Coronary complications during percutaneous coronary intervention (PCI) are uncommon but may lead to abrupt hemodynamic deterioration, myocardial infarction, cardiac tamponade, emergency surgery, other adverse clinical outcomes, or death. As contemporary PCI is increasingly performed in patients with complex coronary anatomy and greater clinical risk, prompt recognition and familiarity with complication-management strategies remain essential. This focused review summarizes contemporary management of coronary perforation, acute vessel closure, and equipment loss or entrapment, with emphasis on recent advances. Recent developments in coronary perforation management include flow-preserving perfusion balloons, improved deliverability and optimization of covered stents, covered-stent fenestration for bifurcation perforations, contemporary embolization strategies, and emerging data regarding anticoagulation reversal. For acute vessel closure, intravascular imaging and chronic total occlusion-derived dissection and re-entry techniques can facilitate restoration of true-lumen flow when conventional rewiring fails, while intracoronary epinephrine and other adjunctive therapies have expanded treatment options for refractory no-reflow. Recent advances in equipment loss and entrapment include novel guidewire-retrieval techniques and percutaneous bailout strategies for entrapped atherectomy devices. Most coronary complications can be managed percutaneously when recognized early and treated with a stepwise approach. A systematic approach incorporating pre-procedural preparation, intraprocedural vigilance and escalation, and structured post-procedural follow-up may further improve outcomes.
This comprehensive overview evaluates recent progress in human pluripotent stem cell-derived cardiomyocyte therapies to improve the outcome of heart failure patients, with emphasis on delivery routes, early clinical employment, and the barriers for sustained functional cardiac repair. Multiple complementary strategies for cardiac remuscularization are being pursued in parallel, including single cell suspension, multicellular spheroids, cardiomyocyte sheets, and engineered myocardial tissues. Early clinical translation has established feasibility across several platforms, while engineered heart muscle has provided the clearest evidence of persistent graft retention and structural myocardial augmentation. Cardiomyocyte sheets have reached conditional regulatory approval, and catheter-based spheroid delivery is entering clinical evaluation. However, arrhythmogenicity, immune rejection, incomplete maturation and manufacturing complexity remain major challenges on the path to the clinic. Pluripotent stem cell-derived cardiac products are transitioning from experimental concepts to clinically tested therapies. Future progress will depend on identifying the optimal patient population, product format and delivery route, reducing the need for immunosuppression, and demonstrating meaningful improvements in patient hospitalization, quality of life, and survival.
This review summarizes the current state-of-the-art in cardiovascular digital twins and discusses their potential to improve treatment planning for congenital heart disease (CHD). We provide an overview of the digital twin workflow, from medical images to virtual procedures and simulations, and review representative applications in pulmonary vascular disease, single-ventricle treatment planning, and electrophysiological interventions. Advances in computational modeling, high-performance computing, and machine learning have enabled the development of cardiovascular digital twins that reproduce cardiovascular biomechanics and physiology with increasing accuracy and on clinically relevant timescales. Examples of current applications include stenting procedures for pulmonary vascular disease, evaluation of Fontan conduit configurations, and optimization of electrophysiological interventions. Although clinical translation remains in its early stages, continued technological advances and clinical validation position digital twins as a promising tool for personalized CHD care.
Coronary angiography remains an imperfect tool for assessing functional ischemia in intermediate lesions. This review highlights evidence-based diagnostic and therapeutic approaches in coronary physiology to bridge the gap between guideline recommendations and real-world clinical practice. Although landmark trials and Class I guidelines establish physiologic testing as central to revascularization, real-world adoption remains critically low at less than 1 in 5 of eligible cases. Recent research emphasizes using both hyperemic (FFR) and non-hyperemic pressure ratios (iFR, RFR, DFR, dPR) grounded in pressure-flow dynamics to improve decision-making. Invasive physiology optimizes percutaneous coronary intervention (PCI) accuracy and patient outcomes. Implementing a systematic step-by-step approach empowers clinicians to overcome technical barriers, driving higher adoption and expanding precise, physiology-guided revascularization into routine practice. In this review, we provide a practical guide to performing, interpreting, and applying physiologic testing in contemporary practice.
Atrial fibrillation (AF) is increasingly recognized among endurance athletes, but despite growing awareness, athlete-associated AF remains poorly characterized and is often managed using non-specific treatment paradigms. A one-size-fits-all approach is unlikely to adequately address the unique needs of this population. Subsequently, we propose and describe a practical, phenotype-based framework for evaluating and managing AF in athletes. We describe five overlapping mechanistic and clinical - especially the latter two – athlete phenotypes: vagally mediated/trigger-dominant, adrenergic/exercise-triggered, substrate-dominant, older with mixed mechanisms, and competitive/contact sport. Those that are vagally mediated/trigger dominant represent the true endurance athlete and are characterized by paroxysmal yet highly symptomatic episodes with low AF burden that are highly susceptible to pulmonary vein isolation alone. Adrenergic/exercise-triggered athletes may follow traditional teaching and experience symptoms at peak exertion, but these are challenging to manage because of performance limitations with traditional therapies. Substrate-dominant individuals develop profound left atrial remodeling, which evidence suggests increases recurrence risk despite catheter ablation. The older athlete with mixed mechanisms may have conventional AF risk factors that require traditional management in addition to the etiologies above. Lastly, those in competitive/contact sports are defined less by arrhythmia than by the implications of anticoagulation and return-to-play considerations. Athletes represent a distinct and heterogeneous group in which exercise-related triggers, autonomic influences, atrial remodeling, anticoagulation considerations, and performance goals substantially influence disease expression and management. The management of AF in athletes should prioritize not only arrhythmia suppression but also preservation of exercise capacity and athletic identity. This more nuanced understanding of athlete-associated AF will be essential as the population of athletes with AF continues to grow.
