Background:Established biomarkers are used for risk stratification after STEMI, but their relationship with cardiac magnetic resonance (CMR)-derived infarct characteristics at 30 days remains incompletely understood. Because 30-day CMR reflects an intermediate post-infarction stage between acute myocardial injury and the later chronic infarct state, we evaluated whether baseline high-sensitivity troponin T (hsTnT), N-terminal pro-B-type natriuretic peptide (NT-proBNP), cellular communication network factor 1 (CCN1), and proprotein convertase subtilisin/kexin type 9 (PCSK9) are associated with 30-day CMR parameters. Methods:In this pre-specified CLEVER-ACS substudy, associations between baseline biomarkers and 30-day CMR parameters were assessed using Spearman correlation. Receiver operating characteristic (ROC) analysis with area under the curve (AUC) was performed for associations after median dichotomization. Exploratory analyses assessed associations with relative CMR changes. Results:56 STEMI patients were analyzed. hsTnT and NT-proBNP showed the strongest association pattern across functional, structural, volumetric, and microvascular 30-day CMR parameters. CCN1 was associated only with left ventricular ejection fraction (LVEF), and PCSK9 showed no significant associations. hsTnT and NT-proBNP showed relevant discriminatory performance for parameters including LVEF (AUC 0.79, 95% CI 0.67-0.91, and 0.81 [0.69-0.93]), left ventricular scar (0.87 [0.77-0.96] and 0.76 [0.63-0.89]), scar mass (0.84 [0.74-0.95] and 0.79 [0.67-0.91]), and microvascular obstruction (0.72 [0.56-0.87] and 0.71 [0.55-0.86]), respectively. Exploratory analyses linked only hsTnT and NT-proBNP to changes in CMR parameters. Conclusions:Baseline hsTnT and NT-proBNP showed strong associations with 30-day CMR parameters after STEMI, whereas CCN1 and PCSK9 provided no discriminatory value in this intermediate post-infarction stage.

BACKGROUND:Quantitative flow ratio (QFR) is a guideline-recommended angiography-based estimation of fractional flow reserve (FFR) for functional lesion evaluation. The FAVOR III Europe trial raised concerns regarding the safety and efficacy of QFR compared with FFR. Whether the poor clinical outcomes in the trial were attributable to software limitations or suboptimal in-procedure QFR analysis is unknown. AIMS:We aimed to compare in-procedure and core laboratory QFR, and to evaluate the quality of in-procedure QFR analyses. METHODS:The 1,008 patients randomised to QFR in FAVOR III Europe were assessed for eligibility. Core laboratory QFR analyses were performed by two blinded observers. The quality of in-procedure QFR analyses were evaluated during patient enrolment. Quality scores from 1 (very poor) to 5 (very good) were assigned based on adherence to the standard operating procedure (SOP). RESULTS:Of 1,233 vessels with in-procedure QFR, 1,191 (96.6%) were analysable in the core laboratory and were included in the paired analysis. The median in-procedure QFR was 0.81 (interquartile range [IQR] 0.71-0.90) and core laboratory QFR was 0.84 (IQR 0.73-0.91). The mean difference was 0.02 (95% limits of agreement: -0.26 to 0.29). Spearman's rank correlation coefficient was 0.58, and diagnostic agreement was 72%. Most in-procedure QFR analyses demonstrated very good (19%), good (45%), or acceptable (28%) SOP adherence, while 8% were rated as poor or very poor. Suboptimal angiographic quality, poor in-procedure QFR analysis quality, high SYNTAX score, and diabetes were predictors of increased variability. CONCLUSIONS:In FAVOR III Europe, agreement between in-procedure and core laboratory QFR was modest. Measurement variability increased with reduced angiographic quality, poor in-procedure QFR analysis quality, and more advanced coronary artery disease.

