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CTO-PCI performed by highly experienced specialists achieved a high technical success rate.

To assess the incidence and impact on clinical outcomes of subintimal tracking in patients undergoing percutaneous coronary intervention for chronic total occlusion (CTO). Patients at 27 centres were consecutively enrolled when guidewire crossing of the CTO by either the antegrade or the retrograde approach was confirmed by intravascular ultrasound (IVUS). IVUS images were examined to identify the course of the wire. Clinical follow-up at one year and angiographic follow-up at nine months were performed after everolimus-eluting stent implantation. Among a total of 163 patients (59 antegrade and 104 retrograde), subintimal tracking was more frequent with the retrograde approach (24.2% vs. 12.3%, p=0.10). Although there was no difference in the one-year target vessel revascularisation rate between intimal and subintimal tracking with either the antegrade or the retrograde approach, angiographic follow-up revealed greater late loss in the subintimal group compared with the intimal group. Multivariate analysis identified the pre-procedural reference diameter as a predictor of subintimal tracking. Subintimal tracking was more frequent with the retrograde approach. After medium-term follow-up, no negative clinical impact of subintimal tracking was observed in this small study. However, further evaluation of the angiographic impact is needed.

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ransient left ventricular apical ballooning [1][2][3][4][5][6] in patients with normal coronary angiography results is characterized by transient left ventricular (LV) dysfunction and chest symptoms, together with electrocardiographic (ECG) changes that mimic those of acute myocardial infarction (AMI). Generally, the prognosis for transient LV apical ballooning is good, because in most patients ventricular function improves with conservative therapy. Nevertheless a very small number die from cardiogenic shock. We report a patient, treated for transient LV apical ballooning, who died from LV free wall rupture. Such an occurrence has not been reported previously in association with transient LV apical ballooning. Case ReportA 79-year-old woman was admitted to hospital in September 2003 with sudden onset of chest pain. Her level of consciousness was clear, her pulse rate was 84 beats/min, and blood pressure was 124/80 mmHg. Auscultation of the heart and lungs was normal. An ECG showed sinus rhythm with ST-segment elevation in leads I, aVL and V1-5, depression in leads III and aVF, and abnormal Q wave in leads V1-4 (Fig 1). Echocardiogram at the time of admission revealed akinesis in the LV apical wall. Laboratory data showed increased creatine kinase concentration (768 IU/L). An acute AMI was suspected, and the patient underwent emergency cardiac catheterization. However, coronary angiography did not reveal a stenotic lesion in any coronary artery (Fig 2A,B) (Fig 2C,D), and the LV ejection fraction was 31%. A diagnosis was subsequently made of transient LV apical ballooning, and she was only treated with diuretics.On the fifth day following admission, another ECG indi-