bluuebunny/crossref_metadata_2025 huggingface dataset:
722 NATURAL ACTIVATORS OF AUTOPHAGY PROTECT THE HEART FROM DOX-INDUCED CARDIOMYOPATHY
Authors: Schirone Leonardo , Vecchio Daniele , Forte Maurizio , Sciarretta Sebastiano
Published: December 2022

Introduction

Heart failure is a frequent death cause for oncological patients who received treatment with doxorubicin (DOX). DOX administration inhibits autophagy in cardiomyocytes and causes myocardial damage. Natural activators of autophagy (NAA) such as trehalose, a natural disaccharide, and spermidine, a putrescine-derived polyamine initially isolated from semen, were previously found to be promising candidates to recover the autophagic flux and treat cardiovascular diseases in mice.

Hypothesis

The administration of natural activators of autophagy protects the heart from DOX-induced myocardial injury.

Methods

C57BL/6J WT mice were fed ad libitum with trehalose or spermidine in drinking water and received 3 weekly injections of DOX, reaching a final cumulative dose of 15 mg/kg. Echocardiographic, histological and biochemical analyses were performed 6 weeks after the first administration of DOX. Also, in vitro experimentation was performed on neonatal rat primary cardiomyocytes.

Results

Mice treated with DOX had reduced systolic function (FS: 44±1.05% vs. 34.1±2.33%, n=6-8), but trehalose administration preserved left ventricular fractional shortening (FS: 34.1 [Office1]±2.33% vs. 45.1±0.75%, n=6-8). Autophagy-deficient Beclin1+/- mice had reduced FS and were not protected by trehalose administration (35.4±2.48% vs. 45.1±0.75%, n=7-8). Mice treated with DOX developed fibrosis (0.1±0.08% vs. 8.6±3.5%, n=5), but this effect was reduced in trehalose-fed mice that received DOX (8.6±3.5% vs. 2±0.68%, n=4-5). DOX administration increased the levels of damaged-mitochondria disposal (2.6±0.74 vs. 9.4±1.7 mitophagic bodies per TEM field, n=13) and trehalose administration further boosted this effect (9.4±1.7 vs. 24.1±1.45, n=13).

The mRFP-eGFP-Lc3-dots assay was used for evaluating the autophagic flux in neonatal primary cardiomyocytes and a reduction of autophagy was observed in cells treated with DOX (51.9±4.57 vs. 29.9±3.52 red dots per cell, n=34-51), while trehalose recovered the autophagic flux (29.9±3.52 vs. 121.5±8.02 red dots per cell, n=33-34). Mitochondrial biogenesis reporter ‘MitoTimer’ mice that received DOX showed increased levels of biogenesis (0.8±0.38 vs. 3.3±0.9, n=5-6), while mice receiving DOX and trehalose did not (3.3±0.9 vs. 0.3±0.12, n=5-6). Similarly, spermidine preserved systolic function (FS: 29.4±2.03 vs. 39±3.22, n=5-6) and increased myocardial autophagy.

Conclusion

NAA-mediated mitophagy induction protects the heart from developing DOX-induced cardiomyopathy by disposing of damaged mitochondria.

[Office1]Le virgole diventano punti
821 DAPAGLIFOZIN ON LEFT VENTRICULAR DIASTOLIC FUNCTION IN PATIENTS WITH CHRONIC HEART FAILURE AND WITHOUT DIABETIC MELLITUS.
Authors: Lamaida Norman , Cerciello Antonio
Published: December 2022

Background

:Heart failure (HF) with reduced ejection fraction (HFrEF) remains a challenging problem due to its high mortality rate. Another novelty in HF therapy is dapagliflozin, a sodium–glucose transporter–2 inhibitor (SGLT2i) which decreased the rates of cardiac death and worsening of HF in the DAPA–HF trial, when added in other guideline recommended therapy.

Material and Methods

A prospective cohort study of 30 symptomatic HF patients with EF < 35% (aged 65 610 years) (20 males and 10 females) was conducted. The patients of NYHA classification II–III, previously treated with ARNI, b– blocker, and mineralocorticoid receptor antagonists (MRA) were included. Dapagliflozin 10 mg was added as a novel therapy of HF patients. Clinical examination and complete echocardiographic evaluation were performed at baseline and 30 days after the addition of SGLT2i to their treatment. 2D echocardiography and Doppler measurements were used for the evaluation of left ventricular function, and more specifically, peak early (E–wave) and late (A–wave) transmitral filling velocities and their ratio E/A, deceleration time of E velocity (DTE). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected.

Results

After 30 days of therapy with dapagliflozin, blood pressure was reduced significantly and the echocardiographic parameters of diastolic function were improved. More specifically, after 6.163.6 months of treatment E/A ratio decreased from 1.7 61.5 to 1.0160.70 (P < 0.05), the E/Ea ratio decreased from 13.56 6.3 vs. 10.26 5.2 (P < 0.05), tricuspid regurgitation peak velocity decreased from 3.060.4 to 2.46 0.5m/s (P ¼ 0.03) and left atrial volume decreased from 53 629.3 to 40.3611.5ml/m2 (P < 0.05). Subsequently, both left–ventricular diastolic function and filling pressure improved significantly (P < 0.05,).

Conclusions

Our data support the evidence that SGLT2i ameliorate echocardiographic indexes of diastolic function. The ratio of early diastolic transmitral flow velocity seems to correlate well with LV filling pressures, and may be use das a prognostic tool in patients with HFrEF. We have to emphasize that the diastolic function improvement may be considered an early marker.
852 DAPAGLIFOZIN IN PATIENTS WITH CARDIAC HEART FAILURE
Authors: Lamaida Norman , Cerciello Antonio
Published: December 2022

Dapaglifozin on diastolic function in patients with type 2 diabetic mellitus and chronic heart failure

Heart failure (HF) with reduced ejection fraction (HFrEF) remains a challenging problem due to its high mortality rate. Another novelty in HF therapy is dapagliflozin, a sodium-glucose transporter-2 inhibitor (SGLT2i) which decreased the rates of cardiac death and worsening of HF in the DAPA-HF trial, when added in other guideline recommended therapy.