BACKGROUND:Quantitative flow ratio (QFR) is an angiography-based method for estimating fractional flow reserve (FFR). The FAVOR III Europe trial showed that QFR guidance did not meet non-inferiority to FFR guidance, as measured by a composite endpoint of all-cause death, myocardial infarction, and unplanned revascularisation at 12 months. AIMS:We sought to report the 2-year outcomes of the QFR-guided diagnostic strategy and the FFR-guided strategy as applied in the FAVOR III Europe trial. METHODS:FAVOR III Europe was a multicentre, randomised, open-label, non-inferiority trial. A total of 2,000 patients from 34 European medical centres were randomised to undergo QFR- or FFR-guided revascularisation of intermediate coronary artery stenoses. Endpoints assessed at the 2-year follow-up included the rates of major adverse cardiac events (MACE) and its individual components of all-cause death, myocardial infarction, and unplanned revascularisation. The rates of MACE were compared for superiority by unadjusted Cox regression analysis. The outcomes from 1 to 2 years were explored in a landmark analysis. RESULTS:At 2 years, the rates of MACE were 9.7% in the QFR group and 7.4% in the FFR group (hazard ratio [HR] 1.34, 95% confidence interval [CI]: 0.98-1.81; p=0.064). In the landmark analysis, the rates of MACE between 1 and 2 years were 3.2% in the QFR group and 3.2% in the FFR group (HR 0.97, 95% CI: 0.58-1.62; p=0.92). CONCLUSIONS:The excess risks associated with QFR-guided revascularisation compared with FFR were confined to the first year. From 1 to 2 years, the rates of MACE developed similarly in the QFR and the FFR groups.

Renal dysfunction might affect outcomes in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel coronary artery disease (MVD) undergoing percutaneous coronary intervention (PCI). In MULTISTARS AMI, patients with STEMI and MVD were randomized to immediate or staged PCI of non-culprit lesions. In this pre-specified analysis, patients were stratified according to the presence of renal dysfunction at baseline, defined at an estimated glomerular filtration rate (eGFR) of 60 ml/min/1.73 m2. Patients with an eGFR < 30 ml/min/1.73 m2 were excluded from the trial. The primary endpoint was a composite of death, non-fatal myocardial infarction, stroke, unplanned revascularization, or hospitalization for heart failure at 1 year. In MULTISTARS AMI, 108 (13

High-risk plaque features detected by optical coherence tomography (OCT) in culprit lesions (CL) of acute coronary syndrome (ACS) are linked to adverse cardiovascular outcomes. Whether the coexistence of multiple high-risk features within the same CL confers additional prognostic impact remains unknown. Within the multicentric, translational OPTICO-ACS study, the CL of 338 ACS-patients undergoing pre-intervention OCT-imaging were screened for the presence of conventional high-risk plaque features. The primary endpoint was the incidence of major adverse cardiac events plus (MACE +) defined as a composite of cardiac death, non-fatal myocardial infarction, target vessel revascularization and re-hospitalization for progressive or unstable angina pectoris at two years follow-up. The relationship between each individual and multiple co-occurring high-risk features were comprehensively compared between patients with – and without clinical events. A ruptured fibrous cap [80

BACKGROUND:Approximately one half of patients undergoing transcatheter aortic-valve implantation (TAVI) have concomitant coronary artery disease. Although percutaneous coronary intervention (PCI) is often performed before TAVI, the preferred treatment strategy has not been established. METHODS:We conducted an international, open-label, randomized, noninferiority trial at 48 centers in Europe. Patients with severe aortic stenosis and coronary artery disease were randomly assigned in a 1:1 ratio to a strategy of either TAVI before PCI (TAVI-first group) or PCI before TAVI (PCI-first group). The primary end point was a composite of death from any cause; nonfatal myocardial infarction; ischemia-driven revascularization; rehospitalization related to the valve, procedure, or heart failure; or life-threatening, disabling, or major bleeding at 1 year after randomization. The noninferiority margin was 6.6 percentage points, with testing for noninferiority of TAVI first as compared with PCI first. RESULTS:A total of 986 patients underwent randomization: 498 were assigned to the TAVI-first group and 488 to the PCI-first group. A primary end-point event occurred in 105 patients (22.2%) in the TAVI-first group and in 112 patients (24.2%) in the PCI-first group (risk difference, -2.0 percentage points; 95% confidence interval, -7.4 to 3.4; P<0.001 for noninferiority). Serious adverse events occurred in 264 patients in the TAVI-first group and in 273 patients in the PCI-first group. CONCLUSIONS:Among patients with severe aortic stenosis and coronary artery disease, a strategy of TAVI before PCI was noninferior to a strategy of PCI before TAVI with respect to the primary end point at 1 year. (Funded by University Hospital Zurich and others; TAVI PCI ClinicalTrials.gov number, NCT04310046.).

