Edition 2022/05

An infrequently diagnosed case of atrial infarction (AI) which occurred in conjunction with left ventricular myocardial infarction is presented. Atrial infarction was recognized by the presence of PR-segment depression in conjunction with premature atrial complexes. Spatial vector analysis of premature atrial complexes, is highlighted as a means to localize AI.

Background: Transvenous lead extraction (TLE) is the recommended management strategy for a variety of cardiac implantable electronic device (CIED) infections, malfunctions, and other conditions. Large registries have established the safety and efficacy of TLE per se but temporal outcome data after the introduction of an institutional lead management program remain scarce.

Objective: To investigate the impact of a structured institutional lead management program on TLE outcomes.

Methods: All patients who underwent TLE at our institution between 01/2013 and 12/2020 were included. We assessed procedural outcomes after TLE for two separate timeframes: from 01/2013-12/2018 and 01/2019-12/2020 (after introduction of a structured institutional lead management program).

Results: In 2013-2018, the median number of TLE procedures per year at our center was 14 (range 10-19, total 84). In 2019/2020, the median number of interventions per year increased to 46 (range 41-51, total 92). Non-infectious indications for TLE became more frequent (p<0.001), while the proportion of TLE due to infections decreased. Median lead dwell time was not different (4.3 years [2013-2018] vs. 4.4 years [2019-2020], p=0.43). Clinical success rates improved from 90% to 98% (p=0.020) and complete procedural success increased from 85% to 95% (p=0.027). There was a trend towards a lower number of TLE-associated complications (p=0.07).

Conclusion: A structured institutional lead management program and increasing experience significantly improve TLE outcomes. TLE can be safely performed in high-volume centers, allowing for a more liberal extraction policy also in the case of non-infectious TLE indications.

Takotsubo syndrome after mRNA Covid-19 vaccination is a very rare complication. There have been only few cases published yet. However, Takotsubo syndrome has already been detected after influenza related vaccinations in two other cases. The hypothesis for sudden post vaccination change in the cardiac sympathetic discharge was the most likely precipitant of Takotsubo syndrome in these cases.

Diagnosis of vascular anomalies of the aortic arch is often delayed in adolescents and adult patients. In presence of dyspnea that cannot be explained through a pulmonary and/or cardiac disease, and sudden dysphagia in children and adult patients, a cross-sectional imaging examination of the chest is mandatory to exclude or confirm malformation or malposition of the aortic arch and/or aberrant supra-aortic vessels.

Background: Direct oral anticoagulants (DOACs) are considered advantageous compared to vitamin K antagonists in eligible atrial fibrillation patients but the efficacy and the safety of DOACs are not well defined in the morbidly obese population.

Methods: We report the case of a 59-year-old woman patient (160 cm, 188 kg, BMI 73.5 kg/m²) with multiple comorbidities including non-valvular atrial fibrillation anticoagulated with apixaban 5mg twice a day who was admitted to our hospital because of acute renal failure.

Results: We report changes in apixaban concentration levels over the course of management. Apixaban concentrations were quantified using Liquid Anti-Xa HemosIL® Werfen. Table and Figure report apixaban concentration according to therapeutic modifications and renal function.

Conclusion: This case illustrates the interest of measuring occasionally the DOAC concentration in case of intercurrent pathology, in particular acute renal insufficiency, or in case of using topic drugs medication known to interact with DOAC by the oral route. Plasma DOAC measurement would be also interesting in case of co-medication unknown for drug interaction. This case also shows an effective and safe anticoagulation by DOAC in a superobese patient.

Pulmonary vein isolation is a well-established therapy for symptomatic atrial fibrillation. The standard access for left atrial procedures is performed using a transfemoral approach. Rarely, access to the heart from an inferior approach is not feasible due to congenital or acquired interruption of the inferior vena cava. In the present case we discuss relevant aspects and technical issues related to the superior approach for pulmonary vein isolation.

Terlipressin is a vasopressin synthetic analogue recommended as a vasoactive drug with relative specificity for the splanchnic circulation in patients with portal hypertension and bleeding esophageal varices or hepato-renal syndrome. We report a relapsing terlipressin-induced acute pulmonary edema in a 59 year-old man with Child B9 alcoholic liver cirrhosis.

Aims

Bring to light the necessity of further work-up in young patients with syncope.

Methods and Results

A 26-year old male was admitted after a syncope after complaining of chest pain and breathing difficulties. Transthoracic echocardiography showed tamponade and pericardiocentesis was performed with removal of hemorrhagic fluid. Cardiac magnetic resonance showed a heterogeneous, highly perfused mass in the right atrium (RA) with necrotic areas. Histopathology determined a high grade angiosarcoma in the RA and R0 margins. Adjuvant chemotherapy was started but a local relapse occurred followed by multiple metastases and death.

Conclusion

Hemorrhagic pericardial effusion is highly suspicious of cardiac malignancies and warrants further work-up.