bluuebunny/crossref_metadata_2025 huggingface dataset:
52 A DEEP-LEARNING APPROACH FOR SCAR DETECTION IN EARLY CONTRAST-ENHANCED CARDIAC COMPUTED TOMOGRAPHY IMAGES
Authors: Penso Marco , Babbaro Mario , Moccia Sara , Baggiano Andrea , Pepi Mauro , Andreini Daniele , Caiani Enrico Gianluca , Pontone Gianluca
Published: December 2022

Diagnosis of myocardial fibrosis has a relevant prognostic and therapeutic role. Scar-tissue analysis is commonly performed with late gadolinium contrast-enhanced (CE) cardiac magnetic resonance (CMR). However, CMR might be contraindicated or unavailable. Coronary computed tomography (CCT), which is the technique of choice for many routine assessments, is emerging as an alternative to CMR.

The objective of this study is to evaluate whether artificial intelligence (AI) could allow identification of myocardial fibrosis from routine early CE-CCT images.

Fifty consecutive patients with left ventricular dysfunction (LVD), who underwent both CE-CMR and (early and late) CE-CCT were retrospectively selected. According to the late enhancement CMR patterns, patients were classified as with ischemic (n=15, 30%) or non-ischemic (n=25, 70%) LVD. Scar regions were manually traced on late CE-CCT using CE-CMR as ground-truth. On early CE-CCT images, the myocardial sectors were extracted according to AHA 16-segment model and labeled as with scar or not based on the late CE-CCT manual tracing. A deep-learning model was developed to classify each sector (Picture).

Of the initial 44187 sectors computed out of the 8285 slices available from the early CE-CCT images, 4594 sectors (10%) presented scar. The CNN approach on the early CE-CCT images yielded a classification accuracy for all sectors of 71% (95% confidence interval (CI): 63%-79%) obtained through 5-fold cross validation. The mean sensitivity, positive predictive value (PPV) and negative predictive value (NPV) for the testing fold resulted in 73% (95% CI: 66%-79%), 56% (95% CI: 48%-65%) and 85% (95% CI: 82%- 88%), respectively. The mean AUC across the five folds was 76% (95% CI: 72%-81%). In a per-segment analysis of the 16-segment AHA model the bull's eye segmental comparison of CE-CMR and respective early CE-CCT findings an 91% agreement was achieved.

Artificial intelligence can detect both ischemic and non-ischemic myocardial fibrosis from routine noninvasive coronary scans, without additional contrast-agent administration or radiational dose, thus assisting diagnosis and management of patients with LV dysfunction and coronary artery disease.
622 APPROPRIATENESS OF ECHOCARDIOGRAPHIC REQUESTS FOR DIAGNOSIS OF INFECTIVE ENDOCARDITIS. A RETROSPECTIVE SINGLE-CENTER STUDY.
Authors: Baroni Giulia , Borile Giovanni , Pergola Valeria , Aruta Patrizia , Baritussio Anna , Cecchetto Antonella , Mattesi Giulia , Previtero Marco , Romano Silvia , Iliceto Sabino , Mele Donato
Published: December 2022

Background

Transthoracic echocardiography (TTE) is the first cardiac imaging modality generally requested for diagnosis of suspected infective endocarditis (IE), while transesophageal echocardiography (TEE) can be performed as initial or supplemental test. Although IE is a relatively rare disease characterized by high mortality, the number of daily in-hospital TTE and TEE requests to diagnose this disease is high, probably because of inappropriate prescriptions.

Objective

The principal aim of this study was to assess the clinical appropriateness of TTE and TEE requests for suspected IE.

Methods

Electronical data relative to TTE and TEE examinations performed for suspected IE between September 2013 and July 2022 at our center were extracted and retrospectively analyzed. All TTE and TEE requests were defined as appropriate according to the criteria indicated by the 2017 international guidelines on appropriateness for cardiac imaging in valvular heart disease.

Results

After exclusion of repeated ultrasound examinations, a total of 2249 first requests of echocardiographic examinations for suspected IE were analyzed (patients’ age 64±18 years, 61% males). TEE examinations were 447 (20%). Diagnosis of IE was made in 293/2249 (13%) cases. During the 10-year observation period, 33.1% of the TTE requests was appropriate and 12.2% of the appropriate examinations was positive for IE. Percentages of prescriptive appropriateness and diagnostic TTEs did not change significantly before and after publication of the 2017 international guidelines: in fact, appropriate TTE requests were 31.6% before and 35.3% after (P=0.579), and positive TTEs were 12.1% before and 12.4% after (P=0.948). Regarding TEEs, during the 10-year observation period 51.2% of the 447 examinations was appropriate and 35.8% of these evaluations was positive for IE. As for TTE, percentages did not vary significantly before and after publication of the 2017 international guidelines: appropriate TEE requests were 52.2% before and 50% after (P=0.756), and positive TEEs were 35.9% before and 35.6% after (P=0.965).

Conclusions

The majority of echocardiography requests for diagnosis of IE at our center during a 10-year observation period was inappropriate, especially TTE requests. No significant impact of the 2017 international guidelines on appropriateness for cardiac imaging in valvular heart disease was observed. A corrective strategy could be based on several actions: periodic monitoring of prescriptive appropriateness, dissemination of knowledge about published guidelines and development of in-hospital operative protocols shared among all physicians involved in TTE and TEE prescription.
146 AORTIC ACCELERATION TIME/EJECTION TIME RATIO AND BI-VENTRICULAR PERFORMANCE IN SEVERE AORTIC STENOSIS
Authors: Dotto Alberto , Ciceri Luca , Springhetti Paolo , Urbani Giulia , Del Sole Paolo Alberto , Nistri Stefano , D´ascenzo Fabrizio , Gallone Guglielmo , Tafciu Elvin , Bergamini Corinna , Rossi Andrea , Luciano Ribichini Flavio , Benfari Giovanni
Published: December 2022

Introduction

Echocardiographic evaluation of severe aortic stenosis (SAS) is is important to guide the therapeutic approach but often challenging. Recent studies have demonstrated that the ratio of acceleration time/ejection time (AT/ET) is a simple and reproducible echocardiographic parameter that integrates aortic stenosis severity evaluation and adds information on patient's prognosis.

