V. Sasi, G. Fontos, Á. Kormányos, M. Vértesaljai, Zoltán Ruzsa
Severe aortic paravalvular leaks (PVL) after surgical mechanical aortic valve replacement (AVR) represent high risk for congestive heart failure, haemolysis and infective endocarditis. This is the first case of distal radial artery (DRA) access use for severe mechanical aortic paravalvular leak closure with sequential double vascular plug guided by computed tomography angiography (CTA), transoesophageal echocardiography (TOE) and 3D TOE in acute setting. A 51-year old male presented with significant mixed aortic valve disease. According to guidelines AVR was performed (Slimline Bicarbon A-25mm). Four and 16 days later re-exploration was carried out due to pericardial effusion. Four months after discharge from rehabilitation the patient was readmitted due to worsening dyspnoea on exertion, then at rest. Transthoracic echocardiography (TTE), TOE and consequently CTA revealed severe PVL. Transcatheter PVL closure was opted. DRA access was preferred. After CTA scan analysis, angiographic, TOE and 3D TOE visualization of the leak a 14/5mm and a 10/5mm vascular plug (AVPIII) was deployed to achieve good result. 9-month clinical, echocardiographic and CTA follow up revealed good long term result. For transcatheter PVL closure CTA is helpful with not only vascular access planning, but visualization of the leak size, location and device planning. This case demonstrates that the distal radial approach is feasible in cases of severe mechanical aortic valve PVL retrograde transcatheter closure. DRA access could possibly represent less bleeding and vascular access site complications when compared with femoral access and has some potential advantages over regular radial access.
{"title":"First application of the distal radial approach for severe mechanical surgical aortic valve paravalvular leak transcatheter closure with double vascular plug: a case report","authors":"V. Sasi, G. Fontos, Á. Kormányos, M. Vértesaljai, Zoltán Ruzsa","doi":"10.1093/ehjcr/ytae366","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae366","url":null,"abstract":"\u0000 \u0000 \u0000 Severe aortic paravalvular leaks (PVL) after surgical mechanical aortic valve replacement (AVR) represent high risk for congestive heart failure, haemolysis and infective endocarditis. This is the first case of distal radial artery (DRA) access use for severe mechanical aortic paravalvular leak closure with sequential double vascular plug guided by computed tomography angiography (CTA), transoesophageal echocardiography (TOE) and 3D TOE in acute setting.\u0000 \u0000 \u0000 \u0000 A 51-year old male presented with significant mixed aortic valve disease. According to guidelines AVR was performed (Slimline Bicarbon A-25mm). Four and 16 days later re-exploration was carried out due to pericardial effusion. Four months after discharge from rehabilitation the patient was readmitted due to worsening dyspnoea on exertion, then at rest. Transthoracic echocardiography (TTE), TOE and consequently CTA revealed severe PVL. Transcatheter PVL closure was opted. DRA access was preferred. After CTA scan analysis, angiographic, TOE and 3D TOE visualization of the leak a 14/5mm and a 10/5mm vascular plug (AVPIII) was deployed to achieve good result. 9-month clinical, echocardiographic and CTA follow up revealed good long term result.\u0000 \u0000 \u0000 \u0000 For transcatheter PVL closure CTA is helpful with not only vascular access planning, but visualization of the leak size, location and device planning. This case demonstrates that the distal radial approach is feasible in cases of severe mechanical aortic valve PVL retrograde transcatheter closure. DRA access could possibly represent less bleeding and vascular access site complications when compared with femoral access and has some potential advantages over regular radial access.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141804879","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hypersensitivity reaction is a rare side effect during immunosuppressive treatment with azathioprine (AZA). Some cases of cardiac involvement have already been reported but causality is notoriously difficult to prove. We present the case of a 68-year-old man with two episodes of reversible left ventricular (LV) dysfunction. One month after treatment initiation with AZA, he developed non-specific symptoms, including mild chest pain. In the context of elevated cardiac biomarkers and markers of inflammation, echocardiography showed depressed systolic LV function. Biventricular dysfunction was shown on cardiac magnetic resonance imaging (CMR), but neither myocardial oedema nor late gadolinium enhancement was documented. There was full recovery of LV function after AZA discontinuation. Very similar clinical course and echocardiography findings were observed early after restarting AZA treatment. After definitive cessation of AZA, systolic LV function recovered again and remained stable throughout long-term follow-up. Hypersensitivity reaction with cardiac involvement due to AZA is rare. The exact mechanisms underlying AZA-related cardiac dysfunction are still not completely understood, and causality is often difficult to prove. However, because of re-exposure to the drug, which, considered retrospectively, was inappropriate, the effect was clearly apparent in our patient. Knowledge of this potentially life-threatening side effect of AZA treatment is important. AZA must be discontinued promptly if there is any evidence of hypersensitivity reaction.
