86 years-old man was admitted to our ICCU for chest pain with an ECG diagnosis of atrial fibrillation and inferior STEMI. He had a history of hypertension and ascending aorta aneurysm (48 mm) with no other known cardiovascular risk factor. He reported few episodes of short-duration chest pain in the last days. A fast echocardiogram excluded ascending aorta dissection and pericardial effusion but showed hypokinesia of inferolateral left ventricle wall. Urgent angiography only revealed a moderate stenosis on mid left anterior descending artery associated with slow run-off. No lesions were found on the expected culprit artery. Due to persisting chest pain and patient's history of ascending aorta aneurysm, an urgent Angio CT was performed, but unexpectedly, during the exam, the patient lost consciousness with asistolia. RCP was practised with ROSC. CT scan showed mild pericardial effusion with blushing. A free wall heart rupture was suspected by radiologist. Urgent echocardiogram revealed moderate pericardial effusion with a suggestive colour doppler systolic flow originating from an apparent hole in apical inferolateral left ventricle wall. Rapid hemodynamic failure occurred so pericardiocentesis with amine support and blood transfusions were performed. Heart team excluded urgent surgery due to extremely high operative risk related to patient's age, hemodynamic impairment and poor expected repair durability consequent to acute phase of rupture. ICCU observation was made, with liable hemodynamic stability obtained with norepinephrine infusion. In accordance with patient's family other invasive measurements were not taken. Unfortunately, the patient died the day after. Only few cases of myocardial rupture in myocardial infarction-non obstructive coronary artery disease (MINOCA) are reported in literature. Recurrent chest pain makes plaque complication/embolus resolution a reliable hypothesis. New onset atrial fibrillation might have caused an embolization in coronary artery determining transmural ischaemia, as well as coronary artery plaque rupture/ulceration might have done. Unfortunately, no further exams to exploit the underneath pathological process could be performed: Coronary intravascular ultrasound, optical coherence tomography, Cardiac Magnetic resonance would be a valid help in prognosis and future treatment.

Brugada syndrome mainly affects men in the third and fourth decade of life. It presents with a typical electrocardiographic pattern, unmasked by sodium channel blocking drugs or hyperpyrexia. A 36–year–old young man, with no reported cardiovascular risk factors or family history of sudden death, had convulsions and loss of consciousness during hyperpyrexia, for which family members alerted the local emergency service. During transport to the hospital, the vital parameters and heart rhythm were normal, but, due to the onset of seizures, the patient was sedated, intubated and hospitalized in intensive care unit (ICU). The ECG performed at the entrance (in the course of hyperpyrexia) showed a dubious type 1 Brugada pattern (Figure 1). The echocardiogram (as well as the subsequent cardiac resonance) showed the absence of cardiac structural alterations. Prompt treatment of hyperpyrexia was recommended, the use of drugs listed on brugadadrugs.org was contraindicated and careful ECG monitoring was recommended. Non–sustained ventricular tachycardia was documented during the hospitalization in ICU. When the clinical picture stabilized with resumption of spontaneous breathing, the patient was transferred to our ICU for continuation of the diagnostic and therapeutic process (Figure 2). From the interview with the patient, a previous paroxysmal tachycardia from atrio–ventricular reentry emerged in antiarrhythmic prophylaxis for several years with Propafenone and subsequently treated with catheter ablation of the right lateral accessory path. Considering the lack of documentation of complex ventricular arrhythmias by the 118 during transport to the hospital and during the stay in the UTIC, the long antiarrhythmic therapy with sodium channel inhibitors, as well as the absence of a typical Brugada pattern during fever, we decide to perform a Flecainide test (2 mg / Kg in 10 ‘), negative result for Brugada type 1 pattern (Figure 2) In the following days, considering the absolute negativity of all the neuroradiological and EEG investigations, not having found the cause of the loss of consciousness during hyperpyrexia, we performed ajmaline test (1 mg / kg in 100 cc of SG5% in 10 ‘) with the identification of the diagnostic pattern type 1 (Figure 3). Finally, the implantation of a subcutaneous cardioverting defibrillator (S–ICD) was performed.

Echocontrastography is an echocardiography method that involves the intravenous administration of a particular contrast medium, formed by microbubbles capable of crossing the pulmonary circulation and distributing themselves in the left sections. These micro bubbles hit by ultrasound break or oscillate emitting ultrasound waves with a different frequency than the beam that hit them, generating a series of harmonic signals that can be processed to observe, for example, the opacification of the left cavities. An 82–year–old diabetic hypertensive man with a strong family history of coronary artery disease underwent routine cardiac evaluation. At the time of the visit, sporadic episodes of non–specific chest pain (localized in the right breast), of an intermittent nature, and not related to physical exertion, were reported. On the ECG, finding of sinus rhythm and q waves in V1–V3 (not present at a previous in 2019). On echocardiography (patient with poor acoustic window): Left ventricle of normal size with mild concentric parietal hypertrophy. Slight reduction in global systolic function due to alterations in district kinetics. Akinesia of the apex and middle segment of the septum and anterior wall. FE 48%. Doubtful apical iso–hyperechoicity (artifact?). Urgent hospitalization for coronary angiography was indicated in the suspicion of subacute anterior AMI. Coronary angiography revealed occlusion of anterior interventricular artery (IVA) in the proximal tract, partially re–inhabited downstream by homocoronary circulation (figure 1). Before proceeding with revascularization, given the absence of movement of the myocardiocitonecrosis indices, it was decided to perform myocardial viability tests. In consideration of the suspected apical thrombotic formation, as well as the patient‘s poor acoustic window, echo contrast was necessary (Figure 2). Once the complete opacification of the left ventricular cavity was highlighted by the contrast agent, suggestive of the absence of apex thrombi, we proceeded to ecostress with dobutamine to evaluate myocardial viability. At the explored dosages (5 – 10 and 20 ug/kg/ min) recovery of the apex kinetics was observed, but not of the mid–apical septum, which remained akinetic. We then proceeded to angioplasty on proximal IVA with a good angiographic result and the patient was discharged on the third day from revascularization in excellent clinical conditions.

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.