Background High bleeding risk (HBR) is associated with an increased risk of both ischemic and bleeding events and is known to have a worse prognosis than non‐HBR in patients with acute myocardial infarction. However, data regarding the prognostic impact of complete revascularization (CR) in acute myocardial infarction and multivessel disease patients complicated by HBR remain limited. Methods A total of 13 460 patients with acute myocardial infarction and multivessel disease who underwent successful percutaneous coronary intervention for infarct‐related artery were selected from the nationwide Korean registry from 2011 to 2020. Primary outcome was major adverse cardiac and cerebrovascular events during 3 years of follow‐up. Results Of the 13 460 patients, 4401 (32.7%) were classified as the group with HBR according to modified Academic Research Consortium‐HBR criteria and 1577 patients (35.8%) underwent CR. Among the group without HBR, 3911 patients (43.2%) underwent CR for noninfarct‐related artery. The group with HBR had significantly higher risk of major adverse cardiac and cerebrovascular events (non‐HBR versus HBR; 16.4% versus 35.7%; adjusted hazard ratio [HR], 1.70 [95% CI, 1.56–1.85]; P<0.001) and Bleeding Academic Research Consortium type 2 or greater bleeding (4.5% versus 10.4%; adjusted HR, 1.63 [95% CI, 1.38–1.94]; P<0.001) than the group without HBR. Patients who underwent CR were associated with lower risk of major adverse cardiac and cerebrovascular events at 3 years than those with incomplete revascularization in both groups with HBR (40.0% versus 28.1%, adjusted HR, 0.65 [95% CI, 0.55–0.75], P<0.001) and without HBR (19.0% versus 13.1%, adjusted HR, 0.71 [95% CI, 0.63–0.80], P<0.001). The incidence of bleeding events was similar between the CR and incomplete revascularization groups in both groups with HBR (10.7% versus 10.0%, adjusted HR, 1.07 [95% CI, 0.84–1.37], P=0.572) and without HBR (4.2% versus 5.0%, adjusted HR, 0.98 [95% CI, 0.78–1.23], P=0.867). Conclusions In patients with acute myocardial infarction and multivessel disease, CR was associated with a lower risk of major adverse cardiac and cerebrovascular events compared with incomplete revascularization in both HBR and non‐HBR. Registration KAMIR‐NIH; KCT‐0000863, KAMIR‐V; KCT‐0008355.

Revascularization remains an important component of chronic coronary syndrome (CCS) management, particularly in patients with high-risk coronary anatomy, impaired left ventricular (LV) function, or persistent symptoms despite guideline-directed medical therapy. Evidence indicates that prognostic benefit is most pronounced in patients with left main disease, multivessel disease, proximal left anterior descending artery involvement, and severe LV systolic dysfunction. In other patients, revascularization primarily improves angina symptoms and quality of life. The choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting should be individualized according to coronary anatomy, clinical risk, comorbidities, and the likelihood of complete revascularization. Contemporary PCI increasingly incorporates coronary physiology and intravascular imaging to refine lesion selection and improve procedural outcomes. Long-term CCS management requires structured follow-up to detect disease progression, recurrent ischemia, revascularization failure, and cardiovascular complications. Routine surveillance testing is not recommended in asymptomatic patients after PCI. Instead, follow-up should be tailored to patient risk and clinical status. When complete revascularization fails, mechanisms such as stent thrombosis, in-stent restenosis, graft failure, and progression of untreated coronary disease should be identified; intravascular imaging has an important role in guiding repeat revascularization. Comprehensive CCS management should also address complications, including heart failure, ventricular arrhythmias, and secondary valvular disease, through a multidisciplinary, patient-centered approach.

