bluuebunny/crossref_metadata_2025 huggingface dataset:
P177 COR TRIATRIATUM DEXTER: THE ROLE OF TRANSTHORACIC ECHOCARDIOGRAPHY
Authors: Basile P , Carella M , Monitillo F , Santoro D , Argentiero A , Ciccone M , Guaricci A
Published: May 2023

Introduction

Cor triatriatum dexter (CTD) is an extremely rare congenital cardiac abnormality and its prompt recognition by transthoracic echocardiography (TTE) is essential for a correct diagnosis. Case presentation An 82–years–old woman was admitted to our cardiologic ward for worsening dyspnoea. The physical examination revealed a bilateral lower extremity oedema with elevated jugular venous pressure and hepatomegaly. The ECG showed atrial fibrillation with a heart rate of 70 bpm already treated with beta–blockers and direct–acting oral anticoagulant. TTE revealed a left ventricle with normal dimensions and function, a dilated right ventricle with a mild systolic dysfunction and increased wall thickness, a marked dilation of the right atrium and a tricuspid severe regurgitation. A deeper analysis of the right atrium revealed the presence of membrane partitioning the chamber into two compartments (Figure 1). The separation was incomplete as demonstrated by the flow across the membrane with Color–Doppler technique (Figure 2). The patient was treated using high doses of diuretics with a subsequent clinical improvement. A percutaneous intervention on the tricuspid valve was planned by the Heart Time.

Discussion

CTD derives from the persistence of the right valve of the sinus venosus resulting in a complete or incomplete fibromuscular band which separates the right atrium into two cavities. The spectrum of clinical manifestations is broad, based upon the degree of separation. In older patients CTD is often asymptomatic and incidentally found during diagnostic imaging examinations. TTE plays a key role in the identification of CTD, as a first–line diagnostic imaging tool. It, also, allows a differential diagnosis with a prominent eustachian valve, chiari network, and thebesian valve. However, in difficult cases a multiparametric approach is required including transoesophageal echocardiogram or cardiac magnetic resonance. Echocardiography has a pivotal role in the prompt recognition of other cardiac abnormalities associated with CTD such as atrial septal defect or patent foramen ovale, right ventricular hypoplasia and Ebstein’s anomaly. In our case, none of these were documented. Atrial fibrillation should be investigated due to severe atrial chamber dilation. A multiplane evaluation of the right atrium and the Color–Doppler technique are helpful to visualize the configuration of the membrane and evaluate the absence of flow disturbances.
P203 PLASMA TRANSTHYRETIN FORMS IN PATIENTS WITH WILD–TYPE TRANSTHYRETIN CARDIAC AMYLOIDOSIS: INFLUENCED OF TAFAMIDIS TREATMENT
Authors: Sanguinetti C , Vergaro G , Aimo A , Castiglione V , Caponi L , Paolicchi A , Emdin M , Franzini M
Published: May 2023

Introduction

Transthyretin (TTR) is a plasma protein that transports thyroxin and retinol complexed to retinol–binding protein (RBP). TTR misfolding and aggregation can lead to the extracellular deposition of amyloid in the myocardium, causing TTR cardiac amyloidosis (ATTR–CA). Aim of this study is to develop a native electrophoretic method to characterize circulating TTR forms in plasma samples of ATTR–CA patients, before and after administration of tafamidis, a TTR stabilizer. Material &

Methods

Plasma samples from patients affected by wild–type ATTR amyloidosis (ATTRwt, n=10) were collected before (T0) and during tafamidis treatment at 14, 30 and 90 days. Plasma samples of sex– and age–matched healthy controls (n=6) were also collected. All samples were separated on a native 4–20% Tris–Gly polyacrylamide gel. Western blot analysis was performed with anti–TTR or anti–RBP antibodies. Proteins were detected by Clarity ECL substrate. ImageLab software was used for image acquisition and densitometric analysis of the blots. Total TTR (mg/dl) and RBP (mg/dl) were quantified by nephelometry.

Results

In both groups, the most represented forms were: TTR dimers or trimers (37–50kDa), TTR tetramers complexed with RBP protein in 1:1 (75kDa,) or 1:2 ratio (100kDa), and high molecular weight aggregates (>150kDa). RBP protein was detectable in association with TTR tetramers and some of the TTR aggregates (250kDa, 480kDa). Based on TTR electrophoretic pattern at T0, patients could be divided in 2 groups: ATTR–1, characterised by the presence of TTR tetramers (55kDa), and ATTR–2, characterised by its absence. The ATTR–1 group showed also higher levels of total TTR in comparison with ATTR–2 (mean±SD 25.5±3.8, 16.6±4.2 respectively, p=0.004), while plasma RBP levels were similar (5.1±0.7, 5.1±1.4 respectively). The electrophoretic patterns of ATTR–1 at T0, as well as TTR and RBP levels were comparable to those of controls (TTR 22.6±3.8, RBP 4.4±0.9). Tafamidis treatment was associated with a progressive increase of total TTR levels both in ATTR–1 and –2 (T90 31.4±5.8, 28.7±6.8) but the 2 groups continued to be distinguishable by the electrophoretic pattern.

