bluuebunny/crossref_metadata_2025 huggingface dataset:
P1394 Left atrial strain as a tool to explore disturbed system biology involving cerebral cognition in diabetes: A sub study of the European multicenter MOPEAD project
Authors: Saha S K , Kiotsekoglou A , Borysenko A , Gopal A , Govind S C
Published: January 2020

Funding Acknowledgements

EU GRANT

OnBehalf

MOPEAD STUDY GROUP

Background

Although the 2D speckle tracking software (2DSTE-SW) has been irrevocably proved to be useful for quantification of left ventricular (LV) function, the same SW has also been used successfully in a plethora of cardiac illnesses using left atrial (LA) strain and strain rate, even in the absence of a dedicated LA SW. LA peak longitudinal strain during ventricular systole (LA-Reservoir strain%; LA-Res S), and strain rate during early (LA-SRE) and late (LA-SRA) phases constitute respectively the reservoir (LA-RS%), conduit, and booster pump functions of this chamber. The role of this dynamic function has not been investigated to assess cerebral cognition in type 2 diabetes (DM).

Methods

We enrolled thirty-nine subjects with DM and mild LV dysfunction (76 ± 5 years, 25 F) in the EU- funded MOPEAD (Models of Patient Engagement for Alzheimer’s Disease) project. Fifteen of them underwent standard echocardiography and 2DSTE. We assessed cerebral cognition using the standard MMSE (Mini-Mental Stage Examination) score: we considered a score of less than 28 as a surrogate of mild cognitive impairment (MCI+). Besides LA-Res strain, LA-SRE, LA-SRA, LV-GLS and right ventricular free wall strain (RV-FWS) were also computed (RV-FWS). Routine biochemistry included, among other, HbA1c and NT-proBNP.

Results

Mean values of the 2D STE measures were LVGLS: 14± 3%, LAVI: 36± 21 ml/m2, LA -RS: 18 ±8 %, LA-SRE: 0.6± 0.3, and LA-SRA: 1.6± 0.4. RV FWS was 20± 5 %. HbA1c was 58 ± 16 mmol/mol. LVEF was 53± 7%. There was no difference in theses variable between MCI+ and those with normal cognition (MCI-). However, in the regression model, LA-Res S had the strongest association with MCI (P < 0.01) (Fig), with excellent strength of association ( R2 = 0.8). LA-SRE, indexed LA volume, and NT-proBNP were not retained by the model (p > 0.05).

Conclusion

LA reservoir strain may emerge as a useful tool to explore disturbed system biology involving extracardiac organ such as the brain in older adults with type 2 diabetes, in the background of mild LV dysfunction.

Abstract P1394 Figure. Fig.Regression analysis
P1399 Global longitudinal systolic deformation of the left ventricle during stress echocardiography with physical exercise may identify patients with severe coronary artery disease
Authors: Stepanova A , Alekhin M N
Published: January 2020

Background

Assessment of longitudinal systolic deformation of the left ventricular myocardium during speckle tracking stress echocardiography can potentially be significant in the diagnosis of transient myocardial ischemia. In this regard, determination of the global longitudinal systolic deformation (GLSD) of the left ventricle during stress echocardiography is challenging and its diagnostic capabilities can be assessed by comparing them with the data obtained with invasive methods for diagnosing coronary artery disease (CAD).

Aim of the study

The aim of this study was to determine the diagnostic capabilities of the left ventricular GLSD obtained during stress echocardiography with exercise on the treadmill in defining the presence and significance of CAD.

Methods

The study included 80 patients (mean age 68.3 ± 7.8 years; 29 females). All patients underwent stress echocardiography with exercise on the treadmill. At rest and after treadmill-test, all patients were measured for the values of the left ventricular GLSD using the AFI (Automated functional imaging) algorithm. The delta of the left ventricular GLSD values was counted. The delta of the left ventricular GLSD values was counted as the difference of the left ventricular GLSD values at rest and after the exercise. All patients underwent coronary angiography, assessment of the severity of CAD was counted according to the Gensini score. According to the results of coronary angiography, the patients were divided into 3 groups: 21 patients without CAD, 45 patients with moderate CAD (<34 points on the Gensini score) and 14 patients with severe CAD (> 34 points on the Gensini score).

Results

In the group of patients with severe CAD, the value of the left ventricular GLSD delta at rest and after treadmill-test significantly differed from the groups of patients with moderate CAD and without CAD (-0.56 compared with 2.17; p = 0,009). In the group of patients without CAD, the value of the left ventricular GLSD delta at rest and after treadmill-test did not significantly differ from the group of patients with CAD (0.23 compared to -0.95; p = 0.199).

Conclusions

The delta of the left ventricular GLSD obtained during stress echocardiography with exercise on the treadmill showed a reliable significance in determining severe CAD, but did not demonstrate a reliable significance in identifying the absence of CAD.
P1400 Improving ischemia diagnosis: 3D speckle-tracking stress echocardiography
Authors: Pascual Izco M , Casas Rojo E , Kardos A , Alonso Salinas G L , Garcia Martin A , Hinojar Baydes R , Monteagudo Ruiz J M , Sanchez Vega J D , Ramos Jimenez J , Jimenez Nacher J J , Ruiz S , Moya J L , Zamorano Gomez J L , Fernandez-Golfin Loban C
Published: January 2020

Background

2D stress echocardiography (SE) is based in the visual analysis of wall motion abnormalities and it requires a trained operator. This operator-dependence has promoted the search for a semiautomatic method to reduce SE limitations and improve test accuracy. The aim of this study was to evaluate the value of 3D speckle tracking (3DSTE) in SE in patients with chest pain.

Methods

44 consecutive patients with chest pain and pathological findings on CCTA (>50% stenosis or high calcium score (>400 HU) with undetermined severity) were included. These patients underwent SE with acquisition of 3DSTE at rest and at peak stress.

