Impact of COVID-19 on percutaneous coronary intervention utilization and mortality in New York.

BACKGROUND: COVID-19 has disrupted the care of all patients, and little is known about its impact on the utilization and short-term mortality of percutaneous coronary intervention (PCI) patients, particularly nonemergency patients. METHODS: New York State's PCI registry was used to study the utilization of PCI and the presence of COVID-19 in four patient subgroups ranging in severity from ST-elevation myocardial infarction (STEMI) to elective patients before (December 01, 2018-February 29, 2020) and during the COVID-19 era (March 01, 2020-May 31, 2021), as well as to examine the impact of different COVID severity levels on the mortality of different types of PCI patients. RESULTS: Decreases in the mean quarterly PCI volume from the prepandemic period to the first quarter of the pandemic ranged from 20% for STEMI patients to 61% for elective patients, with the other two subgroups having decreases in between these values. PCI quarterly volume rebounds from the prepandemic period to the second quarter of 2021 were in excess of 90% for all patient subgroups, and 99.7% for elective patients. Existing COVID-19 was rare among PCI patients, ranging from 1.74% for STEMI patients to 3.66% for elective patients. PCI patients with COVID-19 and acute respiratory distress syndrome (ARDS) who were not intubated, and PCI patients with COVID-19 and ARDS who were either intubated or were not intubated because of Do Not Resuscitate//Do Not Intubate status had higher risk-adjusted mortality ([adjusted ORs = 10.81 [4.39, 26.63] and 24.53 [12.06, 49.88], respectively]) than patients who never had COVID-19. CONCLUSIONS: There were large decreases in the utilization of PCI during COVID-19, with the percentage of decrease being highly sensitive to patient acuity. By the second quarter of 2021, prepandemic volumes were nearly restored for all patient subgroups. Very few PCI patients had current COVID-19 throughout the pandemic period, but the number of PCI patients with a COVID-19 history increased steadily during the pandemic. PCI patients with COVID-19 accompanied by ARDS were at much higher risk of short-term mortality than patients who never had COVID-19. COVID-19 without ARDS and history of COVID-19 were not associated with higher mortality for PCI patients as of the second quarter of 2021.

Recovery From the Impact of COVID-19 on Treatment Times and Clinical Outcomes of Patients With ST-Segment Elevation Myocardial Infarction: An Interim Analysis.

BACKGROUND: Previous studies have documented a negative impact of the COVID-19 pandemic on emergent percutaneous treatment of patients with ST-segment elevation myocardial infarction (STEMI), but few have examined recovery of healthcare systems in restoring prepandemic STEMI care. METHODS: Retrospective analysis was performed of data from 789 patients with STEMI from a large tertiary medical center treated with percutaneous coronary intervention between January 1, 2019, and December 31, 2021. RESULTS: For patients with STEMI presenting to the emergency department, median time from door to balloon was 37 minutes in 2019, 53 minutes in 2020, and 48 minutes in 2021 (P < .001), whereas median time from first medical contact to device changed from 70 to 82 to 75 minutes, respectively (P = .002). Treatment time changes in 2020 and 2021 correlated with median emergency department evaluation time (30 to 41 to 22 minutes, respectively; P = .001) but not median catheterization laboratory revascularization time. For transfer patients, median time from first medical contact to device changed from 110 to 133 to 118 minutes, respectively (P = .005). In 2020 and 2021, patients with STEMI had greater late presentation (P = .028) and late mechanical complications (P = .021), with nonsignificant increases in yearly in-hospital mortality (3.6% to 5.2% to 6.4%; P = .352). CONCLUSION: COVID-19 was associated with worsening STEMI treatment times and outcomes in 2020. Despite improving treatment times in 2021, in-hospital mortality had not decreased in the setting of a persistent increase in late patient presentation and associated STEMI complications.

