Changes in Kawasaki disease incidence and phenotype during the COVID-19 pandemic

INTRODUCTION. The aetiology of Kawasaki disease (KD) remains unknown. Changes in infectious exposure during the COVID-19 pandemic owing to infection prevention measures may have affected the incidence of KD, supporting the pathogenic role of an infectious trigger. The purpose of this study was to evaluate the incidence, phenotype and outcome of KD before and during the COVID-19 pandemic in Denmark. METHODS. This was a retrospective cohort study based on patients diagnosed with KD at a Danish paediatric tertiary referral centre from 1 January 2008 to 1 September 2021. RESULTS. A total of 74 patients met the KD criteria of whom ten were observed during the COVID-19 pandemic in Denmark. Alof these patients were negative for SARS-CoV-2 DNA and antibodies. A high KD incidence was observed during the first six months of the pandemic, but no patients were diagnosed during the following 12 months. Clinical KD criteria were equally met in both groups. The fraction of intravenous immunoglobulin (IVIG) non-responders was higher in the pandemic group (60%) than in the in the pre-pandemic group (28.3%), although the rate of timely administered IVIG treatment was the same in both groups (>= 80%). Coronary artery dilation was observed in 21.9% in the pre-pandemic group compared with 0% in KD patients diagnosed during the pandemic. CONCLUSION. Changes in KD incidence and phenotype were seen during the COVID-19 pandemic. Patients diagnosed with KD during the pandemic had complete KD, higher liver transaminases and significant IVIG resistance but no coronary artery involvement.Copyright © 2023, Almindelige Danske Laegeforening. All rights reserved.

ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION in COVID-19

Introduction: The Severe Acute Respiratory Syndrome Coronavirus-2 have been associated with cardiovascular adverse events including acute myocardial infarction due to a prothrombotic and hypercoagulable status, and endothelial dysfunction. Case report: We report the case of a 62-year-old women, admitted to the hospital via the emergency room for acute chest pain and dyspnea. A nasopharyngeal swab was positive for COVID19 real-time reverse transcriptase-polymerase chain reaction 11 day ago. On admission, she was hypotensive with systolic blood pressure measering 87 mmHg and tachycardic with 117 beats/min, oxygen saturation (SO2) was 94%. An 18-lead ECG revealed an infero-postero-lateral ST-elevation myocardial infarction with right ventricular involvement and a seconddegree- Mobitz Type 1 atrioventricular block. The coronary angiography from the right femoral artery showed acute thrombotic occlusion of the first diagonal branch with TIMI 0 flow and acute thrombotic occlusion of proximal right coronary artery with TIMI 0 flow. The most likely diagnosis was myocardial infarction secondary to a non-atherosclerotic coronary occlusion. The angioplasy was performed with dilatations with a semi compliant balloon, bailout implant of BMS, manual thrombus aspiration and intracoronary injection of tirofiban in the right coronary artery. The myocardial revascularization was ineffective. The patient developed significant severe hemodynamic instability and cardiac arrest for pulseless electric activity after 24 hours. Conclusion(s): The COVID-19 outbreak implies deep changes in the clinical profile and therapeutic management of STEMI patients who underwent PCI. At present, the natural history of coronary embolism is not well understood;however, the cardiac mortality rate are hight. This suggests these patients require further study to identify the natural history of the condition and to optimize management to improve outcome.

An Eventful Rotational Atherectomy Over the Left Main Stem and Left Anterior Descending Artery in an Elderly Male

