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Giant cell myocarditis (GCM) is a rare condition with an incompletely understood immune pathogenesis, characterized by inflammatory damage to the myocardium and the presence of multinucleated giant cells on histopathological examination. The frequently fulminant and severe course requires rapid intervention for a correct diagnosis and the initiation of immunosuppressive therapy, which is often life-saving. This article contains information from observational studies and case reports, systematically collected from prestigious publications such as JACC, NEJN, ESC, JCC, Heliyon, and Cureus found in the PubMed and ClinicalTrials.gov databases. Thus, 25 patients diagnosed with giant cell myocarditis between March 2019 and May 2025 were analyzed, with a focus not only on the initial clinical evolution, mortality incidence, and the need for heart transplantation but also on the incidence of major complications such as cardiogenic shock and malignant rhythm and conduction disorders refractory to drug treatment. These parameters were studied according to certain intrinsic factors that cannot be influenced, such as age at onset, gender, and associated pathology of the patient, as well as extrinsic factors that can be influenced, such as the time of diagnosis and the start of immunosuppressive therapy. The results obtained were compared with those in the literature from previous years, considering the limitations of the current study. The selected patients were 13 women (52%) and 12 men (48%), mostly from the US and Japan, aged between 22 and 76 years, with an average age of 44.92 years. An associated autoimmune pathology was found in 40% of patients in this group, and previous cardiovascular pathology in 28%. Only 8% had a history of GCM. The clinical onset of new-onset heart failure, refractory to usual therapy, with progressive dyspnea as the cardinal symptom was found in 12 patients, representing 48% of cases; palpitations as an expression of rhythm or conduction disorders were found in five patients, representing 20%; precordial discomfort to precordial pain accompanied or not by ST-T segment changes was present in four patients, representing 16%; and general signs and symptoms or those of other organs were present in three (12%) cases. The diagnosis was made by histological examination of the biopsy fragment obtained by endomyocardial biopsy or from the myocardial fragment obtained during the implantation of mechanical cardiovascular support devices and, less frequently, on the explanted heart and at autopsy. In terms of progression, of the 25 patients, four (16%) died, four (16%) required heart transplantation, and 16 (64%) had a severe progression with cardiogenic shock, which required mechanical circulatory support in 11 (44%) cases. The outcome was mainly influenced by the early diagnosis and administration of immunosuppressive medication, but also by the age of the patients and associated chronic diseases. Giant cell myocarditis is a serious condition that, in the absence of rapid diagnosis and appropriate immunosuppressive therapy, has a fulminant, often fatal course. Clinical suspicion of giant cell myocarditis remains important in the initial diagnosis. Raising this suspicion, together with modern and improved paraclinical investigations compared to previous years, has led to faster diagnosis and administration of immunosuppressive therapy in this pathology. Histological examination remains the gold standard for final diagnosis, but it should be noted that it may be non-diagnostic. In the face of a strong suspicion of giant cell myocarditis, the best approach is to start immunosuppressive therapy and monitor the patient's progress. Immunosuppressive treatment remains decisive in influencing the evolution of this condition, both through prompt administration and through the adaptation of therapeutic regimens to the evolution of patients. A more detailed understanding of the immune-mediated pathogenesis of GCM and the identification of clinical risk factors for unfavorable short- and long-term outcomes may enable earlier risk stratification and the development of more targeted, individualized therapeutic strategies.

Tumor-associated pulmonary embolism is a rare but potentially fatal cause of cardiac arrest. An 8-year-old girl experienced sudden cardiac arrest and required extracorporeal cardiopulmonary resuscitation (ECPR). Point-of-care ultrasound demonstrated right ventricular dilation with impaired contractility, prompting emergent contrast-enhanced computed tomography (CT). An abdominal tumor and bilateral pulmonary artery occlusion were identified on CT, suggesting tumor-associated pulmonary embolism. Extracorporeal membrane oxygenation support was established; however, the patient developed irreversible hypoxic-ischemic brain injury. A limited biopsy confirmed the diagnosis of Ewing sarcoma. Post-ECPR imaging was crucial in identifying the underlying etiology. This case highlights the importance of comprehensive imaging in cardiac arrest and the ethical challenges of ECPR when cardiac pathology is reversible but the neurological prognosis is poor. Point-of-care ultrasound and CT after ECPR can identify rare reversible causes of cardiac arrest. Tumor-associated pulmonary embolism should be considered in unexplained cases. ECPR decisions require balancing neurological prognosis with the treatability of the underlying pathology.

