<div><h4>Periprocedural Mortality in Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the PROGRESS-CTO Registry.</h4><i>Simsek B, Rempakos A, Kostantinis S, Karacsonyi J, ... Burke MN, Brilakis ES</i><br /><b>Background</b><br />Death is a rare but devastating complication of chronic total occlusion (CTO) percutaneous coronary intervention.<br /><b>Methods</b><br />We examined the clinical characteristics and procedural outcomes of patients who died periprocedurally in the Prospective Global Registry for the Study of CTO Interventions (PROGRESS-CTO).<br /><b>Results</b><br />Of the 12 928 patients who underwent CTO percutaneous coronary intervention between 2012 and 2022, 52 (0.4%) died during the index hospitalization. Patients who died were more likely to have a history of heart failure (43% versus 28%; <i>P</i>=0.023). The J-CTO ([Multicenter CTO Registry of Japan]; 2.8±1.1 versus 2.4±1.3; <i>P</i>=0.019), PROGRESS-CTO mortality (2.6±0.9 versus 1.6±1.1; <i>P</i><0.001), and PROGRESS-CTO pericardiocentesis (2.9±1.1 versus 1.9±1.3; <i>P</i><0.001) scores were higher in patients who died. In these patients, the use of left ventricular assist devices was also higher (41% versus 3.5%; <i>P</i><0.001), and retrograde crossing was more often the first crossing strategy (33% versus 13%; <i>P</i><0.001). The cause of death was cardiac in 43 patients (83%) and noncardiac in 9 patients (17%). Complications leading to cardiac death were: tamponade in 30 patients (58%), acute myocardial infarction in 9 (17.3%), and cardiac arrest/shock in 4 (7.7%). Noncardiac causes of death were: stroke in 3 (5.8%), renal failure in 2 (3.8%), respiratory distress in 2 (3.8%), and hemorrhagic shock in 2 (3.8%).<br /><b>Conclusions</b><br />Approximately 0.4% of patients who underwent CTO percutaneous coronary intervention died during the index hospitalization. The main cause of death was tamponade in 58%. PROGRESS-CTO complication scores might help in risk stratification and procedural planning in patients undergoing CTO percutaneous coronary intervention.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique Identifier: NCT02061436.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Jun 2023:e012977; epub ahead of print</small></div>

<div><h4>Coronary Microvascular Disease in Contemporary Clinical Practice.</h4><i>Smilowitz NR, Toleva O, Chieffo A, Perera D, Berry C</i><br /><AbstractText>Coronary microvascular disease (CMD) causes myocardial ischemia in a variety of clinical scenarios. Clinical practice guidelines support routine testing for CMD in patients with ischemia with nonobstructive coronary artery disease. Invasive testing to identify CMD requires Doppler or thermodilution measures of flow to determine the coronary flow reserve and measures of microvascular resistance. Acetylcholine coronary reactivity testing identifies concomitant endothelial dysfunction, microvascular spasm, or epicardial coronary spasm. Comprehensive testing may improve symptoms, quality of life, and patient satisfaction by establishing a diagnosis and guiding-targeted medical therapy and lifestyle measures. Beyond ischemia with nonobstructive coronary artery disease, testing for CMD may play a role in patients with acute myocardial infarction, angina following coronary revascularization, heart failure with preserved ejection fraction, Takotsubo syndrome, and after heart transplantation. Additional education and provider awareness of CMD and its role in cardiovascular disease is needed to improve patient-centered outcomes of ischemic heart disease.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Jun 2023:e012568; epub ahead of print</small></div>