Clinical Information Patient Initials or Identifier Number: SHS Relevant Clinical History and Physical Exam: Mr. SHS was admitted in August 2022 for acute decompensated heart failure secondary to NSTEMI, complicated with ventricular tachycardia (VT). CPR was performed for6 minutes on the day of admission and was subsequently transferred to the Cardiac Care Unit. His hospital stay was complicated with Covid-19 infection(category 2b) which he recovered well from. During admission, he developed recurrent episodes of angina. Physical examination was otherwise unremarkable. His ejection fraction was 45%. Relevant Catheterization Findings: Cardiac catheterization was performed, which revealed significant calcification of left and right coronary arteries. There was a left main stem bifurcation lesion (Medina 0,1,1) with subtotal occlusion over ostial the LAD, receiving collaterals from RCA and 90% stenosis over ostial LCx. RCA was dominant, heavily calcified with no significant stenosis. He was counselled for CABG (Syntex score26) but refused. As he was symptomatic, he was planned for PCI to the left coronary system. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: The left main was engaged with a 7F EBU 3.5guiding catheter via transradial approach. Sion Blue wired into LAD and LCx. IVUS catheter couldn't cross the LAD and LCx lesions, hence we decided for up front rotational atherectomy. Sion blue was exchanged to Rotawire with the assistance of Finecross microcatheter. A 1.5mm burr was used at 180000 rpm. After the first run of rotablation, patient developed chest pain and severe hypotension (BP ranging 50/30). 4 inotropes/vasopressors were commenced. The shock was refractory hence an intraarterial balloon pump was inserted. Symptoms and blood pressure improved. Another 2 runs of atherectomy done (patient developed hypotension after each run). IVUS examination then showed calcification of proximal to mid LAD with an IVUS Calcium score of 3. LAD was further predilated with Scoreflex balloon 3.0/20mm at 8-22ATM. LCx was predilated with Scoreflex balloon 2.0/15mm at 12-14ATM. DCB Sequent Please NEO2.0/30mm was deployed at 7ATM at ostial to proximal LCx. Proximal to mid LAD was stented with Promus ELITE 2.5/32mm at 11ATM, which was then post dilated with stent balloon at 11ATM. Ostial LM to proximal LAD (overlap) was stented with Promus ELITE 4.0/28mm at 11ATM. LMS POT was then done with NC Balloon 4.0/15mm at 24ATM. LCx was rewired and kissing balloon technique with NC balloon 4.0/15mm at 14ATM (LAD) and NC balloon 2.0/10mm at 12ATM (LCx) was done, followed by a final POT with NC balloon 4.0/15mm at 14ATM. Final IVUS showed good MSA. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): This patient developed hemodynamic instability with each rotational atherectomy run, hence we decided not to perform rotablation to the circumflex artery. His hemodynamic condition improved with the use of intra aortic balloon pump. IABP use can reduce procedural event rate and potentially reduce long term mortality in appropriately selected patients who are at high risk of adverse events. He was followed up a month following the procedure and remained asymptomatic. For complex, calcified coronary lesions involving the left main stem, coronary artery bypass graft surgery is an alternative option.Copyright © 2023

It's not the shunt: an atypical cause of fever in an infant with hydrocephalus

Case Report:We present a 5-year-old male with two days of fever, cough, vomiting, and loose stools. His history is significant for premature birth (35 weeks gestational age) and shunted hydrocephalus. A ventriculoperitoneal (VP) shunt was placed 6 days prior to presentation. Parental report included episodes of post-tussive, nonbloody, non-bilious emesis, poor oral intake, tachypnea, and increased work of breathing. Physical examination demonstrated a dehydrated infant with sunken fontanelles. He had no notable rash, no lymphadenopathy, and clear conjunctiva. His VP shunt site appeared normal without swelling or erythema. Initial evaluation showed elevated inflammatory markers -ESR 51 and CRP 12.32 mg/dL. A viral respiratory PCR panel returned positive for coronavirus (not SARS-CoV-2). A head CT scan and shunt radiography series showed no abnormalities with his shunt. The following morning, Radiology reported an incidental retropharyngeal fluid collection on a re-read of the patient's initial CT scan. A neck CT was obtained and demonstrated a fluid pocket with secondary mass effect in addition to bilateral cervical lymphadenopathy. Screening blood cultures were negative. The patient remained febrile (tmax 103.6F) and developed a transaminitis (ALT 264.9, AST 654), elevated fibrinogen 476, elevated INR 1.4, and low albumin 2.1. Abdominal ultrasound showed a normal the liver and biliary tract. His transaminitis resolved without treatment. The next day, the patient developed lip erythema and conjunctival injection. An echocardiogram showed a dilated right coronary artery (z-score of 3.59) and his inflammatory markers (ESR 26, CRP 9.63) remained elevated. Treatment was initiated with IVIG and moderate-dose aspirin. The patient defervesced, and he remained afebrile for over 48 hours prior to discharge. A repeat echocardiogram 2 days later showed a slight reduction in coronary artery dilatation (z-score 3.39). Hewas discharged on lowdose aspirin, and followed up with cardiology as an outpatient. Kawasaki's Disease (KD) is most common in children from ages 1 to 4 years and is classically characterized by persistent fever with a constellation of symptoms including limbal sparing conjunctivitis, cervical lymphadenopathy, polymorphous rash, strawberry tongue, oral changes, and extremity changes. Our patient presented at a younger age with a concurrent diagnosis of coronavirus upper respiratory tract infection. His atypical hospital course and incidental finding of retropharyngeal edema and transaminitis increased the clinical suspicion for KD. His symptoms rapidly improved after administration of IVIG. Younger patients are at an increased risk for severe complications of KD including coronary aneurysm. KD has been shown in the literature to have an association with coronavirus infection as well as presentation with retropharyngeal edema. Clinicians should consider KD in their differential even if patients do not meet all criteria for diagnosis on initial presentation. Copyright © 2023 Southern Society for Clinical Investigation.