Material and methods

A prospective cohort study of 30 symptomatic HF patients with EF < 35% (aged 65 ±10 years) (20 males and 10 females) was conducted. Diabetic (2TDM) patients of NYHA status II–III, previously treated with ARNI, β-blocker, and mineralocorticoid receptor antagonists (MRA) were included. Dapagliflozin 10 mg was added as an adjunct therapy for 2TDM but also as a novel therapy of HF in diabetic patients. Clinical examination and complete echocardiographic evaluation were performed at baseline and 30 days after the addition of SGLT2i to their treatment. 2D echocardiography and Doppler measurements were used for the evaluation of left ventricular function, and more specifically, peak early (E-wave) and late (A-wave) transmitral filling velocities and their ratio E/A, deceleration time of E velocity (DTE). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected.

Results

After 30 days of therapy with dapagliflozin, blood pressure was reduced significantly and the echocardiographic parameters of diastolic function were improved. More specifically, after 6.1±3.6 months of treatment E/A ratio decreased from 1.7 ±1.5 to 1.01±0.70 (P <0.05), the E/Ea ratio decreased from 13.5± 6.3 vs. 10.2± 5.2 (P <0.05), tricuspid regurgitation peak velocity decreased from 3.0±0.4 to 2.4± 0.5m/s (P =0.03) and left atrial volume decreased from 53 ±29.3 to 40.3±11.5ml/m2 (P <0.05). Subsequently, both left-ventricular diastolic function and filling pressure improved significantly (P <0.05,).

Discussion

Our data support the evidence that SGLT2i ameliorate both the conventional echocardiographic indexes of diastolic function and this effect is noted quite promptly. The ratio of early diastolic transmitral flow velocity seems to correlate well with LV filling pressures, and may be use das a prognostic tool in patients with HFrEF. We have to emphasize that the diastolic function improvement was observed 30 days after the initiation of dapagliflozin treatment, and thus it may be considered an early marker of improvement and adequacy of treatment apart from BNP.

Conclusions

in this study classical diastolic echocardiographic parameters were improved promptly after initiation of dapagliflozin therapy. The ratio of early diastolic transmitral flow velocity at the early filling phase of diastole (E/SRE) may be considered a reliable index of HF therapy responders.
682 UNEXPECTED TRIGLYCERIDES-LOWERING EFFECT OF A NOVEL NUTRACEUTICAL COMPOUND FOR IBS
Authors: Natale Francesco , Loffredo Francesco , Molinari Riccardo , Covino Simona , Alfieri Roberta , Altobelli Ippolita , Pezzullo Enrica , Cimmino Giovanni
Published: December 2022

Background

In the last few years the role of gut microbiome in human health has been reported. Growing evidence indicate that it is linked to intestinatal diseases, such as the irritable bowel syndrome (IBS), and atherosclerotic disorders. The effect on lipid metabolism seems to be one of the potential mechanisms by which gut microbiome might favour the atherosclerotic process. IBS is a functional bowel disorder defined by the presence of recurrent episodes of abdominal pain associated with altered bowel habits. The severity of psychological and gastrointestinal symptoms in IBS has been linked with a distinct intestinal microbiota signature. In this retrospective study the effect of a novel nutraceutical compound, namely Triobiotix, on gastrointestinal symptoms in IBS patients has been evaluated. Effects on lipid profile have bee also recorded.

Methods

Triobiotix is a nutraceutical consisting of: Maltodextrin; mineralized extract of Lithothamnion (Lithothamnion calcareum (Pallas) Areschoug, thallus dry extract); Bioecolians® gluco-oligosaccharides; Ferment mix (corn starch, Bifidobacterium animalis ssp. Lactis BLC1 (DSM 17741), Lactobacillus acidophilus LA3 (DSM 17742), Lactobacillus rhamnosus IMC 501 (DSM 16104), Lactobacillus paracasei Streptococc5 501 IMC102 SP4 (DSM 19385); short-chain fructo-oligosaccharides powder. The database of 40 Italian General Practitioners (GPs) were analyzed. At total of 587 patients with IBS and on Triobiotix were identified. Of these in only 535, a complete first and second control data was available. The primary endpoint of these analysis was to assess whether Triobiotix resulted in a reduction in pain and meteorism, thus resulting in a lesser intensity of the main gastrointestinal symptoms. Secondary endpoints were to look for significative changes in lab values of total cholesterol, triglycerides levels and glycaemia.

Results

Treatment with Triobiotix for four weeks resulted in a reduction in the frequency and intensity of bloating, abdominal pain, and tenesmus. Unexpectedly, at the T1 control, mean cholesterol values were significatively reduced compared to the T0 evaluation. Triglycerides levels were also significantly decreased (186.37±66.4 vs. 176.13±67.9; p < 0.05).

Conclusions

Our analysis showed an unexpected effect of this combination of micronutrients on lipid profile beyond IBS symptoms. However, further studies are needed to confirm this evidence and to evaluate the particular compound responsible of this effect. A goal of LDL-C less of 115mg/dL is desirable for patients at low to moderate CVR, a significative portion of population is far from this target. The discovery of novel micronutrients combinations with cholesterol lowering effects could be of great importance for the management of patients with low-moderate dyslipidaemia.
562 ACQUIRED CORONARY FISTULA IN A PATIENT WITH CONGENITAL AORTIC STENOSIS TREATED WITH PERCUTANEOUS VALVULOPLASTY
Authors: Calvelli Pierangelo , Bianco Francesco , Mancuso Cinzia , Pasceri Eugenia , Canepa Annalisa , Mascaro Giuseppina , Indolfi Ciro , Aquila Iolanda
Published: December 2022

Introduction

coronary fistulas are abnormal communications between coronary arteries and an adjacent structure (vessel or cardiac chamber). They can be congenital or acquired and have traumatic, spontaneous or iatrogenic origin.

