bluuebunny/crossref_metadata_2025 huggingface dataset:
P131 ACUTE RIGHT HEART FAILURE: MASSIVE PULMONARY EMBOLISM OR RIGHT INFARCTION?
Authors: Ottaviani A , De Donno F , Pierfelice F
Published: May 2023

Right ventricular infarction is often unrecognized. Rarely isolated, it complicates up to 50% of inferior infarction, conditioning morbidity and mortality. Clinical presentation, characterized by hypotension, and echocardiografic features, with right ventricular involvement, can often mimic high risk pulmonary embolism. This case report focuses on an 85–years–old woman who called 118 for chest pain and asthenia. The patient is in shock, when accepted into the emergency room. ECG reveals a third–degree AV block with escape rhythm at rate of 35bpm and ST segment elevation in inferior leads, requiring temporary transvenous pacemaker placement. Bedside echo shows a borderline LV systolic function (EF 50%) with inferior wall akinesis and a dilated and hypokinetic right ventricle (TAPSE 15mm). In emergency we perform a coronary angiogram, that reveals a total occlusion of the ostial right coronary artery, treated by PCI 2 DES. During clinical course, no complications occur. At hospital discharge, the patient is hemodynamically compensated, without neurological sequelae and with cardiac enzymes in decrease (Trp I HS peak 94 000pg/ml). The aim of this case report is to focus cardiologist’s attention on right ventricular infarction, knowing its clinical presentation and its laboratory, electrocardiographic and echocardiographic features.
P133 ZEBRA HOOFBEATS: A RARE CASE OF STEMI IN GRANULOMATOUS NECROTIZING AORTITIS
Authors: Facci G , Alberti G , Dotto A , Briani F , Benfari G , Pighi M , Ribichini F
Published: May 2023

We present the unusual case of an AMI STEMI, complicated by ventricular fibrillation, in a 26 years old caucasic male patient, affected by necrotizing and granulomatous aortitis, in the context of a primary immunodeficiency. Initially the patient was referred to the Cardiology Unit for worsening dyspnea and fatigue. In his medical history he has primary immunodeficiency complicated by multiple opportunistic infections. We performed an echocardiography that revealed an aneurismatic ascending aorta (58 mm) with associated significant aortic valvular regurgitation. He was later referred to heart surgery OR where Bentall–De Bono operation was performed. Two years later he developed a lateral STEMI, complicated by ventricular fibrillation. The coronary angiography, performed in foreign country, showed total occlusion of the circumflex coronary artery with diffuse aneurismatic coronary disease, granulomatosis and ulcerative lesions. A percutaneous revascularization approach was tried, but ineffective. Actually the patient, during follow up, presents dilatative post–ischemic cardiopathy with moderate ejection fraction reduction, initial aortic bioprosthesis failure. We noted at follow up echocardiograms early dilatation of the native aortic arch (35 mm), suggesting a progressive disease. In conclusion, AMI‘s etiology includes many non atherosclerotic mechanisms that should be considered alongside common causes. This case shows a rare cause of STEMI in a very young male patient, and teaches us that aortitis is a progressive and complex pathology, often involving multiple arteriosus districts, that needs close follow–up and integrated management.
P140 THE “SMOKER’S PARADOX”: A QUESTION OF SHORTER ISCHEMIC TIME AND YOUNGER AGE. RESULTS FROM A LARGE COHORT OF CONSECUTIVE STEMI PATIENTS TREATED WITH PRIMARY PCI
Authors: Paradossi U , De Caterina A , Dossi F , Raccis M , Benedetti G , Marchi F , Palmieri C , Berti S
Published: May 2023

Background

Smoker’s paradox usually refers to the common observation of a favourable outcome of smoker patients in acute myocardial infarction. The interpretation of this phenomenon is still controversial and not fully explained. We aimed at assessing whether smoking could be associated with mortality in a large cohort of prospectively enrolled patients with ST segment elevation myocardial infarction (STEMI) referred to primary percutaneous coronary intervention (PCI).

Methods

From April 2006 to December 2018 a population of 2456 STEMI patients treated with primary PCI were prospectively enrolled in the MATRIX registry. Ischemic time, clinical, demographics, angiographic data and 1–year follow–up were collected.

Results

Among 2546 patients admitted with STEMI 1007 (41%) were current smokers. Smokers were 10 years younger and had lower crude in–hospital and 1–year mortality (1.5% vs 6%, p<0.0001 and 5% vs 11%, p<0.0001), shorter ischemic time (203 [147–299] vs 220 [154–334] minutes, p=0.002) and shorter decision time (60 [30–135] vs 70 [36–170] minutes, p=0.0063). After adjustment for different risk factors using Cox regression model, age [adjHR: 1.11 (95%CI: 1.03 – 1.18) – p<0.01] and ischemic time [adjHR: 1.01 (95%CI: 1.01 – 1.02) – p<0.05] appeared to be the confounder factor of the relationship between smoking and in hospital mortality.

