Right Coronary Artery to Right Atrial Fistula: Role of Multi-Modality Imaging and Percutaneous Closure.

Coronary artery fistula (CAF) is a connection between a coronary artery and a cardiac chamber or nearby vessel. Our case represents a fistula arising from the right coronary artery and terminating in the right atrium, presenting as atrial fibrillation. CAF closure options include surgical and percutaneous approaches.

Transfemoral aortic valve replacement in a nonagenarian with aortic stenosis and cardiac amyloidosis: case report.

BACKGROUND: Cardiac amyloidosis (CA) is diagnosed with increasing frequency in the elderly population with severe aortic stenosis (AS), especially with the low-flow, low- gradient phenotype. Prognosis is poor with no treatment. CASE PRESENTATION: The patient is a 94-year-old active male who presented with a stroke that fully resolved. He was found to have low-flow, low-gradient severe AS, along with concomitant CA. Gradients across the aortic valve worsened with the dobutamine challenge test. He underwent successful transfemoral aortic valve replacement (TAVR) and did well postoperatively, where he remained in the hospital for only one day. Treatment of his CA with Tafamidis was recommended; however, the patient declined due to its cost and personal preference. CONCLUSION: To our knowledge, we report on one of the oldest patients to undergo TAVR for low-flow, low-gradient AS with concurrent CA (AS-CA). It might be prudent to screen elderly patients with AS for CA, as prognosis is worse with medical management alone. TAVR has overall improved survival in patients with AS-CA and is considered the procedure of choice, as these patients are typically older and at higher risk for surgical intervention.

Acute Coronary Syndromes in Heart Transplant Recipients (from a National Database Analysis).

With an expanding and aging heart transplant population, the incidence of acute coronary syndromes (ACS) is expected to increase. Our study aims to report current trends in in-hospital management and outcomes in heart transplant recipients presenting with ACS. We conducted an analysis of the National Inpatient Sample (2007 to 2014) to study the trends in hospitalization, in-hospital management, and outcomes in heart transplant recipients with a primary diagnosis of ACS. We included patients with ST elevation myocardial infarction (STEMI), non-STEMI (NSTEMI) and those with unstable angina pectoris (UAP). A total of 1,621 ACS (NSTEMI/UAP-76% vs STEMI-24%) hospitalizations were identified. Despite 1,327 (81%) of patients who underwent left heart catheterization, coronary revascularization was performed in only 576 patients (36%). Mortality was significantly higher in patients presenting with STEMI versus NSTEMI/UAP (28% vs 11%, respectively; p <0.05) and those who did not undergo revascularization (19% vs 7%; p <0.05). Cardiogenic shock (CS) was diagnosed in 14.5% patients. Mechanical circulatory support utilization was higher in CS group compared with non-CS group (69% vs 2.8%; p <0.05), as was in-hospital mortality (39% vs 10%; p <0.05). Repeat transplantation during the index hospitalization was done in 4.5% of ACS patients. In conclusion, in heart transplant recipients, ACS is associated with a high incidence of CS and in-hospital mortality. Aggressive treatment strategy that includes revascularization, mechanical circulatory support use (in those developing CS), and urgent retransplantation in suitable candidates seems to lead to better results than a more conservative strategy.