bluuebunny/crossref_metadata_2025 huggingface dataset:
P1583 Usefulness of remote intrathoracic impedance alerts for echo-guided CRT optimization
Authors: Appignani M , Salvatore T , Di Girolamo E
Published: January 2020

Background

Cardiac resynchronisation therapy (CRT) is a strong recommendation in heart failure (HF) patients having sinus rhythm, left bundle branch block, QRS duration ≥ 120 ms and left ventricular (LV) ejection fraction (EF) ≤ 35%, despite optimized medication. Echocardiographic parameters still have a controversial role in the selection of patients ongoing CRT, and no single parameter is recommended to identify a positive CRT response. Even their role in the management after implantation remains still troubleshooting. Atrioventricular (AV) and interventricular (VV) delay reprogramming could be a variable that may influence CRT outcome and, although a systematic AV and VV optimization is not required, it could be useful in selected patients. Remote monitoring networks allow HF patients having a CRT device to be constantly monitored, and notifications of some intrathoracic impedance indexes, may be helpful in the management of HF patients.

Purpose

To evaluate the usefulness of intrathoracic impedance notifications in the selection of HF patients to have echo-guided AV and/or VV delays optimization, the following study was undertaken.

Methods

27 CRT patients having an intrathoracic impedance enabled remote monitoring, with at least one impedance notification during the first six months from implantation, were considered for study. The primary endpoint was a composite of improvement in NYHA functional class and EF, reduction of LV end-systolic volume and rehospitalization for decompensated HF. Secondary endpoint was the effectiveness of echo-guided dealys optimization based on intrathoracic impedance alerts. The AV delay optimization was mainly driven by mitral inflow pattern, whereas VV delay optimization was guided by the assessment of LV synchrony using color Tissue Doppler Imaging (TDI). Patients were weekle evaluated through remote monitoring network over a six-month follow-up. LVEF and LV end-systolic volume were determind at baseline and after six months.

Results

After the six-month follow-up, an improvement of at least 1 NYHA functional class was obtained in 23 patients (85%), while 2 patients (7.4%) experienced an improvement of two NYHA classes. In 21 Patients (77.7%) LVEF increased at least 5%. Optimization was associated with an average 11.9 ± 6.4% increas in EF, from a mean baseline of 28.2 ± 3.2% to 37.8 ±6.2%. End-systolic volume decreased from 161.56 ± 9.87 ml to 143.22 ± 15.83 ml. Among the 27 patients with impedance alerts at baseline, only 6 (22.2%) reported new notifications during follow-up, with a significant reduction (p < 0.03) after optimization.

Conclusions

Intrathoracic impedance monitoring improved the selection of non responders feasible to have echo-guided AV and/or VV delays optimization. Functional status and LVEF increased. Although time-consuming, this multidisciplinary network may increase close cooperation between electrophysiologist and HF physicians to better manage HF patients having a CRT system implanted.
P1584 Characteristics of a new subgroup in chronic heart failure: heart failure with mid-range ejection fraction (HFmrEF)
Authors: Alberts V , Weytjens C , Cosijns B
Published: January 2020

Introduction

Classification of patients with heart failure is based on left ventricular ejection fraction (LVEF). Until recently, two types of patients had been distinguished based on LVEF: those with reduced ejection fraction (HFrEF) and those with HF with preserved ejection fraction (HFpEF). The ESC guidelines of 2016 introduced a third separate subgroup for patients with a LVEF in the range of 40-50%: Heart failure with mid-range ejection fraction (HFmrEF).

Purpose

The goal of this study is to characterize and compare this subgroup (HFmrEF) to the other two subgroups (HFpEF and HFrEF). Secondly, mortality rates were studied and compared, depending on LVEF classification and global longitudinal strain (GLS).

Methods

All patients with Chronic Heart Failure (CHF) seen at the heart failure clinic, during a 1-year period were enrolled in this retrospective study. As an inclusion criterion in our study population, we only allowed patients with chronic heart failure, who were treated at least once with diuretics or a cardiac resynchronization therapy for heart failure. After gathering data of the HF population, the 3 subgroups (HFrEF, HFpEF and HFmrEF) were compared on the basis of different parameters like comorbidities, lab results, medication, ECG and echocardiography.

Results

HFmrEF significantly differed from HFpEF concerning the following parameters: higher prevalence of male gender and ischemic aetiology, lower prevalence of valvular and hypertensive aetiology, more dilated left ventricles and higher usage of ACE inhibitors and betablockers. HFmrEF was similar to HFpEF concerning older age, high prevalence of tachyarrhythmia, low use of device therapy and aldosterone antagonists.

The survival rate after 853 days was 81,6% in HFrEF, 76,3% in HFmrEF and 81,1% in HFpEF (p = 0,634). When looking at the whole patient population, the Kaplan Meier estimation was significant (p < 0,001) with a survival rate after 853 days of 33,3% for the group with lower absolute values than 6,3% for GLS and 85% for group with higher absolute strain values.

Conclusion

Patients with HFmrEF didn’t really differentiate as one class apart from HFrEF or HFpEF, but some characteristics were similar to HFrEF, and some others to HFpEF. Finally some characteristics of HFmrEF were more in a grey zone with none of the characteristics of both HFrEF nor HFpEF.

The all cause survival rate in 853 days among the 3 LVEF based groups, were quite similar. While the Kaplan Meier estimation indicated a lot higher mortality when GLS>-6,3% compared to GLS <-6,3%.

