bluuebunny/crossref_metadata_2025 huggingface dataset:
C33 PERCUTANEOUS CLOSURE OF MITRAL PARAVALVULAR LEAK (PVL): WHEN REVERSAL MAKES ALL THE DIFFERENCE
Authors: Manca F , Cocco D , Siotto P , Melis M , Fele G , Corda M , Loi B
Published: May 2022

PVL is a complication associated with the implantation of a prosthetic valve. Since surgical re–intervention has a high operative risk, percutaneous closure (PC) has emerged due to its reduced invasiveness and the development of dedicated materials. We describe the case of a 66–year–old man with a mechanical oscillating disc mitral prosthesis who was admitted for acute heart failure. An echo showed a left ventricle with normal motion and a postero–medial mitral PVL with significant regurgitation. A transoesophageal echo confirmed the PVL in the 5 o’clock viewing portal with severe regurgitation. After optimising the medical therapy and with no change in echo findings, a cardiac catheterisation showed persistent post–capillary pulmonary hypertension, and therefore PC of the PVL was scheduled. Given the postero–medial location of the PVL, a transseptal puncture was performed using a 8.5 Fr Agilis introducer (Terumo) with telescoping system of a 6 r. JR4 catheter. The PVL was passed through with a Terumo 0.035 J–shaped guide, but without managing to advance the catheter beyond the leak. The guide was therefore advanced into the abdominal aorta and an arteriovenous circuit was created, which allowed the catheter to be advanced beyond the PVL and a closure device (AVPIII 14/5,Abbott St.Jude) was positioned with anterograde placement, with a distal disc on the ventricular side. Obliteration of the PVL, interference with the prosthetic disc and high transprosthetic gradients were observed despite several attempts to relocate the AVP, which was therefore removed. A second procedure was performed at a distance, creating a similar arteriovenous circuit by using a long introducer (110cm–Cook) which was advanced from the femoral artery beyond the leak in the opposite direction. An AVPIII (12/5) with a distal disc on the atrial side was positioned, this time with retrograde placement, with effective closure of the PVL and minimal residual regurgitation, without interference with the prosthesis. The course was free of complications; after one month the echo confirmed the result. Transcatheter closure of the PVL is a complex procedure, but relatively safe in experienced hands. This case is of particular interest due to the difficulty presented by the location of the PVL, which required measures of high technical complexity and because it describes a possible complication of the procedure, which was resolved by the simple reversal of the placement of the device.
C39 ECHOCARDIOGRAPHIC PREDICTORS OF MALIGNANT EVENTS IN ARRHYTHMIC MITRAL VALVE PROLAPSE POPULATION
Authors: Desalvo P , Vairo A , Piroli F , Gaiero L , Fioravanti F , De Lio F , Bellettini M , Montali N , Alunni G , Giustetto C , De Ferrari G
Published: May 2022

Background

Bileaflet mitral valve prolapse (bMVP) has been linked to major arrhythmic events and sudden cardiac death (SCD). Solid evidence of consistent predictors of SCD in this setting is still lacking. Echocardiography is the best tool for the analysis of ventricle mechanics and for the correlation with electrical myocardial activation. The aim of this study was to find new predictors of malignant events within an arrhythmic MVP population.

Methods

We conducted a retrospective comparative analysis, selecting 22 patients with bMVP with a high arrhythmic risk profile. 6 of them had a previous major arrhythmic event (5 aborted SCD, one cardiogenic syncope) and previously received ICD implantation (ICD–MVP), while 16 presented with a high arrhythmic burden without major events (A–MVP). All patients underwent transthoracic echocardiography in the last year. Each echocardiogram followed a specific protocol focused on mitral valve anatomy and ventricular contraction using 2D imaging, 3D imaging, tissue doppler imaging and speckle tracking analysis.

Results

ICD–MVP group, compared with A–MVP group, presented a longer anterior leaflet (AML) length (28,6 mm, IQR: 24,1–31,1 mm; vs 21,4 mm, IQR: 20,4–24,0 mm; p = 0,03), larger mitral valve annulus (MVA) indexed area (6,88 cm2/m2, IQR 6,27–7,87 cm2/m2 vs 5,44 cm2/m2, IQR: 4,93–6,15 cm2/m2, p = 0,02), lower MVA anteroposterior diameter/AML length ratio (1,24, IQR: 1,21–1,41 vs 1,50, IQR 1,32–1,62; p = 0,049), higher inferolateral basal S3 velocity (26 cm/s, IQR: 20,8–29,6 cm/s vs 14,2 cm/s, IQR 10,1–21,3 cm/s; p = 0,02) and a greater mechanical dispersion (MD) of the basal and mid–ventricular segments calculated with speckle tracking (128 ms, IQR: 125–131 ms; vs 58 ms, IQR 45–106 ms; p = 0,03). Mitral regurgitation grading, instead, did not correlate with malignant events. Best predictors of malignant events were AML length and MD of basal and mid–ventricular segments. Cut–off values with highest sensibility and specificity above 80% were 26 mm for AML length and 122 ms for MD of basal and mid–ventricular segments. Logistic bivariate regression confirmed AML length as an independent predictor of malignant events (p = 0,01), while MD of basal and mid–ventricular segments showed a trend toward significancy (p = 0,07).