Coronary artery obstruction by sinus of Valsalva sequestration is a rare, life-threatening complication that occurs during or after the transcatheter aortic valve implantation procedure. An 82-year-old woman with severe symptomatic aortic stenosis underwent uncomplicated transfemoral transcatheter aortic valve implantation with a 23-mm Sapien S3 Ultra valve. Three months later, the patient presented to the hospital for chest pain and was found to have a non-ST elevation myocardial infarction. Diagnostic coronary angiography showed difficult left main coronary engagement despite the presence of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Computed tomography angiography revealed a low-density filling defect within the left coronary sinus consistent with sinus sequestration causing partial left-system obstruction. Surgical revascularization (left internal mammary artery-left anterior descending artery and saphenous vein graft-obtuse marginal) with coronary artery bypass grafting was performed successfully. This case represents the second-only reported case of late sinus sequestration in a native aortic annulus. Risk factors include low coronary heights, narrow sinuses, and shallow sinotubular junction. Electrocardiography-gated cardiac computed tomography imaging remains crucial for diagnosis and for differentiating sinus insufficiency from sequestration. Late coronary obstruction after transcatheter aortic valve implantation may occur due to sinus sequestration even in native valves; prompt computed tomography evaluation is critical for diagnosis and management.

Current guidelines on activity restriction in myocarditis carry significant implications for athletes. We present a case of fulminant myocarditis in a 21-year-old athlete after performance-enhancing drug use. He presented with chest pain and dyspnea with ST-segment elevations on electrocardiogram. Coronary angiography was normal, and cardiac magnetic resonance confirmed myocarditis. His course was complicated by cardiogenic shock requiring inotropic support but improved with diuresis and high-dose corticosteroids. A shared decision-making approach guided a stepwise return-to-exercise strategy based on symptoms, biomarkers, cardiac magnetic resonance, and exercise stress testing. The patient gradually resumed training and returned to unrestricted exercise 3 months after presentation. This case demonstrates the value of individualized, shared decision-making for management of myocarditis in athletes. Individualized, guideline-informed return-to-exercise strategies help balance safety with athlete goals after myocarditis. Screening for performance-enhancing drug exposure is essential because these agents may represent an underrecognized contributor to myocarditis.

Regular physical activity confers substantial cardiovascular benefits, yet it may in rare cases precipitate sudden cardiac arrest (SCA) or sudden cardiac death (SCD) in predisposed individuals. Although preventive frameworks have largely targeted competitive athletes, the rapidly expanding population of recreational participants remains insufficiently addressed. Recreational athletes have a low but significant incidence of SCA/SCD (0.02 to 13 per 100,000 person-years). Coronary artery disease is most common in middle-aged individuals, while inherited cardiomyopathies account for fewer cases. Contemporary preparticipation evaluation for recreational athletes has shifted from universal electrocardiogram-based screening to a risk-stratified, individualized approach emphasizing cardiovascular assessment, symptom recognition, and selective testing based on exercise intensity. Digital and wearable technologies are under evaluation to support symptom-triggered assessment and cardiac rhythm documentation; however, their effectiveness for preventing sports-related SCA/SCD and their optimal clinical workflows remain unproven. Risk-based, symptom-driven preparticipation evaluation enhances safety, reduces unnecessary testing, and promotes lifelong participation in recreational sports.

