Percutaneous thoracic aortic aneurysm repair through transcaval aortic access.

Transcaval aortic access has been used for deployment of transcatheter aortic valves in patients in whom conventional arterial approaches are not feasible. This access can be vital in other situation when large bore access is needed. We described a case of 65-year-old man who had large thoracic descending aortic aneurysm with diffuse bilateral iliac disease precluding the arterial access required for the procedure. The patient underwent successful transcaval access with placement of 22-Fr balloon expandable sheath followed with successful deployments of 32 mm × 32 mm × 150 mm Valiant stent graft (Medtronic, Minneapolis, MN). The aorto-vena cava tract was closed successfully using 12 × 10 PDA occluder device with no residual flow at the end of the case, which was confirmed on repeated CT next day.

Cardiology Critical Care Crisis: Can Working Across The Aisle Be The Salvation?

There are many changes in the demographics of patients admitted to Cardiac Care Unit (CCU) due to the aging of US population and coexistence of chronic illnesses, such as diabetes mellitus, hypertension, renal dysfunction, and obstructive lung disease. There is increasing evidence that intensivist staffing in the critical care settings is associated with not only improvements in both Intensive Care Unit (ICU) and in-hospital mortality, but also with better medical resource use. Evidence for decreased mortality has led to increased involvement of critical care trained physicians in multidisciplinary care teams in both medical and surgical ICUs, a trend that has not been adopted to any significant extent in CCUs. A partnership between cardiologists and critical care specialists may offer a better roadmap to deal with cardiac critical care crisis, provide better care for our patients, and prepare the next generation of cardiologists to deal with emerging challenges in the field.

Successful Percutaneous Transcatheter Patent Foramen Ovale Closure Through The Right Internal Jugular Vein Using Stiff Amplatzer Catheter With A Reshaped Tip.

Percutaneous transcatheter closure of a patent foramen ovale (PFO) remains challenging when femoral venous approach is not available. We describe the successful closure of a PFO using the right internal jugular venous approach and a catheter delivery system with a reshaped tip in a patient with a PFO, recurrent stroke, recurrent gastrointestinal bleeding, bilateral deep venous thrombosis and thrombosed bilateral inferior vena cava filter.

Impact of Catheterization Lab Computer Software Settings on Hemodynamic Assessment of Aortic Stenosis.

BACKGROUND: Accurate assessment of Cardiac Output (CO) is a critical measurement in the calculation of aortic valve area (AVA). Due to the known inaccuracy of estimated Fick calculations, many measure thermodilution (TD) CO as well due to previous studies showing better correlation with the gold standard direct CO. Previous studies showed suboptimal correlation between both methods. Most physicians assume that the TD CO is chosen by catheterization laboratory software for AVA evaluation. Our study was performed to check which CO method is assigned by our popular computer software system [Philips Xper Connect (XIM)] for the AVA calculation and the impact of that on clinical decision. METHODS: We studied one hundred consecutive patients who underwent right and left heart catheterization from 2009 to 2012 for assessment of AVA and who had both estimated Fick and TD CO calculated. Correlation of direct continuous VO2, assumed VO2 and TD based CO measurements were assessed by linear regression analysis and by variance component analysis. RESULTS: We found that whichever CO calculation was entered first to the software system became the determinative output used to calculate the AVA appearing on the final report. This was the estimated Fick method in 32 patients and TD in 68 patients. The CO used for the final report depended solely on the timing of the oxygen saturation samples. The Correlation between AVA based on both methods correlated poorly (Pearson R=0.73, Intra-Class Correlation (ICC) =0.72). This discrepancy affects recommendation for surgery (AVA <1.0 cm2) in 18 cases (18% of patients). CONCLUSION: Our widely used software has an arbitrary method of selecting the determinative CO to calculate the final AVA. For TD CO to 'trump' the Fick CO a complex series of computer commands needs to be performed. None of the physicians or technicians was aware of this software selection process, which affects critical treatment decisions.

The Impact of Direct Cardiac Output Determination On Using A Widely Available Direct Continuous Oxygen Consumption Measuring Device On The Hemodynamic Assessment of Aortic Valve.

