Pericardial disease is common in patients with immune-mediated inflammatory diseases (IMIDs), especially in systemic lupus erythematosus. Pericardial disease may present as an asymptomatic pericardial effusion or acute and recurrent pericarditis, and may sometimes lead to complications (cardiac tamponade and constrictive pericarditis). Pathophysiology of pericarditis in IMIDs is likely related to the underlying immune dysregulation. Diagnosis of IMID-related pericarditis relies on general diagnostic criteria, supported by inflammatory biomarkers and non-invasive multimodality imaging. Initial management of IMID-related pericarditis overlaps with idiopathic pericarditis (nonsteroidal anti-inflammatory drugs and colchicine) together with treatment of the underlying IMID. Glucocorticoids are used in cases of poor response to first-line treatments. The use of immunosuppressive therapies is driven by the underlying IMID and systemic organ involvement beyond the pericardium. Multi-disciplinary care collaboration between cardiologists, radiologists, internists, and rheumatologists is pivotal to develop an appropriate, common treatment plan based on the individual features of each patient with IMIDs.

With the rapid increase in percutaneous left heart interventions, transseptal access to the left atrium has become a widely used procedure. This technique is crucial for electrophysiological procedures, particularly for atrial fibrillation ablation, which is estimated to be performed in more than 250 000 patients per year worldwide, as well as for various structural heart interventions, like percutaneous mitral valve repair. Although transseptal puncture (TSP) is generally considered a simple technique, it is associated with a small risk of potentially life-threatening complications. To ensure a successful and safe procedure, a thorough understanding of TSPs' clinical use, and the anatomy of the interatrial septum-including the fossa ovalis and its anatomical variants-is critical. Since the first fluoroscopy-guided TSP, advancements in echocardiographic imaging have enhanced the precision of the puncture, allowing targeting of specific regions of the fossa ovalis and facilitating difficult procedures. While most TSPs are performed using a Brockenbrough needle and a (steerable) sheath, wide variation in technique exists, and alternative methods have been developed initially aiming for complex cases but now routinely used. Understanding potential complications-such as cardiac tamponade, aortic puncture, and embolism-is essential for prevention, early recognition, and effective management, ultimately improving patients' outcomes. Finally, understanding how to approach specific complex scenarios is crucial for procedural success.

Superior vena cava (SVC) syndrome results from impaired venous return to the right atrium. While malignancy is the most common cause, benign etiologies such as mediastinal fibrosis are increasingly recognized. Endovascular therapy is considered the first-line treatment due to its high technical success and rapid symptom relief. We report the case of a 47-year-old woman with tuberculosis-related mediastinal fibrosis presenting with progressive SVC syndrome. She underwent uncomplicated endovascular stenting of the SVC using an uncovered stent. Twelve hours after the procedure, the patient developed acute chest pain and hypotension. Transthoracic echocardiography revealed cardiac tamponade requiring urgent pericardial drainage. Persistent bleeding despite placement of a covered stent prompted further evaluation. Cross-sectional imaging and surgical exploration demonstrated a combined injury of the SVC and the adjacent ascending aorta. Emergency surgical repair under cardiopulmonary bypass achieved hemostasis, with a favorable postoperative outcome. This case highlights a rare and life-threatening complication of SVC stenting in mediastinal fibrosis, characterized by simultaneous venous and arterial injury leading to cardiac tamponade. The rigid fibro-calcific environment in mediastinal fibrosis may increase the risk of vascular rupture during endovascular procedures. Careful technique, including gradual and low-pressure dilatation, and close post-procedural monitoring are essential to minimize such complications.

