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In this review, recent key publications related to acute coronary syndrome (ACS) are summarized and placed into context of contemporary practice. Landmark trials examining vascular access in ST-elevation myocardial infarction, the management of multivessel disease, acute myocardial infarction and cardiac arrest are discussed. An update in pharmacology for ACS provides updates in major trials relating to P2Y12 inhibitor initiation, deescalation, and use in special populations. Additional updates in the use of lipid-lowering agents and adjunctive medications in ACS are reviewed. Finally, cardiac pathology related to coronavirus disease 2019 (COVID-19), as well as the impact of the COVID-19 global pandemic on the care of patients with ACS, is summarized.

Subclinical hypertrophic cardiomyopathy (HCM) is a phenotypic entity that has emerged from the increased use of cardiovascular magnetic resonance imaging in the evaluation and family screening of patients with HCM. We describe the case of a competitive athlete with a sarcomere gene mutation and family history of HCM who was found to exhibit the subclinical HCM phenotype on cardiovascular magnetic resonance imaging in the absence of left ventricular hypertrophy. We discuss the clinical uncertainties in her management. (Level of Difficulty: Advanced.), Central Illustration

A 40-year-old man with Marfan syndrome presented with chest pain and troponin elevation. Urgent echocardiography was suggestive of hypertrophic cardiomyopathy, but cardiovascular magnetic resonance identified features of acute myocarditis. Repeated imaging 4 months later showed resolution of septal thickness, confirming acute myocarditis. (Level of Difficulty: Intermediate.), Central Illustration

Introduction Idiopathic dilated cardiomyopathy (DCM) is associated with abnormalities in cytoskeletal proteins, mitochondrial ATP transporter, microvasculature, and fibrosis. Mesenchymal stem cells (MSCs) can ameliorate distressed mitochondrial and structural proteins, as well as fibrosis, via the paracrine effect of cytokines. This study aimed to investigate whether the transplantation of adipose tissue-derived MSCs (ADSCs) reverses histological and functional abnormalities in the distressed myocardium of DCM-like hamsters by modulating the expression of adenine nucleotide translocase 1 (ANT-1). Methods Eighteen weeks after birth, ADSCs were implanted onto the cardiac surface of δ-sarcoglycan (SG)-deficient hamsters or sham surgery was performed. Results Left ventricular ejection fraction and end-systolic diameter were maintained in ADSC-treated animals for four weeks, ATP concentration was considerably elevated in the cardiomyocytes of these animals, and ANT-1 expression was significantly upregulated as well. The expression of extracellular matrix and myocardial cytoskeletal proteins, such as collagen, SG, and α-dystroglycan, did not differ between groups. However, significant improvements in myosin and Smad4 expression, cardiomyocyte hypertrophy, and capillary density occurred in the ADSC-treated group. Conclusions We demonstrated that ADSCs might maintain cardiac function in the DCM hamster model by enhancing ATP concentration, as well as mitochondrial transporter and myosin expression, indicating their potential for DCM treatment.

Patients with familial arrhythmogenic cardiomyopathy typically present with ventricular arrhythmias or progressive heart failure. This paper characterizes a rare presentation of an underlying genetic cardiomyopathy with clinical manifestations mimicking an acute myocardial infarction in 2 siblings, each with the same mutation in the desmoplakin (DSP) gene. (Level of Difficulty: Advanced.), Central Illustration

Low flow alarms represent a management challenge in patients with left ventricular assist devices because they are often a consequence of complex patient-device interactions. We present a case of intermittent suction of the postero-medial papillary muscle into the left ventricular assist device inflow cannula during diastole, causing low flows. This case highlights the importance of a systematic approach and use of multiple investigation modalities in making an accurate diagnosis. (Level of Difficulty: Advanced.), Central Illustration

A 75-year-old man, who underwent inadvertent misplacement of pacemaker leads into the left coronary artery and left ventricle through the subclavian artery, was referred to our hospital. We safely performed percutaneous lead extraction in collaboration with surgeons and with the patient under general anesthesia. (Level of Difficulty: Advanced.), Central Illustration