Conclusions

The native electrophoresis allowed us to detect diverse circulating TTR forms and to classify patients in 2 groups according to their electrophoretic pattern. TTR quali/quantitative evaluation by electrophoresis could represent a valid tool to assess the individual pharmacological response to tafamidis.
P230 A RARE CASE OF INFECTIVE MYOCARDIAL INFARCTION
Authors: Condello C , Gasparetto N , Stievano A , Carrer A , Favero L , De Mattia L , Betta D , Balducci E , Cernetti C
Published: May 2023

Background

Prosthetic valve endocarditis (PVE) occurs in 1–6% of patients with valve prostheses. The most common agent of late PVE are S. aureus and Streptococci. Spondylodiscitis may precede the onset of endocarditis or may be the first clinical manifestation. Coronary embolization is a rare but possible complication of endocarditis. Case report: A 61 years–old man was admitted to the Emergency Department for low back pain, fever and chest pain. Four years before he underwent mitral valve bioprosthesis implantation and hybrid myocardial revascularization (percutaneous on right coronary artery). During observation cardiac arrest from ventricular fibrillation occurred, treated with single shock and evidence of anterolateral myocardial infarction at ECG. An urgent coronarography revealed chronic occlusion of CABG on LAD and acute occlusion, of possible embolic origin, involving LAD mid tract, first diagonal branch and intermediate branch. Thromboaspiration and subsequent PTCA was performed. For hemodynamic instability inotropic and vasopressor supports were started. A transthoracic echocardiogram showed severe left ventricular dysfunction (EF 25%) and 3.5x1mm endocardial vegetation on the mitral bioprosthesis without significant bioprosthesis dysfunction (confirmed by transesophageal echocardiogram). Blood cultures resulted positive for Streptococcus gordonii and antibiotic therapy based on the antibiogram was begun. Cardiac surgery was ruled out due to prohibitive surgical risk despite high probability of embolization. Because of the history of back pain spinal MRI was performed with evidence of cervial and lumbosacral spondylodiscitis. Neurosurgical indications were ruled out. Levosimendan infusion allowed weaning of vasopressor and inotropic therapy, however without improvement of left ventricular ejection fraction. Daily echocardiographic follow–up showed disappearance of the vegetation. Antibiotic targeted therapy was continued for 5 months, given the persistence of spondylodiscitis, in anticipation of intracardiac defibrillator (ICD) implantation in primary prevention.

Conclusion

PVE is a severe clinical condition associated with high morbidity and mortality. Antibiotic therapy is recommended for at least 6 weeks in PVE, in this case prolonged up to 5 months given the need to implant an ICD. Regarding the treatment of embolic infarction thromboaspiration is recommended as the initial strategy and, if successful, may be the only interventional option.
P241 SACUBITRIL/VALSARTAN IN HEART FAILURE WITH REDUCED EJECTION FRACTION: REAL–WORLD EXPERIENCE FROM ITALY (THE REAL.IT STUDY)
Authors: Di Lenarda A , Di Gesaro G , Sarullo F , Miani D , Driussi M , Correale M , Bilato C , Passantino A , Carluccio E , Villani A , Degli Esposti L , D‘Agostino C , Peruzzi E , Monopoli S , Iacoviello M
Published: May 2023

Background

Sacubitril/valsartan reduced heart failure (HF)–related hospitalizations and cardiovascular mortality in PARADIGM–HF and has become a foundational treatment for HF with reduced ejection fraction (HFrEF). However, data of its routine real–world use is limited, and evidence from Italian settings is lacking. Aim of the study. The REAL.IT study aimed to characterize the demographics, pharmacotherapy, clinical characteristics, and outcomes of sacubitril/valsartan–treated Italian patients with HFrEF.

Methods

Electronic medical records of patients initiating sacubitril/valsartan from October 2016 to June 2019 at nine specialized hospital outpatient HF Centers across Italy were reviewed.

Results

Overall, 924 adults (mean age 64.5 years, 84.6% male) were included. Clinical characteristics are shown in Table 1. At baseline, 38.7% had an ischemic HF etiology, 45.9% hypertension, 23.2% atrial fibrillation, 25.4% diabetes mellitus, 26.1% an implantable cardioverter–defibrillator, 31.9% coronary artery bypass grafting. There were no clear patterns of patient selection over time. As shown in Table 1, during follow–up NYHA class improved in 37.5% after a mean of 5.3 ± 3.8 months; 36.1% and 16.7% of patients were in NYHA class III during characterization and after one year of follow–up, respectively. Left ventricular ejection fraction (LVEF) improved ≥5% in 56.3% of patients at one year; 39.7% had ≥30% reduction of N–terminal pro–B–type natriuretic peptide; 2.2% had hyperkalemia during characterization and 2.6% during follow–up; 3.8% had hypotension during characterization and 12% during follow–up. A total of 50 (5.8%) of patients had device implantation (ICD/CRT) during follow–up. HF–related hospitalization was recorded in 19.6% of patients during follow–up; 3.8% of patients died, approximately 1.3% from cardiovascular causes.

Conclusions

Our real–world data confirm the favorable effectiveness and tolerability of sacubitril/valsartan observed in pivotal randomized controlled trials.
P243 EXTRACORPOREAL CONTINUOUS VENO–VENOUS ULTRAFILTRATION IN PATIENTS WITH ACUTE HEART FAILURE REFRACTORY TO DIURETIC THERAPY: A SINGLE–CENTER PILOT EXPERIENCE
Authors: Somaschini A , Buscemi M , Cornara S , Astuti M , Cordone S , Botta M , Pentimalli F , Bellone P
Published: May 2023

Introduction

Congestive Acute Heart Failure (C–AHF) is characterized by extracellular fluid overload. Extensive use of loop diuretics may induce worsening renal function, electrolyte imbalance, symptomatic hypotension and diuretic resistance. Extracorporeal veno–venous ultrafiltration (UF) may represent a useful adjunctive therapy. Despite a few randomized clinical trials have been carried out, the results are controversial; aim of this study is to describe our pilot experience using UF.

Methods

We enrolled consecutive patients with C–AHF refractory to diuretic therapy treated with UF from January to December 2022; patients affected by concomitant acute coronary syndrome were excluded. UF was delivered using a modern device specifically designed for fluid removal in C–AHF patients through slow continuous UF (Fig.1). According to our protocol, the initial UF rate was based on baseline systolic arterial pressure (250cc/h if>120mmHg, 100–120cc/h if 100–120mmHg and <100cc/h if<100mmHg; contra–indicated if<90mmHg). Laboratories values, urinary output and fluid balance were monitored at baseline, after 6 hours (T6) and when UF was stopped (T0). Variables are expressed as medians with 25p–75p.

