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Development of left ventricular to coronary sinus fistula is a rare complication of mitral valve surgery. Three of the seven previously reported cases occurred following multiple valve replacement surgeries, all of which were thought to be secondary to a complication of surgery and all were treated with surgical closure of the fistula. We report a case of left ventricular to coronary sinus fistula occurring after two mitral valve replacement surgeries that was treated medically with favorable long-term results.

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Purpose: Patients with end-stage HCM, the most common genetic cardiovascular condition, often require heart transplant (HT) but there is limited data assessing outcomes. We sought to assess the effect of the 2018 UNOS Heart Allocation policy changes on patients with HCM which increased prioritization for this population. Methods: 128 patients with HCM received HT in the year before and after the UNOS policy changes. Pre-(n=65) and post-policy (n=63) cohorts were identified using the UNOS registry. Baseline characteristics were compared using standard statistical analysis. 30-and 180-day outcomes were evaluated using Kaplan Meier survival analysis as well as univariate and multivariate Cox proportional hazards modeling. Results: Baseline characteristics were similar for both groups, but differed in median [IQR] distance (nm) from donor and treatment center (pre: 91 [17, 253]; post: 245 [100.5, 393]; p=0.002) and median PA pressure (mm/ Hg) at registration (pre: 38 [30, 49.2]; post: 45 [31, 58], p=0.036). Donor characteristics differed in mean BMI (pre: 26.1 (SD 7.2); post: 28.9 [SD 7.2]). Pre-and post-policy 30-day survival was 100% (CI 100%, 100%) and 95% (CI 90%, 100%) respectively. Pre-and post-180-day survival was 94% (CI 88%, 100%) and 90% (CI 83%, 98%). Cox univariate hazard ratio (HR) following the UNOS change was 1.62 (CI 0.46, 5.73, p=0.5). Multivariate Cox proportional HR adjusted for recipient age, donor age, serum creatinine, total bilirubin, ischemic time, pre-transplant dialysis, ventilator and ECMO status was 1.54 (CI 0.39, 6.09, p=0.5). Conclusion: UNOS policy changes did not adversely affect survival at 30 and 180 days for patients with HCM receiving HT. Additional research is needed to evaluate the effects these policy changes have on patients with HCM.

We report the fatal course of a left atrial myxoma: its systemic embolization to the coronary, cerebral, renal, and peripheral vascular beds in a 39-year-old W hen a patient presents with simultaneous vascular insults that involve multiple organ systems, a catastrophic clinical outcome can result. We report the case of a patient who had symptoms of systemic embolization, and we discuss the presentation, recognition, and treatment of the left atrial myxoma that was responsible. Case ReportA 39-year-old black woman was found unresponsive and in respiratory distress outside her home. According to her family, she had felt fatigued over the past 2 months and had occasionally reported fevers and night sweats. She had been taking oral contraceptive pills and smoked half a pack of cigarettes per day. Her personal and family medical histories yielded nothing else of note.Upon evaluation by emergency medical personnel, the patient was unconscious, tachypneic, and displaying possible seizure activity. In the emergency department, the patient was comatose with a Glasgow coma scale of 5, a temperature of 37 °C, a blood pressure of 117/77 mmHg, a heart rate of 133 beats/min, a respiratory rate of 30 breaths/min, and an oxygen saturation of 76% on room air. She was immediately intubated. A 12-lead electrocardiogram revealed 2-to 4-mm ST-segment elevation in the lateral leads, consistent with acute ST-elevation myocardial infarction (STEMI). Pertinent laboratory values included a cardiac troponin I level of 1.6 ng/mL, a white blood cell count of 13,800/µL, and an international normalized ratio of 1.21. The patient was anuric. A chest radiograph showed a normal cardiac silhouette with bilateral pulmonary edema. Aspirin (325 mg) was administered through a nasogastric tube, and an intravenous heparin drip was initiated. The diagnosis was cardiac arrest secondary to STEMI. A noncontrast computed tomographic scan of the patient's head was performed, and she was sent for emergent cardiac catheterization.Femoral arterial access was difficult to achieve in either groin because of the aspiration of thrombotic material. A 4F sheath was finally placed in the right femoral artery; the access sheath thrombosed twice during the procedure, necessitating the aspiration of large amounts of dark-red thrombus. Coronary angiograms obtained with use of 4F catheters showed abrupt thrombotic occlusion of the proximal-to-mid left anterior descending coronary artery, first diagonal branch, and proximal-to-mid left circumflex coronary artery (Fig. 1). The right coronary artery was angiographically normal. The occlusions were not suitable for catheter aspiration, balloon angioplasty, or stenting. A left ventriculogram showed a left ventricular ejection fraction (LVEF) of 0.30 and akinesis of the anterolateral, inferolateral, and apical walls. The computed tomographic report, received during the cardiac catheterization procedure, noted a large, acute embolic infarct in the region of the left middle cerebral artery. In view of the substantial thrombotic...