Centers who adopted a regional shock protocol emphasizing the delivery of early MCS with invasive hemodynamic monitoring can achieve rapid door to support times and can improve survival in patients who present with AMICS. Larger national studies will be needed to further validate this pilot feasibility study.

Same sitting HCR appears to be feasible and may offer superior outcomes to standard OPCABG, further studies are warranted.

We present a case of 72-year-old male with reported past medical history of recurrent transient ischemic attacks (TIAs) presenting with myriad of neurological symptoms. Patient was transferred from outlying hospital with complaints of right sided facial droop and dysarthria. Computed tomography angiography (CTA) showed high grade proximal left internal carotid artery (ICA) stenosis along with interesting finding of a free floating thrombus (FFT) in the left ICA. After discussion with the neurosurgical team, our case was treated conservatively with combination of antiplatelet therapy with Aspirin and anticoagulation with Warfarin without recurrence of TIAs or strokes on six-month follow-up.

HCR is associated with lower postoperative cTn release, compared with OPCAB. Further research into the clinical implications of this finding is warranted.

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DescriptionWe present a 50-year-old man with history of end-stage liver disease secondary to hepatitis C, who frequently presents to the hospital with ascites. He recently underwent Trans jugular Intrahepatic Portosystemic Shunt (TIPS) stent placement after becoming resistant to diuresis and large volume therapeutic paracentesis. He presented to the emergency room with altered mental status due to hepatic encephalopathy. On physical exam, he was noted to have a systolic murmur; hence, a transthoracic echocardiogram was ordered. It showed an echo dense ring-like shadow in the right atrium close to intra-atrial septum (figure 1). Transoesophageal echocardiogram was obtained for better visualisation, and it showed a migrated TIPS stent entering the right atrium from the inferior vena cava with its cephalad end close to the intraatrial septum (figure 2). There was no evidence of mechanical complication related to stent migration by echocardiography. The patient declined percutaneous retrieval. He was doing fine on subsequent follow-ups.Stent misplacement and migrations are rare but potentially life-threatening complications of TIPS. Prior case reports in the literature show that stents displaced to distal areas such as right atrium, right ventricle and pulmonary artery. It can also cause conduction abnormalities, valvular damage, perforation and death. [1][2][3] Literature review showed one similar case diagnosed by echocardiography in a 57-year-old male patient, who had cardiac ectopy, where the misplaced stent did not cause acute mechanical complication and was managed in the outpatient setting. 2Our case highlights the role of echocardiography to diagnose such complication of TIPS procedure and evaluate for its consequences. Echocardiography could also help guide the treatment approach including endovascular or surgical stent retrieval.