Westra J, Rasmussen LD, Karim SR
… +7 more, Jensen RV, Ejlersen JA, Gormsen LC, Bøttcher M, Eftekhari A, Winther S, Christiansen EH
EuroIntervention
· 2025 Sep · PMID 40887988
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BACKGROUND: Ischaemia without obstructive epicardial coronary artery disease (CAD) is common and is often related to coronary microvascular disease (CMD). Previous studies primarily focused on functional assessment in pa...BACKGROUND: Ischaemia without obstructive epicardial coronary artery disease (CAD) is common and is often related to coronary microvascular disease (CMD). Previous studies primarily focused on functional assessment in patients with established ischaemia without obstructive epicardial CAD. AIMS: We sought to assess the prevalence of CMD and compare clinical and procedural characteristics including myocardial perfusion imaging, as derived from rubidium-82 positron emission tomography (Rb-PET), and health status according to CAD classification. METHODS: We conducted a prospective, observational study of symptomatic patients with suspected obstructive epicardial CAD on coronary computed tomography angiography. All patients were referred to Rb-PET and invasive coronary angiography with bolus thermodilution. CMD was defined as the absence of obstructive epicardial CAD (fractional flow reserve>0.80 or diameter stenosis <90%) combined with coronary flow reserve <2.5 and/or index of microvascular resistance ≥25. Main analyses included myocardial perfusion characteristics by Rb-PET and health status at baseline and at 3-month follow-up according to CAD classification (no disease, obstructive epicardial CAD, isolated CMD or combined obstructive epicardial CAD and CMD). RESULTS: Among 561 patients, isolated CMD was diagnosed in 131 patients (prevalence 0.23, 95% confidence interval [CI]: 0.20-0.27). Vessel territories with isolated CMD were characterised by similar perfusion characteristics to non-diseased vessels (mean difference in hyperaemic myocardial blood flow 0.03 [95% CI: -0.13 to 0.06] mL/min/g). Patients with isolated epicardial disease on both patient and vessel levels had reduced stress myocardial blood flow compared to patients without disease. The probability of being angina-free at 3 months tended to be lower for the CMD group (odds ratio [OR] 0.56, 95% CI: 0.31-1.00) and higher for the revascularised epicardial disease group (OR 1.52, 95% CI: 0.94-2.48) compared to the group classified as not diseased. CONCLUSIONS: CMD, as identified with bolus thermodilution, is common in patients referred to invasive coronary angiography based on suspected obstructive epicardial CAD even in patients with normal stress myocardial blood flow by Rb-PET. (ClinicalTrials.gov: NCT02264717 and NCT04707859).
Zhang Z, Ding S, Guo Q
… +20 more, Ma C, Lin F, Rao X, Shi Q, Gao Y, Liu K, Yu H, Nie M, Liu C, Li S, Gao Y, Gao H, Peng L, Zhao Z, Zhao K, Tang H, You R, Zhang M, Pu J, Li M
EuroIntervention
· 2025 Sep · PMID 40887987
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BACKGROUND: Coronary microvascular dysfunction (CMD) leads to inadequate myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPC...BACKGROUND: Coronary microvascular dysfunction (CMD) leads to inadequate myocardial perfusion in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI). The index of microcirculatory resistance (IMR) is an intraoperative diagnostic tool for CMD. However, its widespread application is hindered by the requirement for pressure wires and hyperaemic agents. The angiographic microcirculatory resistance (AMR) index is concise, convenient, accurate, and serves as a pressure wire-free alternative to the IMR. AIMS: This study aimed to demonstrate the ability of AMR to detect CMD in patients with STEMI undergoing PPCI therapy and to assess its predictive value for long-term prognosis. METHODS: The EARLY-MYO-AMR trial comprised two cohorts. The derivation cohort included 495 patients with STEMI who underwent PPCI within 12 h and cardiac magnetic resonance (CMR) within 14 days of symptom onset. The optimal AMR cutoff value for diagnosing CMD using CMR was determined by analysing the receiver operating characteristic curves. The validation cohort enrolled 2,663 patients with STEMI who underwent PPCI within 12 h of symptom onset from January 2012 to April 2022 across 5 medical centres. All patients were followed up for at least 1 year. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE), including cardiac death, hospitalisation for heart failure, repeat myocardial infarction, and target lesion revascularisation. RESULTS: The derivation cohort identified an AMR cutoff >26.6 mmHg*s/dm for predicting CMD post-PPCI (area under the curve 0.721, 95% confidence interval [CI]: 0.677-0.763). Multivariable logistic regression analysis indicated that AMR >26.6 mmHg*s/dm was a CMD risk factor (odds ratio 4.10, 95% CI: 2.56-6.56; p<0.001). The MACE incidence was significantly higher among patients in the validation cohort with AMR >26.6 mmHg*s/dm than among those with AMR ≤26.6 mmHg*s/dm (30.9% vs 21.5%, adjusted hazard ratio [HR] 1.47, 95% CI: 1.20-1.80; p<0.001). MACE incidence increased with AMR, with an adjusted HR of 1.30 (95% CI: 1.17-1.46; p<0.001) per 10 mmHg*s/dm increase. The Bland-Altman and Kappa analyses showed good intra- and interobserver agreement for AMR (intraobserver: bias=-0.104, k=0.914; interobserver: bias=-0.032, k=0.958). CONCLUSIONS: AMR >26.6 mmHg*s/dm predicts CMD during PPCI and increased MACE incidence in patients with STEMI. This convenient tool helps in risk stratification and treatment guidance for STEMI prognosis.
