The influence of the Covid-19 pandemic on the shunt revision rate

Introduction: During the first year of the Covid-19 pandemic we observed a decrease of our shunt revision rate. In order to investigate a possible correlation with an assumingly lower general infection rate in children in times of lock down and homeschooling, we performed a detailed analysis of our shunt and general pediatric patient population. Method(s): Electronic patient charts retrieval for children admitted for shunt revision or infectious diseases was performed for four time periods (study period April 2020 - March 2021, control periods from three previous years). A detailed analysis of all shunt revision and infectious cases including age and season specific evaluation followed. Possible correlations were investigated. Result(s): A total of 318 shunt revision and 13,919 pediatric cases have been evaluated. The shunt revision rate during the study period was 29% less compared to the average rate of three previous years (p 0.061), the number of pediatric cases with main diagnosis infection dropped significantly (p < 0.05), whereas other pediatric admissions remained stable. Significant age or seasonal influences did not exist. The number of shunt revisions in association with a documented systemic infection or a primary shunt infection dropped significantly during the study period (p<0.05 each). This was not the case for underdrainage, overdrainage (p>0.05 each) or other indications. In general, infections of upper and lower airways, the gastrointestinal and nervous system decreased during the pandemic, urinary infection rates remained stable. Conclusion(s): The decreased shunt revision rate during the first year of the pandemic seems correlate with a decrease of the general infection rate in children and adolescents at the same time. Infectionassociated shunt failures showed a significant decrease during this period compared to previous years.

Increased shunt and dead space in recovered COVID-19 pneumonitis patients

Introduction/Aim: We previously reported impaired pulmonary gas exchange in acute COVID-19 patients resulting from both increased intrapulmonary shunt (SH) and increased alveolar dead space (AD) 1 . The present study quantifies gas exchange in recovered patients. Method(s): Unvaccinated patients diagnosed with acute COVID-19 infection (March-December 2020) were studied 15 to 403 days post first SARS-CoV-2 positive PCR test. Demographic, anthropometric, acute disease severity and comorbidity data were collected. Breathing room air, steady-state exhaled gas concentrations were measured simultaneously with arterial blood gases. Alveolar CO 2 and O 2 (P A CO 2 and P A O 2 ;mid-exhaled volume) determined;AaPO2, aAPCO2, SH% and AD% calculated. 2 Results: We studied 59 patients (33 males, Age: 52[38-61] years, BMI: 28.8[25.3-33.6] kg/m 2 ;median[IQR]). Co-morbibities included asthma (n = 2), cardiovascular disease (n = 3), hypertension (n = 12), and diabetes (n = 9);14 subjects smoked;44 had experienced mild-moderate COVID-19 (NIH category 1-2), 15 severe-critical disease (NIH category 3-5). PaCO 2 was 39.4[35.6-41.1] mmHg, PaO 2 92.1[87.1-98.2] mmHg;P A CO 2 32.8[28.6-35.3] mmHg, P A O 2 112.9[109.4-117.0] mmHg, AaPO 2 18.8[12.6-26.8] mmHg, aAPCO 2 5.9[4.3-8.0] mmHg, SH 4.3 [2.1-5.9]% and AD 16.6 [12.6-24.4]%. 14% of patients had normal SH (<5%) and AD (<10%);1% abnormal SH and normal AD;36% both abnormal SH and AD;49% normal shunt and abnormal AD. Previous severe-critical disease was a strong independent predictor for increased SH (OR 14.8[2.28-96], [95% CI], p < 0.01), increasing age weakly predicted increased AD (OR 1.18[1.01, 1.37], p < 0.04). Time since infection, BMI and comorbidities were not significant predictors (all p > 0.11). Conclusion(s): Prior COVID-19 was associated with increased intrapulmonary shunt and/or increased alveolar dead space in 86% of this cohort up to ~13 months post infection, with those with more severe acute disease, and older patients, at greater risk. Increased intrapulmonary shunt suggests persistent alveolar damage, while increased alveolar dead space may indicate persistent pulmonary vascular occlusion.

Impact of COVID-19 pneumonia on pulmonary vascular volume.

