BackgroundLate gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended to distinguish Tako-tsubo cardiomyopathy (TTC) from either acute myocardial infarction or myocarditis.Method44 consecutive patients with confirmed Mayo Clinic criteria for TTC underwent CMR imaging at 1.5 Tesla during the acute phase. 10 patients who had CMRI to exclude scar related ventricular tachycardia, and had negative studies, were used as negative controls. LGE was quantitated at two signal intensity thresholds (CircleCVi software) at > 2 and > 5 standard-deviations (SD) above reference myocardium, and compared to biomarkers.FindingsMean door-to-CMR time was 57 hours. 18 patients (41%) had LGE > 2 SD localized to the area of abnormal wall motion, representing 28.9 ± 11.2% LV mass. In 16 of these 18 patients (89%) LGE signal intensity was > 5 SD above normal myocardium, representing 12.1 ± 10% LV mass. LGE signal intensity was significantly greater in TTC than in matched controls (p < 0.05) but lower than in STEMI patients (p < 0.05). Mean troponin was significantly higher in LGE positive patients (2.5 ± 1.8 vs 4.4 ± 6.9, p = 0.001). Mean ejection fraction (EF) by CMR was 45% ± 8.7 in LGE-negative, and 40% ± 7.1 in LGE-positive patients (p = 0.37). Recovery of segmental function was confirmed at follow-up, mean EF was 59% in both groups.ConclusionLGE was present in 41% of cases of TTC, 89% of which had intense enhancement > 5 SD above normal myocardium. Presence of LGE was associated with worse myocardial injury in the acute setting, with no difference in recovery of function.

Introduction Diagnostic coronary angiography (CA) uses ionising radiation with relatively high doses, which impact on both patients and staff. This study sought to identify which patient and procedural factors impact patient and operator dose the most during CA. Methods Patient and procedure related variables impacting on Kerma area product (PKA) and operator dose (OD) were collected for 16 months. Procedures were separated into 10 different procedure categories. PKA was used for patient dose and OD was measured with an instantly downloadable dosimeter (IDD) – downloaded at the end of each procedure. High and low radiation dose was defined by binary variables based on the 75th percentile of the continuous measures. Univariate and multivariate regression were used to identify predictors. Results Of 3860 patients included, the IDD was worn for 2591 (61.7%). Obesity (BMI > 30 compared to BMI < 25) was the strongest predictor for both a PKA (odds ratio (OR) = 19.1 (95% CI 13.5–26.9) P < 0.001) and OD (OR = 3.3 (2.4–4.4) P < 0.001) above the 75th percentile. Male gender, biplane imaging, the X‐ray unit used, operator experience and procedure type also predicted a high PKA. Radial access, male gender, biplane imaging and procedure type also predicted a high OD. Conclusion Radiation dose during CA is multifactorial and is dependent on patient and procedure related variables. Many factors impact on both PKA and OD but obesity is the strongest predictor for both patients and operators to receive a high radiation dose.

Coronary artery perforation is a rare complication of percutaneous coronary intervention (PCI).Covered stents have been successfully used in these situations. We report a case of ostial left circumflex (LCx) artery perforation during rotablation PCI of left main coronary artery (LMCA) and LCx artery. After failed attempts to balloon tamponade the perforation, a PK Papyrus covered stent was deployed from proximal LCx into LMCA. This resulted in acute exclusion of the left anterior descending (LAD) artery from coronary circulation. Using a dual lumen catheter, a stiff wire was advanced through the side port toward the occluded LAD to fenestrate the membrane of the covered stent. A series of balloons were used to dilate the fenestration in the covered stent to restore a normal flow into the LAD. K E Y W O R D S CHIP, coronary perforation, papyrus covered stent, rotablation 1 | INTRODUCTION Coronary artery perforation is one of the most dreadful complications of coronary intervention with an incidence of 0.1-0.6% of cases. 1 Coronary covered stents play a crucial role in the management of this complication. One of the drawbacks of the covered stents when used in bifurcation perforation is an occlusion of the branch vessel and this case depicts one of the management strategies to overcome this mischief. 2 | CASE An independent 91-year-old man presented with a non-ST-elevation myocardial infarction on the background of crescendo angina over 3 months and severe aortic stenosis. His only past medical history included mitral valve repair 24 years ago. On presentation his electrocardiogram had dynamic ischemic changes in the inferolateral leads. His bloods revealed troponin I at 7.2 μg/L (normal <0.040 μg/L) creatinine at 82 μmol/L (81-143 μmol/L), hemoglobin 177 g/L (120-180 g/L). Transthoracic echocardiogram (TTE) showed evidence of global left ventricular (LV) systolic dysfunction with LV ejection fraction (LVEF) of 35%, mild mitral regurgitation and low-flow low gradient severe aortic stenosis (aortic valve area [AVA] 1.1 cm 2 , indexed AVA 0.56 cm 2 , peak velocity 2.7 m/s, mean pressure gradient 16 mmHg, DPI 0.24). Coronary angiography revealed severe three vessel coronary artery disease with critical distal left main coronary artery (LMCA) stenosis, 90% ostial left circumflex (LCx) stenosis, 80% diffuse proximal left anterior descending (LAD) stenosis and moderate diffuse right coronary artery disease (Figures 1 and 4).He was deemed not a surgical candidate given his advanced age and previous sternotomy. His Society of Thoracic Surgeons Score (STS) score was 12% and EUROSCORE II was 13.6%. He was reviewed by the Heart Team and decision was made to proceed with complex percutaneous coronary intervention (PCI) of LMCA, LCx, and LAD with Impella CP mechanical circulatory support in the first instance and followed by transcatheter aortic valve replacement (TAVR) in the near future. | PROCEDUREVia right radial artery, a 7-in-6 Fr sheath was inserted to accommodate 7 Fr EBU guide catheter. 6 Fr sheath in left femoral a...

No abstract