bluuebunny/crossref_metadata_2025 huggingface dataset:
1017 CLINICAL AND HEMODYNAMIC CHARACTERISTICS ASSOCIATED WITH LATENT PULMONARY VASCULAR DISEASE IN HEART FAILURE WITH PRESERVED LEFT VENTRICULAR EJECTION FRACTION
Authors: Caravita Sergio , Baratto Claudia , Filippo Aurora , Soranna Davide , Battista Perego Giovanni , Muraru Denisa , Badano Luigi P , Parati Gianfranco
Published: December 2022

Background

Among patients with heart failure and a preserved left ventricular ejection fraction (HFpEF), a distinct hemodynamic phenotype has been recently described, with potential clinical implication, i.e. latent pulmonary vascular disease (PVD). HFpEF patients with latent PVD have been shown to have worse outcome after creation of an interatrial septal shunt. However, the pathophysiological significance of latent PVD in HFpEF has not been thoroughly investigated.

Methods

We retrospectively analyzed our cohort of consecutive patients with HFpEF who have undergone a right heart catheterization at rest and during exercise between 2016 and 2020. HFpEF was defined based on a resting and/or exercise hemodynamics: pulmonary artery wedge pressure (PAWP) > 15 mmHg at rest; PAWP during exercise >= 25 mmHg; PAWP/cardiac output (CO) slope > 2 mmHg/L/min. Latent PVD was defined based on exercise pulmonary vascular resistance (PVR) > 1.74 WU.

Results

Out of 199 exercise right heart catheterization, 86 patients had a hemodynamic diagnosis of HFpEF. Of these, 68 (79%) qualified as HFpEF without PVD (HFpEF-PVR-) and 16 (21%) qualified as latent PVD (HFpEF-PVR+). HFpEF-PVR+ were older, presented more frequently with diabetes mellitus or glucose intolerance, had higher H2FPEF and HFA-PEFF scores, slightly lower LVEF, had more frequently a history of atrial fibrillation and had more frequently at tricuspid regurgitation ≥ moderate (p<0.05). HFpEF-PVR+ had more frequently high PVR (> 2 WU) also at rest (72% vs 10%, p<0.001). At rest and only in HFpEF-PVR+, PVR was directly associated with PaCO2 (R2=0.21), while at peak exercise PVR was inversely associated with PvO2 as well as with stroke volume index (R2=0.32 and 0.31, respectively). HFpEF-PVR+ presented with a lack of decrease in PVR during exercise, higher mPAP both at rest and during exercise (p<0.05) in spite of non-different mean PAWP, and lower CO increase during exercise (p<0.05) in spite of similar CO at rest (Figure). HFpEF-PVD presented more frequently with exercise-induced tall V waves in the right atrium (50% vs 16%, p=0.002), indicating severe tricuspid regurgitation.

Conclusions

HFpEF-PVR+ is associated with peculiar clinical and hemodynamic characteristics, reflecting a more advanced and polycomorbid HFpEF profile, characterized by heightened pulmonary vascular reactivity and overt cardiac limitation to exercise.
724 AN UNUSUAL CASE OF ECHOCARDIOGRAPHY-ESTIMATED PULMONARY HYPERTENSION
Authors: Menna Alessandro , Sganzerla Paolo , Bilo Barbara Maria , Caravita Sergio , Giannattasio Cristina , Parati Gianfranco
Published: December 2022

Case Presentation

48-years-old woman was diagnosed with severe pulmonary hypertension at transthoracic echocardiography during cardiological evaluation for bariatric surgery.

PAPs was estimated 110 mmHg, mild-moderate tricuspidal insufficiency with no dilatation of right chambers and LVEF preserved (65%).

The patient had history of heart murmur since childhood and now presented with type 2 diabetes mellitus on metformin treatment, third grade obesity (BMI 55) and dyslipidemia (LDL col. 120 mg/dL).

Diagnostic Workup: The patient was symptomatic dyspnea for mild-moderate exertion (NYHA II-III). Heart-beat was rhythmic with 4/6 ubiquitous systolic sharp murmur. Lung auscultation was normal. Bilateral pretibial edema was noted.

The cardiac catheterization showed:

A transesophageal echocardiography confirmed post-tricuspidal right intraventricular obstruction due to mid-ventricular fibro-muscular rims and disclosed a small restrictive membranous defect on interventricular septum with minimum left-to-right shunt.

A cardiac-MRI confirmed an hypertrophic moderator band with obstruction of the outflow tract.

The patients was discharged with a program of sleeve-gastrectomy and after surgical correction of cardiac congenital defects.

Conclusion

The double-chambered right ventricle (DCRV) is an uncommon congenital anomaly: the right ventricle (RV) is divided into two chambers due to the presence of an abnormally located muscular band or anomalous muscle hypertrophy in the sub-infundibular part of RV outflow tract, with a variable grade of obstruction. This anomaly may be missed by the estimation of high pulmonary pressure through tricuspidal regurgitation. Due to limitations of echocardiography in adult patients additional imaging methods, such as MRI, combined with cardiac catheterization data are required for a definitive diagnosis.
121 RELEVANCE OF COMORBIDITIES ON INITIAL COMBINATION THERAPY IN PULMONARY ARTERIAL HYPERTENSION
Authors: Papa Silvia , Badagliacca Roberto , D´alto Michele , Ghio Stefano , Argiento Paola , Brunetti Natale , Casu Gavino , Cedrone Nadia , Confalonieri Marco , Corda Marco , Correale Michele , D´agostino Carlo , Galgano Giuseppe , Manzi Giovanna , Mercurio Valentina , Mulè Massimiliano , Paciocco Giuseppe , Romeo Emanuele , Scelsi Laura , Stolfo Davide , Vitulo Patrizio , Vizza Carmine Dario
Published: December 2022

Rationale

Demographic characteristics of pulmonary arterial hypertension (PAH) patients have changed over time, but the effects of cardiovascular risk factors on risk status and pulmonary vascular resistance (PVR) reduction with initial oral combination therapy are not known. Therefore, we tested the relevance of cardiovascular comorbidities in this setting.

