A 21-year-old female patient visited our hospital for febrile sensation, coughing, sputum, diarrhoea, and shortness of breath during the coronavirus disease 2019 (COVID-19) outbreak in Daegu, South Korea. Nasopharyngeal swab was positive for COVID-19. Troponin I level was 1.26 ng/mL (<0.3 ng/mL) and NT-proBNP was 1929 pg/mL (<125 pg/ mL). The chest radiograph revealed a multifocal consolidation on both lung fields and cardiomegaly (Panel A). Electrocardiography showed nonspecific intraventricular conduction delay and multiple premature ventricular complexes (Panel B). Echocardiography showed severe left ventricular (LV) systolic dysfunction (Supplementary material online, Videos S1-S3). A chest computed tomography (CT) revealed a multifocal consolidation and ground-glass opacification in both lungs in the lower lobe and a peripheral dominant distribution (Panel C). On the cardiac CT, the coronary arteries were normal (Panels D-G), and the myocardium was hypertrophied due to oedema combined with a subendocardial perfusion defect on the lateral left ventricle (Panel N). Cardiac magnetic resonance imaging (MRI) revealed a diffuse high signal intensity (SI) in the LV myocardium on T2 short tau inversion recovery image (Panels H-J; SI ratio of myocardium over skeletal muscle ¼ 2.2), and myocardial wall thickening (LV mass index: 111.3 g/m 2 ), which suggests myocardial wall oedema. On mapping sequence, native T1 ( Figure 1K-M; mid-septum, 1431 ms; lateral wall, 1453 ms, reference value 1150 ms) and extracellular volume (Panels P-R; mid-septum, 29.7%; lateral wall, 61%; reference value 25%) values were diffusely increased (Panel O). Extensive transmural late gadolinium enhancement was noted (Panels S-U).

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Heart transplantation (HTx) has become standard treatment for selected patients with end-stage heart failure. Improvements in immunosuppressant, donor procurement, surgical techniques, and post-HTx care have resulted in a substantial decrease in acute allograft rejection, which had previously significantly limited survival of HTx recipients. However, limitations to long-term allograft survival exist, including rejection, infection, coronary allograft vasculopathy, and malignancy. Careful balance of immunosuppressive therapy and vigilant surveillance for complications can further improve long-term outcomes of HTx recipients.

More than 10% of adult heart transplant recipients developed de novo malignancy between years 1 and 5 after transplantation, and this outcome was associated with increased mortality. The incidence of post-transplant de novo solid malignancy increased temporally, with the largest increase in skin cancer. Individualized immunosuppression strategies and enhanced cancer screening should be studied to determine whether they can reduce the adverse outcomes of post-transplantation malignancy.

Cardiac CT shows a comparable diagnostic performance with TEE for large vegetation and several IE-related complications. TEE is better for detecting small vegetation, valve perforation, and intracardiac fistula, whereas CT is more useful for detecting perivalvular abscess and coronary artery disease.