Congenital coronary artery anomalies are relatively rare, occurring in approximately 0.6%-1.3% of cases undergoing coronary angiography. Among these anomalies, a unique cardiac abnormality known as a dual left anterior descending artery (LAD) stands out. A dual LAD is characterized by the presence of 2 LADs in the anterior interventricular sulcus. This structural deviation consists of a shorter LAD that terminates high in the anterior interventricular sulcus and a longer LAD that extends to the distal sulcus, supplying blood to the cardiac apex. Percutaneous procedures on dual LADs are even less frequent. We describe a 53-year-old woman with typical burning chest pain, ST-elevation in leads I and aVL, and positive troponin I enzyme. Coronary angiography revealed a thrombotic lesion with 99% stenosis at the proximal part of the LAD. The main LAD originated properly from the left coronary cusp, and the remainder of its course was supplied by a second branch originating from the right coronary cusp. Computed tomography angiography and echocardiography were performed for the LAD course. The patient was discharged after an uneventful 1-week hospital stay. Our case is particularly noteworthy for several reasons. Firstly, this dual LAD anomaly is uncommon, and patients with dual LADs less frequently have a ramus artery. Secondly, there have been only a few documented cases of percutaneous transluminal coronary angioplasty performed on short LADs. The key takeaway from this scintillating case study is the significance of identifying the artery responsible for blood supply to the cardiac apex.

Background: Arrhythmia is an abnormal sinus rhythm of the heartbeat, and in addition to threatening the patient';s health, it may also cause fatal complications. Objectives: The present review study was investigated the effects of berberine (BBR) on cardiac arrhythmias and its possible complications. Methods: A systematic search was conducted on electronic databases such as PubMed/MEDLINE, Web of Science, Scopus, Embase, and Cochrane Library to identify relevant studies published before June 10, 2024. Inclusion criteria were defined based on the study';s aim. Two reviewers performed data extraction independently to ensure accuracy and minimize bias. The data were finally extracted and analyzed. Results: Finally, 22 studies were included. BBR revealed antiarrhythmic effects through antioxidant, anti-inflammatory, and anti-apoptotic activity and improved mitochondrial function. Moreover, BBR modulated ion channels and improved electrical remodeling trough inhibited Potassium current (IK), IK1, IKr, IKs, ICa, INa, KATP channels and human ether-a-go-go related gene (hERG) and improved expression of inwardly rectifying potassium (Kir)6.2 and Kir2.1. It also increased action potential duration (APD), prolonged the effective refractory period (ERP), and reduced the frequency and complexity of ventricular premature complexes (VPC). However, it causes some cardiovascular side effects, including prolonged QT interval, bradycardia, and hypotensive effects. BBR may also lead to gastrointestinal complications, immunosuppressive effects, and interaction with concomitant drugs. Conclusion: Although BBR';s cardioprotective properties have satisfactory effects on cardiac arrhythmia, it causes prolonged QT interval, bradycardia, hypotension, and cardiotoxicity. However, more clinical studies are needed to obtain more reliable results.

Key Clinical Message: Before valvular interventions, echocardiography, especially the TEE or the ventilation/perfusion scan, should be performed to detect silent PTE and set a more accurate treatment and surgical plan. Pulmonary hypertension (PH) is a progressive and critical disease that can be caused by mitral stenosis (MS). Some of these patients present with disproportionate PH, which is an uncommon phenomenon and is considered a challenging diagnostic and treatment process. In these patients, other causes may also play a role in developing PH. This report presented two cases with disproportionate PH and severe MS who were scheduled for percutaneous mitral valvuloplasty (PMV). The pre‐procedural echocardiography revealed systolic pulmonary artery pressure (sPAP) of 90 and 120 mmHg, mitral valve area of 0.80 and 0.55 cm ² by three‐dimensional (3D) planimetry, and diastolic pressure gradient (DPG) of 13 and 18.8 mmHg, respectively. Furthermore, in the first patient, 3D transesophageal echocardiography (TEE) revealed multiple saddle‐type organized thrombi in the proximal parts of the right and left pulmonary arteries, extending to the distal branches. In the second patient, 3D TEE revealed a large, relatively fresh, flow‐limiting thrombosis in the proximal part of the right pulmonary artery. The diagnosis of pulmonary thromboembolism (PTE) in both patients was confirmed by CT angiography. In both patients, the valves were surgically repaired, while all thrombi were removed from the cardiac chambers and pulmonary vessels during surgery. In addition, patients underwent warfarin therapy orally. They were followed up 6 months after the intervention, and their clinical symptoms had improved significantly.