Methods

The study enrolled 181 treatment-naive PAH patients with a 6- months (IQR 144-363 days) right heart catheterization and risk assessment after initial oral combination therapy.

Results

Group-A, 96 (53.0%) patients without cardiac comorbidities; Group-B, 54 (29.8%) patients with one cardiac comorbidity; Group-C, 31 (17.1%) patients with ≥2 cardiac comorbidities. Group-C patients were older with a balanced gender distribution. There was a significant difference in PVR reduction moving from the absence to one or ≥2 cardiac comorbidities, respectively, median -45.0%, -30.3%, -24.3%. A ERS/ESC low-risk status was present at first follow-up in 50 (52.0%) patients in Group-A, 19 (35.1%) in Group-B, and 9 (29.0%) in Group-C; a REVEAL 2.0 low-risk status was present at first follow-up in 41 (42.0%) patients in Group-A, 15 (27.7%) in Group-B, and 7 (22.6%) in Group-C. Group-A patients were 2.3 times more likely to achieve/maintain a low risk status compared with Group-B and -C (OR 2.27, 95% C.I. 1.15-4.54, p=0.02). No significant difference was observed between patients with non-cardiac comorbidities and those without comorbidities.

Conclusion

Initial oral combination therapy seems associated with a less effective response for patients with cardiovascular comorbidities compared with the others, related to the magnitude of treatment- induced decrease in PVR.
633 THE EFFECTS OF AEROBIC EXERCISE TRAINING ON CARDIOPULMONARY EXERCISE TESTING AND HEART FAILURE BIOMARKERS IN ADULT PATIENTS WITH HYPOPLASTIC LEFT HEART SYNDROME AND FONTAN CIRCULATION
Authors: Perrone Marco Alfonso , Pomiato Elettra , Palmieri Rosalinda , Panebianco Mario , Già Giulia Di , Gagliardi Maria Giulia
Published: December 2022

Background

Several studies have shown that adult patients with Hypoplastic Left Heart Syndrome (HLHS) and Fontan circulation have a reduced exercise tolerance that affects daily life. Recent studies have investigated the effects of aerobic exercise training in these patients with univentricular heart; however, this research topic is still poorly studied. The aim of this study was to evaluate the effects of an aerobic exercise training program on cardiopulmonary exercise testing parameters and heart failure biomarkers in patients with HLHS.

Methods

We enrolled 12 patients with a mean age of 24 ± 2.5 years (range 22–27 years), 50% male, with HLHS at Bambino Gesù Children's Hospital IRCCS and University of Rome Tor Vergata. All patients underwent a cardiopulmonary test and blood sampling before (T0) and after (T1) a 4-week aerobic exercise program. Cardiac biomarkers hs-cTnT, NT-proBNP, ST2, GDF-15 were studied.

Results

Data analysis demonstrated an increase in cardiorespiratory performance after 4 weeks of aerobic exercise training activity. In particular, the data showed a significant improvement in test duration (p < 0.05), heart rate at rest (p < 0.05), heart rate recovery 1 min (p < 0.05), VO2 max (p < 0.01) and oxygen uptake efficiency slope (p < 0.05). At the same time, the data showed a significant reduction in NT-proBNP and ST2 values (p < 0.01 and p < 0.05, respectively) and a significant increase in GDF-15 (p < 0.01). No significant changes were found between the hs-cTnT values.

Conclusions

Our study demonstrated the 4-week efficacy of an aerobic training program in improving cardiorespiratory performance and heart failure biomarker values in adult patients with HLHS and Fontan circulation. To the best of our knowledge this is the first study that evaluated the effects of an exercise training program in patients with univentricular heart
1115 NON-INVASIVE MYOCARDIAL WORK INDICES IN PATIENTS WITH FONTAN CIRCULATION
Authors: Pozza Alice , Sabatino Jolanda , Cuppini Elena , Cerutti Alessia , Biffanti Roberta , Reffo Elena , Castaldi Biagio , Sirico Domenico , Fumanelli Jennifer , Di candia Angela , Basso Alessia , Di Salvo Giovanni
Published: December 2022

Background

Although the Fontan operation has contributed greatly to the improvement of survival in patients with a single ventricle, cardiac function and exercise capacity may deteriorate over time. However, there have been no quantitative analyses of the effects of Fontan circulation on myocardial work (MW).

Recently, a novel non-invasive method for calculating MW has been introduced on the basis of speckle tracking analysis with the estimation of left ventricular (LV) pressure from brachial artery cuff pressure.

Purpose

Aim of this study was to evaluate the diagnostic performance of the non-invasive myocardial work indices in predicting subclinical myocardial work impairment in Fontan patients.

Methods

A total of 69 patients were included and compared with healthy age- and sex- matched controls (CTRL).

Ventricular systolic function and global longitudinal strain (GLS) were assessed. Cardiopulmonary exercise test was performed. Global myocardial work index (MWI) was calculated as the area of the LV pressure strain loops. From MWI, global constructive work (MCW), wasted work (MWW) and work efficiency (MWE) were estimated.

Results

The two groups were comparable for blood pressure, weight and height. Mean age of Fontan patients was 21.0±9.2 years. MWI (1162 ± 364 mmHg% vs 1777 ± 240 mmHg%, p < 0.001), MCW (1554 ± 450 mmHg% vs 2102 ± 221 mmHg%, p = 0.001) and MWE (90 ± 6% vs 96 ± 2% p = 0.001) were significantly reduced in Fontan patients compared with healthy CTRL. Moreover, GLS (-13,9 ± 3,1% vs -21,2 ± 1.5%, p < 0.001) and the ejection fraction (EF) (58,9 ± 4.5% vs 63.3 ± 3.9%, p < 0.002) were significantly lower in Fontan patients. Fontan patients with normal EF showed, however, significantly reduced values of MWI compared with CTRL (p<0.05).

Fontan patients with functional right ventricle showed significantly reduced MWE compared with patients with functional left ventricle (p=0.030).

