bluuebunny/crossref_metadata_2025 huggingface dataset:
P635 Echocardiographic-fluoroscopic fusion imaging: a new technology applied in pediatric ventricular tachycardia ablation
Authors: Jone P , Runciman M , Collins K K
Published: January 2020

Introduction

Eleven-year-old male presented with nonsustained ventricular tachycardia presented for ablation of ventricular tachycardia located on the left lateral wall that is likely associated with anterolateral papillary muscle. Although he was asymptomatic, his atria have become dilated over time thus he was scheduled for a catheter ablation. Echocardiographic-fluoroscopic fusion imaging has shown transseptal puncture using this technology is safe and required less time in crossing the atrial septum; however, fusion imaging with 3D echocardiography overlay of left ventricular papillary muscle onto fluoroscopy has not been used in ventricular tachycardia ablations.

Purpose

The purpose of this clinical case was to evaluate the application of this new technology of echocardiography-fluoroscopy fusion imaging to guide left ventricular tachycardia ablation.

Methods

Echocardiographic-fluoroscopic fusion imaging was used for transseptal puncture and a 3D echocardiographic image of the left ventricle with anterolateral papillary muscle was overlaid onto fluoroscopy (Figure 1). The radiofrequency catheter was used to ablate the left anterolateral papillary muscle. With fused imaging, the ablation catheter was seen at the left anterolateral papillary muscle, and care was taken to prevent perforation of the lateral wall of the left ventricle.

Results

With fusion imaging of the left anterolateral papillary muscle overlaid onto fluoroscopy, the lateral wall of the left ventricular was also delineated. The catheter was easily visualized with fusion imaging to prevent perforation of the left ventricle while radiofrequency ablation was performed (Figure 1).

Discussion

3D echocardiography provides excellent soft tissue definition of the lateral wall of the left ventricle and papillary muscle while fluoroscopy provides clear visualization of the ablation catheter. The ability of fusion imaging to overlay the 3D echocardiographic images onto fluoroscopy allowed for easy visualization of the anterolateral papillary muscle while the radiofrequency ablation was performed to avoid lateral wall perforation of the left ventricle. Future studies of echocardiographic-fluoroscopic fusion imaging should evaluate the potential to reduce procedure time and improve patient outcomes.

Abstract P635 Figure.
P636 A unique case of purulent pericarditis resulting in cardiac tamponade
Authors: Shah H , Le V K
Published: January 2020

Introduction and case report description

A 54-year-old male with no past cardiac disease was experiencing a productive cough, fevers, chills, and shortness of breath for 3 days in the community. His dyspnea worsened significantly, and he then presented to the emergency room. He admitted to using intravenous recreational drugs. His initial vital signs included a temperature of 38.2 degrees Celsius, a heart rate of 116 beats per minute, and a blood pressure of 88/42 mmHg. He had a positive pulses paradoxus with a decrease in systolic blood pressure of 14 mmHg on inspiration.

Description of the problem and procedures

This presentation was consistent with cardiac tamponade. He had an emergent echocardiogram showing a large pericardial effusion in the apical-four-chamber view (Image 1, A), including collapse of the right ventricle during diastole (Image 1, B, Green Arrow). There were also fibrin strands seen in a modified parasternal long axis view (Image 1, C, Blue Arrow). He had an emergency pericardiocentesis using real-time ultrasound guidance, which drained 400 mL of thick brown purulent fluid. A pigtail catheter was inserted to allow for continued drainage. Immediately afterwards, the patient’s blood pressure normalized, and his shortness of breath improved significantly.

Using the ultrasound, the physician also saw bilateral pleural effusions. The larger left pleural effusion was drained, and a pigtail catheter was inserted into the left pleural space. After confirming that there was no post-procedure left pneumothorax, the right pleural effusion was also drained.

An echocardiogram after the pericardiocentesis showed a significant decrease in the size of the pericardial effusion (Image 1, D).

The patient was started on broad-spectrum antibiotics, which was then narrowed after cultures from both the pericardial fluid and pleural fluid grew methicillin-susceptible Staphylococcus aureus.

Discussion

Cardiac tamponade results in increased compression of the cardiac chambers due to raised pericardial pressures. As it progresses, it can result in significant impairment in venous return, cardiac output, and blood pressure. This is a life-threatening condition if it is not promptly treated. In this case, the patient had a methicillin-susceptible Staphylococcus aureus empyema which spread contiguously into the pericardium and resulted in cardiac tamponade.

Conclusions and implications for clinical practice

This case highlights the clinical benefits of being proficient in performing a point-of-care ultrasound because a bedside echocardiogram by the physician immediately confirmed the diagnosis and allowed for safer drainage of the pericardial effusion using ultrasound guidance to decrease the chance of causing a perforation of the ventricle. Using ultrasound, the clinician was also able to promptly diagnose the pleural effusions and urgently drain them, which was necessary for achieving source control in order to fully treat the infection.

