BACKGROUND: Evaluation of the patients with MINOCA and identifying the underlying aetiology remains challenging. However, investigation in most patients remains limited to coronary angiography (CAG). The study aimed to assess the clinical profile, investigations and cardiac imaging of the patients with MINOCA and its outcomes.
RESULTS: Out of 55 patients with MINOCA, CAG was normal in 16 (29.1%), while 39 (69.9%) had nonobstructive coronary artery disease. Of 55 patients, 34 had limited workup (Group 1) and only 21 had advanced workup (Group 2). In comparison to Group 1, Group 2 had a significantly higher association with the identification of possible underlying aetiology (16 vs. 4, p < 0.001) and a change in the management (10 vs. 3, p = 0.002).
CONCLUSIONS: Diagnostic workup in patients with MINOCA was limited to CAG in 61.8% of patients in this study. However, patients with advanced workup had a significantly higher association with the change in the treatment and identifying possible underlying aetiology in such patients.

BACKGROUND: The optimal treatment for coronary calcified nodules (CNs) is still unclear. The aim of this study was to compare the modification of these lesions by coronary intravascular lithotripsy (IVL) and rotational atherectomy (RA) using optical coherence tomography (OCT).
METHODS: ROTA.shock was a 1:1 randomized, prospective, double-arm multi-center non-inferiority trial that compared the use of IVL and RA with percutaneous coronary intervention (PCI) in severely calcified lesions. In 19 of the patients out of this study CNs were detected by OCT in the target lesion and were treated by either IVL or RA.
RESULTS: The mean angle of CNs was significantly larger in final OCT scans than before RA (92 ± 17° vs. 68 ± 7°; p = 0.01) and IVL (89 ± 18° vs. 60 ± 10°; p = 0.03). The CNs were thinner upon final scans than in initial native scans (RA: 17.8 ± 7.8 mm vs. 38.6 ± 13.1 mm; p = 0.02; IVL: 16.5 ± 9.0 mm vs. 37.2 ± 14.3 mm; p = 0.02). Nodule volume did not differ significantly between native and final OCT scans (RA: 0.66 ± 0.12 mm3 vs. 0.61 ± 0.33 mm3; p = 0.68; IVL: 0.64 ± 0.19 mm3 vs. 0.68 ± 0.22 mm3; p = 0.74). Final stent eccentricity was high with 0.62 ± 0.10 after RA and 0.61 ± 0.09 after IVL.
CONCLUSIONS: RA or IVL are unable to reduce the volume of the calcified plaque. CN modulation seems to be mainly induced by the stent implantation and not by RA or IVL.

UNASSIGNED: Percutaneous coronary intervention with implantation of a bioresorbable scaffold (BRS) provide the vessel support for a limited period allowing the vessel to restore normal vasomotion after degradation of the BRS, opposed to treatment with drug-eluting stents where the metal persist in the vessel wall. Late lumen loss and reduction in lumen area after implantation have been reported. The purpose of this study was to investigate whether intense pre-dilatation before BRS implantation resulted in less reduction of minimal lumen area at 6- and 12-month follow-up after implantation of a Magmaris BRS (MgBRS). Coronary imaging with optical coherence tomography (OCT) and intravascular ultrasound (IVUS) was assessed to track changes in lumen and vessel dimensions.
UNASSIGNED: The prospective Optimal lesion PreparaTion before Implantation of the Magmaris bioresorbable scaffold In patients with coronary artery Stenosis (OPTIMIS) study randomly assigned eighty-two patients with chronic coronary syndrome to two pre-dilatation treatment strategies. Patients were randomized in a 1:1 ratio to pre-dilatation with either a non-compliant scoring balloon or a standard non-compliant balloon prior to implantation of a MgBRS. The treated segment was evaluated with OCT and IVUS at baseline, after 6 and 12 months to assess changes in lumen and vessel dimensions. The hypothesis was that more intense pre-dilatation with a non-compliant scoring balloon before MgBRS implantation can reduce the risk of late lumen reduction compared to standard pre-dilatation. The power calculation used expected MLA after 6 months (6.22 mm2 for the scoring balloon and 5.01 mm2 for the standard non-compliant balloon), power of 80 %, significance level of 0.05 and expected drop-out rate of 15 %, requiring 82 patients to be enrolled.
UNASSIGNED: Eighty-two patients were included in the study. Enrollment was from December 2020 to September 2023.
UNASSIGNED: The hypothesis was that more intense pre-dilatation with a non-compliant scoring balloon before MgBRS implantation can reduce the risk of late lumen reduction compared to standard pre-dilatation.

