bluuebunny/crossref_metadata_2025 huggingface dataset:
P12 SUBCUTANEOUS IMPLANTABLE CARDIOVERTER–DEFIBRILLATOR AFTER TRANSVENOUS LEAD EXTRACTION: SAFETY, EFFICACY AND OUTCOME
Authors: Migliore F , Giacomin E , Pittorru R , Falzone P , Dall’Aglio P , Vianello R , De Lazzari M , Bertaglia E , Iliceto S
Published: May 2022

Background

Subcutaneous implantable cardioverter defibrillator (S–ICD) is a suitable alternative for trans–venous–ICD (TV–ICD) patients underwent transvenous lead extraction (TLE) for any reason, but limited data are available about outcome of s–ICD patients implanted after TLE.

Methods

Thirty–six consecutive patients underwent TLE of TV–ICD and subsequent S–ICD implantation in our center were included in this prospective single–center observational study (72.2% male, median age 52 years–old).

Results

During a median follow-up of 31 months, 3 patients (8.3%) experienced appropriate therapy and 7 patients (19.4%) experienced complications including innapropriate therapy (IAT) (n = 4; 11.1%), pulse generator decubitus with no evidence of infection (n = 2; 5.5%) and ineffective therapy (n = 1; 2.7%). Reasons of IAT were: T–wave oversensing in one patient and extracardiac signals in the remaining 3 patients. Of note, 2 patients who experienced IAT had a left–ventricular assist device (LVAD) for refractory heart failure (HF). Premature device explantation and TV–ICD re–implantation occurred in 4 patients (11%) for pulse generator decubitus despite surgical pocket revisions (n = 2), for recurrent IAT despite reprogramming (n = 1) and ineffective therapy during arrhythmic storm (n = 1). Eight patients (22.2%) died, 3 patients (9%) underwent LVAD implantation due refractory HF during follow-up. Six patients died because of refractory HF, 1 patient died due to intracerebral hemorrhage and 1 due to sarcoidosis. There were no documented deaths associated with the procedure or the S–ICD system itself. No patient had the device removed because of a perceived need for antitachycardia pacing (ATP) or the necessity of pacing or cardiac resynchronization therapy despite 9 patients (25%) after TLE of a two–chamber ICD and one patient (3%) after TLE of a CRT–D. Univariate predictors of death included hypertension (HR 22.72; p = 0.02), diabetes (HR 10.64; p = 0.001), ischemic heart disease (HR 5.92; p = 0.01) and NYHA class > = II (p = 0.04). We did not observed any predictors for complications including IATs and device-related complications requiring surgical revision.

Conclusions

S–ICD implantaion after TLE of TV–ICD is safy and effective. Baseline clinical characterisctics including ischemic heart disease, diabetes, hypertension and NYHA class > = II are associated with worse survival.
P39 ATRIAL MASS IN HEART TRANSPLANTED PATIENT WITH CLINICAL HISTORY OF LYMPHOMA
Authors: Scirpa R , Follesa F , Battistoni A , Volpe M
Published: May 2022

Atrial thrombosis is an uncommon complication of cardiac transplant, especially when performed with standard technique. Pathogenetic mechanisms might involve atrial anatomy distortion and abnormalities in its contractile function, which induce flow stasis and thrombus formation, mostly on the surgical suture. A 77–year–old man underwent orthotopic heart transplantation in 2000 for post–ischemic dilated cardiomyopathy. In 2019 he was diagnosed with diffuse large B–cell lymphoma treated with chemotherapy. On March 2021, during follow up period, he had a total body CT scan which showed a submandibular space–occupying lesion, likely as a disease recurrence, and a large atrial mass (30x50 mm). For this reason, he was admitted to the emergency department. Echocardiography documented a massive hyperechogenic formation in an enlarged left atrium. In order to rule out a neoplastic nature, a cardiac CMR was performed, confirming the presence of an oval mass adhering to the posterior left atrial wall with partial involvement of pulmonary veins ostia, with inhomogeneous isointense signal on T1–weighted sequences and hyper–isointense signal on T2–weighted sequences, without significant contrast enhancement, likely representing an endoluminal thrombotic formation. Given the patient’s clinical status and his hemodynamic stability, a surgical excision was deferred. The patient was discharged on oral anticoagulant therapy with Warfarin (INR target 2–3). Three months later, a chest CT showed a meaningful mass reduction (11x18mm), which was no longer visible at echocardiography. About 9 months later, complete disappearance of the atrial mass was found at a CT scan. According to scientific literature, differential diagnosis of a newly discovered atrial mass in a transplanted heart includes thrombosis or neoplasia. Thrombosis occurs usually early after surgery, but due to promoting factors, it can arise after many years. The most likely triggering condition is an acquired prothrombotic status: in our case the likely lymphoma recurrence may have led to thrombogenesis. In order to exclude with confidence cardiac metastasis, histological examination would have been necessary. Nevertheless, the meaningful mass reduction, as early as three months after starting oral anticoagulation, and its disappearance nine months after, strongly suggests for atrial thrombosis.
P47 MITRAL VALVE REPAIR FOR INFECTIVE ENDOCARDITIS: A PROPENSITY MATCHED STUDY
Authors: Malvindi P , Berretta P , Alfonsi J , Zingale A , Luthra S , Pierri M , Ohri S , Di Eusanio M
Published: May 2022

Background

The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis remain not clearly established. We aim to review the clinical experience in mitral valve surgery for infective endocarditis looking at mid–term survival.

