We aimed to assess the clinical, angiographic, and outcome profiles of patients undergoing chronic total occlusion (CTO) percutaneous coronary intervention (PCI) with the use of drug-coated balloon (DCB)-only approach in a retrospective multicenter international registry. Data from 309 patients with 312 CTO lesions undergoing successful CTO PCI with DCB-only approach at 42 sites were collected. Angiographic and clinical follow-up was performed at 3 and 6 months, respectively. The primary endpoint was target lesion failure (TLF), defined as composite of cardiac death, target vessel myocardial infarction, or clinically-driven target lesion revascularization (TLR). Secondary endpoints included binary restenosis (≥50% stenosis) and late lumen loss (LLL) on angiography. The mean age was 67 ± 10 years, and 58.9% patients were male. The main indication for DCB was small vessel disease (37.1%), and most CTO were recanalized with intraplaque wiring (93%). TLF was 3.5% with no cardiac death at 6 months. Of 157 CTO with angiographic follow-up (50.3%) at a median of 99 days (IQR: 85 to 136 days), the LLL was -0.1 mm (IQR: -0.3 to 0.3 mm), and 47.8% vessels showed positive remodelling. Binary restenosis and re-occlusion were 24.2% and 4.0%, respectively. Coronary CTO with binary restenosis had significantly higher residual stenosis directly post-PCI (p <0.001) than CTO without restenosis. In conclusion, treatment of CTO with a DCB-only approach is safe, with a low number of TLF at 6-month follow-up. In selected population with angiographic follow-up, suboptimal predilatation result was associated with an increased rate of restenosis and warrants further investigation.

Aims: There is little evidence guiding the choice between a one-stent and a two-stent approach in unprotected distal left main coronary artery disease (UDLMCAD) presenting as acute coronary syndrome (ACS). We aim to compare these two techniques in an unselected ACS group. Methods and results: We conducted a single center retrospective observational study, that included all patients with UDLMCAD and ACS undergoing PCI between 2014 and 2018. Group A underwent PCI with a one-stent technique (n = 41, 58.6%), Group B with a two-stent technique (n = 29, 41.4%). A total of 70 patients were included, with a median age of 63 years, including n = 12 (17.1%) with cardiogenic shock. There were no differences between Group A and B in terms of patient characteristics, including SYNTAX score (median 23). The 30-day mortality was 15.7% overall, and was lower in Group B (3.5% vs. 24.4%, p = 0.02). Mortality rate at 4 years was significantly lower in Group B (21.4% vs. 44%), also when adjusted in a multivariable regression model (HR 0.26, p = 0.01). Conclusions: In our study, patients with UDLMCAD and ACS undergoing PCI using a two-stent technique had lower early and midterm mortality compared to one-stent approach, even after adjusting for patient-related or angiographic factors.

Abstract Background This review is based on the case of a 71-year-old female patient, with cardiovascular risk factors, who was referred for emergency cardiological evaluation after experiencing severe anterior chest pain that had lasted for more than 5 hours at the time of admission. A diagnosis of inferior-posterior ST-segment elevation myocardial infarction was established, and emergency coronary angiography was performed. It revealed severe, diffuse dilation of the entire arterial coronary tree with slow flow and the presence of a large quantity of thrombotic material in the right coronary artery. Thromboaspiration was deemed unfit since the operator believed that there was a high risk of distal embolization with subsequent no-reflow, when passing with the catheter. As such, the patient started receiving anticoagulant therapy, and after one month she was scheduled for a control angiogram. The follow-up coronary angiography identified complete dissolution of the thrombus from the right coronary artery and a moderate stenosis in the distal segment, so no stent implantation was required. Rationale for review After performing a complete and comprehensive differential diagnosis, presence of isolated coronary artery ectasia was established. Coronary artery ectasia is a rare disease, usually found incidentally during coronary angiograms performed for other indications (chronic and acute coronary syndromes) with a vast etiology and complex pathophysiology. Because there are common morphopathologic pathways between coronary artery ectasia and atherosclerotic coronary artery disease, the clinical presentation of the former might have similar characteristics with the latter, but the management and prognosis of these patients is much less studied compared to the patients suffering from different phenotypes of coronary atherosclerosis. This review aims to summarize the etiopathogenesis, clinical presentation, diagnostic modalities, and different management pathways of coronary artery ectasia.