Conclusions

In our large prospectively–enrolled population the so–called “smoker’s paradox” is explained by the shorter ischemic time and younger age of the smoking population. Our data shows that smokers were admitted to the hospital for STEMI about 10 years before non–smokers, with a premature coronary atherothrombosis that could be the price to pay for smoking. Smokers had non–significant different risk of in–hospital mortality compared to non–smoking.
P149 INTEGRATED CARDIO–RADIOLOGICAL TEAM
Authors: Pancaldo D , Armando E , Cavallero E , Groppo Marchisio F , Amoroso G , Barbero U , Bassignana A , Battisti A , Bricco G , Coppolino A , Correndo L , Dogliani S , Iacovino C , Moncalvo C , Scollo A , Valeri L , Salmè G , De Benedictis M
Published: May 2023

Introduction

Cardiovascular diseases are the main cause of mortality: a multidisciplinary approach is essential to fight them successfully. CT coronary angiography and cardiac magnetic resonance are diagnostic tests increasingly used to complement traditional methods. At the "SS Annunziata" hospital in Savigliano (CN) there has already been collaboration between dedicated cardiologists and radiologists for many years: first for CT and then also for MRI. In 2020 the collaboration was formalized, through the drafting of an operating procedure, and the "Integrated multidisciplinary cardio–radiological Team" was officially established. Who is part of the team: Dedicated and identified figures, never occasional, of the Cardiology Department and Radiology Department, whose essential requirements are: a) for cardiologists: advanced competence in echocardiography, general technical knowledge, targeted training b) for radiologists: advanced competence in CT and MRI, mastery of specific sequences and processing techniques, cardiological knowledge. Additional requirements for both figures: certifications and publications. Team activities: 1) Scheduling of exams 2) Discuss the case based on the request and documentation and plan the most suitable technical execution. 3) Monitor for the onset of adverse effects if beta–blocker drugs or stimulant drugs are administered 4) Supervise the execution of the exam: 5) Perform image processing and interpretation: for coronary CT, reconstruction of coronary images in the different modalities, search and quantification of stenoses; for MRI, calculation of volumes and ejection fraction for both ventricles, diameters of the cavities and thicknesses of the walls, search for edema, search and quantification of fibrosis, search for basal perfusion defects and after possible pharmacological stimulation, search for any findings extracardiac. 6) Write and sign the report (radiologist and cardiologist). 7) Contact the patient or the referring doctor by the cardiologist if the findings of the tests performed impose decisive implications of a therapeutic nature. 8) Detect the indicators of set goals Perspectives: The technological advance of cardiac imaging diagnostics, with CT and resonance magnetic, suggests that in the near future these techniques can further improve and open up to new applications that will be the task of the group to evaluate, learn and put into practice.
P150 STRESS–REST DYNAMIC–CT MYOCARDIAL PERFUSION IMAGING IN THE MANAGEMENT OF MYOCARDIAL BRIDGING: A “ONE–STOP SHOP” EXAM
Authors: Perna G , Schicchi N , Fogante M , Pirani P , Paolini E
Published: May 2023

Myocardial bridging (MB) is a congenital anomaly characterized by intramyocardial coronary course that can cause coronary compression during systole and can lead to myocardial ischemia. The improvement in computed tomography (CT) scanner technology has increased the detection of MB during coronary–CT (cCT) exam but the assessment of their functional significance is often challenging. Tha stress–rest myocardial perfusion imaging (MPI) single–photon emission CT (SPECT) is often required to decide patient’s management after anatomical evaluation with cCT or Invasine Coronary Angiography (ICA). However, SPECT has long acquisition protocols, poor spatial resolution, and the anatomical/Functional protocols expose patients to significant radiation doses. Thus, dynamic–CT MPI after cCGT can represent a valid alternative. We report the cases of seven patients in which we detected MBs during cCT exam and we evaluated their functional significance using a stress–rest dynamic–CT MPI to decide the correct patient’s management. Three patients showed reversible perfusion defect in the left anterior descending (LAD) territory segments involved with MB and they were referred for treatment. The remnants four patients with MB in the LAD revealed normal MPI and they were conservatively managed. In all patients the results of the stress perfusion were completely overlapping, but the study with SPECT after anatomical evaluation required a longer process. The cCT and stress–rest dynamic–CT MPI allowed to detect and to evaluate the functional significance and to decide the management of MB in a “one–stop shop” exam.
P155 CT EVIDENCE OF PARTIAL ISCHEMIC PAPILLARY MUSCLE RUPTURE
Authors: Del Torto A , Dalla Cia A , Ghulam S , Formenti A , Pontone G , Assanelli E
Published: May 2023

A 77–year–old man was referred for coronary CT following an episode of prolonged chest pain that occurred about 30 days earlier, with subsequent onset of dyspnea on moderate exertion. Coronary CT demonstrated right dominance, occlusion of the right coronary artery, as well as severe stenosis of the distal segment of the left anterior descending artery and of the first obtuse marginal branch. CT scan also showed an intraventricular image consistent with partial rupture of the posteromedial papillary muscle (Figure 1). The patient was transferred to the emergency department. An ECG showed signs of inferolateral necrosis. Transthoracic echocardiography confirmed akinesia of the inferior and inferolateral walls and of the basal segment of the inferior septum, with severe mitral valve insufficiency from anterior leaflet prolapse (A3 scallop) from partial rupture of the posteromedial papillary muscle (Figure 2). Transesophageal echocardiography confirmed the diagnosis (Figure 3). The patient was admitted to the CCU and underwent coronarography, which confirmed the severe triple vessel coronary artery disease with occlusion of the right coronary artery, and then urgent mitral valve replacement with bioprosthesis and aortocoronary bypass with saphenous vein grafting to the posterior descending artery. The postoperative course was uneventful. Ischemic papillary muscle rupture is a rare cause of mitral insufficiency. Papillary rupture typically occurs within 5 days of an acute myocardial infarction, and causes mitral insufficiency by prolapse and flail of one or, more rarely, both mitral valve leaflets. The posteromedial papillary muscle is most commonly affected, since the anterolateral papillary muscle has dual supply from the anterior interventricular artery and the circumflex artery. Papillary muscle rupture can be total or partial; however, most cases of partial rupture progress to complete rupture and therefore require urgent surgical treatment. The peculiarity of this case lies in the fact that it is the first case described in the literature of a papillary muscle rupture documented on CT.
P160 WHEN IMPEDANCE TRENDS LIE, REMOTE MONITORING HELPS FOR DIAGNOSIS
Authors: Scicchitano M , Loricchio M , Schirripa V , Iulianella R , Perna S , Castro A , Centurion Aznaran C , Albano B , Rizzo V , Granatelli A
Published: May 2023

