Omer Goktekin

Background: Aorto‐ostial chronic total occlusions (CTOs) of the right coronary artery (RCA) represent a particularly complex subset of CTO percutaneous coronary interventions (PCI), yet dedicated data remain limited. We aimed to evaluate technical outcomes of aorto‐ostial versus non–aorto‐ostial RCA CTO PCI and to identify predictors of failure in RCA aorto‐ostial lesions. Methods: Patients undergoing RCA CTO PCI between 2016 and 2024 and enrolled in the ERCTO (European Registry of Chronic Total Occlusion) registry were included in the present analysis. The primary end point was technical success. Multivariable logistic regression was used to identify independent predictors of technical failure. Results: A total of 26 374 patients undergoing RCA CTO PCI were included in the analysis, of whom 2850 had aorto‐ostial and 23 524 non–aorto‐ostial lesions. Technical success was lower in aorto‐ostial compared with non–aorto‐ostial lesions (79.6% versus 89.7%; P P P P P P <0.001) were independently associated with technical failure. In‐hospital major adverse cardiac and cerebrovascular events rates were low and did not differ significantly between groups. Conclusions: Aorto‐ostial RCA CTO PCI has a significantly lower technical success despite extensive use of advanced techniques. Technical failure is driven primarily by lesion‐specific anatomical features, underscoring the need for dedicated strategies and refined risk stratification tailored to aorto‐ostial anatomy.

Background: Coronary imaging is increasingly used in chronic total occlusion percutaneous coronary intervention (CTO-PCI), but the impact of different imaging strategies on procedural decisions and outcomes remains unclear. Methods: We retrospectively analyzed 171 consecutive patients undergoing CTO-PCI, stratified by imaging strategy into four groups: angiography-only (n = 48), IVUS-guided (n = 42), CT-guided (n = 40) and CT + IVUS-guided (n = 41). Procedural and in-hospital clinical outcomes were compared. A multivariable logistic regression identified predictors of intense debulking techniques (defined as the use of rotational atherectomy or intravascular lithotripsy). Results: Imaging guidance was associated with progressively longer procedural (p < 0.001) and fluoroscopic time (p = 0.007). Similarly, an increased number of guidewires (p = 0.005) and balloons (p = 0.003) was used in the imaging groups, with the CT + IVUS groups showing the highest features. Regarding stenting characteristics, higher stent length and diameter (p = 0.01) were observed in the imaging groups. In patients with J-CTO score > 2, procedural success rates significantly increased with the use of coronary imaging (p = 0.01). Multivariable analysis showed that both J-CTO score (OR 2.0; 95% CI 1.3–3.0; p = 0.001) and imaging strategies (OR 1.6; 95% CI 1.02–2.4; p = 0.04) independently predicted the use of intense debulking techniques. Importantly, no significant differences were observed in in-hospital complications across groups. Conclusions: The use of coronary imaging, particularly the combination of IVUS and CT, is associated with more complex CTO lesions and led to increased procedural time, fluoroscopic time and more extensive stenting, as well as higher debulking usage. In complex CTO cases, coronary imaging was associated with higher procedural success rates. Imaging strategies independently predicted the need for advanced lesion preparation, beyond anatomical complexity, without compromising safety. Despite higher procedural demands, coronary imaging enables a more tailored and successful approach to CTO-PCI, particularly in complex cases. These findings underscore the pivotal role of multimodal imaging in the procedural planning and optimization of CTO-PCI.

Catheter kinking is a rare but significant complication of trans‐radial coronary interventions, often caused by arterial tortuosity, vessel spasm, or improper catheter manipulation. We present a case of catheter kinking that occurred during coronary engagement in a transradial procedure, which could not be resolved using conventional techniques. Given the failure of guidewire advancement and deep inspiration maneuvers, a femoral access‐assisted balloon trapping technique was employed. This method allowed for the successful retrieval of the kinked catheter while minimizing vascular trauma and ensuring procedural completion. Catheter kinking during trans‐radial coronary interventions poses technical challenges requiring tailored management strategies. This case underscores the effectiveness of femoral access‐assisted balloon trapping technique as a viable and minimally invasive solution. Increased awareness and preparedness for such complications can enhance procedural success and patient safety.