Results

Mean age was 63.9 ± 9.9 years. 90% were men. The images of the 44 patients were processed with automatic tracking and manual corrections. 11 patients developed inducible ischaemia during SE. Patients with ischaemic response showed significant reductions in 3D area strain (AS) compared to resting values. The 33 patients without inducible ischaemia showed, however, a significant increase in this parameter. Results are shown in table 1.

Conclusion

3D area strain SE could help to identify patients with inducible ischemia. However, further studies are need to confirm these data.

Ischemia + (n = 11) Ischemia - (n = 33) P 2D LVEF rest 57.2; 5.5 61.4; 6.0 0.04 2D LVEF peak stress 56.9; 11.7 70.0; 9.0 <0.01 3D LVEF at rest 54.3; 6.9 64.3; 9.7 0.17 3D LVEF peak stress 51.9; 22.5 66.0; 8.6 0.17 AS rest 38.3; 5.1 40.4; 5.7 0.29 AS peak stress 37.2; 11.3 43.6; 7.2 0.03 LVEF: left ventricle ejection fracion; AS: area strain.
P1413 Complexity of changes in right ventricular function in patients undergoing cardiac surgery
Authors: Wejner-Mik P , Kasprzak J D , Szymczyk E , Wdowiak-Okrojek K , Ammer A , Religa G , Lipiec P
Published: January 2020

Background

An impairment of certain echocardiographic parameters of right ventricular (RV) function, such as tricuspid annular peak systolic excursion (TAPSE), is a known phenomenon in patients undergoing cardiac surgery. However, little is known about significance of these alterations with regard to other aspects of RV function. The aim of our study was to clarify this issue using parameters based on 3D echocardiography and speckle tracking technique.

Methods

The study population comprised 105 patients (76 men, mean age 65 ± 16 years), referred for coronary artery bypass grafting and/or replacement of mitral or aortic valve. Patients undergoing tricuspid annuloplasty and with baseline suboptimal image quality were excluded from the study group. Transthoracic echocardiographic examination was performed on average 2 ± 2 days prior to surgery (TTE1) , and 7 ± 4 days after surgery (TTE2), whereas follow-up TTE (TTE3) was performed on average 12 ± 2months after the surgery. Parameters measured during these examinations included both standard and advanced indices of RV size and function, such as TAPSE, systolic velocity of tricuspid annulus (S"), fractional area change (FAC), RV ejection fraction (EF) and RV global longitudinal systolic strain (GLS).

Results

Echocardiographic measurements were completed for TTE1, TTE2 and TTE3 in 95% of patients. We noticed a significant postoperative (TTE2) impairment of parameters of RV longitudinal function (TAPSE, S’ and GLS; p < 0,0001). However, neither RV size assessed by both 2D and 3D technique changed, nor the global RV function measured with the use of FAC and EF. After 12 months (TTE3) we observed an improvement in the parameters of the longitudinal RV function.

Conclusion

Cardiac surgery results in an impairment of the longitudinal systolic RV function, with no influence on the global RV function. After 12 months, an improvement of the longitudinal function can be observed.
P1430 Analysis of echocardiographic study findings prior to an allogeneic hematopoietic stem cell transplantation
Authors: Vallejo Garcia V , Martin Garcia A , Castro Garay J C , Lopez Corral L , Martin Garcia A C , Cabanillas Cabral A , Diaz Pelaez E , Barreiro Perez M , Rodriguez Estevez L , Castillo Y , Avila D , Sanchez Pablo C , Cambronero Cortinas E , Caballero Barrigon D , Sanchez Fernandez P L
Published: January 2020

Allogenic hematopoietic stem cell transplant (Alo-HSTP)has been a therapeutic revolution for patients with hematologic malignancies. Even though this therapy is associated with a high risk of cardiovascular (CV) events during follow-up, a baseline cardiology study is currently not standardised in most centers. Our aim was to analyse transthoracic echocardiogram (TTE) findings in patients candidates to Alo-HSTP.

We undertook a retrospective and descriptive analysis that included all patients treated with Alo-HSTP in our center between 2016-2019. Baseline characteristics and TTE findings including global longitudinal strain (GLS) were analysed.

We analyzed 144 patients (mean age 50 years, 60% males). Acute myeloblastic leucemia (38%) and non-Hodgkins lymphoma (18%) were the most frequent diseases. Figure. 18 patients (13%) had hypertension, 13% had dyslipidemia and 6% diabetes mellitus. Almost 10% had previous CV history. TTE found left ventricle systolic dysfunction (LVEF< 53%) in 10% of patients, diastolic dysfunction in 12%, valvular heart disease in 4 patients (5,5%) and GLS was abnormal (>-19%) in 35 patients (24%). Up to 47 (33%) patients studied has an abnormal TTE finding. Table.

More than one third of patients candidates to Alo-HSTP had an abnormal TTE finding, increasing the risk for CV events during follow-up. A cardiologic study by the Cardio-Onco-Hematology team in these patients before Alo-HSTP could improve their prognosis.

