Background Dual-chamber implantable cardioverter-defibrillator (ICD) discrimination algorithms using the atrial-to-ventricular event ratio predictably misclassify supraventricular tachycardias with a very short ventriculoatrial (VA) interval as ventricular tachycardia (VT). Case Summary A 75-year-old man with nonischemic cardiomyopathy and a dual-chamber ICD had 74 episodes of regular 1:1 tachycardia labeled as nonsustained VT/ventricular fibrillation; some episodes triggered antitachycardia pacing. Stored electrograms were analyzed using 4 questions: how the tachycardia initiated, its response to ventricular overdrive pacing, the direction of cycle-length wobble, and how it terminated. These findings excluded VT and identified typical slow-fast atrioventricular nodal re-entrant tachycardia, confirmed on electrophysiology study and treated with slow-pathway modification. Discussion Tachycardias with short VA intervals may produce a V-on-A pattern with atrial blanking or undercounting, causing ratio-based ICD algorithms to favor VT. Take-Home Message A 4-question electrogram approach can distinguish short-VA supraventricular tachycardia from VT, prevent inappropriate therapy, and guide definitive electrophysiologic evaluation.
Objective The authors aim to describe contrast-free dual-chamber leadless pacemaker implantation using combined intracardiac echocardiography (ICE) and CARTO three-dimensional electroanatomical mapping in near-dialysis-stage chronic kidney disease cases. Key Steps 1) Noncontrast computed tomography reconstruction imported into CARTO as an anatomical roadmap; 2) ICE-guided 3D right-heart geometry reconstruction with color-tagged targets; 3) Aveir VR implantation at the mid-interventricular septum under ICE/CARTO co-registration with echo-fan-guided advancement; 4) Aveir AR implantation at the right atrial appendage base using pectinate muscles as landmarks; 5) sequential impedance monitoring as a tissue-contact surrogate. Potential Pitfalls The echo fan must be directed toward the septum, not the right ventricular apex, before advancing the catheter; misalignment may cause apical fixation. Accurate right atrial appendage base identification via pectinate muscles is essential to avoid fixation at insufficiently thick myocardium. Take-Home Message Combined ICE and CARTO 3-dimensional electroanatomical mapping enables safe, contrast-free dual-chamber leadless pacemaker implantation in chronic kidney disease cases, potentially expanding this therapy to patients in whom contrast is contraindicated.
Background Left atrial appendage closure (LAAC) is increasingly used for stroke prevention in atrial fibrillation, but rare structural complications may occur and require percutaneous treatment. Case Summary A 76-year-old man with atrial fibrillation/flutter was referred for LAAC after LAA thrombus was found on transesophageal echocardiography despite therapeutic anticoagulation. A “no-touch” strategy was planned. The device was deployed in FLX-ball configuration and advanced gently without resistance. However, transesophageal echocardiography and angiography demonstrated deployment within an outpouching adjacent to the true LAA. The device was recaptured, advanced into the true LAA, and LAAC was completed. Postprocedural computed tomography demonstrated a likely iatrogenic pseudoaneurysm, which was successfully closed 2 days later using an Amplatzer ventricular septal defect occluder. Discussion This case highlights multimodality imaging and transcatheter management of an iatrogenic left atrial pseudoaneurysm after LAAC. Take-Home Messages LA pseudoaneurysm is a rare complication of LAAC. Multimodality imaging can identify the defect and guide percutaneous closure.
Background Percutaneous patent foramen ovale (PFO) closure typically uses femoral venous access. Congenital or acquired inferior vena cava (IVC) interruption precludes this route and presents a significant technical challenge. Case Summary A 54-year-old man was referred for PFO closure following cryptogenic embolic stroke. Femoral access failed; intraprocedural venography confirmed IVC interruption. The case was reattempted via the right internal jugular vein. A 30-mm PFO closure device was deployed using a preshaped transcatheter aortic valve replacement guidewire anchored in the left ventricle for support. Review Summary Fifteen published cases detail PFO closure via transjugular, transhepatic, and upper-limb access. The transjugular approach requires specific strategies to overcome the unfavorable crossing angle, including preformed or steerable catheters and distal wire anchoring in the pulmonary veins, left atrium, or left ventricle. Take-Home Messages Congenital or acquired IVC interruption necessitates alternative access strategies for percutaneous PFO closure. While technically demanding, transjugular and transhepatic routes are feasible alternatives.
