Echocardiographic findings in critically Ill patients with COVID-19 treated with and without extracorporeal membrane oxygenation

Objectives: There is a paucity of data on echocardiographic findings in patients with COVID-19 supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO). This study aimed to compare baseline echocardiographic characteristics of mechanically ventilated patients for acute respiratory distress syndrome (ARDS) due to COVID-19 infection with and without VV ECMO support and to describe the incidence of new echocardiographic abnormalities in these patients. Method(s): Single-center, retrospective cohort study of patients admitted from March 2020 to June 2021 with COVID-19 infection, that required mechanical ventilation, and had an available echocardiogram within 72 hours of admission. Follow-up echocardiograms during ICU stay were reviewed. Result(s): A total of 242 patients were included in the study. One-hundred and forty-five (60%) patients were supported with VV ECMO. Median (IQR) PaO2/ FiO2 was 76 (65-95) and 98 (85-140) in the VV ECMO and non-ECMO patients, respectively (P = < 0.001). On the admission echocardiograms, the prevalence of left ventricular (LV) systolic dysfunction (10% vs 15%, P= 0.31) and right ventricular (RV) systolic dysfunction (38% vs. 27%, P = 0.27) was not significantly different in the ECMO and non-ECMO groups. However, there was a higher proportion of acute cor pulmonale (41% vs. 26 %, P = 0.02) in the ECMO group. During their ICU stay, echocardiographic RV systolic function worsened in 44 (36%) patients in the ECMO group compared with six (10%) patients in the non-ECMO group (P< 0.001). The overall odds ratio for death for patients with worsening RV systolic function was 1.8 (95% confidence interval 0.95-3.37). Conclusion(s): Echocardiographic findings suggested that the presence of RV systolic dysfunction in COVIDECMO patients was comparable to the non-ECMO group on admission. However, a higher percentage of patients on ECMO developed worsening RV systolic function during follow-up.

The Effect Of Rhabdomyomas On Underlying Cardiomyopathy: A Case Report

Case Presentation: Term male infant born to SARS-CoV-2 positive mother with infant testing negative. ECG for perinatal bradycardia revealed ventricular pre-excitation. Echocardiogram showed asymmetric LV hypertrophy with prominent trabeculations, subaortic narrowing with no pressure gradient, and normal biventricular systolic function. Rapid increase in RV pressure estimates and NT-proBNP in first week if life concerning for diastolic dysfunction. Anti-arrhythmic therapy initiated for SVT with subsequent resolution. Later, developed progressive LV dilation and systolic dysfunction. Myocardium showed regions resembling non-compaction and others concerning for infiltrative process. Cardiac MRI showed no obvious tumors, but rhabdomyomas could not be ruled out given similar appearance to myocardium. Due to worsening heart failure, everolimus therapy initiated to target potential rhabdomyomas while awaiting genetic testing for tuberous sclerosis. Subaortic narrowing and LV hypertrophy improved within days, and LV appearance became more consistent with non-compaction. Genetic testing revealed a TSC2 gene variant consistent with tuberous sclerosis. Systolic function improved, and patient discharged on afterload reduction. Echocardiogram 6 months post-discharge shows continued LV dilation and mild systolic dysfunction. Discussion(s): Although outflow obstruction and arrhythmias are common with cardiac rhabdomyomas and can cause dysfunction, our patient developed progressive dysfunction in the absence of outflow tract gradient or prolonged arrhythmia. As rhabdomyomas subsided, it became clearer that he had an underlying cardiomyopathy. We suspect that rhabdomyomas in the setting of abnormal myocardium led to abnormalities in myocardial contractility and compliance causing combined systolic and diastolic dysfunction. After complete resolution of rhabdomyomas, cardiac function has improved. However, he continues to have ventricular dilation and mild dysfunction attributable to cardiomyopathy. It is unlikely that mother's SARS-CoV-2 infection played a role as infant tested negative and clinical picture was not consistent with myocarditis.

