Intra-cardiac foreign bodies are a rare occurrence and there is minimal literature on retention of sutures following cardiac surgery. This is an unusual case of a retained intracardiac prolene suture following surgical correction of Tetralogy of Fallot in a 6 month old patient. The patient had an uneventful post-surgical recovery but a foreign body was identified on a routine post-operative transthoracic echocardiogram. Due to the uncertain nature of the structure, the patient underwent fluoroscopy, chest X-ray and a cardiac CT which were unable to identify the nature of the structure. The best modality for identification was echocardiography, which consistently demonstrated the origin, and course of the suture. Due to a high level of suspicion and consistent findings on echocardiograms, the patient underwent surgical exploration 10 days following surgery and a prolene suture was identified originating in the right upper pulmonary vein extending though the mitral and aortic valve to the transverse aortic arch. This was thought to be from the purse string suture used for the left ventricular vent inserted via the right upper pulmonary vein during surgery.

Michael Ellis DeBakey was a Lebanese-American cardiac surgeon and vascular surgeon, scientist and medical educator. After WW II, joined the faculty of Baylor University College of Medicine, serving as chairman of surgical department and hired surgeon Denton A. Cooley and revolutionized the management of cardiac and vascular diseases. His contributions in the development of roller pump for transfusion of blood directly from person to person which later became a component of the heart-lung machine. DeBakey’s surgical innovations included coronary bypass operations, carotid endarterectomy, aortic aneurysm surgery, artificial hearts, ventricular assist devices, vascular grafts (Dacron) saved thousands of lives and made him surgical immortal.

Heart transplant had already developed by a group of US surgeons in the early 1950s, and it was the American pioneer Norman Shumway who validated the technical feasibility in a dog model at Stanford University in 1958. This milestone in medicine was the beginning of a huge race for numerous physicians and researchers to make this operation a clinical reality. Barnard was intrigued by the idea to perform heart transplantation at Groote Schuur Hospital and therefore made it a major focus in his department in the early 1960s. While Shumway and co-workers were further refining the surgical technique in these year, based on his extensive cardio-surgical experience, Barnard was already convinced about the technical feasibility and wanted to enter this new field of cardiac surgery. To accomplish his goal, he recognized that he had to learn more about immunosuppressive therapy and therefore he spent a few months in Richmond, VA, USA, to obtain this important knowledge for postoperative care. In 1966, when Shumway and colleagues announced that they would be ready for a first human patient, Barnard moved ahead of them on 3 December 1967 and performed the world’s first human-to-human heart transplantation.

Peripheral artery disease is a matter of global concern that affects 200 million people and is associated with decreased arterial perfusion in the extremities. The most plausible pathomechanism involves the formation of atheromas which subsequently cause occlusive atherosclerosis that impinge blood supply. Atheroma formation involves endothelial dysfunction with an accumulation of LDL (Low-density lipoprotein) that subsequently become oxidized and consumed by macrophages to form foam cells. The foam cells will release factors such as MMPs (Matrix metalloproteinases) and PDGF (platelet-derived growth factor) that induce the proliferation and migration of smooth muscle cells, forming atheroma. Furthermore, endothelial cell damage can cause a loss of protective mechanisms, such as a reduction in the release of protective vasodilatory prostaglandins and Nitric Oxide. Atherosclerosis formation also decreases oxygen diffusion to the arterial media, resulting in atrophy in the vessel wall and ischemia. Additionally, chronic transmural inflammation cyclically releases increased MMPs and elastases that expand the arterial wall while degrading the protective collagen.

Rationale: Left bundle branch block is a diagnostic utility for ST-segment elevation myocardial infarction equivalent. Consequently, administration of thrombolytic is a pivotal step. Emergent Sgarbosa criteria and their modification are considered helpful guide keys. Wavy triple an electrocardiographic sign (Yasser Sign) is a novel diagnostic sign in hypocalcemia. Interestingly, the presentation of COVID-19 pneumonia with an intertwining left bundle branch block, renal impairment, and hypocalcemia has a risk impact on both morbidity and mortality of COVID-19 patients. Patient concerns: An elderly carpenter male COVID-19 patient was admitted to intensive care unit with COVID-19 pneumonia with interlacing left bundle branch block, renal impairment, and Wavy triple sign (Yasser’s sign). Diagnosis: Left bundle branch block and Wavy triple sign (Yasser’s sign) intertwining COVID-19 pneumonia with renal impairment. Interventions: Arterial blood gases, chest CT scan, electrocardiography, oxygenation, and echocardiography. Outcomes: Gradual dramatic clinical, electrocardiographic, and radiological improvement had happened. Lessons: The triage of the left bundle branch block with the COVID-19 patient is highly significant for both diagnosis of acute myocardial infarction and giving thrombolytic. The combination of left bundle branch block, renal impairment, and hypocalcemia COVID-19 pneumonia signifies the risk in the current case study.