bluuebunny/crossref_metadata_2025 huggingface dataset:
P664 Relationship of left atrial function assessed by 2D speckle tracking echocardiography with left ventricular systolic function in patients with degenerative mitral regurgitation
Authors: Melillo E , Palmiero G , Ferro A , Carlomagno G , Dell"urzo L , Ascione R , Caso V M , Severino S , Ascione L , Caso P
Published: January 2020

Funding Acknowledgements

none

Background

In degenerative mitral regurgitation (DMR), left ventricle (LV) and left atrium (LA) undergo progressive volume overload leading to chamber remodelling and dysfunction in advanced stages. Speckle tracking echocardiography (STE) is an estabilished technique able in detecting subclinical LA and LV dysfunction in this setting. However data are lacking on the relationship of LA and LV function in DMR patients.

Purpose

Our aim was to assess LA function in patients with DMR and to explore its possible correlations with LV dimensions and systolic function.

Methods

We enrolled 95 patients with mild to severe DMR, dichotomizing them on the basis of mitral regurgitation severity (DMR 1-2: mild and mild-to-moderate MR; DMR 3-4: at least moderate to severe MR). LA function was assesed with 2D speckle tracking echocardiography.

Results

The two groups were well matched. DMR 3-4 group (n= 48) showed higher LA and LV volumes, lower right ventricle longitudinal systolic function and higher values of systolic pulmonary pressure. There was not significant difference in LV ejection fraction (LVEF) and global longitudinal strain (GLS). Among LA function indexes, only peak systolic reservoir strain was significantly reduced in DMR 3-4 group (21,9± 6,2% vs 24,7± 7,2% ; p= 0,04). Then population study was further divided in two groups according to the presence (LA dys+) or absence (LA dys-) of LA dysfunction, defined as reservoir strain values below the median [median 23.7%; LAdys- group (n. 49), LAdys+ group (n.46) ]. At the comparison of continuous variables (Tab.1), LAdys+ group showed larger LV end systolic diameter and more impaired LVEF (60,9± 9,8% vs 65,4± 4,8%; p: 0,004) and GLS (20,04 ± 3,7% vs 23,53 ± 2,7%; p <0,001).

Conclusions

Our data showed that LA reservoir strain was impaired in patients with moderate to severe DMR. Furthermore, patients with LA dysfunction showed reduced LVEF and GLS values. Consequently, LA dysfunction assessed with STE may be a novel marker of early LV systolic dysfunction in patients with degenerative mitral regurgitation.

Tab.1 LAdysf- (n = 49) LAdysf+ (n = 46) P value LVESD (mm) 31.78 ± 4.1 34.74 ± 7.6 0.020 LAVI (mL/mq) 44.5 ± 15.1 55.6 ± 25.6 0.015 TAPSE (mm) 26.30 ± 3.96 24.02 ± 3.31 0.004 sPAP (mmHg) 31.4 ± 7.0 36.4 ± 10.9 0.009 LVEF (%) 65.4 ± 4.8 60.9 ± 9.8 0.004 GLS (%) 23.5 ± 2.7 20.0 ± 3.7 <0.001 Comparison of continuous variables between patients with and without LA dysfunction.
P665 Role of 2-dimensional speckle tracking echocardiography in improving diagnosis of coronary artery stenosis in stable angina pectoris patients
Authors: Eldeib M M
Published: January 2020

Background

conventional echocardiography at rest provides little information regarding the presence of CAD, Longitudinally orientated myocardial fibers are located subendocardially, the area most susceptible to ischaemia, that is why measurements of longitudinal motion and deformation may be the most sensitive markers of CAD using (2DSE) The aim of this study was to determine if 2DSE performed at rest can enhance the sensitivity of exercise test and if it can predict the presence of coronary artery disease in patients with stable angina pectoris.

Methods

our study included (120) subjects suspected to be stable angina pectoris patients presented for evaluation of chest pain at Al-Hussein University Hospital – Al-Azhar University – Cairo – Egypt between December 2013 and December 2015, The patients were classified according to coronary angiography results in to two groups:

Group (A): 40 patients with normal coronary angiography as a control subjects,Group (B): 80 patients with significant coronary artery disease.

Results

There was statistically significant difference between the two groups as regard E wave, A wave, E/A ration, DT, Em and E/Em, there was statistically significant difference between the two groups as regard SLSS and GLS 17 and GLS 12, there was statistically significant difference between the two groups as regard SLSr and Sr17and Sr 12, there was statistically significant difference between the two groups as regard ST segment deviation during stress ECG, exercise capacity (METs) and Duke Score,;in this study we found that strain parameters at BA, BAS, MA, MIS, MAS, AI and AL segments were found to be significant predictor of LAD stenosis and BP and MP were found to be significant predictor of LCX stenosis and BI was found to be predictor of RCA stenosis, also we found that strain rate parameters at BA, MA, MAS, AI, AL and apex segments were found to be significant predictor of LAD stenosis, and BL, BP and ML were found to be significant predictor of LCX stenosis and BI and MI were found to be predictor of RCA stenosis, the diagnostic performance of the exercise test was significantly improved by GLS17 in terms of a significant increased AUC for the exercise test in combination with GLS17 Conclusion: In patients with suspected SAP, GLS assessed by 2DSE at rest is a predictor of significant CAD and significantly improves the diagnostic performance of exercise test, and capable of identifying which coronary artery is stenotic.
P666 left ventricular filling pressure using E/E" ratio as a useful marker for predicting periprocedural myocardial injury following percutaneous coronary intervention in diabetic patients
Authors: Khalil M
Published: January 2020

