bluuebunny/crossref_metadata_2025 huggingface dataset:
P35 CARDIAC MAGNETIC RESONANCE: PROMISING SOLUTION IN CLINICAL DILEMMA
Authors: Citarelli G , De Feo D , Parisi G , Lisi F , Ricci G , Ficco M , D’Aprile P , Caldarola P
Published: May 2023

There are many clinical conditions in which symptoms and signs can overlap, resulting in a real "clinical dilemma". Differential diagnosis is essential for identifying the pathology affecting a patient and consequently making the best therapeutic decisions. Herein we report a case of a young patient, with strong smoking habit, who looked for medical attention after experiencing chest pain, associated to upper airways inflammation. EKG revealed ischemic abnormalities, echocardiography showed a preserved ejection fraction (EF: 55%) and global cardiac contractility, although akinesia of the mid–segment of the inferolateral wall, and the presence of a mild inferolateral pericardial effusion. A concomitant increase in myocardial necrosis enzymes and inflammatory markers was observed in blood tests, but the coronarography showed undamaged coronary arteries. This clinical picture characterized by the young age of the patient, by the intercurrent inflammatory event, by the presence of pericardial rubbing on physical examination, by the evidence of echocardiographic end EKG anomalies in the absence of documentable epicardial lesions and by the complete symptomatic remission after anti – inflammatory therapy with acetylsalicylic acid and Colchicine was highly suggestive of pseudoinfarct–presenting myopericarditis. To confirm such diagnosis, cardiac magnetic resonance (CMR) was requested, unexpectedly, it showed oedema on the mid–basal inferolateral T2–weighted STIR sequences, but also microvascular obstruction (MVO) on early EGE contrastographic sequences mid–basal inferolateral site, and finally evidence of transmural fibrosis in the same site to the DE sequences resulting in pathognomonic lesions for acute ischemia in absence of epicardial coronaropathy. CMR imaging, which is able to analyse cardiac structure and function and simultaneously provide tissue characterization, has been an essential investigation for the diagnosis of MINOCA, as CMR can readily pinpoint many conditions responsible for myocardial damage and allow pathological discrimination of patients. Our patient‘s final diagnosis was “STEMI, MINOCA, and concomitant pericarditis” implying a consequent therapeutic modification, introducing DAPT. Making differential diagnosis in similar clinical conditions characterized by overlapping presentations, allows the use of personalized therapeutic strategies for each patient and better final results.
P54 RIGHT SINGLE CORONARY ARTERY AS AN INCIDENTAL FINDING IN ACUTE PERICARDIAL DISEASE
Authors: Nunziata L , Terracciano F , Maresca G , Granata F , Falato S , Ambrosino S , Carbone L , Ruggiero V , Laezza A , Prisco A , Nardiello V , Miele R , Sena L , America R , Volpicelli M , Muto C , Capasso M , Caliendo L
Published: May 2023

An 44–year–old woman was referred to our hospital for chest pain. She had no known cardiovascular risk factors but had a history of previous acute pericarditis following pregnancy. At admission, she still had chest pain improved by leaning forward. Cardiovascular examination and her electrocardiogram showed nothing pathological. On laboratory tests, there were mild elevation of troponin T and normal C–reactive protein. A transthoracic echocardiogram revealed only a minimal pericardial effusion close to the right heart chambers. A chest X–ray was generally normal. She was admitted to the coronary care unit with a provisional diagnosis of myopericarditis. Three days later, due to the persistence of symptoms despite the appropriate pharmacological therapy, it was decided to perform coronary angiography. During the procedure, selective cannulation of the left coronary artery was not possible, and a non–selective injection disclosed no coronary artery arising from the left coronary sinus. On selective injection of the right coronary sinus, a single ostium was visualized. The right coronary artery (RCA) was a great vessel, with no stenosis. A left anterior descending artery (LAD) and left circumflex artery (LCx) were perfused from RCA collateral vessels, both without lesions. Coronary computed tomography angiography confirmed a single coronary artery with its ostium in the right sinus of Valsalva and agenesis of the left main artery (LCA). A physical stress echo ruled out inducible myocardial ischemia. Coronary artery anomalies are rare congenital disorders that are usually diagnosed incidentally. Single coronary artery (SCA) has been known since 1903. It is an anomalous condition in which the SCA originates from a single aortic orifice, either the left or the right aortic ostium, and gives rise to the entire coronary circulation. Isolated congenital SCA is a very rare condition, occurring in 0.024–0.098% of the general population. Right SCA with congenital absence of the LCA is the least common type of SCA, and is extremely rare with a reported incidence of 0.0008%. SCA has been reported in association with atherosclerotic disease, coronary artery fistulas, mitral valve prolapse, bicuspid aortic valves, tetralogy of Fallot, transposition of the great arteries, hypertrophic cardiomyopathy and Takotsubo syndrome. We report this extremely rare case because the concomitant association with pericardial diseases has never previously been reported.
P68 DILATED CARDIOMYOPATHY AND MICRODELETION SYNDROME: A CASE REPORT
Authors: Simeoli P , Rusconi D , Bursi F , Santangelo G , Guazzi M
Published: May 2023

