bluuebunny/crossref_metadata_2025 huggingface dataset:
P1259 When it rains, it pours: Late presentation STEMI in a patient with intricate symptomatology due to concomitant acute pancreatitis and pneumonia
Authors: Nicolae E , Aflorii R , Popescu A C
Published: January 2020

Background

ST segment elevation acute myocardial infarction and acute pancreatitis are diagnostic and therapeutic emergencies. The concomitance of these two pathologies produces intricate and confusing symptoms leading to late presentation.

Clinical Case Description- We present the case of a 62-year-old male patient, non-smoker, admitted in the emergency department for intense, continuous epigastric pain with posterior radiation and dyspnea, started four days before. On admission we found hemodynamic stability, lung crackles in the ½ inferior of the right lung, SaO2= 94% under 3l/min O2, normal cardiac sounds, HR 102/min, mitral systolic murmur, BP 145/80mmHg, abdominal pain on palpation. Lab tests revealed elevated cardiac troponin values and detection of a fall of cTn values in dynamics (hs-cTnI 30372ng/l, TnI 73ng/ml), but also high serum transaminases, amylase and lipase (1278 U/l), with high inflammatory markers, leukocytosis and neutrophilia.

ECG showed sinus rhythm, QRS axis 0 degrees, ST segment elevation in V1-V4, ST segment depression DI, aVL, negative and biphasic T waves in V5-V6, DI, DII, aVL, Q wave in DIII, aVF and poor R wave progression V1-V4.

Admission echocardiography revealed dilated left cavities with severe left ventricular systolic dysfunction (EF 20%), akinesia of the anterior and inferolateral walls, moderate mitral and tricuspid regurgitation, grade III diastolic dysfunction and possible pulmonary arterial hypertension. Coronary angiography revealed distal stenosis of the left main, involving the bifurcation, 80% ostial LAD stenosis, proximal LAD occlusion, 30% ostial LCX. PCI with DES of the proximal LAD, and left main–LDA junction with overlapping was performed successfully.

Abdominal echography showed increased volume of the pancreas and significant decrease in echogenicity. Abdominal CT scan assessed inflammatory changes in pancreas and peripancreatic fat (grade C Balthazar score), superior mesenteric artery partial thrombosis and alveolar consolidation in the right lung. Echocardiography reassessment four days later revealed a fresh apical thrombus of the left ventricle.

He received treatment with low molecular weight heparin, dual antiplatelet therapy statin, loop diuretic, aldosterone antagonist, digoxin, antibiotics and food restriction with gradual oral realimentation. He needed positive inotropic support for the first 4 days from a total of 28 days of hospitalization.

Conclusions

ECG changes and prothrombotic status can occur in patients with acute pancreatitis. The diagnosis and management of STEMI concomitant with acute pancreatitis can be challenging. The multimodality imaging and interdisciplinary approach individualized to the patient’s clinical situation is important, especially when having safety concerns about the revascularization therapy, antiplatelet and anticoagulant therapy.

Abstract P1259 Figure.
P1260 Chagas disease, a new challenge to the old continent
Authors: Dias Ferreira Reis J P , Mano T , Rio P , Galrinho A , Valente B , Silva Cunha P , Oliveira M , Moura Branco L , Ferreira R
Published: January 2020

Case Report

A 53-year-old female patient from the North Region of Brazil with a past medical history of Chagas Disease (CD) with esophageal involvement and permanent atrial fibrillation (AF) presented to the Emergency Department (ED) due to complaints of retrosternal discomfort and dizziness. The patient reported multiple recent syncopal episodes and had performed a recent 24-hour Holter monitoring revealing AF with predominantly slow ventricular rate and frequent ventricular premature beats. Her sister had recently been diagnosed with obstructive hypertrophic cardiomyopathy. During the ED stay, the patient developed a syncopal monomorphic ventricular tachycardia, requiring synchronized electrical cardioversion. Post cardioversion EKG revealed a sinus rhythm with a right bundle branch block, left anterior fascicular block and 1st degree AV block. The patient was admitted in the Cardiology Department for further investigation. Transthoracic echocardiogram revealed a dilated left ventricle with a reduced systolic function (LVEF of 38%, GLS of -7.1%), with an aneurysm of the basal inferior and posterior walls and a markedly dilated left atrium (68mL/m2). Cardiac magnetic resonance imaging showed a marked dilation of both atriums and ventricles, with biventricular systolic dysfunction, hypertrabeculation of the left ventricular wall and the presence of diffuse intramural and subepicardic fibrosis. These features were compatible with chagasic cardiomyopathy. Due to biventricular systolic dysfunction, the documentation of AV conduction disturbance, the natural history of the disease and the need for antiarrhythmic therapy, the patient underwent cardiac resynchronization therapy–defibrillator implantation. 1 week after the procedure, the patient experienced an arrhythmic storm with a total of 6 CRT-D shocks. Amiodarone was initiated and beta-blocker was titulated to the maximum tolerated dose, with no recurrence of ventricular tachycardia. On the 3 month follow-up visit the patient denied symptoms of congestive heart failure. Device interrogation revealed a high percentage of biventricular pacing and no arrhythmic events.

Conclusion

This case describes the most remarkable and characteristic features of chagasic cardiomyopathy. It is almost always progressive and is associated with a worse outcome comparing with other cardiomyopathies. The prevalence of CD is growing in traditionally nonendemic areas and its timely recognition is fundamental.
P1272 Echocardiographic evaluation of left ventricular filling pressure in patients with heart failure with preserved ejection fraction : usefulness of inferior vena cava measurement
Authors: Motiejunaite J , Jourdain P , Gellen B , Bailly M T , Bouchachi A A , Humbert M , Rouquette A , Damy T , Chemla D , Assayag P , Berthelot E
Published: January 2020

Context

Echocardiography is an essential tool for evaluation of left ventricular filling pressure (LVFP). We aimed to assess the usefulness of inferior vena cava (IVC) measurement and the 2016 ESC recommendations in patients with suspected heart failure with preserved ejection fraction (HFpEF).

