Richard Sohn MD

Doing solo-operator ROTAPRO (rotational atherectomy) STARTING POSITION (after testing & adjusting burr speed): Dynaglide ON, wire inside clip inside “brake defeat slot” (make sure to insert clip while pressing black button) #RadialFirst

@baijazvascular @evandrofilhobr @ShariqShamimMD @JayMathewsMD @SCAI Playing around w/ #heartflow app can be insightful. Watch this video 👇🏼 I made while scrolling around (angles displayed at bottom) ➡️ L-CRAN confirmed as best, and shows how caudal can be problematic

What’s your preferred angle to land LM ostium? RAO CRAN ~30/30 for me. I see others using spider view/caudal LM stent deployment sometimes but it often will lead to overhang. Add IVUS/floating wire to nail it.

@realarainmd @AsherElad x.com/rsohnmd/status…

Georgia O’Keeffe on my mind Oscar Wilde famously argued, “life imitates art far more than art imitates life.” The OCT image is from a case skillfully performed and shared by @AsherElad et al. The painting is Oriental Poppies (1928) by O’Keeffe. en.wikipedia.org/wiki/Oriental_…

@jbspadoni Fantastic case 👏👏 Btw, your #IVUS is another great example supporting “mechano-cardiac” (@rajivxgulati) causes for SCAD, eg takosubo, #myocardialbridge. Your patient’s bridge is exactly at proximal end of hematoma (bridges are not only found in LAD!):

SCAD is generally treated medically, but when you treat conservatively type IV you are only waiting for the infarct to complete. ivus> find the area hematoma/lumen compression -> fenestrate. Do not stent as this vessel will heal

Bravo! 👏 👏 👏

@MichaelMegalyMD @MichaelMegalyMD So do you not modify your use of contrast in CKD patients, e.g limiting numbers of angiographic views, tending away from OCT, staging PCIs, etc?

Finally!!! I always believed contrast-induced nephropathy is just an urban myth

1/ MYOCARDIAL BRIDGES (MBs) ANOCA mechanisms: - Slow early diast relaxation - Diast vessel restriction +/- neg remodeling - Branch steal (Venturi effect) - Proximal atherosclerosis - Associated vasospasm, CMD (common!) (see next for MINOCA)

@DocSavageTJU @ChangeAtHeart @AlexandraLansky @HenrytTimothy @mmamas1973 @MyJSCAI @djc795 @TCTConference @crfheart @NishithChandra @ShariqShamimMD @heart_spasms @InocaInternati1 @Hragy @aymanka @aayshacader @AnastasiaSMihai @DrMarthaGulati @saraceciliamtz Such great work by @ChangeAtHeart, @samitshahmd and all the registry investigators! This should help reassure apprehensive ICs to begin their own #ANOCA programs. No doubt a great presentation— wait, that’s me in the headphones!

Safety of #Acetylcholine testing in the #DiscoverInoca registry - outstanding presention by @ChangeAtHeart #TCT2025 #iNOCA @AlexandraLansky @HenrytTimothy @mmamas1973 @MyJSCAI @djc795 @TCTConference @crfheart @NishithChandra @ShariqShamimMD @heart_spasms @InocaInternati1

@mmamas1973 Can’t wait for the 5-year superiority data!

SELUTION DeNovo - non inferiority for TVF at 1 yr demonstrated. Randomisation before lesion prep ➡️ 20% DES use in DEB arm ➡️ 50% non inferiority margin of overall tvf in both arms !!!!! ➡️ TVF 4.4 vs 5.3% in des and deb arms This is a landmark moment- analogous to introduction of DES (even with generous non inferiority margin) #TCT2025 @crfheart Wild clapping in audience @Hragy @jgranadacrf @mirvatalasnag @drptca @SrihariNaiduMD @realarainmd @DrAsifQasim @DavidWienerMD @sbrugaletta @alaide_chief

@SarahFairley7 @mmamas1973 17%

@mmamas1973 What was the intravascular imaging rate in the DES group @mmamas1973 if you don't mind me asking. Not there in person. Devils advocate could say that DEB is non-inferior to DES without imaging....

@jbspadoni Hmm, doesn’t look like bridge or SCAD / hematoma to me. Maybe a vein coursing around the coronary? @jbspadoni do you know what this is? (Why was IVUS done in this otw normal looking coronary?)

Ivus quiz: what do you see here?

@sbrugaletta @AntonioMariaLe2 @ehj_ed @ESC_Journals @escardio Our current terminology is problematic for these reasons but also because these same entities (ie vasospasm, microvascular dysfunction, myocardial bridges, etc) can often cause angina / ischemia in pts who ALSO have epicardial CAD, eg those who don’t improve with PCI / CABG

@AntonioMariaLe2 @ehj_ed @ESC_Journals @escardio I totally agree with you @AntonioMariaLe2. to improve also the inclusion of ANOCA and INOCA in a same pathway..."NOCA" syndrome? or "differently" obstructed coronary disease?

