key: cord-0051882-d0tsfrm2 authors: nan title: Full Issue PDF date: 2020-10-21 journal: JACC Case Rep DOI: 10.1016/s2666-0849(20)31119-0 sha: 8224df39f2040d7207dd1719fcb90b0d6e5e6f51 doc_id: 51882 cord_uid: d0tsfrm2 nan Initial oxygen saturation of 78% on the right foot and an oxygen saturation differential was observed with upper extremity saturation of 92%. Blood pressure was 58/31 mm Hg, heart rate was 147 beats/min, temperature was 36.6 C (97.9 F), and respiratory rate 85 breaths/min. Blood gas showed metabolic acidosis (pH 7.23, bicarbonate 17 mmol/l, base excess À10.0 mmol/l, lactate 7.3 mmol/l). Chest radiograph was notable for pulmonary plethora and bilateral hazy opacities concerning for pulmonary edema. In the setting of respiratory distress with differential cyanosis, the patient was transferred from newborn nursery to the neonatal intensive care unit with a subsequent screening bedside echocardiogram showing severely depressed left ventricular (LV) function. To evaluate cardiogenic shock in a neonate with elevated cardiac enzymes and electrocardiogram changes concerning for myocardial ischemia should prompt evaluation of coronary arteries when no other etiology is immediately apparent. To recommend management of coronary thrombosis in a tertiary care center with availability of extracorporeal membrane oxygenation and a multidisciplinary team for reducing morbidity and mortality. In the neonatal intensive care unit, cardiac markers were elevated with troponin (12 ng/ml) and creatine kinase myocardial band (135.6 ng/ml). The ECG showed a QS pattern in lead I and AVL concerning for lateral infarct (Figure 1 ). An echocardiogram showed severely depressed LV function (ejection fraction, 25%), moderate-to-severe mitral regurgitation, and no evidence of critical aortic stenosis or coarctation (Video 1). The clinical status, lactic acidosis, and troponin levels continued to worsen. Prior suggested etiologies for coronary thrombosis in the structurally normal heart include hypercoagulability, prematurity, neonatal asphyxia, myocarditis, delayed cord clamping, paradoxical systemic emboli off the renal or placental vasculature through a patent foramen ovale into the left side of the heart, and placement of an umbilical venous catheter (1) (2) (3) . In many cases, similar to this patient, no identifiable cause is detected. A common feature of all of these patients at presentation has been global ventricular dysfunction from ischemia causing "myocardial stun," a physiologically reversible process, especially in the neonatal myocardium (4) . Earlier studies have reviewed the important role of hemodynamic stabilization with ECMO and association with long-term survival (5, 6) . In recent years, successful use of selective intra-coronary injection of recombinant tissue plasminogen activator has been described (7) (8) (9) . Others have reported surgical thrombectomy (10) . post-operative day 7, the patient was successfully decannulated from ECMO. Follow-up brain magnetic resonance imaging/magnetic resonance angiography/ magnetic resonance venography showed right parietal subacute ischemic stroke, multifocal hemorrhage supra-and infra-tentorial, and no cerebral venous thrombosis. There was discussion to start anticoagulation with low-molecular-weight heparin for an unprovoked coronary thrombosis; however, given the concern for intra-cranial hemorrhage, the decision was made to hold off. Follow-up head ultrasound showed no change in findings. The patient was discharged home on postoperative day 30 with mildly depressed LV systolic function (ejection fraction 48%). LV function has improved gradually 3 months post event with a normal ejection fraction of 56% (Video 4). All authors have reported that they have no relationships relevant to the contents of this paper to disclose. afebrile with a blood pressure of 92/60 mm Hg, a heart rate of 103 beats/min, and oxygen saturation of 94% on room air. Her physical exam findings were suggestive of volume overload, including jugular venous distension, bilateral lung crackles, hepatomegaly, and lower-extremity edema. Her past medical history was notable for a malignant carcinoid tumor with mesenteric metastasis in 2009, which was resected and treated with monthly octreotide injections. In June 2017, she was deemed to be in remission based on laboratory and imaging studies; therefore, octreotide was discontinued. In early 2018, she suffered multiple major depressive episodes with psychosis and was started on the selective serotonin reuptake inhibitor (SSRI) citalopram with gradual dose up-titration over the course of several months. Six months later, she developed flushing, diarrhea, and progressively worsening dyspnea on exertion requiring multiple hospitalizations. The differential diagnosis for heart failure exacerbation included coronary ischemia, valvular heart To understand the pathophysiology of carcinoid heart disease. To discuss the role selective serotonin reuptake inhibitors may play in the development of valvular heart disease. To emphasize the significant mortality associated with carcinoid heart disease. To discuss a potential mechanism for selective serotonin reuptake inhibitor-induced carcinoid heart disease late after carcinoid tumor therapy. The exact mechanism for development of CHD in the setting of CS is poorly understood. A strong body of evidence implying that 5-HT is linked to cardiac valve disease exists (3, (5) (6) (7) . The popular diet pill fenfluramine-phentermine, which has 5-HT-releasing activity from the 5-HT transporter, brought to light the relationship between 5-HT and valvular heart disease (8) . Remarkably, the valve pathology seen with the use of fenfluramine-phentermine is similar to findings in CHD. 5-HT 2B , a subtype of the 5-HT receptor, is most prevalent on cardiac valves (4) (5) (6) 9) . Activation of 5-HT 2B causes upregulation of fibroblast proliferative properties, such as tissue growth factor B1, which leads to deposition of plaques on the endocardial surfaces of the valve leaflets and the subvalvular apparatus (3) (4) (5) 7) ; thus, resulting in valve regurgitation. Urinary 5-hydroxyindoleacetic acid, the serotonin metabolite which reflects the amount of serotonin production, is significantly higher in patients with CHD compared with those without cardiac involvement (2, 10) , implicating 5-HT as the mechanism for valvular heart disease. SSRIs increase the availability of 5-HT by inhibiting the 5-HT transporter that transports 5-HT from synaptic spaces into presynaptic neurons (9) . Somatostatin receptors are expressed in approximately 80% to 90% of NETs, which makes them a therapeutic target (8) . The mechanisms by which somatostatin and its analogues exert their effects on the NET cells are complex and not well described (8) . We know from various studies that use of somatostatin analogues can modify the 3-dimensional configuration of somatostatin receptors. This alteration affects receptor regulation and density at the cell surface (8) , which may explain why somatostatin analogue resistance is encountered in patients with CS after long-term octreotide therapy. We theorize a similar modification may occur with 5-HT receptors after long-term use of octreotide. Although no evidence establishes the role of SSRIs in CHD, multiple case reports regard SSRIs as responsible for unmasking CS in patients with an occult carcinoid tumor (9) . Her surgery was initially postponed due a continuing rise in chromogranin A level despite octreotide therapy. She was transitioned to lanreotide as this has been shown to have similar efficacy and is better tolerated than octreotide. Telotristat ethyl, a tryptophan hydroxylase inhibitor that reduces peripheral 5-HT levels, was also initiated. Because of the coronavirus disease 2019 pandemic, her surgery has been postponed. Guidance on the safety of antidepressants in NETs, CS, and CHD is lacking. To our knowledge this is the first case report where SSRIs may cause rapid progression of CS to CHD in the setting of previous treatment with a somatostatin analogue. We hypothesize that the exposure to long-term octreotide changes the density and/or sensitivity of 5-HT receptors on carcinoid tumors, laying the foundation for a predisposition to CHD. Coupled with the additional insult of increased 5-HT availability from SSRIs, a reactivation of CS occurred with subsequent CHD. Unmasking of undetectable micro-disease by the use of SSRIs cannot be excluded. This case highlights the The valve thickening other than calcification could result from myxomatous degeneration, postinflammatory valvular involvement (e.g., rheumatic heart disease, endocarditis, and autoimmune diseases such as lupus), and less frequently carcinoid heart valve disease. The rare causes of valvular heart disease include storage diseases and drug-related valvular pathology such as seen in the present case with SSRI use; other drugs include ergotamine and anorectic agents (2, 3) . Distinct pathologic alterations seen in valves in carcinoid heart disease, rheumatic heart disease, and myxomatous degeneration are discussed subsequently (Figures 1 to 3) . In carcinoid heart disease, the endocardium of the right-sided chambers of the heart, tricuspid and pulmonary valves, the subvalvular apparatus (chordae tendineae and papillary muscles), venae cavae, pulmonary artery, and coronary sinus are involved (4) . The right-sided valves account for 92% of the surgically excised valves (5) . Clinically, tricuspid valve is affected in 90% of patients with established carcinoid heart disease (6) . The valvular dysfunction in carcinoid heart disease occurs due to the formation of There is no evidence of commissural fusion, and calcification is usually not seen (11, 12) . On echocardiography, myxomatous Barlow disease appears as thickening and redundancy of the mitral valve leaflets, which can be associated with valve prolapse, flail segments, and mitral annular disjunction. The tricuspid valve can be similarly affected in some patients. On the other hand, fibroelastic deficiency results in a localized prolapse or flail valve segment without diffuse valve thickening. In conclusion, although rare, carcinoid heart disease results in a unique pattern of cardiac pathology and valvular dysfunction, distinct from other more common causes of valvular involvement. Understanding the pathologic basis of this condition helps highlight the features commonly seen on in vivo cardiac imaging. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The electrocardiogram demonstrates atrial dissociation with 2 distinct P-wave morphologies, from both the donor and native sinus nodes ( Figure 3 ). Native sinus node activity is dissociated from the active rhythm. Distinguishing this from other atrial arrhythmias and, specifically, atrioventricular block is important, because the management is different. The patient underwent a heart transplant using the biatrial anastomosis technique, which involves suturing the donor right atrium to a portion of the native right atrium. This was done to displace the ventricles more laterally to the left and reduce the amount of compression on the right ventricle by his pectus excavatum after chest closure. In the biatrial technique, the native sinus node is frequently preserved but does not conduct to the transplanted donor heart because of disruption of blood supply and denervation. There is also conduction block across the suture line in the right atrium (1) . Atrial dissociation after orthotopic heart transplant is not commonly seen these days because the bicaval anastomosis technique is considered a more preferable approach except under unique circumstances (2, 3) . We describe a 70-year-old man who presented with gastrointestinal bleeding and was found to have evidence of heart failure and severe aortic stenosis (peak/mean gradients: 125/80 mm Hg, respectively). Coronary angiography was without significant obstruction. Four-dimensional ECG-gated cardiac computed tomography (CT) angiography ( Figure 1 ) however, a contained area of contrast extravasation was noted on aortography ( Figure 2 , Video 1). The patient remained asymptomatic and hemodynamically stable and was admitted to the cardiac care unit. To review a case of contained annular rupture occurring during post dilation after self-expanding TAVR implantation. To recognize the imaging findings of annular rupture. To understand the role of surgical and nonsurgical management of annular rupture. Prior to presentation, there was no prior medical or surgical history. The differential diagnosis of contrast extravasation from the aorta or LVOT to the extraluminal space is limited and includes contained or uncontained aortic root and LVOT rupture. Uncontained annular rupture is estimated to occur in 0.4% of TAVR cases (1) (2) (3) (4) . Risk factors have been described including subannular LVOT calcification, Contained annular rupture is more common than uncontained rupture, occurring in 1.2% to 4.6% of TAVR cases (11, 12) and is associated with more favorable short and long-term outcomes (5, (11) (12) (13) (14) . Notably, all patients in these prior series were implanted with balloon-expandable valves. For contained rupture, a "watchful waiting" approach is recommended (3) (4) (5) 15 ). Percutaneous management of annular rupture with a self-expanding valve presents unique challenges as the valve scaffold is longer, complicating visualization and reaccess. We are aware of 1 other case where a percutaneous strategy was used (9) . In that case, the rupture was uncontained and the injury was accessible from the left coronary cusp with an XB-LAD guiding catheter (Cordis, Santa Clara, California) in the standard fashion for coronary reaccess after TAVR. Annular rupture is a term that refers to a broad and imprecise category of injuries to the TAVR landing zone (2) and can be further categorized based on anatomical location, completeness of injury (contained or uncontained), and subsequent impact (e.g., pericardial effusion, coronary compromise, or fistula). The reported incidence is 0.5% to 1.0%, but is probably higher due to unidentified contained ruptures of little clinical significance. Annular rupture accounts for 15% of patients requiring a bail-out surgical procedure following TAVR, and in-hospital mortality is 50% for contained and >75% when uncontained (3, 4) . Anatomically, injuries may be annular, subannular, or supra-annular (5) . Detailed knowledge of landing zone anatomy is essential for operators in understanding the mechanism and impact of potential injuries, particularly in the subannular region. Annular injuries are typically localized and may subsequently be sealed by the implanted valve. Supra-annular injuries may traumatize the aortic wall (leading to aortic dissection) or coronary ostia. The differential diagnosis included neurogenic claudication and critical limb ischemia. The patient's orthopedic disease was ruled out by an orthopedic surgeon because the patient did not display any neurological signs. When the right SFA was treated, an angiogram revealed an eccentric calcified plaque in the left distal SFA. As previously reported, IVUS and OCT may be used to diagnose CN plaques in clinical practice (2) . However, it is sometimes difficult to distinguish them from thrombotic lesions. As shown in Figure 2 , highresolution angioscopy can easily distinguish plaque from thrombotic lesions. In combination with angioscopy and IVUS or OCT, diagnostic accuracy can be further improved. Eight months after the patient was treated, the SFA was checked using echography, because of intermittent claudication. Echography showed severe stenosis of the proximal left SFA. When the proximal SFA lesion was checked, angiography, IVUS, and angioscopy were performed in the previously treated distal SFA lesion. This lesion showed mild stenosis in the angiogram and kept sufficient lumen area in the IVUS images and small CNs without thrombi in the angioscopy images ( Figure 4 ). CNs confirmed by angioscopy and histological examination in this case may help to elucidate the histophysiology of this condition. Figure 1 ). The patient's medical history was notable only for palpitations and the above evaluation and treatment. The differential diagnosis included possible drug reaction and allergic reaction to the recently implanted device or other contact allergens. Nickel exposure is known to induce urticaria in a subset of patients with nickel allergy, and has been previously reported in association with various implants (13) . As in the current case, systemic allergic contact dermatitis to nickel following implantation of an intracardiac device that resolved with explantation has been described (14) . In this prior report, patch testing showed a 3þ reaction to nickel sulfate, whereas other investigations such as serum nickel testing and an evaluation of in vitro nickel elution from the device did not show elevated nickel levels. Rates of device-related allergic reactions are difficult to estimate as the entity is poorly defined, not well understood mechanistically, and apparently rare (15 As of 3 months post-procedure, the patient has done well clinically and has remained free of urticaria or any allergic or cardiovascular symptoms. Figure 2D , Supplemental Follow-up coronary angiography 12 months after the last PCI showed a fourth restenosis at the CN lesion. However, PCI was deferred because of its fractional flow reserve at 0.86 ( Figures 5A and 5B ). OCT imaging visualized the presence of multiple protruding CNs, but the lumen area was not substantially compromised. The repeated coronary angiography 2 years after the last PCI identified that the degree of stenosis at the ISR lesion did not change ( Figure 5C ). She continued to take DAPT after the last PCI. In the current case, the CN exhibited refractory ISR following newer-generation DES implantation. Nakano et al. Nakano et al. (12) . However, because CN is protruding into the lumen and its eccentric shape, a caution must be taken to avoid perforation due to a wire bias to the normal site, which was observed in the current case. One can speculate as to the mechanism of action of the laser: as excimer laser ablates only on contact, one wonders whether the acoustic effects of laser energy-fractured calcific segments that allowed more successful balloon compression and less reprotrusion. The authors do appropriately cite orbital atherectomy and intravascular lithotripsy as potential alternatives as well. In summary, this case highlights an infrequent but vexing problem in percutaneous coronary intervention treatment of acute coronary syndromes and demonstrates the value of novel case reports in stimulating new approaches to rare problems. Here, we describe the novel approach of percutaneous insertion and removal of the Impella 2.5 via the brachial artery in two cases: a patient with morbid obesity and poor left ventricular ejection fraction (LVEF) undergoing high-risk PCI, and a patient with cardiogenic shock after acute anterior myocardial infarction who required hemodynamic support. A 45-year-old man with a history of type 2 diabetes mellitus requiring insulin who was morbidly obese (body mass index 51 kg/m 2 ) presented with stable but severe angina pectoris and dyspnea. Coronary angiogram revealed 3-vessel disease with an at least 50% stenosis in the distal left main artery (LM). The To describe the feasibility of a novel approach for Impella support through brachial artery access in patients in whom conventional insertion is not possible. To describe how insertion of larger bore devices via the brachial artery may be safely executed. CLINICAL OUTCOMES. The patient recovered