To the Editor,

Aorto-atrial fistulas are an extremely rare condition where an abnormal connection forms between the aortic structures and the cardiac atria. Among them, fistulas between the aorta and the left atrium (Ao-LA) are particularly uncommon, and mainly associated with complications like infectious endocarditis, paravalvular abscesses, aortic dissections, and cardiac surgery often damaging the aortic valve or root.1 This is the case of a patient with a iatrogenic Ao-LA fistula successfully treated with a percutaneous Amplatzer device.

This is the case of an 82-year-old man admitted to the hospital due to acute heart failure. Three weeks earlier, he had undergone cardiac surgery with mitral and tricuspid valve repair through double annuloplasty plus left anterior descending coronary artery bypass with internal mammary artery graft.

The transthoracic echocardiography revealed the presence of a preserved biventricular and valvular function, but also an abnormal systolic and diastolic jet in the left atrium (figure 1A and video 1 of the supplementary data). On the transoesophageal echocardiography this jet corresponded to an Ao-LA fistula through the aortic non-coronary sinus with a significant shunt across it (figure 1B,C and video 2 of the supplementary data). There were no images suggestive of infective endocarditis and repeated blood cultures remained negative for any bacterial growth. A computed tomography scan confirmed the findings, although mitral annuloplasty triggered metal artifacts, thus hindering 3D reconstruction. The individual was considered a high-risk patient for surgical reintervention by the heart team, and was initially treated with drugs. However, despite the optimal medical therapy he was readmitted twice within the following 3 months. Therefore, interventional management of the fistula was decided. The patient gave his written informed consent.

Figure 1. Transthoracic (A) and transoesophageal echocardiography (B, C) showing a high-velocity jet shunting from the non-coronary sinus of Valsalva towards the left atrium.

A percutaneous approach was attempted under general anaesthesia using retrograde access via right femoral artery. The initial angiography performed using a 6-Fr right Judkins(Medtronic, United States) guiding catheter showed a large flow of contrast from the non-coronary sinus to the left atrium (figure 2A and video 3 of the supplementary data). Afterwards, a Sion Blue (Asahi Intecc, Thailand) wire was placed into the left atrium and the right Judkins guiding catheter advanced into the atrium to be used as a delivery system. A 6 mm Amplatzer DuctOccluder II(Abbott, United States) was successfully deployed with simultaneous angiographic (figure 2B and video 4 of the supplementary data) and transoesophageal echocardiography (figure 2C,D and videos 5 and 6 of the supplementary data) confirmation of almost complete fistula closure. Although the patient was previously on anticoagulant therapy due to permanent atrial fibrillation, empirical combination therapy adding aspirin 100 mg was prescribed for 6 months. The 6-month follow-up was uneventful, and the patient remained in functional class I with no residual shunt on the 2D echocardiography performed at 1 month.

Figure 2. A: Basal aortography with left atrium filling through the fistula (arrow).D: No contrast passage after Amplatzer Duct Occluder II deployment (arrow).E, F: Amplatzer device positioned with no shunt on the color Doppler ultrasound and 3D transoesophageal echocardiography view.

Aorta-atrial fistulas are a rare condition being cardiac surgery a recognized cause.1 Among them, fistulas between the Ao-LA are very unusual, and occurrence is much more common after aortic compared to coronary artery bypass graft surgery. To this date, no cases have ever been associated with mitral valve repairs.1 The abnormal flow between the aorta and the left atrium often leads to volume overload and signs and symptoms of heart failure.2 Early recognition and diagnosis of this severe condition relies on its echocardiographic characterization being the transoesophageal echocardiography the imaging modality of choice regarding diagnosis. Combination with 3D imaging modalities is highly advised, when available either transoesophageal echocardiography or computed tomography scan as they allow spatial orientation and high anatomical definition for procedural planning.3 Evaluation can also include cardiac magnetic resonance imaging or cardiac catheterization to additionally assess shunt quantification.4

Due to the low incidence rate of aorto-atrial fistulas, treatment strategies depend on the underlying disease, and interventions are based on expert opinions and consensus among the treating physicians. Nevertheless, closure of the fistula is highly advised in symptomatic patients.5 Although surgery is the standard treatment, percutaneous closure can be considered in high-risks patients with favorable angiographic characteristics like location in the non-coronary sinus or fistulas of small diameters.1 In the absence of specific percutaneous material, the off-label use of an Amplatzer DuctOccluder II device with simultaneous echocardiographic and fluoroscopy guidance is an amenable option as described in our case and isolated cases in the medical literature available.6,7 Further antiplatelet/anticoagulant therapy after device implantation is advised although evidence regarding the optimal antithrombotic regimen and duration remains empirical.