Abstract Introduction Coronary artery anomalies are rare congenital abnormalities often found incidentally on conventional coronary angio-gram or coronary computed tomography angiography. They may result in various clinical outcomes. The objective of this study was to investigate the prevalence of coronary artery anomalies, the clinical and laboratory characteristics of patients with coronary artery anomalies, and the outcomes at five-year follow-up of these patients in a high-volume coronary interventional center in Romania. Materials and Methods To define the study population we reviewed all coronary angiograms performed between 01.01.2014 and 31.12.2014. A total number of 5832 coronary angiograms were analyzed, and we identified 31 patients with coronary artery anomalies. Results The prevalence of coronary artery anomalies was 0.53%. Eighty-seven point four percent of the patients had origin and distribution anomalies, and twelve point nine percent of the patients had a coronary artery fistula. The most common coronary artery anomalies were the anomalous origin of the right coronary artery and the anomalous origin of the left circumflex artery from the initial segment of the right coronary artery. Sixty-one point three percent of the patients underwent coronary angiogram due to atypical chest pain. Twenty-nine percent of the patients had significant coronary artery disease. No death or significant complication were recorded in the 31 patients during the 5 years follow-up. Conclusions The prevalence of coronary artery anomalies in this study was slightly lower but still like that of previous studies. The majority of patients presented with atypical symptoms, and only a minority had coronary artery disease. In the context of no death or significant complication at 5-year follow-up highlights the benign prognosis of most coronary artery anomalies.

Abstract Background Left main percutaneous coronary intervention (PCI) has been established as an effective and safe treatment option for left main coronary artery disease. There are data suggesting that different stent platforms can impact the outcomes after left main PCI. The aim of current study was to compare the four-year outcomes of patients with left main stenosis treated by PCI with a balloon-expandable stent or a self-apposing stent. Methods and Results A total of 146 patients with left main stenosis treated by PCI were included, of which 84 (57.5%) had balloon-expandable stents (Group A) and 62 (42.5%) had self-apposing stents (Group B). Baseline SYNTAX scores were higher in Group A than in Group B. Proximal optimization technique was used more often in Group A (45.2% in Group B vs 81.4% in Group A, p<0.001). The same observations were made for kissing balloon postdilation (30.6% Group B vs 62.7% in Group A, p<0.001). Procedural success with TIMI 3 flow was achieved in similar proportions in both groups. Mortality rate and MACE rates at 4-year follow-up were higher in Group B compared to Group A but have not reached statistical significance in univariable or multivariable analysis. Implantation of a self-apposing stent has been an independent predictor for target lesion revascularization rate (TLR) in multivariable analysis (HR 0.06, CI − 1.11–11.7, =0.03). Conclusions In our study, TLR rate was significantly higher in patients with left main lesion treated by PCI with self-apposing stents.

Background. Percutaneous coronary intervention (PCI) of unprotected left main coronary artery disease (ULMCAD) have become a feasible and efficient alternative to coronary artery bypass surgery, especially in patients with acute coronary syndrome (ACS). There are limited data regarding early and late outcomes after ULMCAD PCI in patients with ACS and stable angina.The aim of this study was to compare early and four-year clinical outcomes in patients with ULMCAD PCI presenting as ACS or stable angina in a high-volume PCI center.Methods. We conducted a single center retrospective observational study, which included 146 patients with ULMCAD undergoing PCI between 2014 and 2018. Patients were divided in two groups: Group A included patients with stable angina (n = 70, 47.9%) and Group B patients with ACS (n = 76, 52.1%).Results. 30-day mortality was 8.22% overall, lower in Group A (1.43% vs 14.47%, p = 0.02). Mortality and major adverse cardiac events (MACE) rates at 4 years were significantly lower in Group A (9.64% vs 33.25%, p = 0.001, and 24.06% vs 40.11%, p = 0.012, respectively). Target lesion revascularization (TLR) at 4 year did not differ between groups (15% in Group A vs 12.76% in Group B, p = 0.5).Conclusions. In our study patients with ULMCAD and ACS undergoing PCI had higher early and long-term mortality and MACE rates compared to patients with stable angina, with similar TLR rate at 4-year follow-up.

