European Heart Journal: Case Reports最新文献

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.

Background: Shone syndrome is a complex congenital cardiac condition describing multiple obstructive left-sided heart lesions. We present four cases of pregnancies in three women with Shone syndrome and the role for preconception counseling and multidisciplinary delivery planning.

Case summary: Single-centre chart review of pregnant women with Shone syndrome over 5 years, including maternal and foetal outcomes and delivery plans. There were four deliveries amongst three nulliparous women ages 25-31 years with prior surgical repairs for Shone syndrome. Multidisciplinary delivery planning occurred in the third trimester of each pregnancy. There were four term deliveries (vaginal deliveries for three, caesarean for one) with cardiac monitoring and adjustments to typical peripartum protocols. One patient required acute intensive care unit care for postpartum tachycardia and pulmonary oedema, and another required medical management of gestational hypertension. One infant required neonatal intensive care for respiratory distress. All patients and infants were discharged by postpartum Day 3 without early readmission. One patient developed acute decompensated heart failure at 7 months postpartum and died following cardiac arrest.

Discussion: Women with Shone syndrome possess multiple obstructive cardiac lesions often considered in isolation as high risk for cardiac events in pregnancy, though not completely captured in risk prediction algorithms and with heterogeneity requiring case-by-case management. Multidisciplinary delivery planning including cardiologists, obstetricians, and obstetric anaesthesiologists can safely navigate immediate maternal and neonatal care needs. Pre-conception counselling and close follow-up are imperative.

Background: Stereotactic arrhythmia radiotherapy (STAR) is a novel, non-invasive therapeutic option for managing ventricular tachycardia (VT), including in patients with chronic Chagas cardiomyopathy (CCC). However, the histopathological substrate underlying its antiarrhythmic effect remains poorly defined, particularly in the Chagas population. This study aims to characterize the myocardial tissue changes following STAR in two CCC patients, evaluated at different time points after treatment.

Case summary: Two CCC patients with recurrent VT underwent STAR as part of a multidisciplinary treatment protocol. One patient died 50 days post-STAR, and the other underwent heart transplantation 702 days after the procedure. Myocardial tissue was collected from irradiated and non-irradiated regions. Gross pathology, histological staining (haematoxylin-eosin and Masson's trichrome), and immunohistochemistry for apoptosis markers (p53, Bcl-2, and caspase-3) were performed and analysed by a cardiac pathologist. Macroscopic analysis showed fibrosis in the STAR-targeted areas. Histological evaluation revealed varying degrees of myocyte damage, including cytoplasmic vacuolization and myocytolysis, more pronounced in the early post-STAR case. Extensive fibrosis was present in both cases, but also observed in non-irradiated areas, reflecting underlying CCC pathology. Immunohistochemistry for apoptosis markers was negative in both patients.

Conclusion: Stereotactic arrhythmia radiotherapy areas present myocardial changes consistent with acute cellular injury and fibrosis in CCC patients treated for VT. However, apoptotic activity was not detected within the analysed timeframe. Fibrosis was found in both irradiated and non-irradiated areas, and differentiating STAR-induced fibrosis from baseline Chagas-related remodelling remains challenging.