bluuebunny/crossref_metadata_2025 huggingface dataset:
1107 An unusual vegetation on a prosthetic pulmonary valve
Authors: Fusco F , Scognamiglio G , Colonna D , Palma M , Granata G , Russo M G , Sarubbi B
Published: January 2020

Patient presentation

During a routine check up, a 47yo man with Tetralogy of Fallot and congenital absence of left pulmonary branch was found to have a vegetation on his prosthetic pulmonary valve. His surgical history included TOF repair with left pulmonary branch bypass aged 4 years and a redo surgery for pulmonary valve replacement 3 years earlier. Before last surgery, CMR showed severe pulmonary regurgitation, dilated RV with mildly impaired systolic function (EF 40%) and absent flow in left pulmonary branch due to bypass occlusion.

Diagnostic work-up

The patient reported increasing shortness of breath (NYHA class III) over the last months. He reported one single fever peak two months before.He was on Apixaban and Amiodarone for previous history of AF. He was afebrile and an ejective systolic 4/6 murmur was heard. He was in sinus rhythm at 70 bpm. The TTE showed dilated RV with severely reduced systolic function (FAC 12%), severe pulmonary stenosis (peak gradient of 70 mmHg) with mild regurgitation, and a mobile and echogenic vegetation of 10 X 9 mm was seen on the prosthetic pulmonary valve. His blood tests at the admission demostrated raised WBC (9.460/uL) and PCR 11.7 mg/dl (n.v. < 3.0). The PCR remained stable during the following days. Serial blood samples for cultures were obtained, but all resulted negative. Uncommom causes of negative blood culteres infective endocarditis were investigated with specific serological tests for research of fastious agents, but all resulted negative. Antinuclear and antiphospholipid antibodies were also tested. A total-body CT was performed and it showed several liver formations. A FDG PET-CT was requested and it demostrated active marked glucose uptake by a mediastinic node, as well as by liver, brain and prosthetic pulmonary valve.

Diagnosis and outcome

After a careful review of all the clinical and imaging data, our opinion was that the most probable diagnosis was non infective thrombotic endocarditis in patient with metastatic cancer. In this situation, the valvular glucose uptake was likely due active thrombus formation rathen then being a sign of inflammatory response. Unfortunately, the patient died suddenly two weeks after the PET-CT and it was impossible to confirm the diagnosis with biopsy.

Conclusion

Differential diagnosis of cardiac vegetations is a challenging process including microbological tests, multi modality imaging and clinical reasoning. It is always necessary to consider alternative diagnosis, even when traditional imaging tests seem to suggest infective endocarditis.

Non infective thrombotic endocarditis are a rare form of negative blood culteres endocarditis related to systemic hypercoagulable state (i.e. antiphospholipid syndrome, systemic lupus, behcet syndrome, cancer). Malignancies can be considered an unusual cause of cardiac vegetation and they must be taken into account on differential diagnosis.

Abstract 1107 Figure. FDG uptake in pulmonary position
1115 Ultra-slow low-dose thrombolytic therapy as an option of treatment in intracardiac thrombus: a case report
Authors: Alves Pinto R , Torres S , Formigo M , Resende C X , Proenca T , Carvalho J M , Grilo P D , Nunes A , Araujo P M , Sousa E , Neves A , Coentrao L , Honrado T , Maciel M J , Macedo F
Published: January 2020

We present a case of a 57-year-old male with previously known primary severe mitral regurgitation, who was admitted to the ICU due to massive venous thromboembolism with associated right ventricle dysfunction and with two large mobile right atrial thrombi (2.4 x 1.5 cm and 3.6 x 3.7 cm). Despite of five days with a therapeutic aPTT achieved with unfractionated heparin (UFH), a TTE showed deterioration of the right ventricle systolic function, persistence of the right atrial masses with similar dimensions together with new mobile thrombi on the coronary sinus and on the right pulmonary artery. Due to deterioration of his clinical condition and given the refractoriness to the classical treatment with UFH, it was decided to administer an ultra-slow low-dose thrombolysis protocol, which consisted in a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without bolus. The treatment was continued by 48 consecutive hours, with clinical improvement and important reduction of the right atrial masses with resolution of the coronary sinus and right pulmonary artery thrombi. The patient started hypocoagulation with warfarin bridging with low molecular weight heparin (LMWH). Seven days after alteplase discontinuation there was complete resolution of the intracardiac thrombi. One month after ICU admission a successful mitral valve replacement surgery was conducted. Three months after discharge, the patient is in functional New York Heart Association (NYHA) class I with no cardiovascular events or hospitalizations. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to anticoagulation.

Abstract 1115 Figure. TTE showing right atrial masses
1161 Baseline echocardiographic parameters associated with reintervention in children with aortic valve stenosis following balloon aortic valvuloplasty
Authors: Papneja K , Blatman Z , Kawpeng I D , Wheatley J , Osce H , Li B , Manlhiot C , Fan C P S , Lafreniere-Roula M , Benson L N , Mertens L
Published: January 2020

Introduction

Aortic valve (AV) stenosis is the most common type of congenital left ventricular outflow tract obstruction. Short-term outcomes following balloon aortic valvuloplasty (BAV) including residual aortic stenosis, aortic insufficiency, and procedural complications have been established. The impact of pre-intervention AV characteristics on long-term outcomes has not been well studied.