quickly without any chest complaints. There were no signs of neurovascular injury, ischemia, or other procedural complications, and he was discharged the next day. He has resumed his activities and no longer experiences shortness of breath. His LVEF has improved from 24% to 34% at 6 months post-procedure. Our second case was treated some years ago. Briefly, a The authors have reported that they have no relationships relevant to the contents of this paper to disclose. another question that arises is whether the axillary approach has now equal or better outcomes compared with the femoral approach and whether it can be used even in the setting of intact iliofemoral arteries (16, 17) . In conclusion, insertion of Impella 2. Dr. Koutroumpakis has reported that he has no relationships relevant to the contents of this paper to disclose. A 74-year-old man was admitted to the cardiology department with progressively worsening retrosternal chest pain for several weeks. He had now developed chest pain at rest that improved within 5 min after nitroglycerin administration. Physical examination was unremarkable and vital signs were normal (heart rate 52 beats/min, blood pressure 155/70 mm Hg after nitroglycerin). The patient's medical history included non-insulin- Clinical presentation and medical history were highly suggestive for a recurrent acute coronary syndrome. Theoretically, the patient could also have had hypertension or intermittent arrhythmias. In degenerated SVGs, calcifications are predominantly found in the vessel wall instead of in the plaque, because of arterialization. Lithotripsy can be considered for lesion preparation in patients with calcified SVG stenoses. Intravascular imaging should be performed at a low threshold in severely calcified stenoses to optimize treatment selection. The electrocardiogram was unchanged from previous outpatient electrocardiograms (sinus rhythm, heart rate 54 beats/min, negative Optimal stent apposition and expansion were confirmed during the final optical coherence tomographic run ( Figure 2D , Video 5). In contrast to native artery calcification, the process of calcification within an SVG is not limited to the plaque but occurs predominantly in the vessel wall. This is considered to be the result of arterialization: fibrous thickening, medial hypertrophy, and lipid deposition caused by the hemodynamic stress on the graft (1). The resulting calcifications of this process can clearly be seen in the presented case ( Figure 2 ). The combination of these circumferential wall calcifications and an eccentric, severely calcified plaque caused the difficult lesion in this case. Proper lesion Although lithotripsy has proved to be an effective tool to prepare severely circumferential calcified stenoses in native coronary arteries (6), its use within venous grafts has not been described previously. In this case, lesion preparation by lithotripsy allowed straightforward successful treatment of a calcified lesion in a 34-year-old SVG that was resistant to high-pressure NC balloon inflations. Six months after the procedure, the patient is still free from angina. In selected cases, lithotripsy appears to be a feasible option for severely calcified SVG stenoses that are resistant to NC balloon dilation. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. A minimally invasive endovascular approach may be considered for repair of thoracic descending aortic pseudoaneurysms in children with higher surgical risk. Strategies should be chosen based on associated risks and benefits of various approaches and specific anatomy and cause. Multiple aortopulmonary collaterals are also seen originating from the descending aorta. Descending thoracic aortogram obtained 9 months after coil embolization shows complete exclusion of the pseudoaneurysm. Aortic pseudoaneurysms are rarely seen in children. Many are asymptomatic and are discovered inciden- Heart sounds S1 and S2 were normal, without accentuation of S2. S2 was not palpable. Breath sounds were decreased bilaterally, and asymmetrical swelling of the right lower extremity was present. The patient had been found to be heterozygous for the prothrombin gene mutation G20210A 2 years prior on elective carrier screening. She also had a recent To describe unique considerations for treatment of a pulmonary embolism in pregnancy. To illustrate a novel way of treating a submassive pulmonary embolism in pregnancy. To review the published medical literature surrounding the use of catheter-directed thrombolysis for treatment of pulmonary embolism in pregnancy. ISSN 2666-0849 https://doi.org/10.1016/j.jaccas.2020.08.022 Manuscript received March 30, 2020; revised manuscript received July 16, 2020, accepted August 13, 2020. history of immobility after a soft tissue injury of the right knee 2 weeks prior to presentation. She denied any other medical history. Given her history, symptoms, and vital sign abnormalities, differential diagnosis included pulmonary embolism, cardiac arrhythmia, undiagnosed cardiac structural abnormality, pregnancy-related cardiomyopathy, and infectious causes such as pneumonia with pleurisy or pleural effusion and pericarditis. The patient's laboratory results were notable for a hemoglobin of 11.1 g/dl, white blood cell count of 10.1 Â The primary concern for this patient was that without thrombolysis, cardiac dysfunction would worsen with ongoing pregnancy, with the potential for catastrophic urgent preterm delivery or decompensation during term delivery. CDT was chosen over systemic thrombolysis to minimize the dose of tissue plasminogen activator, given concerns regarding risk of bleeding and possible fetal effects (7). This case adds to the limited studies regarding use of CDT in pregnancy. In the review, 5 case reports of CDT were identified for PE in pregnancy ( (2). These 2 patients underwent surgery. The malpositioned stents were cut in both cases to avoid aortic damage and to prevent thromboembolic events and/or endocarditis, in addition to coronary artery bypass grafting and intraoperative balloon stent dilatation, respectively, to treat coronary ischemia. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. KEY WORDS complication, coronary artery bypass, stents To emphasize the fact that restoration of patency of subtotally occluded radial arterial grafts can occur in the long-term, even after more than 5 years. To become familiar with the pathophysiology of coronary graft failure and key properties of radial arterial grafts. Coronary angiography did not reveal significant progression of native vessel disease. LITA graft to LAD and SVG to OM were functioning well, whereas the RA graft to RCA was found diffusely narrowed and subtotally occluded ("string sign") ( Figure 1B, Video 1 ). As the bypassed stenotic lesion of the right coronary artery was of borderline severity (50% diameter) ( Figure 1A , Video 2), the RA graft failure was presumed to be due to competitive flow from the native vessel. Subsequently, further noninvasive testing with single-photon emission computed tomography (SPECT) was performed, which did not reveal myocardial ischemia at any territory. According to current guidelines (1) There is evidence that late functional recovery and restoration of patency can occur in a large proportion of radial artery grafts that appear subtotally or totally occluded, with the presence of a native vessel stenosis of at least 90% constituting an independent predictive factor of graft recovery. This phenomenon has been observed 6 to 12 months post-CABG, but to the best of the authors' knowledge, the present case is the first very late (8 years) string sign reversal to be reported (5, 6) . In this patient's original CABG procedure, the radial artery should have probably been used to graft the more severely stenosed OM1, although it is doubtful if grafting the RCA was indicated at all. Nevertheless, the configuration of grafts used, although inappropriate, provided a valuable insight into the physiology of radial artery grafts. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The patient reported previous good health other than a childhood history of occasional right-sided chest noted with running. A right pulmonary mass can be a primary pulmonary tumor, an infection (which would particularly include tuberculosis), a pulmonary contusion from trauma, or a vascular abnormality. The initial chest CTA showed a mass along the right mediastinum in the region of the azygos vein that Six months later, the warfarin was discontinued, and he was maintained on a daily aspirin 325 mg. Eight (7). In our patient, the varix was considered to be too large for intracavitary coil or device implantation. The proximal azygous was very small and could not be entered. Therefore, the decision was made to place a covered stent in the superior vena cava with the aim Azygos Vein Varix and a Covered Stent hence, 0.5 ㎍/kg/min of norepinephrine was continuously administered. However, her systolic blood pressure remained low, and venoarterial extracorporeal membrane oxygenation (ECMO) was started on the fourth day. On the fifth day, she was transferred to our hospital for more intensive treatment. A venous cannula was placed in the right common femoral vein for extraction, an arterial cannula was placed into the right or left femoral artery for infusion, and the blood flow of ECMO was regulated at 2.1 l/min (the number of rotations was 2,910/min). The patient did not have any other medical history, except hypertrophic cardiomyopathy (HCM). Two days after starting ECMO, she was transferred to our hospital. Almost 1 month before the admission, Continuous intravenous injection of landiolol was started from 3 mg/kg/min and increased to 10 mg/kg/min; oral administration of 300-mg cibenzoline per day was also started (4). After the onset of atrial fibrillation (AF), cardiogenic