Michifumi Tokuda

Background: Computed tomography (CT) calcium scoring is used to adjudicate paradoxical low-flow, low-gradient (LFLG) severe aortic stenosis (AS). However, its reliability may be limited in rheumatic disease. Case summary: An 82-year-old woman with prior mitral valve replacement for rheumatic mitral stenosis was referred for AS. Transthoracic echocardiography revealed an aortic valve area (AVA) of 0.50 cm2, mean pressure gradient of 27 mmHg, stroke volume index of 30 mL/m2, and preserved systolic function, suggesting paradoxical LFLG severe AS. The CT calcium score was 889 Agatston units, below the female threshold for severe AS. Three-dimensional transoesophageal echocardiography (TEE) demonstrated commissural fusion, leaflet tip thickening, and planimetry-derived AVA of 0.69 cm2, confirming severe AS. The patient underwent transcatheter aortic valve implantation, with 6-min walk distance improving from 150 to 254 m. Discussion: In rheumatic morphology, low CT calcium burden may not exclude severe AS because obstruction may be driven by commissural fusion and fibrosis rather than bulky calcification. Three-dimensional TEE planimetry can serve as an anatomy-based adjudicator when echocardiographic and CT calcium findings are discordant.

Background: Unilateral pulmonary oedema is uncommon and frequently misattributed to pneumonia, delaying appropriate heart-failure care. Mechanistic clarification and demonstration of reversibility in a single patient can sharpen diagnostic reasoning and guide management. Case summary: An 88-year-old man presented with fever, inflammatory markers, and a right-upper-lobe ground-glass opacity. While pneumonia was suspected, transthoracic echocardiography revealed decompensated heart failure with severe mitral regurgitation (MR). Three-dimensional transoesophageal echocardiography (3D TEE) and contrast-enhanced computed tomography (CT) localized an eccentric MR jet towards the right superior pulmonary vein (RSPV). Pulmonary vein Doppler showed a vein-specific reversed systolic wave with diastolic extension in the RSPV, whereas the forward diastolic wave was preserved in other veins. After defervescence and partial decongestion, perfusion scintigraphy demonstrated segmental hypoperfusion matching the RSPV territory. Given high surgical risk, transcatheter edge-to-edge repair (TEER) was performed and reduced MR. After TEER, PV Doppler converted to forward systolic/diastolic waves, the chest radiograph cleared, and perfusion improved. Discussion: This case triangulates mechanism and reversibility by aligning morphologic (3D TEE/CT), haemodynamic (PV Doppler), and functional (perfusion scintigraphy) evidence, each demonstrated pre- and post-TEER. The multimodality concordance and TEER-demonstrated reversal strengthen causality beyond PV-flow-only reports and provide an actionable pathway for cases with unilateral opacities.

The neutrophil-to-lymphocyte ratio (NLR) has emerged as a marker of systemic inflammation and a prognostic indicator in acute myocardial infarction (AMI). Simultaneously, infarct size (reflected by peak serum levels of creatine kinase (CK) and creatine kinase-myocardial band [CK-MB]) correlates with clinical outcomes in AMI. Given the inflammatory nature of infarction, elevated NLR at admission may contribute to larger infarct size and higher CK and CK-MB levels; however, this association has not been clearly established. We retrospectively analyzed data from 170 patients hospitalized for AMI. Univariate and multivariate linear regression analyses were conducted to examine associations between peak creatine kinase (peak CK) and CK-MB levels and clinical variables, including age, sex, body mass index, hemoglobin, creatinine, uric acid, B-type natriuretic peptide, albumin, C-reactive protein, mean blood pressure, NLR, and platelet-to-lymphocyte ratio at admission. Structural equation modeling was also employed to explore the relationship between NLR and infarct size. Multivariate analysis revealed a significant positive association between NLR at admission and both peak CK (β = 0.342, P = .002) and peak creatine kinase-myocardial band (β = 0.352, P = .001). Structural equation modeling confirmed these findings, showing significant correlations between NLR and peak CK (β = 0.342, P = .001) and CK-MB (β = 0.352, P < .001). Elevated NLR at admission is significantly associated with increased peak CK and CK-MB levels in patients with AMI, suggesting a potential link between systemic inflammation and infarct size. NLR may serve as an early, accessible predictor of infarct magnitude following AMI.

Diabetes may impair left ventricular (LV) contractility, but clear human evidence remains limited. This study investigated its impact in patients with aortic stenosis (AS), demonstrating that diabetes significantly reduces LV function. Clinically, our findings suggest that relying solely on pressure gradients may underestimate AS severity in patients with diabetes, highlighting the necessity for a more comprehensive assessment to ensure accurate evaluation and management of the disease.

Aims: Catheter ablation (CA) of idiopathic ventricular arrhythmias (VAs) from the epicardial left ventricular summit is challenging. The endocardial approach targets two sites: the endocardial closest site (ECS) to the epicardial earliest activation site (epi-EAS) and the endocardial earliest activation site (endo-EAS). We aimed to differentiate between cases where CA at the ECS was effective and where CA at the endo-EAS yielded success. Methods and results: Fifty-eight patients (47 men; age 60 ± 13 years) were analysed with VAs in which the EAS was observed in the coronary venous system (CVS). Overall, VAs were successfully eliminated in 42 (72%) patients: 8 in the CVS, 8 where the ECS matched with the endo-EAS, 11 at the ECS, and 15 at the endo-EAS. A successful ECS ablation was associated with a shorter epi-EAS–ECS distance (10.2 ± 4.7 vs. 18.8 ± 5.3 mm; P < 0.001) and shorter epi-EAS–left main coronary trunk (LMT) ostial distance (20.3 ± 7.6 vs. 30.3 ± 8.4 mm; P = 0.005), with optimal cut-off values of ≤12.6 and ≤24.0 mm, respectively. A successful endo-EAS ablation was associated with an earlier electrogram at the endo-EAS [23 (8, 36) vs. 15 (0, 19) ms preceding the QRS; P < 0.001] and shorter epi-EAS–endo-EAS interval [6 (1, 8) vs. 22 (12, 25) ms; P < 0.001], with optimal cut-off values of ≥18 and ≤9 ms, respectively. Conclusion: Shorter anatomical distances between the epi-EAS and ECS, and between the epi-EAS and LMT ostium, predict a successful ECS ablation. The prematurity of the endo-EAS electrogram and a shorter interval between the epi-EAS and endo-EAS predicted a successful endo-EAS ablation.