James C. Blankenship

Objectives: Severe aortic stenosis (AS) with cardiogenic shock (CS) presents a complex clinical challenge. For these patients, the optimal management strategy—either direct transcatheter aortic valve replacement (TAVR) or a staged approach with balloon aortic valvuloplasty (BAV) as a bridge to TAVR (BAV-TAVR)—is uncertain. We aimed to compare the outcomes of these two strategies. Methods: We conducted a retrospective cohort study using the TriNetX database. In this study, we identified patients with CS who underwent direct TAVR or who survived to and underwent TAVR within 30 days of balloon aortic valvuloplasty (BAV-TAVR). After matching propensity scores, 198 patients were analyzed in each group (total of 396). The primary outcome was major adverse cardiovascular events (MACE) at 30 days, 1 year, and 3 years. Results: The analysis included 396 matched patients (198 in each cohort). There was no significant difference in the primary endpoint of MACE at 30 days between the staged BAV and direct TAVR groups HR 1.14 (95% CI 0.79–1.64; p = 0.48), and this finding was consistent at 1 and 3 years with HR 1.20 (95% CI 0.89–1.61; p = 0.23) and HR 1.17 (95% CI 0.89–1.53; p = 0.25) respectively. Similarly, no differences were observed in secondary outcomes including all-cause mortality, stroke, and new permanent pacemaker implantation, at 30 days, 1, and 3 years. Conclusions: Among patients with severe AS and cardiogenic shock who survived definitive therapy, staged BAV-TAVR showed no detectable difference in short- or long-term outcomes versus direct TAVR. Given the limited sample size and the exclusion of patients who did not survive to TAVR, these results are hypothesis-generating and should not be read as evidence of equivalence or of bridging safety; prospective study is warranted.

Aim: Severe aortic stenosis (AS) with cardiogenic shock (CS) presents a complex clinical challenge. For these patients, the optimal management strategy- either direct transcatheter aortic valve replacement (TAVR) or a staged approach with balloon aortic valvuloplasty (BAV) as a bridge to TAVR (BAV-TAVR) is uncertain. We aimed to compare the outcomes of these two strategies. Methods: We conducted a retrospective cohort study using TriNetX database. In this study, we identified patients with CS undergoing TAVR or BAV-TAVR. After matching propensity scores, 198 patients were analyzed in each group (total 396). The primary outcome was major adverse cardiovascular events (MACE) at 30 days, 1 year, and 3 years. Results: The analysis included 396 matched patients (198 in each cohort). There was no significant difference in the primary endpoint of MACE at 30 days between the staged BAV and direct TAVR groups (HR 1.14; 95% CI 0.79–1.64; p=0.91), and this finding was consistent at 1 and 3 years with HR 1.20 and 1.17 respectively. Similarly, no differences were observed in secondary outcomes including all-cause mortality, stroke, and new permanent pacemaker implantation, at 30 days, 1, and 3 years. Conclusion: For patients with severe AS complicated by CS, a staged strategy of using BAV-TAVR resulted in comparable short and long-term outcomes to direct TAVR. These findings suggest that BAV is a viable and safe bridging option in high-risk patients whose immediate candidacy for definitive therapy is uncertain.

Percutaneous coronary intervention (PCI) has evolved significantly over the past two decades, yet challenges in achieving optimal stent deployment and long-term outcomes persist, particularly in complex coronary anatomy. Intravascular imaging (IVI) modalities such as intravascular ultrasound (IVUS), optical coherence tomography (OCT), and near-infrared spectroscopy (NIRS) have transformed the precision of PCI by providing detailed cross-sectional visualization of vessel architecture, plaque morphology, and stent apposition. Compared to angiography-guided PCI, imaging-guided PCI enables more accurate lesion assessment, appropriate stent sizing, and detection of suboptimal results including under-expansion, malapposition, and edge dissections, factors strongly linked to restenosis and stent thrombosis. Large-scale randomized trials (e.g., ULTIMATE, ILUMIEN) and meta-analyses have demonstrated that imaging-guided PCI reduces major adverse cardiovascular events (MACE) and improves long-term stent patency, particularly in left main, bifurcation, and calcified lesions. Despite these benefits, adoption remains variable due to cost, procedural complexity, and training gaps. Emerging advances, including artificial intelligence-enhanced imaging, hybrid devices, and fusion of imaging with physiologic assessments, promise to integrate imaging more seamlessly into routine practice. This review summarizes current evidence, practical applications, and future directions of IVI-guided PCI, underscoring its growing role in contemporary interventional cardiology and its potential to personalize and optimize coronary revascularization strategies.

Transradial access (TRA) is the dominant approach for cardiac catheterization and percutaneous intervention (PCI). Radial artery occlusion (RAO) remains the most common complication of TRA. Though upper extremity perfusion is usually maintained due to collateral circulation, RAO poses a challenge to future catheterization access and has previously been considered a relative contraindication to TRA. More recently, cases of successful recanalization of RAO via a distal approach have been reported with favorable success rates and minimal complications. This review summarizes current literature on re‐accessing an occluded radial artery (RA) via a distal RA approach for cardiac catheterization, with a focus on considerations for operators who may attempt this technique.

Background: Mortality after percutaneous coronary intervention (PCI) remains a problem. Clinical databases such as the American College of Cardiology National Cardiovascular Data CathPCI Registry do not contain enough information to determine the specific cause of death after PCI, and thus are not able to identify opportunities for improvement (OFIs) that might have prevented the death of specific patients. We reviewed cases of death after coronary intervention to identify specific OFIs. Methods: The University of New Mexico electronic medical record system was used to identify PCI patients who died before discharge from 1 January 2019 to 30 June 2021. Electronic medical records for each patient were reviewed by two physicians to identify presentation before PCI, procedural success of PCI, complications of PCI, contribution of PCI complications to death, and causes of death after PCI. Results: During the study period, 48 of 894 PCI patients died before discharge. Presentation was ST elevation myocardial infarction in 23 (48%) and out of hospital cardiac arrest in 17 (35%). PCI success rate was 90%. Causes of death were most frequently cardiac (80%), septic shock (4%), mixed cardiogenic and septic shock (4%), COVID (8%), and anoxic brain injury (4%). Conclusion: All post-PCI deaths in this series occurred in acutely unstable patients, with cardiac comorbidities and myocardial infarction or cardiac arrest prior to catheterization. PCI reduced culprit stenosis to ≤50% in 96% of cases with an overall procedural success rate of 90% and only one major complication. No deaths were clearly related to operator error.