Severe Stenosis Research Articles

This study aims to analyze the risk factors for stroke recurrence in patients with symptomatic intracranial artery stenosis and explore their long-term prognosis. By retrospectively analyzing the relationship between intracranial artery stenosis and stroke recurrence, this study provides clinical evidence for the prevention of stroke recurrence. This study retrospectively collected data from 181 patients diagnosed with cerebral infarction or transient ischemic attack (TIA) due to symptomatic intracranial artery stenosis between February 2020 and February 2023 at our hospital, with a follow-up period of 2 years. Patients were divided into a recurrence group and a nonrecurrence group based on whether they experienced a stroke recurrence (cerebral infarction or TIA). Baseline characteristics, clinical data, and imaging data were analyzed. Additionally, univariate and multivariate regression analyses were performed to assess the relationship between related risk factors and stroke recurrence. During the follow-up period, 65 patients (35.9%) had a stroke recurrence, including 42 cases of cerebral infarction and 23 cases of TIA. Univariate regression analysis showed that age, hypertension, diabetes, hyperlipidemia, and severe intracranial artery stenosis (≥70%) significantly increased the risk of stroke recurrence. Multivariate regression analysis further confirmed that hyperlipidemia (OR = 3.80, P <.001), diabetes (OR = 2.60, P = .015), and severe stenosis (OR = 4.20, P <.001) were independent risk factors for stroke recurrence. Furthermore, a synergistic pathogenic effect between diabetes and severe stenosis significantly increased the risk of stroke recurrence (interaction effect OR = 3.25, P = .008). This study indicates that hyperlipidemia, diabetes, and severe intracranial artery stenosis are important independent risk factors for stroke recurrence. The interaction between diabetes and severe stenosis may exacerbate the risk of stroke recurrence. Therefore, clinical attention should be given to the management of these high-risk factors to reduce the risk of stroke recurrence.

Background: Cardiac radioablation (CRA) is emerging as a treatment modality for refractory ventricular tachycardia (VT). This study aimed to evaluate the effects of radiation on the coronary arteries in a swine model of proton beam CRA. Methods: Eighteen domestic swine underwent 30–40 Gy pencil-beam scanning proton therapy in a single-fraction targeting the left ventricle with no attempt to spare coronary arteries and were euthanized 12-40 weeks later. Contrast-enhanced cardiac computed tomography (CT) was performed at baseline for treatment planning and at study end. Using dose-volume histograms, the maximum point (D max ), mean (D mean ) doses and the minimal doses received by the highest irradiated volumes of 0.01 cc (D 0.01cc ) for the left main, left anterior descending, circumflex, and right coronary artery, as well as the large diagonal and obtuse marginal branches were calculated. The D max location for each artery was mapped from the baseline planning CT onto the follow-up CT using deformable registration. Coronary artery segments were harvested from the D max sites for histological analysis. Receiver operating characteristic (ROC) analysis was performed to identify dose thresholds for predicting histologically severe coronary stenoses (≥75%). Results: Ninety-six coronary artery segments were analyzed. No stenoses were observed by CT imaging before irradiation. By histological analysis post-euthanasia, 25/96 (26%) coronary segments sampled at the Dmax site per artery had ≥75% stenosis. The median D max was 4.7 Gy for the &lt;75% stenosis group and 29.7 Gy for the ≥75% stenosis group (p&lt;0.001). The AUC-ROC for the association between D max and severe stenosis was 92.2%. A D max value of 20.1 Gy in a single fraction best predicted severe stenosis, with sensitivity of 92.3% and specificity of 87.1%. The AUC-ROC for the association between severe stenosis versus D mean and D 0.01cc was 84.8% and 91.6%, respectively. Based on histopathologic analysis, intimal hyperplasia was the most common coronary artery abnormality at the D max sites. Conclusion: In this pre-clinical model of proton beam CRA, coronary stenoses occurred in a dose-dependent manner, with D max being a better dosimetric predictor of stenosis than D mean and D 0.01cc . These data provide for the first time radiation dose constraint information for the epicardial coronary arteries that can be considered in treatment planning for CRA and radiation for thoracic malignancies.

