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A Bosnian woman at 20 weeks’ gestation presented with dyspnea and hypoxia. She was diagnosed with Eisenmenger physiology with severe pulmonary hypertension, ventricular septal defect, and patent ductus arteriosus. Given high maternal mortality, coordination of care with a multidisciplinary team approach may allow for best possible outcomes. (Level of Difficulty: Intermediate.), Graphical abstract, A Bosnian woman at 20 weeks’ gestation presented with dyspnea and hypoxia. She was diagnosed with Eisenmenger physiology with severe pulmonary…

A 55-year-old man underwent exercise stress echocardiography for evaluation of left inferior pulmonary vein stenosis. During exercise, ultrasound B-lines developed in the left lung only. Unilateral pulmonary congestion did not lead to forward or backward failure. The patient was followed up conservatively. (Level of Difficulty: Beginner.), Central Illustration

Arteriovenous fistula is a rare complication of lumbar surgery that may cause high-output cardiac failure. We describe the case of a patient with treated lymphoma and recent spinal surgery who presented with heart failure. Logical deduction from clinical and imaging findings helped us arrive at this unusual diagnosis. (Level of Difficulty: Intermediate.), Central Illustration

A large left ventricular pseudoaneurysm was discovered in a patient who presented with bacterial endophthalmitis 1 year after medically treated Staphylococcus aureus mitral valve endocarditis. After medical therapy, the patient underwent cardiac surgery uneventfully. We present a rare finding of a pseudoaneurysm complicated with a very late ocular septic event. (Level of Difficulty: Advanced.), Central Illustration

In select patients, transcatheter pulmonary valve replacement through a percutaneous approach can be challenging because of complicated anatomy or small patient size. In these patients, especially those weighing, Central Illustration

Coronary artery fistula are anomalous connections with coronary vessels or cardiac chambers, potentially resulting in coronary dilatation and pseudoaneurysm formation. We present the case of a 68-year-old woman referred to our institution for a voluminous coronary pseudoaneurysm secondary to coronary artery fistula presenting as a nearly completely obstructive left atrial mass. (Level of Difficulty: Intermediate.), Central Illustration

A pregnant woman presented at term with a fetus with foramen ovale restriction. We illustrate the contrast between fetal and postnatal echocardiography of this rare entity. (Level of Difficulty: Advanced.), Central Illustration

We present a case of a thrombus in the left brachial artery as a cardioembolic presentation of pulmonary carcinoma. There have been few reports describing this clinical presentation, but if present, prognosis is very poor. Therefore, a cardioembolic event should be borne in mind as an atypical presentation of pulmonary carcinoma. (Level of Difficulty: Beginner.), Central Illustration

A 79-year-old woman was treated with a 23-mm balloon-expandable transcatheter heart valve (THV) that was initially complicated by an embolized THV requiring deployment in the descending aorta. She presented 13-years later with a degenerated bioprosthesis requiring redo THV. Pre-procedural computed tomography was important in highlighting underexpansion of the initial THV and open leaflets in the embolized valve. (Level of Difficulty: Advanced.), Central Illustration

A 36-year-old woman with cannabinoid hyperemesis syndrome presented with chest pain and was found to have single-vessel coronary artery disease and an aortic mural thrombus. This case describes unique management with coronary artery bypass and surgical thrombectomy because of the patient’s inability to tolerate uninterrupted antiplatelet therapy given her cannabinoid hyperemesis syndrome. (Level of Difficulty: Intermediate.), Central Illustration

Left ventricular pseudoaneurysm is a potentially life-threatening complication of acute myocardial infarction. Timely diagnosis is crucial to improve the patient’s prognosis. We describe a multimodality diagnostic approach with emphasis on cardiac magnetic resonance imaging for a left ventricular pseudoaneurysm found surreptitiously in 72-year-old man 2 weeks following an acute myocardial infarction. (Level of Difficulty: Beginner.), Graphical abstract

