bluuebunny/crossref_metadata_2025 huggingface dataset:
P813 Association of clinical and echocardiographic signs with atrial fibrillation in coronary artery disease patients: a propensity score matching analysis
Authors: Yaroslavskaya E I , Kuznetsov V , Gorbatenko E A
Published: January 2020

Background

It is known that atrial fibrillation (AF) and coronary artery disease (CAD) may be encountered coincidently in a large portion of patients. However, there are not so much data available about AF association with some clinical and echocardiographic signs in CAD patients.

Purpose

To find out the relationship between clinical and echocardiographic features and AF in CAD patients.

Methods

From local database of coronary angiography we selected patients with significant coronary stenosis (≥50% of lumen of at least one epicardial artery): 178 patients with chronic or paroxysmal AF and 331 patients without AF (the last group was selected by Propensity Score Matching with balancing by sex, age, body mass index, severity of chronic heart failure, prevalence of myocardial infarction, arterial hypertension, thyroid disease).

Results

Patients with AF compared to patients without AF often had higher heart rate (105 ± 32 vs 70 ± 13 beats/min, р<0.001), lower Canadian Cardiovascular Society angina classes (III-IV - 52.9% vs 66.5%, р=0.041), lower triglycerides level (1.74 ± 1.08 mmol/l vs 1.94 ± 1.17 mmol/l, р=0.019). In echocardiographic data the groups did not differ in prevalence and severity of left ventricular (LV) wall motion abnormalities. However LV dimension (26.7 ± 3.6 mm/m² vs 26.1 ± 3.3 mm/m², p = 0.028), right ventricular diameter (13.9 ± 2.0 mm/m² vs 13.3 ± 2.0 mm/m², p < 0.001), left atrial linear dimension (24.1 ± 3.2 mm/m² vs 21.6 ± 2.9 mm/m², p < 0.001), LV myocardial mass (171.0 ± 40.0 g/m² vs 154.8 ± 38.3 g/m², p < 0.001) were higher in AF patients. This group of patients more often demonstrated significant mitral regurgitation (49.1% vs 18.4%, р<0.001) and impaired LV ejection fraction (56.2% vs 39.5%, р<0.001). Coronary angiographic data showed that patients with AF more often had right coronary dominance (87.5% vs 80.4%, р=0.043), right coronary artery lesions (92.1% vs 85.8%, р=0.037), less often left main coronary artery lesions (16.3% vs 24.8%, р=0.027).

Conclusions

AF in CAD patients is associated with higher ventricular, left atrial dimensions, LV myocardial mass, significant mitral regurgitation and impaired LV ejection fraction and some peculiarities of clinical and coronary angiographic symptoms.
P819 Outflow graft twist occlusion in the heartmate 3 left ventricular assist system in 7 cases: analysis of potential mechanisms using computed tomography
Authors: Solowjowa N , Zimpfer D , Mueller M , Krastev H , Falk V , Schloeglhofer T H , Starck C H , Potapov E , Netuka I
Published: January 2020

Background

Twist of the outflow graft (OG) of the HeartMate 3 left ventricular (LV) assist device (HM3) with subsequent occlusion is a rare, but life-threatening complication.

Purpose

We evaluated if potential implantation technique dependent mechanisms of OG twist can be predicted by multislice computed tomography (MSCT).

Methods

We retrospectively analyzed clinical, echocardiographic and MSCT data of 7 patients with angiographically proven and surgically corrected OG twist and of 11 consecutive patients without any type of pump obstruction. MSCT parameters were: position of inflow cannula related to anatomical LV apex (1), angulation of axis of inflow cannula related to LV axis (2), orientation of outflow channel of the pump housing related to LV axis (3), OG course (4). Echocardiographic parameters were LV end-diastolic diameter (LVEDD) and aortic valve opening.

Results

Mean time from implantation to twist was 563 ± 161 days. Preoperative LVEDD (64.6 ± 9.8 mm vs. 67.4 ± 10.2 mm, p = 0.563) was similar. LVEDD reduction after implantation (20% vs. 28%) and prevalence of aortic valve opening was higher in the twist group (71% vs. 45%). The MSCT measurements showed a high degree of heterogeneity in both groups: (1) differed from superior to infero-lateral; (2) varied from cranial to caudal, lateral and medial; (3) varied from antero-septal to inferior. (4) showed an incidence of non-obstructive kinking of 29% and 36%, respectively.

Conclusion

Marked heterogeneity of the measured MSCT parameters was observed in both groups. No specific pattern or geometric relation could be attributed to the OG twist phenomenon.
P835 Mitral valve abscess complicating infective endocarditis
Authors: Hammad B , Saleh Y , Almaghraby A
Published: January 2020

Funding Acknowledgements

n/a

Background

Health care associated infective endocarditis (HAIE) accounted for u to 30% of infective endocarditis (IE) cases, it tends to affect patients with a poor clinical condition and represents a considerable in-hospital mortality.

Case

A 75-years old gentleman with end-stage renal failure secondary to polycystic kidney disease had commenced hemodialysis via a tunneled hemodialysis catheter 3 months ago, presented for pre-operative evaluation before vascular surgery for acute left lower limb ischemia, patient gave history of fever for the past month partially responding to antipyretics along with recent ischemic cerebrovascular stroke with no residual neurological deficits. On examination he had a blood pressure of 110/70 mmHg, a heart rate of 100 bpm, a temperature of 38oC, and a harsh pansystolic murmur over the apex. Laboratory results revealed leukocytosis elevated CRP and blood cultures were positive for staphylococcus aureus. Electrocardiography showed sinus tachycardia.