Patients with ST-segment elevation myocardial infarction (STEMI) and higher Killip class are at an increased risk of death. We sought to assess outcomes of an immediate or staged multivessel percutaneous coronary intervention (PCI) in patients with higher Killip class presenting with STEMI and multivessel coronary artery disease (MVD). We conducted a subgroup analysis of the MULTISTARS AMI trial with stratification of patients according to Killip classes. Outcomes of patients with Killip class I and Killip class ≥ II were compared. The primary end point was a composite of all-cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. The primary end point occurred in 15 (17.9%) patients with Killip class ≥ II and 78 (11.4%) patients with Killip class I (HR, 1.57 [95%CI, 0.92-2.70], p-value = 0.11). Comparing an immediate with a staged multivessel PCI strategy, the immediate strategy reduced the primary endpoint in patients with Killip class I (6.8% vs. 15.8%; HR, 0.40 [95%CI, 0.25-0.65], p-value < 0.01), whereas the difference was not significant in patients with Killip class ≥ II (20.0% vs. 15.4%; HR, 1.37 [95%CI, 0.50-3.78], p-value = 0.55). There was a significant treatment-by-subgroup interaction for the primary endpoint (P interaction = 0.029), with immediate multivessel PCI not showing an advantage in Killip class ≥ II patients. Conclusively, in the MULTISTARS AMI trial, the benefit of immediate multivessel revascularization strategy observed in patients with Killip class I appeared attenuated in those presenting with Killip class ≥ II, suggesting a potential difference in treatment effect that warrants further investigation. (Supported by Boston Scientific; MULTISTARS AMI, NCT03135275).

BackgroundTranscatheter aortic valve implantation (TAVI) outcomes using balloon-expandable valves (BEV) and self-expanding valves (SEV) differ owing to device-specific technical features and anatomical factors.ObjectivesThis study aimed to evaluate prospective TAVI device selection based on anatomic features to optimise outcomes compared with published randomised data using two newer-generation devices.MethodsA total of 607 consecutive patients with severe aortic stenosis treated at a single centre from 2020 to 2023 underwent TAVI using a prospective device selection strategy. Heavy and/or asymmetric valve calcification and bicuspid anatomy were preferentially treated with SAPIEN 3/SAPIEN 3 ULTRA BEV, whereas small annulus dimensions and less calcified valves were preferentially treated with ACURATE neo/ACURATE neo2 SEV. In-hospital Valve Academic Research Consortium-3 endpoints and 1-year mortality were evaluated.ResultsACURATE was used in 182 (30%) patients and SAPIEN 3 in 425 (70%) patients. The proportion of women was higher in the ACURATE group (65% vs. 31%, p < 0.001), and patients were older (84 vs. 80 years, p < 0.001). Technical success (97% vs. 97%, p > 0.99) and new permanent pacemaker implantation during index hospitalisation (10% vs. 10%, p > 0.99) did not differ between the ACURATE and SAPIEN 3 groups. Intended performance was higher in the ACURATE group than in the SAPIEN 3 group (98% vs. 91%, p = 0.005), with aortic regurgitation ≥moderate (2% vs. <1%, p = 0.32), and mean transvalvular gradient ≥20 mmHg (<1% vs. 4%, p = 0.043). The estimated mortality at 1 year was 14% versus 12% (log-rank p = 0.60) in the ACURATE and SAPIEN 3 groups, respectively.ConclusionsA prospective device selection strategy using two complementary TAVI valves resulted in comparable outcomes between the SEV and BEV devices. In-hospital intended performance was higher in the ACURATE group. Despite baseline group differences, there was no difference in 1-year mortality.