<div><h4>Interventional Versus Conservative Strategy in Patients With Spontaneous Coronary Artery Dissections: Insights From DISCO Registry.</h4><i>Benenati S, Giacobbe F, Zingarelli A, Macaya F, ... Porto I, DISCO Collaborators</i><br /><b>Background</b><br />The optimal management of patients with spontaneous coronary artery dissection remains debated.<br /><b>Methods</b><br />Patients enrolled in the DISCO (Dissezioni Spontanee Coronariche) Registry up to December 2020 were included. The primary end point was major adverse cardiovascular events, a composite of all-cause death, nonfatal myocardial infarction, and repeat percutaneous coronary intervention (PCI). Independent predictors of PCI and medical management were investigated.<br /><b>Results</b><br />Among 369 patients, 129 (35%) underwent PCI, whereas 240 (65%) were medically managed. ST-segment-elevation myocardial infarction (68% versus 35%, <i>P</i><0.001), resuscitated cardiac arrest (9% versus 3%, <i>P</i><0.001), proximal coronary segment involvement (32% versus 7%, <i>P</i><0.001), and Thrombolysis in Myocardial Infarction flow 0 to 1 (54% versus 20%, <i>P</i><0.001) were more frequent in the PCI arm. In-hospital event rates were similar. Between patients treated with PCI and medical therapy, there were no differences in terms of major adverse cardiovascular events at 2 years (13.9% versus 11.7%, <i>P</i>=0.467), all-cause death (0.7% versus 0.4%, <i>P</i>=0.652), myocardial infarction (9.3% versus 8.3%, <i>P</i>=0.921) and repeat PCI (12.4% versus 8.7%, <i>P</i>=0.229). ST-segment-elevation myocardial infarction at presentation (odds ratio [OR], 3.30 [95% CI, 1.56-7.12]; <i>P</i>=0.002), proximal coronary segment involvement (OR, 5.43 [95% CI, 1.98-16.45]; <i>P</i>=0.002), Thrombolysis in Myocardial Infarction flow grade 0 to 1 and 2 (respectively, OR, 3.22 [95% CI, 1.08-9.96]; <i>P</i>=0.038; and OR, 3.98 [95% CI, 1.38-11.80]; <i>P</i>=0.009) and luminal narrowing (OR per 5% increase, 1.13 [95% CI, 1.01-1.28]; <i>P</i>=0.037) were predictors of PCI, whereas the 2B-angiographic subtype predicted medical management (OR, 0.25 [95% CI, 0.07-0.83]; <i>P</i>=0.026).<br /><b>Conclusions</b><br />Clinical presentation and procedural variables drive the choice of the initial therapeutic approach in spontaneous coronary artery dissection. If PCI is needed, it seems to be associated with a similar risk of short-to-mid-term adverse events compared to medical treatment.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT04415762.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Jun 2023:e012780; epub ahead of print</small></div>

<div><h4>Transcatheter Mitral Valve Replacement versus Medical Therapy for Secondary Mitral Regurgitation: A Propensity Score-Matched Comparison.</h4><i>Ludwig S, Conradi L, Cohen DJ, Coisne A, ... Granada JF, CHOICE-MI and the COAPT Trial Investigators</i><br /><AbstractText><b>Background:</b> Transcatheter mitral valve replacement (TMVR) is an emerging therapeutic alternative for patients with secondary mitral regurgitation (MR). Outcomes of TMVR versus guideline-directed medical therapy (GDMT) have not been investigated for this population. This study aimed to compare clinical outcomes of patients with secondary MR undergoing TMVR versus GDMT alone. <br /><b>Methods:</b><br/>The CHOICE-MI registry included patients with MR undergoing TMVR using dedicated devices. Patients with MR etiologies other than secondary MR were excluded. Patients treated with GDMT alone were derived from the control arm of the COAPT trial. We compared outcomes between the TMVR and GDMT groups, using propensity score (PS)-matching to adjust for baseline differences. <br /><b>Results:</b><br/>After PS-matching, 97 patient pairs undergoing TMVR (72.9±8.7 years, 60.8% male, transapical access 91.8%) versus GDMT (73.1±11.0 years, 59.8% male) were compared. At 1 and 2 years, residual MR was ≤1+ in all patients of the TMVR group compared to 6.9% and 7.7%, respectively, in those receiving GDMT alone (both p<0.001). The 2-year rate of HF hospitalization was significantly lower in the TMVR group (32.8% vs. 54.4%, HR 0.59, 95% CI 0.35-0.99; p=0.04). Among survivors, a higher proportion of patients were in NYHA functional class I or II in the TMVR group at 1 year (78.2% vs. 59.7%, p=0.03) and at 2 years (77.8% vs. 53.2%, p=0.09). Two-year mortality was similar in the two groups (TMVR vs. GDMT, 36.8% vs. 40.8%, HR 1.01, 95% CI 0.62-1.64; p=0.98). <b>Conclusions:</b> In this observational comparison, over 2-year follow-up, TMVR using mostly transapical devices in patients with secondary MR was associated with significant reduction of MR, symptomatic improvement, less frequent hospitalizations for HF and similar mortality compared with GDMT.