Objectives. The study evaluated the correlation between baseline SYNTAX Score, Residual SYNTAX Score, and SYNTAX Revascularization Index and long-term outcomes in ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) on an unprotected left main coronary artery lesion (UPLMCA). Background. Previous studies on primary PCI in UPLMCA have identified cardiogenic shock, TIMI 0/1 flow, and cardiac arrest, as prognostic factors of an unfavourable outcome, but the complexity of coronary artery disease and the extent of revascularization have not been thoroughly investigated in these high-risk patients. Methods. 30-day, 1-year, and long-term outcomes were analyzed in a cohort of retrospectively selected, 81 consecutive patients with STEMI, and primary PCI on UPLMCA. Results. Cardiogenic shock (p=0.001), age (p=0.008), baseline SYNTAX Score II (p=0.006), and SYNTAX Revascularization Index (p=0.046) were independent mortality predictors at one-year follow-up. Besides cardiogenic shock (HR 3.28, p<0.001), TIMI 0/1 flow (HR 2.17, p=0.021) and age (HR 1.03, p=0.006), baseline SYNTAX Score II (HR 1.06, p=0.006), residual SYNTAX Score (HR 1.03, p=0.041), and SYNTAX Revascularization Index (HR 0.9, p=0.011) were independent predictors of mortality at three years of follow-up. In patients with TIMI 0/1 flow, the presence of Rentrop collaterals was an independent predictor for long-term survival (HR 0.24; p=0.049). Conclusions. In this study, the complexity of coronary artery disease and the extent of revascularization represent independent mortality predictors at long-term follow-up.

Coronary subclavian steal syndrome (CSSS) is a relatively uncommon entity, and its clinical spectrum is characterized by stable exertional angina and rarely as acute coronary syndrome. The diagnosis can be established easily by angiography.We report a case series of three patients with CSSS and acute coronary syndrome and we review the literature in the attempt to understand the nature of symptomatology and the mechanisms of ischemia in this condition. Our study raised some questions about the correct definition of this entity, the pathophysiology of coronary steal and the mechanisms of ischemia, in the setting of unstable angina and acute myocardial infarction.

A 67-year-old man had angina and dyspnea for several weeks during exercise and rest, and he came to our hospital for coronary angiography. He had mild ST-segment variability, without necrosis markers. Cardiac ultrasonograms revealed moderate mitral regurgitation, preserved ejection fraction, and a posterior-wall infarction scar despite no history of infarction. Coronary angiograms, which revealed no obvious culprit lesion, showed mild focal stenosis in the proximal right coronary artery, distal chronic occlusion of a small left circumflex coronary artery, and mild stenosis and haziness in the mid left anterior descending coronary artery (LAD) (Fig. 1). Suspecting thrombus in the mid LAD, we performed optical coherence tomography (OCT) (Fig. 2A). The OCT showed irregular honeycomb-like channels connecting the proximal and distal lumina, smooth appearance of the channels' inner surface and the separating septa, no visible fresh thrombus, and only a small plaque burden at the lesion site (Fig. 2B-E). We thought that the guidewire might have passed into a false lumen of a spontaneous dissection, so we advanced another guidewire, parallel to the first, to ensure entry into the distal true lumen. Given the patient's clinical instability, we performed angioplasty and implanted a bare-metal stent. Afterwards, OCT confirmed good distal flow without residual stenosis and showed a well-apposed stent, mild intima prolapse through the struts (Fig. 3A), and almost complete collapse of the parallel channels (Fig. 3B). Two years later, the patient was asymptomatic and well. Comment Lesions of this type were previously associated with recanalized thrombus. 1,2 They were compared with Swiss cheese, 1 or, when channels were spread over a larger area,

Objective Paravalvular aortic regurgitation is an important independent mortality predictor in transcatheter aortic valve implantation (TAVI). Our study evaluated the association between paravalvular aortic regurgitation and mid‐term mortality in relation with the learning curve, in patients with severe aortic stenosis who underwent transfemoral TAVI in the first 3 years since the establishment of the program. Methods Patients with severe aortic stenosis who underwent transfemoral TAVI between 2017 and 2020 were included in the analysis. Paravalvular aortic regurgitation was assessed by transthoracic echocardiography at 48 hours after the procedure. All‐cause mortality was evaluated after 30 days and at mid‐term follow‐up. Results Paravalvular aortic regurgitation ≥grade II was associated with mid‐term all‐cause mortality (OR 4.4; 95%CI 1.82–11.55; p < 0.001), their prevalence declining after the first 60 cases. Baseline characteristics did not significantly differ in the first 60 patients from the rest of the cohort. Male sex (p = 0.006), advanced age (p = 0.04), coronary artery disease (p = 0.003), or elevated STS Score (p = 0.02) influenced mid‐term survival. When adjusting for the presence of these factors, only age (OR 1.1; 95%CI 1.0–1.2), paravalvular aortic regurgitation ≥grade II (OR 3.9; 95%CI 1.3–12.9), and the number of days spent in the intensive care unit (OR 1.4; 95%CI 1.1–1.8) were independent predictors of mid‐term all‐cause mortality. Conclusions In a group of patients with severe aortic stenosis who underwent transfemoral TAVI in the first 3 years since the establishment of the program, paravalvular aortic regurgitation ≥grade II was associated with mid‐term mortality, both declining after the first 60 cases.

An 86-year-old lady with severe aortic stenosis and interventricular membranous septal aneurysm underwent transfemoral transcatheter aortic valve implantation (TAVI). A balloon-expandable valve was deployed after a difficult native valve crossing. Transesophageal echocardiography showed a rapidly accumulating pericardial effusion, with pericardial thrombus and subsequent cardiac tamponade. The angiographic views raised suspicion of aortic root perforation. Median sternotomy was performed because of sudden hemodynamic collapse.The report presents the uncommon association between severe aortic stenosis and interventricular membranous septal aneurysm in an octogenarian and discusses its impact on the development of a post-TAVI major complication.