Coronary-artery-to-pulmonary-artery fistulae represent rare vascular anomalies defined as abnormal communications between the coronary arteries and the pulmonary arterial system. Takotsubo Syndrome represents a stress-induced cardiomyopathy defined by transient regional systolic dysfunction of the left ventricle, with minimal elevation of cardiac biomarkers, without angiographic evidence of obstructive coronary artery disease. We hereby richly illustrate an unusual and rare case of a female patient with Takotsubo Cardiomyopathy and left-anterior-descending-coronary-artery-to-pulmonary-trunk fistula through multi-modality imaging evaluations, obtaining a detailed anatomical representation of the coronary arteries and the fistulous connection, which further guided the optimal treatment strategy. The patient was treated conservatively. The main teaching points of this case are the following: (1) The coronary fistula may represent just an incidental finding in a Takotsubo Cardiomyopathy clinical scenario. (2) The particularly rare association between left-anterior-descending-coronary-artery-to-pulmonary-trunk fistula and Takotsubo Cardiomyopathy presentation is mainly due to the stress-induced overstimulation of myocardial beta-1 receptors, accentuating the coronary steal phenomenon in the setting of the coronary fistula, manifesting as anginal pain, and also the stress-induced adrenergic drive causing the Takotsubo-like presentation with apical ballooning of the left ventricle.

Background: Conduction disturbances and the subsequent need for permanent pacemaker implantation (PPMI) remain a major limitation of transcatheter aortic valve replacement (TAVR) with self-expanding transcatheter heart valves (SE-THVs). The cusp-overlap technique (COT) has been proposed to optimize implantation depth and reduce PPMI rates compared to the standard three-cusp technique (3CT). Methods: This retrospective, single-center study included 113 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR with the Medtronic CoreValve Evolut™ SE-THV(Medtronic, Minneapolis, MN, USA) between September 2020 and March 2023. Patients were treated using either COT (n = 49) or 3CT (n = 62). Baseline characteristics, procedural outcomes, and 30-day clinical events were compared before and after one-to-one propensity score matching. The primary endpoint was the incidence of PPMI at hospital discharge; the secondary endpoint was a composite of death, stroke, life-threatening or disabling bleeding, major vascular complications, and moderate/severe paravalvular regurgitation at 30 days. A post hoc power calculation was performed given the low observed event rate. Results: Procedural success was achieved in 98.2% of patients. In the unmatched cohort, PPMI occurred in 6.1% (COT) vs. 9.7% (3CT) (p = 0.48). In the matched cohort (49 pairs), PPMI rates were 6.1% (COT) vs. 12.2% (3CT) (p = 0.48). With only 3 vs. 6 PPMI events in the matched cohort, the study had an estimated post hoc power of approximately 19% (two-sided α = 0.05) to detect the observed difference, so the negative primary result should be regarded as inconclusive rather than as evidence of equivalence between techniques. The secondary composite endpoint occurred less frequently in the COT group both before matching (14.3% vs. 32.3%; p = 0.049) and after matching (14.3% vs. 30.6%, p = 0.049). This composite difference was driven predominantly by the moderate/severe paravalvular regurgitation (PVL) component (12.2% vs. 24.2% unmatched; 12.2% vs. 22.4% matched) rather than by death, stroke, or major vascular complications. Evolut device generation differed markedly by arm (COT patients received later-generation devices far more often than 3CT; p < 0.001), and is presented in the Methods/Results Sections as a key temporal confounder. COT was associated with a lower incidence of moderate/severe paravalvular regurgitation, without prolonging procedural time. Conclusions: In this real-world single-center cohort, the cusp-overlap technique was not associated with a statistically significant reduction in PPMI after TAVR with the CoreValve Evolut™ SE-THV. COT was, however, associated with fewer paravalvular leaks and a lower rate of the secondary composite of adverse clinical events at 30 days.

Background: Conduction disturbances and the subsequent need for permanent pacemaker implantation (PPMI) remain a major limitation of transcatheter aortic valve replacement (TAVR) with self-expanding transcatheter heart valves (SE-THVs). The cusp overlap technique (COT) has been proposed to optimize implantation depth and reduce PPMI rates compared to the standard three-cusp technique (3CT). Methods: This retrospective, single-center study included 113 consecutive patients with symptomatic severe aortic stenosis who underwent TAVR with the Medtronic CoreValve Evolut™ SE-THV between September 2020 and March 2023. Patients were treated using either COT (n = 49) or 3CT (n = 62). Baseline characteristics, procedural outcomes, and 30-day clinical events were compared before and after one-to-one propensity score matching. The primary endpoint was the incidence of PPMI at hospital discharge; the secondary endpoint was a composite of death, stroke, life-threatening or disabling bleeding, major vascular complications, and moderate/severe paravalvular regurgitation at 30 days. Results: Procedural success was achieved in 98.2% of patients. In the unmatched cohort, PPMI occurred in 6.1% (COT) vs. 9.7% (3CT) (p = 0.48). In the matched cohort (49 pairs), PPMI rates were 6.1% (COT) vs. 12.2% (3CT) (p = 0.48). The secondary composite endpoint occurred less frequently in the COT group both before matching (14.3% vs. 32.3%; p = 0.049) and after matching. COT was associated with a lower incidence of moderate/severe paravalvular regurgitation, without prolonging procedural or fluoroscopy times. Conclusion: In this real-world single-center cohort, the cusp overlap technique did not significantly reduce PPMI rates after TAVR with the CoreValve Evolut™ SE-THV, but was associated with fewer paravalvular leaks and a lower rate of adverse clinical events at 30 days.