Results

Seven patients were enrolled in the study (5M;2F); in each a femoral central venous catheter (20cm/14G) was placed to perform UF. A standard anticoagulation regimen based on UFH bolus + infusion was adopted aiming to an ACT of 180–220. Median age and LVEF were respectively 40[20–50] and 79[73–85]; 3 patients were diabetics, 2 smokers and 4 hypertensive. Median rate of hospitalization in the previous 12 months was 1 [0–2]; domiciliary dosage of furosemide was 75mg [50–125]. Baseline, T6h and T0 creatinine values were respectively 1.2 [1.1–2], 1.3 [1.1–1.8] and 1.4 [1.1–1.9]. Heart rate and blood pressure were stable during the treatment. UF parameters in the patients of the study are summarized in Tab.1; congestion was resolved or improved in 6/7 patients, no severe complication (bleeding, AKI, death) occurred while 1 premature filter clot is reported.

Conclusions

Our initial experience with UF is promising. Modern heart failure specific devices appear safe, easy to use and require only minimal training. Compared to extensive i.v. diuretic use, predictable fluid removal through UF may be beneficial as it is characterized by higher excretion of sodium, limited neuro–hormonal activation, enhanced spontaneous diuresis and restoration of diuretic response.
P269 AORTA–RIGHT ATRIAL TUNNEL POST TRICUSPID ANNULOPLASTY
Authors: Chiarello G , Donateo M , Garzya M , Marazia S , Cucurachi M , Colonna G
Published: May 2023

Background

Aorta–right atrial tunnel is a rare entity characterized by a iatrogenic vascular fistula, which connects aortic root and right atrium. It is frequently associated with congestive heart failure (HF).

Case

A 54 y female with an history of atrial septal defect (ASD) type ostium secundum closure and a recent mitral and tricuspid annuloplasty surgery, presents to the hospital with significant decrease in exercise tolerance and progressive shortness of breath. At the presentation, physical examination was significant for tachycardia, continuous murmur over precordium and lower extremity edema. ECG showed right ventricular pressure overload with repolarization abnormality. TTE showed moderate systolic flattening of the septum and dilated right sections. Non coronary cusp of aortic valve demonstrated a perforation extending to the right atrium (RA). ETE confirmed the connection between non–coronary aortic cusp and RA, furthermore revealed unkown sinus venosus type ASD. TC angiography showed a marked dilation of the pulmonary artery trunk (egg and banana sign) and a connection between aorta and RA. She was treated with surgical closure of aorta– right atrial tunnel and ASD through detached and pledget stitch closure. Follow–up reveals significant functional recovery of shortness of breath and exercise tolerance.

Discussion

Aorta– right atrial tunnel is a rare entity characterized by a vascular fistula, which connects one of the sinuses of Valsalva and the RA. It is a rare complication of tricuspid plastic surgery. It is classified according to its relation to the aorta to anterior or posterior. The clinical presentation ranges from asymptomatic continuous murmur to the symptoms of right sided HF. In our case, the presence of ASD accelereted and worsened the manifestations of right HF. It is usually diagnosed by TTE or ETE, TC angiography and aortography. The treatment of this condition is important even in asymptomatic cases due to the risk of aortic valve dysfunction, likely regurgitation, congestive right sided HF followed by left sided HF, calcification, infective endocarditis, aneurysmal dilatation and pulmonary hypertension.

Conclusion

The possibility of complications of aorta–right atrium fistula necessitates early therapy, even in asymptomatic patients or those with a hemodynamically insignificant shunt. Available treatment is surgical closure. It has a high mortality rate if it is not diagnosed adequately and surgically treated without delay.
P272 ROLE OF 3D TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN DIANOSIS OF DYSFUNCTION OF MECHANICAL PROSTHESES
Authors: Scollo V , Fede G , Abate G , Belluardo P , Guccione N , Sulsenti G , Ficili S
Published: May 2023

Infections with endocardial vegetation or the exuberant growth of neoendothelialization tissue (cloth –tissue overgrowth) in heart valve prostheses lead, among other complications, to the malfunction of the prostheses themselves due to obstruction. Among the diagnostic methods available to us, to achieve the diagnosis of prosthetic dysfunction, in recent years three–dimensional transesophageal echocardiography (3D TTE) has become increasingly imposed. We present two clinical cases of patients admitted to our Cardiology department Case 1: Patient of 62 years old, hospitalized for established congestive heart failure. In 2006 he underwent ascending aorta replacement with Dacron 28 prosthesis and aortic valve replacement with mechanical prosthesis (Sorin 25) for aortic bicuspid and ascending aortic aneurysm. During the last follow–up was observed a slight increase in the value of intraprosthetic gradients, as well as a variability in INR values. Physical examination showed signs of heart failure (NT–ProBNP >1000 pg/ml); normal inflammation indices (PCR <2.9 mg/l); ECG: sinus rhythm at 85 bpm with left ventricular overload; trans–thoracic echocardiography showed severe intraprosthetic aortic gradient (Gmax 132mmHg–Gmed 72mmHg), doubtful for cloth adhered to prosthetic discs; 3D TTE shoved hyperechoreflective image adhered to the posterior mobile element (5x9mm) which was fixed in semi–closure. Subsequently, the patient underwent prosthetic replacement surgery with biological prosthesis. Case 2: Patient of 67 years old, heavy smoker, hypertensive, with aortic mechanical prosthesis, a few weeks before hospitalized for Corynebacterium Jeikeium infection. Hospitalized again for fever with increased inflammation indices (CRP 202mg/l). A first TTE concluded for suspected endocarditis of the prosthesis; this doubt was also dissolved by 3D TTE which showed a soft protruding image of the posterior mobile element, preventing the opening and determining severe stenosis (Gmax 160mmHg–Gmed of 80 mmHg), so this patients was transferred to the cardiac surgery department.

