bluuebunny/crossref_metadata_2025 huggingface dataset:
P1594 Relationship between left ventricular morphology and systolic performance and coronary microcirculatory dysfunction in hypertrophic cardiomyopathy
Authors: Aguiar Rosa S , Branco L , Galrinho A , Fiarresga A , Lopes L , Celas M , Silva F , Carvalho A F , Mota Carmo M , Cruz Ferreira R
Published: January 2020

Background

Myocardial ischemia constitutes one of the most important pathophysiological features in hypertrophic cardiomyopathy (HCM). Chronic and recurrent myocardial ischemia leads to fibrosis, which may culminate in myocardial dysfunction.

Objective

To analyse the relationship between left ventricular (LV) morphology and systolic performance and coronary microcirculatory dysfunction in HCM.

Methods

The present study prospectively included HCM patients (P) who underwent transthoracic echocardiography. Left ventricular (LV) function was evaluated by ejection fraction (LVEF), global longitudinal strain (GLS) and tissue Doppler septal and lateral s’. The evaluation of coronary flow velocity reserve (CFVR) was performed in apical three chambers view for the left anterior descending (LAD) artery and in an apical three chambers view for the posterior descending (PD) artery. Diastolic coronary flow velocity was measured in basal conditions and in hyperemia, induced by adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). Absolute CFVR was calculated as the ratio of hyperemic to basal peak diastolic flow velocities; relative CFVR was calculated as the ratio between CFVR LAD and CFVR PD.

Results

23 P were enrolled (57% male, mean age 57.9 ± 13.7 years). Asymmetric septal hypertrophy was verified in 70% of P, with maximal wall thickness of 21.6 ± 4.3mm. Obstructive HCM was documented in 35% of patients.

CFV was successfully measured in the LAD in all patients, but only in 70% of patients in the PD due to technical issues related to poor acoustic window and anatomical constraints. 78% of P (n = 18) presented CFVR <2, denoting microcirculatory dysfunction. Relative CFVR (LAD CFVR/ PD CFVR) was ≥1 in 43% of P.

P with maximal wall thickness (MWT)>20mm presented higher CFV PD at baseline (46.5 ± 17.4 vs 32.5 ± 12.6 cm/s; p = 0.072), lower CFVR PD (1.3 ± 0.3 vs 2.5 ± 0.8; p = 0.003) and greater regional difference of microcirculation (relative CFVR 1.4 ± 0.6 vs 0.8 ± 0.3; p = 0.048).

At baseline conditions, CFV LAD was higher in obstructive HCM (44.0 ± 4.8 vs 35.3 ± 10.6 cm/s; p = 0.040).

P with impairment in global longitudinal strain (GLS>-18%) had higher basal CFV LAD (40.1 ± 8.6 vs 30.0 ± 12.2 cm/s; p = 0.059) and PD (44.5 ± 15.2 vs 20.0 ± 5.0 cm/s; p = 0.015) but lower CFVR PD (1.5 ± 0.5 vs 2.8 ± 1.1; p = 0.039). The reduction in CFVR PD was also noted in P with time to peak longitudinal strain dispersion >90mseg (CFVR PD 1.2 ± 0.2vs1.9 ± 0.9;p = 0.012).

Conclusion

Higher CFV at baseline was noted in P with greater MWT, obstructive HCM and worse GLS. Coronary microcirculatory dysfunction was associated with the degree of LV hypertrophy and impairment in LV systolic performance.
P1595 Prognostic role of late gadolinium enhancement for sudden cardiac death risk in non-ischemic dilated cardiomyopathy
Authors: Rodriguez Sanchez I , Onaindia J J , Gomez V , Aguirre Larrakoetxea U , Velasco S , Urkullu A , Ullate A , Capelastegui A , Astigarraga E , Florido J , Natividad R , Garcia Ibarrondo N , Goena C , Rilo I
Published: January 2020

OBJECTIVES

to evaluate the prognosis role of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (cMRI) in patients with non-ischemic dilated cardiomyopathy (NIDM).

BACKGROUND

Risk stratification in NIDM needs to be improved.

METHODS

We included 210 patients with NIDM and cMRI from 2005 to 2018 in our study population. Outcomes were retrospectively assessed by medical records. The pattern of LGE was classified as mid-wall, sub-epicardial, or both patterns. Primary endpoint was sudden cardiac death (SCD) or aborted SCD. Secondary endpoints were global mortality and a composite endpoint of cardiovascular mortality and heart failure hospitalization.

Demographic and clinical parameters were also evaluated. Patients with LGE (LGE+) were more likely to be male (80,6% vs 66,7%, p= 0,03). No significant differences were observed between LGE+ and LGE- patients in comorbidities, NYHA class, left ventricular ejection fraction (LVEF), or neurohormonal treatment.

RESULTS

Of 210 patients (71,4% men, median age 59,8 years) with a median follow up of 5,6 years (3,24-8,15), 72 patients (34,3%) had non ischemic LGE (LGE+) on cMRI. Mean left ventricular ejection fraction (LVEF) was 34%.

SCD or aborted SCD occurred in 11 patients (5,2%): 6 patients (9,5%) with LGE+ vs 5 patients (4,07 %) of LGE- (p = 0,19).

Patients with LGE+ had a higher risk for the composite endpoint (cardiovascular mortality and heart failure hospitalization): OR 2,45, confidence interval (CI): 1,16-5,17, (p = 0,02).

LGE presence was not associated with global mortality.

The subepicardial pattern of LGE was associated with SCD or aborted SCD. 3 out of 11 patients (27%), with subepicardial pattern of LGE suffered from SCD or aborted SCD (p= 0,01).