Background Giant left atrium (GLA) is a rare complication of rheumatic heart disease that may continue to enlarge despite successful valve surgery. Case Summary A 69-year-old man with rheumatic valvular disease and previous mechanical mitral and aortic valve replacement developed progressive GLA and heart failure symptoms. Redo aortic valve replacement was performed for prosthetic dysfunction. Long-term follow-up demonstrated progressive atrial enlargement (indexed left atrial volume up to 1,172 mL/m2), mediastinal displacement, and pulmonary compression. Despite these findings, right heart catheterization confirmed normal pulmonary artery and filling pressures, with preserved left ventricular ejection fraction and sustained clinical stability. Discussion GLA is typically associated with pulmonary hypertension and heart failure progression. This case is notable for extreme progressive atrial remodeling over 2 decades despite correction of the underlying valve disease, while preserving pulmonary hemodynamics and ventricular function. Take-Home Messages Progressive GLA may remain compatible with prolonged survival after successful valve surgery when ventricular function and pulmonary hemodynamics are preserved. Long-term multimodality imaging and invasive hemodynamic assessment are essential for patient management.
Background Transcatheter edge-to-edge repair has emerged as a minimally invasive option for patients at high surgical risk. Residual/recurrent tricuspid regurgitation (TR) is associated with high morbidity and mortality. Case Summary A 79-year-old woman developed recurrent severe TR after initially successful TriClip implantation. Symptoms progressed despite optimal medical therapy. As redo tricuspid transcatheter edge-to-edge repair (T-TEER) was not feasible, the patient underwent surgical intervention. Following careful clip removal, surgical tricuspid valve (TV) repair was successfully performed. At 7-month follow-up, echocardiography confirmed a stable repair with mild TR, and the patient reported substantial symptomatic improvement. Discussion This case shows that surgical TV repair can be a safe and effective treatment option for recurrent TR after T-TEER. With the increasing use of transcatheter therapies, awareness of surgical bailout options will become increasingly important. Take-Home Message Surgical TV repair may represent a safe and effective strategy in selected patients with recurrent TR after T-TEER.
Background Hemophagocytic lymphohistiocytosis (HLH) is a hyperinflammation syndrome causing multiorgan failure. While cardiac involvement is recognized, associated conduction-system abnormalities are exceedingly rare and poorly described. Case Summary A 60-year-old male presented with fever, pancytopenia, and progressive shock, meeting diagnostic criteria for HLH. His clinical course was acutely complicated by transient cardiomyopathy and frequent episodes of sinus arrest. Following the initiation of HLH-directed therapy, the patient experienced a complete recovery of both systolic function and sinus node conduction by day 10. Discussion This case identifies severe sinus node dysfunction as a reversible manifestation of HLH-related cytokine storm. Prompt initiation of immunosuppressive therapy led to complete recovery of left ventricular function and sinus node activity, highlighting the reversible nature of the HLH-related myocardial injury. Take-Home Message This case highlights the importance of early identification of HLH-related cardiac involvement as it is critical to prevent irreversible damage and improve outcomes in these patients.
Background Atrial fibrillation (AF), the most prevalent arrhythmia, poses significant health risks globally, particularly in aging populations. For symptomatic persistent AF resistant to standard treatments, the guidelines recommend hybrid approaches. Convergent hybrid ablation with robotic epicardial surgery enhances access in cases with challenging pericardial adhesions. Case Summary We present a case of persistent AF with past catheter ablation complicated by pericardial effusion now presenting with worsening symptoms. Given anticipated pericardial adhesions, convergent hybrid ablation with a robotic-assisted epicardial component was performed, followed by a successful second-stage endocardial ablation. The patient had an uneventful recovery and remains in sinus rhythm. Discussion This report demonstrates the successful application of a robotic platform to the epicardial component of a Convergent hybrid ablation procedure, in which diffuse adhesions precluded the standard approach. Take-Home Message Robotic-assisted hybrid ablation is a novel approach for hybrid ablation for long-standing persistent AF, especially in patients with pericardial adhesions.
