bluuebunny/crossref_metadata_2025 huggingface dataset:
P367 Cardioprotective effect of angiotensin converting enzyme inhibitors and beta-blockers in the primary prevention of cardiotoxicity: systematic review and meta-analysis of randomised studies
Authors: Moral S , Coma N , Eraso A , Ballesteros E , Vinas G , Frigola J M , Morales M , Robles R , Albert X , Fluvia P , Fort A , Vilardell P , Romera Martinez I , Brugada R
Published: January 2020

Funding Acknowledgements

none

OnBehalf

none

Background

Chemotherapy cardiotoxicity is a serious complication in breast and haematological malignancies. However, its primary prevention with angiotensin converting enzyme inhibitors (ACEI)/angiotensin II receptor antagonists (ARB) and/or beta-blockers (BB) medication has discrepant results. The aim of our study was to establish whether primary prevention using these treatments prevents cardiotoxicity and whether any of them is superior to the others.

Methods

A systematic review and meta-analysis was performed following a search of EMBASE, MEDLINE and PsycINFO from January 2005 to April 2019 of all randomised studies evaluating primary prevention of cardiotoxicity by chemotherapy with any of these treatments. Cardiotoxicity was defined as the drop of the left ventricular ejection fraction below 50% or greater than 10% and/or clinical heart failure during the first year of follow-up.

Results

Nine randomised studies with 913 participants in which chemotherapy was performed were included: 337 (37%) received BB, 152 (17%) received ACEI/ARB, 45 (5%) received BB + ACEI and 379 (41%) were controls. One hundred and eight cases (12%) developed cardiotoxicity (follow-up range: 1-12 months). Patients receiving cardioprotective treatment had a lower risk of developing cardiotoxicity than controls (RR = 0.381, IC95%, 0.160-0.911, P = 0.030, I2 = 63.2%; Fig.1). The subgroup analysis showed a non-significant tendency for both treatments to have a cardioprotective effect (BB: RR = 0.477; IC95%, 0.178-1.275; P = 0.140; I2 = 57.3%) / ACEI/ARB: RR = 0.283; IC95%, 0.027-2.982; P = 0.293; I2 = 79.0%). There was no difference between both treatments in those studies comparing them (RR = 0.743, CI95%, 0.325-1.698, P = 0.481, I2 = 0.0%). The estimated number of patients to be treated to avoid one case of cardiotoxicity was 10 patients.

Conclusions

Primary prevention with BB and/or ACEI/ARB reduces cardiotoxicity by chemotherapy during the first year in breast and haematological malignancies. For every 10 patients treated, one case of cardiotoxicity could be avoided.

Figure 1. Cases treated with BB and/or ACEI/ARB versus control group without treatment of the different randomised studies comparing the number of patients who developed cardiotoxicity during the first year.

Abstract P367 Figure 1
P376 Epicardial to pericardial adipose tissue ratio: predicting ischemic etiology of left ventricular systolic dysfunction
Authors: Garcia Campos A , Alonso Vazquez V , Colunga Blanco S , Velasco Alonso E , Vega Hernandez B , Leon Duran D , Gonzalez Sanchez T , Segovia Martinez-Salinas E , Lozano Martinez-Luengas I
Published: January 2020

Background

Epicardial adipose tissue (EPI) and pericardial adipose tissue (PERI) measured using echocardiography or magnetic resonance imaging have shown to be markers of metabolic syndrome and begin to be regarded as predictors of coronary artery disease. EPI is also thought to have paracrine effects on coronary vessels and, therefore, might be more intimately linked to ischemic heart disease.

Purpose

We aim to study if EPI related to PERI thickness is a predictor of ischemic etiology of left ventricular (LV) systolic dysfunction among ambulatory patients.

Methods

We retrospectively evaluated 56 consecutive patients followed on a heart failure clinic. A cardiologist, blind to the clinical records and systolic dysfunction etiology, reviewed the echocardiographic images and measured EPI and PERI thickness on right ventricle free wall (parasternal long axis view). Cardiovascular risk factors, body mass inex (BMI), LV dimensions by echo, LV systolic dysfunction etiology (investigated by other means such as angiography or magnetic resonance) were analyzed.

Results

Echocardiographic image quality allowed for analyzing 55 patients (80% male, 62% hypertension, 51% diabetes, 44% dyslipidemia, BMI 28,9 ± 4,0, age 66 ± 14 years). Mean EPI thickness was 3,4 ± 2,0 mm and PERI was 5,6 ± 3,4 mm. LV ejection fraction 33 ± 10% and LV end diastolic volume 157 ± 48ml. Supplementary investigations showed an ischemic etiology of LV systolic dysfunction in 45% of patients. We found that patients with EPI thickness equal or greater than PERI were more likely to have an ischemic etiology (univariate analysis: OR 9,8 p = 0,002; adjusted for BMI and diabetes: OR 5,8 p = 0,032).

Conclusions

Epicardial adipose tissue thickness equal or greater than pericardial adipose tissue, parameter easily obtained using transthoracic echocardiography, may predict ischemic etiology of LV systolic dysfunction in a cohort of ambulatory patients . Future research will be necessary to confirm this finding and its possible value in every-day clinical practice as marker of coronary artery disease.

