Early restoration of infarct-related artery (IRA) blood flow and myocardial perfusion in patients with acute ST-segment elevation myocardial infarction (MI) is linked with preservation of left ventricular function, myocardial salvage and a reduction in mortality.¹ Although primary percutaneous coronary artery intervention (PPCI) is superior to hospitaldelivered thrombolytic treatment, the latter remains the firstline therapy in 30–70% of cases worldwide.^1–3 However, thrombolytic therapy fails to restore full patency of the IRA (TIMI grade 3 flow) in up to 54% of those who receive it.

Women have been shown historically to have a greater risk of complications than men following invasive procedures.^1–5 The increased incidence of complications in women appears to occur independently of other factors known to influence the incidence of complications after invasive procedures.^6–8 Moreover, in the past several years, multiple reports have indicated that women also experience a higher incidence of vascular complications after cardiac catheterization (CATH) and percutaneous coronary interventional (PCI) procedures.^9–14 Whether heightened awareness of the increased risk of invasive cardiac procedures in women or practice changes such as smaller sheath size have affected the gender risk of vascular complications is unknown. We hypothesized that the increased risk of vascular complication in women previously observed would be eliminated in an analysis of more contemporary outcomes.

There is extensive literature demonstrating a disturbingly higher mortality rate, intraprocedural coronary artery injury rate and periprocedural vascular complication rate in women versus men. The disparity has been partially explained by more comorbid disease, older age, smaller size and higher prevalence of hypertension, diabetes, peripheral vascular disease and more severe angina at presentation.

Unprotected left main coronary artery (LMCA) is one of the most challenging lesion subsets for interventional cardiologists, and is still considered a strict surgical indication as long-term results of recent randomized trials are awaited.

Although no adequately powered randomized comparisons have yet been completed, many registries have assessed the feasibility and safety of LMCA revascularization with bare-metal stents (BMS),^1–4 particularly in good surgical candidates with a low EuroSCORE (an established means to predict early mortality in patients undergoing cardiac surgery). In-stent restenosis remained, however, a major problem limiting long-term outcomes and freedom from major adverse coronary events (MACE) and mortality.^5,6 Specifically, distal left main lesions involving the bifurcation were associated with the worst outcomes.⁴

The aorto-ostial junction has high elastic fiber content with significant elastic recoil.^1-7 Ostial left main coronary artery (LMCA) stenoses have larger lumen areas with less plaque burden and more negative remodeling than non-ostial LMCA stenoses. Most ostial LMCA stenoses have been categorized as eccentric and less calcified.⁸ The RCA ostium shows a lack of arterial distensibility and excessive rigidity, presumably because it contains highly elastic rigid tissue.^1,7 Both the LMCA and RCA ostia may have similar morphologic characteristics. However, there is limited information about ostial lesions and no study has compared ostial LMCA and ostial RCA lesions.

Despite advances in percutaneous coronary intervention techniques over the last two decades, the unprotected left main has largely remained the domain of cardiovascular surgery.

The physiologic effects of the majority of coronary artery stenosis cannot be determined accurately by conventional angiographic approaches.1,2 Coronary flow reserve3,4 (CFR), and, more recently, fractional flow reserve5 (FFR) have been proposed for assessment of the functional consequence of coronary lesions and evaluation of coronary angioplasty efficiency.6,7 In addition, CFR is a useful tool for the diagnosis of coronary microvascular disease.8,9 Because FFR is the ratio of maximal flow in a stenotic vessel to maximal flow without stenosis, and because CFR is the ratio of maximal-to-basal coronary blood flow, it is of crucial importance for the accuracy of these measurements to achieve maximal coronary vasodilation, i.e., maximal coronary blood flow. In the absence of maximal coronary vasodilation, FFR could be overestimated and CFR could be underestimated, leading to erroneous decisions or diagnosis.

The widespread popularity of drug-eluting stents (DES) had a dramatic impact on the modern interventional therapy of coronary artery disease; accordingly, the cardiac surgical volume has experienced a corresponding decrease. Like the introduction of bare-metal stents (BMS) during the balloon angioplasty era, DES represent yet another quantum advancement towards overcoming the challenges of restenosis. The promises of this potential panacea, however, have been recently attenuated by the looming specter of late angiographic stent thrombosis (LAST). The usual time frame for stent thrombosis is believed to be the initial few months, as reflected by the 3- and 6-month recommendations for dual antiplatelet therapy (DAT) for sirolimus- and paclitaxel-eluting stents (SES [Cypher^™, Cordis Corp., Miami Florida], and PES [Taxus^®, Boston Scientific Corp., Natick, Massachusetts]), respectively.

Direct communication between the right pulmonary artery and the left atrium is an unusual variation of a pulmonary arteriovenous fistula. In fact, there are only about 50 cases reported in the literature.¹ This is one condition in which clinical examination may reveal only cyanosis. Contrast echocardiography may show only right-to-left shunt, and only angiography is truly diagnostic.¹

To the Editor:

The angiographic finding of noncritical coronary stenoses in the setting of acute coronary syndrome and even myocardial infarction has been well described. One potential etiology is Prinzmetal’s angina or coronary spasm.¹ More recent Japanese literature, however, has described the so-called “octopus fishing pot”, or takotsubo cardiomyopathy, which refers to the distinctive left ventricular silhouette. The distinctive apical ballooning with basal hypercontractility resembles that of the pot used by Japanese fishermen for trapping octopi.² Also known as the “broken heart” syndrome, it is typically preceded by severe emotional trauma. Cardiac enzyme levels are normal or mildly elevated, despite typical angina and electrocardiographic ST-segment elevations.³