Search Results (715)

Background: Extensive prior work has established severe aortic stenosis as a whole-heart remodeling process involving chronic pressure overload, concentric hypertrophy, myocardial stiffness, and progressive ventricular fibrosis. However, direct paired histological characterization of both atria remains limited. Methods: This single-center observational comparative study included 28 patients with severe aortic stenosis referred for surgical aortic valve replacement and 14 coronary artery bypass grafting (CABG) controls without significant valvular disease, consecutively enrolled between 9 May 2024 and 28 April 2025. Left- and right-atrial tissue samples were collected intraoperatively. The relative expression of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-alpha), and transforming growth factor-beta (TGF-beta) was quantified by RT-qPCR using pooled tissue samples and interpreted descriptively as a group-level molecular output. Atrial fibrosis was measured histologically at the patient level using Masson’s trichrome staining and digital image analysis. Results: Compared with CABG controls, patients with severe aortic stenosis demonstrated greater left-atrial fibrosis (median: 19.12% [IQR: 16.12–23.12] vs. 11.54% [9.53–14.29]; p < 0.0001) and right-atrial fibrosis (16.33% [15.07–19.13] vs. 8.40% [5.75–11.27]; p = 0.0001). Pooled RT-qPCR outputs descriptively suggested higher IL-6, TNF-alpha, and TGF-beta expression in both atria, although biological replication was insufficient for inferential testing. Echocardiographically, the aortic stenosis group showed higher aortic jet velocity and transvalvular gradients, thicker ventricular walls, a larger right-ventricular diameter, higher pulmonary artery systolic pressure, and a larger estimated left-atrial volume. A sensitivity analysis of 13 within-group correlations found that no correlation retained statistical significance at q < 0.05. Exploratory regressions restricted to patient-level histological outcomes suggested that severe aortic stenosis status remained associated with left- and right-atrial fibrosis after limited adjustment for age and sex. Conclusions: These findings complement the extensive ventricular fibrosis literature by providing paired human biatrial tissue evidence of greater atrial fibrosis in severe aortic stenosis compared with CABG controls. The pooled molecular findings remain descriptive and require validation using patient-level biological measurements. Full article

Enzyme paraoxonase 1 (PON1) plays a protective role against atherosclerosis by preventing the oxidation of low-density lipoproteins (LDL). Polymorphisms in the PON1, particularly Q192R and L55M, have been shown to affect the enzyme activity and, consequently, the cardiovascular risk. The present study aimed to evaluate the association between PON1 haplotypes comprising the Q192R and L55M polymorphisms and the severity of coronary atherosclerosis in a Polish population. The retrospective study involved 282 individuals of both sexes, divided into two groups following coronarography. The study group included patients after PCI (percutaneous coronary intervention) with stent implantation or patients who qualified for CABG (coronary artery bypass graft), with stenoses of minimum 70% (n = 140), whereas the control group included those after coronarography and without essential lesions in coronary vessels (n = 142). The Q192R PON1 polymorphism was identified by PCR-RFLP. The haplotypes 192R-55L and 192R-55M have been shown to be statistically significantly associated with a higher risk of atherosclerosis that requires PCI/CABG (OR = 2.06, 95% CI: 1.29–3.28, p = 0.0022; OR = 1.77, 95% CI: 1.17–2.69, p = 0.007; respectively). Furthermore, the risk of atherosclerosis requiring PCI or CABG was 53% lower in patients with the 192Q-55L haplotype (OR = 0.47, 95% CI: 0.34–0.66, p = 0.000013). Haplotypes 192R-55L and 192R-55M may increase the risk of atherosclerosis requiring PCI/CABG, whereas the 192Q-55L haplotype may lower the risk. Full article

