The application experience of focused ultrasound heart examination in patients with COVID-19 in Prone-position.

Aim of the study. To study the experience of using focused transthoracic echocardiography in patients with COVID-19 in prone position (fEchoPr) in intensive care units (ICU). Materials and methods. The retrospective observational study included 53 patients (period from 15 April to 31 December 2020). Inclusion criteria: confirmed diagnosis of COVID-19, availability of fEchoPr data, outcome certainty (discharge/death). We analyzed electronic medical records. The fEchoPr was performed in patients in the prone position with a bolster under the left side of the chest and left arm raised ('swimmer's position'). We assessed the systolic function of the right ventricle (RV) (tricuspid annular plane systolic excursion (TAPSE)), RV size, RV/LV ratio, systolic function of the left ventricle (LV) (left ventricular outflow tract velocity time integral. (LVOT VTI)), and pulmonary hypertension (PH) (tricuspid regurgitation peak gradient (PGTR). Depending on the results, the patients were divided into 2 groups: informative (+fEchoPr) and non-informative (-fEchoPr) examinations. Results. There was no statistically significant difference in the groups (+fEcho n = 35 vs -fEcho n = 18) by age (65.6 +/- 15.3 vs 60.2 +/- 15.8, p > 0.05), by gender (male: 23 (65.7%) vs 14 (77.8%), p > 0.05), by body mass index (31.3 +/- 5.3 kg/m2 vs 29.5 +/- 5.4 kg/m2, p > 0.05), by mechanical ventilation support (24 (68.6%) vs 17 (94.4%), p = 0.074), by NEWS scale indicators (6.9 +/- 3.7 vs 8.5 +/- 3.5 points), by mortality (82.8% vs 94.4%, p > 0.05). Correlation analysis revealed a moderate inverse relationship between being on mechanical ventilation and the informative value of the study (Spearman's r = -0.30 at p = 0.033). In the +fEchoPr group, the correct measurement of TAPSE and RV/LV was carried out in 100%: a decrease in RV systolic function was recorded in 5 patients (14%), expansion of the RV in 13 patients (37%). Signs of PH were detected in 11 patients (31%), PGTR could not be measured in 10 patients (28%). LV systolic dysfunction was detected in 7 patients (20%). No pathology was detected in 16 patients (46%). One patient was diagnosed with infective endocarditis of native mitral valve, which was later confirmed by autopsy. Conclusion. In 66% of cases, fEchoPr examinations were informative, especially in terms of assessing the state of the right heart. fEchoPr examination is an affordable, valid and reproducible method to assess and monitor the state of the heart in ICU patients.Copyright © 2021 VIDAR Publishing House. All Rights Reserved.

Personalized approach to the management of a patient with COVID-19 with a complicated comorbid background

The aim of the work is to form the principles of a personalized approach to the management of patients with COVID-19 with a complicated comorbid background. Material and methods. The article describes a clinical case of successful recovery of an 87-year-old patient from a new coronavirus infection COVID-19, complicated by pneumonia involving 36% of the lung parenchyma area. Along with age, the situation was aggravated by the comorbid status of the patient: the presence of chronic lymphocytic leukemia, hypertension, mechanical prostheses of the mitral and aortic valves, postinfarction cardiosclerosis, paroxysmal atrial fibrillation, type 2 diabetes mellitus, stage 4 CKD, anemic syndrome, and subclinical hypothyroidism. Results. The C-reactive protein level at admission was 114.46 mg/L. The patient refused hospitalization. Baricitinib 4 mg, favipiravir according to the scheme, vitamin D 2000 units were prescribed for the previously taken therapy. Already after 3 days, C-reactive protein decreased by 4.6 times, and by the 8th day by 15.5 times and amounted to 7.38 mg/ml. The temperature returned to normal on day 2 from the start of baricitinib. In dynamics, a decrease in creatinine level to 177.0 mumol/l was noted, the glomerular filtration rate increased to 30 ml/min/1.73 m2, which corresponded to stage 3b of CKD (a pronounced decrease in glomerular filtration rate). Conclusion. Despite the age of the patient, many comorbidities, each of which could be fatal, the timely use of baricitinib on an outpatient basis made it possible to stop the progressive course of the disease.Copyright © Eco-Vector, 2023. All rights reserved.