Discussion on the causes of thrombolysis failure in a patient with STEMI: a case report.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) has emerged as an increasingly diagnosed cause of ST-segment elevation myocardial infarction (STEMI), which is easily missed or delayed. The effective use of coronary angiography (CAG) and advanced intracoronary imaging examinations in STEMI patients has led to increased detection of SCAD. CASE PRESENTATION: A 59-year-old woman with acute angina pectoris was diagnosed with STEMI detected by electrocardiography combined with measurement of myocardial enzymes. Due to the ongoing pandemic of coronavirus disease 2019 (COVID-19) in Wuhan, she was first given thrombolytic therapy after excluding contraindications according to the requirements of the current consensus statement; however, subsequently, both the symptoms of ongoing chest pain and the electrocardiographic results indicated the failure of thrombolytic therapy, so the intervention team administered rescue percutaneous coronary intervention treatment under third-grade protection. CAG confirmed total occlusion in the distal left anterior descending (LAD) artery, with thrombolysis in myocardial infarction (TIMI) 0 flow, whereas the left circumflex and right coronary arteries appeared normal, with TIMI 3 flow. Intravenous ultrasound (IVUS) was further performed to investigate the causes of occlusion, which verified the absence of atherosclerosis but detected SCAD with intramural haematoma. During the operation, the guidewire reached the distal end of the LAD artery smoothly, the balloon was dilated slightly, and the reflow of TIMI blood could be seen by repeated CAG. During the follow-up period of one and a half years, the patient complained of occasional, slight chest tightness. The repeated CAG showed that the spontaneous dissection in the LAD artery had healed well, with TIMI 3 flow. The repeated IVUS confirmed that the SCAD and intramural haematoma had been mostly resorbed and repaired. CONCLUSION: This was a case of failed STEMI thrombolysis in our hospital during the outbreak of COVID-19. This case indicates that doctors need to consider the cause of the disease when treating STEMI patients, especially patients without traditional cardiovascular risk factors. Moreover, CAG and intracoronary imaging examinations should be actively performed to identify the aetiology and improve the treatment success rate.

Delayed Presentation of Inferior STEMI Complicated by Ventricular Septal Rupture: An Indirect Consequence of the COVID-19 Pandemic.

The COVID-19 pandemic has adversely impacted healthcare delivery. An indirect consequence of the rational fear of contracting the virus is delayed medical attention for life threatening conditions. We present the case of inferior ST elevation myocardial infarction leading to the rare complication of a ventricular septal rupture reflecting transmural infarction. COVID hesitancy caused a 48-hour delay in seeking medical attention after symptom onset. We also discuss the use of MRI to guide decision for timing of VSD repair in an otherwise asymptomatic patient post-revascularization.

Synthetic cannabinoids and ST elevation myocardial infarction.

Synthetic cannabinoids cannot be detected on a standard urine drug screen (UDS), making them a convenient drug of abuse. We report the first case of ST elevation myocardial infarction (STEMI) in a young patient due to coronary artery thrombosis secondary to synthetic cannabinoid use and concurrent COVID-19 infection. A 38-year-old previously healthy male developed severe chest pain and was found to have anterior STEMI and COVID-19 infection. Coronary angiography showed acute thrombotic occlusion of the mid-left anterior descending artery that was managed with thrombectomy and stent placement. He only required supportive care for COVID-19. A comprehensive literature search revealed 34 additional cases of STEMI with synthetic cannabinoid use; majority were males (97%) with mean age of 29 years. 29 patients (85.3%) underwent coronary angiography and majority had left anterior descending artery (LAD) involvement (55%), with 13 (44.8%) undergoing stent placement. We highlight STEMI as a potentially lethal complication of synthetic cannabinoids; prompt angiography may be lifesaving.

Coronary artery aneurysm presenting as ST-elevation myocardial infarction in a man with coronavirus disease 2019: a case report.

