Marco Vugman Wainstein

Background and Purpose: Minor periprocedural ischemic events remain an important limitation of carotid artery stenting (CAS) compared with endarterectomy. Adverse stent–vessel–plaque interactions and in-stent plaque protrusion are proposed as contributing mechanisms. Selective intra-arterial three-dimensional rotational angiography (3DRA) provides high-resolution volumetric imaging directly in the endovascular suite without additional device crossing. Its incremental value for characterizing final implant quality and informing prognosis remains incompletely established. Objectives: We aim to determine whether adding 3DRA to conventional digital subtraction angiography (DSA): (1) improves expert characterization and reproducibility of Final Implant Quality (Imaging Domain); and (2) provides incremental prognostic information for 90-day Textbook Outcome failure beyond baseline clinical risk and conventional DSA (Prognostic Domain). Methods: SISYPHUS is a prospective, multicenter observational cohort of 67 patients undergoing elective CAS across three tertiary centers. Three blinded neuroradiologists will evaluate standardized image packages sequentially under DSA-only and DSA+3DRA conditions. Final Implant Quality will be assessed with a structured 10-item instrument: Q1–Q8 characterize specific findings, Q9 evaluates global implant adequacy (primary imaging variable), and Q10 captures technical image quality. Concealed repeat assessments will be performed in a randomized 17-patient subset for intra-reader reliability. The primary imaging estimand is the within-reader ordinal shift in Q9 after 3DRA is added, modeled with cumulative-link mixed-effects regression. The primary clinical endpoint is 90-day Textbook Outcome failure, integrating early neurological deterioration, major bleeding/procedural complications, stroke, TIA, MI, death, unplanned revascularization, and unplanned readmission within prespecified ascertainment windows. Incremental prognostic performance will be evaluated using nested ridge-penalized logistic regression models (M2 vs M3) with 2,000-resample bootstrap internal validation. Trial Status & Prospective Lock: Recruitment is complete (n=67), while protocol-defined follow-up remains ongoing. The Orthanc/OHIF reader study environment is being implemented; formal reader evaluations have not yet begun. The principal analytical architecture was prospectively locked in the Statistical Analysis Plan (SAP) Version 1.1.1 before formal inspection of reader results and before real-data prognostic model fitting.

Dear Editor, We read with interest the recently published Positioning Statement on the Use of Point-of-Care Ultrasound in Cardiovascular Medicine – 2026, in Arquivos Brasileiros de Cardiologia. This is a relevant initiative that acknowledges the growing role of point-of-care ultrasound (POCUS) as a fundamental tool in contemporary cardiovascular practice. Nevertheless, despite its merits, we believe that the document presents an important limitation: the lack of discussion and incorporation of a substantial body of evidence regarding the assessment of cardiac patients [...] Dear Editor, We read with interest the recently published Positioning Statement on the Use of Point-of-Care Ultrasound in Cardiovascular Medicine – 2026, in Arquivos Brasileiros de Cardiologia. This is a relevant initiative that acknowledges the growing role of point-of-care ultrasound (POCUS) as a fundamental tool in contemporary cardiovascular practice. Nevertheless, despite its merits, we believe that the document presents an important limitation: the lack of discussion and incorporation of a substantial body of evidence regarding the assessment of cardiac patients

Prezado Editor, Lemos com interesse a recente publicação do Posicionamento sobre o Uso do Ultrassom “Point of Care” (POCUS) na Medicina Cardiovascular – 2026, nos Arquivos Brasileiros de Cardiologia. Trata-se de uma iniciativa relevante, que reconhece o papel crescente do POCUS como ferramenta fundamental na prática cardiovascular contemporânea. Entretanto, apesar de seus méritos, consideramos que o posicionamento apresenta uma limitação importante: a falta de discussão e de incorporação de um conjunto expressivo de evidências relacionadas à avaliação de pacientes cardiológicos [...] Prezado Editor, Lemos com interesse a recente publicação do Posicionamento sobre o Uso do Ultrassom “Point of Care” (POCUS) na Medicina Cardiovascular – 2026, nos Arquivos Brasileiros de Cardiologia. Trata-se de uma iniciativa relevante, que reconhece o papel crescente do POCUS como ferramenta fundamental na prática cardiovascular contemporânea. Entretanto, apesar de seus méritos, consideramos que o posicionamento apresenta uma limitação importante: a falta de discussão e de incorporação de um conjunto expressivo de evidências relacionadas à avaliação de pacientes cardiológicos

