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Background COVID-19 infection is known to cause a wide array of clinical chronic sequelae, but little is known regarding the long-term cardiac complications. We aim to report echocardiographic follow-up findings and describe the changes in left (LV) and right ventricular (RV) function that occur following acute infection. Methods Patients enrolled in the World Alliance Societies of Echocardiography-COVID study with acute COVID-19 infection were asked to return for a follow-up transthoracic echocardiogram. Overall, 198 returned at a mean of 129 days of follow-up, of which 153 had paired baseline and follow-up images that were analyzable, including LV volumes, ejection fraction (LVEF), and longitudinal strain (LVLS). Right-sided echocardiographic parameters included RV global longitudinal strain, RV free wall strain, and RV basal diameter. Paired echocardiographic parameters at baseline and follow-up were compared for the entire cohort and for subgroups based on the baseline LV and RV function. Results For the entire cohort, echocardiographic markers of LV and RV function at follow-up were not significantly different from baseline (all P > .05). Patients with hyperdynamic LVEF at baseline (>70%), had a significant reduction of LVEF at follow-up (74.3% ± 3.1% vs 64.4% ± 8.1%, P < .001), while patients with reduced LVEF at baseline (−20%) at baseline had significant improvement at follow-up (−15.2% ± 3.4% vs −17.4% ± 4.9%, P = .004). Patients with abnormal RV basal diameter (>4.5 cm) at baseline had significant improvement at follow-up (4.9 ± 0.7 cm vs 4.6 ± 0.6 cm, P = .019). Conclusions Overall, there were no significant changes over time in the LV and RV function of patients recovering from COVID-19 infection. However, differences were observed according to baseline LV and RV function, which may reflect recovery from the acute myocardial injury occurring in the acutely ill. Left ventricular and RV function tends to improve in those with impaired baseline function, while it tends to decrease in those with hyperdynamic LV or normal RV function.

Although acute coronary syndromes remain crucial diagnoses of chest pain that cannot be missed, there are several other potentially fatal diagnoses that can manifest similarly. This case report applies the 2021 chest pain guidelines emphasizing the importance of considering alternative nonischemic but still serious presentations under the umbrella of chest pain. (Level of Difficulty: Advanced.), Graphical abstract

A 32-year-old developmentally delayed man presenting with dyspnea was found to have severe aortic and mitral valve stenosis. After double valve replacement, unique histologic findings prompted a genetics evaluation, ultimately leading to the diagnosis of mucopolysaccharidosis type I, a rare lysosomal storage disorder with high rates of cardiac manifestations. (Level of Difficulty: Advanced.), Graphical abstract

A retained intracardiac catheter fragment left in situ for 2 years was incidentally found in a patient presenting with worsening heart failure and atrial fibrillation. This case describes the diagnostic evaluation of this rare event, with successful endovascular retrieval and resolution of his symptoms. (Level of Difficulty: Advanced.), Central Illustration

An 80-year-old man with a destination left ventricular assist device (LVAD) presented with decompensated heart failure. Evaluation demonstrated numerous LVAD high power spike events, significant aortic regurgitation, and hemolysis. He underwent successful aortic valve replacement with a novel transcatheter valve and LVAD pump exchange that resulted in an improvement in his clinical status. (Level of Difficulty: Advanced.), Central Illustration

Low flow alarms represent a management challenge in patients with left ventricular assist devices because they are often a consequence of complex patient-device interactions. We present a case of intermittent suction of the postero-medial papillary muscle into the left ventricular assist device inflow cannula during diastole, causing low flows. This case highlights the importance of a systematic approach and use of multiple investigation modalities in making an accurate diagnosis. (Level of Difficulty: Advanced.), Central Illustration

