Immune checkpoint inhibitors (ICIs) are increasingly used to treat certain malignancies due to their higher efficacy compared with conventional chemotherapy. As familiarity with these agents increases, it is becoming apparent that a significant number of patients treated with ICIs experience adverse events. With time, more immune-related adverse events (IRAEs) are being recognised. It is important to be vigilant for IRAEs and recognise that a patient may have multiple IRAEs affecting multiple organ systems. Common cardiovascular adverse events associated with ICIs include myocarditis, arrhythmias and pericarditis. This case report identifies a patient presenting with takotsubo syndrome followed by ketoacidosis (associated with sodium-glucose transport protein 2 (SGLT2) inhibitor) in the setting of combination ipilimumab and nivolumab therapy for metastatic melanoma.

Learning points for cliniciansAt the time of submission of this article, there are nearly 1.4 million confirmed cases of coronavirus disease 2019 (COVID-19) worldwide with around 82 000 deaths.Inarguably, this has led to anxiety and panic all around.It is important to keep in mind that this negative emotion could lead to Takotsubo (stress-induced) cardiomyopathy.

Scrotal haematoma is an extremely rare complication after cardiac catheterisation (CC) with only few cases reported in literature. We report a 56-year-old patient who developed large scrotal haematoma after CC via transfemoral approach requiring blood transfusion due to haemodynamic instability. After an uneventful elective procedure, he was discharged with a collagen plug-based vascular closure device (Angio-Seal). He developed sudden onset, excruciating groin pain with scrotal swelling and shock. Bleeding was stopped with manual compression over the femoral artery and 2 units of packed red blood cells were transfused. CT angiogram revealed scrotal haematoma without active bleeding. Testicular blood supply remained intact. Scrotal swelling improved with conservative management and patient got discharged 3 days later in a stable condition. The review of literature suggests that penoscrotal haematoma is unusual after CC but may result from arterial injury or bleeding into the fascial planes. Majority of patients require observation but surgery is indicated in selected cases for vascular complications.

SESSION TITLE: Heart Failure and Cardiogenic Shock SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Takotsubo cardiomyopathy (TCM), also known as apical ballooning syndrome, mimics acute coronary syndrome. We report a unique case of a female who presented as STEMI with hypotension, and was found to have TCM causing significant Left ventricular outflow tract (LVOT) obstruction. CASE PRESENTATION: A 70-year-old female with history of hypertension, hyperlipidemia presented to our ER with exertional shortness of breath and chest pain. She denied any recent stress. She was hypotensive with BP of 80/43 mmHg and had bibasilar pulmonary rales. Lab showed BNP of 1673 pg/ml and positive cardiac troponins which increased from 3.76 to 4.25 ng/ml. Chest X-ray revealed pulmonary vascular congestion. EKG showed ST-elevation in anterior leads. ECHO showed EF of 35% with akinetic LV apex and dynamic LV outflow tract obstruction with peak velocity of approximately 4 m/s. Patient underwent cardiac catheterization that showed clean coronaries. Left ventriculogram showed basal hypokinesis with apical ballooning during systole (Figure 1). The above findings along with ST-elevation on EKG were consistent with TCM. Thus, the diagnosis of TCM with LVOT obstruction was established. She was medically managed with beta-blockers. Repeat ECHO performed 5-days later showed complete recovery of LV systolic function with resolution of apical ballooning. She was later discharged home in a stable condition and she continued to do well at 3-month follow up. DISCUSSION: TCM is known to cause transient systolic LV dysfunction and ST-T changes on ECG following various triggering factors. Our case is an example of a rare presentation of TCM causing LVOT obstruction and hypotension initially mimicking STEMI. A review of literature suggests that only 10-20% of patients with TCM develop cardiogenic shock. Hypotension may develop in patients with TCM due to multiple mechanisms such as left ventricular systolic dysfunction, significant mitral regurgitation secondary to systolic anterior motion of the mitral valve, dynamic LVOT obstruction, or a combination of these factors (1). As the management of cardiogenic shock due to LVOT obstruction is very different from other causes of cardiogenic shock, all patients with suspected TCM causing shock should first undergo ECHO to rule out LVOT obstruction. Inotropic agents and intraaortic balloon pump (IABP) used for the treatment of cardiogenic shock due to STEMI can paradoxically increase LVOT pressure gradients and worsen the dynamic gradient in patients with TCM and LVOT obstruction (1). This can lead to worsening of shock and catastrophic sequelae. CONCLUSIONS: In patients with hypotension and ECHO suggestive of TCM, LVOT obstruction must be ruled out. Inotropic agents and IABP are relatively contraindicated in cardiogenic shock due to LVOT obstruction. Thus, timely diagnosis and appropriate management of TCM with LVOT obstruction is imperative. Reference #1: Shah BN, et al. JACC Sep 2011;58(11);1195-1196. DOI:10.1016/j.jacc.2011.03.062 DISCLOSURE: The following authors have nothing to disclose: Parita Soni, Sameer Chadha, Nidhi Aggarwal, Anand Kumar Rai, Yizhak Kupfer, Bilal Mailk No Product/Research Disclosure Information

