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Data on the safety and efficacy of percutaneous coronary intervention (PCI) with adjunctive rotational atherectomy (RA) in left main (LM) disease are limited. Current guidelines recommend using a small-size RA burr initially, with upsizing if required. The safety of upfront use of a large-size RA burr (&#x2265;1.75 mm) is unknown. The authors assessed the safety of an upfront large rotablation burr in the treatment of LM calcification and the procedural and long-term outcome of this approach in comparison to a small-size burr. Retrospective analysis of all patients undergoing PCI with adjunctive RA to LM disease. The study outcomes were all-cause mortality and repeat target lesion revascularization (TLR) at medium-term follow-up in patients treated with large burr size (&#x2265;1.75mm) compared to small burr size (<1.75mm). Two hundred forty-three patients (mean age 75 &#xb1; 9 years, 80% males) were included. Approximately half of the patients were treated with a large-size RA burr (&#x2265;1.75 mm). Most treated lesions were bifurcation lesions involving the 3 branches (86%) with SYNTAX score of 35 &#xb1; 11. Radial access was used in two-thirds of patients; 7F sheath was the most used. There was no difference between the small and large burr groups in procedural complications (11% vs 8%, P = .512), all-cause mortality (34% vs 28%, P = .267), and repeat TLR up to 4 years after PCI (2.9% vs 2.1%, P = .473). Upfront use of a large-size RA burr is feasible and safe for treating calcified LM disease, with no increase in procedural complications, repeat TLR, or medium-term all-cause mortality.

Optimal postprocedural antithrombotic management after left atrial appendage closure (LAAC) remains undefined, particularly in patients with high bleeding risk. Early complete cessation (<6 months) of antithrombotic therapy (AT) following LAAC is increasingly adopted, yet supportive evidence is limited. This study sought to evaluate the safety of early (<6 months) complete discontinuation of AT after LAAC. A systematic review and meta-analysis of observational studies was conducted. PubMed and Scopus were searched through September 2025. The primary endpoint was stroke events; secondary endpoints included all-cause mortality, major bleeding, and device-related thrombus (DRT). Random-effects models were used to calculate pooled risk ratios (RRs). Subgroup and sensitivity analyses were performed. Seven studies including 1841 patients (529 with early AT cessation) were analyzed. Patients undergoing early AT discontinuation exhibited high baseline thromboembolic and bleeding risk, and most of them (67%) had prior bleeding events. Over a weighted mean follow-up of 19.2 months, early discontinuation of AT was not associated with increased risk of stroke (RR, 1.04; 95% CI, 0.40-2.66), all-cause death (RR, 1.03; 95% CI, 0.49-2.17), major bleeding (RR, 1.22; 95% CI, 0.75-2.01), or DRT (RR, 0.49; 95% CI, 0.14-1.73). No significant differences were observed between very early (<1 month) and early (<6 months) cessation strategies. Among high-bleeding-risk patients undergoing LAAC, early complete discontinuation of AT was not associated with an increased risk of thromboembolic events or death during mid-term follow-up. These results support the potential ischemic safety of early antithrombotic cessation in carefully selected patients and highlight the need for definite evidence from randomized trials.

To determine if quantification of the myocardial mass supplied by a side branch (SB) could be predictive of bifurcation percutaneous coronary intervention (PCI) outcomes. The authors examined the characteristics and outcomes of 73 patients (81 lesions) who underwent bifurcation PCI and had coronary computed tomography angiography (CCTA) angiography based computed flow-based calculation of myocardial mass at risk within 6 months prior. The lesions analyzed were complex with high V-RESOLVE scores (12.0, 95%, interquartile range [IQR]: 9.0, 13.5). Provisional stenting was used in 67.9%, 2-stent techniques in 32.1%, and conversion from provisional to 2-stent stenting was performed in 11.1% of the lesions. The main vessel (MV) supplied 30.0% (IQR: 24.0%, 36.0%) and the SB supplied 10.0% (IQR: 7.0%, 13.0%) of the myocardium. Technical success was 94.9%. Major adverse cardiovascular events (MACE) occurred in 5.5% of the patients and SB occlusion (SBO) in 12.3% of the lesions. The ratio of SB to MV myocardial mass supply (SB/MV) was not associated with technical success (odds ratio [OR], 11.00; 95% confidence interval [CI], 0.01, 18.79; P = .500) or MACE (OR, 0.02; 95% CI, 0.00, 18.20; P = .300), but was associated with SBO (OR, 6.02*10-6; 95% CI, 2.42*10-10, 0.15; P = .020). SB/MV was normally distributed (W = 0.99, P = .467) with a mean of 0.35 (95% CI, 0.31, 0.38). In lesions where SBO occurred, V-RESOLVE scores were higher (16.0 vs 12.0, P = .017) and the SB/MV ratio was lower (0.22 vs 0.35, P = .007). Myocardial mass derived from CT analysis can help assess the risk of SBO after bifurcation PCI.