{"title":"A case report of reversible left ventricular dysfunction due to azathioprine hypersensitivity syndrome","authors":"Daniel Lüscher, Micha T Maeder, Eva Scheler","doi":"10.1093/ehjcr/ytae368","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae368","url":null,"abstract":"\u0000 \u0000 \u0000 Hypersensitivity reaction is a rare side effect during immunosuppressive treatment with azathioprine (AZA). Some cases of cardiac involvement have already been reported but causality is notoriously difficult to prove.\u0000 \u0000 \u0000 \u0000 We present the case of a 68-year-old man with two episodes of reversible left ventricular (LV) dysfunction. One month after treatment initiation with AZA, he developed non-specific symptoms, including mild chest pain. In the context of elevated cardiac biomarkers and markers of inflammation, echocardiography showed depressed systolic LV function. Biventricular dysfunction was shown on cardiac magnetic resonance imaging (CMR), but neither myocardial oedema nor late gadolinium enhancement was documented. There was full recovery of LV function after AZA discontinuation. Very similar clinical course and echocardiography findings were observed early after restarting AZA treatment. After definitive cessation of AZA, systolic LV function recovered again and remained stable throughout long-term follow-up.\u0000 \u0000 \u0000 \u0000 Hypersensitivity reaction with cardiac involvement due to AZA is rare. The exact mechanisms underlying AZA-related cardiac dysfunction are still not completely understood, and causality is often difficult to prove. However, because of re-exposure to the drug, which, considered retrospectively, was inappropriate, the effect was clearly apparent in our patient. Knowledge of this potentially life-threatening side effect of AZA treatment is important. AZA must be discontinued promptly if there is any evidence of hypersensitivity reaction.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141803693","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Kana Fujita, Yoshitaka Ohashi, Yoshinori Nagasawa, Tomoyuki Otani, K. Hatakeyama
Immunotherapy with immune checkpoint inhibitors (ICIs) enhance the host immune reaction against tumour cells by inhibiting intrinsic down-regulators of the T cell-mediated immune response. Although the advent of ICIs has dramatically changed oncology, ICIs may also trigger an overactivation of T cells against non-cancerous tissues, leading to off-target immune-related adverse events (irAEs). A 64-year-old man with a history of seven courses of atezolizumab, an ICI, for small-cell lung cancer and Coronavirus disease 2019 (COVID-19) as admitted to the hospital complaining of acute chest pain. Transthoracic echocardiography showed preserved ejection fraction (EF), but electrocardiography indicated precordial ST elevations and marked increases in biomarkers for myocardial injury were observed. Emergent cardiac catheterization showed no significant coronary stenosis. On the fifth hospital day, EF decreased to 25% and pericardial effusion occurred. Endomyocardial biopsy was immediately performed, and prednisolone (60 mg/day) was administered. Troponin I level rapidly reduced, ST change and EF improved. Histological examinations demonstrated CD8-predominant T lymphocytic infiltration with myocardial cell injury, consistent with irAE-myocarditis. In irAEs, myocarditis is the most common and severe cardiac manifestation with a high mortality. Even at 20 weeks after the initial ICI treatment, irAE-myocarditis occurs and the clinical presentation may mimic ST elevation myocardial infarction. The histopathological findings suggested the high possibility of irAE-myocarditis rather than COVID-19-induced myocarditis, but COVID-19 has possibly played a role in the development of late-onset irAE-myocarditis. This educational case implies the importance of immediate recognition of irAE even after stable ICI treatment.
