Neelesh Gupta

5/ PCI may be a solo act, but mastery comes from the team you can count on when the unexpected complication inevitably strikes.

I wrote this in a moment I never would have chosen. A sudden pause that made me see my life clearly. The meaning of our work is profound. This experience simply helped me see more clearly what matters most. “Time is Finite” JAMA jamanetwork.com/journals/jama/…

@Dr_ibrahimHarbi @AnasNomanMD Did you end up stenting? Where is the vulnerable or ruptured plaque or is it plaque erosion? In America, some aspect of this management is skewed by reimbursement perspective and often necessitating stenting, IMHO.

@AnasNomanMD Great save! Anas Fully agree I had a similar case yesterday, an inferior STEMI ( you can appreciate distal LAD clot too; managed with a single run of pneumra followed by OCT

Aspiration thrombectomy in STEMI with a heavy thrombus burden, maybe it’s time to take another look? Had a 37F with a huge RCA thrombus. Did 6 Penumbra aspiration runs and pulled out a large amount of clot. Hard to see how this would’ve resolved. Cases like this make you wonder… is it time for a TOTAL trial 2.0? @6ayyeboon @AlkashkariWail @mirvatalasnag @BinAbdulHak_A @amrmohsen213 @MarwanSaadMD @aelsab @MusaSharkawi @djc795 @MohammedQintar @mhammadah @kalazizimd @AdamGreenbaumMD @AlhijjiM @EmoryUniversity @JDDCFratti @acamajmd @crfheart @djc795 @mmamas1973 @TCT_ME_ @crfheart @BakhshiHooman @Almanfi_Cardio @Dr_ibrahimHarbi

@Hragy ?Gastric sleeve 🤔

During a routine PCI for a symptomatic focal proximal LAD lesion, in a F with history of 3 GI surgeries i saw those clips, can you guess the GI surgeries?

@ihtanboga @Ben_Kelemen @GreggWStone @stefano_garzon @DFCapodanno @mirvatalasnag @DocSavageTJU Thank for crisp and succinct summarization.

Good question. But first an important nuance about time zero in this study: It's not the same for everyone. The study pools registries + an RCT: — In the registries (PCI registry + CABG registry): time zero = procedure day. The angiography/decision date is not captured. — In RENOVATE RCT: time zero = randomization, which happens at angiography — before the PCI itself. So IVI-PCI patients from the RCT actually have the pre-procedure gap inside their follow-up, while CABG patients from the registry have it excluded entirely. Now here's the core issue. The bias isn't about what happens after time zero. It's about who gets to time zero. A diabetic patient with LM/3VD is discussed in the heart team. CABG is planned. But surgery is weeks away. During that wait, some patients: — die → never enter the CABG group — have MI or stroke → event never counted — deteriorate → emergency PCI instead (enter PCI group as high-risk) Only those healthy enough to survive the wait appear in the CABG registry. That's the "immortality", you must be alive on surgery day to be counted. For PCI, this gap is hours (ACS) to ~1 week (CCS). Much less filtering. So no, ITB here doesn't give CABG a higher event rate. The opposite: CABG gets an artificially low event rate — sickest patients filtered out before entry. PCI gets an artificially high rate — absorbs crossover patients who failed the CABG wait. Both directions favor CABG. And here's the irony: the IVI-PCI arm (from the RCT) is held to the strictest standard — its follow-up starts at angiography, including the pre-procedure window. CABG gets the most generous — follow-up starts only after surviving the surgical wait. Yet IVI-PCI still matches CABG (HR 0.88). Think about what that implies if the playing field were leveled.

Gim et al. (JACC Cardiovasc Interv 2026) published an interesting report that IVI-guided PCI shows "comparable" outcomes to CABG in diabetic patients with LM or 3-vessel disease. A compelling headline. But the methodology deserves scrutiny before this reshapes practice. A thread.

@grok @DividendTalks @michaeljburry @grok how did the hyperscalers change the landscape during these periods?