Background Coronary artery bypass grafting (CABG) is the standard revascularization method for patients with diabetes mellitus (DM) and complex coronary artery disease. However, with significant advances in percutaneous coronary intervention (PCI), particularly the use of intravascular imaging (IVI), it is uncertain whether contemporary IVI-guided PCI can achieve clinical outcomes comparable with those of CABG. Objectives The aim of this study was to compare the clinical outcomes of IVI-guided PCI, angiography-guided PCI, and CABG in DM patients with left main or 3-vessel disease. Methods A total of 3,402 DM patients with left main or 3-vessel disease were included from individual patient-level data of the RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) trial and the institutional registries of Samsung Medical Center (n = 6,962). The primary outcome, which was a composite of all-cause death, nonfatal myocardial infarction, or stroke at 3 years was compared among IVI-guided PCI, angiography-guided PCI, and CABG. Results In the DM population, the cumulative incidence of the primary outcome at 3 years was 20.1% for angiography-guided PCI, 11.4% for IVI-guided PCI, and 12.4% for CABG. PCI was associated with a significantly higher risk for primary outcome (17.0% vs 12.4%; HR: 1.91; 95% CI: 1.50-2.44; P < 0.001). However, the risk for the primary outcome was comparable between the IVI-guided PCI and CABG groups (11.4% vs 12.4%; HR: 0.88; 95% CI: 0.58-1.32; P = 0.525). A propensity score-matched analysis yielded similar results (HR: 0.85; 95% CI: 0.53-1.36; P = 0.507). Conclusions In this hypothesis-generating study, PCI was associated with significantly higher risk for all-cause death, nonfatal myocardial infarction, or stroke at 3 years than CABG in DM patients with left main or 3-vessel disease. However, IVI-guided PCI had comparable risk for clinical events compared with CABG in DM patients. Further randomized controlled trial is needed to confirm this finding. (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention [RENOVATE-COMPLEX-PCI], NCT03381872; institutional cardiovascular catheterization database of Samsung Medical Center [Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI], NCT03870815; institutional CABG database of Samsung Medical Center, NCT03870815)

Introducción y objetivos A pesar del pronóstico favorable tras la intervención coronaria percutánea (ICP) guiada por imagen endovascular (IVI) para lesiones coronarias complejas, aún no está claro si la ICP guiada por IVI para lesiones coronarias complejas en pacientes con infarto agudo de miocardio (IAM) sería beneficiosa según la clasificación de lesiones ACC/AHA. Métodos Se hizo un análisis combinado a nivel de paciente de 2 registros nacionales de IAM de Corea. De los registros KAMIR-V y KAMIR-NIH, se incluyó a un total de 23.051 pacientes que se sometieron con éxito a una ICP en la arteria relacionada con el infarto, estratificados según la clasificación de lesiones ACC/AHA. Se compararon los resultados clínicos entre ICP guiada por IVI e ICP guiada por angiografía. El criterio de valoración principal fue la aparición de eventos cardiacos adversos mayores (MACE), una combinación de muerte cardiaca, IAM, revascularización repetida y trombosis del stent a los 3 años. Resultados La ICP guiada por IVI mostró una menor incidencia de MACE en comparación con la ICP guiada por angiografía en pacientes con lesiones tipo B2/C (HR ajustada=0,78; IC95%, 0,70-0,88; p <0,001), pero no en aquellos con lesiones tipo A/B1 (HR ajustada=0,81; IC95%, 0,60-1,11; p=0,190). Tanto en el IAM sin elevación del segmento ST como en el IAM con elevación del segmento ST, se observó un riesgo significativamente menor de MACE tras ICP guiada por IVI en comparación con la guiada por angiografía en pacientes con lesiones tipo B2/C (IAM sin elevación del segmento ST: HR ajustada=0,73; IC95%, 0,63-0,84; p <0,001; IAM con elevación del segmento ST: HR ajustada=0,86; IC95%, 0,75-0,98; p=0,027), pero no en aquellos con lesiones tipo A/B1. Conclusiones En pacientes con IAM, la ICP guiada por IVI mostró un riesgo significativamente menor de MACE en aquellos con lesiones tipo B2/C, pero no en aquellos con lesiones tipo A/B1. El beneficio pronóstico de la ICP guiada por IVI aumentó a medida que los pacientes presentaban características de lesión más complejas en la arteria relacionada con el infarto.

