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.
Abstract 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 ischemia. 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 pediatric patients with a substantial intramural segment even without an interarterial course.
Abstract Background Thromboembolic complications are well recognized in cardiac amyloidosis and are traditionally attributed to atrial fibrillation (AF). However, patients with immunoglobulin light-chain (AL) cardiac amyloidosis remain at substantial thromboembolic risk, even in sinus rhythm, presumably due to atrial mechanical dysfunction. Acute limb ischemia as the first clinical manifestation of AL cardiac amyloidosis is exceedingly rare. Case summary A 64-year-old man presented with sudden-onset pain and coldness in the left lower limb. Computed tomography revealed acute occlusion of the left popliteal artery, and an emergency surgical thrombectomy was successfully performed. Electrocardiography showed sinus rhythm, and continuous monitoring during hospitalization detected no atrial fibrillation. Transthoracic echocardiography demonstrated concentric ventricular wall thickening and reduced transmitral A-wave velocity despite preserved sinus rhythm and generally normal left atrial size, suggesting impaired atrial mechanical function. Cardiac magnetic resonance imaging revealed diffuse subendocardial late gadolinium enhancement extending into the left atrial myocardium. Right ventricular endomyocardial biopsy confirmed AL amyloidosis. The patient was accordingly diagnosed with AL cardiac amyloidosis, complicated by systemic arterial thromboembolism. Daratumumab-based therapy and anticoagulation were initiated, resulting in no recurrence of embolic events and excellent functional recovery during follow-up. Discussion This case highlights that AL cardiac amyloidosis can cause clinically significant systemic arterial thromboembolism, even in apparent sinus rhythm. Atrial mechanical dysfunction due to amyloid infiltration, rather than atrial fibrillation, appears to be a key mechanism. Clinicians should consider cardiac amyloidosis in patients with embolic events of unknown origin, particularly when imaging findings suggest infiltrative cardiomyopathy.
Abstract Background Transcatheter tricuspid valve replacement (TTVR) is an option for selected patients with severe tricuspid regurgitation (TR) who are at high surgical risk, but experience remains limited in those with extreme right-heart anatomy, including a giant right atrium and a markedly enlarged elliptical tricuspid annulus. Case summary A 62-year-old man was admitted with progressive dyspnoea and lower-extremity oedema (NYHA class IV). He had prior mechanical mitral valve replacement and transcatheter aortic valve replacement. Echocardiography and CTA showed torrential TR, a giant right atrium (11.59 × 7.73 cm), preserved right ventricular systolic function, and a markedly elliptical annulus with a perimeter-derived diameter of 55.5 mm. Persistent TR despite satisfactory left-sided prosthetic valve function prompted transcatheter evaluation. Redo surgery was prohibitive and transcatheter edge-to-edge repair unsuitable. The Heart Team selected LuX-Valve Plus because its leaflet graspers and septal anchor provide radial force-independent multipoint fixation. A 79.2-mm bend-point-to-annulus distance exceeded the proposed 45–70 mm range, requiring a slightly lateral jugular entry angle and complicating depth control and coaxial alignment. The mechanical mitral prosthesis limited transoesophageal echocardiography (TEE) but served as a fluoroscopic landmark; TEE and fluoroscopy enabled successful implantation. At 1 month, NYHA class improved to II, with stable prosthetic haemodynamics, no obvious transvalvular regurgitation, and trivial paravalvular leak; findings remained stable at 6–7 weeks. Discussion This case highlights the feasibility of transjugular LuX-Valve Plus TTVR in extreme right-heart anatomy and emphasizes the importance of anatomy-driven device selection, tailored delivery and imaging strategies, and individualized postprocedural management.