Background/Objectives: Obesity and diabetes mellitus coexist, but the association of obesity with invasive management and in-hospital outcomes in acute myocardial infarction (AMI) complicated by cardiogenic shock is uncertain. We evaluated these associations among adults with diabetes mellitus. Methods: We performed a retrospective discharge-level analysis of the National Inpatient Sample for 2016–2021. Obesity was identified from ICD-10-CM codes. Survey-design logistic regression accounted for weights, strata, hospital clusters, and prespecified covariates. Results: The cohort comprised 19,399 discharges, representing 96,995 hospitalizations; 24.1% had obesity. Angiography and coronary artery bypass grafting (CABG) were more frequent with obesity, whereas percutaneous coronary intervention (PCI) was less frequent. After adjustment, obesity was associated with higher odds of angiography (adjusted odds ratio [aOR] 1.12, 95% confidence interval [CI] 1.03–1.21) and CABG (aOR 1.49, 95% CI 1.35–1.63), lower odds of PCI (aOR 0.90, 95% CI 0.84–0.97), and similar odds of circulatory support (aOR 1.00, 95% CI 0.93–1.07). Adjusted odds were lower for major adverse cardiovascular and cerebrovascular events (aOR 0.88, 95% CI 0.82–0.95), in-hospital mortality (aOR 0.90, 95% CI 0.83–0.98), acute ischemic stroke (aOR 0.78, 95% CI 0.64–0.95), and major bleeding (aOR 0.86, 95% CI 0.76–0.98). Procedure adjustment attenuated mortality and major bleeding. Conclusions: Obesity was associated with a different invasive-management pattern and lower adjusted odds of several short-term outcomes, consistent with an apparent in-hospital obesity paradox in this high-risk population. Full article

Objective: Robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is a proven alternative to conventional off-pump sternotomy for revascularizing the left anterior descending artery (LAD) in low-risk patients. However, its role in higher-risk candidates remains poorly established. This study compares RA-MIDCAB with off-pump CABG (OPCAB) in intermediate/high-risk patients with moderately reduced left ventricular ejection fraction (LVEF). Methods: We retrospectively analyzed all consecutive high/intermediate-risk patients with depressed LVEF who underwent left internal mammary artery to LAD RA-MIDCAB or OPCAB at our center between January 2021 and August 2025. The primary outcome, assessed at discharge and follow-up, was a composite of all-cause mortality, stroke, and repeat revascularization. Secondary outcomes included ICU stay, red blood cells (RBC) transfusion volume, oro-tracheal intubation time, and acute kidney injury. Kaplan–Meier curves estimated the cumulative freedom from the primary outcome. Restricted mean survival time (RMST) at 1 year was calculated, with non-inferiority confirmed if the lower bound of the 95% CI exceeded − 8 days. A generalized linear model adjusted for confounders. Results: Seventy-two patients were included: 20 RA-MIDCAB and 52 OPCAB. EuroSCORE was 3.8 ± 1.9 and 3.5 ± 2.4 in RA-MIDCAB and OPCAB, respectively (p = 0.384), while mean LVEF was 40 ± 13 and 45 ± 9, respectively (p = 0.454). Other variables were comparable; however, RA-MIDCAB patients had higher rates of prior myocardial infarction (MI) (45% vs. 11.5%; p = 0.003) and PCI (40% vs. 13.4%; p = 0.022). Procedural time was longer for RA-MIDCAB (196 ± 66 vs. 182 ± 66 min; p = 0.048). Thirty-day mortality was comparable (0% RA-MIDCAB, 3.8% OPCAB; p = 0.374), while ICU stay and intubation time were shorter in the RA-MIDCAB group. Fewer RA-MIDCAB patients required >5 RBC units. At one year, freedom from the primary outcome was 95% vs. 83.6% (p = 0.2), with RMST favoring RA-MIDCAB by 34.6 days (p = 0.0067), meeting the non-inferiority threshold. Results remained consistent after adjustment. Conclusions: RA-MIDCAB is noninferior to OPCAB in intermediate- to high-risk patients with moderately depressed LVEF, offering a valuable alternative to conventional surgical revascularization. These findings need further confirm through the analysis of larger datasets and longer follow-up. Full article

Background: This study aimed to evaluate the impact of various preoperative statin types and dosage regimens on early postoperative outcomes following isolated coronary artery bypass grafting (CABG). Methods: A total of 950 patients who underwent isolated CABG between 2022 and 2026 were evaluated and stratified into three groups based on their preoperative statin status: Group A, statin-naive patients (n = 592); Group B, atorvastatin users (n = 293); and Group C, rosuvastatin users (n = 65). To analyze the dose-dependent outcomes of statins, patients in Group B were subsequently segregated into two subgroups and matched using propensity score matching: Group 3, low-to-moderate regimen (≤20 mg/day; n = 75), and Group 4, high-dose regimen (>20 mg/day; n = 75). Results: Except for the higher incidence of diabetes mellitus and hypertension in statin-treated patients, all pre- and intraoperative characteristics of Groups A, B, and C were similar, and all of their postoperative outcomes except new-onset atrial fibrillation (NOAF) were similar. NOAF incidence was significantly higher in statin-naive patients compared to both the atorvastatin and rosuvastatin cohorts [109 (18.4%) - 35 (11.9%) - 7 (10.8%), p = 0.02]. All early postoperative outcomes—including in-hospital mortality and NOAF incidence—were found to be fully similar between Groups 3 and 4. Furthermore, multivariable analysis confirmed preoperative statin use as an independent protective factor against NOAF. Conclusions: The preoperative utilization of either atorvastatin or rosuvastatin was associated with a lower NOAF incidence in isolated CABG, and no significant differences were observed between the atorvastatin and rosuvastatin cohorts regarding NOAF and other postoperative outcomes. Preoperative atorvastatin administration at doses below and above 20 mg/day showed no significant differences in terms of postoperative outcomes. Full article

