Degenerative mitral valve stenosis (DMS) associated with mitral annular calcification (MAC) poses significant diagnostic and therapeutic challenges. Surgical treatment and conventional percutaneous mitral commissurotomy are often contraindicated, and alternative transcatheter options remain limited and associated with high morbidity and mortality. Lithotripsy-assisted balloon valvuloplasty has recently emerged as a novel percutaneous strategy for selected patients. The objective of this article is to report on an initial feasibility and safety experience of lithotripsy-assisted balloon valvuloplasty without the use of noncompliant balloon post-dilatation. We conducted a prospective, single-center study including consecutive patients with symptomatic severe DMS deemed unsuitable for surgery who underwent lithotripsy-assisted balloon valvuloplasty between August and October 2025. The cases were performed under conscious sedation using intracardiac echocardiography guidance. The procedure consisted of a single transseptal puncture accommodating two deflectable sheaths and simultaneous dual-balloon intravascular lithotripsy, without adjunctive noncompliant balloon valvuloplasty. The primary endpoint was technical success according to the Mitral Valve Academic Research Consortium criteria. Safety endpoints included 30-day major procedure-related morbidity and mortality. Three patients (median age 73 years; 67% female) underwent lithotripsy-assisted balloon valvuloplasty. Median baseline noninvasive and invasive transmitral mean gradients were 16 mmHg and 11 mmHg, respectively, decreasing to 7 mmHg after lithotripsy-assisted balloon valvuloplasty. No worsening of baseline mitral regurgitation was observed. There were no major periprocedural complications; one patient experienced a transient, self-limited period of junctional rhythm. This proof-of-concept study of lithotripsy-assisted balloon valvuloplasty using a dual deflectable sheath, dual-balloon lithotripsy strategy was feasible and safe in selected patients with DMS. This approach may represent a promising therapeutic option for patients with limited alternatives, warranting further investigation in larger prospective studies.

Sudden cardiac arrest (SCA) affects individuals across all age groups and is defined as the sudden cessation of normal cardiac activity, leading to hemodynamic collapse. Determining the etiology of SCA is challenging due to its wide range of cardiac and noncardiac causes. Structural heart disease, mainly coronary artery disease, is predominant in older adults, while cardiomyopathies and primary electrical diseases are more common in younger individuals. Noncardiac causes, such as intracranial hemorrhage and pulmonary embolism, account for 15-25% of cases. This review examines the epidemiology, etiology, and investigation of SCA and proposes a diagnostic approach for SCA patients admitted to the emergency department and intensive care unit. The study protocol is divided into four main stages: (1) initial evaluation, identification of reversible causes, and exclusion of ischemic heart disease and extracardiac disease; (2) assessment of nonischemic cardiac causes; (3) neuroprognostication; and (4) clinical autopsy and/or genetic testing, if appropriate. We emphasize the importance of a multidisciplinary approach, involving an intensivist, cardiologist, geneticist, and pathologist, as well as early genetic testing to identify potential heritable diseases and facilitate early referral of patient relatives. By providing this structured diagnostic algorithm, we aim to improve the management and outcomes of SCA patients.

Cardiac metastases from colorectal cancer are exceedingly rare and pose significant diagnostic challenges, particularly in the absence of disseminated disease. A 55-year-old man with ulcerative colitis and previously treated rectal adenocarcinoma presented with rising carcinoembryonic antigen levels during surveillance. Colonoscopy excluded local recurrence. Multimodality imaging identified a right ventricular mass, with cardiac magnetic resonance revealing a 36 × 48 mm lesion arising from the right ventricular free wall with endoluminal growth and late enhancement. In the absence of extracardiac disease, intracardiac echocardiography-guided endomyocardial biopsy confirmed metastatic colorectal adenocarcinoma. Endomyocardial biopsy remains the gold standard for definitive etiological diagnosis of intracardiac masses and is generally safe when performed in experienced centers. Multimodality imaging and operator expertise are essential for accurate diagnosis of high-risk intracardiac masses.

Pulmonary arterial hypertension (PAH) is a severe and potentially life-threatening complication of systemic lupus erythematosus. We present the case of a young woman with dyspnea at rest, hospitalized with a suspected systemic lupus erythematosus flare. Right heart catheterization confirmed pre-capillary pulmonary hypertension with a low cardiac index. She was classified as World Health Organization functional class IV. Instead of initiating triple therapy with a parenteral prostacyclin analog, we opted for immunosuppressive therapy combined with dual oral PAH-specific therapy. Seven days after admission, the patient improved to World Health Organization functional class II, with no clinical signs of heart failure and normalization of echocardiographic parameters. At 6 months, she remains asymptomatic, with hemodynamic reassessment confirming the absence of PAH criteria. Early recognition of severe PAH as a cause of dyspnea and hemodynamic instability in rheumatologic patients is essential for timely intervention. Immunosuppressive therapy should be considered an integral component of PAH-specific treatment, as it may significantly improve prognosis in autoimmune-related PAH.

Apresentação do caso Uma mulher de 63 anos se apresentou com histórico de dois anos de piora da fadiga, dispneia (classe funcional III da Organização Mundial da Saúde) e palpitações. O ecocardiograma demonstrou alta probabilidade de hipertensão pulmonar (HP), e ela foi então encaminhada a um centro especializado em HP. Seu histórico médico incluía hipertensão arterial sistêmica, anemia ferropriva secundária a sangramento gastrointestinal por telangiectasias duodenais (tratadas endoscopicamente) e discectomia extraforaminal prévia em L3-L4 devido à hérnia de disco lombar [...] Apresentação do caso Uma mulher de 63 anos se apresentou com histórico de dois anos de piora da fadiga, dispneia (classe funcional III da Organização Mundial da Saúde) e palpitações. O ecocardiograma demonstrou alta probabilidade de hipertensão pulmonar (HP), e ela foi então encaminhada a um centro especializado em HP. Seu histórico médico incluía hipertensão arterial sistêmica, anemia ferropriva secundária a sangramento gastrointestinal por telangiectasias duodenais (tratadas endoscopicamente) e discectomia extraforaminal prévia em L3-L4 devido à hérnia de disco lombar