bluuebunny/crossref_metadata_2025 huggingface dataset:
P253 EFFECTS OF COLCHICINE TREATMENT AFTER MYOCARDIAL INFARCTION ON TOP OF STANDARD THERAPY: EVIDENCE FROM A PRECLINICAL STUDY
Authors: Aimo A , Burchielli S , Aquaro G , Barison A , Musetti V , Masotti S , Pucci A , Galvez–Monton C , Martinez–Falguera D , Passino C , Emdin M , Bayes–Genis A
Published: May 2023

Background

An intense inflammatory and fibrotic response after myocardial infarction (MI) may lead to scar expansion and left ventricular (LV) remodeling, increasing the risk for ventricular arrhythmias and heart failure. Colchicine is an anti–inflammatory drug that has been reported to improve the outcome of patients with MI; its effects on LV remodeling have not been specifically investigated. We aimed to characterize the effects of the anti–inflammatory drug colchicine in an animal model of reperfused MI.

Methods

In 4–month–old pigs, MI was induced by occluding the LAD artery through an angioplasty balloon for 90 minutes. Pigs surviving MI induction were randomized in a 1:1 fashion to 2 arms: – control group (n=13): MI induction and reperfusion, standard treatment (the same therapies as in the rat study), – colchicine group (n=13): MI induction and reperfusion, standard treatment plus colchicine. The pigs underwent a first CMR scan 72 hours after MI induction, and another CMR at day 30. The pigs were then sacrificed the day after the second CMR. The primary efficacy endpoint was LGE mass (as a percentage of LV mass).

Results

The infarcted area at 72 hours (expressed as absolute mass or as a percentage of the LV mass) and the changes over 1 month did not differ significantly between pigs on colchicine plus standard therapy vs. those on standard therapy alone. When assessing the extent of fibrosis on the explanted hearts (as a percentage of the tissue sample areas) there was a trend toward a lower extent of myocardial fibrosis in pigs on colchicine plus standard therapy (p=0.091). The percent differences in LV volumes, ejection fraction and mass across the two CMR scans did not reach statistical difference.

Conclusions

The results from a pig model of reperfused MI suggest that colchicine has no additional effects to standard MI therapy on MI size and LV remodeling.
P254 "GHOST" IN RIGHT VENTRICLE: AN ECHOCARDIOGRAPHIC FINDING AFTER TRANSVENOUS LEAD EXTRACTION
Authors: Samperi S , De Matteis G , Castro A , Loricchio M , Trambaiolo P , Romano S , Granatelli A
Published: May 2023

Introduction

Prolonged antibiotic therapy and complete hardware removal are recommended in definite cardiac device–related infective endocarditis (CDRIE), as well as in presumably isolated pocket infection, in class I. A tubular mobile mass, known as ghost, that previously surrounded the lead can be detected by ultrasounds, in 8–14% of patients undergoing transvenous lead extraction (TLE). Case presentation: A 72–year–old man with ischemic cardiomyopathy is referred to our center due to a persistent fever. His medical history shows a previous extraction of CRT–D for infection of the left infraclavicular pocket, with a new implantation of CRT–P on the right side of the chest, in consideration of the recovery of the ejection fraction. At the entrance to the ward he has fever and inflammation‘s signs of the pocket of the generator, with positive blood cultures for Staphylococcus Aureus Methicillin resistant. A transesophageal echocardiography (TEE) excludes vegetations of valve systems and electrocatheters. Therefore, the patient begins antibiotic therapy and undergoes full extraction of the device (generator and leads). A post–operative transthoracic echocardiography shows the presence of a linear image of 2.5 cm in the right ventricle, seen as remnants of scar tissue surrounding the lead. ECG monitoring detects phases of BAV 2:1. Considering the high risk of infectious disease, a pacemaker leadless implantation is indicated. The surgery is postposted at the end of the 4 weeks of antibiotic therapy, checking blood cultures before implantation to reduce the residual infectious risk.

Discussion

The persistence of fibrous residues after TLE has been variously described in recent years, but it is unclear whether these are predictors of increased mortality. The current guidelines on the therapeutic management of patients with infectious endocarditis and pacemaker dependency do not indicated the timing of reimplantation, in a potentially infectious ghost setting. Clinical co–morbidities play a crucial role in the prognosis of patients, especially when combined with systemic infections.

Conclusion

An echocardiographic follow–up is recommended to detect ghost disappearance in patients undergoing explant due to a related device infection. In fact, a rapid fibrin dissolution process usually takes place when the thrombogenic stimulus is removed.
P255 A GOOD PERSPECTIVE NEEDS TWO POINT OF VIEW: TRANSVENOUS CRT–D LEAD EXTRACTION COMPLICATED BY INTRAOSSEUS COURSE OF THE CORONARY SINUS LEAD
Authors: Sbragi S , Parollo M , Segreti L , Del Corso A , Carluccio M , Di Cori A , Barletta V , Mazzocchetti L , Paperini L , De Lucia R , Viani S , Canu A , Grifoni G , Cellamaro T , Branchitta G , Soldati E , Zucchelli G
Published: May 2023

A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.
P274 LEFT ATRIAL STRAIN RESPONSE TO HEART RATE IN PATIENTS AFFECTED OR NOT BY CHRONIC HEART FAILURE: CLINICAL CORRELATES
Authors: Di Terlizzi V , Corbo M , Barone R , Goffredo G , Manuppelli V , Pellegrino P , Ieva R , Brunetti N , Iacoviello M
Published: May 2023

Background

and aim of the study. Left atrium (LA) is poorly understood in many pathological conditions and it is often considered a passive bystander of these pathophysiologic alterations. In the setting of impaired heart rate related LV response, the LA function could play a relevant role. The relevance of LA has been also recently demonstrated by studies which have evaluated its function by using new echocardiographic techniques such as two–dimensional speckle tracking evaluation (2D–STE). The aim of this study was to evaluate the relationship between changes in LV and LA function, assessed by 2D–STE, in response to the increase of heart rate (HR) in a group of patients carrying a pacemaker (PM) or an implantable cardioverter defibrillator (ICD).

