bluuebunny/crossref_metadata_2025 huggingface dataset:
P315 Prevalence of left ventricular systolic and diastolic dysfunction in patients with chronic kidney disease and preserved left ventricular ejection fraction
Authors: Tereshina O V , Germanova O A , Rogozina L A , Davydkin I L
Published: January 2020

BACKGROUND

Presence of heart failure (HF) is associated with poor outcome in patients with chronic kidney disease (CKD), although Left ventricular (LV) systolic function is often preserved in them. However, CKD patients may have HF symptoms with preserved LVEF. Myocardial Deformation Imaging is more accurate for detecting LV systolic dysfunction. The aim of this study was to evaluate global longitudinal (GLS) and circumferential strain (GCS) in patients with renal function impairment.

METHODS

Overall, 67 patients (40% men, mean age 45 ± 12 years) with CKD stage 3-4 were studied. All patients had an LV ejection fraction ≥50%. We performed echocardiography including speckle-tracking (STE) measurement of LV GLS and LV GCS and as well as assessment of diastolic function.

RESULTS

Despite preserved LVEF, impaired LV GLS (<18%) was observed in all patients. The mean value of GLS was 14,1 ± 1,5. This finding indicates that systolic dysfunction in CKD started from compromise LV longitudinal function. However, the GCS parameter was in the normal range – 22,7 ± 1,8. Thereby preserved LVEF was compensated by normal or slightly increase circumferential strain. Impaired diastolic function was observed in 18% of patients including 8% patients with increased left ventricle filling pressure (stage II-III).

CONCLUSION

The prevalence of impaired LV GLS despite preserved LVEF in patients with CKD stage 3-4 is high, which proved that renal disease is associated with early and subclinical impairment of LV systolic function. Impaired diastolic function was not so common among them. Assessment of it is not always so easy and reliable using current recommendation. Thus, STE can be recommended for early detection impairment of LV function.
P334 Heart model method: could it be a new echocardiographic gold-standard for the assessment of the left ventricular systolic function in a population under chemotherapy treatment?
Authors: Molinero D , Cabeza P , Hernandez N , Silva E , Delgado W
Published: January 2020

Background

Echocardiographic assessment of the left ventricular systolic function is essential in diagnosis and during the follow up of cardiovascular diseases. Although subjective visual approach method is easily applied, quantitative systems give more objective information about systolic function analyses. The purpose of this study is to evaluate the different quantitative methods of estimating systolic function basal in non-invasive techniques

Methods

We used a group of 40 patients, prospectively collected, under chemotherapy treatment with preserved systolic function. Same echocardiography device (Philips EPIQ-7) has been used in all studies (acquiring apical 4 and 2 chambers and 3 D of apical volume by an experimented operator). We compare three standard methods with impact in the literature (Speckle tracking and 3D Heartmodel system) to the echocardiographic gold-standard (Simpson’s biplane method). The Bland-Altman method has been used for the graphic comparison of the values of the resulting measures while the statistical comparison was made by a T-student method.

Results

Three quantitative methods were used to compare left ventricular systolic function assessment (Heart Model 3D (60.4% ± 5.2%), Strain (60.50% ± 7.1%), global longitudinal strain (-19.7 ± 3.15%) to Simpson’s biplane (mean 62.10% ± 5.75%). Values of differential means (2.73 with Heart model 3D and 2.08 with Strain) compared to Simpson’s biplane were translated to a Bland-Altman plot and means were compared with a T-student method. A statistically significant difference was found in case of the Heartmodel method compared with Simpson’s biplane (p < 0.05), though it does not imply any clinical difference. Less time consuming and better segmentation of the cardiac cavities in just one beat with the 3D-Heart Model technique was a magnificent point compared to the Strain method that needed a postprocessing modification

Conclusions

Heartmodel method is probably the most time-saving and with a good accuracy of left ventricular systolic function assesment and it is not inferior compared to the echocardiographic gold-standard Simpson’s biplane method.

Abstract P334 Figure 1. Bland-Altman analysis
P337 Edge-to-edge mitral valve repair in patients with secondary mitral regurgitation: impact of tethering pattern on clinical, echocardiographic and procedure-related characteristics
Authors: Oneto Fernandez M J , Ruiz Ortiz M , Delgado Ortega M , Rodriguez Almodovar A M , Gonzalez Manzanares R , Pericet Rodriguez C , Fernandez Ruiz A , Luque Moreno A , Paredes Hurtado N I , Romero Moreno M A , Ojeda Pineda S , Suarez De Lezo Herreros De Tejada J , Lopez Granados A J , Pan Alvarez-Ossorio M , Mesa Rubio D
Published: January 2020

Edge-to-edge mitral valve repair (E2E-MVR) has emerged as a therapeutical option in patients with secondary mitral regurgitation (SMR). Two tethering patterns (TP) have been described in SMR: symmetric and asymmetric. However, information on the implications of these TP on E2E-MVR is limited.

Our aim was to assess the impact of mitral valve TP on clinical, echocardiographic and procedure-related characteristics in patients undergoing E2E-MVR.

We consecutively recruited 62 patients with at least moderate SMR who underwent E2E-MVR in our center between 2011 and 2019 and analysed clinical, echocardiographic and procedure-related characteristics according to TP, which we classified into symmetric and asymmetric considering jet direction and mitral valve leaflet position during systole by means of two-dimensional transesophageal echocardiography (Figure 1).

In our series, 43 patients (69.3%) had symmetric TP and 19 (30.7%) had asymmetric TP. Asymmetric TP was associated with ischemic aetiology (52.6% vs 23.3%, p = 0.02) and a non-significant trend to higher frequency of male sex (89.5% vs 67.4%, p = 0.07), diabetes mellitus (52.6% vs 27.9%, p = 0.06), massive regurgitation (78.9% vs 58.1%, p = 0.11) and higher values of left ventricular ejection fraction (LVEF) (34 ± 9% vs 28 ± 11%, p = 0.06).

