Efficacy of Computed Tomography-Based Evaluation of Myocardial Extracellular Volume Combined With Red Flags for Early Screening of Concealed Cardiac Amyloidosis in Patients With Atrial Fibrillation.

BACKGROUND: The prevalence of transthyretin amyloid cardiomyopathy (ATTR-CM) in atrial fibrillation (AF) patients remains unclear. We explored the efficacy of computed tomography-based myocardial extracellular volume (CT-ECV) combined with red flags for the early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.Methods and Results: Patients referred for AF ablation at Oita University Hospital were prescreened using the red-flag signs defined by echocardiographic or electrocardiographic findings, medical history, symptoms, and blood biochemical findings. Myocardial CT-ECV was quantified in red flag-positive patients using routine pre-AF ablation planning cardiac CT with the addition of delayed-phase cardiac CT scans. Patients with high (>35%) ECV were evaluated using technetium pyrophosphate (99 mTc-PYP) scintigraphy. A cardiac biopsy was performed during the planned AF ablation procedure if 99 mTc-PYP scintigraphy was positive. Between June 2022 and June 2023, 342 patients were referred for AF ablation. Sixty-seven (19.6%) patients had at least one of the red-flag signs. Myocardial CT-ECV was evaluated in 57 patients because of contraindications to contrast media, revealing that 16 patients had high CT-ECV. Of these, 6 patients showed a positive 99 mTc-PYP study, and 6 patients were subsequently diagnosed with wild-type ATTR-CM via cardiac biopsy and genetic testing. CONCLUSIONS: CT-ECV combined with red flags could contribute to the systematic early screening of concealed ATTR-CM in AF patients undergoing catheter ablation.

Impact of the COVID-19 Pandemic on the Long-Term Prognosis of Acute Myocardial Infarction in Japan.

Background During the early phase of the coronavirus disease 2019 (COVID-19) pandemic, a global reduction in hospitalizations for acute myocardial infarction (AMI) was observed. Generally, patients experienced increased severity of AMI with delays in time from symptom onset to treatment during the pandemic. However, the impact of the COVID-19 pandemic on in-hospital mortality among patients with AMI remains unclear. This study aimed to compare the long-term prognosis of patients with AMI during the COVID-19 pandemic to that observed in the pre-pandemic period and to evaluate the influence of the COVID-19 pandemic on the prognosis of patients with AMI. Methods We reviewed the data of patients admitted to our hospital for AMI treatment between April 1, 2018, and March 31, 2021. The time from admission to major adverse cardiac events (MACE), as well as the time from admission to all-cause death, were examined between the pandemic period (April 1, 2020, to March 31, 2021) and the pre-pandemic period (April 1, 2018, to March 31, 2020). Results Eighty patients were included in the study, and those admitted during the pandemic exhibited a higher likelihood of advanced age, lower levels of LDL-cholesterol, and a reduced prevalence of hypertension. The 2.5-year MACE-free survival and overall survival rates between the patients during the pre-pandemic and pandemic periods were not significantly different. Conclusion The long-term prognosis of patients with AMI during the COVID-19 pandemic remains unclear. In this study, we reported that the 2.5-year MACE-free survival and overall survival rates of the patients with AMI admitted during the COVID-19 pandemic were not significantly different from those during the pre-pandemic period. The impact of the COVID-19 pandemic on the prognosis of patients with AMI appears to vary according to the study population.

A Heart Failure Smartphone Application That Nudges Patients/Physicians Toward Optimal Medical Therapy　- Development and Usability Study.

Background: The low implementation rate of guideline-directed medical therapy for heart failure (HF) remains a problem worldwide. To address this issue, we hypothesized that a smartphone application (app) based on behavioral economics that nudges physicians and patients towards optimal medical therapy would be a scalable approach. Methods and Results: The app prototype was developed, and its usability was tested with 5 HF patients in the outpatient setting. Adherence to the app was outstanding, with a high usability rating from the patients. Conclusions: It appears feasible to further study our app in a larger cohort to evaluate its efficacy.

Usefulness of Prehospital 12-Lead Electrocardiography System in ST-Segment Elevation Myocardial Infarction Patients in Oita　- Comparison Between Urban and Rural Areas, Weekday Daytime and Weekday Nighttime/Holidays.

