In symptomatic patients, a CTO, even with regional left ventricular impairment and/or excellent collateral development, reveals an ischemic zone. This ischemic zone can be normalized by PCI with outcomes appearing to be comparable to non-CTO patients.

In patients with a CTO and an intermediate donor artery stenosis, the frequency of ischemia in the donor artery territory is relatively high and often normalized by successful CTO recanalization. These data recommend recanalizing the CTO first whenever possible as a preferred therapeutic strategy to avoid the need for PCI to the donor artery or multivessel bypass surgery.

OBJECTIVES The purpose of this study was to test whether a microcatheter can safely be advanced across the right atrial appendage to access the pericardium and then withdrawn despite subsequent high-intensity anticoagulation. We also tested whether transatrial pericardial insufflation of carbon dioxide (CO2) would enhance the safety of subxiphoid needle access to the empty pericardium by separating the heart from the anterior pericardium. BACKGROUND Subxiphoid needle access to the empty pericardium, required for left atrial suture ligation and epicardial ablation for rhythm disorders, risks myocardial or coronary laceration. METHODS A catheter from the femoral vein engaged the right atrial appendage for angiographic confirmation of position. Through that catheter, the back end of a 0.014- or 0.018-inch guidewire crossed the right atrial wall to enter the pericardium and delivered a 2.4-F microcatheter. CO2 1 to 2 ml/kg was insufflated into the pericardium immediately before subxiphoid needle access under lateral projection fluoroscopy. Thirteen patients undergoing subxiphoid suture ligation of the left atrial appendage consented to participate in this research protocol. RESULTS Right atrial exit succeeded in 11 subjects (85%) and failed uneventfully in 2 subjects. CO2 insufflation of 96 ± 22 ml achieved 12 ± 4 mm separation of the anterior pericardium from the myocardial wall, allowed rapid and successful subxiphoid anterior needle and guidewire entry in all 11 subjects, and did not have any evident hemodynamic effects. The immediate pericardial aspirate was serous in all but 1 subject. CONCLUSIONS We report the first human intentional transatrial exit procedure. Transatrial microcatheter access to the pericardium can be achieved safely. Pericardial insufflation with CO2 makes subxiphoid access to the empty pericardium rapid and safe. Although our clinical experience to date remains small, with further experience, this approach may prevent the life-threatening complications of “dry” subxiphoid pericardial access.

Stable angina pectoris owing to isolated right ventricular ischemia from a critical stenosis in a nondominant right coronary artery is a rare entity and documentation of isolated right ventricular ischemia even rarer. We present a case of isolated right ventricular ischemia documented by fractional flow reserve (FFR) and resolution of symptoms after percutaneous coronary intervention.

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We appreciate the interest in our article by Dr Fan and colleagues regarding the first descriptive series of the effect of fractional flow reserve (FFR) change in a donor artery supplying collaterals to a chronic total occlusion (CTO) after it has been successfully revascularized [1]. In a cohort of 50 CTO patients undergoing successful PCI, this phenomenon was seen in 6 out of 14 patients (42%) with intermediate donor artery stenosis.Our data add support to previous case reports that the phenomenon of FFR reversal from [2][3][4] ischemic to non-ischemic may occur. We agree that the sample size in our study is relatively small but is the first series to describe the phenomenon and demonstrates that it is not unusual. From the physician and patient perspective, the major question is in patients with ischemic range FFR in donor artery with an intermediate stenosis and a CTO. Do these patients need to have revascularization in the intermediate stenosis as well as the CTO, only the intermediate donor stenosis, or only the CTO? In the DEFER trial [5], the intermediate stenosis with nonischemic FFR had a very low event rate (3%) at 5 years of follow-up. Based on this landmark trial, it seems preferable not to stent a stenosis with non-ischemic FFR. Our study demonstrates that this phenomenon may occur not infrequently if CTO recanalization is performed initially. Further, there are two studies looking at the longterm effects of CTO revascularization are under way (ClinicalTrials.gov: NCT01078051; NCT01760083), but results will not be available before 2015.Fan et al.[6] raises the question as to whether FFR in intermediate stenosis of the donor artery can worsen after CTO revascularization. Although we did not observe this result, we might speculate that if the donor artery was damaged either through the FFR wire itself or via its passage in a retrograde approach, with consequent worsening of donor artery obstruction, FFR would subsequently worsen.We recommend recanalization of a CTO when feasible in order to avoid unnecessary stenting in some cases of a donor artery. REFERENCES 1. Sachdeva R, Agrawal M, Flynn SE, Werner GS, Uretsky BF. Reversal of ischemia of donor artery myocardium after recanalization of a chronic total occlusion. Catheter Cardiovasc Interv 2013;82:E453-E458. 2. Melikian N, Cuisset T, Hamilos M, De Bruyne B. Fractional flow reserve-the influence of the collateral circulation. Int J Cardiol 2009;132:e109-e110. 3. Iqbal MB, Shah N, Khan M, Wallis W. Reduction in myocardial perfusion territory and its effect on the physiological severity of a coronary stenosis. Circ Cardiovasc Interv 2010;3:89-90. 4. Sachdeva R, Uretsky BF. The effect of CTO recanalization on FFR of the donor artery. Catheter