Faculty Bibliography

BACKGROUND/UNASSIGNED:Recent observational studies have suggested that early treatment (<12 hours from diagnosis) of intermediate risk pulmonary embolism (PE) with catheter-based therapies may reduce morbidity and mortality. However, the effect of early versus late mechanical thrombectomy on acute pulmonary hemodynamics and right ventricular mechanics is less well defined. METHODS/UNASSIGNED:Patients enrolled in SYMPHONY-PE were divided into one of 2 groups based on the time from baseline CT pulmonary angiography to mechanical thrombectomy: Early <12 hours versus late ≥12 hours. The primary safety end point was the rate of major adverse events within 48 hours, as adjudicated by an academic independent safety board. The primary efficacy end point was the core-lab assessed mean change in right ventricle-to-left ventricle ratio from baseline to 48 hours. RESULTS/UNASSIGNED:=0.431) between groups, and there were no mortalities. The differences in efficacy outcomes were greatest in higher-risk patients per the Composite Pulmonary Embolism Shock score. CONCLUSIONS/UNASSIGNED:Early mechanical thrombectomy was associated with larger reductions in right ventricle-to-left ventricle ratio and mean pulmonary artery pressure, with no significant differences in safety event rates compared with patients who underwent late thrombectomy. Randomized trials are needed to test these associations. REGISTRATION/UNASSIGNED:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06062329.

BACKGROUND:The frequency of residual angina and its impact on health status and death following anatomic complete revascularization in symptomatic patients with chronic coronary disease are unknown. METHODS:Data were analyzed from ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) trial participants randomized to invasive management with baseline angina (Seattle Angina Questionnaire Angina Frequency score <100), no prior coronary artery bypass graft surgery, and anatomic complete revascularization within 90 days of randomization. The primary outcome was frequency of residual angina after revascularization, defined as a Seattle Angina Questionnaire Angina Frequency score <100 within 6 months of randomization. Secondary outcomes included 6-month health status and medication use and 5-year all-cause and cardiovascular death. RESULTS:=0.006). Five-year all-cause and cardiovascular death did not differ significantly between groups. CONCLUSIONS:Residual angina is common (>40%) following anatomic complete revascularization for chronic coronary disease and is associated with reduced quality of life and greater antianginal medication use but no increase in death. REGISTRATION/BACKGROUND:Unique Identifier: NCT01471522.

BACKGROUND:Hospital ownership type may influence acute cardiovascular disease disparities that persist across the U.S. We examined associations between hospital ownership type and in-hospital and readmission outcomes for STEMI hospitalizations. METHODS:We performed a retrospective cohort study of hospitalizations for STEMI using the National Readmissions Database (2016-2022). Hospitals were categorized as nonprofit, for-profit, or public. Outcomes included in-hospital mortality and 90-day readmission for acute coronary syndrome, heart failure, cardiovascular, and all causes. Associations were assessed using multivariable logistic and Cox proportional hazards regression, adjusting for patient, hospitalization, and hospital-level characteristics. RESULTS:Of 610,427 STEMI hospitalizations, 460,451 (75.4%) were at nonprofit, 88,965 (14.6%) at for-profit, and 61,011 (10.0%) at public hospitals. Compared with nonprofit hospitals, for-profit hospitals (aOR 1.09, 95% CI 1.05-1.13) and public hospitals (aOR 1.17, 95% CI 1.12-1.22) were each associated with higher odds of in-hospital mortality. For-profit hospitals were associated with higher risk of 90-day readmission for acute coronary syndrome (aHR 1.15, 95% CI 1.10-1.21), heart failure (aHR 1.08, 95% CI 1.03-1.13), cardiovascular (aHR 1.08, 95% CI 1.05-1.12), and all causes (aHR 1.13, 95% CI 1.10-1.16) relative to nonprofit hospitals. Public hospitals were associated with higher risk of 90-day readmission for heart failure (aHR 1.08, 95% CI 1.02-1.13) relative to nonprofit hospitals. CONCLUSIONS:For-profit and public hospitals were associated with higher in-hospital mortality and 90-day readmission for various causes compared with nonprofit hospitals. These findings suggest that hospital-level factors may contribute to disparities in STEMI outcomes and warrant further investigation.

