The impact of contrast volume on long-term renal outcomes after chronic total occlusion (CTO) percutaneous coronary intervention (PCI) remains uncertain, and the causal role of contrast exposure is increasingly questioned, particularly beyond the acute phase. The aim of this study was to evaluate the association between procedural contrast volume and long-term deterioration in renal function among patients undergoing CTO PCI. This retrospective cohort study included consecutive patients undergoing CTO-PCI between 2019 to 2025 and had both baseline and ≥90-day follow-up creatinine measurements available. The main endpoint was persistent kidney dysfunction (≥25% decline in estimated glomerular filtration rate (eGFR)). Other relevant endpoints included Kidney Disease: Improving Global Outcomes (KDIGO) stage progression (≥1 stage), and rapid progression (≥2 stages). Contrast volume was analyzed as a continuous variable and by quartiles. Multivariable regression models and sensitivity analysis (using a ≥40%eGFR decline threshold and baseline chronic kidney disease) were performed. A total of 275 patients were included with a median follow-up of 3.3 years. Renal function significantly declined (median ΔeGFR: -17.0 ml/min/1.73 m²; p < 0.001). Persistent kidney dysfunction occurred in 52.4% of patients, KDIGO stage progression in 60.7% and rapid progression in 12.0%. Contrast volume (median 215 mL) was not independently associated with persistent kidney dysfunction (p = 0.267) and no dose-response relationship was observed across quartiles. Findings were consistent across models for ΔeGFR, KDIGO-based, subgroups and sensitivity analyses. Patient-related factors including age, male sex, hypertension, and diabetes emerged as independent predictors of renal decline. Notably, baseline renal function showed an inverse association with progression (p <0.001), suggesting a "ceiling effect" in advanced stages. In patients undergoing CTO-PCI, contrast volume is not independently associated with long-term renal deterioration. Persistent kidney dysfunction appears primarily driven by patient-related factors rather than procedural contrast exposure.

BACKGROUND:The prognostic value of rapid atrial pacing (RAP)-induced Wenckebach atrioventricular block (W-AVB) as a diagnostic test for predicting permanent pacemaker implantation (PPI) after transcatheter aortic valve replacement (TAVR) remains unclear and requires further validation. The objective of this study was to evaluate the predictive value of RAP-induced W-AVB for PPI and sudden cardiac death within 30 days post-TAVR. METHODS:This prospective, investigator-initiated, multicenter study (PACE-TAVR) included 640 patients undergoing TAVR across 12 centers. RAP was performed before and after TAVR to assess for W-AVB. Using negative predictive values and negative likelihood ratios, the predictive value of W-AVB was evaluated for the primary end point: sudden cardiac death or guideline-based indications for PPI, including complete AVB or alternating bundle branch block (Class I), and preexisting conduction disturbances with new ECG changes, new-onset left bundle branch block, a positive electrophysiology study, or sinus node dysfunction (Class II). RESULTS:RAP was successfully performed post-TAVR in 556 patients, with RAP-induced W-AVB observed in 192 (34.5%). W-AVB was associated with baseline conduction disturbances, amiodarone use, pre-TAVR RAP-induced W-AVB, and anesthesia type. The primary end point was more frequent in patients with W-AVB (15.6% versus 9.3%; odds ratio, 1.80 [95% CI, 1.06-3.04]; P=0.029). However, the absence of W-AVB had a negative predictive value of only 90.7% and a poor negative likelihood ratio (0.79). The test's utility declined in subgroups at high risk for PPI, including self-expanding valve recipients (odds ratio, 1.47 [95% CI, 0.84-2.58]; negative predictive value, 88.4%; negative likelihood ratio, 0.86) and patients with a baseline or new left bundle branch block (odds ratio, 1.14 [95% CI, 0.54-2.42]; negative predictive value, 81.3%; negative likelihood ratio, 0.95). CONCLUSIONS:RAP-induced W-AVB demonstrates limited utility in predicting post-TAVR PPI or sudden cardiac death, particularly in patients at high risk for PPI. Clinicians should be cautious when using this test for post-TAVR rhythm management. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT05278585.