Methods

Invasive hemodynamics and echocardiographic measurements were documented in 132 consecutive patients referred to our centre with dyspnea, left ventricular ejection fraction (LVEF) ≥50%, and suspected pulmonary hypertension on a previous echocardiogram. Echocardiographic measurements of mitral flow (E and A wave velocities), the E/e’ratio, indexed left atrial volume (LAV), tricuspid regurgitation velocity (TRV) and the IVC size and collapsibility were obtained. Increased LVFP was defined by an invasive pulmonary artery wedge pressure (PAWP) > 15 mmHg.

Results

In sinus rhythm patients, the sum of the criteria (E/e’ ratio > 14, TRV > 2.8 m/s and indexed LAV > 34 ml/m²) ≥ 2 had a positive predictive value (PPV) of 63% for PAWP > 15 mmHg, whereas a dilated (> 2.1 cm) and/or non collapsible (≤ 50%) IVC had a PPV of 83%. In atrial fibrillation (AF), a dilated and/or non collapsible IVC had an 86% PPV for increased LVFP. We found that 16% of patients with elevated LVFP were more accurately classified using IVC evaluation than using the current guidelines criteria (net reclassification improvement = 0.25, p <0.05).

Conclusion

Echographic measurements of the IVC size and collapsibility outperformed the classic 2016 recommendations algorithm to evaluate LVFP in sinus rhythm patients with suspected HFpEF. The IVC study was also valuable in patients with atrial fibrillation.
P1273 Effects of surgical septal myectomy on left ventricular function in patients with hypertrophic obstructive cardiomyopathy
Authors: Furugen A , Doi H D , Hashimoto M H , Koshima R K , Mitsube K M
Published: January 2020

Introduction and Purpose

Surgical left ventricular (LV) septal myectomy in patients with obstructive hypertrophic cardiomyopathyhas been shown to reduce left ventricular outflow tract (LVOT) gradient and improve symptoms. We investigated changes in strain analysis, LA volume and LV systolic and diastolic function in patients with HOCM after surgical septal myectomy.

Methods

We enrolled consecutive 30 patients (age 63.7 ± 11.0 years, 47% Female), who underwent surgical LV septal myectomy for HOCM from 2012 to 2019.

We evaluated LV dimension, LVOTG, LV-stroke volume, LV in flow pattern (E wave, A wave, Dct), e’(septal and lateral), LA volume, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM) and Global longitudinal strain. These parameters were evaluated at baseline and after LV myectomy at medium term (at least 6 months after surgery).

Results

They are followed for a mean of 3.4± 1.9 years after surgery. Eight patients underwent concomitant procedure; mitral valve repair and annuloplasty in 3 patients (10%), Maze surgery in 1 patient, LV aneurysmectomy in 2 patients and aortic valve replacement in 3 patients (10%). Patients with concomitant procedure were excluded from LV function analysis. Postoperative LVOTG were controlled in 10mmHg or less.Global longitudinal strain (GLS) improved but no significant change. Otherwise LA volume index decreased (from 52.5 ± 16.7 to 32.9 ± 14.6 ml/m2, p = 0.01) and LV diastolic function improved with an increase in lateral e" velocity (from 4.5 ± 2.8 to 9.2 ± 3.4 cm/sec, p = 0.001) and improved E/e’ (from 18.9 ± 5.6 to 10.6 ± 5.2, p <0.05). Symptoms of dyspnea, chest oppression and heart failure improved with reduction in the New York Heart Association functional class.

Conclusion

Excellent relief of LVOT obstruction in HOCM by surgical LV septal myectomy results in decreased LA volume and LV diastolic function with improved symptoms.
P1280 Vascular and left ventricular mechanics after surgical correction of aortic coarctation of children
Authors: Matanovskaia T , Sinelnikov U S , Orekhova E N
Published: January 2020

Background

The main cause of the suboptimal long-term outcome after surgical correction of aortic coarctation(CoA) is late correction, residual CoA or reCoA. Cardiovascular remodeling after correction CoA in neonatal period without residual CoA is not well established.

Purpose

Evaluation of global longitudinal strain of the left ventricle (LV) and circumferential mechanics common carotid artery in children 5 years after surgical correction of the CoA in the neonatal period.

Methods

We examined 58 children aged 5,2 ± 0,39 years after successful repair CoA in neonate period. We excluded children with residual CoA or reCoA. Echo was performed with using vector velocity imaging. We studied LV longitudinal strain (LS) and strain rate (LSR). In the left common carotid artery we estimated: carotid strain (CC S) and strain rate (CC SR), fraction area change (FAC CC), carotid β2-stiffness index (CC β2), and intima-media thickness (IMT). The obtained data were compared with the results of 25 healthy children.

Results

LS LV and SR LV are worse of children after CoA correction compare with healthy, even LV ejection fraction is similar to healthy children. We found correlation LV mass index (LV MI) with CC S and CC SR. CC β2 of children after Co A repair was higher than of control group. CC β2 correlated with LS LV, SR LV and with LV MI. IMT and FAC didn’t differ of operated and healthy children.

Conclusion

Parameters of the LS of the LV and CC β2 of children 5 years after CoA repair significantly differ from healthy children and reflect the ongoing process of cardiovascular remodeling. Assessment of the CC S allows timely confirmation of the presence of increased arterial stiffening.
P1289 Echocardiograhic prediction of pulmonary arterial capacitance in patients with heart failure with preserved ejection fraction
Authors: Fontes Oliveira M , Trepa M , Costa R , Dias Frias A , Cabral S , Santos M , Torres S , Reis A
Published: January 2020

Background

Pulmonary arterial capacitance (PAC) has emerged as one of the strongest hemodynamic predictors of adverse outcomes in a wide spectrum of cardiovascular diseases, including pulmonary hypertension in heart failure with preserved ejection fraction (HFpEF-PH). We aimed to study non-invasive surrogates for PAC using transthoracic echocardiography in this population.

