[Ventilatory care]

Mechanical ventilation is considered a supportive, nontherapeutic technology used to perform the work of breathing for patients who are unable to do so on their own. In neonatology, mechanical ventilation is often used for premature neonates who are unable to sustain ventilation because of reduced functional residual capacity due to surfactant deficiency. Mechanical ventilation is thus an attempt to mimic the respiratory system's physiological function of gas exchange until the respiratory system reaches maturation. In pediatrics, mechanical ventilation is rarely used for acute respiratory distress syndrome as shown by Dahlem et al. in 2003 who found that only 9.9% of cases of respiratory failure in PICU was caused by ARDS. For this reason, ventilatory techniques in PICU are very heterogenous from the assisted to the most aggressive controlled modes associated with ventilator maneuvers. There are no specific guidelines for the use of mechanical ventilation in children and the low number of infants with ARDS in PICU makes it difficult to run randomized controlled trials in this population. Thus the algorithms are based on the results of either adult or neonatal studies. The advantage of extrapolating data from the neonatal evidence relates mainly to the prevention of ventilator induced lung injury (e.g., CPAP, HFOV, NIV, permissive hypercapnia, surfattant), of which neonatologists are particularly expert.

Computer use, free time activities and metabolic control in patients with type 1 diabetes

We investigated the influence of computer's use on metabolic control in 115 patients with type 1 diabetes (DM1). Multiple linear regression showed that HbA1c% was not related to age, DM1 duration, TV watching or computer use but was independently and negatively related to the weekly hours spent on physical exercise.

Antiplasmodial benzophenone derivatives from the root barks of Symphonia globulifera (Clusiaceae)

In an effort to find antimalarial drugs, a systematic in vitro evaluation on a chloroquine-resistant strain of Plasmodium falciparum (FcB1) was undertaken on sixty plant extracts collected in French Guiana. The ethyl acetate extract obtained from the root barks of Symphonia globulifera exhibited a strong antiplasmodial activity (97% at 10 microg/ml). The phytochemical investigation of this extract led to the isolation of nine polycyclic polyprenylated acylphloroglucinol (PPAPs) compounds and two oxidized derivatives. All compounds showed antiplasmodial activity with IC(50)s ranged from 2.1 to 10.1 microM. A LC/ESI-MS(n) study performed on polyprenylated benzophenones previously isolated from Moronobea coccinea provided a reliable method for their detection in the extract and structural elucidation.

Short and long-term outcomes of percutaneous revascularization in patients with prior coronary artery bypass graft

AIM

Patients with prior coronary artery bypass grafting (CABG) represent a sizable portion of those undergoing percutaneous coronary intervention (PCI): in many instances, it is unclear whether performing PCI on the bypass graft or in the native coronary vessels can offer the best risk-benefit balance.

METHODS

We included patients with prior CABG undergoing PCI at our center between July 2002 and June 2004 and we distinguished them in three groups. Those in whom PCI was performed on stenotic saphenous vein graft (SVG group), those in whom PCI was performed on native vessels despite the presence of potentially treatable SVG disease (optional native group), and those in whom PCI had to be performed mandatorily in the native vessels because of chronic SVG occlusions or disease in non-bypassed segments (mandatory native group). The primary end-point was long-term rate of major adverse clinical events (MACE, i.e. death, myocardial infarction, or target vessel revascularization).

RESULTS

We identified 109 patients: 28 were in the SVG group, 25 in the optional native group, and 56 in the mandatory native group. Early major adverse cardiac events (MACE) occurred with similar frequency in the three groups (respectively, 9.1%, 0% and 5.7%, P=0.35). After more than three years of follow-up, MACE occurred in 39.3% vs. 28 and 39.4% (P=0.59), death occurred in 27.2 vs. 24.0% vs. 13.5% (P=0.30), and TVR in 27.3% vs. 8.0% vs. 28.8% (P=0.14).

CONCLUSION

In selected patients, PCI of native coronary vessels despite the presence of apparently treatable SVG lesions can be envisioned.

Clopidogrel treatment in a patient with ticlopidine-induced hepatitis following percutaneous coronary stenting

Thienopyridines are commonly prescribed antiplatelets drugs, extremely useful for the acute and chronic management of patients with cerebrovascular and cardiovascular diseases. The occurrence of their side effects is fortunately uncommon, although unpredictable. We thereby describe a case of prescription of clopidogrel in a patient with ticlopidine-induced hepatitis confirmed by liver biopsy that had undergone multiple percutaneous coronary stenting procedures necessitating subsequent compulsory antiplatelets treatment. The description of this exceptional clinical case is of relevant knowledge to orientate a physician treating a patient with absolute need of antiplatelets and history of previous drug-induced reactions.

