bluuebunny/crossref_metadata_2025 huggingface dataset:
1101 Multimodality imaging in the assessment of pericardial malign disease
Authors: Codina M , Ramirez-Escudero Ugalde G , Manzanal Rey A , Garcia Ibarrondo N , Cisneros Carpio S , Lambarri Izaguirre A , Candina Urizar R , Ugedo Alzaga K , Castellanos Alcalde M , Rodriguez Martinez M , Sande Sardina L , Galve Calvo E , Arcocha Torres M F , Ormaetxe Merodio J , Ruiz Gomez L
Published: January 2020

Metastases to the heart and pericardium are discovered at autopsy in 10%–12% of all patients with malignancies. The most common primary tumor involving the pericardium is lung cancer, followed by breast, melanoma, and lymphoma. Pericardial effusion may be the result of the tumor spreading to the visceral pericardium which increases production of fluid, or accumulation of the fluid due to the obstruction of venous and lymphatic outflow. A malignant pericardial effusion is associated with decreased survival rate.

We present a 72 year-old woman, former smoker with dyslipidemia and psoriatic arthritis as well as previous bladder carcinoma that was healed in 1986. On august 2017 after an acute intestinal obstruction she was diagnosed with stage IV ileum adenocarcinoma treated initially with palliative chemotherapy (Capecitabine and oxaliplatin) that was suspended for poor tolerance and according to patient desire. Few months later the patient complained of rapidly progressive dyspnoea that prevented her normal life activity, arterial pressure and blood oxygen saturation was normal, but she was tachycardic. Echocardiogram was performed (see figure) which showed marked pericardial nodular thickening and severe pericardial effusion with echocardiographic signs of cardiac tamponade. Curiously, pericardial effusion was dense and markedly hyperechogenic. A computed tomography (CT) was performed to rule out pericardial carcinomatosis and find out the pericardial fluid composition and demostrated several pericardial nodular thickenings that suggested metastases. The pericardial fluid was dense (40 hounsfield units) and consistent with blood. After multidispiplinar consultation and in accordance with patients wishes a palliative pericardial window was performed and hematic pericardial fluid was obtained. Pericardial liquid citology demonstrates atipical cells compatible with carcinoma and pericardial biospy showed fibrinous pericarditis and reactive mesothelial hyperplasia.

Pericardial carcinomatosis consists of macroscopic or microscopic affection of pericardial layers. Metastasis from colorectal cancer to the pericardium is uncommon, and usually indicates terminal stage with multiple metastases, only a few cases have been reported. Malignant Pericardial effusions in patients with cancer may also be triggered by other mechanism than cancer itself, including chemotherapy, radiation therapy, and, less commonly, an infectious disease. Whereas echocardiography is most frequently used to examine the heart and pericardium, multimodaliy imaging with magnetic resonance (MR) or/and CT offer advantages when dealing with metastatic disease.

Abstract 1101 Figure. Echocardiogram and CT images
1108 Inferior vena cava diversion into the left atrium after surgical repair of atrial septal defect: a rare case of chronic hypoxemia
Authors: Vidal Urrutia V , Garcia Gonzalez P , Perez Bosca J L , Juan Samper G , Cubillos Arango A , Ridocci Soriano F , Gradoli Palmero J , Cardenas Tealdo J P , Sanchez Alvarez S , Fernandez Diaz C , Simon Machi J M , Vano Bodi J , Abdala Lizarraga J , Paya Serrano R
Published: January 2020

Abnormal inferior vena cava (IVC) drainage into the left atrium (LA) is an infrequent complication after surgical closure of an atrial septal defect (ASD).

We present the case of a 45-year-old woman, with surgical closure of an ASD 8 years before, who consulted for exertional dyspnea and cyanosis. Transthoracic and transesophageal echocardiography showed no residual shunt after contrast administration in both arms, and thoracic CT scan and pulmonary ventilation / perfusion gammagraphy were normal. In the presence of signs strongly suggesting a right-to-left shunt, we decided to complete the study with a CMR,which revealed an anomalous systemic drainage with IVC draining into the LA with right-to-left shunt. Surgical repair of the abnormal IVC drainage was successfully performed. During the intervention cardiac surgeons found a repaired ASD located in the lower portion of the interatrial septum, a large Eustachian valve, which are anatomical features which can sometimes lead to an erroneous suture causing the drainage of the IVC towards the LA.

In conclusion, it is essential to carry out an extensive search for possible residual anatomical shunts in patients who undergo surgery and develop hypoxia. The reported case underlines the importance of being aware of this possible complication of the closure of an ASD and highlights that the absence of passage of agitated saline contrast to left chambers with conventional injection by the arms does not rule out any residual shunt, recommending its administration by the lower limbs, as well as the CMR for the definitive diagnosis.

Abstract 1108 Figure. CMR imaging 3D reconstruction
1179 Echocardiographic signs of aortic atherosclerosis in combination with clinical parameters for prediction of non-obstructive coronary atherosclerosis in men
Authors: Yaroslavskaya E I , Kuznetsov V , Gorbatenko E A
Published: January 2020

Background

Traditionally the gold standard for diagnosis of coronary artery disease (CAD) is detection of significant stenosis by coronary angiography. However, most myocardial infarctions result from ruptures of plaques that did not significantly compromise coronary lumen before the event. It was proved that significant stenosis is associated with stable CAD but non-significant coronary atherosclerosis is associated with unstable angina and acute coronary syndrome.