Methods

We enrolled 45 patients. Among them, 38 were evaluated with LA strain. 31 patients were affected by CHF, among whom 18 with implanted cardioverter defibrillator (ICD), 13 with ICD and cardiac resynchronization therapy (ICD–CRT) and 7 without CHF who had a PM implanted. All were in clinically stable conditions for at least 30 days and in conventional medical therapy. Starting from basal values, HR was increased by 10 beats/min programming the implantable devices at higher atrial stimulation frequencies to max 90 beats/min. At each HR, echocardiography was performed and for left atrium the strain of reservoir (LAr), strain of conduit (LAcd) and contraction (LAct) were calculated (figure 1). Changes in left ventricle global longitudinal strain (LVGLS) were also calculated.

Results

The LAr shows a significant reduction from baseline at a heart rate of 90 bpm in conjunction with a significant change in the LAcd. No variation in LAct was observed at the various frequencies. Among the 38 patients, 29 showed a worsening of LVGLS and 9 no worsening with increasing heart rate. We demonstrated a close relationship between LV and LA function assessed by longitudinal strain measures (figure 2). A significant decrease in LAr was observed in patients with worsening LV–GLS that was not evident in patients with no or improvement.

Conclusions

Our study demonstrates that, in chronic HF outpatients, HR increase has different and heterogeneous effects on the LA function, assessed by STI and this response is more frequent among patients with LV systolic dysfunction. These results could be useful for guiding the optimal heart rate responsiveness of the implanted devices.
P275 COMBINED NEURO–HUMORAL MODULATION AND OUTCOME IN PATIENTS WITH CHRONIC HEART FAILURE AND MILDLY REDUCED OR PRESERVED EJECTION FRACTION
Authors: Gori M , Marini M , Gonzini L , Carigi S , De Gennaro L , Gentile P , Leonardi G , Orso F , Tinti D , Lucci D , Iacoviello M , Navazio A , Ammirati E , Municinò A , Benvenuto M , Cassaniti L , Tavazzi L , Maggioni A , De Maria R
Published: May 2023

Background

Drug therapy of patients with chronic heart failure (HF) with mildly reduced (HFmrEF) and preserved ejection fraction (HFpEF) remains a challenge. We aimed to assess whether escalating neuro–humoral–modulation (NHM) (renin–angiotensin system inhibitors (RASI), betablockers (BB), mineralocorticoid receptor antagonists (MRA)) was differentially associated with outcome according to phenotype and age groups.

Methods and Results

Between 1999 and 2018 we recruited in a nationwide cardiology registry 4707 patients (HFmrEF n=2298, HFpEF n=2409) and classified them into 3 age groups: young (<65 years), old (65–79 years), oldest–old (80+ years). We analysed clinical characteristics and 1–year all–cause mortality/cardiovascular hospitalization according to none/single (RASI or BB or MRA), double (RASI+BB or RASI+MRA or BB+MRA), or triple (MRA+RASI+BB) NHM. Overall, approximately half of HFmrEF and HFpEF patients had double–NHM. Among HFmrEF, 25.1% received no/single and 26.7% triple NHM. In the HFpEF group, 36.5% had no/single and 17.9% triple NHM. Older age was associated with a higher prescription of no/single NHM among HFmrEF patients (ptrend=0.001); the reverse was observed among HFpEF patients (ptrend =0.005). Prescription of triple NHM increased over time in both phenotypes (all p for trend<0.0001). Compared to no/single NHM, triple, but not double, NHM was associated with better outcome in both HFmrEF (HR 0.700, 95% CI 0.505–0.969, p=0.032) and HFpEF (HR 0.700, 95% CI 0.499–0.983, p=0.039), with no interaction between NHM and age groups (p=0.58, p=0.80, respectively).

Conclusions

In a cardiology setting, among HF outpatient with EF>40%, prescription rates of triple NHM increased over time and were associated with better patient outcome.
P279 IMPACT OF COVID–19 DIAGNOSIS ON HOSPITALIZATION AND MORTALITY RATES IN PATIENTS WITH ISCHEMIC STROKE ADMITTED DURING THE 2020 PANDEMIC IN ITALY
Authors: Rosato S , D’ Errigo P , Giordani B , Seccareccia F , Badoni G , Tavilla A , Mureddu G , De Luca L , Baglio G
Published: May 2023

Background

and purpose. We sought to evaluate the impact of the Covid–19 infection on hospitalization and mortality rates in patients with ischemic stroke admitted during the 2020 pandemic in Italy.

Methods

We analysed a nationwide, comprehensive, and universal administrative database of consecutive patients admitted for ischemic stroke during and after the national lockdown for Covid–19 infection in 2020 and the equivalent periods of the previous 5 years in Italy. The 2020 observed rates of hospitalizations and mortality of stroke patients with and without Covid–19 infection were compared with the expected rates, according to the trend of the previous 5 years.