BACKGROUND: Patients with underlying cardiovascular risk factors have worse clinical outcomes when they have coronavirus disease. In addition, a reduced workload of cardiovascular emergencies has been reported during the coronavirus pandemic due to patients' reluctance to attend hospitals for fear of contracting the disease. Regional health service reorganization, separating hospitals into coronavirus and non-coronavirus can mitigate this effect. However, the effectiveness of this approach on outcomes and patient satisfaction is unknown. CASE PRESENTATION: A 35-year-old Pakistani man with acute ST myocardial infarction was found to have thrombosis of the right coronary artery aneurysm and concomitant coronavirus disease. He had percutaneous coronary angiography and thrombus removal, and was transferred to a coronavirus hospital for the management of the infection. Due to the large size of the aneurysm, he was considered for surgical intervention. Following discharge from the coronavirus hospital and a period of stay at the isolation center, he failed to keep his cardiology follow-up appointment. CONCLUSION: This case illustrates an unusual cause of myocardial infarction in a patient with coronavirus infection whose care may have been adversely affected by the healthcare system restructuring.

Acute Perimyocarditis - an ST-Elevation Myocardial Infarction Mimicker: A Case Report.

BACKGROUND A normal coronary angiogram in ST-elevation myocardial infarction (STEMI) can be considered a myocardial infarction with non-obstructive coronary arteries (MINOCA) until an alternative diagnosis is obtained. However, the COVID-19 pandemic might delay urgent coronary angiography in a resource-limited setting. Perimyocarditis often causes symptoms, such as chest pain, as well as ST-elevation and high cardiac troponin levels. This STEMI mimicker can also cause cardiogenic shock and death when not treated properly. CASE REPORT A 40-year-old man reported having acute onset of substernal chest pain, which was suspected to be STEMI. The patient was an active smoker without any risk factors or a history of cardiovascular disease. The examination showed elevated cardiac troponin I, ST-elevation in high lateral leads, and regional wall motion abnormality (RWMA) by echocardiogram. Furthermore, thrombolytic therapy had failed, and rescue percutaneous coronary intervention was not performed due to the catheterization laboratory limitation during the COVID-19 pandemic. Before coronary angiography, the patient was scheduled for 2 consecutive days of COVID-19 polymerase chain reaction (PCR) swabs. On the second day of hospitalization, the patient experienced a cardiogenic shock. The COVID-19 PCR results were negative, while coronary angiography revealed normal coronary arteries. The patient was eventually diagnosed with probable acute perimyocarditis. CONCLUSIONS Myocarditis is implicated in young patients without typical cardiovascular risk factors or in those with recent infection and cardiovascular symptoms mimicking acute coronary syndrome. It might also be present in situations where ST-elevation distribution on the electrocardiogram is discordant with the RWMA observed on the echocardiogram.

Characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock during COVID-19.

OBJECTIVES: To evaluate characteristics and outcomes of patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) during the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND: The COVID-19 pandemic has created challenges in delivering acute cardiovascular care. Quality measures and outcomes of patients presenting with AMICS during COVID-19 in the United States have not been well described. METHODS: We identified 406 patients from the National Cardiogenic Shock Initiative (NCSI) with AMICS and divided them into those presenting before (N = 346, 5/9/2016-2/29/2020) and those presenting during the COVID-19 pandemic (N = 60, 3/1/2020-11/10/2020). We compared baseline clinical data, admission characteristics, and outcomes. RESULTS: The median age of the cohort was 64 years, and 23.7% of the group was female. There were no significant differences in age, sex, and medical comorbidities between the two groups. Patients presenting during the pandemic were less likely to be Black compared to those presenting prior. Median door to balloon (90 vs. 88 min, p = 0.38), door to support (88 vs. 78 min, p = 0.13), and the onset of shock to support (74 vs. 62 min, p = 0.15) times were not significantly different between the two groups. Patients presented with ST-elevation myocardial infarction more often during the COVID-19 period (95.0% vs. 80.0%, p = 0.005). In adjusted logistic regression models, COVID-19 period did not significantly associate with survival to discharge (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.54-2.19, p = 0.81) or with 1-month survival (OR 0.82, 95% CI 0.42-1.61, p = 0.56). CONCLUSIONS: Care of patients presenting with AMICS has remained robust among hospitals participating in the NCSI during the COVID-19 pandemic.