Objective To report the first case, to our knowledge, of intermittent pancytopenia and cardiac tamponade occurring together in association with Autoimmune Addison's Disease (AAD). Methods A 21 year-old woman presented on three different occasions with multiple complaints. Her evaluation was significant for intermittent pancytopenia (white blood cell, 1.3-3.0 × 103/μL [normal 4.5-11 × 103]; hemoglobin, 8.8-9.6 g/dL [11-16]; and platelets, 102-117 × 103/μL [150-400 × 103/μL]) and pericardial effusion with cardiac tamponade. Further investigation including a morning serum cortisol level of 0.6 μg/dL (5.27-22.45 μg/dL), adrenocorticotropic hormone level of 1027 pg/mL (normal 6-50 pg/mL), and positive 21-hydroxylase antibodies confirmed the diagnosis of primary adrenal insufficiency due to AAD. Treatment with steroids resulted in prompt hemodynamic recovery with normalization of all blood cell lines. Results The diagnosis of AAD is often delayed or overlooked. Pancytopenia occurring in AAD is most likely due to either marrow suppression in the setting of acute illness and exacerbated by hypoadrenalism or possibly an autoimmune-mediated marrow reaction. Pericarditis with cardiac tamponade has been described in AAD occurring in the setting of polyglandular autoimmune syndrome type II. The pathogenesis involves autoimmune inflammation of the pericardium, which precipitates an acute inflammatory reaction and rapid fluid accumulation. Conclusion Pericarditis with cardiac tamponade and intermittent neutropenia may be rare manifestations of an Addisonian crisis.

We present the case of a woman who developed presumed spontaneous coronary artery dissection of a septal branch. She later developed high-grade atrioventricular block that led to a diagnosis of cardiac sarcoidosis involving the interventricular septum. This case illustrates a rare and challenging presentation of cardiac sarcoidosis. (Level of Difficulty: Beginner.), Central Illustration

Intracavitary cardiac thrombi, uncommonly found in the right chambers, have been shown to form secondary to endocardial and myocardial diseases. The differential diagnosis for an intracavitary cardiac mass is broad, including primary cardiac tumors, cardiac metastases, anatomic variants, vegetations, and thrombi. Here we present a unique case with a large calcified intracavitary cardiac thrombus in a 26-year-old woman with obesity, immune thrombocytopenic purpura, and a new diagnosis of systemic lupus erythematosus. Initial imaging presentation in this case masqueraded as a tumor, delaying the true diagnosis. A combination of cardiac imaging techniques, including transthoracic and transesophageal echocardiograms, cardiac CT, and cardiac MRI were required to correctly diagnose this calcified bland thrombus.

Objectives This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-US institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic. Background The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality. Methods Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States. Results Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p, Central Illustration

Thyrotoxic periodic paralysis is a life-threatening complication of hyperthyroidism characterized by transient episodes of muscle paralysis and hypokalemia, commonly seen in Asian men. We present a rare case of ventricular fibrillation as the initial presentation of thyrotoxic periodic paralysis. (Level of Difficulty: Intermediate.), Central Illustration

Atrial septal defect (ASD) is a common congenital defect that leads to various hemodynamic complications if untreated. Transcatheter closure (TCC) of isolated secundum ASD is the preferred treatment. Herein we describe a unique malaligned ASD secondary to a membranous chord. With balloon sizing and intracardiac echocardiography (ICE), TCC was successfully pursued. (Level of Difficulty: Beginner.), Central Illustration

This paper describes the case of a patient who developed refractory heart failure due to a fistula from the left ventricle to the coronary sinus that was unintentionally created after a surgical myectomy and mitral valve replacement. Advanced image guidance with a pre-procedure 3-dimensional physical model and intraprocedure echocardiography fusion facilitated transcatheter plugging of the shunt with symptom resolution. (Level of Difficulty: Advanced.), Central Illustration

Exercise hemodynamic catheterization is helpful to evaluate exertional symptoms when noninvasive investigations fail to provide an explanation in non-ischemic cardiomyopathy. In this case, a rate-related left bundle branch block resulted in severe dynamic mitral regurgitation and acute increase in pulmonary capillary wedge pressure. Cardiac resynchronization therapy resolved her symptoms. (Level of Difficulty: Intermediate.), Central Illustration

