European Heart Journal: Case Reports最新文献

Background: Transthyretin cardiac amyloidosis is associated with various arrhythmias, including atrioventricular block. Despite this correlation, established treatments for transthyretin cardiac amyloidosis-associated arrhythmias are lacking. Left bundle branch area pacing is a promising physiological pacing technique.

Case summary: This case series describes three instances of successful left bundle branch area pacing in patients with transthyretin cardiac amyloidosis presenting with atrioventricular block. Despite significant ventricular septal hypertrophy across all cases, left bundle branch area pacing was implemented effectively without complications.

Discussion: Traditional pacing strategies in transthyretin cardiac amyloidosis, such as right ventricular pacing, have been associated with a reduced left ventricular ejection fraction and worsening heart failure. Although biventricular pacing has been explored, the supporting evidence remains limited and inconclusive. Recent studies have suggested that left bundle branch area pacing poses a lower risk of inducing heart failure than biventricular pacing. Our findings support the safety and efficacy of the left bundle branch area pacing in patients with transthyretin cardiac amyloidosis-related atrioventricular blocks and underscore its viability as a pacing strategy.

Background: While echocardiography and cardiac positron emission tomography (PET) can aid in the diagnosis of prosthetic valve endocarditis (PVE), post-operative changes can lead to false-positive imaging findings. We report a case of a patient with an aortic valve prosthesis with remnant BioGlue deposits mimicking a para-valvular abscess on imaging in the setting of suspected PVE.

Case summary: A 67-year-old man presented with 2 days of fever, chills, and altered mentation. He had a history of two prior aortic root replacements-19 and 4 years prior to his presentation. He had blood cultures that were persistently positive for Pseudomonas aeruginosa. Initial transoesophageal echocardiogram (TEE) was notable for a thickening of the posterior aortic root thought to be consistent with post-surgical changes. Cardiac PET showed significant uptake around the prosthetic aortic valve, concerning for a para-valvular abscess. However, given the patient's high risk for re-do surgery, clearance of blood cultures, and preserved valve function, our multi-disciplinary endocarditis team (MET) recommended non-surgical management and close follow-up. After 6 weeks of appropriate antibiotics, a TEE demonstrated concern for an evolving para-valvular abscess. The MET performed extensive review of his prior surgical interventions and cardiac imaging, revealing the previous use of surgical BioGlue and stability in the aortic root on imaging, consistent with non-infectious post-surgical changes, and conservative management was recommended.

Discussion: Thorough review of prior interventions and serial imaging in patients with suspected PVE through a multi-disciplinary team approach is essential in elucidating the complete, often complex, clinical picture and recommending the most appropriate management.

Background: Cardiac strangulation (CS) from epicardial pacing leads (EPLs) is a rare and potentially lethal mechanical complication associated with epicardial pacemaker (PM) implantation.

Case summary: We report a case of a 44-year-old-female patient presenting with chest and left shoulder pain in the absence of reported trauma with history of congenital atrioventricular block treated with epicardial PM implantation during the childhood and subsequent transvenous reimplantation over the years. Troponin I resulted within normal values and ECG, transthoracic echocardiography and chest X-ray documented no acute cardiopulmonary findings. After 3 months the patient underwent coronary computed tomography angiography (CCTA) documenting the presence of solid and focally calcified tissue grown along the course of the EPLs, determining multiple focal impressions on the left ventricular epicardial edge and a segmental occlusion of the middle left-circumflex artery (LCX) due to ab-extrinseco compression. After 10 days, the patient was admitted at the emergency department with atypical chest pain and underwent invasive coronary angiography (ICA), which confirmed chronic occlusion of the mid-LCX with complete collateral circulation; a stress echocardiography ruled out myocardial ischaemia and the patient was uneventfully discharged.

Discussion: The diagnosis of CS in patients with epicardial PM leads remains challenging, especially in adults with atypical clinical presentation; thus, any clinical or instrumental clue should prompt further higher-level imaging investigations, such as CCTA or ICA. It is also important to disclose that sometimes CS can be only a collateral finding with no relationship with the patient's symptoms.

Background: The initial outcomes of transcatheter aortic valve replacement in patients with left ventricular outflow tract calcification are poor. Furthermore, balloon-expandable transcatheter aortic valve replacement is associated with an increased risk of annular rupture, and self-expandable transcatheter aortic valve replacement is associated with worse post-operative residual paravalvular leakage grades. Therefore, developing an optimal method for transcatheter aortic valve replacement for patients with left ventricular outflow tract calcification is desirable.

Case summary: We present two cases of successful balloon-expandable transcatheter aortic valve replacement, wherein the transcatheter heart valve was implanted above the left ventricular outflow tract calcification to avoid annular rupture and paravalvular leakage, and one case each of balloon-expandable and self-expandable transcatheter aortic valve replacements, wherein the transcatheter heart valve was implanted at a normal height. Although annular rupture did not occur in any of the cases, more-than-mild paravalvular leakage persisted post-operatively in cases where the transcatheter heart valve was placed at a normal height.