Coronary artery disease is one of the leading causes of death worldwide and represents a major health burden in Korea. Chronic coronary syndrome (CCS) encompasses the long-term and heterogeneous clinical manifestations of ischemic heart disease, ranging from obstructive epicardial disease to non-obstructive and microvascular disease. This pathophysiological heterogeneity necessitates individualized diagnostic and therapeutic strategies to prevent progression from CCS to acute coronary syndrome. Since the publication of recent CCS guidelines, new evidence has emerged regarding optimal diagnostic strategies, physiological and intravascular imaging-based assessments, and medical therapy. In addition, contemporary CCS management increasingly emphasizes multidisciplinary integration, including cardiovascular prevention, non-invasive imaging-guided decision-making, and patient-centered revascularization strategies. However, the implementation of these principles in real-world Korean clinical practice remains unclear, highlighting the need for localized, evidence-based guidance for Korean patients with CCS. This expert consensus provides a comprehensive, stepwise framework for the diagnosis, treatment, and long-term management of CCS by integrating the latest international evidence with Korean clinical data and practice patterns.

Introduction and objectives: There are 2 options to achieve revascularization in ischemic cardiomyopathy: percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). While the benefits of PCI for ischemic cardiomyopathy are unclear, achieving complete revascularization with PCI could improve outcomes comparable to CABG. Methods: A total of 1496 patients with left ventricular ejection fraction (LVEF) < 50% and multivessel disease who underwent either PCI or CABG were selected from a single-center cohort registry. They were divided into the PCI with complete revascularization (n = 188), the PCI with incomplete revascularization (n = 263), and the CABG group (n = 1045), and then compared. The primary outcome was a 5-year composite of cardiac death or myocardial infarction. Results: A total of 1496 patients treated for ischemic cardiomyopathy was stratified into CABG (n = 1045) and PCI (n = 451) groups, the latter subdivided into complete (n = 188) or incomplete revascularization (n = 263). PCI showed a higher incidence of the primary outcome compared with CABG (PCI vs CABG, 27.8% vs 22.2%, adjusted HR, 1.35; 95%CI, 1.05-1.73, P = .019). However, PCI with complete revascularization and CABG had similar incidences of the primary outcome (20.5% vs 22.2%, adjusted HR, 1.07; 95%CI, 0.73-1.57; P = .718). Conclusions: CABG is associated with more favorable clinical outcomes than PCI in patients with ischemic cardiomyopathy. However, achieving complete revascularization with PCI could improve outcomes comparable to CABG. (c) 2024 Sociedad Espanola de Cardiolog & imath;a. Published by Elsevier Espana, S.L.U. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

INTRODUCTION AND OBJECTIVES:The clinical benefits of percutaneous coronary intervention (PCI) for chronic total occlusion (CTO) remain controversial. This study aimed to investigate whether PCI for CTO located in the left anterior descending artery (LAD) could have beneficial effects on clinical outcomes. METHODS:Patients were retrospectively selected from a single-center CTO registry and followed up for approximately 10 years. The patients were grouped based on the presence of LAD CTO and whether the CTO was revascularized. Inverse probability weighting adjustment was also performed. The primary outcome was the composite of cardiac death or myocardial infarction at 10 years. RESULTS:Among 1323 patients with CTO, 1034 were male, and 417 had LAD CTO. PCI was attempted in 72.2% of participants in the LAD CTO group and in 49.9% of those in the non-LAD CTO group. In the non-LAD CTO group, PCI did not significantly affect the primary outcome (medical therapy vs PCI, 20.7% vs 13.4%, adjusted HR: 0.72, 95%CI, 0.47-1.10; P=.13). However, a significant difference in the incidence of the primary outcome between the treatment methods was observed in the LAD CTO group (30.8% vs 15.4%; adjusted HR: 0.44; 95%CI, 0.25-0.81; P=.007). A significant interaction was observed between LAD CTO and treatment method (P for interaction=.011). CONCLUSIONS:The benefits of PCI compared with medical therapy for CTO might be more apparent when the CTO is located in the LAD.