SESSION TITLE: Genetic Disorders SESSION TYPE: Case Report Slide PRESENTED ON: Saturday, April 16, 2016 at 02:15 PM - 03:45 PM INTRODUCTION: Left Ventricular Non-Compaction Cardiomyopathy (LVNCC) is a rare myocardial disorder which results from failure of left ventricle to compact in embryogenesis. It is characterized by a two-layered ventricular wall, an outer compacted epicardial layer and an inner non-compacted layer composed of prominent trabeculations and deep inter-trabecular recesses which communicate with LV cavity. CASE PRESENTATION: A 44 year old male with history of dilated cardiomyopathy s/p AICD presented to our ER with complaints of SOB, dry cough, and leg edema. Patient reportedly stopped taking his Lasix two weeks ago. Exam was significant for elevated JVD, mild crackles and pedal edema. Labs showed elevated troponin (0.41 ng/ml) and BNP (1771 pg/ml). Echocardiogram revealed severely decreased LV systolic function (EF <10%) with severely dilated LV cavity, severe diastolic dysfunction, prominent LV trabeculations, and deep inter-trabecular recesses communicating with the LV cavity, consistent with LVNCC (Fig. 1). Patient was initiated on diuretics and an aldosterone antagonist, added to his regimen of beta blocker and ACE inhibitor, started on IV heparin, and subsequently bridged to Coumadin for anti-coagulation for low EF. He was discharged in stable condition to follow up with advanced heart failure for Cardiac Transplant and LVAD evaluation. DISCUSSION: LVNCC was first reported in 1932 in association with other congenital cardiac abnormalities (1). It is a genetically heterogeneous disorder with familial and sporadic forms and can be linked to mutations in mitochondrial, cytoskeletal, Z-line, and sarcomeric proteins. Reported prevalence of LVNCC varies considerably and is estimated to be between 0.014 and 1.3%, however, the true prevalence is unknown as it is often unrecognized. Patients usually present with heart failure, ventricular arrhythmias or systemic embolic events. Echocardiography is the first line imaging modality and diagnostic criteria include end-systolic ratio of non-compacted layer/compacted layer >2 and evidence of blood flow in intertrabecular recesses from the LV cavity on Color Doppler Imaging, in the absence of other cardiac abnormalities. The Cardiac MRI may be used for confirmation of the diagnosis. Treatment consists of standard heart failure therapy, management of arrhythmias and consideration of oral anti-coagulation in high risk patients to prevent systemic embolic complications. Due to high familial recurrence, genetic testing of affected individuals and screening of first-degree family members is also recommended. CONCLUSIONS: Still considered a novel entity, LVNCC is getting increasingly recognized because of heightened awareness and improved cardiac imaging modalities and physicians should be aware of this rare cardiomyopathy. Reference #1: Bellet S, Gouley BA. Congenital heart disease with multiple cardiac anomalies: report of a case showing aortic atresia, fibrous scar in myocardium and embryonal sinusoidal remains, Am J Med Sci. 1932, 183:458-65. DISCLOSURE: The following authors have nothing to disclose: Jeffrey Le, Shelly Brejt, Sameer Chadha, Nadine Montemarano, Joshua Kerstein, Jacob Shani No Product/Research Disclosure Information

