Primary percutaneous coronary intervention (pPCI) has revolutionized the prognosis of ST-segment ele-vation myocardial infarction (STEMI) and is the gold standard treatment. As a result of its success, the number of pPCI centres has expanded worldwide. Despite decades of advancements, clinical outcomes in STEMI patients have plateaued. Out-of-hospital car-diac arrest and cardiogenic shock remain a major cause of high in-hospital mortality, whilst the growing burden of heart failure in long-term STEMI survivors presents a growing problem. Many elements aiming to optimize STEMI treatment are still subject to debate or lack sufficient evidence. This review provides an overview of the most contentious current issues in pPCI in STEMI patients, with an emphasis on unresolved questions and persistent challenges.

Background: Transcatheter aortic valve implantation (TAVI) has become an established therapy for severe aortic stenosis and is increasingly performed in younger and lower-risk patients. Coronary access following TAVI may be technically challenging, particularly with long stent supra-annular self-expandable platforms. We aimed to evaluate the procedural characteristics and clinical outcomes of percutaneous coronary intervention (PCI) after TAVI, comparing patients treated with balloon-expandable valves (BEVs) and self-expandable valves (SEVs) at our center. Methods: In this retrospective single-center study, we included consecutive patients who underwent TAVI with BEVs (Edwards Sapien 3 and sapien 3 Ultra platforms) or SEVs (Medtronic Evolut R, Evolut Pro, Evolut Pro+, Evolut Fx and Abbot Navitor platforms) between 2016 and 2024 and subsequently underwent PCI in the index procedure post valve implantation, or returned for PCI due to chronic coronary syndrome (CCS) or acute coronary syndrome (ACS). Simple diagnostic coronary angiography without PCI was not considered in this analysis. The primary outcome was PCI success and procedural characteristics according to valve platform. A prespecified subgroup analysis was performed according to clinical presentation (CCS vs. ACS). Clinical outcomes were analysed in the whole population. Results: A total of 73 patients underwent PCI after TAVI, including 34 with balloon-expandable (Sapien) and 39 with self-expandable (33 Evolut and 6 Navitor) valves. The mean age was 81 ± 6 years, and 64% were male. The median time from TAVI to PCI was 470 days. LAD PCI was numerically more frequent in the BEV group (59% vs. 41%, p = 0.129), whereas LCX PCI was more common in the SEV group (54% vs. 29%, p = 0.035). PCI success was high overall (95%) and did not differ significantly between BEV and SEV platforms (97% vs. 92%, p = 0.374). Final TIMI 3 flow was achieved in 99% of cases. Intraprocedural coronary complications were infrequent (5%) and did not differ significantly between platforms. At 1 year, overall mortality was 8%, with no significant difference between BEV and SEV platforms. In a subgroup analysis, PCI success was high in CCS and ACS presentations (97% vs. 91%, p = 0.218), with a trend of higher 1-year mortality in ACS compared with CCS (15% vs. 3%, p = 0.061). Conclusions: PCI after TAVI is highly feasible, with excellent angiographic success and low complication rates. Procedural and clinical outcomes were comparable between BEV and SEV platforms.