Purpose

The aim of this study was to determine the relationship between the initial parameters on baseline echocardiogram and the time to reintervention in children with AV stenosis following BAV.

Methods

Children from the newborn period to 18 years of age with AV stenosis who underwent BAV from 2004-2012 were included. Patients with aortic insufficiency prior to BAV, complex congenital heart lesions, or less than two accessible follow-up echocardiograms were excluded. Baseline and serial echocardiographic data pertaining to aortic valve and LV size and function was retrospectively collected until December 2017 or until the first reintervention. Time to reintervention or death was evaluated.

Results

Among the 98 enrolled patients, the median [IQR] age at BAV was 2.8 months [0.2-75]. The median [IQR] duration of follow-up was 6.8 [1.9-9.0] years. Eighty-nine (83%) patients had bicuspid valve morphology and the median [IQR] peak-to-peak catheterization gradient prior to BAV was 49 [34-65] mmHg. The cumulative proportion [95% CI] of reintervention at 5 years following BAV was 33.7% [23.6%, 42.4%]. Primary indications for reintervention were aortic stenosis (57%), aortic insufficiency (14%), or mixed valve disease (30%). Reinterventions included repeat BAV (49%), AV repair (15%), and AV replacement (36%). Increased LVEF at baseline as well as increased mean LV circumferential strain at baseline were associated with decreased risk of reintervention (HR [95% CI] (1 unit increments): 0.974 [0.959-0.989], p < 0.001; 0.939 [0.884-0.997], p = 0.041 respectively). Increased AV annulus z-score was also associated with decreased risk of reintervention (HR [95% CI] (1 unit increments): 0.806 [0.698-0.93], p = 0.003).

Conclusions

Our results demonstrate that better left ventricular function at baseline, measured by LVEF and mean LV circumferential strain, is associated with a decreased risk of reintervention in neonates and children following BAV. We have also shown that a bigger AV annulus prior to BAV is associated with a decreased risk of reintervention.
1163 Diagnostic performance of a new echocardiographic method for coronary arteries abnormalities assessment
Authors: Bianco F , Colaneri M , Bucciarelli V , Surace F C , Iezzi F V , Giusti G , Primavera M , Biasi A , Gallina S , Pozzi M
Published: January 2020

Background

The echocardiographic assessment of coronary arteries abnormalities (CCA) has always been challenging. In this view, we aimed to assess the performance of a new echocardiographic-based diagnostic method for CAA in pediatric and young adults’ population.

Methods

over 5 years, we examined all the outpatients undergoing routine echocardiography in our department. Our method consisted of 4-focused specific view scan: parasternal short-axis, parasternal long-axis, both left and right outflow tract, and apical 5-chamber view. Coronary-CT confirmed the CAA diagnosis. Two independent physicians retrospective reviewed the echocardiographic images, in a double-blinded fashion (coronary-CT and diagnosis), for performance analysis.

Results

in 2014-18, 5,998 outpatients underwent echocardiography (median age 14 years [6, 21 - IQR]). A total of 27 CAA were diagnosed: overall prevalence 0.0045%, 0.022% of incidence. N = 17/27 were anomalous aortic origin of coronary arteries (AAOCA), N = 3/27 anomalous coronary arteries from the pulmonary artery (ACAPA), and 7/27 fistulas. After the implementation, we found a progressive increment of CAA diagnosis (P for Trend = 0.038), in particular of AAOCA: both left and right coronaries (P-trend = 0.021 and P = trend 0.010, respectively). Our method showed better sensitivity than traditional CAA echocardiographic evaluation: 85% vs 55%, P = 0.032 [AUC 0.77, 95% CI (0.68, 0.87) and AUC 0.92, 95% CI (0.85, 0.99), respectively], with a good interobserver agreement for the adjudicated double-blinded retrospective diagnosis (99.75%, K = 0.73, P < 0.001).

Conclusions

the application of a new echocardiographic-based method for CAA-detection led to a significantly increased rate of identified anomalies. This approach demonstrated better sensitivity than traditional echocardiographic assessment. Implementing this protocol in clinical practice may improve the CAA diagnosis, and probably reduce the occurrence of CAA-related sudden cardiac death.
1164 Echocardiographic diagnosis and clinical significance of Eustachian valve hyperplasia
Authors: Legkonogov A
Published: January 2020

Introduction

Eustachian valve (EV) is an embryological valve residue of the inferior vena cava. Currently, the persistence of an unusually elongated or hyperplastic EV is considered as a stigma of dysembryogenesis.

Purpose

Determine the frequency of detection and clinical significance of EV hyperplasia.

Methods

The analysis and clinical evaluation of 37577 transthoracic and transesophageal Doppler-echocardiographic examinations.