Presentation of Takotsubo Cardiomyopathy in a Patient with Coronavirus-19 Disease

Case Report: It is well documented that Coronavirus Disease 19 (COVID-19) patients who suffer cardiac injury have a higher mortality rate, however the exact mechanism of cardiac injury and potential complications are still unknown. Takotsubo Cardiomyopathy (TCM), which was first described in 1990 in Japan, is characterized by a transient systolic and diastolic left ventricular dysfunction with a range of wall motion abnormalities predominantly affecting women often following an emotional or physical trigger. Though TCM is seen less commonly as a cardiac complication of COVID-19, with increasing rates of cardiovascular events due to COVID-19, TCM should be taken into consideration as a potential diagnosis for a COVID-19 positive patient. Case Description: The case of a 75-year old female with a history significant for hypertension, type 2 diabetes mellitus, hyperlipidemia, and gastroesophageal reflux disease presented to the Emergency Department after a ground level fall and subsequent left hip pain. Upon primary survey, EKG showed persistent sinus tachycardia in the 130-150s, with intermittent borderline dynamic changes and a troponin that was mildly elevated at 0.10, and an initial false negative COVID-19 test. Preoperative echocardiogram showed normal left ventricle size, no regional wall abnormalities, and a left ventricular ejection fraction (LVEF) of 60-65%. In post-operative care, EKG illustrated dynamic changes in the form of ST elevation in the lateral precordial leads, as well as an increase in the cardiac troponins, from 0.07 to 3.51. A subsequent echocardiogram illustrated a drop in her ejection fraction from 60-65% to 30-35%, with evidence of left ventricular systolic dysfunction that was not noted on previous echocardiograms. Following the Mayo clinic diagnostic criteria, this patient met the diagnostic criteria for TCM, as evident by new electrocardiograph findings, non-obstructive cardiac catherization findings, echocardiogram findings illustrating transient left ventricular systolic dysfunction, modest elevations in cardiac troponins as well as the patient being a post-menopausal female. Subsequent echocardiogram on 2 week follow up showed a rebound in her ejection fraction to 50-55%. Discussion(s): Possible outcomes of TCM include cardiogenic shock, respiratory failure, and death. It is imperative that clinicians consider TCM as a possible diagnosis when treating COVID-19 patients that may be exhibiting cardiac complications. Frequent ECG monitoring and a vigilant differential should include TCM in patients presenting with COVID-19.

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).

A Rare Case Of Eosinophilic Myocarditis Due To Subacute Sars-cov-2 Illness

Background: Eosinophilic myocarditis is a rare inflammatory cardiomyopathy with a poor prognosis. SARS-CoV-2 (COVID-19) illness has been associated with myocarditis, particularly of lymphocytic etiology. Although there have been cases of eosinophilic myocarditis associated with COVID-19 vaccination, there have been few reported cases secondary to COVID-19 illness, with the majority being diagnosed via post-mortem autopsy. Case: A 44-year-old woman with no significant medical history other than recent COVID-19 illness 6 weeks prior presented with progressive dyspnea. Patient developed acute dyspnea and diffuse pruritic rash after taking hydroxyzine. Labs were significant for mild eosinophilia. Echocardiography showed biventricular systolic dysfunction with left ventricular ejection fraction of 40%, and a moderate pericardial effusion that was drained percutaneously. She underwent left heart and right heart catheterization showing elevated biventricular filling pressures, Fick cardiac index of 1.6 L/min/m2, and no coronary disease. She was started on intravenous diuretics and transferred to our facility for further management. Her course was complicated by cardiogenic shock requiring intra-aortic balloon pump (IABP) support. Mixed venous saturations continued to decline and the patient was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient underwent endomyocardial biopsy (EMB) showing marked interstitial infiltration of eosinophils and macrophages with myocyte injury (see image). She was intubated with mechanical ventilation as well due to worsening pulmonary edema and hypoxemia. She was started on intravenous steroids with improvement of hemodynamics and myocardial function and eventually VA- ECMO was decannulated to low-dose inotropic support which in turn was ultimately weaned after 3 days of mechanical support. Conclusion(s): Eosinophilic myocarditis is a rare and under-recognized sequela of acute COVID-19 infection associated with high mortality rates. It requires prompt diagnosis and aggressive supportive care, including temporary mechanical circulatory support. There are few literature-reported cases of COVID-19 myocarditis requiring use of both IABP and VA-ECMO, none of which were used in biopsy-proven eosinophilic myocarditis, with most of these cases resulting in either fatal or unreported outcomes. Most cases of covid myocarditis required IV glucocorticoids therapy in conjunction with IVIG or interferon therapy. Here, we present a rare case of cardiogenic shock secondary to biopsy-proven eosinophilic myocarditis associated with recent COVID-19 illness with a survival outcome after temporary use of IABP and VA-ECMO support, as well as aggressive immunosuppressive therapy.Copyright © 2022

Acute Severe Heart Failure in Paediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2: A Case Report.