Methods

Prospectively collected data of patients who underwent cardiac surgery for infective endocarditis between 2001 and 2021 at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest–neighbour propensity score matching, including twelve preoperative variables, was performed to account for differences in patients’ profile between the repair and replacement subgroups.

Results

In the unmatched populations, mean age of the patients was 60±15 years and 72% were male. Active infective endocarditis was described in 226 cases (80%). Thirty–four patients (12%) suffered cerebral embolism and in 10% of the cases preoperative inotropic support and/or mechanical ventilation were required. Associated procedure were CABG, aortic valve replacement and tricuspid valve repair, 13%, 36% and 9% of the cases, respectively. Mitral valve repair was performed in 96 cases (32%). Overall in–hospital mortality was 6.7% and was not significantly different between patients who underwent repair or replacement of the mitral valve (7.2% vs 6.4%, p = 0.79). Propensity matching provided 72 well–matched pairs. Mean age was 59±15 years, 75% of the patients were male. Sixteen patients (11%) had a recent cerebral event. An emergency operation was carried out in 15% of the cases, 10% of the patients presented a NYHA class>III and 14 patients (10%) underwent a redo procedure. CABG and aortic valve replacement were associated in 14% and in 35% of the cases, respectively. Overall in–hospital mortality was 6.9% with no difference between the repair and the replacement cohorts 9.7% vs 4.2%, respectively (p = 0.19). Survival probabilities at 1–, 5– and 10–years were 89%, 71% and 67%, respectively after mitral repair, and 90%, 77% and 57%, respectively after mitral replacement; log–rank p = 0.90.

Conclusions

Mitral valve repair was associated with acceptable in–hospital mortality and survival in a high–risk and comorbid cohort of patients with mitral valve infection. We found no difference in early and mid–term survival between patients who underwent repair or replacement of the mitral valve in the setting of infective endocarditis.
P71 LEFT MAIN ANGIOPLASTY: TWENTY YEARS OF EXPERIENCE OF A HIGH–VOLUME SINGLE CENTRE WITH ANGIOGRAPHIC FOLLOW–UP
Authors: Franzé A , Quadri G , Cerrato E , Rolfo C , Tomassini F , Zanda G , Piedimonte G , Varbella F
Published: May 2022

Long term result of left main angioplasty nowadays is still debated. The retrospective analysis of our reporting software detected from 11/2000 to 11/2021 a total of 956 patients that underwent percutaneous transcatheter coronary angioplasty (PTCA) on unprotected left main with de–novo lesions. The average age of our sample was found to be 72 years old (+–10), mainly male (76,4%). The prevalence of hypertension was 74,6%, of diabetes was 26,2%, of dyslipidaemia was 51,7%, of smoke was 49,8%. The indication for PTCA was ACS in 63,8% of patients (610), in particular STEMI were the 19,5% (186) of patients, NSTEMI were the 29,4% (281) and unstable angina were the 15% (143). Of these ACS in 29 patient the presentation was with cardiac arrest. Patient with CCS were the 36,2% (346). Intubation was necessary in 36 patients. Intra–aortic balloon pump was used in 341 patients (35,7%), in 90,9% of cases before the beginning of the procedure. Radial (45,1%) and femoral access (54,9%) were equally used. Among 773 bifurcations (the 80% of patients), a single stent technique was used in the 66,5% of cases (provisional). Considering the two stent techniques, the Crush was used in 12,7% of cases, the Culottes in 11,1%, the TAP in 6,7%, and the SKS in the 3%. Final kissing balloon was achieved in the 80,2% of bifurcations. Intracoronary imaging was used in the 48,4% of cases (463 patients), mainly IVUS (457). In our centre, as experimental protocol, an angiographic follow–up at 1 year is performed in most of patients that undergo angioplasty on left main. Overall, an angiographic follow–up is available for 607 patients (the 63,5% of patients) with an average lenth of 546 days. The indication for the new angiography was STEMI in 1,9% of patients, NSTEMI in 4,1%, unstable angina in 2,4%, stable angina in 8,6%, and only protocol in the 46,5%. Re–stenosis with redo of angioplasty on left main happened in 89 patients (14,7%), but of these only in 50 patients (56%) was clinically driven. Stent thrombosis was in all cases very–late (average 1609 days) and happened only in 7 patients (1,2%). A new PTCA in non–left main segments was performed in 153 cases (25,2%) and was clinically driven only in 50,4% of patients. Angiographic follow–up of complex PTCA such as those on unprotected left main could, in addition to potentially preventing adverse events, also provide interesting and real–world data about the effectiveness of the procedures and of their various technical aspects.
P72 TWO SIDES OF THE SAME … PATIENT: CRITICAL LEFT MAIN STEM STENOSIS IN A CANDIDATE FOR TAVI
Authors: Varotto L , Nicoletti I , Segala P , Bonanno C , Angheben C , Caprioglio F
Published: May 2022

