bluuebunny/crossref_metadata_2025 huggingface dataset:
C48 TEN–YEARS, SINGLE–CENTER EXPERIENCE WITH MELODY TPV IMPLANTATION: EARLY OUTCOMES AND MID–TERM FOLLOW–UP
Authors: Giordano M , Marzullo R , Gaio G , Cappelli Bigazzi M , Fabiani D , Palladino M , Della Cioppa N , Sarubbi B , Russo M
Published: May 2023

Objectives

Melody TPV is the first percutaneous valvular bio–prosthesis approved for trans–catheter pulmonary valve implantation (TPVI). We describe our ten–years experience about Melody TPV implantation in patients with congenital heart disease (CHD).

Methods

This is an observational retrospective single–center study. All patients undergone Melody TPV implantation were included. The early outcomes analyzed were: procedural failure, death of patient, life–threating adverse events. The long–term outcomes analyzed during follow–up were: infective endocarditis, trans–catheter redo–procedure, and surgical redo–procedure.

Results

From 2012 to 2022, 39 patients were evaluated in our catheterization laboratory for TPVI with Melody TPV. Mean age and weight were 21,31±11,58 (range 8–66) years and 57,5±16,24 (range 23–96) kilograms. The patients were affected by the following CHD: tetralogy of Fallot (22 pts, 56,4%), pulmonary atresia with ventricular septal defect (VSD) (4 pts, 10,3%), aortic stenosis s/p Ross surgery (4 pts, 10,3%), transposition of the great arteries with VSD and PS (3 pts, 7,7%), pulmonary stenosis (PS) (2 pts, 5,1%), truncus arteriosus (2 pts, 5,1%), double outlet right ventricle (1 pt, 2,5%), Ebstein’s anomaly (1 pt, 2,5%) In 4 cases (10,3%), the procedure failed because of coronary compression during balloon RVOT interrogation. One patient (2,5%) died due to post–procedural septic shock. In the other 34 patients (87,2%), the Melody TPV was implanted effectively. No life–threating adverse events were recorded. In 3 cases, the Melody TPV was implanted off–label: in tricuspid position (one case) and in “small conduits” (<16 mm) (two cases). The mean follow–up was 4,41±2,82 years. During follow–up, 5 patients (14,7%) developed an infective endocarditis, 7 patients (20,6%) required a trans–catheter procedure (6 Melody balloon dilation and 1 Melody valve–in–valve), and 2 patients (5,9%) underwent surgical Melody TPV replacement.

Conclusion

Trans–catheter Melody TPV implantation is effective to deal RVOT dysfunction. At a mid–term follow–up, the most of the implanted Melody TPV worked properly and only a few patients required surgical valve replacement.
C55 A GIANT PSEUDOANEURYSM OF MITRAL–AORTIC INTERVALVULAR FIBROSA PRESENTING AS RECENT–ONSET ANGINA AND CARDIAC ARREST DUE TO VENTRICULAR FIBRILLATION
Authors: Tofoni P , Patani F , Vagnarelli F , Lofiego C , Capodaglio I , Dottori M , Angelini L , Francioni M , Bonanni C , Grossi P , Galeazzi M , D‘Alfonso A , Marini M , Di Eusanio M , Perna G
Published: May 2023

A 66–year–old man was suddenly referred to the emergency department (ED) for an extra–hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological valve prosthesis (BVP, Perimount Magna n. 23) for severe aortic stenosis. One month after cardiac surgery the patient was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was awake and completely asymptomatic; no fever during days before the episode. He had been complaining of constricting retrosternal chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. TT echo showed a very large pulsatile anaechogenic area posteriorly to BVP. Transesophageal echocardiography (TEE 2D, Traditional 3D and TrueVue) highlighted a very large pseudoaneurysm of mitral–aortic interventricular fibrosa (P–MAIVF; Figures 1 and 2, long axis and short–axis views). TEE features included: 1) a very large cavity with thickened walls, extended for more than two–thirds of the prosthetic circumference and with multiple septa; 2) a large communication between the left ventricular outflow tract (LVOT) and P–MAIVF (see yellow dotted line in Fig.1A) with a to–and–fro flow into the cavity and a prominent systolic pulsation; 3) no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation. These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement. Moreover, the P–MAIVF may have led to “ab extrinseco” compression of the left coronary artery, with a potential role in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin–tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique (Perimount valvular prosthesis n.23 and Gelweave vascular prosthesis n.28). Figure 3 shows an intraoperative image and postoperative TEE. In conclusion, P–MAIVF is an ominous complication of prosthetic valve endocarditis. Presentation with exertional angina and cardiac arrest is unusual. TEE is sensitive for diagnosis and 3D echo provides better insights into the anatomy helping formulate an appropriate surgical strategy.
C72 POSTERIOR WALL CHARACTERIZATION IN PATIENTS AFFECTED BY ATRIAL FIBRILLATION
Authors: Valcher S , Benedetta G , Kamil S , Latini A , Pagani S , Vincenzo B , Del Monaco G , Taormina A , Galimberti P , Poggio L , Ceriotti C , Frontera A
Published: May 2023

Background

Several clinical data in humans demonstrate that atrial fibrillation (AF) dominant frequencies and rotors are mostly localized on the posterior wall (PW), but the correlation among these phenomena and abnormal conduction properties during sinus (SR) and paced rhythm (PR) has never been analyzed. Aims. To provide a characterization of the left atrial PW in patients affected by persistent AF. In particular, the purpose is to describe the electrophysiological properties in terms of rotational and focal activities during AF, propagation uniformity during SR and functional sites definition during PR.

