WATCHMEN: a case report highlighting the closure of a bilobed left atrial appendage using two WATCHMAN-FLX devices.

Background: Left atrial appendage occlusion (LAAO) performed percutaneously has emerged as a widely accepted method for stroke prevention, offering a viable alternative to anticoagulation. Numerous studies have demonstrated the effectiveness and safety of this procedure. However, in certain cases, the use of a single LAAO device may not adequately achieve optimal closure due to variations in the anatomy of the left atrial appendage (LAA). Case summary: In this manuscript, we highlight the successful closure of a bilobed LAA with a large ostium utilizing two WATCHMAN™ FLX devices and using the double sheath technique. The aim was to achieve optimal closure and address the unique anatomical characteristics of the patient's LAA. Discussion: The utilization of two LAAO devices in bilobed appendage anatomy, where a single device may not be sufficient, is possible, although it poses a challenge because of the lack of technical expertise and limited published evidence. Transoesophageal imaging can serve as a valuable tool for assessing the precise anatomy of the LAA and guide the selection and placement of the occlusion devices.

Guide extension catheters: Review of technology and future directions.

Although Percutaneous Coronary Intervention (PCI) has revolutionized the management of CAD, the deliverability of devices including balloons, specialty balloons, stents, atherectomy catheters, thrombectomy devices, and intravascular lithotripsy devices has become a common challenge faced by interventional cardiologists. Guide Extension Catheters (GECs) have been developed and are now widely used to create improved backup support to allow the advancement of interventional equipment required for the PCI. Improved lesion preparation, plaque modification (e.g., with atherectomy), and Guide Extension Catheters (GEC), also called as Mother-Child Technique, has proven critical to procedural success in complex cases. In this review, we discuss the role and limitations of current guide extension devices, with a brief discussion of next-generation GEC.

Melanoma With Cardiac Metastasis.

Melanoma is considered a masquerader of many diseases owing to its potential to metastasize to many organs. Several malignancies can metastasize to the heart including malignant melanoma. Historically, antemortem diagnosis of cardiac involvement of melanoma is not common, but with significant improvement in imaging modalities, the diagnosis can now be made early and accurately, aiding in treatment and improved survival. We present a case of a 36-year-old man with brief neurological symptoms and subsequent diagnosis of cerebrovascular accident (CVA). Cardiac imaging revealed incidental findings of right and left ventricular masses and lymph node biopsy, confirming metastatic melanoma. Cardioembolic etiology was suspected for his CVA. Prompt immunotherapy was initiated with improvement in his clinical condition.

Management of Atrial Fibrillation Post Transcatheter Aortic Valve Implantation.

Atrial fibrillation (AF) is a common complication in patients who underwent transcatheter aortic valve implantation. Some of these patients have preexisting AF as well. The management of these patients is complex, especially after the procedure, when there is a sudden change in hemodynamics. There are no established guidelines about the management of the patients who underwent transcatheter aortic valve replacement with preexisting or new-onset AF. This review article discusses the management of these patients with rate and rhythm control strategies with medications. This article also highlights the role of newer oral anticoagulation medications and left atrial occlusion devices to prevent stroke after the procedure. We will also discuss new advances in the care of this patient population to prevent the occurrence of AF after transcatheter aortic valve implantation. In conclusion, this article is a synopsis of both pharmacologic and device interventions for the management of AF in patients who underwent transcatheter aortic valve replacement.

Coronary Arteriovenous Fistula Originating From the Left Main Coronary Artery.

We report a case of coronary artery fistula arising from the left main coronary artery in a 62-year-old patient presenting with atrial fibrillation. He underwent a transthoracic echocardiogram which suggested a possible coronary artery fistula. Cardiac computed tomographic angiography and cardiac catheterization confirmed the diagnosis. Coronary artery fistula originated from the left main coronary artery, which is rare and terminated in the coronary sinus. Multi-modality imaging helps to delineate anatomy and decide treatment options. Small asymptomatic fistulas do not require treatment, and large or symptomatic fistulas need closure. Our patient was asymptomatic, and we opted for conservative management with close outpatient echocardiographic monitoring.