Methods and Results

2D-Trans-Thoracic Echocardiography (TTE) revealed the presence of echogenic rounded mobile mass measured 2x2 cm attached to the atrial surface of the posterior mitral valve leaflet. There was a severe mitral valve regurgitation and the regurgitant jet was directed anteriorly swirling around the mass. The left ventricle dimensions and function were normal. 2D-Trans-esophageal Echocardiography(TEE) was done for better visualization of the mass and it"s attachment. The mass was overlying the atrial surface of the posterior leaflet middle P2 scallop with a small echo-lucent cavity (abscess formation) in the leaflet in addition to another smaller mass at the atrial surface of the anterior leaflet. The aortic, tricuspid and pulmonary valves were normal in structure and function

Discussion

Echocardiography is a crucial imaging modality in a patient with multiple systemic emboli to rule out cardio-embolic source of embolization. TEE is of added value along with TTE in better definition of masses and detection of IE related complication.

While the patient was prepared for the vascular surgery to secure the ischemic limb his sensorium was disturbed and became unconscious immediate brain computed tomography showed severe intracranial hemorrhage and the patient died.

Conclusions

Patient with chronic kidney disease and on hemo-dialysis are highly vulnerable to health care related infective endocarditis and high clinical suspicion should be given in a situation of prolonged fever and embolic events. Mitral valve abscess is a rare complication of infective endocarditis and if occurs it leads to increase mortality. TEE should be an integral part of management of patients with IE to role out serious complications.

Abstract P835 Figure. Mitral valve infective endocarditis
P838 Accessory Mitral Valve Tissue in a 35-year-ol female with Significant Left Ventricular Outflow Tract Obstruction and Aortic regurgitation
Authors: Cataluna C , Dayag-Cabrera M , Baysa A
Published: January 2020

Accessory mitral valve tissue (AMVT) causing left ventricular outflow tract (LVOT) obstruction and aortic regurgitation is a rare congenital cardiac malformation.The true prevalence is not well known but latest literature review identified 104 cases of AMVT from 1963 to 2013.

We present a case of asymptomatic 35-year-old female who came in due to heart murmur. Chest X-ray showed a right-sided aorta and a dilated ascending aorta. An echocardiographic finding of a mobile serpiginous AMVT that parachutes into LVOT with significant gradient of 74 mmhg. There was mild restriction of the aortic right coronary cusp with moderate aortic regurgitation and other finding noted of persistent left superior vena cava. The patient underwent open heart surgery and had an excision of the AMVT and subcommissuroplasty of the right coronary cusp. Histological analysis of the excised specimen showed fragments of valvular tissue with fibrosis. There was no obstruction on repeat echo with mild aortic regurgitation. No postoperative complication noted and was discharged stable.

AMVT usually seen among young patients and it is uncommon among female adult population. LVOT obstruction and aortic regurgitation may caused by the AMVT. Echocardiography is an important modality in diagnosing and recognising such anomaly and the optimal treatment is surgery in the presence of significant LVOT obstruction.

Abstract P838 Figure. Intraoperative findings
P844 A stroke of bad fortune
Authors: Nguyen Nguyen N , Kadappu K
Published: January 2020

Case description

We report the case of a 78 year old man who was referred to our hospital following identification of an intracardiac mass on transthoracic echocardiogram (TTE). The study was for work-up of a recent left middle cerebral artery thromboembolic stroke, with successful endovascular clot retrieval. His only other active medical issue was metastatic prostate cancer with bony involvement, on palliative hormone therapy with a well controlled prostate specific antigen level. He was an ex-smoker and and had an ECOG performance status of zero. On physical examination, the patient was clinically well, with unremarkable cardiopulmonary auscultation.

The TTE demonstrated an echodense mass in the left atrium (LA), with Doppler colour giving a suggestion of its size (image A). The subsequent transoesophageal echocardiogram illustrated a large, well defined, heterogenous, echodense mass dominating the LA (image B). It was not adherent to the interatrial septum. There was no significant spontaneous echocontrast or thrombus formation in the left atrial appendage (LAA). Considering the location of the mass, the presumptive diagnosis of atrial myxoma was less likely. Differential diagnoses we considered included pure thrombus, infection and benign or malignant cardiac tumours. It was unlikely that this patient had a pure thrombus only considering the LAA was clear. He also did not have any non-specific or focal clinical features suggestive of infection. The patient went on to have a gated CT thoracic aortogram, which showed a contrast-enhancing soft tissue mass within the LA measuring approximately 50x40 millimetre, which invaded into the left inferior pulmonary vein, and was contiguous with a soft tissue mass in the left lower lobe of the lung (image C). He also had a positon emission tomography scan, which showed the highly metabolically active mass in the lung invading into the left inferior pulmonary vein, and as well as left atrium (image D). The patient underwent a biopsy of this left lower lung lesion, which confirmed squamous cell carcinoma of lung origin.