Introduction: Recent clinical data have revealed a role for circulating cardiac troponin I (cTnI) concentrations as a prognostic tool in patients with stable coronary artery disease (CAD). However, the mechanisms underlying cTnI elevations in this population are poorly understood. We utilized a porcine model of chronic CAD to test the hypothesis that cTnI elevations reflect episodic demand-induced ischemia distal to a coronary stenosis and are therefore associated with more severe impairments in regional coronary flow reserve (CFR). Methods: Juvenile swine (n=66) were instrumented with fixed 1.5mm stenoses on the left anterior descending (LAD) and/or left circumflex (LCx) coronary arteries and followed for up to 5 months. Circulating cTnI concentrations were quantified with a porcine-specific high-sensitivity assay (Life Diagnostics) at a total of 98 timepoints across the study population. At the time of blood sampling, coronary stenosis severity was assessed via angiography and myocardial blood flow was quantified with fluorescent microspheres at rest and during intravenous administration of adenosine (0.9 mg/kg/min) to assess regional CFR. Results: cTnI was detectable in 72 of 98 samples (73%) and averaged 14.1±2.7 ng/L across the study population, which consisted of animals with a mean stenosis severity of 84±2% and mean CFR of 2.7±0.2 in the stenotic territory (vs. 5.3±0.2 in the remote territory; p&lt;0.001). Statistically significant correlations were not observed between cTnI and stenosis severity (r=0.14; p=0.15) or between cTnI and CFR (r=-0.12; p=0.24). Stenosis severity (82±2 vs. 83±3%; p=0.76) and CFR (2.7±0.2 vs. 2.6±0.2; p=0.60) did not differ between animals above vs. below the median cTnI value (3.1 ng/L). Similarly, between-group differences in cTnI were absent when animals were stratified by stenosis severity or CFR ( Figure ). Conclusion: In swine with chronic CAD, cTnI is measurable in the majority of subjects but circulating levels are not related to angiographic stenosis severity or regional CFR. These results suggest that demand-induced ischemia may not be a primary determinant of cTnI release in this population and support investigation of alternative causes of myocardial injury in stable CAD.

Background: Although fractional flow reserve (FFR) remains the gold standard for evaluating myocardial ischemia, its invasive nature limits widespread clinical adoption. CT-derived FFR (CT-FFR) offers a noninvasive alternative, yet its diagnostic consistency across different stenosis severity levels remains unclear. This study aims to evaluate the diagnostic accuracy and correlation of CT-FFR compared to invasive FFR, stratified by stenosis severity, to enhance precision in ischemia assessment. Methods: In this prospective study, 138 patients (mean age 62.4 ± 9.7 years; 64.5% male) with suspected or confirmed coronary artery disease (CAD) and stenosis ranging from 30% to 90% in major coronary arteries (≥2.0 mm diameter) underwent coronary CT angiography (CCTA) followed by CT-FFR analysis (Coronary Scope, Shenzhen Yueying Technology Co., Ltd., China). Invasive FFR (St. Jude Medical, Inc., USA) was performed within 15 days post-CCTA as the reference standard. Both CT-FFR and FFR assessments focused on a single target vessel per patient. Ischemia was defined as FFR ≤0.80, with the same threshold applied to CT-FFR. Stenosis severity was categorized into three groups: 30%–49%, 50%–69%, and 70%–90%. Diagnostic performance metrics (sensitivity, specificity) and correlation coefficients (r) were analyzed. Results: CT-FFR demonstrated outstanding diagnostic efficacy, with sensitivity, specificity, and accuracy of 96.2%, 97.7%, and 97.1%, respectively. A robust overall correlation was observed between CT-FFR and invasive FFR (r = 0.832, 95% CI: 0.773–0.877; p &lt; 0.001). Subgroup analysis revealed progressively stronger correlations with increasing stenosis severity: moderate for 30%–49% stenosis (r = 0.700, 95% CI: 0.483–0.836; p &lt; 0.0001), strong for 50%–69% stenosis (r = 0.755, 95% CI: 0.625–0.844; p &lt; 0.0001), and nearly perfect for 70%–90% stenosis (r = 0.914, 95% CI: 0.840–0.955; p &lt; 0.0001). The correlation in the 70%–90% group was significantly superior to the other groups (p &lt; 0.05). Conclusions: CT-FFR exhibits high diagnostic accuracy across a wide spectrum of coronary stenosis (30%–90%), with exceptional performance in severe stenosis (70%–90%). These results underscore the potential of CT-FFR as a frontline noninvasive modality for guiding revascularization strategies, particularly in cases of high-grade stenosis, and advocate for its integration into precision-driven CAD management protocols.

Description of Case: An 82-year-old female with coronary artery disease (CAD) and obesity status post Roux-en-Y gastric bypass was hospitalized with months of postprandial abdominal pain, nausea, and vomiting. The exam revealed mid-left abdominal and umbilical tenderness. CTA revealed bulky calcifications with severe short-segment stenosis in the proximal superior mesenteric artery (SMA), minor proximal narrowing in the celiac artery, and some calcifications at the origin of the inferior mesenteric artery (Image 1). Right femoral arterial access was obtained, and SMA was engaged using a 6-French IMA guide catheter. Angiogram showed a 99% heavily calcified proximal SMA stenosis with a patent celiac artery (Image 2A). A BMW wire was used to cross the proximal SMA lesion. Multiple balloons were tried, but were unable to cross the lesion. Turnpike and Finecross catheters were attempted for Rotawire exchange without success. The lesion was then crossed with a Rotawire. A 1.5 mm RotaPro burr was used to perform two passes of rotational atherectomy for 110 seconds. The Rotawire was exchanged for a Grandslam wire using a Finecross catheter. Balloon angioplasty was performed with 4.0 x 27 mm and 5.0 x 20 mm noncompliant Trek balloons. IVUS showed severe nodular calcific stenosis with fractures in calcium (Image 3). After vessel sizing, a 6.0 x 29 mm Omnilink stent was deployed in ostial-proximal SMA. Post-dilation was performed with a 6.0 x 20 mm Dorado balloon. Final angiography showed the reduction of stenosis to 20% with significantly improved flow (Image 2B). The patient had an uneventful recovery and complete symptom resolution. Discussion: Both surgical and endovascular revascularization are established treatments for chronic mesenteric ischemia, with endovascular therapy often favored in high-risk surgical candidates. Heavily calcified lesions challenge conventional angioplasty and stenting. While rotational atherectomy is established in CAD interventions, peripheral artery use is more conservative, reserving it for select cases. Its use in SMA is rarely reported. This case demonstrates the feasibility and benefit of rotational atherectomy in severe calcific SMA stenosis. It adds to the limited literature supporting this technique as an adjunct in complex abdominal artery interventions, particularly when standard endovascular methods are insufficient and surgical risk is high. The patient was treated without surgery, underscoring its role in high-risk cases.