Rotational atherectomy (RA) is an established technique for the treatment of heavily calcified coronary artery disease. Severe coronary calcification remains a frequent cause of procedural difficulty and device delivery failure during complex percutaneous coronary intervention (PCI). Delivery of the atherectomy burr to the target lesion may be particularly challenging in the presence of limited guide support, proximal vessel tortuosity, or unfavorable coronary anatomy that restricts safe access to distal calcified segments. Guide extension catheters (GECs) are widely used to enhance guide support and improve coaxial alignment during complex PCI. However, their use in combination with RA represents an advanced and selectively applied strategy that is not routinely addressed in conventional atherectomy training and is often avoided because of concerns regarding device interaction and difficulties during burr delivery and retrieval. Despite increasing anecdotal use in complex PCI, the technical principles and procedural safety considerations of performing RA through GECs remain insufficiently described in the literature. This review provides a focused technical overview of RA performed through GECs. We summarize the rationale for this approach, describe key technical considerations including device compatibility and burr advancement strategies, and discuss practical measures to minimize procedural complications. In addition, we outline clinical scenarios in which this technique may be beneficial, as well as situations where it should be avoided. Rather than advocating routine use, this review aims to define the role of guide extension–facilitated RA as a selective strategy for highly complex coronary anatomies.

ST-segment elevation myocardial infarction (STEMI) remains a condition with high morbidity despite advancements in treatment. Physical examination for heart failure and identification of mechanical complications can be inconsistent. Point-of-care ultrasound (POCUS) has proven valuable in acute cardiovascular care. We developed the Focused Assessment in STEMI (FASTEMI) protocol to enhance early evaluation, identify complications, and guide management. This single-center prospective cohort study included patients with presumed STEMI between June 2023 and June 2024. The FASTEMI protocol was performed upon admission and comprised lung ultrasound to assess congestion, and cardiac ultrasound to evaluate ventricular function, detect mechanical complications, measure left-ventricular outflow tract velocity–time integral, and assess the inferior vena cava. A total of 214 patients had a confirmed diagnosis of STEMI, whereas 17 were diagnosed with other conditions. FASTEMI altered diagnosis or management in 33 cases (14%) (CI 95% = 11.2 – 20.9). Identification of left ventricular (OR 1.26, 95% CI = 1.11–1.43; p < 0.001), right ventricular (OR 1.3, 95% CI = 1.04–1.75; p < 0.001), and biventricular dysfunction (OR 1.96, 95% CI 1.14–3.38; p < 0.001) were associated with in-hospital mortality. A normal FASTEMI exam had a 97% negative predictive value for mortality and did not delay door-to-balloon time. FASTEMI enhances early diagnosis, risk stratification, and management of STEMI. It enables rapid identification of complications, optimizes individualized treatment, and provides prognostic information without prolonging door-to-balloon time. Its feasibility supports its role as an adjunctive bedside tool.

Key points […] Venous Excess Ultrasound (VExUS) Score in Patients with ST-Elevation Myocardial Infarction to Predict In-Hospital Mortality Key points […] Venous Excess Ultrasound (VExUS) Score in Patients with ST-Elevation Myocardial Infarction to Predict In-Hospital Mortality

Pontos-chave […] Escore Ultrassonográfico de Congestão Venosa (VExUS) em Pacientes com Infarto do Miocárdio com Supradesnivelamento do Segmento ST para Predição da Mortalidade Intra-Hospitalar Pontos-chave […] Escore Ultrassonográfico de Congestão Venosa (VExUS) em Pacientes com Infarto do Miocárdio com Supradesnivelamento do Segmento ST para Predição da Mortalidade Intra-Hospitalar

Development of ventricular failure and pulmonary edema is associated with a worse prognosis in ST-elevation myocardial infarction (STEMI). We aimed to evaluate the prognostic ability of a novel classification combining lung ultrasound (LUS) and left ventricular outflow tract (LVOT) velocity time integral (VTI) in patients with STEMI. LUS and LVOT-VTI were performed within 24 h of admission in STEMI patients. A LUS combined with LVOT-VTI (LUV) classification was developed based on LUS with < or ≥ 3 positive zone scans, combined with LVOT-VTI > or ≤ 14. Patients were classified as A (< 3zones/ > 14 cm VTI), B (≥ 3zones/ > 14 cm VTI), C (< 3zones/ ≤ 14 cm VTI) and D (≥ 3zones/ ≤ 14 cm VTI). Primary outcome was occurrence of in-hospital mortality. Development of cardiogenic shock (CS) within 24 h was also assessed. A total of 308 patients were included. Overall in-hospital mortality was 8.8%, while mortality for LUV A, B, C, and D was 0%, 3%, 12%, and 45%, respectively. The area under the curve (AUC) for predicting in-hospital mortality was 0.915. Moreover, after exclusion of patients admitted in Killip IV, at each increasing degree of LUV, a higher proportion of patients developed CS within 24 h: LUV A = 0.0%, LUV B 5%, LUV C = 12.5% and LUV D = 30.8% (p < 0.0001). The AUC for predicting CS was 0.908 (p < 0.001). In a cohort of STEMI patients, LUV provided to be an excellent method for prediction of in-hospital mortality and development of CS. LUV classification is a fast, non-invasive and very user-friendly ultrasonographic evaluation method to stratify the risk of mortality and CS.