Background: Pulmonary manifestations of COVID-19 pneumonia are well known. However, COVID-19 is also associated with a range of vascular manifestations such as embolism, congestion, and perfusion changes. Regarding congestion, research from different groups has suggested arteriovenous anastomosis dysregulation as a contributing factor. In this study, we aim to better describe the changes in vascular volume in affected lung zones and to relate them to pathophysiological hypotheses. Methods: We performed automatic vascular volume extraction in 10 chest CTs of patients, including 2 female and 8 male with a mean age of 63.5 ± 9.3 years, diagnosed with COVID-19 pneumonia. We compared the proportion of vascular volumes between manually segmented regions of lung parenchyma with and without signs of pneumonia. Results: The proportion of vascular volume was significantly higher in COVID (CVasc) compared to non-COVID (NCVasc) areas. We found a mean difference (DVasc) of 5% and a mean ratio (RVasc) of 3.7 between the two compartments (p < 0.01). Conclusion: Vascular volume in COVID-19 affected lung parenchyma is augmented relative to normal lung parenchyma, indicating venous congestion and supporting the hypothesis of pre-existing intra-pulmonary arteriovenous shunts.

Left Ventricular Recruitment Utilizing Serial Upsizing of Blalock-Taussig-Thomas Shunt to Achieve Successful Biventricular Repair

Background Surgical strategies to achieve biventricular (BiV) repair in children with borderline left ventricle (LV) continue to evolve. We report our innovative strategy of LV recruitment utilizing systemic to pulmonary artery shunt upsizing along with fenestrated atrial septation (FAS). Case The case is a 22mo old with hypoplastic left heart variant with type A aortic arch interruption and bilateral SVC. The LV, aortic and mitral valve were hypoplastic not meeting criteria for BiV repair. He underwent stage 1 palliation (Norwood with 4mm BTT shunt). Frequent COVID infections and over-circulation led to BiV dysfunction and cardiogenic shock requiring ECMO support for 4 days. At 5 months of age cardiac catheterization (CC) revealed good hemodynamic parameters for a stage 2 Glenn. An MRI also revealed growth of the left ventricle. Decision-making A decision was made to engage in a staged LV recruitment process to achieve BiV repair. We elected to avoid a volume offloading procedure in the form of a Glenn. To optimize continued volume loading on the LV, Stage 2 palliation consisted of upsizing to a 5mm BTT shunt with 4mm FAS. MRI at 22 months showed an LV volume of 60ml/m2 associated with CC hemodynamics showing LA pressure of 13mmHg, and LV end-diastolic pressure of 12mmHg. He underwent BiV repair with takedown of DKS, with primary anastomosis of the aorta and the pulmonary artery to their respective circulations. The postoperative echocardiogram illustrated a gradient of 5mmHg and 3mmHg through the mitral and aortic valve respectively. The pt was placed on a beta blocker and discharged on day 5 following BiV conversion. This strategy provides increased pulmonary blood flow with increased bloodflow across the mitral valve and inflow into the LV. In so doing may enhance the rate of LV growth. Furthermore, this strategy avoids the bidirectional Glenn (BDG), a volume offloading operation. Conclusion Shunt upsizing with FAS is well tolerated. It has the potential advantage for fewer operations to achieve BiV circulation due to rapid LV growth in comparison to other staged LV recruitment strategies involving the BDG.Copyright © 2023 American College of Cardiology Foundation

Echocardiographic detection of transpulmonary bubble transit during coronavirus-2019 disease (COVID-19)

Background: Transpulmonary bubble transit (TPBT) detected with contrast echocardiography is reported as a sign of intrapulmonary arteriovenous shunt. However, its pathological meaning is not clear during coronavirus-2019 disease (COVID-19) related acute respiratory distress syndrome (ARDS). Our aim was to determine the prevalence and clinical significance of TPBT detection during COVID-19 related ARDS. Methods: We carried out a prospective observational study performed in a high complexity intensive care unit from Argentina. Patients with COVID-19 related ARDS underwent transthoracic echocardiography with saline contrast. Moderate-to-large TPBT was defined as right-to-left passage of at least twelve bubbles to left chambers after at least three cardiac cycles and complete opacification of the right atrium. Results: We analyzed the results of 28 patients (24 men and 4 women). Seventy-five percent of the patients received invasive mechanical ventilation. Moderate-to-large TPBT was detected in 1 patient (3.5%). Among the 27 patients without significant TPBT, 23 had no TPBT and 4 had a minor TPBT. TPBT was not associated with invasive mechanical ventilation requirement (p = 0.5737) nor in-hospital mortality (p = 1). Conclusions: TPBT was not associated with severe hypoxemia or invasive mechanical ventilation requirement, although more studies are needed to further clarify its contributing role in COVID-19 hypoxemia. © 2023 Asociación Colombiana de Medicina Crítica y Cuidado lntensivo

