Abstract Background Intracardiac masses are a diagnostic challenge in cardiology because thrombus and malignancy may demonstrate similar imaging features on initial evaluation. Case Summary An elderly male admitted for sepsis was incidentally found to have a right ventricular outflow tract mass initially presumed to be thrombus, and anticoagulation was initiated. Follow-up imaging demonstrated interval enlargement despite therapy, prompting further evaluation. TEE and CMR raised concern for malignancy, and biopsy confirmed poorly differentiated non–small cell lung carcinoma with cardiac metastasis. Given advanced disease and poor functional status, disease-directed therapy was deferred, and hospice care was pursued. Discussion Cardiac metastases are more common than primary cardiac tumors and occur in up to 9-14% of patients with metastatic cancer, with lung cancer representing the most frequent primary source. Prior literature emphasizes multimodal imaging when presumed thrombus fails to respond to anticoagulation. Conclusion Interval growth of an intracardiac mass despite anticoagulation should prompt diagnostic reassessment and advanced cardiac imaging.
Abstract Background Myocardial bridging (MB) is often considered a benign anatomical variant, yet deep or long bridges can result in dynamic coronary compression and ischemia. In rare instances, MB may lead to myocardial infarction with nonobstructive coronary arteries (MINOCA), posing a diagnostic challenge. Case summary We report the case of a 59-year-old man who presented with chest pain and elevated cardiac troponin following exertion. Coronary angiography showed no obstructive coronary artery disease but revealed a myocardial bridge in the mid-left anterior descending (LAD) artery with complete systolic compression. Intravascular ultrasound (IVUS) confirmed the presence of MB without underlying atherosclerosis. Functional assessment using resting full-cycle ratio (RFR) demonstrated a value of 0.91. Single-photon emission computed tomography (SPECT) revealed no perfusion defects, supporting the absence of significant ischemia. The patient was diagnosed with MINOCA secondary to myocardial bridging and treated conservatively with beta-blockers. He remained free of recurrent myocardial infarction and the exertional chest pain was markedly improved. Discussion This case highlights the potential of severe MB to cause infarction in the absence of fixed coronary lesions. It also underscores the diagnostic utility of RFR in assessing MB physiology and its concordance with perfusion imaging.
Abstract Background Coronary stent infection (CSI) is rare but can be fatal. In Staphylococcus aureus bacteraemia (SAB), treatment duration is guided by classification as uncomplicated or complicated SAB. However, whether a recently implanted drug-eluting stent (DES) should be regarded as intravascular prosthetic material remains unclear. Case Summary An 83-year-old woman underwent PCI for a severely calcified right coronary ostial lesion. After rotational atherectomy, a DES was implanted, and final angiography showed adequate expansion. On hospital day 7, cellulitis developed at a peripheral intravenous catheter site. Blood and skin cultures grew methicillin-resistant Staphylococcus aureus (MRSA). Intravenous linezolid was started because of renal dysfunction. The episode was considered to be uncomplicated SAB because follow-up blood cultures were negative, fever resolved, transthoracic echocardiography showed no vegetation, and no metastatic infection was identified. Antimicrobial therapy was stopped after 14 days. Fever and inflammatory markers did not recur, but nonspecific chest symptoms persisted. Follow-up coronary angiography showed no clear abnormalities. After discharge, MRSA bacteraemia recurred. The patient developed shock with inferior ST-segment elevation, followed by pulseless electrical activity and death. Autopsy revealed coronary wall disruption, surrounding haemorrhage, ostial thrombotic occlusion, gram-positive cocci, and neutrophilic infiltration near the right coronary ostial stent, leading to the diagnosis of CSI. Discussion This case raises the possibility that a recently implanted DES may serve as an occult endovascular focus during SAB. Negative follow-up blood cultures, defervescence, normalised inflammatory markers, and unrevealing imaging may not exclude CSI; persistent or recurrent chest symptoms after recent PCI should prompt targeted reassessment.