In univariate analysis, peak VO2 was significantly associated with age, SatO2, MWI. In multivariate regression, lower peak VO2 was associated with older age (p = 0.003) and lower MWI (p = 0.026).

Conclusions

Fontan physiology is associated with disadvantageous ventricular work. In Fontan patients, estimation of MWI may be a more sensitive indicator of myocardial work impairment compared with EF and is able to predict exercise capacity.
22 RELATIONSHIP OF RIGHT VENTRICULAR FUNCTION AND EXERCISE TOLERANCE IN PULMONARY ARTERIAL HYPERTENSION
Authors: Sorvillo Graziano , Ferruzzi Germano , Vigorito Francesco , Ciccarelli Michele , Galasso Gennaro , Vecchione Carmine , Soriente Lucia
Published: December 2022

Introduction

Pulmonary arterial hypertension(PAH) is a rarely disease that is characterized by a progressive increase in pulmonary vascular resistance and arterial pressure. The main characteristic of pulmonary hypertension(PH) is exercise intolerance and determination of exercise capacity has an important role in the evaluation of patients.

Aim

The purpose of our study is to explore the relationship of right ventricular dysfunction(RVD) and poor exercise tolerance.

Materials and Methods

Patients with PAH were prospectively enrolled from 2018 to 2021 at baseline assessment in the PH center. RVD was defined as Tricuspid Annular Plane Systolic Excursion (TAPSE)<17 mm in apical four chamber view. Patients were divided in two subgroups according to the presence or absence of RVD. Finally, all subjects underwent exercise tolerance evaluation with six minute walking test (6MWT). All evaluation were made according to current guidelines.

Results

A total of 33 PAH patients (66,33±12,74 years; 42% male) were included in the study. Most frequent comorbidities were dyslipidemia(n=15;44%), diabetes(n=7;20%), hypertension(n=23;67%). Concerning echocardiographyc evaluation, mean Left Ventricular Ejection Fraction (LVEF), PAPs and TAPSE was 56,64±5,37%, 57,88±25,85 mmHg, 20,93±5,20 respectively. Mean 6MWT was 318,91±11,61 meters. When compared patients with RVD with those without, a higher prevalence of atrial fibrillation/atrial flutter was observed (n=5, 62%; p 0,013) and statistically significant differences of right ventricular basal diameter (p 0,012), right atrial area (p 0,002), LVEF (p 0,015) and 6MWT (p 0,008) were detected. In the overall population a statistically significant linear regression was observed between RVD and 6MWT (p 0,029).

Conclusions

RVD is a predictor of poor functional capacity as assessed with 6MWT in patients with PAH at baseline.
496 LONG TERM PROGNOSIS FOLLOWING TRANSVENOUS LEAD EXTRACTION: INSIGHTS FROM A SINGLE CENTER REGISTRY
Authors: Arabia Gianmarco , Bontempi Luca , Cerini Manuel , Salghetti Francesca , Milidoni Antonino , Cersosimo Angelica , Curnis Antonio
Published: December 2022

Objective

The purpose of this analysis was to investigate the long-term prognosis following transvenous lead extraction (TLE).

Materials and Methods

We retrospectively studied all consecutive CIED patients who underwent TLE between January 2014 and January 2016 followed in our institution. The primary outcome was the composite endpoint of time to death or repeated TLE stratified by the presence of infection; secondary outcomes included individual components.

Results

Of the 191 patients (85% male, median age 70 years) who underwent TLE, 96 (50%) had infection and 95 (50%) were extracted for a different reason. Complete procedural success was achieved in 189 patients (99%) with no major complications. During a follow-up of 6.5 (5.4–7.1) years, infectious indication was associated with a significantly lower event-free survival (67% vs 83%; adjusted hazard ratio [aHR] 1.97, 95% confidence interval [CI] 1.02–3.81, P=0.04). The difference was significant also considering the death component (30% vs 10%, log-rank P<0.01); while the rate of re-repeated TLE was similar (4% vs 7%, P=0.62). In the infectious group, the presence of vegetation (aHR 2.56; 95% CI 1.17–5.63, P=0.02) and positive blood coltures (aHR 2.64; 95% CI 1.04–6.70, P=0.04) were independently associated with the primary outcome.

Conclusion

Our long-term data showed a higher combined death or repeated TLE endpoint for patients who underwent TLE with infectious compared to those with a different indication. In the subgroup of infectious patients, the presence of vegetation and positive blood coltures were associated with poor prognosis despite an uncomplicated extraction and appropriate therapy.
870 COMBINING PERCUTANEOUS CORONARY INTERVENTION AND TRASCATHETER AORTIC VALVE REPLACEMENT PROCEDURES: THE IMPORTANCE OF INTRAVASCULAR LITHOTRIPSY
Authors: Bruno Federica , Sorrentino Sabato , Sportelli Martina , Panarello Alessandra , Spinali Martina , Aquila Iole , Polimeni Alberto , Mongiardo Annalisa , Indolfi Ciro
Published: December 2022

Background

Calcified coronary artery disease and severe valvular aortic stenosis (AS) often coexist. For instance, severely calcified lesions may strongly influence the revascularization strategy in patients undergoing transcutaneous aortic valve replacement (TAVR). Shock wave intravascular lithotripsy (S-IVL) (Shockwave Medical Inc. Santa Clara, CA) is the only technology available that cracks both medial and intimal calcium while minimizing trauma to the vessel wall, thus allowing a safe plaque debulking. We report a case of percutaneous coronary intervention (PCI) and TAVR in the same procedure, where S-IVL has been used to treat a heavily calcified lesion and optimize stent under-expansion.