A 45–year–old man was admitted to our Coronary Care Unit because of acute pulmonary edema and atrial flutter with high ventricular response. The patient was an active smoker, obese and reported a previous alcohol abuse. Blood tests showed increased NT–proBNP values. Transthoracic echocardiography showed a severely enlarged and dysfunctional left ventricle (LVEF 15%). Acute phase treatment required noninvasive ventilation, amine support, and electrical cardioversion with progressive improvement of patient’s clinical condition. At coronary angiography no significant coronary stenosis was found. (fig.2). Cardiac magnetic resonance showed no area of fibrosis or inflammation(fig.3). Furthermore, a new diagnosis of diabetes mellitus type 2 and mild cognitive impairment was also made during hospitalization. Upon clinical stabilization, therapy with bisoprolol, sacubitril/valsartan, spironolactone, furosemide, and direct anticoagulant was introduced and titrated with progressive improvement until normalization during follow–up of systolic function indices, ventricular volumes, and nt–proBNP values until normalization at approximately 6 months after discharge. Cardiopulmonary exercise test was performed and found good cardiopulmonary performance and absence of cardiogenic limitation to exercise (VO2 peak 22.9 ml/min/kg corresponding to 93% of predicted and VO/HR 18 ml/beat, VE/VCO2 slope equal to 24). Genetic test showed a missense mutation in heterozygosity of LMNA gene (1634 G>A, p. Arg545His) currently coded as likely pathogenic and heterozygous deletion of 534 kb at the level of the short arm (p) of chromosome 16 at band p11.2. Dilated cardiomyopathies associated with mutations in the LMNA gene, coding for Lamina A/C (a component of the cellular basal lamina), tend to have an inauspicious prognosis as they are related to arrhythmic and extracardiac manifestations (myopathies, lipodystrophies, and neuropathies). 16p11 microdeletion syndrome is characterized by obesity and cognitive impairment, frequently associated with congenital heart disease, less often with dilated and hypertrophic cardiomyopathy pictures. The rapid introduction and titration to the maximum tolerated dose of heart failure therapy had an extremely positive effect in our patient who had an overlapping of genetically determined dilated cardiomyopathy and 16p11 microdeletion syndrome.
P70 UNEXPLAINED TRANSIENT BIVENTRICULAR DYSFUNCTION IN A PATIENT WITH DISSEMINATED TUBERCULOSIS AND SEVERE EOSINOPHILIA
Authors: Basile P , Santoro D , Bertrandino F , Mandunzio D , Falco G , Carella M , Monitillo F , Ciccone M , Guaricci A
Published: May 2023

Introduction

Tuberculosis (TB) is an infectious disease with significant global burden. Pericardial injury is relatively common, while myocardial involvement has only rarely been described.

Case presentation

A 29-years-old man from Gambia with disseminated TB, treated with isoniazid, rifampin, pyrazinamide and ethambutol, was admitted to our hospital. He denied history of heart disease, cardiovascular risk factors and voluptuary habits. Laboratory exams revealed severe eosinophilia without microbiological evidence of parasitic infection; a lymphocyte proliferation test ruled out allergic reaction to anti-TB therapy. Baseline echocardiographic evaluation showed normal cardiac function with negative troponin. The patient, subsequently, developed worsening dyspnoea and asthenia with progressive biventricular dysfunction. Therefore, he was admitted to our department for further investigations. Cardiac magnetic resonance (CMR) showed a 20% left ventricular ejection fraction and absence of myocardial oedema or fibrosis [Fig.1]. Coronary CT angiography (CCTA) was unremarkable. Endomyocardial biopsy (EMB) showed absence of TB lesions or eosinophilic infiltration. Cardiac troponin and electrocardiogram remained negative throughout. Optimal medical therapy (OMT) for heart failure was promptly initiated. After several months an almost complete recovery of cardiac function was documented [Fig.2].

Discussion

In cases of ventricular dysfunction, establishing an etiological diagnosis is imperative, though sometimes challenging. When pre-test probability is low, CAD can be ruled out by CCTA. Myocarditis is a common cause of reversible cardiac dysfunction. In this case, the absence of Lake Louise criteria, negative bioptic findings, persistently negative cardiac troponin and microbiological tests argue against this diagnosis. However, the timing of investigations can affect diagnostic accuracy; furthermore, focal lesions can be missed by EMB, leading to false negative results. Alcoholic cardiomyopathy (CMP) could be an option, but it was not considered due to absence of alcohol consumption. The clinical picture was not compatible with a typical CMP phenotype. Immune-mediated reaction to anti-TB drugs was ruled out by immunological testing. Although not previously described, ethambutol and pyrazinamide direct cardiotoxicity may explain transient impairment of cardiac function. Recovery may be related to withdrawal of these drugs and introduction of guideline-directed OMT.
P73 CLINCAL AND FUNCTIONAL EFFECTS OF BETA–BLOCKER THERAPY DISCONTINUATION IN PATIENTS WITH BIVENTRICULAR HEART FAILURE
Authors: Ricchetti G , Slavich M , Demarchi B , Mager R , Morciano D , Morosato M , Cavalli G , Spoladore R , Federico F , Federico A , Agricola E , Margonato A , Fragasso G
Published: May 2023

Background

Nearly two–third of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular (RV) dysfunction, which has previously been identified as an independent predictor of reduced functional capacity and poor prognosis. However, RV has received little attention in the past. Beta–blocker therapy (β–BT) has been shown to improve mortality and reduce hospitalizations in patients with HFrEF, being approved as first–line therapy irrespective to RV function. Less is known about the sympathetic nervous system‘ role in RV dysfunction and the potential usefulness (or harmfulness) of β–BT in these patients is still unclear.

Objectives

Our study aimed to evaluate the medium–term effect of β–BT discontinuation on functional capacity and RV remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable HFrEF and RV dysfunction.

