Coronary revascularization: a long-term perspective

Abstract This paper will forecast advancements in coronary revascularization by 2040, drawing on historical trends and recent breakthroughs. Having forecasted in 2000 the impact of innovations like drug-eluting stents, coronary computed tomography angiography, and bioresorbable scaffolds, the authors examine the evolving landscape of coronary artery disease treatment emphasizing artificial intelligence and omics sciences. Imagenomics—the integration of imaging and omics—will be a transformative tool with artificial intelligence enabling more personalized decisions between pharmacological and mechanical revascularization. The shift towards minimally invasive, image-guided procedures is discussed along with the potential obsolescence of current antiplatelet and anticoagulant therapies with novel biomimetic peptides like CD31-covalently bound to metallic or polymeric devices. Advances in photon-counting computed tomography and Fibre Optic Real Shape promise high-resolution imaging with lower radiation, enhancing procedural safety and diagnostic accuracy. It is anticipated that robotics and 3D holograms in percutaneous and surgical revascularization will improve precision and the resulting outcomes. Additionally, the need for mechanical revascularization for younger patients may decline due to effective plaque regression therapies and novel potent anti-atherogenic biologics. However, the aging population will drive demand for mechanical interventions, with advancements in atherectomy and lithotripsy techniques improving outcomes in complex, calcified lesions. This comprehensive analysis outlines a future where myocardial revascularization becomes increasingly personalized, with technology-driven interventions redefining cardiovascular medicine.