Deep septal pacing is an emerging technique for physiologic pacing in adults. We report a case where left bundle capture was inadvertently achieved in a small child with routine lead deployment into a thin septum and discuss the potential feasibility of this technique for future study. (Level of Difficulty: Advanced.), Central Illustration

This report presents the case of fissured subepicardial hematoma and cardiac tamponade after coronary artery perforation during a complex percutaneous intervention. Surgical therapy was required to achieve hemostasis because a percutaneous sealing result was insufficient. Prompt recognition and cardiac surgery availability are essential for patient survival in such situations. (Level of Difficulty: Beginner.), Central Illustration

This study introduces a case in which our novel “Transarterial Snare-Upholding REcovery technique for COMpletely pulled out LV wire for TAVR valve Insert system (TSURECOMI) technique” with snares was successfully performed for bailout of a transcatheter heart valve during transcatheter aortic valve replacement. (Level of Difficulty: Advanced.), Central Illustration

This paper describes the case of a patient who developed refractory heart failure due to a fistula from the left ventricle to the coronary sinus that was unintentionally created after a surgical myectomy and mitral valve replacement. Advanced image guidance with a pre-procedure 3-dimensional physical model and intraprocedure echocardiography fusion facilitated transcatheter plugging of the shunt with symptom resolution. (Level of Difficulty: Advanced.), Central Illustration

Intramural septal substrate presents a challenge in patients undergoing ventricular tachycardia ablation, in terms of both accurate mapping and ablation with unipolar radiofrequency energy. We present the first use of the novel 2-F octapolar catheter in accurately defining intramural septal scar and facilitating bipolar ablation. (Level of Difficulty: Advanced.), Central Illustration

Visual Abstract, Highlights • A simple, biohybrid patch made of polymer (PECUU) and ECM, without cellular components, was able to induce positive remodeling features when applied over chronic infarcts with severely dilated hearts and high cardiac function impairment in rats. • The remodeling benefit was particularly notable in a subgroup of the sickest rats with very low initial ejection fraction in which the echocardiographic endpoints were found to improve after treatment. • This technological approach may hold promise for future translation to patients in a chronic scenario., Summary A biohybrid patch without cellular components was implanted over large infarcted areas in severely dilated hearts. Nonpatched animals were assigned to control or losartan therapy. Patch-implanted animals responded with better morphological and functional echocardiographic endpoints, which were more evident in a subgroup of animals with very low pre-treatment ejection fraction (

We share a rare case of an older adult patient with situs inversus totalis (mirror image of all viscera, including dextrocardia) and congenitally corrected transposition of the great arteries who presented with supraventricular tachycardia. We highlight the unique electrocardiographic characteristics of these rare conditions and the importance of electrocardiogram interpretation skills. (Level of Difficulty: Advanced.), Central Illustration

Surgery is recommended for endocarditis complicated by annular abscess or destruction of the native valve. Guidelines also recommend valvular repair over replacement for endocarditis when feasible. Guidance on management of early repair failure is not well described. (Level of Difficulty: Intermediate.), Central Illustration

Short RP interval atrioventricular re-entrant tachycardias do not typically present as an incessant form. We present 2 cases of incessant atrioventricular re-entrant tachycardias leading to tachycardia-induced cardiomyopathy with severe heart failure presentation in middle-aged adults. Both underwent accessory pathway ablation and recovered normal left ventricle function before hospital discharge. (Level of Difficulty: Intermediate.), Graphical abstract

A 6-month-old infant boy presented with symptomatic heart failure. Dilated cardiomyopathy was found in association with a mutation in TTN. Structural heart disease included novel septation of the left ventricle with a fenestrated membrane resulting from aberrant congenital mitral valve apparatus formation. (Level of Difficulty: Advanced.), Central Illustration

