Background: Cangrelor provides rapid platelet inhibition, making it a potential option for out-of-hospital cardiac arrest (OHCA) survivors undergoing percutaneous coronary intervention (PCI). However, clinical data on its use after OHCA are limited. This study investigates in-hospital outcomes of cangrelor use in this population. Methods: We conducted a prospective, observational study involving OHCA patients from the Lombardia CARe Registry (January 2015–December 2022) who underwent PCI in seven centers in Northern Italy. Propensity score (PS) matching compared patients who received cangrelor to those who did not. Logistic regression tested associations between cangrelor and discharge outcomes. Results: Of 612 OHCA patients admitted, 414 (67.4%) underwent PCI with known antithrombotic therapy, of whom 34 (8.2%) received cangrelor. Radial access was more common in the cangrelor group, which also had a higher troponin peak and a final TIMI flow grade of 3. Survival at discharge was 82.4% in the cangrelor group, compared to 65.3% in the no-cangrelor group (p = 0.043). Univariable logistic regression showed that cangrelor use was associated with higher survival at discharge (OR 2.5; 95% CI: 1.1–6.1, p = 0.049). After multiple PS matchings, cangrelor remained associated with better survival (OR 2.07; 95% CI: 1.16–2.98). Major bleeding rates were higher in the cangrelor group, even after adjusting for baseline bleeding risk (OR: 7.0; 95% CI: 2.9–17.0; p < 0.001). Conclusions: In OHCA patients undergoing PCI, cangrelor use was linked to improved in-hospital survival but higher major bleeding, suggesting a potential net clinical benefit.

Aims Residual cardiovascular risk remains substantial in patients with atherosclerotic cardiovascular disease (ASCVD) despite high-intensity statin therapy. Proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i), including monoclonal antibodies and small-interfering RNA agents, offer additional risk reduction, yet comparative evidence across individual regimens remains limited. Methods and Results We conducted a systematic review and network meta-analysis of randomized controlled trials evaluating approved PCSK9i dosages in patients with ASCVD. The primary outcome was major adverse cardiovascular events (MACE); the secondary outcomes included myocardial infarction, stroke, coronary revascularization, cardiovascular mortality, and all-cause death. A total of eight trials involving 49,847 patients were included. Evolocumab (140 mg every 2 weeks or 420 mg monthly) and alirocumab 150 mg every 2 weeks significantly reduced MACE compared with placebo (risk ratios (RR): 0.78, 95% confidence intervals (CI): 0.66–0.93 and RR: 0.47, 95% CI 0.25–0.86, respectively). Evolocumab was also associated with reductions in myocardial infarction, stroke, and revascularization. Alirocumab 150 mg demonstrated the most pronounced effect on revascularization and was superior to both evolocumab and the lower alirocumab dose in this outcome. No regimen significantly reduced cardiovascular or all-cause mortality. Conclusions These findings suggest that PCSK9 inhibitors are effective in ASCVD, with generally similar efficacy across agents; however, regimens achieving lower and sustained low-density lipoprotein cholesterol levels may confer greater benefit, in line with the concept that “the lower, the better.” Trial Registration PROSPERO identifier no. CRD420251022108.

Recent findings emphasize the potential role of invasive hemodynamic assessment in guiding transcatheter mitral and tricuspid valve percutaneous interventions. Right heart catheterization-derived parameters offer insights into hemodynamic changes associated with valvular heart diseases, pulmonary hypertension phenotyping, and right ventricular to pulmonary artery coupling. This might improve prognostic stratification for candidates to transcatheter therapies. This review provides a clinical overview of available data regarding the utility of preoperative right heart catheterization-derived parameters in patients undergoing mitral and tricuspid percutaneous repair or replacement.