Methods

Six patients from two EP centers have been selected for this analysis. The clinical procedures have been performed with CARTO3 mapping system. All EGMs have been collected with Pentaray and Octaray catheters. For each patient, the module CARTOFINDER has been used during AF to identify areas with shorter and longer cycle length (site of conduction jump), rotational and focal activities; at least 15 areas have been collected in the PW. SR and PR map were performed after electrical cardioversion to exploit the functional phenomena. The paced map has been created by setting an extra beat from the coronary sinus every three sinus beats (pacing interval=local effective refractory period +40ms). Rotational and focal activities during AF have been identified and associated with signals collected during SR and PR. EGMs have been characterized in terms of voltage amplitude (mV), signal duration (ms) and fractionation.

Results

Abnormal areas of conduction recorded during AF were 33; at least one site of conduction jump was found in every patient, in most of the cases (77%, 10 out of 13) it was localized on the PW. 10 areas of focal activities have been found of which 7 (70%) were localized on the PW. Rotational activity has been found in 2 patients (in one on the PW). During SR and paced rhythm, at sites of interest, we found lower voltages (SR 1.9 ± 1,3mV, PR 1,7 ± 1,15mV), signal fragmentation and longer signal duration (SR 52,7 ± 8,85ms, PR 51,3 ± 11,04ms) compared to healthy tissue.

Conclusion

There is a strong correlation between sites of interest during AF and signal abnormalities recorded during SR and PR. This research work may pave the way to the study of abnormal conduction sites during SR which represent a relevant element for AF maintenance, providing a further step towards substrate characterization in patients affected by AF.
C79 NEGATIVE T WAVES ON ECG: NOT JUST HYPERTROPHIC CARDIOMYOPATHY
Authors: Micillo M , Assabbi P , Cossu A , Lapolla D , Boccadoro A , Amantea V , Guardigli G , Tonet E
Published: May 2023

Background

Arrhythmogenic cardiomyopathy is still considered a rare and difficult–to–diagnose condition, yet a well–founded clinical–instrumental suspicion and proper diagnostic procedure can unveil this condition early from common instrumental findings.

Clinical Case

In September, a 34–year–old man presented to our center for the presence on the electrocardiogram of ventricular repolarization changes (negative T waves in D1, inferior site and in all precordial leads with mild ST elevation in V1– V2). He denied family history of cardiological events. In 2018, following a suspected preoperative EKG, he performed an echocardiogram and cardiac magnetic resonance imaging (CMR); these examinations showed mild left ventricular hypertrophy with preserved systolic function. Clinically, the patient reported rare episodes of palpitation presented on ambulatory EKG with the same repolarization changes as mentioned above. In consideration of the clinic–instrumental findings, a diagnostic workup with echocardiogram and CMR was started for suspicion of hypertrophic cardiomyopathy in the first hypothesis. On echocardiogram, an non dilated left ventricle was found with left ventricular ejection fraction, parietal thicknesses, and segmental kinetics within normal limits, in the absence of significant valvulopathy; however, frequent ventricular extrasystoles were reported during the examination. Given the EKG–graphic alterations, although there weren‘t any echocardiographic changes, a CMR was performed, showing extensive irregularity of the epicardial profile of the lateral and infero–lateral mid–apical wall, site of adipose infiltration, in which evidence of intramyocardial late gadolinium enhancement (LGE) was also present; the right ventricle showed extensive microbulging of the mid–basal free wall in the absence of adipose replacement or LGE. In view of the clinical–instrumental pattern, the diagnosis of "left dominant" arrhythmogenic cardiomyopathy with initial involvement of the right ventricle was made.

Conclusions

EKG–graphic interpretation may in some cases be the only instrumental data underlying clinical suspicion of arrhythmogenic cardiomyopathy, allowing early diagnosis of a condition at high risk of sudden cardiac death.
C81 ROLE OF RESTRICTIVE DIASTOLIC DYSFUNCTION FOR RISK STRATIFICATION OF PATIENTS WITH HYPERTROPHIC CARDIOMYOPATHY: A BAYESIAN MODEL AVERAGING
Authors: Buongiorno A , Albani S , Grilli G , Merlo M , Berchialla P , Ricotti A , Pierri A , De Luca A , Barbisan D , Mabritto B , Bongioanni S , Luceri S , Porto I , Musumeci G , Sinagra G
Published: May 2023

Background

Hypertrophic cardiomyopathy (HCM) is characterized by increased left ventricular (LV) stiffness, leading to raised ventricular filling pressures and restrictive diastolic dysfunction (RDD), in itself independently associated with an increased risk of a clinical deterioration. We assessed whether echocardiography evaluation of diastolic function in HCM could yield prognostic value and be useful in HCM risk stratification.

Methods

We retrospectively reviewed clinical and imaging (echocardiography and cardiovascular magnetic resonance, CMR) data from 361 consecutive patients from two HCM Italian referral centers (Mauriziano Hospital, Turin; University Hospital of Trieste, Trieste). Among them, 28 patients were classified after Doppler echocardiography examination as restrictive (E/A > 1.5, DecT E < 140 ms, E/e’ > 10). The primary endpoint was a large cardiovascular composite consisting of sudden cardiac death (SCD), major ventricular arrythmias (MVAs), heart transplant (HT) and hospitalization for heart failure (HF). Other secondary endpoints were investigated as follows: 1) a secondary arrhythmic endpoint consisting of SCD and MVAs, 2) a key secondary composite of HF, HT, non–SCD. A Bayesian Model Averaging (BMA) was then performed to overcome the bias determined by the limited number of observations.