Nogami K, Kanaji Y, Toya T
… +7 more, Sara JDS, Raphael CE, Gulati R, Prasad A, Kakuta T, Lerman LO, Lerman A
EuroIntervention
· 2025 Sep · PMID 40887985
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BACKGROUND: Coronary microvascular dysfunction (CMD) is a common cause of chest pain (CP) in patients with angina and non-obstructive coronary arteries (ANOCA). Although both CMD and CP have distinct classifications, the...BACKGROUND: Coronary microvascular dysfunction (CMD) is a common cause of chest pain (CP) in patients with angina and non-obstructive coronary arteries (ANOCA). Although both CMD and CP have distinct classifications, the relationship between them remains insufficiently understood. AIMS: This study investigated the relationship between CMD and CP patterns and their prognostic impact in ANOCA patients. METHODS: Serial patients with ANOCA who underwent coronary reactivity testing were enrolled. CP patterns were categorised as exertional, resting, or both. Endothelium-dependent CMD was defined as a <50% change in coronary blood flow (CBF) with intracoronary acetylcholine infusion and endothelium-independent CMD as a coronary flow reserve (CFR) <2.5 during adenosine-induced hyperaemia. Microvascular function and prognosis were compared between patients with exertional CP and resting CP. RESULTS: Among 1,264 patients, the median age was 52 years, and 65.3% were women; 23.7% had exertional CP, 27.0% resting CP, and 49.4% both. Exertional CP patients had a lower CFR and a higher prevalence of endothelium-independent CMD compared to resting CP patients (2.8 vs 3.0; p=0.014, 32.1% vs 24.4%; p=0.034). Exertional CP patients showed a significantly lower CBF increase in response to acetylcholine (38.2% vs 50.7%; p=0.015). Survival analysis over a median 7-year follow-up revealed that endothelium-independent CMD significantly increased risk in exertional CP patients (p=0.002) but not in resting CP patients (p=0.388). CONCLUSIONS: ANOCA patients with exertional CP demonstrated worse microvascular function than those with resting CP, with endothelium-independent CMD showing a significant prognostic impact. Exertional CP patients may benefit more from treatment strategies specifically targeting CMD.
Mahfoud F, Tunev S, Kandzari DE
… +8 more, Secemsky EA, Taub PR, Voora RA, Lauder L, Ryan C, Trudel J, Hettrick DA, Schlaich M
EuroIntervention
· 2025 Sep · PMID 40887984
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BACKGROUND: Overactivity of the hepatic and renal sympathetic nerves is associated with chronic cardiovascular and metabolic conditions, including hypertension. AIMS: We studied the effect of combined renal and hepatic d...BACKGROUND: Overactivity of the hepatic and renal sympathetic nerves is associated with chronic cardiovascular and metabolic conditions, including hypertension. AIMS: We studied the effect of combined renal and hepatic denervation through treatment of the common hepatic artery and the renal arteries. METHODS: Denervation was performed in the common hepatic artery and both renal arteries and their major branch vessels in normotensive swine using the same multielectrode radiofrequency (RF) ablation catheter (Symplicity Spyral). Renal and liver tissue samples were obtained for histological examination in two cohorts at 7 and 28 days post-procedure (n=5 sham, n=10 denervation for each timepoint). RESULTS: Combined hepatic and renal denervation was successfully achieved in all animals. At 7 days, the mean lesion depth was 5.8±1.4 mm in the renal arteries and 4.7±0.7 mm in the hepatic artery. Compared with controls, the mean renal cortical norepinephrine (NE) levels were reduced by 88.2% in the 7-day model and by 84.5% in the 28-day model. Liver NE decreased by 94.6% at 7 days and by 91.1% at 28 days (p<0.0001 for all comparisons with baseline). No inadvertent injury was detected in the treated arteries or adjacent tissues. CONCLUSIONS: Combined hepatic and renal denervation using the same multielectrode RF denervation system resulted in a substantial reduction in both renal and hepatic tissue NE levels that was sustained up to 28 days without collateral tissue injury. These mechanistic findings may have implications for the treatment of chronic diseases impacted by hepatic and renal sympathetic nervous system overactivity.
