Covid-19 Vaccine Associated Acute Myocarditis

Case Presentation: A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI (see Figure) was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation. Discussion(s): In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).

Prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players

Background: Identification of athletes with cardiac inflammation following COVID-19 can prevent exercise fatalities. The efficacy of pre and post COVID-19 infection electrocardiograms (ECGs) for detecting athletes with myopericarditis has never been reported. We aimed to assess the prevalence and diagnostic significance of novel 12-lead ECG patterns following COVID-19 infection in elite soccer players. Method(s): We conducted a multicentre study over a 2-year period involving 5 centres and 34 clubs and compared pre COVID and post COVID ECG changes in 455 consecutive athletes. ECGs were reported in accordance with the International recommendations for ECG interpretation in athletes. The following patterns were considered abnormal if they were not detected on the pre COVID-19 infection ECG: (a) biphasic T-waves;(b) reduction in T-wave amplitude by 50% in contiguous leads;(c) ST-segment depression;(d) J-point and ST-segment elevation >0.2 mV in the precordial leads and >0.1 mV in the limb leads;(e) tall T-waves >=1.0 mV (f) low QRS-amplitude in >3 limb leads and (g) complete right bundle branch block. Athletes exhibiting novel ECG changes underwent cardiovascular magnetic resonance (CMR) scans. One club mandated CMR scans for all 28 (6%) athletes, despite the absence of cardiac symptoms or ECG changes. Result(s): Athletes were aged 22+/-5 years (89% male and 57% white). 65 (14%) athletes reported cardiac symptoms. The mean duration of illness was 3+/-4 days. The post COVID ECG was performed 14+/-16 days following a positive PCR. 440 (97%) athletes had an unchanged post COVID- 19 ECG. Of these, 3 (0.6%) had cardiac symptoms and CMRs resulted in a diagnosis of pericarditis. 15 (3%) athletes demonstrated novel ECG changes following COVID-19 infection. Among athletes who demonstrated novel ECG changes, 10 (67%) reported cardiac symptoms. 13 (87%) athletes with novel ECG changes were diagnosed with inflammatory cardiac sequelae;pericarditis (n=6), healed myocarditis (n=3), definitive myocarditis (n=2), and possible/probable myocarditis (n=2). The overall prevalence of inflammatory cardiac sequelae based on novel ECG changes was 2.8%. None of the 28 (6%) athletes, who underwent a CMR, in the absence of cardiac symptoms or novel ECG changes revealed any abnormalities. Athletes revealing novel ECG changes, had a higher prevalence of cardiac symptoms (67% v 12% p<0.0001) and longer symptom duration (8+/-8 days v 2+/-4 days;p<0.0001) compared with athletes without novel ECG changes. Among athletes without cardiac symptoms, the additional yield of novel ECG changes to detect cardiac inflammation was 20% (n=3). Conclusion(s): 3% of elite soccer players demonstrated novel ECG changes post COVID-19 infection, of which almost 90% were diagnosed with cardiac inflammation during subsequent investigation. Most athletes with novel ECG changes exhibited cardiac symptoms. Novel ECGs changes contributed to a diagnosis of cardiac inflammation in 20% of athletes without cardiac symptoms.

Cardiac findings in multisystem inflammatory syndrome in children (MIS-C) - single institution experience

Background: Multisystem inflammatory syndrome in children (MIS-C), associated with coronavirus disease 2019 (COVID-19) is a rare but serious condition, affecting children mostly after acute SARS CoV2 infection. MISC presents with fever, laboratory evidence of inflammation, and multiorgan dysfunction, including heart. Purpose(s): We analized the degree of cardiac involvement and clinical outcomes of MIS-C patients hospitalized in Pediatric department of Cantonal hospital Zenica, to compare with previously reported findings. Method(s): Cardiac testing results in pediatric patients hospitalized with MIS-C from November 2020. until March 2022. were retrospectively analized. For this study, MIS-C patients with positive cardiac testing were defined as having an abnormality of one or more of the following on admission: Cardiac biomarkers, electrocardiogram, and/or echocardiogram. Result(s): Cardiac abnormal findings were present in almost all of our ten patients with MIS-C, but the extent of cardial injury was lower than we expected it to be. Abnormal EKG was found in 80% patients with the most common electrocardiography findings: Low voltage (50%) and T wave abnormality (70%). Echocardiography abnormalities were present in 80% patients mostly including valvular regurgitation (mitral, pulmonal), and rarely pericardial effusion or left ventricular diastolic disfunction (20%). Elevated cardiac biomarkers were seen in 70% patients. By the time of hospital discharge or short time follow-up all cardiological findings were diminished. Six months follow-up found no cardiac sequellae and 24h electrocardiogram with heart rate variability parametres found no disturbancies outside physiological or underlying chronic disease. Conclusion(s): While most patients in our study had evidence of abnormal cardiac testing on hospital admission, all cardiac findings were normal by hospital discharge. Cardiologic findings were representative for subacute myocardial injury with good clinical outcome and no sequellae. The degree of cardiac involvement was mild compared with previous reports.

