Fungal infective endocarditis is rare but highly lethal, with limited evidence to guide management. Diagnosis is often delayed, source control may be difficult, and effective antifungal options may be limited. We describe 8 patients with fungal infective endocarditis, ranging from a 40-day-old infant to a 56-year-old adult. Organisms included Candida parapsilosis in 3 patients, multidrug-resistant Candida auris, Candida glabrata, Candida albicans, Fusarium species, and Apiosporium mycotoxinivorans. Infection involved native valves, prosthetic valves, aortic root grafts, and intracardiac device leads. Five patients underwent definitive source control. In 1 patient, fungal prosthetic valve endocarditis initially mimicked prosthetic valve thrombosis, leading to thrombolysis before infection was recognized. In-hospital mortality was 50%. Outcomes appeared to depend on early recognition, antifungal susceptibility, and feasibility of source control. These cases emphasize the need for microbiological suspicion, multimodality imaging, and multidisciplinary decision-making in fungal infective endocarditis.
ST-segment elevation on an electrocardiogram (ECG) is a hallmark of acute ST-segment elevation myocardial infarction (STEMI). However, thoracic malignancies can produce electrocardiographic patterns identical to acute ischemia through direct myocardial invasion or extrinsic compression, creating a significant diagnostic dilemma. We present 2 patients with primary lung cancer who exhibited ECG findings strongly mimicking acute STEMI. Case 1 involves a 70-year-old man presenting with acute chest pain. His ECG demonstrated anterolateral ST-segment elevation with diffuse PR depression. Coronary angiography revealed nonobstructive disease with mildly elevated troponin. Multimodality imaging identified a hypermetabolic mass externally compressing the anterolateral myocardium. Case 2 describes an 80-year-old man presenting with dizziness and ST-segment elevation in leads V1 to V3. Imaging revealed a large thoracic mass compressing the right ventricular outflow tract and left pulmonary artery without coronary occlusion. After appropriate oncological treatment, the patient demonstrated partial tumor regression on follow-up positron emission tomography-computed tomography, which correlated with the complete resolution of the initial ECG abnormalities. These cases demonstrate that ST-segment elevation in patients with advanced malignancy may arise from myocardial tumor invasion or extrinsic compression rather than acute coronary thrombosis, underscoring the importance of careful correlation between clinical findings and multimodality cardiac imaging.
Physiologic atrial pacing at the Bachmann's bundle region may improve biatrial synchrony, but accurate implantation of atrial leadless pacemakers remains challenging. We report the first case of artificial intelligence (AI)-enabled electrocardiogram (ECG) mapping-guided implantation of an atrial leadless pacemaker in the Bachmann's bundle region. An 86-year-old woman with symptomatic tachy-brady syndrome and bilateral subclavian venous occlusion underwent implantation of an atrial leadless pacemaker guided by intracardiac echocardiography and AI-enabled ECG mapping. Mapping demonstrated earliest activation in the anterior-superior left atrium, consistent with Bachmann's-bundle-region pacing. Implantation was successful without procedural complications. This case demonstrates the feasibility of AI-enabled mapping to facilitate physiologic atrial leadless pacing. First reported use of AI-enabled ECG mapping to guide Bachmann's-bundle-region atrial leadless pacemaker implantation. AI-enabled ECG mapping may enable precise targeting of the Bachmann's bundle region to achieve individualized physiologic atrial pacing.
Heparin-induced thrombocytopenia (HIT) is a prothrombotic immune-mediated complication that complicates cardiac surgery because cardiopulmonary bypass requires systemic heparinization. We report a case of acute severe mitral regurgitation (MR) complicated by clinically suspected HIT, in which conventional surgical repair was not feasible. A 59-year-old man presented with acute severe MR due to chordal rupture and developed cardiogenic shock requiring intra-aortic balloon pump support. While awaiting surgery, his platelet count decreased from 262,000/μL to 23,000/μL. The 4Ts score was 6, and PF4/heparin antibody testing was positive, supporting clinically suspected HIT. Because cardiopulmonary bypass requiring systemic heparinization was considered prohibitively high risk, M-TEER was performed under continuous argatroban infusion. Two PASCAL Ace implants were successfully deployed, reducing MR from severe to trivial without thrombotic or bleeding complications. The patient recovered rapidly with immediate IABP removal and early extubation. This case demonstrates that M-TEER under argatroban anticoagulation can be a feasible alternative when conventional surgery is precluded by suspected HIT and the anticipated challenges of anticoagulation during cardiopulmonary bypass. M-TEER under argatroban may serve as a rescue strategy for critically ill patients with acute severe MR and suspected HIT when surgical management is not feasible.