Case Description: A 54-year-old male with ESRD on hemodialysis, tricuspid valve endocarditis status post bioprosthetic valve replacement, and atrial fibrillation status post catheter ablation one month prior, underwent elective Watchman device implantation. Following successful device placement, the patient continued to require ventilator support. Intra-procedural TEE revealed a known iatrogenic atrial septal defect (iASD) from prior ablation with a moderate right-to-left shunt and a peak gradient of 16 mmHg. The bioprosthetic tricuspid valve demonstrated severe stenosis. Additional findings included moderate-to-severe tricuspid regurgitation, a severely dilated right atrium, and preserved left ventricular ejection fraction. The patient remained ventilator-dependent and developed septic shock within 24 hours secondary to pneumonia. Despite dialysis and antibiotic therapy, hypoxia persisted. The right-to-left shunt across the iASD, driven by elevated right atrial pressure from severe tricuspid stenosis, was identified as a major contributor. On hospital day 9, the patient underwent transcatheter tricuspid valve replacement. Following the procedure, he improved rapidly, was extubated within 48 hours, and was discharged four days later, off supplemental oxygen and ambulating with support. At 45-day follow-up, he remained asymptomatic. TEE showed a well-functioning tricuspid prosthesis, moderately dilated right atrium, and two small ASDs with predominantly left-to-right flow. Discussion: Transseptal puncture is an essential component of Watchman device implantation. Factors such as the size and stiffness of the delivery sheath, repeated septal instrumentation, or prolonged left atrial dwell time may increase the risk of persistent iASD. Recent studies have shown that up to one-third of patients undergoing left atrial appendage closure may have persistent iASDs at 45-day follow-up, with a smaller subset exhibiting right-to-left shunting often in the context of elevated right-sided pressures. In patients with pre-existing iASDs from prior transseptal procedures, the cumulative impact may result in clinically significant hypoxia following device implantation. In this case, the patient’s hemodynamic instability was further exacerbated by sepsis and volume overload due to ESRD, both of which increased right-sided pressures and worsened the shunt. The definitive intervention involved treating the underlying cause, tricuspid stenosis, rather than closing the iASD.

Molecular Imaging of Fibroblast Activation Protein on PET/MRI: Association With Carotid-Ulcerated Plaques and Cerebrovascular Risk Factors.

Background: Regular monitoring of performance in ECG stress tests can enable early detection of subtle conduction/morphological changes and enable more accurate risk stratification. However, repeated stress ECGs are impossible in high-risk patients including those with severe stenosis, recent surgery or significant arrhythmia burden. An ECG foundational model capable of reconstructing 12-lead ECGs from a single lead typically available from wearables (e.g., apple watch: lead I) can create ambulatory stress ECG tests which obviate this problem. Hypothesis: We hypothesized that a self-supervised transformer model pretrained on reconstructing 11 masked leads using lead I can learn latent features for predicting peak heart rate (HR) across exercise stages and synthesize vectorcardiograms (VCG) for risk stratification in stress ECGs. Methods: We collected 7,625 stress test records from a single institution, from which 7,453 samples were included. This was divided into 4,447 training, 759 validation and 2,247 test ECGs which were used to develop a 6-layer transformer encoder architecture. A transposed-convolutional decoder with skip connection was used to reconstruct the masked leads while auxiliary linear layers regressed on VCG obtained using Dower transform and peak HR. A contrastive regularization loss was used to organize the latent space by reducing the distance between beats belonging to the same patient. The model was first trained solely on the reconstruction task (self-supervised pretraining) for 20 epochs, following which the decoder was frozen, and the encoder + auxiliary heads were supervised fine-tuned for 60 epochs to learn peak HR and VCG reconstructions. Training was performed with batch size = 32 and learning rate = 3x10 -3 during pretraining followed by 3x10 -4 during fine-tuning. Results: The model achieved A) a reconstruction mean squared error (MSE) of 0.16 mv2 on the masked leads, B) a R of 0.73 on peak HR regression, AUC = 0.82, AUPRC = 0.9 on high (&gt; 120 bpm) peak HR classification, C) and Pearson R of 0.96, 0.95 and 0.98 on x, y, z axes of VCG in the held-out test dataset. (Fig 1) Conclusion: We are able to faithfully reconstruct 12-lead beat morphology from lead I which was valid across ST segments, QRS complexes and PR intervals. This self-supervised pretraining step was applicable in creating ambulatory, morphology aware stress ECG indices for a large hold-out test set.