Methods

Seventeen outpatients were prospectively enrolled using the following criteria: presence of signs and symptoms of HF while on optimal medical therapy (including β–BT); LVEF ≤40%; echocardiographic criteria of RV dysfunction. Patients were randomized 1:1, either to withdraw (group 0) or prosecute (group 1) β–BT. In group 0 optimal heart rate was obtained with digoxine or ivabradine. Echo and serum biomarkers were performed at baseline, after 3 and 6 months; CPET was performed at baseline and 6 months.

Results

After six months follow up, RV systolic function improved based on S’–DTI in group 0 (ΔS’: 1.01 vs. –0.92cm/s; P=.03). Conversely, worsening of estimated PAPs (ΔPAPs: 0.8 vs. –7.5mmHg; P =.04) and echo LV–remodelling (ΔEDVi: 19.55 vs. –0.96mL/mq P=.03) were observed. No significant improvements in term of functional capacity were obtained. The only variables significantly affected by β–BT withdrawal were LV EDV and ESV, appearing worse in group 0 (meanEDVi 115 vs. 84mL/mq; meanESVi 79 vs. 53mL/mq, P=.03).

Conclusions

β–BT discontinuation did not produced any beneficial effect. Additionally, despite maintenance of optimal heart rate control, β–BT withdraw worsened LV remodelling. Our study corroborates the hypothesis that improvement in LV function may be a major determinant for improvement in RV function, reducing pulmonary wedge pressure and RV afterload, with only a marginal action of its negative inotropic effect. In conclusion, β–BT might be beneficial also in heart failure patients with biventricular dysfunction.
P75 MULTIDISCIPLINARY MANAGEMENT OF INTRACARDIAC LEIOMYOMATOSIS: A CASE REPORT
Authors: Tognola C , Bonelli A , Guasti S , Spanó F , Santambrogio G , De Chiara B , Belli O , Musca F , Casadei F , Giannatasio C , Moreo A
Published: May 2023

A 60–year–old woman with no cardiological history came to our attention for exertional dyspnea since few months. The electrocardiogram and chest radiograph were normal. Trans–thoracic echocardiogram revealed the presence of a floating parenchymatous formation measuring 12 x 2 cm starting from the inferior vena cava (IVC) and jutting into the right chambers, without obstruction to inflow. Chest CT and cardiac MRI described a nonvascularized inhomogeneous formation suggestive of thrombotic apposition in VCI, so the patient was treated with unfractionated heparin. Total body CT/PET scan excluded hypercaptant lesions. After two weeks of anticoagulant therapy, on echocardiogram the mass appeared unchanged in morphology and size. On reevaluation of the CT images, a probable origin of the formation at the level of the right ovarian vein was identified. In light of the positive history of bilateral hysteroannessiectomy for uterine myomas and the lack of response to anticoagulant treatment, the suspicion of intravascular and intracardiac leiomyomatosis was raised. After collegial discussion, given the high risk of an eventual thoraco–abdominal surgery, it was decided to remove only the portion of the mass adherent to the VCI jutting into the right heart chambers. The patient underwent cardiac surgery: a polypoid, capsular, hard–elastic mass, 12 x 2 cm in size, jutting into the right chambers and with the base of implantation located in the anterior wall of the VCI, was removed. The final histologic diagnosis was sclero–jalin leiomyoma. The surgery and postoperative course proceeded without complications. At follow–up at 20 months, the patient is asymptomatic and no mass is detectable on echocardiogram. Intracardiac leiomyomatosis is a rare condition characterized by benign smooth muscle tumors of extracardiac origin reaching the right heart by direct extension into the venous canal, described predominantly in women with a history of uterine myomas. Although histologically benign, intracardiac leiomyomatosis can result in sudden death if there is total obstruction to the outflow tract. In our case, the multimodality imaging approach and serial monitoring by echocardiography were essential to guide treatment choices and for the follow up.
P85 REAL WORLD EXPERIENCE ON THE USE OF SGLT2–I IN ELDERLY PATIENTS WITH HFREF
Authors: Verga F , Orso F , Salucci C , D‘Errico G , Perini E , Vatri M , Poletti E , Cagnoni C , Corti G , Di Bari M , Ungar A , Baldasseroni S
Published: May 2023

SGLT2–i have been shown to improve prognosis in patients with heart failure with reduced ejection fraction (HFrEF) in randomized clinical trials (RCTs). However, at the moment, we have little data on the use of these drugs in clinical practice, both in terms of safety and efficacy profile.

Objectives

To describe the characteristics of HFrEF outpatients who started SGLT2–i in clinical practice; evaluate tolerability and the effect on clinical and biohumoral parameters.

Methods

We prospectively analyzed patients who started SGLT2–i in our Heart Failure clinic. The baseline characteristics, the variations of bio–humoral and clinical parameters were recorded, as well as the onset of adverse effects leading to drug suspension after one month.

Results

We evaluated 37 patients, with a mean age of 77.7± 8.5 years (65% over 75). The baseline characteristics of the population compared to that of the treatment arms of the RCTs are shown in Fig.1. Most patients were in NYHA II (62%), with ischemic etiology (65%), with reduced EF (mean 34.7± 5.1%) and nearly half of the patients received ICD or CRT–D (43.2%). At the one month follow–up, there was a significant reduction in NYHA class (Fig. 2)and furosemide dose (36.3 vs 53.2 mg, p<0.001), without a significant change in NTproBNP values ​​(2499 vs 2431 pg /mL, p=0.804). Furthermore, there was a reduction in systolic blood pressure (115 vs 120 mmHg, p=0.029) with no significant increase in the incidence of orthostatic hypotension (27% vs 21%, p=0.48). In line with the trials, there was a slight, non–significant worsening of renal function (CKD–EPI 52.9 vs 55.9 mL/min, p=0.10). At one month, no patients experienced any adverse effects leading to SGLT2–i discontinuation.