Despite the established clinical efficacy following intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) than angiography-guided PCI, evidence regarding prognostic benefits of IVI-guided PCI in acute myocardial infarction (AMI) patients with high thrombus burden remains limited. Using the nationwide registries of KAMIR-NIH and KAMIR-V, we evaluated the prognostic impact of IVI-guided PCI in AMI patients with high thrombus burden. A total of 4,074 patients with AMI and TIMI thrombus grades 4 or 5 who underwent aspiration thrombectomy were selected, of whom 892 patients (21.9%) received IVI-guided PCI and 3,182 patients (78.1%) received angiography-guided PCI. Primary outcome was major adverse cardiovascular event (MACE, a composite of all-cause death, MI, repeat revascularization, and stent thrombosis). Major secondary efficacy outcome was cardiac death and safety outcome was stroke at 3 years. During the median 3 years of follow-up, the risk of MACE was significantly lower in the IVI-guided PCI group than in the angiography-guided PCI group (12.9% vs 16.3%; adjusted HR, 0.80; 95% CI, 0.65 to 0.98; p = 0.035), mainly driven by a lower risk of all-cause death (5.7% vs 10.0%; adjusted HR, 0.65; 95% CI, 0.48 to 0.89; p = 0.007). IVI-guided PCI also showed lower risk of cardiac death compared with angiography-guided PCI (3.8% vs 7.0%; adjusted HR, 0.65; 95% CI, 0.44 to 0.95; p = 0.025). There was no significant difference in the risk of stroke between the groups. In this hypothesis generating study, IVI-guided PCI was associated with a lower risk of MACE and cardiac death than angiography-guided PCI in AMI patients with high thrombus burden.

Introduction and objectives: The current study aimed to evaluate the causal association between hemodynamically significant stenosis and the occurrence of ischemic myocardium using an experimental animal model of coronary artery stenosis.Methods: In Yorkshire swine (n = 10), coronary stenosis in the left anterior descending artery was induced using a customized vascular occluder to create varying degrees of occlusion severity (40%-99%). Serial changes in coronary pressure and flow velocity were measured in the left anterior descending artery before and after the implantation of the vascular occluder. At 1 month, 13N-ammonia positron emission tomography (PET) was performed, followed by the collection of isolated hearts for 2,3,5-Triphenyltetrazolium chloride (TTC) staining to quantify the percent area of necrotic myocardium. Three animals in the control group were evaluated using the same protocols, but without the implantation of a vascular occluder.Results: The median diameter stenosis after vascular occluder implantation was 61.3% (Q1-Q3: 55.9%-72.3%). Significant differences were observed in hyperemic stenosis resistance, fractional flow reserve (FFR), stress perfusion defect and reversibility in PET, as well as in necrotic myocardium in TTC staining based on stenosis severity (control group: < 50%, 50%-70%, 70%-90%, and > 90%) (all P < .010). Animals with FFR < 0.75 at 1 month exhibited a significantly higher area of stress perfusion defect (30.7 ± 3.1% vs 6.0 ± 4.2%, P < .001), reversibility in PET (11.0 ± 4.0% vs 0.0 ± 0.0%, P = .006), and necrotic myocardium in TTC staining (15.8 ± 6.4% vs 0.0 ± 0.0%, P < .001) than those with FFR ≥ 0.75.Conclusions: In a porcine model, the induction of hemodynamically significant stenosis with FFR < 0.75 was associated with the development of stress perfusion defects and reversibility in PET, as well as necrotic myocardium identified by pathology.

INTRODUCTION AND OBJECTIVES:The current study aimed to evaluate the causal association between hemodynamically significant stenosis and the occurrence of ischemic myocardium using an experimental animal model of coronary artery stenosis. METHODS:In Yorkshire swine (n=10), coronary stenosis in the left anterior descending artery was induced using a customized vascular occluder to create varying degrees of occlusion severity (40%-99%). Serial changes in coronary pressure and flow velocity were measured in the left anterior descending artery before and after the implantation of the vascular occluder. At 1 month, 13N-ammonia positron emission tomography (PET) was performed, followed by the collection of isolated hearts for 2,3,5-Triphenyltetrazolium chloride (TTC) staining to quantify the percent area of necrotic myocardium. Three animals in the control group were evaluated using the same protocols, but without the implantation of a vascular occluder. RESULTS:The median diameter stenosis after vascular occluder implantation was 61.3% (Q1-Q3: 55.9%-72.3%). Significant differences were observed in hyperemic stenosis resistance, fractional flow reserve (FFR), stress perfusion defect and reversibility in PET, as well as in necrotic myocardium in TTC staining based on stenosis severity (control group: <50%, 50%-70%, 70%-90%, and >90%) (all P<.010). Animals with FFR <0.75 at 1 month exhibited a significantly higher area of stress perfusion defect (30.7±3.1% vs 6.0±4.2%, P<.001), reversibility in PET (11.0±4.0% vs 0.0±0.0%, P=.006), and necrotic myocardium in TTC staining (15.8±6.4% vs 0.0±0.0%, P<.001) than those with FFR ≥ 0.75. CONCLUSIONS:In a porcine model, the induction of hemodynamically significant stenosis with FFR <0.75 was associated with the development of stress perfusion defects and reversibility in PET, as well as necrotic myocardium identified by pathology.