Mitral valve thromboendocarditis in a patient with a novel coronavirus disease COVID-19

Since the beginning of the novel coronavirus disease pandemic, which has claimed millions of lives around the world, vaccines and effective therapeutic strategies have been developed, but along with this, approaches to the diagnosis and treatment of well-known diseases have changed, these metamorphoses also affected cardiovascular diseases. So, a flurry of publications is devoted to the development of myocarditis and myocardial damage within the framework of novel coronavirus infectious disease, however, there are practically no data on the concomitant course of COVID-19 and infective endocarditis or thromboendocarditis. In our case, we demonstrate the combined course of novel coronavirus infectious disease, viral pneumonia and infectious thromboendocarditis in a patient with pre-existing corrected valvular heart disease. Of particular interest are the pathogenetic links, the nature of the clinical course and prognosis in the combination of these nosologies.Copyright © 2022 Creative Cardiology. All rights reserved.

Uncontrolled Acromegaly Resulting in the Need for LVAD as Bridge to Heart Transplant

Introduction: Acromegaly is an uncommon pituitary disorder with an incidence of six per million persons. While hypertension is often encountered in these patients, heart failure rarely is seen with an incidence rate under 10%. We describe a case of an individual who was diagnosed with acromegaly after an acute exacerbation of heart failure with subsequent management requiring an LVAD to perform Transsphenoidal Surgery (TSS). Case Description: 37-year-old male otherwise healthy initially presented to an emergency room and was found to be in acute heart failure exacerbation. Concerning acromegaly features included macrognathia, enlarged hands and feet, swollen phalanges, widened spacing of teeth, and frontal bossing. IGF-1 level was found 455 ng/mL. MRI showed a 10mm macroadenoma. A right heart catheterization showed elevated filling pressures. Cardiac MRI showed no defects or enhancement. Endomyocardial biopsy showed no inflammatory infiltrates or evidence of infiltrative diseases. Patient had an ejection fraction of 15% corroborated by cardiac MRI along with the presence of aortic root dilatation and mitral regurgitation. The patient started on 0.5mg of Cabergoline twice weekly and 120mg weekly Lanreotide injections. Patient stabilized with plans for further close monitoring and outpatient neurosurgical evaluation. The COVID-19 pandemic and insurance gaps led the patient to spend two years off his medicines and he was unable to be seen by his medical team. Patient was seen by our system after recurrent hospitalizations for heart failure at our sister hospital, AICD was unable to be placed due to the patient's anatomy, he was placed on wearable cardiac defibrillator and required milrinone infusion for progression to end-stage heart failure with cardiac cachexia. At our institution, the patient was evaluated for Orthotopic Heart Transplant (OHT) but due to active GH secreting macroadenoma there was concern for OHT failure without TSS. Decision was made to utilize LVAD as Bridge-to-Transplant for OHT so the patient could be stabilized and safely undergo TSS. The patient tolerated surgeries well and is currently on the active transplant list. Discussion(s): Heart failure is an uncommon presentation of severe acromegaly requiring multidisciplinary management. We describe a case of a patient who initially presented with heart failure too unstable for surgery. Due to the COVID-19 pandemic the patient's disease progressed resulting in end-stage heart failure requiring LVAD placement for further treatment. We would like to draw attention to the use of LVAD placement in acromegalic patients who develop severe cardiovascular disease who are not candidates for OHT.Copyright © 2023

Mitral valve chordal rupture against the background of cardiac SARS-CoV-2 infection. Cases series.