In conclusion, although rare, aorto-atrial fistulas are a severe complication that can led to refractory heart failure. Closure of the fistulous tract is often advised. Evidence on this regard is scarce and mostly based on case reports or case series.2,6 More data is needed to better define optimal therapeutic strategies in this scenario.


M. Tamargo was partially supported by grants from Fundación para la Investigación Biomédica Gregorio Marañón, Madrid, Spain, and CM20/00054 from Instituto de Salud Carlos III, Madrid, Spain.

Authors’ contributions

All the authors contributed equally to this work.

Conflicts of interest

None whatsoever.


Vídeo 1. Tamargo M. DOI: 10.24875/RECICE.M23000387

Vídeo 2. Tamargo M. DOI: 10.24875/RECICE.M23000387

Vídeo 3. Tamargo M. DOI: 10.24875/RECICE.M23000387

Vídeo 4. Tamargo M. DOI: 10.24875/RECICE.M23000387

Vídeo 5. Tamargo M. DOI: 10.24875/RECICE.M23000387

Vídeo 6. Tamargo M. DOI: 10.24875/RECICE.M23000387


1. Fierro EA, Sikachi RR, Agrawal A, Verma I, Ojrzanowski M, Sahni S. Aorto-Atrial Fistulas: A Contemporary Review. Cardiol Rev. 2018;26:137-144.

2. Foster TJ, Amin AH, Busu T, et al. Aorto-cardiac fistula etiology, presentation, and management: A systematic review. Heart Lung. 2020;49:317-323.

3. Patel V, Fountain A, Guglin M, Nanda NC. Three-Dimensional Transthoracic Echocardiography in Identification of Aorto-Right Atrial Fistula and Aorto-Right Ventricular Fistulas. Echocardiography. 2010;27:E105-E108.

4. Valsangiacomo Buechel ER, Grosse-Wortmann L, Fratz S, et al. Indications for cardiovascular magnetic resonance in children with congenital and acquired heart disease: an expert consensus paper of the Imaging Working Group of the AEPC and the Cardiovascular Magnetic Resonance Section of the EACVI. Eur Heart J Cardiovasc Imaging. 2015;16:281-297.

5. Jainandunsing JS, Linnemann R, Maessen J, et al. Aorto-atrial fistula formation and therapy. J Thorac Dis. 2019;11:1016-1021.

6. Alkhouli M, Almustafa A, Kawsara A, et al. Transcatheter closure of an aortoatrial fistula following a surgical aortic valve replacement. J Card Surg. 2017;32:186-189.

7. Hernández García JM, Alonso-Briales JH, Jiménez-Navarro MF, Cabrera-Bueno F, González-Cocina E, Such-Martínez M. Transcatheter Closure of Aorto-Left Atrial Fistula Using an Amplatzer Device. Rev Esp Cardiol. 2005;58:1121-1123.

* Corresponding author:

E-mail address: (M. Tamargo).


To the Editor,

This is the case of a 62-year-old man who presented to the emergency department with signs of an acute neurological syndrome. He remained under regular monitorization due to spastic paraparesis. The patient’s past medical history also included dyslipidemia, active smoking, former alcohol abuse, and psoriasis. His routine medication included daily aspirin 150 mg, and simvastatin 20 mg. Due to severe worsening of his neurological status, he was admitted for further evaluation. After careful clinical evaluation, diagnosis of cerebellar and pyramidal syndrome in the neurosyphilis setting was achieved. Penicillin was started. During hospitalization, cerebral magnetic resonance imaging revealed the presence of a massive hernia at C4-C5 causing significant spinal cord compression. Decompressive surgery was advised. During hospitalization, he complained of chest pain. The ECG showed signs of sinus rhythm with sustained diffuse ST-segment depression and ST-segment elevation in aVR and V1. The transthoracic echocardiography showed a severely impaired left ventricular ejection fraction with severe hypokinesia of the apex, anterior, posterior, and lateral walls. The aortic root was mildly enlarged, but no flaps were seen. Due to refractory chest pain and progressively worsening hypotension, the patient was given unfractionated heparin (5000 IU) and underwent an emergency coronary angiography that revealed the presence of critical left main coronary artery ostial stenosis (videos 1 and 2 of the supplementary data). No further lesions were identified. Due to the complexity of the lesion, percutaneous angioplasty under left ventricular assist device was advised. It was necessary to make a multidisciplinary decision due to the patient’s condition.