A 17-year-old boy presented during the COVID-19 pandemic in late 2021 with intractable fevers and hemodynamic instability with early gastrointestinal disturbances, resembling features of the pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. Our patient required intensive unit care for persistently worsening signs of cardiac failure; initial admission echocardiography demonstrated severe left ventricular dysfunction with an estimated ejection fraction of 27%. Treatment with intravenous IgG and corticosteroids showed a rapid improvement in symptoms, but further specialist cardiological input was required for heart failure in the coronary care unit. Substantial improvement in cardiac function was shown on echocardiography before discharge, initially to left ventricular ejection fraction (LVEF) 51% two days after the commencement of treatment and then to >55% four days later, and on cardiac MRI. An echocardiogram one month post-discharge was normal, and the patient reported complete resolution of heart failure symptoms by four months in addition to full restoration of functional status.

Impact of cardiovascular disease on in-hospital mortality in patients with COVID-19

Background: The relative association between cardiovascular disease (CVD) and mortality in COVID-19 remains unclear. Aim(s): to evaluate the relationship of CVD with in-hospital death among hospitalized patients with Covid-19. Material(s) and Method(s): retrospective cohort study included hospitalized patients aged >= 18 years with confirmed COVID-19 between October and December 2021 in Single COVID -19 department of UMHAT "Alexandrovska". Demographic, clinical and outcome (in-hospital mortality) data were obtained from medical records. All CVD comorbidites were recorded. Multivariate logistic regression models were fitted to quantify the risk and predictors of in-hospital mortality from COVID-19 in patients with these comorbidities. Result(s): 165 patients with a mean age of 64.6+/-15 of whom 44.8% were men were included. In-hospital mortality was 20%. The presence of CVD was associated with increased in-hospital mortality. Mortality risk was higher in patients having hypertension (28.7% vs. 8.7%, p<0.05), coronary artery disease (27.0% vs. 6.5%, p<0.001), previous ischemic stroke (8.1% vs. 1.6%, p< 0.05), valvular heart diasease (16.2% vs. 4.1%), chronic heart failure (29.7% vs. 4.0%, p<0.001). Significant predictors of mortality from COVID-19 in patients with CVD were three vessel disease (HR: 2.04;95% CI 1.42-9.82, p<0.05), previous percutaneous coronary intervention (HR: 5.0;95% CI 2.05-8.56, p<0.05), systolic dysfunction (HR: 5.4;95% CI 1.85-15.76, p<0.05) and advanced heart failure NYHA III-IV (HR: 2.62;95% CI 1.55-4.78, p<0.001). Conclusion(s): COVID-19 patients with CVD comorbidites have a higher risk of in-hospital death. Optimal care and good control of CVD are essential in this patient group.

Covid-19 Induced Biventricular Takotsubo Cardiomyopathy

Background Takotsubo Cardiomyopathy (TTS) is a syndrome of transient LV dysfunction. Myocardial injury (MCI) has been reported in acute COVID-19 (C19) infections, however, the exact pathophysiology is unclear. Association of rising cardiac biomarkers with inflammatory markers suggests systemic inflammatory response in C19 infection in causing MCI. Case A 52-year-old AA male with history of HTN presents with complaint of worsening shortness of breath and atypical chest pain. Diagnosed with C19 and intubated due to respiratory failure. Chest pain workup included TTE which showed biventricular (BV) systolic dysfunction with apical ballooning and LVEF 25-30%. Left heart catheterization showed non-obstructing coronary disease. Repeat TTE 2 weeks later showed normal BV systolic function with LVEF greater than 55%. Decision-making BV TTS is associated with more hemodynamic instability than is isolated LV TTS. Mayo Clinic diagnostic criteria for TTS requires absence of obstructive CAD or plaque rupture. Rapid recovery of BV function is consistent with TTS with transient BV dysfunction. LV TTS is common in COVID-19 infections, but BV TTS is a less common complication of COVID. Conclusion Due to the propensity of C19 to cause hemodynamic instability it is important to not relate to a patient's instability to C19 alone. It is important to consider TTE in patients with C19, as the patient may be experiencing TTS. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Acute Myocarditis: Secondary to Viral Infection or Pheochromocytoma?

