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  • 1
    Online Resource
    Online Resource
    Right-sided aortic arch with Kommerell’s diverticulum: a case report of a rare cause of type B dissection
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 6 ( 2022-06-02)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 6 ( 2022-06-02)
    Abstract: A right-sided aortic arch (RAArch) is present in approximately 0.1% of the population. A Kommerell’s diverticulum (KD), a remnant of the dorsal aortic arch usually refers to an aneurysmal aortic enlargement at the origin of an aberrant left subclavian artery (ALSA) and is associated with an increased risk of aortic dissection. Case summary A 59-year-old female smoker with a history of hypertension and hypercholesterolaemia presented with a 24-hour history of sudden-onset and severe stabbing chest pain radiating to the interscapular region. Physical examination was normal except for bilateral basal crepitations. Computed tomography angiography (CTA) showed a type B aortic dissection in a RAArch with an ALSA arising from KD with a peri-aortic haematoma and haemothorax without any active contrast extravasation. After medical stabilization, a semi-urgent hybrid repair was performed with a right carotid-subclavian bypass, thoracic endovascular aortic repair (TEVAR), a plug in the left subclavian artery, and left carotid-subclavian bypass due to severe ischaemia of the left arm. The postoperative CTA showed patent bypasses, aortic remodelling, and a minimal type IIa endoleak at the level of the ALSA. Discussion In patients with a type B dissection and KD, hybrid repair including TEVAR is feasible after careful pre-operative assessment of the patient’s unique anatomy and may reduce post-surgical morbidity and mortality compared to open surgery. Prophylactic repair may be considered in patients with an asymptomatic RAArch and KD.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac238
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 2
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    Multimodality delineation of a fistulous ruptured sinus of Valsalva aneurysm: a teaching case report
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 8 ( 2022-08-04)
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    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 8 ( 2022-08-04)
    Abstract: Ruptured sinus of Valsalva (SOV) is a rare cardiac anomaly with poor prognosis if untreated. Early diagnosis with accurate delineation of its anatomy is critical for timely treatment and choice of surgical vs. percutaneous intervention. Here we report a case of fistulous rupture of SOV; the preoperative multimodality studies including echocardiography, cardiac magnetic resonance and cardiac catheterization provided teaching and learning points. Case summary A 48-year-old man with history of heart murmur and hypertension presented with a 5-day history of shortness of breath and peripheral oedema. He was diagnosed with rapid atrial flutter. The transthoracic and transesophageal echocardiography showed severe biventricular systolic dysfunction with a left-to-right shunt from ruptured SOV. The colour Doppler by transthoracic and transesophageal echocardiography and cardiac magnetic resonance revealed a swaying shunt flow exiting in direction to the right atrium (RA) and basal right ventricle (RV) during systole and diastole with no myocardial scaring. The left and right heart catheterization showed elevated right-sided pressures, pulmonary capillary wedge pressure, and left ventricular end-diastolic pressure. There was no difference in O2 saturation between venae cavae and RA but a misleading step-up in O2 saturation between RA and RV. Owing to rupture anatomy with uncertainty, the patient underwent surgical intervention. The ruptured SOV tunnelled through the base of tricuspid annulus to the RA very close to the basal RV. Discussion Even with multimodality studies it can still be challenging to delineate the anatomy of a ruptured SOV without uncertainty preoperatively.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac308
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 3
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    Online Resource
    Evaluations of coronary microvascular dysfunction in a patient with thrombotic microangiopathy and cardiac troponin elevation: a case report
    Oxford University Press (OUP) ; 2023
    In:  European Heart Journal - Case Reports Vol. 7, No. 3 ( 2023-03-06)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 7, No. 3 ( 2023-03-06)
    Abstract: Thrombotic microangiopathy (TMA) syndromes include thrombotic thrombocytopenic purpura (TTP) and haemolytic uremic syndrome, and contribute to myocardial infarction and multiple organ failure. Although coronary microvascular dysfunction (CMD) is the key for understanding the pathophysiology of cardiac involvement in TMA, there is limited knowledge on the recovery from CMD in patients with TMA. Case summary An 80-year-old woman was brought to the emergency department due to worsening back pain, dyspnoea on exertion, jaundice, and fever. Although she had typical TTP symptoms and elevated cardiac troponin level, ADAMTS13 activity was preserved (34%), leading to the diagnosis of TMA with myocardial infarction. She underwent plasma exchange and was administered aspirin and prednisolone. Magnetic resonance imaging revealed