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Blunt chest trauma (BCT) may rarely trigger stress-induced takotsubo syndrome (TTS) which requires dif f erential diagnosis with myocardial contusion and BCT-induced myocardial infarction. So far reported cases have been presented as apical ballooning or inverted (reverse) TTS forms but not as a midventricular variant. The authors described a case of a 53-year-old female admitted to Intensive Care Unit after motor vehicle accident with BCT and airbag deployment during car roll over. For some time after the accident, she was trapped in a car with her head bent to the chest. After being pulled out from the car, she had impaired consciousness and therefore was intubated by the rescue team. Trauma computed tomography scan did not reveal any injuries. However, ECG showed ST-segment depression in II, III, aVF, V4-6, and discrete ST-segment elevation in aVR. Troponin I and NTpro-BNP increased to 2062 ng/l and 6413 pg/ml, respectively. Echocardiography revealed mild midventricular dysfunction of the left ventricle with ejection fraction (EF) and global longitudinal strain (GLS) reduced to 45% and -17.6%, respectively. On day two, the patient's general condition improved and stabilized, so she was extubated. Normalization of ECG, EF and GLS (but not regional LS) was observed on day three. She was discharged home on day fi ve. Post-hospital examinations documented that segmental longitudinal strain remained abnormal for up to 4 weeks. The authors conclude that fast ECG and echocardiographic evolution may result in underestimation of the posttraumatic TTS diagnosis, especially if it takes atypical form and its course is mild. Longitudinal strain evaluation can be helpful in cardiac monitoring of trauma patients.

Brugada syndrome (BrS) is an inherited channelopathy characterized on ECG by coved (type 1) or saddle-back (type 2) ST-segment elevation (STE) of 2 or more mm in the right precordial leads and is associated with an increased risk of malignant ventricular arrhythmias. The term Brugada phenocopy (BrPh) indicates conditions that may reversibly induce Brugada-like ECG pattern in patients without true BrS; e.g.: metabolic abnormalities, mechanical heart compression, ischemia, myocarditis/pericarditis, and pulmonary embolism (PE). Only 9 cases of BPh associated with PE have been described so far. The authors present another case of a 41-year-old-male and analyze the clinical data of all 10 subjects (7 males and 3 females). Type 1 of ECG Brugada pattern was present in 7 patients (including ours), type 2 was found in 2 persons; in 1 case ECG pattern was not defined. In 7 patients STE was prominent (5 mm or more in at least 1 lead). STE was limited to V1-V2 leads in 4 persons, extended to V3 in 3 patients and even to V4 in 3 other patients, which correlated with the significant right ventricular (RV) dilatation. Concomitant left ventricular (LV) systolic dysfunction was reported only in 1 patient, which suggested that paradoxical embolization of coronary artery was not the mechanism of BrS-like STE. Clinical course of PE was usually severe (5 individuals were treated with thrombolysis) and in 3 cases it ended with death. The autopsy was only performed on our patient. It showed diffuse (ischemic) injury of RV and LV secondary to RV overload, decreased cardiac output and severe oxygen deficiency in myocardium, which could have led to BrS pattern in ECG., (© 2022 MEDPRESS.)

Native heart valve thrombosis (NHVT) is a rare valvular pathology, usually associated with prothrombotic state or disturbed intracardiac blood flow related to structural valve abnormalities. While different venous and arterial thromboembolic complications of COVID-19 have been widely described, so far NHVT has not been reported in the context of the disease. The authors describe 4 cases of NHVT associated with COVID-19, revealed on aortic, mitral (2 patients) and tricuspid valve. In a 29-yearold male with mild pneumonia, large thrombus developed on bicuspid aortic valve (BAV), which resulted in fatal brain emboli. In a 76-yearold male with a history of rheumatoid arthritis (RA) being in a recovery period after COVID-19, central retinal artery occlusion (CRAO) was the first sign of mitral valve thrombus, which disappeared after 3 weeks, during apixaban use. Such therapy was also successful in a 46-yearold female with multiple cardiovascular risk factors in whom mitral valve thrombus was found in a routine echocardiography after she got COVID-19 the third time. In a 75-year-old man with moderate COVID-19 pneumonia and bacterial coinfection, coexistent transient focal LV dysfunction and tricuspid valve thrombus were observed. The patient was treated with apixaban as well; however, in this case only reduction in the thrombus size was seen after 4 months therapy. The authors indicate that in patients with COVID-19 and NHVT, other prothrombotic conditions can usually be found. This complication may involve different valves and occur irrespective of COVID-19 severity. Interdisciplinary evaluation of such patients is necessary., (© 2022 MEDPRESS.)