Conclusion

Five parameters were found to be predictors of malignant events in a high–risk MVP population. AML length and MD of the basal and mid–ventricular segments presented the best predictive value.
C47 CORO–CT PLAQUE ANALYSIS IN ASSESSMENT OF CARDIOVASCULAR RISK
Authors: Montonati C , Pergola V , Dellino C , Continisio S , Mattesi G , Zolin A , Scarpa F , Storer V , Gentili A , Cabrelle G , Cattarin S , Motta R , De Conti G , Iliceto S , Mele D
Published: May 2022

Background

Computed tomographic (CT) coronary angiography represents a non–invasive approach to assess plaque characteristics that provides information to change treatment of coronary artery disease (CAD) and to asses risk stratification.

Purpose

Analyze the differences in plaque composition between patients with different plaque features: soft unstable plaques, hard stable plaques and no plaques; identify whether there is a relationship between the plaque density and the pericoronary fat attenuation index (pFAI). Materials and methods: 372 patients retrospectively analyzed who underwent CTCA for exclusion of CAD. They were divided into three groups: 37 (10%) patients with high attenuated plaques (> 60HU), 137 (37%)with low attenuated plaques (<29 HU and a volume of at least 15 mm3 and/or 30–59 HU with a volume greater than 52 mm3) and 198 (53%) patients without significant CAD. For each patients we collected clinical, radiological and follow–up data.

Results and Discussion

Low–attenuated plaques are significantly associated with older age, male sex, dyslipidemia and diabetes mellitus (p < 0.001). Higher values of pFAI were more present in patients with soft plaques than in those with stable plaques and without plaques (p = 0.005). It was also found that soft plaques were present in more CA segments compared to stable plaques. Overall volume of soft plaque appears greater than hard plaques and mainly localized in the anterior descendant coronary artery with higher stenosis values (p < 0.001). Presence of plaques with soft or high–risk features predisposes significantly and independently (p < 0.001) to a composite outcome (death, in–hospital admissions for percutaneous angioplasty or by–pass procedures) at the follow up.

Conclusions

Coronary plaque analysis showed a good correlation between high–risk plaques and pFAI, supporting the hypothesis that the presence of high–risk plaques can be correlated to inflammatory burden. Furthermore, the presence of high risk plaques predispose to death or hospitalization for coronary intervention.
C90 PRE–EXISTING CORONARY ARTERY DISEASE AMONG COVID–19 PATIENTS: A SYSTEMATIC REVIEW AND META–ANALYSIS
Authors: Zuin M , Rigatelli G , Bilato C , Ribichini F , Roncon L
Published: May 2022

Background

The prevalence and prognostic implications of coronary artery disease (CAD) in patients infected by the novel coronavirus 2019 (COVID–19) disease remain unclear.

Methods

We conducted a systematic review and meta–analysis to investigate the prevalence and mortality risk in COVID–19 patients with pre–existing CAD. We searched Medline and Scopus to locate all articles published up to December 8, 2021, reporting data of COVID–19 survivors and non–survivors with pre–existing CAD. Data were pooled using the Mantel–Haenszel random effects models with odds ratio (OR) as the effect measure with the related 95% confidence interval (CI).

Results

Thirty–eight studies including 27.435 patients [mean age 61.5 and 70.9 years] were analysed. The pooled prevalence of pre–existing CAD was 12.6% (95% CI: 11.2–16.5%, I2:95.6%), and resulted higher in ICU patients (17.5%, 95% CI: 11.9–25.1, I2: 88.4%) and in European cohorts (13.1%, 95% CI: 7.8–21.6%, p < 0.001, I2: 98.4%). COVID–19 patients with pre–existing CAD had a twofold risk of short–term mortality (OR 2.61, 95% CI 2.10–3.24, p < 0.001, I2=73.6%) (Figure 1); this risk was higher among Asian cohorts (OR: 2.66, 95% CI: 1.79–3.90, p < 0.001, I2: 77.3%) compared to European (OR: 2.44, 95% CI: 1.90–3.14, p < 0.001, I2:56.9%) and American (OR: 1.86, 95% CI: 1.41–2.44, p < 0.001, I2: 0%) populations (Figure 2). The association between CAD and poor short–term prognosis was influenced by age, prevalence of HT, DM and CKD.

Conclusions

Pre–existing CAD is present in approximately 1 in 10 patients hospitalised for COVID–19 and significantly associated with an increased risk of short–term mortality, which is influenced by age, HT, DM and CKD.
P5 ACCESSORY PATHWAYS HIGH–DENSITY MAPPING IN WOLFF–PARKINSON–WHITE SYNDROME
Authors: Conti M , Serra P , Befacchia G , Santarelli F , Benvenuto M , Fabiani D , Napoletano C
Published: May 2022

