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Background Caring for athletes with cardiac disease requires an approach that caters to the specific needs of the athlete. Case summary A 27-year-old professional rugby player was admitted with decompensated heart failure and atrial fibrillation (AF). Transthoracic echocardiogram showed features in keeping with a dilated cardiomyopathy with severe left ventricular (LV) systolic impairment. He made good progress on evidence-based heart failure medication and his LV systolic function returned to normal. He failed to maintain sinus rhythm with cardioversion and remained in persistent AF. He then suffered a transient ischaemic attack despite appropriate anticoagulation. At 1-year follow-up, he was asymptomatic and against medical advice continued to play competitive rugby whilst taking rivaroxaban. He subsequently underwent implantation with a percutaneous left atrial appendage occlusion device, allowing him to discontinue anticoagulation, reduce his bleeding risk and resume his career, whilst simultaneously lowering the thromboembolic risk. Discussion Counselling should include different management options aimed at minimizing the risks to athletes if they to return to competitive sports. Left atrial appendage occlusion devices are a suitable AF-related stroke prevention strategy in athletes competing in full-contact sports. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.Background  Aortic stenosis (AS) is one of the most common valvular disorders worldwide. An increasing number of transcatheter aortic valve implantation (TAVI) procedures are being performed yearly for managing AS. This, along with the occurrence of common complications, makes timely diagnosis essential to manage rare complications and improve patient outcomes. Case summary  We present a case of a 77-year-old Caucasian male with severe AS with a dysfunctional bioprosthetic valve following previous surgical valve replacement. During valve-in-valve TAVI, we noted bioprosthetic valve leaflet avulsion and embolization causing a major vascular occlusion that resulted in vascular insufficiency of the left lower extremity. This condition was managed successfully via immediate diagnosis using transoesophageal echocardiogram, angiogram, and vascular surgical intervention for retrieving the embolized valve to re-establish circulation. Discussion  To our knowledge, this is the first case of aortic valve leaflet embolization during TAVI resulting in significant vascular insufficiency. Vascular complications are common during TAVI. However, not all vascular complications are the same. Our case highlights an embolic vascular complication from an avulsed prosthetic material during a challenging valve-in-valve TAVI procedure. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.Background Arrhythmogenic ventricular cardiomyopathy (AC) is a genetic progressive disease characterized by fibro-fatty replacement of either ventricles in isolation or in combination. Arrhythmogenic ventricular cardiomyopathy is frequently associated with ventricular tachycardia (VT) having a left bundle branch block (LBBB) morphology and much more rarely with VT having right bundle branch block (RBBB) morphology even when the left ventricle is involved. Cardiac magnetic resonance (CMR) imaging plays a key role in the diagnosis of AC. Sustained VT in AC may occur in the concealed stage of the disease before the manifestation of morphological abnormalities on echocardiogram; however, they almost always are accompanied by structural abnormalities of the ventricles on CMR. Case summary A 54-year-old man presented with sustained VT of LBBB configuration consistent with the diagnosis of AC but with no right ventricular (RV) anomalies at repeat CMR. Ten years later, he developed sustained VT with RBBB morphology and structural changes at CMR compatible with RV involvement in the setting of AC. Two years later, he suffered from recurrent identical sustained RBBB-VT with typical CMR signs of left ventricular involvement. Genetic analysis was negative for any known mutation. Discussion In the present report, we describe a patient with AC who first exhibited LBBB- and 10 years later RBBB-sustained VT. Contrasting with what is usually observed in patients with AC, documentations of the VT's arising from either ventricle were found to precede the structural anomalies in the respective cardiac chambers. This case highlights that normal CMR does not exclude underlying AC contrary to the perceptions of many clinicians. In addition, it strongly encourages repeating CMR after 1-2 years when the diagnosis of AC is highly suspected. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.Background  Hypersensitivity reaction is a classic cause of in-stent restenosis (ISR) in coronary stents, typically reported in bare-metal stents and first-generation drug-eluting stents. Biodegradable polymer sirolimus-eluting stent (BP-SES) was developed with the concept of biocompatibility, and there has been no report of ISR of BP-SES with hypersensitivity reaction. Case summary  An 81-year-old woman presented with ST-elevation acute inferior myocardial infarction. Primary percutaneous coronary intervention was performed for the culprit lesion in the left circumflex artery with a permanent polymer everolimus-eluting stent (PP-EES), followed by BP-SES implantation in the left anterior descending artery. Eight months later, coronary angiography showed total occlusion of the PP-EES and diffuse ISR in the BP-SES, treated with a paclitaxel-eluting balloon. Fluorodeoxyglucose with positron emission tomography showed increased uptake around the BP-SES, and cardiac magnetic resonance imaging revealed a late gadolinium-enhanced area around both stents. Four months later, she developed re-ISR in the BP-SES, and optical coherence tomography demonstrated diffuse-layered neointimal hyperplasia with microvascularization and peri-strut low-intensity area. She was successfully treated with coronary artery bypass grafting. Discussion  Our case demonstrated repetitive short-term ISR of the BP-SES. Observation by both intravascular and non-invasive imaging modalities suggested the presence of hypersensitivity reaction localized in the stent. https://www.selleckchem.com/products/nt157.html Hypersensitivity to the metal may be a possible mechanism because both stents are composed of L605 cobalt-chromium alloy. This is the first report of ISR of a BP-SES with hypersensitivity reaction. Non-invasive imaging can be useful to assess this critical condition. © The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.
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