SESSION TITLE: Cardiology and Cardiothoracic Surgery SESSION TYPE: Case Report Poster PRESENTED ON: Sunday, April 17, 2016 at 11:45 AM - 12:45 PM INTRODUCTION: We report a rare case of an Invasive Thymoma in a 56 year old male. The mediastinal tumor in our patient was invading the superior vena cava (SVC), and through the SVC, the tumor was extending into the right atrium and right ventricle, reaching up to the pulmonic valve. CASE PRESENTATION: A 56 year old male presented to our emergency department with complaints of worsening shortness of breath and pleuritic chest pain. The Chest X-ray showed widening of the mediastinum but no infiltrates or pleural effusion. A CT chest was performed which revealed an 8 x 5.5 x 5 cm heterogeneous mass in the anterior mediastinum along with superior vena cava infiltration and extension of the mass into the right atrium (Figure A). The echocardiogram revealed further extension of the tumor from the right atrium to the right ventricle, up to the pulmonic valve (Figure B). The mass was partially obstructing both tricuspid and pulmonic valves. A biopsy of the mass was performed which came back consistent with an ‘Invasive Thymoma’. The patient was offered surgery but he refused any aggressive measures despite counseling. DISCUSSION: Thymomas account for around 20 percent of all mediastinal neoplasms. They are usually diagnosed as an incidental finding on radiographic studies but can present with chest pain, shortness of breath, SVC obstruction or paraneoplastic syndrome (most commonly myasthenia gravis) [1]. The metastatic involvement of the heart is more common than primary cardiac tumors. The metastasis can occur via direct invasion from the mediastinum, hematogenous spread or rarely, as in our patient, infiltration into the vena cava and then extension into the right atrium. CONCLUSIONS: Although rare, Invasive Thymoma, should be considered while evaluating a right atrial mass. Reference #1: 1. Safieddine N, Liu G, Cuningham K, et al. Prognostic factors for cure, recurrence and long-term survival after surgical resection of thymoma, J Thorac Oncol. 2014 Jul;9(7):1018-22. DISCLOSURE: The following authors have nothing to disclose: Sameer Chadha, Ankur Lodha, Adnan Sadiq, Jacob Shani No Product/Research Disclosure Information

Spontaneous coronary artery dissection is defined as a hemorrhagic separation of the media of the coronary artery with creation of a false lumen. It is an extremely rare clinical entity with an estimated incidence of around 0.1 - 0.2% in patients undergoing cardiac catheterization for acute coronary syndrome. It usually affects middle-aged females and is often associated with pregnancy, use of oral contraceptives, cocaine abuse, hypertension and connective tissue disorders. We describe a rare case of Spontaneous coronary artery dissection in a young male.

Hyperbaric oxygen therapy (HBOT) has been shown to be effective in the treatment of diabetic ulcers, air embolism, carbon monoxide poisoning and gas gangrene with minimal adverse effects. Very few cases of HBOT causing acute pulmonary edema (PE) has been described; with a study on dogs suggesting that a complication of this therapy could be PE. We describe the case of an 80-year-old man with a history of stable systolic heart failure and diabetes mellitus presenting with acute PE following treatment with HBOT for diabetic foot.

A 46-year-old man emergently presented after developing chest pain while running for a taxi. He reported no associated shortness of breath, palpitations, or dizziness. His vital signs were stable, and the results of respiratory and cardiovascular examination were normal. An electrocardiogram showed ST-segment elevation in leads V2 through V6 (Fig. 1). An urgent coronary angiogram revealed narrowing at the origin of the left main coronary artery (LMCA) that did not resolve after intracoronary nitroglycerin was administered (Fig. 2). However, there was no evident atherosclerotic disease.

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TITLE: Cardiovascular Cases

A 73 year old female with no past medical history presented to our emergency department (ED) with gradually worsening shortness of breath for a few weeks. She denied any associated complaints of chest pain, palpitations or dizziness. On physical exam, the patient had bilateral rales at the lung bases. The electrocardiogram showed low voltage complexes with right bundle branch block and left anterior fascicular block (Figure 1). The laboratory work came back significant for an elevated BNP (1452 pg/ml) with a normal complete blood count, serum chemistry and negative cardiac biomarkers. The patient was treated with intravenous diuretics in the ED and admitted to a telemetry floor.

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TITLE: Cardiovascular Case Report Posters II