Leonidas E. Poulimenos

Coronary artery calcification is common in patients undergoing percutaneous coronary intervention (PCI); it impairs device delivery and stent expansion and predicts stent failure. Balloon-based techniques (non-compliant, super high-pressure, cutting and scoring balloons, intravascular lithotripsy), rotational and orbital atherectomy, and excimer laser coronary atherectomy are now widely available. This narrative review describes the mechanism of each technique, the calcium morphology it suits on intravascular imaging, and its advantages and limitations, and synthesizes the randomized trials published between 2018 and 2026, including their longer-term follow-up. Dedicated calcium modification improves procedural success compared with balloon-only strategies in selected calcified lesions, but no trial has shown fewer deaths or myocardial infarctions; the only trial powered for a clinical endpoint comparing preparation strategies found no benefit from routine orbital atherectomy. Head-to-head comparisons were powered for imaging surrogates and mostly found the techniques non-inferior to one another. Intravascular imaging guidance is associated with larger stent areas and fewer adverse events. We also review technique-specific complications and their percutaneous management, and the evidence on performing these procedures in centers without on-site cardiac surgery. Finally, we propose a lesion-based, imaging-guided approach to technique selection and outline the trials still needed.

Background/Objectives: Coronary artery calcification is a leading cause of stent failure and a strong predictor of adverse outcomes after percutaneous coronary intervention (PCI). Accurate characterization of calcium burden, depth, and morphology is central to procedural planning, targeted treatment, and better outcomes. This review summarizes the contemporary armamentarium for imaging calcified coronary lesions, from coronary angiography and computed tomography to advanced intracoronary imaging, and how it facilitates treatment. Methods: We synthesized evidence from landmark studies, validated imaging scoring systems, registries, and current guideline and consensus documents addressing the assessment and imaging-guided treatment of coronary calcification. Results: Invasive angiography shows poor diagnostic accuracy for coronary calcium detection, characterization, and quantification. Coronary CT angiography noninvasively quantifies calcium (Agatston score and three-dimensional volume) and supports preprocedural planning, although it may overestimate calcium volume. Intravascular imaging by means of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) effectively detects coronary calcium. Their use is associated with improved clinical outcomes compared with sole angiographic guidance. The addition of near-infrared spectroscopy (NIRS-IVUS) characterizes lipids within calcified plaque and high-risk calcified nodules. OCT provides the highest spatial resolution and uniquely measures calcium thickness and longitudinal calcium length, while the utilization of artificial intelligence further enhances calcium assessment. Integration of these modalities into a morphology-based, imaging-guided approach facilitates calcium detection and modification and supports PCI optimization. Conclusions: Intravascular imaging, along with coronary CT angiography, has transformed the assessment of calcified coronary lesions. Combining their strengths enables precise, lesion-specific preparation; randomized trials show that intravascular imaging guidance improves outcomes in complex PCI, while CT-guided PCI planning is emerging as a complementary strategy whose clinical value is now being tested in randomized trials.

Background and Objectives: Coronary artery calcification impairs delivery and appli-cation of angioplasty equipment and is associated with worse outcomes following per-cutaneous coronary intervention (PCI). Although complex PCIs with the use of calci-um-modification techniques were historically concentrated in centers with on-site cardiac surgery, advances in PCI practice and percutaneous bailout strategies have expanded their use beyond surgical centers. Contemporary data regarding the safety and feasibility of the contemporary calcium-modification armamentarium at centers without on-site cardiac surgery remain limited. We aimed to evaluate the feasibility and safety of cal-cium-modification strategies at a single tertiary center without on-site cardiac surgery. Materials and Methods: In this single-center, retrospective, observational registry, 112 patients (83.0% male; mean age 71.9 ± 10.7 years) with 121 calcified lesions treated be-tween January 2019 and December 2024 were included; follow-up was available for 82 patients (median 34.2 months). The primary outcome was a composite of major adverse cardiac events (MACE: all-cause death, myocardial infarction, stroke, or clinically driven repeat revascularization). Exploratory analyses were performed to assess associations between clinical or procedural characteristics and adverse events. Results: Access was predominantly radial (90.7%). Calcium-modification strategies in-cluded intravascular lithotripsy (25.9%), rotational atherectomy (25.0%), non-compliant balloons (25.0%), cutting/scoring balloons (15.2%), and orbital atherectomy (8.9%). No patient required emergency coronary artery bypass grafting (CABG) or interhospital transfer for surgical management, and all procedural complications were managed percutaneously. MACE occurred in 18.3%, including all-cause mortality in 1.2%, major periprocedural myocardial injury in 2.4%, late myocardial infarction in 3.7%, no strokes, and clinically driven repeat revascularization in 13.4%. Observed event rates were within the range reported by contemporary calcium-modification trials conducted at centres with on-site cardiac surgery. Exploratory analyses were hypothesis-generating only; the as-sociations observed, for example with non-compliant balloon use and known coronary artery disease, are most consistent with confounding by indication rather than causal effects. Conclusions: In this retrospective single-center registry, contemporary calci-um-modification strategies, including atherectomy, intravascular lithotripsy, and spe-cialty balloon techniques, were feasible and safe at a center without on-site cardiac sur-gery. No patient required emergency CABG or surgical transfer, and observed rates of death, myocardial infarction, stroke, and procedural complications were low. These findings suggest that, in experienced hands and with percutaneous bailout capability, on-site cardiac surgery may not be a prerequisite for complex calcium-modification PCI in selected patients. Confirmation in larger, multicenter cohorts is required.

