BACKGROUND:Transfemoral transcatheter aortic valve implantation (TAVI) is a minimally invasive treatment for patients with severe aortic stenosis who are at elevated surgical risk. Despite widespread use, optimal periprocedural anaesthetic management remains highly variable, and evidence-based guidance is lacking. METHODS:An interdisciplinary panel of Italian experts in anaesthesiology, cardiology, and cardiac surgery conducted a systematic review of the literature and used the RAND/UCLA Appropriateness Method to evaluate 1032 clinical scenarios across a range of risk profiles and comorbid conditions. Ratings were conducted over three rounds, including a moderated in-person meeting to refine and discuss appropriateness scores. RESULTS:A minimally invasive approach, local anaesthesia alone, and conscious sedation were judged appropriate across most clinical scenarios. Invasive monitoring, such as placement of an additional arterial catheter or a central venous catheter, was recommended only in selected high-risk patients. Several approaches or interventions were consistently rated inappropriate across all evaluated scenarios, including nurse-administered anaesthesia, pulmonary artery catheterisation, and cardiac output monitoring using pulse wave analysis. Other approaches, such as general anaesthesia and deep sedation, were considered inappropriate in most cases but retained uncertainty in select clinical contexts. Several recommendations were rated as necessary to define a minimum standard of care. CONCLUSIONS:This Italian consensus statement provides practical, expert-driven recommendations to standardise anaesthetic care for transfemoral TAVI. While many recommendations reached strong consensus, areas of uncertainty remain, underscoring the need for further clinical research. Patient-centred, individualised decision-making remains essential, guided by institutional experience and procedural complexity.

Right ventricular–pulmonary artery (RV-PA) uncoupling, expressed as the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (TAPSE/PAPs) ratio, is a negative prognostic indicator in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). This study aims to investigate the association between the echocardiographically measured TAPSE/PAPs ratio and invasively determined pulmonary hypertension (PH) subtypes in this population, with the goal of identifying patients at higher risk. This study is a retrospective analysis of 667 patients who underwent TAVR for native severe symptomatic AS at our center between January 2015 and December 2022. All patients underwent a comprehensive transthoracic echocardiographic evaluation and right heart catheterization prior to the procedure. PH was classified into: no PH, isolated post-capillary PH (IpcPH), and combined pre- and post-capillary PH (CoPH). Follow-up time was defined as the time from the procedure to the last documented contact with the patient (alive) or to the time of documented death. All-cause mortality at two years was the primary endpoint. eTAPSE/PAPs showed a moderately positive correlation with pulmonary vascular resistance (Spearman’s Rho = 0.52; p = 0.025) and was associated with CoPH (odds ratio 1.29, 95

Background:Myocarditis is an inflammatory disease of the myocardium with infectious or immune-mediated/autoimmune etiology; etiology diagnosis relays on endomyocardial biopsy (EMB). High titre serum anti-heart autoantibodies (AHA) define severe autoimmune forms. In autoimmune myocarditis immunosuppression (IS) may be required to prevent progression to dilated cardiomyopathy, heart transplant or death, but it is not always effective. This study aimed to identify non-invasive cellular biomarkers of etiology and response to IS in biopsy-proven myocarditis peripheral blood. Methods:Fifty-eight EMB-proven myocarditis patients out of IS were enrolled and compared with 9 healthy controls and 20 EMB-proven myocarditis on IS. Cells distribution was evaluated by flow cytometry; results were related to clinical, EMB and AHA findings. Results:Compared to healthy controls, plasmacytoid dendritic cells percentage was reduced in autoimmune (p = 0.017), in lymphocytic (p = 0.012) myocarditis patients, in those without extra-cardiac autoimmune diseases (AD, p = 0.01), and in myocarditis not on IS (p = 0.003). Viral myocarditis had higher CD62L+/CD56+ NK cells percentage (p = 0.001) and CCR2 over-expression in intermediate monocytes when compared with autoimmune myocarditis (p = 0.013). Autoimmune myocarditis was characterized by higher Th1/Th2 (p = 0.004) and Th17/Treg ratio (p = 0.008), Th1 (p = 0.028) and Th17 lymphocytes (p = 0.017) percentage vs. healthy controls. A reduction of Treg cells percentage was specific for autoimmune lymphocytic (p = 0.047 vs healthy controls), for AHA-positive myocarditis (p = 0.03 vs healthy controls) and for myocarditis unresponsive to IS (p = 0.036). Conclusions:Biopsy-proven myocarditis patients showed distinct peripheral immunophenotypes of either innate or adaptive immune cells according to different histology, etiology and response to IS, unveiling potential novel non-invasive etiological biomarkers for myocarditis.