Results

Over a mean follow up of 7 ± 3 years, 61 (17%) patients experienced at least one primary composite endpoint event. Of them, 10 were identified with a restrictive diastolic pattern. When BMA was performed, late gadolinium enhancement (LGE) presence at CMR and RDD were significantly associated with the primary composite outcome (respectively, PI = 100, HR = 3.55, pd = 1.00; PI = 74.5, HR = 3.33, pd = 0.99). Left atrium (LA) diameter was not strongly associated with the arrhythmic endpoint, whereas it was significantly associated with the key secondary composite outcome, as well as with increased filling pressures (E/e’) (respectively, PI = 94.5, HR = 1.10, pd = 1.00; PI = 86.8, HR = 1.08, pd = 0.99).

Conclusions

Restrictive diastolic dysfunction is an independent predictor of poor prognosis in early stages of HCM in absence of systolic dysfunction. In particular, RDD predicted outcomes related to heart failure better then LA diameter and E/e’.
C86 ASSOCIATION OF PLASMA TMAO VALUES WITH ANOTHER ISCHEMIC EVENT DURING LONG–TERM FOLLOW–UP IN PATIENTS WITH MYOCARDIAL INFARCTION
Authors: Aleksova A , Janjusevic M , Stornaiolo M , Fluca A , Zhou X , Hiche C , D’Errico S , Novellino E , Sinagra G
Published: May 2023

Background

Elevated plasma trimethylamine N–oxide (TMAO) levels, a metabolite derived from the intestinal microbiota, are closely related to atherosclerosis due to its involvement in increased inflammation, oxidative stress and cholesterol reverse transport.

Objectives

Blood samples were collected at admission from 81 patients who survived acute myocardial infarction (AMI) and from 10 healthy individuals. TMAO concentrations were measured by means of liquid chromatography–tandem mass spectrometry with an aim to evaluate the predictive value of this biomarker in terms of another major event during long–term follow–up.

Results

Patients with AMI have significantly higher median plasma TMAO concentration compared to healthy individuals (respectively, 1.62 (1.37 – 2.25) µM vs 0.55 (0.35 – 0.74) µM, p < 0.0001). Considering only patients with AMI, TMAO values positively correlated with pro–inflammatory markers CRP and TNF–α. In addition, TMAO positively correlated with creatinine and negatively correlated with GFR. Moreover, we noted the trend of higher TMAO values among patients with diabetes mellitus compared to patients without (1.68 (1.44 – 5.43) µM vs 1.59 (1.33 – 2.099) µM, p=0.065). During a median follow–up of 61.74 (59.34 – 64.24) months, 10 patients suffered another infarction. Those individuals had significantly higher TMAO values compared to subjects without another ischemic event (respectively, 2.29 (1.60 – 6.49) µM vs 1.60 (1.34 – 2.09) µM, p = 0.026). Kaplan–Meier analysis confirmed that elevated values of TMAO were associated with the risk of another infarction (p=0.029), whereas multivariate Cox regression analysis did not demonstrate the prognostic value of TMAO towards re–infarction probably due to the small cohort.

Conclusions

Higher plasma TMAO values at admission in patients with AMI are associated with re–infarction at long–term follow–up.
P4 TRANSTHYRETIN–INDUCED CARDIAC AMYLOIDOSIS: A RARE MUTATION IN AN ITALIAN FAMILIAL CASE
Authors: Moscardelli S , Santangelo G , Bursi F , Rusconi D , Guazzi M
Published: May 2023

A 65–year–old man came to our hospital for a subacute stroke of the left parietotemporal area. An aorto–coronary bypass for stable coronary artery disease and aortobisiliac bypass for infrarenal aortic aneurysm (with post–operative courses complicated by multiple atrial fibrillation paroxisms which were pharmacologically cardioverted) was reported. No undergoing anticoagulant therapy for CHADSVASc=1 was reported. Hypothesizing a cardioembolic origin of the stroke, echocardiographic analysis was performed which showed increased ventricular thickness and mass, inhomogeneous texture, reduced systolic function and strain with apical sparing, II degree diastolic dysfunction and severe left atrial dilatation. The strong suspicion of amyloidosis, raised by the echocardiographic findings, was confirmed by bone scintigraphy. The absence of free immunoglobulin chains in blood and urine and a normal protein electrophoretic pattern, would have instead excluded the diagnosis of AL amyloidosis. Thus we performed genetic testing to characterize the type of ATTR (transthyretin). An homozygous Val142Ile mutation in exon 4 of the TTR gene was found. This mutation, typically found in patients of African ancestry, is extremely rare in the Caucasian population. In fact, only 5 cases of patients with this mutation and with phenotypic manifestations very similar to the African ancestral ones have been so far reported, thus indicating that this mutation is not restricted to African ancestry but may be an underestimated Caucasian variant. The large GnomAD database estimates that this homozygous mutation is present in only 0.72% of the general population, while the remaining part of the carriers are heterozygous. Val142Ile leads to increased formation of amyloid fibrils and to the formation of a particularly unstable TTR tetramer. This variant is associated with a worse quality of life, a higher incidence of AF and a lower survival than the wild type TTR. In light of the worse clinical outcomes associated to this variant it is therefore essential to maintain a high level of clinical suspicion in order to perform an early diagnosis from a clinical and molecular point of view in order to be able to direct the patient as soon as possible to the current available therapies that can modify the course of the pathology and avoid premature fatal events.
P9 INCESSANT ARRHYTHMIC STORM, EFFECTIVELY TREATED BY VENTRICULOPLASTY
Authors: Magnano R , Testa S , Cappelli C , Pezzi L , Occhiuzzi E , Di Marco M , Forlani D , Duronio G , Verrengia E , Vitulli P , D’Alleva A , Gallina S , Paloscia L
Published: May 2023