There were no differences in procedure-related characteristic between groups, in particular in number of devices (1.63 [IQR 1-2] vs 1.52 [IQR 1-2], p = 0.27), number of graspings (3.21 [IQR 2-4] vs 2.78 [IQR 2-3], p = 0.16) and time of procedure (95 ± 38min vs 107 ± 43min, p = 0.29). Procedural success (defined as SMR severity reduction≥2) was high in both groups (89.5% vs 74.4%, p = 0.18).

At discharge, there was a significant reduction in effective regurgitant orifice area (EROA) in (0.36 ± 0.16cm² vs 0.15 ± 0.10cm², p < 0.001) and pulmonary artery systolic pressure (PASP) (46 ± 12mmHg vs 40 ± 12mmHg, p = 0.004). LVEF was impaired in patients with asymmetric TP but not in patients with symmetric TP (difference in LVEF after procedure: -5 ± 9% vs -0 ± 8%, p = 0.03).

In our study, asymmetric TP was related to the ischemic aetiology of left ventricular dysfunction. Procedural characteristics, and EROA and PASP reductions at discharge were similar regardless of TP. However, patients with asymmetric TP had a significantly impairment in LVEF, probably because of afterload mismatch phenomenon.

Abstract P337 Figure 1: example of tethering patterns
P341 Prognostic value of pulmonary congestion assessed by lung ultrasound to predict decompensation in heart failure patients
Authors: Bidaut A , Hubert A , Donal E
Published: January 2020

INTRODUCTION : Lung ultrasound (LUS) evaluation of B lines is a valid tool for the assessment of pulmonary congestion in heart failure (HF) patients. The aim of this study was to evaluate the prognosis of HF patients presenting with B lines, with a primary endpoint of rehospitalization for heart failure and/or death at one year.

METHOD : 93 patients presenting with significant dyspnea (NYHA ≥ 2) underwent an initial analysis of LUS for B-lines, complete TTE, and were propectively followed up for one year.

RESULTS : Data on follow up was obtained for 88 patients. 8 patients presented with HF, and 5 patients died. ROC analysis showed an optimal cutoff of B-lines at 6. Kaplan Meier curves showed a significant difference in rehospitalization for heart failure at 1 year (p = 0,047 for B-lines ≥ 6). There was no significant difference for death. Patients with ≥ 6 B-lines had an OR at 13,7 for HF rehospitalization at 1 year (IC95% , p = 0,017).

CONCLUSION : B-lines assessment by LUS identifies patients more likely to be admitted for decompensated HF in the following year. This tool should be considered in a multi-parametric approach in patients with heart failure to optimize treatment and follow up.

Baseline characteristics Rehospitalization for HF n = 8 No rehospitalization for HF n = 80 p value Age 75,5 +/-8 71,9 +/-9,7 0,325 BMI 23,6 +/- 2,1 26,8 +/- 5,4 0,005 HF history 8 (100%) 35 (43,8%) <0,001 Significant valvulopathy 8 (100%) 45 (56,3%) <0,001 Renal insufficiency 5 (62,5%) 19 (23,8%) 0,019 NYHA ≥3 7 (87,5%) 17 (21,3%) <0,001 Total B-lines 16,1 +/- 9,5 6,8 +/- 9,7 0,012 B-lines ≥ 6 7 (87,5%) 27 (33,8%) 0,003 LVEF 39,3 +/- 11,7 48,5 +/- 15,5 0,109 GLS -9,4 +/- 3,2 -13,3 +/- 5,5 0,018 Mitral S average 4,5 +/- 1,1 6,1 +/- 1,8 0,017 E/A ratio 3 +/- 1,8 1,2 +/- 0,84 0,05 Peak TR velocity (m/s) 3 +/- 0,47 2,5 +/- 0,5 0,018 PASP (mmhg) 52,6 +/- 16 35,8 +/- 14 0,002 HF : heart failure, BMI : body mass index, NYHA : new york heart association, LVEF : left ventricule ejection fraction, GLS : global longitudinal strain, TR : tricuspid regurgitation, PASP : pulmonary artery systolic pressure

Abstract P341 Figure. Kaplan Meier survival curve
P349 Utility and prognostic value of aortic valve area by magnetic resonance imaging in patients with aortic stenosis
Authors: Igual Munoz B , Oscar Blanco Herrera O B H , Francisco Jose Valera Martinez F J V M , Diana Domingo Valero D D V , Pilar Sepulveda Sanchez P S S , Anastasio Montero Argudo A M A , Laura Higueras Ortega L H O , Jose Leandro Perez Bosca J L P B , Alberto Berenguer Jofesa A B J , Rafael Paya Serrano R P S
Published: January 2020

Classically clinical evaluation of patients with aortic stenosis (AS) is made using clinical and echocardiographic parameters but recently new imaging techniques as cardiovascular magnetic resonance (CMR ) are being used increasingly in this clinical setting. We aim to assess utility and prognostic value of aortic valve area (AVA) by CMR in patients with AS regarding echocardiographic data.

METHODS

a retrospective cohort of patients with AS referred to CMR and cardiac echocardiography study for evaluation were included. Patients with known coronary artery disease or another significant valve disease were excluded. Clinical Follow up was performed to asses cardiovascular death, hospital admission or aortic valve replacement at the first year after imaging evaluation. Furthermore symptomatic status was assessed. Echocardiographic severity was estimated used peak and mean gradients . Additionally a CMR study including b-SSFPS for left ventricle ejection fraction (LVEF) quantification and phase-contrast sequences acquired at aortic valve plane to analyze aortic valve area (AVA) by planimetry was performed.

