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The development of acute severe mitral regurgitation (MR) requiring surgery is one of the most dreaded complications of percutaneous transmitral commissurotomy. We present the case of a 29 year-old female with severe rheumatic mitral stenosis whose mitral valve dilatation was performed using an Accura balloon. Once the balloon catheter had crossed the mitral valve to reach the left ventricle, it was facing away from the apico-mitral axis. It was inflated in distal portion, and mitral valve dilatation was done in the usual fashion. She developed acute severe MR. As it was misaligned with the apico-mitral axis, it caused a chordae rupture of the postero-medial papillary muscle which was identified during surgery. We conclude that a misaligned Accura balloon catheter during balloon inflation can pluck the chordae tendinae and can cause acute severe mitral regurgitation, and therefore can unearth the underlying subvalvular pathology.

Acute stent recoil or radial collapse of a stent is a rare phenomenon leading to subsequent acute stent thrombosis or in-stent restenosis as delayed sequelae. Reduced strut thickness, a larger stent/vessel ratio, and a larger balloon/stent ratio are factors leading to stent recoil. Here, we report a case of acute recoil or radial collapse of Promus Element Plus, a third-generation everolimus-eluting stent with thin stent struts in a 66 year-old male who underwent bifurcation percutaneous coronary intervention of left anterior descending artery (LAD) and diagonal branch (D1). Following kissing balloon inflation at 16 atm pressure after deployment of stents in LAD and D1, acute radial collapse of stent in proximal LAD was noted. It was successfully bailed out by further multiple, short sequential inflations using same size noncompliant balloon. Acute radial collapse probably occurred due to inflation at higher pressure with an oversized balloon, and relatively thin struts of the stent.

Percutaneous trans-mitral commissurotomy (PTMC) using an Accura balloon is an effective procedure for the mana- gement of patients with rheumatic mitral stenosis. It is not infrequent to encounter an aneurysmal left atrium (LA), especially in the developing world where patients often present very late. This is a technically challenging procedure as the septum often bulges into the right atrial side, making the puncture often difficult. Furthermore, it bulges anteriorly and inferiorly so it becomes even more challenging. Because of the vertical lie of the septum, the needle often dissects the septum rather than puncturing it. Here, we describe the case of a 17 year-old boy with severe mitral stenosis with a giant, aneurysmal left atrium (LA — 13.5 × 16 cm) where an inter-atrial septal puncture was achieved by probing the fossa ovalis to enter the left atrium instead of a conventional transseptal puncture. PTMC was successfully done, increasing the mitral valve area from 0.8 cm2 to 1.9 cm2.

Anomalous coronary arteries, especially when they are right with a high take-off, are challenging substrates for percuta- neous coronary intervention (PCI). Here, we report the case of a 63 year-old female who had a critical lesion in proximal anomalous right coronary artery having an abnormal take-off, where the ostium failed to get cannulated using multiple guiding catheters. Successful PCI was done using a 5 F TIG diagnostic catheter (Optitorque, Terumo, Japan) through the transfemoral route. The unique shape of the TIG diagnostic catheter allowed coaxial engagement of anomalous right coronary artery, with adequate lesion assessment and stent delivery.

Sinus of Valsalva aneurysm, usually a congenital anomaly, almost always ruptures into the right sided cardiac chambers, causing a left-to-right shunt with profound haemodynamic consequences. With the availability of the current genera- tion of devices and hardware, transcatheter closure has gradually replaced the surgical route. To date, most closures have been performed using an Amplatzer duct occluder (ADO). Here, we report the case of a 21 year-old male where a very large (18 mm) rupture of a sinus of Valsalva aneurysm from non-coronary cusp to right ventricle was closed by a percutaneous approach using a 20/18 mm Cocoon duct occluder (CDO; Vascular Innovations, Nonthaburi, Thailand).

