**Introduction/Hypothesis:**
Coronary artery fistula (CAF) is a rare and abnormal connection between coronary arteries and cardiac chambers. Most CAFs are congenital but others can be acquired through iatrogenic or traumatic injuries and systemic inflammatory conditions. Although anatomy of CAFs vary, common origins include the right and left coronary arteries with connections to the right ventricle or right atrium.

**Methods**
A 37-year-old female presented with exertional dyspnea, heart murmur, and arm paresthesia during pregnancy and was diagnosed with a left circumflex (LCX) to left atrium (LA) fistula on cardiac gated computed tomography angiogram (CTA). This gravida 2 para 2 patient was referred to our center after an insidious onset of exertional dyspnea during 2 pregnancies, the second of which terminated in cesarean section.

**Results**
Transthoracic echocardiography revealed the LCX to LA CAF with turbulent flow into left atrium and a moderately enlarged left atrium. Cardiac CTA confirmed the tortuous and aneurysmal CAF revealing aneurysmal dilations of the involved coronaries to up to 26 mm and several calcified and noncalcified atherosclerotic plaques within the aneurysmal LCX. The fistulous connection was closest to the left atrial appendage. Direct cardiac catheterization of the LCX redemonstrated the LCX to LA CAF with contrast opacification of the LA prior to treatment with coil embolization. The patient tolerated the procedure well without complications

**Conclusion**
Overall, CAFs are a rare phenomenon present in less than 0.002% of the general population. They are rare among cardiac anomalies (0.2%-0.4%) and even coronary anomalies (14%). A few case reports of pregnancy associated CAFs have been described in the literature. Treatment depends on the size and symptoms. Small and asymptomatic CAFs warrant only observation. Small, symptomatic CAFs can be managed with antiplatelet therapy and antibiotics to prevent endocarditis. Large fistulas are best suited for surgical ligation.



Postpartum left circumflex to left atrial fistula

**Introduction/Hypothesis:**
While foreign bodies in the heart or its vasculature are uncommon, iatrogenic and post-traumatic causes account for the majority of foreign bodies described in the literature. Plain chest radiography, echocardiography, and computed tomography (CT) are common and accessible imaging modalities used to evaluate such foreign bodies. We describe an interesting case of a foreign body of unknown type and etiology in the pulmonary artery evaluated with transesophageal echocardiography (TEE) and cardiac CT.

**Methods**
A 58-year-old man, with complaint of chest pain, and known history of remote gastric sleeve surgery, previous knee surgeries, and chronic obstructive lung disease presented for evaluation of a foreign body detected on cardiac CT done for evaluation of chest pain. He did not have a known history of peripherally inserted central catheters, port-a-cath, or Swan Ganz catheters. His cardiac CT showed a linear looping filling defect within the bilateral lobar pulmonary arteries extending into lower lobe pulmonary branches (non-contrast CT image uploaded with the abstract). This was thought to be an embolized wire or a fractured catheter. This foreign body was not observed on a plain chest radiograph.

**Results**
TEE assessment showed an echo-bright foreign body, with railroad-track like appearance in the pulmonary artery, which moved with the respiratory cycle. This object extended from the right pulmonary artery to the proximal left pulmonary artery and did not have the appearance of wire, rather ‘railroad’ parallel linear echodensities the demonstrates some independent motion most consistent with a catheter. 2-D and 3-D imaging (clips uploaded with the abstract) by TEE did not demonstrate any thrombi on the foreign body. The object may be tethered to the wall of the pulmonary artery. Assessment of the right heart structures did not reveal any obvious damage to the tricuspid or pulmonary valves. There was no significant valvular regurgitation. The right ventricle size and systolic function were normal.

**Conclusion**
Based on the patient's clinical presentation, absence of related symptoms (chest pain not felt to be related to the catheter), and imaging characteristics of the foreign body on TEE and chest CT, it was decided to manage the patient conservatively. TEE utilizing 2-D and 3-D imaging reconstruction provides important complimentary information to CT in assessing foreign bodies in the heart and their impact on surrounding structures. TEE can assist surgeons and interventionalists in their decision-making process for monitoring or removing foreign bodies.



Assessment of a mysterious foreign body in the pulmonary artery

**Introduction/Hypothesis:**
Background: Right ventricular (RV) pseudoaneurysm is a rare, life-threatening complication associated with ischemia, infection, or trauma. With no unique clinical findings, identification relies on advanced imaging such as computed tomography angiography (CTA) and magnetic resonance imaging (MRI).

**Methods**
Case: We present a 75-year-old female with a medical history of pulmonary hypertension, bilateral orthotopic lung transplant, hypertension, and paroxysmal atrial fibrillation, who was transferred from an outside hospital for continued management of acute hypoxic respiratory failure. She arrived mechanically ventilated and hemodynamically stable. An initial CTA demonstrated an incidental RV apex pseudoaneurysm.

**Results**
Decision-making: Due to limited view with transthoracic echocardiogram (TTE), an electrocardiogram (ECG) gated CTA was performed, which confirmed the diagnosis. The etiology of the patient’s RV pseudoaneurysm remains unknown. Due to her critical respiratory condition, conservative management was recommended.

**Conclusion**
Conclusion: ECG-gated cardiac CT angiography, with its excellent spatial and temporal resolution should be considered as a form of diagnostic confirmation for suspected RV pseudoaneurysms, especially in cases where TTE is non-diagnostic.



Streamlining the Initial Diagnostic Pathway: Cardiac CT Angiogram in Right Ventricular Pseudoaneurysm

**Introduction/Hypothesis:**
Erdheim-Chester Disease (ECD) is a rare disease of histiocytic neoplasm characterized by clonal expansion of foamy macrophages and inflammatory cells with progression to fibrotic changes in infiltrated tissues. This disease affects a wide range of organ systems, including skeletal, respiratory, renal, central nervous, and cardiovascular systems.
Cardiac Magnetic Resonance Imaging (CMR) or gated computed tomography (CT) are necessary for full cardiac assessment of patients with ECD. Timely recognition of cardiac complications is vital as prompt diagnosis and treatment with targeted inhibitors can lead to stabilization or resolution of cardiac manifestations.

**Methods**
We present CMR findings of three patients with pathology-confirmed ECD.

**Results**
The primary cardiac manifestations included infiltrative soft tissue mediastinal mass, atrioventricular sulcus infiltration, right atrial inflammatory pseudotumor, pericardial thickening and effusion, and aortic mural wall thickening.

**Conclusion**
CMR, with its superior tissue characterization and functional assessment, should be used to assess cardiac involvement in patients with suspected ECD to monitor disease progression and treatment response. CMR is non-invasive without ionizing radiation and can be employed with techniques like late gadolinium enhancement (LGE) and T1/T2 mapping to identify fibrotic, inflamed, and infiltrated tissues of patients with ECD.



