Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

Opportunistic Detection of Coronary Calcium on Dual-Energy Lateral Chest Radiograph.

ABSTRACT: Heart disease remains the leading cause of death among men and women in the world. The majority of cardiac morbidity worldwide is secondary to atherosclerotic coronary disease. In this article, we discuss our experience using dual exposure, dual-energy lateral chest x-ray (CXR) technique to detect coronary calcium. Similar to other reports demonstrating opportunistic detection on imaging studies, here we demonstrate the added value of detection of coronary calcium on the lateral CXR. This technique reinforces the importance of "knowing where to look" and to recognize the appearance of coronary calcium wherein subtle cardiac motion can be a useful artifact in the accurate detection of coronary calcium. In addition, we discuss correlating coronary calcium burden with age, elaborate on the physics behind coronary calcium detection, and how best to optimize imaging technique. Lastly, we show other uses of dual-energy lateral CXR technique to illustrate where using material decomposition and subtle motion can better define contours in the mediastinum and lung.

Impact of COVID-19 pandemic on STEMI care: An expanded analysis from the United States.

OBJECTIVE: To evaluate the impact of COVID-19 pandemic migitation measures on of ST-elevation myocardial infarction (STEMI) care. BACKGROUND: We previously reported a 38% decline in cardiac catheterization activations during the early phase of the COVID-19 pandemic mitigation measures. This study extends our early observations using a larger sample of STEMI programs representative of different US regions with the inclusion of more contemporary data. METHODS: Data from 18 hospitals or healthcare systems in the US from January 2019 to April 2020 were collecting including number activations for STEMI, the number of activations leading to angiography and primary percutaneous coronary intervention (PPCI), and average door to balloon (D2B) times. Two periods, January 2019-February 2020 and March-April 2020, were defined to represent periods before (BC) and after (AC) initiation of pandemic mitigation measures, respectively. A generalized estimating equations approach was used to estimate the change in response variables at AC from BC. RESULTS: Compared to BC, the AC period was characterized by a marked reduction in the number of activations for STEMI (29%, 95% CI:18-38, p < .001), number of activations leading to angiography (34%, 95% CI: 12-50, p = .005) and number of activations leading to PPCI (20%, 95% CI: 11-27, p < .001). A decline in STEMI activations drove the reductions in angiography and PPCI volumes. Relative to BC, the D2B times in the AC period increased on average by 20%, 95%CI (-0.2 to 44, p = .05). CONCLUSIONS: The COVID-19 Pandemic has adversely affected many aspects of STEMI care, including timely access to the cardiac catheterization laboratory for PPCI.

Machine learning for holistic visualization of STEMI registry data.

BACKGROUND: Widespread adoption of evidence-based guidelines and treatment pathways in ST-Elevation Myocardial Infarction (STEMI) patients has considerably improved cardiac survival and decreased the risk of recurrent myocardial infarction. However, survival outcomes appear to have plateaued over the last decade. The hope underpinning the current study is to engage data visualization to develop a more holistic understanding of the patient space, supported by principles and techniques borrowed from traditionally disparate disciplines, like cartography and machine learning. METHODS AND RESULTS: The Minnesota Heart Institute Foundation (MHIF) STEMI database is a large prospective regional STEMI registry consisting of 180 variables of heterogeneous data types on more than 5000 patients spanning 15 years. Initial assessment and preprocessing of the registry database was undertaken, followed by a first proof-of-concept implementation of an analytical workflow that involved machine learning, dimensionality reduction, and data visualization. 38 pre-admission variables were analyzed in an all-encompassing representation of pre-index STEMI event data. We aim to generate a holistic visual representation - a map of the multivariate patient space - by training a high-resolution self-organizing neural network consisting of several thousand neurons. The resulting 2-D lattice arrangement of n-dimensional neuron vectors allowed patients to be represented as point locations in a 2-D display space. Patient attributes were then visually examined and contextualized in the same display space, from demographics to pre-existing conditions, event-specific procedures, and STEMI outcomes. Data visualizations implemented in this study include a small-multiple display of neural component planes, composite visualization of the multivariate patient space, and overlay visualization of non-training attributes. CONCLUSION: Our study represents the first known marriage of cartography and machine learning techniques to obtain visualizations of the multivariate space of a regional STEMI registry. Combining cartographic mapping techniques and artificial neural networks permitted the transformation of the STEMI database into novel, two-dimensional visualizations of patient characteristics and outcomes. Notably, these visualizations also drive the discovery of anomalies in the data set, informing corrections applied to detected outliers, thereby further refining the registry for integrity and accuracy. Building on these advances, future efforts will focus on supporting further understanding of risk factors and predictors of outcomes in STEMI patients. More broadly, the thorough visual exploration of display spaces generated through a conjunction of dimensionality reduction with the mature technology base of geographic information systems appears a promising direction for biomedical research.

