bluuebunny/crossref_metadata_2025 huggingface dataset:
1228 New predictors of sudden cardiac death in hypertrophic cardiomyopathy
Authors: Adamczak D M , Rogala A , Antoniak M , Oko-Sarnowska Z
Published: January 2020

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is a heart disease characterized by hypertrophy of the left ventricular myocardium. HCM is the most common cause of sudden cardiac death (SCD) in young people and competitive athletes due to fatal ventricular arrhythmias. However, in most patients, HCM has a benign course. That is why it is of utmost importance to properly evaluate patients and identify those who would benefit from a cardioverter-defibrillator (ICD) implantation. The HCM SCD-Risk Calculator is a useful tool for estimating the risk of SCD. The parameters included in the model at evaluation are: age, maximum left ventricular (LV) wall thickness, left atrial (LA) dimension, maximum gradient in left ventricular outflow tract, family history of SCD, non-sustained ventricular tachycardia (nsVT) and unexplained syncope. Nevertheless, there is potential to improve and optimize the effectiveness of this tool in clinical practice. Therefore, the following new risk factors are proposed: LV global longitudinal strain (GLS), LV average strain (ASI) and LA volume index (LAVI). GLS and ASI are sensitive and noninvasive methods of assessing LV function. LAVI more accurately characterizes the size of the left atrium in comparison to the LA dimension.

METHODS

252 HCM patients (aged 20-88 years, of which 49,6% were men) treated in our Department from 2005 to 2018, were examined. The follow-up period was 0-13 years (average: 3.8 years). SCD was defined as sudden cardiac arrest (SCA) or an appropriate ICD intervention. All patients underwent an echocardiographic examination. The medical and family histories were collected and ICD examinations were performed.

RESULTS

76 patients underwent an ICD implantation during the follow-up period. 20 patients have reached an SCD end-point. 1 patient died due to SCA and 19 had an appropriate ICD intervention.

There were statistically significant differences of GLS and ASI values between SCD and non-SCD groups; p = 0.026389 and p = 0.006208, respectively. The average GLS in the SCD group was -12.4% ± 3.4%, and -15.1% ± 3.5% in the non-SCD group. The average ASI values were -9.9% ± 3.8% and -12.4% ± 3.5%, respectively. There was a statistically significant difference between LAVI values in SCD and non-SCD groups; p = 0.005343. The median LAVI value in the SCD group was 45.7 ml/m2 and 37.6 ml/m2 in the non-SCD group. The ROC curves showed the following cut-off points for GLS, ASI and LAVI: -13.8%, -13.7% and 41 ml/m2, respectively.

Cox’s proportional hazards model for the parameters used in the Calculator was at the borderline of significance; p = 0.04385. The model with new variables (GLS and LAVI instead of LA dimension) was significant; p = 0.00094. The important factors were LAVI; p = 0.000075 and nsVT; p = 0.012267.

CONCLUSIONS

The proposed new SCD risk factors were statistically significant in the study population and should be taken into account when considering ICD implantation.
1233 Can speckle tracking echocardiography predict outcome in hypoplastic left heart syndrome patients?
Authors: Borrelli N S , Di Salvo G , Sabatino J , Ibrahim A , Avesani M , Filippini E , Josen M , Penco M , Fraisse A , Michielon G
Published: January 2020

Funding Acknowledgements

EACVI Training Grant

Introduction

Children with Hypoplastic Left Heart Syndrome (HLHS) have a high mortality (up to 95%) and morbidity. Systemic right ventricle (RV) dysfunction plays a key-role in their outcome.

Purpose

The aim of this study is to evaluate the accuracy of speckle-tracking echocardiographic (STE) assessment of RV deformation and 2D standard echo parameters in predicting death and need for heart transplantation (HT) in HLHS patients.

Methods

31 patients with diagnosis of HLHS successfully completed Norwood (n = 29) or comprehensive Norwood stage II (n = 2) at our Institution between 2015 and 2019. Survival at 6 months was 90.32%, survival at 18 months was 85.72%. We studied 29 HLHS patients (17 male). Patients with HLHS variant (n = 2) were excluded. All the studied patients underwent in-hospital interstage stay. Serial echocardiographic assessment was performed in all the included patients (baseline, one month after Norwood, three months after Norwood, one week before bidirectional cavopulmonary anastomosis [BCPA] and two months after BCPA). From the apical view we measured: tricuspid annulus peak systolic excursion (TAPSE), fractional area change (FAC), longitudinal strain (LS) and strain rate (LSR).

Results

After a mean follow-up of 1.83 ± 1.16 years, 8 out of 29 of the included patients met the composite endpoint of death/HT. At pre-Norwood assessment, there was no statistical difference in echo measurements between survivors and patients who reached the endpoint. In death/HT group TAPSE and LS declined already at one-month after Norwood procedure evaluation. At one-month evaluation, a TAPSE ≤ 5 mm had a good sensitivity for death/HT (85.71%) and a moderate specificity (66.67%), with an area under the curve of 0.789. Always at one-month evaluation, a Δ LS ([{baseline LS – one-month post Norwood LS}/ baseline LS] *100) of 8.7% showed a 100% sensitivity and good specificity (80.95%) for death/HT, with an area under the curve of 0.888. Multivariate analysis showed that one-month-after-Norwood Δ LS was the best predictor of worse outcome (p = 0.02).

Conclusions

HLHS patients with Δ LS of > 8.7% at one-month after Norwood procedure had a high likelihood of death or HT. These data encourage the routine use of LS to monitor cardiac function in HLHS patients.