At the Heart of the Matter: Cardiac Manifestations of Erdheim-Chester Disease

**Introduction/Hypothesis:**
Introduction
Quadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by a fourth cusp on the aortic valve, often resulting in aortic regurgitation. While historically diagnosed at autopsy or intraoperatively, echocardiography now allows for earlier detection. QAV is usually an isolated finding, but can be linked with other congenital defects, including patent ductus arteriosus and thoracic aortic aneurysm.

**Methods**
N/A

**Results**
Case Presentation
A 60-year-old male with hypertension, hyperlipidemia, and chronic kidney disease presented with progressive dyspnea, orthopnea, fatigue, and leg swelling. Physical examination was notable for an early diastolic decrescendo murmur, bilateral crackles, and peripheral edema. Laboratory tests were significant for elevated NT-pro BNP. Transthoracic echocardiography (TTE) showed a severely enlarged left ventricle and a quadricuspid aortic valve with regurgitation originating from a coaptation gap. Transesophageal echocardiography (TEE) confirmed QAV and severe aortic regurgitation (Figure 1). After a multidisciplinary discussion, the decision was to proceed with surgical intervention with aortic valve replacement with a 25 mm Inspiris bioprosthetic valve, as well as a 2-vessel coronary artery bypass graft due to significant coronary disease seen on preoperative coronary angiogram.

**Conclusion**
Discussion
QAV is a rare congenital defect with about 200 reported cases, manifesting typically in the fifth and sixth decades with a slight male predominance. It arises from abnormal embryonic development, leading to unequal shear stress and aortic regurgitation. Diagnosis relies on echocardiography, with TEE providing detailed imaging. Management of QAV involves monitoring and surgical intervention for symptomatic or severe cases. Aortic valve replacement is indicated for severe aortic regurgitation, with favorable long-term outcomes reported. Surgical strategies may include valve repair or replacement, with various techniques such as bicuspidization or tricuspidization tailored to specific valve morphology. This case highlights the importance of advanced imaging for accurate diagnosis and the role of comprehensive surgical planning and intervention.



Severe Aortic Regurgitation Due to Quadricuspid Aortic Valve with Associated Extensive Coronary Artery Disease

**Introduction/Hypothesis:**
Heart transplantation is the definitive therapeutic option for end-stage heart failure patients, but the scarcity of donor organs necessitates a careful selection process. Mechanical circulatory support devices play a crucial role in bridging patients to transplantation. This study aims to identify echocardiographic factors associated with the use of MCS devices before heart transplantation.

**Methods**
This was a single-center retrospective cohort analysis from 2019 to 2023 and included 144 patients. Echocardiographic factors were extracted for each patient prior to MCS implantation for cardiac transplantation.

**Results**
Echocardiography factors which were found to be associated with a higher odds of MCS before transplantation were elevated heart rate during time of TTE (OR: 1.04 [95% CI: 1.02 – 1.06]), elevated diastolic blood pressure during TTE (OR: 1.04 [95% CI: 1.00 – 1.07]), elevated E/A ratio (OR: 1.69 [95% CI: 1.20 – 2.45]), elevated TR velocity (OR: 3.85 [95% CI: 1.84 – 8.76]), increased LVIDd (OR: 1.05 [95% CI: 1.02 – 1.08]), increased LVISd (OR: 1.04 [95% CI: 1.02 – 1.07]),  and elevated RVSP (OR: 1.07 [95% CI: 1.03 – 1.10]). Factors that were found to have decreased odds of MCS before transplantation were increased LVEF (OR: 0.96 [95% CI: 0.93 – 0.98]), increased pulse pressure during TTE (OR: 0.97 [95% CI: 0.94 – 1.00]), and increased LVOT VTI (OR: 0.85 [95% CI: 0.78 – 0.92]). The interquartile range (IQR) for LVOT VTI was 4.4 – 10.7 (Q1), 10.8 – 13.9 (Q2), 14 – 17 (Q3), and 17.1 – 30.6 (Q4). The Kaplan-Meier survival curve which was generated to compare the IQR for the LVOT VTI showed that a significant difference was apparent between the groups (Figure 1; p-value < 0.05). A Cox-proportional hazards model was generated using Q1 as the reference standard. This demonstrated that in comparison to the lowest IQR those with Q3 or Q4 LVOT VTIs had a statistically significantly lower risk of needing MCS (HR: 0.42 [95% CI: 0.21 – 0.84]), and (HR: 0.22 [95% CI: 0.10 – 0.52]).

**Conclusion**
The study introduces LVOT VTI as a potential non-invasive parameter for determining patient selection for MCS implantation prior to transplant.



Echocardiogram Parameters Associated with Use of Temporary Mechanical Circulatory Support Devices Prior to Heart Transplant

**Introduction/Hypothesis:**
Ventricular free wall rupture is an exceedingly rare, but devastating complication of acute myocardial infarction, occurring in .01 percent of patients presenting with both NSTEMI and STEMI.1 Infrequently, the rupture of the ventricular free wall is contained by epicardial clots or pericardial adhesions; when this happens, it can lead to the formation of a pseudoaneurysm.2 Presentation of patients with pseudoaneurysm is widely variable, with the most commonly reported symptoms being congestive heart failure (36%), chest pain (30%), dyspnea (25%), and up to 12% of patients are asymptomatic at the time of diagnosis.3

**Methods**
An 85 year-old female with a past medical history of hypertension, hyperlipidemia, non-alcoholic steatohepatitis, and chronic kidney disease presented to the Emergency Department with fatigue and sudden onset of shortness of breath. She was normotensive, tachycardic at 110 bpm, saturating at 90% on room air, and mildly tachypneic in the 30s. She appeared nontoxic and further physical exam was largely unremarkable. Labs were pertinent for a troponin of 106, NT proBNP of 10,548, and lactate of 1.5. EKG revealed new T wave inversions in the inferior and lateral leads, septal Q waves, and slight ST-depression in V5 and V6. She[RJ1] was given IV Lasix, 81 mg aspirin, started on heparin, and admitted for potential NSTEMI. TTE revealed a severely reduced ejection fraction of 24.4% and a large mid to apical pseudoaneurysm along the inferolateral wall of the left ventricle contained within the pericardium measuring 5.7 x 8.4 cm with free flow of blood between the LV cavity and the pseudoaneurysm. She was transferred to the CICU and an emergent cardiothoracic surgery consult was placed.

**Results**
The patient underwent emergent coronary catheterization, revealing 100% occlusion of the distal circumflex and 99% occlusion of the middle right coronary artery, which were suspected to be the culprit of the patient’s transmural infarct and subsequent myocardial rupture. An EKG gated CT cardiac angiogram was obtained for evaluation for surgery. Following the catheterization, the patient underwent intra-aortic balloon pump placement for persistent hypotension. The subsequent day, the patient underwent a primary median sternotomy and patch repair of the free wall rupture and coronary artery bypass grafting of the SVG to LAD. Following surgery, the IABP was able to be removed. The patient was discharged to a cardiac rehabilitation facility before ultimately returning home after 3 weeks.

