Search Results (433)

Automated assessment of coronary artery (CA) lesions via Coronary Computed Tomography Angiography (CCTA) is essential for the diagnosis of coronary artery disease (CAD). However, current deep learning approaches confront several challenges, primarily regarding the modeling of long-range anatomical dependencies, the effective decoupling of plaque texture from stenosis geometry, and the utilization of clinically prevalent mixed-grained annotations. To address these challenges, we propose a novel mixed-grained hierarchical geometric-semantic learning network (MG-HGLNet). Specifically, we introduce a topology-aware dual-stream encoding (TDE) module, which incorporates a bidirectional vessel Mamba (BiV-Mamba) encoder to capture global hemodynamic contexts and rectify spatial distortions inherent in curved planar reformation (CPR). Furthermore, a synergistic spectral–morphological decoupling (SSD) module is designed to disentangle task-specific features; it utilizes frequency-domain analysis to extract plaque spectral fingerprints while employing a texture-guided deformable attention mechanism to refine luminal boundary. To mitigate the scarcity of fine-grained labels, we implement a mixed-grained supervision optimization (MSO) strategy, utilizing anatomy-aware dynamic prototypes and logical consistency constraints to effectively leverage coarse branch-level labels. Extensive experiments on an in-house dataset demonstrate that MG-HGLNet achieves a stenosis grading accuracy of 92.4% and a plaque classification accuracy of 91.5%. The results suggest that our framework not only outperforms state-of-the-art methods but also maintains robust performance under weakly supervised settings, offering a promising solution for label-efficient CAD diagnosis. Full article

Background: Restenosis after coronary stent implantation remains a major clinical challenge, especially in patients with diabetes, long lesions, or multiple stents. Standard therapy with aspirin and P2Y12 inhibitors does not reliably prevent this complication. Objectives: We reviewed experimental and clinical evidence on cilostazol, a selective phosphodiesterase-3 inhibitor, as a strategy to reduce restenosis after percutaneous coronary intervention (PCI). Methods: Preclinical and clinical studies were critically appraised, focusing on the effects of cilostazol on vascular smooth muscle and endothelial cells, platelet aggregation, lipid metabolism, and restenosis rates. Results: Experimental models show that cilostazol inhibits smooth muscle proliferation and intimal hyperplasia after arterial injury. Clinical trials demonstrate reduced restenosis after balloon angioplasty and stent implantation compared with aspirin, ticlopidine, or clopidogrel. Although approved by the FDA for intermittent claudication, cilostazol remains underused in the prevention of coronary restenosis. Conclusions: Current evidence supports cilostazol as an effective adjunctive therapy to reduce restenosis following PCI. Wider adoption and further large-scale trials are warranted to better define its role in contemporary interventional practice. Full article

We describe a patient with recurrent, brief episodes of chest discomfort caused by a highly mobile papillary fibroelastoma originating from the aortic wall and intermittently encroaching on the right coronary artery ostium. Initial 2D and 3D transthoracic and 2D transesophageal echocardiography identified a highly mobile mass in the ascending aorta above the aortic valve; the exact site of attachment and its relationship to the coronary ostia could not be clearly defined. Three-dimensional transesophageal echocardiography enabled precise anatomical reconstruction of the lesion and surrounding structures, clearly demonstrating its pedicle and proximity to the right coronary ostium. This imaging modality clarified the pathophysiological mechanism of symptoms and facilitated optimal surgical planning without the need for additional complex imaging techniques. Full article

