Implementation of Microcirculation Examination in Clinical Practice-Insights from the Nationwide POL-MKW Registry.

Background and Objectives: The assessment of coronary microcirculation may facilitate risk stratification and treatment adjustment. The aim of this study was to evaluate patients' clinical presentation and treatment following coronary microcirculation assessment, as well as factors associated with an abnormal coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) values. Materials and Results: This retrospective analysis included 223 patients gathered from the national registry of invasive coronary microvascular testing collected between 2018 and 2023. Results: The frequency of coronary microcirculatory assessments in Poland has steadily increased since 2018. Patients with impaired IMR (≥25) were less burdened with comorbidities. Patients with normal IMR underwent revascularisation attempts more frequently (11.9% vs. 29.8%, p = 0.003). After microcirculation testing, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors were added more often for patients with IMR and CFR abnormalities, respectively, as compared to control groups. Moreover, patients with coronary microvascular dysfunction (CMD, defined as CFR and/or IMR abnormality), regardless of treatment choice following microcirculation assessment, were provided with trimetazidine (23.2%) and dihydropyridine CCBs (26.4%) more frequently than those without CMD who were treated conservatively (6.8%) and by revascularisation (4.2% with p = 0.002 and 0% with p < 0.001, respectively). Multivariable analysis revealed no association between angina symptoms and IMR or CFR impairment. Conclusions: The frequency of coronary microcirculatory assessments in Poland has steadily increased. Angina symptoms were not associated with either IMR or CFR impairment. After microcirculation assessment, patients with impaired microcirculation, expressed as either low CFR, high IMR or both, received additional pharmacotherapy treatment more often.

Elevated resistin opposed to adiponectin or angiogenin plasma levels as a strong, independent predictive factor for the occurrence of major adverse cardiac and cerebrovascular events in patients with stable multivessel coronary artery disease over 1-year follow-up.

BACKGROUND: Adipokines such as adiponectin and resistin, as well as angiogenin, may be associated with inflammation and atherosclerosis. The relationship between their levels and prognosis in high risk patients is, however, still unclear. The aim of this study was to evaluate the prognostic value of these adipokines in patients with stable multivessel coronary artery disease (MCAD). MATERIAL/METHODS: The study group comprised 107 MCAD patients (74% males, mean age 63 ± 8 years). Adiponectin, resistin and angiogenin plasma levels were measured at admission and after 1-year follow-up. Primary end point (major adverse cardiac and cerebrovascular events--MACCE) was defined as cardiac death, nonfatal myocardial infarction, stroke, and hospitalization for angina or heart failure over a 1-year period. RESULTS: After 1-year follow-up, 9 (8%) patients died, all from cardiovascular causes. Primary end point was experienced by 32% of patients. Surgical treatment (CABG) was received by 51% of patients, while 49% were treated medically alone. Total cholesterol concentration levels ≥ 173 mg/dl were associated with a 7-fold increase (OR 7.3; 95% CI, 1.6-33.0); LDL ≥ 93.5 mg/dl with a 16-fold increase (OR 16.3; 95% CI, 2.8-93.8), and resistin ≥ 17.265 ng/ml with a 13-fold increase in MACCE risk (OR 13.5; 95% CI, 2.3-80.3). In multivariate analysis, a medical treatment strategy (p = 0.001), a higher CCS class (p = 0.004), resistin levels (p = 0.003) and a higher Gensini score (p = 0.03) were independent predictors of MACCE. CONCLUSIONS: In stable patients with MCAD, elevated plasma resistin (as opposed to adiponectin or angiogenin) is a strong, independent predictive factor for the occurrence of MACCE over 1-year follow-up.

[Simultaneous subacute thrombosis in bare metal stents implanted into right coronary artery and left anterior descending artery without coexistence of resistance to antiplatelet therapy]. / Równoczesna podostra zakrzepica w stentach metalowych implantowanych do prawej tetnicy wiencowej i galezi miedzykomorowej przedniej bez wspólistniejacej opornosci na leki antyagregacyjne.