Lower extremity swelling is a common clinical presentation with a broad and overlapping differential diagnosis. Although recurrent cellulitis may be commonly seen in such cases, the coexistence of migratory superficial venous thrombophlebitis and chronic edema is uncommon, particularly in the absence of varicose veins. Delayed complications of cosmetic silicone fillers are increasingly recognized; however, vascular manifestations remain rare. We report a 39-year-old woman with a 3-year history of recurrent bilateral lower extremity edema, cellulitis, and migratory superficial thrombophlebitis. Extensive evaluation excluded infectious, lymphatic, cardiac, renal, hepatic, malignant, autoimmune, and hypercoagulable causes. Duplex ultrasonography revealed "snowstorm" echogenicity, and magnetic resonance imaging confirmed migrated silicone deposits in the lower extremities. Surgical removal resulted in complete symptom resolution. Delayed silicone migration can induce chronic inflammatory and vascular complications, posing a diagnostic challenge and mimicking recurrent cellulitis. This case highlights the multifactorial complexity of chronic lower extremity swelling and the importance of multidisciplinary evaluation.

A 39-year-old man presented with hematemesis, bloody diarrhea, and dyspnea. The electrocardiogram revealed electrical alternans, and the focused echography revealed a severe circumferential pericardial effusion. Despite this classic electrocardiogram finding, the patient remained normotensive, without the typical clinical triad of tamponade, reflecting the slow progression of tamponade physiology. Pericardiocentesis drained 1,250 mL of hemorrhagic fluid, with immediate resolution of electrical alternans. Cytology confirmed metastatic pulmonary carcinoma as the underlying etiology. Electrical alternans is highly suggestive of a large pericardial effusion but does not invariably indicate tamponade. Tamponade does not invariably present with the typical clinical triad of hypotension, jugular venous distension, and muffled heart sounds, particularly in slowly progressive cases. In patients without a history of trauma, hemorrhagic pericardial effusion strongly suggests malignancy and prompts further diagnostic evaluation, irrespective of patient age.

Congenital anomalies of the great vessels can coexist in a significant proportion of pediatric patients, but a delayed diagnosis can present with fulminant heart failure later in life. A 12-year-old boy with failure to thrive and recurrent chest infections was referred to the cardiac outpatient department for cardiomegaly noted on chest x-ray. Echocardiography revealed a patent ductus arteriosus (PDA) and coarctation of the aorta (CoA) with impaired left ventricular function. Both lesions were successfully corrected through percutaneous intervention. This case integrates current evidence favoring stent implantation for correction of native CoA. It also demonstrates successful percutaneous management of combined CoA and PDA in a critically ill nonsurgical patient, highlighting adaptive decision-making and safe handling of stent embolization. Congenital defects of the great vessels with compromised hemodynamics demand prompt action. Careful procedural adaptation and structured follow-up are essential for optimal recovery and long-term outcomes.

Left ventricular (LV) pseudoaneurysm is a rare complication of myocardial infarction (MI) that may present with cardiogenic shock. A 61-year-old man who had experienced MI 1 month prior presented with recurrent cardiogenic shock. Transthoracic echocardiography and cardiac magnetic resonance imaging revealed a large apical LV pseudoaneurysm compressing the right ventricle. Given prohibitive surgical risk, the patient was supported with prolonged Impella 5.5 therapy while awaiting heart transplantation. He remained hemodynamically stable throughout support and ultimately underwent successful heart transplantation. Management of LV pseudoaneurysm typically involves surgical repair or conservative surveillance; however, literature describing prolonged mechanical circulatory support in this population remains sparse. This case demonstrates the feasibility of extended Impella support as a bridge to transplantation in a patient with post-MI LV pseudoaneurysm and cardiogenic shock. Impella-assisted LV unloading may mitigate aneurysmal wall stress, serving as a temporizing strategy in select high-risk patients. Prolonged Impella support may represent a viable bridge to heart transplantation in patients with LV pseudoaneurysm and cardiogenic shock who are unsuitable for surgical repair or durable left ventricular assist device therapy.

Anomalous aortic origin of a coronary artery (AAOCA) is an uncommon congenital abnormality associated with sudden cardiac death (SCD), particularly in young athletes. We present a case of a 4-time Olympic medalist track cyclist who experienced sporadic anginal symptoms during maximal efforts and was found to have an anomalous aortic origin of the right coronary artery (AAORCA). The athlete had a successful surgical reimplantation and returned to elite sport. Management decisions are complex: The investigations used to confirm ischemia and to stratify SCD risk are imperfect, and the surgical treatment carries potential risk. Furthermore, the impact of a sternotomy and coronary reimplantation on competitive sports performance has not been detailed. In the absence of definitive ischemic evidence from history or diagnostic tests, diagnosing high-risk AAOCA can be challenging. The decision to pursue surgical intervention should carefully consider the low rate of SCD and the risk/impact of surgery.