Arterial thromboembolic events (ATE) in COVID-19, similarly as venous thromboembolism (VTE), are observed mainly in severely ill patients. ATE include brain, heart, aortic, and peripheral ischemic complications which usually aggravate a course of the disease leading to lifethreatening conditions., A Case Report: The authors describe a case of a 53-year-old male with Duhring disease in the remission period admitted due to severe COVID-19 pneumonia. The patient was treated with ceftriaxone (2000 mg once daily), dexamethasone (8 mg once daily), enoxaparin (60 mg twice daily), baricitinib (4 mg once daily), and remdesivir (200 mg on the first day, followed by 100 mg within 4 consecutive days); he required high flow oxygen therapy. On day 5 of hospitalization, he began to suffer from pain of the right lower extremity; in physical examination the limb was cold with absent femoral, popliteal, and pedal pulses. Urgent computed tomography angiography revealed total occlusion of the right superficial femoral artery (SFA) in the absence of any atherosclerotic plaques in the aorta. The patient was intubated and transferred to department of vascular surgery, where a giant clot was removed from SFA. Unfortunately, the patient outcome was unfavorable due to respiratory failure progression. The authors underline that ATE may occur even in anticoagulated patients and that association of some therapeutic options of COVID-19, like janus kinase (JAK) inhibitors use with an increased risk of ATE, should not be excluded., (© 2022 MEDPRESS.)

COVID-19 patients, particularly those with severe pulmonary involvement, are at an increased thromboembolic risk related, among various causes, to the cytokine storm and excessive activation of the coagulation cascade and platelets. Different intensity of anticoagulation for them is proposed, mainly with low molecular weight heparins (LMWHs); in a confirmed pulmonary embolism (PE) the therapeutic dose of LMWH is routinely used. Some authors suggest that hemorrhagic complications in COVID-19 patients are rare. At the same time, one can find reports on internal bleeding, including retroperitoneal hematoma (RPH) and other abdominal hematomas., Case Reports: The authors describe 5 cases (3 of those aged more than 80 years) with giant RPHs and with moderate/severe COVID-19 pneumonia, treated before RPH diagnosis with different enoxaparin doses. The therapeutic dose was given to the male with verified PE limited to the segmental/subsegmental pulmonary arteries and initially to the female in whom echocardiography was strongly suggestive of PE, yet this diagnosis was excluded on CT angiography. In one patient, the enoxaparin dose was escalated from 40 mg bd to 60 mg bd after the D-dimer increase. Two patients had bleeding complications despite the enoxaparin dose restricted to 40 mg/daily or bd. Two males had a coexistent psoas hematoma while in only one female there was a coexistent femoral hematoma. RPHs occurred between day 4 and 14 of hospitalization and all were treated conservatively. Three patients who died were particularly charged, so their deaths were not merely directly associated with RPH, which was closely analyzed in one autopsy performed. The authors underline that the choice of anticoagulation intensity in patients with COVID-19 pneumonia without venous thromboembolism seems sometimes difficult but recent publications indicate the low prophylactic enoxaparin dose as an optimal option. Anticoagulation dose escalation based only on the D-dimer level may not be appropriate for certain patients; moreover, the D-dimer increase is commonly observed during internal bleeding., (© 2022 MEDPRESS.)

