European Heart Journal: Case Reports最新文献

Background: Takotsubo syndrome (TS), traditionally associated with emotional or physical stressors, manifests as transient left ventricular (LV) abnormalities mimicking acute coronary syndrome. Surgical procedures, such as pacemaker implantation, have emerged as potential TS triggers. Conduction system pacing (CSP), including His bundle pacing and left bundle branch area pacing (LBBAP), is a novel technique utilizing the heart's intrinsic conduction system. Despite documented cases of TS post-pacemaker implantation, the literature exploring the association between CSP and TS remains sparse.

Case summary: In a case involving a 62-year-old woman with 2:1 atrioventricular block, an uncomplicated de novo LBBAP procedure was followed by post-procedural dizziness and dyspnoea. An initial transthoracic echocardiography revealed moderate-severe LV dysfunction, accompanied by elevated troponin levels. Coronary angiography showed unobstructed coronary arteries, while left ventriculography exhibited a classic apical ballooning. The patient had a favourable recovery, with LV function improvement noted before discharge.

Discussion: Takotsubo syndrome may be triggered by other non-traditional physical stressors including traditional RV pacing and LBBAP. Clinicians should be aware of this potential, albeit rare, complication of LBBAP to ensure timely recognition and management. Increased awareness is vital for optimizing patient care during CSP procedures.

Background: Spontaneous coronary artery dissection (SCAD) remains a rare form of acute coronary syndrome (ACS) in young women. It is not always easy to diagnose and its management can be complex, particularly in the case of severe forms.

Case summary: A 29-year-old Mahorese woman presented with non-ST-elevation acute coronary syndrome 72 h after vaginal delivery of an uncomplicated twin pregnancy. Coronary angiography revealed a SCAD of the left anterior descending artery (LAD) treated medically. At Day 4, urgent coronary angiography was performed due to recurrent ACS with unfavourable evolution on LAD SCAD with worsening flow and appearance of right coronary artery (RCA) dissection. Percutaneous coronary intervention (PCI) was performed with drug-eluting stent (DES) implantation in LAD under optical coherence tomography (OCT) guidance. At Day 6, the patient suffered from inferior ST segment elevation myocardial infarction due to extension of the RCA SCAD with occlusion of the posterior descending artery. Once again, under OCT guidance, PCI was performed in RCA with implantation of four DES. At Day 8, the patient presented with an intra-hospital cardiac arrest by electromechanical dissociation. Urgent coronary angiography revealed a diffuse extension of the SCAD to the circumflex artery and the left main trunk (LM). Rescue PCI of the LM was performed under OCT guidance, and a femoro-femoral extracorporeal life support was implanted because of haemodynamic instability. With no hope of left ventricular ejection fraction recovery, the patient eventually benefited from a heart transplant 12 days after the first ACS with excellent evolution.

Discussion: Although the majority of SCAD have a favourable outcome with spontaneous healing, it is important to keep in mind that certain severe forms exist and could require specific management as PCI under OCT guidance and potential transfer to surgical centres where heart transplants and mechanical circulatory support are available.

Background: Intramyocardial dissecting haematoma (IDH) is a rare life-threatening event usually complicating an acute myocardial infarction. Poor data exist about diagnosis, management, and outcome.

Case summary: We reported a case of giant IDH managed conservatively, thanks to stable clinical status and haemodynamics, which evolved towards resorption. Echocardiography and second-level imaging tools, like computed tomography scan and cardiac magnetic resonance, helped in differential diagnosis and studying the haematoma evolution over time, especially providing data about dimension, connection with the left ventricular cavity, consolidation, and resorption. The course is influenced by many factors including localization, edge integrity, and antithrombotic therapy on board. In this case, IDH resorption was observed despite the huge size and anticoagulant therapy on board, used for secondary cardioembolic protection, under close imaging follow-up.

Discussion: Intramyocardial dissecting haematoma management depends on clinical stability, and imaging provides key data about diagnosis and evolution.

Background: It is reasonable to introduce a microaxial flow pump (Impella) before coronary angiography and left ventriculography (LVG) to prioritize treating tissue hypoperfusion in patients with takotsubo syndrome (TTS) and refractory cardiogenic shock. However, left ventricular (LV) unloading by an Impella device might prevent contrast media from filling the left ventricle, making it difficult to evaluate LV wall motion abnormalities during LVG.