CONCLUSIONS

In our cohort of 210 patients with NIDM, LGE was not significatively associated with SCD or aborted SCD, probably because of a low event rate (5,2%) in a relatively small and well treated population, despite a long follow-up (5,6 years). On the other hand, LGE presence was associated with a higher risk for the composite endpoint of cardiovascular mortality and heart failure hospitalization. Finally, the subepicardial pattern of LGE identified a group of patients at high risk of SCD and aborted SCD.
P1601 Relationship between aortic distensibility and aortic regurgitation assessed by CMR in bicuspid valve patients
Authors: La Mura L , Teixido-Tura G , Guala A , Ruiz-Munoz A , Lopez Sainz A , Valente F , Pisaniello M , Strada S , Granato C , Galian Gay L , Gonzalez-Alujas T , Servato M L , Ferreira I , Rodriguez-Palomares J F , Evangelista A
Published: January 2020

Funding Acknowledgements

Spanish Ministry of Economy and Competitiveness RTC-2016-5152-1, ISCIII PI17/00381, La Marató de TV3 (20151330), Eur FP7/People 267128 and CIBERCV

BACKGROUND

The severity of aortic regurgitation can be evaluated with cardiac magnetic resonance (CMR) through calculation of regurgitant fraction (RF) in phase contrast sequences acquired at the aortic root (as close as possible to the aortic valve). However, the impact of aortic distensibility in this evaluation remains unkown.

PURPOSE

The aim of the study was to evaluate the relation between aortic distensibility and RF valve in bicuspid aortic valve patients.

METHODS

We enrolled bicuspid aortic valve patients without significant aortic stenosis (maximum velocity <2.5 m/s) and connective tissue disease. All patients underwent a CMR study with phase contrast sequences for evaluation of regurgitant fraction at the level of the aortic valve. Aortic regurgitation was considered as mild, moderate or severe depending on RF value (mild <15%; moderate 15-30%; severe >30%). Furthermore we used cine-sequences of aortic root, ascending and proximal descending aorta to estimate aortic diameters and distensibilities, using Art Fun software. Distensibility was calculated as (change in aortic area between systole and diastole/diastolic area)/brachial pulse pressure.

RESULTS

A total of 98 bicuspid aortic valve patients were included (30% female, 49.7 ± 14.5 years). 75 (76,5%) AR was mild, 17 (17,4%) moderate and 6 (6,1%) severe. RF valvewas significantly correlated with aortic root diameter (r= 0.430 y p < 0.001 )and aortic distensibility at the level of the ascending (r = 0.273 p =0.016) and descending aorta (r = 0.502 and p< 0.001). Aortic distensibility was positively correlated with RFvalve even after adjustment for aortic diameter ( p = 0.002 and p <0.001 respectively) . (Table) (IMG)

CONCLUSIONS

In our study, aortic regurgitation in bicuspid valve patients, evaluated by CMR using RF valve, is related to aortic distensibility. Thus, aortic distensibility should be included in the evaluation of aortic regurgitation by CMR as additional parameter. However, longitudinal studies are needed to evaluate the impact of including aortic distensibility in the evaluation of AR severity by CMR.

AR SEVERITY MILD MODERATE SEVERE Descending aorta distensibility(mean ± std. deviation) 2693,68 ± 997,5 3285,8 ±1952,7 5042,99 ±2873,44 Correlation between AR severity (by RFvalve) and descending aorta distensibility

Abstract P1601 Figure.
P1602 An adult with mitochondrial cardiomyopathy
Authors: Kandil A , Daniel J , Nata R , Felix P
Published: January 2020

Introduction

Mitochondrial diseases are a group of rare inherited disorders with diverse phenotypes that are caused by mutation in nuclear or mitochondrial DNA. The prevalence of mitochondrial disease is estimated to be one in 5000 livebirths. The heart depends mainly on the energy produced through aerobic respiration and hence cardiac involvement is common, progressive and its presence is an independent predictor of mortality in patients with mitochondrial disease and may occur as the principal clinical manifestation or part of a multisystem disease.

Case report

We present a 31 years old lady who was referred to our hospital with a newly diagnosed hypertension and non-specific ECG changes. The patient had no shortness of breath, no palpitation and no chest pain. She was overweight and had short stature. Her blood pressure was elevated 155/90. There was no signs of heart failure and no murmurs on auscultation of the heart and lung. Her ECG showed sinus bradycardia 55-60 b/min, ST segment elevation in the anterior chest leads with non-specific widespread t wave inversion.

An Echocardiogram was done and showed concentric left ventricular hypertrophy (LVH) at 1.5 cm with speckling and granite-like appearance of the myocardium with no LV out flow tract (LVOT) obstruction and with normal systolic function and no significant valvular disease. A cardiac MRI was done and showed mildly dilated LV with normal geometry, normal systolic function, concentric LV hypertrophy with papillary muscles hypertrophy, relative sparing of the apical segments and with no LVOT flow acceleration and no late gadolinium enhancement.

Our patient had mild hearing loss which is maternally inherited with her mother and her maternal uncle had cochlear implants. She also had borderline diabetes mellitus and she was also found to have the m.3243 > G mutation suggesting a mitochondrial disorder . A diagnosis of mitochondrial cardiomyopathy was made and the patient was started on an antihypertensive and planned to have regular cardiology clinic follow up.

Conclusion

Hypertrophic remodelling is the dominant pattern of cardiomyopathy in all forms of mitochondrial disease; occurring in up to 40% of patients and its presence is associated with higher mortality. The severity can vary from asymptomatic as in our patient to severe heart failure with acute decompensation that can occur with metabolic disorders or general illnesses. Treatment of mitochondrial disorders is mainly symptomatic with no curative therapy available. We aimed at increasing awareness of this rare disease.

Abstract P1602 Figure.
1674 Is Arterial hypertension an intermediate step to heart failure with preserved ejection fraction?
Authors: Pugliese N R , Mazzola M , Fabiani I , De Biase N , Natali A , Gargani L , Pedrinelli R , Dini F L
Published: January 2020

Background

Arterial hypertension (HT) is one of the main risk factors for the development of heart failure with preserved ejection fraction (HFpEF). The evaluation of cardiorespiratory fitness during the exercise may provide a clearer insight into this association.

