Atrioventricular Groove Research Articles

The distribution and mass index of epicardial adipose tissue were correlated with microvascular obstruction formation in patients with ST-segment elevation myocardial infarction

Abstract Introduction Epicardial adipose tissue (EAT), refers to a metabolically active fat depot between the visceral pericardium and the outer margin of the myocardium. EAT has gradually emerged as a novel target for risk stratification of coronary artery disease due to its distinctive location and multifaceted metabolic properties. Microvascular obstruction (MVO) after primary percutaneous coronary intervention (pPCI) is identified as an independent risk factor for poor prognosis in patients with acute myocardial infarction. However, the clinical implications of EAT in MVO formation in patients with ST-segment elevation myocardial infarction (STEMI) remain unclear. Recently, cardiac magnetic resonance (CMR) has emerged as the gold standard technique to detect the extent of MVO and evaluate EAT parameters. Purpose This study aimed to evaluate the correlation between EAT accumulation and MVO occurrence detected by CMR in STEMI patients. Methods A total of 129 STEMI patients who underwent pPCI successfully were enrolled. Clinical characteristics including demographic characteristics, cardiovascular risk factors, laboratory data and angiographic parameters were recorded from each patient by 1 trained physician. All patients underwent CMR within 1 week following pPCI to evaluate infarct size, MVO volume and EAT distribution. All CMR data were transferred to Q-MASS MR 8.1 imaging system (Medis, Leiden, The Netherlands) and interpreted twice by 2 expert radiologists who were blinded to the angiographic and clinical data of patients. Results Compared to STEMI patients without MVO, STEMI patients with MVO presented with higher peak troponin T levels, increase of neutrophil lymphocyte ratio (NLR) and C-reactive protein (CRP), larger infarct size and compromised left ventricular ejection fraction. Total EAT volume, EAT mass index, left atrioventricular EAT volume, left atrioventricular EAT mass index and thickness of EAT in the left atrioventricular groove were unanimously associated with the occurrence of MVO. The left atrioventricular EAT mass index in STEMI patients with MVO were significantly larger than that in STEMI patients without MVO (24.72±5.049 g/m2 vs 18.63±3.670 g/m2, P<0.001). Multivariate logistic regression analysis demonstrated that NLR, peak troponin T levels and left atrioventricular EAT mass index were independent predictors of MVO. LV EAT mass index showed a robust and independent relationship with MVO formation and a cutoff value >21.5192 g/m2 predicted the presence of MVO with a sensitivity and specificity of 79.5% and 80.4%, respectively. Conclusions Left atrioventricular EAT mass index is an independent predictor of MVO. Measurement of EAT using CMR could be used for risk stratification and might be a promising target in developing new therapies to reduce myocardial reperfusion injury in patients with STEMI.

