Calcified Coronary Lesions Research Articles

The impact of novel scoring balloon and cutting balloon after orbital atherectomy on severely calcified coronary lesion as assessed by optical coherence tomography.

Debulking devices are often followed by a scoring or cutting balloon in percutaneous coronary intervention (PCI) for severely calcified lesions. However, there are limited data on balloon preparation after orbital atherectomy (OA) assessed using optical coherence tomography (OCT). We aimed to compare the effects of a novel scoring and cutting balloon on calcified coronary lesions with OCT. We retrospectively examined 38 patients (38 lesions) who underwent PCI with a scoring or a cutting balloon after OA. All patients underwent pre-PCI, preballooning, postballooning, and post-PCI OCT imaging. We divided the patients into novel scoring-balloon (group A: n = 22) and cutting-balloon (group B: n = 16) groups and compared the OCT findings, including minimum lumen area (MLA) and expansion ratio (MLA divided by mean reference lumen area). The mean patient age was 76.1 ± 8.7 years; 71.5% were male. There were no significant differences in patient background between both groups. Regarding procedural characteristics, the maximum balloon pressure was significantly higher in group A (median 23 atm, interquartile range [IQR] 18-24 vs. 12 atm [IQR: 10-12], p < 0.01). Although a calcium score of 4 was more frequently observed in group A (86.4% vs. 62.5%, p = 0.12), post-PCI MLA was comparable between both groups (3.95 mm2 [IQR: 3.27-4.41] vs. 3.43 mm2 [IQR: 2.90-4.82], p = 0.63). Furthermore, the expansion ratio was significantly greater in group A (0.83 ± 0.20 vs. 0.68 ± 0.14, p < 0.01). Despite a higher calcium score, a larger expansion ratio was achieved in patients with a novel scoring balloon than in those with a cutting balloon after OA.

Initial experience with orbital atherectomy in a non-surgical center in Portugal

Introduction and objectivesPercutaneous coronary intervention (PCI) of severely calcified lesions is associated with a higher risk of procedural complications, suboptimal stent expansion, and in-stent restenosis. Lesion preparation with orbital atherectomy (OA) in severely calcified lesions has been shown to increase procedural success and decrease reintervention rates. In this study, we sought to report the procedural safety and efficacy of our initial experience with OA in a non-surgical center in Portugal. MethodsPatients with severely calcified coronary lesions who were treated with intended intravascular ultrasound (IVUS) guided OA were included in a prospective single-center registry. We evaluated several endpoints, including: debulking success, defined <50% residual stenosis severity after OA; procedural success, defined as stent implantation according to Optimal-IVUS PCI criteria; use of additional calcium debulking strategies; and procedural complications, including coronary no-reflow, dissection, perforation or side branch occlusion. Patients were followed up for 30 days to assess early cardiovascular or procedure-related death, myocardial infarction, myocardial injury and reintervention. ResultsBetween January 2023 and September 2023, 37 patients and 53 coronary arteries underwent OA. IVUS imaging was used in all cases. Debulking and procedural success were achieved in 90.5% and 97.3% of cases, respectively. In 26 (49.1%) lesions, additional calcium debulking techniques were needed. Procedural complications occurred in three cases and one patient died during hospitalization. ConclusionOur initial experience with OA for heavily calcified coronary lesions demonstrated high procedural success and overall favorable clinical outcomes.

Diagnostic Improvements Of Calcium-removal Image Reconstruction Algorithm Using Photon-counting Detector Ct For Calcified Coronary Lesions

Diagnostic Improvements Of Calcium-removal Image Reconstruction Algorithm Using Photon-counting Detector Ct For Calcified Coronary Lesions

Current applications, procedural and 1-year outcomes of Rotatripsy for the treatment of calcified coronary lesions.

