Valve-sparing aortic root replacement is increasingly used in selected patients with acute aortic dissection and preserved valve anatomy. We present the case of a 52-year-old man with acute Stanford type A aortic dissection extending from the aortic root to the iliac bifurcation with arch involvement; this was complicated by severe aortic insufficiency and right lower extremity malperfusion. The patient underwent emergent valve-sparing root replacement using the David technique combined with zone 2 arch reconstruction under hypothermic circulatory arrest and selective antegrade cerebral perfusion. Intraoperative echocardiography confirmed excellent valve function with trace residual regurgitation. The postoperative course was notable for transient vasoplegia and re-exploration without bleeding, followed by uneventful recovery and discharge on postoperative day 11. This case highlights the feasibility of combining valve-sparing root replacement with zone 2 arch reconstruction in the acute setting of Stanford type A dissection with malperfusion, allowing restoration of true lumen flow while preserving native valve function.
Coronary artery anomalies can be divided into anomalies of origin, course, or terminations of any of the epicardial coronary arteries. Coexistence of anomalous origin of the left circumflex artery with retroaortic course and anomalous origin of left anterior descending artery arising from the right coronary sinus with interarterial course is an exceedingly rare anatomical configuration. In the presence of this anomaly, conventional catheter angiography is challenging due to technical reasons and may lead to an inadvertent misdiagnosis of significant stenosis or occlusion of the coronary artery. This case highlights the importance of coronary computed tomography angiography in identifying a rare coronary artery anomaly and providing guidance for future endovascular or surgical procedures.
This 58-minute webcast features a conversation on the "State of the Art in Pericardial Disease"-the focus of Issue 22.2 on the theme of pericardial disease. Led by the issue's editor, the discussion engages the authors on emerging themes and lessons learned while researching and writing the articles. View the video at https://vimeo.com/1204339129/42dd65d78b.
A circumaortic renal vein is a congenital vascular anomaly involving an additional renal vein that traverses posterior to the aorta in addition to the normal renal vein traversing anterior to the aorta.12 In aortic surgery, it is common to ligate the left renal vein (LRV) to aid in surgical exposure, which is typically inconsequential due to collateral venous channels. We report a case of a circumaortic LRV with the preaortic branch ligated during abdominal aortic aneurysm (AAA) surgery and, as a result, retroaortic LRV hypertrophy was observed during follow-up.
This case describes a 55-year-old man who presented with complaints of claudication in his left upper limb. Computed tomography angiography revealed a rare anatomical variant in which the left vertebral artery originated from the left thyrocervical trunk.
Scimitar syndrome is a rare congenital anomaly characterized by anomalous right pulmonary venous drainage into the inferior vena cava, resulting in a left-to-right shunt. Surgical correction may be achieved by direct reimplantation of the scimitar vein or by intra-atrial baffling, which often requires deep hypothermic circulatory arrest. We report the case of a 47-year-old man with symptomatic scimitar syndrome and an infradiaphragmatic scimitar vein who underwent successful intra-atrial baffling without circulatory arrest. Preoperative imaging demonstrated a significant shunt with dilation of the right atrium and ventricle. Repair was performed using cardiopulmonary bypass with femoral venous cannulation and vacuum-assisted lower body venous drainage, allowing adequate visualization despite the challenging infradiaphragmatic localization of the anomalous vein without interruption of systemic perfusion. Postoperative echocardiography confirmed unobstructed pulmonary venous return with minimal gradient. The patient had an uneventful recovery and reported symptomatic improvement at 1-year follow-up. This case demonstrates that intra-atrial baffling of an infradiaphragmatic scimitar vein can be safely performed without circulatory arrest using vacuum-assisted venous drainage.
A 66-year-old male with prior right middle cerebral artery stroke status post thrombectomy—as well as right internal carotid artery (ICA) stenting and chronic occlusion, paroxysmal atrial fibrillation, and hypertension—underwent left atrial appendage occlusion with a Watchman device for stroke prevention. Immediately following the procedure, he developed acute bilateral vision loss accompanied by headache and worsening left-sided weakness. Emergent computed tomography (CT) and CT angiography demonstrated no hemorrhagic stroke or new large-vessel occlusion and confirmed the previously known chronic right ICA occlusion. The patient was not a candidate for thrombolysis due to recent heparin exposure during his procedure, and thrombectomy was not pursued given the absence of any new large vessel occlusion. In the context of contrast exposure and negative initial imaging, contrast-induced cortical blindness was considered the leading diagnosis, with embolism, hypoperfusion, and post-stroke recrudescence as alternative considerations. This case highlights the diagnostic complexity of acute cortical blindness and hemispatial neglect following Watchman implantation. Mechanisms may include microembolic shower, transient hypoperfusion, seizure-related cortical dysfunction, post-stroke recrudescence, or contrast induced cortical blindness. Negative initial CT imaging should not preclude suspicion for ischemia, especially in patients with preexisting cerebrovascular compromise. Early magnetic resonance imaging and multidisciplinary coordination are essential.