7246 Cardiac Paraganglioma: A Rare Entity

Abstract Disclosure: L. Javed: None. L. Jonea: None. Cardiac paragangliomas are an exceptionally uncommon subset of neuroendocrine neoplasms. We present a case of a patient presenting with this condition. 70-year-old woman with pertinent past medical history of chronic veinous insufficiency complicated by recurrent abscesses of her right leg since venaseal procedure. The patient had positive IgG lambda on immunofixation that raised concerns for MGUS. Therefore, a F-18 FDG PET-CT scan was performed for further evaluation. PET-CT revealed a hypermetabolic mass in the upper inner right thigh and the right atrium (SUV 17.6) raising concern for septic thrombi. She was admitted in the hospital for initiation of antibiotic therapy. Transesophageal echocardiogram (TEE) revealed a 4.5 cm x 4.0 cm mass in the right atrioventricular (AV) groove region, extending over the root of the main pulmonary artery. Following discharge, despite completing six weeks of IV antibiotic therapy a CT scan on a subsequent clinic visit revealed the same mass as seen on TEE. CT imaging raised suspicion of neuroendocrine tumor. This led to referral to the endocrinology department. Laboratory results showed elevated normetanephrine and dopamine levels increasing likelihood of paraganglioma. Lab Results: 24 hr urine normetaneprhine :7197(N ≤ 376 mcg), 24 hr urinary dopamine :879 (N ≤400 mcg), 24 urinary metanephrine: 84 (N ≤96 mcg) & 24 hr urinary epinephrine <3 (N ≤20 mcg). Her home systolic blood pressure readings varied between 120’s & 170’s. She was initiated on Prazosin 1 mg daily in addition to the existing antihypertensive medications of nebivilol, amlodipine & furosemide. Few months later, this patient successfully underwent cardiac mass resection. Histologic findings of the resected mass were consistent with paraganglioma. Post-surgery, anti-hypertensive medications were discontinued, and blood pressure normalized to systolic readings in the 90s to 120s and diastolic readings in the 60s to 80s. Repeat biochemical tests indicated a normalization of normetanephrine & dopamine levels, validating the success of the resection. This case features an extremely rare entity cardiac paraganglioma that had an atypical clinical manifestation of being asymptomatic. Timely diagnosis and appropriate management are crucial for patient outcomes. Surgical intervention, although fundamental, bears significant risks, necessitating meticulous preoperative management to mitigate potential complications. The medical approach focuses on averting perioperative complications such as hypertensive crisis, cardiac arrhythmias and myocardial infarction. This is achieved by administering alpha and beta adrenoceptor blockers for a minimum of two weeks before the scheduled surgery. Regular follow up is also essential due to the unpredictable malignant potential of these tumors. Presentation: 6/3/2024

Imaging Features Differentiating Between Cardiac Sarcomas and Hematologic Neoplasms.

The aim of the study is to assess the efficacy of computed tomography (CT) and positron emission tomography (PET)/CT findings in differentiating between cardiac sarcoma and cardiac hematologic neoplasms, which are rare but potentially lethal primary cardiac malignancies. We searched the electronic medical record for pathology-proven cases from 2012 to 2023, finding 69 patients (46 sarcomas, 23 cardiac hematologic neoplasms). Imaging features including tumor size, atrioventricular (AV) groove involvement, right coronary artery (RCA) encasement by 180°, pericardial effusion, lymphadenopathy, and metabolic activity on fluorodeoxyglucose PET were reviewed by a radiology fellow. Statistical analysis was performed using Fisher exact test and Wilcoxon test. Cardiac sarcoma patients were younger (median age 49 years) compared to patients with cardiac hematologic malignancies (66 years, P = 0.006). While tumor size and chamber involvement were similar between the 2 categories, hematologic malignancies exhibited a notable predilection for AV groove involvement (70% vs 43%, P = 0.04) and RCA encasement (52% vs 26%, P = 0.02). Pulmonary metastases were more frequent in sarcoma cases (33% vs 4%, P = 0.006). There was no significant difference in fluorodeoxyglucose uptake. Lymphadenopathy was similar between the 2 disease groups. A decision tree constructed using AV groove involvement and patient age achieved 75% accuracy in predicting the diagnosis of the mass. Overall, there is a substantial overlap in imaging features of cardiac sarcomas and hematologic malignancies involving the heart. Involvement of the AV groove and RCA encasement can allow a radiologist to favor hematologic malignancy. Ultimately, biopsy is required to establish a diagnosis.

Cardiac decompression and right ventricular function improvement after bar removal in patients with pectus excavatum.

Pectus excavatum, the most frequent malformation of the chest wall, has been related to cardiac compression and exercise intolerance. Cardiac outcomes after minimally invasive repair of pectus excavatum with retrosternal implants, particularly after removal (> 2 years postoperative) are generally unknown. We evaluated stress echocardiography outcomes before repair and after bar removal. This study comprised a retrospective cohort of patients with diagnosis of isolated pectus excavatum who underwent stress echocardiography before minimally invasive repair with retrosternal implants, and after bar removal. The diastolic function was evaluated by means of the trans tricuspid flow and tissue doppler imaging. The compression of the atrioventricular groove was assessed using the trans tricuspid gradient and the tricuspid area. We included 43 patients, with a mean age of 15.7 ± 4.0 years (91% male). After bar removal, 83% of patients referred improvement of exercise capacity. Furthermore, we found a significant improvement in right ventricular filling patterns, including a better E/A ratio profile during exercise (p = 0.001), lower filling pressures both at rest (p < 0.0001) and during exercise (p = 0.031), and lower rates of resting paradoxical septal motion [70% vs. 20%, p = 0.0007]. The trans tricuspid mean gradient during exercise was significantly lower after bar removal (p < 0.0001). In this study involving patients with minimally invasive repair of pectus excavatum, we demonstrated a beneficial impact of such intervention after bar removal, with significant improvements related to the right ventricular function, as well as signs of relief of cardiac compression.