Best timing for left main stem (LMS) revascularization (staged or combined) is matter of debate in patients with severe aortic stenosis (AS), candidates for transcatheter aortic valve implantation (TAVI). LMS disease represents an additional challenge for 3 reasons: 1) the potential interaction between the coronary stent and the prosthesis due to the anatomic proximity of the LM ostium to the aortic annulus; 2) the risk for hemodynamic compromise during LMS percutaneous coronary intervention (PCI) in the presence of severe AS or TAVI; 3) the optimal treatment strategy for LMS bifurcations. Previous studies showed that outcomes of TAVI plus LMS–PCI were not influenced by an unprotected/protected LMS, the location of the stent or the timing of PCI. Case report. We present the case of an 82–year–old man with severe AS presenting with non–ST–segment elevation myocardial infarction. Coronary angiography revealed a highly complex, calcific LMS lesion. To safeguard the patient, in the event of rapid deterioration of cardiac output and coronary perfusion, a rescue balloon aortic valvuloplasty (BAV) and the Impella device were arranged. PCI was successfully performed by predilatation with Grip and non–compliant balloons, followed by double stenting with Mini–Crush technique. An additional stent in the ostium of the LMS was required without using a circulation support system. Due to the low take–off of the ostium of the LMS, an Edwards Sapien 3 was implanted, protecting the LMS with a guide–catheter and guide–wire. The patient was discharged from hospital on Day 5 post–procedure. Discussion. According to guidelines, decision should be performed case by case, based on the severity/complexity of either AS or LMS disease. The strategy of treating LMS lesions first may limit the risk of potential ischaemic complications during TAVI; its downside is the risk of hemodynamic crash with potential catastrophic evolution in case of PCI complications in severe AS. Mini–crushing can be a good, quick way to treat complex diseases of the LMS bifurcation, less complex to perform in emergency situations. “Bailout BAV” and Impella technology can be helpful bystanders to prevent any complications, being a salvage–strategy in case of advanced status of haemodynamic impairment. These approaches are a very last resort, while appropriate pre–procedural planning is still highly recommended in order to prevent potentially fatal procedural complications in this fragile clinical setting.
P80 PROGNOSTIC IMPACT OF NEW ONSET ATRIAL FIBRILLATION AFTER SINGLE OR DOUBLE STENT LEFT MAIN BIFURCATION PCI
Authors: Rigatelli G , Zuin M , Gianese F , Pastore G , Zanon F , Roncon L
Published: May 2022

Objective

Incidence and prognostic value of new onset atrial fibrillation (NOAF) after single versus double stent strategy in bifurcation Left Main (LM) disease has not been yet investigated.

Methods

We retrospectively analysed the procedural and medical data of patients referred to our center for complex LM bifurcation disease, treated using Cross–over provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT) techniques between January 1st, 2008 to May 1st 2018. Multivariate Cox–regression analysis was used to assess the role of different stent strategies, adjusted for confounders, on the risk of NOAF during the follow–up period.

Results

Five hundred and two patients (316 males, mean age 70.3±12.8 years, mean Syntax score 31.6±6.3) were evaluated. At a mean follow–up of 37.1±10.8 months (range 22.1–39.3 moths), Target lesion failure (TLF) rate was 10.1%. Stent thrombosis and Cardiovascular mortality were observed in 1.2% and 3.6% in of cases, respectively. NOAF occurred in 23 out of 502 patients (4.6%). Patients with NOAF resulted more frequently female, older, obese, diabetic and more frequently experienced TLF and cardiovascular death. NOAF free survival favoured single versus double stent technique and among double stent techniques NIT compared to the others. Single stent strategy had a lower risk of NOAF compared to double stent technique on multivariate analysis (HR: 1.14, 95% CI: 1.10–1.19, p < 0.001 vs HR: 1.28, 95% CI: 1.23–1.32, p < 0.0001).

Conclusions

NOAF in distal LM bifurcation disease treated with PCI had a low incidence but resulted more frequent after double than after single stenting technique and associated with worse outcomes.
P117 INCIDENTAL FINDING OF A PAPILLARY FIBROELASTOMA WITH UNCOMMON LOCATION: CASE REPORT
Authors: Salvatore T , Ceriello L , De Rosa M , Lavorgna A , Ruggieri B , Giancola R , Fabiani D , Napoletano C
Published: May 2022

A 64–year old man with no cardiological history came to our laboratory to perform a transthoracic echocardiogram because of increased blood pressure. Patient was asymptomatic. Echocardiogram revealed the presence of a small mass attached to the proximal part of the interventricular septum (IVS) (Fig. 1), characterized by high mobility within the left ventricular outflow tract (LVOT). Transesophageal echocardiogram confirmed the presence of a 8 mm pedunculated mass with implant base on IVS, 2 cm below the aortic valve and oscillating in LVOT (Fig. 2). The high risk of peripheral embolization led the Heart team to propose cardiac surgery. The operation was conducted through a J–ministernotomy on a fourth intercostal space, cannulation of ascending aorta and right atrium, transverse aortotomy and identification of the mass via the transaortic route. The appearance of the mass, glossy brown and with a gelatinous consistency, first appeared to be attributable to papillary fibroelastoma. The histological investigation (Fig. 3) confirmed the diagnosis. Postoperative course was regular and the patient was discharged on fifth postoperative day.

