Background:Myocarditis has been rarely reported following COVID-19 vaccination, most commonly in younger males. Although a temporal association has been observed, establishing causality in individual cases remains challenging. Myocardial inflammation may involve the cardiac conduction system, rarely resulting in high-grade atrioventricular (AV) block. Importantly, these conduction abnormalities may be transient and resolve as the underlying inflammation improves. Case Summary:We report a rare case of myocarditis following a COVID-19 vaccination in an elderly woman who experienced complete heart block and worsening exertional dyspnea subsequent to receiving a COVID-19 booster. Coronary angiography revealed patent coronary arteries, and magnetic resonance imaging confirmed the presence of myocarditis. Her conduction abnormality progressively resolved without the need for permanent pacing, and she was subsequently discharged in stable condition. Discussion:Myocarditis should be considered as a potentially reversible cause of high-grade AV block. A thorough clinical history and multimodal imaging are essential for diagnosis, as early recognition and appropriate monitoring may allow recovery of AV conduction and avoid unnecessary permanent pacemaker implantation.
Epicardial lipomatosis is a rare cause of constrictive pericarditis. There is a paucity of literature on the condition, and it is possible that it may be missed in contemporary clinical practice. Herein, we report two patients with epicardial lipomatosis who presented with traditional cardiovascular risk factors. After an initial suspicion of pericardial effusion, both patients underwent multimodality imaging with transthoracic echocardiography, computed tomography, and cardiac magnetic resonance imaging, which demonstrated diffuse epicardial fat. Conservative management was pursued in both cases with optimization of heart failure therapy and the dialysis strategy, resulting in clinical improvement.
Ponatinib is a third-generation BCR:ABL1 tyrosine kinase inhibitor used in selected patients with Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL), particularly those with T315I mutations, or disease resistant, or those intolerant to prior tyrosine kinase inhibitors. Although effective, ponatinib has been associated with arterial occlusive events. We report a 63-year-old man with Ph+ ALL who, while receving ponatinib, developed a myocardial infarction requiring quadruple coronary artery bypass grafting, followed by symptomatic intracranial arterial stenosis necessitating superficial temporal artery to middle cerebral artery bypass. Despite multiple cardiovascular risk factors, the chronology of progressive coronary and cerebral vascular disease raised suspicion for ponatinib-associated vasculopathy, although causality cannot be established. To our knowledge, this is the first reported case of sequential coronary and cerebral surgical revascularization occurring during ponatinib therapy. This case highlights the importance of careful cardiovascular surveillance, multidisciplinary management, and individualized risk-benefit assessment in patients treated with ponatinib.
Introduction:Holt-Oram syndrome (HOS) is a rare autosomal dominant disorder characterized by upper limb and congenital heart anomalies, with an estimated incidence of 1 in 100,000 live births. Case Report:An 18-year-old Ethiopian male with a history of congenital heart disease presented with progressive dyspnea and limb deformities. Imaging confirmed a membranous ventricular septal defect, severe pulmonary hypertension, mitral and tricuspid regurgitation, and skeletal anomalies, including thumb hypoplasia and absent distal radial bone. Conclusion:This case underscores the importance of early diagnosis and multidisciplinary management of HOS, especially in resource-limited settings where genetic testing is unavailable. Increased awareness can facilitate timely intervention and improve patient outcomes.
Background:Type II heparin-induced thrombocytopenia (HIT) is a catastrophic immunothrombotic disorder that can be triggered by minimal heparin exposure during routine coronary angiography. Case Summary:A 67-year-old woman developed "explosive" multiterritorial arterial thrombosis-including acute limb ischemia, an inferior STEMI, and a stroke-within minutes of receiving 5000 units of intra-arterial heparin. This followed a brief nadroparin exposure 8 days prior. Crucially, events occurred while platelet counts were still normal. Despite a negative functional assay, a high 4T score (6 points) confirmed HIT. Management involved non-heparin anticoagulation (danaparoid sodium) and thrombectomies. Discussion:This case highlights a major diagnostic pitfall: severe arterial thrombosis preceding overt thrombocytopenia. The immediate "anaphylactoid-like" reaction following a heparin bolus is often misidentified as contrast allergy, delaying life-saving intervention. Take Home Messages:Suspect HIT in acute systemic reactions or multifocal thrombosis after heparin exposure, regardless of initial platelet counts.