Transthoracic echocardiography and global longitudinal strain are pivotal in evaluating myocardial structure and function in cardio-oncology patients, but there are limited reports of using global longitudinal strain to identify intracardiac masses. This case presents a patient with metastatic renal cell carcinoma and cardiac metastasis that was identified using global longitudinal strain on transthoracic echocardiography and subsequently confirmed by cardiac magnetic resonance imaging.
A 49-year-old man presented with acute onset chest pain and new-onset right bundle branch block. Echocardiography revealed mild apical hypokinesia with an ejection fraction of 45%. Coronary angiography showed all three major coronary arteries originating from the right coronary sinus with normal flow. Further evaluation identified an obstructed accessory left anterior descending (LAD) artery arising from the left sinus. Successful wire crossing, balloon dilatation, and deployment of a drug-eluting stent restored TIMI 3 flow. Subsequent computed tomography angiography confirmed a rare Type X dual LAD anatomy. This case highlights the importance of recognizing uncommon coronary artery anomalies since they may significantly influence diagnostic and therapeutic strategies.
Pericardial effusion represents a common clinical entity encountered across diverse medical settings, with presentations ranging from incidental findings to life-threatening cardiac tamponade. The accurate diagnosis and management of pericardial effusion and its hemodynamically significant sequelae demand a comprehensive multimodality imaging approach. Echocardiography remains the cornerstone of initial evaluation, providing real-time assessment of effusion size, hemodynamic impact, and guidance for therapeutic interventions. This review synthesizes contemporary evidence from major cardiology societies to present a structured approach to the diagnosis and management of pericardial effusion and tamponade. We emphasize the pivotal role of echocardiography while integrating complementary modalities, including cardiac computed tomography and cardiac magnetic resonance imaging. Key echocardiographic findings, Doppler parameters, and imaging-guided therapeutic strategies are discussed in detail, with attention to emerging techniques and evidence-based algorithms. Understanding the multimodality imaging approach is essential for optimizing patient outcomes in this potentially life-threatening condition.
Multimodality imaging is used to diagnose a patient with prior acute pericarditis and demonstrated effusive-constrictive physiology characterized by pericardial thickening with effusion, pericardial enhancement consistent with active inflammation, and ventricular interdependence. These findings highlight the complementary role of cardiac magnetic resonance in the diagnosis and management of inflammatory constrictive pericardial disease.
Initially recognized as a key cardiac feature of systemic lupus erythematosus and rheumatoid arthritis, autoimmune pericarditis has gained increasing attention given the recent advances in cardiac imaging, biomarker assessment, and understanding of immune-mediated mechanisms. The prevalence of pericardial involvement varies considerably among autoimmune diseases. Patients may have a small pericardial effusion that remains clinically silent but could also present with acute, recurrent, or chronic pericarditis. A minority develop severe complications such as tamponade or constrictive physiology. Characterizing autoimmune pericarditis is critical, particularly in an era of expanding immunomodulatory therapies. This review summarizes current knowledge on prevalence, pathophysiology, clinical presentation, and diagnostic strategies, with a particular focus on emerging therapeutics in pericardial disease associated with autoimmune disorders. Integrating rheumatology and cardiology expertise is essential to optimize the care of this heterogeneous patient population.
Jane Kenyon (1947-1995) died from leukemia in 1995, a writer in her prime whose work was steadily rising in popularity and amassing critical acclaim. Earlier that year, she had been appointed Poet Laureate of New Hampshire and left behind a rich body of work, including "Otherwise"-the featured work in this Poet's Pen. Kenyon was married to fellow writer Donald Hall (1928-2018) and wrote this piece in response to her husband's presumptively terminal cancer diagnosis. Though Hall's writings have been used extensively in the medical humanities, an argument can be made that several of Kenyon's works are just as worthy of inclusion. Many of her poems provide important insights into topics like bereavement, caregiving, and mental illness, making them ideally suited for consideration as part of health humanities education.
Philip Alexander, MD, is a native Texan, retired physician, and accomplished musician and artist. After 41 years as an internal medicine physician, Dr. Phil retired from his practice in College Station in 2016. A lifelong musician and former music professor, he often performs as an oboe soloist for the Brazos Valley Symphony Orchestra. He began exploring visual art in 1980, evolving from pencil sketches-including an official White House portrait of President Ronald Reagan-to the computer-generated drawings featured in this journal. His images, which first appeared in this journal in the spring of 2012, are his own original creations. This issue of the Journal also includes an artistic submission by Muhammad Umair, MD, assistant professor of radiology at the New York Presbyterian Hospital-Columbia University, whose work focuses on cardiovascular imaging (MRI and CT). He adds that he "sometimes indulges in abstract paintings, inspired by his work in cardiac and vascular imaging." If you would like to see your art published in the Methodist DeBakey Cardiovascular Journal, submit your creation online at journal.houstonmethodist.org as a "Humanities" entry.