Wolff–Parkinson–White syndrome is a common condition characterized by atrioventricular accessory pathways (AP), which can be asymptomatic or can be responsible for atrioventricular reentrant tachycardia or rapid conduction of atrial fibrillation to the ventricles: for this reason, patients are referred for catheter ablation procedures. Although success rates of ablation are >95%, late recurrences can occur in 2–21% of cases mainly depending on the anatomical position. Current approaches remain suboptimal, and when failures occur, they may be due to technical difficulties such as poor contact or catheter stability, inability to access the target site as well as mapping errors resulting in inaccurate location of the AP itself. High–density mapping represents an alternative approach to mapping arrhythmias since the collection of a high density of points allows pathway conduction to be mapped more efficiently. The use of a new software called open–window mapping proved to be reliable in the localization of AP and therefore in the determination of the effective ablation site. A 41–year–old male patient was referred to our Centre following the ECG finding of manifest ventricular preexcitation and short–lasting paroxysmal palpitations. In the Electrophysiology Lab, the diagnostic catheters were inserted with the “fluoroless” technique using the EnSite Precision™ mapping system (Abbott): the ECG and the endocavitary electrograms were indicative of a right Parahissian accessory pathway. The mapping was performed with a multipolar catheter (Advisor™ HD Grid). Once the location of the pathway had been estimated, the roving acquisition interval (RAI) was set according to the expected position of atrial and ventricular electrogram. The RAI window was centered at this point and was opened in both directions (open window mapping) to fully include signals leading up to and traveling away from the AP. It accurately showed the location of the pathway just few millimeters from the Hissian potential. The baseline electrophysiological study revealed an effective antegrade refractory period (PREAP) of 320 msec. In isoproterenol, antegrade PREAP was reduced to 300 msec and inducibility of arrhythmias was not observed. Therefore, in consideration of the poor conductive properties and the non–inducibility of arrhythmias, as well as the anatomical site near the conduction system, it was decided not to proceed with the ablation due to the significant risk of atrio–ventricular block.
P8 TRANSVENOUS LEAD EXTRACTION AS LIFE–SAVING PROCEDURE IN SEPTIC SHOCK
Authors: Dentico A , Ferrieri A , Epicoco G , Troccoli R , Carretta F , D‘Agostino C , Carretta D
Published: May 2022

Introduction

With the increase of implant centers and the related procedures also increased the complications associated with the pacemakers and defibrillators implant. Transvenous lead extraction, saving procedure in presence of sepsis or septic shock, is the best therapy for leads’ infections because medical treatment alone is not effective to eradicating the infection.

Materials and Methods

In May 2021 was sent to our O.U. from the ER a 61–year–old patient for symptomatic Afib with rapid ventricular response. In 2014 the patient received an ICD implantation for obstructive hypertrophic cardiomyopathy, later found to be an amyloidosic infiltrative cardiomyopathy. The TEE reported EF 30%, thrombus filling left and right atrial appendage and vegetations all over the lead. Despite the patient was apyretic, laboratory tests showed neutrophilic leukocytosis and an increase in inflammation indices. The series of blood cultures were instead negative. However, for the occurrence of septic state, has been set up an antibiotic therapy and DOACs therapy on the advice of an infectious disease specialist. PET TAC confirmed an infection along leads. For a progressive clinical improvement, the patient started a cardiological rehabilitation cycle. Six days later, due to the onset of hyperpyressia and septic shock, the patient was intubated bacause of an acute respiratory failure and transferred urgently in intensive care. For the onset of MOF by sepsis on an endocarditic basis, has been indicated an extraction procedure.

Results

After performing the extraction procedure, it was found an immediate improvement of both the clinical conditions and laboratory parameters. In fact the next day it was possible to proceed to the extubation. Laboratory tests showed a progressive normalization of inflammation and leukocytosis indices; TEE confirmed the absence of vegetations and thrombotic material in the atrial appendage. The patient, apyretic, was sent to cardiological rehabilitation to complete the antibiotic–therapy cycle and, subsequently, at home with Life Vest. After cardiological revaluation and in absence of sepsis signs, the patient was re–implanted with a contralateral ICD.

Conclusions

In accordance with guidelines and literature, transvenous leads extraction constitutes, despite the potential risks associated with the procedure, the true resolutive therapy in device infections.
P20 CARDIOMIOPATHY INDUCED BY ATRIAL FIBRILLATION: WHAT’S BEHIND IT?
Authors: Ruffini S , Astegiano M , Pasquero M , Franco E , Moretti C
Published: May 2022

Sustained chronic tachyarrhythmias often cause a deterioration of cardiac function known as tachycardiomyopathy. We report the case of a 69 years old male patient, who was sent to the Emergency Department by his general practitioner for worsening dyspnoea and the discovery of previously unknown atrial fibrillation. His personal history included only arterial hypertension in treatment with ARBs, with no family or personal history of coronary artery disease. At a previous echocardiogram performed in 2019, systolic and diastolic functions were normal. The ECG confirmed the diagnosis of atrial fibrillation with rapid ventricular response, and blood chemistry showed a suppressed level of TSH (< 0,005 mcUI/ml), high FT3/FT4 (4.47 pg/ml/2.34 pg/ml) without any other alterations. A chest X–Ray was normal. The echocardiography evidenced a mildly dilated and hypertrophic left ventricle with severe, global systolic dysfunction, EF 25%, an enlargement of both atria, a mild mitral and tricuspid regurgitation and pulmonary artery mean systolic pressure of 35 mmHg. He was admitted to our Cardiology Department for further investigations. The patient was asymptomatic for dyspnoea at rest, only symptomatic with exertion and NYHA III, and hemodynamically stable. A coronarography excluded critical coronary stenosis. We made diagnosis of autoimmune Grave’s disease, with multiple not vascularized nodules at echography. In addition to betablockers and diuretics, an appropriate therapy for hyperthyroidism was prescribed, with an improvement of dyspnoea and a reduction of mean cardiac frequency. The patient was discharged with the indication to elective atrial cardioversion, only after thyroid function stabilization. In conclusion, we report a case of a severe systolic dysfunction in an atrial fibrillation induced cardiomyopathy, connected to an unknown thyrotoxicosis in Grave’s disease.
P22 USE OF THE LIFE–VEST IN PATIENTS WITH HIGH ARRHYTHMIC RISK: EXPERIENCE OF A SPOKE CENTER IN THE COVID–19 PERIOD
Authors: Corrado L , Sena L , Russo M , Colangelo G , Mazza A , Riccio G
Published: May 2022

Background

Patients with newly found dilated heart disease have a high risk of sudden death. During the COVID period, the follow–up of these patients was difficult due to the limitation of access to the hospital and the impossibility of performing tests with high decision–making power (cardiac MRI) at third–level hospitals.