Background and Aims The gut microbiota is a modulator of cardiometabolic disease. Circulating imidazole propionate (ImP) is a microbiota-derived proatherogenic amino acid metabolite modulating the inflammatory response of myeloid cells, endothelial function, and glucose metabolism. This study examined the prognostic value of ImP in patients with coronary artery disease (CAD). Methods Circulating ImP levels were measured in independent prospective cohorts of patients with acute coronary syndrome (ACS; Swiss ACS cohort n = 4787, Swiss cardiac magnetic resonance imaging cohort n = 150, German ACS cohort n = 1428) and chronic coronary syndrome (CCS; German CCS cohort n = 701). Major adverse cardiovascular events (MACE), defined as the first occurrence of a composite of death, non-fatal myocardial infarction, or non-fatal stroke after admission, were the primary endpoint. Cox models, accounting for established risk factors including the gut-derived cardiovascular risk factor trimethylamine N-oxide, were used to evaluate the predictive value of ImP. Results Circulating ImP was associated with more advanced CAD and with cardiometabolic characteristics including diabetes and elevated high-sensitivity C-reactive protein. High ImP was an independent predictor of MACE [Swiss ACS cohort: hazard ratio (HR) per log2 increase 1.22, 95% confidence interval (CI) 1.10-1.35, P < .001; German ACS cohort: HR 2.34, 95% CI 1.46-3.76, P < .001; German CCS cohort: HR 1.32, 95% CI 1.13-1.53, P < .001)] and of mortality (Swiss ACS cohort: HR 1.34, 95% CI 1.17-1.54, P < .001; German ACS cohort: HR 2.38, 95% CI 1.48-3.82, P < .001; German CCS cohort: HR 1.50, 95% CI 1.14-1.98, P = .004) after adjustment for established risk factors. Imidazole propionate provided predictive value beyond trimethylamine N-oxide (Swiss ACS cohort: HR 1.30, 95% CI 1.05-1.61, P = .014; German CCS cohort: HR 1.31, 95% CI 1.12-1.53, P = .001). Conclusions Gut microbiota-derived ImP predicted MACE in patients with CAD independently of traditional risk factors and holds promise as a therapeutic target. Imidazole propionate may refine risk stratification for personalized secondary prevention strategies.

INTRODUCTION:Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality worldwide, frequently associated with acute coronary syndromes. While immediate coronary angiography is recommended in patients with ST-segment elevation myocardial infarction, it remains controversial in other cases. Further on diagnosing ST-segment elevation can be challenging. Artificial intelligence (AI) has shown promise in electrocardiogram (ECG) interpretation, but its value for predicting relevant coronary artery lesions and the need for intervention after OHCA is unknown. METHODS:We conducted a single-center, retrospective, cohort study of OHCA patients admitted to the intensive care unit between 01/2019 and 12/2021 who underwent coronary angiography within seven days. Admission ECGs were analyzed using an AI-powered interpretation tool (PMcardio®). Clinical, echocardiographic, angiographic, laboratory, and mortality data were collected. The primary outcome was relevant coronary artery stenosis, defined as ≥50% diameter stenosis of the left main coronary artery or ≥70% of all other vessels. The secondary outcome was coronary revascularization. Multivariable logistic regression analysis was performed. RESULTS:Among 204 OHCA patients undergoing coronary angiography within 7 days, relevant coronary artery stenosis was present in 157 patients (77%), and 127 patients (62.3%) underwent coronary revascularization. Age, male sex, initial shockable rhythm, and AI-based ECG-derived occlusion myocardial infarction (OMI) detection were independently associated with relevant coronary artery lesions. These variables formed the CASPER-Score (range 0-8 points), demonstrating good discrimination (AUC = 0.86). The model predicting revascularization demonstrated moderate discrimination (AUC = 0.74). CONCLUSION:The CASPER-Score may improve early risk stratification and support decision-making regarding coronary angiography in OHCA patients.

Diabetic patients with ST-segment elevation myocardial infarction (STEMI) are at an increased risk of cardiovascular events as compared to non-diabetic patients. This analysis investigated outcomes of diabetic patients presenting with multivessel disease (MVD) and STEMI in a contemporary trial and the relevance of an immediate versus staged multivessel PCI strategy in this high-risk population. Patients enrolled in the MULTISTARS AMI trial were stratified according to the presence/absence of diabetes. Baseline characteristics and outcomes of diabetic and non-diabetic patients were compared. The primary end point was a composite of all-cause death, non-fatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. In the MULTISTARS AMI trial, out of a total of 840 patients, 131 (15.6