Background

Identification of patients with risk of myocardial injury during PCI would allow targeted novel therapies capable of limiting the extent of this injury or reducing its patients number.CK-MB, Troponin-T and I have enabled the quantification of previously undetectable myocardial injury that can also be CMRI visualized.Elevated LV filling pressures are associated with adverse remodeling, HF, and worse survival.E" velocity (unlike others) appears to be relatively independent of preload, especially if myocardial relaxation decreased.In addition, early transmitral flow velocity /early diastolic mitral annulus velocity(E/E") ratio has recently been shown as the most accurate noninvasive predictor of high LV filling pressure.Purpose: evaluate the reliability and adverse outcome of high E/E" in predicting periprocedural myocardial injury.

Methods

60 adult diabetic patients with troponin negative CAD admitted for PCI were studied,then analyzed on the basis of post PCI troponin level:(positive and negative group).E/E" ratio was measured and compared with both groups.

Results

24 patients developed high troponin after PCI specially if PCI complicated or number of DES increased (p. value <0.001&0.027 respectively).Septal E" velocity was improved after PCI(p. value 0.031).E/E" ratio was high in troponin positive group as. Average e/e" ratio can differentiate between patient"s with troponin negative and positive values (predict periprocedural myocardial injury) with high p. value <0.0001,with cuttof value >10.7, with sensitivity and specificity(79.17% and 87.11%) respectively. Positive and negative predictive value for average e/e" ratio was (79.2 and 86.1) respectively.

Conclusions

E/E" ratio can provide useful information on LV filling pressure and can be used as a reliable biomarker for early prediction of periprocedural myocardial injury. But, further studies on a larger number of patients are needed for reliability.

Limitations

small sample size and pre-defined set of study parameters.

E/E" ratio and troponin Negative troponin Positive troponin p. value Mean± SD Median(iqr) Mean± SD Median(iqr) EF Biplane 55.8 ± 6.6 56(50:61.5) 53.8 ± 6.5 51(50:59.5) 0.289 LAV index 30.7 ± 4.6 29.5(28:35.5) 31.6 ± 3.6 33(28:35) 0.675 Average E/E" Post 9.1 ± 7.1 7.3(6.5:9.3) 15.9 ± 8.5 14.2(11.1:18.7) <0.001 Lateral E/E" Post 9 ± 6 7(6:9) 15 ± 7 13(11- 18) <0.001 Septal E/E" Post 10 ± 9 8(7:10) 17 ± 11 15(11:20) <0.001 comparison between focused echocardiographic variables & troponin post PCI
P669 Functional remodeling of the left atrium after first acute ST-elevation myocardial infarction: a 3D echocardiography study
Authors: Jarjour F , Civera S , Vijiiac A , Elnagar B , Palermo C , Torlai Triglia L , Previtero M , Muraru D , Badano L P
Published: January 2020

Background

Left atrium (LA) is a dynamic structure which is functionally coupled with the left ventricle and modulates its function in many cardiac conditions. The geometric and functional remodeling of the LA occurring early after myocardial infarction are poorly understood.

Purpose

We sought to evaluate the early changes in LA geometry and function occurring in survivors of a first acute ST-elevation myocardial infarction (STEMI), using three-dimensional echocardiography (3DE).

Methods

LA phasic volumes and strain (both longitudinal and circumferential) were measured using a dedicated automated software package in 54 patients at pre-discharge after STEMI, and in 54 age- and sex-matched healthy volunteers (controls), (figure 1).

Results

In STEMI patients, both maximal (LAV max) and minimal (LAV min) LA volumes were significantly larger than in controls 63 ± 15 vs. 53 ±11 ml; p = 0,002 and 38 ± 15 ml vs. 25 ± 6; p <0.0001 (respectively). Moreover, when compared to controls (Table 1). Both longitudinal (LASr) and circumferential strain reservoirs showed a significant negative correlation with peak cardiac troponin I values (r=-0.344; p = 0.007 and r=-0.357; p = 0.005, respectively) as an estimate of the extent of myocardial damage.

Conclusion

STEMI was associated to significant geometrical and functional remodeling of the LA which was correlated with the extent of myocardial damage.

Table 1 Controls STEMI patients P-value Longitudinal% LASr 21.8 ± 8.4 13.72 ± 8.27 <0.0001 LAScd -12.8 ± 8.48 -6.43 ± 4.74 <0.0001 LASct -9.73 ± 6.04 -7.26 ± 5.87 0.05 Circumferential % LASr-c 27.31 ± 8.07 18.92 ± 9.16 <0.0001 LAScd-c -11.2 ± 5.93 -6.46 ± 5.68 0.0002 LASct-c -16.22 ± 6.33 -12.41 ± 5.94 0.004 LASr longitudinal strain reservoir, LAScd: longitudinal strain conduit, LAScd: longitudinal strain contraction, LASr-c: circumferential strain reservoir, LAScd-c: circumferential strain conduit , LASct-c:circumferential strain contraction

Abstract P669 Figure 1
P692 Curious Bentall procedure complications, not always found in the immediate postoperative period
Authors: Blasco Turrion S , Gonzalez Perez P , Sanchez Brotons J A , Gomez Lopez A , Morales Ponce F J
Published: January 2020

Ascending aorta aneurisms are often diagnosed in patients around 60-70 years old with prior history of hypertension or smoking, or in younger patients with connective tissue illnesses, such as Marfan Syndrome (MS), or bicuspide aortic valve (BAV). In patients with MS an aneurysm of the aortic root, ascending aorta or acute dissection are the most frequent reasons of death, that is why an aggressive surgical approach is recommended, by repairing or replacing the diseased aortic root. Prophylactic aortic root surgery is an effective procedure in preventing acute dissection and rupture with excellent long-term outcomes as published in the literature, being the Bentall procedure usually the treatment of choice. However, the implantation of a mechanic aortic prosthesis makes permanent oral anticoagulation necessary with elevated haemorragic risk.