Methods

We retrospectively evaluated consecutive patients referred to an expert tertiary care referral centre from December 2016 to November 2018. Transthoracic echocardiography (TTE) was performed within 1 year of right heart catheterization (RHC). Echo-Pac software from GE Healthcare® was used to perform echocardiographic analysis. PAC was calculated dividing right ventricular stroke volume by pulmonary arterial pulse (systolic – diastolic) pressure, measured by RHC.

Results

Of the 105 enrolled patients, 43 were had HFpEF-PH. Among these, 72% were female and mean age was 68.9 ± 11.2 years. Median time between TTE and RHC was 68 (IQR 34 – 191) days. Most patients were in NYHA class II (60.5%) and class III (34.9%). Fifty eight percent of the patients had history of paroxysmal or permanent atrial fibrillation. This population presented borderline parameters of right ventricle (RV) systolic dysfunction: fractional area change (FAC) 35.3 ± 9.2%, tricuspid annular plane systolic excursion (TAPSE) 18.3 ± 5.1 mm, tricuspid S’ wave 10.4 ± 2.9 and RV global longitudinal strain -15.5 ± 4.0. Regarding invasive assessment, this population presented mean pulmonary artery pressures of 38.8 ± 13.9 mmHg, pulmonary artery wedge pressure of 21.6 ± 6.4 mmHg, pulmonary vascular resistance of 3.9 ± 2.7 Wood and median PAC of 0.13 (IQR 0.09 – 0.19) ml/mmHg. The TAPSE / Pulmonary arterial systolic pressure (PASP) ratio and the Right ventricular outflow track velocity time integral (RVOT VTI) / PASP ratio were the parameters that best correlated with PAC (r = 0.69, p = 0.002 for both parameters) (table 1). These parameters were obtainable in the majority of patients (31/43). Blant-Altman analysis revealed good agreement between these measures and PAC with a mean difference of - 0.17 (CI -0.21 - -0.13) for RVOT VTI / PASP ratio and -0.23 (CI -0.28 - -0.18) for TAPSE /PASP ratio.

Conclusion

In a HFpEF – PH population, TAPSE / PASP and RVOT VTI / PASP are easily obtainable in most patients and significantly correlate with PAC.

Abstract P1289 Figure.
P1304 Is antibiotic profilaxis really not needed in mitral valve prolapse?
Authors: Suma S , Coli S , Serra W , Spaggiari I , Botti A , Cozza F , Garibaldi S , Gaibazzi N
Published: January 2020

Patient Presentation

A 54 years old woman with dyslipidemia was admitted to the hospital due to the onset of persistent fever. She had no significant comorbidities and she had a known mitral valve prolapse, which was in clinical and echocardiographic follow-up since more than 15 years before.

Two months before the hospitalization she underwent dental hygiene procedure without taking any antibiotic before. The procedure included scaling and polishing of the teeth, and she referred just a mild bleeding. After few days she reported the onset of fever and therefore she started to take amoxicilline/clavulanic acid but without any significant improvement of symptoms.

Initial work up

At the blood chemistry she had a mild leucocytosis with neutrophilia and a rise in inflammatory indices. The Chest x-ray was normal. A systolic murmur was evident at the physical examination. Therefore, Transthoracic Echocardiogram was performed, followed by Transesophageal Echocardiogram (see Figure). At the Echo there was a significant endocarditic involvement of the mitral valve with multiple vegetations, two on the posterior leaflet (scallop P1 and P3) and one on the anterior one (scallop A3); moreover, there was a flail of the posterior leaflet (scallop P1) with subsequent moderate to severe eccentric valve regurgitation.

Diagnosis and management

Diagnosis of Endocarditis was made and, thus, antibiotic therapy was started with gentamicin and daptomycin, then switched to ampicillin and ceftriaxone after the isolation at the blood culture of Enterococcus Faecalis sensitive to them. Cerebral CT was performed with no evidence of embolization. Finally, owing to the significant endocarditis of the mitral valve with associate moderate to severe regurgitation, the patient underwent surgical intervention with mitral valve replacement with bioprosthesis.

Follow-up

The post-operative period was regular with no significant complications. She had no more fever and the antibiotics were stopped after six weeks.

Conclusion

We reported the case of a severe endocarditic involvement of the mitral valve in a patient with known valvular prolapse, who did not take any antibiotic before a minor dental procedure.

2015 ESC guidelines on Endocarditis recommend to not perform antibiotic prophylaxis in patient with no valvular prosthesis but with other form of valvular disease, including mitral valve prolapse (Class III, level of evidence C). Most of the time, patients with other form of valvular disease (e.g. mitral valve prolapse, bicuspid aortic valve, calcific aortic stenosis) do not experience endocarditis, neither after dental procedures. However, this case shows that sometimes it can happen due to the abnormal conformation of the native valve and, hence, it makes us wonder whether the antibiotic therapy should be indicated before dental procedures in those kind of patients.

Abstract P1304 Figure.
P1305 Rare complication of a frequent disease
Authors: Boeangiu S , Stoica E , Anton M , Maresiu C , Margineanu C , Marin G , Penes D , Chioncel O
Published: January 2020

Introduction

Splenic abcess represents a rare complication of left-sided infective endocarditis. Unlike splenic infarction, which is a more benign condition, splenic abcess requires rapid diagnosis and treatment as its course can be fatal.

We present the case of a 52- year old male, with diabetes and hypertension, admitted for shortness of breath and fever in the past two months.

