Background: Robotic-assisted percutaneous coronary intervention (rPCI) offers potential benefits, including improved lesion assessment, optimised stent deployment and reduced radiation exposure. However, comparative data, particularly in Japanese populations, remain limited. Aim: To compare procedural and clinical outcomes between second-generation rPCI and manual percutaneous coronary intervention (mPCI) in patients with chronic coronary syndrome and acute coronary syndrome over a 1-year follow-up period. Methods: This retrospective cohort study included 176 patients who underwent rPCI using the second-generation CorPath GRX Vascular Robotic System. Following 1:1 propensity score matching at the lesion level, 176 patients were identified in the mPCI group. The co-primary endpoints were 1-year all-cause mortality and major adverse cardiovascular events, defined as a composite of cardiac death, non-fatal MI, target lesion revascularisation, stent thrombosis and stroke. Results: Both groups had similar baseline characteristics. Compared with mPCI, rPCI was associated with shorter total procedural time (26 minutes [19–37] versus 71 minutes [52–90]; p<0.01), fluoroscopy time (14 minutes [10–18] versus 16 minutes [10–26]; p=0.04), lower contrast volume (99 [82.8–129.0] versus 141 ml [116–172]; p<0.01) and lower dose area product (3,628.3 [2,552.1–5,352.3] versus 6,349.1 [4,080.0–8,382.3]; p<0.01). At 1 year, the co-primary endpoints of all-cause mortality (p=0.33) and major adverse cardiovascular events (p=0.79) were comparable between groups. Conclusion: Compared with mPCI, rPCI was associated with shorter procedural and fluoroscopy times, lower contrast volume and lower dose area product, while demonstrating similar clinical outcomes at 1 year.
Out-of-hospital cardiac arrest (OHCA) remains associated with poor survival and marked variation in post-resuscitation care. Drawing on discussion from the British Cardiovascular Intervention Society (BCIS) OHCA focus group, this article summarises five practical considerations for management following return of spontaneous circulation. First, selective conveyance to specialist cardiac arrest centres may be most effective when aligned with the BCIS algorithm, particularly for patients with features suggesting a reversible cardiac cause. Second, early risk stratification with MIRACLE2 may support decision-making when interpreted alongside specialist clinical judgement. Third, early multidisciplinary team review may improve coherence in a complex condition that often spans cardiology, intensive care, neurology and emergency medicine. Fourth, neuroprognostication is likely to be most robust when delayed appropriately, guided by European Resuscitation Council recommendations and delivered through a structured multimodal multidisciplinary team process. Finally, post-survival rehabilitation and family support should be regarded as core components of the OHCA pathway rather than optional afterthoughts.
Background: People with severe mental illness (SMI) experience significant health disparities, including in cardiovascular care. This study used natural language processing (NLP), an artificial intelligence method, to investigate care pathways for SMI patients within a highly protocolised urban primary angioplasty network for ST-elevation MI (STEMI). Methods: This cohort study used NLP to extract SMI diagnoses and clinical data from free-text electronic health records, including STEMI and non-STEMI audit data. Primary outcomes included 28-day and 1-year mortality, with secondary outcomes examining pathway performance metrics and procedural data. Exploratory outcomes assessed presenting symptoms and comorbidities. Results: A total of 2,292 adults presented with first-time STEMI from 2012–2019, of whom 51 (2.2%) had recorded SMI diagnoses. No significant differences were found in mortality between SMI and non-SMI patients at 28-day and 1-year, although a non-significant trend toward higher crude mortality in SMI patients emerged at 3 years (23.5% versus 16.1%; p=0.152). Procedure metrics and timings were similar between groups. SMI patients were more likely to have presented with cardiac arrest (adjusted OR 2.48; 95% CI [1.18–5.22]; p=0.017) and had higher rates of chronic obstructive pulmonary disease (adjusted OR 2.20; 95% CI [1.00–4.83]; p=0.049). Percutaneous coronary intervention rates in SMI patients with a non-STEMI were less than their representation in the overall non-STEMI population (2.2% versus 3.3%; p=0.042). Conclusion: Highly protocolised STEMI pathways appear to provide equitable acute care for patients with SMI without excess short-term mortality. However, potential disparities emerge in longer-term outcomes and in non-STEMI treatment pathways, suggesting a need for improved secondary prevention and targeted interventions for this vulnerable population.