Due to the large tumour burden in the LA, the joint decision with medical and radiation oncology teams, was not to administer systemic chemo- or localised radiotherapy, as this would lead to high risk of tumour embolisation. The patient also had a short period of therapeutic anticoagulation with intravenous unfractionated heparin to treat the likely thrombotic coating to the left atrial tumour extension, but developed a retroperitoneal haematoma, and hence anticoagulation was ceased. The patient was referred to palliative care services, and returned back to the community.

Conclusion

Cardiac tumours, whether primary or secondary, are rare. They are most frequently identified on post-mortem examination. This case is unusual, in that the patient had a second primary tumour and has remained completely asymptomatic prior to embolic presentation, despite the large size of the mass.

Abstract P844 Figure 1.
P847 Echocardiographic imaging in primary cardiac tumour-leiomyosarcoma
Authors: Sharnam V , Husni D , Ong J , Ross F , Skarparis Y , Myagerimath S
Published: January 2020

Funding Acknowledgements

N.A

Primary cardiac tumours are rare entities with an incidence rate of 0.0017% to 0.019% of which 25% are malignant. Leiomyosarcomas, a form of primary cardiac sarcoma, accounts for 8-9% of all the cardiac sarcomas (1). Primary cardiac sarcomas typically present late with either quite advanced local cardiac symptoms or non-specific symptoms arising from metastasis (2). We herein report a rare presentation of leiomyosarcoma in a sixty-seven year old female Caucasian female, originally suspected following transthoracic echocardiogram.

A large mass filling the Left Atrium(L.A) with a degree obstruction to the Mitral Valve (M.V) was firstly noted on transthoracic echocardiogram. This mass had a broad base, appeared to be originating from the pulmonary veins and was not encapsulated. A small circumferential pericardial effusion was noted. Overall biventricular function was preserved and there was no evidence of pulmonary hypertension. A contrast-enhanced computed tomography scan of the chest, abdomen and pelvis was performed for staging which in addition to known cardiac mass revealed widespread bony metastases. A core biopsy of one of the lumbar paravertebral metastatic deposit was carried out to establish the diagnosis.

We hope to add to the pool of increasing overall understanding of primary cardiac sarcomas and share our fascinating echocardiogram findings. In addition, we believe this case supports our recommendation for general practitioners in the United Kingdom to have open access to requesting echocardiograms in order to identify such aggressive cardiac malignancies at an earlier stage, with the hope to improve prognosis.

Abstract P847 Figure. Depicting LA mass occupying the whole of
P849 An uncommon reason for transient ischemic attack: nonbacterial thrombotic endocarditis
Authors: Babur Guler G , Kilicgedik A , Zencirkiran Agus H , Kahveci G
Published: January 2020

Introduction

Non-bacterial thrombotic endocarditis (NBTE) is a rare condition which is usually associated with embolic complications. The exclusion of culture positive and negative infective endocarditis and the clinician"s suspicion of NBTE are the most important steps in the diagnosis.

Purpose

Illustrative echocardiographic images of NBTE in a patient with lung adenocarcinoma.

Case Report

A 48-year-old male patient was followed up in oncology clinic for known metastatic lung adeno carcinoma. The patient was referred to cardiology after a transient ischemic attack. Transthoracic echocardiography showed significant thickening of the mitral valve tips. In contrast to the rheumatic mitral disease valve opening was well preserved, signs of calcification and doming of anterior leaflet were absent. Transesophageal echocardiography was performed. Hypoechogenous thickening was observed at the mitral valve tips, measuring 1.39x1.33 cm in diameter. On the atrial side of the P2 scalllop, a mass with a diameter of 3.47 cm was seen. Central mitral regurgitation was observed. Aortic valve was structurally and functionally normal. The patient had no fever, serology and blood cultures were negative. Cranial magnetic resonans imaging showed multiple ischemic foci in the brain. The patient was considered NBTE in the light of these findings. Anticoagulation with warfarin was recommended. After 1 months patient deceased because of cancer.

Conclusion(s): NBTE is a condition that should be included in the differentials when the valve pathology is seen in patients with associated diseases (systemic lupus erythematosus, malignancy, disseminated intravascular coagulation, non-bacterial sepsis). Sterile vegetations seen at the contact surfaces of the mitral and aortic valves are typical lesions. They tend to involve the atrial side of the mitral and ventricular side for the aortic valve. Clinical suspicion is critical in the diagnosis of NBTE. The detection of vegetations on echocardiography without signs of infection and in patients with predisposing conditions leads to diagnosis.

Abstract P849 Figure.
P851 Carney"s complex: a rare cause of Atrial myxoma
Authors: Kasouridis I , Sargent R , Ghani S
Published: January 2020

Funding Acknowledgements

Nil

We present the case of a 53 year old lady who presented to the cardiology services with palpitations. She denied any symptoms of syncope or chest pain but described frequent short episodes of palpitations. Her background medical history at this point included a pituitary macroadenoma with panhypopituitarism requiring transphenoidal hypophysectomy, a follicular adenoma with left thyroid lobectomy and peripheral neuropathy. An echocardiogram was arranged and this showed a large left atrial mobile myxoma with good LV function and no other structural abnormalities. Her ECG showed sinus rhythm with no ischaemic changes and normal electrical intervals. She was admitted and transferred to a tertiary centre where the myxoma was successfuly excised. Her palpitations settled post procedure and holter monitoring didn"t pick up any malignant dysrrhythmias. She was referred to a genetics centre for investigation for Carneys complex which can predispose patient to endocrine and nonendrocrine tumours including pituitary, thyroid and as in our case a cardiac myxoma. This was confirmed on genetic testing and as her mother was found to also have a cardiac myxoma it raised the suspicion of an inherited mutation. Follow-up echo at 2 years post-op showed no recurrence of atria myxoma and patient was stable from a cardiovascular perspective.
P862 A conservative strategy for a frequently fatal post-myocardial infarction mechanical complication
Authors: Ferreira J , Freitas A , Loureiro J , Beringuilho M , Faria D , Roque D , Morais C
Published: January 2020