Intravascular lithotripsy (IVL) combined with rotational atherectomy (RA), known as Rotatripsy, is used to treat severe coronary artery calcification (CAC), though data on efficacy, midterm safety and use sequence is limited. We aimed to identify indicators for Rotatripsy use and to assess its safety and success rates, both acutely and at 1-year follow-up. Patients undergoing Rotatripsy for severe CAC across six centers from May 2019 to December 2023 were included. Demographic, clinical, procedural and follow-up data were collected. Efficacy endpoints included device success (delivery of the RA-burr and IVL-balloon across the target lesion and administration of therapy without related complications), technical success (TIMI 3 flow and residual stenosis <30% by quantitative coronary analysis) and procedural success [composite of technical success with absence of in-hospital major adverse cardiovascular events (MACE: cardiac death, myocardial infarction or target vessel revascularization). Safety endpoints comprised Rotatripsy-related complications and MACE at 1-year follow-up. A total of 114 patients (75 ± 9 years, 78% male) underwent Rotatripsy for 120 lesions. In the majority of procedures RA was followed by IVL, mostly electively (n = 68, 57%) but also for balloon underexpansion (n = 37, 31%) and stent crossing failure (n = 1, 1%). Diverse and complex target lesions were addressed with an average SYNTAX score of 24.6 ± 13.0. Device, technical and procedural success were 97%, 94% and 93%, respectively. Therapy-related complications included two (2%) coronary perforations, one (1%) coronary dissection and one (1%) burr entrapment. At 1-year follow-up(present in 77(67%) patients), MACE occurred in 7(9%) cases. Over a 1-year follow-up period, Rotatripsy was safe and effective, predominantly using RA electively before IVL.

Development and Validation of Artificial Intelligence-Based Algorithms for Predicting the Segments Debulked by Rotational Atherectomy Using Intravascular Ultrasound Images

We develop and evaluate an artificial intelligence-based algorithm that uses pre-rotation atherectomy (RA) intravascular ultrasound (IVUS) images to automatically predict regions debulked by RA. A total of 2106 IVUS cross-sections from 60 patients with de novo severely calcified coronary lesions who underwent IVUS-guided RA were consecutively collected. The two identical IVUS images of pre- and post-RA were merged, and the orientations of the debulked segments identified in the merged images were marked on the outer circle of each IVUS image. The artificial intelligence model was developed based on ResNet (deep residual learning for image recognition). The architecture connected 36 fully connected layers, each corresponding to one of the 36 orientations segmented every 10°, to a single feature extractor. In each cross-sectional analysis, our artificial intelligence model achieved an average sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 81%, 72%, 46%, 90%, and 75%, respectively. In conclusion, the artificial intelligence-based algorithm can use information from pre-RA IVUS images to accurately predict regions debulked by RA and will assist interventional cardiologists in determining the treatment strategies for severely calcified coronary lesions.

Debate. Ablation vs lithotripsy in calcified coronary lesions. Perspective from lithotripsy

Debate. Ablation vs lithotripsy in calcified coronary lesions. Perspective from lithotripsy

Debate. Ablation vs lithotripsy in calcified coronary lesions. The ablation perspective

Debate. Ablation vs lithotripsy in calcified coronary lesions. The ablation perspective

Drug-Eluting Balloons in Calcified Coronary Lesions: A Meta-Analysis of Clinical and Angiographic Outcomes.

Background: The usefulness of drug-eluting balloons (DEBs) has not been fully elucidated in calcified coronary lesions (CCLs). This meta-analysis aimed to evaluate the efficacy of DEBs compared to a drug-eluting stent (DES) in this setting. Methods: PubMed, EMBASE and Cochrane were searched through December 2023. The primary endpoint was 12 months major adverse cardiac events (MACE). Secondary endpoints included clinical outcomes and angiographic results after PCI and at a 12-month follow-up. Results: Five studies and a total of 1141 patients with 1176 coronary lesions were included. Overall, the DEB was comparable to DES in MACE (RR = 0.86, 95% CI: 0.62-1.19, p = 0.36), cardiac death (RR = 0.59, 95% CI: 0.23-1.53, p = 0.28), myocardial infarction (RR = 0.89, 95% CI: 0.25-3.24, p = 0.87) and target lesion revascularization (RR = 1.1, 95% CI: 0.68-1.77, p = 0.70). Although the DEB was associated with worse acute angiographic outcomes (acute gain; MD = -0.65, 95% CI: -0.73, -0.56 and minimal lumen diameter; MD = -0.75, 95% CI: -0.89, -0.61), it showed better results at 12 months follow-up (late lumen loss; MD = -0.34, 95% CI: -0.62, -0.07). Conclusions: This meta-analysis showed that the DEB strategy is comparable to DES in the treatment of CCLs in terms of clinical outcomes. Although the DEB strategy had inferior acute angiographic results, it may offer better angiographic results at follow-up.

