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Aims The purpose of the Multivessel TALENT trial is to compare clinical outcomes of the novel Supraflex Cruz stent with those of the SYNERGY stent in patients with three-vessel disease (3VD) undergoing state-of-the-art percutaneous coronary intervention (PCI). Methods and results In this prospective, randomised, 1:1 balanced, multicentre, open-label trial, 1,550 patients with de novo 3VD without left main disease will be assigned to the Supraflex Cruz or SYNERGY arm. The following treatment principles of "best practice" PCI will be applied: Heart Team consensus based on SYNTAX score II treatment recommendation, functional lesion evaluation by quantitative flow ratio (QFR), stent optimisation by intravascular imaging, optimal pharmacological treatment and prasugrel monotherapy. The primary endpoint is a non-inferiority comparison of the patient-oriented composite endpoint (POCE) of all-cause death, any stroke, any myocardial infarction, or any revascularisation, at 12 months post procedure. The powered secondary endpoint is a superiority comparison of the vessel-oriented composite endpoint (VOCE), defined as vessel-related cardiovascular death, vessel-related myocardial infarction, or clinically and physiologically indicated target vessel revascularisation, at 24 months. Conclusions The Multivessel TALENT trial will be evaluating a novel treatment strategy for complex coronary artery disease with state-of-the-art PCI based on angiography-derived QFR with novel ultra-thin Supraflex Cruz stents, compared with SYNERGY stents. Clinical Trial Registration URL: https://www.clinicaltrials.gov/ct2/show/NCT04390672. Unique Identifier: NCT04390672 Visual summary. Flow chart of the Multivessel TALENT trial. 3VD: three-vessel disease; QFR: quantitative flow ratio; IVUS: intravascular ultrasound; OCT: optical coherence tomography; CTO: chronic total occlusion; OMT: optimal medical therapy; POCE: patient-oriented composite endpoint; VOCE: vessel-oriented composite endpoint.

OBJECTIVES The aims of the present study were to investigate the applicability of quantitative flow ratio (QFR) in patients with 3-vessel disease and to demonstrate the impact of functional SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score derived from QFR (fSS(QFR)) on clinical outcomes.BACKGROUND The applicability of QFR in patients with 3-vessel disease and the feasibility of fSS(QFR) have not yet been investigated.METHODS All lesions interrogated using instantaneous wave-free ratio and/or fractional flow reserve in the SYNTAX II trial were retrospectively screened and analyzed for QFR. The diagnostic performance of QFR was investigated using hybrid wire-derived pressure assessment (instantaneous wave-free ratio and fractional flow reserve), used in the trial as a reference. Patients with analyzable QFR in 3 vessels were stratified according to fSS(QFR) to evaluate its clinical prognostic value on the basis of 2-year patient-oriented composite endpoint.RESULTS QFRs were analyzable in 71.0% of lesions (836 lesions). The diagnostic performance of QFR to predict binary wire-based ischemia was substantial (area under the curve 0.81, accuracy 73.8%), with a positive predictive value of 85.9%. Independent predictors of diagnostic discordance were lesions in side branches, involvement of bifurcation or trifurcation, and small vessel. According to the 2-year patient-oriented composite endpoint, fSS(QFR) reclassified 26.1% of the patients (36 of 138) in the high-to intermediate-risk group into the low-risk group appropriately (net reclassification improvement 0.32; p < 0.001). The area under the curve for fSS(QFR) to predict the 2-year patient-oriented composite endpoint was higher than that of the classic anatomic SYNTAX score (0.68 vs. 0.56; p = 0.002).CONCLUSIONS QFR demonstrated substantial applicability in patients with 3-vessel disease. The fSS(QFR) has the potential to further refine prognostic risk estimation compared with the classic anatomic SYNTAX score. (c) 2019 by the American College of Cardiology Foundation.

Bifurcation lesions represent one of the most challenging lesion subsets in interventional cardiology. The European Bifurcation Club (EBC) is an academic consortium whose goal has been to assess and recommend the appropriate strategies to manage bifurcation lesions. The quantitative coronary angiography (QCA) methods for the evaluation of bifurcation lesions have been subject to extensive research. Single-vessel QCA has been shown to be inaccurate for the assessment of bifurcation lesion dimensions. For this reason, dedicated bifurcation software has been developed and validated. These software packages apply the principles of fractal geometry to address the "step-down" in the bifurcation and to estimate vessel diameter accurately. This consensus update provides recommendations on the QCA analysis and reporting of bifurcation lesions based on the most recent scientific evidence from in vitro and in vivo studies and delineates future advances in the field of QCA dedicated bifurcation analysis.

