It is recommended that the degree of ischemia be evaluated using fractional flow reserve (FFR) before deciding whether to perform percutaneous coronary intervention (PCI) if the degree of stenosis is moderate on coronary angiography. In large trials, FFR-guided PCI was shown to significantly reduce the rates of death, myocardial infarction, and emergency revascularization in comparison to medical therapy alone. However, the effectiveness of using the FFR in coronary artery bypass grafting (CABG) remains controversial. Some studies reported the effectiveness of using the FFR in terms of graft patency. Others reported that it was not effective. The greatest advantage of CABG is that it allows for complete revascularization in a single operation and has a preventive effect against the development of new lesions. This is the most effective revascularization method for multivessel coronary artery disease. In the future, it is believed that the effective use of the FFR and consideration of optimal revascularization by the heart team will further improve patient quality of life.

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Dyslipidemia treatment for the prevention of coronary artery disease (CAD) is mainly based on statin administration, although low-density lipoprotein (LDL)-lowering therapy using statins alone has some limitations. The efficacy of ezetimibe and protein convertase subtilisin kexin (PCSK) 9 inhibitors as combination drugs with statins has been established, with PCSK9 inhibitors having a particularly strong LDL-lowering effect. LDL-lowering therapy has been widely accepted; however, from a medical-economic perspective, PCSK9 inhibitors cannot be used in all patients. Hypertriglyceridemia is the next target of dyslipidemia treatment. Hypertriglyceridemia causes cardiovascular events by increasing low-density LDL cholesterol levels in the blood. It has been reported that the “LDL window”, which is defined by high non-HDL (≥ 170 mg/dL) and high TG (≥ 150 mg/dL) levels, correlates significantly with the serum small dense LDL levels. In this study, we report that stratification using the LDL window in patients undergoing secondary prevention of CAD is a significant predictor of cardiovascular events. Treatment of hypertriglyceridemia with awareness of stratification based on the LDL window may therefore be effective in preventing adverse events in high-risk patients with dyslipidemia.

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Recent updates to clinical guidelines have downgraded the recommendations for coronary artery bypass grafting (CABG) in stable coronary artery disease (CAD), emphasizing optimal medical therapy (OMT) and selective revascularization based on symptom burden and risk assessment. The ISCHEMIA trial played a pivotal role in this shift, suggesting no significant survival benefit of an initial invasive approach compared to OMT. However, the limitations of the trial, including patient selection bias, exclusion of high-risk populations, and short follow-up duration, warrant critical reassessment of its applicability to contemporary practice. Despite these changes, substantial evidence supports the long-term superiority of CABG to OMT in reducing mortality and major adverse cardiovascular events, particularly in patients with multivessel disease, diabetes, or left ventricular dysfunction. In addition, recent advancements in surgical techniques, such as arterial grafting, off-pump procedures, minimally invasive approaches, and hybrid coronary revascularization, have improved patient outcomes while minimizing procedural risks. Given the limitations of recent guideline modifications and the ongoing evolution of CABG techniques, a balanced approach is required. Future guidelines should incorporate emerging evidence reflecting CABG’s long-term benefits of CABG and technological advancements. An individualized, patient-centered strategy guided by a multidisciplinary heart team is crucial for determining the optimal revascularization approach. This review critically examines the evolving role of CABG in CAD management, addressing the controversies surrounding recent guideline updates and advocating for the integration of new surgical innovations into future recommendations to ensure optimal patient outcomes.

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Calcified lesions limit stent expansion and are associated with poor clinical outcome. To address these lesions, several specialized devices have been developed, including atherectomy devices such as rotational atherectomy and orbital atherectomy, modified balloons, and intravascular lithotripsy. Additionally, intracoronary imaging devices, including intravascular ultrasound and optical coherence tomography, help operators to assess the distribution and morphology of calcified lesions. Based on this knowledge and assessment, an optimal strategy for managing calcified lesions must be determined. In this review, we introduce the concepts and mechanisms of these specialized devices and evaluate the distribution and morphology of calcified lesions using intracoronary imaging. Based on this information, we aim to help interventional cardiologists better manage calcified lesions.

