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Background: The BIONICS (BioNIR Ridaforolimus-Eluting Coronary Stent System in Coronary Stenosis) and the NIREUS (BioNIR Ridaforolimus Eluting Coronary Stent System [BioNIR] European Angiography Study) randomized clinical trials showed noninferiority of the ridaforolimus-eluting stent (RES) compared with the zotarolimus-eluting stent (ZES) with respect to 1-year target-lesion failure and 6-month angiographic late lumen loss. We aimed to evaluate clinical outcomes between treatment groups over a 5-year follow-up., Methods and Results: Patient-level data from the BIONICS (n=1919) and NIREUS (n=302) were pooled, comparing the outcomes of patients implanted with RES and ZES. The primary end point was the 5-year rate of target-lesion failure. A total of 2221 patients (63.2±10.3 years, 79.7% men) undergoing percutaneous coronary intervention with RES (n=1159) or ZES (n=1062) were included. Most clinical and angiographic characteristics were similar between groups. At 5 years, the primary end point of target-lesion failure was similar between treatment groups (12.2% RES versus 11.3% ZES, P =0.52). Rates of TLR (7.6% RES versus 6.8% ZES, P =0.42) target-vessel-related myocardial infarction (4.8% RES versus 4.9% ZES, P =0.95) and stent thrombosis (0.9% RES versus 0.9% ZES, P =0.87) also did not differ between groups. Target-vessel revascularization and cardiac death were higher among the RES group (12.3% versus 9.5% P =0.037, and 3.6% versus 2.2% P =0.042, respectively). However, after correction for baseline characteristics, there was no significant difference in cardiac death between groups., Conclusions: In a pooled analysis of 2 randomized trials, 5-year clinical outcomes were similar between patients undergoing percutaneous coronary intervention with RES and ZES. These results support the long-term safety and efficacy of RES for the treatment of patients with coronary artery disease.

Background: The evidence for optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) in improving the prognosis of individuals with in-stent restenosis (ISR) is lacking., Methods and Results: This retrospective study enrolled 588 consecutive individuals with drug-eluting stent ISR undergoing PCI from March 2010 to March 2022. Two hundred seven (35.2%) underwent OCT guidance, and 381 (64.8%) underwent angiography guidance. Clinical outcomes were analyzed using survival curves. The primary clinical endpoint was 2-year major adverse cardiovascular events (MACEs), a composite of all-cause death, myocardial infarction, and target-vessel revascularization. Compared with angiography guidance, OCT guidance demonstrated a higher frequency of drug-coated balloon use and adjunctive therapeutic modalities, including predilation, postdilation, nonslip element balloons, and noncompliant balloons ( P <0.05). Following PCI, the OCT-guided group achieved a significantly larger minimum lumen diameter (2.36 versus 2.15 mm, P <0.001) and a lower percentage diameter stenosis (17% versus 20%, P <0.001) than the angiography-guided group. Survival analysis revealed significantly lower 2-year MACEs in the OCT-guided group compared with the angiography-guided group (7% versus 15%, P =0.007), validated in the propensity matching analysis (7% versus 15%, P =0.001). Multiple sensitivity analyses showed that OCT-guided PCI treatment was an independent protective factor for 2-year MACEs in individuals with drug-eluting stent ISR., Conclusions: Compared with angiography guidance, OCT guidance is associated with a lower 2-year MACE risk among individuals with drug-eluting stent ISR. Therefore, OCT should be actively considered for guiding PCI treatment in individuals with drug-eluting stent ISR., Registration: Url: clinicaltrials.gov. Identifier: NCT03809754.

The aspects of extracorporeal cardiopulmonary resuscitation critical for reestablishing an organized rhythm and subsequent functional survival are unclear. This study characterizes the impact of reperfusion with extracorporeal membrane oxygenation (ECMO) and percutaneous coronary interventions (PCI) on achieving an organized rhythm in patients with refractory shockable out-of-hospital cardiac arrest (OHCA)., Methods and Results: Two hundred eighty-nine consecutive patients in refractory shockable OHCA were placed on ECMO followed by coronary angiogram (n=289) and PCI (n=165). Patients were grouped based on the extracorporeal cardiopulmonary resuscitation stage where a sustained organized rhythm was achieved. Survival outcomes were evaluated by using the Cerebral Performance Category. Logistic regression analysis was performed to determine the relationship between Cerebral Performance Category and timing of organized rhythm. Standard advanced cardiac life support before hospital arrival resulted in 148 of 289 (51%) patients attaining an organized rhythm while 87 of 289 (30%) achieved an organized rhythm post ECMO cannulation but before PCI, and 37 of 289 (13%) achieved an organized rhythm following PCI. Obstructive coronary artery disease was observed in 192 of 289 (66%) patients. A total of 144 of 192 (75%) patients with obstructive coronary artery disease converted to an organized rhythm before PCI and 37 of 192 (19%) following PCI. Cerebral Performance Category score 1 or 2 was significantly more likely in patients with cardiac arrest and obstructive coronary artery disease who achieved an organized rhythm before PCI (odds ratio [OR], 3.9 [95% CI, 1.2-12.0], P =0.024)., Conclusions: Most patients undergoing extracorporeal cardiopulmonary resuscitation for refractory OHCA due to shockable rhythms achieved an organized rhythm before PCI independent of coronary artery disease burden. Also, neurologically favorable survival was more prevalent in those attaining an organized rhythm before PCI.

Failure to close the side branches of the internal mammary artery can result in ischemia due to coronary steal through a patent mammary artery side branch after coronary artery bypass grafting. The authors present the case of a 56-year-old man with recurrent angina after 6 month surgical myocardial revascularization underwent coronary angiography that showed patent left branch of the internal mammary artery. After demonstration of inducible ischemia, effective percutaneous treatment was performed using coil embolization, improving blood flow and clinical symptoms., (© 2024 Wiley Periodicals LLC.)

Background: Angiography-derived fractional flow reserve (virtual FFR) has shown excellent diagnostic performance compared with wire-based FFR. However, virtual FFR pullback curves have not been validated yet., Objectives: To validate the accuracy of virtual FFR pullback curves compared to wire-based FFR pullbacks and to assess their clinical utility using patient-reported outcomes., Methods: Pooled analysis of two prospective studies, including patients with hemodynamically significant (FFR ≤ 0.80) coronary artery disease (CAD). Virtual and wire-based FFR pullbacks were compared to assess the accuracy of virtual pullbacks to characterize CAD as focal or diffuse. Pullbacks were analyzed visually and quantitatively using the pullback pressure gradient (PPG). Patients underwent PCI, and the Seattle Angina Questionnaire (SAQ) was administered at 3-month follow-up., Results: A total of 298 patients (300 vessels) with both virtual and wire-based pullbacks who underwent PCI were included in the analysis. The mean age was 61.8 ± 8.8, and 15% were female. The agreement on the visual adjudication of the CAD pattern was fair (Cohen's Kappa: 0.31, 95% confidence interval: 0.18-0.45). The mean PPG were 0.65 ± 0.18 from virtual pullbacks and 0.65 ± 0.13 from wire-based pullbacks (r = 0.68, mean difference 0, limits of agreement -0.27 to 0.28). At follow-up, patients with high virtual PPG (>0.67) had higher SAQ angina frequency scores (i.e., less angina) than those with low virtual PPG (SAQ scores 92.0 ± 14.3 vs. 85.5 ± 23.1, p = 0.022)., Conclusion: Virtual FFR pullback curves showed moderate agreement with wire-based FFR pullbacks. Nonetheless, patients with focal disease based on virtual PPG reported greater improvement in angina after PCI., (© 2024 Wiley Periodicals LLC.)