**Conclusion**
Clinical suspicion should be high for mechanical complications following a myocardial infarction, with the preferred method of diagnosis being transthoracic echocardiography. If a pseudoaneurysm is identified, prompt surgical intervention with either direct defect closure with sutures or patch closure over an area of viable myocardium is key. In poor surgical candidates, percutaneous closure methods may be conside

Left Ventricular Pseudoaneurysm Presenting as an Acute Heart Failure Exacerbation

**Introduction/Hypothesis:**
Septic cerebral embolism is a common and serious complication of infective endocarditis (IE), affecting the clinical course of approximately 40% of patients with IE. Here, we describe a case of advanced native aortic valve endocarditis complicated by subacute embolic stroke.

**Methods**
Information related to this case was extracted from the Mayo Clinic electronic health record system.

**Results**
A 63-year-old man with recent L1-L2 discitis complicated by Staphylococcus epidermidis bacteremia on therapy with daptomycin was admitted for new-onset intermittent chest pain and shortness of breath. Transthoracic echocardiogram on admission revealed mobile aortic valve vegetations and severe aortic regurgitation. CT thoracic aorta revealed thickening of all 3 aortic valve leaflets with incomplete coaptation indicating severe aortic regurgitation. Infectious disease was consulted and antibiotic regimen was changed from daptomycin to vancomycin along with repeat cultures which were negative. Transesophageal echocardiogram showed vegetations of size 0.8-1 cm attached to the right and left cusps with perforation of the edge of the right cusp and severe aortic regurgitation. In the setting of new-onset diplopia over the past 3 months leading up to the admission, a head CT followed by brain MRI was obtained showing evolving subacute/chronic infarct in the right temporoparietal region with CT angiogram indicating occlusion of one of the right M3-MCA segment branch of the inferior division. Patient was evaluated by cardiothoracic surgery and underwent surgical bioprosthetic aortic valve replacement with pathology showing presence of native valve vegetations secondary to S. epidermidis IE confirmed on broad-range tissue PCR. Diplopia was ultimately felt to be unrelated to the embolic stroke and the patient did not have any other residual deficits aside from left lower quadrantanopia.

**Conclusion**
Both symptomatic and silent cerebrovascular complications can be frequently seen in patients with left-sided infective endocarditis. In most cases, embolization occurs prior to clinical presentation but can occur after initiation of antimicrobial therapy. A thorough history and physical exam is important to raise suspicion for IE and associated complications.



Embolic stroke secondary to native aortic valve infective endocarditis: A case report

Introduction/Hypothesis:
Abstract
Coronary artery anomalies are uncommon, and often incidentally found. An interarterial course is considered malignant with a higher risk of ischemia and sudden cardiac death. Our case focuses on an interarterial right coronary artery originating from the left sinus of Valsalva in an older patient with vague symptoms. This was found incidentally on a coronary artery calcium CT scan, and then confirmed on a dedicated coronary CTA. The patient has since been asymptomatic without inducible ischemia on a nuclear myocardial stress test, and therefore is being managed conservatively. Due to the rarity of this anomaly, further data is needed to track outcomes and hopefully form more definitive guidelines.

Introduction
Coronary artery anomalies are congenital abnormalities where the left or right coronary artery has an abnormal origin, course and/or termination. Often, the anomalous artery originates from the opposite sinus of Valsalva. Coronary artery anomalies are uncommon, with a general population incidence of 0.2 to 1.2 % (1). Patient presentation can vary, though the vast majority of these anomalies are found incidentally in asymptomatic patients. Certain courses and features, however, can result in ischemia, arrhythmias, or sudden cardiac death, with symptomatic patients presenting at a younger age (2).
The four common courses described for anomalous coronary arteries are retroaortic, prepulmonic, transseptal, and interarterial. The interarterial course, where the anomalous coronary artery traverses between the ascending aorta and main pulmonary artery to perfuse its specific myocardial territory, is considered malignant and poses the highest risk of sudden cardiac death and/or ischemia. This case presentation focuses on an interarterial course of the right coronary artery (RCA) originating from the left sinus of Valsalva.

Methods
Case Presentation
A 70 year old male presented to his primary care physician with reported episodes of non-specific left sided chest pressure. An EKG was unremarkable and there were no relevant laboratory abnormalities. Given his past medical history of hyperlipidemia, hypertension, carotid artery stenosis, and elevated body mass index, a coronary artery calcium scoring CT without contrast was obtained. Results revealed a total Agatston score of 21, most notably involving the RCA (with a score of 20). Incidentally, an anomalous origin of the RCA from the left coronary cusp with an interarterial (malignant) course was suspected (Figure 1). Approximately 1 month later, a Coronary CT Angiogram without and with contrast exam (Coronary CTA) was obtained which confirmed the interarterial course of the RCA (Figures 2 and 3). A moderate degree of proximal RCA stenosis with high risk (previously vulnerable) plaque was also present. A nuclear myocardial exercise stress test was performed during which the patient remained asymptomatic and revealed no imaging findings to suggest ischemia or infarct

Case Report of an Interarterial Right Coronary Artery: Imaging Features, Work-Up, and Management 

**Introduction/Hypothesis:**
Background: Arrhythmogenic cardiomyopathy (ACM) is characterized by fibroadipose replacement of the myocardium due to genetic defects in cardiac desmosome proteins. Clinical manifestations of ACM include arrhythmias, heart failure, and myocarditis. The acute phase of the disease often involves chest pain and signs of myonecrosis without evidence of coronary artery disease. This case explores the use of cardiac MRI in the diagnosis of acute phase ACM.