Severely calcified coronary lesions complicate percutaneous coronary intervention (PCI) by impairing device delivery and stent expansion, often necessitating advanced plaque-modification strategies. Three patients with calcified left anterior descending artery disease underwent intravascular ultrasound (IVUS)-guided PCI with orbital atherectomy (OA), intravascular lithotripsy (IVL), and balloon dilation. In patient 1, a balloon-uncrossable lesion was treated with OA, followed by IVL when balloon dog-boning suggested residual deep calcium. In patient 2, OA-related dissection and slow flow were managed with provisional stenting, followed by IVL for persistent proximal calcium-related resistance. In patient 3, Ellis type III coronary perforation during postatherectomy balloon dilation was sealed with a covered stent, followed by IVL for proximal lesion preparation. Angiographic and IVUS assessments showed stent expansion and apposition in patients, with no adverse events during the 5-month follow-up. These cases illustrate the feasibility of an IVUS-guided escalation strategy for resistant calcified coronary lesions. This case series suggests that a stepwise, IVUS-guided multimodality strategy may facilitate successful outcomes and aid optimal stent deployment in complex calcified PCI.
Wellens' sign is a high-risk electrocardiogram (ECG) pattern associated with proximal left anterior descending artery stenoses and high risk of major adverse cardiovascular events. A man with transient chest pain remained asymptomatic including with exertion for 48 hours. His friend performs a home 12-lead ECG using a novel, artificial intelligence-enabled device that showed a classic Wellens' Sign Type A, and the man went to a hospital and subsequently received 2 stents in his proximal left anterior descending artery. The Kardia12L is a Food and Drug Administration-cleared, pocket-sized ECG device that generates an interpreted 12-lead ECG. Devices like Kardia 12L can lead to diagnosis of cardiovascular disease from home and improve outcomes. This case highlights the utilization of novel technology to facilitate accurate diagnosis. This case illustrates Wellens' Type A Sign and Syndrome in an asymptomatic patient with a history of chest pain. New technology enables the recording of a diagnostic ECG in high-risk patients anywhere.
Herbal supplements marketed for cognitive and cardiovascular enhancement are widely used, yet safety data remain scarce. Supplement-associated cardiomyopathy is a rare but life-threatening complication that remains underrecognized. A 39-year-old previously healthy man developed progressive dyspnea, and bilateral leg edema 2 months after initiating a multi-ingredient herbal supplement. Echocardiography revealed severe left ventricular dysfunction (ejection fraction 10%-15%). Comprehensive evaluation excluded ischemic, infectious, autoimmune, infiltrative, and toxicologic causes. Despite maximal guideline-directed therapy, the patient required orthotopic heart transplantation. Genetic testing was not obtained, representing a workup limitation. Multiple supplement ingredients lacked published cardiovascular safety data. The temporal association between supplement initiation and rapid progression to biventricular failure, in the absence of any identifiable alternative etiology, raises concern for supplement-associated cardiotoxicity. Clinicians should obtain thorough supplement histories in unexplained heart failure. This case underscores the cardiotoxic risk of multi-ingredient herbal supplements and the need for heightened clinical vigilance.