Cytotoxic triterpenoid saponins from the stem bark of Antonia ovata

Phytochemical investigation of the MeOH extract of the stem bark of Antonia ovata led to the isolation of four triterpenoid saponins, along with eleven known compounds. Their structures were established by extensive 1D and 2D NMR, as well as HR-MS analysis and acid hydrolysis. All isolated saponins contained the same tetrasaccharide chain O-beta-d-xylopyranosyl-(1-->2)-O-beta-d-glucopyranosyl-(1-->3)-O-[beta-d-glucopyranosyl-(1-->2)]-beta-d-glucuropyranoside linked to C-3 of esterified derivatives of R(1)-barrigenol, A(1)-barrigenol, barringtogenol C, or camelliagenin. Biological evaluation of the compounds against KB cell line revealed a potent cytotoxic activity with IC(50) values ranging from 3.1 to 6.6microM. The known compounds were found to be inactive at 10microg/ml concentration.

Repeat adverse events long after percutaneous coronary revascularization in diabetics

AIM

Diabetics with coronary artery disease face a high risk of adverse events following coronary revascularization. However, recurrence rates of after the first revascularization have never been appraised. The aim of this study was to evaluate recurrent events in diabetics undergoing percutaneous coronary intervention (PCI) in the current era.

METHODS

Authors collected baseline and outcome data of consecutive type-2 diabetics treated with PCI (July 2002-December 2005) . End-points of interest were the long-term rates of major adverse cardiac events (MACE: cardiac death, myocardial infarction [MI], percutaneous target vessel revascularization [TVR-PCI], or coronary artery bypass grafting [CABG]), non-TVR PCI, and stent thrombosis.

RESULTS

A total of 429 diabetics were included, 191 (44%) insulin-dependent, with drug-eluting stents implanted in 232 (54%). After a median of 38 months, events were as follows: MACE in 167 (38.9%) subjects, cardiac death in 38 (8.8%), MI in 42 (9.8%), TVR-PCI in 130 (30.3%), CABG in 11 (2.6%), non-TVR-PCI in 52 (12.1%), and definite stent thrombosis in 9 (2.1%). Among the 129 patients undergoing TVR-PCI as first event, as many as 28 (21.7%) underwent a second TVR-PCI, 7 (5.4%) underwent a third TVR-PCI, and a further 2 (1.5%) underwent a fourth TVR-PCI, whereas CABG was performed in 2 (1.5%) and non-TVR-PCI in 4 (3.1%).

CONCLUSIONS

This work, originally reporting on the risk of recurrent repeat revascularization events among diabetics treated with PCI, showed that adverse events occur frequently in these patients, but can be managed in most cases safely and successfully by means of repeat PCI only.

Non-acid gastro-oesophageal reflux in children with suspected pulmonary aspiration

BACKGROUND & AIMS

In a group of children with suspected pulmonary aspiration, we aimed to describe the type and physical characteristics of gastro-oesophageal reflux (GOR) episodes, and to determine their correlation with the lipid-laden macrophage (LLM) content in bronchoalveolar lavage (BAL).

PATIENTS AND METHODS

Twenty-one children with a diagnosis of bronchial asthma, recurrent lung consolidations and recurrent laryngotracheitis underwent 24-h multichannel intraluminal impedance and pH (MII-pH) monitoring, fibreoptic bronchoscopy and BAL. The following parameters were evaluated: total number of reflux episodes, number of acid reflux [AR; pH<4] and non-acid reflux [NAR] episodes [pH>4], height of reflux episodes, LLM content and percentage of neutrophils in the BAL.

RESULTS

The number of NAR episodes and the number of those reaching the proximal oesophagus were significantly higher in patients with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01 and p<0.01). BAL studies showed a significantly higher LLM content in children with recurrent lung consolidations than in those with bronchial asthma and laryngotracheitis (p<0.01). The LLM content correlated significantly with the total number of reflux episodes (r=0.73; p<0.001) and with those reaching the proximal oesophagus (r=0.67; p<0.001). Finally, the LLM content correlated with the number of NAR episodes (r=0.61; p<0.01), with those reaching the proximal oesophagus (r=0.64; p<0.01) and with the percentage of BAL neutrophils (r=0.7; p<0.01).