Classifying chronic HF patients is probably more complex than simply stratifying patients by LVEF cut-off values. One must not forget to take comorbidities and aetiology in mind while managing heart failure.

Abstract P1584 Figure. Aetiology in LVEF based groups
P1603 Changes of cardiac function in cirrhotic patients after liver transplantation
Authors: Kim H M , Kim H K , Lee J H , Park E A , Park J B , Lee S P , Kim Y J , Sohn D W , Lee Y B , Kim Y J , Yoon J H
Published: January 2020

Funding Acknowledgements

This study was supported by the grant of CJ healthcare 2016 research fund.

Background

Liver cirrhosis (LC) has been known to affect cardiovascular performance. Limited study have evaluated the alteration of myocardial function in patients with LC after liver transplantation (LT).

Purpose

The aim of study was to evaluate changes of cardiac function in patients with cirrhosis following LT using conventional and speckle-tracking echocardiography and late gadolinium enhancement (LGE) of cardiac magnetic resonance (MR).

Methods

Thirty-five patients with cirrhosis (mean age, 57.1 ± 9.0; male, 75%) who were listed for LT were prospectively enrolled. Patients underwent conventional, speckle-tracking echocardiography, and cardiac MR imaging with LGE. Echocardiography and cardiac MR were performed at pre and 1 year after LT. Cirrhotic patients were compared with normal control (n = 20, mean age, 65.0 ± 14.8; men, 11(55%)) and echocardiographic and cardiac MR data were compared pre and post LT.

Results

Conventional and speckle-tracking echocardiography and Cardiac MR imaging demonstrated hyperdynamic left ventricular (LV) function in patients with cirrhosis (LV ejection fraction (EF) with cardiac MR 67.8 ± 7.0% in LC vs. 63.4 ± 6.4% in control, P = 0.028; global longitudinal strain (GLS) -24.3 ± 2.6% in LC vs. -18.6 ± 2.2% in control, P < 0.001). There were no LGE in patients with cirrhosis and no significant differences in LV size, LV wall thickness, LV mass index, and diastolic function between cirrhotic patients and control group (all P > 0.1). Corrected QT interval (QTc) in electrocardiogram was prolonged in LC patients (P < 0.001). One-year after LT, LV end-diastolic diameter and LV end-diastolic volume significantly decreased (P = 0.016 and 0.022, respectively). Although LVEF showed no significant changes 1 year post-LT (P = 0.362), LV-GLS (from -24.7 ± 1.8% to -20.8 ± 3.4%, P < 0.001) significantly decreased. QTc interval also decreased 1 year after LT (from 470.4 ± 29.6msec to 428.2 ± 31.6msec, P = 0.001).

Conclusions

The present study demonstrated that cirrhotic patients showed hyperdynamic circulation and prolonged QTc interval compared with normal controls. After 1 year LT, LV size reduced and augmented LV function was normalized. Given that no LGE in cardiac MR and normalized GLS and QTc after LT, cardiac dysfunction in LC patients could be reversed by LT.
1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography
Authors: Hashimoto G , Ide S , Hayama H , Makino K , Otsuka T , Suzuki M , Iijima R , Hara H , Moroi M , Nakamura M
Published: January 2020

Background

Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS.

Case

A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure.

He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function.

PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved.

Discussion

POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS.

Abstract 1638 Figure. Intra-cardiac echocardiography
1677 Global longitudinal strain during dobutamine stress echocardiography can predict left ventricular remodeling after anterior wall acute myocardial infarction
Authors: Onishi T , Iwakura K , Okamura A , Koyama Y , Inoue K , Iwamoto M , Tanaka K , Nagai H , Hirao Y , Oka T , Tanaka N , Fujii K
Published: January 2020

Background

Although dobutamine stress echocardiography (DSE) at the early stage of acute myocardial infarction (AMI) is useful for the prediction of functional and clinical prognosis, the interpretation requires expertise. In this study, we sought to investigate if global longitudinal strain (GLS) during DSE after AMI can predict left ventricular remodeling (LVR).

Methods

Consecutive 30 patients with anterior wall AMI (18 male, age = 58 ± 13 years) were performed DSE 3 days after AMI. GLS was calculated as an averaged value of peak longitudinal strain in the apical 4- and 2-chamber views at baseline echocardiography, low-dose DSE (10 μg/kg/min) using available software (QLAB, Philips Medical Systems). Left ventricular remodeling (LVR) was defined as an echocardiographically determined increase in both EDVI and ESVI of 20% or more from baseline to the 6 month follow-up echocardiography.

Results

12 patients (40%) evolved with LVR. The change in GLS during low-dose DSE was significantly different between the remodeling and non-remodeling group (8 ± 5% v.s. 27 ± 20%, p < 0.05). Interestingly, it predicted LVR with sensitivity of 88%, specificity of 92% at the cut-off value of 12% (Area under the curve = 0.94, p < 0.0001).

Conclusion

The change in GLS during low-dose DSE can be used as a predictor for the LVR after AMI. This observation has promise for clinical applications.

Abstract 1677 Figure.
P1691 A case of congenital pulmonary stenosis
Authors: Buttigieg L L , Yamagata K , Cassar J , Pace Bardon M , Balzan M , Borg A
Published: January 2020

Introduction

We present an unusual case of sequential right ventricular outflow tract obstruction (RVOTO) caused by pulmonary and subpulmonary stenosis, with formation of aortopulmonary collaterals.