Background: Coronary artery dissections are caused by a tear in the vessel endothelium, resulting in blood extravasation into the subintimal space, with subsequent intramural hematoma (IMH). One potential technique to deal with this complication is the use of cutting balloons, however, a significant number of cases experienced distal propagation of the hematoma. We describe a novel technique that enhances the possibility of creating intimal tears between the false and true lumen, aiding in hematoma drainage and restoring distal coronary flow., Methods: We conducted a retrospective analysis of seven consecutive patients who underwent percutaneous coronary intervention complicated by flow-limiting intramural hematomas. All patients were treated using the "Cuttering Technique," based on the operators' preference. Procedural success was defined as achieving a distal thrombolysis in myocardial infarction 3 (TIMI 3) flow., Results: In five out of seven patients treated with "Cuttering Technique" we observed a complete restoration of TIMI 3 flow into the dissected segment., Conclusions: Our cases show the effectiveness of the "Cuttering Technique" as a viable approach for managing IMHs. This technique enhances the possibility of creating intimal tears between the false and true lumens, aiding in hematoma drainage and restoring distal coronary flow., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: The role of intra-coronary imaging in patients with stent failure undergoing intravascular lithotripsy (IVL) is unclear. We aimed to assess clinical outcomes in patients undergoing IVL treatment for stent failure stratified according to the use of intra-coronary imaging and lesion complexity., Methods: This is a pre-specified subgroup analysis of patients who were included in the coronary intravascular lithotripsy in patients with stent failure (COIL) registry (international multi-centre study assessing IVL treatment for stent failure in 6 European centres). A complex lesion was defined if IVL treatment was used in the left main, true bifurcation, long lesion, or coupled with athero-ablative therapy. The primary endpoint was the composite of cardiac death, spontaneous myocardial infarction, or target vessel revascularization (TVR) at 12 months., Results: There were 102 patients analyzed, of whom 27 (26%) patients had complex anatomy. The use of intra-coronary imaging following IVL in stent failure was more frequent in patients with complex versus Noncomplex anatomy (56% vs. 31%, p = 0.022). IVL treatment was effective in both groups, however, patients with complex anatomy had worse clinical outcomes (30% vs. 11%, p = 0.02), driven by a higher rate of TVR (26% vs. 8%, p = 0.017). In the complex group, patients who underwent intracoronary imaging post intervention had lower event rate compared to those without imaging (13% vs. 50%, p = 0.038)., Conclusions: In patients undergoing IVL treatment for stent failure with complex coronary anatomy, the use of intra-coronary imaging was associated with fewer adverse events compared to angiography guided intervention., (© 2024 Wiley Periodicals LLC.)

Background: Fractional flow reserve (FFR) has emerged as the invasive gold standard for assessing vessel-specific ischemia. However, FFR measurements are influenced by the hydrostatic effect, which might adversely impact the assessment of ischemia., Aims: This study aimed to investigate the impact of hydrostatic pressure on FFR measurements by correcting for the height and comparing FFR with [ 15 O]H 2 O positron emission tomography (PET)-derived relative flow reserve (RFR)., Methods: The 206 patients were included in this analysis. Patients underwent coronary computed tomography angiography (CCTA), [ 15 O]H 2 O PET, and invasive coronary angiography with routine FFR in every epicardial artery. Height differences between the aortic guiding catheter and distal pressure sensor were quantified on CCTA images. An FFR ≤ 0.80 was considered significant., Results: The study found a reclassification in 7% of the coronary arteries. Notably, 11% of left anterior descending (LAD) arteries were reclassified from hemodynamically significant to nonsignificant. Conversely, 6% of left circumflex (Cx) arteries were reclassified from nonsignificant to significant. After correcting for the hydrostatic pressure effect, the correlation between FFR and PET-derived RFR increased significantly from r = 0.720 to r = 0.786 (p = 0.009). The average magnitude of correction was +0.05 FFR units in the LAD, -0.03 in the Cx, and -0.02 in the right coronary artery., Conclusion: Hydrostatic pressure has a small but clinically relevant influence on FFR measurements obtained with a pressure wire. Correcting for this hydrostatic error significantly enhances the correlation between FFR and PET-derived RFR., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Background: The aim of this study is to describe resources and outcomes of coronary computed tomography angiography plus Stress CT perfusion (CCTA ​+ ​Stress-CTP) and stress cardiovascular magnetic resonance (Stress-CMR) in symptomatic patients with suspected or known CAD., Methods: Six hundred and twenty-four consecutive symptomatic patients with intermediate to high-risk pretest likelihood for CAD or previous history of revascularization referred to our hospital for clinically indicated CCTA ​+ ​Stress-CTP or Stress-CMR were enrolled. Stress-CTP scans were performed in 223 patients while 401 patients performed Stress-CMR. Patient follow-up was performed at 1 year after index test performance. Endpoints were all cardiac events, as a combined endpoint of revascularization, non-fatal MI and death, and hard cardiac events, as combined endpoint of non-fatal MI and death., Results: Twenty-nine percent of patients who underwent CCTA ​+ ​Stress-CTP received revascularization, 7% of subjects assessed with Stress-CMR were treated invasively, and a low number of non-fatal MI and death was observed with both strategies (hard events in 0.4% of patients that had CCTA ​+ ​Stress-CTP as index test, and in 3% of patients evaluated with Stress-CMR). According to the predefined endpoints, CCTA ​+ ​Stress-CTP group showed high rate of all cardiac events and low rate of hard cardiac events, respectively. The cumulative costs were 1970 ​± ​2506 Euro and 733 ​± ​1418 Euro for the CCTA ​+ ​Stress-CTP group and Stress-CMR group, respectively., Conclusions: The use of CCTA ​+ ​Stress-CTP strategy was associated with high referral to revascularization but with a favourable trend in terms of hard cardiac events and diagnostic yield in identifying individuals at lower risk of adverse events despite the presence of CAD., Competing Interests: Declaration of competing interest All authors have nothing to disclose., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: The association of coronary computed tomography angiography (CTA) and left ventricular (LV) myocardium measurements with cancer therapy-related cardiac dysfunction (CTRCD) is limited., Objectives: In this study, the authors sought to evaluate the changes in coronary arteries and LV myocardium in patients with left breast cancer (BC) receiving anthracycline with or without radiotherapy, with the use of coronary CTA., Methods: Participants with left BC receiving anthracycline with or without radiotherapy were prospectively included. All participants underwent coronary CTA before and after treatment, including nonenhanced calcium-scoring scan, computed tomography angiography, and dual-energy late enhancement scan. Computed tomographic fractional flow reserve (CT-FFR), pericoronary adipose tissue (PCAT) CT attenuation, and LV segments' extracellular volume (ECV) before and after treatment were compared. Logistic regression analysis was used to assess the association between baseline coronary CTA parameters and CTRCD., Results: Eighty participants receiving anthracycline and 59 participants receiving anthracycline with radiotherapy were included. CT-FFR decreased and PCAT CT attenuation and LV global and segments' ECV increased after treatment (all P < 0.05). After chemoradiotherapy, CT-FFR was lower and PCAT CT attenuation and LV myocardial ECV were higher than after chemotherapy. Twenty-four participants developed CTRCD. After adjustment by Heart Failure Association-International Cardio-Oncology Society risk in multivariable logistic regression analysis, baseline stenosis of the left anterior descending artery (LAD) (OR: 1.987 [95% CI: 1.322-2.768]; P = 0.021), left circumflex artery (LCX) (OR: 1.895 [95% CI: 1.281-2.802]; P = 0.031), and right coronary artery (RCA) (OR: 1.920 [95% CI: 1.405-2.811]; P = 0.028), and baseline CT-FFR of the LAD (OR: 3.425 [95% CI: 1.621-9.434]; P < 0.001), LCX (OR: 2.058 [95% CI: 1.030-5.076]; P = 0.006), and RCA (OR: 2.469 [95% CI: 1.232-6.944]; P = 0.004) were associated with CTRCD., Conclusions: Multiparameter coronary CTA contributes to comprehensive assessment of the coronary arteries and myocardium in patients with left BC receiving anthracycline with or without radiotherapy. Baseline coronary artery stenosis and CT-FFR might be imaging markers for predicting CTRCD in these patients., Competing Interests: Funding Support and Author Disclosures This study has received funding from the National Natural Science Foundation of China (grant number 82071883), the Chongqing University Cancer Hospital Scientific Research Capacity Improvement Project (grant number 2023nlts004), the Chongqing Natural Science Foundation (grant number cstc2021jcyj-msxmX0398), the 2023 SKY Imaging Research Fund of the Chinese International Medical Exchange Foundation (grant number Z-2014-07-2301), the Natural Science Foundation of Chongqing municipality (grant number CSTB2023NSCQ-MSX0787), the Chongqing Shapingba District 2023 Technology Innovation and Application Development Project (grant number 202388), and the Chongqing medical research project of a combination of science and medicine (grant number 2024MSXM096). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous coronary intervention (PCI) is frequently used for patients with chronic coronary syndrome (CCS). However, the role of PCI beyond symptom relief in CCS remains controversial. The objective of this study was to determine whether PCI is associated with better outcomes, compared with medical therapy (MT) alone., Methods: We conducted a retrospective cohort study. Using the Swedish Coronary Angiography and Angioplasty Registry, we included all patients with CCS undergoing coronary angiography in Sweden between 2010 and 2020. Two groups were formed based on treatment strategy: PCI+MT versus MT alone. One-to-one propensity score (PS) matching was used to address confounding. Outcome was assessed using matched win ratio analysis, a statistical method that ranks the components of the composite by clinical importance. The primary outcome was net adverse clinical event (NACE) within 5 years. In the win ratio analysis, the components of NACE were ranked as follows: (1) all-cause mortality, (2) myocardial infarction (MI), (3) bleeding and (4) urgent revascularisation. Secondary outcomes were the individual components of NACE, major adverse cardiovascular events (MACE) and cardiovascular mortality., Results: After PS matching, two groups of 7220 patients each were formed. The hierarchical outcome analysis of NACE and MACE showed that PCI was associated with improved outcome (matched win ratio: 1.28 (95% CI 1.20 to 1.36, p<0.001) and matched win ratio: 1.38 (95% CI 1.29 to 1.48, p<0.001), respectively). The use of PCI was associated with higher win ratio of MI (matched win ratio: 1.15, 95% CI 1.04 to 1.28, p=0.008), urgent revascularisation (matched win ratio: 1.85, 95% CI 1.69 to 2.03, p<0.001) and cardiovascular mortality (matched win ratio: 1.15, 95% CI 1.00 to 1.34, p=0.044). No difference in win ratio was observed for all-cause mortality or bleeding., Conclusions: In this study, which sought to evaluate the outcomes of patients with CCS using a hierarchical approach, patients selected for revascularisation with PCI experienced better outcome compared with MT alone., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Quantitative flow ratio (QFR)-based virtual percutaneous coronary intervention (PCI) is associated with improved post-PCI physiological results. Murray law-based QFR (μQFR) is a new method for physiological assessment that has higher feasibility and efficiency. The purpose of this study was to investigate the performance of μQFR-guided virtual PCI in improving post-PCI outcomes., Methods: The QUITE RIGHT study (Quantitative Flow Ratio Virtual Stenting and Angiography Guided Percutaneous Coronary Intervention) is a prospective, multicenter, blinded, randomized, controlled superiority study. Eligible patients were randomized 1:1 to either the μQFR-guided virtual PCI group or the angiography-guided PCI group. The primary end point was the proportion of the target vessels with a post-PCI μQFR ≥0.90, accepted as an optimal post-PCI physiological outcome., Results: A total of 622 patients with 666 vessels were enrolled. The optimal physiological outcome was reached more often in the μQFR-guided virtual PCI group (absolute difference, 9.1% [95% CI, 4.53-13.76]; P <0.001). The μQFR-guided virtual PCI group had a better QFR value, a lower contrast agent dose and x-ray dose, and a more appropriate stent length than the angiography-guided group., Conclusions: The QUITE RIGHT study showed that the μQFR-guided virtual PCI strategy is superior to angiography-guided PCI in terms of physiological outcomes. The μQFR-guided virtual PCI strategy is associated with lower contrast and x-ray doses and a more appropriate stent length., Registration: URL: https://www.chictr.org.cn/; Unique identifier: ChiCTR2100045452., Competing Interests: Dr Tu reports research grants and consultancy from Pulse Medical. The other authors report no conflicts.