Conclusions

3D TTE is a method of rapid and safe execution that can be exploited not only pre– or intraoperatively but also to settle diagnostic suspicions not clarified by traditional 2d methods, even managing to distinguish cloth deposits from vegetation / abscesses.
P288 TREATMENT OF HEART FAILURE IN CLINICAL PRACTICE: NON–INTERVENTIONAL OBSERVATIONAL STUDY ON PATIENTS WITH HEART FAILURE TREATED WITH DAPAGLIFLOZIN (EVOLUTION–HF ITALY)
Authors: Orso F , Ameri P , Carugo S , Di Lenarda A , Iacoviello M , Indolfi C , Mortara A , Perrone Filardi P , Ungar A , Volpe M , Volterrani M , Granelli V , Mastromauro F , Pluchinotta F , Gnesi M , Rosano G
Published: May 2023

Background

Heart Failure (HF) is a relevant issue for public health issue: it affects more than 64 million people worldwide1, and its burden is anticipated to increase as the population ages. Dapagliflozin is an inhibitor of the sodium–glucose cotransporter–2 (SGLT2i). In the DAPA–HF trial, dapagliflozin reduced the risk of hospitalisation for HF and death in patients with HFrEF (with or without Type 2 Diabetes) compared to placebo2,3,4. Currently, there is a lack of data on characteristics, treatment profiles, and patient reported outcomes (PROs) of patients initiated on dapagliflozin for HFrEF in clinical practice: the EVOLUTION–HF programme is aimed at answering those questions by collecting real–world data in 13 European Countries, including Italy. The primary objective is to characterise patients initiated on dapagliflozin for the treatment of HFrEF and to estimate occurrence of treatment discontinuations. Secondary objectives include an assessment of Health–related Quality of Life (HR–QoL) by means of the Kansas City Cardiomyopathy Questionnaire (KCCQ), patient–reported adherence to prescriptions of pharmacological treatments for HF (Medication Adherence Report Scale – 5 Item), performance on 6–Minutes Walking Test.

Methods

The study has an observational, longitudinal, descriptive design. To be enrolled, patients must be 18 years old or older and have initiated treatment with dapagliflozin according to the approved HFrEF label. Patients with a diagnosis of Type 1 Diabetes or previously treated with any SGLT2i are excluded from the study. Follow–up lasts one year from start of treatment. Sample size has been estimated in 250 patients, that will be enrolled in 11 centres.

Results

The study is currently ongoing, and it will generate evidences on the use and tolerability of dapagliflozin, as well as on treatment patterns of other pharmacological therapies for HF and diabetes. Also, the study will generate data from PROs regarding change of KCCQ across time, adherence to HF therapies in clinical practice, and 6–Minutes Walking Tesst. Multivariate analyses will evaluate association between patients’ characteristics and interruption of treatment, adherence and HR–QoL. The interim analysis will be available in the first months of 2023.

Conclusions

The EVOLUTION–HF Italy study Il programma di studio EVOLUTION–HF supporterà la pratica clinica con dati originali sull‘uso nel mondo reale delle nuove terapie farmacologiche per l‘HFrEF.
P296 WHAT IF CARDIAC SURGEONS PERFORM TRANS–CATHETER AORTIC VALVE INTERVENTIONS?
Authors: Malvindi P , Berretta P , Capestro F , Galeazzi M , Bifulco O , Alfonsi J , Cefarelli M , Zingaro C , Pierri M , D‘Alfonso A , Di Eusanio M
Published: May 2023

Background and aim

Aim of this study is to present the results of our aortic valve interventions program embedding surgical (SAVR) and trans–catheter treatment, both in the hands of cardiac surgeons.

Methods

Data of patients who had isolated aortic valve interventions during the period 2016–2022 were reviewed. SAVR was performed mainly through a minimally invasive approach . TAVI included either TF or TA access procedures, all performed in a cardiac surgery theatre with fluoroscopy equipment.

Results

During the study period, 1435 patients underwent isolated aortic valve intervention: 1022 surgical AVR (665 mini AVR, 357 FS) and 413 TAVI (333 TF and 80 TA). TAVI were introduced during 2018 and gained a wider application over the years with the progressive adoption of awake procedures and fully percutaneous access (Figure 1). The global volume of aortic valve procedures increased of 38% comparing the full–years 2021 with 2018 (295 vs 213 cases). Multivariable logistic regression showed that TAVI was significantly associated with increased age, female gender, a higher rate of comorbidities and lower LVEF. Overall in–hospital mortality was 0.6% – mini AVR 0.3%, FS 0.3%, TF TAVI 1% and TA TAVI 3%. Permanent neurologic injury was recorded in 0.7% of the patients. Permanent PM implantation was higher after TAVI (87/413 vs 32/1022 patients who had surgical AVR).

Conclusions

TAVI procedures can be safely performed by cardiac surgeons. The expertise in both surgical and trans–catheter treatment translated in the possibility of treating aortic valve disease in a higher volume of patients including older and comorbid patients with excellent early results.
P298 TRANS–AXILLARY ACCESS AS AN ALTERNATIVE ROUTE IN TRANSCATHETER AORTIC VALVE IMPLANTATION
Authors: De Michele G , Moscarella E , Acerbo V , Raucci G , Scherillo G , Signore G , Rotolo F , Scialla F , Cesaro A , Calabrò P
Published: May 2023

Background

Transcatheter aortic valve replacement (TAVR) is the main procedure for treating severe aortic stenosis in patients considered at high surgical risk. Generally, this procedure is performed through percutaneous femoral arterial access. The presence of anatomical variants or peripheral atherosclerotic pathology sometimes necessitates the use of alternative vascular accesses, including access through the axillary artery. Data from a meta–analysis involving 1793 patients who underwent TAVR through trans axillary or transapical access showed a statistically significant reduction in 30–day mortality in the former group. We wait for future randomized trials to confirm the consistency of these data.