Age (years) 50 ± 18 Male (n,%) 86 (60%) Hypertension (n,%) 18 (13%) Diabetes mellitus (n,%) 8 (5,6%) Dyslipidemia (n, %) 18 (13%) Past or current smoking (n, %) 25 (18%) Previous cardiovascular history (n, %) 13 (9,3%) Abnormal TTE (n, %) 47 (33%) LVEDV(ml) 99 ± 29 LVESV (ml) 37 ± 16 LVEF (%) LV dysfunction (n, %) 63 ± 8 15 (10,4%) e/e´ Elevated filling pressures (n, %) 8,2 ± 7,3 4 (3%) Valvular heart disease (≥moderate) (n, %) Mitral Aortic Tricuspid 3 (2%) 4 (3%) 1 (1%) GLS (%) abnormal GLS , >-19% (n, %) -20,4 ± 2,8 35 (24%) LVEDV: Left ventricle end-systolic volume, LVESV: Left ventricle end-systolic volume, LVEF: Left ventricle ejection fraction, GLS: global longitudinal strain

Abstract P1430 Figure. Haematologic malignancies
P1436 Diagnostic yield and accuracy of CT coronary angiography compared to invasive coronary angiography: real world data from a district general hospital in the United Kingdom
Authors: Masoud A M , Topping W T , Lynch M L
Published: January 2020

Background

Cost-effectiveness is imperative for a sustainable healthcare service. Non-invasive testing is used to risk stratify patients and reduce the need for invasive investigations in cardiology. The National Institute for Health and Care Excellence (NICE) Clinical Guideline for evaluation of chest pain was updated in 2016 when NICE recommended CT coronary angiography (CTCA) as the first-line investigation for patients with suspected stable coronary artery disease (CAD).

Purpose

To evaluate the accuracy of CTCA in real life daily practice in a district general hospital outside the strict environment of clinical trials.

Methods

A retrospective analysis of all CTCA studies carried out between June and December 2017 was performed. Graft studies were excluded. Potentially obstructive CAD on CTCA was defined as any luminal stenosis ≥50% of a major epicardial coronary artery. On invasive coronary angiography (ICA), clinically significant CAD was defined as a luminal stenosis of ≥50% in the left main stem or a stenosis of ≥70% of any other major epicardial coronary artery.

Results

Out of a total of 528 CTCA studies, 109 patients (mean age 64.2 ± 10.4; 67.9% male) showed potentially significant CAD in at least one major epicardial coronary artery. The median calcium score was 379.7 (IQR = 86-929). 61 (56%) patients had ICA, 20 (18.3%) patients had non-invasive functional coronary assessment (19 stress echocardiogram and 1 stress perfusion cardiac magnetic resonance) and 3 (2.8%) patients had both. The remaining patients were managed medically without further investigation.

Correlation between potentially obstructive CAD on CTCA and clinically significant CAD on ICA showed a sensitivity of 95.8% (95% CI: 85.8%-99.5%), specificity of 68.0% (95% CI: 61.0%-74.5%), positive predictive value of 42.2% (95% CI: 37.1%-47.4%), negative predictive value of 98.5% (95% CI: 94.5%-99.6%) and overall accuracy of 73.5% (95% CI: 67.5%-78.9%). Among patients who had ICA, 21 patients (34.4%) required coronary revascularization (16 percutaneous coronary intervention and 5 coronary artery bypass grafting) and 40 (65.6%) patients were treated medically. Only 1 patient (4.3% of 23 patients) showed evidence of inducible ischemia on non-invasive functional testing.

Conclusion

CTCA in a real world practice has high sensitivity and high negative predictive value compared to the gold standard ICA. CTCA improved patient selection for ICA to those most likely to have significant CAD.
P1455 Succesfully surgical management of "transit thrombus"
Authors: Vera Sainz A , Bastante T , Gonzalez E , De La Cuerda F , Jimenez C , De Rueda C , Montes A , Cecconi A , Rojas A , Diego G , Benedicto A , Dominguez L , Monguio E , Jimenez Borreguero L J , Alfonso F
Published: January 2020

A 74-year-old woman was admitted in the emergency department in November 2018 for dyspnea, sudden chest pain and hemodynamic instability. Se had a previous history of pelvic fracture in September 2018, complicated with subdural hematoma secondary to therapeutic anticoagulation that wassurgically managed in October 2018. A through pulmonary arteries CT revealed massive pulmonary thromboembolism with right ventricle overload and pulmonary infarction. Because of history of cerebral hemorrhage, fibrinolytic treatment was ruled out and surgical approach of pulmonary embolism was decided. An intraoperative transesophageal echocardiogram demonstrates a thrombus in the right atrium (Figure 1A, yellow arrow), with invasion through the interatrial septum through a patent foramen ovale (Figure 1B, yellow arrow) with extension to mitral valve plane in the left ventricle (Figure 1C, yellow arrow). "Transit thrombus" was removed, patent foramen ovale was closed and bilateral pulmonary embolectomy was performed. In postoperative transesophageal echocardiography, no residual thrombus in cardiac chambers was seen and the closure of the foramen ovale was checked (Figure 1D). During the postoperative period, the patient presented cardiac tamponade, treated with pericardial drainage. Once this complication was overcome, the evolution was satisfactory and the patient could be discharged.

This case demonstrates that performing a transesophageal echocardiogram before a surgical embolectomy in the setting of pulmonary embolism is essential. It allows detect the presence of cardiac thrombi, assess the interatrial septum integrity (where the CT has limitations), and allows to guide the surgical treatment.

Abstract P1455 Figure.
P1468 a rare cause of chest pain:sudden rupture of aortic valsalva sinus aneurysm
Authors: Shaaban N , Shehata H , Abdelnabi M , Maghraby A , Othman N
Published: January 2020

Introduction

Sinus of Valsalva aneurysms (SOVAs) occur when there is a congenital defect in the aortic media and incomplete fusion of distal bulbar septum (primitive bulbus cordis) and truncal ridges. These aneurysms usually rupture into the right side of the heart, with the right ventricle being the most common.

Case Presentation

A 32 year old male patient who presented to our facility with an attack of ulcerative colitis activity ,elevated inflammatory markers and thrombocytosis. During hospital stay, he developed sudden onset of retrosternal compressing chest pain. On examination he was afebrile with a blood pressure of 130/80 mm Hg and pulse rate 110 beats per minute. He had soft systolic and early diastolic murmurs with normal chest auscultation; there was no haemodynamic discrepancy between left and right sides or stigmata of endocarditis.

