Health care professionals in fluoroscopic laboratories face significant occupational hazards, including cancer, cataracts, and reproductive concerns due to prolonged exposure to iodizing radiation, and orthopedic injuries stemming from long-term use of heavy aprons as protection from radiation. Despite substantial advancements in radiation protection technology, adoption of these advancements has been slow, hindered by the high upfront costs of implementation and the lag in revising institutional and regulatory radiation exposure thresholds to reflect the capabilities of contemporary enhanced radiation protection devices (ERPDs). This multisociety statement, endorsed by the Society for Cardiovascular Angiography & Interventions, American College of Cardiology, the American Society of Echocardiography, the Heart Rhythm Society, the Society of Interventional Radiology, and the Society for Vascular Surgery, calls for mandatory implementation of ERPDs to meet as low as reasonably achievable standards. This expert consensus statement outlines the ethical and legal responsibilities of government, fluoroscopy laboratory manufacturers, and health care institutions to protect all health care professionals from avoidable workplace hazards and the urgent need to implement ERPDs. The document does not promote or recommend any single ERPD system, and the choice of protection technology is left to department preference. It also addresses the importance of training, monitoring, and continuous research to optimize radiation safety practices. The document advocates for updated regulations and standardized practices across states to ensure comprehensive protection for all fluoroscopy laboratory personnel.

Coronary atherosclerosis is a chronic, multifocal pathophysiologic process punctuated by acute inflammatory flares causing plaque destabilization. Plaque destabilization may smolder over a subacute temporal course, which may be clinically silent with spontaneous lesion healing resulting in multilayered plaques. We report a case who initially presented with acute coronary syndrome with culprit vessel revascularization and residual nonculprit disease who developed arrhythmogenic threat and dynamic ST elevations on remote monitoring that required emergent revascularization of the nonculprit vessel.

Background:Severe acute pulmonary embolism (PE) induces hemodynamic compromise due to a failing right ventricle (RV) and a "dry" hyperdynamic left ventricle (LV). RV systolic dysfunction is the key parameter to determine acute PE risk stratification, clinical management, and prognosis. The present study delineates the determinants of RV performance in acute PE resulting in RV dysfunction. Methods:This was a single-center, retrospective analysis of a high-volume PE response team database of patients with intermediate-high-risk or high-risk PE with an echocardiogram prior to escalation of care. Results:The RV free wall motion (total RVFW motion score = 8.1 ± 2.8) was correlated with the magnitude of RV systolic depression (RV fractional area change [FAC] = 29 ± 13%, tricuspid annular planar systolic excursion = 1.57 ± 0.49 cm, and S' velocity = 10.57 ± 3.14 cm/s). LV preload and stroke volume were markedly reduced (LV end diastolic size = 4.04 ± 0.68 cm and volume = 73.6 ± 25.8 mL; LV stroke volume = 46.2 ± 16.6 mL). LV preload deprivation was correlated with the severity of RV systolic dysfunction (total RVFW motion score, r = -0.11, P = .39; FAC, r = 0.25, P = .04; S' velocity, r = 0.27, P = .03). RV overload induced reversed interventricular septal curvature reflected by LV end diastolic eccentricity index = 1.21 ± 0.21, which correlated with RV systolic dysfunction (total RVFW motion score, r = 0.47, P < .001; FAC, r = -0.35, P < .005; S' velocity, r = -0.43, P < .001) and RV dilation. Conclusions:Afterload strain imposed by PE may induce severe RV systolic dysfunction attributable to marked RVFW dysfunction. RV systolic pressure generation and transpulmonary flow are generated through systolic ventricular interactions mediated by primary septal contraction and paradoxical septal motion.

Background:Mitral regurgitation (MR) may be a cause or contributor to cardiogenic shock (CS). The roles of mitral transcatheter edge-to-edge repair (M-TEER) and mechanical circulatory support (MCS) have not been fully delineated. This prospective registry of patients with significant MR and CS was designed to determine procedural success and survival with M-TEER performed with mandatory MCS. Methods:Over an 8-year period ending August 2024, this single hospital system prospective analysis identified consecutive patients with CS with significant MR. The primary outcome was achieving pre-defined procedural objectives: In aggregate, an absolute >2 Grade MR reduction, normalization of pulmonary venous flow pattern and final mean transvalvular gradient <5 mmHg and 6-month mortality. Results:The cohort included n = 30 patients with acute hemodynamic deterioration (mean age 74.1 + 13.7 years, 63.3% male). Mean Society of Thoracic Surgery score (MV repair) was 13.6% + 14.7%. Clinical profiles included: Chronic progressive shock/Acute shock on chronic CHF (50%), Ruptured mitral valve chordae with leaflet incompetence and intact LVEF (23.3%), Mixed etiology defined as reduced EF and ruptured chordae (13.3%) and Acute myocardial infarction (AMI) induced papillary muscle rupture (13.3%). M-TEER with mandatory MCS was performed in all 30 patients. Procedural objectives were achieved in 25 patients (83.3%). Survival to hospital discharge was 86.6% and at 3-months 80.0%. Overall, 6-month survival was 73.3%. Conclusions:In CS complicated by significant MR, M-TEER with mandatory MCS can be performed with excellent procedural success and is associated with favorable clinical outcomes.