Background Left juxtaposition of the right atrial appendage (RAA) is an extremely rare congenital anomaly in which the RAA is located to the left of the ascending aorta and pulmonary artery. Case Summary A 67-year-old woman with persistent atrial fibrillation underwent pulsed-field ablation. Preprocedural cardiac computed tomography (CCT) revealed left juxtaposition of the RAA without any associated cardiac anomalies. During the procedure, the coronary sinus catheter initially advanced toward the anomalous appendage, and the transseptal needle tended to deflect into it. Careful manipulation under CCT-based anatomical guidance prevented cardiac perforation. Pulmonary vein and posterior wall isolation were successfully achieved without complications. Discussion This case highlights the procedural risk of catheter or transseptal needle misdirection into an anomalously positioned RAA and underscores the critical role of preprocedural CCT in preventing potentially fatal complications. Take-Home Message Preprocedural CCT enables safe transseptal access by delineating the rare atrial anatomy and preventing cardiac tamponade.
BACKGROUND:Adults with repaired tetralogy of Fallot (rTOF) frequently develop right bundle branch block (RBBB)-related dyssynchrony and progressive heart failure. The role of left bundle branch area pacing (LBBAP) in this population remains limited. CASE SUMMARY:A 60-year-old man with rTOF presented with monomorphic ventricular tachycardia and worsening heart failure despite being on an optimal medical therapy. After cardioversion, electrocardiography demonstrated sinus rhythm with RBBB and left anterior fascicular block (QRS = 166 ms), while echocardiography revealed biventricular dysfunction with significant mechanical dyssynchrony. A dual-chamber implantable cardioverter-defibrillator with LBBAP was implanted. At 3-month follow-up, QRS duration narrowed, functional status improved, and echocardiographic indices of left and right ventricular systolic function, strain, and myocardial work improved. DISCUSSION:This case suggests that LBBAP may be associated with improved electrical and mechanical synchrony in cases of rTOF with RBBB. TAKE-HOME MESSAGES:LBBAP may represent a promising physiologic resynchronization strategy in selected adults with congenital heart disease and RBBB. Advanced echocardiography can quantify serial changes in ventricular function and mechanics after pacing.
BACKGROUND:Takotsubo syndrome (TTS) predominantly affects postmenopausal women after emotional or physical stress; men account for only ∼10% of cases and are usually triggered by physical precipitants. CASE SUMMARY:A 48-year-old man presented with 24 hours of dyspnea following psychosocial stress related to financial and occupational strain. He was diagnosed with TTS complicated by dynamic left ventricular outflow tract obstruction and 4 discrete apical thrombi identified on cardiac magnetic resonance, and recovered fully with β-blockade and anticoagulation. DISCUSSION:This case is doubly atypical in sex and trigger. Severe complications arose despite a lower-risk trigger profile, and cardiac magnetic resonance was essential to detect thrombi and exclude infarction and myocarditis. TAKE-HOME MESSAGE:Male patients with psychosocial stress-triggered TTS are rare but face significant risk of severe complications, and multimodality imaging including cardiac magnetic resonance is helpful in this underrecognized population.