Carlo di Mario, MD,cc Kefei Dou, MD,dd Mohaned Egred, MD,ee Basem Elbarouni, MD,ff Ahmed M. ElGuindy, MD,gg Javier Escaned, MD,hh Sergey Furkalo, MD,ii Andrea Gagnor, MD,jj Alfredo R. Galassi, MD,kk Roberto Garbo, MD,ll Gabriele Gasparini, MD,mm Junbo Ge, MD,nn Lei Ge, MD,nn Pravin Kumar Goel, MD,oo Omer Goktekin, MD,pp Nieves Gonzalo, MD,qq Luca Grancini, MD,rr Allison Hall, MD,ss Franklin Leonardo Hanna Quesada, MD,tt Colm Hanratty, MD,uu Stefan Harb, MD,vv Scott A. Harding, MD,ww Raja Hatem, MD,XX Jose P.S. Henriques, MD,yy David Hildick-Smith, MD,zz Jonathan M. Hill, MD,aaa Angela Hoye, MD,bbb Wissam Jaber, MD,ccc Farouc A. Jaffer, MD, PHD,ddd Yangsoo Jang, MD,eee Risto Jussila, MD,fff Artis Kalnins, MD,ggg Arun Kalyanasundaram, MD, MPH,hhh David E. Kandzari, MD,iii Hsien-Li Kao, MD,jjj Dimitri Karmpaliotis, MD, PHD,kkk Hussien Heshmat Kassem, MD, PHD,lll Jaikirshan Khatri, MD,mmm Paul Knaapen, MD,nnn Ran Kornowski, MD,ooo Oleg Krestyaninov, MD,ppp A.V. Ganesh Kumar, MD,qqq Pablo Manuel Lamelas, MD, MSC,rrr Seung-Whan Lee, MD,sss Thierry Lefevre, MD,ttt Raymond Leung, MD,uuu Yu Li, MD,vvv Yue Li, MD,www Soo-Teik Lim, MD,XXX Sidney Lo, MD,yyy William Lombardi, MD,zzz Anbukarasi Maran, MD,aaaa Margaret McEntegart, MD, PHD,bbbb Jeffrey Moses, MD,cccc Muhammad Munawar, MD,dddd Andres Navarro, MD,eeee Hung M. Ngo, MD, PHD,ffff William Nicholson, MD,gggg

This article provides data of the workload of the interventional cardiology centers from Romania during 2019. Members from all interventional cardiology centers from Romania were requested to fi ll a standard form about the total number of various procedures performed during 2019. The report highlights the total number of coronary interventions, peripheral interventions, and interventions for structural heart diseases, that were performed in 2019 in Romania. A comparison of the workload of the interventional cardiology centers from Romania between 2014 to 2019 was done.

Introduction – Most reports on left main bifurcation lesions have demonstrated that treatment with a singlestent strategy is superior to a two-stent strategy but have excluded patients with acute coronary syndromes (ACS). Aims – The aim of the current study was to compare the four year outcomes of patients with unprotected left main coronary artery disease (ULMCAD) treated by percutaneous coronary intervention (PCI) with a one-stent or two-stent strategies in a population including those presenting as ACS. Methods – A total of 135 patients with ULMCAD treated by PCI were included, of which 75 (55.6%) had a one-stent strategy (Group A) and 60 (44.4%) had a two-stent strategy (Group B). Results – Fewer patients in Group A had a TIMI III flow at the end of the procedure (89.4% vs 100%, p=0.03) and complete revascularization (65.3% vs 88.3%, p=0.002). We found a higher early mortality in Group A without reaching statistical significance (13.4% vs 3.3%, p=0.1). Mortality rate at 4-year follow up was higher with Group A after multivariable analysis (adjusted HR 0.36, CI 0.15-0.85, p=0.02). We found no significant differences between the groups in terms of major adverse cardiac event (MACE) (adjusted HR 0.85, CI 0.34-1.48, p=0.7) or target lesion revascularization (TLR) (adjusted HR 1.37, CI 0.42-4.47, p=0.6) at 4-year follow up. Conclusions – Among unselected patients with ULMCAD PCI, with or without ACS, the early mortality rate is similar between one and two-stent strategy. Although, 4 year TLR and MACE rates were similar between the two groups, the 4-year all-cause mortality rate was lower in the two-stent strategy group.

