Gross echocardiographic underestimation of mitral valve calcification--a near fatal experience.

Acute severe mitral regurgitation is a feared complication following percutaneous balloon mitral valvuloplasty (PBMV) for the treatment of severe mitral stenosis, contributing to the 1% peri-procedural mortality rate of this procedure. Whilst there is an extensive experience with the use of the Wilkins echocardiographic score to assess patient suitability and predict long-term clinical outcomes following PBMV, catastrophic severe acute mitral regurgitation, such as that described in our patient, is a remarkably rare occurrence following PBMV in patients with favourable Wilkins echocardiographic criteria. We highlight a case of the gross underestimation of the degree of valvular calcification using trans-oesophageal echocardiography, when compared to the findings at surgery, which contributed to our patients' life-threatening mitral regurgitation following the first balloon inflation. We advocate further research into the utility of multi-detector computed tomography (MDCT) imaging for the adjunctive pre-procedural assessment of the degree mitral calcification in order to further minimise the risk of peri-procedural complications associated with PBMV. This would be particularly suitable in the elderly population who normally have greater degrees of valvular calcification that may be underestimated with echocardiography alone.

Hypereosinophilic syndrome associated with multiple coronary aneurysms.

Aneurysmal coronary artery disease occurring in the absence of stenotic atherosclerotic plaques is extremely rare and the pathophysiology of focal aneurysm formation is poorly understood. Whilst clinical-histological correlates exist linking spontaneous coronary artery dissection and perivascular eosinophilic infiltration in otherwise healthy individuals, the occurrence of aneurysms exclusively affecting the coronary tree in the setting of hypereosinophilic syndrome has not been previously reported. We describe the case of a 72-year-old woman presenting with cardiac chest pain in the context of recently diagnosed idiopathic hypereosinophilic syndrome with subsequent coronary angiography revealing multiple coronary aneurysms but only minor coronary atherosclerosis and no evidence of systemic arterial aneurysm formation. A brief review of the management strategies of patients with ectatic coronary artery disease is presented.

Giant saphenous vein graft pseudoaneurysm rupture presenting with cardiac tamponade.

Saphenous vein graft aneurysms are a rare but potentially fatal complication following coronary artery bypass graft (CABG) surgery, with a wide variation in clinical presentations ranging from recurrent atypical chest pain to sudden cardiac death. Although uncommon, the diagnosis should be considered in all patients presenting with a hilar or mediastinal mass following CABG, as timely treatment may avert potentially fatal aneurysm rupture and death. We report a rare case of a giant vein graft pseudoaneurysm rupture causing cardiac tamponade.

Takotsubo cardiomyopathy following lightning strike.

Lightning strike is the most common environmental cause of sudden cardiac death, but may also be associated with a myriad of injuries to various organ systems. Direct myocardial injury may be manifest as electrocardiographic alterations or elevation in cardiac-specific isoenzymes; however, significant electrical cardiac trauma appears uncommon. A case is presented of severe acute cardiomyopathy in a "Takotsubo" distribution causing cardiogenic shock following lightning strike in a previously healthy 37-year-old woman. Although rarely identified in this context, Takotsubo cardiomyopathy (also known as "transient left ventricular apical ballooning syndrome") is characterised by transient cardiac dysfunction, electrocardiographic changes that may mimic acute myocardial infarction and minimal release of cardiac-specific enzymes in the absence of obstructive coronary artery disease. The condition is associated with a substantial female bias (up to 90% of cases) in reported series, and despite occasionally dramatic presentations recovery of left ventricular function is almost universal over days to weeks. In rare instances, however, the syndrome has been associated with more catastrophic complications such as papillary muscle or cardiac free wall rupture, necessitating emergency surgical intervention to preserve life. In clinical practice, non-lethal lightning strike-induced cardiac injury is frequently associated with small elevations of cardiac isoenzymes without overt clinical sequelae; however, the incidence of silent myocardial mechanical dysfunction remains unknown. Cases such as the one presented highlight the potential for serious, albeit usually transient, cardiac sequelae from lightning strike injury and remind us that our mothers' advice to remain indoors during thunderstorms is probably worth heeding.

Very late stent fracture associated with a sirolimus-eluting stent.

Late stent thrombosis (>1 year after implantation) is a recognised complication involving drug-eluting stents. Stent fracture is increasingly being reported as a complication of drug-eluting stent, and in particular sirolimus-eluting stent use. We report the case of very late sirolimus-eluting stent fracture resulting in an acute coronary syndrome. This case report highlights the need for greater awareness and post-marketing surveillance to detect a potential mechanism for late stent thrombosis in the drug-eluting stent era.