In-stent thrombosis is a rare but devastating complication of coronary stent implantation, occurring in 0.5% to 1.9% of patients with bare metal stents (BMS). The most frequent clinical manifestation of stent thrombosis is ST elevation myocardial infarction (STEMI) and 30 day mortality is 50%. In-stent thrombosis can present as acute (within 24 h), subacute (within 30 days), late or very late after stent placement. We describe a case of a patient presented with STEMI due to subacute stent thrombosis, which occurred simultaneously in BMS, 3 days after implantation. The patient was successfully treated with balloon coronary angioplasty and discharged from a hospital in good condition.

Quality of life in high-risk patients with stable multivessel coronary artery disease treated either medically or with coronary artery bypass graft surgery - 12-month follow-up.

BACKGROUND: Treatment of chronic diseases, such as atherosclerosis, usually leads to significant short-term improvement. Mid- and long-term results are not always as satisfactory. That is why improvement of quality of life should be the leading qualification criterion for invasive procedures, which sometimes carry a risk of complications. AIM: To determine the quality of life in patients with stable, multivessel coronary artery disease (MCAD), treated surgically or medically. METHODS: The study group comprised 107 patients (pts; 80 males) suffering from MCAD, assigned to coronary artery bypass grafting (CABG) (55 pts) or to medical treatment alone (52 pts). The mean Gensini score in the whole group was 90 (66-132). To evaluate quality of life we used a Short Form-36 (SF-36) health status survey by the International Quality of Life Assessment Project. RESULTS: During a 12-month follow-up 9 pts died (6 pts in the medically treated group and 3 in the CABG group), all for cardiovascular reasons. Patients treated conservatively were more often hospitalised due to angina symptoms (20 vs. 5, p = 0.003). Analysis of SF-36 showed that pts treated surgically had better improvement of quality of life in comparison with medically treated patients. Significant differences were found for physical functioning, bodily pain, vitality, mental health and mental component summary. CONCLUSIONS: This study has shown that there is a significant difference in health-related quality of life 12 months after CABG surgery and medical treatment alone in high-risk patients with MCAD. Surgical treatment decreases the number of adverse events, better attenuates of anginal and heart failure symptoms, and improves the quality of life, especially the mental component. Our results should encouraged selecting patients with advanced atherosclerosis for revascularisation procedures, even if there is a very high peri-procedural risk.

A head-to-head comparison of wall motion score index, force, strain, and ejection fraction for the prediction of SYNTAX and Gensini coronary scores by dobutamine stress echocardiography.

BACKGROUND: Predicting the severity of coronary artery disease (CAD) may be possible during dobutamine stress echocardiography (DSE) with various indices of left ventricular function. AIMS: We assessed the relative value of ejection fraction (EF), force, global longitudinal strain (GLS), and wall motion score index (WMSI) in predicting SYNTAX and Gensini scores in patients with known or suspected CAD. METHODS: We prospectively enrolled 223 patients (120 men; mean [SD] age, 62 [9] years) and assessed the following indices: 1) EF (with triplane imaging); 2) force, calculated as the ratio of systolic blood pressure to left ventricular end­systolic volume; 3) GLS; 4) WMSI. All patients underwent coronary angiography within 12 weeks with SYNTAX and Gensini scores evaluation. RESULTS: The correlation of SYNTAX and Gensini scores was highest with peak WMSI (SYNTAX, rho = 0.591; Gensini, rho = 0.612; P <0.001), intermediate with peak force (SYNTAX, rho = -0.346; Gensini, rho = -0.377; P <0.001) and GLS (SYNTAX, rho = -0.205; P = 0.002 and Gensini rho = -0.216; P = 0.001), and the weakest for EF (SYNTAX, rho = -0.149; P = 0.03 and Gensini, rho = -0.191; P = 0.006). The similar hierarchy of variables was detected for changes during DSE. In the subgroup after myocardial infarction (n = 66 [27%]), GLS outperformed the force. CONCLUSIONS: In patients with CAD at DSE peak, theWMSI and force were better predictors of the coronary SYNTAX and Gensini scores and CAD severity than GLS or EF. However, in patients after myocardial infarction, the GLS correlation with coronary scores improved and got closer to the visual assessment.

Novel atherogenesis markers for identification of patients with a multivessel coronary artery disease.