Coronary artery spasm (CAS) after coronary artery bypass grafting (CABG) is rare, and in time may be fatal for the patient if undiagnosed. The purpose of the present study is to report the case of a patient who survived after experiencing a persistent spasm of all native coronary arteries following successful arterial myocardial revascularization. Furthermore, we aimed to discuss the therapeutic strategies which may prevent the occurrence of a coronary artery spasm in settings of myocardial revascularization, in the context of reviewed specific literature evidences.

: Background – Coronary artery bypass surgery (CABG) has been considered the gold standard for the treatment of left main coronary artery disease, for many years. However, the development from last years in stent technology and the use of intravascular imaging to assess the results after percutaneous coronary interventions (PCIs) have rapidly increased the number of patients with unprotected left main coronary artery disease (ULMCAD) treated by PCI. The aim of the current study was to report the current practice of ULMCAD PCI in a Romanian high-volume PCI center and compare the results with those reported by other studies. Methods and Results – A total of 146 patients with ULMCAD treated by PCI were included, 52% presenting with acute coronary syndrome (ACS). Outcomes at 4 years were estimated using the Kaplan Meier methsod. Baseline SYNTAX II score for PCI was intermediate, at a median of 28.9. The early mortality rate was 8.2% with a 2% peri-procedural mortality. 4-year mortality, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were 21.9%, 14% and 32.5%, respectively. The rates of in-stent thrombosis and in-stent restenosis at 4 -year follow up were 2.74% and 11.1%, respectively. Conclusions – The early mortality rate in our study, which included an important number of patients presenting with ACS, was not signi fi cantly higher than in other studies with fewer ACS patients. The main difference with other studies was the higher in-stent thrombosis and in-stent restenosis rate. However, the rate of TLR and mortality at 4-year follow up was not signi fi cantly different than those previously reported by other studies.

Outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) have improved because of advancements in equipment and techniques. With global collaboration and knowledge sharing, we have identified 7 common principles that are widely accepted as best practices for CTO-PCI. 1. Ischemic symptom improvement is the primary indication for CTO-PCI. 2. Dual coronary angiography and in-depth and structured review of the angiogram (and, if available, coronary computed tomography angiography) are key for planning and safely performing CTO-PCI. 3. Use of a microcatheter is essential for optimal guidewire manipulation and exchanges. 4. Antegrade wiring, antegrade dissection and reentry, and the retrograde approach are all complementary and necessary crossing strategies. Antegrade wiring is the most common initial technique, whereas retrograde and antegrade dissection and reentry are often required for more complex CTOs. 5. If the initially selected crossing strategy fails, efficient change to an alternative crossing technique increases the likelihood of eventual PCI success, shortens procedure time, and lowers radiation and contrast use. 6. Specific CTO-PCI expertise and volume and the availability of specialized equipment will increase the likelihood of crossing success and facilitate prevention and management of complications, such as perforation. 7. Meticulous attention to lesion preparation and stenting technique, often requiring intracoronary imaging, is required to ensure optimum stent expansion and minimize the risk of short- and long-term adverse events. These principles have been widely adopted by experienced CTO-PCI operators and centers currently achieving high success and acceptable complication rates. Outcomes are less optimal at less experienced centers, highlighting the need for broader adoption of the aforementioned 7 guiding principles along with the development of additional simple and safe CTO crossing and revascularization strategies through ongoing research, education, and training.