Results

During the period of observation, 300,890 hospitalizations for ischemic stroke occurred in Italy. In 2020, 41,302 stroke patients (1102 with concomitant Covid–19 infection) were admitted at 771 centers. The rate of admissions for ischemic stroke during the 2020 pandemic was markedly reduced compared to the previous years (percentage change –23.5). Based on the 5–year trend, the 2020 expected rate of 30–day and 1–year mortality was 9.8% and 23.9%, while the observed incidence of death was 12.2% and 26.7%, respectively (both p<0.001). After multiple corrections, the higher rate of mortality was observed among patients admitted for stroke with a concomitant Covid–19 diagnosis.

Conclusions

During the Covid–19 pandemic in 2020 in Italy, the rate of hospitalizations for ischemic stroke was dramatically reduced, while both 30–day and 1–year mortality was increased, especially in those with a Covid–19 diagnosis, compared to the previous 5–year trend.
P284 POTENTIAL PROARRHYTHMIC SIDE EFFECT OF HIGH DOSE AND PROLONGED SODIUM NITROPRUSSIDE INFUSION THROUGH CALCIUM ION REDUCTION
Authors: Fazzini L , Gori M , Calabrese A , Giammarresi A , Iorio A , Manca P , Quarta G , Perra F , Cadeddu Dessalvi C , Senni M
Published: May 2023

Patient presentation. A fifty y/o male patient with a history of congenital aortic stenosis surgically corrected previously and with chronic heart failure due to severe left ventricular dysfunction presented to our emergency department complaining dyspnea. Due to acute decompensated heart failure with ongoing cardiogenic shock, he was admitted to our intensive cardiology unit. Initial work up. The blood exams showed a normal renal and liver function, normal total and free calcium, 9.4 mg/dL and 1.16 mmol/L respectively, lactates were mildly increased. The chest x–ray showed pulmonary congestion. At the echocardiography we found severe biventricular dysfunction, moderate mitral regurgitation, severe pulmonary hypertension. Since the patient was unstable, adrenaline, high–dose sodium nitroprusside (SNP), and intra–aortic balloon pump were started. The right heart catheterization revealed combined pulmonary hypertension reversible with SNP and, therefore, the patient was inserted in the heart transplant list. Diagnosis and Management. One of the side effects of SNP is the thiocyanate toxicity. A high dose of SNP was necessary for this patient (2.2 mcg/kg/min). Thus, thiocyanate levels increased up to 10 mg/100 mL (NV<3). Importantly, the patient was asymptomatic despite these levels. However, the free calcium ion progressively decreased up to 0.94 mmol/L, despite normal total calcium and calcium supplementation iv and orally. Since arrhythmic burden markedly increased, we started lidocaine which was not effective. Follow–up. Since we suspected a possible causative role of thiocyanate, which might bond the double positive charged free calcium ion with its two negatively charged sulfur atoms, explaining the normal total calcium level and the low calcium ion, we carefully reduced SNP dose within days. This allowed us to reduce thiocyanate to 6 mg/100 mL, without compromising patient hemodynamics. Concomitantly, the free calcium ion tended to normalize, lowering the arrhythmic burden.

Conclusions

We describe for the first time a proarrhythmic side effect of prolonged SNP infusion, likely related to thiocyanate accumulation and free calcium ion binding, which, despite aggressive calcium supplementation, was normalized only after SNP down titration.
P292 “CAN MIXED REALITY IMPROVE THE RESULTS OF TAVI?”
Authors: Martorana A , Paduvakis I , Cerillo A , Stefano P
Published: May 2023

Background

and Aim: Although the rate of TAVI–related complications has consistently reduced during the last decade, vascular complications still occur, and can be serious. Mixed reality (MR) can be defined as a three–dimensional real world simulation allowing the user to directly interact with it. The present study was designed to explore the potential of MR in facilitating the vascular access and navigation with large–bore devices.

Methods

3D holograms were generated from the CT’s of 20 TAVI patients (age 81.2±6.8 years, STS score 5.1±2.1) and made available to 2 surgeons in training. Different layers were generated: Skin, Arterial tree, and Calcium. A needle simulator was also available. The vascular puncture was echo guided. 2 percutaneous suture system were used to secure the hemostasys.

Results

All the procedures were carried out through the planned access. In 2 patients intravascular lythoplasty was used. There were no vascular complications, and procedural success was 100%. A single puncture was necessary to obtain vascular access in 19/20 patients and in 2 cases the echo was not used, and the operator decided to switch to angio–guided puncture due to the bad quality of the echo images that were in contrast with MR.

Conclusion

MR can be used to predict the optimal puncture site for TAVI. The interactive 3D holograms can be used to identify relevant repere on the skin and to reduce the rate of vascular complications and could become a powerful tool for procedural planning, training and remote proctoring.
P295 WHEN TAVI IS THE RIGHT CHOICE
Authors: Cammardella A , Russo M , Ranocchi F , Pergolini A , Giannelli V , Pellicelli A , Musumeci F
Published: May 2023

Clinical case

We describe a case of a 62–y–old man, affected by hypertension, insulin–dependent diabetes mellitus, advanced liver cirrhosis. After screeing, the patient was listed for liver transplantation. On September 2022, the patient was admitted to our Emergency Room due to HF in class NYHA III. The transthoracic echocardiogram showed a severe aortic regurgitation with mobile vegetations, the largest of which is more than 10 mm on the right aortic cusp. Normal biventricular function was observed with sPAP of 45 mmHg. Thus, we concluded for post–endocarditis severe aortic regurgitation. We discussed tha case in our Department Heart Team with the concomitant presence of the Liver Team. We considered the patient at high surgical risk, mostly due to the risk of postoperative hepatic insufficiency. So, we decided for a TAVI off–label. So, we impantanted a Sapien 3 Ultra 26 mm through transfemoral access. To reduce the risk of cerebral embolization, we used Triguard 3 system, while to prevent coronary embolization we used a closed stent into the right coronary ostia, ready to be opened. The patient was discharged in the fourth postoperative day, without conduction disturbances. The postoperative echo showed normal valvular function and absence of paravalvular leakages.

