BackgroundThe left internal mammary artery (LIMA) graft constitutes the optimal conduit for bypassing the left anterior descending (LAD) artery. Despite its overall excellent long-term patency, the LIMA graft may fail, most commonly because of competitive flow. In case of a failed LIMA graft, a percutaneous coronary intervention (PCI) of the LAD artery may be required to ensure better outcomes. However, persistent competitive flow from an anatomically patent but functionally occluded LIMA graft after a successful PCI of the LAD artery may adversely affect clinical outcomes by predisposing to in-stent restenosis (ISR) and stent thrombosis.Case summaryHerein, we present the case of a patient with unstable angina and a failed LIMA graft exhibiting the “string phenomenon” because of competitive flow, necessitating a PCI of a high-grade stenosis in the LAD artery. Reverse LIMA graft flow, which is an indicator of severe competitive flow, was observed immediately after the PCI and during follow-up angiography, which also revealed an ISR of the LAD artery. Stent failure was attributed to the persisting competitive flow and was managed with drug-coated balloon angioplasty. In order to nullify any future deleterious effects of the competitive flow, we applied the “condom technique” to sacrifice the dysfunctional LIMA graft. The first attempt to apply this technique was complicated by the dislodgment of the remnant balloon from the assembly and migration into the distal LAD artery; however, the second attempt was successful in achieving graft occlusion. The patient was discharged home in good condition and remained free of angina or any cardiovascular events at a 6-month follow-up. An angiogram performed seven months after the drug-coated balloon angioplasty for ISR and occlusion of the LIMA graft showed preserved patency of the LAD artery.ConclusionDeliberate occlusion of a dysfunctional LIMA graft following a PCI of the LAD artery may help reduce the risk of future episodes of stent failure. Choosing to sacrifice the graft using the “condom technique” is feasible, safe, and effective, provided all steps of the technique are thoroughly reviewed and optimally performed.

We present the case of a patient with chest pain whose history suggested vasospastic angina. Despite the absence of ischemic electrocardiographic changes, the patient underwent coronary angiography, which showed no atherosclerotic lesions but a diffuse stenosis of the right coronary artery that was resolved promptly by intracoronary nitrate injection, therefore confirming spasm. Angiography also showed a straight vessel in the posterior atrioventricular sulcus, which was recognized as an intercoronary communication that connected the right coronary artery with the left circumflex artery and enabled bidirectional flow. The intercoronary communication likely served to partially protect the right coronary artery-dependent myocardium from ischemia during spasm. This case highlights the significance of a detailed history in constructing an investigation plan in order to make the correct diagnosis. By precluding concurrent ischemic electrocardiographic changes, the intercoronary communication made the diagnosis more challenging.

Of the patients suffering acute proximal left anterior descending (LAD) artery occlusion, a small but not insignificant minority does not manifest the classical ST-segment elevation myocardial infarction (STEMI) electrocardiographic (ECG) patterns. They manifest junctional upsloping ST-segment depression followed by tall, symmetrical T waves in the precordial leads instead, known as the de Winter pattern. Such patients may suffer a nearly transmural infarct if not managed promptly with percutaneous coronary intervention (PCI). Therefore, they should be treated as suffering a STEMI equivalent. The patient presented here suffered a total proximal "wrap-around" LAD artery in-stent occlusion manifesting the de Winter ECG pattern. The latter, was correctly and promptly recognized and the patient was managed successfully with emergency PCI achieving a good outcome. Discussion pertains to the morphology of ST-segment depression (STD) and the polarity and magnitude of the T waves accompanying STD which provide prognostic information and facilitate risk stratification in patients presenting with non-ST-segment elevation acute coronary syndrome. The pathophysiology underlying the de Winter ECG pattern and the appropriate therapeutic strategy are also discussed. The Littmann concept is also discussed, providing a reliable explanation for the ST-segment elevation observed in a misplaced lead V1.

This report illustrates the development of a new stenosis after coronary stent implantation due to intramural hematoma at the distal edge of the stent. It highlights the utility of intravascular ultrasound in making the diagnosis, clarifying possible etiological factors, and informing treatment decisions.