Aim

The aim of the study is to investigate the role of the ratio of acceleration time (AT) and ejection time (ET) and its major determinants in severe aortic stenosis .

Methods

Consecutive echocardiograms of patients with severe AS referred to our center were analyzed offline using Tomtec Arena (Tomtec, Untershlei heim, Germany). AT was measured from the start of the CW Doppler aortic wave, to the peak of the aortic jet. ET was calculated from the same starting point, to the end of the CW Doppler aortic wave.

Results

A total of 135 patients with severe aortic stenosis formed the study cohort: patients with AT/ET below the median value of 0.35 (vs. higher) presented lower LVEDV (60 vs. 71 ml/mq; p 0.014), left ventricle mass index (116 vs 130 g/m2; p 0.035) and higher LVEF (58 vs 50%; p 0.001), GLS (- 14 vs - 12%; p 0.025), FAC (46 vs 41%; p 0.01), SBP (141 vs 131 mmHg; p 0.003).

At multivariable analysis the major AT/ET determinants were systolic arterial pressure and bi-ventricular performance parameters. The following nested regression were created: the first inclusive of systolic arterial pressure (PAS), fractional area change (FAC), left ventricular mass indexed (LVMI), global longitudinal strain (GLS) (R2=0.48 p<0.001), the second inclusive of PAS, FAC, LVMI, GLS, AVA (R2=0.57, p<0.001), the third inclusive of PAS, FAC, LVMI, LVEF, AVA (R2=0.64, p<0.001).

Conclusion

Our study demonstrated that AT/ET ratio relates quite well with LV performance in the context of SAS. An high ACT/ET ratio tends to be associated with a poor bi-ventricular performance and LV negative remodeling. It is possible that this simple parameter in the next future could help in staging the disease among SAS patients.
501 CASEOUS CALCIFICATION OF THE MITRAL ANNULUS AND THE IMPORTANCE OF ITS IDENTIFICATION IN THE CLINICAL PRACTICE: A REPRESENTATIVE CASE
Authors: Ciceri Luca , Springhetti Paolo , Dotto Alberto , Maffeis Caterina , Tafciu Elvin , Bergamini Corinna , Rossi Andrea , Benfari Giovanni , Luciano Ribichini Flavio
Published: December 2022

1. Introduction

Caseous Calcification of the Mitral Annulus (CCMA) is a rare condition characterized by a liquefaction degeneration that usually involves posterior mitral ring and it is considered a variant of mitral annulus calcification. Its prevalence is very low, but it is possible that it is often underdiagnosed or misdiagnosed. This condition is related with increased age, female sex, chronic kidney disease and calcium metabolism disorders. The lesion can be detected using imaging techniques and its management is conservative in most cases.

2. Case Study

A 72-year-old man hospitalized for bilateral pneumonia complicated with ARDS has come to our attention. The patient had a history of stage IV renal failure, type 2 diabetes mellitus and calcific degenerative aortic valve disease. During its stay in the Intensive Care Unit a routine Transthoracic Echocardiogram showed a vegetation suspected for infective endocarditis that involved the posterior mitral leaflet. However, the clinical presentation did not support endocarditis diagnosis as no microorganisms were isolated at multiple blood cultures and other Duke Criteria were negative. Given the limited acoustic viewing of transthoracic echocardiogram it was necessary to perform a Transesophageal Echocardiogram (TEE) for a better characterization of the valve lesion. TEE showed the presence of a round lesion, about 2×2 cm in size, with smooth borders, located over the mitral annulus with extension up to the posterior mitral leaflet and with a partially mobile portion. The lesion had a corpuscular appearance inside with less echogenicity and without evidence of flow. No significant functional alterations of the mitral valve were detected (anterograde transmitral flow Mean Gradient 4-5 mmHg; Mild regurgitation). We therefore concluded for Caseous Calcification of the Mitral Annulus as the most likely diagnosis and decided for a conservative management. A new TEE was performed as a control after one week showing no significant changes on the valve lesion.

3. Conclusions

It is important for echocardiographers to be familiar with CCMA and to know how to distinguish it from other valve lesions such as infective vegetation, abscesses or tumors. An integration with other cardiac imaging techniques, patient past medical history and clinical-laboratory data can help the physician in the correct characterization of valve lesions and subsequent most appropriate therapeutic approach for the patient.
1098 CHARACTERIZATION OF DIFFERENT TYPES OF LV REMODELING USING QUANTITATIVE INTRACARDIAC FLUID-DYNAMICS
Authors: Calvelli Pierangelo , Sabatino Jolanda , Bella Sabrina La , Rosa Romano Letizia , Strangio Antonio , Leo Isabella , Montemurro Vincenzo , Critelli Claudia , Maglione Marco , Troilo Fabio , Loliva Giuseppe , Salvo Giovanni Di , Indolfi Ciro , Rosa Salvatore De
Published: December 2022

Background

Hyperdoppler is a novel advanced echocardiographic technique for the quantitative assessment of intracardiac fluid-dynamics. Recently, its use has been proven useful to complement traditional echocardiographic evaluation of cardiac function in Heart Failure. However, no specific data are available on its application to differentiate between different types of LV remodeling. Thus, our aim was to investigate whether quantitative changes in fluid dynamics might be able to characterize patients with different ventricular geometry.