BACKGROUND:The management of patients with chronic total occlusion (CTO) poses a persistent challenge, necessitating a tailored treatment strategy. AIMS:This study aimed to investigate the intricate interplay between treatment selection, ischemia burden reduction, and symptom relief in patients with isolated CTO lesions. METHODS:The Prospective Evaluation of Treatment Strategies in patients presenting with Chronic Total Occlusion (PETS-CTO) registry is a prospective, non-randomized study that evaluated patients at enrollment and follow-up using the Seattle Angina questionnaire (SAQ) and stress ischemia tests. Patients were allocated into three treatment arms: optimal medical therapy (OMT), percutaneous coronary intervention (C TO-PCI), or coronary artery bypass grafting (CABG). Changes in the angina symptoms and ischemic burden were the primary endpoints, while a clinical composite of death, myocardial infarction, and angina-related rehospitalization was considered as the secondary outcome. RESULTS:Among 157 patients, 45% were in the CTO-PCI group, 45% in the OMT group, and 10% underwent CABG. CTO-PCI group demonstrated favorable changes in summary SAQ score (12.3%, 95% CI: 3.4%-21.5%, p = 0.008) compared to OMT. CTO-PCI patients more frequently shifted from an ischemic to a nonischemic stress test at follow-up compared to OMT (60% vs. 5.6%, p < 0.001). No correlation was observed between angina scores and proven ischemia at baseline and follow-up assessments. CONCLUSIONS:Effective management of CTO requires comprehensive evaluation, and although angina relief and ischemic burden are individually influential, our findings reveal a lack of correlation between these factors, emphasizing the complexity in guiding treatment decisions (PETS-CTO; NCT04145167).

BackgroundCoronary CT Angiography (CTA) is increasingly being used to plan percutaneous coronary intervention (PCI), offering detailed pre-procedural anatomical and physiological insights. The Precise Procedural and PCI Plan (P4) study evaluates the efficacy of CT- versus intravascular ultrasound-guided PCI. The aim of this study was to assess the utility of various CT-guided PCI tools and strategies as perceived by experienced operators within the context of the P4 study.MethodsA cross-sectional survey was conducted among 25 operators who participate in the P4 trial from multiple international centers. Participants were asked to evaluate the utility of pre-procedural CTA planning, physiological information with virtual PCI, and online guidance. The survey included multiple-choice, Likert scale, and ranking questions.ResultsMost respondents valued pre-procedural planning highly (average score 2.83/3), particularly for the assessment of plaque composition and calcium characterization. Plaque composition evaluation, including calcium analysis, was ranked as the most valued factor, with an average usefulness score of 6.13/7. Calcium arc information was rated as the most useful component of calcium analysis (4/5 rating). The survey highlighted the importance of myocardial mass at risk assessment in bifurcation PCI and pointed to the anticipation of calcium density as a key future aspect of CT-guided PCI procedures.ConclusionsThe integration of CT-guided PCI promises to refine procedural planning and to pave the way for a new standard of care in patients with stable CAD.

BACKGROUND:Arrhythmia-induced cardiomyopathy (AIC) is defined as impaired left ventricular function due to cardiac arrhythmias. We sought to investigate the association between coronary microvascular dysfunction (CMD) and AIC in patients with atrial fibrillation (AF). METHODS:In this multicenter observational study, we enrolled consecutive patients with recent diagnosis of AF (<6 months) who underwent invasive coronary physiology assessment with the bolus thermodilution technique. Patients were divided into two groups according to left ventricular ejection fraction (LVEF): AIC group if LVEF < 50% and preserved LVEF group if LVEF ≥ 50%. A third group of patients with a recent diagnosis of dilated cardiomyopathy (DCM) and without AF was analyzed as control group. CMD was defined as abnormal coronary flow reserve (CFR < 2.5) and/or abnormal index of microcirculatory resistance (IMR ≥ 25). RESULTS:Among 84 analyzed patients, 33 were in the AIC group, 39 in the preserved LVEF group, and 12 in the DCM group. CMD was more frequently detected in the AIC group compared to the preserved LVEF (79% vs. 38%, p < 0.001) and DCM groups (79% vs. 33%, p = 0.01). In patients with AF, a significant correlation was found between CFR and LVEF (beta coefficient: 3.8; 95% CI: 1.8-5.9; p < 0.001), and IMR and LVEF (beta coefficient: -0.3; 95% CI: -0.4 to -0.1; p = 0.001). At multivariable analysis, CMD was independently associated with AIC (adjusted odds ratio: 6.2; 95% CI: 2.2 to 20.1; p = 0.001). CONCLUSIONS:CMD is strongly and independently associated with the degree of left ventricular dysfunction and may play a role in the development of AIC in patients with AF.

