Background Rotational Atherectomy has become increasingly utilised over the past decade. Although a relatively safe procedure in appropriately trained physicians’ hands, there are a number of recognised complications. Case Summary We describe the case of a 64-year-old female who presented with chest pain and was diagnosed with non-ST-segment elevation acute coronary syndrome. A Transthoracic Echocardiogram (TTE) showed normal biventricular function and no valve disease. Invasive coronary angiogram was performed which revealed a severely calcified ostial right coronary artery (RCA) disease which was felt to be the culprit of the presentation. Balloon dilatation was unsuccessful therefore rotational atherectomy with an AL 0.75 guide and a 1.5 mm Rota-Burr was utilised and improved calcium burden. This was complicated by ostial dissection, treated with stenting. A TTE following the procedure revealed moderate aortic regurgitation (AR). The patient was discharged as she remained asymptomatic. An outpatient transoesophageal echocardiogram performed eight months later showed evidence of severe eccentric AR. Cardiac magnetic resonance imaging confirmed severe AR with left ventricular dilatation. Repeat angiogram 10 months after index procedure revealed in-stent restenosis and the patient was accepted by heart multidisciplinary team for aortic valve replacement and grafting of RCA. Discussion As the field of RA continues to expand, we propose that novel complications such as reported in this case may become recognised. Finally, we stress the importance of multi-modality imaging in the investigation and timely planning of interventions in the management of these patients.

Background Coronary artery bypass grafting (CABG) is the preferred revascularization procedure for patients with multivessel disease, and those with complex left main disease, as it is associated with a survival advantage in this group of patients. Sometimes however surgical management is not the treatment of choice due to many factors including; ongoing chest pain, hemodynamic instability or patient preference. In these situations, PCI offers an alternative revascularization strategy. In this case study, we present a successful PCI with rotational atherectomy (RA) for distal LMS, LAD and CX using a double guide catheter technique in a patient with severe calcific disease. Case Summery A 63-year-old female was diagnosed with a non-ST elevation myocardial infarction (NSTEMI). Coronary angiography showed significant distal left main stem disease with a severe proximal/ostial calcified lesion of the LAD and a possible thrombotic lesion at the ostium of the CX. She had ongoing hemodynamic instability with chest pain however could not be offered immediate surgical revascularization. We therefore elected to proceed to complex bifurcation LMS coronary intervention using RA under IVUS guidance achieving an excellent final result with TIMI III flow. Discussion This case demonstrates that rotational atherectomy (RA) using the double catheter technique (also known as Ping-Pong) can be safely performed with minimal complication rates and with very favorable angiographic and IVUS results. The clinical outcome was excellent with early discharge.

Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome, often occurring in younger females. Such a diagnosis should always be considered in this demographic. In this case report, we focus on the importance of optical coherence tomography in the diagnosis and management of this condition in the elective setting.