A 19-year-old healthy male presented with frequent palpitations, which interfered with his daily activities. There was no chest pain, reduced effort tolerance, or pre-syncopal episode. No family history of sudden cardiac death nor significant cardiovascular disease was noted. His physical examination was unremarkable. His electrocardiogram on admission is shown in Figure 1, which showed normal-sized chambers with normal wall motion and preserved ejection fraction. We proceeded to an electrophysiological study (Supplementary material online, Figure S1) which confirmed the presence of a dual node physiology with ventricular ectopics. An atrioventricular (AV) nodal reentrant tachycardia was later induced, for which the patient was symptomatic. The symptoms resolved after successful modification of the slow pathway by radiofrequency ablation. The electrocardiogram post-radiofrequency ablation showed the disappearance of dual node physiology (Figure 2), and there was no complication or recurrence of symptoms postradiofrequency ablation.

Background•Our study aims to examine the impact of gender in patients treated by PCI to unprotected left main stem disease so that we will be able to better risk stratify and plan further management for this group of patients.Methods•This is a retrospective cohort study done involving a multi-ethnic community in the National Heart Institute, Malaysia looking into the impact of gender in patients treated for Left Main Stem (LMS) disease. The study enrolled 1511 patients undergoing PCI to unprotected LMS from 2007 to 2017. Propensity score matching was performed to adjust for differences in baseline clinical characteristics. Primary outcome is Net Adverse Clinical Event which includes Major Adverse Cardiac and Cerebrovascular Event (MACCE)- all cause death, myocardial infarction, target lesion revascularization, stroke and bleeding.Results•In the unadjusted analysis, compared with men, women had higher risk profiles including age- they were older with 25.5% being more than 70 years old, diabetes mellitus- 63.1%, hypertension- 83.6% and pre-existing heart failure- 8.1% which are all statistically significant. Most of the lesions treated were involving the distal LMS and were treated with mostly secondary generation DES (87.6% versus 90.3%). The unadjusted rates of NACE were slightly higher for women- Nil versus 0.5% at 30 days, 1.3% versus 0.5% at 6 months, 2.3% vs 1.6% at 1 year. However these differences were not statistically significant (p-value-0.689). There are no significant differences in NACE after propensity matching too (p-value- 0.424).•Logistic regression equation for multivariate analysis reveals that mortality in women is increased 6.4 times in patients with diabetes mellitus and new onset angina. Mortality in men is 3.9 times in patients with renal failure and 2.2 times higher in those with hypertension.ConclusionsThere is a significant increase of mortality rate in women with new onset angina and diabetes mellitus. There is no conclusive evidence whether women have higher mortality and rate of complications in recent times. Hypertension and dyslipidemia are major risk factors of LMS disease in both genders. In the DES era, differences between sexes were not observed in patients undergoing unprotected PCI to LMS.DisclosuresM. Sundarajoo Nothing to disclose. S. A. Yahaya Nothing to disclose. K. Gurupparan Nothing to disclose. J. Kolanthaivelu Nothing to disclose. D. Yong Nothing to disclose. K. Kaniappan Nothing to disclose. M. Y. Low Nothing to disclose. Background•Our study aims to examine the impact of gender in patients treated by PCI to unprotected left main stem disease so that we will be able to better risk stratify and plan further management for this group of patients. •Our study aims to examine the impact of gender in patients treated by PCI to unprotected left main stem disease so that we will be able to better risk stratify and plan further management for this group of patients. Methods•This is a retrospective cohort study done involving a multi-ethnic community in the National Heart Institute, Malaysia looking into the impact of gender in patients treated for Left Main Stem (LMS) disease. The study enrolled 1511 patients undergoing PCI to unprotected LMS from 2007 to 2017. Propensity score matching was performed to adjust for differences in baseline clinical characteristics. Primary outcome is Net Adverse Clinical Event which includes Major Adverse Cardiac and Cerebrovascular Event (MACCE)- all cause death, myocardial infarction, target lesion revascularization, stroke and bleeding. •This is a retrospective cohort study done involving a multi-ethnic community in the National Heart Institute, Malaysia looking into the impact of gender in patients treated for Left Main Stem (LMS) disease. The study enrolled 1511 patients undergoing PCI to unprotected LMS from 2007 to 2017. Propensity score matching was performed to adjust for differences in baseline clinical characteristics. Primary outcome is Net Adverse Clinical Event which includes Major Adverse Cardiac and Cerebrovascular Event (MACCE)- all cause death, myocardial infarction, target lesion revascularization, stroke and bleeding. Results•In the unadjusted analysis, compared with men, women had higher risk profiles including age- they were older with 25.5% being more than 70 years old, diabetes mellitus- 63.1%, hypertension- 83.6% and pre-existing heart failure- 8.1% which are all statistically significant. Most of the lesions treated were involving the distal LMS and were treated with mostly secondary generation DES (87.6% versus 90.3%). The unadjusted rates of NACE were slightly higher for women- Nil versus 0.5% at 30 days, 1.3% versus 0.5% at 6 months, 2.3% vs 1.6% at 1 year. However these differences were not statistically significant (p-value-0.689). There are no significant differences in NACE after propensity matching too (p-value- 0.424).•Logistic regression equation for multivariate analysis reveals that mortality in women is increased 6.4 times in patients with diabetes mellitus and new onset angina. Mortality in men is 3.9 times in patients with renal failure and 2.2 times higher in those with hypertension. •In the unadjusted analysis, compared with men, women had higher risk profiles including age- they were older with 25.5% being more than 70 years old, diabetes mellitus- 63.1%, hypertension- 83.6% and pre-existing heart failure- 8.1% which are all statistically significant. Most of the lesions treated were involving the distal LMS and were treated with mostly secondary generation DES (87.6% versus 90.3%). The unadjusted rates of NACE were slightly higher for women- Nil versus 0.5% at 30 days, 1.3% versus 0.5% at 6 months, 2.3% vs 1.6% at 1 year. However these differences were not statistically significant (p-value-0.689). There are no significant differences in NACE after propensity matching too (p-value- 0.424). •Logistic regression equation for multivariate analysis reveals that mortality in women is increased 6.4 times in patients with diabetes mellitus and new onset angina. Mortality in men is 3.9 times in patients with renal failure and 2.2 times higher in those with hypertension. ConclusionsThere is a significant increase of mortality rate in women with new onset angina and diabetes mellitus. There is no conclusive evidence whether women have higher mortality and rate of complications in recent times. Hypertension and dyslipidemia are major risk factors of LMS disease in both genders. In the DES era, differences between sexes were not observed in patients undergoing unprotected PCI to LMS. There is a significant increase of mortality rate in women with new onset angina and diabetes mellitus. There is no conclusive evidence whether women have higher mortality and rate of complications in recent times. Hypertension and dyslipidemia are major risk factors of LMS disease in both genders. In the DES era, differences between sexes were not observed in patients undergoing unprotected PCI to LMS.