We present two peculiar cases of Bentall procedure with differentes indications, different scenarios but similar outcomes.

- Case A: A 75-year-old female with MS who underwent Bentall surgery in 1988 due to a severe AR, stable and asymptomatic since then. In a routine check-up in November 2017, a dilatation of 65mm in her native ascending aorta was detected on a computed tomography scan (CT), visualizing a half-moon shaped space between the ascending aorta and the aortic tube of 21x46mm and a leak from de aorto-ostial union, being possible to confirm with the TEE its origin in the left coronary ostium, which was also dilated (10mm), due to a dehiscence in the aortic tube suture on that level.

- Case B: A 43-year-old male who underwent Bentall surgery in 2014 due to a severe AR and aortic root aneurysm that in January 2017 was admitted to our hospital due to chest pain with no other symptoms associated. As part of the study and TTE, TEE and CT were performed in which a periaortic haematoma from de aortic root to the beginning of the aortic arch was found, visualizing a leak from a 5mm hole in the ostium of the right coronary artery. In addition, the left coronary artery had a severe stenosis (85%) due to the compression of the haematoma on that level.

Even though the Bentall procedure has excellent outcomes we discovered unusual either long and short-term complications due to dehiscence of the sutures, causing a huge peri-prosthetic tube haematoma, compressing the left main coronary artery in one of our patients which was the cause of the angina he presented with. We think these images could help the diagnostic process in future cases since these complications are not only found in the immediate postoperative period and should always be in our minds.

Abstract P692 Figure.
P695 Is reference value of left atrial strain using 2D echocardiography really reliable?
Authors: Takeuchi M , Negishi K , Nabeshima Y , Otani K , Otsuji Y
Published: January 2020

Funding Acknowledgements

MT received research grant from GE Healthcare.

Background

Left atrial (LA) longitudinal strain (LALS) assessed by two-dimensional echocardiography (2DE) speckle tracking analysis is increasingly popular for the estimation of left ventricular diastolic dysfunction and the prediction of adverse outcome. Since standard apical 4-chamber and 2-chamber views often maximize the long-axis of the left ventricle, and the long axis of the left ventricle and that of the left atrium do not lie on the same 2D cutting plane, these views have a risk for the foreshortening of the left atrium. It may cause overestimation of LALS due to the reduction of initial perimeter of region of interest that is a denominator for the strain calculation.

Purpose

The aim of this study was to compare LALS values between 2DE and 3D echocardiography (3DE) in healthy subjects, and investigate whether 2DE speckle tracking analysis overestimates reference value of LALS.

Methods

LALS and LA longitudinal length were measured by both 2DE and 3DE in 105 healthy subjects (median age, 42 years; 59 men). For 2DE, LA longitudinal length from the mitral annulus to the roof of the left atrium were measured on apical 4-chamber and 2-chamber views at end-diastole and at end-systole, and the values were averaged. Apical 4-chamber and 2-chamber LALS was also measured using 2DE speckle tracking software (EchoPac PC, GE Healthcare) for calculating biplane LALS. 3DE LALS was measured using new 3DE LA strain software (4D Auto LAQ, GE Healthcare). 3DE determined LA longitudinal length at both end-diastole and end-systole was also measured using the same 3DE datasets.

Results

Mean values of biplane LALS was 39.6 ± 11.8%. 2DE LA longitudinal length at both end-diastole (r=-0.43) and end-systole (r=-0.54) was negatively correlated with biplane LALS. Multivariable regression analysis revealed that both end-diastolic and end-systolic LA longitudinal length had a significant negative association for biplane LALS after adjusting anthropometric and echocardiography image quality parameters. 3DE LALS analysis was not possible in 11 subjects due to the erroneous LA border determination (Feasibility: 90%). 3DE LALS (23.7 ± 7.6%) was significantly lower than biplane LALS (39.5 ± 12.0%, p < 0.001) with a weak correlation (r = 0.33) in 94 subjects who were possible in both analyses. Paired comparison of LA longitudinal length between 2DE and 3DE revealed that 2DE determined LA length at end-diastole (3.51 ± 0.72 cm vs. 4.85 ± 0.56 cm, p < 0.001) and at end-systole (4.63 ± 0.69 cm vs. 5.84 ± 0.54 cm, p < 0.001) was significantly shorter than that obtained from 3DE.