CONCLUSION

NAR episodes reaching the proximal oesophagus correlate with diagnostic marker for pulmonary micro-aspiration. MII-pH monitoring increases the yield in identifying types and proximal extension of reflux episodes, that discriminate between patients with and without pulmonary aspiration.

Respiratory syncytial virus, human bocavirus and rhinovirus bronchiolitis in infants

OBJECTIVE

To investigate the prevalence of 14 viruses in infants with bronchiolitis and to study demographic and clinical differences in those with respiratory syncytial virus (RSV), human bocavirus (hBoV) and rhinovirus (RV) infection.

METHODS

182 infants aged <12 months hospitalised for bronchiolitis were enrolled. Infants underwent nasal washing for the detection of RSV, influenza virus A and B, human coronavirus OC43, 229E, NL-63, HUK1, adenovirus, RV, parainfluenza 1-3, human metapneumovirus and hBoV. Demographic, clinical and laboratory data were obtained from parents and from patient medical files. Main outcome measurements were age, breastfeeding history, family smoking habits, family history for asthma and atopy, blood eosinophil count, chest radiological findings, clinical severity score and number of days of hospitalisation.

RESULTS

A virus was detected in 57.2% of the 182 infants. The most frequently detected viruses were RSV (41.2%), hBoV (12.2%) and RV (8.8%). Infants with dual infections (RSV and hBoV) had a higher clinical severity score and more days of hospitalisation than infants with RSV, RV and hBoV bronchiolitis (mean+/-SD: 4.7+2.4 vs 4.3+/-2.4 vs 3.0+/-2.0 vs 2.9+/-1.7, p<0.05; and 6.0+/-3.2 vs 5.3+/-2.4 vs 4.0+/-1.6 vs 3.9+/-1.1 days; p<0.05). Infants with RV infection had higher blood eosinophil counts than infants with bronchiolitis from RSV and hBoV (307+/-436 vs 138+/-168 vs 89+/-19 n/mm(3); p<0.05).

CONCLUSIONS

Although the major pathogen responsible for bronchiolitis remains RSV, the infection can also be caused by RV and hBoV. Demographic characteristics and clinical severity of the disease may depend on the number of viruses or on the specific virus detected.

First Report of Leaf Spot Caused by Pseudomonas cichorii on Coreopsis lanceolata in Italy

Coreopsis lanceolata L. (Compositae), an ornamental species grown in parks and gardens, is very much appreciated for its long-lasting flowering period. In August of 2008, pot-grown plants with necrotic leaf lesions were observed in a commercial nursery located near Biella (northern Italy). Lesions were present, especially along the margin of basal leaves, and sometimes had a chlorotic halo. On infected leaves, dark brown necrosis developed. Leaf stalks were sometimes affected. In many cases, the leaves, especially those at collar level, were withered. Of 1,500 plants, 15% were infected by the disease. Microscopic examination did not reveal any fungal structures within the lesions. Small fragments of tissue from 30 affected leaves were macerated for 15 min in casein hydrolysate and 0.1-ml aliquots of the resulting suspension were spread onto Luria Bertani agar (LB) and potato dextrose agar (PDA). Plates were maintained at 22 ± 1°C for 48 h. No fungi were isolated from the leaf spots on LB or PDA. Colonies similar to those of Pseudomonas spp. were consistently isolated on LB. Colonies were fluorescent on King's medium B, levan negative, oxidase positive, potato soft rot negative, arginine dihydrolase negative, and tobacco hypersensitivity positive (LOPAT test). The bacterial colonies were identified as Pseudomonas cichorii (2). The internal transcribed spacer (ITS) region of rDNA was amplified using primers 27F and 1492R and sequenced (GenBank Accession No. FJ534557). BLAST analysis (1) of the 998-bp segment showed a 98% homology with the sequence of P. cichorii. The pathogenicity of one isolate was tested twice by growing the bacterium in nutrient broth shake cultures for 48 h at 20 ± 1°C. The suspension was centrifuged, the cell pellet resuspended in sterile water to a concentration of 10⁷ CFU/ml, and 30 4-month-old healthy coreopsis plants were sprayed with the inoculum. The same number of plants was sprayed with sterile nutrient broth as a control. After inoculation, plants were covered with plastic bags for 48 h and placed in a growth chamber at 20 ± 1°C. Five days after inoculation, lesions similar to those seen in the field were observed on all plants inoculated with the bacterium, but not on the controls. Ten days later, 40% of the leaves were withered. Isolations were made from the lesion margins on LB and the resulting bacterial colonies were again identified as P. cichorii. The pathogen caused the same symptoms also on plants of Dendranthema frutescens (cv. Camilla), Chrysanthemum morifolium (cvs. Eleonora and Captiva), and an Osteospermum sp. (cv. Wild side) when artificially inoculated with the pathogen with the same methodology. The same bacterial leaf spot caused by P. cichorii was observed in 2005 in other nurseries in the same area on Phlox paniculata (3). To our knowledge, this is the first report of bacterial leaf spot caused by P. cichorii on C. lanceolata in Italy. References: (1) S. F. Altschul et al. Nucleic Acids Res. 25:3389, 1997. (2) H. Bergey et al. Bergey's Manual on Determinative Bacteriology. Williams and Wilkins, Baltimore, MD, 1994. (3) A. Garibaldi et al. Plant Dis. 89:912, 2005.