Abstract 1233 Figure. HLHS LS and trend of TAPSE and LS.
P1245 Huge left atrial myxoma masks mitral regurgitation
Authors: Toki M , Hayashida A , Sakaguchi T , Aritaka S , Yoshida K
Published: January 2020

A 61-year-old gentleman, he had shortness of breath while few weeks and getting worse, was presented to our hospital. His oxygen saturation was 94 %(O2 5L) and no crackles or rales were heard. His electrocardiogram was sinus tachycardia, and chest X-ray showed cardiomegaly and BNP level was elevated (260.3pg/mL). Transthoracic echocardiography (TTE) revealed huge mass(57 × 39mm) occupying left atrium (LA), the mass was flexible in cardiac cycle and prolapsing from LA to left ventricle, it seems like cardiac myxoma. We suspected mitral stenosis (MS) caused by the mass (peak trans mitral flow velocity 3.1m/s), mitral regurgitation(MR) was not significant, and moderate tricuspid regurgitation with pulmonary hypertension (peak systolic pressure 61 mmHg). We performed transesophageal echocardiography(TEE) and CT angiography revealed the mass at fossa ovalis, we decided surgery of removing the mass considering the risk of mitral annulus obstruction and embolism. Intraoperative findings, after taken off the mass, TEE showed moderate to severe MR not detected preoperative TEE. Additionally, it revealed the mitral annulus enlargement(42 × 38mm by 2D TEE) and may gradually induced by prolapsing the mass. Finally, surgery for mitral valve was performed and postoperative TTE showed no MR. The mass was diagnosed cardiac myxoma by pathology.

MS is relatively common in patients with prolapsing LA myxoma , and it improves after removing the mass. In this case, mitral valve was no degeneration but enlarged mitral annulus and significantly MR had revealed after removing the mass. Keep in mind that there is possibility to underestimate of MR associated with LA myxoma. To take care of mitral valve complex sufficiently in such case, and to detect these findings at preoperative echocardiography, then more useful assessment for surgery.

Abstract P1245 Figure. Huge Left Atrial Myxoma Masks MR
P1246 The Eustachian valve: a structure not so innocent
Authors: Graca Rodrigues T E , Placido R , David C , Goncalves S , Pinto F J , Almeida A G
Published: January 2020

Background

The eustachian valve is an embryological remnant of the inferior vena cava (IVC) valve. It is usually absent or inconspicuous and has no known function in the normal adult. However, there are reports suggesting that the EV is not as innocent as we thought. The EV can be a site of infective vegetations or be mistaken for a thrombus or tumor. The EV can also make interventional procedures (closure of ASD (atrial septal defect) or ablation for atrial flutter) more laborious.

Clinical Case

A 80 year-old female patient was referred to the emergency department after an episode of acute palpitations, right chest pain, followed by syncope. She had a previous medical history of type 2 diabetes and epilepsy. On admission she was normotensive (104/67mmHg). The ECG showed atrial fibrillation with heart rate of 180 beats per minute. The echocardiogram show slight dilation of the right ventricle and bilateral atrial dilatation. The blood tests documented an elevated D-dimers 2,73 μg/mL, troponin (hs-TNT 27ng/L) and NT-proBNP 4339pg/ml, with a normal renal function.

Computed tomographic (CT) pulmonary angiography revealed filling defects on the segmentar and subsegmentar inferior lobes, compatible with the diagnosis of pulmonary embolism and also revealed a dilatation of the main pulmonary trunk (35mm).

Based on this result the patient start anticoagulation with low molecular weight heparin and heart rate control with bisoprolol. However besides of this strategy the patient remain in atrial fibrillation without a controlled hear rate and an transesophageal echocardiography (TOE) was performed.

The TOE shown a small freely mobile mass – thombi - at the inferior vena cava-right atrium (IVC-RA) junction tethered at the eustachian valve; a small atrial septal defect (4mm) – ostium secundum type – with a left to right shunt; and a preserved biventricular function (figure 1).

Based on this exams we optimize the therapy with digoxin and amiodarone with a good control of the heart rate and patient was discharge on warfarine, bisoprolol and digoxin asymptomatic and to be reevaluated on cardiology clinic.

Discussion/Conclusion: The eustachian valve in adult is an embryological remainder of the fetal venous sinus valve. This structure is located in the right atrium and is a common, not pathological, echocardiographic finding. It is known that a small percentage of the pulmonary embolisms, thrombi are discovered in the right side of the heart; however, their presence on the Eustachian valve is very unusual. Besides this in our particular case in the present we will have also to ensure that the anticoagulation is effective to avoid that the trombi migrates into the systemic circulation by the atrial septal defect.

Abstract P1246 Figure.
P1254 Gerbode defect makes sense after 20 years of a prosthetic mitral valve
Authors: Mehtap Yeni M Y
Published: January 2020

60 year old female has been checked for routine prosthetic mitral valve control for the first time in our outpatient clinic. She was also complaining about severe dyspnea for several months. Mitral valve replacement has been done 20 years ago, without tricuspide ring or any other repair.Transthoracic echocardiography showed high normal mitral prosthetic gradients and dilated right heart chambers with severe tricuspid regurgitation. Close to the tricuspid regurgitant flow; there was an additional left to right shunt from left ventricle to right atrium. As she had denied of having a congenital defect before surgery and as there should not have been a possibility of such a missed diagnosis by many echocardiographers for years; we suspected that it had become as a complication of mitral valve surgery, rather than being a congenital defect. Surgical closure of the defect and tricuspide ring annuloplasty repair have been planned.