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 16 May 2023; epub ahead of print</small></div>

<div><h4>Target Lesion Revascularization After Intravascular Ultrasound-Guided Percutaneous Coronary Intervention.</h4><i>Yamamoto K, Shiomi H, Morimoto T, Miyazawa A, ... Kimura T, OPTIVUS-Complex PCI Investigators*</i><br /><b>Background</b><br />Several stent expansion criteria derived from the intravascular ultrasound (IVUS) evaluation have been proposed to predict future clinical outcomes, but optimal stent expansion criteria as a guide during percutaneous coronary intervention (PCI) are still controversial. There are no studies evaluating the utility of stent expansion criteria along with the clinical and procedural factors in predicting target lesion revascularization (TLR) after contemporary IVUS-guided PCI.<br /><b>Methods</b><br />OPTIVUS-Complex PCI study (Optimal Intravascular Ultrasound Guided Complex Percutaneous Coronary Intervention) multivessel cohort was a prospective multicenter study enrolling 961 patients undergoing multivessel PCI including left anterior descending coronary artery using IVUS with an intention to meet the prespecified criteria for optimal stent expansion. We compared several stent expansion criteria (minimum stent area [MSA], MSA/distal or average reference lumen area, MSA/distal or average reference vessel area, OPTIVUS criteria, IVUS-XPL [Impact of Intravascular Ultrasound Guidance on Outcomes of Xience Prime Stents in Long Lesions] criteria, ULTIMATE [Intravascular Ultrasound Guided Drug Eluting Stents Implantation in \"All-Comers\" Coronary Lesions] criteria, and modified MUSIC [Multicenter Ultrasound Stenting in Coronaries Study] criteria) as well as clinical, angiographic, and procedural characteristics between lesions with and without TLR.<br /><b>Results</b><br />Among 1957 lesions, the cumulative 1-year incidence of lesion-based TLR was 1.6% (30 lesions). Hemodialysis, treatment of proximal left anterior descending coronary artery lesions, calcified lesions, small proximal reference lumen area, and small MSA had univariate associations with TLR, while all of the stent expansion criteria except for MSA were not associated with TLR. The independent risk factors of TLR were calcified lesions (hazard ratio, 2.34 [95% CI, 1.03-5.32]; <i>P</i>=0.04) and small proximal reference lumen area (Tertile 1: hazard ratio, 7.01 [95% CI, 1.45-33.93]; <i>P</i>=0.02; and Tertile 2: hazard ratio, 5.40 [95% CI, 1.17-24.90]; <i>P</i>=0.03).<br /><b>Conclusions</b><br />In contemporary IVUS-guided PCI practice, the 1-year incidence of TLR was very low. MSA, but not other stent expansion criteria, had univariate association with TLR. Independent risk factors of TLR were calcified lesions and small proximal reference lumen area, although the findings should be interpreted with caution due to small number of TLR events, limited lesion complexity, and short duration of follow-up.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023; 16:e012922</small></div>