Background/Objectives: Coronary artery calcification is a leading cause of stent failure and a strong predictor of adverse outcomes after percutaneous coronary intervention (PCI). Accurate characterization of calcium burden, depth, and morphology is central to procedural planning, targeted treatment, and better outcomes. This review summarizes the contemporary armamentarium for imaging calcified coronary lesions, from coronary angiography and computed tomography to advanced intracoronary imaging, and how it facilitates treatment. Methods: We synthesized evidence from landmark studies, validated imaging scoring systems, registries, and current guideline and consensus documents addressing the assessment and imaging guided treatment of coronary calcification. Results: Invasive angiography shows poor diagnostic accuracy for coronary calcium detection, characterization, and quantification. Coronary CT angiography noninvasively quantifies calcium (Agatston score and three-dimensional volume) and supports preprocedural planning, although it overestimates calcium volume. Intravascular imaging by means of intravascular ultrasound (IVUS) and optical coherence tomography (OCT) effectively detects coronary calcium and provides the best evidence to avoid stent failure. IVUS accurately measures deep calcium, calcium arc, and length; adding near infrared spectroscopy (NIRS IVUS) characterizes lipid within calcified plaque and high risk calcified nodules. OCT provides the highest spatial resolution and uniquely measures calcium thickness and longitudinal calcium length, while the utilization of artificial intelligence further enhances calcium assessment. Integration of these modalities into a morphology based, imaging guided approach facilitates calcium detection and modification, leading to PCI optimization and improved outcomes. Conclusions: Coronary CT angiography and intravascular imaging have transformed the assessment of calcified coronary lesions. Combining their complementary strengths enables precise, lesion specific preparation and is crucial to improve outcomes in contemporary calcified lesion PCI.

Background/Objectives: Angiographic stenosis severity and functional significance are discordant in up to 65% of intermediate coronary lesions. Fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) has shown better clinical outcomes than standard angiography-guided PCI, therefore functional significance defines revas-cularization. This review evaluates the contemporary evidence for intracoronary physi-ology assessment tools, such as FFR, non-hyperemic pressure ratios (NHPRs), angi-ography-derived wire-free indices, and microvascular function testing and proposes a framework for their implementation into clinical practice. Methods: We conducted a narrative review, synthesizing data from landmark ran-domized controlled trials (DEFER, FAME I–III, DANAMI-3-PRIMULTI, COM-PARE-ACUTE, DEFINE-FLAIR, iFR-SWEDEHEART, iMODERN, FAVOR III China and Europe, FAST III, ALL-RISE, CorMicA), along with pooled analyses, meta-analyses, po-sition papers, and relevant guidelines. Results: FFR-guided revascularization resulted in a 28% reduction in cardiac death or myocardial infarction in pooled analyses (HR 0.72, 95% CI 0.54–0.96) leading to a Class I, Level A indication. NHPRs, including iFR, achieved non-inferiority to FFR at 1 year; however, a 5-year pooled meta-analysis raised concerns of increased all-cause mortality with iFR guidance compared to FFR (HR 1.34, 95% CI 1.08–1.67). Approximately 20% of lesions show FFR–iFR discordance, driven by vessel-specific physiology and microvas-cular factors. Wire-free technologies yielded conflicting results: the FAVOR III China trial favored QFR over angiography, yet FAVOR III Europe failed non-inferiority versus FFR, while recent FAST III and ALL-RISE trials demonstrated non-inferiority of angi-ography-derived physiology at 1 year. Up to 40% of patients with angina have non-obstructed coronary arteries, and coronary vasomotor function testing can identify treatable microvascular endotypes improving symptoms and quality of life. Conclusions: Functional invasive coronary angiography is advocated to decipher vessel hemodynamics and guide treatment. FFR remains the gold standard for invasive physiological assessment while NHPRs and wire-free technologies are valuable adjuncts with specific indications and limitations. Thorough microvascular evaluation is essential for differentiating between various INOCA endotypes and is gradually being adopted by the interventional community. While NHPRs and virtual technologies struggle to de-throne the king FFR, comprehensive intracoronary physiology assessment is essential to guide treatment.