Background: This national survey evaluated awareness of indications and perceived barriers to the application of intracoronary imaging (ICI) among physicians and cath lab allied health professionals (AHP) in the UK. Methods: A web-based questionnaire consisting of 35 questions, covering operator and institutional demographics, physician-based indications for ICI, physician confidence-competence and barriers to ICI use, was distributed to 974 physicians (consultant and trainee operators) and 713 AHPs via the British Cardiovascular Intervention Society. For statistical analyses, a two-sided p<0.05 was considered statistically significant. Results: In all, 327 physicians (including 30% of practising UK consultants) and 125 AHPs responded. The greatest response was observed in early career operators (uptake 38% versus 7% for those with ≤5 years versus >20 years’ experience, respectively). There was a preference for intravascular ultrasound (IVUS) over optical coherence tomography (OCT; 74% versus 26%, respectively). Strongest indications for ICI use by lesion aetiology were left main percutaneous coronary intervention (97.7%), stent failure (96.5%), procedural optimisation (92.6%) and calcific disease (89.8%). Operators reported OCT superiority in the identification of stent failure and plaque rupture, and IVUS superiority in ostial and left main disease, spontaneous coronary dissection and chronic total occlusion interventions. Core barriers to ICI application were procedural turnover (65.4%), lack of training and education (61.8%) and the absence of consultant-level proctorship (56.1%). A mismatch between operator-reported confidence in device use and competency in image interpretation across lesion aetiologies was identified, with 58.9% and 57.7% of operators expressing a desire to actively upskill and increase appropriate ICI usage, respectively. Conclusion: This first UK national survey on ICI highlights important barriers to the application of ICI in routine clinical practice. These data should stimulate a paradigm shift in collaborative widespread national training and education strategies for ICI in the UK.
Aims:Drug-coated balloons (DCBs) are increasingly used in percutaneous coronary intervention (PCI) but there are limited data available on practice patterns. Our survey evaluated the views of interventional cardiologists with respect to various clinical and technical aspects of DCB angioplasty. Methods:A voluntary, online survey involving 13 questions - the Drug Eluting Technologies Evaluation & Current Trends (DETECT) Clinical Practice Survey - was conducted in two waves: a census of Irish interventional cardiologists in April 2025 and an onsite survey at the EuroPCR Congress in May 2025. The question topics included indications for DCB use, device selection factors, dual antiplatelet therapy (DAPT) duration and intravascular imaging use. Respondent characteristics were recorded. Results:A total of 136 respondents (126 consultants, 10 fellows) from 39 countries (60 Ireland, 76 EuroPCR) participated in the survey. The survey revealed that most consider a DCB for in-stent restenosis (ISR; 99%), small vessel disease (95%) and bifurcation lesions (77%). A lower proportion consider a DCB strategy in chronic total occlusion (29%), any vessel size (21%) or acute coronary syndrome (17%). No differences by level of interventional experience (>10 years, <10 years or fellow) (χ²=10.35; p=0.11). DCB comprised 1-10% of annual PCI for half of the respondents (55%); most respondents (82%) anticipated an increase in their use. Paclitaxel DCBs were widely available (93%) but sirolimus DCBs less so (55%). DAPT duration post-DCB in chronic coronary syndromes was commonly prescribed for 3 months (43%) or 6 months (33%). Most use intravascular imaging for 21-50% of their DCB cases. Conclusion:This survey suggests that DCBs have been widely adopted by interventional cardiologists for the treatment of ISR and small vessel disease, with anticipated growth in the next 2 years.
Background: Controversy exists around AF risk after patent foramen ovale (PFO) closure. This study characterised dynamic ECG changes over 6 months after Amplatzer closure, focusing on electrical remodelling. Methods: In all, 246 PFO patients underwent serial ECGs (P wave dispersion [PWD], PR interval, QRS, corrected QT interval [QTc]) and echocardiography before PFO closure and 24 hours and 1, 3 and 6 months after closure. Temporal changes were analysed. Subgroup analyses evaluated ECG changes according to comorbidity (migraine or cerebral infarction). Results: PWD increased significantly at 24 hours and peaked at 1 month, remaining elevated compared with baseline at 6 months (p<0.001). Of all patients, 5.3% had PWD ≥40 ms. The PR interval was significantly shortened after PFO closure, with this persisting at 6 months (p<0.001). AF occurred in six (2.4%) patients and supraventricular tachycardia occurred in eight (3.3%). QRS and QTc were stable. With regard to cardiac structure/function, no significant echocardiographic changes were seen from before to after PFO closure. In subgroups analyses, PR shortening was greater in patients with migraine than in those with cerebral infarction (p<0.001). Conclusion: PFO closure induced a transient elevation in PWD and sustained PR shortening. Under limited spot ECG monitoring, no clinically significant arrhythmias or structural changes were detected. However, extended surveillance is warranted to evaluate potential late-onset arrhythmogenic sequelae.