Results

EV hyperplasia was discovered in 97 cases out of 37577 studies, which accounted 0.25% of the total number of patients examined. EV hyperplasia was found to be significantly more common in people younger than 18 years (1.12%), while those which were over 18 years in age, the detection rate of EV hyperplasia was only 0.16% (p <0.001). In those examined, isolated EV hyperplasia was detected in 28 patients, including 20 men and 8 women, with an average age of 16.1 ± 2.2 years. The isolated EV hyperplasia was essentially an echocardiographic finding and was not accompanied by any obvious clinical symptoms. Furthermore, EV hyperplasia was also detected in patients with congenital heart defects - 28 patients, including 13 men and 15 women, with an average age of 30.6 ± 3.5 years. In this category of patients, atrial septal defect prevailed (18 patients), with concomitantly atrial septum aneurysm (3), partial abnormal pulmonary vein drainage (1 patient). Less frequently observed were stenosis of the pulmonary artery (3), ventricular septal defect (2), complete atrioventricular canal (2), Ebstein"s anomaly (1), aortic coarctation (1), bicuspid aortic valve (1). In 17 patients (15 men and 2 women, mean age 20.0 ± 3.1 years), EV hyperplasia was combined with other small heart abnormalities in the context of connective tissue dysplasia syndrome - abnormalities of the chordal apparatus of the left ventricle (9 patients), mitral valve prolapse (3 patients), atrial septal aneurysm (2); in 3 cases, combined small anomalies of heart development occurred. EV hyperplasia was also discovered in 23 patients (12 men and 11 women, mean age 54.9 ± 4.1 years) with various pathologies of the cardiovascular system of ischemic and non-coronargenic origin - 9 patients with chronic ischemic heart disease, post-infarction cardiosclerosis (3), arterial hypertension (2), myocardiofibrosis (2), aortic valve prosthesis (2), infective endocarditis with aortic valve disease (1), mitral valve stenosis (1), aortic aneurysm (1), Kawasaki (1) and WPW syndrome (1).

Conclusion

EV hyperplasia is a rare usually asymptomatic congenital malformation of the heart, occurring predominantly in the young. The most frequent combination of EV hyperplasia is with an interatrial communication. This may indicate a postnatal delay in the closure of the foramen ovale associated with a persistent EV. Echocardiographic features of a hyperplastic EV require differential diagnosis with intra right atrial echo masses, blood clots, vegetations, embryological rudiments.
1174 Coronary flow velocity assessment in routine echocardiography predicts adverse outcomes in three-year period in different subgroups
Authors: Zagatina A , Zhuravskaya N , Guseva O , Kalinina E , Drozdova Y , Yurkin D , Shmatov D
Published: January 2020

Background

The previous diagnostic study had demonstrated high correlation of maximal coronary flow velocity with significant stenoses by invasive methods. There is a lack of information about the prognostic value of local high velocity in coronary arteries during echocardiography. The present study was aimed at investigating the three-year prognostic value of coronary flow assessment in all patients were referred for routine echocardiography examination in different subgroup.

Methods

The prospective study comprises 747 consecutive patients (380 males; age 58 + 13 years) referred to echocardiography. Routine echocardiography was added with coronary flow velocity assessment in the left main (LM), left anterior descending (LAD) or circumflex (Cx) coronary arteries measured by Doppler method. Death, nonfatal myocardial infarction (MI), acute coronary syndrome (ACS) and/or revascularization were defined as major adverse cardiac events (MACE).

Results

During a median follow-up of 36 months, 192 patients experienced 224 MACE. Twenty-six deaths, 16 non-fatal MI, 2 ACS, 180 revascularizations were observed. The value of 67 cm/s maximal coronary flow velocity in the left main/proximal LAD/proximal LCX arteries was the best predictor for death (area under curve 0.79, 95% CI 0.76-0.82), p < 0.0001, and 66 cm/s was the best predictor for death/MI (area under curve 0.81, 95% CI 0.78-0.84), p < 0.0001. A value of 64 cm/s in left main/proximal LAD/proximal LCX arteries was a significant predictor of all MACE (area under curve 0.83, 95% CI 0.79-0.85), sensitivity 73%, specificity 84%, p < 0.0001.

Death/MI/ACS syndrome were observed in the main group in 17% vs. 1% patients with coronary velocity more than 65 cm/s the left main/proximal LAD/proximal LCX arteries vs. patients with less than 65 cm/s, respectively, p < 0.0001.

Arterial hypertension subgroup. Deaths occurred in 9% vs. 1%, p < 0.003. Death/MI/ACS were observed in 11% vs. 1%, p < 0.004.

Subgroup with known CAD. Deaths occurred in 11% vs. 3%, p < 0.04. Death/MI/ACS were observed in 20% vs. 3%, p < 0.0006.

Subgroup of patient with unknown origin chest pain. Deaths occurred in 3% vs. 1%, p – non significant. Death/MI/ACS observed in 9% vs. 0, p < 0.04.

Subgroup with valve disease. Deaths occurred in 17% vs. 0%, p < 0.02. Death/MI/ACS were observed in 17% vs. 0%, p < 0.02.

Conclusion

The coronary velocity parameters give long-term prognostic information that can be used to identify persons with a high risk of MACE in non-selected patients, also as in patients with arterial hypertension, known or suspected CAD, valve disease.