Clinical Course and Short-Term Follow-up of SARS-CoV-2 Vaccine-Related Myocarditis in Children and Adolescents within the Prospective German Registry for Suspected Myocarditis "MYKKE

Background: Several studies described occurrence of myocarditis after SARS-CoV-2 vaccination in pediatric patients. Weaimed to characterize the clinical course of myocarditis following SARS-CoV2 vaccination including follow-up data within the prospective German registry for suspected myocarditis in children and adolescents "MYKKE." Method: Patients younger than 18 years with suspected myocarditis and onset of symptoms within 21 days followingSARS-CoV2 vaccination were enrolled within the MYKKE registry. The suspect of myocarditis is valid in patients with clinical symptoms and diagnostic findings typically seen in myocarditis. Clinical data are monitored at initial admission and duringshort-term and long-term follow-up. Result(s): Between July 2021 and August 2022, a total of 48 patients with a median age of 16.2 years (IQR: 15.2-16.8)were enrolled by 13 centers, 88% male. Onset of symptoms occurred at a median of 3 days (IQR: 2-7) after vaccine administration, most frequently after the second dose (52%). Most common symptoms at initial admission were anginapectoris (81%), fatigue (56%), dyspnea (24%) and documented arrhythmias (17%). Initial ECG abnormalities included ST-elevation (48%) and T-wave inversion (23%). Elevated Tropon in was observed in 32 patients (67%) and in 19 cases (40%)NT-proBNP was above the normal range with a median level of 171 pg/mL (IQR: 32-501). 11 (23%) patients presentedwith mildly reduced systolic function at initial echocardiography or cardiac MRI. In 40 patients cardiac MRI and/orendomyocardial biopsy was performed (83%) and diagnosis of myocarditis could be verified in 27 cases (68%). Thirty-nine patients underwent short-term follow-up with a median of 2.8 months (IQR: 1.9-3.9) after discharge. 19 patients (49%)presented with either clinical symptoms (n = 9) and/or diagnostic abnormalities (n = 16) at follow-up. 12 patients (38%)still had medical treatment. Except for one patient with malign arrhythmias (ventricular tachycardia), no major cardiac adverse events were observed during initial admission and follow-up. Conclusion(s): Our data confirm that SARS-CoV-2 vaccine-related myocarditis is characterized by a mild disease course. However, after short-term follow-up a considerable number of patients still presented with symptoms and/or diagnostic abnormalities. Data on long-term follow-up are awaited.

A Rare Case Of Peripartum Takotsubo Cardiomyopathy

Background: Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. Case presentation: A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Conclusion(s): Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain;however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.Copyright © 2022

Electrocardiographic predictors of disease severity, mortality, and advanced ventilatory support among hospitalized covid-19 patients: a two year single center retrospective, cohort study

Introduction: For detecting myocardial injury in severe and critical COVID-19, the electrocardiogram (ECG) is neither sensitive nor specific;but in a resource-poor environment, it remains relevant. Changes in the ECG can be a potential marker of severe and critical COVID-19 to be used for predicting not only disease severity but also the prognosis for recovery. Method(s): The admitting and interval ECGs of 1,333 COVID-19 patients were reviewed in a two-year, single-center, retrospective cohort study. Each was evaluated for 29 pre-defined ECG patterns under the categories of rhythm, rate, McGinn-White and RV overload patterns, axis and QRS abnormalities, ischemia/infarct patterns, and AV blocks before univariate and multivariate regression analyses for correlation with disease severity;need for advanced ventilatory support;and in-hospital mortality. Result(s): Of the 29 ECG patterns, 18 showed a significant association with the dependent variables on univariate analysis. Multivariate analysis revealed that atrial fibrillation, HR >100 bpm, low QRS voltage, QTc >500msec, diffuse nonspecific T-wave changes, and 'any AMI' ECG patterns correlate with disease severity;need for advanced ventilatory support and in-hospital mortality. S1Q3 and S1Q3T3 increased the odds of critical disease and need for high oxygen requirement by 2.5-3 fold. Fractionated QRS increased odds of advanced ventilatory support. Conclusion(s): The ECG can be useful for predicting the severity and outcome of more than moderate COVID-19. Their use can facilitate rapid triage, predict disease trajectory, and prompt a decision to intensify therapy early in the disease to make a positive impact on clinical outcomes.

Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection

Objectives: The study aims to determine the association between electrocardiographic abnormalities and in-hospital mortality of patients with Coronavirus Disease 2019 (COVID-19) infection admitted in a tertiary hospital in the Philippines. Material(s) and Method(s): We conducted a retrospective study of confirmed COVID-19-infected patients. Demographic, clinical characteristics, and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram (ECG) recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated. Result(s): A total of 163 patients were included in the study, most were female (52.7%) with a median age of 55 years old. Sinus rhythm (40%), nonspecific ST and T wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients and it was significantly associated with in-hospital mortality (p = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (p = 0.002), supraventricular tachycardia (SVT) (p = 0.011), ventricular tachycardia (p = 0.011), third-degree atrioventricular block (AVB) (p = 0.011), T wave inversion (p = 0.005) and right ventricular hypertrophy (RVH) (p = 0.011). Conclusion(s): The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. ECG abnormalities that were associated with mortality were atrial fibrillation or flutter, SVT, ventricular tachycardia, third-degree AVB, T wave inversion, and RVH. Supporting Documents Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection TARRANZA, Jannah Lee [1];RAMIREZ, Marcellus Francis [1,2];YAMAMOTO, Milagros [1] 1 Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines 2 Division of Electrophysiology, Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines.

Cardiovascular profile and electrocardiographic findings of hospitalized adult patients during the surge of delta and omicron variants of COVID-19 in a COVID-19 tertiary referral center

Background: COVID-19 has been reported to cause cardiac injury. It can be detected by an electrocardiogram (ECG), which may show markers that may predict clinical outcome. Robust data on the ECG abnormalities among COVID-19 patients affected by the alpha, beta, and gamma variants have been reported, but there is paucity of data among patients affected by the delta and omicron variants. Purpose(s): This study aims to describe the cardiovascular profile, ECG findings, and clinical course of adult patients with COVID-19, and to determine the association between certain ECG findings and clinical outcomes among these patients. Method(s): We evaluated 547 COVID-19 patients admitted from June 2021 to June 2022. Clinical profiles were extracted from electronic records. Admission ECGs were independently read and adjudicated by three cardiologists. Logistic regression analysis was done to determine the association between ECG abnormalities and adverse outcomes, including in-hospital mortality, ICU admission, need for mechanical ventilation, acute respiratory distress syndrome (ARDS), shock, acute kidney injury (AKI), myocardial infarction (MI), myocarditis, venous thromboembolism (VTE), and stroke. Result(s): A Total of 547 COVID-19 patients (mean age 54;men 51.2%) were included. The most common comorbidities were hypertension, diabetes, and dyslipidemia. Majority of patients had severe COVID-19 infection (36%). On admission, 6.4% needed intubation and 14.6% died. The most common ECG abnormalities were non-specific ST-T wave changes (41.1%) and sinus tachycardia (25.6%). Other findings were ST segment depression (3.3%), T wave inversion (1.6%), and ST segment elevation (1.3%). On logistic regression analysis, intraventricular conduction delay (IVCD), T wave inversion, and poor R wave progression were significantly associated with mortality;sinus tachycardia, atrioventricular (AV) block, ST segment elevation, and T wave inversion were significantly associated with the development of VTE;left axis deviation, ST segment elevation, and T wave inversion were significantly associated with the development of ARDS;sinus tachycardia, ST segment depression, and T wave inversion were significantly associated with the development of shock;and sinus tachycardia, ST segment elevation, and early repolarization changes were significantly associated with ICU admission. No associations were established for AKI, MI, myocarditis, and need for mechanical ventilation due to the low prevalence of these outcomes. Conclusion(s): A baseline ECG in patients with COVID-19 may help predict patients who may warrant hospitalization or even intensive care monitoring. In our cohort, certain ECG abnormalities, especially sinus tachycardia, left axis deviation, ST segment elevation, ST segment depression, T wave inversion, AV block, IVCD, poor R wave progression, and early repolarization changes, were associated with adverse clinical outcomes, including in-hospital mortality.

Pseudo-ventricular tachycardia- Diagnostic enigma in the emergency department: A case report

Ventricular tachycardia (VT) is a type of broad complex tachycardia originating from a focus in the ventricle. It is one of the four important rhythms which can lead to cardiac arrest. Accurate and timely diagnosis of true VT is the cornerstone for proper management in the emergency department (ED). We present an interesting case of an electrocardiographic artifact mimicking VT, which led to a diagnostic dilemma in the ED.Copyright © 2023 Rehman, Albaroudi, Akram, Ahmad, licensee HBKU Press.

THE CHATTERJEE PHENOMENON: A DEMONSTRATION OF CARDIAC MEMORY IN PACED RHYTHMS.