BACKGROUND:Although patients with high bleeding risk (HBR) often have complex coronary artery lesions, it is not known whether intravascular imaging-guided percutaneous coronary intervention (PCI) improves their prognosis. We sought to investigate the benefit of intravascular imaging-guided PCI for complex coronary artery lesions in patients with HBR. METHODS:This was a secondary analysis of the RENOVATE-COMPLEX-PCI trial (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) in which patients with complex coronary artery lesions undergoing PCI were enrolled at 20 sites in Korea from May 2018 through May 2021. Patients were randomized to receive intravascular imaging-guided PCI or angiography-guided PCI and classified according to the presence of HBR. The primary end point was target vessel failure, which was a composite of cardiac death, target vessel-related myocardial infarction, or clinically driven target vessel revascularization. RESULTS:Of 1639 trial population, 478 patients met HBR criteria. There was no significant difference in the risk of the primary end point between HBR and non-HBR patients (11.8% versus 8.2%; adjusted hazard ratio [HR], 1.05 [95% CI, 0.72-1.54]; P=0.790). However, patients with HBR were at higher risk for cardiac death or spontaneous target vessel-related myocardial infarction (adjusted HR, 2.04 [95% CI, 1.09-3.80]; P=0.025), all-cause death (adjusted HR, 3.30 [95% CI, 1.93-5.62]; P<0.001), and cardiac death (adjusted HR, 2.36 [95% CI, 1.10-5.09]; P=0.028). Intravascular imaging-guided PCI showed a lower risk of the primary end point compared with angiography-guided PCI in both HBR patients (9.7% versus 15.8%; adjusted HR, 0.57 [95% CI, 0.31-1.02]; P=0.060) and non-HBR patients (6.9% versus 10.8%; adjusted HR, 0.65 [95% CI, 0.43-0.99]; P=0.045), without significant interaction (P for interaction=0.796). CONCLUSIONS:Patients with HBR were associated with an increased risk of adverse cardiovascular events after complex PCI compared with those without HBR. Intravascular imaging-guided PCI showed a lower risk of the target vessel failure without significant interaction between treatment strategy and the presence of HBR in patients undergoing complex PCI.

INTRODUCTION AND OBJECTIVES:Despite the favorable prognosis associated with intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) for complex coronary lesions, it is still unclear whether IVI-guided PCI for such lesions provides clinical benefit in patients with acute myocardial infarction (AMI) according to the ACC/AHA lesion classification. METHODS:This study was a patient-level pooled analysis of 2 nationwide Korean AMI registries. We identified 23 051 patients from KAMIR-V and KAMIR-NIH who underwent successful PCI for an infarct-related artery and stratified them by the ACC/AHA lesion classification. Clinical outcomes were compared between IVI-guided and angiography-guided PCI. The primary endpoint was major adverse cardiac events (MACE), a composite of cardiac death, AMI, repeat revascularization, and stent thrombosis, at 3 years. RESULTS:IVI-guided PCI demonstrated a lower incidence of MACE compared with angiography-guided PCI in patients with type B2/C lesions (adjusted HR, 0.78; 95%CI, 0.70-0.88; P <.001), but not in patients with type A/B1 lesions (adjusted HR, 0.81, 95%CI, 0.60-1.11; P=.190). In both non-ST-segment elevation myocardial infarction and ST-segment elevation myocardial infarction, a significantly lower risk of MACE following IVI-guided PCI than angiography-guided PCI was observed in patients with type B2/C lesions (non-ST-segment elevation myocardial infarction: adjusted HR, 0.73; 95%CI, 0.63-0.84; P <.001; ST-segment elevation myocardial infarction: adjusted HR, 0.86, 95%CI, 0.75-0.98; P=.027), but not in those with type A/B1 lesions. CONCLUSIONS:Among patients with AMI, IVI-guided PCI was associated with a significantly lower risk of MACE in those with type B2/C lesions, but not in those with type A/B1 lesions. The prognostic benefit of IVI-guided PCI increased with greater lesion complexity in the infarct-related artery.

