European Heart Journal: Case Reports最新文献

Background: Superior caval vein obstruction is a rare complication of endocardial pacing lead implantation that can result in a right to left shunt.

Case summary: A 3-year-old child with type 2 Brugada syndrome presented with mild cyanosis post-endocardial pacing implantation due to evolutionary right superior caval vein obstruction. This obstruction resulted in a right to left shunt across a previously unrecognized patent levo-atrial cardinal vein associated with partial anomalous pulmonary venous drainage. The patient underwent endocardial pacing explantation, balloon dilation and stenting of the right superior caval vein, banding of the levo-atrial cardinal vein to left upper pulmonary vein venous channel, and implantation of an epicardial pacing system.

Discussion: Levo-atrial cardinal vein and partial anomalous pulmonary venous drainage with dual drainage can go undetected on cardiac imaging and may not ever cause symptoms (high left-to-right shunt or cyanosis). The levo-atrial cardinal vein and associated partial anomalous venous drainage with dual drainage was missed on multiple occasions and with multiple imaging modalities in our patient. Blood flow may not be detected in a small calibre or collapsed levo-atrial cardinal vein with pulmonary venous connection when the pulmonary vein remains widely patent and connected to the left atrium. Detailed comprehensive echocardiography of any child referred for cardiac intervention should include pulsed wave Doppler and colour flow mapping interrogation of the innominate vein from the suprasternal approach.

Background: Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) is a rare and progressive mitochondrial disorder characterized by multi-systemic involvement. This disease manifests in various clinical manifestations, with heart and kidney disorders being among the most common. Accurate diagnosis of MELAS often necessitates a range of complex investigations. Prompt and comprehensive management can significantly improve the prognosis of the disease.

Case summary: A 40-year-old female presented with elevated blood pressure (BP) associated with shortness of breath prior to dialysis. She was found to be hypertensive with a systolic BP of 190 mmHg with prominent signs of congestion. Laboratory examination showed elevated troponin and NT-proBNP. Arterial blood gas revealed severe lactic acidosis, which prompted urgent dialysis. On the latest admission, an echocardiogram showed a left ventricular ejection fraction of 50% with much thickened myocardium compared with the previous study. Linking the past history of hearing impairment, kidney disease, giddiness, and progression of myocardial thickness warranted a genetic test, which revealed the diagnosis of MELAS.

Discussion: This case involved a patient initially diagnosed with hypertensive heart disease based on asymptomatic left ventricular hypertrophy. Further deterioration led to the identification of MELAS syndrome through extensive diagnostic evaluation. This highlights the importance of considering mitochondrial diseases in unexplained cardiac symptoms, especially in younger patients, for timely and appropriate management.

Background: Myocardial bridging (MB) is considered a frequent and benign condition. However, some patients may experience symptoms. The recent ESC guidelines on sports participation provide guidance on the management of these symptomatic patients with MB but do not provide guidance in the presence of another cardiac pathology.

Case summary: A 14-year-old-male was admitted for ongoing chest pain and palpitations. He practiced rowing at a competitive level and had an episode of exercise-induced paroxysmal atrial fibrillation (AF) a month ago. A 12-lead electrocardiogram and biomarkers orientated toward an acute coronary syndrome. Transthoracic echocardiography was normal. Cardiac magnetic resonance imaging ruled out the hypothesis of myocarditis and showed no ischemic scar. A coronary computed tomography scan showed a significant MB of the left anterior descending coronary artery. We introduced a beta-blocker and monitored the absence of inducible ischaemia with an exercise echocardiography. Our conclusion was a myocardial infarction with non-obstructive coronary arteries due to MB and adrenergic AF. Return to rowing practice including competitions was allowed under beta-blocker therapy. The 6-year follow-up showed no recurrence of AF under treatment. The patient kept on training and competing, though at a lower level.

Discussion: This atypical case demonstrates that the so-called benign MB may become malignant, in particular in conjunction with rapid non-physiologic heart rate, and that dealing with this abnormality in athletes remains difficult despite the latest guidelines. Safe return-to-play and competition remain, however, possible under medical therapy if the patient is asymptomatic and has no inducible ischaemia.