An 82–years old female patient with history of hypertension, diagnosis of dilatative cardiomyopathy with normal coronary arteries and permanent atrial fibrillation (AF) was implanted with a dual chamber implantable cardioverter defibrillator (ICD), Guidant Ventak Prizm DR (Boston Scientific,Marlborough,USA) as a secondary prevention of sudden cardiac death in 2002. The ICD was electively replaced in 2005 and in 2010 with a Guidant, Vitality 2 DR (Boston Scientific,Marlborough,USA). In 2016, despite an optimized medical therapy, the patient experienced an episode of palpitation due to an AF with high ventricular response. Considering the difficulties of the heart rate management with the pharmacological therapy the patient underwent to an ablation of AV node. In 2017 we performed a third replacement of the ICD downgrading the system to a single chamber ICD, Fortify Assura VR (Abbott,Sylmar,USA) and providing the patient with a bedside–transmitter Merlin@home (Abbott,Sylmar,USA) The patient, followed for 4 years remotely, did not experience ventricular arrhythmias and the ventricular lead electrical parameters, including pacing and shock impedances, were stable and in the normal range. In March 2021 an alert of the Merlin system triggered an unscheduled transmission that showed several episodes of ventricular oversensing. The episodes revealed that an electrical interference inhibited the ventricular pacing causing episodes of asystole with a maximum duration of three seconds (Fig.1). Unexpectedly electrical parameters such as the pacing and shock impedances showed a stable and normal measurements (Fig .2), while the chest X–rays showed that the ventricular lead was kinked at 90–degrees below the clavicle evidencing a lead fracture (Fig.3). The patient was therefore implanted with a new ventricular lead avoiding inappropriate shocks and further episodes of asystole. The occurrence of a lead failure represents an insidious and potentially harmful event for the device implanted population, especially for ICD or pacemaker–dependent patients. The diagnosis of a lead failure is not easily predictable, and it is usually driven after a clinical event of inappropriate shock or unexplained syncope. Our case highlighted how Remote Monitoring is extremely helpful even more in this case of apparently correct functioning based on electric measurements.
P161 THE ROLE OF CARDIOLOGICAL TELEVISIT FOR THE MANAGEMENT OF PATIENTS WITH POST–ACUTE SEQUELAE OF SARS–COV–2 INFECTION: STUDY DESIGN
Authors: Gatto M , Ferrari I , Biava G , Vergori A , Girardi E , Antinori A
Published: May 2023

Background

WHO defines Post–Acute Sequelae of SARS–CoV–2 (PASC) as a condition that occurs several weeks after the infection, which persists for at least 8 weeks and cannot be explained by alternative diagnoses. Symptoms of PASC are: palpitations, dyspnoea, chest pain. These symptoms require an initial cardiological investigation, but also a cardiological follow–up that could be carried out with telemedicine. Principal aim: To assess the feasibility of cardiological televisit and its socio–economic impact in patients with PASC. Secondary aims: 1) To describe the clinical, laboratory and instrumental characteristics of patients with PASC and to define the possible role of cardiovascular risk factors in the development of the disease; 2) To correlate the symptoms reported by the patients with any clinical objectivity or instrumental alterations; 3) To assess the patient‘s perception of the use of specialist televisit and its possible economic and social impact.

Methods

Prospective observational study. All patients with previous COVID–19 with suspected PASC will be screened. After the first cardiological face–to–face visit, patients with suspected PASC who require follow–up will be consecutively enrolled and assigned in a 1:1 ratio to the televised study group (GT) and the standard of care (GC) control group. Patients in the GT group will perform the control cardiology examination in televisit, while patients in the GC group will perform the cardiological control according to the current standard of care. The specialist televisit (booking mode, use of freeware platform) will be provided as indicated by the latest regional directives. Exclusion criteria: Failure to sign informed consent; inadequate computer literacy (of the patient or his/her caregiver). Evaluation: Patients in the GT and GC group will take a questionnaire with specific questions on how the specialist check–up will be delivered. Expected results: The use of televisit for the follow–up of patients with PASC, as defined in this protocol, play a key role for the digital transition in our operational context and, above all, for the optimisation of healthcare resources.
P162 ARRHYTHMIC MITRAL VALVE PROLAPSE OCCURRING AS ABORTED SUDDEN CARDIAC DEATH
Authors: Alberio A , Garibaldi S , Mirizzi G , Franchi E , Viacava C , Santoro G , Piacenti M , Rossi A , Assanta N
Published: May 2023

