Iatrogenic Aortic Pseudoaneurysm Causing Superior Vena Cava SyndromeA 72-year-old man presented with a 5-week history of exertional dyspnoea and facial swelling on a background of hypertension and previous coronary artery bypass graft (CABG) surgery for acute coronary syndrome (left internal mammary artery to left anterior descending/third diagonal branch and left radial artery to first obtuse marginal) 5 years prior. He denied any facial pain, headache or arm swelling. He was lost to follow-up following his coronary artery bypass graft (CABG) surgery. On clinical examination, the heart rate was 70 bpm and blood pressure was 160/90 mmHg.
This Is Not Ischaemia! Lower Extremity Hyperperfusion After Femoral Veno-Arterial Cannulation for Extracorporeal Membrane Oxygenation SupportA 49-year-old morbidly obese female was transferred to our hospital from an outside facility after presentation with hypotension and massive pulmonary embolism following a podiatric procedure. Emergency extracorporeal membrane oxygenation (ECMO) support was instituted by the referring hospital prior to transfer. Details of cannulation included the need to construct a “chimney” graft (8 mm Hemashield, Maquet, Rastatt, Germany) specifically to address the issue of an extremely small (<5 mm diameter) right common femoral artery.
Giant Partial Endocardial Cushion Defect Challenging Mitral Valve Replacement in Adults: Surgical ApproachAtrial septal defect (ASD) is one of the most common congenital heart diseases diagnosed in children and adults . Interventional closure devices or surgical patch closure are potential treatment options in haemodynamically relevant ASD. Concomitant severe mitral valve regurgitation is impeded by persisting type I ASD, as a congenital partial endocardial cushion defect (PECD) might be present. Partial endocardial cushion defect is a rare form of congenital heart failure, accounting for about 3% of the overall incidence .
A Rather Unusual Cause of Dyspnoea – Pericardial Malignancy“More is missed by not looking than by not knowing”
Septum Primum Malposition: An Uncommon Cause of Right Ventricular Volume OverloadA 24-year-old woman was hospitalised for a systolic murmur with exertional fatigue. Transthoracic echocardiography found an enlarged right heart, mild pulmonary hypertension (39 mmHg systolic pressure), and an interatrial septum exhibiting a leftward deviation of its dorsocranial insertion (Figure 1A; Supplementary Video 1). On Doppler examination, partial anomalous pulmonary venous drainage (PAPVD) to the right atrium (RA) was suspected (Figure 1B; Supplementary Video 2). Transoesophageal echocardiography demonstrated an interatrial septum aneurysm and a patent foramen ovale with a right-to-left shunt (Figure 1C; Supplementary Video 3).
Multiple Anastomotic Dehiscences After the Bentall Procedure for Aortitis SyndromeA 53-year-old man with aortitis was transferred to the current hospital for severe cardiogenic shock. He had undergone the Bentall procedure for annulo-aortic ectasia at the age of 30 years and had received steroid therapy following the diagnosis of aortitis. The preoperative 12-lead electrocardiogram showed ST-segment elevation in lead aVR with diffuse ST-segment depression, suggesting coronary malperfusion. Computed tomography (CT) images demonstrated a retrosternal super-giant pseudoaneurysm (Figure 1A-C) and dehiscence of the distal end of the composite graft from the native aorta (Figure 1B).
Cardiac Strangulation by Epicardial Pacing WiresThis 10-year old patient underwent implantation of an epicardial dual chamber pacing system for complete atrioventricular block post an interruption of the aortic arch repair and patch closure of two ventricular septal defects in the neonatal period. Serial follow-up indicated a resolution of the complete heart block and minimal utilisation of pacing device. Eight (8) years following the implantation of the device he presented with episodes of presyncope at rest.
Resting Hypoxia and a Strongly Positive Bubble Test: Do Not Forget Hepato-Pulmonary SyndromeA 40-year-old male presented to the hospital with a tender right calf, right-sided pleuritic chest pain, and haemoptysis. He has a strong family history of anti-thrombin-3 deficiency and unprovoked deep-vein thrombosis in many of his paternal family members. Computed tomography (CT) pulmonary angiography demonstrated a segmental pulmonary embolism (PE) and associated pulmonary haemorrhage/infarct in the right middle lobe (Panel-A). X-ray chest demonstrated mild pulmonary congestion (Panel-B). Resting oxygen saturation on room air (RA) was 81%; disproportionately low for his presentation with PE, however, the patient did not complain of dyspnoea.
Regression of Left Ventricular Hypertrophy in a Case of Adult Hypertrophic Cardiomyopathy: Importance of Clinical Context at Initial DiagnosisA 24-year-old male with no significant past medical or family history of cardiovascular or neurological disease presented with bilateral paresthesia and weakness of his upper and lower limbs, along with a left facial droop. A few days later he developed a persistent dull left-sided chest pain that was not pleuritic, positional, or exertional in nature. He was initially evaluated in a regional primary health care centre and referred 3 weeks later to a tertiary care hospital. The workup of the patient—including extensive genetic testing and family screening—led to the diagnoses of mild Guillain-Barré syndrome (GBS) with associated Bell’s palsy, as well as hypertrophic cardiomyopathy (HCM).