Coronary CT angiography (CTA) derived fractional flow reserve (FFR CT ) is recommended for physiological assessment in intermediate coronary stenosis for guiding referral to invasive coronary angiography (ICA). In this study, we report real-world data on the feasibility of implementing a CTA/FFR CT test algorithm as a gatekeeper to ICA at referral hospitals. Retrospective all-comer study of patients with new onset stable symptoms and suspected coronary stenosis (30-89%) by CTA. Evaluation of CTA datasets, interpretation of FFR CT analysis, and decisions on downstream testing were performed by skilled CT-cardiologists. CTA was performed in 3974 patients, of whom 381 (10%) were referred directly to ICA, whereas 463 (12%) to non-invasive functional testing: FFR CT 375 (81%) and perfusion imaging 88 (19%). FFR CT analysis was rejected in 8 (2%) due to inadequate CTA image quality. Number of patients deferred from ICA after FFR CT was 267 (71%), while 100 (27%) were referred to ICA. Obstructive coronary artery disease (CAD) was confirmed in 62 (62%) patients and revascularization performed in 53 (53%). Revascularization rates, n (%), were higher in patients undergoing FFR CT -guided versus CTA-guided referral to ICA: 30-69% stenosis, 28 (44%) versus 8 (21%); 70-89% stenosis, 39 (69%) versus 25 (46%), respectively, both p < 0.05. Implementation of FFR CT at referral hospitals was feasible, reduced the number of invasive procedures, and increased the revascularization rate., (© 2024. The Author(s).)

Background: The 1.5 mm Baby J hydrophilic narrow J-tipped wire is a development of the standard 0.035" 3-mm J-tipped peripheral guidewire, designed to improve efficiency of transradial coronary procedures by safely navigating small caliber radial arteries to the aorta. There is currently a lack of evidence comparing the procedural success and safety of different peripheral guidewires used in transradial cardiac procedures. We compared the efficacy and safety of a narrow J-tipped hydrophilic 0.035" wire (intervention, Radifocus Baby J guidewire; TERUMO Co, Tokyo, Japan) versus a standard fixed-core 0.035" J wire (control)., Methods: Investigator-initiated, blinded, Australian, multicenter randomized trial in patients undergoing clinically indicated coronary angiography or percutaneous coronary intervention. Patients were randomized 1:1 to use either the control guidewire or the intervention guidewire. The primary end point (technical success) was defined as gaining aortic root access with the randomized guidewire., Results: In all, 330 patients were randomized between October 2022 and June 2023 (median age was 69 years, 36% were female, and body mass index was 29 kg/m 2 ). The primary end point was achieved more frequently in the intervention group (96% versus 84%; absolute risk reduction 12% [95% CI, 5.7-18.3]; P <0.001). Women assigned to the control wire experienced a higher failure rate compared with men (31% versus 8% in men; P <0.001). Fluoroscopy time was significantly lower in the Baby J group (median, 344 versus 491 seconds; P =0.024). The main mechanisms of failure using the control wire were radial artery spasm (15/26; 57%) and subclavian tortuosity (5/26; 19.2%). There were no differences in overall procedure times, major adverse cardiovascular events, or vascular complications between guidewires., Conclusions: A narrow 1.5 mm J-tipped hydrophilic guidewire resulted in greater technical success and reduced fluoroscopy time compared with the standard 3-mm J-tipped nonhydrophilic guidewire. The guidewire is safe and demonstrated key incremental benefits for the transradial approach, particularly in women., Registration: URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12622001557729., Competing Interests: None.

We present a real-life case of a very young man with multiple risk factors who progressed rapidly from minimally obstructive non-calcified plaque on computed tomography angiography (CCTA) to severe three-vessel coronary disease presenting with STEMI. It questions the reliability of zero coronary calcium in high-risk subgroups like familial hypercholesterolemia, high Lp(a), and the young. While CCTA can accurately visualize non-calcified plaque, its interpretation requires expertise and clinical judgment should consider both imaging and clinical risk factors for management. Advanced plaque quantification, peri-coronary (PCAT), and epicardial (EAT) adipose tissue could help better-stratified patients but the evidence-based clinical application remains unknown., (© 2024. The Author(s).)

Patients with acute coronary artery disease (CAD) exhibit reduced global and regional strain and strain rate (S/SR). However, knowledge about segmental S/SR in stable CAD patients is still limited. This study aimed to investigate whether resting segmental S/SR measurements differ in patients with chronic chest pain who have normal coronary arteries or stenotic coronary arteries, and to compare these measurements to those in patients with revascularized myocardial infarction (MI). We prospectively enrolled 510 patients with chronic chest pain referred for coronary computed tomography angiography (CCTA) and 102 patients revascularized after MI. All participants underwent transthoracic echocardiography featuring S/SR analysis. In addition to the patients with MI, patients with suspected CAD based on CCTA findings subsequently underwent invasive coronary angiography (CAG). We assessed global longitudinal strain (GLS) and averaged segmental peak longitudinal strain during systole (PLS), peak systolic strain rate (SRs), peak early diastolic strain rate (SRe), and post systolic shortening (PSS). We also determined functionally reduced segment percentages using differing S/SR cut-off values. There were significant disparities in all average segmental S/SR metrics between the No-CAD and MI groups. SRe was the only S/SR metric that differed significantly between the No-CAD and PCI groups. Differences in SRe, PLS and GLS measurements were observed between the No-CAD and CABG groups. The proportion of diminished segmental S/SR mirrored these findings. For the percentage of pathological segments with varying cut-off values, segmental SRe below 1.5 s - 1 displayed the most marked difference among the four groups (p < 0.001). Revascularized MI patients or those referred to CABG present with diminished segmental S/SR values. However, among patients with chronic chest pain, only segmental SRe discerns subtle disparities between the No-CAD and the PCI group. The diagnostic accuracy of SRe warrants further exploration in subsequent studies., (© 2024. The Author(s).)