Renal artery stenosis caused by neurofibromatosis is a rare cause of renovascular hypertension. This hypertension can develop during childhood and is one of the leading causes of poor outcome. We report the case of a 17-year-old girl who was incidentally diagnosed with severe hypertension. During her examination for secondary hypertension, we reached a diagnosis of neurofibromatosis type 1 on the basis of a cluster of typical findings: optic nerve glioma, café au lait spots, nodular neurofibromas, and axillary freckling. Renal angiograms revealed a hemodynamically significant left renal artery stenosis (70%). Renal angioplasty with a self-expanding stent was performed one month later for rapidly progressive renal artery stenosis (90%) and uncontrolled blood pressure. Excellent blood pressure control resulted immediately and was maintained as of the 2-year follow-up evaluation. We think that percutaneous transluminal renal angioplasty can be effective in select patients who have neurofibromatosis type 1 and refractory hypertension caused by renal artery stenosis.

În ciuda recentelor progrese care au fost făcute în domeniul angioplastiei de trunchi comun arteră coronară stângă percutanată, tratamentul leziunilor de bifurcaţie trunchi comun distal rămâne o provocare. Tehnicile cu două stenturi, deşi nici una dintre ele nu s-a dovedit a fi superioară celorlaltora, sunt frecvent utilizate la pacienţii cu leziuni Medina 1,1,1 de trunchi comun distal arteră coronară stângă. Din aceste tehnici cu două stenturi, cu tehnica Culotte putem realiza o reconstrucţie optimă a bifurcaţiei trunchiului comun. Tehnica culotte poate fi difi cilă din punct de vedere tehnic, mai ales atunci când sunt utilizate stenturi balon expandabile. Dar, noile stenturi auto expandabile cu un sistem de livrare pe balon pot depăsi multe limitări ale stenturilor pe balon şi pot facilita tehnica Culotte în stenoza de trunchi comun arteră coronară stângă. Prezentăm cazul unui pacient în vârstă de 74 de ani, de sex masculin, cu leziune Medina 1,1,1 trunchi comun distal tratată prin tehnica Culotte cu noul stent Stentys Xposition S (un stent farmacologic activ autoexpandabil cu sistem de livrare pe balon). Cuvinte cheie: Stenoza trunchi comun, tehnica Culotte, interventie coronariana percutana, stent autoexpandabil Romanian Journal of Cardiology Vol. 26, No. 2, 2016 165 Marin Postu et al. Left main stenosis treated by Culotte technique day of aspirin and 90 mg twice a day of ticagrelor), beta-blocker, calcium-channel blocker, angiotensin converting enzyme inhibitor and high dose statin. Coronary angiogram was performed using right radial access showing a 90% stenosis on mid right coronary artery (RCA), important calcifi cation of the fi rst and second segment of RCA (Figure 1), distal left main with a calcifi ed 90% stenosis, 80% ostial stenosis of left anterior descending artery (LAD) and left circumfl ex artery (LCx), multiple atheromatous plaques on LAD and LCx (Figure 2). The Syntax Score was 27 and the EuroSCORE II was 2.67%. Because this patient with multivessel disease had a Syntax score of 27 and a low surgical risk, the fi rst choice of revascularization would have been coronary artery bypass surgery. Because the patient refused surgery, the heart team decided to treat the RCA and left main stenosis by percutaneous coronary intervention (PCI). PCI was performed using a 7F right femoral access. We used to engage the RCA ostium an 0.75 Amplatz left guiding catheter, because it offered more support than the right Judkins guiding catheter. Two 0.014” BMW Universal II guidewires were advanced distal in the RCA to enhance the support of the guiding catheter and to