Discussion: Annular rupture is more likely to occur in areas with high calcification at the joint than in noncalcified areas. Furthermore, the greater the calcification in the landing zone of the transcatheter heart valve, the more the paravalvular leakage persists. Therefore, high implantation of transcatheter heart valves above the left ventricular outflow tract calcification can be an effective method to avoid annular rupture and paravalvular leakage.

Background: A partial atrioventricular septal defect (AVSD) with a hypoplastic left ventricle and common atrium is a rare combination of cardiac anomalies that can be associated with Ellis-van Creveld (EVC) syndrome.

Case summary: A female neonate with EVC syndrome was diagnosed with an unbalanced AVSD and hypoplastic left ventricle. Pulmonary artery banding and ductus ligation were performed at 23 days after birth. The postoperative course was complicated by moderate atrioventricular valve (AVV) regurgitation and low cardiac output. On postoperative Day 6, emergent extracorporeal membrane oxygenation (ECMO) was performed to treat acute circulatory failure. Under suspicion of systemic ventricular outflow tract obstruction, the Damus-Kaye-Stansel procedure with a systemic-to-pulmonary artery shunt and AVV plasty were performed. Intraoperatively, no ventricular septal defect was found. The right and left AVV orifices were found to be separated. Postoperatively, the patient could not be weaned from cardiopulmonary bypass and continued to receive ECMO support. Eight days postoperatively, a right ventricle-to-pulmonary artery shunt and division of the systemic-to-pulmonary artery shunt were performed to increase the pulmonary blood flow. On postoperative Day 5, the ECMO was successfully removed under continuous infusion of adrenalin, but the patient died of severe renal failure 4 days later. The parents consented to autopsy. The heart was permanently preserved by perfusion-distention fixation and wax infiltration.

Discussion: We reported a rare combination of cardiac defects of common atrium, partial AVSD, and hypoplastic left ventricle associated with EVC syndrome. Accurately diagnosing the presence of ventricular septal defect is essential part in determining surgical treatment strategy.

Background: While viruses remain the leading cause of infectious myocarditis, improved diagnostic methods have highlighted the role of bacteria as a possible cause. We report two cases of myocarditis as a complication of Campylobacter jejuni infection.

Case summaries: Patient A, a 17-year-old Caucasian male with a history of asthma, presented to the emergency department (ED) after experiencing fever and nausea for four days, followed by 1 day of diarrhoea and chest discomfort. Laboratory evaluation revealed elevated troponin levels. Transthoracic echocardiography showed left ventricular enlargement and apical dyskinesia. C. jejuni was identified in stool cultures. Cardiac magnetic resonance imaging confirmed the diagnosis of myocarditis. The patient was treated with furosemide and enalapril, with improvement of symptoms. Patient B, a previously healthy 14-year-old Caucasian male, presented to the ED with retrosternal chest pain lasting 2 h. He also reported a 3-day history of fever, nausea, and diarrhoea. Electrocardiography showed widespread PR-segment depression and concave ST-segment elevation. Laboratory testing revealed elevated Troponin I levels, and C. jejuni was identified in stool cultures. Cardiac magnetic resonance imaging findings were consistent with acute myocarditis. The patient was treated with ibuprofen and azithromycin, leading to resolution of symptoms. Eight months later, he returned with recurrent chest pain and dry cough. Cardiac magnetic resonance imaging at this time showed T1 and T2 criteria consistent with recurrent myocarditis.

Discussion: Although rare, clinicians should be aware of the potential cardiac involvement in patients with Campylobacter gastroenteritis, paying special attention to myocarditis symptoms like chest pain or shortness of breath, especially in areas with elevated Campylobacter infection rates.

Background: Pulmonary hypertension caused by extrinsic pulmonary vascular compression secondary to mediastinal neuroendocrine tumours is a very rare condition, posing a diagnostic challenge. There is no clear consensus regarding the best treatment strategy due to the lack of clinical data, leading to poor prognoses for these patients.

Case summary: We present the case of a 38-year-old man hospitalized with signs of pulmonary hypertension and acute heart failure. He had experienced progressive dyspnoea over the 12 months prior to admission. Studies performed at our institution revealed dilation of the right heart chambers with right ventricular systolic dysfunction and pulmonary hypertension. Cardiac tomography showed extrinsic vascular compression, leading to emergency endovascular treatment for superior vena cava syndrome, followed by stent implantation in the pulmonary arteries and innominate vein. Further studies identified a mediastinal neuroendocrine tumour, for which chemotherapy was initiated, without clinical response. During outpatient follow-up, cardiac function worsened, and the patient died 48 months after symptoms onset due to a lung infection.

Discussion: Pulmonary hypertension secondary to extrinsic vascular compression by mediastinal tumour is a rare condition that presents a diagnostic challenge. This case highlights the importance of considering oncological aetiology in patients with progressive dyspnoea and pulmonary vascular extrinsic compression. Despite early treatment, the prognosis for these patients remains poor.