Case Report

A 79 years-old male patient with a history of diabetes mellitus type 2, hypertension, and peripheral artery disease, was admitted to our institution with symptomatic severe AS and severe calcified left anterior descending (LAD) artery lesion at CT scan. Deemed eligible for TAVR, Heart Team planned a percutaneous coronary intervention (PCI) of LAD and TAVR in the same procedure. Through the left radial artery, coronary angiography confirmed 90% stenosis of the LAD at the central segment. Accordingly, pre-dilatation of the stenosis was performed with a 2.5×12 mm non-compliant balloon (NCB) and, because of the severe calcification, S-IVL with a 3.0×12 mm balloon inflated at 4-6 Atmospheres (ATM), delivering 40 pulses. Following, a 3.5×18-mm drug-eluting stent was implanted at 18 ATM. After implantation, an inadequate expansion of the stents was observed, which persisted despite post-dilation with 3.75×8 mm NCB at high-pressure. Bail-out S-IVL was then performed with the 3.0×12 mm balloon inflated at 4-6 ATM, delivering 40 pulses in-stent, followed by a further stent post-dilated with a 3.75×8 mm NCB up to 20 ATM. The final angiogram showed a satisfactory stent expansion. Since the low contrast volume was used, we decided to go ahead with transfemoral TAVR. Therefore, through the left femoral artery access, a 34-mm self-expandable Evolut R valve was implanted. Transthoracic echocardiography showed optimal valve implantation with a trivial periprosthetic leak. No complications were observed after the procedures and the patient was discharged after 6 days with 6 months of mandated dual antiplatelet therapy (Aspirin and Clopidogrel).

Discussion

In this case, the bail-out use of S-IVL was essential for an optima stent implantation, allowing TAVR procedure and avoiding prolonged theoretical antithrombotic therapy underlying suboptimal stent implantation. Despite encouraging initial results, future large studies with long-term observation are required to evaluate the safety and efficacy of S-IVL in this scenario.
1150 SEX-BASED DIFFERENCES IN CORONARY PLAQUE PHENOTYPE AND HEALING AT OPTICAL COHERENCE TOMOGRAPHY (OCT) ANALYSIS
Authors: Buonpane Angela , Ricchiuto Alfredo , Lombardi Marco , Maino Alessandro , Bianchini Emiliano , Busco Marco , D´amario Domenico , Leone Antonio Maria , Aurigemma Cristina , Romagnoli Enrico , Burzotta Francesco , Trani Carlo , Crea Filippo , Vergallo Rocco
Published: December 2022

Introduction

Atherosclerotic plaque healing is a dynamic process that promotes plaque repair after destabilization. Previous studies showed that healed plaques are more common in patients with chronic coronary syndrome than in those with acute coronary syndrome, suggesting that they might be a marker of clinical stability. The mechanisms underlying plaque healing are not completely understood. The aim of the present study was to evaluate sex-based differences in plaque phenotype and healing of non-culprit coronary lesions by optical coherence tomography.

Methods

In this observational, single-center cohort study, we enrolled patients from the OCT Registry of the Fondazione Policlinico A Gemelli IRCCS. A total of 205 patients with both acute coronary syndromes or chronic coronary syndromes undergoing coronary angiography and intravascular OCT imaging of non-culprit vessels were included in the analysis and divided into two groups according to gender.

Results

Of 205 patients, 153 were male (75%) and 52 (25%) female. Compared with male patients, female patients had lower prevalence of lipid-rich plaque (40.4% vs. 57.7%; p=0.030), plaque rupture (7.7% vs. 21.2%; p=0.028) and cholesterol crystal (13.5% vs. 29.5%; p=0.022). Mean lipid arc and calcium depht were significantly lower in female patients than in male ones (118.0° ± 79.9° vs. 135.5° ± 77.9°; p=0.011; and 52.7 µm ± 79.2 µm vs. 72.3 µm ± 93.5 µm; p=0.007) while fibrous cap tended to be thicker (108.2 µm ± 70.4 µm vs. 96.2 µm ± 72.9 µm; p=0.055). Healed plaques were significantly more frequent in female patients than in male patients (51.9% vs 34.6%; p = 0.027). The prevalence of fibrous plaque, thrombi, neovascularization, diffuse calcifications and spotty calcification was not different between the two groups.

Conclusion

Females have a distinct atherosclerotic phenotype and healing capacity compared with male patients, including lower prevalence of lipid-rich plaque, cholesterol crystals and plaque ruptures and higher prevalence of healed plaques in non-culprit coronary lesions.
279 LAYERED PLAQUES: NOT ALL ARE HEALED
Authors: Ciardetti Niccolò , Mattesini Alessio , Di Muro Francesca Maria , Nardi Giulia , Kucukseymen Selcuk , Francesca Ristalli , Stolcova Miroslava , Meucci Francesco , Di Mario Carlo
Published: December 2022

Layered plaques are the effect of a previous plaque event. They are associated with coronary spasm and found in more than 50% of patients with stable angina and a quarter of those with an acute coronary syndrome. Nevertheless, it is not clear whether their presence is indicative of a healing process or rather is predictive of an increased risk of future events. A 71-year-old male, heavy smoker and hypertensive, presented with episodes of angina at rest that resolved spontaneously in less than 5 minutes, with evidence of ST-segment elevation (STE) in the lower leads during one of these episodes. Coronary angiography showed an intermediate stenosis at the end of the mid segment of the dominant right coronary artery (RCA) (Figure A). Optical coherence tomography (OCT) revealed a layered plaque, consisting of high backscattering layers alternated with low reflection layers (Figures A1-3). Given the minimum luminal area of 3.65 mm2 and the absence of other criteria for plaque instability (erosion, thin-cap, etc.), we treated the patient conservatively with medical therapy alone, consisting of a single antiplatelet agent and a high-dose statin with ezetimibe. A non-dihydropyridine calcium antagonist and a long-acting nitrate were started given the suspicion of coronary spasm. Four months later the patient returned to the emergency department for persistent oppressive chest pain unresponsive to sublingual nitrates with evidence of STE in the lower leads. Emergency coronary angiography showed an acute occlusion of RCA with TIMI 0 flow in correspondence to the layered plaque highlighted 4 months earlier on OCT (Figure B). Antegrade flow was restored with manual thrombus aspiration (Figure C) and OCT showed lesion progression with many new layers, together with a cavity suggestive of plaque rupture (Figures C1-3). A 3.5×38 mm everolimus eluting stent was deployed – based on OCT sizing – and post-dilated with a 4.0×8 mm non-compliant balloon, obtaining an excellent angiographic result with TIMI 3 flow (Figure D). Low-reflecting layers within layered plaques are generally considered to be lipid deposits, but they could also represent intraplaque haemorrhages, generated by coronary spasm. The haematoma can be reorganised within the plaque to create a new layer, leading to lesion progression without necessarily requiring a loss of endothelial integrity. The progressive increase of the haematoma may lead to plaque rupture when the pressure exceeds the resistance of superficial layers. This case reveals a new possible mechanism of plaque progression in patients with coronary spasm and explains how layered plaques can be ambivalently considered to be either stable or vulnerable. Their treatment should be meticulously tailored not only based on classical criteria of plaque instability but also according to the underlying trigger mechanism.
547 AN UNUSUAL CONSERVATIVE STRATEGY FOR ACUTE AORTIC RUPTURE AFTER TAVI POST-DILATATION
Authors: Ciardetti Niccolò , Kucukseymen Selcuk , Meucci Francesco , Stolcova Miroslava , Di Muro Francesca Maria , Nardi Giulia , Ristalli Francesca , Mattesini Alessio , Di Mario Carlo
Published: December 2022