We describe a case of testicular teratoma with metastasis to the right ventricle. The mass nearly completely resolved with chemotherapy, obviating the need for upfront surgery. We review the workup of intracardiac metastatic tumors. (Level of Difficulty: Intermediate.), Graphical abstract

We report the case of a patient critically ill with coronavirus disease–2019 (COVID-19) in which atrial flutter with high ventricular response rate occurred, contributing to worsening of the respiratory distress. After failure of noninvasive rate and rhythm control strategies, successful transcatheter ablation was performed and the respiratory distress of the patient improved. (Level of Difficulty: Beginner.), Graphical abstract

Pericardial lipomas are very uncommon benign primary cardiac tumors. We describe the case of a patient with symptomatic large pericardial mass who presented with heart failure. Multimodality cardiac imaging helped us in the diagnosis of this unusual entity. (Level of Difficulty: Intermediate.), Central Illustration

We present herein the case of a delayed covered coronary wall rupture occurring as a rare complication of rotational atherectomy performed in the subintimal space after antegrade dissection reentry for percutaneous recanalization of a long and heavily calcified left anterior descending chronic total occlusion, which was successfully managed percutaneously with the implantation of 2 covered stents. (Level of Difficulty: Intermediate.), Graphical abstract

We report the case of an extended pseudo-subarachnoid hemorrhage (PSAH) related to contrast intracerebral diffusion from blood-brain barrier breakdown on periprocedural percutaneous coronary intervention right corticofrontal ischemic stroke. PSAH is a rare and complex phenomenon, and it is important to differentiate PSAH from subarachnoid hemorrhage to avoid inappropriate treatment with potentially severe consequences. (Level of Difficulty: Beginner.), Graphical abstract, We report the case of an extended pseudo-subarachnoid hemorrhage (PSAH) related to contrast intracerebral diffusion from blood-brain barrier…

Percutaneous coronary intervention (PCI) in patients with chronic kidney disease is associated with a high-risk of contrast-induced nephropathy. We describe a case of ultra-low contrast PCI guided using optical coherence tomography using normal saline for clearance complicated by distal wire perforation treated with embolization. (Level of Difficulty: Intermediate.), Graphical abstract

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (ACS). We report a case of acute coronary syndrome due to SCAD of the right coronary artery. Diagnosis was based on clinical presentation and coronary angiography, and confirmed by optical coherence tomography which guided our treatment strategy. (Level of Difficulty: Beginner.), Graphical abstract

We report a rare case of crown fracture and detachment from a coronary orbital atherectomy system. During orbital atherectomy in an angulated and calcified coronary vessel, the crown was completely detached and left distal to the stenosis. It was successfully retrieved using a gooseneck snare and a guide-extension catheter. (Level of Difficulty: Advanced.), Graphical abstract

Pre-operative optimization of cardiovascular conditions in patients awaiting renal transplantation significantly improves post-transplantation cardiac complications. We describe a case of symptomatic coronary fistula treated with percutaneous coil embolization in a young adult awaiting renal transplantation. (Level of Difficulty: Advanced.), Graphical abstract

Primary cardiac tumors in the right ventricular outflow tract are often misdiagnosed as pulmonary embolism due to rarity and inadequate imaging characterization. Multimodality imaging offers advantages and facilitates subsequent diagnostics and management. We present a case of a woman with suspected submassive pulmonary embolism who was found to have pleomorphic leiomyosarcoma. (Level of Difficulty: Intermediate.), Graphical abstract

This paper presents the case of a 67-year-old female with primum atrial septal defect and congenital mitral cleft status-post surgical repair 40 years previously who was recently found to have severe mitral regurgitation. Percutaneous mitral valve repair was successfully performed using implantation of 2 MitraClips with mild residual mitral regurgitation. (Level of Difficulty: Advanced.), Graphical abstract

