Trans-coronary Pacing via Rota Wire Prevents Bradycardia During Rotational Atherectomy: A Case Report

Back ground Rotational atherectomy (RA) is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion. In this report, we present a case of trans-coronary pacing via a Rota wire to prevent bradycardia during RA in the proximal right coronary artery (RCA). Case summary A 72-year-old woman with a one month history of worsening effort angina was admitted to our hospital. Computed tomography coronary angiography disclosed significant coronary stenosis with severe calcification in proximal RCA. Coronary angiography revealed significant coronary stenosis with severe calcification in the proximal RCA. Subsequently, percutaneous coronary artery intervention was performed under the guidance of intravascular ultrasound(IVUS). The pull-back IVUS showed a circumferential calcified lesion in the proximal RCA, that was treated using RA, which induced significant bradycardia requiring temporary pacemaker insertion. Immediately, trans-coronary pacing was provided via a Rota wire placed in the far distal RCA; this was used for back-up pacing during RA. RA was completed by safely modifying the calcified lesion. After successful debulking of the calcified lesion, we dilated with a balloon, and a drug-eluting stent was implanted at the proximal RCA. Final IVUS and angiography showed good stent apposition and expansion. we did not observe any serious intraprocedural complications. Discussion RA is used for plaque modification in patients with heavily calcified coronary lesions. RA can induce significant bradycardia or atrioventricular block requiring for temporary pacemaker insertion via the transvenous route. This method could be an effective method to prevent bradycardia during RA.

Pacemaker Implantation Via Femoral Vein and Successful Arrhythmia Management in an Elderly Patient with Fontan Circulation: A Case Report

Background The frequency of arrhythmias increases after the Fontan operation over time; atrial tachycardia (AT) and sinus node dysfunction (SND) are frequently observed. Case summary Our patient was 63-year-old woman who underwent a lateral tunnel Fontan operation for double outlet right ventricle at age 36. She experienced paroxysmal AT for one year, and antiarrhythmic medication was not feasible due to symptomatic SND. Computed tomography revealed a 45 mm-sized thrombus in the high right atrium (RA). The patient had three coexisting conditions: paroxysmal AT, symptomatic SND and the RA thrombus, for which total cavopulmonary connection conversion and epicardial PMI would have been effective; however, given her age and comorbidities, surgical treatment was considered high-risk. Catheter ablation was avoided because of the RA thrombus. Finally, a transvenous pacemaker was implanted via the right femoral vein to avoid the RA thrombus and severe venous tortuosity from the left subclavian vein to the RA. After PMI, the patient was prescribed amiodarone and bisoprolol for AT suppression. AT occurred once in the third month after discharge. We increased the dose of amiodarone, and she has been tachycardia-free. Discussion Transvenous PMI must be considered in cases where open thoracic surgery or catheter ablation cannot be performed. This is the first report of transvenous PMI via the right femoral vein and successful AT and SND management in an elderly Fontan patient.

Effusive–constrictive pericarditis after the second dose of BNT162b2 vaccine (comirnaty): a case report

Background Whereas effusive-constrictive pericarditis can rarely occur in COVID-19, to date no cases of effusive-constrictive pericarditis related to SARS-CoV2 vaccine have been documented. Case summary A 59-year-old caucasian man presented to our emergency department with effusive-constrictive pericarditis. Symptoms occurred shortly after the second dose of BNT162b2 (Comirnaty) vaccine. No other etiological causes were identified. Guidelines directed therapy for acute pericarditis was implemented, with clinical benefit. Discussion Systemic inflammatory response to COVID-19 can rarely trigger pericarditis. In our case a strong temporal relation between the second dose of BNT162b2 vaccine and symptoms occurrence was documented, indicating a possible rare adverse reaction to the vaccine, similarly to natural infection. Further research is needed to confirm a causal relationship.