A 88-year-old female was admitted for an anterior ST-segment elevation myocardial infarction (STEMI). Patient had a history of intermittent chest pain for 2 days with worsening on the day of admission. Electrocardiogram (ECG) at admission showed ST-segment elevation on leads from V2 to V6 and leads DI and aVL. Initial observation on the emergency department was described as unremarkable apart from the chest pain. Aspirin and Ticagrelor loading doses were administered and patient underwent emergent coronary angiography, which showed left anterior descendent artery occlusion after the emergence of second diagonal branch. Coronary angioplasty of this lesion was tried, with a total of 3 drug-eluted stents implantation but with no success as in the end there was no reflow of the artery.

Patient was then admitted on cardiac intensive care unit, and on observation at that time there was a remarking holosystolic murmur. Transthoracic echocardiogram showed (apart from left ventricle systolic disfunction with akinesia of the apical segments as well as middle segments of the interventricular septum (IVS) and anterior wall) an apical IVS defect with a left to right shunt with a gradient of around 50mmHg evaluated by Doppler, and no signs of right ventricle overload. Case was promptly discussed with cardiothoracic surgery and it was decided that she was not a candidate to urgent surgical intervention. Patient had an initial evolution in Killip class II, and remained hemodynamically stable for the rest of the admission, having no signs of heart failure on discharge at 17 days later. Serial ETTs during admission and at discharge were similar to the evaluation performed at admission.

In the meanwhile, during admission, case was discussed in multidisciplinary heart team with cardiothoracic surgery and interventional cardiology. Given the favourable evolution and comorbidities and frailty of the patient it was decided to adopt a conservative strategy with medical follow-up, only considering intervention if there was worsening of heart failure. Until now, with 4 months follow-up, patient remains in New York Heart Association (NYHA) functional class I.

Discussion

Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD.

Abstract P862 Figure. Ventricular Septal Defect
P865 Ecstasy s use an unusual cause of dilated cardiomyopathy a case report
Authors: Mouadili M , Elqadi M , Goulehcen A , Echarai N , Elhattaoui M
Published: January 2020

Background

3,4-methylenedioxymethamphetamine is a stimulant used illegally around the world, including Morocco. Cardiomyopathy and heart failure may occur following chronic MDMA use and may cause many other acute cardiac complications.

Case report

A 30-year-old man, with a history of MDMA use, 2 tablets/week since 2 months, and 6 tablets the week before admission, presentedwith severe dyspnea at rest. The first evaluation shows a sinus tachycardia with tachypnea and signs of global heart failure, loud systolic murmur heard over the apex andcrackles at the base of the lungs were observed.

The blood tests performed, including erythrocyte sedimentation rate, blood picture, liver function and kidney function tests, protein, iron, phosphocalcic balance, glucose, and thyroid hormones,were within normal range. Moreover, immunological assays [immunoglobulin M (IgM) and immunoglobulin G (IgG) anti-Epstein–Barr virus] and toxoplasmosis were negative. Cytomegalovirus IgM was also absent, and IgG titer value was also absent.

Electrocardiogram (ECG) tracing showed a complete left bundle branch block (LBBB)with a regular sinus rhythm (100 bpm). Transthoracic echocardiography showed dilated cardiomyopathy with severe systolic dysfunction (12% by Simpson’s method) (Fig. 1).

Additional evaluation in the hospital excluded other etiologies of the cardiomyopathy. Thus, his condition was referred to the MDMA use.

The patient now is a heart transplant candidate.

Conclusion

There are several reports that show an increase in frequency of MDMA use, suggesting that cardiomyopathy and acute heart failure secondary to the Ecstasy use may be a new medical concern. Thus, proper history of illicit drug intake is crucial in the diagnosis of unexplained cardiomyopathies.
P868 Dissecting myocardium
Authors: Laymouna R , Samoka A , Haggag A , Almaghraby A , Hassan Y , El-Sharkawy E , Zaki A
Published: January 2020

Introduction

Incomplete rupture is a relatively uncommon type of free-wall rupture. It is found in 10% to 15% of total free-wall ruptures.

Case report

A 68-year-old male patient, heavy smoker, with medical history of diabetes mellitus and hypertension, had experienced an attack of acute retrosternal chest pain associated with dyspnea grade II-III one week before presentation.

He presented to our facility complaining acute chest pain. Upon examination, the patient had stable vital signs and an unremarkable clinical examination except for distant heart sounds on auscultation. Electrocardiogram showed deep Q waves in V1 to V4 with residual ST segment elevation. Routine lab investigations were unremarkable including a negative troponin.

A Chest X-ray showed an enlarged cardiac shadow. Echocardiography revealed a poor left ventricular systolic function due to an akinetic anterior wall and a dyskinetic apical cap containing a large highly mobile thread like mass which was suspected to be a thrombus.

