European Heart Journal: Case Reports最新文献

Background: Overdoses of carbamazepine may occur due to various reasons. The summary of product characteristics of carbamazepine includes information about the possibility of side effects after taking this drug. However, the symptoms described do not include coronary vasospasm, which occurred in the case described. Making such a diagnosis is a key element in therapeutic management, as it changes further clinical decisions.

Case summary: A 46-year-old patient was admitted to the hospital for disorders of consciousness following an overdose of carbamazepine. On the second day, the patient exhibited respiratory distress. Subsequently, the patient was transferred to the intensive care unit, intubated, and placed on mechanical ventilation. On the same day, the patient experienced recurrent cardiac arrhythmias in the form of pulseless ventricular tachycardia and ventricular fibrillation; the patient was resuscitated and defibrillated eight times. Due to a rapid decline in cardiac output coupled with persistent electrocardiographic changes and haemodynamic instability, the patient underwent urgent coronary angiography. The procedure revealed a spasm in the initial segment of the circumflex branch of the left coronary artery, which subsequently resolved following nitroglycerin administration. Subsequent to the implementation of this therapeutic approach, a reduction in the demand for norepinephrine and dobutamine was achieved. In the following days, the patient's general condition improved. The patient was discharged home while maintaining full cognitive capacity and cardiovascular and respiratory fitness.

Discussion: In the case described, the expeditious performance of a cardiological diagnostic evaluation played a pivotal role in achieving therapeutic success, enabling the prompt initiation of appropriate treatment.

Background: Spontaneous coronary artery dissection (SCAD) is the most important cause of acute coronary syndromes during pregnancy and in the post-partum period and involves a spontaneous intimal tear or intramural haematoma of a coronary artery. Pregnancy-associated SCAD accounts for a minority of SCAD cases but is associated with a high rate of adverse events.

Case summary: We present a series of three cases with pregnancy-associated SCAD. All patients presented with acute coronary syndromes in the post-partum period, between 12 days and 5 months after delivery. They all had additional conditions that are associated with SCAD, such as fibromuscular dysplasia and migraine. The management of one patient was uncomplicated, however, the courses of the other two were characterized by adverse events. One presented after an out-of-hospital cardiac arrest, the other presented with multivessel SCAD and developed progression and recurrence of SCAD during follow-up. In conclusion, the patients could be successfully treated conservatively and were in good condition at their latest follow-ups.

Discussion: This case series highlights the wide range of clinical courses that could exist in pregnancy-associated SCAD, from a benign manifestation to a life-threatening condition. Importantly, those patients are at an increased risk for acute and late adverse events.

Background: Cor triatriatum sinister (CTS) is a rare congenital heart defect sometimes complicated with atrial fibrillation (AF). Catheter ablation (CA) relieves the AF-associated symptoms, but CA for AF with CTS has been reported rarely. Because CTS can be associated with other congenital heart disease, detailed preoperative assessment is important.

Case summary: An 80-year-old man was referred to our institution for shortness of breath that had persisted for 2 months when he was first diagnosed with AF. Transthoracic echocardiography revealed an enlarged left atrium (LA) divided into two chambers by a membrane. Transoesophageal echocardiography showed the membrane extending from the fossa ovalis (FO) to the Coumadin ridge, with the accessory (dorsal) chamber (AC) in closer proximity to the FO. Computed tomography showed that all pulmonary veins (PVs) flowed into the AC, with no PV anomalies. No other heart anomaly was identified, with no thrombus in the LA. With these findings, PV isolation (PVI) with CA was considered safe. Transseptal puncture was performed with intracardiac echocardiography for precise catheterization of the AC. Pulmonary vein isolation was performed successfully. The patient was discharged 4 days after the procedure, without any complications. His symptoms improved post-procedure, and sinus rhythm was maintained without antiarrhythmic drug therapy during the 18-month follow-up.

Discussion: Cor triatriatum sinister is a rare anomaly that accounts for 0.1% of all congenital heart diseases. Cor triatriatum sinister sometimes complicated with symptomatic AF. Detailed preoperative anatomical assessment with multiple imaging modalities helped us achieve safe and effective CA for a patient with AF and CTS, even in an octogenarian.

