Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant.

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

Hereditary transthyretin amyloidosis caused by the rare Phe33Leu mutation.

Hereditary transthyretin amyloidosis is a rare progressive systemic disease. We describe a physically active 46-year-old man who presented with dyspnoea on exertion. An echocardiogram showed increased left ventricular wall thickness and diastolic dysfunction, but normal systolic function. The QRS voltage on ECG was normal. The patient was diagnosed with hypertrophic cardiomyopathy, and several years passed before establishment of the accurate diagnosis of hereditary transthyretin amyloidosis caused by the rare mutation ATTR Phe33Leu, previously described in only five case reports. Further investigation revealed neuropathy and nephropathy, and the patient developed severe heart failure. The patient is treated with tafamidis, has undergone heart transplantation and is currently planned for liver transplant. Hereditary transthyretin amyloidosis is likely underdiagnosed, especially in patients presenting with cardiomyopathy. A discrepancy between the left ventricular mass indicated by echocardiogram and that on ECG is an important indicator of amyloidosis, as is involvement of multiple organs.

Haemolytic anaemia after mitral valve repair due to recurrent mild to moderate mitral regurgitation.

A 52-year-old man underwent mitral valve repair for mitral regurgitation. Four months postoperatively, the patient developed dyspnoea, fatigue and dark urine. He presented to his primary care physician 6 months postoperatively, where an evaluation revealed anaemia and mild renal failure. The haemoglobinuria was misdiagnosed as gross haematuria and the patient consequently underwent several unnecessary invasive urological exams. A transthoracic echocardiogram showed a recurrent mitral regurgitation that was considered non-significant, before performing additional laboratory testing and a renewed echocardiogram. The above results showed evidence of haemolysis and a mild to moderate mitral regurgitation, although with a high velocity jet. The patient was diagnosed with haemolytic anaemia that necessitated blood transfusions and a reoperation with a mechanical valve, after which the patient made a full recovery. Importantly, it was mainly the velocity of the jet and not the severity of the mitral regurgitation that caused the mechanical trauma to red blood cells.