Coronary angiography revealed proximal 85% stenosis followed by mid segment total occlusion of the Left anterior descending (LAD) artery, proximal 75% stenosis of the left circumflex (LCX) artery and a tight lesion in the mid segment of the right coronary artery (RCA).

The patient was diagnosed to have multi-vessel coronary artery disease and was maintained on medical treatment. Cardiac MRI was requested to detect myocardial viability before revascularization.

Subsequently, cardiac magnetic resonance (CMR) revealed a dilated left ventricle with very poor systolic function, akinetic inferior wall, aneurysmally dilated apex and anterior wall with the same large highly mobile mass. Late gadolinium enhancement revealed scarred anterior, septal and inferior walls including all apical segments and surprisingly the mobile intra-ventricular mass also contained a scar tissue continuous with the anterior myocardial scar which means it is a part of the myocardium which was dissected or partially ruptured.

Unfortunately, the patient suddenly experienced an attack of ventricular arrhythmia which was not resuscitated successfully.

Conclusion

Incomplete rupture is a rare type of free-wall rupture. It is thought that the infarcted myocardium wall is made weak in part by activation of metalloproteinases, which degrade the myocardial matrix. Structural weakness is associated with increased intra-cavitary pressure which predisposes the myocardial wall to rupture.

Although Echocardiography is a good method of diagnosis but CMR is superior due to its high spatial resolution and good tissue characterization, plus the use of late gadolinium enhancement helps in identifying the location and the extent of prior infarctions guiding us to the next step in management.

Abstract P868 Figure. Myocardial dissection with scarred flap
P871 Giant left ventricular (pseudo?)aneurysm complicating anterior myocardial infarction
Authors: Menezes Fernandes R , Mota T , Azevedo P , Bispo J , Guedes J , Costa H , Cunha S , Bento D , Cordeiro P , Bettencourt N , Marques N , Pereira S , Nobre A , Jesus I
Published: January 2020

Introduction

Clinical approach of cardiac aneurysms and pseudoaneurysms is significantly distinct. Therefore, it is crucial to accurately differentiate these two entities, which could be a real challenge.

Case report

We describe a case of a 55-year-old woman, with hypertension and previous smoking habits. She was admitted in our Cardiology Department with the diagnosis of anterior acute myocardial infarction, and was submitted to emergent coronariography, unveiling an occlusion of the middle segment of the anterior descending artery. She underwent successful primary percutaneous coronary intervention (PCI) 1h45 after the chest pain onset. Transthoracic echocardiogram (TTE) revealed depressed left ventricle ejection fraction (LVEF 30%), with akinesia of anterior and septal walls and all apical segments. She evolved in Killip-Kimbal class 2 and was discharged clinically stable. One week later, the patient performed a control TTE that showed an apical thrombus, with a small pericardial effusion, and she initiated warfarin. Three weeks later, a reevaluation TTE demonstrated a severe increase of the left ventricle dimensions, with LVEF 32%, and a small pericardial effusion. In apical 4-chambers incidence, it was visualized a linear structure (42 mm x 5 mm) attached to the endocardial border of the anterolateral apical segment and to the apical segment of the interventricular septum, of undefined nature. The apical segments were dyskinetic and had a very thin wall, which could correspond to aneurysm versus pseudoaneurysm. To clarify these findings, the patient performed a cardiac magnetic resonance revealing a large anterior myocardial infarction complicated with extensive myocardial necrosis, severe depression of LV systolic function (LVEF 25%) and septum rupture distal to the right ventricle apex (without connecting with it), compatible with a large apical pseudoaneurysm. The clinical case was discussed in the Heart Team and it was decided to perform cardiac surgery. However, surgical findings showed integrity of septal and free walls, and she underwent an aneurysmectomy, without further complications. Histological examination confirmed the presence of a thin myocardial wall with marked fibrosis and, consequently, the diagnosis of ventricular aneurysm. She was discharged clinically stable and maintains follow-up in Cardiology consultation of our Hospital.

Conclusion

In this patient, initially admitted with an anterior myocardial infarction submitted to primary PCI, follow-up with advanced imaging modalities pointed to the diagnosis of pseudoaneurysm. Despite the preoperative diagnosis, surgical findings were compatible with a giant left ventricular aneurysm. Even with high spatial resolution exams, postoperative evaluation of tissue layers remains the gold standard for this differential diagnosis.

Abstract P871 Figure. Apical pseudoaneurysm vs aneurysm
P885 Pulmonary artery stent implantation in an adult with chronic thromboembolic pulmonary stenosis
Authors: Khalifa E A , Helmy S , Elallus F , Mohamed S F , Alkuwari M
Published: January 2020

Introduction

Pulmonary artery stenosis presenting in adults is rare. Chronic thromboembolic pulmonary hypertension (CTEPH) is by far the most common cause of pulmonary artery stenosis. Stenosis in these patients are not caused by an abnormality of the arterial wall itself, but by intraluminal narrowing as a result of the only partially resolved and organized thromboembolism. In contrast to paediatric patients, in adults with pulmonary artery stenosis, pulmonary stenting is not routinely performed.

Case report

A 51-year male, smoker, diabetic, hypertensive, and with chronic kidney disease. He was diagnosed two years earlier with bilateral multiple pulmonary emboli and was maintained on oral anticoagulation therapy. Recently, he presented with gradually progressive shortness of breath and signs of right ventricular failure.

