bluuebunny/crossref_metadata_2025 huggingface dataset:
C73 COVID–19 DIAGNOSIS AND MORTALITY IN PATIENTS WITH ACUTE MYOCARDIAL INFARCTION ADMITTED IN ITALY DURING THE NATIONAL OUTBREAK
Authors: D’Errigo P , De Luca L , Rosato S , Giordani B , Cuomo M , Duranti G , Mureddu G , Tavilla A , Badoni G , Seccareccia F , Baglio G
Published: May 2023

Background

and objective: There are limited data on the clinical impact of Covid–19 in patients with acute myocardial infarction (AMI). Aim of this work is to assess the impact of Covid–19 infection on mortality in AMI patients admitted during the national outbreak in Italy.

Methods

Retrospective nationwide cohort study enrolling consecutive AMI patients admitted between March,11st and May 3rd, 2020 (national outbreak) and the equivalent periods of the previous 5 years in Italy. The main outcomes were 30–day and 6–month all–cause mortality.

Results

The actual number of AMI admission during the 2020 outbreak in Italy was significantly reduced as compared to that expected based on the trend of the previous 5 years (STEMI: 4048 vs 5523, p<0.0001; NSTEMI: 4981 vs 8633, p<0.0001). A Covid–19 diagnosis was reported in 4.2% of STEMI and 3.5% of NSTEMI patients. In STEMI patients the 2020 expected rate of 30–day and 6–month mortality was 9.2% and 12.6%, compared to observed rates of 10.8% (p=0.016) and 14.4% (p=0.017), respectively. In NSTEMI patients the 30–day and 6–month expected mortality rates in 2020 were 6.5% and 12.2%, compared to observed rates of 8.3% (p=0.001) and 13.6% (p=0.041), respectively. Excluding patients diagnosed with Covid–19, the mortality rates become consistent with the trend of the previous 5–year for STEMI, but remain higher for NSTEMI. After multivariate adjustment, diagnosis of Covid–19 resulted an independent predictor of both 30–day mortality (OR=4.7, p<0.0001 for STEMI; OR=4.5, p<0.0001 for NSTEMI) and 6–month mortality (OR=3.6, p<0.0001 for STEMI; OR=3.8, p<0.0001 for NSTEMI).

Conclusion

During the 2020 national outbreak in Italy, a concomitant diagnosis of Covid–19 was associated with a significantly higher rate of mortality in both STEMI and NSTEMI patients. Excluding patients diagnosed with Covid–19, the mortality rates become consistent with the previous 5–year trend for STEMI, while they remain higher for NSTEMI.
P5 DISCOVERY OF A NEW HATTR GENETIC VARIANT: A CASE REPORT OF A PATIENT WITH CARDIAC UPTAKE AT 99–MTC–DIPHOSPHONATES SCINTIGRAPHY AND ABNORMAL MONOCLONAL PROTEINS TESTS
Authors: Fargione L , Pandolfi A , Carugo S , Spaziani C , Vicenzi M
Published: May 2023

Introduction

Cardiac amyloidosis is an infiltrative disease that remains an under–diagnosticated cause of heart failure. Diagnostic algorithms focus on identifying the two most frequent forms of the disease, light chains amyloidosis (AL) and transthyretin amyloidosis (ATTR), by the initial use of 99mTc–DPD scintigraphy coupled to assessment of monoclonal proteins. Etiological distinction is and of pivotal importance since the availability of specific disease modifying treatments.

Case Description

We report the case of a 61–year–old man hospitalized for new onset of heart failure. Past medical history highlights bilateral carpal tunnel syndrome and monoclonal gammopathy of undetermined significance (MGUS). Cardiovascular examination reveals clinical signs of pulmonary and peripheric congestion. ECG shows conduction disturbances and low QRS voltage. Transthoracic echocardiography reveals left ventricular hypertrophy, normal systolic function (LVEF 58%), 3rd degree LV diastolic disfunction and mild pericardial effusion. Laboratory tests shows abnormal levels of TnT and pro–BNP. A diagnosis of cardiac amyloidosis is considered, and further exams are executed: cardiac magnetic resonance, haematological laboratory tests and 99mTc–DPD scintigraphy (tab. 1). Since both bone scintigraphy and monoclonal proteins tests are positive, diagnosis of cardiac amyloidosis cannot be made without non–invasive modalities (fig.1) and the patient is referred to an Amyloidosis Centre. Haematological evaluation and abdominal fat pad biopsy show stability of haematological disease and confirms the deposition of amyloidogenic TTR both in wild–type and mutated Ile88Arg variants. The results of genetic analysis confirms the presence of a heterozygous mutation of TTR gene (p.Ile88Arg – c.263T>G) (fig. 2). This mutation is not reported in database ClinVar nor in gnomAD, but according to the ACMG criteria it can be considered likely pathogenic. Considering the final diagnosis of cardiac hATTR the patient is considered eligible for treatment with Tafamidis.

Discussion and Conclusion

Despite clinical history with cardiac conduction system abnormalities and bilateral carpal tunnel syndrome, some gene TTR variants can bring false negative results at 99mTc–DPD scintigraphy, so ATTR form should not be excluded basing on non–invasive modalities. Performing a compete diagnostic workup led us to discover a new TTR pathogenic variant and confirm ATTR form without performing endomyocardial biopsy.
P7 INJECTABLE LOOP RECORDER IMPLANTATION IN CHILD WITH DANON SYNDROME AND VENTRICULAR EXTRASYSTOLES
Authors: Catucci S , Lombardi M , Maiorano A , Meliota G , Pirolo T , Massari E , Vairo U
Published: May 2023

Introduction

Danon syndrome is a rare X–linked storage disorder caused by mutation of the LAMP2 gene, which is expressed in the heart with hypertrophic cardiomyopathy, heart failure and arrhythmias.