Case summary: A 76-year-old female with ST elevations in I, II, aVL, and V1-6 on electrocardiography and severe LV dysfunction on echocardiography immediately received circulatory support with Impella CP to treat refractory cardiogenic shock. Subsequent coronary angiography showed no significant stenosis. Biplane LVG was performed using an additional pigtail catheter inserted into the left ventricle while the pump catheter remained there in temporary surgical mode, which was able to protect the motor because the purge system remained active while the pump was stopped. Left ventriculography in temporary surgical mode revealed apical ballooning with a mismatch between epicardial coronary artery perfusion and LV contraction without compromised haemodynamics. The patient was diagnosed with TTS.

Discussion: Coronary angiography and LVG are considered essential diagnostic tools to confirm TTS and exclude acute myocardial infarction. Left ventriculography with Impella temporarily set to surgical mode was able to clearly evaluate LV wall motion abnormalities without affecting haemodynamics. This case highlights that it is perfectly acceptable to prioritize Impella insertion over coronary angiography and LVG in patients with refractory cardiogenic shock in whom the differentiation between TTS and acute myocardial infarction has not yet been made.

Background: Orthostatic hypotension (OH) is a common cardiovascular disorder typically associated with autonomic dysfunction. However, various other mechanisms can contribute to its occurrence.

Case summary: An 88-year-old woman was referred to the cardiology unit due to recurrent syncope episodes while standing. Echocardiography revealed a normally contracting left ventricle with severe hypertrophy, a restrictive filling pattern, reduced stroke volume, and a decreased inferior vena cava diameter (4 mm/m²). In the standing position, she experienced syncope, and invasive blood pressure monitoring confirmed OH, alongside a normal increase in heart rate and evidence of mid-left ventricular obstruction (MVO) on echocardiogram. Discontinuation of diuretics and administration of fluids and beta-blockers effectively resolved the OH.

Discussion: This case underscores the importance of considering mechanisms beyond autonomic dysfunction and volume depletion in the aetiology of OH in elderly patients. Notably, this is the first documented case of OH associated with MVO occurring in an upright posture, resulting in a significant decrease in cardiac output and subsequent syncope. Preventing volume depletion and using non-vasodilating beta-blockers may represent optimal therapeutic strategies in such cases.

Background: Sarcoidosis is a disease characterized by non-caseating granulomas and may affect any organ system. Cardiac involvement may lead to conduction abnormalities, heart failure, or malignant ventricular arrhythmias. As sarcoidosis may present with heterogeneous manifestations, a detailed past medical history may provide clues that help guide further workup. We present a rare case of a patient with undiagnosed oral sarcoidosis who subsequently experienced cardiac arrest from cardiac involvement.

Case summary: A 43-year-old male with a history of palpitations and periodontitis consistent with oral sarcoidosis presents after experiencing sudden cardiac arrest. He was subsequently diagnosed with cardiac and pulmonary sarcoidosis. With contemporary management (both immunosuppression and antiarrhythmics), he has not experienced any recurrent arrhythmias.

Discussion: In the setting of cardiac arrest and non-ischaemic cardiomyopathy, a careful clinical history and targeted cardiac testing may help clinicians determine when to consider cardiac sarcoidosis as a diagnosis. While oral sarcoidosis is a very rare condition, this case highlights how infrequent manifestations of sarcoidosis may be encountered in the clinical setting.

Background: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare vasculitis associated with significant cardiac morbidity and mortality. This case report presents the diagnostic and management challenges of EGPA-related arrhythmias in a remote general hospital setting.

Case summary: A 64-year-old Caucasian male presented with an indolent prodrome of fatigue, shortness of breath and anorexia, that culminated in an acute presentation with pulmonary embolism. His complicated clinical course included intracranial haemorrhage and refractory ventricular arrhythmias. Eosinophilia and sub-endocardial hypoattenuation observed on chest computed tomography were key findings that led to the diagnosis of EGPA. Multiple anti-arrhythmic therapies were required as temporary measures whilst control of the underlying eosinophilic inflammation was achieved.Once stable, the patient was transferred to a tertiary cardiac centre for further investigation and cardioverter-defibrillator implantation. With EGPA now well controlled, he has experienced no further ventricular arrhythmias and has fully recovered.

Conclusion: Cardiac complications of EGPA, including ventricular arrhythmias, are difficult to manage without concurrent immunosuppression, which may itself further destabilize cardiac electrophysiology. The role of multiple imaging modalities in the diagnosis and monitoring of EGPA is emphasized, with cardiac magnetic resonance imaging playing a crucial role in detecting sub-endocardial fibrosis.