Coronavirus disease-2019 (COVID-19) and legionnaires disease (LD) caused by Gram-negative water-born bacteria Legionella pneumophila show certain similarities, including a predisposition to pulmonary involvement and extrapulmonary manifestations in some of the patients infected. One disease can mimic the other, both can rarely coexist., Case Series Report: The authors describe 7 such cases (5 females), aged 51-90 years (mean 69.7 years) detected while screening 133 subjects with moderate to severe pneumonia and confirmed COVID- 19, which constituted 5.3% of the patients in whom urinary antigen test (UAT) for L. pneumophila was performed. The patients had multiple concomitant disorders: hypertension (6), heart failure (4), diabetes (4), obesity (4), coronary heart disease (3), chronic kidney disease (3), chronic obstructive pulmonary disease (3), anemia (3). Positive UAT was obtained at admission in 4 patients, and on 3rd, 11th and 14th days of hospitalization in the remaining 3 patients. One patient also had positive UAT for Streptococcus pneumoniae. We analyzed: radiological imaging, laboratory data (CRP, interleukin-6, procalcitonin, troponin I, BNP), ECG, echocardiography, treatment and outcome. Three patients required a modification of initial antibiotic therapy, two developed Clostridioides difficile infection. The duration of hospitalization ranged from 13 to 59 days (mean 24.3 days); two patients died., Conclusions: The authors suggest that the coexistence of COVID- 19 and LD may result in prolonged hospitalization, in increased mortality risk and in subsequent cardiovascular complications, including takotsubo syndrome (TTS) which was found in 2 cases, both presented as focal TTS (fTTS)., (© 2022 MEDPRESS.)

Cardiovascular complications of the COVID-19 comprise cardiac arrhythmias, including sinus bradycardia (SB)., Case Reports: The authors present clinical data of 19 hospitalized patients (12 males), aged 20-73 years, with marked (less than 45/min during daily hours) self-limiting SB. None of them had SB at admission or earlier, none had used cardiovascular medications potentially decreasing the heart rate. Pulmonary involvement was severe in 4, moderate in 13 and mild in 2 patients; 14 needed oxygen therapy (4 using high flow oxygen equipment), none required treatment in the intensive care unit. All patients were given low molecular weight heparin in a prophylactic dose, 13 intravenous ceftriaxone, 12 dexamethasone, 8 convalescent plasma. Before SB appearance, 12 patients were treated with remdesivir (3 patients did not receive a full planned dose) and 2 with tocilizumab. SB appeared suddenly on day 5-14 from the onset of the disease, with a minimal heart rate of 32-44/min and in 3 cases it was mildly symptomatic; 2 of those received ad-hoc atropine, one orciprenaline. Interleukin-6 (Il-6) and C-reactive protein (CRP) concentrations at SB onset were significantly lower than at admission (9.3 vs 70.0 pg/ml and 16.8 vs 98.5 mg/l, respectively). Cardiac troponin I was slightly elevated in 2 patients. ECG morphology abnormalities (transient negative T waves or ST depression) were found in 4 males. All subjects had normal left ventricular ejection fraction; in 5 echocardiography revealed small pericardial effusion; in 10 patients, longitudinal strain was also studied: reginal abnormalities were found in all of them, particularly in basal segments. SB lasted 3-11 days and was reversible in all patients; none required temporary stimulation. The COVID-19 course was favorable in all patients; they were stable at discharge. During 4-12 months of posthospital observation, including clinical features, control ECG and 24-hour Holter monitoring, none of the patients was qualified for pacemaker implantation., (© 2021 MEDPRESS.)

In the course of COVID-19 pandemic, many patients with diagnosed or suspected disease do require echocardiography. At the same time, when it comes to the echocardiographers, there is a fear of their being exposed to contamination. At COVID-19-dedicated hospital examinations are bedside, and in some patients hand-held or tablet-based echocardiography should be preferred; the echocardiographer routinely puts on a complete protective uniform. The prevalence of stress-induced takotsubo syndrome (TTS) during the Covid-19 pandemic is higher than previously reported. The authors present the images obtained using tabletbased limited echocardiography in patients with different forms of TTS. The time of the examination of patients and decontamination of the equipment was short (5-7 min and less than 2 min, respectively); the images were of fairly good quality., (© 2021 MEDPRESS.)