Percutaneous thrombectomy and right ventricular mechanical circulatory support for pulmonary embolism in a COVID-19 patient: Case report, one-year update, and echocardiographic findings

Background We previously described percutaneous thrombectomy and right ventricular mechanical support of a COVID-19 patient with a massive pulmonary embolism. Here we present a detailed echocardiographic and clinical timeline with 1 year follow-up. Case Summary A 57-year-old female with COVID-19 went into shock from a massive pulmonary embolism. After percutaneous removal of a large thrombus burden (AngioVac system; AngioDynamics Inc, Latham, NY, USA), she became severely hypotensive, requiring CPR, and was resuscitated with an Impella RP device (Abiomed, Danvers, MA, USA). A pediatric TEE probe monitored the procedure because an adult probe would not pass (S7-3t—Philips Medical Systems, Andover, MA, USA). Post thrombectomy, surface imaging documented gradual resolution of right ventricular dysfunction, tricuspid regurgitation, and elevated pulmonary artery pressure. Her course was complicated by renal failure requiring temporary dialysis. She was discharged home on apixaban. Hypercoagulability work-up was negative. Two months later, vocal cord surgery was performed for persistent stridor. Esophagoscopy at that time was prevented by osteophyte obstruction. At 10 months, she received the Pfizer-BioNTech vaccine. At one year, the patient remains healthy on apixaban, and her echocardiogram is normal. Discussion This case illustrates the pivotal role of echocardiography in the diagnosis, percutaneous treatment, and near- and long-term follow-up and management of a patient with massive pulmonary embolism due to COVID-19 with documentation of complete recovery from severe right ventricular dysfunction and hemodynamic collapse. A pediatric TEE probe was a crucial alternative to the adult probe because of possible osteophyte obstruction.

Fulminant Myocarditis Following COVID-19 Vaccination: A Case Report

Background The BNT162b2 vaccine received emergency use authorization from the U.S. Food and Drug Administration for the prevention of severe COVID-19 infection. We report a case of biopsy and MRI-proven severe myocarditis that developed in a previously healthy individual within days of receiving the first dose of the BNT162b2 COVID-19 vaccine. Case Summary An 80-year-old female with no significant cardiac history presented with cardiogenic shock and biopsy-proven fulminant myocarditis within 12 days of receiving the BNT162b2 COVID-19 vaccine. She required temporary mechanical circulatory support, inotropic agents and high-dose steroids for stabilization and management. Ultimately her cardiac function recovered, and she was discharged in stable condition after 2 weeks of hospitalization. A repeat cardiac MRI 3 months after her initial presentation demonstrated stable biventricular function and continued improvement in myocardial inflammation. Discussion Fulminant myocarditis is a rare complication of vaccination. Clinicians should stay vigilant to recognize this rare, but potentially deadly complication. Due to the high morbidity and mortality associated with COVID-19 infection, the clinical benefits of the BNT162b2 vaccine greatly outweighs the risks of complications.

Dual Atrial Rhythms: A Case Report Of An Unusual Cause Of Pacemaker Syndrome

Background Atrial dissociation (AD) is described as the existence of two simultaneous electrically isolated atrial rhythms. Theoretically, detection of dual atrial rhythms with a sufficiently high rate by pacemaker can lead to automatic mode switching and associated pacemaker syndrome. Such a clinical observation has not been reported before in the literature. Case Summary An 87-year-old female with Ebstein’s anomaly status post tricuspid valve annuloplasty and tricuspid valve replacement and a dual chamber pacemaker presented with congestive heart failure one week after undergoing atrial lead revision. Interrogation of her dual chamber pacemaker revealed two atrial rhythms: sinus or atrial-paced rhythm and electrically isolated atrial tachycardia (AT). Sensing of both atrial rhythms by the pacemaker led to automatic mode switching, which manifested as ventricular paced rhythm with retrograde P waves on electrocardiogram (ECG). Adjusting the atrial lead sensitivity to a level higher than the sensing amplitude of AT restored atrial paced and ventricular sensed rhythm, which resulted in resolution of heart failure symptoms. Discussion Regardless of the cause of AD, there must be electrical insulation between the two rhythms for their independent coexistence in the atria. AD can lead to pacemaker syndrome from automatic mode switching. If the sensing amplitude during sinus rhythm is significantly larger than that of AT, adjusting the atrial lead sensitivity would solve the issue, as in the present case. Otherwise, atrial lead revision, pharmacotherapy or AT ablation should be considered.