The authors conducted a review of the US Food and Drug Administration's (FDA) emergency use authorization (EUA) pathway as a mechanism to use the Occlutech Atrial Flow Regulator (AFR) (Occlutech International AB) for critically ill pediatric patients with congenital heart disease. The authors describe 8 pediatric patients in whom the EUA pathway was activated to permit AFR implantation and provide potentially lifesaving therapy. Emergency authorization was granted for each of the 8 cases with successful implantation of the AFR. There were 2 cases in which the patient required a repeat catheterization for thrombus on the device, but all 8 patients were able to progress their care. These cases demonstrate the feasibility of the EUA pathway to access emerging technologies for pediatric patients. The Occlutech AFR may provide an important therapeutic option for critically ill children with congenital heart disease. The EUA pathway can facilitate timely access to unapproved but potentially beneficial technologies when no satisfactory approved alternatives exist.

Coronary intravascular lithotripsy (IVL) and coronary atherectomy are increasingly used for calcified coronary lesions, yet comparative data on their cardiovascular benefits remain limited. This real-world study compared outcomes of coronary IVL vs atherectomy using the TriNetX Global Collaborative Network. Adult patients (&#x2265;18 years) undergoing PCI with either IVL or atherectomy between 2021 and 2024 were identified using procedural and diagnosis codes. Propensity score matching (1:1) balanced baseline demographics, comorbidities, laboratory values, and concomitant medications. The primary endpoint was all-cause mortality (ACM), while secondary endpoints included major adverse cardiovascular events (MACE), heart failure exacerbation (HFE), and procedural safety outcomes. Among 51 856 patients, 18 686 underwent IVL and 33 170 underwent atherectomy. After matching, 13 617 patients were retained in each group. At 30 days, IVL was associated with significantly lower risks of ACM (risk ratio [RR]: 0.67; 95% CI, 0.60-0.75; P < .001), MACE (RR: 0.42, 95% CI, 0.36-0.48; P < .001), and HFE (RR: 0.64; 95% CI, 0.57-0.72; P < .001) compared with atherectomy. These benefits persisted at 1 year for ACM (RR: 0.78; 95% CI, 0.73-0.84; P < .001), MACE (RR: 0.66; 95% CI, 0.60-0.72; P < .001), and HFE (RR: 0.79; 95% CI, 0.73-0.85; P < .001). Safety outcomes were comparable between groups. In this propensity-matched, real-world cohort, IVL was associated with lower mortality and fewer adverse cardiovascular events than atherectomy, with a comparable safety profile. Given the likelihood of residual selection bias, these observational findings require confirmation in randomized trials.

Coronary artery disease affects nearly half of patients undergoing transcatheter aortic valve implantation (TAVI), but the accuracy of angiography-derived, wire-free coronary physiology in severe aortic stenosis remains uncertain. The authors evaluated its diagnostic performance for detecting fractional flow reserve (FFR)-defined significant stenoses in TAVI candidates and assessed whether accuracy differed when invasive FFR was measured before vs after TAVI. A diagnostic accuracy meta-analysis was performed including studies reporting lesion-level comparisons between angiography-derived physiology (threshold &#x2264;0.80) and invasive FFR (&#x2264;0.80) in patients undergoing TAVI evaluation. All included studies evaluated quantitative flow ratio (QFR) or Murray-law-based QFR; no eligible studies using FFRangio or vFFR were identified. Pooled sensitivity and specificity were calculated using random-effects models. Diagnostic odds ratios (DOR), likelihood ratios, and post-test probabilities were derived. Meta-regression evaluated the impact of FFR timing (CRD420261332222). Five studies met inclusion criteria. Four studies (422 lesions) contributed to the primary analysis and 3 studies (250 lesions) to the secondary analysis. In the primary analysis, pooled sensitivity was 0.79 (95% CI, 0.68-0.87) and specificity 0.88 (95% CI, 0.80-0.93) (DOR 28). In the secondary analysis, sensitivity was 0.71 (95% CI, 0.57-0.82) and specificity 0.95 (95% CI, 0.90-0.98) (DOR 46.5), with comparable global discrimination (Youden index 0.66 vs 0.67). Meta-regression showed no significant interaction by reference timing (P = .39). Angiography-derived coronary physiology demonstrates good diagnostic performance in patients undergoing TAVI evaluation, with comparable overall discrimination when referenced to both pre- and post-TAVI FFR, although interpretation is limited by the absence of a stable reference standard across hemodynamic states.