Purpose

We assessed the hemodynamic, respiratory and metabolic characteristics of HT subjects and patients with HFpEF and HT (HFpEF-HT), combining cardiopulmonary exercise test (CPET) and exercise stress echocardiography (ESE).

Methods

We studied 170 consecutive subjects, undergoing a symptom-limited graded ramp bicycle CPET-ESE: 52 stable (NYHA I-III) outpatients with HFpEF-HT (69 ± 13 years; 44 males, 85%) on optimal medical therapy, 86 well-controlled HT subjects (66 ± 10 years; 72 males, 84%) and 32 age and sex-matched healthy controls (59 ± 15 years; 24 males, 75%). Oxygen consumption (VO2), left ventricular (LV) ejection fraction (EF), global longitudinal strain (GLS), E/e’ and LV compliance (expressed as end-diastolic volume [EDV] / E/e’ ratio) were measured during exercise, including rest and peak lung ultrasound for B-lines evaluation.

Results

HT patients showed peak VO2 values (18.7 ± 2 ml/min/kg) higher than HFpEF-HT (15.2 ± 2 ml/min/kg, p < 0.0001) but lower than controls (24.4 ± 7.3 ml/min/kg, p < 0.0001). Regardless of a similar EF, HT subjects had lower low-load (at 4 min of effort) GLS (18.2 ± 3%) than controls (20.9 ± 3%, p < 0.0001), but higher than HFpEF-HT (16.8 ± 5%, p = 0.04). Likewise, peak diastolic function (E/e’ and LV compliance) was altered in HT patients (9.1 ± 2 and 13.4 ± 2) when compared to controls (6.2 ± 1 and 17.8 ± 2, all p < 0.0001), but less than in HFpEF (12.7 ± 3, p < 0.0001 and 12.1 ± 3, p = 0.003), as confirmed by peak B-lines (HFpEF-HT: 16 [interquartile range (IQR): 10 – 22], HT: 8 [IQR: 4 – 10] and controls: 0 [IQR: 0 – 2]; p < 0.0001). LV hypertrophy was reported in 37 patients (27%); it was more common in HFpEF (24/37, 65%) and associated with a significantly worse peak VO2 and systo-diastolic profile (all p < 0.05).

Conclusions

HT subjects represent an intermediate step from healthy subjects to HFpEF, showing altered functional capacity and systo-diastolic profile (Figure). LV hypertrophy characterises the clinical stage and portends a more severe cardiorespiratory fitness impairment.

Abstract 1674 Figure
P1684 Cardiac amyloidosis hits the valve first
Authors: Iakovlev S , Kalinskaya A I
Published: January 2020

Case report.

60-year-old man without previous history of coronary artery disease was admitted to our hospital. He complained of weakness, low extremities edema. Physical examination revealed also enlargement of the liver, positive hepatojugular reflux, multiple ecchymoses on patient’s face, especially in periorbital area. The arterial blood pressure was 100/60 mm Hg. ECG showed sinus rhythm 83/min, low R waves in V2, V3 with biphasic T waves in V4-V6. The last coronary angiography revealed normal coronary arteries, it was performed 6 months ago because of atypical chest pain and inconclusive stress test.

Echocardiography revealed severe tricuspid regurgitation (TR) due to leaflets restriction and malcoaptation. TR gradient was about 10 mm Hg. Interventricular septum 12 mm, left ventricle posterior wall 9 mm, mass index 87 g/m2, relative wall thickness 0.38; no LV regional wall motion abnormalities was noted, left ventricular ejection fraction (LV EF) was about 50%, mitral valve E/A ratio was 1,4, but average E/E" = 17. Left atrium volume 33 ml/m2. Insignificant amount of pericardial effusion also was found.

3D evaluation of tricuspid valve (TV) showed no leaflets defects and chordal ruptures. LV global longitudinal strain (LV GLS) was – 11,1 % with the apex/(mid + base) ratio 1,3 - apical sparing pattern. Cardiac MRI with gadolinium also showed severe TR and diffuse late subendocardial gadolinium enhancement in both ventricles. We suspected cardiac amyloidosis with significant tricuspid valve involvement, torrential TR, and right ventricle volume overload. The rectum biopsy was negative. The cardiac muscle biopsy with congo red straining was positive for amyloidosis. The patient was transferred to hematology clinic where the diagnosis of AL-amyloidosis was confirmed. The treatment with lenalidomide and prednisone was started. Unfortunately, one month later the patient died. The autopsy was not performed due to religious reasons.

Discussion

AL-amyloidosis is a systemic disease characterized by multiple organ and tissue changes and associated with poor prognosis. Cardiac involvement is a major prognostic factor as it accounts for approximately 75% of death due to heart failure or arrhythmias. Infiltration of myocardium with amyloid leads to diastolic than systolic dysfunction of the heart and to developing of the heart failure. The most common presentation of heart involvement in AL-amyloidosis is fatigue and dyspnea. In this case the main complaint of the patient was peripheral edema, echocardiography showed damaged TV and preserved LV systolic function. In literature, we found only one case report describing cardiac amyloidosis presented as severe TR.

Conclusion

In patients presenting with significant isolated valvular dysfunction and heart failure the cardiac amyloidosis can be suspected. The comprehensive echocardiography is the most useful tool to detect this problem.

Abstract P1684 Figure. 3D picture of tricuspid valve
P1686 Inverted biventricular takotsubo syndrome: early onset in heart transplanted patient
Authors: Vriz O , Al Humeid M , Adham M , Al Amro B , Galzerano D , Al Admawi M , Al Sergiani H , Al Hussein M , Al Buraiki J
Published: January 2020

Introduction

Takostubo syndrome (TTS) is supposed to be a disturbances of myocardial microcirculation and increased catecholamine concentration (ie, epinephrine, norepinephrine, and dopamine), could be responsible of microvascular spasms or myocyte involvement. Catecholamine increased is related to sympathetic overactivity caused by stress but also as inotropic drugs.