The retroesophageal right subclavian artery (ROSRA; arteria lusoria) is one of the anatomical abnormalities encountered at innominate-arch junction during transradial catheterization by right route. Here, we report a case of a 49-year old female who presented with chronic stable angina (Canadian Cardiovascular Society class-III) despite guideline directed medical treatment. Coronary arteries were cannulated with difficulty showing critical lesion of proximal left anterior descending artery (LAD). During angiography, diagnostic catheter has a peculiar cobra loop in the ascending aorta. As the left subclavian artery also has critical lesion at the proximal part, percutaneous coronary intervention of proximal LAD artery was successfully performed with 3.5×23 mm Xience Prime Everolimus eluting stent (Abott, USA) through right femoral route. Multi detector computed tomography (MDCT) contrast aortography showed the origin of the right subclavian artery in the right posterior side of the horizontal aorta with a tortuous course, proximal stenosis of left subclavian artery (LSC), and a bicarotid truncus. This abnormality can be easily detected by angiographic visualization, in the anteroposterior projection, of the angle of the catheter when it engages the ascending aorta, and by manual angiography at the ostium of the right subclavian artery. In such a case, selective catheterization of both coronary arteries may be very difficult, time consuming, and require more catheters. In such cases, one should not be hesitant to switch to transfemoral route if left radial route cannot be utilised.

A 10 year-old girl was admitted to hospital for evaluation of sudden onset chest pain of three days’ duration. There were no co-morbidities or family history of coronary artery disease. There was a disparity of blood pressure in the upper limbs, while pulses in the lower limbs were barely palpable. Her electrocardiogram revealed ST segment elevation in II, III, and aVF leads. Laboratory tests showed elevated troponin T (0.8 ng/mL), total leukocyte count (13,800/ μ L), C-reactive protein (94 mg/L), and erythrocyte sedimentation rate (56 mm in first hr). Echocardiography showed mildly impaired left ventricular systolic function with an ejection fraction of 58%. Aortogram showed total occlusion of the brachiocephalic trunk, diffuse thoraco-abdominal coarctation, and osteo-proximal stenosis (80%) of the left renal artery. Coronary angiography revealed total occlusion of the left circumflex artery and tubular lesion of the proximal left anterior descending artery with 70% stenosis. Based on these findings, she was diagnosed to be in the active phase of juvenile Takayasu’s arteritis having acute inferior wall myocardial infarction. Her treadmill test for reversible ischaemia (modified Bruce protocol) was negative, and she was discharged on medication (antiplatelets, corticosteroids, and immunosuppressive agents).

Aortico–left ventricular tunnel (ALVT) is a rare congenital paravalvular communication between the aorta and the left ventricle (LV), with few hundred odd cases reported till date. Most commonly the tunnel arises from the right aortic sinus. We herein report a case of AVLT in a 28-year old male where a common pouch, which was communicating to both the left, as well as right aortic sinus, was draining to the left ventricle. He presented with progressive heart failure where a long diastolic murmur was audible. The patient succumbed to death because of progressive cardiac decompensation before surgical correction could have been performed. This is a first ever report of AVLT where proximal chamber as a common sac, communicating with both the left, as well as right aortic sinus, was communicating distally to the left ventricle. Key words- Aortico- left ventricular tunnel, Congenital heart defect, Aortic regurgitation; Diastolic murmur; Cardiac decompensation

A small portion of lesions are refractory even when very high pressures are used to deploy the stent. Here, we report a 7-years old boy referred for evaluation of refractory hypertension. There was a bruit on auscultation on the back in lumber region. Renal angiogram revealed bilateral renal artery stenosis. Right and left renal arteries were stented with 7x23 mm and 7x19 mm Hippocampus bare metal stent (Medtronic, USA). Despite delivering stent in left renal artery at 10 atm pressure, it didn’t open up properly. We successfully attempted the technique of hugging balloons or two noncompliant balloons- 4x10 mm each, inflated simultaneously side by side at 20 atm to successfully dilate the stent. This technique enables success as the geometry of two kissing balloons is different from one balloon. This altered geometric configuration may be important in successfully dilating a stent refractory to standard dilating techniques. Higher pressures can be attained with two smaller balloons as the burst pressure is higher in smaller balloons compared to larger balloons.

