Cardiovasc Revasc Med
· 2026 Feb · PMID 41792013
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BACKGROUND: Angina with non-obstructive coronary arteries (ANOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) are increasingly recognized as manifestations of coronary vasomotor dysfunction....BACKGROUND: Angina with non-obstructive coronary arteries (ANOCA) and myocardial infarction with non-obstructive coronary arteries (MINOCA) are increasingly recognized as manifestations of coronary vasomotor dysfunction. Intracoronary acetylcholine (ACh) testing remains the gold standard for diagnosing endothelial-dependent coronary dysfunction, epicardial spasm, and microvascular spasm; however, variability in protocols and safety concerns has limited broader adoption. OBJECTIVES: To provide a contemporary, practice-oriented review of the indications, mechanisms, protocols, safety profile, and clinical utility of ACh provocation testing, integrating emerging multicenter registry data and recent mechanistic insights. METHODS AND RESULTS: We review standardized ACh dosing strategies (bolus and continuous infusion), diagnostic endotypes, and integration with wire-based hemodynamic assessment. Building upon prior state-of-the-art reviews, this article incorporates new data from abstracts presented in 2025 from the DISCOVER-INOCA registry and recent prospective multicenter endotype studies demonstrating (1) high diagnostic yield, (2) quantitative differentiation of epicardial spasm, microvascular spasm, isolated endothelial dysfunction, and enhanced nociception, and (3) a very low incidence of major complications (<1%). Contemporary meta-analysis further clarifies the safety profile of ACh relative to ergonovine. We also provide updated contraindications aligned with 2024 ESC chronic coronary syndrome guidance and MINOCA recommendations. Importantly, emerging data support a shift from purely qualitative spasm provocation toward mechanism-guided, endotype-specific therapy. CONCLUSIONS: This review advances the field by integrating prospective North American registry validation, contemporary safety meta-analyses, and quantitative endotype phenotyping frameworks. ACh testing is repositioned not only as a diagnostic tool but as a platform for precision medicine in ANOCA and MINOCA, enabling tailored therapy and improved patient-centered outcomes.
Witzig T, Puricel S, Witzig A
… +4 more, Faucherre Y, Simioni L, Togni M, Cook S
Cardiovasc Revasc Med
· 2026 Feb · PMID 41781239
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BACKGROUND: Since their creation in 2002, drug-eluting stents (DES) have proven their superiority over their bare-metal counterparts and significantly evolved. Efforts are now concentrated on improving the DES platform,...BACKGROUND: Since their creation in 2002, drug-eluting stents (DES) have proven their superiority over their bare-metal counterparts and significantly evolved. Efforts are now concentrated on improving the DES platform, particularly by integrating thinner stent design. We aimed to compare outcomes between a broad range of current generation DES to evaluate the impact of thinner strut design in a real-world setting. METHODS: We analysed data from 3092 patients who underwent percutaneous coronary intervention (PCI) with thin (≤80 μm) or thick (>80 μm) DES in the Cardio-FR database. Of these, 2551 (1567 thick DES and 984 thin DES) met the inclusion and exclusion criteria and completed a two-year follow-up: The primary outcome was the device-oriented composite endpoint (DOCE) of cardiac death, non-fatal target vessel myocardial infarction (TVMI) and target lesion revascularization (TLR). RESULTS: The mean age was 67 years, and 75% were male. After multivariable adjustment, thick-strut DES were associated with higher 2-year DOCE compared with thin-strut DES (adjusted OR for thick vs thin: 1.298; 95% CI: 1.006-1.674; p = 0.045). In contrast, stroke was less frequent with thick-strut DES (2.0% vs 3.4%; p = 0.041). All other event rates were similar between the groups. CONCLUSION: Clinical follow-up up to two years shows treatment with thin strut DES significantly lowers DOCE rates compared with thick strut DES. More research is needed to assess the impact of thinner strut design on performance.