Clinical case

71–year–old man, smoker, hypertensive and dyslipidaemic. In 2018, he underwent bilateral aorta–iliac–femoral bypass surgery for severe lower limb arteriopathy. Due to the onset of angina and dyspnea at rest, he went to the ER where a diagnosis of NSTEMI was made. On echocardiogram, there was evidence of severe high–gradient aortic stenosis while coronary angiography showed 80% RCA stenosis in the middle tract. Because of the high surgical risk (EUROSCORE II: 12%) and the evidence of bilateral femoral artery occlusion on CT–angiography, the Heart Team concluded to perform TAVR through percutaneous left trans–axillary access with concomitant percutaneous coronary revascularization. Obtained the backup access on the left radial artery, PTCA+DES was performed on RCA through the right radial access with subsequent placement of a pigtail catheter in the non–coronary sinus of Valsalva. Once the temporary pacemaker had been placed through the right femoral vein, an angio–guided puncture of the left axillary artery was performed with placement of the 14 Fr introducer for implantation of the Medtronic Evolut R 26 mm aortic biological prosthesis. Post–procedure ultrasound examination showed a residual mean aortic valve gradient of 17 mmHg with evidence of a small periprosthetic leak. Seven days after the procedure, the patient was discharged, asymptomatic and in good hemodynamic compensation without vascular complications.

Conclusions

Trans–axillary arterial access should be considered a viable alternative to transfemoral access for the performance of TAVR.
P300 AORN A. CARDARELLI NAPOLI/ FEDERICO II UNIVERSITY INTERHOSPITAL PROTOCOL: TAVI IN A COMPLEX SCENARIO
Authors: Furbatto F , Carpinella G , D‘Andrea D , Moscato R , Serino F , Mauro C
Published: May 2023

Rational: In order to provide the best treatment for patients affected by severe aortic stenosis at intermediate–high surgical risk, since more than 3 years an interhospital protocol beetween the Cardiology, UTIC and Cath–lab department of AORN A. Cardarelli of Naples, a center without cardiac surgery, and the cath–lab of the department of Cardiovascular Emergencies, Clinical Medicine and Ageing Medicine of AOU Federico II, is active. The agreement provides the carrying out of a TAVI procedures for patients hospitalized at the A. Cardarelli, by transfering them with a resuscitation ambulance to the Federico II cath–lab, and subsequent return to the department of origin after the execution of the interventional procedure. Case report: 85 year old lady with hypertension, moderate–severe chronic respiratory failure and atrial fibrillation treated with NOAC, is admitted in the emergency room for acute pulmonary edema and contextual diagnosis of severe aortic stenosis is made. After clinical stabilization, the TAVI program is started: both an angio–CT scan and a coronary angiography are carried out, with the detection of a critical calcified stenosis involving left main branch and proximal LAD and a chronic occlusion of Cx branch. Multidisciplinary evaluation and collegial evaluation with the colleagues from the Federico II University are carried out, and indication is given to TAVI with contextual PTCA of LM and LAD critical stenosis. A joint procedure of PTCA with 2 DES and TAVI with Evolute R 29 valve is then carried out in a single session at the Federico II University of Naples and after post–procedural observation, the patient is transferred back to the UTIC of A. Cardarelli for hospitalization. During the hospital stay, no procedural complications are reported and the patient is discharged 4 days after in good clinical conditions; a triple therapy with NOAC and DAPT is started, continuing it for 1 month with subsequent suspension of ASA and carrying on therapy with NOAC + Clopidogrel. At 1 and 6 months clinical follow–up, the patient is stable and well compensated, without significant clinical complications and with NYHA class 2.

Conclusions

The results of these years–experience, highlight the feasibility and safety of this strategy, making it possible to plan and carry out TAVI procedures even in centers that do not have onsite cardiac surgery, considering the growing indications for TAVI and the subsequent increase of patients who need this procedure
P306 MANAGEMENT OF MASSIVE EMBOLIZATION OF STRATIFIED THROMBUS FROM A CORONARY ANEURYSM: A CASE OF MUTUAL CAMOUFLAGE
Authors: Allievi L , Mircoli L , Barbieri L , Colombo F , Tumminello G , Carugo S
Published: May 2023

Introduction

We report the intraprocedural, post–procedural management and long–term therapeutic strategy in a case of an acute coronary syndrome caused by occlusion of a posterior interventricular branch (IVP) originating from a segment of the right coronary artery with a normal diameter, but, affected by an aneurysm with an extensive stratified thrombotic formation that embolized during the procedure. Case description: 47–year–old man, a heavy smoker, comes to the emergency room about 24 hours after the onset of constant chest pain. ECG: basically, within the limits. Echocardiogram: mild concentric hypertrophy. Mild infero–basal hypokinesia. Blood tests: troponin 355 pg/ml –> 854 pg/ml (pre–coronarography). On coronary angiography, occlusion of the interventricular branch posterior to the ostium originates from a segment of the right coronary artery of apparently normal diameter. The angioplasty procedure caused the mobilization of extensive parietal thrombotic formation adhering to the distal section of the right coronary artery and in the proximal section of the posterior atrioventricular branch with massive embolization of the posterolateral branches, revealing the presence of a coronary ectasia in the same site, not visible before thrombus mobilization.

Discussion

The goal of intraprocedural management was to obtain reperfusion of the embolized branches by numerous passages of the manual thromboaspirator and numerous balloon inflations on the embolized branches, without placing stents. The antithrombotic therapeutic strategy was dual antiplatelet therapy (DAPT) with acetylsalicylic acid/ticagrelor 90 mgx2, Tirofiban in the first 12 hours and anticoagulation with enoxaparin (8000 IUx2).