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for symptomatic severe aortic stenosis in patients deemed to be at high operative risk for the surgery. Despite its high success, TAVI is associated with rare life-threatening complications. The frequency of aortic annular rupture (AAR) has been reduced by advances in pre-procedural screening and patient selection but, when occurs, often requires emergency surgery with a very high mortality. We described an unusual case managed conservatively.

A 86-year-old female patient with NYHA Class III and STS score for mortality of 4.8% underwent TAVI via a transfemoral approach. At preprocedural MDCT the aortic annular area was 293 mm2 with severe calcification of the valve leaflets extending in the outflow tract and in the sinotubular junction with effacement of the coronary sinuses (Fig. 1A-B). Following deployment of a 23-mm self-expanding valve (Medtronic Evolut Pro+) without predilatation, moderate-to-severe residual aortic regurgitation (AR) was observed (Vid. 1). After balloon post-dilatation using a 20×40mm noncompliant (NC) OSYPKA - VACS III balloon, mild-to-moderate AR still persisted (Fig. 1C, Vid. 2). Accordingly, we decided to perform a second post-dilatation using a 22×40mm NC balloon which reduced AR to mild but caused a contained AAR was observed (Fig. D&E, Vid. 3). The patient remained hemodynamically stable with no chest pain and had no pericardial effusion on echo. The risk of a Bentall operation in such a frail elderly patient was judged prohibitive and a conservative strategy was recommended. Postprocedural MDCT confirmed the presence of a pseudoaneurysm with the maximum dimensions of 24×15 mm (Fig. 1F). Patient was followed-up for 23 days first in hospital keeping a low blood pressure with iv nitrates and then in a rehabilitation centre. An MDCT control on day 10 showed no growth of the pseudoaneurysm with a reduction of the brisk filling initially observed. She was discharged without additional problems, and scheduled for a three month control MDCT.

Established risk factors for AAR include valve and balloon oversizing, bicuspid valve, small annulus, shallow Valsalva sinuses, and massive annular or sub/supra-annular calcification. When these recognized risk factors are present, a conservative strategy for valve postdilatation is strongly recommended. Early recognition and prompt surgical management of AAR are essential but occasionally also a conserative strategy can prove successful.
806 BRIDGING COLLATERALS OF CHRONICALLY OCCLUDED LEFT INTERNAL MAMMARY ARTERY BYPASS GRAFT TO LEFT ANTERIOR DESCENDING ARTERY
Authors: De Ornelas Benjamin , Ferraiuoli Giovanni , Di Caccamo Leandro , Di Fazio Luca , Alaimo Chiara , Buccheri Giancarlo , Sacco Tania , Lentini Emanuele , Testa Gabriella , Vadalà Giuseppe , Galassi Alfredo
Published: December 2022

Methods and results

The internal mammary artery (IMA) is the conduit of choice to bypass the left anterior descending (LAD) coronary artery in patients eligible for coronary artery bypass grafting (CABG).

In case of graft occlusion, it is still not clear whether it is better to revascularize the graft or the recipient native vessel, on top of optimal medical therapy.

A 55-year-old man, with prior CABG, underwent urgent coronary angiography for an acute coronary syndrome.

LAD CTO, severe proximal circumflex artery stenosis, and mild atherosclerosis of the right coronary artery were found. Moreover, a proximal occlusion of the venous graft to the obtuse marginal branch and LIMA CTO within the body of the graft were shown as well. Surprisingly, many well-developed bridging collaterals, arising close to the proximal cap of the LIMA occlusion, supplied the bloodstream circulation distal to the occlusion within the LIMA.

At that time, a left main–proximal circumflex artery stenting was performed (3.5×24-mm Xience Sierra, Abbott) because that was judged the culprit lesion.

One month later the patient still complained of effort angina and dyspnoea despite optimized antianginal medical therapy. The patient was scheduled for elective antegrade LIMA CTO PCI, considered the most appropriate treatment strategy. Indeed, the presence of a prior stent implanted in the left main– circumflex artery would have made difficult a proximal cap negotiation and its penetration by guidewires in case of antegrade LAD CTO PCI. Thus, the LIMA CTO negotiation was initially attempted with a Fielder FC guidewire (Asahi Intecc) and a supporting Corsair Pro (Asahi Intecc) microcatheter. The polymeric soft wire prolapsed preferentially into the bridging collaterals without the chance to engage the CTO proximal cap. Finally, a moderate-weight hydrophilic GAIA second (Asahi Intecc) succeeded in cap penetration and final CTO crossing. After lesion predilatation with a 2.0×15-mm balloon (Emerge, Boston Scientific), 2 overlapped stents, respectively 2.75×44 mm and 3.0×18 mm (VIVO ISAR, Translumina) were deployed and postdilated by a 3.0×15-mm non-compliant balloon (Accuforce, Terumo). The final result was deemed very satisfactory with a TIMI 3 flow.