Abstract P1254 Figure.
P1261 A heart with red flags
Authors: Oliveira C C , Vieira C , Rodrigues C , Campos I , Medeiros P , Flores R , Mane F , Braga C , Salgado A , Marques J
Published: January 2020

A 67 years old woman with a previous history of hypertension, atrial fibrillation (AF) and known severe concentric hypertrophy (more pronounced at the interventricular septum) with moderate pulmonary hypertension and diastolic dysfunction of the left ventricle (LV) resorted to the urgency service for weight loss, asthenia and dyspnea for minor efforts. Her physical examination was innocent. Her ECG showed AF and low voltage in limb and precordial leads. Patient was admitted at the Cardiology Department for investigation. A new TTE revealed fast progression of the hypertrophic pattern (IVS 26 mm, and posterior wall 18 mm) with a rest outflow tract gradient of 18 mmHg; free right ventricular wall was also hypertrophied with 12 mm and a type II diastolic dysfunction was present. A complete investigation for ventricular hypertrophy and constitutional syndrome was done. CMR demonstrated preserved biventricular systolic function, LV hypertrophy with septal predominance (24 mm) with elevated myocardial mass indexed to body mass (114 g/m2) and late difuse subendocardial gadolinium enhancement. (99m)Tc -DPD scintigraphy was negative for ATTR; Anderson-Fabry disease was excluded by genetic testing. Blood analysis revealed a normocytic/ normochromic anemia and a disproportional ratio of free light immunoglobulin chains K/λ, with a predominance of lambda chains. β2-microglobulin was also elevated. 24 hours urine analyses were normal. The hypothesis of non-secretor multiple myeloma (MM) with light chain immunoglobulin amyloidosis (AL) was then admitted. The patient underwent bone marrow and salivary gland biopsies which confirmed MM and deposition of amyloid, respectively. The FISH analyses demonstrated a delection of RB1 gene on 13q14.3 sequence and of TP53 on 17p13.1, both associated with a poorly prognosis in MM. The patient was referred for oncology where she is currently undergoing chemotherapy for MM and AL amyloidosis.

Amyloidosis represents a large spectrum of systemic diseases. Heart failure may be its first sign. This case reflects the diagnostic work-up in the presence of a hypertrophic LV pattern as well as the importance of high clinical suspicious and early diagnosis. While AL amyloidosis occurs in isolation, 10% of patients with multiple myeloma develop systemic AL amyloid with cardiac involvement. The distinction between these entities is not only semantic, but has extremely important prognosis and therapeutic considerations.
P1281 Are left atrial and left ventricular strains independent from each other?
Authors: Malaescu G , Petrescu A , Capota R , Duchenne J , Cvijic M , Bezy S , Voigt J-U
Published: January 2020

Introduction

Left atrium (LA) and ventricle (LV) share the mitral annular plane so that the motion and deformation of both chambers are coupled.

Purpose

To investigate the interdependence between LA and LV strain curves using strain-strain loops.

Methods

We included 101 patients with a wide range of pathology and selected for having sufficient image quality for both LA and LV analysis. Patients with a mobile interatrial septum and more than mild valvular regurgitation were excluded. LA and LV strains were assessed using speckle tracking in 4 and 2 chambers apical views, using the same cardiac cycle and R-R gating. Strain-strain-loops were reconstructed using LV strain data on the x-axis and corresponding, synchronized LA strain data on the y-axis (Fig .A). Linear regressions were calculated for the entire strain-strain-loop as well as for the three phases of the cardiac cycle (systole, early and late diastole) seperately. LA and LV volumes were also measured on the same images and their ratio was calculated and correlated with the slope of the regression line of the strain-strain loop (Fig. B).

Results

Our study population comprised normal volunteers (27), amyloidosis (8), hypertrophic cardiomyopathy (6), ischemic disease (19), non-ischemic cardiomyopathy (22), aortic stenosis (13) atrial fibrillation (6).

On average, LA and LV strain curves correlated with an R2= 0.92 ± 0.04 for the entire loop, R2= 0.97 ±0.01 in systole, R2= 0.98 ± 0.02 in early diastole and R2= 0.97 ±0.03 late diastole. Further, in the individual patients, the ratio of LV/LA volumes correlated with the LA/LV strain ratio with a slope of ∼1.0 (R2 = 0.8).

Conclusions

LA and LV deformation are closely coupled. Strain curves have a similar shape throughout the cardiac cycle leading to a tight correlation of strain values from both chambers. The relation of LA and LV strain is dominated by the two chambers" dimensions.

Abstract P1281 Figure.
P1284 The role of three-dimensional echocardiography in the evaluation of geometry and function of the left ventricle in patients with chronic chagas cardiomyopathy
Authors: Barros-Filho A C L , Moreira H T , Martins K S M , Simoes M V , Schmidt A , Maciel B C , Marin-Neto J A , Romano M M D
Published: January 2020