It remains unclear whether extracorporeal cardiopulmonary resuscitation (ECPR) is more efficacious than conventional cardiopulmonary resuscitation (CPR) at improving survival with favorable neurological outcomes among patients with out-of-hospital cardiac arrests (OHCA). The authors sought to determine the efficacy of ECPR vs conventional CPR among patients with OHCA in the pre-hospital setting. The authors searched MEDLINE, EMBASE, and the Cochrane Library for randomized controlled trials (RCTs) comparing ECPR with conventional CPR for patients with OHCA. The primary outcome was survival with a favorable neurological outcome at 6-month follow-up. Count data were pooled across trials through random-effects models with inverse variance weighting to estimate risk ratios (RRs) and 95% confidence intervals (CIs). A total of 3 RCTs (n = 420) were included. Most patients (85%) were male, and the mean/median age ranged from 54 to 59 years. At 6 months, 28.4% of the patients randomized to ECPR survived with favorable neurological outcomes compared with 18.6% of the patients randomized to conventional CPR (RR, 1.47; 95% CI, 0.43-5.09). Similar results were obtained for survival at hospital discharge (RR, 1.35; 95% CI, 0.35-5.19). Risk of Bias 2 analysis indicated low risk in 1 trial and some concerns in others. ECPR may be associated with improved survival with favorable neurological outcomes at 6 months compared to conventional CPR for the treatment of OHCA. However, the available evidence remains inconclusive, and additional trials are needed to definitively assess the efficacy of ECPR compared to conventional CPR for OHCA.

Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) can lead to positive vascular remodeling after revascularization, potentially resulting in late stent malapposition. Self-expanding drug-eluting stents (SE-DES) may adapt better to dynamic vessel diameters than balloon-expandable drug-eluting stents (BE-DES), potentially reducing strut malapposition after CTO-PCI. The authors compared stent malapposition at 6 months between SE-DES and BE-DES in CTO-PCI using optical coherence tomography (OCT). In this single-center, prospective, randomized controlled trial, 23 patients with CTO were allocated 1:1 to SE-DES (STENTYS Xposition S [STENTYS S.A]) or BE-DES following successful lesion crossing and balloon predilatation. The primary endpoint was the percentage of malapposed stent struts on 6-month OCT. Secondary endpoints included neointimal hyperplasia, late lumen loss, in-stent restenosis (ISR), and clinical outcomes. At 6 months, OCT showed significantly lower malapposition in the SE-DES group compared with BE-DES (0.0% [0.0-0.0] vs 0.8% [0.0-2.4]; P = .01). SE-DES was associated with greater neointimal thickness (0.3 mm vs 0.1 mm; P < .001) and late lumen loss (0.7 mm vs 0.1 mm; P = .003). ISR occurred more frequently in the SE-DES group (4 vs 1 patients), without reaching statistical significance. No major clinical events were reported in either group. SE-DES were associated with a statistically significant reduction in strut malapposition compared with BE-DES. However, the absolute malapposition burden was very low in both groups, making the clinical relevance of this imaging finding uncertain. These findings emphasize the importance of individualized stent selection and systematic intracoronary imaging in complex PCI.