Dual coronary - cameral fistula "double the trouble".

A patient presenting with worsening dyspnea and left-sided chest pain underwent heart catheterization, found to have a rare connection between the right and left coronary arteries draining into the left ventricle, consistent with dual coronary-cameral fistula.

Initial Presentation of Renal Cell Carcinoma as Heart Failure Secondary to Tumor-Thrombus Extension to the Right Atrium.

Renal cell carcinoma (RCC) can invade locally through the renal vein and into the inferior vena cava (IVC) with tumor-thrombus formation reported in 5%-15% of patients. From the IVC, RCC can grow intravascularly and extend into the right atrium. We present a rare case with two uncommon findings: tumor-thrombus extension leading to a right atrial mass and initial presentation of RCC as heart failure. A 69-year-old woman presented with signs and symptoms of heart failure. Electrocardiogram was normal and the initial troponin level was mildly elevated to 0.09 ng/mL. Echocardiography revealed a dilated right atrium with a 6.9 cm x 3.8 cm echogenic mass consistent with a tumor impinging on the tricuspid valve leading to a functional stenosis. Computed tomography (CT) of the abdomen revealed a large right-sided renal mass with enlargement of the renal vein suggestive of tumor thrombus. Although the initial presentation of RCC with cardiac symptoms is surprising, this case highlights the importance of maintaining a comprehensive differential diagnosis. It also signifies the need for further imaging as not all atrial masses are cardiac tumors. Many other primary tumors - kidney, liver, lung, and thyroid - can directly invade or metastasize into the atrium by way of the vena cava.

Ticagrelor-Induced Syncope/Bradyarrhythmia.

Ticagrelor (BRILINTA®) is a very commonly used oral antiplatelet agent in acute coronary syndrome and after percutaneous coronary intervention (PCI). It is a reversible, direct inhibitor of the adenosine diphosphate (ADP) P2Y12 receptor. Most of the patients tolerate the drug well but it is known to cause brady arrhythmias and ventricular pauses, the exact mechanism of which is unclear. We present a case of acute coronary syndrome/unstable angina in a 58-year-old Caucasian gentleman requiring cardiac catheterization and PCI with drug eluting stent deployment and syncope following Ticagrelor loading from long ventricular pauses.

Rare and unusual presentation of gastrocardiac syndrome.

Gastrointestinal pathology can cause cardiac symptoms and disorders. We present a case of a patient who had worsening of her palpitations with food intake. She was found to have a high burden of premature ventricular contractions in the setting of hiatal hernia and gastro-oesophageal reflux disease. After extensive investigations and ruling out cardiac causes, her arrhythmia resolved with the surgical correction of hiatal hernia.

Right atrial mass-multimodality imaging-Massive lipomatous hypertrophy of the atrial septum.

Asymptomatic cardiac masses are often diagnosed incidentally. Massive lipomatous hypertrophy can be confused for other cardiac masses and need careful evaluation including multimodality imaging to manage appropriately.

An Unusual Presentation of Median Arcuate Ligament Syndrome.

Median arcuate ligament syndrome (MALS) is a rare benign condition typically affecting young females. It usually presents with abdominal symptoms of pain, nausea, and unintentional weight loss. They are usually diagnosed incidentally on CT of the abdomen done for abdominal pain. Here we present a rare case of MALS which presented with an anginal type of chest pain without any abdominal symptoms leading to an extensive workup and incidental diagnosis.

Non-ischemic Cardiomyopathy: A Rare Adverse Effect of Clozapine.