Considerations for cardiac catheterization laboratory procedures during the COVID-19 pandemic perspectives from the Society for Cardiovascular Angiography and Interventions Emerging Leader Mentorship (SCAI ELM) Members and Graduates.

The novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is highly infectious, carries significant morbidity and mortality, and has rapidly resulted in strained health care system and hospital resources. In addition to patient-related care concerns in infected individuals, focus must also relate to diminishing community spread, protection of staff, case selection, and concentration of resources. The current document based on available data and consensus opinion addresses appropriate catheterization laboratory preparedness for treating these patients, including procedure-room readiness to minimize external contamination, safe donning and doffing of personal protective equipment (PPE) to eliminate risk to staff, and staffing algorithms to minimize exposure and maximize team availability. Case selection and management of both emergent and urgent procedures are discussed in detail, including procedures that may be safely deferred or performed bedside.

When the pressure drops: A case of vasoplegia during a structural heart intervention.

A 67-year-old male underwent general anesthesia for left atrial appendage occlusion. During the procedure, the patient developed catecholamine refractory hypotension requiring the administration of several vasopressin boluses to maintain adequate perfusion pressure. At the conclusion of the procedure, mild venous bleeding necessitated the administration of protamine. This led to a further decrease in the patient's blood pressure. Tamponade and continued volume loss were quickly ruled out leading to a diagnosis of vasoplegia syndrome (VS). The patient was appropriately treated with a vasopressin infusion with normalization of blood pressure and no significant morbidity or adverse outcome. With the use of general anesthesia during structural heart interventions on the rapid rise, we discuss the two common causes for vasoplegia along with evidence-based treatments and possible prevention strategies.

Myopericarditis and pericarditis in the deployed military member: a retrospective series.

In this study, we investigated the incidence and etiology of pericarditis and myopericarditis of military members deployed to Iraq and Kuwait from 2004 through 2008. The importance of acute pericarditis and myopericarditis in the deployed military service member has resurfaced with the reintroduction of the smallpox vaccination by the U.S. Department of Defense in 2002. There are limited epidemiologic data on acute pericarditis and myopericarditis in the general population. As a primary evacuation node for cardiology patients between 2004 and 2008, the United States Military Hospital Kuwait cardiology clinic was uniquely situated to reliably extrapolate epidemiologic data for U.S. Armed Service Members serving in the Middle East. Between these years, approximately 721,600 service members served in Kuwait and Iraq. A total of 70 cases of pericarditis and 9 cases of myopericarditis were diagnosed. This yields an estimated incidence of 7.4 and 0.95 cases per 100,000 per year for pericarditis and myopericarditis, respectively. A total of eleven patients had received the smallpox vaccine 4 to 30 days before being diagnosed with pericarditis or myopericarditis. Four of the eleven patients (36.3%) had pericarditis, with a mean duration of 28.3 days since vaccination. Seven of these eleven (63.6%) patients had myopericarditis, with a mean duration of 13.7 days since smallpox vaccination. The incidence of pericarditis and myopericarditis was lower than previously reported incidence rates in the population. In all cases of myopericarditis and pericarditis, smallpox vaccination was preferentially related to myopericarditis versus pericarditis.