Introduction: While T-wave inversions (TWI) are associated with various pathologies, they are rarely associated with cardiac memory, termed the Chatterjee phenomenon. Case: A 76-year-old man with sick sinus syndrome with a pacemaker presented with chest tightness and new onset TWI in his precordial leads. On admission, he tested positive for COVID-19, but remained stable and only required minimal supplemental oxygen. His troponin was only slightly elevated, and EKG showed TWI throughout his precordial leads. A previous EKG had shown normal sinus rhythm without a paced rhythm or ST wave abnormalities. Interrogation of his pacemaker revealed an AV-paced rhythm. Given his chest tightness without dynamic changes in his troponin or EKG, the symptoms were considered more likely related to his COVID-19 infection, and he was discharged home. Discussion: Aberrancies in normal cardiac conduction can result in altered electrical activation, especially for those with AV pacemakers, leading some patients to develop cardiac memory, manifesting as TWI. Conclusion: AV-paced rhythm and narrow QRS complexes with TWI localized to precordial leads without evidence of active cardiac ischaemia may suggest cardiac memory, termed the Chatterjee phenomenon, requiring no invasive interventions. LEARNING POINTS: In patients with T-wave inversions, various conditions should considered in the differential diagnosis, including left bundle branch block and sick sinus syndrome, although T-wave inversions in V1-V3 are non-specific and benign.Cardiac memory, termed the Chatterjee Phenomenon, is one of the causes of T-wave inversions which is sometimes ignored.No invasive interventions are needed for T-wave inversions with the Chatterjee phenomenon.

Is T-Wave Alternans a Repolarization Abnormality Marker in COVID-19? An Investigation on the Potentialities of Portable Electrocardiogram Device.

Background: Cardiac arrhythmias are significantly associated with poor outcomes in coronavirus disease 2019 (COVID-19) patients. Microvolt T-wave alternans (TWA) can be automatically quantified and has been recognized as a representation of repolarization heterogeneity and linked to arrhythmogenesis in various cardiovascular diseases. This study aimed to explore the correlation between microvolt TWA and COVID-19 pathology. Methods: Patients suspected of COVID-19 in Mohammad Hoesin General Hospital were consecutively evaluated using Alivecor® Kardiamobile 6L™ portable electrocardiogram (ECG) device. Severe COVID-19 patients or those who are unable to cooperate in active ECG self-recording were excluded from the study. TWA was detected and its amplitude was quantified using the novel enhanced adaptive match filter (EAMF) method. Results: A total of 175 patients, 114 COVID-19 patients (polymerase chain reaction (PCR)-positive group), and 61 non-COVID-19 patients (PCR-negative group) were enrolled in the study. PCR-positive group was subdivided according to the severity of COVID-19 pathology into mild and moderate severity subgroups. Baseline TWA levels were similar between both groups during admission (42.47 ± 26.52 µV vs. 44.72 ± 38.21 µV), but higher TWA levels were observed during discharge in the PCR-positive compared to the PCR-negative group (53.45 ± 34.42 µV vs. 25.15 ± 17.64 µV, P = 0.03). The correlation between PCR-positive result in COVID-19 and TWA value was significant, after adjustment of other confounding variables (R2 = 0.081, P = 0.030). There was no significant difference in TWA levels between mild and moderate severity subgroups in patients with COVID-19, both during admission (44.29 ± 27.14 µV vs. 36.75 ± 24.46 µV, P = 0.34) and discharge (49.47 ± 33.62 µV vs. 61.09 ± 35.99 µV, P = 0.33). Conclusions: Higher TWA values can be observed on follow-up ECG obtained during discharge in the PCR-positive COVID-19 patients.

A case of mRNA COVID-19 vaccine-associated myocarditis in a child

Background and Aim: Accumulation of cases is needed to determine whether vaccines should be recommended for children because of their potential to cause myocarditis in healthy children. Method(s): We report a case in which changes in laboratory data, electrocardiogram (ECG), and magnetic resonance imaging (MRI) were tracked at our hospital. Result(s): A 12-year-old girl developed fever a day after receiving the second dose of the COVID-19 vaccine. Three days after vaccina-tion, she also developed chest pain and went to a hospital. ECG showed ST-T segment elevation. However, the symptoms were mild, and she was treated with antipyretics and analgesics. The next day, she visited the hospital again because she had mild chest pain. ECG showed a negative T-wave, and she was referred to our hos-pital. Her real-time reverse-transcription polymerase chain reac-tion tests for COVID-19 yielded negative results. Computed tomography revealed no anatomical abnormalities of the coronary arteries. The serum concentration of troponin T was elevated by 131 ng/L. Echocardiography showed the left ventricular ejection fraction to be 64%. MRI showed a normal T2 value on T2-weighted imaging;however, extracellular volume increased by 33%. Although the Lake Louise criteria was not met, we diagnosed the condition as myocarditis. She was hospitalized for 2 days and discharged without the need for steroids or gamma globulin treat-ment to relieve her symptoms. Although these findings improved 17 days after vaccination, late gadolinium enhancement was noticed on MRI. Conclusion(s): The COVID-19 vaccine-related myocarditis (C-VAM) in this case was mild and like as cases in Europe and the United States. The risk of COVID-19 associated myocarditis is more than three times the risk of C-VAM. In addition, the mor-tality rate for COVID-19 associated myocarditis is higher than that for C-VAM. The need for a vaccine to protect populations from COVID-19 should be properly recognized. However, because the symptoms of C-VAM are mild, there may be many potential patients with C-VAM. Therefore, it may be advisable to avoid strenuous exercise for approximately 1 week after vaccination. Further research is needed to determine the long-term outcomes of C-VAM because of the late enhancement identified on MRI.