Conclusions

Coronary angiography at 7 days showed complete disappearance of residual thrombotic formations. The choice of long–term pharmacological strategy was only DAPT with an extension program of over 12 months with ticagrelor 60x2 even though the Pegasus criteria were not present.
P309 DIFFERENT KINETICS OF NT–PROBNP AND SST2 HIGHLIGHT DIFFERENT THERAPEUTIC PATHWAYS OF SACUBITRIL/VALSARTAN
Authors: Mapelli M , Mattavelli I , Salvioni E , Bonomi A , Palermo P , Banfi C , Paolillo S , Biondi M , Agostoni P
Published: May 2023

Background

N–terminal pro–B–type natriuretic peptide (NT–proBNP) and soluble interleukin 1 receptor–like 1 ST2 (sST2) are biomarkers used to grade heart failure with reduced ejection fraction (HFrEF) severity. The first is associated with the patient’s hemodynamic status, while the second is indicative of the inflammatory component and of myocardial fibrosis and both are potential targets of HFrEF treatment. Aim of the study: The aim of this study was to assess the kinetics of these biomarkers after treatment with sacubitril/valsartan in HFrEF.

Methods

We analyzed blood samples of HFrEF patients at baseline (before sacubitril/valsartan treatment), after 1, 2, 3 months (respectively after a month taking the 24/26 – 49/51 – 97/103mg doses), and 6 months after the maximum tolerated dose was reached (end–study).

Results

We obtained samples from 34 HFrEF patients (age 65.9±9.0, 74% males). NT–proBNP and sST2 values progressively and significantly reduced up to 21%±33 and 9%±16, respectively, with a greater reduction for NT–proBNP (p<0.05). Specifically, NT–proBNP reduced from 1286 [609–3205] to 877 [437–1866] pg/mL and sST2 from 29.3 [19.5–34.1] to 20.4 [15.6–28.9] ng/mL, p<0.05 in both cases). The reduction of the two biomarkers over time occurred with statistically significant different kinetics: deferred for sST2 and faster for NT–proBNP. No significant changes in renal function and potassium levels were recorded.

Conclusions

These findings suggest that, in HF patients, sacubitril/valsartan effects on the cardiovascular system share a double pathway: a first, hemodynamic, faster pathway and a second, non–hemodynamic, delayed pathway. Both likely contribute to the sacubitril/valsartan benefits in HFrEF.
P320 AN UNUSUAL CASE SYNCOPE DUE TO SILENT CORONARY VASOSPASM
Authors: Somaschini A , Astuti M , Cordone S , Botta M , Ghione M , Buscaglia E , Cornara S , Bellone P
Published: May 2023

Background

Variant angina is a condition due to a transient vasospasm of the epicardial coronary arteries, which usually causes chest pain episodes and may be associated with dangerous arrhythmias. A non–negligible subset of patients can also experience silent myocardial ischemia, defined as objective documentation of myocardial ischemia in the absence of angina or equivalents. This condition is associated with increased cardiac mortality and incidence of acute cardiac events. Description of the case. A 65–years–old man was admitted to our Emergency Department for syncope. He reported palpitations before the event without chest pain. ECG showed biphasic T waves in V2–V6 (Fig 1A), troponin values were normal. Immediately after admission in our coronary care unit for monitoring, he developed dynamic ST segment elevation with signs of inferior and posterior transmural ischemia (Fig 1B) and non–sustained polymorphic ventricular tachycardias (Fig 2), being symptomatic only for palpitations. ECG abnormalities and symptoms quickly resolved after intra–venous nitrates administration. Coronary angiography was performed showing a critical non–occlusive (85%) fixed stenosis at the proximal right coronary artery (Fig 3 A). The lesion was treated by angioplasty and stenting (Fig 3 B) and the patients was discharged on dual anti–platelet therapy, statins and oral high–dose calcium–channel antagonist.

Discussion

This case underlines first the importance of searching for high–risk features in patients with syncope of non–obvious origin: our patient reported palpitations and ECG changes consistent with myocardial ischemia (even with normal troponin values and echocardiographic findings). A peculiarity of our case is that the patient did not complaint any chest pain despite the presence of ST elevation, a condition known as silent ischemia. The transient nature of ECG modification and ventricular arrhythmias, their dramatic response to nitrates and coronary angiography findings were suggestive of silent vasospasm. Coronary vasospasm induces transient myocardial ischemia and may cause ventricular arrhythmias which in turn can cause syncope due to transient cerebral hypoperfusion or, when sustained, even cardiac arrest and sudden death. We did not perform provocative test with acetylcholine or ergonovine due to the likely vasospastic origin of myocardial ischemia and to their potential risks, especially in the presence of non–sustained plymorphic ventricular tachycardias.
P326 FALSE POSITIVE BONE–SCINTIGRAPHY IN ELDERLY HYPERTROPHIC CARDIOMYOPATHY
Authors: Vernile A , Ajmone F , Ballatore F , Maggio E , Mancuso G , Ciaramella P , Chimenti C , Velardo R , Alfarano M , Vizza C , Cristina C
Published: May 2023

