Coronary tortuosity has been recognized as a potential pathophysiological mechanism in the development of non-obstructive coronary artery disease (CAD). The aim of this study was to examine the role of two coronary tortuosity measurement methods in the detection of clinically significant coronary tortuosity. The study included 160 patients with angina symptoms and myocardial ischemia detected by cardiac stress tests in chronic settings and those diagnosed with acute coronary syndrome. After coronary angiography, tortuosity of coronary arteries was assessed by two methods, including measurement of tortuosity angles and calculating of tortuosity index. Significantly more tortuous coronary arteries were detected in the group with non-obstructive CAD (p < 0.01 for all three arteries), with significantly higher tortuosity index (TI) for all three coronary arteries in this group of patients, compared to patients with obstructive CAD. The highest TI for LCX was found in patients with lateral ischemia (p < 0.001) and for LAD in patients with anterior ischemia (p < 0.001). When measured by the angle method, the only association was found between LCX tortuosity and lateral ischemia (OR 4.9, p = 0.046). In conclusion, coronary tortuosity represents a pathophysiological mechanism for myocardial ischemia in non-obstructive CAD. The coronary tortuosity index could be a reliable and widely applicable tool for the quantification of coronary tortuosity.

Clot-in-transit (CIT) is a free-floating thrombus in the right heart and can enter pulmonary circulation at any moment. Possible treatments include anticoagulation, systemic thrombolysis, surgical embolectomy, and endovascular catheter-based therapies. The optimal treatment is still undetermined, heavily relying on clinical judgment and multidisciplinary team discussion. We report a case of a 70-year-old woman presenting with tachydyspnoea following recent abdominal surgery, who was diagnosed with massive bilateral pulmonary embolism (PE) complicated by a clot-in-transit. Point-of-care ultrasonography revealed a large mobile thrombus in the right atrium with severe right ventricular dysfunction. Due to haemodynamic instability and a contraindication for systemic thrombolysis, mechanical thrombectomy was performed. A large thrombotic burden was aspirated from the right heart and pulmonary arteries, resulting in haemodynamic stabilization and recovery of right ventricular function. The patient remained stable throughout hospitalization and was discharged on oral anticoagulation therapy with complete recovery on follow-up. This case highlights several points. Firstly, CIT is a rare finding but should be considered in patients with massive pulmonary embolism and shock. Furthermore, POCUS is essential for diagnosing CIT. Finally, mechanical thrombectomy is a valuable therapeutic option in high-risk PE patients with contraindications to systemic thrombolysis and haemodynamic instability. Further studies are needed to establish adequate guidelines for the optimal management of CIT patients.