Case presentation

We report a case of a 47 year old Senegalese man who presented with a three year history of shortness of breath on exertion which worsened over the past week. Cardiovascular examination revealed a parasternal heave, a systolic murmur loudest in the pulmonary area and no evidence of fluid overload.

A transthoracic echocardiogram revealed leftward septal deviation during systole due to right ventricular pressure overload, severe right ventricular hypertrophy (RV free wall end-diastolic thickness of 8mm) and normal systolic function (FAC 47%), a dilated right atrium and moderate tricuspid regurgitation with estimated maximum pressures of 112mmHg. On continuous-wave doppler of the right ventricular outflow tract (RVOT), there was a late peaking systolic flow with maximum velocity of 3.8m/s.

A cardiac computed tomography (CT) and cardiac magnetic resonance imaging (MRI) was performed which showed sequential stenoses of the RVOT; one at subvalvular level by an infundibular muscular ridge with an area of 0.7 cm2 in mid-systole and one at the level of a dome-shaped pulmonary valve with planimetered valve area of 0.5cm2, severe RV hypertrophy and normal RV ejection fraction. Aortopulmonary collaterals from proximal thoracic descending aorta were seen. The main pulmonary artery was shown to be dilated with no evidence of pulmonary artery branch stenosis. See image: In-plane phase contrast velocity flow mapping of the RVOT using a VENC of 80cm/s, showing aliasing at the level of the pulmonary valve (red arrow) and at the level of the infundibulum (white arrow).

Conclusion

Congenital pulmonary stenosis (PS) occurs in 8% of congenital heart defects. 80% of pulmonary valve stenosis is typically dome-shaped with commissural fusion whilst the remainder is of the dysplastic type. Congenital PS can be associated with RVOTO at the infundibular level secondary to reactive muscular hypertrophy. In our case, there is a discrete, circumferential muscular ridge at the level of the infundibulum resulting in sequential outflow tract obstruction.

PS with intact ventricular septum occurs in conjunction with varying degrees of right ventricular hypertrophy and elevated right ventricular systolic pressures. A dilated pulmonary artery is common in dome-shaped subtype of PS.

Survival into adulthood of severe PS is primarily dependent on the adequacy of pulmonary blood flow from systemic-to-pulmonary collateral arteries, which serve as an additive, or the only source of blood supply to the pulmonary arterial vasculature. These collaterals are usually seen in association with cyanotic congenital heart disease such as pulmonary atresia and tetralogy of fallot.

Abstract P1691 Figure. Sequential RVOTO
P1692 The past returns after 20 years: a case report
Authors: Habjan S , Cantisani D , Scarfo` I S , Guarneri M C , Semeraro G , Romeo F , Cicchini L , La Canna G
Published: January 2020

Introduction

Radiation therapy is one of the cornerstones of treatment for many types of cancer. These patients can later in life develop cardiovascular complications associated with radiation treatment. Late cardiovascular effects of radiation treatment include coronary artery disease (CAD), valvular heart disease, congestive heart failure, pericardial disease and sudden death. The most common sign of radiation-induced valvular heart disease is the calcification of the intervalvular fibrosa between the aortic and mitral valve.

Case presentation

A 71-year-old male patient with a history of Non-Hodgkin lymphoma treated with radiotherapy and chemotherapy 20 years ago, CAD, arterial hypertension, diabetes type II, dyslipidemia, obesity and currently smoking presented in the emergency room in our medical facility with acute pulmonary edema. The patient had unstable angina pectoris in 2018, the coronary angiography showed two-vessel disease with a non-significant stenosis of the left main coronary artery (LMCA) and 70% stenosis of the left anterior descending artery (LAD), for which he refused the percutaneous coronary intervention. At the same time, a transthoracic echocardiography (TTE) showed severe aortic stenosis and moderately severe mitral stenosis, at that time the patient refused the operation. After the initial treatment for pulmonary edema, TTE and transesophageal echocardiography (TEE) were performed and showed a tricuspid aortic valve with calcification of the cusps and a very severe aortic stenosis (planimetric aortic valve area 0.74 cm², functional aortic valve area 0.55 cm², indexed functional aortic valve area 0.25 cm²/m², mean gradient 61 mmHg, peak gradient 100 mmHg, stroke volume (SV) 69 ml, stroke volume index (SVI) 31 ml/m², flow rate 221 ml/s, aortic annulus 20x26 mm). The left ventricle was severely dilated (end diastolic volume 268 ml) with diffuse hypokinesia and severe systolic dysfunction (ejection fraction 32%). We appreciated a calcification of the mitral-aortic intervalvular fibrosa and the mitral annulus, without mitral stenosis but with moderate mitral regurgitation. The calcification of the intervalvular fibrosa suggested our final diagnosis of radiation-induced valvular heart disease with a severe aortic stenosis in low-flow conditions. The patient was successfully treated with transcatheter aortic valve implantation (TAVI).

Conclusion

Radiation-induced heart disease is a common reality and is destinated to raise due to the increasing number of cancer survivors. Effects are seen also many years after the radiation treatment. The exact primary mechanism of radiation injury to the heart is still unknown. The treatment of radiation-induced valve disease is the same as the treatment of valve disease in the general population.