Clinical examination revealed respiratory distress, tachypnea, diastolic murmur on the left sternal border. Baseline laboratory investigations showed elevated inflammation markers, leukocytosis and thrombocytosis. Enterococcus faecalis was isolated from the hemocultures.

Transthoracic echocardiography revealed a dilated left ventricle (LV), with preserved LV ejection fraction, with severe aortic regurgitation due to valve destruction. A large (11mm diameter) vegetation-like structure attached to the ventricular side of the right coronary cusp, protruding into the left ventricular outflow tract was identified. Further evaluation by transoesopahgeal echocardiography did not identify other lesions, except for secondary moderate mitral regurgitation, with intact mitral leaflets. Dual antibiotic therapy with Ampicilin and Gentamycin was initiated. Surgery was planned after infection control.

The first three days were uneventful, with rapid resolution of fever and inflammatory markers, but on the fourth day, the patient developed severe abdominal pain, with its focal point in the left hypochondrium. Contrast abdominal CT was performed and large multiple subcapsular lesions were identified. These findings, correlated with the symptomatology, suggested embolic splenic abcess and infarction.

The patient successfully underwent laparoscopic splenectomy, but soon after he developed sepsis with respiratory failure and neurological deterioration (with normal CT scan) and was admitted to the intensive care unit, where he was intubated and mechanically ventilated.

Consensus after discussions between cardiology, cardiac surgery and neurology services was to immediately replace the aortic valve, given the inability to otherwise control the infection. Intraoperative images were consistent with perforation of the right coronary cusp.

During hospitalization in the ICU following cardiac surgery, the patient was extubated and his neurological function markedly improved. Repeated TTE and TEE showed normal prosthetic valve function and resolution of mitral regurgitation. The patient continued to improve clinically until his discharge.

Conclusions

We presented a case of a rare pathogenic entity- splenic abscess and infarction- due to systemic embolization from infective aortic valve endocarditis. Multidisciplinary teamwork was required between cardiologist, intensive care specialist, neurologist, infectionist, general surgeon and cardiac surgeon. Splenectomy was performed before valve replacement, a treatment-course characteristic in the occurrence of these rare cases.
P1307 An echocardiographic observation over the disappearing process of the prosthetic valve thrombus caused by the inflammatory hypercoagulability; a case report
Authors: Suzuki S , Takeuchi Y , Hiramatsu N , Tsuneyoshi H , Shimada T
Published: January 2020

Background

Whenever fever and inflammatory reaction continue for a while in the patients with a prosthetic valve, than usual, we must keep infective endocarditis in mind. On the other hand, inflammation and thrombosis are well known to coexist often. There are several reports of thrombotic valves associated with inflammation-activated hypercoagulability. Furthermore, C-reactive protein (CRP) has been reported to imply an increased risk of thrombus especially in the presence of an injury on the prosthetic valve.

Case report

We report a case of a 70-year-old male with a leaflet thrombus on the bioprosthetic aortic valve. He suffered from fever, and symptoms of heart failure and was hospitalized for treatment. Blood tests presented that white blood cell count was 4900/μL (neutrophil 81.1%) and CRP 10.82 mg/dL. Infectious endocarditis (IE) was suspected. Transthoracic echocardiography (TTE) was per-formed, however, vegetation and abscess were not found. Noteworthily, the bioprosthetic valve leaflet on the right coronary cusp showed thickening and opening dysfunction (Figure A, parasternal short axis). Mean pressure gradient (mPG) through the aortic valve was 15mmHg and peak velocity (Vmax) 2.7m/s. Blood culture was negative, and his body temperature and CRP were improved by empirical antibiotic administration. The anticoagulation therapy with warfarin was started, he was discharged from the hospital and followed up in the outpatient clinic. TTE after the initiation of anticoagulation therapy, did not reveal any more dysfunction on the bioprosthetic valve (mPG: 9mmHg, Vmax: 2.2m/s) (Figure B, parasternal short axis). The diagnostic and therapeutic process of this case implied success. The opening-dysfunction of prosthetic valve leaflets was reversible and therefore, we concluded that the thickening of the prosthetic valve could be attributed to thrombus adhesion. Computed Tomography (CT) was not performed because he suffered from chronic kidney disease.

Conclusion

Surely, CT is very useful for the evaluation of thrombotic valves in the patients in whom it is permissible to use contrast agent. However, we could successfully evaluate the recovery process of leaflet thrombosis by echocardiography because of a difficult reason of CT use in this case. The prolongation of inflammatory reaction in the patients with a prosthetic valve should keep IE in mind in everyday life. Even if the findings of bacterial infection are obscure, it is more and more important to observe carefully the change of leaflets, whenever an open-dysfunction and a thrombus adhesion of the prosthetic valves exist.

Abstract P1307 Figure.
P1317 Very late onset of platypnoea orthodeoxia syndrome as first clinical scenario of patent foramen ovale
Authors: Binno S M , Moderato L , Pastorini G , Matrone B , Aschieri D , Moccia L , Magri P , Franco C , Villani G Q
Published: January 2020

We report a case of a 83-year-old female, who had an admission for dyspnea. Laboratory showed D-dimer 1000 ng/ml, haemoglobin 12.4 mg/dL, CPR 0.08mg/dl whereas on Arterial Blood Gas test she had hypoxia with respiratory alkalosis.

In view of suspected pulmonary embolism, she underwent Thoracic Computed Tomography scan that excluded it.

During the stay the patient seemed more symptomatic while in standing position(with SpO2s 89% while supine plunging to 50% while standing): ABGs were performed both standing (reservoir 15 l/min pH 7.50, pO2 37.2 mmHg, pCO2 37.1 mmHg, HCO3 28.9 mmol/l) and recumbent position (reservoir 15 l/min pH 7.47, pO2 65.5 mmHg, pCO2 35.1 mmHg, HCO3 25.6 mmol), showing a difference of 28 mmHg.