A Case of Massive Pulmonary Embolus Extending into a Patent Foramen Ovale: An Impending Catastrophe

Background Massive pulmonary embolus (PE) is a life-threatening condition, however thrombus in transit in the setting of patent foramen ovale (PFO) poses catastrophic risk including systemic thromboembolism. Case An 88 year-old with history of COVID-related PE in 2020 previously on anticoagulation (AC) presented with chest pain & dyspnea. She was found to have lower extremity DVTs & extensive PE in the main pulmonary arteries & its branches. Transthoracic echo (TTE) revealed severe right ventricular dysfunction & right atrial (RA) thrombus in transit that extended into a PFO with right to left shunt. She was hemodynamically stable, but hypoxic on 4L/min of oxygen with a ProBNP 7712 pg/L, Troponin T 104 ng/dl, & pulmonary embolism severity (PESI) score of 104 (10% risk of 30 day mortality). Decision-making Due to the high PESI score & thrombus burden with risk of systemic thromboembolism, a multidisciplinary PE Response Team reached a consensus to pursue urgent mechanical thrombectomy. Inari FlowTriever system was successfully used for thrombectomy & retrieval of the RA clot in transit, with rapid improvement in right sided pressures. Repeat TTE showed no residual clot or shunting. Patient was placed on AC with plan for future PFO closure. Conclusion A multidisciplinary team approach was pivotal in managing this complex case with potential for hemodynamic compromise & systemic thromboembolism. We also demonstrate that mechanical thrombectomy is a feasible strategy for retrieving RA clot in transit. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Management of two circulations in a COVID-19 patient with secondary superinfection.

Optimal oxygenation in the intensive care unit requires adequate pulmonary gas exchange, oxygen-carrying capacity in the form of hemoglobin, sufficient delivery of oxygenated hemoglobin to the tissue, and an appropriate tissue oxygen demand. In this Case Study in Physiology, we describe a patient with COVID-19 whose pulmonary gas exchange and oxygen delivery were severely compromised by COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. His clinical course was complicated by a secondary superinfection with staphylococcus aureus and sepsis. This case study is provided with two goals in mind (1) We outline how basic physiology was used to address life-threatening consequences of a novel infection-COVID-19. (2) We describe a strategy of whole-body cooling to lower the cardiac output and oxygen consumption, use of the shunt equation to optimize flow to the ECMO circuit, and transfusion to improve oxygen-carrying capacity when ECMO alone failed to provide sufficient oxygenation.

Endotipsitis in an Immunocompetent Patient With Lactobacillus Bacteremia.

Transjugular intrahepatic portosystemic shunt (TIPS) is a procedure commonly performed to decompress portal venous pressure since the early 1990s. Endotipsitis, which refers to persistent bacteremia caused by endovascular infection of the TIPS stent, is a rare but serious complication of this procedure. Very few cases of endotipsitis have been reported worldwide. We report the case of an immunocompetent patient diagnosed with endotipsitis, an atypical risk factor for Lactobacillus infection. This case report adds to the literature on underreported complications of TIPS, highlighting an urgent need for introducing clinical practice guidelines regarding the definition, diagnosis, and treatment of endotipsitis.

A Case Report of Normal Pressure Hydrocephalus Developing After COVID-19 Infection.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 virus) has been reported to cause significant injury to the central nervous system (CNS). Herein, we describe the case of a 48-year-old male with a past medical history of attention-deficit/hyperactivity disorder (ADHD), hypertension, and hyperlipidemia who developed typical symptomatology of normal pressure hydrocephalus (NPH) with cognitive impairment, gait dysfunction, and urinary incontinence after a mild coronavirus disease (COVID-19) infection. The diagnosis was confirmed by imaging and lumbar puncture (LP). The patient was treated with a ventriculoperitoneal (VP) shunt placed by neurosurgery and had a complete recovery. Despite increasing reports of neurological manifestations of COVID-19 infection, the mechanism of such pathology is still not well understood. Hypotheses include viral invasion of the CNS either through the nasopharynx and olfactory epithelium or directly through the blood brain barrier.