Treatment of coronary bifurcation lesions remains an ongoing challenge for interventional cardiologists. Stenting of coronary bifurcations carries higher risk for in-stent restenosis, stent thrombosis, and recurrent clinical events. This review summarizes the current evidence regarding application and use of biomechanical modeling in the study of stent properties, local flow dynamics, and outcomes after percutaneous coronary interventions in bifurcation lesions. Biomechanical modeling of bifurcation stenting involves computational simulations and in vitro bench testing using subject-specific arterial geometries obtained from in vivo imaging. Biomechanical modeling has the potential to optimize stenting strategies and stent design, thereby reducing adverse outcomes. Large-scale clinical studies are needed to establish the translation of pre-clinical findings to the clinical arena. (C) 2015 by the American College of Cardiology Foundation.

with the image data widely available throughout the hospital by means of cardiovascular PACS systems. Major differences were of course that on cinefilm the coronary arteries were displayed as bright arteries on a darker background, and there was always an associated pincushion distortion caused by the concave input screen of the image intensifier. With the digital systems the arteries are now displayed as dark vessels on a bright background and the modern flat panel X-ray detectors are free from geometric distortions. Although there have been many years of debate about the resolution of cinefilm versus digital, the higher contrast resolution of the digital approach has compensated much of the higher spatial resolution of the 35 mm cinefilm, and thus digital has been completly accepted. Also, extensive validation studies have not proven major differences in accuracy and precision between cinefilm and digital: the variability in the analysis is for both in the order of about pixel, or 0.11 mm [2, 3]. For many years, quantitative coronary arteriography (QCA) has been used in clinical research in the hospitals and in core laboratories to assess regression and progression of coronary obstructions in pharmacological interventions, to assess the efficacy of coronary interventions after the introduction of PTCA and stenting by bare-metal (BMS), drug-eluting (DES) and presently biodegradable stents, and of course for vessel sizing. In all these cases, the analyses were done on straight vessels. New developments have been directed at bifurcation stenting and the associated QCA, and on 3D QCA and registration with IVUS/ OCT. These new issues are elegantly described in the section guest edited by Ricardo A. Costa. It has been well recognized for many years that despite the wide availability of the angiogram and the QCA, an angiogram is only a lumenogram, and that the disease is in the vessel wall. For proper decision making purposes, the interventionalist must know what the composition is of the plaque. This was made possible with intravascular ultrasound, but with the recent advent of Virtual Histology and the iMAP, even more information has become available, which has revived the field of intravascular ultrasound. In this issue, all the possibilities, limitations and applications of IVUS in interventional cardiology are clearly described in the papers selected by guest

Coronary artery disease(CAD) is one of the leading causes of mortality and morbidity worldwide. Clinically, it refers to atherosclerotic changes in the coronary arteries and is usually assessed with a stress electrocardiogram and conventional coronary angiography(CCA). CCA, however, is an invasive technique and carries a small risk of complications. Non-invasive techniques such as coronary angiography with CT(CTCA), and myocardial perfusion imaging (MPI) with SPECT and MR are therefore used as gatekeeper tests before CCA. These techniques provide valuable information on both the coronary stenoses and their hemodynamic impact on the myocardial function. However, each of these techniques presents only one aspect of CAD. To achieve a higher level of accuracy and precision in CAD assessment, integration of information from different cardiac imaging modalities is essential. The goal of this thesis was therefore to develop techniques to realize this multimodal diagnostic image integration to enhance CAD diagnosis. To this end, we developed novel algorithms for near automated analysis of magnetic resonance based myocardial perfusion images. In addition, we developed and evaluated a new integration framework that allows comprehensive visualization of physiologic information from myocardial perfusion imaging -either with MR or SPECT and anatomical information from CTCA

This thesis proposes several new algorithms including X-ray angiographic image enhancement, three-dimensional (3D) angiographic reconstruction, angiographic overlap prediction, and the co-registration of X-ray angiography with intracoronary imaging devices, such as intravascular ultrasound (IVUS) and optical coherence tomography (OCT). The algorithms were integrated into prototype software packages that were validated at a number of clinical centers. The feasibility of using such software packages in typical clinical population was verified, while the advantages and accuracy of the proposed algorithms were demonstrated by phantoms and in-vivo clinical studies. In addition, based on the proposed approaches and the conducted studies, this thesis reports a number of findings including the impact of acquisition angle difference on 3D quantitative coronary angiography (QCA), the clinical characteristics of bifurcation optimal viewing angles and bifurcation angles, and the discrepancy of lumen dimensions as assessed by 3D QCA and by IVUS or OCT.