BACKGROUND: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of aortic valve area (AVA). Estimation of oxygen consumption (VO2) and Thermodilution (TD) is employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO and AVA. METHODS AND MATERIALS: Seventeen consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R= 0.57; ICC =0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R= 0.51; ICC=0.60). Similarly AVA derived from direct continuous VO2 correlated poorly with those of assumed VO2 (R= 0.68; ICC=0.55) and TD (R=0.66, ICC=0.60). Repeated direct continuous VO2 CO and AVA measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) and (R=0.99; ICC>0.99) respectively], suggesting that this was the most reliable measurement of CO. CONCLUSIONS: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO and AVA measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.

The Value of Quality Improvement Process in the Detection and Correction of Common Errors in Echocardiographic Hemodynamic Parameters in a Busy Echocardiography Laboratory.

BACKGROUND: Accurate assessment of cardiac structures, ventricular function, and hemodynamics is essential for any echocardiographic laboratory. Quality improvement (QI) processes described by the American Society of Echocardiography (ASE) and the Intersocietal Commission (IAC) should be instrumental in reaching this goal. METHODS: All patients undergoing transthoracic echocardiogram (TTE) followed by cardiac catheterization within 24 hours at Christiana Care Health System in 2011 and 2012 were identified, with 126 and 133 cases, respectively. Hemodynamic parameters of diastolic function and pulmonary artery systolic pressure (PASP) on TTE correlated poorly with catheterization in 2011. An educational process was developed and implemented at quarterly QI meetings based on ASE and IAC recommendations to target frequently encountered errors and provide methods for improved performance. The hemodynamic parameters were then reexamined in 2012 postintervention. RESULTS: Following the QI process, there was significant improvement in the correlation between invasive and echocardiographic hemodynamic measurements in both systolic and diastolic function, and PASP. This reflected in significant better correlations between echo and cath LVEF [R = 0.88, ICC = 0.87 vs. R = 0.85, ICC = 0.85; P < 0.001], average E/E' and of left ventricle end-diastolic pressure (LVEDP) [R = 0.62 vs. R = 0.09, P = 0.006] and a better correlation for PASP [R = 0.77, ICC = 0.77 vs. R = 0.30, ICC = 0.31; P = 0.05] in 2012 compared to 2011. CONCLUSION: The QI process, as recommended by ASE and IAC, can allow for identification as well as rectification of quality issues in a large regional academic medical center hospital.

The effects of right ventricular apical pacing with transvenous pacemaker and implantable cardioverter defibrillator on mitral and tricuspid regurgitation.

BACKGROUND: The incidence of new or worsening tricuspid regurgitation (TR) or mitral regurgitation (MR) after permanent pacemaker (PPM) or implantable cardioverter defibrillator (ICD) lead placement has not been well investigated. We studied the effect of transvenous leads implantation and right ventricular (RV) pacing on tricuspid and mitral valve regurgitations. METHODS: We reviewed the charts of all patients undergoing PPM or ICD lead placement in our electrophysiology laboratory from December 2001 to December 2006. RESULTS: A total of 206 patients (120 with PPM and 86 with ICD) had baseline echocardiography within 6months before, and a follow up study at least 6months after lead insertion. The mean age was 74±14years; 56% were men. The follow-up period was 29±19months. TR worsened by at least one grade after lead insertion in 44.7% patients (P<0.001). Pre- and post-implant changes in TR severity did not differ with respect to lead type (ICD vs. PPM) or degree of RV pacing dependence. As for MR; patients with high frequency of RV pacing (>40%) had a higher incidence of worsening MR when compared to those with low frequency of RV pacing (44% vs. 19%; P<0.001). CONCLUSION: PPM or ICD lead implantation worsens TR; that effect is probably induced by mechanical interferences with the TV closure and was consistent regardless the lead type or degree of RV Pacing. MR was noted to increase in patients with high frequency of RV pacing frequency; this is probably caused by the mechanical dyssynchrony induced by RV pacing.

Aggressive Measures to Decrease Door to Balloon Time May Increase the Incidence of Unnecessary Cardiac Catheterization and Delay Appropriate Care.

