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Acute aortic dissection (AAD) is the most fatal aortic condition and is frequently overlooked during initial clinical presentations. Aortic dissection associated with acute coronary syndrome (ACS) is relatively rare but can pose diagnostic challenges and prove highly fatal. Retrograde extension of AAD may result in partial or complete occlusion of coronary vessels. Documented cases exist involving aortic dissection presenting as ST-segment-elevation myocardial infarction, with the right coronary artery being most commonly affected. A middle-aged woman with no comorbidities presented to the emergency department with sudden onset substernal chest discomfort radiating to her back and breathlessness for the past 5 hours. She had a tall and thin build and appeared anxious, diaphoretic, and orthopneic. Her vitals revealed tachycardia with a heart rate of 124 beats per minute and a systolic blood pressure of 80 mm Hg. Auscultation revealed a soft early diastolic murmur with fine crepitations at the lung bases. The chest X-ray indicated acute pulmonary edema and a widened mediastinum. The 12-lead ECG (Figure 1. A) demonstrated sinus rhythm with ST depression in leads II, III, aVF, and V3--V6 and ST elevation in leads aVR and I, indicating ACS involving the left main coronary artery (LMCA). Emergency endotracheal intubation was performed, and inotropes were initiated as stabilizing measures. The duty cardiologist was notified, and the catheterization laboratory was activated in anticipation of emergency coronary intervention. Concurrently, a point-of-care 2D transthoracic echocardiography was conducted, revealing severe left ventricular dysfunction (left ventricular ejection fraction =30%) with global left ventricular hypokinesia, a tricuspid aortic valve, and severe acute aortic regurgitation. Upon meticulous examination, an oscillating flap-like structure was identified in the ascending aorta (Figure 1. B-F). AAD was suspected, and an emergency multidetector computed tomography (CT) aortogram validated the diagnosis of Stanford type A AAD with a curvilinear dissection flap extending from the ascending aorta, involving the aortic arch and reaching the right common femoral artery. The intimal flap occluded the LMCA, leading to hypoperfusion in the supplied territory and causing severe left ventricular dysfunction (Figure 2 A-E) (Video 1). The attending cardiothoracic and vascular surgeon was promptly notified, and the patient was transferred for emergency surgery. [ABSTRACT FROM AUTHOR]

Bifurcation lesions, especially around the left main coronary (LMC), are occasionally encountered. More frequent LMC lesion are present in Complex and High risk Patients (CHIP) and this case represent a real challenge for interventional cardiologists. Bifurcation lesions PCI reported to have high overall major adverse cardiovascular events, and require the use of various complex interventional techniques. Here, we report a case of successful percutaneous coronary intervention supported by Impella on an LMC bifurcation treatment with culotte stenting in patient with cardiogenic shock.

Migration and embolization of a deployed stent is a rare complication of percutaneous coronary interventions (PCI) and can result in serious and potentially life-threatening complications. There are many reports of intracoronary stent entrapment, stripping, and dislodgement during PCI, however, only a few reports about migration. We report a rare case of migration of the left main coronary stent into the aortic root, which happened 5 months after the procedure and was treated by its partial removal through aortotomy along with surgical revascularization. The patient was discharged 5 days later, after an uneventful hospital stay.

Migration and embolization of a deployed stent is a rare complication of percutaneous coronary interventions (PCI) and can result in serious and potentially life-threatening complications. There are many reports of intracoronary stent entrapment, stripping, and dislodgement during PCI, however, only a few reports about migration. We report a rare case of migration of the left main coronary stent into the aortic root, which happened 5 months after the procedure and was treated by its partial removal through aortotomy along with surgical revascularization. The patient was discharged 5 days later, after an uneventful hospital stay. [ABSTRACT FROM AUTHOR]

Introduction: The significant stenosis of the left main coronary artery is associated with poor outcomes and is considered a strong indication for revascularization. However, deciding whether the stenosis is significant can sometimes be challenging, especially when the degree of stenosis is intermediate, and can necessitate additional tests and imaging modalities. Areas covered: We did a literature search using keywords like ‘left main’, ‘imaging’, ‘intravascular ultrasound’, ‘fractional flow reserve’, ‘computed tomographic angiography’ and ‘magnetic resonance imaging’. The most commonly used methods for better characterizing intermediate left main coronary stenoses are intravascular ultrasound and fractional flow reserve, while optical coherence tomography is the newer technique that provides better images, but for which not as much data is available. The noninvasive techniques are coronary computed tomographic angiography and, to a lesser degree, coronary magnetic resonance imaging. Expert commentary: Accurately determining the severity of left main coronary stenosis can mean the difference between a major intervention and conservative therapy. The reviewed newer imaging modalities give us greater confidence that patients with left main stenosis are assigned to the right treatment modality. [ABSTRACT FROM PUBLISHER]

