bluuebunny/crossref_metadata_2025 huggingface dataset:
P793 Is gender a key determinant of exercise tolerance in moderate-to-severe aortic stenosis?
Authors: Bandera F , Ghizzardi G , Milani V , Boveri S , Alfonzetti E , Guazzi M
Published: January 2020

Background

Gender-related differences are known about pathophysiology and clinical outcome of aortic stenosis (AS). Nevertheless, the impact due to gender on effort intolerance as well as its mechanisms has not been defined. We sought to assess functional capacity in AS labelling gender differences.

Methods

Sixty patients [age 69(63-76)years; female 24(40%)] with at least moderate AS (rest Vmax >3 m/s) underwent to rest and exercise echocardiography with simultaneous cardiopulmonary exercise test (CPET) during maximal symptom-limited exercise. Differences on echocardiographic and CPET variables were assessed according to gender.

Results

Women showed lower effort tolerance [female vs male: workload 51(46.5-72.5) vs 92.5(74-118.5)watts, p<.0001; peakVO2 13.2(12-15.2) vs 17.7(14.2-22-7)mL/kg/min, p=.002; Predicted peakVO2 63.5(53.5-74) vs 76(61.5-101)%, p=.006; anaerobic threshold 11.4(9.8-13.2) vs 12.8(11.4-15-7)mL/kg/min, p=.01; VE/VCO2 29.5(26.1-30.2) vs 26.2(24.3-28.5), p=.008] characterized by lower chronotropic reserve [age-predicted heart rate (HR) reserve 69.5(58.6-78.9) vs 82.8(74.6-89.7)%, p=.003; HR reserve 40.5(33.6-51) vs 47.5(39-67.5), p=.02; HR recovery at 1 min 9(4-12) vs 14(8.5-20), p=.002)], lower cardiac output (CO) response [exercise CO 7.9(6.4-8.8) vs 8.6(7.9-9.9) L/min, p=.01; CO reserve 2.9(2.1-3.6) vs 4.3(3.2-5.4)L, p=.0008] and lower peripheral extraction [C(A-V)VO2 12(9.7-14.2) vs 15.4(13.8-16.6)mL/100mL, p=.0007]. At 12 months follow up, the incidence for AVR was 0.55(0.31-0.73) in women and 0.29(0.15-0.45) in men, while at 60 months it was respectively 0.69(0.44-0.85) and 0.59(0.11-0.35).

Conclusions

in women, moderate-to-severe AS generates a higher degree of functional limitation compared to men. A lower CO reserve, mainly determined by an impaired chronotropic response and lower C(A-V)O2, plays a central role. This unfavourable phenotype is associated with a less advanced LV remodelling pattern and an earlier incidence of AVR.
P796 Feasibility of exercise stress echocardiography and its correlation with angiographically significant coronary disease
Authors: Chowdhary A , Nadarajah R , Hammond C , Burnett N , Mwambingu T , Artis N , Patel P A
Published: January 2020

Background

European Society of Cardiology (ESC) guidelines on the management of stable coronary artery disease (CAD) advocate stress echocardiography (SE) as a first line assessment for functionally significant ischaemia. Pharmacological stressors such as dobutamine are typically utilised in most UK centres in view of practical benefits when compared with treadmill testing. However, exercise provides the best physiological mimic and enables additional data on haemodynamics and electrocardiogram (ECG) changes to be obtained.

Purpose

To assess the feasibility and safety of exercise stress echocardiography (ESE), and the correlation of positive testing with significant coronary disease and major adverse cardiovascular events.

Methods

A retrospective, single-centre analysis of 500 consecutive patients undergoing ESE for investigation of stable CAD. Cases were excluded when a pharmacological stressor was utilised, or in contexts where ESE was performed for other clinical indications. ESE reports were interrogated for patient demographics, co-morbidities, achievement of target heart rate (HR), procedural sequelae, image quality and findings. Electronic records were reviewed after 24 months to assess results of invasive angiography, when performed, and long-term outcomes including myocardial infarction (MI) and cardiovascular mortality. Concordance between ischaemic territory on ESE and coronary lesions on angiography was also collated.

Results

95% (475/500) of patients were suitable for inclusion. Of these, 83% (394/475) achieved target HR. Sequelae arose in 0.02% (9/475), with the most frequent being ectopy (4 cases). Image quality was adequate in 98% (465/475), with the requirement for contrast agent in the remainder. There were no significant differences in burden of cardiovascular risk factors between the positive and negative ESE groups. 13% (63/475) were positive for inducible ischaemia in one or more myocardial segments. Of these, 71% (45/65) underwent angiography, with 48% (31/65) requiring stenting or bypass surgery. Ischaemic territory on ESE correlated with angiographic lesions in 65% (29/45) of cases. ESE underestimated extent of significant CAD in only 7% (3/45). In the subcohort positive for ESE, 3% (2/63) suffered a MI and cardiovascular mortality was 1.5% (1/63).

Conclusions

ESE is a safe, non-invasive modality for functional testing that reaches diagnostic threshold in the vast majority of cases. It has reasonable concordance in localising ischaemic coronary territory to enable targeted revascularisation.
P808 Association between left ventricular diastolic dysfunction and subclinical coronary artery calcification
Authors: Mansour M , Chammas E , Hamoui O , Honeine W , Aljaroudi W
Published: January 2020

Funding Acknowledgements

None

Background

Assessment of diastolic dysfunction (DD) by echocardiography is an integral part of the evaluation of patients with normal ejection fraction (EF) and symptoms suggestive of heart failure. However, many patients with DD are asymptomatic. Computed tomography calcium scoring (CTCS) is often used to assess patients at low-intermediate risk for coronary artery disease (CAD).

Aim

The purpose of this study is to evaluate the association of DD with subclinical coronary artery calcification.

Methods

Consecutive patients presenting for executive check-up who underwent resting transthoracic echocardiography followed by CTCS were retrospectively identified between January 2010 and December 2014. Two‑dimensional and tissue Doppler imaging parameters were analyzed for assessing and grading of DD. Coronary artery calcium (CAC) score was quantified.