Conclusions

Our results highlighted that LA cavity visualizing on the standard apical 4-chamber and 2-chamber views are often longitudinally foreshortened, and this is a potential cause for the overestimation of LALS. 3DE may overcome this limitation.
P701 Usefulness of echocardiography in diagnosis and monitoring in patient with pulmonary embolism during pregnancy, a case report
Authors: Starzyk K , Dybich P , Ciuraszkiewicz K , Rokita W , Wozakowska-Kaplon B
Published: January 2020

Pulmonary embolism is one of the leading causes of maternal mortality despite a low incidence of during pregnancy. We present 32-year-old woman, in the 35 week of first pregnancy, admitted to the Intensive Care Unit with dyspnea, tachycardia, cyanosis. Echocardiography confirmed the presence of embolic material in the main trunk of pulmonary artery, spreading to the right pulmonary artery. D-dimer and troponin T level were elevated, BNP remained within the normal range. The risk in PESI scale was assumed as intermediate high. LMWH therapy was initiated, the patient was constantly monitored. Venous thrombotic disease in lower extremities was excluded by ultrasonography. The treatment was carried out under obstetric supervision. The clinical state gradually improved, the patient was hemodynamically stable. Serial echocardiographic testing, revealed gradual regression of changes in the pulmonary trunk. Normalization of troponins and lowering of BNP levels were observed. The pregnancy was terminated in 39 week, by cesarean section (obstetric indications). The LMWH was continued few days after delivery, as the patient started lactation. She decided to terminate lactation in a first week after delivery so the therapy was switched into rivaroxaban for at least 3 months. Echocardiography after 3 month confirmed lack of changes in pulmonary trunk, the risk of pulmonary hypertension was low. Echocardiography can be a method of choice for confirming and monitoring pulmonary embolism during pregnancy, in a situation of high or intermediate clinical risk and good visualization of changes in pulmonary arteries

Abstract P701 Figure. Embolism of pulmonary trunk and RPA
P702 An unusual echocardiographic finding of protrusive vegetation caused by perivalvular abscess perforation into the left atrium
Authors: Suzuki S , Takeuchi Y , Hiramatsu N , Tsuneyoshi H , Shimada T
Published: January 2020

Background

It is well-known that Infective endocarditis (IE) caused by S. aureus progresses rapidly and is highly destructive. The most often abscess formation after aortic valve replacement (AVR) is the mitral-aortic intervalvular fibrosa (MAIVF). It is difficult to cure MAIVF radically once infection occurs, and then the abscess tends to spread. After abscess formation is once established, IE tends to be widespread, the prognosis is definitely poor unless surgical repairment is executed, and then an emergency surgery is essential and unavoidable for complete cure. We report an unusual case of aortic valve abscess with perforation of vegetation into the left atrium after aortic valve replacement.

Case report

A 77-year-old man underwent the bioprosthetic AVR for aortic valve stenosis one month ago. On the 9th day after discharge, he visited the hospital for the follow-up. At the time, the body temperature was 36.6 ° C, the blood pressure 133/50 mmHg, white blood cell count 10500/μL, and C-reactive protein 3.31 mg/dL. Transthoracic echocardiography (TTE) demonstrated the perivalvular abscesses on the prosthetic aortic valve and mass structures attached to the MAIVF in the left atrium (Figure A, C). He was hospitalized again and had an emergency re-operation. Intraoperative transesophageal echocardiography (TEE) showed a perivalvular abscess on the prosthetic valve, and a high-intensity structure (vegetation like) protruding from the Valsalva Sinus into the left atrium of the MAIVF (Figure B, D). Surgical findings did not reveal any wart on the native valve itself. One-third of the annulus was disrupted. The subvalvular tissue all around was abscessed. Notably, the abscess cavity between NCC and LCC reached MAIVF of the anterior mitral leaflet, and the structure projecting to the left atrium was vegetation. In this case, TTE pointed out a perivalvular abscess of the aortic valve, IE was suspected at the time of outpatient visit at an early stage after discharge, and the spread of inflammation was observed with a high speed beyond the expectation at the time of operation.

Conclusion

Early after the operation, TTE revealed a mass was protruded into the left atrium. Generally, vegetation is soft and flexible in itself. However, in this case, the vegetation was less mobile, and for that reason, abscesses or tumors were suspected. TEE enabled us to obtain anatomically more detailed information and to foresee the left atrial wall repairment at the time of reoperation. We reported an unusual case of IE with solid vegetation attached to the wall and difficult to diagnose.

Abstract P702 Figure.
P711 Rapid and severe decompensation of obstructive hypertrophic cardiomyopathy
Authors: Pascal A M , Scarlatescu A , Alexandrescu A , Dorobantu M
Published: January 2020

INTRODUCTION

Obstructive hypertrophic cardiomyopathy (HCM) is a complex disease which affects not only the ventricular walls, but frequently the mitral apparatus and the aortic valve are also involved. Many patients adapt over time tolerating different grades of pulmonary hypertension and heart failure (HF). However, complications such as severe valvulopathies, can often end up in difficult to manage situations.

CASE REPORT

A 46 years old woman was admitted for chest pain and heavy breathing. She was diagnosed with HCM at the age of 28, but her clinical course was stable since then. Her clinical examination, EKG and blood test showed no relevant modifications.

Transthoracic and transesophageal echocardiography

Important left ventricular outflow tract (LVOT) obstruction. Maximum wall thickness-23 mm. Severe subvalvular aortic stenosis: classical dynamic stenosis in HCM because of SAM, and a possible semicircular subvalvular aortic membrane. Severe mitral regurgitation due to ruptured chordae attached to the P2 scallop. Severe pulmonary hypertension. Pericardial effusion-maximum 16 mm. The cardiac catheterization noticed a cardiac output of 1.78 l/min.

The association of the severe mitral regurgitation to the LVOT obstruction results in a very low cardic output leading to acute heart failure. The pacient had surgical indication for the ruptured chordae. The heart team decided that the risks exceeded the benefits. The following few months were marked by multiple episodes of HF. After 6 months she died of cardiac arrest.

