BACKGROUND:Spontaneous coronary artery dissection (SCAD) is an underrecognised cause of acute coronary syndrome (ACS). The left anterior descending artery (LAD) is most frequently affected, but the clinical and prognostic implications of SCAD in this location unclear. AIMS:We sought to evaluate the clinical characteristics, angiographic features, management, and outcomes of patients with SCAD involving the LAD (LAD-SCAD) using data from a nationwide registry. METHODS:The Spanish Registry on SCAD (SR-SCAD) is a prospective, multicentre registry enrolling consecutive patients with angiographically confirmed SCAD from 34 hospitals across Spain. Coronary angiograms were reviewed by a central core laboratory, and all clinical events were independently adjudicated. Primary endpoints were in-hospital major adverse events and long-term major adverse cardiovascular and cerebrovascular events (MACCE). Outcomes were compared between patients with and without LAD involvement. RESULTS:Among 388 patients (mean age 54±11.5 years), 190 (49%) had LAD involvement, after excluding 8 patients with concomitant left main extension. Compared with other vessels, LAD dissections were longer (35 mm [interquartile range [IQR] 22-50] vs 30 mm [IQR 20-40]; p=0.01), more often multivessel (16% vs 3%; p<0.001) and multisegment (30% vs 19%; p=0.024), with higher creatine kinase-myocardial band (170 U/L [IQR 112-190] vs 24 U/L [IQR 4-78]; p=0.032), lower left ventricular ejection fraction (55±5.4% vs 58±6.6%; p=0.034), and more frequently treated with percutaneous coronary intervention (27% vs 17%; p=0.027). Notably, LAD involvement independently predicted higher long-term MACCE (adjusted hazard ratio 2.00, 95% confidence interval: 1.10-3.97; p=0.046), compared with SCAD in other locations. CONCLUSIONS:LAD-SCAD identifies patients with more complex angiographic features and higher long-term risk compared with non-LAD-SCAD. Despite frequent percutaneous coronary intervention, outcomes were not improved in this high-risk LAD population, emphasising the prognostic relevance of dissection location and supporting individualised treatment.
The assessment of myocardial ischaemia is entering a new computational era. Beyond the traditional boundaries of anatomical imaging and invasive fractional flow reserve (FFR), emerging techniques based on coronary computed tomography (CT) angiography and invasive coronary artery angiography now allow the derivation of physiological information without pressure wires, hyperaemic agents, or additional procedures. These image-based indices, commonly referred to as FFR-CT and angiography-derived FFR, are reshaping both diagnostic and interventional cardiology. This review provides an updated synthesis of the latest evidence on their clinical integration. FFR-CT has demonstrated its ability to refine diagnostic pathways, reduce unnecessary invasive angiography, and safely guide management decisions within precision diagnostic strategies. In parallel, angiography-derived FFR has matured into a real-time wire-free solution within the catheterisation laboratory. Randomised studies confirm that physiology-guided revascularisation improves procedural efficiency and optimises outcomes compared with angiography alone. Beyond ischaemia detection, these technologies now extend to virtual stenting, procedural simulation, and the identification of vulnerable plaques through haemodynamic indices such as endothelial shear stress and perivascular inflammation mapping. Together, these developments mark a paradigm shift: from anatomy-based to physiology-driven and, ultimately, prediction-guided coronary intervention. By merging artificial intelligence, computational modelling, and advanced imaging, CT- and angiography-derived physiology offer the prospect of fully integrated real-time functional assessment. This convergence defines a new frontier in coronary medicine, where precision, automation, and clinical impact coalesce to transform everyday cardiovascular practice.
BACKGROUND:Transcatheter tricuspid valve replacement (TTVR) is increasingly performed to treat patients with severe or greater symptomatic tricuspid regurgitation (TR) at high risk for surgery. However, patients with large tricuspid annuli are not eligible for most TTVR systems. AIMS:This study aimed to report intraprocedural and 30-day clinical success rates for patients undergoing TTVR with the 55-70 mm LuX-Valve Plus system in the European TRINITY study cohort. METHODS:The co-primary endpoints were intraprocedural and 30-day clinical success, as defined by the Tricuspid Valve Academic Research Consortium criteria. Clinical and echocardiographic outcomes were reported. RESULTS:Enrolled patients (n=114) had a mean age of 77.8±5.8 years and a high Society of Thoracic Surgeons risk score of 9.9±6.0%. Intraprocedural success was 95.6%, with no cases of intraprocedural mortality or stroke. Two patients (1.8%) required cardiac surgery within the first 24 hours. At 30 days, 7 patients (6.1%) required a pacemaker implantation. Thirty-day clinical success was 91.2%, with residual severe TR being the primary reason for failure. In 93.7% of patients, residual TR was moderate or less. The mean Kansas City Cardiomyopathy Questionnaire score improved from 57.3±20.7 points to 71.0±23.5 points (p<0.001), and the proportion of patients with New York Heart Association Class III-IV symptoms reduced from 57.1% at baseline to 20.9% at 30 days (p<0.001). CONCLUSIONS:TTVR with the LuX-Valve Plus system to treat patients with severe or greater symptomatic TR and a large tricuspid annulus was associated with high intraprocedural and 30-day clinical success rates, significant TR reduction and functional improvement, and low permanent pacemaker implantation rates.
