European Heart Journal: Case Reports最新文献

Background: Atrial flutter (AFL) is usually effectively treated by cavotricuspid isthmus (CTI) ablation. If AFL recurs despite ablation, there is risk of progression to atrial fibrillation (AF) and clinicians should consider underlying structural heart diseases. This consideration becomes especially critical when right-heart-chambers are dilated.

Case summary: A 50-year-old man presented with palpitations due to AFL. Fifteen years earlier, after polytrauma, mild tricuspid regurgitation (TR) and pericardial effusion had been diagnosed on transthoracic echocardiography (TTE). At present, TTE showed dilated right-heart-chambers and moderate TR. Despite two CTI-ablations, he developed AF for which he underwent pulmonary vein isolation (PVI). A further ablation was performed because of right-sided AFL due to transcrista conduction. Atrial fibrillation recurred, accompanied by heart failure. Tricuspid regurgitation severity and right-heart-chamber dilatation worsened. Finally, 3D-transoesophageal echocardiography (3D-TEE), performed 20 years after the first TTE, revealed that TR was due to restriction of the septal leaflet. The patient underwent surgery. The tricuspid valve was repaired by ring annuloplasty and a cleft between the anterior and septal leaflets was closed. Three years post-operatively, he is asymptomatic with chronic AF but no recurrent AFL. Transthoracic echocardiography shows only mild TR, though the right-heart-chambers remain dilated, likely due to long-standing TR.

Discussion: Tricuspid regurgitation and AFL/AF have a bidirectional relationship. Tricuspid regurgitation can both cause and result from AFL/AF. Structural heart diseases, including post-traumatic valve damage, should be considered in patients with recurrent AFL despite CTI-ablation and progression to AF. In cases with TR and right-heart-chamber enlargement, 3D-TEE is essential for accurate diagnosis and should be performed without delay.

Background: Traumatic tricuspid valve regurgitation is a rare condition related to blunt chest trauma. In the early phase, the patients may remain asymptomatic. Progressive tricuspid regurgitation leads to the development of symptoms thereafter. Progressive right ventricular dysfunction aggravates symptoms, and the diagnosis is made by subsequent echocardiography at a later time. The treatment is usually surgical, especially in younger patients.

Case summary: We describe a 30-year-old patient with traumatic tricuspid valve regurgitation after a motorcycle accident. No cardiac injury was detected at the moment of the collision, and the patient remained asymptomatic at the initial phase. Five years later, the patient was admitted to our hospital with symptoms of dyspnoea at exertion. Echocardiography demonstrated severe tricuspid valve regurgitation with right ventricle dilatation. Surgical tricuspid valve repair including ring annuloplasty and implantation of artificial chords via an endoscopic approach was performed. Surgery was complicated by impingement of the right coronary artery by one of the annuloplasty sutures, which was addressed by subsequent percutaneous coronary intervention.

Discussion: Traumatic tricuspid valve regurgitation requires careful evaluation. Transthoracic echocardiography should be recommended to exclude post-traumatic tricuspid regurgitation after major blunt chest trauma. Early diagnosis is important to avoid right ventricular failure. First-line surgical treatment consists of tricuspid repair by means of ring annuloplasty and implantation of artificial chords.

Background: Charcot-Marie-Tooth is the most common inherited neuromuscular disorder. Rarely, it can be associated with heart failure and various arrhythmic disturbances. This case illustrates the challenges of making decisions to prevent sudden cardiac death in a patient with Charcot-Marie-Tooth disease.

Case summary: A 69-year-old male with a history of Type 1A Charcot-Marie-Tooth disease was admitted due to repetitive runs of ventricular tachycardia. Twelve-lead electrocardiogram, echocardiography, selective coronary angiography, and cardiac magnetic resonance did not clarify the cause of the electrical storm. As conservative therapy was not successful, radiofrequency ablation was chosen to treat the electrical storm. After this procedure, implantable cardioverter defibrillator (ICD) was implanted. The follow-up revealed severe perforation by the ventricular lead. An extraction was performed with no complications and a new lead was immediately implanted. The patient remains asymptomatic. Three episodes of non-sustained ventricular tachycardia were recorded during the last follow-up.

Discussion: This case illustrates the challenges of making decisions to prevent sudden cardiac death in a patient with Charcot-Marie-Tooth disease after successful ablation for electrical storm. Due to a lack of evidence, atypical origin of arrhythmia, and clinical presentation, we did not consider this as idiopathic arrhythmia and decided to implant an ICD, which was complicated by severe perforation by the lead. Specific recommendations for preventing sudden cardiac death in rare cardiac conditions, such as Charcot-Marie-Tooth disease, still need to be refined.

