Objectives. To compare two different forms of mechanical circulatory support (MCS) in patients with complex high-risk indicated PCI (CHIP): the Impella CP system and veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Background. To prevent hemodynamic instability in CHIP, various MCS systems are available. However, comparable data on different forms of MCS are not at hand. Methods. In this multicenter observational study, we retrospectively evaluated all CHIP procedures with the support of an Impella CP or VA-ECMO, who were declined surgery by the heart team. Major adverse cardiac events (MACE), mortality at discharge, and 30-day mortality were evaluated. Results. A total of 41 patients were included, of which 27 patients were supported with Impella CP and 14 patients with VA-ECMO. Baseline characteristics were well-balanced in both groups. No significant difference in periprocedural hemodynamic instability was observed between both groups (3.7% vs. 14.3%; ). The composite outcome of MACE showed no significant difference (30.7% vs. 21.4%; ). Bleeding complications were higher in the Impella CP group, but showed no significant difference (22.2% vs. 7.1%; ) and occurred more at the non-Impella access site. In-hospital mortality was 7.4% in the Impella CP group versus 14.3% in the VA-ECMO group and showed no significant difference ( ). 30-Day mortality showed no significant difference (7.4% vs. 21.4%; ). Conclusions. In patients with CHIP, there were no significant differences in hemodynamic instability and overall MACE between VA-ECMO or Impella CP device as mechanical circulatory support. Based on this study, the choice of either VA-ECMO or Impella CP does not alter the outcome.

Purpose of Review: This review will outline the current evidence on the anatomical, functional, and physiological tools that may be applied in the evaluation of patients with late recurrent angina after coronary artery bypass grafting (CABG). Furthermore, we discuss management strategies and propose an algorithm to guide decision-making for this complex patient population.Recent Findings: Patients with prior CABG often present with late recurrent angina as a result of bypass graft failure and progression of native coronary artery disease (CAD). These patients are generally older, have a higher prevalence of comorbidities, and more complex atherosclerotic lesion morphology compared to CABG-naïve patients. In addition, guideline recommendations are based on studies in which post-CABG patients have been largely excluded.Summary: Several invasive and non-invasive diagnostic tools are currently available to assess graft patency, the hemodynamic significance of native CAD progression, left ventricular function, and myocardial viability. Such tools, in particular the latest generation coronary computed tomography angiography, are part of a systematic diagnostic work-up to guide optimal repeat revascularization strategy in patients presenting with late recurrent angina after CABG.

BACKGROUND: Coronary flow capacity (CFC) is a measure that integrates hyperemic myocardial blood flow and coronary flow reserve to quantify the pathophysiological impact of coronary artery disease on vasodilator capacity. This study explores the prognostic value of modified CFC derived from [ ¹⁵ O]H ₂ O positron emission tomography perfusion imaging. METHODS: Quantitative rest/stress perfusion measurements were obtained from 1300 patients with known or suspected coronary artery disease. Patients were classified as having myocardial steal (n=38), severely reduced CFC (n=141), moderately reduced CFC (n=394), minimally reduced CFC (n=245), or normal flow (n=482) using previously defined thresholds. The end point was a composite of death and nonfatal myocardial infarction. RESULTS: During a median follow-up of 5.5 (interquartile range, 3.7–7.8) years, the end point occurred in 153 (12%) patients. Myocardial steal (hazard ratio [HR], 6.70 [95% CI, 3.21–13.99]; P <0.001), severely reduced CFC (HR, 2.35 [95% CI, 1.16–4.78]; P =0.018), and moderately reduced CFC (HR, 1.95 [95% CI, 1.11–3.41]; P =0.020) were associated with worse prognosis compared with normal flow, after adjusting for clinical characteristics. Similarly, in the overall population, increased resting myocardial blood flow (HR, 3.05 [95% CI, 1.68–5.54]; P <0.001), decreased hyperemic myocardial blood flow (HR, 0.68 [95% CI, 0.52–0.90]; P =0.007) and decreased coronary flow reserve (HR, 0.55 [95% CI, 0.42–0.71]; P <0.001) were independently associated with adverse outcome. In a model adjusted for the combined use of perfusion metrics, modified CFC demonstrated independent prognostic value (overall P =0.017). CONCLUSIONS: [ ¹⁵ O]H ₂ O positron emission tomography–derived resting myocardial blood flow, hyperemic myocardial blood flow, coronary flow reserve, and CFC are prognostic factors for death and nonfatal myocardial infarction in patients with known or suspected coronary artery disease. Importantly, after adjustment for clinical characteristics and the combined use of [ ¹⁵ O]H ₂ O positron emission tomography perfusion metrics, modified CFC remained independently associated with adverse outcome.