BACKGROUND: Patients with advanced coronary artery disease (CAD) have an unfovourable prognosis. Therefore, early identification of this high-risk group is important. AIM: To asses the utility of clinical, electrographic and echocardiographic parameters, supported by novel atherogenesis markers, to identify patients with triple vessel coronary artery disease (CAD). METHODS: The study group comprised 37 patients (29 males, mean age 64+/-8 years) suffering from multivessel CAD and a control group of 16 patients (8 males, mean age 60+/-10 years), in whom - despite typical stenocardial symptoms, positive exercise stress test and segmental contractility disturbances - coronary angiography did not reveal any haemodynamically significant CAD. Apart from coronary angiography, each patient had additionally an entire test panel performed assessing both the disease severity and the presence of other systemic dysfunction. Mean Gensini score in the study group was 91.9+/-43.8, including proximal Gensini score 52.6+/-45.6 and distal one 39.4+/-29.7. RESULTS: Patients with triple vessel disease had a long history of angina (mean 84 months), of whom 30 (81%) experienced at least Q-wave myocardial infarction (MI). ECG changes typical for ischaemia were observed more often than in the control group. Also in patients with triple vessel disease echocardiography showed more escalated segmental contractility disorders, and left ventricular ejection fraction in this group was significantly lower than in the control group (44 vs. 55%, p <0.001). There were significant differences between CAD patients and control groups with respect to serum levels of: adiponectin (10.5+/-4.2 vs. 17.6+/-3 microg/ml, p=0.001), resistin (13.7+/-6.1 vs. 7.2+/-2.4 ng/ml, p=0.007), TNF-alpha (4.2+/-2.9 vs. 2.1+/-1.1 pg/ml, p=0.02) and IL-8 (18.4+/-4.1 vs. 12.2+/-4.1 pg/ml, p=0.008). Significant differences were also noted in lipid profile (total cholesterol: 201+/-47.1 vs. 183+/-18 mg/dl, NS; HDL cholesterol: 45+/-8.5 vs. 54+/-11 mg/dl, p=0.005; LDL cholesterol: 126.1+/-46.9 vs. 102+/-29 mg/dl, p=0.004), NT-proBNP [516 (174-1426) vs. 187 (39-573) pg/ml, p=0.02] and fasting blood glucose levels (97+/-14 vs. 94+/-11 mg/dl, p=0.03). Significantly lower serum adiponectin levels were observed in men and tobacco smokers. CONCLUSIONS: Medical history, supported by interpretation of selected, routine imaging studies and novel biochemical markers, such as adiponectin, resistin, TNF-alpha, IL-8 or NT-proBNP, seem to be the key factors when assessing the risk of presence of advanced coronary artery atherosclerosis.

[Implantation of the Figulla Occlutech device in a patient with an ostium secundum atrial septal defect]. / Implantacja zapinki Occlutech Figulla u chorej z ubytkiem w przegrodzie miedzyprzedsionkowej typu wtórnego.

A case of a 50 year old female with a secundum atrial septal defect is described. The patient underwent successful implantation of a new occluder - Figulla Occlutech device. Differences in the types of occluders used for this purpose are discussed.

Takotsubo cardiomyopathy in the case of 72-year-old teacher after work-related psychological stress. Evolution of left ventricular longitudinal strain - Delayed but complete recovery in automated function imaging (AFI).

Takotsubo cardiomyopathy (TC) is related to a transient systolic dysfunction of left ventricle (LV), accompanied by clinical and electrocardiographic symptoms of myocardial ischemia in the absence of hemodynamically significant coronary artery disease. Takotsubo cardiomyopathy is usually provoked by a psychologically or/and physically stressful event which may be related to occupational activities. Although visually assessed evolution of LV function is well documented, the data concerning strain changes is sparse and various patterns of deformation abnormalities are suggested. We have described a 72-year-old woman with chest pain related to a lecture given at the meeting of the Senior University, fulfilling all the Mayo Clinic criteria of the TC. The longitudinal strain analysis with automated function imaging (AFI) documented severe impairment and stepwise recovery of regional and global LV contractility. The case described confirms that accurate diagnosis, treatment and documenting of functional improvement in takotsubo cardiomyopathy may enable the return to occupational activities even for elderly persons. Int J Occup Med Environ Health 2017;30(4):681-683.

Prognostic factors in patients with advanced multi-vessel coronary artery disease.