2000s fiber/telecom bubble: Capex exploded ($500B+ debt-funded fiber, 1M→10M miles US 1996-2000); capex/EBITDA hit ~70% (AT&T peak). FCF deeply negative from overspend. PE/FPE extreme (Nasdaq ~90x), ignored earnings/FCF. Outcome: 85% dark fiber, bankruptcies (WorldCom etc), valuations collapsed. 2010s cloud (AWS/Azure/GCP): Capex high (e.g. MSFT $43B cumulative 2006+, Amazon scaling billions/yr) but FCF-funded internally. FCF pressured short-term, then strong (cloud gross margins ~50%). PE/FPE 25-40x, supported by 20-40%+ rev growth. Outcome: sustained demand, high ROIC, no bust—revenue scaled profitably. Fiber: speculative overbuild. Cloud: proven enterprise shift.

A question I have for $ORCL, $GOOG, $META, $MSFT, $AMZN, $NVDA, $CAT, and all the rest, “When does the spending for AI data center buildout actually end?” It is consuming all your cash flow, you are borrowing, you are financing in ways you never have, apparently because it is so urgent, because it scales? But if it scales, when does it end? Now you are engaging in accounting tricks to hide expense, to protect earnings, as the impact is so severe. You will be tortuously adjusting your earnings in a new and sinister ways. When does it end?

@DividendTalks @michaeljburry @grok bring few key points during these 2 periods ie 2000s fiber and 2010s cloud services especially with regards to the different aspects like Capex fcf pe fpe etc.

Serious question back: If AI capex truly scales, shouldn’t the debate be less about when it ends and more about what incremental ROIC it earns? Hyperscalers historically deploy capital at 20–30%+ returns. If this buildout drops below cost of capital, you’re right. If it sustains high incremental returns, it’s not excess - it’s reinvestment. So the real question: Is this 2000-style overcapacity… or 2005-style cloud buildout?

@jbspadoni @grok analyze this IVUS imaging run. Thanks.

Here an interesting IVUS. What do you see?

@jbspadoni @grok help us out here!

IVUS quiz: How many findings can you identify in this IVUS run? What are those?

@DrRajeshG1 Shark fin in V2. STE V1,V3 --> Proximal LAD or Left Main?

Patient who had laparotomy and resection of intestinal mass 2 days back developed acute onset retrosternal pain and was shifted to Cardiology CCU and had emergency CAG, what is the Culprit?

@22tabbah_randa True Bicuspid AV Sievers type 0

Case of the day 😊

Saturn released a commercial in 2003 that ironically highlighted the inefficiency of cars and how much space they occupy.

The intracardiac electrograms – the basics! Many thanks to the amazing @kellyarps and all the @CardioNerds especially @RawanAAmir, @jholtzman3, @Dr_DanMD, and @AmitGoyalMD.

@RiyaSam12 @escardio @ESCardioNews @American_Heart @ACCinTouch Unroll @threadreaderapp

@escardio @ESCardioNews @American_Heart @ACCinTouch

19. ARREST: In adult pts w/o STe, expedited transfer by ambulance to a cardiac arrest center following resuscitation from an OHCA did not reduce deaths compared with transfer to the closest ED.

Cardiac cycle #MedEd #FOAMed

@mirvatalasnag @PCRonline @PushpaShivaram @DrJenniferCo_Vu @doubleaguptamd Left Atrial Enlargement!! EKG strip shows bifid p wave as well.

#ACCFIT #EAPCI #ACCIC @PCRonline What do u call this? @PushpaShivaram @DrJenniferCo_Vu @doubleaguptamd

@DrRajeshG1 Coumadin ridge! Also described as left lateral “ridge” between the appendage and the left pulmonary veins was first described by Keith in 1907 as the “left tenia terminalis.” doi.org/10.1161/CIRCEP…

What is the structure pointed with arrow?

@PPodrid Junctional Rhythm (or accelerated IVR) with varying degrees of retrograde p waves. LVH criteria met with anterolateral TWI likely strain pattern. (? Apical HOCM)

ECG for the weekend. Hope your mind will be accelerated. #PodridECGs #ECG #meded #cardiotwitter

People need to understand that: • It's Okay to fail, • It's Okay to make mistakes, • It's Okay to admit that you are wrong. • It's Okay to not have an opinion about something • It's Okay to say "I don't know"