shock occurred, and the systolic blood pressure decreased to 80 mm Hg; amiodarone was started, which effectively prevented AF. Invasive coronary angiography revealed no significant stenosis of the coronary arteries on the eighth day. PTSMA was planned because of the risk of cardiogenic shock caused by the recurrent AF or after the procedure, ECMO support was terminated on the 11th day, and she was extubated next day. Cardiac magnetic resonance imaging was performed on the 22th day, and late gadolinium enhancement was clearly detected in the interventricular septum ( Figure 6 ). Pulmonary congestion finally disappeared on her chest x-ray film on the 25th day ( Figure 3B ). An implantable cardioverter-defibrillator was implanted for secondary prevention of VT on the 30th day, and she was finally transferred to the previous hospital for rehabilitation on the 45th day of admission. Electrocardiogram showing a normal sinus rhythm and ST-segment depression in leads V 3 to V 6 , aVL, and I. ECMO support was necessary when AF or hypovolemia occurred; therefore, she was considered an appropriate candidate for septal reduction therapy. Minimally invasive treatment was finally selected, considering her age and ECMO treatment. We obtained written informed consent from the patient for the publication of this report. Post-treatment, she was discharged and periodically followed up. Based on our literature review, no other case report described a patient undergoing PTSMA while under ECMO support. PTSMA is useful for patients with HOCM, even in those with deteriorated hemodynamic situation under ECMO support. To examine the distal location of SCAD in middle-aged women with nonobstructive, nonatherosclerotic coronary arteries and wall motion abnormalities consistent with TC. To be aware of the dynamic nature of coronary pathology seen in patients with SCAD who have recurrent chest pain and have had an initial diagnosis of TC. To understand that treatment and prognosis of SCAD and TC differ: single antiplatelet therapy and beta blockers are used in SCAD, whereas ACE inhibitors are the treatment of choice in TC. MANAGEMENT. The patient was treated medically with low-dose aspirin, an ACE inhibitor, spironolactone, and beta-blockers. TTE on the day of discharge (day 18) showed a nearly full recovery of the global and regional left ventricular functions. The patient was discharged in good health. Figure 1 . Abbreviations as in Figures 1 and 2. . Figure 1 . When SCAD Hides in a Pot MANAGEMENT. The patient was treated medically with low-dose aspirin. She was already taking ACE inhibitors, spironolactone, and beta-blockers. SCAD is a noniatrogenic separation of the coronary arterial wall. The underlying mechanism has yet to be elucidated, but an intimal tear or bleeding of the vasa vasorum could be the driving force (1), leading to a false lumen with intramural hematoma (2). Until recently, SCAD was considered a rare disease, primarily seen in young women during the peripartum period and in patients with connective tissue disorders. The emergence of high sensitivity biomarkers and the use of intracoronary imaging have The second angiogram of Patient 2 shows type IIb SCAD of the first diagonal branch of the LAD (white arrows). Abbreviations as in Figure 1 . A 70-year-old male with a history of orthotopic heart transplantation (OHT) presented with decompensated heart failure. On examination, heart rate was 117 beats/min and blood pressure was 121/ 69 mm Hg with no significant murmurs on cardiac auscultation. Chest radiography showed pulmonary edema and brain natriuretic peptide was elevated at 1,480 pg/ml (reference <100 pg/ml). The sirolimus level was therapeutic. Electrocardiogram (ECG) showed sinus tachycardia with a typical left bundle branch block (LBBB) and QRS duration of 170 ms ( Figure 1A ). The patient had a history of ischemic cardiomyopathy followed by a bicaval OHT 8 years before current LBBB has not been readily reported in transplant hearts. Patients with nonischemic cardiomyopathy and a LBBB have less response to guidelinedirected medical therapy compared to those with a narrow complex QRS. LBBB-induced cardiomyopathy is a relatively newly described entity in which patients with a LBBB develop LVSD without an alternative etiology, have evidence of mechanical dyssynchrony and subsequent super-response to CRT. HBP for CRT is a novel treatment which provides direct correction of the LBBBinduced electrical dyssynchrony compared to conventional BVP. It can be used in nonresponders to BVP or as a first-line strategy. LBBB-induced cardiomyopathy can occur in transplant hearts. HBP as a bail-out strategy for failed BVP or as an initial strategy for CRT (8) . Khaira et al. At this time, the patient experienced acute onset of aphasia and right homonymous hemianopsia. To review ICI-induced vasculitis. To propose a new adverse event, ICI-induced myocardial vasculitis. The patient had a history of malignant melanoma and hypertension. In this patient, acute coronary syndrome was most suspected, followed by myocarditis, pericarditis, and stress cardiomyopathy. Figures 3B and 3C) . Furthermore, we also detected prominent expression of immunoreactive PD-1 One month later, transthoracic echocardiography showed a left ventricular ejection fraction of 62% ICIs including pembrolizumab may cause myocardial injury due not only to myocarditis but also to myocardial vasculitis. The patient's medical history included: ulcerative colitis on sulfasalazine; intermittent urticaria and angioedema; allergic rhinitis on cetirizine, ranitidine, and montelukast; and migraines on topiramate. The differential diagnosis included eosinophilic myocarditis (Loeffler's syndrome), hypereosinophilic To develop a broad differential diagnosis with specific consideration of eosinophilic myocarditis in patients with new-onset heart failure and history of atopy. To understand clinical, laboratory, and imaging findings associated with eosinophilic myocarditis. To learn treatment strategies for eosinophilic myocarditis to include high-dose steroids, anticoagulation, guideline-directed medical therapy, and anti-IL-5 therapy with routine follow-up imaging to assess response. syndrome (HES), eosinophilic granulomatosis with polyangiitis (EGPA), drug-induced eosinophilia, and leukemia/myeloproliferative disorder ( Table 1) . Laboratory testing showed N-terminal pro-brain natriuretic peptide 478 pg/ml, troponin 0.10 ng/ml, D-dimer 1,600 ng/ml, complete blood count showed Eosinophilic myocarditis, or Loeffler's syndrome, is a hypereosinophilic syndrome defined by organ damage with 20% of cases having cardiac involvement and persistent eosinophilia (1). Although endomyocardial biopsy is the gold standard for diagnosis of eosinophilic myocarditis, the sensitivity is only 54% (2). The most likely etiology of this patient's peripheral eosinophilia is primary HES, but the differential diagnosis includes EGPA, malignancy/lymphoproliferative disorder, and drug-induced eosinophilia ( Table 1) . A diagnosis of HES requires the presence of functional class III heart failure and concern for constrictive pericarditis (CP) for further management. ECP may present after treatment of hemopericardium due to rivaroxaban. ECP may sometimes be the initial presentation of TCP. Many cases of constriction may resolve on anti-inflammatory therapy. In some cases recurrence may occur, which necessitates surgical pericardiectomy. His past medical history was significant for hypertension and hyperlipidemia. He was a non-smoker. He had no family or personal history of autoimmune diseases. He was treated with furosemide 80 mg intravenous daily and started on triple anti-inflammatory therapy with colchicine 0.6 mg twice-a-day, prednisone 50 mg once-a-day, and aspirin 650 mg once-a-day. His chest pain and shortness of breath improved (from NYHA functional class III to NYHA functional class I to II) and he was discharged 1 week later. On follow-up after 4 months (March 2014), a repeat cardiac MRI showed a decrease in pericardial thickness (4 to 3 mm), edema, inflammation, and the associated constrictive physiology ( Figures 1B2 to 1C2) . The colchicine dose was reduced to 0.6 mg once-a-day, and prednisone was tapered very slowly every 2 weeks as per European The authors have reported that they have no relationships relevant to the contents of this paper to disclose. systemic sarcoidosis. Steroid treatment was subsequently started, and repeat cardiac MRI is planned in 3 months for evaluation of treatment efficacy and permanent implantable cardioverter-defibrillator candidacy. Distinct defects on myocardial perfusion studies that do not correlate with coronary anatomic distributions should raise suspicion, and further work-up for cardiac sarcoidosis should be pursued even if findings on coronary angiography are normal. A 99m Tc sestamibi myocardial perfusion study demonstrated severe, multifocal, predominantly fixed and distinct perfusion defects involving different parts of myocardium, which did not correlate with any specific coronary distribution. The quantitative analysis showed a summed stress score of 24, a summed differential score of 8, and a summed rest score of 16. Left ventricular ejection fraction was 36%, end-diastolic volume was 65 ml, and end-systolic volume was 42 ml. He had a history of hepatitis B, asthma, intravenous drug use, and excessive use of alcohol. The most probable diagnosis in this case was ischemic stroke secondary to EM, given its ability to develop left ventricular (LV) thrombus and neurological Cyclophosphamide therapy was begun, which resulted in a partial response, with a reduction of the eosinophil count to a range of 20 to 30 Â 10 9 cells/l from 70 Â 10 9 cells/l (reference, 0 to 0.5 Â 10 9 cells/l). A 79-year-old woman was referred from her endocrinologist's office to the