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Intracoronary physiology is routinely used in setting the indication for percutaneous coronary intervention (PCI) but seldom in assessing procedural results. This attitude is increasingly challenged by accumulated evidence demonstrating the value of post-PCI functional assessment in predicting long-term patient outcomes. Besides fractional flow reserve, a number of new indexes recently incorporated to clinical practice, including nonhyperemic pressure and functional angiographic indexes, provide new opportunities for the physiological assessment of PCI results. Largely, the benefit of these tools is derived from longitudinal analysis of the treated vessel, which allows precise identification of the vessel segment accounting for a suboptimal functional result and enabling operators to perform accurate PCI optimization. In this document the authors review available evidence supporting why physiological assessment should be extended to immediate post-PCI with the aim of improving patient outcomes. A step-by-step guide on how available physiological tools can be used for such purpose is provided.

Objectives This study sought to evaluate the prognostic value of post–percutaneous coronary intervention (PCI) distal coronary pressure to aortic pressure ratio (Pd/Pa) in predicting long-term clinical outcomes and to determine whether Pd/Pa combined with fractional flow reserve (FFR) post-intervention provides additional prognostic information superior to either marker alone. Background Post-PCI FFR has been shown to be a predictor of long-term outcomes in numerous studies. The role of post-PCI resting Pd/Pa has not been previously studied in this setting. Methods Consecutive patients undergoing PCI who had pre- and post-PCI Pd/Pa and FFR were followed for major adverse cardiovascular events (MACE) including death, myocardial infarction, and target vessel revascularization. Results A total of 574 patients were followed for 30 months (25th to 75th percentile 18 to 46 months). Using receiver-operating characteristic curve analysis post-stenting FFR cutoff of ≤0.86 had the best predictive accuracy of MACE (17% vs. 23%; log-rank p = 0.02), whereas post-stenting Pd/Pa ≤0.96 was the best predictor of MACE (15% vs. 24%; log rank p = 0.0006). There was a significant interaction between post-PCI Pd/Pa and FFR on MACE risk such that patients with Pd/Pa ≤0.96 and FFR ≤0.86 had the highest event rate (25%), whereas those with Pd/Pa >0.96 and FFR >0.86 had the lowest event rate (15%), which was not different from patients with Pd/Pa >0.96 and FFR ≤0.86 (17%). In a fully adjusted Cox regression analysis, Pd/Pa was an independent predictor of MACE (hazard ratio: 2.07; 95% confidence interval: 1.3 to 3.3; p = 0.002). Conclusions Post-PCI resting Pd/Pa is a powerful prognostic tool for MACE prediction. It adds complementary and incremental risk stratification over established factors including post-PCI FFR.

The management of atherosclerotic renal artery stenosis can be challenging. Whether race has an impact on outcomes after revascularization is unknown. We report a single-center experience with patients with high-grade stenosis Patients with high-grade renal artery stenosis (a reduction in lumen

This study sought to evaluate the impact of fractional flow reserve (FFR) after percutaneous coronary intervention (PCI) on subsequent in-lab interventional management vessels that had undergone pre-PCI FFR and its prognostic value in predicting long-term (1 year) outcomes.Post-PCI FFR has been shown to be a predictor of intermediate-term (6 months) adverse events. However, its impact on immediate post procedure clinical decision making and long-term outcomes is not known.Consecutive patients undergoing PCI who had pre- and post-PCI FFR evaluations were followed for major adverse cardiovascular events (MACE).In the study 574 patients (664 lesions) were followed for 31 ± 16 months. PCI led to significant improvement in FFR from 0.65 ± 0.14 to 0.87 ± 0.08 (p 0.0001). Despite satisfactory angiographic appearance, 143 lesions (21%) demonstrated post-PCI FFR in the ischemic range (FFR ≤0.81). After subsequent interventions, FFR in this subgroup increased from 0.78 ± 0.08 to 0.87 ± 0.06 (p 0.0001). Final FFR cutoff of ≤0.86 had the best predictive accuracy for MACE and ≤0.85 for TVR. Patients who achieved final FFR0.86 had significantly lower MACE compared to the final FFR ≤0.86 group (17% vs. 23%; log-rank p = 0.02). Final FFR ≤0.86 had incremental prognostic value over clinical and angiographic variables for MACE prediction.Post-PCI FFR reclassified 20% of angiographically satisfactory lesions, which required further intervention thereby providing an opportunity for complete functional optimization at the time of the index procedure. This is particularly important as FFR post-PCI FFR was a powerful independent predictor of long-term outcomes.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) placement is often indicated in severe cardiogenic shock and those undergoing prolonged resuscitation for cardiac arrest. However, the initiation of VA-ECMO may be associated with severe left ventricular (LV) afterload with all of its

To evaluate the safety and efficacy of percutaneous mitral valve repair for the management of functional mitral insufficiency. Severe functional mitral regurgitation (FMR) is present in 25–30% of patients with heart failure and is an independent predictor of mortality and hospitalizations in

When oncological and coronary artery disease (CAD) coincide, complications occur. Percutaneous coronary intervention (PCI) with subsequent dual antiplatelet therapy often delays cancer therapy. Recent data favor fractional flow reserve (FFR) over quantitative coronary angiography (QCA) for stable