A 39-year-old women underwent heart transplant due to rheumatic heart disease, status post mitral valve repair, in New York Heart Association Class IV heart failure despite optimal therapy. The donor was a 36-year-old young women without significant past medical history. The echocardiogram before explantation was normal and palpation of the epicardial coronary arteries did not reveal any gross pathology, areas of atheromatous disease, or calcium.

An orthotopic heart transplantation was carried out using the bicaval technique without any complication. The postoperative course was in post-surgery intensive care unite with the patient on mechanical ventilation and inotropic support. Within the first 24-hours, changes in T wave were observed and the echocardiography revealed normal left ventricle (LV) size, LV systolic function was mildly reduced (Ejection Fraction 45- 50%), presence of wall motion abnormalities characterized by akinesia of the basal septum, dyskinesia of the basal segment of the lateral wall and hypokinesia of the basal segments of the other walls and akinesia of the basal segments of the right ventricle (RV) suggesting TTS. Because of the donor’s age and risk profile, epicardial coronary artery disease was not considered to be the causing factor of the wall motion abnormality, coronary catheterization plus biopsy was done 7 days later with no evidence of coronary obstruction and biopsy result showed 1R rejection. The echocardiogram performed in the same day showed complete recovery of the wall motion abnormalities while the global strain was still low for the basal segments either for LV or RV.

The rest of the hospitalization was uneventful and she was discharged after 10 days from heart transplant and the echocardiographyic study showed an additional improvement of the global strain for both ventricle but not complete recovery.

Conclusion

This is a rare case of TC that happened the first day after heart transplant, when the heart is denervated. We hypothesized that the present case of TTS was more related to the drug inotropic support and by epinephrine released by suprarenal medulla rather than endogenous catecholamines released locally by the systemic nervous.

Figure 1.

First echocardiographic exam during the acute phase of TTS, LV GLS was – 6.5% and RV free wall GLS -4%. After 7 days the LV GLS was -9.1% and RV free wall was -7.6%. After 3 weeks the LV GLS was – 10.5% and the RV free wall was – 11%.

Abstract P1686 Figure.
P1689 Mitral valve prolapse secondary to ischemic cardiomyopathy
Authors: Babur Guler G , Kilicgedik A , Zencirkiran Agus H , Kahveci G
Published: January 2020

Introduction

Mitral valve prolapse is the most common form of degenerative mitral valve disease. However, ischemic mitral valve prolapse is a rare cause of mitral regurgitation. The mechanism was initially thought to be papillary muscle dysfunction, but more complex mechanisms were suggested recently.

Purpose

Try to understand the pathophysiology of ischemic mitral valve prolapse on a case example.

Case Report

A 42-year-old male with a history of inferoposterior myocardial infarction was admitted from outpatient clinic due to NYHA class 3 heart failure symptoms. On physical examination, a 4/6 holosystolic murmur was heard in the apex.

He had a permanent pacemaker implanted for sick sinus syndrome. Transthoracic echocardiography showed 1-global dysfunction of the left ventricle (posterior segment akinetic and thinned), 2- prolapse of the posterior mitral leaflet (suspicion of ruptured chordae) 3-severe mitral regurgitation (with anterior eccentric jet), 4- moderate tricuspid regurgitation and high systolic pulmonary artery pressure (65 mmHg), 5- pacemaker lead in the right heart chambers. 6- normal right ventricular systolic function. Transesophageal echocardiography showed P2 scallop prolapse and chordae were intact, there were no redundant or myxamous components of the leaflets. It was observed that the posteromedial papillary muscle was elongated and did not contract. We commented that these echocardiographic findings represented ischemic mitral valve prolapse. Other echo findings in favour of this hypothesis were the posteromedial papillary muscle prolongation in systole and reduced the free strain of papillary muscle in the the apical long axis view. The patient underwent mitral ring anuloplasty and surgical neocord implantation. Surgery also reported the aetiology as ischemic mitral prolapse secondary to chordal extension in accordance with echocardiography.

Conclusion(s): Ischemic mitral prolapse is a complex pathology involving multiple components of the mitral valve apparatus as left ventricle, papillary muscle, chordae, annulus, leaflets. The diagnostic criteria for ischemic mitral valve prolapse and its management are not defined. The presence of myocardial infarction and the exclusion of other possible valve pathologies with transesophageal echocardiography are important steps in the diagnosis.

Abstract P1689 Figure.
P1694 Prosthetic mitral valve infective endocarditis complicated by left ventricle to right atrial fistula
Authors: Abayazeed R M , Shehata H , Elgebaly O , Abdel-Aziz M A , Abdel-Hay M A
Published: January 2020

Left ventricle (LV) to right atrial (RA) shunt is a rare type of ventricular septal defect. Acquired LV-RA shunt is rare and may occur as complication of cardiac surgery, endocarditis, thoracic trauma or myocardial infarction. Infective endocarditis is the second most important cause of this type of shunt.

Case presentation

A 44 year old female patient presented to our hospital complaining of progressive exertional dyspnea and palpitations for 6 months, and high grade fever for 2 weeks. The patient had history of mitral valve replacement with mechanical prosthesis 16 years ago. The patient had no history of recent invasive procedures or dental interventions. General examination revealed an irregular pulse at rate of 100 beats per minute (bpm), blood pressure of 100/60 mmHg, temperature of 38.5 ͦ C and congested neck veins. Cardiac examination revealed an audible prosthetic mitral click with a harsh pansystolic murmur heard on the apex and left sternal border, and an accentuated P2 over the pulmonary area. Her resting electrocardiogram (ECG) showed atrial fibrillation with ventricular response of 110 bpm. Her laboratory investigations revealed normochromic normocytic anemia with Hemoglobin level of 8 g/dl (13-16), and leucocytosis with white blood cell count of 16.24 103 cell/ ul (4.00-11.00); as well as elevated C-reactive protein (CRP) level of 73 (0-3). Her international normalized ratio (INR) was 3 (1-1.3) on warfarin 5 mg.

