Despite lower rates of bleeding and vascular complications as compared to transfemoral approach (TFA), the adoption has been relatively slow particularly due to higher failure rates. Anatomical complexities of RA and BA vasculature play an important role for TRA failure cases. Using a simply framework to classify the anatomical or functional problem, and then approach these challenges in a logical sequence should facilitate management and increase success rate for TRA.

Percutaneous balloon pulmonary valvuloplasty (BPV) is the mainstay of treatment for significant pulmonary stenosis with doming leaflets. Various techniques have been described in the literature including the use of Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter with standard 0.025″ guidewire. But if right ventricular anatomy is not suitable, 0.025″ guidewire doesn't provide enough support to track the Inoue PTMC catheter. Here, we report a case of successful BPV using a novel technique of slenderizing the Inoue Percutaneous Transseptal Mitral Commissurotomy (PTMC) catheter over an Amplatz superstiff 0.035″ guidewire. This technique may be useful during BPV in difficult right ventricular inflow and outflow tract anatomy in patients with congenital pulmonary valve stenosis.

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We report a patient who presented with takotsubo cardiomyopathy but was misdiagnosed as an anterior wall ST elevation myocardial infarction (AWMI). We illustrate how misdiagnosis led to mismanagement by initiating intravenous inotropic agents that led to further hemodynamic compromise. Subsequent withdrawal of the inotropic agents and simultaneous administration of oral metoprolol therapy led to hemodynamic and clinical improvement re-affirming the diagnosis of takotsubo cardiomyopathy.

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