Coronary perforation is a potentially life-threatening complication of percutaneous coronary intervention (PCI). We studied incidence, outcomes and temporal trends following PCI-related coronary artery perforation (CAP).MethodsProspective systematic review and meta-analysis including meta-regression using MEDLINE and EMBASE to November 2020. We included ‘all-comer’ PCI cohorts including large PCI registries and randomised controlled trials and excluding registries or trials limited to PCI in high-risk populations such as chronic total occlusion PCI or cohorts treated only with atheroablative devices. Regression analysis and corresponding correlation coefficients were performed comparing perforation incidence, mortality rate, tamponade rate and the rate of Ellis III perforations against the midpoint (year) of data collection to determine if a significant temporal relationship was present.Results3997 studies were screened for inclusion. 67 studies met eligibility criteria with a total of 5 568 191 PCIs included over a 38-year period (1982–2020). The overall pooled incidence of perforation was 0.39% (95% CI 0.34% to 0.45%) and remained similar throughout the study period. Around 1 in 5 coronary perforations led to tamponade (21.1%). Ellis III perforations are increasing in frequency and account for 43% of all perforations. Perforation mortality has trended lower over the years (7.5%; 95% CI 6.7% to 8.4%). Perforation risk factors derived using meta-regression were female sex, hypertension, chronic kidney disease and previous coronary bypass grafting. Coronary perforation was most frequently caused by distal wire exit (37%) followed by balloon dilation catheters (28%). Covered stents were used to treat 25% of perforations, with emergency cardiac surgery needed in 17%.ConclusionCoronary perforation complicates approximately 1 in 250 PCIs. Ellis III perforations are increasing in incidence although it is unclear whether this is due to reporting bias. Despite this, the overall perforation mortality rate (7.5%) has trended lower in recent years. Limitations of our findings include bias that may be introduced through analysis of multidesign studies and registries without pre-specified standardised perforation reporting CMore research into coronary perforation management including the optimal use of covered stents seems warranted.PROSPERO registration numberCRD42020207881.

Background Constrictive pericarditis can be one of the most challenging conditions to diagnose within cardiovascular medicine. Iatrogenic causes of constrictive pericarditis are increasingly recognised in higher income countries. This case provides insight into the need for clinical suspicion when diagnosing this relatively under recognised clinical entity as well as the need for multi-modality imaging combined with invasive haemodynamic assessment. Case Summary A 68-year-old man presented with decompensated heart failure four weeks after open-heart surgery. A diagnosis of early-onset post-cardiotomy constrictive pericarditis was made using multi-modality imaging and invasive haemodynamic assessment which demonstrated the cardinal features of constrictive physiology. Surgical intervention with two pericardiectomy procedures was pursued given the aggressive and recalcitrant nature of his presentation. Our patient died shortly after his second surgery due to progressive multi-organ dysfunction. Conclusion Constrictive pericarditis is a challenging but important clinical entity to diagnose. Differentiating constrictive pericarditis from restrictive cardiomyopathy is important as there are key differences in management and prognosis. Our case supports the clinical utility of multimodality imaging combined with invasive haemodynamic assessment in patients with suspected constrictive pericarditis.

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