Clinical case

Little C. comes to our observation at the age of 3 years for ventricular extrasystoles. The maternal grandmother died suddenly at the age of 36, with the autopsy of hypertrophic cardiomyopathy being found. The mother, who died at the age of 28 from heart failure, was suffering from Danon syndrome with non–obstructive hypertrophic cardiomyopathy with dilatative evolution, episodes of atrial fibrillation and sustained ventricular tachycardia, WPW syndrome, already subjected to ICD implantation and on list for cardiac transplantation. The little girl presents a normal echocardiogram at our first evaluation; Holter documents numerous isolated, monomorphic ventricular extrasystoles. Genetic analysis is started to ascertain the presence of the germline mutation in the LAMP2 c.928G>A gene (related in the literature to Danon disease). During the follow–up the patient, always asymptomatic for syncope and / or palpitations, presents the appearance of slight concentric hypertrophy of the left ventricle; to Holter persistence of monomorphic, non–repetitive ventricular extrasystoles. At the age of 5, injectable loop recorder implantation is performed. The procedure is well tolerated and with no complications. The sensing of the R wave (1.03 mV) was great. Beta–blocker therapy is also undertaken. At remote monitoring, some false episodes of tachyarrhythmias due to double counting due to the presence of high voltage T waves are observed in the first month after the implant; after reprogramming the gain, false alarms do not occur. Over the course of about 3 years, monitoring with loop recorder allowed to document the absence of sustained brady and tachyarrhythmias. At the clinical follow–up, a reduction in the arrhythmic burden was observed, with almost total disappearance of ventricular extrasystoles.

Conclusions

The loop recorder implant is a safe and reliable procedure in pediatric age for the monitoring of patients at arrhythmic risk who do not have indication for defibrillator implantation. Danon syndrome is expressed phenotypically with hypertrophic cardiomyopathy in the second to third decade of life; it is, therefore, necessary to identify paediatric subjects who may be most at risk of sudden arrhythmic events.
P18 PROGNOSTIC IMPACT OF MITRAL REGURGITATION BEFORE AND AFTER TRANSCATHETER AORTIC VALVE REPLACEMENT IN PATIENTS WITH SEVERE LOW FLOW, LOW GRADIENT AORTIC STENOSIS
Authors: Ferruzzi G , Silverio A , Cimmino M , Corcione N , Bellino M , Attisano T , Baldi C , Morello A , Biondi–Zoccai G , Citro R , Vecchione C , Galasso G
Published: May 2023

Background

There is little evidence about the prognostic role of mitral regurgitation (MR) in patients with low flow, low gradient aortic stenosis (LFLG–AS) undergoing transcatheter aortic valve replacement (TAVR). Aims: The aim of this study was to assess the prevalence and outcome implication of moderately severe to severe MR in patients with LFLG–AS before and after TAVR.

Methods

This study included consecutive patients with LFLG–AS undergoing TAVR at two Italian high–volume centres. The study population was categorized according to the baseline MR severity and to the presence of MR improvement at discharge. The primary outcome was the composite of all–cause death and hospitalization for worsening heart failure (HF) up to one year. The secondary outcomes were the single components of the primary outcome.

Results

The study included 268 patients; 57 (21%) patients showed MR>2+. Patients with MR>2+ showed a lower one–year survival free from the primary outcome (Log–Rank <0.001; Figure1), all–cause death (Log–Rank <0.001), and HF hospitalization (Log–Rank <0.001) compared to patients with MR≤2+. At multivariable analysis, baseline MR>2+ was an independent predictor of the primary outcome (p<0.001). Among patients with baseline MR>2+, MR improvement was reported in 24 (44%) cases after TAVR. The one–year survival free from the primary outcome was significantly higher in patients with MR improvement than in those without (Log–Rank = 0.009), and both groups had a significantly lower survival free from the primary outcome when compared with patients with baseline MR <2+ (Figure 2). One–year survival free from the all–cause death (Log–Rank = 0.036) and HF hospitalization (Log–Rank = 0.005) was consistently higher in patients with MR improvement than in those without.

Conclusions

In this study, the presence of moderately severe to severe MR in LFLG–AS patients undergoing TAVR portend a worse clinical outcome at one year. TAVR may improve MR severity in nearly half of the patients, resulting in a potential outcome benefit after discharge.
P19 INCIDENTAL DIAGNOSIS OF MASSIVE MOBILE LEFT VENTRICLE THROMBI FOLLOWING COVID–19 INFECTION IN A HEART FAILURE PATIENT
Authors: Mapelli M , Celeste F , Conte E , Palermo P , Mancini E , Maiolo G , Ghulam Ali S , Agostoni P
Published: May 2023

Background

Intracardiac thrombus can be a complication of ischemic heart disease and cardiomyopathies. The advancements in imaging modalities have increased the capacity to diagnose this condition helping to reduce the associated complications (i.e. embolization). Previous reports suggest a possible link between intracardiac thrombosis and COVID–19 infection, especially in patients with severe “endotheliitis”, pneumonia, or myocarditis. COVID–19 effects on the cardiovascular system are partly evaluated. Venous and arterial thrombosis is commonly associated with COVID–19 but detection of intracardiac thrombus has not been frequently reported. Case Description: A 71–year–old woman, known to have a non–ischemic dilated cardiomyopathy with reduced ejection fraction (EF) and a previous transcatheter edge–to–edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars–Cov–2, experienced a paucisymptomatic COVID–19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast echocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses. The largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49x15 mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses’ dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2–week a complete resolution of the masses was documented with no clinical or embolic events.