Conclusions

Many studies showed that IMA has active biological functions, providing a sort of protection against atherosclerosis and self-reparative properties. These biological properties might justify the IMA high long-term patency rates as CABG conduits. The development of bridging collaterals in this patient, represents a clear proof of the LIMA self-reparative properties. Whereas bridging collaterals are a common feature of coronary CTO, their development in a LIMA bypass graft represents a unique finding which requires further investigation.
63 CHEST PAIN AND THE DYNAMIC EVOLUTION OF SPONTANEOUS CORONARY ARTERY HEMATOMA
Authors: Franzino Marco , Costa Francesco , De Ferrari Tommaso , Vizzari Giampiero , Di Bella Gianluca , Micari Antonio , Carerj Scipione
Published: December 2022

Background

Spontaneous coronary intramural hematoma (SCIH) is a rare but underdiagnosed condition, with dynamic evolution.

Clinical presentation

A 45-year-old woman was admitted to the emergency department with chest pain and fever in the previous days. Markers of myocardial injury were elevated, white blood cell count and C-reactive protein were mildly elevated, whereas D-dimer, chest X-ray and ECG were normal. Transthoracic echocardiography showed inferior wall hypokinesia, so an urgent coronary angiogram was performed showing no evidence of obstructive coronary artery disease.

Investigations

Cardiac magnetic resonance (CMR) was performed two days later showing inferior wall ischemic pattern (Figure 1) and ECG showed changes in the inferior leads with T waves inversion. A second coronary angiogram with planned intravascular imaging was than performed and showed a critical stenosis of the mid-distal right coronary artery determining functional vessel occlusion (Figure 2). Coronary vasospasm was ruled-out after intracoronary nitrates infusion and intravascular ultrasound (IVUS) showed diffuse intramural hematoma of the ostial, proximal and mid-segment of the right coronary artery with subocclusive stenosis at the mid segment with no evidence of atherosclerosis (Figure 3).

Management

Considering the clinical and radiological evidence of evolving myocardial injury, conservative management was excluded, and direct stenting of the lesion was performed with IVUS guided implantation of four overlapping drug-eluting stents.

Conclusion

Our case highlights the dynamic and treacherous nature of spontaneous coronary intramural hematoma, causing initial symptoms of myocardial ischemia without evident coronary obstruction, and then rapidly evolving in a severe and life-threatening coronary occlusion upon hematoma expansion. Higher level diagnostic testing such as CMR and intravascular imaging were instrumental for correct diagnosis and treatment in this complex scenario.

Figure 1

Figure 2

Figure 3
1005 STROKE VOLUME INDEX AND TRANSVALVULAR FLOW RATE TRAJECTORIES IN SEVERE AORTIC STENOSIS TREATED WITH TAVR
Authors: Gallone Guglielmo , Gorla Riccardo , Melillo Francesco , Leone Pier Pasquale , Cimaglia Paolo , Pastore Maria Concetta , Franzone Anna , Landra Federico , Bruno Francesco , Scudeler Luca , Bragato Renato , Ilardi Federica , Toselli Marco , Conrotto Federico , Montorfano Matteo , Manzo Rachele , Cameli Matteo , Patti Giuseppe , Stefanini Giulio , Testa Luca , Giannini Francesco , Agricola Eustachio , D´ascenzo Fabrizio , De Ferrari Gaetano Maria
Published: December 2022

Aims

The prognostic impact of flow trajectories according to stroke volume index (SVi) and transvalvular flow rate (FR) in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) remains poorly assessed. We evaluated and compared SVi and FR prior and after TAVR for severe AS.

Methods and results

Patients were categorized according to SVi (<35 ml/m2) and FR (<200 ml/sec). The association of pre- and post-TAVR SVi and FR with all-cause mortality up to 3 years was assessed with multivariable Cox regression models. Among 980 patients with pre-TAVR flow assessment, SVi was reduced in 41.3% and FR in 48.1%. Baseline flow status was not an independent mortality predictor (SVi: HR 1.39, 95%CI 0.81-2.40, FR: HR 0.86, 95%CI 0.51-1.46). Among 731 patients undergoing early (5 days, IQR 2-29) post-TAVR flow assessment, SVi recovered in 40.1% and FR in 49.0% patients with baseline low-flow. Reduced FR following TAVR was an independent predictor of mortality (HR 2.08, 95%CI 1.07-4.04) while SVi was not (HR 0.68, 95%CI 0.34-1.36). Three-year estimated mortality in patients with recovered FR was lower as compared to patients with reduced FR (13.3% vs 37.7% vs, p=0.003) and similar to patients with normal baseline FR (p=0.317).

Conclusions

Baseline flow status was not an independent predictor of mid-term mortality among all-comers with severe AS undergoing TAVR. Flow recovery early after TAVR was frequent. Post-TAVR FR, but not SVi, was independently associated with mid-term all-cause mortality. By impacting flow status, AV replacement modifies the association of flow status with outcomes.
298 MPACT OF GUIDELINES-ORIENTED AGE CUT-OFF IN INTERMEDIATE TO LOWVRISK PATIENTS UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT WITH NEWEST GENERATION SELF-EXPANDING VALVES: A COMBINED ANALYSIS FROM NEOPRO AND NEOPRO-2 REGISTRIES
Authors: Sticchi Alessandro , Gitto Mauro , Pagnesi Matteo , Baggio Sara , Scotti Andrea , Barbanti Marco , Costa Giuliano , Adamo Marianna , Di Marco Federico , Casenghi Matteo , Lunardi Mattia , Regazzoli Damiano , Reimers Bernhard , Maffeo Diego , Buono Andrea , Saccocci Matteo , Giannini Francesco , Di Ienno Luca , Lanzillo Giuseppe , Ferlini Marco , Ielasi Alfonso , Latib Azeem , Mangieri Antonio , Colombo Antonio
Published: December 2022

Introduction

While randomized controlled trials have widely shown superiority or non-inferiority of transcatheter aortic valve replacement (TAVR) across the whole spectrum of surgical risks, 2021 ESC guidelines on valvular heart disease provide a class Ia indication for TAVR for patients at high surgical risk or, alternatively, aging >=75 years, irrespective of their surgical risk. Conversely, for patients aging <75 y and at low risk, surgical aortic valve replacement is recommended. Thus, in intermediate-low (IL) risk patients, the 75 y age cut-off is pivotal to guide the choice of intervention. The aim of the present study was to explore the impact on such cut-off on clinical outcomes in a real-world setting.

