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Perforation of the left internal mammary artery (LIMA) graft is a rare but severe complication of coronary artery bypass grafting (CABG). A 75-year-old Caucasian man with hypertension, diabetes, dyslipidaemia, and a history of SARS-CoV-2 presented with exertional dyspnoea. After CABG with a Y-graft anastomosis using the right internal mammary artery, he experienced severe chest pain. A transthoracic echocardiogram revealed a haemopericardium. A computed tomography scan identified a LIMA pseudoaneurysm in contact with the haemopericardium near the anterior and anterolateral left ventricle walls. Angiography confirmed the LIMA pseudoaneurysm and left anterior descending artery (LAD) graft occlusion. The LIMA pseudoaneurysm was treated with a covered stent, and the LAD was revascularized with rotational atherectomy and drug-eluting stent. At the three-year follow-up, the patient remained asymptomatic, and the scan performed at the two-year mark indicated patent grafts with no signs of restenosis. This case illustrates the successful percutaneous management of a rare LIMA pseudoaneurysm, preventing high-risk reoperation. It also highlights the importance of multimodal imaging and interventional strategies in managing complex post-CABG complications.

Introduction: Beta-aminopropionitrile (BAPN) administration is a chemically induced model for preclinical aortic pathologies research. Angiotensin II (AngII) has been widely used to promotes aortic dissections in mice. Here, we provide insight on a modified aortic dissection model in rats. The effect of smooth muscle cell (SMC) relaxation with vasodilators is studied in this model. Methods: Forty Sprague-Dawley rats were divided in 4 groups: control, isosorbide dinitrate (ISDN, 30 mg/kg/day) in the drinking water, BAPN (0.02%) in the food, BAPN + ISDN (same doses). Thoracic and abdominal aortic diameters were evaluated through transthoracic ultrasound echography. After 6 weeks, all rats were infused with AngII (1 mg/kg/day) subcutaneously. Survival and type of aortic events were numbered. Histological and histochemical analyses of aorta were performed. Results: Initial telesystolic ascending aorta diameters were equal in all groups and became significantly larger in the BAPN + ISDN group compared to the BAPN group (control: 3.37 ± 0.17 mm, ISDN: 3.49 ± 0.16 mm, BAPN: 3.53 ± 0.13 mm, BAPN + ISDN: 3.61 ± 0.16 mm, analysis of variance p < 0.0001). BAPN followed by AngII infusion showed a significant lower survival rate (p = 0.029) and produced a large panel of aortic events. Association of ISDN and BAPN significantly reduces survival (p = 0.001) and provides more aortic events compared to BAPN alone (p = 0.031). In both BAPN-treated groups, orcein staining revealed split and dissected elastic fibers in the media, alcian blue staining showed mucoid degeneration of the aortic wall, and Perls-diaminobenzidine staining revealed an accumulation of Fe 2+ . Conclusion: SMC relaxation with ISDN increases aortic dilatation, worsens aortic prognosis, and reproduces human histological findings in a low-dose BAPN/AngII-induced aortic dissection model in rats.

Left Bundle Branch Block (LBBB) is a frequently encountered electrical abnormality in patients with chronic (more than 3 months after myocardial infarction, or evidence of coronary artery disease with ischemia) coronary syndromes (CCS), but its prognostic significance remains unclear. We aimed to describe the prevalence, incidence and five-year outcomes of LBBB in outpatients with CCS using the CLARIFY registry. Main outcome was a composite of CV death, MI or stroke. Secondary outcomes included all cause death, hospitalization for heart failure (HF) and permanent pacemaker implantation. Among 23.544 patients with available information regarding LBBB status at baseline, 1.041 (4.4%) had LBBB at baseline and 1.015 (4.5%) patients developed a new LBBB during 5-year follow-up. In multivariate analysis, LBBB at baseline was not associated with the composite outcome of CV death, MI or stroke (HR 1.06, 95% CI [0.86 – 1.31], p = 0.67) or the risk of all-cause death (HR 1.07, 95% CI [0.87 – 1.32], p = 0.52) but was significantly associated with a higher risk of hospitalization for HF (HR 1.50, 95% CI [1.21 – 1.88], p < 0.001) and permanent pacemaker implantation (HR 2.11, 95% CI [1.45 – 3.07], p < 0.001). The main factors associated with new-onset LBBB were male sex (HR 0.8 [0.66-0.98], p = 0.028) history of atrial fibrillation (HR 1.29, 95% CI [1.01 – 1.64], p = 0.04), CABG (HR 1.27, [1.08 – 1.51], p = 0.004) and MI (HR 1.19, 95% CI [1.01 – 1.40], p = 0.034). In conclusion, in a contemporary registry of outpatients with CCS, the prevalence of LBBB was 4.4% and the additional 5-years incidence 6.2%. LBBB, in itself, was not associated with a higher risk of major adverse cardiovascular events or all cause mortality. It was however an independent predictor of risk of hospitalization for heart failure and permanent pacemaker implantation.

