Background: Left atrial appendage occlusion (LAAO) is an alternative to anticoagulation for stroke prevention in select patients with atrial fibrillation (AF). In this study, we describe the case of a patient with delayed device-related thrombus (DRT) at 13 months post-LAAO in a setting of atrial stasis due to a worsening mitral bioprosthetic stenosis. Case summary: A 69-year-old woman with a history of rheumatic mitral stenosis and regurgitation post-bioprosthetic mitral valve replacement (6 years prior) and paroxysmal AF was referred for percutaneous LAAO due to recurrent severe gastrointestinal bleeding while on anticoagulation. She underwent an uncomplicated LAAO, for which a 35 mm Watchman Flx device was used. Peri-procedural transoesophageal echocardiogram (TEE) at the time of implant showed thickened and calcified mitral bioprosthetic leaflets and a mild mitral stenosis. Her 45-day post-LAAO TEE showed a mild mitral stenosis and no peri-device leak or DRT. At 12 months, the patient had worsening exertional dyspnoea and pedal oedema. Her 12-month transthoracic echocardiogram (TTE) showed a moderate mitral stenosis and LAAO remained free of DRT. Her symptoms were deemed secondary from a worsening mitral valve stenosis. Mitral valve-in-valve (MViV) replacement was planned because the patient was deemed a prohibitive risk for a redo surgical replacement. Transthoracic echocardiogram on the day of MViV showed a large thrombus on the LAAO device. MViV was postponed. After the patient completed 45 days of anticoagulation with warfarin, a repeat TTE was performed, which showed a resolution of DRT. Transcatheter MViV was performed successfully. Discussion: This case demonstrates that increased stasis and left atrial dysfunction from prosthetic mitral stenosis can be a risk factor for late DRT after successful LAAO. The use of a LAAO occlusion device in the presence of a mitral bioprosthesis requires more frequent echocardiographic monitoring to assess both the function of the prosthesis and a delayed formation of thrombus. More studies need to be conducted to assess the safety of percutaneous LAAO devices in those with mitral bioprosthesis.

Cor triatriatum sinister (CTS) is a rare congenital anomaly characterized by a fibromuscular membrane that divides the left atrium into proximal and distal chambers. Typically, the pulmonary veins drain into the proximal chamber, while the distal chamber remains continuous with the left atrial appendage and the mitral valve. Communication between the two chambers occurs through one or more fenestrations of variable size. We report the case of a 61-year-old woman with a history of atrial flutter status post-ablation and atrial septal defect repair in infancy, who was incidentally found to have CTS on multimodal imaging. In the absence of hemodynamic compromise or CTS-related symptoms, conservative management was deemed appropriate. This case highlights the value of contemporary imaging modalities in the incidental detection of congenital anomalies in adults and emphasizes the need for individualized management strategies.

Subclinical atrial fibrillation (SCAF) episodes are frequently detected in patients with cardiac implantable electronic devices (CIEDs). These asymptomatic arrhythmias are increasingly recognized as potential harbingers of clinical atrial fibrillation and thromboembolic events. However, the management of SCAF—particularly regarding the use of oral anticoagulation (OAC)—remains controversial. This literature review (Medline, Scopus, Goggle scholar, Embase) focuses on using current literature and clinical studies to guide decision-making regarding anticoagulation therapy and other treatment options that can limit complications for patients with SCAF. The decision to initiate anticoagulation in patients with atrial high-rate episodes (AHREs) should be individualized, balancing stroke risk against bleeding potential. Ongoing research and post hoc analyses will further clarify which subgroups may benefit most from therapy, informing future guideline recommendations.

Aims: The role of coronary CT angiography (CCTA) in improving outcomes among patients undergoing percutaneous coronary intervention (PCI) for obstructive coronary artery disease (CAD) remains unclear. Methods and results: A retrospective cohort study using the TriNetX U.S. Research Network identified adults (≥18 years) who underwent de novo PCI (2013–2025). Patients with prior or presenting PCI, coronary artery bypass grafting, or acute coronary syndrome were excluded. Those with CCTA within 1 year before PCI were compared to those without CCTA. After 1:1 propensity score matching, 4936 patients remained in each group. The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), or heart failure (HF) at 1 and 5 years. Baseline characteristics were well-balanced post-matching. CCTA prior to PCI was associated with lower rates of the composite outcome at 1 year (9.6% vs. 13.0%; hazard ratios (HR) 0.74, 95% CI 0.66–0.83) and 5 years (16.1% vs. 23.7%; HR 0.79, 95% CI 0.72–0.86). Reductions were mainly driven by lower MI and mortality rates. HF showed no difference at 1 year but was significantly lower at 5 years (HR 0.85, 95% CI 0.76–0.95). Conclusion: Pre-procedural CCTA within 1 year of PCI was associated with improved cardiovascular outcomes at 1 and 5 years, suggesting potential benefits from enhanced anatomical assessment and medical optimization before revascularization.

A 76-year-old female with a complicated medical history presented for Watchman (Boston Scientific) placement 2 months after mitral valve transcatheter edge-to-edge repair (TEER). Preoperative workup before Watchman placement confirmed the presence of a thrombus in the left superior pulmonary vein. Post-procedure mitral valve TEER transesophageal echocardiogram showed no thrombus in the left atrium appendage or pulmonary veins. We believe the thrombus in the left superior pulmonary vein occurred secondarily due to epithelium damage during the mitral valve TEER.

A 52-year-old male with a past medical history significant for hypertension, bipolar disorder, tobacco use, gout, homelessness, intravenous drug use, untreated hepatitis C (spontaneous clearance), and human immunodeficiency virus presented to the emergency department with complaints of left foot pain and lower back pain. He was found to have fever, mild leukocytosis, and blood cultures with positive methicillin-sensitive Staphylococcus aureus infection. Transesophageal echocardiography was performed to check for intracardiac vegetations due to high risk of infective endocarditis. A mobile echo density was seen attached to the Chiari network, leading to diagnosis of Chiari network endocarditis.