Introduction: ICI and TKI have several cardiotoxicity side effects. We present a case of TKI-ICI toxicity resulting in multiorgan inflammatory syndrome with myocarditis and thrombotic STEMI that was treated with high-dose steroids and PCI. Case Presentation: 72-year-old man presented with acute SOB and inferior STEMI. He complains of severe DOE for the past 3 months, chronic diarrhea, and altered mental status. PMH of renal cell carcinoma (RCC) limited to kidney s/p nephrectomy. Follow-up CT scan with 4cm inferior left adrenal gland mass avid for FDG-PET and IR-biopsy positive for RCC. He was started on Pembrolizumab 200mg IV q3 weeks and axitinib 5mg PO q12h for the past 5 months. Investigation: LHC showed a thrombotic lesion in RCA with normal rest of coronaries without evidence of atherosclerosis or bystander plaque with successful PCI-DES. TTE with inferior wall hypokinesis and moderate pericardial effusion with organized material. Elevated CRP/ESR. Despite PCI, he is unable to walk 200ft due to DOE and needs supplemental O2. VQ scan low % for PE, PFT mild obstructive disease with severe reduction DLCO, and HRCT moderate emphysema, bronchial/ septal thickening, and normal hemodynamics in RHC. CMR demonstrated moderate pericardial effusion with internal debris, LVEF 38%, myocardial edema, and delayed gadolinium enhancement from base to apical inferior wall. Treatment: Empirical trial of IV-methylprednisolone 500mg IV q12 was started with drastic improvement of shortness of breath, resolution of AMS, ESR/CRP, and discontinuation of oxygen. Follow-up TTE with normal LVEF and resolution of pericardial effusion. Conclusions: ICI-Myocarditis is a severe irAE. The diagnosis requires clinical suspicion and exclusion of other cardiac conditions due to the high fatality rate. Early recognition and prompt treatment are needed to improve mortality. TKI-related arterial-thromboembolic events is not common but if present different therapy options should be offered.

A patient in their 80s with a history of atrial fibrillation, hypertension, and hyperlipidemia presented to a rural hospital with suddenonset chest pain and shortness of breath. For the prior few weeks, the patient had had intermittent chest pain that resolved with rest but was now persistent. The patient had no history of coronary artery disease (CAD). The physical examination was notable for tachycardia, 3/6 mid systolic ejection murmur, and significant pedal edema. An electrocardiogram (ECG) was obtained (Figure).Questions: Other than the left bundle branch block (LBBB), what are the salient findings? What is the next step of management?

Background: Venous and arterial thromboembolic events are common sequelae of COVID-19 infection. However, there are no set guidelines as to the appropriate duration of anticoagulation for such thrombotic events. Case Presentation: A 62-year-old woman presented with chest pain 2 weeks after she was diagnosed with COVID-19. She was found to have an anterior STEMI with a thrombotic occlusion of the left anterior descending artery as well as multiple left ventricular (LV) thrombi. The patient was treated with guideline directed medical therapy for acute coronary syndrome. As for the LV thrombi, she was bridged from heparin to warfarin with plan to continue anticoagulation for a minimum of 3 months; however, she was noted to have resolution of the thrombi in 2 months with no subsequent recurrence. Conclusion: In the setting of an acute myocardial infarction with apical akinesis, an LV thrombus is not uncommon. In such cases, ACC/AHA recommends oral anticoagulation (OAC) for 3 months while ESC recommends OAC for up to 6 months. There have been no large studies looking at the optimal duration for OAC for LV thrombi due to COVID-19. Given resolution of the thrombi in our patient within 2 months, we suggest a shorter length of anticoagulation for such cases guided by echocardiographic imaging. However, prospective data regarding this matter is first needed.

The length of anticoagulation for thrombotic events related to COVID‐19 is unknown. We present a patient with COVID‐19 complicated by a thrombotic anterior STEMI and multiple left ventricular (LV) thrombi that resolved after 8 weeks of anticoagulation. We suggest a shorter length of anticoagulation with COVID‐19‐related LV thrombus.