Fixed obstruction at the aortic isthmus may preclude transfemoral transcatheter aortic valve replacement (TAVR). Covered-stent implantation can restore large-bore access, but immediate passage of balloons and delivery systems through a newly implanted stent may expose it to longitudinal traction. Secondary stent migration during withdrawal of a valvuloplasty balloon and its intraluminal balloon-assisted rescue have not been well characterized. An 87-year-old man with New York Heart Association class III symptoms had severe bicuspid aortic stenosis (peak velocity, 4.4 m/s; mean gradient, 48 mmHg; valve area, 0.65 cm2; left ventricular ejection fraction, 55%) and a focal juxtaductal aortic-isthmus stenosis with a peak-to-peak gradient of 32 mmHg. Because of high surgical risk and unfavorable alternative access, same-session covered-stent treatment followed by transfemoral TAVR was selected. A 12 × 29-mm Advanta V12 covered stent was deployed and flared using an 18-mm noncompliant balloon. After aortic-valve predilation with a 23-mm noncompliant balloon, the stent migrated distally during balloon withdrawal. Guidewire access was preserved, and the stent remained coaxial. The balloon was recentered within the migrated stent and partially reinflated, allowing the balloon and stent to be advanced proximally as a single unit. After restoration and re-expansion of the stent, a 23-mm Myval valve was implanted successfully. Final transvalvular and isthmic gradients were 8 and 5 mmHg, respectively, with trivial paravalvular regurgitation and no aortic injury. The patient was discharged on day 3 and remained in NYHA class I at 6 months. Withdrawal of a large valvuloplasty balloon may cause secondary migration of a newly implanted aortic-isthmus stent. When guidewire access, coaxial alignment, and structural integrity are preserved, controlled intraluminal balloon-assisted repositioning may provide an effective bailout while maintaining transfemoral access.

Percutaneous vertebroplasty is a minimally invasive procedure injecting polymethylmethacrylate cement to increase vertebral stability in vertebral compression fractures. We present a patient who presented with recurrent pulmonary embolism due to intracardiac cement embolism after vertebroplasty with successful percutaneous cement removal. A 72-year-old woman presented with chest pain, dyspnea, hypotension, and atrial fibrillation 1 month after vertebroplasty. Transthoracic echocardiography revealed a freely mobile hyperechoic linear structure in the right atrium; estimated pulmonary artery systolic pressure was 45 mmHg. Computed tomography angiography demonstrated a cement cast extending from L2 vertebra through the inferior vena cava into the right atrium and cement emboli in distal pulmonary arterial branches. Intracardiac cement was successfully removed using a three-lobed snare with balloon assist. Intracardiac cement embolism is a rare, potentially life-threatening complication following vertebroplasty. Percutaneous removal may be considered a safe and effective alternative to open surgery in selected patients.

Congenital coronary artery anomalies are quite uncommon-they are observed in 1.3% of the coronary angiograms. Although most of them are benign, some coronary anomalies are associated with poor clinical outcomes. The exact mechanism of these outcomes in patients with anomalous RCA from the left aortic cusp with interarterial course is hypothesized to be either compression of the coronary artery during its course between the aorta and the pulmonary artery, or obstruction of the coronary flow during exercise due to the acute angulation of the RCA ostium. We present the case of a 54 y/o patient with NSTEMI, who, after a diagnostic coronary angiogram and coronary CT, was found to have complex coronary artery disease, including an anomalous RCA from the left aortic cusp with "malignant" interarterial course. In order to determine the optimal treatment, we proceeded with IVUS assessment of the ostial and proximal RCA with dobutamine challenge, which showed significant stenosis of both the RCA ostium and the interarterial segment at the peak dose of the dobutamine challenge. As a result a decision was made to treat both the RCA ostium and its interarterial segment with PCI, producing an excellent final result. Our case underscores the importance of the combination of IVUS and dobutamine challenge in order to answer the ever-important pathophysiologic mechanism of a lesion and accordingly provide tailor-made treatment for anomalous coronary arteries.

There is a growing need for large-bore femoral access across cardiac interventions. This has led to a need for more widely accessible vascular closure techniques to facilitate reliable vascular closure and wider access to these interventions. We present a stepwise approach to femoral artery closure using two Angioseal devices in a case of Impella-assisted PCI. This case demonstrates a simple and easy-to-perform method to achieve hemostasis in large-bore femoral access. A larger series to confirm safety and reproducibility would help support this approach.

Transcatheter edge-to-edge repair (TEER) is an established intervention for patients having severe mitral regurgitation (MR) with prohibitive surgical risk. Complications during deployment related to device malfunction are uncommon but necessitate prompt decision-making and management. A 54-year-old gentleman with dilated cardiomyopathy, severe left ventricular dysfunction, and severe MR underwent TEER using the MyClip system (Meril Life Sciences Pvt. Ltd., Vapi, Gujarat, India). Initial deployment across the A2-P2 scallops of mitral leaflets achieved partial MR reduction. Significant residual MR required a second clip for optimal leaflet coaptation. While deploying the second clip, it failed to close because of a mechanical locking failure. So, we everted the clip, pulled back to LA, and it stayed in open position and failed to close. We report a novel bailout snare technique that enabled safe retrieval without the need for a second transseptal puncture. The ability to close the clip arms prior to withdrawal minimized the risk of tearing the atrial septum and facilitated the successful completion of the TEER procedure. Another clip was deployed successfully, resulting in significant MR reduction. This case demonstrates a rare complication during deployment, a malfunction of the device, and a novel strategy for safely bailing out a challenging intra-procedural complication.

As life expectancy in patients with congenital heart disease continues to increase, coronary artery disease and acute coronary syndromes are encountered more and more in this population, with a higher level of complexity, especially in the acute setting. We present a case of acute thrombotic occlusion of the left circumflex coronary artery in a patient with congenitally corrected transposition of the great arteries. This case highlights several challenges from ECG and computed tomography interpretation to coronary angiography and PCI performance. Key pre-procedural and procedural steps are revised to guide toward prompt and successful revascularization.