Severe coronary calcification is a challenge to optimal percutaneous coronary intervention (PCI). Adequate lesion preparation is essential to achieve appropriate stent expansion and improve long-term outcomes. Recently, orbital atherectomy (OA) has emerged as an important tool for calcium modification, offering a unique mechanism of action based on centrifugal sanding and differential cutting. This review summarizes the contemporary evidence supporting OA in heavily calcified coronary disease, compares it to other established calcium modification strategies, and highlights practical scenarios where OA offers distinctive advantages. Several calcium algorithms exist, detailing start points according to balloon crossability and stepwise escalation guided by intravascular imaging. Orbital atherectomy has recently become available across centers in Europe and the United Kingdom, providing an alternative calcium‑debulking toolkit that is of particular use in some indications, with advantages over other techniques. In this review, we look at the emerging role of OA in calcified lesions, with a critical appraisal of the data and highlighting its utility drawing examples from the published literature and our center's experience.

Coronary artery calcium (CAC) scoring is selectively used to refine cardiovascular risk assessment in primary prevention, but interpretation still relies largely on absolute thresholds applied similarly to women and men. This approach may overlook relevant sex-related differences in coronary atherosclerosis. Women tend to develop detectable CAC later in life and have lower absolute CAC values for a given age, while sex-related differences in coronary plaque composition may not be fully captured by calcium scoring alone. Consequently, a low absolute CAC score may still represent a high age- and sex-specific percentile in women. Traditional risk algorithms and CAC-based strategies also do not systematically account for female-specific risk enhancers, including hypertensive disorders of pregnancy, gestational diabetes, premature menopause, and polycystic ovary syndrome. Relevant literature was identified through a PubMed search from database inception to September 2026. This Perspective examines sex-related differences in CAC distribution and prognosis and discusses how absolute CAC scores, demographic percentiles, and female-specific risk enhancers can inform preventive care. We propose integrating these measures while retaining established absolute CAC categories. The clinical value of distinct numerical treatment thresholds for women and men requires prospective evaluation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia worldwide and remains a major contributor to stroke, heart failure, hospitalization, and cardiovascular mortality. Catheter ablation has become a central strategy for rhythm control, while left atrial appendage occlusion (LAAO) offers an effective mechanical option for stroke prevention in patients with contraindications to oral anticoagulation. Performing AF ablation and LAAO during the same procedure addresses complementary therapeutic goals while potentially improving procedural efficiency, reducing hospital exposure, and enhancing patient convenience. This narrative review summarizes the rationale, patient selection, procedural considerations, clinical outcomes, and future directions of concomitant AF ablation and LAAO. Evidence demonstrates high procedural success rates, generally exceeding 90%, with acceptable acute complication rates in experienced centers. Combined procedures benefit from shared transseptal access, consolidated imaging and anesthesia requirements, and a single recovery period. Rhythm-control efficacy compared with standalone ablation remains unclear, with recurrence rates reported as both elevated and comparable across studies, reflecting the limited randomized data for concomitant procedures. Important knowledge gaps persist regarding optimal sequencing, periprocedural antithrombotic therapy, patient selection, and newer technologies such as pulsed-field ablation. Concomitant AF ablation and LAAO represent a logical and evolving strategy for integrated rhythm and stroke management.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and a leading cause of cardioembolic stroke. In nonvalvular atrial fibrillation (NVAF), thrombus formation occurs predominantly within the left atrial appendage (LAA), making it a key therapeutic target. While oral anticoagulation remains standard for thromboembolic risk reduction, contraindications, elevated bleeding risk, and therapy intolerance drive the need for nonpharmacologic alternatives. This review examines the role of the WATCHMAN left atrial appendage occlusion (LAAO) device in NVAF-related stroke prevention, encompassing pathophysiologic rationale, device design, procedural technique, clinical evidence, post-implantation management, and outstanding evidence gaps. The PROTECT AF and PREVAIL trials established WATCHMAN-based LAAO as noninferior to warfarin for prevention of stroke, systemic embolism, and cardiovascular death, though early procedural complications underscored the importance of operator experience. Subsequent real-world registries confirmed safety and effectiveness in higher-risk, anticoagulation-ineligible populations. Newer-generation platforms including the WATCHMAN FLX and FLX Pro, demonstrate improved sealing performance and procedural safety, while contemporary randomized trials further define LAAO's role relative to DOAC therapy. WATCHMAN-based LAAO represents an important alternative for carefully selected patients, particularly those with high bleeding risk. Optimal patient selection, antithrombotic regimens, and long-term outcomes warrant continued investigation.

Pulmonary artery banding (PAB) remains an important palliative strategy in congenital heart disease (CHD), particularly for temporary modulation of pulmonary blood flow and pressure during staged management. Over the past two decades, catheter-based pulmonary flow restrictors (PFRs) have emerged as less invasive alternatives to surgery, expanding treatment options for fragile infants and selected older patients. This review traces the evolution of transcatheter PFR, from early experimental concepts to off-label use of manually fenestrated Medtronic microvascular plugs (MVPs). It examines device mechanics, fenestration geometry and technique, implantation strategies, pulmonary vascular interaction, complications, antithrombotic management, retrieval, and long-term limitations. Key challenges include non-standardized fenestration, device-vessel mismatch, progressive loss of restriction with growth, anatomy-dependent performance, and increasingly time-dependent retrieval difficulty. The principal strength of the MVP-based approach is its intraprocedural adaptability, allowing fenestration to be tailored to individual anatomy, hemodynamics, and therapeutic goals. Given the dynamic and heterogeneous physiology of CHD, future dedicated platforms should preserve this adaptability rather than impose a fixed design. Technical refinement should therefore remain embedded within a patient-centered strategy that allows ongoing adjustment. Multicenter registries and purpose-built platforms may help define the future of controlled and durable transcatheter pulmonary flow modulation.

Spontaneous coronary artery dissection (SCAD), once considered rare, is increasingly recognized as a cause of acute coronary syndrome (ACS) owing to advances in coronary imaging. Although classically described in women with no or minimal cardiovascular risk factors, differentiation from atherosclerotic myocardial infarction remains challenging when multiple risk factors are present. Accurate diagnosis by coronary angiography is essential, because interventions such as percutaneous coronary intervention and thrombolysis may cause harm in SCAD. Diagnostic overlap with Takotsubo cardiomyopathy (TTC; also called stress cardiomyopathy) further complicates early evaluation. Important gaps remain regarding who is at risk, the triggers involved, and the association with fibromuscular dysplasia (FMD). We report a 51-year-old woman with multiple cardiovascular risk factors who developed SCAD two days after an acute emotional stressor, with negative FMD screening.