Abstract P1692 Figure. Radiation-induced valvular heart disease
P1698 Mitral valve endocarditis in hypertrophic obstructive cardiomyopathy
Authors: Shirka E , Gjergo H , Avdullari O , Goda A
Published: January 2020

Introduction

Endocarditis complicating hypertrophic cardiomyopathy (HCM) is not commonly reported but occurs almost universally in patients showing evidence of outflow tract obstruction. The estimated cumulative 10 year probability of developing endocarditis in obstructive HCM is < 5%. We report a rare case of mitral valve endocarditis in a young man with hypertrophic obstructive cardiomyopathy.

Case report

A 45 years old man was admitted to the emergency room after a 7 days history of weakness, thoracic discomfort, short of breath, cough and temperature up to 40 °C. He was treated with oral antibiotics in ambulatory setting, but symptoms persisted. He had no previous history of hypertension or known heart disease, family history of coronary heart disease and excessive smoker. On clinical examination, the patient was afebrile with a harsh systolic murmur. Initial blood tests showed normal inflammatory markers (C reactive protein 0.2 mg/l and fibrinogen 202 mg/dL) and normal blood sample. An ECG showed major left ventricular hypertrophy and abnormal lateral repolarisation. Transthoracic echocardiography showed localized septal hypertrophy (2.4 cm) and systolic anterior motion of the anterior mitral leaflet. Continuous wave Doppler ultrasound in the left ventricular cavity and outflow tract, had given a maximal predicted gradient of 73 mmHg. There was suspicion of vegetation on the anterior mitral valve leaflet and mitral regurgitation was quantified as moderate. Transoesophageal echocardiography confirmed the presence of vegetation on the anterior mitral valve leaflet, posterior leaflet prolapse and moderate mitral regurgitation. We found normal coronary arteries on coronary angio-CT. Treatment with intravenous antibiotics was initiated and the case was discussed with a microbiologist and a cardiothoracic surgeon.

Discussion

Infective endocarditis is a rare complication of hypertrophic cardiomyopathy (HCM). It is clear from morphological studies that systolic anterior motion of the anterior mitral valve leaflet is relevant to the pathogenesis of endocarditis. Pathogenesis of infective endocarditis in obstructive HCM can be explained by endocardium damage of the mitral or aortic valve, consequence of turbulence of blood flow during ejection and of the contact between the mitral anterior leaflet and the septum during systole as well as mitral regurgitation. Antibiotic therapy is the mainstay of the treatment. Surgery should be considered promptly whenever there is traditional indication (haemodynamic, emboli, persistent fever, abscess). Surgical procedure may consist of valve replacement or repair, and some authors reported relieve of outflow tract obstruction after mitral valve replacement which may be explained by the removal of systolic anterior motion of the mitral valve. Valve surgery combined with septal myectomy seems logical but requires great expertise and carries a higher operative mortality

Abstract P1698 Figure.
P1725 An easily dismissed suspect
Authors: Santos H , Almeida I , Miranda H , Santos M , Almeida L , Sa C , Almeida S , Sousa C , Chin J , Tavares J
Published: January 2020

Funding Acknowledgements

None

Introduction

Constrictive pericarditis (CP) is a rare etiology of heart failure. Is a chronic inflammatory process, characterized by scarring, fibrosis and pericardial calcification. Several etiologies can be associated with CP, namely infectious, idiopathy and post-surgical. In some cases, CP can extend to the myocardium and/or lead to cardiac dysfunction.

Case Report

58 years old woman, active smoking, referred to the emergency room for tachycardia on a routine electrocardiogram. History of 5 months of fatigue and dyspnea to ordinary activities, with progressive aggravation in the last month, associated with weight loss and episodic palpitations. Upon the physical examination presented jugular vein engorgement and peripheral edema. Admission electrocardiogram with atrial flutter at 150 of ventricular frequencies, without other findings. Thoracic radiography without variation (tenues pericardium enhancement), abdominal echography with moderate ascites. Blood work showed elevated liver enzymes, BNP of 230pg/ml, exclusion of infectious tuberculosis and autoimmune panel with isolated positive rheumatoid factor. Transthoracic echocardiography (TTE) at the emergency room show a non-dilated and global left ventricle hypokinesia, with reduced left ventricular ejection fraction (LVEF) and dilatation of the mitral valve ring in the genesis of moderate mitral regurgitation. Anticongestive and antiarrhythmic therapy started with rhythm conversion and clinical improve. Thoracic computed tomography scan reveals an extensive pericardial calcification. 2 months later TTE reveal a preserved LVEF, pericardial calcification, moderate mitral regurgitation, grade III diastolic dysfunction, respiration-related ventricular septal shift, increased of the mitral E-wave velocity with an E/A of 2.76, the peak mitral E-wave decreases 36% with the inspiration, dilated inferior vena cava without respiratory variation. Cardiac magnetic resonance imaging exposes a septal bounce and pericardial calcification, suggestive signs of constrictive pericarditis. The patient waits for cardiac catheterization for confirmation, being with anticoagulation, ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonist medication, remaining in NYHA class I.