Methods

Consecutive IL surgical risk patients enrolled in the NEOPRO and NEOPRO-2 registries were included. A 1:1 propensity score matching (PSM) was used to match patients aged >= vs. <75 years old. The primary endpoint was the composite of all-cause death or cardiovascular hospitalizations.

Results

A total of 3642 patients undergoing TAVR with self-expanding transcatheter heart valves (THVs) from 2012 to 2021 were enrolled. After PSM, 484 patients (N=242 in both groups) were included in the final analysis. Mean age was 70.1±5.2 in patients aged <75 y and 81.56±4.18 in those aged >=75 y (p<0.001), while mean Society of Thoracic Surgeon (STS) score was 3.6±2.5%. Implanted THVs were Acurate Neo, Evolut Pro, Acurate Neo 2 and Evolut Pro+ in 199 (41.1%), 188 (38.8%), 73 (15.1%) and 24 (5%) patients respectively, with no between-groups differences. Rates of in-hospital complications were comparable across the two age categories. At 1-year follow-up, the cumulative incidence of all-cause death was 11% in patients aged >=75 y and 13% in those aged <75y (Log-Rank p=0.627); similarly, the composite of all-cause death or cardiovascular hospitalizations occurred in 14% vs. 16% of patients (Log-Rank p=0.554).

Conclusions

TAVI has comparable benefit across age strata in IL risk patients. The age cut-off suggested by current guidelines is not predictive of adverse events during hospital stay, neither of all-cause mortality through a mid-term follow-up. This opens the question to future studies focusing on lifetime management and not age cut-off.
526 ALAGILLE SYNDROME, A CASE REPORT
Authors: Nobile Edoardo , De Filippis Aurelio , Circhetta Simone , Bernardini Federico , Viscusi Michele , Gallo Paolo , Ussia Gian Paolo
Published: December 2022

Alagille syndrome (AGS) is a dominantly inherited multisystem disorder caused by heterozygous mutations of genes that are components of the Notch signaling pathway. The main clinical manifestations of AGS are intrahepatic bile duct paucity, congenital heart defects involving primarily the pulmonary arteries, butterfly vertebrae, anterior chamber defects of the eye and facial dysmorphism.

A male patient of 39 years old came to our observation due to the worsening of dyspnea, cyanosis, dizziness, heartbeat and asthenia for about two years. His cardiological history includes percutaneous pulmonary artery angioplasty in both left and right main pulmonary artery in 1994. In 2012, finding of pulmonary hypertension and diagnosis of Alagille syndrome confirmed by genetic analysis (JAG1 gene), and vasoreactivity testing of the pulmonary circulation was positive. Intrastent restenosis of the right lobar pulmonary artery treated with POBA in 2016. Patient therapy includes, diltiazem 60 mg OD, macitentan 10 mg OD, sildenafil 40 mg TID. Echocardiogram showed: preserved global and segmental systolic function. Minimal mitral valve insufficiency. Dilated right ventricle (RV / LV> 1), ipokinetic. Right atrium of increased size. Mild tricuspid valve insufficiency (VD-AD 20 mmHg). reduced systolic flow acceleration time (80 msec). Inferior vena cava of normal caliber with preserved inspiratory collapse. Indirect signs of pulmonary hypertension. The six minutes walking test showed severe desaturation after only one hundred meters.

Right catheterization showed severe pulmonary hypertension (PAPm 63 mmHg). blood gas analysis showed oxygen saturation of 83% in the pulmonary artery. Angiography of the pulmonary arteries showed intrastent restenosis on the left pulmonary artery and fracture of the stent on the right pulmonary artery. For which was performed angioplasty with stent intrastent implantation in the right pulmonary artery.

After the procedure there was immediate reduction in pulmonary mean arterial pressure (53 mmHg), a progressive improvement in 02 saturation (88% at discharge) while the echocardiogram after the procedure results unchanged except for the increasing of the systolic flow acceleration time (100 msec).

Right catheterization showed a gradient trans-stenosis of 96 mmHg. We performed angioplasty with stent intrastent implantation in the right pulmonary artery.

After that we saw a drop in the gradient trans-stenosis (63 mmHg) and a raise in the systolic pressure of the left pulmonary artery.

In Conclusion, in this particular population of patients with pulmonary hypertension even if on maximal therapy, the worsening of symptoms should in our opinion be an indication for right cardiac catheterization and angiography of the pulmonary arteries.
79 PERCUTANEOUS TREATMENT OF HIGH-MODERATE RISK PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH LOCAL ULTRASOUND-ASSISTED THROMBOLYSIS
Authors: Perfetti Silvia , Costa Francesco , Micari Antonio , Di Bella Gianluca
Published: December 2022

Objective

A 74 y/o female presented at our emergency department with syncope and head trauma. At the physical examination she was dispnoic and tachycardic. Laboratory analysis showed elevated troponin and NT-proBNP. The TTE showed a dilated and dysfunctional right ventricle, 60/60 sign, elevated PAPs with flattening of interventricular septum. CT angiography showed massive pulmonary embolism (PE) affecting both branches of the pulmonary artery. The lower extremity venous ultrasound showed a long thrombus in the left distal tract of the common femoral vein, superficial femoral vein and popliteal vein.

