European Heart Journal: Case Reports最新文献

Background: Mitral annular calcification (MAC) is characterized by severe calcification of mitral annulus and might be associated with both mitral regurgitation and stenosis. It is technically challenging for both surgical and percutaneous approach and is burdened by high mortality.

Case summary: The present case report describes a complex case of mitral steno-insufficiency (baseline transvalvular gradient = 5 mmHg, effective regurgitant orifice area 0.45 cm², vena contracta 0.8 cm), due to MAC in an 83-year-old lady. In consideration of the clinical context (MAC) and patient's several comorbidities and history of previous surgical interventions, she was deemed not suitable for surgery and a percutaneous treatment was selected (valve-in-MAC). Due to significant paravalvular leak, further implantation of a plug was required.

Conclusion: The MAC represents a clinical and technical challenge for surgery. Transcatheter mitral valve implantation in MAC is a feasible alternative although it is technically challenging and burdened by high mortality. Detailed procedural planning is of utmost importance to achieve successful outcomes.

Background: Radiofrequency ablation (RFA) procedures including cavo-tricuspid isthmus (CTI) ablation have proven to be safe and effective therapies for the treatment of many cardiac tachyarrhythmias. The incidence of coronary arterial injury (CAI) associated with RFA including CTI ablation is estimated to occur in <0.1% of patients. Most instances of CAI occur during ablation procedures or within a few weeks after RFA.

Case summary: We report a case of delayed manifestation of CAI of the right coronary artery 1 year after RFA, likely associated with a CTI ablation. The coronary angiography and intravascular ultrasound images revealed significant stenotic lesions primarily consisted of heterogeneous fibrous plaques including few echolucent lesions that consisted of a relatively smaller lipid or necrotic core without echo-attenuated plaques consisting of a fibroatheroma with a necrotic core or pathological intimal thickening with a lipid pool, and corresponded to the site of the CTI ablation. The patient remained stable without any symptoms 6 months post-percutaneous coronary intervention at that site.

Discussion: Physicians should consider the possibility of CAI associated with RFA procedures involving ablation near the coronary arteries (CAs) in patients presenting with chest discomfort after RFA, even when the presentation is remote from the index procedure. Unanticipated anatomic variations can predispose to CAIs. Therefore, awareness of the relationship between CA course and anatomical ablation site before RFA may be important to prevent CAIs and improve procedural safety.

Background: Accessory pathways (AP) are associated with an increased risk of atrioventricular reentry tachycardia (AVRT), presenting as a wide QRS tachycardia if the mechanism is antidromic. Rarely, AVRT may not respond to adenosine, suggesting a duodromic mechanism if the patient has multiple APs. Herein, we present a case of a male patient with multiple APs, wide QRS complex tachycardia, and resistance to adenosine.

Case presentation: A 45-year-old man with Wolff-Parkinson-White (WPW) syndrome was referred for AP ablation. He had previously been admitted with persistent palpitations and wide QRS tachycardia, which was resistant to adenosine. Electrophysiologic study revealed both right lateral and left lateral APs. Ablation successfully eliminated conduction through both pathways. Six months later, the patient remained asymptomatic but exhibited recurrence of pre-excitation on electrocardiogram, suggesting the presence of a third AP. A repeat electrophysiology study confirmed a posteroseptal AP, which was successfully ablated. The patient remained free of pre-excitation at follow-up.

Discussion: This case highlights the complexity of the diagnosis and treatment of wide QRS tachycardias in a patient with WPW. In this case, the failure to respond to adenosine was attributed to the use of a second AP as the retrograde limb of the AVRT circuit, a rare phenomenon known as duodromic AVRT. Successful identification and ablation of all APs was crucial in preventing recurrent arrhythmias, and rare mechanisms such as duodromic tachycardia should be considered when standard treatments fail.

Background: Constrictive pericarditis (CP) can arise from various causes, including post-operative degeneration, tuberculosis, and sequelae of pericarditis. Immunoglobulin (Ig) G4-related disease is a rare but recognized cause of CP. However, the specific mechanisms underlying these aetiologies and pathologies remain unclear.