Background: Transcatheter edge-to-edge mitral valve repair (M-TEER) using the MitraClip system is primarily performed using the transfemoral approach. However, when this approach is not feasible, the transjugular approach can be used as an alternative.

Case summary: A 57-year-old man presented with heart failure and persistent New York Heart Association class IV symptoms, refractory to guideline-directed medical therapy, intravenous therapy, and intra-aortic balloon pumping. His medical history included pulmonary embolism secondary to deep vein thrombosis, which occluded the inferior vena cava (IVC). Transthoracic echocardiography (TTE) revealed severe functional mitral regurgitation (FMR). The IVC occlusion made the transfemoral approach impossible; hence, transjugular M-TEER was planned. Transseptal puncture was performed via the right internal jugular (RIJ), 32 mm above the mitral annulus. A Confida wire was positioned in the left ventricle, and a steerable guiding catheter was introduced with 180° clockwise rotation of the +knob for septal crossing through the stiff wire. The MitraClip XTW was inserted into the catheter with a 90° counterclockwise rotation. After adjusting to a straddle position to move the clip laterally, additional knob rotations were performed to position the clip at A2/P2. Once the clip was placed, only trivial mitral regurgitation (MR) remained. No complications occurred, and the patient improved, allowing discharge. Transthoracic echocardiography at 1-year post-procedure demonstrated sustained MR reduction.

Discussion: We have described the successful completion of M-TEER using the RIJ approach in a patient with severe FMR. Technical considerations in M-TEER require special attention because of limited reports on the M-TEER procedure via the RIJ.

Background: Anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA) (ALCAPA) is a rare congenital abnormality. We present a case of an ALCAPA in a 25-year-old man.

Case summary: A 25-year-old male with no past medical history was admitted to our intensive cardiac care unit after sudden cardiac arrest due to ventricular fibrillation and suspected acute coronary syndrome. After being treated with shock by automated external defibrillator, an electrocardiogram (ECG) demonstrated sinus tachycardia with antero-lateral ST-segment elevation. Initial transthoracic echocardiography showed severe and diffuse left ventricular dysfunction and dilatation. Coronary angiography revealed anomalous origin of the LCA from the PA and extensive collateral circulation from a giant RCA. An ECG-gated cardiac computed tomography confirmed the diagnosis of anomalous left main originating from the left PA. Cardiac magnetic resonance demonstrated an enlarged left ventricle with globally reduced function and extensive sub-endocardial scarring of the anterior, antero-lateral, and lateral walls. Following a multidisciplinary heart team discussion, the patient successfully underwent repair of aberrant LCA with direct LCA re-implantation to the aorta and subcutaneous implantable cardioverter defibrillator implantation. Optimal medical therapy for heart failure with reduced ejection fraction was initiated, and the patient was discharged home for a close clinical and echocardiographic follow-up.

Discussion: In conclusion, ALCAPA in the adulthood is a very rare congenital anomaly that clinicians should be aware of. The preferred treatment, when diagnosed in time, is direct re-implantation of the LCA to the aorta.

Background: Left bundle branch block (LBBB) is a rare conduction disorder in athletes associated with ventricular dyssynchrony, which can lead to left ventricular systolic dysfunction and exercise intolerance. Inappropriate sinus tachycardia (IST) is characterized by an excessive heart rate (HR) that is not related to physiological needs, often resulting in reduced exercise capacity. Managing these conditions in athletes can be challenging, as standard treatments like beta-blockers and ivabradine, while effective in controlling HR, are described to be associated with a reduction in maximal exercise performance.

Case summary: A 50-year-old amateur athlete presented with exercise intolerance, LBBB, and mild dilated cardiomyopathy due to ventricular dyssynchrony. Resting electrocardiogram and 24-h monitoring confirmed IST. Initial cardiopulmonary exercise testing (CPET) off-therapy showed rapid HR increase during exertion, an early plateau in oxygen pulse, and reduced peak oxygen consumption (VO2, 22.1 mL/kg/min, 76% of the predicted value). After 1 month of ivabradine 5 mg b.i.d., there was some improvement in these parameters. At the third follow-up, with combined therapy of ivabradine (5 mg b.i.d.) and metoprolol (50 mg b.i.d.), the HR response during exercise normalized, and CPET parameters significantly improved, with peak VO2 reaching 29.2 mL/kg/min (101% of the predicted value).