Comparison of histopathological and triphenyl tetrazolium chloride test in diagnosing myocardial infarction: An autopsy study

Background Sudden and unexpected deaths are increasing drastically. The main cause of sudden death is cardiovascular disease, out of which coronary artery disease predominates forming 80% of the cases. Most of the time, detecting early changes in myocardial infarction during the autopsy is challenging since gross infarct changes do not appear until after 24 to 48 hours of myocardial ischemia injury. So, the aim of this study was to compare two test to detect early changes of Myocardial Infarction one by using Triphenyl Tetrazolium Chloride (TTC) staining of the myocardial tissue, during autopsy and other by histopathological examination. Methods The sample size of 60 hearts taken from all the sudden deaths cases brought to Mortuary with suspected cause of death due to cardiac origin. The heart was obtained from the deceased by standard post-mortem technique. Serial full-thickness transverse sections of the heart were taken at 2 cm intervals from the apex to the atrioventricular groove. All the serial slices of heart are taken for histochemical staining and TTC staining. Results In histopathological examination 34 hearts were diagnosed with myocardial infarction and 26 hearts reported non myocardial infarction. With TTC 40 hearts remained unstained suggestive of myocardial infarction and 20 hearts were stained suggestive of non-infarcted hearts. TTC staining in our study shows an accuracy of 88.33%. Conclusion The result of this study shows that the Triphenyl Tetrazolium Chloride test, a histochemical staining technique of heart, is reliable approach for forensic pathologists to diagnose early myocardial infarction during the post-mortem examination.

Efficacy of balloon-expandable extreme-low-temperature ventricular epicardial cryoablation: A preclinical proof of concept evaluation

BackgroundCurrent epicardial ablation technologies are limited by the inability to create adequate depth lesions and risk of collateral injury to extracardiac structures. ObjectiveThe purpose of this study was to evaluate the feasibility and efficacy of ventricular epicardial ablation with a novel balloon-expandable extreme-low-temperature (XLT) cryoablation catheter with an embedded insulation pontoon for protection of extracardiac structures, which has been specifically designed for epicardial ablation. MethodsTen healthy swine underwent surgical (n = 6) and subxiphoid percutaneous (n = 4) epicardial access. A total of 3–6 sites were targeted in the right and left ventricular wall for different exposure durations. Ablation was performed with a large footprint (surgical) and smaller footprint (percutaneous) version of the HeartPad (Corfigo Inc., Montclair, NJ) XLT system. The system consists of the balloon-expandable cryoablation catheter and a console. The console vaporizes liquid helium (–269°C) and controls continuous delivery of extremely cold helium gas at high flow rates through a high-efficiency ablation element mounted on an expandable insulation pontoon to protect extracardiac structures. Ablation lesions were assessed by gross pathology and histologic examination. ResultsA total of 42 epicardial lesions were created. Mean lesion depth increased progressively with ablation time (surgical catheter: 11 ± 2 mm at ≤30 seconds, 13 ± 4 mm at 60 seconds, 15 ± 3 mm at ≥120 seconds, P = .001; percutaneous catheter: 10 ± 2 mm at 30 seconds, 14 ± 2 mm at 60 seconds, 16 ± 2 mm at 120 seconds, P = .001). Lesion geometry seemed unaffected by presence and thickness of epicardial fat. One episode of ventricular fibrillation occurred after ablation over the atrioventricular groove and 2 adjacent obtuse marginal arteries. ConclusionSurgical or percutaneous epicardial ablation using the HeartPad XLT cryoablation system is feasible and can efficiently produce deep ventricular lesions in different epicardial locations.