Abstract P636 Figure. Image 1. Cardiac Tamponade
P680 Aortic arch myxoma with multiple peripheral embolism.
Authors: Starzyk K , Pietrzyk E , Starzyk Z , Gluszek S , Wozakowska-Kaplon B
Published: January 2020

We report an unusual localisation of myxoma, the most common primary cardiac neoplasm. A 58-year-old woman was admitted to surgery department with exacerbation of abdominal discomfort and symptoms of lower limb claudication.The abdominal CT showed embolism in the upper mesenteric artery arms with intestinal ischemia, in the minor renal arteries with kidney infarcts and in the minor arteries of lower extremities. She was urgently, succesfully operated and partial resection of the small intestine was performed. The chest angio-CT conducted three days after the operation revealed additional structure in the aortic arch. Local aortic arch dissection with a thrombus was initially suspected. Echocardiography showed homogenous tumor on the minor curvature of the aortic arch, with a base of 11 mm of width, reaching down with the blood stream towards the descending aorta. The aortic wall was linear, with no signs of dissection or atherosclerotic lesions, echogenicity indicated rather solid mass. The patient was operated cardiosurgically and tumor of a myxoma type was confirmed intraoperatively. Another, small tumor of the same type was found below isthmus, in a descending aorta. Partial resection of aortic arch, alloplasty of aortic arch with the use of a dacron prosthesis were performed. The tumor below the isthmus was removed, without resection of aortic wall, due to the high risk associated with the widening of the procedure. Multimodality imaging with the essential role of echocardiography is useful especially in differential diagnostics of the atypically localized tumors causing diffuse peripheral embolization.

Abstract P680 Figure. Aortic arch myxoma tumor
P707 Positive rest and negative adenosine stress perfusion in typical angina
Authors: Mitrousi K , Moharem-Elgamal S , Manghat N , Hamilton M
Published: January 2020

Clinical Presentation

A 45 year old gentleman seen in Rapid Access Chest Pain Clinic with typical angina (exertional chest pain). No risk factors for CAD. Normal ECG. Pre-test probability of significant CAD 51% .

Diagnostic techniques and findings

The patient was referred for adenosine stress CMR. CMR was performed on a 1.5 Tesla scanner. Cine was performed first, followed by stress perfusion, gadolinium enhance images and finally rest perfusion images. LV systolic function was normal. A significant perfusion defect of the LAD territory was noted on the rest but not on the stress perfusion images. The radiographers confirmed that stress and rest perfusion images were performed normally (stress first). A good physiological response was obtained during the assumed vasodilator stress with > 20% in the HR (from 65-75bpm to 91-107bpm respectively). During the presumed rest perfusion acquisition, HR was similar to the previously recorded resting HR. The spleen was not adequately visible to comment on splenic switch off.

This type of perfusion defect (normal stress/abnormal rest) had not been described before, and there is no evidence that it was due to acquisition error.

A coronary CT was advised to assess the LAD. CT coronary angiogram showed mild coronary calcification. A severe (80%), focal, non-calcified mid LAD stenosis was identified. A mild proximal OM1 stenosis was also noted.

The patient subsequently underwent an invasive angiogram which confirmed the presence of a severe mid LAD stenosis. PCI was performed in the same setting with deployment of a single 4x18mm XIENCE drug eluting stent. The successful procedure was optimised with OCT guidance.

Learning points

Resting perfusion is often considered an integral part of adenosine perfusion imaging in order to overcome dark ring artefact, but it requires an additional contrast injection, prolongs imaging time and adds to cost. Some experts suggest that resting perfusion does not add to clinical interpretation and is not required.

Our case is interesting, showing a previously unreported phenomenon. We cannot explain the reason for it but do not believe that the stress/rest order was reversed (as this would require two radiographers to go off protocol, and they and the supervising physician to be lying) and the physiological response is as expected. It therefore suggests that a rest study may occasionally provide helpful diagnostic information.

Abstract P707 Figure.
P722 Unrepaired complex severe aortic coarctation determining restrictive cardiomyopathy with pulmonary hypertension in adulthood
Authors: Graziani F , Panaioli E , Lillo R , Delogu A B , Perri G , Grandinetti M , Burzotta F , Cialdella P , Lanzillo C , Massetti M , Crea F
Published: January 2020

A 54-year-old female presented to our Emergency Department with acute pulmonary edema. On physical examination she was tachypneic with arterial oxygen saturation of 91% and a grade 3/6 systolic murmur in the apex and left second intercostal space that was irradiated to the intrascapular area. Bilateral femoral and pedal pulses were quite faint on palpation. The blood pressure was 260/120 mmHg. Results of routine blood chemistry were normal with the exception of increased NT-proBNP (2746 pg/mL). Twelve-lead electrocardiogram revealed left ventricular hypertrophy with repolarization abnormalities and left atrial enlargement. The two dimensional (2D) echocardiography showed significant left ventricular hypertrophy (RWT 0.6; LVmass index 150 g/m2), no wall-motion abnormalities and normal left ventricular ejection fraction (EF 60%) but with reduced longitudinal components at TDI evaluation (6 cm/s). Severe ventricular diastolic dysfunction was detected with E/A 2,11 and E/e" 26 with a significant left atrial dilatation (LAVi 73 ml/m2) and severe pulmonary arterial hypertension ( PASP of 85 mmHg) . We were unable to visualize the aortic arch but reduced/absent pulsatile wall motion of abdominal aorta was identified. The patient reported to be affected by unrepaired aortic coarctation diagnosed at the age of 32 during pregnancy. She refused the surgical treatment twice and the she did not undergo any specific follow up but she had several admissions in emergency department for uncontrolled arterial hypertension. Our further evaluation with CT angiography showed a severe narrowing of the post isthmic aortic lumen with significant development collateral vessels (Figure 1). The patient was discharged after resolution of pulmonary edema and titration of hypertension treatment with a planning of hybrid approach to treat the aortic coarctation. The case shows a restrictive cardiomyopathy with post-capillary pulmonary hypertension due to severe unrepaired aortic coarctation.