<div><h4>Transcatheter Aortic Valve Replacement and Impact of Subclinical Leaflet Thrombosis in Low-Risk Patients: LRT Trial 4-Year Outcomes.</h4><i>Waksman R, Bhogal S, Gordon P, Ehsan A, ... Satler LF, Rogers T</i><br /><b>Background</b><br />The LRT trial (Low-Risk Transcatheter Aortic Valve Replacement [TAVR]) demonstrated the safety and feasibility of TAVR in low-risk patients, with excellent 1- and 2-year outcomes. The objective of the current study is to provide the overall clinical outcomes and the impact of 30-day hypoattenuated leaflet thickening (HALT) on structural valve deterioration at 4 years.<br /><b>Methods</b><br />The prospective, multicenter LRT trial was the first Food and Drug Administration-approved investigational device exemption study to evaluate feasibility and safety of TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis. Clinical outcomes and valve hemodynamics were documented annually through 4 years.<br /><b>Results</b><br />A total of 200 patients were enrolled, and follow-up was available on 177 patients at 4 years. The rates of all-cause mortality and cardiovascular death were 11.9% and 3.3%, respectively. The stroke rate rose from 0.5% at 30 days to 7.5% at 4 years, and permanent pacemaker implantation rose from 6.5% at 30 days to 11.7% at 4 years. Endocarditis was detected in 2.5% of the cohort, with no new cases reported between 2 and 4 years. Transcatheter heart valve hemodynamics remained excellent post-procedure and were maintained (mean gradient 12.56±5.54 mm Hg and aortic valve area 1.69±0.52 cm<sup>2</sup>) at 4 years. At 30 days, HALT was observed in 14% of subjects who received a balloon-expandable transcatheter heart valve. There was no difference in valve hemodynamics between patients with and without HALT (mean gradient 14.94±5.01 mm Hg versus 12.3±5.57 mm Hg; <i>P</i>=0.23) at 4 years. The overall rate of structural valve deterioration was 5.8%, and there was no impact of HALT on valve hemodynamics, endocarditis, or stroke at 4 years.<br /><b>Conclusions</b><br />TAVR in low-risk patients with symptomatic severe tricuspid aortic stenosis was found to be safe and durable at 4 years. Structural valve deterioration rates were low irrespective of the type of valve, and the presence of HALT at 30 days did not affect structural valve deterioration, transcatheter valve hemodynamics, and stroke rate at 4 years.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT02628899.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023; 16:e012655</small></div>

<div><h4>Antithrombotic Management After Left Atrial Appendage Closure: Current Evidence and Future Perspectives.</h4><i>Mesnier J, Cepas-Guillén P, Freixa X, Flores-Umanzor E, ... O\'Hara G, Rodés-Cabau J</i><br /><AbstractText>Left atrial appendage closure is an alternative to chronic oral anticoagulation to prevent embolic events related to nonvalvular atrial fibrillation. After device implantation, antithrombotic treatment is prescribed to prevent device-related thrombosis, a dreadful complication associated with an increased risk of ischemic events. However, the optimal antithrombotic treatment after left atrial appendage closure, effective on both device-related thrombus prevention and bleeding risk mitigation, remains to be determined. In more than 10 years experience with left atrial appendage closure, a wide range of antithrombotic treatments have been used, mostly in observational studies. In this review, we analyzed the body of evidence for each antithrombotic regimen after left atrial appendage closure to provide tools to guide the physician choice and describe future perspectives in the field.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023; 16:e012812</small></div>

<div><h4>Transcatheter Aortic Valve Replacement in Patients With Reduced Ejection Fraction and Nonsevere Aortic Stenosis.</h4><i>Ludwig S, Schofer N, Abdel-Wahab M, Urena M, ... Kim WK, Clavel MA</i><br /><b>Background</b><br />The potential benefit of transcatheter aortic valve replacement (TAVR) in patients with nonsevere aortic stenosis (AS) and heart failure is controversial. This study aimed to assess outcomes of patients with nonsevere low-gradient AS (LGAS) and reduced left ventricular ejection fraction undergoing TAVR or medical management.