Asymptomatic Severe Aortic Stenosis with Left Ventricular Dysfunction: Watchful Waiting or Valve Replacement?

Aortic stenosis (AS) is the most common valvular heart disorder in older adults. Patients with severe AS are generally treated nonsurgically if asymptomatic and referred to aortic valve replacement when symptoms develop. However, patients with severe asymptomatic AS with left ventricular dysfunction may benefit from early aortic valve replacement. Although operative mortality in patients with severe AS and left ventricular dysfunction is greater than in patients with preserved left ventricular function, the overall mortality risk is substantially lower than that of watchful waiting. Operative risk in patients with severe AS and left ventricular dysfunction is often overestimated and, consequently, most are not referred to surgery despite clinical data in support of early aortic valve replacement. Asymptomatic patients with echocardiographic confirmation of severe AS and left ventricular dysfunction should be referred for aortic valve replacement.     

Late Right Ventricular Perforation After Permanent Pacemaker Implantation: How Far Can the Lead Go?

This case report describes the incredible dislocation of a right ventricular lead 1 month after pacemaker implantation. The lead's tip was found in the subcutaneous fat beneath the left breast. Extraction was uneventful. The key steps in the diagnosis and management of this rare complication are discussed.