Conclusions

Patients with advanced liver cirrhosis are at risk of organ failure following use of extracorporeal circulation. In selected patients, TAVI may be a valid alternative. The peculiarity of the specific case was due to the use of the TAVI in an off–label procedure of aortic insufficiency with the simultaneous presence of mobile vegetation at high embolic risk.
P299 WATCHMAN DEVICE THROMBOSIS FOLLOWING THE PERCUTANEOUS CLOSURE OF THE LEFT ATRIUM APPENDAGE: A "CUL–DE–SAC" IN THE ANTITHROMBOTIC STRATEGY
Authors: Zanarelli L , Lapolla D , Marchini F , Tonet E , Guardigli G , Campo G , Passarini G , Pavasini R
Published: May 2023

Background

The percutaneous closure of the left atrium appendage (LAA) is a valuable therapeutic tool in patients with atrial fibrillation (AF) who have contraindications to anticoagulant drugs. However, the procedure can lead to complications and the device positioning determines a risk of thrombosis that can‘t be underestimated, especially during the first period from the intervention.

Clinical Case

In this report we propose the case of a 72 years old man in chronic therapy with NOAC (non–vitamin K antagonist oral anticoagulants) for a paroxysmal AF (CHA2DS2–VASC = 3), that presented intracranial hemorrhage after 3 years due to a cerebral arteriovenous malformation. This condition represents an absolute contraindication to anticoagulant therapy, because of the high hemorrhagic risk, and led to the percutaneous device positioning (WATCHMAN 24 mm) for LAA closure. After the implantation procedure we started a single antiplatelet therapy (SAPT) with clopidogrel 75 mg for 6 months. At one month follow–up a trans–esophageal echocardiogram (TEE) showed the presence of a swinging samll trombotic formation (4x2,5 mm) attached to the device. At that time antithrombotic therapy with enoxaparin 6000 IU was started, in addition to SAPT. Ten days later, another TEE showed the thrombus resolution and we decided to continue with clopidogrel alone. No relevant clinical events were observed to the subsequent follow–up.

Discussion

Current recommendations suggest double antiplatelet therapy (DAPT) for 1–6 months followed by SAPT, in patients who have absolute contraindication to anticoagulant drugs, or SAPT for at least 1 month in those who have an extreme hemorrhagic risk. LAA closure device thrombosis affects 3% of patients and represents an independent predictor of cerebral ischemic events, according to various registers and meta–analyses. This event determines an indication to anticoagulant therapy in patients who would have an absolute contraindication, creating a difficult management that assume clinical relevance. In our experience a 10 days therapy with heparin added to SAPT led to thrombosis resolution. However the therapeutic management of these complications is currently not standardized and more studies are needed.
P307 "REAL WORLD" EVALUATION OF LONG–TERM OUTCOMES RELATED TO FIRST AND SECOND GENERATION BIORESORBABLE AVASCULAR SCAFFOLDS
Authors: Berlier N , Albani S , Bernardi A , Amato G , Biava L , Bonino C , Pisano F , Scacciatella P
Published: May 2023

Introduction

The studies currently available in the literature support worse outcomes in first generation bioresorbable scaffold (Absorb; Abbott USA) compared to second generation devices (Magmaris; Biotronik CHF); the proposed retrospective study aims to analyze and compare long–term adverse events in the two groups and to estimate any predictors.

Methods and Results

236 consecutive cases selected between 2012 and 2018 from the hemodynamic registers of the Aosta valley health authority (VdA) and subjected to an average follow–up of 72.0 months, the composite endopint (Mortality, Target Lesion Revascularization, Target Vessel Myocardial Infarction, Stent Thrombosis) involved 38 patients (16.1%) in the Absorb group and 7 subjects (9.1%) treated with the Magmaris stent (p=0.058), with a lower number of ST and TVMI in the second group. The total mortality rate was very low in both populations, and it appears to be linked mainly to non–cardiac causes. The duration of DAPT seems to confirm a protective role against adverse events (HR 0.79; p = 0.14).

Conclusions

The results obtained, with the limitations related to the low sample size and the nature of the study, confirm the lower long–term complication rate of new generation stents compared to first generation stents. Prolonging DAPT appears to be a reasonable choice in subjects treated with resorbable stents.
P312 TAKOTSUBO SYNDROME DURING INFECTIVE ENDOCARDITIS: AN UNUSUAL COMBINATION
Authors: Caldarella Y , Betta D , Possamai M , Carrer A , Favero L , Cernetti C , Iliceto S , Gasparetto N
Published: May 2023