Background In a young healthy patient, acute cardiogenic shock with a dilated, thickened left ventricle is strongly suggestive of acute myocarditis. Case SM is a 33 year-old healthy man who presented with decompensated heart failure with severe hypervolemia. Notably, he was exposed to Hand-Foot-Mouth disease (HFMD) two weeks prior. B-type natriuretic peptide was elevated at 3,417 pg/mL (normal range < 50 pg/mL), and troponin was elevated. Echocardiogram revealed dilated, severe systolic dysfunction with thickened left ventricular walls. He progressed to cardiogenic shock and multi-organ failure. Right heart catheterization revealed significantly reduced cardiac output and index of 2.36 and 1.2, respectively. His course was complicated by left ventricular thrombus and subacute embolic stroke, acute renal failure and liver failure. He was treated with afterload reduction, inotropes, and diuresis. His shock resolved, and he improved with medical therapy for cardiomyopathy. Decision-making The clinical course is consistent with acute myocarditis leading to cardiogenic shock with multi-organ failure. A broad differential was considered, including viral etiologies, autoimmune diseases, vasculitis, and toxin-mediated myocarditis. Viral labs including COVID-19 and influenza, as well as HIV, and hepatitis B and C viruses were negative. Coxsackie B2 antibody was positive at 1:80, which is consistent with past or current infection. Rheumatology evaluation was unrevealing, and vasculitis was deemed unlikely given normal inflammatory markers. Urine drug screen was unrevealing. However, adrenergic myocarditis remained on the differential given an adrenal nodule noted on imaging. Plasma free metanephrines were significantly elevated, consistent with pheochromocytoma. Conclusion This is a case of acute myocarditis with two likely etiologies. The patient's presentation correlates temporally with exposure to HFMD, suggesting viral myocarditis. However, he had gross hypervolemia and diuresed 50 pounds, which suggests a more indolent course. We propose that he had adrenergic myocarditis and undetected cardiomyopathy which was exacerbated by a second insult, the Coxsackie virus.Copyright © 2023 American College of Cardiology Foundation

Myocarditis and Pericarditis related to mRNA COVID-19 Vaccination: A Case Report.

INTRODUCTION: Reported cases after the post-commercialization phase of mRNA vaccines against COVID-19 have revealed that myocarditis and pericarditis may occur predominantly in male adolescents after the second dose of the vaccine. CASE PRESENTATION: We report two cases of cardiac disorders associated with mRNA COVID-19 vaccination, both of them in 15 year-old males. One of the patients presented acute pericarditis and the second one presented acute myocarditis with left ventricular dysfunction at hospital discharge. DISCUSSION AND CONCLUSION: Physicians should be aware with the typical manifestations of these cardiovascular events after the vaccination and report suspicious cases to pharmacovigilance agencies as soon as possible. The population should rely on the pharmacovigilance system that continues to recommend vaccination as the most effective strategy to reduce the negative consequences of the pandemic.

Cardiac implantable device interrogation in left ventricular systolic dysfunction reveals physiologic abnormalities prior to symptom onset in COVID-19: a case series.

Background: COVID-19 has affected individuals across the globe, and those with cardiac implantable electronic devices (CIEDs) likely represent a high-risk group. These devices can be interrogated to reveal information about the patient activity, heart rate parameters, and respiratory rate. Case summary: Four patients with CIEDs and left ventricular dysfunction were admitted to a single institution for COVID-19 infection. Each patient survived hospitalization, and none required intensive care. Retrospectively, CIED interrogation revealed each patient had decreased activity level prior to their reporting COVID-19 symptoms. Similarly, respiratory rate increased before symptom onset for three of the patients, while one did not have these data available. Of the three patients with heart rate variability (HRV) available, two had decreased HRV before they developed symptoms. After hospital discharge, these parameters returned to their baseline. Discussion: This case series suggests physiologic changes identifiable through interrogation of CIEDs may occur prior to the reported onset of COVID-19 symptoms. These data may provide objective evidence on which to base more sensitive assessments of infectious risk when performing contact tracing in communities.

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

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

Acute myocardial infarction in a 9-year-old boy due to multisystem inflammatory disease