The SELUTION SLR 014 In-stent Restenosis (SELUTION4ISR) trial showed noninferiority of DCB for the outcome of target lesion failure (TLF) when compared with standard of care (80% DES and 20% POBA). It was notable that in the DCB vs DES subgroup analysis there was a numerically higher rate of TLF with DCB (15.3% vs 7.1%). The authors aimed to re-evaluate the outcomes of drug-eluting stent (DES), drug-coated balloon (DCB), or plain old balloon angioplasty (POBA) in patients with coronary in-stent restenosis (ISR). The authors searched PubMed and EMBASE databases for randomized clinical trials (RCTs) that compared these 3 percutaneous revascularization strategies for ISR until March 15, 2026. Outcomes included major adverse cardiovascular events (MACE), target lesion revascularization, all-cause mortality, cardiovascular mortality, and stent thrombosis. From 19 RCTs that randomized 4238 patients with ISR at mean follow-up of 19.6 months, there was a significant reduction in MACE and TLR with both DCB (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.28; 95% CI, 0.16-0.49, respectively) and DES (OR, 0.35; 95% CI, 0.24-0.52 and OR, 0.22; 95% CI, 0.12-0.42, respectively) when compared with POBA. There were no significant differences in clinical outcomes between DCB and DES. In patients with ISR, DCB reduced MACE/TLR when compared with POBA. There were no clinical differences between DCB and DES even after inclusion of the SELUTION4ISR trial, thus suggesting that DCB are reasonable alternative to repeat stenting in patients presenting with ISR.

Prior studies suggest sex differences in clinical outcomes following transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis (AS). The authors hypothesized that among patients with low-flow aortic stenosis (LFAS), outcomes differ based on sex and subtype of LFAS: classical (cLFLG), paradoxical (pLFLG), and high gradient (LFHG). This single-center, observational, longitudinal cohort study included adults with LFAS who underwent TAVR. Differences in clinical outcomes (all-cause mortality, heart failure hospitalization [HFH], and myocardial infarction [MI]) by subtype of LFAS within each sex were examined via Kaplan Meier curves. Log rank P-values were reported. A total of 599 patients with LFAS were followed for 12 months after TAVR. Of the male patients (n = 373), 25.2% had LFHG, 32.7% cLFLG, and 42.1% pLFLG AS. Of females (n = 226), 26.1% had LFHG, 13.3% cLFLG, and 60.6% pLFLG AS. Event rates in males were 13.1% all-cause mortality, 6.2% HFH, and 0.8% MI. Event rates in females included 6.6% all-cause mortality, 8.0% HFH, and 0 MI. In males, the LFHG vs cLFLG vs pLFLG subtypes demonstrated significant differences in time to all-cause mortality (P < .001), HFH (P = .014), and MI (P = .045). In this cohort, clinical outcomes in males significantly differed by subtype of LFAS, whereas these differences were not found in females.

Coronary computed tomography angiography (CCTA) can be used beyond diagnostic purposes to support the preprocedural planning of percutaneous coronary intervention (PCI). Advances in scanner technology, software platforms, and physiology- and plaque-based visualization tools have expanded the role of CCTA-guided PCI. CCTA provides detailed assessment of coronary anatomy, plaque and calcium morphology, lesion length, vessel size, and noninvasive physiology, offering opportunities to anticipate procedural complexity, optimize resource utilization, and individualize PCI strategy. Emerging data, including randomized studies in chronic total occlusions and ongoing multicenter trials, support the feasibility and potential clinical value of this approach. In April 2024, the first CCTA-guided PCI summit in the United States convened interventional cardiologists and cardiac imagers, as well as industry stakeholders, to discuss the evidence, technical considerations, clinical applications, and unmet needs related to CCTA-guided PCI. This manuscript summarizes the key discussions and conclusions specific to this meeting, with a focus on the transition of CCTA from a diagnostic to a therapeutic planning tool, emerging artificial intelligence applications, its complementary role with intravascular imaging, and opportunities to enhance procedural planning and decision-making. While early experience is promising, broader adoption will require broader educational efforts, access to purpose-built visualization software tools designed for interventional cardiologists, multidisciplinary collaboration, and additional randomized and real-world studies to define its impact on clinical outcomes and procedural efficiency.