Drug-coated balloons (DCBs) have emerged as an alternative to drug-eluting stents (DESs) in percutaneous coronary intervention, delivering antiproliferative drugs without leaving a permanent implant. This review provides a comparative analysis of sirolimus-coated DCBs (DCB-S), paclitaxel-coated DCBs (DCB-P), and DESs across key scenarios: de novo coronary lesions in chronic coronary syndrome (CCS), acute coronary syndromes (ACS), and in-stent restenosis (ISR). We discuss late lumen loss (LLL), target lesion/vessel revascularization (TLR/TVR), vessel patency, and major adverse cardiac events (MACE) outcomes, along with current guidelines and emerging indications for DCB-S. We also examine pharmacological differences between sirolimus and paclitaxel (mechanisms of action, tissue uptake, and healing profiles), trial methodologies, and recent innovations in DCB technology. Across stable de novo lesions (especially small vessels and high bleeding-risk patients), multiple trials show DCB-P can achieve non-inferior clinical outcomes to DES. Early data suggest newer DCB-S may likewise match DES outcomes in broader populations. In ACS, DCB-only strategies have demonstrated feasibility and safety in carefully selected lesions without heavy thrombus, with randomized studies like REVELATION (STEMI) showing non-inferior fractional flow reserve and low revascularization rates compared to DES. For ISR, DCB-P is an established Class I treatment in both BMS-ISR and DES-ISR, yielding similar or lower TLR rates than repeat stenting. DCB-S are now being evaluated as an alternative in ISR, aiming to avoid additional stent layers. Contemporary guidelines endorse DCB use in ISR and small vessels, and experts anticipate expanding indications as evidence grows. Sirolimus and paclitaxel differ in antiproliferative mechanisms and pharmacokinetics—sirolimus (cytostatic, mTOR inhibition) may offer faster endothelial recovery, whereas paclitaxel’s high lipophilicity ensures sustained arterial wall retention. Technological advances (e.g., phospholipid micro-reservoirs for sirolimus) are enhancing drug transfer and addressing prior limitations. In summary, DCB-P and DCB-S now represent viable alternatives to DES in specific scenarios, especially where “leaving nothing behind” could reduce long-term complications. Ongoing large randomized trials, such as SELUTION DeNovo, currently available as conference-presented data, together with longer-term follow-up will further clarify the optimal niches for DCB-S versus DCB-P and DES. Full article

Background: Coronary artery disease (CAD) remains a significant health challenge, placing a heavy burden on people and healthcare systems worldwide. Objectives: This narrative review aims to provide a comprehensive overview of recent advancements in the diagnosis, intervention, and pharmacological management of CAD, with a focus on emerging technologies shaping its future. Methods: This is a narrative review that synthesises information from diverse sources, including clinical trials, systematic reviews, meta-analyses, and preclinical studies, to provide a comprehensive overview of the current landscape and emerging trends in CAD management. The literature included in this review was sourced from original research articles and review papers published between January 2010 and December 2025. Results: Early detection has been transformed by non-invasive imaging, such as PCAT, and the addition of invasive and non-invasive FFR technology enables quicker and more accurate diagnoses. Biomarkers, such as high-sensitivity troponin, have further improved the precision of acute coronary syndrome detection, enhancing early intervention. In interventional cardiology, new-generation drug-eluting stents (DESs) have lowered restenosis rates, whereas robotic-assisted percutaneous coronary intervention (PCI) offers precision and reduced operator radiation exposure. Furthermore, the efficacy of drug-coated balloons (DCBs) has been established in the management of in-stent restenosis, and their application in de novo coronary lesions and bifurcation anatomy remains promising. Looking ahead, nanomedicine promises targeted plaque reduction and vascular repair, while 3D-bioprinted blood vessels offer durable, biocompatible grafts for surgical applications. Pharmacological developments, including modern cholesterol-lowering drugs, have also been crucial in achieving cholesterol targets. Conclusions: Despite significant advancements in diagnosis, intervention, and pharmacotherapy, several critical challenges remain, including the need for validated biomarkers and imaging modalities to identify vulnerable atheroma before symptoms arise. Continued research is essential to improve patient outcomes and address the global burden of CAD. Full article