Assessing medium term cardiac outcomes in children with multi-system inflammatory syndrome

Background and Aim: Multi-system inflammatory syndrome in chil-dren (MIS-C) causes widespread systemic inflammation including a pancarditis in the weeks following a COVID infection. Further coronavirus surges appear inevitable and with vaccination rates lower in young people an understanding of the medium-term car-diac impacts of this condition is important for planning further treatment and understanding the impacts on their health. Method(s): A retrospective single-center study of 67 consecutive patients with MIS-C was performed. Three time points were determined as the point of worst cardiac dysfunction during the acute admission, then at intervals of 6-8 weeks and 6-8 months. Echocardiographic findings were used to evaluate both 2D and 3D measures of cardiac function. Coronary artery measurements were recorded. Corresponding serial ECG findings were evaluated. Result(s): The worst cardiac function arose 6.8 +/- 2.4 days after the onset of fever. The mean M mode-derived FS was 30.9 +/- 8.1% during the acute phase. The mean 3D left ventricle (LV) ejection fraction (EF) was borderline at 50.5 +/- 9.8%. A pancarditis was typ-ically present: 46.3% showed cardiac impairment;31.3% had some pericardial effusion;26.8% had moderate (or worse) valvar regur-gitation and;26.8% had coronary dilatation. Cardiac function returned to normal in all patients by 6-8 weeks (mean 3D LV EF 61.3 +/- 4.4%, plt;0.001 compared to admission). Coronary dila-tation normalized in all but one patient who initially developed large aneurysms at presentation;these continued 6 months later. ECG findings mainly featured T-wave changes resolving at fol-low-up. There were a small number of adverse events: need for ECMO (2), death as an ECMO-related complication (1), suben-docardial infarction (1), LV thrombus formation (1). Conclusion(s): MIS-C causes a pancarditis with decreased cardiac function and almost a quarter of patients showing coronary changes. In most, discharge from long-term follow-up can be con-sidered as full cardiac recovery is expected by 8 weeks. The excep-tion includes patients with medium sized aneurysms or greater or those with more of a Kawasaki disease phenotype as these require on-going surveillance for persistence of coronary changes.

Cardiovascular manifestation in multisystem inflammatory syndrome in children temporally associated with COVID-19-single center experience

Background and Aim: Cardiovascular manifestations are common (35-100%) in multisystem inflammatory syndrome in children (MIS-C), including ventricular dysfunction, shock, coronary artery dilation, pericardial effusion and conduction abnormalities. Our study aimed to analyse cardiovascular involvement in our patients with MIS-C treated in our hospital. Method(s): The retrospective cohort study included all patients with MIS-C treated from April 2020 to December 2021 in the Mother and Child Health Institute of Serbia. In every case, cardiovascular manifestations were analysed: ventricular dysfunction, coronary artery dilatation, pericardial effusion, shock and ECG changes. Result(s): The study included 77 patients, 45 boys and 32 girls, aver-age years of age 9.3 +/- 4.8. Elevated cardiac troponin I and pro-BNP were observed in 35.9% and 87.8% of patients, respectively. Myocardial dysfunction was observed in half of our patients (50.6%), with an average ejection fraction of 50.5 +/- 8.9%. Children older than 10 years had 4 times higher chances for myo-cardial dysfunction (OR 4.3, 95%CI 1.6-10.8;p = 0.003). Shock syndrome had 21.1% of children on admission, while 5.3% devel-oped shock during the in-hospital stay. Transient coronary artery (CA) dilatation was observed in 6.5% of patients;left CA in 3 pts (Z score +2,95 +/- 0.3), right CA in one patient (Z score +2), and in one LCA and RCA (RCA Z score 2.6). Transient CA dilatations were observed only in patients with KD-like clinical presentation (5/54 pts). Mild pericardial effusion with spontaneous resolution was detected in 28.6% of children, while one female adolescent had severe pericardial effusion with threatening cardiac tamponade. On the standard ECG, 53% of children had negative T wave in inferior or/and precordial leads averagely on day 2 (IQR 1-3 day);transient QTc prolongation was registered in 46% of patients, averagely on day 7 (IQR 5-9). Sinus bradycardia and coronary rhythm were registered in 42.1% of patients, while premature ven-tricular beats were observed in 2.7% of pts. left ventricle thrombus was detected in one patient with normal echocardiography find-ing. In this patient, increased activity of Factor VIII and XII was proven. Conclusion(s): Cardiac manifestations are common and potentially life-threatening in MIS-C and should be assessed for at presenta-tion and during the clinical course as indicated.