ALL ISCHEMIC NON ISCHEMIC p Epicardial Adipose Tissue 3,4 ± 2,0 3,7 ± 1,6 3,1 ± 2,2 0,53 Pericardial Adipose Tissue 5,6 ± 3,4 4,6 ± 3,0 6,4 ± 3,5 0,09 Ratio EPI/PERI 0,82 ± 0,66 1,16 ± 0,83 0,55 ± 0,28 0,000 Table Adipose tissue thickness measured on paraesternal long axis (mm): mean ± SD.
420 Vortex formation in the pre-ejection phase in the left ventricle
Authors: Daae A , Wigen M , Lovstakken L , Stoylen A
Published: January 2020

Funding Acknowledgements

Central Norway Regional Health Authority

Background/Introduction:

Vortex formation during left ventricular filling have been described since the 1980’s. We have investigated vortices in the left ventricle (LV) in healthy adults with a new technology based on high frame rate vector flow imaging (VFI) using blood speckle tracking.

Purpose

In this study we investigated the intraventricular flow pattern during the pre-ejection period.

Material and methods

We examined 21 healthy volunteers with a GE E95 ultrasound scanner, both in ordinary clinical mode and with an experimental setup. The latter was developed to achieve high frame rates by utilizing plane waves in combination with ECG-gating over multiple (5-6) heart cycles, allowing continuous acquisition of > 3500 FPS. Blood speckle tracking followed by model based regularization was used to obtain vector flow velocity measurements.

Results

During the pre-ejection phase we observed blood flow from the apex to the basis of the LV along the septum. At the base, the flow is deflected. A basal vortex is then created just above the mitral valve, which persists into the isovolumetric contraction (IVC). The lateral part of the vortex is then seen as an apically directed flow during IVC, as shown in the illustration. The vortex is also visible in the first phase of the ejection; the part of the blood in the LV not passing through the aortic valve is deflected and continues to conserve this vortex. These findings correspond to patterns found in colour M-Mode (CMM), showing a column of blood toward the apex in the IVC/early ejection phase. Time from peak R to the first sighting of this IVC vortex, and to the pre-ejection spike in tissue Doppler imaging (TDI), are similar, as reported in table 1.

Conclusion(s):

Our imaging setup allows for a very high temporal resolution (>3500 FPS), and enables VFI using blood speckle tracking, without using a contrast agent. We observed an intraventricular vortex during pre-ejection and into early ejection, with the same direction as the later vortices seen in filling. Initiation of this vortex may be conserved energy from late filling. This vortex is simultaneous with the pre-ejection spike in TDI. We postulate that this IVC vortex contributes to the closing of the anterior mitral leaflet in the IVC. As we also observe this vortex during the early ejection phase, we believe it may conserve rotational energy into early filling.

Table 1 Timing of the IVC vortex and the pre-ejection spike in TDI Mean Median SD Min Max Time between R and the basal vortex during IVS (ms) 16,7 16 15,1 -13 47 Time between R and the pre-ejection spike TDI (ms) 16,3 21 14,4 -10 36

Abstract 420 Figure.
424 Left ventricular function after correction of a proportionate mitral regurgitation: impact of the clipping approach
Authors: Hubert A , Galli E , Leurent G , Corbineau H , Leclercq C , Donal E
Published: January 2020

Aims : Secondary mitral regurgitation (MR) is associated with poor outcome in systolic heart failure (HF-)patients. Percutaneous edge-to-edge mitral valve repair (PMVR) recently failed to prove any beneficial effect over optimal medical treatment (OMT). Nevertheless, little is known about the effect of PMVR on LV performance and mechanics in HF-patients with severe secondary MR.

Method and results

Thirty-seven patients with severe secondary MR treated by PMVR were included and compared (according to indices of LV myocardial function) to nineteen patients with treated by OMT. Both groups were clinically comparable. At 6-month follow-up, only LV constructive work improve significantly in both groups (977 vs 1101 mmHg.%, p =0,003, 967 vs 1110 mmHg.%, p = 0,002 for PMVR and OMT groups, respectively) whereas left ventricular (LV) end-systolic volume index, LV ejection fraction and global longitudinal strain were not different. Compared to MITRA-FR and COAPT studies, our population had a proportionate MR (blue point in Figure 1, panel A). Figure 1-panel B demonstrate that only five patients of PMVR group had disproportionate MR (red points). Interestingly, these patients hadn’t any major event during 6 months FU.

Conclusion

Echocardiographic characteristics at 6-month follow-up are not different when compare PMVR and OMT for HF- patients with a severe proportionate secondary MR.

Main echocardiographic characteristics PMVR OMT Inclusion 6-month p Inclusion 6-month p NYHA 2.6 ± 0.6* 1.8 ± 0.7* <0.0001 2.3 ± 0.5* 2.2 ± 0.4* 0.43 LVESVi(ml.m-2) 76 ± 36 75 ± 35 0.6 94 ± 32 90 ± 31 0.35 LVEF (%) 33 ± 6 33 ± 13 0.78 30 ± 8 31 ± 8 0.53 GLS (%) -9.8 ± 4 -9.9 ± 3.9 0.84 -10.0 ± 4 -10.3 ± 3.3 0.62 MR grade 3.4 ± 0.5 1.3 ± 1.0* <0.0001 3.5 ± 0.5 2.8 ± 1.1* 0.007 Global work index (mmHg.%) 831 ± 370 933 ± 406 0.07 875 ± 314 939 ± 304 0.14 Constructive work (mmHg.%) 977 ± 366 1101 ± 404 0.003 967 ± 290 1110 ± 349 0.002 *symbols denote p < 0.05 between both groups

Abstract 424 Figure.
473 Chloroma: an unusual case with extensive cardiac involvement detected by echocardiography
Authors: Oliveira Da Silva C , Eliasson S , Sequeira C , Bernardes A , Gunyeli E , Manouras A
Published: January 2020

Introduction

Chloroma, also known as myeloid sarcoma, is a localized extramedullary tumour composed of malignant cells of the myeloid cell line, most frequently occurring in myelogenous leukemia. Heart involvement is exceptional, only about 20 cases have been reported in the literature.