Background and Aim: Myocardial infarction after coronavirus dis-ease 2019(COVID-19) is a quite uncommon clinical disease in children. We present a case about a 9-year-old boy with total occlusion of the right main coronary artery(RMCA) attending to the hospital with chest pain. It was related pediatric multisystem inflammatory disease (MIS-C). Method(s): It is a case presentation. Result(s): Case Presentation: The patient had no previous cardiac or family history. Electrocardiography(ECG) showed a definite elevation on the extremity derivatives(DI, DII, DIII, and aVF), and marked ST depression on the chest derivatives (V1 to V6) and aVR, aVL, all representing lateral inferior ischemia. Transthoracic echocardi-ography revealed left ventricular systolic dysfunction, and global wall hypokinesia. Existence of fever and two-body system involvement (cardiac, gastrointestinal), CRP rise, and prior SARS-CoV-2 exposure in a month, MIS-C was a foremost diag-nosis. The total antibody for SARS-CoV-2 was positive. Lipid profiles(LDL, HDL, VLDL, triglyceride), lipid electrophoresis, routine coagulation, and thrombophilia tests were evaluated for differential diagnosis and all were normal. Because of the possible MI, it was planned to visualize coronary arteries by angiography. Total occlusion of the right main coronary artery(RMCA) with a large thrombus was detected without any dilatation of the coro-nary arteries in the coronary angiography. Two coronary stents were implanted into the distal and proximal part of the RMCA. After the procedure, clopidogrel was added to acetylsalicylic acid for platelet inhibition. During the follow-up, LVEF rose to 55% and there was a little hypokinesia on the left inferior wall of ventricles. Conclusion(s):. It should be kept in mind that acute coronary throm-bosis could be an important complication of COVID-19 exposure or MIS-C. A coronary stent implantation is a good treatment option even in small children.

Cardiopulmonary exercise test in children with pediatric inflammatory multisistemic syndrome associated with COVID-19 (PIMS)

Background and Aim: Coronavirus infection (COVID-19) in paedi-atric population has a generally mild course. In Spain, patients under 15 years old have accounted only for 0,4% of hospital admis-sions and 0,7% of intensive care admissions. However, in May 2020, cases of children with a systemic inflammatory syndrome related to a recent COVID-19 infection were described. In severe forms, left ventricular systolic dysfunction, mitral regurgitation, pericardial effusion and coronary artery dilatation or aneurysms have been described. The aim of this study is to describe the results obtained in cardiopulmonary exercise test (CPET) in previously healthy patients with PIMS. Method(s): Prospective study of PIMS patients who performed CPET. Godfrey ramp protocol recommended by European Society of Cardiology (ESC) was used in all cases. Measured var-iables, expressed by predicted values, were: forced vital capacity (FVC), forced expiratory volume (FEV1), ratio of minute venti-lation to carbon dioxide production (VE/VO2 slope), maximal oxygen consumption (VO2 max), oxygen uptake efficiency slope (OUES), oxygen pulse (O2 pulse) and maximum heart rate (HR). Result(s): Eight patients (75% boys) aged 5-14 years (median 10,5 years) performed CPET reaching a mean peak load of 105,87 W (median 112,5 W and mean load per kg of weight 2,34 W/kg). Only 1 patient (12,5%) presented basal spirometric disturb-ances in context of asthma without chronic treatment. Obtained mean respiratory parameters were: FVC 97,88%, FEV1 92,7%, Tiffeneau 83% and VECO2p 32,47. Oxygen satu-ration before and after CPET was greater than 95% in 100% of patients. In 6 patients (75%) the V02max and oxygen pulse was greater than 80% of predicted value (100% of patients reached at least 40% of V02 max at anaerobic threshold). Obtained mean cardiovascular parameters were: VO2 max 1624mL/min (median 1655 ml/min and V02 per kg of weight 36,9 ml/kg), pulse oxygen 9 ml and OUES 1,92. Conclusion(s): PIMS may cause severe cardiac disturbances justifying cardiological monitoring of these patients. CPET allows to assess functional capacity of these children after the disease. In our serie, most of patients had a good functional capacity (75%). Studies with more patients are needed to make extended conclusions.

Clinical characteristics, treatment response and short-term general and cardiac outcomes in multisystem inflammatory syndrome in children (MIS-C)