BACKGROUND:Differentiating healed spontaneous coronary artery dissection (SCAD) from woven coronary arteries or recanalized thrombus can be challenging. CASE SUMMARY/METHODS:A 33-year-old man presented with chest pain and was found to have a severe atypical-appearing lesion in the proximal left anterior descending artery. Differential diagnoses included healed dissection, woven coronary, and recanalized thrombus. Coronary computed tomography angiography demonstrated SCAD. Optical coherence tomography revealed extensive lipid plaque, foamy macrophages, cholesterol crystals, and plaque rupture with recanalized thrombus. The patient underwent successful percutaneous coronary intervention, with complete resolution of symptoms. DISCUSSION/CONCLUSIONS:Angiographic and computed tomographic features of healed SCAD, woven coronary arteries, and recanalized thrombus can overlap. Optical coherence tomography can differentiate by visualizing dissection flaps, intramural hematomas (SCAD), or small channels within a thrombus. TAKE-HOME MESSAGES/CONCLUSIONS:Healed SCAD, woven coronary artery, and recanalized thrombus have resembling angiographic features. Differentiating among them is critical, as the management differs. Intravascular imaging can help.

OBJECTIVES/OBJECTIVE:The SELUTION SLR 014 In-stent Restenosis (SELUTION4ISR) trial showed noninferiority of DCB for the outcome of target lesion failure (TLF) when compared with standard of care (80% DES and 20% POBA). It was notable that in the DCB vs DES subgroup analysis there was a numerically higher rate of TLF with DCB (15.3% vs 7.1%). The authors aimed to re-evaluate the outcomes of drug-eluting stent (DES), drug-coated balloon (DCB), or plain old balloon angioplasty (POBA) in patients with coronary in-stent restenosis (ISR). METHODS:The authors searched PubMed and EMBASE databases for randomized clinical trials (RCTs) that compared these 3 percutaneous revascularization strategies for ISR until March 15, 2026. Outcomes included major adverse cardiovascular events (MACE), target lesion revascularization, all-cause mortality, cardiovascular mortality, and stent thrombosis. RESULTS:From 19 RCTs that randomized 4238 patients with ISR at mean follow-up of 19.6 months, there was a significant reduction in MACE and TLR with both DCB (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.28; 95% CI, 0.16-0.49, respectively) and DES (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.22; 95% CI, 0.12-0.42, respectively) when compared with POBA. There were no significant differences in clinical outcomes between DCB and DES. CONCLUSIONS:In patients with ISR, DCB reduced MACE/TLR when compared with POBA. There were no clinical differences between DCB and DES even after inclusion of the SELUTION4ISR trial, thus suggesting that DCB are reasonable alternative to repeat stenting in patients presenting with ISR.

BACKGROUND:Myocardial infarction with non-obstructive coronary arteries (MINOCA) has several underlying causes, including mimicking conditions in some cases. Imaging is recommended to identify MINOCA etiologies, but it remains unclear which patients are most likely to have abnormal findings. We characterized MINOCA mechanisms, analyzed predictors of imaging abnormalities and explored sex differences. METHODS:We enrolled patients with clinical diagnosis of MI in an international, prospective, diagnostic study at 28 sites in US, Canada and UK. After a women-only phase, we included both sexes. Individuals with ≥50% diameter stenosis or coronary dissection on angiography, or alternate causes for the clinical presentation, were excluded. Participants had multi-vessel coronary optical coherence tomography (OCT) during index coronary angiography and cardiac magnetic resonance imaging (CMR) within one week. Independent core laboratories interpreted imaging, blinded to other results. RESULTS:Among 754 patients enrolled, 389 had MINOCA and 336 with MINOCA underwent OCT (270 women and 66 men); CMR was completed in 284 (85%). An OCT-defined culprit lesion was identified in 45% (116/270 women [43% ] and 35/66 men [53%], p=0.18). CMR demonstrated an ischemic pattern in 114/284 (40%), similar by sex (96/225 women [43%] vs. 18/59 men [31%], p=0.12). A non-ischemic pattern was observed in 23% (23% of women, 25% of men, p=0.78). We identified a cause of the clinical presentation in 79% of patients with both tests completed: 59% had an ischemic cause of MINOCA and 20% had a non-ischemic mimicking condition. OCT alone found a MINOCA etiology in 151/336 (45%) and CMR alone in 180/284 (63%). Predictors of an OCT culprit lesion included age, abnormal angiogram, and number of vessels imaged, but 27% of normal angiograms harbored a culprit lesion. Predictors of abnormal CMR were peak troponin, shorter time to CMR, and non-Asian race, but CMR was abnormal in 40% when troponin was <4-fold above the upper reference limit. CONCLUSIONS:The combination of multi-vessel coronary OCT and CMR in patients with a clinical diagnosis of MINOCA confirmed MI in 59% and identified an alternate cause (MINOCA mimic) in 20%. Clinical factors had limited utility to predict imaging abnormalities. No sex differences in imaging results were detected.