Background: Aortic stenosis (AS) severity assessment traditionally relies on Doppler echocardiography, which is time-consuming and may be inconclusive in a subset of patients. Efficient, automated approaches using routinely acquired 2D echocardiographic views could support clinical workflows by rapidly classifying AS severity with minimal user input. Research Question: Can a computer vision algorithm applied to a single echocardiographic view efficiently classify AS severity based on aortic valve leaflet motion? Methods: We conducted a retrospective analysis of 223 echocardiograms from patients undergoing routine clinical evaluation for suspected AS across the entire severity spectrum. All studies included parasternal long-axis (PLAX) views for visualising aortic valve motion. A semi-automated computer vision algorithm was developed to track the angular motion of the right coronary cusp (RCC) of the aortic valve. From this, we derived a novel quantitative feature, leaflet angular displacement. To normalise for hemodynamic variability, leaflet displacement was indexed by transaortic volumetric flow rate derived from Doppler measurements, resulting in a derived metric termed displacement:flow ratio. AS severity was classified into three categories – no AS, moderate AS, and severe AS – based on current clinical guidelines. We evaluated model performance using area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity. Results: Of the 223 patients included, 65 had no AS, 69 had moderate AS, and 89 had severe AS. The algorithm achieved an overall classification accuracy of 87.13%, with an AUC of 0.96 (Figure 1), demonstrating excellent discriminative capability. The sensitivity for detecting AS was 95.24%, while the specificity was 84.38%. Performance was highest in studies with optimal leaflet visualisation, where the algorithm exhibited robust tracking and consistent measurements. Conclusions: Leaflet motion analysis from the PLAX view using computer vision enables efficient classification of AS severity without the need for Doppler data. This approach holds promise as a rapid screening tool to augment existing clinical workflows, particularly where Doppler measurements are challenging or unavailable. Future work will focus on improving robustness to suboptimal imaging, extending the approach to incorporate additional echocardiographic views, and validating model performance to support generalizability and translation.

Background: The ramus intermedius (RI) is a variant artery arising from the trifurcation of the left main (LM) coronary artery. While RI has been found to be associated with greater LM plaque burden, its relationship with total coronary atherosclerotic plaque burden across the coronary tree remains unclear. We aimed to assess whether the presence of RI is associated with greater plaque, stenosis, and segment involvement across the coronary tree. Methods: We conducted a large retrospective single-center study of 11,497 adults who underwent coronary CT angiography between October 2006 and December 2022 in Los Angeles, California. Kruskal-Wallis test was used to compare total plaque score (TPS), total stenosis score (TSS), and segment involvement score (SIS) among individuals with and without RI. Multivariable logistic regression was performed to evaluate the association between the presence of RI and overall coronary plaque burden, adjusting for traditional cardiovascular risk factors, including age, ethnicity, sex, BMI, hypertension, diabetes, dyslipidemia, and smoking status. Results: Among the 11,497 subjects (mean age 62.0 ± 12.4 years, 64% male), 11% had a ramus intermedius present. Individuals with RI had significantly higher total plaque scores [median 5.0, IQR 2.0 - 8.0 vs. 3.0, IQR 0.0 - 8.0], total stenosis scores [6.0, IQR 2.0 - 11.0 vs. 3.0, IQR 0.0 - 9.0], and segment involvement scores [6.0, IQR 2.0 - 12.0 vs. 3.0, IQR 0.0 - 6.0] compared to those without RI (all p &lt; 0.0001). In a multivariable logistic regression model adjusting for cardiovascular risk factors, the presence of an RI was associated with the presence of any coronary plaque (OR 1.71 [1.51,1.95] p &lt; 0.001). Conclusion: The presence of the ramus intermedius variant is associated with significantly greater overall coronary plaque burden, stenosis severity, and segment involvement. These findings suggest that RI may be linked to more diffuse coronary atherosclerosis, potentially due to altered hemodynamic stability in the coronary vasculature.