Conclusions

In this preliminary analysis, after one month of SGLT2–i therapy in elderly patients, there was a clinical and hemodynamic improvement as demonstrated by the improvement of the NYHA class and the reduction of the diuretic therapy. SGLT2–i have been shown to be relatively safe, with no adverse effects and no increased risk of orthostatic hypotension or significant worsening of renal function.
P132 A CASE REPORT OF A STEMI MIMICKER IN A PATIENT WITH TUMORAL MYOCARDIAL INFILTRATION AND LITERATURE REVIEW
Authors: Carmina M , Pieri E , Romano G , Geraci G , Minà C , Bonnì E , Polizzi V
Published: May 2023

Introduction

We report a case of ‘STEMI–like’ presentation, with marked STE on ECG in a patient with lung cancer and cardiac catheterization showing no significant coronary obstruction. A 76y woman presented in the emergency room with dyspnea and chest pain.She had a history of hypertension, obesity, previous cerebellar ischemia and pulmonary neoplasia with involvement of left upper lobe and stenosis of main left bronchus and mediastinal infiltration, on palliative treatment.First ECG showed atrial fibrillation (AF) 150 bpm and marked convex STE in I and aVL leads with reciprocal changes, so urgent coronary angiography (CA) was performed. Initial therapy was BB, ASA and UFH. CA surprisingly showed no significant coronary obstruction. Transthoracic echo (TTE) showed a large mass involving pericardium and left atrium, with infiltration of left myocardial lateral wall with a fingernail shape. HS troponin reached 10xN. The STE persisted on subsequent ECGs. In conclusion the ECG changes are due to neoplastic infiltration of left ventricle lateral wall, while AF is due to atrial infiltration. Discharged on day3, the patient was maintained on palliative care plus BB but no antithrombotic therapy due to very high risk of pulmonary bleeding and hemorrhagic infarction of ventricular wall. In our case no Thoracic CT Scan was performed, so we cannot differentiate between cardiac muscular involvement by pericardial metastasis and infiltration by the primary tumor, which is more likely because of the anatomic relationship between left upper lobe and the heart.

Discussion

Cardiac metastases varies in incidence (2.3 –18.3%), decrease with age, and most frequently origin from respiratory system. They can involve any heart chambers, clinical patterns depend on degree and site of myocardial infiltration.When ventricular wall is infiltrated pseudo–ischemic ECG changes may be induced;persistency of STE suggests tumour compression and/or myocardial infiltration. Patients with known malignancy with chest pain and STE should be screened for cardiac metastases and treated with a single (and not double) antiplatelet agent until coronary stenosis are confirmed. If systemic thrombolysis is considered, a bedside TTE should be performed before therapy.
P146 PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER AND PERSISTENT LEFT SUPERIOR VENA CAVA: WHAT SHOULD WE KNOW?
Authors: Gatto M , Celli E , Ferrari I , Biava G , Nicastri E , Antinori A
Published: May 2023

Peripherally inserted central catheters (PICCs) are widely used medical devices to provide medium to long–term infusion treatment and therapy. PICC placement is contraindicated in cases of deep–vein thrombosis, end–stage renal disease or if deep venous access is compromised. Among the possible complications there are some related to the interventional procedure (e.g. accidental puncture of an arterial vessel, injury to peripheral nerves, misplacement, arrhythmias, haematoma) and others related to the post–implantation phase (e.g. thrombosis, infection, gas emboli, phlebitis). One of the possible intra–procedural complications is the occasional finding of a persistent left superior vena cava (PLSVC). PLSVC is an anatomical variant present in at least 0.5% of the general population and its occurrence during interventional procedures is not uncommon. Clinical case description An 82–year–old woman was admitted to our Institute following a diagnosis of herpetic encephalitis (HSV1). She had a history of hypothyroidism undergoing substitution treatment. Cause the poor peripheral venous patrimony and the need of infusion therapy with acyclovir, levetiracetam and ceftriaxone, the indication for PICC implantation was given. After antibiotic prophylaxis and sterile field preparation, the procedure was performed with ultrasound–guided Seldinger technique by puncturing the left basilic vein. A successive X–ray showed the PICC running unusually parallel to the right sternum (Fig. 1). The echoscopy with bubble test allowed to visualize the agitated saline solution in the right atrium. In view of the suspected venous abnormality, the PICC was removed and a single–lumen MiniMidline 4F of 11 cm length was placed in the right basilic vein (4 mm). A subsequent chest CT scan visualised the PLSVC and its intrathoracic course, the presence of the right superior vena cava was also observed (Fig. 2). The PLSVC is an anatomical variant encountered during interventional procedures involving peripherally inserted central venous catheters. It is important to recognise this variant to avoid possible procedural and/or post–procedural related surgical complications.
P164 PERCUTANEOUS LEFT STELLATE GANGLION BLOCK IN REFRACTORY LEFT ATRIAL TACHYCARDIA
Authors: Morena A , Gravinese C , Frea S , Angelini F , Bocchino P , Bruno F , Saglietto A , Toscano A , Anselmino M , De Ferrari G , Dusi V
Published: May 2023