BACKGROUND:Evidence regarding prosthesis-patient mismatch (PPM), measured (mPPM), and predicted (pPPM), after transcatheter aortic valve replacement in bicuspid aortic valve stenosis remains limited. This study sought to evaluate the incidence, predictors, and prognostic implications of mPPM and pPPM in patients with Sievers type 1 bicuspid aortic valve undergoing transcatheter aortic valve replacement. METHODS:The AD-HOC registry is a retrospective, multicenter study including 781 patients with severe aortic stenosis and bicuspid aortic valve treated with transcatheter aortic valve replacement between 2016 and 2023 across 24 centers. PPM was defined according to Valve Academic Research Consortium-3 criteria. The primary outcome was all-cause mortality. RESULTS:Moderate-to-severe mPPM was more frequent than pPPM (22% versus 8%; P<0.001). Balloon-expandable valves were independently associated with both mPPM and pPPM, while smaller valve size and supra-annular sizing predicted only pPPM. During a mean follow-up of 621±470 days, neither mPPM nor pPPM was associated with mortality in the overall cohort. Among patients with a small annulus (≤430 mm2; n=145), pPPM occurrence was significantly higher (19% versus 5.5%; P<0.001) and was associated with increased all-cause mortality, but not with cardiovascular mortality. CONCLUSIONS:In patients with Sievers type 1 bicuspid aortic valve undergoing transcatheter aortic valve replacement, pPPM occurred less frequently than mPPM and was predominantly driven by anatomic characteristics and sizing strategies. Although pPPM was associated with increased all-cause mortality among patients with small annuli, this association did not extend to cardiovascular mortality and should be considered hypothesis-generating. Further prospective investigations are warranted to better delineate the impact of anatomic constraints on clinical outcomes in this anatomically challenging subset.

Relevant mitral regurgitation (MR) is associated with significant morbidity and mortality. Surgical mitral valve (MV) repair represents the treatment of choice for symptomatic severe degenerative mitral regurgitation (DMR) in patients with acceptable surgical risk. However, surgical failure and high perioperative risk may limit reintervention options, particularly in elderly patients with multiple comorbidities. In this context, transcatheter edge-to-edge mitral valve repair (M-TEER) may represent a viable alternative strategy, particularly in patient who underwent previous surgery. We report the case of a 79-year-old man with severe DMR due to P2 flail, who underwent minimally invasive surgical MV repair with NeoChord implantation. The postoperative course was complicated by acute hemodynamic and respiratory deterioration requiring invasive mechanical ventilation, veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and continuous renal replacement therapy (CRRT). Transoesophageal echocardiography revealed early NeoChord apical detachment, with persistence of prosthetic material attached to the posterior leaflet, recurrent severe MR and new-onset left ventricular dysfunction. Due to prohibitive surgical risk, the patient was deemed unsuitable for redo surgery and underwent urgent M-TEER with veno-arterial extracorporeal membrane oxygenation support. Two MitraClip XTW G4 devices were successfully implanted achieving successful reduction of MR without significant increase in mitral gradient. Meticulous preprocedural echocardiographic assessment and advanced intraprocedural imaging guidance was essential to optimize procedural success. This complex case highlights that transcatheter M-TEER can represent a safe and effective bail-out strategy in patients with hemodynamically unstable severe DMR after surgical repair failure when redo surgery is contraindicated.

Objective We report the successful management of a 30-mm Hydra self-expanding tall-frame transcatheter heart valve (THV) pop-up through a redo TAVI procedure. Key Steps A new Safari extra-stiff guidewire was advanced externally in respect of a 30-mm Hydra valve frame. A 25-mm Amplatz Goose Neck snare was manipulated to engage the proximal arches of the Hydra THV. In parallel, a 12 × 40 mm Atlas Gold high-pressure balloon was positioned between the Hydra valve frame and ascending aorta, and was then inflated while a new Edwards Sapien 3 Ultra 23-mm valve was advanced and eventually successfully deployed. Potential Pitfalls Although index THV pop-up was favored by pacing loss of capture during balloon postdilation, the lack of an external sealing skirt in the Hydra THV system may have increased its susceptibility to migration during balloon maneuver, as occurred in our case. Take-Home Message To our knowledge, this is the first reported case describing the use of this combined technique to address embolization of a self-expanding tall-frame THV, resulting in an effective and safer procedure.