Background Cardiovascular disease (CVD) can occur in COVID-19 and has impact on clinical course. Data on CVD prevalence in hospitalized COVID-19 patients and sequelae in survivors is limited. Aim of this prospective study carried out on consecutive unselected COVID-19 population, was to assess: 1) CVD occurrence among hospitalized COVID-19 patients, 2) persistence or new onset of CVD at one-month and one-year follow-up. Methods Over 30 days n = 152 COVID-19 patients underwent cardiovascular evaluation. Standard electrocardiogram (ECG), Troponin and echocardiography were integrated by further tests when indicated. Medical history, arterial blood gas, blood tests, chest computed tomography and treatment were recorded. CVD was defined as the occurrence of a new condition during the hospitalization for COVID-19. Survivors attended a one-month follow-up visit and a one-year telephone follow-up. Results Forty-two patients (28%) experienced a wide spectrum of CVD with acute myocarditis being the most frequent. Death occurred in 32 patients (21%) and more frequently in patients who developed CVD (p = 0.032). After adjustment for confounders, CVD was independently associated with death occurrence. At one-month follow-up visit, 7 patients (9%) presented persistent or delayed CVD. At one-year telephone follow-up, 57 patients (48%) reported persistent symptoms. Conclusion Cardiovascular evaluation in COVID-19 patients is crucial since the occurrence of CVD in hospitalized COVID-19 patients is common (28%), requires specific treatment and increases the risk of in-hospital mortality. Persistence or delayed presentation of CVD at 1-month (9%) and persistent symptoms at 1-year follow-up (48%) suggest the need for monitoring COVID-19 survivors., Graphical abstract Unlabelled Image

Bileaflet mitral valve prolapse (Bi-MVP) is associated with increased risk for cardiac arrest. We describe a patient who presented after a cardiac arrest with Bi-MVP and variants in Lamin A/C (LMNA) and the sodium channel alpha-subunit 5a (SCN5A). Genetic variants may be the culprit for arrhythmogenesis in Bi-MVP patients. (Level of Difficulty: Intermediate.), Central Illustration

A newborn with pulmonary hypertension due to the premature fetal arterial duct occlusion was diagnosed with a giant left ventricle thrombus. Cardiopulmonary compromise required multidrug therapy with vasopressors infusions, high-frequency oscillation, and nitric oxide. Alteplase infusion through a guiding catheter into the left atrium dissoluted the clot without sequelae. (Level of Difficulty: Advanced.), Graphical abstract

Visual Abstract, Highlights • A large animal model that recapitulates the clinical heterogeneity of HFpEF has been developed. • Multiple comorbidities, including obesity, hypercholesterolemia, pre-diabetic phenotype, as well as pulmonary and systemic arterial hypertension, were induced in adult female Göttingen minipigs by mineralocorticoid excess and a diet high in cholesterol, fat, fructose, and salt. • Severity of each comorbidity was titrated, such that marked left ventricular and left atrial diastolic dysfunction, profound left ventricular concentric remodeling, impaired coronary vasorelaxation, and extensive multiorgan fibrosis were achieved over a relatively short time. • This novel heart failure model was generated in Göttingen minipigs to allow for translational studies of novel pharmacological agents and for human-sized device testing in adult-aged animals. • This novel “multihit” minipig heart failure model enabled investigations into the pathology of HFpEF without the confounding effects inherent with invasive surgical procedures or the administration of agents that induce hypertension and end-organ damage in an artificial manner., Summary A lack of preclinical large animal models of heart failure with preserved ejection fraction (HFpEF) that recapitulate this comorbid-laden syndrome has led to the inability to tease out mechanistic insights and to test novel therapeutic strategies. This study developed a large animal model that integrated multiple comorbid determinants of HFpEF in a miniswine breed that exhibited sensitivity to obesity, metabolic syndrome, and vascular disease with overt clinical signs of heart failure. The combination of a Western diet and 11-deoxycorticosterone acetate salt−induced hypertension in the Göttingen miniswine led to the development of a novel large animal model of HFpEF that exhibited multiorgan involvement and a full spectrum of comorbidities associated with human HFpEF.