Arrhythmic storm is an emergency characterized by cardiac electrical instability leading to multiple episodes of sustained ventricular arrhythmias in a short period of time. Patients have multiple comorbidities that require multidisciplinary interventions to achieve clinical stability. The genesis of arrhythmic storm involves a complex interaction between a predisposing arrhythmogenic substrate, triggering factors, autonomic nervous system, and patient comorbidities. Antiarrhythmic drug therapy plays a key role and has been shown to be associated with a significant reduction in VT recurrence. Transcatheter ablation in patients refractory to drug therapy has been shown to reduce arrhythmic recurrences, ICD shocks, and improve patients‘ cumulative survival over time. Rare cases of arrhythmic storm refractoriness treated by plastic ventricle for the purpose of excluding scar are reported in the literature. We present the case of a 62–year–old man, Caucasian race, suffering from chronic ischemic heart disease with hypokinetic–dilated evolution carrying CRT–D, diabetic, obese, dyslipidemic, undergoing multiple percutaneous revascularizations. Sent to our hospital from a peripheral hospital for arrhythmic storm refractory to maximal antiarrhythmic therapy treated with multiple internal and external DC shocks. During hospitalization, the patient underwent SEF and attempted ATC which was ineffective in the following days due to recurrence of numerous episodes of TVS. In view of the clinical picture and refractoriness to therapy, it was decided to perform coronary examination which found subocclusion of the 1st diagonal branch treated by implantation of medicated stent. On ventriculography, the presence of severe pseudoaneurysmal formation supplied at the level of the anterior wall of the left ventricle was confirmed. It was decided to transfer the patient to cardiac surgery to perform ventriculoplasty surgery. In the following days, the patient underwent surgery through exclusion of the aneurysm by patching in pericardium in CEC. Procedure was free of complications. On follow–up echocardiogram dilated left ventricle with severe left ventricular dysfunction with findings of cardiac aneurysm exclusion. In the following days, the patient presented no further arrhythmic episodes.
P38 SINGLE VERSUS DOUBLE STENTING IN NSTEMI PATIENTS WITH COMPLEX LEFT MAIN BIFURCATION DISEASE
Authors: Rigatelli G , Zuin M , Pasquetto G , Bilato C , Roncon L
Published: May 2023

Background

Among patients with non–ST–segment elevation myocardial infarction (NSTEMI) the presence of a bifurcation left main (LM) disease represents a particular subset graved by both clinical and technical challenges. We sought to assess the long–term outcomes of patients with NSTEMI treated either by single or double stent strategy, having an LM bifurcation culprit lesion.

Methods

We retrospectively analyzed the procedural and medical data of consecutive patients referred to our center for NSTEMI due to complex LM bifurcation disease as the culprit lesion, treated using either single or dual stenting (provisional stenting, T or T–and–Protrusion (TAP), Culotte, and Nano–inverted–T (NIT)) techniques between January 2008 and May 2018. Target lesion failure (TLF) was defined as the composite of cardiovascular death, target–vessel myocardial infarction (MI), and clinically driven target lesion revascularization (TLR).

Results

Four hundred and forty–five patients (54.1% males, mean age 70.3 ± 12.8 years, mean Syntax score 31.6 ± 6.3) were evaluated. Of these, 155 patients (34.8%) were treated using a single stent while the remaining were treated with a double stent strategy. After a mean follow–up of 37.1 months (IQR 22.1–39.3), TLF rate was 8.7% (n = 39): 5/155 (3.2%) in the crossover group; 10/53 (18.8%) in T/TAP group, 14/89 (15.7%) in the culotte group, and 10/148 (6.7%) in the NIT group of patients. Cardiovascular mortality rate was 2.9% (n = 13) while stent thrombosis was 0.89% (n = 4). On multivariate analysis dyslipidemia, Syntax score > 25, triple vessel disease, additional LM ostial, or LM body lesions and the use of Rotablator, were independent predictors of TLF.

Conclusions

Either a single or double stent strategy resulted in low rates of TLF, cardiovascular death, and stent thrombosis in the long–term period in NSTEMI LM patients with contraindications or refusal of surgery. A single stent strategy appeared to have a slightly better outcome compared to a 2–stent strategy.
P42 ACUTE STENT THROMBOSIS IN CATH LAB DURING OPTIMIZED PCI: HOW TO RECOGNIZE IT AND POSSIBLE TREATMENT
Authors: Formigli D , Parente A , Pirozzi E , Cocozza S , Franco V , Moscato F , Silvestri P , Scherillo M
Published: May 2023

Angiographic Acute Stent Thrombosis occur in 0.5%–2% of procedures.OCT–PCI or Optimized PCI represents a new approach particularly indicated in complex high thrombotic risk lesions, in patients at high bleeding risk with need for short DAPT and in the treatment of vulnerable plaques. Post–stent OCT thrombus finding was defined in previous studies as mass with diameter ≥250μm attached to the stent struts, was present until 40% of cases and is associated with definite angiographic thrombosis. Outcome of OCT thrombus is generally favorable although in about 25% there may be a progression. Case 1: 75–y smoker female with hypertension and atrial fibrillation on NOAC therapy presented in ICU with NSTEMI. At angiography: 75% stenosis focal plaque at proximal circumflex (Fig1A). At OCT vulnerable plaque: ulcerated with intimal flap < 90°, thin fibrous cap 20 µm, MLA 2.17mm² and AS 63%, intimal micro–calcifications and cholesterol crystals (Fig1C). We implanted DES with post–dilatation. Treatment was Cangrelor, heparin 100 IU/kg and ASA 250 mg ev. OCT showed acute 660 µm thrombosis of the stent body although there was perfect angiographic result (Fig1D+B). Further multiple balloon dilatation of the stent was carried out with thrombosis persistence on OCT control (Fig1E) and new appearance of multiple thromboses adhering to the intravascular side stent struts (Fig1F–G). Switch from Cangrelor to Tirofiban was done. Patient‘s clinical course was uneventful with discharge after six days on triple antithrombotic therapy with low–dose NOAC, ASA and clopidogrel.Case 2: 63–y smoker man arrived in cath lab for anterior STEMI. He had already taken ASA 300 mg ev and Ticagrelor 180 mg oral bolus about 60 minutes earlier in the ambulance. In Cath Lab was done heparin 100 IU/kg. P–PCI was performed for acute sub–occlusion (Fig2A) of the ostial DA treated by pre–dilation, DES implantation on Left Main–DA and multiple post–dilations according to the POT technique. OCT control showing extensive stent malapposition (860 µm) with evidence of multiple thromboses adhering to the stent struts on Left Main (diameter 410 µm) although there was perfect angiographic result (Fig2B–E). Procedure was optimized by adequate post–dilatation of the LM and administration of Abciximab. Patient‘s clinical course was uneventful with discharge after five days on ASA and Ticagrelor.