BACKGROUND: We have reported that a prehospital 12-lead electrocardiography system (P-ECG) contributed to transport of suspected acute coronary syndrome (ACS) patients to appropriate institutes and in this study, we compared its usefulness between urban and rural areas, and between weekday daytime and weekday nighttime/holiday.Methods and Results: Consecutive STEMI patients who underwent successful primary percutaneous coronary intervention after using P-ECG were assigned to the P-ECG group (n=123; 29 female, 70±13 years), and comparable STEMI patients without using P-ECG were assigned to the conventional group (n=117; 33 females, mean age 70±13 years). There was no significant difference in door-to-reperfusion times between the rural and urban cases (70±32 vs. 69±29 min, P=0.73). Door-to-reperfusion times in the urban P-ECG group were shorter than those in the urban conventional group for weekday nighttime/holiday (65±21 vs. 83±32 min, P=0.0005). However, there was no significance different between groups for weekday daytime. First medical contact to reperfusion time (90±22 vs. 105±37 min, P=0.0091) in the urban P-ECG group were significantly shorter than in the urban conventional groups for weekday nighttime/holiday, but were not significantly different between the groups for weekday daytime. CONCLUSIONS: P-ECG is useful even in urban areas, especially for patients who develop STEMI during weekday nighttime or while on a holiday.

Role of polyunsaturated fatty acids in Japanese patients with coronary spastic angina.

BACKGROUND: n-3 polyunsaturated fatty acids (PUFAs) reduce the risk of ischemic heart disease. However, there are few reports of a relationship between n-3 PUFAs and coronary spastic angina (CSA). This study aimed to assess the age-dependent role of serum levels of fatty acid in patients with CSA. METHODS AND RESULTS: We enrolled 406 patients who underwent ergonovine tolerance test (ETT) during coronary angiography for evaluation of CSA. All ETT-positive subjects were diagnosed as having CSA. We categorized the patients by age and results of ETT as follows: (1) young (age ≤ 65 years) CSA-positive (n = 32), (2) young CSA-negative (n = 134), (3) elderly (age > 66 years) CSA-positive (n = 36), and (4) elderly CSA-negative (n = 204) groups. We evaluated the serum levels of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid, and dihomo-gamma-linolenic acid. In the young groups, the serum levels of EPA (64.3 ±â€¯37.7 µg/mL vs. 49.4 ±â€¯28.8 µg/mL, p = 0.015) and DHA (135.7 ±â€¯47.6 µg/mL vs. 117.4 ±â€¯37.6 µg/mL, p = 0.020) were significantly higher in the CSA-positive group than in the CSA-negative group, respectively. However, this was not the case with elderly groups. In the multivariate analysis in young groups, the serum levels of EPA (p = 0.028) and DHA (p = 0.049) were independently associated with the presence of CSA, respectively. CONCLUSION: Our results suggested that the higher serum levels of EPA and/or DHA might be involved in the pathophysiology of CSA in the young population but not in the elderly population.

Vagal response is involved in the occurrence of ventricular fibrillation in patients with early repolarization syndrome.

BACKGROUND: Patients with early repolarization syndrome (ERS) and Brugada syndrome (BruS) have comparable clinical symptoms. In both conditions, ventricular fibrillation (VF) is experienced often near midnight or in the early morning hours when the parasympathetic tone is augmented. However, differences between ERS and BruS regarding the risk of VF occurrence have recently been reported. The role of vagal activity remains especially unclear. OBJECTIVE: The goal of this study was to determine the relationship between VF occurrence and autonomic nervous activity in patients with ERS and BruS. METHODS: We enrolled 50 patients with ERS (n = 16) and BruS (n = 34) who received an implantable cardioverter-defibrillator. Of these, 20 patients (5 ERS and 15 BruS) experienced VF recurrence (recurrent VF group). We investigated baroreflex sensitivity (BaReS) with the phenylephrine method and heart rate variability using Holter electrocardiography in all patients to estimate autonomic nervous function. RESULTS: In both patients with ERS and BruS, there was no significant difference in heart rate variability between the recurrent VF and nonrecurrent VF groups. However, in patients with ERS, BaReS was significantly higher in the recurrent VF group than in the nonrecurrent VF group (P = .03); this difference was not evident in patients with BruS. High BaReS was independently associated with VF recurrence in patients with ERS according to Cox proportional hazards regression analyses (hazard ratio 1.52; 95% confidence interval 1.031-3.061; P = .032). CONCLUSION: Our findings suggest that in patients with ERS, an exaggerated vagal response, as represented by increased BaReS indices, may be involved in the risk of VF occurrence.