Aim

we report the case of a coronaro-cameral fistula in an asymptomatic 23-year-old male, with a congenital aortic stenosis treated with two percutaneous valvuloplasties in the first year of life, who was evaluated in our Division of Cardiology.

Methods

transthoracic echocardiography and angio-CT with 3D reconstructions were performed.

Results

echocardiography showed a dilated ventricle with ipertrabeculated aspect and a mildly reduced ejection fraction (47% Simpson), a moderate mitral regurgitation, a moderate/severe aortic insufficiency (PHT 242 ms) and a moderate aortic stenosis (valvular area 1.1 cm2; Gr max/mid 98/61 mmHg). In parasternal long axis view we appreciated a non-echogenic space between the aortic root and the right ventricle, communicating with left ventricular cavity. Angio-CT allowed us to appreciate a fistula connecting left ventricular outflow tract and right coronary artery, which was markedly dilated and tortuous. Surgical correction was deemed necessary for the patient, because of the severity of coronary dilatation and aortic and ventricular disfunction.

Conclusions

acquired fistulas are rare findings which can complicate surgical and non-surgical interventions. They are more often right-sided, but left fistulas have also been described. Integrated imaging is particularly useful for correct definition of anatomy and for surgical planning.
394 PROGNOSTIC POWER OF A NEW INDEX OF RIGHT VENTRICLE-PULMONARY ARTERY COUPLING BASED ON RIGHT VENTRICULAR VOLUMES IN PATIENTS WITH SECONDARY TRICUSPID REGURGITATION
Authors: Cascella Andrea , Gavazzoni Mara , Muraru Denisa , Heilbron Francesca , Caravita Sergio , Tomaselli Michele , Parati Gianfranco , Badano Luigi Paolo
Published: December 2022

Background

Echocardiographic surrogates of right ventricle (RV) to pulmonary artery (PA) coupling have been reported to be associated with outcomes in secondary tricuspid regurgitation (STR). However, pulmonary artery systolic pressure (PASP) is difficult to be estimated using echocardiography in patients with severe STR and 3D-derived indexes are loading dependent.

Objectives

To evaluate the predictive power of a new surrogate of RV-PA coupling obtained using RV volumes measured by three-dimensional echocardiography (3DE), accounting for regurgitant volume of STR.

Methods

Patients with moderate or severe STR were enrolled. The primary outcome was the composite endpoint of death from any cause and heart failure hospitalization.

Results

180 patients were included with a median follow up of 24 months (IQR: 2-48); 72 patients (40%) reached the primary endpoint. Among the tested RV-PA coupling indexes, the ratio between (RV stroke volume [SV]-regurgitant volume)/ RV End-systolic volume (ESV) (i.e. RV forward SV/ESV) showed the highest predictive power of the combined endpoint (AUC 0.85 [IC 95% 0.78-0.93]), with a threshold value of 0.40. It was followed by RV ejection fraction/PASP (AUC 0.75 [IC 95% 0.67-0.84]), and TAPSE/PASP (AUC 0.76 [IC 95% 0.68-0.85]). Severe TR (HR 2.04 [CI 95%: 1.10-3.78], p=0.02), TAPSE/PASP <0.36 mm/mmHg (HR 2.39 [CI 95%: 1.26-4.54], p=0.01), and RV forward SV/ESV <0.40 (HR 5.45 [CI 95% 2.47-12.00], p<0.001) were independently associated with the combined endpoint.

Conclusions

RV forward SV/ESV is able to stratify the risk of death and HF hospitalization in patients with STR when added to TR severity, RV ejection fraction and TAPSE/PASP
363 TRICUSPID ANNULUS DISJUNCTION: THE MISSING PIECE IN THE ARRHYTHMIC MITRAL VALVE PROLAPSE?
Authors: Cecere Annagrazia , Cipriani Alberto , De Lazzari Manuel , Graziano Francesca , Brunetti Giulia , Conti Giorgio De , Motta Raffaella , Iliceto Sabino , Marra Martina Perazzolo
Published: December 2022

Background

Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis, due to an excessive myocardial stretch on the LV basal-mid inferolateral wall. Mitral annulus disjunction (MAD) and curling are common findings in arrhythmic MVP patients, thus representing the excessive traction of mitral apparatus on myocardium. Cardiac magnetic resonance (CMR) demonstrated to clearly identify these typical morpho-functional alterations, as well as LV fibrosis, in MVP patients. The involvement of right-sided annulus disease recently emerged as an interesting missing piece in the natural history of MVP patients. However, its role in a population of arrhythmic MVP patients in absence of significant mitral regurgitation (MR) has not been evaluated.

Purpose

The primary aim of the study was to evaluate the prevalence and the role of tricuspid annulus disjunction (TAD) in the arrhythmic MVP patients. Secondly, we evaluated the role of TAD in the prevalence and severity of the common morpho-functional alterations of MVP, MAD and curling.

Methods

Consecutive MVP patients with normal systolic function and without significant MR, referred for palpitations, were enrolled. Morpho-biventricular evaluations, including MAD and curling assessment, as well as LV fibrosis were evaluated using CMR.