DISCUSSIONS

HCM is a genetic disease which associates numerous echocardiographic particularities. One of them is the elongation of the anterior mitral cusp and a greater laxity of the entire mitral valve, predisposing to mechanical complications. The particularity of this case is that although the patient adapted very well over time having obstructive HCM and secondary severe pulmonary hypertension, a complication of the mitral valve (ruptured chordae) resulted in a very low cardiac output and rapid decompensation.

The patient also associated pericardial effusion probabily secondary to severe pulmonary hypertension. Although the effusion was not large, in such cases with very low cardiac output, an impairment of the left ventricle’s diastolic function could be an important factor.

The management of a patient with obstructive HCM that associates a severe valvulopathy is always challenging. The use of diuretics has to be carefully managed, as this medication can be harmful by lowering the cardiac output even more. On the other hand, the diuretic’s dose has to be efficient on improving the symptoms.

CONCLUSIONS

Patients with obstructive HCM can develop a great variety of complications. In this case, the hyperlaxity of the mitral apparatus which accompanies this affliction led to a ruptured chordae and secondary severe mitral regurgitation. The valvulopathy severely decompensated a known cardiomyopathy resulting in acute HF.

Abstract P711 Figure. HCM
P720 Antenatal and postnatal echocardiographic diagnosis of Truncus Arteriosus III (TAIII) complicated by spontaneous PDA (patent ductus arteriosus) closure and LPA (left pulmonary artery) disconnection
Authors: Alabdulkarim N , Asahari A T I F , Alotay A M , Thabet SHERIF , Alqahtani TURKI
Published: January 2020

Introduction

TA III is a rare form of truncus arteriosus when the branch pulmonary arteries originate independently from the common arterial trunk or aortic arch, with origin of one pulmonary artery from the underside of the aortic arch from a ductus arteriosus.

Accurate diagnosis and timing of surgery is essential for survival of neonates affected.

Purpose

Illustration of various imaging modalities utilized to diagnose and manage this lesion and the importance of spontaneous PDA closure.

Results

TAIII diagnosed at 24 weeks gestation by fetal echocardiography images 1,2,3. Baby was spontaneously delivered at term with 3 Kg weight and 8,9 Apgar score. Diagnosis was confirmed by transthoracic echocardiography images 4,5 , however on 7th day of life routine echocardiogram was performed to assess PDA , markedly decreased flow noted in LPA/left pulmonary veins and no PDA could be seen at that time images 5,6.

Spontaneous ductal closure was confirmed by tomography image 7 then cardiac intervention performed to establish LPA patency image 8,9. Successful total repair was done within the neonatal period with excellent results at follow up ( image 10 at 3 years old).

Conculsions

1- TAIII can can be diagnosed and assessed by echocardiography.

2- PDA patency to maintain LPA continuity is essential in TAIII management.

3- Successful total surgical repair with good outcomes can be achieved for neonates with this rare complex cyanotic CHD.

Abstract P720 Figure. Images
P723 A dissecting thoracic aortic aneurysm presenting with mild symptoms in a young woman
Authors: Bardos K , Tomoaia R , Mada R , Beyer R , Gurzau D
Published: January 2020

Introduction

Acute aortic dissection is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat.

Case presentation

We present the case of a 29 years old young woman, brought to the emergency department with mild chest and back pain, shortness of breath on exertion with an onset of 12 days prior to admission. The patient has a history of 3 pregnancies delivered by natural birth and C-section (last one 2 years ago), but no personal cardiovascular disease history. She relates a family history of sudden cardiac death at a young age (mother, grandmother, great-grandmother) and a sister with diagnosed aortic aneurysm associated with a genetic mutation. Physical examination revealed a marfanoid habitus, diastolic heart murmur, low diastolic blood pressure (BP of 90/25 mmHg). Transthoracic echocardiography performed in the ED, discovered an anuloaortic aneurysm with a maximum diameter of 8.7 cm at the aortic root and a dissecting intimal flap of the ascending aorta up to the aortic arch. We also detected a dilated left ventricle with a low ejection fraction (30%) and a severe aortic regurgitation. The findings were confirmed by contrast-enhanced CT Angiography, showing the aneurysm of 8.4/8.7 cm and the intimal dissection flap with patency of both true- and false lumens. At this point we diagnosed an anuloaortic aneurysm with Stanford type A acute aortic dissection and a Marfan syndrome (according to the Ghent Nosology criteria). She immediately underwent surgery, the Bentall procedure was performed, consisting of a composite graft replacement of the entire ascending aorta and aortic valve, followed by direct implantation of the coronary arteries. Histopathological examination of the excised aortic wall reinforced the diagnoses of a connective tissue disorder. The early postoperative evolution was marked by the development of a left-sided hemiparesis and seizures, caused by an acute ischemic stroke. The patient was discharged after the complete resolution of the neurological symptoms under appropriate medication. Recommendations were made for periodic follow-up, genetic testing and the screening of her children after the age of 10 years old.

Conclusion

Discussions evolve around the interesting fact that she managed to survive 3 pregnancies, natural births and a C-section, without developing an aortic dissection or even a possible fatal rupture up until this presentation. It is imperative to mention that the lack of a follow-up from a general practitioner, who could have notice the signs of a possible connective tissue disorder, have possibly led to the development of such aortic sizes. The current guidelines sustain the importance of surgical approach in all types of ascending aortic dissection, the only treatment proven to increase the short- and long term mortality.