iliopsoas abscess, which is a possible aetiologic factor of sepsis-related TTP. She had impaired coronary flow reserve (CFR) with angiographically non-obstructive epicardial coronary arteries. Improved CFR was observed on follow-up, suggesting existence of transient CMD caused by TMA. After treatment of the iliopsoas abscess with antibiotics for 3 months, she was discharged without any adverse complications. Discussion Coronary microvascular dysfunction is an underlying mechanism of myocardial infarction, with or without epicardial obstructive coronary artery stenosis. TMA is characterized by pathological lesions caused by endothelial cell damage in small terminal arteries and capillaries, with complete or partial occlusion caused by platelet and hyaline thrombi. CMD and its recovery are keys for understanding the natural history of cardiac involvement in TMA. In vivo evaluations of CMD can provide mechanistic insights into the cardiac involvement in TMA.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac318
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2023
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  • 4
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    Use of a smartphone electrocardiogram to diagnose arrhythmias during exercise in athletes: a case series
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 4 ( 2022-04-13)
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    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 4 ( 2022-04-13)
    Abstract: While athletes are generally very fit, intense exercise can increase the risk of atrial fibrillation. Moreover, other arrhythmias such as atrial flutter or supraventricular tachycardia can cause distressing, exercise-related symptoms. Given symptoms are infrequent and may occur during intense exertion, traditional monitoring devices are often impractical to use during exercise. Smartphone electrocardiograms (ECGs) such as the Alivecor Kardia device may be the portable and reliable tool required to help identify arrhythmias in this challenging population. This case series highlights the use of such devices in aiding the diagnosis of arrhythmias in the setting of exercise-related symptoms in athletes. Case summary The six cases in this series included one elite non-endurance athlete, two elite cricketers, one amateur middle-distance runner, and two semi-elite ultra-endurance runners, with an age range of 16–48 years. An accurate diagnosis of an arrhythmia was obtained in five cases (atrial fibrillation/flutter and supraventricular tachycardias) using the smartphone ECG, which helped guide definitive treatment. No arrhythmia was identified in the final case despite using the device during multiple symptomatic events. Discussion The smartphone ECG was able to accurately detect arrhythmias and provide a diagnosis in cases where traditional monitoring had not. The utility of detecting no arrhythmia during symptoms in one case was also highlighted, providing the athlete with the confidence to continue exercising. This reassurance and confidence across all cases is perhaps the most valuable aspect of this device, where clinicians and athletes can be more certain of reaching a diagnosis and undertaking appropriate management.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac126
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 5
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    Progression and interventional therapy of a coronary pseudoaneurysm: a case report
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 7, No. 1 ( 2022-12-27)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 7, No. 1 ( 2022-12-27)
    Abstract: Coronary pseudoaneurysms (PSAs) occur as a rare complication following drug-eluting stent implantation and have been reported to occur between 1 week and 4 years after implantation. Most of them remain in a stable state, but progression of PSAs increases the risk of rupture and haemorrhagic cardiac tamponade. Case summary Here, we present a case of a 55-year-old patient, who developed a PSA of the proximal left circumflex artery after stent implantation of the left main artery, left anterior descending artery, and left circumflex artery. Within & lt;1 year, the patient was readmitted to different hospitals due to cardiac decompensation and myocardial infarction. Thereafter, coronary angiography and computed tomography scans were performed, and progression of the PSA could be documented. Interventional therapy was chosen due to the high surgical risk of the patient. Implantation of a covered stent from the left main artery into the left anterior descending artery was chosen to treat the PSA, thereby silencing the chronically occluded left circumflex artery, followed by dilatation with a non-compliant balloon. The patient has remained asymptomatic in a 6-month follow-up. Discussion Coronary PSA should be controlled with respect to progression, and appropriate therapy can be chosen for treatment.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac478
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 6
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    Effects of ageing on aortic hemodynamics measured by 4D-flow MRI: a case series
    Oxford University Press (OUP) ; 2023
    In:  European Heart Journal - Case Reports Vol. 7, No. 4 ( 2023-04-10)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 7, No. 4 ( 2023-04-10)