BACKGROUND: Intravascular imaging-guided percutaneous coronary intervention (PCI) has been shown to improve clinical outcomes in patients with complex coronary artery lesions compared with angiography-guided PCI. However, the prognostic impact of suboptimal findings on intravascular imaging such as stent underexpansion, malapposition, or dissection is unclear in the era of contemporary drug-eluting stents. METHODS: From RENOVATE-COMPLEX-PCI (Randomized Controlled Trial of Intravascular Imaging Guidance Versus Angiography-Guidance on Clinical Outcomes After Complex Percutaneous Coronary Intervention) which compared imaging-guided PCI with angiography-guided PCI in patients with complex lesions, post-PCI intravascular imaging findings, including minimum stent area (MSA), relative stent underexpansion (MSA≤80% of the average reference lumen area), malapposition, or dissection, were assessed in nonleft main target lesions. The primary end point was target lesion failure (TLF), a composite of cardiac death, target lesion–related myocardial infarction, target lesion revascularization, or definite stent thrombosis. RESULTS: A total of 897 nonleft main lesions from 714 patients undergoing imaging-guided PCI were included. During a median follow-up duration of 2.1 years, the optimal cutoff value of MSA to predict the occurrence of TLF was 5.5 mm 2 , and MSA<5.5 mm 2 was associated with a significantly higher risk of TLF than MSA≥5.5 mm 2 (2.2% versus 4.8%; adjusted hazard ratio, 3.09 [95% CI, 1.01–9.50]; P =0.048). Compared with the reference group (MSA≥5.5 mm 2 and no suboptimal findings), the subgroup of patients with MSA≥5.5 mm 2 and post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, or major dissection was associated with a numerically increased risk of TLF (0.0% versus 3.2%; P =0.057). Compared with the same reference group, the subgroup of patients with MSA<5.5 mm 2 and suboptimal post-PCI intravascular imaging findings was associated with a significantly increased risk of TLF (0.0% versus 4.7%; P =0.017). CONCLUSIONS: After intravascular imaging–guided PCI with contemporary drug-eluting stents for nonleft main complex lesions, inadequate absolute stent expansion was independently associated with a higher risk of TLF. Suboptimal post-PCI intravascular imaging findings of relative stent underexpansion, major malapposition, and major dissection seem to contribute to the risk of TLF. REGISTRATION: https://www.clinicaltrials.gov ; Unique identifier: NCT03381872.

BACKGROUND AND OBJECTIVES:Rotational atherectomy (RA) is a technique used to ablate calcified plaques. There is speculation that operators' experience with RA could play a role in the outcomes. METHODS:From December 2015 to April 2020, patients with calcified coronary lesions requiring percutaneous coronary intervention (PCI) with RA were enrolled in a prospective, multicenter, observational registry. The patients were divided into two groups based on the number of RAs performed by their operator in the past. A propensity score matching was done for a sensitivity analysis. The primary outcome was a composite of cardiac death, myocardial infarction, and target vessel revascularization at 1 year. RESULTS:A total of 497 patients were enrolled in the study. The calculated cutoff number of RA-PCI between the two groups was 82 cases. The more experienced group underwent PCI with less fluoroscopy time (less experienced vs. more experienced, 38.8 vs. 30.0 minutes, p<0.001), and more frequent intravascular imaging (54.6% vs. 69.0%, p=0.012). The primary outcome did not differ significantly between the groups (5.2% vs. 7.3%, hazard ratio, 1.46; 95% confidence interval [CI], 0.57-3.74; p=0.433). No significant difference in the incidence of complications was observed between the groups (5.5% vs. 7.0%, odds ratio, 1.38; 95% CI, 0.57-3.04; p=0.526). Similar results were observed in the propensity-score matched population. CONCLUSIONS:In PCI using RA for calcified lesions, the composite outcome of cardiac death, myocardial infarction, and target vessel revascularization at 1 year was not significantly different according to RA experience among operators.