Transthoracic echocardiography (TTE) revealed a dehiscent prosthetic mitral valve with severe paravalvular regurgitation, severe tricuspid valve regurgitation and pulmonary hypertension with predicted resting pulmonary artery systolic pressure of 60 mmHg. It also showed an abnormal jet passing from the LV into the RA above the tricuspid valve during systole, both right and left ventricular systolic functions were preserved. Subsequent 2D/3D transoesophageal echocardiography (TEE) confirmed the TTE findings with detection of LV-RA fistula with significant left to right shunt; it also visualized multiple vegetations attached to the mitral annulus at the site of the valve dehiscence.

The patient was diagnosed with prosthetic mitral valve infective endocarditis, empirical antibiotics were started and the patient was referred for another center for urgent surgery. Redo mitral valve replacement, tricuspid valve repair and closure of the defect were done; the patient developed complete heart block postoperatively and permanent pacemaker was inserted.

Conclusion

Infective endocarditis remains a major health problem with high mortality and severe complications. It is important to keep high index of suspicion in high risk patients for infective endocarditis as delayed diagnosis increases the risk of serious complications and mortality, and makes surgical intervention, if indicated, more demanding with increased incidence of perioperative complications.

Abstract P1694 Figure. TTE&TEE of prosthetic mitral IE
P1695 Late mycobacterium abscessus endocarditis, a case report
Authors: Aguilar-Aguilar L F , Guzman-Ramirez D , Gaxiola-Cadena B A , Farias-Vergara S K
Published: January 2020

Endocarditis due to mycobacterial pathogens is a very rare entity, linked with hospital environment and early after valve replacement, with only a few cases reported of Mycobacterium abscessus.

To our knowledge, there are 13 case reports in the literature, with only one case on native valve.

A 66-year old male patient, with no previous intravenous drug use, and mechanical aortic valve replacement with myocardial revascularization (posterior descendent artery) eleven years ago, presented with fever and dyspnea, transthoracic echocardiography showed a 7x5 mm-sized vegetation in the aortic prosthetic valve, and thickness in mitral-aortic fibrosa extended to mitral anterior leaflet (Panel A). Blood cultures reported fast growing mycobacteria, and microarray genetic testing revealed Mycobacterium abscessus. HIV, B and C hepatitis testing results were negative. Antibiotic therapy started with imipenem, cotrimoxazole and amikacin, and after culture guided adjustment, continued with amikacin and tygecicline. One month after, patient presented persistence of positive blood cultures and a new transthoracic echocardiography reported abscessus in mitral-aortic fibrosa (Panel B), after that finding, surgery was planned, the aortic valve was replaced by another mechanical prostheses. Patient was discharged after multiple negative blood cultures and clinical stablility. Three months after, patient presented fever, empirical antibiotic treatment was tigecicline and amikacin, blood cultures reported Mycobacterium abscessus, new transthoracic echocardiography revealed 11x8 mm-sized vegetation, and new abscessus on mitral-aortic fibrosa (Panel C). Blood cultures remain positive, and new valve replacement is decided by Heart Team with bad prognosis, after surgery patient died. Pathology department reported valve prosthesis with inflammatory infiltrate, with presence of grampositive bacilli, and positive Ziehl-Neelsen stain (Panel E,D). Non-tuberculous mycobacteria is an emergent pathogen group, with wide spectrum of infections, specially reported in lung, soft tissues and eyes, with few cases reported of cardiac disease. These pathogens showed multidrug resistance, and high mortality. The most large series report 50 patient affected with mycobacterial endocarditis, and seven caused by Mycobacterium absccesus. There are several problems regarding treatment, with a lack of consensus among it; literature suggest early susceptibility test for macrolides (clarythromicin), aminoglucosides, quinolones, cotrimoxaole, tygecicline and carbapenem antibiotic. Treatment usually involves initial combination antimicrobial therapy with macrolide plus intravenous agents for at least 2 weeks to several months followed by oral macrolide-based therapy. In vitro MIC of tygecicline are low, and the drug should also be considered in treatment regimen.

Abstract P1695 Figure. Echocardiography and pathology images
P1705 Is mitral stenosis per se worthy of anticoagulation therapy?
Authors: Suma S , Gaibazzi N
Published: January 2020

We present the case of a 76-year-old man with hypertension and previous mitral valve repair (MVR) due to severe mitral valve regurgitation. He had never experienced atrial fibrillation (AF), and therefore he was not anticoagulated.

He had been asymptomatic for 15 years, however, recently he reported the onset of dyspnoea and a transthoracic echocardiogram showed moderate to severe mitral valve stenosis (MVS) in the context of previous MVR. A transesophageal echocardiogram was then requested and it confirmed the degree of MVS (panel A Color flow on mitral valve, panel B CW Doppler), but, astonishingly, it also showed the presence of a giant thrombus in the roof of the left atrium (Panel C,D,F 2D TOE, Panel E 3D TOE). The maximal dimensions of the mass were 3.3 to 4.5 centimetres and, surprisingly, no thrombus was found in the left appendage, which nevertheless had low-flow.

MVS is very often associated with severe left atrial dilation and with the onset of atrial fibrillation. However, when a patient has at least moderate MVS and he is in sinus rhythm, there is no robust evidence supporting the initiation of anticoagulants. Though, this case underlines the tight correlation between MVS and thrombus formation regardless of the detectable presence of AF. Moreover, in contrast to usual AF patients, in this particular case left appendage was not involved and the huge mass occupied most of the left atrium, showing that MVS provokes significant low-flow in the atrium too.