Background: Coronary artery crossing (CACr) constitutes a rare but clinically relevant anomaly of intrinsic coronary arterial anatomy. Current literature on this subject comprises isolated case reports and one case series. The purpose of this report is to present all cases of CaCr that have been reported in the English literature, highlighting its clinical implications. Case: We present the case of a patient with intermittent chest discomfort associated with psychological stress and evidence of crossing between the left anterior descending (LAD) artery and the first diagonal artery (DgA) on invasive coronary angiography. Myocardial bridging was also noted in the mid LAD artery but not at the crossing point or any other crossing artery segments, and produced obstructive (≥50%) dynamic lumen compromise. The patient was discharged in good condition and was prescribed aspirin, a statin, and diltiazem. Conclusions: This review included 24 records that represented 27 patients, including the one presented in this report. The anomaly has been predominantly diagnosed in male patients and the diagnosis has predominantly been made using computed tomography coronary angiography. The most frequent CACr pattern revealed in 12 patients (44%) was a crossing between the LAD and left circumflex arteries while the second most frequent CACr pattern revealed in six patients (22%) was a crossing between the LAD artery and a DgA. There were five cases (19%) with evidence of an intramyocardial course, either at the point of vessel crossover or beyond that point. The crossing coronary arteries themselves were found to have atherosclerotic lesions in three patients (11%). Even though CaCr has not been associated with any clinical repercussions, cardiologists and cardiac surgeons should bear knowledge of this anomaly not only for diagnostic purposes when performing coronary artery angiograms but also in order to properly select and execute a revascularization procedure. Furthermore, CaCr may be associated with clinically relevant, functional coronary artery abnormalities such as spasm affecting the segments of the arteries crossing over each other or having an intramyocardial course. Unique patterns of coronary blood flow and wall shear stress may also be created at the crossover area, potentially increasing the risk of developing atherosclerosis.

This report illustrates a rare, but serious, complication of rotational atherectomy, that is, burr entrapment, in an older patient with a severely calcified, proximal left anterior descending coronary artery/diagonal artery bifurcation stenosis and a background of aortic valve stenosis scheduled for percutaneous treatment. A series of events made us select a 1.25-mm burr, which became entrapped immediately distal to the stenosis. The complication was ascribed to the Kokeshi phenomenon and was successfully tackled percutaneously.

We present a patient with acute coronary syndrome manifesting dynamic evolution from an anterior ST-segment elevation myocardial infarction electrocardiographic pattern to the de Winter electrocardiographic pattern suggestive of severe residual myocardial ischemia owing to a partially recanalized but still subtotally occluded culprit artery. Emergency percutaneous coronary intervention was successfully performed.

We present a challenging case of a patient with an isolated right ventricular myocardial infarction (iRVMI) caused by the spontaneous occlusion of a right ventricular branch mimicking an anterior myocardial infarction on the electrocardiogram.A high index of suspicion is required to diagnose an iRVMI because the electrocardiogram may be misleading.

We report the case of a young patient with systemic lupus erythymatosus (SLE) who presented with chest pain and was subsequently diagnosed with concomitant acute atherosclerosis-related myocardial infarction (MI) and acute myocarditis ascribed to SLE. Although cardiovascular magnetic resonance imaging (CMR) is well-suited for making the distinction between ischemic and non-ischemic myocardial injury, the frequently non-specific presentation of patients with SLE-related myocarditis or MI, makes the choice between CMR and invasive coronary angiography as the first-line diagnostic imaging modality perplexing. This case highlights the role of electrocardiographic interpretation in choosing invasive coronary angiography for initial patient investigation and the complementary role of CMR in making the diagnosis.

aDepartment of Cardiology, Limassol General Hospital, Limassol bUniversity of Nicosia Medical School, Nicosia, Cyprus Received 21 June 2023 Accepted 13 August 2023. Correspondence to Andreas Y. Andreou, MD, FESC, FACC, FSCAI, Department of Cardiology, Limassol General Hospital, Nikeas street, Pano Polemidia, Postal code 3304, PO Box 56060, Limassol, Cyprus, Tel: +357 25801437; fax: +357 25801432; e-mail: [email protected]

An infrequently diagnosed case of atrial infarction which occurred in conjunction with left ventricular myocardial infarction is presented. Atrial infarction was recognised by the presence of PR segment depression in conjunction with premature atrial complexes. Spatial vector analysis of premature atrial complexes, is highlighted as a means to localise atrial infarction.

The existence of a tetrafascicular intraventricular conduction system is widely accepted by researchers. In this review, we have updated the criteria for left septal fascicular block (LSFB) and the differential diagnosis of prominent anterior QRS forces. More and more evidence points to the fact that the main cause of LSFB is critical proximal stenosis of the left anterior descending coronary artery before its first septal perforator branch. The most important characteristic of LSFB that has been incorporated in the corresponding diagnostic electrocardiographic criteria is its transient/intermittent nature mostly observed in clinical scenarios of acute (ie, acute coronary syndrome including vasospastic angina) or chronic (ie, exercise-induced ischemia) ischemic coronary artery disease. In addition, the phenomenon proved to be phase 4 bradycardia rate dependent and induced by early atrial extrastimulus. Finally, we believe that intermittent LSFB has the same clinical significance as "Wellens syndrome" and the "de Winter pattern" in the acute coronary syndrome scenario.