hospital for a persistent heart rate in the 30s (beats/min). She has carried a pre- The patient had a history of hypertension and hyperlipidemia. To consider use of leadless pacemakers in management of arrhythmias for patients with ECD who have right atrial involvement. To understand common structural and electrophysiological cardiac manifestations of ECD. The most likely cause of bradycardia in this patient was thought to be progressive infiltration of the conduction system from ECD. Other differential diagnoses included medicationinduced bradycardia, myocardial ischemia or infarction, and alternate infiltrate disorders including amyloidosis and lymphoma. The patient's admission troponin was negative, and the electrocardiogram demonstrated a new junctional escape rhythm (Figure 2) . The patient underwent cardiac magnetic resonance imaging that demonstrated infiltrative lesions involving the superior vena cava (SVC), aorta, proximal pulmonary artery, and right atrium (Figures 3A to 3C) . There was evidence of Immunostaining identified cells with CD163, BRAF V600E, and factor XIIIa positivity and CD1a and S100 negativity, a typical expression pattern in ECD (1). The patient's home metoprolol use was discontinued. After several days of inpatient monitoring, her cardiac rhythm continued to fluctuate among a junctional escape rhythm, ectopic atrial bradycardia, and atrial fibrillation with slow ventricular response. At this point, a decision was made for the patient to undergo pacemaker placement. Given the concern that standard lead placement could worsen SVC ste- On comparison of (A) angiographic chest computed tomography 6 years earlier with (B) steady-state free precession cine cardiac magnetic resonance acquisition from current admission, there has been an interval decrease of the patient's pericardial effusion (asterisk), but progression of right atrial infiltration along the interatrial septum (arrowheads). The infiltrative lesion along the descending thoracic aorta has remained (arrow). The authors have reported that they have no relationships relevant to the contents of this paper to disclose. (Figures 1D and 1E ). This patient presented with acute cardiopulmonary symptoms and was found to have a primary cardiac sarcoma. Acute thrombus was initially suspected; however, gross pathology ultimately showed no thrombus present ( Figure 1F ). Primary cardiac malignancies are rare with an incidence rate of w0.02% based on autopsy studies (1) . Conventional CT imaging is often not sensitive enough to distinguish tumor from thrombus, therefore multimodal imaging is helpful to better characterize RVOT lesions. Cardiac magnetic resonance imaging is particularly useful in distinguishing tumor from thrombus and malignant tumors from benign (2, 3) . Positron-emission tomography can be useful in further delineating intracardiac masses as thrombi tend to not be fludeoxyglucose avid. This patient did well in the post-operative period and was discharged to rehabilitation. This case highlights the utility of multimodal imaging in characterizing intracardiac masses and in guiding therapeutic and further diagnostic strategies. To understand the importance of echocardiographic imaging in the work-up of cardiogenic stroke in the older adult population. To comprehend the pathophysiology of left atrial appendage masses. To recognize the pathogenesis of intravascular papillary endothelial hyperplasia. To understand that Masson tumor is curative but residual tumor can recur after resection; therefore, careful follow-up with echocardiography should be paramount. 98% sensitive with positive and negative predictive values of 100% and 86%, respectively (11) . The patient tolerated the surgical procedure well and was discharged 7 days after cardiac surgery on longterm apixaban. On her 3-month follow-up, her TEE did not show mass recurrence. In patients with STEMI without any culprit lesion or significant atherosclerotic disease, coronary artery embolization should be considered. Coronary artery embolization can be due to cardiac diseases (atrial fibrillation, dilated cardiomyopathy, endocarditis, and intracardiac tumor), systemic diseases (malignancy, systemic autoimmune diseases, and antiphospholipid syndrome) or aortic thrombus. Interventional cardiologists, besides focusing on the coronary vessel, need to pay attention to other details such as reflux of contrast into the aorta, as an aortic thrombus may be visualized. Additionally, if an aortic thrombus obstructs the coronary ostium, a catheter can be manipulated to force the thrombus away from the ostium to allow proper engagement and intervention. The patient presents with recurrent inferior STEMI without any clear etiology-there was no culprit lesion or significant atherosclerotic disease on coronary angiography or IVUS. The differential diagnoses at this point were either a plaque rupture not well seen on angiography or IVUS, or an embolic phenomenon in a patient with a hypercoagulable state (e.g., antiphospholipid syndrome, malignancy, inherited thrombophilia), intracardiac or aortic thrombus, atrial fibrillation, or a paradoxical embolus from the venous circulation. Coronary artery embolization is a rare cause of STEMI, and aortic thrombus is a differential diagnosis. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Cai et al. A 48-year old man presented to the emergency department roughly 23 h after acute-onset dysarthria and persistent right upper and lower extremity weakness, which led to a fall. He thought his symptoms would resolve spontaneously, but they did not. Presenting vital signs were blood pressure 142/76 mm Hg, heart rate 84 beats/min, and O 2 saturation 98%. The patient had a history of popliteal arterial thrombosis of unclear origin and had been noncompliant with recommended anticoagulation. The patient's symptoms were highly consistent with an acute cerebrovascular event, the differential diagnosis for which included hemorrhagic event, embolic ischemic event originating from a cardiac structure (e.g., thrombus in the left atrial appendage or left ventricle, myxoma, fibroelastoma), embolic event originating from the aorta (i.e., aortic arch atheroma), and intrinsic atherosclerotic cerebrovascular disease. To understand that aortic thrombus is one of the causes of embolic acute stroke. To understand potential treatment options for ascending aortic thrombus. To better understand the technical and practical or clinical implications of percutaneous aspiration thrombectomy in the ascending aorta. Past medical history includes hypertension and depression. Differential diagnosis included intracranial hemorrhage, pulmonary embolism, myocardial infarction, aortic dissection, seizure, arrhythmia syndromes (e.g., Brugada syndrome, long QT syndrome), and cardiomyopathies (e.g., dilated cardiomyopathy, hypertrophic cardiomyopathy). To recognize the complications of manual and mechanical CPR. To review the current literature and guidelines surrounding the use of mechanical CPR devices. Although acute coronary syndrome was suspected given the initial rhythm of VF, the patient was first There are also concerns regarding potential injuries from the more powerful compressions delivered. Observational studies found that LUCAS CPR resulted in a higher incidence of skeletal and soft tissue injury than manual CPR (9,10). Conversely, a recent randomized controlled trial did not find that the LUCAS caused any more serious or lifethreatening visceral damage than manual CPR did (11) . In this case, a hypothesized mechanism of injury is that cephalad displacement of the LUCAS may in- The remainder of patient's recovery was complicated by an acute kidney injury and transient ischemic encephalopathy. Nonetheless, 2 months later, he was discharged to a long-term care facility with a cerebral performance category score of 2, which corresponds to moderate cerebral disability. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The patient had no known medical or surgical history. To highlight how Libman-Sacks endocarditis can mimic infective endocarditis. To describe a severe, rare presentation of this uncommon clinical entity. Chest radiography revealed diffuse pulmonary edema. An electrocardiogram showed sinus tachycardia. The white blood cell count was 11.7 Â 10 3 /ml with 81% neutrophil predominance. The hemoglobin was 8.9 g/dl and the platelet count was 226 Â 10 3 /ml. The constellation of heart failure, fever, murmur, and echo findings raised concern for infective endocarditis (IE). Abbreviations as in Figure 1 . regarding compliance with anticoagulation. The patient was maintained on coumadin, He had undergone left lower limb BK amputation 10 years ago for nonhealing wounds and swelling. The exact diagnosis and treatment received at that time were not known due to a lack of records and the inability of the patient to recollect. Widespread dissemination and extensive cardiac involvement can occur with actinomycosis. Appropriate diagnosis through meticulous evaluation is a must to cure and prevent dissemination and fatalities. Given the significant history, chronicity, indolent nature, and peripheral discharging sinuses, the following differential diagnoses were made: 1) actinomycosis from the previous actinomycetoma; 2) eumycotic mycetoma with dissemination; or 3) tuberculosis with right heart failure of uncertain cause. Although disseminated actinomycosis can involve any organ system, commonly, the lungs, skin, long bones, liver, brain, and muscles are affected. CARDIAC ACTINOMYCOSIS. Actinomycosis rarely involves the heart. A review of cardiac actinomycosis in the medical literature since the first report of "lumpy jaw" in 1877 by Bollinger (8) to be effective (11, 12) . The availability of a wide number of antibiotics and the absence of resistance has greatly improved the prognosis of all forms