Discussion: This case highlights a paradoxical improvement in exercise tolerance and peak VO2 with combined ivabradine and beta-blocker therapy in a patient with IST. The treatment optimized the HR response during exercise, suggesting that individualized strategies can enhance exercise performance in patients with IST and mild cardiomyopathy, despite the expected limitations of these medications.

Background: In patients with infective endocarditis, brain embolism portends a poor prognosis. The timing of surgery in patients who require emergency valve surgery in the setting of deteriorating level of consciousness from recurrent embolic events, and brain infarction with haemorrhagic transformation, remains controversial.

Case summary: We report a case of a 54-year-old male who presented with Streptococcus salivarius mitral valve endocarditis, recurrent episodes of cerebral embolic infarctions with haemorrhagic transformation and deteriorating level of consciousness, and successfully underwent emergency mitral valve surgery without extension of the preoperative cerebral embolic complication or worsening of neurological symptoms.

Discussion: Mitral valve surgery can be performed successfully in patients with mitral valve endocarditis and cerebral embolism earlier than the recommended 2-4 weeks, and this should be considered in deteriorating patients.

Background: The 'univentricular' heart encompasses a variety of congenital cardiac defects characterized by a single functional ventricle and an underdeveloped ventricular chamber. Surgical intervention, typically in infancy or childhood, aims to regulate pulmonary blood flow volume. In adulthood, untreated patients may experience limitations in physical activity and elevated morbidity due to persistent cyanosis and arrhythmias, notably after the Fontan procedure.

Case summary: A 38-year-old Mexican man with an unrepaired morphologically right single ventricle and a common atrium presented with palpitations. Diagnostic imaging revealed a hypertrophic systemic single ventricle with severe atrioventricular valve regurgitation and pulmonary stenosis. Despite ongoing anticoagulant and beta-blocker therapy, persistent symptoms prompted catheter ablation guided by CARTO-Merge^®, a function that overlays computed tomography or magnetic resonance imaging onto a CARTO^® electroanatomical map. Ablation along the cavo-annular isthmus was successfully performed, achieving arrhythmia termination. Post-ablation, the patient developed sinus rhythm and second-degree atrioventricular block, necessitating the implantation of an epicardial pacemaker.

Discussion: Atrial flutter ablation in univentricular hearts without prior surgery is rare. Such patients are predisposed to post-Fontan arrhythmias, often requiring intervention due to increased morbidity. Atrial flutter arises from scarred post-surgery regions, necessitating careful assessment and management. Our case demonstrates successful ablation in a complex congenital heart condition, highlighting the importance of comprehensive imaging, understanding arrhythmia mechanisms, and meticulous procedural techniques for optimal outcomes.

Background: Patients after transcatheter pulmonary valve implantation (TPVI) are at increased risk for infective prosthetic valve endocarditis. Diagnosis of infective endocarditis (IE) following TPVI is particularly difficult due to impaired visualization of the transcatheter pulmonary valve (TPV) with echocardiography [Delgado V, Ajmone Marsan N, de Waha S, Bonaros N, Brida M, Burri H, et al. 2023 ESC guidelines for the management of endocarditis. Eur Heart J 2023;44:3948-4042]. The aim of this case report is to describe the significant role of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in diagnosing IE post-TPVI.

Case summary: A 22-year-old woman presented to the emergency department with fever and chest pain. Relevant past medical history included a left ventricular outflow membrane resection at infancy, a Ross procedure at the age of 4 with post-operative pacemaker implantation and Melody™ TPVI at the age of 16 because of pulmonary valve stenosis. Blood tests showed elevated inflammatory markers. Transthoracic echocardiography revealed elevated systolic pulmonary artery pressure of 53 mmHg. After 2 days, blood cultures appeared positive for Streptococcus species. Subsequently, transoesophageal echocardiography showed an elevated TPV peak gradient (25 mmHg). No clear valvular nor pacemaker lead vegetations were identified but could not be ruled out as inspection of the TPV was difficult. However, 18F-FDG PET/CT demonstrated heightened metabolism at the TPV, which confirmed the diagnosis of TPV IE. Intravenous antibiotic treatment was administered, which led to clinical improvement and normalization of the inflammatory markers.

Discussion: Transthoracic echocardiography and transoesophageal echocardiography often fail to provide adequate assessment, making 18F-FDG PET/CT crucial for diagnosing TPV IE in this case. Important to notice is the possibility of false-negative and false-positive diagnoses and the radiation exposure, particularly in this young population.