PCR-based assay for the detection of Xanthomonas euvesicatoria causing pepper and tomato bacterial spot

AIMS

To develop a PCR-based assay for Xanthomonas euvesicatoria detection in culture and in planta.

METHODS AND RESULTS

A fragment of 1600 bp specific for X. euvesicatoria was found by repetitive extragenic palindromic sequence-PCR. Among the primers designed on the basis of the partially sequenced fragment, the primers Xeu2.4 and Xeu2.5 direct amplification of the expected product (208 bp) for all the X. euvesicatoria strains and not for other related and unrelated phytopathogenic bacteria or saprophytic bacteria isolated from pepper and tomato phyllosphere. The assay permits the detection of X. euvesicatoria in pure culture, with a limit of detection of two bacterial cells and 1 pg of DNA per PCR, and in extracts obtained from asymptomatic inoculated tomato and pepper plants.

CONCLUSIONS

Primers Xeu2.4 and Xeu2.5 provide a specific, sensitive and rapid assay for the detection of X. euvesicatoria in culture and in pepper and tomato plants.

SIGNIFICANCE AND IMPACT OF THE STUDY

Because X. euvesicatoria is a quarantine organism in the European Union, and it is subjected to stringent international phytosanitary measures, this highly sensitivity PCR-based assay is suitable for its detection in pepper and tomato plant materials to avoid the introduction and spread of the bacterium.

First Report of Verticillium dahliae on Squash (Cucurbita pepo) in Italy

During field surveys in February and March of 2007 and 2008, unusual symptoms of wilting were observed on squash plants (Cucurbita pepo L.) cultivated near Fondi (Latium-Central Italy) in two commercial plastichouses. Because of the high incidence of the disease (between 20 and 30%), we performed specific diagnostic assays. Symptoms included yellowing, stunting, vascular discoloration, and premature death of leaves. A fungus was consistently isolated on potato dextrose agar (PDA) from discolored vascular tissues in the stems. On the basis of fungal morphology (one-celled conidia, 1 to 2 μm in diameter, and produced on verticillate conidiophores), the fungus was identified as Verticillium dahliae Kleb. (1). To verify the pathogenicity of three fungal isolates, 2-week-old seedlings (15 plants per isolate) were inoculated by dipping the roots in a suspension of 10⁵ conidia per ml for 30 s. Inocula were obtained from 2-week-old fungal cultures grown on PDA at 20 ± 2°C. Roots of 15 control plants were dipped in water. The seedlings were transplanted into pots containing peat and river sand (1:1, v/v) and placed in a greenhouse at 20 to 25°C. One month after inoculation, all fungal isolates caused wilting, while no symptoms were observed on control plants. The morphological features of the reisolated fungus, obtained only from the inoculated plants, were identical to the original isolates. V. dahliae has been recorded in Italy on a number of other plants (1,2). To our knowledge, this is the first report of V. dahliae on squash in Italy. Recently, V. dahliae was recorded for the first time on C. pepo L. in Trinidad (3). References: (1) M. Cirulli. L'Italia Agricola 112:120, 1975. (2) A. Matta et al. Inf. Fitopatol. 30:5, 1980. (3) S. N. Rampersad. Plant Dis. 92:1136, 2008.

