Contemporary Management of Patent Foramen Ovale: A Multinational Survey on Cardiologists' Perspective.

OBJECTIVES: The purpose of our survey is to analyze the clinical approach used by interventional and imaging cardiologists to diagnose, treat, and follow-up patients with PFO-related left circulation thromboembolism in different parts of the world with particular emphasis on adherence to current guidelines. BACKGROUND: Firm guidelines do not cover many aspects of PFO-related patient care. Consequently, very disparate approaches exist among clinicians in the real-world. METHODS: A 24-item electronic questionnaire was sent directly to experienced cardiology specialists practicing at consultant/attending positions directly involved in PFO closure management in the United States, United Kingdom, Gulf countries, and other countries. There were no unanswered questions. Responses were recorded between October 2019 and July 2020. RESULTS: Seventy-one responses were obtained: 31 from the UK, 19 from the US, 16 from Gulf countries, 2 from Poland, and 1 response from Australia, Italy, and Switzerland. The overall response rate was 76%. Significant differences between regions were noted in the duration of ECG monitoring during the diagnostic process, PFO closure for left circulation thromboembolism other than stroke/transient ischemic attack, and intraoperative use of intracardiac echocardiography. A similar pattern was noted in the lack of routine screening for thrombophilia and the use of the long-term single antiplatelet therapy. CONCLUSIONS: The study shows a vast spectrum of opinions on the optimal approach to PFO closure with significant differences between the US, UK, and Gulf countries. The results stress the need for systematic, high-quality data on the diagnostic work-up and follow-up strategies to inform the standardized approach.

Transcatheter mitral valve implantation using TENDYNE valve for the treatment of residual severe mitral regurgitation post-transcatheter mitral valve edge-to-edge repair: a case report.

Background: Functional mitral regurgitation (MR) in patients with heart failure can be treated medically or by transcatheter edge-to-edge repair (TEER) if medical therapy fails. Patients who are not suitable for TEER or surgical intervention might benefit from transcatheter mitral valve implantation using the TENDYNE valve. Case summary: A 58-year-old male with a history of heart failure was admitted frequently with acute heart failure and functional MR, treated medically without significant improvement. He underwent mitral TEER therapy using MitraClip. A few months later, he was admitted with acute decompensated heart failure. Echocardiography showed severe MR with a detached clip from the posterior leaflet. He underwent redo mitral TEER using MitraClip as an option for treating single leaflet device detachment. He was readmitted with the same symptoms and his echocardiography showed detachment of both clips from the posterior leaflet. The patient underwent TMVI using the TENDYNE valve being not suitable for another attempt of mitral TEER. On follow-up, he was asymptomatic and echocardiography showed normal functioning mitral bioprosthesis with a mean gradient of 4 mm/Hg and no paravalvular leak. Discussion: Transcatheter mitral valve implantation using TENDYNE valve is an option for treating patients with functional MR and detached MitraClips.

Transcatheter mitral valve implantation using the Tendyne valve in a patient with prior transcatheter aortic valve implantation: a case report.

Background: The presence of aortic and mitral disease in a patient who is not a suitable candidate for surgical correction poses significant challenges in the diagnostic workup as well as management plans. Percutaneous treatment can be staged to fix the aortic valve with transcatheter aortic valve implantation (TAVI) as a first step, followed by reassessment and percutaneous correction of mitral regurgitation (MR). Case summary: A 65-year-old female with multiple co-morbidities presented with acute coronary syndrome and heart failure. She was diagnosed with three-vessel coronary artery disease and degenerative low-flow low-gradient severe aortic stenosis, along with severe degenerative MR with a left ventricular ejection fraction of 35%. Because of the high surgical risk, she underwent multi-vessel percutaneous coronary intervention with stenting. Transcatheter aortic valve implantation was done as a staged procedure, which partially improved her symptoms. Mitral regurgitation was not suitable for percutaneous mitral valve edge-to-edge repair. After a discussion by the heart team, she underwent transcatheter mitral valve implantation, for which the Tendyne mitral valve (Tendyne™; Abbott) was used through a transapical approach. There was no paravalvular leak, and the mean gradient across the valve was 2 mmHg. She was symptomatically better at follow-up and an echocardiogram showed a normally functioning aortic valve and Tendyne mitral valves. Discussion: Transapical transcatheter mitral valve implantation using the Tendyne valve is a feasible option for patients with prior TAVI. This can be considered an alternative treatment for MR in patients who are not suitable for edge-to-edge mitral repair.