Lichtenberg MKW, Holden A, Scheinert D
… +9 more, Schmidt A, van den Berg JC, Piorkowski M, Hertting K, Thieme M, Andrassy M, Wissgott C, Miller LE, Zeller T
EuroIntervention
· 2025 Aug · PMID 40828546
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Redfors B, Madhavan MV, Kirtane AJ
… +11 more, Fearon WF, Yeh RW, Cohen DJ, Al-Lamee R, Jeremias A, Witberg G, Sharma RP, Popma A, Kaki A, Froimovich A, Leon MB
EuroIntervention
· 2025 Aug · PMID 40828315
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Wire-based indices of coronary physiology are the gold standard for guiding revascularisation decisions in patients with coronary artery disease and angiographically intermediate coronary stenoses. FFRangio is a novel an...Wire-based indices of coronary physiology are the gold standard for guiding revascularisation decisions in patients with coronary artery disease and angiographically intermediate coronary stenoses. FFRangio is a novel angiography-based technology for assessing the functional significance of epicardial coronary stenoses without pressure wires or hyperaemic stimulus. The primary objective of the Advancing Cath Lab Results with FFRangio Coronary Physiology Assessment trial (ALL-RISE; ClinicalTrials.gov: NCT05893498) is to compare clinical outcomes in patients with chronic coronary syndromes or non-ST-segment elevation acute coronary syndromes undergoing coronary angiography with ≥1 coronary lesion suitable for physiological assessment. Patients will be randomised to FFRangio-guided or to pressure wire-guided treatment. The primary endpoint is the occurrence of major adverse cardiovascular events (MACE) at 1 year (a composite of all-cause death, myocardial infarction, or unplanned clinically driven revascularisation), assessed for non-inferiority of FFRangio-based versus pressure wire-based guidance. If non-inferiority is met, reflex superiority guidance will be tested. Secondary endpoints include periprocedural and early complications up to 30 days, individual components of MACE at 1 year, patient-reported health status, procedural resource utilisation and healthcare-related costs, and operator-assessed usability of the FFRangio and pressure wire systems. With a sample size of 1,924 patients, the study has 82.7% power to assess non-inferiority with a non-inferiority margin of 3.5%. The ALL-RISE trial will provide prospective clinical outcomes data on the relative safety, efficacy, and cost-effectiveness of a workflow using FFRangio as compared with pressure wire-based approaches for coronary lesion assessment among patients being considered for percutaneous coronary intervention.
Yu FC, Peng XP, Yao J
… +20 more, Yan YF, Corona S, Fu B, Wang S, Wang HP, Zhuang XJ, Jiang ZM, Zhao YW, Tang YD, Xu JZ, Li CB, Chen H, Han K, Huang H, Guo L, Ben Ali W, Modine T, Jilaihawi H, Piazza N, Song GY
EuroIntervention
· 2025 Aug · PMID 40828314
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BACKGROUND: Transcatheter aortic valve implantation (TAVI) in pure aortic regurgitation (AR) remains challenging because of inadequate anchoring forces. Traditional approaches, which rely solely on virtual annulus oversi...BACKGROUND: Transcatheter aortic valve implantation (TAVI) in pure aortic regurgitation (AR) remains challenging because of inadequate anchoring forces. Traditional approaches, which rely solely on virtual annulus oversizing, have demonstrated limited success. We propose a novel anatomical classification system and dual-anchoring theory to optimise the TAVI strategy in patients with pure AR. AIMS: We aimed to evaluate the efficacy and safety of TAVI in pure AR using a novel anatomical classification system and dual-anchoring theory. METHODS: The AURORA trial is a prospective, multicentre, single-arm study conducted across 16 centres in China. Patients with severe pure AR underwent comprehensive anatomical assessment using multidetector computed tomography (CT). Based on the ability to provide adequate anchoring forces (≥10% of oversizing) in three zones (left ventricular outflow tract, anatomical annulus, and ascending aorta), patients were classified into 4 types. Those with anatomical types 1-3 were enrolled and underwent TAVI using the VitaFlow valve system. The primary efficacy endpoint was device success, and the primary safety endpoints included 30-day mortality and major complications. RESULTS: Among 187 screened patients, 100 patients with suitable anatomy (types 1-3) were enrolled. The mean age was 72.7±7.2 years, and the mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 9.10±5.81%. Device success was achieved in 91% of cases, with no procedural mortality. The new permanent pacemaker implantation rate was 9%. Postprocedural CT analysis in 43 patients revealed that the maximum contact forces were primarily localised between the virtual annulus and the sinotubular junction (83.7% of cases). No device failure occurred in later cases. CONCLUSIONS: The AURORA classification system shows that comprehensive anatomical assessment can lead to favourable outcomes in pure AR using conventional TAVI devices. The low pacemaker implantation rate and the absence of device failure in later cases suggest that optimal anatomical matching may be superior to aggressive oversizing strategies.
