Contemporary Management of Stable Coronary Artery Disease.

Coronary artery disease (CAD) continues to be the leading cause of mortality and morbidity in developed countries. Assessment of pre-test probability (PTP) based on patient's characteristics, gender and symptoms, help to identify more accurate patient's clinical likelihood of coronary artery disease. Consequently, non-invasive imaging tests are performed more appropriately to rule in or rule out CAD rather than invasive coronary angiography (ICA). Coronary computed tomography angiography (CCTA) is the first-line non-invasive imaging technique in patients with suspected CAD and could be used to plan and guide coronary intervention. Invasive coronary angiography remains the gold-standard method for the identification and characterization of coronary artery stenosis. However, it is recommended in patients where the imaging tests are non-conclusive, and the clinical likelihood is very high, remembering that in clinical practice, approximately 30 to 70% of patients with symptoms and/or signs of ischemia, referred to coronary angiography, have non obstructive coronary artery disease (INOCA). In this contest, physiology and imaging-guided revascularization represent the cornerstone of contemporary management of chronic coronary syndromes (CCS) patients allowing us to focus specifically on ischemia-inducing stenoses. Finally, we also discuss contemporary medical therapeutic approach for secondary prevention. The aim of this review is to provide an updated diagnostic and therapeutic approach for the management of patients with stable coronary artery disease

First report of totally robotically assisted hybrid coronary artery revascularization combining RE-MIDCAB and R-PCI: Case report.

A 62-year-old man presents to the Cardiology Department with a history of angina on exertion. Invasive coronary angiography revealed a severe three vessels coronary artery disease. The "Hybrid Heart Team" successfully performed a fully robotically assisted hybrid revascularization combining robotically enhanced-minimally invasive direct coronary artery bypass on the left anterior descending (LAD) and robotically assisted percutaneous coronary intervention on non-LAD lesions

Safety of Right and Left Ventricular Endomyocardial Biopsy in Heart Transplantation and Cardiomyopathy Patients.

Endomyocardial biopsy (EMB) facilitates a histopathologic diagnosis with unique prognostic and therapeutic implications in both native and donor hearts. It is a relatively safe procedure, with an overall complication rate ranging from <1% to 6% depending on the experience of the operator, the clinical status of the patient, the presence or absence of left bundle branch block, the access site, and the site of procurement (right ventricular [RV] vs left ventricular [LV] approach). This study aimed to assess the incidence of procedure-related complications in a real-world population. EMBs were performed either for surveillance of rejection episodes after heart transplantation or for diagnosis of etiology of cardiomyopathy. The authors retrospectively analyzed 1,368 biopsies obtained in 561 consecutive patients between May 2011 and May 2021. Patients were stratified according to the underlying heart disease, sex, age, access site, body mass index, and RV vs LV approach. The analysis revealed an overall complication rate of 4.1%. Serious life-threatening cardiac complications occurred in <1% of EMBs, with tamponade necessitating pericardiocentesis in 0.2% and urgent cardiac surgery in 0.1% of the procedures. Minor complications occurred in 3.3% of the overall population and were more often encountered during LV EMBs (3.9%) and when the native heart was sampled (5.3%). In experienced hands, LV and RV EMB for heart transplantation rejection surveillance and cardiomyopathy diagnosis is a safe procedure with low risk of complications. Older, female patients and those undergoing native heart EMB were more prone to complications following EMB

Prospective evaluation of the learning curve and diagnostic accuracy for Pre-TAVI cardiac computed tomography analysis by cardiologists in training: The LEARN-CT study.

To investigate the learning curve and the minimum number of cases required for a cardiologist in training to acquire the skills to an accurate pre-TAVI cardiac CT (CCT) analysis using a semi-automatic software. In this prospective, observational study, 40 CCTs of patients scheduled for TAVI were independently evaluated twice by 5 readers (80 readings each, 400 in total): a certified TAVI-CT specialist served as the reference reader (RR) and 4 cardiology fellows (2 interventional and 2 non-invasive cardiac imaging) as readers. The primary outcome was the minimum number of cases required to achieve an accuracy in imaging interpretation ≥80%, defined as the agreement between each reader and the RR in both balloon and self-expandable valve size choice. The secondary outcomes were the intra- and inter-observer variability. After 50 readings (25 cases repeated twice) cardiology fellows were able to select the appropriate valve size with ≥ 80% of accuracy compared to the RR, independently of valve calcification, image quality and slice thickness. Learning curves of both interventional and non-invasive cardiac imaging fellows showed a similar trend. Cardiology fellows achieved a very high intra- and inter-observer reliability for both perimeter and area assessment, with an intraclass correlation coefficient (ICC) ranging from 0.96 to 0.99. Despite the individual differences, cardiology fellows required 50 readings (25 cases repeated twice) to get adequately skilled in the pre-TAVI CCT interpretation. These results provide valuable information for developing adequate training sessions and education protocols for both companies and cardiologists involved

Reproducibility of bolus versus continuous thermodilution for assessment of coronary microvascular function in patients with ANOCA.