Cardiac metastases can trigger malignant ventricular arrhythmias and limit transvenous therapy with right ventricular (RV) involvement. A 67-year-old patient with metastatic clear-cell renal cell carcinoma and RV metastasis developed ventricular fibrillation during ambulance transport after chest pain and a hypertensive crisis. Coronary angiography revealed severe 3-vessel coronary artery disease, followed by high-risk percutaneous coronary intervention. For secondary prevention, a subcutaneous implantable cardioverter-defibrillator (S-ICD) was implanted because RV lead placement was considered unsafe. Subsequent syncope due to sinus arrest led to discontinuation of beta-blocker therapy and was followed by recurrent ventricular tachycardia treated with 6 appropriate S-ICD shocks. Implantation of a dual-chamber pacemaker with a coronary sinus ventricular lead enabled resumption of beta-blocker therapy, with no further events before discharge. In RV tumor involvement where transvenous leads may be unsafe, this case highlights a hybrid strategy providing defibrillation and bradycardia support. S-ICD plus coronary sinus ventricular pacing is a practical option when transvenous RV lead placement is not feasible.

Primary native aortic root thrombus is a rare complication after single-ventricle palliation. We describe a case of a pediatric patient with a single ventricle who developed a native aortic root thrombus and coronary artery thrombi after undergoing Fontan palliation and following COVID-19 infection. This report describes the transcatheter techniques employed to manage the thrombi, as well as the management of an unexpected complication involving thrombus embolization to the left common iliac artery. Native aortic root thrombus and coronary artery thrombi in single-ventricle patients are potentially fatal events that require urgent intervention. Transcatheter procedures for thrombus resolution are inherently high risk and demand meticulous risk-reduction strategies. Risk of thrombotic complications may be higher in Fontan patients with COVID-19 infection. Timely use of high-risk procedural strategies in a single-ventricle patient with intracardiac and coronary artery thrombosis may be necessary to avoid lethal complications.

Iatrogenic atrial septal defects (iASDs) after mitral transcatheter edge-to-edge repair (M-TEER) are generally benign. However, advanced atrial remodeling can trigger catastrophic mechanical failure via rapid morphologic expansion. An 84-year-old woman with atrial fibrillation and diastolic dysfunction underwent M-TEER. Despite a stable intraprocedural iASD, she developed cardiogenic shock within 3 hours. Three-dimensional transesophageal echocardiography documented hyperacute doubling of the defect area. The mechanism was direct tricuspid regurgitation (TR)-jet impingement on the thinned septum, reflecting severely impaired left atrial compliance. Emergency iASD closure using "stationary deployment" prevented further traumatic tearing, resulting in immediate hemodynamic stabilization. This case identifies TR-jet impingement as a predictor of acute iASD expansion. Transesophageal echocardiography is essential for monitoring this mechanical vicious cycle. Impaired atrial compliance and TR-jet impingement can cause rapid iASD enlargement after M-TEER. Prompt recognition and closure are vital for managing this life-threatening complication.

Conduction disturbances are common after transcatheter aortic valve replacement (TAVR), whereas alternating bundle branch block reflects advanced conduction system disease. A 76-year-old man underwent TAVR with an initially normal postprocedural electrocardiogram (ECG). Six days later, he presented with syncope. The admission ECG demonstrated wide QRS complexes. A retrospective review of early 12-lead Holter monitoring revealed alternating bundle branch block. Conduction system pacing was performed. This case illustrates how dynamic conduction instability after TAVR may remain undetected on a resting ECG and require extended rhythm assessment for early recognition. Extended rhythm surveillance after TAVR can detect transient or intermittent conduction abnormalities not apparent on a standard ECG. Early identification of such changes may enable timely electrophysiological evaluation and appropriate device therapy.