A Not So Innocent MurmurA 45-year-old female was found to have a heart murmur during a routine check-up. Transthoracic echocardiogram showed normal chambers volumes and biventricular systolic function; there was mild tricuspid regurgitation with a transvalvular gradient of ±56 mmHg and an elevated gradient (±32 mmHg) was present in the suprasternal view (Figure 1A).
Dual Versus Split Right Coronary Artery: Similar, Yet Different!A 52-year-old man underwent coronary computed tomography (CT) angiography for evaluation of suspected atherosclerotic coronary artery disease (CAD). CT angiography revealed a dual right coronary artery (RCA) with a single proximal trunk splitting into two branches in the region of mid-RCA, immediately after origin of an early branching acute marginal artery (AM). The two similar-sized branches were seen running closely together in the right atrioventricular (AV) groove, for the rest of the course of RCA (Figure 1A–C).
Early Bioprosthetic Valve Dysfunction Following TAVR: The Role of CT Imaging in Diagnosing Acute Leaflet ThrombosisA 79-year-old female with severe aortic stenosis and hypertension was referred for transcatheter aortic valve replacement (TAVR). Computed tomography (CT) was performed for prosthesis sizing and ilio-femoral assessment (Figure 1A). She received aspirin and clopidogrel prior to TAVR. The patient received intra-arterial heparin (100 IU/kg) to achieve an activated clotting time above 250 seconds. A 23 mm Sapien 3 valve (Edwards Lifesciences, Irvine, CA USA) was implanted (Figure 1B) and aortogram revealed no regurgitation.
Unroofed Coronary Sinus: Incidentally Detected on Pulmonary Computed Tomography AngiographyA 56-year-old female presented to the Emergency Department with palpitations and shortness of breath. The patient had a history of hypertension, diabetes mellitus, and hyperthyroidism. The patient's body temperature was 36.7°C and blood pressure was 125/80 mmHg. On electrocardiogram, negative T-waves were observed in the right precordial leads. Laboratory analysis revealed low haemoglobin value (11.4 g/dL; reference, 12–14 g/dL), high fasting blood glucose (185 mg/dL; reference, 74–106 mg/dL), and elevated D-dimer level (788 ng/mL; reference, <280 ng/mL).
Surgical Management for Traumatic Septal Rupture in a Child With Cardiogenic ShockA 12-year-old boy had a blunt chest trauma in a motor vehicle accident. He arrested on arrival to the hospital and underwent clamshell thoracotomy for bilateral haemothorax. He required direct cardiac massage and massive transfusion for chest wall bleeding and pulmonary haemorrhage. Computerised tomography revealed a large apical ventricular septal defect (VSD) (Figure 1A). He developed cardiogenic shock with blood pressure 65/50 mmHg, central venous pressure 15 mmHg and lactate of 24 mmol/L, despite adrenaline/noradrenaline at 1.5 mcg/kg/min and vasopressin at 0.06 units/kg/hr.
Ventricular Double Rupture: A Rare Combination of Ventricular Septal Rupture and Concealed Post-Infarction Free Wall RuptureA 72-year-old woman with well-controlled hypertension presented to our hospital due to worsening symptoms of heart failure. She had a history of acute anterior wall ST-elevation myocardial infarction (MI) diagnosed 2 weeks previously, when she received clinically successful fibrinolytic therapy at another regional hospital 4 hours after symptom onset. Four (4) days after hospital discharge, she gradually developed dyspnoea on exertion and orthopnoea. No recurrent chest pain was reported. On examination, her blood pressure was 120/65 mmHg with a regular pulse rate at 90/minute.
Intrathoracic Migration of a Loop Recorder Device: An Unusual Clinical EntityIntrathoracic migration of devices implanted into the chest wall causing major intrathoracic injuries has been documented [1-3]. To our knowledge, there have been no reports on intrathoracic migration of an implanted loop recorder.
Mitral Arcade Causing Severe Stenosis in an Adult PatientA 23-year-old non-dysmorphic female was admitted for congestive heart failure. She was diagnosed with mitral stenosis, congenital hypopituitarism confirmed by genetic tests (defect of gene encoding growth hormone secretion [GH1]; defect of gene encoding pituitary cell differentiation [PROP1]) and coeliac disease. Echocardiography and cardiac computed tomography (CT) showed a congenital mitral arcade causing severe stenosis [1–5]. Mitral arcade has some anatomical features in common with the parachute valve, such as deformed and restricted leaflet mobility and underdeveloped commissures.