Analysis of recurrent revascularization events following percutaneous coronary intervention of diabetic patients

AIM

Greater incidence of recurrent events following percutaneous coronary intervention (PCI) has been described among patients with diabetes mellitus (DM). A clear actual picture of these events can hitherto be considered as lacking. Aim of this study was to describe frequency and peculiarity of recurrent cardiovascular events following PCI in a group of high risk DM patients and to compare the impact of repeat PCI and/or surgical revascularizations on the need of further coronary interventions in a long-term follow-up.

METHODS

254 consecutive DM patients undergoing PCI for known coronary artery disease (CAD) were followed by outpatient visits for 39+/-9 months. The registered endpoints were target vessel PCI (TVR PCI), target vessel surgical revascularizations (TVR CABG), non target vessel percutaneous revascularization interventions (NON TVR PCI), and no repeat revascularizations.

RESULTS

74 (35%) of the DM patients undergoing an index PCI required further revascularization and 10 (17%) patients needed more than one repeat TVR procedure. Second TVR revascularisation procedures occurred similarly following first PCI (15%) or surgical revascularisation (17%) driven by coronary lesions located in epicardial vessels treated during the index PCI. Patients undergoing TVR surgical revascularisation disclosed a higher probability of incurring in a second PCI driven by coronary lesions located in epicardial vessels not previously treated (P=0.003) compared to those approached by PCI.

CONCLUSIONS

The present study reports on a seemingly superior coronary protection of PCI compared to surgical revascularization in preventing disease progression upon the native coronary arteries. These results need confirmation in larger population samples.

Percutaneous aortic valve replacement in two cases at high surgical risk: procedural details and implications for patient selection

The morbidity and mortality burden of heart valve disease is increasing in the developing world, especially among the elderly. Whereas surgery remains the standard of care in fit patients with degenerative aortic stenosis, percutaneous aortic valve replacement could become an effective alternative to surgery in selected higher risk patients. The authors report on two women with aortic stenosis, both at high surgical risk (an 81-year-old female with coronary artery and cerebro-vascular disease, and a 70-year-old female with end-stage cirrhosis), in whom percutaneous valve replacement was effectively performed by means of transfemoral access and retrograde CoreValve Re-valving System implantation. Two major post-procedural complications occurred, both effectively managed, in the second patient: a third degree atrio-ventricular block (requiring permanent pace-maker implantation) and bleeding from the right femoral artery access (requiring implantation of two covered stents and blood transfusion). Despite the increased baseline risk, both patients were discharged asymptomatic, the first twelve days and the other three weeks after admission. In the authors' experience percutaneous aortic valve replacement can be performed with reasonable safety in patient with severe aortic stenosis at high surgical risk.

Antiplasmodial benzophenones from the trunk latex of Moronobea coccinea (Clusiaceae)

In an effort to find antimalarial drugs, a systematic in vitro evaluation on a chloroquine-resistant strain of Plasmodium falciparum (FcB1) was undertaken on sixty plant extracts collected in French Guiana. The methanol extract obtained from the latex of Moronobea coccinea exhibited a strong antiplasmodial activity (95% at 10microg/ml). The phytochemical investigation of this extract led to the isolation of eleven polycyclic polyprenylated acylphloroglucinols (PPAPs), from which eight showed potent antiplasmodial activity with IC50 ranged from 3.3microM to 37.2microM.

Safety of coronary collateral stenting in a patient with acute coronary syndrome

A protective role of the presence of collateral arteries, generating smaller infarcts, improved ventricular function, fewer future cardiovascular events, and improved survival following a myocardial ischemia has been described in numerous reports. However little is known about atherosclerotic disease of the collateral vessels, and the possibility to treat critical stenosis of these vessels has never been described. Therefore this report describes a unique case of percutaneous coronary intervention on a well developed yet atherosclerotic coronary collateral vessel triggering an acute coronary syndrome with hemodynamic instability. In the present case balloon angioplasty and stenting of the collateral vessel was safe and effective. Nonetheless, further studies are warranted.

Temporal trends in baseline characteristics and peri-procedural complications of percutaneous drug-eluting stent implantation for unprotected left main disease: a single high-volume center experience

AIM

Percutaneous drug-eluting stent (DES) implantation is commonly used in patients with unprotected left main (ULM) disease. As this procedure has been performed routinely in Turin Center since 2002, this article aimed to summarize a five year-experience in DES implantation in the ULM.