Mitral valve prolapse (MVP) is the common valvular heart disease, with a prevalence about 1–3% in the population. MVP is characterized on echocardiography by an abnormal systolic displacement of mitral valve leaflets into left atrium (LA) ≥ 2 mm above the mitral annulus. We described a clinical case of a 15 years–old boy with a first clinical presentation of out–of–hospital cardiac arrest related to ventricular fibrillation (VF) with a successful resuscitation after 2 DC shocks. Retrospectively, an episode of loss of awareness reported as post–minational. No familiar history of sudden cardiac death (SCD) or MVP was noticed. In the emergency room, the patient was hemodynamically unstable and was sedated and intubated. The surface electrocardiogram (ECG) showed sinus rhythm, QRS with fragmentation, and frequent monomorphic isolated premature ventricular contractions (PVCs) with RBBB/LAFB configuration.Frequent monomorphic PVCs with bigeminy was observed during continuous ECG monitoring, so the patient was treated with magnesium sulphate and metoprolol. The patient was subsequently weaned from ventilation support, presenting good gas exchange and without neurological sequalae. The 24h Holter monitoring showed an average of 53 bpm, extremely rare supraventricular extrasystoles, high incidence of monomorphic PVCs (23% of the total beats) with 4 couplets. Transthoracic echocardiography documented normal size and thickness with systolic function (GLS –21%, mild asynchrony of posterior basal segments), bi–leaflet prolapse associated to mild–moderate mitral regurgitation, and mitral annular disjunction (MAD) of 6.2 mm. The late gadolinium enhancement cardiac magnetic resonance showed bi–leaflet prolapse with mild insufficiency and maximum MAD 9 mm, mild LA dilatation, and slightly dilated both ventricles, without regional wall motion abnormalities; no scar or fibrosis at the late gadolinium enhancement was observed. According to guidelines, the patient received a subcutaneous implantable cardiac defibrillator for the secondary prevention of SCD and maintained under betablockers in order to control the arrhythmic burden. The genetic sampling did not show any pathogenetic mutation potentially related to cardiomyopathies or channelopathies. This case show an arrhythmic MVP complex with probably posterior papillary muscle source. The early PVCs with R/T constituted a possible trigger of VF. The betablocker therapy exhibited a full suppression of extrasystolic burden.
P163 THE ELECTROCARDIOGRAPHIC CHANGES ASSOCIATED WITH HYPOTHERMIA: THE OSBORN WAVE
Authors: Costantino M , Calculli G , Stolfi L , Cortese F
Published: May 2023

A 93–year–old patient came to our observation for general malaise, sensory obnubilation, aphasia and dysphagia. He had arterial hypertension in drug treatment. At the first medical contact, the body temperature was 28 °C. The ECG showed a non–evaluable atrial activity (likely atrial paralysis) with the presence of a junctional rhythm at the frequency of 37 bpm. Blood pressure was around 100/60 mmHg with preserved cardiovascular compensation, in the presence of a moderately depressed cardiac function. Furthermore, the presence of a positive deflection in the terminal part of the QRS complex with elevation of the point J, in the precordial lateral leads V4–V6, and a terminal slowing of the QRS complex in the inferior leads, the so–called ‘wave of Osborn’, were also observed Figure 1. Given the reduction of the sensory, the patient was subjected to brain CT scan with finding of a thin hyperdense layer around the right and left hemispheric convexity suggestive for subdural haematoma. After adequate warming and supportive therapy, a progressive increase in heart rate was observed with restoration of the sinus rhythm and disappearance of the Osborn wave, Figure 2. The Osborn wave is the most specific electrocardiographic sign of hypothermia. It consists of an electrocardiographic deflection which is manifested as a late delta wave or as a small r ’wave following the QRS. It is the manifestation on the surface ECG of the electric gradient between a more prominent spike and dome action potential of epicardial cells than that of endocardial cells, an effect that is believed to be linked to a slowing down of the kinetics of activation of K þ channels Ito compared to calcium channels, associated with low temperature. This wave is not specific for hypothermia but can also occur in other clinical conditions such as subarachnoid haemorrhage, myocardial ischaemia, acidosis, in the presence of hypercalcemia, early repolarization and even in normal subjects. Its amplitude also tends to increase in conjunction with the reduction in body temperature. The bradyarrhythmias and conduction disorders associated with hypothermia cease spontaneously with an increase in body temperature, so the use of beta stimulating drugs and the insertion of transvenous pacemakers, the latter for the mechanical irritation effect on the endocardium, should be considered with caution due to the high risk of inducing ventricular tachyarrhythmias and ventricular fibrillation.
P167 CARDIAC ARREST IN SUSPECTED LONG QT: APPROACH TO ARRHYTHMIC MITRAL VALVE PROLAPSE
Authors: Bevere E , Mastroianno S , Greco A , Brunetti N , Salvatori M , Potenza D , De Luca G , Di Stolfo G
Published: May 2023

Mitral valve prolapse is a common condition. It affects 1–3% of the population. Clinical manifestations range from the absence of symptoms to sudden cardiac death. The arrhythmogenic mechanism is related to fibrotic changes in myocardial posterior caused by valve prolapse. ECG abnormalities indicative of high risk are inverted or biphasic T waves, ST depression, QT prolongation or dispersion, and BEV originating from the left outflow tract or papillary muscles. The echocardiogram allows the identification of mitral prolapse and disjunction of the mitral annulus (MAD), while MRI shows fibrosis. ICD implantation should be considered in high–risk patients with documented ventricular arrhythmias.

Clinical case

A 29–year–old woman with a family history of sudden cardiac death reported a state of absolute well–being until September 2022 when she presented with syncope with referred pulse failure for which she underwent cardiac massage, without defibrillation, by family members. At the arrival of 118 the patient presented bigeminal ventricular extrasystole with superior axis and BBsx type morphology (Fig.1). When she arrived at the hospital, ECG showed long QT (484 ms) associated with hypokalemia (2.8 mmol / l). During hospitalization, the coronary angiography was normal, while the cardiac MRI showed a globular and dilated left ventricle with preserved EF, thickening of the mitral leaflets, prolapse of both leaflets more evident at the level of P2/P3, MAD more evident in P3 with separation maximum end–systolic of 12 mm and absence of edema (Fig. 2). The patient underwent ICD implantation. In the presence of hypertelorism, prognathism, and flat feet, even in the absence of anomalies affecting the aorta and epiaortic vessels, scarring defects or ease to joint sprain, genetic screening was started for channelopathies and collagen diseases.

