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A 71-year-old man with ischemic cardiomyopathy, a left ventricular (LV) ejection fraction of 23 %, left bundle branch block with a QRS duration of 160 milliseconds, and nonsustained ventricular tachycardia was admitted for cardiac resynchronization therapy combined with an implantable defibrillator. During LV lead placement, the guiding sheath encountered strong resistance during deep coronary sinus (CS) cannulation. CS venography showed a complete occlusion, and we diagnosed venospasm because the occlusion self-resolved after several minutes. After administering intravenous isosorbide dinitrate and waiting several minutes without manipulating the catheters, we could successfully place the LV lead in the target branch. Although CS spasm is considered a rare complication of LV lead placement, in some cases catheter manipulation can trigger it. Therefore, clinicians should recognize its possibility and be aware of the associated angiographic findings and treatment. LEARNING OBJECTIVE: In some cases, coronary sinus (CS) spasm can be triggered during left ventricular lead placement. It presents as occlusion with abrupt tapering on CS venography. After administering intravenous nitrates and waiting several minutes without manipulating the catheters, the spasm resolves and the catheter can be advanced.

We herein report a 79-year-old man with recurrent atrial flutter (AFL) following catheter ablation for pulmonary vein (PV) isolation and block line of the cavotricuspid isthmus. An electrophysiological study and three-dimensional mapping results revealed left atrium (LA)-PV macroreentrant flutter caused by a conduction gap, possibly correlated to prior application, which mimicked cavotricuspid isthmus-dependent AFL. This LA-PV flutter was terminated after applying radiofrequency to the gap at the antrum near the bottom left inferior PV in the posterior LA wall. During follow-up, the patient did not present with atrial tachyarrhythmias; antiarrhythmic drugs were therefore not administered.

A 31-year-old female with an 18-year history of systemic lupus erythematosus (SLE) complained of epigastralgia and consulted the emergency outpatient department at our hospital. Her physical examination revealed tenderness at the scrobiculus cordis, which was a non-specific symptom of coronary heart disease (CHD). We ultimately gave a diagnosis of acute myocardial infarction based on coronary angiography and performed percutaneous coronary intervention. Although pre-interventional intravascular ultrasound demonstrated distinct atherosclerotic lesions in the coronary arteries, there were no atherosclerotic lesions in other systemic arteries. Although CHD in young SLE patients is a significant cause of morbidity and premature death, it tends to be misdiagnosed because their symptoms may be non-specific. In addition, this case highlights the fact that even SLE patients with no systemic atherosclerosis are at risk for the development of CHD. .

A 44-year-old woman had a 15-year history of asthma and had recently been treated for sinusitis and unidentified limb eruption. She had presented at a nearby clinic with inspiratory chest pain one week before hospitalization, and was diagnosed as having eosinophilic pneumonia based on peripheral blood eosinophilia and ground glass opacities in the right lung field, without pericardial effusion, as detected by chest computed tomography. She additionally presented with a feeling of chest tightness, and extensive pericardial effusion appeared within a week. She developed heart failure on admission, and we performed pericardiocentesis. We gave a clinical diagnosis of acute probable myopericarditis as the cause of pericardial effusion based on pleuritic chest pain, pericardial effusion, and elevation of cardiac enzymes, as well as eosinophilic granulomatosis with polyangiitis (EGPA) based on eosinophilia, her history of sinusitis, asthma, and migratory pulmonary opacities. We initiated oral prednisone 25 mg daily and pericardial effusion disappeared. In patients with EGPA, cardiac involvement is more serious than the involvement of other organs, and is associated with a poor prognosis. In this report we describe a rare case of EGPA complicated with progressive pericardial effusion and discuss the importance of the early diagnosis and treatment of EGPA. Learning objective: Eosinophilic granulomatosis with polyangiitis (EGPA), or Churg Strauss syndrome, is a multisystem disorder. It is important for patients with EGPA complicated with cardiac involvement to be diagnosed and treated early because cardiac involvement may lead to a fatal outcome.>