Discussion

Clinical suspicion of CP is key for its identification, since there is not a specific clinical manifestation and generally patients presented heart failure symptoms. Echocardiography is best tool for a clinical physician evaluate heart failure etiologies, and can be used with higher sensitivity and specificity associated to the correct criteria to the diagnosis of CP. Pericardiectomy is the standard treatment, however the moment of its performance is not well established, since patients can remain in NYHA class I several years and the surgical procedure have higher mortality rates.
P1731 Multiple floating thrombi in aortic arch leading to acute stroke: A case report and systematic review of literature
Authors: Mahmood M , Avula S , Patti D K , Khan M S , Singh H
Published: January 2020

Introduction

Around 10-15% of acute cerebrovascular events occur in young adults with age less than 40 years. Trans-oesophageal echocardiogram (TOE) is routinely performed to rule out any cardio-embolic source in patients with ischemic stroke. TOE has shown to significantly change management strategy in up to 16.7% of stroke cases. We report a rare case of recurrent stroke in a young female who was found to have multiple mobile thrombi in aortic arch on TOE. We also report systematic review of literature of similar cases to highlight the management strategies.

Case Presentation

A 38-year-old female presented with one-week history of right upper and lower extremity paresthesia along with headache. Physical examination was unremarkable for any focal neurological deficits at time of initial evaluation. She had pertinent history of acute stroke two years ago associated with non-occlusive left common carotid artery thrombus for which she was previously on anticoagulation with rivaroxaban. The anticoagulation, however, was stopped five months ago after repeat imaging revealed complete resolution of thrombus. Electrocardiogram showed normal sinus rhythm without any other significant abnormality. CT head showed no acute bleeding or infarct. MRI brain showed scattered infarcts in right cerebral hemisphere and left cerebellar hemisphere. CT angiography of head and neck showed multiple small nodular and linear pedunculated thrombi in distal arch of aorta (see Figure 2). TOE was then performed which confirmed two pedunculated and mobile echogenic masses, largest measuring 0.9 x 0.6 cm, in the distal aortic arch (see Figure 1). TOE did not show intracardiac source of embolism. Laboratory testing for thrombophilia was negative for Factor V and Prothrombin gene mutation and heterozygous positive for Methylenetetrahydrofolate reductase (MTHFR)-677T gene. She was also found to have elevated homocysteine levels. She was restarted on anticoagulation with rivaroxaban.

Discussion and Conclusion

Young patients with stroke should undergo detailed investigation to rule out hypercoagulable pathology and cardiovascular embolic source. This should also include multimodality imaging including TOE in the selected patients. During TOE examination, a particular attention should be paid for evaluation of aortic source of thombo-embolism. Our patient was heterozygous for MTHFR-66T gene which is associated with decreassed activity of MTHFR by 35 % with elevated homocysteine levels. Treatment of floating aortic thrombus is still controversial. Anticoagulation is suggested as primary modality by multiple authors who reported complete resolution of thrombus. Other option includes surgical thrombectomy. Our patient was treated with anticoagulation alone due to hypercoagulable state and small size of thrombi.

Abstract P1731 Figure.
P1732 Congenital absence of the inferior vena cava: challenge for catheter ablation of arrhythmias via the femoral vein approach
Authors: Prisecaru R S , Leatu C , Purcar O , Pitis C , Costache V
Published: January 2020

Introduction

Congenital anomalies of the inferior vena cava (IVC) are a well described entity. These anomalies include complete absence, partial absence or duplication of the IVC. They are seen more frequently in those with other congenital cardiac anomalies (0.6%–2%). This congenital condition can be discovered incidentally, or due to symptoms of associated congenital heart disease, asplenia, polysplenia, congenital kidney anomalies or deep venous thrombosis.

Case report

We report the case of a 48 years old man scheduled for pulmonary vein isolation due to persistent atrial fibrillation resistant to antiarhythmic drugs, symptomatic for palpitations and dyspnea on exertion. Transthoracic ecgocardiography showed mild left atrium enlargement, normal systolic LV function and no significant valve disease. The transoesophageal echocardiography revealed dilation of the left atrium and absence of thrombus in the left atrium or left appendage. Multi-slice spiral thoracic computed tomography (MSCT) was also performed before the procedure and revealed absence of the inferior vena cava and significant dilation of the azygos and hemiazygos veins with subsequent drainage into the superior vena cava. Abdominal CT showed also partial situs inversus. Pulmonary vein isolation (PVI) through femoral vein approach was cancelled and the patient was scheduled for remote magnetic navigation PVI through arterial approach.

Conclusions

Whether the absence of the IVC is an embryonic anomaly or the result of perinatal thrombosis with regression and subsequent congenital absence of the IVC, absence of the IVC creates difficulties for catheter ablation of arrhythmias via the femoral vein approach.
P1736 An unexpected cause of ventricular tachycardia in a young patient
Authors: Tomoaia R , Beyer R S , Puiu M , Dadarlat A , Fringu F I , Gurzau D , Bardos K T , Comsa D H , Simu G , Pop D , Zdrenghea D
Published: January 2020

Introduction

Hypoplastic coronary artery disease (HCAD) refers to a congenital underdevelopment of one or more coronary arteries, which are greatly reduced in diameter or length. It is a rare congenital abnormality which has rarely been documented in living patients and which may lead to myocardial infarction (MI) and sudden cardiac death (SCD).

This case describes an otherwise healthy young male, which was admitted in the emergency department (ED) for repeated sustained ventricular tachycardia (VT) and was thereby diagnosed with an isolated hypoplasia of the left circumflex coronary artery (CX). Investigations revealed scar-related tachycardia, due to a prior silent myocardial infarction caused by HCAD. These findings were suggested by echocardiography and coronary angiography and were later confirmed by magnetic resonance and 3D cardiac mapping.