Purpose

To reveal predictors of non-significant coronary atherosclerosis using echocardiographic and clinical parameters in suspected CAD men without obstructive CAD by coronary angiography.

Methods

Out of 17.784 patients from coronary angiography database we selected 1.957 men without obstructive CAD. Selected men were divided into two groups randomly (1.389 - studied group and 568 – test group). The studied group was divided into subgroups: 304 men with non-significant coronary atherosclerosis (luminal narrowing or stenosis less than 30%) and 1.085 men with smooth coronary artery. Clinical and functional parameters of subgroups patients were compared. For selection of scoring variables, we used the values of the Cramer coefficient and the information value index - IV. All quantitative variables were converted into categorical using the binning procedure. Based on the values of WoE, the model of logistic regression was constructed using stepwise variable selection.

Results

The model includes independent variables with an average and high prognostic ability: echocardiographic signs of atherosclerosis of the ascending aorta, age, atherogenic index, arterial hypertension. By converting the coefficients of the logistic regression equation obtained into scores, a scoring model was developed to assess the probability of non-obstructive coronary atherosclerosis in men. Based on ROC analysis, in the studied group the specificity of the model for detection of nonsignificant coronary atherosclerosis was 67%, the sensitivity was 65%, the area under the ROC curve - 0.711. For the patients of the test group sensitivity was 68% and specificity - 63%, the area under the ROC curve - 0.687.

Conclusion

Nonsignificant coronary atherosclerosis in men with suspected CAD can be predicted before CAG by screening test based on echocardiographic signs of aortic atherosclerosis, age, atherogenic index and arterial hypertension.
1226 Prognostic impact of concomitant cardiac amyloidosis in aortic stenosis patients referred for transcatheter aortic valve implantation
Authors: Ferreira V , Aguiar Rosa S , Rodrigues I , Moura Branco L , Galrinho A , Rio P , Patricio L , Cacela D , Ramos R , Mendonca T , Castelo A , Garcia Bras P , Branco Mano T , Reis J , Cruz Ferreira R
Published: January 2020

Background

The prevalence of cardiac amyloidosis (CA) and aortic stenosis (AS) both increase with age. Transcatheter aortic valve implantation (TAVI) expands the number of patients (P) eligible for treatment of AS, emphasizing the need to understand the prevalence of CA in AS and its prognostic associations. Echocardiography with speckle tracking has emerged as a useful method to enhance the clinical suspicion and to provide prognostic information.

Purpose

To estimate the prevalence of CA in P with severe AS referred for TAVI and to evaluate the impact of concomitant CA in prognosis.

Methods

94 consecutive AS P who underwent TAVI with maximum left ventricular wall thickness (LVWT)>12 mm were retrospectively identified. Clinical data, pre TAVI echocardiographic parameters and follow up (FU) data regarding all-cause mortality and MACE (including all-cause mortality, admission for heart failure, pacemaker implantation and stroke) were analysed. We registered apical sparing pattern in bull’s eye plots (ASPB), calculated relative apical longitudinal strain formula (RALS) [average apical LS/(average basal LS + mid-LS)] and ejection fraction/global longitudinal strain (EF/GLS) ratio.

Results

Mean age was 82.2 ± 5.8 years (Y), with 43 men (45.7%). 27.7% were in NYHA functional class II, 64.9% in functional class III and 7.4% in functional class IV. Median EF was 57 ± 15% and 26.6% presented EF < 50%. Suspected CA evaluated by ASPB was found in 39 P (41.5%) and RALS > 1 was identified in 22 P (23.4%). An EF/GLS ratio > 4.1 was obtained in 53 P (56.4%). Over a median follow-up of 13.4 ± 25.8 months, 28 deaths (29.8%) and 31 MACEs (33.0%) occurred.

The presence of ASPB was associated with increased all-cause mortality (33.3% vs. 5.6%, p = 0.002), new bundle branch block and indication for pacemaker implantation (46.2% vs 37.0%, p = 0.05) and MACE (48.7% vs 22.2%, p = 0.01). All-cause mortality was also higher in P with RALS (31.8% vs. 12.5%, p = 0.04). P with GLS>-14.8% and ASPB had significantly worse prognosis regarding all-cause mortality (p = 0.003) and MACE (p = 0.007). Kaplan–Meier survival analysis showed that survival was significantly worse for P with ASPB (log-rank 0.002). With multivariate Cox regression analysis, ASPB was independently associated with all-cause mortality (HR = 4.49, p = 0.039).

Conclusions

Suspected CA appears prevalent among patients with AS and associates with all-cause mortality. The importance of screening for CA in older AS patients and optimal treatment strategies in those with CA warrant further investigation, especially in the era of transcatheter aortic valve implantation.