Due to the patient’s unstable and worsening hemodynamic condition, a coronary angioplasty using a drug-eluting stent was decided and successfully performed (figure 1, and figure 2). Before the angioplasty was performed, the patient was given a loading dose of ticagrelor 180 mg. The procedure was backed by intracoronary ultrasound (IVUS), which showed good stent positioning and expansion at the end of the procedure (minimum in-stent area of 16 mm2) (videos 3 and 4 of the supplementary data). No signs of coronary artery dissection were reported. After the procedure, the patient was pain-free, and blood pressure levels came back to normal.

Figure 1. Coronary angiography images. A: protection guidewire placed in the left anterior descending coronary artery. B: protection guidewire placed in the left circumflex artery. C: left main coronary artery predilatation with a noncompliant balloon (Emerge PTCA, Boston Scientific, United States; 3.5 mm × 8 mm; 16 atm); D: implantation of an everolimus-coated stent (XIENCE Sierra, Abbott, United States; 4.0 mm × 8 mm; 22 atm) in the left main coronary artery ostium. E: overdilatation of the previously implanted stent using another noncompliant balloon (Emerge PTCA, Boston Scientific, United States; 5.0 mm x 8 mm; 24 atm); F: good final angiographic results.

Figure 2. Intravascular ultrasound (IVUS). A: IVUS performed after predilatation showing a heterogeneous lesion at left main coronary artery ostium level possibly due to aortitis phenomena. B: the IVUS performed after stent implantation revealed proper stent expansion.

The transthoracic echocardiography was repeated, and confirmed a mildly dilated aortic root (40 mm to 41 mm) with apparent posterior wall thickening. The left ventricle was not dilated. The left ventricular ejection fraction was 30%-35% with an apical akinetic area, and anterior, lateral, and posterior walls. The right ventricular function was normal. No significant valvular disease, pericardial effusion or intracardiac masses were reported.

A thoracic computerized tomography scan showed multiple atheromatous aortic calcifications and significant wall thickening, which correlated to aortitis phenomena of syphilitic etiology. The patient remained on dual antiplatelet therapy and completed his antibiotic cycle with penicillin. The patient had favorable cardiovascular progression with gradual improvement of the left ventricular function and was discharged to the neurosurgery unit after 7 days. At 1 month, ticagrelor was withdrawn, and the patient underwent neurosurgery. His neurological recovery was uneventful and after 6 months, left ventricular function was normal.

Although cardiovascular signs have been previously described in the medical literature as well-known complications of syphilis, this case illustrates a particularly rare cardiac complication in the modern era.1-3 A possible sign of syphilitic aortitis is ostial coronary narrowing that can lead to an acute myocardial infarction, most cases being identified post-mortem.1 The underlying mechanism can be associated with atherosclerotic plaques, inflammatory phenomena, and/or calcium protrusion to the coronary arteries.1-3 High level of suspicion and the proper clinical setting were essential to achieve diagnosis and further treatment.1 Other differential diagnoses can be questioned like ankylosing spondylitis, temporal arteritis, and Takayasu’s arteritis since they can cause ascending aortitis.2,3

This case underlines the complexity of treating ostial lesions of left main coronary artery especially in situations where coronary obstruction seems to be conditioned by calcifications at ascending aorta, aortic root or aortitis level. Displacement of calcium in the aorta can lead to critical obstructions that, in the emergency setting, can complicate percutaneous revascularization or make it unfeasible. The absence of left ventricular assist devices and the close availability of cardiac surgery in our hospital made this scenario frightening and difficult to manage in the acute phase. Former studies have reported angioplasties in patients with left main coronary artery ostial stenosis, most requiring left ventricular assist devices to support the angioplasty of left main coronary artery.4-6 Fortunately for the patient, emergence angioplasty was possible with favorable cardiovascular progression. The patient’s written informed consent was obtained.


None whatsoever.


R. Flores, F. Mané, C. Braga, and C. Oliveira treated the patient. R. Flores drafted the manuscript, and F. Mané, C. Braga, and C. Oliveira reviewed it.


None reported.


