European Heart Journal: Case Reports最新文献

Background: Suicide left ventricle (LV) is a rare, potentially fatal complication after transcatheter aortic valve implantation (TAVI). It is typically caused by dynamic left ventricular outflow tract obstruction (LVOTO) following abrupt afterload reduction. Accelerated junctional rhythm (AJR) is an uncommon peri-procedural arrhythmia, and its role in precipitating suicide LV has not been reported.

Case summary: An 87-year-old woman with extremely severe aortic stenosis was admitted for transfemoral TAVI. Concentric LV hypertrophy with a sigmoid septum and preserved systolic function was observed on baseline transthoracic echocardiography. She developed profound hypotension immediately after valve deployment. Transoesophageal echocardiography (TOE) revealed severe LVOTO and marked mitral regurgitation (MR) due to systolic anterior motion (SAM) of the mitral valve. The simultaneous appearance of AJR abolished atrial contraction, further reducing LV preload. Left ventricular outflow tract obstruction and SAM resolved during sinus rhythm, but recurred during AJR. Haemodynamics improved with rapid volume loading, vasoconstrictor administration and continuous right ventricular pacing, thereby reducing obstruction via induced ventricular dyssynchrony. Accelerated junctional rhythm resolved spontaneously following emergence from anaesthesia, and a stable sinus rhythm was maintained. The patient was discharged on postoperative Day 12 without recurrence.

Discussion: This case reports AJR as a novel trigger for suicide LV after TAVI, leading to preload reduction and promoting SAM, LVOTO, and MR. Intraoperative TOE provided clear rhythm-dependent imaging of LVOT dynamics. Vigilant rhythm monitoring and prompt, targeted haemodynamic management, including pacing to induce ventricular dyssynchrony, are crucial for prevention and treatment in predisposed patients with small, hypertrophied ventricles with a sigmoid septum.

Background: Sports participation in patients with inherited cardiac conditions remains a major challenge, particularly when balancing arrhythmic risk against quality of life.

Case summary: A case of a 38-year-old recreational athlete diagnosed with hypertrophic cardiomyopathy (HCM) is described. A comprehensive assessment was performed, including electrocardiogram, echocardiography, exercise stress testing, Holter monitoring, and cardiac magnetic resonance, which revealed asymmetric non-obstructive HCM with extensive late gadolinium enhancement. Genetic testing identified two missense variants in MYBPC3, one of which was reclassified as likely pathogenic. Risk stratification using European Society of Cardiology (ESC) and American Heart Association/American College of Cardiology (AHA/ACC) calculators demonstrated a 5.73% 5-year risk of sudden cardiac death (SCD). A subcutaneous implantable cardioverter-defibrillator was implanted after a shared decision-making process, allowing the patient to continue recreational sport while avoiding competitive athletics.

Discussion: This case highlights the value of multimodal imaging, genetic testing, and guideline-based SCD risk stratification in guiding individualized management of athletes with HCM.

Background: Left ventricular (LV) thrombus represents a critical complication following acute myocardial infarction (MI), particularly in patients with reduced LV ejection fraction (LVEF) < 40%, extensive MI, and LV aneurysm. Chronic myeloid leukaemia (CML), a haematological malignancy, is a recognized risk factor for thrombosis. While transthoracic echocardiography (TTE) serves as a 'goalkeeper' for the initial screening modality, its sensitivity in detecting mural thrombi remains limited. Cardiac magnetic resonance (CMR) with gadolinium enhancement has emerged as the diagnostic gold standard due to its superior spatial resolution and ability to recognize thrombus.

Case summary: A 47-year-old male with CML, undergoing chemotherapy and a history of extensive anterior ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) of the proximal left anterior descending (LAD) coronary artery, presented with exertional dyspnoea. Although serial non-contrast TTEs over 12 months revealed reduced left ventricular ejection fraction (LVEF) and extensive regional wall motion abnormalities, with pulmonary hypertension (PASP 46 mmHg), no thrombus was detected. Contrast-enhanced CMR identified a large transmural MI involving the anterior, anterolateral walls, and apex with an apical LV mural thrombus. After 3 months of warfarin therapy, the thrombus reduced in size and showed no improvement in LV systolic function (LVEF 36%).

Conclusion: CMR is superior to non-contrast TTE in detecting and monitoring LV thrombus treatment. The early CMR should be considered in high-risk patients post MI, particularly in those with concomitant haematological malignancy.