of actinomycosis. Presently, cure rates are high, and neither deformity nor death is common if actinomycosis is diagnosed and treated at early stages before dissemination and organ damage (11, 12) . However, studies guiding the management of disseminated actinomycosis with cardiac involvement, although rare, are sparse. Even though the patient showed signs of initial improvement (decrease in discharge from sinuses, After aggressive diuresis, the patient improved clinically and was able to undergo pulmonary endarterectomy, with good results ( Figure 1C) . Pulmonary pressures taken intraoperatively ( Table 1) The patient was later seen in the heart failure clinic for worsening dyspnea. A right heart catheterization showed moderate PH ( Table 1) . Pre-admission testing for pulmonary endarterectomy was ordered, including a carotid ultrasound that showed bilateral carotid occlusions. Given the patient's age, previous symptoms, atypical presentation, and the findings of her carotid ultrasound, a whole-body PET scan ( Figure 3B ) along with MRA of carotids, chest ( Figures 3C and 3D) , and abdomen were ordered. MRA showed complete bilateral common carotid artery occlusion with subtle mural thickening of the Many other mimickers also exist such as pulmonary cement embolism after kyphoplasty, and thoughtful evaluation with a multidisciplinary approach involving an experienced radiologist is paramount. Certainty of the diagnosis is crucial as taking the patient to the operating room without the correct diagnosis can lead to significant morbidity and mortality (6) . Takayasu arteritis are rarer diagnoses with atypical presentations that include PH (2, 7) . Therefore, while evaluating patients for signs of right heart failure, the index of suspicion for these diseases should be high, especially if there is concern of refractory or worsening obstructive burden while on anticoagulation. Timely diagnosis can help reduce significant morbidity and mortality. A 58-year-old woman presented with paroxysmal atrial fibrillation (AF) and a report of symptomatic episodes occurring at least once a month and lasting several days at a time. Because of her drug-refractory symptoms, she was referred for AF ablation and underwent ganglionated plexus (GP) ablation as part of a pilot study. The patient had hypertension, good left ventricular systolic function, and a left atrial diameter of 3.6 cm. Flecainide was used as "pill-in-the-pocket" therapy. She previously had an electrophysiology study, which detected a concealed septal accessory pathway but no inducible tachycardia. This condition was left untreated. The differential diagnoses included atrial tachycardia, atrial flutter, and AF. A 12-lead electrocardiogram confirmed AF (Figure 1 ). To understand how specific GP can be stimulated to trigger PV or non-PV ectopy and AF (ET-GP) with HFS. To understand that ET-GP ablation without PVI can provide a more patient-centric approach to AF ablation and achieve longterm freedom from AF. Despite improvements in catheter ablation techniques, the success rate of PVI is only modest, at 50% to 60% (5) . Incomplete PVI has also been associated with freedom from AF (6) . Therefore, other mechanisms and therapeutic approaches need consideration. This finding suggests that the upstream focal PV trigger responsible for the paroxysmal AF was exclusively from the ET-GP situated at the LIPV antrum. It This is the first report of a single site of ET-GP ablation without PVI in a patient who achieved long-term freedom from AF. In this case we stopped ablation after a single ET-GP because there were no further spontaneous AF episodes after ablating this GP site. This an important, but fortuitous, observation because it implies that the other GP sites that were identified were not part of the AF triggering mechanisms. We cannot compare this with previous GP studies because data on the exact ablation performed we are yet to find the silver bullet for AF ablation. In To confirm that when it rains it pours, there are data from canine studies suggesting that there could be not only no benefit in reduction of AF burden, but also proarrhythmic sequelae to GP ablation potentially secondary to reduction in the atrial effective refractory period in the long term, although all data are again based on anatomical ablation of GPs (12) (13) (14) . On the clinical side, more recently the AFACT high-frequency stimulation of a ganglionated plexus in sinus rhythm, which induces an atrial ectopic and leads to atrial fibrillation. thoracoscopic ablation for advanced AF and indeed resulted in a higher proportion of adverse events (15) . A 60-year-old female presented with dyspnea 1 to 2 weeks after an illness characterized by chest pain and vomiting that she thought was a viral infection. Initial vital signs were blood pressure of 135/78 mm Hg, a heart rate 95 beats/min, and respirations of 20 breaths/min. Electrocardiography showed anterior Q waves. Coronary angiography revealed left anterior descending artery occlusion, and echocardiography revealed a VSR ( Figure 1 ). An intra-aortic balloon pump was placed. Percutaneous VSR closure was performed, but she developed apical extension 4 days later (Figure 1) , which was treated with open surgical repair. She ultimately progressed to hospital discharge. This report describes 2 late-presenting myocardial infarctions complicated by VSR. It is notable that the COVID-19 pandemic seemingly influenced each patient to avoid seeking immediate care after symptom onset. At the time of this writing, the authors were aware of 3 additional VSR cases treated during the pandemic at our institution. Historically reported to occur in 0.21% of hospitalizations for STEMI (1), the occurrence of 5 VSR cases at a single institution during the pandemic was indeed curious. Among 366 patients treated for STEMI at the authors' institution in 2019, 2 (0.5%) had VSR. In contrast, the rate of VSR per STEMI hospitalizations at the authors' institution during the pandemic was 6.7%. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Twitter: @RyanMadderMD. (Figures 1C and 1D) ; electron microscopy showed viral particles ( Figures 1E and 1F) . During the coronavirus-2019 (COVID- 19) pandemic, the treatment of ST-segment elevation myocardial infarction has changed to prioritize a safe intrahospital environment with thrombolysis preferred to primary angioplasty (1) . In this patient with hemorrhagic pericardial effusion, the differential diagnosis included post-infarction pericarditis, mechanical complications of myocardial infarction, complications associated with thrombolysis, Dressler syndrome, and viral pericarditis. Viral pericarditis has been recognized as the cause of up to 62% of hemorrhagic pericardial effusions (2) . The presence of SARS-CoV-2 in pericardial fluid has TEE revealed a thickened mid-A2 segment and a cleft between A2/A1 with distorted anterior mitral leaflet shape ( Figure 1B) . Given the patient's high surgical risk and severe chronic lung disease, the heart team decided to attempt transcatheter repair using a MitraClip. Initially, an NTR MitraClip was placed at the A2/P2 scallops medial to the residual cleft ( Figure 1B) , which eliminated the central MR jet ( Figure 1C , right, Video 2). However, there appeared to be moderate residual MR lateral to the clip secondary to the mitral cleft ( Figure 1C, left) residual MR ( Figure 1F, Video 2) . The transmitral mean gradient was 5 mm Hg, and there was significant improvement in the pulmonary venous flow pattern (Supplemental Figure 2 ). This case illustrates some unique aspects. The usual approach to implant a second MitraClip would be to grasp it as parallel as possible lateral to the first clip (2) . In the present case, the A1/A2 cleft limited the grasp of a second clip immediately adjacent to the first clip. Thus, this novel approach, implanting the second MitraClip so that it grasped the cleft scallops (perpendicular to the initial clip), resembles the surgical repair and could be an effective strategy to decrease residual MR in challenging anatomies. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. implantation of clips will become more widespread and will demonstrate durability. The reasons for the under-representation of women in cardiology (WIC) are multiple ( Figure 1 ). The primary objective for the collaboration of Global WIC-Early Careers is to improve female representation, for both cardiologists and patients. Our focus is directed primarily on 5 major issues we have identified, as described in Figure 1 : the impact on the per- In an effort to make this initiative truly international and inclusive, we reached out to 3 other WIC, Paola Morejon (South America), Nafisa El Sammani (Africa), and Louise Segan (Australia) to form a group representing the 6 continents ( Figure 2) . We subsequently wrote a manifesto and planned our launch project, which, by virtue of its virtual format, ensured equal opportunity for all WIC across the world to participate, thus obviating traditional challenges such as the need for travel and related expenses as well as time away from work and family. We launched our inaugural project, a global WIC case report competition, which attracted more than 60 submissions across 6 continents from aspiring With regard to future goals, as the Pink IYAC community, we believe in looking into the next steps. This is reflected in our plans, where we strive to create trust and an unbreakable bond between us and the millions of women who want to collaborate with our community. Because the 21st century is a time when social media is brighter than ever before, we Young Academy aim to be more active on all major social media platforms to ensure that we can reach all women around the globe. In addition, steps will be taken to bring Pink IYAC to the level of advancement where it can