Conclusion

The pro–thrombotic nature of COVID–19 infection is well known. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non–severe COVID–19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring and/or the use of anticoagulant therapies could yield a benefit in selected patients.
P21 INFECTIVE ENDOCARDITIS COMPLICATED BY BLOCKED ATRIAL FIBRILLATION AND AORTIC VALVE RUPTURE: A CASE REPORT
Authors: De Maio J , Caputi A , Martelli A , Bagni E
Published: May 2023

A 63–year–old male patient with a mechanical mitral prosthesis and permanent atrial fibrillation in TAO was hospitalized for heart failure during a SARS CoV–2 infection in April 2022; the transthoracic echocardiogram performed during the hospitalization showed an ejection fraction of 38% The patient was rehospitalized in September 2022 due to worsening general conditions during suspected pneumonia. The hospitalization was complicated by brady AF with heart rate < 30 b.p.m. symptomatic for asthenia and dyspnoea despite the suspension of beta–blocker and digitalis therapy. Therefore, we decided on the implantation of a temporary pacemaker in urgency and subsequently a definitive pacemaker (Essentio MRI – Boston Scientific). During the hospitalization, the clinical conditions continued to be precarious; a transthoracic echocardiogram revealed suspicious formation of endocardic nature at the aortic valve with consensual severe regurgitation. This datum was confirmed with the TEE echo. At this point, in the suspicion of infective endocarditis, antibiotic therapy was set up and the patient was taken to our reference cardiac surgery where he underwent aortic valve replacement with a mechanical prosthesis, reconstruction of the coronary sinus and of the outflow tract of the left ventricle with heterologous pericardial patch. Currently, the patient performs regular clinical follow up at our Center and is in good general condition.
P26 TRANSIENT GLOBAL AMNESIA AS A POSSIBLE CONSEQUENCE OF ICA DISSECTION: A CASE REPORT
Authors: Natale F , Loffredo F , Molinari R , Alfieri R , Covino S , De Luca L , Limatola M , Mollo N , Pezzullo E , Cimmino G
Published: May 2023

Case Report

A 42–year–old woman was carried to emergency room lamenting sudden memory loss. Her husband witnessed the onset of the episode. No recent head trauma was reported, blood pressure was under control. Anterograde and retrograde memory loss was present and confirmed by a neurologist. No other neurological signs were elicitable. Blood exams and toxicological analysis were negative. ECG, chest radiography, and cerebral TC showed no abnormalities. At physical examination a carotid bruit could be appreciated. The patient was asymptomatic. Subsequently an eco–colour–Doppler of carotid artery was performed showing a left common and internal carotid artery dissection. The diagnosis of ICA dissection was confirmed with a contrast CT furthermore excluding the coexistence of an aortic dissection. The anterograde amnesia resolved 15 h after the admission. A neurologist confirmed that the patient experimented an episode of transient global amnesia. After a vascular surgery consultation, a conservative treatment was deemed appropriate. After a 6 month follow up the patient didn’t complain of any other neurological symptom or sign. Transient global amnesia (TGA) is characterized by reversible anterograde and retrograde amnesia of sudden onset that resolves spontaneously within 24 h. The pathophysiological mechanisms underlying this puzzling neurological syndrome are yet not completely clarified. Some studies support an ischemic aetiology for TGA and cases of TGA following ICA–stenting or aortic dissection with involvement of the supra–aortic branches are reported in literature, thus supporting the hypothesis that a cause–effect relationship between ischemic pathologies of supra–aortic trunks and TGA might be present. In the case here presented, a Doppler ultrasound of carotid arteries performed in a patient presenting with TGA, asymptomatic for neck pain, led to a diagnosis of ICA dissection. In order to not miss a spontaneous ICA dissection as a rare ethology of TGA, we suggesto perform an eco–colour–Doppler of the epi–aortic vessels in patients affected by such amnesic syndrome.
P36 A CHALLENGING CASE OF MINOCA
Authors: Zagarese G , Candelora A , Vinco G , Giovannelli C , Angheben C , Moggio P , Musuraca G , Cemin C , Del Greco M
Published: May 2023

Myocardial infarction in the absence of obstructive coronary artery disease (MINOCA) accounts for 5–6% of all myocardial infarctions. The causes that can lead to this diagnosis are many and not always clearly identifiable; in fact, despite optimal work–up, the cause of MINOCA remains undetermined in 8–25% of patients and diagnosis represents a real challenge for the cardiologist clinician. Because patients with MINOCA have clinical outcomes comparable to those with myocardial infarction with obstructive coronary artery disease, they should undergo a careful diagnostic work–up in order to set up a therapy related to the specific diagnosis.

Introduction

A 51–years old woman presented to the emergency room after a sudden onset of an oppressive, prolonged and non–radiating chest pain, with gradual resolution after intravenous nitroderivates therapy. Smoking was the only cardiovascular risk factor. A recent uncomplicated COVID 19 infection (2 months before hospital admission) was the only event reported in clinical history. Physical examination was unremarkable with the exception of an apical mid–end systolic murmur. The electrocardiogram was normal and the Troponin T peak was 391 pg/ml. An echocardiogram showed a normal biventricular function without alterations of segmental kinetics and mitral valve prolapse with moderate degree regurgitation. The patient was admitted to the Intensive Care Unit department and underwent a coronary angiography study with evidence of main epicardial coronaries free from stenosing atherosclerotic lesions. In addition, a cardiac magnetic resonance (CMR) was performed before discharge, with evidence of normal biventricular systolic function in the presence of limited area of ​​late enhancement with ischemic pattern at the level of the middle segment of the inferolateral wall of the left ventricle without edema. In the light of the clinical instrumental picture, a diagnosis of MINOCA was made.