BACKGROUND

A hallmark of chronic Chagas" cardiomyopathy (CCC) is the early appearance of regional wall motion abnormalities of the left ventricle (LV), especially in the lateral and apical regions. The morphological and functional assessment of LV by two-dimensional (2D) echocardiography, besides depending on geometric assumptions, may not include the most affected segments. The three-dimensional (3D) method offers advantage for the quantification of chamber volumes, but its role in the assessment of patients with CCC is not well established. PURPOSE: The aim of this study is to evaluate the concordance between 3D and 2D methods in the quantification of left ventricular end-diastolic volume (LVEDV) and left ventricular ejection fraction (LVEF) in patients with CCC. METHODS: 44 patients with CCC were selected. Seven subjects were excluded from the analysis (3 for atrial fibrillation, 1 for frequent ventricular extrasystoles, 3 for inadequate acoustic window), resulting in 37 patients. Subjects were submitted to 2D and 3D transthoracic echocardiography by a single experienced examiner following the recommendations from the chamber quantification guidelines. The concordance between the methods was evaluated using the Lin concordance correlation coefficient (CCI) and the Bland-Altman graph analysis. Descriptive analyses of the percentage of individuals reclassified as to altered or to non altered-LVEDV and LVEF values were performed using normal values of 3D as a reference. RESULTS: Age = 58 ± 12 years, 54% men. LVEF-2D = 47 ± 9% and LVEDV- 2D = 73 ± 18 ml / m². The CCI for the measurements of LVEDV and FEVE by both methods was 0.861 and 0.833, respectively. The mean difference found was 3 mL for LVEDV and 3% for LVEF. The 95% agreement limits found were (-14, 20 ml) for LVEDV and (-5; 11%) for LVEF. When assessed with 2D, 27% of individuals previously classified as having LV enlargement were reclassified as having normal LV volumes using the 3D method. Conversely, regarding LVEF, 16% of individuals considered normal by 2D were reclassified as having reduced LVEF with the 3D method. CONCLUSION: In individuals with CCC measurements of LVEDV and LVEF by 3D and 2D methods show high agreement. However, 3D evaluation allows the reclassification of 27% and 16% of the individuals regarding the presence of LV dilatation and LV systolic dysfunction, respectively.

Abstract P1284 Figure. Bland-Altman plot - LVEF
P1288 Male gender and left atrial volume index predict non valvular atrial fibrillation recurrence. The NeAfi echo registry
Authors: Sorrentino R , Capone V , Esposito L , Lo Iudice F , De Roberto A M , Lembo M , Santoro C , Esposito R , Canonico M E , Galderisi M
Published: January 2020

Background

In non-valvular atrial fibrillation (AF) patients, risk stratification scores such as CHA2DS2VASc and HASBLED allow the prediction of thromboembolic and bleeding risks, respectively. However, no risk score for the prediction of AF recurrence has been yet validated.

Purpose

To evaluate the mayor anthropometric and echocardiographic determinants of AF recurrence in non-valvular paroxysmal AF patients at 1 year follow-up.

Methods

Among 395 consecutive adult patients with non valvular AF enrolled in the Neapolitan Atrial Fibrillation (NeAfi) Echo registry, 177 (F/M = 87/90, age = 66.5± 11.9 years) had paroxismal AF and underwent 1-year follow-up. Fifteen patients had AF recurrence. Anthropometric parameters and blood pressure (BP) were recorded and CHA2DS2VASc and HASBLED scores were calculated. At baseline, patients underwent a comprehensive echo-Doppler exam, including quantification of left atrial (LA) size measurements, peak atrial longitudinal strain (PALS) and left ventricular (LV) global longitudinal strain (GLS). Binary logistic regression analysis was used to establish a mathematical model of the relationship between the variables and AF recurrence. The covariates for regression analysis were chosen as potential confounding factors based on their significance in independent T test analyses for continuous variables of chi-square for dichotomous variables, or on their biological plausibility.

Results

AF recurrence was higher in male than in female patients (14.4 vs 2.3%, p = 0.008). Patients with AF recurrence had similar body mass index, systolic and diastolic BP and heart rate compared to those without. The two groups were similar for LV end-systolic and end-diastolic volumes, ejection fraction, LV mass index, diastolic indexes, pulmonary artery systolic pressure and GLS. LA diameter (p = 0.235) and PALS (p = 0.375) were also similar between the two groups, whereas LA volume index (LAVi) was greater in patients experiencing AF recurrence (45.5 ± 15.7 vs. 36.7 ± 10.4 ml/m², p = 0.003). Binomial multiple regression analysis model explained 25% (Nagelkerke R²) of the variance in AF recurrence and correctly classified 95.0% of cases. Males were 8.9 times more likely to exhibit AF recurrence than females (p = 0.04). Greater LAVi was associated with an increased likelihood of exhibiting AF recurrence (OR = 1.07, p = 0.03), whereas CHA2DS2VASc >1 in men and >2 in women, HASBLED >3 and greater LA diameter or lower PALS did not add significant information to the model.

Conclusions

Male gender and, with a lower extent, LAVi appear to be major determinants of AF recurrence in non-valvular paroxysmal AF. The quantification of PALS does not seem to add valuable information in the prediction of recurrent AF.
P1300 Analysis of clinical and echocardiographic follow-up of patients with heart failure and severe secondary mitral regurgitation 1 year after MitraClip implantation, single centre experience
Authors: Petr R , Linkova H , Paskova E , Bednar F , Budesinsky T , Kocka V
Published: January 2020

Introduction

MitraClip implantation is one possible method of treatment of patients with heart failure and severe mitral regurgitation.

Goal. Analysis of clinical and echocardiographic data of patients 1 year after MitraClip implantation.

Methods

The first 63 consequtive patients whom underwent MitraClip implantation at our cardiocentre were analyzed. Implantation was performed after all possible conservative treatment options according to guidelines were exhausted. Each patient underwent careful clinical and echocardiographic examination before and 12 months after implantation.

Results

Average age of the patient population was 70,5 ± 7,4 years. Baseline average ejection fraction (EF) of left ventricle (LV) was 35,2 ± 12,6%, enddiastolic volume of LV 196 ± 53ml, 63 (100%) had mitral regurgitation (MR) ≥ 3/4, average ERO 27,4 ± 10,2cm2 RV 40,5 ± 12,9ml. During 1 year follow-up 11 (17%) of patients died, 1 (1,6%) from a periprocedural complication. In the patients who survived we observed a decreasing incidence of severe mitral MR , (MR ≥ 3/4 before procedure in 63 (100%) vs. 12 (19%) in patients after procedure). A significant improvement in functional class NYHA (NYHA II-IV before implantation in 63 (100%) patients vs. 17 patients (33%) at one year follow-up). Mortatility was mostly influenced by Euroscore (p 0,08), creatitnine level (p 0,10), from echocardiographic parameters LV EF (36,4% vs. 29,5% p 0,10) and TAPSE (17,8 vs. 15,2mm p 0,04).