Results

A total of 191 patients (mean age 52 ± 12 years, 17% age ≥ 65, 20% with diabetes) were included. Of them, 69 (36%) patients had DD. Patients with higher CAC score were older, had more comorbidities, lower e’ velocity, and were more likely to have DD. In the multivariate analysis, DD alone, age > 65 years, or both were associated with almost 3-fold increase of subclinical atherosclerosis. After propensity analysis, DD was still associated with increased odds ratio (OR) for subclinical CAC (OR 3.66 [1.54-8.72], P = 0.03), and similarly for e’< 10 cm/s. Compared to patients age < 65 years and normal diastolic function, those age > 65 years or DD had OR 3.49 (1.45-8.35) for subclinical coronary atherosclerosis (CAC > 0), whereas those age > 65 years and DD had OR 9.30 (2.00-42), (P = 0.005 and P = 0.004, respectively).

Conclusions

Our analysis suggests that DD was strongly associated with CAC > 0 even after adjusting for age and comorbidities. Assessment of CAC as part of the routine clinical evaluation of patients with normal EF and atypical symptoms without a history of coronary atherosclerotic disease is warranted for further risk stratification.

Table 1

Abstract P808 Figure. Baseline characteristics
P816 Right Ventricular assessment using Advanced Cardiac Imaging in Mid-Range patients: Keys to detect the risk
Authors: Pascual Izco M , Garcia Martin A , Lorente Ros A , Hinojar Baydes R , Alonso Salinas G L , Vieitez Flores J M , Gonzalez Gomez A , Sanchez Vega J D , Ramos Jimenez J , Casas Rojo E , Jimenez Nacher J J , Garcia De Vicente A , Urena A , Zamorano J L , Fernandez-Golfin Loban C
Published: January 2020

Background

Patients with mid-range ejection fraction heart failure (HFmrEF) are a new category defined in actual guidelines. The aim of this study was to establish the prognostic value of several parameters obtained by Cardiac Magnetic Resonance (CMR) and Transthoracic Echocardiography (TTE) in patients with HFmrEF.

Methods

Thirty patients, defined as HFmrEF by TTE and CMR, were included between 2012-2018. Patients with structural heart disease different from Left Ventricular (LV) dysfunction were excluded. Cine sequences in CMR (SSFP) were used to obtain atrial and ventricular volumes and mass. Myocardial fibrosis was quantified by late gadolinium enhancement. TTE was used to obtain anatomical and functional parameters as LV and Right Ventricular (RV) ejection-fraction, LV and RV global longitudinal strain, and RV free-wall longitudinal strain.

The primary endpoint was the combination of all-cause death or heart failure admission. The median follow-up was 1.9 (0.5-3.3) years.

Results

Mean age was 59.3 ± 12.4 years, and 67.9% patients were male. The aetiology of LV dysfunction was mainly ischemic (n = 16, 53.3%). Results are shown in Table1. Patients who presented the primary endpoint had a lower RV ejection-fraction by CMR and a lower absolute value of RV free-wall longitudinal strain by TTE(Figure 1).

Conclusions

In HFmrEF patients, worse RV function (by CMR and TTE-Speckle Tracking) may be associated with a worse prognosis. Larger studies are needed to confirm this hypothesis.

Table1 All-cause death or HF admission (n = 5; 16.7%) No all-cause death of HF admission (n = 25; 83.3%) p iRVEDV (ml/m2) by CMR 65.5 ± 13.5 66.2 ± 12.3 0.906 iRVESV (ml/m2) by CMR 30.4 ± 7.5 24.4 ± 6.2 0.065 iLVEDV (ml/m2) by CMR 85.8 ± 23.7 98 ± 19.5 0.225 iLVESV (ml/m2) by CMR 47.8 ± 15.3 54.9 ± 11.7 0.246 Indexed LA Volume (ml/m2) by CMR 42.8 (36.5 - 49) 48.4 (42 - 63.5) 0.386 LVEF (%) by CMR 44.9 ± 3.3 44 ± 2.6 0.506 RVEF (%) by CMR 52.2 ± 7.2 61.7 ± 7.2 0.012 RV-FAC (%) by TTE 43.4 ± 4.4 44.7 ±7.5 0.378 TAPSE by TTE 2.1 ± 0.3 2.5 ± 0.1 0.032 LV Longitudinal Global Strain by TTE -14.3 ± 3.3 -15.5 ± 4.9 0.663 RV Longitudinal Global Strain by TTE -11.3 (-13.2 - -7.0) -19.5 (-23.7 - -10) 0.089 RV Free-Wall Longitudinal Strain by TTE -11.5 (-14.2 - -8.2) -20 (-26 - -13.7) 0.043 HF: Heart Failure; CMR: Cardio Magnetic Resonance; LV: Left Ventricle; RV: Right Ventricle; iRVEDV: Indexed RV End-Diastolic Volume; iRVESV: Indexed RV End-Systolic Volume; iLVEDV: Indexed LV End-Diastolic Volume; iLVESV: Indexed LV End-Systolic Volume; LA: Left Atrium; LVEF: LV Ejection Fraction; RVEF: RV Ejection Fraction; RV-FAC: RV Fractional Area Change; TAPSE: Tricuspid Annular Plane Systolic Excursion

Abstract P816 Figure 1
P823 Usefulness of myocardial deformation imaging for assessment and long - term prognosis in young patients with Kawasaki disease
Authors: Marinov R , Hristova K , Telcharova A , Chakarov I
Published: January 2020