Diagnostic imaging: 1-Transthoracic and transesophageal echocardiography showed normal global systolic left ventricular function with no regional wall motion abnormalities, dilated right ventricle (RV) with moderately impaired function, severe pulmonic valve incompetence, mild tricuspid incompetence and a severely elevated right ventricular systolic pressure (RVSP) of 82 mmHg. In addition, a small rounded mass (6 x 11 mm) was visualized attached to the posterior wall of the RV outflow tract (RVOT) about 15mm proximal to the pulmonary valve annulus, (figure A). 2- Computed tomography pulmonary angiography showed a right main pulmonary artery (RPA) with circumferential narrowing, which was highly suggestive of chronic thrombosis. There was an abrupt tapering noted in the segmental branches of the right lower lobar pulmonary artery, with non-opacification of the distal arteries. No contrast opacification was noted in the right upper lobe pulmonary arteries. The left main pulmonary artery showed thickening of its bifurcation, again suggestive of chronic thrombosis, with narrowing of its left upper lobar branch, (figures B&C). 3-Cardiac magnetic resonance (CMR) showed a non enhancing RVOT mass protruding through the incompetent pulmonary valve during systole with features suggestive of a thrombus.

Management

In view of the clinical history, CTEPH was considered to be the most likely aetiology of the pulmonary hypertension. The decision was to perform balloon angioplasty and stent implantation in the RPA. Immediately after the procedure, RVSP was reduced from 80 to 50 mmHg. The clinical course after this procedure was uncomplicated and the patient showed significant clinical improvement.

Follow up CMR showed patent stent with improvement of RV function ( fig D)

Abstract P885 Figure.
P887 Two sides of the same mass
Authors: Saraiva M , Moura A , Craveiro N , Vieira M J , Abecassis J , Pitta M L , Martins V
Published: January 2020

Echocardiography (echo) remains the first-line imaging modality for the evaluation of cardiac masses. Three-dimensional (3D) echo, either transthoracic or transesophageal (TTE and TEE respectively), has allowed for better definition imaging, providing more information about the size, mobility, attachment and relation of these lesions with cardiac structures. Nevertheless, due to its superior tissue characterization capability, other imaging techniques, such as cardiac magnetic resonance (CMR), are very helpful in the differential diagnosis, making multimodality imaging the most attractive option for the study of intracardiac masses.

We present the case of a 85 year-old male, with paroxysmal atrial fibrillation (under effective anticoagulation), type 2 diabetes mellitus, hypertension, referred for the study of an asymptomatic cardiac mass found in a routine TTE. There were no relevant findings on physical examination. The TTE showed a bilobar spheroid mass, in the right atrium, attached to the interatrial septum, with 33x23mm and regular edges. A 3D TEE was performed confirming the previous findings, but also showing extension of this mass through the fossa ovalis membrane, reaching the left atrium; this aspect raised the doubt about either protrusion or invasion of the left atrium and, respectively, a benign (like a myxoma) versus malignant behaviour (such as a sarcoma). To better characterize this lesion, a CMR was ordered, which revealed a bilobar heterogeneous mass, attached to the right side of the interatrial septum, at the fossa ovalis membrane, without signs of adjacent tissue invasion, namely unequivocal invasion of the left atrium; it presented with intermediate T1 signal, hyperintense T2 signal and heterogeneous pattern of gadolinium enhancement, features mostly in favour of a right atrial myxoma. The complimentary study found no other relevant changes, namely no findings suggestive of endocarditis (negative blood cultures), autoimmune disease or malignancy. The patient refused undergoing heart surgery and, therefore, kept follow-up with clinical and echocardiographic stability.

Although histological examination remains the only tool for definitive diagnosis, multimodality imaging allows a quite comprehensive evaluation of intracardiac masses, enlightening the differential diagnosis. Here the imaging findings helped to establish a benign origin as the most likely, very important in this case of a probable right atrial myxoma, due to its peculiar protrusion to the left atrium through the fossa ovalis membrane.

Abstract P887 Figure. atrial myxoma
P889 3D guided CT assessment to define the right pulmonary vein on standard apical 4-chamber view
Authors: Chan J , Mehta O H , Mottram P , Tay I M , Teng J
Published: January 2020

Introduction

Pulmonary vein(PV) assessment is an integral component of the transthoracic echocardiogram(TTE) examination; typically assessed in the apical four-chamber view(A4Ch). There is disagreement in current textbooks and literature regarding which specific right pulmonary vein is visualised on A4Ch; as either the right superior(RSPV) or right inferior PV(RIPV).

Given the high reliability of cardiac CT for PV assessment, we aimed to characterize right PV anatomy on A4Ch by utilizing multi-modality comparison of echocardiography and a 3D-guided A4Ch on CT.

Methods

Retrospective analysis was performed on consecutive patients with TTE demonstrating PV flow(by colour or pulse-wave Doppler) and cardiac CT within 30days; studies not meeting image quality criteria excluded. To simulate the A4Ch on CT, multi-planar reconstruction was used to create an image plane including right PV ostia and LV apex. This image was rotated along the long-axis to achieve an A4Ch with both ventricles and atria, tricuspid and mitral valves in view without LVOT or aorta. This was attempted for right superior, inferior and middle(RMPV, if present) PV’s.