Background: The applicability of quantitative flow ratio (QFR), a nonhyperemic, invasive coronary angiography‐derived computation of fractional flow reserve (FFR), has not been studied in coronary artery bypass grafts. We sought to explore the correlation and diagnostic agreement between QFR and FFR in saphenous vein grafts (SVGs). Methods and Results: A total of 129 prospectively included patients (mean age 73±8 years, 84% male) with prior coronary artery bypass grafting underwent invasive coronary angiography and pressure‐derived functional assessment in 150 nonoccluded SVGs. QFR dedicated angiography images of the SVGs were acquired and used for offline QFR computation. The diagnostic performance of QFR was compared with 2‐dimensional quantitative coronary angiography, using FFR as a reference. A threshold of ≤0.80 was used to define functional significance. QFR was successfully computed in 140 (93%) SVGs. We found a significant correlation between QFR and FFR (r=0.72, P <0.001). FFR indicated significant disease in 43 (31%) SVGs, whereas QFR analysis showed significant lesions in 53 (38%) bypass grafts. QFR exhibited a higher sensitivity and diagnostic accuracy compared with angiographic lesion assessment (84% versus 63%, P =0.030 and 83% versus 74%, P =0.036, respectively), whereas specificity did not differ (82% versus 79%, P =0.466). Lastly, QFR demonstrated a higher area under the receiver operating curve than quantitative coronary angiography (0.90 versus 0.82, P =0.008) for the detection of FFR‐defined significant vein graft disease. Conclusions: This study shows the potential applicability of contemporary QFR computation in venous bypass grafts with a moderate correlation and good diagnostic accuracy compared with functional assessment using FFR.

Coronary chronic total occlusions (CTOs) are diagnosed in a significant portion of patients undergoing coronary angiography and represent one of the most complex scenarios in contemporary percutaneous coronary interventions (PCI). This review systematically examines how adjunctive imaging modalities’—intravascular ultrasound (IVUS), optical coherence tomography (OCT), and coronary computed tomography angiography (CCTA)—co-registration enhances the precision and success rates of CTO-PCI during the procedure. The strategic integration of these technologies enables the development of patient-specific intervention strategies tailored to individual vascular architecture and lesion characteristics. This personalized approach marks a transition from standardized protocols to precision interventional cardiology, potentially optimizing procedural success rates while minimizing complications.

Cangrelor is the first and only intravenous P2Y₁₂-inhibitor and is indicated when (timely) administration of an oral P2Y₁₂ inhibitor is not feasible in patients undergoing percutaneous coronary intervention (PCI). Our study evaluated the first years of cangrelor use in two Dutch tertiary care centers. Cangrelor-treated patients were identified using a data-mining algorithm. The cumulative incidences of all-cause death, myocardial infarction, definite stent thrombosis and major bleeding at 48 h and 30 days were assessed using Kaplan–Meier estimates. Predictors of 30-day mortality were identified using uni- and multivariable Cox regression models. Between March 2015 and April 2021, 146 patients (median age 63.7 years, 75.3% men) were treated with cangrelor. Cangrelor was primarily used in ST-segment elevation myocardial infarction (STEMI) patients (84.2%). Approximately half required cardiopulmonary resuscitation (54.8%) or mechanical ventilation (48.6%). The cumulative incidence of all-cause death was 11.0% and 25.3% at 48 h and 30 days, respectively. Two cases (1.7%) of definite stent thrombosis, both resulting in myocardial infarction, occurred within 30 days, but after 48 h. No other cases of recurrent myocardial infarction transpired within 30 days. Major bleeding occurred in 5.6% and 12.5% of patients within 48 h and 30 days, respectively. Cardiac arrest at presentation was an independent predictor of 30-day mortality (adjusted hazard ratio 5.20, 95%-CI: 2.10–12.9, p < 0.01). Conclusively, cangrelor was used almost exclusively in STEMI patients undergoing PCI. Even though cangrelor was used in high-risk patients, its use was associated with a low rate of stent thrombosis.