act like a buddy wire and to ease the predilatation. The RCA lesion was predilated with a 2.0x20 mm balloon expanded at 12 atmospheres (atm). A 3.5x23 mm Xience Pro stent was deployed at 12 atm and postdilated with a 3.5x15 mm noncompliant balloon infl ated at 22 atm. After stent implantation, there was a small dissection distal to the stent, which was covered with a 3.0x12 mm Xience Pro stent expanded at 14 atm, with a good angiographic fi nal result (Figure 3). For the left main lesion we used a 7F 4.0 XtraBackup guiding catheter. Two 0,014” BMW Universal II guidewires were placed distal into the LAD and LCx. The left main was predilated toward LAD and LCx using a 3.5x15 mm semicompliant balloon infl ated at 12 atm. A 3.5-4.5x27 mm Stentys Xposition S stent was implanted from the left main to the LAD infl ated at 8 atm. The stent was postdilated at the bifurcatioen level with a 4.0x15 mm noncompliant balloon infl ated at 16 atm (Figure 4A). After rewiring, the stent struts towards LCx were dilated using a 3.0x12 mm semicompliant balloon to facilitate the passage of the second stent. Accordingly to the Culotte technique a second 3.54.5x17 mm Stentys Xposition S was deployed at 8 atm from the left main to the LCx (Figure 4B). The second stent was postdilated with a 4.0x15 mm noncompliant balloon infl ated at 16 atm. After rewiring the second stent struts were dilated with a 3.5x15 mm noncompliant balloon from the left main to the LAD. A fi nal Figure 1. Diagnostic coronary angiogram – right coronary artery (RCA) (RAO 30): 90% stenosis on mid RCA, important calcifi cation of the fi rst and second segment of RCA. Figure 2. Diagnostic coronary angiogram – left coronary artery. A) RAO 20 CAU 20; B) LAO 20 CRA 20 distal left main with a calcifi ed 90% stenosis, 80% ostial stenosis of left anterior descending artery (LAD) and left circumfl ex artery (LCx), multiple atheromatous plaques on LAD and LCx. Marin Postu et al. Left main stenosis treated by Culotte technique Romanian Journal of Cardiology Vol. 26, No. 2, 2016 166 stenting is a single-stent strategy, although it allows the placement of a second stent if required [T stenting, postdilatation of the stents in the left main was done with a 4.5x15 mm noncompliant balloon infl ated at 16 atm (Figure 4C), with a good fi nal angiographic result (Figure 5 and Figure 6). Clinical evolution of the patient was good, he was free from angina and he was discharged the following day. DISCUSSIONS AND IMPLICATIONS FOR CLINICAL PRACTICE When we are dealing with a distal left main bifurcation lesion, we must take into account many characteristics in order to choose the best bifurcation stenting technique: Medina classifi cation, the difference in diameter between left main, LAD and LCx, the amount of calcium, the angle between LAD and LCX 1. True distal bifurcation lesions may be treated by either a single-stent or by a two-stent strategy. The provisional Figure 3. RCA fi nal angiogram (RAO 30). Figure 5. Left coronary artery fi nal angiogram (RAO 30 CAU 20). Figure 4. A) The result after implantation of a 3.5-4.5x27 mm Stentys Xposition S stent from the left main to LAD (LAO 30 CRA 20); B) Implantation of a 3.5-4.5x17 mm Stentys Xposition S stent from left main to LCx; C) Final proximal optimization of the stents in the left main with a 4.5x15 mm noncompliant balloon. Figure 6. Left coronary artery fi nal angiogram (LAO 50 CAU 30). Romanian Journal of Cardiology Vol. 26, No. 2, 2016 167 Marin Postu et al. Left main stenosis treated by Culotte technique angle between LAD and LCX. Taking into account the high amount of calcium and the difference in diameter between left main, LAD and LCX we