Background: Advancing age is incorporated as a strong risk variable in EuroSCORE II and is consistently associated with adverse outcomes after conventional coronary artery bypass grafting (CABG). Whether minimally invasive direct coronary artery bypass (MIDCAB)—which avoids both sternotomy and cardiopulmonary bypass—modifies this age-related risk in patients with single-vessel or LAD-predominant coronary artery disease remains insufficiently characterised. Methods: We retrospectively analysed 350 consecutive patients who underwent MIDCAB at Hannover Medical School between July 1999 and April 2025 (follow-up to April 2025). Elderly patients (age ≥70 years; n = 117) were compared with younger patients (age <70 years; n = 233) before and after 1:1 propensity score matching using greedy nearest-neighbour matching with a caliper of 0.2 × SD of the logit propensity score; age was excluded from the propensity model as it represented the exposure variable. A pre-specified sensitivity propensity model that additionally excluded EuroSCORE II (because EuroSCORE II contains an age component) was also evaluated. The primary endpoint was all-cause long-term mortality; secondary endpoints included perioperative complications and in-hospital outcomes. Long-term survival was assessed by Kaplan–Meier analysis and multivariable Cox proportional hazards regression, with a pre-specified parsimonious Cox model (age, LVEF, renal impairment) and cluster-robust standard errors on matched-pair identifiers. Results: Matching produced 109 pairs with excellent covariate balance (all standardized mean differences < 0.20). MIDCAB was completed without intraoperative conversion in all patients. No 30-day mortality, perioperative stroke, or new postoperative dialysis was observed in either age stratum (Clopper–Pearson 95% CI 0.00–3.33% for each zero-event outcome). Perioperative complications—including new-onset atrial fibrillation, re-exploration for bleeding, and intensive care unit and hospital length of stay—did not differ significantly between elderly and younger patients in the matched cohort (Newcombe 95% CI for risk differences all crossing zero; McNemar’s exact tests non-significant for all matched-pair binary endpoints; Hodges–Lehmann median difference for hospital length of stay +1.0 day, bootstrap 95% CI 0.0–1.0 days). At a median follow-up of 19.0 years (IQR 11.5–24.3; reverse Kaplan–Meier potential median 19.7 years), all-cause mortality was higher in the elderly (20.2% vs. 5.5%, p = 0.002; log-rank p = 0.001; exact McNemar’s p = 0.0025 for the matched-pair mortality endpoint). After multivariable adjustment, elderly age (≥70 years) was independently associated with long-term mortality (adjusted hazard ratio 4.48, 95% CI 1.79–11.20, p = 0.001), as was EuroSCORE II (HR 2.40 per unit, p = 0.034); a pre-specified parsimonious model (age, LVEF, renal impairment) with pair-cluster robust standard errors yielded an essentially identical adjusted HR for elderly age of 4.08 (95% CI 1.65–10.04, p = 0.002), and a sensitivity propensity model without EuroSCORE II yielded HR 3.95 (95% CI 1.68–9.29, p = 0.002). Conclusions: In this propensity-matched analysis with a median follow-up of ~19 years, MIDCAB was associated with excellent observed perioperative outcomes in appropriately selected elderly patients (no 30-day mortality, stroke, or new dialysis observed; upper 95% CI 3.3%) and no evidence of an excess of major in-hospital complications compared with younger patients within the statistical resolution of the cohort. The long-term mortality excess in the elderly is consistent with age-related life-expectancy curves in the source population; cause-specific mortality was not available in this cohort. External benchmarks from large MIDCAB cohorts in which long-term survival approximates that of the age-matched general population support this interpretation indirectly. These findings support MIDCAB as a feasible revascularization strategy associated with favourable observed early outcomes and long-term survival consistent with published MIDCAB literature, in appropriately selected elderly patients with single-vessel or LAD-predominant coronary artery disease treated at experienced centres. Full article