Intravascular leiomyomatosis with cardiac extension: a case report

Background Intravascular leiomyomatosis with intracardiac extension is a rare benign tumor seen exclusively in women, characterized by proliferation of uterine smooth muscle cells through the venous circulation into the inferior vena cava and the right heart chambers. Case summary A 47 years old women with history of previous hysterectomy due to myomatosis, presented with nausea, anorexia and bilateral lower limb swelling over the preceding two months. An outpatient abdominal ultrasound discovered a mass in the Inferior vena cava. Echocardiogram and Computed tomography demonstrated a large intravascular mass extending from the pelvis to the right heart chambers. The tumor was completely removed in a concomitant open-heart surgery and laparotomy. Post operative course was uncomplicated. A month later the patient was feeling well and in good clinical condition. The histological analysis consisted with intravascular leiomyomatosis. Discussion Intracardiac leiomyomatosis is a rare clinical condition which requires high index of suspicion. Multimodality imaging is usually required to establish the preoperative diagnosis, although the final diagnosis is achieved with tissue investigation. Complete surgical resection of the tumor is curative and associated with good long-term prognosis.

Giant coronary fistula aneurysm presenting as a progressing left-sided asymptomatic mediastinal mass with systolic dominant Doppler flow: a case report

Background Cases of giant coronary artery aneurysms associated with coronary fistula are rarely reported, and they present with various symptoms, including coronary steal syndrome. We report an uncommon case of an asymptomatic giant coronary fistula aneurysm presenting as a progressing left-sided mediastinal mass that has been tracked for years. Case summary A 67-year-old healthy asymptomatic woman was referred to our hospital because of an abnormal shadow on her chest radiography revealing a left-sided mediastinal mass that had progressed in size over the past 4 years. Computed tomography revealed mass progression from 4 cm to 5 cm in diameter within 2 years. Coronary computed tomography and coronary angiography identified a giant coronary artery aneurysm in a coronary fistula originating in the left anterior descending artery and draining into the main pulmonary artery. Transthoracic Doppler echocardiography revealed a unique systolic-dominant flow. She underwent coronary artery aneurysmectomy and fistula ligation. The patient has been in good health without any events for 10 months since her discharge. Discussion A giant coronary artery aneurysm in a coronary fistula can present as an asymptomatic left-sided mediastinal mass that has progressed in size for years in older adults. Echocardiography can provide clues of the steal phenomenon in coronary artery fistula. A close investigation of mediastinal abnormalities can facilitate the detection of coronary aneurysms.

A report of two cases of myocarditis following mRNA COVID-19 vaccination

Background Vaccination is the most important measure to control the coronavirus disease 2019 (COVID-19) pandemic. Myocarditis has been reported as a rare adverse reaction to COVID-19 vaccines. The clinical presentation of myocarditis in such cases can range from mild general symptoms to acute heart failure. Case summary We report the cases of two young men who presented with chest pain and dyspnoea following the administration of the mRNA COVID-19 vaccine. Cardiac investigations revealed findings typical of acute myocarditis. Discussion Myocarditis is a rare complication following mRNA COVID-19 vaccination. In this case series, the temporal proximity of the development of acute myocarditis and the administration of the mRNA COVID-19 vaccine was acknowledged. In the absence of other causative factors, myocarditis in these patients potentially occurred due to an adverse reaction to the mRNA COVID-19 vaccine. However, a causal relationship remains speculative. Clinical suspicion of myocarditis should be high if patients present with chest pain or dyspnoea after receiving COVID-19 vaccination.