Methods

The patient was admitted to the cardiac intensive care unit. Due to her worsening respiratory condition and her moderate-high early mortality risk PE with high risk of bleeding due to recent trauma, we decided to treat her with local ultrasound-assisted thrombolysis (Ekos). This combines ultrasound fragmentation of the thrombus with in situ reduced-dose thrombolysis. Two catheters were placed in the two pulmonary arteries through two right femoral venous accesses. The Ekos catheters were left on site for 6 hours and then removed without complications.

Results

The treatment was immediately effective and the clinical conditions improved within 24-48 hours. The follow up TTE showed improved right ventricle function with attenuated signs of PE. CT angiography at one week showed resolution of the vascular thrombosis. Our patient was discharged in good clinical conditions and with prescription of a NOAC. The monthly follow up was normal and any complication was referred.

Conclusions

A local thrombolysis technique is useful in intermediate-high risk patients at elevated bleeding risk. Future studies will shed light on the comparison between these catheter directed treatments and standard of care.
989 ANAESTHESIOLOGICAL MANAGEMENT IN PATIENTS UNDERGOING TEER: A NEW APPROACH IMPROVES CV OUTCOMES
Authors: Russo Massimo , Marchei Massimo , Idone Gaetano , Lecis Dalgisio , Di Landro Alessio , Macrini Massimiliano , Di Luozzo Marco , Sanseviero Angela , Romeo Francesco , Muscoli Saverio , Barilla´ Francesco , De Vico Pasquale
Published: December 2022

Background

Transcatheter edge-to-edge repair (TEER) with the MitraClip system is an alternative procedure for the treatment of severe mitral regurgitation (MR) in high-risk patients who are not suitable for conventional surgery and is usually performed under general anaesthesia (GA). GA may be associated with potential haemodynamic complications. A new alternative approach is deep sedation (DS) with spontaneous breathing using a target-controlled infusion (TCI). The aim of this study is to compare TCI during DS with manual administration of total intravenous anaesthesia (TIVA) during GA in patients undergoing TEER evaluating the impact of these approaches on anaesthesia time, remifentanil dose administered, haemodynamic profile, vasopressor requirements, adverse events and postoperative hospital stay.

Methods

The study population included 90 consecutive patients treated with MitraClip (mean age 73.5 ± 9.54 years). 65 patients (72%) suffered from functional MR. Mean LVEF was 35 ± 13% and logistic EuroSCORE was 23 ± 19%. 24 patients received GA and TIVA; 66 patients underwent DS and TCI, consisting of administration of midazolam and fentanyl citrate as induction of anaesthesia followed by continuous infusion of remifentanil hydrochloride.

Results

Acute procedural success was 100%, with no major complications during the procedure. No statistical differences were found between the GA-TIVA and the DS-TCI group in terms of demographics and surgical risk profile. Anaesthesia time was significantly shorter in the DS-TCI group (71 ± 30 vs. 118 ± 35 minutes; p < 0.0001), as was procedure duration (54 ± 29 vs. 99 ± 74 minutes; p = 0.00007). In addition, there was a significant reduction in the remifentanil dose administered (249 µg vs. 2865 µg, p < 0.01), the incidence of hypotension (p = 0.08) and the need for vasopressors (29.6% vs. 63%, p = 0.03) in the DS-TCI group. There were no differences in days of hospital stay after the procedure (5.4 days vs. 5.8 days, p = 0.4).

Conclusions

DS with spontaneous breathing using TCI could be a valid alternative during TEER which can ensure stable anaesthetic conditions, less drug administration, higher haemodynamic stability and fewer side effects, with particular advantages in patients at high risk for general anaesthesia.
441 EFFECTS OF TRANSCATHETER AORTIC VALVE IMPLANTATION ON RENAL FUNCTION IN CT-DEFINED SARCOPENIC PATIENTS
Authors: Ruzzarin Alessandro , Bonatti Matteo , Pernter Patrizia , Engl Patrick , Pescoller Felix , Pesarini Gabriele , Ribichini Flavio Luciano , Donazzan Luca
Published: December 2022

Introduction

Sarcopaenia, the age-associated decline in skeletal muscle and function, increases the risk of procedure-related complications and mortality in patients undergoing transcatheter aortic valve implantation (TAVI). We sought to investigate whether CT-determined sarcopenia impacts on in-hospital renal function and on midterm outcomes following TAVI.

Methods

This was a retrospective cohort study including patients who underwent TAVI. Sarcopaenia was CT-defined as skeletal muscle mass index <55.4 cm2/m2 in males and <38.9 cm2/m2 in females at the level of L3 vertebra. Acute kidney injury (AKI) was defined as an increase in creatinine concentration of at least 0.3 mg/dL within 48 hours of TAVI according to Valve Academic Research Consortium-3 Criteria. Acute kidney recovery (AKR) was determined as an increase of 25% in eGFR within 48 hours following TAVI. The primary endpoint was freedom from major adverse cardiac and cerebrovascular events (MACCE; composite of any cause of death, any coronary revascularization, stroke and heart failure hospitalization) at the 1-year follow up in sarcopaenic and non-sarcopaenic patients.

Results

A total of 113 patients (mean age 82.2 ± 4.03 years, 52.2% female) were followed for a median of 1.1 year. Sarcopenia was found in the 59% of the TAVI population, more frequently among males (72.2% versus 33.8%, p<0.01). The incidence of AKI was 8.0% and AKR was 6.9% without differences between sarcopaenic and non-sarcopaenic patients (9.4% versus 6.5%, p=0.59 and 11.6% versus 2.2%, p=0.08). The freedom from MACCE at 1 year follow up was 74.5% for sarcopaenic and 70.3% for non-sarcopaenic patients (p= 0.6). In sarcopaenic patients, the incidence of AKI and AKR had no significant impact on the freedom from MACCE at 1-year (p=0.58 and p=0.87).

Conclusions

Sarcopaenic patients had similar out of hospital incidence of adverse events to non-sarcopaenic patients following TAVI confirming the safety of this procedure in sarcopaenic patients.