Percutaneous Edge-to-Edge Valve Interventions: The Role of Surgical Salvage in Complex Percutaneous Techniques.

Hemodynamically significant mitral regurgitation (MR) is associated with major morbidity and mortality. Transcatheter edge-to-edge repair (TEER) is an interventional procedure for MR, which has gained popularity in recent years as an alternative solution to surgical valve repair in high-risk surgical candidates. However, there are no definite guidelines following TEER failures to determine if patients would benefit from a redo TEER or surgical mitral valve (MV) repair. Here, we present one such clinical dilemma. In patients who have failed the TEER of the MV, surgical risk must be determined in conjunction with a multidisciplinary team, as surgical MV replacement may be performed at advanced centers in high-risk patients with good results.

A case report of recurrent spontaneous coronary artery dissection and Takotsubo cardiomyopathy: a treatment dilemma.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome in younger females with no pre-existing history of coronary artery disease. Recurrent SCAD is common after a first episode and can involve the same coronary artery or present as a new dissection unrelated to the initial lesion. Current recommendations advise for a conservative approach in the absence of haemodynamic compromise and flow limitations. Conversely, there are no clear guidelines for the management of early recurrent SCAD. CASE SUMMARY: A 52-year-old woman with history of obesity, asthma, and prediabetes presented with chest pain and electrocardiogram (ECG) showing inferior wall ST-elevation myocardial infarction (STEMI). Coronary angiography revealed proximal right coronary artery (RCA) dissection and distal left anterior descending artery (LAD) dissection, while left ventriculogram showed Takotsubo cardiomyopathy (TC). Angiography revealed no flow limitations so conservative management was pursued. She returned within a couple of days with recurrent chest pain and ECG showing similar findings of inferior STEMI. Repeat angiography confirmed progression of the proximal RCA SCAD with resolution of distal LAD SCAD. Since flow through the distal RCA was still preserved, conservative medical management was continued. She presented a third time for palpitations only and another repeat coronary angiogram showed healing RCA SCAD. DISCUSSION: Management of early recurrent SCAD continues to be a clinical dilemma. In addition, our patient had features of TC which shares a similar clinical risk factor profile with SCAD thus it may be prudent to further investigate for TC in patients presenting with SCAD and have suggestive features of TC on history and echocardiography.

Forme Fruste in Recurring Mid-Ventricular Variant of Takotsubo Cardiomyopathy.

BACKGROUND Takotsubo cardiomyopathy (TC) is characterized as acute left ventricular dysfunction precipitated by intense emotional or physiological stress. The mid-ventricular variant of TC usually has akinesis, with or without ballooning of the mid-ventricular segment, and a hyperdynamic base and apex. Recurrence of the typical and atypical (reversed and mid-ventricular type) forms has been reported in only a very small number of cases. We report a forme fruste presentation of mid-ventricular variant of TC. CASE REPORT A 69-year-old woman with a prior history of stress-induced cardiomyopathy presented with complaint of moderate intensity, persistent, sub-sternal chest discomfort. She reported that her symptoms were similar to those she had during a previous hospitalization in 2015, and this time cited the death of her mother as an inciting stressor. No significant obstructive flow-limiting coronary artery disease was found on cardiac catheterization. However, the left ventriculogram was suggestive of mid-ventricular pattern of TC. Her first symptomatic episode of apparent TC did not reveal completion of the mid-ventricular pattern of the TC variant. The subsequent episode, during this hospitalization, manifested as a completed version of her initial apparent forme fruste of mid-ventricular variant of TC. CONCLUSIONS TC may present in a myriad of clinical forms that must be considered in the evaluation of patients with suspected acute coronary syndromes or cardiomyopathy. Treatment is mainly supportive, and recurrence rates range from 7.7% to 11.4%. To the best of our knowledge, this forme fruste presentation has not been previously reported in recurrent variants of TC.