Convolution Neural Network Algorithm for Shockable Arrhythmia Classification Within a Digitally Connected Automated External Defibrillator.

Background Diagnosis of shockable rhythms leading to defibrillation remains integral to improving out-of-hospital cardiac arrest outcomes. New machine learning techniques have emerged to diagnose arrhythmias on ECGs. In out-of-hospital cardiac arrest, an algorithm within an automated external defibrillator is the major determinant to deliver defibrillation. This study developed and validated the performance of a convolution neural network (CNN) to diagnose shockable arrhythmias within a novel, miniaturized automated external defibrillator. Methods and Results There were 26 464 single-lead ECGs that comprised the study data set. ECGs of 7-s duration were retrospectively adjudicated by 3 physician readers (N=18 total readers). After exclusions (N=1582), ECGs were divided into training (N=23 156), validation (N=721), and test data sets (N=1005). CNN performance to diagnose shockable and nonshockable rhythms was reported with area under the receiver operating characteristic curve analysis, F1, and sensitivity and specificity calculations. The duration for the CNN to output was reported with the algorithm running within the automated external defibrillator. Internal and external validation analyses included CNN performance among arrhythmias, often mistaken for shockable rhythms, and performance among ECGs modified with noise to mimic artifacts. The CNN algorithm achieved an area under the receiver operating characteristic curve of 0.995 (95% CI, 0.990-1.0), sensitivity of 98%, and specificity of 100% to diagnose shockable rhythms. The F1 scores were 0.990 and 0.995 for shockable and nonshockable rhythms, respectively. After input of a 7-s ECG, the CNN generated an output in 383±29 ms (total time of 7.383 s). The CNN outperformed adjudicators in classifying atrial arrhythmias as nonshockable (specificity of 99.3%-98.1%) and was robust against noise artifacts (area under the receiver operating characteristic curve range, 0.871-0.999). Conclusions We demonstrate high diagnostic performance of a CNN algorithm for shockable and nonshockable rhythm arrhythmia classifications within a digitally connected automated external defibrillator. Registration URL: https://clinicaltrials.gov/ct2/show/NCT03662802; Unique identifier: NCT03662802.

Comparative Analysis of Patients With STEMI and COVID-19 Between Canada and the United States.

Background: Important health care differences exist between the United States (US) and Canada, which may have been exacerbated during the pandemic. We compared clinical characteristics, treatment strategies, and clinical outcomes of patients with ST-segment elevation myocardial infarction (STEMI) and COVID-19 (STEMI-COVID) treated in the US and Canada. Methods: The North American COVID-19 Myocardial Infarction registry is a prospective, investigator-initiated study enrolling patients with STEMI with confirmed or suspected COVID-19 in the US and Canada. The primary end point was in-hospital mortality. Additionally, we explored associations between vaccination and clinical outcomes. Results: Of 853 patients with STEMI-COVID, 112 (13%) were enrolled in Canada, and compared with the US, patients in Canada were more likely to present with chest pain and less likely to have a history of heart failure, stroke/transient ischemic attack, pulmonary infiltrates or renal failure. In both countries, the primary percutaneous coronary intervention was the dominant reperfusion strategy, with no difference in door-to-balloon times; fibrinolysis was used less frequently in the US than in Canada. The adjusted in-hospital mortality was not different between the 2 countries (relative risk [RR], 1.0; 95% CI, 0.46-2.72; P = 1.0). However, the risk of in-hospital mortality was significantly higher in unvaccinated compared with vaccinated patients with STEMI-COVID (RR, 4.7; 95% CI, 1.7-11.53; P = .015). Conclusions: Notable differences in morbidities and reperfusion strategies were evident between patients with STEMI-COVID in the US compared with Canada. No differences were noted for in-hospital mortality. Vaccination, regardless of region, appeared to associate with a lower risk of in-hospital mortality strongly.