Abstract P722 Figure. CT angiography,echo, right heart cath
P725 An unexpected direction: a case report of a double aortic arch in an asymptomatic woman in adulthood
Authors: Campos I , Vieira C , Salome N , Pereira V H , Costeira Pereira A , Bettencourt N , Costa Oliveira C , Marques Pires C , Medeiros P , Flores R , Mane F , Marques J
Published: January 2020

Introduction

Complete vascular rings represent about 0.5-2% of all congenital cardiovascular malformations, with the double aortic arch (DAA) being the most common of the complete vascular rings, causing tracheoesophageal compression. The right (posterior) arch is usually dominant (70%), although the two arches can have the same size (5%). The left (anterior) arch is dominant in only approximately 25% of cases. In most cases, this anomaly is diagnosed during childhood due to symptoms caused by oesophageal or tracheal compression. For this reason, case reports of adults are rare. This report describes a case of a 61-year-old woman with DAA with dominant left arch, diagnosed accidentallyby thoracic CT angiography.

Case Report Description

A 61 years old woman with a previous story of hypertension and type 1 diabetes presented to the emergency service with dyspnoea and thoracic pain. She also referred a history of intermittent dysphagia and cough with at least 12 years of progression. All the parameters of the physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm with no evidence of acute ischemia and her blood analyses did not show any abnormalitie. She also performed a thoracic CT angiography, which excluded signs of pulmonary embolism, but revealed a vascular ring suggesting a double aortic arch with permeability in both right and left arches as well as their collaterals. The Cardiac MRI was performed with the purpose of excluding ischemia, confirming the double aortic arch with left dominance. The right arch, posterior to the oesophagus and trachea, and the left arch, in an anterior position, showed an anatomic compression of the oesophagus as well as the proximal trachea, capable of eliciting the symptoms mentioned. Other congenital anomalies were excluded. The echocardiography did not demonstrate any additional cardiac malformation. Endoscopy shows a pulsatile extrinsic compression of the esophagus (aortic ring). The patient is currently being studied and closely monitored in the Cardiology consultation.

Discussion

The most common type of complete vascular ring is the double aortic arch, which accounts for 70% of the complete rings. In most cases, there are two permeable arches, usually with right dominance (70% of the cases). Rarely, both arches are symmetrical. Symptoms usually appear in the fifth month of life. In most cases, only supportive treatment is required.

Conclusion

This case illustrates the atypical features of this congenital malformation, namely the diagnosis during adulthood as well as the left dominance.

Abstract P725 Figure. A double aortic arch
P727 Unexpected ventricular aneurysm: further ischemic aetiology
Authors: Vieitez Florez J M , Hinojar R , Pascual M , Ramos J , Jimenez Nacher J J , Sanchez D , Carvelli A , Esteban A , Kristo D , Moya J L , Abellas M , Lorente A , Zamorano J L , Fernandez-Golfin C
Published: January 2020

Introduction

Ventricular aneurysm is an infrequent complication of myocardial infarction. In absence of an ischemic event, alternative aetiologies include: thoracic trauma, hypertrophic cardiomyopathy, myocarditis, Chagas disease, cardiac sarcoidosis or arrythmogenic cardiomyopathy. In the absence of any of the previous, congenital aneurysm diagnosis is made.

Case

We present the case of 57-year-old man referred to cardiology department because a new onset of atrial fibrillation with left bundle branch block. Past medical history included high blood pressure and dyslipidaemia without any history or smoking, alcohol consumption or any other toxic abuse. No chest pain, shortness of breath or other significant symptoms were reported. Physical examination was unremarkable except for an arrhythmic pulse at 85-90 bpm.

Echocardiogram showed moderate dilated left ventricle with mild-moderate LV dysfunction (EF 40% ) with a septal aneurysm of 2.4x1cm (Picture A). A coronary CT was performed that ruled out coronary heart disease and confirmed the presence of the septal aneurysm (Picture B). To better characterize this image, a cardiac magnetic resonance (CMR) was performed. Moderate dilated LV with significant dysfunction (EF 31%) was reported. A septal aneurysm of 13 x 22 x 33 mm composed of a 2.8 m thin wall of true myocardial tissue was documented (picture C and D-late gadolinium enhance). No myocardial delayed enhancement was detected in any area of the LV. Moreover, no signs of myocardial non compaction, arrythmogenic cardiomyopathy, hypertrophic cardiomyopathy or myocarditis were seen. Chagas serology as well as sarcoidosis diagnosis work up were negative. Patient denied any thoracic traumatism. Congenital aneurysm diagnosis was finally established.