Although potent P2Y12 inhibitors, such as ticagrelor and prasugrel, are standard treatment in patients with acute myocardial infarction (AMI), evidence for their efficacy and safety compared with clopidogrel is limited in patients with AMI complicated by cardiogenic shock. Among 28,949 patients from the nationwide pooled registry of KAMIR-NIH and KAMIR-V, a total of 1482 patients (5.1

Introducción y objetivos: Existen dos opciones para lograr la revascularización en la miocardiopatía isquémica, la intervención coronaria percutánea (ICP) o la cirugía de revascularización coronaria (CABG). Aunque los beneficios de la ICP para la miocardiopatía isquémica no están claros, conseguir una revascularización completa con ICP podría mejorar los resultados de forma comparable a la CABG.Métodos: Se seleccionó de un registro de cohortes de 1 solo centro a 1.496 pacientes con fracción de eyección del ventrículo izquierdo (FEVI) < 50% y enfermedad multivaso que se sometieron a ICP o CABG. Se dividieron en el grupo de ICP con revascularización completa (n = 188), el grupo de ICP con revascularización incompleta (n = 263) y el grupo de CABG (n = 1.045), y luego se compararon. El resultado primario fue la combinación de muerte cardiaca o infarto de miocardio a los 5 años.Resultados: Un total de 1.496 pacientes tratados por miocardiopatía isquémica se estratificaron en los grupos CABG (n = 1.045) y PCI (n = 451), este último subdividido en revascularización completa (n = 188) o incompleta (n = 263). La ICP mostró una mayor incidencia del resultado primario en comparación con la CABG (ICP frente a CABG, el 27,8 frente al 22,2%; HR ajustada = 1,35; IC95%, 1,05-1,73; p = 0,019). Sin embargo, la ICP con revascularización completa y la CABG tuvieron incidencias similares del resultado primario (el 20,5 frente a<l 22,2%; HR ajustada = 1,07; IC95%, 0,73-1,57; p = 0,718).Conclusiones: La CABG se asocia con resultados clínicos más favorables que la ICP en pacientes con miocardiopatía isquémica. Sin embargo, lograr una revascularización completa con ICP podría mejorar los resultados de forma comparable a la CABG.

BACKGROUND:Previous trials have shown that coronary artery bypass graft (CABG) has better clinical outcomes compared with percutaneous coronary intervention (PCI) for patients with left main coronary artery or 3-vessel disease. However, it is unclear whether intravascular imaging (IVI)-guided PCI would reduce the difference in clinical events compared to CABG. OBJECTIVES:The present study sought to compare the clinical outcomes of patients with left main or 3-vessel disease who underwent IVI-guided PCI with those who underwent CABG. METHODS:A total of 6,962 patients with left main or 3-vessel disease from the RENOVATE-COMPLEX-PCI trial (n = 1,639) and the institutional registry of Samsung Medical Center (2,972 patients underwent PCI and 6,600 patients underwent CABG) were analyzed. The primary outcome was a composite of death from any cause, nonfatal myocardial infarction, or stroke at 3 years. RESULTS:Among the study population, 848 patients underwent IVI-guided PCI, 987 patients underwent angiography-guided PCI, and 5,127 patients underwent CABG. Patients treated with PCI had significantly higher risk of primary outcome than patients who underwent CABG (13.3% vs 10.8%; HR: 1.23; 95% CI: 1.05-1.44; P = 0.013). However, the risk of primary outcome was comparable between IVI-guided PCI and CABG (8.7% vs 10.8%; HR: 0.77; 95% CI: 0.59-1.01; P = 0.058). The propensity score-matched analysis showed similar results between IVI-guided PCI and CABG (9.5% vs 9.4%; HR: 0.98; 95% CI: 0.69-1.40; P = 0.914). CONCLUSIONS:In this hypothesis-generating study, PCI had significantly higher risk of a composite of death, nonfatal myocardial infarction, or stroke than CABG. However, IVI-guided PCI had comparable risk of clinical events compared with CABG. (Intravascular Imaging- Versus Angiography-Guided Percutaneous Coronary Intervention For Complex Coronary Artery Disease [RENOVATE-COMPLEX-PCI], NCT03381872; Institutional cardiovascular catheterization database of Samsung Medical Center (Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI, NCT03870815; Institutional coronary artery bypass grafting database of Samsung Medical Center (Long-Term Outcomes and Prognostic Factors in Patient Undergoing CABG or PCI, NCT03870815).