Background: The PREVENT equations estimates 10-year total CVD risk using clinical and laboratory data. Its association with coronary plaque morphology using coronary CT angiography (CCTA) remains unclear. Moreover, it is unknown whether lipoprotein(a) [Lp(a)], an established marker of cardiovascular risk, provides additional predictive value for coronary plaque burden beyond that offered by the PREVENT equations. Objective: Assess the association between predicted 10-year total CVD risk and coronary plaque features, and evaluate whether Lp(a) adds predictive value. Methods: We conducted a retrospective study, asymptomatic patients without prior cardiovascular events underwent coronary computed tomography angiography (CCTA) between 2018 and 2024. Coronary plaque characteristics were quantified using artificial intelligence (AI)-based analysis. One-way ANOVA was used to assess differences in plaque burden across risk categories using the 10-year total predicted CVD based on the PREVENT equations: low risk (&lt;5%), borderline risk (5-7.4%), intermediate risk (7.5-19.9%), and high risk (≥20%). We used linear regression to assess associations between 10-year total predicted CVD risk and total plaque volume (TPV), calcified plaque (CP), non-calcified plaque (NCP), and low-density non-calcified plaque (LDNCP). Lp(a), modeled per 50 nmol/L, was then added to a model that included 10-year predicted total CVD risk to assess its contribution beyond the PREVENT score. Results: The cohort included 525 adults with a mean age of 55.8 years; 30% were female; and 51% were taking a statin. Total, calcified and non-calcified plaque burden, stenosis severity, and remodeling index increased across higher 10-year total CVD risk categories (p&lt;0.001 for trend; Figure 1 ). LDNCP was not associated with 10-year total CVD risk. When analyzing the PREVENT score as a continuous variable, higher scores were associated with greater TPV, CP, and NCP (all p&lt;0.001, Table 1 ), but not LDNCP (p=0.15). Higher Lp(a) was associated with TPV, CP, and NCP after adjustment for 10-year total CVD risk ( Table 1 ). Conclusion: The 10-year predicted total CVD risk estimated by the PREVENT equations was associated with coronary plaque burden, including calcified and non-calcified components. These results support estimating 10-year predicted total CVD risk using the PREVENT equations as a tool for subclinical atherosclerosis risk assessment and highlight the relevance of Lp(a) in identifying residual plaque risk.

Background: Body composition indicators (BCIs) are metrics for assessing the components of the body, such as waist circumference (WC), body mass index (BMI), lean body mass index (LBMI), and visceral-to-subcutaneous fat area ratio (V/S ratio), and are considered associational factors of coronary artery disease (CAD). LBMI is a convenient marker of frailty and sarcopenia and can be calculated using an estimation formula that requires only an individual’s height and weight. Recently, abdominal fat distribution (AFD) assessed by the V/S ratio has been determined as one of the important risk factors for CAD. However, studies investigating the relationship between BCIs and CAD severity are limited. The computed tomography (CT)–derived SYNTAX score (CT-SX score) is a feasible method for grading CAD severity based on the coronary CT angiography (CTA) findings. This study aimed to evaluate the association between BCIs and CAD severity using the CT-SX score. Methods: We enrolled 931 consecutive patients with suspected CAD who underwent CTA. Plain abdominal CT was also performed at the umbilical level to measure WC by tracing the body contour and to calculate the V/S ratio to assess the AFD. The severity of coronary artery stenosis was assessed using CTA, with significant stenosis defined as a stenosis diameter of ≥50%. The CT-SX score was calculated in patients with &gt;1 significant stenosis. Each stenotic lesion was assessed to calculate the CT-SX score, following the same methodology as the invasive coronary angiography assessment. Finally, the relationship between the BCIs (i.e., WC, BMI, LBMI, and V/S ratios) and the CT-SX score was evaluated. Results: Of the 931 patients enrolled, 308 (33.1%) had ≥1 significant stenosis. Although WC and BMI had no association with the CT-SX score, strong correlations were observed between the CT-SX score and the factors LBMI and V/S ratio. In the multivariate regression analysis after adjusting for traditional coronary risk factors, LBMI and V/S ratio remained as the independent predictors of CAD severity based on the CT-SX score (Figure). Conclusions: The findings suggest that among the BCIs studied, only LBMI and the V/S ratio are strong predictors of CAD severity, as stratified by the CT-SX score. Because the estimated LBMI can be more easily assessed than the V/S ratio, the former may be a valuable predictor of CAD severity in daily clinical practice.

The optimal treatment approach for patients with severe atherosclerotic vertebral artery ostial stenosis (VAOS) is not yet supported by evidence from large-scale studies. Even with optimal medical treatment and effective risk factor management, substantial numbers of patients experience symptoms or recurrent strokes. Endovascular treatment is a potential solution, particularly when medicinal therapy alone is insufficient for symptom and stroke risk reduction. This study was aimed at assessing the safety and effectiveness of stent angioplasty in patients with VAOS. This single-centre retrospective analysis included 564 procedures in 525 patients (symptomatic n=265, without recent symptoms n=260; 72.2% male; median age: 70 years; stenosis >75% n=371) who underwent stenting for atherosclerotic VAOS between 2008 and 2022. Vertebrobasilar tandem lesions and dissections were excluded. Digital subtraction angiography was performed in all patients during the follow-up. Patients' characteristics, periprocedural and postprocedural neurological events, and follow-up data were evaluated. Stenting was successfully performed in all cases. The in-hospital stroke rate was 0.6% (disabling n=2; non-disabling n=1). No ipsilateral stroke or treatment-associated deaths occurred during a mean follow-up period of 56 months (min.-max., 9-183 months). In-stent restenosis >50% was found in 89 (15.8%) implanted stents, with the majority (70 out of 89) diagnosed within the first year, at a median time of 7 months. Stent angioplasty was demonstrated to be a safe and feasible option for patients with VAOS, with a low risk of periprocedural stroke and symptom recurrence, and favourable stent patency rates at mid-term and long-term follow-up.