Electrical cardioversion was performed after 1 month of correct oral anticoagulation and heart failure treatment was started. Case was presented in the Heart Team session and a conservative management was decided based on asymptomatic status and absence of ventricular arrhythmias. After 3 years of clinical follow up, the patients is in good status, asymptomatic and in sinus rhythm. Discussion: Congenital ventricular aneurysm is a rare cardiac malformation that arises during the fourth embryonic week. Most frequently, left ventricular aneurysms are found in the apex and the perivalvular area, being the septal location an atypical one. Most patients are asymptomatic but when symptoms occur, they are mostly related to the presence of ventricular arrhythmias. Aneurysm rupture incidence is variable, ranging from 3.7% to 12 % according to the different series. For this reason, surgery is recommended in symptomatic patients. However, management of asymptomatic patients is not clear since prognosis studies are lacking.

Abstract P727 Figure. A.Echo B.-CT C.-CMR. D.-CMR gadolinium
P731 When cardiac imaging saves the day - a rare cause of embolic stroke
Authors: Demetriades P , Ahluwalia V , Speke L , Wilson L , Khan J N
Published: January 2020

INTRODUCTION

Hypereosinophilic syndrome (HES) is a rare disorder characterised by infiltration of tissues by eosinophils. Myocardial infiltration occurs in 50-60% of HES and leads to a condition called Loeffler’s endocarditis. Eosinophilic protein toxicity initiates endomyocardial necrosis. This is followed by a thrombotic stage and finally by endomyocardial fibrosis leading to a form of restrictive cardiomyopathy. Thrombosis is often located in the apical region of the ventricles and can result in stroke, which is the most devastating neurological consequence of hyperoesinophilia. We describe a case of a patient that presented with neurological symptoms and was found to have multiple embolic strokes secondary to Loeffler’s endocarditis.

CASE

A 57-year-old female presented to our institution with new onset confusion and reduced level of consciousness. Initial neurological assessment was consistent with encephalopathy. She had a 2-year history of eosinophilia that had been investigated by the haematology and rheumatology teams with no obvious aetiology identified.

Initial haematological investigations showed a raised eosinophil count at 13mmol/L. Her cerebral MRI scan showed multiple embolic infarcts and therefore a transthoracic echo (TTE) was booked. This did not show any obvious intracardiac cause of emboli although the appearances of the LV apex were suspicious of thrombus. This was confirmed later, on contrast imaging (Fig 1). Staphylococcus aureus was grown in a single blood culture specimen raising the suspicion of infective endocarditis and a transoeosophageal echocardiogram (TOE) ruled out vegetations but again illustrated the apical filling defect despite absence of wall motion abnormalities (Fig 2). Finally, a cardiac MRI was arranged and this confirmed the diagnosis of Loeffler’s endocarditis with endomyocardial fibrosis and superimposed LV thrombus (Fig 3). She was treated with anticoagulation and steroids and her eosinophil count normalised before discharge. She remains well with no recurrence at two months post-event.

DISCUSSION

The diagnosis of Loeffler’s endocarditis depends on the presence high eosinophil count in combination with cardiac involvement on imaging. Transthoracic echocardiography can provide useful information such as apical thickening and thrombus in the left ventricle. As in our case, contrast TTE often provides further detail however contrast-enhanced cardiac MRI remains a key tool in the diagnosis and monitoring of this condition. It provides an assessment of systolic and diastolic function, tissue characterisation and typical features notably endomyocardial fibrosis and thrombosis on late enhancement imaging.

CONCLUSIONS

We presented a case where cardiac imaging has revealed the diagnosis in a patient presenting with systemic symptoms. We encourage clinicians to use multi-modality cardiac imaging as this has an invaluable role in the diagnostic process of complex patients.

Abstract P731 Figure.
P765 Does detection of thrombus in left atrial appendage increase risk of ischemic stroke and mortality?
Authors: Kagawa E , Kato M , Oda N , Kunita E , Nagai M , Shiota H , Dote K
Published: January 2020

Background

Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival.

Methods

The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared.

Results

Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p < 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p < 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p < 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p < 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p < 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p < 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B).

Conclusions

The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue.

Abstract P765 Figure
P781 Role of serum biomarkers combined with two-dimensional speckle tracking echocardiography for screening of immunotherapy-induced cardiotoxicity
Authors: Fusco F , Scognamiglio G , Vitiello F , Gilli M , Piantedosi F , Colonna D , Palma M , Granata G , Sarubbi B
Published: January 2020

Background

Immune checkpoint inhibitors (ICIs) are a novel class of antineoplastic drugs which have dramatically changed the management of non-small cell lung cancer. ICI-associated cardiotoxicity is rare, but potentially fatal, presenting in most of cases as autoimmune acute myocarditis during the first phase of treatment. However, since an extensive cardiac monitoring is not routinely performed in most immunotherapy trials, the true incidence of ICIs related cardiac effects is largely unknown.

Aim

Aim of our study is to ascertain a possible subclinical cardiac involvement in patients with non-small cell lung cancer treated with ICIs.

Methods

We prospectively recruited 40 patients (13 males; mean age 64.3 ± 8.3 years) starting immunotherapy with PD-1/PDL-1 inhibitors for non-small lung cancer between January and August 2018. Demographic and clinical data were recorded and all patients underwent a standard 12-lead ECG and a transthoracic echocardiogram with assessment of left ventricular global longitudinal strain (LV GLS). Furthermore, blood samples for pro BNP-nt and high sensitivity Troponin T (hsTnT) measurements were collected. Serial assessments were performed before and 1 and 3 months after initiation of immunotherapy.