<br /><b>Methods</b><br />Patients undergoing TAVR for LGAS and reduced left ventricular ejection fraction (<50%) were included in a multinational registry. True-severe low-gradient AS (TS-LGAS) and pseudo-severe low-gradient AS (PS-LGAS) were classified according to computed tomography-derived aortic valve calcification thresholds. A medical control group with reduced left ventricular ejection fraction and moderate AS or PS-LGAS was used (Medical-Mod). Adjusted outcomes between all groups were compared. Among patients with nonsevere AS (moderate or PS-LGAS), outcomes after TAVR and medical therapy were compared using propensity score-matching.<br /><b>Results</b><br />A total of 706 LGAS patients undergoing TAVR (TS-LGAS, N=527; PS-LGAS, N=179) and 470 Medical-Mod patients were included. After adjustment, both TAVR groups showed superior survival compared with Medical-Mod patients (all <i>P</i><0.001), while no difference was found between TS-LGAS and PS-LGAS TAVR patients (<i>P</i>=0.96). After propensity score-matching among patients with nonsevere AS, PS-LGAS TAVR patients showed superior 2-year overall (65.4%) and cardiovascular survival (80.4%) compared with Medical-Mod patients (48.8% and 58.5%, both <i>P</i>≤0.004). In a multivariable analysis including all patients with nonsevere AS, TAVR was an independent predictor of survival (hazard ratio, 0.39 [95% CI, 0.27-0.55]; <i>P</i><0.0001).<br /><b>Conclusions</b><br />Among patients with nonsevere AS and reduced left ventricular ejection fraction, TAVR represents a major predictor of superior survival. These results reinforce the need for randomized-controlled trials comparing TAVR versus medical management in heart failure patients with nonsevere AS.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT04914481.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023; 16:e012768</small></div>

<div><h4>Clinical Presentation and Medium-Term Outcomes of Children With Anomalous Aortic Origin of the Left Coronary Artery: High-Risk Features Beyond Interarterial Course.</h4><i>Doan TT, Wilkes JK, Reaves O\'Neal DL, Bonilla-Ramirez C, ... Heinle JS, Molossi S</i><br /><b>Background</b><br />Anomalous aortic origin of the left coronary artery (AAOLCA) confers a rare, but significant, risk of sudden cardiac death in children. Surgery is recommended for interarterial AAOLCA, and other subtypes considered benign. We aimed to determine the clinical characteristics and outcomes of 3 AAOLCA subtypes.<br /><b>Methods</b><br />All patients with AAOLCA <21 years old were prospectively enrolled (December 2012-November 2020), including group 1: AAOLCA from the right aortic sinus with interarterial course, group 2: AAOLCA from the right aortic sinus with intraseptal course, and group 3: AAOLCA with a juxtacommissural origin between the left and noncoronary aortic sinus. Anatomic details were assessed using computed tomography angiography. Provocative stress testing (exercise stress testing and stress perfusion imaging) was performed in patients >8 years old or younger if concerning symptoms. Surgery was recommended for group 1 and in select cases in group 2 and group 3.<br /><b>Results</b><br />We enrolled 56 patients (64% males) with AAOLCA (group 1, 27; group 2, 20; group 3, 9) at median age of 12 years (interquartile range, 6-15). Intramural course was common in group 1 (93%) compared with group 3 (56%) and group 2 (10%). Seven (13%) presented with aborted sudden cardiac death (group 1, 6/27; group 3, 1/9); 1 (group 3) with cardiogenic shock. Fourteen/42 (33%) had inducible ischemia on provocative testing (group 1, 32%; group 2, 38%; group 3, 29%). Surgery was recommended in 31/56 (56%) patients (group 1, 93%; group 2, 10%; and group 3, 44%). Surgery was performed in 25 patients at a median age 12 (interquartile range, 7-15) years; all have been asymptomatic and free from exercise restrictions at median follow-up of 4 (interquartile range, 1.4-6.3) years.<br /><b>Conclusions</b><br />Inducible ischemia was noted in all 3 AAOLCA subtypes while most aborted sudden cardiac deaths occurred in interarterial AAOLCA (group 1). Aborted sudden cardiac death and cardiogenic shock may occur in AAOLCA with left/nonjuxtacommissural origin and intramural course, thus also deemed high-risk. A systematic approach is essential to adequately risk stratify this population.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023; 16:e012635</small></div>