His ECG showed sinus rhythm with no ST segment changes, and chest x ray was normal. Full blood count revealed thrombocytosis & normochromic normocytic anemia , cardiac enzymes were normal, blood cultures were sterile.

A 2D transthoracic echocardiography (TTE) revealed dilated left ventricular dimensions , there is an aneurysm of the right sinus of Valsalva which is communicating with the right ventricle (RV)confirmed by color Doppler and negative contrast seen inside RV during bubble study.

3D TTE showed a small fistulous track between the right sinus and RV.

The patient refused surgical or percutaneous closure.

Conclusion

Congenital RSVAs account for 0.1–3.5% of congenital heart defects.It has a higher incidence in Asian versus Western populations with male to female ratio 3:1. SOVAs arise from the right sinus of Valsalva in 80–85% of these cases and from the noncoronary sinus in 5–15%. They rarely arise from the left sinus, as the left coronary cusp embryologically is not derived from bulbar septum. This is distinct from acquired SOVAs, which can occur in any of the sinuses Traditionally, surgical closure has been the mainstay of treatment for RSOVAs, with an operative mortality rate of <5% and excellent long-term outcomes.

Abstract P1468 Figure. RSOVA
P1470 Rare cause of papillary muscle rupture post cardiac surgery
Authors: Lopez Rodriguez E , Calvo Iglesias F , Blanco Gonzalez E , Varela Martinez M A , Legarra Calderon J J
Published: January 2020

Introduction

Papillary muscle rupture (PMR) secondary to mitral valve repair surgery is a rare complication in the postoperative period of cardiac surgery

Purpose

We present a case of PMR with fatal outcome after mitral valve repair with a rigid ring secondary to accidental ligature of the circumflex artery (CA).

Methods

An 83-year-old male referred for valvular surgery for symptomatic mitral regurgitation (MR). In the last echocardiography LVEF was mildly depressed (45-50%), severe organic MR (A2 chord rupture), functional TR, and moderate degenerative AR. With these findings and together with a normal coronary angiography, he was presenting at the Heart Team for triple valvular surgery. The procedure consisted of implanting aortic biological prosthesis, mitral and tricuspid annuloplasty. During the pump output, he presented ventricular arrhythmias, but in the intraoperative transesophageal echocardiography (TEE) a good result was demonstrated. At 24h postoperatively the patient enters arrhythmic storm, ischemia data appear on ECG (ST-segment depression of V1-V3 and DI-aVL) and elevation of markers of myocardial damage (TnIc 450 ng/mL), which point to complication postsurgical cardiology is contacted for urgent echocardiography.

Results

The echocardiography showed a massive MI due to postero-medial PMR, inferior and inferolateral akinesia and severe biventricular dysfunction. With these findings and with the suspicion of accidental ligation of CA during the implantation of the mitral annulus, urgent catheterization is considered. Given the evolution of the ischemic event and the delicate hemodynamic situation, this option is discarded, so that angiographic confirmation is not achieved. Finally, the patient undergoes cardiac revision surgery as a last option. After performing sternotomy, cardiac rupture at a lower level is evidenced, patch closure is attempted but due to tissue friability it is not achieved and the patient dies in the surgical act.

Conclusion

RMP after mitral valve surgery is a very rare complication. The majority of published cases are related to increased tension forces after mitral replacement with preservation of the subvalvular apparatus. Our case would be the first described of MPR secondary to accidental ligation of AC after mitral annuloplasty.
P1486 An unexpected case of paediatric heart failure
Authors: Theocharis P , Morrison M L , Storring N , Adhavaryu K , Jivanji S , Rosenthal E , Miller O , Mathur S , Speggiorin S
Published: January 2020

A 9-month-old male presented in heart failure with a 2-day history vomiting that followed a viral upper respiratory tract infection 10 days previously. Echocardiography demonstrated a normally connected heart with a severely dilated and poorly functioning left ventricle with bright mitral valve papillary muscles. It was difficult to demonstrate the origin of the left coronary artery and retrograde flow was seen in the vessel (Fig 1, Panel A). The right coronary artery appeared normal. A gated cardiac CT was performed and showed a normal right coronary origin and no clear connection of the LCA to Ao and there was suspicion of retrograde filling. Images of the left coronary origin did not show clear connection of the LCA to Ao (Fig 1, Panel B). As the case was extremely unusual coronary angiography was performed which confirmed the suspicion of a dominant right coronary system with collateral connection to the left coronary system and retrograde filling and no antegrade filling of the LCA from the Ao (Fig 1, Panel C). This was consistent with atresia of the left coronary ostium, which was confirmed at operation. The left coronary sinus was opened, as was the roof of the left coronary artery and an anastomosis was performed to aorta using an autologous patch. The post operative TOE showed good flow into the LCA (Fig 1, Panel D). There was good and quick post op clinical recovery but the left ventricular function remains still poor at the moment with slow recovery as expected. The cardiac function will be monitored echocardiographically and the reconstructed coronary artery with CT.

Abstract P1486 Figure 1
P1487 Anomalous right coronary artery from mid left anterior descending artery
Authors: Fyyaz S A , Katsigris A , David S , Alfakih K
Published: January 2020

55-year-old male with history of transient ischaemic attack, excised gastro-intestinal stromal tumour, and osteoarthritis presented to rapid access chest pain clinic with history of atypical chest pain. There were no resting electrocardiographic changes. In accordance with NICE stable chest pain guidelines, a CT coronary angiogram was requested to further assess for any underlying coronary artery disease. This showed normal origin of left main stem (LMS) from left coronary sinus of aorta, however there was an anomalous origin of the right coronary artery (RCA) as a branch from the mid portion of left anterior descending artery (LAD). This was deemed to be an incidental finding with a benign course and not the cause of his symptoms.