**Methods**
Case Presentation: A 47-year-old female presented to Mayo Clinic FL emergency room with complaints of sharp pleuritic chest pain that improved with leaning forward, dyspnea, orthopnea, and progressively worsening bilateral leg swelling following a recent viral illness. Pertinent medical history included arrhythmogenic cardiomyopathy with recurrent myopericarditis, inducible VF status post ICD placement 10 months prior, and fibromuscular dysplasia. Previous genetic testing revealed pathologic desmoplakin variant and variant of uncertain significance in the desmin gene. The patient was hemodynamically stable. EKG showed normal sinus rhythm with nonspecific ST changes. Serial troponins peaked at 48, then down trended. NT-proBNP and CXR were unremarkable. D-dimer was elevated, but CTA was negative for pulmonary embolism and there was no DVT on lower extremity ultrasound. ICD interrogation showed no events. Coronary CTA was negative for spontaneous coronary artery dissection and significant coronary artery disease. A transthoracic echocardiogram demonstrated increased LV wall thickness to cavity ratio, grade 1/3 LV diastolic dysfunction, preserved EF of 65%, collapsible IVC, no regional wall motion abnormalities, and no pericardial effusion. The patient continued to have moderate chest discomfort despite normal leukocyte count, CRP and ESR. Given her symptoms and elevated troponins without coronary disease, there was high suspicion for a recurrent episode of myocarditis, prompting a cardiac MRI. T1 images showed a thin mid-myocardial stripe of late gadolinium enhancement along the basal to mid-inferoseptal left ventricular wall similar to her previous cardiac MRI one year prior. There was also mild asymmetric hypertrophy of the basal septum of the left ventricle. T2 images were not available to differentiate acute and chronic myocarditis or prior scar. Nonetheless, her increase in troponin from baseline and new clinical symptoms suggested an acute flare of myocarditis. Artifact from her ICD limited full pericardial visualization, making the MRI less reliable in evaluating for pericarditis. The patient’s overall findings and clinical picture were most consistent with myocarditis possibly triggered by her viral illness. She was given colchicine 0.6 mg daily. She continued to experience pleuritic chest discomfort and decreased exertional capacity, so a trial of prednisone with slow taper was pursued with clinical improvement.

**Results**
Cardiac MRI T1 and SSFP imag

Equivocal Cardiac MRI In Myopericarditis In A Patient With Arrhythmogenic Cardiomyopathy

**Introduction/Hypothesis:**
Primary cardiac tumors are exceedingly rare with an incidence rate of only 0.001 to 0.03%. Of those, pericardial hemangiomas are the rarest form, comprising up to 2-5% of benign cardiac tumors. Pericardial hemangiomas are well-circumscribed and diffusely vascular tumors, with differential diagnoses including vascular metastases and paragangliomas. Most patients remain asymptomatic with tumor discovery often occurring at the time of autopsy. We present a case of an incidentally found pericardial hemangioma on routine cardiovascular evaluation.

**Methods**
74-year-old male with a history of hypertension, hyperlipidemia, obstructive sleep apnea, and ascending aortic dilation underwent a routine coronary calcium computerized tomography (CT) scan and found to have an incidental 3.3 x 1.7 cm intrapericardial mass in the interventricular groove adjacent to the left anterior descending (LAD) artery. Subsequent cardiac magnetic resonance imaging (MRI) redemonstrated a well-defined avidly enhancing 3.4 x 2.3 mass abutting the mid LAD with epicardial and pericardial inflammatory changes, concerning for coronary artery aneurysm versus paraganglioma versus metastases from an unknown primary. Follow-up coronary CT angiogram visualized the same mass with avid arterial enhancement concerning for an enhancing neoplasm. A coronary artery aneurysm was felt less likely as the mass was not in continuity with the adjacent LAD, though it was inseparable from a septal perforator. Coronary angiogram confirmed a hypervascular mass with feeding vessels from septal perforators and a diagonal vessel.

**Results**
Due to concern for neoplasm, the mass was surgically resected and pathology ultimately revealed a benign hemangioma. Routine CT one year later showed mass recurrence with continued growth on serial imaging. He was treated with five fractions of external beam radiation with interval decrease in size and has since been managed with active surveillance.

**Conclusion**
Pericardial hemangiomas are an extremely rare phenomenon. However, clinicians should maintain a high level of suspicion when encountering patients with a highly vascular and well-circumscribed mass within the pericardial space.



Intrapericardial Hemangioma

**Introduction/Hypothesis:**
A 60-year-old female with history of COPD on 2L of oxygen at baseline presented to emergency department with worsening dyspnea. In the ER, the patient was in respiratory distress and tested PCR positive for influenza A. Additional laboratory values were significant for elevated lactate 8.9, leukocytosis WBC 17.5, and troponin T mildly elevated at 36. A Triple rule out CT with coronary angiography and retrospective gating was performed which demonstrated apical akinesis with ballooning, preserved basal contraction and an apical left ventricular thrombus. The coronary arteries demonstrated minimal atherosclerotic disease with minimal stenosis. This was most apparent on a specialized 512 Matrix Cine reconstruction series which was possible due to retrospective gating. Left ventricular ejection fraction was estimated at 24%. Subsequent echocardiogram confirmed the findings seen on the CT. The patient was treated for influenza and COPD exacerbation and discharged from the hospital 10 days later. The patient completed a 3-month prescription of coumadin for the left ventricular thrombus. Follow-up echocardiogram 3 months later demonstrated normal LV size without wall motion abnormalities. Cardiac MRI 6 months after initial presentation demonstrated normal LV size and global systolic function. No residual thrombus was present. Interestingly, the patient had a prior episode of stress induced cardiomyopathy 4 years prior with apical dyskinesia and reduced LVEF of 25% with subsequent recovery of function and normal cardiac MRI in the interim.

**Methods**


**Results**
This case demonstrates the utility of retrospectively gated triple rule out CT to diagnose stress induced cardiomyopathy. A few notable advantages of retrospective coronary CT in the setting of possible stress induced cardiomyopathy include relatively quick acquisition (compared with echocardiography, conventional angiography and MRI), simultaneous evaluation of coronary arteries, and the ability to assess wall motion abnormalities with 512 matrix cine images (1). Assessment for interventricular thrombi can be performed utilizing multiplanar reformats which can overcome the possible issue of poor acoustic windows on echocardiography. In stable patients with low suspicion of ACS and high suspicion of new or recurrent stress induced cardiomyopathy, coronary angiogram CT may be chosen instead of conventional coronary angiography (2). A disadvantage of using CT rather than MRI or echocardiography is exposure to ionizing radiation, however the dose is presumably less than conventional coronary angiography (3).

**Conclusion**
In conclusion, retrospectively gated triple rule out CT with coronary computed tomography angiography can be used to diagnose stress induced cardiomyopathy. This diagnosis can be aided by utilizing cine imaging to evaluate wall motion abnormalities.
1. Zghyer F, Botheju WSP, Kiss JE, Michos ED, Corretti MC, Mukherjee M, Hays AG. Cardiovascular Ima

Stress Induced Cardiomyopathy diagnosed on CT 

**Introduction/Hypothesis:**
For evaluation of hernias, patients may be asked to perform voluntary Valsalva during their CT scan, which has been reported to produce a transient narrowing of the aorta and iliac arteries (1, 2). This case highlights a rarely imaged phenomenon, captured as the patient involuntarily retched in the middle of a multiphase CT scan, with the venous phase images showing transient aortic collapse.