Anomalies of the coronary arteries are reported in 1–2% of patients who undergo a diagnostic angiogram. An ectopic origin of the right coronary artery from the opposite sinus is one of these anomalies, and while most are benign, at times it may be malignant. We report the case of a 43-year-old female who underwent primary percutaneous coronary intervention for acute inferior wall myocardial infarction where an ectopically arising right coronary artery (RCA) with abnormally high take-off was the culprit. We describe the various technical challenges faced during intervention, from cannulation to tracking of hardware. The RCA was cannulated using the floating wire technique and revascularised by the deployment of a 3.5 × 33 mm Xience Prime drug-eluting stent (Abbott Vascular, Santa Clara, CA, USA). In such a scenario where a conventional technique fails and where door-to-balloon time must be kept as short as possible, a little improvisation should resolve the problem.

A 49-year-old diabetic woman who had end stage renal disease associated with membranous glomerulonephritis, was undergoing dialysis through a left brachiocephalic arteriovenous fistula. After sometime, fistula became infected and stopped functioning. It was closed and arterial segment was resected and repaired with reverse saphenous vein graft. After 6 months interval, she presented with painful, expansile swelling with intermittent bleeding. Arteriogram showed ruptured aneurysm of reverse saphenous vein graft with a proximal venous stenosis. It was successfully closed with 6 × 60 mm Fluency Plus self-expanding vascular stent graft (Bard, Tempe, AZ) with resolution of her symptoms.

A 65-year-old diabetic and hypertensive woman was admitted for evaluation of syncope. Her baseline electrocardiogram revealed normal sinus rhythm with left anterior hemiblock. Her treadmill test, holter monitoring and external loop recorder examinations were normal. Right sided carotid sinus massage (CSM) revealed 2:1 atrioventricular block (AV) (Mobitz II type) while left sided CSM had no effect. Permanent pacemaker implantation was performed (DDIR, St Jude Medical, USA). Mobitz II type AV block due to CSM reflects enhanced vagal efferent tone on AV node and his bundle fibre.

Percutaneous balloon mitral valvuloplasty (BMV)using an Accura balloon is an effective procedure for the management of patients with rheumatic mitral stenosis.The inability to cross the mitral valve is one of the prime reasons for procedural failure. Here, we describe the case of a 24 year-old male with severe mitral stenosis with agiant, aneurysmal left atrium (left atrium12.3 × 10.4 cm) where the traditionally described technique of mitral valve entry failed. BMV was successfully performed by a U-shape modification of hairpin loop entry (the modified hairpin entry method), expanding the mitral valve area from 0.8 cm 2 to 1.9 cm 2 .

Anomalous origin of the left circumflex coronary artery from the right sinus of Valsalva is a relatively common anatomical variation. Here, we report the case of a 45 year-old male patient with a history of diabetes mellitus, dyslipidemia and smoking whounderwent primary percutaneous coronary intervention of the left anterior descending artery in lieu of anterior wall myocardial infarction where dual left circumflex coronary artery was diagnosed angiographically, the first arising from the left main artery in the usual fashion, and the second in the form of an obtuse marginal branch coming from the large diagonal branch.

A 49-year old woman presented with exertional dyspnoea NYHA class-II for last three year, with recent worsening in the past six months. Transrthoracic echocardiography (TTE) revealed dilated left ventricle and atrium with systolic dysfunction (EF=35%). Apical 4-chamber view showed continous low flow signals (diastolic more than systolic) in the interventricular septum detected by continous Doppler interrogation (Fig.1, 2). Beside mild mitral regurgitation, and dilated ostium of right coronary artery (RCA), other abnormalities could not be detected. Coronary angiogram showed absent left coronary ostium in aortic sinus, dilated and tortuous right coronary artery (RCA) giving abundant intercoronary anastomoses to left coronary artery (LCA) which was later opacifying the main pulmonary artery in the delayed filling phase thus establishing diagnosis of ALCAPA (Fig. 3). The left coronary ostium arising from the pulmonary trunk, a sign qua non could not be seen on TTE because of poor parasternal short-axis echo window. ALCAPA is a rare congenital coronary anomaly with an incidence of 1 in 300,000 live births [1-3]. Angiography whether invasive or computed is its important modalities. However, they carry the disadvantage of radiation, contrast exposure, cost, and nephrotoxity. On the other hand, transrthoracic echocardiography (TTE) is an important non-invasive reliable modality which helps in its diagnosis as it gives important information regarding the anatomic, functional, and hemodynamic evaluation. Abundant intercoronary septal collaterals with continuous flow, particularly in mid-systole and more in diastole were imparting septal fluttering indicating ALCAPA which was subsequently confirmed on angiogram. Such low flow signals differentiate it from the small muscular ventricular septal defects which shunt in systole and RCA to pulmonary artery fistula where connections are epicardial and will have different angiographic appearances. Although LCA originating from the pulmonary artery in parasternal short-axis view is most diagnostic, it may not always be appreciated because of poor widow, and LCA remaining close to the aorta, and therefore septal fluttering in another pointer towards its diagnostic [4]. It suggests left-to-right shunting from RCA via LCA to main pulmonary artery through intercoronary septal collaterals, and low pulmonary vascular resistance which is in the opposite direction of normal LCA and is prominent in the diastolic phase. Adult survivors of ALCAPA are often incapacitated by myocardial ischemia, arrhythmias and cardiomyopathy. Survival without surgery (direct transfer of LCA from pulmonary artery, bypass or Takeuchi repair) is exceedingly rare beyond fourth or fifth decade as low pulmonary artery pressure results in coronary steal phenomenon [5]. Some may remain asymptomatic until adulthood due to superdominant RCA, become symptomatic due to fixed myocardial ischemia and coronary steal phenomenon [6]. The more collateral channels exist between RCA and anomalous left coronary system (ALCA), the longer the patient may survive.