A bolus thermodilution-derived index of microcirculatory resistance (IMR) has emerged as the standard for assessing coronary microvascular dysfunction (CMD). Continuous thermodilution has recently been introduced as a tool to quantify absolute coronary flow and microvascular resistance directly. Microvascular resistance reserve (MRR) derived from continuous thermodilution has been proposed as a novel metric of microvascular function, which is independent of epicardial stenoses and myocardial mass. We aimed to assess the reproducibility of bolus and continuous thermodilution in assessing coronary microvascular function. Patients with angina and non-obstructive coronary artery disease (ANOCA) at angiography were prospectively enrolled. Bolus and continuous intracoronary thermodilution measurements were obtained in duplicate in the left anterior descending artery (LAD). Patients were randomly assigned in a 1:1 ratio to undergo either bolus thermodilution first or continuous thermodilution first. A total of 102 patients were enrolled. The mean fractional flow reserve (FFR) was 0.86±0.06. Coronary flow reserve (CFR) calculated with continuous thermodilution (CFR <sub>cont</sub> ) was significantly lower than bolus thermodilution-derived CFR (CFR <sub>bolus</sub> ; 2.63±0.65 vs 3.29±1.17; p<0.001). CFR <sub>cont</sub> showed a higher reproducibility than CFR <sub>bolus</sub> (variability: 12.7±10.4% continuous vs 31.26±24.85% bolus; p<0.001). MRR showed a higher reproducibility than IMR (variability 12.4±10.1% continuous vs 24.2±19.3% bolus; p<0.001). No correlation was found between MRR and IMR (r=0.1, 95% confidence interval: -0.09 to 0.29; p=0.305). In the assessment of coronary microvascular function, continuous thermodilution demonstrated significantly less variability on repeated measurements than bolus thermodilution

Coronary Microvascular Dysfunction in Patients With Heart Failure: Characterization of Patterns in HFrEF Versus HFpEF.

Coronary microvascular dysfunction (CMD) is involved in heart failure (HF) onset and progression, independently of HF phenotype and obstructive coronary artery disease. Invasive assessment of CMD might provide insights into phenotyping and prognosis of patients with HF. We aimed to assess absolute coronary flow, absolute microvascular resistance, myocardial perfusion, coronary flow reserve, and microvascular resistance reserve in patients with HF with preserved ejection fraction and HF with reduced ejection fraction (HFrEF). Single-center, prospective study of 56 consecutive patients with de novo HF with nonobstructive coronary artery disease divided into HF with preserved ejection fraction (n=21) and HFrEF (n=35). CMD was invasively assessed by continuous intracoronary thermodilution and defined as coronary flow reserve <2.5. Left ventricular and left anterior descending artery-related myocardial mass was quantified by echocardiography and coronary computed tomography angiography. Myocardial perfusion (mL/min per g) was calculated as the ratio between absolute coronary flow and left anterior descending artery-related mass. Patients with HFrEF showed a higher left ventricular and left anterior descending artery-related myocardial mass compared with HF with preserved ejection fraction (P<0.010). Overall, 52% of the study population had CMD, with a similar prevalence between the 2 groups. In HFrEF, CMD was characterized by lower absolute microvascular resistance and higher absolute coronary flow at rest (functional CMD; P=0.002). CMD was an independent predictor of a lower rate of left ventricular reverse remodeling at follow-up. In patients with HF with preserved ejection fraction, CMD was mainly due to higher absolute microvascular resistance and lower absolute coronary flow during hyperemia (structural CMD; P≤0.030). Continuous intracoronary thermodilution allows the definition and characterization of patterns with distinct CMD in patients with HF and could identify patients with HFrEF with a higher rate of left ventricular reverse remodeling at follow-up

Same Day Discharge Strategy by Default in a Tertiary Catheterization Laboratory in Belgium: Value Based Healthcare-Change in Practice.