Coronary artery perforation (CAP) is a rare but potentially life-threatening complication of percutaneous coronary intervention, particularly during complex procedures such as rotational atherectomy. Ellis type III perforations are associated with high morbidity and mortality and usually require covered stent implantation or embolization techniques. We report the case of an 83-year-old man undergoing rotational atherectomy of a severely calcified left anterior descending artery. An Ellis type III coronary perforation occurred following abrupt burr exit at a curved mid-LAD segment. Immediate and prolonged balloon tamponade was performed, and the ping-pong technique was used to secure distal coronary access while maintaining continuous mechanical hemostasis. Partial heparin reversal with protamine was administered under sustained balloon inflation after exclusion of cardiac tamponade, using a half-dose strategy as a temporary bridging measure. During distal rewiring, no further contrast extravasation was observed, and the guidewire crossed easily into the distal true lumen. This structured bailout strategy resulted in successful sealing of the perforation without cardiac tamponade, pericardiocentesis, or covered stent implantation. Final angiographic and clinical outcomes were favorable. A systematic follow-up angiography performed at 3 weeks demonstrated an excellent result. At 8-month follow-up, the patient remained asymptomatic with normalization of left ventricular function and sustained clinical stability. This case illustrates a rare mechanism of coronary perforation related to burr exit during rotational atherectomy and highlights a structured bailout strategy combining prolonged balloon tamponade, the ping-pong technique, and controlled partial anticoagulation reversal. This approach may allow safe stabilization and facilitate definitive management in selected cases, without challenging the established role of covered stent implantation in major coronary perforations.

Over 350,000 patients experience out-of-hospital cardiac arrest annually in the United States. Patients presenting to the emergency department (ED) in cardiac arrest are critically ill and require emergent clinical decisions and treatment. Point-of-care ultrasound (POCUS) is useful as a rapid, bedside diagnostic imaging tool to help elucidate possible causes of cardiac arrest and guide management. Using a validated systematic approach such as the SHoC and CASA protocols, clinicians can safely perform POCUS with shortened pauses during pulse checks. POCUS is key in evaluating cardiac arrhythmias such as ventricular fibrillation (VF), which has higher survival rates with defibrillation, versus cardiac standstill, which has higher mortality per recent research studies. When performed by experienced users, POCUS also facilitates identification of reversible causes for improved cardiac arrest patient outcomes and can guide decisions in resuscitative efforts. In summary, this manuscript is a narrative review that illustrates identifiable POCUS findings and synthesizes them to guide potential emergent intervention in patients in cardiac arrest including: ventricular fibrillation, cardiac standstill, pericardial effusion, cardiac tamponade, right heart strain such as from acute pulmonary embolism, reduced cardiac function, wall motion abnormality, ruptured ventricular pseudoaneurysm, and aortic dissection.

Background: Cardiac tamponade (CT) is a rare but life-threatening medical emergency caused by fluid accumulation in the pericardial sac, impairing cardiac filling and reducing output. More than 20% of CT cases are iatrogenic. CT is a recognized complication of central venous catheter (CVC) placement, with mortality rates in pediatric patients reported to reach 50%. Clinical presentation is often nonspecific, and echocardiography remains the diagnostic gold standard. Case report: We present two pediatric cases of CT due to late CVC migration, managed in the pediatric intensive care unit (PICU). The first case involved a 25-day-old neonate with short bowel syndrome who received prolonged parenteral nutrition via CVC. Four days after catheter insertion, the patient developed sudden cardiocirculatory collapse. The second case featured a 2-year-old child with Leigh syndrome who required mechanical ventilation and multimodal pharmacological therapy. Six days after CVC placement, the patient developed acute hemodynamic deterioration. In both cases, echocardiography confirmed CT, while chest radiography suggested intracardiac positioning of the catheter tip. Management and outcome: Emergency pericardiocentesis and advanced cardiopulmonary resuscitation were performed. Despite transient hemodynamic stabilization, both patients developed multiorgan failure with fatal outcomes. Conclusions: CT is a critical complication in pediatric patients with CVCs. Accurate verification of catheter tip position is essential, and intracardiac placement should be avoided. Any sudden clinical deterioration in a patient with a CVC should raise suspicion of late catheter migration and requires immediate life-saving intervention.