Discussion

This clinical case is an example of how sometimes the cause relating to a MINOCA cannot always be well identified. However, the multi–imaging approach and in particular the resonance allowed to identify a localized area of ​​late enhancement with an ischemic type pattern. The origin of the ischemia could be dated from a picture of distal embolization, from a microvascular disease or from a myocardial stretching due to prolapse.
P37 MULTIMODALITY DIAGNOSTIC APPROACH TO A JUVENILE CASE OF SUSTAINED VENTRICULAR TACHYCARDIA
Authors: Castello L , Di Fusco S , Colivicchi F
Published: May 2023

Clinical case

31–year–old male subject, former competitive athlete, with family history of coronary artery disease and no further cardiovascular risk factors or previous cardiac events. Previous SARS–CoV2–related paucisymptomatic infection (January 2022) and subsequent episode of fever (August 2022) with negative SARS–CoV2 nasal swab. In September 2022 he reported sudden onset of palpitations after hearty meal. Because of such symptoms, the patient underwent Holter ECG showing 90 episodes of ventricular tachycardia (VT) and one episode of sustained VT. Based on such evidence, the patient went to the emergency room (ER). During the ER stay, blood exams (blood count, high–sensitivity troponin, BNP, CRP, D–dimer) and ECG were normal and SARS–CoV2 test was negative. The patient was then hospitalized in cardiac ICU. The echocardiogram showed left ventricle with normal dimension, thickness and wall motion (EF: 65%, mean GLS: –20%), trivial mitral and aortic regurgitation, no pericardial effusion. Subsequently, a cardiac coronary CT scan was performed showing absence of atherosclerotic lesions and myocardial bridge of the middle segment of LAD artery. The diagnostic pathway went on with cardiac magnetic resonance (CMR) demonstrating focal hypokinesia and wall thickness reduction of the anteroseptal–anterior junctional wall at middle–distal level (minimum thickness: 3 mm) where a millimetric area of late gadolinium enhancement with transmural distribution was described; absence of myocardial oedema. In addition, an EPS was performed with electroanatomical high–density/definition mapping of the left ventricle showing normal volumes, signals and activation and absence of LAVA/LV. Taking into account such findings, a subcutaneous defibrillator was implanted for primary prevention and a control CMR was scheduled in the follow–up period.

Conclusions

This case underlines the central role of CMR in identifying areas of myocardial fibrosis that can represent the electroanatomical substrate for triggering ventricular arrhythmias. In this case, the arrhythmic events are associated with a focal area of transmural fibrosis and wall thinning, usually indicating ischaemic damage, nonetheless in the presence of normal coronary arteries.
P39 MANAGEMENT OF A CASE OF LAST REMAINING PATENT VESSEL
Authors: Legnazzi M , Azzarelli S , Tomasello S , Di Giorgio A , Di Simone E , Scardaci F , Argentino V , Amico F
Published: May 2023

A 72–year–old hypertensive, dyslipidemic and smoker (20 cig/day) gentleman was admitted to the emergency department for pulmonary edema. Past medical history included COPD, anterior MI treated with PCI and stenting of proximal LAD 5 years back, recent TIA. He was admitted to cardiac intensive care unit and treated with CPAP, IV furosemide and norepinephrine. Echocardiogram showed severe ventricular dysfunction (LVEF 20%) and severe functional mitral regurgitation; lab tests pointed out mild troponin elevation (50 ng/L) and high levels of BNP (1300 pg/mL). After stabilization, he underwent coronary angiography: in–stent CTO of LAD, critical stenosis of distal LM and ostio–proximal LCX (last remaining patent vessel, LRPV); hypoplastic RCA. At the end of angiography, new episode of pulmonary edema that required treatment with inotropes, CPAP and diuretics. Considering hemodynamic instability and high surgical risk (combined STS 37%), the Heart Team decided to proceed to PCI with mechanical circulatory support with Impella CP. From left radial access we achieved advancement of JR4 guiding catheter with guide extension in right common iliac artery. We performed angiography and then put a coronary guidewire in superficial femoral artery to facilitate right femoral access (angio–guided). From this femoral access we implanted Impella CP device. From left radial access we performed PCI: cannulation with JL 3 guiding catheter, wiring with Sion Blue ES guidewire, pre–dilatation with NC balloons until 3.0 mm diameter, stenting of LM–LCX with 1 DES 4.0/32 mm, post–dilatation with NC balloons (4.5 and 5.0 mm diameter). Good angiographic result; IVUS examination revealed good expansion and apposition of stent. Femoral access was closed with 2 Perclose Proglide. Patient was then monitored in cardiac intensive care unit, with clinical improvement and without complications. 10 days after PCI the patient, asymptomatic, was discharged. The echocardiogram displayed betterment of contractile function (LVEF 28%) and of mitral regurgitation (now moderate). At 4–month follow–up visit, patient is paucisymptomatic (NYHA class II), without angina episodes, with good quality of life in guideline–directed optimal medical therapy. Critical disease of LRPV is a severe condition, with unpredictable evolution and poor prognosis. PCI of LRPV in HFrEF patients is an high–risk PCI scenario in which mechanical circulatory support with Impella can prove to be essential.
P40 LIGHTS AND SHADOWS OF THE MICROCOAXIAL PUMP DEVICE IN A UNIQUE SETTING: CARDIOGENIC SHOCK DUE TO ACUTE MYOCARDIAL INFARCTION IN PATIENT WITH UNKNOWN HYPERTROPHIC CARDIOMYOPATHY
Authors: Demola P , Bosi D , Romagnoli F , Manca F , Azzarone M , Pignatelli G , Musto D' Amore S , Copelli S , Navazio A , Guiducci V
Published: May 2023