Abstract 1174 Figure.
P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports
Authors: Dias Ferreira Reis J P , Mano T , Mendonca T , Portugal G , Ferreira L , Galrinho A , Fiarresga A , Cacela D , Moura Branco L , Ferreira R
Published: January 2020

Introduction

Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR.

Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms.

Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic.

Conclusion

Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.
P1274 Early surgery versus watchful waiting in patients with moderate aortic stenosis and left ventricular systolic dysfunction
Authors: Moon I , Lee S P , Kim M K , Park J B , Kim H K , Kim Y J , Sohn D W
Published: January 2020

Background

Aortic stenosis (AS) induces significant pressure overload to the left ventricle (LV) and its burden may increase if there is concomitant LV systolic dysfunction. Severe AS with LV systolic dysfunction is a class I indication for aortic valve replacement (AVR) irrespective of symptoms, however, this recommendation is not well established in those with moderate AS and LV systolic dysfunction. In this study, we sought to investigate the clinical impact of surgical AVR among patients with moderate AS and LV systolic dysfunction.

Methods

From 2001 to 2017, we retrospectively but consecutively identified patients with moderate AS and LV systolic dysfunction from a single tertiary hospital. Moderate AS was defined as aortic valve area between 1.0 and 1.5cm2 and LV systolic dysfunction as LV ejection fraction less than 50%. The primary outcome was all-cause death and we additionally analyzed cardiac death as a secondary endpoint. The outcomes were compared between those who underwent early surgical AVR at the stage of moderate AS versus those who were followed without AVR at the outpatient clinic.

Results

Among a total of 257 patients with moderate AS and concomitant LV systolic dysfunction (70.0 ± 11.3 years, 63.4% of male), 34 patients received early AVR. Patients in the AVR group was younger than the observation group (64.2 ± 8.1 vs. 70.9 ± 11.5, respectively), and had a lower prevalence of hypertension and chronic kidney disease. During a mean of 3-year follow up, 112 patients (47.5%) died and the overall death rate was 15.367 per 100 person-year (PY). The AVR group showed a significantly lower rate of all-cause death than the observation group (5.241PY vs. 18.160PY, p-value = 0.002). After multivariable Cox proportional hazard regression adjusting for age, sex, comorbidities and laboratory data, early AVR at the stage of moderate AS significantly reduced the risk of all-cause death (hazard ratio [HR] 0.340, 95% confidence interval [CI] 0.117 - 0.985, p-value = 0.047). However, there was no risk reduction of cardiac death (HR 0.578 95% CI 0.150 - 2.231, p-value = 0.426).

Conclusions

In patients with moderate AS and LV systolic dysfunction, AVR reduces the risk of all-cause death. A prospective design study is warranted to confirm our findings in the near future.

Abstract P1274 Figure. Kaplan-Meier curves for deaths
P1306 A large cardiac mass of left sections in a young man
Authors: Scheggi V , Stefano P L , Alterini B
Published: January 2020

Background

Heart tumors are very rare lesions. Their prevalence is about 0.001 to 0.03 % in an autopsy series.

In most cases, primitive lesions are benign, with atrial myxomas that represent up to 2/3 of cases. Malignant neoplasms have a high mortality; sarcomas are the most frequent typologies. The most aggressive tumors are characterized by greater size, muscle invasion and pericardial effusion.

Clinical case

A 39-year-old man with recent history of worsening dyspnea went to the emergency room because of an aggravation of the symptoms.

An echocardiogram showed a large atrial inhomogeneous mass, adherent to the mitral ring and involving both left atrial and ventricle, causing a severe valvular stenosis, suggestive for malignancy. Thus the patient performed a cardiac-MRI, confirming the neoplasm localization with parietal infiltration, pericardial extension and effusion. A total-body CT scan ruled out metastasis. The patient underwent heart surgery and a partial excision was performed. Macroscopically the tumor had a scirrhous consistency and a diameter of about 5 cm. The histologic examination showed a high-grade sarcoma with fused cells and with condrosarcomatous areas.

Discussion

The study of heart massesincludes the execution of echocardiographies as first-line examinations, while the in-depth diagnostics (necessary in the anticipation of surgery) require cardiac-MRI or CT. Malignant lesions are characterized by an inomogeneous appearance, with a wide plant base and sizes larger than 5 cm, they are also able to take contrast medium during diagnostic examinations. High grade neoplasms are rapidly evolving with a very severe prognosis. The symptoms are essentially due to the localization and the mass bulk. In our case, its development on the mitral valve caused severe hemodynamic impairment, requiring immediate intervention. The treatment of these lesions is necessarily surgical. The only positive prognostic factor is a complete excision of neoplasm with free resection margins. As the diagnosis is often not early, chemotherapy or radiotherapy are often required after surgery.

Conclusion

Cardiac masses are rare entities and their evaluation may be a diagnostic challenge. Myxoma represent the most common primary cardiac neoplasm in adults, while about 25% of other primary ones are malignant. Our patient was suffering from a sarcoma, whose incomplete debulking made further therapies necessary. The correct interpretation of instrumental findings together with a possible radical surgery are mandatory for a successful therapeutic strategy.