Mensink FB, Los J, Reda Morsy MM
… +20 more, Oemrawsingh RM, von Birgelen C, Ijsselmuiden AJJ, Meuwissen M, Cheng JM, van Wijk DF, Smits PC, Paradies V, van Wijk DJ, Rai H, Ten Cate TJF, Camaro C, Damman P, van Nunen LX, Dimitriu-Leen AC, van Wely MH, Cetinyurek-Yavuz A, Byrne RA, van Royen N, van Geuns RM
EuroIntervention
· 2025 Aug · PMID 40828313
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BACKGROUND: Prolonged lipid-lowering therapy has demonstrated its ability to induce plaque regression and improve the plaque morphology of mild atherosclerotic lesions. AIMS: This trial aimed to assess the short-term eff...BACKGROUND: Prolonged lipid-lowering therapy has demonstrated its ability to induce plaque regression and improve the plaque morphology of mild atherosclerotic lesions. AIMS: This trial aimed to assess the short-term effect of evolocumab in addition to high-intensity statin therapy (HIST) on relevant non-culprit coronary artery lesions using fractional flow reserve (FFR) measurements and multimodality intracoronary imaging. METHODS: Patients with an acute coronary syndrome (ACS) and relevant multivessel disease were randomised to receive either evolocumab or placebo for 12 weeks in addition to HIST. Patients underwent serial FFR and intravascular ultrasound (IVUS)-near-infrared spectroscopy imaging of a non-culprit vessel. The primary endpoints were the differences in the change in FFR and in the maximum lipid core burden index within any 4 mm segment (maxLCBI). The secondary endpoints were the differences in the change in IVUS-derived atheroma volume parameters. RESULTS: Among 150 patients (mean age 64.2±8.5 years; 27 [18.0%] female) randomised to evolocumab (n=74) or placebo (n=76), 143 underwent follow-up coronary angiography. After 12 weeks of treatment, the adjusted mean change in FFR was 0.00 (95% confidence interval [CI]: -0.02 to 0.02) with evolocumab versus 0.01 (95% CI: -0.01 to 0.03) with placebo (adjusted mean difference: -0.01, 95% CI: -0.03 to 0.01; p=0.6). The adjusted mean change in the maxLCBI was -27.8 (95% CI: -72.2 to 16.6) for evolocumab-treated patients versus -35.6 (95% CI: -82.5 to 11.4) for placebo-treated patients (adjusted mean difference: 7.8, 95% CI: -40.9 to 56.4; p=0.8). No between-group differences in any IVUS-derived parameter were found. CONCLUSIONS: In patients with ACS and relevant non-culprit coronary artery lesions, the addition of evolocumab to HIST for 12 weeks, compared to placebo, did not result in improvement of FFR or maxLCBI. (ClinicalTrials.gov: NCT04141579).