We present the novel use of a deep learning–derived technology trained on the skilled hand movements of cardiac sonographers that guides novice users to acquire high-quality bedside cardiac ultrasound images. We illustrate its use at the point of care through a series of patient encounters in the COVID-19 intensive care unit. (Level of Difficulty: Beginner.), Graphical abstract

Eisenmenger syndrome refers to any untreated congenital cardiac defect with an intracardiac communication that leads to pulmonary arterial hypertension, reversal of intracardiac shunting, and cyanosis. We describe a 40-year-old cyanotic patient with congenital heart disease with presumed Eisenmenger syndrome who was considered inoperable. Testing revealed a partial atrioventricular septal defect with no evidence of pulmonary arterial hypertension, and the patient underwent successful cardiac repair. (Level of Difficulty: Intermediate.), Graphical abstract

A 14-year-old with Duchenne muscular dystrophy (DMD) developed chest pain with ST-segment elevation, elevated serum troponin, and progressive ventricular dysfunction. Multimodality imaging showed an anomalous right coronary artery from the left sinus of Valsalva with intramural course, but further diagnostic testing led to the diagnosis of acute presentation of DMD-associated cardiomyopathy. (Level of Difficulty: Beginner.), Graphical abstract

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) is a multiorgan syndrome with rare and heterogenous cardiac manifestations. We present the case of a man with pericardial effusion complicated by cardiac tamponade, new onset atrial fibrillation, and high-degree atrioventricular block leading to a diagnosis of POEMS syndrome. (Level of Difficulty: Advanced.), Graphical abstract

Rare cardiac malpositions are faced with diagnostic challenges and may not follow set rules. The presence of more than one pathology simultaneously makes diagnosis challenging. The present case report describes antennal diagnosis topsy-turvy heart with crossed ventricular inlets. (Level of Difficulty: Intermediate.), Central Illustration

We present a complex Marfan case, with previous type A aortic dissection, subsequent progressing aortic arch aneurysm, type B chronic aortic dissection, and Barlow disease with severe mitral regurgitation, all expressions of the same phenotype, all needing staged complex surgical therapies. (Level of Difficulty: Intermediate.), Graphical abstract

A 62-year-old male with symptomatic persistent atrial fibrillation underwent radiofrequency catheter ablation. During exchange of the saline irrigation bag, the patient developed sudden hypotension and bradycardia and was found to have a massive air embolism. Air was successfully aspirated with catheters, and the patient did not suffer any permanent sequelae. (Level of Difficulty: Intermediate.), Graphical abstract

Intramyocardial dissection is a rare complication of myocardial infarction, trauma, and percutaneous intervention. It is usually caused by hemorrhagic dissection among the spiral myocardial fibers. We hereby report the case of a patient with left ventricular intramyocardial dissection who presented with acute decompensated heart failure. (Level of Difficulty: Advanced.), Graphical abstract

A patient with severe mitral regurgitation and chronic systolic heart failure taking inotropic support at home presents for transcatheter edge-to-edge mitral valve repair, complicated by torrential mitral regurgitation from damaged mitral leaflets requiring escalating mechanical circulatory support and ultimately expedited orthotopic heart transplantation. (Level of Difficulty: Intermediate.), Graphical abstract