D-59 | Pooled Cardiovascular Outcomes With Combined Atherectomy and Intravascular Lithotripsy in Calcified Coronary Lesions

D-59 | Pooled Cardiovascular Outcomes With Combined Atherectomy and Intravascular Lithotripsy in Calcified Coronary Lesions

OR5-1 | Intravascular Lithotripsy Compared With Rotational Atherectomy for Calcified Coronary Lesions: A Meta-Analysis of Outcomes

OR5-1 | Intravascular Lithotripsy Compared With Rotational Atherectomy for Calcified Coronary Lesions: A Meta-Analysis of Outcomes

Coronary Intravascular Lithotripsy Effectiveness and Safety in a Real-World Cohort.

Background: Coronary artery calcification is a predictor of adverse outcomes after percutaneous coronary intervention (PCI). Intravascular lithotripsy (IVL) is a promising tool for the treatment of calcified lesions. The aim of this study was to assess the effectiveness and safety of IVL. Methods: A single-center observational study of PCI procedure, with assessment of the outcomes of patients undergoing PCI using IVL, was performed. Angiographic procedural success was used as the primary effectiveness endpoint. The primary safety endpoint was defined as a composite of cardiac death, myocardial infarction and target vessel revascularization within 30 days. Results: A total of 111 patients were included. Indications for PCI spanned the spectrum of chronic (53.2%) and acute coronary syndromes (43%). Lesion preparation before IVL was performed with non-compliant (42%), cutting or OPN (14.4%) balloons and with atherectomy techniques in 11% of procedures. Intravascular imaging was used in 21.6% of procedures. The primary effectiveness endpoint was achieved in 100% and the primary safety endpoint in 3.6% of procedures. Peri-procedural complications were minimal and successfully resolved. Conclusions: IVL was an effective and safe technique for the treatment of calcified coronary lesions. These findings contribute to the growing body of evidence supporting the use of IVL in the management of these challenging scenarios.

Effectiveness and Safety of a Novel Intravascular Lithotripsy System for Severe Coronary Calcification: The CALCI-CRACK Trial

BackgroundIntravascular lithotripsy is effective and safe for managing coronary calcification; however, available devices are limited, and complex lesions have been excluded in previous studies. This study aimed to investigate the effectiveness and safety of a novel intravascular lithotripsy system for severe calcification in a population with complex lesions. MethodsCALCI-CRACK (treatment of severe calcified coronary lesions with a novel intracoronary shock wave lithotripsy system) (ChiCTR2100052058) was a prospective, single-arm, multicentre study. The primary end point was the procedural success rate. Major safety end points included major adverse cardiovascular events (MACE) and target lesion failure (TLF) at 30 days and 6 months, and severe angiographic complications. Calcification morphology was assessed in the optical coherence tomography (OCT) subgroup. ResultsIn total, 242 patients from 15 high-volume Chinese centres were enrolled, including 26.45% of patients with true bifurcation lesions, 3.31% with severely tortuous vessels, and 2.48% with chronic total occlusion, respectively. The procedural success rate was 95.04% (95% confidence interval 91.50%-97.41%), exceeding the prespecified performance goal of 83.4% (P < 0.001). The 30-day and 6-month MACE rates were 4.13% and 4.55%, respectively. TLF rates at those time points were 1.24% and 1.65%, respectively. Severe angiographic complications occurred in 0.42% of patients. In the OCT subgroup (n = 93), 93.55% of calcified lesions were fractured, and minimal lumen area increased from 1.55 ± 0.55 mm2 to 4.91 ± 1.22 mm2 after stent implantation, with acute gain rate of 245 ± 102%. ConclusionsThe novel intravascular lithotripsy system is effective and safe for managing severely calcified coronary lesions in a cohort that included true bifurcation lesions, severely tortuous vessels, and chronic total occlusion. Clinical Trial RegistrationChinese Clinical Trial Registry (ChiCTR), number ChiCTR2100052058