免疫检查点抑制剂（ICIs）免疫疗法通过抑制T细胞介导免疫反应的内在下调因子，增强宿主对肿瘤细胞的免疫反应。尽管 ICIs 的出现极大地改变了肿瘤学，但 ICIs 也可能引发 T 细胞对非癌组织的过度激活，导致脱靶免疫相关不良事件（irAEs）。 一名 64 岁的男性因急性胸痛入院，主诉其曾因小细胞肺癌和 2019 年冠状病毒病（COVID-19）接受过七个疗程的阿特珠单抗（一种 ICI）治疗。经胸超声心动图显示射血分数（EF）保留，但心电图显示心前区ST段抬高，并观察到心肌损伤生物标志物明显增加。急诊心导管检查显示冠状动脉无明显狭窄。住院第五天，EF 降至 25%，并出现心包积液。立即进行了心内膜活检，并服用了强的松龙（60 毫克/天）。肌钙蛋白 I 水平迅速降低，ST 改变和 EF 改善。组织学检查显示，CD8为主的T淋巴细胞浸润伴有心肌细胞损伤，与虹膜急性心肌梗死一致。 在虹膜急性心肌梗死中，心肌炎是最常见、最严重的心脏表现，死亡率很高。即使在首次接受 ICI 治疗 20 周后，也会发生虹膜急性心肌炎，其临床表现可能与 ST 段抬高型心肌梗死相似。组织病理学结果表明，irAE-心肌炎的可能性很大，而不是 COVID-19 引发的心肌炎，但 COVID-19 可能在晚发性irAE-心肌炎的发展中起了一定作用。这一具有教育意义的病例表明，即使在接受了稳定的 ICI 治疗后，也应立即识别虹膜急性心肌炎。
{"title":"Immune-related adverse event-myocarditis with marked ST-segment elevation requiring differentiation from COVID-19-induced myocarditis: a case report","authors":"Kana Fujita, Yoshitaka Ohashi, Yoshinori Nagasawa, Tomoyuki Otani, K. Hatakeyama","doi":"10.1093/ehjcr/ytae370","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae370","url":null,"abstract":"\u0000 \u0000 \u0000 Immunotherapy with immune checkpoint inhibitors (ICIs) enhance the host immune reaction against tumour cells by inhibiting intrinsic down-regulators of the T cell-mediated immune response. Although the advent of ICIs has dramatically changed oncology, ICIs may also trigger an overactivation of T cells against non-cancerous tissues, leading to off-target immune-related adverse events (irAEs).\u0000 \u0000 \u0000 \u0000 A 64-year-old man with a history of seven courses of atezolizumab, an ICI, for small-cell lung cancer and Coronavirus disease 2019 (COVID-19) as admitted to the hospital complaining of acute chest pain. Transthoracic echocardiography showed preserved ejection fraction (EF), but electrocardiography indicated precordial ST elevations and marked increases in biomarkers for myocardial injury were observed. Emergent cardiac catheterization showed no significant coronary stenosis. On the fifth hospital day, EF decreased to 25% and pericardial effusion occurred. Endomyocardial biopsy was immediately performed, and prednisolone (60 mg/day) was administered. Troponin I level rapidly reduced, ST change and EF improved. Histological examinations demonstrated CD8-predominant T lymphocytic infiltration with myocardial cell injury, consistent with irAE-myocarditis.\u0000 \u0000 \u0000 \u0000 In irAEs, myocarditis is the most common and severe cardiac manifestation with a high mortality. Even at 20 weeks after the initial ICI treatment, irAE-myocarditis occurs and the clinical presentation may mimic ST elevation myocardial infarction. The histopathological findings suggested the high possibility of irAE-myocarditis rather than COVID-19-induced myocarditis, but COVID-19 has possibly played a role in the development of late-onset irAE-myocarditis. This educational case implies the importance of immediate recognition of irAE even after stable ICI treatment.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141807535","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined. We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines the patient spontaneously converted to sinus rhythm. Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra PV triggers can be considered to treat patients with persistent AF and durable PVI.