**Methods**
A 67 year old patient with metastatic colon adenocarcinoma underwent surveillance imaging that consisted of combined contrast-enhanced chest CT and multiphase abdomen and pelvis CT. On the chest CT images (acquired during venous phase of contrast injection), the descending aorta at the level of the diaphragmatic hiatus was severely compressed and had a flattened appearance with greater than 50% luminal narrowing (Fig 1).

**Results**
The aorta was normal caliber on the previous surveillance chest CT from just seven months prior.
Review of the same-day CT abdomen and pelvis images showed the aorta to be normal caliber on the delayed phase images. After discussion with the CT technologists, the radiologist learned that the patient had become nauseated during the scan and vomited, corresponding to the time of imaging findings. A 3D reformatted image of the aorta was created comparing venous and delayed phase acquisitions showing marked aortic luminal narrowing during the venous acquisition with resolution on delayed phase. The patient denied any symptoms of mesenteric or lower extremity ischemia.

**Conclusion**
While this involuntary Valsalva maneuver did not compromise the other imaging findings, it could lead to a diagnostic pitfall and false positive interpretation of aortic stenosis. In a similar case, unbeknownst to the reading radiologist, a patient vomited during their CT scan and had signs of increased abdominal pressure, including narrowing of the aorta, for which the radiologist suggested further workup for abdominal compartment syndrome (3). Knowledge of this phenomenon, review of multiphase CT images, and discussion with CT technologists can avoid false positive diagnoses of aortic stenosis. Thus, for patient comfort and better images, it is recommended to suspend imaging while a patient is actively vomiting.



Transient Aortic Collapse Captured on Multiphase CT During Involuntary Retching

Introduction/Hypothesis:
Abstract:Among primary benign cardiac tumors papillary fibroelastoma is the most common. Usually, papillary fibroelastomas are asymptomatic and discovered incidentally, either by echocardiography, cardiac surgery or autopsy, but sometimes they could lead to impressive clinical manifestations, such as strokes. This case involves a 63-year-old male patient with new onset atrial fibrillation and significant comorbidities, in whom papillary fibroelastoma was found on the aortic valve during pre-conversion echocardiographic evaluation. Despite initial difficulties with an attempted transesophageal echocardiography-guided removal due to coronary complications from air emboli, a successful percutaneous catheter- based procedure was later performed using a novel approach at a second institution. Multimodal imaging and careful evaluation of the expert team revealed silent cerebral infarctions, underscoring the need for comprehensive assessment and the importance of surgical intervention to prevent further embolic events. Our case highlights the critical role of multidisciplinary team and integrated cardiac and neurological imaging in managing such tumors.

Methods
Introduction:Primary cardiac tumors are rare and typically benign. Papillary fibroelastoma (PFE) is the most common type, generally presenting benign pathological findings (1). Most papillary fibroelastomas are asymptomatic and are found incidentally through echocardiography, cardiac surgery, or autopsy. However, they can sometimes lead to significant clinical issues, such as stroke caused by embolization (2,3). Therefore, a multidisciplinary heart team- comprising a cardiologist, sonographer, cardiovascular surgeon, interventional cardiologist, radiologist, and neurologist- should collaborate to ensure accurate diagnosis and assess embolization risk. This collaboration is crucial for selecting the appropriate treatment and achieving optimal clinical outcomes for each patient.

Results
Case presentation: We present the case of a 63-year-old male, admitted with new onset atrial fibrillation diagnosed during a routine cardiovascular examination. He had medical comorbidities including, but not limited to, coronary artery disease with prior three vessel artery by-pass grafting and rheumatoid polyarthritis. In the context of atrial fibrillation anticoagulation therapy was introduced, and the patient underwent a transesophageal echocardiogram (TEE) for scheduled cardioversion. Left atrial appendage thrombosis was excluded and surprisingly a small mass (6x7mm) attached to the left coronary cusp of aortic valve suggestive for PFE was discovered without valvular function impact. In completion of investigator protocol for an accurate description of the morphological characteristics of the mass on the aortic valve and to establish its relationship with surrounding structures, with the concomitant advantage of assessing the coronary arteries status, a cardiac CT angiography with con

A papillary fibroelastoma hidden behind the curtain of new onset atrial fibrillation…

**Introduction/Hypothesis:**
Papillary fibroelastomas (PFE) have recently been identified as the most common benign cardiac tumors, often found on valvular surfaces, most commonly the aortic valve followed by the mitral valve. However, PFEs can also attach to extra-valvular structures, including the left atrial appendage (LAA) and its surroundings, although this is less common. An area of interest related to PFEs is the coumadin ridge, also known as the Q-tip, a unique anatomical ridge in the left atrium specifically between the LAA and the left upper pulmonary vein (LUPV). This area is associated with an increased risk of thrombus formation due to blood stasis, which is why it derives its name from the anticoagulant medication coumadin (warfarin) which is often used to reduce this risk.
LAA tumors can pose a diagnostic challenge due to their anatomical complexities. The coumadin ridge, despite being a normal anatomical structure, can be mistaken for a tumor or thrombus due to its shape and position. This can lead to unnecessary and costly treatments for patients. These neoplasms are best detected by transesophageal echocardiography (TEE), and despite their benign nature, they have been associated with a range of serious embolic events. Therefore, accurately identifying and categorizing a mass in this region is notably important for accurate management, and yet can be clinically challenging.

**Methods**
We describe 13 cases of pathology-proven PFEs located in the LAA, including seven cases specifically on the coumadin ridge. Patient data, including demographics, mass characteristics, diagnostic imaging, and histopathologic evaluations were collected and analyzed.

**Results**
Thirteen patients with pathology-proven PFEs in the LAA were included in the study, of which seven cases involved the coumadin ridge. The median age of the cohort is 73 (IQR 67-77), and 54% of the patients were male. Tumor sizes ranged from 2mm to 20mm, with a median of 5mm (IQR 3.5-8.5). Twelve (92.3%) of the PFEs were initially visualized on TEE, and one case was diagnosed postoperatively by pathologists after the excision of the LAA. The majority of cases were incidental diagnoses, with 46% of cases incidentally discovered intraoperatively by routine TEE, and 30% visualized on TEE done for diverse reasons including valvular assessment, exclusion of infective endocarditis, assessment of intra-cardiac source of embolism and coronary artery disease (CAD) assessment. One case was incidentally detected on cardiac magnetic resonance imaging (MRI) performed as part of a metastatic tumor workup. Four (30%) patients presented with symptoms of stroke/transient ischemic attack (TIA), of which two had a previous history of stroke. One patient had symptoms of both TIA and angina pectoris. Cardiovascular disease and atherosclerotic risk factors were prevalent: 69% had hyperlipidemia, 38% had atrial fibrillation (Afib) all of whom were therapeutically anticoagulated for at least 3 mont

Pathologically Proven Papillary Fibroelastomas Attached to the Left Atrial Appendage 

**Introduction/Hypothesis:**
Papillary fibroelastomas (PFEs) are the most common primary benign cardiac tumors, often involving valvular surfaces. However, they can occasionally be found in atypical locations such as the left atrium, where they may mimic cardiac myxomas (CM). This case aims to illustrate the diagnostic challenges when a PFE presents with clinical and imaging features suggestive of a myxoma.