Background: Acute coronary syndrome (ACS) is primarily due to obstructive coronary artery disease (CAD). Nevertheless, in 1-14% of cases, ACS is present without evidence of obstructive CAD. Coronary artery spasm is an uncommon cause of ACS. Diagnostic work-up includes acute invasive coronary angiography and afterwards provocation testing. The optimal patient management is for patients presenting with cardiogenic shock due to ACS caused by coronary artery spasm is unclear.

Case summary: A 67-year-old Caucasian, who underwent elective revision of hip arthroplasty, presented with ST elevations with circulatory collapse, leading to resuscitation due to anaesthesia induction. Extracorporeal membrane oxygenation (ECMO) implantation led to restoration of spontaneous circulation. Coronary angiography revealed coronary vasospasm, which was successfully treated with nitrates i.c. Later, despite of implanted ECMO, recurring haemodynamic deterioration required continuous administration of nitrates i.v., which finally resulted in the stabilization of circulatory system. Extracorporeal membrane oxygenation removal was possible 48 h after implantation and another 12 h later we extubated the patient. Furthermore, we administered calcium antagonists and an intra-cardiac defibrillator was implanted. Finally, the patient was discharged 12 days after admission with no physical or neurological restrictions after resuscitation.

Discussion: This unique case highlights that rare causes of severe ACS with cardiogenic shock need to be considered. Administration of vasodilators, which are not part of the standard care in cardiogenic shock, represents the adequate treatment of a patient with spasm of coronary arteries. Furthermore, the recurrence of acute coronary events must be prevented by drug and device therapy in these patients.

Background: An atrioventricular node (AVN) ablation and permanent pacing have been previously reported as effective treatments for patients with atrial tachyarrhythmias. However single-ventricle patients requiring chronic ventricular pacing are at a higher risk of developing ventricular dysfunction and atrioventricular valve regurgitation. We report a case of successful AVN ablation in a 3-month-old infant with hypoplastic left heart syndrome and ectopic atrial tachycardia (EAT).

Case summary: A boy with hypoplastic left heart syndrome who had a refractory EAT resistant to various medications. At 2 months old, we performed an urgent radiofrequency (RF) catheter ablation of the EAT and the applications delivered at the cavo-atrial junction. Although it disappeared after the first catheter ablation for 2 weeks, it recurred on the next day after the diaphragm plication. At 3 months old and weighed 3.1 kg, we decided to perform an urgent AVN ablation of the EAT. The application was performed on the mid-septum of the tricuspid septum. A permanent pacemaker was implanted after the ablation. After the AVN ablation, the haemodynamics stabilized during the EAT. However, he died from a bacteraemia infection at 4 months.

Discussion: This patient received an AVN ablation due to failure to previous RF catheter ablation and was haemodynamically stable with the dual-chamber pacemaker. The AV block was successfully created by RF energy on the mid-septum of the tricuspid annulus in this hypoplastic left heart syndrome patient. Pathological findings exhibited that the compact AVN was totally ablated without damage to the tricuspid leaflets or coronary artery.

Background: Radiofrequency catheter ablation in the left ventricular summit region is a challenging procedure due to proximity to the coronary arteries. Pulsed field ablation, a novel non-thermal ablation modality, does not cause damage to coronary arteries and may be used in the left ventricular summit region.

Case summary: We describe a 45-year-old symptomatic patient with epicardial left ventricular summit premature ventricular complexes. Successful ablation of the focus was achieved by pulsed field ablation via a subxiphoid epicardial approach. Radiofrequency ablation would most likely have been ineffective due to the epicardial fat layer and potentially unsafe due to the proximity to the coronary arteries. Six months after ablation, the patient was asymptomatic and without ventricular ectopy.

Discussion: For the first time, epicardial pulsed field ablation was successfully used for ablation of left ventricular summit extrasystole, where radiofrequency ablation could not be used because of the proximity of the coronary arteries. We conclude that pulsed field ablation might be a feasible option for this indication.

Background: In patients with non-valvular atrial fibrillation (AF), at high stroke risk, and who are ineligible for long-term oral anticoagulation, the left atrial appendage closure (LAAC) could be an alternative to anticoagulation. Pulsed field ablation (PFA) is a new non-thermal method for cardiac ablation modality based on high-voltage electrical energy for irreversible electroporation. We first report a case of a concomitant PFA pulmonary vein isolation (PVI) and LAAC.

