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A 48-year-old woman underwent preoperative cardiac testing prior to gastric bypass. She was incidentally found to have a right atrial mass on transthoracic echocardiography. Subsequent cardiac magnetic resonance confirmed this finding. She underwent excision of the mass. Tissue pathology revealed ectopic hepatic tissue. (Level of Difficulty: Advanced.), Central Illustration

History and physical examination are the diagnostic cornerstones of transient loss of consciousness (TLOC). However, details can be scarce and examination unrevealing, thus making the diagnosis elusive. In a case of convulsive TLOC, the initial diagnosis was incorrect, but a fortuitously captured event on telemetry yielded the diagnosis: extrinsic idiopathic atrioventricular block. (Level of Difficulty: Beginner.), Central Illustration

Introduction: Coronary artery calcium score (CACS) is a known predictor of cardiac events, however its association with inpatient mortality in COVID-19 infection remains unknown. Hypothesis: We hypothesized that elevated CACS is associated with increased mortality in inpatient patients with COVID-19. Methods: Inpatients with COVID-19 between March and May, 2020 at a single center were identified. All patients had a non-contrast chest CT during admission, and CACS and Multi-Ethnic Study of Atherosclerosis (MESA) percentile were retrospectively measured. Patients were grouped in quartiles: no CACS (0 AU), mild CACS (1-99 AU), moderate CACS (100-399 AU), and severe ( > 400 AU). Inpatient mortality was compared between groups using logistic regression adjusted for age and troponin level. Results: One hundred thirty-nine patients were included with 107 (80%) surviving to discharge. Eighty-two patients self-identified as black or African American (59%) and 66 were female sex at birth (47%). The mean CACS for the survivors was 319 AU and 406 AU for non-survivors (p = 0.02). The mean MESA percentile for survivors and non-survivors was 41% and 60%, respectively (p = 0.03). Fifty-nine patients had no CACS, 19 had mild CACS, 28 had moderate CACS, and 33 had severe CACS. Fifty-three of the no CACS group survived (89%), 13 of the mild group survived (68%), 17 of the moderate group survived (60%), and 24 of the severe group survived (73%). After adjustment for age and troponin level, CACS > 0 AU versus those with CACS of 0 AU had 4-fold higher odds of mortality (OR 4.0, 95%CI 1.3 - 12, p= 0.02). However, there was no significant increased odds of death within higher quartiles of CACS (OR 1.4, 95%CI 1.0 - 2.1, p=0.08). Conclusion: The presence of coronary artery calcium positively correlates with inpatient COVID-19 mortality, even after accounting for age and myocardial injury. Severity of CACS, however, is not associated with mortality.

BackgroundChronic kidney disease is common, leads to end stage renal disease, and is a major risk factor for cardiovascular disease. Although both chronic kidney disease and hypertension, the main risk factor for disease progression, are not difficult to diagnose, both often go unrecognized by primary care providers. It has yet to be determined whether a multicomponent intervention that leverages electronic health records and behavioral economic principles can improve diagnosis, treatment, and control of hypertension in chronic kidney disease. MethodsThe aim of this pragmatic, cluster-randomized controlled trial is to evaluate a clinical decision support system based in behavioral economic and user-centered design principles that will: 1) synthesize existing laboratory tests, medication orders, and vital sign data; 2) increase recognition of chronic kidney disease, 3) increase recognition of uncontrolled hypertension in chronic kidney disease patients, and 4) deliver evidence-based chronic kidney disease and hypertension management recommendations. The intervention has been designed and piloted. The primary endpoint is the change in mean systolic blood pressure between baseline and 6 months compared across arms. We will use an effectiveness-implementation hybrid trial type 2 design and the RE-AIM framework to guide evaluation of process and outcome measures. Patients with two prior eGFR 16-59 mL/min/1.73m2 separated by 90 days or two prior UACR >30mg/g, one SBP >140 mmHg within the 2 years preceding the enrollment visit, and SBP >140 mmHg at enrollment will be included; patients with a most recent eGFR ≤ 20 or 2 previous eGFRs within 2 years separated by at least 90 days ≤ 15 will be excluded. Rao-Scott chi-square tests and GEE z-tests will be used. We calculated that 497 evaluable patients per arm and an average of 6 patients per provider would provide over 80% power to detect an average 3 mmHg SBP decrease in the intervention arm. Discussionhe proposed study, if successful, would be the first to improve hypertension in chronic kidney disease patients through a multicomponent intervention that incorporates clinical decision support and behavioral methods. Trial RegistrationClinicalTrials.gov identifier: NCT03679247. Registered September 20, 2018, https://clinicaltrials.gov/ct2/show/NCT03679247?term=Samal&draw=2&rank=1.