COVID-19-induced myocarditis in patient with anomalous origin of the left circumflex artery from the right coronary artery: a case report.

The prevalence of coronary artery anomalies has been increasing due to the increasing usage of coronary angiography. There is a paucity of literature concerning management of viral-induced myocarditis in patients with anomalous coronary artery. We present a very unusual case of a 44-year-old man with anomalous origin of the left circumflex artery from the proximal ostium of the right coronary artery who was admitted for COVID-19-induced myocarditis. He presented with signs of heart failure and coronary angiography revealed the left circumflex artery with a separate ostium originating from the proximal right coronary artery. He was treated medically with Bisoprolol, Perindopril Arginine, Rivaroxaban, and Furosemide. His condition improved rapidly and he resumed regular life within 1 month. Coexistence of cardiac disease such as viral-induced myocarditis with an underlying anomalous origin of the coronary artery is challenging to spot and can lead to worse outcomes in case of misdiagnosis and inaccurate management.

A prevalência de anomalias da artéria coronária vem aumentando devido ao uso crescente da angiografia coronariana. Há uma escassez de literatura sobre o manejo da miocardite induzida por vírus no contexto de artéria coronária anômala. Apresentamos um caso incomum de um homem de 44 anos com origem anômala da artéria circunflexa esquerda do óstio proximal da artéria coronária direita admitido por miocardite induzida por COVID-19. O paciente apresentava sinais de insuficiência cardíaca, e a cineangiocoronariografia revelou artéria circunflexa esquerda de óstio separado originando-se da artéria coronária direita proximal. Ele foi tratado clinicamente com bisoprolol, perindopril arginina, rivaroxabana e furosemida. Sua condição melhorou rapidamente, e o paciente recuperou uma vida normal em 1 mês. A coexistência de doença cardíaca, como miocardite induzida por vírus com uma origem anômala subjacente da artéria coronária, é difícil de detectar e pode levar a resultados piores em caso de diagnóstico incorreto e manejo impreciso.

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.

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

Severe Agitation as an Unusual Presentation of Multisystem Inflammatory Syndrome in Children.

Multisystem inflammatory syndrome in children (MIS-C) is a rare hyperinflammatory syndrome that mainly affects children after a primary infection with coronavirus disease 2019 (COVID-19), with the possibility of severe and lethal complications. We report a case of a unique presentation of MIS-C in a four-year-old boy who presented with severe agitation, muscle spasms, and two days of fever. Other findings consistent with MIS-C were revealed later, and he was managed with intravenous immunoglobulin (IVIG) and steroids. He showed a dramatic response of improvement and was discharged. This case report aimed to raise health professionals' awareness about the atypical presentations of MIS-C and the importance of early diagnosis, treatment, and follow-up MIS-C cases to avoid complications affecting children's lives.

Coronary Artery Dilation in Pediatric Patients with Asymptomatic or Mild COVID-19 Infection

Background: COVID-19 infection and Multisystem Inflammatory Syndrome in Children (MIS-C) in hospitalized pediatric patients have been associated with cardiac manifestations . Generally, children have asymptomatic or mild COVID-19 infection and MISC is rare. We examined the cardiac implications of asymptomatic or mild COVID-19 infection in non-hospitalized children to better define this outcome. Methods: We queried the electronic medical record for patients ≤18 years-old referred for outpatient pediatric cardiology evaluation following COVID-19 infection from 5/1/2020 - 4/30/2021. We excluded patients without a confirmatory COVID test (PCR or serology), who had been hospitalized for any condition related to COVID-19 (including MIS-C), or with history of cardiac disease that could affect coronary artery dimension. We recorded electrocardiogram (EKG) and echocardiogram (ECHO) findings, and laboratory studies performed during a preceding emergency department or most recent cardiology clinic visit. Results: Of 277 records reviewed, 134 met inclusion criteria (Figure 1);mean age 9.6 +/- 5.4 years, 53% male. 131 patients had a normal or minor variant on EKG and ECHO (Table 1). Three patients had coronary artery (CA) abnormalities on ECHO: 1) 7-year-old male with history of mild COVID-19 infection;borderline left main CA dilation (Z-score +2.1 on largest measurement). Plan for close follow-up and repeat ECHO. 2) 16-year-old male with positive COVID serology;dilated right CA (Z-score +2.3);started on aspirin. Plan for close follow-up, repeat ECHO, and possible CT angiography. 3) 8-yearold male with history of mild COVID-19 infection;dilated left main CA (Z-score +2.6);started on aspirin;CT angiography confirmed enlarged left main CA. Plan for close follow-up and repeat ECHO. Prior to COVID-19 this patient had an ECHO with normal CA dimensions (Z-score -0.4). Conclusion: While cardiac disease in children with COVID-19 infection is uncommon, we report three pediatric patients who may have developed CA dilation following confirmed mild or asymptomatic COVID-19 infection. Current return to play guidelines recommend cardiology evaluation after moderate to severe COVID-19 infection, as studies have reported myocarditis in young healthy athletes. Our study adds to the body of literature on COVIDrelated cardiac disease and may have important implications for post-COVID surveillance in young healthy children following minimal illness. Data collection is ongoing.