Mitral transcatheter edge-to-edge repair (M-TEER) is an established treatment for severe mitral regurgitation. However, acute left ventricular (LV) dysfunction may complicate the procedure through mechanisms with distinct implications. An 81-year-old man with severe primary mitral regurgitation underwent elective M-TEER. Immediately after clip deployment, he developed acute LV dysfunction, initially managed as afterload mismatch (AM) with vasodilators. The clinical evolution was associated with apical ballooning on echocardiography, with electrocardiographic changes and troponin elevation without obstructive coronary disease, supporting Takotsubo syndrome (TTS). The patient remained stable, and LV function fully recovered within 1 week. This case illustrates the difficulty of distinguishing AM from TTS after M-TEER, 2 entities with overlapping features but different prognostic and therapeutic implications. Acute LV dysfunction after M-TEER should not be automatically attributed to AM. TTS should be considered, and the integration of clinical, echocardiographic, and electrocardiographic findings is essential to management.

Background/Objectives: Invasive coronary physiology has evolved from a tool for assessing intermediate stenoses to a comprehensive framework for guiding diagnosis and treatment across the spectrum of coronary artery disease (CAD). This review aims to provide an updated, catheterization laboratory-centered overview of contemporary invasive coronary physiology, emphasizing its role in optimizing percutaneous coronary intervention (PCI) and in evaluating patients with angina and non-obstructive coronary arteries (ANOCA/INOCA). Methods: A narrative review of contemporary evidence, including randomized trials, consensus documents, and guideline recommendations, was conducted. Key physiological indices—fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPRs), coronary flow reserve (CFR), and index of microcirculatory resistance (IMR)—were examined alongside emerging tools such as longitudinal vessel analysis and the pullback pressure gradient (PPG). Applications in pre- and post-PCI assessment, physiology–imaging integration, and comprehensive functional testing in ANOCA/INOCA were evaluated. Results: Physiology-guided PCI improves clinical outcomes and resource utilization compared with angiography-guided strategies. Longitudinal vessel assessment and PPG enable characterization of focal versus diffuse CAD, improving procedural planning and prediction of post-PCI physiological results. Post-PCI physiological assessment identifies residual ischemia and guides optimization strategies. In patients without obstructive CAD, combined assessment of microvascular function and vasomotor reactivity allows identification of distinct pathophysiological endotypes, supporting mechanism-based, individualized therapy. Integration with intracoronary imaging further enhances procedural precision. Conclusions: Contemporary invasive coronary physiology provides a multidimensional approach integrating epicardial, microvascular, and vasomotor domains. This framework supports personalized decision-making, optimizes revascularization, and reduces unnecessary interventions, representing a cornerstone of modern coronary care.

Background: Cardiogenic shock (CS) complicates 5–10% of myocardial infarctions and is a major cause of morbidity and mortality. Temporary mechanical circulatory support (MCS), such as the Impella CP device, has become crucial for stabilizing patients with severe left ventricular dysfunction. However, device positioning remains challenging, particularly when complications arise, such as the need for repositioning or replacement. This case report presents an innovative approach to fluoroscopy-free Impella repositioning using transesophageal echocardiography (TEE) guidance, which has not been previously documented in the context of coronary artery bypass grafting (CABG) and mitral valve surgery. Case Description: A 55-year-old male with severe left ventricular dysfunction and a history of diabetes and dyslipidemia was admitted with acute chest pain. Coronary angiography revealed severe three-vessel disease. After initial stabilization with an intra-aortic balloon pump (IABP), an Impella CP device was deployed for additional hemodynamic support. The patient then underwent CABG with five grafts and mitral valve repair via a median sternotomy. Before the CABG, the Impella device was temporarily positioned in the descending aorta to allow clamping of the ascending aorta during surgery. After the procedure, the Impella device was repositioned from the descending aorta to the left ventricle (LV) under TEE guidance. Manual pressure was applied externally by the surgeon to facilitate the pigtail catheter’s passage through the valve. Once the device entered the LV, its final position was confirmed with TEE in both long-axis and short-axis views, ensuring optimal placement in the left ventricular cavity. Conclusions: This case demonstrates the feasibility and safety of performing Impella repositioning without fluoroscopy. By utilizing echocardiography for device guidance, the approach reduces the risk of vascular injury and eliminates the need for additional large-bore arterial access. This method represents a novel strategy for improving the management of patients with severe left ventricular dysfunction post-surgery.