RotaTripsy Risk and Rewards: Findings from a Registry of Patients Undergoing Combined Rotational Atherectomy and Intravascular Lithotripsy

Background: Heavily calcified coronary artery lesions are a therapeutic challenge for interventional cardiologists worldwide. Recently, RotaTripsy has gained popularity as a calcium modification technique prior to stent implantation. In this procedure, operators employ rotational atherectomy to debulk luminal calcium alongside intravascular lithotripsy to fracture deeper concentric calcifications. Aims: To identify the demographics and outcomes of patients undergoing RotaTripsy. Methods: Baseline clinical characteristics, procedural details and in-hospital and 30-day outcomes were recorded and reported for a registry of patients in whom combined rotational atherectomy and intravascular lithotripsy were performed in one procedure at the discretion of the primary operator at one high-volume tertiary centre. Results: Over 2020–2022, 57 consecutive patients underwent RotaTripsy during percutaneous coronary intervention. In this cohort, 23 (40%) had acute coronary syndrome and three (5.3%) had an ST-elevation MI. Additionally, 10 (18%) were on dialysis, 20 (35%) had unprotected left main coronary artery/left main coronary artery equivalent lesions, seven (12%) had acute heart failure and nine (16%) required intraprocedural intra-aortic balloon pump support. Of the procedures, 51 (89.5%) were successful, defined as successful stent implantation and &lt;30% residual angiographic stenosis without in-hospital major adverse cardiac events. Complications included slow/no-reflow (six patients; 11%), cerebrovascular events (three patients; 5.3%), in-hospital MI (three patients; 5.3%) and mortality (three patients; 5.3%). The 30-day MI rate was 5.3% (three patients) and the mortality rate was 7.0% (four patients). Conclusion: RotaTripsy was successful in facilitating stent delivery and restoring flow, even in a relatively sick cohort. Nevertheless, complication rates were high, reflecting the challenge of treating these complex patients.

Efficacy of intravascular lithotripsy (IVL) in coronary stenosis with severe calcification: A multicenter systematic review and meta-analysis.

With heavily calcified coronary and peripheral artery lesions, lesion preparation is crucial before stent placement to avoid underexpansion, associated with stent thrombosis or restenosis and patency failure in the long-term. Intravascular lithotripsy (IVL) technology disrupts superficial and deep calcium by using localized pulsative sonic pressure waves, making it to a promising tool for patients with severe calcification in coronary bed. The aim of the study is to systematically review and summarize available data regarding the safety and efficacy of IVL for lesion preparation in severely calcified coronary arteries before stenting. This study was conducted according to the PRISMA guidelines. We systematically searched PubMed, SCOPUS, and Cochrane databases from their inception to February 23, 2023, for studies assessing the characteristics and outcomes of patients undergoing IVL before stent implantation. The diameter of the vessel lumen before and after IVL, as well as stent implantation, were analyzed. The occurrence of major adverse cardiovascular events (MACE) was assessed using a random-effects model. This meta-analysis comprised 38 studies including 2977 patients with heavily calcified coronary lesions. The mean age was 72.2 ± 9.1 years, with an overall IVL clinical success of 93% (95% confidence interval [CI]: 91%-95%, I2 = 0%) and procedural success rate of 97% (95% CI: 95%-98%, I2 = 73.7%), while the in-hospital and 30-days incidence of MACE, myocardial infarction (MI), and death were 8% (95% CI: 6%-11%, I2 = 84.5%), 5% (95% CI: 2%-8%, I2 = 85.6%), and 2% (95% CI: 1%-3%, I2 = 69.3%), respectively. There was a significant increase in the vessel diameter (standardized mean difference [SMD]: 2.47, 95% CI: 1.77-3.17, I2 = 96%)and a decrease in diameter stenosis (SMD: -3.44, 95% CI: -4.36 to -2.52, I2 = 97.5%) immediately after IVL application, while it was observed further reduction in diameter stenosis (SMD: -6.57, 95% CI: -7.43 to -5.72, I2 = 95.8%) and increase in the vessel diameter (SMD: 4.37, 95% CI: 3.63-5.12, I2 = 96.7%) and the calculated lumen area (SMD: 3.23, 95% CI: 2.10-4.37, I2 = 98%), after stent implantation. The mean acute luminal gain following IVL and stent implantation was estimated to be 1.27 ± 0.6and 1.94 ± 1.1 mm, respectively. Periprocedural complications were rare, with just a few cases of perforations, dissection, or no-reflow phenomena recorded. IVL seems to be a safe and effective strategy for lesion preparation in severely calcified lesions before stent implantation in coronary arteries. Future prospective studies are now warranted to compare IVL to other lesion preparation strategies.