Percutaneous left stellate ganglion block (PLSGB) has been recently implemented for the acute treatment of refractory ventricular arrhythmias (VAs). The beneficial effect on supraventricular arrhythmias susceptibility and their ventricular response is well characterized in animal models, less so in humans. Available data suggest a significant prolongation of atrial refractory period, a reduction in inducibility and duration of atrial fibrillation and of all spontaneous intra– and postoperative atrial arrhythmias after thoracic and cardiac surgery. Here we describe a case of PLSGB for focal atrial tachycardia (AT). Case: we present a 68–year–old men with hypertension, obesity, OSAS and previous anterior myocardial infarction in the setting of a trivessel coronary disease, treated with PCI and complicated by apical aneurysm, with a LVEF of 38% and a moderate mitral and aortic regurgitation. He was on chronic antiarrhythmic therapy with bisoprolol 1.25 mg and ranolazine. He presented in the ED due to palpitations, pre–syncopal episodes, and worsening dyspnea. The ECG showed very frequent, self–limiting episodes of AT with a 1:1 atrioventricular (AV) conduction and a variable heart rate (HR) between 100 and 160 bpm, alternating with sinus rhythm at 45–50 bpm, sometimes conducted with aberrancy. Isolated and repetitive premature ventricular beats (PVB, maximum 8 beats) were also documented. Amiodarone, lidocaine, and intravenous unloading therapy were tried, without benefit. Coronary angiography was negative. PLSGB with an ultrasound–guided lateral approach (local bolus of lidocaine 100 mg+ropivacaine 20 mg) was performed, without complications, inducing palpebral ptosis. Over the next 15 hours we observed the disappearance of non–sustained VAs, the reduction of PVBs, and a progressive reduction of AT burden, of mean hourly HR (from 84 to 50 bpm, –40%) and of mean HR during AT (from 158 to 84 bpm, –47%, with AV 1:1 conduction). The patient subsequently underwent ablation of an extra systolic focus found near the ostium of the right inferior pulmonary vein, with no recurrences after 18 months.

Conclusions

This case highlights the potential efficacy of PLSGB in the acute treatment of supraventricular arrhythmias refractory to medical therapy. Prospective studies will help us to identify the extent, time of onset, and duration of its benefit depending on the type and mechanism of the underlying arrhythmia and the clinical characteristics of the patient.
P170 WHICH DIAGNOSTIC PROCEDURE IN CANCER SURVIVORS WITH CHEST PAIN? DESCRIPTION OF A CLINICAL CASE
Authors: Ferretti M , Demola P , Farì R , Pignatelli G , Grimaldi T , Menzà G , Mantovani F , Guiducci V , Navazio A , Tarantini L
Published: May 2023

Introduction

Cancer and CVD often share common risk factors and pathophysiological mechanisms, the relationship can be amplified by oncological treatment. In the case of aromatase inhibitors (AIs), used for a long time in breast cancer (BC) expressing the estrogen receptor there is a significant association with dyslipidemia, metabolic syndrome, ischemic heart disease and heart failure. For this reason the ESC guidelines on Cardio–oncology (LG–CO) recommend the evaluation of the baseline CV risk using SCORE2 or SCORE2–OP and aggressive control of CV risk factors (RF) to be integrated with the management of cancer. In case of suspicion of coronary artery disease (CAD), ESC LG–CO recommended the adoption of ESC 2019 guidelines for CAD. We present a case of atypical chest pain (LG 2019 ESC CAD pre–test probability < 15%) in a woman at very high CV risk and in adjuvant therapy with AI for BC

Clinical case

August 2022: 63–year–old female with multiple RF (premature family history of CAD, smoke, hypertension and dyslipidemia) in adjuvant treatment with Exemestane (Letrozole not tolerated) for BC (2020: T2N0M0 ER 99%, PGr– HER2– Ki67 20%) presents in ER for chest pain typical for site, character and irradiation (constricting – burdening, retrosternal radiating to the neck and shoulders) mainly at rest, in the evening, very rarely induced by rapid efforts. Statin therapy was discontinued after initiation of letrozole therapy for arthralgias – myalgias. At the most recent evaluation of blood chemistry: LDL cholesterol 185 mg/dl, Hb, glycemia and thyroid hormones were normal. ECG and rest, troponin, echocardiogram and exercise ECG were normal. Non–synchronized CT with ECG, performed for tumor staging, showed the presence of multiple calcifications on DA, CX and CD (Figure 1). The CGF confirmed the presence of a critical stenosis on the right coronary artery (Figure 2) and a non–critical stenosis on the DA (Figure 3). Successfully performed PTCA with DES implant and started DAPT + high intensity statin with Ezetimibe in addition to antihypertensive therapy obtaining asymptomaticity and optimal control of CV risk factors (FR)

Conclusions

Aggressive control of CV RF is mandatory in women with BC on AI therapy and high CV risk; the onset of symptoms suggestive of CAD must not be overlooked and in this context coronary CT can be a valid tool for estimating the atherosclerotic burden and to establish the diagnosis.
P171 CARDIOTOXICITY IN A PATIENT WITH UROTHELIAL CARCINOMA TREATED WITH DURVALUMAB AND CARBOZANTINIB
Authors: Mautone F , Casavecchia G , Pesolo M , Brunetti N
Published: May 2023