Clozapine is a dibenzodiazepine antipsychotic used for treatment-resistant schizophrenia. Its association with several side effects such as agranulocytosis, seizure, and insulin resistance is well known. Cardiac side effects such as myocarditis and cardiomyopathy are less common and have been seldom reported. Here we report an unusual case of clozapine-induced nonischemic dilated cardiomyopathy. A 50-year-old female with treatment-resistant schizophrenia on clozapine presented with gradually worsening shortness of breath, productive cough, and pleuritic chest pain. She was found to have non-ischemic dilated cardiomyopathy due to clozapine use as no other causative factor was found. Clozapine was gradually tapered and then discontinued. Repeat echocardiogram in three months revealed improvement in ejection fraction. This case is unique as it outlines clozapine as a rare cause of nonischemic cardiomyopathy, as discontinuation of the drug showed improvement in symptoms and heart function.

A right atrial fat ball: Rare case of cardiac lipoma.

Due to varied presentation, a high index of suspicion is needed for diagnosis of cardiac lipoma. Treatment should only be reserved for symptomatic patients. This case acknowledges the importance of cardiac MRI in making the diagnosis of cardiac lipoma and further delineating the management options available.

Slit in the Coronaries: A Case of Spontaneous Coronary Artery Dissection.

Spontaneous coronary artery dissection (SCAD) is a noniatrogenic epicardial coronary artery dissection unrelated to an atherosclerotic disease process. SCAD is responsible for a small percentage of acute coronary syndrome (ACS) cases. The left anterior descending (LAD) artery is the most common artery affected in SCAD, although any coronary artery can be affected. We present an interesting case of SCAD presenting as an ST-elevation myocardial infarction complicated with dissection extending to the left main and distal LAD requiring emergent coronary artery bypass grafting. Our case emphasizes the importance of considering SCAD as a cause for ACS, especially in young patients with minimal atherosclerotic risk factors. Also, a very high recurrence rate demands strict follow-up and multidisciplinary decision making in the population impacted with this rare entity.

A Case of Left Ventricular Noncompaction Presenting as Atrial Fibrillation.

Ventricular noncompaction is a rare congenital cardiomyopathy resulting from failure in cardiac embryogenesis. Both left and right ventricular involvement has been reported in nature. We present a case of a 69-year-old male presenting with atrial fibrillation complicated with in-hospital cardiac arrest in the setting of left ventricular noncompaction (LVNC). Our case demonstrates the fatal nature of this disease entity thus demanding a high index of suspicion for early detection and treatment.

Association Between Pulmonary Hypertension and Transcatheter Aortic Valve Replacement: Analysis of a Nationwide Inpatient Sample Database.

INTRODUCTION: This study was done to review the association of pulmonary hypertension (PH) with Transcatheter Aortic Valve Replacement (TAVR) procedures done in the US for years 2010 to 2012. METHODS: We used Nationwide Inpatient Sample (NIS) data to extract data for patients who were hospitalized with a primary/secondary diagnosis of TAVR as specified by International Classification of Disease (ICD-9) codes 35.05 and 35.06. PH was identified with ICD-9 codes 416.0 and 416.8. Logistic regression models were used to analyze the association between PH and clinical outcomes of TAVR. RESULTS: A total of 8,824 weighted discharges were identified with a primary/secondary diagnosis of TAVR, of which 1,976 (22.4%) also had PH. Mean age of patients undergoing TAVR with and without PH was 81.4 and 81.1 years, respectively. More females had a diagnosis of PH with TAVR when compared to males, (56.9% vs. 43.1). When controlling for demographics, diabetes and hypertension; the association between PH and TAVR was statistically significant (p<.0001). Estimated odds of TAVR with PH was 5.46 (95% CI: 4.63, 6.41) times greater than for TAVR without PH. Similarly, the estimated odds for a length of stay greater than 1 week for TAVR with PH was 1.43 (95% CI: 1.12, 1.82; p=.0034) times greater than odds for TAVR without PH. PH was not statistically significant for in-hospital mortality in patients receiving TAVR (p=0.7067). CONCLUSION: This study suggests that underlying PH does not influence the immediate mortality of patients underlying TAVR. Further studies are needed to delve into the bearing of PH on TAVR.