Purpose

To evaluate the use of the Life–Vest in patients with newly found dilated heart disease as a protection system for early discharge and the related cost/benefit ratio in relation to an early ICD implant.

Methods

In the COVID period, a Life–Vest was applied to 18 patients with newly found dilated heart disease (4 post ischemic and 16 without coronary artery disease), to monitoring ventricular arrhythmias and to protect them against any life–threatening ventricular tachycardias. These patients showed an high arrhythmic risk for ventricular tachycardias, (VT found on monitoring) and an unfavorable echocardiographic aspect. Each week, the patient‘s telemetry was remotely viewed and a telephone assessment was performed for clinical conditions. A control echocardiogram was performed at 30 days to evaluate the FE and the possible continuation of monitoring.

Results

Of the 18 patients (mean age 59 years) analyzed, 5 (28%) underwent ICD implantation for persistent severe reduction in FE during 3 months after diagnosis and 13 (72%) normalized FE (duration average follow–up 50 days); there are no significant differences between the postischemic and non–postischemic DCM groups. The cost of renting the Life–Vest is about 4000 euros for 40 days and the average cost for an ICD implant, considering the device and the costs related to the days of hospitalization and use of human resources/advanced technological support, amounts to about 20700 euros. Considering these data, we observed a saving of approximately 261900 euros for 18 observed patients. To this saving must be added the costs related to the reduction of the days of hospitalization (average 5 days) and the costs to any future replacement of the ICD.

Conclusion

In patients with newly found dilated heart disease at high arrhythmic risk, the use of the Life–Vest reduces the days of hospitalization, allows patients to be discharged safely and generates substantial savings for the National Health System.
P50 IMPLEMENTATION OF PROTOCOLS FOR “ENHANCED RECOVERY AFTER CARDIAC SURGERY” IN AORTIC VALVE SURGERY
Authors: Alfonsi J , Berretta P , Malvindi P , Cefarelli M , D‘Alfonso A , Alessandroni E , Capestro F , Zingaro C , Di Eusanio M
Published: May 2022

Objective

Although, the use of protocols for “enhanced recovery after surgery” (ERAS) have been associated with improved results in different surgical disciplines, no data are available for EARS in cardiac surgery, thus far. In the late 2016 a mutlidisciplinary ERAS program to treat patients who require AVR was implemented in our institution. The aim of this study was to assess safety and 30 day outcomes in patients receiving ERAS management.

Methods

To improve multidisciplinary ERAS program, our mini–invasive approach (Fig. 1), that goes beyond a small incision, includes: (i) mini–surgical access (ministernotomy–minithoracotomy), to reduce the traumatic impact, postoperative pain and to increase patient’s satisfaction; (ii) minimal invasive extracorporeal circulation system, to improve end–organ protection and decrease systemic inflammatory response; (iii) ultra fast–track anaesthesia, to decrease the rate of postoperative complications and assure better and earlier recovery (Fig. 2).

Results

Between September 2016 and December 2021, 600 consecutive patients (mean age 72 years, Euroscore II 1,62%) underwent isolated mini–AVR in our institution. UFT anaesthesia was used in 195 patients (32.5%) and MiECC in 173 (28.8%). All patients received a timely rehabilitation therapy (3–6 hours after surgery) and an early family contact in ICU. At 30 days, the overall mortality and stroke rates were 0,3% (n = 2) and 0,5% (n = 3), respectively. Respiratory insufficiency occurred in 16 pts (2,5%). Median blood loss at 12 hours was 174,5 cc; blood transfusions were reduced to minimum intraoperatively and avoided in 66% of patients. Twenty three patients (3,8%) received definitive pacemaker implantation. The median ICU and in–hospital lengths of stay were 1 and 6 days, respectively.

Conclusions

Findings from our study confirms that mini–AVR yields excellent clinical outcomes with very low mortality and morbidity rates. The implementation of ERAS protocol in patients undergoing mini–AVR demonstrated to be safe and was associated with promising results. Thus, by reducing surgical injury and promoting faster recovery, ERAS management may further enhance minimally invasive interventions.
P62 LEFT ANTERIOR DESCENDING CACIFIED LESION IN A PATIENT WITH RECENT INFERIOR STEMI SUPPORTED WITH VENTRICULAR ASSISTANCE FROM IMPELLA 2.5, TREATED WITH ORBITAL ATHERECTOMY AND DRUG ELUTING STENT AND OPTIMIZED WITH IVUS CO–REGISTRATION
Authors: Forlani D , Di Marco M , D‘Alleva A , Magnano R , Pezzi L , Fulgenzi F , Verrengia E , Vitulli P , Corazzini A , Paloscia L
Published: May 2022