Methods

We enrolled 100 consecutive patients with one of the following: LV concentric hypertrophy (CH), eccentric hypertrophy (EH), concentric remodeling, normal LV geometry (CTRL). They underwent a complete echocardiographic examination with intracardiac fluid-dynamic analysis by Color Vector Flow Mapping (Hyperdoppler, Esaote, Genova, Italy). The following parameters were obtained: vortex area (VA); vortex length (VL); vortex depth (VD). Bland Altman Plot has been used to assess intra and inter-observer variability.

Results

Mean Vortex Depth was significantly higher in CR (p=0.011), CH (p=0.001) and EH (p=0.025) compared to CTRL (p=0.013, p=0.001 and p=0.022, respectively). In addition, CH had significantly higher Vortex Length (p= 0.008) and larger VA (p=0.012) compared to CTRL. No significative differences in vortices parameters have been observed between CH and EH.

Conclusion(s)

Quantitative fluid-dynamic assessment was feasible and reliable in the whole population and is a promising tool to complement standard echocardiography for the early characterization of different types of LV remodeling.
381 PROGNOSTIC VALUE OF TWO DIMENSIONAL STRAIN IN EARLY ISCHEMIC HEART DISEASE: A 5-YEAR FOLLOW-UP STUDY
Authors: Campanella Francesca , Licordari Roberto , Pistelli Lorenzo , Parisi Francesca , Cocuzza Federica , Allegra Marta , Lo Savio Armando , La Cognata Olga , Poleggi Cristina , De Sarro Rosalba , Morabito Claudia , Crea Pasquale , Imbalzano Egidio , Micari Antonio , Di Bella Gianluca , Dattilo Giuseppe
Published: December 2022

Introduction

Dipyridamole stress echocardiography (Dipy-stress) compared to exercise ECG, has an higher specificity in non-invasive detection of coronary artery disease (CAD). Two-dimensional strain echocardiography (2D-SE) is able to detect even minimal abnormalities of systolic function. The aim of the study was to observe changes in 2D-SE parameters during dipy-stress and to assess prognosis in a group of patients who had previously a non-diagnostic dipy-stress test result.

Methods

In the first phase 71 patients were enrolled and a dipy-stress test was performed. Each patient was then studied by off-line measurement of 2D-SE and coronary computed tomography angiography (CCTA), to check the presence of CAD. In the follow-up phase, an echocardiographic re-evaluation and outcome analysis during a mean follow-up of 78 months was carried out.

Results

In the first phase, Global Longitudinal Strain (GLS) was reduced (p < .0001) in the CCTA positive group compared to the CCTA negative group (23±3 vs 26±2 at rest; 20±3 vs 26±2 after stress). CCTA negative group and the CCTA positive group did not differ in terms of clinical features, cardiovascular risk factors, or treatments. Despite a trend in reduction for positive CCTA group (23±3 vs 20±3 at rest; 20±3 vs 19±3 after stress), no statistically significant changes were seen in the analysis of GLS rest and stress values, between baseline and follow-up in the two groups. None of the enrolled patients experimented cardiac events during follow-up.

Conclusions

Left ventricular GLS analysis improves the accuracy of dipy-stress echocardiography in the detection of mild CAD compared with the assessment of Wall Motion changes, particularly in those with preserved left ventricular ejection fraction. Patients may have a better mid-term prognosis thanks to close follow-up and early treatment of all cardiovascular risk factors.
1116 DOUBLE-CHAMBERED RIGHT VENTRICLE AND VENTRICULAR SEPTAL DEFECT IN AN ELDERLY WOMAN: A RARE CASE.
Authors: Cristiano Mario , Iuliano Giuseppe , Rispoli Antonella , Soriente Lucia , Ciccarelli Michele , Galasso Gennaro , Vecchione Carmine , Citro Rodolfo
Published: December 2022

Introduction

Double-chambered right ventricle (DCRV) is a rare congenital heart defect with right ventricular outflow tract (RVOT) obstruction. The right ventricle (RV) is divided into anatomically proximal high-pressure and distal low-pressure chambers by abnormal muscle bundle. DCRV is frequently associated with others congenital heart defects, particularly ventricular septal defects (VSDs). Although its typically presents during childhood and adolescence, it can also present in adulthood.

Case Presentation

An 84-years-old woman was admitted to our hospital, in emergency department, with a 30-days history of worsening dyspnea and exercise intolerance. She was Ukrainian and did not speak Italian or English. The patient past medical history was unknow except for untreated bilateral glaucoma complicated by blindness. Vital signs were notable for tachycardia, tachypnea (respiratory rate, 28/minute), blood pressure of 118/76 mm Hg, SpO2 of 91%. Physical exam revealed left-sided parasternal systolic murmurs, abolished vesicular murmur at lung bases and jugular vein distension with hepatojugular reflux. The ECG showed atrial fibrillation. Chest X-ray showed moderate cardiomegaly, bilateral pleural effusions, and pulmonary congestion. Transthoracic echocardiography (TTE) was performed and revealed a normal-sized left ventricle with mildly reduced left ventricle ejection fraction (EF 48%), left atrial enlargement, biventricular hypertrophy with asymmetrical interventricular septal hypertrophy. Also, we found massive right atrium and enlarged right ventricle with reduced longitudinal contractility (TAPSE of 13 mm and tricuspid annular tissue Doppler S’ velocity = 7.0 cm/sec). Color flow Doppler in parasternal short-axis view revealed a turbulent systolic flow into the right ventricle. Continuous-wave spectral Doppler analysis showed a peak velocity of 5.6 m/ sec corresponding to a peak gradient of 120 mmHg. Real time 3D-TTE confirmed the of mid-ventricular obstruction due to abnormal trabecular tissue. Therapy including diuretics, beta-blockers and anticoagulants was started. Subsequently, a transesophageal echocardiography (TOE) confirmed the presence of an anomalous mid-ventricular muscle bundle and revealed an associated small sub-aortic ventricular septal defect (VSD) leading to the diagnosis of acute RV failure due to double-chambered RV with VSD and atrial fibrillation. Due to the high risk of complications, patient was considered not amenable for surgery. She was discharged on medical therapy.