Over the past decades, coronary revascularization has evolved dramatically with the introduction of bioresorbable scaffolds (BRSs), designed to provide temporary vessel support, elute antiproliferative drugs, and then fully resorb, ideally restoring natural vasomotion and eliminating long-term foreign-body reactions. Early enthusiasm for first-generation polymeric devices, such as the Absorb bioresorbable vascular scaffold, was tempered by increased rates of scaffold thrombosis and late adverse events, largely attributed to thick struts, suboptimal implantation techniques, and unpredictable degradation kinetics. Subsequent developments in polymeric (e.g., MeRes-100, NeoVas) and metallic magnesium-based scaffolds (e.g., Magmaris) have focused on thinner struts, improved radial strength, and refined resorption profiles. Clinical trials and meta-analyses, including ABSORB, AIDA, BIOSOLVE, and BIOSTEMI, reveal that optimized procedural strategies, especially the “PSP” approach (Prepare–Size–Post-dilate) and routine intravascular imaging, substantially reduce thrombosis and restenosis rates, aligning outcomes closer to those of contemporary drug-eluting stents (DESs). Nonetheless, challenges persist regarding inflammatory responses to degradation by-products, mechanical fragility in complex lesions, and patient selection. Ongoing innovations include hybrid polymer–metal designs, stimuli-responsive drug coatings, and AI-assisted imaging for precision implantation. While early-generation BRSs demonstrated both promise and pitfalls, next-generation platforms show steady progress toward achieving the dual goals of transient scaffolding and long-term vessel restoration. The current trajectory suggests that bioresorbable technology, supported by optimized technique and material science, may soon fulfill its original vision; offering safe, effective, and fully resorbable alternatives to permanent metallic stents in coronary artery disease. This review provides an updated synthesis of the design principles, clinical outcomes, and procedural considerations of drug-eluting bioresorbable scaffolds (BRSs). It integrates recent meta-analytic evidence and emerging insights on device mechanics, including the influence of strut thickness on radial strength and the potential role of non-invasive imaging in pre-implantation planning. Special focus is given to magnesium-based scaffolds and future directions in patient selection and implantation strategy. Full article

Coronary artery bypass grafting (CABG) remains a cornerstone of treatment for patients with advanced or complex coronary artery disease, yet long-term success is influenced by graft patency, progression of native disease, and ventricular remodeling. Optimizing the follow-up of these patients requires a structured approach in which multimodality cardiovascular imaging plays a central role. Echocardiography remains the first-line modality, providing readily available assessment of ventricular function, valvular competence, and wall motion, while advanced techniques, such as strain imaging and myocardial work, enhance sensitivity for subclinical dysfunction. Coronary computed tomography angiography (CCTA) offers excellent diagnostic accuracy for graft patency and native coronary anatomy, with emerging applications of CT perfusion and fractional flow reserve derived from CT (FFR-CT) expanding its ability to assess lesion-specific ischemia. Cardiovascular magnetic resonance (CMR) provides comprehensive tissue characterization, quantifying scar burden, viability, and inducible ischemia, and stress CMR protocols have demonstrated both safety and independent prognostic value in post-CABG cohorts. Nuclear imaging with single-photon emission computed tomography (SPECT) and positron emission tomography (PET) remains essential for quantifying perfusion, viability, and absolute myocardial blood flow, with hybrid PET/CT approaches offering further refinement in patients with recurrent symptoms. In patients after CABG, multimodality imaging is tailored to the patient’s characteristics, symptoms, and pre-test probability of disease progression. In asymptomatic patients, imaging focuses on surveillance, risk stratification, and the early detection of subclinical abnormalities, whereas in symptomatic individuals, it focuses on establishing the diagnosis, defining prognosis, and guiding therapeutic interventions. Therefore, the aim of our review is to propose updated and comprehensive guidance on the crucial role of multimodality cardiovascular imaging in the evaluation and management of post-CABG patients and to provide a practical, evidence-based framework for optimizing outcomes. Full article