High prevalence of complex coronary artery lesions in sport-related myocardial infarction. Contemporary data from the RICO survey

Background: Underlying mechanisms for sport-related acute myocardial infarction (SR-AMI) are only poorly understood. Moreover, their coronary artery disease (CAD) characteristics and lesion complexity are poorly described. Purpose: To characterize coronary angiographic feature of patients with SR-AMI Methods: From the RICO database, a large regional acute MI survey, all consecutive patients hospitalized in our University Hospital from 2010 to 2021 who underwent coronary angiography for SR-MI were retrospectively analysed. SR-MI was defined as MI occurring during sport activity or within the first hour of recovery. Results: Among the 174 patients included, most were male (n=157(91%)). Median (IQR) age was 59 y (48-66), and had ST segment elevation MI (STEMI) (n= 112 (64%)). The SR-MI often occurred while cycling (41%), jogging (23%), hiking (9%) or playing soccer (9%). Patients commonly experienced pre-hospital (PH) sudden cardiac arrest (SCA) (17%). Atherothrombotic risk factors were dyslipidaemia (32%), current smoking (31%) or hypertension (28%). A history of CAD was documented in 31 (18%) patients. Most (n=156(91%)) had significant lesions, of whom 140 (81%) were considered as culprit. Culprit lesions were located on left anterior descending (39%), circumflex (14%) and right coronary artery (33%). Median (IQR) Syntax score was 10.5 (6-15). The vast majority of patients (n=152 (87%)) had at least one complex lesion;114 of them had several characteristics of complex lesion. Lesions were eccentric in 68 (39%) patients;an intraluminal thrombus was documented in 85 patients (49%), in 55% of STEMI and 37% of non-STEMI (p =0.027). However, 18 subjects (10%) had optically normal coronary angiogram or non-significant lesions, suggesting alternative mechanism such as type 2 MI. Treatment of the lesions was mainly achieved by PCI and/or stenting (n=132(77%)) or coronary artery bypass grafting (n=11(6%)). In-hospital death occurred in 11 patients (6%), of whom 10 experienced a PH-SCA and one was admitted with a cardiogenic shock during the Covid-19 pandemics lockdown. Among the 5 patients treated with extracorporeal membrane oxygenator, only one survived. Conclusion: In our large retrospective study, SR-MI was commonly associated with complex coronary lesions, often characterized by intraluminal thrombus. Our findings suggest that the mechanisms of these events could be mainly related to type 1 MI patterns Moreover, PH-SCA was frequent, thus justifying mass-education to basic life support and deployment of automated external defibrillators, especially in the sport settings.

Difficulties with optical coherence tomography in assessment of an in-stent restenosis lesion

In-stent restenosis (ISR) is a critical drawback of coronary stents, although initially described as benign, guidelines both support the use of intravascular imaging in the diagnosis and treatment of stent failure (Class IIa);however, our case highlights the limitation of optical coherence tomography in the assessment of the ISR (stent failure), it also highlights the association of self-limited severe acute respiratory syndrome coronavirus-2 illness and an acute coronary syndrome ISR presentation.