Comparison of Angiographic and Clinical Outcomes After Primary Percutaneous Coronary Intervention for ST-elevation Myocardial Infarction Between Patients With and Without Concomitant COVID-19 Infection.

OBJECTIVE: COVID-19 infection can involve the cardiovascular system and worsen the prognosis of the patients. This study aimed to investigate the adverse effects of COVID-19 on angiographic and clinical outcomes of primary percutaneous coronary intervention (PCI) in patients with acute ST-elevation MI and compare results with those patients without COVID-19 disease. METHODS: The study was a retrospective observational cohort, in which patients presented with ST-elevation MI from February 2020 to April 2021, treated with primary PCI were divided into 2 groups based on the COVID-19 infection. Then, the procedural and angiographic indices and also clinical outcomes were compared between the 2 groups. RESULTS: A total of 1150 patients were enrolled in the study. Those with established COVID-19 infection had worse baseline thrombolysis in myocardial infarction flow grade and also were at higher risk for worse procedural outcomes such as lower thrombolysis in myocardial infarction frame count, myocardial blush grade, and slow-flow coronary disease, after the primary PCI. Additionally, the presence of COVID-19 at the time of primary PCI was related to a significantly higher duration of hospitalization and in-hospital mortality. Given the potential impact of other factors on outcomes, analysis for all of the primary endpoints was done again after adjustment of these factors and the results were the same as before, suggesting the independent effect of COVID-19 infection. CONCLUSIONS: The concomitant COVID-19 infection in the patients undergoing primary PCI is associated with significantly worse angiographic, procedural and clinical outcomes. Surprisingly, this finding is regardless of patients' baseline risk factors and demographical characteristics.

Decreased door-to-balloon time in patients with ST-segment elevation myocardial infarction during the early COVID-19 pandemic in South Korea: An observational study.

The coronavirus disease 2019 (COVID-19) resulted in a marked decrease in the number of patient visits for acute myocardial infarction and delayed patient response and intervention in several countries. This study evaluated the effect of the COVID-19 pandemic on the number of patients, patient response time (pain-to-door), and intervention time (door-to-balloon) for patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI). Patients with STEMI or NSTEMI visiting a hospital in South Korea who underwent primary coronary intervention during the COVID-19 pandemic (January 29, 2020, to December 31, 2020) were compared with those in the equivalent period from 2018 to 2019. Patient response and intervention times were compared for the COVID-19 pandemic window (2020) and the equivalent period from 2018 to 2019. We observed no decrease in the number of patients with STEMI (P = .88) and NSTEMI (P = 1.00) during the COVID-19 pandemic compared to that in the previous years. Patient response times (STEMI: P = .39; NSTEMI: P = .59) during the overall COVID-19 pandemic period did not differ significantly. However, we identified a significant decrease in door-to-balloon time among patients with STEMI (14%; P < .01) during the early COVID-19 pandemic. We found that the number of patients with STEMI and NSTEMI was consistent during the COVID-19 pandemic and that no time delays in patient response and intervention occurred. However, the door-to-balloon time among patients with STEMI significantly reduced during the early COVID-19 pandemic, which could be attributed to decreased emergency care utilization during the early pandemic.

Impact of COVID-19 pandemic on STEMI thrombolysis and Emergency Department's performance in a non-PCI capable tertiary hospital.

