Spontaneous coronary artery dissection (SCAD) is a rare, but increasingly recognised cause of myocardial infarction. Our aim was to provide comprehensive real-world data on the prevalence of SCAD among patients who present with ST-segment elevation myocardial infarction (STEMI). Retrospective analysis of medical records and review of coronary angiograms allowed identification of all SCAD cases in a cohort of consecutive patients with STEMI, and review of clinical data provided further characterisation. Among 2707 consecutive STEMI patients, the prevalence of SCAD was 0.9

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

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.).

Background In patients with ST-elevation myocardial infarction (STEMI), rapid reperfusion is essential for optimal outcomes, yet factors influencing intraprocedural delays remain insufficiently investigated. Methods In this single-center retrospective study, consecutive STEMI patients undergoing primary percutaneous coronary intervention (PCI) between 2015 and 2024 were analyzed. Prolonged time between vascular puncture and wire passage (puncture-wire time; PWT) was defined as a value in the fourth quartile of the study population (>17.1 minutes). Multivariable logistic regression identified independent predictors and procedural determinants of prolonged PWT. Results A total of 1,235 patients (70.7% male, median age 64.5 years [IQR 56.0-75.25]) were included. Radial-to-femoral access crossover (OR 2.539, 95% CI 1.381-4.665, p = 0.003), arterial kinking or severe radial spasm (OR 3.669, 95% CI 1.986-6.778, p < 0.001) and challenging revascularization of the culprit lesion (OR 2.330, 95% CI 1.319-4.116, p = 0.004) were independently associated with prolonged PWT. Direct intervention of the culprit lesion was independently associated with a lower likelihood of prolonged PWT (OR 0.445, 95% CI 0.201 - 0.988, p = 0.047). In contrast, the primary choice of vascular access (radial vs. femoral) was not associated with prolonged PWT (p=0.06). Conclusion While some factors are system- or patient-dependent, early recognition of procedural difficulties and individualized access-site decision making may help minimize procedural delays. In selected patients, a primary femoral access route may be considered, and direct intervention of the culprit lesion should be pursued to minimize PWT.Clinical trial number Not applicable.

Beyond global left ventricular function, identification of regional wall motion abnormalities (RWMA) is an essential component of emergency echocardiography in patients with non-ST-elevation myocardial infarction (NSTEMI). This study investigated the prognostic significance and diagnostic value of RWMA. Echocardiographies of 1110 consecutive NSTEMI patients undergoing coronary angiography were analyzed. Patients were classified as type 1 NSTEMI if an atherosclerotic culprit lesion was identified, otherwise as type 2. Adverse in-hospital events were a composite of in-hospital death, cardiogenic shock, and mechanical ventilation. Among 895 patients with type 1 NSTEMI and 215 with type 2, RWMA were present in 68.2

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:The DK-mini-Crush (DKMC) technique, an established strategy to treat coronary bifurcation stenoses, is known to be complex, with possible strain on time and resources. AIMS:To analyze predictors of technical failure as well as time and resourced required for each procedural step of th DKMC technique. METHODS AND RESULTS:We prospectively enrolled 105 patients scheduled for coronary revascularization using the DKMC technique. Technical failure-defined as the inability to complete all mandatory procedural steps or any switch to other bifurcation stent deployment techniques-occurred in 10% (11/105) of the patients, most commonly due to inability to correctly place the side branch (SB) stent (3/11) or the inability to perform the 1st kissing balloon dilatation (KBD; 4/11). Even procedures with technical success required material that exceeded the base requirement in 83% of cases and the average procedure time was 47:24 min (IQR 39:00-57:09). The most time and resource-intense steps were the placement of the SB balloon for the 1st (additional material 48%; 01:38 min [00:35-03:23]) and the 2nd KBD (additional material 58%; 02:10 min [IQR 01:00-04:18]). Performance of a 1st proximal optimization technique (POT)-following crush of the SB stent-was associated with reduced overall need for additional material (OR 0.164 [95% CI 0.046-0.588], p = 0.006). CONCLUSION:Technical failure occurs in approximately 10% of DKMC procedures and is mainly due to challenges in SB stent placement or inability to perform the 1st KBD. Importantly, a 1st POT is associated with reduced resource utilization and might help to simplify this technique.