The Subintimal Tracking and Re-entry (STAR) technique is conventionally used during chronic total occlusion percutaneous coronary interventions as a bailout strategy to re-establish flow. This case highlights its use in the setting of primary percutaneous coronary intervention for ST-elevation MI (STEMI). An 80-year-old woman presented with anterior STEMI. The lesion was wire-uncrossable, and the STAR technique was used to successfully re-establish flow. Drug-coated balloon angioplasty was also performed. A follow-up angiogram 3 months later confirmed widely patent left anterior descending sub-intimal drug-coated balloon segments, and definitive stenting was performed. The procedural team faced the daunting challenge of a left anterior descending occlusion with no distal visualisation from collaterals. The STAR technique proved integral in ensuring successful re-establishment of thrombolysis in MI 3 flow. The patent vessel on the interval angiogram reinforces that the STAR technique is a safe and effective method to re-establish flow in STEMI patients with wire-uncrossable lesions.
Covered stents are often used to manage coronary perforations, but they can inadvertently obstruct side branches. Perforations in the left main artery can lead to severe haemodynamic instability, especially if the side branch, the left circumflex artery, becomes completely occluded by the covered stent. The authors describe a successful case of sealing a distal left main perforation using fenestration of a covered stent in combination with a jailed-balloon technique to preserve blood flow to the left circumflex artery.
Following the recently upgraded recommendations for intravascular imaging use from the European Society of Cardiology and the American Heart Association, we present a UK consensus statement on the use of intravascular ultrasound (IVUS) in percutaneous coronary intervention. Developed by 26 senior interventional cardiologists across a range of UK centres, this statement reflects growing evidence and changing expectations for IVUS use. We discuss the indications for IVUS, the current patterns of use in the UK, anticipated future standards and the need for broader adoption. We propose a standardised workflow and recommend routine documentation of a core IVUS dataset to support quality and as a mechanism for improvement. Persistent barriers, such as perceived cost, training variability and procedural integration, are addressed with practical solutions, including the introduction of national training curricula incorporating intravascular imaging accreditation for operators and targeted education for allied health professionals. Our goal is to support clinicians, catheter lab teams and service leads in embedding IVUS more consistently into practice to optimise patient outcomes.
Complete revascularisation during ST-elevation MI (STEMI) has Class 1A guideline support based on multiple randomised controlled trials showing improved clinical outcomes compared with culprit-only percutaneous coronary intervention. However, the concept that all STEMI patients with bystander disease should undergo complete revascularisation is flawed. The randomised controlled trials have highly variable anatomical and physiological inclusion criteria and drivers for outcome benefit, to the extent that it is hard to pick out a possible mechanism of effect. There is a case to pursue some fundamental questions about how prophylactic stenting may help bystander disease in STEMI patients, as well as to try to establish whether there are high-risk patients/vessels/lesions that derive substantial benefit from stenting and, conversely, others in whom it is futile.
Background:The DynamX Coronary Bioadaptor System incorporates a novel uncaging element that disengages approximately 6 months post-implantation following polymer resorption, while preserving longitudinal structural integrity. This innovative design aims to address the limitations of conventional drug-eluting stents by facilitating restoration of physiological vessel function in the treated segment without compromising radial support. Methods:This retrospective study assessed the acute mechanical performance of the DynamX Bioadaptor in complex coronary lesions, as evaluated by optical coherence tomography (OCT) before and after DynamX implantation, with specific focus on lumen gain, device expansion, and strut apposition. Results:A total of 29 coronary lesions from 24 patients were retrospectively analysed by OCT. Pre-implantation plaque morphology revealed ruptured plaques in 34.5% of lesions and calcified plaques in 55%. An OCT-based calcium score of 3 or 4 was observed in nine lesions. Post-implantation OCT demonstrated an acute lumen gain of 1.37 ± 0.8 mm and a residual area stenosis of 14.7 ± 9%. The incidence of malapposed struts (strut-lumen distance >300 μm) was low (0.64 ± 1.34%). Edge dissections were observed in four lesions, with two (6.9%) requiring bailout stenting. Conclusion:The DynamX Bioadaptor showed favourable acute performance, achieving adequate lumen enlargement and optimal expansion and apposition in calcified and thrombotic lesion subsets, supporting its use in contemporary clinical practice.
