Search

A 52-year-old male visited our hospital with abnormal electrocardiogram and exertional fatigue. The electrocardiogram showed first-degree atrioventricular block, complete right bundle branch block, and inverted T waves in Leads II, III, aVF, V3, and V4. Echocardiography showed biventricular wall thickening involving granular sparkling of the interventricular septum. Late gadolinium enhancement on cardiovascular magnetic resonance (CMR) was found at the circumferential right ventricular wall and patchy regions of the left ventricle. Although these findings strongly suggested cardiac amyloidosis, he was finally diagnosed with systemic sarcoidosis due to the following. First, endomyocardial biopsy revealed non-caseating epithelioid granuloma with giant cells. Second, 18 F-fluorodeoxyglucose positron emission tomography showed uptake in bilateral hilar lymph nodes, para-aortic lymph nodes, and the biventricular wall of the heart. Although echocardiography and CMR are very useful tools for diagnosis of cardiomyopathies, their specificity and accuracy need to be considered.

Complete situs inversus is a congenital condition which involves complete transposition of all thoracic and abdominal organs. This condition poses a technically challenging issue for the procedure of transcatheter pulmonary vein isolation to treat atrial fibrillation. We have recently experienced one case of situs inversus complicated with cardiac tamponade after successful ablation. The patient is a 67-year-old woman with a history of situs inversus totalis. She presented to our emergency department with repeated episodes of drug-resistant paroxysmal atrial fibrillation. Radiofrequency ablation was preferred. During the procedure, we performed interatrial septal puncture under intracardiac ultrasound guidance and isolation of all 4 pulmonary veins was achieved. Ten minutes after removing the sheaths from left atrium the patient developed cardiac tamponade and prompt pericardiocentesis was needed. Pericardial effusion resolved on the next day and she was discharged 3 days later. No recurrence of atrial fibrillation has been documented after the procedure. Judging from clinical progress, pericardial effusion is speculated to occur after removal of the sheath.

We experienced a case of asymptomatic coronary artery rupture two years after type A acute aortic dissection which was successfully treated with coronary embolization. A 51-year-old man underwent total arch replacement for type A acute aortic dissection two years ago. Although he had been followed uneventfully, follow-up computed tomography scan two years after the operation incidentally identified the hemopericardium compressing the posterolateral wall of the left ventricle. Echocardiography showed significant compression of the left ventricle due to the hemopericardium, but did not show any deterioration of cardiac function. ECG-gated 320-sliced multi-detector computed tomography (MDCT) revealed extravasation from the left circumflex artery. He was hemodynamically stable and asymptomatic despite this potentially life threating condition. After the admission, coronary angiography was performed which revealed coronary artery rupture from the distal part of the second obtuse marginal artery (OM2). The artery was successfully treated with coil embolization. However, four-dimensional computed tomography (4D-CT) three days after the embolization still showed persistent extravasation from the first obtuse marginal artery (OM1). As the artery dominated large areas, OM1 was treated with absorbable gelatin sponge particles. 6 months after the procedures, additional coil embolization was performed for recurrence bleeding from these arteries. After these coil embolization, cardiac enzymes were slightly elevated, but no deterioration of cardiac function was noted and successful hemostasis were achieved. Although considerably rare, asymptomatic coronary artery rupture could happen after the thoracic surgery. 4D-CT is efficient for identifying ruptured sites and coronary embolization is reasonable treatment to achieve hemostasis.