Conclusions

The approach to the patient with cardiac arrest and typical facies must be based on a systemic overview of the patient, whose phenotypic characteristics may suggest involvement of connective tissue diseases. In the future, the cardiologist must develop adequate knowledge to fully collect the information that the patient provides not only during instrumental examinations but also during an adequate clinical objective examination and facies, possibly supported by artificial intelligence.
P168 FOLLOW–UP IN A PATIENT WITH LYMPHOMA UNDERGOING CHEMOTHERAPY TREATMENT
Authors: Mautone F , Casavecchia G , Pesolo M , Gravina M , Brunetti N
Published: May 2023

We present the case of a 55–year–old hypertensive patient, with no other cardiovascular risk factors and no noteworthy cardiovascular history. Suffering from lymphoma, derived from grade I/II peripheral B lymphocytes, diagnosed in January 2018, underwent chemotherapy according to the R–CHOP scheme and continued until September 2021 with immunotherapy (Rituximab). The follow–up cardiological evaluation in September 2022 refers to dyspnoea for moderate exertion and some episodes of stinging chest pain, of short duration, not associated with neurovegetative symptoms. The Echocardiogram documented a left ventricular global systolic function at the lower limits of the norm evaluated with Eco3D (FE 53%). GLS –17.6%. ECG normal. A Coro–Tc was recommended and scheduled which documented the presence on the middle part of the anterior descending artery of partially calcified atheromatous plaque which extends for about 5 mm and which determines the reduction of the area by 67% and of the diameter of 70% therefore the patient underwent a coronary angiography with angioplasty with implantation of a medicated stent on IVA. This case demonstrates how important it is to perform a careful follow–up in cancer patients and how properly used imaging methods can help us in diagnosis and treatment.
P176 GLOBAL LONGITUDINAL STRAIN AS A PREDICTOR OF RESPONSE TO CARDIAC CONTRACTILITY MODULATION IN PATIENTS WITH HEART FAILURE: A CASE SERIES
Authors: Matteucci A , Pignalberi C , Pandozi C , Magris B , Meo A , Schiaffini G , Di Fusco S , Cianfrocca C , Aquilani S , Colivicchi F
Published: May 2023

Background

Cardiac contractility modulation (CCM) in heart failure (HF) patients with reduced ejection fraction (HFrEF) is an innovative therapy which may contribute to increased exercise capacity and quality of life and reduced hospitalizations. With speckle–tracking echocardiography and global longitudinal strain (GLS), changes in myocardial function can be detected with greater sensitivity than conventional approaches for measuring diastolic and systolic function, including left ventricular ejection fraction. We aim to analyze the usefulness of GLS in detecting improvement in systolic function and response to CCM treatment.

Methods

We studied 5 patients with CCM referred to our outpatient cardiology clinic. All patients underwent complete echocardiography with evaluation of GLS and ejection fraction. Follow–ups were performed at 1, 3, and 6 months.

Results

All patients were men (mean age 65.3±15.7 yrs). Mean baseline ejection fraction was 37.1±9.3%, mean GLS was 7.7±3.1%, and patients had mild–to–moderate left ventricular enlargement (mean indexed telediastolic volumes 101.4±8.7 ml/m2). Follow–up performed at the first month showed values similar to baseline values. Between the third and sixth months, a non–significant improvement in ejection fraction and GLS was recorded (EF 40.75±9.6% p=0.51; GLS 8.9±4.2 p=0.62). Indexed telediastolic volumes were reduced (101.4±9.3 ml/m2 vs 89.5±7.4 ml/m2 p=0.05).

Conclusions

CCM therapy seems to be useful in achieving volumetric remodeling in patients with HFrEF. GLS assessment may be useful in detecting improvement in systolic function. Further studies with larger samples and longer follow–up are needed to confirm these results.
P181 COMPARISON OF ECGRAPHIC CRITERIA FOR LEFT VENTRICULAR HYPERTROPHY
Authors: Cavarra M , Chiaranda‘ M , Salerno E , Chiaranda‘ G , Tamburino C
Published: May 2023

The diagnosis of Left ventricular hypertrophy (LVH) in the hypertensive patient is important for the prognosis and therapeutic implications that must be more aggressive in hypertensive with organ damage. On the other hand, echocardiography laboratories (Echo) are overwhelmed by an excessive indiscriminate demand for exams in hypertension. Purpose of Work: In a large population of subjects with high blood pressure we tested some ecgraphic standard criteria for LVH Materials and methods: 12859 ecgs with preoperative cardiological examination have been performed in a cardiological surgery consecutively in the last 3 years. From this population was selected a series of 7615 subjects who had carried out an echocardiogram in the last year ( Echo). Average age 66 23 aa, 61% women and 39% males. The sensitivity ( Se) and specificity (Sp) of several LVH ecgraphic criteria were evaluated in this population: Romhilt–Estes score; Sokolow–Lyon; Cornell, Perugia. Echo reference parameters for LVH were left ventricular mass (LVM) and/or diastolic thickness of interventricular septum (IVS) and posterior wall (PW) of the LV reported in the echo taking into account the reference values for LVH of the last LLGG of the European Society of echocardiography.

Results

The prevalence of IVS on the ecg for the scores studied was respectively 5.9%, 11.9%, 12.8%, 18.5%. The IVS echo prevalence ranged from 27.8% for LVM > 125 g/m2 to 57.1% for LVM > 51g/m2. Using this last parameter or the thickness of the IVS or PW of the LV the Se and Sp of the various scores / criteria were respectively: 6.9% and 95.9% for Romhilt–Estes; 10.9% and 90.8% for Sokolow–Lyon; 15.9% and 92.1% for Cornell; 23.6% and 84.8% for Perugia. Combining the positivity of at least one of three score/ecgraphic criteria ( Romhilt–Estes, Cornell, Perugia) the SE increased to 35.4% with a slight reduction of the SP of 86.5%.