We present a case of a 65 years old patient with hypertension.He comes to our cath lab with an inferior STEMI treated with primary PCI of right coronary artery and we found a sub–occlusive and severly calcified lesion on proximal left anterior descending artery (LAD) and a diffused disease of its middle and distal portion (Fig 2). After collegial discussion on Heart Team we decided to proceed with a staged percutaneous revascularization on LAD. After an accurate planning we decided to proceed with a single femoral access a 14f femoral sheat was positioned on femorl artery, so we put the ventricular assistance catheter and then on the same sheat we put our 7 f guiding catheter to use only a single access for IMPELLA and for the guiding catheter (Fig. 1).The IVUS catheter doesn’t be able to cross the calcified lesion on LAD so we go on with a debulking using the orbital atherectomy of Diamond Back, with several passages antegrade and retrograde.At this point we are able to perform an IVUS Co–registration that demostrated also a critical lesion on ostial LAD.After multiple pre–dilatation to prepare the lesion we put three big drug eluting stent till 5 mm of diameter.The IVUS shows us a little malapposition so we proceed with a big non compliant balloon of 6mm with optimal result (Fig 3).In conclusion we go on with a reduction of ventricular assistance and final removal of IMPELLA catheter and closure of 14f vascular access with a single Pro–glide previously implanted.This procedure has some discussion points, first of all the possibility to treat a sub–occlusive lesion of an important non culprit artery after a few days of an acute coronary syndrome in safe mode with a ventricular assistance, that allowed us to work peacefully, being able to carry out all the maneuvers we considered appropriate (multiple balloon dilatations, IVUS evaluations, orbital atherectomy).An other point of discussion is the use of this new orbital atherectomy easy to use because with a single device,6f guiding catheter compatible, we are able to treat artery from 2.5 till 4mm only setting the rotational speed and removing not only the intraluminal calcium but also the deeper one and this allows a better stent expansion.The procedure is IVUS guided associated with angiographic images on Co–registration that allow us to obtain even more informations.The last comment is for the new stent Megatron, the only stent that are able to treat coronary artery till 6 mm.
P65 THE USE OF CPAP IN A HEMODYNAMICS ROOM ON A PATIENT UNDERGOING CORONARY PROCEDURE – SAFETY AND FEASIBILITY
Authors: Gribaudo M
Published: May 2022

Context of the Study

It’s not uncommon that patients who suffer from Acute Coronary Syndrome (ACS) also show respiratory failure from acute pulmonary edema. The need to treat these patients preemptively with an invasive approach is made harder by the difficulty of managing them in a hemodynamics room in a supine decubitus position. Therefore, the risk is that the procedure is delayed, or that it becomes necessary to proceed with an orotracheal intubation. Not much data is available on the use of non–invasive assisted ventilation with cPAP during revascularization in a hemodynamics room. In general, there is quite some distrust over both the hemodynamic effects of positive pressure and the managerial difficulties for the nursing staff.

Goal of the Study

To evaluate the safety and feasibility of the use of cPAP in patients with ACS and severe acute respiratory failure, radiological framework of acute pulmonary edema and severe hypoxemia, decubits semiortopnoic cumpolsory. Materials and methods Patients who suffer from ACS and acute pulmonary edema, undergoing urgent coronary catheterization with the use of cPAP in a hemodynamics room, with a “total face” mask. Description of the management by the nursing staff.

Results

27 patients were analyzed. For all patients, cPAP was positioned before the procedure and maintained at all times during the coronary interventional procedure. Never was necessary the intervention of a rianimator, nor was orotracheal intubation.

Conclusions

The use of cPAP, in a hemodynamics room, by the nursing staff, has been proven to be feasible and safe, and it might reduce the need for orotracheal intubation in patients suffering from ACS and acute pulmonary edema. Proposal for a multicentre study.
P70 ESPERIENZA CLINICA DELLE PRIME 41 PROCEDURE DI LITOTRISSIA INTRACORONARICA IN UN CATH–LAB ITALIANO
Authors: Barbero U , Pavani M , Moncalvo C , Ajassa M , De Benedictis M
Published: May 2022

Introduction

Stent under expansion is one of the main predictors of percutaneous coronary intervention (PCI) failure, being a trigger for both in–stent restenosis and stent thrombosis, with their obvious clinical impact. Among the main causes of stent failure, the presence of a severely calcified lesion is the most frequent and dangerous. Correct recognition and preparation of target lesion are therefore mandatory before stenting.

Methods

We enrolled all the patients treated with angioplasty and IVL (Shockwave Medical Inc, Santa Clara, USA) from October 2020 to October 2021 in our cath lab. Each patient signed informed consent.

Results

We enrolled 35 patients (with 41 lesions treated with IVL). Mean age was 73 years old, 29 were males (82%). Clinical characteristics are shown in the table. Twenty–one lesions (50%) were treated up–stream before stenting, 6 (16%) were bail–out IVL for inadequate stent expansion after post–dilation and 14 (37%) were in–stent restenosis with evidence of stent under–expansion because of the high burden of calcium. Fifty–four per cent of patients were treated in the context of Acute Coronary Syndrome (ACS). Seventy–three per cent of patient had three–vessel disease. The majority of procedure were done through radial access (74%) and 79% of the stenosis was prepared with NC balloons (at least 2.5 mm diameter) before deployment of the IVL balloon; in 2 case IVL was done after rotational atherectomy. Intravascular ultrasound (IVUS) guidance was used in in 15 pts. Two balloon were broken during lithotripsy. In 26 of 41 stenosis (63%) IVL delivery was obtained on a single wire, while 11 required buddy–wire (of whom 8 required child–in–mother technique to obtain adequate support for delivery). We had two major complications: 1 case of ventricular fibrillation (in a patients with recent myocardial infarction and severe reduction of ejection fraction, and 1 case of perforation at the time of inflation of the NC balloon after IVL easily treated with positioning of a covered stent which was easily delivered thanks to the previous IVL treatment).