<div><h4>Catheter-Induced Postextrasystolic Potentiation in the Assessment of Severity of Low-Gradient Aortic Valve Stenosis.</h4><i>Dehghani P, Singh J, Singer Z, Booker J, ... Clavel MA, Pibarot P</i><br /><b>Background</b><br />Deciphering which patients with low-gradient aortic valve disease have severe stenosis can be difficult. We aimed to correlate the postextrasystolic potentiation (PESP) with dobutamine stress echocardiography and multidetector computed tomography in patients with low-gradient aortic valve stenosis.<br /><b>Methods</b><br />Patients with an aortic valve area ≤1 cm<sup>2</sup> and a mean gradient <40 mm Hg were included. Aortic valve stenosis severity was assessed by a core lab with dobutamine stress echocardiography, followed by a multidetector computed tomography aortic valve score if indeterminate. A premature ventricular contraction was induced by intentional catheter contact with the myocardium within the left ventricle. PESP was calculated as a percent change of pre-to-post mean gradient. Multidetector computed tomography was used to measure the aortic valve calcification score, and subsequently, aortic valve calcification density.<br /><b>Results</b><br />Twenty-eight patients (age, 77±10 years; 19 female) were included. Dobutamine stress echocardiography increased mean gradient from baseline of 25±7 mm Hg to 36±11 mm Hg; pre-premature ventricular contraction mean gradient was 25±7 mm Hg and increased to post-premature ventricular contraction mean gradient of 32±10 mm Hg, representing a PESP of 24±11%. A ≥20% in PESP resulted in 100% sensitivity, 77% specificity, 83% positive predictive value, and 100% negative predictive value for diagnosing severe aortic valve stenosis. There was a significant correlation between PESP and projected aortic valve area and aortic valve calcification density (R=-0.64, <i>P</i>=0.0003; R=0.057, <i>P</i>=0.014, respectively).<br /><b>Conclusions</b><br />In patients with low-gradient aortic valve stenosis, catheter-induced premature ventricular contractions during cardiac catheterization causing ≥20% PESP has a 100% sensitivity for severe aortic valve stenosis. Validation of this 20% cutoff in larger groups with correlation to clinical end points is required.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 May 2023:e012892; epub ahead of print</small></div>

<div><h4>Ischemia in Anomalous Aortic Origin of a Right Coronary Artery: Large Pediatric Cohort Medium-Term Outcomes.</h4><i>Doan TT, Sachdeva S, Bonilla-Ramirez C, Reaves-O\'Neal DL, ... Heinle JH, Molossi S</i><br /><b>Background</b><br />Anomalous aortic origin of a right coronary artery may cause myocardial ischemia and sudden death in the young. Data on myocardial ischemia or longitudinal outcomes are sparse in pediatric anomalous aortic origin of a right coronary artery population.<br /><b>Methods</b><br />Patients <21 years with anomalous aortic origin of a right coronary artery were prospectively enrolled. Computerized tomography angiography defined morphology. Exercise stress test and stress perfusion imaging (sPI) were performed if >7 years or younger with concern for ischemia. High-risk features included intramural length, slit-like/hypoplastic ostium, exertional symptoms, or evidence of ischemia.