Coronary anomalies have a reported incidence of 1.3% at invasive coronary angiography (1), and a reported incidence of 0.014-0.066% of single coronary artery (2). Anomalous RCA usually courses from the LMS and courses between the aorta and pulmonary artery. We present an extremely rare variant of single coronary artery arising from the mid LAD without any associated congenital or structural abnormality, on CT coronary angiography (the gold standard for demonstrating coronary anatomy). This is rarely reported in the literature and is a benign coronary anomaly.

Abstract P1487 Figure.
P1490 Congenital right coronary artery fistula into right atrium diagnosed with help of multimodality imaging
Authors: Erciyes D , Ozden Tok O , Yurdakul S , Bakan S , Goktekin O
Published: January 2020

Introduction

Coronary artery fistula (CAF) is an anomaly in which abnormal connections are present between the coronary artery and the cardiac chambers or a major vessel. It is an uncommon anomaly with an estimated incidence of 1 in 50,000 live births and usually occurs in isolation.

We report a case of CAF into right atrium in a patient who admitted to our outpatient department with dyspnea and fatique. With help of transthoracic echocardiography (TTE), transesophageal echocardiography (TOE) and cardiac computerized tomography (CCT) we put the definite diagnosis and decided to close this fistula percutaneously with a PDA occluder.

Case

A 43-year- old male admitted to our outpatient department with complaints of exertional dyspnea and fatique for 5 years. His physical examination revealed a holosystolic murmur on the aortic valve area. His TTE showed enlarged right heart chambers with a high pulmonary artery systolic pressure (50 mmHg) and a suspicious flow from the aortic root into right atrium. Qp/Qs was 2.1. TOE depicted a shunt between aorta and right atrium as well, we couldn’t truly demonstrate the connection though .

In order to define the defect precisely, we performed a cardiac CT. Cardiac CT clearly showed a markedly dilated and mildly tortuous and calcified fistula arising from the osteal part of right coronary artery draining into right atrium. Right coronary artery was thin and there was no stenosis. Cardiac CT helped us to exclude coronary arter disease as well.

As it was suitable to close percutaneously, we decided to close it with a PDA occluder.

Conclusion

CAF is a rare, generally congenital anomaly and may cause right heart chamber dilatation and pulmonary hypertension if the diagnosis is missed. It is important to support and clarify the underlying pathology with help of other cardiovascular imaging modalities like cardiac CT and cardiac magnetic resonance imaging (CMR), if TTE and TOE cannot demonstrate us the exact pathology.In our case our choice of extra method was cardiac CT, as we wanted to exclude accompanying coronary artery disease at the same time. In today’s era, the use of multimodality imaging is increasing with a tremendous rate and it helps clinical cardiologists, cardiovascular imaging specialists and interventional cardiologists all.

Abstract P1490 Figure. 2D,3D TOE and CCT images of CAF
P1496 Congenital anomalous origin of the left coronary system
Authors: Ahmad S , Ahmed I , Jibran R , Raimondo C
Published: January 2020

A 62 year old gentleman presented with a history of recurrent central chest pains radiating to the left arm and jaw lasting up to 15-20 minutes and relieved with GTN. He had numerous admissions to hospital over a period of three years with negative Troponins and normal ECGs. There were several cardiovascular risk factors including obesity, diabetes, hypertension and dyslipidaemia. He also had a family history of ischaemic heart disease, with his mother and brother having heart attacks in their 60s.

He was referred for outpatient investigations on multiple occasions but did not attend. This lead to a delay in a formal diagnosis until we eventually convinced him to undergo invasive diagnostic coronary angiography in June 2018. Prior to this, an Echocardiogram was done and showed reasonably preserved cardiac systolic function.

Coronary angiography demonstrated unique anatomical distribution of the three main coronary vessels, with an anomalous origin of the left main system (LMS) and left sided arteries arising from the right coronary cusp. The right coronary artery stemmed from its natural position and was the dominant vessel. Hence, all the coronary arteries arose from the same cusp. The LMS was anomalous and hypoplastic; an exceedingly rare occurrence of less than 0.03%. These unusual findings were then confirmed on CT Coronary Angiogram.

Although a surgical opinion was sought, the decision was a non-operative approach in view of no significant obstructive lesions and given the technical difficulties of undertaking coronary bypass. Viability imaging and ischaemia testing were then pursued with nuclear modalities. Ultimately, it was proven that the lesions did not show any significant reversible ischaemia and so a continued aggressive secondary prevention strategy was adopted. The patient is stable and doing well on optimal medical therapy.

Abstract P1496 Figure. LMS Arising From Right Coronary Cusp
P1497 Atypical variant of takotsubo cardiomyopathy due to an unusual non-emotional trigger
Authors: Perez Fernandez O M , Higuera Leal S A , Jaimes C P , Contreras L M , Gelves J , Isaza D , Medina H
Published: January 2020

Background

Takotsubo Cardiomyopathy (TCM) is characterized by left ventricular regional wall motion abnormalities, classically described as apical ballooning (atypical features such as midventricular, basal, or focal wall motion abnormalities also have been described) and triggered by emotional or physical stress. In this case, TCM was triggered by non-emotional stress, and eventually an unusual definite diagnosis was ascertained based on pathological specimen.

Case report

a 63-year-old woman presented to the emergency room complaining of 5 days of epigastric pain, nausea and emesis followed by chest tightness, dyspnea and diaphoresis. Physical examination was noticeable for abdominal pain with positive Murphy´s sign. ECG showed normal sinus rhythm, with T-wave inversion in DIII and aVF, and elevated troponin I. She also had leukocytosis and neutrophilia with normal liver function tests. Abdominal ultrasound showed a distended gallbladder with gallstones, without definitive evidence of cholecystitis. Accordingly, she was admitted to the Coronary Care Unit with suspected Non-ST elevation myocardial infarction.