We present the case of a symptomatic young woman with mitral stenosis and regurgitation due to a congenital mitral arcade. Multimodality imaging with echocardiography and computed tomography were used for diagnosis and surgical planning. The patient underwent successful bioprosthetic valve replacement. (Level of Difficulty: Intermediate.), Central Illustration

Background The novel severe acute respiratory syndrome coronavirus-2 virus, which has led to the global coronavirus disease-2019 (COVID-19) pandemic is known to adversely affect the cardiovascular system through multiple mechanisms. In this international, multicenter study conducted by the World Alliance Societies of Echocardiography, we aim to determine the clinical and echocardiographic phenotype of acute cardiac disease in COVID-19 patients, to explore phenotypic differences in different geographic regions across the world, and to identify parameters associated with in-hospital mortality. Methods We studied 870 patients with acute COVID-19 infection from 13 medical centers in four world regions (Asia, Europe, United States, Latin America) who had undergone transthoracic echocardiograms. Clinical and laboratory data were collected, including patient outcomes. Anonymized echocardiograms were analyzed with automated, machine learning–derived algorithms to calculate left ventricular (LV) volumes, ejection fraction, and LV longitudinal strain (LS). Right-sided echocardiographic parameters that were measured included right ventricular (RV) LS, RV free-wall strain (FWS), and RV basal diameter. Multivariate regression analysis was performed to identify clinical and echocardiographic parameters associated with in-hospital mortality. Results Significant regional differences were noted in terms of patient comorbidities, severity of illness, clinical biomarkers, and LV and RV echocardiographic metrics. Overall in-hospital mortality was 21.6%. Parameters associated with mortality in a multivariate analysis were age (odds ratio [OR] = 1.12 [1.05, 1.22], P = .003), previous lung disease (OR = 7.32 [1.56, 42.2], P = .015), LVLS (OR = 1.18 [1.05, 1.36], P = .012), lactic dehydrogenase (OR = 6.17 [1.74, 28.7], P = .009), and RVFWS (OR = 1.14 [1.04, 1.26], P = .007). Conclusions Left ventricular dysfunction is noted in approximately 20% and RV dysfunction in approximately 30% of patients with acute COVID-19 illness and portend a poor prognosis. Age at presentation, previous lung disease, lactic dehydrogenase, LVLS, and RVFWS were independently associated with in-hospital mortality. Regional differences in cardiac phenotype highlight the significant differences in patient acuity as well as echocardiographic utilization in different parts of the world.

Recurrent chylopericardium after cardiac surgery is a rare entity. This paper presents the case of a 69-year-old female who developed a large recurrent chylopericardium related to surgical myectomy and resection of sub-aortic membrane for hypertrophic sub-valvular aortic stenosis. Treatment required pericardiocentesis followed by lymphangiogram with glue embolization of the lymphatic leak. (Level of Difficulty: Intermediate.), Central Illustration

A 62-year-old woman with human T-lymphotropic virus type 1 cell lymphoma developed heart failure after mogamulizumab, an immunotherapy agent. Clinical presentation and cardiac magnetic resonance imaging were consistent with myocarditis, and a recurrence of heart failure occurred after rechallenge with the therapy. (Level of Difficulty: Advanced.), Central Illustration

Tumoral obstruction is a small, but broadly defined, category of pulmonary hypertension that encompasses microvascular tumor emboli, tumor thrombotic microangiopathy, and macrovascular tumor obstruction within the pulmonary circulation. We present 4 patients with solid tumors, severe pre-capillary pulmonary hypertension, right ventricular failure, and pulmonary veno-occlusive–like disease. (Level of Difficulty: Advanced.), Central Illustration