Results

66 patients met the inclusion criteria (29% male, median age 44 years). TAD was identified in 22 MVP patients (27% male, median age 52 years). No differences for ventricular arrhythmias (p: 0.459) between MVP patients without (n: 44) and with TAD (n: 22) were identified. MVP patients with TAD were older (52 vs 42 years, p: 0.009) and presented reduced biventricular end-diastolic volumes, despite normal, in comparison with those without TAD (left ventricle: 80.5 vs 93.5 ml/m2, p: 0.002; right ventricle: 72.5 vs 85.5 ml/m2, p: 0.018). MAD and curling were more common in patients without TAD (respectively, 25 vs 19, p:0.014 and 24 vs 20, p: 0.002) than in those with TAD. Conversely, MAD and curling are more severe in patients with TAD (respectively, 5.9 vs 4.7 mm and 4 vs 3 mm, both p: 0.034) than in those without TAD. No differences for LGE distribution were identified in the two groups (p: 0.062).

Conclusion

In arrhythmic MVP patients, presence of TAD was associated with a great severity of MAD and curling. So, despite uncommon, the contextual presence of TAD and MAD in arrhythmic MVP patients suggests a more severe biannular disease, characterized by an increased biventricular myocardial stretch. Conversely to MAD, TAD wasn't associated with ventricular arrhythmias. Thus, its role in ventricular arrhythmogenesis in MVP patients appeared limited.
1000 THE EFFECT OF RIGHT VENTRICULAR SIZE AND FUNCTION ON TRICUSPID REGURGITATION SEVERITY
Authors: Niro Lorenzo , Iseppi Manuela , Tafciu Elvin , Maffeis Caterina , Bergamini Corinna , Rossi Andrea , Benfari Giovanni , Luciano Ribichini Flavio
Published: December 2022

Background

Tricuspid regurgitation (TR) is a relatively common echocardiographic finding and its proportional influence on prognosis and quality of life has been well described. A bidirectional relationship connects TR severity and its volume overload with right ventricular (RV) dilation and dysfunction.

Purpose

to assess the impact of RV size and function on TR severity.

Material and Methods

116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV size was assessed by RV End Diastolic Area (EDA) and RV function by RV Free Wall Longitudinal Strain (FWLS).

Results

TR was quantified mild in 23 patients, moderate in 53 and severe in 40 patients, with higher predominance of functional rather than organic etiology (101 vs 15 patients); median EROA was 31 mm2 and median RVol was 30 mL. Mean RV-FWLS was -25.9±7%, -21.4±7.4% and -18.4±6.4% respectively in mild, moderate and severe TR with a statistically significant difference between the groups (p=0.001). Mean RV-EDA was 19±7.7 cm2 in mild TR, 21.7±8.5 cm2 and 26.2±7 cm2 in moderate and severe TR respectively (p=0.002).

In univariate analysis both RV-FWLS and RV-EDA were predictor of TR grade estimated by TR-EROA (p=0.012 and p<0.0001 respectively). In linear multivariable analysis only RV-EDA was an independent predictor of TR-EROA (p=0.001).

A ROC curve analysis confirmed the better ability of RV-EDA to identify severe TR (sTR) compared to RV-FWLS (AUC=0.738 vs AUC=0.669).

Conclusions

RV remodeling in terms of chamber dilation seems to better predict a higher TR severity compared to RV dysfunction.
945 TRANSIENT LEFT VENTRICULAR THROMBOSIS TAKOTSUBO-RELATED
Authors: Lofrumento Francesca , Mancinelli Anna , Trio Olimpia , Cusmà-piccione Maurizio , Di Bella Gianluca , Micari Antonio , Carerj Scipione , Zito Concetta
Published: December 2022

Background

Takotsubo syndrome (TTS) is an increasingly widespread syndrome characterized by an acute and usually transient left ventricular (LV) dysfunction. Despite its transient nature, the acute phase can be characterized by serious complications such as LV thrombosis, as occurred in this case.

Case description

A 93-year-old woman was admitted to our emergency department due to a recent and self-limiting episode of acute chest pain. The ECG showed ST-elevation in leads V2, V3 and V4 (Fig.1), with cardiac biomarkers elevation. Transthoracic echocardiography (TTE) revealed apical akinesia and hypokinesia of the other LV segments with a severely reduced ejection fraction (EF 35%). Emergency coronary angiography showed normal epicardial coronary vessels. So, Takotsubo cardiomyopathy was hypothesized as diagnosis. A mass suspect for a thrombus was detected into the apex on day 3, despite a mild improvement of the other segments contraction (EF 40%), and clearly confirmed with the contrast echocardiography on day 5 (Fig.2). Unexpectedly, any LV thrombus was identified with cardiac MRI study performed on day 7 (Fig.3). Meanwhile, the patient never showed neurological disorders or other signs of thromboembolic complications. Echocardiography performed on day 11, before discharge, showed a great improvement of regional wall motion with residual LV apical hypokinesia (EF 55%) and no apical masses.

Discussion

This case emphasizes the need of frequent echocardiographic follow up in stress-induced cardiomyopathy, not only during the akinetic phase but also during the period of wall motion recovery, in order to diagnose and treat as soon as possible a LV apical thrombosis avoiding thromboembolic complications. We hypothesized that the early anticoagulation therapy combined with the initial improvement in LV wall motion facilitated the process of thrombosis resolution. Cardiac MRI played a relevant role in the comprehensive assessment of the functional and structural LV changes; the absence of late gadolinium enhancement (LGE) can be considered as a positive prognostic factor, indicating a complete resolution without residual fibrosis.

Conclusion

A multimodality imaging approach, based on a frequent echocardiographic follow up combined with cardiac MRI, is fundamental for an early diagnosis and a rapid treatment of LV thrombosis Takotsubo-related.
271 AUTOMATED REAL TIME ECHOCARDIOGRAPHIC TOOL FOR EDGE TRACKING OF INFERIOR VENA CAVA AND NON-INVASIVE ESTIMATION OF RIGHT ATRIAL PRESSURE
Authors: Mesin Luca , Policastro Piero , Re Andrea , Sanson Cristian , Albani Stefano , Petersen Christina , Sciarrone Paolo , Taddei Claudia , Giannoni Alberto
Published: December 2022

The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability.

