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Background. Spontaneous recanalization of a chronically occluded artery is rare and reported anecdotally. Case Summary. We report a case of a patient with a chronically occluded right coronary artery, found on a coronary angiography performed due to acute ST elevation myocardial infarction with an occluded circumflex artery as a culprit lesion. Three months later, a follow-up angiography was performed and a recanalization of the occluded right coronary artery was detected. Discussion. There is a possibility that intrinsic fibrinolytic mechanisms with the additional effect of standard antithrombotic drugs administrated after the acute coronary event led to the recanalization. [ABSTRACT FROM AUTHOR]

Background: Systematic screening for coronary artery disease (CAD) and routine percutaneous coronary intervention (PCI) of significant lesions before for transcatheter aortic valve implantation (TAVI) have been reconsidered recently because of no evidence of benefit.1,2 We wanted to investigate important clinical factors that could predict the importance of coronary artery disease in patients scheduled for TAVI. Patients and Methods: We retrospectively analyzed all patients with confirmed CAD who underwent TAVI in our center from April 2012 to May 2023. Data on CAD diagnosis and management were compared between patients with different CAD treatment strategies, in regard to complications and composite event rate of death and myocardial infarction during follow-up. Results: Among 349 patients (median age 80 years, 52% males, median AVA 0.7 cm2 ), 124 (36%) had confirmed CAD. Routine invasive coronary angiography during TAVI work-up was performed in 328 (94%) of patients. Patients with CAD had median age of 79, with 88/124 (71%) of males. History of PCI or CABG was noted in 61 (49%) and 46 (37%) of patients, respectively. Significant CAD deserving clinical attention was found in 80 (65%) patients, out of which 48 (60%) patients underwent PCI before TAVI. There were no differences in TAVI complications in regard to CAD management. Composite event rate of death and myocardial infarction during follow-up did not differ significantly between patients treated conservatively (28%) and patients who received PCI (21%) (OR 1.58, 95% CI 0.66-3.64). Significant univariate predictors of composite endpoints were male gender, peripheral artery disease (PAD), history of CABG, and reduced LVEF below 50%. Only PAD remained significant in a multivariate Cox regression analysis (OR 3.02, 95% CI 1.16-7.84). Conclusion: Routine PCI before TAVI did not impact clinical outcomes, so CAD could be considered bystander disease in most TAVI candidates. However, our data showed that CAD with history of CABG, reduced EF, and PAD, probably deserves a more scrutinized approach for better long-term outcomes after TAVI, and therefore it should not be considered as bystander in TAVI patients with any of these characteristics. [ABSTRACT FROM AUTHOR]

Introduction: Functional coronary testing rather than systematic stenting in chronic coronary syndromes has been advocated by the most recent guidelines. However, its use in patients with acute coronary syndromes (ACS) is controversial.1 We aimed to evaluate the penetration of functional coronary testing in patients with ACS in our center. Patients and Methods: We analyzed data from quantitative coronary angiography and functional coronary testing in patients who underwent invasive coronary angiography in 2022. Results: Out of 2075 patients who underwent coronary angiography in 2022, 536 (26%) patients had acute coronary syndrome. Among 536 acute coronary syndrome patients, 42 (8%) patients received invasive functional testing. All patients had non-hyperemic indices (instantaneous wave-free ratio [iFR] or coronary resistance reserve [cRR]) analyzed, with 4 (10%) patients with borderline results requiring additional fractional flow reserve (FFR). In 40/42 patients functional testing was done in another setting, in order to assess non-culprit lesions. In only 2 patients functional testing was done during invasive assessment of an acute coronary episode (1 in the circumflex artery territory, and 1 in the proximal left anterior descending artery) and in both cases percutaneous coronary intervention (PCI) was deferred. Generally, there were no adverse events in deferred patients during 6-months follow-up. Conclusion: Functional testing in patients with acute coronary syndromes was mostly performed in a staged procedure in order to assess non-culprit lesions. The use of functional testing to defer or confirm PCI indication in a suspected culprit lesion in acute setting, or ad hoc in by-stander lesions immediately after culprit lesion PCI, is still controversial and requires additional study. Additional imaging methods would probably help identify culprit lesions among intermediate stenoses found in patients with acute coronary syndromes. [ABSTRACT FROM AUTHOR]

