Although several techniques have been reported for managing an on-wire dislodged stent in the coronary artery, very few reports have focused on the much rarer complication of an off-wire dislodged stent. In a 73-year-old man who experienced an off-wire dislodged coronary stent, the proximal elongated segment was lodged in the left main coronary artery, and the distal segment was floating in the aorta like a wind sock. After a failed attempt at retrieval using a gooseneck microsnare, the dislodged stent was successfully removed using a 3-loop vascular snare via the left radial artery. There was no obvious vascular injury. This novel technique for removing a partially floating dislodged stent was successful after conventional retrieval techniques failed.Abstract
Reverse takotsubo cardiomyopathy is triggered by emotional or physical stress and has a presentation similar to that of acute coronary syndrome. A 39-year-old woman with a history of heroin use disorder presented with intractable nausea, vomiting, and diarrhea. She was diagnosed with heroin withdrawal and started on buprenorphine-naloxone. On day 2 of her hospitalization, she developed chest heaviness and had an elevated troponin I level of 3.2 ng/mL (reference range, 0.015–0.045 ng/mL); electrocardiography showed new T-wave inversions in the anterior and inferior leads. Emergent coronary angiography showed patent coronary arteries, and left ventriculography showed basal hypokinesis and apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy secondary to heroin withdrawal. She was started on antihypertensive agents, and her buprenorphine-naloxone dose was increased. At her 3-month follow-up visit, she reported no symptoms consistent with angina or heart failure. This appears to be the first report of heroin withdrawal causing reverse takotsubo cardiomyopathy. Awareness of this association can lead to earlier recognition and treatment of reverse takotsubo cardiomyopathy.Abstract
A 55-year-old man presented with chest pain and was diagnosed with non–ST-segment elevation myocardial infarction. Coronary angiography revealed a 95% eccentric lesion in the mid-right coronary artery. After 3 intracoronary stents were placed, the guidewire became entrapped in 1 of the stents; multiple attempts at retrieval were unsuccessful. Ultimately, the guidewire fractured, and a coronary artery bypass graft surgery was performed to remove the guidewire fragments. This report reviews the procedural steps for wire retrieval that are critical for operators to avoid coronary artery bypass surgery.Abstract
A 21-year-old man with sensorineural hearing loss and glaucoma presented with severely limited exercise capacity since childhood. He was found to have biventricular concentric hypertrophy with greatest wall thickening at the posterior and lateral walls of the left ventricle apex (1.7 cm) and the free wall of the right ventricle (1.1 cm). There was no inducible left ventricular outflow tract obstruction. Metabolic testing revealed marked lactic aciduria (1,650.1 μmol/mmol creatinine) and plasma lactate (3.9 mmol/L). A sarcomeric hypertrophic cardiomyopathy gene panel was unremarkable, but mitochondrial gene analysis revealed a homozygous c.385G>A (p.Gly129Arg) pathogenic mutation in the BCS1L gene. This gene is responsible for an assembly subunit of cytochrome complex III in the respiratory transport chain and is the rarest respiratory chain defect. This gene has not frequently been implicated in cardiomyopathy. Mitochondrial hypertrophic cardiomyopathy is more rare than hypertrophic cardiomyopathy resulting from sarcomeric mutations and is more likely to be symmetric, less frequently results in left ventricular outflow tract obstruction, and is more likely to progress to dilated cardiomyopathy. Evidence-based screening protocols have not been established; treatment follows guideline-directed medical therapy for congestive heart failure, including evaluation for heart transplantation. This report expands the phenotype of the BCS1L mutation and suggests that affected patients may need screening for underlying cardiomyopathy.Abstract
Primary cardiac sarcoma is a rare type of intracardiac mass. This report describes a patient with atrial flutter who had a new right atrial mass incidentally discovered on transesophageal echocardiography. A thrombus was suspected based on radiographic appearance, but there was minimal change with anticoagulation. The mass was resected and found to be an undifferentiated pleomorphic cardiac sarcoma, an uncommon sub-type within the already rare category of primary cardiac neoplasms. This report highlights the importance of considering primary malignancy and thoroughly correlating radiographic and clinical evidence during the diagnostic workup of patients with intracardiac masses.Abstract