A 66–year–old woman presented to medical attention for low back pain, weight loss and evening fever for about 2 weeks, with concomitant mood deflection. Blood cultures were positive for Streptococcus mutans. Lumbar spondylodiscitis was found on spinal MRI and splenic infarction on abdominal ultrasound. The echocardiogram revealed the presence of vegetations on the aortic valve, which was severely regurgitant, and on the tricuspid valve, which was moderately regurgitant, in a setting of preserved biventricular dimensions and function. The patient was diagnosed with infective endocarditis, complicated by systemic embolization. The hospital stay was complicated, despite the appropriate antibiotic therapy, with acute pulmonary edema and cardiogenic shock, with a sudden worsening of the left ventricular function which became severely reduced, in the presence of an "apical ballooning" appearance. Anterior T–wave inversion with prolongation of the QT interval was documented on the electrocardiogram. Coronary lesions were excluded by coronary CT scan. According to the InterTAK criteria, the patient achieved a score of 80, suggestive of a high probability of Takotsubo syndrome. In the following days, thanks to continuous infusion of diuretics and inotropic support, a hemodynamic compensation was obtained; there was a progressive recovery of the left ventricular function and of the apical wall motion abnormalities, with suspension of the inotropic support and reduction of the dosage of the diuretic. We concluded for Takotsubo syndrome in the setting of acute infective endocarditis. The patient, with a stabilized clinical picture, finally underwent cardiac surgery to replace the aortic and tricuspid valves without complications. Takotsubo syndrome (TS) is a condition characterized by a transient impairment of left ventricular function and kinetics, typically triggered by physical or emotional stress. In the literature only four cases of concomitant endocarditis and TS are reported, in which other triggers are recognizable (recent surgery, cerebral involvement with embolization or meningitis). In our case, there are no other apparent triggers other than endocarditis. Endocarditis could therefore represent in itself a new trigger for TS or even manifest, from the beginning, with a TS.
P316 CHEST PAIN: ONE, NONE AND A HUNDRED THOUSAND DIAGNOSES. A CASE REPORT
Authors: Piscione M , Bianco S , Castaldo G , Polito D , De Luca V , Nafisio V , Crispino S , Gatto L , Grigioni F , Prati F
Published: May 2023

A 62–year–old woman, with a history of systemic hypertension, smoking habit and paroxysmal atrial fibrillation treated with Flecainide, was admitted to the ER of our Hospital for chest pain. She reported that the symptoms appeared after an emotional stress at work. Troponin I was of 895 pg/mL. The electrocardiogram showed: negative T waves in the inferior leads and an early repolarization pattern/ ST elevated in the antero–lateral leads. The patient underwent transthoracic echocardiography which showed: EF 45%, akinesia of the posterior and inferior segments of the septum. Invasive coronary angiography showed absence of lesions. CMR presented: EF 51% and mild hypokinesia of the mid septum and inferior segment; signs of oedema affecting the left ventricular myocardium in the apex, the mid inferior segment and in the lower apical wall, with subendocardial hypoperfusion layer in the mid inferior septum (microvascular dysfunction?). The patient was dismissed with the diagnosis of M.I.N.O.C.A. A month later, she was admitted again to our ER suffering from a new episode of acute chest pain; she also reported a short episode of atrial fibrillation (documented by an EKG) lasting about 10 minutes occurred the day before. The EKG showed: negative T waves in anterolateral leads. TnI was of 2052,5 pg/ml. The patient underwent a transthoracic echocardiogram which demonstrated: reduced global systolic function (EF 35%), akinesia of the apex, mid–anterior septum and mid– anterior wall. The day after the echo was repeated and it demonstrated a gaining of Vsx EF which was of approximately of 50%. Invasive coronary angiography showed absence of lesions. A methylergometrine test was negative for vasospasm on anterior descending artery. The CMR showed: EF 58%, signs of oedema in the basal and mid anterior wall, mid–anterior septum. LGE intra wall of the apical septum and of the basal part of the anterior wall (coronary spasm? Vasculitis?) Absence of edema. The final diagnosis was of Tako Tsubo.

Discussion and conclusions

This case offers the inspiration to reflect on differential diagnosis of chest pain with undamaged coronary arteries. In addition to this, it should be considered coronary emboli arisen through various mechanisms including left atrial appendage thrombi due to atrial fibrillation, so that also anticoagulation therapy is suggested as discharge treatment.
P317 A…TELL–TALE HEART
Authors: Fischetti S , Brunelli V , Schettini F , Varricchione N , Viati L , Capitelli L
Published: May 2023

We present the clinical case of a 67–year–old male. He was affected by hypertension, hypercholesterolemia; he was heavy smoker. He went to the ED for paresthesias and tremors in the left upper limb, which resolved spontaneously in a few minutes, to which there followed severe thoracic discomfort lasting more than 5 minutes, which resolved during the arrival at the hospital. Upon arrival, the ECG showed ST–segment elevation in leads V4 – V6. POCUS demonstrated akinesia of the apex in its entirety with hypercontractility of the basal segments and the EF was 35%. Blood tests showed an increase in cTI (0.89 ng/ml; vn < 0.16) and CK–MB (57 U/L; vn < 25 U/L). Complete blood count and PCR result in the norm. Coronary angiography showed <50% circumflex artery stenosis, not hemodynamically significant, not treated. Over the next few days the ECG showed marked changes in repolarization, up to T wave inversion; normalized blood tests. During the 3rd day of hospitalization, the patient presented an episode of sensorimotor epileptic seizure in the left upper limb, lasting about 3 minutes, which resolved spontaneously. He underwent a brain CT scan which revealed multiple, edematous brain lesions, probably of a repetitive nature. A whole body CT scan diagnosed lung malignancy. After the oncological evaluation, the patient started chemotherapy. Subsequent follow–ups documented recovery of apical movement at two months. The patient presented a clinical–instrumental picture compatible with the diagnosis of MINOCA. In particular, the echocardiography was suggestive of takotsubo syndrome (TTS). TTS affects 1–2% of patients presenting to ED with ACS and positive troponins or suspected STEMI. It mostly affects women and elderly patients. The exact pathophysiology of TTS is still unknown, but there are numerous determining factors, such as physical and/or emotional stress, that are responsible for sharp increases in levels of circulating catecholamines. Also neurological pathologies, such as ischemic and above all haemorrhagic stroke are implicated. Recent evidence suggests that about one in six TTS patients also have cancer. In conclusion, we described a case where the first clinical manifestation of a lung metastatic cancer was a SCA. In the TTS there can be a "theory of everything", capable of bringing together the various specialists (emergency physician, cardiologist, pulmonologist, general internist, oncologist, etc.) to reach a single outcome, the patient–care.
P324 LEFT VENTRICULAR ISOLATED CARDIOMYOPATHY OR DILATED CARDIOMYOPATHY: THE ROLE OF GENETIC ANALYSIS
Authors: Dei L , Trambaiolo P , Loricchio M , Mustilli M , Castro A , Starnazzi F , Samperi S , Cioffi A , Renda M , Sciarra L , Romano S , Granatelli A
Published: May 2023