Results

A history of previous coronary artery disease was documented in eight cases (20%). At follow-up no cardiovascular events were recorded. Compared with baseline, echocardiographic parameters of ventricular function did not significantly changed at 1 and 3 months (LVEF 61 ± 6% at baseline, 61 ± 5% at 1 month, 60,2 ± 5% at 3 months, p =0.1; E/E’at baseline 9.2 ± 3, 9.2 ± 2.8 at 1 month, 9.1 ±3,5 at 3 months, p = 0.2;TAPSE 20 ± 3.4 mm at baseline, 21.3 ± 2.8 mm at 1 month, 20 ± 3.8 mm at 3 months, p =0.1; LV GLS -20.3 ± 3.6% at baseline, -20.8 ± 2.3% at 1 month, -20.6 ± 3% at 3 months; p = 0.4). Analogously, no significant increase in circulating levels of cardiac biomarkers was found with hsTnT <0.015 ng/ml in all patients at baseline, 1 month and 3 months and median proBNP-nt 118 pg/ml (IQR 47-200) at baseline, 171 pg/ml (IQR 91-520) at 1 month, and 182 pg/ml (IQR 78-470) at 3 months, p = 0.9.

Conclusions

In our study no significant clinical or subclinical evidence of myocardial involvement was detected during treatment with ICIs in patients with non-small cell lung cancer, thus suggesting the potential cardiovascular safety of this promising class of antineoplastic drugs.
P789 Reverse left atrial functional remodeling after surgical aortic valve replacement is dependent on impaired left atrial function and reverse left ventricular remodeling
Authors: Pessoa Amorim G , Vouga L , Gama V , Bettencourt N , Fontes-Carvalho R , Mancio J
Published: January 2020

Funding Acknowledgements

Fundação Portuguesa para a Ciência e Tecnologia (SFRH/BD/104369/2014) and Sociedade Portuguesa de Cardiologia (“Bolsa de investigação João Porto”)

OnBehalf

EPICHEART Study

Background

Left atrial (LA) functional remodeling is an important mechanism in the pathophysiology of aortic stenosis (AS), and readily-assessable using speckle-tracking echocardiography (STE). It is uncertain whether and how surgical aortic valve replacement (SAVR) affects reverse LA functional remodeling.

Aims

We aimed to evaluate LA functional remodeling post-SAVR using STE and to explore potential underlying mechanisms.

Methods

73 symptomatic severe AS patients (72.6 ± 8.14 years, 53.4% male) were assessed before and six months after SAVR (Fig.1-A). LA function was evaluated using STE-derived LA longitudinal strain during reservoir (LASr), conduit (LAScd) and contraction (LASct) phases (Fig1.-B); reverse LA remodeling was represented by their relative percentual changes. LA structure was assessed by LA area and indexed volume.

Results

LA structure and left ventricle (LV) indexed mass, end-diastolic diameter (LVEDD) and mean E/e" improved after SAVR (Table 1). Although paired-samples analysis did not show signiﬁcant changes in LA function, multiple linear regression revealed that preoperative LA strain parameters were the sole baseline predictors of reverse LA remodeling: lower baseline LASr, LAScd and LASct were related to improved LASr, LAScd and LASct, respectively (Fig.1-C); mean E/e’ decrease was associated with LAScd improvement (Fig.1-D2). LV mass and LVEDD decrease were not associated with LA functional recovery.

Conclusion

Reverse LA functional remodeling is compromised after SAVR, and increased in patients with impaired baseline LA function. LV diastolic function recovery was linked to improved LA conduit function. An optimal echocardiographic cut-off should be further explored in order to better adjudicate surgical timing, and foster LA functional recovery.

Echocardiographic assessment Baseline 6-months post-SAVR Paired t-test (p-value) Mean aortic gradient (mmHg) 49.6 ± 12.2 11.2 ± 5.1 <0.0001 LA area (cm2) 20.9 ± 4.9 19.5 ± 4.1 0.02 LA indexed volume (mL/m2) 37.4 ± 12.4 30.7 ± 8.3 <0.0001 LASr (%) 30.0 ± 10.4 29.3 ± 11.2 0.57 LAScd (%) 14.3 ± 7.4 14.3 ± 6.8 0.95 LASct (%) 15.6 ± 6.5 15.0 ± 7.2 0.50 LV indexed mass (g/m2) 128.6 ± 31.8 124.5 ± 30.0 <0.0001 LV end-diastolic diameter (mm) 45.7 ± 5.19 44.7 ± 5.7 0.03 LV ejection fraction (%) 66.0 ± 6.0 64.6 ± 5.5 0.54 Mean E/e´ ratio 14.2 ± 5.5 11.2 ± 4.3 0.0004 Values are mean ± SD

Abstract P789 Figure. Left atrial remodeling after SAVR
P791 Left atrial stiffness as a predictor of cardiac events in patients with heart failure and reduced ejection fraction: the impact of diabetes
Authors: Bytyci I , Pugliese N R , Bajraktari A , Mazzola M , Bajraktari G , Henein M Y , Dini F L
Published: January 2020

Background and Aim

Diabetes mellitus (DM) affects left ventricular remodeling in patients with heart failure (HF), but its effect on left atrial (LA) remodeling and their combined effect on survival and other clinical events (CE) remain to be elucidated. We evaluated in this study the relationship between DM and left atrial (LA) remodeling in a group of HF patients with reduced ejection fraction (HFrEF),

Methods

This studied 136 consecutive HFrEF patients (65 ± 11 years), 36 diabetics, using conventional and tissue Doppler echocardiography. LA dimension and function were measured and cavity stiffness was calculated with the formula: LA stiffness = E/e’ratio/LA strain.

