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Claudiu Ungureanu,1 Giuseppe Colletti,1 Marc Blaimont,1 Alexandre Avran2 1Department of Cardiology, Jolimont Hospital, La Louvière, Belgium; 2Department of Cardiology, Clinique Pasteur Essey les Nancy, Nancy, FranceCorrespondence: Claudiu Ungureanu, Department of Cardiology, Jolimont Hospital, Rue, Ferrer, 159, La Louvière, Belgium, Tel +32495489442, Email ungureanu.claudiu@ymail.comBackground: Percutaneous coronary intervention (PCI) of the “culprit” artery is the recommended mechanical reperfusion strategy in the setting of ST-segment elevation myocardial infarction (STEMI). As PCI of bypass grafts may be associated with higher risks and lower procedural success rates, in patients with a history of previous coronary artery surgery, PCI directed at revascularization of the native vessels should be considered, but this may be difficult in the setting of a chronically occluded artery.Case Presentation: A patient with a history of multivessel coronary artery disease and a chronic total occlusion (CTO) of the right coronary artery (RCA) requiring arterial bypass surgery, presented with an acute inferior STEMI and cardiogenic shock. It was felt that shock was caused by the acute thrombotic occlusion of a right internal thoracic artery (RITA) bypass graft that had been sequentially anastomosed to the left circumflex (LCx) and right coronary arteries. Despite initiation of extracorporeal membrane oxygenation (ECMO), the patient remained in refractory shock and acute revascularization of the right coronary artery was performed through the RITA bypass segment using antegrade access to the graft through the LCx and then a retrograde approach to open a CTO of the RCA. After successful revascularization, the patient was successfully weaned from ECMO. Over 12 months of follow-up, the patient did well and was documented to have improved left ventricular systolic function.Conclusion: This report is the first to document the successful use of a retrograde approach through an arterial graft segment to revascularize a chronic total occlusion in the setting of acute STEMI and cardiogenic shock.Keywords: chronic total occlusion, STEMI, rotational atherectomy, coronary bypass

A healthy 66-year-old female presented to the emergency department with acute chest pain, T-wave inversion in the anterior leads, and elevated troponin-I. Coronary angiography showed a stenosis in the midportion of the left anterior descending coronary artery (LAD), which did not wrap the left ventricle (LV) apex. LV angiography demonstrated a large LV apical akinetic systolic ballooning with a 45% ejection fraction. Fractional flow reserve (FFR) of LAD lesion was 0.71. Percutaneous intervention was performed. At six months, transthoracic echocardiography was normal. Fifteen months later, the patient presented with chest pain and a small rise in troponin-I. Coronary angiogram was unchanged. Repeat FFR in distal LAD was 0.86 and left ventriculography was normal. Diagnostic criteria for Takotsubo cardiomyopathy (TTC) require the absence of obstructive coronary artery disease. In the present case, TTC was highly suspected on the basis of typical LV apex ballooning. However, significant ischemia in the same territory was demonstrated by positive FFR, which could not be falsely positive in this context. Current TTC diagnostic criteria increase specificity for diagnosing TTC. This case reminds us that it is at the price of reduced sensitivity, since there is no reason to believe that coronary lesions may protect from TTC.