2025, Volume 32 (online first)

Systemic inflammatory diseases (SIDs) can present with a wide range of cardiac manifestations, which, although uncommon, are frequently associated with significant morbidity and poor prognosis. Behçet’s disease and antiphospholipid syndrome (APS) are two distinct immune-mediated disorders encompassed within this spectrum, both capable of causing intracardiac thrombi and systemic embolisation, which causes diagnostic and therapeutic challenges. While Behçet’s disease is a classic systemic inflammatory vasculitis, APS primarily represents a prothrombotic autoimmune disorder with variable inflammatory features. This case series highlights two patients with cardiac involvement in SIDs, emphasising the importance of early recognition, individualised treatment strategies, and a multi-disciplinary approach to optimise outcomes in these complex clinical scenarios.

A coronary artery fistula (CAF) is an abnormal connection between a coronary artery and another structure. This rare condition has an incidence in the general population of 0.002%. A 57-year-old woman presented with angina, a normal electrocardiogram (ECG) and a peak troponin I of 0.22 µg/L (normal <0.04 µg/L). She was treated with a standard medical regimen for non-ST-elevation myocardial infarction. Coronary angiography revealed non-obstructed coronary arteries, with fistulae arising from the left anterior descending, left circumflex and right coronary arteries, all terminating in the pulmonary artery. Cardiac magnetic resonance (CMR) imaging was performed to investigate coronary steal syndrome. This confirmed there was no significant shunt or evidence of infarction. There was a small concentric pericardial effusion with a focal region of inferolateral epicardial fibrosis, suggesting a diagnosis of myopericarditis. The patient was treated with colchicine for three months.

CAF can cause patients to present with a variety of symptoms or potentially life-threatening complications, including fistula rupture and myocardial infarction. Early recognition, characterisation and shunt analysis are imperative to facilitate management. Although left/right heart catheterisation is considered the gold standard, CMR proved to be a useful diagnostic tool in our case, ruling out significant shunting and helping to identify a differential diagnosis.

This case report highlights the clinical course of a young patient with a history of ischaemic cardiomyopathy and severely impaired left ventricular (LV) systolic function following a delayed anterior myocardial infarction, which was further complicated by the presence of large LV thrombus. The patient subsequently presented with persistent ventricular tachycardia (VT) refractory to multiple anti-arrhythmic medications and antitachycardia pacing (ATP). VT ablation was contraindicated due to the LV thrombus, and the failure of conventional medical therapy. Heart transplantation was considered as the final viable management strategy. This case highlights the complexity of managing patients with advanced heart failure and ventricular arrhythmias, emphasising the importance of timely consideration of advanced therapeutic options in refractory scenarios.

A 44-year-old man presented with chest pain and an unusual pattern of ST-elevation in leads aVL and V2, and ST-depression in leads II, III and aVF on electrocardiogram (ECG). Artificial intelligence (AI)-augmented ECG interpretation reported the abnormality as indicative of occlusive myocardial infarction (OMI) and highlighted the abnormal leads in the pattern that was recognised to be that of the South African flag. This previously reported pattern is associated with acute occlusion of the intermediate or high diagonal coronary arteries, which was then confirmed on coronary angiography, but only when an extreme left anterior oblique (LAO) caudal view was used. The intermediate artery was successfully treated with percutaneous coronary intervention (PCI). It is our experience, like that of Louis Pasteur, that chance appears to favour the prepared mind. This case highlights the importance of being prepared by recognising non-typical ECG patterns associated with acute coronary occlusion, and being aware of which vessel is likely to be occluded. This demonstrates the utility that AI-augmented ECG interpretation can bring to cardiologists to refine patient management.

Saphenous vein grafts (SVGs) are frequently used for coronary artery bypass grafting (CABG) of severe coronary artery disease; however, re-stenosis is common. Restoration of blood flow to the SVG is uncommonly achieved via revascularisation of the native vessel. A man in his 70s with previous CABGs presented with prolonged chest pain at rest. The left anterior descending (LAD) and left circumflex arteries had chronic total occlusions (CTO), and the SVG and left internal mammary artery, previously used to bypass the LAD, were severely diseased with sluggish flow and an inability to pass a balloon or microcatheter. Rotational atherectomy was successfully performed to cross the LAD CTO, with good flow post-stenting. He remained asymptomatic one year later. Where management of calcified venous grafts precludes passage with balloon or microcatheter, rotational atherectomy of the native coronary may represent an alternative method of restoring blood flow.