Normal myocardium is usually perfused by three coronary arteries- a left main system bifurcating into left anterior descending artery (LAD), and left circumflex artery (LCx), and right coronary artery (RCA). Coronary artery anomalies are congenital changes in their origin, course, and/or structure, which are usually discovered as incidental findings during coronary angiographic studies. Here, we report a case of 56-year-old hypertensive, and diabetic male who was being evaluated for exertional angina and dyspnoea whose coronary angiogram revealed a rare coronary anomaly: normal LAD, absent LCx, and superdominant RCA which was better delineated on Multidetector coronary angiography (MDCT). Multislice CT is the non-invasive modality of choice for imaging anomalies of coronary arteries and provides high speed with excellent spatial resolution.

Single coronary artery (SCA) is a rare congenital anomaly of the coronary circulation, the incidence of which has been reported as being from 0.6–1.3% among the population undergoing coronary angiography. The absence of a right coronary artery (RCA) with the origin of the RCA arising from the distal circumflex artery is an exceedingly rare variant of the SCA. The exact incidence of this anomaly is uncertain, with very few cases reported. We here report the case of a 56 year-old diabetic, hypertensive male presenting with acute inferior wall myocardial infarction who was thrombolysed with tenecteplase. Subsequent coronary angiogram demonstrated RCA arising from the distal left circumflex coronary artery (LCx) as its extension, thereby making the LCx super-dominant. RCA had ostial plaquing, and therefore the patient was managed conservatively.

Percutaneous trans-mitral commissurotomy (PTMC) using Accura balloon is an effective procedure for management of patients with rheumatic mitral stenosis. It is not uncommon to come across giant left atrium (LA) especially in the developing world as patient often present late in the course of the disease. This is a technically challenging situation as usual landmark changes which make the procedure difficult beginning from septal puncture to negotiation of balloon into left ventricle across the mitral valve. Here we report a case of 16-year old girl suffering from rheumatic mitral stenosis in which left atrium was giant (13cm x 11cm) where the mitral valve could not be negotiated with standard technique. Valvotomy was successfully executed by reverse loop entry technique.

Patent ductus arteriosus (PDA), a persistent left to right shunt at great arterial level, accounts up to 10% of all congenital heart disease. Here, we report a case of a 6-month old baby with large PDA (5mm) whose percutaneous closure was planned. The Coccoon Duct Occluder (CDO) - 8/6 was fitted by rotating it clockwise over the delivery cable and the assembly of loader-cable-device was advanced into the descending aorta. The device was properly positioned across the PDA as both the aortic, and pulmonic side of the devise was properly opened. The device was then released by turning the delivery cable counter-clockwise using the pin vise, but inadvertently the delivery sheath remained attached to the pulmonic side of the device. All efforts to rescrew the delivery cable to the device failed. The delivery sheath was gently rotated counter-clockwise over the device to detach it successfully from the pulmonic end of the device, thereby securing its perfect placement. Aortogram using the pigtail catheter confirmed its perfect position with no residual shunt. Therefore, delivery sheath should be pulled fair enough proximal to the pulmonic end of the device before releasing it by rotating the pin-vise counter clockwise. Key words- Patent ductus arteriosus; Coccoon Duct Occluder; Delivery cable; Pin-vise