RESULTS

ninety eight patients, mean age 67+ 15 years, 52(58%) males, 23 (25%) with decreased left ventricular ejection fraction. A significant negative correlation was observed between AVA by CMR and echocardiographic gradients ( -0.49 for mean gradient and -0.58 for peak gradient). AVA was strongly associated to symptomatic status (AUROC curve 0.66, p < 0.001). A multivariate logistic regression model including echocardiographic gradients,CMR, LVEF and AVA was performed and mean gradient

( OR:1.02 p = 0.01) and AVA (OR: 0.002 p = 0.001) were shown to be independent predictors of events.

Conclusion

1.AVA by planimetry in phase-contrast CMR sequences is a valid tool to asses severity of aortic valve stenosis . 2 AVA was strongly associated to symptomatic status.3. AVA has proven to have additional prognostic value beyond echocardiographic gradients.

Abstract P349 Figure. Aortic valve area by planimetry by MR
P368 Ross procedure: homograft deterioration, clinical outcomes and predictors after 21 years follow up. A single center experience
Authors: Fernandez Ruiz A , Pardo Gonzalez L , Pericet Rodriguez C , Gonzalez Manzanares R , Ruiz Ortiz M , Delgado Ortega M , Rodriguez Amodovar A , Carnero Montoro L , Luque Moreno A , Oneto Fernandez M J , Paredes Hurtado N , Villalba Montoro R , Merino Cejas C , Pan Alvarez-Ossorio M , Mesa Rubio D
Published: January 2020

Background and purpose

Pulmonary homograft stenosis can appear in long-term follow-up after Ross

intervention. Our aim was to describe the incidence, clinical impact and predictors of homograft stenosis and reintervention after the Ross procedure in a prospective series in a tertiary referral hospital after 21 years followup.

Methods

From 1997 to 2009, 107 patients underwent the Ross procedure (mean age: 30 ± 11 years; 69% men; 21 aged <18 years). In all of them, a comprehensive clinical and echocardiographic evaluation was performed before the intervention and at discharge, at 6, 12 months and annually after surgery. We analyzed echocardiographic homograft stenosis (peak gradient > 36 mmHg) and surgical or percutaneous homograft reintervention.

Results

At the end of follow-up (21 years, median: 17 years, interquartile rank 12-19 years), echocardiographic and clinical data were available in 95 (89%) and 105 (98%) patients, respectively: 28/95 (29%) patients developed homograft stenosis and 13/105 (12%) patients underwent diferent homograft reintervention procedures (five patients underwent surgical replacement, four received a percutaneous pulmonary valve and one needed stent implantation). The other three patients underwent two or even three consecutive procedures in follow-up; two died because of complications after percutaneous pulmonary valve implantation and other one after surgical replacement. Rates of survival free from homograft stenosis and reintervention at the end of the follow-up were 71% and 88%, respectively. Younger age, and especially being part of paediatric group (<18 years) at surgical

time predicted worse survival free from homograft stenosis (hazard ratio [HR] 3.88, 95% confidence interval [CI]: 1.78-8,43; p = 0.001), although there were no significant differences regarding reintervention (HR 1.54, [CI] 95% 0.42-5.58, p = 0.52). We found no significant association of this outcome with previous cardiac surgery, donor age, donor or recipient sex, homograft size, time of freezing or congenital aetiology.

Conclusions

After 21 years follow-up, incidence of homograft stenosis and reintervention after the Ross procedure were 29% and 12%, respectively; three patients had a reintervention-related death. Younger recipient age at Ross procedure was associated with a higher rate of stenosis.
423 Effects of mitral valve repair on left ventricular remodeling and ventricular arrhythmia in mitral valve prolapse patients: five-year follow-up
Authors: Malev E , Omelchenko M , Mitrofanova L , Gordeev M , Bondarenko B , Reeva S , Timofeev E
Published: January 2020

Introduction

There is limited data on the efficacy of surgical repair in reducing ventricular arrhythmia (VA) in mitral valve prolapse (MVP) patients. Improvement in malignant ventricular arrhythmias has been reported only in isolated cases after mitral valve surgery. Our aim was to evaluate the possible effects of mitral valve repair on left ventricular (LV) reverse remodeling and incidence of VA in MVP patients in mid-term follow-up.

Methods

30 consecutive patients (mean age 53.1 ± 9.4, 47% male) undergoing mitral valve repair for severe mitral regurgitation (MR) due to mitral valve prolapse were enrolled in our observational, prospective, single-center study. Resected abnormal segments of the mitral leaflets were examined by experienced pathologists for signs of myxomatous degeneration. Transthoracic echocardiography extended with speckle-tracking echocardiography and 24-hour Holter monitoring were performed pre- and postoperatively annually. Atrial fibrillation, PVCs and nonsustained ventricular tachycardia (VT) runs were reviewed.

Results

During 144 person-years of follow-up no deaths, and 3 cases (10%) of recurrent moderate or severe (≥2) MR occurred. The total number of PVCs and non-sustained ventricular tachycardia runs dropped significantly in 1st (p=.04, Wilcoxon matched pairs test) and 2nd (p=.03), years of postoperative follow-up. Postoperative incidence of PVC and VT correlates strongly with postoperative end-diastolic LV diameter (EDD rs=.70; p=.005), moderate negatively with LV ejection fraction (EF rs=-.55; p=.01), but not postoperative MR (p>.05). EDD (58.8 ± 7.6 mm vs. 49.9 ± 5.6 mm; p=.00001) and EDV (156.6 ± 32.1 ml vs. 104.1 ± 22.8 ml; p=.00001) decreased in 1st year after repair with non-significant changes in EF (63.8 ± 12.8% vs. 59.6 ± 14.5%; p=.20), global systolic longitudinal strain –13.8 ± 2.5% vs. –14.6 ± 2.7%; p=.20) and SR (–0.93 ± 0.12 s-1 vs. –0.98 ± 0.13 s-1; p=.09) values.