Background: Brugada syndrome (BrS) is a hereditary arrhythmic disorder associated with an increased risk of ventricular arrhythmias (VA) and sudden cardiac death (SCD). Certain triggers may unmask the diagnostic high-risk BrS Type 1 electrocardiographic (ECG) pattern. However, conversion to a Type 1 pattern during peak exercise testing is uncommon. Despite the established benefits of physical activity, exercise in patients with inherited arrhythmia syndromes may provoke malignant arrhythmias. Current guidelines allow for some degree of sports participation in asymptomatic individuals with BrS, including mutation carriers and athletes with only an inducible ECG pattern.

Case summary: We describe a case of a young man who survived a cardiac arrest during physical exertion. A treadmill stress test revealed a diagnostic Type 1 BrS ECG pattern at peak exercise. The resting ECG was non-diagnostic, and comprehensive evaluation excluded other causes of cardiac arrest.

Discussion: In BrS, VA most commonly occur at rest, during sleep, or during exercise recovery, when vagal tone is predominant. This case demonstrates that BrS Type 1 ECG changes may also be elicited during peak sympathetic stimulation, such as intense exercise. This rare presentation suggests that exercise stress testing could play a role in the diagnostic and risk stratification process in selected patients with suspected BrS. Furthermore, it raises questions regarding the safety of physical activity in this population and whether current recommendations on sports participation warrant re-evaluation in light of such findings.

Background: Pulmonary vein isolation (PVI) using pulsed field ablation (PFA) has emerged as a promising treatment for atrial fibrillation (AF). However, haemolysis-induced acute kidney injury (AKI) remains a concern, particularly with higher numbers of applications.

Case summary: We report the case of a 62-year-old male with a history of CABG who underwent PVI using a 35 mm pentaspline PFA catheter. Pre-procedural CT imaging revealed a large 37 mm left common PV ostium. Standard energy delivery protocols were followed, including two 'olive' applications per vein. The patient was discharged the same day. That evening, he developed dark 'cola-coloured' urine. Upon remote consultation the next day, he was advised to increase fluid intake to 3 L that day. His urine colour normalized by the following day, but he experienced a 3 kg weight gain and oliguria and presented to the emergency department. Laboratory tests showed severe AKI (eGFR to 6 mL/min/1.73 m²), necessitating urgent dialysis. Laboratory results showed modest but clinically relevant elevation of haemolysis markers, while urine analysis showed breakdown product of erythrocytes. After several haemodialysis sessions, the patient's urine output improved, and he was eventually discharged. Two months after the procedure, his renal function recovered to normal values.

Discussion: While prior experience suggests that limiting PFA applications to fewer than 70 may reduce the risk of haemolysis-associated renal injury, this case demonstrates that even with 40 applications and minimal systemic haemolysis, AKI requiring dialysis can occur. This highlights the need for heightened vigilance, early fluid management, and prompt intervention to support renal recovery after PFA.

Background: Pheochromocytoma is associated with serious cardiovascular complications resulting from the effect of catecholamines, such as ventricular arrhythmias, cardiomyopathy with left ventricular dysfunction, and cardiogenic shock. Bidirectional ventricular tachycardia (BVT) is a rare but potentially fatal form of polymorphic tachycardia associated with elevated sympathetic tone.

Case summary: A 27-year-old Caucasian woman was admitted to the intensive care unit with cardiogenic shock. The electrocardiogram showed BVT, and the transthoracic echocardiogram showed a dilated left ventricle with severe systolic dysfunction. Computed tomography revealed an adrenal mass with haemorrhage, which was confirmed by abdominal magnetic resonance imaging. The patient underwent a laparoscopic right adrenalectomy after pre-operative preparation with alpha-beta blockade, with subsequent histopathological confirmation of the diagnosis.

Discussion: The acute presentation of haemorrhagic necrosis of a pheochromocytoma is a rare and potentially lethal condition. Its diagnosis can be challenging, especially in cases with atypical manifestations. However, the presence of BVT might serve as a crucial guide for its identification. Early recognition of this condition is essential, as it significantly impacts the patient's prognosis.

Background: Left ventricular free wall rupture (LVFWR) without coronary artery occlusion in the setting of acute myeloid leukaemia (AML) is exceedingly rare. We report a rare case of spontaneous cardiac rupture in a patient ultimately diagnosed with acute myeloid leukaemia.