Background: Cold agglutinin disease (CAD) is a rare autoimmune hemolytic anemia that poses critical challenges during cardiopulmonary bypass (CPB). Exposure to hypothermia during cardiac surgery can lead to hemolysis, transfusion reactions, and disseminated intravascular coagulation (DIC). Meticulous thermal control and interdisciplinary coordination are essential to optimize outcomes. Case: A 68-year-old man with prior mitral valve repair, atrial fibrillation, and multivessel coronary artery disease presented with progressive heart failure. Imaging confirmed severe mitral stenosis, tricuspid regurgitation, and a high coronary calcium burden. He underwent CABG, mitral valve replacement, tricuspid repair, Maze procedure, and left atrial appendage exclusion. Preoperative labs revealed CAD, prompting a normothermic CPB strategy. Despite avoiding hypothermia and using warmed fluids, the patient developed hemolysis, DIC, and multiorgan failure postoperatively. Escalation to intra-aortic balloon pump and VA-ECMO was ineffective, and he ultimately died. Decision-making: The presence of CAD required early hematology input and intraoperative modifications including normothermic perfusion and warmed cardioplegia. Plasmapheresis and complement blockade (e.g., sutimlimab) were not accessible in this urgent setting but represent important future strategies. Despite optimal support, including transfusions and ECMO, the patient experienced progressive hemolysis and hemodynamic collapse. This case highlights the need for proactive planning, especially in patients with known CAD undergoing cardiac surgery. Conclusion: CAD can result in fatal complications during CPB despite best practices. This case underscores the importance of CAD screening, perioperative vigilance, and early use of targeted therapies. It highlights a need for consensus guidelines and research into disease-specific interventions, and reinforces the role of a coordinated, multidisciplinary approach in managing rare hematologic conditions during cardiac surgery.

Case Description: A 66 year old female with past medical history of rheumatic heart disease requiring mechanical mitral valve (MV) replacement on warfarin, HFpEF (EF 60%), atrial fibrillation requiring dual chamber pacemaker presented with worsening dyspnea on exertion. The patient was admitted for acute on chronic heart failure exacerbation requiring diuresis. Transthoracic echocardiogram (TTE) revealed significantly elevated gradients across the mitral prosthesis, concerning for significant prosthetic stenosis (peak velocity 2.4 m/s and mean gradient of 14 mmHg). Transesophageal echocardiogram (TEE) demonstrated moderate to severe mitral stenosis with a valve area of 0.6 sq cm by 3D planimetry, and poor leaflet excursion concerning for thrombus or pannus (Figure 1). Cardiac CT was suggestive of thrombus around the mechanical MV leaflets (Figure 2). Clinically, the patient had interval worsening heart failure symptoms and chest x-ray with worsening pulmonary edema. After consultation with cardiothoracic surgery, tPA was administered over 24 hours under close monitoring in the Cardiac Critical Care Unit. Repeat TEE post-thrombolysis showed improvement in MV area to 1.57 sq cm by 3D planimetry, with increased mobility of one mechanical MV leaflet (Figure 3). Persistent restriction of the other leaflet concerning for pannus remained, with no urgent surgical intervention indicated. Methods/Methodology: Multimodal imaging, including TTE, TEE with 3D planimetry, and cardiac CT, guided diagnosis. Management involved low-dose, prolonged-infusion thrombolysis for a stable patient at high surgical risk. Clinical and imaging responses were monitored to guide further treatment decisions. Discussion: Mechanical valve thrombosis management is a serious complication that can be caused by subtherapeutic anticoagulation or poor medication adherence. Management is guided by symptom severity, thrombus size, and surgical risk. Surgery can provide definitive treatment, but carries high risk, especially in unstable or comorbid patients. Thrombolytic therapy offers a less invasive option and is often preferred for stable patients (NYHA class I-III) with small thrombi and high surgical risk. Protocols utilizing low dose, slow infusion thrombolytics are associated with improved safety outcomes. Echocardiography is essential for diagnosis and monitoring response to therapy. A multidisciplinary approach along with close follow up and INR monitoring helps prevent recurrence.