    Abstract: It has been demonstrated that the rate of aortic dilatation is influenced by alteration of aortic hemodynamics, such as normalized flow displacement (FDN) and wall shear stress (WSS). However, the effects of ageing on aortic hemodynamics have not yet been described. Case summary 4D-Flow MRI derived aorta hemodynamics were derived in the ascending aorta of a patient with ascending aortic aneurysm (mean ± standard deviation: 46 ± 1 mm) and a healthy volunteer (aortic diameter 30 ± 1 mm) with long-term follow-up of ten and eight years, respectively. At all timepoints, compared to the healthy volunteer, the patient demonstrated higher magnitudes of FDN (7% ± 1% vs. 3% ± 1%) and WSS angle (36° ± 3° vs. 24° ± 6°), and lower WSS magnitude (565 ± 100 mPa vs. 910 ± 115 mPa), axial WSS (426 ± 71 mPa vs. 800 ± 108 mPa) and circumferential WSS (297 ± 64 mPa vs. 340 ± 85 mPa). The patient and healthy volunteer demonstrated different aortic dilatation rates (regression slope ± standard error: 0.2 ± 0.1 vs. 0.1 ± 0.2 mm per year) and trends in FDN (0.1% ± 0.1% vs. 0.1% ± 0.2% per year), WSS magnitude (22 ± 9 vs. 35 ± 13 mPa per year), axial WSS (19 ± 4 vs. 37 ± 7 mPa per year), circumferential WSS (9 ± 8 vs. 5 ± 15 mPa per year), and WSS angle (-0.5° ± 0.4° vs. -0.8° ± 1.0° per year). Discussion Aortic hemodynamic parameters are marginally affected by ageing and the aortic diameter in this case series. Since aortic hemodynamic parameters have been associated with aortic dilation by previous studies, the outcomes of the two subjects suggest that the aortic dilatation rate will remain constant while individuals are ageing and dilating.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytad130
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2023
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  • 7
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    Infective endocarditis of a left atrial appendage closure device: a case report and literature review
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 11 ( 2022-11-03)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 11 ( 2022-11-03)
    Abstract: Due to advances in interventional cardiology in recent years, more and more patients are currently receiving cardiac devices, with a subsequent increase in the number of patients with device-associated endocarditis. Device-associated endocarditis is a life-threatening disease with special diagnostic and therapeutic challenges. Interventional devices for left atrial appendage (LAA) closure have been available for several years. However, there have been very few case reports of LAA closure device–associated endocarditis. Case summary An 83-year-old woman presented with fever and fatigue. She had a history of permanent atrial fibrillation and recurrent bleeding on oral anticoagulation. Consequently, the patient underwent interventional LAA closure ∼20 months earlier. Blood cultures grew Staphylococcus aureus. Transoesophageal echocardiography revealed an LAA closure device–associated mobile, echo-dense mass that was consistent with infectious vegetation in this clinical context. Intravenous antibiotic therapy was started, and our heart team recommended complete removal of the device, which the patient refused. The patient subsequently died as a result of progressive endocarditis and multiple pre-existing co-morbidities. Discussion Left atrial appendage occlusion device–associated endocarditis has rarely been reported. Due to the increase in LAA closure device implantation, device-associated endocarditis is expected to increase in the future. Transoesophageal echocardiography is required for correct diagnosis. Our case report suggests that an infection can occur long after implantation.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac434
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 8
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    Paroxysmal supine hypoxaemia with hyperthyroidism and atrial fibrillation: a case report of a diagnostic challenge
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 6 ( 2022-06-02)
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    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 6 ( 2022-06-02)
    Abstract: A patent foramen ovale (PFO) is a persistent embryonic defect in the interatrial septum. Platypnoea-orthodeoxia syndrome is characterized by positional hypoxaemia that is most commonly due to right-to-left shunting through a PFO. Dynamic right-to-left shunting through a PFO can also exacerbate positional hypoxaemia without platypnea-orthodeoxia syndrome. Case summary A 78-year-old woman with hyperthyroidism and paroxysmal atrial fibrillation (AF) presented with positional hypoxaemia exacerbated by supine positioning. Diagnostic testing revealed intermittent right-to-left shunting through a PFO triggered by worsening atrial functional tricuspid regurgitation and elevated right atrial pressures. Diuresis, rate control, and thyroidectomy initially led to resolution of positional hypoxaemia, but recurrent AF episodes triggered right-to-left shunting with recurrent desaturation. Left atrial and cavo-tricuspid isthmus ablation led to restoration of normal sinus rhythm and resolution of positional hypoxaemia without PFO closure. Discussion The clinical presentation of intermittent intracardiac right-to-left shunting can mimic decompensated heart failure with pulmonary oedema. Persistent hypoxaemia out of proportion to the degree of pulmonary oedema and minimally responsive to supplemental O2 should raise suspicion for right-to-left shunt aetiology. Positional arterial blood gases can facilitate the diagnostic evaluation of refractory hypoxaemia in cases of suspected shunting. Diagnostic imaging for PFO detection includes both transthoracic and transesophageal echocardiography with Valsalva manoeuver and agitated saline injection. Closure of a PFO for management of arterial deoxygenation syndromes should not be performed before treating other causes of arterial deoxygenation and optimizing factors that may exacerbate shunting across the PFO.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac214