Results

The age, gender, LV end-systolic dimension, LV end-diastolic dimension, LV EF and BNP level did not differ between diabetic and non-diabetic patients. Diabetic patients with HFrEF had higher NYHA functional class (p = 0.02), reduced right ventricle (RV) systolic function (p = 0.01) and increased LA stiffness (p = 0.02) .

At follow up of 55 ± 37 months, survival free from CE was 69% in non-diabetics compared with 44.4% in diabetics (X2 12.7; p< 0.0001). The CE free survival was lower in patients with increased LA stiffnes, irrespective of the presence of DM: 1) Patients with HFrEF without DM and normal LA stiffness (85%); 2) Patients with HFrEF without DM and with increased LA stiffness (50%); 3) Patients with HFrEF with DM and with normal LA stiffness (71%) and patients with HFrEF with DM and with increased LA stiffness (27%) (X2 29.6; p< 0.0001, Figure 1).

Conclusion

Compromised LA stiffness as surrogate of LA remodeling is associated with poor outcome in patients with heart failure and reduced EF. The presence of diabetes in patients with HFrEF and increased LA stiffness has incremental prognostic value.

Abstract P791 Figure.
P794 Treadmill exercise stress echocardiography in children; our experience.
Authors: Cotrim C , Joao I , Guardado J , Cordeiro P , Sampaio M ANA , Marques A , Cafe H , Martins R , Cotrim H , Baquero L
Published: January 2020

Background

Exercise stress echocardiography (ESE) is routinely used in adults but its role in children (C) is less established

Purpose

To assess the feasibility and clinical value of ESE in outpatient children

Methods

We enrolled 309 consecutive C (mean age = 14,1 ± 2,6 years, range 6-17 yrs) who underwent treadmill ESE between 2002 and 2019: One group (Group I) of 258 C including: 237 with exercise related symptoms (chest pain and/or dyspnea and/ or lypotimia-syncope), 15 with resting ECG alterations, 6 with positive ECG stress test and other group of C (Group II) including: 10 asymptomatic for screening requested by parents, 11 with symptoms unrelated to exercise, 12 with antecedents of sudden death in the family, and 17 with known pathology - 10 with hypertrophic cardiomyopathy, 2 with aortic coarctation, 1 each with Cortriatriatum sinister, pulmonary stenosis, subaortic stenosis, bicuspid aortic valve, left ventricular hypertrophy related to arterial hypertension, aortic switch operation. Regional wall motion abnormalities (RWMA) by 2-D and continuous wave Doppler (transvalvular or transaortic or intraventricular (IVG) gradients were assessed in all.

Results

The success rate was 309/309 (100%). Only one complication (allowing asthma diagnosis by serendipity) occurred: a severe asthmatic crisis in one girl studied because of chest pain with exercise (with ESE negativity), Stress-induced RWMA occurred in 2 pts (one with HCM, the other with normal coronary arteries). A significant orthostatic exercise induced IVG (> 30 mmHg) was present in 101 of the 258 C (39%) studied due to symptoms, ECG alterations or positive stress ECG.

In group II the C with induced IVG attained

greater heart rate (HR) 184 ± 12 vs 174 ± 16 (p < 0,001); greater blood pressure (BP) 150 ± 19 mmHg vs 136 ± 23 mmHg (p < 0,001). The OR to the reproduced symptoms that motivated the exam during the SE comparing the 101 C with IVG with the 158 without IVG was 8,22 (4,83-13,99) p < 0,001 (95% CI).

Conclusions

Treadmill ESE is feasible and safe in young people. RWMA are of limited usefulness in our outpatient C group. Doppler often documents significant exercise induced IVG, occult at rest that associate with symptoms.

Abstract P794 Figure. ESE Induced IVG in a C with chest pain
P806 Cavitation phenomenon in mechanical valves: not only microbubbles
Authors: Vriz O , Archi F , Aldmawi M , Ahmed M , Alhumaid M , Alnahdi F , Raim A , Galzerano D , Kinsara M J , Alshahid M
Published: January 2020

Introduction

It is well described the presence of microbubbles (MBs) which are high-velocity, small, bright echoes presences that occur with the closing/opening of the mechanical double disk valve, more frequently in mitral position but less frequent growth of the cavitation bubbles are described.

We considered the echo studies of patients with growth of cavitation bubbles and we evaluate the possible impact of the hemodynamic parameters of their formation and then misdiagnosis with endocarditis.

Methods

We analyzed retrospectively the echocardiographic studies of 49 patients with growth of cavitation bubbles and we went back to all studies until the date of surgery if available, to see in how many of those echos, this phenomenon was present.

Patient"s blood pressure (BP) and heart rate (HR) measurement were available for each echo study. For the present analysis the last echo study with or without growth of cavitation bubbles were considered. The last echo study without growth of cavitation bubbles was considered as control group.