BACKGROUND:Catheter-directed thrombolysis (CDT) reduces the right-to-left ventricular ratio (RV/LV ratio) in patients with intermediate-risk pulmonary embolism (PE). Prior randomised studies comparing CDT to anticoagulation used ultrasound-assisted devices and high doses of thrombolytics with extended infusion durations, which may increase healthcare costs and complications, thereby limiting its clinical applicability. AIMS:We sought to evaluate the efficacy and safety of low-dose, short-duration CDT compared with unfractionated heparin (UFH) in patients with acute intermediate-high-risk PE. METHODS:In this open-label, randomised controlled trial, patients with acute intermediate-high-risk PE were randomised 1:1 to receive CDT (4 mg recombinant tissue plasminogen activator [r-tPA] per catheter over 2 hours) plus UFH or UFH alone. The primary endpoint was the change in RV/LV ratio at 24 hours. Secondary endpoints included thrombus burden reduction, changes in vital signs and echocardiographic measures of RV function, length of hospital stay, 30-day mortality, and 90-day recurrent PE. Safety endpoints included major and minor bleeding. RESULTS:Between August 2020 and October 2024, 60 patients were randomised, with 58 completing follow-up (CDT: n=29; UFH: n=29). CDT plus UFH improved the RV/LV ratio at 24 hours compared with UFH alone (-0.17 vs +0.02; p=0.01). Secondary endpoints did not differ between groups. One death occurred in the UFH group. One patient experienced haemodynamic deterioration during CDT, successfully managed with additional r-tPA. No major bleeding occurred. Minor bleeding occurred in three patients (10%) in the CDT group and one (3%) in the UFH group (p=0.29). CONCLUSIONS:Low-dose, short-duration CDT plus UFH improved the RV/LV ratio without increasing major bleeding compared with UFH alone in intermediate-high-risk PE.
BACKGROUND:Invasive coronary functional testing enables the classification of angina with non-obstructive coronary arteries (ANOCA) into distinct endotypes. However, real-world data linking endotype identification to subsequent pharmacological management and patient-reported symptom outcomes remain limited. AIMS:We sought to evaluate the association between coronary endotypes, post-testing pharmacological treatment patterns, and changes in angina-related quality of life in patients with ANOCA in a multicentre real-world registry. METHODS:Consecutive ANOCA patients undergoing invasive coronary functional testing were included. Patients were classified into six endotypes using adenosine- and acetylcholine-based testing. Pharmacological therapy was adjusted at the discretion of the treating physician based on the functional test results. The primary endpoint was a clinically meaningful improvement in angina-related health status, defined as a ≥5-point increase in the 7-item Seattle Angina Questionnaire (SAQ-7) summary score, assessed within each endotype. RESULTS:Among 525 patients, endotype distribution was as follows: normal physiology 10.5%, elevated resting coronary blood flow 8.8%, high resistance 13.9%, compensated high resistance 14.9%, epicardial spasm 33.3%, and microvascular spasm 18.7%. After testing, prescription patterns differed across the endotypes, with increased use of beta blockers, ranolazine, and renin-angiotensin-aldosterone system blockers in coronary microvascular dysfunction endotypes and greater use of non-dihydropyridine calcium channel blockers in vasospastic endotypes. At follow-up, a ΔSAQ-7 summary score ≥5 points was observed in elevated resting flow, high-resistance, compensated high-resistance, and epicardial spasm endotypes (all p<0.001) but not in microvascular spasm or normal physiology. CONCLUSIONS:In this multicentre real-world registry, invasive coronary endotyping was associated with distinct pharmacological management patterns and differential changes in angina-related quality of life across ANOCA endotypes.