In an ever-changing information flow on coronavirus disease 2019 by the fact that the infection symptoms were mild, followed by signs (COVID-19) pandemic, we describe a case series of mitral valve chordal of probable endomyocarditis, unrecognized in time, and acute mitral rupture (MVCR) in non-comorbid middle-aged men that occurred over valve regurgitation developed against the background of physical a period of 3 to 5 weeks after Severe Acute Respiratory Syndrome provocation (exercise and cough). Two patients had previously been CoronaVirus 2 (SARS-CoV-2) infection. With significant advances diagnosed with mitral valve prolapse (myxomatous degeneration in the prevention of acute rheumatic fever, the treatment of bacterial and connective tissue disease). Two patients were successfully endocarditis and acute coronary syndrome, acute mitral regurgitation operated on in different clinics. The described cases emphasize that has become a relatively rare diagnosis. During the pandemic, there has the consequences of inflammation persistence may be more severe been a surge in the incidence of spontaneous MVCR, and new data on than the primary viral damage, which determines the importance of a the problem are accumulating. The presented case series are united comprehensive examination and long-term follow-up. To date, the differential diagnosis of patients with sudden onset of dyspnea and chest pain associated with an infectious process should include MVCR.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.

Outside The Box But All Squeezed In: A 23- year-old Man With Progressive Dyspnea After Overseas Travel

Case Presentation: A 23-year-old previously healthy man presented with progressive dyspnea. Physical examination revealed jugular venous distension and lower extremity edema. Laboratory testing demonstrated elevated B-type natriuretic peptide (193 pg/mL) and normal high sensitivity troponin. Echocardiogram revealed small pericardial effusion, respiratory variation in diastolic flow across the mitral valve, diastolic septal bounce, and annulus reversus (Figure). The differential diagnosis for constrictive pericarditis was broadly considered in the context of a recent febrile illness and frequent travel to Hawaii and Vietnam;we included infectious, autoimmune, and malignant etiologies. Cardiac magnetic resonance imaging revealed thickening and diffuse enhancement in the pericardium as well as ventricular interdependence. Chest CT identified hilar and anterior mediastinal lymphadenopathy. Laboratory testing was positive for QuantiFERON gold and negative for COVID-19, HIV, and ANA. Transbronchial biopsy demonstrated non-necrotizing granulomas with negative acid-fast bacilli smear, culture, and polymerase chain reaction for mycobacterial DNA. Reexamination identified a red-brown plaque on the patient's thigh;biopsy showed granulomatous inflammation and rod-shaped organism with positive FITE staining. A presumed unifying diagnosis was made of extrapulmonary tuberculosis (TB) complicated by constrictive pericarditis. Discussion(s): Despite being a primarily pulmonary disease, systemic involvement can occur with TB with the heart being one of the most common extrapulmonary sites. This case highlights 1) the utility of extra-cardiac diagnostic testing (e.g., dermatologic biopsy) in the diagnosis of constrictive pericarditis, and 2) the diagnostic challenge associated with extrapulmonary TB, particularly paucibacillary disease that requires a detailed social history with "out-of-the-box" thinking.

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).

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.

The use of handheld ultrasound device in cardiac examination of patients with history of COVID-19