Results

Fourty nine patients (M26/F23) with mean age of 46.5 ± 13.6 years were identify as having growth of the cavitation bubbles and a total of 325 echo studies were reviewed. All patients had mitral valve replacement but 4, that had only aortic mechanical valve. 43% had mitral-aortic valve replacement and 5 had 3 or 4 valves replaced. The follow-up period was of 3697 ± 2481 days, 52%±31% of the echo studies reviewed had growth of the cavitation bubbles.

At the time of the study systolic BP was 124 ± 12.5 vs 121.1 ± 16.4 mmHg, p = 0.1 (echo study with versus without growth cavitation respectively), diastolic 72.7 ± 10.1 vs 69.4 ± 14.9 mmHg, p= 0.2; HR 81.3 ± 19.4 vs 73.7 ± 14.1 bpm, p = 0.05. No statistical differences in trans mitral gradients were found between the two groups (peak 11.8 ± 3.9 vs 11.7 ± 4.3 mmHg, p = 0.7; mean 4.6 ± 1.9 vs 4.2 ± 1 mmHg.6p = 0.1). 33 TEE were performed and in 50% of cases because of suspecion of endocarditis. Only 2 TEE were positive for endocarditis and one positive for pannus and high gradients across the valve in addition to cavitation.

Conclusion

Cavitation phenomenon in mechanical valves, in particular mitral bi-leaflet valve is well known but growth of cavitation bubbles is seldom described. We found that this fenomenon is frequently present although not constant, is related with increased HR and can be responsible of misdiagnosis with endocarditis.

Abstract P806 Figure.
P817 Lung ultrasound in the evaluation of pulmonary congestion in patients with aortic stenosis
Authors: Szabo I , Gargani L , Illes B , Frigy A , Varga A , Agoston G
Published: January 2020

Background

Aortic stenosis (AS) has a prolonged latent period, as AS worsens, the left ventricular adaptations become inadequate and impaired systolic and/or diastolic dysfunction, may lead to clinical heart failure (HF). The development of HF is an inflexion point in the natural history of AS. Pulmonary congestion is a nearly universal pathophysiological finding in HF, and may precede symptoms. Lung ultrasound (LUS) evaluation of B-lines has been proposed as a simple, non-invasive tool to assess pulmonary interstitial edema.

Aim

To assess pulmonary interstitial edema with LUS in patients with moderate and severe aortic stenosis, to define performance of LUS compared with clinical assessment and echocardiographic parameters.

Methods

Sixty-eight consecutive patients (36 women, mean age 74 ± 9 years) with moderate or severe aortic stenosis were enrolled. Exclusion criteria were as follows: moderate or severe aortic regurgitation, moderate or severe mitral regurgitation, cardiomyopathies and pulmonary disease. All patients underwent comprehensive echocardiography examination and LUS according to a previously validated 28 scanning-site assessment.

Results

we found a significant number of B-lines (≥15) in 79% of patients. B-lines were positively correlated with left atrial volume index (p < 0,05, r = 0,3) and estimated pulmonary pressure ( p < 0,0001, r= 0,62 Figure 1.) The number of B-lines didn’t correlate with the severity of AS (mean gradient vs. B-lines: p = 0,2, valve area vs. B-lines: p = 0,2.), however properly reflects different functional status of the patients (p < 0,0001, Figure 2.)

Conclusion

Lung ultrasound is a promising tool to detect lung congestion related to AS. The severity of congestion doesn’t correlate with the severity of AS, albeit B-lines better reflect the deteriorating functional status of the patients and the haemodynamic consequences related to AS.

Abstract P817 Figure. Correlation PASP vs Blines, NYHA/B-lines
P824 Impact of cardiovascular risk factors and treatment strategies on the presence of intramyocardial hemorrhage visualized by magnetic resonance in patients with reperfused infarction
Authors: Igual Munoz B , Elena Sanchez Lacuesta E S L C , Jose Luis Diez Gil J L D G , Maria Ferre Valverdu M F V , Francisco Ten Morro F T M , Vicente Miro Palau V M P , Maryem Ezzitouny M E , Jose Leandro Perez Bosca JLPB , Rafael Paya Serrano R P S
Published: January 2020

Intramyocardial hemorrhage (IMH) is considered a marker of tissue damage severity in patients with reperfused ST-segment elevation myocardial infarction (STEMI) and has been associated with a poor prognosis despite successful revascularization of the culprit artery . We aim to study the impact of cardiovascular risk factors and treatment strategies on the presence of IMH studied with T2* -w cardiovascular magnetic resonance (CMR) in this clinical setting

METHODS

A prospective observational study including patients with repefused STEMI who underwent an MRI during the first week post-revascularization were conducted . The presence of IMH was analyzed in ECG triggered T2 * w sequences as presence of hipointensity area . Clinical data including cardiovascular risk factors and treatment strategies at cath lab were studied.

RESULTS

94 patients with reperfused STEMI were included. Demographic data are shown at the the table. No significant association was observed between the presence of IMH and the different treatment strategies used. All data were introduced in a multivariate model including presence of thrombus, total ischemia time and culprit coronary artery. The analysis showed previous infarction as an independent risk factor (OR: 6 p = 0.03, CI: 1.1-29) while history of hypertension (OR: 0.9, p = 0.04, CI: 0.1- 0.9) and systolic blood pressure showed independent protective effect (OR: 0.3 p = 0.02 IC: 0.9-0.99.)