Case summary: A 77-year-old woman presented with acute chest pain and haemodynamic collapse. Coronary angiography revealed no significant stenosis, whereas left ventriculography demonstrated contrast extravasation from the apical region, consistent with LVFWR. The patient underwent emergent surgery; however, no discrete rupture site was identified. Following temporary weaning from cardiopulmonary bypass and re-inspection, no obvious rupture site was observed. Since it appeared that the blow-out-type rupture had transitioned to an oozing type, suture less repair with TachoSil® was chosen, achieving initial haemodynamic stabilization. Postoperatively, the patient remained haemodynamically stable without persistent bleeding. However, on Postoperative Day 3, the patient was diagnosed with AML, followed by rapidly progressive malignant lactic acidosis and multiorgan failure, leading to death despite intensive care.

Conclusion: This case underscores three key clinical considerations:(1) In instances of LVFWR without culprit coronary artery occlusion, the possibility of leukaemia-associated myocardial pathology should be actively evaluated.(2) For oozing-type LVFWR lacking a clearly identifiable rupture site, sutureless repair may represent a feasible and effective surgical option.(3) The onset or progression of lactic acidosis in the setting of marked leucocytosis constitutes a medical emergency, warranting prompt initiation of cytoreductive therapy and empiric thiamine supplementation.

Background: Sick sinus syndrome often necessitates permanent pacemaker implantation; however, when sinus node artery ischaemia is the cause, sinus node dysfunction may be reversible. While age-related fibrosis is generally considered the main mechanism, ischaemia should also be recognized as a potential aetiology.

Case summary: An 80-year-old woman with breast cancer, hypertension, and diabetes mellitus presented with dyspnoea. Electrocardiography showed marked bradycardia at 38 beats per minute (b.p.m.) without ST-segment changes. Chest radiography revealed a cardiothoracic ratio of 61% with mild pulmonary congestion, and echocardiography showed preserved left ventricular ejection fraction (>60%) without wall motion abnormality. Although referred for pacemaker implantation, the acute onset of severe bradycardia together with multiple coronary risk factors prompted coronary angiography, which demonstrated 99% stenoses in the proximal right coronary and proximal left circumflex arteries, and 90% in the mid left anterior descending artery. Flow delay was noted in the sinus node branch of the right coronary artery. Percutaneous coronary intervention of the proximal right coronary artery promptly restored sinus rhythm during the procedure. She has since remained stable with a sinus rate of 70 b.p.m. for 1 year without pacing.

Discussion: Despite no chest pain or ST changes, the acute presentation and multiple coronary risk factors suggested an ischaemic aetiology. Intermittent right coronary artery impairment, bradycardia-facilitated collateral flow, and repolarization abnormalities likely obscured typical ischaemic signs. This case highlights the importance of ischaemic evaluation before pacemaker implantation, even in elderly patients.

Background: Retrievable inferior vena cava (IVC) filters, when not removed after the period of thromboembolic risk has resolved, are prone to delayed complications such as limb fracture, migration, and embolization. Fragment embolization to the heart can result in pericardial penetration or other life-threatening sequelae yet may remain entirely asymptomatic and identified only incidentally.

Case summary: A 54-year-old woman with a retrievable IVC filter placed in 2009 for pulmonary embolism, during a period of high bleeding risk from active breast cancer treatment, underwent elective left heart catheterization in 2025 for a 2-month history of chest discomfort. Coronary computed tomography (CT) angiography revealed multi-vessel coronary artery disease but did not visualize the migrated filter strut. During angiography, a linear radiopaque foreign body was seen within the right ventricle. A kidney-ureters-bladder radiograph confirmed filter fracture with a missing limb. Echocardiography 2 months earlier showed preserved bi-ventricular function and no pericardial effusion. During coronary artery bypass grafting, a fractured metallic filter limb ∼1-2 cm in length penetrating the pericardium was surgically removed. The remaining filter was left in situ with planned radiographic surveillance. Recovery was uneventful.

Discussion: Thin metallic struts may evade CT detection due to in-plane alignment or artefact, and echocardiography may fail to identify fragments lacking haemodynamic significance. Management options include endovascular retrieval, surgical extraction, or observation. This case highlights the importance of structured IVC filter follow-up and timely retrieval to prevent silent but potentially life-threatening complications.