Door-to-balloon (DTB) time is an important quality measure for ST-segment myocardial elevation infarction (STEMI). Aggressive measures to reduce DTB time can increase the incidence of false positive-STEMI and may increase mortality in that group. Efforts to reduce DTB time should be monitored systematically to avoid unnecessary procedures especially in critically ill patients who don't have STEMI and may benefit from other appropriate therapies in timely manner. We report two cases where trying to achieve an aggressive DTB time may have led to unwarranted outcomes.

Subvalvular Aortic Stenosis.

Obstruction of the left ventricular outflow tract (LVOT) occurs in six out of 10,000 live births. The obstruction occurs in the aortic valve level in 71 percent, in subvalvular level in 14 percent, and supravalvular level in 8 percent of cases. Subvalvular aortic stenosis (AS) can be either a fixed stenosis resulting from subaortic membrane or a dynamic stenosis because of hypertrophic cardiomyopathy. Here, we report a patient with subaortic membrane who became symptomatic in her sixth decade of life. Echocardiography is the preferred diagnostic modality. Indications for surgery include symptoms, LVOT gradient of 50 mmHg or more, and development of significant aortic regurgitation.

The Effects of Right Ventricular Apical Pacing Frequency on Left Ventricle Function and Pulmonary Artery Pressure.

OBJECTIVE: We studied the effect of the frequency of right ventricular (HV) pacing on left ventricle (LV) function pulmonary hypertension. BACKGROUND: The incidence of new or worsening pulmonary hypertension after permanent pacemaker (PPM) or implantable cardioverter defibrillator (lCD) lead placement has not been well investigated. METHODS: We reviewed the charts of all patients undergoing PPM or ICD lead placement in our electrophysiology laboratory from December 2007 to December 2012. RESULTS: Two hundred and six patients (120 with PPM and 86 with ICD) had baseline echocardiography within six months before, and a follow up study at least six months after lead insertion. The mean age was 74 ± 14 years; 56 percent were men. The follow-up period was 29 ± 19 months. RV pacing was associated with a worsening of left ventricular ejection fraction (LVEF) in patients with high frequency of RV (55 ± 16 vs. 44 ± 18; P = 0.001), but not with those with low frequency pacing (55 ± 16 vs. 54 ± 17; P = 0.87). Similarly, RV pacing was associated with a worsening in both right ventricular systolic pressure (RVSP) (42 ± 14 vs. 48 ± 15; P = 0.01) and Pulmonary Artery Systolic Pressure (PASP) (50 ± 17 vs. 56 ± 18; P = 0.005) in patients with high frequency RV, but not in those with low frequency RV pacing [RVSP (43 ± 12 vs. 46 ± 13; P = 0.06) and PASP (51 ± 15 vs. 54 ± 16; P = 0.11)]. ONCLUSION: PPM or IICD lead implantation worsens LV function and pulmonary hypertension in patients with high frequency of RV pacing frequency. This is probably caused by the mechanical dyssynchrony induced by RV pacing.

Thrombus in Transit through a Patent Foramen Ovale: Surgical Prevention of Impending Stroke.

A Transesophageal Echocardiography (TEE) is essential in identifying thrombus in transient in patients with deep venous thrombosis (DVT) presenting with symptoms suggesting potential systemic emboli. We present a case of a 71-year-old gentleman with recent DVT who developed slurred speech and was assumed to have transient ischemia attack (TIA). TEE showed the presence of a large Thrombus in Transit (TIT) through a patent foramen ovale (PFO). Surgical intervention in low to intermediate risk is probably the best option associated with fewer complications of recurrent embolic events than both thrombolysis and anticoagulation.

Traumatic myocardial infarction in a young athletic patient after a football game.

Myocardial injury from blunt chest trauma can result from either direct contusion or coronary artery injury due to acute coronary syndrome or coronary dissection. Although rare, blunt chest trauma is one of the non-atherosclerotic mechanisms leading to acute myocardial infarction (MI) in patients younger than 45 years. We are reporting a case of a 36-year-old athletic man who presented with infero-lateral ST elevation MI secondary to a thrombotic occlusion of right coronary artery after a blunt chest trauma. Early recognition of myocardial infarction in patients presenting with chest trauma and differentiating it from other causes of chest pain in this setting is critical in guiding the diagnosis and management of this rare, but potentially fatal complication.

Acute severe hypothyroidism is not associated with hyponatremia even with increased water intake: a prospective study in thyroid cancer patients.