A 34-year-old man presented with fever, palpitations, maculopapular rash, pharyngitis, left cheilitis, and bilateral gonalgia. High-sensitivity troponin I concentration was 4,900 ng/l. Transthoracic echocardiogram revealed reduced global longitudinal strain. Cardiac magnetic resonance imaging showed acute myocarditis. Adult-onset Still’s disease was diagnosed, and treatment with intravenous corticosteroids and tocilizumab was initiated. (Level of Difficulty: Beginner.), Central Illustration

We present the case of a 60-year-old man who was successfully treated for obstructive fungal infective endocarditis of the ascending aorta caused by Geotrichum capitatum. This extremely rare cause of fungal infective endocarditis required surgical and prolonged medical management, facilitated by effective multidisciplinary cooperation. (Level of Difficulty: Intermediate.), Central Illustration

Primary cardiac angiosarcomas are rare malignant tumors with a very poor prognosis. We present a case of a 48-year-old man with no previous cardiac history who developed an incessant focal atrial tachycardia complicated by tachycardia-mediated cardiomyopathy as a consequence of cardiac angiosarcoma. (Level of Difficulty: Beginner.), Central Illustration

A multisystem inflammatory syndrome mimicking Kawasaki disease has been increasingly reported, mainly in children, in the context of coronavirus disease-2019 (COVID-19). We report on the first case of coronary aneurysm resolution after treatment with steroids and intravenous immunoglobulins in an adult patient with multisystem inflammatory syndrome temporally associated with COVID-19. (Level of Difficulty: Beginner.), Graphical abstract

A 78-year-old woman with bioprosthetic mitral valve degeneration at high risk for reoperation was referred for transcatheter mitral valve replacement. We describe the use of a preemptive alcohol septal ablation pre-procedurally to minimize the risk of acute left ventricular outflow tract obstruction given the anticipated need for a bioprosthetic valve fracture. (Level of Difficulty: Advanced.), Graphical abstract

Right ventricular infarction is often associated with significant morbidity and mortality. Here, we report a case of right ventricular infarction associated with persistent hypoxia due to acute right-to-left shunting through a patent foramen ovale. (Level of Difficulty: Intermediate.), Central Illustration

With increasing atrial septal defect (ASD) repairs, more women of childbearing age will have ASD closure devices. Current ASD closure trials have excluded women planning pregnancy, making their management challenging. We present a pregnant woman, with a repaired ASD, who presented with device-related infective endocarditis. (Level of Difficulty: Beginner.), Graphical abstract

A newborn with pulmonary hypertension due to the premature fetal arterial duct occlusion was diagnosed with a giant left ventricle thrombus. Cardiopulmonary compromise required multidrug therapy with vasopressors infusions, high-frequency oscillation, and nitric oxide. Alteplase infusion through a guiding catheter into the left atrium dissoluted the clot without sequelae. (Level of Difficulty: Advanced.), Graphical abstract

Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) is a multiorgan syndrome with rare and heterogenous cardiac manifestations. We present the case of a man with pericardial effusion complicated by cardiac tamponade, new onset atrial fibrillation, and high-degree atrioventricular block leading to a diagnosis of POEMS syndrome. (Level of Difficulty: Advanced.), Graphical abstract

A 39-year-old man presented with chest pain initially attributed to viral pericarditis. He was found to have an embolized inferior vena cava filter strut that perforated the right ventricle. Inferior vena cava filter fracture and embolization should be considered in patients with chest pain and pericardial effusion. (Level of Difficulty: Beginner.), Graphical abstract

Obstruction of the inferior vena cava (IVC) following surgical repair of an atrial septal defect (ASD) is a rare complication. We present the case of a patient who developed IVC obstruction following surgical repair of a large secundum ASD. The diagnostic and management approaches used to care for this patient are discussed. (Level of Difficulty: Intermediate.), Graphical abstract

Graphical abstract

A 52-year-old man presented with acute onset of chest pain and was found to have an inferolateral ST-segment elevation myocardial infarction and acute mitral regurgitation due to papillary muscle rupture. This case describes a rare, potentially fatal mechanical complication of acute myocardial infarction. (Level of Difficulty: Beginner.), Graphical abstract