A man with a presumed diagnosis of hypertrophic cardiomyopathy presented after a ventricular fibrillation arrest. Review of prior cardiac magnetic resonance imaging revealed a pattern of late gadolinium enhancement that was atypical for hypertrophic cardiomyopathy and most consistent with cardiac sarcoidosis, with diagnosis confirmed by endomyocardial biopsy. (Level of Difficulty: Beginner.), Graphical abstract

Bicuspid pulmonary valve is a rare echocardiographic finding, particularly if not associated with other congenital heart diseases. We report the incidental case of a severe giant pulmonary arterial aneurysm associated to bicuspid pulmonary valve in an asymptomatic 79-year-old patient. Multimodality cardiac imaging was important for the correct diagnosis and to exclude any other potential complication. (Level of Difficulty: Beginner.), Graphical abstract, Bicuspid pulmonary valve is a rare echocardiographic finding, particularly if not associated with other congenital heart diseases. We report the…

We report a case of sudden-onset pulmonary edema due to failure of a bioprosthetic mitral valve. Gross inspection revealed a leaflet tear at a stent post without calcification or pannus formation and no evidence of sutures. This case highlights the mechanical failure of a bioprosthetic mitral valve associated with missing sutures. (Level of Difficulty: Intermediate.), Graphical abstract, We report a case of sudden-onset pulmonary edema due to failure of a bioprosthetic mitral valve. Gross inspection revealed a leaflet tear at a stent…

Extensive pericardial calcification is rare in patients with chronic constrictive pericarditis (CCP). We report the case of a young man who had CCP with “eggshell” calcification of the pericardium and the classic features of CCP on echocardiography and cardiac catheterization. The patient had an uneventful recovery following surgical pericardiectomy. (Level of Difficulty: Intermediate.), Graphical abstract, Extensive pericardial calcification is rare in patients with chronic constrictive pericarditis (CCP). We report the case of a young man who had CCP with…

One of the dreaded complications of left ventricular assist device implantation is mechanical obstruction of the device secondary to pump thrombosis or mechanical outflow cannula obstruction. We describe a case of outflow cannula obstruction caused by kinking and twisting of the outflow graft after surgical manipulation of the pump. (Level of Difficulty: Beginner.), Graphical abstract, One of the dreaded complications of left ventricular assist device implantation is mechanical obstruction of the device resulting from pump thrombosis…

Using 3-dimensional speckle-tracking echocardiography-derived activation imaging system, we visualized interventricular dyssynchrony in a repaired tetralogy of Fallot case with pacing-induced left ventricular dysfunction. The activation imaging system visualized interventricular dyssynchrony and resynchronization after cardiac resynchronization therapy and may be useful to assess electromechanical disturbance in complicated congenital heart diseases. (Level of Difficulty: Intermediate.), Graphical abstract, Using 3-dimensional speckle-tracking echocardiography-derived activation imaging system, we visualized interventricular dyssynchrony in a repaired…

A 70-year-old man with severe tricuspid regurgitation and large coaptation gap (0.8 cm) was referred to transfemoral valve repair using the PASCAL system. The procedure was successful in reducing tricuspid regurgitation. The PASCAL device facilitated maximum leaflet insertion and to span large coaptation gap in severe tricuspid regurgitation without ventilation maneuvers under general anesthesia. (Level of Difficulty: Intermediate.), Graphical abstract, A 70-year-old man with severe tricuspid regurgitation and large coaptation gap (0.8 cm) was referred to transfemoral valve repair using the PASCAL…

We describe the management and clinical decision making in a cardiogenic shock patient with a free-floating left ventricular thrombus found during temporary mechanical support with an Impella CP. The management of these patients can be challenging because there are no guidelines or data to support any particular treatment strategy. (Level of Difficulty: Intermediate.), Graphical abstract, We describe the management and clinical decision making in a cardiogenic shock patient with a free-floating left ventricular thrombus found during temporary…

