Coronary artery disease (CAD) is a leading cause of death worldwide, despite the recent remarkable progress in medical and interventional remedies. Cholesterol is an established causal factor and therapeutic target for CAD; however, the role of triglyceride (TG) in atherogenesis remains unknown. Triglyceride deposit cardiomyovasculopathy (TGCV) is a novel disease concept that was first reported in patients who required cardiac transplantation in 2008. Defective intracellular lipolysis of TG results in cellular steatosis and energy failure mainly in smooth muscle cells and cardiomyocytes. Patients with TGCV exhibit unique TG-deposit atherosclerosis, with diffuse narrowing of concentric stenosis in advanced cases. These pathological characteristics are different from those of classic cholesterol-induced atherosclerosis, which shows focal and eccentric stenosis. The Japan TGCV study group developed the diagnostic criteria for TGCV, in which a low washout rate of ¹²³I-β-methly-p-iodophenyl pentadecanoic acid in myocardial scintigraphy is an essential item. Patients with TGCV often complain of atypical cardiovascular symptoms and are resistant to cholesterol-lowering therapy and percutaneous coronary intervention with second-generation drug-eluting stents. Our recent registry study reported low 5-year overall and cardiovascular event-free survival rates in previously diagnosed patients. However, the administration of tricaprin to facilitate myocardial lipolysis of TG has been reported to regress diffuse atherosclerotic lesions in some cases of TGCV. Notably, a substantial number of patients with TGCV exist (most remain undiagnosed) in the population with acute and chronic CAD. In this review, we briefly present the disease concept, pathophysiology, diagnosis, and clinical characteristics of TGCV.

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Objectives: Coronary artery bypass grafting (CABG) has a favorable prognosis when scheduled; however, the postoperative outcomes in acute coronary syndrome (ACS) are poor. Whether or not patients requiring resuscitation should be transferred to the operating room remains unclear. We investigated the outcomes of patients who underwent emergency CABG, including salvage CABG.
Materials and methods: Of the 276 single CABG procedures performed at our hospital, 67 patients underwent emergency CABG (9 salvage and 58 non-salvage cases) for ACS, and 209 underwent elective CABG. We evaluated the preoperative factors and postoperative course, including all-cause mortality and major adverse cardiac and cerebrovascular events, as endpoints. Furthermore, the time required to establish mechanical circulatory support (MCS) to save salvage cases was investigated.
Results: Chronic kidney disease was significantly more prevalent in the salvage group than in the non-salvage group. In the salvage group, preoperative inotropic agents and use of cardiopulmonary bypass during CABG were more frequent (p < 0.0001 and p = 0.0009, respectively), the intensive-care unit stay longer (p = 0.0010), all-cause mortality higher (p = 0.0031), and major adverse cardiac and cerebrovascular events (MACCE) (p < 0.0001) than the non-salvage group. Furthermore, 2 patients (22%) died within 30 days after CABG, and there was difficulty in establishing MCS before CABG, while 4 patients (44%) died in the late phase. Troponin I level was an independent risk factor for long-term mortality, and hyperlipidemia and salvage CABG were independent risk factors for MACCE.
Conclusions: The prognosis of salvage CABG is very poor; however, 30-day (22%) and long-term (44%) mortalities are acceptable. Salvage CABG is not an independent risk factor for long-term mortality but is an independent risk factor for MACCE in patients after CABG for ACS. The establishment of MCS before circulatory collapse and prompt consultation with cardiac surgeons may improve the outcomes.

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Objective: The prevalence of coronary artery disease (CAD) in patients with transthyretin amyloid cardiomyopathy (ATTR-CM) remains unknown. We aimed to clarify the prevalence of CAD in patients with ATTR-CM and determine their clinical characteristics.
Method: In this single-center retrospective cross-sectional study, we retrieved the electronic medical records of patients diagnosed with ATTR-CM who were admitted between April 1992 and July 2023. Patients with ATTR-CM were identified using the International Classification of Diseases tenth revision (ICD-10) diagnosis and classified into 3 categories: (1) definite, (2) probable, and (3) possible, based on clinical data including endomyocardial biopsy, ^99mTc-PYP scintigraphy, and cardiac magnetic resonance imaging. Cardiac catheterization data and a history of percutaneous coronary intervention (PCI) were reviewed.
Results: Among 80 patients diagnosed with ATTR-CM, 42 underwent a CAD work-up. Of these, 18 (43%) were identified as having CAD. Overall, high-sensitivity troponin I and BNP levels in the chronic phase were 154.5 (80.0–253.1) pg/mL and 446.9 (240.0–719.4) pg/mL, respectively. There were no significant differences in clinical characteristics between the CAD and non-CAD groups. Sixteen patients underwent PCI, and 6 patients were treated for acute coronary syndrome. Comorbidities included atrial fibrillation (n = 12, 67%), a history of hospitalization for heart failure (n = 8, 44%), and bradycardia requiring pacemaker treatment (n = 6, 33%). One patient died in the hospital after PCI.
Conclusions: The presence of CAD may be overlooked in patients with ATTR-CM owing to multiple comorbidities. Clinicians should be aware that CAD may be present in patients with ATTR-CM, similar to the general population.

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Perioperative use of the Impella device has become common in the management of cardiogenic shock. Bleeding and thrombotic complications associated with mechanical circulatory support devices can occur. The incidence and risk factors of thrombotic complications associated with the Impella remain unclear. We herein report a case of extensive intra-aortic thrombosis following Impella CP-assisted surgical ventricular septal perforation repair in an elderly woman. Since there seemed to be no abdominal malperfusion and considering her advanced age and frailty, conservative treatment was selected. Intensive anticoagulation therapy with heparin and warfarin was started. The aortic thrombus regressed, and the patient was discharged without major kidney or gastrointestinal complications. In conclusion, thromboembolic complications should be considered in a perioperative setting.

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We performed an emergency root-commando procedure in a 41-year-old man with a dissecting aneurysm of the sinus of Valsalva and severe acute heart failure due to infective endocarditis, aortic regurgitation, and mitral regurgitation against a background of type 1 diabetes mellitus. The coronary artery was reconstructed using the Carrel patch method. The postoperative infection control was good, and computed tomography on postoperative day 13 showed no abnormalities. However, the patient complained of back pain on postoperative day 30, and computed tomography revealed a pseudoaneurysm of the left coronary artery. We decided to perform a reoperation. After resecting the tongue-shaped Valsalva graft around the left coronary artery button, the defect was patched with the bovine pericardium. The left coronary artery was reconstructed using a modified Cabrol technique. The post-reoperative course was good, and the patient was discharged home on day 17 after the reoperation. We experienced a case of left coronary artery button pseudoaneurysm in the subacute phase after an emergency root-commando procedure. Coronary artery button pseudoaneurysm is an important postoperative complication that requires detailed examination and re-operative planning. We report our experience and review the relevant literature.

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We report a case of catastrophic Ellis type III coronary perforation caused by high-pressure balloon dilation after intravascular lithotripsy (IVL) of a heavily calcified coronary artery. We observed valuable intravascular ultrasound images in this situation, which suggested that high-pressure balloon dilation after IVL might be suboptimal because IVL-induced deeply cracked calcification can exhibit unexpected reactions.

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