An acute pulmonary hypertension (PH) crisis causes dynamic electrocardiographic (ECG) changes, but complete post-therapy normalization-especially in post-transplant thrombotic microangiopathy (TMA) patients-is rarely documented. A 53-year-old man with acute myeloid leukemia after allogeneic hematopoietic stem cell transplantation presented with dyspnea. Right heart catheterization confirmed an acute pulmonary hypertension crisis (mean pulmonary arterial pressure: 52 mm Hg) secondary to thrombotic microangiopathy. Treatment with inhaled nitric oxide and treprostinil led to improvement. Follow-up echocardiography showed normalized pulmonary arterial pressure (35 mm Hg), resolution of ECG abnormalities (including a myocardial infarction pattern in the right precordial leads), and no PH recurrence. This case highlights TMA as a rare cause of reversible, vasoreactive PH after hematopoietic stem cell transplantation and documents the full ECG evolution during PH crisis and recovery. ECG monitoring is essential for diagnosing and tracking acute PH crises in transplant patients. Post-transplant TMA can cause reversible PH, requiring prompt hemodynamic assessment and targeted therapy.
Dynamic ischemic mitral regurgitation (IMR), provoked by ischemia or exercise, may escape detection at rest and is associated with adverse outcomes. A 65-year-old man with ischemic cardiomyopathy (left ventricular ejection fraction, 20%) and recurrent left circumflex in-stent restenosis refractory to multiple interventions presented with progressive dyspnea and chest pain. Resting filling pressures were mildly abnormal, though symptoms remained out of proportion to findings. During balloon angioplasty of the left circumflex, transient ischemia provoked large V waves on the pulmonary catheter wedge pressure tracing; simultaneous echocardiography confirmed severe MR that resolved on deflation of the intracoronary balloon. Stress echocardiography corroborated exercise-induced severe MR. Despite revascularization and medical therapy optimization, symptoms persisted, and mitral transcatheter edge-to-edge repair (M-TEER) was performed with successful resolution of symptoms. Dynamic IMR may be underdiagnosed when diagnostic studies are performed at rest. This case demonstrates concordant invasive and noninvasive provocative strategies for diagnosis, with M-TEER for refractory symptoms. Dynamic IMR requires a high index of suspicion and provocative multimodality testing. M-TEER may benefit patients with severe IMR refractory to revascularization and optimized medical therapy.
Trifascicular block can progress to complete atrioventricular (AV) block and sudden cardiac death. Its clinical and electrocardiographic presentation is usually dramatic but may occasionally be subtle and intermittent, making recognition difficult. A 45-year-old man presented with exertional dyspnea and no structural heart disease. Surface electrocardiography revealed right bundle branch block with alternating left anterior and left posterior fascicular block and intermittent AV conduction delay, consistent with Rosenbaum syndrome and advanced His-Purkinje disease at high risk of progression to complete AV block. Anticipating this risk, a dual-chamber pacemaker was implanted using left bundle branch area pacing. At follow-up, symptoms resolved and ventricular activation normalized. Rosenbaum syndrome is a rare, potentially life-threatening conduction disorder that may present insidiously. To our knowledge, this is the first report of left bundle branch area pacing used to treat it, illustrating the potential of physiological pacing to restore conduction and prevent adverse outcomes. Trifascicular blocks carry a high risk of adverse outcomes. In rare cases, they present insidiously and intermittently. Physiological pacing via the left bundle branch area appears to be an appropriate therapeutic strategy in Rosenbaum syndrome.
Cor triatriatum sinister (CTS) is a rare congenital anomaly, infrequently identified in asymptomatic adults. A 64-year-old man presented with asymptomatic atrial flutter detected on routine electrocardiogram. Rate control was suboptimal, and because of unknown arrhythmia duration, transesophageal echocardiography (TEE) was performed before cardioversion. TEE excluded intracardiac thrombus and incidentally revealed a left atrial membrane. Cardiac magnetic resonance imaging confirmed nonobstructive CTS. The patient underwent successful TEE-guided electrical cardioversion and was discharged on anticoagulation. CTS has been associated with atrial arrhythmia, although causality remains uncertain, particularly when arrhythmia originates from the right atrium. This case highlights the role of multimodality imaging in identifying incidental congenital anomalies and guiding safe management. Careful atrial evaluation during TEE may reveal incidental CTS. Distinguishing associations from causation is essential for appropriate management.