BACKGROUND: Hypothyroidism, commonly induced in preparation for radioiodine treatment of differentiated thyroid cancer, is a text-book cause for hyponatremia. Nausea, stress, and increased fluid intake associated with the treatment are expected to exacerbate hyponatremia. METHODS: We prospectively studied 212 (80% females) consecutive thyroid cancer patients for the incidence of hypothyroidism-induced hyponatremia and associated risk factors. RESULTS: Mean(SD) age was 39.7(14.1) year, creatinine 82.0(20.8) µmol/l, TSH 141.6(92.0) mU/l, pre- and post-isolation sodium 139.5(2.3) and 137.8(3.0) mEq/l, respectively, and estimated fluid intake during isolation 9.7(6.2) L. Mild hyponatremia (≥130 mEq/l) was present in 18 patients (8.5%) and moderate hyponatremia (≥120 mEq/l) in 4(1.9%), 3 of the latter had elevated creatinine concentration and 2 were on diuretics. There was no significant correlation between post-isolation sodium concentration and TSH concentration (r = 0.03, p = 0.69) or estimated fluid intake (r = 0.10, p =0.17). There was significant correlation between post-isolation sodium concentration and age (r = -0.24, p < 0.0001) and creatinine concentration (r = -0.22, p = 0.001). Pre-post-isolation drop in sodium concentration was more in females (mean difference 1.21, p = 0.02). Compared to eunatremic patients, hyponatremic patients were more likely to have pre-isolation hyponatremia (9% vs. 0.5%, p = 0.03), elevated creatinine concentration (36% vs. 13%, p = 0.008), and to be on diuretics (23% vs. 1%, p = 0.0001). CONCLUSIONS: In the setting of acute severe hypothyroidism: 1) clinically-important hyponatremia is uncommon; sodium concentration may not need to be monitored unless patients have impaired renal function or are on diuretics, 2) age and female gender are associated with lower sodium concentration. Uncomplicated acute severe hypothyroidism didn't cause clinically-important hyponatremia/SIADH in this cohort of patients.

Consenting options for posthumous organ donation: presumed consent and incentives are not favored.

BACKGROUND: Posthumous organ procurement is hindered by the consenting process. Several consenting systems have been proposed. There is limited information on public relative attitudes towards various consenting systems, especially in Middle Eastern/Islamic countries. METHODS: We surveyed 698 Saudi Adults attending outpatient clinics at a tertiary care hospital. Preference and perception of norm regarding consenting options for posthumous organ donation were explored. Participants ranked (1, most agreeable) the following, randomly-presented, options from 1 to 11: no-organ-donation, presumed consent, informed consent by donor-only, informed consent by donor-or-surrogate, and mandatory choice; the last three options ± medical or financial incentive. RESULTS: Mean(SD) age was 32(9) year, 27% were males, 50% were patients' companions, 60% had ≥ college education, and 20% and 32%, respectively, knew an organ donor or recipient. Mandated choice was among the top three choices for preference of 54% of respondents, with an overall median[25%,75%] ranking score of 3[2,6], and was preferred over donor-or-surrogate informed consent (4[2,7], p < 0.001), donor-only informed consent (5[3,7], p < 0.001), and presumed consent (7[3,10], p < 0.001). The addition of a financial or medical incentive, respectively, reduced ranking of mandated choice to 7[4,9], p < 0.001, and 5[3,8], p < 0.001; for donor-or-surrogate informed consent to 7[5,9], p < 0.001, and 5[3,7], p = 0.004; and for donor-only informed consent to 8[6,10], p < 0.001, and 5[3,7], p = 0.56. Distribution of ranking score of perception of norm and preference were similar except for no-organ donation (11[7,11] vs. 11[6,11], respectively, p = 0.002). Compared to females, males more perceived donor-or-surrogate informed consent as the norm (3[1,6] vs. 5[3,7], p < 0.001), more preferred mandated choice with financial incentive option (6[3,8] vs. 8[4,9], p < 0.001), and less preferred mandated choice with medical incentive option (7[4,9] vs. 5[2,7], p < 0.001). There was no association between consenting options ranking scores and age, health status, education level, or knowing an organ donor or recipient. CONCLUSIONS: We conclude that: 1) most respondents were in favor of posthumous organ donation, 2) mandated choice system was the most preferred and presumed consent system was the least preferred, 3) there was no difference between preference and perception of norm in consenting systems ranking, and 4) financial (especially in females) and medical (especially in males) incentives reduced preference.