BackgroundIdentifying significant coronary artery disease (CAD) in patients with reduced left ventricular ejection fraction (rLVEF) is essential for guiding therapeutic decisions, including medical management, device implantation and potential revascularisation. Prior studies suggested that rest cardiac MRI (CMR) with late gadolinium enhancement (LGE) could reliably detect significant CAD. We aimed to evaluate the diagnostic accuracy of rest LGE-CMR for predicting significant CAD in rLVEF patients.MethodsIn this prospective, multicentre cohort study across 10 centres, adults with new-onset rLVEF≤45% without obvious cause were included. All patients underwent rest CMR and coronary angiography. Independent, blinded committees reviewed images. Significant CAD was defined as ≥70% stenosis in major coronary arteries. Ischaemic scars were identified on CMR as subendocardial LGE. The primary outcome was the sensitivity of CMR in detecting significant CAD.ResultsAmong 380 patients (median age 63 years, 68% male), significant CAD was present in 49 (13%). CMR identified ischaemic scars in 106 (28%). The sensitivity of CMR for detecting significant CAD was 57% (95% CI: 43% to 71%), specificity 76% (95% CI: 72% to 81%), positive predictive value 26% (95% CI: 18% to 35%) and negative predictive value 92% (95% CI: 89% to 95%). A CMR-first strategy would have missed 43% of significant CAD cases, many requiring revascularisation (86% of missed cases).ConclusionsIn this large, prospective multicentre study with independent image review, rest LGE-CMR demonstrated limited sensitivity for detecting significant CAD in patients with rLVEF. Relying solely on CMR could lead to missed diagnoses and undertreatment. CMR should be integrated with other diagnostic tools to optimise care in this population.Trial registration number NCT03231189.

Background The COMPASS trial showed a reduction of ischemic events with low‐dose rivaroxaban and aspirin in chronic coronary syndromes (CCS) compared with aspirin alone, at the expense of increased bleeding. Hypothesis The CHA2DS2VaSc Score, REACH Recurrent Ischemic (RIS), and REACH Bleeding Risk Score (BRS) could identify patients with a favorable trade‐off between ischemic and bleeding events, among COMPASS‐eligible patients. Methods We identified the COMPASS‐eligible population within the CLARIFY registry (>30.000 patients with CCS). High‐bleeding risk patients (REACH BRS > 10) were excluded, as in the COMPASS trial. Patients were categorized as low (0–1) or high (≥ 2) CHA2DS2VaSc; low (0–12) or intermediate (13–19) REACH RIS, and low (0–6) or intermediate (7–10) REACH BRS. Ischemic outcome was the composite of cardiovascular death, myocardial infarction or stroke. Bleeding was defined as serious bleeding (haemorrhagic stroke, hospitalization for bleeding, transfusion). Results The COMPASS‐eligible population comprised 5.142 patients with ischemic and bleeding outcome of 2.3 (2.1–2.5) and 0.5 (0.4–0.6) per 100 patient‐years, respectively. Patients with intermediate REACH RIS (n = 1934 [37.6%]) had the higher ischemic risk (3.0 [2.6–3.4]) with similar bleeding risk (0.5 [0.4–0.7]) as the overall population. Patients with low CHA2DS2VaSc (n = 229 [4.4%]) had a very low ischemic risk (0.6 [0.3–1.3]) with similar bleeding risk (0.5 [0.2–1.1]). Conclusions Intermediate REACH RIS identified potential optimal candidates for adjunction of low‐dose rivaroxaban while patients with low CHA2DS2VaSc score .appears unlikely to benefit from the COMPASS regimen. None of the three risk scores predicted the occurrence of serious bleeding.