A myocardial bridge (MB) is a condition where a segment of an epicardial coronary artery passes through the myocardial muscle. While traditionally regarded as benign, MBs have been associated with various cardiovascular conditions. Therefore, assessing their hemodynamic impact is crucial for informed treatment decisions. Intracoronary functional assessments, such as fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR), have proven useful, especially under inotropic stimulation. However, their invasive nature limits their widespread clinical application. The Quantitative Flow Ratio (QFR) has emerged as a minimally invasive alternative for functional evaluation of MBs, though data on its use are still limited. This study aims to compare the diagnostic efficacy of FFR, iFR, and QFR for evaluating MBs both at rest and under stress conditions. Patients with confirmed MB on the LAD and typical angina (or abnormal noninvasive tests indicating myocardial ischemia) were included. According to a prespecified protocol, all patients underwent functional intracoronary evaluation with FFR and iFR at rest and after dobutamine and atropine intravenous infusion. QFR was also calculated for all cases both at rest and during dobutamine infusion. FFR values ≤0.80, iFR values ≤0.89 and QFR values ≤0.84 were considered indicative of significant myocardial ischemia. A total of 21 patients were included. Median FFR remained unchanged from rest (0.85) to stress (0.85), with only 1 patient showing a positive stress-FFR. In contrast, median iFR significantly decreased from 0.91 to 0.79 (p <0.001), with stress-iFR ≤0.89 in 18 patients. Resting QFR did not indicate significant hemodynamic impact of the MB (median 0.90), but under inotropic stimulation, ischemia was detected in 18 patients (median 0.79, p <0.001). QFR and iFR were concordant during stress in 19 patients, showing a significant positive correlation (Spearman's ρ = 0.702, p = 0.037) and comparable sensitivity (0.86). QFR, computed during inotropic infusion, shows high sensitivity for detecting MB-related ischemia, comparable to stress-iFR and superior to stress-FFR. The correlation between stress-induced iFR and QFR suggests QFR as a reliable, minimally invasive alternative for functional lesion-specific evaluation in MB patients. Larger studies are necessary to confirm these preliminary findings and standardize QFR use in dynamic coronary stenosis assessments.

Precapillary (PrPH) and combined pre and postcapillary pulmonary hypertension (CoPH) increase all-cause and cardiovascular mortality risk in patients undergoing TAVI for severe symptomatic aortic stenosis. Since pulmonary artery (PA) diameter adapts to increased pulmonary artery pressure, this study evaluates the correlation between CT-derived main PA (MPA), right PA (RPA), left PA (LPA) diameters, and the MPA/ascending aorta (AA) ratio with PH subtypes defined by right heart catheterization (RHC), as well as their prognostic impact. This retrospective study includes all consecutive patients undergoing TAVR between June 2007 to December 2022 with pre-TAVI RHC and ECG-gated CT scans. The primary endpoint was all-cause mortality. Mean follow-up time was 5 years. Among 638 consecutive patients, 329 (51%) had normal mPAP, while 309 (49%) had PH. Of these, 143 (46%) had isolated postcapillary PH (IpcPH), and 166 (54%) had CoPH. Patients with PrPH were excluded. CoPH patients had higher PAP than both IpcPH and no-PH groups. In univariable and multivariable analysis, MPA, MPA index (MPAi), RPA, RPA index (RPAi), MPA/AA, MPAi/AA, and RPA/LPA correlated with PH, while MPA, MPAi, RPA, RPAi, MPA/AA, and MPAi/AA were associated with CoPH. The best AUC for PH discrimination was MPAi (AUC = 0.71, cutoff = 16 mm/m², sensitivity = 66%, specificity = 72%), while MPA/AA best discriminated CoPH (AUC = 0.73, cutoff = 0.88, sensitivity = 67%, specificity = 72%). Patients with PA/AA <0.88 had significantly lower 5-year mortality after TAVI than those with PA/AA ≥0.88 (log-rank p = 0.046, HR 1.39). In conclusion, Increase in MPA/AA CT-derived ratio is predictive of Combined PH, highlighting patients who could benefit from a RHC in term of CV stratification before TAVI.

