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patent ductus arteriosus, infective endocarditis, congenital heart disease, transthoracic echocardiographyA 25-year-old man with a history of "childhood murmur" was admitted to our institution Figure 1. Transthoracic echocardiogram, parasternal short axis view at cardiac base (Zoom on main pulmonary artery). A high-velocity jet (PDA) is seen directed from the inferior aspect of the MPA (I indicated with arrow) just above the pulmonary bifurcation. The jet flows superiorly to the mass (indicated with arrow) residing in the MPA.with a 1-week history of left-sided chest pain, dyspnea, fevers, and night sweats. On examination, his blood pressure was 110/75 mmHg, pulse 90/min, and temperature 38.7 • C. There was no jugular venous distention, and his lungs were clear to auscultation. There was a harsh, continuous murmur of III/VI in intensity at the

Recent large-scale trials have demonstrated superior clinical outcomes associated with the use of enoxaparin in patients with acute coronary syndromes and have led to its incorporation into the recent American College of Cardiology/American Heart Association guidelines for the management of patients with unstable angina/non-ST elevation myocardial infarction. Despite clinical trial evidence, questions arise as to how best to manage patients who have received subcutaneous enoxaparin who may then require subsequent coronary intervention. We present four potential management strategies for handling the transition of these patients to the catheterization laboratory and specific dosing recommendations for the use of enoxaparin in these circumstances.

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