Heterogeneity of Ventilation/Perfusion Mismatch at Different Levels of PEEP and in Mechanical Phenotypes of COVID-19 ARDS.

BACKGROUND: COVID-19-related ARDS is characterized by severe hypoxemia with initially preserved lung compliance and impaired ventilation/perfusion (V̇/Q̇) matching. PEEP can increase end-expiratory lung volume, but its effect on V̇/Q̇ mismatch in COVID-19-related ARDS is not clear. METHODS: We enrolled intubated and mechanically ventilated subjects with COVID-19 ARDS and used the automatic lung parameter estimator (ALPE) to measure V̇/Q̇. Respiratory mechanics measurements, shunt, and V̇/Q̇ mismatch (low V̇/Q̇ and high V̇/Q̇) were collected at 3 PEEP levels (clinical PEEP = intermediate PEEP, low PEEP [clinical - 50%], and high PEEP [clinical + 50%]). A mixed-effect model was used to evaluate the impact of PEEP on V̇/Q̇. We also investigated if PEEP might have a different effect on V̇/Q̇ mismatch in 2 different respiratory mechanics phenotypes, that is, high elastance/low compliance (phenotype H) and low elastance/high compliance (phenotype L). RESULTS: Seventeen subjects with COVID-related ARDS age 66 [60-71] y with a PaO2 /FIO2 of 141 ± 74 mm Hg were studied at low PEEP = 5.6 ± 2.2 cm H2O, intermediate PEEP = 10.6 ± 3.8 cm H2O, and high PEEP = 15 ± 5 cm H2O. Shunt, low V̇/Q̇, high V̇/Q̇, and alveolar dead space were not significantly influenced, on average, by PEEP. Respiratory system compliance decreased significantly when increasing PEEP without significant variation of PaO2 /FIO2 (P = .26). In the 2 phenotypes, PEEP had opposite effects on shunt, with a decrease in the phenotype L and an increase in phenotype H (P = .048). CONCLUSIONS: In subjects with COVID-related ARDS placed on invasive mechanical ventilation for > 48 h, PEEP had a heterogeneous effect on V̇/Q̇ mismatch and, on average, higher levels were not able to reduce shunt. The subject's compliance could influence the effect of PEEP on V̇/Q̇ mismatch since an increased shunt was observed in subjects with lower compliance, whereas the opposite occurred in those with higher compliance.

An unusual cause for hypoxemia and breathlessness

Thanks to the author's interest, complementary diagnostic tests were performed and the diagnosis was made. The author also made it possible to treat the patient through contact with the colleagues that performed the procedure. 75-year-old woman with past medical history of ischemic stroke in 2019, when complementary diagnostic tests were performed and it was found that the patient had a patent foramen ovale (PFO). Current hospitalization due to COVID-19 pneumonia, which was complicated by bacterial co-infection and intermediate-low risk right main pulmonary artery thromboembolism. The patient was successfully treated, with improvement of the clinical condition and evident imaging resolution of pulmonary cavitations and recanalization of the right pulmonary artery. However, something intriguing was observed: The patient presented dyspnea in the upright position and a decline in transcutaneous oxygen saturation from 96% in the supine position to 85% in orthostatism, with reversal of these findings with the recumbency. This led to the suspicion of platypnea-orthodeoxia syndrome. A transesophageal echocardiogram with bubble test was then performed, revealing an atrial shunt in the supine position without Valsalva maneuver. With these evidences, the diagnosis of platypnea-orthodeoxia syndrome was made. Even though the patient was >60 years, due to important right-to-left shunt, the history of stroke and the current platypnea-orthodeoxia, it was decided to close the PFO. The day after the procedure, the patient was placed in the upright position, maintaining an oxygen saturation of 96%. This case is an example that the decision of closing PFO must be individualized, not focusing only on patient's age, but also on his medical history and current situation, as indicated in the 2022 Guidelines for the Management of Patent Foramen Ovale. (Figure Presented).

Exertional desaturations after COVID-19: A case for PFO closure.