Objective(s) To determine the influence of surgical techniques adopted to avoid suture line disruption, periprosthetic leakage, patch dislodgement, pericardial patch aneurysm formation, and the long-term stability of aortic root enlargement (ARE) during aortic valve replacement (AVR). Methods One hundred fifteen patients undergoing AVR or combined aortic and mitral valve replacements with Nicks' posterior ARE between 1997 and 2019 underwent long-term echocardiographic and angio-computed tomographic evaluation. Age was 11-72 years (AVR: median, 30; interquartile range, 21-47 years; AVR and mitral valve replacement: median, 27.5; interquartile range, 20-37.5 years). The aortotomy was closed using autologous pericardial patch and Teflon-buttressed sutures. Results Hospital mortality was 1.7% (n = 2), with 4 (3.5%) late deaths. At a mean follow-up of 123.11 ± 77.67 months, the survival probability from Kaplan–Meier was 93.25 ± 0.03%. No cases of severe prosthesis–patient mismatch (PPM) were observed, and only 2 patients had moderate PPM. Median aortic root diameters at the level of sinus of Valsalva and sinotubular junction were 32 (29-35) mm and 33 (30-36) mm, respectively, at discharge, and were 33 (30-36) mm, and 33 (31-37) mm, respectively, at latest follow-up, with no cases of late pericardial patch aneurysm. Conclusions ARE is a safe adjunct to AVR in patients with a small aortic annulus to prevent PPM. Retention of a pericardial collar and Teflon-buttressed sutures is an expedient, safe, and effective technique in reducing bleeding at the enlarged ventriculo-aortic junction. Autologous pericardial patch aortoplasty is not associated with late aneurysm/pseudoaneurysm formation., Graphical abstract Pericardial collar and Teflon buttressed sutures at the ventriculo-aortic junction with no aneurysm/pseudoaneurysm formation (n = 115).

Patients with restrictive or hypertrophic cardiomyopathy (HCM) are often ineligible for a left ventricular assist device (LVAD) due to the risk of suction events with a small left ventricular cavity size and left ventricular inflow cannula. We describe an alternative LVAD configuration using a left atrial inflow cannula as a bridge to transplantation in an adult with HCM. (Level of Difficulty: Advanced.), Graphical abstract

We report the case of an adult patient, affected by complete transposition of great arteries with ventricular septal defect, who survived until 68 years of age without surgery, thanks to the presence of a common atrium and pulmonary stenosis. (Level of Difficulty: Advanced.), Graphical abstract, We report a case of an adult patient, affected by complete transposition of great arteries with ventricular septal defect, who survived until…

Left ventricular noncompaction cardiomyopathy (LVNC) was diagnosed in a 59-year-old woman, based on echocardiography. Later, diagnostic criteria were also found positive by cardiac magnetic resonance (CMR). However, coronary angiography revealed thebesian veins were causing the noncompacted appearance. The complementary role of CMR and echocardiography criteria, including flow assessment in the recesses, is discussed. (Level of Difficulty: Advanced.), Graphical abstract

Background Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial injury remain unclear and prior studies have not reported cardiovascular imaging data. Objectives This study sought to characterize the echocardiographic abnormalities associated with myocardial injury and their prognostic impact in patients with COVID-19. Methods We conducted an international, multicenter cohort study including 7 hospitals in New York City and Milan of hospitalized patients with laboratory-confirmed COVID-19 who had undergone transthoracic echocardiographic (TTE) and electrocardiographic evaluation during their index hospitalization. Myocardial injury was defined as any elevation in cardiac troponin at the time of clinical presentation or during the hospitalization. Results A total of 305 patients were included. Mean age was 63 years and 205 patients (67.2%) were male. Overall, myocardial injury was observed in 190 patients (62.3%). Compared with patients without myocardial injury, those with myocardial injury had more electrocardiographic abnormalities, higher inflammatory biomarkers and an increased prevalence of major echocardiographic abnormalities that included left ventricular wall motion abnormalities, global left ventricular dysfunction, left ventricular diastolic dysfunction grade II or III, right ventricular dysfunction and pericardial effusions. Rates of in-hospital mortality were 5.2%, 18.6%, and 31.7% in patients without myocardial injury, with myocardial injury without TTE abnormalities, and with myocardial injury and TTE abnormalities. Following multivariable adjustment, myocardial injury with TTE abnormalities was associated with higher risk of death but not myocardial injury without TTE abnormalities. Conclusions Among patients with COVID-19 who underwent TTE, cardiac structural abnormalities were present in nearly two-thirds of patients with myocardial injury. Myocardial injury was associated with increased in-hospital mortality particularly if echocardiographic abnormalities were present., Central Illustration

