogenic aorto-ostial dissection is a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), most commonly involving the right coronary artery. Although ostial stenting is generally considered the standard bailout strategy, failure of initial sealing may occur in selected anatomical settings and remains poorly understood. A focused narrative review of the literature was conducted through PubMed/MEDLINE, Scopus and Web of Science to identify reports of PCI-related aorto-coronary dissection with particular attention to dissection morphology, propagation mechanisms, bailout strategies, and outcomes after ostial stenting; Case Presentation: A 76-year-old man presented with non-ST-elevation myocardial infarction. Coronary angiography showed severe ostial right coronary artery (RCA) disease and significant left anterior descending artery stenosis. Following drug-eluting stent implantation in the RCA, extensive aorto-ostial dissection with retrograde extension into the sinus of Valsalva occurred. Initial ostial stenting failed to seal the dissection and was complicated by hyperacute stent thrombosis. After successful rewiring of the true lumen, a second overlapping drug-eluting stent was implanted using a stent-in-stent technique, followed by prolonged balloon inflation, achieving complete sealing and stabilization. Serial computed tomography angiography confirmed stability, and staged PCI of the LAD was successfully performed five days later; Conclusions: Failure of primary sealing may depend not only on procedural factors but also on dissection morphology. Transverse dissections with wide entry tears may be less effectively sealed by a single ostial stent, whereas overlapping stenting with prolonged balloon inflation may represent a more effective bailout strategy. Full article

Background and Objectives: This retrospective study evaluated patients with diabetes classified according to cluster-derived diabetes phenotype groups and compared their baseline metabolic characteristics, documented complication profiles, and HbA1c course during follow-up. Materials and Methods: A total of 158 patients with type 1 or type 2 diabetes followed at Zonguldak Bülent Ecevit University Endocrinology Outpatient Clinic were included. Phenotype assignment was based on baseline domains corresponding to the Ahlqvist framework: age at diagnosis, BMI category, HbA1c, beta-cell function, insulin resistance, and autoantibody status. Complications were not used for phenotype assignment. Baseline characteristics, binary complication status, exploratory phenotype-contrast logistic regression, and longitudinal HbA1c data were evaluated. Results: The groups showed significant differences in age, age at diagnosis, HbA1c, obesity status, fasting glucose, C-peptide, fasting insulin, HOMA1-%B, HDL cholesterol, ALT, and eGFR. Hepatic steatosis/suspected NAFLD, retinopathy, nephropathy, polyneuropathy, and ketosis/ketoacidosis differed among groups when complications were analyzed as ever-positive versus negative. In exploratory phenotype-contrast logistic regression, Clusters 3–4 were associated with hepatic steatosis/suspected NAFLD, Cluster 2 with retinopathy and polyneuropathy, Cluster 3 with nephropathy, and Clusters 1–2 with ketosis/ketoacidosis; the contrast for coronary artery disease did not reach statistical significance. In a linear mixed-effects model for repeated HbA1c measurements, phenotype group was associated with HbA1c levels, whereas the time effect and group-by-time interaction were not statistically significant. Conclusions: Cluster-derived diabetes phenotype groups showed distinct baseline metabolic characteristics and different documented complication profiles. These findings should be interpreted as exploratory because of the retrospective design and incomplete follow-up data. Full article

Background: Cardiac arrest complicating acute coronary syndrome (ACS) is associated with high mortality and neurological morbidity despite advances in percutaneous coronary intervention (PCI) and post-resuscitation care. This study evaluated clinical outcomes in ACS patients presenting with cardiac arrest undergoing invasive coronary angiography, with particular focus on resuscitation status before catheterization and location of cardiac arrest. Methods: A retrospective analysis of 15,595 ACS patients undergoing coronary angiography between 2014 and 2025 identified two cohorts. The first cohort included 131 patients stratified according to mechanical cardiac activity upon arrival to the catheterization laboratory: previously resuscitated patients (RES, n = 109) and patients in refractory cardiac arrest requiring automatic resuscitation devices (ARD, n = 22). The second cohort included 159 patients grouped by arrest location: out-of-hospital (OHCA, n = 83), in-hospital (IHCA, n = 48), and catheterization laboratory cardiac arrest (CLCA, n = 28). The primary outcomes were in-hospital mortality and neurological status after resuscitation. Results: In-hospital mortality was significantly higher in the ARD group compared with the RES group (86.4% vs. 39.4%, p < 0.001). Survivors in the RES group more frequently achieved favorable neurological recovery (66.2%). Mean resuscitation duration and admission lactate levels were significantly greater in the ARD group (66.1 vs. 21.9 min, p < 0.001; 10.7 vs. 7.7 mmol/L, p = 0.006). According to arrest location, mortality was highest in the CLCA group (78.6%), followed by IHCA (60.4%) and OHCA (39.8%) (p < 0.001). Despite high mortality, all surviving CLCA patients had favorable neurological outcomes. Culprit coronary vessel distribution was not associated with mortality or neurological outcome. Conclusions: In ACS patients with cardiac arrest, ongoing refractory arrest during coronary angiography and cardiac arrest occurring in the catheterization laboratory were associated with markedly increased mortality. Successful resuscitation prior to catheterization was associated with significantly better survival and neurological recovery. Full article

