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Percutaneous active mechanical circulatory support (MCS) devices are being increasingly used in the treatment of acute myocardial infarction-related cardiogenic shock (AMICS) despite conflicting evidence regarding their effect on mortality. We aimed to ascertain the effect of early routine active percutaneous MCS versus control treatment on 6-month all-cause mortality in patients with AMICS.

Previous meta-analyses have shown reduced risks of composite adverse events with intravascular imaging-guided percutaneous coronary intervention (PCI) compared with angiography guidance alone. However, these studies have been insufficiently powered to show whether all-cause death or all myocardial infarction are reduced with intravascular imaging guidance, and most previous intravascular imaging studies were done with intravascular ultrasound rather than optical coherence tomography (OCT), a newer imaging modality. We aimed to assess the comparative performance of intravascular imaging-guided PCI and angiography-guided PCI with drug-eluting stents.

IMPORTANCE: Patients with left main coronary artery disease presenting with an acute coronary syndrome (ACS) represent a high-risk and understudied subgroup of patients with atherosclerosis. OBJECTIVE: To assess clinical outcomes after PCI vs CABG in patients with left main disease with vs without ACS. DESIGN, SETTING, AND PARTICIPANTS: Data were pooled from 4 trials comparing PCI with drug-eluting stents vs CABG in patients with left main disease who were considered equally suitable candidates for either strategy (SYNTAX, PRECOMBAT, NOBLE, and EXCEL). Patients were categorized as presenting with or without ACS. Kaplan-Meier event rates through 5 years and Cox model hazard ratios were generated, and interactions were tested. Patients were enrolled in the individual trials from 2004 through 2015. Individual patient data from the trials were pooled and reconciled from 2020 to 2021, and the analyses pertaining to the ACS subgroup were performed from March 2022 through February 2023. MAIN OUTCOMES AND MEASURES: The primary outcome was death through 5 years. Secondary outcomes included cardiovascular death, spontaneous myocardial infarction (MI), procedural MI, stroke, and repeat revascularization. RESULTS: Among 4394 patients (median [IQR] age, 66 [59-73] years; 3371 [76.7%] male and 1022 [23.3%] female) randomized to receive PCI or CABG, 1466 (33%) had ACS. Patients with ACS were more likely to have diabetes, prior MI, left ventricular ejection fraction less than 50%, and higher SYNTAX scores. At 30 days, patients with ACS had higher all-cause death (hazard ratio [HR], 3.40; 95% CI, 1.81-6.37; P < .001) and cardiovascular death (HR, 3.21; 95% CI, 1.69-6.08; P < .001) compared with those without ACS. Patients with ACS also had higher rates of spontaneous MI (HR, 1.70; 95% CI, 1.25-2.31; P < .001) through 5 years. The rates of all-cause mortality through 5 years with PCI vs CABG were 10.9% vs 11.5% (HR, 0.93; 95% CI, 0.68-1.27) in patients with ACS and 11.3% vs 9.6% (HR, 1.19; 95% CI, 0.95-1.50) in patients without ACS (P = .22 for interaction). The risk of early stroke was lower with PCI vs CABG (ACS: HR, 0.39; 95% CI, 0.12-1.25; no ACS: HR, 0.35; 95% CI, 0.16-0.75), whereas the 5-year risks of spontaneous MI and repeat revascularization were higher with PCI vs CABG (spontaneous MI: ACS: HR, 1.74; 95% CI, 1.09-2.77; no ACS: HR, 3.03; 95% CI, 1.94-4.72; repeat revascularization: ACS: HR, 1.57; 95% CI, 1.19-2.09; no ACS: HR, 1.90; 95% CI, 1.54-2.33), regardless of ACS status. CONCLUSION AND RELEVANCE: Among largely stable patients undergoing left main revascularization and with predominantly low to intermediate coronary anatomical complexity, those with ACS had higher rates of early death. Nonetheless, rates of all-cause mortality through 5 years were similar with PCI vs CABG in this high-risk subgroup. The relative advantages and disadvantages of PCI vs CABG in terms of early stroke and long-term spontaneous MI and repeat revascularization were consistent regardless of ACS status. TRIAL REGISTRATION: ClinicalTrials.gov Identifiers: NCT00114972, NCT00422968, NCT01496651, NCT01205776

Percutaneous coronary intervention (PCI) is increasingly used in revascularisation of patients with left main coronary artery disease in place of the standard treatment, coronary artery bypass grafting (CABG). The NOBLE trial aimed to evaluate whether PCI was non-inferior to CABG in the treatment of left main coronary artery disease and reported outcomes after a median follow-up of 3·1 years. We now report updated 5-year outcomes of the trial.

The optimal revascularisation strategy for patients with left main coronary artery disease is uncertain. We therefore aimed to evaluate long-term outcomes for patients treated with percutaneous coronary intervention (PCI) with drug-eluting stents versus coronary artery bypass grafting (CABG).

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events.These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Numerous randomised trials have compared coronary artery bypass grafting (CABG) with percutaneous coronary intervention (PCI) for patients with coronary artery disease. However, no studies have been powered to detect a difference in mortality between the revascularisation strategies.