Discussion

Papillary fibroelastoma is the third most common primary cardiac tumour, after myxoma and lipoma, with an incidence of around 10%. In 90% of the cases the origin is from the valvular endocardium (the aortic and mitral valve surfaces are the most affected sites), while the origin from the endocardium of left ventricle, as in the case of our patient, is much more rare (less than 10% of cases). Atypical locations, in addition to IVS, are papillary muscles, tendinous chords and atrial endocardium. Although most patients are asymptomatic, consequences related to peripheral embolization can be very serious (neurological complications, acute coronary sindrome, peripheral ischaemia, pulmonary embolism). Mobility rather than size appears to be an indipendent predictor of death and non fatal embolization; for this reason, in the presence of mobile and pedunculated mass, surgical intervention is always reccomended. Surgical excision is associated with a low operative risk and the minimally invasive approach, as in our case, allows for a rapid recovery.
P127 PERI–VASCULAR ADIPOSE TISSUE ATTENUATION ON CHEST COMPUTED TOMOGRAPHY IN PATIENTS WITH MARFAN SYNDROME: A CASE SERIES
Authors: Tuttolomondo D , De Filippo M , Sartorio D , Nicolini F , Niccoli G , Gaibazzi N
Published: May 2022

Background and aim of the work

Marfan Syndrome is a genetic disorder that determines histopathological alterations of the aortic vascular wall leading to increased inflammatory component. The peri–vascular adipose tissue attenuation is a method able to capture localized vascular inflammation by mapping spatial changes of perivascular tissue attenuation on computed tomography.

Methods

We measured peri–vascular adipose tissue attenuation around the ascending aorta in three consecutive subjects with confirmed genetic diagnosis of Marfan Syndrome. All subjects received the genetic diagnosis of fibrillin–1 gene mutation as part of the family screening of patients with known Marfan Syndrome. Chest computed tomography was performed in such asymptomatic subjects after genetic confirmation of Marfan Syndrome. None of these subjects showed aortic aneurysms or suffered from chronic inflammatory/infectious disease.

Results

In the three subjects identified with Marfan Syndrome the value of aortic peri–vascular adipose tissue attenuation measured at chest computed tomography was higher than normal and the volume of aortic peri–vascular adipose tissue was lower.

Conclusion

These preliminary observations suggest that peri–vascular adipose tissue attenuation is unexpectedly high in patients with Marfan Syndrome, notwithstanding the normal aortic diameter at the time of computed tomography. Whether this observation may find a clinical use in suspected Marfan Syndrome or in predicting aortic complications in Marfan Syndrome is worth to be assessed in prospective studies.
P141 CORRELATION BETWEEN TAKO–TSUBO SYNDROME AND OCCULT CANCER
Authors: Isola U , Pittau R , Marchetti M , Boscarelli D , Tuveri M , Caggiari L , Maiani S , Contini F , Montisci R
Published: May 2022

Introduction

Tako–Tsubo Syndrome (“TTS”) is a cardiomyopathy characterized by an acute reversible left ventricular dysfunction, mainly triggered by emotional or physical stress. Several variants have been reported, including reverse TTS, characterized by hypokinesia of basal segments and hyperkinesis of the apical ones. TTS has a clinical presentation similar to acute coronary syndrome but without evidence of obstructive coronary artery disease. A surprising association between TTS and cancer arose out of recent studies.

Case Presentation

74–year–old patient got to the emergency room of our hospital for the appearance, apparently in the health, in the absence of physical or emotional stress of oppressive chest pain. On the ECG, there was evidence of ST–segment elevation in inferior leads, for which urgent coronary angiography was performed. It did not show significant stenotic lesions nor evidence of elevated troponin values. The Echocardiogram showed hypokinesia of the basal segments and hyperkinesis of the mid–apical ones, with EF 40%. In the following days, the patient performed MRI–heart with detection of LGE of the intramyocardial type (non–ischemic pattern) in correspondence with the inferior wall in the medioventricular area. During hospitalization on routine chest x–ray, hypodiaphanous image was found in the left apex for which an HR CT scan of the chest was performed which a lesion in the left apical lung area with spiculated margins of a heteroplastic nature, associated with multiple bilateral lesions suggestive of secondaryism. Therefore, the patient was taken over by the Oncology service.

Conclusions

Such case confirms the association between TTS and occult cancer. In the absence of obvious physical or emotional stress that may explain the onset of TTS, it is important to research for any silent neoplastic pathology. The literature shows that the prevalence of malignant diseases is high in patients with TTS. Recent studies have pinpointed the activation of the sympathetic nervous system promotes cardiac inflammation by upregulating ICAM–1 and the expression of p53. Furthermore, inflammation can lead to the activation of p38 MAP Kinase, thus contributing to myocardial stunning. The specific role of inflammation as a cofactor of adrenaline–induced stunning deserves further investigation in the specific context of malignant tumors, which are frequently associated with an enhanced inflammatory state.
P156 TRANSCATHETER CLOSURE OF ATRIAL SEPTAL DEFECT IN OVER 60 YEARS OLD PATIENTS
Authors: Marzullo R , Gaio G , Giordano M , Palladino M , Ancona R , Scognamiglio G , D‘Alto M , Russo M , Sarubbi B
Published: May 2022

Background

Ostium secundum ASD (ASDII) is the most common type of congenital heart disease in adults. Percutaneous closure has emerged as the first–line treatment for the majority of ASDII. However, the occurrence of Pulmonary Hypertension (PH) with combined pre– and post–capillary component may render ASD management challenging in elderly patients.

Methods

We report the hemodynamic data and clinical findings of elderly patients (> 60 years old) undergoing transcatheter closure of an ASDII at our department.