Cardiogenic shock remains the leading cause of death in patients with acute myocardial infarction (AMICS). The IntraAortic Balloon Pump (IABP) has been the device of first choice for these patients for years, but it has not shown a mortality benefit over optimal medical therapy. The Impella (AbioMed, Danvers, Massachusetts) is an alternative circulatory support system that produces cardiac output appropriate for the needs of the patient. A 59–year–old mailman suddenly lost consciousness during his work. Basic life support was administered, and ROSC was achieved after a single effective defibrillator discharge. When the ambulance arrived, the patient presented conscious but complained of oppressive chest pain, with soreness in his left arm and head. EKG showed an ST elevation in aVR and aVL and a right bandle branch block (Fig 1). Aspirin, Heparin, and opioids were administered. During the transport, hemodynamic parameters appeared to deteriorate towards cardiogenic shock. Coronary angiography showed a total occlusion of the left main. Cangrelor was started promptly. Hemodynamic conditions dictated the application of a mechanical circulatory support device (MCSD), so IABP was applied. Primary angioplasty was performed with restoration of TIMI 3 flow. A 3.50 x 23 mm everolimus–eluting stent was implanted with a good result. Norepinephrine was ineffective in achieving satisfactory hemodynamic status with systemic arterial pressure below 50 mmHg. After volemic restoration, neither IABP nor the vasopressor could interrupt the spiral of cardiogenic shock. A coaxial pump, i.e. the Impella CP, was applied via left arterial femoral access. Despite the precise placement of this device, the parameters suggested a poor suction capacity from the pump–inlet into the left ventricle (LV) to systemic circulation in aorta. Meanwhile, echocardiogram revealed an unknown and severe hypertrophic cardiomyopathy that did not allow a proper functioning of the Impella CP device (Fig. 2). When a temporary pacemaker was applied due to reperfusion bradycardia, there were a better LV diastolic filling and Impella functioning due to right pacing. The patient was transferred to the intensive care unit, Impella was removed after 3 days, he was extubated within two weeks, no brain damage was reported but he is still hospitalised after a concomitant urinary infection, with predictable low ejection fraction (around 30%). We‘ll see: luckily, slow improvement, it is still an improvement!
P41 INCIDENCE AND PREDICTORS OF PERIPROCEDURAL MYOCARDIAL INFARCTION IN PATIENTS UNDERGOING COMPLEX VS NON–COMPLEX PERCUTANEOUS CORONARY INTERVENTION
Authors: Leone A , Piccolo R , Avvedimento M , Simonetti F , Angellotti D , Verde N , Manzi L , Franzone A , Napolitano G , Esposito G
Published: May 2023

Background

Percutaneous Coronary Intervention (PCI) is the most used treatment strategy for patients with coronary artery disease (CAD) undergoing revascularization. Periprocedural Myocardial Infarction (PMI) still represents a frequent complication after PCI. Complex PCI procedures carry a higher risk of adverse events. Despite several studies assessed the incidence of PMI, no data exist about the rate of PMI according to different definitions in patients undergoing complex PCI. Aims. This study aims to evaluate the incidence of PMI in patients with chronic coronary syndrome (CCS) undergoing PCI according to the complexity of the procedure and different definitions of PMI. Independent predictors of PMI according to the 4th Universal definition of myocardial infarction (UDMI) were also investigated.

Methods

1010 patients treated with PCI from 2017 to 2021 at Federico II University Hospital, Naples, Italy were enrolled. PMI was adjudicated by full trained cardiologists. Primary outcome of interest was PMI according to the 4thUDMI. Secondary outcomes of interest were PMI rates according to different definitions available in literature and myocardial injury according to 4th UDMI and Academic Research Consortium –2 (ARC–2).

Results

Of the 1010 patients, 226 underwent Complex PCI (22.4%). The incidence of the primary outcome was significantly higher in complex PCI group compared with non–complex PCI (26.5% vs 14.5%, p<0.001). After multivariate adjustment, complex PCI (OR 1.54, 95% CI: 1.04–2.27 p= 0.031), presence of calcified lesions (OR 2.05, 95% CI: 1.38–3.03 p<0.001) and multivessel disease (OR 2.94, 95% CI: 1.76–4.89 p<0.001) were found to be independently associated with PMI.

Conclusions

Patients undergoing complex PCI have an increased risk of PMI. Multivessel disease, calcified lesions and complex PCI represent independent predictors of PMI.
P46 TRANSAXILLARY MITRAL VALVE SURGERY IS ASSOCIATED WITH EARLY RECOVERY AND SHORTER ICU AND HOSPITAL STAY
Authors: Malvindi P , Berretta P , Wilbring M , Bifulco O , De Angelis V , Cefarelli M , Zingaro C , Kappert U , Di Eusanio M
Published: May 2023

Background and Aim

Several thoracic incisions have been described and different techniques used for cardiopulmonary bypass, myocardial protection and valve exposure in minimally invasive mitral valve surgery (MIMVS). Aim of this study is to compare the early outcomes of patients operated through a right trans–axillary (TAxA) approach with those achieved in conventional full sternotomy (FS) operations.