BACKGROUND: The potential benefit on long term outcomes of Percutaneous Coronary Intervention (PCI) on Unprotected Left Main (ULM) driven by IntraVascular UltraSound (IVUS) remains to be defined.
METHODS: IMPACTUS LM-PCI is an observational, multicenter study that enrolled consecutive patients with ULM disease undergoing coronary angioplasty in 13 European high-volume centers from January 2002 to December 2015. Major Adverse Cardiovascular Events (MACEs) a composite of cardiovascular (CV) death, target vessel revascularization (TVR) and myocardial infarction (MI) were the primary endpoints, while its single components along with all cause death the secondary ones.
RESULTS: 627 patients with ULM disease were enrolled, 213 patients (34%) underwent IVUS-guided PCI while 414 (66%) angioguided PCI. Patients in the two cohorts had similar prevalence of risk factors except for active smoking and clinical presentation. During a median follow-up of 7.5 years, 47 (22%) patients in the IVUS group and 211 (51%) in the angio-guided group underwent the primary endpoint (HR 0.42; 95% CI [0.31-0.58] p < 0.001). After multivariate adjustment, IVUS was significantly associated with a reduced incidence of the primary endpoint (adj HR 0.39; 95% CI [0.23-0.64], p < 0.001), mainly driven by a reduction of TVR (ad HR 0.30, 95% CI [0.15-0.62], p = 0.001) and of all-cause death (adj HR 0.47, 95% CI [0.28-0.82], p = 0.008). IVUS use, age, diabetes, side branch stenosis, DES and creatinine at admission were independent predictors of MACE.
CONCLUSIONS: In patients undergoing ULM PCI, the use of IVUS was associated with a reduced risk at long-term follow-up of MACE, all-cause death and subsequent revascularization.

OBJECTIVE: In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants.
METHODS: This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up.
RESULTS: A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87).
CONCLUSIONS: Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.

OBJECTIVE: To explore the long-term clinical outcomes following intravascular lithotripsy (IVL) in calcified coronary lesions from a real-world population.
BACKGROUND: IVL is a relatively new but promising modality for treating coronary calcified lesions, but there is a dearth of long-term outcome data from real-world patients.
METHODS: This was a multicenter, observational study in which we enrolled all patients treated with IVL from November 2018 to February 2021 from eight centers in Europe and the United Kingdom. Procedural success, complications, and clinical outcomes (cardiac death, target vessel myocardial infarction [TVMI], target lesion revascularization [TLR], and MACE [major adverse cardiac events, the composite of cardiac death, TVMI, and TLR]) were assessed.
RESULTS: In total, 273 patients with a mean age of 72 ± 9.1 years were treated with IVL. Major comorbidities included diabetes mellitus (n = 110, 40%) and chronic kidney disease (n = 45, 16%). Acute coronary syndrome accounted for 48% (n = 132) of patients, while 52% (n = 141) had stable angina. De novo lesions and in-stent restenosis accounted for 79% and 21% of cases, respectively. Intravascular imaging was used in 33% (n = 90) of patients. An upfront IVL strategy was adopted in 34% (n = 92), while the rest were bailout procedures. Adjuvant rotational atherectomy (\"RotaTripsy\") was required in 11% (n = 31) of cases. The procedural success was 99%. During a median follow-up of 687 days (interquartile range: 549-787), cardiac death occurred in 5% (n = 14), TVMI in 3% (n = 8), TLR in 6% (n = 16), and MACE rate was 11% (n = 30).
CONCLUSIONS: This is the largest multicenter registry with a long-term follow-up showing the remarkably high procedural success of IVL use in calcified coronary lesions with low rates of hard endpoints and MACE.