Angina with non-obstructive coronary arteries: coronary function testing or angiography alone to guide treatment? Clinical trial results are out. doi.org/10.1093/eurhea… #INOCA #MI #coronary #angina #cardiotwitter, @ESC_Journals, @escardio

Calcium score CAC = ZERO ➡️ But this 👇🏼👇🏼👇🏼 👀 (Class 3 angina on meds) PCI or CABG❓

@realarainmd Thanks for looking at this! Tbh, not entirely sure what happened. AWE attempt but Pilot 200 entered false lumen. MC exchange for Mongo knuckle

@RSohnMD Beautiful IVUS images! 👌🏼 What wire did you use for the STAR? I ask because most wire knuckles don’t have the penetrating power to go into and out of the media - except perhaps the tight Mongo knuckle. (There is a valuable lesson here! I am trying to figure it out. 🧐😅)

CTO technique 👇🏼👇🏼👇🏼 STAR (subintimal tracking & reentry) 🤔 subINTIMAL or subMEDIAL ?? 🤔 ➡️ can be BOTH ! See 👇🏼 IVUS pullback 👀, follow wire position relative to MEDIA (thin dark layer, RED arrow) Start ➡️ subMEDIAL Beat 7 ➡️ subINTIMAL Beat 17 ➡️ subMEDIAL again

@ColletCarlos Supposing it’s the LAD with low PPG, and unacceptable angina despite maximal OMT. Would we expect a LIMA to be beneficial?

👇 How would you approach diffuse disease & low PPG?

🚨 We can now identify and quantify diffuse coronary artery disease using #PPG. That’s a game changer. But here’s the dilemma: how do we manage diffuse pressure losses that can’t be fixed with stents? 👇 Poll in thread @PCRonline @crfheart @ESC_Journals

@DrJayMohan IVL can cause electrical capture w/ associated myocardial contraction (seen it many times). If you mean the shocks specifically in this screenshot, they seem to fall in the refractory period of the QRSes … until it doesn’t @yeh_james3 @TroelsThim

This has been suggested prior but is IVL actually causing electrical capture of the myocardium?

Just doing elective PCI w/ #Shockwave (red) Then this 👇🏼👇🏼👇🏼 … 👀 #R-on-T #ventricularfibrillation #defibrillation

@TheECGMedic @rajivxgulati Before & after cath (eferred as OMI / STEMI)

Do you have a picture of the ECG? I think diagnosing TCM with solely echo is a risk. Both TCM and an LAD occlusion can cause the appearance of apical ballooning / WMA - both can portend what looks like an occlusive pathology on ECG. Really nice case tho! Thanks for sharing! I wonder if SCAD caused ischaemic insult which triggered the physiological stress-mediated catecholamine surge that maybe responsible for TCM?

Simultaneous SCAD + TAKOTSUBO SCAD-subo or tako-SCAD — which came first ?? 👀 60F w/ NSTEMI Echo ➡️ takotsubo Angio ➡️ prob SCAD of ramus note coronary AK + microvasc staining in distribution of #takotsubo (eg AP cranial washout) @rajivxgulati

@UKheartresearch @BernardBruyne @divaka_perera @CircIntv @DrOzanDemir @TheBHF @PCRonline @MortonKern @ColletCarlos @monaltiren @ziadalinyc @wfearonmd @SimoneBiscaglia @GianlucaCampo78 Or PW in LAD alone overcalls LMCA lesions ~1 in 4 ?

@BernardBruyne @divaka_perera @CircIntv @DrOzanDemir @TheBHF @PCRonline @MortonKern @ColletCarlos @monaltiren @ziadalinyc @wfearonmd @SimoneBiscaglia @GianlucaCampo78 As @BernardBruyne points out, the unequivocal finding from this study is that Pd and all related indices (like FFR iFR) are lower in the LAD than LCX. Whatever the reason, does this matter? YES. If assessed by PW in LCx alone ~ 1 in 4 significant LMCA lesions would be missed

Is FFR/iFR the same in the LAD and LCx in isolated LMCA disease? We are excited to share our #disruptive findings, online @CircIntv today ahajournals.org/doi/10.1161/CI… ‼️ All pressure-based indices are LOWER in the LAD than in LCx (misclassification 21% by FFR 28% by iFR)

@yourheartdoc1 @mirvatalasnag Seems a nearly impossible task to wire its tiny floating lumen. This was my partner's case, finished with an appropriately sized stent crushing that short un-deployed segment of prior stent

@RSohnMD @mirvatalasnag If they didn't image (should have) at least a stent boost during post dil would have picked that up. Did you manage to wire it through the undeployed stent lumen?

What an UNDERSIZED STENT looks like by #OCT 👀 👇🏼👇🏼👇🏼