Mechanical Circulatory Support in Patients With COVID-19 Presenting With Myocardial Infarction.

ST-segment elevation myocardial infarction (STEMI) complicating COVID-19 is associated with an increased risk of cardiogenic shock and mortality. However, little is known about the frequency of use and clinical impact of mechanical circulatory support (MCS) in these patients. We sought to define patterns of MCS utilization, patient characteristics, and outcomes in patients with COVID-19 with STEMI. The NACMI (North American COVID-19 Myocardial Infarction) is an ongoing prospective, observational registry of patients with COVID-19 positive (COVID-19+) with STEMI with a contemporary control group of persons under investigation who subsequently tested negative for COVID-19 (COVID-19-). We compared the baseline characteristics and in-hospital outcomes of COVID-19+ and patients with COVID-19- according to the use of MCS. The primary outcome was a composite of in-hospital mortality, stroke, recurrent MI, and repeat unplanned revascularization. A total of 1,379 patients (586 COVID-19+ and 793 COVID-19-) enrolled in the NACMI registry between January 2020 and November 2021 were included in this analysis; overall, MCS use was 12.3% (12.1% [n = 71] COVID-19+/MCS positive [MCS+] vs 12.4% [n = 98] COVID-19-/MCS+). Baseline characteristics were similar between the 2 groups. The use of percutaneous coronary intervention was similar between the groups (84% vs 78%; p = 0.404). Intra-aortic balloon pump was the most frequently used MCS device in both groups (53% in COVID-19+/MCS+ and 75% in COVID-19-/MCS+). The primary outcome was significantly higher in COVID-19+/MCS+ patients (60% vs 30%; p = 0.001) because of very high in-hospital mortality (59% vs 28%; p = 0.001). In conclusion, patients with COVID-19+ with STEMI requiring MCS have very high in-hospital mortality, likely related to the significantly higher pulmonary involvement compared with patients with COVID-19- with STEMI requiring MCS.

Gerbode defect with Staphylococcus lugdunensis native tricuspid valve infective endocarditis.

Coagulase-negative staphylococci are generally not considered to be very virulent; they are an uncommon cause of native valve endocarditis. Staphylococcus lugdunensis is an important exception and causes more severe infections, clinically mimicking S. aureus. We present a case of direct Gerbode defect associated with S. lugdunensis native valve infective endocarditis (IE) requiring cardiac surgery.

Management Principles for the Cardiac Catheterization Laboratory During the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) Pandemic.

The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is a highly contagious pathogen resulting in the 2019 coronavirus disease (COVID-19) pandemic with direct impact on cardiac catheterization laboratory (CCL) operations. Initially, major challenges in limiting the spread of aerosolized pathogens existed until protocols were implemented to limit infectivity to staff and patients. COVID-19 increases the risk of myocardial infarctions and cardiogenic shock requiring acute management in the CCL. In this review, we specify best practices in the CCL for the management of infected patients in the preprocedure, intraprocedure, and postprocedure environments harmonizing available evidence, recommendations from international heart associations, and consensus opinion.

Impact of COVID-19 on Acute Myocardial Infarction Care.

The global health crisis caused by the COVID-19 pandemic has evolved rapidly to overburden health care organizations around the world and has resulted in significant morbidity and mortality. Many countries have reported a substantial and rapid reduction in hospital admissions for acute coronary syndromes and percutaneous coronary intervention. The reasons for such abrupt changes in health care delivery are multifactorial and include lockdowns, reduction in outpatient services, reluctance to seek medical attention for fear of contracting the virus, and restrictive visitation policies adopted during the pandemic. This review discusses the impact of COVID-19 on important aspects of acute MI care.