We present the clinical case of a 53–year–old patient with urothelial carcinoma enrolled in the ARCADIA study since April 2020, in therapy with Durvalumab and Carbozantinib (24 cycles). Durvalumab was suspended in October 2022 due to the increase in pancreatic enzymes and the probable autoimmune genesis of pancreatitis. On 04/12/2022, due to the onset of epigastralgia with ECG finding of sinus tachycardia and ST elevation in the lower site with HS–TnI 18883.8, he performed emergency coronary angiography which was negative for significant stenosis. On the Echocardiogram: Severe left ventricular systolic dysfunction (FE 25%). The patient presented increased inflammation indices and acute renal failure with Exitus.
P289 HEART FAILURE DUE TO HIGH OUTPUT ARTERIOVENOUS FISTULA IN A DIALYSIS PATIENT AFFECTED BY AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE
Authors: Massa L , Buratti S , Guazzi M
Published: May 2023

Autosomal dominant polycystic kidney disease (ADPKD) can determine end stage renal disease (ESRD) which require haemodialysis. Surgical creation of arteriovenous fistula (AVF) has been associated with development of left ventricular (LV) dilatation and high output heart failure (HF) and right ventricle (RV) dysfunction at long term follow–up. Databases show an association between ADPKD and idiopathic dilated cardiomyopathy, suggesting that PKD mutations contribute to development of heart failure. 36 ys old female patient affected by ADPKD who required in 2018 bilateral nephrectomy, due to a relapse of severe urinary tract bleeding, and then put in thrice–weekly hemodialysis. Before the procedure in 2016 an echocardiogram showed normal biventricular function, with valvular defects. An AVF, between left humeral artery and the perforator vein of the elbow, was employed as vascular access. 6 months later she was referred to our center for atypical chest pain and palpitations. A transthoracic echocardiogram showed a diffuse hypokinesia with severe left ventricular dysfunction and dilation (EF 25%, VTDi 90ml/mq), a cardiac output of 6,5 l/min, moderate mitral insufficiency, hypokinetic RV, pulmonary artery systolic pressure (PASP) of 56mmHg, severe biatrial dilatation. No signs of congestion. She was admitted to our service. The coronary angiogram was normal, ruling out an underlying ischemic cardiomyopathy. Therapy with b–blocker and ACE–I was started. Doppler ultrasonography of the AVF was performed and showed an high output fistula. Two weeks later at Hospital discharge with medical therapy only, EF improved to 43%. Five months later, the AVF was ligated, after the creation of another more distal one. Echocardiographic re–evaluation one month after the intervention showed a normalization of left ventricular function and volumes ( EF 55%, VDTi 54ml/mq)and of PASP. In 2020 she underwent renaltransplant without complications. The patient is nowadays stable only on beta–blocker for some PVCs, with ongoing annual follow–up. Even if dilated cardiomyopathy and HF in patients affected by APDKD can be caused by genetic predisposition, in our case the main factor was a high output AVF, as showed by complete reversion of left ventricular dysfunction after its ligation.
P291 BUILDING UP A TRANSFEMORAL TAVI PROGRAM DONE BY CARDIAC SURGEONS: OUR EXPERIENCE IN 502 PATIENTS
Authors: Berretta P , Capeestro F , Galeazzi M , Bifulco O , Alfonsi J , Buratto B , Cefarelli M , Malvindi P , Di Eusanio M
Published: May 2023

Background

Current evidence on TAVI has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here we describe the development of our TAVI program and report the results of transfemoral TAVI done by cardiac surgeons on their own.

Methods

The “surgical” TAVI program was built from the ground up in October 2018. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A multivariable logistic regression was used to study the association of preoperative clinical characteristics, the progression of the experience and the operators, with postoperative early outcomes.

Results

A total of 502 patients were included in the study. Mean patients’ age was 82 years and STS score was 3.1% (2.2 – 4.4). Eighty–five patients underwent transapical TAVI and 417 patients had a transfemoral approach. We progressively moved from TA TAVI towards TF procedures now routinely performed on conscious sedation and using a fully percutaneous approach (Figures 1–3). Both balloon expandable (60.3%) and self–expandable valves (39.6%) were used. After TF TAVI technical success (according to VARC 3 criteria) was achieved in 99.1% of cases. Thirty–day mortality rate was 1%, stroke occurred in 2% of the cases and permanent pacemaker implantation was necessary in 23% of the patients. A moderate or severe paravalvular leak was observed in 4.4% and 0.7% of patients, respectively.

Conclusions

The acquisition of catheter–based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with excellent early results.
P304 ACUTE ST–ELEVATION MYOCARDIAL INFARCTION DUE TO AORTIC DISSECTION: HISTORY OF A LATE DIAGNOSIS AFTER PRIMARY ANGIOPLASTY
Authors: Allievi L , Mircoli L , Colombo F , Barbieri L , Tumminello G , Carugo S
Published: May 2023

Introduction

We report a case of aortic type A dissection, involving the right coronary ostium, presented as an inferior STEMI. The aortic dissection diagnosis was formulated only after the coronary angioplasty on the right coronary was successfully done, leading to chest pain resolution. Dual antiplatelet therapy was administered. We want to underline how sometimes, mostly in emergencies, can be difficult to do the right diagnosis at the right time, even if some angiographic findings could help us to avoid life–threatening mistakes. Case presentation: 60 years–old man with typical angina chest pain started after an effort. The electrocardiogram showed ST elevation in inferior leads, while the echocardiogram akinesia of the inferior wall, a preserved EF, a normal diameter of the aortic root, no dissection signs, no pericardial effusion. The coronary angiography showed ostial RCA occlusion, critical stenosis in mid–distal LAD. Angioplasty on the RCA ostium with one drug–eluting stent (DES 3.5 x 18 mm) achieving reperfusion with TIMI 3 flow, complete resolution of ECG alteration and symptoms. Then PCI of LAD with DES was performed. During hospitalization in ICU recurrence of mild chest pain without ECG alterations. Routine echocardiogram performed the following day showed signs of aortic root dissection and moderate aortic valve regurgitation; an angio–CT scan was immediately performed confirming the aortic dissection, and cardiac surgery was immediately performed with good result. Reanalysis of the angiographic images showed some signs that should have made us think right away of an aortic dissection: abnormal convexity of the right coronary sinus, extravascular stagnation of contrast medium, and ostial RCA stent create a communication between the real and the false lumen, visible at the final injection.