Results

From 2000 to 2021, 82 elderly patients were scheduled (mean age 65,4+ 4,4) of which 60 (73%) were female. Systemic arterial hypertension and supraventricular arrhythmias were the most common comorbidities accounting respectively 51% and 38% of cases. The right ventricular overload supported the ASD closure in 76 cases (93%) and paradoxical embolism in the remaining 6 (7%). 17 patients (21%) were in NYHA class III– IV. At right heart catheterization, 33 patients had normal pulmonary arterial pressure and 49 patients showed a mean pulmonary artery pressure > 20 mmhg. In the latter cohort, 33 showed a pulmonary artery wedge pressure (PAWP) < 15 mmHg (Group I) and 16 > 15 mmHg (Group II). The device implantation was completed in all patients except one with elevated pulmonary vascular resistance (PVR) of the Group I. For 14 patients of Group II, balloon occlusion test was required during the catheterization. ASD closure was achieved promptly in 10 patients. However, to reduce the risk of acute pulmonary oedema, in one case we created a small fenestration in the occluder device and in other case we retained the patency of additional defect (both patients exhibiting slightly PAWP increase during balloon occlusion test). In one patient showing significantly PAWP increase during balloon test, delayed ASD closure was performed ensuring the improvement of hemodynamic parameters at 3 months initiation of medical therapy with angiotensin–converting enzyme inhibitor and loop diuretic diuretics. For the remaining 4 patients, the percutaneous closure was not been done because of prohibitive hemodynamic parameters. Overall, ASD closure was performed successfully in 94% of cases.

Conclusions

Age and comorbidities are not absolute contraindications to ASDII percutaneous closure. In the complex cases, both medical therapies and balloon occlusion test may be use to support the decision–making process.
P159 AN INSIDIOUS CASE OF VENTRICULAR STRESS EXTRASYSTOLES IN A YOUNG ATHLETE
Authors: Di Naro A , Piovesana P , Carraro N , Balestriero G , Penzo M , Pagliani L , Nicolosi E , Rivaben D , Luzza G , Antonini–Canterin F
Published: May 2022

VEBs in young people and athletes are generally benign; however, in some cases, they can be a sign of underlying heart disease and predispose to the risk of SCD during sports.

Clinical Case

A 14–year–old boy arrives for renewal of competitive sports eligibility. He practices competitive football; always eligible according to previous checks; not familiar with heart disease or SCD; asymptomatic; with normal cardiac objectivity. Basic ECG: RS conduction and repolarisation within normal limits. ECG during exercise: 2 monomorphic VEBs, RBB type with superior axis (Fig. 3). For this reason, he performs TT Echocardiogram and ECG sec. Holter. Holter ECG: 1 SVEB 0 VEB. MB Color Doppler Echocardiogram: LV of normal size and wall thickness with a normal pump function; no alterations of the regional dynamics, undamaged valve systems, RV in the standard; suspected image due to anomaly of coronary origin (right coronary artery from the left sinus of Valsalva). Fig. 1 shows a modified PSAX. In particular, the image highlights the origin of the right coronary and left coronary from the left sinus of Valsalva. The course of the right coronary is parallel to the anterior aortic wall. The cardiac CT confirmed the anomalous origin of the right coronary from the left coronary sinus with a course between the aorta and pulmonary artery. In the proximal section, the right coronary would seem to run for about 12 mm within the adventitia of the aortic wall (Fig. 2) Hence, myocardial scintigraphy was performed on stress testing, given a possible corrective strategy.

Discussion

Anomalies involving the origin of the coronary arteries and among these, the right coronary artery originating from the left represent one of the leading causes of SCD in athletes under 35 years of age. It is a pathology challenging to diagnose. Indeed, the affected subjects, in most cases, are healthy at the sports doctor visit. Early identification is a priority in the diagnostic classification of a young athlete. In this case, the evidence of extra systolic beats on the exercise stress test and the subsequent ultrasound demonstration of the anatomical anomaly proved significant. The importance of echocardiography in recognizing coronary anomalies in young athletes, as highlighted in our report, should also suggest introducing this method as a screening test for their early identification and, consequently, the prevention of MCI.
P162 AN UNUSUAL CASE OF RIGHT VENTRICULAR DILATATION
Authors: Casolo G , Del Meglio J , Tessa C
Published: May 2022

We describe the case of a 58 years old man presenting to our Cardiology Clinic because of palpitations, after a complete evaluation performed elsewhere. His symptoms showed a progressive worsening althoug present since at least 15 years. No other significant information came from his clinical history. Both his physical examination and EKG did not show abnormalities. An isolated mild enlargement of the right ventricle was seen by ecocardiography. 24–hour ECG recording revealed few ventricular ectopic beats and some couplets. An ergometric stress test did not suggest an impaired coronary reserve. Cardiac MRI was performed and the report described again a mild right ventricular enlargement without any other abnormalities. Both wall motion and late enhancement were analyzed and no pathologic behavior was detected. The patient was admitted to our Clinic for a second opinion. The analysis of the patients‘ chest x–ray showed a “tongue–like” presence of pulmonary tisse between the aortic knob and the pulmonary trunk (arrow), and a less pronounced right mediastinal border (Fig 1). A careful analysis of the Cardiac MRI showed a leftward rotation of the heart, a pronounced fatty area between the heart and the anterior thoracic wall. Finally it can be appreciated the partial absence of the pericardium limited to its anterior portion. The partial absence of pericardium is a rare congenital condition often diffucult to detect. Its prevalence ranges from 0.007–0.015% in autoptic and 1–0.044% in surgical series. Usually isolated it can accompany other malformations. It may be complete or partial, and sometimes so limited in extension to determine a sort of foramen that may strangle the heart itself. While this condition is usually benign when the heart is constricted through the above mentioned pericardial orifice a sudden death may occurr. Symptoms may be absent but sometimes the absence of pericardium is associated with an atypical chest pain, often piercing, sometimes very intense. In our patient no condition at risk was detected. We excluded other potential causes for his ventricular arrhythmyas (particular attention was posed to excluding ARVC as this suspicion was the one that prompted all the exams that the patient had previously performed) . He will be followed regularly without any specific measure.
P164 VERY LONG TERM FOLLOW UP OF PRIMARY TRANSCATHETER PATENT FORAMEN OVALE CLOSURE FOR MIGRAINE CURE
Authors: Rigatelli G , Zuin M , Gianese F , Adami A , Aggio S , Roncon L
Published: May 2022

