Transcatheter mitral valve-in-valve replacement is an established therapy for intermediate and high-risk patients with degenerated bioprostheses, but restricted transcatheter valve (THV) expansion within rigid surgical frames and elevated gradients have raised durability concerns. This study aimed to evaluate midterm outcomes of mitral valve-in-valve patients according to THV expansion and sizing strategy. Patients who underwent mitral valve-in-valve with balloon-expandable valves at Mayo Clinic Rochester between 2014 and 2023 were retrospectively analyzed. THV expansion (inflow, waist, outflow) was measured from procedural fluoroscopy and indexed to nominal size, with zero indicating expansion to nominal dimensions. Median index values were used as subgroup cutoffs to compare the incidence of the primary composite outcome of all-cause mortality, heart failure readmission, and valve reintervention. The analysis included 80 patients with a median follow-up of 2.5 years. A total of 53 (66%) valves were underexpanded across all 3 diameters, with median inflow, waist, and outflow expansion indices of -10.2, -16.2, and -3.2, respectively. Across all indices, THV expansion closer to nominal size was associated with lower rates of the primary outcome (P<0.05). Greater expansion correlated with a larger mitral valve area and lower transvalvular mean gradient. Oversized THVs were significantly less expanded and had a higher incidence of the primary composite outcome compared with recommended-size THVs (P=0.02). THV underexpansion in degenerated mitral bioprostheses is common and associated with elevated gradients and worse midterm outcomes. Further research is warranted to define THV expansion targets to improve midterm outcomes following mitral valve-in-valve intervention.

Pulmonary atresia with ventricular septal defect is a rare and complex congenital heart disease. In cases where pulmonary blood flow is supplied exclusively by major aortopulmonary collateral arteries, traditional surgical interventions may be challenging or delayed, especially in resource-limited settings. This study evaluated the feasibility, safety, and outcomes of the right ventricular outflow tract perforation through the retrograde trans-collateral approach in patients with pulmonary atresia with ventricular septal defect and major aortopulmonary collateral arteries dependent pulmonary circulation. The study cohort comprised 10 patients with pulmonary atresia and ventricular septal defect who underwent attempted retrograde trans-collateral right ventricular outflow tract perforation via major aortopulmonary collateral arteries from October 2021 to February 2025, including 1 unsuccessful procedure. The median age at intervention was 4.1 years, and the median weight was 17 kg. Post-procedure, systemic oxygen saturation increased significantly (P<0.01). Follow-up imaging demonstrated substantial growth of the pulmonary arteries following retrograde trans-collateral right ventricular outflow tract recanalization, with significant improvements in both right and left pulmonary artery Z scores (P<0.01) and a significant increase in the Nakata index from a median of 49 to 111.7 mm2/m2 (P<0.01). Retrograde trans-collateral right ventricular outflow tract perforation is a feasible and safe catheter-based strategy for selected patients with pulmonary atresia with ventricular septal defect, promoting central pulmonary artery growth and serving as a bridge to future surgical repair.

Isolated coronary artery ectasia (CAE) is a less common form of CAE. The clinical significance of isolated CAE has not been elucidated yet. We aimed to compare the patients with myocardial infarction (MI) due to isolated CAE with the patients without CAE. We retrospectively included patients who underwent coronary angiography with a diagnosis of first MI caused by isolated CAE. We excluded patients with >20% stenosis in any vessel other than the lesion responsible for the MI. A second group of patients with MI without CAE was selected as the control group. The primary outcome was the composite of all-cause death and nonfatal recurrent MI occurring after index hospitalization. A total of 404 patients were included. Overall, 63.9% of MIs were ST-elevation MI. Almost all patients in the isolated CAE group had multivessel diffuse ectasia, with 71.3% classified as Markis I, and 26.7% as Markis II. Death or MI recurrence occurred in 54 (26.7%) patients in the isolated CAE group and 33 (16.3%) patients in the control group (P=0.011). Death occurred in 8 (4.0%) patients in the isolated CAE group versus 6 (3.0%) patients in the control group; recurrent MI in 46 (22.8%) versus 27 (13.4%) patients, respectively. Stent thrombosis was more common in the CAE group compared with the control group (8.9% versus 1.5%; P<0.001). In multiple variable analysis, the presence of CAE was associated with death/recurrent MI (hazard ratio, 1.84 [95% CI, 1.11-3.05]; P=0.017), and recurrent MI (hazard ratio, 2.07 [95% CI, 1.08-3.96]; P=0.029). The patients with MI due to isolated CAE had a higher risk of recurrent MI and stent thrombosis compared with the patients without CAE. In this study, the rate of recurrent MI from the index infarct artery was also higher in the patients with CAE.