Background: Radiation exposure in the cardiac catheterization laboratory remains a critical occupational hazard for interventional cardiologists and staff, contributing to orthopedic injuries, cataracts, and malignancy. In parallel, procedural complexity continues to increase, demanding both precision and safety. Robotic-assisted percutaneous coronary intervention (R-PCI), alongside advanced shielding systems and imaging integration, has emerged as a transformative strategy to minimize radiation and enhance operator ergonomics. Objective: This state-of-the-art review synthesizes the current clinical evidence and technological advances that support a radiation-reduction paradigm in percutaneous coronary intervention (PCI), with a particular focus on the role of R-PCI platforms, procedural modifications, and emerging shielding technologies. Methods: We reviewed published clinical trials, registries, and experimental studies evaluating robotic PCI platforms, contrast and radiation dose metrics, ergonomic implications, procedural efficiency, and radiation shielding systems. Emphasis was given to the integration of CT-based imaging (coronary computed tomography angiography—CCTA, fractional flow reserve computed tomography—FFR-CT) and low-dose acquisition protocols. Results: R-PCI demonstrated technical success rates of 81–100% and clinical success rates up to 100% in both standard and complex lesions, with significant reductions in operator radiation exposure (up to 95%) and procedural ergonomic burden. Advanced shielding technologies offer radiation dose reductions ranging from 86% to nearly 100%, while integration of (CCTA), (FFR-CT), and Artificial Intelligence (AI) -assisted procedural mapping facilitates further fluoroscopy minimization. Robotic workflows, however, remain limited by lack of device compatibility, absence of haptic feedback, and incomplete integration of physiology and imaging tools. Conclusions: R-PCI, in combination with shielding technologies and imaging integration, marks a shift towards safer, radiation-minimizing interventional strategies. This transition reflects not only a technical evolution but a philosophical redefinition of safety, precision, and sustainability in modern interventional cardiology.

Background/Objectives: Persistent high Premature Ventricular Contraction (PVC) burden (>10%) may result in PVC-induced cardiomyopathy. Current guidelines, supported by limited evidence, recommend flecainide for PVCs originating from the ventricular outflow tract (Class IIa). UNIFLECA is a prospective cohort study, aiming to assess the efficacy and safety of flecainide in PVC burden reduction in adults, irrespective of PVC origin, focusing secondarily on symptom relief and improvement of left ventricular ejection fraction (LVEF) in patients suffering from PVC-induced cardiomyopathy. Methods: Participants were adults with frequent PVCs, defined as PVC burden > 5%, confirmed by two 24 h Holter recordings taken at least one month apart, who denied catheter ablation treatment. Patients who were deemed ineligible for catheter ablation were also included. A total of 50 patients were screened and 35 were administered Flecainide, with dosage adjustment based on follow-up Holter results and QRS increases. Changes in PVC burden, LVEF, symptomatic status, along with treatment adherence, were evaluated. Results: In adults with frequent PVCs, flecainide led to a significant reduction in PVC burden, with a mean decrease of 76.2% in the first month, and 63.1% of patients achieving a PVC burden reduction greater than 80%. Conclusions: UNIFLECA contributes to the understanding of how personalized, non-interventional therapeutic modalities can be employed to manage PVCs, especially for patients unwilling to have or ineligible for ablation procedures.

