Primary cardiac tumors are rare. Atrial myxomas are one of the most frequent benign tumors of the heart. These tumors typically manifest as obstructive symptoms, including dyspnea and syncope. Constitutional symptoms, including fever, weight loss, and fatigue, are also common. Embolic phenomena are rare. Neurological manifestations primarily occur as ischemic infarction, whereas hemorrhagic transformation is infrequent. We present a young adult who experienced an ischemic stroke followed by hemorrhagic transformation, ultimately diagnosed with an atrial myxoma. During the patient's hospitalization, neurological improvement was noted while he received antiplatelet and statin therapy. The definitive treatment, consisting of surgical excision, was performed in this patient, followed by echocardiographic surveillance to monitor for recurrence.

Proposed emergency department approach to syncope. After confirming true syncope and excluding immediately apparent diagnoses, assessment focuses on identifying patients at high risk of clinically significant bradyarrhythmia or other specific cardiac conditions requiring hospital admission, while avoiding unnecessary admission for isolated non-specific ECG abnormalities. The proposed recommendations and algorithm reflect the authors' interpretation of the available evidence and are intended to complement current ESC recommendations. Although informed by observational studies, they remain exploratory and have not yet been prospectively validated.

This narrative review summarizes the latest clinical evidence on xanomeline-trospium in schizophrenia, a first-in-class centrally acting dual-target muscarinic receptor modulator. Xanomeline-trospium combines the muscarinic receptor agonist xanomeline, with with functional preference for M1/M4 subtypes, and the peripherally acting muscarinic antagonist trospium chloride in a 4.2:1 ratio. Xanomeline mediates central therapeutic effects, whereas trospium mitigates xanomeline-induced peripheral adverse effects, including nausea, vomiting, and diarrhea. Five EMERGENT trials were reviewed, comprising three short-term efficacy studies and two long-term extension studies evaluating efficacy and safety. In five-week short-term trials, xanomeline-trospium significantly reduced total Positive and Negative Syndrome Scale (PANSS) total scores, with reductions in positive symptoms approximately 1.5-2 times greater and negative symptoms 1.5-3.5 times greater than those observed with placebo. In the EMERGENT-4 and EMERGENT-5 long-term extension trials, sustained therapeutic effects were observed along with potential improvements in quality of life in patients with mild-to-moderate schizophrenia over 52 weeks. Nevertheless, tolerability remains a major challenge, with high overall discontinuation rates (EMERGENT-4: 78.2% discontinuation; EMERGENT-5: 51% withdrawal). Notably, voluntary withdrawal accounted for a substantial proportion of discontinuations, exceeding adverse event-related withdrawals in certain subgroups. The most common adverse events included gastrointestinal symptoms (nausea, constipation, vomiting) and syncope. Compared with traditional dopamine D2 antagonists, xanomeline-trospium was associated with lower risks of weight gain, hyperprolactinemia, and extrapyramidal symptoms. Key limitations of this review include reliance on placebo-controlled trials without head-to-head comparisons, exclusion of treatment-resistant schizophrenia populations, and limited generalizability to outpatient settings due to the focus on acute inpatient cohorts. Future research should focus on identifying risk factors for early discontinuation and developing both pharmacological and non-pharmacological strategies to improve long-term adherence. Overall, as a novel non-dopaminergic antipsychotic strategy, xanomeline-trospium offers an important therapeutic option for patients who are intolerant to the metabolic or motor adverse effects of traditional antipsychotics, although challenges related to long-term adherence remain to be addressed.

Massive pulmonary embolism (PE) is a life-threatening condition typically requiring systemic thrombolysis. The presence of a left ventricular (LV) thrombus represents a relative contraindication due to the high risk of systemic embolization, requiring individualized management. We present a 73-year-old woman with a history of non-Hodgkin lymphoma in remission, severe LV dysfunction from chemotherapy and radiotherapy, permanent atrial fibrillation under apixaban, and stage 3 chronic kidney disease. She presented with progressive dyspnea, edema, and syncope. On admission, she presented with cardiogenic shock. Imaging confirmed massive bilateral PE and an LV intracavitary thrombus. Thrombolysis was contraindicated due to multiple high-risk factors: LV thrombus, ongoing anticoagulation, advanced age, and renal dysfunction. Management consisted of therapeutic anticoagulation with unfractionated heparin, vasopressor and inotropic support, and close monitoring, showing progressive clinical improvement. This case highlights the complexity of managing massive PE in cardio-oncology patients and underscores the need for individualized strategies when thrombolysis poses unacceptable risks.

Erdheim-Chester disease (ECD) is a rare systemic non-Langerhans cell histiocytosis of unknown etiology characterized by multiorgan xanthomatous infiltration by foamy histiocytes. Cardiovascular involvement in ECD is frequent at the level of the right atrium and superior vena cava. We present the case of a 67-year-old woman with a history of ECD and cardiac involvement, referred to our attention following syncopal episodes and paroxysmal atrial fibrillation alternating with phases of marked sinus bradycardia and asystolic pauses. Transesophageal echocardiogram and cardiac magnetic resonance imaging confirmed the increased wall thickness and the marked reduction of the internal diameter of the superior vena cava and of the right atrium. This can be a major obstacle to the implantation of a bicameral pacemaker, necessary for the sick sinus syndrome. Despite this problem, we decided to try an implant with a traditional approach from the left axillary vein; we followed the procedure with fluoroscopic and ultrasound guidance that was very useful in crossing the stenotic superior vena cava and in the positioning of the active fixation electrode in the right atrial appendage. This case confirms how a multimedial imaging approach is crucial to organize and best perform electrostimulation procedures in particular anatomical contexts such as in ECD with cardiac involvement, minimizing the risks.