BACKGROUND:The pullback pressure gradient (PPG) is a novel physiological metric that quantifies coronary artery disease patterns as focal or diffuse on a scale from 0 to 1. This study assessed the relationship between PPG and residual angina at 1 year.METHODS:PPG Global is a prospective, investigator-initiated, single-arm, multicenter study that enrolled patients with at least 1 lesion with a fractional flow reserve ≤0.80 intended to be treated with percutaneous coronary intervention. After the PPG calculation, physicians could revise treatment assignment to medical therapy or coronary artery bypass graft surgery instead of percutaneous coronary intervention. Focal and diffuse disease were defined based on the median PPG value of 0.62. Patient-reported outcomes were assessed using the Seattle Angina Questionnaire at baseline and 1-year follow-up.RESULTS:The study included 947 patients with PPG and the Seattle Angina Questionnaire at 1 year. The mean age was 67.6±10.2 years, 24% were female, and 29% had diabetes. At 1 year, patients with focal coronary artery disease reported less angina than those with diffuse disease (Seattle Angina Questionnaire angina frequency score, 95.3±9.9 versus 92.5±15.0; P=0.006). PPG was independently associated with improvement in angina (P=0.017).CONCLUSIONS:In patients with flow-limiting coronary artery disease, a focal disease pattern defined by high PPG was associated with greater symptomatic relief at 1 year compared with diffuse disease (low PPG). By capturing the underlying pathophysiologic distribution of epicardial disease and its relation to post-treatment symptom relief, PPG may support a more tailored revascularization decision-making and percutaneous coronary intervention strategy.

The DynamX bioadaptor, a novel coronary implant, is designed to restore vessel function when the thin polymer coating covering the helical strands resorbs 6 months post-percutaneous coronary intervention. We aimed to evaluate vessel conformability 1 year after percutaneous coronary intervention with the bioadaptor, compared with conventional drug-eluting stents (DESs). Vessel segments were 1:1 randomized to a novolimus-eluting bioadaptor or a durable polymer novolimus-eluting second-generation DES. Coronary computed tomography angiography was performed at 1 and 12 months post-implantation, and the 3-dimensional geometry of the treated segments in coronary computed tomography angiography was analyzed. The primary outcome was the change in dynamic vessel geometry, including curvature flexibility (bending motion), torsion flexibility (twisting motion), and path flexibility (3-dimensional motion) of the treated segment during the cardiac cycle. A total of 48 vessel segments in 48 patients were randomized, with 24 receiving bioadaptor and 24 receiving DES. In within-group paired analyses, the bioadaptor group showed a significant improvement in torsion flexibility from 1 to 12 months, whereas no significant change was observed in the DES group. Although curvature and path flexibility increased numerically in the bioadaptor group, these within-group differences were not statistically significant. However, when comparing the magnitude of change between groups, the increase in path flexibility was significantly greater with the bioadaptor than with DES, indicating a superior restoration of 3-dimensional vessel motion. The novel bioadaptor technology demonstrated favorable restoration of 3-dimensional dynamic geometry of the treated vessel segment 12 months after implantation, in comparison with traditional DES. These initial mechanistic findings suggest a potential explanation for the favorable clinical outcomes observed in prior trials, and our analytical approach may offer new insights to guide future vascular implant designs and evaluations. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04936191.

The treatment of calcified coronary lesions requires optimal lesion preparation to achieve a larger minimal stent area (MSA), the strongest predictor of long-term outcomes. The comparative mechanisms of action of calcium-modifying therapies have not been well defined. In a prospective, multicenter ECLIPSE trial (Evaluation of Treatment Strategies for Severe Calcific Coronary Arteries: Orbital Atherectomy Versus Conventional Angioplasty Technique Before Implantation of Drug-Eluting Stents), 2005 patients with severely calcified lesions were randomized to vessel preparation with orbital atherectomy (OA) versus balloon angioplasty (BA) before drug-eluting stent implantation. The primary end point of the optical coherence tomography (OCT) substudy was the MSA at the site of maximal calcification; MSA across the entire stent was also assessed. Postprocedural OCT images were available in 286 lesions in 276 patients treated with OA and 292 lesions in 279 patients treated with BA. By angiographic core laboratory analysis, 567 (98.1%) of lesions were severely calcified. By postprocedural OCT, the maximal calcium arc, maximal calcium thickness, and total calcium length measured 204° (149°-268°), 0.85 mm (°0.69-1.03°), and 22.0 (16.0-31.0) mm. Compared with BA, calcium modification was greater in the OA group (greater number, total length, and maximal depth of calcium fractures), especially in lesions with thicker calcium. Nonetheless, the MSA at the site of maximal calcification was large in both groups and not different (median [interquartile range], 7.44 [6.03-8.94] mm2 versus 7.05 [5.78-8.66] mm2; P=0.08). Similar results were observed for the MSA across the entire stent (5.86 [4.60-7.38] mm2 versus 5.57 [4.50-6.97] mm2; P=0.10). Among patients in the OCT substudy, 1-year target-vessel failure rates were low and not different between the groups (7.8% with OA and 6.6% with BA, P=0.61). In lesions that are severely calcified by angiography, the extent of calcification by OCT was highly variable. Despite greater calcium modification after OA, the acute MSA and 1-year target-vessel failure rates were not different between OA and BA. URL: https://www.clinicaltrials.gov; Unique identifier: NCT03108456.