Subsequently the patient underwent v/p pulmonary scintigraphy: no signs of pulmonary embolism though it revealed a multiple focus of capitation Tc-99m macro aggregated albumin in brain, thyroid and kidneys (IMG top), compatible for veno-arterial shunt.

Trans-esophageal echocardiography (TOE) revealed a massive stretched patent foramen ovale (PFO) with continuous right-to-left shunting through the atria. The bubble test (IMG bottom) confirmed the presence of patency along with sudden passage of microbubbles through the foramen. Qp/Qs = 0.8, due to volume overload in the left atrium from the right atrium. The imaging along with clinical scenario confirmed the suspected diagnosis of platypnea-orthodeoxia, finding the patent foramen ovale as the anatomical cause.

Platypnea-orthodeoxia syndrome is a clinical condition characterized by dyspnea. Typically blood oxygen saturation declines with standing position while it resolves with recumbent.

The classification entails 3 groups: intracardiac shunting (most common presentation), pulmonary shunting, ventilation-perfusion mismatch.

Presence of multiple focus of albumin macroaggregates outside the lungs in v/p scintigraphy examination is suggestive for veno-arteriuous shunt: without shunt, normally all the albumin aggregates are hampered in the lungs’ field.

Images in bottom are taken in sequence from a single acquisition during the TOE, in one single cardiac beat. Here is depicted the evidence of the PFO, the influx of bubbles in the right atrium and the instantaneous and massive shunt of the bubbles across the interatrial septum, in the left atrium.

Usually the diagnosis is performed within 55 years old: it is interesting how late the diagnosis occurred in this patient with such resounding clinical manifestation.

Top

Scintigraphy with ventilation and perfusion lung scan sequences. Next, scintigraphy with capitation of Tc-99m macro aggregated albumin in brain, thyroid and kidneys.

Bottom, Transesophageal echocardiogram: images taken within the same heart beat proving right-to-left passage of bubble across the septum.

Abstract P1317 Figure. Scintigraphy and Transesophageal echo
P1326 Recurrent isolated pulmonary valve endocarditis complicated by heart failure, septic pulmonary embolism and multiple lung abscesses in an intravenous drug abuser
Authors: Zaborska B , Imiela T , Makowicz G , Pilichowska-Paszkiet E , Grochowicz U , Budaj A
Published: January 2020

Background

Right-sided infective endocarditis (IE) ( 5-10% of all IE cases)is the most frequently observed in intravenous drug abusers (IVDA) with tricuspid valve as the most predominant site. Isolated pulmonary valve IE is an extremely rare entity in adults.

Case report

27-year-old women, IVDA for 15 years, was admitted to the hospital due to fever and severe shortness of breath. Her past history was significant for isolated pulmonary valve IE of methicillin-susceptible Staphylococcus aureus 9 months before with mild pulmonary regurgitation and normal right ventricular (RV) function at discharge after medical treatment. At admission on physical examination, the patient showed tachycardia 140/’, tachypnoea, hypotension and crackles. Initial chest X-ray documented massive bilateral infiltrates. Laboratory tests showed highly elevated inflammatory markers and anaemia. Transthoracic echocardiography (TTE) revealed large (36 x 20 mm) very mobile vegetations on the pulmonary valve (Fig A), pulmonary trunk dilatation, mild pulmonary regurgitation and moderate pericardial effusion. No sign of IE was found on the tricuspid valve (Fig C), which presented anterior leaflet prolapse with mild regurgitation. Computed tomography (CT) revealed numerous cavitary infiltrates in both lungs surrounded by ground-glass opacification. Blood cultures were positive for methicillin-resistant Staphylococcus aureus. The patient was started on vancomycin. On day seven the patient status worsened with symptoms of heart failure and elevated pro-BNP up to 2833pg/ml. TTE revealed severe pulmonary regurgitation (Fig B) with pulmonary hypertension and RV dysfunction (Fig D). Repeated CT showed pulmonary embolism (PE), RV enlargement and multiple abscesses in both lungs. The patient was consulted with cardio surgeon but the intervention was denied and medical treatment was continued with vancomycin, gentamicin, rifampin, glicocorticoids, enoxaparin, betablockers, digoxin and diuretics. Under serial TTE and CT control antibiotics were continued up to 10 weeks. Ultimately patient was discharged in relatively good condition without any symptoms of heart or respiratory failure with smaller vegetation (15-16mm) on the pulmonary valve but with severe pulmonary regurgitation and mild RV enlargement and dysfunction in TTE and significant regression of pulmonary lesions and PE in CT.

Discussion

With respect to the high recurrence rate of right-sided IE in IVADs surgery should generally be avoided. A prolonged course of parental antibiotics is recommended in cases with lung abscesses.

Conclusions

We report a case of recurrent isolated pulmonary valve IE and extensive complications but with a positive outcome. Pulmonary valve IE is very rare in IVADs but requires early as well as serial multimodality imaging in the diagnostic workup.

Abstract P1326 Figure. TTE of complicated pulmonary valve IE
P1330 A rare coronary anomaly in the adult: an extremely large arteriovenous fistula
Authors: Garcia Bras P , Cacela D , Moura Branco L , Ramos R , Vaz Ferreira V , Castelo A , Branco Mano T , Ilhao Moreira R , Ferreira R C
Published: January 2020

Introduction

Arteriovenous coronary fistulae are a rare coronary anomaly, which can be congenital or acquired. They can be diagnosed in older adults with heart failure symptoms, atherosclerosis or cardiac arrhythmias.

The authors report the case of an adult patient with an extremely large coronary artery fistula of the left main coronary artery (LMCA).

Clinical case

A 57-year-old caucasian male with known background of arterial hypertension, obesity, pulmonary emphysema and bronchiectasis presented to a Cardiology outpatient appointment with symptoms of congestive heart failure and new-onset atrial fibrillation.