Key points Tricuspid regurgitation (TR) is highly prevalent and leads to poor outcomes if left untreated. Surgical treatment of TR, if indicated, is generally recommended at the time of left heart valve surgery. Patients with only mild TR not meeting indications for concomitant tricuspid repair/replacement may develop progressive TR requiring treatment. A strategy of trans‐catheter tricuspid valve replacement in select patients with prior left heart valve surgery is feasible

BackgroundThis study of radiation exposure (RE) to physicians performing structural heart procedures evaluated the efficacy of a novel comprehensive radiation shield compared to those of traditional shielding methods. A novel comprehensive shielding system (Protego, Image Diagnostics Inc) has been documented to provide superior RE protection during coronary procedures compared to that provided by a standard “drop down” shield. The purpose of this study was to assess the efficacy of this shield in transcatheter aortic valve replacement (TAVR) procedures, which are associated with disproportionate RE to operators.MethodsThis single-center, 2-group cohort, observational analysis compared RE to the primary physician operator performing TAVR using the Protego shield (n = 25) with that using a standard drop-down shield with personal leaded apparel (n = 25). RE was measured at both thyroid and waist levels with a real-time dosimetry system (RaySafe i3, RaySafe) and was calculated on a mean per case basis. Data were collected on additional procedural parameters, including access site(s) for device implantation, per case fluoroscopy time, air kerma, and patient factors, including body mass index. Between-group comparisons were conducted to evaluate RE by group and measurement sites.ResultsThe Protego system reduced operator RE by 99% compared to that using standard protection. RE was significantly lower at both the thyroid level (0.08 ± 0.27 vs 79.2 ± 62.4 μSv; P < .001) and the waist level (0.70 ± 1.50 vs 162.0 ± 91.0 μSv, P < .001). “Zero” total RE was documented by RaySafe in 60% (n = 15) of TAVR cases using Protego. In contrast, standard protection did not achieve zero exposure in a single case.ConclusionsThe Protego shield system provides superior operator RE protection during TAVR procedures. This shield allows operators to work without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Right ventricular infarction (RVI) complicates 50% of cases of acute inferior ST-segment elevation myocardial infarction, and is associated with high in-hospital morbidity and mortality. Ischemic right ventricular (RV) systolic dysfunction decreases left ventricular preload delivery, resulting in low-output hypotension with clear lungs, and disproportionate right heart failure. RV systolic performance is generated by left ventricular contractile contributions mediated by the septum. Augmented right atrial contraction optimizes RV performance, whereas very proximal occlusions induce right atrial ischemia exacerbating hemodynamic compromise. RVI is associated with vagal mediated bradyarrhythmias, both during acute occlusion and abruptly with reperfusion. The ischemic dilated RV is also prone to malignant ventricular arrhythmias. Nevertheless, RV is remarkably resistant to infarction. Reperfusion facilitates RV recovery, even after prolonged occlusion and in patients with severe shock. However, in some cases hemodynamic compromise persists, necessitating pharmacological and mechanical circulatory support with dedicated RV assist devices as a “bridge to recovery.”