CARDIAC RECOVERY IN CHILDREN ADMITTED TO THE PEDIATRIC INTENSIVE CARE UNIT WITH MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN

Purpose of Study Objective: To evaluate the short and midterm cardiac outcomes in children hospitalized with MIS-C in two pediatric intensive care units (PICU) in New Jersey. Methods Used Design/Methods: We conducted a retrospective review of children admitted to the PICU with a diagnosis of MIS-C between April 2020 through March 2021. Cardiac biomarkers and echocardiograms performed during hospitalization were analyzed. Follow-up echocardiograms were performed two to eight weeks post-discharge, with interval follow-up of up to one year. Shortening fraction (SF) was used to assess left ventricular systolic function using standard M-mode (SF < 28% considered abnormal). Summary of Results Results: Twenty-seven patients (18 male;median age 11 years) were included. The mean peak Troponin I in 25 patients was 2.10 +/- 5.0 ng/dL, and mean peak NTProBNP level in 26 patients was 1,606 +/- 1293 pg/dL. Most patients had normalization of cardiac biomarkers by time of discharge (table 1). Seven of the 23 patients who had an echocardiogram on admission had a SF less than 28%. Lowest SF and SF at the time of discharge were compared in 21 patients with a median improvement of 6% (p <0.001) (table 2). Nineteen patients had a follow-up echocardiogram two to ten weeks post discharge and 18 of those had normal left ventricular systolic function (p < 0.001). No patient had evidence of diastolic dysfunction at follow-up. Eight patients had midterm follow-up five to seven months post-discharge;one patient was followed for one-year post-discharge. Abnormalities that persist in these patients include low normal left ventricular systolic function. Three subjects had evidence of left coronary artery dilation (z score >2) during hospitalization and continued to have diffuse dilation at follow up, with one developing right coronary artery dilation. Conclusions Conclusion: In this cohort of patients, most children admitted to the PICU with MIS-C had abnormal cardiac biomarkers with normal to mildly decreased left ventricular systolic function that improved by time of discharge and continued to improve with midterm (5-7 months) follow-up. A very small subset of patients, however, continue to have cardiac complications including diffuse coronary artery dilation. (Table Presented).

Regression of coronary arteries dilatation 6 months after multisystem inflammatory syndrome in children (MIS-C)

Introduction: Multisystem inflammatory syndrome in children (MIS-C) is a rare complication of SARS-CoV-2 infection, with an incidence of about 1:100'000 children. According to published case series, between 10% and 40% of MIS-C develop coronary artery modifications, mainly hyperechogenicity, with a lower incidence of aneurysm. Evolution and outcome of coronary artery aneurysm post MIS-C is unknown. Methods: We report the case of a 10-year old male with medium left anterior descending coronary artery (LAD) aneurysm (diameter of 6.2 mm, z-score +7.9) and small right coronary artery (RCA) aneurysm (z-score +2.9) detected one week after his hospital admission for hypotensif shock in the context of MIS-C and positive serologies for SARS-CoV-2. He didn't meet diagnosis criteria for Kawasaki disease. He was treated with 2 g/kg immunoglobulin (administered after coronary artery dilatation was observed, as the recognition and definition of MIS-C was contemporary with our case), corticosteroids and anakinra. He rapidly normalized his initial mild LV dysfunction and cardiac enzymes elevation. Results: Since discharge, the patient was treated with antiplatelet therapy (100 mg aspirin daily) and carefully followed up in outpatient cardiology. On echocardiography, coronary artery dimensions progressively regressed, prompting a control computed tomography (CT) 6 months after MIS-C episode. CT confirmed LAD and RCA dimension near-normalization, compared to the fusiform dilatations 6 months ago : LAD maximal diameter of 3.7 mm (z-score +2.3), RAD maximal diameter of 4 mm (zscore +1.8). Moreover, no coronary stenosis was observed. Conclusions: Coronary artery aneurysm in the context of MIS-C probably represents a post-infectious vasculitis. This case illustrates a regression of coronary artery dilatation after a few months. Further research is needed to assess if this finding reflects a generalisable outcome and to study the effect of medical treatment on the evolution of coronary artery dilatation post MIS-C.

TCTAP C-005 Conundrum of a ‘Primary’ Angioplasty: Provisional Stenting of Left Main Stem / Left Anterior Descending During STEMI With Double Bifurcation