INTRODUCTION: Some guidelines had recommended "thrombolysis first" in ST-elevated myocardial infarction (STEMI) during the Coronavirus Disease 2019 (COVID-19) outbreak. The impact of COVID-19 solely on STEMI thrombolysis is lacking as most studies reported outcomes related to percutaneous coronary intervention (PCI) setting. Thus, this study aimed to assess the impact of the COVID-19 pandemic on STEMI thrombolysis outcomes and the Emergency Department's performance in a non-PCI capable centre. METHODS: This single-centre retrospective study analysed data on consecutive STEMI patients who received thrombolytic therapy from May 2019 to December 2020 (20 months) in a non-PCI capable tertiary hospital. Total population sampling was used in this study. We compared all patients' characteristics and outcomes ten months before and during the pandemic. Regression models were used to assess the impact of COVID-19 pandemic on door-to-needle time (DNT), mortality, bleeding events, and the number of overnight stays. RESULTS AND DISCUSSION: We analysed 323 patients with a mean age of 52.9 ± 12.9 years and were predominantly male (n = 280, 88.9%). There was a 12.5% reduction in thrombolysis performed during the pandemic. No significant difference in timing from symptoms onset to thrombolysis and DNT was observed. In-hospital mortality was significantly higher during the pandemic (OR 2.02, 95% CI 1.02-4.00, p = 0.044). Bleeding events post thrombolysis remained stable and there was no significant difference in the number of overnight stays during the pandemic. CONCLUSION: STEMI thrombolysis cases were reduced during the COVID-19 pandemic, with an inverse increase in mortality despite the preserved Emergency Department performance in timely thrombolysis.

Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction.

BACKGROUND AND HYPOTHESIS: Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients. METHODS: Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models. RESULTS: A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13). CONCLUSIONS: In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.

Impact of COVID-19 pandemic on the management of nonculprit lesions in patients presenting with ST-elevation myocardial infarction: Outcomes from the pan-London heart attack centers.

BACKGROUND: The impact of COVID-19 on the diagnosis and management of nonculprit lesions remains unclear. OBJECTIVES: This study sought to evaluate the management and outcomes of patients with nonculprit lesions during the COVID-19 pandemic. METHODS: We conducted a retrospective observational analysis of consecutive primary percutaneous coronary intervention (PPCI) pathway activations across the heart attack center network in London, UK. Data from the study period in 2020 were compared with prepandemic data in 2019. The primary outcome was the rate of nonculprit lesion percutaneous coronary intervention (PCI) and secondary outcomes included major adverse cardiovascular events. RESULTS: A total of 788 patients undergoing PPCI were identified, 209 (60%) in 2020 cohort and 263 (60%) in 2019 cohort had nonculprit lesions (p = .89). There was less functional assessment of the significance of nonculprit lesions in the 2020 cohort compared to 2019 cohort; in 8% 2020 cohort versus 15% 2019 cohort (p = .01). There was no difference in rates of PCI for nonculprit disease in the 2019 and 2020 cohorts (31% vs 30%, p = .11). Patients in 2020 cohort underwent nonculprit lesion PCI sooner than the 2019 cohort (p < .001). At 6 months there was higher rates of unplanned revascularization (4% vs. 2%, p = .05) and repeat myocardial infarction (4% vs. 1%, p = .02) in the 2019 cohort compared to 2020 cohort. CONCLUSION: Changes to clinical practice during the COVID-19 pandemic were associated with reduced rates of unplanned revascularization and myocardial infarction at 6-months follow-up, and despite the pandemic, there was no difference in mortality, suggesting that it is not only safe but maybe more efficacious.

Acute ST-segment elevation myocardial infarction secondary to vaccine-induced immune thrombosis with thrombocytopaenia (VITT).

A 40-year-old man with no cardiac history presented with central chest pain 8 days after receiving the ChAdOx1 nCov-19 vaccine against COVID-19. Initial blood tests demonstrated a thrombocytopaenia (24×109 µg/L) and a raised d-dimer (>110 000 µg/L), and he was urgently transferred to our tertiary referral central for suspected vaccine-induced immune thrombocytopaenia and thrombosis (VITT). He developed dynamic ischaemic electrocardiographic changes with ST elevation, a troponin of 3185 ng/L, and regional wall motion abnormalities. An occlusion of his left anterior descending coronary artery was seen on CT coronary angiography. His platelet factor-4 (PF-4) antibody returned strongly positive. He was urgently treated for presumed VITT with intravenous immunoglobulin, methylprednisolone and plasma exchange, but remained thrombocytopaenic and was initiated on rituximab. Argatroban was used for anticoagulation for his myocardial infarction while he remained thrombocytopaenic. After 6 days, his platelet count improved, and his PF-4 antibody level, troponin and d-dimer fell. He was successfully discharged after 14 days.