Abstract P723 Figure. Imaging studies
P726 Cardiac amyloidosis: unmasking the simulator
Authors: Sanchez Vega J D , Pascual Izco M , Ramos Jimenez J , Alonso Salinas G L , Carvelli A , Jimenez Nacher J J , Moya Mur J L , Garcia A , Hinojar Baydes R , Gonzalez A , Zamorano J L , Fernandez-Golfin C
Published: January 2020

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case
P750 Dynamics of tricuspid regurgitation after right ventricular lead implantation
Authors: Haydar M , Azzam E , Samniah N , Sharif-Rasslan A , Dobrecky Mery I , Sharif D
Published: January 2020

Placement of ICDs, permanent pacemakers, and biventricular devices is performed under fluoroscopic guidance. Implantable device leads can cause tricuspid regurgitation (TR) when they interfere with leaflet motion. In the past, we had the experience of 2 cases with RV lead who had severe TR; one had lead repositioning and the other needed surgery. Aim: Evaluation of TR after right ventricular (RV) permanent lead implantation to check if echocardiographic guidance is needed for adequate lead positioning. Methods: Seventy six patients had trans-thoracic Doppler echocardiographic studies before and after implantation of permanent RV leads. Results: Before RV lead implantation 96% of patients had TR, grade 1 in 57 patients (75%), grade 2 in 12 (16%), grade 3 and 4 in 4 (5%). After RV lead implantation 44 patients with grade 1 TR remained with the same degree (77%) while in 2 (3.5%) TR progressed to grade 2, and in the remainder the TR disappeared. Most of the patients with grade 2 TR before RV lead implantation (75%) remained in grade 2 while 25% the grade decreased to grade 1. In all the patients with grade 3 and 4 TR pre-implantation, the severity of TR decreased by one grade. In 56 patients with non-CRT device implantations, 39 (70%) had grade I TR before procedure and in 28 (72%) of them TR grade did not change and 11(28%) TR grade progressed to grade 2 after implantation. Grade 2 TR before implantation in 8 patients (14%), the TR grade decreased in3 (37.5%) and did not change in the others. In 3 (5.4%) patients with grade 3 and 4 TR before procedure, the TR decreased after procedure. Conclusions: Implantation of permanent RV leads did not worsen TR grade.
P761 Clinical manifestation of bicuspid aortic valve in single center registry
Authors: Nowak M , Marlega J , Strozyk A , Nowak R , Galaska R , Gruchala M , Fijalkowski M
Published: January 2020

INTRODUCTION

Bicuspid aortic valve (BAV) is a congenital cardiac defect which may contribute to aortic stenosis (AS) and regurgitation (AR), aortopathy, endocarditis or in some group of patients remains without echocardiographic deviations. Prognosis of BAV population is hardly predictable. Nevertheless, the population of BAV requires regular medical control.

PURPOSE

The aim of our study was to assess the BAV appearance and characteristics in the Single Center Registry.

METHODS

All patients with recognition of BAV admitted to First Department of Cardiology at Medical University of Gdansk in years 2012-2018 were enrolled to analysis. Echocardiographic data were collected. Anthropometrics and comorbidities were recorded. Patents were categorized depending on BAV phenotype: coronary cusps fusion (Type 1), right-noncoronary cusps fusion (Type 2), left-noncornary cusps fusion (Type 3) and BAV without raphe (True Type).

RESULTS

323 (25,7% female) patients were enrolled into the Registry. Average age of studied group was 55 ± 16.0. 190 (58.8%) patients were characterized by Type 1 BAV, 75 (23.2%) by Type 2 and 8 (2.4%) by Type 3. There were only 3 patients with True Type. In 14.5% of patients we were unable to clearly identify BAV phenotype. For the further analysis there were included Type 1 and Type 2 groups due to low prevalence of other types. Patients with Type 2 were slightly younger (51.3 ± 16.2 years vs 57.5 ± 13.4 years in Type 1 group; p < 0.01). The aortopathy appeared in 221 patients (68.4% of studied group). Type 1 was associated with larger diameter of aortic root comparing with Type 2 (40.7 ± 6.0 mm vs 38.7 ± 10.6 mm, respectively; p < 0.001), without significant difference in ascending aorta diameter (42.3 ± 7.1 mm in Type 1 and 40.9 ± 6.7 mm in Type 2; p = 0.19). In contrary, Type 2 was correlating with the higher prevalence of severe AR (16% vs 5.7% in Type 1; p < 0.01). Prevalence of AS was similar in both groups (48.4% in Type 1 and 37.85 in Type 2; p = 0.1). In the subgroup with severe AS (75 patients), there was no significant differences in the hemodynamic profile of AS between Type 1 and Type 2 group (respectively; peak transvalvular velocity- 4.5 ± 0.5 m/s2 vs 4.3 ± 0.6 m/s2, p = 0.2; mean transvalvular pressure- 54.2 ± 13.6 mmHg vs 46.6 ± 13.8 mmHg, p = 0.08; aortic valve area- 0.7 ± 0.1 cm2 vs 0.8 ± 0.1 cm2, p = 0.5). 4.3% of studied group were hospitalized due to endocarditis. Average age in that subgroup was 42.3 ± 12.0 years. There was no correlation between BAV phenotype and endocarditis prevalence.