Conclusion

One year mortality in our study population was comparable with previously published data from larger registries. Significant regression of mitral regurgitation and improvement of symptoms was observed in patients after implantation. Moratility was affected by comorbidities, and systolic function of left and right ventricle.
P1302 B-cell lymphoma presenting as an ejection systolic murmur
Authors: Constantinides T , Ioannides M , Yiagou K , Avraamides P
Published: January 2020

OnBehalf

Nicosia General Hospital

We present the case of a young patient with large B-cell lymphoma causing severe extrinsic pulmonary stenosis. This patient presented to the emergency department with chest discomfort ,fatigue and dyspnea on minimal exertion. A loud ejection mid-systolic crescendo-decrescendo murmur with widely split S2 located in 2nd left parasternal border, raised the suspicion of pulmonary stenosis and patient underwent immediate transthoracic echocardiography as the first imaging modality of choice.On transthoracic echocardiography a large mass was seen, causing severe extrinsic pulmonary stenosis, and was further diagnosed as B-cell lymphoma after CT-guided biopsy. We discuss the high index of lymphoma suspicion in cases of pulmonary stenosis findings such as loud ejection murmur in pulmonic valve auscultation area, in otherwise healthy patients, with no history of congenital heart disease. Lymphoma and other mediastinal masses represent the most common aetiology of acquired pulmonary stenosis and should be suspected in otherwise healthy patients who present with clinical findings of pulmonary stenosis and vice-versa, pulmonary stenosis should be suspected in the presence of symptomatic mediastinal masses.

Abstract P1302 Figure. Lymphoma PSAX
P1319 Speckle tracking echocardiography in patients with acute coronary syndrome: the added value
Authors: Di Lisi D , Polizzi A , Bentivegna R , Nugara C , Lunetta M , Immordino F , Novo S , Novo G
Published: January 2020

Background

Speckle tracking echocardiography with assessment of left ventricular global longitudinal strain (GLS) allows to identify early signs of cardiac dysfunction.

The superiority of GLS in the prediction of all-cause mortality in the general population compared with LVEF is well known; in addiction GLS improves risk stratification and recognize early left ventricular dysfunction in several clinical setting.

Purpose

the aim of this study was to assess the diagnostic and prognostic role of global and segmental strain in the early identification of cardiac dysfunction in patients with myocardial infarction without persistent ST segment elevation (NSTEMI) and without obvious wall motion abnormalities and to assess the ability to predict the presence/extension of coronary artery disease in this population.

Methods

an observational study was carried out enrolling 56 patients (median age 66 ± 11,7 years) admitted for NSTEMI. Electrocardiogram, echocardiogram with global and segmental strain measurement (GE’s Automated Function Imaging) and coronary angiography were performed in all patients. In addition we measured territorial longitudinal strain (TLS) defined as the mean of peak systolic strain of the segments pertinent to the perfusion territories of each epicardial coronary arteries in a 17-segment LV model.

Results

mean LVEF was 53%. We found a significant relationship between GLS values and coronary artery disease extension: GLS -19,1 % ±5,7% in patients without significant coronary artery stenosis, -18,74% ±4,85% in patients with one coronary artery disease, -15,6% ±4,3% in patients with two coronary artery disease, -14,2% ±5,4% in patients with 3 coronary artery disease (p = 0,03).

We also found a correlation between territorial strain value and corresponding coronary artery stenosis.

TLS was significantly reduced in patients with significant coronary disease of the perfused territory for each artery (LAD TLS 15,1% ± 6,74 % vs -20,73± 4,47 p = 0,002; CX TLS -11,42 % ± 6,59 %,vs -17,06 ± 7,1, p = 0,0 05 , RCA -14,02 % ± 6,00 % vs-17,6 ± 5,21 p = 0,02).

At ROC analysis we identified a TLS value of -16,9 % to identify patients with significant stenosis of LAD (sensibility 58,3% and specificity 89,4%, AUC = 0,74, P < 0,001), TLS -18,2% for circumflex artery (sensibility 86,2% and specificity 78,9%, AUC = 0,78, P < 0,001) TLS -18% for right coronary (sensibility 73,9% and specificity 56,2%, AUC = 0,67, P = 0,027)

Conclusions

global and segmental strain measurement in patients with NSTEMI help to identify the presence and extension of significant coronary artery disease.
P1340 Clinical report: alert to iatrogenia
Authors: Redondo Bermejo B , De La Torre Carpente M M , Alonso Rodriguez M C , Tapia Ballesteros C , Munoz San Jose J C , Escudero Caro T , Revilla Martinez M , Rollan Gomez M J
Published: January 2020

Background

Leftatrial appendageclosure is an alternative to systemic anticoagulation for stroke prevention in appropriate atrial fibrillation patients,however, it is not without complications. Most complications arise during the procedure and in the following days, however they can also be extended over time and therefore, we must be alert.

Case summary

We present the clinical case of a 68-year-old man admitted to our hospital three weeks after being discharged due to a percutaneous closure of the left appendage complicated with a pericardial tamponade resolved mediated pericadiocentesis with pericarditis clinic with persistent severe pericardial effusion. After a week without being able to remove the drainage tube, he required pericardiotomy due to superinfection with adequate subsequent evolution. In the following weeks he presented a recurrent left pleural effusion that required several evacuating thoracocentesis. After last thoracocentesis, he presented a cardiac perforation showing the catheter lodged in the pulmonary artery in the chest Computed Tomography, so he was again submitted to cardiac surgery for catheter extraction. Finally after stabilization, the patient could be discharged and after 6 months of follow-up he is stable and without new complications.