Vídeo 1. Flores R. DOI: 10.24875/RECICE.M23000375

Vídeo 2. Flores R. DOI: 10.24875/RECICE.M23000375

Vídeo 3. Flores R. DOI: 10.24875/RECICE.M23000375

Vídeo 4. Flores R. DOI: 10.24875/RECICE.M23000375


1. Jadeed R, Paarmann R, Harringer W, El-Essawi A. Syphilitic Aortitis Presenting with Coronary Ostial Stenosis and Aortic Regurgitation. J Heart Valve Dis. 2016;25:18-20.

2. Barbosa-Barros R, Pérez-Riera AR, Koivula K et al. Acute coronary syndrome of very unusual etiology. Ann Noninvasive Electrocardiol. 2018;23:e12531.

3. Nomura R, Yamazaki F, Egawa Y. Syphilitic aortitis: chronic left coronary ostial occlusion and aortic regurgitation with aortitis. Gen Thorac Cardiovasc Surg. 2021;69:736-739.

4. Predescu LM, Zarma L, Platon P, et al. ST Segment Elevation Myocardial Infarction Due to Severe Ostial Left Main Stem Stenosis in a Patient with Syphilitic Aortitis. Rom J Intern Med. 2016;54:74-79.

5. Li X, Wang X, Wang Z et al. Cardiovascular syphilis-associated acute myocardial infarction: A case report. Medicine (Baltimore). 2021;100:e24788.

6. Hosoba S, Suzuki T, Koizumi Y et al. Syphilitic aortitis causing bilateral coronary ostial stenosis. Heart Surg Forum. 2011;14:E59-60.

* Corresponding author.

E-mail address: (R. Flores).

To the Editor,

In left atrial appendage closure (LAAC), venous access is often predictable. These are 2 cases of venous disease found during LAAC and the alternatives proposed for its resolution. Both patients gave their informed consent for publication purposes.

In case #1, an 88-year-old man who was a pacemaker carrier, with permanent atrial fibrillation, ventricular dysfunction, and non-surgical sacral fracture was referred for LAAC due to recurrent hemorrhages.

Through previous ultrasound-guided venous puncture a transseptal system was advanced that experienced significant resistance in the iliac curvature, difficult torsion at the right atrium, and loss of driving force in the fossa ovalis (figure 1, videos 1-4 of the supplementary data). Transseptal puncture was achieved through the rigid section of a 0.014 in angioplasty guidewire by exchanging the flexible section and advancing the sheath towards the pulmonary vein. Afterwards, it was exchanged for a 14-Fr sheath, and the pigtail catheter was mounted over the high-support guidewire. However, significant resistance during retraction and rotation maneuvers was reported. Nevertheless, it was successfully placed in the left atrial appendage and several angiographies were performed. During pigtail catheter withdrawal, resistance was very significant with evidence of severe torsion following the previous lumbosacral surgery. Since it was impossible to advance the device due to damage to the distal border or recanalize the sheath with a 0.035 in guidewire the procedure was stopped. Computed tomography (CT) scan revealed the presence of lateral deviation and elongation of the inferior vena cava bifurcation with endofibrosis at this level and loss of cleavage plane with the sacrum, posterior compression of the right common iliac vein, and horizontalization of the left common iliac vein. Conservative treatment was decided.

Figure 1. Limited contact pressure of transseptal system (A), and difficult maneuverability of the pigtail catheter (B) due to the severe torsion of the delivery catheter (C). Procedure stopped due to the impossibility of advancing a new device or guidewire (D, E). Computed tomography scan (F) of a compressed right iliac vein (asterisk) between the fracture and the homolateral common iliac artery. Presence of endofibrosis (arrows) and lack of cleavage plane between the left common iliac vein and the sacrum.

In case #2, a 74-year-old man with permanent atrial fibrillation, on hemodialysis, prostate cancer, and an old right pelvic fracture was referred for LAAC due to severe hemorrhages in arteriovenous fistula.

During ultrasound-guided venous puncture, a large caliber common femoral vein with flow inside was reported. Since the Teflon-coated guidewire could not be advanced antegradely, an angiography documented the presence of iliofemoral deep venous thrombosis (figure 2, videos 5-8 of the supplementary data). Procedure went on via left access using a BRK-1 XS needle (Abbott Vascular, United States) by pre-shaping a secondary curve of additional 15° to 20° while the guidewire was being manipulated and elevated to prevent needle deformation. Given the limited contact with the septum, the rigid section of an angioplasty guidewire was required to perform the puncture. A pigtail catheter, and a high-support guidewire were used to bring the 14-Fr sheath closer to the left atrial appendage. A 31 mm Watchman FLX device (Boston Scientific, United States) was successfully implanted The CT scan confirmed the presence of chronic deep venous thrombosis at right common iliac vein level.

