Case Reports in Cardiology最新文献

Background: Coronary artery fistulas (CAFs) are rare congenital anomalies, with the left circumflex artery to coronary sinus (LCx-CS) fistula representing an uncommon subtype. Pulmonary hypertension (PHTN) may arise as a consequence of large, unrepaired CAFs. While most patients experience improvement following surgical repair, there are instances where PHTN persists, necessitating ongoing monitoring and pharmacological intervention.

Case description: We present the case of a middle-aged woman with no significant medical history who presented with dyspnea. She was found to have PHTN secondary to a large LCx-CS fistula. She underwent surgical ligation of the fistula. Postoperatively, the patient remained symptomatic, with elevated pulmonary arterial pressure persisting, prompting the initiation of triple therapy comprising macitentan, selexipag, and sildenafil. This therapeutic regimen significantly resolved her symptoms and improved her functional capacities.

Discussion: This case highlights the hemodynamic implications associated with a long-standing LCx-CS fistula. Although congenital, such anomalies can remain asymptomatic for extended periods. The most likely hypothesis is that a large chronic fistula can cause irreversible histopathological changes to the pulmonary microvasculature, resulting in a "point of no return" and leading to persistent symptoms even after anatomical correction. In most reported scenarios, the surgical or interventional correction of CAF results in symptom resolution and hemodynamic improvement. However, the described case illustrates an atypical presentation, revealing the potential for sustained elevation of pulmonary arterial pressures. Consequently, this necessitates ongoing pharmacological management.

Conclusion: While LCx-CS fistulas are infrequent and often asymptomatic, chronic fistula cases may result in various complications and symptomatic presentations. The case illustrates a rare case of persistent PHTN in a corrected LCx-CS fistula. Thorough follow-up, early diagnosis, and timely interventions, complemented by pharmacotherapy when necessary, are essential in managing these complex clinical scenarios.

Background: Cardiac metastases from colorectal adenocarcinoma are rare and may present with varied or absent symptoms.

Case summary: A middle-aged woman with recurrent colorectal adenocarcinoma presented with an infiltrating ventricular septal cardiac mass. Multimodal imaging, including PET-CT and cardiac MRI, was crucial for both identifying the lesion as a metastasis and for subsequent serial monitoring. Extensive cardiac involvement necessitated specialized surgical and radiation oncology expertise at a high-volume center, though extra-cardiac lesions led to deferring surgery or radiation as therapeutic options. Ultimately, lesion regression was achieved with intensive chemotherapy and immunotherapy targeting the primary malignancy.

Discussion: To our knowledge, no prior cases have documented colorectal adenocarcinoma metastasizing to the interventricular septum with interatrial extension. Management of intracardiac metastases is complex and requires a multidisciplinary approach.

Take home messages: Accurate diagnosis and characterization of cardiac masses requires a multimodal imaging approach, while effective management depends on a multidisciplinary strategy tailored to treatment goals and patient-specific factors. Surgical resection can be considered at high-volume centers but may be deferred in metastatic disease if it does not improve prognosis or symptoms. Factoring in the expected response to medical therapy is also important.

Clinical management of massive pulmonary embolism is challenging when active hemorrhage, a contraindication to thrombolytics, is concurrently present. We describe a successful attempt in using low-dose catheter-directed thrombolysis (CDT) in a high-risk patient with absolute contraindications to systemic thrombolysis. A 69-year-old Asian female with cardiac arrest was brought to a resource-limited rural hospital. The patient underwent 50 min of cardiopulmonary resuscitation (CPR) before regaining the pulse but remained in cardiogenic shock. Computerized tomography (CT) of the chest found massive PE. The patient was found with multiple fractures and subarachnoid hemorrhage. Catheter-directed embolectomy was performed without clinical improvement. A low-dose CDT with alteplase was attempted by giving 5 mg over 2 h with a repeated session 24 h later for a total of 10 mg. The patient started improving, was extubated on Day 9, and transferred out of the ICU on Day 15. Low-dose CDT in massive PE could be lifesaving despite the presence of absolute alteplase contraindications. Patients with contraindications, a high risk of bleeding, or of Asian race may benefit more from the low-dose alteplase regimen.

Vascular closure devices (VCDs) have significantly advanced catheter-based interventions by expediting hemostasis following arterial puncture. The Mynx closure device, which uses a sealant consisting of polyethylene glycol (PEG) to facilitate hemostasis, is a widely used tool for arterial closure. Despite their effectiveness, these devices are still associated with complications, including thrombosis and vessel occlusion, which warrant attention. We report a case involving a 58-year-old male with a complex medical history, including atrial flutter and nonischemic cardiomyopathy, who presented with right lower extremity pain following catheter ablation for atrial flutter. Hemostasis was effectively achieved by using the Mynx closure device. Despite successful recovery, the patient developed a DVT within the right lower extremity, involving the femoral and iliac veins which necessitated mechanical thrombectomy. While VCDs such as the Mynx closure device have shown superior benefits in reducing hemostasis time and improving patient comfort, instances of complications such as deep vein thrombosis and vessel occlusion have been reported. The potential for such complications suggests a need for proper training and careful monitoring to minimize risks.

Background: Libman-Sacks endocarditis is a noninfectious form of endocarditis associated with systemic lupus erythematosus (SLE), antiphospholipid antibody syndrome (APS), and solid malignancies.

