Patent foramen ovale (PFO) is a common congenital cardiac anomaly, generally responsible for cryptogenic stroke. Still, it can cause severe positional hypoxia via a right-to-left shunt if associated with anatomic distortion of the interatrial septum. A man in his 90s with a known atrial septal defect (pulmonary blood flow/systemic blood flow (Qp/Qs) ratio of 0.85) and ascending aortic aneurysm presented with sudden worsening of chronic exertional dyspnoea and had profound hypoxia, requiring bilevel positive airway pressure. Workup was negative for pulmonary embolism with an unremarkable prior transthoracic echocardiogram (TTE). During hospitalisation, he was found to have worsening hypoxia in the upright position, which improved in the supine and right lateral decubitus positions. A repeat TTE with agitated saline was performed, which showed a PFO with a large right-to-left shunt, confirmed by transoesophageal echocardiogram (TEE), along with a severe atrial septum aneurysm on TEE. Percutaneous PFO closure with a 37 mm Gore occluder resulted in immediate resolution of hypoxaemia and clinical improvement.

Background: Aorto-atrial fistula is a rare pathological communication associated with diagnostic difficulties, progressive hemodynamic consequences, and potential infective complications. Methods and Results: We present a 53-year-old woman with a long-standing congenital non-coronary sinus of Valsalva-to-right atrial fistula that had been followed for nine years under the working diagnosis of a Gerbode defect. The communication was first detected at the age of 44 years during pregnancy and was managed conservatively while the patient remained largely asymptomatic. At the age of 53 years, recurrent exertional dyspnea prompted definitive reassessment. Right heart catheterization demonstrated a hemodynamically significant left-to-right shunt at the right atrial level, with a pulmonary-to-systemic blood flow (Qp/Qs) ratio of 2.1. Intraoperatively, the communication was shown to originate immediately above the non-coronary cusp and drain into the right atrium, establishing the diagnosis of a congenital aorto-right atrial fistula. A granulomatous, windsock-like endocardial lesion was identified at its right atrial opening, and Staphylococcus capitis was isolated from surgically obtained tissue. Histopathology showed nonspecific regressive changes without specific features of active infective endocarditis. The fistula was closed with an autologous pericardial patch, and intravenous flucloxacillin was administered because of probable localized infective involvement. Conclusions: This case illustrates the diagnostic difficulty of distinguishing an aorto-atrial fistula from a Gerbode defect and supports careful multimodality evaluation of the anatomical origin and flow characteristics of intracardiac shunts. Persistent high-velocity flow may contribute to endocardial injury and create a substrate for subsequent bacterial colonization, although causality cannot be established from a single case. Isolation of a low-virulence skin commensal from pathological cardiac tissue should be interpreted in the complete clinical, operative, microbiological, and histopathological context rather than automatically classified as contamination.

A 72-year-old woman with type A acute aortic dissection and a patent false lumen underwent emergency hemiarch replacement. On postoperative Day 13, routine contrast-enhanced computed tomography revealed an impending paradoxical embolism (IPE) and a right main pulmonary embolism. Surgical pulmonary thrombectomy and patent foramen ovale closure were performed. This case provides mechanistic insight into IPE development in the postoperative period. Early-phase hypercoagulability after acute aortic dissection, increased right atrial pressure due to pulmonary embolism, and anatomical factors such as pericardial effusion and altered aortic geometry after graft replacement may have facilitated right-to-left shunting through a previously undetected or functionally latent patent foramen ovale. The patient was discharged on postoperative Day 14 (hospitalization Day 27) and remained asymptomatic without recurrence during 5-year follow-up. This case highlights the importance of considering IPE after type A acute aortic dissection repair and supports routine postoperative imaging to detect clinically silent but life-threatening complications.

