Cardiac masses may mimic tumors or vegetations. Differentiation is essential, particularly in the context of bacteremia and embolic complications. A 75-year-old man presented with fatigue, myalgia, and new-onset atrial fibrillation. Transesophageal echocardiography revealed a mitral valve mass with features suggestive of fibroelastoma or myxoma. Blood cultures were positive for Streptococcus mitis. The patient subsequently developed an intracerebral hemorrhage requiring craniotomy. Serial imaging demonstrated resolution of the mitral valve mass, supporting a diagnosis of vegetation. Diagnosis of infective endocarditis requires integration of clinical context, microbiologic data, and serial imaging rather than reliance on echocardiographic appearance alone. Anticoagulation strategies must be individualized after hemorrhagic events. Cardiac masses in the setting of bacteremia require careful interpretation as lesions that appear benign may represent vegetations. ⁠Accurate diagnosis depends on integration of Duke criteria and serial transesophageal echocardiography evaluations, rather than reliance on a single echocardiogram.

Anomalous right coronary artery (RCA) arising from the left sinus of Valsalva presents a challenge during angiography, often leading to failed engagement, prolonged procedure time, and delayed reperfusion. This case highlights an innovative technique in which a standard guide catheter was manually modified to mimic a Leya catheter when the dedicated device was unavailable, allowing timely revascularization. A 47-year-old man presented with chest pain and elevated troponin, consistent with non-ST-elevation myocardial infarction. Angiography showed an anomalous RCA taking off anterior and superior to the left main coronary artery. Several standard diagnostic and guiding catheters failed to engage the vessel; the procedure was then switched from radial to femoral access, and an Amplatz Left 1 (AL1) guide catheter was manually modified by applying a 45–60° right-angled twist at the tip to reproduce the curvature of a Leya catheter. This modification allowed stable engagement of the RCA and successful percutaneous coronary intervention. In patients with anomalous RCA where standard catheters fail, manual modification of a guide catheter to achieve optimal engagement can be a useful alternative when a dedicated design is unavailable. Femoral access is preferred in difficult cases, especially with anomalous RCA, as it provides greater stability and facilitates successful engagement.

Background/Objectives: Type 2 myocardial infarction (T2MI) results from a myocardial oxygen supply–demand imbalance without acute coronary atherothrombosis, and the role of invasive coronary angiography in its management is undefined. Prior literature has largely compared T2MI to type 1 myocardial infarction (T1MI) rather than examining angiography selection within T2MI itself. This systematic review with narrative synthesis identified and synthesized factors associated with angiography utilization among T2MI patients, distinguishing adjusted from unadjusted evidence. Methods: PubMed, Embase, and ClinicalTrials.gov were searched for studies reporting patient or clinical characteristics associated with undergoing invasive coronary angiography among patients with T2MI, identified via multivariable regression, univariate comparison, or stratified baseline tables. Studies using angiography as an inclusion criterion, an event-risk outcome, or a randomized treatment assignment, or comparing T2MI to T1MI as groups without addressing within-T2MI factors, were excluded. This review was conducted in accordance with PRISMA 2020 guidance. Given clinical and methodological heterogeneity and no common effect-size metric across studies, findings were synthesized narratively without quantitative pooling. Results: Three studies met inclusion criteria (two large US administrative-data cohorts, n = 268,850 and n = 18,606 T2MI; one French two-center cohort, n = 224). Younger age was independently associated with greater odds of angiography in the largest cohort reporting age-specific estimates, with a monotonic decline in angiography utilization across advancing age strata; a second cohort’s unadjusted group comparison was directionally concordant, but its own multivariable estimate for age was internally inconsistent and is not treated as confirmatory. Chronic ischemic heart disease and heart failure were independently associated with higher odds of angiography, while chronic kidney disease, chronic obstructive pulmonary disease, peripheral vascular disease, and atrial fibrillation were independently associated with lower odds. Commercial insurance and Midwest or South United States residence were independently associated with higher odds in the single study assessing these factors. Cardiology consultation showed conflicting directions of adjusted association between the two studies reporting it. Conclusions: Selection for invasive angiography in T2MI is heterogeneous and inconsistently studied. Age was the only factor with cross-study directional support, and even that lacked confirmed adjusted concordance. Other factors were supported by single studies or conflicting findings, and no included study reported the bedside clinical variables plausibly driving real-time decisions. Certainty was very low for every factor examined (modified GRADE), underscoring the need for prospective study of angiography selection in T2MI.

Infective endocarditis is a life‐threatening infection of the endocardial surface, most commonly resulting from bacteremia originating from the oral cavity or intravascular sources. However, in some cases, the source of bacteremia remains unidentified, and the role of gastrointestinal pathology is not well defined. We report a patient in her 70s with multiple comorbidities, including mitral annular calcification, who presented with fever, altered mental status, and abdominal pain. Blood cultures grew Streptococcus mitis . Transthoracic and transesophageal echocardiography demonstrated a mobile vegetation on the mitral valve consistent with infective endocarditis. Brain magnetic resonance imaging revealed multiple acute cardioembolic infarctions. During hospitalization, persistent abdominal symptoms prompted further evaluation, which identified severe fecal impaction and a previously undiagnosed ileal neuroendocrine tumor with hepatic lesions. No recent dental procedures or other clear sources of bacteremia were identified. This case raises the possibility that gastrointestinal pathology, including bowel dysfunction and malignancy, may contribute to bacteremia and subsequent infective endocarditis. In patients without an identifiable source, targeted gastrointestinal evaluation may be considered, although further studies are needed to clarify this relationship.