Background: Techniques for treating difficult chronic total occlusions (CTOs) have evolved with the discovery of the tip detection-antegrade dissection re-entry (TDADR) guided by intravascular ultrasound (IVUS). This case demonstrates TDADR as a viable bailout in failed subintimal tracking and re-entry (STAR) technique.

Case summary: A 78-year-old man with stable angina on optimal medical therapy had exertional angina pectoris secondary to a residual CTO lesion of the left circumflex coronary (LCX) artery. Percutaneous coronary intervention was performed for a mid-LCX CTO with a blunt proximal stump where the dissection plane expanded along the main vessel and side branch 2. Due to lack of promising collaterals for the retrograde approach, STAR successfully recanalized side branch 1. As main vessel failed to be recanalized, we proceeded with an AnteOwl IVUS-guided TDADR, intending guidewire penetration into the true lumen from the middle of the dissection plane at the main vessel, proximal to side branch 2 origin. Accurate wiring was achieved, and a guidewire was placed on side branch 2 for protection. After stent placement in the main vessel and kissing inflation, cutting balloon dilatation was performed to create re-entries for the STAR-induced extended main vessel haematoma. The procedure resulted in complete revascularization of main vessel and side branches. At 12-month follow-up, no further angina was reported, and coronary computed tomography showed patent side branches with no significant in-stent restenosis.

Discussion: Imaging-based TDADR method was effective in our present case despite failed STAR technique. Limited IVUS and operator availability may become a barrier in implementing TDADR.

Background: Totally implantable venous access devices or chemoports are progressively being used in oncologic patients for long-term chemotherapy administration. We present the case of an iatrogenic arterial catheter placement in the aortic arch complicated with multi-focal ischaemic stroke.

Case summary: A case of a 73-year-old woman with a history of hypertension, diabetes mellitus, pineal gland tumour status post ventriculoperitoneal shunt, and breast and bladder cancer presented with a 2-week history of impaired balance, dysarthria, and right-sided facial drop. The chemoport was placed less than a month prior to the onset of symptoms at another institution. A brain magnetic resonance imaging revealed a left hemispheric supra- and infra-tentorial subacute ischaemic infarcts. The head and neck computed tomography angiography notably showed a misplaced venous port at the left subclavian artery with a distal tip projecting towards the ascending aortic arch, revealing the most likely aetiology of multi-focal ischaemic stroke. The patient underwent successful subclavian artery catheter extraction and endovascular repair with a suture-mediated closure device system without complications.

Discussion: Subclavian artery iatrogenic cannulation may lead to catastrophic outcomes, including stroke. A high level of suspicion for venous port misplacement must be entertained when ipsilateral multi-focal ischaemic infarct occurs in time relation to catheter placement. Conducting an endovascular catheter retrieval and using a suture-mediated closure device is an alternative approach to manual compression in locations where achieving an haemostasis is challenging. A suture-mediated closure device system might be useful for anatomy not amenable to manual compression, such as the subclavian artery.

Background: The Pill-in-the-Pocket (PiP) approach may be used in highly selected patients to achieve acute pharmacological cardioversion into sinus rhythm. Flecainide toxicity is rarely reported, especially with patients who take flecainide as PiP, and only limited evidence exists in its management. We present a case of accidental flecainide overdose for a patient who is on PiP and the acute management strategy.

Case summary: A 78-year-old female with persistent atrial fibrillation (AF), previously underwent pulmonary vein isolation and maintained on verapamil 240 mg twice daily, presented to the electrophysiology clinic following a recent hospital admission for recurrent AF. Due to infrequent recurrent episodes of symptomatic AF, the patient preferred to avoid both repeat ablation and additional daily medications. After an initial trial on telemetric monitoring, a PiP approach with flecainide 300 mg was adopted. Unfortunately, palpitations and dyspnoea in the context of chronic obstructive pulmonary disease exacerbation led the patient to self-medicate with multiple doses of albuterol and flecainide. Twelve-lead electrocardiogram showed slow AF with a wide QRS complex. The patient received 1 g of calcium gluconate with a 180 mEq bolus of sodium bicarbonate 8.4% and was started on continuous sodium bicarbonate infusion at 150 mL/h. Over a 12 h period, the QRS complex narrowed down, and the rhythm returned to normal sinus rhythm with a QRS interval of 136 ms.

Discussion: The PiP strategy with flecainide is safe and effective. Reinforcement of medication dosing and frequency with patient read back is key to avoid accidental toxicity, which could be life-threatening. Treatment with sodium bicarbonate is quick and highly effective.