Case summary: A 67-year-old man presented with a 6-month history of bilateral leg oedema, anorexia, and dyspnoea on exertion. Computed tomography (CT) revealed significant pericardial thickening without calcification, right pleural effusion, and ascites. Echocardiography demonstrated a reduced left ventricular ejection fraction and pericardial thickening. The early diastolic mitral annular tissue velocity (e') was preserved as 11.7 cm/s, despite inferior vena cava dilation. Respiratory variations in mitral inflow velocities and septal bounces were unremarkable. Cardiac catheterization further showed a 'dip and plateau' pattern with equalization of bilateral ventricular end-diastolic pressure. A preliminary diagnosis of CP was made, and pericardiectomy was performed, increasing the cardiac index from 2.0 to 3.0 L/min/m². Pathological examination revealed marked IgG4-positive plasma cell infiltration and tissue fibrosis. Additionally, the patient's post-operative serum IgG4 level was 679 mg/dL. Given these findings, IgG4-related CP without involvement of other organs was determined as the definitive diagnosis. His clinical status improved without requiring corticosteroid therapy.

Discussion: Optimal therapy for IgG4-related CP remains elusive due to its rarity. Potential therapeutic options include pericardiectomy, pericardiotomy, and corticosteroid therapy. Further examination through the accumulation of similar cases is crucial to establish definitive treatment approaches for this condition.

Background: High-risk pulmonary embolism (PE) is associated with significant mortality. Thrombolysis is the therapy of choice, while interventional thrombectomy may be a helpful strategy in case of contraindications or failed thrombolysis. However, the procedure may be complicated by catheter-induced embolization of clots and/or haemodynamic compromise.

Case summary: We present a 32-year-old patient woman with fulminant pulmonary artery embolism. Despite immediate systemic thrombolysis, the patient remained in cardiogenic shock with rising lactate levels. Furthermore, floating clots were observed in the right atrium of the patient. As a rescue strategy, we performed interventional thrombectomy by using the Inari FlowTriever system supported by periinterventional veno-arterial extracorporeal membrane oxygenation (VA-ECMO) implantation. After a successful thrombectomy, the patient recovered and showed immediate haemodynamic improvement.

Discussion: Interventional thrombectomy may be considered in patients with high-risk PE and failed thrombolytic therapy. Support by a VA-ECMO should be considered in order to prevent transient haemodynamic instability associated with accidental, catheter-induced clot mobilization from the vena cava or right atrium.

Background: Transvenous lead extraction (TLE) has become an essential component of lead management strategies, but it carries the risk of severe complications, including damage to the tricuspid valve. Currently, there are no established predictors that can help prevent these complications.

Case summary: An 84-year-old male with a dual-chamber pacemaker was admitted to the hospital due to a pocket fistula resulting from a local infection. Approximately 1 year prior, he underwent the implantation of a new ventricular lead and pacemaker replacement due to lead damage and battery depletion. Another lead had been abandoned. The patient underwent a procedure to remove the entire pacing system, which was complicated by tricuspid leaflet avulsion, resulting in acute and severe tricuspid regurgitation. A biological valve was successfully implanted to replace the damaged valve. Twenty days later, a new pacing system was implanted, which included one atrial lead and another positioned in the posterolateral coronary vein of the left ventricle. Post-procedural transthoracic echocardiography (TTE) showed the biological valve in place at the tricuspid orifice, with no regurgitation and preserved ejection fraction. Following recovery, the patient was discharged in good condition.

Discussion: While pre-procedural TTE and intra-procedural transesophageal echocardiography are commonly used to identify lead-induced tricuspid insufficiency, they often do not clarify the underlying mechanisms or predict potential complications during TLE. To address this issue safely, further research into new imaging techniques is necessary, as some existing methods may not be adequate in certain situations.