Eosinophilic myocarditis is a rare form of myocarditis characterized by eosinophilic infiltration and usually associated with peripheral hypereosinophilia. The clinical spectrum of eosinophilic myocarditis ranges widely, from mildly symptomatic to fulminant disease. When patients have fulminant eosinophilic myocarditis, high-dose corticosteroids can lead to dramatic improvement and peripheral eosinophil counts are used as an indicator of response to treatment. However, in some patients, peripheral eosinophilia is absent at initial presentation; reaching a diagnosis and determining treatment response can be challenging in this situation. This report describes a patient with fulminant eosinophilic myocarditis who initially presented with a normal peripheral eosinophil count, was diagnosed through an early endomyocardial biopsy, and was successfully treated with corticosteroids. Endomyocardial biopsy should be performed to confirm the presence of myocardial eosinophilic infiltration, especially for patients who present with fulminant myocarditis, even when peripheral eosinophilia is absent.Abstract
Although the management of traumatic injuries to the thoracic aorta has shifted toward endovascular management, the historical standard of care is open reconstruction. Choosing to reoperate when faced with a complication from a prior open repair can be challenging; endovascular management can be a reasonable option in this situation. This report describes a 54-year-old man with a remote history of open surgery for a traumatic injury to the descending thoracic aorta who underwent endovascular aortic stent graft placement for coverage of extrathoracic graft extension with pseudoaneurysm formation and distal embolization. He returned a year later with a type IIIb endoleak with rupture into the posterolateral chest wall. A sec ond endovascular approach was used to successfully reline the graft and exclude the rupture.Abstract
Transcatheter aortic valve replacement is a well-established procedure for older patients with symptomatic, severe aortic stenosis. However, data are lacking on its durability and long-term complications, particularly in young patients and patients treated for aortic valve regurgitation. This article describes the case of a 27-year-old woman with complex congenital cardiovascular disease who, after 4 previous aortic valve replacement procedures, presented with structural deterioration of her most recent replacement valve, which had been placed by transcatheter aortic valve replacement inside a failed aortic root homograft 6 years earlier. After the patient had undergone this transcatheter aortic valve replacement procedure to treat aortic valve regurgitation related to her degenerated aortic root homograft, she became pregnant and successfully carried her high-risk pregnancy to term. However, the replacement valve deteriorated during the late stages of pregnancy, resulting in substantial hemodynamic changes between the first trimester and the postpartum period. To avoid repeat sternotomy, a redo transcatheter valve-in-valve replacement procedure procedure was performed through the right carotid artery. Because the patient wanted to have more children and therefore avoid anticoagulation, a SAPIEN 3 transcatheter valve (Edwards Lifesciences) was placed as a bridge to a future, more-durable aortic root replacement. The result in this case suggests that in patients with complex adult congenital pathology, transcatheter aortic valve replacement can be used as a temporizing bridge to subsequent, definitive aortic valve repair.Abstract
Late lumen enlargement after percutaneous coronary intervention (PCI) with drug-coated balloon has contributed to good clinical results. However, late lumen enlargement with drug-coated balloon following rotational atherectomy has not been well reported. This report describes a case of calcified napkin-ring ostial lesion at the left main trunk that showed a sustained lumen area after PCI with drug-coated balloon following rotational atherectomy. An 85-year-old female patient was admitted to the hospital with dyspnea. Echocardiography showed hypokinesis in the anteroseptal and inferior walls. Electrocardiograph-gated cardiac computed tomography showed a calcified ostial lesion in the left main trunk. Invasive angiography of the coronary artery showed severe stenosis in the left main trunk ostium. Percutaneous coronary intervention was performed with a drug-coated balloon after rotational atherectomy. The minimal lumen area measured by intravascular ultrasound grew mildly from 4.09 to 4.17 mm2 immediately after PCI. Follow-up angiography and intravascular ultrasound performed after 6 months showed that the minimal lumen area in the left main trunk ostium was further enlarged from 4.17 to 4.69 mm2. The presence of sustained lumen area after PCI with drug-coated balloon following rotational atherectomy for a napkin-ring left main trunk ostial lesion was confirmed. This case demonstrates sustained lumen area after drug-coated balloon following rotational atherectomy in the left main trunk ostium, improving the patient's chest symptom. Hence, drug-coated balloon after rotational atherectomy may be an option for complex stent sites, such as the left main trunk ostium in geriatric patients and sites with highly calcified lesions.Abstract