Clinical Information Patient Initials or Identifier Number: R Relevant Clinical History and Physical Exam: A 64-year-old lady with underlying dyslipidemia presented to our emergency department with typical chest pain. Immediate electrocardiogram was performed which showed sinus rhythm, ST elevation at lead 1, aVL and V1, hyperacute T wave at V2 till V3 with ST depression at leads II, III and aVF. Hence a diagnosis of acute anterolateral myocardial infarction, Killip 1 was given and urgent referral to cardiologist was made. Subsequently, she was subjected for primary angioplasty. Relevant Test Results Prior to Catheterization: Blood results showed sodium of 134 mmol/L, potassium of 3.5 mmol/L, urea of 3.2 mmol/L and creatinine of 67 mmol/L. Liver enzymes were within normal limits with aspartate transaminase of 38 U/L and alkaline phosphatase of 91 U/L. Creatinine kinase was 330 U/L but increased to 2861 U/L during subsequent day. In addition, COVID-19 RTK antigen was negative. Relevant Catheterization Findings: Coronary angiogram revealed mild disease at proximal right coronary artery and proximal left circumflex. Minimal disease was noted at distal left main stem, but severe disease was observed from proximal left anterior descending till mid left anterior descending. Heterogenous plague suggesting thrombus was seen at ostial first diagonal as well. [Formula presented] [Formula presented] Interventional Management Procedural Step: Right femoral assess was obtained with 7Fr sheath, and SL 3.5 7Fr guiding catheter was engaged to left coronary artery. Intracoronary heparin and tirofiban were given prior to wiring. First diagonal was wired with Sion Blue while left anterior descending was wired with Runthrough Floppy. Post-wiring both vessels, coronary flow remained TIMI 3 and hence we decided to proceed with IVUS. From IVUS, noted fibrous elastic plague with heavy thrombus burden. Intracoronary streptokinase was given and noted improvement of thrombus from IVUS. BMW wired to left circumflex. Lesion predilated with scoring balloon and associated with no reflow events, resolved post vasodilators. Left main stem was stented with Onyx 3.5 x 26 mm and deployed at 16 atm. Both side branches wires were rewired into same branches via Crusade microcatheter. LMS stent was post dilated with NC Euphora 4.5 mm at nominal pressure. Noted impingement of both ostium diagonal and circumflex branches. Balloon kissing inflation was performed for both LAD/Diagonal bifurcation and LMS/LAD/circumflex bifurcation. POT was performed post balloon kissing inflation with NC Euphora 3.5 mm and 4.5 mm for both LAD and LMS respectively. Next, IVUS was repeated for mid LAD stent length and Onyx 3.0 mm X 15 mm was deployed at nominal pressure. IVUS repeated and noted under-expansion of overlapped segments and post dilated with NC Euphora 3.0 mm at high pressure. [Formula presented] [Formula presented] [Formula presented] [Formula presented] Conclusions: Our clinical vignette demonstrated few learning points including utilization of IVUS during primary angioplasty. Understanding of plague characteristic ensures adequate stents expansion especially with fibro elastic plague. In addition, we also demonstrated several precautions in dealing with bifurcation lesions including usage of double lumen microcatheter for wiring the side branches. Even though we opted for provisional stenting, balloon kissing inflation played pivotal role in preserving flow into side branches.

TCTAP C-082 One Moment Percutaneous Treatment of Heavily Calcific Subocclusive Left Main Stenosis and Triple Coronary Artery Disease With Concomitant Severe Aortic Stenosis: Valvuloplasty for Impella Implantation and All Stenosis Treatment