Case Report

A 34-year-old male patient was admitted to the intensive care unit with recurrent sustained VT causing hemodynamic instability. After receiving two electric shocks and amiodarone in the ambulance, the patient became hemodynamically stable. There was no remarcable medical history besides a syncopal fall 5 years before and no symptoms prior to the current event. Initial physical examination, ECG and laboratory testing were normal. Echocardiography revealed a dilated left ventricle with akynesia of the lateral wall and a mildly reduced ejection fraction (EF = 45%), moderate mitral regurgitation due to restriction of the posterior mitral leaflet. A subsequent emergent coronary angiography was therefore performed, which showed no sign of atherosclerotic lesions, yet it revealed a hypoplastic CX, without compensatory collateral vessels supplying the lateral wall. Cardiac MR demonstrated delayed enhancement with transmural necrosis and no viability in the lateral wall of the LV, suggesting a long-standing MI. Therefore, the final diagnosis was scar-related VT, due to a prior silent MI caused by HCAD. The management of this patient included implantation of an ICD in the secondary prevention of SCD. Moreover, we performed an EPS, which identified a scar at the level of the lateral and inferolateral LV walls as a substrate for VT (electroanatomic 3D voltage mapping) and of the critical istmus (3D activation mapping). The next step was radiofrequency ablation of the critical isthmus, with no inducibility of the VT after the procedure. After 6-months follow-up, there was no recurrence of the VT.

Conclusion

Finding the cause of myocardial infarction in a young patient with VT can be very challenging. We emphasise the role of imaging for the diagnosis and management of these patients. HCAD is a rare congenital anomaly, which can lead to progressive fibrosis in the territory with poor blood supply, MI and SCD. Although it is a rare condition, it should be considered in young adults who present with MI and/or SCD.

Abstract P1736 Figure. Investigations
P248 Changes of atrial septum defect caused by posture during three-dimensional transesophageal echocardiography ( a case of Platypnea-orthodeoxia syndrome)
Authors: Takeuchi Y , Suzuki S , Tsuneyoshi H , Sakamoto H , Shimada T
Published: January 2020

Background

Platypnea-Orthodeoxia syndrome (POS) is a rare phenomenon which is characterized postural hypoxia due to the intracardiac shunt from right to left through a patent foramen ovale, an atrial septal defect or a pulmonary arteriovenous malformation. POS is often underestimated because the hypoxia by postural change is difficult to be detected. We evaluated three-dimensional transesophageal echocardiography (TEE) to diagnose POS in an elderly patient.

Case report

A 84-year-old woman suffered from repetitive syncope for several years. She undertook twelve leads electrocardiogram (ECG), screening transthoracic echocardiography (TTE), twenty-four hours ECG and treadmill stress ECG, however, the cause of syncope was not identified. After another syncope event happened, she was transferred to the emergency room. Then, the hypoxia caused by sitting position was pointed out for the first time.

Her hypoxia was improved by supine position and oxygen administration. TTE demonstrated no right heart enlargement. Shunt flow was suspected on her atrial septum; however, it was difficult to reveal it by TTE because of her obesity. Therefore, she underwent intravenous saline injection test. In the decubitus position, an intravenous injection of saline under Valsalva maneuver revealed the shunt flow from the right atrium to the left atrium. Her arterial oxygen saturation (SpO2) was 95%. In the sitting position, a visible shunt flow was observed, then her SpO2 dropped to 85%. By TEE, the shunt hole was found in the oval fossa of the atrial septum. TEE was evaluated by different positions. The atrial defect hole became larger in the sitting position (area 1.05cm2) than in the supine position (area 0.43cm2). As a result, the postural change to sitting revealed Platypnea-Orthodeoxia syndrome associated with ASD. The pulmonary blood flow/systemic blood flow ratio (Qp/Qs) was estimated at 1.6. After surgical ASD closure, she was discharged without any symptoms.

Conclusion

Unclearness of TTE and the absence of a right heart overload may lead to misdiagnosis of POS. If a syncope patient caused hypoxia in the only sitting position, detailed echocardiography should be needed to rule out a diagnosis of POS. This is considerably valuable case of three-dimensional TEE confirmed the changes of ASD size by postural change.

Abstract P248 Figure.
P1741 Echocardiographic assessment of rate versus rhythm control strategy in patients with persistent atrial fibrillation
Authors: Piatkowski R , Kosior D A , Kochanowski J , Szulc M
Published: January 2020

BACKGROUND

Patients with persistent atrial fibrillation (AF) can be managed with either rhythm or rate control strategy. The restoration and maintenance of the sinus rhythm (SR) is not superior to the rate control regarding the total mortality and the rate of thromboembolic complications. Data concerning the effect of these strategies on left ventricular morphology and function is missing.

PURPOSE

The objective of our prospective randomised multicenter study in patients with persistent AF was to evaluate the effect of these two approaches on left ventricular morphology and function.