{"title":"Case report of persistent atrial fibrillation with durably isolated PVs: What’s next?","authors":"Philipp Bengel, Samuel Sossalla, Borislav Dinov","doi":"10.1093/ehjcr/ytae358","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae358","url":null,"abstract":"\u0000 \u0000 \u0000 Pulmonary vein isolation (PVI) has emerged as a safe and effective treatment for patients with paroxysmal and persistent atrial fibrillation. Nevertheless, in some patients a relapse of atrial fibrillation occurs although pulmonary veins are durably isolated. For those patients the underlying mechanisms of atrial fibrillation perpetuation are manifold and optimal treatment options are not yet defined.\u0000 \u0000 \u0000 \u0000 We describe a case of a 55-year-old man with a history of atrial fibrillation and previous PVI presenting with persistent AF and arrhythmia induced cardiomyopathy. During the redo procedure electro-anatomical mapping revealed durably isolated PV. Bipolar mapping showed large low-voltage areas at the posterior wall and the septum. As the patient was refractory to electrical cardioversion it was decided to modify the large low-voltage areas as potential arrhythmic substrate. After performing additional ablation with isolation of the posterior wall and two anterior/septal lines the patient spontaneously converted to sinus rhythm.\u0000 \u0000 \u0000 \u0000 Ablation in patients with persistent AF despite durable PVI remains a challenge for the treating team. Individualized ablation approaches addressing additional arrhythmic substrates or extra PV triggers can be considered to treat patients with persistent AF and durable PVI.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141812730","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
N. Tsuboya, Y. Mitani, Hiroyuki Ohashi, H. Sawada, Masahiro Hirayama
In cases of atrial septal defect with pulmonary arterial hypertension (PAH), a treat-and-repair strategy that adopts pulmonary vasodilator therapy and subsequent defect closure is postulated to be effective. However, this strategy has not been applied to large patent ductus arteriosus (PDA) with PAH. A 10-year-old girl with trisomy 21 was referred to our hospital for the treatment of large PDA with PAH. Cardiac catheterisation and angiography revealed a type C tubular PDA with a minimal diameter of 8.1 mm, an increase in mean pulmonary artery pressure (mPAP) 60mmHg, the ratio of pulmonary to systemic blood flow (Qp/Qs) 2.7 and pulmonary artery resistance (Rp) 7.1 U·m2. Because she was categorized in the grey zone for operability, we adopted a hybrid treat and repair strategy, in which palliative surgical duct banding was performed before pulmonary vasodilator therapy to prevent excessive pulmonary blood flow and was followed by transcatheter closure of PDA. Postoperatively, we confirmed the flow-restricted duct with a minimal diameter of 3.3 mm, decreased Qp/Qs 1.38, high mPAP 40mmHg, and Rp 7.3 U·m2. Six months after treatment with macitentan and tadalafil, we confirmed a decrease in Rp 4.1 U·m2 as well as low Qp/Qs 1.12, which was low enough for the duct occlusion. The transcatheter occlusion of the surgically created type A conical duct was easily and safely performed. In the mid-term follow-up, favourable haemodynamics and improved exercise were confirmed. This is the first proof-of-concept case report to show the successful hybrid treat and repair strategy for large PDA, which warrants further investigation.