Background: Clinical usefulness of Handheld Ultrasound Device [HUD] was previously confirmed in numerous clinical scenarios. During the previous two years Covid-19 patients become a focal point of healthcare worldwide. The assessment of long term consequences of this infection is bound to overload already burdened healthcare system. Purpose(s): To assess clinical usefulness of HUD as an adjunct to physical cardiac examination of patients with history of COVID-19. Method(s): Study population consisted of randomly selected patients with no symptoms of cardiovascular pathology, who had been hospitalized due to COVID-19 one year prior to examination. Physical examination and clinical assessment was augmented with short examination with the use of HUD, which included: Visual evaluation of the global and regional LV function, measurement of RV size, screening for the significant valve defects and the presence of pericardial effusion. Subsequently full echocardiographic examination with the use of high-end workstation was performed, which results were treated as reference. Result(s): 54 patients (35 men, mean age 63+/-13 years) were enrolled into the study. In clinical examination no significant cardiovascular abnormalities were discovered. In 30 [56%] of patients cardiac abnormalities in HUD examination were detected. In 18 patients [33%] LV function assessment was not performed, due to insufficient quality of registered view. In the remaining group significant impairment of LV ejection fraction (<50%) was detected in HUD examination in 3 [6%] patients (2 confirmed in full examination, positive predictive value [PPV] 57%, negative predictive value [NPV] 97%, AUC 0,82+/-0,17, P 0,057). WMA were diagnosed in 6 [11%] patients (4 confirmed in full examination, PPV 84% NPV 78%, AUC 0,69+/-0,17, P 0,02). RV enlargement was identified in 21 [39%] patients (PPV 57%, NPV 97%, AUC 0,85+/-0,05, P<0,0001), mild pericardial effusion in 3 [6%] patient (1 confirmed in full echocardiographic examination;2 false positive, no false negative), at least moderate mitral/tricuspid/aortic valve insufficiency in 7 [13%] patients (3 confirmed, 4 false positive cases, no false negative). A total mean time of the heart and lungs HUD examination was 2,1+/-0,6 minute. Conclusion(s): Cardiac abnormalities exposed in brief assessment with the use HUD are a relatively common finding in asymptomatic patients previously hospitalized due to COVID infection in a 1-year follow-up, despite normal physical examination. Normal HUD examination excludes the presence of significant cardiac abnormalities with high probability. However one should keep in mind a relatively high percentage of false positive results, which may lead to an exceeding number of patients referred for a full echocardiographic examination.

Structural Valve Dysfunction As An Atypical Presentation Of Cardiac Sarcoidosis

Introduction: Cardiac sarcoidosis (CS) classically manifests as a restrictive cardiomyopathy or conduction abnormalities, though the full scope of phenotypes may be underrecognized. We present an atypical case of mitral regurgitation (MR) and aortic regurgitation (AR) attributed to CS. Case Presentation: A 33-year-old woman with a history of hypertension, tobacco use, and COVID-19 infection two months prior presented with worsening dyspnea on exertion, orthopnea and lower extremity edema. Initial work up revealed elevated pro-BNP and troponin, and a CXR with pulmonary edema. A prior CTA showed mediastinal and hilar lymphadenopathy. Echocardiogram was notable for mildly dilated LV, severe hypokinesis of the basal inferior myocardium, LVEF 50-55%, moderate MR and moderate AR. cMR revealed multiple foci of predominantly mid-wall late gadolinium enhancement (LGE) in the LV, including a focus adjacent to the posteromedial papillary muscle (Fig. 1). Cardiac PET showed extensive patchy, focal hypermetabolic activity in the LV inferobasal, anterobasal and anterolateral walls. With high suspicion for CS, the patient opted for treatment with steroids and follow-up PET over extracardiac lymph node biopsy due to procedural risk. Discussion(s): Isolated CS is underdiagnosed and can present with a wide range of symptoms. Detection is limited by current diagnostic criteria, namely difficulty ascertaining affected tissue, which may limit recognition of the full range of presentations. Diagnosis and treatment vary widely among institutions but there is consensus on starting immunosuppression and pursuing follow-up cardiac PET for suppression of inflammatory activity in cases of high clinical suspicion. Our patient plans to undergo repeat PET and have ongoing discussion about lymph node biopsy. COVID-19 myocarditis remains on our differential, however given the patchy nature of LGE on cMR which correlated with the FDG uptake on PET, CS is considered the most probable diagnosis. Conclusion(s): CS should be considered in the differential diagnosis for young patients with structural valve abnormalities, even in the absence of arrhythmias or cardiomyopathy. High clinical suspicion may justify early immunosuppressive treatment to prevent irreversible myocardial injury and/or fatal arrhythmias. Whether this treatment will result in resolution of the structural defects remains to be seen and further investigated.Copyright © 2022

An unexpected overlap syndrome of mitral valve prolapse with COVID-19 related myocarditis: case report from two patients.