Conclusions

Post–stent OCT thrombus may guide the choice of use of Glicoprotein IIb/IIIA Inhibitors in Cath Lab.
P57 VOLTAGE CHARACTERIZATION OF ABNORMAL CONDUCTION ZONES IN PATIENTS AFFECTED BY ATRIAL FIBRIALLATION
Authors: Gregusova N , Grossi B , Pagani S , Taormina A , Ceriotti C , Poggio L , Galimberti P , Battaglia V , Del Monaco G , Latini A , Valcher S , Stankowski K , Mincione G , Condorelli G , Frontera A
Published: May 2023

Background

In case of persistent atrial fibrillation (AF), atrial substrate assumes a dominant role in sustaining the arrhythmia. Recent studies prove that low voltage areas (LVA, Voltage Amplitude < 0,5 mV) represent an additional target for ablation of AF patients. Purpose. The purpose of this study is to analyse whether structural atrial conduction abnormalities (i.e., pivot sites and slow conduction corridors) may occur outside low voltage areas.

Methods

The study is based on the retrospective analysis of 31 consecutive maps of patients undergoing AF ablation (16 paroxysmal and 15 persistent cases). The clinical procedures have been performed with the support of a mapping system. Sinus rhythm activation maps and bipolar maps used for this analysis have been created with a multipolar mapping catheter. Map points were only acquired when the electrode was in contact with the endocardial tissue to avoid misleading voltage amplitude information. Slow conduction corridors and pivot sites have been analysed. At these sites, EGMs characterization included voltage amplitude (mV), signal duration (ms) and fractionation.

Results

The average value of EGMs amplitude reported at pivot sites and slow conduction zones, respectively, amounted to 2,08 ± 0,63 mV and 2,1 ± 0,66 mV in paroxysmal cases. In persistent cases, there were slight decreased values to 1,95 ± 0,93 mV and 1,89 ± 0,89 mV. Characterization at pivot sites documented a mean duration value of 45,4 ± 4,64 ms and 49,93 ± 5,51 ms in paroxysmal and persistent patients, respectively, while in slow conduction zones 41,53 ± 7,94 ms and 49,04 ± 6,41 ms have been reported. As for fractionation, more than five deflections per signal have been identified in all abnormal conduction areas.

Conclusion

Our study proves that functional electrophysiological phenomena can occur outside low voltage areas, even in persistent cases. According to this analysis, not all LVA represent the correct target for catheter ablation, encouraging the development of further methods for investigation of atrial substrate.
P62 SEASON VARIABILITY IN ATHEROSCLEROSIS COMPOSITION: INSIGHTS FROM 1848 NON–CULPRIT CORONARY PLAQUES
Authors: Sammartini E , Biccirè F , Debelak C , Budassi S , Varricchione G , La Porta Y , Romagnoli E , La Manna A , Marco V , Boi A , Fabiocchi F , Taglieri N , Calligaris G , Burzotta F , Francesco V , Arbustini E , Prati F
Published: May 2023

Background

Several environmental and seasonal factors are thought to be crucial in the risk of acute coronary syndromes (ACS), including temperature, latitude, longitude, atmospheric air pressure, wind velocity and circadian period. However differences in coronary plaque composition according to season variation is still poorly understood. Purpose. Our study aims to analyse the characteristics of non–culprit coronary plaques in patients undergoing optical coherence tomography evaluation (OCT) evaluation of the left anterior descending artery.

Methods

We included 1848 non–culprit coronary plaques from 1003 patients of the CLIMA registry. The season of OCT pullback acquisition was collected for each patient.

Results

Overall, median age was 66 years (56–74), with 24.6% of women and 53.4% of ACS. At patient–level analysis, patients admitted in summer were less frequently affected by hypertension (59.8% vs 69.4% in autumn, 68.5% in winter and 72% in spring; p=0.027) and chronic kidney disease (14.8% vs 15.9% in autumn, 10.3% in winter and 19.4% in spring; p=0.037) in. At lesion–level analysis, similar values of fibrous cap thickness, maximum lipid arc, length of plaques and presence of macrophages were observed (Table 1). Summer plaques had a smaller minimum lumen area than spring plaques (5.7±3.1 vs 5.1±239; p=0.044) and also a less frequent superficial macrophage infiltration (23% vs 36.1% in autumn, 30.5% in winter and 30.6% in spring; p=0.030) and presence of cholesterol crystals (16.7% vs 23.8% in autumn, 28.4% in winter and 22.1% in spring; p=0.037 than three other season).