Differential diagnosis of cardiomyopathies with hypertrophic phenotype is crucial because some secondary forms of cardiac hypertrophy can be susceptible of specific treatment aimed to revert and/or stabilize the increase in wall thickness.A positive nuclear scintigraphy with hydroxy bisphosphonate bone tracer (99mTc–HPD)is believed to have high sensitivity and specificity for the diagnosis of transthyretin (TTR) amyloid cardiomyopathy. An 85–year–old man with systemic arterial hypertension was admitted because of pre–syncope associated to evidence at Holter monitoring of both bradiarrhythmias(1st degree AV block with PR interval of 300 ms and several episodes of 2nd degree Mobitz type 1 AV block with electrical pause >3 s) and tachyarrhythmias.He suffered from a bilateral carpal tunnel syndrome that underwent surgery 2 years earlier.Routine laboratory tests were normal except for elevated cardiac troponin HS(0.295 mcg/L,nv < 0.014 mcg/L) and N–terminal pro–BNP (384.3 pg/mL,nv = 0–254 pg/mL).Because of clinical suspicion of senile amyloidosis,nuclear scintigraphy with hydroxy bisphosphonate bone tracer(99mTc–HPD)was performed,that revealed a grade 3 myocardial uptake.Serum–urine immunofixation and immunoglobulin free light–chain was negative for monoclonal gammopathy.Neurological examination was unremarkable Genetic test did not show TTR mutation.Thus,a diagnosis of wild–type TTR cardiac amyloidosis was suggested.The patient,in view of Tafamidis treatment,underwent a LV endomyocardial biopsy.Six specimens were drawn from the LV,cut and processed for histology,immunohistochemistry,and transmission electron microscopy. Unexpectedly,histology failed to confirm amyloid deposition but revealed the presence of severely hypertrophied disarrayed cardiomyocytes fragmented in short runs by interstitial and replacement fibrosis,denoting a sarcomeric hypertrophic cardiomyopathy.Congo red staining at polarized light scored negative for areas of apple–green florescence.Immunohistochemistry form transthyretin,kappa/lambda light chain and SAA was negative.Transmission electron microscopy failed to demonstrate the presence of rigid unbranched amyloid fibrils.Thus,a final diagnosis of hypertrophic cardiomyopathy was reached. Coclusion:A positive cardiac signal of bone scintigraphy can occur in other pathologic settings.Future studies are needed to investigate the incidence of false–positive TTR cardiac amyloidosis to bone scintigraphy compared with endomyocardial biopsy.
P329 MANAGEMENT OF ADVANCED AND TERMINAL HEART FAILURE IN AN ELDERLY PATIENT WITH REDUCED EJECTION FRACTION
Authors: Verga F , Orso F , Salucci C , D‘Errico G , Perini E , Vatri M , Poletti E , Cagnoni C , Corti G , Di Bari M , Ungar A , Baldasseroni S
Published: May 2023

Heart failure (HF), despite new therapeutic strategies, remains a condition characterized by an inauspicious prognosis and poor quality of life. The management of advanced and then terminal SC proves to be a current challenge, especially in elderly patients. A.C, 87 years old is autonomous and cognitively intact (BADL preserved 5/6, MMSE 28/30). In June ‘21 femur fracture complicated by cerebral hemorrhage (no relics) and anterior STEMI (FE 25%). Not performed coronarography (contraindication to antiplatelet therapy). Discharged to NYHA II with ARNI, MRA and beta blocker. After 1 month hospitalized for HF in the course of AF, performed infusion of levosimendan. In September ‘21 taken over by our "HF clinic" with progressive titration of therapy and insertion of SGLT2–i. In January ‘22 due to precarious clinical compensation (NYHA III–IV) progressive increase in furosemide dosage and undertaken sequential nephron blockade with metolazone, with good response. Given advanced–HF situation, performed Levosimendan infusions under DH regimen (8 h; 0.05–>0.2 mcg/Kg/min; three times every 2 weeks) with clinical stabilization. In April, hospitalization for decompensation flare–up with worsening creatinine (0.8 >>>2 mg/dL). On discharge, given the precarious compensation, activated the "Hospital–Territory Rapid Intervention Group" with home diuretic infusions and stabilization of the clinical picture and subsequent new referral from the "heart failure clinic" with monthly FU. By November 2022, clinical (NYHA IV with diuretic resistance), cognitive and functional (MMSE 22/30, BADL preserved 2/6) worsening. Evaluated as an end–stage scenario (in the absence of further treatment options), family interview was performed, home nursing service activated for infusions of furosemide, and referred to the palliative care service to assist the patient in the terminal phase of illness at home (Fig. 1).

Conclusion

in order to ensure the best quality of life in the terminal phase of the disease, the management of advanced SC in the elderly patient must involve individualization of the care pathway, through multidimensional assessment of the patient and sharing of goals at the different stages: from intensive FU with optimization of therapy in the early stages to early activation of home and palliative care services in the more advanced stages.
P331 ANALYSIS OF THE CLINICAL AND THERAPEUTIC CHARACTERISTICS OF PATIENTS ADMITTED TO THE HEART FAILURE CLINIC IN THE PERIOD APRIL–SEPTEMBER 2022. ORGANIZED BY THE ANMCO AREA CARDIO RENO METABOLICA
Authors: Benvenuto M , Iacoviello M , Fabiani D , Gronda E
Published: May 2023

In recent years, the pharmacological treatment of HFrEF has undergone considerable development. Two pharmacological classes in particular have been shown to significantly reduce cardiovascular events and hospitalizations: ARNI and SGLT2i. The objective of this observational study was to provide "real word" data on the effective use of these drugs, the efficacy, safety and tolerability of their simultaneous administration. We analyzed 82 patients admitted to our clinic over a period of 6 months and reported their clinical characteristics and the effective therapies administered. The data of 82 patients, 64% male, with an average age of 70.5 years were analysed. 49% with ischemic heart disease, 54% hypertension and 31% type 2 diabetes mellitus. Of these, 47.5% with HFrEF, 21% with HFmrEF, and the remaining 30% with HFpEF. At the time of visit, 19.5% of patients had a GFR <59 mL/min/1.73m2. 31% of the patients were in NYHA Class III. We then analyzed the drug therapies provided. Assuming that a very high percentage of patients were taking beta blockers and MRA (91% and 79% respectively), we found that about 72% of patients were on concomitant therapy with a renin angiotensin system inhibitor (51% ARNI, 21% ACEI/ARBs). Among the 51% of patients in ARNI, as many as 32% took the minimum dose of the drug (24/26mg bid), 11% the intermediate dose (49/51mg bid) and only the 8% the maximum recommended dosage (97/103 mg bid). In the group of patients with HFrEF, 10% were not on ARNI therapy or this drug had been discontinued during the follow–up (92% for hypotension, 8% for ARF on IRC). As for gliflozines, 46% of the patients analyzed were on SGLT2i therapy (and of these, approximately 70% had HFrEF). 30% of the total patients were in concomitant therapy with ARNi and SGLT2i (62% of patients affected by HFrEF).