Coronary artery thrombus resulting in ST-elevation myocardial infarction in a patient with COVID-19.

COVID-19 is a prothrombotic condition that is also associated with raised troponin levels and myocardial damage. We present a case of a 54-year-old man who was admitted with respiratory failure due to COVID-19 and developed a ST-elevation myocardial infarction (STEMI) during his admission. His coronary angiogram did not show any significant coronary artery disease other than a heavily thrombosed right coronary artery. In view of heavy thrombus burden, the right coronary artery was treated with thrombus retrieval using a distal embolic protection device in addition to manual thrombectomy and direct (intracoronary) thrombolysis without the need for implantation of a coronary stent. After successful revascularisation, triple antithrombotic therapy was instituted with an oral anticoagulant in addition to dual antiplatelets. This case illustrates the association of COVID-19 with coronary artery thrombosis, which may require disparate management of a STEMI than that resulting from atherosclerotic coronary artery disease.

Urgent Percutaneous Coronary Artery Intervention and Coronary Artery Bypass Grafting in STEMI Patients with Confirmed COVID-19.

BACKGROUND: Our aim of this study was to evaluate the cardiac symptoms, coronary angiographic results, and clinical outcomes of patients with confirmed COVID-19 and ST-segment elevation with myocardial infarction (STEMI) or myocardial ischemia. MATERIAL AND METHODS: Thirty-seven patients, who already were confirmed with COVID-19 using reverse transcriptase-polymerase chain reaction (RT-PCR), were admitted to our hospital due to chest pain with STEMI. The median patient age was 66 years (range: 27-84 years). Female/male ratio was 22/15. We performed a second RT-PCR test in all patients. We investigated myocardial enzymes (creatine kinase myocardial band (CK-MB), cardiac troponin-I (c-TnI), and C-reactive protein (CRP), and liver enzymes (alanine amino transferase (ALT) and aspartate amino transferase (AST) also were measured. Blood d-dimer, thromboplastin time (PT), partial thromboplastin time (PTT), and fibrinogen were investigated. Transcutaneous oxygen saturation was monitored for each patient in the emergency department (ED). To evaluate myocardial wall abnormalities, transthoracic echocardiography was performed. RESULTS: Coronary artery disorders requiring revascularization were detected in 25 patients (67.5%). There was no evidence of coronary artery disease in the remaining 12 patients. Out of 25, nine coronary artery disease patients had a history of coronary intervention (24.3%). All patients had high levels of myocardial enzyme release. Percutaneous coronary interventions (PCI) were performed in patients with culprit lesion(s). Success rate of PCI was 87.5% (N = 21). The median number of stent use was 2.9±0.7 (range: 1-4). Because PCI failed in four patients, we suggested elective coronary artery bypass grafting (CABG) surgery after medical treatment. Six patients required re-intervention owing to early stent thrombosis (30%). Seven patients died after PCI (33.3%). For patients with negative or positive RT-PCR test results, we performed thoracic computed tomography (CT), which is a sensitive diagnostic method for COVID-19. Interlobular septal and pleural thickening with patchy bronchiectasis in the bilateral or unilaterally lower and/or middle lobe(s) were the main pathologies in 24 patients. D-dimer, fibrinogen, and CRP levels were high in 11 PCI patients with bilaterally pulmonary involvement by COVID-19 (52.3%), while fibrin degradation products did not significantly change. For three patients with normal coronary arteries with a transient hypokinesia or hypokinesia as result of myocarditis, we decided to perform atypical Takotsubo cardiomyopathy. We medically treated using inodilator (levosimendan), diuretic, angiotensin-converting enzyme inhibitors and beta-blockers. To prevent the risk of thromboembolism, we also administered a heparin drip. The myocardial contractility of the apex did improve, and patients were discharged from the hospital, with the exception of one young female patient. She is following in the ICU with stabil hemodynamics. CONCLUSION: Chest pain with STEMI can develop in patients with confirmed COVID-19. Nearly one-third of patients had COVID-19 with chest pain and concomitant STEMI and normal coronary angiography (32.4%). Urgent PCI may be performed in hemodynamically unstable patients with high mortality. Complications, including sudden cardiac arrest, severe ventricular arrhythmia, and Takotsubo cardiomyopathy, related to COVID-19 patients with normal coronary arteries.