Saphenous vein graft (SVG) aneurysms are a rare but potentially life-threatening complication after coronary artery bypass grafting, with an estimated incidence of 0.07%. Presentations range from incidental imaging findings to severe complications, including rupture, myocardial infarction, or compression of mediastinal structures. A 65-year-old man with prior 3-vessel coronary artery bypass grafting presented with progressively worsening substernal chest pressure. Coronary angiography and computed tomography angiography identified a 71 × 45-mm saccular pseudoaneurysm of the SVG. Following heart team discussion, the patient underwent intravascular ultrasound-guided percutaneous coronary intervention with sequential covered stent deployment, resulting in complete exclusion of the pseudoaneurysm. Optimal management remains uncertain because of limited clinical data. This case emphasizes the feasibility of intravascular ultrasound-guided covered stent placement; to our knowledge, this is the largest reported de novo SVG pseudoaneurysm treated with this approach. In selected patients, covered stent placement offers a safe, minimally invasive alternative to surgery while preserving graft patency.
We present a case of short QT syndrome (SQTS) initially manifesting as atrial fibrillation (AF) and degenerating to polymorphic ventricular tachycardia (PMVT), successfully managed with quinidine. A 66-year-old man presented with palpitations and was found to be in AF with a QTc interval of 335 ms. He developed PMVT with hemodynamic collapse, requiring 3 successive defibrillation shocks. Refractory to amiodarone and lidocaine, he met Gollob criteria for SQTS. He was successfully managed with oral quinidine, resulting in QTc normalization to 430 ms. A secondary prevention implantable cardioverter-defibrillator was implanted. Genetic testing was unrevealing. He remained arrhythmia-free at 6 months. With an estimated prevalence of 0.02%, SQTS is frequently underrecognized. This case underscores the specific efficacy of quinidine in normalizing the QT interval and suppressing malignant ventricular arrhythmias in SQTS. Prompt recognition of a short QTc interval is crucial in patients presenting with PMVT, as diagnosis directs targeted pharmacologic therapy with quinidine.
Epicardial access for ventricular tachycardia (VT) ablation may be limited in patients with previous cardiac surgery. Substrate depth is a key determinant of ablation success, and deep intramural circuits may not be adequately targeted with conventional endocardial radiofrequency (RF) ablation alone. Recurrent VT in a patient with previous cardiac bypass surgery and failed endocardial RF ablation. Mapping demonstrated a midmyocardial isthmus, successfully targeted with VT interruption by using focal combined endocardial pulsed field (PF) and RF ablation. Emerging in vivo evidence suggests that successive PF applications, as well as combined RF-PF ablation, can enhance lesion depth. This case demonstrates immediate VT termination and subsequent noninducibility with successive endocardial PF-RF lesions directly apposed to the far-field midmyocardial/epicardial isthmus, demonstrating the critical depth achieved in real time. Hybrid RF-PF energy delivery may expand the therapeutic options for complex multiplanar VT circuits when epicardial access is not feasible.
Coronary dissection during percutaneous coronary intervention (PCI) may create a dissection-related cavity that destabilizes device passage. When rewiring alone does not ensure stable true-lumen device delivery, a balloon spacer technique may serve as a bailout option. A man in his 50s underwent staged PCI for severe mid-left anterior descending artery stenosis. After cutting-balloon dilation, intravascular ultrasound (IVUS) suggested a dissection-related cavity. IVUS-guided rewiring placed a second guidewire in the true lumen, but repeat balloon passage followed the cavity. IVUS-based assessment guided selection of a 1.5 × 10 mm semicompliant balloon for focal occlusion, after which stents were successfully delivered. This case highlights the gap between true-lumen rewiring and stable device passage during PCI-related dissection. True-lumen rewiring does not necessarily ensure stable device passage. IVUS may help guide balloon spacer bailout when device passage remains unstable after rewiring.
Platypnea-orthodeoxia syndrome is a rare clinical entity with posture-dependent hypoxemia. A 47-year-old woman presented with progressive dyspnea and positional hypoxemia. Multimodal imaging revealed a bicuspid aortic valve, an ascending aortic aneurysm, and a patent foramen ovale with persistent right-to-left shunting despite normal pulmonary vascular resistance. The aneurysmal aorta displaced the cardiac axis, compressed the interatrial septum and right atrium, and, in combination with a prominent Eustachian valve, promoted venous flow across the foramen ovale. Surgical replacement of the ascending aorta and aortic valve, with concomitant closure of the patent foramen ovale, resulted in complete resolution of hypoxemia. This case highlights the interplay of structural and flow-related mechanisms and introduces the concept of the SPACE framework (shunt, patent foramen ovale, axis deviation, compression, and Eustachian valve) in patients with aortic aneurysm. In patients with positional hypoxemia, systematic evaluation of the SPACE factors may help identify treatable intracardiac shunting.