Angiography-derived physiology (ADP) is an emerging technique that offers streamlined, wire-free assessment of epicardial coronary physiology. This is accomplished by applying computational fluid dynamics or, in some cases, mathematical formulas in conjunction with artificial intelligence to standard coronary angiographic images. This approach represents a potential paradigm shift in the catheterization laboratory workflow. Despite its early promise, obstacles to the adoption and routine use of ADP remain. This document represents expert opinion from a scientific roundtable on ADP for coronary artery assessment sponsored by the Society for Cardiovascular Angiography & Interventions. It provides a comprehensive overview of the underlying concepts of ADP, outlines its optimal clinical application based on current evidence, highlights key advantages and limitations, reviews available software solutions, and discusses future directions.

BACKGROUND:In patients with intermediate-risk pulmonary embolism (PE), there are limited tools to assess therapeutic response following catheter-based intervention. This study evaluates pulmonary vascular resistance (PVR), an invasive marker of right ventricular (RV) afterload, and its prognostic significance in acute PE. METHODS:This single-center retrospective study included patients from October 2020-May 2025 with intermediate-high risk PE undergoing large bore mechanical thrombectomy (LBMT) with pulmonary artery catheter-derived hemodynamic indices obtained pre- and post-procedure. The primary objective was to evaluate the effect of LBMT on PVR. Secondary objective was to evaluate the predictors of post procedure elevated PVR (defined as PVR >2 Wood units, WU) and its effect on clinical composite outcome (PE mortality, resuscitated cardiac arrest, hemodynamic instability and 90-day hospital readmission) and hospital length of stay (LOS). RESULTS:A total of 131 patients were included. Following LBMT, median PVR decreased significantly from 2.9 to 1.8 WU (p < 0.001), with greater reduction in patients with higher baseline PVR (baseline PVR tertile 3 to 1: 50% vs. 40% vs. 20%; p < 0.001). Persistently elevated post procedure PVR (>2 WU) was seen in 43.6% of patients. However, the incidence of post-procedure severe PVR >5 WU was extremely low (11.5% pre-procedure, 0.8% post-procedure). Multivariable predictors of elevated post-procedural PVR were pre-procedural mean pulmonary artery pressure (OR: 1.07, 95% CI 1.01-1.14, p = 0.026) and pre-procedural PVR (OR 2.20, 95% CI: 1.20-4.04, p = 0.011). In an age and sex adjusted model, elevated post-procedure PVR was associated with a longer in-hospital LOS of 4.2 days (95% CI: 0.60-7.88; p = 0.023) and a 4-fold higher risk of the composite outcome (20.7% vs 5.3%, adjusted hazard ratio: 4.02, 95% CI: 1.28-12.61, p = 0.017). CONCLUSIONS:In patients with intermediate-high risk PE, LBMT significantly reduced PVR and may be a valuable hemodynamic marker of disease severity and treatment response. Elevated post-procedural PVR identified patients at increased risk of adverse outcomes.