Conclusions

We report a rare case of DCRV and VSD diagnosed in an elderly patient. Due to its rarity, DCRV continues to be misdiagnosed, especially in adulthood. Three-dimensional echocardiography and TOE were most useful tool to define diagnosis and pathophysiology in such an elderly and non-compliant patient.
49 GLOBAL LONGITUDINAL STRAIN TO EVALUATE THE SUCCESSFUL OF MEDICAL TREATMENT IN SECONDARY CARDIAC LYMPHOMA: A CASE REPORT
Authors: Tonia D´amico Anthea , Giubertoni Ailia , Degiovanni Anna , Patti Giuseppe
Published: December 2022

Background

Cardiac lymphoma is often lately diagnosed and associated with a poor outcome because of delayed treatment. We report the case of a patient with diffuse large B-cell lymphoma (DLBCL) massively infiltrating the heart, who showed significant improvement in echocardiographic features after high-dose chemotherapy.

Case summary

A 39-year-old female was admitted to our hospital after a vasovagal syncope secondary to excisional biopsy of an inguinal lymph node. Symptoms and signs were consistent with heart failure. Brain natriuretic peptide was markedly elevated (472 pg/ml). Transthoracic echocardiography (TTE) revealed moderate hypertrophy of both ventricles, with preserved left ventricular ejection fraction, reduced function of the right ventricle and a monophasic diastolic pattern. Left Ventricular Global longitudinal strain (LV GLS) was significantly reduced (up to -5%). These findings led us to the strong suspicion of biventricular infiltrative heart disease. Positron emission tomography-computed tomography (PET-CT) scan showed metastases to the kidneys, mesenteric and skeletal systems. The results of histological analysis and immunohistochemical staining confirmed the diagnosis of stage IV-B DLBCL. Prompt and aggressive treatment was initiated, performing a multiparametric cardiac monitoring based on biomarkers and TTE prior to and after each cycle of chemotherapy. We early observed a significant reduction of myocardial infiltration with an impressive recovery of LV GLS up to -10% after the 1st cycle of chemotherapy. The echocardiographic abnormalities of the right chambers resulted totally restored. Complete regression of the cardiac lymphoma was obtained, with a recovery of LV GLS up to -11.2% at the end of protocol and -16.8% at the 1st month follow-up. The PET-CT scan confirmed the recovery of the heart.

Discussion

In this case, functional heart improvement due to total regression of cardiac lymphoma has been early detected by strain imaging. GLS could be an early indicator of therapy responsiveness and may be implemented in routinely evaluation of these patients with infiltrative cardiac diseases.
311 CORONARY CT ANGIOGRAPHY A NEW PROMISING TOOL IN HEART TRANSPLANTED PATIENTS: FROM CLINICAL AND ECONOMICAL BENEFITS TO CORONARY INFLAMMATION DETECTION
Authors: Dellino Carlo Maria , Pergola Valeria , Scarpa Francesco , Storer Vittorio , Galzerano Domenico , Tessari Chiara , Fraiese Angela , Motta Raffaella , Gerosa Gino , Iliceto Sabino , Mele Donato
Published: December 2022

Background

Heart transplanted patients are mainly monitored with invasive diagnostic techniques for detecting cardiac allograft vasculopathy (CAV). However coronary CT angiography (CCTA) is a new promising tool that brings clinical and economical benefits.

Objectives

primary aim: demonstrate the non-inferiority of CCTA in comparison to invasive coronary angiography (ICA), in terms of radiation and contrast dose, costs, in-hospital stay and complications. Other aims: analyse in the subgroup of patients undergoing CCTA the role of immunological and non-immunological risk factors and the role of pericoronary-fat-attenuation-index (pFAI) in predicting CAV.

Methods

Between March 2021 and May 2022, 179 consecutive heart transplanted patients underwent either CCTA (78 patients) or ICA (101 patients) based on medical preference to study CAV. The 78 patients who underwent CCTA were also divided in patients with no previous CAV (npCAV, previous ISHLTV=0) and patients with previous CAV (pCAV, ISHLTV≤1). CAV progression was considered if there was any progression in ISHLTV.

Results

CCTA delivered lower radiation doses in comparison with ICA (3,52 mSV [1.46-7.23] versus 10,8 mSV [8.8-20.3]; p=0.03) and required also less in-hospital stay (0.5 ± 0,2 hours versus 23.7 ± 12.31 hours; p<0.001), lower costs (120 euros versus 2800 euros; p<0.001) and less contrast agent (60.4 ± 8.7 ml versus 95.68 ± 47.6ml; p<0.001). The rate of complications of CCTA and ICA was low in both of them (0 (0%) vs 3 (3%); p=0,258). Among the non-immunological risk factors for CAV, only smoking was related with the progression of CAV (0% with ISHLTV=0 and 15% with ISHLTV 1; p=0.015). Among immunological risk factors, TNF was the only independent predictor in the progression of CAV (HR 8.23; IC 95% 1.47-45.81; p=0.019). PFAI either as a continuous variable or as a categorical variable (>-70.1HU) did not show a statistically significance in the progression of CAV (p=NS).