Conclusions

Coronary plaques during summer had less local sign of inflammation such superficial macrophage infiltration and cholesterol crystals. Further studies are needed to confirm these results and investigate clinical implications.
P84 RAPID OPTIMIZATION OF HEART FAILURE THERAPY: ROLE OF THE HOSPITAL – TERRITORY NETWORK
Authors: Scardovi A , Renzi M , Festinese S , Del Sindaco D , Di Giacomo T , Ricci R
Published: May 2023

Heart Failure (HF) Guidelines take into account the close administration of the four classes of "pillar" drugs (Beta–blockers, Sacubitril–Valsartan, SGLT2i, MRA) completing their titration in the shortest possible time. The hospital outpatient clinic for HF (HOCHF), with the collaboration of the dedicated nursing clinic (DNCA), is the ideal place to follow patients (pts) in the phase immediately following discharge (7–10 days), in order to rapidly optimize the therapy and achieve stabilization: this can only be possible if the HOCHF is inserted in a Hospital–Territory–Hospital (HTH) network capable of continuing and sharing the follow up (FU) of stabilized patients. In ASL Roma 1, a HTH has been active in districts 1–2–3 since 2017, which includes the Santo Spirito Hospital –NRM, 3 Health Centers and 7 territorial outpatient clinics where 23 cardiologists and 50 nurses operate. The hospital component of the HTH is represented by the HOCHF Santo Spirito (supported by the DNC) which, thanks to the close collaboration with the territorial cardiology (TC), manages to concentrate mainly on the pts just discharged for the optimization of the therapy, on the unstable ones or the ones requiring advanced treatment. The clinic performs an average of 25 weekly examinations supported by the DNC which performs face–to–face and telephone services. In the period January – December 2022, 1,109 cardiological examinations were performed. 123 pts (mean age 76 + 4 years, 25% women) had access to the HOCHF within 10 days of discharge. The target therapy was achieved in the first 4 weeks in 42 pts (34% of the total) with 3–4 accesses. A further 50 pts achieved the therapeutic goal at 8 weeks (40.6% of the total) with 4–6 accesses. Of the remaining 31 pts, 5 (4% ​​of the total) were re–hospitalized at 30 days, 4 died (3.2% of the total), 22 (17.8% of the total) reached the target therapy in the following months. All the stabilized pts continued the FU in the proximity TC. In conclusion, in our experience, it was possible to titrate the therapy suggested by the guidelines in 74.7% of pts discharged for HF within 8 weeks. This result was obtained by focusing the activity of the HOCHF and DNC on appropriate pts, thanks to the close collaboration with the TC.
P89 THE INTEGRATED CARDIOGENETICS CLINIC FOR CARDIOMYOPATHIES – FIRST YEAR OF ACTIVITY RESULTING FROM A NEW ORGANIZATIONAL MODEL
Authors: Bianco M , Gazzola V , Nangeroni G , Biolè C , Deaglio S , Giachino D , Chinaglia A
Published: May 2023

Introduction

Over the last year our center has empowered a specific clinic for the follow–up of patients affected by cardiomyopathies. In this context, genetic testing was offered to specific patients suspected of having genetically determined cardiomyopathies. We present here how we organized the genetic diagnostic pathway of these patients and the result of the first year of activity.

Methods

The diagnostic workup of patients with a suspect of genetically determined cardiomyopathies was implemented with the goal of time and resources optimization. After a comprehensive evaluation by clinical cardiologists the blood sample of patients who gave their informed consent are directly referred to the reference center for NGS analysis. In particular, patients are considered for NGS when they have familiarity for cardiomyopathies and/or when a clear explanation for their clinical picture is lacking. A dedicated platform is employed to require genetic testing by cardiologists and to provide meaningful information to the geneticists performing the genetic analysis. Once test results are available, all patients are offered a joint consultation with the cardiologist and medica geneticists to discuss the results.

Results

A total of 69 patients were recruited during the first year of this project. The majority of patients (60 patients) underwent NGS, whereas a minority (9 patients) underwent Sanger sequencing. The clinical suspects prompting NGS were DCM (20 patients), HCM (14 patients), ARVD (10 patients), amyloidosis (10 patients), NCM (2 patients), or others (4 patients). To date, 47 patients ha received the results of their genetic investigation, with a mean time from blood sampling to test results date of 88 days. In particular, the results of testing showed: 4 pathogenic variants (C5), 13 likely pathogenic variants (C4), 24 variants of uncertain significance (C3) and 22 negative results. The remaining 22 patients are waiting for results and subsequent genetic counseling, as they underwent test in the last 3 months.

Conclusions

Easy and time effective access to genetic testing is of paramount importance in the management of patients with cardiomyopathies. Here we presented the results of an innovative approach to optimize the diagnostic workup of these diseases, which allowed us to provide answers to the patients in a fast and effective way, optimizing our resources and avoiding the loss of patients during follow–up.
P93 NATURAL HISTORY AND CLINICAL BURDEN OF MODERATE AORTIC STENOSIS: A SYSTEMATIC REVIEW AND META–ANALYSIS
Authors: Morelli M , Galasso M , Soriano F , Nava S , Da Pozzo C , Esposito G , Piccaluga E , Bossi I , Montalto C , Oliva F , Oreglia J , Giannattasio C
Published: May 2023

Objectives

The aim of this study was to assess the natural history and clinical burden of moderate aortic stenosis and to investigate the interaction of left ventricular ejection fraction and of age with prognosis.

Background

The mortality risk of patients with moderate aortic stenosis is not well known but recent studies suggested that it might negatively affect prognosis.

Methods

A systematic research was conducted on PubMed. The inclusion criteria were: 1) inclusion of patients with moderate aortic stenosis; 2) report of the survival at 1–year follow–up (minimum). Incidence ratios related to all–cause mortality in patients and controls of each study were estimated and then pooled using a fixed effects model. Meta–regression analysis was performed to assess the impact of left ventricular ejection fraction and age on the prognosis of patients with moderate aortic stenosis.