**Methods**
We describe an interesting case of pathology-proven PFE mimicking a cardiac myxoma. Patient data, including demographics and mass characteristics, clinical presentation, diagnostic imaging, and histopathologic evaluations are described.

**Results**
A 66-year-old female with a medical history notable for paroxysmal atrial fibrillation and two cerebrovascular accidents (CVA) in the last 10 years presented with new complaints of fatigue, shortness of breath, and dizziness on exertion for the past few months. Her first stroke occurred in 2014, during which she experienced dizziness, and a brain MRI revealed acute diffusion restriction in the right cerebellum. The second stroke, in 2015, presented with dizziness, aphasia, and right arm numbness, with an MRI showing multiple small infarcts in the left cerebral hemisphere, including the frontal, parietal and temporal lobes, likely of embolic origin. Following her last stroke, she was prescribed coumadin for anticoagulation after continuous telemetry detected atrial fibrillation. Since starting anticoagulation therapy, she did not experience any cerebrovascular symptoms.
The patient underwent a transthoracic echocardiogram (TTE) revealing a 21x15mm echodensity in the left atrium. Transesophageal echocardiogram (TEE) 2 weeks later confirmed the findings.  The mass had a heterogenous appearance and an irregular border. It appeared to be attached to the left atrial wall above the posterior mitral valve leaflet, findings suggestive of a myxoma.
Following discussion with multidisciplinary team and given her history of multiple CVAs and current symptoms, open surgical resection of the mass was performed, surprisingly yielding a 23 x 22 mm mass with numerous papillary fronds on gross pathological examination. Histologically, the papillary fronds were thin and branching (Hematoxylin & Eosin, 2x). The cores were comprised of mostly collagen fibrosis and elastic tissue, highlighted by the elastin stain (Verhoeff-Van Gieson stain, 2X). Focally, the papillary fronds were collapsed and predominantly myxoid, consistent with a PFE. Consequently, a calretinin immunostain (inset), which is used to identify myxoma cells, was performed to ensure the diagnosis and yielded a negative result.

**Conclusion**
Despite their rarity, PFEs should be considered in patients presenting with left atrial masses, even if the clinical presentation is atypical. Accurate histopathological diagnosis is crucial for proper management and improving patient outcomes.  This case points out that although PFE is most commonly foun

A Rare Case of Left Atrial Papillary Fibroelastoma mimicking a Myxoma 

**Introduction/Hypothesis:**
A complex case of a 59 year old male with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) diagnosed at age 39 status post combined Takeuchi repair with interpulmonary baffle and mitral valve annuloplasty who presented with massive thrombosed right coronary artery pseudoaneurysm exerting mass effect on the right atrium and right ventricle and chronic myocardial infarcts in multiple vascular territories with resultant severe tricuspid regurgitation and left-sided heart failure.

**Methods**
Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac anomaly accounting for less than 0.5% of all  left ventricle congenital heart diseases, though it is the most common congenital coronary artery anomaly presenting in children. It usually presents in infancy with congestive heart failure symptoms occurring in 85% of patients within the first 2 months of life. ALCAPA often results in left ventricular myocardial ischemia due to perfusion of the left coronary artery (LCA) with low-pressure, deoxygenated blood from the pulmonary system. This can result in LAD territory ischemia and infarction leading to poor left ventricle (LV) function and mitral regurgitation. Up to 90% of cases of ALCAPA are fatal if not surgically treated. Surgical techniques include direct transfer of the LCA to the aortic root, bypass grafting, and Takeuchi repair with interpulmonary baffle from the aorta to the anomalous LCA origin. The mortality despite surgery is 5-10%, usually related to poor LV function.

**Results**
This patient presented to Mayo Clinic Florida for tricuspid regurgitation, worsening heart failure, and possible hepatic cirrhosis. Initial imaging workup with echocardiogram and cardiac CT and MRI demonstrated post surgical changes of Takeuchi repair with interpulmonary baffle and mitral valve annuloplasty, massive thrombosed large right coronary artery pseudoaneurysm with occlusion of the right coronary artery and mass effect on the right atrium and right ventricle, severe tricuspid regurgitation, transmural infarct in the RV free wall and LAD-territory, 4 chamber dilitation, and depressed systolic function with LVEF of 36%.

**Conclusion**
The treatment for this patient was heart transplant occurring approximately 8 months after initial consultation with the cardiac transplant team with a good clinical outcome for the patient to this date. In conclusion, ALPACA is a congenital cardiac anomaly associated with high mortality if undiagnosed and untreated. Surgical correction of the anomalous LAD origin can greatly reduce mortality; however, some patients may experience poor left ventricle function due to myocardial infarct occurring prior to surgical correction and may require cardiac transplant as in this case.



ALCAPA with Massive RCA Aneurysm After Takeuchi Repair

Introduction/Hypothesis:
Pulmonary Angiosarcoma is a rare cancer found in blood/lymphatic vessels or on the skin surface. Most cases are cutaneous lesions which may be seen on physical exam, but visceral lesions may only reveal themselves when tumor mass effect causes local compression and correlating symptoms. The incidence is 1:1,000,000 and is most likely found in white men over 70, post-radiation treatment. Angiosarcomas contribute roughly 1% of all sarcomas, which in and of themselves make up 1% of cancers. This patient is a 38yo man who initially presented to the ED at an outside institution for dyspnea. The patient underwent a CT scan which showed soft tissue density in the pulmonary artery, diagnosed with PE and treated with anticoagulation. The patient returned to the ED with progression of symptoms and re-visualization of the soft tissue density. The patient was then referred to MCF for evaluation. The patient underwent surgical resection at MCF with pathology-proven sarcoma and + margins. The tumor had metastasized to numerous distant sites including the brain, adrenal, liver, and retroperitoneum.

Methods
This patient's history and imaging was obtained from the EMR. This patient has been followed exclusively by Mayo Clinic Florida since beginning cancer treatment.

Results
This patient attempted to treat his cancer aggressively with a combination of radiation and chemotherapy options post-surgical resection. A combination of Doxorubicin and daily fractionated therapy was unable to halt disease progression. Unfortunately, this patient eventually succumb to his illness. 

Conclusion
Angiosarcoma is a rare aggressive cancer that is notoriously resistant to treatment. This patient suffered unfortunate circumstances of diffuse metastasis throughout the chest, abdomen, and pelvis which caused significant pain, emotional stress, and ultimately led to his death. Imaging of this mass initially prompted a diagnosis of pulmonary embolism which led to a delay in treatment and potentially life saving surgery. Clinicians should be aware of unique malignant presentations and continue to keep a wide differential when interpreting routine studies.