Abstract Background Fabry disease (FD) is a rare X-linked lysosomal storage disorder and also a rare cause of coronary stenosis. We present a case of coronary stenosis in a 39-year-old man with FD, including optical coherence tomography (OCT) imaging findings. Case summary A 39-year-old man was admitted with unstable angina. He had been previously diagnosed with FD through α-galactosidase A enzyme activity testing and genetic analysis. Coronary angiography (CAG) revealed 90% stenosis in the proximal left anterior descending artery (pLAD). The pre-procedural CAG-based fractional flow reserve (caFFR) was 0.57, and the CAG-based index of microcirculatory resistance (caIMR) was 14.4. Drug-coated balloon (DCB) angioplasty was performed, achieving post-procedural stenosis of 0%, with caFFR improving to 0.86 and caIMR decreasing to 9.4. He had no traditional atherosclerotic cardiovascular disease (ASCVD) risk factors. Although CAG indicated 90% stenosis of the pLAD, OCT imaging did not demonstrate typical atherosclerotic or fibrocalcific plaques. However, based on the patient's clinical features, OCT findings, and previous literature, we could not definitively determine the specific etiology of the coronary stenosis (FD, coronary atherosclerosis, or both). During a 2-year follow-up, he remained angina-free. Discussion Although OCT may aid in differentiating FD-related coronary involvement due to its high resolution and ability to detect FD-compatible changes, it cannot reliably determine whether the fibrous plaque morphology and loss of layered architecture are attributable to FD-related coronary pathology or premature atherosclerosis, representing a fundamental imaging limitation.
Background:Transcatheter edge-to-edge repair (TEER) has emerged as an effective therapeutic option for patients with severe mitral regurgitation (MR) deemed high risk for surgery. Two devices are currently available in Europe, MitraClip (Abbott Vascular, Santa Clara, CA, USA) and PASCAL (Edwards Lifesciences, Irvine, CA, USA). The PASCAL system provides unique features, such as a central spacer and nitinol flexibility, that may expand eligibility in anatomically and clinically challenging cases. Case summary:We present the case of a 78-year-old female with ischaemic cardiomyopathy and advanced heart failure (HF) [ejection fraction (EF) of 25%), severe secondary MR (SMR), chronic kidney disease, and recurrent pulmonary oedemas with hospitalizations with an STS score of 26.8%]. Thus, transcatheter TEER was deemed the best option. The baseline mitral valve area (MVA) and mean gradient were 2.7 cm2 and 2.4 mmHg, respectively. Therefore, TEER with the PASCAL P10 device was selected as the most optimal device. A single device was implanted at the A2-P2 scallops, resulting in significant MR reduction and an acceptable final mean gradient of 4.5 mmHg. The patient was discharged clinically improved and without any hospitalizations for heart failure in 1-year follow up period. Discussion:This case illustrates the feasibility of TEER with PASCAL in a frail, high-risk patient with severe SMR and borderline anatomy. The spacer technology and leaflet-friendly design allowed safe and effective MR reduction while maintaining acceptable gradients. This case highlights the importance of individualized heart team decision-making, the potential advantages of the PASCAL device in anatomically challenging scenarios and increased operator experience.
Background:Arrhythmogenic cardiomyopathy (ACM) is a genetic myocardial disease classically characterized by ventricular arrhythmias and right ventricular involvement. Biventricular variants involving PKP2 mutations are increasingly recognized but rarely present primarily as severe heart failure and multi-focal thromboembolism. Case summary:A 22-year-old woman presented with progressive exertional dyspnoea and severe biventricular dysfunction [left ventricular systolic dysfunction (LVEF) 20%]. The clinical course was complicated by right subclavian vein thrombosis and an acute cerebellar infarction. Cardiac magnetic resonance imaging demonstrated biventricular involvement with a non-ischaemic pattern of myocardial fibrosis. Genetic testing identified a pathogenic heterozygous PKP2 variant, which, integrated with the phenotype, established the diagnosis of ACM. Serial electrocardiographic assessment revealed a high burden of multifocal premature ventricular complexes, which persisted despite catheter ablation and increased during ambulation, indicating ongoing electrical instability. The patient received optimized guideline-directed medical therapy and rivaroxaban. At follow-up, she demonstrated reverse remodelling with an improved LVEF of 31%. Discussion:This case expands the clinical spectrum of PKP2-associated ACM, emphasizing that severe heart failure and thromboembolism can dominate the clinically apparent presentation. While significant arrhythmias, including non-sustained ventricular tachycardia and a high premature ventricular contraction (PVC) burden, are classic hallmarks of the disease, in this case, they did not prompt initial medical attention and were instead documented on later surveillance. Although electrical remodelling occurs early, it may remain clinically concealed until unmasked by progressive structural damage. Early integration of multimodality imaging and genetic testing is essential for accurate diagnosis and risk stratification. Implantable cardioverter-defibrillator implantation was planned for primary prevention of sudden cardiac death.