Case presentation: A 20-year-old woman with no medical history presented with left-sided weakness and facial drooping. Laboratory tests were unremarkable except for thrombocytopenia and a prolonged activated partial thromboplastin time. Brain magnetic resonance imaging revealed an acute ischemic infarct in the bilateral frontal lobes. A transthoracic echocardiogram (TTE) and subsequent transesophageal echocardiogram (TEE) identified two mitral vegetations with regurgitation: the first located on the posterior leaflet with perforation (1.2 × 1.0 cm) and the second (1.0 × 0.9 cm) situated on the subvalvular apparatus of the anterior leaflet. The patient reported no signs of infection, and multiple blood cultures showed no bacterial growth. A rheumatological panel indicated SLE and APS, which resulted in a diagnosis of Libman-Sacks endocarditis. The patient received treatment with Coumadin and hydroxychloroquine, and a surgical resection of the vegetation was scheduled if the valvular lesions did not resolve within 1 month. However, a follow-up TTE demonstrated near-complete resolution of the masses.

Conclusion: A stroke in a young individual should raise suspicion for Libman-Sacks endocarditis. Due to limited evidence regarding surgical versus conservative management, a multidisciplinary approach is recommended. This case illustrates the successful conservative management of two large vegetations.

Outflow tract premature ventricular contractions (OT-PVCs) with an R wave pattern break in Lead V2 (PBV2) pose significant treatment challenges due to their refractory nature and complex anatomical origins. A 56-year-old male with drug-resistant palpitations underwent detailed electroanatomical mapping using a microcatheter to identify the earliest activation site. This precision mapping was crucial for directing the ablation strategy accurately. The "enveloped ablation" technique was employed, involving multisite, low-power ablations surrounding the critical activation site, tailored to address the unique electrical and structural characteristics of OT-PVCs with a PBV2. This case highlights the importance of accurate mapping and tailored ablation strategies in managing OT-PVCs with PBV2.

Adenosine is a well-known product in the field of cardiology, known to cause coronary vasodilation. However, in rare cases, it has been associated with coronary vasoconstriction. In this case-the first to our knowledge-we have demonstrated that adenosine could be the cause of microvascular coronary spasms, based on the symptoms, ECG, and coronary functional assessments. Additionally, we have linked this case with a transient prolonged QT and mild dilated left ventricle, which was further investigated with a loop recorder and genetic testing revealing variants in the LMNA gene and PRKAG2 gene. This case also emphasizes that physicians should always take into account unexpected side effects during standard procedures.

Coronary artery perforations (CAPs) during percutaneous coronary interventions (PCIs) are rare and potentially fatal complications. Delayed CAPs are extremely rare. Here, we report a case of a delayed CAP in a small side branch that was not the target vessel of the PCI, which was difficult to salvage and was caused by a hydrophilic guidewire during PCI for bifurcation lesions. Finally, intracoronary administration of gelatin microspheres resulted in complete occlusion of the CAP site. Although the mechanism(s) of the delayed CAP onset had not been entirely elucidated, its pathogenesis is believed to have been multifocal. The key factors contributing to the delayed CAP may have included the nimious platelet-suppressing effects of dual-antiplatelet therapy, the prolonged anticoagulant effect of heparin used during PCI, the use of stiff-tip and hydrophilic guidewires, inadvertent guidewire advancement into small coronary arteries, and the fragility of coronary arteries associated with coronary risk factors. Meticulous attention to any patient signs, symptoms, or a nimble definite diagnosis, and effective, timely management of delayed CAPs may be essential for practicing cardiologists to reduce subsequent complications and improve patient prognosis after PCI, especially in cases of complex lesions.

Abstract: Pulmonary embolism is a rare complication post-bioprosthetic valve replacement, which is seldom reported in the literature.

Case description: A 76-year-old woman was admitted to our institution with a diagnosis of pulmonary embolism, occurring 14 days after undergoing a second bioprosthetic valve replacement, which had been performed due to failure of the initial prosthesis. Postoperatively, the patient had been managed with aspirin monotherapy for the prevention of thromboembolic events. Transthoracic echocardiography demonstrated normal age-related diastolic function, a left ventricular ejection fraction of 59%, no evidence of bioprosthetic valve stenosis, and overall satisfactory prosthetic valve function. The patient was discharged on the eighth hospital day with the initiation of warfarin therapy.

Importance to practitioners: It is crucial to closely monitor for clinical signs and symptoms of thromboembolism, such as pulmonary embolism, following bioprosthetic valve implantation, particularly in patients with high-risk factors including advanced age, female sex, hypertension, and a history of previous valve implantation failure. In such cases, clinicians should also consider intensifying antiplatelet or anticoagulation therapy beyond standard daily low-dose aspirin.

Background: Managing massive thrombi in the coronary arteries of patients with acute myocardial infarction presents considerable challenges, and the effectiveness of immediate versus deferred stenting as a treatment option remains uncertain. Moreover, it is unclear whether dual antiplatelet plus direct oral anticoagulant therapy is more effective for massive thrombi in the coronary arteries than dual antiplatelet therapy alone. We report the case of a patient with acute myocardial infarction with a long and massive thrombus in the left anterior descending artery treated with an immediate stenting strategy and antithrombotic combination therapy.

Case presentation: A 90-year-old female presented with a chief complaint of chest depression due to a long and massive thrombus in the left anterior descending artery with associated acute myocardial infarction. Immediate stenting to cover the ruptured plaque and trap the massive thrombus without encountering slow flow/no-reflow phenomenon, and employing thrombolysis through a combination of antiplatelet agents and a direct oral anticoagulant resulting in sustained coronary blood flow during the transition from the acute to subacute phases, led to favorable procedural and clinical outcomes.

Conclusions: If immediate stenting with thrombolysis using a direct oral anticoagulant plus dual antiplatelet agents is successful without distal embolism, this strategy could be a better treatment than deferred stenting in terms of preventing periprocedural cardiac adverse events and reducing healthcare costs. Furthermore, dual antiplatelet agents plus direct oral anticoagulant combination therapy are considered to suppress platelet function and fibrin generation strongly, leading to the disappearance of thrombus.