Figure 2. Venography reveals the presence of a complete obstruction that triggered change to left access route (A). Note the unusual position and limited support of both the transseptal puncture needle (B) and the delivery catheter (C). The increased support provided by the rigid guidewire to the 6-Fr pigtail catheter facilitated sheath placement and device release (D, E). The CT scan (F) revealed the presence of an oversized right common iliac vein with hyperdensities inside.

Venous damage is one of the most dreaded complications of lumbosacral surgery. May-Turner syndrome of posterior location (iliac vein compression due to incorrect alignment following spinal instrumentation) has been described by analogy with the anterior location one due to right common iliac artery crossing.1 In addition, lower limb fractures can become complicated with deep venous thrombosis and eventually trigger chronification in a third of the cases.2 The growing prevalence of this plethora of clinical signs and symptoms requires knowing different alternatives to complete structural heart procedures (table 1).

Table 1. Technical resources to perform left atrial appendage closure in the presence of elongation, calcification, tortuosity or venous obstruction

Stage of the procedure Maneuver proposed
Suspected venous disease Past medical history of trauma/vertebral or pelvic surgery or venous thromboembolic disease
Ultrasound-guided access (hypoplasia, increased caliber due to venous hypertension, collateral circulation)
Computed tomography scan (venous stage) and specialized assessment
Correction of tortuosity, and increased passive support Work on a larger caliber introducer sheath like the ones used for transcatheter valve implantation (anticipate risk of venous lesion and possibilities of transcatheter repair)
Transseptal puncture Pre-shaping of the needle additional curve
Needle with additional sharpening (XS series)
Sequential use of the rigid and flexible parts of the angioplasty guidewire
SafeSept system
Radiofrequency or electrocautery needle
System crossing through the septum Greater support guidewires
Septal dilatation with balloon or dilators like the ones used for transcatheter mitral valvuloplasty
Navigation through left atrium and placement into the left atrial appendage Use of flexible, deflectable or pre-shapable sheaths
Additional support with a catheter of a larger caliber (≥ 6-Fr), and a high-support guidewire inside
Impossibility of lower access route Upper limb access with deflectable sheath
Epicardial closure (eg, stapling or clips)
Anticoagulation at lower doses compared to the standard ones

In case #1, the CT scan revealed the presence of an inelastic right axis, high risk of venous fracture, and extreme elongation and horizontalization of the left axis to an extent that all lower limb procedures were ill-advised. Although procedures have been performed via upper3 or transhepatic access,4 experience on this regard is very limited. Case #2 illustrates the possibility of left access in patients without extreme elongation or iliofemoral axis horizontalization. As a last resort, epicardial approaches can be used. However, operators should be aware of the need for an associated transseptal access (hybrid procedures) or thoracotomy.


None whatsoever.


All the authors participated in the management of the patients, collection of clinical information, drafting, and critical review of the manuscript.


D. Martí Sánchez received consultancy and training fees from Boston Scientific Ibérica. The remaining authors declared no conflicts of interest whatsoever.


Vídeo 1. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 2. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 3. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 4. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 5. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 6. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 7. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364

Vídeo 8. Martí Sánchez D. DOI: 10.24875/RECICE.M23000364


1. Woo EJ, Ogilvie RA, Krueger VS, Lundin M, Williams DM. Iliac vein compression syndrome from anterior perforation of a pedicle screw. J Surg Case Rep. 2016;2016:rjw003.

2. Cannon KA, Badiee J, Wallace JD, et al. The prevalence of chronic deep venous thrombosis in trauma: Implications for hospitals and patients. J Trauma Acute Care Surg. 2018;84:170-174.

3. Galea R, Roten L, Siontis GCM, Brugger N, Windecker S, Räber L. Percutaneous left atrial appendage closure with superior vascular access. EuroIntervention. 2022;18:e695-e696.

4. Zare P, Rechani L, Smithson S. Left atrial appendage closure device implantation via transhepatic vascular access: a case report. Eur Heart J Case Rep. 2020;4:1-5.

* Corresponding author.

E-mail address: (D. Martí Sánchez).