Case presentation

A 38-year-old woman presenting with fatigue and pre-syncope was admitted to the hospital. The patient had a history of acute myeloid leukaemia diagnosed 2017, treated with chemotherapy and transplanted with allogenic bone-marrow the same year, remaining thereafter in clinical remission. Initial electrocardiogram showed sinus bradycardia and recurrent sinus arrests and therefore a pacemaker was implanted. An echocardiogram was performed which revealed multiple infiltrative masses with involvement of the superior vena cava extending to the right atrium, atrial septum, left atrium, mitral valve and aortic root. Magnetic resonance imaging was done confirming the echocardiographic results and showing even involvement of pulmonary veins, coronary arteries and myocardial infiltration. Chemoradiation was administered with initial response, however, disease progression led to the patients´death.

Conclusion

To our knowledge, this is the first case describing a chloroma with extensive involvement of cardiac walls, vessels and valves. This case also illustrates the value of echocardiography as a tool for early detection of cardiac masses.

Abstract 473 Figure. Echo with contrast
475 A rare cause of right ventricular mass
Authors: Briosa A , Almeida A R , Gomes A C , Pereira A R , Marques A , Alegria S , Sebaiti D , Santos J , Carrington M , Miranda R , Joao I , Sousa S , Pereira H
Published: January 2020

Introduction

Intracardiac masses are always a challenging diagnosis, especially when it involves the right side of the heart. There are multiples etiologies that can be responsible for these masses, namely thrombosis, neoplasm or vegetations. Occasionally, these may be related to an autoimmune process not yet discovered.

Case Report

17-year-old male, with a previous history of genital ulcers, medicated with penicillin with complete resolution of symptoms.

In January 2019, he started an history of recurrent fever, associated with right anterior thoracalgia, weight loss and oral afthosis. He went to the emergency department several times, where he was medicated with antibiotic, with partial symptom relief.

Three months later, he returned to medical attention due to an episode of abundant hemoptysis, followed by hematemesis and cough. At hospital admission, he was hemodynamically stable, tachycardic (100/min) and with occasional episodes of cough. Cardiac and pulmonary auscultation were unremarkable. Thoracic CT revealed the presence of pulmonary thromboembolism (PTE) and a large mass in the right ventricle (RV). It was performed an echocardiogram (echo) that confirmed the presence of a large mass in the RV (50x53mm) from which a projecting hypermobile mass appeared to prolapse into the right atrium.

Taking into account the diagnosis of PTE and the presence of a right ventricular mass, the patient was hospitalized and started anticoagulation. The case was immediately discussed with cardiac surgery, that confirmed that there was no surgical indication. During hospitalization, there were no more episodes of hemoptysis or hematemesis.Consecutive echos were performed, that did not reveal a significant decrease in mass dimensions despite anticoagulation. Viral serologies and autoimmunity panel were all negative. Cardiac RMI was performed raising the suspicion of a possible mass covered with thrombus.

After discussion with rheumatology, and according to clinical signs, the hypothesis of vasculitis was placed, and the patient started treatment with steroids. This treatment had to be suspended after a few days due to an infectious intercurrence. After a course of antibiotic therapy, the patient started therapy with cyclophosphamide with good clinical and echocardiographic response (reduced mass dimensions).

It was admitted Behçet’s disease with cardiac complications, and the patient was referred to the rheumatology consultation.

Conclusion

Behçet’s disease is a multi-system, chronic disorder that behaves like vasculitis.There are some typical clinical manifestations associated with this disease, such as oral and genital afthosis, uveitis, arthritis, skin lesions and nervous system involvement.Presentations with cardiac symptoms are one of the extremely rare manifestations of this disease, posing a challenge for the treating physician.

Abstract 475 Figure. Right ventricular mass
476 An unusual location and size of a papillary fibroelastoma
Authors: Valentim Goncalves A A , Sousa M J , Matos P , Pinto E , Banazol N , Branco L , Cruz Ferreira R
Published: January 2020

Background

The incidence of primary cardiac tumours is low. Although histologically benign, left-sided, larger sized (≥ 1 cm) and highly mobile tumors have a higher risk of embolization.

Papillary fibroelastomas frequently occur on the aortic or mitral valves, with only 10% arising from nonvalvular surfaces. Since they are small and usually attached to moving valves, CT and MRI technique modalities have more difficulty in detecting them, with echocardiography remaining the most common exam for the diagnosis.

Clinical case description:

A 69-year-old woman, with known history of breast cancer treated with chest radiation ten years ago. She was completely asymptomatic, but in a routine echocardiography a left ventricular heterogeneous round mass with 22x25mm with a likely pedunculated attachment in the apical region was diagnosed. The remaining exam was remarkably normal, namely with normal left ventricular size and function with no wall motion abnormalities.