Background and Introduction:Cardiac tamponade is a medical/traumatic emergency characterized by the increased intrapericardial pressure from the accumulation of excessive fluid (either exudate, transudate, or blood) in the pericardium. Emergency sonography is a vital part of the rapid assessment of cases with traffic accidents and chest traumas, as pericardial injuries are among the hidden affected organs. Here, we present a case of successful resuscitation of cardiac tamponade. Case Presentation:An 18-year-old male presented as a case of a traffic accident within 30 min with hemodynamic instability from bradycardia, hypotension, decreased Glasgow Coma Scale, and distended jugular venous pressure. Bilateral air entry was present, with the aid of E-FAST, tension pneumothorax was excluded, and cardiac tamponade was diagnosed. Immediately, needle pericardiocentesis was done under the supervision of a senior traumatologist, followed by rapid improvement. A central venous line was inserted in the pericardium for continuous drainage. A total of 810 mL of blood and serosanguineous fluid were drained. The patient was discharged home after 4 days of intensive care stay and 1 day in the ward. Discussion:Beck's triad, along with bradycardia, indicates cardiac tamponade until proven otherwise. Any case presenting with features of hypotension, especially following trauma to the chest, should have tamponade excluded by using E-FAST. Needle pericardiocentesis is a life-saving procedure that can provide immediate relief through aspiration of the pressure.
Löffler endocarditis, an idiopathic hypereosinophilic syndrome, can present symptoms of heart failure and peripheral eosinophilia. We present the case of a 46-year-old woman with fatigue, shortness of breath, and edema, who was found to have thrombocytopenia, elevated cardiac biomarkers, and hypereosinophilia (2.96 k/uL). Cardiac MRI revealed hypertrophic cardiomyopathy, right ventricular hypertrophy, and a restrictive filling pattern, raising suspicion for Löffler endocarditis. Despite initial corticosteroid and diuretic treatment, she was readmitted with persistent symptoms. This case highlights the diagnostic imaging and treatment challenges with corticosteroid therapy, to control eosinophilic infiltration and prevent irreversible cardiac damage. Löffler endocarditis should be considered in the imaging differential diagnosis of unexplained heart failure.
A systolic murmur best heard at the aortic area with radiation to the neck is considered a hallmark of aortic stenosis. We report a patient with this auscultatory pattern in whom investigation revealed an unexpected diagnosis. Accompanying symptoms reinforced the initial suspicion, adding another layer of complexity to the diagnostic process. This case highlights the limitations of relying solely on symptom profile and murmur topography, and underscores the importance of comprehensive physical examination and diagnostic imaging in evaluating valvular heart disease.
Background:Myocardial bridging (MB) is usually benign but may occasionally be associated with ischemia or arrhythmias. Exercise induced conduction abnormalities are rare and poorly understood. Case Summary:A 69-year-old asymptomatic male developed transient right bundle branch block (RBBB) at peak exertion during treadmill stress testing, without angina, ischemic ECG changes, or hemodynamic instability. The RBBB resolved immediately during recovery. Coronary computed tomography angiography identified a superficial myocardial bridge of the mid-left anterior descending artery without luminal narrowing or atherosclerosis. Discussion:The findings supported a benign, rate dependent conduction delay rather than ischemia. Conclusion:This case illustrates a rare coexistence of MB with exercise-induced RBBB and highlights the importance of recognizing nonischemic conduction phenomena to avoid unnecessary invasive studies.
Background:Immune checkpoint inhibitors (ICIs) such as durvalumab improve survival in solid tumors but can rarely cause fulminant myocarditis (reported in 1% of cases, with 25%-40% mortality). Clinical overlap with coronary artery disease (CAD), chemotherapy-related cardiomyopathy, or malignancy-associated complications makes diagnosis challenging. Case Presentation:A 62-year-old woman with gallbladder adenocarcinoma on gemcitabine, cisplatin, and durvalumab presented with 1 week of progressive dyspnea, leg edema, and chest pain. She had a history of portal vein thrombosis on apixaban. On exam, she was tachycardic and hypoxic with signs of volume overload. Labs showed elevated BNP and troponin. EKG revealed lateral T-wave inversions and chest x-ray demonstrated pulmonary edema. Echocardiography showed a large fibrinous pericardial effusion without tamponade and reduced LVEF (41%) with apical wall motion abnormalities. Differentials included ischemia, chemotherapy toxicity, ICI myocarditis, or malignant/hemorrhagic effusion. After a multidisciplinary discussion, anticoagulation was held, and the patient was transfused. Serial echocardiography showed a stable effusion but persistent ST-T changes. Coronary angiography excluded obstructive CAD. Cardiac MRI demonstrated diffuse myocardial edema, most pronounced in apical segments, consistent with myocarditis. Given the temporal relationship to ICI therapy, durvalumab-associated myocarditis was diagnosed. High-dose corticosteroids were initiated with symptomatic improvement. She was discharged on gemcitabine-cisplatin, with durvalumab omitted. Anticoagulation was resumed. Discharge echocardiography showed persistent apical wall motion abnormalities with a small effusion. Conclusion:This case highlights the diagnostic complexity of dyspnea in oncology patients, where multiple cardiac pathologies may coexist. A systematic, multidisciplinary approach-progressing from pericardial evaluation to ischemic work-up to advanced imaging-was crucial for diagnosis. Clinicians should maintain suspicion for ICI myocarditis when new heart failure or wall motion abnormalities occur without obstructive CAD, as early immunosuppressive therapy is critical.
