European Heart Journal: Case Reports最新文献

Background: Atrial fibrillation (AF) is associated with structural and electrical remodelling of the left atrium, but in rare cases, it may occur secondary to external compression or local inflammation. Cardiac involvement of malignant lymphoma is uncommon, and its contribution to AF mechanisms remains poorly understood. We report a case of recurrent lymphoma involving the right inferior pulmonary vein (RIPV), in which pulsed field ablation (PFA) restored sinus rhythm, supported by multimodality imaging and cytological evaluation.

Case summary: A 71-year-old man with a history of follicular lymphoma presented with new-onset AF and palpitations. Contrast-enhanced cardiac computed tomography (CT) revealed an irregular soft tissue lesion involving the RIPV. A retrospective review of a prior non-contrast CT showed subtle thickening in the same region. Pulsed field ablation achieved isolation of all pulmonary veins. Although no abnormal voltage or electrograms were noted near the RIPV, AF terminated immediately upon its electrical isolation. Cytologic analysis of left atrial aspirate obtained near the RIPV revealed Class III atypical lymphoid cells. Post-ablation Positron emission tomography-CT demonstrated intense ^18F-fluorodeoxyglucose (FDG) uptake in the RIPV lesion, supporting metabolically active lymphoma. The patient remained arrhythmia-free without antiarrhythmic therapy at 1-month follow-up and was referred for haematologic treatment.

Discussion: This case illustrates a rare presentation of AF associated with recurrent lymphoma involving the RIPV. Although AF termination after RIPV isolation suggests a pulmonary vein-mediated mechanism, local tumour involvement may have facilitated AF initiation from the RIPV by increasing its arrhythmogenic potential. Multimodal imaging and intracardiac cytology enabled diagnosis without biopsy, while PFA provided safe and effective rhythm control in a structurally compromised region.

Background: Libman-Sacks endocarditis is a form of non-bacterial thrombotic endocarditis, associated with autoimmune conditions such as systemic lupus erythematosus and antiphospholipid syndrome (APLS). Vegetations are usually small and are managed with immunosuppression and anticoagulation.

Case summary: A 50-year-old female presented to her hospital with left leg weakness, with imaging showing a right parietal stroke and an old occipital lobe stroke. Inpatient transthoracic echocardiography showed a large mitral valve (MV) vegetation with moderate-to-severe mitral regurgitation (MR). She self-discharged against medical advice before further workup could be completed and was lost to follow-up until persuaded to have an outpatient transoesophageal echocardiogram, which showed severe MR with a large (2 cm × 3 cm) mass attached to the posterior MV leaflet. Blood cultures were negative. Review of previous blood tests showed a triple-positive APLS panel, which was positive on repeat testing. She underwent successful mechanical MV replacement. Valve histology was consistent with Libman-Sacks endocarditis. Warfarin therapy was continued, complicated by subdural haematoma (successfully treated), but with no further thrombo-embolic events. Subsequent anti-nuclear antigen testing was positive, and hydroxychloroquine was commenced. Transoesophageal echocardiography 1 year later showed a well-functioning MV prosthesis.

Discussion: The management of young individuals with ischaemic stroke should include attention to atypical causes. Libman-Sacks endocarditis is usually associated with small vegetations and high thrombotic risk, usually managed medically with anticoagulation and treatment of underlying conditions. Our case was atypical, with the presence of a large vegetation causing significant valvular dysfunction, but it demonstrates that replacement with mechanical prostheses can be a feasible management strategy.

Background: Percutaneous coronary intervention (PCI) for heavily calcified bifurcation lesions presents unique challenges, side-branch occlusion representing a serious complication. Tip-detection antegrade dissection and re-entry (TD-ADR), originally developed for chronic total occlusion, enables true lumen re-entry when guidewires advance subintimally. We report its novel application as an effective bailout technique for calcification-induced side-branch occlusion.

Case summary: A 67-year-old man with prior inferior myocardial infarction underwent PCI of a heavily calcified mid-left anterior descending (LAD) artery stenosis with ostial narrowing of diagonal branches D1 and D2. Rotational atherectomy and modified balloon dilation fragmented the calcific plaque, abruptly displacing fragments that occluded the D2 ostium. Conventional re-crossing attempts with multiple wires resulted in subintimal tracking. Intravascular ultrasound (IVUS) confirmed the guidewire entered the false lumen at D2 origin. Using a double-guide catheter setup and IVUS guidance, TD-ADR with a Conquest Pro 12 ST guidewire targeted the true lumen point, achieving precise re-entry and restoring TIMI 3 flow to D2. Culotte stenting of LAD and D2 was subsequently performed.