METHODS

The study group consisted of 205 patients (F/M 71/134; mean age 60.8 ± 11.2 years), including 101 patients randomized to the rate control approach (Group I) and 104 patients randomized to SR restoration with cardioversion and subsequent antiarrhythmic drug treatment (Group II). Mean duration of AF was 231.8 ± 112.4 days. At the end of follow-up (12 months), SR was present in 64% of patients in Group II. Echocardiographic examination was performed at a baseline and at 2 and 12 months. In the rate-control group, both right (22.1 ± 4.1 vs. 23.2 ± 3.8 cm2; p < 0.05) and left atrial (25.9 ± 5.2 vs. 26.8 ± 4.6 cm2 p < 0.05) enlargement was observed during the 12 months follow-up. A significant decrease in right (21.8 ± 3.0 vs. 21.2 ± 3.5 cm2; p < 0.05) and left atrial (26.2 ± 4.6 vs. 25.5 ± 5.0 cm2; p < 0.05) size in the rhythm control arm was observed. Both strategies led to a significant increase in left ventricular fractional shortening (32.1 ± 7.3 vs. 34.2 ± 6.5% and 31.3 ± 6.7 vs. 35.5 ± 8.9%, respectively; p < 0.05). The comparison of the left ventricular end-diastolic diameter revealed no difference within and between groups (50.8 ± 5.6 mm vs. 52.2 mm ± 6.8 mm at a baseline and 50.0 ± 6.0 vs. 52.0 ± ± 7.4 mm at 12 months, respectively). In rhythm-control group such trend was observed only in pts. with successfully maintained SR. According to LV function improvement, rhythm-control strategy was preferred in pts. with hypertension (RR 2.63; 95% C.I.: 0.93-5.45; p < 0.05) or congestive heart failure in NYHA II or III class (RR 2.13; 95% C.I.: 0.98-4.42; p < 0.05).

CONCLUSIONS

Both strategies led to a significant increase in LV FS. Rate-control strategy led to right and left atrium enlargement, but rhythm control resulted in their decrease.
P1752 Prognostic role of Multilayer Strain Speckle Tracking Echocardiography in patients with severe aortic stenosis treated with Transcatheter Aortic Valve Implantation
Authors: Cimino S , Maestrini V , Monosilio S , Luongo F , Neccia M , Birtolo L I , Petronilli V , Salvi N , Cantisani D , Filomena D , Mocci M , Quaranta S , Mancone M , Fedele F , Agati L
Published: January 2020

Background

Myocardial Strain evaluation helps to assess the efficacy of therapeutic interventions and to predict the prognosis and clinical outcomes. The aim of the present study was to assess whether Multilayer Global longitudinal Strain (GLS) can be useful in estimation of left ventricle (LV) function in patients with severe symptomatic aortic stenosis (AS) who have undergone transcatheter aortic valve implantation (TAVI).

Methods

35 patients with severe AS who successfully underwent TAVI, were enrolled in the study. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function. Occurrence of cardiovascular (CV) events (rehospitalization for HF or CV death) were collected after 24 months follow-up.Results: CV events occurred in 7 patients (20%). Patients were divided in two groups accordingly with CV events occurrence. No differences in baseline, demographic, echocardiographic and procedural characteristics were found. Patients who developed CV events had a more impaired pre-procedural GLS (-10.2 ± 2.4% vs -12.6 ± 2.2%, p = 0.029), mostly due to his subendocardial layer (Endo-LS -10.8 ± 2 vs -13.9 ± 2, p = 0.003). Moreover, by ROC curve analysis, a cut-off value of -12.4% of endo LS was associated with CV events (sensitivity of 83% and specificity of 65 %, AUC 0.8, p = 0.024), with a log-rank p value assessed by survival analysis of 0.044.

Conclusion

Multilayer GLS analysis could provide additional information for prognosis stratification in patients with severe symptomatic AS before TAVI, above and beyond assessment of LVEF alone.

Parameter Event-group (7/35 pz= 20%) Non-event group (28/35 pz= 80%) p Age (y.o) 86 ± 4 80 ± 7 NS LVEDV (ml) 112 ± 34 94 ± 32 NS LVESV (ml) 51.2 ± 6 56.9 ± 6 NS LVEF(%) 55.7 ± 6 56.9 ± 6 NS AVA (cm2) 0.77 ± 0.2 0.73 ± 0.2 NS GLS (%) -10.2 ± 2.4 -12.6 ± 2.2 0.029 Endo-LS (%) -10.8 ± 2 -13.9 ± 2 0.003 Epi-LS (%) -10.2 ± 2 -11.9 ± 2 NS

Abstract P1752 Figure.
P1753 Echocardiographic assessment of prosthetic aortic valve in children
Authors: Hayashi T , Shindo T , Misaki Y , Ono H
Published: January 2020

Introduction

Although the diagnostic utility of Doppler-derived hemodynamic parameters of prosthetic aortic valve (PAV) for detecting prosthetic dysfunction has been demonstrated in adults, interpreting these parameters in children is difficult, as the relative size of PAV varies more greatly in them than in adults. We aimed to elucidate how the Doppler-derived hemodynamic parameters change as the PAV size decreases relative to the somatic growth of children.

Methods

We reviewed 11 echocardiographic examinations of 9 mechanical PAVs in 8 children. The median age at echocardiographic examination was 10.2 (0.5-17.7) years. Underlying diagnoses leading to aortic valve replacement were aortic regurgitation due to dysplastic aortic valve in 3 children, Marfan syndrome in 1, persistent truncus arteriosus in 1, and aortic stenosis associated with interrupted aortic arch/coarctation of the aorta in 3. The PAV functioned normally in all examinations. PAV size was 19 mm in 8 examinations and 17 mm in 3 examination, which was standardized to body surface area at the examination by calculating z-scores based on previously published normative data of aortic valve diameter. We assessed the Doppler-derived hemodynamic parameters, namely peak velocity, mean pressure gradient, and accerelation time of the transprosthetic flow, the velocity-time integral (VTI) ratio of the left ventricular outflow to the transprosthetic flow, and effective orifice area (EOA) of the PAV calculated by using the continuity equation. The Pearson correlation coefficients between the PAV size z-score and Doppler-derived hemodynamic parameters of the normally functioning PAVs were evaluated. A p-value of <0.05 was considered statistically significant.

