Patient Background: A 36-year-old man with well-controlled first-grade essential hypertension presented for a routine cardiovascular evaluation. He had a known heart murmur since childhood and had previously been told he might have a ventricular septal defect. Physical examination was unremarkable.

Assessment and Diagnosis: Initial ECG showed sinus rhythm (62 bpm), poor R-wave progression in leads V1–V4, and T wave inversions. Transthoracic echocardiography (TTE) revealed atypical cardiac positioning with suboptimal image acquisition. Atrial septal defect was suspected. Cardiac magnetic resonance (CMR) imaging delineated complete left-sided pericardial agenesis—demonstrating the heart displaced laterally and posteriorly into the left hemithorax, lung interposition between the great vessels, and absence of the left-sided pericardium. A patent foramen ovale (PFO) without significant right-to-left shunting was also identified.

Suggested Treatment Plan and Patient Education: No treatment was advised for the pericardial defect given the patient’s asymptomatic status. However, the potential risk of paradoxical embolism through the PFO was discussed, and closure of the defect was considered. Patient education focused on recognizing signs of cryptogenic stroke and understanding the clinical implications of the PFO.

Follow-up: Annual echocardiographic follow-up was recommended. At 6 months, the patient remained asymptomatic.

1. Why was CMR essential in diagnosing pericardial agenesis in this asymptomatic patient? Answer CMR delineated heart displacement, lung interposition, and absence of pericardium—details not discernible on suboptimal TTE—making it essential for confirming the diagnosis.
2. What is the management for asymptomatic pericardial agenesis with a PFO? Answer Asymptomatic pericardial agenesis requires no treatment. However, the PFO may increase stroke risk, and closure may be considered to prevent paradoxical embolism.

Patient Background: An 82-year-old woman with severe symptomatic aortic stenosis was evaluated for transcatheter aortic valve replacement (TAVR). Her baseline electrocardiogram (ECG) showed right bundle branch block (RBBB) and a prolonged QRS duration.

Assessment and Diagnosis: She underwent TAVR. Her baseline right bundle branch block (RBBB; adjusted odds ratio [ORadj], 2.49) and each 1-millisecond increase in QRS duration (ORadj, 1.01) were identified as independent predictors of permanent pacemaker implantation (PPI).

Clinical Outcome: Approximately 21.5% of patients undergoing TAVR require PPI, most commonly due to third-degree atrioventricular (AV) block (46.4%).

Suggested Treatment Plan: When PPI is necessary, physiological pacing techniques—such as His-bundle or left bundle branch pacing—should be considered to minimize electromechanical dyssynchrony.

Patient Education: Patients should be counseled on the increased risk of PPI after TAVR and its association with higher long-term mortality.

Follow-up: Ongoing follow-up is essential. PPI is an independent predictor of mortality, with an estimated 7-year mortality of 43.3% in PPI recipients versus 30.9% in those without PPI.

1. What ECG markers help predict pacemaker need post-TAVR? Answer Baseline right bundle branch block and increased QRS duration are key predictors. Prosthetic valve type, particularly self-expanding designs, also influences pacemaker need.
2. What pacing strategies can reduce long-term mortality after TAVR? Answer His-bundle or left bundle branch pacing helps reduce dyssynchrony. In low-dependency cases, AV conduction algorithms are useful. Leadless pacing is promising but needs more data.