Objective To describe shared decision-making-guided prehabilitation as a bridge to repair in unrepaired high-risk anomalous aortic origin of the left main coronary artery. Key Steps A young woman developed cardiogenic shock after hysteroscopic hemorrhage, required extracorporeal membrane oxygenation, and was found to have severe ostial compression of an anomalous left main coronary artery. After initial weaning, oral feeding was followed by recurrent shock requiring renewed support. Because repair was deferred for ventricular dysfunction, malnutrition, frailty, and emotional distress, she underwent 20 days of multidisciplinary prehabilitation capped at 2-3 METs after circulatory support was withdrawn. Potential Pitfalls Feeding and exercise may become hemodynamic stressors; resting echocardiography cannot exclude exercise-induced compression. Premature ventricular contractions during cycling required activity cessation and reassessment. Take-Home Message Cautious monitored prehabilitation may bridge selected frail patients with unrepaired high-risk coronary anomaly to definitive repair.
Background Angiomatoid fibrous histiocytoma (AFH), a type of primary pulmonary artery tumor, is a rare pathology without well-established risk factors, making it a challenging diagnosis. Case Summary A 28-year-old man with a history of stage 3 Burkitt lymphoma in remission presented with a new systolic heart murmur. Transthoracic echocardiography noted an indeterminate structure in the main pulmonary artery. Cardiac magnetic resonance imaging and positron emission tomography-computed tomography revealed a 1.9 cm hyperintense mass attached to the pulmonic valve and main pulmonary artery wall. The patient underwent resection of the main pulmonary artery and pulmonic valve with pulmonary artery homograft implantation. Surgical pathology revealed angiomatoid fibrous histiocytoma. Discussion AFH is a rare condition with poor outcomes that is often mistaken for pulmonary embolism. Prompt diagnosis and intervention are crucial to improve prognosis. Take-Home Message AFH is a rare pathology with poor prognosis that should be considered in all patients with prior oncologic history presenting with a cardiac murmur.
Background Cardiac myxomas are the most common primary cardiac tumors and are usually solitary and sporadic. The presence of multiple synchronous lesions should raise suspicion for an underlying syndromic condition such as Carney complex (CNC). Case Summary A 39-year-old asymptomatic man underwent transthoracic echocardiography for recurrent ventricular extrasystoles on electrocardiogram, which incidentally revealed multiple intracardiac masses. Multimodality imaging, including transesophageal echocardiography, computed tomography, and cardiac magnetic resonance, identified 4 distinct, highly mobile lesions involving the left ventricle, the mitro-aortic curtain, and left atrium, with features suggestive of myxomas. Given the high embolic risk, surgical excision was performed with concomitant mitral valve repair. Histopathological analysis confirmed cardiac myxomas, whereas immunohistochemistry showed reduced protein kinase A regulatory subunit 1-alpha expression. Genetic testing subsequently identified a protein kinase A regulatory subunit 1-alpha autosomal mutation, establishing the diagnosis of CNC. Discussion This case underscores the importance of multimodality imaging for accurate diagnosis and surgical planning. The detection of multiple synchronous cardiac masses should prompt genetic evaluation and long-term surveillance for CNC in clinical practice, because this syndrome may lead to endocrinological diseases such as Cushing syndrome and malignant endocrine tumors.
Background Extravascular implantable cardioverter-defibrillators (EV-ICDs) use a substernal route to avoid intravascular lead placement, but substernal tunneling carries a risk of pericardial injury not encountered with transvenous systems. Case Summary A 48-year-old man with ischemic cardiomyopathy (ejection fraction 14%) survived an out-of-hospital cardiac arrest due to monomorphic ventricular tachycardia at 240 beats/min. Cardiac magnetic resonance confirmed an extensive nonviable inferior scar. An EV-ICD was implanted for secondary prevention. Substernal tunneling was complicated by pericardial puncture and pneumopericardium. After lead repositioning, intraoperative defibrillation testing (DFT) failed twice, with subsequent sensing deterioration. Therapies were deactivated. Serial chest radiographs confirmed complete pneumopericardium resorption by day 30 with stable lead position. Repeat DFT at 5 weeks succeeded without reintervention. Device parameters remained normal at 1-year follow-up. Discussion Pneumopericardium is an under-recognized complication of substernal EV-ICD implantation that can transiently impair sensing and DFT. Conservative management with deferred re-testing illustrated a safe pathway, avoiding unnecessary system revisions.