To assess the effects on outcomes and hospital revenues (societal cost) of a by default strategy of same day discharge (SDD) in patients undergoing a cardiac catheterization procedure in a Belgian Hospital. Outcome and complete financial data were obtained in all consecutive patients with a cardiac catheterization performed in 2019 (n=5237) and in 2021 (n=5377). Patient-reported experience, patient satisfaction and Net promotor score were obtained prospectively for the SDD cohort in 2021. The proportion of patients receiving catheterization procedure in SDD increased from 28 to 44 % (p<0.001). This translates to the saving of 889 conventional hospitalizations in 2021. All-cause death and readmission rate remained unchanged (0,17% vs 0,15% (p=0,004); and 0,7% vs 1,8% (p>0,05)) in 2019 and 2021, respectively. Patients satisfaction top box score was 91% and the Net Promotor Score was 89,5. The by default SDD strategy was associated with reduction in in-hospital health care spending, on average 3206€ per procedure is saved. This means a 57% decrease in hospital revenues and translates into an important decrease in physician income. Implementing a by default SDD cardiac catheterization strategy results in a reduction of societal cost, excellent patient satisfaction and unchanged clinical outcome. Yet, in the given context this approach negatively impacts hospital and physician revenues precluding the sustainability of such protocol

Combined Cardiac Damage Staging by Echocardiography and Cardiac Catheterization in Patients with Clinically Significant Aortic Stenosis.

Cardiac damage (CD) staging enhances risk stratification in patients with clinically significant aortic stenosis (AS). We aimed to assess the prognostic value and reclassification rate of right heart catheterization (RHC) compared to echocardiography (TTE) in characterizing CD-staging at 3-year follow-up in patients with clinically significant AS; to identify patients that would benefit from RHC for prognostic stratification; to test the prognostic value of "combined" CD-staging. Observational cohort study of 432 AS patients undergoing TTE and RHC, divided into moderate/asymptomatic severe (m/asAS) and symptomatic severe AS (ssAS). Kaplan-Meier curves were used to compare survival. The accuracy in prognostic stratification was tested by AUC analysis and Delong's test. In both cohorts, TTE- and RHC-derived staging systems had prognostic value, although the agreement between them appeared moderate. A higher proportion of patients were assigned to Stage 2 by TTE, compared to RHC. Patients in TTE-derived Stage 2 had a high reclassification rate, with 40-50% presenting with right chambers involvement (stages 3-4) at RHC. "Discordant" cases were significantly older, with higher prevalence of atrial fibrillation, markedly elevated N-terminal pro-brain natriuretic peptide, higher left atrial volume indexed, E/e' and systolic pulmonary artery pressure versus "concordant" cases (p<0.05). The "combined" CD-staging, integrating TTE and RHC, was more accurate in predicting mortality than TTE-derived system (p<0.05). In patients with m/asAS and ssAS, the "combined" CD-staging, derived from TTE and RHC, was more accurate in predicting mortality than TTE. In a subset of AS patients, the integration of RHC may significantly improve prognostic stratification

Continuous vs Bolus Thermodilution to Assess Microvascular Resistance Reserve.

Coronary flow reserve (CFR) and microvascular resistance reserve (MRR) can, in principle, be derived by any method assessing coronary flow. The aim of this study was to compare CFR and MRR as derived by continuous (CFR <sub>cont</sub> and MRR <sub>cont</sub> ) and bolus thermodilution (CFR <sub>bolus</sub> and MRR <sub>bolus</sub> ). A total of 175 patients with chest pain and nonobstructive coronary artery disease were studied. Bolus and continuous thermodilution measurements were performed in the left anterior descending coronary artery. MRR was calculated as the ratio of CFR to fractional flow reserve and corrected for changes in systemic pressure. In 102 patients, bolus and continuous thermodilution measurements were performed in duplicate to assess test-retest reliability. Mean CFR <sub>bolus</sub> was higher than CFR <sub>cont</sub> (3.47 ± 1.42 and 2.67 ± 0.81 [P < 0.001], mean difference 0.80, upper limit of agreement 3.92, lower limit of agreement -2.32). Mean MRR <sub>bolus</sub> was also higher than MRR <sub>cont</sub> (4.40 ± 1.99 and 3.22 ± 1.02 [P < 0.001], mean difference 1.2, upper limit of agreement 5.08, lower limit of agreement -2.71). The correlation between CFR and MRR values obtained using both methods was significant but weak (CFR, r = 0.28 [95% CI: 0.14-0.41]; MRR, r = 0.26 [95% CI: 0.16-0.39]; P < 0.001 for both). The precision of both CFR and MRR was higher when assessed using continuous thermodilution compared with bolus thermodilution (repeatability coefficients of 0.89 and 2.79 for CFR <sub>cont</sub> and CFR <sub>bolus</sub> , respectively, and 1.01 and 3.05 for MRR <sub>cont</sub> and MRR <sub>bolus</sub> , respectively). Compared with bolus thermodilution, continuous thermodilution yields lower values of CFR and MRR accompanied by an almost 3-fold reduction of the variability in the measured results