A 58-year-old White man with no known medical history initially presented to the emergency department for fatigue and was ultimately diagnosed with COVID-19. He was in stable condition and discharged to quarantine at home. He returned to the emergency department 2 weeks later with a chief report of progressive pain and swelling of his legs. Initial vitals were remarkable for a heart rate of 115/minute. Physical examination revealed edematous and erythematous lower extremities with weeping wounds. Laboratory workup was remarkable for a white blood cell count of 12.7 × 1,000/μL, platelet count of 81 × 1,000/μL, troponin I level of 0.678 ng/mL, brain natriuretic peptide level of 4,000 pg/mL, C-reactive protein level of 121 mg/L, lactate level of 3.7 mmol/L, and international normalized ratio of 1.5.Chest computed tomographic angiography revealed acute emboli of subsegmental pulmonary arteries of the left upper, middle, and lower lobes (Fig. 1). Echocardiogram revealed a severely dilated left ventricle with apical akinesis and an ejection fraction of 10% to 15%. Large, layered thrombi were seen in the apex of the left and right ventricles (Fig. 2). Duplexes of the lower extremities showed acute occlusive calf vein thrombi in the right posterior tibial and bilateral peroneal veins. Arteries were patent in both lower extremities. Venous duplex of the right upper extremity revealed acute superficial venous thrombi in the right basilic and cephalic veins. Cardiac magnetic resonance imaging was performed to assess viability, which revealed significant transmural scarring and a large thrombus (8 × 6 × 5 cm) occupying the mid- and complete apical left ventricle cavity (Fig. 3). Multiple small thrombi in the right ventricle apex were seen.Given the thrombocytopenia on presentation, there was concern for disseminated intravascular coagulation; however, with such extensive clot burden, the patient was started on a heparin drip. Four days later, he sustained a cardiac arrest secondary to venous thromboembolism. Upon achieving return of spontaneous circulation, he was taken for left heart catheterization, which revealed severe triple-vessel disease. Cardiothoracic surgery was consulted, but it was determined that the patient to be too high risk to undergo coronary artery bypass graft or operative thrombectomy. Ultimately, his clinical status deteriorated, and the patient along with family proceeded with comfort measures.SARS-CoV-2 infection primarily affects the lower respiratory tract, but there are reports of COVID-19–induced cardiac complications, including acute coronary syndromes, arrythmias, myocarditis, and thrombosis.1 Venous thromboembolism is reported to occur in approximately 30% of patients with COVID-19, but intracardiac thrombus in very rare.2 Cardiac thrombus should be considered in the diagnosis of COVID-19 in patients presenting with chest pain and leg swelling.

Introduction: Coronary artery calcium (CAC) score is a good predictor of coronary plaque burden and cardiovascular events, however its role in ischemic stroke and transient ischemic attacks (TIA) has been sparsely studied. Methods: Participants age ≥18 years with heart screen done from Nov 2008- Feb 2019 were selected and were assessed for documented Ischemic events (Ischemic stroke and TIA) after their heart screen. Only the most recent heart screen per person was considered. Patients were further divide into two groups based on their age. Comparisons between the two age groups was done using chi-square for categorical variables. Logistic regression was used to assess age and CAC as predictors of ischemic events and ROC curves were formed. Results: A total of 330896 individuals were included in the study over a span of 10 years, of which 53.9% were females. 894 (0.2%) patients were observed to have a documented diagnosis of ischemic stroke or TIA. Older patients (Age ≥50) were found to have significantly higher percentage of ischemic events as compared to young patients (3.5% vs 0.9%, p<0.001), which was also observed among various CAC groups. There was also a significant difference in distribution of CAC where older patients had higher CAC even when splitting the cohort into distinct CAC categories (P <0.001). On regression analysis elevated CAC and age were found to be a good predictors of ischemic events. Predictability of cerebrovascular ischemic events was significantly higher when elevated CAC score and patient age were considered together as compared age and CAC alone (P<0.001). Conclusion: Elevated coronary artery calcium score and age are a good predictor of ischemic stroke and TIA.

A 29-year-old female with a history of bioprosthetic mitral valve replacement was admitted with fever, chills, and shortness of breath of two weeks duration. Transthoracic echocardiography revealed a thickened bioprosthetic mitral valve with a 26 mmHg mean gradient consistent with severe mitral stenosis and associated large vegetation. Blood cultures demonstrated no growth. The patient underwent repeat mitral valve replacement surgery. At the time of operation, diffuse mitral valve thickening was observed, causing decreased mobility in both cusps with vegetation covering both sides of the valve. PCR with 16s rRNA sequencing of the tissue specimen revealed Gemella species DNA. Her recovery period was uneventful. Infective endocarditis very rarely causes obstructive/functional stenosis. When present, fungal organisms are typically implicated. These patients often present acutely with distinctive clinical evidence of obstruction, and they usually demonstrate rapid deterioration. Prompt diagnoses and timely surgery are essential.

Coronary artery calcium score (CAC) measured at a single time point can be used to estimate cardiovascular risk using specified age ranges. The purpose of this study was to examine the change in this risk estimate with serial measurement of CAC. Data was analyzed for patients enrolled in the