In univariate analysis, postoperative end-diastolic LV diameter (p=.001), low EF (p=.003), myxomatous degeneration (p=.008) were identified as risk factors of persistent PVCs/VT after surgery.

Conclusions

Mitral valve repair in MVP with severe mitral regurgitation is associated with reduction in ventricular arrhythmia, which strongly correlates with postoperative LV dimensions and function. Further investigation in larger cohorts to evaluate the association between degenerative mitral valve disease and ventricular arrhythmia is needed.
502 Secondary cardiac lymphoma complicated with tamponade
Authors: Lee P H
Published: January 2020

Introduction

A 72-year-old lady presented with one-week history of palpitation and shortness of breath. She had pyrexia of unknown origin for 4 weeks associated with weight loss. Initial clinical examination revealed sinus tachycardia of 110 beats/min and saturations of 96% on 2L/min oxygen. Neck exam revealed a 2 x 3 cm firm mass at left supraclavicular fossa. Electrocardiogram showed sinus tachycardia at 106 beats/min. There was fixed T wave inversions over anterolateral chest leads and inferior limb leads. Chest radiograph showed enlarged cardiac silhouette and evidence of pulmonary congestion

Procedure

Transthoracic echocardiogram revealed a moderate pericardial effusion with an 8 x 4 cm pericardial mass compressing at the right atrioventricular groove (Figure B & C). Respiratory variation of Doppler mitral and tricuspid inflow velocities suggested cardiac tamponade (Figure A). Inferior vena cava was engorged with impaired inspiratory collapse. Left ventricular size and function were otherwise normal. Urgent pericardiocentesis was performed which yielded 1 litre of light blood stained fluid. Her had subjective improvement of symptoms. There was also resolution of sinus tachycardia and pulmonary congestion. PET/CT scan showed multiple enlarged hypermetabolic lymph nodes in multiple regions above and below the diaphragm, worrisome for malignant lymphoma. Cytological assessment of pericardial fluid showed scattered large lymphoid cells which are immunoreactive to B cell marker CD 20 (Figure E & F). Bone marrow exam showed normal marrow.

First cycle of R-CEOP and intrathecal methotrexate was given. Follow-up echocardiogram in one week after chemotherapy showed complete resolution of pericardial effusion. Prior pericardial mass also showed marked reduction in size (Figure D). No tamponade physiology was present. She tolerated the chemotherapy well with complete resolution of palpitation and shortness of breath. She was discharged from hospital with outpatient follow up and continuation of chemotherapy course.

Discussion

Cardiac tumors are rare and secondary tumors remain the most common etiology. Most of these metastatic tumors arise from solid organs such as lung, breast, kidney, melanoma as well as lymphoma. Echocardiography is a valuable tool both in diagnosis and assessment of hemodynamic significance of cardiac masses. It also aids in diagnosis of associated condition such as pericardial effusion.

In this case, the cardiac tamponade is both contributed by mechanical compression of cardiac mass coupled with moderate pericardial effusion. Successful pericardiocentesis achieved temporary normalization of tamponade physiology and aided in early histological diagnosis of malignant lymphoma with pericardial metastasis. Timely initiation of intensive systemic chemotherapy was the key to rapid tumor size reduction, complete resolution of tamponade physiology and control of recurrent pericardial effusion.

Abstract 502 Figure. Echo & histology
559 An analysis of myocardial efficiency in patients with severe asymptomatic mitral regurgitation
Authors: Cetin Guvenc R , Arugaslan E , Guvenc T S , Ozpamuk Karadeniz F , Kasikcioglu H , Cam N
Published: January 2020

Funding Acknowledgements

None declared.

Background and Aims

It is difficult to determine left ventricular systolic performance in patients with severe mitral regurgitation (MR) since left ventricular ejection fraction (EF) could be preserved until the end stages of the disease. Myocardial efficiency describes the amount of external work (EW) done by the left ventricle per unit of oxygen consumed (mVO2). In the present study, we aimed to investigate MEf in patients with asymptomatic severe MR using a novel echocardiographic method. Methods: A total of 27 patients with severe asymptomatic MR and 26 healthy volunteers were included in this cross-sectional study. EW was measured using stroke volume and blood pressure, while mVO2 was estimated using double product and LV mass. Results: There were no differences between the groups with regards to EF (66%±5% vs. 69%±7%), while MEf was significantly reduced in patients with severe MR (25%±11% vs. 44%±12%, p < 0.001) (Table 1). This difference was maintained even after adjustment for age, gender and body surface area (adjusted :0.44, 95%CI: 0.39–0.49 for controls and adjusted :0.24, 95%CI: 0.19–0.29 for patients with severe MR). Further analysis showed that this reduction was due to an increase in total mVO2 in the severe MR group (Figure 1). Conclusions: Myocardial efficiency was significantly lower in patients with asymptomatic severe MR and preserved EF.

Table 1 Parameter Control Group (n = 26) Severe Mitral Regurgitation (n = 27) P Value Age (y) 36.5 ± 8.9 41.3 ± 14.2 0.23 Gender (%Male) 9 (35%) 10 (37%) 1.0 BSA (m2) 1.82 ± 0.20 1.76 ± 0.18 0.64 LV End-Diastolic Volume (ml) 83.13 ± 18.88 121.91 ± 37.63 <0.001 LV End-Systolic Volume (ml) 28.07 ± 9.57 45.30 ± 17.42 <0.001 Left Ventricular Ejection Fraction (%) 0.69 ± 0.07 0.66 ± 0.05 0.29 Systolic Mitral Velocity (cm/s) 7.88 ± 1.14 8.07 ± 1.81 0.66 Stroke Work (j) 1.14 ± 0.21 1.15 ± 0.36 0.91 Minute External Work (j) 65.96 ± 14.71 70.17 ± 23.15 0.85 mVO2 (ml.min-1.100g-1) 6.79 ± 1.93 9.48 ± 4.71 0.02 Total mVO2 (j) 166.58 ± 77.14 346.46 ± 202.71 <0.001 Myocardial Efficiency (%) 44 ± 12 25 ± 11 <0.001 Table 1. Demographic, anthropometric, echocardiographic and mechanoenergetic data for study groups. BSA, body surface area; LV, left ventricle; mVO2, myocardial oxygen consumption.

