Clinical case 59 years old male known case of long standing diabetes and dyslipidemia presented to our institute with Non-STEMI.His past history was significant for multiple admissions with acute coronary syndromes and percutaneous coronary interventions(PCI). Echocardiogram in this presentation showed preserved biventricular systolic function with no valvulopathies. He was taken up for coronary angiogram which showed significant calcified angulated lesion in LAD/LCX(Left anterior descending and circumflex) with diffuse disease in Ramus/RCA. Mode of revascularisation was discussed in detail with the patient for Rotablation-guided PCI to LAD/LCX vs CABG.He preferred and underwent complex PCI to LAD. During the procedure he developed acute heart failure which was managed conservatively. Immediate TTE showed new severe aortic regurgitation(AR) with probable left coronary cusp(LCC) perforation and preserved LVEF.After stabilization, he was scheduled for TEE which showed tear in the LCC with complex fragmented jet of holodiastolic AR filling the entire LVOT.There was new late diastolic to early systolic MR.3DTEE Enface view of the aortic valve was evident of ovoid shaped laceration in LCC extending till the free margin (Fig 1C). There were additional tears in Non-coronary cusp(NCC) extending till the free margin of right coronary cusp(RCC).3DTEE colour was notable for regurgitant jet origin from LCC/NCC (Fig 2B). Based on above findings,He was offered aortic valve intervention but was reluctant initially.He presented 2 months later with exertional dyspnoea, mild LV dilatation and drop in LVEF to 50%.He consented for surgery and underwent bioprosthetic Aortic valve replacement because of extensive cusp tear and deformation of the valve along with complete revascularisation of the remaining diseased coronaries.Post-operative course was complicated by vasoplegic arrest and acute renal failure which was successfully managed conservatively. Discussion We report this case for the rarity of this post-PCI iatrogenic complication and the incremental role of 3DTEE in identifying the exact pathology.It was proposed that during PCI multiple stalling of rotatbur in calcified LAD caused traction and eventually disengagement of guide causing rotabur to freely hang in ascending aorta close to the cusps.Possibly this rotablator with very high speed(180000rpm) would have momentarily come in contact with the aortic cusps causing cuspal perforation and heart failure in Cath lab.3DTEE correlated very well with the anatomo-pathology and matched with intraoperative finding as shown in figures 2A & 2C.These findings prior to aortic cross clamp could significantly reduce time of surgery as he had an additional CABG procedure to be performed.There are few isolated case reports of post PCI aortic valve perforation but probably ours is the first one secondary to the use of rotablator with near involvement of all the cusps and reasonably accurate 3DTEE-anatomic characterisation. Abstract P249 Figure.
Background Constrictive pericarditis (CP) is one of the most serious sequelae of tuberculous pericarditis, which is characterized by heart constriction secondary to intense pericardial inflammation and thickening. Several invasive and non-invasive diagnostic modalities are crucial to address the challenges of confirming the diagnosis of CP and to expedite timely intervention. Case summary This study reports the case of a Bahraini male with tuberculous lymphadenitis diagnosed with CP as a result of various evaluations. The patient underwent urgent total pericardiectomy and showed remarkable recovery with complete resolution of heart failure symptoms. Discussion This case demonstrates the paramount importance of early diagnosis and treatment for patients with CP. In this unique case, the acoustic windows on echocardiography were suboptimal because of pericardial thickening. Further, computed tomography did not show significant calcification of the thickened pericardium. A novel approach of assessing haemodynamics through the right antecubital vein and right radial artery facilitated the accurate diagnosis of CP with confidence. Thereafter, successful pericardiectomy revealed a markedly thickened and stiff pericardium with many abscesses and dense adhesions encasing the heart, and pericardial biopsy showed large caseating granulomas. This case exemplifies the difficulty in diagnosing CP and the favourable outcomes achieved with well-timed surgical intervention.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.