Kawasaki disease is an autoimmune process, which characterizes with the engagement of arteries and especially - the coronary arteries of the heart.The aim of the study was to assess global and regional LV myocardial function and to predict the long-term prognosis of Kawasaki disease.Design and method: We analyzed 62 children (mean age 9,4 ±3,9 years ), 28 of them with a residual coronary aneurism and 20 healthy children ( mean age 9,6 ±4, 8). The myocardial deformation indexes of the LV – global and regional longitudinal, circumferential and radial stain were analyzed. The patients are divided into groups according to the type of treatment and the occurrence of complications - residual aneurysms. Apical, middle and basal short axis for 2D images were acquired (65 ± 7 frames/s) in addition to apical four, three and two-chamber views. Global and regional peak systolic strain - longitudinal, radial and circumferential of the LV was derived and the strain curves (eLL, eCC, eRR) were extracted using a commercial softwareResults: Global longitudinal strain measurements of the LV were non-significantly different between the Kawasaki group without an aneurysm and normals (GLS -19,81± 1,91% vs -19,69 ± 1,91%) In the group of Kawasaki with an aneurysm was found significantly reduced GLS compared to healthy patients (-17,25 ± 3.48% vs -19,69± 1,81%. ). Concerning the regional analysis,in the group with aneurysms, the radial, circumferential and longitudinal strain were significantly reduced, especially on the basal and middle LV-segments.

Conclusion

Decreased myocardial strain values are signs of regional hypokinesia with a possible local segmental ischemia in the group with coronary aneurysms on coronary artery and are marker for developing severe LV dysfunction in the future. The contribution in this study was the introduction of a new non-invasive assessment of myocardial function after Kawasaki disease, despite the apparently "normal" global systolic heart function.

Global and regional myocardial strain 2D strain % Healthy controls Patients with Kawasaki disease and aneurysms Patients with Kawasaki disease without aneurysms 2Ds_rr 51.06 ± 4.95 37.24 ± 7.53* 41.91 ± 4.87 2Ds_cc -20.91 ± 0.76 -16.45 ± 3.01* -18.91 ± 2.73 2Ds_ll -19.69 ± 1.82 -17.25 ± 3.48* -19.81 ± 1.91 Basal level 2Ds_rr 2Ds_cc 2Ds_ll 52.03 ± 9.09 -20.68 ± 1.56 -19.74 ± 1.94 36.40 ± 12.57* -15.32 ± 2.81* -15.32 ± 2.81* 46.10± 8.37 -18.32 ± 2.01 -19.32 ± 0.97 Middle 2Ds_rr 2Ds_cc 2Ds_ll 49.54 ± 6.41 -21.3 ± 2.27 -20.92 ± 3.37 35.77 ± 9.26* -15.44 ± 3.04* -15.01 ± 2.79* 44.01 ± 10.12 -17.92 ± 1.11 -19.02 ± 1.31 Apical 2Ds_rr 2Ds_cc 2Ds_ll 51.30 ± 2.27 -21.30 ± 2.27 -20.92 ± 3.37 39.52 ± 12.93* -17.73 ± 4.45* -16.78 ± 4.49* 46.66± 8.57 -19.22 ± 1.87 -19.32 ± 1.01 * p < 0.01
P841 Case report of cardiac myxoma presenting with palpitations in young female
Authors: Nalmpantis A
Published: January 2020

Funding Acknowledgements

none

Introduction

Atrial myxoma is a benign tumor of the heart , most commonly found in left atrium. The tumor must be surgically removed, because if remain untreated can lead to embolism, to arrhythmia and/or obstruction of mitral valve.

Case report

A 29 years old female presented due to palpitations and fatigue In the last two-three months. From recent blood tests she had a normal hematocrit and normal function of the thyroid gland. From the physical examination she had a blood pressure of 95/55 mmHg, S1S2 without any murmur, ECG with sinus rhythm and rsr" pattern. A bedside transthoracic echocardiography has performed and the findings were normal left systolic cardiac function, normal right systolic cardiac function, a large mass in left atrium without obstruction of mitral valve and a mild mitral regurgitation.

The young female has been submitted for surgical removal of the cardiac mass and the anatomopathological examination has confirmed the benign nature of the atrial myxoma.

Conlusion

A common symptom such as palpitations are , has lead the young female to us in order to evaluate her and finally to reveal a benign cardiac tumor .

Abstract P841 Figure. myxoma
P848 Left sided cardiac lymphoma
Authors: Scheggi V , Mazzoni C
Published: January 2020

Background

Primary cardiac lymphoma (PLC) is a rare neoplasm, defined as a lymphoma with the main bulk localized in the heart; diffuse B-cell lymphoma (DLBCL) is the most common type. It usually involves the pericardium and the right heart, especially the right atrium, and have a poor prognosis with a median survival of less than one year.

Case summary

A 62-year-old female presented to the emergency department on February 2018 for palpitations and recent-onset dyspnea on exertion. Her previous medical history was unremarkable except for a hospital admission in october 2017 for dyspnea, when she underwent pleuroscopy of a left pleural effusion with histologic findings negative for a neoplastic process.

The echocardiogram showed a round-shaped mass (23x13mm) in the left atrium, attached to its lateral wall, a mild circumferential pericardial effusion and an hyperechogenic mass at the level of the atrio-ventricular junction of suspected pericardial origin.

A subsequent thoracic CT scan demonstrated the presence of a bulky mediastinal mass with colliquative aspects developing around the cardiac structures, strictly attached to the left heart and infiltrating its posterior wall, the left pulmonary veins and the inferior lobar bronchus. Another mass of similar characteristics surrounded the antero-superior portion of the right heart. Colliquative lymphadenopathies and a left basal pleural effusion were also present.

After performing a total-body CT scan which excluded the presence of lesions in other districts, the patient underwent CT-guided biopsy and the diagnosis of double-expressor DLBCL was made. Given the potential risk of heart rupture during chemotherapy, the first cycle of R-CHOP was performed in a in-hospital setting with initial reduction of the mediastinal mass and of the lymphadenopathies. The patient was discharged home and referred to the hematology department. After completing 6 cycles of R-CHOP, imaging studies showed rapid progression of the disease; the patient was then started on the salvation protocol R-DHAOX but died of septic shock in december 2018.

Discussion

PCL is rare and accounts for less than 2% of primary cardiac tumors; double-expressor DLBCL carries a poor prognosis.