Conclusions

CCTA is superior to ICA in terms of radiation and contrast dose, costs and in-hospital stay. TNF was the only independent predictor related with the progression of CAV. PFAI, didn't reach statistically significance probably due to the small sample size. Further studies are necessary to understand the role of pFAI in this subset of patients.
585 SPONTANEOUS CORONARY ARTERY DISSECTION: THE ROLE OF CORONARY CT ANGIOGRAPHY IN THE FOLLOW-UP MANAGEMENT
Authors: Dellino Carlo Maria , Pergola Valeria , Continisio Saverio , Gentili Alessandto , Montonati Carolina , De Conti Giorgio , Motta Raffaella , Iliceto Sabino , Tarantini Giuseppe , Mele Donato
Published: December 2022

Background

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) and sudden death (SD). This condition predominantly affects young women with a few or no conventional risk factors for CAD. Diagnosis is traditionally made with invasive coronary angiography (ICA); nevertheless, coronary computed tomography angiography (CCTA) is going to be a new useful tool in the acute diagnosis and at follow-up in these patients. Conventional treatment could involve a conservative approach with medical therapy or an invasive approach with percutaneous coronary intervention (PCI).

Methods

We retrospectively analyzed data of 57 SCAD patients followed up with Coronary CT angiography (CCTA) at our centre. Clinical and angiographic (invasive and non invasive) data were collected at baseline and at the follow-up. The primary outcome was a composite of all cause mortality and hospitalization for cardiovascular cause evaluated at 1690,7±1082,3 days; the secondary outcome was the evaluation of the vessels with CCTA at 777,9 ± 271,6 days.

Results

57 patients were divided in 2 groups: 46 patients underwent a conservative treatment (80,7%) and 11 patients a PCI treatment (19,3%). The first group is composed of 15,2% male and the second of 27,3% male (p=0,387), mean age is 52,8±11,1 years vs 48,0±10,7 years (p=0,201). Patients treated with PCI has a significative higher incidence of smoking habits (45,5% vs 15,2%; p=0,042), peripheral arteriopathy (18,2% vs 0%; p=0,034), higher troponin peak (40425,8 vs 13436; p=0,011) and lower ejection fraction (51,4±11,0 vs 57,1±7,6; p=0,050). Moreover the PCI population has a more common involvement of 2 vessels (72,7% vs 6,5%; p<0,001), of the left main coronary artery (45,4% vs 0%; p<0,001) and of the circumflex coronary artery (45,4% vs 2,2%; p=0,001). At the follow up, there were no statistical differences for the primary and secondary outcomes between the 2 groups (p>0,05). Among patients treated with conservative therapy, there were a more frequent recurrence of SCAD in those treated with DAPT than in those treated with SAPT (33,3% vs 5,9%; p=0,033).

Conclusions

in patients with SCAD, conservative management is comparable to PCI treatment in terms of clinical and angiographic outcomes. Among patients treated with conservative therapy, DAPT at discharge was independently associated with a higher rate of SCAD recurrence at follow-up.
809 A CASE OF CASEOUS MITRAL ANNULUS CALCIFICATION
Authors: Diana Davide , Diana Giovanni , Geraci Salvatore , Martello Natale Marco , Savarino Dario , Caramanno Giuseppe
Published: December 2022

Caseous mitral annular calcification (CMAC) is a rare variant of degenerative mitral annular calcification (MAC) with an echocardiographic prevalence of 0.6% of all MACs and an overall prevalence of up to 0.07% in the general population. It primarily affects older patients with hypertension and chronic kidney disease. Due to the general benign prognosis, conservative management of this lesion is recommended in most cases.

Herein we describe the case of a 78-year-old female patient admitted for sustained ventricular tachycardia treated with Amiodaron infusion followed by electrical cardioversion for hemodynamically instability. Her past medical history was remarkable for hypertension, HFpEF and chronic kidney disease. Trans-thoracic echocardiogram showed the presence of an echo-dense mass with central echo-lucency surrounded by calcifications at the posterior peri-annular and leaflet region of the mitral valve, not associated with valvular disfunction.

To define the etiology of the arrythmia, a coronary angiography was performed and excluded significant coronary artery disease. Nevertheless, a round-shape hyperdense mass was observed in the left atrium near the atrio-ventricular groove (figure 1): during injection through coronary vessels the contrast was not visible in the lesion. In order to better define the nature of the mass, a Trans-esophageal Echocardiogram was performed and showed a “toothpaste-like” echo-dense mass with central echo-lucency surrounded by a calcified envelope at the posterior peri-annular region of the mitral valve suggestive for CMAC (figure 2); 3D zoom imaging clarified its relationship with P2 scallop of posterior mitral valve leaflet (figure 3). For the best tissue characterization and to definitely exclude other mass-like lesions, such as myxoma, papillary fibroelastoma, myocardial abscess, vegetations, lipomatous hypertrophy, Cardiac Magnetic Resonance was performed and showed low-signal intensity in both T1- and T2-weighted sequences, reflecting its calcium content. First-pass perfusion sequence reveals no contrast enhancement, whereas late gadolinium enhancement depicts a peripheral rim of enhancement confirming our suspect.