Background and Purpose

Results of previous trials about PFO closure as a treatment for migraine are still doubtful and inconclusive. We sought to evaluate the long–term (>10 years) effectiveness of migraine treatment by means of patent foramen ovale (PFO) closure.

Method

From 2006 to 2010, 86 patients (68 female, mean age 40.0 ±3.7 years) with disabling, medication–refractory migraine and PFO were enrolled in a prospective study over a 48–month period. Criteria for transcatheter closure were all the following: presence of a permanent right–to–left shunt (RLS) having a shower/curtain pattern, presence of interatrial septal aneurysm and Eustachian valve, 3 to 4 class Migraine Disability Assessment Score (MIDAS), coagulation abnormalities, and medication–refractory migraine with or without aura.

Results

Forty patients (46.5%) (34 females, mean age 35.0±6.7 years, mean MIDAS 35.8 ± 4.7) underwent transcatheter closure. After a mean follow–up of 118.2 ±19.1 months (range 96 to 144), 37 patients continued the follow–up and experienced symptomatic improvement: aura was abolished in the totality of patients along with a durable improvement of migraine throughout the extended follow up also in patients without aura. The mean MIDAS significantly decreased in the closure group (p < 0.0001). Patients with complete migraine resolution presented a shorter history of migraine, a more severe thrombophilic profile, more severe RLS and larger left atrial diameter and volume.

Conclusions

Primary transcatheter PFO closure in selected high–risk patients having disabling refractory migraine resulted in abolition of aura and in a sustained reduction in migraine in the very long–term period.
P166 “LONG QT SYNDROME:AN ENTIRE FAMILY WITH KCNQ1 MUTATION”
Authors: Di Domenico A , De Carolis B , De Raffele M , Vitali F , Balla C
Published: May 2022

Introduction

Congenital long QT syndrome (LQTS) is characterized by prolongation of the QT interval that can trigger life–threatening arrhythmias leading to syncope and sudden death. Mutations in genes encoding for ion channels have been identified in 75% of LQTS cases. Long QT syndrome type 1 (LQTS1) is one of three subtypes of LQTS identified based on genetic substrate. LQTS1 is linked to a “loss–of–function” mutation in the gene encoding the potassium channel KCNQ1, and arrhythmias tend to occur during childhood with prevalence in the male sex. Adrenergic triggers are the most important trigger for arrhythmic events.

Clinical Case

Extensive family with long QT syndrome with positive genetics for mutation in the KCNQ1 gene. The index case in the family appears to be a woman who at the age of approximately 30 years died suddenly after surgery. The first patient subjected to genetic analysis, with positive result, was the daughter of this woman who, at the age of about 25 years has experienced a ventricular arrhythmia during induction of anesthesia for surgery with baseline ECG finding of prolonged QTc. Set beta–blocker therapy, arrhythmias no longer occurred. Subsequently, a cardiological screening including electrocardiogram, transthoracic echocardiography and genetic analysis was undertaken in first–degree relatives and, in cases of positivity, this screening was progressively extended to second–, third– and fourth–degree relatives. All the women in the family analyzed, eight in total, including two girls aged 5 and 12 years, tested positive for genetic analysis, and one of the women had a syncopal episode at the age of 50 years. Of the men analyzed, four in total, only two (father and son) tested positive on genetic analysis. In all patients with positive genetics a QTc >480 msec was detected on ECG in clinostatism and/or orthostatism, for which a diagnosis of LQTS1 (mean Schwartz–score 4) was made and beta–blocker therapy was started.

Conclusions

This clinical case describes an entire family with LQTS with positive genetics for KCNQ1 with phenotypic manifestations different from those described in the literature, in particular with prevalence in the female sex and with onset of arrhythmias in adulthood.
P178 TYPE–A AORTIC DISSECTION IN MARFANOID HABITUS
Authors: Manca F , Cocco D , Pistis L , Serra E , Cirio E , Corda M , Pilleri A
Published: May 2022