Results

50 patients were analysed: mean age 66yrs, 48% female, mean LA volume(indexed) 43.5ml/m². A4Ch was feasible in 100%(n = 50) of CT simulations using the RIPV, only 24%(n = 12) were feasible using RSPV with all excluded cases due to LVOT/aorta persistently in view. RMPV was present in 6 cases with feasible A4ch in 67%.

Conclusion

This study demonstrates that the right PV on A4Ch is highly likely to be the RIPV due to the RSPV being anatomically impossible in the significant majority of cases.

Abstract P889 Figure. CT multiplanar reconstruction of A4Ch
P892 Accuracy of right atrial pressure estimation using a multi-parameter approach derived from Inferior vena cava semi-automated edge-tracking echocardiography
Authors: Albani S , Pinamonti B , De Scordilli M , Fabris E , Perkan A , Geri P , Gregori C , Barbati G , Sinagra G , Mesin L
Published: January 2020

Background

In clinical practice, as stated in the ASE guidelines, the echocardiographic estimation of right atrial pressure (RAP) is based on the size of the inferior vena cava (IVC) and its inspiratory collapse. However, this method has proven to have limits of reliability and reproducibility. The use of a recently developed software that with a semi-automatic technique highlight the edges of the IVC could help to standardize the echocardiographic assessment of RAP.

Aim of the study: The aim of the study was to assess feasibility and accuracy of a new semi-automated approach to estimate the RAP.

Standard acquired echocardiographic images were processed with a semi-automatic technique, indexes related to the collapsibility of the vessel during inspiration (Caval Index, CI), during the whole respiratory cycle (Respiratory Caval Index, RCI) and through the heart cycle transmitted movements’ (Cardiac Caval Index (CCI) were derived (figure 1).

Using these indexes, we developed two models:

a) the Binary Tree Model (BTM), further divided in BTM3 and BTM5 (RAP estimated in 3 and 5 classes, respectively);

b) the Regression Model (RM), further divided in RM linear (continuous model) and RM3 and RM5 (RAP estimated in 3 and 5 classes respectively).

RAP assessed using these innovative techniques were compared with two standard estimation (SE) echocardiographic methods A and B.

Direct RAP measurements obtained during a right heart catheterization (RHC), performed within 6 hours, were used as reference.

Results

62 consecutive ‘all-comers’ patients that had a RHC were enrolled; 13 patients were excluded for technical reasons. Therefore 49 patients were included in this study (26 males and 23 females; mean age of 62.2 ± 15.2 years, 75.5% pulmonary hypertension, 34.7% severe left ventricular dysfunction and 51% right ventricular dysfunction). The two SE methods showed poor accuracy for RAP estimation (method A: ME = 51%, R2= 0.22; method B: ME = 69%, R2= 0.26). Instead, the new semi-automatic methods BTM3 and BTM5 based on parameters derived from IVC edge tracking (mean IVC diameter, CI, CCI and RCI) had a misclassification error of only 14% (R2 = 0.47) and 22% (R2 = 0.61), respectively, to classify RAP. The accuracy was lower for RM than BTM (RM3: ME = 61%, R2 = 0.39; RM5: ME = 55%, R2 = 0.39). However, the RM showed the lowest mean bias in estimating RAP: 0.23 [-8.34; 8.81] mmHg.

Conclusions

A multi-parametric approach using the new indexes, such as CCI and RCI, derived from a semi-automated edge tracking of the IVC is a promising tool for a more accurate estimation of RAP. This study proposes an innovative method for the non-invasive estimation of the RAP, which requires confirmation on larger population.

Abstract P892 Figure 1
P911 3D echo imaging of tricuspid valve: new look at the tricuspid valve
Authors: Abdelgawad H S A , Shehata M , Abdelnabi M , Almaghrabi A , Abayazeed R , Abdelhay M A
Published: January 2020

Introduction

"" En face"" visualisation of the tricuspid valve (TV) leaflets and commissures is not possible using two-dimensional transthoracic echocardiography (TTE) unless the right ventricle (RV) is dilated via parasternal short axis or subcostal views. With the aid of three dimensional echocardiography (3DE) , complete assessment of the TV apparatus including the leaflets, annulus and subvalvular apparatus can be easily accomplished.

Aim

To use different modes of three dimensional (3D TTE) to assess TV in three standard views in different diseases.

Methods : 6 patients with different tricuspid valve diseases (mean age is 29 ± 18 years, 3 were women)were studied.We used three-dimensional echocardiography to acquire zoomed mode and multi-beat, full-volume data sets of the TV to assess the leaflets and commissures. .Moreover, tricuspid valve area(TVA) was assessed by direct planimetry of the valve orifice at the level of the leaflets tips at end diastolic frame in cases of TV stenosis.

Results

Direct visualization of the leaflets motion and number, commissures and TVA were achieved in all patients.Tricuspid valve posterior leaflet prolapse was seen in two patients (figures A, B).2 patients had tricuspid valve stenosis ; one showed characteristic commissural fusion in a rheumatic heart (3D TVA= 1.2 cm2 )(Figure D) and the other has a peculiar commissural sparing in a carcinoid pathology (3D TVA = 1.9 cm2) (Figure E) .One patient revealed rudimentary anterior leaflet suggesting unguarded TV orifice (Figure F). Regarding the numerical variations: one patient got 4 leaflets (Figure C) while another one had 2 leaflets only.