Clinical Information Patient Initials or Identifier Number: CE 16/04/1941 Relevant Clinical History and Physical Exam: An 80 years of age lady without any previous disease were conducted to our emergency department due to dyspnoea lasting several hours. At arrival in our emergency department, the patient was still dyspnoeic. Her ECG demonstrated diffuse ischemic changes without certain site definite ischemia. Her chest X-ray showed thickening of the interlobular septa, peri-bronchial cuffing, thickening of the fissures, increased vascular marking, bilateral pleural effusions, cardiomegaly and aortic calcifications. [Formula presented] Relevant Test Results Prior to Catheterization: Her laboratory data revealed increase in myocardial necrosis markers as her TnI-HS was 3450 ng/ml and relatively normal values of other parameters. At echocardiography flash we found severe aortic valve calcification causing stenosis with peak gradient 48 mmHg, mean gradient 28 mmHg and diffuse segmental hypokinesis of left ventricle with global systolic function about 30%. The DAPT was started, and the patient was planned for coronary angiography within 24 hours of admission. [Formula presented] [Formula presented] Relevant Catheterization Findings: Coronary angiography performed through the right radial artery shoed ostial and mid RCA stenosis, severe calcific distal left main (Medina 1.1.1.), mid LAD and mid Lcx stenosis (Fig. 3). At the time of COVID any transfer to any surgical center was extremely difficult so after discussion with the patient and the family we fixed the RCA with one in the mid segment and one ostial DES. Then after aortic valvuloplasty (Valver 20 mm) for Impella 2,5 placement in the left ventricle was done. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: Through right radial artery access, the right coronary artery was fixed with stenting. Then aortic balloon valvuloplasty (Valve 20 mm). The Impella device was advanced and after crossing the dilated aortic valve the tip was placed in the left ventricle. Sequential predilatations of LM-LAD and LM-LCx with semi-compliant, non-compliant and scoring balloons were performed. For persisting of unacceptable for stenting result we continued the preparation of LM bifurcation with predilatation using intravascular lithotripsy (IVL) with Shockwave balloon on LM-LAD and LM-CX. Then we implanted one bifurcation dedicated stent Bioss Lim on the axis LM-LCx. After predilatation of mid LAD we placed one drug eluting stent from LM to LAD proximal through the Bioss stent (short culotte stenting). The procedure was ended with drug coated balloon on LAD mid and with drug coated balloon inflation on LCx mid. Then, Impella was removed, and vascular closure was achieved with Manta closing device. In the ICCU, the patient complained of intensive pain in the left lumbar and iliac region, nausea and severe hypotension (80/40 mmHg blood pressure). Contralateral injection demonstrated common femoral artery injury with large amount of blood passage in the pelvic cavity. A self-expandable covered stent 8 x 60 mm was introduced and placed at the site of artery rupture. The control angiography evidenced complete closure of the artery wall with no blood passage. [Formula presented] [Formula presented] [Formula presented] Conclusions: In time of pandemic restrictions, decision of treatment must be done using available in-hospital facilities. The presence of aortic valve stenosis and multi-vessel disease and low ejection fraction requires contemporary preparation of aortic valve for haemodynamic support during coronary angioplasty. Vessel preparation can be achieved with new devices as intravascular lithotripsy (IVL) to reduce the risk of complication. DCB are valid alternative to DES particularly in small vessels with long atherosclerotic disease. Vascular access site dramatic complications in the experienced hands and well-organized catheterization laboratory can be managed within the cath lab percutaneously.

CAUGHT IN THE ACT: MINOCA IN A PATIENT WITH SEVERE CORONARY VASOSPASM

Background: Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a complex and diagnostically challenging entity. Case: A 62-year-old female with recent COVID19 infection presented with chest pain. She was discharged just one week prior for NSTEMI, with mild non-obstructive CAD by left heart catheterization (LHC) and a normal transthoracic echocardiogram. This admission, Initial Troponin I peaked at 0.87 ng/mL and ECG without ischemic changes. Cardiac MRI (CMR) showed no myocarditis/pericarditis but moderate-severely hypokinetic apical cap, distal inferior and septal walls, with a small focus of subendocardial scar/infarction involving the distal septum (Fig.1A,B,C). LHC showed severe vasospasm in the right coronary artery and left anterior descending artery (Fig. 1D,E), which resolved after intracoronary nitroglycerin (Fig. 1F). With initiation of isosorbide mononitrate to manage coronary vasospasm, the patient’s symptoms improved. At 6-month follow-up, patient was doing well with no repeat hospitalizations. Decision-making: Even though initial workup did not identify a clear etiology, CMR was pivotal in prompting further evaluation that revealed severe coronary vasospasm. Given the transient nature of vasospasm, it is likely this had resolved prior to her initial LHC, but was caught on repeat imaging. Conclusion: CMR is a key diagnostic tool in preliminary investigation of MINOCA when a clear cause is not found, and can alter next steps in management. [Formula presented]

FIRST REPORTED CASE OF TAKOTSUBO CARDIOMYOPATHY INDUCED BY PERCUTANEOUS CORONARY INTERVENTION

Background: We report an unusual case of Takotsubo cardiomyopathy (TTC) caused by radial spasm during percutaneous coronary intervention (PCI), resulting in a fatal outcome. Case: A 70-year-old Caucasian female presented with an acute anterior myocardial infarction (MI) with anterior ST segment elevation. Coronary angiography showed critical proximal left anterior descending artery stenosis, and she underwent successful PCI via the right radial artery. Post-MI echocardiogram showed anterior wall hypokinesis with a left ventricular ejection fraction (LVEF) of 45%. The right coronary artery (RCA) had 70% stenosis in the mid-vessel and a staged outpatient intervention was planned. Decision-making: The staged procedure was delayed by seven months due to the COVID-19 pandemic. The same right radial access was selected but she developed significant radial spasm. Despite vasodilators, radial spasm persisted, so balloon-assisted tracking technique was used to advance guiding catheter. Fractional flow reserve of the RCA stenosis was positive at 0.76. PCI was then successfully performed using a 3x48 mm Xience stent. Thirty minutes later, she developed severe chest pain with widespread ST segment elevation. Repeat angiography via the right femoral artery showed patent coronary arteries. Echocardiography showed new apical ballooning pattern, typical of TTC with LVEF was 35%. She was discharged after 48 hours, but she re-presented a week later with cardiogenic shock. She had florid pulmonary oedema and an echo showed new torrential mitral regurgitation due anterior mitral leaflet chordal rupture. The apical ballooning that was observed a week earlier had resolved. An intra-aortic balloon pump was inserted, and the patient underwent emergency repair of the mitral valve. The procedure was technically successful, but the patient died on postoperative day one, due to multi-organ failure. Conclusion: We believe that TTC in our patient was caused by radial artery spasm. To our knowledge, this is the first case of TTC caused by radial spasm. Furthermore, chordal rupture secondary to TTC has been reported only once before.