Right-sided cardiac catheterization (RHC) is selectively recommended in mitral valve transcatheter edge-to-edge (M-TEER) workup because right ventricle (RV) hemodynamic parameters predict adverse outcomes. This study examines the impact of RV hemodynamics and the prognostic value of the 2022 European Society of Cardiology (ESC) pulmonary hypertension definitions on outcomes after M-TEER. Of 152 patients treated with M-TEER for symptomatic severe mitral regurgitation (MR) between December 2014 and February 2024 at our tertiary center, 71 underwent elective RHC before the procedure. The primary outcomes assessed were all-cause mortality and a composite of heart failure hospitalization and death at the longest available follow-up. In a cohort of 152 mostly male patients (64%) with a median age of 79 years who were treated for symptomatic severe MR, 71 underwent elective RHC. The causes were categorized as degenerative (47%), functional ventricular (41%), and atrial (12%). Pulmonary hypertension (PH) was common, with 74% showing mean pulmonary artery pressure (mPAP) >20 mm Hg and 39% with pulmonary vascular resistance (PVR) >2 Wood Units. Success rates were high, with technical, device, and procedural success at 97%, 88%, and 84%, respectively. At a median follow-up of 681 days, all-cause mortality was 50%, and the composite outcome (death or heart failure hospitalizations) occurred in 61%. Key hemodynamic parameters, including mPAP, PVR, and the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio, were independently linked to mortality risk. Kaplan-Meier analysis found significant associations with mPAP >20 mm Hg and pulmonary capillary wedge pressure >15 mm Hg for long-term mortality, whereas the 2022 ESC PH thresholds showed greater sensitivity, correlating with increased mortality risk. In patients with severe MR who undergo M-TEER, most RV invasive hemodynamic parameters are linked to adverse long-term outcomes, with mPAP, PVR, and the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio identified as independent predictors of mortality. Despite the study's limited sample size, the updated ESC PH definitions enhance prognostic assessment.

AIMS:Standardized immunosuppressive therapy (IS) had been previously investigated in biopsy-proven (BP) lymphocytic myocarditis with heart failure (HF). This study evaluated efficacy and safety of tailored IS in BP immune-mediated myocarditis, irrespective of histology and clinical presentation. METHODS AND RESULTS:Consecutive BP myocarditis patients treated with long-term tailored IS on top of optimal medical therapy (OMT), were compared with OMT non-IS controls using propensity-score weighting. The primary outcome was a composite of death or heart transplant, the secondary outcome was a composite of biventricular function, New York Heart Association (NYHA) class variation, and relapse. IS was managed by a multidisciplinary Cardioimmunology Team, involved a safety checklist and active patients' education. Ninety-one IS patients were compared with 267 non-IS patients. IS patients more frequently had systemic immune-mediated diseases (35% vs. 9.7%), lower baseline echocardiographic left ventricular ejection fraction (35% vs. 43%), lower right ventricular fractional area change (34% vs. 41%) and higher frequency of active lymphocytic, eosinophilic and giant cell myocarditis (71% vs. 58%, 12% vs. 1.1%, and 6.6% vs. 1.5%, respectively). At 5-year follow up, no difference was observed in the primary outcome (survival rate 93% in IS vs. 87% in non-IS), but IS patients had a higher relapse rate. Thus, IS patients, with a lower biventricular function and a higher risk profile at baseline, presented similar biventricular function and NYHA class to non-IS patients at follow-up. Minor adverse drug reactions occurred in 13% of patients, all resolved with therapy switch. CONCLUSIONS:Prolonged tailored IS is effective and safe in BP immune-mediated myocarditis irrespective of histology and clinical presentation.

Aortic stenosis (AS) is the most prevalent valvular heart disease in Europe and North America, with transcatheter aortic valve implantation (TAVI) revolutionizing its management. Hypertrophic left ventricle (HLV) frequently coexists with AS, complicating treatment due to the associated risk of left ventricular outflow tract (LVOT) obstruction, heart failure, and sudden death. A rare but severe post-aortic valve replacement (AVR) complication, termed “suicide left ventricle” (SLV), has emerged, necessitating further study. This report synthesizes current literature on SLV, its pathophysiology, and management strategies, alongside four patient case studies. The patients aged 79–87 years, underwent AVR for symptomatic AS with HLV. Post-AVR, all experienced severe complications, including dynamicLVOT gradients, systolic anterior motion (SAM) of the mitral valve, and severe hypotension, leading to death in two cases. One patient survived following surgical aortic valve replacement (SAVR) with surgical myectomy. One patient survived after TAVI. These cases highlight the critical importance of multidisciplinary Heart Team evaluations and personalized treatment plans in managing SLV. Despite advancements in AVR, SLV remains a complex, life-threatening condition, requiring an exhaustive and multifaceted approach for optimal patient outcomes. This report offers valuable insights into SLV occurrence and management from a clinical perspective.