We present a case of sarcomeric hypertrophy cardiomyopathy diagnosed in a child who had hypertrophy degree regression during adolescence, with no left ventricular dysfunction and no increase of the ventricular diameters. (Level of Difficulty: Intermediate.), Graphical abstract, We present a case of sarcomeric hypertrophy cardiomyopathy diagnosed in a child who had hypertrophy degree regression during adolescence, with no left ventricular…

In patients with acute myocardial injury secondary to coronavirus disease-2019 (COVID-19), cardiovascular magnetic resonance imaging can identify the underlying pathology. We highlight a case of acute myocardial injury secondary to COVID-19, which demonstrated both epicardial vessel thrombosis and the recently described phenomenon of microvascular thrombosis. (Level of Difficulty: Advanced.), Central Illustration

A young woman with mandibuloacral dysplasia, a syndrome on the progeria spectrum with accelerated vascular calcification and calcific valve stenosis, presented with symptomatic severe aortic stenosis. She underwent transcatheter aortic valve replacement with a balloon-expandable valve, and her exertional symptoms improved significantly. (Level of Difficulty: Intermediate.), Central Illustration

A 53-year-old man with a background of acute myelomonocytic leukemia in remission presented with pleurisy. Repeat transthoracic echocardiography over several weeks revealed thickening left ventricular walls and decreasing systolic function. He died of decompensated heart failure due to cardiac myeloid sarcoma, with autopsy revealing an enlarged heart weighing >1 kg. (Level of Difficulty: Intermediate.), Central Illustration

Quadricuspid aortic valve is rare and requires surgery when symptomatic severe regurgitation/stenosis is present. Associated anomalous coronary ostia location demands accurate diagnosis to avoid intraoperative complications, and several imaging techniques have been used, with drawbacks of low sensitivity, radiation and contrast exposure. We report a pre-operative assessment using 3-dimensional echocardiography. (Level of Difficulty: Intermediate.), Central Illustration

Physical examination is becoming a lost art. We describe a case of a patient who was referred to us with an initial diagnosis of ventricular septal defect. Discordance between imaging findings and the physical examination led to a diagnosis of an accessory left ventricle, a rare but benign congenital cardiac condition. (Level of Difficulty: Beginner.), Central Illustration

A patient with occlusion of the left superficial femoral artery (SFA) underwent endovascular intervention. Six-month follow-up angiography revealed aneurysmal dilatation of the previously stented artery. This finding may be a result of maladaptive vascular remodeling or arterial injury resulting in aneurysmal dilatation secondary to subintimal crossing, atherectomy, and paclitaxel therapies. (Level of Difficulty: Beginner.), Graphical abstract

Accurate echocardiographic evaluation of the systemic right ventricle is challenging because of its specific morphology and contraction patterns. We present a detailed multimodality assessment of the systemic right ventricle, analyze the relative contribution of the longitudinal, radial, and anteroposterior components of systolic function, and identify reasons for a potential discrepancy among imaging modalities. (Level of Difficulty: Intermediate.), Central Illustration

We present an exceptional case of a quadricuspid aortic valve associated with a left atrial myxoma. Both are rare conditions, and this association has not been reported yet. These conditions can be silent but may lead to several complications. This case highlights importance of a careful echocardiographic evaluation for early management. (Level of Difficulty: Beginner.), Graphical abstract

Orbital atherectomy is a commonly used procedure for peripheral arterial disease. Crown entrapment is a rare but potentially dangerous complication of orbital atherectomy. We describe a case of crown entrapment by markedly excessive atheromatous intimal tissue attachment to the device and an innovative retrieval technique that may minimize vascular injury. (Level of Difficulty: Beginner.), Graphical abstract

We report fluttering bioprosthetic leaflet, assessed by intravascular ultrasound, during valve-in-valve transcatheter aortic valve replacement, successfully treated by using chimney stenting. Valve-in-valve transcatheter aortic valve replacement is still a challenging situation, particularly in cases with a shallow distance between leaflet and coronary ostium; a multimodality imaging approach helped manage this situation. (Level of Difficulty: Intermediate.), Central Illustration