A young man was hospitalized for evaluation of acute neurologic symptoms. Initial diagnostic testing was unrevealing; however, a 12-lead electrocardiogram demonstrated notching at the apex of the R wave in the inferior leads, consistent with the crochetage sign. Further cardiac evaluation was pursued. Transthoracic echocardiography identified an atrial septal aneurysm with evidence of interatrial shunting on agitated saline contrast study, consistent with a patent foramen ovale. This case highlights the diagnostic value of careful electrocardiographic interpretation and demonstrates how subtle electrocardiogram findings may strongly suggest underlying structural heart disease.
Wolff-Parkinson-White (WPW) syndrome is rare and can predispose to tachyarrhythmias. This case illustrates the heterogeneous electrocardiographic (ECG) features of WPW syndrome. A 57-year-old woman was admitted with pneumonia and atrial fibrillation with rapid ventricular response (174 beats/min). Atrial fibrillation terminated after diltiazem infusion, and repeat ECG showed sinus rhythm with pre-excitation (delta waves and a short PR interval). Subsequently, she developed an irregular wide complex tachycardia consistent with atrial fibrillation with pre-excitation (WPW syndrome). Catheter ablation of the accessory pathway was successfully performed. Varying degrees of pre-excitation in WPW can occur depending on accessory pathway properties and location, which can confound the diagnosis of WPW. WPW can present without classic features of pre-excitation on initial ECG; comprehensive serial ECG analysis is crucial to accurately diagnose WPW. Ventricular tachycardia should be considered in the differential diagnosis of WPW, as ECG cannot reliably differentiate between antidromic WPW and ventricular tachycardia.
Coronary vasospasm is a major cause of ischemia with nonobstructive coronary arteries; however, its long-term structural and energetic consequences on the myocardium remain under-recognized. A 72-year-old postmenopausal woman presented with chest discomfort and electrocardiographic findings suggestive of myocardial ischemia. Acetylcholine provocation testing revealed epicardial and microvascular coronary spasm. Cardiac magnetic resonance revealed focal late gadolinium enhancement in the interventricular septum, confirming replacement fibrosis mimicking hypertrophy. Additionally, the patient showed a supranormal ejection fraction of 79% and a markedly reduced end-systolic volume, indicating a hyperdynamic small left ventricle. This case demonstrates that recurrent coronary spasm is not benign and can be related to irreversible myocardial fibrosis and maladaptive hyperdynamic remodeling, increasing the risk of diastolic dysfunction and heart failure. Recurrent coronary spasm may contribute to focal myocardial fibrosis. Left ventricular ejection fraction should be interpreted with end-systolic volume to identify hyperdynamic states.
Acute coronary thrombosis without atherosclerosis may mimic myopericarditis, particularly in young patients. A 20-year-old woman presented with pleuritic chest pain following a viral illness. Serial electrocardiography showed dynamic ST-segment elevation in leads V3 to V6, and high-sensitivity troponin T increased from 18.6 to 1,151 ng/L. Echocardiography demonstrated regional wall motion abnormalities in the left anterior descending territory. Coronary angiography revealed a proximal left anterior descending intraluminal thrombus causing severe narrowing without underlying atherosclerosis. Conservative management with anticoagulation and dual antiplatelet therapy was initiated. Repeat angiography after 3 days showed complete thrombus resolution with no residual stenosis. Further evaluation revealed marked thrombocytosis and a JAK2 V617F mutation, confirming essential thrombocythemia. This case highlights a mechanism-based approach to myopericarditis-like presentations. JAK2-positive essential thrombocythemia represents a plausible prothrombotic contributor after the exclusion of common causes of coronary artery disease in very young patients. Dynamic regional electrocardiogram changes, rapid troponin elevation, and regional wall motion abnormalities should prompt coronary evaluation despite pleuritic symptoms.