To the Editor,

Very late stent thrombosis—the one occurring, at least, 1 year after stenting—is a rare complication of tremendous clinical relevance. The mechanisms underlying its physiopathology have been widely studied thanks to the use of intracoronary imaging modalities, especially optical coherence tomography. The 2 main mechanisms of action found are, in the first place, neoatherosclerosis, and secondly, no strut endothelization.1 Despite of this, its approach is still under discussion and focused on resolution or minimization of the factors leading to its appearance.

On the other hand, drug-coated balloon (DCB) has been part of the therapeutic armamentarium of interventional cardiologists for quite some time. Currently, its main indications are to treat in-stent restenosis, and small vessel de novo coronary artery lesions. New indications are emerging like bifurcations (especially of the side branch) and large vessel de novo lesions. However, there is a clinical setting where its use has instilled quite a few serious doubts: ST-segment elevation acute coronary syndrome (STEACS). Since plaque rupture followed by thrombosis is its main pathogenic mechanism and it’s different from the therapeutic target of DCB—the inhibition of neointimal proliferation—the use of DCB to treat STEACS is ill-advised. Former studies on this matter have proven so.2 However, isolated, and well-designed studies have obtained good results like the REVELATION.3

However, in very late stent thrombosis—the one associated with the thrombotic phenomenon per se—other pathogenic processes are involved like restenotic lesions and neoatherosclerosis, which could respond to DCB therapy even with a lower risk of complications compared to new stenting since this approach is less aggressive and avoids stenting multiple overlapping stents in the culprit vessel.

This is the first series ever reported of patients with very late stent thrombosis treated with DCB. All of them signed the informed consent form, and received the approval of our hospital ethics committee.

Table 1 shows the clinical, anatomical, and procedural characteristics of the 6 patients included. We should mention the very late onset of stent thrombosis that occurs in 1 of the cases occurred 19 years after the index procedure. A total of 4 patients had complete vessel thrombosis. In all of them percutaneous thrombectomy was performed unlike in the other 2 who had partial thrombosis with baseline TIMI (Thrombolysis in Myocardial Infarction) grade-3 flow. We should mention that in 2 out of the 6 patients significant changes were reportes regarding measurements taken on the days that preceded the onset of STEACS. In the first patient, single antiplatelet therapy was withdrawn due to a scheduled dental procedure while in the second patient, dual antiplatelet therapy was changed for single antiplatelet therapy plus oral antiacoagulation due to the presence of deep venous thrombosis. In the only patient treated with optical coherence tomography, neoatherosclerosis was identified as the pathogenic mechanism of thrombosis (figure 1 and figure 2). All the lesions received proper preparation with different predilatation and plaque modification devices before using the DCB, the SeQuent Please Neo with paclitaxel coating technology (BBraun, Germany) in all cases. No adverse events were ever reported at a median follow-up of 6 months.

Table 1. Clinical and procedural characteristics

Patient #1 Patient #2 Patient #3 Patient #4 Patient #5 Patient #6
Sex Woman Man Man Man Man Man
Age (years) 71 81 83 52 63 75
Hypertension Yes Yes Yes Yes Yes No
Diabetes No Yes No No No No
Dyslipidemia Yes Yes Yes Yes Yes Yes
Smoking Yes Former smoker Former smoker Yes Former smoker Former smoker
Kidney disease No (Cr, 0.79) No (Cr, 0.78) No (Cr, 1.02) No (Cr, 1.02) No (Cr, 1.13) No (Cr, 0.98)
Years since stenting 19 3 4 6 15 10
Previous treatment ASA NOA ASA ASA Clopidogrel NOA + clopidogrel
Location of culprit lesion Mid-right coronary artery Mid-left anterior descending coronary artery Saphenous vein graft Distal left circumflex artery Diagonal branch Mid-right coronary artery
Early TIMI grade flow 0 0 3 0 3 0
Predilatation device Scoring NC Cutting + NC Scoring + cutting NC NC
Final TIMI grade flow 3 3 3 3 3 3
Intracoronary images No No No Yes No No
Size of DCB used 3.5 2.5 + 3 4 3 2.5 3
Treatment at discharge ASA + prasugrel NOA + ASA + clopidogrel ASA + ticagrelor ASA + ticagrelor ASA + ticagrelor NOA + ASA + clopidogrel
Follow-up (months) 10 9 6 6 3 2
Adverse events at follow-up No No No No No No

ASA, acetylsalicylic acid; Cr, plasma creatinine concentration (mg/dL); DCB, drug-coated balloon; NC, noncompliant balloon; NOA, new oral anticoagulant; TIMI, Thrombolysis in Myocardial Infarction.