Current guidelines recommend balloon pulmonary valvuloplasty (BPV) for symptomatic adults with moderate or severe pulmonary valve stenosis (PVS) when the valve anatomy is suitable. However, when the resting gradient is near the lower boundary of the moderate range, establishing whether exercise intolerance is attributable to PVS can be challenging. We describe the case of a 52-year-old woman with longstanding PVS who developed progressive exercise intolerance. Resting echocardiography revealed a peak gradient of 38 mmHg, which remained stable during follow-up. Exercise stress echocardiography (ESE) demonstrated a blunted stroke volume response, whereas cardiopulmonary exercise testing (CPET) showed reduced peak VO2. Based on these objective findings, BPV was performed for symptomatic moderate PVS. Following successful intervention, both the stroke volume response and peak VO2 improved markedly. This case highlights that exercise-based diagnostic modalities, particularly ESE in conjunction with CPET, can help guide treatment decisions in symptomatic moderate PVS.
Transcatheter valve-in-valve mitral valve replacement (ViV TMVR) is an established therapeutic alternative for selected patients with symptomatic degeneration of a surgical mitral bioprosthesis and high or prohibitive surgical risk. We present a 75-year-old woman with a failed Pericarbon More 29-mm mitral bioprosthesis and severe prosthetic mitral stenosis, which was resolved with transseptal transcatheter ViV TMVR. Baseline echocardiography showed mitral valve area 0.45 cm2 by pressure half-time, mean transmitral gradient 13 mmHg, preserved left ventricular systolic function, estimated systolic pulmonary artery pressure of 55 mmHg, and severe tricuspid regurgitation. ECG-gated computed tomography was performed for proper procedural planning. During the procedure, after dilation of the interatrial septum, an abrupt left-to-right shunt caused hemodynamic compromise. Rapid rescue balloon dilation of the stenotic mitral bioprosthesis and subsequent implantation of a 26-mm SAPIEN 3 valve restored forward transmitral flow, reduced the interatrial shunt to a minimum, and avoided septal occluder implantation. Postprocedural echocardiography showed a mean transmitral gradient of 3.5 mmHg, no intraprosthetic or paravalvular regurgitation, no LVOT obstruction, and a minimal, hemodynamically insignificant residual shunt. At 6-month, 12-month, and 2-year follow-ups, the patient remained asymptomatic with stable prosthetic valve function, although the estimated pulmonary artery pressure remained mildly to moderately elevated and tricuspid regurgitation persisted at a moderate degree. Beyond demonstrating the feasibility of valve-in-valve TMVR, this case highlights that septal dilation in severe prosthetic mitral stenosis can precipitate abrupt hemodynamic deterioration by creating a clinically significant left-to-right interatrial shunt before relief of the mitral obstruction.
Saphenous vein graft (SVG) pseudoaneurysms are a rare cause of late graft failure with potentially lethal consequences if left untreated. We present the case of a patient who underwent multivessel coronary artery bypass grafting more than 10 years earlier and presented with chest pain. She was found to have a large 10 cm pseudoaneurysm involving the SVG-to-PDA graft. Workup demonstrated compression of the right ventricle by the pseudoaneurysm, a reduced ejection fraction of 27%, and filling of the pseudoaneurysm from the right coronary system without distal graft filling. Given the patient's symptoms, imaging findings, and pseudoaneurysm size, urgent resection and revascularization were performed. Postoperatively, ventricular function improved, and despite a complicated hospital course, the patient was discharged to rehabilitation with intact motor function and subsequent resolution of cardiopulmonary symptoms.
Background:Heart failure secondary to autoimmune diseases is uncommon. Systemic sclerosis (SSc) is a chronic autoimmune disorder marked by microvascular damage and progressive fibrosis in multiple organ systems. Case Summary:A man in his 60s, without cardiovascular risk factors, presented with worsening dyspnea (in cardiogenic pulmonary edema), chronic finger cyanosis with ischemic ulcers, progressive dysphagia for about 2 years, and a 10 kg weight loss over 6-12 months. Echocardiography showed a severely impaired left ventricular ejection fraction of 10%. Computer tomography excluded malignancy but demonstrated pleural effusion and pulmonary edema. The patient received immediate treatment for cardiogenic pulmonary edema and was stabilized. Further diagnostic evaluation confirmed diffuse cutaneous systemic sclerosis (dcSSc). Discussion:Primary cardiac involvement as an initial manifestation of dcSSc is rare and remains a significant source of morbidity and mortality.