CONCLUSION

Despite higher prevalence of severe AR in patients with Type 2 BAV, Type 1 is more predisposing to aortic root abnormalities. That discrepancy may confirm complex pathophysiology of BAV complications. Prevalence of AS and hemodynamic profile of severe AS does not present correlation with the type of BAV phenotype.
P762 Preserved mitral apparatus dynamics predict the improvement of acute ischemic mitral regurgitation: four-dimensional quantitative echocardiographic study
Authors: Kimura T , Watanabe N , Nishino S , Kuriyama N , Ashikaga K , Nishihira K , Furugen M , Shibata Y
Published: January 2020

Background

We sought to evaluate the predictive value of acute stage mitral apparatus geometry and dynamics for the reduction of ischemic mitral regurgitation (IMR) in the remote phase after successful primary percutaneous coronary intervention (pPCI) by using real-time 3D-transthoracic echocardiography (3D-TTE).

Methods

We performed 2D and 3D-TTE in consecutive 44 first acute MI patients with more than mild IMR within 3 days after successful pPCI. 3DTTE of left ventricle (LV) volumes and mitral apparatus dynamics through the cardiac cycle were quantified offline. We compared the 3D geometric and dynamic parameters in the acute phase between 1)20 remained MR group and 2)24 improved MR group in 6-to-12 months after MI onset.

Results

Ejection fraction (EF) was preserved in the improved MR group compared to the remained MR group (49.0 ± 11.2 vs. 56.5 ± 7.0%, p = 0.013). Mitral valve annulus area, leaflet tenting length and papillary muscles spatial position had no significant difference between the two groups (all p > 0.05) throughout cardiac cycle. In contrast, mitral annulus saddle shape was preserved in the improved MR group than the remained MR group (p = 0.010) and annular area changed dynamically through early- to late-systole in the improved MR group (phasic p = 0.017) despite it was adynamic in remained MR group (phasic p = 0.201). Conclusions: IMR improvement in the remote phase after AMI associated with preserved EF, mitral annulus saddle shape and dynamics during systole in the acute phase of MI. 4D dynamics of the mitral apparatus can be clinically useful predictor of the improvement in acute IMR and may contribute to the clinical decision making including surgical or percutaneous intervention for IMR.
P770 Does intraoperative transesophageal match postoperative echocardiography in mitral valve surgery?
Authors: Alves P , Marinho V , Branco C , Ramalho A R , Maldonado M J , Coutinho G , Prieto D , Goncalves L , Antunes P
Published: January 2020

BACKGROUND

Intraoperative transesophageal echocardiography (iTEE) has an important role in mitral valve (MV) surgery, but may have dissimilar parameters from postoperative echocardiography (post-TTE). We aimed to evaluate iTTE Doppler flow profile and compare with the post-TTE in MV surgery.

METHODS

We conducted a prospective, observational study of 126 patients that underwent MVsurgery during 2 years. iTEE evaluated mean pressure gradient (MPG) and functional area. Patients were re-evaluated with TTE, 72 hours after surgery (post-TTE). iTEE and post-TTE Doppler values were compared and correlated. Preoperative TTE (pre-TTE) parameters were also determined.

RESULTS

The mean age was 59 ± 18 years and 55% were female. The prevalence of severe mitral regurgitation (MR) was 77.6% and severe mitral stenosis (MS) 23.7%. Globally, mitral valve repair was performed in 71%cases (83% for MR and 15% for MS) and replacement in 29% (64% for MR and 46% for MS). Left ventricular ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), tricuspid annular plane systolic excursion (TAPSE) assessed in pre-TTE and post-TTE, as also MPG and functional area in post-TTE and iTEE are depicted on table 1. There was a higher numerical difference in iTEE vs post-TTE MPG values in mechanical valves (n = 5) (3.5 ± 1.2 to 5.2 ± 1.6, difference of 1.65 ± 2.4mmHg), than in biological valves (n = 17) (3.1 ± 1.1 to 3.9 ± 1.5, difference of 0.8 ± 1.7mmHg). Globally, iTEE-derived MPG and functional area were strongly correlated with their post-TTE values (r2 0.7 and 0.8,p < 0.001).

CONCLUSIONS

iTEE Doppler parameters were strongly correlated with postoperative TTE parameters, with minimal differences: postoperative MPG were +0.4 ± 1mmHg higher in MV repair and +1.0 ± 1.8mmHg in MV replacement. There was a global improvement in sPAP. Our study demonstrates the usefulness of iTEE and its importance in stablishing possible reference values for postoperative follow-up.

MR MS pre-TTE post-TTE P value pre-TTE post-TTE P value LVEF (± SD,%) 57 ± 9 52 ± 10 <0.001 58 ± 6 56 ± 7 <0.001 sPAP (± SD,mmHg) 42 ± 17 33 ± 9 <0.001 47 ± 18 35 ± 6 <0.001 TAPSE (± SD,mm) 18 ± 2 14 ± 3 <0.001 18 ± 2 14 ± 3 <0.001 MV repair MV replacement iTEE post-TTE P value iTEE post-TTE P value MPG (± SD, mmHg) 2.8 ± 1.5 3.1 ± 1.4 0.084 3.2 ± 1.4 4.2 ± 1.6 0.016 Functional Area (± SD, cm2) 2.8 ± 0.6 2.8 ± 0.7 0.665 2.8 ± 0.6 2.7 ± 0.8 0.653
P778 Evaluation of left auricular and ventricular subclinical function by strain imaging in a cohort of hereditary TTR + amyloidosis
Authors: Aceves Velazquez E D , Guzman Ayon A M , Gonzalez Duarte A , Vasquez Ortiz Z Y
Published: January 2020

Hereditary amyloidosis represents 10% of all amyloid deposit diseases. Cardiac involvement clinically presents as heart failure. As advanced imaging methods have become available, subclinical detection of cardiac involvement has become a must in those patients since it changes the prognosis of the disease. The objective of the present paper was to determine if echocardiographic parameters of auricular and ventricular mechanics better predict cardiac involvement compared to the classic echocardiographic parameters suggestive of amyloid deposit in the heart.