Safety and utility of dobutamine and pressure wire use in the hemodynamic assessment of low-flow, low-gradient aortic stenosis with reduced left ventricular ejection fraction.

BACKGROUND: The ACC/AHA guidelines recommend low-dose dobutamine challenge for hemodynamic assessment of the severity of AS in patients with low flow, low gradient aortic stenosis with reduced ejection fraction (EF) (LFLG-AS; stage D2). Inherent pitfalls of echocardiography could result in inaccurate aortic valve areas (AVA), which have downstream prognostic implications. Data on the safety and efficacy of coronary pressure wire and fluid-filled catheter use for low dose dobutamine infusion is sparse. METHODS: We retrospectively analyzed 39 consecutive patients with EF<50%, AVA<1cm2 and SVI<35ml/m2 on echocardiography who underwent simultaneous right and left heart catheterization. Hemodynamic assessments were performed at baseline and at every increment in the dobutamine infusion rate (The infusion was continued until maximal dose of dobutamine or a mean AV gradient>40mmHg was attained. The occurrence of sustained ventricular arrhythmias, symptomatic hypotension or intolerable symptoms leading to cessation of infusion was recorded. Transient ischemic attacks (TIAs) or clinically apparent strokes periprocedurally or up to 30days after the procedure were recorded. RESULTS: Dobutamine challenge confirmed true AS in 26 patients (67%) and pseudosevere AS in 34%. No sustained arrhythmias, hypotension or cessation of infusion from intolerable symptoms were observed. No clinical strokes or TIAs were observed up to 30days after procedure in any of these patients. CONCLUSIONS: Hemodynamic assessment of AS using a pressure wire with dobutamine challenge is a safe and effective tool in identifying truly severe AS in patients with LFLG-AS with reduced EF.

Long-term use of dual antiplatelet therapy for the secondary prevention of atherothrombotic events: Meta-analysis of randomized controlled trials.

BACKGROUND: The potential benefit of long-term dual antiplatelet therapy (DAPT) for secondary prevention of atherothrombotic events is unclear. Data from different randomized controlled trials (RCT) using different agents in different subgroups showed inconsistent results. METHODS: We performed a systematic review and meta-analysis from RCTs that tested different prolonged durations of DAPT for secondary prevention. Long term DAPT arm was defined as those receiving DAPT for more than 12months. Long-term aspirin arm was defined as those receiving either aspirin alone long term or DAPT for less than 12months. RESULTS: The use of long term DAPT was associated with a significant decrease in composite of death, myocardial infarction (MI) and stroke (6.08% vs. 6.71%; odds ratio OR=0.86 [0.78-0.94]; P=0.001). This reduction of death, MI and stroke was mainly noticed in patients with prior MI or stroke, but not with PAD or multiple risk factors. The reduction was seen with post PCI patients with prasugrel and only in those with prior MI with clopidogrel and ticagrelor. Long-term use of DAPT was associated with significant increase in major bleeding (1.47% vs. 0.88%; OR=1.65 [1.23-2.21]; P=0.001). CONCLUSION: Long-term use of DAPT for secondary prevention is associated with lower risk of death, MI and stroke beneficial especially in patients with prior MI and stroke, but it is associated with increased risk of bleeding. Prolonging DAPT requires careful assessment of the trade-off between ischemic and bleeding complications and should probably be reserved for patients with higher risk for atherothrombotic events.

Impact of a Multidisciplinary Team Approach Including an Intensivist on the Outcomes of Critically Ill Patients in the Cardiac Care Unit.

