High-risk acute pulmonary embolism (PE) is a life-threatening condition necessitating hemodynamic stabilization and rapid restoration of pulmonary perfusion. In this context, evidence regarding the benefit of advanced circulatory support and pulmonary recanalization strategies is still limited. In this observational study, we assessed data of 1060 patients treated for high-risk acute PE with 991 being included in a target trial emulation to investigate all-cause in-hospital mortality estimates with different advanced treatment strategies. The four treatment groups consisted of patients undergoing (I) veno-arterial extracorporeal membrane oxygenation (VA-ECMO) alone (n = 126), (II) intrahospital systemic thrombolysis (SYS) (n = 643), (III) surgical thrombectomy (ST) (n = 49), and (IV) percutaneous catheter-directed treatment (PCDT) (n = 173). VA-ECMO was allowed as bridging to pulmonary recanalization in groups II, III, and IV. Marginal causal contrasts were estimated using the g-formula with logistic regression models as the primary approach. Sensitivity analyses included targeted maximum likelihood estimation (TMLE) with machine learning, inverse probability of treatment weighting (IPTW), as well as variations of estimands, handling of missing values, and a complete target trial emulation excluding the VA-ECMO alone group. In the overall target trial population, the median age was 62.0 years, and 53.3

The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for temporary mechanical circulatory support in various clinical scenarios has been increasing consistently, despite the lack of sufficient evidence regarding its benefit and safety from adequately powered randomized controlled trials. Although the ARREST trial (Advanced Reperfusion Strategies for Patients with Out-of-Hospital Cardiac Arrest and Refractory Ventricular Fibrillation) and a secondary analysis of the PRAGUE OHCA trial (Prague Out-of-Hospital Cardiac Arrest) provided some evidence in favor of VA-ECMO in the setting of out-of-hospital cardiac arrest, the INCEPTION trial (Early Initiation of Extracorporeal Life Support in Refractory Out-of-Hospital Cardiac Arrest) has not found a relevant improvement of short-term mortality with extracorporeal cardiopulmonary resuscitation. In addition, the results of the recently published ECLS-SHOCK trial (Extracorporeal Life Support in Cardiogenic Shock) and ECMO-CS trial (Extracorporeal Membrane Oxygenation in the Therapy of Cardiogenic Shock) discourage the routine use of VA-ECMO in patients with infarct-related cardiogenic shock. Ongoing clinical trials (ANCHOR [Assessment of ECMO in Acute Myocardial Infarction Cardiogenic Shock, NCT04184635], REVERSE [Impella CP With VA ECMO for Cardiogenic Shock, NCT03431467], UNLOAD ECMO [Left Ventricular Unloading to Improve Outcome in Cardiogenic Shock Patients on VA-ECMO, NCT05577195], PIONEER [Hemodynamic Support With ECMO and IABP in Elective Complex High-risk PCI, NCT04045873]) may clarify the usefulness of VA-ECMO in specific patient subpopulations and the efficacy of combined mechanical circulatory support strategies. Pending further data to refine patient selection and management recommendations for VA-ECMO, it remains uncertain whether the present usage of this device improves outcomes.

Patients with coronary artery disease (CAD) remain vulnerable to future major atherosclerotic events after revascularization, despite effective secondary prevention strategies. Inflammation plays a central role in the pathogenesis of CAD and recurrent events. To date, there is no specific anti-inflammatory medicine available with proven effective, cost-efficient, and favorable benefit-risk profile, except for colchicine. Initial studies with colchicine have sparked major interest in targeting atherosclerotic events with anti-inflammatory agents, but further studies are warranted to enforce the role of colchicine role as a major treatment pillar in CAD. Given colchicine's low cost and established acceptable long-term safety profile, confirming its efficacy through a pragmatic trial holds the potential to significantly impact the global burden of cardiovascular disease.The COL BE PCI trial is an investigator-initiated, multicenter, double-blind, event-driven trial. It will enroll 2,770 patients with chronic or acute CAD treated with percutaneous coronary intervention (PCI) at 19 sites in Belgium, applying lenient in- and exclusion criteria and including at least 30% female participants. Patients will be randomized between 2 hours and 5 days post-PCI to receive either colchicine 0.5 mg daily or placebo on top of contemporary optimal medical therapy and without run-in period. All patients will have baseline hsCRP measurements and a Second Manifestations of Arterial Disease (SMART) risk score calculation. The primary endpoint is the time from randomization to the first occurrence of a composite endpoint consisting of all-cause death, spontaneous non-fatal myocardial infarction, non-fatal stroke, or coronary revascularization. The trial is event-driven and will continue until 566 events have been reached, providing 80% power to detect a 21 % reduction in the primary endpoint taking a premature discontinuation of 15% into account. We expect a trial duration of approximately 44 months.The COL BE PCI Trial aims to assess the effectiveness and safety of administering low-dose colchicine for the secondary prevention in patients with both chronic and acute coronary artery disease undergoing PCI. Trial registration: ClinicalTrials.gov: NCT06095765.

