Cardiovascular magnetic resonance and echocardiographic findings of a large thrombosed intramyocardial dissecting hematoma: a case report and a brief review of literature.

Intramyocardial dissecting hematoma (IMDH) is an uncommon fatal complication after acute myocardial infarction. It is usually under identified. Transthoracic echocardiography is the first-line modality that can detect IMDH. Cardiac magnetic resonance could confirm the diagnosis. In this paper, we reported a unique partially thrombosed large left ventricle IMDH that mimics thrombosed true aneurysm aiming to highlight the supporting diagnostic transthoracic echocardiography and cardiac magnetic resonance criteria of IMDH.

Treatment of severe mitral regurgitation that mimics a para-ring mitral regurgitation after failed annuloplasty ring with MitraClip: A case report.

BACKGROUND: Progressive remodelling of the left ventricle with lateral and apical displacement of one or both papillary muscles can lead to recurrence of severe mitral regurgitation (MR) in the presence of the mitral valve (MV) ring. The MitraClip (Abbott, USA) is the only option in cases with annuloplasty rings too large for implantation of a Sapien prosthesis in high surgical-risk patients. We present a case where the MR jet was directed toward a para-ring hole, and the MitraClip system was used successfully to treat this severe MR. CASE SUMMARY: An 80-year-old woman underwent coronary artery bypass surgery plus MV repair with C-shaped ring 6 years ago. In the past year, she experienced severe shortness of breath; her ejection fraction dropped to 15%. A transesophageal echocardiogram revealed that severe MR started at the level of MV leaflets and then passed to the left atrium beside the MV ring. Live 3D showed the severe MR coming through the oval-shaped hole beside the C-shaped MV repair ring. MitraClip implantation was decided, the two leaflets were grasped successfully, the clip was fully closed, and only trace MR remained at the MV leaflets with no flow to the para-ring hole. The patient was extubated after 12 hours and discharged home after 2 days. Follow-up transthoracic echocardiography after 6 months showed the clip in place and trace residual MR. CONCLUSION: Implantation of MitraClip in the presence of MV repair ring is feasible and safe. The para-ring defect can be left if the origin of MR from the MV coaptation line is treated successfully with MitraClip. Symptomatic improvement with no rehospitalization was documented in this case.

Ultraslow thrombolytic therapy in stuck mechanical aortic valve, case report, and review of the literature.

BACKGROUND: Stuck mechanical heart valves had a debate about the management plan. There is debate regarding the type, dose, and rate of administration of various thrombolytic agents. We report a case with successful thrombolysis using an ultraslow regimen. CASE SUMMARY: A 43-year-old female with a history of aortic valve (AV) and mitral valve replacement (bi-leaflet metallic valves), and tricuspid valve repair (MINI band) at October 2017. Physical examination showed normal metallic first heart sound and weak metallic second heart sound. Laboratory investigations were normal except low INR, hematocrit, and hemoglobin level (9 gm/L due to iron deficiency anemia). Transthoracic echocardiogram (TTE) and Transoesophageal echocardiogram (TEE) confirmed stuck aortic valve leaflet, with a high mean pressure gradient across prosthetic AV (34 mmHg). The mechanical mitral valve was working well. Fluoroscopy showed stuck one of the AV leaflets in a closed position. The treating physician decided to give her the chance for thrombolytic therapy. This case was treated with ultraslow thrombolytic therapy (Alteplase, 1 mg, every hour) with follow up transthoracic echocardiogram every 24 h to check the pressure gradient on the AV. She was young, asymptomatic, and hemodynamically stable. After 48 h of Alteplase, the stuck leaflet was released. The mean pressure gradient dropped to 16 mmHg. DISCUSSION: Ultraslow thrombolytic regimen advised to be tried in stuck mechanical valves and hemodynamically stable patients.

Percutaneous closure of iatrogenic anterior mitral leaflet perforation: a case report.