Jailed wire technique i.e wiring of the side branch (SB) before main vessel (MV) stenting is recommended to keep it open when the SB is deemed important ( > 2mm). Rarely, it becomes difficult to retrieve the jailed wire behind the stent and it may suffer fracture or entrapment, although exceedingly rare. It may be asymptomatic or can lead to abrupt closure of side branch resulting into periprocedural myocardial infarction. Here, we report a case of 56-old male who had undergone percutaneous coronary intervention (PCI) of proximal left anterior descending artery in 2012 during which jailed balance middle weight wire (BMW, Abott Vascular, USA) of diagonal branch got unravelled and entrapped. As patient was asymptomatic, he was conservatively managed. 6-years later, he suffered acute inferior wall myocardial infarction with complete heart block. Primary angioplasty of totally occluded right coronary artery was done with 3x38 mm Xience prime stent (Everolimus eluting stent; Abott vascular, USA). In coronary angiography of left system, left anterior descending and diagonal branches were completely patent. The fractured and retained jailed wire was still in diagonal branch with no displacement in comparison with previous coronary angiography. The patient was discharged in stable cardiac condition with appropriate follow up advise. To the best of our knowledge, this is the longest follow up of entrapped, and fractured BMW wire.

Transradial approach scores over transfemoral approach as it is associated with less complications, mortality, and morbidity. Though right sided approach is more convenient for manipulating catheters and devices, aorto-subclavian tortuosity may result into looping, entrapment, kinking, and rarely intravascular knot formation. Here, we describe a case of a 60-year old female which had gone transradial catheterization from right side. Due to aorto-innominate tortuosity, excessive clockwise torque was applied to the catheter to cannulate right coronary artery which resulted into pressure damping, and intravascular knot formation in brachial artery. It was unravelled by counter clockwise rotation of catheter, and thus completing the procedure.

Chronic mesenteric ischemia (CMI) is a challenging problem especially when both the superior mesenteric artery (SMA) and celiac artery (CA) are involved. We report a case 65-year-old female with hypertension, type II diabetes, and dyslipidemia who presented with exertional angina for 11-months duration and abdominal angina with weight loss for 5-months. Coronary computed tomographic (CT) angiogram revealed critical discrete lesion of mid right coronary artery (RCA). A contrast CT angiogram revealed a high grade, long segment stenosis of supra-renal abdominal aorta which was mildly calcified, mild ostial stenosis of celiac artery, and critical ostial stenosis of superior mesenteric artery (SMA) suggesting middle aortic syndrome with mesenteric artery stenosis. RCA was revascularised by deployment of 3.5x18 mm Xience prime Everolimus eluting stent (Abott Vascular; USA) at 13 atm pressure achieving TIMI III flow through left transbrachial approach. Aorta was stented transfemorally using two overlapping Epic self-expanding stents (Boston scientific, USA) - 12x60 mm proximally and 10x40 mm distally. SMA was stented with 6x18 mm stent (Herculink, Boston, USA) after predilatation achieving complete revascularization.

Left ventricular noncompaction (LVNC) is a rare form of cardiomyopathy caused by the failure of myocardial compaction during embryogenesis. Clinical features spectrums from are from being totally asymptomatic to systolic dysfunction, heart failure (HF), tachyarrhythmias, and systemic thromboembolism. However, there have been only few reports regarding its coexistence with LV aneurysm. A 34-year-old man with no significant cardiopulmonary history was evaluated for progressive exertional dyspnoea. The chest radiography exhibited cardiomegaly, mild pulmonary congestion and huge calcified shadow at apex. The laboratory data was unremarkable except for elevated brain-type natriuretic peptide. Transrthoracic echocardiography demonstrated global hypokinesia with an ejection fraction of 30%, prominent trabeculation and deep intertrabecular recesses, and calcified aneurysm (12.3x7.8 cm), and increased noncompacted (NC) endomyocardial layer depth compared to the compacted (C) epicardial layer (NC/C= 2.4) which was further confirmed on multi detector computed tomography (MDCT). Based on these findings, he was diagnosed as LVNC complicated with a giant calcified aneurysm. He was discharged with carvedilol, ramipril, and frusemide and referred for surgical restoration/resection of aneurysm. Here, to the best of our knowledge, we report the patient who had LVNC with biggest LV aneurysm.