Introducción y objetivos Los beneficios clínicos de la intervención coronaria percutánea (ICP) en la oclusión total crónica (OTC) siguen siendo controvertidos. El objetivo del estudio es investigar si la ICP en la OTC localizada en la arteria descendente anterior (ADA) podría tener efectos beneficiosos sobre los resultados clínicos. Métodos Se seleccionó retrospectivamente a pacientes de un registro de OTC de un solo centro y se les realizó un seguimiento durante aproximadamente 10 años. Los pacientes se agruparon en función de la presencia de OTC en la ADA y de si la OTC se había revascularizado. También se realizó un ajuste de ponderación de probabilidad inversa. El objetivo primario fue el resultado combinado de muerte cardiaca o infarto de miocardio a los 10 años. Resultados De los 1.323 pacientes con OTC, 1.034 eran varones y 417 tenían OTC en la ADA. Se intentó la ICP en el 72,2% de los sujetos del grupo con OTC en la ADA y en el 49,9% del grupo con OTC en una zona distinta a la de la ADA. En este último grupo, la ICP no afectó significativamente al resultado primario (tratamiento médico en el 20,7% de los pacientes frente a ICP en el 13,4%; HR ajustada=0,72; IC95%, 0,47-1,10; p=0,13). Sin embargo, se observó una diferencia significativa en la incidencia del resultado primario entre los métodos de tratamiento en el grupo de OTC de la ADA (el 30,8 frente al 15,4%; HR ajustada=0,44; IC del 95%, 0,25-0,81; p=0,007). Se observó una interacción significativa entre la OTC de la ADA y el método de tratamiento (p para la interacción=0,011). Conclusiones Los beneficios de la ICP en comparación con el tratamiento médico para la OTC podrían ser más evidentes cuando esta se localiza en la ADA.

BACKGROUND:Recent trials have shown that intravascular imaging (IVI)-guided percutaneous coronary intervention (PCI) improves clinical outcome, as compared to angiography-guided PCI, in complex coronary artery lesions. However, it is unclear whether this benefit is affected by overall lesion complexity in each patient. AIMS:The present study sought to investigate the impact of overall lesion complexity on the benefit of IVI-guided PCI. METHODS:A total of 4,611 patients with complex coronary artery lesions from the RENOVATE-COMPLEX-PCI trial (n=1,639) and the institutional registry of the Samsung Medical Center (n=2,972) were classified according to the number of complex lesion features found in each patient. The primary outcome was target vessel failure (TVF) at 3 years, a composite of cardiac death, target vessel myocardial infarction, or target vessel revascularisation. RESULTS:The cutoff value for the number of complex lesion features to predict TVF, determined using the maximally selected log-rank test, was 3. Patients with ≥3 complex lesion features had a higher risk of TVF than those with <3 complex lesion features (11.0% vs 7.2%, hazard ratio [HR] 1.59, 95% confidence interval [CI]: 1.28-1.96; p<0.001). IVI-guided PCI significantly reduced the risk of TVF compared with angiography-guided PCI in both groups (≥3 complex lesion features: 7.4% vs 14.4%, HR 0.49, 95% CI: 0.35-0.69; p<0.001; <3 complex lesion features: 5.7% vs 8.1%, HR 0.72, 95% CI: 0.53-0.98; p=0.039). The benefit of IVI-guided PCI tended to increase as the number of complex lesion features increased (absolute risk reduction for TVF: -0.012 vs -0.027 vs -0.055 vs -0.077, respectively, for 1 vs 2 vs 3 vs ≥4 complex lesion features; interaction p=0.048). CONCLUSIONS:In patients with complex coronary artery lesions, IVI-guided PCI showed a lower risk of TVF across all degrees of lesion complexity. The prognostic benefit of IVI-guided PCI tended to increase as patients had more complex lesion features. (RENOVATE-COMPLEX-PCI [ClinicalTrials.gov: NCT03381872]; Institutional cardiovascular catheterisation database of the Samsung Medical Center [ClinicalTrials.gov: NCT03870815]).