Intravascular ultrasonography (IVUS) and optical coherence tomography (OCT) guided percutaneous coronary interventions (PCI) are alternative techniques to angiography-guided (ANG-g) PCI in patients with coronary artery disease (CAD), especially for optimal stent deployment in coronary arteries. We conducted a network meta-analysis including studies comparing those three techniques. We searched databases for studies that compared IVUS, OCT, and ANG-g PCI in patients with CAD. Overall, 52 studies with 231,137 patients were included in this meta-analysis. ANG-g PCI had higher major adverse cardiovascular events (MACEs), all-cause death, cardiac death, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis (ST) than IVUS-guided PCI. Of note, both OCT-guided and IVUS-guided PCI had similar outcomes. The frequency of MACEs, cardiac death, and MI were higher in ANG-g PCI than in OCT-guided PCI. The highest benefit was established with OCT for MACEs (P-score=.973), MI (P-score=.823), and cardiac death (P-score=.921) and with IVUS for all-cause death (P-score=.792), TLR (P -score=.865), and ST (P-score=.930). This network meta-analysis indicated that using OCT or IVUS for optimal stent implantation provides better outcomes in comparison with ANG-g in patients with CAD undergoing PCI., Competing Interests: Declaration of InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Despite the detailed imaging information provided by optical coherence tomography (OCT) during percutaneous coronary intervention (PCI), clinical benefits of this imaging technique in this setting remain uncertain. The aim of the OCCUPI trial was to compare the clinical benefits of OCT-guided versus angiography-guided PCI for complex lesions, assessed as the rate of major adverse cardiac events at 1 year., Methods: This investigator-initiated, multicentre, randomised, open-label, superiority trial conducted at 20 hospitals in South Korea enrolled patients aged 19-85 years for whom PCI with drug-eluting stents was clinically indicated. After diagnostic angiography, clinical and angiographic findings were assessed to identify patients who met the criterion of having one or more complex lesions. Patients were randomly assigned 1:1 to receive PCI with OCT guidance (OCT-guidance group) or angiography guidance without OCT (angiography-guidance group). Web-response permuted-block randomisation (mixed blocks of four or six) was used at each participating site to allocate patients. The allocation sequence was computer-generated by an external programmer who was not involved in the rest of the trial. Outcome assessors were masked to group assignment. Patients, follow-up health-care providers, and data analysers were not masked. PCI was done according to conventional standard methods with everolimus-eluting stents. The primary endpoint was major adverse cardiac events (a composite of cardiac death, myocardial infarction, stent thrombosis, or ischaemia-driven target-vessel revascularisation), 1 year after PCI. The primary analysis was done in the intention-to-treat population. The margin used to establish superiority was 1·0 as a hazard ratio. This trial is registered with ClinicalTrials.gov (NCT03625908) and is completed., Findings: Between Jan 9, 2019, and Sept 22, 2022, 1604 patients requiring PCI with drug-eluting stents for complex lesions were randomly assigned to receive either OCT-guided PCI (n=803) or angiography-guided PCI (n=801). 1290 (80%) of 1604 patients were male and 314 (20%) were female. The median age of patients at randomisation was 64 years (IQR 57-70). 1588 (99%) patients completed 1-year follow-up. The primary endpoint occurred in 37 (5%) of 803 patients in the OCT-guided PCI group and 59 (7%) of 801 patients in the angiography-guided PCI group (absolute difference -2·8% [95% CI -5·1 to -0·4]; hazard ratio 0·62 [95% CI 0·41 to 0·93]; p=0·023). Rates of stroke, bleeding events, and contrast-induced nephropathy were not significantly different across the two groups., Interpretation: Among patients who required drug-eluting stent implantation for complex lesions, OCT guidance resulted in a lower incidence of major adverse cardiac events at 1 year compared with angiography guidance. These findings indicate the existence of a therapeutic benefit of OCT as an intravascular imaging technique for PCI guidance in patients with complex coronary lesions., Funding: Abbott Vascular and Cardiovascular Research Center., Translation: For the Korean translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests S-JH reports speaker fees from AstraZeneca, Amgen, ChongKunDang, Hanmi, and Viatris; and participation on the data safety monitoring board of the IVUS-DCB trial. S-JL reports research grants and speaker fees from Boston Scientific, Medtronic, ChongKunDang, and Sam Jin Pharmaceutical. JHH reports consulting and speaker fees from Abbott Vascular. J-WL reports consulting fees from Genoss; speaker fees from Yuhan, Boryoung, Sam Jin Pharmaceutical, ChongKunDang, Korea United Pharm, HK inno.N, Novartis, Boehringer Ingelheim, AstraZeneca, Medtronic, Abbott Vascular, Amgen, Sanofi, Boston Scientific, Daiichi-Sankyo, Daewoong Pharmaceutical, Biosensors, Dong-A ST, and JW Pharmaceutical; and participation on the data safety monitoring board of the Rescue-SHOCK trial. J-SK reports grants from Sam Jin Pharmaceutical, Yuhan, Daiichi-Sankyo, Biosensors, and Qualitech Korea and proctoring fees from Abbott Vascular. Y-GK reports research grants from Medtronic, Korea United Pharm, Cook Medical, Boston Scientific, Otsuka Korea, Dong-A ST, Sam Jin Pharmaceutical, Cordis, HK inno.N, and GC Biopharma. M-KH reports research grants, paid to their institution, from Sam Jin Pharmaceutical and ChongKunDang and honoraria for lectures from Medtronic and Edwards Lifesciences. YJ reports research grants, paid to their institution, from Abbott Vascular. B-KK reports research grants and speaker or consulting fees from Abbott Vascular, Yuhan, Sam Jin Pharmaceutical, ChongKunDang, Medtronic, Boston Scientific, Biotronik, Genoss, CGBIO, MicroPort, Daewoong Pharmaceutical, Amgen, Bayer Korea, DIO Medical, Hanmi, AstraZeneca, and Novartis. All other authors declare no competing interests., (Copyright © 2024 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)

Background: Percutaneous coronary intervention (PCI) has become one of the most commonly performed interventional life-saving procedures worldwide. Intravascular Imaging (intravascular ultrasound (IVUS) and optical coherence tomography (OCT)) have initially evolved to guide PCI compared with angiography. However, this technology is not universally employed in all PCI procedures, and there is ongoing controversy regarding its additional benefits to patient outcomes. We aim to estimate the efficacy and safety of imaging modalities during PCI, allowing pre-, per, and post-intervention assessment of coronary vascularization., Methods: A systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs), which were retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through September 2023. We used R, version 4.2.0. Effect sizes will be presented as odds ratios with accompanying 95% credible intervals., Prospero Id: CRD42024507821., Results: Our study, encompassing 36 RCTs with a total of 17,572 patients, revelead that compared to conventional angiography, IVUS significantly reduced the risk of major adverse cardiovascular events (MACE) (OR: 0.71 [95% CrI: 0.56 to 0.87]) but not OCT (OR: 0.91 [95% CrI: 0.62 to 1.39]), IVUS and OCT significantly reduced the risk of cardiac death (OR: 0.50 [95% CrI: 0.33 to 0.76]) and (OR: 0.55 [95% CrI: 0.31 to 0.98]), respectively, IVUS significantly reduced the risk of target vessel-related revascularization (OR: 0.60 [95% CrI: 0.48 to 0.75]) but not OCT (OR: 0.86 [95% CrI: 0.60 to 1.19]), IVUS and OCT significantly reduced the risk of stent thrombosis (OR: 0.50 [95% CrI: 0.28 to 0.92]) and (OR: 0.48 [95% CrI: 0.22 to 0.98]), respectively, IVUS significantly reduced the risk of re-stenosis (OR: 0.65 [95% CrI: 0.46 to 0.88]) but not OCT (OR: 0.55 [95% CrI: 0.15 to 1.99]), neither IVUS (OR: 0.97 [95% CrI: 0.71 to 1.38]) nor OCT (OR: 0.75 [95% CrI: 0.49 to 1.22]) were associated with statistically significant reductions in all-cause mortality, neither IVUS (OR: 0.70 [95% CrI: 0.45 to 1.32]) nor OCT (OR: 0.81 [95% CrI: 0.47 to 1.59]) were associated with statistically significant reductions in target vessel failure, neither IVUS (OR: 0.88 [95% CrI: 0.43 to 2.44]) nor OCT (OR: 0.81 [95% CrI: 0.37 to 2.04]) were associated with statistically significant reductions in target lesion failure, and neither IVUS (OR: 0.82 [95% CrI: 0.60 to 1.06]) nor OCT (OR: 0.84 [95% CrI: 0.59 to 1.19]) were associated with statistically significant reductions in myocardial infarction., Conclusion: Intravascular imaging-guided, including IVUS and OCT, improved the postinterventional outcomes of PCI, notably suggesting their advantage over traditional angiography with no significant difference between IVUS and OCT., (© 2024. The Author(s).)