A transthoracic echocardiogram was performed which revealed a possible coronary fistula with multiple rosary-like folds between the LMCA and the coronary sinus. Other echocardiographic findings were left ventricular and biatrial enlargement with biventricular systolic dysfunction (left ventricular ejection fraction 44%) and a GLS of -7.8% as well as mild pericardial effusion.

The patient was referred to our hospital for further diagnostic work-up and clarification of the coronary anatomy.

A cardiac computed tomography (CT) scan was done which showed ectasia and calcification of the LMCA, left anterior descending and circumflex arteries and a large caliber tortuous coronary fistula between the LMCA, the right atrium and the coronary sinus comprised of multiple folds covering from the pulmonary artery to the left atrium.

A coronary artery angiography was also performed, which confirmed the detailed anatomy and dimensions of the coronary fistula.

Follow-up magnetic resonance imaging revealed dilation of both left and right cardiac chambers with no significant shunt (QP/QS = 1)

The patient was started on heart failure medical therapy and was referred to the Cardiac Surgery Department and is currently asymptomatic awaiting for surgical correction of the coronary fistula.

Abstract P1330 Figure. CT scan: large caliber coronary fistula
P1332 Breaking the dichotomy of myocardial infarction and stress cardiomyopathy
Authors: Jimenez Mendez C , Cecconi A , Vera A , De La Cuerda F , Gonzalez Bartol E , Benedicto A , Rojas A , Diego G , Martinez Vives P , Dominguez L , Bastante T , Oliveira M J , Caballero P , Jimenez-Borreguero J , Alfonso F
Published: January 2020

INTRODUCTION

An 83-year-old woman with a past medical history of hypertension, dyslipidaemia and recent diagnosis of disseminated breast cancer was admitted at Emergency department for acute heart failure. She complained about short chest pain episodes on previous days, the ECG showed new T negative waves on precordial leads and high sensitive troponin serum levels were modestly increased (TropT 1200ng/l). Echocardiographic assessment documented moderate left ventricular dysfunction (LVEF 40%) with apical and midventricular dyskinesia associated with hypercontractility off basal segments.

The following day the patient underwent a coronary angiography that showed an occlusion in the distal segment of a large obtuse marginal branch (Panel A) with no other significant stenosis in the remaining vessels. Ventriculography showed a typical apical ballooning pattern (Panel B). Despite the occluded coronary artery was reaching the apex, the myocardial wall motion abnormalities extended beyond the ischemic territory. Therefore, a cardiac magnetic resonance (CMR) was performed a few days later in order to clarify the diagnosis.

CMR confirmed the mid LVEF dysfunction with apical dyskinesia and the T2 weighted spin echo images showed myocardial oedema in all the apical segments (Panel C). Remarkably, a subedocardial late gadolinium enhancement (LGE) restricted to the apical segment of the inferolateral wall was detected, being consistent with the ischaemic territory of the occluded obtuse marginal branch (Panel D). These findings supported the concomitant diagnosis of an apical stress cardiomyopathy and an acute inferolateral myocardial infarction. The patient was successfully discharged one week later with a normal LVEF and no signs of congestion.

DISCUSSION

Apical ballooning in the scenario of an acute coronary syndrome may be secondary to both an acute coronary artery occlusion or to stress cardiomyopathy. Cardiac MR has a key role to resolve the differential diagnosis of these two aetiologies, since ischemia typically produces a subendocardial late gadolinium enhancement pattern and stress cardiomyopathy shows an apical oedema without coronary stenosis or extending beyond a localized ischemic territory. Our case is astonishing because in the clinical practice these two diagnoses frequently excludes each other, but as demonstrated in our case, the differential diagnosis between myocardial infarction and stress cardiomyopathy is not a proper dichotomy.

Abstract P1332 Figure
P1349 POCUS by general and family physician - advancing physical examination
Authors: Dos Santos J , Fernandes P , Rocha Goncalves F , Pereira Rodrigues P , Ribeiro J , Goncalves A
Published: January 2020

BACKGROUND

Alongside with the development of hand held equipment, echo is becoming more accessible to nontraditional settings. General and family medicine (GPs) are at the forefront of any health system, but the use of cardiac echo by GPs is still unexplored. PURPOSE: This study aims to evaluate the accuracy of echocardiography assessment performed as an extension of the physical exam by GPs. METHODS: Two GPs underwent standard echocardiography training for 6 months. Subsequently, patients with diabetes or arterial hypertension were submitted to an echocardiogram performed by their GPs using a pocket ultrasound. Views obtained (with and without color Doppler) were parasternal long and short axis, apical and subcostal, with measurements of the posterior wall (PW), interventricular septum (IVS), left ventricle (LV), left atrium (LA), aorta and inferior vena cava (IVC). Studies were reviewed at the workstation and measured by two experts who classified the exams according to the image quality. RESULTS: Sixty echocardiograms were analyzed (mean age of 61y, 42% females and 58% males). In 50% the image quality was considered sufficient, 42% considered good and 8% considered bad. There were statistically significant differences between the GPs and expert measurements on the sinus of Valsalva (30.3 ± 3 to 28.8 ± 3.1mm, p = 0.001), LV in systole (p < 0.001, 28[24,31] for 31[29,34]mm), IVS (p = 0.001, 10.9 ± 1.7 for 10.1 ± 1.5mm), PW (p = 0.018, 8.7 ± 1.1 to 9.2 ± 1.6mm) and TAPSE (p = 0.021, 20.9 ± 2.3 to 20.1 ± 2.7mm). There were no significate differences in the measurements of the ascending aorta, LA, LV in diastole and IVC. Agreement between the GPs and the experts was moderate for the evaluation of LVH (k = 0.48). The concordance was substantial for evaluation of LV function (k = 0.66) and excellent for evaluation of pericardial effusion (k = 1) and right ventricular function (k = 1). Concordance was excellent for mitral insufficiency (k = 0.83) and substantial for aortic insufficiency (k = 0.68) and tricuspid insufficiency (k = 0.61). A case of mitral stenosis was identified by both. GPs signalized a case of mild aortic stenosis that the expert did not consider. CONCLUSION: GPs trained in echocardiography, using pocket ultrasound, can obtain cardiac images with sufficient quality for interpretation by experts in the majority of cases. In this study, differences in dimensions might be explained by interobserver variability and/or by the performance of measurements in different environments, mobile vs workstation. Overall the differences were minor and clinically meaningless.
P1356 Effects of sacubitril/valsartan on vascular resistance in patients with heart failure with reduced ejection fraction and arterial hypertension
Authors: Bayraktarova I , Katova T
Published: January 2020

