Congenital absence of the pericardium (CAP) is a rare thoracic anomaly that is frequently asymptomatic but may mimic ischemic heart disease clinically and on initial evaluation. Its diagnosis relies heavily on imaging, yet characteristic radiologic findings are often overlooked. We present the case of a young adult male whose condition was accurately identified and successfully managed through clinical expertise and comprehensive multimodality imaging. A 22-year-old male presented with recurrent nonexertional chest pain and sinus bradycardia. Initial investigations, including electrocardiography and laboratory tests, were unremarkable. Chest radiography was initially interpreted as normal. Transthoracic echocardiography suggested abnormal cardiac mobility and axis deviation. Cardiac magnetic resonance imaging (MRI) confirmed complete right-sided and partial left-sided pericardial absence. Retrospective review of chest X-ray demonstrated the classic "Snoopy sign." Cardiac stress testing showed no inducible ischemia. The patient was managed conservatively with complete symptom resolution. This case highlights the critical role of multimodality imaging in diagnosing congenital absence of the pericardium (CAP) and emphasizes the importance of recognizing subtle radiographic signs. Early radiologic identification can prevent misdiagnosis and unnecessary interventions. Radiologists should maintain a high index of suspicion when encountering unexplained cardiac displacement or abnormal cardiac mobility. A structured diagnostic approach incorporating both clinical reasoning and advanced imaging is essential to help delineate anatomical abnormalities and exclude ischemia, enabling appropriate management decisions.

Conduction disturbances requiring permanent pacemaker (PPM) implantation remain a frequent complication of transcatheter aortic valve implantation (TAVI). This study aimed to evaluate the "Vectorial Angle"-a novel computed tomography (CT)-derived biomechanical parameter-alongside traditional anatomical and electrocardiographic predictors of PPM following balloon-expandable TAVI. This retrospective cohort study included 67 patients with severe symptomatic aortic stenosis undergoing TAVI with the balloon-expandable Myval system. The Vectorial Angle was defined on preprocedural CT at the elliptical left ventricular outflow tract (e-LVOT) level as the angular deviation between the minor axis (representing the axis of maximal radial expansion force) and the midpoint of the right coronary to noncoronary (RCCNCC) commissure (approximating the anatomical course of the conduction system).PPM implantation was required in 12 patients (17.9%). In multivariate logistic regression analysis, a narrower Vectorial Angle (OR 0.935 per 1° increment, 95% CI 0.889 to 0.982; p = 0.007) and a shorter membranous septal length (MSL) (OR 0.447 per 1 mm increment, 95% CI 0.241 to 0.831; p = 0.011) emerged as the only independent predictors of PPM requirement. Valve oversizing index was not associated with PPM implantation (p = 0.954). Implantation depth was numerically greater in the PPM group but did not reach independent predictor status (p = 0.079). Pre-existing right bundle branch block (RBBB) lost independent predictive value after adjustment for these structural parameters. Receiver operating characteristic (ROC) curve analysis for the Vectorial Angle yielded an area under the curve of 0.806 (p = 0.001), with an optimal cutoff of ≤52°. The Vectorial Angle is a novel, independent preprocedural predictor of PPM after balloon-expandable TAVI. This finding highlight that the spatial orientation of the valve's maximal radial force relative to the conduction tissue is a potential anatomical determinant associated with conduction-system vulnerability, complementing conventional anatomical assessments such as MSL.

Atrial septal defects (ASDs) and ventricular septal defects (VSDs) account for the majority of congenital heart disease and may remain clinically relevant from infancy into adulthood. Echocardiography is the gold standard for diagnosis and detailed anatomical assessment of these defects; however, the electrocardiogram (ECG) may provide additional pathophysiological and prognostic insights. This review summarizes ECG findings in ASD and VSD before and after repair, with respect to the effects of defect type, timing of intervention, and postoperative evolution of electrical disturbances. A structured literature search was conducted to identify studies reporting ECG or rhythm abnormalities before and after repair. In hemodynamically significant ASD, ECG changes before repair generally correlate with chronic right-sided chamber volume overload. Secundum defects present with right-axis deviation and incomplete right bundle branch block. Primum defects are mainly associated with left-axis deviation and atrioventricular conduction delay, whereas sinus venosus defects may present with sinus node dysfunction. After closure, right-sided overload markers may return to normal; however, persistent atrial arrhythmias and conduction-system lesions frequently occur. In VSD, preoperative findings may include a normal ECG in small restrictive defects, to left, right, or combined ventricular overload patterns when associated with elevated left ventricle preload or right ventricle afterload. After surgery, the ECG tends to reflect evolving conduction-system injury and late rhythm-related vulnerability, such as right bundle branch block, atrioventricular block, QTc prolongation, progressive PR/QRS widening, and late complete atrioventricular block. Future studies with standardized timing and outcome-related follow-up are warranted to solidify the clinical relevance of specific ECG findings.