Transcatheter aortic valve implantation (TAVI) is an established treatment strategy in aortic valve disease. Infolding, as a non-uniform expansion of the prosthesis leading to introflection of part of the device circumference, is a complication specific to self-expandable prostheses. The aim of the study is to determine incidence, predictors, treatment strategy and outcomes of infolding during Medtronic™ Evolut TAVI. Between January 2018 and March 2022 all patients treated with Evolut TAVI were included in a multicenter observational retrospective study. According to the occurrence of infolding, the enrolled cohort was divided into two groups; peri-procedural characteristics and 30-day outcomes were compared. A total of 1470 patients were included. Twenty-three infolding cases (1.6%) were detected. Pre-procedural imaging showed larger aortic anatomy and higher calcium burden in the infolding group. Infolding occurred mostly with Evolut Pro+ and size 34 mm and was diagnosed before full prosthesis release in 78.3%. The rate of moderate-to-severe paravalvular regurgitation was higher in the infolding group (21.7% vs 1.9%; p<0.001). Short-term follow-up showed higher all-cause and cardiovascular mortality (respectively, 4.3% vs 0.7% and 4.3% vs 0.6%; p<0.05) and higher rate of pacemaker implantation (33.3% vs 15.7%; p=0.042) in case of infolding. High right cusp calcium score and resheathing maneuvers were independent predictors of infolding. In conclusion, prosthesis infolding is a TAVI complication burdened by worse cardiovascular outcomes. Prompt intraprocedural infolding diagnosis is pivotal, especially in case of high native valve calcium burden and resheathing maneuvers, to safely overcome this complication by prosthesis recapture or post-dilation.

Scant data exploring potential suboptimal physiological results after angiographic successful percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) are available. Sixty cases of successful CTO-PCI were selected for this retrospective analysis. Post-CTO-PCI angiography-based fractional flow reserve was computed using the Murray-based fractional flow reserve (μFR) software. Vessel-specific μFR, residual trans-stent gradient (TSG) and corrected TSGstent were calculated. In physiological suboptimal results (μFR < 0.90), the virtual pullback pressure gradient (PPG) curves were analyzed to localize the main pressure drop-down and characterize the patterns of residual disease. The virtual pullback pressure gradient index (vPPGi) was then calculated to objectively characterize the predominant pattern of residual disease (diffuse vs focal). The physiological result was suboptimal in 28 cases (46.7

Chronic total occlusions (CTOs) are frequent in patients with previous coronary artery bypass graft (CABG) surgery. Percutaneous coronary intervention (PCI) is the usual revascularization strategy. Whether or not the presence of a graft on a CTO vessel and post-PCI graft patency impacts outcomes after CTO-PCI is unknown. We sought to evaluate the impact of post-PCI graft patency on the durability of CTO-PCI. In total, 259 patients with previous CABG who underwent CTO-PCI in 12 international centers in 2019 to 2023 were categorized into "grafted" and "ungrafted" groups based on the presence of graft on a CTO vessel. The grafted group was subdivided into "graft-occluded" and "graft-patent" groups, depending on graft patency. The primary end points were (1) technical success rate, (2) target vessel failure, and (3) CTO failure rates at 1 year. CTO failure was defined as target vessel revascularization and/or significant in-stent restenosis. A total of 199 patients (77%) were in the grafted group. Grafted CTOs showed higher complexity and lower technical success rates (70% vs 80%, p = 0.004) than nongrafted CTOs. Of the grafted CTOs, 140 (70%) were in the grafted-occluded group and 59 (30%) were in the grafted-patent group. The technical success was lower in the former group (65% vs 81%, p = 0.022). An occluded graft was an independent predictor of technical failure (odds ratio 2.04, 95% confidence interval 1.03 to 4.76, p = 0.049) and persistent post-PCI graft patency was a strong independent predictor of CTO failure at 1 year (hazard ratio 5.6, 95% confidence interval 1.2 to 27.5, log-rank p = 0.033). In conclusion, in patients with previous CABG who underwent CTO-PCI, post-PCI graft patency was a significant predictor of CTO failure.