Introduction

Vascular resistance as assessed by noninvasive measurement of the pulse-wave velocity (PWV) is a well-established separate risk factor for early cardiovascular morbidity and mortality.

High vascular resistance leads to higher pulse wave velocities and augmented values of systolic blood pressure (SBP). That leads to elevation in myocardial oxygen consumption and elevated left ventricular (LV) wall stress, indirectly worsening the systolic function of an already failing LV. PWV can be taken as an integral index of the vascular structure and function.

Sacubitril/valsartan is the first ARNI approved for the treatment of heart failure with reduced ejection fraction (HFrEF) – it simultaneously inhibits the renin-angiotensin-aldosterone system and employs the positive effects of the natriuretic peptides. The mechanisms of these remarkable effects – reduction of cardiovascular morbidity, of heart failure hospitalisations, of sudden cardiac death and of composite mortality, in patients with HFrEF are quite complex. The concomitant lowering of BP is an important element of the pathophysiologic process that improves the haemodynamic status of the patients.

Purpose

To evaluate the effect of sacubitril/valsartan on vascular level parameters.

Materials and methods

In 18 newly established patients with HFrEF and arterial hypertension we prescribed 6-month sacubitril/valsartan treatment protocol at a dose level 97/103 mg.

We measured the baseline office pressure, LV ejection fraction, 2D LV strain and Е/E1 values, and we performed analysis of the arterial rigidity by measuring the following parameters:

Arterial elastance

Еа= systolic BP / LV stroke volume

LV endsystolic elastance

ЕV = systolic BP / LV telesystolic volume

End-systolic stress of the LV wall: ЕSS = (0.33 х TSDLV х SBP) / PW х (1 + PW) / TSDLV)

Ventricular-arterial impedance: Zva = (SBP + mean transaortic gradient) / indexed LV stroke volume.

At the end of the six months" treatment protocol we measured the same parameters again.

Results

During the six months treating period the systolic arterial pressure fell significantly from 128 ± 9.8 mmHg to 113 ± 17 mmHg (р=0.002), and diastolic BP, also significantly, fell from 83.5 ± 9.5 mmHg to 70.1 ± 6.8 mmHg (р=0.001). There was a significant decrease in PWV, arterial elastance, end-systolic LV wall stress and in ventricular-arterial impedance, but not in the other measured parameters.

Conclusion

Treatment with sacubitril/valsartan at a high dose level of 97/103 mg for six months improves the indices of arterial rigidity, but does not lead to significant change in ventricular-arterial coupling, despite of significant lowering of the arterial elastance and pulse wave velocity.
P1359 Left ventricle hypertrophy and diastolic dysfunction in haemodialysis patients after surgical reduction of arteriovenous fistula blood flow
Authors: Valerianova A , Kovarova L , Hruskova Z , Bednarova V , Tuka V , Trachta P , Malik J
Published: January 2020

Funding Acknowledgements

Grant of the Grant Agency of Charles University and grant of the Czech Health Research council

Introduction

Over 50% of patients treated by chronic haemodialysis programme die of cardiovascular diseases. Changes of heart structure and function can be detected by echocardiography. The most frequent changes are left ventricle hypertrophy (LVH) and its diastolic dysfunction. One of the considered contributing mechanisms is the hyperkinetic circulation.

Purpose

The aim of this study was to analyse the effect of high flow arteriovenous fistula (AVF) on eft ventricular hypertrophy and diastolic function.

Materials and methods

We included 30 patients with a high-flow arteriovenous fistula into the study, indicated for AVF blood flow reduction because of heart failure or hand ischemia. All the patients underwent echocardiographic examination and ultrasonographic measurement of AVF blood flow before and 6 weeks after the surgery.

Results

The AVF banding led to significant reduction of Qa (from 2977 ± 1408 to 1295 ± 610 mL/min; p ˂ 10-6, accompanied by significant decrease of cardiac index (from 4.34 ± 1.09 to 3.56 ± 0.90 L/min.m2). These findings were accompanied by significant reduction of left ventricle mass index (from 125 ± 31 to 116 ± 32 g/m2; p = 0.04) and by improvement of diastolic dysfunction grade (from 1.66 ± 0.67 to 1.14 ± 0.95; p = 0.03). The maximum velocity of tricuspid regurgitation decreased (from 3.1 ± 0.4 to 2.7 ± 0.5), and so did the left atrium volume index (from 47 ± 14 to 42 ± 15 mL/m2; p = 0.01).

Conclusions

LVH and diastolic dysfunction are frequent in haemodialysis patients; hyperkinetic circulation caused by high-flow arteriovenous fistula is one of the significant contributing mechanisms. Surgical reduction of AVF blood flow improved diastolic function of the left ventricle and reduced the hypertrophy in our patient population. AVF flow volume should be always considered during cardiological examination of haemodialysis patients.
P1360 Tricuspid peak systolic S wave tissue doppler velocity >12 cm/s avoid 50% of right heart catheterization in Pulmonary Arterial Hypertension
Authors: Fauvel C , Raitiere O , Burdeau J , Si Belkacem N , Bauer F
Published: January 2020

Background

Clinical risk stratification in pulmonary arterial hypertension (PAH) relies on BNP level, NYHA functional class, 6min-walk distance and cardiac output by right heart catheterization (RHC) with no place for non-invasive mean like echocardiography.