OBJECTIVES:This study evaluated the efficacy of a novel comprehensive shield designed to minimize radiation exposure (RE) to Physicians performing coronary and structural heart procedures. BACKGROUND:The Protego™ radiation shielding system (Image Diagnostics Inc., Fitchburg, Ma) is designed to provide comprehensive protection from RE and has been State certified sufficient to allow operators to perform procedures without orthopedically burdensome lead aprons. METHODS:This single center two-group cohort study assessed the efficacy of this shield in a large number of cardiac procedures (coronary and structural), comparing operator RE compared to standard protection methods (personal lead apparel and "drop down" shield). RESULTS:The Protego™ system reduced operator RE by 99 % compared to Standard Protection. RE was significantly lower at both "Head" level by thyroid median dose 0.0 (0.0, 0,0) vs 5.7 (2.9, 8.2) μSv (p < 0.001), as well as waist dose 0.0 (0.0, 0.0) vs 10.0 (5.0, 16.6) μSv (p < 0.001). "Zero" Total RE was documented by Raysafe™ in 64 % (n = 32) of TAVR cases and 73.2 % (n = 183) of the coronary cases utilizing Protego™. In contrast, standard protection did not achieve "Zero" exposure in a single case. These dramatic differences in RE were achieved despite higher fluoroscopy times in the Protego™ arm (11.9 ± 8.6 vs 14.3 ± 12.5 min, p = 0.015). Per case procedural exposure measured by Dose Area Product was higher in the Protego™ group compared to standard protection (115.4 ± 139.2 vs 74.9 ± 69.3, p < 0.001). CONCLUSION:The Protego™ shield provides total body RE protection for operators performing both coronary and structural heart procedures. This shield allows procedural performance without the need for personal lead aprons and has potential to reduce catheterization laboratory occupational health hazards.

Key points Decisions surrounding if, and when, to perform coronary revascularization in patients undergoing trans‐catheter aortic valve replacement (TAVR) are often complex. Concomitant percutaneous coronary interventions (PCI) and TAVR is associated with comparable technical success, but higher rates of bleeding and acute kidney injury, compared to staged procedures or no PCI. Timing of PCI relative to TAVR should be individualized based on clinical status, lesion complexity and anticipated risks of bleeding and renal injury.

•The catheterization laboratory predisposes to occupational health hazards.•Chronic radiation exposure direct injuries include a predilection to cataracts and concerns for cancers.•Indirectly adverse effects underly the prevalence of orthopedic maladies in interventionists, linked to the burden of mandatory protective lead aprons.•Novel comprehensive shielding systems have been validated in early studies to provide excellent radiation protection.

Key Points Proximal pulmonary embolism reduces trans‐pulmonary flow and induces RV Strain which induces hemodynamic compromise Aspiration Thrombectomy improves pulmonary flow by reducing pulmonary vascular resistance and relieving RV Strain Mechanical aspiration of proximal pulmonary artery clot is beneficial for both main and branch thrombi

Key Points TAVR effective in CS, but mortality still high and outcomes determined by non‐procedural factors AS with intact LV ejection fraction rarely induces CS: Must delineate non‐valvular hemodynamic compromise factors “Primary” TAVR strategy preferable, with BAV reserved as “Bridge” to Definitive Decision