Abstract P1705 Figure.
P1706 Trilogy of stroke
Authors: Koenig A , Moser M , Dannenberg V , Bergler-Klein J , Binder T , Gabriel H , Schneider M
Published: January 2020

A 53 y/o female patient presented with clinical signs of stroke. Substantial cardiovascular risk factors were present with arterial hypertension, hyperlipidemia, impaired glucose tolerance, and a history of smoking. Transthoracic echocardiography revealed a suspicious structure on the aortic valve. Consequently, transesophageal echocardiography (TEE) was ordered.

In TEE, the structure proved to be highly suspicious for fibroelastoma. In addition, significant plaque of the aortic arch, and a persistent foramen ovale (PFO) were diagnosed in this examination.

The patient was referred to cardiac surgery for excision of the mass on the aortic valve and for PFO closure.

This case stresses the importance of echo in patients presenting with stroke. Apart from left atrial thrombus, several other possible embolic substrates can be diagnosed.

Abstract P1706 figure 1
P246 Exercise E/e refines diagnosis of diastolic impairment in patients with chronic kidney disease
Authors: Gan G , Kadappu K , Bhat A , Fernandez F , Chen H , Eshoo S , Thomas L
Published: January 2020

Background

Diastolic dysfunction is common in chronic kidney disease (CKD) patients and is associated with reduced exercise capacity. The ratio of early diastolic mitral inflow velocity to early diastolic mitral annulus velocity (E/e’) correlates with invasively measured left ventricular pressures, both at rest and during exercise. The aim of our study was to evaluate the relationship of resting and exercise E/e’ to exercise capacity in patients with stage 3 and 4 CKD.

Methods

CKD patients were prospectively recruited. All patients were required to be in sinus rhythm, without previous cardiac disease and with normal LVEF. The E/e’ ratio was assessed at rest and patients were stratified into 3 groups based on conventional clinical classifications (normal: ≤8, indeterminate: 8-14, raised: >14). Patients then underwent a symptom limited exercise stress echocardiogram whereby patients with resting E/e’ <14 additionally had post exercise E/e’ measured. Exercise capacity was assessed as metabolic equivalents (METs). A raised exercise E/e’ was defined as exercise E/e’ of ≥13. Lastly, we grouped patients based on abnormalities of baseline and exercise E/e’ (resting E/e’<14 & exercise E/e’<13, resting E/e’<14 & exercise E/e ≥13, resting E/e’ ≥14) and the relationship to METs achieved was evaluated.

Results

The cohort consisted of 156 CKD patients (62.8 ± 10.6 yrs, male 62%). 85% had hypertension and 39% had diabetes mellitus. 52/156 (34%) CKD patients had resting E/e’ of ≥14. Of the 104/156 (66%) CKD patients with normal/indeterminate resting E/e’, 66/104(63%) had normal exercise E/e’ <13 whilst 38/104(37%) had exercise E/e’ ≥13. Patients with resting E/e" & raised exercise E/e’ ≥13 achieved significantly lower METs compared to CKD patients with resting E/e’ <14 & exercise E/e’ <13 (5.0 ± 2.2 vs 8.8 ± 2.5, p< 0.01). Of note, METs achieved in this group were comparable to that achieved by CKD patients with raised resting E/e’ ≥ 14 (5.0 ± 2.2 METs vs 5.3 ± 2.6 METs, p = 0.55).

Conclusion

In CKD patients with normal/indeterminate resting E/e’, there is utility in performing exercise E/e’, which was increased in 37% of patients. Raised exercise E/e’ is associated with poorer exercise capacity and is a potential tool to refine diastolic abnormalities in patients with CKD.

Group Total (n,%) METs Achieved Exercise Duration (minutes) Resting E/e’ ≤ 14 & Exercise E/e’ ≤ 13 66/156 (42%) 8.8 ± 2.5 8.4 ± 3.1 Resting E/e’ ≤ 14 & Exercise E/e’ ≥ 13 38/156 (24%) 5.0 ± 2.2 6.0 ± 3.1 Resting E/e’ ≥ 14 52/156 (34%) 5.3 ± 2.6 5.6 ± 2.2
P1737 Echocardiographic estimation of pulmonary artery pressure in young non-complicated patients with type 1 diabetes: results from a single-center observational study
Authors: Schiavone A , Bergamini C , Trombetta M , Sabbagh L , Mantovani A , Targher G , Rinaldi E , Bonora E , Zoppini G
Published: January 2020

OBJECTIVE Right ventricle and pulmonary artery pressure have received less attention in type 1 diabetes compared to the left ventricle. The aim of the present study was to compare right heart performance and the estimated peak systolic pulmonary artery pressure in young non complicated patients with type 1 diabetes with healthy controls.

RESEARCH DESIGN AND METHODS Ninety-three patients with type 1 diabetes without cardiovascular and respiratory diseases were recruited and compared to 56 healthy controls. All subjects were evaluated with a comprehensive trans-thoracic echocardiography and pulmonary peak systolic arterial pressure was estimated with an established formula based on pulmonary artery acceleration time.

RESULTS None of the subjects showed alterations of either systolic or diastolic function of the left ventricle. The estimated peak systolic pulmonary artery pressure was significantly higher in patients with type 1 diabetes compared to controls (38.5 ± 8.6 vs 35.4 ± 6.7, p = 0.019). The highest value of EPSPAP was observed in smoker female patients with type 1 diabetes. Basal and mid cavity diameter of the right ventricle were higher in patients with type 1 diabetes. In the multivariate analyses, factors associated with EPSPAP were female sex, body mass index, mid cavity diameter and, with an inverse correlation, HDL cholesterol.

CONCLUSIONS The present study suggests that young, uncomplicated patients with type 1 diabetes have a higher estimated peak systolic pulmonary artery pressure. Future studies are needed to better define the mechanisms underlying this alteration and its clinical consequences.
P1740 Normal values for TAPSE in the HUNT study of subjects without evidence of heart disease
Authors: Stoylen A , Molmen H E , Dalen H
Published: January 2020

Background

TAPSE is a simple and robust measure of RV function, but only in the absence of regional dysfunction and translational effects from the LV. Normal values from large normal studies are scarce, however. The aim of this study was to present normal values from the HUNT 3 study.

