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The introduction of transradial access for percutaneous coronary diagnostic and interventional procedures has led to a decrease in access site complications. The aim of this paper is to propose a combined stepwise technical approach where real time ultrasound ("echo-first" approach) can be used to select the best vascular access and, together with angiography, to manage the potential obstacles that may occur during transradial procedures. In each section, we summarize some tips and tricks based on both our experience and current literature that can be easily implemented in daily practice to increase the success of transradial procedures.

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Myocardial infarction with non-obstructive coronary artery disease (MINOCA) is a heterogeneous clinical condition affecting 5% to 8% of patients presenting with acute myocardial infarction. Initially it was considered a favorable clinical diagnosis, nowadays it is known that MINOCA can significantly affect patient quality of life and portends a guarded prognosis. Therefore, it is of utmost importance to identify the specific pathophysiological mechanism underlying this clinical condition in order to set up a targeted pharmacological and non-pharmacological therapy. Coronary angiography is still a mandatory diagnostic test to rule out obstructive coronary artery disease but has limited capability to identify other potential functional and structural etiologies of MINOCA. The purpose of this review is to provide an overview of the invasive diagnostic work-up of patients with MINOCA, highlighting the diagnostic tools warranted beyond coronary angiography inside the cath lab (intracoronary provocation tests, intracoronary imaging and indexes for the assessment of coronary microvascular dysfunction), and the remaining essential knowledge gaps in this field.

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Background: Percutaneous ventricular-assistance by Impella (IMP) represents an emerging strategy to manage patients with reduced left-ventricular (LV) ejection-fraction (EF) undergoing percutaneous-coronary-intervention (PCI). The hemodynamic behave during IMP-protected PCI has been scarcely investigated. Methods: We reviewed the IMP console's function and hemodynamic data (which are continuously recorded during assistance) in a consecutive series of 37 patients who underwent elective IMP-protected PCI in two high-volume centers. All patients had multivessel disease and impaired LVEF. Coronary artery disease burden was graded using the British-Cardiovascular-Intervention-Society jeopardy-score (BCIS-JS) score. IMP motor speed and pressure signals (systolic blood pressure, SBP, and mean blood pressure, MBP) were analyzed. Primary hemodynamic end-points were “critical systolic blood pressure (SBP) drop” (SBP decrease ≥ 20 mm Hg reaching ≤90 mm Hg values) and “critical mean blood pressure (MBP) drop” (MBP decrease reaching ≤60 mm Hg). Results: Over mean assistance duration of 254 ± 549 min, no IMP motor drop occurred. During PCI, SBP and MBP significantly decreased but all patients had SBP values >78 mm Hg. Critical SBP and MBP drops occurred in 10.8% of patients. Among all baseline and procedural characteristics, BCIS-JS was the only significant predictor of SBP drop (p = 0.001) while BCIS-JS and LV end-diastolic volume significantly predicted MBP drop (p = 0.001 for both). Conclusions: In patients with reduced EF undergoing IMP-protected PCI, a significant pressure decrease occurs during PCI but pressure is systematically maintained at levels warranting vital organ perfusion. Critical pressure drops during PCI occur in some patients with higher jeopardized myocardium and left ventricular diastolic volumes.

Objectives: We sought to investigate the possible impact of transaortic valve replacement (TAVR) on common femoral artery (CFA) integrity as assessed by angiography. Background: CFA represents the most adopted access for TAVR but various degrees of vascular damage may be induced by the procedure. Methods: Patients underwent percutaneous transfemoral TAVR who had both pre- and post-TAVR access-site angiography were retrospectively selected. Clinical and procedural data (including technique and complications) were prospectively recorded into a structured TAVR database. Pre-TAVR and post-TAVR angiograms were analyzed using a quantitative angiographic analysis software to assess reference diameters, minimum luminal diameter (MLD), and percentage of diameter stenosis (DS). Results: A total of 124 patients entered the study (mean age: 85 years, mean Euroscore II: 10%). ProStar (13.5%) and double ProGlide (82.2%) preclosure were the main hemostatic techniques. CFA exhibited a significant shrinkage with TAVR as assessed by significant MLD reduction (5.6 mm after TAVR vs. 6.8 mm before, P <.001) and DS increase (30.3% after vs. 17.0%, P <.001). Such differences remained statistically significant after exclusion of 18 patients (14.2%) who had (minor or major) vascular complications. At multivariable analysis, pre-TAVR DS (P =.03) and history of peripheral arterial disease (P =.01), were significantly associated with vascular complications. Conclusions: Percutaneous TAVR induces an angiographically detectable CFA lumen reduction. Such findings call for further studies assessing clinical impact of this phenomenon and open the door for further refinements of the TAVR access management aimed at preserving vessel integrity.

The data presented in this article are related to the research article entitled "Optical coherence tomography guidance for the management of angiographically intermediate left main bifurcation lesions: early clinical experience" [1]. In this article we reports details about our clinical experience with frequency domain-optical coherence tomography (FD-OCT) guidance for the management of patients with left main (LM) bifurcation lesions of intermediate angiographic severity. LM patients were assessed by FD-OCT and, on the bases of the findings, managed by myocardial revascularization or conservative treatment (revascularization deferral). The observed outcomes support the feasibility of FD-OCT guidance for LM bifurcated lesions and call for further clinical evaluations in appropriately designed prospective studies.