BACKGROUND: Coronary artery ectasias and aneurysms (CAE/CAAs) are among the less common forms of coronary artery disease, with undefined long-term outcomes and treatment strategies. AIMS: To assess the clinical characteristics, angiographic patterns, and long-term outcomes in patients with CAE, CAA, or both. METHODS: This 15-year (2006-2021) retrospective singlecentre registry included 281 patients diagnosed with CAE/CAA via invasive coronary angiography. Major adverse cardiovascular events included all-cause death, non-fatal myocardial infarction, unplanned ischaemia-driven revascularisation, hospitalisation for heart failure, cerebrovascular events, and clinically overt bleeding. Time-dependent event risks for the CAE and CAA groups were assessed using Cox regression models and Kaplan- Meier curves. RESULTS: CAEs (n = 161, 57.3%) often had a multi-district distribution (45.8%), while CAAs (78, 27.8%) exhibited a single-vessel pattern (80%). The co-existence of CAAs and CAE was observed in 42 cases (14.9%), and multi- vessel obstructive coronary artery disease was prevalent (55.9% overall). Rates of major adverse cardiovascular events were 14.3% in-hospital and 38.1% at a median follow-up of 18.9 (interquartile range [IQR] 6.0-39.9) months. The presence of CAAs was associated with increased major adverse cardiovascular events risk in comparison to CAE (hazard ratio [HR] = 2.26, 95% confidence interval [CI] 1.38-3.69, p = 0.001), driven by a higher hazard ratio of non-fatal myocardial infarctions (HR = 5.00, 95% CI 1.66-15.0, p = 0.004) and unplanned ischaemia-driven revascularisation in both dilated (HR = 3.23, 95% CI 1.40-7.45, p = 0.006) and non-dilated coronary artery segments (HR 3.83, 95% CI 2.08-7.07, p = 0.001). CONCLUSIONS: Overlap between obstructive and dilated coronary artery disease is frequent. Among the spectrum of dilated coronary artery disease, the presence of a CAA was associated with worse long-term outcomes.

Background Coronary microvascular dysfunction has been associated with adverse cardiovascular events following acute myocardial infarction. This study evaluates the role of the angiography‐derived index of microcirculatory resistance (angio‐IMR) in predicting myocardial damage in patients with ST‐segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI). Methods and Results In this post hoc analysis of the CLEVER‐ACS (Controlled‐Level Everolimus in Acute Coronary Syndromes) trial, the associations between post‐PCI angio‐IMR of infarct‐related coronary arteries (IRAs) and infarct size, microvascular obstruction, and left ventricular ejection fraction at 30 days as assessed by cardiac magnetic resonance were investigated. High post‐PCI angio‐IMR was defined as ≥40 mm Hg*s . In non‐IRAs, angio‐IMR was measured before IRA‐PCI. A total of 52 IRAs and 94 non‐IRAs of 52 patients were analyzed. Post‐PCI angio‐IMR was 41.5 (interquartile range [IQR], 28.5–55.7) mm Hg*s in IRAs and pre‐PCI angio‐IMR was 43.7 (IQR, 31.7–54.0) mm Hg*s in non‐IRAs (P=0.70). Patients with high post‐PCI angio‐IMR (52%) exhibited a larger myocardial infarct size (36.0 [IQR, 23.0–52.5] g versus 14.5 [IQR, 6.50–26.5] g, P<0.001) and a lower left ventricular ejection fraction (46.5% [IQR, 39.5%–49.5%] versus 55.0% [IQR, 48.0%–61.4%], P=0.002) at 30 days as compared with those with low post‐PCI angio‐IMR values. Post‐PCI angio‐IMR positively correlated with myocardial infarct size (r=0.45, P=0.001) and extent of microvascular obstruction (r=0.40, P=0.004) at 30 days. Post‐PCI angio‐IMR predicted myocardial infarct size (area under the curve, 0.78 [IQR, 0.65–0.92]; P=0.001) and extent of microvascular obstruction (area under the curve, 0.74 [IQR, 0.60–0.89]; P=0.009) at 30 days. Conclusions In patients with ST‐segment–elevation myocardial infarction, post‐PCI angio‐IMR was identified as independent predictor of myocardial infarct size and extent of microvascular obstruction. Registration URL: https://clinicaltrials.gov; Unique Identifier: NCT01529554.