OBJECTIVES:The aim of this study was to evaluate the feasibility, effectiveness, and safety of coronary intravascular lithotripsy (IVL; Shockwave Medical) in the treatment of severe coronary artery calcification (CAC) in a real-world setting. BACKGROUND:Severe CAC can be an arduous obstacle in interventional cardiology, often leading to suboptimal results of percutaneous coronary interventions (PCI). Coronary IVL is a novel technique that modulates severe CAC, thereby facilitating stent implantation. METHODS AND RESULTS:In this multicenter observational study, data from 134 IVL procedures in 5 Belgian hospitals were prospectively obtained. Successful delivery of the IVL catheter was achieved in all cases but 1 (99.3%). The primary endpoint was final overall procedural success, which was obtained in 88.1% of cases, an aggregate of 92.6% in de novo lesions and 77.5% in stent underexpansion or in-stent restenosis (ISR). IVL therapy effect was considered successful by the operators in 94% of cases, with 68.7% achieving optimal and 25.3% achieving suboptimal results. The 1-month major adverse cardiovascular event rate was 3%, including 2 cardiovascular deaths (1 in-stent thrombosis and 1 coronary artery perforation). CONCLUSIONS:This real-world experience suggests that Shockwave IVL is a feasible, effective, and safe technique for the treatment of heavily calcified coronary lesions.

Cardiogenic shock during a pheochromocytoma crisis is a life-threatening disorder. This case report illustrates a 49-year-old male with profound cardiogenic shock, extreme hemodynamic instability (systolic blood pressure ranging from 45 up to 290 mmHg in a cyclic pattern), and progressive multiple organ failure in the presence of a unilateral adrenal mass. Emergency adrenalectomy led to rapid hemodynamic stabilization. Histological investigation confirmed the diagnosis of pheochromocytoma. This case indicates that emergency adrenalectomy, although usually not considered first choice, is a valid option in cardiogenic shock and extremely fluctuating hemodynamics due to a pheochromcytoma-induced catecholamine storm.

Coronary embolism due to prosthetic valve thrombosis is a rare cause of acute coronary syndrome. We report the challenging case of a 66-year-old female patient with non-ST-elevation myocardial infarction caused by left main coronary artery bifurcation embolism in the setting of mechanical aortic valve thrombosis. The patient was treated with intravenous thrombolysis. Four hours later, she suffered an anterior ST-elevation myocardial infarction due to left anterior descending artery embolization. Repeat coronary angiogram showed complete disappearance of the LMCA embolus with only distal LAD occlusion. The patient was further treated medically with excellent outcome.

Abstract Background Spontaneous coronary artery dissection (SCAD) is an unusual cause of acute coronary syndrome (ACS), rapidly gaining recognition over the last decade. SCAD occurs predominantly in young, otherwise healthy women and coronary angiogram often lacks typical (atherosclerotic) features. Therefore, SCAD remains notably underdiagnosed. As optimal treatment strategy differs greatly from atherosclerotic ACS, early (differential) diagnosis is crucial. Purpose/Methods In this paper, all coronary angiograms performed for ACS in women up to 50 years of age were retrospectively reviewed by three independent interventional cardiologists. Results The obtained insights are comparable to recent literature. SCAD incidence was 26% in this cohort. Left anterior descending coronary artery was the main affected vessel with SCAD subtype 2B as predominant angiographic presentation. Correct diagnosis during index procedure was poor with only 33% accuracy. Nevertheless, a favourable trend over time was noted. Percutaneous coronary intervention success was 56%, as in 44% of patients initial stenting was complicated by progressive dissection. Overall, outcome was excellent with no reported fatalities. Conclusion SCAD remains an underdiagnosed subtype of ACS and the importance of increasing awareness amongst (interventional) cardiologists needs to be emphasised.

Coronary-subclavian steal syndrome (CSSS) is a severe complication of coronary artery bypass graft (CABG) surgery with internal mammary artery grafting. It is caused by functional graft failure due to a hemodynamically significant proximal subclavian artery stenosis. In this manuscript, we provide a comprehensive review of literature and we report a series of five consecutive CSSS cases. This case series illustrates the variable clinical presentation, thereby emphasizing the importance of raised awareness concerning this pathology in CABG patients.

Ischemic polymorphic ventricular ectopy was documented during exercise testing in a 65‐year‐old Caucasian male patient. Coronary angiogram revealed four coronary to pulmonary artery fistulas (CPAFs) originating from the right and left coronary artery, leading to myocardial ischemia due to steal phenomenon. The three dominant fistulas were coiled percutaneously, while one small fistula was left untreated. During follow‐up, no significant residual ventricular arrhythmia was detected.

Constrictive pericarditis (CP) is a rare cause of heart failure and is characterized by impaired chamber filling owing to a fibrotic pericardium encasing the heart. The diagnosis is often challenged by nonspecific symptoms, discrepant investigation results, and a low level of suspicion. Nevertheless, timely recognition remains crucial, as it is a potentially curable condition. We present the intriguing case of a 78-year-old patient with CP 1 year after cryoballoon pulmonary vein isolation (PVI) for atrial fibrillation (AF).

"Percutaneous left atrial appendage occlusion in a lamin A/C gene mutation related cardiomyopathy patient with persistent left atrial appendage thrombus: a case report." Acta Cardiologica, 74(2), pp. 182–183