Background: The 2015 European Society of Cardiology non-ST-elevation myocardial infarction (NSTEMI) guidelines recommend angiography within 24 h in high-risk patients with NSTEMI. An organized STEMI-like approach with pre-hospital or immediate in-hospital triage for acute coronary angiography (CAG) may be of therapeutic benefit but it remains unknown whether the patients can be properly diagnosed in the pre-hospital setting. We aim to evaluate whether it is feasible to diagnose patients with NSTEMI in the pre-hospital phase or immediately upon admission.Methods and results: We randomized 250 patients to either acute or subacute CAG (i.e. <72 h of admission). Pre-hospital electrocardiogram acquisition and point-of-care troponin-T measurement ensured that 148 (59%) patients were identified already in the ambulance, whereas the remaining 102 (41%) patients were identified immediately after hospital admission. An acute coronary syndrome was verified in 215 (86%) and NSTEMI in 159 (64%) patients. The CAG rate was significantly higher in the acute CAG group (98% vs. 87%, p<0.001). A culprit lesion was identified in 74% and 64% of the patients underwent coronary revascularization: acute CAG group: 53% percutaneous coronary intervention, 5% hybrid, 7% coronary artery bypass grafting; conventional treatment: 48% percutaneous coronary intervention, 2% hybrid, 14% coronary artery bypass grafting, p=0.32. In patients randomized to acute CAG, time from randomization to CAG was 1.1 h; in patients randomized to subacute CAG it was two days. Time from randomization to initial revascularization was 1.3 h versus 2.4 days, and the median hospital stay was 4.0 days versus 4.5 days. Among patients randomized to subacute CAG, 17% crossed over to acute CAG and 5% developed STEMI before catheterization.Conclusion: Diagnosing NSTEMI patients in the pre-hospital phase or immediately upon hospital admission is feasible. Acute CAG may impact the mode of revascularization and is associated with earlier revascularization and shorter hospital stay. The clinical benefit of acute CAG in NSTEMI patients remains to be clarified.

Coronary artery bypass grafting (CABG) is the standard treatment for revascularisation in patients with left main coronary artery disease, but use of percutaneous coronary intervention (PCI) for this indication is increasing. We aimed to compare PCI and CABG for treatment of left main coronary artery disease.

Despite successful treatment of the culprit artery lesion by primary percutaneous coronary intervention (PCI) with stent implantation, thrombotic embolisation occurs in some cases, which impairs the prognosis of patients with ST-segment elevation myocardial infarction (STEMI). We aimed to assess the clinical outcomes of deferred stent implantation versus standard PCI in patients with STEMI.

Background: The safety of therapeutic hypothermia combined with percutaneous coronary intervention (PCI) after out-of-hospital cardiac arrest has been challenged after reports of high risk of stent thrombosis.Methods: We searched the Western Denmark Heart Registry to identify patients with an acute coronary angiography due to out-of-hospital cardiac arrest performed at our institution between September 2010 and September 2013. We identified 68 unconscious patients, who were resuscitated after out-of-hospital cardiac arrest and underwent acute PCI with stent implantation and immediate therapeutic hypothermia, and followed these for 30 days. Target temperature of 32-34°C was achieved by either an invasive or a non-invasive cooling system.Results: All patients had elevated myocardial biomarkers and 37 patients had ST-segment elevation myocardial infarction. Bare metal stents were implanted in 14 and drug-eluting stents in 54 patients. All patients received antithrombotic treatment with a standard loading dose of 300 mg acetylsalicylic acid and 10,000 units heparin intravenously prior PCI. Clopidogrel or ticagrelor was administered orally through a gastric tube immediately after PCI. During the procedure abciximab or bivalirudin was administered in 44 patients. Electrocardiographic and clinical signs of stent thrombosis were found in one patient.Conclusions: We observed one stent thrombosis in this cohort of 68 consecutive patients with out-of-hospital cardiac arrest who were treated with PCI and therapeutic hypothermia. This suggests that PCI with stent implantation can be performed with acceptable safety in these patients.

Aortic valve replacement is the recommended therapy for patients with severe aortic stenosis who have symptoms or decreased left ventricular (LV) function. Transcatheter aortic valve implantation (TAVI) is a treatment alternative in surgically high-risk or inoperable patients with severe aortic stenosis. The objective of this study was to analyze LV function assessed by global LV longitudinal systolic strain (GLS) and relation to prognosis in patients with severe aortic stenosis treated with femoral or apical TAVI.

In patients with pulmonary arterial hypertension (PAH), chest pain is most likely due to right ventricular demand ischemia. We report a patient with idiopathic PAH who developed severe angina due to extrinsic compression of the left main coronary artery (LMCA) from a dilated pulmonary artery trunk. The diagnosis was verified by electrocardiogram after exercise, coronary angiography including intravascular ultrasound, and cardiac multidetector computed tomography (MDCT). The origin of the LMCA was high in the left coronary sinus, facilitating extrinsic compression. The patient was successfully treated by percutaneous coronary intervention with stent implantation in the LMCA. Extrinsic compression of the LMCA is a severe and potentially fatal complication that should be considered in all patients with PAH and angina. MDCT is the method of choice for first-line diagnosis.

In patients with pulmonary arterial hypertension (PAH), chest pain is most likely due to right ventricular demand ischemia. We report a patient with idiopathic PAH who developed severe angina due to extrinsic compression of the left main coronary artery (LMCA) from a dilated pulmonary artery trunk. The diagnosis was verified by electrocardiogram after exercise, coronary angiography including intravascular ultrasound, and cardiac multidetector computed tomography (MDCT). The origin of the LMCA was high in the left coronary sinus, facilitating extrinsic compression. The patient was successfully treated by percutaneous coronary intervention with stent implantation in the LMCA. Extrinsic compression of the LMCA is a severe and potentially fatal complication that should be considered in all patients with PAH and angina. MDCT is the method of choice for first-line diagnosis.

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