Objectives This study sought to evaluate the safety and efficacy of stent retriever for the management of acute ischemic stroke. Background Stroke is the third leading cause of death and the most common cause of disability in the United States. Early reperfusion has been associated with favorable outcomes. Stent retrievers are novel endovascular devices that provide vessel recanalization via thrombus retrieval mechanical thrombectomy. Methods The authors performed a literature search using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from May 2005 to May 2015. Randomized controlled trails (RCTs) comparing endovascular therapy (ET) with the use of retrievable stents against standard therapy (ST) for the management of acute stroke were included. Results Five RCTs (the MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT studies) with 634 patients in the ET group and 653 patients in the ST group met inclusion criteria. The frequency of a low 90-day modified Rankin Score (0 to 2) in the intervention group was 42.6% compared with 26.1% in the control group (odds ratio: 2.43; 95% confidence interval [CI]: 1.9 to 3.09; p Conclusions On the basis of the results of this meta-analysis of RCTs, ET with stent retrievers appears as a safe and effective therapeutic option for acute ischemic stroke due to large vessel occlusion.

Objectives: The aim of this study was to assess the impact of length and hydrophilic coating of the introducer sheath on radial artery spasm, radial artery occlusion, and local vascular complicatio...

We read with great interest the article by Li et al. [(1)][1] relating post-percutaneous coronary intervention (post-PCI) fractional flow reserve (FFR) to long-term prognosis. We agree with their primary finding that post-PCI FFR predicts long-term major cardiovascular events. The authors stated

Recent randomized controlled trials (RCTs) have questioned the clinical efficacy and even safety of routine aspiration thrombectomy (AT) during primary PCI. A systematic synthesis of this randomized data is hence very timely to address this clinical equipoise. We performed a meta-analysis of the

Thrombotic lesions of saphenous venous grafts (SVGs) are frequently encountered, and interventions may be technically fraught with embolic complications. The following 2 cases suggest the potential role in selected cases of novel oral anticoagulants (NOACs) in the treatment of SVG thrombosis to

ObjectivesThis study sought to evaluate the safety and efficacy of stent retriever for the management of acute ischemic stroke.BackgroundStroke is the third leading cause of death and the most common cause of disability in the United States. Early reperfusion has been associated with favorable outcomes. Stent retrievers are novel endovascular devices that provide vessel recanalization via thrombus retrieval mechanical thrombectomy.MethodsThe authors performed a literature search using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from May 2005 to May 2015. Randomized controlled trails (RCTs) comparing endovascular therapy (ET) with the use of retrievable stents against standard therapy (ST) for the management of acute stroke were included.ResultsFive RCTs (the MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT studies) with 634 patients in the ET group and 653 patients in the ST group met inclusion criteria. The frequency of a low 90-day modified Rankin Score (0 to 2) in the intervention group was 42.6% compared with 26.1% in the control group (odds ratio: 2.43; 95% confidence interval [CI]: 1.9 to 3.09; p < 0.0001). The frequency of intracranial bleeding was 4.2% in the ET group compared with 4.3% in the ST group (risk ratio: 1.08; 95% CI: 0.64 to 1.82; p = 0.78). 90-day mortality was 15.1% in the ET group compared with 18.7% in the ST group (risk ratio: 0.81; 95% CI: 0.58 to 1.12; p = 0.19). There was no evidence of significant heterogeneity or publication bias for any of the endpoints.ConclusionsOn the basis of the results of this meta-analysis of RCTs, ET with stent retrievers appears as a safe and effective therapeutic option for acute ischemic stroke due to large vessel occlusion.

ObjectivesThe aim of this study was to assess the impact of length and hydrophilic coating of the introducer sheath on radial artery spasm, radial artery occlusion, and local vascular complications in patients undergoing transradial coronary procedures.BackgroundRadial artery spasm is common during transradial procedures and the most common cause for procedural failure.MethodsWe randomly assigned, in a factorial design, 790 patients scheduled for a transradial coronary procedure to long (23-cm) or short (13-cm) and hydrophilic-coated or uncoated introducer sheaths. The primary outcome measure was clinical evidence of radial artery spasm, and secondary outcome measures were patient discomfort and local vascular complications.ResultsProcedural success was achieved in 96% of the cases, and radial artery spasm accounted for 17 of 33 failed cases. There was significantly less radial artery spasm (19.0% vs. 39.9%, odds ratio [OR]: 2.87; 95% confidence interval [CI]: 2.07 to 3.97, p < 0.001) and patient reported discomfort (15.1% vs. 28.5%, OR: 2.27; 95% CI: 1.59 to 3.23, p < 0.001) in patients receiving a hydrophilic-coated sheath. No difference was observed between long and short sheaths. Radial artery occlusion was observed in 9.5% of the patients and was not influenced by sheath length or coating. A local large hematoma or arterial dissection was seen in 2.6% of the patients with no difference in groups allocated at randomization. Younger age, female sex, diabetes, and lower body mass index were identified as independent predictors of radial artery spasm.ConclusionsHydrophilic sheath coating, but not sheath length, reduces the incidence of radial artery spasm during transradial coronary procedures.

Wiisanen et al. ([1][1]) performed a meta-analysis of 23 studies comparing drug-eluting stents (DES) with bare-metal stents for saphenous vein graft lesions, and they demonstrated the superiority of DES in reducing death, myocardial infarction, and target vessel revascularization. Eleven meta