<br /><b>Results</b><br />A total of 220 patients (60% males) were enrolled December 2012 to April 2020 at a median age 11.4 years (interquartile range, 6.1-14.5), including 168 (76%) with no/nonexertional symptoms (group 1) and 52 (24%) with exertional chest pain/syncope (group 2). Computerized tomography angiography was available in 189/220 (86%), exercise stress test in 164/220 (75%), and sPI in 169/220 (77%). Exercise stress test was positive in 2/164 (1.2%) patients in group 1, both had positive sPI. Inducible ischemia (sPI) was detected in 11/120 (9%) in group 1 and 9/49 (18%) in group 2 (<i>P</i>=0.09). Intramural length was similar in patients with/without ischemia (5 [interquartile range, 4-7] versus 5 [interquartile range, 4-7] mm; <i>P</i>=0.65). Surgery was recommended in 56/220 (26%) patients with high-risk features. In 52 surgical patients (38 unroofing, 14 reimplantation), all subjects were alive and have returned to exercise at last median follow-up of 4.6 (interquartile range, 2.3-6.5) years.<br /><b>Conclusions</b><br />Anomalous aortic origin of a right coronary artery patients can present with inducible ischemia on sPI despite symptoms or intramural length. Exercise stress test is a poor predictor of ischemia and caution should be given to determine low-risk based solely on this assessment. All patients are alive at medium-term follow-up.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Apr 2023; 16:e012631</small></div>

<div><h4>Amputation After Endovascular Therapy With and Without Intravascular Ultrasound Guidance: A Nationwide Propensity Score-Matched Study.</h4><i>Setogawa N, Ohbe H, Matsui H, Yasunaga H</i><br /><b>Background</b><br />Intravascular ultrasound (IVUS) provides precise intravascular information during endovascular therapy (EVT). However, the clinical efficacy of IVUS in patients who undergo EVT remains unknown. The present study aimed to determine whether the use of IVUS-guided EVT is associated with better clinical outcomes in a real-world setting.<br /><b>Methods</b><br />Using the Japanese Diagnosis Procedure Combination administrative inpatient database from April 2014 to March 2019, we identified patients diagnosed with atherosclerosis of arteries of extremities and underwent EVT (percutaneous endovascular transluminal angioplasty and thrombectomy for extremities or percutaneous endovascular removal). Propensity score matching analysis was performed to compare outcomes between the patients who underwent IVUS on the same day as the first EVT intervention (IVUS group) and the others (non-IVUS group). The primary outcome was major and minor amputation for extremities within 12 months of the first EVT procedure. Secondary outcomes were bypass surgery, stent grafting, reintervention, all-cause death, readmission, and total hospitalization costs within 12 months of the first EVT procedure.<br /><b>Results</b><br />Among 85 649 eligible patients, 50 925 (59.5%) were IVUS group. After propensity score matching, the IVUS group had significantly lower incidence of 12-month amputation compared with the non-IVUS group (6.9% in the IVUS group versus 9.3% in the non-IVUS group; hazard ratio, 0.80 [95% CI, 0.72-0.89]). Compared with the non-IVUS group, the IVUS group showed a lower risk of bypass surgery and stent grafting and decreased total hospitalization costs, while a higher risk of reintervention and readmission. No significant differences in all-cause death were found between the 2 groups.<br /><b>Conclusions</b><br />In this retrospective study, IVUS-guided EVT was associated with a lower amputation risk than non-IVUS-guided EVT. Our findings should be interpreted carefully because of the limitations of an observational study using administrative data. Further studies are warranted to confirm whether IVUS-guided EVT leads to decreased amputations.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 01 Apr 2023; 16:e012451</small></div>