In Conclusion, CMAC is a rare disorder requiring a multimodal imaging approach to differentiate it with other intra-cardiac masses. Its course is generally benign and whether not associated with valvular or hemodynamic significance, it could be considered as a bystander.

Figure 1

Figure 2

Figure 3
503 SPECKLE-TRACKING ECHOCARDIOGRAPHY FOR ARRHYTHMIC RISK ASSESSMENT IN HYPERTROPHIC AND FABRY CARDIOMYOPATHY
Authors: Faro Denise Cristiana , Losi Valentina , Rodolico Margherita Stefania , Licciardi Salvatore , Paola Monte Ines
Published: December 2022

Background

Hypertrophic Cardiomyopathy (HCM) is burdened by sudden cardiac death (SCD) risk of 0.9%/year, and is the most common cause of SCD in young adults. It is an autosomal dominant inherited disease caused by mutations in cardiac sarcomere genes, but the hypertrophic phenotype can also be an expression of cardiac involvement in multiorgan metabolic storage diseases, such as Anderson-Fabry disease (AFD). Mechanical Dispersion (MD) by Speckle-Tracking Echocardiography (STE) has recently emerged as an additional arrhythmic risk marker.

Purpose

Aim of the study was to evaluate LV systolic and diastolic function, global longitudinal strain (GLS) and MD by STE and analyze their association with ventricular arrhythmias in patients with HCM and AFD.

Methods

We included in our analysis 36 patients with HCM, 54 with AFD, of which 10 with left ventricular hypertrophy (AFD-LVH) and 44 without (AFD-N), and 27 healthy subjects. We performed a comprehensive basic echocardiographic study and analyzed GLS and MD (post-processing through EchoPAC 2.02). We also evaluated ventricular arrhythmias (V-AR), including ventricular fibrillation and sustained and non-sustained ventricular tachycardia, by Holter ECG, and the data obtained by cardiac magnetic resonance (CMR) in hypertrophic patients. Data were analyzed by unpaired Student t-test or chi-square/Fisher's exact test as appropriate, and binary logistic regression (SPSS Statistics ver.26).

Results

Diastolic function was impaired in HCM and AFD-LVH patients compared to control and AFD without LVH. GLS was significantly lower in the V-AR group compared to patients without V-AR (9.7±2.9 vs 14.1±4, P=0.007), MD was significantly higher in the V-AR group (111±47 vs 68.1±16, P=0.03). We found a significant association between ventricular arrhythmias and GLS (P=0.005) and between ventricular arrhythmias and MD (P<0.001). We found also a significant association of late gadolinium enhancement at CMR with GLS (P=0.005) and MD (P=0.03).

Conclusions

GLS and MD are useful additional indices in the evaluation of patients with HCM or AFD, also in presence of preserved LV ejection fraction, and promising prognostic predictors to identify patients at high risk for ventricular arrhythmias

Figures: MD in an HCM patient (on the left) and in an AFD-LVH patient (on the right).
911 THE HYPERTROPHIC SEPTAL PERFORATING BRANCH MISINTERPRETED AS INTERVENTRICULAR DEFECT
Authors: Ferraro Daniel , Aquila Iolanda , Volpe Lorenzo , Purri Ilaria , Pasceri Eugenia , Chiarello Claudia , Mascaro Giuseppina , Petullà Maria , Mongiardo Annalisa , Indolfi Ciro
Published: December 2022

Introduction

the septal perforating arteries of the heart usually branch off from the anterior and inferior interventricular arteries and supply the interventricular septum and the conduction system therein.

Aim

we present the case of hypertrophic septal perforating branch in a 71-year-old man who experienced dyspnoea in which was initially misinterpreted as interventricular defect.

Materials and methods

transthoracic echocardiography without and with contrast, coronary angiography and angioTC with 3D reconstructions were performed.

Results

echocardiography showed dilative cardiopathy with EF 30%, akinesia of IVS, apical and inferior wall. Hypokinesia of the remaining walls. At color-Doppler: severe mitral regurgitation and moderate tricuspidal regurgitation. Coronary angiography showed severe multivessel atherosclerotic coronary artery disease. At the echocardiographic control was reported the presence of turbulent flows at the level of medio-basal segment of posterior IVS. Echo-power-Doppler showed no shunts. For persisting suspect of interventricular defect was performed contrast echocardiography that showed hypoperfusion of IVS after contrast infusion but no clear signs of interventricular shunts. To complete the diagnostic iter was performed finally CT-Scan of coronary arteries that reported a presence of hypertrophic septal perforating branch with long intramyocardial course in the interventricular septum, but was no detected interventricular defect.

Conclusions

Septal perforating arteries have a large variability in their anatomy. Particular clincal conditions such as chronic coronary syndromes could lead to a reactive hypertrophy. Is important recognise it due to its similarity with interventricular defect or myocardial bridging effect. A better understanding of these arteries will help physicians to enhance cardiac care for their patients.
1048 MYOCARDIAL WORK AND OUTCOME IN PATIENTS PARADOXICAL WITH LOW FLOW, LOW GRADIENT AORTIC STENOSIS
Authors: Iuliano Giuseppe , Junior Ferruzzi Germano , Migliarino Serena , Cristiano Mario , Bellino Michele , Silverio Angelo , Pamela Peluso Angela , Vecchione Carmine , Ciccarelli Michele , Galasso Gennaro , Citro Rodolfo
Published: December 2022

Aim

The aim of this study was to investigate the potential impact of non-invasive derived myocardial work (MW) indexes on outcome of patients with severe paradoxical low flow, low gradient (PLFLG AS) undergoing transcatheter aortic valve implantation (TAVI).