Trans-thoracic echocardiogram (TTE) showed akinesia of all mid left ventricular segments with moderate systolic dysfunction -LVEF: 40%- (Figure 1A) suspicious for atypical TCM without a clear and identifiable emotional stress. Coronary angiography was negative for coronary stenosis and cardiac magnetic resonance (CMR) showed mid anterior and anterolateral segments dyskinesia, as well as mid septal, inferior and inferolateral segments akinesia (Figures 1B), with myocardial edema and no late gadolinium enhancement (Figure 1C), findings suggestive of TCM. Concomitant abdominal MRI demonstrated gallbladder distention, wall thickeningandedema, gallstones and peri-vesicular fat edema (Figure 1D).

Consequently, an infrequent type 2 (mid-ventricular) TCM, triggered by abdominal pain and inflammatory response due to acute cholecystitis, was diagnosed. Surgery was differed until full recovery of left ventricular function. One month later, after a full course of antibiotics and a new TTE showing no regional wall motion abnormalities (Figure 1E), a cholecystectomy was performed. Surprisingly, pathology revealed acute on chronic cholecystitis with eosinophilic infiltration, findings compatible with subacute cholecystitis (surgery performed 4 weeks after onset of symptoms). Currently, the patient is followed by Gastro-enterology for additional work-up.

Conclusion

We highlight the importance of multimodality imaging during diagnostic approach of atypical TCM. In this case, TTE findings in addition to a normal coronary angiogram, resulted in clinical suspicion of mid-ventricular TCM (present in 15% of cases) which was confirmed by CMR during the index event, followed by a normal TTE 4 weeks later. Cholecystitis is one of the multiple physical stressors, in addition to emotional triggers, causing TCM.

Abstract P1497 Figure.
P1499 A case of missing left ventricular apex
Authors: Jappar I A , Naing T T , Schumacher-Maurer A , Vineet T , Tang H C
Published: January 2020

Introduction

Isolated left ventricle (LV) apical hypoplasia is a rare congenital anomaly. Echocardiographic diagnosis is challenging if one is not aware of this condition. It can masquerade as LV non-compaction or apical aneurysm. Multimodality imaging with cardiac magnetic resonance (CMR) can be useful to secure the diagnosis.

Case description

An asymptomatic 18-year-old man, with no significant personal or family medical history, was referred to cardiology clinic due to abnormal electrocardiogram (ECG) during routine cardiac screening. ECG showed right axis deviation and delayed precordial QRS-transition. He had excellent effort tolerance during treadmill exercise test (standard Bruce Protocol stage 6). Ambulatory ECG monitoring was within normal limits.

Transthoracic echocardiogram showed a truncated appearance of LV apex with increased apical trabeculation, and bulging right ventricle apex (see image A and B). LV ejection fraction was preserved. The LV appearance was initially thought to be due to foreshortened apical view. A diagnosis of LV non-compaction cardiomyopathy was also inaccurately considered.

He was further evaluated with CMR imaging. The study showed a truncated LV apex and apical insertion of the papillary muscles. RV apex was seen wrapping around the LV (see image C and D). Both the LV and RV function were normal. There was no late gadolinium enhancement (LGE). The morphological abnormalities were consistent with the diagnosis of isolated LV apical hypoplasia.

Patient continued to be physically active and asymptomatic. Follow up CMR five years later showed similar findings of preserved biventricular functions and no fibrosis on LGE imaging.

Discussion

We described a rare case of isolated LV apical hypoplasia with longitudinal clinical and cardiac imaging follow up. Initial diagnosis from transthoracic echocardiogram was elusive, and supportive findings from CMR helped to secure the diagnosis.

In the literature, the clinical presentation ranges from chest pain syndrome, arrhythmias, heart failure or as incidental finding during cardiac imaging, as in our case. It is commonly diagnosed as nonspecific cardiomyopathy when the clinician is not aware of this condition.

Being a rare congenital anomaly, the prognosis is not well established. Our patient remained asymptomatic clinically with preserved biventricular function in his 5 years follow-up.

Abstract P1499 Figure. Echo and CMR imaging
P1503 Aortic root distensibility and stiffness assessed by echocardiography as predictors of coronary artery lesion severity in patients undergoing coronary angiography
Authors: El-Naggar H M , Anwar H S , Helmy H A , Demitry S R
Published: January 2020

Background

Aortic stiffness (AS) and distensibility (AD) have been shown as predictors for cardiovascular morbidity and mortality.

Aim: To assess the relation of aortic stiffness and distensibility using simple two-dimensional (2D) and tissue Doppler imaging (TDI) derived measures with the severity of coronary artery disease (CAD) assessed using the syntax score (SS), evaluating which of these measures has better predictivity for CAD severity.

Methods

We prospectively enrolled 150 individuals who underwent elective coronary angiography for suspected CAD, out of them 29 subjects (19.3%) had normal angiographic findings, while 121 (80.7%) subjects had CAD for whom the SS was calculated. All patients underwent simple 2D and TDI echocardiographic assessment of AS and AD.

Results

Patients with CAD had significantly higher aortic stiffness and elastic modulus and significantly lower aortic distensibility, aortic strain, aortic peak systolic and peak early diastolic velocities compared to those without CAD. Univariate and multivariate logistic regression analysis showed that decreased aortic distensibility, aortic strain, aortic peak early diastolic velocity and increased elastic modulus were predictors for the severity and complexity of CAD. However, along with diabetes, increased aortic stiffness index (> 17.7) was the only independent predictor of CAD severity, carrying twice the odds of having moderate-high syntax score (OR= 2.19, 95% CI= 0.97 – 4.95, p< 0.05).

Conclusion

Aortic stiffness index can be a screening tool for detecting patients with more severe CAD.