Conclusion

Simultaneous visualization of the three TV leaflets is limited by using 2DE.On the other hand, RT-3DE allows better understanding of the anatomy and mechanisms of the TV diseases .Comprehensive assessment of the morphology and function using RT-3DE can provide a valuable road map to guide the intervention according to each individual case.

Abstract P911 Figure. Different TV morpholgies.
P912 Echocardiographic analysis of acute effects after treatment of functional mitral regurgitation by percutaneous mitral annuloplasty
Authors: Stoebe S , Kreyer K , Lavall D , Laufs U , Hagendorff A
Published: January 2020

Background

Secondary or functional mitral regurgitation (FMR) is associated with increased morbidity and mortality, especially in heart failure patients, patients with many comorbidities and/or in the elderly. Previous studies about percutaneous mitral annuloplasty have shown evidence for long-term reduction of degree of FMR severity and left ventricular (LV) remodeling. In comparison to previous studies the present study did focus on the echocardiographic analysis of acute effects after percutaneous mitral annuloplasty (PMA).

Methods

Transthoracic echocardiography (TTE) has been performed in 30 patients with moderate or severe FMR before and after (± 3.5 days) percutaneous mitral annuloplasty (Carillon®). LV volumes and LV ejection fraction and semi-quantitative parameters, e.g. tenting Area, vena contracta and velocity-time-integral ratios of transmitral inflow and LV outflow (VTIMV/VTILVOT) were assessed. The assessment of the regurgitant volume (RV), regurgitant fraction (RF) and effective regurgitant orifice area (EROA) was quantitatively performed by the PISA method. RV and RF was also estimated by subtracting the effective forward stroke volume (SVLVOT, SVRVOT) from the total stroke volume (SVLV planimetry). Further, parameters of left ventricular contractility, e.g. global longitudinal strain (GLS), cardiac efficiency, peak power index etc., were assessed.

Results

a postinterventional reduction of degree of FMR severity was achieved in 25/30 patients (83%). In average, RF was reduced from 49 ± 11% to 34 ± 13% (p < 0.001), RV from 33 ± 13ml to 25 ± 12ml (p < 0.001) and EROA from 0.24 ± 0.1cm2 to 0.19 ± 0.1cm2 (p < 0.05). Significant decreases were also noted for vena contracta and VTIMV/LVOT. DiamMV (long axis) was reduced from 3.6 ± 0.6cm to 3.4± 0.6cm (p < 0.001), DiamMV (4-chamber view) from 3.9 ± 0.5cm to 3.6 ± 0.6cm (p < 0 .05). In patients with sinus rhythm (SR) or pacemacer stimulation a considerably higher reduction of RF was observed (ΔRF 20 ± 12%) in comparison to patients with atrial fibrillation (ΔRF 10 ± 12%). No significant changes were obtained for parameters of LV remodeling and LV contractility, e.g. GLS, cardiac efficiency, peak power index.

Conclusion

A reduction of degree of FMR severity can be achieved by percutaneous mitral annuloplasty (PMA) and acute effects can be quantitatively assessed by echocardiography. Further data are necessary to evaluate whether these acute effects will maintain in follow-up investigations.

Abstract P912 Figure. Fig1-Reduction of RF and VC after PMA
P917 Additional value of atrial parameters evaluated by echocardiography on the scales of cardioembolic risk in atrial fibrillation
Authors: Moral S , Panaro A , Ballesteros E , Morales M , Frigola J M , Robles R , Albert X , Trucco E , Aboal J , Vilardell P , Palet J , Carballo J , Brugada R , Evangelista A
Published: January 2020

Background

Atrial morphological parameters may influence the presence of atrial thrombus, a factor strongly associated with cardiac thromboembolism, independently of those included in the CHA2DS2-VASc risk estimation scale in patients with a history of atrial fibrillation (AF). The aim of our study was to evaluate this possible association by transthoracic echocardiography (TTE).

Methods

Prospective multicenter study including 401 patients with a history of AF, in which a TTE and a transesophageal echocardiogram (TEE) were performed for evaluation of atrial thrombus between 2016-2019. The parameters included in the CHA2DS2-VASc scale, the heart rhythm at the time of the study and the anticoagulant treatment performed, as well as the atrial morphological parameters were collected.

Results

Twenty-three patients (6%) presented with atrial thrombus in TEE. The left atrial area (28 ± 6cm2 vs 33 ± 6cm2; p < 0.001), the presence of AF during the study (83% vs 17%; p = 0.002) and CHA2DS2-VASc (1.7 ± 1.5cm2 vs 3.0 ± 1.3cm2; p < 0.001) were associated with the presence of atrial thrombus. The left atrial area was a diagnostic predictor of atrial thrombus (area under the curve = 73%; p = 0.001): a value >30cm2 presented a sensitivity of 79% and a specificity of 70% to detect its presence. Logistic regression analysis, including heart rhythm during the study and anticoagulant treatment, showed that CHA2DS2-VASc (OR = 1.5; CI95%=1.1-1.9; p = 0.003) and left atrial area >30cm2 (OR = 5.2;CI 95% =1.7-16.0; p = 0.004) were independent predictors of atrial thrombus presence.

Conclusions

The left atrial area is associated with the presence of atrial thrombus in patients with a history of AF independently of the CHA2DS2-VASc scale, heart rhythm during the study, and anticoagulant treatment. This parameter should be evaluated to be included in the cardioembolic risk scales.