We present a case of a woman with past medical history notable for mild COVID-19 infection who presented with dyspnea on exertion, then developed progressively worsening exertional desaturations and was found to have a patent foramen ovale (PFO). Extensive cardiopulmonary testing revealed no clear alternate etiology for her symptoms. After much discussion, she underwent successful closure of the PFO with complete resolution of her symptoms and significantly improved exertional desaturation.

Glomerulonephritides associated with infections.

Glomerulonephritides associated with infections constitute an important group of diseases. Their occurrence is shifting from children and young people to elderly people. The rates of acute post-streptococcal glomerulonephritis, a condition with a good prognosis, are decreasing, and the rates of glomerulonephritides associated with various bacterial, viral, or parasitic infections, often with a poor prognosis, are increasing. Renal biopsy plays an important role in the diagnostic process. Manifestations of glomerulonephritis can be the initial sign of an occult infection. When evaluating renal biopsy specimens, certain signs may suggest this option, but it cannot be relied on completely. The search for an active infection is warranted in every patient with newly diagnosed glomerulonephritis. Hepatitis B and C serology is always performed, with other investigations depending on individual risk factors, clinical manifestations, and laboratory and histological findings. Failure to follow this rule may have serious consequences, in part because immunosuppressive therapy for glomerulonephritis can worsen the underlying infection and also because the progressive nature of parainfective glomerulonephritis cannot be reversed without eliminating the causative infection. Distinguishing between parainfective and autoimmune glomerulonephritis can be difficult, as there are no major differences in clinical manifestations, laboratory, and sometimes even histological findings. In the setting of the Czech Republic, important diseases include, in particular, staphylococcus infection-associated glomerulonephritis (SAGN) and, in general, infective endocarditis-associated glomerulonephritis, shunt nephritis, and other cases associated with foreign-material infection, such as catheters or electrodes. Among viral diseases, glomerulonephritides associated with the hepatitis B virus, hepatitis C virus, and the SARS CoV-2 virus are of major significance. The treatment of parainfectious glomerulonephritides involves elimination of the causative infection; only in rare cases, a combination of anti-infective treatment and mild immunosuppression can be indicated.

Initiating a pediatric cardiac surgery program in europe during the COVID-19 pandemic: Methods, challenges and outcomes

Background and Aim: Before 2020, no pediatric cardiac surgery pro-gram was available at our institution, despite being a university hospital providing tertiary care for 6 million inhabitants. Our goal is to describe the preparation and the first year of expe-rience of our pediatric cardiac surgery program, which will even-tually cater for 300 patients annually. Method(s): The project was supported by European funds (INTERREG program). Medical and nursing staff training was performed via a transborder collaboration. Significant investments were necessary to reach the required standards for the facilities (operating rooms, pediatric intensive care beds) and equipment (cardiopulmonary bypass and ECMO machines, ultrasound sys-tems etc.). A multidisciplinary team was built over 3 years. The pediatric ECMO program was started a year prior to the surgical program. In parallel, a program dedicated to the study and care of neurological impact of congenital heart diseases and interventions was set up. Importantly, a progressive upscale was devised: only children with a weight gt;5 kg requiring non-complex surgeries were operated on during the first year. Result(s): The first year of experience was marked by challenges caused by the successive COVID-19 waves, such as restricted access to the operating room and a subsequent slow-down in the progression of the schedule. Fifty-nine patients constituted the cohort of the first year (October 2020-October 2021). In addition to low-risk procedures (left-to-right shunts closures etc.), cases included 6 tetralogy of Fallot repairs, 1 Ross procedure and 2 bilateral cavopulmonary connections. There were no early or late deaths. Median age was 6.3 years old (1.8-9.8) and median weight was 18.5 kg (10.0-32.0). Fourteen patients (23.7%) were operated on with a weight lt;10 kg. Bypass cases represented 72.9% (43 patients) of all cases. Median cardiopulmonary bypass and cross-clamping times were 88 (52-153) and 51 (26-98) minutes respectively. Median intensive care and hospital stays were 3 (2.0-6.7) and 6 days (5-11) respectively. Conclusion(s): Despite COVID-19-related difficulties, our pediatric cardiac surgery program achieved excellent outcomes in selected patients. Institutional support, meticulous planning, team cohesion and perseverance are keys for successful initiation of a program requiring such high technicality.