Results

All the Doppler-derived hemodynamic parameters except for EOA had a statistically significant correlation with PAV size z-score (Pearson correlation coefficients: peak velocity, -0.76; mean pressure gradient, -0.70; acceleration time, -0.66; and VTI ratio, 0.76). Multivariate analysis revealed that VTI ratio was the sole parameter that independently correlated with PAV size z-score.

Conclusions

VTI ratio, which is theoretically less dependent on cardiac preload than other hemodynamic parameters, strongly reflects BSA-indexed PAV size. Disproportionately decreased VTI ratio in relation to PAV size might indicate prosthetic obstruction in children with PAV.

Abstract P1753 Figure. Correlation of PAV size and VTI ratio
P1769 Levels of serum markers of myocardial injury in patients with ST-elevation myocardial infarction correlate with global left ventricular longitudinal deformation
Authors: Szymczyk E , Lipiec P , Michalski B , Kasprzak J D
Published: January 2020

The aim of this study was to assess the correlation of levels of serum markers of myocardial injury with parameters of myocardial function assessed by 2D-speckle tracking echocardiography in patients with ST-elevation myocardial infarction (STEMI)

Material and methods. The study group comprised 96 patients (69 male, mean age 58 ± 10 years) with first STEMI treated with successful primary percutaneous coronary intervention. Levels of serum markers of myocardial injury (troponin T and CKMB mass) were assessed on admission and then monitored during the hospitalization. 7-12 days after STEMI, all patients underwent resting 2D echocardiography with subsequent offline analysis using 2D speckle tracking algorithm. Measurements of left ventricular deformation included peak systolic longitudinal and transverse strain (SLS and STS) – maximal value before aortic valve closure, peak longitudinal and transverse strain (PLS and PTS) – including possible postsystolic contraction, systolic longitudinal and transverse strain rate (SLSR and STSR) at baseline.

Results

On admission median values (I – III quartile) of CKMB mass and troponin T were 20,0 ng/ml (6,3 – 59,0; range 1,9 – 475,3) and 0,25 ng/ml (0,06 – 1,04; range 0,01 – 11,2), respectively. Maximal values (I – III quartile) of CKMB mass and troponin T were 94,1 (28,0 – 215,7; range 3,2 – 500) and 3,29 (1,6 – 6,3; range 0,42 – 17,2), respectively. Statistically significant correlations were observed for the global values of the longitudinal strain parameters and the concentration of troponin T and CKMB mass (rs from 0.22 to 0.36). The strongest correlations were noted for the maximum serum level of troponin T. Among the best strain parameters was the global systolic longitudinal deflection (SLS). There was no statistically significant correlation between the parameters of transverse deformation and the concentrations of markers for myocardial necrosis.

Conclusions

Troponin T correlates with global left ventricular longitudinal deformation in patients with ST-elevation myocardial infarction.
P1778 Preeclampsia is associated with reduced myocardial work efficiency during pregnancy
Authors: Chow Y Y , Chapman M , Mahadevan D , Dekker G , Arstall M
Published: January 2020

AIM

Preeclampsia (PrE) is a systemic disorder unique to human pregnancy, which is characterised by hypertension and multiorgan involvement. It is associated with cardiac dysfunction with a reduction in global longitudinal strain (GLS) and long-term cardiovascular disease. The aim of this study is to evaluate the effects of the loading conditions on the GLS results utilising myocardial work (MW) a non-invasive assessment of left ventricular (LV) pressure strain loops.

Methods

We evaluated 41 pregnant women, aged between 18-40, at 28.4-40 (Mean 35) weeks of gestation and within one week of the diagnosis of PrE. 49 normotensive pregnant women (control) were matched for age and gestation. These patients were reassessed after six months postpartum. All patients underwent echocardiography for left ventricular indices and assessment with speckle tracking for global longitudinal strain (GLS%) and myocardial work indices - performed at both time points.

Result

PrE had a mean LV mass index (LVMi) of 14.53g.m2 higher than control (P value = 0.000) during pregnancy which normalised at six-months postpartum. There was a reduction in GLS between PrE and controls during pregnancy (p = 0.002) and this remained significant postpartum (p = 0.001). (Fig1) However, there was no change over time within each group. During pregnancy, peak global myocardial work efficiency (GWE%) in PrE was significantly lower than controls (p = 0.001) and no different six months postpartum (p = 0.169) (Fig2). In contrast, during pregnancy, myocardial work index (GWI mmHg) was significantly higher in PrE (p < 000) compared to control, but not in postpartum (p = 0.165) There was a significant change over time of GWI in both groups (p < 0.05) (Fig3).

Conclusion

During pregnancy and post-partum PrE patients show a reduction in GLS when compared to matched normotensive pregnant women. This finding is consistent with previous studies which suggests subclinical LV dysfunction in PrE. However, the GWI was significantly increased but reduced in efficiency (GWE). The GWI increase is likely a result of an increase in LV mass index. The hypertrophied LV allows the increase in work at the cost of a reduction in efficiency but normalises when the hypertrophy improves post-partum. Our study is the first to use myocardial work in PrE patients, which we believe provides a better assessment of cardiac adaptation post-partum and does not suggest long term subclinical LV dysfunction.

Abstract P1778 Figure.