Abstract 1226 Figure. Kaplan–Meier curves and ASPB
P1247 Bilateral endogenous endophthalmitis as the initial presentation of hacek prosthetic valve infective endocarditis
Authors: Parr E , Mcaloon C , Morley-Davis A , Ridley P , Duckett S
Published: January 2020

A 75 year old lady with a prosthetic aortic valve (St Jude mechanical AVR) presented to ophthalmology with a one month history of black spots in the vision of her left eye with a further episode in her right eye two weeks later, leading to a diagnosis of bilateral endogenous endopthalmitis and was admitted to hospital. There was no history of trauma and the chest and abdominal examination was normal. The erythrocyte sedimentation rate (40) and C reactive protein (45.8) were elevated. She had several sets of blood cultures, which were positive for Aggregatibacter actinomycetemcomitans, a HACEK organism and was started on empirical Ceftriaxone. The transthoracic echocardiography was normal. However, the suspicion of Infective Endocarditis (IE) was high, therefore a transoesophageal echocardiography was performed and showed an aortic root abscess (Image 1). An urgent computerised aortogram was performed. Following a planned two week period of intravenous antibiotics the patient was taken to theatre to have a redo AV valve replacement and root repair. Following a prolonged period on intensive care and a six week course of pathogen directed antibiotic therapy she was then fit enough to be discharged.

Conclusion

We present the first case in the literature of a HACEK Prosthetic Valve endocarditis presenting with bilateral endogenous endophthalmitis.

Abstract P1247 Figure. TOE image of Absess
P1270 Systolic blood pressure at age 40 is associated with left atrial volumes at age 64
Authors: Selmer Roenningen P , Berge T , Solberg M G , Enger S , Nygaard S , Pervez O , Orstad E B , Kvisvik B A , Aagaard E N , Lyngbakken M N , Ariansen I , Rosjo H , Steine K , Tveit A
Published: January 2020

Funding Acknowledgements

Vestre Viken Hospital Trust

Background

Left atrial (LA) enlargement is associated with elevated blood pressure (BP) and with cardiovascular morbidity and mortality. In the assessment of LA size, echocardiographic guidelines recommend the use of LA end-systolic volume (LAVmax). LA end-diastolic volume (LAVmin) and LA emptying fraction (LAEF) may add valuable information in risk assessment. The knowledge of early adulthood BP and its association to LA volumes and LAEF later in life is limited.

Purpose

To explore the association between systolic BP at age 40 and LA volumes and LAEF at age 64.

Methods

We linked data from subjects who had participated in both a nationwide cardiovascular screening survey (1990-1991) at the age of 40, and the Akershus Cardiac Examination (ACE) 1950 Study (2012-2015) at the age of 64 (n = 2,597). In the ACE 1950 Study, LAVmax and LAVmin were measured with echocardiography according to the summation of discs method. LAEF was calculated as (LAVmax-LAVmin/LAVmax)x100%. The association between systolic BP at age 40 and LA volumes and LAEF at age 64 was assessed in univariate and multivariate linear regression analyses.

Results

Systolic BP at age 40 was associated with LAVmax and LAVmin but not with LAEF at age 64. In our multivariate model, a 10 mm Hg higher systolic BP at age 40 was associated with a 0.9 ml greater LA end-systolic volume and a 0.5 ml greater LA end-diastolic volume at age 64.

Conclusion

Early adulthood systolic BP is associated with LA volumes 24 years later in life.

Table. Association of systolic blood pressure at age 40 to left atrial (LA) volumes and LAEF at age 64 Univariate Multivariate* Dependent variable B (95% CI) p-value B (95% CI) p-value LAVmax (ml) 2.4 (2.0, 2.9) <0.001 0.9 (0.4, 1.4) 0.001 LAVmin (ml) 1.5 (1.1, 1.8) <0.001 0.5 (0.1, 0.9) 0.015 LAEF (%) -0.01 (-0.3, 0.3) 0.938 0.2 (-0.2, 0.5) 0.294 *Adjusted for gender, body mass index, smoking, resting heart rate and antihypertensive treatment, all assessed at age 40. B (95% CI), regression coefficient for systolic blood pressure (per 10 mm Hg) with 95% confidence interval; LAVmax, LA end-systolic volume; LAVmin LA end-diastolic volume; LAEF, LA emptying fraction
P1275 In-hospital outcome of patients with infective endocarditis: is echocardiography enough?
Authors: Motoc A , Kessels J , Roosens B , Lacor P , Van De Veire N , De Sutter J , Droogmans S , Cosyns B
Published: January 2020

Background

Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce.

Purpose

We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms.

Methods

We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery.

Results

183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters.

Conclusion

Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.
P1277 Cardiac remodeling in secondary tricuspid regurgitation: should we just look at the tricuspid annulus diameter?
Authors: Guerin A , Dreyfus J , Vabret E , Le Tourneau T , Lavie-Badie Y , Sportouch C , Eicher J C , Marechaux S , Donal E
Published: January 2020

Funding Acknowledgements

Financial support: French society of cardiovascular imaging.

Background

The respective strength of the different mechanisms that could lead to significant secondary TR occurrence remains debated.

Purpose

The main objective of our study was to characterize the determinants of tricuspid regurgitation (TR) severity in stable patients with preserved left ventricle ejection fractionand without significant left valvular heart disease. Patients were classified into 5 groups according to echocardiographic TR severity assessment: mild / moderate / severe / massive / torrential. Secondary objectives were to describe the evolution of the dimensions of the right cavities and the right ventricle (RV) function parameters according to the severity of the TR.