Ventriculoseptal rupture (VSR) is a rare complication of takotsubo syndrome that often requires immediate treatment. Patients with VSR experience a range of outcomes and should be managed at centers with cardiac and surgical expertise. We present 2 cases of VSR complicating takotsubo syndrome that highlight potential outcomes. (Level of Difficulty: Intermediate.), Graphical abstract

Isolated chylopericardium is an exceedingly rare complication in any age group. Review of the limited published case series shows the most common cause of isolated chylopericardium to be cardiac surgery. We present a case of isolated chylopericardium after a bidirectional Glenn procedure in an infant with hypoplastic left heart syndrome. (Level of Difficulty: Intermediate.), Graphical abstract

We present a case of late presentation nontropical endomyocardial fibrosis isolated to the right ventricle and tricuspid valve (TV). In response to deteriorating hemodynamics, surgical debulking and TV removal were performed before initiation of centralized venoarterial extracorporeal membrane oxygenation support. Definitive endomyocardial resection with a TV prosthesis was then successfully completed. (Level of Difficulty: Advanced.), Central Illustration

A 70-year-old man with mechanical aortic and mitral valves was admitted with progressive shortness of breath. He was found to have thrombosis of the aortic valve prosthesis. Treatment with intravenous thrombolysis was complicated by an acute coronary syndrome related to coronary embolism. The patient was successfully managed conservatively with long-term anticoagulation. An algorithm for the management of coronary embolism is suggested. (Level of Difficulty: Advanced.), Graphical abstract

Coronary artery fistula are anomalous connections with coronary vessels or cardiac chambers, potentially resulting in coronary dilatation and pseudoaneurysm formation. We present the case of a 68-year-old woman referred to our institution for a voluminous coronary pseudoaneurysm secondary to coronary artery fistula presenting as a nearly completely obstructive left atrial mass. (Level of Difficulty: Intermediate.), Central Illustration

Tetralogy of Fallot (TOF) is a complex congenital cardiac defect. Surgical correction is well established as the treatment of choice and has resulted in a rapidly growing group of adults living with TOF. We describe potential complications of patients who have undergone TOF repair and were lost to follow-up. (Level of Difficulty: Intermediate.), Graphical abstract, Tetralogy of Fallot (TOF) is a complex congenital cardiac defect. Surgical correction is well established as the treatment of choice and has resulted in…

A 66-year-old woman with advanced diffuse large B-cell lymphoma (DLBCL) was referred for chimeric antigen receptor (CAR) T cell therapy. She was diagnosed with DLBCL 6 years prior to presentation and had no significant past medical history. She received a total of 10 cycles of rituximab

Levo-transposition of the great arteries is a congenital heart disease characterized by atrioventricular and ventricular-arterial discordance. Aortic valve disease in levo-transposition of the great arteries patients is uncommon. We present a patient with levo-transposition of the great arteries and severe aortic stenosis who successfully underwent transcatheter aortic valve replacement and the diagnostic and procedural challenges involved. (Level of Difficulty: Intermediate.), Graphical abstract, Levo-transposition of the great arteries is a congenital heart disease characterized by atrioventricular and ventricular-arterial discordance. Aortic…

The differential diagnosis of true aneurysms and pseudoaneurysms is challenging, and multimodality cardiac imaging is often necessary. We report a case in which the limitations of these techniques are exposed, showing that post-operative evaluation of tissue layers remains the gold standard in establishing this diagnosis. (Level of Difficulty: Beginner.), Graphical abstract

A 39-year-old man, painter by profession, presented with symptoms of heart failure. His work up was unrevealing except for elevated blood lead levels (BLL). He was started on guideline-directed medical therapy and was referred to occupational therapy. No improvement in his ejection fraction was noted until his BLL decreased. (Level of Difficulty: Intermediate.), Graphical abstract, A 42-year-old man, painter by profession, presented with symptoms of heart failure. His work up was unrevealing except for elevated blood lead levels (B…

