Search Results (241)

Background: This narrative review introduces the “From Plaque to Perfusion” framework, a clinically pragmatic approach that maps multimodality imaging technologies to critical decision points in the acute coronary syndrome (ACS) patient journey. By integrating non-invasive assessment, invasive procedural guidance, and post-event tissue characterisation, this framework provides a structured pathway for deep phenotyping of ACS. Artificial intelligence (AI) is highlighted as an essential enabling layer that enhances diagnostic precision, automates quantification, and supports scalable, data-driven care. Contemporary ACS management pathways, while effective, often leave residual clinical uncertainty. The diagnostic objective has evolved beyond confirming myocardial injury to comprehensively phenotyping the entire ACS cascade: defining the plaque substrate, identifying the culprit mechanism, and quantifying the myocardial consequence. This requires a systematic integration of advanced imaging modalities. Methods: This narrative review is based on a comprehensive literature search of major medical databases (PubMed/MEDLINE, Scopus, Embase, Google Scholar) for high-level evidence, including randomized controlled trials, meta-analyses, and international expert consensus documents published between January 2010 and February 2026. Results: The “From Plaque to Perfusion” framework consists of three core stages. First, non-invasive assessment with coronary computed tomography angiography (CCTA), fractional flow reserve (FFR-CT), and PET-CT defines plaque substrate and vascular inflammation. Second, invasive precision in the catheterization laboratory, guided by optical coherence tomography (OCT) and intravascular ultrasound (IVUS), resolves the culprit mechanism and optimizes percutaneous coronary intervention (PCI). Third, post-event tissue characterization with cardiac magnetic resonance (CMR) quantifies myocardial injury and refines prognosis. AI-driven platforms are shown to enhance each stage by automating analysis, standardizing interpretation, and providing actionable metrics for clinical decisions, including complex scenarios like Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA). Conclusions: The “From Plaque to Perfusion” framework, enabled by AI, reframes ACS imaging as an integrated, mechanism-driven pathway. This approach moves beyond isolated test interpretation toward a scalable model of precision, phenotype-led care that promises to improve diagnostic certainty and personalize patient management. Full article

Background: Contemporary coronary artery bypass grafting (CABG) is often performed in patients with diffuse atherosclerosis, severe calcification, prior percutaneous coronary intervention (PCI), and fragile myocardium, creating intraoperative scenarios that can compromise target selection, anastomotic quality, and completeness of revascularization. We synthesize operative strategies and outcomes across five predefined “complex CABG” scenarios. Methods: A focused literature review was performed targeting intraoperative CABG challenges in adult patients. Two reviewers independently screened titles/abstracts and selected studies describing operative details, technical considerations, or outcomes relevant to (1) intramyocardial/embedded coronaries, (2) severely calcified or diffuse disease requiring reconstruction, (3) small-caliber targets/flow-limited grafting, (4) iatrogenic right ventricular (RV) injury, and (5) failed PCI/stent-related surgical management. Disagreements were resolved through discussion and consensus. Results: Thirty core publications were synthesized across five complex intraoperative CABG scenarios (intramural/embedded coronaries n = 7; calcified/diffuse disease n = 7; small-caliber/flow-limited targets n = 7; iatrogenic RV injury n = 5; failed PCI/stent-related management n = 5). Intramural/embedded targets: reported intramyocardial LAD prevalence ranged from 2.2–13%, and studies emphasized structured localization strategies with a small but real risk of ventricular injury depending on technique. Severely calcified/diffuse disease: reconstructive approaches (endarterectomy, patch angioplasty, long-segment LAD reconstruction) were used to create graftable beds when standard anastomosis was not feasible, with series reporting acceptable early mortality and generally high early-to-midterm patency when paired with planned antithrombotic and imaging follow-up strategies. Small-caliber targets: vessel size alone did not preclude durable grafting when flow was optimized, with evidence supporting flow-augmenting designs (e.g., sequential grafting) and intraoperative flow verification to reduce low-flow failure in limited runoff beds. Iatrogenic RV injury: bailout techniques prioritized rapid hemostasis while preserving LAD/graft patency using buttressed closure concepts designed for constrained exposure and ongoing bleeding risk. Failed PCI/stent-related pathology: long stented segments shifted operative planning from distal target selection to target reconstruction (stentectomy/endarterectomy with long-segment LAD reconstruction), with angiographic follow-up cohorts demonstrating feasible revascularization but variable patency by territory and lesion extent. Conclusions: Complex CABG is best approached as structured, anatomy-driven problem-solving: deliberate target localization, creation of a graftable bed when needed, flow-augmenting graft design, and predefined bailout options. Standardized comparative studies are needed to define optimal strategies across these common clinically important scenarios. Full article

Coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) are the two dominant revascularisation strategies for obstructive coronary artery disease, yet their relative roles continue to shift because they address coronary pathophysiology differently with ever-evolving techniques. PCI has advanced through iterative improvements, including balloon angioplasty, bare-metal stents, and drug-eluting stents, with contemporary outcomes increasingly driven by procedural optimisation using intracoronary imaging and physiology-guided lesion selection rather than device category alone. CABG has progressed through perioperative management, improvements in operative safety, and, critically, conduit durability. Recognition of progressive saphenous vein graft failure has underpinned a conduit-optimisation era in which the left internal mammary artery to left anterior descending artery remains the gold standard. Further, broader arterial grafting (including radial artery use, multiple arterial grafting, and selected total-arterial strategies) has been increasingly applied, albeit with deliverability and competing-risk constraints highlighted in randomised evidence. This perspective review reframes the CABG versus PCI comparison not as a binary contest, but as a context-dependent assessment in which the relative value of each strategy depends on the specific technologies, techniques, and conduits available at the time of comparison. We summarise comparative effectiveness where evidence is most consistent and where it remains sensitive to anatomy, comorbidity, and endpoint definitions. In diabetes with multivessel disease, trial data favour CABG for long-term survival and clinical outcomes despite higher stroke risk. In left main disease, outcomes depend on lesion pattern and overall complexity, with trial-era stent technology and composite endpoint definitions influencing conclusions. In ischaemic left ventricular dysfunction, a long-term survival benefit is established for CABG added to medical therapy, while multi-vessel PCI has not demonstrated comparable prognostic modification in contemporary data. We then examine hybrid coronary revascularisation as territory-specific allocation, highlighting its physiological rationale, program dependence, and limited, adequately powered randomised evidence. Finally, we outline how artificial intelligence (AI) and robotics may accelerate a precision revascularisation paradigm by standardising lesion assessment, supporting procedural planning, improving procedural reproducibility, and enabling more patient-specific selection among PCI, contemporary CABG with optimised conduits, and hybrid pathways. Full article

The use of excimer laser atherectomy (ELA) has significantly evolved from the mid-1990s to the present, showing substantial improvements in both coronary and peripheral artery interventions. Initially associated with suboptimal outcomes due to low-energy settings and limited techniques, advancements such as high-energy delivery, improved catheter designs, contrast injection protocols, and refined procedural approaches have greatly enhanced clinical efficacy. In coronary applications, ELA has become an established technique for treating intracoronary thrombus, under-expanded stents, in-stent restenosis, and heavily calcified lesions, offering favorable procedural and clinical outcomes with low complication rates. The excimer laser operates through photochemical, photothermal, and photomechanical mechanisms, enabling precise plaque ablation with minimal collateral damage. In peripheral interventions, especially in critical limb ischemia (CLI), ELA has emerged as a viable option for complex, non-crossable lesions and in-stent restenosis, demonstrating high technical success, improved patency, and promising limb salvage rates. Multiple clinical trials and registries support the safety and effectiveness of ELA, particularly in high-risk patient populations. This narrative review summarizes current evidence and practical considerations on the use of excimer laser atherectomy in coronary and peripheral interventions. Full article