chose a coronary self-expandable stent, because of its better conformability and it can be easier appose to the vessel wall. Stentys Xposition S is a self-expandable sirolimus eluting stent that ensure a complete and continuous apposition to vessel wall and from the diameter it was implanted it can achieve a 6 mm maximum vessel diameter. Another important characteristic that made Stentys Xposition S suitable for this lesion was that it can be precisely positioned in order not to miss the lesion. Thanks to these characteristics of the stent, Culotte technique becomes friendlier. We no longer need to make “kissing” and proximal optimization. We didn’t used intravascular ultrasound to check the fi nal result because the new Stentys Xposition S can achieve a good vessel wall apposition and a continuous expansion. To our knowledge, this is the fi rst report on treatment of distal left main bifurcation lesion by Culotte technique using the new Stentys Xposition S stent. Acknowledgment: none declared. Disclosure: The authors declare that there is no confl ict of interest. References 1. Predescu LM., Zarma L, Platon P. et al. Current treatment of left main coronary artery disease. Cor et Vasa 2015;Article in Press, DOI: http://dx.doi.org/10.1016/j.crvasa.2015.05.007. 2. Fajadet JC, A. Current management of left main coronary artery disease. European heart journal 2012;33:36-50b. 3. Ahn JM, Lee PH, Park SJ. Practical based approach to left main bifurcation stenting. BMC cardiovascular disorders 2016;16:49. 4. Smolka G, Wanha W, Roleder T, Pluta A, Ochala A. Treatment of left main coronary artery stenosis with the STENTYS self-expandable drug-eluting stent a pilot registry. Postepy w kardiologii interwencyjnej = Advances in interventional cardiology 2014;10:226-30. 5. Chen SL, Xu B, Han YL, et al. Clinical Outcome After DK Crush Versus Culotte Stenting of Distal Left Main Bifurcation Lesions: The 3-Year Follow-Up Results of the DKCRUSH-III Study. JACC Cardiovascular interventions 2015;8:1335-42. 6. Kervinen K, Niemela M, Romppanen H, et al. Clinical outcome after crush versus culotte stenting of coronary artery bifurcation lesions: the Nordic Stent Technique Study 36-month follow-up results. JACC Cardiovascular interventions 2013;6:1160-5. T stenting and small protrusion, culotte techniques]. More complex lesions may require double-stent strategy (T stenting, TAP, crush, mini crush, culotte, V stenting) 2. Culotte stenting in left main is a strategy suitable for lesions where the ostium of the LCx is diseased, the angulation between the vessels is <600 (higher risk of plaque shift), and the two vessels are of similar diameter3. The main vessel, usually the left main to the LAD, is stented. A second stent is then passed through the struts of the fi rst stent into the side vessel, leaving an overlap of both stents in the left main. The left main LCx stent is deployed. The procedure is completed with a ‘kissing balloon’ infl ation. This technique provides an optimal reconstruction of distal left main bifurcation but with a signifi cant area of stent overlap. The culotte technique is more technically demanding compared to other bifurcation strategies. But, the use of new generation of stents, like self-expandable stents with open cells facilitates this technique. Culotte technique in left main is not routinely applied in left main given the relative large size of the left main compared to the available drug eluting stents diameters. Again this problem is solved by self-expandable stents that can reach a diameter in left main with 2 mm higher than the diameter of the LAD or LCX, facilitating a correct vessel wall apposition4. Another problem