Khialani B, Sim EWJ, Shing AA
… +6 more, Khaing T, Fairley S, Touma G, Ada C, Kartikhesan D, Wong B
Cardiovasc Revasc Med
· 2026 Feb · PMID 41741260
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Ostial coronary lesions present significant technical challenges during percutaneous coronary intervention (PCI), where imprecise stent positioning can result in geographic miss, stent protrusion, or compromised future a...Ostial coronary lesions present significant technical challenges during percutaneous coronary intervention (PCI), where imprecise stent positioning can result in geographic miss, stent protrusion, or compromised future access. Angiographic guidance alone is often limited by vessel foreshortening, overlapping structures, and variable aortic root anatomy. Although intravascular ultrasound (IVUS) provides high-resolution visualization of the coronary ostium and plaque morphology, its integration into real-time ostial stent deployment has been inconsistent, partly due to equipment and technical constraints. The Fluoroscopic IVUS X-mark IT (FIX-IT) technique offers a simple, reproducible solution by using IVUS to identify the true anatomical ostium and translate this landmark precisely onto fluoroscopy. This facilitates accurate stent placement while minimizing contrast use and reducing the risk of geographic miss. We describe the application of FIX-IT for ostial left anterior descending (LAD) artery stenting across three different IVUS platforms, demonstrating its adaptability, procedural reliability, and potential to improve technical success and long-term outcomes in ostial PCI.
Cardiovasc Revasc Med
· 2026 Jun · PMID 41702823
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Type II myocardial infarction (MI), caused by myocardial oxygen supply-demand imbalance rather than acute plaque rupture, represents a growing clinical challenge with high mortality but limited evidence-based management...Type II myocardial infarction (MI), caused by myocardial oxygen supply-demand imbalance rather than acute plaque rupture, represents a growing clinical challenge with high mortality but limited evidence-based management strategies. It requires a rise and/or fall in cardiac troponins with objective evidence of ischemia and should be distinguished from acute myocardial injury without ischemic features. Current guidelines provide limited, but largely diagnostic and principle-based guidance and do not provide trial-validated pathways for coronary evaluation or revascularization in type II MI with coexisting coronary artery disease. Observational studies suggest potential benefit of revascularization and secondary prevention, yet selection bias and procedural risks complicate decision-making. Emerging strategies, including the use of drug-coated balloon (DCB) angioplasty, may offer a balance between invasive therapy and bleeding risk in this high-risk population. This article highlights the diagnostic complexities, therapeutic dilemmas, and the urgent need for randomized trials to define optimal management pathways. A pragmatic framework is proposed, integrating systemic trigger correction, coronary evaluation, physiology-based testing, and individualized revascularization strategies, with emphasis on underutilized guideline-directed medical therapy. The proposed diagnostic and management framework is pragmatic and expert-opinion-based, reflecting current evidence gaps rather than validated trial data.
Choi WG, Rha SW, Choi BG
… +15 more, Choi SY, Byun JK, Lee Y, Park S, Park EJ, Kang DO, Choi CU, Lee JH, Lee JY, Sun JH, Kim SM, Hwang KK, Kim DW, Jeong MH, KAMIR NIH Investigators
Cardiovasc Revasc Med
· 2026 Feb · PMID 41680033
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BACKGROUND AND AIMS: Coronary stent length has been considered an important predictor of adverse events in stable patients undergoing percutaneous coronary intervention (PCI). However, data regarding on the impact of lon...BACKGROUND AND AIMS: Coronary stent length has been considered an important predictor of adverse events in stable patients undergoing percutaneous coronary intervention (PCI). However, data regarding on the impact of long drug-eluting stent (DES) length on the clinical outcomes in acute myocardial infarction (AMI) patients are limited. METHODS: The study analyzed a total of 9021 AMI patients who underwent PCI with 2nd generation DESs from Korea AMI registry-National Institutes of Health. The patients were categorized into three groups according to the stent length (SL) in a treated coronary artery: <38 mm, n = 6821, 38-59 mm, n = 1735 and ≥60 mm, n = 465 and compared using the inverse probability of treatment-weighted (IPTW) method. The primary endpoint was the incidence of major adverse cardiac events up to 3 years. RESULTS: After adjustment for differences in the baseline risk factors, SL was significantly associated with higher cumulative rates of MACE [Odds ratio (OR) 1.15 for 38-59mm group, 95% confidence interval (CI): 1.06-1.26, p = 0.001, and OR 1.23 for ≥60mm group, 95% CI:1.13-1.34, p < 0.001], especially, non target vessel revascularization (TVR), not TVR. Stent thrombosis (ST) showed a significant association with long DESs after IPTW. Patients with very long DESs ≥60 mm showed a markedly higher risk (HR: 1.798, 95% CI: 1.149-2.814, P = 0.010). CONCLUSIONS: DES length reflecting diffuse coronary atherosclerosis was associated with adverse long-term clinical outcomes in AMI patients treated with 2nd generation DESs. Long stent implantation did not affect TVF but was associated with increased non-TVR. Although the incidence of ST is low, patients with SL ≥60 mm had an increased risk of ST, underscoring an important consideration during PCI.