We report a rare and complex case of cardiac sarcoidosis in a patient presenting with ventricular tachycardia. Multimodality imaging, along with clinical and histological examination, was essential in establishing the diagnosis of cardiac sarcoidosis. (Level of Difficulty: Beginner.), Graphical abstract

Limited arterial vascular access precluded necessary transcatheter intervention in a 22-year-old woman with repaired interrupted aortic arch type B. Alternative transcaval vascular access enabled percutaneous therapy. This practice evolution is likely to benefit the growing numbers of adults with congenital heart disease. (Level of Difficulty: Advanced.), Graphical abstract, Limited arterial vascular access precluded necessary transcatheter intervention in a 22-year-old woman with repaired interrupted aortic arch type B…

Paragangliomas are rare tumors of chromaffin cells arising from an extra-adrenal location. Unlike pheochromocytomas, they are seldom functional. We present a case of pericardial paraganglioma incidentally encountered on an echocardiographic study, focusing on the characteristic features the tumor demonstrates on different imaging modalities. (Level of Difficulty: Intermediate.), Graphical abstract

A 38-year-old woman presented with syncope and palpitations. A myocardial perfusion study demonstrated multifocal, distinct defects not correlating with any specific coronary distribution, which is characteristic of cardiac sarcoidosis. Cardiac magnetic resonance imaging subsequently confirmed systemic sarcoidosis with cardiac involvement. (Level of Difficulty: Intermediate.), Graphical abstract

Pathological studies have revealed spontaneous recanalized coronary thrombi as a frequent evolution of coronary occlusions; however, they are poorly recognized on coronary angiography, and the optimal therapeutic strategy for clinical evolution is unknown. We report the role of optical coherence tomography in identifying a recanalized coronary thrombus causing myocardial ischemia after 11 years of follow-up. (Level of Difficulty: Intermediate.), Graphical abstract

In acute severe aortic regurgitation, an inversion of pressure gradient from the left ventricle to the left atrium causes the classical sign of end-diastolic mitral regurgitation. Here we present a case of mid-diastolic mitral regurgitation in a 51-year-old man with severe aortic regurgitation secondary to infective endocarditis. (Level of Difficulty: Beginner.), Graphical abstract, In acute severe aortic regurgitation, an inversion of pressure gradient from the left ventricle to the left atrium causes the classical sign of end…

The presence of a left ventricular (LV) thrombus is considered an absolute contraindication to transcatheter aortic valve implantation (TAVI) because of the very high embolic risk. We report a case of TAVI under complete protection of the cerebral arteries in a patient with a large LV thrombus, severely impaired LV function, and no surgical options. (Level of Difficulty: Beginner.), Graphical abstract, The presence of a left ventricular (LV) thrombus is considered an absolute contraindication to transcatheter aortic valve implantation (TAVI) because of…

A young male presented to the hospital with chest pain. A coronary angiogram and a subsequent computed tomography coronary angiogram revealed a single coronary artery arising from the right coronary sinus which bifurcated into the right coronary artery and a large branch which supplies the left coronary artery territory. (Level of Difficulty: Beginner.), Graphical abstract, A young male presented to the hospital with chest pain. A coronary angiogram and a subsequent computed tomography coronary angiogram revealed…

A 71-year-old man with chronic atrial fibrillation underwent insertion of a left atrial appendage occlusion device. Before release, a large thrombus was noted within the left atrium, attached to the left atrial appendage occluder delivery system. With continuous negative pressure, the device was deployed and thrombus successfully aspirated with no clinical sequelae. (Level of Difficulty: Intermediate.), Graphical abstract, A 71-year-old man with chronic atrial fibrillation underwent insertion of a left atrial appendage occlusion device. Before release, a large thrombus…