Platypnea-orthodeoxia syndrome (POS) is a rare condition which presents with positional dyspnoea and deoxygenation on an orthopneic position which resolves when supine. We present a rare presentation of POS in a 75-year-old man, who initially presented with mixed symptomology including dyspnoea on exertion and syncope. He was found to have intermittent symptomatic hypoxia and initial investigations ruled out infection, pulmonary embolism and interstitial lung disease. Pulse oximetry confirmed positional variations in oxygenation. A transthoracic echocardiogram and a transoesophageal bubble echocardiogram with positional manoeuvres confirmed the presence of a large patent foramen ovale (PFO) with shunting. The patient was referred to the tertiary centre for PFO closure which resulted in resolution of his symptoms. This case report highlights the importance of recognising POS as a rare differential in causes of unexplained dyspnoea and utilising multiple imaging techniques to confirm the diagnosis.

A 32-year-old man presented to the emergency department with shortness of breath and altered mental status. He reported a two-day history of epigastric pain, nausea, and vomiting. His past medical and family history were unremarkable. He was haemodynamically unstable, and his initial electrocardiogram (ECG) revealed a Brugada type 1 ECG pattern. The initial diagnostic assessment revealed significant metabolic derangements consistent with diabetic ketoacidosis, accompanied by hyperkalaemia. Notably, the prompt and effective management of hyperkalaemia resolved the Brugada type 1 ECG pattern, confirming the diagnosis of Brugada phenocopy.

This case report describes a young man in his early thirties with insulin-dependent diabetes mellitus and ulcerative colitis, who developed acute myocardial infarction (AMI) during an acute flare-up of ulcerative colitis. The case highlights the diagnostic and therapeutic challenges involved in managing AMI in patients with systemic inflammatory diseases and metabolic conditions. The patient was successfully treated with a combination of thrombectomy and a drug-eluting balloon procedure for coronary occlusion, along with pharmacotherapy consisting of intravenous steroids, intravenous glycoprotein IIb/IIIa inhibitor and the involvement of a multi-disciplinary team of cardiologists and gastroenterology specialists. This case underscores the need for an integrated care approach, aggressive cardiovascular risk management, and interdisciplinary collaboration to optimise outcomes in complex clinical scenarios where systemic inflammation intersects with cardiovascular events.

Severe mitral regurgitation (MR), when complicated by a co-existing lung abscess, is a management challenge, as both conventional cardiac and thoracic surgical interventions may be contraindicated. In the case described below, transcatheter edge-to-edge mitral valve repair (TEER) was utilised to achieve haemodynamic stability, permitting subsequent thoracic surgical lung abscess resection.

We report the case of a 60-year-old man with torrential MR secondary to chordal rupture presenting with recurrent pulmonary oedema, complicated by lung sepsis and abscess formation resistant to antibiotic therapy and precluding open valvular repair. The presence of a lung abscess contraindicated open mitral valve repair, and the severity of MR precluded thoracic surgical treatment of the lung abscess, precluding any form of surgical intervention.

A successful TEER procedure resulted in a reduction of MR from severe to no more than mild-to-moderate, enabling haemodynamic stabilisation and permitting subsequent thoracic surgical treatment of the lung abscess.

Our case demonstrates the possibility of treating severe MR with TEER in the presence of a lung sepsis and abscess, when both conventional cardiac and thoracic surgical interventions were considered contraindicated. This later enabled thoracic surgery and treatment of the lung abscess.

A 79-year-old woman presents to the hospital with dyspnoea, fever, and hypotension, and is diagnosed with community-acquired pneumonia and septic shock. Resuscitation is initiated with fluids and vasopressors, and a central venous catheter is placed. However, during the procedure, the guide experiences resistance and cannot be removed, becoming trapped. This is confirmed with tomography and reconstruction, demonstrating intravascular position. The patient is then sent to interventional cardiology for extraction, which is successfully performed using the EN Snare (Merit Medical). The significance of this case lies in the complications of not guiding procedures with ultrasound and how to resolve them, such as the guide being trapped in this patient.

A 24-year-old male bodybuilder presented with cardiac symptoms following long-term performance-enhancing drug (PED) use. He was diagnosed with heart failure with reduced ejection fraction and body dysmorphic disorder. Treatment included cardiac medical therapy and psychiatric support. After PED discontinuation and ongoing psychological care, symptoms improved and relapse was prevented. This case highlights the potential severe cardiovascular consequences of PED abuse in young, healthy individuals. It emphasises the importance of early recognition, multidisciplinary intervention addressing both physical and psychological aspects, and increased awareness about PED risks, particularly among those with body image disorders.

