Although coronary angiography is the standard method employed to assess the severity of coronary artery disease and to guide treatment strategies, it provides only two-dimensional image of the intravascular lesions. In contrast with the luminogram obtained by angiography, intravascular imaging produces cross-sectional images of the coronary arteries of far greater spatial resolution, capable of accurately determining vessel size as well as plaque morphology, and eliminates some of the disadvantages inherent to angiography, such as contrast streaming, foreshortening, vessel overlap, and angle dependency. Growing body of literature recommends intravascular imaging, especially intravascular ultrasound and optical coherence tomography, which can be competently used to answer questions that arise during daily practice in interventional cardiology such as: Is this stenosis clinically relevant? Which is the culprit lesion? Is this plaque at high risk for rupture? How can I optimize stent results? Why did thrombosis or restenosis occur in this stent? Patients with more complex coronary disease likely benefit more from a revascularization approach that includes intravascular imaging. The aim of this review was to discuss the basic principles of intravascular imaging, characterization of atherosclerosis, optimization of angioplasty results and to identify technical challenges because of artefacts.

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In contemporary practice, the legacy of coronary angiography as the “one technique” to answer all questions in interventional cardiology has been proven inaccurate. Intravascular imaging techniques have advanced from the framework of research to clinical decision-making in daily practice. Regardless of its routine use, angiography has several limitations that restrict the ability to accurately predict lesion architecture and hemodynamic significance. Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) images with far superior spatial resolution compared with angiography result in more precise characterization of lesion length, eccentricity, calcification, thrombus, necrotic cores, dissections, and stent apposition. Due to the technical complexity and potential prognostic implications, revascularization of specific subsets such as acute coronary syndrome, left main coronary artery, bifurcation, and chronic total occlusions poses additional challenges; therefore, it requires careful lesion preparation and cautiously optimized stenting for successful outcomes. Intravascular imaging has now become a mandatory procedural step in the therapeutic, interventional approach to treat these subsets and has been shown to improve stenting technique, procedure results, and consequently, patient outcomes. Stent malapposition, underexpansion, geographical miss, and significant stent edge dissection are all possible stent-related complications easily detectable by intravascular imaging. In this article, we present the salient features of evaluation and treatment of high-risk coronary interventions by IVUS and OCT.

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A bifurcation lesion is traditionally defined as a coronary artery narrowing occurring adjacent to and/or involving the origin of a significant side branch. Long before the nomenclature of lesion complexity matured, side-branch involvement was recognized as an unfavorable determinant of angioplasty success. Miere and associates were among the first to define the risk of side-branch occlusion associated with parent vessel angioplasty, emphasizing the importance of plaque extension into the side branch as the predictor of percutaneous coronary intervention (PCI) outcome. PCI of coronary bifurcation lesion poses a challenge to the operator in terms of difficulty in wiring, passage of hardware, recrossing, and immediate/long-term outcomes. Several important factors such as anatomic variation, angulation between branches, downstream territory, and the extent of plaque burden should be taken into consideration when addressing a bifurcation lesion to choose the most appropriate approach and achieve an optimal result. Factors to be considered before strategizing a bifurcation angioplasty include the extent of disease (whether it is limited to ostium or extending beyond), size (>2.5mm reference diameter), and area of distribution of side branch. Implantation of a single stent in the main branch is the most widely used approach and should be considered the default strategy. Two-stent strategy as “intention to treat” should be considered for large side branches or when the disease extends beyond the ostium or a branch supplying a significant territory.

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Objective: This prospective, open-label, randomized study compared the efficacy and safety of prasugrel and ticagrelor in the Indian patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Materials and methods: Patients were randomized to prasugrel (n = 50; 60mg loading dose, thereafter 10mg once daily [OD]) or ticagrelor (n = 50; 180mg loading dose, thereafter 90mg twice daily [BD]) for 12 months. Patients received aspirin 325mg loading and 150mg maintenance doses OD with prasugrel and 150mg bolus and 75mg OD with ticagrelor. Efficacy end points were reinfarction/repeat angina/repeat ischemia, death from cardiovascular causes, ischemic stroke, and stent thrombosis. Safety end points included bleeding, arrhythmias, and dyspnea. Results: At 12 months, the occurrence of composite efficacy end points was not significantly different between the groups (6.4% for both; P = 0.999). The incidence of stent thrombosis, reinfarction/recurrent angina/repeat ischemia was comparable between the groups. No significant difference was observed for major bleeding (0% for both groups) and minor bleeding (10.6% vs. 4.3%; P = 0.436) episodes between the groups. Similarly, bradycardia (6.5% vs. 0%; P = 0.242) and dyspnea (10.6% vs. 2.1%; P = 0.204) were not significantly different between the groups. No deaths were reported. Conclusion: Head-to-head comparison of prasugrel and ticagrelor in the Indian patients with ACS undergoing PCI showed that both are equally efficacious. Clinical safety and tolerance of the patients were comparable between prasugrel and ticagrelor groups at the end of 1 year.