Background and Aim: In April 2020, clinicians in the United Kingdom observed a group of children with hyperinflammatory shock with significant cardiovascular effects, with features similar to Kawasaki disease and toxic shock syndrome. This new syn-drome that is temporally related to previous exposure to SARS-CoV-2 infection, is now known as multisystem inflammatory syn-drome in children (MIS-C). The aim of this study is to describe the incidence, the clinical, laboratory and echocardiografic character-istics of hospitalized children who met criteria for the MIS-C and analyse short time general and cardiac outcomes in our region. Method(s): Data from children admitted who fulfilled the case def-inition of MIS-C were collected between October 2020 and November 2021. Result(s): 10 cases of MIS-C were reported;the incidence of MIS-C during this period was 1 per 10000 positive sars-cov2 cases (diag-nosed by polymerase chain reaction test or antigen test). The median age was 10 years (IQR 6-12). 70% were male and 50% corresponded to ethnic minority group in our country (20% Latin American and 30% African). 8 of 10 patients (80%) had evi-dence of current or prior SARS-CoV-2 infection and 2 of 10 (20%) had an antecedent of contact with a COVID positive patient. Fever (100% patients), hematologic disturbances (90%), cardiac involvement (biochemical or echocardiographic) (80%), gastrointestinal (80%) and mucocutaneus (50%) symptoms were common presenting features. 8 of 10 were admitted in the pedi-atric intensive care unit. When referring to cardiovascular involve-ment, 1 of 10 (10%) patients had left ventricular systolic dysfunction, 2 of 10 (20%) had mild pericardial effusion and 4 of 10 (40%) mild coronary artery abnormalities. Conclusion(s): Although the incidence is low, in this case series most patients show homogeneous clinical and laboratory findings. Since cardiac involvement is described in a high proportion of patients, long-term follow-up is required due to the unclear prognosis and risk of progression of cardiac manifestation.

Cardiac manifestations of multisystem inflammatory syndrome in children

Background and Aim: We aimed to evaluate cardiac manifestations of the multisystem inflammatory syndrome in children(MIS-C) and the changes in cardiac function during one year of follow-up. Method(s): All children diagnosed as MIS-C with cardiac involve-ment were enrolled in this prospective study. The diagnosis and severity of the disease of MIS-C was made according to the Centers for Disease Control and World Health Organization guidelines. Clinical findings, laboratory parameters including car-diac markers, electrocardiographic and echocardiographic findings at the time of diagnosis and during follow-up were evaluated. Cardiac magnetic resonance imaging (MRI) was performed on all children with echocardiographic abnormality. Result(s): Between April 1st 2020 and December 1st 2021,71 chil-dren were diagnosed with MIS-C and 44 of these patients had car-diac involvement (25 male and 19 female). 24 patients were followed up in the intensive care unit and all of these patients had myocardial involvement. All the patients had elevated NT-proBNP levels (median:5893pg/ml) whereas troponin-T levels were above upper limit in 13 patients. A significant positive cor-relation was found between troponin-T and NT-proBNP (plt;0.01). The NT-proBNP levels were also positively correlated with the severity of MIS-C (plt;0.05). On admission 22 patients had tachycardia and atrioventricular conduction disturbances and supraventricular tachycardia developed in 5 of these patients during follow-up. Bradycardia was observed in 18(40%) patients during hospitalization (4 of these occurred after tachycardia). Although 26 patients had an echocardiographic abnormality, only twelve patients had systolic dysfunction (9 with mild and 3 with moderate) and two patients had diastolic dysfunction. NT-proBNP and troponin-T were negatively correlated with ejection fraction ve fractional shortening (respectively, p = 0.003, p = 0.013). Cardiac MRI was normal in all patients except 3 patients who had myocardial late gadolinium enhancement of left ven-tricle. Pericardial effusion was observed in 14 patients. The echo-cardiographic abnormalities disappeared in 42 patients during follow-up, one patient died on the second day of hospitalization and and 1 patient has ongoing LV systolic dysfunction. Conclusion(s): Bradycardia and myocardial involvement is common during MIS-C. Although myocardial dysfunction can be observed during acute disease, commonly the disease does not cause perma-nent damage during one year of follow-up.

Echocardiographic Evaluation of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19

Cardiac involvement is an observable issue in multisystem inflammatory syndrome in children (MIS-C) associ20 ated with COVID-19. The most common echocardiographic findings in MIS-C are abnormal coronary arteries, decreased left ventricular function, mitral regurgitation, and pericardial effusion. Abnormalities in the coronary arteries were seen in less than 20% of MIS-C patients. These abnormalities include dilatation or aneurysms in the coronary arteries;however, giant or large aneurysms are rare. On the other hand, transient coronary artery dilatation (which can occur secondary to viral myocarditis) may also mean that the coronary artery Z-scores never exceed 2.5. Reviewing large case series revealed that approximately 30 - 40% of MIS-C patients had decreased left ventricular function. In most cases, left ventricular function is mildly depressed, and severe left ventricular dysfunction was observed in only one-fifth of cases. Hypoxia, myocardial ischemia secondary to coronary involvement, stress-induced cardiomyopathy, injury caused by systemic inflammation, and viral myocarditis are the possible etiologies for the myocardial injury in MIS-C. It is now clear that myocardial strain imaging indices such as a global longitudinal strain (GLS), end-diastolic strain rate (EDSR), and peak left atrial strain (LAS) can demonstrate systolic or diastolic dysfunction in myocarditis patients with preserved left ventricular ejection fraction. Furthermore, right-sided ventricular deformation imaging abnormalities have been reported in adult patients with MIS-C. Less information is currently available on mitral regurgitation and pericardial effusion in pediatric patients with MIS-C;however, in an extensive study on 286 pediatric patients with MIS-C, 28% had pericardial effusion, and 42.7% had mitral regurgitation;both were mild in most patients.