Introduction/Background: Retrograde aortic valve crossing is a fundamental step in transcatheter aortic valve replacement (TAVR). With the expansion of TAVR programs, rare but challenging cases of failure to cross the valve may arise. Alternate access routes, while helpful, may still prove ineffective in select anatomies or re-operative valves. Research Question: What are the alternative strategies when retrograde crossing of the aortic valve fails during TAVR, and can a transseptal approach provide a viable solution in anatomically complex or previously operated patients? Goals/Aims: To describe a case of bioprosthetic valve-in-valve TAVR complicated by inability to cross the aortic valve via both transfemoral and transcarotid retrograde approaches, requiring an unconventional transseptal antegrade solution. Case Presentation: A 73-year-old male with prior type A aortic dissection repair and a 27 mm bioprosthetic aortic valve (Magna) presented with progressive dyspnea. Echo revealed severe valve stenosis (mean gradient 40 mmHg, AVA 0.6 cm, EF 55–60%). After surgical turndown, valve-in-valve TAVR was pursued. Despite multiple attempts by three experienced operators, retrograde valve crossing failed via transfemoral and left carotid routes, even with a stiff wire support. A transseptal puncture was then performed under TEE and fluoroscopic guidance using the VersaCross system. A balloon catheter and wire were passed antegrade from the left atrium through the left ventricle and across the aortic valve into the descending aorta. The wire was snared retrogradely via the carotid sheath, establishing rail access. This enabled retrograde valve crossing and delivery of a 26 mm Sapien Resilia valve. Management/Outcome: The valve was deployed successfully after balloon valvuloplasty under rapid pacing. TEE confirmed optimal position with a mean post-deployment gradient of 4 mmHg and no paravalvular leak. The patient remained stable and experienced no procedural complications. Conclusion: Although rare, failure to cross the aortic valve retrogradely can occur, particularly in patients with prior complex aortic surgery. When standard retrograde and alternate access routes fail, a transseptal antegrade approach may offer a safe and effective bailout strategy. Familiarity with this technique can be critical for heart teams managing complex valve-in-valve scenarios in high-risk patients.

Introduction: Primary malignant cardiac tumors are extremely rare, with an incidence rate of less than 0.005%, and among these, intimal sarcoma is a poorly differentiated, highly aggressive tumor associated with a poor prognosis. Symptoms range from fever, weight loss, dyspnea, and orthopnea to embolic phenomena leading to stroke. Pleural effusion is an uncommon and underreported manifestation of this tumor. Case Presentation: A 67-year-old woman presented to the pulmonary clinic for a work-up of a left-sided pleural effusion with a 2-month history of exertional dyspnea, palpitations, and dry cough. The Holter monitor identified episodes of atrial fibrillation, and ECHO showed moderate to severe mitral stenosis and preserved ejection fraction of 59%. Thoracocentesis revealed lymphocytic effusion, negative cytology, and culture; other labs showed unremarkable immunological markers. A PET scan revealed a small left pleural effusion with minimal FDG uptake and nonspecific increased FDG uptake within the left atrial appendage. TEE revealed a large left atrial mass, which was initially thought to be a left atrial thrombus or myxoma. Cardiac MRI characterized the mass as hyperintense on T2-weighted sequences, enhancement on the first pass of gadolinium, and hyperintense on late gadolinium enhancement sequences, suggesting malignancy, as opposed to a thrombus. The patient had tumor excision, revealing a 7.5 cm Intimal-type sarcoma with non-eventful post-op recovery. Discussion: Intimal (spindle cell) sarcoma is an aggressive cardiac tumor that typically arises from large vessels and pulmonary veins, though it rarely involves the left atrium. Histologically, these tumors show positive immunoreactivity to vimentin, osteopontin, and Murine double minute 2[MDM2] with variable expression of other markers. While vascular markers like CD31 and CD34 are usually negative, they may sometimes show focal positivity. Immunohistochemistry is vital for diagnosis, with MDM2 overexpression seen in over 70% of cases. Among these tumors, about 40% of cases metastasize to the lungs, causing left-sided pleural effusion presenting with nonspecific symptoms such as dyspnea and orthopnea, often posing diagnostic challenges due to their rarity and similarity to non-neoplastic conditions, delaying diagnosis. Intimal sarcoma prognosis is poor, with average survival ranging from 3 months to 1 year, but early surgical intervention can improve outcomes.

ABSTRACTEndoscopic ultrasound‐guided hepaticogastrostomy (EUS‐HGS) is an effective method for cases where transpapillary approaches to pancreato‐biliary diseases are challenging, though serious complications often occur. Here, we report an extremely rare case of delayed biliary hemorrhage due to pseudoaneurysm rupture after EUS‐HGS, caused by migration of the placed plastic stent. The patient was pathologically diagnosed with unresectable advanced pancreatic cancer and presented with severe duodenal stenosis and bile duct obstruction. Before chemotherapy, EUS‐HGS with a biliary plastic stent (7Fr Type IT stent) was successfully performed without early complications. However, after 46 days, the patient developed massive melena, and computed tomography revealed a biliary hemorrhage within the common bile duct. Imaging revealed that the hepatic end of the plastic stent had migrated from the hepatic hilum to the posterior segment. After 71 days, the patient experienced a recurrent biliary hemorrhage, and an 8 mm pseudoaneurysm was identified in the posterior hepatic region at a location consistent with the migrated hepatic end of the plastic stent. Hemostasis was successfully achieved by emergency transcatheter arterial embolization with N‐butyl cyanoacrylate. During the 6 months after the intervention, no recurrence of the pseudoaneurysm was observed, and the patient continued systemic chemotherapy with stable disease control. We suggest that biliary hemorrhage due to pseudoaneurysm rupture, which may be caused by migration of the placed plastic stent, should be considered a life‐threatening late complication of EUS‐HGS, requiring thorough follow‐up.