BACKGROUND: Multivessel coronary artery disease (CAD) not suitable for revascularisation remains a challenge for present cardiology. Due to high mortality and difficulties in pharmacological therapy patients with this particular disease constitute a group of great interest. AIM: To define the main unfavourable prognostic factors in patients with clinically stable multivessel CAD who do not qualify for percutaneous or surgical revascularisation. METHODS: The analysed group consisted of 106 patients (79 men, 66+/-8 years) with multi-vessel CAD, confirmed in coronary angiography, who were primarily disqualified from interventional treatment. Thirty-eight (36%) of them had diabetes and 5 (5%) had a previous stroke. The left ventricular ejection fraction was 37+/-15%, and mean Gensini score - 72+/-34. RESULTS: During 7.4+/-4 years of follow-up, 19 (18%) patients died. Predicting factors of mortality included older age (p=0.014), higher heart rate (p=0.02), diabetes (0.003), renal failure (p=0.0003), heart failure (p=0.013), past stroke (p=0.006) and lower left ventricular ejection fraction (p=0.0012). In multivariate logistic analysis the only significant parameter related to prognosis was decreased level of haemoglobin (p=0.007) and elevated leucocytosis (p=0.002). The ROC curves analysis showed that decreased Hgb (<12.3 g/dl) and increased leucocytosis (>11.3 t/mm3) were significantly associated with higher mortality (HR 6.3). CONCLUSIONS: In patients with multi-vessel CAD not amendable revascularization the haemoglobin level and leucocytosis seem to be at least as important as well known risk factors. More intensive complex pharmacotherapy and innovative cell and gene therapeutic methods may improve the prognosis in this group of patients.

Ultrasound evaluation of forearm arteries in patients undergoing percutaneous coronary intervention via radial artery access: results of one-year follow-up.

BACKGROUND: A proven advantage of radial over femoral arterial access has led to an increase in the number of interventions performed via radial artery access in patients with acute coronary syndromes. Both assessment of the pulse volume and the Allen's test are subjective and subject to investigator bias. An ultrasound examination of the forearm arteries provides important information about the anatomy of the forearm vessels, and indirectly also about the efficiency of collateral blood supply to the hand. It also enables determination of the relevant vessel diameter before the planned intervention, and may be used to assess local complications. AIM: To assess the morphology of forearm blood vessels and measure the diameter of both radial and ulnar arteries at the cannulation site using ultrasound imaging. We also aimed to identify potential vascular anomalies and local complications associated with radial artery puncture. METHODS: The study included 109 patients with cardiologic indications for coronary angiography or coronary angioplasty. An ultrasound evaluation of forearm arteries was performed prior to the intervention, and the vascular anatomy was later verified by angiography during the procedure. Ultrasound measurements of the vessel diameter were also performed and local complications of the cannulation were assessed. Measurements were performed immediately after the procedure and at 30 days and 12 months. RESULTS: Fifty-nine right and 50 left forearm arteries were evaluated. Women were 29% of the study population. The mean patient age was 59.2 ± 7.9 years. The mean diameter of the right radial artery was 2.17 ± 0.54 mm, and the mean diameter of the left radial artery was 2.25 ± 0.43 mm. The measurements revealed gender-related differences in forearm artery diameter (p = 0.003). Vascular anomalies of the radial artery were identified by ultrasound examination in 10% of subjects. A significant dilatation of the cannulated blood vessel was observed which lasted up to 12 months. An occlusion of the cannulated artery was demonstrated in 6.4% of patients. CONCLUSIONS: Ultrasound imaging is a reliable method to evaluate the diameter of forearm arteries and track their course in patients undergoing invasive cardiovascular procedures via radial artery access. The diameter of the radial artery by ultrasound evaluation is larger compared to that of the ulnar artery. The diameter of forearm arteries in women is smaller compared to men. A dilatation of the radial artery which may last up to 12 months develops following its percutaneous cannulation. Ultrasound imaging allows detection and monitoring of local complications such as radial artery occlusion. An unfavourable ratio of blood vessel diameter to the size of the used introducer sheath is a predictor of radial artery occlusion. Ultrasound imaging enables reliable evaluation of vascular anomalies involving the radial artery, especially within the distal forearm.

[Prognostic value of the parameters of left ventricular systolic function in patients with heart failure]. / Wartosc prognostyczna wskazników funkcji skurczowej lewej komory u chorych z niewydolnoscia serca.