Methods

Prospectively collected data of patients who underwent mitral valve surgery between 2017 and 2022 at two academic centres were reviewed. Among them, 454 patients underwent MIMVS through TAxA access and 667 patients through FS (associated aortic and CABG procedures, infective endocarditis and urgent operations were excluded). A propensity match analysis was performed using seventeen preoperative and intraoperative variables.

Results

There was no difference in preoperative characteristics in matched populations. The rate of mitral valve repair was similar in both groups. Patients in TAxA group had a higher rate of repair using artificial chordae. Operative times were shorter in FS group but in patients operated in minimally invasive approach there was a trend towards decreasing CPB and cross–clamp time over the study period. Hospital mortality in TAxA group was 0.25%, postoperative cerebral stroke rate was 0.7%. TAxA mitral surgery was associated with shorter intubation time (p<0.001) and ICU stay (p<0.001). After a median hospital stay of 8 days, 30% of patients who had TAxA surgery were discharged home vs. 5% in the FS group (p<0.001).

Conclusions

TAxA approach is safe and effective. Compared to FS, it allows shorter mechanical ventilation, ICU and postoperative hospital stay with a higher rate of patients able to be discharged home without any further period of cardiopulmonary rehabilitation.
P52 DIGEORGE SYNDROME: HYPOCALCEMIC PARALYSIS AND INTERVENTRICULAR DEFECT
Authors: Greco A , Mastroianno S , Bevere E , Massaro R , Potenza D , Salvatori M , Brunetti N , Di Stolfo G
Published: May 2023

Introduction

DiGeorge syndrome (DGS), known as "22q11.2 deletion syndrome" (22q11DS) (MIM#192430#188400), is caused by microdeletion of the long arm of chromosome 22 resulting in impaired development of the pharyngeal pouch. It is the most frequent chromosomal microdeletion syndrome with an estimated prevalence of 1 in 3 in 6,000 live births and approximately 1 in 1,000 fetuses. 22q11DS is the second leading chromosomal cause of congenital heart malformations, after trisomy 21. Patients with DGS may have developmental abnormalities of the craniofacial structures, parathyroid glands, thymus, and cardiac outflow tract. Doctors have been screening infants with conotruncal heart abnormalities for DGS since the late 1990s, before which the diagnosis was only clinical.

Clinical case

A 48–year–old woman came to our attention for recurrent episodes of tetanus paresis, the worst in her youth, associated with a systolic murmur. Her face was characterized by hypertelorism, thin lips, micrognathia, and low–set ears associated with short stature. Blood chemistry tests showed hypocalcemia during the tetanic crisis, exacerbated also during blood pressure measurement (Trosseau‘s sign with obstetrician‘s hand). The electrocardiogram showed sinus rhythm, high QRS voltages and the presence of U wave in some precordial leads (Fig. 1). The echocardiographic examination showed a globular left ventricle with evidence of a subaortic interventricular defect (Fig.2). The patient was sent for genetic evaluation with subsequent evidence of 22q11.2 microdeletion (Di George syndrome) and placed on oral calcium treatment and cardiac surgery evaluation for possible correction of the congenital defect. At the same time, psychological support was guaranteed for adequate coping with the diagnosed disease.

Conclusions

The presence of multiple stigmata in the same patient, such as typical facies, congenital heart defects and hypocalcemia, must raise the suspicion of syndromic involvement of the patient and consequent genetic evaluation oriented towards diagnosis and adequate counseling.
P64 PERSISTENT ST–ELEVATION WITH HIGH MYOCARDIONECROSIS MARKERS: A CASE OF MYOCARDIAL CONTUSION
Authors: Galasso M , Stucchi M
Published: May 2023

Myocardial contusion (MC) is a note rare and potentially fatal complication of blunt chest trauma (BCT). The spectrum of manifestations of post–traumatic cardiac injury varies widely: from clinically silent injuries to severe reductions in cardiac function, myocardial hematomas, heart ruptures, and life–threatening arrhythmias1. There is no unique definition for this entity, and the diagnostic criteria proposed by different authors vary widely. Some authors define MC as a mild increase in cardiac biomarkers in the context of chest trauma, while for others the diagnosis requires evidence on imaging of pathologic findings2. Consequently, the true incidence of MC remains unknown, varying in reports between 8% and 71%3. We describe a case of cardiac contusion secondary to a low–energy trauma manifested as persistent ST elevation and pathologic elevation of myocardiocytosis markers, with consequent myocardial stunning of the right ventricular free wall. As there is no consensus regarding the correct diagnostic pathway, it is essential to integrate first–level pathologic examinations (ECG and laboratory diagnostics) with cardiac magnetic Resonance Imaging (MRI) to define the presence of cardiac contusion and its extent, especially if the echocardiographic data are unconclusive.
P65 A STRANGE CASE OF ACUTE CORONARY SYNDROME WITH VESSEL SQUEEZING AND INTRAMURAL HEMATOMA
Authors: Dominici T , Schiavoni M , Bernardo V , Dato I , De Luca A , Moretti A , Percoco F , Pontiroli C , Tung M , Evangelista F , Kol A
Published: May 2023