Background: Right ventricular function is strongly associated with the mortality in mitral stenosis (MS). The ratio of tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery systolic pressure (PASP) serves as a noninvasive measure of right ventricle-pulmonary artery (RV-PA) coupling, which reflects the ability of RV to handle a given pulmonary afterload. Our aim is to assess the relationship between TAPSE/PASP and outcomes in calcific MS. Methods: A single-center retrospective cohort study was performed. Patients diagnosed with calcific MS on echocardiography between October 2010 and August 2020 were identified. We included patients with severe calcific MS due to mitral annular calcification (MAC) who had TAPSE and PASP measurements available. Propensity score (PS) was performed using a logistic regression model, with TAPSE/PASP &gt;0.45 as the dependent variable and seven clinically relevant covariates (age, sex, NYHA class, hypertension, atrial fibrillation, Charlson comorbidity index, left ventricular ejection fraction). After PS matching, we compared all-cause mortality between the two groups. Outcomes: Of 7,154 patients with MS, 229 patients with severe calcific MS were included (72 with TAPSE/PASP &gt;0.45 and 157 with TAPSE/PASP ≤0.45). In the entire cohort, the mean age was 72 ± 11 years and 65.9% were female. During the median follow-up duration of 345 days (25 th -75 th percentile: 80 – 851 days), 80 patients (34.9%) underwent mitral valve surgery, and there were 74 (32.3%) deaths. The cumulative survival of patients with TAPSE/PASP ≤0.45 was lower than patients with TAPSE/PASP &gt;0.45 in the entire cohort (p = 0.001), the conservative treatment group (p = 0.023), and the mitral valve intervention group (p = 0.020). After PS matching in 144 patients (72 patients in each group), similar results were obtained (p = 0.002, p = 0.028, p = 0.021). Conclusion: TAPSE/PASP is strongly associated with all-cause mortality in patients with severe calcific MS. This relationship was also observed after PS matching, suggesting this is a valuable non-invasive marker in calcific MS.

Introduction: Sarcomatoid carcinoma is an aggressive, poorly differentiated malignancy with both epithelial and mesenchymal features. While previously described in the lungs, kidneys, and soft tissues, no cases have been documented with a primary origin in the pericardium. Its diagnostic ambiguity and aggressive course present significant challenges. We present the first reported case of primary sarcomatoid carcinoma of the pericardium. Case Description: An 81-year-old male with multiple comorbidities including hypertension, atrial fibrillation, bioprosthetic aortic valve replacement (2022), Crohn's disease, and HFmrEF presented with gastrointestinal symptoms. CT abdomen incidentally revealed a large pericardial mass (10×7 cm) compressing the left atrium and basal left ventricle, causing severe mitral stenosis (mean gradient 15 mmHg). Initial differential included mesothelioma and metastatic pulmonary sarcomatoid carcinoma. The patient underwent 10 sessions of palliative radiation. Post-radiation, he developed worsening nausea, vomiting, dysphagia, atrial fibrillation with RVR, and pleural effusions. Cardiac imaging (MRI [Figure 1] and PET [Figure 2]) confirmed the pericardial mass with compression effects and no distant metastases. Thoracentesis and supportive care provided temporary relief. Pericardial FNA pathology revealed a biphasic keratin-positive malignant neoplasm consistent with sarcomatoid carcinoma. Immunohistochemistry was positive for AE1/AE3, CK7, vimentin, and OSCAR. Negative markers ruled out mesothelioma, RCC, melanoma, and other sarcomas. Despite multidisciplinary input, the mass was inoperable. Planned AV nodal ablation and Micra pacemaker were deferred due to anesthetic risk. Inpatient chemotherapy (carboplatin + pemetrexed) was planned, but the patient decompensated before initiation. Discussion: Sarcomatoid carcinoma of pericardial origin is undocumented. PET/CT imaging and immunohistochemistry were key to diagnosis. Tumor compression mimicked valvular and heart failure symptoms, complicating management. Despite early multidisciplinary care, prognosis was poor due to rapid clinical decline. Conclusion: This case highlights the importance of early recognition, tissue diagnosis, and aggressive multidisciplinary planning in rare cardiac malignancies. Sarcomatoid carcinoma should be considered in the differential diagnosis of atypical pericardial masses. Further literature and registry data are needed to guide future management.