Univariate analysis Multivariate analysis Variables Odd’s ratio 95% confidence interval P value Odd’s ratio 95% confidence interval P value Age (years) 0.98 0.94-1.01 0.3 – –- – Sex (male) 1.52 0.58- 3.94 0.3 – –- – Smoking 1.21 0.59- 2.50 0.5 – –- – Diabetes mellitus 5.00 2.29-10.90 0.000 4.99 2.21- 11.31 0.000 Body mass index 0.93 0.83- 1.04 0.2 – –- – ↓↓ Distensibility (≤3.8)* 2.62 1.08- 4.70 0.02 2.01 0.91- 4.46 0.08 ↑↑ Stiffness index (>17.7)* 2.06 0.99- 4.27 0.05 2.19 0.97- 4.95 <0.05 ↑↑ Elastic modulus (>68.7)* 2.22 1.06- 4.64 0.03 2.01 0.91- 4.45 0.08 ↓↓ Aortic strain (≤9.3%)* 2.04 0.97- 4.27 0.05 1.64 0.73- 3.67 0.2 ↓↓ SAo (≤7cm/sec) 1.49 0.71- 3.12 0.2 – –- – ↓↓ EAo (≤9cm/sec) 2.30 1.08- 4.90 0.03 1.80 0.79- 4.10 0.1 Predictors of severity and complexity of CAD
P1507 Early and late morphological changes in the athlete"s heart: a longitudinal cohort study in young elite athletes
Authors: Bjerring A W , Landgraff H E W , Leirstein S , Lihagen M , Skei M , Murbraech K , Brun H , Stokke T M , Haugaa K H , Hallen J , Edvardsen T , Sarvari S I
Published: January 2020

Funding Acknowledgements

South-Eastern Norway Regional Health Authority

OnBehalf

Center for Cardiological Innovation

Background

Recent studies have suggested an initial concentric remodelling in the early development of the athlete’s heart in endurance athletes. However, the development from the early to the fully developed endurance athlete’s heart has not been described in longitudinal studies.

Aims

This study aims to explore the morphological changes occurring in hearts of young endurance athletes transitioning through adolescence.

Methods

Forty-eight cross-country skiers were examined at age 12 (12.1 ± 0.2 years) and then again at age 15 (15.3 ± 0.3 years). Cardiopulmonary exercise test and echocardiography, including 3D acquisitions, was performed in all subjects at both baseline and follow-up.

Results

At follow-up, 31 (65%) of the endurance athletes were still active and 17 (35%) were not. No differences in cardiac morphology were identified at baseline. At 15 years of age, the active endurance athletes had greater VO2 max, 3D indexed left ventricular end-diastolic and end-systolic volumes (Table). Relative wall thickness (RWT) decreased in the active endurance athletes during follow-up (0.35 ± 0.05 to 0.31 ± 0.04, p < 0.001), but not in the former athletes. Four active endurance athletes had RWT above the upper reference values at baseline; at follow up, all had normalized.

Conclusion

After an early concentric remodeling in the 12 years old athletes, those who continued regular endurance training developed eccentric changes with chamber dilatation and a drop in RWT. In contrast, those who ceased endurance training maintained a comparable wall thickness, but did not develop chamber dilatation nor experience a drop in RWT.

Baseline Follow-up Active athletes (n = 31) Former athletes (n = 17) p-value Active athletes (n = 31) Former athletes (n = 17) p-value VO2 max, indexed 65 ± 7 63 ± 7 0.33 62 ± 8 57 ± 6 <0.05 Interventricular septum thickness, mm 7.9 ± 0.8 7.8 ± 1.0 0.54 8.1 ± 1.2 7.8 ± 0.9 0.41 LV end-diastolic diameter, mm/m2 2.1 ± 0.3 2.0 ± 0.3 0.60 3.0 ± 0.2 2.9 ± 0.2 0.34 LV poster wall thickness, mm 7.3 ± 0.9 6.8 ± 0.9 0.07 7.8 ± 1.2 8.1 ± 1.2 0.42 3D LV end-diastolic volume, mL/m2 76 ± 8 74 ± 8 0.89 84 ± 11 79 ± 10 <0.05 3D LV end-systolic volume, mL/m2 33 ± 4 33 ± 4 0.99 36 ± 6 32 ± 3 <0.05 3D LV ejection fraction, % 56 ± 3 56 ± 3 0.93 58 ± 3 59 ± 2 0.52 3D LV Mass/BSA, g/m2 69 ± 7 71 ± 4 0.57 76 ± 11 74 ± 6 0.19 Relative wall thickness 0.35 ± 0.05 0.33 ± 0.05 0.12 0.31 ± 0.04 0.33 ± 0.05 0.05 Data expressed as mean ± SD. P-values calculated using the Student"s paired t-test. Volumes are indexed to body surface area.
P1508 Left ventricular diastolic function plays a different role on mortality depending on the severity of systolic dysfunction in acute heart failure patients with reduced ejection fraction
Authors: Nakamura K , Yamada A , Jinno S , Kato M , Takahashi A , Sugimoto K , Sugimoto K , Ishikawa T , Ozaki Y , Ishii J
Published: January 2020