UNLABELLED: There are several parameters of left ventricular (LV) systolic function assessment. The calculation of the ejection fraction (EF) strongly relates to the preload and afterload conditions. Wall motion score index (WMSI) seems to be to impractical as the semi-quantitative method. Measurement of the LV pressure rise by Doppler evaluation of mitral regurgitation is a reproducible and an accurate method for dP/dt evaluation. As a method for LV systolic function estimation it does not depend on loading conditions. We have compared the prognostic value of these three methods in patients with a broad spectrum of systolic dysfunction. The study group consisted of 75 patients evaluated by all these methods in years 1995-1999 in our echocardiographic laboratory (73%--men, mean 54 +/- 12 years). In 13 patients the coronary artery disease was diagnosed but LV function was apparently normal, in 35--regional dysfunction after myocardial infarction was described, and in 27--global dysfunction due to idiopathic dilated cardiomyopathy. The EF ranged from 11% to 70% (mean 34 +/- 14%), WMSI--from 1 to 3.6 points (mean 2.2 +/- 0.7), and dP/dt from 235 to 4000 mmHg/s (mean 1108 +/- 698 mmHg/s). The closest relationship was noted between EF and dP/dt (R2=0.50). During 38 +/- 19 months of follow-up, 40 patients died (53%). In the multivariate logistic analysis the only significant parameter related to prognosis was EF (p=0.001). WMSI (p=0.12) and dP/dt (p=0.16) were not statistically significant correlated to death. CONCLUSION: The left ventricular ejection fraction still remains the most important parameter for the evaluation of prognosis in patients with depressed systolic function. Left ventricular pressure rise describes the systolic function but does not have impact on the prognostic evaluation.

Feasibility and correlation of standard 2D speckle tracking echocardiography and automated function imaging derived parameters of left ventricular function during dobutamine stress test.

Speckle tracking echocardiography (STE) is a method of quantitative assessment of myocardial function complementary to ejection fraction and visual evaluation. Standard STE analysis, demands manual tracing of the myocardium whereas automated function imaging (AFI) offers more convenient (based on selection of three points) assessment of longitudinal strain. Nevertheless, feasibility and correlation between both methods were not thoroughly examined, especially during tachycardia at peak stage of dobutamine stress echocardiography (DSE). We performed DSE in 238 patients (pts) with recording of apical views during baseline (0) and peak (1) DSE and analyzed them by STE and AFI. According to angiography, 127/238 pts had significant (≥70%) lesions in coronary arteries. We assessed correlations between STE and AFI derived peak systolic longitudinal strain values for global and regional parameters, feasibility, time of analysis and interobserver agreement. Global systolic longitudinal strain measured during baseline and peak stage of DSE by AFI showed very good correlation with standard STE parameters, with correlation coefficients r = 0.90 and r = 0.86 respectively (p < 0.0001). For regional parameters correlation coefficients ranged from 0.83 to 0.85 for baseline and from 0.70 to 0.79 for peak DSE. Both methods provided good and similar feasibility with only 1% segments excluded from analysis at peak stage of DSE with shorter time and lower coefficient of variance offered by AFI. Global and regional longitudinal strain achieved by faster and less operator-dependent AFI method correlate well with standard more time-consuming STE analysis during baseline and peak stage of DSE.

Characteristics, management and five-year outcomes of patients with high risk, stable multivessel coronary heart disease.

BACKGROUND: Multivessel coronary artery disease (MCAD) is a common manifestation of advanced coronary atherosclerosis. AIM: To determine the clinical characteristics and long term follow up prognostic factors in patients with high risk, stable MCAD from a single institution. METHODS: We included in the final analysis 270 patients with stable MCAD. Patients were followed for the occurrence of death, stroke and myocardial infarction (MI). We defined a cumulative major adverse cardiac and cerebrovascular event (MACCE) asa composite of death, stroke, MI and urgent revascularisation. Median follow up was 5 years (4-5.5 years). 176 (65%) patients were treated surgically (coronary artery bypass grafting, CABG), 19 (7%) patients were treated percutaneously, while 75 (28%) patients were treated medically; this meant that 94 (35%) patients were treated non-surgically. RESULTS: Predictors of MACCE in the study group of patients revealed by univariate logistic regression analysis were: diabetes mellitus (p = 0.04), kidney failure (p = 0.05), total cholesterol (p = 0.05), LDL-cholesterol (p = 0.02), chest pain symptoms in CCS III class (p = 0.05), heart rate (p = 0,02), NT-proBNP (p = 0.01), left ventricular diastolic (p = 0.003) and systolic diameter (p = 0.003), left ventricular ejection fraction (p = 0.001), Gensini score (p = 0.05) and CABG treatment strategy (p = 0.001). In Cox logistic regression analysis, non CABG treatment strategy (b = 0.06), heart rate (b = 0.02), and LDL cholesterol level (b = 0.006) were independent predictors of MACCE (p = 0.01). CONCLUSIONS: Our study showed that patients with advanced MCAD who are qualified for complete surgical revascularisation benefitted more with regard to several primary end points at five-year follow-up than those who were not qualified for surgery and who were treated with medical therapy supplemented in selected cases with incomplete percutaneous revascularisation.