Background and Objectives: Diagnosis of myocarditis remains a challenge in clinical practice; however, magnetic resonance imaging (CMRI) can ease the diagnostic approach by providing various parameters. The prevalence of right ventricular involvement in acute myocarditis is suggested to be more frequent than previously hypothesized. In this study, we sought to investigate subclinical RV involvement in patients with acute myocarditis and preserved RV ejection fraction (EF), using CMRI RV speckle-tracking imaging. Materials and Methods: CMRI of 27 patients with acute myocarditis (nine females, age 35.1 ± 12.2 y) was retrospectively analyzed. A control group consisting of CMRI images of 27 healthy individuals was included. Results: No significant differences were found regarding left ventricle (LV) and atrium dimensions. LV ejection fraction was significantly different between groups (56.6 ± 10.6 vs. 62.1 ± 2.6, p < 0.05). No significant differences were present between parameters used for conventional assessment of RV. However, RV strain absolute values were significantly lower in the acute myocarditis group in comparison with that of the control group (18.4 ± 5.4 vs. 21.8 ± 2.8, p = 0.018). Conclusions: Subclinical RV dysfunction detected by CMR-derived strain may be present in patients with acute myocarditis even with preserved RVEF.

Background: Balloon uncrossable lesions are defined as lesions that cannot be crossed with a balloon after successful guidewire crossing. Methods: We analyzed the association between balloon uncrossable lesions and procedural outcomes of 8671 chronic total occlusions (CTOs) percutaneous coronary interventions (PCIs) performed between 2012 and 2022 at 41 centers. Results: The prevalence of balloon uncrossable lesions was 9.2%. The mean patient age was 64.2 ± 10 years and 80% were men. Patients with balloon uncrossable lesions were older (67.3 ± 9 vs. 63.9 ± 10, p < 0.001) and more likely to have prior coronary artery bypass graft surgery (40% vs. 25%, p < 0.001) and diabetes mellitus (50% vs. 42%, p < 0.001) compared with patients who had balloon crossable lesions. In-stent restenosis (23% vs. 16%. p < 0.001), moderate/severe calcification (68% vs. 40%, p < 0.001), and moderate/severe proximal vessel tortuosity (36% vs. 25%, p < 0.001) were more common in balloon uncrossable lesions. Procedure time (132 (90, 197) vs. 109 (71, 160) min, p < 0.001) was longer and the air kerma radiation dose (2.55 (1.41, 4.23) vs. 1.97 (1.10, 3.40) min, p < 0.001) was higher in balloon uncrossable lesions, while these lesions displayed lower technical (91% vs. 99%, p < 0.001) and procedural (88% vs. 96%, p < 0.001) success rates and higher major adverse cardiac event (MACE) rates (3.14% vs. 1.49%, p < 0.001). Several techniques were required for balloon uncrossable lesions. Conclusion: In a contemporary, multicenter registry, 9.2% of the successfully crossed CTOs were initially balloon uncrossable. Balloon uncrossable lesions exhibited lower technical and procedural success rates and a higher risk of complications compared with balloon crossable lesions.

Objective: This study aimed to examine complications that may occur after carotid artery stenting (CAS) and their relationships with carotid artery stenosis rate. Materials and Methods: Complications, such as cerebral hyperperfusion, stroke, death, stent thrombosis or occlusion and restenosis, were evaluated on the 30th day after CAS and at the end of the first year. Results: Of the 205 CAS procedures, complications developed in 12 patients. The complication rate for the first 30 days after the procedure was 4,87%, and at the end of the first year, it was 5,85%. Of the 12 patients with complications, 8 had carotid stenosis of ≥90%. Death occurred in 4 of 195 patients with carotid artery stenosis. The mortality rate within the first 30 days and during the 1-year follow-up period was 1,53% and 2,05%, respectively. Ischemic stroke occurred in 6 of 195 patients with carotid artery stenosis. After the first 30 days and one year follow-up, ischemic stroke had occurred in 3,07% of patients. Stent thrombosis and occlusion rate was 4,87% in 205 CAS procedures, and 7 of them occurred in the first 24 hours and another 3 occurred within the first 30 days. Restenosis rates were 0,48% and 0,97% at 6 months and the first year, respectively. Conclusion: The complications of CAS have been associated with the urgency of treatment (emergency), symptom presence (symptomatic patients) and high degree of stenosis (≥90%); whereas bilateral stenosis is not associated with complications. In addition, stent thrombosis and occlusion were observed as the most common CAS complication.