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The optimal choice between percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) for complex coronary artery disease (CAD), such as unprotected left main or multivessel disease, remains a topic of debate. Recent developments in PCI techniques and devices have contributed to the shift from CABG to PCI in clinical practice. In this review, we provide an overview of the current status and latest evidence regarding revascularization strategies for severe CAD.

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Objectives: In an extremely aging society, it is beneficial to precisely predict the prognosis of high-risk late-elderly patients with coronary artery disease (CAD). Therefore, we aimed to investigate the prognostic value of the Geriatric Nutritional Risk Index (GNRI) for major adverse cardiac events (MACE) in elderly patients aged ≥ 75 years.
Materials and methods: This study included 754 consecutive late-elderly patients with CAD who underwent percutaneous coronary intervention (PCI). The patients were prospectively followed up for up to 3 years or until the occurrence of MACE, defined as a composite of all-cause death, non-fatal myocardial infarction, and non-fatal stroke.
Results: During the follow-up period, MACE occurred in 157 patients. Kaplan–Meier analysis showed that the lower the GNRI, the higher the probability of MACE. According to a multivariable logistic analysis with the highest GNRI level as the reference, the lowest GNRI level was related to the highest occurrence of MACE. In the stratified analysis, the lowest GNRI group had an increased risk of MACE, especially those with a female sex, no hemodialysis, a non-smoking status, statin use, no loop diuretics, no acute coronary syndrome, or multivessel disease had an increased risk of MACE, even with only a small reduction in GNRI compared with the highest level.
Conclusion: GNRI can effectively predict the occurrence of MACE in elderly patients after PCI.

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A 54-year-old woman with mitral valve regurgitation and isolated unilateral absence of the right pulmonary artery underwent mitral valve repair through a median sternotomy. Collateral circulation from both sides of the coronary artery to the right lung was observed. These vessels were ligated before cardiac arrest and mitral valve repair was successfully performed without complications. In this particular patient with unilateral absence of the right pulmonary artery, it was mandatory to assess collateral circulation to the right lung when performing surgery using cardiopulmonary bypass.

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Coronary artery aneurysms are often discovered incidentally during coronary angiography. The prognosis and other factors are unknown, and the optimal treatment methods have not yet been determined. In this report, we performed coil embolization in three patients with coronary artery aneurysms. The three cases consisted of two males and one female. One case was a pseudoaneurysm resulting from coronary stenting, while the other two cases were saccular aneurysms arising in the left coronary artery bifurcation. In the case of a wide-neck aneurysm, a coronary stent was used to assist in filling the coil; however, it did not completely prevent coil protrusion from the stent strut and additional stenting was required. Optical coherence tomography clearly demonstrated coil prolapse and it proved to be useful for evaluation. Coil protrusions can lead to restenosis. Despite the non-selection of a covered stent due to bifurcation, the potential for covered stenting in a manner that would preserve the side branch was considered as a means of averting coil prolapse. It is therefore imperative to emphasize that ongoing follow-up is essential to substantiate the long-term prognosis of the patients.

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Coronary artery aneurysms (CAA) are rare and most commonly associated with atherosclerosis. Post-PCI CAA formation is an unusual complication, with a limited understanding of its mechanisms. We herein report a case of dissecting CAA diagnosed 14 years after drug-eluting stent (DES) placement, which gradually enlarged over time. The aneurysm was surgically managed with plication and coronary artery bypass grafting (CABG), along with simultaneous aortic valve replacement and mitral valve repair. This case underscores the importance of long-term imaging follow-up after PCI, especially in patients with complex dissections, and it also highlights surgical plication as a viable option for managing CAA in the context of combined cardiac surgery.

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