Background

It remains to be clarified whether clinical significance of left ventricular (LV) diastolic function differs depending on the severity of LV systolic dysfunction in patients with acute heart failure (AHF). The aim of this study was to examine the prognostic role of LV diastolic function in AHF patients with various systolic dysfunction.Methods: We studied consecutive hospitalized AHF patients with LV ejection fraction (LVEF) <50%. The exclusion criteria were as follows: atrial fibrillation, severe mitral regurgitation, and inadequate echo image quality. They underwent echocardiography on admission. The eligible patients (n = 289, 165 males, 76 ± 10 years) were divided into 4 groups based on LVEF and left atrial pressure (LAP) grade estimated as in the ESC guidelines: Group I (LVEF 40-49% (mildly reduced LVEF)/normal LAP, n = 28), II (mildly reduced EF/increased LAP, n = 38), III (LVEF <40% (severely reduced LVEF)/normal LAP, n = 110), and IV (severely reduced LVEF/increased LAP, n = 113). Cardiac death was examined up to 60 months.Results: In total, 58 patients (20%) died because of cardiac events during the follow-up (mean 20 ± 19 months). In patients with mildly reduced LVEF, Group I showed significantly less cardiac death ratio than II (n = 1 vs 10, Group I vs II, p = 0.03). On the other hand, in patients with severely reduced LVEF, there was no significant difference in cardiac death ratio between Group III and IV (n = 23 vs 24, Group III vs IV, p = 0.80). That is, LAP grade was a prognostic marker when the patients had mild LV systolic dysfunction, whereas it did not contribute to the prediction of cardiac mortality when patients showed severely reduced LV systolic function. Group I showed significantly better prognosis than those with severe LV systolic dysfunction regardless of LAP grade (Group III, IV) (Group I vs III, p = 0.04; Group I vs IV, p = 0.04).Conclusions: LV diastolic function may have a different clinical significance depending on the severity of LV systolic dysfunction in AHF patients.
P1526 Updated prevalence of lambls excrescences using the latest three-dimensional transesophageal echocardiography
Authors: Takahashi T , Kusunose K , Hayashi S , Morita S , Torii Y , Hirata Y , Yamao M , Nishio S , Yuichiro O , Abe M , Yamada N , Yamada H , Wakatsuki T , Sata M
Published: January 2020

Background

Lambl’s excrescences (LEs), filiform strands that occur at sites of cardiac valves, have been suggested the cause cryptogenic stroke. The diagnosis is primarily based upon the echocardiographic study, but conventional two-dimensional transthoracic echocardiography has limitation to detect such as small strands. Latest three dimensional-transesophageal echocardiography (3D-TEE) have high-resolution images with many slices, so small structures are able to be clearly visible and detected.

Purpose

The aim of this study was to assess the prevalence of LEs using the latest 3D-TEE images.

Methods

We retrospectively reviewed consecutive 140 patients who underwent 3D-TEE from November 2018 to May 2019. Forty-seven patients were excluded due to unmeasurable, such as mitral valve prolapse, severe aortic stenosis, prosthetic valves and poor-quality images. We carefully evaluated the mitral and aortic valve leaflets in order to find mobile string structure (diameter <1 mm and length 1–20 mm) in each cardiac cycle. Total analyzed images were over 50 slices per one patient.

Results

Among 93 patients, 83 patients (89%) was detected the presence of LEs. No difference in age and gender were found between patients with LEs and patients without LEs. Of the total 83 patients, there were 35 patients with strands on mitral valve, 32 patients with strands on aortic valve, and 16 patients with strands on both valves. Distribution of LEs at each valve leaflet were shown in Figure. Right coronary cusp of aortic valve (42%) and P2 of mitral valve (35%) were high prevalence among leaflets.

Conclusions

3D-TEE provides an update prevalence of LEs. The prevalence of LEs might be potentially high in the real world.

Abstract P1526 Figure.
P1530 Dense spontaneous echo contrast and thrombus in patients on new oral anticoagulant and warfarin therapy: a retrospective audit
Authors: Thakur A , Thananjeyan A , Garrett C , Reeks M , Khaja S , Shugman I , Premawardhana U , Kadappu K K
Published: January 2020

Background

Cardioembolic stroke is a known complication of atrial fibrillation (AF), which is increasing in global prevalence. Spontaneous echo contrast (SEC) in the left atrium (LA) is a precursor for thrombus formation detected on transesophageal echocardiography (TEE). There is limited data regarding the prevalence of dense SEC and/or left atrial thrombus (LAT) detected by TEE in patients on novel oral anticoagulants (NOACs) compared with Warfarin.

Purpose

To determine and compare the prevalence of dense SEC and/or LAT among patients with AF/atrial flutter undergoing TEE while on continuous NOAC or Warfarin therapy.

Methods

Retrospective analysis of prospectively entered data for all patients who were on continuous oral anticoagulants and underwent TEE with DC cardioversion, over a 9-year period (1st January 2011 to 31st December 2018) at a public teaching hospital in NSW, Australia. SEC was classified according to emptying flow velocities, as per the European Association of Cardiovascular Imaging guidelines.

Results

Among the 195 patients, 94 (48%) patients were on NOAC therapy (52% Apixaban, 25% Rivaroxaban, 23% Dabigatran) while 101 (52%) patients were on Warfarin. There was no difference in age (mean ± SD: 64 ± 12 vs. 65 ± 13, p = 0.71) or proportion of males (71% vs 69%, p = 0.76) between patients on NOAC therapy compared with Warfarin. However, the NOAC therapy group had a lower prevalence of ischaemic heart disease (IHD) (18% vs. 33%, p < 0.05) and chronic kidney disease (CKD) (2% vs. 19%, p < 0.001), in addition to a lower CHA2DS2-VASc score (2.1 ± 1.7 vs 2.7 ± 1.7, p = 0.03) and higher haemoglobin levels (145.3 ± 19 vs 133.8 ± 24, p = 0.001). The overall rate of dense SEC and/or LAT detected by TEE was 9.7%. There was no significant difference in the prevalence of dense SEC and/or LAT between patients on NOACs and Warfarin (6.4% vs. 12.9%, p = 0.13). On multivariable analysis of IHD, CKD, Warfarin, NOACs and CHA2DS2-VASc score, there was no significant difference in prevalence of SEC/LAT between Warfarin and NOACs.

Conclusions

In this study, 6.4% of patients on continuous NOACs and 12.9% of patients on Warfarin therapy had dense SEC and/or LAT detected by TEE. Although the trend towards higher rates of dense SEC and pre-thrombus in the Warfarin group did not reach statistical significance, it still holds clinical significance as these patients cannot be cardioverted. Therefore, these data support the need to consider anticoagulant optimisation in the overall management of patients with SEC.