Figure 1. Angiography of the patient treated with optical coherence tomography. Baseline coronary angiography imaging showing a thrombotic occlusion at left circumflex artery level (A) after predilatation with plaque modification balloons (B), and final clinical outcomes after drug-coated balloon implantation (C).

Figure 2. Optical coherence tomography imaging with angiographic co-registration after achieving flow. Yellow arrows are indicative of the process of neoatherosclerosis (restenotic heterogeneous plaque), the red arrow points at a red thrombus, and white stars are indicative of the stent struts.

Scientific evidence on the utility of DCB to treat STEACS due to very late stent thrombosis is scarce, only just a few isolated case reports.4 Since, conceptually, the DCB looks like an excellent therapeutic tool in this clinical setting, we believe trials with big enough samples and clinical and angiographic follow-up should be conducted to confirm or refute such hypothesis. We should mention the need for proper lesion preparation before using DCBs, and how important—actually mandatory—should be to use intracoronary imaging modalities (especially optical coherence tomography for its greater resolution capabilities) to clearly identify the pathogenic mechanisms involved. Therefore, the scarce use of such techniques in our series was our study main limitation.


None whatsoever.


All the authors were involved in the process of patient recruitment and manuscript revision. J. Valencia drafted the manuscript, conducted the clinical follow-up, and prepared the images.


None reported.


1. Adriaenssens T, Joner M, Godschalck TC, et al. Optical Coherence Tomography Findings in Patients With Coronary Stent Thrombosis. A Report of the PRESTIGE Consortium (Prevention of Late Stent Thrombosis by an Interdisciplinary Global European Effort). Circulation. 2017;136:1027-1031.

2. Jeger RV, Eccleshall S, Wan-Ahmad WA, et al. Drug-Coated Balloons for Coronary Artery Disease: Third Report of the International DCB Consensus Group. JACC Cardiovasc Interv. 2020;13:1391-1402.

3. Vos NS, Fagel ND, Amoroso G, et al. Paclitaxel-Coated Balloon Angioplasty Versus Drug-Eluting Stent in Acute Myocardial Infarction: The REVELATION Randomized Trial. JACC Cardiovasc Interv. 2019;12:1691-1699.

4. Alfonso F, Bastante T, Cuesta J, Benedicto A, Rivero F. Drug-Coated Balloon Treatment of Very Late Stent Thrombosis Due to Complicated Neoatherosclerosis. Arq Bras Cardiol. 2016;106:541-543.

* Corresponding author.

E-mail address: (J. Valencia).

To the Editor,

Myocardial infarction is the leading cause of morbidity and mortality in our setting. Percutaneous coronary intervention has improved the prognosis of patients with ST-segment elevation myocardial infarction (STEMI).1 However, there is a subgroup of patients who suffer from suboptimal myocardial reperfusion with appearance of myocardial fibrosis, ventricular dysfunction, and development of heart failure.2

Recently, several pharmaceutical and procedural strategies have been developed to improve these results.3 The PiCSO system (Pressure-controlled intermittent coronary sinus occlusion) developed by Miracor Medical SA, Belgium consists of a balloon catheter to occlude the coronary sinus periodically:

  • 1) During the occlusion stage (5 to 15 s), venous flow is redistributed from well perfused areas towards ischemic regions through the formation of collateral circulation. Also, through an increased venous systolic pressure, the plasma skimming phenomenon allows better perfusion of venules with oxygen-and-metabolite-rich plasma.
  • 2) During the release stage (3 to 4 s) the dramatic drop of venous pressure creates a gradient that ends up clearing all thrombotic debris, toxic metabolites, and myocardial edema.
  • 3) These pressure variations can induce mechanotransduction by activating vascular cells and releasing growth factors, vasodilator substances, and microRNA into microcirculation (figure 1).

Figure 1. Representation of the mechanism of action of the PiCSO system in the occlusion (A) and release stages (B). The PiCSO system includes a balloon catheter (C) connected to a console (D) to automatically occlude the coronary sinus intermittently.

The PiCSO system has proven capable of improving microvascular function and reducing the infarction size in non-randomized clinical trials of patients with high-risk anterior STEMI.4 As a matter of fact, it was granted the CE marking in 2020 with a clinical indication for the management of anterior STEMI with < 12-hour evolution and early TIMI grade 0-1 flow (Thrombolysis in Myocardial Infarction) and culprit lesion in the proximal or middle segments of the left anterior descending coronary artery. We wish to use this scientific letter to share our experience with this novel device in 2 case reports. The patients’ informed consent was obtained, and the study was approved by the ethics committee according to the principles set forth in the Declaration of Helsinki.