Abstract P1306 Figure.
P1318 Clinical utility of global longitudinal strain in acute myocarditis: a case report
Authors: Lai Chin Kon D , Mcconnell O , Andrade I , Simpson A , Luckie M
Published: January 2020

The role of conventional 2D echocardiography in the setting of acute myocarditis is limited as often it reveals no significant changes in global systolic function. Published studies have demonstrated the usefulness of myocardial deformation imaging in acute myocarditis with global longitudinal strain (GLS) being more sensitive in the recognition of myocardial dysfunction even in preserved systolic function and its strong correlation to the amount of myocardial oedema found on cardiac MRI. It also has the advantage of being more readily available, requiring a shorter interpretation time and is significantly cheaper as compared to cardiac MRI. GLS has also been shown to play a role in risk stratification with a lower GLS being associated with a higher rate of major adverse cardiac events (MACE) among all myocarditis cases independent of LV ejection fraction.

We describe a case where there was strong correlation between GLS and myocardial oedema on CMR T1 weighted imaging. A 26 year old with no relevant past medical history presented to hospital complaining of pleuritic sounding chest pain. ECG showed ST segment changes suggestive of pericarditis. White blood cell count and troponin levels were elevated. Echocardiography performed on the same day showed apical akinesia and reduced longitudinal LV function. Global longitudinal strain was an average of -8% and was notably reduced in the apical, inferior, posterior and lateral regions. The overall left ventricular function was normal (55% by bi-plane Simpson"s method).

Cardiac MRI showed normal LV size and function with myocardial oedema in the mid inferolateral, apical inferior and apical anterior segments. These findings were consistent with acute myocarditis affecting the involved segments.

Our case demonstrates that the global longitudinal strain reduction correlated very similarly to the pattern of myocardial oedema in the affected segments and is consistent with similar findings from published studies. GLS by 2D speckled imaging may therefore play an important role in the assessment of acute myocarditis especially in patients with preserved ejection fraction and may help in risk stratification.

Abstract P1318 Figure. combined GLS CMR
P1325 Lymphoma encasing the heart: intra-cardiac or extra-cardiac mass?
Authors: Ahmad S , Lashein M , Khan W
Published: January 2020

A 70-year-old gentleman was referred to our department for atypical chest pains and night sweats. He had an unremarkable past medical history and denied any history of familial disease. There were no complaints of dyspnoea, dizziness or palpitations. A routine echocardiogram showed a suspicious right atrial mass, seemingly extra cardiac in origin. Clinical examination was entirely unremarkable and further investigations were arranged as a matter of urgency.

Contrast echocardiography confirmed a lesion wrapping around the right atrium with possible myocardial infiltration. Trans-oesophageal echocardiography showed extension of the mass into the adjacent atrioventricular groove. The appearances were of a compressive, non-vascular lesion measuring 4.8cm x 5.6cm. Overall cardiac systolic function remained preserved with no significant intra-cardiac abnormalities.

A CT Thorax with contrast was the next step in investigation. This demonstrated nodular soft tissue infiltration of the entire pericardium, mainly involving the right heart chambers with encasement of the aortic root and coronary arteries. Significant lymphadenopathy was also identified suggesting a malignant process.

Cardiac MRI was then performed and this substantiated the findings on CT, raising concern for encasement and external compression of the right coronary artery. Urgent transfer to a tertiary cardiac centre was arranged and subsequent biopsy confirmed histological diagnosis of Stage 4 Lymphoma. After a multi-disciplinary meeting, a non-operative approach was decided. Treatment with steroids and chemotherapy was commenced without delay leading to a significant reduction in the size of the mass.

Abstract P1325 Figure.
P1328 A bridge to sucess
Authors: Ranchordas S , Oliveira P , Madeira M , Marques M , Nolasco T , Aguiar C , Andrade M J , Sousa Uva M , Abecasis M , Neves J P
Published: January 2020

A 36-old-man was admitted in hospital with fever and cough, fatigue, rapidly progressive exertional dyspnoea and orthopnoea. Transthoracic echocardiogram (TTE) revealed a mildly dilated left ventricle (LV) with very low ejection fraction (EF), normally sized right chambers, severe right ventricular dysfunction, moderate tricuspid regurgitation and pulmonary artery systolic pressure (PASP) of 52mmHg. The diagnosis of myocarditis was suspected, and he was transferred to the ICU in our centre to proceed the diagnostic work up. Cardiac magnetic resonance showed a severely dilated LV with an EF of 13% and a transmural fibrotic scar on the lateral wall, without signs of myocardial oedema. There was an apical thrombus. Right ventricular EF was 25%. Coronary angiography showed thrombotic occlusion of the circumflex artery with delayed filling of marginal branches. Endomyocardial biopsy was performed but no myocardial lesion was seen. Temporary inotropic support was needed for low cardiac output. Optimized therapy for heart failure and anticoagulation were given and he received an implantable cardioverter defibrillator before discharge in NHYA class II. Two months later, he was re-admitted in his local hospital, complaining of cough with sputum, fever and shortness of breath. He was hypotensive, tachycardic and cyanotic. Blood workup revealed renal failure, coagulopathy and liver dysfunction with C-reactive protein of 10 mg/dL, but no leucocytosis. NT pro-BNP was 2459 pg/mL. Empirical antibiotics and inotropes were started. TTE revealed an EF of 10-15%, moderate functional mitral regurgitation, right ventricular dysfunction, moderate tricuspid regurgitation, and a PASP of 50 mmHg. He was transferred back to our centre. On admission, he was hemodynamically stable with perfusions of dobutamine and noradrenaline. Work up for inclusion in heart transplant waiting list was initiated. However, he deteriorated rapidly. It was decided to implant a biventricular assist device (BiVAD) for circulatory support as bridge to transplant. A short/medium term assist device was chosen as it was expected that a donor would be found in less than a month, and if this was not the case, it could be upgraded to a medium/long term device. Cannulas for LVAD were introduced on the LV apex and ascending aorta and for RVAD in the femoral vein and pulmonary artery. Good flows were achieved on both devices and there were no complications in the immediate post-operative period. He was extubated and weaned off inotropes on day 2. On day 9, a heart donor was found, and he was transplanted. No complications occurred in the post-operative period. He was discharged home on day 24, and resumed an active life.

