Background and Objectives: To assess the correlation between the degree of target coronary artery stenosis measured by instantaneous wave-free ratio (iFR) and the intraoperative transit time flow measurement (TTFM) of attached grafts as well as evaluate flow competition between the native coronary artery and the attached graft according to the severity of stenosis. Materials and Methods: In total, 89 grafts were subjected to intraoperative transit time flow measurement after coronary artery bypass grafting (CABG) in 25 patients with multivessel coronary artery disease (CAD). The iFR was evaluated for all coronary arteries with grafts. The coronary artery stenoses were divided into three groups based on the iFR value: iFR < 0.86 (group 1); iFR 0.86–0.90 (group 2); and iFR > 0.90 (group 3). Results: The mean graft flow (MGF) was 46.9 ± 18.4 mL/min for group 1, 45.3 ± 20.9 mL/min for group 2, and 31.3 ± 18.5 mL/min for group 3. A statistically significant difference was confirmed between groups 1 and 3 (p = 0.002) and between groups 2 and 3 (p = 0.025). The pulsatility index (PI) was 2.49 ± 1.20 for group 1, 2.66 ± 2.13 for group 2, and 4.70 ± 3.66 for group 3. A statistically significant difference was found between groups 1 and 3 (p = 0.006) and between groups 2 and 3 (p = 0.032). Backward flow was detected in 7.5% of grafts for group 1, in 16.6% of grafts for group 2, and in 16% of grafts for group 3. A statistically significant difference was found between groups 1 and 2 (p = 0.025) and between groups 1 and 3 (p = 0.029). Conclusions: The iFR is a useful tool for predicting the impact of competitive flow observed between a native artery and an attached graft. The effect of competitive flow significantly increases when the graft is attached to a vessel with mild coronary stenosis. In a coronary artery where the iFR was not hemodynamically significant, the MGF was lower, the PI was higher, and a larger proportion of grafts with backward flow (BF) was detected compared to when there was significant stenosis (iFR < 0.86).

Objectives: To evaluate the impact of concomitant tricuspid valve (TV) repair on the right ventricular (RV) function postoperatively and within the 6 months following degenerative mitral valve (MV) repair. Methods: The prospective study included 37 patients (mean age 57.32 ± 2.13 years) with severe MV regurgitation due to primary MV prolapse. Nineteen underwent successful MV repair (TV(−) group). Additional TV repair due to moderate-to-severe TV regurgitation was performed in 18 (TV(+) group). Two-dimensional (2D) speckle-tracking and tissue Doppler echocardiography was performed for all patients before surgery and 7 days and 6 months after surgery. Results: Preoperative dimensions and indices of RV longitudinal function did not differ between the groups (right ventricle end-diastolic diameter (RVEDD) was 33.53 ± 0.94 mm vs. 34.67 ± 1.72 mm, tricuspid annular systolic motion (S’) was 15.06 ± 0.85 cm/s vs. 16.0 ± 1.27 cm/s, tricuspid annular plane systolic excursion (TAPSE) was 24.02 ± 1.06 mm vs. 22.4 ± 1.36 mm, respectively; p>0.05). RVEDD decreased significantly and did not change within the follow-up in the TV(−) group. In the TV(+) group, RVEDD decreased early after surgery and more markedly six months later in comparison to the TV(−) group. Indices of RV systolic longitudinal function decreased early after surgery and had a tendency to increase after six months in both groups. Regional longitudinal strains of the lateral RV wall decreased early after surgery and improved within the six months in the TV(−) group and did not change significantly in the TV(+) group. Conclusions: Additional TV repair in degenerative MV repair more markedly reduces RV dimensions and does not have a negative impact on RV systolic function in comparison to an isolated MV repair although these conclusions are of limited value due to the lack of a control group.