Discussion

Post-cardiac injury syndromes is a group of inflammatory pericardial syndromes including post-myocardial infarction pericarditis, post-pericardiotomy syndrome and post-traumatic pericarditis iatrogenic or not, that’s include pericarditis after invasive cardiac interventions. It is presumed that these syndromes have an autoimmune pathogenesis triggered by an initial damage and after a latent period of a few weeks are revealed.

Our patient evidence of pericardial effusion with elevated CRP several weeks after a cardiac injury due to perforated during a percutaneous closure of the left appendage complicated with a pericardial tamponade resolved mediated pericadiocentesis. The persistent effusion motivated he imposibility of removed pericadiocentesis tube, and it superinfecction required an urgent pericardiotomy. After pericardial window, the effusion continued into the left pleural.

The perforation of cardiac cavities after an evacuatorythoracocentesis is a described but unusual complication that requires surgical removal.

Our patient survived a pericardiocentesis, several evacuatorythoracocentesis and two cardiac surgeries, all after a percutaneous closure of the left appendage.

Conclusion

Any invasive procedure presents a risk of iatrogenic complication, especially in elderly patients with comorbidities. We must be alert and start a treatment as soon as possible to solve the problem.

Abstract P1340 Figure. Chest-CT_EECHO2019
P1341 An old patient with two tales: left cor triatriatum and atrial septal defect
Authors: Agoston Vas Coldea L N , Vrancianu P , Tutu A , Agoston R , Muresan I , Mocan T
Published: January 2020

Introduction

Cor triatriatum sinistrum is a rare congenital condition, diagnosed in 0.4% of cases at autopsy, in which the left atrium is divided in two chambers by a fibromuscular membrane. In 80% of the cases it is associated with other cardiac abnormalities, the most common being ostium secundum atrial septal defect.

Case report

A 71-year-old man with a history of congestive heart failure was admitted to the hospital for dyspnoea, fatigue and ankle swelling. The physical examination revealed jaundice, severe pretibial oedema, bibasal crackles, irregular heart sounds, a 3/6 mitral and tricuspid systolic murmur, jugular vein distension, hepatomegaly. Electrocardiographical findings included atrial fibrillation and right bundle branch block. Transthoracic echocardiography showed severely enlarged right cavities, an ostium secundum atrial septal defect of 23 mm with right to left shunt, a dilated left atrium divided by a membrane and severe pulmonary arterial hypertension. Cardiac magnetic resonance imaging revealed nodular late gadolinium enhancement (LGE) areas and confirmed ostium secundum atrial septal defect and also a fibromuscular membrane, dividing the left atrium into a proximal and distal chamber. Despite appropriate therapy, the patient’s clinical state altered in the following days and he eventually died, due to ventricular fibrillation. The autopsy confirmed the ostium secundum atrial septal defect and the cor triatriatum sinister and also revealed an abnormal emergence of the circumflex artery from the left coronary sinus (Figure).

Conclusion

Cor triatriatum sinistrum and also ostium secundum atrial septal defect are rare abnormalities usually recognized early in lifetime due to unspecified symptoms of heart failure. In adults it can become symptomatic later in time, like in our case, with the development of multiple associated conditions: atrial fibrillation, pulmonary hypertension, left ventricle dysfunction, with a poor prognosis.

Abstract P1341 Figure
P1344 Right ventricular mass: multimodality diagnostic approach to an incidental finding
Authors: Ambrozic J , Kovac A , Zbacnik R , Ponorac S , Kogoj P , Dimitrovska L , Dolenc-Strazar Z , Antolic B , Sinkovec M
Published: January 2020

Background

Cardiac masses are rare entities and often diagnostically challenging. When incidentally found multimodality diagnostic approach is warranted for further characterization and evaluation of its contribution to the patient’s symptoms.

Case report

62-year-old male, smoker, with a history of non-Hodgkin lymphoma treated with radiation and chemotherapy 10 years ago, was admitted due to subacute myocardial infarction. Coronary angiogram showed subacute occlusion of partly collateralized RCA, subsequently treated with dilatation and stenting. Echocardiography revealed signs of dilated cardiomyopathy with severely reduced left ventricular ejection fraction (EF 20%), that could be due to chemotherapy-related cardiotoxicity. On admission CTA was performed to exclude aortic dissection since the patient presented with very severe chest pain radiating to the back. It showed a heterogeneous formation within the right ventricle (RV) extending along the interventricular septum from the apex towards the tricuspid annulus, appearing to involve interventricular septum as well. According to the imaging characteristics the mass was suspected to be a liposarcoma (Figure A). With contrast echocardiography hypoechogenic formation in the RV on parasternal long-axis view could be visualized (Figure B). Due to previous history of malignancy PET scan was performed that revealed hypometabolic RV mass, suggesting a benign tumor, without any sign of metastasis. We decided for percutaneous biopsy that was done under intracardiac echocardiography (ICE) guidance using the view from the RV towards RV outflow tract (Figure C). Histology revealed proliferation of mature adipocytes, either orthotopic or multiplied (Figure D). To exclude well-differentiated liposarcoma FISH (fluorescent in situ hybridization) with amplification of MDM2 gene was undertaken, confirming benign lesion, most probably cardiac lipoma. It was concluded that the mass was an incidental finding, not related to the patient’s symptoms and not causing any functional disturbances; therefore surgical therapy could be avoided.