This case illustrates the usefulness of temporary devices to bridge critically ill candidates to heart transplantation. Also, it emphasizes the importance of identifying patients who definitely need a BiVAD when end-stage heart failure involves both ventricles.

Abstract P1328 Figure.
P1339 Clinical masks of aortic aneurysm: staged rupture of an aortic aneurysm under the guise of a recurrent infection
Authors: Volkova A L , Bykov V A , Petrova E V , Grigoryev V A , Tyurin M Y U , Averkov O V , Mednikov G N , Baldin D G
Published: January 2020

A 63-year-old man was admitted to the medical intensive care unit because of hypotension and suspected sepsis. Two months before he was admitted to military hospital for cerebrovascular event, considered as transient ischemic attack. Few days after discharge the fever (with a temperature of 39.5°C) occurred and patient was readmitted to the same hospital. Empirical treatment with cefalosporine was inefficient. Only combination carbapenem and vancomycin after E.coli was verified in blood culture stopped the infection. With normal body temperature, normal leukocytes count, mild azotemia, sterile blood and urine cultures and diagnosis of treated urosepsis patient was discharged. Two echocardiogram during hospital stay found no abnormal findings and chest CT scan was also normal.

Seven days later, he was seen in our hospital because of fever (with a temperature of 40°C), severe sweating and arterial hypotension. Immediately fluids and norepinephrine infusion was started. Fluoroquinolone was chosen as an antibiotic.

There was complete LBBB on ECG that had been registered previously. Leucocyte count at admission was 14 x 109/l and creatinine 300 µmol/l. Transthoracic echo (TTE) reportedly showed evidence of mild aortic and mitral regurgitations, pericardial effusion (1.0 – 1.3 cm with signs of right atrium compression). Aortic root seemed quite normal. On the third day, the number of leukocytes and creatinine increased significantly, reaching 450 µmol/l and 41 x 109/l respectively. Chest CT scan revealed signs of bilateral pneumonia, pericardial and left-sided pleural effusions. Vancomycin and ceftriaxone intravenously were started. Transesophageal echo revealed degenerative changes of aortic valve with mild insufficiency, mild mitral regurgitation. The amount of fluid in the pericardium was approximately unchanged. Patient became normotensive and norepinephrine infusion was discontinued. On the 6th day after admission patient’s temperature became normal, level of creatinine decreased to 230 µkmol/l and leukocytes reached 11.4 x 109/l. On the same day, the patient"s condition worsened. He complained of mild heartburn and progressive weakness, the number of leukocytes and the activity of transaminases increased, his blood pressure dropped to 75/40 mm Hg. This has led to the resumption of norepinephrine infusion. Repeated CT scan revealed inhomogeneous contents in the pericardium. Repeated TTE found increase of pericardial effusion with heterogenous content and signs of cardiac tamponade. Patient was transferred to operating room. After pericardiotomy multiple blood clots and active bleeding from pseudoaneurysm of ascending aorta were found. Despite surgical attempts and massive transfusion, patient died. Autopsy revealed the rupture of pseudoaneurysm of ascending aorta and flat hematoma in pericardium.

Abstract P1339 Figure.
P1348 Impact of left ventricular ejection fraction and aortic valve sclerosis on cardiovascular outcome in patients with acute ischemic stroke
Authors: Kim M , Kim H L , Park K T , Lim W H , Seo J B , Kim S H , Kim M A , Zo J H
Published: January 2020

Background/Introduction

Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic marker in patients with acute ischemic stroke (AIS).

Purpose

Various echocardiographic parameters in the same patient were systemically evaluated for their prognostic significance in AIS.

Methods

A total of 900 patients with AIS who underwent transthoracic echocardiography (TTE) (72.6 ± 12.0 years and 60% male) were retrospectively reviewed. Composite events including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization were assessed during clinical follow-up.