{"title":"Hybrid Treat and Repair Strategy for Large Patent Ductus Arteriosus: A Proof-of-Concept Case Report","authors":"N. Tsuboya, Y. Mitani, Hiroyuki Ohashi, H. Sawada, Masahiro Hirayama","doi":"10.1093/ehjcr/ytae354","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae354","url":null,"abstract":"\u0000 \u0000 \u0000 In cases of atrial septal defect with pulmonary arterial hypertension (PAH), a treat-and-repair strategy that adopts pulmonary vasodilator therapy and subsequent defect closure is postulated to be effective. However, this strategy has not been applied to large patent ductus arteriosus (PDA) with PAH.\u0000 \u0000 \u0000 \u0000 A 10-year-old girl with trisomy 21 was referred to our hospital for the treatment of large PDA with PAH. Cardiac catheterisation and angiography revealed a type C tubular PDA with a minimal diameter of 8.1 mm, an increase in mean pulmonary artery pressure (mPAP) 60mmHg, the ratio of pulmonary to systemic blood flow (Qp/Qs) 2.7 and pulmonary artery resistance (Rp) 7.1 U·m2. Because she was categorized in the grey zone for operability, we adopted a hybrid treat and repair strategy, in which palliative surgical duct banding was performed before pulmonary vasodilator therapy to prevent excessive pulmonary blood flow and was followed by transcatheter closure of PDA. Postoperatively, we confirmed the flow-restricted duct with a minimal diameter of 3.3 mm, decreased Qp/Qs 1.38, high mPAP 40mmHg, and Rp 7.3 U·m2. Six months after treatment with macitentan and tadalafil, we confirmed a decrease in Rp 4.1 U·m2 as well as low Qp/Qs 1.12, which was low enough for the duct occlusion. The transcatheter occlusion of the surgically created type A conical duct was easily and safely performed. In the mid-term follow-up, favourable haemodynamics and improved exercise were confirmed.\u0000 \u0000 \u0000 \u0000 This is the first proof-of-concept case report to show the successful hybrid treat and repair strategy for large PDA, which warrants further investigation.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141813232","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Takotsubo syndrome (TTS) is characterized by transient regional left ventricular dysfunction occurring in individuals exposed to physical or emotional stress. Various stressors are triggers for TTS in cancer patients, and anti-cancer drugs have recently been proposed as a trigger. Therefore, further studies are needed to clarify these triggers and avoid the unnecessary interruption of anti-cancer treatment. A 66-year-old woman presented with dyspnea 10 days after the initiation of atezolizumab in combination with bevacizumab. She had previously received osimertinib as first-line therapy for recurrent lung cancer after primary resection and atezolizumab in combination with bevacizumab, paclitaxel, and carboplatin as second-line therapy. She was admitted due to electrocardiography abnormalities and elevated troponin I and BNP levels. Echocardiography revealed circumferential severe left ventricular (LV) hypokinesis at the mid-ventricular level, with preserved wall motion at the base and apex. Cardiac catheterization performed after the attenuation of symptoms with 20 mg of intravenous furosemide showed normal coronary arteries. Cardiac MRI on Day 4 revealed increases in T1 and T2 values and extracellular volume fraction; however, neither myocardial infiltration of inflammatory cells or myocardial necrosis was observed in endomyocardial samples obtained on the day of her arrival. Atypical TTS was suspected and she was treated with perindopril, bisoprolol, and spironolactone. MRI 1.5 months after the onset of TTS showed improvements in LV contractility, T1 and T2 values, and the extracellular volume fraction. A more detailed understanding of the relationship between anti-cancer drugs and TTS is crucial for preventing interruptions to anti-cancer therapy.