Aortic dissection (AD) is the tearing of the tunica intima of the aortic wall with creation of a false lumen. Type–A AD, in which the intimal flaps originates in the aortic tract proximal to the left subclavian artery, is a surgical emergency because – if left untreated – it has mortality rates as high as 1–2% every hour, from the onset of symptoms. Certain collagenopathies, such as Marfan Syndrome, are a predisposing condition for AD. We describe the case of a 25–year–old man with Marfanoid habitus who came to the Emergency Room of our facility, with acute pulmonary oedema. He had been complaining about thoraco–abdominal pain, bloody mucus and worsening dyspnoea since the week before. Upon cardiology consultation, a transthoracic echocardiogram showed an aneurysm of the aortic root (70 mm) and the ascending aorta (90 mm), with dissection flap extended beneath the aortic valvular plane, with torrential aortic valve insufficiency and eccentric jet, a left ventricle severely dilated and a severe systolic dysfunction (EF 25%). On urgent CT angiography the dissection flap was observed to extend cranially to the right common carotid artery and caudally to the renal arteries. The patient then underwent cardiac surgery to replace the aortic valve with a mechanical prosthesis and the ascending aorta as per the Bentall procedure and to replace the aortic arch with reimplantation and debranching of the supra–aortic trunks. Four months after discharge, the patient presented again due to sustained ventricular tachycardia (SVT) which was interrupted by electric cardioversion. On this occasion, an ICD implant was indicated as a secondary prevention measure. After one month, recurrence of SVT was observed, which was successfully treated by the implanted ICD, and therefore indication was given for an electrophysiologic study and subsequent transcatheter radiofrequency ablation of the ventricular arrhythmia. The case presented is of particular interest as it highlights the crucial role of a rapid echocardiographic assessment focussed on making a diagnosis and directing treatment, despite a misleading clinical picture due to duration and atypicality of symptoms. It should also be stressed that an overall assessment of the patient, based on habitus and age, plays a major role in establishing a suspected diagnosis and guiding the patient towards the most appropriate treatment.
P196 CHANGE IN THE DAILY HOSPITALIZATION RATE FOR ACUTE MYOCARDIAL INFARCTION IN THE VENETO REGION FROM 2006 TO 2018
Authors: Zuin M , Picariello C , Anselmi M , Roncon L , Bilato C
Published: May 2022

Background

Acute myocardial infarction (AMI) continues to represent the leading cause of cardiovascular mortality in Italy, with important prognostic and health consequences both in the short and long term. The aim of the study is to evaluate the long–term variation in the daily hospitalization rate for AMI in the Veneto region.

Materials and Methods

Data regarding the total number of hospitalizations due to AMIbetween 2006 and 2018 were extracted from the periodic epidemiological reports of the Veneto region which can be consulted on the website www.ser–veneto.it and then re–elaborated and analyze. In particular, changes in daily hospitalization rates for AMI were calculated, then sub–classified into AMI with ST–segment elevation myocardial infacrction (STEMI) and without (NSTEMI). The trend of change in daily hospitalization rates was assessed with the Jonckheere–Terpstra test, using the SPSS statistical software version 19.0 (SPSS; SPSS Inc., USA).

Results

During the study period, in the Veneto region 87,490 hospitalizations for AMI [48,165 (55.0%) STEMI and 32,325 (45.0%) NSTEMI], of which 75.7% were managed in Cardiology / ICU wards were registered. The overall average daily hospitalization rate for AMI over the entire period was 18.3 ± 0.6 admissions / day [range 17.5 / 19.8] with a decrease of 11.4% / year (p = 0.009). Among these, patients admitted for STEMI were hospiutalized for 10.1 ± 1.2 / day [range 8.6–12.4]; however their daily hospitalization rate decreased by 32.4% / year (p < 0.001). Conversely, 8.2 ± 0.8 patients with NSTEMI / day were hospitalized in the observation period [range 7–8.9]. showing a growing hospitalization trend in the period considered (+ 20.9% / year, p < 0.001) (Figure 1).

Conclusions

The daily hospitalization rate for AMI in the Veneto region has overall decreased in recent years, however, there has been a significant increase in daily hospitalizations for NSTEMI. The high number of daily hospitalizations requires close synergy between the cardiology departments of the region in order to ensure adequate care for patients with acute cardiac events in the area.
P201 PURSUING COMPLETENESS OF CORONARY REVASCULARIZATION IN ACUTE SETTING: TIMING AND STRATEGIES
Authors: Fazzini L , Ricci S , Angius S , Cadeddu M
Published: May 2022

Patient Presentation

A 59 y/o male with history of arterial hypertension and allergic asthma was admitted to our Coronary Care Unit because he went to a spoke emergency department after complaining oppressive and not continuous chest pain for a couple of hours travelling up to the left arm. Increase in cardiac troponin and mild ST–elevation in D3 lead were found. At the spoke cardiology department was treated with intravenous nitrates with relief and Ticagrelor loading dose was administered. He underwent two coronary angiographies, the first one aimed to treat the culprit lesion and the second one to complete revascularization before discharge Management: A heart ultrasound (US) described normal left ventricle ejection fraction (LVEF) with some of the right coronary segments akinesis. The first coronary angiography showed eccentric stenosis (80%) of distal right coronary artery (RCA) with endoluminal thrombosis; intraluminal filling defect of the left main coronary artery (LMCA) which request Optical Coherence Tomography evaluation that showed plaque rupture and red thrombus of LMCA; chronic total occlusion of left anterior descending artery (LAD) with several stenosis up to the apical segments. Glycoprotein IIb/IIIa receptor antagonist infusion was started, and we’ve been forced to treat first the LMCA with drug–eluting stent and then the culprit lesion with angioplasty and two drug–eluting stents complicated by intrastent thrombosis treated with mechanic and rheolytic thrombectomy. Seven days later rotational atherectomy was performed due to LAD artery’s severe calcifications complicated by LMCA intrastent thrombosis caused by stenting crush; cardiopulmonary arrest occurred. Impella ventricular assist device was placed. After LMCA stent optimization, one more drug–eluting stent was placed. Eight days later, heart US described LVEF 37% with apex and right coronary segments hypo–akinesis.