Introduction: Initial reports suggest that patients may delay seeking medical attention during the Coronavirus Disease 2019 (COVID-19) pandemic. Our aim was to determine if the COVID-19 outbreak is associated with a higher incidence of late presentations for patients with STEMI, greater need for mechanical circulatory support and PCI. Methods: We retrospectively evaluated consecutive patients that presented to a single, academic medical center with acute chest pain and ST-segment elevation on ECG from March 15 through June 17 in years 2019 and 2020. All patients were referred for emergent coronary angiography and the final cohort consisted of 32 patients. Medical records were reviewed to determine time between symptom onset and hospital arrival, need for PCI and/or mechanical circulatory support, total fluoroscopy time and volume of contrast administration during catheterization. Results: There was no significant difference in age, gender, cardiac risk factors or history of CAD between the cohorts that presented in 2019 compared with 2020 (Table 1). The mean time from symptom onset to arrival in the ED was 6.5 ± 8 and 9.2 ± 17 hours in 2019 and 2020 (p=0.55), respectively. PCI was performed during the index catheterization in 5 (50%) and 21 (95%) patients in 2019 and 2020 (p=0.01), respectively. Mean volume of contrast media used per case was 142 ± 65 ml in 2019 and 237 ± 104 ml in 2020 (p=0.017). There was a trend towards greater need for mechanical circulatory support and total fluoroscopy time during cases in 2020 (Table 1). Conclusions: In patients with suspected STEMI during the COVID-19 pandemic, there was a trend towards longer duration between symptom onset and arrival to the ED. More patients presenting with ST-segment elevation required PCI and there was a trend towards greater utilization of mechanical circulatory support. These findings may reflect a decline in access to outpatient services and/or delays in patients seeking care for acute chest pain.

A left ventricular (LV) false tendon is a frequently visualized structure in echocardiography with unclear clinical significance. We present the case of a false tendon serving as a nidus for thrombus in a post-orthotopic heart transplantation patient. Three-dimensional transthoracic echocardiography (3DTTE) was utilized to visualize a LV mass and facilitate its identification as a thrombus as well as the surrounding structures. Using datasets from 3DTTE, the lack of ventricular wall attachment and circumferential formation of the thrombus around the false tendon was identified. Serial imaging demonstrated resolution of the thrombus with anticoagulation.

Left ventricular free wall rupture is a feared complication of acute myocardial infarction typically presenting with cardiogenic shock. We present a case of spontaneous coronary artery dissection with free wall rupture and cardiac tamponade in an uncommon demographic. Friable myocardial tissue frequently precludes suture technique making biological glue repair a suitable option.

Hypertrophic cardiomyopathy (HCM) has a variable clinical presentation due to the diversity of causative genetic mutations. Animal models allow in vivo study of genotypic expression through non-invasive imaging, pathologic sampling, and force analysis. This review focuses on the spontaneous and induced mutations in various animal models affecting mainly sarcomere proteins. The sarcomere is comprised of thick (myosin) filaments and related proteins including myosin heavy chain and myosin binding protein-C; thin (actin) filament proteins and their associated regulators including tropomyosin, troponin I, troponin C, and troponin T. The regulatory milieu including transcription factors and cell signaling also play a significant role. Animal models provide a layered approach of understanding beginning with the causative mutation as a foundation. The functional consequences of protein energy utilization and calcium sensitivity in vivo and ex vivo can be studied. Beyond pathophysiologic disruption of sarcomere function, these models demonstrate the clinical sequalae of diastolic dysfunction, heart failure, and arrhythmogenic death. Through this cascade of understanding the mutation followed by their functional significance, targeted therapies have been developed and are briefly discussed.