Giant coronary artery aneurysm associated with familial retinal artery macroaneurysm: a case report.

Background: The term 'Giant' coronary aneurysm is usually defined as any coronary aneurysm more than 8 mm in maximum diameter. The form of familial retinal arterial macroaneurysms (FRAMs) is a rare autosomal recessive disease that is described by arterial aneurysm formation in the retina. Here, we report an association of coronary artery aneurysms with FRAM in a young male who presented with the acute coronary syndrome. Case summary: A 31-year-old male smoker presented to the emergency department with atypical chest pain for 5 days. Blood investigations showed raised troponin enzymes. Review of his past medical history revealed decreased vision in the left eye, starting at the age of 10 years which progressed to blindness. He was diagnosed to have IGFBP7 mutation which causes eye manifestations in the form of FRAM. Fundoscopy showed bleeding retinal artery macroaneurysms in the right retina and sub-retinal gliosis suggesting laser treatment for the prior retinal arterial aneurysm. Coronary angiogram revealed a large aneurysm in the proximal segment of the left anterior descending (LAD) artery. Cardiac computed tomography scan with contrast was done which showed a 2.28 × 1.64 cm coronary aneurysm at the proximal segment of the LAD artery with peripheral calcification with a narrow neck of about 0.6 cm. After the heart team discussion, he underwent surgical ligation of the LAD and coronary aneurysm with implantation of the saphenous venous graft to distal LAD. Discussion: Coronary artery aneurysms can be a part of multisystem diseases like FRAM. The management should be individualized based on symptoms at presentation, size of coronary aneurysms, and local expertise.

A Case Report of Giant Ascending Aortic Aneurysm: Role of Multimodality Imaging.

Giant ascending aortic aneurysm (AscAA >10 cm) is an uncommon entity with a variable presentation. The size of the aneurysm, rapid expansion, and calcification are associated with an increased risk of rupture. Atherosclerosis is the most common etiology of aortic aneurysm in the elderly population. Multimodality imaging can be wisely used for diagnosis, risk stratification, and follow-up. We herein report a case of successfully repaired giant calcified AscAA with a maximum diameter of 10 cm. We also provide a brief discussion on the role of multimodality imaging.

Non-invasive Cardiac Imaging During the Coronavirus Disease 2019 (COVID-19) Pandemic: A Statement from the Cardiac Imaging Working Group of the Saudi Heart Association.

COVID-19 pandemic has led to major changes in the delivery of medical care around the globe. Many investigations and elective procedures had to be rescheduled to decrease the risk of spreading the infection. Non-invasive cardiac imaging studies are requested to guide appropriate cardiac care in a variety of urgent, semi-urgent, and elective procedures. This position statement of the Cardiac Imaging Working Group of the Saudi Heart Association provides guidance into the protection of healthcare personnel, assessment of the indications of the imaging studies, and highlights consideration before, during, and after the study.

Obstructive bioprosthetic mitral valve thrombus: management options?

Bioprosthetic valve thrombosis is an extremely rare event, therefore, long-term anticoagulation can be avoided. There is limited experience in the diagnosis and treatment of such a situation. We present the case of a patient with a porcine mitral bioprosthesis who presented with acute pulmonary edema, likely secondary to obstructive valve thrombosis. A favorable outcome was observed after conservative anticoagulant treatment.

Surgical approach to huge cardiac hydatid cyst of the interventricular septum.

Cardiac echinococcosis is a rare but potentially fatal condition. The cysts are frequently located in the left or right ventricle; involvement of the interventricular septum is exceptional. We report the case of a 29-year-old woman who presented with palpitation and generalized T-wave inversion on her electrocardiogram. Transthoracic echocardiography, magnetic resonance imaging, and contrast-enhanced computed tomography showed a huge hydatid cyst originating from the interventricular septum. She was started on albendazole tablets, and surgical excision on cardiopulmonary bypass was carried out after 5 days of treatment. She had an uneventful postoperative recovery, and was continued on albendazole tablets for 4 months.