Background:ST-elevation myocardial infarction (STEMI) in very young adults is rare and is commonly attributed to non-atherosclerotic mechanisms. Atherosclerotic coronary artery disease in this age group is exceptional and warrants thorough evaluation of contributing risk factors. The increasing prevalence of electronic cigarette use among young individuals raises concern regarding its potential role in premature coronary atherosclerosis. Case summary:A 21-year-old man presented with a 3-h history of typical anginal chest pain. He had a significant history of combined tobacco cigarette and electronic cigarette use for more than 5 years. Electrocardiography demonstrated ST-segment elevation in the inferior leads, consistent with inferior STEMI. Laboratory testing revealed elevated troponin I, leukocytosis, and prediabetes (HbA1c 6.2%). Coronary angiography identified an atherosclerotic culprit lesion with ∼80% stenosis and thrombus formation in the mid-right coronary artery. The patient underwent successful primary percutaneous coronary intervention with TIMI grade III flow. Transthoracic echocardiography showed preserved left ventricular systolic function. Further evaluation excluded autoimmune and secondary thrombotic aetiologies. The patient recovered well, was discharged on guideline-directed medical therapy, and remained asymptomatic at 3-month follow-up without recurrent ischaemic events. Discussion:This case highlights premature atherosclerotic STEMI in a very young adult without established cardiovascular disease or autoimmune aetiology. Chronic exposure to combustible and electronic cigarettes has been associated with endothelial dysfunction and vascular inflammation, which may contribute to accelerated atherosclerosis. Clinicians should maintain a high index of suspicion for atherosclerotic myocardial infarction in young patients with significant nicotine exposure and emphasize early prevention and cessation strategies in accordance with current European Society of Cardiology guidelines.
Abstract Background Case Coronary artery bypass grafting (CABG) is a common revascularization strategy, yet ischemic symptoms may persist despite patent grafts. Case Summary We describe a 60-year-old man with three-vessel coronary artery disease treated with triple CABG who presented with persistent dyspnea and infero-lateral myocardial hypoperfusion. Repeat coronary angiography demonstrated patent grafts but identified a collateral branch of the right internal mammary artery causing a steal phenomenon. Coil embolization of the collateral vessel led to complete symptom resolution and normalization of myocardial perfusion. Discussion This case highlights a rare cause of CABG steal syndrome and emphasizes the need for careful assessment of internal mammary artery branches in patients with ongoing post-CABG ischemia
Background:Early bioprosthetic mitral valve thrombosis (BPVT) is a rare but life-threatening cause of acute prosthetic obstruction after mitral valve surgery. Management is particularly challenging in postcardiotomy shock requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO), where low native cardiac output and left-sided stasis may promote thrombosis despite systemic anticoagulation. Case summary:A 74-year-old man underwent bioprosthetic mitral valve replacement, tricuspid annuloplasty, pulmonary vein isolation, and left atrial appendage closure for severe primary mitral regurgitation, with intra-operative identification of ascending aortic dissection requiring replacement of the ascending aorta and hemiarch. Because of severe postcardiotomy shock with biventricular dysfunction, peripheral VA-ECMO was initiated. On post-operative Day 2, transoesophageal echocardiography demonstrated severe bioprosthetic mitral obstruction with restricted leaflet motion and a mean transmitral gradient of 25 mmHg. Repeat imaging showed persistent obstruction with extensive left atrial thrombus despite anticoagulation optimization. Surgical reintervention and systemic fibrinolysis were considered prohibitive. After Heart Team discussion, rescue transseptal percutaneous mitral balloon valvuloplasty was performed under cerebral embolic protection using a 26-mm Inoue balloon. Immediate post-procedural imaging showed improved leaflet mobility and reduction of the mean transmitral gradient from 25 to 4 mmHg, without significant mitral regurgitation. The patient was successfully weaned from VA-ECMO and remained clinically stable at 2-month follow-up. Discussion:This case illustrates that, in carefully selected critically ill patients with catastrophic early BPVT during VA-ECMO support, rescue transseptal balloon dilatation may be considered as an exceptional salvage strategy when surgery and fibrinolysis are not viable. In highly selected patients with early BPVT causing severe haemodynamic compromise during VA-ECMO support, transseptal balloon dilatation may serve as a bridge-to-recovery option when surgery and fibrinolysis are contraindicated or carry prohibitive risk.
Background:Left main coronary artery (LMCA) aneurysms are exceedingly rare, found in ∼0.1% of coronary angiograms, and acute coronary syndromes are an uncommon first presentation. When the aneurysm involves the distal LMCA and its bifurcation, percutaneous covered-stent treatment is generally not feasible, leaving surgical and medical therapy as the only realistic options, with no controlled data to favour either. Case summary:We report two male patients presenting with non-ST-elevation myocardial infarction and thrombosed distal LMCA aneurysms. Both patients were evaluated by a multidisciplinary heart team but received divergent therapeutic strategies. Case 1 (44-year-old male) underwent surgical revascularization with coronary artery bypass grafting and aneurysm ligation following unsuccessful percutaneous recanalization of the left circumflex artery. Case 2 (65-year-old male) declined surgery and was managed medically with intensive antiplatelet and anticoagulation therapy. Both remained asymptomatic during three months of follow-up. Discussion:This case series underscores the diagnostic and therapeutic complexity of thrombosed distal LMCA aneurysms. Although surgical exclusion of the aneurysmal sac may, on anatomical grounds, be hypothesized to reduce the risk of recurrent thromboembolism, medical management remains a legitimate option in selected patients who decline or are unsuitable for surgery. The risk of recurrent thrombosis in medically managed patients remains incompletely characterized, and the short follow-up in our cases limits long-term conclusions. In the absence of randomized controlled trials, management decisions must be individualized through multidisciplinary heart team discussion, incorporating aneurysm size, morphology, thrombus burden, clinical presentation, and patient preferences.