As in most cases, diagnosis was made after the onset of nonspecific symptoms (dyspnea) but -despite the strong predilection for right heart involvement reported in literature- our patient had a predominant left atrial infiltration.

Abstract P848 Figure.
P850 Role of echocardiography in a patient with heart failure and multiple cerebral strokes
Authors: Ansari-Ramandi M M , Yarmohammadi H , Baghaie B , Jafarian Moghaddam F , Fathabadi B
Published: January 2020

A 78 years old male with a history of hypertension and heart failure from 10 years before presented to our hospital with dyspnea, transient loss of consciousness and fatigue. He also had a history of frequent transient ischemic attacks previously with the most recent one being one year before. He was on standard heart failure treatment without any echocardiography done during the past year. On physical examination, he had stable blood pressure and heart rate but increased respiratory rate and respiratory distress. He also had aphasia and rales in the base of his lungs. His oxygen saturation was 70% and was admitted in the intensive care unit. On baseline laboratory data he had a creatinine level of 3.6 mg/dl. After treatment with furosemide and oxygen (O2) therapy and stabilization, brain computed tomography (CT) was done for the patient which showed an old stroke in the territory of right posterior cerebral artery and a new stroke in the territory of the inferior division of the middle cerebral artery (shown in part A of the figure). Echocardiography was done for the patient which showed a large mobile apical left ventricle (LV) clot and moderate LV systolic dysfunction (Three chamber view is shown in part B of the figure) . He was put on anticoagulation and was a candidate for referral to a tertiary center for surgery but after consult due to his acute renal failure and taking in mind his own and family concerns and their refusal for surgery he stayed at our center for continuing his treatment. Unfortunately, after 2 days of treatment, his brain status deteriorated and he had more ischemic brain symptoms for which brain CT scan was done which showed a new infarct in the upper parietal lobes (shown in part C of the figure). Echocardiography was repeated (Three chamber view shown in part D of the figure) which showed a smaller LV clot which was possibly due to a partial detachment of the clot and embolization into the cerebral arteries. With heart failure treatment and proper hydration his creatinine level reduced to 1.1 mg/dl after 6 days of treatment but because of respiratory infection and distress he was intubated and put on mechanical ventilation (Lung CT scan is shown in part E of the figure). He was then put on antibiotic treatment and anticoagulation was done with heparin. His INR level increased and he had a high bleeding tendency which forced us to discontinue anticoagulation. Although his vital signs were stable all through treatment but unfortunately after 14 days of treatment he had bradycardia and asystole and did not respond to cardiopulmonary resuscitation. Conclusion: The case describes a patient with heart failure and multiple cerebral strokes because of an LV clot diagnosed by echocardiography. The case emphasizes the difficulties faced while treating a heart failure patient with co-morbid conditions and the role of echocardiography in diagnosis and guiding management.

Abstract P850 Figure
P854 The role of multimodality imaging in revealing a rare cause of persistent ascites
Authors: Buburuz A M , Marcu D T M , Demsa I , Tinica G , Petris A , Crisu D
Published: January 2020

Primary cardiac tumors are very rare causes of intracavitary masses, about 5% of all cardiac tumors. Most of them are benign tumors, and 50% are represented by atrial myxomas. They are usually developed in the left atrium, with a pedicle attached to the interatrial septum. Cardiac myxomas are one of the "greatest mimes" of pathology, with a polymorphic clinical presentation, from obstructive, to embolic and constitutional clinical manifestation.

We present the case of a 58-year-old female patient with 4 years history of chronic obstructive pulmonary disease (COPD), on bronchodilator treatment and long-term oxygen therapy. She accused two months duration of abdominal distension due to ascites, for which she was evaluated in the gastroenterology department and received diuretics association. The symptoms were refractory to the treatment, so the patient was referred for cardiovascular examination.

At presentation, the patient was afebrile, with a heart rate of 100/minute, blood pressure was 125/90 mmHg. Cardiovascular examination did not reveal any murmurs, jugular venous distension was present. 12-lead electrocardiogram (ECG): sinus rhythm, with right atrial enlargement. The transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a lobulated giant mass in RA, which occupied almost the entire cavity, with prolapse towards the right ventricle during diastole. Due to the large intracavitary mass, the point of attachment could not be ascertained. Computed tomography (CT) of the thorax was performed and it confirmed the presence of the giant right cardiac mass.

The patient underwent surgical excision of the tumor under cardiopulmonary bypass. Intraoperative findings were represented by a yellowish-brown lobulated friable mass in the right atrium cavity, measuring 70/30/35 mm. The pedicle of the tumor was inserted on the free wall of the right atrium. The histopathological examination revealed round to stellate cells in a myxoid stroma, specific for cardiac myxoma. Postoperative evolution was influenced by the severe pulmonary disease, with prolonged mechanical ventilation and positive inotropic support, but it was slowly favorable, and the patient was discharged in good condition.

Right atrial myxoma is a very rare intracardiac tumor with nonspecific forms of clinical presentations, that create difficulties in diagnosis. Ascites represents an unusual form of manifestation in a patient with a cardiac tumor. The insertion of the pedicle of the myxoma was atypical and induced difficulties in early evaluation of the tumor type. Even though myxomas are mainly benign tumors, the complication rate is very high, especially of embolic events due to the friable tumoral mass, so they can become life threatening conditions. Early diagnosis of cardiac myxoma based on multimodality imaging is essential, leading to optimal surgical management, with good long-term survival.

Abstract P854 Figure. TEE view of giant RA tumor
P859 Can we connect intraventricular exercise induced gradients to sudden cardiac death?
Authors: Cotrim C , Costa F , Severino D , Baquero L , Guardado J
Published: January 2020

Background

Some publications, on exercise induced intraventricular gradients, admit the possibility they can be related to some cases of unexplained sudden cardiac death (SCD).

Clinical case

We present the case of a young male athlete (16 years) that after winning a triathlon competition has sudden cardiac death.

No cardiovascular risk factors.