<div><h4>Angina After Percutaneous Coronary Intervention: Patient and Procedural Predictors.</h4><i>Collison D, Copt S, Mizukami T, Collet C, ... Berry C, Oldroyd KG</i><br /><b>Background</b><br />Twenty percent to 40% of patients are affected by angina after percutaneous coronary intervention (PCI), which is associated with anxiety, depression, impaired physical function, and reduced quality of life. Understanding patient and procedural factors associated with post-PCI angina may inform alternative approaches to treatment.<br /><b>Methods</b><br />Two hundred thirty patients undergoing PCI completed the Seattle Angina Questionnaire (SAQ-7) and European quality of life-5 dimension-5 level (EQ-5D-5L) questionnaires at baseline and 3 months post-PCI. Patients received blinded intracoronary physiology assessments before and after stenting. A post hoc analysis was performed to compare clinical and procedural characteristics among patients with and without post-PCI angina (defined by follow-up SAQ-angina frequency score <100).<br /><b>Results</b><br />Eighty-eight of 230 patients (38.3%) reported angina 3 months post-PCI and had a higher incidence of active smoking, atrial fibrillation, and history of previous myocardial infarction or PCI. Compared with patients with no angina at follow-up, they had lower baseline SAQ summary scores (69.48±24.12 versus 50.20±22.59, <i>P</i><0.001) and EQ-5D-5L health index scores (0.84±0.15 versus 0.69±0.22, <i>P</i><0.001). Pre-PCI fractional flow reserve (FFR) was lower among patients who had no post-PCI angina (0.56±0.15 versus 0.62±0.13, <i>P</i>=0.003). Percentage change in FFR after PCI had a moderate correlation with angina frequency score at follow-up (<i>r</i>=0.36, <i>P</i><0.0001). Patients with post-PCI angina had less improvement in FFR (43.1±33.5% versus 67.0±50.7%, <i>P</i><0.001). There were no between-group differences in post-PCI FFR, coronary flow reserve, or corrected index of microcirculatory resistance. Patients with post-PCI angina had lower SAQ-summary scores (64.01±22 versus 95.16±8.72, <i>P</i>≤0.001) and EQ-5D-5L index scores (0.69±0.26 versus 0.91±0.17, <i>P</i>≤0.001) at follow-up.<br /><b>Conclusions</b><br />Larger improvements in FFR following PCI were associated with less angina and better quality of life at follow-up. In patients with stable symptoms, intracoronary physiology assessment can inform expectations of angina relief and quality of life improvement after stenting and thereby help to determine the appropriateness of PCI.<br /><b>Registration</b><br />URL: https://www.<br /><b>Clinicaltrials</b><br />gov; Unique identifier: NCT03259815.<br /><br /><br /><br /><small>Circ Cardiovasc Interv: 28 Mar 2023:e012511; epub ahead of print</small></div>

<div><h4>Management of Stable Angina in the Older Adult Population.</h4><i>Nanna MG, Wang SY, Damluji AA</i><br /><AbstractText>As society ages, the number of older adults with stable ischemic heart disease continues to rise. Older adults exhibit the greatest morbidity and mortality from stable angina. Furthermore, they suffer a higher burden of comorbidity and adverse events from treatment than younger patients. Given that older adults were excluded or underrepresented in most randomized controlled trials of stable ischemic heart disease, evidence for management is limited and hinges on subgroup analyses of trials and observational studies. This review aims to elucidate the current definitions of aging, assess the overall burden and clinical presentations of stable ischemic heart disease in older patients, weigh the available evidence for guideline-recommended treatment options including medical therapy and revascularization, and propose a framework for synthesizing complex treatment decisions in older adults with stable angina. Due to evolving goals of care in older patients, it is paramount to readdress the patient\'s priorities and preferences when deciding on treatment. Ultimately, the management of stable angina in older adults will need to be informed by dedicated studies in representative populations emphasizing patient-centered end points and person-centered decision-making.</AbstractText><br /><br /><br /><br /><small>Circ Cardiovasc Interv: 14 Mar 2023:e012438; epub ahead of print</small></div>