The authors reported two patients with a history of asymptomatic mild mitral valve prolapse, a male in his late 40s (Case 1, vaccinated) and a female in her late 20s (Case 2, unvaccinated), who developed worsening (severe) mitral prolapse and New York Heart Association symptoms class III-IV after exposure to coronavirus disease 2019 with evidence of myocarditis on MRI. Both patients received similar 6-month of heart failure therapy; however, the outcomes did not affect the severity of their symptoms or mitral regurgitation. Subsequently, both patients underwent mitral valve surgery.

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

Streptococcus Anginosus Causing Infective Endocarditis - a Rare Case of Multiple Splenic Infarctions

Background Information on infective endocarditis (IE) caused by the Streptococcus anginosus (S. anginosus) group is scarce. We present a case of IE with multiple splenic septic infarcts that was further complicated by renal involvement and osteomyelitis, caused by S. anginosus in a patient with diabetes. Case 58-year-old male with diabetes presented with fever and bilateral flank pain. His CT showed splenomegaly with multiple splenic infarctions and symmetric bilateral perinephric stranding indicative of nephritis. His Labs showed leukocytosis and two blood culture sets grew S.anginosus. Transesophageal echocardiogram confirmed vegetations on aortic valve (1.3 x 1.0 cm)(Image A, red arrow) and mitral valve (1.4 x 1.0 cm)(Image B, blue arrow). Lumbar spine MRI showed L2-3 vertebral osteomyelitis. [Formula presented] Decision-making Due to patient's normal oxygen saturation and clear lung auscultation and imaging, COVID-19 was ruled out. The etiology of his fever was diagnosed as S. anginosus IE, as evidenced by his vegetations and positive cultures. The patient started on IV antibiotics and IV fluids and was transferred to another facility to receive aortic and mitral bioprostheses. Conclusion This, to the best of our knowledge, is the first documented case of S. anginosus with splenic and renal involvement. The presence of multiple splenic infarcts in immunocompromised patients, in this case in someone with diabetes, should raise suspicion for the presence of vegetations and the diagnosis of S. anginosus IE.Copyright © 2023 American College of Cardiology Foundation

Complete Heart Block: A Case Report and Review of a Rare Manifestation of COVID-19

Covid19 is still one of the major public health problems of all countries nowadays. The most common cardiac manifestations reported till now are acute coronary syndrome, myocarditis, and arrhythmia. The prevalence of COVID-19 induced arrhythmias is different in recent reports and varies from benign sinus tachycardia to more ominous cases of severe bradycardia or even malignant ventricular arrhythmias. Here in, we describe a case of complete heart block in severe covid-19 pneumonia and review all recent relevant case reports published to date in order to understand the probable mechanisms and contributing factors of this rare complication of the disease.Copyright © 2022, Isfahan University of Medical Sciences(IUMS). All rights reserved.

Multisystem Inflammatory Syndrome in Children (MIS-C) Associated With Covid-19 - Single-Center Experience

OBJECTIVES: To describe the clinical presentation, phenotype and outcome of multisystem inflammatory syndrome in children (MIS-C) associated with coronavirus disease 2019 (Covid-19) from a tertiary care center in southern India. METHOD(S): 257 children fulfilling the inclusion criteria of MIS-C were prospectively enrolled from June, 2020 to March, 2022. RESULT(S): Median (range) age at presentation was 6 year (35 day to 12 years). Presenting features were fever (98%), vomiting (75.8%), red eyes (63%), rashes (49%), pain abdomen (49%), shock (45.9%), lymphopenia (73%, thrombocytopenia (58.3%) and anemia (45%). 103 (39.7%) children required intensive care admission. Shock phenotype, Kawasaki-like phenotype and no specific phenotype were diagnosed in 45.9%, 44.4%, and 36.6% children, respectively. Left ventricular dysfunction (30.3%), acute kidney injury (13%), acute liver failure (17.4%), and hemophagolymphohistiocytosis (HLH) (13.6%) were the major system involvement in MIS-C. Mitral regurgitation (P=0.029), hyperechogenic coronaries (P=0.006), Left ventricular dysfunction (P=0.001) and low ejection fraction (P=0.007) were significantly associated with shock. Overall mortality was 11.7%. CONCLUSION(S): Kawasaki-like and shock-like presentation were common in MIS-C. Coronary abnormalities were seen in 118 (45.9%) children. Children with acute kidney injury, HLH, need for mechanical ventilation, and echocardiogram evidence of mitral regurgitation in MIS-C have a poor outcome.