In patients with critical stenosis or total occlusion of either the left anterior descending artery or right coronary artery, the conus branch of right coronary artery sometimes serves as a major source of inter-coronary collateral. These collateral channels form the Vieussens ring. Here we report a case of a 74-year-old diabetic and hypertensive male whose angiogram revealed normal appearing left main, discrete lesion with critical stenosis of proximal left circumflex (LCx), left anterior descending artery (LAD) revealing diffuse disease of mid segment with critical stenosis and dissection, and chronic total occlusion of right coronary artery. However, diagonal branch could not be visualized. The large and tortuous conal branch was filling the large diagonal branch of LAD. In our case, Vieussens ring was serving as collateral to diagonal branch instead of LAD. It has both diagnostic, as well as therapeutic implication as it helps surgeon to avoid any inadvertent damage to the conus artery especially if surgery involves manipulation of the right infundibulum. It may serve as an alternative to the retrograde route when the lesion cannot be successfully crossed using an anterograde approach for LAD recanalization.

Anomalies of the coronary arteries are reported in 1–2% of patients subject to a diagnostic angiogram. Ectopic origin of right coronary artery from the opposite sinus is one of the most common, and while mainly benign, at times may be malignant. We report the case of a 72 year-old male who underwent percutaneous coronary intervention for chronic stable angina who had a critically diseased obtuse marginal branch, and an anomalous right coronary artery (RCA) arising from the left aortic sinus on coronary angiogram, and various technical challenges during the procedure. RCA was cannulated using a Judkins left guiding catheter and revascularised by deployment of a 2.75 × 18 mm Promus Premier Stent (everolimus-eluting stent, Boston Scientific, USA) at 12 atm.

A 68 year-old male with hypertension, dyslipidemia, and current smoking as coronary risk factors was referred for coronary angiography (CAG) in lieu of chronic stable angina. He was Canadian Cardiovascular Society class III despite guideline-directed medical treatment. The CAG revealed a critical stenotic lesion (90%) in the proximal left circumflex (LCx) coronary artery with mild calcification. A 3.5 × 23 mm Xience prime drug-eluting stent (Abbott Vascular, USA) was deployed at 8 atm. Duringthe procedure, he developed chest pain. Angiogram revealed a long spiral dissection starting from the distal edge of the stent. To bail out, another overlapping 3 × 38 mm Xience prime stentwas deployed at 10 atm pressure, showing proper stent expansion and no residual dissection flap with TIMI-3 coronary flow. This case highlights that dissection can occur in a calcified vessel even below the nominal pressure which could be successfully bailed out by implantation with another coronary stent with complete cover of the coronary dissection.

Iatrogenic coronary dissection is a rare but potentially catastrophic complication of percutaneous coronary intervention. The proximal left anterior descending artery (LAD) dissection may extend into distal left main bifurcation which may further engulf left circumflex artery (LCx). Here, we report a case of a 69-year-old male where dissection at proximal edge of well deployed stent led to total closure of left circumflex artery causing hemodynamic compromise. It was bailed out using T-and-protrusion (TAP) stenting where LAD and LCx were stented using 3.5x12mm and 3x24 mm sirolimus-eluting stent (Yukon Choice, Translumina) respectively. TAP technique is a feasible and reasonable management strategy for immediate bail-out stenting for this lethal complication

Contrast-induced nephropathy (CIN) is a serious complication in patients with chronic kidney disease with coronary artery disease who undergo percutaneous coronary intervention (PCI), and is associated with higher morbidity and mortality in short and long term. The limiting volume of contrast agent is safest and most reliable strategy to prevent CIN. Here, we report a case of suc¬cessful PCI using only 13 ml of contrast (iodixanol) of mid left anterior descending artery where wire in diagonal branch served as a landmark in a 75-year-old diabetic and hypertensive male who had presented with acute coronary syndrome and had marked renal dysfunction having serum creatinine of 2.9 mg%. There was no change in basal renal function after the procedural and safely discharged.