Predictors of outcome after catheter ablation for atrial fibrillation: Group analysis categorized by age and type of atrial fibrillation.

BACKGROUND: The outcome of catheter ablation could probably differ among patients with atrial fibrillation (AF), depending on age and AF type. We aimed to investigate the difference in predictors of outcome after catheter ablation for AF among the patient categories divided by age and AF type. METHODS AND RESULTS: A total of 396 patients with AF (mean age 65.69 ± 11.05 years, 111 women [28.0%]) who underwent catheter ablation from January 2018 to December 2019 were retrospectively analyzed. We divided the patients into four categories: patients with paroxysmal AF (PAF) or persistent AF (PeAF) who were 75 years or younger (≤75 years) or older than 75 years (>75 years). Kaplan-Meier survival analysis demonstrated that patients with PAF aged ≤75 years had the lowest AF recurrence among the four groups (log-rank test, p = .0103). In the patients with PAF aged ≤75 years (N = 186, 46.7%), significant factors associated with recurrence were female sex (p = .008) and diabetes (p = .042). In the patients with PeAF aged ≤75 years (N = 142, 35.9%), the only significant factor associated with no recurrence was medication with a renin-angiotensin system inhibitor (p = .044). In the patients with PAF aged >75 years (N = 53, 14.4%), diabetes was significantly associated with AF recurrence (p = .021). No significant parameters were found in the patients with PeAF aged >75 years (N = 15, 4.1%). CONCLUSIONS: Our findings indicate that the risk factors for AF recurrence after catheter ablation differed by age and AF type.

Role of computed tomography-based evaluation of skeletal muscle area in predicting cardiovascular outcomes in patients with chronic heart failure after cardiac resynchronization therapy.

AIM: This study aimed to determine possible associations between sarcopenia and poor cardiovascular outcomes in patients with chronic heart failure after cardiac resynchronization therapy. METHODS: This retrospective study evaluated 120 patients who underwent cardiac resynchronization therapy between March 2004 and June 2018. In total, 58 patients who underwent computed tomography within 30 days of cardiac resynchronization therapy implantation were eligible for inclusion, and their data were analyzed (25 women; 33 men; mean age 71.6 ± 8.7 years). Skeletal muscle area was measured at the third lumbar vertebra, and skeletal muscle index was calculated. Major adverse cardiovascular events included cardiovascular death, hospitalization due to heart failure, cerebral infarction, acute myocardial infarction and cardiac arrest. RESULTS: During the follow-up period (mean 868 ± 617 days), major adverse cardiovascular events occurred in 22 of 58 patients (38%). The patients were allocated to two groups according to sex-based tertiles of skeletal muscle index. The lowest tertile was defined as the low skeletal muscle index group. Kaplan-Meier survival analysis showed that the low skeletal muscle index group had a higher incidence of major adverse cardiovascular events (log-rank 4.38; P = 0.036). Cox proportional hazards regression analysis also showed that low skeletal muscle index values were significantly associated with major adverse cardiovascular events (hazard ratio 3.08; 95% confidence interval 1.26-7.66, P = 0.014). CONCLUSIONS: Decreases in skeletal mass index on computed tomography might predict the occurrence of major adverse cardiovascular events in patients with chronic heart failure who underwent cardiac resynchronization therapy. Geriatr Gerontol Int 2022; 22: 1013-1018.

Prehospital 12-Lead Electrocardiography System in Oita Assisted Transport of "True" Acute Coronary Syndrome Patients to Optimal Institutes.