Conclusions

most of our outpatients are affected by HFrEF, they benefit from the best pharmacological strategy recommended by the most recent international guidelines . The simultaneous administration of ARNI and SGLT2i is not burdened by significant adverse events. None of our patients discontinued SGLT2i therapy since there were no adverse effects related to drug administration.
P332 A CASE OF METABOLIC ACIDOSIS AFTER INITIATION OF SGLT2–I THERAPY IN HEART FAILURE WITH REDUCED EJECTION FRACTION
Authors: D’Errico G , Orso F , Verga F , Salucci C , Perini E , Vatri M , Poletti E , Cagnoni C , Corti G , Di Bari M , Ungar A , Baldasseroni S
Published: May 2023

In July 2022 C.M., a 58–year–old woman, was admitted to our Heart Failure Outpatient Clinic. Patient with permanent AF undergoing DOAC therapy, previous double mitral and tricuspid valve replacement with bioprosthesis. As comorbidities she had stage IIIb CKD, previous ischemic stroke without outcome, multifactorial anaemia, asthma, ulcerative rectocolitis non–responsive to biological therapy. Since April 2022 progressive reduction in exercise tolerance with dyspnoea for previously well–tolerated exertion, with finding of severe left ventricular systolic dysfunction (FE 25%) due to widespread hypokinesia previously unknown. In September angiographic control confirmed the absence of coronary artery disease. Amiodarone therapy was started for frequent runs of VT. Cardiac MRI confirmed FE 27% with fibrosis of the interventricular septum and lower basal wall of non–ischemic appearance. In view of the clinical–instrumental findings, a single–chamber ICD pacemaker was implanted and the therapy for heart failure with reduced FE was optimised with the introduction of Sacubitril/Valsartan (later discontinued due to hypotension), MRA and SGLT2–I (Empagliflozin). Due to the persistence of labile haemodynamic compensation, an indication was given to perform three cycles of Levosimendan infusion at our Day Hospital. The routine EGA taken during the first infusion cycle showed metabolic acidosis in the absence of significant worsening of renal function (Fig. 1) with mild hypobicarbonatemia and electrolytes in the normal range. On the assumption that the acidosis was secondary to the introduction of SGLT2–I (about two months earlier), Empagliflozin was discontinued. One week after discontinuation, the control EGA (Fig. 1) showed resolution of the acidosis, with a substantially stable glomerular filtrate, so that discontinuation of the drug was confirmed.

Conclusions

In the literature there are reviews and case reports of euglycaemic diabetic ketoacidosis (euDKA) in DM2 patients on SGLT2–I therapy although there are currently only hypotheses regarding the pathophysiological mechanism. The possibility of inducing acidosis with hypobicarbonatemia in the absence of worsening renal function is unclear. A ‘Fanconi–like‘ mechanism could be hypothesised with induction of type 2 tubular acidosis with bicarbonate loss due to glycosuria.
P382 TEAMWORK IS SUCCESSFUL (2): PATIENT WITH DIFFUSE LARGE B–CELL LYMPHOMA (DLBCL) AND MULTIPLE HEART MASSES
Authors: Pennacchioni A , Nizzoli M , Roncali M , Alvarez De Celis M , Turina C , Laurito M , Merli F , Navazio A , Luminari S , Tarantini L
Published: May 2023

Introduction

Patients (Pts) with lymphoma are at high risk of cardiovascular events for the cardiotoxic effects of therapies and direct involvement of the heart. Autopsy series, indeed, indicate that cardiac localization may be observed in 10 – 25% of DLBCL Pts. The presence of cardiac mass, in DLBCL poses further complexity to the management beyond myocardial chemotherapy–related cardiotoxicity for the possible unfavorable/unpredictable evolution of the lymphoma mass (arrhythmias, AV block, myocardial ischemia, pericardial effusion and cardiac tamponade). We report the case of pt. with diffuse DLBCL, and multiple cardiac locations discovered, incidentally, on total body PET performed for disease stratification.

Clinical case

A 72–year–old woman with worsening asthenia and advanced stage non–GCB DLBCL presented multiple cardiac radiotracer uptake at 18FDG PET. The basal echocardiogram evidenced a roundish pedunculated mass at the level of the outflow tract of the right ventricle (24 x 22 mm) with significant obstruction of the RVOT, an oval formation at right ventricular apex with possible myocardial infiltration and a further mass in the right atrial site. Mild (< 1 mm) circumferential pericardial effusion, finally, was appreciated. No other notable alterations . After multi–disciplinary discussion, the patient underwent R–COMP based induction regimen, thus substituting conventional doxorubicin (R–CHOP) with non–pegylated liposomal doxorubicin in order to reduce the risk of acute cardiotoxicity. The first cycle was administered as inpatient under close cardiac monitoring, that was subsequently carried on before each cycle. No embolic and/or mechanical complications occurred. The response to chemotherapy was excellent: after the first cycle a substantial reduction in size of the cardiac masses was observed and after 3 cycles a complete resolution of the same was observed. Interim response evaluation by 18FDG PET after cycle 3 upheld early ultrasound observations by displaying a complete disappearance of pathological uptake.

Conclusions

In the case of patients with advanced DLBCL, multi–imaging evaluation enable appropriate assessment of cardiac conditions, including possible cardiac location and nature of masses. The personalized multidisciplinary management allows a tailored management of complex cases that enables both the achievement of treatment goals and the avoidance of acute complications.