Trends in Clinical Presentation, Management, and Outcomes of STEMI in Patients With COVID-19.

BACKGROUND: We previously reported high in-hospital mortality for ST-segment elevation myocardial infarction (STEMI) patients with COVID-19 treated in the early phase of the pandemic. OBJECTIVES: The purpose of this study was to describe trends of COVID-19 patients with STEMI during the course of the pandemic. METHODS: The NACMI (North American COVID-19 STEMI) registry is a prospective, investigator-initiated, multicenter, observational registry of hospitalized STEMI patients with confirmed or suspected COVID-19 infection in North America. We compared trends in clinical characteristics, management, and outcomes of patients treated in the first year of the pandemic (January 2020 to December 2020) vs those treated in the second year (January 2021 to December 2021). RESULTS: A total of 586 COVID-19-positive patients with STEMI were included in the present analysis; 227 treated in Y2020 and 359 treated in Y2021. Patients' characteristics changed over time. Relative to Y2020, the proportion of Caucasian patients was higher (58% vs 39%; P < 0.001), patients presented more frequently with typical ischemic symptoms (59% vs 51%; P = 0.04), and patients were less likely to have shock pre-PCI (13% vs 18%; P = 0.07) or pulmonary manifestations (33% vs. 47%; P = 0.001) in Y2021. In-hospital mortality decreased from 33% (Y2020) to 23% (Y2021) (P = 0.008). In Y2021, none of the 22 vaccinated patients expired in hospital, whereas in-hospital death was recorded in 37 (22%) unvaccinated patients (P = 0.009). CONCLUSIONS: Significant changes have occurred in the clinical characteristics and outcomes of STEMI patients with COVID-19 infection during the course of the pandemic.

North American COVID-19 Myocardial Infarction (NACMI) Risk Score for Prediction of In-Hospital Mortality.

Background: In-hospital mortality in patients with ST-segment elevation myocardial infarction (STEMI) is higher in those with COVID-19 than in those without COVID-19. The factors that predispose to this mortality rate and their relative contribution are poorly understood. This study developed a risk score inclusive of clinical variables to predict in-hospital mortality in patients with COVID-19 and STEMI. Methods: Baseline demographic, clinical, and procedural data from patients in the North American COVID-19 Myocardial Infarction registry were extracted. Univariable logistic regression was performed using candidate predictor variables, and multivariable logistic regression was performed using backward stepwise selection to identify independent predictors of in-hospital mortality. Independent predictors were assigned a weighted integer, with the sum of the integers yielding the total risk score for each patient. Results: In-hospital mortality occurred in 118 of 425 (28%) patients. Eight variables present at the time of STEMI diagnosis (respiratory rate of >35 breaths/min, cardiogenic shock, oxygen saturation of <93%, age of >55 â€‹years, infiltrates on chest x-ray, kidney disease, diabetes, and dyspnea) were assigned a weighted integer. In-hospital mortality increased exponentially with increasing integer risk score (Cochran-Armitage χ2, P â€‹< â€‹.001), and the model demonstrated good discriminative power (c-statistic â€‹= â€‹0.81) and calibration (Hosmer-Lemeshow, P â€‹= â€‹.40). The increasing risk score was strongly associated with in-hospital mortality (3.6%-60% mortality for low-risk and very high-risk score categories, respectively). Conclusions: The risk of in-hospital mortality in patients with COVID-19 and STEMI can be accurately predicted and discriminated using readily available clinical information.

Serial Echocardiographic Follow-up of Structural Heart Interventions Performed During Pacific Partnership Interventional Cardiology Subject Matter Exchanges From 2015 to 2017 in Da Nang, Vietnam.