Background: Many rare complications are associated with blunt chest trauma and right ventricular contusion. Among these, post-traumatic severe tricuspid regurgitation is a relatively rare clinical entity. Furthermore, only a few cases reported in the literature are associated with trauma due to kicking by a horse.

Case summary: We present the case of a 56-year-old woman who was diagnosed with early massive tricuspid regurgitation caused by traumatic rupture of the anterior papillary muscle, which was successfully treated by surgical tricuspid repair. The patient had no symptoms suggestive of valvular dysfunction, which was incidentally detected on routine transthoracic echocardiogram following a horse kick.

Discussion: The most commonly cited mechanism is an anteroposterior compression of the chest, causing a sudden increase in right ventricular pressure during the end-diastolic phase. The mean interval to diagnosis of traumatic tricuspid regurgitation is usually long, leading to a progressive right ventricular remodelling and deterioration of right ventricular function. As a result, surgical repair of the valve is often not possible and an early tricuspid valve replacement is required.

Background: Valve sparing aortic root replacement (VSARR) is a treatment for aortic root dilatation and aortic regurgitation (AR), which preserves the aortic valve. However, AR may recur, and redo surgery often carries high risk. Transcatheter aortic valve replacement (TAVR) can be performed but there is a paucity of literature to guide procedural planning.

Case summary: Two cases are presented herein with recurrence of severe AR following VSARR (David procedure). In both cases, computed tomography (CT) scans demonstrated absence of calcium and a narrow sinus of valsalva. Both cases were considered at prohibitive risk for redo surgery and were successfully treated with TAVR using balloon-expandable valves. The valves were sized based on CT (aiming for moderate oversizing of 10%-11%) and by assessing the anchoring and waist of sizing balloons. Post-procedure aortography and echocardiography revealed no transvalvular or paravalvular regurgitation. Both patients were successfully discharged with follow-up CT scans also showing no migration and preservation of coronary access, together with suitability of future redo TAVR if required.

Discussion: TAVR can be successfully performed after VSARR surgery with a balloon-expandable valve in the absence of aortic valve calcification. Moderate THV oversizing (10%-11%) appears safe and effective. Careful assessment with a sizing balloon is recommended to ensure adequate anchoring, without the need for aggressive oversizing which risks rupture at the graft suture line.

Background: Atrial infarction is a complication of myocardial infarction with ventricular infarction; however, isolated atrial infarction (IAI) has rarely been reported. Herein, we report a case of IAI associated with sick sinus syndrome and atrial fibrillation (AF).

Case summary: An 83-year-old woman was brought to the emergency department with a complaint of general malaise. An electrocardiogram at the time of her arrival showed a junctional rhythm with sinus arrest (SA) at a heart rate of 30 bpm; therefore, temporary pacing was placed urgently, and coronary angiography (CAG) was performed. Coronary angiography showed a solitary occlusion of the sinus node (SN) artery originating from the proximal portion of the right coronary artery. Therefore, revascularization was performed for the occluded SN artery to recover SN function. Bradycardia persisted for several days after the procedure but returned to normal sinus rhythm on day 10. However, during hospitalization, AF attacks frequently appeared with an SA for up to 10 s at AF termination, which is known as the bradycardia-tachycardia syndrome. Catheter ablation (CA) was performed for AF, and no recurrence of AF or bradycardia occurred thereafter. She was discharged without any symptoms.

Discussion: We have experienced a patient who underwent revascularization for the occluded SN artery and CA for paroxysmal AF following IAI, which evaded permanent pacemaker implantation.

Background: The use of single-chamber, right ventricular (RV) leadless pacemakers (LPs) has been well established, the introduction of a right atrial LPs has opened the door for dual-chamber leadless pacing. Cardiac computed tomography (CT) segmentation integration might provide proper visual guide during the procedure.

Case summary: A 58-year-old male patient was brought to the emergency department with dizziness and complete heart block. The patient underwent single-chamber permanent LP implantation. During the upgrade to a dual-chamber LP, 3D CT image fusion with fluoroscopy was utilized to accurately identify the ideal and safe implantation site for the device.

Discussion: Integrating CT image guidance with fluoroscopy could enhance procedure safety, success rates, and reduces fluoroscopy time.