Abstract 559 Figure 1
P630 Recovery of non-bacterial thrombotic endocarditis and severe aortic regurgitation in a young patient with acute promyelocytic leukemia
Authors: Kuffer L , Koerber M I , Nettersheim F , Tichelbaecker T , Hohmann C , Schaetzle A K , Kabbasch K , Borrega J G , Boell B , Kohle F , Warnke C , Baldus S , Ten Freyhaus H
Published: January 2020

Introduction

Non-bacterial thrombotic endocarditis (NBTE) is characterised by non-infectious vegetations on the cardiac valves and is typically seen in patients with malignancies or systemic lupus erythematosus. Risk of thromboembolic events is high and treatment of choice consists of anticoagulation, if feasible, as well as treatment of the underlying disease. Severe valvular dysfunction is rarely seen and in these cases, surgical valve replacement is usually performed.

Case presentation

A 28-year old female patient presented with left-sided hemiparesis persisting for several hours. Angio-CT scan of the brain revealed a branch occlusion of the middle cerebral artery with a correlating infarct core and without an area of penumbra. Blood tests showed decreased thrombocyte levels (45 x109/l). Given the thrombocytopenia and the time between the onset of symptoms and presentation, no thrombolysis was administered.

A subsequently performed transoesophageal echocardiography for diagnostic work-up of cardioembolic sources of stroke revealed a right ventricular thrombus and vegetations on the aortic valve causing severe aortic regurgitation with a holodiastolic flow reversal in the descending aorta (Fig. 1 (a) and (b) showing a large central coaptation defect). There were no of signs of infection or inflammation and blood cultures remained negative, thus infectious endocarditis was unlikely. A bone marrow biopsy led to the diagnosis of acute promyeolocytic leukemia (PML). Despite the inherent high risk of bleeding due to PML, anticoagulation with unfractionated heparin was initiated and treatment with prednisolone, all-trans retinoic acid and arsenic trioxide was started. After three weeks of therapy aortic valve vegetation size decreased considerably leading to dramatic reduction of aortic regurgitation (Fig. 1 (c) and (d)). No further embolic event or bleeding occurred.

Conclusion

This case is remarkable in many aspects. First, PML typically causes bleeding complications whereas NBTE is characterised by a high risk of thromboembolic events. Thus, the decision to start or not to start anticoagulation is challenging.

Second, NBTE, unlike infectious endocarditis, rarely causes severe valvular dysfunction and reported treatment in most cases consisted of surgical valve replacement or repair. However, in this case, conservative treatment alone led to almost complete resolution of valvular vegetations and of aortic regurgitation.

We conclude that conservative treatment of severe valvular disease in the setting of NBTE should be strongly considered, especially given the small number of cases reported worldwide.

Abstract P630 Figure. Fig.1
P631 A misleading EKG and the saviour echo
Authors: Miranda H , Santos H , Almeida I , Sousa C , Chin J , Almeida S , Santos M , Santos L , Tavares J
Published: January 2020

Introduction

Floating right heart thrombi (in transit from the legs to the pulmonary arteries) are a severe form of venous thromboembolism, with a high early mortality rate without treatment. Evidence-based recommendations do not adequately address the treatment of right heart thrombi in patients who present with acute symptomatic pulmonary embolism.

Case Report

Woman, 76 years old. Previous medical history of hypertension, dyslipidaemia, mitral valve repair and hypothyroidism. Recent admission in our cardiology department with de diagnosis of NSTEMI. She performed an echocardiogram that revealed only an enlarged left atrium, with no other changes. EKG only revealed inversion of T waves in V2-V4 with posterior normalization during hospital stay. She underwent to coronary angiography and right dominance without any coronary lesions was showed. The presence of a fistula, with a badly defined route, was also pointed in the coronary angio.

One month after this episode she was admitted again in our emergency department due to onset of dyspnoea and productive cough. The physical examination showed SatO2: 90%; BP: 95/53 mmHg; HR: 100 bpm; Respiratory rate: 27 cpm; Apyretic (36,9ºC). Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination. EKG revealed a sinus tachycardia, HR 122 bpm, with ST elevation in aVR and ST depression in DI, DII, aVL and V2-V6. Presence of S wave in DI and Q wave in DIII. While the EKG was being performed the patient presented a sudden cardiovascular deterioration (with blood pressure (BP: 67/35mmHg) drop and appearance of chest pain). We performed an arterial-blood gas test that revealed: pH7,16; pCO2 26,5; pO78,7; Potassium 4; Sodium 138; lactates 8,8. With these findings we decided to perform an echocardiogram to identify a possible cause for the shock. The echo showed right dilated chambers (with D-shape in parasternal short axis) with dilated IVC. We also point out the presence of a mobile intra-cardiac mass at the level of right atrium, suggestive of thrombus.

We assumed the presence of obstructive shock in the context of pulmonary embolism. Thrombolysis was performed with clinical improvement of the patient. Medical therapy was optimized and heparin was initiated after the patient finished alteplase perfusion.

During hospital stay the patients didn’t have any other cardiovascular complication and went home after 7 days in hospital. A venous doppler was performed before hospital discharge and it revealed the presence of a deep venous thrombosis at the level of right femoral vein.