OBJECTIVE: To investigate the impact of integrating a medical intensivist into a cardiac care unit (CCU) multidisciplinary team on the outcomes of CCU patients. PATIENTS AND METHODS: We conducted a retrospective cohort study of 2239 CCU admissions between July 1, 2011, and July 1, 2013, which constituted patients admitted in the 12 months before and 12 months after the introduction of intensivists into the CCU multidisciplinary team. This team included a cardiologist, a medical intensivist, medical house staff, nurses, a pharmacist, a dietitian, and physical and respiratory therapists. The primary outcome was CCU mortality. Secondary outcomes included hospital mortality, CCU length of stay, hospital length of stay, and duration of mechanical ventilation. RESULTS: After the implementation of a multidisciplinary team approach, there was a significant decrease in both adjusted CCU mortality (3.5% vs 5.9%; P=.01) and hospital mortality (4.4% vs 11.1%; P<.01). A similar impact was observed on adjusted mean CCU length of stay (2.5±2.0 vs 2.9±2.0 days; P<.01), adjusted mean hospital length of stay (7.0±4.5 vs 7.5±4.5 days; P<.01), and adjusted mean ventilation duration (2.0±1.0 vs 4.3±2.5 days; P<.01). CONCLUSION: The implementation of a multidisciplinary team approach in which an intensivist and a cardiologist comanage the critical care of CCU patients is feasible and may result in better patient outcomes.

Cardiac output determination using a widely available direct continuous oxygen consumption measuring device: a practical way to get back to the gold standard.

BACKGROUND: Accurate assessment of cardiac output (CO) is essential for the hemodynamic assessment of valvular heart disease. Estimation of oxygen consumption (VO2) and thermodilution (TD) are employed in many cardiac catheterization laboratories (CCL) given the historically cumbersome nature of direct continuous VO2 measurement, the "gold standard" for this technique. A portable facemask device simplifies the direct continuous measurement of VO2, allowing for relatively rapid and continuous assessment of CO. METHODS AND MATERIALS: Thirty consecutive patients undergoing right heart catheterization had simultaneous determination of CO by both direct continuous and assumed VO2 and TD. Assessments were only made when a plateau of VO2 had occurred. All measurements of direct continuous and assumed VO2, as well as, TD CO were obtained in triplicate. RESULTS: Direct continuous VO2 CO and assumed VO2 CO correlated poorly (R=0.57; ICC=0.59). Direct continuous VO2 CO and TD CO also correlated poorly (R=0.51; ICC=0.60). Repeated direct continuous VO2 CO measurements were extremely correlated and reproducible [(R=0.93; ICC=0.96) suggesting that this was the most reliable measurement of CO. CONCLUSIONS: CO calculated from direct continuous VO2 measurement varies substantially from both assumed VO2 and TD based CO, which are widely used in most CCL. These differences may significantly impact the CO measurements. Furthermore, continuous, rather than average, measurement of VO2 appears to give highly reproducible results.

Vitamin D deficiency plays an important role in cardiac disease and affects patient outcome: Still a myth or a fact that needs exploration?

There is increasing evidence that a low vitamin D status may be an important and hitherto neglected factor of cardiovascular disease. This review is an overview of the current body of literature, and presents evidence of the mechanisms through which vitamin D deficiency affects the cardiovascular system in general and the heart in particular. Available data indicate that the majority of congestive heart failure patients have 25-hydroxyvitamin D deficiency. Furthermore, the low serum 25-hydroxyvitamin D level has a higher impact on hypertension, coronary artery disease an on the occurrence of relevant cardiac events. A serum 25-hydroxyvitamin D level below 75 nmol/l (30 ng/l) is generally regarded as vitamin D insufficiency in both adults and children, while a level below 50 nmol/l (20 ng/l) is considered deficiency. Levels below 50 nmol/l (20 ng/l) are linked independently to cardiovascular morbidity and mortality.

Transcatheter retrieval of device entrapment: management of a rare complication of percutaneous coronary intervention: case report and literature review.

With the continued advancement in PCI equipment and techniques, complications arising from intracoronary manipulation are encountered. Such complications are associated with major adverse outcome including death; myocardial infarction (MI) and the need for urgent coronary artery bypass surgery (CABG), and they require prompt recognition and mediation by the interventional cardiologist. We report a case of a broken stent shaft system in the setting of acute coronary syndrome and its successful retrieval using a non-compliant balloon to trap the proximal portion of the shaft within the guide ("trapping" a procedure used in coronary Chronic Total Occlusions (CTO) interventions) followed by slow withdrawal of the whole system. This was followed by successful PCI of the culprit lesion using a drug eluting stent without any residual complications.