Chest pain is one of the most common chief complaints in both inpatient and outpatient settings in the United States. Given that coronary artery disease (CAD) remains the leading cause of death in the United States, discriminating between patients presenting with actionable cardiac disease vs those with other “noncardiac” etiologies for their symptoms is of the utmost importance. Over the past 5-10 ​years, we have seen a rise in various biomarkers (eg, high-sensitivity troponins), clinical decision pathways (eg, HEART score), and novel diagnostic imaging modalities (eg, coronary computed tomography angiography [CCTA]) to improve diagnostic discrimination; however, there is considerable care variability in clinical practice across the United States. To help standardize this process, the American College of Cardiology and American Heart Association Joint Committee on Clinical Practice Guidelines released a guideline document on the evaluation and diagnosis of chest pain.1Gulati M. Levy P.D. Mukherjee D. et al.2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 144: e368-e454Google Scholar Many of the central themes of this document align with prior guideline recommendations, although there are some nuanced central themes worth noting (Figure 1). Based on a recent SCAI webinar on this topic, we have highlighted the key areas of the guideline most likely to impact interventional cardiologists. The evaluation of chest pain is often subjective and relies on patient history and physician assessment of symptoms. Within this clinical evaluation, conscious and unconscious biases with regard to sex, age, ethnicity, and/or cultural background can influence the classification of symptoms within the ischemic continuum. In managing the diverse group of patients presenting with chest pain, the guideline provides a framework for the provision of equitable care to improve clinical outcomes. For example, although women are more likely to present to the emergency department with chest pain, they are less likely to have timely and clinically appropriate care than men.2Meisel Z.F. Armstrong K. Mechem C.C. et al.Influence of sex on the out-of-hospital management of chest pain.Acad Emerg Med. 2010; 17: 80-87Crossref PubMed Scopus (21) Google Scholar Women presenting with chest pain are also more frequently labeled as having “noncardiac” pain that is often associated with symptoms such as palpitations and neck pain.3Hemal K. Pagidipati N.J. Coles A. et al.Sex differences in demographics, risk factors, presentation, and noninvasive testing in stable outpatients with suspected coronary artery disease: insights from the PROMISE trial.JACC Cardiovasc Imaging. 2016; 9: 337-346Crossref PubMed Scopus (86) Google Scholar Therefore, for women presenting with chest pain, the guideline recommends obtaining a history that emphasizes accompanying symptoms that are more common in women with acute coronary syndromes (ACS). The management of elderly patients with chest pain can also be complex because while they have greater risk factors for cardiovascular disease, they also have comorbidities that may lead to misdiagnosis of chest pain as noncardiac.4Gupta R. Munoz R. Evaluation and management of chest pain in the elderly.Emerg Med Clin North Am. 2016; 34: 523-542Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar The guideline recommends that for patients over the age of 75 ​years, atypical presenting features such as a fall, syncope, or acute delirium should be considered to be possible manifestations of ACS. There are significant disparities in the management of chest pain across ethnic groups as well, with Black and Hispanic patients being far more likely to be undertreated and receive lower quality care than their Caucasian counterparts.5DeVon H.A. Burke L.A. Nelson H. Zerwic J.J. Riley B. Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White.Heart Lung. 2014; 43: 270-277Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar The guideline recommends the introduction of cultural competency training to break down cultural barriers and the use of formal translation processes while managing patients in order to improve the quality of care. The new guideline places emphasis on the early recognition of acute ischemic symptoms, including nonclassic anginal symptoms, and prompt activation of emergency medical services by the patient dialing 9-1-1. In the emergency department, initial evaluation should focus on rapid identification of patients at highest risk of a cardiac emergency, including those with ACS, aortic dissection, and pulmonary embolism or nonvascular emergencies such as esophageal rupture or pneumothorax. The 12-lead electrocardiogram and preferred high-sensitivity troponin facilitate rapid and accurate detection of myocardial injury, thereby aiding risk assessment. Once acute chest pain is confirmed, stratification into low-, intermediate-, and high-risk categories through the routine use of structured risk assessments can help guide further diagnostic testing, including coronary angiography. Coronary angiography is still recommended for patients with true ACS, hemodynamic instability, and/or a high-risk clinical assessment. Intermediate-risk patients can often undergo functional stress testing or CCTA. Low-risk patients typically require no further testing and can be discharged with close clinical follow-up.1Gulati M. Levy P.D. Mukherjee D. et al.2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.Circulation. 2021; 144: e368-e454Google Scholar Evaluating patients with stable, chronic chest pain also relies on risk, although this is less well defined and typically overestimates disease burden compared with those with acute chest pain. As defined in the guideline, the pretest probability calculation is based on age, sex, and symptom characterization and can be augmented by a coronary artery calcium score if available. For low-risk patients with stable symptoms, a coronary artery calcium score can be useful in selected cases to exclude the presence of calcified CAD, although an exercise treadmill test can also be useful in this group. For those patients determined to be at intermediate-to-high risk for CAD, CCTA or stress imaging is recommended, including fractional flow reserve computed tomography (FFR-CT) when available for those found to have intermediate stenoses during CCTA. Of note, in this guideline, if nuclear stress imaging is selected, positron emission tomography is preferred over single-photon emission