Global vasospasm treated with simultaneous use of anti-hypertensive and vasopressor

Case Report A Rare Presentation of Multivessel Vasospastic Angina in the Setting of Septic Shock Background Prinzmetal or vasospastic angina is an unusual but important consideration when evaluating a patient with chest pain. Unlikely acute coronary syndromes (ACS) which primarily occur as a result of coronary artery occlusion, prinzmetal angina occurs angina occurs mainly as a result of coronary artery vasospasm. We present the unusual case of a patient who suffered cardiac arrest and was found to have >90% occlusion in multiple coronary arteries on a left heart catheterization (LHC) performed within 60 minutes. Case presentation Patient is a 70-year-old female who was initially being treated in the hospital for COVID-19. She spent a few days in the ICU due to requiring high flow nasal cannula but was transferred to the floor after she was weaned down to 3L/min via regular nasal cannula. On day of arrest, patient had increasing oxygen requirements and was on ventimask immediately prior to the code blue. Patient received 2 rounds of CPR and her initial rhythm was found to be ventricular fibrillation. Pt was defibrillated and ROSC was immediately achieved. EKG showed ST elevations in inferior leads. Patient was, however, alert and oriented x3 on initial evaluation by critical care team. She was not intubated after the arrest. She was transferred to the intensive care unit, given 300 mg intravenous amiodarone and therapeutic dose lovenox. On LHC, her left anterior descending artery (mid/ distal portion), distal diagonal vessel, left circumflex artery (mid portion), distal portion of the obtuse marginal and right coronary artery were found to be severely spasmodic. Patient had recurrence of angina after the catheterization which was transiently relieved with nitro. Patient had sustained relief of angina after starting nitro drip. Patient was also started on amiodarone drip upon transfer back to the ICU. Discussion The obvious side-effect of our therapeutic treatment was hypotension that was initially responsive to intravenous fluids. Patient, however, became hypoxic a few hours later and needed to be diuresed to return to baseline oxygen requirement. Patient was then started on norepinephrine drip with goal to maintain mean arterial pressure above 65. After patient was loaded with amiodarone, nitro drip was discontinued. She was then transitioned to oral amiodarone. She was started on isosorbide dinitrate prior discontinuing nitro drip. Patient's blood pressure stabilized as her per oral intake improved and norepinephrine drip soon thereafter. Novel presentations require novel treatment and creative thinking lead to the decision to continue nitro drip to keep her stable, even if it meant the simultaneous use of an anti-hypertensive and a pressor. It is possible that COVID-19 served as a trigger for such a global vasospasm event. Patient was restarted on her home medication of long-acting nitrates which were held on admission due to hypotension.

Vascular Thromboembolism is a Grave Complication of COVID-19

There is ample evidence that the coronavirus can cause fatal blood clots. Angiotensin-converting enzyme 2 (ACE2) receptors act as a gateway for the coronavirus to enter the body and facilitate infection. ACE2 receptors are scientifically linked to disease severity in smokers because nicotine is thought to affect ACE2 expression in different ways. Patients admitted with severe COVID-19 infection with high levels of factor V Leiden are prone to serious damage from blood clots such as deep vein thrombosis or pulmonary embolism. Damage to the vascular endothelium is a complication that can be caused by the coronavirus. It can cause vascular clots, in the formation of which factors such as age, sex, blood type, and underlying diseases are effective. Thrombotic events, especially venous thrombosis, following COVID-19 infection have already been described;nonetheless, data are scarce on arterial thrombosis. Herein we report 4 cases of COVID-19 infection complicated by arterial thrombosis. (Iranian Heart Journal 2022;23(1): 223-227).