Mahendiran T, Stalikas N, Gallinoro E
… +11 more, Keulards D, Sakai K, Bouisset F, Viscusi MM, Corradetti S, Sonck J, van 't Veer M, Wilgenhof A, Pijls NHJ, Collet C, De Bruyne B
EuroIntervention
· 2025 Aug · PMID 40828311
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BACKGROUND: Patients with coronary microvascular dysfunction (CMD) exhibit impaired vasodilatation of the microcirculation. This manifests as reduced microvascular resistance reserve (MRR) due to either increased resting...BACKGROUND: Patients with coronary microvascular dysfunction (CMD) exhibit impaired vasodilatation of the microcirculation. This manifests as reduced microvascular resistance reserve (MRR) due to either increased resting flow (Q; functional CMD) or decreased hyperaemic flow (Q; structural CMD). However, coronary flow is intimately linked to myocardial mass, potentially confounding the interpretation of flow and resistance measurements. AIMS: We investigated the relationship between subtended myocardial mass, microvascular resistance, and coronary flow to determine whether the disturbed resistance and flow patterns seen in CMD persisted after indexing by subtended myocardial mass. METHODS: We recruited 100 patients with angina with non-obstructive coronary arteries who underwent coronary computed tomography angiography to quantify vessel-specific subtended myocardial mass. Continuous intracoronary thermodilution was used to quantify absolute coronary flow and microvascular resistance, both at rest and during hyperaemia. Among patients with an MRR <3.0, hyperaemic microvascular resistance (R) ≥475 Wood units (WU) defined structural CMD (versus functional CMD). Flow and resistance measurements were analysed both in absolute terms and after indexing by subtended mass. RESULTS: Mass and flow were analysed in 100 patients in the left anterior descending artery. The mean subtended myocardial mass in the structural CMD group (47.00±13.83 grams) was significantly lower than in the control group (59.64±21.69 grams; p=0.027), with no significant difference between the control group and the functional CMD group (53.75±13.99 grams; p=0.339). After indexing by the subtended mass, patients with structural CMD still had higher R (control: 20.68±7.99 WUâ¢kg vs structural CMD: 30.58±11.63 WUâ¢kg; p<0.001) and lower Q (control: 4.56±2.20 ml/min/g vs structural CMD: 3.20±0.90 ml/min/g; p=0.013). Conversely, patients with functional CMD exhibited similar indexed values of Rand Q to controls. CONCLUSIONS: Despite significantly lower subtended mass, patients with structural CMD exhibit abnormal indexed R and Q, supporting the notion of hyperaemic flow restriction at the tissue level that is independent of subtended mass. However, patients with functional CMD have similar subtended myocardial mass to controls and exhibit no flow restriction during hyperaemia.
McCabe JM, Newton S, Danek BA
… +10 more, Elison D, Chung CJ, Sheu R, Jelacic S, Condos GJ, Canovas E, Greenbaum AB, Babaliaros VC, Lederman RJ, Mackensen GB
EuroIntervention
· 2025 Aug · PMID 40828310
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BACKGROUND: The management of interventricular septal hypertrophy is an area of rapidly increasing interest, spurred by continued challenges with transcatheter mitral valve replacement (TMVR) and the management of obstru...BACKGROUND: The management of interventricular septal hypertrophy is an area of rapidly increasing interest, spurred by continued challenges with transcatheter mitral valve replacement (TMVR) and the management of obstructive hypertrophic cardiomyopathy (oHCM). AIMS: We sought to evaluate the reproducibility of septal scoring along the midline endocardium (SESAME), a novel transcatheter intervention designed to replicate surgical myotomy. METHODS: This single-centre, retrospective review included all patients who underwent the SESAME procedure at the University of Washington from January 2022 to September 2024. RESULTS: A total of 54 consecutive patients underwent SESAME at our institution: 47 prior to TMVR, 6 for oHCM, and 1 for a subaortic membrane. Technical success was achieved in 100% of patients. In pre-TMVR patients, the median neo-left ventricular outflow tract (LVOT) and the median skirt neo-LVOT areas gained were 146 (first quartile [Q1]: 76.5, third quartile [Q3]: 286.3) mm and 54 (Q1: 32.8, Q3: 100.2) mm, respectively. In the oHCM population, invasive resting and provocable LVOT gradients immediately decreased from 59 (Q1: 32, Q3: 99) mmHg to 10 (Q1: 5, Q3: 19) mmHg and from 121 (Q1: 53, Q3: 205) mmHg to 34 (Q1: 16, Q3: 56) mmHg, respectively. The median echo gradients decreased from 62 (Q1: 53, Q3: 64) mmHg at baseline to 6 (Q1: 6, Q3: 8) mmHg at 30 days. Among the pre-TMVR population, there were 2 procedural deaths from free-wall rupture early in the experience and 3 restrictive ventricular septal defects that did not require intervention. Three patients (5.5%) required a pacemaker. Procedural complications significantly decreased after the first 10 cases in 2022 (p<0.01). CONCLUSIONS: Our study corroborates the feasibility and efficacy of SESAME for prohibitive surgical risk patients needing septal reduction therapy prior to TMVR or for treatment of oHCM or a subaortic membrane.