Conclusion

IVL is a safe and all–around technique for treatment of severely calcified lesion in different clinical contexts from stable coronary artery disease to ACS, useful for upstream calcium treatment as well as bail–out stent optimization and correction of under expansion in calcified in–stent restenosis.
P87 MEDIASTINAL SYNDROME REVEALED HEART LOCALIZATION OF A PRIMARY MEDIASTINAL B–CELL LYMPHOMA
Authors: Branca E , Cicco S , Susca N , Longo L , Albanese F , Pappagallo F , Giliberti T , Morelli C , Dell‘Atti C , Ingravallo G , Prete M , Solimando A , Lauletta G , Vacca A , Ria R
Published: May 2022

Background

Primary mediastinal B–cell lymphoma (PMBCL) is an aggressive B–cell lymphoma that represents 2–3% of non –Hodgkin lymphoma cases and typically affects young adult Caucasian women. Diagnosis can be difficult and often need a multidisciplinary approach.

Case

a 75 year old female, with history of hypertension, came to ER for severe dyspnea. She complains also neck and left arm oedema. Blue swelling of face and trunk were described. Heart PoCUS was inconclusive, describing only a hypoechoic dilation of right atrium while the other three heart chambers were reduced in dimensions. Chest TC revealed a huge mediastinal mass next to a thrombosis of superior cava vein and right atrium (7 cm diameter) and a diffuse subsegmental pulmonary embolism. Arm and neck Lymphnodes were also enlarged . Low molecular weight heparin was given twice a day. Due the respiratory failure a high–flow nasal cannula oxygen treatment was performed. PET revealed FDG uptake in antero–superior mediastinum, but there was the same uptake in heart right atrium without a connection with the previous described. Therefore, this was no more considered as thrombus but as mass. The micro–bubble test revealed right to left shunt. She refused heart MRI. The patient was not suitable for an open–surgery biopsy, thus she was scheduled for a TC guided one, in order to obtain a pathological diagnosis for a suspected right atrium sarcoma. Due to the high risk we choose to perform the less invasive as possible way to have a histological sample. Thus, and intravascular biopsy of atrial mass by femoral vein was performed. The patient did not present any sequelae after procedure and she continued anticoagulation. The subsequent histological analysis revealed a PMBCL with a primary localization in Right atrium. Unfortunately, a sepsis by multiple resistant pseudomonas Aeruginosa and Aspergillus spp. arose and the patient died three weeks after biopsy.

Conclusion

A PMBCL is a rare and aggressive disease. Like in our patient, mediastinal syndrome is often associated to the disease. However, intracardiac localization are even rarer events. In large case series, less than 1% of intracardiac masses were lymphomas. In our patient, open–surgery was not suitable for multiple comorbidities. However, intravascular approach was less aggressive but effective to obtain enough tissue for diagnosis. Unfortunately, the immune suppression related to PMBCL and opportunistic infections drive a mortal sepsis.
P105 A MARBLE IN THE HEART: A MYSTERIOUS MITRAL MASS
Authors: Cosmi D , Buccolieri M , Capponi E , Di Pasquale T , Da Col U , Murrone A
Published: May 2022

A 70–year–old woman came to our observation for acute heart failure during atrial fibrillation with high ventricular response. In the medical history she presented a previous radiofrequency ablation of paroxysmal supraventricular tachycardia, a previous episode of atrial fibrillation treated with electrical cardioversion, two hospitalizations for transient ischemic attack (TIA), the last two months before hospitalization . The patient had always refused the introduction of oral anticoagulant therapy. The transthoracic echocardiogram showed a rounded formation, with regular margins, of 20x19 mm, isoechoic and poorly mobile, adhered to the atrial side of the annulus and the posterior mitral flap, confirmed by the transesophageal echocardiogram (Fig 1,2,3). The formation did not result in mitral obstruction or significant mitral regurgitation. The left atrium appeared markedly dilated, with moderate spontaneous echo inside. In the left appendage there was no thrombus, and there were no other relevant findings. Markers of inflammation and serial blood cultures taken during hospitalization were negative, so bacterial endocarditis appeared unlikely. Mixoma or fibroelastoma appeared to be the most likely diagnosis. In consideration of the high risk of embolization and to clarify the diagnosis, the patient underwent cardiac surgery with exeresis of the formation (Fig 4–5), subsequent quadrangular resection of the posterior mitral flap, sliding and mitral annuloplasty. Macroscopically, the mass appeared brownish–red, with a smooth surface, solid and compact consistency. The histological analysis showed red blood cells and platelets mixed with vessels and granulation tissue; the wall of the mass was made up of connective tissue. Based on the findings, the differential diagnosis was between a blood cyst or a native mitral valve thrombosis. Blood cysts are generally congenital and disappear spontaneously in childhood, rarely occurring in adults. They are fluid or semi–fluid formations, and ultrasonographically they appear as masses with anechoic or hypoechoic content, surrounded by a thin wall. Thrombosis on native mitral valve is also an infrequent event, but described in literature, particularly in the presence of hypercoagulative states, mitral stenosis, atrial fibrillation. Based on the characteristics of the mass, we believe that the most likely hypothesis is that of a rare case of thrombosis on a native mitral valve.
P118 THE ROLE OF PULMONARY ACT IN THE PATIENT WITH SARS–COV–2 INFECTION
Authors: Bava A , Zema D , Zito C , Benedetto F
Published: May 2022