Pulmonary Angiosarcoma - An Unfortunate Distribution Center for Diffuse Metastasis

**Introduction/Hypothesis:**
Cardiac computed tomography angiography (CCTA) has emerged as a versatile tool in the non-invasive and rapid assessment of patients presenting with chest pain. It has excellent sensitivity, specificity, and negative predictive value. Alternative diagnoses, such as pulmonary embolism and acute aortic syndrome, have been well described. However, coronary artery wall characterization may be particularly valuable in patients with acute coronary syndromes (ACS).

**Methods**
We present a 42-year-old female with a past medical history of Ehlers-Danlos syndrome and gastric bypass that presented to the emergency department for an episode of chest pain and syncope. She experienced a short episode of non-cardiac chest pain at rest followed by a 30 second episode of loss of consciousness. After her loss of consciousness, the patient experienced shortness of breath and waxing and waning of severe chest pain. The patient’s physical exam was unremarkable. High sensitivity troponin-T was elevated with a baseline of 14 ng/L, a 2-hour value of 24 ng/L, and a 6-hour value of 37 ng/L. Electrocardiogram showed sinus bradycardia without ischemia. The patient was initiated on medical therapy for ACS. CCTA was performed and demonstrated a high-grade, heterogeneously attenuating eccentric lesion in the proximal right coronary artery (RCA) (Figure 1) with surrounding epicardial fat stranding and a coronary artery calcium score (CACS) of 30.6 (98th percentile). This pattern can be seen in both spontaneous coronary artery dissection (SCAD) and an acutely ruptured plaque. Invasive coronary angiography (ICA) with intra-vascular ultrasound was performed and demonstrated a severe stenosis of the RCA without dissection for which percutaneous coronary intervention (PCI) was performed.

**Results**
Our case highlights how CCTA can be utilized to help differentiate low risk stable plaque from high-risk unstable ruptures. The attenuation of structures on CCTA can help distinguish stable plaques from unstable ruptures and are quantified using Hounsfield units (HU). There has been an effort to correspond HU with different plaque types. For example, the average HU density for lipid-rich soft plaques ranges from 15-75 HU, fibrous plaques range from 67-149 HU, and calcified plaques range from 135-1,089 HU. The most critical histological predictors of plaque ruptures and acute injuries on CCTA are cap thickness and necrotic core. Unstable lesions tend to be non-calcified with low attenuation, have larger overall plaque burden, and higher positive remodeling index when compared to stable lesions. When an atheroma consists of a lipid-rich necrotic core and a fibrous capsule, it results in an area of low attenuation surrounded by a ring of high attenuation known as a napkin-ring sign. The low attenuation, positive remodeling that is seen as compensatory enlargement of the vessel wall, and the napkin-ring sign are all prognostic indicators of a myocardial infarct

Critical CCTA Findings in NSTEMI 

**Introduction/Hypothesis:**
Here, we present a 47-year-old woman presenting to our emergency department with fatigue, bilateral lower extremity swelling and dyspnea on exertion for 1-2 weeks. Patient has a past medical history of IV and intranasal drug use, including cocaine, heroin, methamphetamine, fentanyl; had recent left lower extremity cellulitis treated with oral antibiotics. She also has hepatitis C, bipolar disorder, hypertension and COPD. BP on arrival was 173/102, patient had worsening respiratory status with tachypnea and hypoxemia, chest x-ray revealed pulmonary edema, likely cardiogenic origin vs hypertensive flash pulmonary edema. Diuresis with Lasix 40 mg IV push doses was initiated with adequate response and slight improvement. A diagnosis of NSTEMI was made with a troponin trend of 182-191-187 in 0-2-6 hours respectively; NT-Pro BNP was 8249; IV Heparin was started with an intention to continue for 48 hours and a coronary anatomy investigation. A diagnostic test was obtained.
TTE revealed a LVEF 42%, with hypokinesis in all the mid ventricular segments and akinesis throughout the apical segments, with severely enlarged left atrial size, LAVI 55, normal RV size and function, TAPSE 20 mm. Our top differentials were a type 1 MI in the LAD region, stress-induced cardiomyopathy and substance use-related cardiomyopathy (especially cocaine), affecting the whole mid and apical region.
In the light of low-risk nature of the presumed NSTEMI picture, further risks of noncompliance assuming PCI is pursued (i.e. patient may not be compliant with DAPT which may lead to worse outcomes post PCI), troponin peaking at 191 and downtrending, patient's respiratory status improving with diuresis, a coronary CTA was obtained instead of a coronary angiogram. CCTA was significant for scattered calcification in the left main, LAD, left circumflex, and right coronary arteries resulting in up to mild stenosis, CAD RADS 2. A diagnosis of biventricular stress-induced cardiomyopathy was made, guideline-directed medical therapy was initiated with Carvedilol 6.25 mg BID and Lisinopril 10 mg daily, with a plan to uptitrate GDMT and repeat echocardiogram as an outpatient.
Biventricular stress-induced (Takotsubo) cardiomyopathy occurs in 25-42% of the cases, is associated with worse hemodynamics, more invasive management and a longer hospitalization course. Our case highlights the imaging features of this entity on TTE and utilization of coronary CTA to rule out obstructive coronary disease or angiographic evidence of plaque rupture in this population, highlighted by Mayo Clinic Diagnostic Criteria proposed by Prasad et al.

**Methods**
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**Results**
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**Conclusion**
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A Case of Biventricular Stress-Induced Cardiomyopathy

Background: Advent of non-invasive diagnosis of transthyretin cardiomyopathy (ATTR-CM) using 99m-technetium pyrophosphate scan (99m-Tc PYP) and approval of Tafamidis for ATTR-CM have revolutionized the field. The utility of 99m-Tc PYP scan to quantify disease burden while receiving Tafamidis therapy has been proposed. Here, we report a case that questions the reliability of 99m-Tc PYP scan during Tafamidis therapy.
Case: A 76-year-old man with MGUS and diagnosis of ATTR-CM (based on a positive 99m-Tc PYP scan; Figure 1A) on Tafamidis therapy for 5 months presented to our institution for a second opinion. Due to unavailability of outside images at the time, 99m-Tc PYP scan was repeated and was negative (Figure 1B).
Decision-making: Negative repeat 99mTc-PYP scan after 5 months of Tafamidis therapy and non-specific cardiac MRI findings lead to discontinuation of Tafamidis. During follow up, presence of MGUS, elevated cardiac biomarkers and suspicious musculoskeletal findings lead to an endomyocardial biopsy (EMBx), which confirmed the diagnosis of ATTR-CM. TTR gene testing was negative. Tafamidis therapy was resumed.
Conclusion: In addition to emphasizing routine use of EMBx in suspected cardiac amyloid patients with MGUS, this case underscores the importance of EMBx in case with incongruent non-invasive tests and those requiring confirmation of the diagnosis while on Tafamidis therapy.