Background: Extracorporeal membrane oxygenation (ECMO) is commonly used for temporary support in patients with severe cardiogenic shock and may serve as a bridge to heart transplantation. In recent years, outcomes have improved with better timing, patient management and advances in ECMO technology. Case presentation: We describe the case of a 61-year-old man who developed refractory cardiogenic shock after an extensive acute myocardial infarction complicated by recurrent ventricular arrhythmias. After an initial period of stabilization following complex percutaneous coronary intervention, the patient suddenly deteriorated with acute pulmonary edema and severe hypoxemia. A peripheral femoro-femoral veno-arterial ECMO with distal limb perfusion was promptly implanted using the ECMOLIFE system and the Landing Advance system (Eurosets s.r.l., Medolla, MO, Italy) to stabilize the patient and enable continuous monitoring. Due to severe left ventricular distension, surgical left ventricular venting was performed through a minimally invasive approach. ECMO support allowed rapid hemodynamic stabilization without major complications. During ECMO support, the patient remained stable and after less than 48 h a suitable donor heart became available. The patient was safely transferred to a transplant center while on ECMO and successfully underwent heart transplantation. Conclusions: This case shows that early ECMO implantation, combined with appropriate ventricular unloading and careful management with an advanced monitoring system, can be an optimal support as a bridge to heart transplantation. Limiting the duration of ECMO support and ensuring timely referral to a transplant center may improve outcomes in patients with refractory cardiogenic shock. Full article

Background: Inflammatory bowel disease (IBD), comprising Crohn’s disease (CD) and ulcerative colitis (UC), has been associated with elevated cardiovascular risks. However, the impact of IBD on outcomes following percutaneous coronary intervention (PCI) remains underexplored. We aimed to evaluate the clinical and procedural outcomes of PCI in patients with concurrent IBD. Methods: This study utilized the National Readmission Database from 2016 to 2020 to evaluate outcomes such as all-cause mortality and post-PCI complications, including various cardiovascular and gastrointestinal (GI) complications in IBD patients undergoing PCI. Patients with concurrent IBD and PCI were compared to non-IBD controls via multivariable logistic regression. Results: On propensity-score-matching analysis, IBD patients undergoing PCI had a higher prevalence of GI complications, including acute liver failure (Odds ratio (OR) 1.48, 95% confidence interval (CI) 1.13–1.93, p = 0.004), mesenteric ischemia (OR 5.34, 95% CI 1.56–18.40, p = 0.007), and need for blood transfusion (OR 1.74, 95% CI 1.46–2.08, p < 0.001). There was also a higher rate of cardiac complications (OR 1.31, 95% CI 1.05–1.64, p = 0.017). No significant difference in all-cause mortality (OR 0.86, 95% CI 0.72–1.04, p = 0.113) was observed. Conclusions: IBD patients undergoing PCI face increased GI and cardiovascular complications without a significant mortality difference. These findings highlight the complex interplay between systemic inflammation, vascular integrity, and procedural outcomes in IBD patients. Full article

Interventional treatment of very elderly patients with severe coronary artery disease is currently one of the central topics in interventional cardiology. Technological progress and increased life expectancy have made these patients appropriate candidates for contemporary standards of care, especially those with an active lifestyle. We hereby report the case of a 95-year-old patient hospitalized for acute myocardial infarction, who underwent a complex percutaneous coronary intervention with mechanical circulatory support. A literature review on mechanical circulatory support devices in older adults is also provided. Full article