While glucose-driven mitochondrial dysfunction has been proposed to promote vascular dysfunction responsible for saphenous vein graft failure (VGF) following bypass surgery, the impact of type 2 diabetes mellitus (T2DM) on mitochondrial function in human saphenous vein smooth muscle cells (HSVSMCs) responsible for maladaptive remodelling is unknown. Our aim was to identify signalling pathways that mediate any mitochondrial dysfunction in HSVSMCs in vitro and assess the impact of T2DM. HSVSMCs explanted from surplus HSV tissues from consenting T2DM and non-diabetic patients undergoing coronary artery bypass graft surgery were treated with known activators and inhibitors of the JAK/STAT and MAPK/ERK pathways. Following this, real-time oxygen consumption rate (OCR) and extracellular acidification rate (ECAR) measures of mitochondrial function were then determined. Our findings revealed that both IL-6/sIL-6Rα trans-signalling complexes and platelet-derived growth factor-BB (PDGF-BB) significantly increased OCR in HSVSMCs from T2DM patients but not non-diabetic controls. Meanwhile, only PDGF-BB increased ECAR in HSVSMCs from T2DM patients but not in non-diabetic controls. The observed increases in OCR and ECAR were abolished by JAK1/2-selective inhibitor ruxolitinib. Furthermore, thrombin caused a significant increase in OCR, specifically in HSVSMCs from T2DM patients, and this effect was abolished by the MEK1/2-selective inhibitor trametinib. Both ruxolitinib and trametinib significantly reduced basal OCR and ECAR in HSVSMCs from both T2DM and non-diabetic patients. Together, these findings demonstrate a JAK/STAT- and MAPK/ERK-mediated regulation of mitochondrial function in HSVSMCs. As such, they represent potential targets for regulation of HSVSMC function that can be explored for drug development to limit saphenous VGF in T2DM. Full article

Background: Minimally invasive approaches for combined aortic valve and ascending aortic surgery remain challenging. We report a case of utilizing a transaxillary approach (TAX) in combination with the RAM^® system. Methods: A 65-year-old male presented with exertional angina and palpitations. He reported a one-year history of dizziness. Diagnostics revealed severe aortic regurgitation due to a calcified bicuspid aortic valve and an ascending aortic aneurysm measuring 57 × 54 mm. Left ventricular ejection fraction was reduced to 42%. Coronary artery disease was excluded. Surgery was performed via a right transaxillary mini-thoracotomy (3rd intercostal space) using endoscopic visualization. Cardiopulmonary bypass was established through femoral cannulation. After aortic cross-clamping and cardioplegic arrest, the bicuspid valve was excised and replaced with a bioprosthesis. A supracoronary ascending aortic replacement was performed using a Dacron graft. The RAM^® system was used for annular suturing and proximal anastomosis, with automated fastener fixation. Results: The patient was extubated on postoperative day 1 and transferred to intermediate care on day 2. Postoperative recovery was uneventful, with no neurological deficits, bleeding, or other complications. Discharge occurred on postoperative day 9 in stable condition. Conclusions: This case highlights the feasibility and safety of a minimally invasive transaxillary approach for combined aortic valve and ascending aortic replacement using the RAM^® system. This technique may expand the surgical armamentarium for complex aortic pathology while avoiding sternotomy. Further studies are required to evaluate reproducibility, long-term outcomes, and broader applicability. Full article

Background: Erectile dysfunction and cardiovascular disease share common pathophysiological mechanisms, yet little is known about the postmortem cardiac profile of men with detectable sildenafil use. This study investigated whether postmortem sildenafil positivity is associated with acute or chronic cardiac pathological findings in men who died of ischemic heart disease. Methods: In a sample of 154 male decedents who died of ischemic heart disease, postmortem cardiac and toxicological findings in 77 sildenafil-positive cases were compared with those of age-matched controls. Heart weight z-scores were calculated based on 27,645 reference autopsies. Multivariable logistic regression analyses were performed to identify independent associations. Results: No significant differences were observed between groups regarding acute ischemic pathologies. However, chronic cardiac findings were more prevalent in the sildenafil-positive group, including coronary artery disease (96.1% vs. 85.7%; p = 0.025), congestive heart failure (40.3% vs. 24.7%; p = 0.039), prior coronary artery bypass grafting (24.7% vs. 11.7%; p = 0.037), increased heart weight (547.7 gr vs. 507.5 gr; p = 0.037) and z-score (+1.63 vs. 1.08; p = 0.040), and coronary calcification (88.3% vs. 74.0%; p = 0.023). After adjustment for cardiovascular comorbidities, only coronary calcification remained independently associated (adjusted OR: 2.586; 95% CI: 1.076–6.215; p = 0.034). Conclusions: Sildenafil-positive cases showed no excess of acute ischemic pathology. However, sildenafil-positive cases had a greater burden of chronic cardiac pathology, particularly coronary calcification. These findings are consistent with the proposed role of coronary artery calcification as a surrogate marker of erectile dysfunction and cardiovascular disease. They also underscore the importance of cardiovascular risk assessment in sildenafil users and support a cautious approach in individuals with poor cardiac reserve. Full article