Conclusion

While echocardiography remains the first-line imaging modality, multimodality diagnostic approach is mandatory for evaluation and treatment decision of a newly-discovered cardiac mass. Histology provides definitive diagnosis and ICE could be helpful for guiding percutaneous biopsy, thus avoiding invasive open-heart procedures.

Figure. Cardiac CTA (A), contrast echocardiography (B), intracardiac echocardiography (C) and histologic specimen (D) of the right ventricular mass (arrows).

Abstract P1344 Figure.
P1354 Prognostic value of the left ventricular longitudinal and circumferential function in patients with takotsubo syndrome during the acute phase
Authors: Koshino K , Yamaguchi N , Oshima T , Hiroe K , Ohta Y , Okada S , Ohta T , Tanabe K
Published: January 2020

Background

Takotsubo syndrome is generally considered a benign disease with a reversible condition; however, hemodynamic and electrical instability during the acute phase exposes patients to the risk of serious adverse in-hospital events. The purpose of this study was to investigate the prognostic value of the left ventricular longitudinal and circumferential function in patients with TTS during the acute phase.

Methods

We divided the 27 patients with TTS (77.4 ± 10.2 years old, 21 females) into two groups; the severe group (SG) of 9 patients (in-hospital death, mechanical assist devices such as IABP or ECMO, oozing rupture) and non-severe group (NSG) of 18 patients. The echocardiographic examination on admission, catheter hemodynamic assessment, and laboratory data, and ST-T change in electrocardiogram were compared between two groups.

Results

There were no differences in age, laboratory data, electrocardiogram findings between the two groups. The LVEF was lower in SG (35.3 ± 6.1% vs. 45.9 ± 13.5%, p = 0.03). The index of Ballooning, the ratio of the systolic left ventricular diameter of ballooning segments to that of basal segments, was higher in SG (2.07 ± 0.61% vs.1.60 ± 0.32%, p = 0.016). The circumferential fractional shortening (CFS) of ballooning segments was lower in SG (4.6 ± 3.2% vs. 18.2 ± 8.2%, p = 0.00007), CFS of basal segments was not different between the two groups, and the ratio of CFS of ballooning segments to CFS of basal segments (CFS imbalance index) was lower in SG (5.60 ± 3.84 vs. 10.83 ± 3.92, p = 0.00003). The left ventricular longitudinal fractional shortening was lower in SG (0.12 ± 0.09 vs. 0.46 ± 0.19, p = 0.00003). The absolute value of GLS was lower in SG (7.6 ± 4.3% vs. 13.0 ± 3.6%, p = 0.002). In all three cases of in-hospital death, the CFS imbalance index was lower than 0.14.

Conclusion

In patients with TTS, left ventricular longitudinal and circumferential function could be related to serious adverse in-hospital events.
P1357 Left atrial function decreases with age in patients with repaired tetralogy of Fallot decrease
Authors: Hosono Y , Takahashi K , Akimoto S , Ifuku M , Iso T , Yazaki K , Yamada M , Matsui K , Akimoto K , Nakanishi K , Nii M , Kawasaki S , Kishiro M , Shimizu T
Published: January 2020

BACKGROUND

Left ventricular function has been shown to be an important prognostic indicator in patients with repaired tetralogy of Fallot (rTOF) and tends to decrease with age. In recent years, left atrial (LA) function was reported to be a useful prognostic indicator more than or equal to left ventricular function in acquired heart diseases. However, atrial function in rTOF has not yet been sufficiently examined.

PURPOSE

The aim of this study was to investigate the relationship between LA dysfunction and age in rTOF using strain analysis.

METHODS

In order to assess the relationship between LA function and age, we recruited 59 patients with rTOF ranging in age from 5-40 years. We stratified the patients into 3 groups (T1: 5-10 years, T2: 11-20 years, T3: 21-40 years) and divided 54 controls of similar age into 3 corresponding groups (N1, N2, and N3). Two-dimensional speckle tracking images (2D-STI) obtained from four- and two-chamber views were used to assess LA functions by measuring reservoir, conduit, and pump strain. Additionally, we measured the strain rate (SR) in the systole, early diastole, and late diastole.

RESULTS

LA reservoir strain (37.4 ± 2.2% vs. 47.9 ± 1.7%, P= 0.004), LA pump strain (8.3 ± 1.4% vs. 14.1 ± 2.7%, p <.001), atrial systolic LA-SR (1.5 ± 0.4% vs. 2.4 ± 0.6%, p <.001), and systolic LA-SR (1.5 ± 0.3% vs. 2.1 ± 0.4%, p = 0.003) were significantly decreased in T3 compared with N3. Although only LA conduit strain decreased with aging (r = -0.3204, p = 0011) in controls, all of the LA reservoir (r = -0.325, p = 0.020), conduit (r = -0.314, p = 0.025), and pump strain (r = -0.481, p < 0.001) in rTOF decreased with aging.

Early diastole SR was significantly decreased in the T1 and T3 groups compared with the N1 and N3 groups (T1 vs N1, 3.00 ± 0.63% vs. 4.03 ± 0.0.80%, p <.0.001, T3 vs N3, 2.31 ± 0.57% vs.3.31 ± 0.47%, p < 0.001). Both systolic SR and late diastole SR decreased in T3 group compared with the N3 (1.54 ± 0.32% vs. 2.08 ± 0.42%, p = 0.003, 1.42 ± 0.32% vs.2.42 ± 0.61%, p < 0.001), respectively. Although only early diastole SR decreased with aging (r = -0.415, p < 0.001) in controls, all of the systole (r = -0.287, p = 0.041), early diastole (r = -0.337, p = 0.019), and late diastole SR (r = -0.407, p = 0.003) in rTOF decreased with aging.