Intravascular imaging (IVI) with percutaneous coronary intervention (PCI) in the United States has historically been low, but there have been recent increases. However, how IVI use has changed at an operator level and the characteristics of operators who adopted IVI vs those who did not are unknown. Using Medicare Provider Utilization and Payment data, the authors identified PCI operators in 2019 and 2023 who performed at least 30 PCI annually. IVI use was categorized as low/none (IVI to PCI ratio [IPR]: 0.0-0.30), intermediate (IPR: 0.31-0.70), and high (IPR: &#x2265;0.71). Regression models identified provider characteristics associated with IVI adoption. In 2019, 3385 operators performed at least 30 PCI. IVI use in 2019 was low/none among 77.8% operators, intermediate in 15.7%, and high in 6.4%. In 2023, 2289 operators performed at least 30 PCI. IVI use in 2023 was low/none among 48.8% operators, intermediate in 21.8%, and high in 29.3%. Among 1671 operators active in both years, 30.9% of prior low/none users adopted IVI. Only 12.2% of intermediate or high IVI users had a reduction in IVI use. Newer high-volume operators showed high IVI use (51.1%). Non-adoption of IVI was associated with earlier graduation year, smaller hospitals, Southern region, and higher procedural volume, while gender, practice focus, teaching status of affiliated hospital, and hospital affiliation changes were not significant. IVI use has increased nationally but adoption remains uneven, with structural and generational factors driving persistent disparities and highlighting the need for targeted implementation strategies.

Emergency surgery is an infrequent but severe complication of percutaneous coronary intervention (PCI). The authors sought to examine clinical characteristics, procedural features, and outcomes of patients undergoing emergency cardiac surgery after PCI. The authors analyzed the clinical characteristics and outcomes of 15 patients who underwent emergency surgery after PCI from the PROGRESS-COMPLICATIONS registry. Of 18 691 patients who underwent PCI at 2 tertiary care centers between 2016 and 2023, 15 (0.08%) required emergency surgery: 14 underwent coronary artery bypass graft surgery (CABG) and 1 underwent aortic valve replacement and CABG. Patients had high prevalence of comorbidities such as hypertension (93.3%), diabetes mellitus (73.3%), dyslipidemia (93.3%), and prior heart failure (53.3%). The most common presentations included non-ST segment elevation acute myocardial infarction (40.0%) and stable angina (33.3%). Target lesions were complex and often had moderate/severe calcification (60.0%) or involved a bifurcation (40.0%). Mechanical circulatory support was used in 53.3% (intra-aortic balloon pump 12.5%; Impella 2.5 [Abiomed] 12.5%; Impella 5.0 37.5%; Impella CP 12.5%; venoarterial extracorporeal membrane oxygenation 25.0%). In-hospital mortality was 33.3%. The most common indications for emergent CABG were coronary dissection (46.7%), aortocoronary dissection (26.7%), and coronary perforation (26.7%). Post-CABG complications included death (33.3%), arrhythmia (33.3%), hemodynamic instability (26.7%), and cardiogenic shock (13.3%). The median hospital stay was 10.0 days (6.0-18.5). During a median follow-up of 24 months, 53.3% of patients experienced major adverse cardiovascular events (MACE), 46.7% died, and 26.7% required target vessel revascularization. Patients who underwent emergency surgery after PCI had multiple comorbidities, complex coronary anatomy, and high incidence of MACE.

Failed transradial approach (TRA) in patients undergoing percutaneous coronary procedures is associated with higher rates of vascular complications. While female sex is associated with an increased risk of failed TRA, it is unknown if females are also exposed to an increased risk of adverse events after access crossover. The authors compared the outcomes of males and females experiencing crossover following a failed TRA. The REPEAT study prospectively enrolled patients undergoing coronary procedures through TRA with access failure. In this subanalysis, patients were stratified according to sex. Propensity score matching for major confounders was used to generate comparable groups. The primary outcome was a composite of vascular complication and significant bleeding. Of 462 patients experiencing TRA failure, 245 were male and 217 female. Female patients were older and showed fewer comorbidities. TRA failure was more commonly related to radial tortuosity in females and subclavian tortuosity in males. After propensity score matching, 123 pairs were selected. Females showed higher rates of femoral crossover compared with males, in whom a contralateral radial access is mostly preferred. The incidence of the primary outcome was comparable between the 2 groups (males: 8.1% vs females: 12.2%; odds ratio [OR], 1.57; 95% CI, 0.68-3.64; P = .294). Consistent results were evident in a sensitivity analysis on patients undergoing cross over to femoral access (males: 14.5% vs females: 13.0%; OR, 0.8; 8 95% CI, 0.33-2.33; P = .805). In patients experiencing a failed TRA, no statistically significant differences were evident in terms of vascular complications or bleeding between females and males.

