Surviving a Left Main coronary artery (LMCA) total occlusion depends upon the presence of well-developed collaterals. We report a 44 year male patient, with past history of Ischemic heart disease, who underwent Angioplasty to Left Anterior Descending Artery (LAD) in 2009, and presented with Acute Coronary Syndrome (ACS)-Non ST Elevation of Myocardial Infarction (NSTEMI). Subsequently, cardiac catheterization revealed a total occlusion of the LMCA with dominant right coronary artery (RCA) giving collaterals to the left coronary arteries. The patient was immediately referred for coronary artery bypass surgery (CABG) and was symptom free on follow up. This case demonstrates the power of collateral circulation in protecting the patient from symptoms and death despite total occlusion of the LMCA.

An inadvertent puncture during PTMC in the region where right atrium (RA) and left atrium (LA) have overlapping walls may lead the catheter/needle to perforate the right atrial wall, enter the pericardial space and then enter the LA leading to "stitching phenomenon". We describe a case of cardiac perforation resulting in cardiac tamponade during PTMC due to stitching phenomenon, promptly recognized and managed, completed PTMC and referred to surgery for cardiac perforation repair.