UNASSIGNED: Iatrogenic left main coronary artery (LMCA) dissection resulting from cardiac surgery is a rare complication. Its early detection is challenging and often poses a significant threat to the patient\'s life. However, evidence regarding the most effective management strategy for this condition remains limited at present.
UNASSIGNED: We present a case of 65-year-old female patient who developed cardiogenic shock after mechanical aortic valve replacement surgery associated acute myocardial infraction. Despite concurrent coronary artery bypass graft (CABG) surgery, the patient\'s condition remained unimproved. Subsequent coronary angiography revealed extensive LMCA dissection involving the left circumflex (LCx) artery. Percutaneous coronary intervention (PCI) guided by intravascular ultrasound (IVUS) led to an immediate improvement in hemodynamic status. The patient was successfully discharged after 22 days of treatment.
UNASSIGNED: Iatrogenic LMCA dissection is an uncommon complication following cardiac surgery. It can manifest in a variety of ways, including as incidental findings, cardiogenic shock or sudden cardiac arrest. The precise prevalence rates of causes linked to cardiac surgery remain largely unknown due to the scarcity of reported cases and the absence of research on this issue. Currently, a definitive management strategy for this condition has not been established. However, previous reported clinical cases provide insight that CABG could be considered if coronary artery dissection is detected during cardiac surgery. Upon postoperative identification, diagnostic coronary angiography and PCI may be feasible alternatives.

BACKGROUND: Emergence of coronary giant pseudoaneurysm (PSA) after stent implantation is potentially catastrophic and may end up with life threatening complications if not managed promptly. There is scarcity of data in existing literature with respect to guidelines on the management of coronary PSA following stent implantation. We report the recurrence of coronary PSA following initial percutaneous management of a giant coronary PSA using multiple stent grafts.
METHODS: A 38-year-old male who underwent primary angioplasty of the right coronary artery (RCA) about a month back, presented with dull aching precordial chest pain for the last 15 days. A repeat coronary angiography revealed giant coronary PSA in proximal to mid RCA. Considering the significantly large size of the coronary PSA with symptoms of impending rupture, the giant coronary PSA was successfully excluded by implanting three sequentially coronary stent grafts. However, after one and a half months, the patient again presented with a similar kind of dull aching chest pain. We found a recurrence of coronary PSA in a segment of the coronary artery distal to the portion excluded by stent grafts. This recurrent coronary PSA was once again successfully excluded by redeploying two more stent grafts with the help of a guide extension catheter.
CONCLUSIONS: In this case, vessel wall injury as a result of aggressive post dilatation using an oversized balloon during the index procedure was the contributor to the giant coronary PSA formation. It usually appears early after the index procedure (within 4 weeks). Though the usual strategy used to exclude coronary aneurysm is by using the minimal number of stent grafts (due to the inherent increased risk of restenosis/thrombosis in stent grafts) in post angioplasty traumatic aneurysm it is prudent to exclude the entire damaged artery by placing stent grafts to prevent recurrence in segments with even minimal dilatation on initial evaluation.

BACKGROUND: With the development of percutaneous coronary intervention (PCI), the number of interventional procedures without implantation, such as bioresorbable stents (BRS) and drug-coated balloons, has increased annually. Metal drug-eluting stent unloading is one of the most common clinical complications. Comparatively, BRS detachment is more concealed and harmful, but has yet to be reported in clinical research. In this study, we report a case of BRS unloading and successful rescue.
METHODS: This is a case of a 59-year-old male with the following medical history: \"Type 2 diabetes mellitus\" for 2 years, maintained with metformin extended-release tablets, 1 g PO BID; \"hypertension\" for 20 years, with long-term use of metoprolol sustained-release tablets, 47.5 mg PO QD; \"hyperlipidemia\" for 20 years, without regular medication. He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours, on February 20, 2022 at 15: 35. Electrocardiogram results showed sinus rhythm, ST-segment elevation in leads I and avL, and poor R-wave progression in leads V1-3. High-sensitivity troponin I level was 4.59 ng/mL, indicating an acute high lateral wall myocardial infarction. The patient\'s family requested treatment with BRS, without implantation. During PCI, the BRS became unloaded but was successfully rescued. The patient was followed up for 2 years; he had no episodes of angina pectoris and was in generally good condition.
CONCLUSIONS: We describe a case of a 59-year-old male experienced BRS unloading and successful rescue. By analyzing images, the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations. We discuss preventive measures for BRS unloading.