Methods

This is a prospective observational and multicentric study. Criteria for inclusion were: age ≥ 18 years; at least moderate TR; euvolemic status. We excluded patients with organic TR. All patients underwent standard trans-thoracic echocardiographyat distance from initial diagnosis and after stable optimized medical treatment. All exams were analysed in a Core Laboratory.

Results

100 patients (12 presented mild TR, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled and we used effective regurgitant orifice area (EROA) to quantify the severity of TR. To explain TR severity in multivariate analysis, right atrium (RA) indexed volume and tethering area were statistically significant (p < 0.001). For an increase of 10 mL/m2of RA volume, EROA increases by 4.2 mm2and for an increase of 0.1 cm2of tethering area, EROA increases by 2.2 mm2. The right heart dilation and the degree of restriction of tricuspid apparatus change significantly according to the severity of the TR (p < 0.001). RV function parameters did not differ significantly according to the degree of TR.

Conclusion

Early TA enlargement is present in secondary isolated TR. Then, increase in tethering area and RA indexed volume are associated with increase in TR severity. All right heart cavities dilate progressively without clear impact on RV-function parameters when TR increase.

Factor determining increase in EROA coefficient SD p value RA volume (mL/m2) 0.42 0.09 < 0.001 Tethering area (cm2) 22.1 3.9 < 0.001 Multivariate linear regression model. EROA: Effective Regurgitant Orifice Area; SD: Standard Deviation; RA: Right Atrium.

Abstract P1277 Figure. RV-EDA: probability of TR class severity
P1286 A retrospective clinical and anatomical characteristics study of transaortic extended left ventricular myectomy for obstructive hypertrophic cardiomyopathy
Authors: Furugen A , Doi H D , Mitsube K M , Hashimoto M H , Koshima R K
Published: January 2020

Objective

Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM). The aims of our study are to investigate anatomical characteristics and make clear effectiveness of transaortic extended left ventricular (LV) myectomy for HOCM.

Methods

This study enrolled 28 consecutive patients (age 66.7 ± 12.1 years, 46% Female) from 2012 to 2018 who met the following inclusion criteria: symptoms of heart failure persisting despite optimal medical therapy including beta blockers and Class I anti-arrhythmic agent, LV outflow tract gradient (LVOTG) > 50mmHg at rest or with provocation using stress echo (exercise TTE or low-dose dobutamine stress echo). We evaluated LV dimension, LVOTG, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM), Mitral complex morphology, high echoic region of endocardium and appearance of abnormal muscle bundles including apical-basal muscle bundle. These parameters were evaluated based on changes in LVOTG, MR and SAM at after LV myectomy. Also, intraoperative findings and cardiomyocytes pathological findings were evaluated. Stress echo were performed to investigate sustained reduction of LVOTG at medium term.

Results

All patients were successfully underwent transaortic extended LV myectomy. SAM was identified in all and moderate MR in 14 patients. The anterior mitral valve leaflet height was large in all patients and 16 patients had LV abnormal muscle bundles.

Postoperative LVOTG were controlled in 10mmHg or less. SAM disappeared completely in all patients and MR were decreased mild or less. LVOTG were sustained good control in 10mmHg or less under stress echo at medium term.

Conclusion

LV myectomy provides excellent relief from LVOT obstruction. The appearance of mitral valve anterior leaflet and abnormal band may be important keys of LVOT obstruction.
P1303 Pseudo-severe aortic stenosis due to mechanical dyssynchrony in a patient with low contractile reserve
Authors: Breskvar U , Mrak M , Zupan Meznar A , Zizek D
Published: January 2020

Introduction

Aortic stenosis characterization in patients with low flow – low gradient stenosis (LF-LG) and reduced left ventricular (LV) ejection fraction (EF) is challenging. In this subgroup, pseudo- severe stenosis should be properly identified, as these patients are treated conservatively with heart failure therapy. Its identification relies mainly on preserved contractile reserve seen during dobutamine echocardiography. We present a patient with low contractile reserve and pseudo-severe stenosis due to mechanical dyssynchrony.

Case presentation

83-years old patient with ischemic heart disease and chronic kidney disease was admitted to our department due to progressive exertional dyspnea. In 2014 he underwent dual-chamber pacemaker (PM) implantation due to sick sinus syndrome and was programmed to asynchronous pacing mode (VVI mode) in 2016 as atrial electrode dysfunction was observed. Coronary angiogram was normal. Echocardiography showed enlarged left ventricle (LV EDV 180 ml), reduced EF (33%) and signs of mechanical dyssynchrony. Peak aortic valve velocity was 2.5 m/s, mean pressure gradient (MPG) 13 mmHg and AVA 1.0 cm2. Stroke volume was reduced (SVI 28 ml/m2). LF-LG aortic stenosis was suspected. Stress echocardiography using dobutamine at peak infusion of 15 mcg/kg/min showed low contractile reserve (EF 37%, SVI 33 ml/m2) with no significant changes in aortic valve parameters (MPG 29 mmHg, AVA 0.9 cm2). However, significant masurement disparity was noted and at least partly contributed to atrio-ventricular (A-V) and inter-ventricular dyssynchrony because of asynchronous VVI pacing. To overcome A-V and intraventricular dyssynchrony we decided for atrial lead reposition and upgrade to cardiac resynchronization therapy (CRT-P). After six months of CRT, normalization of EF and improvement of exercise capacity were observed. Furthermore, additional evaluation of aortic valve showed only moderate stenosis (peak velocity 2,8 m/s, MPG 18 mmHg and AVA 1.4 cm2). Stroke volume was normal (SVI 48 ml/m2). Consequently, we postponed potential surgical or interventional treatment of the aortic valve.