Die kontinuierliche Weiterentwicklung der Stenttechnologien seit Einführung der perkutanen Koronarintervention stellt interventionelle Kardiologen fortwährend vor neue medizinische und technische Herausforderungen. Die Auswahl geeigneter Stents oder medikamentös-beschichteter Ballons erfordert nicht nur eine fundierte Kenntnis aktueller Studienergebnisse, sondern auch eine individuelle Anpassung an die spezifische klinische Situation jedes Patienten. Zusätzlich bietet eine breitere Einsetzung von Bildgebung einen Zugewinn an Informationen, die eine individualisierte Strategie möglich macht. Dieses Update des Positionspapiers bietet einen umfassenden Überblick über die in Deutschland verfügbaren medikamentös beschichteten Stents, Scaffolds und Ballons. Neben einer detaillierten Analyse aktueller Studien werden insbesondere die klinischen Indikationen beleuchtet.

BACKGROUND:Even though current guidelines recommend intracoronary pressure measurement such as fractional flow reserve (FFR) to assess the hemodynamic relevance of angiographically intermediate stenoses, little is known about the incidence of side effects and there is no large-scale data on complications of intracoronary pressure measurements. METHODS:The PubMed database was searched for large multicenter trials and registries of patients undergoing intracoronary pressure measurement. Publications were screened regarding side effects and complications. Data on chest pain, dyspnea, arrhythmia, bronchospasm, hypotension, nausea, and coronary artery injury were collected and analyzed. RESULTS:A total of 19 studies with 22,768 patients were included. FFR measurement was reported to cause chest pain in 29% (95% CI 2-91%), dyspnea in 20%, hypotension in 0.8% (95% CI 0.3-2.1%), vomiting or nausea in 0.9%, and bronchospasm in 0.2% (95% CI 0.0-0.7%) of patients. Arrhythmia occurred in 3% (95% CI 1-16%), more specifically atrioventricular block in 2% (95% CI 0-14%) and ventricular arrhythmia in 0.1% (95% CI 0.1-0.3%), during intracoronary pressure measurement. The pressure wire was reported to have caused coronary artery dissection in 0.2% (95% CI 0.1-0.5%), coronary artery occlusion in 0.2% (95% CI 0.1-0.3%), and coronary artery perforation in 0.1% of patients. Coronary artery injury required revascularization on rare occasions and was fatal in two patients. CONCLUSIONS:Transient side effects due to adenosine administration are common when FFR is measured. While infrequent, coronary artery injury caused by the pressure wire occurs in 0.5% of patients and is a relevant complication of intracoronary pressure measurement.

The absence of chest discomfort has been hypothesized to delay treatment and consequently result in worse outcomes in patients with non-ST-elevation myocardial infarction (NSTEMI). In 888 consecutive patients with type 1 NSTEMI, symptoms were systematically classified as chest discomfort defined as chest pain or pressure, dyspnea or other symptoms, e.g. epigastric pain. Patient characteristics predictive for the absence of chest discomfort and the impact of the symptom type on adverse in-hospital events (all-cause mortality, cardiogenic shock, and mechanical ventilation) were analyzed. Chest discomfort was reported in 81.0

Frauen in der Kardiologie und Kinderkardiologie sind besonderen gesundheitlichen Risiken ausgesetzt, die eine bedenkenlose Weiterbeschäftigung während der Schwangerschaft und Stillzeit infrage stellen und mitunter zu betrieblichen Beschäftigungsverboten führen können. Schwangere, stillende und jüngst entbundene Frauen unterliegen einem besonderen gesetzlichen Schutz, um sie (und ihre Kinder) vor unverantwortbarer Gefährdung und beruflicher Benachteiligung zu bewahren. In diesem Konsensuspapier der Deutschen Gesellschaft für Kardiologie, der Deutschen Gesellschaft für Pädiatrische Kardiologie und Angeborene Herzfehler und der Deutschen Gesellschaft für Arbeitsmedizin und Umweltmedizin sollen die gesetzlichen Rahmenbedingungen des Mutterschutzgesetzes dargestellt und Anpassungs- und Umgestaltungsmöglichkeiten der Arbeitsbedingungen diskutiert werden, um die berufliche Teilhabe auch während der Schwangerschaft und Stillzeit uneingeschränkt zu ermöglichen und pauschalisierte Beschäftigungsverbote sowie die sich daraus ergebenden Karriereeinbußen und Verzögerungen in der Weiterbildung zu vermeiden.

Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow. This study aimed to analyze the use of coronary physiology in clinical practice. Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed. F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8

Eingriffe in der Elektrophysiologie und in der interventionellen Kardiologie haben in den letzten Jahren enorm an Bedeutung gewonnen. Ein Teil dieser Eingriffe wird unter Sedierung durchgeführt. Diese ist erforderlich, um Patientenkomfort und Sicherheit zu gewährleisten, ggfs. transösophageale Echokardiographien durchzuführen, eventuell in Kombination mit Analgetika Schmerzen zu lindern oder komplexe, lange Prozeduren mit z. B. stabilen Mappingbedingungen zu ermöglichen. Dieses Dokument wurde gemeinsam von der Deutschen Gesellschaft für Kardiologie (DGK) und der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) erstellt. Es beschreibt – basierend auf aktueller Evidenz – strukturierte Sedierungspfade in der kardiovaskulären Medizin. Hauptziel ist die Gewährleistung der Patientensicherheit im Rahmen von Analgosedierungen bei elektrophysiologischen und interventionellen Eingriffen. Dieses Konsensuspapier orientiert sich an der bereits publizierten S3-Leitlinie für Sedierung in der Gastroenterologie.

Abstract Background Among patients with non-ST-segment elevation myocardial infarction (NSTEMI) about 80% present with chest discomfort. Others have less obvious symptoms, but early diagnosis is crucial. Sex differences in symptoms have been reported to delay diagnosis in about half of women. This study aims to analyze the symptoms and its disparities caused by sex, age, comorbidities, and culprit lesion location. Methods Patients presenting with troponin elevation and at least one angiographically confirmed atherosclerotic lesion causing the myocardial ischemia (culprit lesion) between February 2018 and July 2023 were prospectively included in a single-center, all-comers, real-world registry. Results Information regarding symptoms was available for 842 NSTEMI patients with an identifiable culprit lesion. Chest discomfort was reported by 684 patients (81.2%), dyspnea by 361 (42.9%) with it being the primary symptom in 102 (12.1%), and atypical symptoms by 317 (37.6%) with it being the primary symptom in 56 (6.7%). Concretely, dizziness or syncope was reported by 82 patients (9.7%), nausea, vomiting or any other gastrointestinal symptoms by 73 (8.7%), epigastric, shoulder, arm, back, neck or jaw pain by 57 (6.8%), diaphoresis by 66 (7.8%), other vegetative symptoms like palpitations or anxiety by 56 (6.7%), fatigue by 37 (4.4%), and neurologic symptoms like sensory or motor impairments by 28 (3.3%). In women, the primary complaint was less often chest discomfort (76.3 vs. 82.9%, p=0.040), more often atypical symptoms (9.8 vs. 5.6%, p=0.049) and equally often dyspnea (14.0 vs. 11.5%, p=0.403). Gastrointestinal symptoms were more often reported by women (13.5 vs. 7.0%, p=0.006). Elderly, i.e., age ≥80 years, reported chest discomfort less often (75.4 vs. 83.0%, p=0.023), dyspnea more often (19.5 vs. 9.9%, p<0.001) and atypical symptoms equally often (5.1 vs. 7.1%, p=0.418). Likewise, diabetic had chest discomfort less often (74.3 vs. 84.5%, p<0.001), dyspnea more often (18.2 vs. 9.2%, p<0.001), and atypical symptoms equally often (7.4 vs. 6.3%, p=0.633). No differences regarding primary symptoms were observed for dyslipidemia (82.1 vs. 78.9% for chest discomfort, 12.1 vs. 12.1% for dyspnea, 5.8 vs. 9.0% for atypical symptoms, p>0.05 for all) and obesity (84.5 vs. 81.2% for chest discomfort, 9.8 vs. 12.5% for dyspnea, 5.7 vs. 6.3% for atypical symptoms, p>0.05 for all). For LM culprit lesions, dyspnea was more often the primary symptom compared to LAD, LCX, and RCA culprit lesions (17.4% for LM vs. 13.6% for LAD, 5.7% for LCX, and 13.2% for RCA, p=0.023), while no differences were observed for chest pain (73.9% for LM, 80.6% for LAD, 86.1% for LCX, and 80.2% for RCA, p=0.235) and atypical symptoms (8.7% for LM, 5.9% for LAD, 8.1% for LCX, and 6.6% for RCA, p=0.758). Conclusions Chest discomfort is significantly less often the primary symptom of NSTEMI in women, elderly and diabetic making these groups more vulnerable for delayed diagnosis or misdiagnosis.