Because the wall motion appeared normal, the mass was interpreted as a tumour. However, a thrombus could not be excluded. After four weeks of therapy with Warfarin and aspirin, a MRI was performed. The apical mass had similar dimensions (22x23mm) and the exam was inconclusive (myxoma? fibroma? thrombus?) despite no signs of left ventricular fibrosis with late gadolinium enhancement.

Since the risk of embolization was high and there was no reduction in size with anticoagulation therapy, surgery was performed. Using a transaortic valve route, a 28x30mm mass with a pedunculated attachment in the apical region was removed. The mass had a macroscopic appearance of a sea anemone with gelatinous material. Histological examination made the final diagnosis of a papillary fibroelastoma.

Conclusion

Large, left-sided mobile tumors should be excised to prevent sudden death and embolization. Here we present the case of a papillary fibroelastoma with a rare localization and an unusual size. Some clinical cases have raised the question for a relation between previous chest radiotherapy and the occurrence of papillary fibroelastomas.

Abstract 476 Figure.
481 Mass compromising left atrium
Authors: Rodrigo Carbonero D , Estandia U , Perez P M , Perez C , Voces R , Cortes A , Panera E
Published: January 2020

A 47-year-old woman presented to the ER with a sudden-onset left side chest pain of less than one hour in duration that started at rest. The pain was severe and radiated to the left shoulder. This was accompanied with symptoms of shortness of breath and sweating but no similar episodes in the past. There was no significant history of coronary artery disease or any other illness in the family. She had dyslipidemia and a smoking habit of 1 pack/day for the previous 10years.

In the ERt, she was hemodynamically stable and her physical examination was within normal limits. ECG showed ST-segment elevation in the inferior leads. No prior ECG was available for comparison. She underwent emergent PCI which showed spontaneous proximal segment circumflex (dominant) artery dissection with TIMI angiographic flow grade 0. All other coronaries were patent with TIMI III flow and no atherosclerotic changes. PCI was carried out, but unfortunately, it was complicated with coronary rupture having to implant a drug eluting stent in order to seal the vessel rupture, with optimal final result (TIMI 3).

An urgent TTE was performed for evaluation of the patient due to persistence of chest pain after coronariography, revealing an echogenic mass at the left atrium suggesting extracardiac hematoma vs. left atrium dissection. TC scan confirmed space compromise of the left atrium by a mass, without being able to rule out active bleeding. The patient was transferred to our center for emergent CABG surgery.

Upon arrival, the patient had persistent chest pain, sinus tachycardia, and hypertension. Intraoperative TOE findings consisted of a mass compromising left atrium and minimal pericardium effusion. Comprehensive study identified a mobile intimal flap of the atrial wall that was creating a false chamber.

Intraoperative surgery findings were compatible with a huge left atrial desiccant hematoma . Two orifices were performed on the epicardium of the inferior and lateral border of the left atrium, in order to drain the retained blood and lavage. No active bleeding was evidenced.

TTE control evidenced disappearance of the left atrium mass a The patient had a satisfactory evolution and discharged without complications.

Even though left atrial desiccant hematoma is a rare STEMI complication , in this patient, we concluded the etiology was iatrogenic due to the performance of PCI.

Conclusion

Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. Its diagnosis requires a high index of suspicion.

Predisposing factors and catheterization, surgical or pathologic findings should be reviewed in order to identify the pathogenic mechanism . Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, blunt chest trauma and iatrogenic PCI are related to its development.

Abstract 481 Figure. MASS COMPROMISIN LEFT ATRIUM
507 Heat failure in restrictive ventricular septal defect
Authors: Lam L T , Tam C M , Fan K Y Y
Published: January 2020

Introduction

Patients with small restrictive ventricular septal defect are usually asymptomatic. This case report presented a case of shortness of breath in a patient with known restrictive ventricular septal defect.

Case report

A 51 years old woman was diagnosed to have a small supra-cristal ventricular septal defect in early twenties. She enjoyed good functional state since the diagnosis. Routine echocardiogram assessment one year ago found normal left ventricular size and systolic function. However, she presented with exertional shortness of breath and severe bilateral lower limbs edema for two weeks. Transthoracic echocardiogram found both left and right ventricles were dilated. Left ventricular ejection fraction was 50%. The right ventricular systolic pressure(RVSP) was 70mmHg from tricuspid regurgitation peak velocity estimation. It was significantly raised compared with the RVSP 35mmHg measured last year. This caused right ventricular pressure overload with systolic flattening of interventricular septum. On color doppler examination, apart from the known ventricular septal defect flow, there was an abnormal turbulent flow at the right ventricular outflow tract. The two jets was close to each other and the nature of the abnormal jet could not be clearly identified. During trans-esophageal echocardiogram, in order to differentiate the two different jets, the baseline of the color doppler was shifted towards the directions of the jets to look for the proximal isovelocity surface area (PISA). Finally there were two PISA could be clearly seen. One was the PISA of the ventricular septal defect while the other one was due to ruptured right coronary sinus with shunting from aorta to right ventricular outflow tract. The findings was supported by continuous wave doppler examination. The ventricular septal defect flow was predominantly systolic whereas the aorto-right ventricular shunting was a continuous flow. Moreover, three dimension echocardiogram also showed the two closely related holes. Finally the patient underwent percutaneous closure of the ruptured sinus of valsalva. And the patient recovered well afterwards.