Cardiac Management in Pediatric COVID-19 Disease

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can involve children of all ages, although less frequently and with a milder presentation than adults. Cardiovascular abnormalities (myocardial injury, acute myocarditis, cardiomyopathy, heart failure, arrhythmias, pericarditis, cardiogenic shock, pulmonary embolism, myocardial infarction) may accompany, especially with the multisystem inflammatory syndrome in children and adolescents (MIS-C). Severe disease is managed in the hospital setting. Supportive care is the mainstay of therapy. Antiviral therapy, immune-mediated therapies, empiric antibiotics, and therapy for influenza infection are used in selective patients. Cardiac management focuses on maintaining hemodynamic stability and providing adequate systemic perfusion. Children presenting with shock should be resurrected according to standard protocols. Vasoactive agents such as epinephrine or norepinephrine and, if possible, milrinone is used in fluid-refractory shock. Children with Kawasaki disease (KD) features should receive standard therapies for KD, including intravenous immune globulin (IVIG), aspirin, and glucocorticoids. Patients with severe LV dysfunction, intravenous diuretics and inotropic agents, such as milrinone, dopamine, and dobutamine are suggested. Continuous cardiac monitoring is essential. In cases of the fulminant disease, mechanical hemodynamic support may be necessary. For moderate or severe manifestations (shock, left ventricular systolic dysfunction, elevated troponin or brain natriuretic peptide, arrhythmia, coronary artery aneurysm, or presentations requiring PICU care), therapy with combined IVIG plus a glucocorticoid is suggested. Patients may be at risk for venous thromboembolism due to COVID- 19 associated hypercoagulability. Patients with MIS-C and those with severe LV dysfunction or CA aneurysms are at increased risk. It is suggested that all patients with MIS-C receive low-dose aspirin, and severe cases requiring PICU care receive prophylactic-dose anticoagulant therapy. Patients with current or prior VTE, severe LV dysfunction, large or giant CA aneurysms, markedly elevated D-dimer should receive therapeutic anticoagulation (low molecular weight heparin) plus aspirin. Most children with cardiac involvement have recovery of function by hospital discharge. The overall mortality rate for MIS-C is approximately 1 to 2 percent. Cardiology follow-up after discharge is recommended.

TCTAP C-105 Nightmare in Cathlab- When Simple Case Turns to Complex by Tearing Off the Stent Delivery System Shaft

Clinical Information Patient Initials or Identifier Number: Mr. AL Relevant Clinical History and Physical Exam: 59-year-old gentleman. CAD risk factors: Hypertension, Diabetes Mellitus, Dyslipidaemia, Positive family history of CAD. Admitted with Acute Anterior MI & got Tenecteplase. Relevant Test Results Prior to Catheterization: Troponin-I: >50000 ng/L, ECG: ST Elevation in V1-V6, Echo: Anterior wall is hypokinetic with Mild LV systolic dysfunction (EF- 45%). Hb-14.2 gm/dl, Creatinine: 1.12 mg/dl, Na- 135, K- 4.0, Cl- 100 m mol/L, Plasma BNP: 235 pg/ml, COVID-19 RT-PCR- Negative, S. Bilirubin- 0.3 mg/dl, ALT- 45 IU/L, AST- 107 IU/L, Anti-HCV- Negative, Anti-HIV- Negative, HbsAg- Negative, Relevant Catheterization Findings: LMCA: Normal. LAD: Got 90-99% narrowing in its proximal segment followed by 90-99% diffuse disease. DG1 is small and diseased. DG2 has got sub-total occlusion at its origin. LCX: Good size artery with mild ostial narrowing & 50% narrowing in its mid segment. Principal OM has got 50% narrowing in its ostium. RCA: Dominant artery has got 60% narrowing in its proximal segment. PDA is a good size artery & got mild irregular narrowing in its proximal segment. Recommendation: PCI to LAD [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: LCA was engaged with guiding catheter EBU -3.5 (6F). Sion Blue wire crossed the lesion of LAD, another wire crossed the lesion of Diagonal branch and pre-dilatation was done with 2.0 x 15 mm balloon at 08-10 ATM. Proximal lesion was stented with a 2.75 mm x 18 mm stent (Xience Alpine) at 12-14 ATM. After withdrawing the wire following angiogram showed proximal LAD was well dilated but mid LAD having a long dissection which interrupted the distal flow. So, decided to put stent in mid LAD. Again, repeated ballooning was done in mid LAD to prepare the lesion and a 2.25 mm x 28 mm stent (Xience Xpedition) was taken for mid LAD but stent didn't cross the mid LAD lesion. During stent withdrawal, it was struck in the previous Proximal stent and proximal calcified segment. When trying to pull it back, the delivery system shaft was tear off. Tried to get the shaft by coronary snare but failed to get it back. Finally, he was recommended to retrieve the torn delivery system & stent surgically. [Formula presented] [Formula presented] [Formula presented] Conclusions: • Stent with torn delivery system entrapment might not be rare. • In this situation, emergency decision to tackle the situation and Bail out decision to send the patient for surgical retrieval of the delivery system & stent saved the life of the patient. Take Home Message: • No case is simple in intervention. • Preparedness to tackle any untoward consequence is the key to success and save lives.