Left main (LM) coronary artery disease remains a critical and high-risk clinical entity with considerable prognostic impact. While surgical revascularization has long been the standard of care, advances in percutaneous coronary intervention (PCI) techniques have significantly improved outcomes, challenging traditional treatment paradigms. Nevertheless, PCI in LM lesions continues to be associated with increased rates of repeat revascularization. This has underscored the importance of precise procedural planning and stent optimization, for which intravascular imaging is central. Among available modalities, intravascular ultrasound (IVUS) is well-established and widely endorsed in clinical guidelines for LM PCI. Optical coherence tomography (OCT), although increasingly utilized in other coronary settings, has a more limited but growing body of evidence in LM disease. This review explores the evolving application of OCT in LM interventions, focusing on its capabilities in plaque characterization, vessel sizing, stent selection, and identification of failure mechanisms such as malapposition and underexpansion. In addition, it discusses the utility of OCT in guiding bifurcation strategies and provides a comparative assessment with IVUS, integrating the most recent clinical data. Full article

Multimodal imaging plays a central role in optimizing the evaluation and management of myocardial ischemia by leveraging the complementary strengths of echocardiography, cardiac magnetic resonance imaging (CMR), single photon emission computed tomography (SPECT), positron emission tomography (PET), and invasive coronary angiography (ICA). Noninvasive functional imaging is typically recommended for patients with intermediate to high pre-test probability of coronary artery disease, while coronary computed tomography angiography (CCTA) is preferred for low to intermediate risk. Stress echocardiography is valuable for detecting wall motion abnormalities and is particularly effective in multivessel or left main disease, where perfusion techniques may miss balanced ischemia. CMR offers high spatial resolution and quantitative assessment of myocardial blood flow (MBF), while SPECT and PET quantify ischemic burden, with PET providing superior accuracy for MBF and microvascular disease. ICA remains the gold standard for defining the presence, location, and severity of epicardial coronary stenosis. It is indicated when noninvasive imaging reveals high-risk features, when symptoms are refractory to medical therapy, or when noninvasive results are inconclusive. While ICA offers high spatial resolution, it alone cannot assess the hemodynamic significance of intermediate lesions, nor the coronary microvasculature. Adjunctive invasive hemodynamic and provocative coronary testing (e.g., Fractional Flow Reserve—FFR, invasive Coronary Flow Reserve—CFR, Index of Microcirculatory Resistance—IMR, acetylcholine test) provide essential insights, especially in ischemia with nonobstructive coronary arteries. Given its procedural risks, ICA should be reserved for cases where it will impact management. Intravascular imaging may be used to further characterize lesions. In summary, modality selection should be individualized based on patient characteristics, comorbidities, contraindications, and the need for anatomical versus physiological data. Integrating noninvasive and invasive modalities provides a comprehensive, patient-centered approach to ischemia evaluation. Full article

Background and Objectives: Perioperative myocardial infarction (PMI) after coronary artery bypass grafting (CABG) remains difficult to diagnose due to varying biomarker thresholds and ECG criteria. This study aimed to evaluate the predictive value of ECG changes and cardiac biomarkers for identifying pathological findings in repeat coronary angiography after CABG. Materials and Methods: This retrospective study included 137 patients who underwent repeat coronary angiography due to suspected PMI. ECG changes and serial measurements of CK, CK-MB, and hsTnT were analyzed at 4, 8, and 18 h postoperatively. The primary endpoint was the identification of graft-related complications or new coronary lesions. Results: Pathological angiographic findings were detected in 85.4% (n = 117) of cases, predominantly graft-related complications (96.6%). ST-segment elevation (p < 0.01) and ST-segment depression (p = 0.02) were significantly associated with pathological findings. The combination of ST-segment elevation and CK-MB > 1.0 µkat/L also showed a high predictive accuracy (p < 0.01). HsTnT demonstrated the strongest diagnostic performance, with a threshold of 1231 ng/L at 18 h (AUC = 1.0; p < 0.01). Earlier postoperative biomarker elevations did not show significant discriminatory value. Conclusions: ECG remains the most accessible and fastest predictive tool for PMI detection. However, cardiac biomarkers only gain diagnostic relevance beyond 8 h postoperatively. A multimodal approach integrating biomarker kinetics and ECG changes may enhance early decision-making and improve patient outcomes, as ST-segment elevation in combination with CK-MB > 1.0 µkat/L serves as a relevant predictor. Notably, hsTnT levels > 1231 ng/L at 18 h reliably identified patients with pathological angiographic findings. These findings were derived from a highly selected cohort (~2% of all CABG patients) referred for coronary angiography and should therefore be interpreted as hypothesis-generating rather than directly generalizable to the broader surgical population. Full article