BACKGROUND:In patients undergoing transcatheter aortic valve implantation (TAVI), the presence of a low-flow, low-gradient (LFLG) status has been associated with higher mortality at short-term follow-up. AIMS:We aimed to evaluate long-term survival after TAVI in patients with classical (cLFLG) and paradoxical LFLG (pLFLG) aortic stenosis (AS) compared to high-gradient (HG)-AS. METHODS:Patients undergoing TAVI at our centre with a hypothetical minimum 5-year follow-up were divided into 3 groups: (1) HG-AS (mean gradient [MG] >40 mmHg), (2) cLFLG-AS (MG <40 mmHg, ejection fraction [EF] <50%), and (3) pLFLG-AS (MG <40 mmHg, EF ≥50%). The primary endpoint of the study was all-cause mortality. Propensity score-weighted survival analysis was performed to adjust for possible baseline confounders. RESULTS:A total of 574 subjects were included (73% HG-AS, 15% pLFLG-AS, 11% cLFLG-AS). The median survival time was 4.8 years, with a maximum of 12.3 years. Patients with cLFLG-AS presented the highest baseline cardiovascular risk. At unadjusted survival analysis, patients with cLFLG-AS showed the worst long-term prognosis, with a rapid decrease in survival within the first year, while pLFLG- and HG-AS patients presented similar survival rates (p=0.023). At weighted long-term analysis, cLFLG- and HG-AS had similar survival rates. Baseline EF was not related to long-term mortality, while patients with a post-TAVI left ventricular ejection fraction (LVEF) improvement >10% lived significantly longer (p=0.02). CONCLUSIONS:Classical LFLG-AS patients had lower long-term survival rates as compared to pLFLG-AS and HG-AS patients. However, after adjustment for possible baseline confounders, a low-flow status per se did not have an impact on long-term mortality after TAVI. Post-TAVI LVEF recovery was associated with improved long-term outcome.

BACKGROUND:Raphe-type bicuspid aortic valve (BAV) is a potential hostile scenario in trans-catheter aortic valve replacement (TAVR) due to pronounced calcium burden, possibly associated with tapered valve configuration. Trans-Catheter heart valve (THV) sizing strategy (annular vs. supra-annular) is controversial in this valve subtype. OBJECTIVES:To describe the phenotypical characteristics of severe, tapered, raphe-type, BAV stenosis undergoing TAVR and to explore safety and efficacy of modern-generation THVs, analysing the impact of annular and supra-annular sizing strategies on short- and mid-terms outcomes. METHODS:This is a retrospective, multicenter registry enrolling consecutive stenotic Sievers type 1 BAV treated with TAVR. Study population was divided into tapered and non-tapered configuration according to MSCT analysis. Matched comparison between annular and supra-annular sizing groups was performed in tapered population. RESULTS:From January 2016 to June 2023, 897 patients were enrolled. Of them, 696 patients displayed a tapered configuration. Of those, 510 received a THV according to annular sizing. After propensity score matching 186 matched pairs were selected. Technical success (96.2 % vs 94.1 %, OR 1.61 [0.61-4.24], p = 0.34), 30-day device success (83.6 % in both groups, OR 1.42 [0.78-2.57], p = 0.25) and 30-day early safety (71.8 % vs 70.5 %, OR 1.07 [0.68-1.68], p = 0.78) were similar between the annular and supra-annular sizing groups; a higher post-TAVR gradient was observed in supra-annular group, although it was only 2 mmHg mean. At mid-term follow-up, the rate of clinical efficacy was 84.7 %. CONCLUSIONS:TAVR with modern-generation devices is safe and effective for tapered raphe-type BAV, showing comparable results for annular and supra-annular sizing strategies.