Relapsing pericarditis (RP) is a chronic inflammatory disorder characterized by two or more episodes of acute pericarditis flares after a minimum of a 4-week symptom-free period. Recurrent pericarditis develops in approximately 15% to 30% of patients following an initial episode of acute pericarditis, and nearly half of these individuals experience subsequent recurrences. Although the course is heterogeneous, RP has substantial morbidity and impaired quality of life implications and is associated with pericardial complications, including cardiac tamponade and constrictive pericarditis. This review summarizes current knowledge about clinical perspectives, predictors, and risk stratification tools for relapses in RP and critically appraises the evolving role of exercise restriction as part of RP management. Many adverse prognosticators for RP in clinical, laboratory, multimodality cardiac imaging, and treatment factors have been identified from clinical trials, observational studies, and experiences of managing RP patients. Several risk scores have been recently developed to assist in risk stratification and treatment guidance for RP patients, such as the Athens, Torino, INFLA, and Klein scores. There is also growing evidence for exercise restriction strategies with a focus on practical individualized strategies in the multimodal treatment of RP that have been included in recent pericarditis guidance documents. Multicenter external validation and randomized trials remain necessary to assess the roles and performance of risk scores and exercise restriction in treating RP to improve their clinical outcomes.
Constrictive pericarditis is a condition of diastolic heart failure with unique hemodynamic manifestations. While potentially curable if treated appropriately, constrictive pericarditis remains a diagnostic challenge, particularly during early manifestation of disease when there are subtle clinical symptoms and when confounding comorbidities are present. In this focused review, we describe the characteristic and diagnostic hemodynamics of constrictive pericarditis as well as the utility of invasive (cardiac catheterization) and noninvasive (echocardiography) diagnostic testing for this complex disease.
Post-cardiac injury syndrome (PCIS) encompasses inflammatory pericardial syndromes occurring after cardiac injury, including post-pericardiotomy syndrome (PPS) following cardiac surgery, post-myocardial infarction (Dressler syndrome), and post-traumatic pericarditis. With the expanding use of cardiac surgical and interventional procedures, PCIS has become increasingly prevalent despite a marked decline in Dressler syndrome in the contemporary reperfusion era. The syndrome is believed to result from an immune-mediated inflammatory response to myocardial and pericardial injury, leading to pericarditis with associated pericardial and, often, pleural effusions. Clinical presentation typically occurs days to weeks after the inciting event and includes fever, pleuritic chest pain, elevated inflammatory markers, and imaging evidence of pericardial effusion. Early recognition is essential, as prompt treatment can relieve symptoms and prevent complications such as cardiac tamponade or progression to constrictive pericarditis. First-line therapy consists of high-dose aspirin or nonsteroidal anti-inflammatory drugs combined with colchicine, which accelerates symptom resolution and reduces recurrence. In refractory or recurrent cases, corticosteroids or interleukin-1 inhibitors, such as anakinra, are effective. Prophylactic colchicine administered around the time of cardiac surgery significantly reduces the incidence of post-pericardiotomy syndrome. This review summarizes current evidence and incorporates the 2025 European Society of Cardiology guidelines to guide optimal evaluation and management of PCIS.
Pericardial effusion secondary to an underlying neoplasm carries a poor prognosis because it often represents an advanced stage of malignancy. In approximately one-third of affected patients, the initial presentation may be cardiac tamponade.
Pericardial diseases span a spectrum from acute and recurrent pericarditis to chronic constrictive pericarditis. While echocardiography remains the first-line test in the evaluation of patients with suspected pericardial disease, advanced cardiac imaging with cardiac magnetic resonance and computed tomography have become complementary and often essential in refining diagnosis and guiding management in many patients. The recent Concise Clinical Guidance Statement from the American College of Cardiology as well as updated European Society of Cardiology guidelines have given new emphasis and recommendations on the use of advanced imaging in both pericarditis and pericardial constriction. This review summarizes the techniques, indications, and recent studies on the use of advanced cardiac imaging in pericarditis and pericardial constriction.
Constrictive pericarditis represents a form of severe diastolic heart failure characterized by impaired diastolic filling due to a rigid, noncompliant pericardium. Surgical pericardiectomy is the definitive treatment for chronic or refractory subacute constrictive pericarditis; however, outcomes vary widely depending on disease etiology, chronicity, myocardial involvement, end-organ dysfunction, and surgical technique. This review summarizes contemporary best practices for the surgical management of constrictive pericarditis, with emphasis on patient selection, timing of intervention, operative approach, and perioperative considerations. Accurate differentiation between inflammatory, transient constrictive phenotypes and irreversible fibrotic disease is central to therapeutic decision-making. Etiology-based risk stratification, assessment of hepatic and renal dysfunction, and careful evaluation of myocardial involvement provide critical prognostic information. Multimodality imaging plays a central role in diagnosis, surgical planning, and identification of patients most likely to benefit from intervention. Radical pericardiectomy is associated with superior functional recovery compared with partial resection, whereas radiation-associated disease, mixed constrictive-restrictive physiology, and advanced end-organ dysfunction are consistently linked to worse outcomes. High-volume centers of excellence in pericardial disease are critical in optimizing results after radical pericardiectomy.