A 53–year–old woman presented herself at our center for the appearance of oppressive chest pain radiating to the upper limbs associated with cold sweat, which arose in resting conditions. The patient had as cardiovascular risk factors tobacco habits and an important family history of cardiovascular diseases (father died of AMI at a young age) and had entered menopause for some months. The ECG showed signs of anterior transmural ischemia (Figure 1a) with corresponding echocardiographic kinetic abnormalities of the cardiac apex (EF 40%). The patient underwent an emergency coronary angiography documenting an intramyocardial bridge with evident systolic squeezing of the vessel in the proximal–middle section of the anterior descending artery and normal appearance of the remaining coronary tree (Figure 2). She was subjected to infusion of intracoronary nitrates with improvement of the instrumental picture and on that occasion it was opted for medical therapy alone with double antiplatelet therapy and low–dose calcium antagonist. On the second day after the diagnostic procedure, there was a recurrence of anginal symptoms with evidence on the ECG of anterolaterally reversed T waves (figure 1b). The patient underwent a new coronary angiography, IVUS–guided, with documentation of probable intramural hematoma in the absence of non–flow–limiting dissection image with an area of 7 mm² (Figure 3). During the subsequent hospitalization, the patient remained asymptomatic with stable ECG tracing, but telemetry revealed ventricular tachyarrhythmias for which beta–blocker therapy was optimized with improvement of the arrhythmic burden. The pre–discharge echocardiogram showed improvement of cardiac kinesis with resumption of systolic function (EF 48%). The patient was discharged stable and asymptomatic with follow–up at our dedicated ischemic heart disease clinic. This case report is an example of an infrequent cause of acute coronary syndrome, of non–atherosclerotic origin, to be considered in clinical practice.
P66 PROGNOSTIC IMPACT OF PERCUTANEOUS CORONARY INTERVENTION IN ACUTE MYOCARDIAL INFARCTION PATIENTS OLDER THAN 75 YEARS. REAL–WORLD FINDINGS FROM THE LOMBARDY REGION
Authors: Della Rocca M , Trombara F , Cosentino N , Bonomi A , Leoni O , Marana I , Moltrasio M , Cava F , Agostoni P , Savonitto S , Marenzi G
Published: May 2023

Background

Older patients, generally defined as individuals age >75 years, are less likely to receive percutaneous coronary intervention (PCI) for treatment of acute myocardial infarction (AMI) compared to younger patients. This is due to the paucity of evidence derived from randomized trials, concerns about possible PCI–related side effects, and multimorbidity. We investigated the prognostic impact of PCI in a large population of patients hospitalized with AMI in the period 2003–2018, by using the administrative Lombardy Health Database.

Methods

We analyzed data of all patients >75 years hospitalized with AMI (both STEMI and NSTEMI) from 2003 to 2018 in Lombardy. Patients were grouped according to whether they were treated or not with PCI during index hospitalization. The primary outcome was in–hospital mortality. One–year mortality and 1–year re–hospitalization for acute heart failure (AHF) or AMI were considered as secondary endpoints.

Results

During the study period, 116,063 patients (mean age 83±6; 48% males; 46% STEMI) were hospitalized with a primary diagnosis of AMI. Thirty–seven percent of them (n=42,912) were treated with PCI. The in–hospital mortality rate in the entire cohort was 12%. It was significantly lower in patients treated with PCI than in those not treated with PCI (6% vs. 15%; P<0.0001). In the overall population, 1–year mortality was 32% and 1–year re–hospitalization for AHF/AMI was 19%. Both these endpoints were less frequent in PCI–treated patients (16% vs. 41% and 15% vs. 21%, respectively; P<0.0001). The adjusted risk of the study endpoints was significantly lower in patients treated with PCI: OR 0.37 (95% CI 0.36–0.39) for in–hospital mortality; HR 0.37 (95% CI 0.36–0.38) for 1–year mortality; HR 0.74 (95% CI 0.71–0.77) for 1–year re–hospitalization for AHF/AMI. Similar results were found in STEMI and NSTEMI patients considered separately.

Conclusions

Our real–world data showed that in patients with AMI >75 years of age, PCI use is associated with a significantly lower in–hospital mortality and up to 1 year. This work was partly financed by the Italian Ministry of Health and the Lombardia Region (Grant NET–2016–02364191; EASY–NET)
P83 EFFICACY AND SAFETY OF LEVOSIMENDAN IN AN ISCHEMIC CARDIOGENIC SHOCK POPULATION: A 10–YEARS SINGLE CENTRE RETROSPECTIVE STUDY
Authors: Belfioretti L , Marini M , Francioni M , Battistoni I , Angelini L , Pongetti G , Shkoza M , Matassini M , Piangerelli L , Corinaldesi C , Patani F , Pupita G , Compagnucci P , Perna G
Published: May 2023

Background

Levosimendan is a Ca2+–sensitizer with inodilator action able to improve cardiac contractility without increse oxygen demand. In AHF setting clinical trial and registries showed an improvement in systemic haemodynamics without a decrease in in–hospital mortality. Purpose: evaluate safety and efficacy of Levosimendan in an ischemic CS population.

Methods

All consecutive patients with CS after AMI admitted at our CICU from March 2012 to July 2021 were included in this single–centre retrospective study. 39 patients received Levosimendan alone or in combination with other inotropic drugs. All patients had an invasive monitoring of arterial pressure and continuous ECG–monitoring. Patients with severe renal failure were excluded. An echocardiogram was performed before drug infusion and 3 days after. We collected data from haemodynamics and from ECG monitoring looking for arrhythmic events.

Results

We enrolled 167 patients with CS after AMI, 39 patients received Levosimendan and 10 of them required association with low–dosage noradrenaline. 32 received Levosimendan at dosage of 0,1 mcg/kg/min. The drug was started on average 4 days after hospitalization. Statistical analysis showed a significant change in left ventricular EF assessed by echocardiogram from 25% to 31% (P = 0.018, fig 1). We observed also an improvement of symptoms with an overall relief of dyspnea and fatigue clinically evaluated. The ECG monitoring showed ventricular arrhythmias (VA) in 11 patients (NSVT, SVT, VF) but the most frequent arrhythmia after Levosimendan was atrial fibrillation (AF) which was significantly associated with in–hospital mortality (OR = 1,82, p = 0,002), whereas VA did not. Moreover patients with new onset AF after Levosimendan showed a lower clinical and instrumental response to the drug. No significant changes in electrolytes (sodium and potassium) have been documented during arrhythmic events.