UNASSIGNED: Tip detection-antegrade dissection and re-entry (TD-ADR) technique allows operators to accurately observe both guidewire tip direction and a true lumen in chronic total occlusion (CTO) lesions, while the torque direction of the guidewire on IVUS images does not invariably correspond to that on fluoroscopic images.
UNASSIGNED: A 41-year-old man with hypertension who smokes presented with sudden onset of dyspnoea, acute heart failure, and ischaemic findings on electrocardiogram; we performed percutaneous coronary intervention (PCI) for a sub-totally occluded mid-left anterior descending artery lesion. All antegrade wiring attempts failed to enter the distal true lumen followed by subintimal tracking and re-entry technique. Since the lesion re-occluded the next day, we treated the lesion using a novel TD-ADR technique, termed the \'integrated TD-ADR\', because of no interventional retrograde channel. This method integrates fluoroscopic and intravascular ultrasound (IVUS) images, ensuring congruence in the torque direction of the guidewire across both modalities and enabling vertical puncture of the stiff guidewire from the extraplaque space to the distal true lumen quickly and precisely. Final angiography showed good results. Five months later, coronary angiography showed that the lesion remained open.
UNASSIGNED: The integrated TD-ADR technique merges fluoroscopic and IVUS images, allowing operators to torque the guidewire in the same direction on both images. This approach might be more user-friendly than the original technique and has the potential to enhance the success rate of PCI in complex CTO cases. However, further investigations are warranted to address the clinical feasibility and applicability of this technique.

BACKGROUND: Spontaneous Coronary Artery Dissection (SCAD) is an acute coronary event of uncertain origin. SCAD occurs when the coronary artery wall dissects non-traumatically and non-atherosclerotically, leading to the formation of an intramural hematoma or intimal tear, ultimately compressing and restricting the true lumen, or even occluding it. The management of SCAD remains controversial despite modern imaging techniques. In addition to supportive drug therapy, percutaneous coronary intervention (PCI) is another option that can be used as an effective treatment modality.
METHODS: We describe A 50-year-old male with SCAD presented to the hospital emergency department complaining of chest pain. Coronary angiography incidentally showed spiral dissection from the proximal to distal right coronary artery (RCA). Three overlapping coroflex stents were deployed from the distal to the proximal RCA.
CONCLUSIONS: To stabilize the coronary artery in Acute Coronary Syndrome (ACS) patients due to SCAD, prompt interventions such as stenting and angioplasty are needed. However, it is necessary to pay attention to the clinical condition of patients and quick diagnosis for the recovery of patients and reduction of complications.

Ticagrelor is contraindicated in combination with cytochrome P450 3A4 and 3A5 enzyme (CYP3A4/5) inducers due to increased clearance, causing diminished antiplatelet effects. The emergent nature of acute coronary syndromes (ACS) may preclude scrutinization of home medications before P2Y12 inhibitor administration. The purpose of this case series is to establish the temporal impact of CYP3A4/5 enzyme induction on ticagrelor\'s pharmacodynamic effect by utilizing VerifyNow platelet aggregation studies. This was a retrospective case series of three patients who were taking a CYP3A4/5-inducing medication and loaded with ticagrelor for ACS. The duration of ticagrelor\'s antiplatelet effect was dramatically shortened in the presence of background CYP3A4/5 induction. The offset of antiplatelet effect, defined by platelet reactivity units (PRU), was 10-24 hours in the presence of CYP3A4/5 enzyme induction compared to the anticipated 36-48 hours. This was consistent across CYP3A4/5-inducing medications including carbamazepine, phenobarbital, and phenytoin. This study demonstrates rapid return of platelet function after a ticagrelor loading dose in the presence of CYP3A4/5-inducing medications. Monitoring of PRU every 6-12 hours with subsequent loading with clopidogrel or prasugrel should be considered. Larger scale studies are warranted to confirm these results.