Cardiac findings and short-term outcomes of multisystem inflammatory syndrome associated with COVID-19 single center experiences from turkiye

Background and Aim: Multi-system inflammatory syndrome in chil-dren (MISC) associated with COVID-19 has been described as a potentially life-threatening disease. In this study, we aimed to evaluate cardiovascular findings in children diagnosed with MISC at initial presentation and follow up. Method(s): Between November 2020 and November 2021, 35 children diagnosed with MISC based on WHO criteria were evaluated in this retrospective study.Cardiac markers, electrocardi-ography and echocardiography were performed in all cases at pre-sentation. Cardiac evaluation were repeated at the mean of 10th week after discharge(range:5 to 33weeks). Result(s): At this period, 633 children had positive PCR test of Covid-19. The freguency of MISC was 5.5% in our cohort. The median age was 9 years at diagnosis. Comorbid diseases were found in 20% cases, but none had preexisting heart disease. All patients had high grade fever and laboratory evidence of hyperin-flammation. Most cases had mild form disease, however 12 patients had been hospitalized in ICU median 6 day. 27 cases (77%) had cardiovascular involvement.Kawasaki-like findings were found in 10 patients and 5 cases were presented with shock(Figure-1) Echocardiography;Left ventricular (LV)systolic dysfunction (EFlt;57%) was detected in 11 cases (31.4%) and coronary artery (CA) dilatation(z scoregt;2)was found in five(14.2%) cases. Pericardial effusion was seen in 12 cases. Electrocardiography: Sinus tachycardia was the most common finding. 2 cases had pro-longed QTc interval and four cases had T wave alterations. Four cases had experienced complex ventricular arrhythmia. Cardiac markers:24 cases had high Pro-BNP level. 18 cases also had high Troponin T levels. Pro-BNP and Troponin T levels were not found to be correlated with LVEF. Only one adolescent boy who had severe cardiac dysfunction died during the acute period. Followup:There were two cases with persistent cardiac symptom, but no case had LV systolic dysfunction. The mean PR intervale was significantly lower than initial measurements. The mean of QT and QTc at follow up were not different from basal measurements.The mean LVEF was significantly higher than the initial levels. The basal CA z scores normalized at followup. Conclusion(s): MISC is characterized predominantly by cardio-vascular system involvement, but the children with MISC have good cardiac outcomes at short term follow up.