Case summary: A 74-year-old female patient was referred to our department for PVI for persistent AF (CHA₂DS₂-VASc score 5). A concomitant percutaneous LAAC was proposed because of a history of previous cerebellar transient ischaemic attack despite continuous oral anticoagulation therapy. Pulmonary vein isolation was achieved with a pentaspline PFA catheter, and LAAC was performed with a WATCHMAN FLX™ device (Boston Scientific, Plymouth, MN, USA). After PVI, a swelling of the left atrial ridge was observed, yet a 27 mm LAAC device was successfully implanted. The follow-up transesophageal echo (TEE) after 6 weeks showed complete resolution of the oedema, no device-related thrombus, but a slight proximal tilting of the LAAC device without leakage could be observed. The 6-month follow-up demonstrated a stable sinus rhythm, no stroke, or bleeding events were recorded.

Discussion: In this case of synchronous PFA-PVI procedure in AF and WATCHMAN FLX™ device implantation, the electroporation created an acute oedema at the ridge level which at the TEE follow-up after 6 weeks was resolved. This resulted in a slightly tilted WATCHMAN device position which was nevertheless stable and showed no leakage.

Background: Takayasu's arteritis is an infrequent manifestation of vasculitis affecting the aorta and its primary branches with numerous symptoms. This report details a rare case wherein a patient developed interventricular septal dissection following aortic valve replacement.

Case summary: A middle-aged woman diagnosed with Takayasu's arteritis previously underwent aortic valve replacement with a mechanical valve owing to severe aortic regurgitation. Subsequently, she received a redo aortic valve replacement following an episode of prosthetic valve infective endocarditis with paravalvular leak. Heart failure symptoms emerged during follow-up, revealing aortic root dissection extending into the interventricular septum, causing significant prosthetic valve movement. A Trido Bentall operation and interventricular septum repair were performed, and the patient recovered smoothly.

Discussion: Interventricular dissection, although uncommon, may be due to factors such as infection, myocardial infarction, congenital anomalies, trauma, or post-surgical shear stress. Timely diagnosis is imperative to prevent life-threatening complications; surgery remains the primary treatment. The present case report describes a rare presentation that was successfully managed through a Bentall operation and underscores the necessity of prompt intervention in treating this condition.

Background: Phaeochromocytoma multisystem crisis (PMC) is characterized by labile blood pressures (extremes of hypo- and/or hypertension) and multiorgan failure as a result of catecholamine excess. Initial stabilization requires pharmacological and/or mechanical circulatory support, followed by the institution of antihypertensives to correct the underlying pathophysiology.

Case summary: A previously well 40-year-old male developed a sudden onset of breathlessness. On presentation, he was in shock with multiorgan failure. He required intubation, mechanical ventilation, dual inotropic support, and renal replacement therapy. Bedside echocardiogram showed a severely impaired left ventricular ejection fraction (LVEF) of 25%. Coronary angiography revealed normal coronary arteries. In view of raised inflammatory markers and transaminitis, a computed tomography abdomen/pelvis was performed. An incidental left adrenal mass was found. Further work-ups revealed raised plasma metanephrine and normetanephrine, 24-h urine epinephrine, and norepinephrine. A cardiac magnetic resonance (CMR) showed myocardial inflammation and reverse Takotsubo pattern of regional wall motion abnormality (RWMA). The diagnosis of cardiogenic shock and stress cardiomyopathy secondary to PMC was made. He was subsequently initiated on α- and β-blockers and goal-directed medical therapy for heart failure. A ⁶⁸Ga-DOTATATE scan showed avid tracer uptake of the left phaeochromocytoma. An interval CMR 3 weeks from presentation showed near normalization of the LVEF and RWMA. He underwent a successful laparoscopic left adrenalectomy and was antihypertensive-free since.

Discussion: The clinical suspicion for PMC as the cause of cardiogenic shock requires astute clinical judgement, while the management requires an understanding of the underlying pathophysiology that calls for multidisciplinary inputs.