Rotational atherectomy (RA) is an established technique for modifying heavily calcified and fibrotic coronary artery lesions. Despite its efficacy, the use of a high-speed rotating burr can provoke platelet activation and endothelial injury, thereby increasing thrombotic risk, promoting inflammation, and impairing vascular healing. This study investigated the effects of RA and its procedural characteristics on endothelial function and platelet activation by assessing circulating biomarkers. We prospectively analyzed 34 patients undergoing elective RA at a tertiary center. Blood samples were obtained before and 12–24 h after the procedure. Plasma levels of soluble E-selectin, soluble intercellular adhesion molecule-1 (ICAM-1), platelet factor 4 (PF4), P-selectin, and cluster of differentiation 40 ligand (CD40L) were measured. The study population had a mean age of 71 ± 8.9 years, and 73.8% were male. Cardiovascular comorbidities were prevalent, including diabetes (61.9%), hypertension (92.9%), hypercholesterolemia (42.9%), heart failure (45.2%), atrial fibrillation (21.4%), prior PCI (81%), and prior CABG (11.9%). RA significantly increased levels of P-selectin (55.5 ± 26.1 vs. 68.9 ± 26.5, p < 0.001), CD40L (2261.3 ± 2489.9 vs. 3602.0 ± 2428.5, p = 0.01), and PF4 (6054.7 ± 5751.8 vs. 10,877.6 ± 4979.7, p < 0.001). Moreover, mean burr speed correlated with CD40L elevation, while burr-to-artery ratio correlated with E-selectin increase (all p < 0.05). RA induces significant platelet activation and endothelial injury, with biomarker changes suggesting correlation with procedural parameters. These findings highlight the biological impact of RA and may inform strategies to optimize the safety of complex PCI. Full article

Background/Objectives: Diabetes mellitus (DM), especially insulin-dependent DM (IDDM), is strongly associated with adverse outcomes following percutaneous coronary intervention (PCI) failure. Polymer-free drug-eluting stents (PF-DESs) have emerged as a promising strategy to mitigate long-term coronary inflammation. This study aimed to evaluate the role of PF-DES, as compared to permanent-polymer DES (PP-DES) and biodegradable-polymer DES (BP-DES), in a real-world cohort of IDDM patients with obstructive coronary artery disease (CAD) undergoing PCI. Methods: IDDM patients with CAD who underwent PCI with DES at Parma University Hospital were divided into two study groups: PF-DES group vs. BP/PP-DES group. The primary endpoint was target vessel failure (TVF) at the 4-year follow-up. Survival analyses and propensity score matching (PSM) were performed to account for baseline differences. Results: A total of 170 IDDM patients with 215 treated lesions (31.6% PF-DES; 68.4% BP/PP-DES) were included. The PF-DES group experienced significantly lower rates of TVF (10.3% vs. 27.2%, p < 0.01, log rank p = 0.0072) compared with the BP/PP-DES group. PSM analysis confirmed the good clinical performance of PF-DES (HR 0.27, p < 0.01). Conclusions: In this PSM-based observational study, PF-DESs were associated with significantly lower rates of TVF compared with BP/PP-DESs in IDDM patients undergoing PCI for CAD. These suggest that PF-DES may represent a personalized PCI strategy for IDDM patients, with prognostic benefits that become increasingly pronounced as the clinical and anatomical risk profile worsens. Full article