Methods

The HUNT study examined 1266 subjects without evidence of heart disease, from a mixed urban / rural population of North Tøndelag county in Norway. TAPSE was measured by reconstructed M-mode through the lateral tricuspid ring of the RV, in apical four-chamber view as shown in figure 1.

Results

Age and gender related values are given in table 1. TAPSE was normally distributes with a skewness of 0.42. Mean TAPSE was 2.8 cm (SD = 0.5), TAPSE declined with increasing age (p < 0.001), but the correlation with age was moderate (R=-0.15, p < 0.001). There was only a small gender difference (p < 0.001), and a moderate correlation with BSA (R = 0.24, p < 0.005). In linear regression with BSA and gender, only BSA was significant.

Conclusions

As all long axis measures, it declines with age, but this is moderate, so the relevance of age-specific measures can be discussed. TAPSE is near gender independent, and gender differences are only due to body size.

Age and gender related values for TAPSE Age (years): <40 40-60 >60 All Women TAPSE(cm) 2.9 (0.5) 2.7 (0.5) 2.5 (0.5) 2.8 (0.5) Men TAPSE(cm) 3.0 (0.6) 2.9 (0.6) 2.8 (0.6) 2.9 (0.6) All TAPSE(cm) 2.9 (0.5) 2.8 (0.5) 2.7 (0.5) 2.8 (0.5)

Abstract P1740 Figure. Fig. 1
P1749 Does treatment with sacubitril/valsartan improve ventricular function?
Authors: Ramis Barcelo M F , Mas Llado C , Valadron Sucasas C I , Pericas Ramis P , Morcuende A , Pasamar L , Noris Mora M , Forteza Alberti J F , Gonzalez Codino R , Rodriguez Fernandez A , Peral Disdier V
Published: January 2020

Introduction

Sacubitril/valsartan (S/V) has shown to reduce the risk of death and hospitalizations for heart failure in patients with reduced ejection fraction (HFrEF). Very few studies have described changes in ventricular function and in reverse remodelling parameters. The aim of this study is to describe the changes in echocardiographic parameters in patients with HFrEF before and after treatment with sacubitril/valsartan

Methods

Our study is a prospective observational study performed with patients with HFrEF who, according to the ESC guidelines, had indication to initiate S/V. An echocardiographic examination previous to start the treatment and 6 month after having been treated with S/V was performed.

Results

A total of 96 patients with HFrEF, in an ambulatory situation and with optimal medical treatment, were included (figure 1). After six months of treatment with S/V it was found an improvement in LVEF, a reduction in end-systolic and end-diastolic diameters and left ventricular end-systolic volume (LVESV) that achieves the statistical significant (Results in table 1). The results also showed a trend in a reduction of left ventricular end-diastolic volume (LVEDV) without achieving the statistical significance. The E/e" relation was also improved after the instauration of treatment. The grade of mitral regurgitation dropped from grade I-II/IV to 0-I/IV. Not significant changes were observed on the right ventricle function and on pulmonary pressure. Finally it was observed an improvement in the value of NT-proBNP that reaches the statistical significance.

Conclusion

Treatment of patients with HFrEF with S/V improves left ventricle function and size, the relation E/e’ and NT-proBNP levels in our population. More follow-up and data is needed to correlate these results with a better prognosis of these patients.

Figure 1: Population characteristics Gender (male, %) 78.6 Dyslipidaemia (%) 58.2 Age (mean) 62.2 Rhythm (%) Cardiomyopathy (ischemic, %) 55.1 Sinus Rhythm 75.5 Functional class (%) Atrial fibrilation 17.3 I 3.2 Pacemaker 5.1 II 66.3 Treatment (%) III 30.6 Beta blockers 95.9 Smokers (%) 16.3 Aldosterone antagonists 90.8 High blood pressure (%) 59.2 Diuretics 74.5 Diabetes Mellitus (%) 42.9 Resynchronization therapy (%) 10.2

Abstract P1749 Table 1
P1750 Association of high-sensitivity troponin elevation and LVEF decline in anthracycline-treated breast cancer patients
Authors: Cardoso Torres S , Sousa C , Maia Araujo P , Simoes J , Nunes A , Tavares Silva M , Pinto R , Paiva M , Macedo F , Maciel M J
Published: January 2020

Introduction

Cancer therapies have been linked to a wide variety of side effects, with cardiotoxicity being the most significant one. Early detection of subclinical cardiac dysfunction in cancer patients (pts) is necessary in order to prevent unfavorable outcomes. High-sensitivity troponin I (hsTI) levels have been proposed as predictors of cancer therapy related cardiotoxicity and may guide cardioprotective therapy initiation.

Purpose

To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer pts under chemotherapy in a single center cardio-oncology unit and to assess its relationship with hsTI levels.

Methods

We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.

CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to a value below 50%. Elevation of hsTI was defined as at least one measurement above the 99th percentile upper reference limit during follow-up (>34 ng/L).

Pts had an organized follow-up in our cardio-oncology unit, consisting of a clinical, laboratorial (with dosing of cardiac biomarkers) and echocardiographic assessment at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases).

Results

A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 17 pts (20.5%) were considered at high risk of cardiac dysfunction due to hsTI elevation.

During follow-up, the percent increase in the hsTI level (from basal level) correlated with CTRCD (p = 0.02). On the other hand, the absolute maximum value of hsTI did not (p = 0.159).

In fact, pts who developed CTRCD had a significantly higher percent increase in the hsTI levels (142.9% +- 57.5%) vs those without CTRCD (14.29% +- 4.6%), p < 0.001. On ROC curve analysis, percent increase in troponin was a good identifier of CTRCD (AUC of 0.986; 95% CI 0.95-1.00; p = 0.022) and the best cut-off value was a 79.8% increase in hsTI (sensitivity: 100%; specificity: 97.2%).