Already from the first data in China it emerged that patients with cardiovascular comorbidities had an increased risk of contracting SARS–CoV–2 infection and a more unfavourable clinical course. From March to May 2020, 85 patients affected by COVID–19 were enrolled, hospitalized at the Hospital of Reggio Calabria. All patients underwent anamnesis, clinical evaluation, chest CT, ECG and measurement of markers of cardiovascular damage (Troponin I, CK–MB, LDH, D–dimer, BNP) and of inflammation (PCR, IL–6, and PCT). Thirty–one patients underwent echocardiography. In particular, we evaluated parietal dimensions and thicknesses, biventricular function and transvalvular tricuspid and pulmonary flows and correlated the data obtained with ECG, radiological, clinical, and biohumoral parameters. The aim of our study was to evaluate the prognostic impact of cardiovascular involvement in COVID– 19, investigating the effect of cardiovascular risk factors, levels of cardiovascular damage markers and newly emerging ECG and echocardiographic changes on a composite primary endpoint, consisting of the combination of death and the need for intensive care (ICU). The enrolled patients were divided into two subpopulations: those with better prognosis and those with poorer prognosis (ICU/exitus). We analysed the reciprocal correlation of each of the parameters and searched for the presence of echocardiographic signs of repercussion on the right sections of the pulmonary pathology. All markers of cardiovascular damage had significantly higher values in the most critically ill patients and similar behaviour had indices of inflammation. Patients with poorer prognosis had significantly lower lung AcT values, which correlated with higher D–dimer levels and more complicated hospital stays. There were no statistically significant differences between PAPs, right ventricular size, TAPSE and pulmonary trunk diameter in the two subpopulations. Larger right ventricular diameters were associated with more dilated lung trunks and higher IL–6 levels. The most interesting data of our study is the behaviour of pulmonary AcT: lower values of AcT were associated with higher levels of D–dimer, expression of a greater pulmonary microthrombotic burden, and a poorer prognosis, in the presence of PAPs normal. The dynamic analysis of this parameter, which is easy to calculate in the patient’s bed, can play a crucial role in the instrumental follow–up of patients hospitalized for SARS–CoV–2 infection.
P124 ECOCARDIOGRAPHIC DIAGNOSIS OF TYPE A AORTIC DISSECTION
Authors: D‘Agostino S , Gizzi G , Parato V
Published: May 2022

Clinical case

In August 2021, an 89–year–old woman with no previous cardiovascular history, suffering from systemic arterial hypertension under pharmacological treatment, dyslipidemia and M. di Parkinson came to our observation for syncopal episode. The clinical presentation was characterized by a syncopal episode in the absence of prodromes and reported chest pain upon awakening. At the time of arrival in PS the patient was alert, attentive, and oriented, asymptomatic, hemodynamically stable with PAS 90 mmHg, with normo–iso–sphygmic peripheral pulses. A cardiological evaluation was requested and the transthoracic echocardiography revealed dissection of the proximal ascending aorta with evidence of intimal flap starting from the aortic root and extending to the proximal tract of the aortic arch, moderate aortic valve insufficiency and moderate circumferential pericardial effusion (2 cm), with the presence of blood clots, in the absence of signs of hemodynamic compromise. CT angiography confirmed Stanford type A aortic dissection with intimal flap originating in the supravalvular site (maximum diameter 6 cm), longitudinally extended for about 6 cm at the level of the ascending aorta until the emergence of the epiaortic vessels which were not involved. Consequently, cardiac surgery teleconsultation was required which, based on the patient‘s advanced age, did not allow surgical treatment due to a prohibitive operative risk, considered comparable to the natural course of the disease. The patient was then admitted to intensive care where remained asymptomatic and in cardio–circulatory compensation until death occurred on the third day due to cardio–circulatory arrest from PEA.

Conclusions

Aortic dissection is a high–mortality condition that requires an immediate diagnostic–therapeutic approach. In the diagnostic process, transthoracic echocardiography represents the most promptly performed examination and not infrequently allows the diagnosis before radiological confirmation by angioTC.
P160 RIGHT SISTEMIC VENTRICLE AND PREGNANCY
Authors: Urru M , Orrù L , Stara R , Congia M , Marini E , Scano F , Campagnolo A , Marini A , Montis S , Tumbarello R
Published: May 2022

Patient with complex congenital heart disease: situs inversus with dextrocardia and transposition of the great vessels (D–TGA), right aortic arch and inferior cava agenesis with azygos continuation; at 4 months Mustard atrial switch (intratrial baffle for redirection of the systemic venous circulation in the left subpulmonary left ventricle and of the pulmonary venous circulation in the right subaortic systemic ventricle). At 22 years, 1st pregnancy without complications, caesarean section, birth weight 2.2 kg. Two pregnancies spontaneously terminated in the firts trimester. At 29 years echocardiography: right systemic ventricle hypertrophic, dilated and slightly hypokinetic with tricuspid (systemic) valve with mild to moderate insufficiency; Mustard circuit normally functioning on the systemic side, mild stenosis of the pulmonary buffle (Gmax 6mmHg). At 33 years monochorionic biamniotic twins pregnancy; the risk linked to pregnancy for the patient on the basis of her heart disease was included in a WHO class III worsened by twinning. Because of the high probability of maternal and fetal complications related to the continuation of pregnancy, it was necessary to recommend a selective interruption of the pregnancy of the fetus affected by severe selective underdevelopment with signs of twin to twin transfusion at the 20th week of gestation. Maternal clinical and haemodynamic conditions have been stable during pregnancy. At the 24th week of gestation echocardiography: worsening of the systemic right function ventricle, moderate tricuspid insufficiency and increased gradients in the Mustard circuit (systemic Gmax 13mmHg and pulmonary venous Gmed 8mmHg). After the pregnancy team‘s discussion, a delivery plan was proposed to transfer the patient to a third level cardiac surgery center with experience in congenital heart disease adult between the 35th and 36th week. This was not possible because the patient at 32th week presented preterm labor with caesarean section without maternal and newborn complications (birth weight 1,650 kg). In the puerperium ehocardiography: hypertrophic, dilated and moderately hypokinetic systemic right ventricle with moderate tricuspid insufficiency; Mustard circuit: systemic baffle max gradient 16mmHg and pulmonary venous medium gradient 9mmHg. 7 years after this pregnancy at the last visit: stable clinical and echocardiographic situation with persistence of moderate dysfunction of the systemic right ventricle.
P175 ELECTROCARDIOGRAPHIC ELEMENTS ASSOCIATED WITH ARRHYTHMIC RISK IN BRUGADA SYNDROME
Authors: Berloni M , Di Domenico A , De Carolis B , Canovi L , Vitali F , Bertini M , Guardigli G , Balla C
Published: May 2022

