Alagille syndrome is a rare multisystemic genetic condition most commonly associated with neonatal liver disease. Variable expressivity is a defining feature of Alagille syndrome, resulting in a broad spectrum of phenotypic variation among individuals who meet the diagnostic criteria. We present an atypical case of cardiac‐predominant Alagille syndrome diagnosed in adulthood after the detection of peripheral pulmonary stenosis on cardiac magnetic resonance imaging (CMR).

Chronic deep venous thrombosis (DVT) can result in a significant venous outflow obstruction, often prompting the development of extensive compensatory mechanisms to maintain adequate circulation. We report a case of recurrent DVT, presenting with left lower extremity pain and edema. Venography revealed complete occlusion of the left common femoral vein with extensive collateral venous circulation. Given the presence of well‐formed collaterals and clinical stability, the patient was treated conservatively with continued anticoagulation without additional invasive intervention. This case highlights the physiologic adaptation of collateral formation that can allow for conservative management in chronic DVT and contributes to a better understanding of management strategies for high‐risk patients with recurrent thrombotic events.

Infective endocarditis is a rare phenomenon that may have devastating consequences. While uncommon, the spectrum of causative organisms can include Corynebacterium species. Corynebacterium diphtheriae endocarditis bears a high potential for systemic complications and overall mortality. We present a case of mitral and tricuspid native valve endocarditis caused by C. diphtheriae in an immunocompetent patient and highlight the severe manifestations of this condition.

Congenital complete atrioventricular block (CAVB) is a rare cardiac condition occurring in approximately one in 15,000 to one in 22,000 live births. Maternal autoimmune diseases, with anti‐ssA (Ro) and anti‐ssB (La) antibodies implicated in 56%–90% of cases, are primary causes. We present a case of a 31‐year‐old primigravid woman referred at 29 weeks of gestation for fetal high‐grade AVB, initially diagnosed as 2:1 AVB with a ventricular rate of 45 bpm. Maternal corticosteroid therapy was initiated for suspected immune‐mediated etiology, pending autoantibody test results. Upon transfer, a 3:1 AVB was detected, with fetal heart failure signs. Genetic and autoimmune evaluations ruled out primary electrical heart diseases and infections. Prompt intervention was necessitated due to fetal cardiac decompensation. Sympathomimetic drugs via placental circulation were ineffective. Cesarean section was scheduled at 30 weeks and 1 day. The neonate, weighing 1280 g, had an APGAR score of 7 and a heart rate of 40 bpm. Initial resuscitation and isoproterenol infusion resulted in a moderate heart rate increase. Temporary pacing wires were surgically placed. As permanent pacemaker implantation became necessary, traditional venous access was impractical. A “tiny pacemaker” made with modification of a Medtronic Micra MC1VR01 generator connected to an epicardial lead ensured hemodynamic stability. Approval of this off‐label device from the Italian Ministry of Health was swiftly obtained. Diagnosis of CAVB typically involves fetal echocardiography and fetal magnetocardiography for precise arrhythmia diagnosis. Treatment varies, with fluorinated steroids reducing block severity in autoimmune cases. Miniaturized pacemakers offer a promising solution for neonates, addressing challenges of conventional devices. Further research is needed to evaluate their long‐term efficacy and safety, potentially benefiting patients with venous and cardiac abnormalities.

Misplacement of pacemakers lead into the left ventricle (LV) is a rare but clinically important complication, often facilitated by unrecognized intracardiac shunts such as a patent foramen ovale (PFO). Early recognition is essential to avoid systemic embolization and ensure safe device function. We report a man in his 70s with a background of bioprosthetic aortic valve replacement, coronary bypass grafting, hypertension, chronic kidney disease, Parkinson′s disease, and prostate cancer, who underwent permanent pacemaker implantation for symptomatic sinus pauses. Follow‐up echocardiography 1 year later, performed as part of surveillance of his aortic valve prosthesis, unexpectedly revealed that the ventricular lead had crossed a PFO and was positioned in the LV via the mitral valve. His 12‐lead ECG demonstrated a right bundle branch block‐like paced morphology, raising suspicion of LV pacing. The patient remained asymptomatic with no evidence of systemic embolization. He was anticoagulated with apixaban and subsequently underwent successful lead extraction and repositioning into the right ventricle (RV). Correct RV placement was confirmed using multiple fluoroscopic views, particularly the left anterior oblique (LAO) projection and by postprocedure ECG, chest x‐ray, and echocardiogram. This case underlines the importance of careful assessment of paced ECG morphology, fluoroscopic views during implantation (especially LAO), and postimplant imaging to confirm lead location. Suspicion should be raised when an RBBB‐like QRS morphology is observed during RV pacing. Timely recognition and management with anticoagulation, followed by extraction and repositioning, can prevent potentially devastating complications. Operators should remain vigilant for inadvertent LV lead placement, particularly in patients with unrecognized PFO. Routine use of multiple fluoroscopic projections and correlation with ECG and echocardiography can aid early diagnosis and improve procedural safety.