Asymptomatic Giant Left Atrial Appendage Cavernous Haemangiona Misdiagnosed as a Mediastinal MassA 50-year-old female was admitted because a chest computed tomography (CT) incidentally noted a mediastinal mass. Physical examination revealed a regular heart rate of 84 beats/minute and blood pressure of 124/88 mmHg. Moreover, no cardiac murmurs were auscultated. Preoperative contrast-enhanced chest CT demonstrated an 8.2 cm × 6.0 cm non-enhancing mass in the left anterior mediastinum (Figure 1A). No abnormalities were illustrated in the 3D heart vasculature reconstruction (Figure 1B) and echocardiogram (Figure 1C).
Arrhythmogenic Right Ventricular Cardiomyopathy With Right Ventricular Thrombus Found Incidentally on a Trauma CT ScanA 19-year-old patient with no prior medical history was involved in a medium speed motor vehicle accident. The patient could not recall if they had a syncopal event immediately prior or sustained any loss of consciousness after the accident. The patient underwent a trauma protocol computed tomography (CT) scan of their brain, neck, chest, abdomen, and pelvis. The CT chest identified an enlarged right ventricle (RV) with a filling defect that was concerning for a RV thrombus (Figure 1A). A single non-occlusive pulmonary embolus in a segmental branch of the pulmonary artery to the right lower lobe was also present (not pictured).
Multiple Haemorrhagic Pulmonary Nodules and Spontaneous HaemothoraxA 26-year-old man presented with a left-sided spontaneous haemothorax and multiple pulmonary nodules. On admission, he had a heart rate of 97 beats per minute, a respiratory rate of 23 breaths per minute; he was otherwise stable. In addition, he had signs of left pleural collection on chest examination. Laboratory studies showed low haemoglobin (8.9 g/L), elevated C-reactive protein (165 mg/L), and erythrocyte sedimentation rate (125 mm/hr) levels. Chest radiograph demonstrated left-sided moderate pleural effusion and variably sized nodules on the right side.
Connective Tissue Disease Associated Myocarditis on Computed Tomography Coronary AngiogramA 27-year-old lady presented to the emergency department with an acute episode of chest pain, on the background of a 6-year history of poorly controlled mixed connective tissue disease manifested by gastro-oesophageal reflux disease, digital ulceration, Raynaud’s phenomenon and interstitial lung disease (forced vital capacity 42% and diffusion capacity for carbon monoxide 27% of predicted). There were no preceding infective symptoms or fevers. Electrocardiogram demonstrated isolated non-dynamic q waves in aVL.
Real-Time Massive Right Atrial Thrombus Migration During Atrial Fibrillation AblationThe cardiologists who were about to perform an atrial fibrillation (AF) ablation on this 73-year-old man with paroxysmal AF were surprised by a large thrombus visualised during intraoperative transoesophageal echocardiography. Long-term direct oral anticoagulant (apixaban) was omitted only the night before the procedure as per departmental protocol. Immediately after general anaesthesia and prior to any cardiac instrumentation, a large thrombus (10 cm2 by planimetry) was seen to oscillate between right atrium and right ventricle before embolising to the pulmonary artery.
Takotsubo Cardiomyopathy After mRNA COVID-19 VaccinationA healthy 63-year-old woman with no cardiovascular risk factors was admitted to the emergency room with new-onset dyspnoea and fever. The symptoms started 1 day after receiving the first of two mRNA-1273 (Moderna, Cambridge, MA, USA) COVID-19 vaccinations. She had no other prior complaints. A retronasal severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was negative. Laboratory tests revealed normal results for creatinine, creatine kinase, and creatine kinase MB (myocardial type).
Reversal of Femoral Vein Pulsatility Due to Severe Tricuspid Regurgitation After Transcatheter Tricuspid Valve-in-Valve Implantation: A “Wave Dissipation” EffectA 40-year-old female with Ebstein’s anomaly and three previous surgeries of the tricuspid valve (TV) presented with a degenerated 33 mm Sorin-Pericarbon MoreTM bioprosthesis (Sorin Biomedica, Saluggia, Italy) in TV position, with severe regurgitation, significant stenosis and worsening right ventricular function (Figure 1A1–A3; Movie 1A). After heart team discussion, a transfemoral transcatheter tricuspid valve-in-valve implantation (TTVI) was performed under local anaesthesia and guided by fluoroscopy and transthoracic echocardiography (TTE).
A Stuck Amplatzer Septal OccluderA 32-year-old man underwent, at another hospital, device closure of ostium secundum atrial septal defect (ASD) with a 40-mm Amplatzer septal occluder (ASO). The defect was then reported to be 36 mm with adequate rims on transoesophageal echocardiography (TEE), and the largest available ASO (40 mm) was chosen. The device was incidentally detected to have migrated on routine echocardiography performed 3 months after the procedure. The patient was asymptomatic and was referred to the current centre for further management.