Sex-based disparities have been widely reported in the management and outcomes of out-of-hospital cardiac arrest (OHCA), often complicating acute coronary syndromes (ACS). While previous studies have demonstrated that female patients are less likely to undergo invasive coronary angiography (ICA) or percutaneous coronary intervention (PCI), little is known about potential differences in coronary anatomy or PCI strategies in this context. The authors sought to evaluate sex-related differences in ICA findings and PCI management among OHCA survivors with angiographically confirmed ACS. The authors conducted a retrospective, single-center study including consecutive OHCA patients admitted to the intensive care unit of a tertiary center between 2007 and 2024 who underwent emergent PCI. Propensity score matching was used to compare female and male based on key baseline characteristics. Coronary lesion characteristics, procedural data, and clinical outcomes were analyzed. Among 486 patients (mean age 60.6 &#xb1; 12.2 years), 105 (21.6%) were female patients. After matching, 210 patients (105 female, 105 male) were included. No significant differences were observed in the extent of coronary artery disease, lesion complexity, or PCI strategies. Female patients had more frequent right coronary artery culprit lesions and less left circumflex involvement. Thrombus aspiration was more common in female patients (33.3% vs 21.0%, P = .04). Adjusted in-hospital and 3-month mortality rates were not significantly different. In OHCA survivors with ACS undergoing PCI, females and males had similar angiographic profiles and PCI approaches. These findings suggest that coronary and procedural factors do not explain sex-based differences in OHCA outcomes, underlining the need for equitable access to early invasive management.

The OPN super high-pressure noncompliant (NC) balloon (SIS Medical AG) can safely reach inflation pressures of 45 to 50 atm, offering a valuable option for complex coronary interventions. This study aimed to evaluate its safety and efficacy in a real-world setting. The authors conducted an observational, single-center registry including consecutive patients treated with the OPN balloon over 13 years. Procedural indication, safety, and efficacy were assessed using quantitative coronary angiography (QCA). Major adverse cardiovascular events (MACE)-defined as cardiovascular death, myocardial infarction, or target lesion revascularization-were analyzed at 1-year follow-up. A total of 275 patients (289 lesions) were included. The cohort was highly complex (mean age 70 &#xb1; 10 years, 66% multivessel disease, 66% diabetes, 35% in-stent restenosis [ISR]). The main indication was plaque preparation (68%), followed by stent optimization (32%). Procedural success was 95%, with one-third of lesions requiring inflation pressures of greater than or equal to 40 atm. QCA demonstrated a significant increase in minimal lumen diameter (1.31 &#xb1; 0.66 mm to 2.13 &#xb1; 0.62 mm, P < .001) and a reduction in diameter stenosis (51% to 24%, P < 0.001). Safety outcomes were excellent, with very low complication rates. At 1 year, MACE occurred in 3.8% of patients (stent thrombosis 0.7%). Outcomes were similar between de novo and ISR lesions. Diabetes and chronic kidney disease independently predicted MACE. In routine clinical practice, the OPN NC balloon demonstrated high efficacy and an excellent safety profile, achieving significant luminal gain at ultra-high pressures. These findings support its role for lesion preparation and stent optimization.

In the transcatheter aortic valve replacement (TAVR) era, the presence of low-flow, low-gradient aortic stenosis (LFLG AS) itself does not preclude intervention. However, chronic kidney disease (CKD) and right-sided extravalvular damage (RSED) complicate procedural risk assessment. Both their association with each other and their joint impact on post-TAVR mortality in LFLG AS and across its subtypes remain incompletely characterized. The authors performed a retrospective study of patients with LFLG AS who underwent TAVR between 2019 and 2022, stratified by CKD stage (from no CKD to end-stage renal disease [ESRD]) and LFLG AS subtype (classical vs paradoxical). RSED was defined by greater than or equal to moderate pulmonary hypertension, greater than or equal to moderate tricuspid regurgitation, or right ventricular (RV) systolic dysfunction. Poisson regression models assessed associations between CKD stage and RSED, while multivariable Cox regression models and Wald tests compared mortality across cohorts. Among 402 patients (137 classical, 265 paradoxical), ESRD was independently associated with RSED and RV dysfunction, whereas earlier CKD stages were not. ESRD was associated with increased RV dysfunction in paradoxical LFLG AS but not in classical LFLG AS. Advanced CKD and RSED were each associated with increased post-TAVR mortality. In paradoxical LFLG AS, combined RSED and advanced CKD were associated with significantly higher mortality than either condition alone. This effect was not observed in classical LFLG AS patients. Advanced renal dysfunction is associated with RSED in LFLG AS. In paradoxical LFLG AS, their combination has a possibly multiplicative association with mortality.