Exploring the interplay between epicardial fat, coronary artery calcium score, and nonalcoholic fatty liver disease through non-ECG-gated chest computed tomography: A cross-sectional study.

This study examines the relationships between epicardial adipose tissue (EAT), nonalcoholic fatty liver disease (NAFLD), and coronary artery calcium score (CACS) using non-ECG-gated CT scans. It aims to determine the effectiveness of EAT measurements and NAFLD as predictors for coronary artery disease (CAD). This cross-sectional study was conducted at a specialized center, focusing on individuals who underwent non-ECG-gated chest CT scans without contrast. We evaluated EAT thickness and density in three areas: the right atrioventricular groove, the free wall of the right ventricle, and the central area of the right anterior interventricular groove. Additionally, we measured CACS and determined the presence of NAFLD by comparing liver-to-spleen density ratios. Statistical analyses, including regression models, were performed using SPSS (version 26). In this study, we enrolled 365 participants, including 203 males with an average age of 47 ± 17.93 years. EAT thickness was 6.28 ± 1.62 mm, and EAT density was -96.07 ± 12.47 Hounsfield units (HU). The mean CACS was 22.27 ± 79.01, and the mean liver density was 50.01 ± 10.76 HU. A significant positive correlation was observed between EAT thickness and CACS (r = 0.208, p < 0.001). EAT density showed a significant negative correlation with CACS (r = -0.155, p = 0.003). No correlation was found between NAFLD and CACS. Univariate logistic regression analysis identified significant predictors of increased CACS, including EAT thickness (OR: 1.803), EAT density (OR: 0.671), diabetes mellitus (DM) (OR: 5.921), and hypertension (HTN) (OR: 7.414). Multivariate analysis confirmed the significance of EAT thickness (OR: 0.682), DM (OR: 3.66), and HTN (OR: 2.79) as predictors of elevated CACS. Our findings demonstrate that increased EAT thickness and decreased density are associated with higher CACS. Also, both DM and HTN significantly contribute to increased CACS. These results support the inclusion of EAT measurements in cardiovascular risk assessment models to enhance diagnostic accuracy.

Pectus excavatum: the effect of tricuspid valve compression on cardiac function

BackgroundPectus excavatum (PE) is a common congenital chest wall deformity with various associated health concerns, including psychosocial impacts, academic challenges, and potential cardiopulmonary effects.ObjectiveThis study aimed to investigate the cardiac consequences of right atrioventricular groove compression in PE using cardiac magnetic resonance imaging.Materials and methodsA retrospective analysis was conducted on 661 patients with PE referred for evaluation. Patients were categorized into three groups based on the degree of right atrioventricular groove compression (no compression (NC), partial compression (PC), and complete compression(CC)). Chest wall indices were measured: pectus index (PI), depression index (DI), correction index (CI), and sternal torsion.ResultsThe study revealed significant differences in chest wall indices between the groups: PE, NC=4.15 ± 0.94, PC=4.93 ± 1.24, and CC=7.2 ± 4.01 (P<0.0001). Left ventricle ejection fraction (LVEF) showed no significant differences: LVEF, NC=58.72% ± 3.94, PC=58.49% ± 4.02, and CC=57.95% ± 3.92 (P=0.0984). Right ventricular ejection fraction (RVEF) demonstrated significant differences: RVEF, NC=55.2% ± 5.3, PC=53.8% ± 4.4, and CC=53.1% ± 4.8 (P≥0.0001). Notably, the tricuspid valve (TV) measurement on the four-chamber view decreased in patients with greater compression: NC=29.52 ± 4.6; PC=28.26 ± 4.8; and CC=24.74 ± 5.73 (P<0.0001).ConclusionThis study provides valuable insights into the cardiac consequences of right atrioventricular groove compression in PE and lends further evidence of mild cardiac changes due to PE.Graphical abstract

Short-term outcomes of robotic left ventricular patch ventriculoplasty for significant mitral annular calcification