Conclusion

Aortic root dissection, involving coronary ostium, could be a sneaky diagnosis since signs and symptoms could be very similar to myocardial infarction ones. A correct diagnosis is very important, leading to the right surgery treatment, the PCI and the dual antiplatelet therapy could lead to worsening outcomes. It is mandatory to pay attention to the signs that could help us doing the right diagnosis when we are performing coronary angiography. Always check the patient accurately during the ICU stay in order not to lose signs that can let us change the wrong to the correct diagnosis.
P318 A LETHAL SPASM
Authors: Bellin A , Cutolo A , Antonucci A , Gallo F , Themistoclakis S
Published: May 2023

S.F.E.G., a 52–year–old woman of Filipino origin, with no previous cardiology except arterial hypertension under therapy, came to our attention for a witnessed episode of cardiac arrest at home. Rescued by the emergency medical team, who found ventricular fibrillation at presentation, and performed ACLS with ROSC obtained after 3 DC shocks. The first ECG was unremarkable (sinus rhythm, diffuse ST depression). Total body CT was negative. Admitted to the Coronary Unit, the echocardiogram was normal for cavity dimensions and kinetics, as well was coronary angiography except for “short intramyocardial course in the second segment of LAD with slight systolic "milking". In the following days, however, there was a significant rise in HsTnI (1,000 → 47,000 ng/L), with concomitant sudden ventricular bigeminy and negative anterior T waves, akinesia of the anterior apical segments of the LV at cardiac ultrasound (not present at admission), in a patient still intubated and therefore with a non–evaluable clinic. Coronary angiography was repeated, which highlighted this time significant vasospasm affecting the middle segment of the LAD, that regressed after intracoronary nitrates. She was extubated without neurological sequelae, and subjected to ICD implantation by secondary prevention. To treat the vasospastic angina she was discharged with calcium channel blockers at the maximum tolerated dosage, as per guidelines (diltiazem 120mg TID + nifedipine 60mg BID). One month later the patient returned to our attention due to worsening dyspnoea, abdominal pain and anasarca (ascites, bilateral pleural effusion, peripheral oedemas). Hospitalized in a medical setting and treated with diuretics for suspected heart failure, despite the echocardiogram showing preserved biventricular systolic function, normal diastolic function, no valve disease, no pericardial effusion. BNP was 359 pg/mL, subsequently decreasing to 148 pg/mL. After excluding every other possible causes even with total body CT, our hypothesis was that of calcium channel blocker collateral effect (vasodilatory edema). We tapered the dosage until only diltiazem 60mg TID was mainteined, obtaining a significant clinical improvement (weight loss by 10 kg), without further recurrence of coronary vasospasm. This clinical case demonstrates the potential lethality of coronary vasospasm, and a rare complication during therapy with high doses of calcium channel blockers, with very few cases described in the literature.
P321 NEOVASC REDUCER IMPLANTATION AS A USEFUL THERAPEUTIC CHANCE IN REFRACTORY ANGINA
Authors: Acerbo V , De Michele G , Raucci G , Scherillo G , Signore G , Rotolo F , Scialla F , Cesaro A , Calabrò P
Published: May 2023

Refractory angina is a clinical condition caused by myocardial ischemia inadequately controlled by medical therapy and coronary revascularization. Emblematic case of this condition concerns a 72–year–old man with chronic coronary syndrome (percutaneous transluminal coronary angioplasty [PTCA] + drug–eluting stent [DES] on the proximal portion of the left main coronary artery [LMCA] in 2009 and PTCA + 2 overlapping DES on the proximal portion of the right coronary artery [RCA] in 2017) who accessed in the emergency room for unstable angina. The patient‘s past medical history was positive for repeated hospitalizations for unstable angina: in particular, was registered an admission in 2019 with angiographic evidence of intermediate stenosis 30% at the mid–distal tract of LMCA and good distant outcome of previously implanted stents on LMCA and RCA, and a further admission in 2021 with coronary evidence overlapping the previous one. In both hospitalizations, medical therapy optimization was carried out by adding also 2nd–line drugs to the antianginal therapy with Bisoprolol 2.5 mg and Amlodipine 5 mg such as transdermal Nitroglycerin 15 mg, Ranolazine 750 mg bis in die, and subsequently Trimetazidine 20 mg ter in die during the first and second hospitalizations, respectively. In the context of this re–hospitalization, coronarography was repeated again with evidence of unchanged angiographic picture from the previous one (2021) and, in view of the refractoriness of the anginal symptoms, was placed an indication for Neovasc Reducer device implantation. This device creates a pressor gradient in the coronary sinus, determining a redistribution of blood flow from the subepicardial areas to the ischemic subendocardial areas. Therefore, by performing jugular venous access we engaged the coronary sinus with 6F diagnostic catheter then by mother and child technique we placed the 9F guide catheter advancing as distally as possible in the coronary sinus and finally we implanted the Neovasc Reducer device (4 atm for 60‘‘), obtaining a good final angiographic result. At 6–month follow–up, the patient experienced symptomatic improvement, in particular he improved by 2 Canadian Cardiovascular Society (CCS) angina classes. The Neovasc Reducer device, by improving quality of life and reducing the need for hospitalizations for unstable angina, is a viable therapeutic strategy in patients angina unresponsive to medical therapy and coronary revascularization.
P363 EFFECTS OF ALIROCUMAB AND EVOLOCUMAB ON THE OUTCOMES AND LIPID PROFILE OF DIABETIC PATIENTS: META–ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
Authors: Orlando L , Quartuccio S , Vatrano M , Imbalzano E
Published: May 2023

Objective

To evaluate the specific effects of alirocumab and evolocumab on major cardiovascular events (MACE) and lipid profile in patients with diabetes.

