Background: The current guidelines recommend both repeat stenting and drug-coated balloons (DCB) for in-stent restenosis (ISR) lesions, if technically feasible. However, real-world clinical data on the interventional strategies in patients with left main bifurcation (LMB)-ISR have not been elucidated. Methods: Seventy-five patients with LMB-ISR, who underwent percutaneous coronary intervention (PCI) between January 2009 and July 2015, were retrospectively reviewed for the present study (repeat drug eluting stent [DES] implantation [n = 51], DCB angioplasty [n = 24]). Results: Analysis of the baseline characteristics showed that the patients in the DCB group had a lower incidence of non-ST segment elevation myocardial infarction/ST segment elevation myocardial infarction at the index PCI (8.3% vs. 25.5%; p = 0.12), higher low-density lipoprotein-cholesterol level (92.9 mg/dL vs. 81.7 mg/dL; p = 0.09), and more “stent-in-stent” lesions (25% vs. 7.8%; p = 0.07) than those in the DES group. A smaller post-procedural minimal target lesion lumen diameter was also noted in the DCB group than in the DES group (2.71 mm vs. 2.85 mm; p = 0.03). The cumulative incidence rates of major adverse cardiac events (MACEs) were similar between both groups (median follow-up duration, 868 days; MACE rate, 25% in the DCB group vs. 25.5% in the DES group; p = 0.96). The multivariate Cox regression analysis indicated that the true bifurcation of ISR was an independent risk predictor of MACEs (hazard ratio, 4.62; 95% confidence interval, 1.572–13.561; p < 0.01). Conclusions: DES and DCB showed comparable long-term clinical results in patients with LMB-ISR lesions.

Herein, we present a brief case of anomalous coronary arteries mistaken to be chronic total occlusion. Since we first presumed the anomalous coronary arteries to be chronic total occlusion of the distal right coronary artery, percutaneous coronary intervention was attempted for the presumed lesion, but it failed. Before the second attempt of percutaneous coronary intervention, coronary computed tomography angiography revealed the coronary artery from the left anterior descending artery corresponding with the distal part of the right coronary artery without connection to the right coronary artery. Therefore, we recognized the patient had anomalous coronary arteries with no connection of the vascular wall between the main and distal segments of the right coronary artery. This case may give insights to the importance of meticulous examination of coronary computed tomography angiography imaging before chronic total occlusion percutaneous coronary intervention to avoid the unnecessary procedure.

Background: Constrictive pericarditis (CP) can coexist with severe aortic stenosis (AS), especially in patients with previous mediastinal radiation. Because impaired diastolic filling by CP may aggravate hemodynamic abnormalities from severe AS, leading to very low cardiac output, concomitant AS and CP result in a critical debilitating condition and pose a challenge to therapy. Case Report: A 79-year-old woman was brought to our hospital with New York Heart Association class IV dyspnea and severe frailty (clinical frailty scale 8). She had a history of chronic constrictive pericarditis, severe aortic stenosis with reduced left ventricular systolic function (ejection fraction 40%), paroxysmal atrial fibrillation, diabetes mellitus, and radiation dermatitis complicated by a cold abscess in the anterior chest wall from previous mediastinal radiation. She continually complained of dizziness, general weakness, and dyspnea despite optimal medical treatment, and her symptoms worsened recently while bedridden. Although simultaneous surgical pericardiectomy and aortic valve replacement is curative treatment, and the surgical risk was not high (Society of Thoracic Surgery score 4.745), her other comorbidities (radiation dermatitis, cold abscess, and severe frailty) eliminated the possibility of surgical treatment. Therefore, we decided on palliative treatment for CP after performing transcatheter aortic valve implantation (TAVI) for severe AS. We could not predict how she would recover from these conditions and were concerned about the high procedural risk associated with TAVI. Indeed, the patient had cardiac arrest during the TAVI procedure, and we implanted a 31-mm CoreValve while performing cardiac massage. After the patient recovered from cardiac arrest, we safely completed the TAVI procedure with a temporary pacemaker because of complete atrioventricular block. She recovered remarkably after TAVI with permanent pacemaker implantation, and is now able to walk without support. Conclusion: Reduced diastolic filling by chronic CP aggravates hemodynamic deterioration through severe AS, leading to a very serious debilitating condition including severe frailty and decompensated heart failure. Although surgical pericardiectomy and aortic valve replacement are recommended as optimal therapy, TAVI alone can be an alternative therapeutic option if surgery is not possible.