Background and Clinical Significance: Pulmonary hypertension (PH) is a recognized complication of chronic liver disease, most commonly manifesting as portopulmonary hypertension (POHP) prior to liver transplantation. While the natural history and management of pre-transplant PH are well described, the development of de novo pulmonary arterial hypertension (PAH) following liver transplantation remains exceedingly rare and poorly understood. In such cases, establishing true causality is challenging, and alternative explanations—including previously unrecognized or masked disease—must be carefully considered. This entity poses significant diagnostic and therapeutic challenges and may adversely affect post-transplant outcomes if not promptly recognized and treated. Case Presentation: We report the case of a 46-year-old man with end-stage liver disease secondary to alcohol use who underwent deceased donor liver transplantation without preoperative evidence of PH. His pre-transplant evaluation revealed preserved biventricular function and no measurable PH. Eight days postoperatively, he was readmitted with acute dyspnea, hypoxemia, and signs of right ventricular failure. Transthoracic echocardiography demonstrated severe right ventricular dilation and dysfunction with markedly elevated pulmonary artery systolic pressure. Right heart catheterization confirmed severe PAH. Secondary causes of PH were excluded. The patient was initiated on sildenafil and continuous intravenous epoprostenol, resulting in clinical, echocardiographic, and hemodynamic improvement. Subsequent follow-up demonstrated sustained response to therapy despite concurrent progression of coronary artery disease requiring complex percutaneous intervention. Conclusions: This case highlights a rare presentation of severe PAH occurring shortly after liver transplantation, in the absence of documented pre-transplant PH. While a causal relationship cannot be definitively established, the temporal association raises important clinical considerations. It underscores the need for heightened clinical vigilance for pulmonary vascular disease in post-transplant patients presenting with cardiopulmonary symptoms. Further research is warranted to elucidate the underlying mechanisms, risk factors, and optimal management strategies for PAH diagnosed after liver transplantation. Full article

Background: Managing elderly patients with simultaneous acute cardiovascular and orthopedic emergencies presents a unique challenge. While ST-elevation myocardial infarction (STEMI) requires prompt revascularization and dual antiplatelet therapy (DAPT), pertrochanteric femoral fractures usually necessitate early surgical fixation to reduce morbidity and mortality. However, the combination of these conditions complicates both standard treatment pathways. Case presentation: We present the case of an 86-year-old woman admitted after a low-energy fall, with a radiologically confirmed unstable pertrochanteric fracture of the right femur (AO/OTA 31-A2). Upon routine electrocardiogram, anterior STEMI with new-onset atrial fibrillation was diagnosed. Although asymptomatic from a cardiac perspective, bedside echocardiography revealed a severely reduced left ventricular ejection fraction of 10%. Urgent coronary angiography demonstrated a critical mid-left anterior descending lesion, successfully treated with rotational atherectomy, intravascular lithotripsy, and stent implantation. She was initiated on DAPT (aspirin + clopidogrel) and anticoagulated with low-molecular-weight heparin. Given the extremely high bleeding risk, surgical intervention for the femoral fracture was deemed unsafe. Instead, conservative management with skeletal traction (6 kg) was employed. Despite optimal supportive care and early rehabilitation, the patient experienced a complicated hospital course, including delirium, hematuria, and lower respiratory tract infection. She passed away 52 days post-admission. Conclusions: This case illustrates the complexity of clinical decision-making in geriatric patients with competing acute conditions. Current evidence on how to proceed in patients requiring both antithrombotic therapy and urgent orthopedic surgery is limited. Multidisciplinary teams must carefully weigh the risks and benefits of both surgical and conservative strategies. Further guidelines addressing such scenarios in elderly patients are urgently needed. Full article

Background: Intravascular lithotripsy (IVL) has emerged as a safe and effective modality for treating severely calcified coronary lesions. While the Shockwave™ system is well-established, clinical data on newer IVL platforms such as the Shunmei ShockFast™ system remain limited. Objectives: To evaluate the safety, feasibility, and procedural outcomes of the ShockFast IVL device in patients with heavily calcified de novo coronary artery disease. Methods: We conducted a prospective, single-center case series of 16 patients undergoing percutaneous coronary intervention (PCI) with the ShockFast IVL system between June and December 2025. Inclusion required angiographic or optical coherence tomography (OCT) evidence of severe coronary calcification. The primary efficacy endpoint was acute procedural success and absence of in-hospital MACE. Secondary endpoints included, among others, device deliverability, presence of calcium fracture and post-stent expansion metrics. Results: All patients underwent successful lithotripsy delivery with the ShockFast IVL system. Acute procedural success was 100%, with no intraprocedural complications, abrupt closure, or in-hospital MACE. OCT was performed in 50% of cases and demonstrated calcium fractures in all imaged lesions, with ≥2 fractures in 63% of cases. Median stent expansion was 90% [IQR 9], with no major malapposition or edge dissections. Quantitative coronary analysis showed a median acute lumen gain of 1.86 mm [0.62]. Conclusions: The ShockFast IVL system showed excellent safety and procedural performance in this first-in-center experience. Outcomes were encouraging and consistent with those reported in early-stage studies of other IVL platforms. These findings support the clinical feasibility of ShockFast as a novel tool for calcium modification in complex PCI. Full article