Background Transcatheter aortic valve implantation and rapid-deployment aortic valve replacement represent two emerging therapies for patients with intermediate surgical risk and severe aortic stenosis. However, head-to-head comparisons between such novel therapies are lacking. Methods Severe aortic stenosis patients with intermediate surgical risk treated with rapid-deployment valve replacement at our institution were identified and compared with a propensity-matched population of patients who underwent transcatheter aortic valve replacement. Postoperative echocardiographic findings, in-hospital and midterm clinical outcomes were compared. Results We identified 60 patients who received transcatheter (n = 30) or rapid-deployment (n = 30) valve replacement. On postoperative echocardiography, freedom from paravalvular regurgitation was higher in the rapid-deployment valve group (p < 0.001), while postoperative mean transprosthetic gradient was lower in the transcatheter valve group (p = 0.03). Permanent pacemaker implantation was required more frequently in transcatheter valve patients (p = 0.01). Postoperative atrial fibrillation was more common in the rapid-deployment valve group (p = 0.03). Hospital mortality was similarly low in both groups (p = 0.33). At midterm follow-up, mortality was comparable (p = 0.42) but the rapid-deployment valve group still had a lower degree of paravalvular regurgitation. Conclusions Transcatheter and rapid-deployment valve replacement are promising treatment options for patients with intermediate surgical risk. These two techniques are associated with specific patterns of prosthesis function and postoperative complications. Further evaluation of the clinical impact of these therapies in this patient population is needed.

Objectives: We sought to investigate the possible impact of transaortic valve replacement (TAVR) on common femoral artery (CFA) integrity as assessed by angiography. Background: CFA represents the most adopted access for TAVR but various degrees of vascular damage may be induced by the procedure. Methods: Patients underwent percutaneous transfemoral TAVR who had both pre- and post-TAVR access-site angiography were retrospectively selected. Clinical and procedural data (including technique and complications) were prospectively recorded into a structured TAVR database. Pre-TAVR and post-TAVR angiograms were analyzed using a quantitative angiographic analysis software to assess reference diameters, minimum luminal diameter (MLD), and percentage of diameter stenosis (DS). Results: A total of 124 patients entered the study (mean age: 85 years, mean Euroscore II: 10%). ProStar (13.5%) and double ProGlide (82.2%) preclosure were the main hemostatic techniques. CFA exhibited a significant shrinkage with TAVR as assessed by significant MLD reduction (5.6 mm after TAVR vs. 6.8 mm before, P<.001) and DS increase (30.3% after vs. 17.0%, P<.001). Such differences remained statistically significant after exclusion of 18 patients (14.2%) who had (minor or major) vascular complications. At multivariable analysis, pre-TAVR DS (P=.03) and history of peripheral arterial disease (P=.01), were significantly associated with vascular complications. Conclusions: Percutaneous TAVR induces an angiographically detectable CFA lumen reduction. Such findings call for further studies assessing clinical impact of this phenomenon and open the door for further refinements of the TAVR access management aimed at preserving vessel integrity.

Radial approach is the emerging arterial access for percutaneous coronary interventions (PCIs) in patients with coronary artery disease. Among the different subset of complex targets for PCI, chronic total occlusion (CTO) still represent a challenge for the interventional cardiologist. Is radial approach suitable for PCIon CTO? Aseries of data collected in selected centers with high volume of transradial procedures supported the change from elective transfemoral approach to systematic transradial approach. In this paper, we tried to provide an update on the technical aspects and the theoretical data which may be useful during the planning of CTOprocedures. Overall, a full knowledge of upper limb vascular anatomy, arterial sheaths/guiding catheters selections, transradial PCItechnique and CTOlesion management skill is pivotal to safely offer CTO patients the potential benefit of reduced bleeding risks through radial access adoption.

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Background The need for adenosine administration to achieve maximal hyperaemia limits the widespread application of fractional flow reserve (FFR) in the real world. We previously demonstrated that Pd/Pa ratio registered during submaximal reactive hyperaemia induced by conventional non-ionic radiographic contrast medium (contrast medium induced Pd/Pa ratio: CMR) can be sufficient for the assessment of physiological severity of stenosis in the majority of cases. In this study we aimed to test the accuracy of CMR in predicting an FFR≤0.80 in comparison with other adenosine-free indexes, such as basal Pd/Pa and instantaneous wave-free ratio (iFR).Methods 450 patients with 532 intermediate coronary stenoses were prospectively and consecutively enrolled. FFR was measured after administration of adenosine, CMR was obtained after intracoronary injection of 6 ml of radiographic contrast medium, while Pd/Pa and iFR were measured at rest. Results Pd/Pa was measured in all 532 lesions, while CMR in 405 and iFR in 95. Although we found a significant correlation between FFR and all measured indexes, the strongest correlation was between FFR and CMR (r=0.89, p<0.001; r=0.73, p<0.001 for correlation between FFR and Pd/Pa; r=0.67, p<0.001 for correlation between FFR and iFR). ROC curve analysis confirmed these data, showing an excellent accuracy of CMR cut-off of ≤0.83 in predicting a positive FFR (AUC 0.97 [95% CI: 0.95-0.99], specificity 0.99, sensitivity 0.82). Moreover CMR was superior than basal Pd/Pa≤0.92 (AUC 0.89 [95% CI: 0.86-0.92], specificity 0.84, sensitivity 0.80; p<0.001) and iFR ≤0.88 (AUC 0.92 [95% CI: 0.85-0.97], specificity 0.94, sensitivity 0.75; p=0.018) in predicting a positive FFR, and the two resting methods were not different (p=0.674). Conclusions in the present study we confirm in a much larger population our previously published data, showing that CMR is accurate in predicting the functional significance of coronary stenosis but also we demonst