Blunt aortic injury is a serious condition with a high mortality rate. Although rare, blunt aortic injury associated with spinal fracture has also been reported, and appropriate management of aortic disease is key to a good outcome. This report is a case of a 78-year-old man who was found to have a transverse fracture (Chance fracture) in the ninth thoracic vertebra, with a sharp bone fragment compressing the thoracic aorta. Early spinal surgery was needed; however, there was concern about the possibility of bleeding from the aorta and surrounding small arteries associated with the bone fragment during spinal surgery. Therefore, thoracic endovascular aortic repair was performed before spinal surgery. The next day after thoracic endovascular aortic repair, posterior spinal instrumentation was performed, and the postoperative course was uneventful. Because aortic injury associated with vertebral fracture can lead to massive bleeding and spinal cord injury, endovascular repair before spinal surgery is reasonable.Abstract
A 73-year-old male patient presented with shortness of breath at rest resulting from new-onset severe primary mitral regurgitation with a flail posterior leaflet, left ventricular dysfunction, and cardiogenic shock. After initial stabilization in the intensive care unit, multiple treatment options were considered for this patient, all associated with significant mortality. Ultimately, operative mitral valve repair with Impella 5.5 placement was performed for postoperative hemodynamic support. Surgical repair provided elimination of mitral regurgitation. Impella support was maintained for 7 days to provide unloading of the left ventricle. After device removal, the patient had sustained left ventricular recovery with significantly improved ejection fraction. Full left ventricular support and unloading may decrease operative risk and promote left ventricular recovery in patients with severe mitral regurgitation and left ventricular dysfunction. This case emphasizes the value of ventricular unloading to facilitate the recovery of left ventricular function as a treatment option for patients with challenging cases of severe mitral regurgitation and left ventricular dysfunction.Abstract
A 72-year-old woman with no history of coronary artery disease presented with an acute left middle cerebral artery stroke and was found to have a large left ventricular pseudoaneurysm measuring 8.7 × 7.6 cm and 2 large left ventricular thrombi, the source of her systemic embolization. Despite initial medical management, she developed refractory New York Heart Association functional class III heart failure, uncontrolled atrial fibrillation, and further enlargement of her pseudoaneurysm to 5.5 × 10.6 × 9.2 cm. She underwent urgent aneurysmectomy. Left ventricular pseudoaneurysms are rare and most commonly occur following an acute myocardial infarction when a ventricular free-wall rupture is contained by pericardium or thrombi. Historically, left ventricular angiography displaying a lack of an overlying coronary artery was the gold standard for diagnosis. Now, noninvasive imaging such as computed tomography, magnetic resonance imaging, and echocardiogram with ultrasound-enhancing agent, are reliable diagnostic tools. They can distinguish a pseudoaneurysm from a true left ventricular aneurysm using characteristic findings such as a narrow aneurysm neck, bidirectional doppler flow between the pseudoaneurysm and the left ventricle, and abrupt changes in the cardiac wall structures. Progressive dilation, wall thinning, and dyskinesis can result in refractory heart failure, arrhythmias, and thrombi formation from venous stasis. Pseudoaneurysms have a 30% to 45% risk of rupture and can be treated with left ventricular aneurysmectomy.Abstract
Thoracic endovascular aortic repair has become the preferred modality of treatment of complicated type B aortic dissections. However, persistent pressurization of the false lumen can lead to negative aortic remodeling with aneurysmal dilation. Described herein is the coil embolization technique that can be used to manage this complication and a review of the literature on the recent development of management options.Abstract