Aim:This meta-analysis aims to assess the effectiveness of hypothermia as an adjunctive therapy in percutaneous coronary intervention (PCI) for patients with ST-elevation MI. Methods:A comprehensive literature search was conducted using electronic databases to identify relevant studies published up to September 2023. Studies investigating the use of adjunctive hypothermia in ST-elevation MI patients undergoing PCI were included. Data on clinical outcomes, including mortality, infarct size, left ventricular function, major adverse cardiac events and microvascular obstruction, were extracted and analysed. Bleeding and infection events as primary safety endpoints in the safety analysis were also assessed. Results:Eight studies involving 488 patients were included in this meta-analysis. The pooled analysis revealed no significant difference in all-cause mortality between the adjunctive hypothermia group and the control group (OR 0.60; 95% CI [0.24-1.53], p=0.29). There was no significant difference in major adverse cardiac event rates between the two groups (OR 1.59; 95% CI [0.63-4.01]). Additionally, no significant differences were observed in infarct size, left ventricular function or microvascular obstruction. In the safety analysis, hypothermia significantly increased the risk of infection (OR 7.22, 95% CI [2.47-21.10]; p=0.0003; I²=0%) but showed no significant impact on bleeding events (OR 2.27; 95% CI [0.76-6.78]; p=0.14; I²=0%). Conclusion:While previously believed to show promise, hypothermia as adjunctive therapy in PCI fails to achieve any significant superiority over standard interventions according to our analysis. Furthermore, hypothermia was associated with a significantly increased risk of infection without a notable impact on bleeding events, raising concerns about its safety profile. Nevertheless, our findings should be interpreted with caution, considering the limitations of our analysis, such as the small number of studies available in the literature. Continued research efforts on larger sample sizes are essential to either refine or refute the current findings.
Background: Percutaneous coronary intervention (PCI) for complex anatomy is increasingly common. The third-generation Ultimaster TANSEI drug-eluting stent (DES) was developed to optimise safety and efficacy in challenging lesions. Methods: This was a prospective, single-arm, multicentre registry (August 2020-November 2022) of patients with complex lesions - left main, bifurcations, small vessels and long lesions - treated with Ultimaster TANSEI DES and followed for 1 year. The primary endpoint was the device-oriented composite endpoint (DoCE), including cardiac death, target-vessel MI, target-vessel revascularisation (TVR) and stent thrombosis. The secondary endpoint was the patient-oriented composite endpoint (PoCE), including all-cause death, any MI and any revascularisation. Results: In total, 501 patients with 591 complex lesions (mean age 66.7 years; 79.6% male; 33.4% with diabetes) were treated. Lesion types: left main 11%, bifurcations 43.9%, small vessels 40.7%, long lesions 34.3%. At 1 year, incidence rates were: DoCE 3.23 per 100 person-years (95% CI [1.84-5.24]) and PoCE 5.04 per 100 person-years (95% CI [3.26-7.44]). In subgroup analyses, long lesions (>35 mm) showed consistently higher risk: DoCE RR 4.22 (95% CI [1.49-11.95]; p=0.006), PoCE RR 4.93 ([2.10-11.57]; p<0.001), overall mortality RR 4.79 [1.53-15.06]; p=0.007) and TVR RR 17.60 [2.22-139.51]; p<0.001).
This is a case report of a 62-year-old male patient who developed coronary perforation during a percutaneous coronary intervention. He presented with a non-ST-elevation MI and had a history of hypertension and hypercholesterolaemia, with an elevated BMI. Coronary angiography revealed severe calcific coronary disease within an angulated proximal left anterior descending artery. Following a heart team meeting, the consensus was for complex percutaneous coronary intervention to the left anterior descending artery, with or without left main stem involvement. Following initial balloon dilatation within the left anterior descending artery there was a clear coronary perforation. The operators could not advance a balloon past the point of perforation. It was thought that a calcific spur was preventing this. The patient suffered no acute haemodynamic compromise and there was no evidence of pericardial effusion on bedside echocardiography. After a period of observation, the operators made the decision to stop. The patient remained in the cardiac care unit on dual antiplatelet therapy for 2 weeks. The operators then brought the patient back to the laboratory and completed the case with relative ease. This case highlights the potential for conservative, non-surgical management in selected patients with contained coronary perforations, suggesting that appropriate monitoring and pharmacotherapy can mitigate the risks associated with invasive correction.
Intravascular ultrasound (IVUS) has been in clinical use for more than three decades. Despite evidence that supports the application of the technology from multiple registries, randomised trials and meta-analyses, adoption remains low. Potential barriers to the adoption of IVUS are a lack of understanding as to how to accurately interpret images and how to incorporate it into clinical workflow. To address this, this paper summarises evidence-based protocols for the application of IVUS during percutaneous coronary intervention (PCI) into an easily understood workflow. Standardisation of approaches and wider adoption of IVUS-optimised PCI should improve patient outcomes and PCI durability.