Conclusion

Considerable LV mechanical dyssynchrony could interfere with determining the severity of aortic stenosis. As demonstrated in the present case report, special considerations should be taken in patients with notable LV dyssynchrony and low contractile reserve as it may not be overcome with dobutamine stress echocardiography as recommended by the current guidelines.
P1309 A jellyfish in the sea
Authors: Tong J , Lee E , Joseph Francis P
Published: January 2020

Background

The unexpected presence of a left ventricular (LV) mass is always a cause of concern for physicians. This is especially so in the presence of a cerebrovascular accident and a recent cardiac event, where the hunt for a cardioembolic source begins. We describe a case of an unusual presentation of a LV thrombus masquerading as a cystic mass, where diagnosis was confirmed with multimodality imaging tools.

Purpose

A 58 year old Thai male first presented to the emergency department with left brachio-facial syndrome secondary to a right pre-central gyrus stroke. He had chest pain 2 days prior, and was pain free on admission. An electrocardiogram done showed an evolved anterior myocardial infarction.

Methods and Results

A transthoracic echocardiogram performed on the 4th day of admission revealed a mildly impaired left ventricular systolic function with an ejection fraction of 45%, and wall motion abnormalities in the left anterior descending artery territory. There was an apical gelatinous-like, cystic and mobile mass with soft flexible walls, measuring 2.4 X 2.1cm. Differentials at this point included cystic thrombus, hydatid cyst, capillary haemangioma and intracardiac tumour.

A cardiac MRI was performed which showed an irregular apical mass with features suggestive of fresh thrombus. The mass demonstrates hyperintensity T1-w FSE sequences (with and without fat sat), increased hyperintensity in T2-w triple IR FSE, with no increased uptake in first pass perfusion, T1-w post contrast, or early and late gadolinium enhancement images.

A repeat transthoracic echocardiogram done 11 days after anticoagulation showed a 50% reduction in the size of the mass.

See images below for more information.

Conclusion

In the era of early primary percutaneous coronary intervention and anticoagulation following an acute myocardial infarction (AMI), LV thrombus is an uncommon complication. It can occur within 2 weeks after an AMI, where increased blood stasis from dyskinesia or akinesia of associated wall segments, and a hypercoagulable state increases the risk of thrombus formation. A literature search has shown that presentation of the thrombus as a cystic mass is rare as well. As such, early diagnosis allowing for early treatment, especially when systemic embolism of thrombus is suspected, is important. Other causes of cystic LV thrombus do need to be considered in the relevant clinical context. These include infectious causes such as hydatid cyst, capillary hemangioma or intracardiac tumour, which are less likely given the history and investigation results. In this case, a trial of therapy with anticoagulation reduced the size of the cystic mass, and along with imaging findings, confirmed the diagnosis of a cystic LV thrombus.

Abstract P1309 Figure. TTE and MRI heart
P1320 Percutaneous mitral valve leaflet plication to reduce systolic anterior motion and mitral regurgitation using the transcatheter mitral clip system
Authors: Drakopoulou M , Soulaidopoulos S , Oikonomou G , Stathogiannis K , Aggeli K , Toutouzas K , Tousoulis D
Published: January 2020

A 72-year-old female patient with a past medical history of severe mitral regurgitation, atrial fibrillation and embolic cerebrovascular events was admitted to our institution. The patient was under optimal medical therapy and complained for progressive worsening of activity-related dyspnea with limitation of physical activity (NYHA III).

Transthoracic echocardiography showed the presence of severe mitral regurgitation with a central jet. There was prolapse of both mitral valve leaflets and interestingly the anterior leaflet presented systolic anterior motion (SAM) at the same time. There was no significant left ventricular outflow tract obstruction (LVOT). Further evaluation of the regurgitant mitral valve with a transesophageal echocardiography (TOE) confirmed the above findings and the mechanism of MV regurgitation was attributed to prolapse in addition to SAM of an elongated anterior leaflet. Laboratory test showed elevated NT-pro-BNP levels. A coronary angiography was performed and excluded significant coronary artery disease.

The findings were assessed by our institution’s HEART TEAM and, in the presence of high surgical risk (LogEuroscore 32,76%), a decision for transcatheter mitral valve repair with a Mitral Clip implantation was taken. The Mitral Clip was succesfully implanted with immediate significant reduction of the regurgitant jet and no signs of stenotic behavior of the repaired valve. There was only mild mitral valve regurgitation. Notably, after the procedure there was elimination of the SAM and no LVOT obstruction (Figure). In accordance to the echocardiography findings, the patient demonstrated a significant clinical improvement and was discharged home 1 day after the procedure. Mitral clip implantation in this case showed improvement of the MR by reducing the SAM of the mitral valve.

Abstract P1320 Figure.
P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain
Authors: Karanikas S , Pavlidis A , Hamid S , Wasan B , Shakespeare C , Papamichael N
Published: January 2020

A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities.