BACKGROUND: Severe mitral regurgitation (MR) through the body of the anterior mitral leaflet (AML) is rare. The cause either iatrogenic during open-heart surgery or due to infective endocarditis. We present a case where a successful percutaneous closure of the AML perforation was an alternative to surgery. CASE SUMMARY: A 60-year-old male presented with shortness of breath (SOB) class III of 12 months duration. He underwent coronary artery bypass surgery with four grafts plus mitral valve (MV) repair 20 months ago. Transthoracic echocardiogram (TTE) and transoesophageal echocardiogram (TOE) revealed severe MR through the body of AML at A3. The percutaneous closure plan was to cross the AML perforation from the left ventricular side. The venacontracta of the perforation was 6 mm, an amplatzer septal occluder device 6 mm considered appropriate for closure of this hole. A snare catheter snared the wire and exteriorized creating arteriovenous loop. Amplatzer septal occluder 6 mm loaded to the delivery system till larger disc (left-sided) opened safely and freely below the MV apparatus. Once the left ventricular side disc opposed the ventricular surface of AML, the waist and left atrial disc gently released. The patient discharged in the next day. After 6 months, the patient had no more SOB, he returned to his daily activity. Follow-up TTE showed no MR, the closure device was stable in place. DISCUSSION: We added a successful case of transcatheter AML perforation to the literature. The role of TOE is crucial in diagnosis and procedure guidance.

Transesophageal echocardiography guidance of percutaneous mitral valve replacement in failed annuloplasty ring: A case report.

Severe mitral regurgitation and stenosis due to failed mitral annuloplasty ring can be managed with percutaneous mitral valve in ring in high surgical risk patients. A 66-year-old male underwent coronary artery bypass surgery and mitral valve ring annuloplasty 7 years previously. He started to have shortness of breath with minimal effort in the past 2 years. Transthoracic echocardiogram revealed a new severe mitral regurgitation and severe mitral stenosis. The patient was turned down from surgery due to high surgical risk. The transcatheter mitral valve in ring implantation was decided. In this case, there was a low probability of left ventricular outflow tract obstruction. A stiff wire crossed the mitral valve ring and positioned in the left ventricular apex. The Sapien 3 valve size 26 mm (Edwards Lifesciences, Irvine, CA, USA) was positioned to have 80% ventricular and 20% atrial side. Transesophageal echocardiogram evaluation revealed a mean gradient of 5 mmHg. The left ventricular outflow tract (LVOT) had laminar color flow and the mean pressure gradient across LVOT was 1 mmHg. The patient was discharged after 2 days in good condition. At one year follow up, he had no shortness of breath and no rehospitalization. In conclusion, the percutaneous mitral valve in ring is feasible in selected patients. The risk of LVOT obstruction should be assessed carefully before the procedure with a transthoracic and transesophageal echocardiogram. 〈Learning objective: Understand how to guide the mitral valve in ring procedure with a transesophageal echocardiogram and how to avoid left ventricular outflow tract obstruction. Understand how to position the Sapien valve in mitral valve ring.〉.

Diathermy-assisted recanalization of chronic superior vena cava obstruction, case report.

The number of cases of superior vena cava syndrome (SVCS) increased due to increased cardiac devices and central venous catheters. Management of benign SVCS is still controversial. A 51-year-old male known to have ischemic cardiomyopathy and chronic renal failure on regular hemodialysis. In the last 12 months, he had progressive shortness of breath and swelling of his upper part of the body. Examination revealed engorgement of the neck veins, facial puffiness, and pitting edema of both upper limbs. Venography showed occluded SVC. We applied a 50 Watt of energy via electrocautery pen to a Hi-Torque 0.014 Astato guidewire to cross the occluded segment retrogradely. We used 2 stents 39 mm, mounted on BIB 20/40 mm. Final angiography revealed full restoration of SVC flow. Diathermy use to cross a chronic total SVC obstruction is feasible and safe. Endovascular techniques are suitable as initial management of benign SVC syndrome.

Percutaneous closure of ruptured noncoronary sinus of Valsalva to right atrium causing severe right heart failure, a case report.

In all young and middle-aged patients presenting with symptoms of acute heart failure and new heart murmurs, sinus of Valsalva aneurysm (SVA) rupture should be considered in the differential diagnosis. Most of SVAs rupture into the right side of the heart. Percutaneous closure is a less invasive alternative to surgery. A 25-year-old man presented with shortness of breath New York Heart Association class III of nine months' duration with a progressive course. He had a continuous murmur with maximum intensity over the left sternal border and propagated all over the pericardium. Chest radiographs revealed moderate congestion. Transthoracic and transesophageal echocardiograms with 3D imaging revealed a shunt between the ruptured noncoronary SVA and the right atrium. Percutaneous closure decided; the wire passed from superior vena caca through the ruptured sinus to the aorta. The distal disc of the device deployed in the aorta and the proximal disc in the right atrium. The ruptured aneurysm closed with no more flow to the right atrium. The patient was discharged from the hospital after two days. In conclusion, device closure of ruptured coronary sinus to the right atrium is feasible and safe. Surgery should be reserved for patients with failed device closure. .