Post-infarction left ventricular aneurysm is an uncommon but severe mechanical complication of transmural myocardial infarction, particularly in patients with delayed presentation or incomplete myocardial salvage. It may lead to profound distortion of left ventricular geometry, adverse remodelling, intraventricular thrombosis, mitral regurgitation, pulmonary hypertension, and advanced heart failure. We report the case of a 65-year-old male patient referred two months after a late-presenting anterior ST-segment elevation myocardial infarction caused by proximal occlusion of the left anterior descending coronary artery. At admission, the patient presented with severe decompensated heart failure, low-output status, multiorgan dysfunction, and a left ventricular ejection fraction of 12%. Transthoracic echocardiography and cardiac magnetic resonance imaging demonstrated a giant apical left ventricular aneurysm involving approximately 75% of the ventricular cavity, partial intraluminal thrombosis, extensive transmural scarring in the left anterior descending territory, and imaging features suggestive of a chronic contained free-wall rupture/pseudoaneurysmal component. Following multidisciplinary evaluation, the patient underwent surgical ventricular reconstruction using an endoventricular circular restoration technique guided by an intraventricular balloon sizer, combined with left internal thoracic artery bypass grafting to the left anterior descending artery. The early postoperative course required temporary inotropic, vasopressor, inhaled nitric oxide, and intra-aortic balloon pump support, followed by progressive haemodynamic recovery. The patient was discharged on postoperative day seven with functional improvement to NYHA class II. At six-month follow-up, he remained clinically stable without overt signs of heart failure, and echocardiography showed preserved ventricular geometry and improvement of left ventricular ejection fraction to 45%. This case highlights the potential role of carefully planned, balloon-guided surgical ventricular reconstruction in selected patients with giant post-infarction left ventricular aneurysms and end-stage heart failure when residual viable myocardium is present. Full article

Background: Postoperative antiplatelet selection after coronary artery bypass grafting (CABG) in adults aged ≥70 years requires balancing ischemic protection against bleeding risk. Methods: We conducted a single-center retrospective cohort study of adults aged ≥70 years who underwent isolated CABG for unstable angina between 2017 and 2021. The exposure was the initial discharge antiplatelet pathway: aspirin 100 mg once daily or indobufen 100 mg twice daily as the cyclooxygenase-inhibitor component, combined with a P2Y12 inhibitor during the first postoperative year and followed by the same cyclooxygenase inhibitor during the second year. Propensity scores were estimated using multivariable logistic regression with 16 prespecified baseline covariates, and stabilized inverse probability of treatment weighting (IPTW) was applied. The primary analyses used IPTW-weighted Cox models. Results: Among 336 screened patients, 79 were included in the final analytic cohort (aspirin-based pathway, n = 49; indobufen-based pathway, n = 30). After weighting, measured covariate balance improved, although residual imbalance remained for prior myocardial infarction and prior percutaneous coronary intervention. At 24 months, no statistically significant association was observed between pathway and MACCE (HR 0.858, 95% CI 0.257–2.866; p = 0.803), BARC grade ≥2 bleeding (HR 0.359, 95% CI 0.093–1.385; p = 0.137), or NACE (HR 0.526, 95% CI 0.204–1.360; p = 0.185). Graft surveillance was evaluable in 77/79 patients at 1 year and 71/79 at 2 years and was analyzed descriptively. Conclusions: In this real-world cohort of older patients undergoing CABG for unstable angina, an initial indobufen-based discharge pathway was not statistically significantly associated with 24-month MACCE, BARC grade ≥2 bleeding, or NACE compared with an aspirin-based pathway after stabilized IPTW. These findings add exploratory CABG-specific data on indobufen in older patients and should be confirmed in larger prospective studies. Full article