The authors compared palpitations, presyncope, syncope, and postural orthostatic tachycardia syndrome (POTS) prevalence among patients with hypermobile Ehlers-Danlos syndrome (hEDS) and hypermobility spectrum disorder (HSD). A retrospective analysis of patients referred for cardiac evaluation at the New York Institute of Technology Ehlers-Danlos Syndrome/Hypermobility Treatment Center between January 2019 and November 2023 was conducted. hEDS and HSD patients underwent cardiac evaluation and were stratified by median age into younger (<35 years) and older (&#x2265;35 years) groups. Symptom prevalence was compared between hypermobile patients overall and by age cohort. Data were presented as mean &#xb1; SD; P < .05 was considered statistically significant. One hundred-nine patients (75 hEDS, 34 HSD) underwent cardiac evaluation: 75 hEDS (71 females/4 males; age 33.9 + 11.6 years) and 34 HSD (29 females/ 5 males; age 40.0 + 13.8 years). POTS (48% vs 23.5%, P = .016) was significantly more prevalent in the hEDS group; palpitations, presyncope, and syncope were common in both groups. No significant differences were observed in Cohort 1 (age less than 35 years). In Cohort 2 (age &#x2265;35 years), presyncope (100% vs 82.6%, P = .04) differed; palpitations, syncope, and POTS were similar. POTS was prevalent in patients younger than 35 years with hEDS (58.3% vs 29.6%, P = .022) and HSD (45.5% vs 13.0%, P = .042). Patients with h EDS exhibited greater symptoms than HSD patients, and symptoms were particularly more pronounced with age. POTS prevalence decreased with age in both groups. Larger prospective studies are needed to explore underlying mechanisms.

Patients with coexisting severe aortic stenosis (AS) and critical coronary artery disease (CAD) face high procedural risk when treated percutaneously. Although mechanical circulatory support (MCS) can mitigate hemodynamic instability, evidence guiding the use of cardiopulmonary bypass (CPB) or extracorporeal membrane oxygenation (ECMO) during concomitant transcatheter aortic valve replacement (TAVR) and percutaneous coronary intervention (PCI) is lacking. The authors retrospectively reviewed 6 high-risk patients who underwent concomitant TAVR and PCI with planned MCS using CPB or venoarterial (VA)-ECMO between 2015 and 2023. Outcomes were classified according to VARC-3 criteria. Six male patients (mean age 77.3 &#xb1; 8.3 years) underwent concomitant TAVR and PCI with planned MCS using CPB (n = 4, 2015-2020) or VA-ECMO (n = 2, 2022-2023). Complete coronary revascularization was achieved in 4 cases (66.7%). Implanted valves included 2 self-expanding and 4 balloon-expandable prostheses. The mean catheter-measured transaortic gradient decreased from 37.2 &#xb1; 17.6 mm Hg to 3.9 &#xb1; 2.1 mm Hg (P = .006). Trace (1+) paravalvular leak occurred in 4 patients (66.7%), with none 2+ or higher. There were no intraprocedural complications, neurologic events, major bleeding, vascular complications, or 30-day deaths. Three patients (50%) developed new conduction abnormalities, all without pacemaker requirement. Acute kidney injury occurred in 3 (Stage I, 50%). The mean intensive care and total hospital stays were 5.5 &#xb1; 3.5 and 8.3 &#xb1; 6.0 days, respectively. Planned CPB or VA-ECMO support enabled safe performance of concomitant TAVR and PCI in non-surgical, high-risk patients, representing a feasible approach for selected complex cases.