Discussion

According to latest NSTEMI guidelines, a single stage pursuing of completeness revascularization on multiple vessel disease would have been the best option. In this case, completeness of revascularization hasn’t been achievable due to LMCA plaque rupture. From a technical point of view, considering the complexity of the few days earlier treated LMCA lesion, proximal to LAD lesions we were going to treat, it would have been suitable waiting about four weeks to complete stent endothelization. By the way, it would have been out–guidelines approach.
P244 BRISK WALKING CAN BE A MAXIMAL EFFORT IN HEART FAILURE PATIENTS. A COMPARISON OF CARDIOPULMONARY EXERCISE AND SIX–MINUTE WALKING TEST CARDIORESPIRATORY DATA
Authors: Mapelli M , Salvioni E , Paneroni M , Gugliandolo P , Bonomi A , Scalvini S , Raimondo R , Sciomer S , Mattavelli I , La Rovere M , Agostoni P
Published: May 2022

Aims

Cardiopulmonary exercise test (CPET) and six–minute walking test (6MWT) are frequently used in heart failure (HF). CPET is a maximal exercise, whereas 6MWT is a self–selected constant load test usually considered a submaximal, and therefore safer, exercise but this has not been tested previously. The aim of this study was to compare the cardiorespiratory parameters collected during CPET and 6MWT in a large group of healthy subjects and patients with HF of different severity.

Methods and Results

Subjects performed a standard maximal CPET and a 6MWT wearing a portable device allowing breath–by–breath measurement of cardiorespiratory parameters. HF Patients were grouped according to their CPET peak oxygen uptake (peakV̇O2). One–hundred and fifty–five subjects were enrolled, of whom 40 were healthy (59±8 years; male 67%) and 115 were HF patients (69±10 years; male 80%; left ventricular ejection fraction 34.6±12.0%). CPET peakV̇O2 was 13.5±3.5 ml/kg/min in HF patients and 28.1±7.4 ml/kg/min in healthy (p < 0.001). 6MWT–V̇O2 was 98±20% of the CPET peakV̇O2 values in HF patients, while 72±20% in healthy subjects (p < 0.001). 6MWT–V̇O2 was >110% of CPET peakV̇O2 in 42% of more severe HF patients (peakV̇O2<12ml/kg/min). Similar results have been found for ventilation and heart rate. Of note, the slope of the relationship between V̇O2 at 6MWT, reported as percentage of CPET peakV̇O2 vs. 6MWT V̇O2 reported as absolute value, progressively increased as exercise limitation did.

Conclusions

6MWT must be perceived as a maximal or even supra–maximal exercise activity at least in patients with severe exercise limitation from HF. Our findings should influence the safety procedures needed for the 6MWT in HF.
P245 A RARE CAUSE OF OVERESTIMATION OF PULMONARY PRESSURE BY ECHOCARDIOGRAPHY: WHEN HEMODYNAMICS RELIEVES ECHOCARDIOGRAPHY AND ECHOCARDIOGRAPHY EXPLAINS HEMODYNAMICS
Authors: Caravita S , Baratto C , Curti E , Villella F , Sganzerla P , Perego G , Badano L , Muraru D , Parati G
Published: May 2022

Echocardiography is the gatekeeper of the diagnostic workflow of pulmonary hypertension (PH). However, it lacks precision, and right heart catheterization (RHC) may be needed in selected cases. A morbidly obese 47–year–old woman (BMI= 58 Kg/m2) with dyspnea NYHA II was referred to our Center after a high probability of PH was found at echocardiography, this latter performed as a routine assessment before bariatric surgery. Despite a suboptimal acoustic window, the tricuspid regurgitant jet profile was well–defined, with an estimated systolic pulmonary artery pressure (PAP) of 100 mmHg. There were no overt echocardiographic signs of left heart disease. During RHC, mean PAP was just above normal values, with filling pressures at the upper limit of normal (Figure 1), high cardiac index (3.6 L/min/m2) and normal pulmonary vascular resistance (1.4 WU). The echocardiographic estimate of high systolic PAP was explained by an intraventricular RV pressure gradient of about 100 mmHg (Figure 2). Oximetry ruled out a significant intracardiac shunt. Since resting hemodynamics did not explain the patient’s symptoms, the patient pre–test probability of having heart failure with preserved ejection fraction (HFpEF) was intermediate–high, and PAWP was in a grey–zone. Accordingly, we performed an exercise RHC. The test eventually unmasked HFpEF, as witnessed by an abnormal increase of PAWP and LV end–diastolic pressure (Figure 1 panel C and D). Exercise capacity was mildly reduced (71% of predicted) due to peripheral limitation with normal cardiac and respiratory reserves. Transesophageal echocardiography was then performed. It showed a muscular obstruction below the infundibulum dividing the RV into a high–pressure apical portion and a low–pressure infundibulum (Figure 3). This rare congenital anomaly was also associated with a restrictive perimembranous ventricular septal defect. Double–chambered RV has been reported to present rarely in adults, but it might be a cause of false Doppler echocardiographic estimate of PAP. Based on a meticulous invasive hemodynamic characterization at rest and during exercise, integrated with cardiovascular imaging, we could perform such a diagnosis. This congenital anomaly did not fully explain the patient’s symptoms, which may better be attributed to cardiovascular complication of obesity (HFpEF). Accordingly, we referred the patient for bariatric surgery first, postponing the indication to cardiac surgery during the follow–up.