Background: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V1 (aVR‐V1≥ 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V6 greater than or equal to ST deviation in V1 (V6‐V1≥ 0) might be a good determinant of LMCA disease. Methods: We compared admission 12‐lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V6‐V1≥ 0 to aVR‐V1≥ 0 in both groups. We also looked at ratios of ST deviations in V6,V1 (V6/V1≥ 1) and aVR,V1 (aVR/V1≥ 1) in patients where ST segment in V1 was not isoelectric (group I = 54 and group II = 55). Results: ST deviation in V6 was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V6‐V1≥ 0, V6/V1≥ 1, aVR‐V1≥ 0, and aVR/V1≥ 1 in predicting LMCA disease were determined. Conclusion: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V6‐V1≥ 0 and V6/V1≥ 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V1.

Determining the most appropriate revascularization strategy for patients presenting with unprotected left main coronary (UPLM) disease has been a topic of great recent interest. During this current decade, there have been multiple clinical trials and registries addressing this subject. Previously, UPLM disease has almost exclusively resulted in utilizing a surgical revascularization treatment strategy. However, recent improvements in percutaneous coronary intervention (PCI) techniques in parallel with the benefits of drug-eluting stents (DES) to reduce clinical restenosis have enabled further investigation in catheterization-based treatment strategies as possible alternative therapeutic options. These advances as well as an increased understanding of both the procedural and anatomical challenges involved with complex coronary interventions have allowed further advancements in the field. Better adjunctive antithrombotic pharmacological therapy in the PCI setting has favored such progress. American College of Cardiology/American Heart Association/Society for Coronary Angiography and Interventions guidelines do not currently endorse the performance of PCI as an appropriate alternative to surgical revascularization for patients with UPLM disease. This paper is a review of the current evidence on UPLM PCI and proposes future directions in this evolving field. [Copyright &y& Elsevier]

Background: Acute coronary syndrome (ACS) resulting from culprit lesion in left main coronary artery (LMCA) can cause rapid hemodynamic deterioration. It is important to identify these patients early to facilitate timely revascularization. ST segment elevation in aVR greater than or equal to V1 (aVR-V1≥ 0) has been suggested as a sensitive predictor of LMCA disease. As a result of balanced forces, we hypothesized that ST deviation in V6 greater than or equal to ST deviation in V1 (V6-V1≥ 0) might be a good determinant of LMCA disease. Methods: We compared admission 12-lead ECGs of ACS resulting from culprit LMCA lesion (n = 75, group I) with ACS resulting from culprit left anterior descending lesion (n = 81, group II). Group I was selected over a period of 10 years. We compared V6-V1≥ 0 to aVR-V1≥ 0 in both groups. We also looked at ratios of ST deviations in V6,V1 (V6/V1≥ 1) and aVR,V1 (aVR/V1≥ 1) in patients where ST segment in V1 was not isoelectric (group I = 54 and group II = 55). Results: ST deviation in V6 was significantly greater in group I as compared to group II (P < 0.001). The reliabilities of V6-V1≥ 0, V6/V1≥ 1, aVR-V1≥ 0, and aVR/V1≥ 1 in predicting LMCA disease were determined. Conclusion: This is the largest series of ECG analysis on ACS resulting from culprit LMCA lesion. V6-V1≥ 0 and V6/V1≥ 1 were more sensitive in predicting LMCA as culprit vessel in comparison to previously reported greater ST segment elevation in aVR than V1. [ABSTRACT FROM AUTHOR]

Anomalous origin of the left main coronary artery (LMCA) from the right sinus of the Valsalva or the proximal right coronary artery (RCA) is one of the most clinically important anomalies of coronary circulation. We report the case of a patient with chest pain and abnormal thallium myocardial perfusion scan in whom the anomaly was first detected on invasive coronary arteriography. The exact anatomic course of anomalous LMCA was confirmed using contrast enhanced computed tomography. [ABSTRACT FROM AUTHOR]

Abstract: During diagnostic angiographic procedures or percutaneous coronary angioplasty-stenting of the other coronary arteries, the overall risk for a complication related to the left main coronary artery (LMCA) is low; however, if such complications occur, they tend to be life-threatening and contribute to a large part of the total catheter-related mortality. We encountered a case of iatrogenic significant subtotal left main coronary artery thrombotic stenosis in a patient who had undergone prior percutaneous transluminal coronary artery angioplasty-stenting of the left circumflex artery. In light of the literature, an extremely rare clinical presentation of iatrogenic left main coronary artery thrombosis is discussed. [Copyright &y& Elsevier]