hold special sessions in its name at major conventions, such as at the annual conferences of European or American societies, where we hope it can shine as a significant community in the field of cardiology. Nevertheless, a mentoring program has been established where talented women will use their experiences in a one-to-one relation to help women who are facing hard times. Last but not least, we hope that Pink IYAC meet- In this paper, we will take a deep dive into the perception of women not supporting one another and discuss its relevance to female cardiologists. PERCEPTION OR REALITY? The "queen bee phenomenon" is a phrase first coined over 50 years ago to describe female leaders who assimilate into male-dominated organizations (i.e., 20-year period, this study found that when women were in senior roles, they promoted other women, but when men were in senior roles, only one-half as many women were promoted to senior roles (6) . In a study performed in university settings in the Netherlands and Italy (7), the authors investigated gender differences in 2 factors that may contribute to the under-representation of women among university faculty-work commitment of student scientists and perceptions of these levels of work commitment by faculty members. In both countries, male and female students generally reported being equally committed to different work aspects. However, only older female, but not younger female or male faculty members perceived their female students as less committed to their work than male students. Older female faculty also had a more masculine selfdescription than younger female faculty. These results were thought to be due to overall smaller number of older female faculty and reflection of their own difficult career journey into their genderstereotypical perceptions of the female students. Other studies looking at incivility in the workplace have found that women report significantly more female-instigated incivility compared with men, but there was no difference between men and women experiencing male-instigated incivility. They also found that women who exhibit dominant behaviors at work (agentic) were likely to report receiving uncivil treatment by other women. For agentic women especially, such incivility had damaging consequences, resulting in reduced job satisfaction, lower psychological vitality, and higher turnover intentions (8) . Women perhaps start their career with low gender identification and as they progress, experience a high roles that leads to the belief that assertive behavior is expected from men but not from fewer female leaders? It is critical to acknowledge that the queen bee phenomenon may be the result of a gender-biased milieu in the workplace rather than the cause of gender discrimination (9) . While WIC have been expressing their concerns regarding gender equality for years, WIC continue to face multiple obstacles. In many countries, due to cultural expectations, women are not able to progress professionally, and it is impossible for them to hold a leadership position. Even in developed countries, women are less likely to be hired and/or promoted because of their sex (10) . Compensation inequities persist for WIC, despite several studies in the past decade demonstrating that large differences in physician salaries are found when stratified by sex (11) . Sexual harassment is a huge obstacle in women's efforts for progress and has been demonstrated to worsen burnout and affect productivity (12) . However, it is severely under-reported due to fear of stigmatization or retaliation. Motherhood can be a very important part of a woman's life, whether she is partnered or unpartnered. To this day, many women are still forced to choose between career or family, as there continue to be significant discrepancies in parental leave policies across the world. Furthermore, pathways should be created to allow women to continue to advance professionally while taking into account prioritization of family and family responsibilities. Women are also often unfairly and negatively labeled as emotional, hysterical, or aggressive for the same actions or behaviors that in a man may be called passionate, assertive, or ambitious, due to both conscious and unconscious biases (13) . When the challenges of WIC at personal, organizational, or institutional levels are the same, the time has come for WIC to band together to the battle these common issues. women leaders hire more women to work for them compared to when men lead (15) . This effect is the strongest when a woman leader is re-elected; when a woman does not have to worry about the security of her own role or position, she is able to advance and promote other women, who in turn, continue to promote more women, learning by example (15) . Leadership training for both sexes but particularly WIC should explicitly include not only why to mentor, but how to mentor and advocate for other WICs. As more WIC leaders rise to leadership positions and promote other WICs, the hope is that like the example above, continued sponsorship and further promotion of WIC will self-sustain. Social media has become an important avenue for discussing WIC issues (18) . Women in cardiology can survive, thrive, and succeed the decades-long quest for professional equity by supporting one another. Forming the raft of otters will keep us united and create a critical mass that will help us reach our goal of equality and equity within our field of cardiology. As more female cardiologists rise in leadership, we should get past the concept of queen bees and believe in the power of amplification of other women that can bring upon the change. ACKNOWLEDGMENT The authors thank Caroline Volgman for her help with the Figure 1 . The Women as One vision is one of reciprocity. When women are put in a position to succeed, everyone succeeds. Women as One programming is aimed at positioning women for this collective success and opens its doors to all who are looking to achieve and expand on this shared goal. To learn more about Women as One, visit www. womenasone.org. Dr. Mehran has received grants, personal fees, and advisory service fees from When an author submits a manuscript on behalf of an author group, the editorial office does an initial quality check. That is why we encourage authors to carefully read the author instructions. Fairness is a priority, so we maintain standards for the word count and the number of the authors to treat all authors equally. If a paper successfully passes through the quality check, then it is "checked in" and moves to the editor-in-chief. The next person to adjudicate the manuscript is the editor-in-chief, who provides a few comments on the manuscript. If there are important features missing, such as videos for the respective figures that are crucial for peer review, then we may ask the authors to provide them. Again, we encourage authors to read the instructions as we have listed videos as a necessary feature of a clinical case. When the manuscript is about to undergo peer review, the editor-in-chief sends the manuscript to an associate editor who specializes in the topic area. This is a second stage during which an associate editor may feel that the manuscript does not warrant publication or that there were important pitfalls. If that is the case, then the associate editor will provide his/her comments, and the manuscript will be sent to the editorial board agenda. If the manuscript is determined to merit peer review, we then allocate reviewers who are experts in the field. Typically, JACC journals' associate editors invite 2 reviewers, but it is at the discretion of members of the editorial board to choose more reviewers or not, if they feel that the existing reviews are insufficient. Furthermore, we do not allow comments that lack collegiality to reach the authors-the aim of a review is to be constructive to each other. Once a week, the editorial board, including the deputy and associate editors together with the editorin-chief, holds a meeting to discuss all pending manuscripts that are decision-ready. We often have long agendas, sometimes approximately 50 pages to adjudicate all of the papers we managed within a week. Therefore, the communal discussion allows for transparency on whether papers need further discussion before a decision is made, or whether they are ready to be accepted, revised, or rejected. Most importantly, we take the time to discuss the manuscripts one by one through a democratic process. One person cannot decide on their own, but altogether we gather a consensus on whether each manuscript is worthy of publication. We welcome inquiries regarding manuscript decisions from authors. However, it is important to note that the appropriate forum for this discussion is in an e-mail to the editorial office (jacccr@acc.org), whereby staff will coordinate communications regarding decisions, publication timing of accepted papers, and so on. We request that authors avoid contacting members of the editorial board via social media or text message, as it is not the appropriate forum for this discussion. We also encourage feedback on content from readers, but prefer to consider that discourse in the form of a letter to an editor, which allows for the peer review process and the invitation of an author response. In the world of publishing, where we strive for fairness and transparency, texting an editor-in-chief directly on social media is not a professional approach. It is not fair for the readers, the authors, or the editors-some of whom may not have social media-and to remove the quality controls that are upheld during the editorial process to promote fairness. I hope by explaining the editorial process that our authors and readers will understand our reasonings. The meeting every week is a democratic approach to reaching an agreement on what is