Background:Transthyretin amyloid cardiomyopathy (ATTR-CM) coexists in up to 15% of elderly patients with severe aortic stenosis (AS), presenting complex diagnostic and therapeutic challenges due to overlapping clinical phenotypes. Case summary:An 85-year-old female presented with a 2-month history of heart failure and a previous medical history of total knee replacement. Echocardiography and computed tomography confirmed severe AS, alongside left ventricular hypertrophy out of proportion to the valvular load and an 'apical sparing' strain pattern. Due to the accompanying red flags, a Tc99m-PYP bone scintigraphy was done. This showed a Grade 3 cardiac uptake, and further testing confirmed wild-type ATTR-CM. Given her recent symptom onset, preserved ejection fraction, and high-gradient AS, the Heart Team prioritized transcatheter aortic valve implantation (TAVI). Following a successful procedure, she demonstrated excellent functional recovery at one month, which clinically justified the subsequent initiation of transthyretin stabilizers. Discussion:Concomitant ATTR-CM must be suspected in elderly AS patients presenting with disproportionate hypertrophy or other clinical/imaging 'red flags'. A sequential management strategy-prioritizing TAVI to relieve the haemodynamic bottleneck, followed by clinical reassessment-can effectively identify appropriate candidates for long-term, disease-modifying transthyretin stabilizer therapy.
Background:Combined mitral transcatheter edge-to-edge repair (M-TEER) and left atrial appendage occlusion (LAAO) may be considered in selected high-risk patients with severe mitral regurgitation (MR) and atrial fibrillation (AF). However, the optimal transseptal puncture site differs between procedures, potentially limiting the feasibility of a single-session approach. Case summary:An 80-year-old frail woman with severe atrial functional MR, permanent AF, chronic kidney disease, and recent severe anaemia was referred for treatment. Considering the patient's high thromboembolic and bleeding risk and overall frailty, a combined percutaneous approach was selected. A supero-posterior transseptal puncture optimized for mitral repair enabled successful M-TEER with significant MR reduction. Subsequent LAAO was challenged by suboptimal alignment with the appendage. The use of a steerable introducer restored coaxiality, allowing stable device delivery and successful deployment of a 24-mm occluder with complete sealing and no peri-device leak. Discussion:This case demonstrates the feasibility of a combined one-stop strategy in frail patients at high procedural risk. It highlights the importance of procedural planning and the role of steerable delivery systems in overcoming anatomical constraints imposed by a mitral-oriented transseptal puncture, thereby facilitating successful completion of both interventions in a single session.
Background:Anomalous aortic origin of a coronary artery (AAOCA) is a rare congenital anomaly. The most frequently reported and surgically treated form involves origin of a coronary artery from the opposite sinus that follows an interarterial course, often termed 'malignant'. In contrast, AAOCA arising from the appropriate sinus without an interarterial course is uncommon, and its clinical significance and optimal management remain poorly defined. Case summary:A 12-year-old girl with exertional syncope during physical activity was referred to our hospital. Contrast-enhanced computed tomography revealed an anomalous origin of the left coronary artery from the left sinus of Valsalva with an acute-angle take-off and an intramural segment. Intravascular ultrasound (IVUS) confirmed an intramural course within the aortic wall and demonstrated luminal deformation, with the lumen appearing more elliptical at end-diastole. Because of exertional syncope and a substantial intramural segment, surgical unroofing was performed without postoperative aortic valve dysfunction. Conclusion:This report describes a rare variant of AAOCA characterized by a long intramural course confined to the left sinus of Valsalva without an interarterial course. Despite the absence of a typical malignant course, the patient had symptoms suggestive of myocardial ischaemia. Multimodality imaging played a key role in diagnosis and surgical planning, while IVUS provided complementary structural and dynamic information by demonstrating luminal changes. Surgical unroofing may therefore be considered for symptomatic paediatric patients with a substantial intramural segment even without an interarterial course.