Introduction A 38-year-old female with history of beta thalassemia requiring several blood transfusions yearly presented with fatigue and dyspnea. Case Report Transthoracic echocardiogram (TTE) revealed severe RV dysfunction and severe tricuspid regurgitation (figure 1) with elevated estimated RV systolic pressure. A presumptive diagnosis of right heart failure secondary to PH was made and the patient was empirically started on PH-specific therapy. The PH team was consulted. Careful review of the TTE revealed several features that were inconsistent with a RV failing due to high afterload. Systolic interventricular septal flattening occurs when the RV is being subjected to a high pulmonary vascular resistance (PVR). Notching of the RV outflow tract (RVOT) Doppler and earlier time to peak velocity (acceleration time) occurs with high pulmonary arterial impedance. None of these features were present on TTE. Right heart catheterization was confirmatory, demonstrating right atrial pressure 19 mmHg, pulmonary artery pressure 33/22 mmHg, wedge pressure 8 mmHg, PVR 4 Woods units, and cardiac index 2.6 L/min/m2. The degree of RV dysfunction was felt to be out of proportion to the degree of PH. Taken together with frequent premature ventricular contractions, cardiac MRI was performed to evaluate for another etiology of RV failure. T2 measurements were consistent with cardiac iron overload (figure 1). Serum ferritin was 26,713 ng/mL. Secondary hemochromatosis was diagnosed due to frequent blood transfusions for thalassemia management. The patient underwent IV iron chelation therapy with improvement in RV function and tricuspid regurgitation. Summary The severity of RV failure should be interpreted relative to the severity of PVR elevation in PH. Septal position and RVOT Doppler assessment on TTE can provide valuable insight into the physiology and mechanism of right ventricular failure. This case demonstrates this application, with subsequent use of MRI to confirm a rare diagnosis of RV failure due to secondary hemochromatosis

A 75-year-old man with a history of mechanical aortic valve replacement with aortic conduit for severe aortic insufficiency underwent routine screening computed tomography evaluation revealing right coronary anastomosis endoleak and proximal aortic root pseudoaneurysm.

Myocarditis encompasses both primary and secondary processes causing inflammation of the myocardium. Viral infections are a common secondary cause of myocarditis with important clinical relevance. Viral myocarditis has a varied clinical presentation, potentially resulting in significant morbidity and mortality. Acutely, systolic dysfunction and sudden cardiac death may ensue; chronically, myocarditis may result in a dilated cardiomyopathy requiring heart transplantation. Myocarditis is thought to be one of the most common causes of myocardial infarction with nonobstructive coronary arteries (MINOCA), with important consequences for cardiovascular outcomes. Patients with myocarditis are currently underdiagnosed. Cardiac MRI has evolved as the noninvasive test of choice, with cardiac MRI-specific diagnostic requirements defined in the Lake Louise Criteria (LLC). Detecting the presence of tissue edema, hyperemia, and necrosis in both acute and chronic stages form the foundation of the LLC. Cardiac MR for chronic myocarditis (greater than 8 weeks from symptom onset) has decreased sensitivity for diagnosis. Emerging sequences such as T1 and T2 parametric maps provide tissue characterization regarding inflammation without reliance on reference tissue, overcoming limitations of the LLC. Beyond diagnostic criteria, these imaging techniques have proven useful in further characterizing the diseased tissue, prognostication, and clinical decision-making. This review describes the utility and evolving use of cardiac MRI in clinical practice. Level of Evidence: 1 Technical Efficacy Stage: 5 J. Magn. Reson. Imaging 2018;47:1061-1071.