Introduction

arrhytmogenic cardiomyopathy (ACM) is a genetic heart muscle disease caracterized by substitution of the ventricular myocardium with fibrofatty tissue. The disease was originally termed “arrhytmogenic right ventricular (dysplasia)/cardiomyopathy” to define a condition which distinctively affected the right ventricle and predisposed to fatal ventricular arrhythmias. New insights led to comprehending that the left ventricle is also frequently affected.

Clinical case

62 yo, male, no cardiovascular risk factors, positive history for frequent ventricular premature beats treated with Sotalol 40 mg twice a day. No other previous cardiological events. Accesses the ER with suddenly occured dyspnea for minimal exertion, without palpitation, chest discomfort or loss of consciousness. EKG: synus rhythm, low voltages, negative V4–V6 T waves, fragmented QRS. Blood testing: TnI 0,532 ng/ml (n.v. 0–0.034) NTproBNP 3840. Echocardiography: dilated left ventricle. 20% EF due to infero–lateral wall akynesia. Coronary angiography was performed and showed no coronary stenosis. Considered the frequent NSVTs showed by the telemetry, he was admitted to ICU and treated with Amiodarone, Atenolol 100 mg, Sacubistril/Valsartan 24/26 mg, diuretic therapy showing good control of major arrhytmic events. To evaluate characterize heart tissue, a magnetic resonance was performed, which showed: scalloping of the mid and apical left ventricular lateral wall, with fibrofatty substitution. Subepicardial, mid–wall and transmural LGE of the LV anterior, lateral and inferior walls. No RV abnormalities. Considered the reduced EF and the presence of arrhytmic substratum, an ICD was implanted. Finally, a genetic evaluation was discussed with the patient, but was declined.

Discussion

in patients presenting with typical LV abnormalities, without RV involvement, the phenotipic Padua criterias are not enough for a certain diagnosis. This is because of the phenotipic overlap between ACM and other diseases, such as dilated cardiomyopathy, myocarditis and cardiac sarcoidosis. In the presence of LV involvement, consistent with ACM, the evidence of a pathogenetic mutation is key for the diagnosis.
P327 A STRANGE CASE OF ACUTE CORONARY SYNDROME
Authors: Cannillo M , Rahbari E , Lonni E , Suppo U , Grosso Marra W
Published: May 2023

We report a case of a 46–years–old man hypertensive, diabetic with dyslipidemia with a previous hospitalization for NSTEMI. The Coronary angiography highlighted right coronary artery vasospasm. Echocardiogram reported good left ventricular function with left ventricular hypertrophy. ECG showed Sinus Rhythm with HR 60 bpm, PR 110 msec and right bundle branch block (Figure 1). He was discharged in dual antiplatelet therapy and with Diltiazem and nitrates. Later the patients reported several events of worsening angina and required the ER access: his therapy was integrated with ranolazine. After that he was bring to our attention for a relapse of NSTEMI. ECG: Sinus Rhythm with HR 55 bpm, PR 110 msec and right bundle branch block. Echocardiogram showed LV with severe wall thickening (ventricular septum/posterior wall 17/14 mm), LVEF 55% in the absence of segmental kinetic alterations, no intraventricular and/or outflow obstruction. There was a first degree diastolic disfunction, and there was mild reduction in both systolic and diastolic velocities on TDI. The right ventricle was not dilated, with thickened free wall, and normal systolic function [figure 2]. A repeated coronary angiography excluded a critical coronary artery disease, but it reveals again evidence of right coronary artery vasospasm. Diltiazem was replaced with nifedipine.A careful anamnesis revealed a history of tinnitus, with right receptive hypoacusia as a result of vestibular neuritis. Blood tests revealed proteinuria with 1800 mg/24 h with glycated Hb 5.8%. Based on the clinical history and the ECG and echocardiographic findings screening for Fabry disease was performed: the results showed abnormal levels of alpha–galactosidase A and plasma lyso–Gb3. Further investigations included cardiac MRI, which confirmed interventricular septal hypertrophy but no late gadolinium enhancement, and ophthalmologic examination, which revealed cornea verticillata in the left eye. Electromyography showed signs of peripheral neuropathy, and renal biopsy was consistent with Fabry disease. Genetic analysis revealed a mutation in exon 1 of the GLA gene (c.62 T>G) that results in the amino acid substitution p.L21R, which has been previously described in patients with Fabry disease. The final diagnosis was Fabry disease with cardiac, renal, and peripheral neuropathic involvement. Enzyme replacement therapy was started with regression of angina episodes.
P334 PHARMACOUTILIZATION AND ADHERENCE TO SACUBITRIL/VALSARTAN IN REAL–WORLD: THE REAL.IT STUDY IN HEART FAILURE WITH REDUCED EJECTION FRACTION
Authors: Iacoviello M , Di Gesaro G , Sarullo F , Miani D , Driussi M , Correale M , Bilato C , Passantino A , Carluccio E , Villani A , Degli Esposti L , D’Agostino C , Peruzzi E , Poli S , Di Lenarda A
Published: May 2023

Aims

The current European Society of Cardiology guidelines provide clear indication for the treatment of acute and chronic heart failure (HF).Nevertheless,there is the constant need of real–world evidence concerning the effectiveness,adherence and persistence to drug therapy.We investigated the use of sacubitril/valsartan for the treatment of HF with reduced ejection fraction in real–world clinical practice in Italy.