The purpose of this series was to improve assessment of the aortic valve by echocardiography and to encourage echocardiographers to assess the cause of aortic regurgitation. The study illustrates the use of the Carpentier classification system for classifying the causes of regurgitation with a case series. (Level of Difficulty: Intermediate.), Graphical abstract, The purpose of this series was to improve assessment of the aortic valve by echocardiography and to encourage echocardiographers to assess the cause…

We report a case of giant cell myocarditis in a 76-year-old patient managed with combined immunosuppression and biventricular intravascular microaxial blood pumps. This case highlights a feasible approach for managing such patients who are not candidates for transplantation or durable ventricular assist devices. (Level of Difficulty: Intermediate.), Graphical abstract, We report a case of giant cell myocarditis in a 76-year-old patient managed with combined immunosuppression and biventricular intravascular m…

A significant concern in current coronavirus disease-2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation myocardial infarction (STEMI), due to reluctance to visit the hospital. We report a case of delayed presentation of STEMI as ventricular septal rupture during the COVID-19 pandemic, a rare presentation in the current age of primary percutaneous coronary intervention. (Level of Difficulty: Beginner.), Graphical abstract, A significant concern in current coronavirus disease 2019 (COVID-19) pandemic era is delay in first medical contact in patients with ST-segment elevation…

Drug rash with eosinophilia and systemic symptoms (DRESS)–associated myocarditis is a rare but life-threatening adverse drug reaction with a very high mortality rate and no effective therapies. We report a case of DRESS-associated myocarditis complicated by cardiogenic shock successfully treated with a novel targeted therapy. (Level of Difficulty: Advanced.), Graphical abstract, Drug rash with eosinophilia and systemic symptoms (DRESS)–associated myocarditis is a rare but life-threatening adverse drug reaction with a very…

Immunoglobulin G4–related disease is a systemic fibroinflammatory disease; pericardial involvement has occasionally been reported in publications. A 79-year-old man with biopsy-proven immunoglobulin G4–related disease with pleural involvement was admitted in acute heart failure, with imaging and hemodynamic studies consistent with constrictive pericarditis. He was treated with corticosteroids for 2 months with partial response manifest by decreases in pericardial thickening and immunoglobulin G4 levels. However, persistent constriction required pericardiectomy, leading to significant symptomatic improvement. (Level of Difficulty: Intermediate.), Graphical abstract, Immunoglobulin G4–related disease is a systemic fibroinflammatory disease; pericardial involvement has occasionally been reported in publications. A…

Septal reduction techniques can reduce morbidity and mortality in patients with hypertrophic cardiomyopathy. In a patient with hypertrophic cardiomyopathy who was a poor candidate for surgical myectomy and alcohol septal ablation, endocardial radiofrequency ablation of septal hypertrophy provided durable reduction in left ventricular outflow tract gradients and symptomatic improvement. (Level of Difficulty: Intermediate.), Graphical abstract, Septal reduction techniques can reduce morbidity and mortality in patients with hypertrophic cardiomyopathy. In a patient with hypertrophic…

Our patient presented in her third trimester of pregnancy with new onset of heart failure. A thorough workup in the initial postpartum period with detailed past medical history, advanced imaging modalities, and a multidisciplinary approach revealed a rare and treatable etiology of cardiomyopathy. (Level of Difficulty: Intermediate.), Graphical abstract, Our patient presented in her third trimester of pregnancy with new heart failure. A thorough workup in the initial postpartum period with detailed past…

A patient with severe, symptomatic functional mitral regurgitation was initially considered not suitable for MitraClip (Abbott Vascular, Abbott Park, Illinois) implantation because of non-coapting mitral leaflets. Repeated levosimendan infusions in combination with intensive diuresis induced sufficient valve coaptation, thus allowing MitraClip implantation to be performed. (Level of Difficulty: Intermediate.), Graphical abstract, A patient with severe, symptomatic functional mitral regurgitation was initially considered not suitable for MitraClip (Abbott Vascular, Abbott Park…