Day-case percutaneous coronary procedures. A clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the European Society of Cardiology (ESC) and the Association of Cardiovascular Nursing & Allied Professions (ACNAP) of the ESC.

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

The uptake of percutaneous coronary procedures via the radial artery has increased internationally due to the decreased risk of complications and increased patient satisfaction. The increased susceptibility of the radial artery to spasm however presents a potential risk for procedural failure. Although most experts agree on the need for prophylactic medications to reduce radial artery spasm, currently there is inconsistency in literature regarding the most effective vasodilatory medication or combination of medications. The objective of this study is to identify the effectiveness of vasodilatory medications on radial artery spasm in patients undergoing transradial coronary artery procedures. This review considered studies that included participants aged 18 years and over undergoing non-emergent transradial percutaneous coronary artery procedures. This review considered studies that used vasodilating intravenous and intra-arterial medications or combinations of medications prior to commencing and during transradial coronary approaches to reduce radial artery spasm. The outcomes of interest were the incidence of radial artery spasm during percutaneous coronary procedure using objective and/or subjective measures and its effect on the successful completion of the procedure. Randomized controlled trials published in the English language between 1989 to date were considered for inclusion. The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial search of MEDLINE, CINAHL and Scopus was undertaken, followed by a search for unpublished studies. Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments. Any disagreements that arose between the reviewers were resolved through discussion. Quantitative data was extracted from papers included in the review using the standardized data extraction tool from RevMan5 (Copenhagen: The Nordic Cochrane Centre, Cochrane). Quantitative data, where possible, was pooled in statistical meta-analysis using RevMan5. All results were subject to double data entry. Effect sizes expressed as risk ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals were calculated for analysis. Nine trials involving 3614 patients were included in the final review. Pooled data involving 992 patients on the effect of calcium channel blockers demonstrated a statistically significant reduction in the incidence of vasospasm in patients who received verapamil 5 mg compared to those who received a placebo (OR 0.33; 95%CI 0.19, 0.58). Similarly patients who received verapamil 2.5 mg or 1.25 mg had significantly fewer incidences of vasospasm when compared to those who received a placebo. Nitroglycerine 100mcg was demonstrated to be associated with a statistically significant reduction in the incidence of vasospasm. The evidence demonstrates a benefit in the use of vasodilatory medications for the reduction of vasospasm in patients having radial coronary procedures. Further large-scale multi-center trials are needed to determine the preferred medication.

The Clinical Consensus Statement of the European Society of Cardiology (ESC) updates expert opinions on conduction system pacing (CSP). It does not represent afocused update of the ESC pacemaker guidelines of 2021 since that would require the publication of new results of randomized trials. But an official statement became necessary because at the time of preparing the ESC guidelines on pacing and cardiac resynchronization, only very limited data on left bundle branch pacing were available rendering this form of pacing almost completely ignored in the recommendations. Second, daily implantation practice has changed substantially worldwide since the advent of CSP. Third, basically all international heart rhythm societies apart from the ESC have published new guidelines on the use CSP in 2023 which differ significantly from the European recommendations. The Clinical Consensus Statement on CSP of the ESC differs from the 2021 ESC guidelines only in nuances since ESC statutes do not allow that an ESC expert opinion paper substantially contradict current ESC guidelines. However, it is important for daily practice that CSP be recommended as apotential alternative to right ventricular pacing in patients with good left ventricular function or rare ventricular pacing is expected. Similarly, CSP is recommended as an alternative to biventricular pacing (BiVP) in reduced left ventricular function, in context with ablation of the atrioventricular node, in heart failure with wide QRS complex and for upgrading in pacing-induced cardiomyopathy. Finally, CSP is recommended in nonresponders to BiVP.

Comparison of transradial and transfemoral artery approach for percutaneous coronary angiography and angioplasty: A retrospective seven-year experience from a north Indian center

Stent Graft-Induced Aortic Wall Injury—Anesthesia Pitfalls and Pearls for the Thoracic Endovascular Aortic Repair Procedure

Imaging plays an integral role in all aspects of managing heart disease and cardiac imaging is a core competency of cardiologists. The adequate delivery of cardiac imaging services requires expertise in both imaging methodology-with specific adaptations to imaging of the heart-as well as intricate knowledge of heart disease. The European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging have developed and implemented a successful education and certification programme for all cardiac imaging modalities. This programme equips cardiologists to provide high quality competency-based cardiac imaging services ensuring they are adequately trained and competent in the entire process of cardiac imaging, from the clinical indication via selecting the best imaging test to answer the clinical question, to image acquisition, analysis, interpretation, storage, repository, and results dissemination. This statement emphasizes the need for competency-based cardiac imaging delivery which is key to optimal, effective and efficient, patient care.