Background:There is a lack of studies systematically addressing long-term echocardiographic features after patent foramen ovale (PFO) closure. Thus, the present study investigated long-term echocardiographic features after percutaneous closure of PFO. Methods:This was a single-centre observational study based on the institutional registry of consecutive patients undergoing PFO closure. Clinical and echocardiographic features during the follow-up were investigated. Results:Between 2006 and 2023, 355 consecutive patients underwent PFO closure following transitory ischaemic attack (TIA) or cerebrovascular insult (CVI). Echocardiography immediately after the procedure and at 6 months was performed in 306 (86%) patients, who had repeat examinations at either between 1 and 5 years (median 1.32 years), between 5 and 10 years (median 7.10 years) or after 10 years (median 11.64 years). The percentage of patients with complete closure (no bubbles during the Valsalva manoeuvre) increased from 64% after the procedure to 80% at 6 months (p<0.05), and ranged between 77% and 81% thereafter (NS). Functional closure (≤10 bubbles) was observed in 93% of patients after the procedure and remained between 94% and 97% thereafter (NS). Except for decreased immediate complete closure (60% versus 83%; p<0.001), there was no difference between the Amplatzer PFO occluder and alternative devices. Among the 15 patients with greater than moderate residual shunt, reasons for the shunt were determined in 73% of patients and included leakage at the level of device, fenestration/atrial septal defect and pulmonary arteriovenous malformation. There was no late device embolisation, thrombus formation or pericardial effusion. Clinical follow-up revealed recurrent TIA and CVI rates of 0.11 and 0.06 per 100 patient-years, respectively. Conclusion:We demonstrated high (>90%) and persistent functional PFO closure beyond 10 years, independent of closure device. There was no late device embolisation, thrombus formation or pericardial effusion. Favourable echocardiographic features were associated with very low rates of recurrent TIA or CVI.
Background:Despite class 1 recommendations and clinical evidence supporting optical coherence tomography (OCT), its adoption is limited. While randomised controlled trials show clinical benefits of OCT under strict protocols, its real-world performance is unclear. Aims and methods:All-comEr Registry of OCT (AERO) to Investigate the MLD-MAX Algorithm for OCT-guided-precision-PCI in Daily Routine (ILUMIEN-V-AERO; NCT05324683) is a prospective, multicentre OCT registry aiming to recruit 2,000 patients across sites in the UK, Germany and Saudi Arabia. The study seeks to evaluate the real-world use of an algorithmic approach to OCT-guided percutaneous coronary intervention (PCI) (MLD-MAX) and directly compares its outcomes to those from the ILUMIEN-IV randomised controlled trial. The primary endpoint for this comparison is post-PCI minimum stent area relative to the reference segments. Secondary endpoints include OCT imaging assessments (minimum stent area, edge dissection, stent malapposition, mean stent expansion, plaque protrusion, reference segment disease), procedural outcomes (procedural and fluoroscopy time, contrast use, renal replacement therapy) and clinical endpoints (a composite endpoint of target lesion failure [cardiac death, ischaemia-driven target lesion revascularisation, target vessel MI] and unplanned hospitalisation for unstable angina). All patients will undergo clinical follow-up at 30 days and 6 months to assess target lesion failure. Beyond the inclusion criteria of the ILUMIEN-IV trial, this study will explore the role of OCT in diagnosing acute coronary syndrome, its application in guiding drug-coated balloon PCI and the impact of core laboratory support and critical evaluation on operator performance. Conclusion:ILUMIEN-V-AERO is a large, prospective registry designed to assess the real-world performance of OCT and provide insights into its role in underexplored areas of PCI guidance.
Transcatheter aortic valve replacement (TAVR) has developed into a viable treatment for aortic regurgitation (AR), particularly in high-risk or elderly patients unable to undergo surgery. Early generation devices encountered significant challenges, including high mortality rates, residual paravalvular leaks, and complications such as valve embolisation. However, advancements in TAVR technology, including self-expanding and balloon-expandable devices, have improved procedural outcomes. Dedicated devices, such as the Trilogy system (JenaValve) and J-Valve (Edwards Lifesciences), specifically designed for AR, have demonstrated superior performance with reduced complications and better patient survival. Other devices, such as Cusper (Cuspa) and the Zeta/Alpha systems (Laguna Tech), show potential for treating complex AR cases, including those with non-calcified valves or active endocarditis. These innovations offer hope for patients with severe AR, highlighting the need for tailored approaches based on individual anatomical and pathological variations.
