Acute COVID-19 Pneumonia Unmasking a Large Left Atrial Myxoma.

This is a case of acute coronavirus disease 2019 pneumonia that revealed an incidental large atrial myxoma with obstructive physiology that ultimately required emergent treatment with a definitive atriotomy and resection of the underlying myxoma.

The Challenge of Intermediate-Risk Pulmonary Embolism.

BACKGROUND: Intermediate-risk pulmonary embolism is a common disease that is associated with significant morbidity and mortality; however, a standardized treatment protocol is not well-established. AREAS OF UNCERTAINTY: Treatments available for intermediate-risk pulmonary embolisms include anticoagulation, systemic thrombolytics, catheter-directed therapies, surgical embolectomy, and extracorporeal membrane oxygenation. Despite these options, there is no clear consensus on the optimal indication and timing of these interventions. THERAPEUTIC ADVANCES: Anticoagulation remains the cornerstone of treatment for pulmonary embolism; however, over the past 2 decades, there have been advances in the safety and efficacy of catheter-directed therapies. For massive pulmonary embolism, systemic thrombolytics and, sometimes, surgical thrombectomy are considered first-line treatments. Patients with intermediate-risk pulmonary embolism are at high risk of clinical deterioration; however, it is unclear whether anticoagulation alone is sufficient. The optimal treatment of intermediate-risk pulmonary embolism in the setting of hemodynamic stability with right heart strain present is not well-defined. Therapies such as catheter-directed thrombolysis and suction thrombectomy are being investigated given their potential to offload right ventricular strain. Several studies have recently evaluated catheter-directed thrombolysis and embolectomies and demonstrated the efficacy and safety of these interventions. Here, we review the literature on the management of intermediate-risk pulmonary embolisms and the evidence behind those interventions. CONCLUSIONS: There are many treatments available in the management of intermediate-risk pulmonary embolism. Although the current literature does not favor 1 treatment as superior, multiple studies have shown growing data to support catheter-directed therapies as potential options for these patients. Multidisciplinary pulmonary embolism response teams remain a key feature in improving the selection of advanced therapies and optimization of care.

Lessons from timing of ablation therapy for multi-drug refractory gestational atrial tachycardia with abruptio placentae: a case report.

Background: Supraventricular tachycardia poses a clinical challenge during pregnancy, particularly if refractory to antiarrhythmic medications. Performing catheter ablation during pregnancy necessitates careful risk benefit analysis for both the mother and foetus, especially with left-sided ablations that may require post-procedural systemic anticoagulation. Case summary: We describe a case of a 31-year-old pregnant woman with refractory atrial tachycardia which failed a multi-antiarrhythmic drug regimen and ultimately developed abruptio placentae, requiring a carefully staged ablation approach for definitive treatment. Discussion: This case highlights the importance of taking into consideration the risks of post-procedural anticoagulation in the event of clinical complications in pregnancy such as abruptio placentae and coordinating carefully with gynaecologists to optimize maternal and foetal outcomes. Here, careful risk stratification was paramount to successfully navigate through the management of her atrial tachycardia while ensuring foetal viability.

Comparison of minimal versus zero-fluoroscopic catheter ablation in gestational supraventricular arrhythmias.

BACKGROUND: The management of symptomatic gestational supraventricular tachycardia (SVT) is challenging and requires a multidisciplinary approach for optimal management. Catheter ablation during pregnancy has traditionally been considered a last option due to procedural safety and ionizing radiation risks. Recent advances including intracardiac echocardiography and multi-electrode electroanatomic mapping have greatly enhanced the safety and efficacy profile to successfully perform ablations with minimal to no fluoroscopy even during pregnancy. This is the first review to compare the efficacy, safety, and aggregate outcomes of purely zero-fluoroscopic and minimal fluoroscopic approaches in gestational SVT. METHODS: A literature search was performed for catheter ablations in the past 15 years for gestational arrhythmias that used minimal or no fluoroscopy. Sixteen cases describing catheter ablations with zero-fluoroscopy were compared to twenty-four cases using minimal fluoroscopy, defined as total documented exposure time of less than 10 min. RESULTS: Analysis of both groups demonstrated that zero-fluoroscopic approaches have comparable efficacy and procedural safety outcomes with the utilization of earlier trimester ablations and in older maternal ages. The utilization of electroanatomic mapping with or without concomitant intracardiac echocardiography in the zero-fluoroscopy group further demonstrated equal efficacy rates of successful ablation when compared to the control group. Furthermore, there were no reported immediate or long-term periprocedural complications in either group, including delivery outcomes. CONCLUSION: Our review demonstrates that zero-fluoroscopy catheter ablation for SVT in pregnancy is both effective and safe when compared to minimal fluoroscopy ablations while eliminating the theoretical risks of ionizing radiation.