Left anterior descending artery percutaneous coronary intervention via the left internal mammary artery in a 54-year-old type 1 diabetic woman: a case report.

Data on the treatment of left anterior descending artery (LAD) stenosis involving or localized distally to left internal mammary artery anastomosis are scarce and not homogeneous. Both surgery (CABG) and percutaneous interventions (PCI) have been attempted, but the most effective treatment has not yet been established. We report a case of a 54-year-old woman suffering from chronic, stable angina and diabetes type 1 successfully treated with percutaneous angioplasty of LAD via the left internal mammary artery with drug-eluting stent implantation with excellent short-term results.

Advanced peripheral arterial disease in a 59-year-old man with suspected acute coronary syndrome and normal coronary angiogram.

Atherosclerosis is a systemic process with variable expression in different vascular beds. Peripheral arterial disease (PAD) is thought to be found in 12% of the age-adjusted population. Reasons for differential anatomic expression of atherosclerosis may involve the interplay between inflammation, shear stresses, flow characteristics, and other local factors. It's well known that synchronous PAD and coronary artery disease is very common and is likely the result of the systemic impact of atherosclerotic risk factors. On the other hand, there are limited data concerning atherosclerotic process restricted to specific vascular areas in the human body.

[Severe coronary artery disease in premenopausal woman with familial hypercholesterolaemia]. / Zaawansowana choroba wiencowa u premenopauzalnej kobiety z hipercholesterolemia rodzinna

We present a case of a 51 year-old, premenopausal, non-smoker for many years woman with severe, two-coronary artery disease in the form of acute coronary syndrome (ACS), and severe hypercholesterolaemia as the predominant risk factor. The first clinical diagnosis of familial hypercholesterolaemia has been established at the time of diagnosis of ACS. Satisfactory effect of pharmacological treatment is achieved by a complex lipid-lowering therapy.

[A 59 year-old patient with acute anterolateral myocardial infarction, complicated by cardiogenic shock, with chest wall deformity caused by Heine-Medin disease]. / Mezczyzna w wieku 59 lat z zawalem sercasciany przednio−bocznej, we wstrzasie kardiogennym, z deformacja klatki piersiowej w przebiegu poliomyelitis.

We report a case of a 59 year-old patient in a condition of acute myocardial infarction with ST elevation, in a cardiogenic shock, with multiple cardiac arrests in mechanism of ventricular fibrillation with a significant chest wall deformity caused by Heine-Medin disease in childhood. To our knowledge, this is the first case report of a patient in critical condition with a considerable pectus deformity after poliomyelitis who needed to undergo cardiovascular angioplasty. Although severe patient's condition and numerous difficulties during percutaneous coronary intervention, therapy was successful.

[Acute coronary syndrome without ST segment elevation in a 78 year-old woman caused by critical proximal right coronary artery stenosis with concomitant chronic total occlusion of left main coronary artery]. / Ostry zespól wiencowy bez uniesienia odcinka ST u 78-letniej pacjentki z krytycznym zwezeniem proksymalnego odcinka prawej tetnicy wiencowej i ze wspólistniejaca przewlekla okluzja pnia lewej tetnicy wiencowej.

Total occlusion of the left main coronary artery is a rare finding at coronary angiography. When present, patients most often have extensive collateral circulation from the right coronary artery. The mainstay of treatment is surgical with coronary artery bypass grafting. We present a case of a 78 year-old woman admitted to our department with two days history of nonspecific, abdominal pain. Her coronarography revealed chronic total occlusion of left main with concomitant critical, proximal right coronary artery stenosis.