No family history of SCD

A previous episode of dizziness, accompanied by nausea and vomiting related to intense training happens 6 months before.

In September 2018 about 30 minutes after winning a triathlon competition has SCD episode having been resuscitated on site by the competition physician having been defibrillated and transported to intensive care unit.

After discharge, cardiac MRI, Coronary AngioTC, complete genetic study for heart diseases, flecainid test, transthoracic echocardiogram, stress echocardiogram with hyperventilation and ergometrine. All have normal results (Figure)

During 24 hours Holter ECG isolated premature ventricular complexes were detected and during exercise stress echocardiography a significant intraventricular gradient without systolic anterior movement of mitral valve was detected (Figure).

The athlete was disqualified for sports practice, refuses CDI implantation and started bisoprolol 2,5 mg daily.

To the best of our knowledge this is the first case of association between SCD and exercise induced intraventricular gradient. This possible association should be studied in the future.

Abstract P859 Figure. Intraventricular gradient in SCD athlete
P872 A case of transient atrioventricular block: the role of cardiac magnetic resonance imaging
Authors: Ferreira J , Faria D , Augusto J , Teixeira P , Beringuilho M , Roque D , Ferreira H , Morais C
Published: January 2020

A 42-year old man with no relevant past medical history presented to the emergency department for recurrent transient loss of consciousness in the last 12 hours. 3 weeks earlier he had flu-like symptoms which spontaneously resolved.

Physical examination revealed altered mental state, heart rate 30 beats per minute, respiratory rate 30 cycles per minute, blood pressure 70/40mmHg and basal lung rales on pulmonary auscultation. Blood gas analysis revealed hyperlactacidemia with hypocapnia.

Electrocardiogram showed third-degree atrioventricular block. Atropine was administrated (total dose 3mg) with no rate response. Transcutaneous pacing was initiated followed by a temporary transvenous pacemaker, removed after 72 hours.

Transthoracic echocardiogram revealed compromised left ventricular systolic function (ejection fraction by Simpson’s method 45%) due to septal dyskinesia and reduced global longitudinal strain (-11%).

Blood analysis revealed erythrocyte sedimentation rate 20mm/hr, C-reactive protein 2.43mg/dL and negative high-sensitivity troponin T (9.44ng/L). Rheumatologic screening was negative. Coronary computed tomography angiography revealed normal epicardial coronaries.

Cardiac magnetic resonance imaging (CMRI) performed 7 days after admission revealed preserved left ventricular systolic function (ejection fraction 51%). Late gadolinium enhancement showed scared myocardium in the medium and basal segments of the interventricular septum, compatible with subacute myocarditis.

Due to the history of recurrent syncope, a permanent pacemaker was inserted. The patient was discharged the day after. No further syncope occurred. In last pacemaker follow-up, 9 months after presentation, patient had 0% auricular and ventricular pacing and 100% sensing over the previous 6 months.

Discussion

Transient atrioventricular block is a well-known complication of myocarditis when there is involvement of the conduction system by the inflammatory reaction. However, in rare cases it can persist or recur. CMRI plays an important role in these cases. Gadolinium-enhanced CMRI can be used to access the extent of inflammation and cellular edema and delayed-enhanced CMRI can also be used to quantify scarring which has important prognostic value. CMRI can also play a crucial role in excluding infiltrative disorders with conduction system involvement. Also, in these patients, the transient aspect of atrioventricular block poses a challenge when deciding about permanent pacemaker insertion.

Abstract P872 Figure. Magnetic Ressonance IVS
P881 Young patient with left ventricular hypertrophy and accidentally discovered aortic dissection: hypertensive heart or hypertrophic cardiomyopathy?
Authors: Gawor M , Franaszczyk M , Kowalik E , Spiewak M , Michalowska I , Grzybowski J
Published: January 2020

A 36-year-old male with positive family history of sudden cardiac death (his uncle"s son died suddenly at the age of 25), hospitalized a month ago in a local hospital due to acute hypertensive cardiogenic pulmonary edema, was referred to our institution for further evaluation with suspicion of hypertrophic cardiomyopathy.

On admission patient was asymptomatic, without fatigue, exertional dyspnoea, chest pain or syncope. On physical examination his BP was significantly elevated (180/100 mmHg). The lungs were clear on auscultation, liver was not enlarged, jugular veins were normal, there was no oedema of lower extremities. Abdominal auscultation revealed vascular murmur in umbilical region.

The baseline level of NT-proBNP was 811.4 (range 0–125) pg/mL, and high-sensitivity cardiac troponin T was 20.2 (range 0–14) ng/L. The standard 12-lead electrocardiogram demonstrated sinus rhythm, left atrial enlargement and left ventricular (LV) hypertrophy with nonspecific ST segment and T-wave changes (Fig. 1A). No significant pathology was present on chest X-ray (Fig. 1B).

Transthoracic echocardiography revealed significant concentric LV hypertrophy with preserved LV ejection fraction (EF 70%) and moderately decreased global longitudinal strain (GLS-13.7%). There was mild dilatation of left atrium. Ascending aorta diameter was in normal range (Fig. 1C-D). Cardiac magnetic resonance (CMR) scan confirmed concentric LV hypertrophy with the maximal wall thickness of 18 mm at interventricular septum, and increased myocardial mass (LV mass index 124 ml/m2, range 59–92). Moreover, small areas of late gadolinium enhancement were found in LV segments (Fig. 1E-F).

Due to presence of vascular murmur in abdomen, ultrasound imaging was performed. The exam revealed abdominal aortic dissection (Fig. 1G-H). Patient was transferred to the computed tomography (CT) unit to confirm the diagnosis. Aortic dissection originated below renal arteries and involving common illiac arteries was detected (Stanford B). The presence of thrombi within the lumen created by the aortic dissection suggested chronic presentation.

Patient was managed conservatively with strict blood pressure control and close follow up arranged. We decided to perform genetic analysis. Currently we are awaiting the results in hope that it will help us to establish the diagnosis and differentiate hypertensive heart from hypertrophic cardiomyopathy.