BACKGROUND: Mobile cloud electrocardiography (C-ECG) can reduce the door-to-balloon time of acute coronary syndrome (ACS) patients, so we hypothesized it would also assist in transporting ACS-suspected patients to the optimal institutes.Methods and Results: Initially, 10 fire departments in Oita had 10 ambulances equipped with C-ECG. Ambulance crews recorded a 12-lead ECG from the patient at the first point of contact and transmitted them to 18 hospitals (13 institutions (PCII) with 24-h availability for percutaneous coronary intervention (PCI) and 5 regional core hospitals (RCH) without 24-h PCI) for analysis by a cardiologist. During 41 months, 476 ECGs suspected to be ACS were transmitted and analyzed. Of these, 24 ECGs transmitted to PCII were judged as not requiring PCI, and the patients were directly transported to a RCH (PCII-RCH); 35 ECGs sent to a RCH were judged as requiring PCI, and the patients were directly transported to a PCII (RCH-PCII). The prevalence of cardiovascular disease was significantly higher in the RCH-PCII group than in the PCII-RCH group (P<0.01). There was no significant difference in the door-to-balloon time between the RCH-PCII and the group in which the C-ECG was sent to a PCII and the patients were transported directly to PCII (PCII-PCII) (49±14 vs. 59±20 min, P=0.14). CONCLUSIONS: Prehospital 12-lead ECG can assist in transporting ACS-suspect patients to the optimal treatment facility.

Fulminant myocarditis spreading from the right ventricle treated with extracorporeal membrane oxygenation and impella.

Although the pathogenesis of fulminant myocarditis varies, it is usually recognised by symptoms such as chest pain or syncope, echographic findings such as abnormal left ventricular (LV) wall motion, elevated cardiac enzymes and arrhythmias. We encountered a case of acute myocarditis with syncope, electrocardiographic changes suggestive of coronary artery disease in the inferior wall with abnormal wall motion in the right ventricle, which eventually developed into fulminant disease. Multidetector CT showed a contrast effect localised to the right ventricle in the late-contrast phase, suggesting a right ventricular myocardial injury. Thereafter, the LV function rapidly decreased. Finally, mechanical circulatory support with extracorporeal membrane oxygenation and an intra-aortic balloon pump was needed. A myocardial biopsy of the right ventricular septum showed severe degenerative findings such as myocyte tearing and segmentation with infiltration of inflammatory cells including lymphocytes. After insertion of an Impella pump, the right ventricular function gradually improved.

Potential efficacy of multipoint pacing in the reduction of mitral regurgitation volume: a case report.

A 70-year-old woman who had cardiac sarcoidosis and severe tethering mitral regurgitation (MR) and had been implanted with a biventricular pacemaker experienced recurrent hospitalisation due to decompensated heart failure (HF). Application of MultiPoint™ pacing reduced the MR volume and maintained the symptoms under control; however, the predicted longevity of the device significantly decreased because of the very high threshold of the added pacing site. Transcatheter mitral valve repair (TMVR) using MitraClip® was performed to further diminish the severe MR, thereby enabling the switch from highly consumptive multipoint pacing (MPP) to energy-saving single-point pacing. MPP could further reduce MR compared to the conventional single-point pacing, and this could be a bridging therapy to TMVR in some patients implanted with a biventricular pacemaker. This is the first case to report that switching from conventional single-point pacing to MPP decreased the MR, to some extent, resulting in the improvement of HF symptoms.

Fragmented QRS as a risk marker for the occurrence of ventricular fibrillation in patients with variant angina.

BACKGROUND: Variant angina (VA) is caused by reversible coronary artery spasm, which is characterized by chest pain with ST-segment elevations on standard 12-lead electrocardiogram (ECG) at rest. Ventricular fibrillation (VF) is often caused by VA attack, but the risk stratification is not well understood. The purpose of this study was to evaluate the impact of fragmented QRS (fQRS) on VF occurrence in VA patients. METHODS: Ninety-four patients who showed ST elevation on 12-lead ECGs with total or nearly total occlusion in response to coronary spasm provocation test were enrolled. Among them, 16 patients had documented VF before hospital admission (n = 12) or experienced VF during provocation test (n = 4) (VF occurrence group). The fQRS was defined as the presence of spikes within the QRS complex of two or more consecutive leads. RESULTS: The prevalence of fQRS was more often observed in the VF occurrence group than in the non-VF occurrence group (63% [10/16] vs. 27% [21/78], p = 0.009). Univariate analyses revealed that age, history of syncope, QTc, and the presence of fQRS were associated with VF occurrence (p = 0.004, 0.005, 0.029, and 0.008, respectively). Furthermore, upon multivariate analyses using those risk factors, age, QTc, and fQRS predicted VF occurrence independently (p = 0.007, 0.041, and 0.014, respectively). CONCLUSIONS: The present study demonstrated that fQRS in VA patients is a risk factor for VF. The fQRS may be a useful factor for the risk stratification of VF occurrence in VA patients.