Stent fracture is an emerging complication of coronary angioplasty as a result of the complex interplay between stent design, the stented segment, stent over-expansion, a long stent and tortuous and complex lesions including chronic totally occluded vessels and calcified lesions.Its temporal course may be acute as well as delayed, including totally asymptomatic restenosis, migration of the stent, vessel perforation, and stent thrombosis. Here, we report the case of a 60 year-old patient who had acute stent fracture of an Endeavour Resolute stent (zotarolimus-eluting stent 3 × 33 mm) in a fibrocalcific lesion causing vessel perforation which was successfully treated with restenting by another Endeavour Resolute stent (3 × 29 mm).

Cardiac resynchronization therapy (CRT) device implantation is hampered by difficult placement of the left ventricular (LV) lead. Here we report a case of 68-year old male who presented with heart failure having New York Heart Association (NYHA) class III. He was hospitalized with ventricular tachycardia which was restored to normal rhythm by cardioversion. Electrocardiogram revealed normal sinus rhythm, and complete left bundle branch block (LBBB) with prolonged QRS complex duration (198ms). Echocardiogram showed dilated left atrium, and ventricle with severe left ventricular (LV) systolic dysfunction (ejection fraction= 35%). Coronary sinus cannulation was failed with conventional technique, steerable electrophysiology (EP) catheters, and other guiding catheters. CS was successfully cannulated with the help of Tiger Diagnostic Catheter (Terumo, Japan) using mother-in child system and LV lead was implanted into desired territory, thus completing the procedure.

The incidence of coronary artery anomalies in double-outlet right ventricle (DORV) or tetralogy of Fallot (TOF) has been reported to be 2% to 10%. Surgical correction in such a scenario, across a narrowed and under-developed right ventricular outflow tract (RVOT), poses a significant challenge and has been associated with increased morbidity and mortality. These combinations at times may change the approach of primary repair to one of initial palliation. Single coronary artery, meaning anomalous origin of the right coronary artery from the left anterior descending artery, is a benign and very rare coronary artery anomaly. Here, we report the case of an 11 year-old boy with double-outlet right ventricle (DORV) with pulmonary stenosis (PS) where pre-operative catheterisation and multi detector CT angiography (MDCT) revealed anomalous right coronary artery arising from left anterior descending artery.

Fracture of catheter fragment in a coronary artery during percutaneous coronary angioplasty is a rare complication, which may result into embolization or impaction leading to complete or near complete occlusion of respective territory, arrhythmia, or rarely sudden death. Here, we report an unusual complication of a broken balloon catheter during angioplasty of a calcified right coronary artery in a 78-year old female which was successfully retrieved by balloon assisted trapping in guiding catheter.

A single coronary artery is a rare coronary artery anomaly. A 39 year-old female underwent coronary angiography for unstable angina. This revealed a common coronary trunk arising from the right sinus of Valsalva giving rise to a right coronary artery (RCA) and a long left main trunk further dividing into a Type-I left anterior descending artery (LAD) and co-dominant left circumflex coronary artery. Distal RCA showed a discrete lesion in the posterior descending artery. Her treadmill test (TMT) was negative for reversible ischaemia. Considering her stable condition and TMT results, she was discharged on medical treatment.

Coronary artery anomaly in form of dual origin of the circumflex artery is a rare anomaly. Though mostly described as having separate origin, both arising from left main coronary as twin circumflex artery itself has not been reported so far. Here we report a case of 57-year old male patient who had presented with ST elevation anterior wall myocardial infarction. His angiogram revealed left main trunk which was giving a left circumflex artery (LCx). On further coursing, left main trunk was trifurcating into left anterior descending artery (LAD), ramus intermedius and second left circumflex artery. Second circumflex branch was giving larger obtuse marginal branch while right coronary artery was smooth, non-dominant, and normal flowing artery. There was discrete eccentric stenosis with critical lesion in proximal LAD for which patient refused any intervention. Based on angiographic findings, it was diagnosed as a twin circumflex, both arising from left main trunk as one coming before the bifurcation while another after the bifurcation. An extensive search of literature and to the best of our knowledge, such type of anomaly is being reported for the first time.