Discussion

Small ventricular septal defect with restrictive physiology usually will not lead to heart failure. When patient presented with heart failure while having a small ventricular septal defect, other pathology should be carefully looked for. Ruptured sinus of valsalva was known to associate with ventricular septal defect. However, the jet of ruptured sinus of valsalva may be missed in view of the close proximity with the ventricular septal defect jet as in this case. Methods to better delineate the different jets including demonstration of double PSIA, continuous flow on continuous wave doppler and three dimension echocardiogram. Nowadays, ruptured sinus of valsalva could also be closed percutaneously with success.

Abstract 507 Figure.
539 Optimized multiparametric analysis of cardiac dyssynchrony: machine learning and prediction of response to cardiac resynchronization therapy based of the apical 4-chamber view
Authors: Gallard A , Donal E , Le Rolle V , Hubert A , Bidaut A , Leclercq C , Galli E , Hernandez A
Published: January 2020

Aims. We hypothesized that a multiparametric evaluation, based on the combination of electrocardiographic and echocardiographic parameters, could enhance the appraisal of the likelihood of reverse remodeling and prognosis of favorable clinical evolution after cardiac resynchronization therapy (CRT). Also, we sought to test the respective value of automatically extracted parameters from left ventricular (LV) strain curves recorded in apical 4-chamber view as compared to the other echocardiographic views.

Methods and results;

This is a machine learning study based on a dataset of 161 patients who were treated by CRT according to current ESC-guidelines. The longitudinal strain curves of the 6 LV-segments of the left ventricle were plot for the three different apical views. Several features as times or integrals were extracted as previously published. These features were classified by importance using the out-of-bag method(fig1). Half of the most important features come from the 4-chamber view and a third from the 2-chamber view. The correlation between the most important features was studied to determine the relationship between them. Almost all the features from the 2-chamber and apical long-axis views are correlated with others and generally with one acquired from the 4-chamber view.

Conclusion

The high number of important features indicate the relevance of the 4-chamber as unique view for applying machine learning approaches on strain curves. Optimizing selection of patients for CRT should be possible just on the dataset coming from one apical 4-chamber view.

Abstract 539 Figure. fig1
564 Cardiac magnetic resonance myocardial feature tracking for optimized risk assessment after acute myocardial infarction in patients with type 2 diabetes
Authors: Kowallick J T , Backhaus S J , Stiermaier T , Lange T , Navarra J L , Koschalka A , Rommel K P , Lotz J , Gutberlet M , Kutty S , Hasenfus G , Thiele H , Eitel I , Schuster A
Published: January 2020

Objective

Type 2 diabetes mellitus (T2DM) associates with worse cardiovascular outcome following acute myocardial infarction (AMI) as compared to non-diabetic patients. Since the mechanisms behind these observations are not fully understood we aimed to quantify the underlying pathophysiology on ventricular and atrial levels and study their prognostic implications using cardiovascular magnetic resonance (CMR) quantitative feature-tracking (FT) and tissue characterization.

Research Design and Methods:

A total of 1147 consecutive patients with AMI (n = 265 with diabetes; n = 882 without diabetes) undergoing cardiac magnetic resonance (CMR) imaging in median 3 days after AMI were included in this multicenter study. Left ventricular (LV) function and volumetry included LV ejection fraction (LV-EF), global longitudinal (GLS), radial (GRS) and circumferential strain (GCS) as well as left atrial (LA) strain and strain rate parameters of LA reservoir, conduit and booster pump function. LV damage assessment included infarct size (IS), edema and microvascular obstruction (MO). The clinical study endpoint was the rate of major adverse cardiovascular events (MACE) at 12 months.

Results

T2DM patients had impaired LA reservoir (19.8 vs. 21.2%, p < 0.01) and conduit strains 7.6 vs. 9.0%, p < 0.01) but no differences in ventricular function or myocardial damage. They were at higher risk of MACE than non-diabetic patients (10.2% vs. 5.8%, p < 0.01) with the majority of MACE occurring in patients with LVEF ≥ 35%. Whilst LVEF was an independent predictor of adverse events in non-diabetic patients (p = 0.04 on multivariable analysis), LV GLS as well as LA strain emerged as independent predictors of poor prognosis in patients with diabetes (p < 0.02 on multivariable analysis). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with higher 12-month event rates.

Conclusions

In patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above LVEF.
P629 An uncommon cause for a frequent problem
Authors: Miranda H , Santos H , Almeida I , Santos M , Sousa C , Almeida S , Santos L , Tavares J
Published: January 2020

Introduction

Libman-Sacks endocarditis is the most characteristic cardiac manifestation of the autoimmune disease systemic lupus erythematosus. Embolic phenomena, although uncommon, can also complicate valvular abnormalities and can cause neurologic and systemic complications.

Case Report

Man, 52 years old. Active smoker and with previous peptic ulcer history. Admitted to our emergency department due to sudden onset of confusion and incoherent speech. The physical examination showed only a Glasgow Coma Scale of 9 and the presence of expressive aphasia. Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination.