Background: Syntax 1 and recently Syntax 2 (SS2) scores are validated risk prediction models in coronary disease., Objectives: To find out the long term outcomes following stenting for unprotected left main bifurcation disease (LMD) and to validate and compare the performance of the SYNTAX scores 1 and 2 (SS1 and SS2 PCI) for predicting major adverse cardiac events (MACE) in Indian population., Methods: Single-center, retrospective, observational study involving patients who underwent percutaneous coronary intervention (PCI) with at least one stent implanted for the LMD. Discrimination and calibration models were assessed by ROC curve and the Hosmer-Lemeshow test., Results: Data of 103 patients were analyzed. The mean SS1 and SS2 scores were 27.9 and 30.7 and MACE was 16.5% at 4 years. The target lesion revascularization (TLR) rate at 4 years was 11(10.7%). There were 4 deaths (3.8%). The mean left ventricular ejection fraction (LVEF) was the only variable in SS2, which predicted cardiac events. ROC curve analysis showed both models to be accurate in predicting TLR and mortality following LM PCI. SS2 score showed a better risk prediction than SSI with AUC for TLR (SSI 0.560 and SS2PCI 0.625) and AUC for mortality (SS1 0.674 and SS2PCI 0.833). Hosmer-Lemeshow test validated the accuracy of both the risk models in predicting the events., Conclusions: Both risk models were applicable for Indian patients. The SS2 score was a better predictor for mortality and TLR. In the SS2 score, the LVEF was the most useful predictor of events after LM PCI., (Copyright © 2017. Published by Elsevier B.V.)

A 48-year-old hypertensive male presented with acute retrosternal pain and aortic regurgitation. The electrocardiogram showed ST-segment depression with T-wave inversion in anterolateral leads. Transesophageal echocardiography in long axis view of aorta revealed a spiral intimal flap in ascending aorta extending to the arch, diagnostic of Type A aortic dissection. The short axis view of the aorta showed partial obstruction of the left main coronary artery (LMCA) by the intimal flap with turbulent flow at its ostium. An emergency repair of aortic dissection with reconstruction of aortic wall was done. Postoperative period and ECG were normal. At 12-months of follow up, patient was doing well. [ABSTRACT FROM PUBLISHER]

Abstract: The coexistence of Brugada Syndrome and resting vasospastic angina resulting in cardiac arrest is rare. We describe a 64year-old man presenting with cardiac arrest and vasospastic angina with diagnostic criteria of symptomatic Brugada Syndrome. Recognition of the coexistence of these potentially fatal conditions has important therapeutic implications when using calcium channel antagonists and may shed light on the mechanisms of coronary spasm. A common pathogenesis, such as a common underlying channelopathy, may explain its coexistence with Brugada Syndrome. [Copyright &y& Elsevier]

Abstract: Thirty years after LMCA balloon angioplasty was performed. LMCA percutaneous intervention is still controversial because of its potential complications due to this site and of the good results of LMCA surgery. The poor balloon angioplasty is definitively given up. For the first time, bare stents were used in the middle of the 90 with excellent results concerning the in-hospital and one-year mortality, with a high rate of repeated revasculm-isation (TLR from 15 to 20 %). After the introduction of DES several physicians demonstrated the feasibility and the acceptable one-year mortality of this « off-label « indication; furthermore, cumulative experience with DES treatment for LMCA have naturally shown a reduction of the target vessel revascularisation. Nevertheless follow-up at 3 and 5 years of randomized compm-isons with CABG surgery will be necessary to dedicate LMCA eluting stenting as the new gold standard. [Copyright &y& Elsevier]

Objective: Heavily calcified left-main coronary diseases (LMCA) remain a formidable challenge for percutaneous interventions (PCI). This study was to investigate the safety and efficacy of using rotational atherectomy (RA) in treating such lesions in actual practice., Methods: From February 2004 to March 2012, all consecutive patients who received RA for heavily-calcified LMCA lesions in our cath lab were enrolled. The relevant clinical and angiographic characteristics at the time of index PCI, as well as the clinical follow-up outcomes, were retrieved and analyzed., Results: A total of 34 consecutive patients were recruited with a mean age 77.2 ± 10.2 years. There were 82.4% presented with acute coronary syndrome and 11.8% with cardiogenic shock. Chronic renal disease and diabetes were seen in 64.7% and 52.9%, respectively. Triple-vessel coronary disease was found in 76.5% of them. The mean SYNTAX score was 50 ± 15 and EuroSCORE II scale 5.6 ± 4.8. The angiographic success rate was 100% with a procedural success rate of 91.2%. The mean number of burrs per patient was 1.7 ± 0.5. Crossing-over stenting was used in 64.7%. Most stents were drug-eluting (67.6%). Intra-aortic ballon pump was used in 20.6% of the procedures. Three patients died during hospitalization, all due to presenting cardiogenic shock. No major complication occurred. Among 31 hospital survivors, the major adverse cardiac events (MACE) rate was 16.1%, all due to target lesion revascularization or target vessel revascularization., Conclusions: In high-surgical-risk elderly patients, plaque modification with RA in PCI of heavily-calcified LMCA could be safely accomplished with a minimal complication rate and low out-of-hospital MACE.