of value for the scientific community and, of course, meets the Journal's objectives. In the final stage, the manuscript's decision letter will be drafted and sent to the author. Importantly, if the decision is to reject the manuscript, the authors should not be discouraged, but should view the decision as an opportunity to submit to another jour- Commonly, the person hangs up and rejoins when we finish the discussion about the specific manuscript. This is one more step toward seeking fairness inside the editorial process. As I mentioned earlier, we seek to ensure that everyone within the editorial process feels valued: our Associate/Deputy Editors, editorial consultants, guest editors, reviewers, and of course, the authors. On every manuscript, we aim to provide constructive feedback, but our priority is the maintenance of fairness, objectivity, and the elimination of scientific misconduct. Thus, although we had the opportunity to bombard our readers with coronavirus disease-2019 (COVID-19) manuscripts, we decided to act sensibly and to publish only the most interesting and educational cases from around the globe-as the first case reports journal to have a call for COVID-19 cases and also to help the authors publish their findings, by waiving any publication fees and expediting the peer review process. We will always aim to maintain the high quality of JACC journals to demonstrate a wellproven cause-causation relationship. In publishing, it is easier to mass produce manuscripts rather than spending time selecting the best of the best. Although it was hard work to be selective in light of the higher number of submissions, we published the special issue on COVID-19 cases in July 2020 with only the highest-quality submissions. Make sure you read the author instructions carefully. Watch the video of our webinar on "How To Write A Case Report" (1) before you submit. This is an important first step prior to the submission. Do not be discouraged if the decision of the journal is not the desired outcome. Collect feedback and plan your next move. Remember: Every effort, every experience-either positive or negative-is an opportunity for you to grow as cardiovascular clinicians and researchers. We are grateful for your trust and support. This has been a great year, and we promise to do our best to encourage the authors and make the editorial process a positive publishing experience. 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Is there a price to pay? 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Cases in the U.S.: Coronavirus Disease 2019 (COVID-19) Endovascular thrombus removal for acute iliofemoral deep vein thrombosis: analysis from a stratified multicenter randomized trial Scientific and standardization committee communication: clinical guidance on the diagnosis, prevention and treatment of venous thromboembolism in hospitalized patients with COVID-19 ) © 2020 The Authors American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license He was dyspneic, with 85% arterial oxygen saturation, a heart rate of 84 beats/min and blood pressure of 106/87 mm Hg. Diffuse pulmonary rales were found, predominantly at the left lung base. The electrocardiogram showed ST-segment elevation on the inferior and posterior leads. The chest radiograph showed bilateral diffuse interstitial infiltrates, predominantly in the left lung. The result of real-time reverse transcription-polymerase chain reaction for detection of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) RNA was positive, so antiviral therapy was added. A transthoracic echocardiogram (TTE) showed inferolateral and inferior wall akinesia and an ejection fraction of 30% without pericardial effusion. Given the rapid progression (<12 h after chest pain onset), thrombolysis with alteplase was established with reperfusion criteria. On the ninth day of the illness, he had oliguria, sinus tachycardia, and dyspnea. A new TTE showed echogenic pericardial effusion with tamponade physiology (Figures 1A and 1B, Video 1). A pericardial window was performed From the a Cardiovascular Critical Care Unit, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico; b Coronary Care Unit, Ignacio Chávez National Institute of Cardiology The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page The usefulness of diagnostic tests on pericardial fluid Cardiac tamponade secondary to COVID-19 Social Determinants of Health Disparities in cardiovascular disease risk in the United States COVID-19 and health equity-a new kind of "herd immunity Stolen breaths KEY WORDS COVID-19, health disparities, health equity, patient-physician relationship, social determinants of health Burden of valvular heart diseases: a populationbased study Outcome and undertreatment of mitral regurgitation: a community cohort study Cleftlike indentations in myxomatous mitral valves by three-dimensional echocardiographic imaging Quantitative three-dimensional echocardiographic correlates of optimal mitral regurgitation reduction during transcatheter mitral valve repair Mitral valve anatomic predictors of hemodynamic success with transcatheter mitral valve repair Diagnosis of isolated cleft mitral valve using threedimensional echocardiography Women in cardiology: the British Junior Cardiologists' Association identifies challenges How do we attract and retain women in cardiology? 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A natural experiment at a national funding agency Sex differences in faculty rank among academic cardiologists in the United States clinical perspective Representation of women in cardiovascular clinical trial leadership Ó 2020 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY-NC-ND license Massive myocardial calcium deposition: hardened heart Idiopathic massive myocardial calcification: a case report and review of the literature Inappropriate ICD shock as a result of Taser Discharge A shocking tale The influence of agency policies on conducted energy device use and police use of lethal force Benefits, risks, and myths of TASERâ handheld electrical weapons TASER conducted electrical weapons and implanted pacemakers and defibrillators TASER electronic control devices and cardiac arrests: coincidental or causal? Inappropriate ICD shock as a result of TASER discharge A shocking tale Training bulletin 15.0 medical research update and revised warnings When Tasers fail USA: Excessive and lethal force? Amnesty International's concerns about deaths and ill-treatment involving police use of TASERs JACC: Case Reports: how to write a case report The authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Barbhaiya and Johar wrote excellent expositions on the first documented case of an implantable cardioverter-defibrillator (ICD) shock due to conducted electrical weapon (CEW) discharges (1, 2) .To appreciate the rarity of the event, there have been more than 4 million field uses of just the TASER brand (Axon, Scottsdale, Arizona) of CEW.CEW use reduces the non firearm arrest-related death rate by 59% to 66%, consistent with the twothirds reduction in firearm fatalities in agencies where CEW use was not overly restricted (3). The 2 key injury studies, covering collectively more 40,000 uses of force, found that the CEW reduced subject injury by 65% to 78% (4).It is misleading to state that CEW use is associated with asystole. Asystole is the most common cardiac arrest rhythm with drug and alcohol abuse, but it is not inducible with electrical stimulation (5) . Hence, any association is artificial.The editorial suggests a risk of myocardial capture and cites a report of a prison rioter having an asymptomatic elevated heart rate during a CEW discharge to the chest. That was not direct capture but, rather, the result of the pacemaker housing funneling some CEW charge directly into the right ventricle via the pacemaker lead (6) .Of greater concern is the repetition of the myth that humans have ever been electrocuted by a CEW.All present Taser CEWs deliver <2 W, which satisfies the 5 to 7 W allowed by the UL electric fence standard (UL, Northbrook, Illinois), as well as the international The reduction in power delivery in more recent models is acknowledged by the manufacturer to have a "significantly improved safety margin" (4).Furthermore, there is evidence that, in addition to being used to avoid lethal force, many U.S. police agencies deploy CEWs more routinely to subdue unarmed, noncompliant, or disturbed individuals who do not pose a serious danger to themselves or others. (5) Reassurance that the CEW death rate is low disregards the potential harms that may result from CEW discharge (4, 6) . A full appreciation of device risks and benefits is, therefore, made difficult or impossible. ALARA (as low as reasonably achievable) is a concept embraced within the cardiology community regarding medical radiation use. Although the risk of radiation exposure related to medical imaging is "extremely low," it is not zero. Because the benefits of this radiation are clear, we aim to minimize harm while optimizing benefit. Similarly, we believe that our case report contributes to the body of evidence suggesting that although there is a role for CEW use in law enforcement, its use should be ALARA. Dr. Barbhaiya has received speaker fees/honoraria from Abbott and Medtronic; and received research support from Biotronik. Dr. Aizer has served as a consultant for Biosense Webster; has received research support from Abbott and Sentreheart; and has received fellowship support from Abbott, Biotronik, Boston Scientific, and Medtronic. Dr. Chinitz has received speaker fees/honoraria from Abbott, Medtronic, Biotronik, and Biosense Webster; and has received fellowship/research from Medtronic, Biotronik, and Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors' institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.