Background: The prevalence of chronic total occlusion (CTO) lesions is as high as 30% in patients undergoing coronary angiography (CAG). Some CTO patients do not undergo revascularization due to procedural complexity and high risks. This study aimed to investigate the value of cadmium-zinc-telluride (CZT) SPECT dynamic myocardial perfusion imaging (MPI) for risk stratification and prognosis assessment in patients with coronary CTO. Methods: This study retrospectively included 62 patients who underwent CZT SPECT dynamic MPI examination and were diagnosed with CTO by angiography. The primary endpoint was major adverse cardiovascular events (MACEs), defined as cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, hospitalization for heart failure, late coronary revascularization, or hospitalization for unstable angina. Results: Over a median follow-up of 17 months (IQR 11–23), 15 MACEs occurred. The stress myocardial blood flow (sMBF) and coronary flow reserve (CFR) in the CTO territory were significantly lower in the MACEs group compared to the non-MACEs group (all p < 0.05). Receiver operating characteristic analysis determined the optimal cut-off values for predicting MACEs as sMBF < 0.75 (sensitivity 78.7%, specificity 73.3%, AUC = 0.74, p < 0.05) and CFR < 1.39 (sensitivity 70.2%, specificity 80.0%, AUC = 0.75, p < 0.01). Kaplan–Meier survival analysis showed that patients with impaired sMBF (p < 0.001) or impaired CFR (p < 0.01), defined by these cut-off values, had significantly worse clinical outcomes. Conclusions: The results of this study indicate that sMBF and CFR obtained from CZT SPECT dynamic MPI provide valuable prognostic prediction for patients with coronary CTO lesions, offering critical evidence for identifying high-risk patients requiring active intervention. Full article

Severe coronary artery calcification (CAC) remains a major challenge in percutaneous coronary intervention (PCI), driving stent under-expansion and higher rates of restenosis and adverse events. Balloon-based calcium modification remains central to lesion preparation, with the available tools ranging from high-pressure non-compliant balloons and ultra-high-pressure balloons to cutting, scoring, and intravascular lithotripsy (IVL) balloons. While traditional IVL has advanced the field by permitting circumferential fracture of deep calcium through acoustic shockwaves, important drawbacks persist, including problems in deliverability, energy distribution, and questionable efficacy in nodular or eccentric calcium. This review examines all contemporary balloon-based modification strategies and introduces the novel Hertz-contact IVL (HC-IVL), a new technology designed to transmit mechanical energy through direct contact rather than shockwave propagation. Based on Hertzian mechanics, this device may facilitate more focused energy delivery, improved lesion crossing, and enhanced calcium fracture in complex morphologies. A detailed comparison between HC-IVL and standard IVL is provided, along with a proposed algorithm for device selection. Taking into consideration the limitations of current tools, HC-IVL represents a promising mechanistic innovation in balloon-based calcium modification, warranting further validation in randomized, imaging-guided clinical studies. Full article

Accurate assessment of the functional significance of coronary artery stenoses is essential for guiding revascularization decisions and improving clinical outcomes in patients with coronary artery disease (CAD). While invasive wire-based fractional flow reserve (FFR) remains the gold standard for physiological lesion assessment, its adoption in routine clinical practice is limited by procedural complexity, patient discomfort, time consumption, and cost. These limitations have driven the development of angiography-derived FFR techniques that enable physiological evaluation without pressure wires or pharmacologic hyperaemia. Recent advances in computational modelling, artificial intelligence, and image processing have facilitated the estimation of FFR from conventional coronary angiography, including approaches that require only a single angiographic view. Single-view angiography-derived FFR methods—such as Murray law-based quantitative flow ratio (µQFR), FFR2D, Angio-iFR/FFR, sAccuFFR, and X1-FFR—aim to simplify workflow while maintaining diagnostic accuracy. Among these, µQFR has demonstrated the most consistent validation against invasive FFR across a broad range of clinical scenarios, including complex lesions, severe aortic stenosis, multivessel disease, and acute coronary syndromes. This review summarizes the principles, validation data, clinical applications, and limitations of single-view angiography-derived FFR technologies and highlights their potential to expand the adoption of physiology-guided coronary intervention. Full article