ObjectiveSurgical management of mitral annular calcification remains challenging. Our institution pursued a strategy of total mitral annular calcification resection with pericardial patch reconstruction of the left ventricle when primary atrioventricular groove closure was not possible. We present the short-term outcomes derived after implementing this strategy. MethodsA single-institution retrospective analysis included patients with significant mitral annular calcification undergoing totally endoscopic robotic mitral valve surgery between October 2009 and August 2023. Mitral valve repair was performed in patients with sufficient posterior leaflet length. Patients requiring pericardial patch ventriculoplasty were compared with those in whom primary atrioventricular groove closure was possible (non–pericardial patch ventriculoplasty). ResultsOf 1441 patients who underwent totally endoscopic mitral valve surgery, 217 (15.1%) presented with significant mitral annular calcification. Pericardial patch ventriculoplasty was performed in 69 patients (31.8%). Patients undergoing non–pericardial patch ventriculoplasty were significantly younger than patients undergoing pericardial patch ventriculoplasty (63.4 vs 67.8 years, P = .01). Mitral valve repair was conducted in 145 patients (98.0%) in the non–pericardial patch ventriculoplasty group versus 56 patients (81.2%) in the pericardial patch ventriculoplasty group (P < .01). The median postoperative length of stay was significantly shorter in the non–pericardial patch ventriculoplasty group (3 vs 5 days, P < .01). There was no significant difference in postoperative stroke (0.7% vs 2.9%, P = .50) or 30-day mortality (1.4% vs 1.4%, P = 1.00). Three-year survival was comparable between the groups (97.4% vs 93.7%, P = .52). ConclusionsTotally endoscopic robotic mitral valve repair is a safe and feasible technique for the management of mitral annular calcification with promising results at 3 years. Patients who required atrioventricular groove pericardial patch reconstruction had similar outcomes to those in whom primary closure was possible.

Approach to Severe Mitral Annular Calcification Using Ultrasonic Aspiration

Severe mitral annular calcification (MAC) is perhaps the greatest challenge faced in mitral valve surgery. Valve replacement in the setting of severe MAC carries with it the risk of numerous surgical complications and modes of technical failure, including catastrophic atrioventricular (AV) groove disruption. In the face of these challenges, a variety of surgical approaches to severe MAC have been described but without clear consensus. We describe an approach using the Cavitron Ultrasonic Surgical Aspirator (CUSA) emphasizing minimal, focal disruption of annular calcium. Ultrasonic aspiration is applied only when needed and only at the precise site of valve suture placement to aspirate away or merely soften dense calcium such that sutures can be placed through or around the calcified annulus. Our approach is simple and eliminates the need for complete annular decalcification which risks avoidable AV groove destabilization and requires complex annular reconstruction. In our experience of 55 cases of high-risk mitral replacement in the setting of very severe MAC, we report two cases of AV groove disruption (4%), two cases of coronary injury (4%), and two cases of stroke (4%), with no cases of paravalvular leak worse than mild. In-hospital mortality was 16%, due largely to significant underlying cardiac and non-cardiac comorbidity and underscoring the often underestimated non-technical risks inherent in these cases. While no single approach may be optimal in every case of severe MAC, we feel our technique of limited ultrasonic aspiration is an important tool in the mitral surgeon's armamentarium.

Secondary cardiac lymphoma presenting with cardiac tamponade and cardiac mass: a case report

BackgroundCardiac tamponade as the presenting manifestation of systemic lymphoma is relatively uncommon. Pericardium is the commonest site of involvement in secondary malignancies with systemic lymphoma involving the heart in 20% of the cases.Case presentationWe describe a case of a 78-year-old gentleman, who presented with symptoms of new onset cardiac failure, and hemodynamic compromise. An echocardiography revealed cardiac tamponade, necessitating an emergency pericardiocentesis. With the aid of multimodality imaging, he was found to have a right atrioventricular groove mass, widespread lymph node enlargement with bone and peritoneal involvement. Ultimately, a histopathological evaluation revealed a diagnosis of Diffuse Large B Cell Lymphoma (DLBCL).ConclusionsOur case illustrates that a patient with DLBCL may present with cardiac tamponade as a result of metastasis. This diagnosis, although rare, is likely to be missed, which can cause fatal complications, such as cardiac tamponade, fatal arrhythmias or sudden cardiac death.