False Negatives and Final Verdicts: A Complex Journey to Transthyretin Amyloid Cardiomyopathy Diagnosis

**Introduction/Hypothesis:**
An 87-year-old female with a history of atrial fibrillation and prior mitral valve replacement with a 27 mm Edwards bioprosthesis, alongside a tricuspid repair with a 32 mm Edwards annuloplasty ring in 2007, presented with severe dyspnea on exertion and recurrent pleural effusions following a COVID-19 infection. Outside imaging raised concerns for bioprosthetic mitral stenosis, prompting direct admission to our center for further evaluation and management.

**Methods**
On physical examination, the patient exhibited mild jugular venous distention, a subtle precordial lift, and a thrill at the left lower sternal border. Auscultation revealed two distinct murmurs: a 3/6 harsh systolic ejection murmur at the left lower sternal border and a 3/6 blowing apical murmur suggestive of regurgitation, without an accompanying diastolic rumble.

**Results**
A transthoracic echocardiogram identified moderate prosthetic mitral valve stenosis and at least moderate eccentric mitral valve regurgitation, previously obscured by significant shadowing from the mitral prosthesis. Subsequent transesophageal echocardiography confirmed a flail prosthetic leaflet resulting in torrential mitral regurgitation.

**Conclusion**
The patient underwent successful transcatheter mitral valve-in-valve replacement with a 26 mm Edwards Sapien S3 Ultra valve, leading to the resolution of mitral regurgitation. The patient was discharged to inpatient rehabilitation in stable condition.



Torrential Prosthetic Mitral Valve Regurgitation Hidden by Shadowing Artifact​

**Introduction/Hypothesis:**
Introduction: Ventricular septal rupture (VSR) is a devastating complicating following acute myocardiac infarction and is often complicated by cardiogenic shock with high in-hospital mortality.

**Methods**
Case: A 73-year-old woman developed left-sided chest and back pain 10 days prior to presentation to the emergency department with shortness of breath. Comorbidities notable for type 2 diabetes mellitus, chronic kidney disease stage II, and hypertension. On arrival, patient was tachycardic but otherwise vitally stable. Physical exam was notable for a new 3/6 holosystolic and 2+ pitting edema bilaterally. Electrocardiogram (EKG) showed ST segment elevation in the anterior lateral and inferior leads and initial troponin was elevated.  Patient was loaded with aspirin and heparin and transferred to hospital with a cardiac catheterization laboratory.
There, patient underwent a transthoracic echocardiogram (TTE) which demonstrated a ventricular septal defect with a left to right shunt and decreased ejection fraction of 34%. The right ventricle was also noted to be enlarged with a mildly reduced systolic function and RVSP of 56 mm Hg (Figure 1). VSR was again appreciated on computed tomography cardiac angiogram (Figure 2). 
A subsequent coronary angiography revealed 90% occlusion of the mid-left anterior descending (LAD) with TIMI 2 flow (Figure 3).  Revascularization was not attempted. A right heart catheterization demonstrated Qp/Qs ratio of 2.5, cardiac index of 1.5 L/minute/m2, pulmonary capillary wedge pressure of 24 mm Hg, and mean right atrial pressure of 16 mm Hg.  An intra-aortic balloon pump (IABP) was placed during procedure to optimize hemodynamics. 
Patient was aggressively diuresed in the CCU with improvement in symptoms and hemodynamics.  Cardiovascular surgery were consulted and elected for operative closure of the VSR but gave time for scar formation prior to repair.
After 34 days in the hospital, patient underwent successful operative ventricular septal defect closure. She did well postoperatively and was subsequently transferred to the inpatient rehabilitation service and later dismissed to home with family support.

**Results**
Decision Making: This patient was diagnosed with post-myocardial infarction VSR complicated by cardiogenic shock (CS) and multiorgan failure requiring hemodynamic support with IABP.  The ideal timing of surgical intervention for post-myocardial infarction VSR with cardiogenic shock remains controversial as there is high mortality when surgery is performed acutely compared to delayed intervention. In this case, patient was able to undergo successful IABP placement to maintain hemodynamic stability and allow for delayed surgery.

**Conclusion**
Conclusion: We present a case of post myocardial infarction VSR complicated by cardiogenic shock. Patient underwent IABP placement with improvement in hemodynamic stability and subsequent bridge to delayed repair.



Post-Myocardial Infarction Ventricular Septal Rupture complicated by Cardiogenic Shock: Successful Intraaortic Balloon Pump Bridge to Delayed Surgical Repair 

**Introduction/Hypothesis:**
Mitral annular calcification (MAC) is a progressive degenerative process associated with comorbidities and increased mortality. A staging system that considers extramitral cardiac damage in MAC may help improve patient selection for mitral valve interventions.

**Methods**
We retrospectively evaluated all adults who underwent TTE over 1 year at Mayo Clinic with MAC and significant mitral valve dysfunction defined as mitral stenosis and/or at least moderate mitral regurgitation. Patients were categorized into 5 stages according to extramitral cardiac damage by TTE. All-cause mortality and heart failure hospitalization were assessed.

**Results**
For the 953 included patients, the mean age was 76.2   10.7 years, and 54.0% were women. Twenty-eight (2.9%) patients were classified in stages 0 to 1, 499 (52.4%) in stage 2, 115 (12.1%) in stage 3, and 311 (32.6%) in stage 4. At the 3.8-year follow-up, mortality was significantly higher in patients in stages 2 to 4 compared to stages 0 to 1 and increased with each stage. Survival differences were maintained after adjustment for age, diabetes mellitus, and glomerular filtration rate. The rate of heart failure hospitalization was significantly higher in stages 3 and 4 compared to stages 0 to 1. Similar results were observed in subgroup analysis in patients with moderate or severe MAC, predominant mitral stenosis, or predominant mitral regurgitation.

**Conclusion**
Using the proposed extramitral cardiac damage staging system in patients with MAC and significant mitral valve dysfunction, more advanced stages are associated with higher mortality.



Staging Extramitral Cardiac Damage in Mitral Annular Calcification With Mitral Valve Dysfunction

This course will explore basic and cutting-edge imaging techniques to improve patient care and hone individual skills in performance and interpretation of echocardiography, nuclear cardiology, cardiac computed tomography, and cardiovascular magnetic resonance imaging. Days will reinforce how cardiovascular imaging may improve comprehension in ischemic heart disease, structural heart disease, cardiomyopathies, and heart failure. Experts will utilize novel techniques to reinforce key topics including taped interventional cases and a strong emphasis on case presentations.