The patients with severe left main stem (LMS) stenosis have a very high risk of major cardiovascular events because of the extent of ischaemic myocardium. At 3rd year, the mortality rate for patients with significant LMS stenosis treated medically is 50%. Coronary artery bypass grafting (CABG) is considered the gold standard for the treatment of complex LMS stenosis, especially if it is associated with multivessel coronary disease. Many studies have showed that percutaneous coronary interventions (PCI) can be a safe and efficient alternative to CABG in carefully selected patients by the Heart Team, with similar mortality rates. The LMS PCI results have been continuously improved by the new PCI techniques developed and by the use of newer generation drug eluting stents. Furthermore, different invasive imagistic methods (intravascular ultrasound or optical coherence tomography) or haemodynamic assessment tools (fractional flow reserve) can improve the LMS PCI results. With those new developments in the technique of LMS PCI, the current guidelines about the treatment of left main coronary artery disease can be modified in the future. (C) 2015 The Czech Society of Cardiology. Published by Elsevier Sp. z o.o. All rights reserved.

Contact address: Călin Iulian, MD ARES, Centers of Excellence in Interventional Cardiology and Radiology, Bucharest, Romania Hypertrophic cardiomyopathy (HCM) is the most frequent congenital heart disease and the most frequently detected cardiomyopathy. The location of the hypertrophy varies at the level of the left ventricle and more types of left ventricular hypertrophy are being described (Maron types): limited to the anterior segment of the IVS (interventricular septum) 10%, present in both the anterior and posterior segments of the IVS (20%), affecting both the IVS and the anteriorside loose wall (52%), and other areas, including the apical one (18%)1. The apical type of HCM was initially reported in Japan by Sakamoto and col2 and then by Yamaguchi and col3. This disease is common in Japan and it is estimated at 25% of the Japanese patients with HCM. In patients with non-asian origins, occurrence of this localization does not exceed 1-2%. The apical hypertrophic cardiomyopathy has typical features on ECG, ecocardiography and ventriculography. On ECG, it displays gigantic T waves and high R waves. Angiographically, in telediastole, the left ventricle cavity displays a confi guration similar to “ace of spades”. Although this type of HCM has been reported to present a benign prognostic, a third of these patients may have severe complications, such as myocardial infarction, atrial fi brillation and cerebral stroke. The changes displayed by the ECG and the symptoms associated with HCM in the apical form sometimes look like coronary acute syndromes4. We report a case of symptomatic apical hypertrophic cardiomyopathy and ECG changes which mimics ischemic cardiac disease: 69 years old patient, with cardiovascular risk features (smoker, hypertensive, age, dyslipidemic, low tolerance to glucose), with symptoms such as: dyspnea of effort, angina of effort and palpitations, with paroxystic atrial fi brillation and TVNS documented on ECG Holter monitoring. Physical examination shows good general condition, rhythmic, clear, cardiac sounds, without pulmonary rales; with no murmurs on femoral and carotid arteries, peripheral pulse present in both limbs, to distally; BP = 130/90 mmHg, VA = 70 bpm. ECG: regular sinus rhythm, 50 bpm, QRS <0.12 sec, terminal phase changes displayed as biphasic T waves in all leads but more accentuated in precordial ones. Echocardiography good systolic function of the LV, EF 60%, with no signifi cant valvulopathy, with no hypertrophy of the VS walls, free pericardium, no pulmonary hypertension (the evaluation took place in the context of a diffi cult echographic view). Because of the symptoms, the ECG changes and of the risk factors associated with the coronary disease, we performed coronary angiogram which showed a right dominant coronary artery system (Fig. 1) with no signifi cant athero-sclerotic lesions but with intramus-

Cardiovascular manifestations of tertiary syphilis infections are uncommon, but represent an important cause of mortality and morbidity. Syphilitic aortitis is characterized by aortic regurgitation, dilatation of ascending aorta and ostial coronary artery lesions. We report a case of 36 years old man admitted to our hospital for acute anterior ST segment elevation myocardial infarction complicated with cardiogenic shock (hypotension 75/50 mmHg). Transthoracic echocardiography revealed a dilated left ventricle with severe systolic dysfunction (ejection fraction = 25%), severe mitral regurgitation, moderate aortic regurgitation and mildly dilated ascending aorta. Coronary angiography showed a severe ostial lesion of left main coronary artery which was treated by urgent stent implantation and an intra-aortic contrapulsation balloon was implanted. Blood tests for syphilitic infection were positive. The patient was discharged with treatment including benzathine penicillin. In our case, we present an acute manifestation of a syphilitic ostial left main stenosis treated by primary percutaneous coronary intervention in acute myocardial infarction. Long term follow-up of the patient is crucial as a result of potential rapid in-stent restenosis caused by continuous infection of the ascending aorta. This case is particular because it shows that syphilitic aortitis can be diagnosed in acute settings, like ST segment elevation myocardial infarction.

Contact address: Cristina Bucşa, MD, Fundeni Clinical Institute, Bucharest. E-mail: cristinabucsa@yahoo.com INTRODUCTION Many studies show that the renal transplantation is now seen as the best treatment for patients with end-stage renal disease (ESRD) because the renal transplant recipients have a better quality of life and a longer survival compared to patients on dialysis1. Still, the cardiovas-