Cracking The Case of The Cryptic Coronary: Diagnostic Strategies for Anomalous RCA Originating from LAD

Background: Coronary artery anomalies are typically congenital, though they may remain undetected until routine cardiac catheterization is performed. With a detection rate of only 1.3%, these anomalies often go unnoticed. In rare cases, the right coronary artery may originate from the left coronary system, but this anomaly is generally benign. Case presentation: A 55-year-old male patient was diagnosed with NSTEMI and underwent coronary angiography. However, despite multiple attempts, the medical team could not cannulate into the right coronary ostium. The left coronary ostium was located in the left sinus of Valsalva. Selective left coronary arteriography revealed normal courses of the left main and LAD but identified a critical stenosis in the LCx and a possible CTO at the RCA ostium. The patient received a stent in the LCx and returned the following month for another angiography, during which he received a stent in the proximal LAD. However, during cine angiography, it was found that the patient had an anomalous RCA that originated from the mid-portion of LAD, coursing anteriorly to the pulmonary artery and down to the right atrioventricular groove. Subsequent CCTA confirmed the RCA's origin from the mid-LAD. Conclusion: The report finds a rare RCA origin in the mid-LAD. The heart and its complex arterial network may be examined thoroughly, appreciate to coronary CTA, a non-invasive imaging approach. This allows for effective interventional cardiovascular therapy and is helpful for medical cardiac abnormality detection and assessment. Keyword: Anomalous Right Coronary Artery, CT Coronary Angiography, RCA from LAD, Single Coronary Artery.

Cardiovascular manifestations of Erdheim-Chester disease: A narrative review with two cases.

Erdheim-Chester disease (ECD) is a rare 'L' (Langerhans) group histiocytic neoplasm that affects a multitude of organ systems, causing osteosclerotic bone lesions, periaortic encasement ('coated' aorta), retroperitoneal fibrosis involving kidneys and ureters ('hairy kidney'), and infiltration of the central nervous system. Cardiovascular involvement can occur in up to 70% of patients and is usually found during computed tomography/magnetic resonance imaging evaluation. When present, cardiovascular symptoms can have wide variability in presentation from asymptomatic to pericarditis, fatal cardiac tamponade, myocardial infarction, conduction abnormalities, heart failure, renal artery stenosis, and claudication. Cardiac involvement found on imaging includes right atrial pseudotumor, right atrioventricular groove infiltration, and pericardial effusions. ECD can involve the large- and medium-sized arteries, often seen as periarterial thickening (commonly coating the aorta) with stenosis/occlusion. Although more cardiovascular ECD cases have begun to be published in the literature, more data are needed on the outcomes of these patients, as well as how cardiovascular manifestations respond to treatment of ECD.

The Correlation between Region-specific Epicardial Adipose Tissue and Myocardial Ischemia Defined by CT-FFR in Type 2 Diabetes Mellitus Patients.

Epicardial Adipose Tissue (EAT) accumulation is closely associated with the presence and severity of coronary artery disease (CAD), myocardial ischemia, plaque vulnerability, and major adverse cardiovascular events. The aim of this study was to investigate the correlation between myocardial ischemia defined by computed tomography-derived fractional flow reserve (CT-FFR) and region-specific EAT in patients with type 2 diabetes mellitus (T2DM). Between January 2022 and May 2023, 200 T2DM patients were randomly selected from the Department of Endocrinology in The Central Hospital of Wuhan. These patients were divided into two groups based on myocardial ischemia defined by CT-FFR: myocardial ischemia group (152 cases) and control group (48 cases). Both groups of patients used a post-treatment workstation to measure the thickness of region-specific EAT. Receiver operating characteristic (ROC) curve analysis and binary logistic regression were used to evaluate the correlation between various parameters and myocardial ischemia. Patients in the myocardial ischemia group had significantly higher values of age, male gender, systolic blood pressure, total cholesterol, triglycerides, LDL, HDL, fasting blood glucose, fasting insulin, HOMA-IR, EAT thickness in right ventricular wall, left atrioventricular groove, and superior and inferior interventricular groove. ROC curve analysis results showed that EAT thickness in the left atrioventricular groove had the largest area under the ROC curve for diagnosing myocardial ischemia (0.837 [95% CI 0.766-0.865]; P < 0.001). Binary logistic regression analysis showed that EAT thickness in the left atrioventricular groove was an independent risk factor for myocardial ischemia in patients with T2DM (P < 0.05). The EAT thickness in the left atrioventricular groove is an independent risk factor for myocardial ischemia in patients with T2DM. Adipose tissue in the left atrioventricular groove region plays a major role in EAT-mediated CAD.