Key Clinical Message: Recurrence of valvular involvement may occur after Libman–Sacks endocarditis surgery, emphasizing the need for frequent multivalvular evaluations with echocardiography or more sensitive methods to optimize surgical outcomes. This report presented a 32‐year‐old woman, complaining of recurrent fever and chills. Physical examination revealed the presence of a third heart sound (S₃), a pan‐systolic murmur (III/VI) at mitral and tricuspid foci, tachycardia, and fine pulmonary crackles. Transesophageal echocardiography (TEE) revealed severe mitral regurgitation (MR) and moderate tricuspid regurgitation (TR) with vegetations on the mitral valve. Initially, intravenous antibiotic therapy was started simultaneously with diagnostic studies. Despite a positive TEE, negative blood cultures on three separate occasions precluded meeting the diagnostic criteria outlined in the modified Duke criteria. Moreover, the patient's condition continued to deteriorate after antibiotic therapy, leading to the diagnosis of Libman–Sacks endocarditis. The patient was considered a candidate for mitral valve surgery. All vegetations were completely debrided and then the mitral valve was reconstructed. Follow‐up post‐surgery echocardiography revealed the absence of MR and mitral stenosis (MS). Four months later, the patient presented again complaining of fatigue, dyspnea, lower extremity edema, and ascites with evidence of pulmonary hypertension and right heart failure on physical examination. TEE was performed, which revealed severe MR, severe TR, detached artificial chordae, and blood leak from the perforated pericardial patch. Therefore, she was necessitated for valvular surgery and underwent mitral and tricuspid valve surgery. The mitral ring and perforated pericardial patch were removed, and a mitral prosthetic valve was implanted. In addition, the tricuspid valve was repaired. Follow‐up post‐surgery echocardiography revealed the absence of MR and TR. To our knowledge, this is the first case of LSE recurrence with multi‐valvular involvement.

Background: Concomitant cardiac amyloidosis (CA) and aortic stenosis (AS) may be mistaken for isolated AS, potentially impacting the treatment strategy and patient’s prognosis. Therefore, it is crucial to distinguish between these conditions, as failure to promptly diagnose CA may lead to considerable complications. The aim of this study is to investigate the diagnostic value of strain predictors in patients with concomitant CA and AS compared to isolated AS. Methods: Forty-two patients with severe AS suspected of concomitant CA based on a comprehensive clinical evaluation were selected to undergo ⁹⁹mTc-DPD scintigraphy. Those showing Perugini grade 2 or 3 tracer uptakes without evidence of monoclonal gammopathy were diagnosed with CA and underwent speckle-tracking echocardiography. Furthermore, strain analysis was performed to evaluate myocardial deformation, with a focus on detecting apical sparing and reduction in bull’s eye mapping, resulting in the characteristic “cherry on top” sign. Results: Eight patients were diagnosed with CA, representing 19.0% of those suspected of concomitant CA and 7.8% of the overall cohort with severe AS. AF arrhythmia was significantly more frequent in these patients compared to those with isolated AS. Echocardiography findings revealed that E/E’ ratio and RALS were significantly higher in patients with concomitant CA, while GLS and mean basal LS were significantly lower in this group. The “cherry on top” sign was detected in 19 patients (45.2%), present in 100% of those with concomitant CA and AS, versus 32.4% in isolated AS cases (P = 0.04). This sign demonstrated a sensitivity of 100% and a specificity of 67.6% for predicting concomitant CA and AS. Conclusions: In conclusion, the “cherry on top” sign was significantly more prevalent in patients with concomitant CA and AS, compared to those with isolated AS, demonstrating a sensitivity of 100% and a specificity of 67.6% for predicting concomitant CA. Moreover, RALS and E/E’ ratios were significantly higher in patients with concomitant CA, whereas GLS and mean basal LS were significantly lower in this group.