Cardiac myxomas, the most common primary cardiac tumors, are benign tumors that arise from cardiac connective tissue. The most common site of origin is the left atrium, and occurrence at other sites is relatively rare. We present a case of a 19-year-old male, with a history of multiple episodes of syncope. The electrocardiogram showed right axis deviation, right ventricular hypertrophy with a strain pattern, and right bundle branch block. Echocardiography revealed multiple masses in the right atrium (RA) and right ventricle (RV) extending into the RV outflow tract (RVOT) and main pulmonary artery. The masses resulted in severe RVOT obstruction, which was the likely cause of recurrent syncope. The patient was referred for surgical excision. On histopathological examination, the mass was found to be a myxoma. The syncopal attacks resolved completely after resection of the mass, and he is asymptomatic on follow-up at 14 months. Cardiac myxomas arising in the right-sided cardiac chambers, though rare, can occur. When present, they may be multiple and may present with syncope due to RVOT obstruction. An early diagnosis and surgical excision are crucial for symptom relief and may be lifesaving. Histopathological examination is important in confirming the benign nature, for prognostication and for guiding further therapy.

Cardiac involvement in rheumatoid arthritis (RA) is uncommon and often clinically silent, but may encompass valvular, structural, and conduction system abnormalities. Involvement of the mitral-aortic intervalvular fibrosa (MAIVF) and the membranous interventricular septum is exceptionally rare and has not been previously described in RA. A 61-year-old man with longstanding seropositive RA presented with syncope due to intermittent complete atrioventricular block. Multimodality imaging revealed severe degenerative mitral regurgitation, moderate-to-severe aortic regurgitation, a pseudoaneurysm of the MAIVF extending into the left ventricular outflow tract, and a membranous interventricular septal aneurysm. Infective and congenital etiologies were excluded by repeated negative blood cultures, 18F-FDG PET, and comprehensive imaging. The patient underwent successful surgical mitral and aortic valve replacement. Histopathological analysis demonstrated rheumatoid nodules within both excised valves, confirming immune-mediated valvular involvement. Persistent conduction abnormalities required permanent pacemaker implantation. This report describes the first documented case of a MAIVF pseudoaneurysm in a patient with RA, associated with multivalvular disease and high-grade conduction disturbance. The findings highlight the potential for severe, atypical cardiac manifestations of RA in the absence of active systemic inflammation and underscore the pivotal role of multimodality imaging and multidisciplinary evaluation in establishing diagnosis and guiding management.

Pulmonary arterial hypertension is a rare diagnosis and, when present with pulmonary arteriovenous malformations, a diagnosis of hereditary haemorrhagic telangiectasia should be considered. This case highlights the difficulties in this form of PH. https://bit.ly/4tAmW9R.

Persistent left superior vena cava (PLSVC) can complicate transvenous device implantation due to challenging venous anatomy and limited sheath support during physiologic pacing lead delivery.

We report improvements in debilitating cervicogenic dizziness (CD), as well as neck pain and upper and lower back pain, using Chiropractic BioPhysics[®] (CBP[®]) orthopedic rehabilitation with a one-year follow-up. CD is extremely debilitating and strongly impacts health outcomes. Reports of successful conservative treatments for CD combined with neck and spine pain with improved outcomes and sustained long-term results are rare, and this study adds to the literature. A 29-year-old female suffered from sudden-onset dizziness and frequent syncope elicited by cranio-cervical extension motions. The patient concomitantly reported moderate neck pain, upper mid-back pain, and low back pain, self-reported significant disability, and objectively displayed poor posture and altered spine alignment on radiography. Due to the worsening of her condition, she sought treatment at a facility in Shoreline, WA, USA. Following examination and diagnostic evaluation, she undertook an in-office treatment regimen. The multi-modal orthopedic regimen included postural exercises, postural spinal manipulation, and specific spinal structural traction. This combination Mirror Image (MI®) protocol has been shown to reduce pain and disability in musculoskeletal conditions, with improvement in CD and cervical lordosis. Following 68 in-office treatments over 5.5 months, all initial outcome assessments and physical, orthopedic, and neurological examinations were repeated and recorded. At the post-treatment assessment, the patient reported improvements in CD symptoms and neck, upper back, and lower back pain. Cervical lordosis improved from C2 to C7, measuring +9.4° (kyphotic) to -16.4° (lordotic). At the one-year follow-up, all outcome measures were stable; syncope was fully resolved, and 90% of the previously reported CD symptoms were resolved. Cervical lordosis remained stable at -17.6° (lordotic). This case documents successful treatment in a single patient using conservative spine and posture treatment protocols. This case report followed reporting guidelines. This study may contribute to the evidence aiming to fill the gap in the understanding of CD and potential conservative therapeutic interventions that are directed toward improving spine alignment.