BACKGROUND: Coronary computed tomography angiography (CCTA) is emerging as a valuable tool for noninvasive surveillance of cardiac allograft vasculopathy (CAV) in patients with heart transplant (HTx). We assessed the diagnostic performance of a comprehensive CCTA-based approach compared with the invasive reference, which includes invasive coronary angiography, intravascular ultrasound, and fractional flow reserve, for detecting CAV. METHODS: This was a multicenter prospective study including 37 patients with HTx who underwent CCTA, invasive coronary angiography, intravascular ultrasound, and fractional flow reserve. The comprehensive CCTA-based approach included quantitative and qualitative plaque analysis and functional assessment by fractional flow reserve derived from coronary computed tomography. CAV was diagnosed based on invasive coronary angiography (International Society for Heart and Lung Transplantation criteria) and intravascular ultrasound. Univariable logistic regression analysis was performed to test CCTA-derived predictors of CAV. The area under the curve and accuracy indicators were calculated to evaluate the performance and best cutoffs of CCTA predictors of CAV. RESULTS: The median interval between CCTA and HTx was 5 years. Among the 37 recipients, 23 (62.2%) were diagnosed with CAV. The integration of diameter stenosis and plaque morphology (including plaque burden at minimum lumen area >42% and percent atheroma volume >23%) at CCTA yielded the highest diagnostic performance (accuracy, 84%; sensitivity, 83%; specificity, 86%). The integration of ∆fractional flow reserve derived from coronary computed tomography trans-vessel gradient led to increased sensitivity, albeit with decreased specificity and overall accuracy. The noninvasive approach was associated with a lower contrast and radiation dose, compared with the invasive approach. CONCLUSIONS: A noninvasive strategy based on CCTA is accurate for managing patients with HTx. CCTA might be considered the preferred imaging modality for annual CAV surveillance after the first year post-HTx.

We report a case of a clinically asymptomatic patient with extreme P-wave separation on the electrocardiogram mimicking atrial tachycardia with atrioventricular block. The accurate examination of the patient, analysis of the electrocardiogram, and echocardiographic findings led to proper diagnosis, management, and treatment. (Level of Difficulty: Intermediate.)

Background: Atypical atrial flutter (AFL) is a complex clinical challenge, particularly in patients with prior atrial fibrillation (AF) treated with pulmonary vein isolation (PVI). Arrhythmias involving the vein of Marshall (VOM) often require extensive lesion sets, including ethanol infusion, to effectively target the epicardial substrate. To minimize tissue damage, an alternative strategy has been proposed, emphasizing advanced electroanatomical mapping, entrainment maneuvers, and highly targeted ablation techniques. Case Presentation: We describe a 72-year-old woman with recurrent atrial arrhythmias following pulmonary vein isolation (PVI), who presented with palpitations as her primary symptom. After ineffective pharmacological therapy, she underwent a catheter ablation procedure. Electroanatomical mapping revealed significant left atrial scarring and suggested a macroreentrant circuit involving the VOM. Entrainment maneuvers confirmed the VOM’s involvement. A single targeted endocardial ablation guided by the ablation index terminated the arrhythmia within 12 s, without the need for ethanol infusion or extensive lesion sets. Discussion: This case underscores the VOM’s role in sustaining atypical AFL post-PVI and highlights the effectiveness of precise electroanatomical mapping combined with targeted endocardial ablation. Unlike broader ablation or ethanol infusion strategies, a focused lesion at the critical isthmus achieved arrhythmia termination with minimal tissue damage. Conclusions: Endocardial ablation at the site of entrainment can safely and effectively treat VOM-related AFL, offering symptom relief and restoration of sinus rhythm. This approach may reduce procedural risks and expand the feasibility of VOM-related arrhythmia management in centers without access to ethanol infusion.

Background: Mediastinal bronchogenic cysts are sporadic congenital tumors, accounting for approximately 10%–15% of all mediastinal masses. In most cases, they remain asymptomatic. We present a case of a young man with new-onset atrial fibrillation caused by extra cardiac compression of the left atrium by mediastinal bronchogenic cyst. We report the first documented case in our country of a patient with a mediastinal bronchogenic cyst presenting with cardiac symptoms. Case summary: A 39-year-old man was admitted to the emergency department with palpitations, dyspnea, and tachycardia that developed after physical activity. Electrocardiography demonstrated the first episode of atrial fibrillation. Echocardiography revealed an oval echolucent mass compressing the left atrium. Cardiac magnetic resonance imaging showed a massive mediastinal bronchogenic cyst causing compression of the left atrium, right inferior pulmonary vein, and esophagus, which was displaced to the left side. Robot-assisted thoracoscopic surgery was planned and performed successfully. Discussion: Although typically asymptomatic, bronchogenic cysts can acutely present with life-threatening complications, particularly when they compress important cardiovascular structures. This case highlights the important role of comprehensive evaluation in young patients. It is crucial to consider extra cardiac causes in new-onset atrial fibrillation, especially in young adults. Fast and accurate diagnosis is essential to prevent further complications, with management extending beyond restoring sinus rhythm.