Background: Coronary computed tomography angiography (CCTA) in patients with post-coronary artery bypass graft (CABG) has a high diagnostic accuracy for visualization of grafts. Invasive coronary angiography (ICA) in patients with CABG is associated with increased procedural time, contrast agent administration, radiation exposure, and complications, compared with non-CABG patients. The aim of this multicenter, randomized controlled trial was to compare the strategy of CCTA-guided ICA versus classic ICA in patients with prior CABG., Methods: Patients with prior CABG were randomly assigned (1:1 ratio) to have a CCTA before ICA (CCTA-ICA, group A) or not (ICA-only, group B). The primary end point of the study was the total volume (milliliters) of the contrast agent administered., Results: A total of 251 patients were randomized, and 225 were included in analysis; 110 in group A and 115 in group B. The total contrast volume was higher in group A (184.5 [143-255] versus 154 [102-240] mL; P =0.001). The contrast volume administered during the invasive procedure was lower in group A (101.5 [60-151] versus 154 [102-240]; P <0.001). Total fluoroscopy time was decreased in group A (480 [259-873] versus 594 [360-1080] seconds; P =0.027), but total effective dose was increased (24.1 [17.7-32] versus 10.8 [5.6-18] mSv; P <0.001). The rate of contrast-induced nephropathy, periprocedural complications, and major adverse cardiac events during 3 to 5 and 30 days did not differ significantly between the 2 groups., Conclusions: A CCTA-directed ICA strategy for patients with CABG is associated with expedition of the invasive procedure, and less fluoroscopy time, at the cost of higher total contrast volume and effective radiation dose, compared with the classic ICA approach., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04631809., Competing Interests: None.

Background: The value of physiological ischemia versus anatomic severity of disease for prognosis and management of patients with stable coronary artery disease (CAD) is widely debated., Methods: A total of 1764 patients who had rest-stress cadmium-zinc-telluride single-photon emission computed tomography myocardial perfusion imaging and angiography (invasive or computed tomography) were prospectively enrolled and followed for cardiac death/nonfatal myocardial infarction. The CAD prognostic index (CADPI) was used to quantify the extent and severity of angiographic disease. Prognostic value was assessed using Cox models, adjusted for pretest risk, known CAD, stressor, left ventricular ejection fraction, %ischemia and infarct, CADPI, and early (90-day) revascularization. Incremental prognostic value was evaluated using net reclassification index., Results: The mean age was 69.7±9.5 years, 24.4% were women, and 29.3% had known CAD. Significant ischemia (>10%) was present in 28.4%. Nonobstructive, single, and multivessel disease was present in 256 (14.5%), 772 (43.8%), and 736 (41.7%), respectively. Early revascularization occurred in 579 (32.8%). Cardiac death/myocardial infarction occurred in 148 (8.4%) over a 4.6-year median follow-up. Both %ischemia and CADPI provided independent and incremental prognostic value over pretest clinical risk ( P <0.001). In a model containing both ischemia and anatomy, ischemia was prognostic (hazard ratio per 5% ↑, 1.35 [95% CI, 1.11-1.63]; P =0.002) but CADPI was not (hazard ratio per 10-unit ↑, 1.09 [95% CI, 0.99-1.20]; P =0.07). Early revascularization modified the risk associated with %ischemia (interaction P =0.003) but not with CADPI (interaction P =0.6). %Ischemia and single-photon emission computed tomography variables added incremental prognostic value over clinical risk and CADPI (net reclassification index, 20.3% [95% CI, 9%-32%]; P <0.05); however, CADPI was not incrementally prognostic beyond pretest risk, %ischemia, and single-photon emission computed tomography variables (net reclassification index, 3.1% [95% CI, -5% to 15%]; P =0.21)., Conclusions: Ischemic burden provides independent and incremental prognostic value beyond CAD anatomy and identifies patients who benefit from early revascularization. The anatomic extent of disease has independent prognostic value over clinical risk factors but offers limited incremental benefit for prognosis and guiding revascularization beyond physiological severity (ischemia)., Competing Interests: Dr Patel reports receiving funding from the National Institutes of Health (award numbers: R03AG082994 and 5P30AG028741-07) and an institutional research grant from Jubilant DraxImage. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The other authors report no conflicts.

Background: Transcatheter aortic valve replacement (TAVR) is the most common treatment in patients with symptomatic severe aortic stenosis (AS). As concomitant coronary artery disease is common in AS patients, access to the coronary arteries following TAVR is of increasing importance., Objectives: This study evaluated the incidence and risk factors for unplanned coronary angiography following TAVR and, using fluoroscopic time as a surrogate, analyzed the complexity of coronary artery cannulation., Methods: All patients who underwent TAVR in Sweden between 2008 and 2022 were identified using the SWEDEHEART registry. The cumulative incidence of coronary angiography after TAVR was analyzed with mortality as a competing risk. Angiography and PCI complexity were analyzed using fluoroscopic time and compared across different transcatheter heart valve designs., Results: Out of 9806 patients, 566 subsequently required coronary angiography. The incidence was highest for three-vessel and/or left main disease. Younger age, the extent of prior coronary artery disease, and peripheral vascular disease were associated with an increased risk of coronary angiography. Fluoroscopy time was increased in TAVR patients compared to the control group with the longest fluoroscopy times observed in cases involving supra-annular and self-expanding valves., Conclusions: The incidence of coronary angiography following TAVR is still low. Younger patients and patients with concomitant coronary artery disease have a higher risk. Procedural time is longer in patients with a previous THV replacement. As TAVR is emerging as the first-line treatment in patients with longer life expectancy, facilitating coronary access is an important factor when considering which THV device to implant., (© 2024 The Author(s). Catheterization and Cardiovascular Interventions published by Wiley Periodicals LLC.)

Competing Interests: Declaration of competing interest DL, AF – Supported by institutional grants from Amgen and Philips. DD, DSB, PJS – Software royalties from Cedars-Sinai Medical Center. LS – Institutional grants from Amgen and Philips. Site PI for Ocean(a) trial.

Calcified nodules (CNs) cause in-stent restenosis (ISR) frequently. Although reprotrusion of CNs through stent struts is one of the mechanisms of ISR, the process of this phenomenon has not been understood. Furthermore, little is known about stent fracture (SF) occurring at the site of CNs. We are presenting a case of an 82-year-old male who developed early ISR due to the combination of an in-stent CN and SF in the hinged right coronary artery. The process of progression of the in-stent CN was recorded sequentially with angiography and intravascular ultrasound (IVUS). IVUS from the fulcrum of hinge motion revealed the repetitive protruding movement of the CN into the stent lumen., (© 2024 Wiley Periodicals LLC.)

A 65-year-old man with end-stage renal failure, severe aortic stenosis, and triple vessel coronary artery disease was admitted for percutaneous coronary intervention to the left anterior descending artery prior to transcatheter aortic valve replacement.