Background Intravascular lithotripsy is a new method used to treat calcified coronary lesions (CCLs). Percutaneous coronary intervention of CCLs has conventionally been classified as a complex procedure. In the majority of calcified cases, atherectomy is required for sufficient plaque modification prior to stent implantation. Intravascular lithotripsy has been shown to be safe and effective in clinical trials, but as worldwide usage increases, cases of complications are beginning to emerge. Case summary We describe a 71-year-old woman, who after an episode of non-ST-elevation acute coronary syndrome underwent coronary angiography. The culprit vessel was identified to be a severely stenosed left anterior descending artery which was also heavily calcified and tortuous. Intravascular lithotripsy (IVL) was employed for calcium modification prior to stent implantation, but the IVL balloon ruptured during shockwave lithotripsy, resulting in coronary artery dissection. Subsequent management steps and stent deployment resulted in favourable angiographic results. Our findings are further detailed on optical coherence tomography, demonstrating certain features which might predispose to IVL balloon rupture. Discussion We discuss the mechanism of action during intravascular lithotripsy, and how the shockwaves from the lithotripter modify calcified lesions, whilst keeping soft tissue unharmed. Results from clinical trials and multiple real-world studies have shown that complication rates are low. This case report aims to illustrate how the rupture of an intravascular lithotripsy balloon can result in coronary artery dissection. Optical coherence tomography can help in identifying potential anatomical features which may precede such complications.

Thyroid crisis is a life-threatening form of thyrotoxicosis characterized by multi-system dysfunction. Therapeutic plasma exchange has been reported to be effective in removing excessive circulating thyroid hormones. We present a 46-year-old female with recently diagnosed Graves’ disease associated with thyrotoxic cardiomyopathy admitted for thyroid crisis complicated by propranolol-induced circulatory collapse, acute kidney injury and ischemic hepatitis. The tachyarrhythmia was refractory to conventional therapy. Initiation of TPE resulted in rapid clinical and biochemical stabilization.