BACKGROUND:The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).AIMS:This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms.METHODS:We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization.RESULTS:Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195).CONCLUSION:The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.

BACKGROUND: Coronary chronic total occlusions (CTO) are associated with an increased chance of untreatable symptoms and worse prognosis. However, limited data are available about the interaction between treatment strategy, potential ischemia burden reduction and quality of life (QoL) improvement. METHODS: Our prospective registry aims to assess the potentially different impacts of treatment strategies (coronary artery bypass grafting vs.. percutaneous coronary intervention vs. optimal medical therapy) on clinical outcomes and QoL domains. This article specifically focuses on describing the registry's rationale, design, and baseline characteristics of the enrolled patients. RESULTS: A total of 157 patients were enrolled. Every patient was evaluated for baseline symptoms, ischemic burden and QoL and allocated to a treatment arm. In 112 patients (71.3%) ischemia baseline assessment was performed and for 116 (73.9%) Seattle Angina Questionnaire (SAQ) was available. At baseline, a significant functional limitation was evident, especially in terms of angina stability (mean score 69 +/- 31%) and disease perception (mean score 69 +/- 27%). In 49.1% of patients, ischemia testing was positive. Patients with documented ischemia were generally more symptomatic (CCS class 1 36.4% vs.. 57.9%, P=0.023) and a significant inverse correlation between CCS class and SAQ domains was found. No association between ischemia burden and self-reported QoL scores was found. CONCLUSIONS: The PETS-CTO registry is the first prospective registry investigating the impact of different treatment strategies on QoL and ischemia burden in patients with CTOs. At baseline, the severity of symptoms was directly associated with ischemia burden and inversely associated with self-reported QoL evaluation.

BACKGROUND:Distal trans-radial access (dTRA) for percutaneous coronary interventions (PCI) is increasingly gaining attention due to its potential to mitigate radial artery occlusion (RAO). However, a comprehensive understanding of the mechanical impact of the devices on the radial artery (RA) wall remains limited. Using a complete intravascular ultrasound (IVUS) evaluation of the RA, including also the vascular access site, we aimed to evaluate all the consequences related to the catheterization on the RA wall, starting from the vascular access, comparing conventional sheath and sheathless approaches. METHODS:This is an observational, prospective, multicenter study aimed to assess the entire RA wall immediately after IVUS-guided PCI via-dTRA. IVUS assessment included quantitative measurements (minimal lumen area [MLA], minimal vessel area [MVA]) and qualitative observations (dissections, vasospasm). Study objectives included delineating RA wall structure post-PCI and comparing findings between conventional and sheathless approaches. RESULTS:Fifty patients (21 [42%] with conventional sheath, 29 [58%] sheathless) were enrolled between March 2023 and February 2024. Female patients were more prevalent in the convention sheath group (38% vs. 7%, p < 0.001). Sheathless approach utilized 7-French guiding catheters more frequently (33% vs. 86%, p < 0.001). Post-procedural IVUS identified dissections in 12% of cases, with no significant difference between approaches. Arterial vasospasm was present in a quarter of patients, numerically higher in the conventional sheath group (29% vs. 21%, p = 0.5). MLA and MVA were comparable between groups, though MLA and MVA were lowest at the proximal segment of the RA only in the conventional sheath group (p < 0.001). No RAO was documented during the IVUS evaluation. CONCLUSIONS:The intravascular assessment of dTRA after coronary interventions, utilizing either conventional or sheathless approaches, including large-bore guiding catheters, demonstrated a relatively low incidence of access-related complications such as dissection and vasospasm, without affecting the flow and patency of the proximal RA.