Results

During a median follow-up of 3.3 years (interquartile range, 0.6-5.1 years), there were 151 (16.8%) composite events. Univariable analyses showed that low left ventricular ejection fraction (LVEF) (< 60%), increased peak tricuspid regurgitation (TR) velocity (> 2.8 m/s) and aortic valve (AV) sclerosis were associated with composite events (P < 0.05 for each). In the multivariable analyses after controlling for potential confounders, LVEF < 60% (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.30-2.77; P = 0.001) and AV sclerosis (HR, 1.56; 95% CI, 1.10-2.21; P = 0.013) were independent prognostic factors associated with composite events. Multivariable analysis showed that HR for composite events gradually increased according to LVEF and AV sclerosis: HR was 2.8-fold higher in the highest-risk group than in the lowest group (P = 0.001).

Conclusions

In patients with AIS, LVEF < 60% and the presence of AV sclerosis predicts the future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention

Abstract P1348 Figure. COX plot for composite event
P1351 Right ventricular diameter added to D-dimer independently influence on prognosis of patients with pulmonary embolism and intermediate risk
Authors: Bosevski M , Krstevski G , Gjorgievski A , Mitevska I , Jovanova S , Srbinovska Kostovska E
Published: January 2020

Purpose

The paper was aimed to determine predictors for of patients with pulmonary embolism (PE) and intermediate risk.

Methods

84 patients with PE from National registry on VTE (age 60.3 + 12.5 years) were selected in a prospective study. Bedside echocardiography was done in all of them. Pulmonary embolism was confirmed by CT angiography. They were stratified as intermediate risk pts due to simplified PESI score > 1. Study population was followed up for 6.7 months. Multivariate regression analysis was done when right ventricular diameter (RV, mean 37.5 mm), systolic pulmonary artery pressure (68 + 23 mmHg), measured by echocardiography, D-dimer level at baseline 2654.5 + 420,3ng/ml, number of comorbidities (2.4 + 0,7) and occurred symptoms (3.1 + 0,9) entered the model. A model was adjusted for age.

Results

D-dimer revealed as a predictor for length of hospitalization (β 0,25, p 0,05), and RV diameter as a factor for duration of anticoagulation (β 0,29, p 0,05).

Conclusion

Our results imply that baseline measurement of right ventricular diameter when added to D-dimer independently influence on short and long term prognosis of patients with pulmonary embolism and intermediate risk.
P1368 Effect of angiotensin receptor blocker in patients with moderate or severe aortic stenosis: a randomized controlled trial
Authors: Hwang I , Lee J M , Park J B , Yoon Y E , Lee S P , Kim H K , Kim Y J , Cho G Y , Park S J , Kim K H , Hong G R
Published: January 2020

Funding Acknowledgements

This study was supported by grants from Boryung Pharmacy Research Fund.

Background/Introduction: Pathophysiology of aortic stenosis (AS) and several previous studies suggested the potential role of angiotensin receptor blocker (ARB) in patients with AS.

Purpose

We aimed to investigate the effects of Fimasartan, an ARB, on exercise capacity and progression of AS in patients with moderate to severe AS.

Methods

We conducted a prospective, randomized, double-blind, placebo-controlled trial in 32 normotensive or controlled-hypertensive patients with moderate or severe AS. Study participants were randomized to Fimasartan 30 mg to 60 mg daily (n = 14) or placebo (n = 18) for 1 year, and underwent cardiopulmonary exercise test, 6-minute walk test, and echocardiography at 0, 6, and 12 months, with follow-up data available in 29 subjects.

Results

Significant reductions in blood pressures were observed in the Fimasartan group but not in the placebo group. Two of the 14 patients in the Fimasartan group withdrew the study due to mild symptoms probably related with the decreased blood pressure, and one patient decline the study protocol. After the 12-month treatment, the peak oxygen consumption (VO2; the primary outcome) in the Fimasartan group was significantly decreased (from 28.3 ± 5.9 to 25.4 ± 3.8 mL/min/kg, P = 0.021) but not in the placebo group (P for interaction = 0.046) (Figure 1A). The severity of AS showed a gradual progression in both groups, without inter-group differences (mean transaortic pressure; Fimasartan group, +4.0 ± 3.8 mmHg/year; placebo group, +5.3 ± 6.2 mmHg/year; P for interaction = 0.429) (Figure 1B). Parameters of left ventricular systolic and diastolic function did not change in both groups.

Conclusions

The use of ARB impaired exercise capacity in patients with moderate or severe AS, and did not prevent the progression of AS. However, due to the small number of participants, further studies are required to confirm these findings.

Abstract P1368 Figure.
P1381 The utility of left ventricle deformation in patients with myocarditis with midle-range and preserved ejection fraction
Authors: Krljanac G , Veljic I , Ristic A , Maksimovic R , Milinkovic I , Asanin M , Stanisavljevic D , Polovina M , Seferovic P M
Published: January 2020