We introduce an automated real time method to process ultrasound scans of IVC and to measure pulsatility indexes, which are then used, together with other non-invasive measurements, to estimate RAP. Specifically, our method is based on the cardiac collapsibility (cardiac caval index - CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 hour in condition of clinical and therapeutic stability (170 patients, age 64±14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features using machine-learning approaches. Three RAP classes (low <5 mmHg, intermediate 5-10 mmHg and high >10 mmHg) were generated and RHC values used as comparator.

Our classifications showed a higher accuracy than Guidelines (71% and 61% for our machine-learning method and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.
241 LEFT ATRIAL SEPTAL POUCH THROMBOSIS AFTER COVID19 INFECTION: IS IMMUNOTHROMBOSIS THE CULPRIT MECHANISM?
Authors: Morello Matteo , Maestroni Alerto , Matteo Federica , Tavano Elisa , Rossetti Giuseppe , Franzoni Irene , Crenna Marco , Sgaria Riccardo , Golino Michele , De Ponti Roberto
Published: December 2022

Aims

The atrial septal pouch (ASP) is an incomplete fusion between septum primum (SP) and septum secundum (SS), resulting in a kangaroo pouch, that has a high prevalence in general populations (47%) and it is a potential site of blood stasis and thrombosis. After the novel coronavirus disease (COVID19) -related thrombotic complications, immunothrombosis has been widely investigated and proposed as key pathogenic mechanism linking coagulation and inflammation, leading sometimes to intracardiac thrombosis. In this paper we describe a case of thrombus in the ASP interestingly developed after COVID19 and made a literature review.

Methods and Results

A 85 years old woman with a history of hypertension and chronic atrial fibrillation (AF) in therapy with dabigatran, was admitted to our hospital for dyspnea, atypical chest pain and fever. Laboratory exams showed only mild leukocytosis and elevated levels of d-dimer; EKG confirmed AF with a normal ventricular rate and CT scan excluded pulmonary embolism.

Transthoracic and transesophageal echocardiogram (TEE) (Figure 1) showed a mobile ovoid mass (13×26 mm) attached to a left-sided ASP mimicking a myxoma, no mass was seen in the left atrial appendage (LAA). Four months earlier she had been hospitalized for idiopathic thrombocytopenia and concurrent COVID19 infection with mild symptoms, therefore dabigatran was discontinued for a month. The patient underwent surgery and histopathology confirmed it was a thrombus. In the PubMed search we conducted for reports demonstrating ASP masses, or alleged thromboembolism (TE) from this site, we found 25 reports, whose characteristics are briefly summarized in Table 1. Interestingly mild thrombocytopenia was described just in one case.

Conclusions

In addition to the LAA, the atrial septal pouch is a newly described, common anatomic entity of the interatrial septum, that potentially serves as a site of stasis and thrombus formation. Despite its high prevalence, the finding of a thrombus in this site is very rare. According to Virchow triad, we assume that in this case an endothelial injury and hypercoagulability could have played a pivotal role, since the concomitant thrombocytopenia and high levels of d-dimer. This could be the first case of a thrombus in the ASP associated with COVID19-immunothrombosis.
795 MYOCARDIAL WORK AND LEFT HEART DEFORMATION PARAMETERS ACROSS MITRAL REGURGITATION SEVERITY
Authors: Pastore Maria Concetta , Mandoli Giulia Elena , Lisi Matteo , Iuliano Maria Alma , Paolo Niglio Francesco , Santoro Alfonso , Barilli Maria , Focardi Marta , Cavigli Luna , D´ascenzi Flavio , Valente Serafina , Cameli Matteo
Published: December 2022

Background

Myocardial work (MW) estimation by pressure-strain loops using an implemented speckle tracking software has showed to estimate LV contractile properties overcoming the load-dependency limit of left ventricular (LV) global longitudinal strain (GLS). This has proved useful particularly in clinical setting characterized by frequent hemodynamic variations, such as heart failure and valvular heart disease. However, the variation of MW parameters across different stages of mitral regurgitation (MR) and its impact on symptoms has never been investigated.

Objective

The aim of this observational study was to assess the variations of MW and deformation parameters of left heart chambers in mild, moderate and severe MR.

Methods

consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery.Clinical evaluation, blood sample tests, ECG and echocardiography were performed. Speckle tracking analysis completed by myocardial work were performed offline. Patients were then divided into groups first according to MR severity. Differences among the groups were analyzed by student T test (or non-parametric tests for non-normally distributed variables) and predictors of symptoms (as NYHA class ≥ 2) were explored by logistic regression analysis.

Results

overall, 120 patients were enrolled (40 mild, 40 moderate, 40 severe MR). LV GLS improved according to severity, while Global PALS reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved in patients with moderate and severe MR, while global work efficiency (GWE) showed a trend towards reduction in patients with higher grades of MR. Global work index did not changed significantly in the three groups (Fig.1). Among strain parameters, global PALS emerged as a predictor of NYHA class (R2=0.2, p<0.001) These results are explained by the pathophysiology of MR, characterized by a mechanism of attempted LV compensation to volume overload with increased contractility parallel to the disease progress, although with low efficacy on increasing LV stroke volume and increased wasted work; while LA and diastolic function have an early reduction which is associated with the occurrence of symptoms.

Conclusions

myocardial deformation parameters of the left heart chambers accurately reflect the pathophysiologic mechanisms of MR stages and are associated with the burden of symptoms.