This was a prospective, observational and descriptive study of a cohort of 30 patients with diagnosis of hereditary TTR+ amyloidosis without known cardiac involvement. We performed 2 and 3D echocardiography with left auricular and ventricular mechanics by strain method. Each patient was evaluated at the beginning of the study and at a 1-year follow-up visit.

The grade of diastolic disfunction increased from a normal diastole in 67% of patients to only 53% at 1-year follow-up. The antero-posterior diameter of the left atrium increased (p = 0.04), the E/e’ Index also increased (p = 0.01), both suggestive of increased left ventricular filling pressures. The LVEF, as a classic parameter of left ventricular function remained normal in 97% of patients during follow-up. No differences were found in terms of systolic ventricular mechanics; however, diastolic mechanics were altered. Untwist was increased (p = 0.02) and the reservoir auricular function was decreased from 34 to 30% (p = 0.03). Table.

Echocardiographic strain and 3D echocardiography can show changes early in patients with cardiac involvement in patients with hereditary TTR+ amyloidosis.

Statistically significant results Variable Basal 1 year follow-up P Left atrial anteroposterior diameter (mm) 32.8 ± 5 35.1 ± 5.6 0.004 Ventricular mass (gr/m2SC) 70.7 (61-90.8) 82.6 (69.2-113.7) <0.0001 Left ventricular telediastolic volume (ml) 37.2 ± 11 41.6 ± 11.6 0.03 Mitral A velocity (ms) 113.7 ± 28.6 130.5 ± 19.5 0.03 Lateral e mitral velocity (cm/s) 13.8 ± 5.5 12.4 ± 4.8 0.04 Mitral E/e’ index 7.9 ± 5.2 9.5 ± 5.5 0.01 Untwist 110.8 ± 49.9 127.5 ± 62.6 0.02 Reservoir auricular strain (%) 34.8 ± 8.6 30.8 ± 9.4 0.03 Telesystolic left atrial volume (ml) 25.9 ± 8.8 27.4 ± 11 0.01 Telediastolic left atrial volume (ml) 42.5 ± 12.9 40.7 ± 13.7 0.03 Left atrial ejection fraccion (%) 0.42 ± 0.20 0.34 ± 0.18 0.03 Table 1. Statistically significant results.
P783 Global longitudinal strain detects trastuzumab induced cardiotoxicity early in a clinical population
Authors: Grylls J , Ellis C , Ingram T , Lee E
Published: January 2020

Background

Trastuzumab is highly effective in the treatment of breast cancer, and is often used as an adjuvant therapy. Due to its potential cardiotoxicity, serial monitoring of cardiac function is vital. Ejection fraction (EF) by two-dimensional echocardiography is routinely used but has limitations in measurement variability. Myocardial deformation imaging, in particular Global Longitudinal Strain (GLS), can detect pre-clinical myocardial dysfunction. However, its use is not yet adopted into routine clinical practice.

Aims

Our aim was to ascertain if a clinically significant reduction in GLS (≥11% from baseline) occurred before the onset of EF reduction, in patients who developed cardiotoxicity whilst receiving trastuzumab.

Methods

Between January 2014 and January 2019, 235 consecutive patients received trastuzumab and underwent serial echocardiography at 3 monthly intervals at our institute. Cardiotoxicity is defined as a ≥10% EF reduction from baseline or an EF <50%. Women who developed cardiotoxicity as defined by this change in EF were retrospectively studied.

Two-dimensional speckle tracking was used to derive peak longitudinal strain in each myocardial segment from the apical four-, three- and two-chamber view images. GLS was taken as the average value of all these segments. The median time to ≥11% GLS reduction and ≥10% EF reduction or EF <50% was compared.

Results

Thirteen women (mean age 53 ± 9.5 years) developed cardiotoxicity. EF was 61.8 ± 4.4% at baseline and 45.7 ± 7.5% following therapy (p = 0.00). A ≥11% reduction in GLS from baseline was observed in all patients: GLS -20.2 ± 1.5% and -15.6 ± 2.1%, p = 0.00. The median time to cardiotoxicity as defined by EF and GLS was 6 months and 3 months, respectively (p = 0.031), as shown in Table 1. Repeatability analysis showed both EF and GLS measurements in our cohort have good measurement reproducibility. Inter-observer intraclass correlation (ICC) for EF and GLS were 0.912 and 0.913, respectively. Intra-observer ICC for EF and GLS were 0.925 and 0.900, respectively.

Conclusion

Cardiotoxicity developed in a significant portion (6%) of our patients receiving trastuzumab. As a reduction in GLS was detectable early and preceded that of EF by 3 months, this may represent a therapeutic window for initiation of cardio-protective medication, if and when the use of GLS is incorporated into routine practice for cardiotoxicity surveillance.

Table 1: Summary of Findings. Baseline Cardiotoxicity Paired t-test p value Median time of onset EF 61.8 ± 4.4% 45.7 ± 7.5% P < 0.01 6 months* GLS -20.2 ± 1.5% -15.6 ± 2.1% P < 0.01 3 months* *denotes exact sign-test p < 0.05.