Popolo Rubbio A, Celeski M, Sisinni A
… +10 more, Guerrini M, Barletta M, Mainardi C, Cannone G, Desimone P, Nicodemo AA, Brambilla N, Tusa M, Bedogni F, Testa L
Cardiovasc Revasc Med
· 2026 Jan · PMID 41633891
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BACKGROUND: Transcatheter mitral edge-to-edge repair (M-TEER) has transformed the management of patients with severe mitral regurgitation (MR) at high or prohibitive surgical risk. However, data on long-term survival and...BACKGROUND: Transcatheter mitral edge-to-edge repair (M-TEER) has transformed the management of patients with severe mitral regurgitation (MR) at high or prohibitive surgical risk. However, data on long-term survival and causes of death after M-TEER remain limited. METHODS AND RESULTS: This single-center registry included consecutive patients undergoing M-TEER with the MitraClip device for severe MR between February 2016 and June 2020. The primary objective was long-term mortality trends and causes of death. Over a median follow-up of 3.3 years (IQR 1.3-5.1; maximum 8.5 years), 130 of 218 patients (59.6%) died, with 55.4% due to cardiovascular (CV) causes, mainly heart failure (HF, 34.6%). Non-CV deaths were attributed to sepsis (15.4%), malignancy (10.8%), trauma (3.8%), and multi-organ failure (1.5%). CV mortality accounted for 55% of deaths within 1 year and 68.4% beyond 5 years, with no significant change in the CV/non-CV mortality ratio over time. Among 88 survivors, non-fatal CV events were infrequent: 12.5% were rehospitalized for HF and 2.3% underwent repeat M-TEER. Non-CV hospitalizations occurred in 9.1%, mainly due to fractures or pneumonia. Independent predictors of all-cause mortality included ischemic secondary MR etiology, prior HF, TAPSE/sPAP ≤0.36, and ≥moderate tricuspid regurgitation, while a low MitraScore predicted better survival. A low MitraScore risk was associated with a significantly lower all-cause and CV mortality compared to a high Mitrascore risk (48.6% vs 83.9%, p < 0.001; 21.0% vs 64.4%, p ≤ 0.001). CONCLUSION: Long-term mortality after M-TEER remains influenced by extra-mitral cardiac involvement and non-cardiac comorbidities. The MitraScore preserves its prognostic accuracy during extended follow-up.
Sisinni A, Rojas Sanchez AM, Tusa M
… +2 more, Bedogni F, Testa L
Cardiovasc Revasc Med
· 2026 May · PMID 41629182
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Acute mitral regurgitation (MR) is a critical condition arising from diverse etiologies, including infective endocarditis, ischemic heart disease, stress-induced cardiomyopathy, and iatrogenic injury. While surgical repa...Acute mitral regurgitation (MR) is a critical condition arising from diverse etiologies, including infective endocarditis, ischemic heart disease, stress-induced cardiomyopathy, and iatrogenic injury. While surgical repair or replacement has traditionally served as the standard of care, particularly in emergent cases, the evolution of transcatheter mitral valve therapies offers viable alternatives for patients deemed high-risk for conventional surgery. This review examines the pathophysiological mechanisms underlying acute MR in specific clinical contexts, and explores the expanding role of transcatheter edge-to-edge repair.