In conclusion, aortic dissection typically presents with tearing chest pain and severe hemodynamic compromise. Painless dissection, like in this case, is relatively rare. Differential diagnosis between hypertensive heart and hypertrophic cardiomyopathy is crucial as it has direct therapeutic impact.

Abstract P881 Figure 1
P893 Left ventricular flow energetics predicts worsening heart failure in dilated cardiomyopathy
Authors: Takahashi L , Uejima T , Hayama H , Cho J , Chikamori T , Yamashita T
Published: January 2020

Background

Blood flows through healthy hearts form optimal flow structures; they store flow kinetic energy (KE) that can be used for ejection. In contrast, in failing hearts, intracardiac flows become disorganized so that they may be energetically inefficient. However, it remained unknown whether left ventricular (LV) flow energetics prognosticates in heart failure.

Methods

This study included 61 patients with dilated cardiomyopathy (DCM). The temporal change in KE during early diastole (ED), atrial contraction (AC) and isovolumic contraction (IVC) was measured using Vector Flow Mapping particle tracking (Hitachi, figure top). LV inflow (total flow) were divided, based on whether they were ejected (direct flow, DF) or stayed in LV (retained flow, RF) in the following systole. KE of DF can be made use of for ejection, whereas KE of RF is supposed to be wasted. Diastolic function was graded, according to current EACVI/ASE guidelines. The patients were followed up for three years. Primary endpoint was hospitalization for worsening heart failure (WHF).

Results

12 patients had hospitalizations for WHF in the follow-up period. KE of total flow did not show any significant difference through the cardiac cycle between patients with and without WHF. KE of DF was slightly, but not significantly, smaller (ED: p = 0.252, AC: p = 0.119, IVC: p = 0.122), and KE of RF was slightly, but not significantly, larger (ED: p = 0.971, AC: p = 0.085, IVC: p = 0.134) in patients with WHF than those without events. The ratio of DF and RF (DF/RF ratio) showed significant differences between these two groups, especially from AC through IVC (figure, bottom-left). Cox proportional hazard analyses demonstrated that DF/RF ratio during IVC showed a significant correlation with clinical outcomes (p = 0.033, hazard ratio = 0.067). It remained significant even after adjusted for diastolic function grade (p = 0.046, hazard ratio = 0.074). Kaplan-Meier analysis confirmed the above results (figure, bottom-right). Conclusion: Efficiency of KE recruitment for LV ejection during IVC is associated with clinical outcomes in DCM.

Abstract P893 Figure. LISA
P900 The Heart Model: Automated LVEF calculation in the real world
Authors: Dhunnoo G , Mills A , Lloyd E F , Sabra A , Margulescu A , Bahlay B , Etheridge J , Ionescu A
Published: January 2020

Background

Heart Model (HM) is a proprietary, model-based algorithm for measurement of left ventricular ejection fraction (LVEF) in a 3D dataset acquired from an apical 4-chamber view by transthoracic echocardiography (TTE). There is evidence for superior reproducibility compared to 2D echo methods for LVEF measurement.

Objective

To assess the correlation of LVEF by HM with conventional, 2D LVEF methods.

Methods

All TTEs performed between 04-08/02/2019 by 2 HM-trained sonographers were included. Demographic characteristics, indication for TTE, LVEF by Simpson"s (LVEF_S), by "eyeballing" (LVEF_EB) and by HM (LVEF_HM), were recorded; LVEF for each study was also estimated by eye-balling by an experienced observer unaware of the reported LVEF (LVEF_IND). We compared LVEF by each method, their reciprocal correlations and their correlation with LVEF_HM. Image quality was rated excellent (endocardial border visible for all segments in the 3 apical views), good (< 1 segment was not visible / view), adequate (< 3 segments were not visible) and limited (<4 segments were not visible). Indications for TTE were: assessment of LVEF in 1/3 of the studies, murmurs in 1/5, and other indications in the rest.

Results

We included 74 patients (42 M, mean age (SD) 69.8(13.9), range 18-92 years). Forty-nine (66%) patients were in sinus rhythm, 23 (31%) were in AF, and the rest were in various paced rhythms. Fifty patients (68%) had excellent, good or adequate images. The EFs calculated by different methods are shown in the Table (p > 0.05 for all), an the Bland Altman plot (LVEF_EB vs HM) in the figure. LVEF_HM correlated modestly with the other methods if all studies were included (r = 0.535 LVEF_HM vs. LVEF_EB); the correlation improved if only good-quality studies were included (r = 0.769, p < 0.001 for both). All combinations of LVEF_IND, LVEF_EB and LVEF_S had correlation coefficients >0.93.

Conclusions

The Heart Model algorithm for LVEF measurement correlates well with traditional 2D methods in patients with good endocardial border definition, where its use can potentially improve reproducibility and reduce exam duration.

LVEF by method (good-quality studies) N = 50 Simpson"s Eyeballing HeartModel Independent Mean(%) 48.6 48.9 50.9 48.8 SD(%) 17.8 16.6 14.9 15.7 Median(%) 54.5 52.5 53 50 Range(%) 16-74 17.5-72.5 19-88 15-75 SD - standard deviation Independent - LVEF estimate (eyeballing) by independent observer unaware of reported EFs. LVEF_EB was chosen as it was available inall the reports.

Abstract P900 Figure. Bland Altman Plot (LVEF_EB vs LVEF_HM)
P902 Abnormal diastolic function in patients with transfusion dependant thalassemia major
Authors: Abdelmottaleb W A , Nadar S , Daar S , Al-Rahbi S , Hassan M
Published: January 2020

Aim and Background

Cardiac complications secondary to iron deposition are the commonest cause of death in patients with beta thalassemia major (TM) and can cause various abnormalities. The aim of this study was to assess the diastolic function in patients with transfusion dependant TM and compare with normal controls.

Methods

This was a retrospective study involving patients with transfusion dependant TM , on chelation therapy who had a MRI T2* and a transthoracic echocardiogram during the preceeding 6 months. We compared the findings with those from normal controls. We also correlated the echo findings with the MRI T2* values.