Globe in the Heart: A Rare Case Report of Giant Coronary Artery Aneurysm

A 22-year-old male having cardiomegaly with prominent right atrium (RA) enlargement in his chest X-ray underwent echocardiography which revealed an anterior mediastinal cystic lesion. Contrast-enhanced computed tomography of the thorax showed saccular contrast filling outpouching from ostia of the right coronary artery (RCA) of size 5.9 × 6.4 cm in anterior atrioventricular groove compressing RA and right ventricle along the RCA course. The left main coronary artery also appeared to be dilated with a diameter of 1.1 cm proximally. The patient denied any prior angina, palpitation, and dyspnea on exertion. This case is reported for its rarity and the dilemma involving its appropriate medical and surgical management.

A case report of left circumflex stent infection and mycotic aneurysm: a rare but life-threatening complication of percutaneous coronary intervention

BackgroundCoronary stent infections are an uncommon but deadly complication of percutaneous coronary intervention. Mortality remains as high as 40–60% even with adequate treatment. We report such an interesting case of left circumflex stent (LCX) infection and mycotic aneurysm that was successfully managed with antibiotics and surgery.Case presentationA middle-aged man who underwent percutaneous coronary intervention (PCI) to the left circumflex artery four weeks prior was referred as a case of pyrexia of unknown origin, not responding to antibiotics, and colchicine started for suspected Dressler syndrome. Although the inflammatory markers were elevated, the results of the blood culture did not show any growth. Echocardiography showed a doubtful echogenic structure in the left atrioventricular groove and mild pericardial effusion, and a stent infection was suspected. PET scan showed focal metabolic activity in the region of the LCX stent, with metabolically active supraclavicular and paratracheal lymph nodes, and a coronary angiogram revealed an aneurysm arising distal to the stented LCX. A diagnosis of stent infection and associated mycotic aneurysm was made, and the patient underwent surgery which included aneurysm repair, stent retrieval, and coronary artery bypass graft (CABG) to the major and terminal OM. The postoperative course was uneventful, and the patient was discharged without complications.ConclusionsIt is important to investigate the possibility of coronary stent infection in individuals experiencing prolonged fever following PCI. PET scans and coronary angiograms can aid in diagnosis when echocardiograms are inconclusive. Adequate antibiotic therapy and timely surgery are crucial for successfully managing coronary stent infections.

The epicardial adipose tissue confined in the atrioventricular groove can be used to assess atrial adipose tissue and atrial dysfunction in cardiac magnetic resonance imaging.

The growing interest in epicardial adipose tissue (EAT) as a biomarker of atrial fibrillation is limited by the difficulties in isolating EAT from other paracardial adipose tissues. We tested the feasibility and value of measuring the pure EAT contained in the atrioventricular groove (GEAT) using cardiovascular magnetic resonance (CMR) imaging in patients with distinct metabolic disorders. CMR was performed on 100 patients from the MetaCardis cohort: obese (n = 18), metabolic syndrome (MSD) (n = 25), type-2 diabetes (T2D) (n = 42), and age- and gender-matched healthy controls (n = 15). GEAT volume measured from long-axis views was obtained in all patients with a strong correlation between GEAT and atrial EAT (r = 0.95; P < 0.0001). GEAT volume was higher in the three groups of patients with metabolic disorders and highest in the MSD group compared with controls. GEAT volume, as well as body mass and body fat, allowed obese, T2D, and MSD patients to be distinguished from controls. GEAT T1 relaxation and peak longitudinal left atrial (LA) strain in CMR were decreased in T2D patients. Logistic regression and random forest machine learning methods were used to create an algorithm combining GEAT volume, GEAT T1, and peak LA strain to identify T2D patients from other groups with an area under curve (AUC) of 0.81 (Se: 77%, Spe: 80%; 95% confidence interval 0.72-0.91, P < 0.0001). Atrioventricular groove adipose tissue characteristics measured during routine CMR can be used as a proxy of atrial EAT and integrated in a multi-parametric CMR biomarker for early identification of atrial cardiomyopathy.

