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1422 Problem solved: Challenging situations in the Cath Lab

due to the rarity of the disease. Treatment is generally reserved for symptomatic
patients with either chest pain due to steal phenomenon or RV uid overload.
The management of CS stulas was purely surgical until 1983 when the rst tran-
scatheter treatment was reported. Multiple techniques have been described in
case reports with successful stula closure through transcatheter approach in-
cluding the use of coils or occlusion devices. The use of septal occluder devices
in this situation is off-label. To our knowledge this approach has not been reported
in literature where the treatment of the stula is directed at the ostium of the artery
relying on collateral supply to the distal vessel. This case is a good demonstra-
tion of how thinking outside the box in the rare settings can lead to a successful
procedural and clinical outcome.

A life-saving plug: spontaneous closure of ventricular rupture by a
coincident thrombus after STEMI
V.D. Dornberger 1 , R.B. Buelow 2 , A.H. Hummel 3 . 1 German Centre for Car-
diovascular Research (DZHK), Greifswald, Germany; 2 University Medicine of
Greifswald, Radiology, Greifswald, Germany; 3 University Medicine of Greifswald,
Cardiology, Greifswald, Germany
A 47 year old previously healthy male complained of pain in the left shoulder after
physical strain. Four days later, the consulted general practitioner referred him
to cathlab because of anterolateral ST segment elevation. Subsequently a veri-
ed proximal thrombotic occlusion of the LAD (panel 1A) was dilated and treated
Takayasu arteritis is characterized as panarteritis that leads to the stenosis and by bare metal stent implantation. Ventriculography showed a moderately reduced
occlusive lesions in large vessels however coronary involvement is also well doc- ejection fraction with all apical segments being hypokinetic. Images were char-
umented. Regression of carotid stenosis1 and left main coronary ostium stenosis acteristic for an apical left ventricular thrombus (panel 1B). A few hours after this
after surgical revascularization2 were shown before. High level of suspicion is re- angiography, the patient rapidly developed cardiogenic shock. Echocardiography
quired to recognize vasculitis related coronary disease in young patients without revealed a hemodynamically relevant pericardiac tamponade. The patient was im-
conventional risk factors. Pharmacological management with immunosuppressive mediately transferred back to cathlab to perform a pericardiocentesis evacuating
agents in patients with vasculitis related coronary disease may help to avoid un- 500 ml of blood. The subsequent coronary angiography revealed no leakage of
necessary revascularization procedures. contrast agent. After the initial pericardiocentesis no further pericardial effusion
occurred and the patient stabilized quickly. Myocardial contrast echocardiogra-
phy suggested the ventricular thrombus to be plugged in a free wall rupture of
1176 the apex (arrow in panel 1C) and septal microvascular occlusions (MVO, small
Percutaneous closure of a large right coronary artery to coronary arrows). Contrast enhanced cardiac magnetic resonance imaging conrmed this
sinus stula perception (panel 1D).
M. Alawami, M. Webster. Auckland District Health Board, Auckland, New Zealand
Introduction: Congenital coronary artery stulas are uncommon abnormalities.
The incidence of this abnormality is estimated to be around 0.06% in all an-
giograms. Fistulous connection between a coronary artery to the coronary sinus
(CS) is extremely rare and leads to dilation of both the coronary artery and the
Clinical problem: A 65 year old male rst presented 2 years ago with New York
Heart Association (NYHA) class II-II symptoms of heart failure. Examination re-
vealed signs of uid overload. His baseline blood tests were unremarkable apart
from slightly elevated liver enzymes. His electrocardiogram (ECG) showed bor-
derline right axis deviation and few ventricular ectopic beats of superior axis. His
trans-thoracic echo showed a large CS associated with severe right atrial (RA)
dilatation, moderate right ventricular (RV) dilatation with preserved systolic func-
tion and mild increase in the pulmonary arterial systolic pressure. His left ventricle
(LV) was normal in size and systolic function. A diagnostic coronary angiogram
showed a large ectatic RCA with a stulous connection to the CS. The proximal
RCA segment diameter measured 46 mm. The inferior and infero-lateral wall of
the LV was supplied by collaterals from the left coronary system. Despite medical Panel 1
management patient remained symptomatic. A decision was made for percuta-
neous intervention and closure of the RCA ostium with a small septal occluder For further therapeutic purposes the patient was immediately sent to cardiac
device, with an impression that occluding the RCA ostium should reduce the surgery where the thrombus was being removed and an epicardial patch plas-
symptoms of RV overload without causing ischemic symptoms given the good tic of the LV apex was successfully performed. The patient was able to return
collateral supply. There were no procedural complications. The overall clinical back to working life with only a mildly reduced ejection fraction.
outcome was successful on follow up.

Percutaneous treatment of mitral insufciency and pseudo-aneurism:
a case report
A. Carbone, G.S. Salerno, G.S. Santoro, G.L. Limongelli, R.V. Vastarella,
F.V. Valente, R.G. Gravino, M.D. Masarone, M.V. Verrengia, G.P. Pacileo. Second
University of Naples, Cardiology, Naples, Italy
Introduction: Left ventricular pseudo-aneurysm (PA) is a rare but serious compli-
cation after acute myocardial infarction or cardiac surgery, accounted for 33% and
55%, respectively. Untreated PAs have a great risk of rupture with 48% of mortal-
ity within the rst year. We describe an interesting case of post-MI PA and severe
mitral regurgitation, treated percutaneously with Amplatzer Occluder device and
then with Mitraclip system.
Case report: A 61 years-old-male with post-ischemic dilated cardiomyopathy with
previous coronary artery bypass surgery, arterial hypertension, dyslipidemia, was
admitted to our outpatient clinic of Heart Failure for exertional dyspnea (NYHA
class III). A left ventricular PA was diagnosed previously. 2D transthoracic echo-
Large ectatic RCA due to stulous connection to the CS. cardiography (TTE) showed a large PA (11.8 cm x 6 cm) with a high velocity bidi-
rectional jet between the inferior and posterior-lateral wall of the LV close to the
Discussion: There are no guidelines on the management of CS stula possible posterior-lateral papillary muscle. The left ventricle was dilated with EF 28% with

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