MANIFESTATIONS OF SCIMITAR SYNDROME IN AN ADULT

SESSION TITLE: Anatomical Cardiovascular Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Scimitar Syndrome is a rare congenital disorder characterized by partial or complete anomalous pulmonary venous drainage to the inferior vena cava, right lung hypoplasia and displacement of the cardiac structures into the right hemi-thorax (1) The name Scimitar Syndrome is derived from the resemblance of the anomalous pulmonary vein to a curved Middle Eastern sword known as a scimitar (1). Some patients experience no symptoms while others may have severe pulmonary hypertension and dyspnea (2) (3). Cases may be discovered in infancy although some patients are not diagnosed until early adulthood. Here we present a case of a woman who was discovered to have symptomatic scimitar syndrome in her teenage years and opted to forego correction. CASE PRESENTATION: Patient was a 38 year old female with past medical history of Scimitar Syndrome who presented to the pulmonary clinic after a short hospitalization with mild COVID-19. Prior to contracting COVID-19 she had experienced worsening dyspnea over one year and now becomes short of breath after walking one half block. Open surgical correction was offered at diagnosis but was not pursued due to patient preference. A CT Angiogram of the chest was performed while she was hospitalized which showed an anomalous right pulmonary vein draining to the hepatic IVC, minimal bilateral patchy opacities and displacement of the heart into the right hemi-thorax. Echocardiography showed normal right ventricular size and function and did not show evidence of pulmonary hypertension. She was referred to the adult congenital heart disease clinic and continued to have severe dyspnea and fatigue. 6 months later, repeat echocardiography and cardiac MRI demonstrated borderline dilation of the right ventricle and atrium but no echocardiographic evidence of pulmonary hypertension. The patient remains hesitant to undergo invasive procedures or interventions. She has been offered a right heart catheterization to better characterize her volume status and obtain direct measurement of her pulmonary artery pressures. DISCUSSION: Although generally discovered in infancy and childhood, Scimitar syndrome may not be discovered until adulthood. Various treatments are available for correction of scimitar syndrome including open surgical approaches with direct implantation of the scimitar vein into the left atrium, trans-catheter occlusion of aorto-pulmonary collaterals and re-routing of the anomalous vein into the left atrium via endoscopic graft placement (4) (6) (7) (8). If left uncorrected worsening left to right shunting and pulmonary hypertension may occur (5). Our patient has developed borderline right ventricular dilation and has experienced severe functional limitation. A right heart catheterization is indicated to determine her pulmonary artery pressures. This case illustrates the potential consequences of deferring early treatment for Scimitar Syndrome CONCLUSIONS:. Reference #1: Frydrychowicz A, Landgraf B, Wieben O, François CJ. Images in Cardiovascular Medicine. Scimitar syndrome: added value by isotropic flow-sensitive four-dimensional magnetic resonance imaging with PC-VIPR (phase-contrast vastly undersampled isotropic projection reconstruction). Circulation. 2010 Jun 15;121(23):e434-6. doi: 10.1161/CIRCULATIONAHA.109.931857. PMID: 20547935 Reference #2: Abdullah A. Alghamdi, Mansour Al-Mutairi, Fahad Alhabshan, Scimitar syndrome: restoration of native pulmonary venous connection, European Heart Journal Supplements, Volume 16, Issue suppl_B, November 2014, Pages B41–B43, https://doi.org/10.1093/eurheartj/suu025 Reference #3: Khan A, Ring NJ, Hughes PD. Scimitar syndrome (congenital pulmonary venolobar syndrome). Postgrad Med J. 2005 Apr;81(954):216. doi: 10.1136/pgmj.2004.027813. PMID: 15811882;PMCID: PMC1743239 DISCLOSURES: No relevant relationships by John Prudenti No relevant relationships by Anthony Smith