Background: Diabetes accelerates atherosclerosis and restenosis and impairs vascular healing, complicating percutaneous coronary intervention (PCI). Drug-coated balloons (DCBs) deliver antiproliferative therapy without a permanent scaffold, but their comparative mid-term performance in diabetic patients relative to non-diabetic patients is incompletely defined. Methods: We analysed a large all-comers cohort of consecutive patients who underwent a DCB-based PCI between 2018 and 2022, stratified by diabetes status. The primary endpoint was a composite of cardiac death, target vessel revascularisation (TVR) and target vessel myocardial infarction. Cumulative incidence was estimated by Kaplan–Meier analysis, and predictors were assessed by Cox regression. Results: Among 853 patients (304 diabetic, 549 non-diabetic), diabetic patients had more comorbidities and more frequent in-stent restenosis (52.3% vs. 41.8%). Over a median follow-up of 376 days, the two-year incidence of the composite endpoint was higher among diabetic patients (21.3% vs. 10.6%, p = 0.007), as was target lesion revascularisation (TLR; 13.6% vs. 5.5%, p = 0.004). Diabetes independently predicted the composite endpoint (adjusted hazard ratio: 1.87; 95% CI: 1.10–3.17) and TLR (adjusted HR: 2.33; 95% CI: 1.18–4.62), whereas DCB type and procedural variables did not. Conclusions: In an all-comers DCB-PCI population, diabetes was independently associated with higher rates of mid-term major adverse cardiovascular events and target lesion revascularisation, while device and procedural variables did not drive outcomes, underscoring the importance of systemic risk management in regard to diabetic patients. Full article

Background/Objectives: Atrial fibrillation (AF) and chronic kidney disease (CKD) frequently coexist and are associated with a high risk of cardiovascular complications. Previous studies have primarily focused on differences in clinical profiles by anticoagulant therapy or arrhythmia. Only a limited number of studies have evaluated the impact of CKD severity on patients’ clinical characteristics. Methods: This retrospective observational study aimed to characterize the clinical profile of contemporary patients with AF and CKD with an estimated glomerular filtration rate (eGFR) of 15–49 mL/min/1.73 m². The analysis included patients with AF from the CRAFT registry (NCT02987062). Patients were divided into two groups according to eGFR: 15–49 mL/min/1.73 m² and ≥50 mL/min/1.73 m². The groups were compared with respect to demographic characteristics, comorbidities, and treatment patterns. Statistical analyses included the Mann–Whitney U test, the chi-square test and multivariable logistic regression analysis. Results: A total of 3203 patients with AF were included, of whom 1153 had eGFR < 50 mL/min/1.73 m². Compared with patients with eGFR ≥ 50 mL/min/1.73 m², those with lower eGFR were significantly older, more often female, and had a higher burden of comorbidities, including arterial hypertension, heart failure, coronary artery disease, and diabetes mellitus. Direct oral anticoagulants were the predominant anticoagulant therapy, irrespective of renal function. Conclusions: Patients with AF and moderate-to-severe CKD present a distinct clinical profile characterized by advanced age and a higher burden of comorbidities. These findings improve the understanding of the clinical profile of patients with AF and moderate-to-severe CKD and may support risk assessment and clinical decision-making. Full article