Lower revascularization rates after high-speed rotational atherectomy compared to modified balloons in calcified coronary lesions: 5-year outcomes of the randomized PREPARE-CALC trial.

In the PREPARE-CALC trial, severely calcified lesion preparation with rotational atherectomy (RA) before biodegradable polymer sirolimus-eluting stent (SES) implantation demonstrated higher procedural success and comparable rates of acute lumen gain and late lumen loss compared to modified balloons (MB) (scoring/cutting). We aimed to analyze the 5-year outcomes of both lesion preparation strategies. PREPARE-CALC randomly assigned 200 patients 1:1 to MB or RA, followed by SES implantation. The principal endpoint of the current analysis was target vessel failure (TVF) at 5years. At 5years, MB had comparable rates of TVF to RA (19% vs. 21%, HR 1.14, 95% CI 0.60-2.16, p = 0.687). Subgroup analysis showed a lesion length treatment interaction, favoring MB for short lesions and RA for long ones (p for interaction = 0.042). Target lesion revascularization (TLR) was significantly less common with RA (12 vs. 3%, HR 0.28, 95% CI 0.08-0.98, p = 0.048). In a multivariate analysis, RA was independently protective against TLR (adj. HR 0.17, 95% CI 0.04-0.78, p = 0.022), while ostial lesions were associated with higher TLR independent of treatment strategy (adj. HR 11.3, 95% CI 2.98-42.6, p < 0.001). In patients with severely calcified coronary lesions, using MB or RA for lesion preparation followed by biodegradable polymer SES implantation was associated with comparable rates of TVF at 5years. However, a significant reduction of TLR was observed after RA. PREPARE-CALC is the first randomized trial showing potential clinical advantages of RA over MB during long-term follow-up. URL: https://www. gov . Unique identifier: NCT02502851.

Gender Differences in the Short and Long-Term Outcomes Following Rotational Atherectomy: A Meta-Analysis