ObjectiveThe European Society of Cardiology guidelines have recently defined new cut-offs for pulmonary hypertension (PH) and pulmonary vasculature resistance (PVR; median pulmonary artery pressure (mPAP) >20 instead of 25 mm Hg and PVR >2 instead of 3 Wood unit). The prognostic value of this updated classification after transcatheter aortic valve implantation (TAVI) is unknown. Methods579 consecutive patients treated by TAVI with preprocedural right heart catheterisation evaluation were included. Patients were grouped as: (1) no PH, (2) isolated precapillary/combined (I-PreC/Co) PH and (3) isolated postcapillary PH (I-PoC). All-cause death, cardiovascular death and hospitalisations for heart failure (HF) were evaluated at follow-up. We also analysed the prognostic role of residual postprocedural PH. ResultsOut of 579 patients, 299 (52%) had PH according to the new criteria compared with 185 (32%) according to the previous ones. Overall median age was 82 years, while 55.3% patients were male. Patients with PH were more frequently diagnosed with chronic obstructive pulmonary disease and atrial fibrillation and were characterised by higher surgical risk as compared with patients without PH.At a median follow-up of 2.9 years, the presence of PH according to previous definition was associated with worse survival (p<0.001) and HF hospitalisation (p=0.002) rates, irrespective of PVR values. With newer cut-offs, PH was associated with worse outcomes only in patients with increased PVR, while no differences were found between patients with PH and normal PVR values and those without PH. Postprocedural mPAP normalisation was observed in 45% of the cases, but it was associated with improved long-term survival only in the I-PoC PH group. ConclusionsNew ESC PH cut-offs increased the number of PH diagnoses. The presence of PH, particularly in the setting of increased PVR, identify patients at higher risk for postprocedural mortality and rehospitalisation. Normalisation of PH was associated with better survival only in I-PoC group.

Aim of this single-center, retrospective study was to assess early and long-term clinical and hemodynamic results of transapical aortic valve implantation (TA-TAVI), and to identify predictors of survival at follow-up. All patients undergoing TA-TAVI for severe aortic valve stenosis at our institution were reviewed. A hybrid approach based on machine -learning techniques was employed to identify survival predictors, using a bagging-decision-tree algorithm and a Random-Forest algorithm, respectively. Two -hundred-thirty-four consecutive patients underwent TA-TAVI (March 2009-May 2019). All cause 30-day mortality was 5.1%. Device success was 95.7%. Median follow-up time was 35.2 months. Kaplan -Meier overall survival rates at 2, 5, and 8 years were 75%, 44%, and 15%, respectively. Structural-valve -deterioration occurred in 25 patients (11.3%) overall. The strongest predictors of survival at follow-up were age, body-mass-index, and ejection fraction. TA-TAVI provided valid early and long-term outcomes. These data support its choice as an optimal alternative access whenever the transfemoral route is not feasible.

BACKGROUND:Data on left main (LM) percutaneous coronary interventions (PCI) have mostly been obtained in studies using drug-eluting stent (DES) platforms without dedicated large-vessel devices and with limited expansion capability.AIMS:Our study aimed to investigate the safety and efficacy of LM PCI with the latest-generation Resolute Onyx DES.METHODS:ROLEX (Revascularization Of LEft main with resolute onyX) is a prospective, multicentre study (ClinicalTrials.gov: NCT03316833) enrolling patients with unprotected LM coronary artery disease and a SYNTAX score <33 undergoing PCI with the Resolute Onyx zotarolimus-eluting coronary stent, that includes dedicated extra-large vessel platforms. The primary endpoint (EP) was target lesion failure (TLF): a composite of cardiac death, target vessel myocardial infarction (TVMI) and ischaemia-driven target lesion revascularisation (ID-TLR), at 1 year. All events were adjudicated by an independent clinical event committee. An independent core lab analysed all procedural angiograms.RESULTS:A total of 450 patients (mean age 71.8 years, SYNTAX score 24.5±7.2, acute coronary syndrome in 53%) were enrolled in 26 centres. Of these, 77% of subjects underwent PCI with a single-stent and 23% with a 2-stent technique (8% double kissing [DK] crush, 6% culotte, 9% T/T and small protrusion [TAP] stenting). Intravascular imaging guidance was used in 45% (42% intravascular ultrasound [IVUS], 3% optical coherence tomography [OCT]). At 1 year, the primary EP incidence was 5.1% (cardiac death 2.7%, TVMI 2.7%, ID-TLR 2.0%). The definite/probable stent thrombosis rate was 1.1%. In a prespecified adjusted subanalysis, the primary EP incidence was significantly lower in patients undergoing IVUS/OCT-guided versus angio-guided PCI (2.0 vs 7.6%; hazard ratio [HR] 0.28, 95% confidence interval [CI]: 0.13-0.58; p<0.001).CONCLUSIONS:In this large, multicentre, prospective registry, LM PCI with the Resolute Onyx DES showed good safety and efficacy at 1 year, particularly when guided by intracoronary imaging.