Extremally rare cause of AV block during typical atrial flutter ablation not related to conduction tissue injury.

BACKGROUND: 51-year-old female with extensive prior atrial surgery involving myxoma resection and patch septum repair and prior typical atrial flutter as well as peripatch reentry underwent redo radiofrequency ablation of typical atrial flutter. METHODS: After high density mapping was performed, and gap in the prior typical flutter line was ablated. RESULT: During the ablation transient atrioventricular (AV) block was noted. Subsequent remapping of the right atrium revealed that there was a narrow strip of tissue between the cavo-tricuspid isthmus (CTI) and the coronary sinus (CS) os on which activation of the AV node was now depending. From all other directions, the AV node was surrounded by scar tissue. CONCLUSIONS: The most likely explanation for the transient AV block during the ablation procedure is that there was reversible injury to the tissue strip between the CTI and the CS os, which is critical for the activation of the AV node.

Causes of Death in COVID-19 Patients with Cardiac Injury.

BACKGROUND: The causes of death in COVID-19 patients with cardiac injury are uncertain. METHODS: We conducted a case-control study and reviewed the electronic medical record of 109 deceased COVID-19 patients with cardiac injury on admission and 32 deceased COVID-19 patients without cardiac injury at two hospitals in Rhode Island. RESULTS: Among the 109 deceased COVID-19 patients who had cardiac injury on admission, 79 patients (72.5%) died of hypoxic respiratory failure, 21 patients (19.2%) of multi-organ failure and septic shock, 6 patients (5.5%) of cardiac arrhythmia, 3 patients (2.8%) of severe kidney failure as the immediate causes of death. We observed a similar pattern of distribution when compared to deceased patients without cardiac injury on admission (n=32). CONCLUSION: The main causes of death of COVID-19 patients with cardiac injury were non-cardiac, mostly hypoxic respiratory failure. Cardiac-related arrhythmia only accounted for a small proportion of cases.

Kugel's Artery: Silent Bystander or Savior?

Kugel's artery is defined as a rare anatomical variant of the coronary artery vascular bed consisting of an anastomotic connection between branches of the right coronary artery (RCA) and/or left circumflex artery (LCX). Kugel's artery has been reported to have an incidence of 6% in the general population. The presence of this anastomotic communication may play a pathophysiological role in a patient with a right dominant coronary circulation and an underlying coronary artery disease (CAD) affecting the right coronary system. Understanding the existence and significance of Kugel's artery and the anastomotic network cannot be overemphasized. The presence of an anomalous vascular connection bypassing an area of epicardial vessel occlusion may be a lifesaving pathophysiological finding that maintains myocardial perfusion and viability. Herein, we present a case with multivessel occlusion myocardial infarction found to have anomalous vascular anastomosis between the proximal RCA and distal segment of the same artery.

Aortic root fistula complicating Austrian syndrome.

Austrian syndrome occurs in 1.2% of all patients with pneumococcal infective endocarditis. It presents with the triad of meningitis, pneumonia, and endocarditis. It is commonly seen in elderly males with a history of alcohol abuse, an immunocompromised state, or recent valve surgery. We present a case of Austrian syndrome presenting with paravalvular complications in the form of aortic root fistula. In this report, we describe the second patient with the community-acquired, pneumococcal, native, aortic valve, endocarditis with Austrian syndrome complicated by the development of an aortic fistula.

Differentiating Pseudo Versus True Aortic Stenosis in Patients Without Contractile Reserve: A Diagnostic Dilemma.

Low-flow, low-gradient (LF-LG) aortic stenosis with depressed left ventricular (LV) ejection fraction is a diagnostic challenge that is frequently encountered in the management of valvular heart disease. True-severe LF-LG aortic stenosis is amenable to valve replacement, whereas pseudo-severe aortic stenosis requires management of the underlying cardiomyopathy. This distinction is important as it serves as a critical branch point in guiding therapeutic decisions. We present the case of a 71-year-old male with LF-LG aortic stenosis who had a reduced and biphasic augmentation of LV flow during dobutamine stress echocardiography (DSE). Further evaluation revealed a stenotic left subclavian artery proximal to the left internal mammary artery graft to the left anterior descending (LAD) artery. Bypass of the subclavian stenosis reversed the LAD territory ischemia and confirmed pseudo-severe aortic stenosis on repeat DSE. Traditional DSE parameters are inconclusive in patients with LF-LG aortic stenosis with poor flow reserve. Calculation of the projected orifice area or measurement of aortic valve calcium via multidetector computed tomography (MDCT) may be required in this scenario. Most importantly, reversible causes of LV dysfunction identified during DSE for LF-LG aortic stenosis require a different treatment approach than that of true aortic stenosis.

Cor Triatriatum Dexter as an Incidental Finding: Role of Two-Dimensional Transthoracic Echocardiography.

Cor triatriatum dexter (CTD) is a rare congenital cardiac anomaly in which a membranous structure divides the right atrium (RA) into two chambers. Persistence of the right valve of the sinus venosus, which usually regresses as a part of normal embryological development, is responsible for membranous partition. There is a high incidence of right-sided congenital abnormalities of the heart associated with this condition. Clinical manifestations vary depending on the degree of partitioning or septation of the RA. We present a case of CTD discovered as an incidental finding during transthoracic echocardiography and further discuss the role of two-dimensional echocardiography as a noninvasive diagnostic tool.