Abstract P1329 Figure 1
P1350 New 3D Doppler flow method for quantitation of aortic regurgitation
Authors: Berg E A R , Avdal J , Espeland T , Torp H , Aakhus S
Published: January 2020

Funding Acknowledgements

Centre for Innovative Ultrasound Solutions, NTNU

OnBehalf

Centre for Innovative Ultrasound Solutions

Introduction

The echocardiographic assessment of valvular regurgitation severity may be challenging. This is reflected in the current EACVI and ASE recommendations, which are quite extensive and include numerous parameters. To date, there are no widely reliable quantitative methods. Moreover, the inter-observer variability in the overall severity assessment is substantial.

Purpose

Development of a new, automated 3D Doppler method for reliable and accurate quantitation of regurgitant volume.

Methods

A 3D high frame rate plane wave imaging sequence is employed to insonate the vena contracta region of the jet using a modified GEVU Vivid E95 system with a 4V probe. In this way we obtain spectral information from all voxels within the sample volume of approximately 2cm x 2cm x 2cm. Vena contracta is localised from the plane containing the maximum velocities and its cross sectional area determined by a power threshold. Velocity-time-integral is then estimated for all voxels within the designated cross sectional area.

For clinical validation, we include patients with aortic regurgitation ranging from mild to severe with a stable sinus rhythm. 3D flow data is recorded immediately after a comprehensive standard echocardiographic exam. The standard exam undergoes expert evaluation in accordance with EACVI recommendations. 3D flow data are currently processed and analysed offline by an independent investigator, blinded to the results from the standard exam.

Results

The results from the first twelve patients are presented in Figure 1. Compared to expert echocardiographic evaluation, the 3D flow method seems to overestimate the regurgitant volume in some patients with mild aortic regurgitation. This may be caused by limitations in lateral resolution. Due to failure of aligning the vena contracta within the sample volume, there is a significant underestimation of regurgitant volume in one patient (Figure 1: red dot). As 3D flow analysis is currently performed offline, this was not obvious at the time of recording. The 3D flow method clearly discriminates the other two patients with severe aortic regurgitation from the patients with mild or moderate regurgitation.

Conclusion

We find these preliminary results encouraging, motivating further work on method refinement and validation.

Abstract P1350 Figure 1
P1353 Left ventricular performance patterns in patients with dilated cardiomyopathy and advanced heart failure
Authors: Kinova E , Somleva D , Spasova N , Borizanova A , Goudev A
Published: January 2020

Background

Left ventricular (LV) global longitudinal strain (GLS) is a more sensitive parameter than ejection fraction in the assessment of LV function. It has been established as a predictor of cardiac death and adverse events. In patients with dilated cardiomyopathy (DCM) LV deformation and twist mechanics are reduced in varying degrees.

Purpose

The aim of the study was to determine different LV performance patterns in patients with DCM and advanced heart failure (HF).

Methods

In 52 patients with DCM with HF NYHA class III-IV (62 ± 13 years, 36 males) LV function had been assessed by conventional, Tissue Doppler and 2D-speckle tracking echocardiography (2D-STE) with measurement of GLS, circumferential strain (CS) and twist mechanics. Patients were divided into two groups: with GLS≥-7 %, and GLS<-7 %.

Results

In a group with more reduced GLS≥-7% systolic parameters were worse, Table. Systolic velocities of medial and lateral mitral annulus (S’lat), and CS at the LV basal and mid levels (CSmid) were significantly more altered. Rotational parameters did not differ between the groups. In a multivariate regression model CSmid (p < 0.0001; B = 0.66, 95%CI [0.37 ÷ 0.95]), S’lat (p = 0.001; B=-0.34, 95%CI [-1.5÷-0.46]) and VCW (p = 0.002; B = 0.31, 95%CI [0.15 ÷ 0.66]) were independent predictors of GLS. ROC curves identified CSmid (AUC 0.91, p < 0.0001) and VCW (AUC 0.69, p = 0.02) as the best discriminators of patients with severely reduced GLS≥-7%.

Conclusions

Patients with DCM and HF with severely depressed LV function assessed by GLS were characterized with more altered CS and more pronounced MR. Rotational parameters failed to be significant determinants of LV performance.

Echocardiographic parameters GLS≥-7% N = 24 GLS<-7% N = 28 p End diastolic volume index(ml/m²) 113.55 ± 41.64 87.98 ± 26.98 0.01 End systolic volume index(ml/m²) 84.50 ± 39.05 55.51 ± 21.93 0.001 Ejection fraction (%) 28 ± 8 35 ± 7 0.001 Systolic velocity of medial mitral annulus (cm/sec) 3.57 ± 0.81 4.88 ± 1.52 0.001 Systolic velocity of lateral mitral annulus (cm/sec) 4.38 ± 1.09 5.38 ± 1.42 0.014 Circumferential strain at basal level (%) -5.92 ± 3.15 55.52 ± 21.93 0.014 Circumferential strain at mid-level (%) -5.11 ± 1.77 -8.71 ± 2.34 <0.0001 Epicardial Torsion (°/cm) 0.31 ± 0.18 0.47 ± 0.35 0.05 Vena contracta width of mitral regurgitation (mm) 7.34 ± 2.23 5.58 ± 2.82 0.017 GLS - global longitudinal strain.
P1375 Echocardiographic estimation of right ventricle wall tension: hemodynamic comparison and long term follow up
Authors: Annone U , Bocchino P , Grosso Marra W , Milan A , D"ascenzo F , Magnino C , Montefusco A , Omede P , Veglio F , Rinaldi M
Published: January 2020

Introduction

Natural history of pulmonary hypertension (PH) is linked to right ventricle (RV) failure; in first phases of PH, coupling is preserved at the price of augmented RV wall tension (RVWT), which may represent an early sign of disease.