(1) Background: Chronic total occlusion percutaneous coronary intervention (CTO-PCI) is a complex, high-risk procedure compared to standard percutaneous coronary intervention (PCI). Scoring systems such as the Japanese Chronic Total Occlusion (J-CTO), European Chronic Total Occlusion (EuroCTO), and Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) evaluate lesion difficulty and predict outcomes. Nutritional status, measured by the Prognostic Nutritional Index (PNI), may also affect procedural success and long-term survival. The objective of this study was to evaluate the combined impact of procedural complexity and nutritional status on the clinical outcomes of patients undergoing CTO-PCI. (2) Methods: We analyzed 118 patients undergoing CTO-PCI between May 2021 and March 2022. Procedural complexity was assessed using the J-CTO, EuroCTO, and PROGRESS-CTO scores, while nutritional status was evaluated using the PNI. Primary outcomes included all-cause mortality and repeat revascularization, which were analyzed using Cox proportional hazards regression and Kaplan–Meier survival analyses. (3) Results: Adverse outcomes occurred in 25 patients (mortality: 17; revascularization: 8). Patients with adverse outcomes had significantly lower left ventricular ejection fraction (LVEF) (46 ± 13.7% vs. 52.1 ± 10.5%, p < 0.001), lower PNI (p < 0.001), and higher J-CTO, EuroCTO, and PROGRESS-CTO scores (all p < 0.05). A PNI cut-off value of 46 predicted mortality with a sensitivity of 70.6% and specificity of 75.2% (area under the curve [AUC] = 0.739, p = 0.001). Multivariable analysis identified LVEF (hazard ratio [HR] 0.966, p = 0.036), J-CTO score (HR 1.598, p = 0.027), and PNI (HR 0.925, p = 0.022) as independent predictors of mortality. (4) Conclusion: Both procedural complexity and nutritional status significantly influence outcomes following CTO-PCI. Incorporating PNI together with procedural complexity scores into pre-procedural assessments may enhance risk stratification and optimize patient management. Full article

Background/Objectives: Sex-based differences in clinical profiles and outcomes following percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) remain poorly understood. We sought to examine the association between sex and long-term clinical outcomes following CTO-PCI in a contemporary real-world cohort. Methods: We conducted a retrospective study of 928 consecutive patients (788 men, 140 women) undergoing CTO-PCI at a high-volume centre between 2011 and 2024. The primary endpoint was a composite of major adverse cardiac events (MACE: all-cause death, myocardial infarction [MI], or stroke) at a 6-year follow-up. To account for baseline differences, an Inverse Probability of Treatment Weighting (IPTW)-adjusted Cox regression analysis was performed. Results: Women were significantly older (69.7 ± 10 vs. 64.1 ± 10 years; p < 0.001) and had a higher prevalence of diabetes and hypertension. However, women exhibited lower angiographic complexity, with lower J-CTO scores (2 [1–2] vs. 2 [1–3]; p < 0.001) and less frequent severe calcification or tortuosity. Technical and procedural success rates were comparable between sexes (85.4% vs. 86.7%; p = 0.695). Unadjusted MACE rates were higher in women (29.3% vs. 22.1%; hazard ratio (HR) 1.51, 95% CI: 1.08–2.13; p = 0.017). After adjustment, the female sex was no longer associated with the primary endpoint (aHR 1.15, 95% CI: 0.76–1.74; p = 0.517), but the risk of MI remained significantly higher in this group (aHR 2.85, 95% CI: 1.23–6.63; p = 0.015). Conclusions: CTO-PCI appeared to be equally safe and effective in women and men. Over long-term follow-up, although the overall adjusted MACE risk was similar between sexes, the female sex was associated with a higher risk for MI. Full article