Background: Transcatheter aortic valve implantation (TAVI) has become an established therapy for severe aortic stenosis and is increasingly performed in younger and lower-risk patients. Coronary access following TAVI may be technically challenging, particularly with long stent supra-annular self-expandable platforms. We aimed to evaluate the procedural characteristics and clinical outcomes of percutaneous coronary intervention (PCI) after TAVI, comparing patients treated with balloon-expandable valves (BEVs) and self-expandable valves (SEVs) at our center. Methods: In this retrospective single-center study, we included consecutive patients who underwent TAVI with BEVs (Edwards Sapien 3 and sapien 3 Ultra platforms) or SEVs (Medtronic Evolut R, Evolut Pro, Evolut Pro+, Evolut Fx and Abbot Navitor platforms) between 2016 and 2024 and subsequently underwent PCI in the index procedure post valve implantation, or returned for PCI due to chronic coronary syndrome (CCS) or acute coronary syndrome (ACS). Simple diagnostic coronary angiography without PCI was not considered in this analysis. The primary outcome was PCI success and procedural characteristics according to valve platform. A prespecified subgroup analysis was performed according to clinical presentation (CCS vs. ACS). Clinical outcomes were analysed in the whole population. Results: A total of 73 patients underwent PCI after TAVI, including 34 with balloon-expandable (Sapien) and 39 with self-expandable (33 Evolut and 6 Navitor) valves. The mean age was 81 ± 6 years, and 64% were male. The median time from TAVI to PCI was 470 days. LAD PCI was numerically more frequent in the BEV group (59% vs. 41%, p = 0.129), whereas LCX PCI was more common in the SEV group (54% vs. 29%, p = 0.035). PCI success was high overall (95%) and did not differ significantly between BEV and SEV platforms (97% vs. 92%, p = 0.374). Final TIMI 3 flow was achieved in 99% of cases. Intraprocedural coronary complications were infrequent (5%) and did not differ significantly between platforms. At 1 year, overall mortality was 8%, with no significant difference between BEV and SEV platforms. In a subgroup analysis, PCI success was high in CCS and ACS presentations (97% vs. 91%, p = 0.218), with a trend of higher 1-year mortality in ACS compared with CCS (15% vs. 3%, p = 0.061). Conclusions: PCI after TAVI is highly feasible, with excellent angiographic success and low complication rates. Procedural and clinical outcomes were comparable between BEV and SEV platforms. Full article

Background: Transradial access has become a preferred strategy for chronic total occlusion (CTO) percutaneous coronary intervention (PCI) because of lower access site complication rates and increasing feasibility for complex CTO techniques using large-bore slender or sheathless systems. However, long-term outcomes after successful transradial CTO recanalization and their predictors remain incompletely defined. We aimed to identify long-term clinical and procedural predictors of major adverse cerebrovascular and cardiac events (MACCEs) after successful transradial CTO PCI. Methods: We performed a prospective dual-center cohort study including 227 consecutive patients who underwent successful transradial CTO PCI at two high-volume catheterization laboratories with dedicated CTO programs. A total of 405 CTO PCI procedures were screened; all femoral access cases were excluded and only transradial cases were eligible. Baseline clinical characteristics, left ventricular ejection fraction (LVEF), lesion complexity including J-CTO score, coronary disease extent, and procedural variables were prospectively collected and/or verified from institutional databases. The primary endpoint was MACCEs, defined as a composite of all-cause death, non-fatal myocardial infarction, target vessel revascularization, and stroke/transient ischemic attack. Event rates were estimated using Kaplan–Meier methods. Predictors were explored using Cox proportional hazards regression with clinically relevant covariates and procedural characteristics entered into multivariable models. Results: Among 227 patients with successful transradial CTO recanalization and complete 5-year follow-up among survivors, cumulative MACCEs and all-cause mortality were 44.0% and 21.5%, respectively. In multivariable Cox analysis, prior myocardial infarction, right coronary artery target vessel, and a higher number of implanted stents were independently associated with increased MACCE risk, whereas previous PCI and preserved LVEF (≥40%) were associated with lower MACCE risk. For all-cause mortality, preserved LVEF was independently protective, while right coronary artery target vessel intervention was associated with increased mortality risk; severe chronic kidney disease showed a significant univariable association and remained a strong signal after multivariable adjustment. Conclusions: After successful transradial CTO PCI, long-term MACCEs appear to be driven primarily by baseline comorbidity and coronary disease burden. No deaths were related to access site bleeding, and vascular access was not associated with fatal complications. These findings contribute to personalized cardiovascular medicine by identifying readily available clinical, anatomical, and procedural factors that enable individualized long-term risk stratification following successful transradial CTO recanalization. Integrating these predictors into post-procedural assessment may support tailored secondary prevention, follow-up strategies, and patient management according to individual risk profiles. Full article