Introduction: The impact of multidisciplinary supervised cardiac rehabilitation programs on reducing the risk of having heart problems in the future is well documented. However, little is known about nurse-led post-coronary heart disease (post-CHD). Purpose: Our aim was to evaluate the effectiveness of an educational and counseling-structured nurse-led post-CHD support program by assessing the prediction of psychological, behavioral and dietary variables in relation to adherence to a care plan in a single hospital in Athens (Greece). Method: A prospective follow-up comparative approach in a single group of CHD patients was applied. The structured nurse-led program included eight topics (management of anxiety, physical activity, dietary habits, weight control, smoking cessation, alcohol moderation, family engagement and adherence to a care plan). Participants received tailored nursing interventions focused on psychological and behavioral needs and dietary habits by a CHD-specialized nurse based on patients’ medical prescriptions and/or instructions. A modified clinical assessment questionnaire by the European Society of Cardiology was applied to identify pre–post clinical baseline measurements. A nurse-led post-coronary Heart Disease Support Program was evaluated by assessing the predictivity (effect) of specific interventions on adherence to a care plan by employing a logistic regression beta coefficient (Generalized Estimating Equations model). Results: The sample consisted of 275 patients (66.2% male), with a mean age of 68.5 ± 12.5 years old. CHD patients presented significantly lower anxiety rates (54.27 [1st m] vs. 49.63 [2nd m], p < 0.05). In addition, significant differences were observed between the first and the second measurements of total cholesterol (163.27 [1rst m] vs. 134.44 [2nd m], p < 0.001), BMI (obesity) (33.69 [1rst m] vs. 32.79 [2nd m], p < 0.001), smoking (42.18 [1rst m] vs. 22.55 [2nd m], p < 0.001) and adherence to a care plan (78.90 [1rst m] vs. 89.10 [2nd m], p < 0.001). A Generalized Estimating Equations model revealed that participants with higher levels of anxiety showed significantly lower adherence to a care plan (beta −0.10, p < 0.001) and those with family history of CHD (beta −0.71, p = 0.04) in comparison to those with no CHD history. No significant differences were observed in the predictive variables of smoking (beta 0.08, p = 0.69), alcohol consumption (beta 0.09, p = 0.79) and family engagement (beta −0.11, p = 069) with respect to adherence to a care plan, even after adjusting for age, sex and history of CHD. Conclusion: Our findings indicate that the nurse-led post-CHD support program was found to be partially feasible and effective in our single-group study, emphasizing the need for effective training and retention strategies to enhance the specialization of nurses providing post-CHD care and support.

GReek-AntiPlatElet Atrial Fibrillation registry is a multicenter, observational, noninterventional study of atrial fibrillation patients undergoing percutaneous coronary intervention. Primary endpoint included clinically significant bleeding rate at 12 months between different antithrombotic regimens prescribed at discharge; secondary endpoints included major adverse cardiovascular events and net adverse clinical events. A total of 647 patients were analyzed. Most (92.9%) were discharged on novel oral anticoagulants with only 7.1% receiving the vitamin K antagonist. A little over half of patients (50.4%) received triple antithrombotic therapy (TAT)—mostly (62.9%) for ≤1 month—whereas the rest (49.6%) received dual antithrombotic therapy (DAT). Clinically significant bleeding risk was similar between TAT and DAT [Hazard ratio (HR) = 1.08; 95% confidence interval (CI), 0.66–1.78], although among TAT-receiving patients, the risk was lower in those receiving TAT for ≤1 month (HR = 0.50; 95% CI, 0.25–0.99). Anticoagulant choice (novel oral anticoagulant vs. vitamin K antagonist) did not significantly affect bleeding rates (P = 0.258). Age, heart failure, leukemia/myelodysplasia, and acute coronary syndrome were associated with increased bleeding rates. Risk of major adverse cardiovascular events and net adverse clinical events was similar between ΤAT and DAT (HR = 1.73; 95% CI, 0.95–3.18, P = 0.075 and HR = 1.39; 95% CI, 0.93–2.08, P = 0.106, respectively). In conclusion, clinically significant bleeding and ischemic rates were similar between DAT and TAT, although TAT >1 month was associated with higher bleeding risk.