Introduction: The left distal trans-radial approach is not only more convenient for the operator than the conventional left forearm radial approach, it is also more comfortable for right-hand patients during the peri-procedural period. Comparing with conventional approach, it has lower bleeding risk, less pain and lower risk of radial artery occlusion. The aim of this study was to determine the feasibility and the safety of left distal trans-radial approach for coronary angiogram and percutaneous coronary intervention in Hong Kong Chinese who had smaller body built and therefore smaller radial arterial size., Method: In this single-center prospective study, 72 patients undergoing elective coronary angiography and/or percutaneous coronary intervention were recruited from August to October 2018. All right-handed patients aged 18 or above undergoing elective procedures during the period were recruited. Exclusion criteria were non-palpable radial arteries, pregnancies, incapability to consent, abnormal Allen's test, and emergency procedures. Sixty patients (42 males, age ranging from 45 to 86 years old) were recruited and underwent the procedures via left distal radial approach. The measurements during access establishment, the procedure details, complications, patients' satisfaction, and arterial occlusion rate were studied., Results: The procedures with left distal radial approach were successful in 51 patients (85%). Crossover rate to conventional right radial approach was 15% (nine patients). Among successful cases, the mean patients' satisfaction was 8.32/10 and the mean pain score was 1.6/10. Post-procedural radial artery occlusion was not encountered., Conclusion: Left distal radial approach is a feasible alternative for patients undergoing coronary angiography and/or percutaneous coronary intervention in Hong Kong Chinese patients. It provides good comfortability with minimal pain in right-handed patients. The risk of radial artery occlusion is minimal., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Intravascular lithotripsy is effective and safe for managing coronary calcification; however, available devices are limited, and complex lesions have been excluded in previous studies. This study aimed to investigate the effectiveness and safety of a novel intravascular lithotripsy system for severe calcification in a population with complex lesions., Methods: CALCI-CRACK (treatment of severe calcified coronary lesions with a novel intracoronary shock wave lithotripsy system) (ChiCTR2100052058) was a prospective, single-arm, multicentre study. The primary end point was the procedural success rate. Major safety end points included major adverse cardiovascular events (MACE) and target lesion failure (TLF) at 30 days and 6 months, and severe angiographic complications. Calcification morphology was assessed in the optical coherence tomography (OCT) subgroup., Results: In total, 242 patients from 15 high-volume Chinese centres were enrolled, including 26.45% of patients with true bifurcation lesions, 3.31% with severely tortuous vessels, and 2.48% with chronic total occlusion, respectively. The procedural success rate was 95.04% (95% confidence interval 91.50%-97.41%), exceeding the prespecified performance goal of 83.4% (P < 0.001). The 30-day and 6-month MACE rates were 4.13% and 4.55%, respectively. TLF rates at those time points were 1.24% and 1.65%, respectively. Severe angiographic complications occurred in 0.42% of patients. In the OCT subgroup (n = 93), 93.55% of calcified lesions were fractured, and minimal lumen area increased from 1.55 ± 0.55 mm 2 to 4.91 ± 1.22 mm 2 after stent implantation, with acute gain rate of 245 ± 102%., Conclusions: The novel intravascular lithotripsy system is effective and safe for managing severely calcified coronary lesions in a cohort that included true bifurcation lesions, severely tortuous vessels, and chronic total occlusion., Clinical Trial Registration: Chinese Clinical Trial Registry (ChiCTR), number ChiCTR2100052058., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Aims: The impact of sex-related factors on current clinical management and outcomes of chronic coronary syndromes (CCS) are unclear., Methods: All patients belonging to the prospective, nationwide START registry were included. Their baseline characteristics, diagnostic workup, revascularization strategy, pharmacological treatment and 1-year clinical outcomes were compared with respect to sex overall and in age tertiles., Results: A total of 5070 consecutive patients were included. Most patients were males (80.1%). As expected, the prevalence of females increased with age. Distribution of risk factors and history of cardiovascular disease were different depending on sex, as well as diagnostic workup, with lower use of exercise stress testing in women (25.1% vs. 36.7%, P < 0.0001). The use of coronary angiography was similar in the two groups. Women had lower rates of multivessel coronary artery disease (CAD) (33.0% vs. 40.6% P < 0.0001) and higher rates of nonobstructive CAD (18.3% vs. 11.3%, P < 0.0001). Rates of myocardial revascularization were similar, but women were more likely to receive percutaneous coronary intervention than men (84.3% vs. 77.8%, P < 0.0001) and less likely to receive surgical/hybrid revascularization (10.0% vs. 15.1%, P < 0.0001). At 12-month follow-up, no differences were observed for the combined endpoint of all-cause mortality, re-hospitalization for myocardial infarction, heart failure, stroke or myocardial revascularization between males and females; however, a significantly worse perceived quality of life was observed in women., Conclusions: In a large nationwide cohort of patients with CCS, clinical outcomes were not different depending on sex. However, several differences in the diagnostic work-up, treatment strategies and quality of life were found between sexes., (Copyright © 2024 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Objectives: The diagnostic performance of fractional flow reserve with computed tomography (FFR-CT) is affected by the presence of calcified plaque. Subtraction can remove the influence of calcification in coronary computed tomography angiography (CCTA) to increase confidence in the diagnosis of coronary artery stenosis. Our purpose is to investigate the accuracy of post-subtraction FFR-CT in predicting early revascularization., Design: Based on CCTA data of 237 vessels from 79 patients with coronary artery disease, subtraction CCTA images were obtained at a local post-processing workstation, and the conventional and post-subtraction FFR-CT measurements and the difference in proximal and distal FFR-CT values of the narrowest segment of the vessel (ΔFFR-CT) were analyzed for their accuracy in predicting early coronary artery hemodynamic reconstruction., Results: With FFR-CT ≤ 0.8 as the criterion, the accuracy of conventional and post-subtraction FFR-CT measurements in predicting early revascularization was 73.4% and 77.2% at the patient level, and 64.6% and 72.2% at the vessel level, respectively. The specificity of post-subtraction FFR-CT measurements was significantly higher than that of conventional FFR-CT at both the patient and vessel levels (P of 0.013 and 0.015, respectively). At the vessel level, the area under the curve of receiver operating characteristic was 0.712 and 0.797 for conventional and post-subtraction ΔFFR-CT, respectively, showing a difference (P = 0.047), with optimal cutoff values of 0.07 and 0.11, respectively., Conclusion: The post-subtraction FFR-CT measurements enhance the specificity in predicting early revascularization. The post-subtraction ΔFFR-CT value of the stenosis segment > 0.11 may be an important indicator for early revascularization.

Background: Coronary disease complexity is commonly used to guide revascularization strategy in patients with multivessel disease (MVD)., Objectives: The aim of this study was to assess the interactive effects of coronary complexity on percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) outcomes and identify the optimal threshold at which PCI can be considered a reasonable option., Methods: A total of 1,444 of 1,500 patients with MVD from the FAME (Fractional Flow Reserve versus Angiography for Multi-vessel Evaluation) 3 randomized trial were included in the analysis (710 CABG vs 734 PCI). SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were transformed into restricted cubic splines, and logistic regression models were fitted, with multiplicative interaction terms for revascularization strategy. Optimal thresholds at which PCI is a reasonable alternative to CABG were determined on the basis of Cox regression model performance., Results: The mean SYNTAX score (SS) was 25.9 ± 7.1. SS was associated with 1-year major adverse cardiac and cerebrovascular events among PCI patients and 3-year death, myocardial infarction, and stroke among CABG patients. Significant interactions were present between revascularization strategy and SS for 1- and 3-year composite endpoints (P for interaction <0.05 for all). In Cox regression models, outcomes were comparable between CABG and PCI for the 3-year primary endpoint for SS ≤24 (P = 0.332), with 44% of patients below this threshold and 32% below the conventional SS threshold of ≤22., Conclusions: In patients with MVD without left main disease, PCI and CABG outcomes remain comparable up to SS values in the mid- rather than low 20s, which allows the identification of a greater proportion of patients in whom PCI may be a reasonable alternative to CABG., Competing Interests: Funding Support and Author Disclosures This work was supported by grants from Medtronic and Abbott Vascular. Dr Dawson is supported by the Australian National Health and Medical Research Council and the Australian National Heart Foundation postgraduate scholarships. Dr Kobayashi serves as a consultant for Abbott Vascular. Dr Fearon has received institutional research support from Abbott Vascular, and Medtronic; and has stock options with HeartFlow. Dr De Bruyne has consulting relationships with Boston Scientific, Abbott Vascular, CathWorks, Siemens, and Coroventis Research; has received research grants from Abbott Vascular, Coroventis Research, CathWorks, and Boston Scientific; and holds minor equities in Philips-Volcano, Siemens, GE Healthcare, Edwards Lifesciences, HeartFlow, Sanofi, and Celyad. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: In patients with coronary artery disease treated with permanent polymer-coated drug-eluting stents (DES), the persistent presence of a less biocompatible polymer might delay arterial healing. Thin strut polymer-free DES have the potential to improve clinical outcomes and reduce the duration of dual antiplatelet therapy (DAPT). The purpose of this first-in-human study was to assess the safety and effectiveness of a novel polymer-free DES in patients with de novo coronary lesions. The TIGERevolutioN® stent (CG Bio Co., Ltd., Seoul, Korea) consists of a cobalt chromium platform with a strut thickness of 70 μm and a surface treated with titanium dioxide onto which everolimus-eluting stent (EES) is applied abluminally (6 µg/mm of stent length) without utilization of a polymer., Methods: A total of 20 patients were enrolled, with de novo coronary lesions (stable or unstable angina) and > 50% diameter stenosis in a vessel 2.25 to 4.00 mm in diameter and ≤ 40 mm in length for angiographic, optical coherence tomography (OCT), and clinical assessment at 8 months. All patients received DAPT after stent implantation. The primary endpoint was angiographic in-stent late lumen loss (LLL) at 8 months., Results: Twenty patients with 20 lesions were treated with TIGERevolutioN®. At 8 months, in-stent LLL was 0.7 ± 0.4 mm. On OCT, percent area stenosis was 29.2 ± 9.4% and stent strut coverage was complete in all lesions. No adverse cardiovascular event occurred at 8 months., Conclusion: The new polymer-free EES was safe and effective with low LLL and excellent strut coverage at 8 months of follow-up., Trial Registration: Trial Registration: Clinical Research Information Service Identifier: KCT0005699., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2024 The Korean Academy of Medical Sciences.)

Coronary intervention involving the region of bifurcation remains a challenging issue for the cardiologist as well as a complication. A number of factors including the angulation of side branch with the main branch determines the success. Though provisional strategy remains the best option in bifurcation intervention, at times a two-stent strategy cannot be avoided. We report a case in which percutaneous coronary intervention was performed on the left anterior descending artery (LAD) at its bifurcation with a major diagonal branch (> 2.5 mm). The ostium of the diagonal was diseased, and the branch took off from the LAD at an unfavorable angle (> 120°). We describe the use of the "shepherd's crook wire curve" approach, a modification of the reverse wire technique, which allowed us to successfully wire, dilate, and protect the diagonal and so named to reflect its resemblance to the shape of a shepherd's crook., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

The 2023 European Bifurcation Club (EBC) meeting took place in Warsaw in October, and the latest evidence for the use of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) to optimise percutaneous coronary interventions (PCI) on coronary bifurcation lesions (CBLs) was a major focus. The topic generated deep discussions and general appraisal on the potential benefits of IVUS and OCT in PCI procedures. Nevertheless, despite an increasing recognition of IVUS and OCT capabilities and their recognised central role for guidance in complex CBL and left main PCI, it is expected that angiography will continue to be the primary guidance modality for CBL PCI, principally due to educational and economic barriers. Mindful of the restricted access/adoption of intracoronary imaging for CBL PCI, the EBC board decided to review and describe a series of tips and tricks which can help to optimise angiography-guided PCI for CBLs. The identified key points for achieving an optimal angiography-guided PCI include a thorough analysis of pre-PCI images (computed tomography angiography, multiple angiographic views, quantitative coronary angiography vessel estimation), a systematic application of the technical steps suggested for a given selected technique, an intraprocedural or post-PCI use of stent enhancement and a low threshold for bailout use of intravascular imaging.