OBJECTIVE: Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data.
METHODS: This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery.
RESULTS: OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017).
CONCLUSIONS: Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

The Lipid Rich Plaque (LRP) Study established the association between high volume of lipidic content (maximum Lipid Core Burden Index [maxLCBI4mm] >400) in the coronary arteries and subsequent non-culprit major adverse cardiac events (NC-MACE). This analysis sought to assess the clinical impact of more than one lipid-rich plaque in the coronary tree.
The LRP patient population was divided into four cohorts: 1) patients with all segments with maxLCBI4mm = 0; 2) patients with all coronary segments maxLCBI4mm < 400, but >0; 3) patients with 1 segment maxLCBI4mm > 400; and 4) patients with 2+ coronary segments with maxLCBI4mm > 400. Baseline characteristics, plaque-level characteristics, and follow-up outcomes were described.
Among 1550 patients, only 3.2 % had all segments with maxLCBI4mm = 0; 65.1 % had segments with maxLCBI4mm > 0 but <400; 22.5 % had one segment with maxLCBI4mm > 400; and 9.5 % had 2+ coronary segments with maxLCBI4mm > 400. Distribution within the coronary tree (one versus multiple arteries) did not differ. Overall, 1269 patients were allocated to follow-up (per study design). The composite of all-cause death, cardiac death, any revascularization, and NC-MACE was statistically higher in patients with 1 segment maxLCBI4mm > 400 and numerically even higher in patients with 2+ segments with maxLCBI4mm > 400. Patients with maxLCBI4mm = 0 had no events within two years.
There is a stepwise increased risk of all-cause death, cardiac death, any revascularization, and NC-MACE according to the number of coronary segments with maxLCBI4mm > 400. In contrast, maxLCBI4mm = 0 results in a low event rate.
The Lipid-Rich Plaque Study (LRP), https://clinicaltrials.gov/ct2/show/NCT02033694, NCT02033694.

Large plaque burden (PB) has been linked to adverse coronary events. We sought to assess the correlation between lipidic content and arterial PB within the Lipid Rich Plaque (LRP) study.
This analysis included 1269 patients and 5743 coronary segments with both evaluable Lipid Core Burden Index (maxLCBI4mm) and PB. Non-culprit major adverse cardiac events (NC-MACE; defined as a composite of cardiac death, cardiac arrest, non-fatal myocardial infarction, acute coronary syndrome, revascularization, and hospital readmission for angina with progressive stenosis) were assessed by hazard ratios (HR) at 2 years.
NC-MACE for segment cohorts in the most vulnerable quadrant of maxLCBI4mm > 400 and PB >40% was the highest (HR, 3.78 [95% confidence interval (CI) 2.39-5.66]) with similar rates for just PB >40% (HR 1.31 [95% CI 0.81-2.02]) and just maxLCBI4mm > 400 (HR 1.11 [95% CI 0.10-5.38]). Fewer events occurred in the maxLCBI4mm ≤ 400 and PB ≤40% quadrant (HR 0.25 [95% CI 0.11-0.50]).
Coronary segments with high lipid content but no measurable PB were still associated with events at 2 years. NC-MACE vulnerability increased as the lipidic content and PB increased, with the highest incidence within segments having maxLCBI4mm > 400 and plaque >40%.
The Lipid-Rich Plaque Study (LRP), NCT02033694, https://clinicaltrials.gov/ct2/show/NCT02033694.

Peri-strut low intensity areas (PLIA) visualized by optical coherence tomography (OCT) have been related to neointimal proliferation and increased incidence of target lesion revascularization in stable coronary artery disease. The aim of this study was to determine the association between PLIA by OCT and the long-term vascular healing response after bioresorbable scaffold (BRS) implantation in the setting of ST-segment elevation myocardial infarction (STEMI).
This is a single-centre, longitudinal, cohort study with a serial: baseline, 1, 2 and 5 years OCT evaluation of neointimal response (lumen area and neoatherosclerosis) after percutaneous coronary intervention (PCI) with BRS Absorb™ 1.0 implantation in patients presenting with STEMI. PLIA was analyzed in every cross section and scored: 0-no PLIA; 1-PLIA < 1 quadrant; 2-PLIA ≥ 1 and <2 quadrants; 3-PLIA ≥ 2 and <3 quadrants; 4-PLIA in ≥3 quadrants.
Of the 23 patients implanted BRS, 18 completed 2-year follow-up, whereas complete OCT data up to 5 years were available in 12 patients. Presence of PLIA was identified in 100% patients at 1 and 2 years, whereas at 5 years neither PLIA nor scaffold struts were visualized by OCT. Neoatherosclerosis was identified in 73,68% patients after 1 year and in all patients at 2 and 5 years. The mean PLIA score > 1 at 2 years was associated with greater percentage of minimum lumen area decrease after 2 years from index procedure.
The extent of PLIA by OCT at 2 years after primary PCI with BRS was associated with lumen area decrease. Neoatherosclerosis formation was detected in all patients at 2 and 5 years. PLIA assessment could serve as an additive means to predict neointimal healing pattern after next generation BRS implantation.