Background

Predicting malignant ventricular arrhythmias and heart failure in patients (pts) with acute myocarditis and middle-range and preserved EF is challenge Aim: to define whether quantification of myocardial mechanics in early, acute phase of myocarditis offers more information to predict six months outcome of patients.Methods: In the 36 consecutive pts with myocarditis, middle age 32.86 ± 12.04yr, 75% males, echocardiography exam was done 1-3 day of diseases, including conventional parameters and comprehensive speckle tracking LV deformation analysis with longitudinal (L), circumferential (C) strain (S;%), strain rate (SR, 1/sec) and rotational LV mechanics. Results: The most patients were present as infarct-like myocarditis (80.56%), the others patients were present as heart failure-like (11.11%) and arrhythmia-like myocarditis (8.33%). At admission 27 (90%) pts had chest pain, 20 (66.7%) pts had ECG changes, 15 (50%) pts had symptoms of heart failure, 5 (16.7%) pts had arrhythmias. Amount of edema and fibrosis assessed by cardiovascular magnetic resonance (CMR) and echo correlate significantly. Classical and conventional parameters of LV systolic function, and deformation were not significantly different between groups. However, mechanical dispersion index (IMD) of global LS and systolic S were significantly different between groups (p < 0.05). Conclusion: Myocardial deformation imaging, like speckle tracking echocardiography, offers deeper insight into complex mechanical abnormalities during not only LV contraction but LV relaxation in longitudinal directions in patients with acute myocarditis.

Infarct-like Arrhythmia-like Heart failure-like p EF (%) 57.5 ± 5.42 54.7 ± 12.9 58.3 ± 6.8 NS GLS endo (%) -20.8 ± 2.59 -19.78 ± 2.27 -17.36 ± 5.65 NS GLS (mid (%) -18.31 ± 2.4 -17.31 ± 1.52 -15.3 ± 5.10 NS GLS epi (%) -16.15 ± 2.28 -15.20 ± 0.92 -13.55 ± 4.68 NS IMD LS (ms) 37.04 ± 7.71 33.04 ± 6.58 60.75 ± 38.56 0.008 CS endo (%) -26.39 ± 6.93 -21.59 ± 3.88 -25.17 ± 6.48 NS CS mid (%) -17.32 ± 6.77 -13.03 ± 2.07 -15.95 ± 4.41 NS CS epi (%) -10.99 ± 6.89 -7.13 ± 0.72 -9.53 ± 2.73 NS IMD CS (ms) 47.69 ± 8.86 41.43 ± 23.92 41.01 ± 20.51 NS IMD SL peak S* 12.27 (21) 13.96 (4) 20.28 (84) 0.042 *Median and range values are presented.
P1385 Mechanical dispersion of the right atrium in dilated cardiomyopathy: does the etiology matter?
Authors: Vijiiac A E , Iancovici S , Onciul S , Petre I , Zamfir D , Onut R , Stoian M , Dorobantu M
Published: January 2020

Funding Acknowledgements

This work was supported by CREDO Project - ID: 49182, financed through the SOP IEC -A2-0.2.2.1-2013-1 cofinanced by the ERDF

Background

Mechanical dispersion assessed by myocardial strain reflects a susceptibility for arrhythmia development. While the contractile heterogeneity of both ventricles has been assessed in different clinical settings, the incidence and significance of right atrial (RA) dyssynchrony in dilated cardiomyopathy (DCM) are unknown.

Methods

50 consecutive patients with DCM were divided in 2 groups according to the etiology: group I had 26 patients with ischemic DCM (68 ± 10 years, 23 men), group N had 24 patients with non-ischemic DCM (52 ± 12 years, 18 men). We assessed the RA strain by 2D speckle-tracking analysis, and we calculated RA mechanical dispersion as the standard deviation of the time-to-peak contraction strain in 6 RA segments. 20 healthy individuals served as controls. Data were compared between groups with one-way analysis of variance and using a post-hoc Bonferroni correction.

Results

The RA strain was reduced in DCM patients, both in group I and in group N. All three components of the RA strain were most reduced in group I (p < 0.001 for reservoir and conduit strain, p = 0.001 for contraction strain) (Table). The RA mechanical dispersion was highest in group I (56.8 ± 21.6 ms), followed by group N (39.9 ± 15.3 ms) and controls (23.8 ± 7.7 ms)(p < 0.001). Patients with DCM and documented supraventricular arrhythmias (either atrial fibrillation, atrial flutter or premature atrial contractions) had higher RA mechanical dispersion (57.5 ± 19.7 ms) than DCM patients with no documented atrial rhythm disturbances (44.9 ± 19.9 ms, p = 0.04).

Conclusion

Mechanical dispersion of the RA is pronounced in patients with DCM and it is higher in patients with documented supraventricular arrhythmias. Patients with ischemic DCM have a more pronounced mechanical dispersion of the RA than patients with non-ischemic DCM, reflecting a more heterogenous RA contraction in ischemic heart disease when compared to other forms of DCM. The prognostic significance of RA dyssynchrony in a disease primarily involving the left heart warrants further studies.

Group I Group N Controls P value Reservoir RA strain (%) 12.9 ± 7.4§ 17.6 ± 12.9§ 30.1 ± 9.9 <0.001 Conduit RA strain (%) -6 ± 5.5§ -8 ± 8.9§ -15.2 ± 6.4 <0.001 Contraction RA strain (%) 6.9 ± 6§ 9.6 ± 8.1 14.9 ± 6.1 0.001 RA mechanical dispersion (ms) 56.8 ± 21.6§ 39.±15.3§* 23.8 ± 7.7 <0.001 § significant difference with controls; * significant difference with group I