ST-Elevation Myocardial Infarction due to Acute Thrombosis in an Adolescent With COVID-19.

STEMI can be the presenting diagnosis in adults with COVID-19; presented is a case of a 15-year-old girl with coronary thrombosis-induced STEMI associated with COVID-19. ST-elevation myocardial infarction (MI) is an identified presentation of coronavirus disease 2019 in adults but has not been reported in children. We present a case of a 15-year-old girl with a coronary thrombosis-induced ST-elevation MI in the setting of acute severe acute respiratory syndrome coronavirus 2 infection, not associated with multisystem inflammatory syndrome in children. The patient presented with chest pain, ST elevation, and myocardial dysfunction. Coronary angiography identified thrombosis treated with anticoagulation and antiplatelet therapy. MI must be considered in children who present with coronavirus disease 2019-associated myocardial dysfunction.

Distinct Coagulopathy With Myocardial Injury and Pulmonary Embolism in COVID-19.

In this article, we report a case of a 61-year-old male who was diagnosed with SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), presenting with acute respiratory distress syndrome requiring intubation and hemodynamic support, marked D-Dimer and troponin I elevation, worsening ST-elevation myocardial infarction on repeat electrocardiograms, and a negative coronary angiogram ruling out a coronary artery thrombosis or occlusion. With worsening diffuse ST-segment elevation on electrocardiograms and reduced ejection fraction on echocardiography in the setting of systemic inflammation, fulminant myocarditis was highly suspected. Despite optimal medical treatment, the patient's condition deteriorated and was complicated by cardiac arrest that failed resuscitation. Although myocarditis was initially suspected, the autopsy revealed no evidence of myocarditis or pericarditis but did demonstrate multiple microscopic sites of myocardial ischemia together with thrombi in the left atrium and pulmonary vasculature. Additionally, scattered microscopic cardiomyocyte necrosis with pathological diagnosis of small vessel micro-thrombotic occlusions. These findings are potentially exacerbated by inflammation-induced coagulopathy, hypoxia, hypotension, and stress, that is, a multifactorial etiology. Further research and an improved understanding are needed to define the precise pathophysiology of the coagulopathic state causing widespread micro-thrombosis with subsequent myocardial and pulmonary injury.

A Rare Case of Partial Aortic Mechanical Valve Thrombosis With Intact Mitral Mechanical Valve Presenting With ST-Elevation Myocardial Infarction Patients.

The incidence of mechanical valve thrombosis (MVT) is around 0.4 per 100 patient-years. Mitral valve thrombosis has a higher incidence than aortic valve thrombosis with a nearly 5-fold increase. Various factors contribute to MVT. The most common cause of valve thrombosis is poor adherence/disruption of anticoagulation therapy. Low cardiac output is known to increase the risk of prosthetic valve thrombosis. Other factors such as diabetes, hypertension, and other patient comorbidities might also play a role. Decreased flow promotes hypercoagulability. Lower pressure in the left atrium (and higher velocities in the left ventricle) can partially contribute to the higher incidence of mitral MVT versus aortic MVT. The presenting symptoms usually depend on the severity of the valve thrombosis; nonobstructive valve thrombosis patients have progressive dyspnea, signs of heart failure, and systemic embolization with strokes being the most common complication. In this article, we present a case of a middle-aged woman with a history of mitral and aortic mechanical prosthesis who presented with an ST-segment elevation myocardial infarction and pulmonary edema due to mechanical aortic valve prosthesis thrombosis. She had an isolated mechanical aortic valve prosthesis thrombosis with intact mitral valve, which, to the best of our knowledge, has not yet been described. We performed a literature review by searching PubMed and Embase using the keywords "mechanical valve," "thrombosis," "aortic," and "mitral," our search did not show similar cases.