{"title":"Takotsubo syndrome in a Cancer Patient Treated with a Combination of Anti-cancer Drugs Including Immune Checkpoint Inhibitors: A Case Report","authors":"Keita Yamada, Mizuki Ida-Ichikawa, Naoki Fujimoto, Masaki Ishida, Kaoru Dohi","doi":"10.1093/ehjcr/ytae355","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae355","url":null,"abstract":"\u0000 \u0000 \u0000 Takotsubo syndrome (TTS) is characterized by transient regional left ventricular dysfunction occurring in individuals exposed to physical or emotional stress. Various stressors are triggers for TTS in cancer patients, and anti-cancer drugs have recently been proposed as a trigger. Therefore, further studies are needed to clarify these triggers and avoid the unnecessary interruption of anti-cancer treatment.\u0000 \u0000 \u0000 \u0000 A 66-year-old woman presented with dyspnea 10 days after the initiation of atezolizumab in combination with bevacizumab. She had previously received osimertinib as first-line therapy for recurrent lung cancer after primary resection and atezolizumab in combination with bevacizumab, paclitaxel, and carboplatin as second-line therapy. She was admitted due to electrocardiography abnormalities and elevated troponin I and BNP levels. Echocardiography revealed circumferential severe left ventricular (LV) hypokinesis at the mid-ventricular level, with preserved wall motion at the base and apex. Cardiac catheterization performed after the attenuation of symptoms with 20 mg of intravenous furosemide showed normal coronary arteries. Cardiac MRI on Day 4 revealed increases in T1 and T2 values and extracellular volume fraction; however, neither myocardial infiltration of inflammatory cells or myocardial necrosis was observed in endomyocardial samples obtained on the day of her arrival. Atypical TTS was suspected and she was treated with perindopril, bisoprolol, and spironolactone. MRI 1.5 months after the onset of TTS showed improvements in LV contractility, T1 and T2 values, and the extracellular volume fraction.\u0000 \u0000 \u0000 \u0000 A more detailed understanding of the relationship between anti-cancer drugs and TTS is crucial for preventing interruptions to anti-cancer therapy.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141814309","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%. A 52-year–old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the LM/LAD area, likely caused by the coronary snare. These interventions were crucial in stabilising the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up. Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal, however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach. This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.
{"title":"Consequences and Management of Guidewire Fracture—Entrapment in the Left Circumflex Artery: A Case Report","authors":"Mathews Paul","doi":"10.1093/ehjcr/ytae341","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae341","url":null,"abstract":"\u0000 \u0000 \u0000 Entrapment and fracture of the coronary guidewire are rare but major complications of percutaneous coronary intervention (PCI). The incidence of these complications is reported to be <1%.\u0000 \u0000 \u0000 \u0000 A 52-year–old male patient with diabetes and dyslipidaemia presented with posterior wall myocardial infarction. An angiogram revealed occlusion in the left circumflex (LCX) artery. Attempts to pass a guidewire through the lesion led to its entrapment and eventual fracture. Several techniques and manoeuvres failed to retrieve the fractured guidewire, which remained lodged in the LCX. An endovascular snare catheter also proved unsuccessful. The fragment was eventually removed using the triple-wire technique, although this caused coronary perforation and dissection. The perforation was identified and stented. A subsequent stent addressed a dissection in the LM/LAD area, likely caused by the coronary snare. These interventions were crucial in stabilising the patient's condition, leading to recovery with a left ventricular ejection fraction of 50% and a viable LCX artery. The patient exhibited an uneventful progression at the 1-year follow-up.\u0000 \u0000 \u0000 \u0000 Coronary guidewire fracture during PCI is a rare event often associated with coronary calcifications. Percutaneous removal remains the mainstay treatment for fragment removal, however, it carries risks. The triple-wire technique, a newer method that entangles and extracts the fractured guidewire without specialized equipment, was effective in removing the fragmented guidewire. If asymptomatic, leaving the wire in situ is documented as a favourable approach.\u0000 \u0000 \u0000 \u0000 This case highlights that the triple-wire technique can effectively be used for the extraction of fractured guidewire fragments from the coronary vessels.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141810436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cetera Vera, Cantinotti Massimiliano, Barberi Elisa, Pak Vitali
Abiotrophia defectiva forms Gram-positive cocci, part of normal oropharyngeal and gastrointestinal flora and is rarely involved in endocarditis in children population. Its special nutritional requirements and subacute clinical course, may delay diagnosis and proper treatment, leading to life-threatening consequences. We report a rare case of huge and destructive Abiotrophia Defectiva infective endocarditis of the aortic valve and the aortic wall in a 3-years-old child, in follow-up after surgical valvuloplasty for congenital aortic stenosis. The child presented at our department with signs of left side hemiplegia. Transthoracic echocardiography showed severe aortic regurgitation due to large vegetation extending to the aortic wall up to the aortic arch. Blood cultures resulted positive for A. Defectiva. Initially treated conservatively with antibiotic therapy, but 10 days after admission, sudden clinical deterioration, required intubation and an emergency Ross-Konno operation. Despite the critical conditions and highly risky surgery, the child recovered well and was discharged home 5 weeks after the operation. A. Defectiva IE is rare in children. Since 1995, only sixteen cases of A. Defectiva IE have been reported in children, including our case. This pathogen has a higher rate of complications when affecting children rather than adult population. Our case demonstrates that conservative strategy with antibiotics is rarely resolutive in case of IE caused by A. Defectiva. Whenever one or more indications for surgery are present, surgical intervention should be always taken into consideration, even if clinical conditions are prohibitive and surgery is at very high risk.