Primary cardiac lymphoma (PCL) is an exceptionally rare cardiac malignancy with heterogeneous presentations and variable multimodality imaging features. A 60-year-old man presented with heart failure and complete atrioventricular block. Echocardiography revealed a massive infiltrative right atrial mass with pericardial effusion. The mass demonstrated malignant features on cross-sectional imaging. As biopsy was considered high risk and a definitive pathologic diagnosis was lacking, radiotherapy was initiated in the setting of a structural oncologic emergency to maintain clinical stability, and extracardiac biopsy ultimately established primary cardiac diffuse large B-cell lymphoma. The patient received dose-adjusted R-EPOCH chemotherapy, achieving complete metabolic response after 3 cycles. PCL and cardiac angiosarcoma can share overlapping imaging features that may delay diagnosis; early histopathological confirmation is pivotal to guide therapy. In selected cases, radiotherapy can provide temporary stabilization until tissue diagnosis is established. PCL requires individualized management in the absence of established guidelines.

Retrograde valve crossing during valve-in-valve transcatheter aortic valve replacement (ViV TAVR) may fail despite modern delivery systems. A 67-year-old man with a degenerated 27-mm Magna Ease bioprosthesis and unfavorable aortic geometry (kinked ascending aorta at a prior surgical graft site) underwent ViV TAVR, where retrograde valve crossing failed despite multiple stiff guidewires and snare traction alone. Successful delivery of a 29-mm Evolut FX+ was ultimately achieved by combining gooseneck-snare traction for coaxial realignment with a partially inflated Tyshak buddy balloon acting as a mechanical ramp across the surgical valve frame. This case demonstrates a structured, stepwise approach to managing failed valve crossing in ViV TAVR, highlighting the mechanical roles of snare traction and balloon-mediated coaxial alignment. A combined snare and buddy-balloon strategy can facilitate valve delivery when conventional retrograde crossing fails during ViV TAVR.

Aortic root abscesses represent severe complications of infective endocarditis, rarely resulting in fistula formation. Serial imaging is critical for early detection of disease progression and complications. A 67-year-old man presented with atrial fibrillation and Streptococcus salivarius bacteremia. Echocardiography revealed aortic insufficiency with subvalvular vegetation. Despite intravenous antibiotics, he developed respiratory distress. Repeat echocardiography showed an aortic root abscess with subaortic-left atrial fistula requiring urgent surgical repair. Despite early diagnosis and guideline therapy, the patient experienced clinical deterioration. This case is notable for the progression of uncomplicated aortic valve vegetations to an aortic root abscess with subaortic-left atrial fistula, noting the role of consistent imaging to identify complications and the need for surgical interventions. Early diagnosis, multidisciplinary management, and consistent monitoring are critical in infective endocarditis. Surgery remains the gold standard for abscess and fistula repair, with percutaneous methods emerging as a less-invasive option.

Baroreflex activation therapy may ameliorate autonomic imbalance in HFrEF; however, its effects on systemic inflammation and autonomic indices remain unknown. Seven patients with advanced HFrEF underwent BAT implantation. Three cases are presented in detail, illustrating distinct response patterns: clinical improvement, robust parasympathetic restoration, and anti-inflammatory response. Following BAT, patients demonstrated improvements in quality of life, heart rate variability (HRV), and inflammatory biomarkers. These preliminary findings suggest BAT may exert therapeutic benefits through both autonomic restoration and anti-inflammatory modulation.

Transseptal puncture is essential for transcatheter edge-to-edge repair (TEER) but is challenging in patients with previously implanted septal closure devices. A 79-year-old woman with prior transcatheter closure of both a patent foramen ovale and an atrial septal defect developed severe degenerative mitral regurgitation (MR). Transseptal access was considered difficult due to the 2 closure devices. However, chronic MR caused enlargement of the left atrium and interatrial septum, creating a narrow but feasible puncture zone. Using the VersaCross system, transseptal puncture was achieved, allowing TEER completion. Left atrial and septal enlargement from MR can create puncturable spaces despite prior septal closure devices. The VersaCross system enables controlled septal crossing, expanding the feasibility of TEER in anatomically complex patients. Chronic atrial remodeling secondary to severe MR may facilitate transseptal access after septal closure, and the VersaCross system can support safe puncture in challenging TEER cases.