CONCLUSIONS

In rTOF, most of the LA functions assessed by strain analysis decreased compared to normal controls in over 20 years old age. Furthermore, all measured functions decreased with age in rTOF while only two parameters decreased with age in normal controls. These results suggest that LA function may be an important indicator in long-term rTOF follow-up. These are new insights into LA function in patients with rTOF.
P1365 Different response of myocardial contractility by layer following acute pressure unloading after transcatheter aortic valve implantation
Authors: Cimino S , Maestrini V , Monosilio S , Luongo F , Neccia M , Birtolo L I , Petronilli V , Cantisani D , Salvi N , Filomena D , Mocci M , Quaranta S , Mancone M , Fedele F , Agati L
Published: January 2020

Background

Transcatheter aortic valve implantation (TAVI) is an effective therapeutic option for severe symptomatic aortic stenosis (AS) with intermediate/high surgical risk. Aim of this study was to examine the acute effect of TAVI in terms of pressure unloading, on left ventricular (LV) mechanics using multilayer global longitudinal strain (GLS) by 2D speckle-tracking echocardiography (ST-E).

Methods

A total of 44 patients (mean age 81.8 ± 2, 34% male) with severe symptomatic AS and preserved LV ejection fraction (LVEF) underwent 2D echocardiography at baseline and 5 ± 2 days after TAVI. GLS was measured from the endocardial layer (Endo-LS), epicardial layer (Epi-LS) and full thickness of myocardium before and after the procedure. Analysis included other parameters such as age, sex, LV volumes and ejection fraction (LVEF), type of prosthesis implanted, right ventricular (RV) dimension and function.

Results

By dividing patients in two groups accordingly with LV geometry assessed with regional wall thickness measurement (concentric vs eccentric hypertrophy), better values of Endo-LS were recorded at baseline, in patients with concentric hypertrophy (-12.9 ± 2 vs -11 ± 3, p = 0.048). After TAVI, a significant improvement in Endo-LS was observed, but only in patients with concentric hypertrophy (-12.9 ± 2 vs -14.2 ± 2, p = 0.003).

Conclusion

The improvement in LS was more prominent in the endocardium, which was evident even immediately after TAVI only in patients with concentric hypertrophy. Evaluation of multilayer strain may provide new insights into the positive effects of unloading in patients with AS and may be potentially useful to predict patients with better outcome after TAVI.

Parameter RWT > 0.42 31 pz (70%) RWT ≤ 0.42 13 pz (30%) p Male sex (n, %) 8 (25%) 7 (53%) NS Age (y.o) 81 ± 6 83 ± 7 NS CAD (n, %) 3 (9%) 8 (61%) NS LVEDV (ml) 97 ± 29 134 ± 14 0.002 LVESV (ml) 43 ± 15 72 ± 38 0.001 LVEF(%) 56.2 ± 6 50 ± 12 NS AVA (cm2) 0.8 ± 0.2 0.8 ± 0.3 NS GLS (%) -11.4 ± 3 -10.5 ± 3 NS Endo-LS (%) -12.9 ± 2 -11 ± 3 0.048 Epi-LS (%) -10.8 ± 4 -9.9 ± 3 NS

Abstract P1365 Figure.
P1374 Clinical outcomes of patients with solid left atrial appendage thrombi. Predictors of thrombus resolution and impact of anticoagulation regimens
Authors: Nelles D , Lambers M , Schafigh M , Schueler R , Vij V , Schrickel J W , Nickenig G , Hammerstingl C , Sedaghat A
Published: January 2020

OBJECTIVE

Current guidelines recommend vitamin k antagonist (VKA) therapy with a therapeutic international normalized ratio of 2.0 to 3.0 for at least 3 weeks upon detection of an LA/LAA thrombus in patients with atrial fibrillation (AF). Reported thrombus resolution rates with VKAs vary between approximately 50% and 90%. Data on thrombus resolution after a therapy with a direct-acting oral anticoagulant (DOAC) are scarce but efficacy data on DOAC indicate on potential favorable outcomes.

METHODS

We analyzed 78 patients diagnosed with a solid LA thrombus by transesophageal echocardiography and compared baseline characteristics, the anticoagulatory regime and the clinical outcomes of patients with and without thrombus resolution.

RESULTS

Mean age of the population was 76 ±8 years old. Patients were male in 61.5% and presented with a high risk for thromboembolism (CHA2DS2-VASc 4.3 ± 1.1). At the time of thrombus diagnosis 44,9% (35/78) patients were treated with a DOAC, 47,4% (37/78) were under therapy with a VKA and only 14,1% (11/78) of the patients had no prior DOAC or VKA treatment. Mean thrombus size was 1,63 ± 0,61cm x 0,98 ± 0,31cm. Complete thrombus resolution was achieved after a mean 116 ± 79 days in a total of 48,2% (40/78) of patients. There was no statistically significant difference in the rate of LAA thrombus resolution between VKA and DOACs (41,2% vs. 57,1%), but in cases in which therapy with a DOAC led to a complete thrombus resolution, the time needed for the resolution was significantly shorter than with VKA (81 ± 38 days vs. 129 ± 46 days, p = 0,03).

CONCLUSIONS

There was difference in the rate of LAA thrombus resolution between VKA and DOACs, the resolution time was shorter in patients prescribed a DOAC. In clinical practice the individual risk for thrombus persistence can not be predicted. 80,1% of patients were prescribed, what would be considered, an appropriate anticoagulant regimen, but only 48,2% had thrombus resolution at any point of follow up documented via TEE. Switching to DOAC after prior VKA therapy is an effective and valid alternative to patients presenting with LAA thrombi.