Coronary artery bypass grafting is frequently performed in combination with valve surgery; however, minimally invasive approaches for such combined procedures remain limited due to challenges in exposure and access. While bilateral minimally invasive strategies have been described in selected cases, standardized access concepts for concomitant procedures are not well defined. This study aimed to assess the anatomical accessibility and procedural workflow of a minimally invasive biaxillary access strategy for combined coronary and valve surgery in a human cadaver model. Combined coronary artery bypass grafting and valve procedures were performed in nine Thiel/ethanol-fixed human cadavers using a biaxillary access approach. Anatomical exposure, conduit length, graft harvesting and anastomosis times, and valve positioning were evaluated by macroscopic inspection and postprocedural three-dimensional computed tomography imaging. All planned procedural steps were completed in all nine cadavers. The mean left and right internal thoracic artery lengths were 18.1 ± 1.8 cm and 18.9 ± 1.9 cm, respectively. The average bilateral internal thoracic artery harvest and anastomosis times were 52.0 ± 17.6 min and 46.6 ± 12.6 min, respectively. Postprocedural three-dimensional computed tomography imaging and macroscopic inspection demonstrated consistent graft positioning and anatomical valve seating across all specimens. This cadaveric study demonstrates that a minimally invasive biaxillary access strategy allows anatomical exposure and supports a conceptual procedural workflow for combined coronary and valve interventions. These findings represent an early-stage technical proof-of-concept and require further validation before clinical application can be considered. Full article

Coronary artery bypass grafting (CABG) remains one of the most effective treatments for advanced coronary artery disease; however, substantial variability persists in both perioperative and long-term outcomes despite advances in surgical technique, myocardial protection, and risk stratification. Oxidative stress is a central mediator of tissue injury during cardiac surgery, contributing to ischemia–reperfusion injury, endothelial dysfunction, systemic inflammation, and postoperative organ complications. At the same time, chronic exposure to ambient air pollution has emerged as an important environmental determinant of cardiovascular disease through mechanisms that converge on many of the same redox-sensitive pathways. We propose the concept of environmental oxidative priming, whereby long-term exposure to particulate matter, nitrogen oxides, ozone, and other pollutants establishes a persistent state of endothelial dysfunction, mitochondrial impairment, chronic inflammation, nitric oxide depletion, and reduced antioxidant reserve before surgery. Within this framework, CABG represents a second oxidative challenge superimposed on a pre-existing environmentally conditioned phenotype. We discuss the mechanistic overlap between air pollution-induced cardiovascular injury and cardiac surgical stress and examine how this interaction may contribute to postoperative complications, graft adaptation, major adverse cardiovascular events, and long-term survival. Recognition of air pollution as a modifier of biological resilience provides a novel framework for understanding outcome heterogeneity after CABG and may support future precision-based risk stratification and preventive strategies. Full article

Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009–2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain. Full article

Background: Coronary artery bypass grafting (CABG) is the standard revascularization procedure, and the left internal mammary artery (LIMA) is the most widely used conduit owing to its long-term patency and favorable impact on survival. Although fibrosis and calcification are comparatively infrequent in internal mammary artery (IMA) grafts, progressive remodeling may still compromise patency. Tumor necrosis factor-α (TNF-α) is a pro-inflammatory cytokine implicated in vascular remodeling and calcification, whereas L-arginine, a precursor of nitric oxide, may exert vasoprotective effects. Aim: To investigate the effects of ex vivo TNF-α and combined TNF-α plus L-arginine treatment on the morphology, calcification, elemental composition, and biomechanical properties of human LIMA grafts. Patients and Methods: LIMA graft segments from 18 male CABG patients were allocated to one control group (G0) and two ex vivo treatment groups. Grafts were assessed using hematoxylin and eosin and Masson’s Trichrome staining under brightfield microscopy, using Alizarin Red S fluorescence staining to measure calcification, and by scanning electron microscopy with energy-dispersive spectroscopy (SEM/EDS) to assess ultrastructure and elemental composition. Scanning acoustic microscopy (SAM) was used to derive acoustic impedance as a label-free index of tissue stiffness. Results: TNF-α treatment was associated with increased acoustic impedance, consistent with graft stiffening, together with greater calcification signatures, whereas combined TNF-α and L-arginine treatment shifted impedance toward control-like values and showed more organized tissue architectures with reduced calcification. Conclusions: In this preliminary ex vivo model, L-arginine attenuated TNF-α-associated remodeling and stiffening of LIMA grafts, suggesting a potential role in supporting graft durability; larger, statistically powered studies with molecular validation are required to confirm these findings. Full article