THROMBUS IN TRANSIT CAPTURED BY BEDSIDE ULTRASOUND: A LIFE-SAVING TOOL

SESSION TITLE: Thrombosis Jamboree: Rare and Unique Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Point of care ultrasound used by the provider is rapidly expanding in internal medicine. Thrombus in transit (TIT) is defined on ultrasound as mobile echogenic material temporarily present in the right heart chambers to the pulmonary circulation via the tricuspid valve or systemic circulation via an atrial septal defect. In this case, we were able to identify echogenic material traversing the tricuspid valve into the pulmonary circulation, which confirmed the diagnosis of pulmonary embolus [1] CASE PRESENTATION: This is a 71-year-old female with a history of hypertension who presented to the emergency room with 4-day pleuritic chest pain, productive cough, fever, and exertional dyspnea. She was hemodynamically stable, afebrile, tachycardic, and tachypneic. Initial diagnostic workup demonstrated elevated cardiac enzymes and creatinine, ground-glass opacities on chest CT, positive COVID PCR, and sinus tachycardia with nonspecific T wave abnormalities. Given her renal insufficiency, CTA was initially held off. The patient was found to have right lower extremity deep venous thrombosis, and a heparin infusion was started while waiting for a V/Q scan. Shortly after admission, she had a syncopal episode after using the bathroom. CPR was initiated for suspected cardiac arrest, and a bedside ultrasound demonstrated a sizeable mobile thrombus in the right atrium traversing the tricuspid valve into the right ventricle. Given this finding, we elected to move forward with CTA chest, and this study confirmed extensive bilateral PE with right heart strain. DISCUSSION: TIT is a rare emergency in PE (4%) with a staggering mortality rate twice as high as PE without TIT [2]. The gold standard for diagnosis of PE is CT angiogram, and early echocardiography is a cornerstone in diagnosis and risk stratification. However, patients similar to the one discussed in this care may present with conditions preventing timely utilization of these tools. POCUS allows for the rapid assessment and implementation of time-sensitive treatments. Historically, it has been a must-have skill set among ER and critical care physicians. Only 35% of internal medicine residency programs have fully integrated formal diagnostic POCUS within the past decade despite increasing interest among trainees. The expeditious medical decision made for our patient was possible following a focused echocardiogram performed by an internal medicine resident. In patients with massive PE, only 35% of echocardiograms obtained within 24 hours were done in the ER, and still, 1 in 6 happened after 6 hours [3]. CONCLUSIONS: As with any operator-dependent skill, proficiency in POCUS is a prerequisite for reliable findings and time-sensitive medical decision-making. POCUS only becomes a lifesaving tool in experienced hands. Hence, it is imperative that internal medicine residency programs consider this tool an essential component of resident training. Reference #1: Arboine-Aguirre L, Figueroa-Calderón E, Ramírez-Rivera A, et al. Thrombus in transit and submassive pulmonary thromboembolism successfully treated with tenecteplase. Gac Med Mex. 2017;153(1):129–33. Reference #2: Casazza F, Bongarzoni A, Centonze F, Morpurgo M. Prevalence and prognostic significance of right-sided cardiac mobile thrombi in acute massive pulmonary embolism. Am J Cardiol. 1997;79(10):1433-1435. doi:10.1016/s0002-9149(97)00162-8 Reference #3: Torbicki A, Galié N, Covezzoli A, et al. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol. 2003;41(12):2245-2251. doi:10.1016/s0735-1097(03)00479-0 DISCLOSURES: No relevant relationships by Varinder Bansro No relevant relationships by Olayiwola Bolaji No relevant relationships by clarence findley No relevant relationships by Faizal Ouedraogo

IDIOPATHIC TROPONEMIA AFTER TRANSCAROTID ARTERY REVASCULARIZATION

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo

CASE REPORT OF SPONTANEOUS CORONARY ARTERY DISSECTION IN A PATIENT POSITIVE FOR COVID-19

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare cardiac phenomenon associated with autoimmune and inflammatory conditions seen often in young women with few conventional atherosclerotic risk factors. The presentation is indistinguishable from acute coronary syndrome and can lead to acute myocardial infarction, arrhythmias, and sudden death. We share a thought-provoking case of SCAD in a COVID-19 positive patient. CASE PRESENTATION: 51-year-old physically fit female with BMI of 22.46kg/m2, non-diabetic with recent unremarkable lipid panel and history of anxiety, postpartum cardiomyopathy 15 years prior with recovered ejection fraction presented with complaints of midsternal chest pain at rest, 9/10 intensity, radiating to the right shoulder associated with dyspnea, lasting for 3 hours until relieved by nitroglycerine patch. Initial workup revealed troponin of 3.08 and EKG consistent with acute ischemic changes without STEMI. She was incidentally found positive for SARS-CoV-2. Echocardiogram showed dyskinetic apex with normal ejection fraction. The following day, while she was on aspirin and heparin drip, she developed chest discomfort with EKG revealing dynamic T wave inversions and troponin trending up to 14.79. The patient was taken for an emergent cardiac catheterization which revealed patent coronaries with concern for distal left anterior descending artery dissection. Subsequently, the patient was continued on a heparin drip with an improvement of her symptoms. Troponin declined to 7.97 with no other COVID-19 related concerns. She was deemed medically stable and discharged home after completing her isolation. Furthermore, she underwent a cardiac and coronary artery CT angiogram 2 weeks later, showing patent coronaries and a calcium score of 0 and no findings of coronary artery disease. DISCUSSION: SCAD is an emergent condition closely associated with inflammatory conditions, systemic arteriopathy, emotional stress triggers, fibromuscular dysplasia, and pregnancy. It is not iatrogenic, traumatic or associated with atherosclerosis. The mainstay of detection of SCAD is coronary angiography. In our patient, since it was a distal LAD disease, the echo findings of dyskinetic apex helped established the diagnosis of SCAD. Management is mainly supportive usually carrying a good prognosis. In our case report, the connecting factor to SCAD was the presence of SARS-CoV-2. Our patient was without traditional risk factors for coronary artery disease, which reinforced the likelihood of SCAD instead of acute coronary syndrome. CONCLUSIONS: Thus, as the manifestations, complications, and sequelae of COVID-19 continue to emerge, we believe SCAD needs to remain a top differential in COVID -19 positive patients presenting with symptoms of the acute coronary syndrome. To better elucidate the pathophysiology of SCAD in SARS-CoV-2 patients, we encourage further vigilance of this phenomenon. Reference #1: Hayes, S. N. et al (2018, February 22). Spontaneous coronary artery dissection: Current state of the science: A scientific statement from the American Heart Association. Circulation. Retrieved April 1, 2022, from https://www.ahajournals.org/doi/10.1161/cir.0000000000000564 Reference #2: Ahmed, T., Jeudy, J., & Srivastava, M. C. (2020). Imaging modalities to delineate sequelae of spontaneous coronary artery dissection managed with percutaneous coronary intervention. Cureus. https://doi.org/10.7759/cureus.7591 DISCLOSURES: No relevant relationships by Hareesh Lal No relevant relationships by Jennaire Lewars No relevant relationships by Avani Mohta

