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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.

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.

Mobitz type I atrioventricular (AV) block is traditionally regarded as benign. However, when associated with underlying conduction system disease, it may reflect advanced disease pathology. A 78-year-old woman with chronic obstructive pulmonary disease presented with 3 days of progressive weakness. Initial electrocardiogram demonstrated Mobitz type I second-degree AV block with baseline left bundle branch block. Within 24 hours, her rhythm progressed to high-grade 2:1 AV block with ventricular rates in the 30s, unresponsive to atropine. She required emergent transvenous pacing followed by permanent dual-chamber pacemaker implantation. This case illustrates rapid progression of conduction disease from Wenckebach with left bundle branch block to high-grade AV block. Given the patient's unclear response to atropine and advanced conduction disease, early pacing was appropriate. Mobitz type I AV block with concomitant bundle branch block should be recognized as a potentially high-risk conduction pattern requiring prompt diagnosis and treatment.

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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.

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Hemolysis is a well-recognized consequence of microsecond pulsed-field ablation (PFA); however, its occurrence with nanosecond PFA has not been determined. The aim of this study was to compare hemolysis profiles across different PFA systems. Consecutive patients with atrial fibrillation undergoing first-time PFA with Pentaspline (FARAWAVE; Boston Scientific), Lattice tip (Sphere-9; Medtronic), or Nano PFA 360 (CellFX; Pulse Bioscience) catheters were included in this prospective analysis. Hemolysis was assessed by haptoglobin (Hp), lactate dehydrogenase, and bilirubin measured before ablation (T1) and 24 hours after the procedure (T2). Hemolysis was defined as a >10 mg/dL decrease in Hp between T1 and T2. Significant hemolysis was defined as Hp &#x2264; 25 mg/dL. A total of 94 (67% male, mean age 58.9 &#xb1; 11.68) patients were included. No statistically significant differences in the baseline and procedural characteristics were found among the 3 systems. The catheters used were Nano PFA 360, Pentaspline, and Lattice tip in 30 (32%), 34 (36%), and 30 patients (32%), respectively. Hemolysis occurred in 88 (93.6%) patients. Significant hemolysis was observed in 21 (70%) Nano PFA 360, 27 (79.4%) Pentaspline, and 7 (23%) Lattice tip cases (P < 0.001). Multivariable analysis showed that the Nano PFA 360 and Pentaspline were associated with a similarly high risk of significant hemolysis compared with Lattice tip (P < 0.001). No statistically significant difference was observed between Nano PFA 360 and Pentaspline catheters. Hemolysis commonly occurs across PFA procedures, irrespective of pulse duration, and is greater with single-shot than focal systems.

Drug-coated balloons provide antiproliferative therapy without permanent implants and may benefit lesion subsets where drug-eluting stent performance is suboptimal. To evaluate safety and effectiveness of a paclitaxel-coated balloon in a real-world cohort of ethnically Chinese patients with in-stent restenosis (ISR) or de novo coronary artery disease. This was a prospective, multicenter, single-arm registry across 9 sites in Taiwan, Hong Kong, and Singapore. Patients undergoing percutaneous coronary intervention with paclitaxel-coated balloon (AGENT, Boston Scientific Corp.) for ISR or de novo coronary artery disease were included. Primary endpoint was 12-month major adverse cardiac events (MACEs; cardiac death, myocardial infarction, or target vessel revascularization). Secondary endpoints included target lesion revascularization, target lesion thrombosis, and 9-month angiographic outcomes. Events adjudicated by independent clinical events committee; angiography analyzed by independent core laboratory. A total of 500 patients (mean age 65.6 &#xb1; 11.2) were enrolled. At 365 days (IQR: 354-379) after the index procedure, 13.9% (68 of 489) of patients experienced MACE. MACE rates were 16.3% (48 of 294) and 10.5% (20 of 191), in ISR and de novo patients, respectively. Cardiac death and myocardial infarction rates were 1.6% (8 of 489) and 2.0% (10 of 489), respectively; target vessel revascularization occurred in 11.7% (57 of 489). Angiographic follow-up was performed in 35% (175 of 500) of patients. The 12-month MACE was significantly higher in patients undergoing surveillance angiography compared to without (26.9% [47 of 175] vs 4.9% [15 of 305], P < 0.001), driven by increased target lesion revascularization. Paclitaxel-coated balloon was safe and effective in ethnically Chinese patients. Surveillance imaging significantly influenced revascularization rates, underscoring its impact on clinical decision-making. (An "All-Comers" Study of the AgentTM MONORAILTM Paclitaxel-Coated PTCA Balloon Catheter Used in Real-World Clinical Practice in Chinese Patients; NCT04085445).

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.

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.

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.

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AccuIMR is a novel angiography-based method for assessing microvascular dysfunction (MVD) by simulating the index of microcirculatory resistance (IMR). In a prior study, AccuIMR showed a strong correlation with wire-based IMR. This study aimed to evaluate the clinical significance of the angiography-derived index of microcirculatory resistance (AccuIMR) in patients with ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of a prospective multicenter registry of STEMI patients who underwent cardiac magnetic resonance (CMR). This investigation included 482 STEMI patients. AccuIMR was obtained using angiographic images after percutaneous coronary intervention. The patients were categorized into the MVD group (AccuIMR >40) and the non-MVD group (AccuIMR &#x2264;40). CMR results at 5 &#xb1; 2 days after percutaneous coronary intervention served as the reference standard for assessing CMR-derived microvascular obstruction (CMR-MVO) and infarct size. Compared with the non-MVD group, the MVD group exhibited a larger CMR-MVO area, a larger infarct size area, and a lower left ventricular ejection fraction. Multivariate logistic regression analysis indicated that AccuIMR >40 was an independent predictive factor for CMR-MVO (OR: 4.730, 95% CI: 2.868-7.799, P < 0.001) and larger infarct size (OR: 2.101, 95% CI: 1.323-3.337, P = 0.002). DeLong's test, net reclassification index/integrated discrimination improvement, and likelihood ratio test demonstrated that incorporating AccuIMR into conventional predictive factors significantly improved the predictive accuracy for CMR-MVO and larger infarct size. AccuIMR is an efficient and dependable method for evaluating MVD in STEMI patients after percutaneous coronary intervention. When combined with conventional predictive factors, it provides supplementary information regarding cardiac function.

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A man in his early 50s with no cardiovascular risk factors presented after a brief syncopal episode and was found to have bradycardia with 2:1 atrioventricular block on electrocardiogram. Careful inspection of the inferior leads showed hyperacute T waves with subtle ST-segment elevation and reciprocal ST-segment depression, suggesting evolving inferior occlusion myocardial infarction. He underwent urgent coronary angiography, which revealed proximal right coronary artery occlusion, followed by successful percutaneous revascularization. This case highlights that syncope with new atrioventricular block may reflect acute coronary occlusion requiring early reperfusion therapy. Syncope with newly developed bradyarrhythmia or atrioventricular block warrants meticulous assessment of the inferior leads for subtle ischemic changes, even when chest pain is absent. Dynamic hyperacute T waves with reciprocal inferior ST-segment changes in high-grade atrioventricular block should prompt suspicion of early inferior occlusion myocardial infarction; reperfusion is the key treatment for this symptomatic bradycardia.

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