Results

Patients with TM (n = 92, 45% male, mean age 26+ 6 years), with median MRI T2* of 32 (18-39) and normal LV function had signs of diastolic dysfunction as compared to normal controls (41% male, mean age 25 + 6 years) with E/E’ at 6.6 + 1.6 vs 5.5 +1.2 (p < 0.001) and altered pulmonary vein s/d ratio (0.88 + 0.30 vs 1.04 +0.42 for controls, p = 0.02)even in the presence of normal LV systolic function (Ejection fraction 61+ 7% vs 3.4% for controls). There was no difference in the other dimensions. The E/A ratio also corelated well with the MRI T2* (spearmans correlation rho -0.226 p 0.04). There were no other significant correlations between either the MRI T2* or myocardial Iron concentration and any of the other echo parameters

Conclusion

In patients with TM signs of diastolic dysfunction appear before LV systolic dysfunction and may be used to monitor these patients in absence of MRI facilities.

Echo findings in thalassemia Controls (n= 53) Thalassemia Major (n = 92) P value Sex Male Female 22 (41%) 31(59%) 42(45%) 50(55%) 0.5 Mitral E 0.84 + 0.16 1.01 + 0.16 <0.001 Mitral A 0.47 +0.11 0.55 +0.16 <0.001 E/A 1.85 +0.52 1.98 + 0.71 0.24 TDseptal 13.1 + 2.6 13.2 + 3.4 0.9 TDlateral 17.1+ 3.3 17.3 +4.1 0.7 E/E’ 5.5 +1.2 6.6 + 1.6 <0.001 PVs/d 1.04 + 0.41 0.88 +0.30 0.02 TD= tissue doppler; PV- pulmonary vein
P905 Value of global longitudinal strain (GLS) in the short term prognosis of geriatric patients with asymptomatic severe aortic stenosis
Authors: Ramos Sanchez M , Quezada M , Garcia A , Ayala R , Herrera C , Gomez Pavon F J , Jaramillo J , Toro R
Published: January 2020

Funding Acknowledgements

VII Convocatoria del Banco de Santander and Alfonso X el Sabio University.

Background

Detection of symptoms in geriatric population with aortic stenosis (AS) is challenging, especially when they associate other comorbidities or frailty. Left ventricular global longitudinal strain (GLS) occurs before left ventricular ejection fraction impairment and could be useful for risk stratification and management of these patients.

Purpose

We sought to analyze the usefulness of GLS for predicting major cardiovascular adverse events (MACEs) in geriatric patients with asymptomatic severe AS.

Material and Methods:

Prospective study on 54 patients older than 70 years old with severe asymptomatic AS. Patient evaluation included biochemistry tests, electrocardiogram and echocardiography. We use a GLS cut-off point of 18% to dichotomize patients. Outcomes were defined as the composite of MACEs – occurrence of death from any cause, hospitalization for heart failure, appearance of symptoms or change in treatment.

Results

The mean age was 83.2 ± 7.1, with 60.4% of women. 24.5% showed atrial fibrillation. At 6 months of follow-up, 33% of patients reached the endpoint: 5.6% CHF, 11.1% death, 3.7% symptoms without changes in management and 13% were referred to an invasive treatment. The event-free survival rate at 6 months for the global population was 83%. 41.5 % of the subjects had GLS < 18%. Kaplan Meier analysis showed that the probability of freedom from MACEs was not significant in patients with lower GLS (Log Rank p = 0.39). In the multivariate analysis only AVA was an inverse predictor of events (AVA) HR 0.05 (95% CI 0.007- 0.471, p < 0.05).

Conclusions

The value of GLS was not a predictor of short term events in geriatric patients. Only assessment of AVA was an independent marker of MACES and in this kind of subjects.

Charasteristics of the global population Global N = 53 (%) GLS ≥ 18 N = 31 (58.5%) GLS < 18 N = 22 (41.5%) (p) HBP 42 (79.2) 27 (87.1) 19 (82.6) 0.09 Atrial fibrillation 13 (24.5) 6 (19.4) 7 (31.8) 0.29 CVD 6 (11.3) 1 (3.2) 5 (22.7) 0.02 LVEF: Normal >50% 48 (92) 31 (100) 17 (77.2) 0.05 Peak velocity 3.72 ± 0.72 3.81 ± 0.71 3.60 ± 0.74 0.315 Mean gradient 34.01 ± 14.06 35.61 ± 13.54 32.09 ± 15.07 0.29 Integral ratio 0.25 ± 0.08 0.26 ± 0.09 0.25 ± 0.08 0.83 AVA 0.8 ± 0.26 0.78 ± 0.27 0.83 ± 0.26 0.651 Indexed AVA 0.48 ± 0.16 0.48 ± 0.17 0.48 ± 0.16 0.9 AVA Aortic valve area; CVD: cerebro vascular disease; HBP: High blood presure; LVEF: left ventricule ejection fraction.

Abstract P905 Figure. Kapplan-Meier event-free survival curves
P915 Bicuspid aortic valve: differences between populations
Authors: Sharif D , Azzam E , Sharif-Rasslan A , Dobrecky Mery I
Published: January 2020