{"title":"Huge, Invasive, and Destructive Abiotrophia Defectiva Endocarditis of the Aortic Valve and the Aortic Wall. A Case Report of an Emergency but Successful Ross-Konno Operation in a Child","authors":"Cetera Vera, Cantinotti Massimiliano, Barberi Elisa, Pak Vitali","doi":"10.1093/ehjcr/ytae356","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae356","url":null,"abstract":"\u0000 \u0000 \u0000 Abiotrophia defectiva forms Gram-positive cocci, part of normal oropharyngeal and gastrointestinal flora and is rarely involved in endocarditis in children population. Its special nutritional requirements and subacute clinical course, may delay diagnosis and proper treatment, leading to life-threatening consequences.\u0000 \u0000 \u0000 \u0000 We report a rare case of huge and destructive Abiotrophia Defectiva infective endocarditis of the aortic valve and the aortic wall in a 3-years-old child, in follow-up after surgical valvuloplasty for congenital aortic stenosis. The child presented at our department with signs of left side hemiplegia. Transthoracic echocardiography showed severe aortic regurgitation due to large vegetation extending to the aortic wall up to the aortic arch. Blood cultures resulted positive for A. Defectiva. Initially treated conservatively with antibiotic therapy, but 10 days after admission, sudden clinical deterioration, required intubation and an emergency Ross-Konno operation. Despite the critical conditions and highly risky surgery, the child recovered well and was discharged home 5 weeks after the operation.\u0000 \u0000 \u0000 \u0000 A. Defectiva IE is rare in children. Since 1995, only sixteen cases of A. Defectiva IE have been reported in children, including our case. This pathogen has a higher rate of complications when affecting children rather than adult population. Our case demonstrates that conservative strategy with antibiotics is rarely resolutive in case of IE caused by A. Defectiva. Whenever one or more indications for surgery are present, surgical intervention should be always taken into consideration, even if clinical conditions are prohibitive and surgery is at very high risk.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141811149","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jasmin Büchel, Gregor Leibundgut, P. Badertscher, Michael Kühne, P. Krisai
We report endocardial radiofrequency (RF) ablation as an alternative treatment approach for a symptomatic patient with obstructive hypertrophic cardiomyopathy (oHCM), who is not suitable for surgical septal myectomy or alcohol septal ablation. Endocardial RF ablation, with detailed 3D-mapping of the intrinsic conducting system, offers the possibility of reducing the risk of complete heart block rates and of effectively relieving symptoms. We present a symptomatic 51-year-old female patient with oHCM and a maximum left ventricular outflow tract (LVOT) gradient of 148mmHg. Because of alcohol septal ablation failure, endocardial RF ablation in combination with detailed mapping of the intrinsic conduction system and intraprocedural imaging was performed. The 6-month follow-up showed a significant improvement in exercise tolerance, no relevant dynamic LVOT obstruction with a gradient of 22mmHg under Valsalva. In the current case report, endocardial RF ablation persistently reduced LVOT gradients in a patient with oHCM. Pre-interventional imaging, detailed 3D-mapping of the conduction system and correlation to intracardiac and transthoracic echocardiography were key for an effective and safe ablation of a small target zone.