BACKGROUND:The trans-radial approach for cardiac catheterization led to an increasing adoption of 5 French (F) catheters. We aim to evaluate reliability and reproducibility of coronary physiology assessment performed with 5F guiding catheter (GC). METHODS:Physiological measurements were performed in a coronary flow simulator, which provides two pulsatile flows, the baseline and hyperaemic flows. Two screws, positioned proximally and distally to the distal sensor of a pressure-temperature guidewire, were used to determine various combinations of stenoses and distal obstructions, simulating different pathophysiological conditions. For each setting, 5 measurements of fractional flow reserve (FFR), coronary flow reserve (CFR) and index of microvascular resistance (IMR) were performed with 6F and 5F GCs. RESULTS:A total amount of 190 measurements were performed, 95 with 6F GC and 95 with 5F GC. Minimal differences between 6F and 5F GCs were detected for FFR [0.91 (IQR: 0.87-0.94) and 0.87 (IQR: 0.82-0.92) respectively, p < 0.001] and IMR (16.5 ± 8.8 and 15.4 ± 8.3 respectively, p = 0.001). Mean CFR was comparable between 6F and 5F GCs (3.6 ± 1.1 and 3.5 ± 0.7 respectively, p = 0.38). Misclassification rates were 1.0 %, 1.0 % and 0 % for FFR, CFR and IMR, respectively. According to Passing-Bablok analysis, an excellent agreement between 6F and 5F GCs was demonstrated for FFR and IMR, and a modest agreement for CFR. All measurements with 5F GC showed high reproducibility. CONCLUSIONS:In our in-vitro model, a complete physiological assessment including FFR, CFR and IMR resulted substantially comparable between 6F and 5F GCs. Further in-vivo analysis is required to support these findings.

The transradial approach (TRA) has become the primary choice for percutaneous coro-nary intervention (PCI); however, it may not be always feasible because of clinical and/or technical challenges. Alternative forearm accesses, such as transulnar approach (TUA) and distal radial approach (dTRA) may allow maintaining a wrist approach for the proce-dure, avoiding the femoral artery. This issue is particularly relevant in patients who underwent multiple revascularizations, such as those with chronic total occlusion (CTO) lesions. This study aimed to evaluate whether the use of TUA and/or dTRA is comparable with TRA in CTO PCI using a minimalistic hybrid approach algorithm, which limits the number of accesses used to minimize vascular access complications. Patients with CTO PCI treated solely through a fully alternative approach (TUA and/or dTRA) were com-pared with those treated solely through a standard TRA approach. The primary efficacy end point was procedural success, whereas the primary safety end point was the composite of major adverse cardiac and cerebral events and vascular complications. Of 201 CTO PCIs attempted, 154 procedures were considered for analysis (standard, n = 104, alterna-tive, n = 50). Alternative and standard groups demonstrated comparable rates of both pro-cedural success (92% vs 94.2%, p = 0.70) and primary safety end point (4.8% vs 6.0%, p = 0.70). Of interest, 7 French guiding catheters were more frequently used in the alterna-tive group (44% vs 26%, p = 0.028). In conclusion, CTO PCI after minimalistic hybrid approach by way of alternative forearm vascular accesses (dTRA and/or TUA) is feasible and safe to perform, compared with CTO PCI by way of standard TRA. & COPY; 2023 Elsevier Inc. All rights reserved. (Am J Cardiol 2023;200:57-65)