Highlights • MRSA rarely causes infective pancarditis in healthy children. • Optimal timing of surgical intervention is unclear in the guidelines. • A 12-year-old otherwise healthy girl presented with infective pancarditis. • Despite infection control, she developed a cardiac pseudoanerysm. • Emergency surgical interventions are crucial in pediatric left-sided pancarditis., Introduction Infective endocarditis is more prevalent among children with congenital heart diseases as compared to healthy children. Community-acquired methicillin-resistant Staphylococcus aureus is a causative pathogen of infective endocarditis, and it rarely causes pancarditis in healthy children. The clinical decision for surgical intervention of left-sided heart vegetation is challenging despite the availability of management guidelines. Presentation of case We report a case of a previously healthy 12-year-old girl who presented with aggressive endocarditis secondary to community-acquired methicillin-resistant Staphylococcus aureus infection, with left-sided vegetation, mitral valve regurgitation, pancarditis, brain abscess, and stroke. She underwent an emergency vegetectomy and mitral valve repair. Three weeks after the first surgery, she developed left ventricular pseudoaneurysm that required life-saving surgical intervention. The child gradually recovered and was discharged home with acceptable cardiac function and mild neurological deficit. Discussion Pancarditis, especially with an aggressive progression resulting in intracardiac pseudoaneurysm, is rarely reported in healthy children. The definition of the optimal timing of surgical intervention in pediatric infective endocarditis management is lacking and the clinical decision-making process remains challenging. The development of left ventricular pseudoaneurysm is serious and also needs an immediate intervention, given the high risk of its rupture and subsequent devastating outcomes. Conclusion Community-acquired methicillin-resistant Staphylococcus aureus is an etiology for aggressive infective pancarditis in a healthy child, leading to an intracardiac pseudoaneurysm. Emergency surgical interventions should be considered in children with left-sided vegetation to prevent devastating consequences.

Ablation is an established treatment for ectopy originating from the left ventricle (LV). We report on a case of noninvasive 3-dimensional mapping locating the origin precisely in the epicardial LV summit area. However, after failed attempts from LV and epicardially, ablation via the left atrial appendage was finally successful. (Level of Difficulty: Advanced.), Graphical abstract, Ablation is an established treatment for ectopy originating from the left ventricle (LV). We report on a case of noninvasive 3-dimensional mapping…

Background: The role of late gadolinium enhancement (LGE) in cardiac MRI (CMR) as prognostic marker in non-ischemic dilated cardiomyopathy (NIDCM) is evolving. Objective: To study the effect of LGE in the prognosis of NIDCM patients. Methods: 112 consecutive NIDCM patients, who underwent CMR, were prospectively followed up for 745 ± 320 days. Primary end point was occurrence of MACE {composite of all-cause mortality, resuscitated cardiac arrest, sustained ventricular tachycardia (VT)/appropriate ICD shock, heart failure (HF) hospitalization}. Results: LGE was present in 44 out of 112 patients (39%). The primary end point (MACE) was significantly higher in LGE + ve group compared to the LGE –ve group (72.7% vs. 29.4%; p 14% of LV predicted MACE with 90.6% sensitivity and 86% specificity. HR of LGE extent >14% of LV for MACE is 6.12; p 14% of LV volume were strongest predictor of MACE. Conclusion: LGE and its extent >14% predicts adverse cardiac events in NIDCM irrespective of LVEF and LGE location, pattern or distribution. This study emphasises the role of CMR in risk stratification of NIDCM patients and guiding therapy.