A Controversy: Warfarin Failure in Covid-19 with Supratherapeutic Inr

Background COVID-19 has been previously associated with thromboembolism. We present a unique case of a patient who was compliant with warfarin and yet developed breakthrough Deep Venous Thrombosis after recently being diagnosed with COVID-19. Case A 49-year-old female with past medical history of rheumatic fever complicated with mitral stenosis and treated with mechanical mitral valve replacement in 2003, presented with right-sided leg swelling, warmth, and pain for the past 1 week. She tested positive for COVID-19 almost 2 weeks ago but was not hospitalized or treated due to minimal symptoms. She had been on warfarin for the last 19 years due to underlying mechanical valve with an INR (international normalized ratio) goal of 2.5-3.5. On examination, the right calf was swollen and tender to palpation. Homan sign was positive. INR was elevated to 9.88 (a month ago it was within the therapeutic range of 2.5-3.5). The rest of the lab work up including fibrinogen levels, PT, aPTT, CBC, and CMP was unremarkable. A lower extremity venous duplex was performed that came back remarkable for acute right popliteal DVT. Decision-making Warfarin was held considering elevated risk of bleeding. INR was repeated daily and once it was below 2.5, therapeutic dose of enoxaparin 1mg/kg twice daily was started for 3 months. Due to limited anticoagulation options, a shared decision was made to place the patient back on warfarin, since she was out of the window of COVID-19 infection. She was not a candidate for DOAC's considering her mechanical valvular heart disease history and patient did not want to consider invasive interventions as well. Conclusion Our case study is the first ever reporting warfarin failure with supratherapeutic INR due to COVID-19 infection. It also raises concerns if warfarin is safe to use in COVID-19 patients, which might need further research studies to have clear answers. In patients with mechanical heart valves and supratherapeutic INR who present with concerns of warfarin failure, treatment options are limited. Recommended management is holding warfarin to achieve therapeutic INR levels, switch to enoxaparin temporarily, and eventually placement of IVC filter.Copyright © 2023 American College of Cardiology Foundation

A Rare Case of Heart Failure in Third Trimester Pregnancy - Diagnostic and Therapeutic Dilemma

Background Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is an extremely rare disorder. Case A 20-year-old, 36-week pregnant female (G1P0) presented with acute shortness of breath, sharp chest pain and fever. She was COVID-19 positive and required BiPAP. Echocardiogram showed 40% EF, dilated LV with global hypokinesis and moderate mitral regurgitation (MR). She was hypotensive and on oxygen despite diuresis, emergent cesarean and COVID-19 treatment. Left heart catheterization showed anomalous takeoff of the left main coronary artery (LCA) from the dilated pulmonary artery (PA) with coronary steal (Figure 1). She had ALCAPA repair with LIMA to LAD bypass grafting. Decision-making Differential diagnoses included peripartum cardiomyopathy, Covid-myocarditis, pulmonary embolism, and spontaneous coronary artery dissection. LHC was performed only when symptoms failed to improve and troponin kept rising. ALCAPA has two major clinical subtypes - Infantile type and adult type. Adult type presents as dyspnea, chest pain, reduced exercise ability, and sudden cardiac death. Despite having good RCA to LCA collaterals, adult patients can still have ongoing ischemia of the LV myocardium, causing ischemic MR, malignant ventricular dysrhythmias. Diagnosis was delayed due to pregnancy and COVID-19 infection. Conclusion ALCAPA is a lethal coronary disorder. Elevated troponin and dilated cardiomyopathy with acute MR should raise suspicion of ALCAPA in young adults. [Formula presented]Copyright © 2023 American College of Cardiology Foundation