Witberg G, Kikuta Y, Dan K
… +17 more, Matsumura M, Maehara A, Tanigaki T, Yokoi H, Hikichi Y, Nanasato M, Miura K, Sato K, Taniguchi M, Goto K, Haruta S, Levi A, Otake H, Fearon WF, Matsuo H, Kornowski R, Takebayashi H
Cardiovasc Revasc Med
· 2026 Jan · PMID 41620337
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BACKGROUND: Wire-based fractional flow reserve (wbFFR) is the gold standard for physiologic assessment of coronary artery disease (CAD). Recently, angiogram-based FFRangio have shown good diagnostic performance against w...BACKGROUND: Wire-based fractional flow reserve (wbFFR) is the gold standard for physiologic assessment of coronary artery disease (CAD). Recently, angiogram-based FFRangio have shown good diagnostic performance against wbFFR. Limited outcome data is available for FFRangio. The present study aimed to investigate the clinical outcomes of FFRangio-guided treatment for CAD in real-world practice. METHODS: In an international multicentre registry, CAD patients assessed using FFRangio underwent angiography/revascularisation at 7 centres. The primary endpoint was 1-year cumulative incidence of cardiovascular death/myocardial infarction (MI)/unplanned revascularisation (UR). RESULTS: Our cohort included 2129 lesions from 1579 patients. In 1951 lesions (91.6%) and 1435 patients (90.9%), treatment was concordant with FFRangio results. Mean age was 70.3 years and 30.6% were female. Mean FFRangio was 0.86 (0.66 and 0.95 in the revascularised and deferred lesions, respectively). After a median follow up of 365 (Q1-Q3: 326-365) days, the primary endpoint for the revascularisation and deferral groups was 6.8% and 1.6% (cardiovascular death 0% and 0.4%, MI 1.0% and 0.1%, UR 6.8% and 1.2%). Risk for the primary endpoint was 3.6% and 8.7% in the concordant and discordant groups, respectively (adjusted HR 0.38 [95%CI: 0.19-0.88], p = 0.006), driven by lower incidence of event in the concordant revascularisation vs. discordant deferral groups (6.8 vs. 12.3%, HR 0.43 [95%CI: 0.19-0.95], p = 0.038). CONCLUSIONS: In real-world setting, FFRangio-guided treatment yields excellent one-year outcomes for both revascularisation and deferred lesion, which are comparable with current data for wbFFR-guided treatment. FFRangio-concordant revascularisation was associated with better prognosis than FFRangio-discordant deferral for patients with FFRangio ≤ 0.8. TRIAL REGISTRATION: NCT05648396.
Kiyohara Y, Minami K, Freeman L
… +5 more, Wilson Tang WH, Pinney SP, Yano Y, Naito T, Miyashita S
Cardiovasc Revasc Med
· 2026 Jan · PMID 41617604
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BACKGROUND: Reperfusion therapy is the cornerstone of treatment for acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). However, older adults with AMI and CS face higher risks of adverse outcomes and...BACKGROUND: Reperfusion therapy is the cornerstone of treatment for acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). However, older adults with AMI and CS face higher risks of adverse outcomes and procedure-related complications. Since this population is under-represented in clinical trials, the efficacy of reperfusion therapy remains unclear. We performed a meta-analysis to evaluate the impact of reperfusion therapy on mortality in older adults with AMI and CS. METHODS: We searched PUBMED and EMBASE through 4/1/2025 for studies comparing reperfusion therapy with percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) and non-reperfusion therapy for AMI and CS in patients aged ≥75 years. We included prospective and retrospective observational trials reporting clinical outcomes. The primary outcome was set as short-term mortality, and the secondary outcome was long-term mortality. We performed subgroup analysis of the primary outcome for patients with ST-segment elevation myocardial infarction and those without. RESULTS: Our search identified 14 eligible studies in a total of 4583 patients. Reperfusion therapy was associated with significantly reduced short-term mortality, compared with non-reperfusion therapy with high heterogeneity (odds ratio (OR): 0.47; 95% confidence interval (CI): 0.30-0.73, I = 76.8%). There was no significant difference in long-term all-cause mortality between reperfusion and non-reperfusion therapy (OR: 0.66; 95% CI: 0.34-1.26, I = 79.7%). The subgroup analyses were largely consistent with the main findings. CONCLUSIONS: Reperfusion therapy was associated with reduced short-term mortality, compared to non-reperfusion therapy for older patients with AMI and CS. Reperfusion therapy showed a tendency towards reduced long-term mortality.