ACUTE CORONARY ARTERY THROMBOSIS AND ST-ELEVATION MYOCARDIAL INFARCTION IN AN ALREADY HOSPITALIZED PATIENT WITH COVID-19 INFECTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: It is well established that SARS-CoV-2 infection predisposes patients to develop thromboses. Here we present an elderly Hispanic male with who was hospitalized for COVID-19 pneumonia and was on therapeutic anticoagulation, yet still developed an acute right coronary artery occlusion secondary to thrombus formation. CASE PRESENTATION: An 81 year-old Hispanic male with hypertension, coronary artery bypass graft (LIMA to LAD and SVG to OM), congestive heart failure was admitted to the hospital for SARS-CoV-2 pneumonia. Inflammatory markers were elevated with a D-Dimer level of 2.95 mg/mL. An EKG at that time showed normal sinus rhythm with a heart rate of 69 bpm and no ST-T wave abnormalities. Troponin-I level was unremarkable. He was started on remdesivir, steroids, and continuous heparin infusion. During hospital stay, the patient’s overall clinical status continued to improve. On day 9, the patient started complaining of 9/10 intensity, non-radiating substernal squeezing chest pain. He appeared diaphoretic. A STAT 12-lead EKG showed ST elevations in the inferior leads concerning for Inferior Wall MI (IWMI). The patient was immediately taken to the catheterization lab. The right coronary artery (RCA) had 99% stenosis with filling defect secondary to thrombus in its proximal, middle, and distal portion. Thrombus removal was achieved with a thrombectomy catheter and patient received two drug eluting stents (DES) in the proximal and distal RCA. The patient was continued on heparin infusion, aspirin 81mg daily, clopidogrel 75mg daily, and atorvastatin 80mg daily. He was discharged home two weeks later and had good outpatient follow up. DISCUSSION: ST-segment elevation myocardial infarction (STEMI) is commonly encountered in patients with COVID-19 infection. About 40% of COVID-19 patients with STEMI had no evidence of coronary artery disease (CAD) which excludes Type I Myocardial Infarction (MI). This suggests that a large proportion of patients had Type II MI. Our patient developed an occlusive thrombus requiring thrombectomy. It is difficult to know in this case whether the patient may have still suffered a STEMI without the hypercoagulable state from COVID-19 infection since he already had underlying CAD. Incidence rates of STEMI in patients with COVID-19 infection are variable (0.3-11%). Nonetheless, we can highlight the fact that SARS-CoV-19 remains a significant risk factor for STEMI. Acute thrombus formation causing STEMI is an uncommon occurrence. CONCLUSIONS: This case emphasizes the hypercoagulable state in the setting of SARS-CoV-2 infection and encourages clinicians to be mindful of the potential complications that can affect nearly all organ systems. It is important for clinicians to acknowledge that patients with COVID-19 infection may develop blood clots despite systemic anticoagulation. Further investigation is needed to address the management of these patients after thrombectomy. Reference #1: Kermani-Alghoraishi, M. (2021). A Review of Coronary Artery Thrombosis: A New Challenging Finding in COVID-19 Patients and ST-elevation Myocardial Infarction. Current Problems in Cardiology, 46(3), 100744. https://doi.org/10.1016/j.cpcardiol.2020.100744 Reference #2: Green, C., Nadir, A., Lester, W., & Dosanjh, D. (2021). Coronary artery thrombus resulting in ST-elevation myocardial infarction in a patient with COVID-19. BMJ Case Reports, 14(8), e243811. https://doi.org/10.1136/bcr-2021-243811 Reference #3: Genovese, L., Ruiz, D., Tehrani, B., & Sinha, S. (2021). Acute coronary thrombosis as a complication of COVID-19. BMJ Case Reports, 14(3), e238218. DISCLOSURES: No relevant relationships by Utku Ekin No relevant relationships by Rajapriya Manickam No relevant relationships by Rutwik Patel