Investigations showed a normal EKG, chest X-Ray and arterial-blood gas test. Blood test showed only the presence of thrombocytopenia, leucocytosis and renal disfunction. Brain CT revealed left-sided thalamic lacunar lesion. We assumed an ischemic stroke and admitted the patient in our emergency department. Neurological deterioration in the first 24h. A new brain CT was performed and showed multiple lesions in the middle cerebral artery territory. The echocardiogram was performed and showed the presence of multiples vegetations in both mitral leaflets with moderate to severe mitral regurgitation associated. We assume an ischemic stroke in the context of possible infective endocarditis. Medical therapy was optimized and empirical antimicrobial therapy was started (ampicillin + gentamicin + flucoxacillin).

The patient never had fever during hospital stay. Duke criteria with only 1 major criteria. Persistent negative microbiological cultures with decreasing inflammatory parameters. Blood tests revealed a progressive increase level of INR (2-4) and renal function deterioration. Patient began with massive episodes of diarrhea and sudden decrease of haemoglobin level (sudden reduction of 3g/dl). Endoscopic studies were performed and multiple ischemic lesions of embolic etiology and small vessel disease had been described. Serology test revealed a positive IgG for Mycoplasma pneumoniae. Autoimmune lab tests showed positivity for lupus anticoagulant, anticardiolipin and anti–beta-2 glycoprotein I.

We discussed the clinical case with our autoimmune experts team and the diagnosis of Systemic Lupus Erythematosus + Antiphospholipid Syndrome + Libman-Sacks Endocarditis was assumed. The patient started immunosuppressive therapy (Azathioprine + Mycophenolate Mofetil + Prednisolone).

Despite the used therapy the size of vegetation persisted and mitral regurgitation didn’t improve.

In this context, the patient was presented to our cardiac surgery team and underwent surgical intervention (vegetation removal + mitral valve repair). Evaluation one year after surgery revealed progressive functional and echocardiographic improvement.

Conclusion

The authors presented a didactic clinical case where valvular surgery was required thanks to a hemodynamically significant valvular dysfunction and embolic events.
P644 A not so innocent athlete"s heart
Authors: Oliveira C C , Vieira C , Campos I , Rodrigues C , Medeiros P , Flores R , Mane F , Braga C , Rocha S , Marques J
Published: January 2020

We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service.

ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.
P655 Prognostic value of the new classification of ventricular remodeling in severe aortic stenosis
Authors: Gonzalez Estriegana S , Gamaza Chulian S , Diaz Retamino E , Serrano Munoz B , Giraldez Valpuesta A , Oneto Otero J
Published: January 2020

Introduction

remodeling is defined as the changes produced in the geometry of the left ventricle after damage or overload of the myocardium. The most common classification only considers left ventricle relative wall thickness and mass index, but a new classification includes also end-diastolic volume index.

Purpose

to determine if the new patterns of ventricular remodeling had clinical relevance according to symptoms or cardiovacular outcomes.

Methods

patients with severe aortic stenosis (valve area <1cm2) between 2015 and 2018 were included, excluding other concomitant at least moderate valvular diseases.

The patients were classified according to the indexed ventricular mass, relative parietal thickness and left ventricular volume. Cardiovascular mortality was analyzed as the primary endpoint.

Results

we recruited 234 patients with severe aortic stenosis (55% women, age 77 ± 9 years) with a BMI of 29 ± 5, of which 82% were hypertensive, 47% diabetic, 47% dyslipidemic and 19% smokers. 81% were symptomatic. The average time of follow-up was 280 ± 231 days.

1% had eccentric hypertrophy, 7% mixed hypertrophy, 3% dilated hypertrophy, 73% concentric hypertrophy, 15% concentric remodeling; no patient presented normal ventricle or physiological hypertrophy.

Dyspnea was the predominant symptom

100% in eccentric, mixed and dilated hypertrophy; 72% in concentric hypertrophy and 85% in concentric remodeling (p = 0.05).

Most patients with mixed hypertrophy had NYHA functional class> II: 0% vs 62% vs 37% vs 27% vs 37% (p = 0.008).

The group with the highest cardiovascular mortality was mixed hypertrophy (0% vs 43% vs 0% vs 14% vs 11%, p = 0.04), also shown in the survival analysis (Log Rank = 0.009) (Graph 1).

Conclusions

in patients with severe aortic stenosis, the pattern of mixed hypertrophy was an adverse prognostic marker in our study, although prognostic role of these new remodeling patterns needs to be investigated in future prospective studies.

Abstract P655 Figure. Graph 1.: Kaplan-Meier survival function
P675 ECHO COLOR DOPPLER EVALUATION OF SPLANCHNIC HEMODYNAMIC DURING ACUTE HEART FAILURE
Authors: Ricco" B , Sacchi A , Galassi A , Messora R , Bertolotti M , Pinelli G , Turrini F
Published: January 2020

BACKGROUND

Acute heart failure (AHF) seems to provoke profound derangement of abdominal hemodynamic, which causes symptoms and impacts on renal function.

METHODS

27 patients (10 F - age 78 - EF 0.39) admitted for AHF underwent cardiac and abdominal ultrasound at day 1 and 5. Arterial and venous flow within liver, spleen and kidney were recorded. Portal and Splenic Vein flow was described as continuous, pulsatile or reversed, whereas hepatic vein systolic and diastolic ratio was measured. Renal Venous Doppler Profile (VDP) was classified as: continuous, pulsatile, biphasic or monophasic. Arterial Resistive Index (RI) ≥0.7 was considered elevated.