Methods

Patients with suspected PH, in absence of RV failure, underwent right heart catheterization and nearly-simultaneous echocardiography. We extrapolated RVWT from Laplace’s law as RV length × tricuspid regurgitation peak gradient (TRPG), and we correlated it with RV haemodynamic profile. Its impact on survival was tested.

Results

190 patients were enrolled; RVWT correlated with invasive measure of RV telediastolic pressure, mean pulmonary artery (PA) pressure, PA compliance, transpulmonary gradient, pulmonary vascular resistance, right atrial pressure and RV stroke work index (all p < 0.001). At a mean follow-up of five years and three months, RVWT predicted all-cause mortality at univariate and multivariate analysis (p 0.036, p 0,023); tricuspid annular plane systolic excursion (TAPSE) (p 0.536), RV fractional area change (p 0.383), RV S’ (p 0.076) and TAPSE/TRPG (p 0.181) did not.

Conclusions

We identified a novel echocardiographic predictor of precocious RV impairment, able to predict all-cause mortality at a long-term follow-up.

Regression: RVWT and invasive parameters Characteristics R - R2 p value mPAP 0.742 - 0.550 <0.001 PA pulsatory pressure 0.740 - 0.547 <0.001 RV differential pressure 0.794 - 0.630 <0.001 Mean RAP 0.326 - 0.106 <0.001 CI/RAP 0.209 - 0.044 0.012 RVSWI 0.326 - 0.106 <0.001 PA compliance 0.449 - .202 <0.001 PVR 0.531 - 0.282 <0.001 RV basal diameter 0.326 - 0.106 <0.001 RV medium diameter 0.403 - 0.162 <0.001 Right atrium area 0.204 - 0.042 0.013 RV FAC 0.382 - 0.146 <0.001 RV telediastolic area 0.347 - 0.120 <0.001 Correlation between RVWT and invasive haemodynamic parameters of RV function. mPAP, mean pulmonary artery pressure. RAP, right atrial pressure. CI, cardiac index. RVSWI, right ventricle stroke work index. PVR, pulmonary vascular resistance. RV, right ventricle. FAC, fractional area change.

Abstract P1375 Figure. RVWT and invasive hemodynamic profile
P1380 tissue Doppler and speckeled tracking of left ventricle post coarctation repair
Authors: Hassan F , Abdelsattar E , Emam S , Ebrahem R , Ebrahem H
Published: January 2020

Introduction

Left ventricular dysfunction was observed after repair of coarctation of the aorta (COA) before development of left ventricular concentric hypertrophy.

Aim

The aim of this study was to assess the the LV functions after COA repair.

Methods

Thirty pediatric patients with COA repair underwent echocardiographic examinations using Conventional echocardiography, tissue doppler image (TDI) and 2D-STE.

Results

The LV systolic functions assessed by TDI and 2-D-STE showed a significant reduction of (S׳׳LW LV, IVA at LW LV, IVA at the septum, longtudinal strain (LS) basal and global radial (GRS) in cases compared to control group . There is significant increase in GCS in cases compared to control group, the conventional Doppler derived MPI of LV in post coarctation repair cases was significantly prolonged compared to control. Analysis of mitral annulus velocities including E", A", E"/A" ratio and E/E′ ratio revealed worsening of the left ventricular diastolic mechanics in the post COA repair cases compared to healthy controls. The E" wave velocity (at the left ventricular lateral wall) was significantly lower in post COA repair in cases compared with controls , E"/A" ratio was significantly lower in post COA repair cases compared with controls . The E/E′ ratio was significantly higher in the post COA repair cases compared to the control group .

Conclusions

LV systolic and diastolic dysfunction was fount in patient after COA repair.

LV systolic function by 2-D-STE Cases Control P value Mean SD mean SD GLS -21.51 2.79 -22.63 2.99 .094 LS basal -19.94 2.83 -22.63 2.99 <0.01 (S) LS Mid -21.08 2.75 -21.87 2.78 .273 LS apical -23.52 4.22 -21.74 4.23 .109 GRS 22.58 5.24 49.01 10.08 <0.01 (S) RS basal 20.92 8.29 43.56 18.95 <0.01 (S) RS mid 25.03 7.59 56.80 14.27 .223 RS apical 21.78 8.34 46.66 15.11 <0.01 (S) GCS -20.09 2.66 -16.73 2.78 <0.01 (S) CS basal -21.49 2.70 -16.98 4.69 <0.01 (S) CS mid -21.27 4.09 -15.83 3.67 <0.01 (S) CS apical -17.51 4.63 -17.39 4.57 .920
P1389 Less dependent to loading conditions, TAPSE and S peak systolic tricuspid velocity are the 2 most robust indices to investigate right ventricular systolic function
Authors: Fauvel C , Raitiere O , Burdeau J , Si Belkacem N , Bauer F
Published: January 2020

Background

The daily challenge in pulmonary hypertension (PH) is to utilize a non-invasive echocardiographic parameter that is less load-dependent to follow-up right ventricular (RV) systolic function. VMAX, also called the maximum no-load contractile element velocity is known to be a strong load-independent contractility parameter, as good as the end-systolic pressure volume relationship that is simply obtained from pressure tracing.