BackgroundCardiac metastases from colorectal adenocarcinoma are rare and may present with varied or absent symptoms.Case SummaryA middle-aged woman with recurrent colorectal adenocarcinoma presented with an infiltrating ventricular septal cardiac mass. Multimodal imaging, including PET-CT and cardiac MRI, was crucial for both identifying the lesion as a metastasis and for subsequent serial monitoring. Extensive cardiac involvement necessitated specialized surgical and radiation oncology expertise at a high-volume center, though extra-cardiac lesions led to deferring surgery or radiation as therapeutic options. Ultimately, lesion regression was achieved with intensive chemotherapy and immunotherapy targeting the primary malignancy.DiscussionTo our knowledge, no prior cases have documented colorectal adenocarcinoma metastasizing to the interventricular septum with interatrial extension. Management of intracardiac metastases is complex and requires a multidisciplinary approach.Take Home MessagesAccurate diagnosis and characterization of cardiac masses requires a multimodal imaging approach, while effective management depends on a multidisciplinary strategy tailored to treatment goals and patient-specific factors. Surgical resection can be considered at high-volume centers but may be deferred in metastatic disease if it does not improve prognosis or symptoms. Factoring in the expected response to medical therapy is also important.

Outflow tract premature ventricular contractions (OT-PVCs) with an R wave pattern break in Lead V2 (PBV2) pose significant treatment challenges due to their refractory nature and complex anatomical origins. A 56-year-old male with drug-resistant palpitations underwent detailed electroanatomical mapping using a microcatheter to identify the earliest activation site. This precision mapping was crucial for directing the ablation strategy accurately. The “enveloped ablation” technique was employed, involving multisite, low-power ablations surrounding the critical activation site, tailored to address the unique electrical and structural characteristics of OT-PVCs with a PBV2. This case highlights the importance of accurate mapping and tailored ablation strategies in managing OT-PVCs with PBV2.

BackgroundManaging massive thrombi in the coronary arteries of patients with acute myocardial infarction presents considerable challenges, and the effectiveness of immediate versus deferred stenting as a treatment option remains uncertain. Moreover, it is unclear whether dual antiplatelet plus direct oral anticoagulant therapy is more effective for massive thrombi in the coronary arteries than dual antiplatelet therapy alone. We report the case of a patient with acute myocardial infarction with a long and massive thrombus in the left anterior descending artery treated with an immediate stenting strategy and antithrombotic combination therapy.Case PresentationA 90-year-old female presented with a chief complaint of chest depression due to a long and massive thrombus in the left anterior descending artery with associated acute myocardial infarction. Immediate stenting to cover the ruptured plaque and trap the massive thrombus without encountering slow flow/no-reflow phenomenon, and employing thrombolysis through a combination of antiplatelet agents and a direct oral anticoagulant resulting in sustained coronary blood flow during the transition from the acute to subacute phases, led to favorable procedural and clinical outcomes.ConclusionsIf immediate stenting with thrombolysis using a direct oral anticoagulant plus dual antiplatelet agents is successful without distal embolism, this strategy could be a better treatment than deferred stenting in terms of preventing periprocedural cardiac adverse events and reducing healthcare costs. Furthermore, dual antiplatelet agents plus direct oral anticoagulant combination therapy are considered to suppress platelet function and fibrin generation strongly, leading to the disappearance of thrombus.

A 73-year-old woman who suffered from major depressive disorder was candidated to receive electroconvulsive therapy (ECT) in combination with medical treatment. Shortly after ECT, she complained of severe chest pain. ECG findings revealed new QRS widening and ST-segment elevation in anterior leads, and echocardiography revealed anteroapical wall akinesia and reduced ejection fraction. Epicardial coronary arteries were normal in emergent coronary angiography, and the diagnosis of Takotsubo cardiomyopathy was considered. In addition, Troponin I was also elevated. The patient had a good recovery after medical treatment for heart failure, and the ejection fraction in echocardiography improved in a few days. This studied case demonstrates the increasing risk of Takotsubo cardiomyopathy following ECT, which needs special attention for patients with chest pain and ECG abnormalities after ECT.