Acoustic energy and cardiac electrophysiology: Ultrasonic cardiac pacing and novel shockwave ablation catheters.

Sonic shockwaves (SSW) can cause cardiac pacing. This observation first came to notice with the early urologic lithotripters and later with the cumulative use of shockwaves to treat calcified coronary lesions. There have been multiple observations of cardiac pacing and tachyarrhythmias occurring during SSW delivery using the Shockwave Intravascular Lithotripsy system. The underlying mechanism of cardiac cell depolarization by SSW is still under debate. At the end of the last decade, we are witnessing this technology in electrophysiology with the WiSE-CRT system that uses sonic waves to synchronize the ventricles and novel shockwave ablation catheters that can treat tachyarrhythmia foci with minor collateral damage.

Large paradoxical embolus through a patent foramen ovale following arteriovenous graft thrombectomy.

An 86-year-old man with end-stage renal disease on hemodialysis with an arteriovenous fistula in his left upper extremity presented to his hemodialysis session with thrombosis of his arteriovenous fistula. The patient underwent surgical thrombectomy. The patient later showed evidence of peripheral embolization and livedo reticularis. Transthoracic and transesophageal echocardiograms revealed a large thrombus (5 × 2 cm) in the right atrium prolapsing to the left atrium via a patent foramen ovale and another thrombus adherent to the apical wall of the right ventricle. The thrombus in the left atrium was intermittently crossing the mitral valve and entering the left ventricle.

Kounis syndrome following COVID-19 vaccination.

Coronary stent thrombosis is a life-threatening condition induced by multiple factors, including allergic reactions. A 64-year-old man presented with stent thrombosis in the left anterior descending artery and multiple cardiorespiratory arrests immediately after the first dose of the BNT162b1 mRNA vaccine. He underwent emergent percutaneous coronary intervention. Anaphylaxis-induced stent thrombosis, or type III Kounis syndrome, is a highly possible diagnosis. Cardiogenic shock can hide the skin manifestations of anaphylaxis, making this syndrome challenging to diagnose. This clinical case underscores the importance of surveillance for at least 30 minutes after vaccine administration, especially in patients at risk.

Atrial Flutter Following Shockwave Intravascular Lithotripsy During Percutaneous Intervention of Left Anterior Descending Disease.

A 72-year-old woman undergoing percutaneous intervention to a calcified proximal left anterior descending (LAD) coronary artery lesion using Shockwave Intravascular Lithotripsy (S-IVL) developed new atrial flutter. She then returned to sinus rhythm after treatment with amiodarone. S-IVL can cause cardiomyocyte depolarization. We hypothesize that pacing can occur during atrial repolarization, inducing supraventricular tachyarrhythmias and even triggering atrial macro re-entrant circuits. We recommend synchronizing shock wave delivery with R waves on the electrocardiogram to lower the risk of arrhythmias.

Takotsubo cardiomyopathy following a simple partial seizure.

A 67-year-old woman presented to the emergency department for a simple partial seizure of her left upper and lower limbs that lasted for 1 hour and ultimately resolved before her presentation. She had no history of coronary artery disease, and her neurological exam was normal. Five hours later, she complained of chest pain. An electrocardiogram showed ST segment elevation in the lateral leads, and her troponin level was increased. She was diagnosed with takotsubo cardiomyopathy. This case reflects the brain-heart connection and is the first reported case of takotsubo cardiomyopathy following a simple partial seizure.