BackgroundRotational atherectomy (RA) is used to address complex calcified coronary lesions but data regarding the association between gender and outcomes of patients undergoing RA remained uncertain. We aimed to investigate the short and long-term outcomes of patients undergoing RA based on sex. MethodsA systematic literature search was performed in PubMed, Embase and Cochrane databases from its inception until August 2023 for relevant studies. Endpoints were pooled using the DerSimonian and Laird random-effects model as odd ratio (OR) with 95% confidence intervals (CI). Results7 studies with 8,490 patients (2,565 women and 5,925 men) undergoing RA were included in the study. In terms of periprocedural outcomes, women had a higher risk of in-hospital mortality (OR 2.00, 95% CI 1.08-3.68, p=0.03), coronary dissection (OR 1.80, 95% CI 1.05-3.10, p=0.03), coronary perforation (OR 1.96, 95% CI 1.19-3.23, p=0.01), and stroke (OR 4.22, 95% CI 1.06-16.82, p=0.04) compared to men. There were no significant differences between women and men in terms of MACE (OR 1.43, 95% CI 0.69-2.94, p=0.33), MI (OR 1.35, 95% CI 0.87-2.08, p=0.18), bleeding (OR 1.71, 95% CI 0.88-3.30, p=0.11), and cardiac tamponade (OR 2.30, 95% CI 0.45-11.68, p=0.32). Over a follow-up period of 3 years, results of meta-analysis showed that women had a higher risk of all-cause mortality (OR 1.45, 95% CI 1.19-1.77, p<0.001), long-term MACE (OR 1.38, 95% CI 1.10-1.74, p=0.01), and long-term stroke (OR 3.41, 95% CI 1.63-7.17, p<0.001). The risk of long-term MI was found to be similar between both gender (OR 1.45, 95% CI 0.95-2.22, p=0.09). ConclusionIn conclusion, female gender is associated with adverse periprocedural and long-term outcome following RA. Women consistently demonstrated higher risk of in-hospital mortality, coronary dissection, coronary perforation, and stroke in the periprocedural period. Long-term follow-up further highlighted a heightened risk for women in terms of all-cause mortality and stroke.

A Prospective, Multicenter, Real-World Registry of Coronary Lithotripsy in Calcified Coronary Arteries: The REPLICA-EPIC18 Study

BackgroundIntravascular lithotripsy (IVL) has demonstrated effectiveness in the treatment of calcified lesions in selected patients with stable coronary disease. ObjectivesThe authors sought to assess the performance of coronary IVL in calcified coronary lesions in a real-life, all comers, setting. MethodsThe REPLICA-EPIC18 study prospectively enrolled consecutive patients treated with IVL in 26 centers in Spain. An independent core laboratory performed the angiographic analysis and event adjudication. The primary effectiveness endpoint assessed procedural success (successful IVL delivery, final diameter stenosis <20%, and absence of in-hospital major adverse cardiovascular events [MACE]). The primary safety endpoint measured freedom from MACE at 30 days. A predefined substudy compared outcomes between acute coronary syndrome (ACS) and chronic coronary syndrome (CCS) patients. ResultsA total of 426 patients (456 lesions) were included, 63% of the patients presenting with ACS. IVL delivery was successful in 99% of cases. Before IVL, 49% of lesions were considered undilatable. The primary effectiveness endpoint was achieved in 66% of patients, with similar rates among CCS patients (68%) and ACS patients (65%). Likewise, there were no significant differences in angiographic success after IVL between CCS and ACS patients. The rate of MACE at 30 days (primary safety endpoint) was 3% (1% in CCS and 5% in ACS patients [P = 0.073]). ConclusionsCoronary IVL proved to be a feasible and safe procedure in a “real-life” setting, effectively facilitating stent implantation in severely calcified lesions. Patients with ACS on admission showed similar angiographic success rates but showed a trend toward higher 30-day MACE compared with patients with CCS. (REPLICA-EPIC18 study [Registry of Coronary Lithotripsy in Spain]; NCT04298307)

Comparison of intravascular lithotripsy and rotational atherectomy for the treatment of heavily calcified coronary lesions: the STIFF ( S tenoses with calcificaTIon treated with angioplasty e FF ected with dedicated interventional tools) study.