Ischemia with non-obstructive coronary arteries (INOCA) and coronary microvascular dysfunction (CMD) are increasingly recognized causes of angina, reduced quality of life, and elevated cardiovascular risk, yet mechanistic heterogeneity complicates diagnosis and treatment. This narrative review synthesizes evidence from clinical guidelines, consensus documents, landmark trials, cohorts, mechanistic studies, and high-quality reviews identified through structured, non-exhaustive searches of PubMed/MEDLINE, Google Scholar, and major cardiovascular society documents. Current evidence indicates that endothelial mitochondria function primarily as signaling organelles, regulating reactive oxygen species, nitric oxide bioavailability, endothelium-dependent hyperpolarization, calcium signaling, inflammatory activation, mitophagy, and endothelial survival. Cardiometabolic risk factors, aging, chronic kidney disease, and postmenopausal hormonal changes may converge on mitochondrial quality-control and redox pathways, contributing to CMD susceptibility and sex-specific vulnerability. However, direct human evidence linking endothelial mitochondrial dysfunction causally to CMD defined by invasive coronary function testing remains limited. Coronary physiological testing and acetylcholine provocation are validated tools for CMD endotyping, whereas mitochondrial biomarkers remain investigational. Endotype-guided diagnosis and management remain central, while mitochondria-targeted strategies require prospective CMD-specific validation. Full article

Background: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is an extremely rare and potentially fatal congenital heart defect, accounting for approximately 0.003% of all coronary artery anomalies. Methods: A literature search was performed in the PubMed and eLibrary databases using the keywords “ARCAPA” and “anomalous origin of the right coronary artery from the pulmonary artery” for the period from 2005 to 2025. A total of 158 papers were screened, from which 57 articles reporting 59 clinical cases in adult patients were selected. Results: The median age was 55 years [18–80]. Males accounted for 54.2% (32/59). ARCAPA was an incidental finding during evaluation for another condition in 35.9% (21/59) of cases. Clinical presentation: retrosternal pain—47.5% (28/59), dyspnea—44.1% (26/59), and reduced exercise tolerance—35.9% (21/59). A completely asymptomatic course was observed in 22.0% (13/59) of patients. In rare cases, the initial presenting manifestations included atrial fibrillation, cardiac arrest during a marathon, and worsening dyspnea during pregnancy. The most commonly used diagnostic modalities were computed tomography angiography—in 67.8% (40/59) of cases—and coronary angiography—in 49.2% (29/59) of cases. Cardiac catheterization confirmed the diagnosis in only 10.2% (6/59) of patients. Surgical correction was performed in 54.2% (32/59) of patients; the most frequently used technique was reimplantation of the right coronary artery into the ascending aorta—in 42.4% (25/59) of cases. One long-term complication was recorded—right coronary artery thrombosis 17 years after surgery—and one case of sudden cardiac death occurred in an unoperated patient. Conservative management was chosen in 40.7% (24/59) of patients, mainly due to an asymptomatic course, high surgical risk, or patient refusal. Conclusions: ARCAPA is a rare anomaly for which surgical treatment appears to be the preferred approach in symptomatic patients or those with documented ischemia, while conservative management may be acceptable in selected asymptomatic patients. Conservative management is acceptable in truly asymptomatic patients, but regular follow-up is recommended. Full article

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) is common and presents important diagnostic and therapeutic challenges, particularly in patients being considered for transcatheter aortic valve replacement. Accurate assessment of coronary lesion significance in this setting is difficult because severe AS alters coronary haemodynamics, myocardial oxygen demand, microvascular function, and the balance between resting and hyperaemic flow. These changes may influence the interpretation of conventional physiological indices and complicate decisions regarding revascularisation. This narrative review summarises the pathophysiological interaction between severe AS and CAD and examines the contemporary evidence supporting invasive and non-invasive approaches to coronary assessment. We review the limitations and potential utility of fractional flow reserve, and non-hyperaemic pressure ratios, highlighting the frequent discordance observed between indices and the uncertainty regarding optimal thresholds in severe AS. Importantly, identification of physiologically significant lesions should be distinguished from evidence that revascularisation of these lesions improves clinical outcomes, as prospective outcome data remain limited. While recent trials support physiology-guided revascularisation in patients undergoing TAVR, outcome data remain linked primarily to conventional FFR thresholds rather than proposed AS-specific cutoffs. We also discuss emerging non-wire-based approaches, including quantitative flow ratio and computed tomography-derived fractional flow reserve, which may offer complementary value in selected patients. In addition, we examine the practical implications of coronary physiology for clinical decision-making before and after valve intervention, including the timing of percutaneous coronary intervention and the need to distinguish lesion-level diagnostic performance from evidence of clinical benefit. Current data suggest that no single modality is universally applicable and that assessment should be individualised according to lesion characteristics, clinical context, and procedural strategy. Proposed severe AS-specific thresholds for FFR and NHPR are derived from small predominantly observational studies, have not been prospectively validated against clinical outcomes and should be hypothesis-generating. A hybrid approach integrating angiographic, physiological, and computed tomography-based information may be most useful. Further prospective studies are needed to define optimal thresholds, validate management algorithms, and clarify whether physiology-guided strategies improve outcomes in severe AS. Full article