Papillary fibroelastoma (PFE) is a benign primary cardiac tumor that most commonly arises from valvular endocardium, whereas nonvalvular involvement, particularly within the left ventricle, is rare. Despite benign histology, PFEs are clinically relevant due to mobility and embolic risk. We report a case of a 64-year-old woman in whom a small nonvalvular left ventricular PFE was identified during evaluation for ventricular arrhythmias. Cardiac imaging demonstrated a mobile mass attached to the apical inferior left ventricular wall, which was successfully resected surgically under cardiopulmonary bypass with pathologic confirmation of PFE. We additionally performed a focused review of published cases of nonvalvular left ventricular PFEs, including lesions arising from the subvalvular mitral apparatus. The literature demonstrates heterogeneous clinical presentation, diverse anatomic attachment sites, and a strong preference for surgical management. This case and review highlight the importance of considering PFE in the differential diagnosis of left ventricular masses and support surgical excision for mobile nonvalvular lesions.
Infective endocarditis is a life-threatening infection of the endocardial surface, most commonly resulting from bacteremia originating from the oral cavity or intravascular sources. However, in some cases, the source of bacteremia remains unidentified, and the role of gastrointestinal pathology is not well defined. We report a patient in her 70s with multiple comorbidities, including mitral annular calcification, who presented with fever, altered mental status, and abdominal pain. Blood cultures grew Streptococcus mitis. Transthoracic and transesophageal echocardiography demonstrated a mobile vegetation on the mitral valve consistent with infective endocarditis. Brain magnetic resonance imaging revealed multiple acute cardioembolic infarctions. During hospitalization, persistent abdominal symptoms prompted further evaluation, which identified severe fecal impaction and a previously undiagnosed ileal neuroendocrine tumor with hepatic lesions. No recent dental procedures or other clear sources of bacteremia were identified. This case raises the possibility that gastrointestinal pathology, including bowel dysfunction and malignancy, may contribute to bacteremia and subsequent infective endocarditis. In patients without an identifiable source, targeted gastrointestinal evaluation may be considered, although further studies are needed to clarify this relationship.
BackgroundVentricular arrhythmias originating from the left ventricular summit (LVS) are challenging to treat with conventional catheter ablation due to the region ' s complex anatomy, proximity to coronary arteries, and epicardial fat coverage. Percutaneous guidewire ablation via the coronary venous system (CVS) provides a minimally invasive therapeutic option for refractory arrhythmias in this area.Case PresentationHerein, we present the case of a 60-year-old Asian female patient who had a 1-year history of palpitations and was diagnosed with symptomatic, frequent ventricular premature beats (VPBs). The patient exhibited an inadequate response to metoprolol and amiodarone as pharmacological therapy and conventional ablation approaches. Following guidewire ablation via the CVS, the VPBs were eliminated entirely, her palpitations fully resolved, and no procedure-related complications, such as coronary artery injury or thrombosis, were observed. During follow-up, there was no recurrence of VPBs, and left ventricular function remained normal.ConclusionBy employing precise mapping, individualized parameter settings, and strict safety monitoring, percutaneous guidewire ablation via the CVS can effectively treat drug-refractory VPBs originating from the LVS. Importantly, this approach could serve as a complementary option when traditional ablation methods are unsuccessful, offering a feasible therapeutic strategy for complex ventricular arrhythmias.
This case report describes a rare clinical scenario involving a 40-year-old Ethiopian female patient with very severe rheumatic mitral stenosis, found to have an anomalous transposition of the inferior vena cava (IVC). She successfully underwent a technically challenging percutaneous mitral balloon commissurotomy. To the best of our knowledge, this is the first documented case in an African patient where such a procedure has been successfully performed in the context of a congenital IVC anomaly.
We present a successful case of 3D printed cardiac reconstruction for a custom-made LAAO LAmbre (Lifetech Scientific Corp., Shenzhen, China) device of gigantic and challenging LAA anatomy.
Background:Biventricular thrombi (BVT) is a rare presentation associated with high morbidity and mortality due to the potential sequela of life-threatening complications including embolic events and cardiac failure. As an uncommon entity, there is limited research on best practice for the management of BVT. Presentation:We present a case of BVT with Streptococcus anginosus and Staphylococcus hominis concomitant bloodstream infection, tricuspid valve infective endocarditis (TVIE), septic emboli and decompensated dilated cardiomyopathy (LVEF 20%-25%). Guideline directed heart failure management, antimicrobials and anticoagulation were initiated with a remarkable recovery within 2 months. Discussion:Given the rarity of this presentation, a multidisciplinary approach was taken to guide management. Follow-up echocardiography after completion of antimicrobial therapy demonstrated an LVEF of 53%, no detectable thrombus and resolution of congestive symptoms. Although there is minimal population-based evidence, this case supports a conservative approach for the treatment of TVIE, BVT and its potential sequelae in select patients.
