Coronary artery spasm remains an important yet rarely recognized cause of myocardial ischemia, which may manifest as vasospastic angina, ventricular arrhythmia, or sudden cardiac death. Here we present a case of ST-segment elevation myocardial infarction complicated by cardiac arrest secondary to coronary artery spasm, diagnosed with invasive coronary function testing.

Background Inadvertent lead malposition (ILM) in the left ventricle (LV) via the subclavian artery is a rare complication during the insertion of cardiac implantable electronic devices (CIED). If not identified, there is a risk of systemic thromboembolism. Transarterial pacing lead extraction often requires surgical removal and carries high risks of bleeding and thromboembolism, but percutaneous extraction has also been previously described. Case summary A 71-year-old female presented with left homonymous hemianopia on Day 1 post-insertion of a dual-chamber permanent pacemaker (PPM). A computed tomography (CT) angiogram of the brain and aortic arch revealed an acute occlusion of a branch of the right posterior circulating artery (PCA) and a malpositioned pacing lead in the left subclavian artery. Urgent percutaneous removal of the transarterial lead using the retained wire technique was successfully performed. Discussion Inadvertent lead malposition in the arterial system is rare and often requires lead extraction due to systemic thromboembolic complications. The retained wire technique has been previously described for percutaneous transvenous lead extraction and exchange, but to our knowledge, we are the first to report utilizing this technique for transarterial lead extraction. Using a case report, we highlight the utility, safety, and effectiveness of the retained wire technique in extracting a malposition lead in the subclavian artery and LV.

Ventricular septal rupture is an extremely rare sequelae of blunt chest trauma, and is mostly diagnosed postmortem. We present a case of a large isolated traumatic ventricular septal rupture after a suicide attempt by jumping from a height of 5 stories, which was successfully treated with surgical closure. (Level of Difficulty: Intermediate.).

Introduction: Open aortic arch repair remains one of the most challenging aspects of cardiac surgery, primarily due to the disruption of blood-flow to the cerebral circulation. Over the past 50-years, several cerebral protection strategies have been developed with the aim of minimising adverse post-operative neurological outcomes. The choice of strategy is often centre and surgeon dependent, with some favouring one over another. Despite the variation in technique, centres performing a high annual number of aortic surgeries have still consistently demonstrated satisfactory post-operative outcomes with their open arch repairs, regardless of their preferred neuroprotective strategy. Low volume aortic centres, however, face unique challenges with open arch repairs, mainly due to the limited annual number of procedures performed. The aim of this study is to highlight the reproducibility, safety and efficacy of bilateral selective antegrade cerebral perfusion (bSACP) as a neuroprotective strategy during open aortic arch repair in a low volume aortic centre. Methods: We performed a retrospective analysis of data collected from 23 patients who underwent open aortic arch repair over a 43-month period (January 2011 to August 2014). The data consisted of patient demographics, surgical indications, and various pre-/intra-/post-operative variables. All emergency and elective open aortic repair procedures (proximal, mid to distal arch) were included, with emergency and elective surgeries being defined using the STS definition. All the patients underwent a median sternotomy with cardiopulmonary bypass, circulatory arrest and bSACP. Bilateral radial artery monitoring as well as cerebral pulse oximetry were employed. Results: The median age of the patients was 66 years (range 37 – 77 years). Nineteen patients were male (83%); twelve patients (52%) required emergent surgery. Median circulatory arrest time was 29 minutes (range 19 – 123 minutes), while median bSACP was 23 minutes (14 – 123 minutes). Early mortality was 13% (3 patients), all of which were emergent cases. There was 1 new post-operative stroke in a patient with acute Type A dissection. The incidence of temporary neurological dysfunction (TND) was 17.4% (4 patients). The mean hospital stay was 11.8 + /- 7 days. Survival at 1 year was 79%. Discussion: Our early experience with the utilisation of bSACP as a neuroprotective strategy during open aortic arch repair shows a low incidence of neurological deficit (both temporary and permanent), and also an acceptable mortality rate. The outcome for patients with established pre-operative stroke, however, remains poor. The results in our centre with a relatively small annual number of aortic arch surgeries suggest that the method of bSACP employed in our institute is reliable, reproducible and safe.