CONCLUSIONS.

1. Previous infarction was shown to be an independent risk factor for IMH .

2. Arterial hypertension and systolic blood pressure showed a protective effect.

Age (years) 62 ±13 Male sex 72 (77) Diabetes mellitus 32 (34) Hypertension 53 (56) Hyperlipidaemia 52 (55) Current or prior smoking 55 (58) Time to reperfusion 203 (142-300) Infarct-related artery LAD 38 (41) RCA 49 (52) Cx 7 (7) Infarct size (% LV mass) 18 ± 11 MO (% LV mass) 3.15 (1.44-5.48)

Abstract P824 Figure. Intramyocardial hemorraghe T2* sequences
P836 Long-term survival of a rare case of pseudoaneurysm of the mitral-aortic intervalvular fibrosa as a complication of endocarditis of a bicuspid aortic valve
Authors: Al Shehadat M , Khalifa E , Mohamed S , Ghareep A , Gomaa M , Alkuwari M , Helmy S
Published: January 2020

Introduction

This is a case report of a rare condition of pseudoaneurysm of the mitral-aortic intervalvular fibrosa (P-MAIVF).

Case presentation

The patient was a 42-year-old Filipino gentleman. He first presented to us in 2014, for routine echocardiographic examination as a part of a preoperative assessment for a non-cardiac surgery. Patient was asymptomatic and had a history of bicuspid aortic valve, which was complicated by endocarditis in 2006, and was treated with antibiotics.

Echocardiography findings: Transthoracic echocardiography (TTE) showed a bicuspid aortic valve of no hemodynamic significance . A P-MAIVF was noted by Transesophageal echocardiography as a cavity expanding posteriorly into the left atrium from the left ventricular outflow tract, with a narrow neck at the junction of the aortic posterior cusp and the anterior mitral leaflet (Figure A). The cavity showed the characteristic expansion during ventricular systole, and collapse in diastole. Color flow showed the flow through the neck in systole and emptying during diastole (Figures C,D). There was mild mitral incompetence and no fistula was detected. Diagnosis was confirmed by cardiac magnetic resonance (Figure B).

Follow up

Because of the known complications of this condition, some of which are potentially fatal (such as rupture into the pericardium and tamponade), he was offered a surgical repair, which he had refused. Alternative conservative follow-up strategy was implemented and we had the opportunity to follow him for more than 5 years. During these years he was asymptomatic and uncomplicated. There was no change in the size of the pseudoaneurysm or its flow pattern.

Conclusion

This report demonstrates a rare case of P-MAIF as a complication of bicuspid aortic valve endocarditis and a long-term patient survival of a potentially fatal condition without corrective surgery.

Abstract P836 Figures A,B,C,D
P840 A surprising outcome
Authors: Rocha R , Fernandes R , Carvalho J , Pais J , Bras D , Guerreiro R , Aguiar J
Published: January 2020

Introduction

infective endocarditis(IE) is a high morbidity and mortality disease, and heart failure,central nervous system embolization and annular abscess account for common complications.Nevertheless,intracardiac fistula is rare and predicts higher mortality and urgency for surgery.

Case

84years old male patient,with an aortic bioprosthesis valve Perimount n23 since 2015,was admitted to internal medicine ward 3months before,due to Enterococcus faecalis bacteremia.at that time,transoesophageal echocardiography(TEE) revealed moderate to severe mitral valve(MV) regurgitation(vena contracta 0.7cm) and trivial tricuspid regurgitation,but did not showed any suggestive images of endocarditis.the patient was treated with 14days of amoxicillin-clavulanate.

On the current presentation,due to fadigue to mild physical activity and fever for 2weeks,he was admitted to cardiology ward for further investigation.blood cultures were positive for the previous agent,so antibiotherapy with ampicillin 12g/day and gentamicin 240mg id was started.TEE revealed thickening of aortic bioprosthesis’ leaflets with preserved systolic opening.aortic valve annulus thickening,mainly near the non-coronary cusp,was evident, without characteristic features of peri-annular abscess.on ventricular side of the prosthesis,there was a vegetation(10.7x10.8mm). a small nodule lesion,coherent with a second vegetation,was present on the MV’s posterior leaflet,without regurgitation’s worsening. a third one was observed on the septal leaflet of the tricuspid valve(7.3x6.5mm),which also caused an increasement in severity of the regurgitation,quantified as moderate.

On the sixth day,the patient presented with right arm paresis,so a brain CT was performed,showing an ischemic lesion on the left middle cerebral artery.Reevaluation,5days later,owing to new neurological changes,showed multiple acute vertebrobasilar embolic strokes.

As a result of poor medical response and embolic strokes,the patient was referred to surgical treatment. however, due to prohibitive surgical risk (euroscore 59%), the patient was refused.

After 6weeks of blood culture driven antibiotherapy,a reevaluation TEE revealed a periprosthetic pseudoaneurysm with small aorta-to-right atrium fistula.no vegetations were found.

Conclusion

rate complication of cardiac fistulae is high,60%of the patients develop heart failure and mortality rate is higher than 40%.although conservative treatment was addressed,after 8months discharge,the patient remains with few heart failure symptoms(NYHA classII).