METHODS

Baseline, procedural and in-hospital outcome data of all patients with ULM undergoing percutaneous coronary intervention (PCI) with DES between July 2002 and October 2006 at Turin Center have been collected. Patients were randomized into four groups: A (patients treated between July 2002 and December 2003), B (treated in 2004), C (treated in 2005) and D (treated in 2006). The baseline surgical risk features was to be compared with the European System for Cardiac Operative Risk Evaluation, disease location in the ULM, and in-hospital major adverse cerebro-cardiovascular events (MACCE), defined as death, myocardial infarction, repeat percutaneous revascularization, coronary artery bypass grafting, stroke, or stent thrombosis.

RESULTS

Out of a total of 4 432 coronary interventional procedures 198 patients treated with DES in the ULM were identified. There was a significant increase in the number of patients treated (P=0.00095), but no difference in EuroSCORE across groups (P=0.14). Conversely, there was a significant temporal trend in the incidence of bifurcational ULM being treated with DES (P=0.03). Intriguingly, despite this increase in adverse lesion characteristics, no significant increase was found in the rate of in-hospital MACCE (P=0.93).

CONCLUSION

In this single-center study, the number of patients being treated with DES for ULM disease has risen across the years, although keeping a similar surgical risk profile. Distal ULM involvement is no longer considered an absolute contraindication to PCI, as testified by the increasing frequency of such lesion among patients undergoing DES implantation at this Institution, with remarkably low rates of adverse events.

Iatrogenic coronary-to-right ventricle fistula: benign outcome irrespective of patency?

Coronary perforation is an uncommon, but potentially lethal complication of percutaneous coronary interventions. Most perforations have proved to lead to intramyocardial or intrapericardial extravasation. However, perforation may also lead to direct coronary-to-right ventricle fistula, more commonly occurring in complex lesions and/or the use of atheroablative devices. To prevent this complication careful manipulation of the guidewire across the obstruction is mandatory, together with avoidance of oversized balloons and high-pressure inflations. The factors that determine the hemodynamic significance of the fistulas include size of the communication, resistance of the recipient chamber, and potential for development of myocardial ischemia. Accordingly a broad range of signs and symptoms may be referred. Despite iatrogenic fistulas are usually benign and asymptomatic, spontaneous closures are very rare. In most cases fistulas need to be treated by percutaneous or surgical closure, being the conservative management a debated option. In isolated cases serious complications have been described resulting from volume overload and distal myocardial flow impairment. We hereby describe two cases of coronary-to-right ventricle fistula occurred during percutaneous coronary intervention, highlighting full angiographic iconography and the issues involved in the management and follow-up of this iatrogenic complication.

Phenolic glycosides from the stem bark of Caryocar villosum and C. glabrum

Mushroom tyrosinase inhibitory activity of methanol extracts and polar fractions of the stem bark of Caryocar villosum and C. glabrum has been assessed. Seven new phenolic glycosides (1-7) were isolated from the most active fractions, along with 15 known compounds (8-22). The structures of these compounds were established on the basis of spectroscopic methods including 1D and 2D NMR analysis, HRESIMS, and comparison with literature experimental data for known compounds.

Percutaneous unprotected left main angioplasty with drug-eluting stents in a nonagenarian: feasible and safe despite recurrent restenosis

The management of severe coronary artery disease in the very elderly is challenging and the most appropriate revascularization strategy highly debated. To date, coronary artery bypass surgery has been the treatment of choice for significant stenosis of unprotected left main (ULM) coronary. Whether this holds true also in very old patients is unknown. The Authors hereby report the case of a 91-year-old diabetic man who underwent coronary angiography in June 2005 for subacute unstable angina. Angiography disclosed a critical stenoses in the distal unprotected left main, left anterior descending, and distal left circumflex, which were treated with a paclitaxel-eluting stent and a bare-metal stent (BMS), respectively. Four months later, recurrent angina lead to a second angiography which showed critical restenosis in the left anterior descending and significant ostial stenosis in the left circumflex. Another paclitaxel-eluting stent was implanted in the left anterior descending, followed by kissing balloon in the left main, achieving a good angiographic result. Six months later angina recurred again: at angiography diffuse restenosis in the left main, left anterior descending and left circumflex was documented. A crushing technique was thus employed to deliver 2 sirolimus-eluting stents, achieving a satisfactory final result. Since then, and to date for more than 17 months since the last procedure, this nonagenarian has remained free from anginal chest. This case highlights the potentials and drawbacks of percutaneous coronary intervention for unprotected left main disease, suggesting nonetheless, that this revascularization strategy can be safely repeated even in elderly patients.