computerized tomography to improve diagnostic accuracy and decrease the rate of nondiagnostic results (2a, B-R recommendation). In those with intermediate-to-high pretest probabilities for disease, it is always important to remember that CCTA or coronary angiography can be utilized in those patients with negative or inconclusive stress imaging studies and/or ongoing symptoms without explanation. Additionally, coronary angiography is indicated with those patients with documented ischemia and ongoing symptoms despite optimal medical therapy (OMT), FFR-CT ≤0.8, or high-risk anatomy seen on CCTA. For patients with ongoing symptoms and no clear explanation, evaluation for ischemia with nonobstructive coronary arteries (INOCA) may be appropriate. In applying these recommendations to INOCA patients, we must remember that (1) approximately half have “nontypical” angina, which does not mean “noncardiac,” nor does it mean not cardiac in etiology, (2) they have recurrent, mostly stable symptoms, so while they may present to the emergency department with a flare, their course is generally chronic rather than acute, (3) pretest probability is used for determining the likelihood of obstructive CAD and is therefore not a relevant guidepost for pursuing further evaluation in these patients, and (4) conventional stress testing is insufficient for identifying who will have an occult coronary cause of their chest pain, so a negative stress test does not preclude further evaluation.6Cassar A. Chareonthaitawee P. Rihal C.S. et al.Lack of correlation between noninvasive stress tests and invasive coronary vasomotor dysfunction in patients with nonobstructive coronary artery disease.Circ Cardiovasc Interv. 2009; 2: 237-244Crossref PubMed Scopus (49) Google Scholar, 7Pargaonkar V.S. Kobayashi Y. Kimura T. et al.Accuracy of non-invasive stress testing in women and men with angina in the absence of obstructive coronary artery disease.Int J Cardiol. 2019; 282: 7-15Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 8Lee B.K. Lim H.S. Fearon W.F. et al.Invasive evaluation of patients with angina in the absence of obstructive coronary artery disease.Circulation. 2015; 131: 1054-1060Crossref PubMed Scopus (210) Google Scholar Thus, regardless of whether a patient’s stress test was positive or negative, for those with ongoing chest pain with exertion, emotional stress, or even when unprovoked, who have nonobstructive coronary arteries by CCTA or coronary angiography, further testing for an occult coronary etiology should be considered. While noninvasive tests, specifically positron emission tomography and cardiovascular magnetic resonance imaging, may assess for microvascular dysfunction, definitive testing falls to the interventional cardiologist, who can perform comprehensive invasive testing for endothelial dysfunction, epicardial spasm, microvascular dysfunction, and/or myocardial bridging, providing a diagnosis that directs management, reduces angina, and improves quality of life.9Ford T.J. Stanley B. Good R. et al.Stratified medical therapy using invasive coronary function testing in angina: the CorMicA trial.J Am Coll Cardiol. 2018; 72: 2841-2855Crossref PubMed Scopus (226) Google Scholar, 10Ford T.J. Stanley B. Sidik N. et al.1-Year outcomes of angina management guided by invasive coronary function testing (CorMicA).JACC Cardiovasc Interv. 2020; 13: 33-45Crossref PubMed Scopus (68) Google Scholar, 11Pargaonkar V.S. Kimura T. Kameda R. et al.Invasive assessment of myocardial bridging in patients with angina and no obstructive coronary artery disease.EuroIntervention. 2021; 16: 1070-1078Crossref PubMed Scopus (4) Google Scholar As noted above, the guideline recommendations for noninvasive diagnostic testing and coronary angiography utilization are stratified by the pretest probability of CAD and likelihood of detecting ischemia. How should interventional cardiologists interpret these recommendations? Probability-based diagnostic testing of patients presenting with chest pain should improve the diagnostic yield of invasive coronary angiography and can help guide decisions regarding revascularization, though we should be cautious about the possibility of overdiagnosis with anatomic testing of lower-risk patients and underdiagnosis in patients with INOCA.12Knuuti J. Ballo H. Juarez-Orozco L.E. et al.The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability.Eur Heart J. 2018; 39: 3322-3330Crossref PubMed Scopus (168) Google Scholar Regardless, all patients with CAD should receive goal-directed OMT, with revascularization reserved for patients presenting with ACS, highly symptomatic patients despite OMT, and those with high-risk anatomic disease burden.13Amsterdam E.A. Wenger N.K. Brindis R.G. et al.2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 64: e139-e228Crossref PubMed Scopus (1894) Google Scholar,14Boden W.E. O'Rourke R.A. Teo K.K. et al.Optimal medical therapy with or without PCI for stable coronary disease.N Engl J Med. 2007; 356: 1503-1516Crossref PubMed Scopus (3574) Google Scholar In conclusion, the guideline provides new evidence-based recommendations for the assessment and evaluation of acute and stable chest pain syndromes. A careful, structured evaluation allows for patients to be categorized into risk profiles. That risk profile then helps determine the diagnostic workup. Invasive coronary angiography remains the gold standard for diagnosing CAD but also enables physiological assessment of the epicardial arteries (FFR and nonhyperemic pressure indices) and microvasculature (coronary flow reserve measurement, microvascular spasm), detection of coronary abnormalities (myocardial bridge, coronary aneurysms, and fistula), and intravascular imaging to diagnose spontaneous coronary artery dissection and plaque rupture/erosion for appropriate patients. Additionally, we will likely continue to see evolution of synergistic noninvasive modalities for identifying many of these coronary diagnoses in the years to come. Dr Robert F. Riley provides consultation for Boston Scientific, Abbott Vascular, Medtronic, and Shockwave Medical. Dr Farouc Jaffer is a speaker in Boston Scientific and provides consultation for Boston Scientific and Siemens Healthineers. Dr Jennifer Tremmel provides consultation for Boston Scientific and Abbott Vascular, is an advisory board member in Boston Scientific and Abbott Vascular, and reports research support from Boston Scientific . The other authors have no conflicts to report.