INTRODUCTION: The U.S. Navy Medicine has a long history of conducting global health missions that foster international diplomacy through medical knowledge exchange with a goal of increasing partner nation's health care capacity. Pacific Partnership is an annual U.S. Navy-sponsored joint operation that enhances medical collaboration with participating nations throughout the Indo-Asia-Pacific region. Since 2015, a U.S. Navy Cardiology team has conducted a structural heart disease interventional workshop focused on congenital heart disease with the cardiologists at the Da Nang General Hospital, Da Nang, Vietnam. Herein, we describe the multinational collaborative project including the patient registry we developed to monitor the short- and long-term outcomes of structural heart disease interventions preformed during Pacific Partnership 2015 and 2016. MATERIALS AND METHODS: Our team developed a sustainable procedural registry with the goal of following the long-term outcomes of cardiac interventions for congenital heart disease in Vietnamese patients. Specifically, the registry was designed to record the changes in symptoms referable to the cardiovascular system and for device placement-associated complications for devices placed in 2015 and 2016 and has been updated annually thereafter. RESULTS: Twelve patients (age range, 7 months to 31 years) underwent successful atrial septal defect closure in 2015 without procedural complications. The follow-up rate was 75% at 1 year and 67% at 2 years, and all devices were in appropriate position with no complications identified. Fifteen patients (age range, 20-66 years) underwent successful atrial septal defect closure in 2016. The follow-up rate was 62.5% at 1 year, and all devices were in appropriate position with no complications identified. Three patients (age range, 5-25 months) underwent successful device closure of the patent ductus arteriosus in 2015 without complications. The follow-up rate was 67% in 2016 and again in 2017. Six patients (age range, 9-74 years) underwent successful patent ductus arteriosus closure in 2016 without complications. The follow-up rate was 67% in 2017, and all devices were in appropriate position with no device-related complications identified. CONCLUSIONS: The development of a patient registry during these missions allowed for the longitudinal monitoring of outcomes for cardiac interventions. Notably, treated patients experienced symptomatic improvement without significant long-term procedural complications. Following patients longitudinally across medical missions is of recognized importance but remains a difficult objective to achieve for a multitude of factors including administrative and financial burdens on both the medical systems and the patients of host nations. Despite these limitations, longitudinal follow-up of patient care facilitated by a patient registry has a vital role in monitoring the quality of care provided and should be an integral part of all future global medical missions.

Joint Trauma System Clinical Practice Guideline: Acute Coronary Syndrome (ACS). 14 May 2021.

Deployed medical providers at all roles of care must be prepared to recognize and manage acute coronary syndrome (ACS). Under optimal conditions, treatment is initiated with medical therapy and may be followed by prompt coronary angiography and revascularization. Emergent percutaneous coronary intervention (PCI) is not available in most deployed locations, however, and the time for such intervention is often dependent on long-range evacuation. This CPG provides guidance on best management for ACS patients in the deployed and resource-constrained environment.

Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

A novel technique for ultra-low contrast administration during angiography or intervention.

Contrast-induced nephropathy (CIN) after coronary angiography or intervention is associated with substantial morbidity. The data supporting various prophylactic measures and adjunctive therapies to prevent this complication are conflicting. However, contrast volume is clearly related to CIN after percutaneous coronary intervention (PCI), and the risk of CIN has been shown to be directly related to contrast dose. Therefore, minimizing contrast exposure is a primary method to reduce the risk of CIN, especially in at-risk patients. We report a novel technique designed to deliver ultra-low (<15 cm(3)) volume contrast to patients with chronic kidney disease undergoing coronary angiography and PCI.

"Asymptomatic" Flash Pulmonary Edema by Point-of-Care Ultrasound: A Novel Bedside Finding of Transient Global Ischemia.

A 65-year-old man with remitted chest pain and no tachypnea was taken urgently to catheterization because of diffuse lung ultrasound B-lines on bedside examination. He was found to have severe left-main disease. This case emphasizes the value of ultrasound to recognize acute cardiogenic interstitial pulmonary edema despite minimal symptoms. (Level of Difficulty: Advanced.).