Interventions in electrophysiology and interventional cardiology are increasingly common. Many of these interventions are performed under sedation. This is necessary to ensure the patient's comfort and safety to facilitate transesophageal echocardiography, pain control, or long procedure duration, e.g., with stable mapping conditions. This consensus document by the German Cardiac Society (DGK) together with the German Association of Anesthesia and Intensive Care (DGAI) describes-based on current evidence-the structured pathways for sedation in cardiovascular medicine. The major goal is patient safety for patients undergoing electrophysiology and endovascular cardiovascular procedures. This consensus document is also aligned to the published German S3 guideline for sedation in gastroenterology.

BACKGROUND:The optimal treatment for coronary calcified nodules (CNs) is still unclear. The aim of this study was to compare the modification of these lesions by coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA) using optical coherence tomography (OCT). METHODS:ROTA.shock was a 1:1 randomized, prospective, double-arm multi-center non-inferiority trial that compared the use of IVL and RA with percutaneous coronary intervention (PCI) in severely calcified lesions. In 19 of the patients out of this study CNs were detected by OCT in the target lesion and were treated by either IVL or RA. RESULTS:The mean angle of CNs was significantly larger in final OCT scans than before RA (92 ± 17° vs. 68 ± 7°; p = 0.01) and IVL (89 ± 18° vs. 60 ± 10°; p = 0.03). The CNs were thinner upon final scans than in initial native scans (RA: 17.8 ± 7.8 mm vs. 38.6 ± 13.1 mm; p = 0.02; IVL: 16.5 ± 9.0 mm vs. 37.2 ± 14.3 mm; p = 0.02). Nodule volume did not differ significantly between native and final OCT scans (RA: 0.66 ± 0.12 mm3 vs. 0.61 ± 0.33 mm3; p = 0.68; IVL: 0.64 ± 0.19 mm3 vs. 0.68 ± 0.22 mm3; p = 0.74). Final stent eccentricity was high with 0.62 ± 0.10 after RA and 0.61 ± 0.09 after IVL. CONCLUSION:RA or IVL are unable to reduce the volume of the calcified plaque. CN modulation seems to be mainly induced by the stent implantation and not by RA or IVL.

Debulking techniques are often necessary for successful lesion preparation in percutaneous coronary intervention. The aim of this study was to compare plaque modification of severely calcified lesions by coronary intravascular lithotripsy (IVL) with that of rotational atherectomy (RA) using optical coherence tomography (OCT). ROTA.shock was a 1:1 randomized, prospective, double-arm, multicenter noninferiority trial designed to compare final minimal stent area after IVL with RA for lesion preparation in percutaneous coronary interventional treatment of severely calcified lesions. On the basis of OCT acquired before and immediately after IVL or RA in 21 of the 70 patients included, we performed a detailed analysis of the modification of the calcified plaque. After RA and IVL, calcified plaque fractures were present in 14 of the patients (67%), with a significantly greater number of fractures after IVL (3.23 ± 0.49) than after RA (1.67 ± 0.52; p < 0.001). Plaque fractures after IVL were longer than after RA (IVL: 1.67 ± 0.43 mm vs RA: 0.57 ± 0.55 mm; p = 0.01), resulting in a greater total volume of the fractures (IVL: 1.47 ± 0.40 mm3 vs RA: 0.48 ± 0.27 mm3; p = 0.003). Use of RA was associated with a greater acute lumen gain than was use of IVL (RA: 0.46 ± 0.16 mm2 vs IVL: 0.17 ± 0.14 mm2; p = 0.03). In conclusion, we were able to show differences in plaque modification of calcified coronary lesions by OCT: although RA leads to a greater acute lumen gain, IVL induces more and longer fractures of the calcified plaque.

Zusammenfassung Der demografische Wandel sowie innovative Fortschritte in der interventionellen Kardiologie führen zu Veränderungen in der Qualität der medizinischen Versorgung von Patienten mit kardiovaskulären Erkrankungen. Ein erfolgreiches Management von Herzkatheterlaboren kann hier eine effizienzorientierte Organisation der medizinischen Leistungsprozesse sowie ein belastbares Berichtswesen realisieren, wobei die Medizin und Ökonomie nicht im Widerspruch stehen müssen. Durch die Etablierung und Standardisierung von Prozessschritten können Prozesskennzahlen abgeleitet werden, die die Qualität der Versorgung von Patienten mit kardiovaskulären Erkrankungen verbessern sollen.