Conclusions

The ecg Se for LVH is low with a good Sp; combining multiple scores/ecgraphic criteria of LVH, Se increases without a significant reduction of Sp. The ecg could be used to address the execution of the Echo with a better appropriateness and therefore use of resources .
P184 TRANSESOPHAGEAL ELECTROPHYSIOLOGICAL STUDY FOR FOLLOW UP OF NEONATAL PAROXYSMAL SUPRAVENTRICULAR TACHYCARDIA
Authors: Catucci S , Lombardi M , Maiorano A , Massari E , Meliota G , Pirolo T , Vairo U
Published: May 2023

Introduction

Paroxysmal supraventricular tachycardia (TPS) is the most common form of arrhythmia in neonatal age. The transesophageal electrophysiological study allows us to demonstrate the possible persistence of arrhythmia after the first year of age. Aim of the study: To evaluate the reliability of transesophageal electrophysiological study in the follow–up of these patients. Materials and methods: We retrospectively observed 8 patients who came to our observation in neonatal age for TPS. All patients underwent echocardiogram and Holter and were discharged to effective drug therapy for rhythm control (with one or two drugs). Afterwards, they carried out follow–up with Holter in drug therapy every 3 months. Within one year of age, antiarrhythmic therapy was discontinued and a transesophageal electrophysiological study was performed, including atrial stimulation at increasing frequencies and programmed atrial stimulation with single, double and triple extrastimulus. In case of TPS inducibility, therapy was resumed and the study was repeated after one year in wash out.

Results

We observed 8 patients who came for TPS in neonatal age. 7 of these had a structurally normal heart; one patient had aortic coarctation corrected with aortoplasty. After one year of therapy, 4 patients (50%), half of whom were in dual therapy (flecainide associated with beta–blocker and/or amiodarone) were non– inducible; these patients, who were permanently discontinued, no longer presented arrhythmic episodes in the follow–up. The remaining 4 resumed therapy (double in half of the cases) for another year and then repeated the study in wash out: one patient continued to present arrhythmias (patient with correct aortic coarctation); the other 3 were non–inducible. In the subsequent follow–up, 3 of these patients only one showed a recurrence of arrhythmia.

Conclusions

The transesophageal electrophysiological study is a simple, minimally invasive and reliable method to identify subjects at risk of TPS recurrence. The persistence of arrhythmia in our study is independent of the pharmacological treatment carried out in mono or dual therapy. We also observed that in case of positivity after one year of therapy, the study can be repeated later allowing therapy to be interrupted at a later time.
P187 INCREASING ROLE OF REMOTE CONTROL AND OPTIMIZATION IN CARDIAC RESYNCHRONIZATION THERAPY
Authors: Caruso D , Setti S , Lercari F , Canonero D , Brunacci M , Agosti S , Parodi A , Merello M , Costa S , Camerini A
Published: May 2023

Background

Patients (pts) with heart failure and reduced ejection fraction (HFrEF) treated with resynchronization therapy (with or without defibrillator: CRT–D or CRT–P) require echocardiographic or device algorithms optimization for better clinical results. With remote control is further possible improve follow–up of these pts.

Methods

From 01/01/2019 42 pts treated with CRT (33 men and 9 women 30 CRT–D and 12 CRT–P) were split in 3 groups: 14 pts underwent optimization and remote control, 14 underwent optimization without remote control, 14 underwent remote control only with implant parameters.

Results

In the first group ejection fraction (EF) improved from 28 to 43% (p 0.0001)(median age 78.2 years) (y), 3 pts died (2 m and 1 w, for heart failure, neoplastic cause and pneumonia). In the second group (median age 83.3 y) EF improved from 29 to 45% (p 0.0001) 4 pts died (3 m, 1 w, all CRT–D 3 for heart failure and 1 for unknown causes). In the third group (median age 79.2 y) EF improved from 32 to 40% (p 0.012), 2 pts died (1 m and 1 w with heart failure). There weren’t relevant differences for device interventionts in the 3 groups (1 appropriate shock and 1 inappropriate shock for atrial fibrillation in the 1st group, 1 appropriate shock in the 2nd group, 1 appropriate shock in the 3rd group). In the groups with remote control a severe malfunction that needed immediate replacement of CRT and optimal elective replacement timing for 3 device were found.

Conclusions

Biventricular stimolation optimization with echocardiography and with device algorythm should be always utilized after CRT implant. In our work, although the number of pts is little, a better EF is obtained in the groups with optimization compared to the group only in remote control. In the COVID19 era early recognition of arrhytmias and malfunctions of device and of suboptimal biventricular stimolation is possible with remote control and could improve pts clinical conditions, hospitalization and survival. Further data need to evaluate if remote control can improve prognosis of pts with CRT–D and CRT–P.
P197 EFFECTS OF PCSK–9 INHBITORS ON ARTERIAL STRUCTURE AND FUNCTION: PRELIMINARY RESULTS
Authors: Maloberti A , Vatta A , Grasso A , Garofani I , Morelli M , Giani V , Fortuna M , Gualini E , Giannattasio C Prof
Published: May 2023

Background

One of the latest chapters in the research for new and stronger lipid lowering therapies has led to the development of PCSK9 inhibitors. In addition to the benefit on lipid profile, a limited number of studies have been published showing a possible improvement in vascular function and structure following their administration. Purpose: To evaluate the effects of PCSK9 inhibitors on structural (via carotid Intima Media Thickness – IMT) and functional (carotid–femoral Pulse Wave Velocity – cf–PWV – and brachial artery Flow Mediated Dilatation – FMD) arterial properties.

