In this opening chapter, Prof. Nicolas Van Mieghem previews the FRACTURE registry, which evaluates a new intravascular lithotripsy (IVL) device based on laser technology rather than traditional sparks. He discusses the technology's unique mechanism and its potential for greater flexibility and uniform circumferential therapy delivery in heavily calcified coronary artery disease.

In this chapter, Prof. Nicolas Van Mieghem explores emerging data comparing IVL with other lesion modification tools. He highlights the SHORTCUT IVUS sub-study, which compares IVL to cutting balloons, and the I-CARE trial, comparing IVL to rotational atherectomy. These studies aim to understand how different technologies deal with specific types of calcium, such as circumferential versus nodular phenotypes.

In this chapter, Prof Nicolas Van Mieghem discusses the ORACLE trial, a mechanistic study comparing rotational versus orbital atherectomy. He evaluates the premise that orbital technology may reduce microcirculatory compromise, focusing on the index of microvascular resistance (IMR) as a primary endpoint. The study aims to determine if mechanistic differences between the two devices lead to measurable differences in microvascular integrity.

In this chapter, Prof Nicolas Van Mieghem reviews the three-year data from the SMART randomized trial, comparing self-expanding versus balloon-expandable valves in patients with small aortic anatomies. He examines whether the superior hemodynamic performance of self-expanding valves observed in early follow-up will eventually translate into significant clinical benefits at three years. He also discusses the potential impact of pressure recovery on how these valve types are evaluated via echocardiography.

In this chapter, Prof Nicolas Van Mieghem turns to the tricuspid space, discussing a new analysis from the Tri-Valve registry focused on afterload mismatch. He explores how the right ventricle adapts to the sudden increase in afterload following successful tricuspid regurgitation correction. 

In this chapter, Prof Nicolas Van Mieghem discusses the PROTECT-EU registry, which evaluates the use of Impella CP in high-risk PCI. He frames these registry findings within the context of recent randomized data, such as CHIP-BCIS3, discussing the difficulties in identifying which patient phenotypes benefit most from mechanical support. He also notes the upcoming PROTECT IV study which continues to assess survival and quality of life benefits in this population.

In this final chapter, Prof Nicolas Van Mieghem presents a meta-analysis comparing mechanical thrombectomy versus catheter-directed thrombolysis for pulmonary embolism. He discusses how emerging trial data, including HI-PEITHO, STORM-PE, and PEERLESS, are shaping the global adoption of these therapies. The analysis evaluates the trade-offs between immediate thrombus removal and procedural complexities like bleeding risk and large-bore access.