Ticagrelor-induced Angioedema After Percutaneous Coronary Intervention in a Patient with a History of Ischemic Stroke and Low Response to Clopidogrel: A Rare Dilemma.

Dual antiplatelet therapy (DAPT) is widely recognized as the mainstay of treatment after percutaneous coronary intervention (PCI). Premature discontinuation may pose a risk of in-stent thrombosis, acute myocardial infarction, and death. With the increased usage of antiplatelet agents, increased attention has been drawn to their potential allergic reactions. A 66-year-old male with a history of coronary artery disease and ischemic stroke was admitted with worsening severity angina for cardiac catheterization. He was on dual antiplatelet agents, clopidogrel, and aspirin prior to admission. He had PCI and a drug-eluting stent deployment to the culprit vessel. Due to low responsiveness to clopidogrel, he was started on ticagrelor, as prasugrel was contraindicated due to the history of ischemic stroke. A few hours after ticagrelor initiation, he developed shortness of breath, swelling of the throat and tongue, and was diagnosed with angioedema. He didn't have any prior reported history of allergy to any medications to the contrast medium or heparin. The offending medication, ticagrelor, was discontinued. He was managed with intravenous steroids and antihistamines. After the resolution of angioedema, he was discharged with double the dose of clopidogrel in addition to aspirin. The patient did not have any ischemic symptoms or coronary events for the following six-month period of follow-up. The case highlights a relatively rare side effect of ticagrelor. Health care providers should be vigilant about the angioedema following ticagrelor administration. In our patient, it was effectively managed by discontinuing the offending medication and the administration of steroids and histamine blockers. The recovery was prompt, without any serious untoward effects. The DAPT was changed to clopidogrel, double the conventional dose, in addition to aspirin.

Rapidly progressing mycotic aortic aneurysm masquerading as acute coronary syndrome.

Mycotic aortic aneurysms are rare. The most common cause of a mycotic aortic aneurysm is bacterial seeding in a diseased or injured aortic intima with subsequent arteritis. Because the clinical presentation of mycotic aortic aneurysms can be quite variable, the diagnosis hence can often be quite challenging. We herewith report an interesting case study in which the patient with a mycotic aortic aneurysm presented with the clinical picture masquerading as an acute coronary syndrome. The scenario reiterates the fact that despite the availability of accurate noninvasive imaging techniques, strong clinical suspicion might be imperative for the diagnosis of mycotic aneurysms.

Simultaneous left ventricular and cerebral artery air embolism after computed tomographic-guided transthoracic needle biopsy of the lung.

Air embolism is rare and potentially fatal. Its early recognition and prompt treatment can help to prevent life-threatening sequelae. Herein, we report the case of a 75-year-old man who underwent a computed tomographic-guided lung biopsy of a left-lower-lobe pulmonary nodule. A few minutes after the procedure, he experienced numbness and weakness in his right hand; this lasted for approximately 10 minutes and resolved on its own. Similar symptoms developed in his left hand and subsided in 5 minutes. His speech then became garbled. An urgent computed tomographic scan of the head showed no acute abnormality. Review of the chest computed tomographic scans that were performed during the biopsy revealed 10 cc of air in the left ventricular cavity. The patient was placed on 100% forced inspiratory oxygen and was kept in the Trendelenburg position on his left side. After 4 hours, computed tomography revealed that the air had been absorbed into the circulation. The patient had no residual neurologic deficits. In addition to reporting this case, we discuss possible causes of air embolism and the management of the condition after percutaneous lung biopsy.

Coronary stent malapposition as a result of a post-stenotic aneurysm detected by optical coherence tomography.

Stent malapposition remains an important cause of complications following stent implantation. Stent underexpansion is a frequent cause of this. We describe a case of coronary stent malapposition as a result of a post-stenotic aneurysm. Both the malapposition and its etiology were clearly demonstrated by optical coherence tomography, a novel high-resolution imaging technology.