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Structural deterioration is a major and inevitable complication of bioprosthetic heart valves. So far, a repeat surgery has been the only practical treatment option available for patients with hemodynamically significant bioprosthetic valve dysfunction. However, the exceedingly successful emergence of transcatheter aortic valve replacement therapy for native aortic valve disease has paved way for its extension to failed bioprosthetic valves also. Initially adopted for aortic bioprosthesis, this technique has now been successfully used for failed mitral bioprosthetic valves as well. This review summarizes the technical aspects and current evidence related to transcatheter mitral valve-in-valve procedures for failed mitral bioprosthetic valves.

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Percutaneous coronary intervention forms the mainstay of treatment of coronary artery disease. Anomalous coronary artery origin is uncommon, and multivessel coronary intervention in such setting is a rarer entity. We report a case of multivessel coronary intervention in a patient with a single coronary artery from right coronary sinus bifurcating into left coronary artery and right coronary artery.

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Anomalous origin of the right coronary artery from the ascending aorta above the left sinus of Valsalva is a very rare coronary anomaly, which can pose extreme difficulties for the operator, especially in the setting of an acute myocardial infarction. Herein, we describe a patient with this very rare anomaly in whom computed tomography coronary angiographic guidance was used to identify its presence and perform successful angioplasty in the setting of an inferior wall myocardial infarction complicated by 2:1 atrioventricular block.

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Human coronary collaterals are intercoronary communications that are believed to be present from birth. In the presence of chronic total coronary occlusions (CTO), a total occlusion of perceived or known duration of 3 months or longer is labeled as chronic occlusion. Recruitment of flow via these collateral anastomoses to the arterial segment distal to occlusion provides an alternative source of blood flow to the myocardial segment at risk. Although coronary angiography is the standard method to visualize collateral arteries, it has a limited resolution. The visible collaterals have a diameter from 0.3 up to 0.5mm, therefore arterioles <100 µm are unseen by the human eye. In addition, nitrates and adenosine allow a better visualization of collateral branches, exploiting their vasomotor properties. A reported quantitative angiographic analysis of collateral diameters on high-resolution cine films underscored the relevance of the collateral diameter for the collateral function. Aside from the complexity of this approach, its applicability to modern digital storage standards with lower resolutions is limited. ELShafey speculation is based on using a modified pattern of the inverted gray scale of cine angiograms for a better visualization of different ambiguity coronary artery lesions.

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Dislodgement of coronary stents while performing coronary interventions is not an uncommon phenomenon. Although more frequently encountered with stents that were manually crimped, dislodgement can also occur with the newer generation, balloon-mounted stents despite their superior trackability and deliverability. We describe a case with severe right coronary artery (RCA) and obtuse marginal (OM) disease in which an initial coronary angioplasty to the RCA followed by OM was planned. The RCA was stented and while negotiating a second balloon-mounted stent across the RCA, it slipped off the balloon and initially embolized into the aortic sinuses. Subsequently and fortuitously, the stent migrated into the OM vessel and was seated right at the lesion, which needed to be stented. Using the clear cell stent boost function, the embolized stent was wired and then deployed using sequential balloon dilations.

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Rheumatic mitral stenosis is the most common lesion among valvular heart disease in Asian countries. Coexistence of coronary artery disease and rheumatic heart disease is not uncommon. Case summary of a middle-aged woman with kyphoscoliosis, significant left circumflex artery stenosis, and severe mitral stenosis who was managed successfully with percutaneous transvenous mitral commissurotomy followed by percutaneous coronary intervention in the same sitting is presented. The major challenge was interatrial septal puncture in distorted anatomy, which was overcome by meticulous defining of septal plane by angiography and proper technique of puncture. The controversy about the timing of administration of loading dose of antiplatelet and heparin is discussed.

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Coronary artery ectasia is a unique form of the coronary artery disease, which when encountered poses therapeutic dilemma and difficulties in the management. The diffuse dilatation of coronary arteries involving more than two adjacent coronary segments commonly presents as acute coronary syndrome secondary to thrombotic and ischemic manifestations. Usually, primary angioplasty in the setting of coronary artery ectasia is a challenging task for interventional cardiologists as the entry of guide wire across the lesion secondary to slow flow, dilated segments, and large thrombus burden. Further, high chances of the no-reflow phenomenon and distal embolization of thrombus are additional challenges while performing primary angioplasty in the setting of coronary artery ectasia. We combined pharmacological method such as the injection of intracoronary tenecteplase and invasive approach using thrombo-aspiration catheter for visualization of mid- and distal segments of the vessel, the passage of guide wire, and dethrombosis. The novel therapeutic uses of thrombo-aspiration catheter included working as a multidomain technique for intracoronary delivery of drugs like perfusion balloon, injection of contrast like guide catheter, the passage of guide wire through stenosis like micro-catheter, and finally, as thrombo-aspiration as in the present case.

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We report a case of retrieval of partially degloved and distorted coronary stent using a novel improvised technique of higher sized sheath. The stent could not be removed into the regular guiding catheter of 6F. We removed the partially degloved coronary stent by withdrawing it into the descending aorta and then exchanging femoral sheath with higher sized (11F) femoral sheath followed by removing the stent into 11F sheath.

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Transcatheter aortic valve implantation (TAVI) is a rapidly evolving therapeutic option for patients with severe aortic stenosis (AS) who are at a high risk for surgery or inoperable. The data on the use of TAVI in rheumatic AS are not widely available and have not been reported from India. We present a case report of TAVI in rheumatic AS and prior mitral valve replacement with multiple comorbidities.

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