Conclusion

In our population, the percent increase in the hsTI levels correlated with CTRCD. Larger studies are needed to prove this parameter as a predictor of CTRCD.

Abstract P1750 Figure.
P1755 Clinical and echocardiographic outcomes of mitral valve repair surgery
Authors: Garcia Bras P , Moura Branco L , Coelho P , Vaz Ferreira V , Castelo A , Galrinho A , Timoteo A T , Banazol N , Rodrigues R , Fragata J , Ferreira R C
Published: January 2020

Background

Mitral valve regurgitation (MVR) represents the second most frequent valvular heart disease. MV surgical repair is often the preferred treatment when MV anatomy is suitable.

Purpose

To characterize the population who underwent MV repair surgery and evaluate the outcomes of residual MVR, allcause mortality and functional classification.

Methods

Retrospective analysis of 262 patients (P) admitted between 2008 and 2017 for MV repair surgery. P who undergone simultaneous coronary artery bypass graft (CABG) surgery, atrial fibrillation (AF) surgery and tricuspid valve repair were also included. P with endocarditis, P who underwent simultaneous aortic valve replacement and P with rheumatic predominant MV stenosis were excluded, the remaining 204 P were analysed. Clinical and echocardiographic characteristics were evaluated in a mean follow-up of 30 months.

Results

204 P, 67.2% male, mean age 62 + 14 years. The most frequent etiology was organic (80.4%), mostly of degenerative cause. Functional etiology was present in 19.6%, mostly ischemic (72.4%). 16.8% underwent simultaneous CABG, 12.3% tricuspid valve repair and 7.8% AF ablation.

Hypertension was significantly associated with functional etiology (90% vs 72.8%, p = 0.022), as well as hypercholesterolemia (80% vs 48.2%, p < 0.001) and diabetes mellitus (32.5% vs 10.4%, p < 0.001). Baseline left ventricular ejection fraction (LVEF) was >50% in 78.4%, reduced (30-50%) 18.1% and poor (<30%) in 3.4%.

Functional etiology was significantly associated with LVEF <50% (70% vs 9.1%, p < 0.001).

161P (78.9%) had MV prolapse: 120P (74.5%) posterior, 29P (18%) anterior and 7.4% (12P) of both leaflets. P2 was the most frequently involved scallop, in 92P (57.1%), followed by P3, in 41P (25.4%). There was MV chordae rupture in 94P (58.3%).

Post-surgery echocardiography revealed that 93.8% had mild or no residual MVR.

30-day mortality rate was 0%.

There was MVR recurrence with MV replacement surgery in 15P (7.5%), mean time 37.1 months. All-cause mortality was registered in 28P (13.7%), with a mean time of 43.7 months after MV surgery.

Of the P without MVR recurrence or mortality, 111P (70%) were in NYHA class I, 41P (26%) in NYHA class II and 6P (4%) in NYHA class III. 6P were lost to follow-up. Upon echocardiographic revaluation there was no residual MVR in 53P (39%), mild MVR in 67P (49%) and moderate MVR in 16P (11.8%).

Conclusion

In P who underwent MV repair surgery, there was 7.5% recurrence rate with follow-up MV replacement surgery and an all-cause mortality of 13.7%. In a mean follow-up of 30 months, 70% of P were in NYHA I class and there was none or mild residual MVR in 88% of P.
P1760 Cardiac prognosis of patients with subaortic membrane according to their morphology
Authors: Graterol Torres F R E , Moral S , Robles R , Ballesteros E , Morales M , Maria Frigola J , Albert X , Muntaner L , Ramos R , Vilardell P , Brugada R
Published: January 2020

INTRODUCTION

Subaortic membrane is an entity which evolves during adulthood and can associate cardiac complications. Different morphologies have been described, although it is unknown if their prognosis varies according to these patterns. The aim of this study was to evaluate the cardiac prognosis of patients with subaortic membrane according to their morphological characteristics in adulthood.

METHODS

Forty-five patients diagnosed with subaortic membrane by imaging techniques were consecutively included (March 1999-August 2018). Three morphologies were described: fibromuscular ridge (FR), crescent-shaped (CS) and filamentous-shaped (FS). Cardiac complications were defined as mortality due to heart failure and/or necessity of aortic valve surgery and/or membrane resection.

RESULTS

Twenty-six cases (58%) had FR, 16 (35%) had CS and 3 (7%) presented FS (7%) (Fig.1). No differences were found in basal clinical parameters between groups. FR type was associated with the presence of dynamic gradient in baseline study (27% vs 0%, p = 0.014), but there were no differences in left ventricular ejection fraction (68 ± 8% vs 64 ± 8%; p = 0.092), nor in maximum thickness of basal interventricular septum (12.1 ± 3.9mm vs 11.7 ± 4.1mm, p = 0.699), nor in the presence of moderate/severe aortic stenosis (15% vs 11%, p > 0.999) with the other morphologies. During follow-up (mean ± SD= 5.8 ± 4.4years) 15 (33%) patients presented cardiac complications (2 deaths due to heart failure and 12 valvular interventions and/or membrane resection). FR type patients presented a higher cardiac complication rate (50% vs 11%, p = 0.006) and greater necessity of open-heart surgery (46% vs 11%, p = 0.011) than the other groups during follow-up.

CONCLUSIONS

FR type is associated with a higher rate of cardiac complications during follow-up than other subaortic membrane morphologies. Dynamic gradient associated to this pattern could be the basis of a possible pathophysiological mechanism related to the worst prognosis of these patients.

Figure 1. Different morphologies of subaortic membranes. (A) Fibromuscular ridge type; (B) Crescent-shaped type; (C) Filamentous-shaped type. aL: anterior leaflet of mitral valve ; Ao: aorta; LA: left atrium; LV: left ventricle; RV: right ventricle.

Abstract P1760 Figure.