Ventriculoatrial shunts (VAS) are an alternative to ventriculoperitoneal shunts (VPS) for cerebrospinal fluid (CSF) diversion in patients with peritoneal contraindications. Although rare, complications such as catheter migration or malposition can occur and may be exacerbated by underlying congenital venous anomalies. Endovascular techniques have emerged as a minimally invasive option for VAS revision, yet reports remain limited and primarily focus on acquired malpositions. To our knowledge, no prior case describes endovascular VAS repositioning in the context of a duplicated superior vena cava (SVC) with catheter termination in the coronary sinus. In this case, a 15-year-old female patient with a history of congenital hydrocephalus and prior VPS placement underwent conversion to a VAS due to abdominal pseudocyst formation. Chest radiography obtained postoperatively demonstrated an abnormal left-sided venous course of the distal catheter. Subsequent chest CT confirmed traversal of the catheter through a duplicated left SVC with termination in the coronary sinus, risking the development of thromboembolism. To avoid the risks associated with open surgical revision, such as vascular injury, infection, and compromised venous access, an endovascular approach was selected. Using transfemoral venous access and fluoroscopic guidance, the catheter was successfully repositioned from the coronary sinus into the right atrium, with correct positioning confirmed on postoperative chest X-ray. Fluoroscopy time was 11.3 minutes, maximum radiation dose was 24.9 mGy (968.21 µGy/m[2]), and total procedural time was 28 minutes. The catheter was repositioned within eight minutes of procedure onset. No contrast was used during the procedure, and image guidance was purely with fluoroscopy. The patient had no postoperative complications. During yearly follow-up, the patient remained free of symptoms of shunt malfunction, and surveillance chest radiography confirmed the distal catheter tip within the right atrium. This case highlights the importance of targeted preoperative imaging, as preoperative transthoracic echocardiography (TTE) may fail to identify anomalous thoracic venous anatomy. In such cases, screening chest CT or CT venography may be prudent when anatomical variants are suspected. In addition, endovascular repositioning of malpositioned distal VAS catheters within the venous system may represent a lower-risk alternative to open distal shunt revision in carefully selected patients.

Transcatheter edge-to-edge repair (TEER) requires precise echocardiographic guidance because the operator cannot directly visualize the mitral valve. Intraprocedural transesophageal echocardiography (TEE) is indispensable for safe and accurate device positioning and manipulation, whereas transthoracic echocardiography (TTE) plays a central role in preprocedural evaluation and serial postprocedural follow-up as part of comprehensive echocardiographic assessment. Before the procedure, echocardiography is essential for assessing the underlying mechanism and severity of mitral regurgitation (MR), determining anatomical suitability for TEER, and estimating procedural difficulty. Measurements such as mitral valve area, transmitral pressure gradient, tethering height, coaptation length, prolapse width and gap, as well as lesion location, leaflet morphology, and calcification distribution are crucial for predicting feasibility and technical complexity. During TEER, TEE must rapidly provide optimal views to guide each procedural step-from transseptal puncture to leaflet grasping and device deployment. Although X-plane imaging and three-dimensional reconstruction are now standard in many centers, live multiplanar reconstruction allows optimal imaging planes to be reconstructed in real time from acoustically favorable probe positions chosen to minimize device-related shadowing, thereby facilitating accurate and efficient intraprocedural guidance. Intraprocedural TEE is also vital for the early detection of complications, including pericardial effusion, leaflet injury, and clinically significant iatrogenic atrial septal defect with right-to-left shunting, as well as for immediate post-deployment hemodynamic assessment. In the postprocedural period, TTE focuses on detection of residual MR, evaluation for iatrogenic mitral stenosis, identification of single-leaflet device attachment or leaflet perforation, and serial assessment of cardiac function. Recent risk scores for patient selection and prognostication underscore the importance of comprehensive, evidence-informed echocardiographic evaluation that integrates both morphological and hemodynamic information.

Hereditary hemorrhagic telangiectasia (HHT) is characterized by mucocutaneous telangiectases and visceral arteriovenous malformations (AVMs). Pulmonary AVMs (PAVMs) create an anatomic right-to-left shunt, increasing the risk of hypoxemia and paradoxical embolic events, and are commonly treated with transcatheter embolization. We report a 25-year-old man with suspected HHT based on Curaçao criteria, including recurrent epistaxis, prior cerebral AVM, and multiple PAVMs, presenting with exertional dyspnea and hypoxemia. He underwent embolization under general anesthesia with air management, lung isolation capability, and tailored ventilatory management. The procedure was completed without complications, with resolution of symptoms and normalization of oxygenation. This case highlights the importance of understanding PAVM pathophysiology and implementing targeted anesthetic strategies to ensure safe perioperative management.

Coronary cameral fistula (CCF) is a rare coronary anomaly involving an abnormal communication between a coronary artery and a cardiac chamber or great vessel. While often asymptomatic, large fistulae may result in myocardial ischaemia, arrhythmias, or heart failure.

Drainage of the left hepatic vein into the coronary sinus is an extremely rare anomaly reported in the literature. Typically, haemodynamics remain unimpaired in the absence of concomitant anomalies, and detection is expected to be incidental.