Coronary artery spasm (CAS), or Prinzmetal angina, is a recognised cause of myocardial ischaemia in non-obstructed coronary arteries which typically presents with anginal chest pain. This case report describes an atypical presentation of CAS in a 68-year-old white British male with cardiovascular risk factors. The patient presented with recurrent palpitations and pre-syncope, with no chest pain. Ambulatory electrocardiography (ECG) monitoring revealed recurrent polymorphic ventricular tachycardia (PMVT). Coronary angiography identified moderate stenosis of the right coronary artery (RCA), without significant flow restriction by invasive pressure wire interrogation.

Inpatient monitoring revealed episodes of recurrent PMVT coinciding with transient inferior ST elevation and a distinct ‘shark fin’ waveform, indicating dynamic RCA occlusion. The arrhythmias persisted despite initial medical management, including calcium channel blockers and intravenous glyceryl trinitrate. Percutaneous coronary intervention to the moderate RCA lesion was performed, which definitively treated the arrhythmias.

This case emphasises the importance of recognising plaque-associated CAS as a potential trigger for life-threatening arrhythmias, even in the absence of chest pain. While medical therapy remains first-line treatment, life-threatening presentations may necessitate invasive interventions to stabilise the patient and prevent recurrence.

Pericardial cyst is a rare diagnosis, mainly considered a congenital condition. Most patients with pericardial cysts present without symptoms. Symptomatic presentation often relates to the size and location of the pericardial cyst. We report a case of a 49-year-old man who presented with subacute breathlessness in which the diagnosis of a pericardial cyst was made following various investigations – from transthoracic echocardiography and computed tomography scan to video-assisted thoracoscopic surgery biopsy, upon which a histological diagnosis was made. This case report reviews and discusses the available literature on the epidemiology and potential presenting features of a pericardial cyst, and the current recommended assessment and management strategies thereof. This case highlights the importance of effective multidisciplinary communication and joint input towards clinical decision-making, particularly in complex scenarios, to achieve optimal patient outcomes.

Though a rare condition, acute type A aortic dissection (ATAAD) is associated with high morbidity and mortality; hence, timely diagnosis and surgery are important to reduce the risk of mortality. If the dissection extends into the aortic arch branches, ensuring adequate cerebral perfusion during surgery is crucial to preventing stroke.

A 50-year-old man presented to the emergency department with symptoms of acute chest pain, dizziness, and headache. His blood pressure was 180/110 mmHg and heart rate was 100 bpm. He had a high blood pressure and heart rate and was initially treated with glyceryl trinitrate. Initial investigations ruled out acute coronary syndrome. Further investigations revealed ATAAD with the involvement of arch branches, an incomplete (open) circle of Willis and cerebral malperfusion. He was prepared for a branch-first total aortic arch replacement. Due to the high risk of stroke in this patient, off-pump axillo-axillary bypass (adaptive perfusion technique) was used to ensure bihemispheric cerebral perfusion throughout the surgery. The surgery was uneventful, and the patient was discharged 12 days later. Postoperative follow-up at six months was normal.

In conclusion, ATAAD is a surgical emergency that can mimic other acute thoracic conditions, such as pulmonary embolism and acute coronary syndrome; therefore, a judicious approach should be applied in the diagnosis and early management of symptoms. The reconstruction technique should be tailored to the patient’s needs; as this patient had a poorly functioning circle of Willis and cerebral hypoperfusion, continuous bilateral cerebral perfusion was essential to prevent irreversible cerebral ischaemic insult. The adaptive technique is easy to learn for surgeons who are already proficient in aortic dissection procedures, it is reproducible and requires only minor changes to the surgical setup without any substantial increase in operative time. Adoption of this technique in other surgical centres could be beneficial in increasing the success rate for the treatment of ATAAD.

Wellens’ syndrome, characterised by specific T-wave changes on electrocardiogram (ECG), indicates critical proximal left anterior descending (LAD) stenosis and high acute myocardial infarction risk. While revascularisation is the standard treatment, it may be unsuitable for elderly patients with comorbidities. We present a case of successful medical management of Wellens’ syndrome type B in a 94-year-old woman deemed unfit for invasive interventions. The patient was treated with dual antiplatelet therapy, high-intensity statin, and anti-anginal medications. Symptom control was achieved, and serial ECGs and cardiac biomarkers remained stable. This case demonstrates that aggressive medical management can be a viable alternative in elderly patients with Wellens’ syndrome type B, unsuitable for invasive procedures.