Purpose

To avoid systematic RHC in PAH patients, we aimed to determine both tricuspid peak systolic S wave tissue Doppler velocity (S-DTI, cm/s) and tricuspid annular plane systolic excursion (TAPSE, mm) cut-off values that best correlated to invasive cardiac index ≥2.5l/min/m² (CI, meaning low risk clinical worsening or death) in an initial cohort and to test them in a validation cohort.

Methods

From a single referral pulmonary hypertension centre, 125 PAH patients (initial cohort) underwent 406 hemodynamic investigations with RHC and echocardiography on the same day. S-DTI and TAPSE were performed from a standard manner following the 2015 EACVI/ASE recommendations. This initial cohort served for the receiver operating characteristic analysis from which the cut-off values were investigated in a validation cohort, to test the cardiac index stratification.

Results

The initial cohort had a mean age of 66.9 ± 14.4 y. Mean pulmonary artery pressure averaged 44 ± 12 mmHg, CI was 2.8 ± 1.0 l/min/m2, S-DTI was 11.2 ± 2.9 cm/s and TAPSE was 18.4 ± 4.7 mm. Both pulsed S-DTI and TAPSE were correlated to invasive CI (p < 0.001 and p < 0.0001, respectively). S-DTI ≥12 cm/s or between <12 cm/s and ≥10 cm/s with TAPSE > 17 mm had a specificity of 0.89 and 0.90, respectively to detect CI ≥ 2.5l/min/m² from the ROC curve analysis. Applying this cutoff-based stratification provided similar results in the validation cohort of 97 PAH patients (mean age = 65 ± 16 y, mean pulmonary artery pressure = 45 ± 16 mmHg, CI = 3.0 ± 1.0 l/min/m2, while S-DTI = 11.1 ± 3.1 cm/s, TAPSE = 17.8 ± 5.4 mm). Overall, almost 50% of patients were appropriately classified avoiding RHC

Conclusion

Considering tricuspid peak systolic S wave tissue Doppler velocity ≥12 cm/s or <12 cm/s but ≥10 cm/s with tricuspid annular plane systolic excursion by M-mode >17 mm, then RHC may be avoided in almost 50% of patient to predict CI≥2.5l/min/m² in PAH patients.
P1361 Loading conditions might mimic right ventricular longitudinal dysfunction in patients with chronic left heart disease and forward failure
Authors: Bech-Hanssen O , Fredholm M , Bartfay S E , Karason K , Dellgren G , Ricksten S E
Published: January 2020

Background and aim

Right ventricular failure (RVF) in patients with chronic left heart disease (LHD) has important prognostic implications. RV longitudinal function parameters (tricuspid annular plane systolic excursion, TAPSE; peak systolic longitudinal strain, RV-Str; tricuspid annulus systolic velocity, TAPSm) are today commonly used to define RV dysfunction. In the present study we hypothesized that longitudinal RV dysfunction (LDF) might be due to loading conditions and not necessarily RV dysfunction.

Methods

We retrospectively included 66 patients with LHD (age 52 ± 13 years, males 79%) that underwent right heart catheterization (RHC), ergospirometry (n = 47) and echocardiography (Echo) within 48 hours. Patients were divided into three groups from Echo data: normal RV function (TAPSE ≥17 mm + normal central venous pressure (CVP) from collapsibility of cava inferior, n = 18); LDF (TAPSE < 17 mm + normal CVP, n = 22) and RVF (CVP≥10 mmHg, n = 26).

Results

Patients with RVF had compared with normal and LDF lower peak VO2, more advanced LHD, enlarged RV and higher RV afterload (Table). Patients with LDF had compared with normal reduced stroke volume index (SVI). The patients with normal and LDF did not differ regarding right atrial pressure (RAP) response during exercise (P = 0.84). The longitudinal parameters did not differ between patients with LDF and RVF.

Conclusions

Longitudinal parameters in patients with chronic LHD and normal CVP should be interpreted with caution. Loading conditions with reduced stroke volume might mimic LDF.

Normal (n = 18) LDF (n = 22) RVF (n = 26) Overall P-value Normal vs LDF Normal vs RVF LDF vs RVF Peak VO2 (mlO2/min/m2) 14.8 ± 3.3 13.5 ± 3 11 ± 2 0.001 0.29 <0.001 0.005 RAP (mmHg) 4 ± 3 4 ± 4 12 ± 3 <0.001 0.55 <0.001 <0.001 PASP (mmHg) 32 ± 13 37 ± 14 47 ± 11 <0.001 0.28 <0.001 0.002 PCWP (mmHg) 10 ± 6 14 ± 7 22 ± 5 <0.001 0.03 <0.001 <0.001 SVI(ml/m2) 43 ± 10 34 ± 6 30 ± 9 <0.001 <0.001 <0.001 0.15 PVR (Wood unit) 2.0 ± 1.1 2.0 ± 0.8 2.3 ± 1.1 0.29 - - - RVdA (cm2) 19 ± 3 22 ± 7 26 ± 7 0.003 0.16 <0.001 0.04 RVsax (mm) 23 ± 4 25 ± 8 34 ± 8 <0.001 0.42 <0.001 <0.001 TAPSE (mm) 21 ± 4 12 ± 3 12 ± 3 <0.001 <0.001 <0.001 0.98 TAPSm (cm/s) 11 ± 3 8 ± 2 8 ± 2 <0.001 <0.001 <0.001 0.55 RV-Str (%) -24 ± 5 -16 ± 5 -15 ± 5 <0.001 <0.001 <0.001 0.87 PASP, pulmonary systolic pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RVdA, RV diastolic area; RVsax, RV short axis diameter.