Congenital bicuspid aortic valve (BAV) is the most common congenital valve abnormality, with an estimated incidence of 0.5-2% in adults. However, BAV is much less prevalent in some populations and racial differences were reported. Aim: Comparison between Arab and Jewish patients with BAV in Israel. Methods: Screening of 18962 echocardiographic studies in Bnai Zion Medical Center and evaluation of demographic, atherosclerotic risk factors, clinical and echocardiographic parameters was performed. Results: Male to female ratio in Arab patients was 4.6:1 while in Jewish patients 1.6:1, p < 0.01. The age of both populations with BAV was similar 45 ± 21yeras, however larger prevalence was found of cigarette smoking and diabetes mellitus in Arabs 31.1% and 6.7% than in Jews 8.2% and 3.5% respectively, p < 0.05. Left ventricular, left atrial and aortic dimensions as well as Doppler parameters were similar in both groups except for large mitral peak A-wave velocities in Jewish patients. Prevalence of aortic valve stenosis in Jewish patients was 35% similar to that in Arabs 33% with similar severity and mean pressure gradients. Aortic valve regurgitation was fond in 53% of Arab patients and in 46% of Jewish patients, p = ns, however, moderately severe and severe aortic regurgitation was more prevalent in Arab patients 22% compared to 13% of Jewish patients, p < 0.05. During 10 years follow up, 25% of Arab patients needed aortic valve replacement while in Jewish patients 10% had surgery, p < 0.05. Conclusion: In Arab patients, male to female ratio was larger, with higher prevalence of moderately severe to severe aortic regurgitation and higher rate of aortic valve replacement compared to Jewish patients.
P921 Left atrial appendage flow velocity (LAAV) and n-terminal pro brain natriuretic peptide (NT-proBNP) as strong predictors of high thromboembolic events in patients with nonvalvular atrial fibrillatio
Authors: Luntungan M , Panda A L P
Published: January 2020

Background

Many studies demonstrated that the presence of non valcular atrial fibrillation (NVAF) increased the risk of cardioembolic stroke from fivefold to sixfold. Cardioembolic stroke is commonly sourced by thrombi in Left Atrial Appendage (LAA) and since this is a treatable condition, early detection would be highly beneficial for a better prognosis.

Aim : The aim of this study was to investigate the change of LAA flow felocity (LAAV) and its correlation with NT-proBNP plasma levels, Left atrial spontaneous echo contrast (LASEC) and CHA2DS2-Vasc score, as well as evaluating the prognostic value of these parameters in detecting thromboembolic events in patients with NVAF.

Methods

A non-interventional, cross-sectional observational study of 31 people with NVAF.

Baseline patient characteristics, CHA2DS2-Vasc score, the five-grades of LASEC, NT-proBNP plasma levels were measured and LAAV visualized by transesophageal echocardiography (TEE) were performed.

Results : LAAV were correlated with NT-proBNP (r = -0,511 , p = 0,003), high degree of SEC (r= -0,866 , p < 0,0001) and high CHA2DS2-VASc Score (p = 0.004). In addition, the receiver operating characteristic analysis revealed that the best cut-off value of NT-proBNP to predict higher risk of thromboembolic evants in patientswas 1052pg/mL with 76% sensitivity and 83.3% specificity (area under the curve: X2 = 7,441, p = 0.003). In the subgroup analysis based on different CHA2DS2-VASc scores, the predictive value of NT-proBNP remained significant in patients with a CHA2DS2-VASc score of ≥ 2.

Conclusion

LAAV were significanty correlated positively with NT-proBNP levels, degrees of SEC and CHA2DS2-VASc score. Plasma NT-proBNP along with CHA2DS2-VASc score were strong predictors of thromboembolic events in patients with NVAF
P922 Thrombus and dense spontaneous echo con-trast in left atrial appendage yield high risk of stroke and death, how to resolve it ?
Authors: Kosmalska K , Malgorzata Rzyman M-R , Marcin Fijalkowski M-F
Published: January 2020

Background

Thrombi and sludge in patients with atrial fibrillation and atrial flutter are common. Both thrombus and sludge worses prognosis. Thrombus is a contraindication for cardioversion but further therapeutic guidance is not stated. We focused on: (i) death and stroke risk of patients with thrombus or sludge, (ii) effectiveness of anticoagulation in thrombus resolution and influence of resolution on prognosis (iii) comparison of solid clot and sludge

Methods

77 from 267 (29%) patients with persistent AF were diagnosed in TOE with left atrial thrombus or sludge. After the diagnosis 34 of patients (44%) were marked as chronic AF with OAC therapy. 43 patients (56%) were the group of further attempts of cardioversion with 3 methods of anticoagulation (VKA with rigorous control of INR, higher doses of NOAC or therapeutic doses of low molecular weight heparin). Risk of death and stroke was analyzed (i) in thrombus/sludge vs clean appendage, (ii) in chronic AF with standard anticoagulation versus persistent AF with „intensive" anticoagulation, (iii) with regard to method of anticoagulation, (iv) in persistent thrombus/sludge versus resoluted thromboembolic material, (v) in sludge vs clean appendage and (vi) in sludge vs thrombus.

Results

Annual death risk in patients with thrombus/sludge is high : 17 of 77 (22%). In patients free from thrombus/sludge annual death risk is low: only 3 from 190 (1,6%). Annual risk of stroke in thrombus/sludge is also high: 13 patients (17%); in 6 patients - 46% stroke was fatal. Risk of stroke in patients without diagnosed thrombus/sludge is very low: 2 from 190 (1%); none of the strokes was fatal. More effective in thrombus resolution was LMWH (81% effectiveness) than NOAC (44%) and VKA (43%). Heparin vs OAC, despite better effectiveness, did not yield better survival. Strokes were not significantly less frequent in LMWH group - 9% than OAC - 13%. Incidence of stroke and death in patients with thrombus resolution was not significantly lower: 2 strokes (8%) and 4 deaths (15%) in group of resoluted thrombus and 2 strokes (12%) and 4 deaths (25%) in the group of persistent thrombus. We picked up less cases of deaths and strokes in patients referred to further TOE control versus those not subjected to TOE control but the differences were not significant: 4 patients (9%) of supervised patients had ischemic stroke and 7 (16%) died but in the group with no supervision 7 patients (21%) experienced stroke and 10 (29%) died. There is no statistical difference comparing sludge to clot : 2 patients experienced ischemic stroke (11%) and 3 (16%) died in sludge group and 9 strokes (16%), 16 deaths (24%) occured in clot group.

Conclusions

Patients with thrombus in LAA are of high risk of death and stroke. Best treatment for thrombus resolution was LMWH. Neither resolving the thrombus nor any treatment method decreases the risk significantly. Sludge is equally threatening as solid thrombus.