turbo-field-echo sequence-4 chamber view). No focal fibrosis was detected in late gadolinium enhancement sequences (Figure 1c, single-shot inversion recovery sequence-4 chamber view). Global edema in T2 weighted images was visible (Figure 1d, T2 [short tau inversion recovery] sequence-3 chamber view) as well as globally elevated T2 (56 ms, referent 48 § 3 ms) (Figure 1e, T2 mapping-short-axis view) and T1 (1,090 ms, referent 989 § 28 ms) (Figure 1f, T1 mapping -short-axis view) mapping times, suggesting acute myocardial injury. On March 26, 2020, hypoxic respiratory failure (saturation of 80%) required mechanical ventilation. The patient improved and was extubated, and the level of cardiac biomarkers declined (N-terminal proBtype natriuretic peptide 631 ng/liter, troponin 61 ng/liter) in due course.Cardiac MRI with its unique accuracy in defining cardiac morphology and function and its ability to provide tissue characterization makes it well suited to study cardiac involvement in COVID-19. Recently, Inciardi et al 3 proved severe biventricular myocardial injury with edema and late gadolinium enhancement. In the absence of epicardial coronary artery stenosis, sub-clinical myocardial dysfunction in COVID-19 may be a consequence of an impairment of microcirculatory endothelial function observed during the early stages of the systemic inflammatory response to the infection, which portends a poor prognosis in patients with established cardiovascular disease and impaired microcirculatory endothelial function. 4 In addition, direct COVID-19-mediated infection of endothelial cells might contribute to cardiac injury. 5 In summary, we show that elevated biomarkers of cardiac injury were associated with generalized myocardial edema without late gadolinium enhancement in cardiac MRI despite a normal echocardiogram during COVID-19.

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Objective: We hypothesized that clinic-based, hepatic-ultrasound, elastography measurements, either alone or in combination with other noninvasive variables, might correlate with liver-biopsy fibrosis scores in patients post-Fontan. Results: We identified a total of 79 post-Fontan patients that underwent cardiac catheterization and liver biopsy. Of the 79 patients, 53 met inclusion criteria, and 32 consented to undergo hepatic-ultrasound elastography. Of the 32 that underwent elastography, data from 30 patients was used for analysis. We found no statistically significant differences in demographics, laboratory values, or cardiac catheterization data between the 30 included patients and the 21 that did not participate. Utilizing data from the 30 included patients, we found a strong, highly statistically significant correlation between the Fontan hepatic index values and total fibrosis scores (R 5 0.8, P < .00001). However, the cohort size prevented reliable discriminating cut-off values for the range of total fibrosis scores.Conclusions: In a small cohort of patients post-Fontan, preliminary findings suggest that the composite Fontan hepatic index might be a clinically useful, noninvasive method of serially monitoring for hepatic fibrosis. Further studies, with large patient cohorts, are necessary to validate our findings and develop clinically useful discriminatory cutoff values. K E Y W O R D SFontan, hepatic fibrosis, shear-wave elastography

Despite inherent risks and complexities of OHT or CHLT in patients with a failed Fontan, transplant is a reasonable therapy. Peri- and postoperative complications are common and may require surgical reintervention. Continued observation of practices and unifying themes may help improve patient selection, pre- and postoperative treatment and ultimately outcomes.