Methods

An observational, retrospective,non–interventional cohort study based on electronic medical records from nine specialized hospital heart failure Centers in Italy was carried out on patients prescribed with sacubitril/valsartan.

Results

Overall,948 patients had a prescription of sacubitril/valsartan, 924 (mean age 64.5 years, 84.6% male) had 6 months of characterization and 12 months of follow–up. The initial dose was 24/26 mg for 548 (59.3%),49/51 mg for 333 (36.0%),97/103 mg for 43 (4.7).The final dose was available for 881 patients and it was:24/26 mg for 254 (28.8%),49/51 mg for 229 (26.0%),97/103 mgfor 398 (45.2).The time to maximal dose prescribed (weeks) was:for 97/103 mg 6.9 ± 6.2 weeks;for 49/51 mg 6.2 ± 6.7 weeks.Blood pressure and hypotension in 65% of the patients, and worsening of chronic kidney disease in 10.6% were the main reasons for not reaching target dose; fifty percent had a change in sacubitril/valsartan dose during follow–up and 70.2% patients were persistent with treatment during the last three months of follow–up, with a sensitivity analysis (persistence during the last four months of follow–up) showing 72.0% persistence. Adherence data, available for 387 patients, showed fully adherence for 53%.Discontinuation (102/387 patients) was mainly due to hypotension and occurred after a mean time of 34.3 ± 28.7 weeks. During follow–up, of the 606 patients with available data, 434 patients (71.6%) had an HF add–on drug or drugs concomitant to sacubitril/valsartan. Although not significantly (p=0.405), HF–related hospitalization during follow–up was higher in not persistent patients (23.9%) versus persistent (19%) to sacubitril/valsartan treatment.Pharmacoutilization data at 1–year expressed as medication possession ratio (MPR) are shown in the Figure.

Conclusions

Real–world data of sacubitril/valsartan use in clinical practice in Italy show a rapid titration of to target dose, high therapeutic adherence allowing a good level of therapeutic management in line with ESC guidelines in patients with reduced ejection fraction.
P343 WHAT IS HIDING BEHIND A ‘STEMI‘?
Authors: Foroni M , Schiavo M , Pagano V , Bendandi F , Saia F
Published: May 2023

Introduction

Stanford type A aortic dissection associated with ST–segment elevation myocardial infarction (STEMI) is a rare event with a high mortality rate. Emergency coronary angiography and antithrombotic therapy expose to a greater risk of complications and mortality. Case presentation: A 57–year–old heavy smoker gentleman with no previous medical history was admitted to the emergency department due to the sudden onset of severe oppressive chest pain. The ECG was suggestive of inferior STEMI and thus he was brought to the cath lab. During coronary angiography, there was spontaneous regression of the ST–segment alterations with persistence, however, of chest pain. The coronary angiography was unremarkable, but the cannulation of the right coronary artery was unexpectedly difficult. In light of the clinic and the suspicious fluoroscopic images (dilated aorta and severe valvular calcifications), an aortography was performed showing a type A aortic dissection. CT angiography confirmed the presence of dissection confined to the ascending aorta with origin of the right coronary artery from the false lumen. The supra–aortic trunks were not involved by the dissection. A bicuspid aortic valve and a bovine trunk were also found. The patient therefore underwent emergency cardiac surgery: a composite aortic valve conduit (Bentall procedure) was implanted and double aorto–coronary bypass surgery was performed, due to intraoperative evidence of complete detachment of the right coronary ostium and partial detachment of the left. The operation was successful and the following hospitalization was uneventful.

Conclusions

This case report exemplifies an important alternative diagnosis in patients referred for STEMI, particularly if with an inferior localization (the right coronary artery is the most frequently involved by the dissection). It is necessary to pay attention to the possible clues coming from the clinical findings and from the radioscopic and angiographic images obtained in the cath lab in order not to miss the diagnosis of a pathology on whose recognition and timely treatment the patient‘s life depends.
P344 OCCURRENCE OF PERMANENT PACE–MAKER IMPLANTATION DURING HOSPITALIZATION AFTER INTUITY RAPID DEPLOYMENT AORTC BIOPROSTHESIS IMPLANTATION: A RETROSPECTIVE SINGLE CENTER STUDY
Authors: Cortese F , Costantino M , Stolfi L , Stabile E , Luzi G
Published: May 2023