Methods

Twenty–two dyslipidemic patients with a clinical indication to PSCK9 inhibitors were prospectively recruited at the Cardiology Rehabilitation of ASST Grande Ospedale Metropolitano Niguarda Hospital (Milan, Italy). Anthropometric, clinical and therapeutic data were recorded. Each patient underwent instrumental examinations to assess cf–PWV, IMT and FMD at T0 (before the start of therapy), T1 (after 6 months) and T2 (after 12 months).

Results

In the 22 patients who reached 6 months of follow up there was a significant reduction in LDL cholesterol (from 127.8±31.7 to 47.4±29.1 mg/dl, p<0. 0001) while there was no significant difference in arterial parameters (cf–PWV: from 10.5±3.5 to 9.4±2.3 m/s, p=0.092; FMD: from 11.4±8.1 to 9.8±8.3%, p=0.407; IMT: from 775.6±192.8 to 768.7±144.7, microm, p=0.854). Similar results were also obtained in the 12 patients who reached one year of follow–up: LDL from 129.4±29.1 to 48.8±21.9 mg/dl, p<0.0001; cf–PWV from 10.4±3.3 to 10.5±2.9, p=0.874; FMD from 12.0±9.1 to 11.0±5.6%, p=0.930; IMT from 745.1±203.9 to 770.0±127.3 microm, p=0.710.

Conclusion

Our study confirm the strong LDL reduction with PCSK9 inhibitors that are needed in order to reach the targets set by the ESC 2019 guidelines. In contrast, they do not show a significant effect on arterial function and structure in terms of cf–PWV, FMD and carotid IMT.
P198 PRELIMINARY 30–60 DAY EVALUATION OF INCLISIRAN EFFICACY
Authors: Caporale R , Battista F , Chiappetta D , Alberti S , Leone A , Greco F
Published: May 2023

Background

Inclisiran is a small–interfering RNA that selectively silences the hepatic synthesis of PCSK–9 protein with a two doses per year administration, increasing the availability of LDL receptors. Consequent reduction in circulating LDL levels observed in clinical trials, when associated with statin and ezetimibe therapy, is about 50%, with effect onset 14 days after the first administration.

Methods

This initial experience refers to three male patients with post–infarction ischemic heart disease who underwent revascularization (two with PCI, one with BPAC) one to three years previously, treated with ezetimibe 10 mg OD and high–dose atorvastatin (two with 80 mg OD, one with 40 mg OD). LDL levels were higher than recommended in patients at very high cardiovascular risk by European Society of Cardiology guidelines (mean 90 mg/dL, range 87–95). Patients were informed of the available data on Inclisiran and consented to the terms of use. Subcutaneous administration was performed by a physician in a hospital outpatient setting. Lipid values were checked on the 30th day.

Results

Two patients continued oral therapy and got a 58% reduction in values (mean 39 mg/dL, range 22–55). One patient, despite informed of the need to continue oral treatment, spontaneously stopped statin and ezetimibe treatment, obtaining a 30–day increase in LDL of 50% (131 vs 87 mg/dL). At the next control, 30 days after the resumption of oral therapy, the value was 44 mg/dL, with a reduction of 49% compared to baseline. No adverse events were recorded.

Conclusions

Data at 30–60 days on three patients treated with Inclisiran show that its addition to statin and ezetimibe treatment resulted in an average reduction in LDL cholesterol of 56% allowing the achievement of the target in 100% of cases. The favorable interaction between Inclisiran, statin and ezetimibe represents an effective strategy in patients at very high cardiovascular risk. The case of suspension of oral treatment seems to suggest a marked interaction of Inclisiran effect with statin therapy. Administration by a healthcare professional represents an opportunity for better follow–up management, allowing monitoring of therapeutic adherence and re–evaluation of concomitant therapies.
P204 CARDIAC INVOLVEMENT IN NEUTRAL LIPID STORAGE DISEASE (NLSD): A CASE REPORT
Authors: Marino G , Di Fusco S , Colivicchi F
Published: May 2023

Introduction

Neutral Lipid Storage Diseases (NLSDs) are rare diseases with autosomal recessive transmission characterized by a defect in the metabolism of triglycerides that accumulate in many tissues. Vacuoles containing lipids in white blood cells (Jordans anomaly) are considered a diagnostic marker. In particular, NLSD–M (NLSD–myopathy) is caused by mutations in the PNPLA2 gene (Patatin Like Phospholipase Domain Containing 2, chromosome 11p15.5) that codes for an enzyme involved in the first phase of triglyceride hydrolysis in adipose tissue. In this patient the mutation of the PNPLA2 gene is c.542delCA, truncating the protein with loss of the hydrophobic domain. This mutation is associated with more severe infiltrative and arrhythmic cardiac involvement than those known in the literature.

Case Report

52–year–old man with NLSD–M. The first symptoms of the disease appeared when he turned 35: weakness and atrophy of axial and proximal muscles, increased CK, scoliosis, fatty liver, electromyographic changes, arterial hypertension, dyslipidemia, renal failure and hypertransaminasemia. At 49, ECG revealed sinus rhythm, absence of ventricular repolarization abnormalities and echocardiogram revealed wall hypertrophy with a trabecular appearance of the left ventricle, sigmoid interventricular septum, preserved EF (58%), moderate diastolic dysfunction, left atrial enlargement, absence of significant valvulopathies. Cardiac MRI revealed lipid infiltration. An ICD was implanted for sustained ventricular tachycardia. At 50, atrial fibrillation was detected. EF was 53% and there was a small partially organized circumferential pericardial effusion. The last medical check, performed at 52 during hospitalization for atrial fibrillation with high ventricular response associated with hypokalemia and hypomagnesaemia, revealed ST–T alterations on ECG and a further reduction of EF to 46% on echocardiogram.