An 86-year-old woman being treated for metastatic breast cancer developed severe chest pain at rest during a follow-up visit at a hospital's outpatient oncology clinic. An electrocardiogram showed severe ST-segment elevation. The patient was given sublingual nitroglycerin and was transferred to the emergency department. Diagnostic coronary angiography revealed moderate coronary artery disease with calcific stenoses and transient spastic occlusion of the left anterior descending coronary artery. For this patient, sublingual nitroglycerin aborted the spastic event and apparent transient takotsubo cardiomyopathy. Chemotherapy can potentially cause endothelial dysfunction and increased coronary spasticity, which could result in takotsubo cardiomyopathy.Abstract
Patients with bicuspid aortic valves (BAVs) tend to develop dilation of the ascending aorta. The aim of this study was to analyze the impact of leaflet fusion pattern on aortic root diameter and outcomes in patients undergoing surgery for BAV vs tricuspid aortic valve (TAV) disease. This is a retrospective review of 90 patients with aortic valve disease (mean [SD] age, 51.5 [8.2] years) who underwent aortic valve replacement for BAV (n = 60) and TAV (n = 30). Fusion of right-left (R/L) coronary cusps was identified in 45 patients, whereas the remaining 15 patients had right-noncoronary (R/N) cusp fusion. Aortic diameter was measured at 4 levels, and Z values were computed. There were no significant differences between the BAV and TAV groups for age, weight, aortic insufficiency grade, or size of implanted prostheses. However, a higher preoperative peak gradient at the aortic valve was significantly associated with R/L fusion (P = .02). Preoperative Z values of ascending aorta and sinotubular junction diameter were significantly higher in patients with R/N fusion than with the R/L (P < .001 and P = .04, respectively) and TAV (P < .001 and P < .05, respectively) subgroups. During the follow-up period (mean [SD], 2.7 [1.8] years), 3 patients underwent a redo procedure. At the last follow-up, the sizes of ascending aorta were similar among all 3 patient groups. This study suggests that preoperative dilation of the ascending aorta is more common in patients with R/N fusion than in patients with R/L and TAV but is not significantly different between all groups in the early follow-up period. R/L fusion was associated with an increased risk of preoperative presence of aortic stenosis.Background
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Pericardial effusion (PE) is a commonly encountered condition in clinical practice, but its etiology can be difficult to identify, with many cases remaining classified as idiopathic. This study aimed to investigate whether an association exists between asthma and idiopathic PE (IPE). Patients who had been diagnosed with PE in the authors' outpatient cardiology clinics between March 2015 and November 2018 were retrospectively analyzed. The study population was divided into 2 groups—non-IPE (NIPE) and IPE—based on whether a cause had been identified. Demographic, laboratory, and clinical data for the 2 groups were examined statistically. A total of 714 patients were enrolled in the study after exclusion of 40 cases. Of these 714 patients, 558 were allocated to the NIPE group and 156 to the IPE group (NIPE group median [IQR] age, 50 [41–58] years vs IPE group median [IQR] age, 47 [39–56] years; P = .03). Asthma was significantly more prevalent among patients in the IPE group than among those in the NIPE group (n = 54 [34.6%] vs n = 82 [14.7%]; P < .001). In multivariate logistic regression analysis, asthma (odds ratio, 2.67 [95% CI, 1.53–4.67]; P = .001) was found to be an independent predictor of IPE. In the IPE group, patients with asthma had either mild or moderate PE, with the right atrium being the most common location in these patients. Asthma was an independent predictor of mild to moderate IPE. The right atrium was the most frequently encountered location for PE in patients with asthma.Abstract
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Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.Abstract