Abstract Background Eosinophilic myocarditis (EM) is a rare form of myocarditis which may be caused by eosinophilic granulomatosis with polyangiitis (EGPA), a rare disease which frequently affects the heart. The case of a young woman with a rare initial manifestation of EGPA as a cause of EM is reported. Case Summary A 39-year-old woman presented with diffuse neurological symptoms. She was diagnosed with multiple, bilateral, simultaneous ischemic strokes. No obvious stroke origin was detectable. However, significantly elevated troponin levels and eosinophilia were noted. Cardiac computed tomography ruled out coronary artery disease. Cardiac magnetic resonance imaging (CMR) proved myocarditis. However, endomyocardial biopsy (EMB), did not confirm EM. Nevertheless, EGPA with primary cardiac involvement was diagnosed due to eosinophilia, history of asthma, evidence of pANCA and matching CMR findings. Treatment with benralizumab was initiated. Follow-up CMR after about 6 months showed a significant reduction in inflammatory activity. Discussion EGPA and EM associated with EGPA are rare but in patients with EGPA, cardiac involvement is frequent. Ischemic strokes as an initial manifestation of EGPA is particularly rare. Other potential causes of stroke were ruled out. In the presence of CMR-proven myocarditis associated with peripheral eosinophilia, EM may be diagnosed without histological confirmation. EMB may be false negative in a relevant number of cases but CMR is usually abnormal. However, there are no specific CMR findings that occur exclusively in EM.
Abstract Background Primary cardiac angiosarcoma is a rare and highly aggressive malignancy whose clinical presentation is primarily driven by local invasion and metastatic dissemination. Its rapid progression and frequent diagnostic delay contribute to a markedly poor prognosis. Case summary We report a 64-year-old man who initially presented with pericardial effusion and symptomatic sick sinus syndrome, for which he underwent dual-chamber pacemaker implantation. A right atrial mass closely related to the pacing lead was subsequently detected and repeatedly interpreted as thrombus-like on transthoracic echocardiography, with markedly elevated D-dimer levels. Despite anticoagulation, the mass enlarged and multiplied, ultimately causing superior vena cava obstruction. Concurrent pulmonary nodules and ground-glass opacities developed. Surgical exploration and debulking revealed extensive tumour infiltration of the right atrium and venae cavae. Histopathology confirmed cardiac angiosarcoma. The patient remained haemodynamically unstable after surgery and was considered unsuitable for systemic antitumour therapy. He died 13 days after surgery. Discussion This case highlights the diagnostic difficulty of primary cardiac angiosarcoma presenting with pericardial effusion and sick sinus syndrome, particularly when a right atrial mass is spatially related to a pacing lead and repeatedly appears thrombus-like on echocardiography. Progressive enlargement despite anticoagulation should prompt early reconsideration of malignancy and multidisciplinary evaluation.
Abstract Background Transcatheter closure of a patent foramen ovale (PFO) is an established strategy for secondary prevention of cryptogenic stroke in selected patients. During pregnancy, the timing and method of closure require individualized assessment of recurrent embolic risk and maternal–fetal procedural risk. In selected first-trimester patients, avoiding fluoroscopy, contrast, procedural transoesophageal echocardiography (TEE), and sedation may be desirable when adequate alternative imaging is available. Case summary A 34-year-old woman at 7 weeks’ gestation presented with acute ischaemic stroke. Work-up demonstrated a non-lacunar cortical infarct, long-tunnel PFO with a large provoked right-to-left shunt, and no alternative embolic source; the Risk of Paradoxical Embolism score was 9. After multidisciplinary discussion, early percutaneous closure was performed using a completely zero-fluoroscopy, intracardiac echocardiography (ICE)-only workflow under local anaesthesia, without procedural TEE. Key adaptations included use of a pre-shaped transseptal sheath for stable cannulation and a left atrial rail using a pre-shaped support wire. Stop-flow balloon sizing was performed and agitated saline was injected through the delivery sheath as an adjunctive visual check of left atrial position prior to device release. A 25/18-mm Amplatzer Talisman PFO occluder was deployed successfully with no complications. Discussion This case demonstrates the feasibility of zero-fluoroscopy, zero-contrast PFO closure under ICE-only guidance in a carefully selected first-trimester pregnant patient. The combination of stable sheath engagement, a pre-shaped left atrial support-wire rail, stop-flow balloon sizing, and sheath-through agitated saline injection facilitated controlled device deployment without fluoroscopy or contrast. This approach depends on operator expertise and institutional familiarity with ICE-guided structural intervention.