Introduction

Brugada syndrome is an inherited disease characterized by an increased arrhythmic risk and sudden death. The type 1 ECG pattern is the only standard required to make a diagnosis but the stratification of arrhythmic risk remains a controversial element. Some electrocardiographic signs have been described as associated with an increased arrhythmic risk. We present a case of Brugada Syndrome in which different electrocardiographic elements of incremental risk could have predicted the later evolution of the clinical case.

Clinical Case

A 68–year–old male patient with family history of sudden cardiac death (brother 51aa) and occasional finding of Brugada type 1 ECG pattern (2009), implanted with Medtronic bicameral ICD device in primary prevention. The electrocardiogram shows type 1 Brugada pattern in the right precordials with characteristic ST–elevation, followed by a concave ST segment, one of the signs of association with an increased arrhythmic risk; first–degree AV block with a long PR (323 msec) associated with the presence of the SCN5A mutation and an increased risk of arrhythmic events and sudden cardiac death; in the end a fragmented QRS in V2 with extended duration (153 ms). At the next follow–up the patient had some episodes of arrhythmic storm, effectively treated by the device; in consideration of the arrhythmic burden, he was subjected to epicardial ablation and was also subjected to genetic analysis that was positive for pathological mutation on the SCN5A gene (SCN5A ex 22: c.3929C>T;p.Pro1310Leu).

Conclusions

Brugada Syndrome can be diagnosed from the type 1 ECG pattern, but the current risk stratification score remains a controversial element. Electrocardiographic signs of malignancy can contribute to create a multiparametric evaluation of the patient in order to predict future arrhythmic events. Fig 1. ECG: RS 74 bpm, first–degree AV block (PR 323 msec), BFA, Brugada type 1 pattern (QRS 153 ms), fragmented QRS in V2. Fig. 2 Family tree.
P186 PROLONGED ASYSTOLIA REQUIRING CRP ON THERAPY WITH TICAGRELOR AND CYCLOSPORINE
Authors: Stucchi M , Lazzarotti M , Sacchi R , Cirò A
Published: May 2022

64–year–old man, from SriLanka, affected by arterial hypertension, complicated diabetes mellitus (retinopathy, vasculopathy, peripheral neuropathy) and chronic kidney injury in hemodialysis. Liver transplantation for hepatocarcinoma due to alcholic cirrhosis required cyclosporine as immunosuppressive agent. He also suffered from chronic multifactorial anemia and mild thrombocytopenia. Home therapy included atenolol 50mg, clonidine, lercanidipine, insulin, kayexalate, cyclosporine. He was admitted in ED for a chest pain during hemodialysis, associated with high blood pressure values and lateral ST–depression on ECG. Iv nitroglycerin relieved symtoms and normalized the repolarization. Echocardiogram showed a concentric ventricular hypertrophy, without wall motion changes or significant valvulopathy. Laboratory tests detected the known anemia, thrombocytopenia (Hb 9.6g/dl, PLT 100x109/L) and renal injury (creat 10mg/dl, K + 5.1mmol/L) with a stable rise of troponin T hs 80pg/ml (n.v.<14). Aspirin and ticagrelor 180mg were administered and Patient admitted for unstable angina. Coronary angiography (femoral approach) was performed and revealed a critical stenosis of proximal IVA with subocclusion of diagonal branch; no other significant lesion was detected. Coronary artery disease was effectively treated by PCI with 2 DES. During the 2nd day of hospitalization an asystolia up to 10” occurred and atenolol was stopped. The next day, he had a new diurnal sinus arrest, lasting about 40”; external pacing had no efficacy. After CPR, he had a ROSC with recovery of sinus rhythm. No electrolyte alteration or ischemic recurrences. Aminophylline was started and ticagrelor was suspended for possible side effect enhanced by interaction with cyclosporine; shift to clopidogrel was made. No recurrence of rhythm alteration occurred neither after aminophylline interruption at 72 hours nor after reintroduction of beta–blocker on the 8th day for sinus tachycardia. Cyclosporinemia was mildly elevated. It’s known that ticagrelor is associated with a higher incidence of bradyarrhythmias mediated by increase in adenosine concentration, but these are mainly asymptomatic and nocturnal. Cyclosporine– ticagrelor interaction, through inhibition of cytochrome P450 (CYP3A4) and P–gp, increased the concentration of ticagrelor and promoted its side effect: in our case prolonged episodes of asystolia requiring CPR, solved by drug withdrawal and aminophylline with target on adenosine receptors.