Coronary artery disease remains the leading cause of cardiovascular morbidity and mortality worldwide, affecting millions of individuals each year. Coronary artery calcification is a common finding in patients with advanced atherosclerosis and represents an important determinant of procedural success during percutaneous coronary intervention. Severe calcifications are associated with increased procedural complexity and elevated complication rates due to challenging lesion preparation, suboptimal stent expansion, and less favorable long-term clinical results. This review summarizes the present understanding of vascular calcification mechanisms, discusses relevant diagnostic imaging modalities, and describes current plaque modification techniques used to optimize procedural outcomes. Methods such as rotational, orbital, and laser atherectomy, as well as specialized balloon technologies and intravascular lithotripsy, are discussed with regard to their mechanisms of action, clinical effectiveness, and safety profiles. Particular emphasis is placed on the integration of advanced imaging for precise lesion assessment, improved patient selection, and the use of combination strategies in complex cases. Finally, emerging technologies and future directions are highlighted, with the goal of enhancing procedural safety, device deliverability, and treatment outcomes in the evolving field of interventional cardiology. Full article

Cardiac computed tomography (CT) has long evolved as a highly accurate screening tool for coronary artery disease. New technologies such as multi-detector rows and artifact reduction by a new motion correction algorithm have made it possible to evaluate coronary artery stenosis with higher diagnostic accuracy and lower radiation exposure. In addition to the anatomical evaluation of coronary arteries, the introduction of fluid dynamic analysis enables the measurement of coronary fractional flow reserve (FFR) for each stenotic lesion, which can only be achieved through invasive catheter evaluation. Myocardial ischemia can now also be detected using myocardial stress perfusion CT imaging. In addition, with the advent of dual-energy imaging or new image reconstruction technology, the addition of late contrast phase imaging enables myocardial late enhancement and left ventricular (LV) extracellular volume (ECV) analysis, which was previously possible only with cardiac magnetic resonance imaging (MRI). It has also been reported that LV ECV may be useful in predicting prognosis in cases with cardiomyopathies. In addition, retrospective imaging of the entire heart in a single cardiac cycle is now possible with lower radiation exposure, enabling not only morphological evaluation of the heart and valves but also myocardial strain analysis, which has conventionally been evaluated mainly by echocardiography and is expected to be applied in clinical practice in the future. Cardiac CT, which overcomes the weaknesses of other modalities while demonstrating greater usefulness through the latest technological development, is expected to expand its field of application to the entire heart analysis. The purpose of this review is to provide an overview of the technological development of cardiac CT, which has seen remarkable development in recent years, along with its clinical utility, with the aim of enabling clinicians to fully utilize it in daily practice. Full article

In coronary artery disease (CAD), the initiation, progression, and regression of atherosclerosis remain incompletely understood, limiting the effectiveness of specific diagnostic and personalized medicine management strategies based on current imaging and assessment methods. In this scientific rationale and study design analysis, the framework conceptualizes the cardiovascular system as an integrated hydraulic network of pumps and pipes, advancing a shift from static imaging of luminal stenosis toward dynamic assessment of coronary flow. Grounded in fluid mechanics and acoustic principles, this analysis establishes a scientific rationale for an angiographic investigation of hemodynamic disturbances that compromise endothelial integrity in coronary arteries. The first section examines injury arising from repetitive flexion and extension of coronary segments driven by left ventricular contraction, most prominent at the transition from diastole to systole. The second section evaluates the hypothetical effects of thickened boundary layers and intimal injury caused by oxygen deprivation along the proximal portion of the outer curvature of side branches. The third section explores the hypothetical role of recirculating flow in accelerating lesion development at these sites. The fourth section presents an acoustic-based diagnostic framework for assessing the hypothetical impact of retrograde pressure-wave propagation associated with water-hammer phenomena. Collectively, these mechanisms establish the systematic codification and spatial delineation of coronary lesions as represented on the coronary acoustic map. Building on these insights, the present analysis proposes a clinical trial framework integrating AI-driven algorithmic protocols to rigorously assess the diagnostic performance and predictive accuracy of the coronary acoustic map. Full article