Methods

Complete demographic, clinical characteristics, laboratory analyses and echocardiographic parameters were collected. Severe PLFLG AS was defined as indexed aortic valve area (iAVA) ≤0.6 cm2/m2, mean transaortic gradient < 40 mmHg and stroke volume index <36 ml/m2 and preserved LVEF >50%. MW was obtained from the non-invasive strain-pressure loop obtained pressure by combining GLS and the left ventricular systolic pressure, which was derived by adding the mean aortic valve gradient to systolic brachial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted MW (WMW) were measured. The normal values ​​considered for the MW parameters were: MWI ≥ 1300 mmHg%; CMW ≥ 1500 mmHg%; WMW < 240 mmHg%; MWE ≥ 90%. Odds ratio, sensitivity and specificity were used to quantify the ability of MW parameters (abnormal vs normal values) in predicting the primary outcome defined as all-causes mortality.

Results

study population included 30 patients with severe PLFLG AS undergoing TAVI. The most frequent comorbidities were hypertension (93%; n=28), dyslipidaemia (66%; n=20), diabetes (23%; n=7). Atrial fibrillation/flutter and chronic kidney disease were identified in 12 (40%) and 18 (60%) patients, respectively. Concomitant coronary artery disease and history of stroke were reported in 23% (n=7) and 10% (n=3), respectively. Society of Thoracic Surgeons score in overall population was mean 11,34±4,34. During median of 209 days (IQR: 104–213 days) all-causes mortality occurred in 13 patients (43%) (just 1 for non-cardiac death). Abnormal values of MWI, CMW and MWE identified significant statistical correlation with primary outcome [(odds ratio for primary outcome: 7.5 (95% confidence interval: 1.4 to 39.8); 7.5 (1.4 to 39.5) and 5.2 (1.1 to 25.3) respectively, Table 1)]. The MWI, CMW and MWE have the same sensitivity (62%) but higher specificity (82% for MWI and CMW, 88% for WMW and 76% for MWE).

Conclusion

In a population of patients with PLFLG-AS characterized by normal ejection fraction the abnormal MW parameters seem to be significantly associated with all-causes mortality during mid-term follow up and might provide additional information on outcome of this peculiar subgroup of patients with AS.

Table 1
1076 AN UNUSUAL PAPILLARY MUSCLE PRESENTATION AT CARDIAC-MRI.
Authors: Figliozzi Stefano , Francone Marco , Bragato Renato Maria , Stefanini Giulio Giuseppe , Condorelli Gianluigi , Monti Lorenzo
Published: December 2022

Background

Cardiac-MRI is the gold-standard non-invasive imaging modality to evaluate cardiac masses.

Case Summary

A 58-year-old man underwent surgical excision of a sacral chordoma. At the time of surgery, there was neoplastic infiltration of bones and soft tissues (immunophenotype: CKMNF116+, EMA+, S100 +/-) and radiotherapy was performed. The patient underwent superior-lobectomy of the left lung six years later because of pulmonary metastasis of the chordoma. Nine years later, the patient was asymptomatic and referred to us for Cardiac-MRI because a suspected cardiac mass at echocardiography. At Cardiac-MRI, we found normal bi-ventricular volumes, wall thickness, wall motion and ejection fraction. Atria, heart valves and pericardium were normal too. In ssFP-cine images, an oval, hypointense mass with sharp margins (26×18 mm) was evident in the context of the posteromedial papillary muscle (Panel, A-B). Compared to the myocardium, the lesion was hyperintense at T2-weighted (Panel, C), native T1-(Panel, D) and T2-mapping sequences (Panel, E). After contrast injection, there was no increased mass signal at first-pass perfusion (Panel, F), whereas the late sequences revealed a soft, heterogeneous enhancement of the central core of the lesion, and a bright peripheral rim (Panel, G-H). These findings were interpreted as a cardiac metastasis of the chordoma and systematic treatment with imatinib was started.

Discussion

Six cases of cardiac metastasis secondary to chordoma were previously described. The present case is the first to provide advanced, multiparametric Cardiac-MRI assessment and represents the first description of a location within the context of a papillary muscle. Cardiac-MRI was essential to identify cardiac metastasis, leading patient's management and targeting appropriate treatment.
777 TISSUE CHARACTERIZATION IN TAKOTSUBO SYNDROME
Authors: Garau Enrica , Francesca Marchetti Maria , Biddau Mattia , Licciardi Marco , Utzeri Elena , Santus Sara , Maiani Silvia , Aste Francesca , Mandas Martina , Montisci Roberta
Published: December 2022

Aims

Takotsubo Syndrome (TTS), also known as stress cardiomyopathy, is an important form of acute reversible myocardial damage characterized by a transient systolic dysfunction of the left ventricle, which generally occurs following intense emotional or physical stress.

The availability of new imaging techniques broadened knowledge about TTS and allowed for more accurate risk stratification and their use as a potential guide to clinical management.

The aims of our study was that of evaluating changes in myocardial tissue characterization on cardiac magnetic resonance imaging in patients diagnosed with TTS admitted to our center.

Methods and Results

From December 2018 to December 2021, 52 patients diagnosed with TTS according to the 2018 InterTAK diagnostic criteria were admitted to our ICU; only 27 patients who underwent cardiac magnetic resonance imaging were included in our study.

Cardiac magnetic resonance was performed after an average of 7 days from admission to the ward, therefore not in all patients the regional wall motion abnormalities of the left ventricle found on the first echocardiogram performed were then still evident.