BACKGROUND: As acute myocardial infarction (AMI) prevalence is increasing because of lifestyle changes, the incidence of atypical symptoms in acute coronary syndrome (ACS) is rising and making misdiagnosing of this fatal event more probable. To better approach the patients with atypical symptoms, we tend to present a rare case of AMI with wrist pain.
METHODS: A 41-year-old man presented to the emergency room (ER) with severe both-hand wrist pain and mild epigastric pain. His electrocardiogram (ECG) showed anterior ST-elevation myocardial infarction (MI) with an ejection fraction of 35-40%. His angiography showed severe left anterior descending artery (LAD), and first obtuse marginal artery (OM1) artery stenosis. He underwent Primary percutaneous coronary intervention (PCI). The patient recovered without serious complications and was discharged the day after PCI.
CONCLUSIONS: In this rare case of AMI with wrist pain, it is important to know that atypical symptoms can be present at various levels of symptoms, which prevents future misdiagnosis.

UNASSIGNED: In complex bifurcation percutaneous coronary intervention, 2-stent strategies are often required. Commonly used 2-stent techniques can lead to suboptimal results due to their complexity. We developed the balloon-assisted double-kissing T-stenting (DKT) technique, which uses balloons to optimize stent placement, delivery, and final architecture.
UNASSIGNED: With the balloon-assisted DKT technique, a balloon is inflated into the main branch (MB) to identify the best position of the side-branch (SB) stent instead of relying on angiography. DKT aims at supporting the SB ostium with stent crowns instead of distorted open cell(s), by achieving a longitudinal deformation with minimal crush of the SB stent upon implantation of the MB stent. This hypothesis was tested on a bench model. We report how the technique was performed in 2 cases and provide intracoronary imaging of the results.
UNASSIGNED: As hypothesized, DKT resulted in a longitudinal accordion-like deformation and minimal crush effect on bench. The SB ostium was supported by stent crowns. The SB wall opposed to the carina was well covered with crowns from the MB stent after proximal optimization technique and final kissing. The technique was successfully used in 2 complex left main cases with perfect coverage of the SB ostium as assessed with intracoronary imaging.
UNASSIGNED: The balloon-assisted DKT is a simple technique that combines strengths of double-kissing crush and culotte techniques, results in appropriate SB ostium coverage, and deserves further investigation.

BACKGROUND: Clinical events such as angina pectoris, acute coronary syndrome, and sudden death caused by myocardial bridge (MB) have attracted increasing attention. It is still a challenge to diagnose whether MB can cause the symptoms of patients with MB. For most MB patients, medication remains the primary treatment.
METHODS: This article reports a case of chest pain in a patient with MB in the middle segment of the left anterior descending artery (LADm) with moderate stenosis in the proximal segment (LADp). Through functional assessment, we found that neither MB nor fixed stenosis had sufficient effect on coronary blood flow to cause myocardial ischemia, but their synergistic effect resulted in myocardial ischemia. Finally, a stent was implanted in LADp and good clinical results were achieved.
CONCLUSIONS: For symptomatic patients with MB combined with fixed stenosis, functional evaluation may be necessary, which has significant guiding significance for treatment strategy selection. For asymptomatic patients, early detection of myocardial ischemia may also improve the prognosis of patients.

Spontaneous coronary artery dissection (SCAD) has been increasingly recognized in recent years as an important cause of acute coronary syndrome, myocardial infarction, and sudden death, especially among young women. However, due to the lack of clinical trials on SCAD, evidence-based guidance on management is currently lacking. Presented are four case studies that illustrate the recent insights and challenges in SCAD diagnosis and treatment.
Spontaneous coronary artery dissection (SCAD) is a condition where the layers of a coronary artery tear without any apparent cause. In recent years, it has become more recognized as an important cause of chest pain, heart attacks, and sudden death, especially in younger women. However, because of the lack of clinical trials focused on SCAD, there is insufficient evidence-based guidance on managing the condition. This article shares four cases to show the current knowledge and challenges in diagnosing and treating SCAD.