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.
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.
