Failure to penetrate the proximal cap or cross with equipment remains the most frequent cause of procedural failure in CTO PCI. In the "BASE" technique concerns were raised over the risk of proximal side branch loss. We here describe the evolution of this technique and highlight examples where the sub-intimal space was accessed proximal to the occlusion by using the side branch. This technique can be of use both in resolving proximal cap ambiguity and also in cases where there is difficulty crossing a resistant proximal cap.

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SS is rarely performed, usually as last resort, to recanalize complex IS-CTOs. It is associated with favorable acute and mid-term outcomes, but given the small sample size of our study additional research is warranted.

Objectives The aim of this study was to quantify the radiation dose reduction during coronary angiography and percutaneous coronary intervention (PCI) through removal of the anti-scatter grid (ASG), and to assess its impact on image quality in adult patients with a low body mass index (BMI). Methods A phantom with different thicknesses of acrylic was used with a Westmead Test Object to simulate patient sizes and assess image quality. 129 low BMI patients underwent coronary angiography or PCI with or without the ASG in situ. Radiation dose was compared between both patient groups. Results With the same imaging system and a comparable patient population, ASG removal was associated with a 47% reduction in total dose-area product (DAP) (p < 0.001). Peak skin dose was reduced by 54% (p < 0.001). Operator scatter was reduced to a similar degree and was significantly reduced through removal of the ASG. Using an image quality phantom it was demonstrated that image quality remained satisfactory. Conclusions Removal of the ASG is a simple and effective method to significantly reduce radiation dose in coronary angiography and PCI. This was achieved while maintaining adequate diagnostic image quality. Selective removal of the ASG is likely to improve the radiation safety of cardiac angiography and interventions.

Repeat cardiac surgery in patients with a previous sternotomy is associated with significant morbidity and mortality. While transcatheter aortic valve implantation in high risk surgical patients is now well established, experience with transcatheter mitral valve replacement is still at an early stage. Although many successful reports of transcatheter mitral valve replacements now exist, the predominant approach has been via a transapical approach. It is likely that, as with the evolution of favoured access routes for transcatheter aortic therapies, future directions for transcatheter mitral valves will focus on smaller delivery systems favouring the transvenous transseptal approach where possible. We present the first reported case of combined transseptal para-ring leak closure followed by transcatheter mitral valve implantation using a 12/5mm Amplatzer III vascular plug and a 29mm SAPIEN 3 valve.