MIS-CM imicking Acute Appendicitis

Introduction: Abdominal pain is one of the most common complaints seen in the pediatric acute care setting. SARS-CoV-2 disease in children includes a hyperinflammatory syndrome called Multisystem Inflammatory Syndrome in Children (MIS-C). Gastrointestinal symptoms are most common in pediatric acute SARS-CoV-2 infection as well as in MIS-C. Case Description: A 13- year-old female presented with diffuse lower abdominal pain for 3-days. Pain was 10/10 in intensity, worsened with movement, and had associated constipation, anorexia, nausea, and vomiting. Exam showed an ill-appearing female with labile vitals and generalized lower abdominal tenderness with good bowel sounds. Ultrasound suggested features of acute appendicitis but a follow-up CT did not visualize the appendix. She was admitted to the inpatient unit after routine screening revealed positive SARS-CoV-2 antibody but negative PCR. She received IV fluid bolus, narcotic analgesics, and ampicillin-sulbactam preoperatively. Within hours, she spiked high-grade fevers (101.4F), sustained hypotension, and tachycardia with concern for sepsis secondary to a possible ruptured appendix. She underwent emergency diagnostic laparoscopy which revealed bile-tinged fluid in the lower quadrant, a mildly inflamed appendicular tip without perforation, and thickened mesenteric nodes within the inflamed distal ileum. Intra-operatively, she had persistent hypotension requiring fluid boluses and vasopressors. Her admission labs revealed elevated inflammatory markers, deranged coagulation profile, and elevated cardiac enzymes. Her differential diagnosis was then revised to include MIS-C and severe sepsis. Antibiotic coverage was broadened to Vancomycin and Meropenem. An Echocardiogram showed mitral regurgitation with moderately to severely decreased right and left ventricular systolic dysfunction with an ejection fraction of 32.8% The patient was then transferred to the pediatric cardiac critical unit where she received treatment with IVIG, steroids, and anticoagulants. Her clinical status and lab studies improved with EF > 50%. She was discharged from the intensive care unit after 7 days and has had an uneventful follow-up. Discussion: Differential diagnosis for acute lower abdominal pain in an adolescent female is broad. Similar cases with predominant GI symptoms and later generalized multisystem involvement have been reported, however, most were managed conservatively. Two reports have been published on MIS-C presenting as acute appendicitis, but neither had significant cardiac involvement. Our patient's presentation can easily be confused with an acute surgical abdomen but the pathology report confirmed a congested appendix without any fecoliths supporting either inflammation or vasculitis as the cause for her presentation, which is in concordance with the hyperinflammatory state that has previously been described in patients presenting with a history of past SARS-CoV- 2 infections. Conclusion: MIS-C can mimic serious pediatric illnesses including sepsis, acute abdomen, and Kawasaki disease. Clinicians should have a low threshold for suspecting MIS-C, as prompt treatment can be lifesaving. Universal screening for COVID-19 infection with PCR and antibody tests can expedite the diagnostic evaluation of severely ill children. Showing reactive wall thickening of the cecum and small bowel loops (red arrow) and enlarged mesenteric lymph nodes (yellow arrow). The appendix could not be visualized here.