Percutaneous coronary interventions in heavily calcified coronary lesions are associated with technical difficulties and the worse prognosis. Lesion preparation is important to reduce complications and improve outcomes. The aim of this study is to compare the results of rotational atherectomy (RA) and intravascular lithotripsy (IVL) at achieving optimal stent implantation using intravascular ultrasound criteria. Retrospective, single-center study comparing patients with heavily calcified coronary lesions that underwent percutaneous coronary interventions using RA or IVL. 25 patients (13 in the RA group and 12 in the IVL group) were included. Reference vessel diameter was similar between the groups [2.59 (2.51-3.63) mm in the RA group vs. 2.79 (2.59-3.16) mm in the IVL group; P = 0.89], as were minimal lumen area [1.02 (0.80-1.23) mm vs. 1.40 (1.01-1.40) mm; P = 0.43] and diameter stenosis [60.4% (52.3-72.3) vs. 56.1% (47.8-61.3); P = 0.56). The final minimal lumen area was significantly larger in the IVL group [7.6 mm 2 (5.8-8.6) vs. 5.4 mm 2 (4.5-6.2); P = 0.01] as were lumen area gain [4.1 mm 2 (2.6-5.9) vs. 2.3 mm 2 (1.4-3.6); P = 0.01] and final stent volume [491.2 mm 3 (372.2-729.8) vs. 326.2 mm 3 (257.1-435.4); P = 0.03]. In the RA group, 69.2% of the patients achieved the preestablished intravascular ultrasound-based criteria for successful stent implantation, vs. 100% of the patients in the IVL group ( P = 0.04). Patients in the IVL group achieved the Intravascular Ultrasound Versus Angiography-Guided Drug-Eluting Stent Implantation trial criteria of successful stent implantation more frequently than those treated with RA.

Association of pulmonary artery capacitance with long-term outcomes in acute coronary syndrome patients with left ventricular systolic dysfunction.

Hemodynamic monitoring via right heart catheterization (RHC) is critical for managing acute coronary syndrome (ACS) patients with heart failure or cardiogenic shock. However, the prognostic value of RHC-derived hemodynamic indices in ACS patients with left ventricular systolic dysfunction (LVSD) but without heart failure or shock remains uncertain. A retrospective cohort study included 1151 consecutive ACS patients who underwent RHC during hospitalization from 2007 to 2016. After excluding patients with shock, pulmonary edema, and severe valvular disease, 750 ACS patients with LVSD and ejection fraction < 50% were analyzed. Major adverse cardiovascular events (MACEs), including myocardial infarction and all-cause mortality, were followed for five years. Cox regression identified predictors of MACEs, adjusting for comorbidities, treatments, and hemodynamic indices, including pulmonary arterial capacitance (PAC). After a mean follow-up of 4.0 ± 1.7 years, 113 (15.1%) patients experienced MACEs. Multivariate analysis showed that independent predictors included prior stroke, calcified coronary lesions, and PAC. Patients in the lowest PAC tertile (≤2.89 ml/mmHg) had significantly higher risks of myocardial infarction (adjusted hazard ratio [HR]: 3.74; 95% confidence interval [CI]: 1.55-9.07; p = .003), all-cause mortality (adjusted HR: 2.55; 95% CI: 1.27-5.10; p = .008), and MACEs (adjusted HR: 2.35; 95% CI: 1.25-4.42; p = .008) compared to those in the highest tertile (>4.43 ml/mmHg). The study demonstrated that PAC is a notably strong hemodynamic parameter with independent long-term prognostic value in ACS patients with LVSD, who do not present with shock or heart failure. This is the first study to establish the prognostic significance of hemodynamic indices obtained from RHC in this population, extending the clinical relevance of RHC from high-risk to intermediate-risk ACS populations. The use of RHC to assess hemodynamic indices, including PAC, during index hospitalization in this population may enhance long-term risk stratification and improve outcome prediction.

Management of Calcified Coronary Lesions.

With an aging population, coronary calcification is increasingly encountered in modern day interventional practice. Unfortunately, it is associated with lower procedural success and higher rates of periprocedural complications, such as failure to deliver stents, perforations, dissections, and other major adverse cardiac events. Furthermore, suboptimal stent deployment in the setting of severe calcification is associated with both short-and long-term major adverse cardiac events, including stent thrombosis, MI, in-stent restenosis, and target lesion revascularization. A variety of treatment options for these lesions exist, including specialized balloons, atherectomy, and intravascular lithotripsy. While there is currently no universally accepted algorithm for choosing between these treatment strategies, several different algorithms exist, and the optimization of these treatment regimens will continue to evolve in the coming years. This review aims to provide insights on the different therapeutic modalities and an understanding of the current body of evidence.