The first case is a 83-year-old man without a past medical history of interest with thoracic pain and anterior ST-segment elevation of 3 mm in V1-V4 on the electrocardiogram. The coronary angiography revealed the presence of an acute thrombotic occlusion in the proximal segment of the left anterior descending coronary artery with early TIMI grade-0 flow (figure 2A). Thrombus aspiration and drug-eluting stent implantation led to TIMI grade-3 flow after 115 min of total ischemia (figure 2B). Since this was a large anterior STEMI with early TIMI grade-0 flow, right femoral venous access, cannulation (figure 2C), and PiCSO balloon catheter implantation in the coronary sinus were used (figure 2D) with a 21 min therapy time, and PiCSO doses of 824 mmHg (values > 800 mmHg are advised since they are associated with a reduced infarction size in former studies)4 (figure 2E). The first electrocardiogram revealed a left ventricular ejection fraction (LVEF) of 30% with peak troponin levels of 197 419 ng/L. The patient was discharged without any signs of angina or heart failure and a LVEF of 35% to 40% at 7 days.

Figure 2. Coronary angiography showing an acute thrombotic occlusion in the proximal left anterior descending coronary artery (A). Coronary flow recovery after thrombus aspiration and stenting (B). Afterwards, via right femoral vein (12-Fr), a 8.5-Fr Destino Reach introducer sheath (Oscor, United States) was used for cannulation (C) and the PiCSO balloon catheter was implanted in the coronary sinus (D). The console (E) shows charts with information on coronary sinus pressures and an algorithm to estimate the dose of PiCSO in mmHg—which is a reference of the performance of PiCSO—based on inflation time, the coronary sinus maximum pressure in systole and diastole, and the mean pressure during the release stage.

The second case was a 67-year-old man, active smoker, who had sustained a cardiac arrest due to ventricular fibrillation with recovered circulation 25 min after starting cardiopulmonary resuscitation. The electrocardiogram confirmed the presence of anterior ST-segment elevation of 20 mm in V1-V4, and the coronary angiography the presence of acute thrombotic occlusion in the middle segment of the left anterior descending coronary artery (TIMI grade-0 flow). Thrombus aspiration and drug-eluting stent implantation led to TIMI grade-3 flow (total ischemia time, 120 min). Since this was also a high-risk anterior STEMI, it was decided to implant the PiCSO system in the coronary sinus via right femoral vein with a 20 min therapy time and a PiCSO dose of 830 mmHg. The first electrocardiogram showed a LVEF of 35% and peak troponin levels of 63 141 ng/L. The patient neurological and cardiologic progression was good. The patient’s LVEF was 55% 10 days after the infarction.

The PiCSO system is a safe and easy to implement tool in the management of STEMI. However, PiCSO will have to demonstrate its efficacy in ongoing randomized trials.


None whatsoever.


S. Brugaletta, and P. Vidal-Calés participated in the manuscript idea, design, and data analysis. O Abdul-Jawad Altisent, F. Spione, V. Arévalos, and M.Sabaté reviewed and edited the manuscript.


None reported.


Dr. Pablo Vidal Calés received a research grant at the end of his residency at Hospital Clínic de Barcelona.


1. Ibanez B, James S, Agewall S, et al. 2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J. 2018;39:119-177.

2. Stone GW, Selker HP, Thiele H, et al. Relationship Between Infarct Size and Outcomes Following Primary PCI: Patient-Level Analysis From 10 Randomized Trials. J Am Coll Cardiol. 2016;67:1674-1683.

3. Vidal-Calés P, Cepas-Guillén PL, Brugaletta S, Sabaté M. New Interventional Therapies beyond stenting to Treat ST-Segment Elevation Acute Myocardial Infarction. J Cardiovascular Dev Dis. 2021;8:100.

4. De Maria GL, Alkhalil M, Borlotti A, et al. Index of microcirculatory resistance-guided therapy with pressure-controlled intermittent coronary sinus occlusion improves coronary microvascular function and reduces infarct size in patients with ST-elevation myocardial infarction: the Oxford Acute Myocardial Infarction - Pressure-controlled Intermittent Coronary Sinus Occlusion study (OxAMI-PICSO study). EuroIntervention. 2018;14:e352-e359.

* Corresponding author.

E-mail address: (S. Brugaletta).


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