Coronary fistulas draining into the left ventricle (LV) are exceptionally rare, and left main (LM) donor vessels almost invariably connect to right-sided structures rather than the LV. We report the case of a 69-year-old gentleman with prior mechanical surgical aortic valve replacement (SAVR) and a left internal mammary artery-to-left anterior descending (LIMA-LAD) bypass graft who presented with new-onset heart failure and a newly reduced left ventricular ejection fraction (∼40%). Transthoracic echocardiography demonstrated a normally functioning mechanical aortic valve, moderate functional mitral regurgitation and a color jet near the aortic root initially interpreted as mild paravalvular regurgitation. Coronary angiography revealed severe, calcified LM ostial and bifurcation disease together with a discrete contrast communication from the LM to the LV. Three-dimensional transthoracic echocardiography reclassified the jet as a coronary fistula (LM-to-LV) anatomically distinct from the prosthetic sewing ring, while intravascular ultrasound (IVUS) confirmed heavy ostial/bifurcation calcification and a focal opening in proximal LM resembling a side-branch, corresponding to the fistulous segment. IVUS-guided LM-LCx percutaneous coronary intervention with two drug-eluting stents resulted in optimal stent expansion and apposition, with preserved competitive LAD flow via the LIMA graft, while the LM-to-LV communication remained angiographically modest. To our knowledge, this is the first reported iatrogenic LM-to-LV fistula after mechanical SAVR and highlights the pivotal role of multimodality imaging in distinguishing LM originating fistulas from paravalvular regurgitation or aorto-LV tunnels, and in guiding management by prioritizing safe LM revascularization while deferring targeted fistula closure pending assessment of shunt burden and clinical impact.

Contrast-enhanced transcranial Doppler (c-TCD) is a promising noninvasive method for detecting patent foramen ovale (PFO) in adults, but its diagnostic accuracy compared to the gold standard transesophageal echocardiography (TEE) requires up-to-date evaluation. We conducted a systematic review and meta-analysis of studies from 2015 to 2025 assessing c-TCD for PFO detection in adults, following the PRISMA guidelines. A comprehensive search identified 37 relevant articles; of these, five primary studies met the inclusion criteria for quantitative analysis. Data on sensitivity, specificity, and othervdiagnostic performance metrics were extracted, and study quality was appraised using QUADAS-2. The included studies (mostly cryptogenic stroke patients) indicated that c-TCD had high sensitivity (~95%) and good specificity (~90%) for detecting PFO compared to TEE. In our meta-analysis, the summary sensitivity of c-TCD was 94.8% (95% confidence interval [CI]: 91%-98%) and the specificity was 89.7% (95% CI: 85%-94%). The pooled positive likelihood ratio was ~9, and the negative likelihood ratio was ~0.06. The diagnostic odds ratio was approximately 150, and the area under the curve of the summary receiver operating characteristic curve was approximately 0.97, reflecting excellent overall accuracy. Contrast TCD demonstrates robust diagnostic performance for PFO detection, approaching that of TEE. A negative result on c-TCD reduces the likelihood of clinically significant PFO in patients with stroke, whereas a positive c-TCD strongly suggests PFO and should prompt confirmatory TEE for anatomical details. These findings support the use of c-TCD as a first-line screening tool in the evaluation of cryptogenic stroke.

Background Hearts suitable for Fontan palliation include those with an anatomically single ventricle (absence of a second ventricular mass), those with a single atrioventricular connection, and those with two ventricles in whom biventricular repair is not feasible due to anatomical or physiological complexity (functionally univentricular physiology). We describe the anatomical spectrum of such hearts over a decade at a single tertiary center. Methodology We encountered 420 patients undergoing the Fontan operation over a decade, between 2010 and 2019. Their detailed medical records were reviewed in this retrospective study, and the information gathered is presented in this article. The cardiac anatomy is presented depending on the information gathered from the medical records. Results A total of 420 patients underwent the Fontan operation during the study period. Only 30 (7.1%) had a true anatomically single ventricle. The remaining 390 had two ventricular chambers, including those with a hypoplastic ventricle. The most common anatomical diagnosis was double-outlet right ventricle (DORV) in 143 (34%) patients, followed by tricuspid atresia in 118 (28%) patients. Major aortopulmonary collateral arteries were present in 250 (59.5%) patients, and left superior vena cava in 61 (14.5%) patients. Completion Fontan operation after bidirectional Glenn shunt was the most common surgical pathway (n = 254, 60.5%), though primary Fontan (n = 15, 3.6%) and other staged approaches were also performed. Conclusions The anatomical spectrum of patients undergoing Fontan operation is wide and includes true anatomically single ventricle, single atrioventricular connection, and functionally univentricular physiology with two ventricular chambers. DORV was the most common diagnosis, followed by tricuspid atresia. The decision for Fontan operation was driven by a combination of anatomical and physiological factors. Early and long-term outcomes were not analyzed in this study.