European Heart Journal: Case Reports最新文献

Background: Pericardial haemangiomas represent a very rare subset of benign cardiac tumour in an unusual location, posing a diagnostic and clinical challenge. Historically, the definitive diagnosis was achieved through surgical resection or at biopsy. In recent years, multi-parametric cardiac magnetic resonance imaging (MRI) has proven to offer a non-invasive, biopsy-like approach to tumour characterization.

Case summary: In our case, multimodality imaging was used to characterize a pericardial mass as a haemangioma discovered coincidentally with a brain glioma. Diagnostic certainty was substantially improved through utilization of successive post-contrast bright-blood imaging at cardiac MRI, demonstrating a characteristic enhancement pattern of haemangiomas in direct comparison to the blood pool. Conservative management and mid-term follow-up showed an uneventful clinical course and partial regression of the presumed pericardial haemangioma.

Discussion: In the presence of typical features and application of individually tailored protocols, multimodality imaging can characterize cardiac tumours and guide patient management so that more invasive measures may be avoided. In our case of a suspected pericardial haemangioma, a conservative strategy was adopted with clinically uneventful course over a 2-year period. Whether this strategy can be applied to other patients with this rare tumour remains unclear, but the case report provides important information about the natural history of this entity and tissue characterization by cardiac MRI.

Background: Early bioprosthetic valve dysfunction (BVD) due to pannus formation is uncommon in elderly patients, and only a limited number of cases have been reported.

Case summary: An 84-year-old man presented with exertional dyspnoea 3 years after surgical aortic valve replacement (SAVR) with a 19 mm Epic™ valve (Abbott, Santa Clara, CA, USA). Transthoracic echocardiography demonstrated progressive BVD, and cardiac computed tomography (CT) revealed sub-aortic pannus formation. Re-operative SAVR was performed using a 19 mm INSPIRIS RESILIA® valve (Edwards Lifesciences, Irvine, CA, USA), and pathological examination confirmed valve leaflet deformation caused by pannus overgrowth. At the 18-month follow-up, the patient exhibited favourable progress, with no indications of BVD or pannus recurrence.

Discussion: This case highlights the importance of recognizing early pannus formation as a cause of BVD, even in elderly patients. Early detection of BVD based on clinical symptoms and echocardiography is vital to allow timely surgical intervention before the deterioration of cardiac function. Cardiac CT helps to differentiate pannus from thrombus formation and guide treatment decisions.

Background: The concepts of myocardial infarction with non-obstructive coronary arteries (MINOCA) are now widely accepted. Calcium channel blockers (CCBs) are the first-line medication for coronary spastic angina (coronary spastic angina: CSA/vasospastic angina: VSA), while β-blockers sometimes do not improve CSA/VSA. However, β-blockers are essential for managing symptoms of coronary microvascular dysfunction and considered vital for treating heart failure with reduced ejection fraction (HFrEF).

Case summary: We present the case of an 83-year-old female admitted with shortness of breath persisting for over 1 year and worsening ejection fraction (EF) from 65% to 32%. On admission, she experienced chest pain at rest despite finding no significant stenosis on coronary angiography. Several days later, we performed functional coronary angiography (FCA), revealing diffuse epicardial coronary spasm upon injecting acetylcholine. The coronary flow reserve was 4.4 (≧2.0), and the microvascular resistance index was 20 (<25). We diagnosed the patient with a myocardial injury event induced by CSA/VSA and initiated dihydropyridine CCBs. A few months later, her chest pain resolved; the HF symptoms improved (NYHA: from Ⅲ to Ⅱ), accompanied by a reduction in B-type natriuretic peptide levels (from 4561.2 to 75.4 pg/mL) and EF improvement (from 32.0% to 62.6%).

Discussion: We managed a patient with HFrEF and MINOCA. Although CCBs are not routinely recommended for HFrEF, we added dihydropyridine CCBs to treat CSA/VSA based on comprehensive diagnostic procedures. This approach sedated chest pain and may have contributed to her EF improvement. Detailed examinations and tailored treatment strategies might be helpful for HF treatment.