ACUTE MESENTERIC ISCHEMIA IN COVID-19: A DEVASTATING SEQUELAE OF A DEVASTATING DISEASE

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: The COVID-19 pandemic has reshaped modern history with an estimated death count over 6 million globally. Symptoms are primarily respiratory;however, COVID also confers an increased risk for hypercoagulability with the common presentations of venous and small vessel arterial thrombi (1). Acute mesenteric ischemia (AMI) is rare. We present a case of severe AMI with arterial and venous thrombi related to COVID. CASE PRESENTATION: A 50-year-old non-COVID-vaccinated male with a history of alcohol abuse presented with 1 day of emesis and abdominal pain and was found to be COVID-19 positive without respiratory symptoms. Computed tomography angiogram of the chest, abdomen and pelvis revealed normal lungs, extensive non-calcified thrombi in the abdominal aorta extending into the celiac artery causing severe stenosis, complete occlusion of the superior mesenteric, right portal, and splenic veins, partial occlusion of the extrahepatic portal vein, left lower pulmonary embolism, small bowel perfusion injury, and splenic and right hepatic lobe infarcts. He denied a personal or family history of hypercoagulability. The patient was placed on a heparin drip and underwent placement of a transjugular intrahepatic portosystemic shunt and an infusion catheter for administration of tissue plasminogen activator into the portal vein. He ultimately required a thrombectomy. Later imaging showed patency of previously occluded vessels and resolution of arterial thrombus. Over the course of his hospitalization, his respiratory status did decompensate, and he required 13 days of mechanical ventilation, after which he was extubated, transitioned to warfarin, and discharged. DISCUSSION: AMI in COVID has been identified as a rare but serious complication with a reported incidence of 3-4%, with a reported mortality of up to 47% in all-cause-related AMI(2,3). COVID causes a prothrombotic state due to its affinity to angiotensin-converting enzyme-2(ACE2) receptors on enterocytes and endothelium, allowing it to infect the cells and causing direct damage to bowel tissue and vessels. The binding of ACE2 also increases IL-6, inducing cytokine storm and hypercoagulability (1). While there are no clear guidelines, treatment mainly involves revascularization and removal of necrotic bowel. Anticoagulation generally has favorable results within 48 hours and invasive intervention is not required (1,4). Thus, early recognition of AMI as a potential complication of COVID is essential for early treatment and reduction of the staggering morbidity and mortality. CONCLUSIONS: While the incidence of AMI in COVID is low, it can have severe effects on patients and requires early recognition and treatment. Further studies are needed to develop awareness of the disease, therefore improving surveillance and standard of care to minimize the chances of these poor outcomes. Reference #1: Patel, Suyog et al. "Bowel ischemia in COVID-19: A systematic review.” International journal of clinical practice vol. 75,12 (2021): e14930. doi:10.1111/ijcp.14930 Reference #2: Kaafarani, Haytham M A et al. "Gastrointestinal Complications in Critically Ill Patients With COVID-19.” Annals of surgery vol. 272,2 (2020): e61-e62. doi:10.1097/SLA.0000000000004004 Reference #3: Cudnik, Michael T et al. "The diagnosis of acute mesenteric ischemia: A systematic review and meta-analysis.” Academic emergency medicine : official journal of the Society for Academic Emergency Medicine vol. 20,11 (2013): 1087-100. doi:10.1111/acem.12254 Chen, Can et al. "Acute Mesenteric Ischemia in Patients with COVID-19: Review of the literature.” Journal of the National Medical Association vol. 114,1 (2022): 47-55. doi:10.1016/j.jnma.2021.12.003 DISCLOSURES: No relevant relationships by Mohamed Abdelhabib No relevant relationships by Naomi Habib No relevant relationships by Daniel Rabulinski No relevant relationships by Suresh Uppalapu

COVID-19 Vaccination May Provoke Intracranial Hypertension

In parallel to the spread of the novel severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), there has been the growing recognition that active SARS-CoV-2 infection has the potential to effect both the peripheral and central nervous systems. When it comes to the SARS-CoV-2 vaccine, however, reporting has been more uncertain. As the vaccination rate has risen, we have seen a rise in rare neurological complications thought to be associated with the vaccination including acute transverse myelitis, Guillain-Barre syndrome, optic neuritis, and Tolosa-Hunt syndrome. The Centers for Disease Control and Prevention (CDC) estimates 98 confirmed cases of Guillain-Barre syndrome out of 12.6 million doses. Given the initial age limits of vaccination eligibility, most reports have been limited to the adult population. Here, we report a case of intracranial hypertension (IH), evolving to fulminant IH in a healthy female after receiving the SARS-CoV-2 vaccine. While elevated intracranial pressure has been reported in the context of active SARS-CoV-2 infections and postinfection multisystem inflammatory syndrome (MIS-C), this is the first reported case of pediatric IH after vaccination alone.