Conclusion

The authors presented a didactic clinical case where the EKG mislead us to a possible Acute Coronary Syndrome involving the left main artery. Although there is no clear consensus for the management of right heart thrombus associated with pulmonary embolism, thrombolysis is readily available and can be effective in carefully selected patients.
P686 Right atrial, right ventricular and pulmonary cement embolism: a rare complication of percutaneous vertebroplasty
Authors: Akhunova S , Khayrullin R , Stekolshchikova N , Samigullin M , Padiryakov V
Published: January 2020

A 68-year-old man was admitted to the hospital with complaints of pain in the lumbar spine. He had L5 disc herniation, Spinal stenosis of the L5 root canal - S1 on the right in the past medical history. Percutaneous vertebroplasty at the level of L3 and Th8 vertebral bodies was performed six months ago due to painful vertebral hemangioma. The man is suffering from arterial hypertension, receives antihypertensive therapy.

During routine transthoracic echocardiography, a hyperechoic structure with a size of 9.5 x 0.9 cm was found in the right atrium and right ventricle. Chest computed tomography with contrast enhancement revealed signs of bone cement in the right atrium and right ventricle, in the right upper lobe artery, in the branches of the upper lobe artery, in the paravertebral venous plexuses.

Considering the duration of the disease, the stable condition, the absence of clinical manifestations and disorders of intracardiac hemodynamics, it was decided to refrain from surgical treatment. Antiplatelet therapy and dynamic observation were recommended.

Conclusion

Percutaneous vertebroplasty is a modern minimally invasive surgical procedure for the treatment of degenerative-dystrophic diseases of the spine. However, the cement can penetrate into the paravertebral veins and migrate to the right chambers of the heart and the pulmonary artery. This clinical case demonstrates asymptomatic cement embolism of the right chambers of the heart and pulmonary artery after percutaneous vertebroplasty, detected incidentally during routine echocardiography.

Abstract P686 Figure.
P696 The role of three dimensional echocardiography in a case of recurrent infundibular pulmonary stenosis in a surgically corrected tetralogy of fallot
Authors: Hussien A , Abdelgawad H , Almaghraby A , Abdelnabi M , Abdelhay M A
Published: January 2020

Background

Tetralogy of Fallot (TOF) represents approximately 7%-10% of congenital heart diseases (CHDs), and it is the most common cyanotic CHD, with 0.23-0.63 cases per 1,000 births. In our case report we are reviewing the added value of three dimensional echocardiography in the assessment of degree of infundibular and valvular stenosis in tetralogy of Fallot.

Case report

A 29-year-old female patient with history of congenital heart disease (Fallot’s tetrology) and history of total surgical correction at the age of 10 presented to our facility by dyspnea grade III that started 1 month before presentation .On examination; an ejection systolic murmur was heard over the pulmonary area with palpable thrill. Electrocardiogram (ECG) revealed normal sinus rhythm with a heart rate of 75bpm with right axis deviation and right ventricular hypertrophy voltage criteria.

Transthoracic two dimensional echocardiography revealed increased thickness of the right ventricle (RV) free wall , and aliasing of the color Doppler flow across the right ventricular outflow tract (RVOT) with a peak systolic gradient across the RVOT 69mmHg .

By performing three dimensional transesophageal echocardiography we were able to demonstrate the RVOT narrowing in RVOT enface view and by using specific software we were able to demonstrate the morphology of the pulmonary valve and the pulmonary valve orifice area and we found that the pulmonary valve is a bicuspid valve as shown and the pulmonary valve orifice area was 3.8cm2 signifying the absence of significant valvular stenosis.

Conclusion

3D echocardiography in adult congenital heart disease provides unique projections from the living complex anatomy (such as en face views) and true volumetric quantification without geometric assumptions

Abstract P696 Figure. Infundibular stenosis
P699 Atrial septum tearing due to balloon sizing in percutaneous closure of ASD
Authors: Alak C , Ozpelit E , Cirgamis D , Badak O , Goldeli O
Published: January 2020

INTRODUCTION

Percutanous closure of atrial septal defect (ASD) has become an accepted ,reliable procedure and alternative to surgical treatment.Various complications associated with this procedure have been identified but tear of atrial septal rim is a very rare complication.We report a case of atrial septal rim tear due to balloon sizing and diagnosed at the same time by transesophageal echocardiography (TEE).

CASE

A 64-year-old female patient was admitted to our clinic with dyspnea.Transthoracic echocardiography (TTE) was performed.Ejection fraction was %60 .Moderate tricuspit regurgitation was observed and pulmonary artery pressure was 45 mmHg. TTE revealed a left to right shunt and TEE was planned.2D and 3D-TEE was performed.Two separate secundum type ASD were observed and diameters of defects were measured as 15 mm and 14 mm.Measurement of rim between two defects was 7 mm.(Figure 1 A-B-C) It was observed that the aortic rim was absent but the other rims were sufficient for percutaneous closure.Percutaneous closure was planned .Balloon sizing with a 34-mm AGA balloon resulted in a stretched defect diameter of 26 mm using the stop-flow technique.After the measurement of ASD with sizing balloon flail structure was observed in atrial septal rim.We evaluate this image from various echocardiographic window and we diagnosed the atrial septal rupture. (Figure 1-E ) The patient was hemodynamically stable during the intervention and the atrial septal rupture diameter did not increase. Therefore it was decided to continue the process.ASD diameter was measured again after the rupture of the atrial septum and it was measured 26 mm by TEE and sizing balloon. A 28-mm Amplatzer septal occluder (ASO) was selected.In the same session 28 mm ASO device was successfully placed in the defect.In the TEE examination, it was found that the device was in correct place, there was no shunt from left to right and the torn was between the two discs of the device.(Figure 1-F) The procedure was successfully completed without complications.