Reduction of bleeding complications on puncture site after percutaneous coronary intervention using a 6.5-French sheathless guiding catheter.

BACKGROUND: Reducing complications at the puncture site after percutaneous coronary intervention (PCI) is important. The diameter of a 6.5-French (Fr) sheathless guiding catheter (GC) is smaller by approximately 2-Fr compared to a 6-Fr conventional sheath. In the present study, we investigated the post-PCI puncture site complications of a transradial approach in each gender while using a 6.5-Fr sheathless GC. METHODS AND RESULTS: Our study consisted of 332 patients who underwent transradial coronary intervention (TRI) between August 2017 and July 2019. We classified the patients into either the 6.5-Fr sheathless GC (Asahi, Intecc, Aichi, Japan) Group (Sheathless group: n = 182 males, 58 females) or the 6-Fr sheathed GC Group (Sheathed group: n = 150 males, 36 females). We determined the complications at the puncture site: oozing, subcutaneous hemorrhage, formation of hematoma, pseudoaneurysms, and peripheral neuropathy. The body mass index of the patients was greater in the sheathless GC group compared to the sheathed GC group (24.5 ± 3.5 kg/m2 vs. 23.6 ± 3.7 kg/m2, p = 0.02). In males, there was no significant difference in the complication rate at the puncture site between the sheathless GC and sheathed GC groups (19.3% vs. 18.6%, p = 0.88). However, the complication rate at the puncture site in females was higher in the sheathed GC group than in the sheathless GC group (36% vs. 15.5%, p = 0.02). A multiple logistic regression analysis revealed that the use of a 6.5-Fr sheathless GC independently reduced the complications in female patients (p = 0.006). CONCLUSION: The use of the 6.5-Fr sheathless GC system in a transradial approach reduced the complications at the puncture site in female patients. The 6.5-Fr sheathless GC system may be a safe option for them compared to the conventional sheath system.

Atrial Fibrillation-triggered Ventricular Fibrillation in a Patient with Early Repolarization Syndrome.

A 54-year-old man with early repolarization syndrome (ERS) implanted with an implantable cardioverter-defibrillator (ICD) developed persistent atrial fibrillation (AF) three years after the implantation. Similarly, the remote monitoring system begun frequently detecting ventricular fibrillation (VF) and polymorphic ventricular tachycardia (PVT). Longer RR intervals were repeatedly observed just before the initiation of PVT/VF. Catheter ablation for AF successfully diminished both the PVT and VF events.

Suppression of acute heart failure rehospitalization by biventricular pacing in wide QRS and mid-range ejection fraction.

We present a 66-year-old male patient with heart failure, mid-range ejection fraction and QRS widening suffering from recurrent hospitalization due to acute heart failure. We measured intra-cardiac pressure by cardiac catheterization to clearly demonstrate the augmentation of afterload by a vasoconstricting drug induced increase of left ventricular end-diastolic blood pressure and pulmonary capillary wedge pressure with pulmonary arterial V-wave augmentation (indicator of worsening of mitral regurgitation). Because the patient was considered as refractory to optimal medication, cardiac resynchronization therapy (CRT) was performed. After CRT implantation, these factors were improved, and the patient has not experienced recurrent hospitalization for >2 years.

Role of fragmented QRS and Shanghai score system in recurrence of ventricular fibrillation in patients with early repolarization syndrome.

BACKGROUND: The Shanghai Score System, which weighs electrocardiogram (ECG) findings reflecting repolarization abnormalities, has been proposed for diagnosis of early repolarization syndrome (ERS). However, recent studies have suggested the involvement of depolarization abnormalities in some ERS patients. The aim of this study was to validate the Shanghai Score System in predicting the recurrence of ventricular fibrillation (VF) in ERS patients. The predictive value of fragmented QRS (fQRS) was also investigated. METHODS: Fifteen consecutive ERS patients (14 males, median age of 47 years) with a history of VF were retrospectively reviewed. The Shanghai Score System points were calculated, and the presence of fQRS was evaluated. RESULTS: During the median follow-up period of 79.2 months, five patients experienced VF recurrence. In the VF recurrence group, two patients showed augmented amplitude of J waves with horizontal ST-segment, while the other three patients had dynamic changes in J-wave amplitude. The Shanghai Score System points in the VF recurrence group were higher than those in the VF non-recurrence group (6.5 [range: 5.8-6.8] vs. 4.5 [range: 4.0-4.5], p = 0.002). The presence of fQRS on standard 12-lead ECG was more frequently observed in the VF recurrence group compared with the non-recurrence group (100% vs. 10%, p = 0.002). CONCLUSIONS: The present study demonstrated that the Shanghai Score System could effectively identify ERS patients at high risk for VF recurrence. The results also suggested that the presence of fQRS, a marker of depolarization abnormalities, may be useful for predicting VF recurrence in ERS patients.