OUTCOME

At day 1 most patients presented with some degree of deranged VDP and high RI in all examined organs. At day 5, a significant proportion of patients improved their VDP in Liver, Kidney and Spleen, while the percentage of patients with collapsing IVC did not significantly change. On the arterial side, the proportion of patients with high Hepatic RI dropped significantly.

CONCLUSIONS

Our preliminary data show that most deranged VDP in abdominal organs and Hepatic RI improve after decongestion despite a nonsignificant trend in improvement in IVC profile.

RESULTS Classification day 1 day 5 p IVC Collapsing 24% 34% ns Portal Vein Continous 22% 50% Pulsatile 72% 50% Reversed 6% 0% <.05* Hepatic Vein S/D≥1 24% 59% S/D <1 60% 28% Reversed S 16% 14% <.05* Hepatic Artery RI ≥0.7 87% 36% <.05 Splenic Vein Flat 28% 57% Pulsatile 56% 33% Reversed 16% 10% <.05* Splenic Artery RI ≥ 0.7 52% 48% ns Renal Vein Continous 11% 39% Pulsatile/Biphasic 52% 52% Monophasic 37% 9% <.05* Renal Artery RI ≥0.7 63% 65% ns * Refers to normal profile versus all other deranged profiles
P705 Is chest wall deformity a serious issue? A rare case of TGFBR1 mutation in the paediatric population
Authors: Abood L , Padmanabhan S
Published: January 2020

INTRODUCTION

Mutations in the genes encoding transforming growth factor β receptors 1 and 2 (TGFBR1 and TGFBR2) have recently been found in association with a continuum of clinical features.

Mild association – a presentation similar to that of Marfan"s syndrome.

Severe association – a complex phenotype in which aortic dissection or rupture commonly occurs in childhood and at aortic diameters, that ordinarily would not be predictive of these events. Classified as the Loeys–Dietz syndrome.

Is chest wall asymmetry a serious issue? A study of 71 patients with Loeys-Dietz – 9% died from aneurysm rupture or dissection with aortic diameters of less than 4.5cm and as early as 6 months of age.

Genetic variants of unknown clinical significance - how should they be managed?

CASE

History

3-year old girl seen in general paediatric clinic with 5 months history of worsening chest wall deformity.

Examination

Asymmetrical pectus deformity. Spinal asymmetry and soft systolic murmur at the lower left sternal edge.

INVESTIGATION

Chest x-ray: Grossly enlarged and distorted cardiac/mediastinal silhouette.

Echocardiogram

Massive ascending aortic root dilatation (5.5cm) with significant aortic regurgitation.

MRI whole body angiogram

Massively dilated aortic root and ascending aorta to the proximal arch, hugely tortuous and ectatic cerebral vessels, diffuse marked dural ectasia, asymmetrical pectus deformity and a diaphragmatic morgagni hernia in the lower right hemi thorax.

Genetic analysis

Heterozygous missense variant of unknown clinical significance in exon 3 of TGFBR1 gene. The first heterozygous missense variant of its kind in the paediatric population for which its clinical significance remains unknown.

TREATMENT

As risk of dissection, a Bentall procedure was performed.

Family screening - Father has a dilated proximal ascending aorta.

LEARNING POINTS

Chest wall deformity should prompt clinicians to expedite investigations for aortic root dilatation/aneurysm and connective tissue disorders.

The continuum of clinical features of these genetic associations emphasises the importance of early recognition of the phenotype, prophylactic intervention and meticulous surveillance of the distal aorta and vascular tree for optimal management.

A genetic variant of uncertain significance (VUS) should not be used in clinical decision making. Efforts to resolve the classification of the variant as pathogenic or benign should be undertaken with good working relationships with clinical geneticists.

A VUS is difficult for patients and parents to understand and may also cause psychological distress. The importance of careful clinical and molecular characterisation to identify patients and families at risk cannot be overemphasised. This allows the use of a structured approach to intervention, informed counselling regarding the risk of recurrence, concerns related to pregnancy, and guidelines for clinical management.

Abstract P705 Figure. Case Photography and Imaging
P717 Isolated left ventricular tamponade in a patient with severe pulmonary hypertension due to chronic thromboembolisms: a case report
Authors: Vinter O , Trbusic M , Menegoni M
Published: January 2020