Purpose

We aimed to investigate which among the 6 most common RV systolic function echocardiographic indices are less load-dependent by comparing them to VMAX.

Population

Sixteen patients scheduled for suspected or established PH had right-heart catheterization and ultrasound study the same day. Tricuspid annular plane systolic excursion (TAPSE), peak S tricuspid annulus velocity, both RV free wall and septal 2D strain, RV TEI index, tricuspid regurgitation - dP/dt and RV fractional area change were acquired from standardized echocardiographic protocol. The PressureWire Certus (Saint Jude Medical, Minnesota, USA) used to monitor invasive RV pressure is a 0.014" wire with high-fidelity sensor technology, operating with a frequency response of 0 to 25 Hz and exhibiting an accuracy of ± 1 mm Hg. A dedicated software was used to display simultaneously RV pressure and dP/dt and tracings where stored for offline analysis. VMAX was the y-axis intercept obtained by fitting a straight line through multiple points on the stress and pressure derivative curves by a least squares technique during isovolumic contraction.

Results

VMAX averaged 2.1 ± 0.9 length/s (range 0.80 to 4.43 length/s). The relationship is acceptable for the 2D strain (y = 0.08 x + 0.89, r = 0.53, p = 0.038) compared with VMAX, is improved between TAPSE and VMAX (y = 1.19x + 0.03, r = 0.76, p < 0.0001) but is best between peak S tricuspid annulus velocity and VMAX (y = 0.26 x – 0.60, r = 0.90, p < 0.0001). The TEI index, non-invasive dP/dt and right ventricular fractional area change did not correlate with VMAX. (FIG 1)

Conclusion

Both TAPSE and S peak systolic velocity are good markers of RV contractility with relatively load-independency in the setting of pulmonary hypertension.

Abstract P1389 Figure.
P1392 Association of iron deficiency with left ventricular longitudinal function abnormalities in patients with acute myocarditis
Authors: Kosmala W , Franczuk P , Jasic-Szpak E , Tkaczyszyn M , Drozd M , Sidorowicz N , Kulej-Lyko K , Walczak T , Zapolska A , Przewlocka-Kosmala M , Ponikowski P , Jankowska E A
Published: January 2020

Background

Recent evidence suggests that iron depletion may be involved in the pathophysiology of acute myocarditis (MCD), however no data on the contribution of this mechanism to the MCD-associated cardiac performance abnormalities are available. The decrease in longitudinal deformation is an early manifestation of left ventricular (LV) dysfunction. Nonetheless, global longitudinal strain (GLS) is afterload-dependent, and the estimation of myocardial work correcting GLS for changes in systolic blood pressure may permit a more adequate assessment of LV contractility.

Aim

We sought to investigate the association between iron status and LV function in patients with MCD.

Methods

We prospectively included 30 patients (age 32 ± 8 years; 97% male) hospitalized for acute MCD in a tertiary cardiology center. MCD was diagnosed based on the following criteria: 1) new onset symptoms suggestive of myocarditis (exercise intolerance, dyspnea, palpitations or chest pain), 2) elevated high sensitivity cardiac troponin I (hscTnI), 3) exclusion of obstructive coronary artery disease, 4) confirmation of myocardial oedema based on T2 mapping in cardiac magnetic resonance. On admission, each participant underwent echocardiography with LV strain and myocardial work (global work index [GWI], global constructive work [GCW], global wasted work [GWW], global work efficiency [GWE]) analysis, and laboratory assessment including the iron status markers: ferritin and transferrin saturation (TSAT). Iron deficiency (ID) was defined as transferrin saturation (TSAT) <20%; we did not use serum transferrin to categorize iron status because of the strong association of this marker with acute inflammation, which might affect the interpretation of its values.

Results

ID was found in 16 (53%) enrollees. Patients with reduced TSAT demonstrated lower GCW and GWI than their peers with normal TSAT (Table). No significant between-group differences were found for GLS, LV ejection fraction, early diastolic tissue velocity (e’) and E/e’ ratio. Both subsets did not significantly differ with respect to hemoglobin, creatinine, NT-proBNP, hscTnI and CRP. Both GWI and GCW significantly correlated with TSAT (r = 0.39, p = 0.03, and r = 0.37, p = 0.04, respectively). In multivariable analysis, after adjustment for patient age, body mass index, creatinine, hscTnI and CRP, TSAT was an independent predictor of GWI (beta = 0.40; p = 0.02) and GCW (beta = 0.38; p = 0.02).

Conclusion

In patients with MCD, ID defined as low TSAT is associated with a worse LV longitudinal performance as assessed by GCW and GWI, which might suggest a role of this pathophysiological pathway in the development of cardiac dysfunction. Myocardial work parameters seem to outperform GLS in diagnosing LV functional impairment in this clinical setting.

Abstract P1392 Figure.