Clinical Presentation and Therapy of Coronary Artery Anomalies.

There are two major coronary arteries that arise normally directly above the aortic valve in the sinus. The left main coronary artery (LCA or LMCA) arises from the left coronary sinus and divides shortly after its origin into the left anterior descending and the circumflex coronary arteries (LCX). Branches of the left anterior descending (LAD) coronary artery include the left conus, septal, and diagonal arteries. Branches of the circumflex coronary artery may include the sinus node artery, Kugel's artery, marginal arteries, and the left atrial circumflex artery (Fig. 47.1). The LAD follows the interventricular septum to the apex, the LCX turns posterior, follows the atrioventricular groove between the left atrium and ventricle to the coronary sinus. Branches of the right coronary artery (RCX) include the conal branch, the sinus node artery, an atrial branch, the right ventricular muscle branches (including the acute marginal branch), the posterior descending coronary artery, the atrioventricular node artery, and septal branches (Fig. 47.2). The RCX follows the atrioventricular groove between the right atrium and ventricle. The "dominant coronary artery" is the one giving rise to the posterior descending coronary artery. It originates from the right coronary artery in 80% of people.

Compressive Intrapericardial Hematoma Following Thoracotomy to Seal Coronary Artery Perforation

Abstract A 68-year-old male developed cardiac tamponade secondary to coronary artery perforation following percutaneous coronary artery intervention. He underwent thoracotomy to seal the perforation of the acute marginal branch of the right coronary artery. Following sealing of perforation with application of cyanoacrylate to the right atrioventricular groove, the patient remained stable with minimal pericardial effusion for 1 month and later developed a large (6 cm × 5 cm) intrapericardial hematoma compressing the right ventricular inflow with intermittent fever. The patient declined repeat surgery and showed some regression of hematoma and a decrease in trans-tricuspid pressure gradients with colchicine after 1 month. The case is reported for its rarity with a review of literature.

Successful surgical treatment for primary cardiac angiosarcoma: a case report

BackgroundPrimary cardiac angiosarcomas are extremely rare and their prognosis is poor. Surgical resection is the first-line treatment; however, no clear standard of care has been clearly established because of the rarity of these tumors.Case presentationA 61-year-old man who had presented with dyspnea on exertion was referred to our hospital. Contrast-enhanced computed tomography revealed massive pericardial effusion and a 40-mm enhanced mass adherent to the anterior wall of the right atrium and involving the right coronary artery. Having diagnosed the mass as a cardiac tumor, we resected the mass under the guidance of epi-cardiac echocardiography guidance, which showed continuity between the tumor and the right atrium, reconstructed the right atrial free wall with a bovine pericardial patch, and performed coronary artery bypass grafting to the right coronary artery using the great saphenous vein. The right atrial wall was resected with adequate tumor-free margin. On the right ventricular side, we resected the right atrial wall 1 cm from the tumor, 2 cm from the atrioventricular groove. Because hemodynamic deterioration occurred after aortic declamping, intra-aortic balloon pumping and veno-arterial extracorporeal membrane oxygenation were instituted. Postoperatively, circulatory support devices were removed safely, and the patient was discharged on the 25th postoperative day. Histopathological examination of the surgical specimens resulted in a diagnosis of angiosarcoma, with positive surgical margins. Chemotherapy and radiotherapy (69 Gy in 30 fractions) were therefore initiated after discharge. To date, the patient has been alive and well with no recurrence of tumor for 4 years and 10 months since surgery.DiscussionThis case study suggests the usefulness of multimodality treatment comprising surgical resection and adjuvant therapy, for cardiac angiosarcoma.