Results

Fifteen studies and 11,596 patients with moderate aortic stenosis were included. All–cause mortality was significantly higher among patients with moderate aortic stenosis than among controls: 10.7% (95% CI: 0.1010–0.1136) vs 4.5% (95% CI: 0.0438–0.0454) at 1–year (p < 0.0001), 17.7% (95% CI: 0.1692–0.1854) vs 7.6% (95% CI: 0.0754–0.0775) at 2–year, 23.0% (95% CI: 0.2204–0.2387) vs 9.9% (95% CI: 0.0973–0.0997) at 3–year, 27.9% (95% CI: 0.2685–0.2899) vs 11.9% (95% CI: 0.1177–0.1203) at 4–year, and 32.4% (95% CI: 0.3125–0.3360) vs 14.2% (95% CI: 0.1402–0.1430) at 5–year follow–up. Left ventricular ejection fraction did not significantly impact on the prognosis of patients with moderate aortic stenosis (estimate = –0.0020; 95% CI: –0.0078–0.0038; p = 0.4584), unlike of age (estimate = 0.0067; 95% CI: 0.0007–0.0127; p = 0.0323).

Conclusions

Moderate aortic stenosis is not a benign disease. Further studies are necessary to confirm the prognostic impact of this valvulopathy and the possible benefit of the aortic valve replacement. Figure 1: All–cause mortality of patients with moderate aortic stenosis (red) vs controls (black) at 1–, 2–, 3–, 4– and 5–year follow–up. Figure 2: Impact of left ventricular ejection fraction on prognosis of patients with moderate aortic stenosis. Figure 3: Impact of age on prognosis of patients with moderate aortic stenosis.
P94 LATE–ONSET POST–INFECTIVE AORTIC PSEUDO–ANEURYSM AFTER BIOPROSTETHIC AORTIC VALVE REPLACEMENT
Authors: Ianni U , Alfieri M , Molisana M , D’Agostino S , Gizzi G , Cicchitti V , Di Eusanio M , Parato V
Published: May 2023

A 74 year–old man was admitted three months after SAVR symptomatic for dyspnea. Past medical history: DM type 2, PAD and recent SAVR after diagnosis of severe aortic stenosis, complicated by Stafilococcus Epidermidis blood culture sternal wound dehiscence, requiring Robicsek technique treatment and long–term parenteral antibiotics. He was finally discharged to our cardiac rehab unit. Blood analysis: negative blood culture at admission with negative CPR. Late positivity (after 2 weeks) for a Staphylococcus epidermidis reinfection. EKG: normal atrio–ventricular and intra–ventricular conduction with regular repolarization. TTE: Normal left ventricular volume and ejection fraction with severe aortic regurgitation secondary to suspected partial bioprosthesis detachment. TOE: valvular detachment with a newly–formed pouch located in the mitro–aortic membrane. Bioprosthetic valvular failure (BVF) is a pathological entity arising from a variety of conditions affecting prosthetic heart valves. We present the case of a late–onset partial valvular bioprosthesis detachment associated with a newly–formed pseudoaneurysm due to late infective endocarditis occurred after cardiac surgery, initially manifested with negative cultural findings and suddenly evolved in severe aortic regurgitation. Valvular detachment is an infrequent complication of infective endocarditis. Surgery is the only option capable of restoring a proper anatomy and a correct function of the valvular apparatus. Patient underwent re–do surgery and a new SAVR was needed after confirmation of diagnosis with no residual aortic regurgitation after discharged. BVF is a fearsome and severe condition presenting with a wide spectrum of clinical presentation. Our experience highlights the need of a prompt diagnosis. Late positivity of blood cultures for Stafilococcus Epidermidis probably depend on prolonged antimicrobial therapy after sternal dehiscence treatment which have probably masked laboratoristic finding in early phase (negative CPR and blood cultures). An early intervention is mandatory in order to prevent systemic dissemination or acute decompensation secondary to severe aortic regurgitation. Surgical approach in this case guaranteed a radical treatment with no residual regurgitation or sub–acute microbial infection. 4–weeks parenteral antibiotics during cardiac–rehab efficacy–controlled relapse of CPR and blood–culture (negative before final discharge).
P98 A CASE OF “RECURRENT” AORTIC VALVE STENOSIS
Authors: Baroni G , Deola P , Alderighi C , Peluso D , Cucchini U , Chirillo F
Published: May 2023

Clinical Case

A 80–year–old man underwent coronary angiography in 2006 because of stable angina. There was chronic total occlusion of middle left anterior descending artery requiring percutaneous intervention. In 2009 he underwent coronary angiography for recurrent angina: a severe stent restenosis was treated with stenting in stent (DES in BMS). The patient was subsequently asymptomatic till 2018 when he complained of exertional dyspnea and angina. Stent patency and severe aortic valve stenosis (AVA 0.85 cm2) were documented. The patient underwent successful transcatheter aortic valve implantation and discharged with dual antiplatelet therapy (DAPT) (Asa 100 mg and Clopidogrel 75 mg). Clinical and echocardiographic follow–up was unremarkable (mean prosthetic gradient 17 mmHg, DVI=0.45). In July 2021 during a cardiological check the patient complained of bruising: ASA was discontinued. In February 2022 the patient suffered from an exertional angina. A dipyridamole stress–echocardiography failed to demonstrate inducible ischemia, although the patient experienced angina at the peak load step. Transthoracic echocardiogram (TTE) revealed high mean trans–prosthetic aortic gradient (52 mmHg, DVI=0.18). A trans–esophageal echocardiogram (TEE) showed reduced mobility of the thickened left coronary and non–coronary aortic prosthetic leaflets. In the hypothesis of prosthetic valve thrombosis, warfarin (INR range 2–3) was started after stopping clopidogrel. After three months a TTE showed normalized mean trans–prosthetic gradients (17 mmHg, DVI=0.5). When a 6 month–period of anticoagulant therapy was accomplished, warfarin was stopped and DAPT administered again. In September 2022 the patient complained of worsening dyspnea and chest pain on exertion. At TTE mean trans–prosthetic gradients (46 mmHg) was increased. A new TEE showed thickening of non–coronary and right coronary leaflets, suggestive of recurrent valve thrombosis. After stopping DAPT, warfarin was started again with good result (mean prosthetic gradient 12 mmHg, DVI=0.5).