The British Cardiovascular Intervention Society Jeopardy Score (BCIS-JS) is an established, simplified scoring system for assessing coronary artery disease (CAD) extensiveness with excellent agreement between the invasive and the computed tomography (CT) angiography-based scores. Originally developed for use during invasive coronary angiography, it supports procedural planning and risk stratification by estimating the extent of myocardium at risk. The computed tomography (CT)-based version (CT-BCIS-JS) has shown excellent agreement with the invasive score. We aimed to investigate the value of the CT-BCIS-JS in predicting long-term outcomes. This retrospective single-center study included 337 patients referred for coronary CT angiography (CCTA). CT-BCIS-JS was calculated using a purpose-developed online calculator, and patients were divided into extensive and non-extensive CAD (BCIS ≥ 6 and BCIS < 6, respectively). The primary outcome was the composite of all-cause death and nonfatal myocardial infarction (MI) and the secondary outcome was major adverse cardiovascular events (MACEs), including all-cause mortality, MI, unstable angina requiring hospitalization, and coronary revascularization. Kaplan-Meier curves and multivariable-Cox regression analyses were utilized to compare outcomes between groups. Of the 337 patients, 249 (73.9

STUDY AIMS: Left atrial appendage occlusion (LAAO) is an accepted alternative stroke prevention strategy for patients with atrial fibrillation (AF) and contraindications to oral anticoagulation despite the lack of randomised data in this population. This study aims to compare the outcomes of LAAO and direct oral anticoagulation (DOAC) therapy in patients with high bleeding risk. METHODS: This cardinality-matched analysis comprised data from the Beat-AF and Swiss-AF cohorts (n = 3960; enrolment from 2010 to 2014 and from 2014 to 2017, respectively), along with the Zurich LAAO Registry (n = 535; patients included between 2010 and 2023). The primary endpoint was a composite of stroke, cardiovascular death or major bleeding. The individual components constituted the secondary endpoints. Time-dependent cumulative incidence curves were constructed and a competing risk analysis was included. RESULTS: After matching, 478 patients with a DOAC score ≥8 and 159 patients with previous major bleeding were compared in a 1:1 and 1:2 ratio, respectively, regarding their stroke prevention strategy (DOAC versus LAAO). After a median follow-up time of 4.9 years (interquartile range [IQR]: 2.2–6.1) in all patients with a DOAC score ≥8 and 4.4 years (IQR: 2.0–6.0) in all patients with previous major bleeding, there were no significant differences in the primary endpoint (hazard ratio [HR]: 0.88, 95% confidence interval [CI]: 0.67–1.14, p = 0.33 and HR: 0.79, 95% CI: 0.50–1.27, p = 0.33) and in the rates of stroke (HR: 0.74, 95% CI: 0.39–1.42, p = 0.36 and HR: 1.09, 95% CI: 0.33–3.62, p = 0.89) and cardiovascular death (HR: 0.97, 95% CI: 0.68–1.38, p = 0.85 and HR: 0.91, 95% CI: 0.50–1.64, p = 0.74). The rate of major bleedings was significantly lower in the LAAO group of both cohorts (HR: 0.55, 95% CI: 0.32–0.94, p = 0.029 and HR: 0.32, 95% CI: 0.13–0.79, p = 0.013). CONCLUSION: In this high bleeding risk population, LAAO was associated with similar effectiveness in preventing atrial fibrillation-related stroke and cardiovascular death and significantly lower rates of major bleeding compared to DOAC therapy. This strengthens the value of LAAO as an alternative stroke prevention strategy for patients at high risk of bleeding.