Background: The prognostic impact of functionally significant coronary artery disease, as assessed with quantitative flow ratio (QFR), in patients with severe aortic stenosis treated with transcatheter aortic valve replacement is unknown., Methods: This is a retrospective study with blind analysis of angiographic data, enrolling consecutive patients with severe aortic stenosis treated with transcatheter aortic valve replacement at 4 Italian centers. None of the patients enrolled received pre-transcatheter aortic valve replacement or concomitant coronary revascularization, either for the absence of significant coronary stenoses or by clinical decision. Visual estimation of diameter stenosis and QFR analysis were performed in all coronary arteries. The end point was all-cause mortality at a 3-year follow-up., Results: A total of 318 patients were enrolled. At visual estimation, 140 patients (44%) presented a diameter stenosis ≥50% in at least 1 coronary artery, whereas 78 patients (24.5%) had at least 1 vessel with QFR <0.80 and, therefore, included in the positive QFR group. Overall, 69 (21.7%) patients died during the follow-up. In the Kaplan-Meier analysis, patients with positive QFR experienced significantly higher rates of death during follow-up compared with those without (51.1% versus 12.1%; P <0.001), whereas no significant difference was evident in terms of death between patients with or without significant coronary artery disease according to angiographic evaluation (24.3% versus 19.7%; P =0.244). In a multivariate regression model, positive QFR was an independent predictor of all-cause death during follow-up (hazard ratio, 5.31 [95% CI, 3.21-8.76])., Conclusions: Coronary QFR can predict mortality in patients with severe aortic stenosis treated with transcatheter aortic valve replacement without revascularization., Competing Interests: None.

Although multiple randomized clinical trials (RCTs) have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) is associated with improved clinical outcomes compared with angiography-guided PCI, its benefits specifically in calcified coronary lesions is unclear due to the small number of patients included in individual trials. We performed a meta-analysis of RCTs to investigate benefits of IVI-guided PCI compared with angiography-guided PCI in heavily calcified coronary lesions. The primary endpoint was major adverse cardiac events (MACE), a composite of cardiac death, target-vessel or target-lesion myocardial infarction, and target-vessel or target lesion revascularization. Pooled odds ratios (OR) and 95% confidence intervals (CI) were calculated by using a random-effects meta-analysis based on the restricted maximum likelihood method. A search PubMed, EMBASE, and Cochrane Library from their inception to January 2024 identified 4 trials that randomized 1319 patients with angiographically moderate or severe or severe coronary calcification to IVI-guided (n = 702) vs. angiography-guided PCI (n = 617). IVI-guided PCI resulted in a significantly lower odds of MACE (OR 0.57, 95% CI 0.40-0.80) compared with angiography-guided PCI at a weighted median follow-up duration of 27.3 months. There was no evidence of heterogeneity among the studies (I 2  = 0.0%), and included trials were judged to be low risk of bias. Compared with angiography-guided PCI, IVI-guided PCI was associated with a significantly lower MACE in angiographically heavily calcified coronary lesions., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Competing Interests: Declaration of competing interest None declared.

Many lesions in patients undergoing percutaneous coronary intervention (PCI) exhibit significant calcification. Several techniques have been developed to improve outcomes in this setting. However, their impact on coronary microcirculation remains unknown. The aim of this study is to evaluate the influence of plaque modification techniques on coronary microcirculation across patients with severely calcified coronary artery disease. In this multicenter retrospective study, consecutive patients undergoing PCI with either Rotablation (RA) or Shockwave-intravascular-lithotripsy (IVL) were included. Primary endpoint was the impairment of coronary microvascular resistances assessed by Δ angiography-derived index of microvascular resistance (ΔIMRangio) which was defined as the difference in IMRangio value post- and pre-PCI. Secondary endpoints included the development of peri procedural PCI complications (flow-limiting coronary dissection, slow-flow/no reflow during PCI, coronary perforation, branch occlusion, failed PCI, stroke and shock developed during PCI) and 12-month follow-up adverse events. 162 patients were included in the analysis. Almost 80% of patients were male and the left descending anterior artery was the most common treated vessel. Both RA and IVL led to an increase in ΔIMRangio (22.3 and 10.3; p = 0.038, respectively). A significantly higher rate of PCI complications was observed in patients with ΔIMRangio above the median of the cohort (21.0% vs. 6.2%; p = 0.006). PCI with RA was independently associated with higher ΔIMRangio values (OR 2.01, 95% CI: 1.01-4.03; p = 0.048). Plaque modification with IVL and RA during PCI increases microvascular resistance. Evaluating the microcirculatory status in this setting might help to predict clinical and procedural outcomes and to optimize clinical results., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Background: Coronary angiography and percutaneous coronary intervention (PCI) in patients with chronic kidney disease (CKD) is associated with increased risk of contrast induced nephropathy (CIN) and requirement for renal replacement therapy (RRT)., Objectives: We aimed to evaluate our single center experience of ultra-low contrast PCI in patients with CKD and to characterize 1 year outcomes., Methods: We performed a retrospective analysis of ultra-low contrast PCI at our institution between 2016 and 2022. Patients with CKD3b-5 (eGFR <45 mL/min/1.73m 2 ), not on RRT who underwent ultra-low contrast PCI ( < 30 mL of contrast during PCI) were included. Primary outcomes included change in eGFR post-procedurally, and death, RRT requirement, and major adverse cardiac events (MACE) at 1 year follow-up., Results: One hundred patients were included in the study. The median age was 67 years old and 28% were female. The median baseline eGFR was 21.5 mL/min/1.73m 2 (IQR 14.08-32.0 mL/min/1.73m 2 ). A median of 8.0 mL (IQR 0-15 mL) of contrast was used during PCI. Median contrast use to eGFR ratio was 0.37 (IQR 0-0.59). There was no significant difference between pre-and postprocedure eGFR (p = 0.84). At 1 year, 8% of patients died, 11% required RRT and 33% experienced MACE. The average time of RRT initiation was 7 months post-PCI. Forty-four patients were undergoing renal transplant evaluation, of which 17 (39%) received a transplant., Conclusions: In patients with advanced CKD, ultra-low contrast PCI is feasible and safe with minimal need for peri-procedural RRT. Moreover, ultra-low contrast PCI may allow for preservation of renal function in anticipation of renal transplantation., (© 2024 Wiley Periodicals LLC.)

Background: The practical application of 'virtual' (computed) fractional flow reserve (vFFR) based on invasive coronary angiogram (ICA) images is unknown. The objective of this cohort study was to investigate the potential of vFFR to guide the management of unselected patients undergoing ICA. The hypothesis was that it changes management in >10% of cases., Methods: vFFR was computed using the Sheffield VIRTUheart system, at five hospitals in the North of England, on 'all-comers' undergoing ICA for non-ST-elevation myocardial infarction acute coronary syndrome (ACS) and chronic coronary syndrome (CCS). The cardiologists' management plan (optimal medical therapy, percutaneous coronary intervention (PCI), coronary artery bypass surgery or 'more information required') and confidence level were recorded after ICA, and again after vFFR disclosure., Results: 517 patients were screened; 320 were recruited: 208 with ACS and 112 with CCS. The median vFFR was 0.82 (0.70-0.91). vFFR disclosure did not change the mean number of significantly stenosed vessels per patient (1.16 (±0.96) visually and 1.18 (±0.92) with vFFR (p=0.79)). A change in intended management following vFFR disclosure occurred in 22% of all patients; in the ACS cohort, there was a 62% increase in the number planned for medical management, and in the CCS cohort, there was a 31% increase in the number planned for PCI. In all patients, vFFR disclosure increased physician confidence from 8 of 10 (7.33-9) to 9 of 10 (8-10) (p<0.001)., Conclusion: The addition of vFFR to ICA changed intended management strategy in 22% of patients, provided a detailed and specific 'all-in-one' anatomical and physiological assessment of coronary artery disease, and was accompanied by augmentation of the operator's confidence in the treatment strategy., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: Competing interests: FB received unrestricted grants from the Federation Française de Cardiologie, and consultancy fees from Boston Scientific, B-Braun and Amgen. DA reports receiving consultancy fees from HeartFlow and GE Healthcare. CC reports receiving research grants from Biosensor, Coroventis Research, Medis Medical Imaging, Pie Medical Imaging, CathWorks, Boston Scientific, Siemens, HeartFlow, Abbott Vascular, and consultancy fees from HeartFlow, OpSens, Abbott Vascular and Philips Volcano.