Fig. 1

Fig. 2
517 RIGHT ATRIAL THROMBUS IN A PATIENT WITH CARDIAC AMYLOIDOSIS: A MULTIMODALITY IMAGING APPROACH
Authors: Pece Cinzia , Tomaselli Michele , Radu Noela , Perelli Francesco , Muscogiuri Giuseppe , Castelletti Silvia , Torlasco Camilla , Giorgio Oliverio , Heilbron Francesca , Rella Valeria , Gavazzoni Mara , Caravita Sergio , Baratto Claudia , Parati Gianfranco , Muraru Denisa , Crotti Lia , Paolo Badano Luigi
Published: December 2022

Case Presentation

A 47-year-old man was referred to our outpatient clinic for dyspnea and chest pain. His past medical history was remarkable for an admission of acute congestive heart failure, occurred two weeks before presentation. On that occasion, the patient was discharged after a few days of diuretic therapy.

Diagnostic Workup

at presentation, the patient was symptomatic for dyspnea with signs of systemic congestion. The ECG showed sinus rhythm, inferolateral negative T waves and absent progression of R wave in precordial leads. Transthoracic echocardiography revealed markedly thickened left ventricular (LV) walls (maximum interventricular septum dimension 19 mm) with a granular-sparkling appearance of the myocardium, bi-atrial enlargement, preserved LV ejection fraction, restrictive mitral flow pattern thickened interatrial septum and atrio-ventricular valves. No significant valvular regurgitations were detected. Global LV longitudinal strain was significantly reduced (-9.4%), with relative apical sparing. Given the high suspicion for infiltrative disease we performed further investigations. The cardiac computed tomography (CCT) excluded significant coronary artery disease, but it raised the suspicion of a thrombus at the level of the right atrial appendage, that was confirmed by a transesophageal echocardiography showing a mobile round mass of 14×12 mm. Finally, tissue characterization by cardiac magnetic resonance exhibit a diffuse myocardial delayed enhancement, with a dark blood pool and, an increase in extracellular volume and T1 mapping values (1266.3 ms). Laboratory tests showed increased levels of creatinine, BNP and, lambda light chains. Bone scintigraphy imaging didn't identify any uptake of radiotracers at myocardial level. These findings were suggestive for cardiac light-chain (AL) amyloidosis. Accordingly, a treatment with warfarin, beta-blockers, steroid, and diuretics was initiated.

Conclusions

cardiac amyloidosis is an infiltrative disease characterized by the deposition of aggregates of amyloid fibrils in the myocardium. Multimodality imaging is pivotal to determine the diagnosis, assess the potential complications, and stratify the patients’ prognosis. Our case demonstrates that cardiac AL amyloidosis is associated with an increased thromboembolic risk, irrespective of the presence of atrial fibrillation. Moreover, although the left atrial appendage is most frequently the site of thrombus formation, it is advised to look for them also in uncommon sites as the right atrial appendage.
506 TECHNIQUES OF ARTIFICIAL INTELLIGENCE FOR THE DETERMINATION OF THE OPTIMAL INVERSION TIME: THE THAITI PROJECT
Authors: Torlasco Camilla , Papetti Daniele M , Sabatini Maria , Muscogiuri Giuseppe , Castelletti Silvia , Xue Hui , Kellman Peter , Parati Gianfranco , Badano Luigi P , Nobile Marco S , Besozzi Daniela
Published: December 2022

Introduction

Identifying the optimal Inversion Time (TI) is pivotal to null the myocardium and obtain high quality cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Setting the optimal TI can be challenging in some diseases and for less experienced operators. We propose an Artificial Intelligence (AI) tool to automatically predict the optimal TI in CMR-LGE imaging.

Methods

The AI tool, named THAITI, consists of a Random Forest regression model whose hyperparametrs were optimized by means of evolutionary computation. The model considers as input parameters patient-specific TI determinants, such as age, gender, weight, height, kidney function, heart rate, contrast dose, and time from injection to image acquisition. THAITI was trained on 155 patients (2588 CMR-LGE images) with mixed cardiac conditions who underwent CMR (1.5T Siemens AvantoFit; Gadovist; averaged, motion-corrected, free-breathing true-FISP IR). Clinical testing was performed on 55 matched patients, randomized to experimental (THAITI-set TI) vs control (experienced operator-set TI) group. A user interface was developed for clinical testing. Image quality was assessed blindly by 2 independent experienced operators.

Results

THAITI Mean Squared Error (MSE) in the validation set was 4.7 and percentage of mispredicted TI of 4.5%. During clinical testing, LGE quality did not differ between the experimental vs control group: quality was “optimal” or “good” in 96% vs 93%, “poor” in 4% vs 7%. The average number of LGE images acquired and LGE imaging duration were similar (experimental vs control group: 17 ± 3 vs 16 ± 3 LGE images per patient; 12:14 vs 12:20 mm:ss, respectively).

Conclusion

THAITI efficiently predicts optimal TI for CMR-LGE imaging. Further development is needed to increase generalizability (multi-vendor, multi-sequence, multi-contrast) and to test its potential to improve LGE image quality and reduce the need for repeated imaging for inexperienced operators. Figure 1. Top panel: THAITI interface. Bottom panel: examples of experimental group LGE imaging. Table 1. Control vs experimental group. Data expressed as absolute number (%), mean ±SD
105 A CASE OF RARE ATYPICAL ATRIAL STRUCTURE
Authors: Lalario Andrea , Maione Davide , Carriere Cosimo , Merlo Marco , De Luca Antonio , Sinagra Gianfranco
Published: December 2022

A 27-year-old woman, without previous cardiological history, was admitted at our emergency department in the clinical context of an acute pericarditis. Echocardiography documented mild pericardial effusion (8 mm) without any sign of hemodynamic impact.