A 39-year-old man presented with complaints of chest pain, dyspnea, and cough after a long-distance flight. He gave a history of having been involved in a major traffic accident 20 years ago in which he was run over by a truck, which resulted in extensive musculoskeletal injuries that necessitated several operations. He had been experiencing intermittent chest pain and dyspnea for 2 years. At the emergency department, a large upper-mediastinal mass was found on chest radiography (Figure, panel A). CT showed a large thoracic aortic aneurysm, and the patient was referred for cardiovascular MRI before surgery. This revealed a large …

The aim of this study was to quantify ambulatory use of ticlopidine and clopidogrel in association with percutaneous coronary revascularization procedures (PTCA, atherectomy, stent) in a national managed care organization. Retrospective administrative claims data over a 3-year period (1996-1998) from 12 UnitedHealth Group-affiliated health plans in four geographic regions were collected. Pharmacy and medical claims data were used to determine the patients exposed to ticlopidine and clopidogrel between January 1, 1996 and December 31, 1998, the duration of use, prescriptions within 2 weeks of a coronary procedure, and stent patients prescribed either drug within 2 weeks of stent placement in 1998. Substantial short-term use of ticlopidine and clopidogrel was found. The percentage of members with duration of use < or = 30 days ranged from 50.4% in 1996 to 56.9% in 1998 for ticlopidine and was 52.7% for clopidogrel. In 1998, 46% and 33% of ticlopidine and clopidogrel users, respectively, had a medical claim for a coronary procedure that fell within 2 weeks of a prescription. The rate was lower for Medicare beneficiaries. In 1998, 78% of stent patients filled a prescription for either drug within 2 weeks of stent implantation. Although little difference was found overall in the use of these agents across geographic regions, a higher proportion of stent patients in the Southeast were prescribed ticlopidine within this time frame. The findings suggest that during the study time period ticlopidine and clopidogrel are frequently used off-label in association with percutaneous coronary revascularization procedures. These results were important in considering the overall benefit-risk profile.

Reply to “Predictable Superiority of Everolimus-Eluting Stent Over Paclitaxel-Eluting Balloon in Patients with In-Stent Restenosis”

Primary percutaneous coronary intervention (PPCI) is recommended by the European Society of Cardiology (ESC) treatment guidelines as the preferred treatment for ST-elevation acute myocardial infarction (STEMI) whenever it is available within 90–120 minutes of the first medical contact. A survey conducted in 2008 in 51 ESC countries found that the annual incidence of hospital admissions for acute myocardial infarction is around 1,900 patients per million population, with an incidence of STEMI of about 800 per million. It showed that STEMI patients’ access to reperfusion therapy and the use of PPCI or thrombolysis (TL) vary considerably between countries. Northern, western and central Europe already have well-developed PPCI services, offering PPCI to 60–90 % of all STEMI patients. Southern Europe and the Balkans are still predominantly using TL. Where this is the case, a higher proportion of patients are left without any reperfusion treatment. The survey concluded that a nationwide PPCI strategy results in more patients being offered reperfusion therapy. To address the inequalities in STEMI patients’ access to life-saving PPCI, and to support the implementation of the ESC STEMI treatment guidelines in Europe, the Stent for Life (SFL) Initiative was launched jointly by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and EuroPCR in 2008. National cardiac societies from Bulgaria, France, Greece, Serbia, Spain and Turkey signed the SFL Declaration at the ESC Congress in Barcelona in 2009. The aim of the SFL Initiative is to improve the delivery of, and STEMI patients’ access to, life-saving PPCI and thereby reduce mortality and morbidity. Currently, 10 national cardiac societies support the SFL Initiative in their respective countries. SFL national action programmes have been developed and are being implemented in several countries. The formation of regional PPCI networks involving emergency medical services, non-percutaneous coronary intervention hospitals and PPCI centres is considered to be a critical success factor in implementing PPCI services effectively. This article describes examples of how SFL countries are progressing in implementing their national programmes, thus increasing PPCI penetration in Europe.

Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.