DISCUSSION

Rupture of the interatrial septum or rim during percutaneous ASD closure is a very rare complication. Possible causes of rupture in the interatrial septum when using sizing balloon may be the manipulation of the sizing balloon, passing the guide wire through a small atrial septum fenestration , and the over-stretching of the sizing balloon.There are very rare case reports in the literature about this subject. The rupture of the atrial septum can be enlarged, and therefore surgical treatment has to be performed in these cases in the literature.

CONCLUSION

In this case, we tried to present the rupture of the interatrial septum, which is a rare complication that may develop when using sizing balloon, and successful percutaneous closure of ASD in the same session.

Abstract P699 Figure.
P706 LMCA and LAD coronary ectasia in an asymptomatic young patient reassessment with multimodality imaging after 17 years
Authors: Ayduk E , Karaca Ozer P , Dursun M , Umman S , Toktas Y C , Bugra Z
Published: January 2020

A 25 years old male patient was referred to an advanced center because of 2/6-degree systolo-diastolic murmur heard at meso-cardiac area during his pre-military routine examination. ECG revealed T wave inversions at standard D1 to D3 and precordial V1 to V4 leads, treadmill was non-diagnostic for ischemia.

In his transthoracic echocardiogram, measurement of heart chambers and wall thicknesses were within normal range with normal wall motion of the left ventricle, EF was 55%. 2D and color-Doppler echocardiography revealed a cystic structure with venous flow in it at the right ventricular apex, and created a suspicion of a fistula. Myocardial perfusion scintigraphy showed ischemia at the apical sections of the septal wall. He underwent coronary angiography, LMCA and proximal LAD were ectatic, LAD ectasia was in consistent with the first septal branch, circumflex (Cx) and right coronary artery (RCA) angiograms were normal. LAD flow was examined and no fistula was detected. Right and left ventriculography revealed normal ventricular functions, oxygen saturations were 70.9% in pulmonary artery, 70.4% in right ventricle, 72.9% in right atrium, and 97.4% in the aorta. Pulmonary capillary wedge pressure was 10 mmHg, pulmonary artery pressure 10/26/5 mmHg, right ventricular pressure 13/6 mmHg, left ventricular pressure 120/0/8 mmHg. Further investigations for etiology and congenital malformations were planned and the patient was discharged with oral anticoagulant therapy.

The patient had no contact with the outpatient clinic for 17 years. At the 17th year of the diagnosis he was called and reevaluated. He was still asymptomatic and oscultation findings were the same. Transthoracic 2D and 3D and color-Doppler echocardiography revealed the same cystic structure at the right ventricular apex, but this time with no-flow. Coronary CT angiography was performed, LMCA was ectatic and the diameter was 8.1 mm, proximal LAD was ectatic and the diameter was 6 mm, ectasia was in continuous with the first septal branch. The ectatic septal branch was at the apical level of the right ventricle, appearing like a cystic structure with a diameter of 2.8 cm, and the lack of contrast enhancement was thougt to be in consistent with thrombus formation. Cx and RCA artery calibrations were found to be normal. In order to confirm the diagnosis of thrombus formation, MR angiography was performed. Perfusion MRI showed no evidence of thrombus in the ectatic septal branch.

Abstract P706 Figure.
P752 Mitral regurgitation in patients with severe aortic stenosis: role of valvular calcification in the persistence of mitral regurgitation after aortic valve replacement
Authors: Squeri A , Ferri A , Calvi S , Albertini A , Censi S , Conti R , Barbieri A
Published: January 2020

Introduction

mitral regurgitation is often associated with severe aortic stenosis but the indications for its correction at the time of aortic valve surgery are still unclear. Despite the indication for mitral valve repair or replacement in the case of severe secondary mitral regurgitation, many patients are left untreated. This is due to the common belief that secondary mitral regurgitation mostly improves after the aortic valve is treated.

Purpose

the aim of the study is to investigate the prevalence and distribution of mitral calcifications, their role in the development of mitral regurgitation and in its reduction after aortic valve replacement.

Methods

we reviewed all patient’s records who underwent aortic valve replacement for aortic stenosis at our institution from 12/2014 to 12/2016. Pre and post-operative echocardiograms were reviewed by experienced echocardiographer. Patients were then divided into 4 categories (functional, mild, moderate and severe calcification) on the basis of the presence, distribuition and severity of calcification on the mitral apparatus.

Results

at the end 651 patients were collected and analyzed. Mean age was 74yo. 334 (51,4%) of them were males. Most patients (63,1%) had only mild mitral regurgitation but 147 (22,6%) of them had moderate or severe mitral regurgitation. The presences of moderate or severe calcification of the mitral apparatus resulted to be a risk factor for the presence of mitral regurgitation associated with aortic stenosis as shown in Table 1. After surgical aortic valve replacement less than 21% of the patients showed a reduction of the degree of mitral regurgitation. We found no statistical difference between groups about mitral regurgitation changes after aortic valve replacement.

Conclusions

Mitral regurgitation is a common finding in patients with severe aortic stenosis and it’s prevalence is higher in patients with mitral calcifications. Few patients, however showed a reduction in the degree of mitral regurgitation after surgical aortic valve replacement with no difference related to the severity of annular or leaflets calcifications.