Background: Drug-coated balloon (DCB) angioplasty seems a safe and effective option for specific de novo coronary lesions. However, the beneficial effect of intravascular ultrasound (IVUS)-guided DCB angioplasty in de novo lesions remains uncertain., Objectives: This study aimed to assess the benefits of IVUS guidance over angiography guidance during DCB angioplasty in de novo coronary lesions., Methods: A total of 260 patients with high bleeding risk who had a de novo coronary lesion (reference vessel diameter 2.0-4.0 mm, and lesion length ≤15 mm) were randomly assigned to either an IVUS-guided or an angioplasty-guided DCB angioplasty group. The primary endpoint was in-segment late lumen loss (LLL) at 7 months after procedure. The secondary endpoint was target vessel failure at 6 months., Results: A total of 2 patients in the angiography-guided group and 7 patients in the IVUS-guided group underwent bailout stent implantation (P = 0.172). The primary endpoint of 7-month LLL was 0.03 ± 0.52 mm with angiography guidance vs -0.10 ± 0.34 mm with IVUS guidance (mean difference 0.14 mm; 95% CI: 0.02-0.26; P = 0.025). IVUS guidance was also associated with a larger 7-month minimal lumen diameter (2.06 ± 0.62 mm vs 1.75 ± 0.63 mm; P < 0.001) and a smaller diameter stenosis (28.15% ± 13.88% vs 35.83% ± 17.69%; P = 0.001) compared with angiography guidance. Five target vessel failures occurred at 6 months, with 4 (3.1%) in the angiography-guided group and 1 (0.8%) in the IVUS-guided group (P = 0.370)., Conclusions: This study demonstrated that IVUS-guided DCB angioplasty is associated with a lower LLL in patients with a de novo coronary lesion compared with angiography guidance. (Intravascular Ultrasound Versus Angiography Guided Drug-Coated Balloon [ULTIMATE-III]; NCT04255043)., Competing Interests: Funding Support and Author Disclosures This study was supported by the National Natural Science Foundation of China (NSFC 81970307, NSFC 82100357, NSFC 82270344, and NSFC 82200385), and was jointly supported by Jiangsu Natural Science Foundation (BK20221173), Six Talent Peaks Project of Jiangsu Province (2019-WSN-156), Jiangsu Health Committee (H2019077), and Nanjing Health Committee (JQX22007 and ZKX23030), and Social development project of Jiangsu province (BE2019615). The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac allograft vasculopathy (CAV) is still the main drawback of heart transplantation (HTx) and percutaneous coronary intervention (PCI) is a palliative measure because of the high incidence of failure., Objective: This study aimed to investigate the safety and efficacy of bioresorbable scaffolds (BRSs) as potential novel therapeutic tool for the treatment of coronary stenoses in CAV., Methods: This is a multicenter, single-arm, prospective, open-label study (CART, NCT02377648), that included patients affected by advanced CAV treated with PCI and second-generation ABSORB BRS (Abbott Vascular). The primary endpoint was the incidence of 12-month angiographic in-segment scaffold restenosis (ISSR). Secondary endpoints were the incidence of major adverse cardiac events (MACEs) at 12- and 36-month follow-up and the incidence of ISSR at 36 months. A paired intracoronary imaging analysis at baseline and follow-up was also performed., Results: Between 2015 and 2017 35 HTx patients were enrolled and treated for 44 coronary lesions with 51 BRSs. The primary endpoint occurred in 13.5% of the lesions (5/37), with a cumulative ISSR rate up to 3 years of 16.2% (6/37). Angiographic lumen loss was 0.40 ± 0.62 mm at 12 months and 0.53 ± 0.57 mm at 36 months. Overall survival rate was 91.4% and 74.3%, and MACEs incidence 14.2% and 31.4% at 12 and 36 months, respectively. At the paired intracoronary imaging analysis, a significant increase of the vessel external elastic membrane area in the treated segment and some progression of CAV proximally to the BRS were detected., Conclusions: BRS-based PCI for the treatment of CAV is feasible and safe, with an ISSR incidence similar to what reported in retrospective studies with drug-eluting stents., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Objective: Patients undergoing vascular surgery procedures have poor long-term survival due to coexisting coronary artery disease (CAD), which is often asymptomatic, undiagnosed, and undertreated. We sought to determine whether preoperative diagnosis of asymptomatic (silent) coronary ischemia using coronary computed tomography (CT)-derived fractional flow reserve (FFR CT ) together with postoperative ischemia-targeted coronary revascularization can reduce adverse cardiac events and improve long-term survival following major vascular surgery METHODS: In this observational cohort study of 522 patients with no known CAD undergoing elective carotid, peripheral, or aneurysm surgery we compared two groups of patients. Group I included 288 patients enrolled in a prospective Institutional Review Board-approved study of preoperative coronary CT angiography (CTA) and FFR CT testing to detect silent coronary ischemia with selective postoperative coronary revascularization in addition to best medical therapy (BMT) (FFR CT guided), and Group II included 234 matched controls with standard preoperative cardiac evaluation and postoperative BMT alone with no elective coronary revascularization (Usual Care). In the FFR CT group, lesion-specific coronary ischemia was defined as FFR CT ≤0.80 distal to a coronary stenosis, with severe ischemia defined as FFR CT ≤0.75. Results were available for patient management decisions. Endpoints included all-cause death, cardiovascular death, myocardial infarction (MI), and major adverse cardiovascular events (MACE [death, MI, or stroke]) during 5-year follow-up., Results: The two groups were similar in age, gender, and comorbidities. In FFR CT , 65% of patients had asymptomatic lesion-specific coronary ischemia, with severe ischemia in 52%, multivessel ischemia in 36% and left main ischemia in 8%. The status of coronary ischemia was unknown in Usual Care. Vascular surgery was performed as planned in both cohorts with no difference in 30-day mortality. In FFR CT , elective ischemia-targeted coronary revascularization was performed in 103 patients 1 to 3 months following surgery. Usual Care had no elective postoperative coronary revascularizations. At 5 years, compared with Usual Care, FFR CT guided had fewer all-cause deaths (16% vs 36%; hazard ratio [HR], 0.37; 95% confidence interval [CI], 0.22-0.60; P < .001), fewer cardiovascular deaths (4% vs 21%; HR, 0.11; 95% CI, 0.04-0.33; P < .001), fewer MIs (4% vs 24%; HR, 0.13; 95% CI, 0.05-0.33; P < .001), and fewer MACE (20% vs 47%; HR, 0.36; 95% CI, 0.23-0.56; P < .001). Five-year survival was 84% in FFR CT compared with 64% in Usual Care (P < .001)., Conclusions: Diagnosis of silent coronary ischemia with ischemia-targeted coronary revascularization in addition to BMT following major vascular surgery was associated with fewer adverse cardiovascular events and improved 5-year survival compared with patients treated with BMT alone as per current guidelines., Competing Interests: Disclosures C.K.Z. has a financial interest in HeartFlow, Inc., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: While transradial access is favored for cardiac catheterization, the radial artery (RA) is increasingly preferred for coronary artery bypass grafting. Whether the RA is suitable for use as a graft following instrumentation for transradial access remains uncertain., Methods: Consecutive patients from 2015 to 2019 who underwent coronary artery bypass grafting using both the left and right RAs as grafts were included. Instrumented RAs underwent careful preoperative assessment for suitability. The clinical analysis was stratified by whether patients received an instrumented RA graft (instrumented versus noninstrumented groups). Eligible patients with both instrumented and noninstrumented RAs underwent computed tomography coronary angiography to evaluate graft patency. The primary outcome was a within-patient paired analysis of graft patency comparing instrumented to noninstrumented RA grafts., Results: Of the 1123 patients who underwent coronary artery bypass grafting, 294 had both the left and right RAs used as grafts and were included. There were 126 and 168 patients in the instrumented and noninstrumented groups, respectively. Baseline characteristics and perioperative outcomes were comparable. The rate of major adverse cardiac events at 2 years following coronary artery bypass grafting was 2.4% in the instrumented group and 5.4% in the noninstrumented group (hazard ratio, 0.44 [95% CI, 0.12-1.61]; P =0.19). There were 50 patients included in the graft patency analysis. At a median follow-up of 4.3 (interquartile range, 3.7-4.5) years, 40/50 (80%) instrumented and 41/50 (82%) noninstrumented grafts were patent (odds ratio, 0.86 [95% CI, 0.29-2.52]; P >0.99). No significant differences were observed in the luminal diameter or cross-sectional area of the instrumented and noninstrumented RA grafts., Conclusions: There was no evidence found in this study that RA graft patency was affected by prior transradial access, and the use of an instrumented RA was not associated with worse outcomes in the exploratory clinical analysis. Although conduits must be carefully selected, prior transradial access should not be considered an absolute contraindication to the use of the RA as a bypass graft., Registration: URL: https://www.anzctr.org.au/; Unique identifier: ACTRN12621000257864., Competing Interests: None.