Concomitant transcatheter closure of post-myocardial infarction ventricular septal defect and inferior wall aneurysm: case report.

BACKGROUND: The incidence of the post-infarct ventricular septal defect (VSD) is 0.17%. Surgical repair is the definitive treatment and percutaneous closure is an alternative in high-risk patients. We report a case of post-myocardial infarction inferior wall aneurysm associated with a large ventricular septal rupture, with a communication between the aneurysm and right ventricle. Successful percutaneous closure of both the aneurysm and the post-infarct (VSD) was performed using two Amplatzer septal occluder devices. CASE SUMMARY: A 76-year-old man was referred to the clinic 2 weeks after an inferior wall myocardial infarction. A harsh, pansystolic murmur was appreciated on his left parasternal area and across the pericardium. An echocardiogram demonstrated a large, true aneurysm in the mid-cavity inferior wall. The inferior septum was ruptured and dissected, with a large, left-to-right shunt. The patient's coronary angiography revealed a multi-vessel disease. The patient was considered as high surgical risk and thus transcatheter closure of both the post-infarct VSD and inferior wall aneurysm was recommended. We crossed the VSD from the venous side. An Amplatzer septal occluder (18 mm) was deployed to close the VSD completely. We crossed the aneurysm mouth from the arterial side. Another Amplatzer septal occluder (26 mm) was deployed with the large disc inside the aneurysm, sealing it with no more flow. After discharge from the intensive care unit, the patient underwent complete revascularization for his right coronary artery, left main artery, proximal left anterior descending artery, and ramus intermedius. At his 3-month follow-up, the patient remained well with reasonable exercise tolerance. DISCUSSION: Percutaneous closure of a post-infarct VSD and aneurysm is an option for patients whose comorbidities preclude surgical repair and whose septal anatomy is favourable to device placement.

Percutaneous Tricuspid Valve in Failed Annuloplasty Ring and Paravalvular Leak Closure for Mechanical Aortic Valve.

Transcatheter valvular interventions are established as an alternative for surgery in selected patients in symptomatic high surgical risk patients. Tricuspid valve replacement after failed repair ring had limited experience to date. We report this case to highlight the procedure details and results.

Percutaneous retrieval of an embolized gunshot bullet from right ventricle: a case report and review of literature.

BACKGROUND: Gunshots embolizing to the heart is a rare occurrence. We report a case of percutaneous retrieval of a gunshot bullet from the right ventricle (RV) cavity of a 40-year-old lady. To the best of our knowledge, this is the first case to be reported with a right supraclavicular inlet of the bullet and successful percutaneous retrieval using a snare from the RV cavity. CASE SUMMARY: A 40-year-old female patient was referred to our cardiac centre from a general hospital with a gunshot injury 8 days prior. On arrival, she was haemodynamically stable, there was an inlet wound at the right supraclavicular area. Transthoracic echocardiography revealed the bullet in the RV cavity. Under conscious sedation, right femoral vein access succeeded to retrieve the shot from the RV to the groin. The bullet slipped out and resnared from the right internal iliac vein and came out safely from the right femoral vein through the 24-Fr sheath. The vein was closed using a figure of 8 suture. The patient discharged home after 2 days. DISCUSSION: Bullet emboli to the heart are rare, endovascular retrieval of a bullet from the right ventricular cavity is feasible and relatively safe; however, more research is required. Echocardiography during the procedure is strongly recommended to early detect any complications. Accurate use of available tools such as X-ray, echocardiography, computed tomography, and fluoroscopy is a must for precise diagnosis.

Percutaneous Paravalvular Leak Closure Early Post-MV Replacement With Retrieval of Embolized Muscular VSD Device.

This report describes a case of paravalvular leak (PVL) closure 20 days after surgery that was complicated by an embolized 10-mm device in a patient who underwent redo PVL closure after 6 months. Waiting for 3 months postoperatively to close a PVL is recommended. If earlier leak closure is mandatory, accepting a suboptimal result with a moderate residual leak is advised. (Level of Difficulty: Intermediate.).