Between March 2017 and June 2020, 97 consecutive patients underwent aortic valve replacement (AVR) with the Edwards Intuity and its evolution Intuity Elite rapid deployment bioproshesis were enrolled at the Cardio Surgery Department at the “San Carlo” Hospital in Potenza. A total of nine patients were excluded: 3 patients for incomplete data, 3 patients because they already had a pacemaker at the time of admission, and other 3 patients because they underwent combined aortic and mitral valve surgery. The remaining 88 patients were evaluated. Among these, 62 (70%) underwent insolated AVR and the remaining 26 (30%) combined procedure with myocardial revascularization, performed through mini–sternotomy or full sternotomy respectively. Population was divided into two groups according to the date of surgery: before (N: 66, 75%), group A, and after (N: 22,25%), group B, September 2019, when we modified prosthesis implantation technique in order to reduce the incidence of permanent pacemaker implantation (PPI), with a particular attention in annular decalcification compared to standard technique near to the interventricular septum, in order to prevent hard calcium block compression on conduction system. Subjects underwent serial ECGs at baseline, after the intervention and every 24 hours until hospital discharge, moreover they had continuous monitoring till discharge. ECG Holter monitoring were prescribed during the first year after discharge if any alteration at basal ECG were observed. The policy for PPI followed the current guidelines. All the ECGs and the Holter monitoring were analyzed by two independent physicians blinded to each other’s. At the end of our study, we observed 4 PPI in the group A, 3 cases for complete AV block (third degree AV block) and one case for tachy–brady syndrome about four months after the AVR, no PPI were observed in the group B. In conclusion the new technique of aortic valve decalcification during INTUITY rapid deployment bioprosthesis implantation, introduced in our institution in September 2019, provided to be safe and effective in reducing the occurrence of cardiac conduction disorders and consequently of PPI compared to standard technique.
P348 COMBINATION THERAPY IN A PATIENT WITH TTRV AMYLOIDOSIS
Authors: Bellini F , Di Gesaro G , Di Stefano V , Nardi E , Cefalù A , Noto D
Published: May 2023

73 year old male. He has a brother with an unspecified heart disease, three children, all in good health. Former smoker, arterial hypertension, bilateral carpal tunnel syndrome for several years. Therapy used: zofenopril 7.5 mg 1 cp/day. In August 2019 hospitalization for acute heart failure. Echocardiogram showed severe concentric left ventricular hypertrophy with a granular sparkling myocardial appearance, moderately reduced EF, moderate mitral regurgitation, restrictive transmitral pattern, and pulmonary hypertension (PAPS 60 mmHg). ICV with increased dimensions and not collapsible. Moderate circum–cardiac pericardial effusion. During this hospitalization, therapy with an ACE inhibitor, beta blocker and MRI was started with clear clinical benefit. He also started anticoagulant therapy for evidence of atrial fibrillation. At discharge, NYHA class II. Myocardial scintigraphy with bone tracer was positive for the presence of grade 2 myocardial uptake according to the Perugini score. Blood chemistry tests were performed to exclude the AL form and finally the genetic test showed the presence of a mutation on the transthyretin Val122Ile gene (mutation associated with a variant of amyloidosis with a predominantly cardiological phenotype). Then, heart failure therapy was optimized and disease modifying therapy was started with Tafamidis 61 mg/day. Over time there was a reduction in left ventricular function, so sacubitril/valsartan was started; this drug was not tolerated due to hypotensive episodes. The NYHA class has however always remained stable (class II). During the follow–up in September 2022 he had a new hospitalization for heart failure during which the therapy was optimized with the insertion of the SGLT–2 inhibitor, which was well tolerated. During this hospitalization, symptoms related to the neurological involvement of the pathology emerged: severe weight loss and paresthesias in the four limbs for which it was decided to associate therapy with patisiran IV. To date, the approved therapy for amyloid cardiomyopathy is tafamidis but, in consideration of the neurological symptoms and the results obtained from patisiran in patients with the variant form, it was decided to associate the two therapies, taking care to also optimize therapy for heart failure.
P349 EARLY DIAGNOSIS OF HEREDITARY CARDIAC AMYLOIDOSIS(ATTRV) IN A CARRIER: WHEN IS ENDOMYOCARDIAL BIOPSY INDICATED?
Authors: Chimenti C , Alfarano M , Ballatore F , Sciarra R , Verardo R , Frustaci A
Published: May 2023

Background

Hereditary transthyretin amyloidosis (ATTRv) is a rare, adult–onset, autosomal dominant genetic disorder caused by mutations in the TTR gene. The growing availability of effective therapies determining a greater benefit the earlier they start, highlights the importance of identifying cardiac involvement even in the absence of left ventricular hypertrophy.

Clinical Case

A 58–year–old man came to our observation for exertional dyspnea and received a diagnosis of hereditary transthyretin amyloidosis (Val142Leu). Family screening led to the identification of the 56–year–old brother who was carrier of the same mutation. This patient was symptomatic for palpitations. Blood tests, including cardiac Troponin and NTproBNP, were normal. The ECG showed sinus rhythm, with normal atrioventricular and intraventricular conduction but frequent premature ventricular contractions. Transthoracic echocardiogram was normal, including strain rate evaluation. In order to identify early cardiac involvement, the patient underwent cardiac magnetic resonance imaging and biphosphonate scintigraphy that were negative for cardiac involvement. Neurological examination showed initial bilateral carpal tunnel syndrome. Due to the presence of premature ventricular contractions, the patient underwent to an endomyocardial biopsy which unpredictably showed a slight focal positivity to Congo Red staining, and immunohistochemistry confirmed a slight focal positivity for transthyretin. Therefore, the patient started therapy with Tafamidis. At 12–month follow up cardiac scintigraphy was still negative as well as ventricular thickness resulted within normal limits.

Conclusion

This case shows that in ATTR mutation carriers, an initial cardiac involvement can be present even in the absence of left ventricular hypertrophy and positive bisphosphonate scintigraphy. In the presence of clinical symptoms and/or suspicious signs of disease, such as arrhythmias, an endomyocardial biopsy may be indicated in order to start disease modifying therapy earlier.