Conclusion

Thrombosis of aortic valve prothesis is an infrequent event usually occurring in early post–implantation period. In our case it occurred four years after implantation following DAPT interruption. The likely initial prosthetic valve degeneration together with a simplification of DAPT may have had a causative role. Since the proved efficacy of warfarin and the limited experience of DOAC in this field, the patient was given warfarin sine die.
P100 RENAL DENERVATION FOR ATRIAL FIBRILLATION IN DRUG–RESISTANT HYPERTENSIVE PATIENTS. AN UPDATED META–ANALYSIS OF RANDOMIZED CONTROLLED TRIALS
Authors: Meco M , Belli G , Fouladvand F , Agosteo E
Published: May 2023

Introduction

This meta–analysis of randomized controlled trials (RCT) was permormed to compare clinical outcomes following renal denervation (RDN) in drug–resistant hypertensive patients with atrial fibrillation (AF).

Methods Data collection

We applied the methods recommended by the Preferred Reporting Items for Systematic Reviews and Meta–Analyses (PRISMA) statement. We searched Pubmed, and the Cochrane Central Register for randomized controlled trials (RCT) that evaluated AF catheter ablation associated with RDN compared with AF catheter ablation alone, in drug–resistant hypertensive patients. Outcome: The primary outcomes was the rate of AF recurrence throughout the follow–up period. Statistical Analysis: The analyses were performed using RevMan version 5.3. The results are presented as odds ratios (OR) for dichotomous outcomes (Inverse variance method, random effect model) with 95% confidence interval (CI).

Results

Five full texts met inclusion criteria. A total of 531 patients were included (269 patients randomized to catheter ablation and RDN and 262 patients randomized to catheter ablation alone), with a mean follow–up of 16.8 months. We found a significantly lower number of patients with AF recurrence in the AF catheter ablation with RDN group (83/269), respect to AF catheter ablation alone (125/262) at the end of the follow–up (OR 0.51 (0.35–0.72) p 0.0002) RDN procedure in these trials was was safe with an overall compilcation rate of 6.32%

Conclusions

Combined AF catheter ablation and RDN is beneficial for patients with drug resistant hypertension and AF reducing the risk of AF recurrence.
P119 WHEN THE ELECTROCARDIOGRAM CHANGES YOUR DIAGNOSIS
Authors: Magnano R , Diella N , Pezzi L , Corazzini A , Cappelli C , Ricci F , Genovesi E , Verrengia E , Fulgenzi F , Vitulli P , Forlani D , D‘Alleva A , Gallina S , Di Marco M , Paloscia L
Published: May 2023

Sarcomeric hypertrophic cardiomyopathy is among the most common genetic cardiovascular diseases.Clinical,electrocardiographic and echocardiographic evaluation plays a crucial role in the diagnosis and initial framing of the hypertrophic phenotype. A 51–year–old Caucasian man with multiple myeloma,previous autologous transplant,undergoing chemotherapy for disease recurrence,without cardiovascular risk factors or family history of MCV or MCI came to our outpatient clinic for a follow–up visit.At another center,cardiac amyloidosis was diagnosed due to the echocardiogram finding of concentric left ventricular hypertrophy. Patient asymptomatic for angor,NYHAI dyspnea,heart palpitation,syncope,presented with rhythmic cardiac action,2/6 systolic murmur at centrum and tip,no central or peripheral stasis.On ecg sinus bradycardia at fc57 bpm,PR202 msec,high QRS V4–V6 voltages with negative T waves in infero–lateral site,suggestive for left ventricular hypertrophy. On echocardiogram:concentric left ventricular hypertrophy with posterolateral papillary hypertrophy,preserved contractile function,FE 62%,grade I diastolic dysfunction,no signs of elevated filling pressures,left atrium and right ventricle in normal range;tripartite aortic valve in absence of gradients,prolapse of the LAM(A1–A2)with mild grade insufficiency,mild tricuspid insufficiency. At cardiac MRI:non–dilated left ventricle with concentric hypertrophy,maximum thickness 16mm at basal SIV level,apical inferior wall,15mm anterior wall,anterolateral media,apex systolic obliteration 14mm,FE 64%.Right ventricle and atria in normal.T2–STIR sequences tenuous hyperintensity at infero–lateral media wall,inferior apical wall and lateral,increased T2 mapping in relation to myocardial edema. Subendocardial LGE of middle infero–lateral,apical lateral and postero–medial papillary wall,slight increase in native T1 mapping,ECV 27%,picture of sarcomeric hypertrophic heart disease.Holter ecg showed no arrhythmias;at HCM score low risk,no indication for ICD implantation. The patient was undergoing genetic screening test for HCM.The presence of left ventricular hypertrophy may mimic different forms of hypertrophic cardiomyopathy,leading to misdiagnosis or delayed diagnosis.Differential diagnosis,ecg and specific use of imaging tests are of paramount importance.