We describe a 54-year-old male in whom eosinophilic myocarditis secondary to T-cell lymphoma complicated by bilateral ischemic stroke was diagnosed. The source, identified as an apical tear with thrombus formation, was revealed by transthoracic echocardiography. (Level of Difficulty: Advanced.), Graphical abstract

Redo tricuspid valve replacement has high surgical operative mortality. Transcatheter valve-in-valve provides a viable option for valve replacement. We discuss the decision-making process involved in performing transcatheter tricuspid valve-in-valve replacement in a 23-week pregnant woman with multiple comorbidities and symptomatic severe bioprosthetic stenosis. (Level of Difficulty: Intermediate.), Graphical abstract

A 39-year-old man, painter by profession, presented with symptoms of heart failure. His work up was unrevealing except for elevated blood lead levels (BLL). He was started on guideline-directed medical therapy and was referred to occupational therapy. No improvement in his ejection fraction was noted until his BLL decreased. (Level of Difficulty: Intermediate.), Graphical abstract, A 42-year-old man, painter by profession, presented with symptoms of heart failure. His work up was unrevealing except for elevated blood lead levels (B…

Visual Abstract, Highlights • Contractile assays were performed using multicellular preparations isolated from the left and right ventricles of organ donors and patients with heart failure. • Heart failure reduced maximum force and power by approximately 30% in the myocardium from both ventricles. • Heart failure increased the Ca2+ sensitivity of contraction, but the effect was bigger in right ventricular tissue than in left ventricular samples. • The changes in Ca2+ sensitivity may reflect ventricle-specific post-translational modifications to sarcomeric proteins., Summary This study measured how heart failure affects the contractile properties of the human myocardium from the left and right ventricles. The data showed that maximum force and maximum power were reduced by approximately 30% in multicellular preparations from both ventricles, possibly because of ventricular remodeling (e.g., cellular disarray and/or excess fibrosis). Heart failure increased the calcium (Ca2+) sensitivity of contraction in both ventricles, but the effect was bigger in right ventricular samples. The changes in Ca2+ sensitivity were associated with ventricle-specific changes in the phosphorylation of troponin I, which indicated that adrenergic stimulation might induce different effects in the left and right ventricles.

A 65-year-old man with remitted chest pain and no tachypnea was taken urgently to catheterization because of diffuse lung ultrasound B-lines on bedside examination. He was found to have severe left-main disease. This case emphasizes the value of ultrasound to recognize acute cardiogenic interstitial pulmonary edema despite minimal symptoms. (Level of Difficulty: Advanced.), Graphical abstract, A 65-year-old man with remitted chest pain and no tachypnea was taken urgently to catheterization because of diffuse lung ultrasound B-lines…

A 34-year-old man was admitted with acute lung injury and COVID-19 pneumonia. In intensive care unit, he experienced episodes of prolonged asystole accompanied by hypotension without loss of consciousness. Once reversible causes were excluded, symptoms were related to dysfunction of the sinus node and patient underwent PM implantation., Graphical abstract

Transcatheter mitral valve-in-valve replacement (TMVR) offers a less invasive strategy for managing bioprosthetic mitral valve dysfunction. TMVR positioning is challenging in the setting of a radiolucent bioprosthetic sewing ring. We present 2 cases demonstrating the roles of fluoroscopy and echocardiography in guiding TMVR placement within bioprostheses with radiolucent sewing rings. (Level of Difficulty: Intermediate.), Graphical abstract, Transcatheter mitral valve-in-valve replacement (TMVR) offers a less invasive strategy for managing bioprosthetic mitral valve dysfunction…

A 64-year-old asymptomatic man had an incidental finding of a giant left circumflex artery (LCX) aneurysm, with the distal LCX draining into a confluence receiving terminal portions of all coronary arteries and communicating with the left ventricle through a transmural fistulous tract. We believe that this is the first case reported with such a complex LCX abnormality. (Level of Difficulty: Beginner.), Graphical abstract, A 64-year-old asymptomatic man had an incidental finding of a giant left circumflex artery (LCX) aneurysm, with the distal LCX draining into a confluence…

Saw-tooth cardiomyopathy is a very rare disease, and only few cases have been published since its first description 10 years ago. We report the clinical presentation, imaging features and genetic analysis of a saw-tooth cardiomyopathy and argues that it should not be confused with left-ventricular noncompaction. (Level of Difficulty: Intermediate.), Graphical abstract, Saw-tooth cardiomyopathy is a very rare disease, and only few cases have been published since its first description 10 years ago. We report the…