Rai H, Byrne KK, O'Callaghan D
… +8 more, Durand R, Coughlan JJ, Colleran R, Kennedy M, Blake GJ, Hanratty CG, Spence MS, Byrne RA
Cardiovasc Revasc Med
· 2026 Jan · PMID 41617603
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BACKGROUND: The Patient Experience in the Catheterization Laboratory (PATCATH) Questionnaire was developed by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) to evaluate patient understanding...BACKGROUND: The Patient Experience in the Catheterization Laboratory (PATCATH) Questionnaire was developed by the European Association of Percutaneous Cardiovascular Intervention (EAPCI) to evaluate patient understanding of coronary catheterization procedures. In this study, we aimed to compare patient experience after coronary catheterization using the PATCATH questionnaire following provision of standard printed patient information leaflets (PILs) and PILs supplemented by specially developed video animations to aid informed consent. METHODS: The PATCATH questionnaire was administered anonymously to patients following coronary catheterization at a single tertiary referral center over two consecutive time periods. The questionnaire comprises 17 questions, divided into 3 domains, assessing patient experience before, during, and after the procedure. During phase 1, standard PILs were provided (PIL group). In phase 2, the PILs were supplemented with videos (PIL+ video group). RESULTS: The PATCATH tool was administered to a total of 296 patients following cardiac catheterization (22% female, 60.5% aged >65 years). 213 patients were included in the PIL group and 83 in the PIL + video group. Overall, positive patient satisfaction was reported in each domain. Positive patient satisfaction was comparable in both the PIL and the PIL+ video group in all 3 domains (before: 96.7% versus 100%, p = 0.20; during: 96.3% versus 97.3%, p > 0.99; after: 98.6% versus 97.6%, p = 0.62). CONCLUSIONS: The use of a video animation in addition to a PIL when performing informed consent did not result in an increase in patient satisfaction as assessed by the PATCATH questionnaire.
Min S, Kadiyala V, Has P
… +7 more, Elkaryoni A, Lu F, Khetpal V, Agyeman H, Hyder O, Saad M, Abbott JD
Cardiovasc Revasc Med
· 2026 Jan · PMID 41617602
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BACKGROUND: Coronary artery bypass grafting (CABG) ineligibility is associated with increased mortality in patients undergoing PCI. Limited data exist about CABG-eligible patients who decline surgery and opt for PCI. MET...BACKGROUND: Coronary artery bypass grafting (CABG) ineligibility is associated with increased mortality in patients undergoing PCI. Limited data exist about CABG-eligible patients who decline surgery and opt for PCI. METHODS: National Cardiovascular Data Repository CathPCI data from 2018 to 2024 at two high-volume PCI centers was used to identify patients that had surgical consultation prior to PCI. Baseline characteristics and in-hospital outcomes were compared between patients who were turned down for surgery (CABG-ineligible) and those who were offered surgery but declined (CABG-eligible). RESULTS: The cohort included 388 patients (313 CABG-ineligible and 75 CABG-eligible). CABG-ineligible patients were younger (70.4 vs 73.4 years; p = 0.01) and had higher rates of chronic lung disease, diabetes, and frailty, but with no difference in lesion complexity between the groups. PCI in the CABG-ineligible group was more likely urgent, emergent, or salvage, including STEMI and NSTEMI. Overall, PCI technical success was high, 92.9%, and in-hospital mortality was 4.8% in CABG-ineligible versus 2.7% in the CABG-eligible group (p = 0.54). There was no difference in bleeding, myocardial infarction, cardiogenic shock, cardiac arrest, or new-onset dialysis. CONCLUSIONS: Among patients who underwent PCI after referral for CABG, technical success was high and in-hospital mortality was acceptable in patients who were deemed eligible or ineligible for CABG. Further study is warranted to examine long-term outcomes of PCI in CABG-ineligible patients versus those who decline CABG.