Objectives: To assess whether instantaneous wave – free ratio (iFR) value is associated with left internal mammary artery (LIMA) graft failure at 12 months follow-up post coronary artery bypass graft (CABG). Background: Data suggests bypass to a non-significant left anterior descending artery (LAD) lesion due to visual over-estimation may lead to LIMA graft failure. Implementing iFR may result in better arterial graft patency. Methods: In iCABG (iFR guided CABG) study patients planned to undergo an isolated CABG procedure was prospectively enrolled and iFR was performed for LAD. Coronary computed tomography angiography was performed at 2 and 12 months follow-up. The primary endpoint of this study was to determine the rate of LIMA graft occlusion or hypoperfusion at 2 and 12-months follow-up. We considered a composite secondary endpoint of Major adverse cardiovascular and cerebrovascular event (MACCE) as a secondary outcome. Results: In total 69 patients were included with no differences regarding age, sex and risk factors. At 2 months, 50 of LIMAs with pre-CABG iFR median 0.855 (0.785 – 0.892) were patent. Hypoperfusion was found in 8 LIMAs (median iFR 0.88 (0.842 – 0.90)). While, 7 LIMAs (median iFR 0.91 (0.88 – 0.96)) were occluded ( p = 0.04). At 12 months, when iFR of LAD was >0.85: just 12 (31.6% out of all patent LIMAS) grafts were patent and 24 (100.0% out of all hypoperfused/occluded) grafts were hypoperfused or occluded ( p < 0.001). In terms of MACCE, no difference ( p = 1.0) was found between all 3 groups divided according to iFR value. Conclusions: Instantaneous wave – free ratio value above 0.85 in LAD is a powerful tool predicting LIMA graft failure at 1-year follow up period.

Background and Clinical Significance: Infective endocarditis is a disease of the endocardial surface of the heart, most often affecting heart valves (native or prosthetic) or intracardiac device. Although relatively rare, it carries high embolic risk of complications and mortality. Complete device extraction is recommended; however, conventional surgery may be prohibitive in frail patients with multiple comorbidities. Case presentation: We present a case of a 74-year-old male with implantable cardioverter-defibrillator (ICD)-related infective endocarditis and large lead-associated vegetation measuring approximately 3 cm in size. Due to a high operative risk assessed by Euro SCORE II, a minimally invasive percutaneous approach using the Penumbra vacuum-assisted aspiration system was selected. The procedure enabled successful debulking of the vegetation, followed by complete device removal and targeted antibiotic therapy. The patient’s clinical condition improved, with normalization of inflammatory markers and no recurrence of infection, and a new ICD was safely reimplanted after recovery. Conclusions: This case highlights the potential role of percutaneous vacuum-assisted aspiration as an effective and less invasive therapeutic option in high-risk patients with CIED-related infective endocarditis, particularly when conventional surgical management is contraindicated or requires bridging therapy until the patient’s status is stabilized.

Background: Coronary artery bypass grafting (CABG) to physiologically non-significant coronary artery stenosis may result in graft failure due to competitive native flow. We evaluated whether an instantaneous wave-free ratio (iFR)-guided revascularization strategy improves graft patency and clinical outcomes compared to conventional angiography-guided CABG. Methods: In this prospective, randomized, single-blinded trial, patients with multivessel disease and at least one angiographically intermediate stenosis (50%–75%) were randomized to either CABG guided by angiography alone or angiography supplemented with iFR assessment groups. The primary endpoint was graft patency (occlusion or hypoperfusion of the graft) evaluated by coronary computed tomography angiography (CCTA) at 2, 12, and 36 months. Results: At 36 months, 78% of the patients completed follow-up. Left internal mammary artery (LIMA)-to-left anterior descending (LAD) artery graft patency was significantly higher in the iFR-guided group than in the angiography-guided group (80.5% vs. 56.8%; absolute risk difference, 23.7% [95% CI , 3.7%–43.8%]; RR , 1.42 [95% CI , 1.03–1.95]; P = 0.03). Saphenous vein graft patency also improved with iFR guidance (90.2% vs. 70.3%; P = 0.046). Major adverse cardiac and cerebrovascular events (MACCE) were similar between groups (28% vs. 20%; RR , 1.40 [95% CI , 0.69–2.85]; P = 0.48). Conclusions: iFR-guided CABG advocates significantly improved mid-term graft patency compared with angiography-guided CABG by optimizing surgical target selection and reducing competitive flow. CLINICAL PERSPECTIVE: What Is New?: This prospective randomized trial demonstrates that physiological guidance using instantaneous wave-free ratio (iFR) significantly improves both arterial and venous graft patency at 36 months follow up compared to angiography-guided coronary artery bypass grafting (CABG). A pre-operative iFR threshold of >0.875 in the target vessel was identified as a potent predictor of subsequent graft occlusion or hypoperfusion. The study provides longitudinal evidence that competitive flow, identified by iFR, remains a critical determinant of long-term conduit durability. What Are the Clinical Implications?: Integrating routine iFR assessment into the surgical planning for multivessel coronary artery disease may identify fewer significant stenoses, reducing the need for CABG. Using physiological rather than purely anatomical criteria for revascularization may mitigate the risk of graft failure associated with competitive native flow. These results suggest that preoperative physiological assessment can refine surgical revascularization strategies and enhance long-term conduit durability.