Conclusion

Levosimendan is useful in CS after AMI setting because has demonstrated to improve systemic hemodynamics parameters and symptomatology. Overall Levosimendan is safe with a low rate of ventricular arrhythmias that, in our sample, are not associated with in–hospital mortality. Moreover we observed also a significant increase in AF that was associated with in–hospital mortality, but further studies in larger populations could be advisable to describe the real incidence of AF after Levosimendan infusion and its prognostic role in CS patients.
P87 GENETIC CARDIOMYOPATHIES: THE FIRST YEAR OF THE FONDAZIONE IRCCS CÀ GRANDA OSPEDALE MAGGIORE POLICLINICO OF MILAN DEDICATED CLINICAL SERVICE
Authors: Faggiano A , Calcagnino M , Paganini S , Ruscica M , Carugo S
Published: May 2023

Objectives

Cardiac genetic counselling and testing for inherited cardiomyopathies have become essential aspects of cardiovascular care. A genetic diagnosis in a family can offer an invaluable tool for cascade genetic testing of at–risk relatives. A careful clinical and individualized approach to genetic cardiomyopathies is now needed to guarantee the best care possible. We report the results of our first–year genetic cardiomyopathies single–centre experience.

Methods

From September 2021, 69 genetic tests have been carried out at Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico of Milan by the staff of a new specific clinical service dedicated to genetic cardiomyopathies.

Results

The present study collects the data of 69 patients who underwent genetic testing and clinical follow up at our centre in suspicion of underlying genetic etiology of disease. Next generation sequencing was adopted to conduct genetic testing either by a customized panel of 54 specific genes for cardiomyopathies or by a clinical exome (180 genes). Time required for reporting and patient communication were 8 and 12 weeks, respectively. Female sex was 36%, mean age was of 53.2 ± 21.3 years. The main indications for genetic testing were dilated cardiomyopathy (DCM) and hypertrophic cardiomyopathy (HCM). Figure 1. 41% of DCM and 50% of HCM patients tested positive for a pathogenic or likely pathogenetic mutation. Cascade genetic tests conducted on at–risk relatives were 21 (30%). Among these subjects, 38% resulted positive at genetic screening and 57% were in turn positive at phenotypic screening. The genes hit by pathogenic or likely pathogenetic mutations are illustrated in Figure 2.

Conclusion

The first year of a specific clinical service dedicated to genetic cardiomyopathies made it possible to identify a substantial number of patients and at–risk relatives affected by pathogenic or likely pathogenetic genetic mutations.
P88 CARDIAC INVOLVEMENT IN FOUR NOVEL NESPRIN–1 GENETIC VARIANTS
Authors: Manai R , Dusi V , Pidello S , Angelini F , Bocchino P , Gallone G , De Lio G , Gobello G , Saglietto A , Castagno D , Anselmino M , Giustetto C , Callegari M , Deaglio S , De Ferrari G , Raineri C
Published: May 2023

Background

Nesprins are proteins encoded by synaptic nuclear envelope (SYNE)–1 and –2 genes, that concur, together with lamin A/C and emerin, to nuclear envelope function. Almost 140 disease–related variants were identified, mostly resulting in central nervous system and skeletal muscle disorders; only a few were associated with cardiomyopathy, mostly with relatively late onset and no specific arrhythmic profile.

Purpose

To describe cardiac involvement in 4 novel SYNE1 variants.

Methods

189 patients underwent genetic analysis in our center (2019–2022) for suspected genetic cardiomyopathy (TruSight Cardio panel, Illumina); 72% had a positive genetic report, including pathogenic/likely pathogenic or variants of undetermined significance (VUS). Among them, 4 (2%) males presented with a sole SYNE1 heterozygous VUS (figure).

Results

None had muscle or neurological involvement. Patients 1 and 2 had negative family history (FH) and underwent pacemaker implantation under 50 years old for high–grade atrioventricular block (AVB). Transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) showed a mildly impaired left ventricular ejection fraction (LVEF) without oedema or fibrosis. During 3 and 6 years of follow–up (FU), several non–sustained episodes of fast ventricular tachycardia (VT) and of atrial tachycardia occurred. Patient 3 is a 55–year–old man with negative FH and a left bundle branch block (LBBB) known since the age of 45.In 2021, while playing football, he suffered a cardiac arrest due to ventricular fibrillation treated with two DC shocks; ECG showed first–degree AVB and LBBB; TTE and CMR revealed a mildly impaired LVEF without oedema or fibrosis. A subcutaneous ICD was implanted, which recorded 3 atrial fibrillation episodes in a 1–year FU. Patient 4 is a 49–year–old man, with FH of sudden death (mother’s brothers at 40 and 50 years) and of polycystic kidney, who underwent renal transplant. He had left anterior fascicular block and suffered 2 episodes of sustained monomorphic VT from the right ventricle treated with ablation. TTE and CMR showed mild LV concentric hypertrophy with normal LVEF, segmental abnormalities in right and LV strain, no fibrosis.

Conclusions

SYNE1 genetic variants were found to be associated with a complex cardiac phenotype, including early onset conduction disease, atrial and ventricular arrhythmias, and cardiomyopathy. Further studies are needed to determine the functional significance of the variants.