Pectus excavatum can rarely result in clinically significant right ventricular (RV) compression, leading to impaired diastolic filling, reduced stroke volume, and secondary biventricular dysfunction involving both the right and left ventricles. We report a 19-year-old male who presented with progressive exertional dyspnea and was found to have severe pectus excavatum with a Haller index of 5.8 on cardiac magnetic resonance imaging and 3.6 on computed tomography. Multimodal cardiac evaluation demonstrated focal RV compression, moderate RV systolic dysfunction on cardiac MRI with a right ventricular ejection fraction (RVEF) of 31%, mild left ventricular (LV) systolic dysfunction with an ejection fraction of 44%-45%, and trivial mitral and tricuspid regurgitation. Spirometry was overall normal, without obstructive changes or exercise-associated bronchoconstriction, and electrocardiography revealed marked right-axis deviation. Coronary computed tomography angiography demonstrated normal coronary anatomy, while cardiac MRI showed no delayed gadolinium enhancement to suggest myocardial scar or infiltrative cardiomyopathy. In the absence of alternative clinical or imaging evidence for another cardiomyopathic process, the patient met morphologic and physiologic criteria for surgical repair and underwent minimally invasive correction with pectus bar placement without complication. At five-month follow-up, he reported resolution of dyspnea, although repeat postoperative cardiac imaging had not yet been performed. This case emphasizes the importance of recognizing extrinsic RV compression from pectus excavatum as a surgically correctable and likely reversible contributor to ventricular dysfunction and highlights the role of comprehensive imaging in guiding timely surgical intervention.

Background: Cardiac amyloidosis represents a challenging diagnosis in patients with multiple myeloma, often presenting as refractory heart failure with subtle early manifestations that can delay appropriate treatment. Case: We report a 55-year-old male with a three-year history of multiple myeloma who presented with progressive dyspnea and bilateral lower limb edema. Despite being normotensive and non-diabetic, he exhibited clinical signs of volume overload with elevated jugular venous pressure and bilateral crepitations. Electrocardiography revealed left ventricular hypertrophy with strain pattern, left axis deviation, and left bundle branch block, raising suspicion for infiltrative cardiomyopathy. Transthoracic echocardiography demonstrated moderate concentric left ventricular hypertrophy with reduced ejection fraction (40%) and severe grade III diastolic dysfunction. Global longitudinal strain analysis revealed markedly reduced GLS at -9.7% with characteristic apical sparing pattern, creating the pathognomonic "cherry-on-top" appearance. Despite optimal heart failure management and continued multiple myeloma treatment, six-month follow-up demonstrated dramatic GLS deterioration to -1.9% , indicating progressive cardiac amyloidosis and poor prognosis. Conclusion: Global longitudinal strain serves as both a sensitive diagnostic tool and powerful prognostic marker in cardiac amyloidosis secondary to multiple myeloma, supporting its integration into routine cardiac surveillance protocols for patients with plasma cell disorders to enable earlier diagnosis and better risk stratification.

Pulmonary valve stenosis is a congenital heart disease that is usually diagnosed during childhood, while presentation in adulthood is uncommon and may lead to delayed diagnosis. We report the case of a 21-year-old patient with no significant medical history who presented with a six-month history of exertional dyspnea and constrictive chest pain. Electrocardiography showed right axis deviation with signs of right ventricular hypertrophy, and chest radiography revealed dilatation of the left pulmonary artery. Transthoracic echocardiography demonstrated severe valvular pulmonary stenosis with a peak velocity of 4.53 m/s and a maximum systolic gradient of 82.23 mmHg, associated with right ventricular hypertrophy and preserved systolic function, without evidence of pulmonary hypertension. Computed tomography pulmonary angiography confirmed focal post-stenotic dilatation of the left pulmonary artery. After a multidisciplinary discussion, balloon pulmonary valvuloplasty was recommended. This case highlights the importance of considering congenital pulmonary valve stenosis in young adults presenting with exertional symptoms and underscores the challenges of access to advanced interventional therapies in resource-limited settings.