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The transradial approach (TRA) to coronary angiography reduces vascular complications but is associated with greater radiation exposure than the transfemoral approach (TFA). It is unknown whether exposure remains higher when TRA is performed by experienced operators. Patients were randomly, prospectively assigned to TRA or TFA. The primary end point was patient radiation dose; secondary end points were the physician radiation dose and 30-day major adverse cardiac event rate. Coronary angiography was performed by experienced operators using a standardized protocol. Clinical and procedural characteristics were similar between the TRA (n = 150) and TFA (n = 149) groups, and they had comparable mean (SD) radiation doses for patients (616.51 [252] vs 585.57 [225] mGy; P = .13) and physicians (0.49 [0.3] vs 0.46 [0.29] mSv; P = .32). The mean (SD) fluoroscopy time (3.52 [2.02] vs 3.13 [2.46] min; P = .14) and the mean (SD) dose area product (35,496.5 [15,670] vs 38,313.4 [17,764.9] mGy·cm2; P = .2) did not differ. None of the following factors predicted higher radiation doses: female sex (risk ratio [RR], 0.69 [95% CI, 0.38–1.3]; P = .34), body mass index >25 (RR, 0.84 [95% CI, 0.43–1.6]; P = .76), age >65 years (RR, 1.67 [95% CI, 0.89–3.1]; P = .11), severe valve disease (RR, 1.37 [95% CI, 0.52–3.5]; P = .68), or previous coronary artery bypass graft (RR, 0.6; 95% CI, 0.2–1.8; P = .38). TRA for elective coronary angiography is noninferior to TFA when performed by experienced operators.Abstract
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Significant uncertainty exists about the optimal timing of surgery for infectious endocarditis (IE) surgery in patients with active SARS-CoV-2 infection. This case series and a systematic review of the literature were carried out to evaluate the timing of surgery and postsurgical outcomes for patients with COVID-19–associated IE. The PubMed database was searched for reports published from June 20, 2020, to June 24, 2021, that contained the terms infective endocarditis and COVID-19. A case series of 8 patients from the authors' facility was also added. A total of 12 cases were included, including 4 case reports that met inclusion criteria in addition to a case series of 8 patients from the authors' facility. Mean (SD) patient age was 61.9 (17.1) years, and patients were predominantly male (91.7%). Being overweight was the main comorbidity among patients studied (7/8 [87.5%]). Among all patients evaluated in this study, dyspnea (n = 8 [66.7%]) was the leading symptom, followed by fever (n = 7 [58.3%]). Enterococcus faecalis and Staphylococcus aureus caused 75.0% of COVID-19–associated IE. The mean (SD) time to surgery was 14.5 (15.6) days (median, 13 days). In-hospital and 30-day mortality for all evaluated patients was 16.7% (n = 2). Clinicians must carefully assess patients diagnosed with COVID-19 to prevent missing underlying diseases such as IE. If IE is suspected, clinicians should avoid postponement of crucial diagnostic and treatment steps.Abstract
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Left ventricular assist devices (LVADs) are increasingly used to treat patients with end-stage heart failure. Implantable LVADs were initially developed in the 1960s and 1970s. Because of technological constraints, early LVADs had limited durability (eg, membrane or valve failure) and poor biocompatibility (eg, driveline infections and high rates of hemolysis caused by high shear rates). As the technology has improved over the past 50 years, contemporary rotary LVADs have become smaller, more durable, and less likely to result in infection. A better understanding of hemodynamics and end-organ perfusion also has driven research into the enhanced functionality of rotary LVADs. This paper reviews from a historical perspective some of the most influential axial-flow rotary blood pumps to date, from benchtop conception to clinical implementation. The history of mechanical circulatory support devices includes improvements related to the mechanical, anatomical, and physiologic aspects of these devices. In addition, areas for further improvement are discussed, as are important future directions—such as the development of miniature and partial-support LVADs, which are less invasive because of their compact size. The ongoing development and optimization of these pumps may increase long-term LVAD use and promote early intervention in the treatment of patients with heart failure.Abstract
arteriovenous fistula A 57-year-old man with a history of 2 percutaneous coronary interventions through the right radial artery (6 months and 5 months prior) reported a right radial bruit with a palpable thrill. Doppler ultrasound imaging revealed a radial arteriovenous fistula (AVF). Transbrachial angiogram showed blood flow between the radial artery and venous system (Fig. 1). The patient's condition was managed conservatively because it was a case of AVF without pain or heart failure symptoms. Two years later, the patient presented with progressive development of the bruit and new wrist pain. PhysicalAbbreviations and Acronyms
Case Description