Abstract Background Left atrial appendage closure (LAAC) is an established stroke-prevention strategy for selected patients with atrial fibrillation who are unsuitable for long-term oral anticoagulation. Device embolization is rare but potentially life-threatening, particularly when the occluder migrates into the left ventricle, where it may interfere with the mitral or aortic valve apparatus or provoke ventricular arrhythmia. Case summary A 68-year-old woman with permanent atrial fibrillation, recurrent gross hematuria during anticoagulant therapy, chronic heart failure, and a high thromboembolic risk underwent LAAC under transesophageal echocardiographic guidance. Pre-procedural imaging showed a left atrial appendage ostium of 30 mm, a landing-zone diameter of 28 mm, and a depth of 32 mm. During the first deployment attempt with a 28/34-mm LAmbre occluder, the device showed insufficient anchoring and was not released. During attempted recapture and exchange, the partially deployed device embolized across the mitral valve into the left ventricular cavity, with a short self-terminating episode of ventricular tachycardia. Because the patient remained hemodynamically stable and real-time imaging showed no valvular entrapment or structural injury, retrograde transaortic percutaneous retrieval was performed using a 14-Fr steerable sheath and grasping forceps. After successful retrieval and immediate confirmation of valve integrity, a larger 32/36-mm LAmbre occluder was implanted in the same session with stable position and no residual peri-device leak. Discussion This case illustrates that, in carefully selected hemodynamically stable patients without valvular entrapment, left ventricular outflow tract obstruction, or structural injury, retrograde transaortic percutaneous retrieval of a left-ventricularly embolized LAAC device may be feasible. Same-session redo LAAC can be considered after successful retrieval when valve integrity is confirmed and the left atrial appendage anatomy remains suitable.
Abstract Background Prosthetic valve endocarditis (PVE) is associated with substantial morbidity and mortality, particularly when complicated by severe prosthetic valve dysfunction and paravalvular leak. Although redo surgery remains the standard treatment, some patients may be unsuitable for surgical intervention because of prohibitive operative risk. Case summary A 64-year-old man with previous surgical bioprosthetic aortic valve replacement had a history of Enterococcus faecalis prosthetic valve endocarditis (PVE) and received targeted antimicrobial therapy. Following targeted antimicrobial therapy with documented microbiological control, he presented with cardiogenic shock due to severe residual prosthetic valve dysfunction, including severe prosthetic stenosis, severe central transprosthetic regurgitation, and severe paravalvular leak. Given his prohibitive surgical risk, the multidisciplinary Heart Team selected transfemoral valve-in-valve transcatheter aortic valve implantation as a rescue strategy. The procedure resulted in marked haemodynamic improvement with only mild residual regurgitation. At 1-year follow-up, the patient remained clinically stable with a well-functioning prosthetic valve and no evidence of recurrent infection. Discussion This case demonstrates that valve-in-valve transcatheter implantation may be considered as a rescue option in carefully selected patients with controlled prosthetic valve endocarditis and residual prosthetic valve dysfunction who are unsuitable for redo surgery. Multimodality imaging and multidisciplinary Heart Team evaluation are essential for individualized decision-making in this challenging clinical scenario.
Abstract Background Commotio cordis is a rare, potentially fatal arrhythmic event precipitated by blunt trauma to the chest, typically during sports, in the absence of structural heart disease. The term, derived from Latin meaning “agitation of the heart,” reflects the mechanism in which a precisely timed impact during the vulnerable phase of ventricular repolarization induces ventricular fibrillation. Case Summary A 25-year-old male athlete with no past medical history or known cardiac conditions, and no family history of sudden cardiac death, suffered a cardiac arrest during an intermediate hurling championship match after a high-speed collision in which an opponent’s knee struck his anterior chest. Ventricular fibrillation (VF) was detected, and spontaneous circulation was restored after 1x shock. Extensive evaluation excluded structural or inherited cardiac disease. At two-year follow-up, the patient remains asymptomatic, with serial echocardiograms and has resumed competitive hurling without restrictions. Discussion Commotio Cordis occurs when blunt chest trauma, precisely timed during the upslope of the T-wave, induces ventricular fibrillation or ventricular tachycardia. Our case demonstrates classic features of commotio cordis: a previously healthy adult with no personal or family history of cardiac disease, cardiac arrest temporally related to a precordial impact, rapid restoration of circulation via AED, and favourable long term outcome.