Discussion: In calcified bifurcation interventions, plaque fracture during lesion preparation can directly obstruct side-branch ostia and render conventional guidewire re-crossing techniques ineffective. When guidewires enter the subintimal space and angiography-guided re-entry fails, IVUS-guided TD-ADR can pinpoint and penetrate the true lumen vertically, minimizing subintimal tracking, preserving side-branch perfusion, and providing a reliable bailout. This case demonstrates the utility of IVUS-guided TD-ADR as a targeted bailout strategy for achieving true lumen access in difficult side-branch occlusions during complex bifurcation PCI.

Background: Cardiac fibromas are rare, benign primary cardiac tumours predominantly observed in paediatric populations, with their occurrence in adults being exceptionally uncommon.

Case summary: We present the case of a 40-year-old physically active male with an incidentally discovered, large left ventricular fibroma during investigation for presumed ischaemic heart disease. Multimodal imaging, including computed tomography (CT) coronary angiography, transthoracic echocardiography, cardiac magnetic resonance imaging, and positron emission tomography-CT, revealed a 42 × 30 × 58 mm myocardial mass with significant calcification and myocardial invasion, ultimately diagnosed as a fibroma via biopsy. Given the patient's asymptomatic status, frequent ventricular ectopics, and high surgical risk associated with resection, a conservative management strategy was adopted. This included regular Holter monitoring and echocardiography to assess for arrhythmias, tumour progression, or functional compromise. The case underscores the limited evidence available for managing cardiac fibromas in adults, necessitating extrapolation from paediatric data and an individualized, patient-centred approach.

Discussion: This report highlights the challenges of decision-making in adult cardiac fibromas, particularly regarding arrhythmogenic potential and surgical considerations, and emphasizes the need for further studies to establish evidence-based guidelines for this rare condition.

Background: Infective endocarditis caused by Lactobacillus rhamnosus is extremely rare, particularly in immunocompetent patients without structural heart disease or recent invasive procedures.

Case summary: A 42-year-old immunocompetent man with no structural heart disease or recent interventions presented with fever and dyspnoea. Blood cultures grew L. rhamnosus. Transoesophageal echocardiography revealed a large vegetation on the aortic valve causing severe regurgitation, along with severe mitral regurgitation due to anterior leaflet perforation. The only identifiable risk factor was regular probiotic consumption. The patient underwent successful double valve replacement and completed 6 weeks of antibiotic therapy with favourable outcome.

Discussion: A literature review identified 22 published cases of L. rhamnosus endocarditis. Most were associated with underlying valvular disease, invasive procedures, or probiotic use. This case highlights the need to consider Lactobacillus spp. as a potential pathogen, not merely a contaminant, in the appropriate clinical context, and calls for careful patient selection and monitoring when prescribing probiotics.

Background: Thrombotic thrombocytopaenic purpura (TTP) is a rare and potentially life-threatening form of thrombotic microangiopathy, characterized by thrombocytopaenia, haemolytic anaemia, neurological disturbances, and organ dysfunction. Clopidogrel is widely used in patients undergoing percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) due to its antiplatelet effects. However, the occurrence of TTP as an adverse effect of clopidogrel, though rare, requires greater awareness within the medical community.

Case summary: We present a case of a female patient with symptoms of thrombocytopaenia, haemolytic anaemia, neurological disturbances, and renal impairment following clopidogrel administration after PCI for STEMI. The patient was diagnosed with TTP, which was confirmed by the resolving of the symptoms after the withdrawal of clopidogrel.

Discussion: This case underscores the importance of awareness and prompt management of TTP as a serious adverse effect of clopidogrel. The main takeaway is the critical need for clinicians to recognize and address this rare complication to improve patient outcomes. Documenting such cases is essential to raise awareness among healthcare providers about this potentially life-threatening condition.

Background: Pan-valvular heart disease involving both native and prosthetic valves is rare and challenging to manage, especially in frail patients with limited treatment options.

Case summary: A 74-year-old woman on dialysis with prior tricuspid and pulmonary bioprosthetic valve replacements presented with abdominal pain, diarrhoea, dyspnoea, and progressive jaundice. Echocardiography revealed severe aortic stenosis (AS) with pulmonary and tricuspid bioprosthetic valve dysfunction. Right heart catheterization confirmed significant pressure gradients and low cardiac index. Due to financial constraints and the high surgical risk, transcatheter valve-in-valve procedures and surgical treatment were not pursued. Instead, balloon valvuloplasty was performed on all three valves, resulting in transient haemodynamic improvement and bilirubin reduction. The patient later died from complications.

Discussion: This case illustrates the balloon valvuloplasty as a palliative option in pan-valvular heart disease when definitive therapies are inaccessible. Such cases highlight a need for individualized, multidisciplinary care.

[This corrects the article DOI: 10.1093/ehjcr/ytaf579.].