The patient was then admitted at our Cardiology Unit. During the hospitalization a complete transthoracic echocardiogram showed a normal biventricular morphology and function, normal valvular function and found an anechoic structure on the postero-lateral left atrial wall (1.75×1.5 cm). To better characterize this accidental finding, a transesophageal echocardiography was performed unmasking a dilated coronary sinus with anomalous course.

A subsequent cardiac computed tomography was performed showing anomalous systemic venous return with the persistency of the left superior vena cava draining into the coronary sinus. No other congenital anomalies were found.

PLSVC is present in approximatively 0.5% of individuals in the general population and is the most frequent congenital malformation of the thoracic venous return.

In about 90% coexists with the right superior vena cava and co-occur in almost 40% of patients with other congenital heart abnormalities such as atrial septal defect, aortic coarctation, bicuspid aortic valve, tetralogy of Fallot, transposition of the great vessels, anomalous connections of the pulmonary veins, dextroversion and cor triatatum.

Patients usually are asymptomatic. Nevertheless, this congenital malformation may cause chest discomfort, cardiac arrhythmias, thromboembolic events, decreased exercise tolerance and syncope.

Moreover, the correct identification of this condition has important clinical implications. In fact, it is a relative contraindication to the administration of retrograde cardioplegia during cardiac surgery. Furthermore, the placement of central venous-access line, pulmonary artery catheterization or the implantation of pacemaker/resynchronization leads could be difficult or can result in incorrect positioning. In these cases, it is recommended to access to the right heart through the right subclavian vein instead the left one.

Legend: *: Anomalous course of coronary sinus; LA: Left Atrium; LV: Left Ventricle; Ao: Aorta; RA: Right Atrium; R-SVC: Right superior vena cava; L-SVC: Left superior vena cava; LSPV: Left superior pulmonary vein.
972 PULMONARY HYPERTENSION AND EMBRYOLOGICAL REMNANT: WHAT DO THEY HAVE TO DO WITH EACH OTHER? A CASE REPORT
Authors: Fumarola Francesca , Favaretto Virginia , Collini Valentino , Pavoni Daisy , Driussi Mauro , Imazio Massimo , Sinagra Gianfranco
Published: December 2022

Background

Pulmonary hypertension (PH) is defined as a resting mean pulmonary artery pressure of 20 mmHg or above. The importance of identifying the underlying causes of PH is well known for a correct management and treatment. In particular, any cardiac causes, included shunt, must be investigated.

Case Summary

A 73-year-old woman presented to the emergency room for asthenia and dyspnea. First line exams as ECG and X-ray were executed resulting normal. Laboratory assessment showed an elevated brain natriuretic peptide at 675 pg/ml and a D-dimer value of 1116 ng/mlFEU (n.v. < 500 ng/mlFEU) so with the suspect of pulmonary thromboembolism a CT-scan with contrast was performed. It was negative for acute thromboembolism, but it revealed an enlarged pulmonary artery (with a diameter of 39 mm), a possible defect of interatrial septum and an anomalous drainage of inferior vena cava (IVC) into the left atrium (LA). A transthoracic echocardiogram confirmed the anomalous drainage of IVC into the LA that appears dilated but was not diagnostic for the interatrial defect. Furthermore, PH was suspected (systolic peak tricuspid regurgitation velocity of 3,5 m/s, RA area of 24 cm2, tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure of 0.26 mm/mmHg). A 6-minute walking distance was 376 m. The patient completed the exams with a transesophageal echocardiography that revealed an inferior-type caval vein defect and an over-developed Eustachian valve which divides the right atrium (RA) and connect the IVC with the LA directing the blood flow towards it through the inter-atrial septal defect.

Discussion

The Eustachian valve is an embryologic remnant at the junction of the IVC and RA. While it typically does not have any pathologic significance, veno-arterial shunting can rarely occur in patients with prominent eustachian valves and atrial septal defects.
253 EXCERCISE-INDUCED PULMONARY HYPERTENSION AND CORONARY ARTERY ANOMALY: AN UNUSUAL ASSOCIATION
Authors: Savonitto Giulio , Rizzi Jacopo Giulio , Barbisan Davide , Stolfo Davide , Korcova Renata , Sinagra Gianfranco
Published: December 2022

A healthy 55-year-old competitive sportsman, with familial history of early sudden cardiac death, came to our attention following the finding of asymptomatic exercise-induced myocardial ischemia (ST depression in V3- V6).

Computed tomography (CT) coronary angiogram excluded atherosclerotic disease but showed a dominant right coronary artery (RCA) originating from left Valsalva sinus and with an interarterial course between the ascending aorta and the pulmonary artery. Both the trunk of the pulmonary artery and the right ventricle were reported as mildly dilated

Transthoracic echocardiography showed a normal left ventricle (LV), while confirmed right ventricle (RV) dilatation, moderate tricuspid regurgitation (TR) and interatrial septal aneurysm. Stress echocardiography excluded inducible ischemia, but highlighted exercise-induced pulmonary hypertension (PH) (PAPs 25 → 70 mmHg), while a transesophageal echo confirmed a left-to-right shunt due to a 8-mm Patent Foramen Ovale (PFO).

Rheumatological, thromboembolic and parenchymal lung diseases were excluded as possible causes of exercise-induced PH; a rest right heart catheterization (RHC) showed a Qp/Qs ratio at the upper limits of normal range without PH. Nuclear stress testing identified trivial asymptomatic septal ischemia. The patients started medium dose of beta-blockers and early follow-up was planned.

This clinical case raises some questions: why is RV dilated? What role does PFO play? What is the cause of the inducible ischemia? What is the pathogenesis of exercise-induced PH?

Pulmonary Arterial Hypertension, in early stages, often manifests only under exertion, but it is usually characterized by exercise dyspnea and low oxygen saturation. Moreover, intracardiac shunts may be involved in developing PH.