Baroreflex Sensitivity in Patients With Atrial Fibrillation.

Background It has been reported that atrial fibrillation (AF) may contribute to impairment of baroreflex sensitivity (BRS). However, the difference of BRS between patients with persistent AF (PeAF) and those with paroxysmal AF (PAF) is unknown. We tested the hypothesis that patients with PeAF have a more impaired BRS compared with those with PAF. Methods and Results From October 2015 onwards, a total of 67 patients (14 women [20.9%]; mean age 65.2±10.1 years) with PAF (n=46, 68.7%) and PeAF (n=21, 31.3%), who underwent catheter ablation, were prospectively enrolled. The baseline BRS was evaluated during sinus rhythm. The baseline BRS in patients with PeAF was significantly lower than those with PAF (2.97 [0.52-6.62] ms/mm Hg versus 4.70 [2.36-8.37] ms/mm Hg, P=0.047). The BRS was significantly depressed after catheter ablation in all the patients (4.66 [1.80-7.37] ms/mm Hg versus 0.55 [-0.15 to 1.22] ms/mm Hg, P<0.001). However, the depression of BRS because of catheter ablation appeared attenuated in patients with PeAF when compared with those with PAF. The number of patients who did not show depression of BRS was significantly greater, that is, patients with PeAF (3/12, 25%) than those with PAF (0/46, 0%, P<0.01). Conclusions Our findings demonstrated that the baseline BRS was more depressed in patients with PeAF compared with PAF. Catheter ablation depressed BRS irrespective of the type of AF, with a greater effect in patients with PAF than PeAF.

Determinants of survival and favorable neurologic outcomes in ischemic heart disease treated by veno-arterial extracorporeal membrane oxygenation.

Overall mortality and neurologic outcome of patients treated by veno-arterial extracorporeal membrane oxygenation (V-A ECMO) was still not satisfactory. The aim of this study was to clarify the determinants of survival and favorable neurologic outcomes in patients with ischemic heart disease (IHD) treated by V-A ECMO. We identified IHD patients who received V-A ECMO, and divided those patients into the survived and the in-hospital death group. Multivariate logistic regression analysis was performed to identify the determinants of survival and favorable neurologic outcomes. Fifty-eight patients were divided into the in-hospital death group (n = 35) and the survived group (n = 23). Cardiogenic arrest for the reason for V-A ECMO introduction (vs. non-cardiac arrest: OR 0.34, 95% CI 0.002-0.65, P = 0.03) and final thrombolysis in myocardial infarction (TIMI-3) flow grade (vs. TIMI ≤2 flow grade: OR 17.44, 95% CI 1.65-184.04, P = 0.02) were determinants of in-hospital survival. Time from collapse to initiation of V-A ECMO was inversely associated with favorable neurologic function (10 min increase; OR 0.49, 95% CI 0.28-0.89, P = 0.02), while final TIMI-3 flow grade was not associated with favorable neurologic function. In conclusion, the rapid establishment of V-A ECMO system as well as obtaining TIMI-3 flow grade should be sought for better survival with maintaining neurological function in IHD patients who requires V-A ECMO.

Ruptured saphenous vein graft pseudoaneurysm successfully treated with covered stents.

Saphenous vein graft (SVG) pseudoaneurysms are rare complications following coronary bypass graft surgery. A 46-year-old man presented with streptococcal infectious endocarditis and needed sequential operations for aortic root reconstruction. Shortly after the surgeries, a composite SVG on the right coronary artery developed a ruptured pseudoaneurysm, which was successfully treated using covered stents.