Background: Sarcoidosis is a rare disease, and cardiac involvement is seen in the minority of patients. The clinical symptoms depend on the location of the noncaseating granulomas in the heart and vary from asymptomatic to atrioventricular (AV) conduction block, ventricular arrhythmia, heart failure, and sudden cardiac death. Clinically manifest cardiac sarcoidosis seldomly presents with supraventricular tachycardia.

Case summary: We present a case where a female patient presented with AV nodal re-entrant tachycardia as an uncommon initial presentation of cardiac sarcoidosis. Her resting electrocardiogram showed a complete left bundle branch block and first-degree AV conduction block. During hospitalization, there was continuous switching between sinus rhythm with first-degree AV block, 2:1 AV block, and AV nodal re-entrant tachycardia.

Discussion: It is important to be aware that cardiac sarcoidosis can rarely present with supraventricular tachycardia as initial symptom. Given the elevated risk of sudden cardiac death, early detection is crucial and all patients who require permanent pacing should be considered for implantable cardioverter-defibrillator implantation.

Background: Stent fractures are a rare complication of angioplasties and are an unusual substrate for coronary abscesses.

Case summary: A 63-year-old patient came into the emergency department for ongoing chest pain. The patient had recently undergone coronary stent implantation, 3 months prior. Computed tomography coronary angiography revealed a coronary abscess and stent fracture, with blood effraction into the pericardium. The patient underwent emergency open-heart surgery to clear the infection and perform coronary artery bypass graft surgery. Post-operative outcome was tentatively favourable. The patient suffered acute kidney injury and required haemodialysis.

Discussion: Coronary stent fracture is a rare complication which can be life-threatening and which can lead to severe sequelae.

Background: The reverse-wiring technique (RWT) using a hairpin-bend wire is useful for percutaneous coronary intervention of a bifurcation lesion with an extremely angulated side branch (SB); however, it is not necessarily effective in some anatomical situations. We report a novel SB wiring technique, the U-turn wiring technique (UWT), that is useful for wiring an extremely angled SB proximal to the ectasia.

Case summary: In the first case, the bare wire took a U-turn in the ectasia of the diagonal branch and crossed towards the angled left anterior descending artery, but a coronary dissection occurred in the diagonal branch due to the continuous wire-pushing force. Therefore, in the second case, we used a microcatheter with distal flexibility to prevent guidewire-induced vessel injury at the ectasia site and safely advanced the wire to the distal portion of the extremely angulated SB.

Discussion: The UWT takes advantage of the ectasia as a space to U-turn the guidewire. The UWT does not require a hairpin-bend guidewire or a dual-lumen catheter. The guidewire can be easily pushed forward through a reversed SB. After successful wire insertion, the guidewire can be easily advanced deep into the side branch. The UWT facilitates wire crossing to a reverse-angled branch utilizing the coronary ectasia anatomy through a simple manipulation.

Background: The sudden onset of heart failure in high-risk transcatheter aortic valve implantation (TAVI) candidates poses significant challenges, necessitating meticulous planning and consideration of mechanical circulatory support options. Nevertheless, existing data on the efficacy and safety of mechanical circulatory support in this context are limited, along with criteria for patient selection.

Case summary: An 87-year-old patient, with severe low-flow low-gradient aortic stenosis, presented with acute heart failure and concurrent COVID-19 pneumonia. Despite initial conservative management, her clinical condition deteriorated, requiring inotropic support. The decision was made to perform a rescue TAVI procedure with veno-arterial extracorporeal membrane oxygenation (ECMO) support. The patient underwent successful TAVI while managing complications, including cardiac arrest, with haemodynamic support from veno-arterial ECMO. Post-procedure, the patient showed improved cardiac function and was discharged in stable condition.

Discussion: This case underscores the significance of strategic patient selection, proactive haemodynamic management, and the judicious use of veno-arterial ECMO in high-risk TAVI, particularly in complex scenarios involving acute heart failure and respiratory insufficiency, exacerbated by COVID-19. It highlights the challenges and critical decision points in TAVI planning, emphasizing the need for further research and standardized guidelines to refine indications for prophylactic mechanical circulatory support in TAVI procedures.