A case presents a 37 years old patient who presented to emergency department with progression of dyspnea. Patient had a history of pulmonary hypertension due to chronic thromboembolism and known, repetitive thrombosis of both legs with both of them postthrombotically altered, especially left leg. During his emergency department workup he had a pulmonary angiography performed which showed evidence of old thromboembolism in right pulmonary main branch and circumferential pericardial effusion which was dominantly locularized behind left ventricular posterior wall. Emergency echocardiography was performed which showed marked respiratory variations in mitral and aortic flow with mid to late diastolic left ventricular collapse. Also left ventricular cavity was severely reduced ( EDD 29 mm) due to prominent interventricular septum (right ventricular pressure overload) and hyperkinetic posterior wall (pericardial effusion). There were no apparent signs of compression of right ventricular chambers. Clinically patient had no pulsus paradoxus and had an RR of 115/70 mmHg. Emergency pericardiocentesis was performed using subxiphoid approach. However, pericardiocentesis setting was challenging because patient also had ample of ascites which made orientation by aspiration impossible. Instead puncture was performed under fluoroscopy while slowly instilling the contrast until contrast was delievered intradiaphragmally. From there needle was advanced 3-4 mm into pericardial cavity and pigtail catheter was placed. A total of 2200 ml of milky pericardial fluid was removed during the following 48 hours (cytology – mixed type; triglycerides 1.9 mmol/L). Patient was initially treated with corticosteroids and colhicin, but had a relapse of pericardial effusion once drainage was stopped so re-pericardiocentesis was performed. This time a total of 7200 ml of pericardial fluid was drained so we opted for pericardial fenestration (into left pleural space). Unfortunately, patient died on the 8th postoperative day due to complications (developed subcutaneous emphysema at the place of insertion of thoracal drainage and developed respiratory, then refractory cardiac arrest).
P729 A shocking tumor
Authors: Lorente Ros A , Pascual Izco M , Hinojar-Baydes R , Carvelli A , Vieitez Florez J M , Abellas Sequeiros M , Pinacho J , Navarro M , Fernandez Santos S , Alonso Salinas G , Hernandez S , Gonzalez Ferrer E , Jimenez Nacher J J , Zamorano Gomez J L , Fernandez Golfin C
Published: January 2020

Introduction

Primary cardiac tumors are a relatively uncommon condition, which may appear both in asymptomatic patients or in a myriad of clinical presentations. Imaging techniques are crucial for its diagnosis, and a multi-modality approach may be useful in the evaluation of this masses.

Case description

A 57 year-old man with history of hypertension presented in the emergency department with acute pulmonary edema and cardiogenic shock. He was admitted to the coronary care unit, and on bedside echocardiography a mass on the tricuspid valve was observed.

Upon clinical improvement, a cardiac CT and cardiac MRI was performed (figure 1). A solid mass with no calcium content and dependent exclusively on the anterior leaflet of the tricuspid valve was seen on CT-scan (fig 1, A and B). Thrombus on the right atrial appendage could also be appreciated.

MRI confirmed the presence of a 18x19 mm mass with isointense signal on T1-turbo spin echo black-blood (fig 1, C) and cine steady-state free precession sequences, whereas an hyperintense signal was evident on T2 weighted images (T2-STIR; fig 1 D). In first pass sequences the central core was hypointense and late gadolinium enhancement showed peripheral enhancement with a non captating central core (fig 1, E).

The patient underwent surgery and the anatomopathological results showed a tumor constituted by dense connective tissue, scarce cellular content and an avascular matrix of mucopolysaccharides, elastic fibers and fusiform cells consistent with the diagnosis of papillary fibroelastoma.

Discussion

The imaging characteristics of papillary fibroelastoma are not commonly reported on MRI. We present an unusually large right-sided fibroelastoma with a characteristic distribution of late gadolinium enhancement, which has not been consistently described on a fibroelastoma.

Cardiac tumors are rare, and a non-invasive differential diagnosis is always a challenge. A multi-modality approach (echocardiography, cardiac-CT and cardiac MRI) as well as integration of relevant morphological information, including the location of the lesion and tissue characteristics was essential to the orientate the most plausible diagnosis. The distinctive images are presented.

Abstract P729 Figure 1.
P742 The role of oxidative stress and inflammation for stress induced right ventricular diastolic dysfunction in non-severe chronic obstructive pulmonary disease patients
Authors: Cherneva Z , Lozanov V L , Sugareva P S , Cherneva R C H
Published: January 2020

Background

Oxidative stress and inflammation have been implicated in the pathogenesis of diastolic dysfunction (DD) and are both present in chronic obstructive pulmonary disease (COPD).

Aim

To evaluate the role of oxidative stress markers (8-isoprostane) and inflammation (prostaglandin E2, resistin) in the pathogenesis of stress induced right ventricular diastolic dysfunction (RVDD) in non-severe COPD.

Materials and methods

104 patients with non-severe COPD (FEV1 > 50%) and preserved left ventricular ejection fraction >50% underwent incremental cardio-pulmonary exercise testing (CPET). Echocardiography was performed before CPET and 1-2 minutes after peak exercise. Peak E/e’ ratio > 6 was a marker for stress induced RVDD. Urine concentration of 8-isoprostanes was assumed as surrogate marker for oxidative stress; urine concentration of prostaglandine-E2 and plasma resistin levels as inflammatory markers. Mass spectrometry was applied for 8-isoprostane and prostglandine E2 (Cayman. Chemical) measurement. Values were normalised to urine creatinine (µmol/l/cre). ELISA was applied for resistin measurement (Raybio_Human) (ng/ml).

Results

Patients were divided into two groups: subjects with stress RVDD (82) and those without stress RVDD (22). In patients with and without RVDD the levels of 8-isoprostane were similar (30.78 vs 30.41µmol/l/cre). The urine concentration of prostaglandin E2 in patients with and without RVDD significantly differed (49.73 vs 62. 19µmol/l/cre; p < 0.05). The same is observed regarding resistin plasma levels - in patients with and without RVDD (18.91 vs 5.47ng/ml).

Conclusions

In non-severe COPD patients oxidative stress levels are similar in the studied groups. Inflammation (resistin) seems to be the predominant pathogenetic factor, associated with stress induced RVDD. The exact role of prostaglandine E2 for RVDD remains elusive.