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 9
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    A case of covered stent failure in sealing up a coronary perforation potentially related to intravascular lithotripsy treatment: insights from optical coherence tomography
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 10 ( 2022-10-08)
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    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 10 ( 2022-10-08)
    Abstract: Intravascular lithotripsy (IVL) is a new modality in treatment of calcified coronary lesions which improves procedural outcomes. Coronary perforation is an extremely uncommon but potentially catastrophic complication of percutaneous coronary intervention (PCI) and IVL therapy. Case summary We report a case of an elective PCI to a calcified left anterior descending (LAD) and diagonal bifurcation lesion in a 65-year-old man. LAD was treated with two stents. Despite high pressure non-compliant balloon inflation, a focal area of under-expansion remained. IVL successfully treated the under-expansion but was complicated with a large coronary perforation. The perforation was successfully sealed with a PK-PAPYRUS covered stent sacrificing the diagonal branch. Patient remained stable until 3 hours later when he developed tamponade requiring urgent pericardial drainage. Repeat angiography demonstrated recanalization of the diagonal branch and ongoing contrast extravasation along its course. Optical coherence tomography intracoronary imaging was used to delineate the mechanism of ongoing bleeding. This demonstrated an interrupted elastic membrane of the covered stent, potentially caused by underlying fractured calcium. Therefore, a second overlying PAPYRUS stent was deployed which satisfactorily sealed the perforation. Discussion IVL is an emerging less invasive treatment for calcified coronary stenosis but could be associated with drastic complications. This case highlights the importance of awareness of IVL-related coronary perforation and the potential limitation of new generation thinner-wall covered stents. Intracoronary imaging plays an important role in identifying mechanisms of stent failure, tailoring treatment, and optimizing outcomes.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac410
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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  • 10
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    Usefulness of transpedal intervention for inferior epigastric artery bleeding following catheter ablation: a case report
    Oxford University Press (OUP) ; 2022
    In:  European Heart Journal - Case Reports Vol. 6, No. 5 ( 2022-05-04)
    Details
    In: European Heart Journal - Case Reports, Oxford University Press (OUP), Vol. 6, No. 5 ( 2022-05-04)
    Abstract: Cardiovascular interventions may result in access-site complication, including inferior epigastric artery (IEA) bleeding. The IEA injury is generally treated through surgery and transcatheter embolization; however, additional complications should be avoided in the bailout procedure. Here, we present a case of catheter ablation complicated by IEA haemorrhage that we managed by transcatheter embolization using a transpedal intervention (TPI). Case summary A 58-year-old man underwent catheter ablation for symptomatic paroxysmal atrial fibrillation. Pulmonary vein isolation was performed uneventfully via catheterization of the right femoral artery and vein access. After the procedure, he complained of persistent abdominal pain and had a palpable mass in the lower right abdomen. Computed tomography angiography (CTA) revealed a haematoma in the right rectus abdominis with signs of active bleeding from a branch of the right IEA. We performed transcatheter arterial embolization through a TPI to stop bleeding and avoid further complication. No leakage of contrast media was detected after embolization using a microcoil and the abdominal pain improved. We did not observe any serious intraprocedural complications. Discussion Catheter ablation procedures may be complicated by access-site complications such as active bleeding. Arterial embolization is a feasible treatment approach to control the resulting haemorrhage. Embolization through the transpedal route (TPI) could be an effective bailout technique in the setting of emergent transcatheter arterial embolization to achieve haemostasis and avoid further complication.
    Type of Medium: Online Resource
    ISSN: 2514-2119
    URL: Article
    DOI: 10.1093/ehjcr/ytac181
    Language: English
    Publisher: Oxford University Press (OUP)
    Publication Date: 2022
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