Background: This case report highlights the conduction disorder anomalies associated with dengue infection, particularly bradyarrhythmias due to dysfunction of the sinus node and atrioventricular node, which may require cardiac stimulation such as pacemaker implantation. This case emphasizes the importance of continuous monitoring and the use of additional diagnostic techniques to detect complications in a timely manner.

Case summary: A 31-year-old male patient was admitted to our institution with symptoms of dyspnoea, orthopnoea, and severe bradycardia. During hospital admission, atrial fibrillation with a low ventricular response was evident. A 24-h Holter examination revealed additional electrical conduction abnormalities, including first-, second-, and third-degree atrioventricular block, 3.8 s pauses, and migrating atrial rhythm. Since the patient remained asymptomatic and did not present circulatory compromise, conservative management was chosen, with gradual recovery observed during the 30-day follow-up.

Discussion: Dengue can significantly affect the cardiovascular system, presenting a variety of abnormalities in cardiac conduction. This case highlights electrical abnormalities and the importance of proper evaluation and management. It was decided to avoid temporary or permanent pacemaker implantation. This case underscores the need for continuous monitoring and the use of alternative diagnostic tools demonstrating that arrhythmias in this context can be successfully managed conservatively.

Background: Transcatheter aortic valve implantation (TAVI) is a safe and effective therapy for patients with severe aortic stenosis. A Stuck leaflet and severe intraprosthetic regurgitation after valve implantation occur rarely but can lead to sudden haemodynamic deterioration. We encountered a case of a stuck leaflet following post-dilatation with the Edwards Sapien 3 Ultra RESILIA valve.

Case summary: A 72-year-old woman was referred to our hospital for severe aortic stenosis with shortness of breath. She underwent transfemoral TAVI. After deployment of a 23 mm Sapien 3 Ultra RESILIA valve, post-dilatation was performed due to the presence of paravalvular leak (PVL). Transoesophageal echocardiography revealed a stuck leaflet and severe intraprosthetic regurgitation. Aortography also demonstrated severe aortic regurgitation. We performed valve-in-valve procedure using the second 23 mm valve. Post-valve-in-valve transoesophageal echocardiography showed no PVL nor aortic regurgitation, and haemodynamics improved.

Discussion: A stuck leaflet is a rare complication following post-dilatation. Severe intraprosthetic regurgitation can lead to sudden haemodynamic changes and may, in some cases, necessitate the use of extracorporeal membrane oxygenation. If haemodynamic changes occur, it is essential to promptly investigate the cause through multiple diagnostic modalities, including transoesophageal echocardiography and angiography.

Background: Takotsubo syndrome (TTS) is characterized by transient left ventricular dysfunction, often triggered by emotional or physical stress. It usually presents with clinical features similar to acute coronary syndrome, making its occurrence following elective percutaneous coronary intervention (PCI) challenging to diagnose and treat.

Case summary: A 67-year-old man with ischaemic heart disease and recurrent angina underwent elective PCI of the right coronary artery. The procedure, although technically challenging, was completed without immediate complications. However, shortly after the intervention, the patient experienced acute chest pain, initially thought to be due to subocclusion of a postero-lateral branch, which was treated with balloon angioplasty. Despite this intervention, the patient developed severe ventricular arrhythmias and exhibited dynamic electrocardiographic changes and echocardiographic features consistent with TTS. Cardiac magnetic resonance (CMR) imaging confirmed the diagnosis, revealing classic apical ballooning and left ventricular dysfunction. With comprehensive medical management and haemodynamic support, the patient gradually recovered. He was discharged after stabilization, with follow-up showing complete resolution of the left ventricular dysfunction.

Discussion: This case highlights the importance of recognizing TTS as a potential complication following PCI, particularly in patients with a heightened stress response. It emphasizes the need for increased awareness and the use of advanced diagnostic tools, such as CMR imaging, to accurately identify TTS. Early diagnosis and appropriate management are crucial for improving outcomes, especially in complex PCI cases where TTS can mimic more common coronary complications.