BACKGROUND:Antegrade wiring using only antegrade guiding catheter without contralateral injection (defined as "blind antegrade wiring") may represent a valid initial treatment strategy for selected chronic coronary total occlusions (CTOs) due to the potentially lower risk of vascular complications. A careful selection of lesions eligible for this strategy as well as an accurate balance between the likelihood of success and failure is paramount. The aim of the study is to determine the rate of successful revascularization, the potential predictors of failure and the incidence of major complications, when using a "blind antegrade wiring" technique.METHODS:In this multicentric study, consecutive patients with CTO undergoing percutaneous coronary intervention (PCI) were retrospectively screened. All cases approached using "blind antegrade wiring" technique were included.RESULTS:Out of 155 consecutive CTO-PCIs, 94 involved initial "blind antegrade wiring" strategy. Successful revascularization by means of "blind antegrade wiring" technique was achieved in 73 (78%) patients. Final successful revascularization was obtained in 19 of the remaining 21 procedures with "blind antegrade wiring" failure using other techniques (by adding a second contralateral guiding catheter; 98% total successful revascularization). Logistic regression analysis identified higher J-CTO Score as the only predictor of "blind antegrade wiring" failure. One complication occurred (wire-based coronary perforation).CONCLUSIONS:"Blind antegrade wiring" may be considered as initial strategy for selected CTO-PCI, mainly for CTOs with low J-CTO Score. This strategy would allow in a substantial number of cases to avoid a priori dual injection, keeping it as secondary strategy in case of "blind antegrade wiring" failure.

The presence of collateral channels providing distal blood supply is a distinctive characteristic of chronic total occlusion (CTO) lesions. However, data about the distinct baseline and procedural characteristics of each collateral subset are scarce. Accordingly, we sought to explore the procedural aspects specific for each collateral typology (ipsilateral collaterals [ICs], contralateral collaterals [CCs] or mixed) in CTO-percutaneous coronary intervention (PCI). A retrospective analysis of our CTO-PCI registry was performed to investigate the prevalence, procedural characteristics, and outcomes specific for each CTO-PCI subset, defined according to the inter-arterial connection anatomy. A total of 209 cases were included. Of the included cases, 45 (22%) and 92 (44%) patients displayed solely IC or CC, respectively, whereas in 72 (34%) both IC and CC were present (mixed). The procedural success rate was high (91.1%) and comparable among the different groups, despite greater lesion complexity in the CC group. The most frequent target vessel was the left circumflex in the IC group (51% of cases) and the right coronary artery in the CC (63%) and mixed (57%) groups. Among the IC cases, 42% showed a poor collateral connection function (2% and 10% for the CC and mixed group, respectively), and 46% showed a suboptimal collateral recipient artery filling (21% and 20% for the CC and mixed group, respectively). Most of the IC cases were performed using a single access (96%). In conclusion, the success and complication rates were comparable among the collateral typology groups, irrespective of the differences in the baseline and procedural characteristics. Phenotyping CTO as hereby proposed might be helpful for targeted procedural considerations.

Left circumflex coronary artery (LCx) injury related to mitral valve surgery is a rare complication. The best treatment option is not defined, and percutaneous coronary intervention (PCI) may represent an effective treatment to avoid prolonged myocardial ischemia. To evaluate feasibility and efficacy of PCI treatment, all records of LCx injury related to mitral valve surgery and treated with PCI were included after a systematic PubMed searching. Moreover, we retrospectively analyzed our single-center PCI database and patients fulfilling the inclusion criteria were included. Patients undergoing transcatheter mitral valve intervention, non-mitral valve surgery, conservatively or surgically treated after LCx injury were excluded. Data about patient characteristics, procedural details, PCI success, and in-hospital mortality were collected. Fifty-six patients were included, 58.9% were male (n = 33) and the median age was 60.5 years (IQR = 21.75). The majority had left dominant or codominant coronary system (62.2%, n = 28 and 15.6%, n = 7, respectively). Clinical manifestations ranged from hemodynamic stability (21.1%, n = 8) to hemodynamic instability (42.1%, n = 16) and cardiac arrest (18.4%, n = 7). On ECG, 23.5% of patients (n = 12) presented ST-segment depression, 58.8% (n = 30) ST-segment elevation, 7.8% (n = 4) atrioventricular block, and 29.4% (n = 15) ventricular arrhythmias. Left ventricle dysfunction was present in 52.3% (n = 22) of patients and wall motion abnormalities in 71.4% (n = 30). PCI success rate was 82.1% (n = 46) and in-hospital mortality 4.5% (n = 2). LCx injury related to mitral surgery is a rare complication characterized by an increased risk of mortality. PCI seems a feasible treatment option, still burdened by suboptimal results, probably related to the technical challenges posed by the surgical failure.