Methods

We conducted a systematic review of literature according to the PRISMA statement. A total of 8 randomized control trials (RCTs) enrolling 20651 patients with diabetes were included. Mean follow–up was 51 weeks. We included RCTs which had compared the PCSK9i alirocumab and evolocumab with placebo in subjects with hypercholesterolemia and diabetes mellitus.

Results

MACE occurred in 8.7% of patients with diabetes randomized to PCSK9i vs. 11.0% of those randomized to placebo. Thus, the use of alirocumab or evolocumab reduced MACE by 18% (relative risk [RR] 0.82, 95% confidence interval [CI] 0.74–0.90), without differences between PCSK9i compounds (p= 0.70, I2 0.0%). Compared to control group, the use of PCSK9 inhibitors was associated with a significant % change from baseline in LDL–C (mean difference [MD]–58.48%; 95% CI: –63.73 to –53.22%), p<0.0001), HDL–C (MD5.21%; 95% CI: 3.26 to 7.17 %), triglycerides (MD–14.59%; 95% CI: –19.42 to –9.76%), non–HDL–C (MD –48.84%; 95% CI: –54.54 to –43.14%) and total cholesterol (MD–33.76%; 95% CI: –38.71 to –28.8%). A significant reduction of Lp(a) (MD–32.90%; 95% CI: –38.55 to –27.24%) were observed in PCSK9i group compared to placebo. Moreover, while LDL–C reduction was similar in both subgroups (Evolocumab: MD –63,3%; 95% CI: –74.87 to –51.72%, p<0.0001; alirocumab: MD –55.58%; 95% CI: –61.49 to –49.67%, p<0.0001; Test for subgroup differences: P= 0.24; I226.2%), the percentage of Lp(a) reduction was higher in evolocumab subgroup compared to alirocumab (MD –46.68 %; 95% CI: –60.73 to –32.63%, p<0.0001 vs –22.92 %; 95% CI: –28.58 to –17.25%, p<0.0001, respectively; Test for subgroup differences: P= 0.002; I2=89.4%).

Conclusions

Alirocumab and evolocumab appear to be effective in reducing the risk of MACE in subject with diabetes. Moreover, the use of PCSK9 inhibitors provides enhancement of lipid profile of patients with diabetes and dyslipidemia by reducing LDL–c and Lp(a) values.
P377 PERCUTANEOUS TREATMENT OF INTERMEDIATE AND HIGH–RISK PULMONARY EMBOLISM: A CASE REPORT
Authors: Verrengia E , Pezzi L , Testa S , D’Alleva A , Genovesi E , Magnano R , Forlani D , Fulgenzi F , Vitulli P , Di Marco M , Paloscia L
Published: May 2023

Pulmonary embolism is the third most frequent cardiovascular pathology, with an incidence of 100–200 cases for 100.000 inhabitants and is one of the main causes of mortality, morbidity and hospitalizations. Systematic thrombolysis represents the treatment of first choice in high–risk/high–intermediate–risk patients who experience hemodynamic instability, however there are absolute and relative contraindications that do not allow its use in all patients: in these cases, percutaneous catheter treatment can be attempted. A hypertensive and obese 84–year–old woman arrives at the emergency room with the onset of chest pain associated with dyspnea. In the emergency room, high levels of D–Dimer and highly sensitive Troponin T are found, therefore cardiological advice is requested. The echocardiogram shows severe dilatation of the right ventricle with McConnel sign, D–Shape and multiple thrombotic formations in the right atrium. On the advice of the consultant cardiologist, a pulmonary CT angiography is performed with evidence of thromboembolism of the main arterial trunks, massive at the level of the distal juxta–hilar portions. Therefore, high–intermediate–high risk pulmonary embolism is diagnosed and the patient is transferred to the ICU for proper treatment. Despite the infusion therapy with sodium heparin, there is a sudden worsening of the clinical and hemodynamic picture: thus, in the light of the impossibility of performing a rescue thrombolysis due to the recent patient’s femoral fracture, it is decided to perform a percutaneous treatment by thrombectomy, using an “INARI” thrombus–aspirator catheter positioned to the right femoral route. Pulmonary angiography reveals thrombotic sub–occlusion of booth main branches. Five aspiration cycles are performed, two of which in the right pulmonary artery and the remaining three in the left pulmonary artery. Control angiography shows reperfusion of the left lower lobe and partial reperfusion of the left upper lobe, while partial reperfusion of the right upper lobe is found on the right. Abundant thrombotic and partly fibrous material is found during aspiration. After the 5th cycle, cardio–circulatory arrest occurs and despite the resuscitation maneuvers, the patient dies. At present, percutaneous treatment in acute pulmonary embolism is still scarcely used in daily clinical practice, but it will certainly play an important role in the near future as a valid therapeutic alternative .