Introduction: In stable patients planned for transcatheter aortic valve implantation (TAVI), systematic screening for coronary artery disease (CAD) and routine percutaneous coronary intervention (PCI) of angiographically significant lesions before TAVI has been considered a standard of care.1 However, recent analyses showed no evidence of benefit after coronary revascularization before TAVI in stable patients. Patients and Methods: We retrospectively analyzed all patients who underwent TAVI in our center from 2012 to 2022. Data on coronary artery disease (CAD) diagnosis and management were compared to other relevant clinical characteristics, in regard to composite event rate of death and myocardial infarction during follow-up. Results: Among 293 patients (median age 80 years, 53% males, median AVA 0.7 cm2, with 62% of balloon expandable valves), 105 (36%) had confirmed CAD. History of previous revascularization (PCI or surgical) was noted in 84 (29%) of patients. Routine coronary angiography before TAVI was performed in 280 (96%) patients, with significant CAD deserving clinical attention found in 63 (23%) patients. Composite event rate of death and myocardial infarction during follow-up was not significantly higher among patients with confirmed CAD (OR 0.93, 95% CI 0.54-1.58), in contrast to peripheral artery disease (OR 3.25, 95% CI 1.91-5.54). Among 63 patients with significant CAD, 41 (65%) patients received PCI before TAVI, and their composite event rate did not differ from the remaining 35% of patients treated conservatively (OR 0.86, 95% CI 0.27-2.80). Conclusion: Stable CAD showed no impact on survival or myocardial infarction after TAVI, as well as routine PCI before TAVI in a subgroup of patients with significant CAD requiring clinical attention. Therefore, in a cohort of patients with similar characteristics, routine invasive coronary angiography during diagnostic work-up before TAVI could be redundant because invasive CAD management did not impact clinical outcomes. [ABSTRACT FROM AUTHOR]

Introduction: Recent guidelines proposed routine functional assessment of all 20-90% coronary artery stenoses without objective signs of myocardial ischemia within the chronic coronary syndromes1,2. We present the results of functional assessment of coronary stenoses found in patients with stable angina pectoris and no evident myocardial ischemia during a one year period and analyze its impact on treatment strategy. Patients and Methods: We evaluated clinical data, 2D quantitative coronary angiography, and functional assessment results in all patients undergoing coronary angiography for stable angina pectoris from October 2021 to October 2022. Results: Out of 1088 patients who underwent coronary angiography because of stable angina pectoris, invasive functional testing was performed in 98 (9%) of patients. Median percentage of luminal stenosis assessed was 60%, with 25 (26%) patients having two or more different segments involved. In 98 patients a total of 127 stenoses were analyzed, with 66 (52%) stenoses in the left anterior descending artery (LAD), 22 (17%) in the circumflex artery (CxA) /marginal/diagonal, and 39 (31%) stenoses in the right coronary artery (RCA). All patients had non-hyperemic indices (instantaneous wave free ratio (iFR) or cRR) analyzed, with 10 (10%) patients with borderline results requiring additional fractional flow reserve (FFR). Positive iFR or cRR was found in 32 (48%) LAD stenoses, and only 4 (19%) and 9 (24%) stenoses in the CxA/marginal/diagonal and RCA, respectively. Positive mismatch of the iFR/cRR with the FFR was found in 3/10 stenoses with borderline results. All patients with positive functional tests received percutaneous coronary intervention (PCI). There were no complications related to the pressure wire (Verrata) or the pressure microcatheter (TruePhysio) during functional assessment. There was one case of a trapped pressure wire during post-PCI assessment that required additional non-compliant balloon optimization of the proximal segment of the stent after successful removal of the pressure wire. In comparison to the same period in 2019, functional assessment increased significantly from 1.3% to 9%, whereas the proportion of elective PCI for stable angina pectoris among all PCI performed decreased from 55% to 45%. Conclusion: Most non-LAD lesions were non-significant according to functional assessment. Functional testing is increasing according to guidelines, and it clearly affects the rates of PCI in chronic coronary syndromes. [ABSTRACT FROM AUTHOR]

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Abstract: Coronary stent fracture is a relatively rare but potentially serious complication of coronary artery stenting. It has been recognised as a cause of in-stent restenosis as well as acute stent thrombosis. Most fractures occur in stents after aggressive post-dilatation, stents implanted in tortuous and calcified lesions, and after cardiac trauma [M.S. Lee, D. Jurewitz, J. Aragon, J. Forrester, R.R. Makkar, S. Kar Stent fracture associated with drug-eluting stents: clinical characteristics and implications. Catheter Cardiovasc Interv. Feb 15 2007;69(3):387–394.,Makaryus AN, Lefkowitz L, Lee AD, Coronary artery stent fracture. Int J Cardiovasc Imaging. Jun 2007;23(3):305–309. Electronic publication 2006 Sep 28.,E.S. Brilakis, C. Maniu, M. Wahl, G. Barsness (2004) Unstable angina due to stent fracture J Invasive Cardiol 16(9):545.,G. Sianos, S. HOfma, J.M. Ligthart et al. Stent fracture and restenosis in the drug eluting stent era. Catheter cardiovasc Interv 2004; 61(1):111–116.]. We report on a case of delayed stent fracture that gradually lead to in-stent restenosis (distal part), significant fragment displacement with the formation of a coronary artery aneurysm that was unsuitable for percutaneous intervention. [Copyright &y& Elsevier]