In this specific case, pulmonary trunk may be expanded by pressure overload, causing the compression of aberrant RCA and consequent ischemic abnormalities. RV dilatation might be explained by exercise-induced PH itself, but it was not severe and has to be demonstrated by exercise right heart catheterization.

The main questions are: which is the primary etiology of right chamber enlargement and myocardial ischemia? Which is the most appropriate therapeutic approach (i.e. conservative vs interventional)?
728 GALECTINE-3 AND SST2 IN SYSTEMIC SCLEROSIS: AN EARLY DETECTION OF PULMONARY VASCULAR INVOLVEMENT IS REALLY POSSIBLE?
Authors: Tempestini Federica , Cristiano Ernesto , Pala Barbara , Tifi Priscilla , Magrì Damiano , Marcoccia Antonella , Romaniello Antonella
Published: December 2022

Introduction

Pulmonary arterial hypertension (PAH) is a rare form of pulmonary hypertension (PH) that may also be associated with connective tissue diseases (CTD). In particular, PAH may affect from 5 to 19% of patients with systemic sclerosis (SSc), leading to a significant prognostic worsening. The current challenge is an early detection of PAH in such patients, in order to provide an early referral to PH centers to supply specific therapies as soon as possible. In the latest ESC guidelines for PH, cardiopulmonary exercise testing (CPET) has been included in the diagnostic algorithm for patients with unexplained exertional dyspnoea and/or suspected PH. Patients with PAH show a typical pattern, with a low end-tidal partial pressure of carbon dioxide (PETCO2), high ventilatory equivalent for carbon dioxide (VE/VCO2), low oxygen pulse (VO2/ HR) and low peak oxygen uptake (VO2). CPET may identify patients with SSc at low risk of PAH, to avoid unnecessary right heart catheterization (RHC). However, CPET is not available in all centers. So, we designed a preliminary study to identify new biomarkers that correlate with CPET's parameters.

Material and Methods

We enrolled 62 SSc patients [53 females, median age 52 years] with no other comorbidities and asymptomatic for dyspnea or other symptoms. 56% and 44% of them presented limited cutaneous SSc (lcSSc) and diffuse cutaneous SSc (dcSSc), respectively.

For all patients we performed serum analysis for sST2, Galectine-3, pro-ANP, BNP and IL6, diagnostic imaging with echocardiography and cardiac MRI, CPET and pulmonary functionality test (PFT).

Results

All patients presented normal echocardiographic and RMI imaging findings.

Galectin-3, sST2, pro-ANP, BNP and IL6 presented respectively the following median value: 13.45 ng/mL [11.78; 18.70], 23.25 ng/mL [13.04; 43.35], 1897 fmol/ml [1487; 2445], 12.18 pg/mL [9.34; 15.01]. Both Galectin-3 and sST2 showed a linear correlation with VE/VCO2 slope with R 0.339 (P-value 0.018) and 0.355 (P-value 0.013) respectively. After linear regression analysis, Galectin-3 and sST2 were overall statistically significant with R2 of 0.115 and 0.126, F of 5.97 and 6.62 and P-value of 0.018 and 0.013, respectively. It was found that Galectin-3 and SST2 significantly predicted VE/VCO2 slope with β = 0.364 [0,064; 0,665] for Galectin-3 and 0.137 [0,030; 0,244] for SST2.

All other CPET parameters did not show correlation with the biomarkers.

Conclusion

Our preliminary results suggest that Galectine-3 and sST2 may be useful biomarkers for predicting increasing VE/VCO2 slope. Future analysis may confirm the role of these new biomarkers for early detection of pulmonary vascular involvement in SSc patients to allow an early referral and treatment and, conversely, to avoid unnecessary RHC.
463 WOVEN CORONARY ARTERY AN INCIDENTAL FINDING
Authors: Agnello Federica , Mauro Maria Sara , Calderone Dario , Scalia Lorenzo , Legnazzi Marco , Capodanno Davide , Tamburino Corrado
Published: December 2022

Introduction

Woven coronary artery is a rare congenital vascular anomaly, namely a coronary segment divided into many independent thin channels, which intertwine around the coronary axis for several centimeters, and then re-anastomose distally in a single lumen. The etiology of woven coronary arteries is unknown; however, it is commonly considered a benign condition which only rarely results into myocardial ischemia and acute coronary events

Clinical case

A 47-year-old man, with history of hypertension and drug addiction, presented to the emergency department due to dyspnea (NYHA IV). The chest x-ray showed bilateral pneumonia with pleural effusion, and depressed left ventricular ejection fraction of 32% with antero-lateral ipokinesia and moderate mitral regurgitation was shown at echocardiography. The electrocardiogram showed right bundle branch block. Troponin levels were elevated, denoting myocardial injury and possibly an acute coronary syndrome; therefore the patient was referred to invasive coronary angiography. The coronary angiogram showed the aspect of“woven coronary artery” both in the right (more frequent) and in the circumflex coronary (Figure 1). As in this case, woven coronary is usually incidentally diagnosed during coronary angiography, in fact the anomaly could not explain this clinical scenario. Sometimes woven coronary can be confounded with dissections, recanalized thrombus and chronic total occlusion with bridging collaterals. In the current case the vessels presented a thrombolysis in myocardial infarction (TIMI) flow grade 3 and there was no coronary occlusion; moreover, the simultaneous multivessel presence of this suggestive angiographic aspect makes the hypothesis of a congenital anomaly more likely.

Conclusion

Woven coronary artery is a rare vascular anomaly, usually benign. Intravascular imaging, which was not performed in this case, may be helpful in equivocal circumstances to avoid unnecessary and potentially high-risk percutaneous coronary intervention.