Autoimmune disorders are associated with microvascular obstruction (MVO) detected with cardiac magnetic resonance imaging (MRI). A 36-year-old man with systemic lupus erythematosus (SLE) presented to a hospital with chest pain. Positive cardiac enzymes and inferior ST elevations on

Objective Commotio cordis, sudden death with chest impact, occurs clinically despite chest wall protectors worn in sports. In an experimental model of commotio cordis, commercially available chest wall protectors failed to prevent ventricular fibrillation (VF). The goal of the current investigation was to develop a chest wall protector effective in the prevention of commotio cordis. Design In the Tufts experimental model of commotio cordis the ability of chest protectors to prevent VF was assessed. Impacts were delivered with a 40-mph lacrosse ball, timed to the vulnerable period for VF. Intervention A chest wall protector or no chest wall protector (control) was randomly assigned to be placed over the chest. Four iterative series of 2 to 4 different chest wall material combinations were assessed. Materials included 3 different foams (Accelleron [Unequal Technologies, Glen Mills, PA], closed cell high density foam; Airilon [Unequal Technologies, Glen Mills, PA], closed cell low density soft foam; and an open cell memory foam) that were adhered to a layer of TriDur (Unequal Technologies, Glen Mills, PA), a flexible elastomeric coated aramid that was bonded to a semirigid polypropylene polymer (ImpacShield, Unequal Technologies, Glen Mills, PA). Main outcome measure Induction of VF by chest wall impact was the primary outcome. Results Of 80 impacts without chest protectors, 43 (54%) resulted in VF. Ventricular fibrillation with chest protectors ranged from a high of 60% to a low of 5%. Of 12 chest protectors assessed, only 3 significantly lowered the risk of VF compared with impacts without chest protectors. These 3 chest protectors were combinations of Accelleron, Airilon, TriDur, and ImpacShield of different thicknesses. Protection increased linearly with the thicker combinations. Conclusions Effective protection against VF with chest wall protection can be achieved in an experimental model of commotio cordis. Clinical relevance Chest protector designs incorporating these novel materials will likely be effective in the prevention of commotio cordis on the playing field.

Compression of the left main coronary artery (LMCA) has been reported with pulmonary artery enlargement but rarely from aortic pathology. A 75-year-old man with history of mechanical aortic valve replacement (AVR) with aortic conduit for severe aortic insufficiency underwent routine screening

Substituted vinylcyclopropanes are prepared through a ruthenium-catalyzed, tandem three-component coupling between an olefin, alkyne, and diazoester. Grubbs’ 2nd generation (NHC) ruthenium complexes in the presence of ethylene effect a stereoselective enyne-cross metathesis between alkynes and olefins to generate 1,3-substituted dienes. The slow introduction of diazoacetates to this reaction mixture then allows for the regioselective cyclopropanation of the resulting diene. When the olefin reaction partner is just ethylene (i.e., R′ = H), the tandem process is less efficient. In this case, the byproducts provide unique insight into possible catalyst decomposition pathways.

Sudden cardiac death is a major issue in patients with HCM. The young are at particular risk for SCD, while those over 60 are less affected by SCD. There are five traditional risk factors for sudden cardiac death in patients with HCM, including: massively thick myocardium, unexplained syncope, family history of SCD due to HCM, nonsustained ventricular tachycardia, and hypotensive response to exercise. Currently, an ICD is recommended for resuscitated SCD and/or those with sustained ventricular tachycardia, and reasonable for those with massive hypertrophy (>3 cm), unexplained syncope and/or a family history of SCD, and also reasonable for patients with NSVT or abnormal blood pressure response to exercise, but usually when combined with other markers of heightened risk.

Substituted vinylcyclopropanes are prepared through a ruthenium-catalyzed, tandem three-component coupling between an olefin, alkyne, and diazoester. Grubbs’ 2nd generation (NHC) ruthenium complexes in the presence of ethylene effect a stereoselective enyne-cross metathesis between alkynes and olefins to generate 1,3-substituted dienes. The slow introduction of diazoacetates to this reaction mixture then allows for the regioselective cyclopropanation of the resulting diene. When the olefin reaction partner is just ethylene (i.e., R′ = H), the tandem process is less efficient. In this case, the byproducts provide unique insight into possible catalyst decomposition pathways.

Percutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) is associated with a high risk of complications due to distal embolization and no-reflow. Although distal protection devices are routinely used, periprocedural ischemic complications still occur in up to 10% of SVG interventions