{"title":"Radiofrequency Ablation in Obstructive Hypertrophic Cardiomyopathy: A Case Report","authors":"Jasmin Büchel, Gregor Leibundgut, P. Badertscher, Michael Kühne, P. Krisai","doi":"10.1093/ehjcr/ytae359","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae359","url":null,"abstract":"\u0000 \u0000 \u0000 We report endocardial radiofrequency (RF) ablation as an alternative treatment approach for a symptomatic patient with obstructive hypertrophic cardiomyopathy (oHCM), who is not suitable for surgical septal myectomy or alcohol septal ablation. Endocardial RF ablation, with detailed 3D-mapping of the intrinsic conducting system, offers the possibility of reducing the risk of complete heart block rates and of effectively relieving symptoms.\u0000 \u0000 \u0000 \u0000 We present a symptomatic 51-year-old female patient with oHCM and a maximum left ventricular outflow tract (LVOT) gradient of 148mmHg. Because of alcohol septal ablation failure, endocardial RF ablation in combination with detailed mapping of the intrinsic conduction system and intraprocedural imaging was performed. The 6-month follow-up showed a significant improvement in exercise tolerance, no relevant dynamic LVOT obstruction with a gradient of 22mmHg under Valsalva.\u0000 \u0000 \u0000 \u0000 In the current case report, endocardial RF ablation persistently reduced LVOT gradients in a patient with oHCM. Pre-interventional imaging, detailed 3D-mapping of the conduction system and correlation to intracardiac and transthoracic echocardiography were key for an effective and safe ablation of a small target zone.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141812294","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Hung-Chang Jong, Kexuan Ngoh, Yu-Kai Lin, Hsu-Ting Tu, Ta-jung Wang
Left ventricular (LV) unloading prior to primary angioplasty in patients experiencing acute myocardial infarction holds promise for mitigating reperfusion injury and minimizing infarct size. This report delves into the utilization of left atrial venoarterial extracorporeal membrane oxygenation (LAVA-ECMO) as a pre-percutaneous transluminal coronary angioplasty (PTCA) intervention strategy aimed at augmenting circulatory support while unloading the LV. Three cases of patients with ST elevation myocardial infarction (STEMI) involving the left ascending coronary artery who underwent LAVA-ECMO before primary PTCA are presented. Each patient maintained robust LV systolic function following weaning from ECMO support. These cases underscore the potential benefits of mechanical LV unloading prior to revascularisation in reducing infarct size and mitigating the risk of post-MI heart failure.
{"title":"Utilizing Left Atrial Venoarterial Extracorporeal Membrane Oxygenation to unload the left ventricle prior to angioplasty in acute myocardial infarction. A Case Series","authors":"Hung-Chang Jong, Kexuan Ngoh, Yu-Kai Lin, Hsu-Ting Tu, Ta-jung Wang","doi":"10.1093/ehjcr/ytae362","DOIUrl":"https://doi.org/10.1093/ehjcr/ytae362","url":null,"abstract":"\u0000 \u0000 \u0000 Left ventricular (LV) unloading prior to primary angioplasty in patients experiencing acute myocardial infarction holds promise for mitigating reperfusion injury and minimizing infarct size.\u0000 \u0000 \u0000 \u0000 This report delves into the utilization of left atrial venoarterial extracorporeal membrane oxygenation (LAVA-ECMO) as a pre-percutaneous transluminal coronary angioplasty (PTCA) intervention strategy aimed at augmenting circulatory support while unloading the LV. Three cases of patients with ST elevation myocardial infarction (STEMI) involving the left ascending coronary artery who underwent LAVA-ECMO before primary PTCA are presented. Each patient maintained robust LV systolic function following weaning from ECMO support.\u0000 \u0000 \u0000 \u0000 These cases underscore the potential benefits of mechanical LV unloading prior to revascularisation in reducing infarct size and mitigating the risk of post-MI heart failure.\u0000","PeriodicalId":507701,"journal":{"name":"European Heart Journal - Case Reports","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2024-07-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141812675","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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