Aim   Hypertrophic cardiomyopathy (HCM) is a relatively common, heritable cardiomyopathy, and cardiac magnetic resonance (CMR) studies have been performed previously to evaluate different aspects of the disease. However, a comprehensive study, including all four cardiac chambers and analysis of left atrial (LA) function, is missing in the literature. The aim of this retrospective study was to analyze CMR-feature tracking (CMR-FT) strain parameters and atrial function of HCM patients and to investigate the association of these parameters with the amount of myocardial late gadolinium enhancement (LGE). Material and Methods In this retrospective, cross-sectional study, we analyzed the CMR images (CMRI) of 58 consecutive patients, who from February 2020 to September 2022 were diagnosed with HCM at our tertiary cardiovascular center. Patients who were younger than 18 yrs or who had moderate or severe valvular heart disease, significant coronary artery disease, previous myocardial infarction, suboptimal image quality, or with contraindication to CMR were excluded. CMRI was performed at 1.5 T with a scanner, and all scans were assessed by an experienced cardiologist and then re-assessed by an experienced radiologist. SSFP 2-, 3- and 4‑chamber, short axis views were obtained and left ventricular (LV) end-diastolic volume (EDV), end-systolic volume (ESV), ejection fraction (EF), and mass were measured. LGE images were obtained using a PSIR sequence. Native T1 and T2 mapping and post-contrast T1 map sequences were performed and each patient’s myocardial extracellular volume (ECV) was calculated. LA volume index (LAVI), LA ejection fraction (LAEF), LA coupling index (LACI) were calculated. The complete CMR analysis of each patient was performed with CVI 42 software (Circle CVi, Calgary, Canada), off-line. Results The patients were divided into two groups, HCM with LGE (n=37, 64 %) and HCM without LGE (n=21, 36 %). The average patient age in the HCM patients with LGE was 50.8±14 yrs and 47±12.9 yrs in the HCM patients without LGE. Maximum LV wall thickness and basal antero-septum thickness were significantly higher in the HCM with LGE group compared to the HCM without LGE group (14.8±3.5 mm vs 20.3±6.5 mm (pConclusion This study sheds light on the CMR-FT differences between HCM with and without LGE. We found a greater burden of LA volume but significantly lower LA and LV strain in the LGE patients. These findings highlight further the LA and LV remodeling in HCM. Impaired LA function appears to have physiological significance, being associated with greater LGE. While our CMR-FT findings support the progressive nature of HCM, beginning with sarcomere dysfunction to eventual fibrosis, further studies are needed to validate these results in larger cohorts and to evaluate their clinical relevance.

Medina,bifurcation,ostial,coronary,stenting

Background: Paravalvular leak (PVL) is a common, serious complication related with prosthetic valve replacement. Although surgical closure reoperation is the choice of treatment, percutaneous device closure is a good alternative with good results in patients with very high surgical risk. Case summary: In this case report, we present the percutaneous closure of PVL of mitral valve replacement (MVR), in a patient with cardiogenic shock who failed conservative medical treatment and was deemed inoperable due to recurrent operations. Successful closure of the PVL with the use of the four consecutive PVL closure devices was performed under general anaesthesia with guidance of 2D and 3D transoesophageal echocardiography. The procedure was performed with no complications and the patient has remained asymptomatic after 10 months following the PVL closure procedure with marked improvement in her NYHA class and echocardiographic values. Discussion: Percutaneous PVL closure is a very challenging and high clinical skills requiring procedure, but has a good success and low complication rate in high-risk patients. It is not a standard procedure and the type and size of device should be tailored for each patient with a good 2D and 3D echocardiographic guidance.