Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the patho-physiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.

Background: Peripheral artery disease represents an important chapter of cardiovascular pathology in which atherosclerosis (promoted by major risk factors—hypertension, smoking, dyslipidemia, and diabetes mellitus) is the major etiology. The severity of this pathology is not only due to local injury but also due to frequent association with atherosclerotic disease with other localizations, thus increasing cardiovascular morbidity and mortality in these patients. Diagnosis is based on clinical data, functional tests (the ankle–brachial index is very useful in these cases) and imagistic methods (Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography). Therapeutic options vary depending on the location and severity of the lesions but also on the chronic or acute nature of the disease. Thus, in addition to pharmacological treatment and nonpharmacological measures (related to lifestyle), revascularization therapy is a very important step. Areas of Uncertainty: There are still many things that need to be clarified in this pathology: importance of developing national registries (because epidemiological data are often poor), role of drug-eluting stents/drug-eluting balloons in femoropopliteal lesions, optimal duration of double antiplatelet treatment after stenting, and more. Current guidelines for the management of peripheral artery disease are built from the results of many trials and research groups regarding to the evaluation and therapy of these patients. Therapeutic Advances: Endovascular therapy is particularly targeted for cases with short lesions/occlusions or in patients with high surgical risk; instead, surgical revascularization (bypass) brings benefits in patients with long or distal stenoses/occlusions or where anatomy does not allow for interventional intervention. Anticoagulant and thrombolytic treatment plays an important role in acute limb ischemia. Conclusions: So, in the patients with peripheral artery disease (especially acute limb ischemia), early diagnosis and prompt application of therapeutic measures are the cornerstone of management in these cases.

The development of coronary stents has represented a revolution in the treatment of coronary heart disease. Beyond their many advantages, stents also have their limitations and complications. Allergic reactions to coronary stents are more common than acknowledged. These stented patients are exposed to foreign substances inserted in direct contact with the coronary intima. Hypersensitivity to stent components and drugs prescribed after stent insertion together with any environmental exposure seem to contribute to these adverse reactions. Patients can present to the hospital with a wide range of symptoms and multiple complications, the most important ones being instent restenosis and stent thrombosis. Although not very common (and not always easy to identify), allergic reactions after coronary or peripheral stents should be taken into account. Careful selection of patients (for elective stent implantation) depending on the propensity to allergies, although hard to achieve, represents a key factor in reducing the number of these complications.

Rationale: Coronary chest pain is usually ischemic in etiology and has various electrocardiographic presentations. Lately, it has been recognized that myocardial bridging (MB) with severe externally mechanical compression of an epicardial coronary artery during systole may result in myocardial ischemia. Such a phenomenon can be associated with chronic angina pectoris, acute coronary syndromes (ACS), coronary spasm, ventricular septal rupture, arrhythmias, exercise-induced atrioventricular conduction blocks, transient ventricular dysfunction, and sudden death. Patient concerns: We report the case of a 58-year-old woman presenting with recurrent episodes of constrictive chest pain during exercise within the last 2 weeks. Except for obesity, general and cardiovascular clinical examination on admission were normal. Diagnoses: The resting 12 lead electrocardiogram (ECG) revealed changes typically for Wellens syndrome. High-sensitive cardiac troponin I was normal. We established the diagnosis of low-risk non-ST-segment elevation acute coronary syndrome with a Global Registry of Acute Coronary Events risk score of 92 points. Interventions: The patient underwent coronary angiography, who showed subocclusive dynamic obstruction of the left anterior descending artery due to MB. Outcomes: The patient was managed conservatively. Her hospital course was uneventful and she was discharged on pharmacological therapy (clopidogrel, bisoprolol, amlodipine, atorvastatin, and metformin) with well-controlled symptoms on followup. Lessons: MB is an unusual cause of myocardial ischemia. Wellens syndrome is an unusual presentation of ACS. We present herein a rare case of Wellens syndrome caused by MB. This case highlights the importance of subtle and frequently overseen ECG findings when assessing patients with chest pain and second, the importance of considering nonatherosclerotic causes for ACS.

Background Wellens syndrome is a clinical, biological, and electrocardiographic complex that identifies a subgroup of patients with unstable angina who have an impending risk of myocardial infarction and death, representing an equivalent of ST segment elevation myocardial infarction. Methods We conducted a prospective analysis of 64 consecutive patients, recruited over 2 years, with Wellens syndrome who underwent coronary angiography and we compared them with an age- and sex-matched group of patients with non-ST segment elevation acute coronary syndrome who underwent coronary angiography. The primary endpoints of our study were the rate of cardiovascular rehospitalizations, the rate of ischaemic reccurences, the rate of subsequent or recurrent revascularization, and the rate of mortality at six months from the index event. Results At 6 months, the patients in the control group had a higher rate of cardiovascular rehospitalizations (41.9% vs. 21.9%, p = 0.016). The rate of ischaemic recurrences and the rate of global mortality were similar across the two groups. Conclusion Physiopathologically and angiographically, Wellens syndrome is an abortive form of ST segment elevation myocardial infarction, but electrocardiographically and prognostically, it evolves similarly to a non-ST segment elevation acute coronary syndrome.

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Despite continuous efforts in early recognition and timely management, acute coronary syndromes (ACS) continue to be the most common cause of death worldwide. The electrocardiogram (ECG) is the fastest, repeatable and most accesible instrument with diagnostic value, prognostic significance and therapeutic implications. Based on the ECG, ACS are divided into ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation ACS (NSTEACS). Current guidelines recommend emergency reperfusion theraphy only in patients with STEMI. Conventional criteria for the diagnosis of STEMI exclude the patients with atypical ECG findings, correlated with an increased risk of transmural myocardial infarction and considered STEMI equivalents. These particular ECG phenotypes are: new or presumably new bundle branch block, ST segment elevation in aVR, isolated posterior myocardial infarction, de Winter T waves, Wellens syndrome and ischaemia induced Brugada phenocopy. Rapid risk stratification in patients with NSTEACS is crucial for adequate management. The particular ECG phenotypes discussed herein proove the need to redefine the signs of the present or iminent coronary artery occlusion, especially the left anterior descending (LAD) artery, because many patient may benefit from early invasive treatment instead of conservative pharmacological treatment.

The recurrence of ischemic events in patients with prior coronary artery bypass graft surgery (CABG) is an actual and challenging problem. Advances in surgical techniques and intensive care treatment have decreased the short-term mortality after CABG. Nevertheless, the increase in age and comorbidities of patients referred for CABG impacts the likelihood of graft degeneration or graft failure. More patients are referred to the cardiologist after CABG for the recurrence of symptoms. Particularities in the diagnosis and treatment of these patients need to be considered by the interventional cardiologist to ensure good angiographic and clinical results.