The clinical value of fractional flow reserve and non-hyperaemic pressure ratios are well established in determining an indication for percutaneous coronary intervention (PCI) in patients with coronary artery disease (CAD). In addition, over the last 5 years we have witnessed a shift towards the use of physiology to enhance procedural planning, assess post-PCI functional results, and guide PCI optimisation. In this regard, clinical studies have reported compelling data supporting the use of longitudinal vessel analysis, obtained with pressure guidewire pullbacks, to better understand how obstructive CAD contributes to myocardial ischaemia, to establish the likelihood of functionally successful PCI, to identify the presence and location of residual flow-limiting stenoses and to predict long-term outcomes. The introduction of new functional coronary angiography tools, which merge angiographic information with fluid dynamic equations to deliver information equivalent to intracoronary pressure measurements, are now available and potentially also applicable to these endeavours. Furthermore, the ability of longitudinal vessel analysis to predict the functional results of stenting has played an integral role in the evolving field of simulated PCI. Nevertheless, it is important to have an awareness of the value and challenges of physiology-guided PCI in specific clinical and anatomical contexts. The main aim of this European Association of Percutaneous Cardiovascular Interventions clinical consensus statement is to offer up-to-date evidence and expert opinion on the use of applied coronary physiology for procedural PCI planning, disease pattern recognition and post-PCI optimisation.

Aortic stenosis (AS) is common and can cause heart failure (HF) or contribute to the progression of pre-existing HF. The management of patients with concomitant AS and HF poses specific clinical challenges. Optimization of guideline-directed medical therapy for HF may be difficult in patients with AS, especially in case of reduced left ventricular ejection fraction. Transcatheter or surgical aortic valve replacement (AVR) is the evidence-based treatment of choice for patients with severe AS and HF. However, advanced cardiac damage, concomitant conditions that can cause HF in addition to AS, as well as some procedure-related factors, may contribute to persistence or worsening of HF after AVR. A multidisciplinary management involving an HF specialist is crucial in this setting and should include a dedicated pre-procedural HF and AS assessment, as well as a careful post-procedural follow-up, including monitoring of HF status. The aim of this clinical consensus statement is to summarize current knowledge on AS and HF, with a focus on pre-procedural and post-procedural management of patients with HF undergoing AVR.

Thrombotic and bleeding risks differ between sexes, partly in relation to distinct biology and hormonal status, but also due to differences in age, comorbidities, and body size at presentation. Women experience frequent fluctuations of prothrombotic and bleeding status related to menstrual cycle, use of oral contraceptives, hormone replacement therapy, or menopause. Although clinical studies tend to underrepresent women, available data consistently support sex-specific differences in the baseline thrombotic and haemorrhagic risks. Compared with men, women feature an increased risk of in-hospital bleeding related to invasive procedures, as well as long-term out-of-hospital bleeding events. In addition, the inappropriate dosing of antithrombotic drugs, which is not adapted to body weight or renal function, is more frequently associated with an increased risk of bleeding in women compared to men. While acute coronary syndrome (ACS) studies support similar antithrombotic drug efficacy, irrespective of sex, women may receive delayed treatment due to bias in their referral, diagnosis, and invasive treatment decisions. The current clinical consensus statement highlights the need for an increased awareness of sex-specific risks and biases in ACS management, with a focus on sex-specific bleeding mitigation strategies, antithrombotic management in special conditions (e.g., myocardial infarction with non-obstructive coronary arteries), and barriers to female representation in cardiovascular trials. This manuscript aims to provide expert opinion, based on the best available evidence, and consensus statements on optimising antithrombotic therapy according to sex, which is critical to improve sex-based disparities in outcome.

This clinical consensus statement of the European Association of Percutaneous Cardiovascular Interventions was developed in association with the European Society of Cardiology Working Group on Cardiovascular Surgery. It aims to define procedural and contemporary technical requirements that may improve the efficacy and safety of percutaneous coronary intervention (PCI), both in the acute phase and at long-term follow-up, in a high-risk cohort of patients on optimal medical therapy when clinical and anatomical high-risk criteria are present that entail unacceptable surgical risks, precluding the feasibility of coronary artery bypass grafting (CABG). This document pertains to patients with surgical contraindication according to the Heart Team, in whom medical therapy has failed (e.g., residual symptoms), and for whom the Heart Team estimates that revascularisation may have a prognostic benefit (e.g., left main, last remaining vessel, multivessel disease with large areas of ischaemia); however, there is a lack of data regarding the size of this patient population. This document aims to guide interventional cardiologists on how to proceed with PCI in such high-risk patients with reduced left ventricular ejection fraction after the decision of the Heart Team is made that CABG - which overall is the guideline-recommended option for revascularisation in these patients - is not an option and that PCI may be beneficial for the patient. Importantly, when a high-risk PCI is planned, a multidisciplinary decision by interventional cardiologists, cardiac surgeons, anaesthetists and non-invasive physicians with expertise in heart failure management and intensive care should be agreed upon after careful consideration of the possible undesirable consequences of PCI, including futility, similar to the approach for structural interventions.