Background In patients undergoing high‐risk percutaneous coronary intervention, Impella has become an important adjunctive tool to support revascularization. The impact of age on the outcomes of patients undergoing high‐risk percutaneous coronary intervention is limited. The aim of this study is to describe the characteristics and outcomes of patients ≥75 years of age undergoing Impella‐supported high‐risk percutaneous coronary intervention. Methods and Results Baseline characteristics and outcomes of patients ≥75 years of age versus those of patients <75 years of age in patients enrolled in the cVAD PROTECT III (Catheter‐Based Ventricular Assist Device Prospective, Multi‐Center, Randomized Controlled Trial of the IMPELLA RECOVER LP 2.5 System Versus Intra Aortic Balloon Pump in Patients Undergoing Non Emergent High Risk Percutaneous Coronary Intervention) study (NCT04136392). Major adverse cardiovascular and cerebral events (composite of all‐cause death, nonfatal myocardial infarction, stroke/transient ischemic attack, and repeat revascularization) were assessed at 30 and 90 days and all‐cause death at 1 year. Out of 1237 patients, 493 (39.9%) patients were ≥75 years of age. Patients ≥75 years of age had less diabetes and prior myocardial infarction, more hypertension and dyslipidemia, worse renal function, more severe valvular heart disease, but higher left ventricular ejection fraction (P<0.05 for all comparisons). Baseline Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery scores were similar between groups. Older patients underwent more left main percutaneous coronary intervention (58% versus 39%; P<0.0001), atherectomy (32% versus 22%; P<0.0001), and femoral access (87% versus 79%, P=0.0003) as compared with younger patients. In‐hospital vascular complications did not differ, but rates of respiratory failure, pericardial tamponade, and cardiogenic shock were higher in older patients. Rates of all‐cause death and major adverse cardiovascular and cerebral events did not differ between groups at 30 and 90 days. Rates of all‐cause death at 1 year were higher in patients ≥75 years (adjusted hazard ratio, 1.99 [95% CI, 1.24–3.18], P=0.004). Conclusions Impella‐supported high‐risk percutaneous coronary intervention in older patients is feasible with an acceptable safety profile. However, age ≥75 years remained a statistically significant predictor for all‐cause death at 1 year. Registration URL: https://clinicaltrials.gov; Unique Identifier: NCT04136392.

A 74-year-old female was found hemiplegic in a public restroom. After arrival in our stroke unit, a computed tomography (CT) was performed, and she was diagnosed with bilateral carotid artery and right vertebral artery occlusion due to an acute type A aortic dissection. The patient deteriorated quickly to a GCS of 3 and was brought to the operating room, where a salvage replacement of the ascending aorta and the proximal aortic arch was performed with unilateral antegrade cerebral perfusion. Three days later, a significant decrease in left ventricular function and increase in cardiac biomarkers were observed. Coronary CT displayed residual dissection of the aortic root, extending into the left main coronary artery. The patient underwent an intravascular ultrasound-guided stenting of the left main, resulting in total recovery of heart function. She was extubated on the fourth postoperative day, with no residual neurological impairment. This case report advocates for the proper management of patients with ATAAD with severe neurological impairment, emphasizing the importance of a robust multidisciplinary approach in their care.

Background:The aim of this study was to evaluate the hypothesis that employing the "flare the outflow" technique might allow anchoring of transcatheter balloon-expandable valves (BEVs) in patients with pure aortic regurgitation. Methods:This was a single-center, 6-patient, consecutive, retrospective observational cohort. Inoperable patients with pure AR were included to perform transcatheter aortic valve implantation. The technique involved deploying BEVs with 2-mm oversizing and "flare the outflow" technique. Computed tomography scans were obtained at baseline and after implantation. Results:BEVs with the flared outflow were successfully implanted in all patients. All patients were discharged without device migration and none or trace paravalvular leak. At 1-year follow-up, no deaths, valve dysfunction, or reinterventions were observed. Among the 5 patients out of 6 who underwent follow-up computed tomography scans, findings confirmed the overexpanded outflow of the BEVs compared to the annulus, indicated by mean (24.5 vs. 23.3 mm, p = 0.02) and minimal diameters (24.6 vs. 22.2 mm, p = 0.01). Conclusions:The utilization of BEVs incorporating the "flare the outflow" technique demonstrated feasibility and effectiveness in inoperable patients with pure AR. Further studies are required to determine the durability and lifetime management associated with this technique.

The impact of sex on the baseline characteristics, morphology, and clinical presentation of degenerative aortic stenosis (AS) is well-documented but remains poorly understood. Unlike valve surgery, for which patients have been predominantly male, percutaneous treatment of AS has shown balanced representation of both sexes, with women demonstrating greater benefit from transfemoral aortic valve replacement compared to surgical treatment. This review explores sex-specific differences in the epidemiology, pathophysiology, diagnostic challenges, treatment approaches, and clinical outcomes of degenerative AS. Furthermore, it addresses technical, sex-specific considerations in transfemoral aortic valve replacement, including preprocedural screening, device selection, implantation strategy, and postprocedural management.