Conclusions

There is currently no medical treatment. A dietary supplement with medium–chain fatty acids (CNT–02) can be used to slow down the accumulation of lipids. The search for specific mutation is important to stratify cardiac risk.
P206 DO WE NEED LOWER CUT–OFFS OF LEFT VENTRICULAR WALL THICKNESS TO SUSPECT CARDIAC TRANSTHYRETIN AMYLOIDOSIS IN WOMEN?
Authors: Aimo A , Tomasoni D , Porcari A , Adamo M , Bonfioli G , Lombardi C , Nardi M , Varrà G , Saro R , Rossi M , Merlo M , Castiglione V , Vergaro G , Passino C , Metra M , Sinagra G , Emdin M
Published: May 2023

Background

Echocardiographic reference values for interventricular septal (IVS) thickness (upper reference limit [URL] 11.2 mm in women vs. 12.4 mm in men), and posterior wall (PW) thickness (URL 11.5 mm vs. 12.3 mm, respectively) exist. According to a European Society of Cardiology position statement, cardiac amyloidosis (CA) should be suspected when left ventricular (LV) wall thickness is ≥12 mm and at least one red flag is present. Given the normal difference between men and women, a same cut–off might cause a diagnostic delay in women.

Methods

Consecutive patients diagnosed with amyloid transthyretin (ATTR)–CA at 3 centers were evaluated.

Results

The cohort included 302 patients (Pisa, n=215; Brescia, n=58; Trieste, n=29). Women (n=49, 16%) were older than men (median age 83 years [interquartile range 80–85] vs. 80 years [76–84], p=0.009), but their survival free from all–cause death (p=0.380) or heart failure (HF) hospitalization (p=0.381) did not differ significantly. N–terminal pro–B–type natriuretic peptide values (p=0.897), the proportion of patients with variant ATTR (p=0.369), the prevalence of hypertension (p=0.659), diabetes (p=0.629), or New York Heart Association class III–IV (p=0.613) were not different. LV ejection fraction was 53% (43–60%) in women vs. 50% (43–65%) in men (p=0.066), and tricuspid annular plane systolic excursion was 16 mm (13–20) in women vs. 16 mm (14–19) in men (p=0.674). Even relative wall thickness (RWT) did not differ significantly (0.61 [0.49–0.98] in women vs. 0.69 [0.57–0.87] in men; p=0.448). Conversely, women had lower IVS (15 mm [14–18] vs. 17 mm [15–20]) and PW thickness (13 mm [12–16] vs. 15 mm [13–17]). These differences disappeared when IVS and PW thicknesses were indexed for height (as m), height2,7, or body surface area: IVS, p=0.150, 0.212, 0.325, respectively; PW, p=0.309, 0.107, 0.743, respectively.

Conclusions

At the time of diagnosis, women with ATTR–CA are older, but their biventricular function, the pattern of LV remodeling, and final outcome did not differ significantly from men, suggesting a similar disease stage. Even indexed IVS or PW thicknesses are similar, while non–indexed measures may point to a less advanced disease and then be misleading. Indexed measures or sex–specific cut–offs (e.g., 11 mm in women vs. 12 mm in men) to suspect CA might be considered.
P211 BLEEDING AND THROMBOSIS: A MULTIDISCIPLINARY SLALOM
Authors: Vecchio C , Nassiacos D
Published: May 2023

GG is a 75 kg and 75 years old smoker man with metabolic syndrome, potus, OSAS and LBBB. In 1/2022 the echo imaging showed EF 35%, high dissincrony and PVCs so a myocardial SPECT had been recommended but not carried out by the patient. In 6/2022 new exertional dyspnea, orthopnea and peripheral oedema lead the patient to the Emergency Department: the ECG indicated new onset AF 75 bpm, at laboratory tests creatinine 1.8 mg/dL and NTproBNP 6200 pg/ml and echocardiography confirmed hypokinetic cardiopathy with EF 35%, mild–moderate mitral and tricuspidal regurgitation with pulmonary hypertension and vascular congestion. Admitted for heart failure and new onset AF, diuretic and levosimendan ev, MRA, BB and LMWH started with benefit. At the end of inotropic therapy, ARNI, SGLT2 and inhaled cortisone began. Myocardial SPECT proved moderate fixed inferior wall hypoperfusion. Hospitalization was complicated by ecchymoses and hematomas of abdomen superficial soft tissues during LMWH and proximal saphenous vein and III middle left thigh thrombophlebitis, so apixaban 5mg BID and elastic stockings started with resolution. The onset of paresthesias, pain and left leg progressive hyposthenia led to diagnosis of a partial hematoma of the ilio–psoas muscle resulting in a complete left femoral nerve lesion and severe obturator nerve and left lumbosacral trunk suffering plus further right iliac and rectus abdominis muscles hematomas. Discontinued apixaban, after 72 hours the hematoma was surgically removed without complications and fast recovery thanks to FKT. 9 days later left leg DVT recurrence was observed: in absence of absolute contraindications to anticoagulant therapy and blood count stability, without evident new bleedings, heparin infusion was set with maintenance of the aPTT values at the lower therapeutic range limits. One week later radiological imaging demonstrated reduction of left retroperitoneal hematoma so dabigatran 150 mg BID was initiated. Control echo showed EF 42%, mild MR and TR. Regular the subsequent rehabilitation course: the patient was discharged with dabigatran 110 mg twice daily to limit long–term bleeding risk. The thrombotic/bleeding risks require a complex therapeutic modulation in a multidisciplinary teamwork.