Despite this, at the evaluation of the T2-STIR sequences, the presence of myocardial edema in the segments with previous regional dissynergies was highlighted in all patients included in the study, indicating a greater sensitivity of tissue characterization techniques.

Furthermore, the analysis of T2 mapping, for the quantification of edema, also showed a significant lengthening of the average values ​​of the global T2 mapping, compared to the reference values ​​at our center [65.9 +/- 7.7 msec, vn T2 mapping = 53 ± 3 msec; mean baseline T2 mapping value: 60.4 +/- 5.5 msec, mean T2 mapping value: 65 +/- 7.1 msec, apical T2 mapping: 71 +/- 7.7 msec], with evidence of a clear base-apex gradient on 19/23 patients (82.6%) compatible with the greater involvement of the mid-apical segments typical of the classic form of "apical ballooning" TTS.

Finally, the evaluation of the systolic strain also showed a significant reduction in the values ​​both in the radial component and in the circumferential and longitudinal components, especially in the mid-apical segments, even in the absence of significant regional wall motion abnormalities or with preserved left ventricular EF [mean values global radial strain (GRS) of 28.6 +/- 9.5; global circumferential strain (GCS) of 15.4 +/- 7.9; global longitudinal strain (GLS) of 12.6 +/- 3.2].

Conclusions

Our study confirms that tissue characterization and functional evaluation techniques using myocardial strain with cardiac magnetic resonance appear to be more accurate, compared to the evaluation of regional wall motion abnormalities and left ventricular EF alone, in identifying pathophysiological changes and in diagnostic framework of TTS patients.
737 CLINICAL AND PROGNOSTIC SIGNIFICANCE OF LEFT VENTRICULAR OUTFLOW TRACT VELOCITY TIME INTEGRAL (LVOT-VTI) IN PATIENTS WITH CHRONIC HEART FAILURE
Authors: Gentile Francesco , Buoncristiani Francesco , Chubuchny Vlad , Sciarrone Paolo , Panichella Giorgia , Bazan Lorenzo , Gasparini Simone , Fabiani Iacopo , Taddei Claudia , Poggianti Elisa , Petersen Christina , Pasanisi Emilio , Passino Claudio , Emdin Michele , Giannoni Alberto
Published: December 2022

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI may be a more reproducible surrogate of systolic function and showed prognostic value in the critical care setting. However, the role of this measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced (41-49%) LV ejection fraction (LVEF) were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of cardiac death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%, 74% HFrEF). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles, i.e., ≤19 (n=324), 20-24 (n=324), or >24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI ≤19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e’, left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure, and NT-proBNP concentration (all p<0.001). No differences were observed as for patients’ age, HF etiology, and therapies (all p>0.05). Over a median follow-up of 22 (9-34) months, 68 (7%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of cardiac death, observing 44 (13%), 15 (5%), and 9 (3%) events across the subgroups with values ≤19, 20-24, or >24 (log-rank 25.9, p<0.001). At multivariable regression analysis, LVOT-VTI ≤19 (HR 2.32 [95% 1.20-4.49], p=0.002), but not LVEF <30% (p=0.614) was an independent predictor of cardiac death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e’, LAVi, TAPSE, and NT-proBNP. Of note, this finding was consistent both in the HFrEF and HFmrEF subsets (p for interaction =0.899).

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.
860 TRICUSPID REGURGITATION RELATED TO CARDIAC IMPLANTABLE DEVICES: A NEW ENTITY?
Authors: Ghisletti Andrea , Sabusco Alexandra , Vecchi Simona De , Patti Giuseppe
Published: December 2022

Background. The incidence of cardiac implantable electronic device (CIED) implantation is currently growing. Patients who develop a moderate to severe CIED-induced tricuspid regurgitation (TR) are at higher risk of pulmonary hypertension, right heart failure (HR) and have higher mortality. Transthoracic echocardiography (TTE) is the most common method for TR grading, while transesophageal echocardiography (TOE) with three-dimensional (3D) imaging is nowadays gaining importance to reconstruct valve morphology and to determine the TR pathophysiology.

Case Summary. We present the case of an 83-year-old man with multiple comorbidities, affected by non-ischemic dilated cardiomyopathy, for which a biventricular defibrillator (ICD-CRT) was implanted in 2007 in primary prevention. Over the years, the patient has been a CRT-responder, with partial recovery of the ejection fraction (40% in 2022 versus 25%). In 2018 he had an episode of acute pulmonary oedema and ventricular fibrillation with ICD intervention; during that hospitalization, the right ventricular catheter (EC) was replaced due to dysfunction. In 2022, the patient presented to our hospital for anasarca due to right HF. TTE and TOE showed new onset of right heart dilation and dysfunction with severe TR, which was predominantly caused from lead impingement of the septal tricuspid valve (TV) leaflet and later from secondary dilation of the TV annulus. The patient responded well to medical therapy and was discharged.

Discussion. CIED-related TR is getting more relevant since its growing prevalence and its prognostic impact, even if little is known about why some patients develop moderate-to-severe CIED-related TR. Clinicians should be aware of this entity and follow the patients with TR over the time with periodic echocardiograms. TOE and 3D imaging should always be performed to understand the mechanism of the TR and to select the optimal treatment. Currently, no guidelines nor randomized data are available in order to guide treatment in these patients. Figure 1:4-chamber views with and without color Doppler showing the ventricular EC passing the TV through with the presence of peri-catheter TR.Figure 2:trans-gastric TOE xPlane views showing how the ventricular EC determines a restrictive movement of the septal TV leaflet, causing the severe TR to form.