TABLE 1 Logistic regression for the presence of mitral regurgitation Mitral Regurgitation Change after Aortic Valve Replacement CALCIFICATION DEGREE OR C.I. 95% p Reduced p Unchanged p Increased p Functional 53(21%) 176(71%) 18(7%) Mild 1.244571 0.81 - 1.93 0.32 28(20%) 0.86 105(76%) 0.43 6(4%) 0.34 Moderate 1.637297 1.05 - 2.56 0.03* 25(17%) 0.41 109(76%) 0.34 9(6%) 0.86 Severe 2.369245 1.46 - 3.85 <0.01* 29(25%) 0.48 78(68%) 0.67 7(6%) 0.86 OR= Odds Ratio; C.I.=Confidence Interval; Functional= no calcification; Mild, Moderate and Severe= degree of mitral annular and leaflets calcifications.
P798 Right atrial phasic function and correlation with right ventricular function in patients with reduced left ventricular ejection fraction and no pulmonary hypertension:insights from 3D echocardiography
Authors: Vijiiac A E , Muraru D , Jarjour F , Kupczynska K , Palermo C , Cecchetto A , Baritussio A , Aruta P , Dorobantu M , Badano L P
Published: January 2020

Background

The right atrium (RA) is a highly dynamic chamber with 3 mechanical functions (reservoir, conduit, booster pump) and prognostic implications in heart failure (HF) and pulmonary hypertension (PH). However, RA function and its interplay with the right ventricular (RV) performance in patients (pts) with reduced left ventricular ejection fraction (LVEF) and without PH remain to be clarified.

Methods

We used three-dimensional echocardiography to study 55 pts (61 ± 14 years, 43 men) with LVEF < 40% no more than mild tricuspid regurgitation (TR), and maximum velocity of the TR jet < 3 m/s. We measured the three-dimensional RA total, passive, active ejection volumes (EV) and the respective emptying fractions (EF). In addition, we compared RV volumes and ejection fraction (RVEF) between patients with normal and abnormal RA function.

Results

Mean LVEF was 30 ± 7%. Mean echo-derived pulmonary vascular resistance was 1.64 ± 0.54 Wood units. 28 pts (51%) had reduced RA reservoir function (total EF = 34 ± 9%), 34 pts (62%) had reduced RA conduit function (passive EF = 15 ± 4%), and 10 pts (18%) had reduced RA pump function (active EF = 11 ± 3%). Pts with reduced RA reservoir function showed larger RV end-systolic volume (RVESV 124 ± 48ml vs. 90 ± 32ml; p = 0.004) and lower RVEF (38 ± 8% vs. 46 ± 6%; p < 0.001) than pts with normal RA function. Pts with reduced RA conduit function showed smaller RV stroke volume (RVSV 65 ± 19 ml vs. 80 ± 22ml; p = 0.009). Pts with impaired RA pump function showed larger RVESV (142 ± 45ml vs. 99 ± 41ml; p = 0.02) and lower RVEF (36 ± 6% vs. 43 ± 8%; p = 0.006).

RVESV was positively correlated with total (r2 = 0.47, p < 0.001), passive (r2 = 0.29, p = 0.03) and active (r2 = 0.39, p = 0.003) RAEV, while it was negatively correlated with total (r2=-0.41, p = 0.002), passive (r2=-0.34, p = 0.01) and active (r2=-0.31, p = 0.02) RAEF. RVSV showed a positive correlation with both total (r2 = 0.4, p = 0.002) and passive (r2 = 0.41, p = 0.002) RAEV. Finally, RVEF was positively correlated with total (r2 = 0.51, p < 0.001), passive (r2 = 0.47, p < 0.001), and active (r2 = 0.36, p = 0.007) RAEF.

Conclusions

RA dysfunction is not uncommon in pts with reduced LVEF, even in the absence of PH. In these pts, RA function is associated with significant changes in RV function. The RA acts as a dynamic modulator of RV pump function by redistributing RV filling and ejection force among reservoir, conduit and pump functions in the setting of altered hemodynamics. The clinical and prognostic significance of RA function in pts with reduced LVEF warrant further studies.
P801 A virtual reality tool for measurement of 3D echocardiographic images
Authors: Wheeler G , Deng S , Pushparajah K , Schnabel J A , Simpson J M , Gomez A
Published: January 2020

Funding Acknowledgements

Work supported by the NIHR i4i funded 3D Heart project [II-LA-0716-20001]

Background/Introduction

Cardiac measurements are clinically important and are invariably required in any clinical imaging software. The advent of Virtual Reality (VR) imaging systems is introducing intuitive and natural ways of visualising and interrogating echo images in a 3D environment. The 3D nature of the VR experience requires purpose-designed measurement tools, which may benefit from better depth perception and easier localisation of 3D landmarks.

Purpose

Comparison of the accuracy of our VR 3D linear measurement system to commercial clinical imaging software, using both multi-plane reformatting (MPR) and volume rendered views.

Method

Each virtual reality measurement was made by selecting two points in 3D, directly in the volume rendering. The participants could edit the measurements until satisfied with their accuracy. 5 expert clinicians carried out 26 measurements each - 6 measurements on a calibration phantom, and 5 anatomically meaningful measurements (for example: aortic valve, left atrium, left ventricle) on 4 datasets. The same measurements were made by all participants using our VR system (volume rendering), Philips" QLAB (MPR) and Tomtec (volume rendering). The frame number and view (for example: long axis) were consistent for each measurement across the 3 packages used.

Results

Preliminary results are shown in the figure below. MPR measurements made on Philips’ QLAB are used as a reference, as this is the most commonly used software for this purpose at our institution. We compare measurements made in Tomtec and VR, both using volume rendering, using Bland-Altman plots. Each measurement data point is the mean of all participants measurements for each dataset/measurement combination. The mean of the measurement differences for the VR system is closer to zero, compared to Tomtec. However, the variation of these differences is larger for the VR system than for Tomtec.

Conclusion

Our preliminary results suggest that the accuracy of line measurements made using volume rendering within a VR system is comparable to measurements made using approved software packages for volume rendering displayed on a 2D screen. This shows promise for more complex interrogation methods.

Abstract P801 Figure. Comparison of Tomtec and VR with QLAB