bluuebunny/crossref_metadata_2025 huggingface dataset:
P77 A “GIANT” IN THE PANDORA’S BOX OF PARACARDIAC MASS
Authors: Briani F , Dotto A , Facci G , Bagli M , Tavella D , Ribichini F
Published: May 2023

In this case report, we describe a giant coronary aneurysm (CAAs) of the right coronary artery occasionally found in a patient that underwent Bentall procedure 18 years earlier for acute aortic dissection. A 77–year–old man, former smoker, with type II diabetes, hypertension, dyslipidaemia, and obesity, was referred to our echo lab for echocardiography in December 2020. His medical history included anteroseptal non–Q–wave myocardial infarction (1983), type A acute aortic dissection treated with Bentall procedure and implantation of mechanical aortic valve (2002), and reparation of abdominal aortic aneurysm (2003). During the echocardiogram a paracardiac mass was incidentally found, in close contact to the right atrium and with a diameter of 60 mm in A4Ch–view, with the appearance of a cystic formation (Figure A). After a few days, a CT angiography was performed, with evidence of 61.6 mm–sized giant aneurysm located in the proximal right coronary artery, characterised by calcified walls, eccentric thrombosis, and compression of the right atrium (Figure B). The patient was subsequently evaluated by the Cardiac Surgery Division. Conservatively management with regular follow–up was performed, because of the high surgical risk of redo and the lack of symptoms. In November 2022 we performed a follow–up echocardiography with evidence of stability of the size of coronary artery aneurysm (Figure C). CAAs are defined as giant when the diameter of the vessel is greater than 20 mm. These pathological entities are extremely rare, with an incidence rate of 0.02%, and aetiologies are various. The most frequent aetiologies comprehend atherosclerosis (about 50% of cases), congenital (17%), arteritis (e.g., Kawasaki disease), connective tissue disease. Our case is characterised by the occasional diagnosis of CAA 18 years after Bentall Surgery, in absence of inflammatory vessels disease. To the best of our knowledge, It’s the largest giant CAA described in literature after Bentall cardiac surgery. Therefore, cardiologists should consider these rare entities when approaching an incidental echocardiographic finding of paracardiac mass, especially in patients with high burden of atherosclerotic disease. This case report underlines furthermore the importance of an integrated approach in the differential diagnosis of a paracardiac mass.
P81 IMPACT OF CORONAROGRAPHY AND CORONARY ANGIOPLASTY ON MORTALITY IN A COHORT OF PATIENTS WITH NEW–ONSET HEART FAILURE IN ITALY
Authors: Seccareccia F , De Luca L , D’Errigo P , Rosato S , Duranti G , Badoni G , Baglio G
Published: May 2023

Background

Although myocardial ischemia and coronary artery disease play a crucial role in the pathophysiology of new–onset heart failure (HF), the impact of coronary angiography and percutaneous coronary angioplasty (PCI) revascularization on HF mortality is not well clarified.

Objective

To evaluate the efficacy of performing coronary angiography and PCI in reducing medium–term outcomes in a cohort of patients hospitalized with new–onset HF in Italy.

Methods

Retrospective cohort study enrolling all patients aged 18–100 years hospitalized for new–onset heart failure in an Italian accredited public or private hospital in the years 2015–2019 and survived 30 days after index hospitalization. Patients with a prior diagnosis of CAD were excluded from the analysis. The enrolled patients were classified into: patients not undergoing coronary angiography (No CVG); patients undergoing coronary angiography without PCI (CORO) and patients undergoing coronary angiography and PCI (PCI). The primary outcome measure of the study was all–cause mortality 1 year after the index hospitalization. A multivariate Cox model estimated through a stepwise procedure was used to compare the study groups taking into account the different distribution of risk factors.

Results

342,090 hospitalizations for new–onset HF were recorded in Italy during the study period. Of these, 32,240 (9.42%) patients underwent coronary angiography without PCI and only 5,890 (1.72%) underwent PCI as well. Patients undergoing an invasive procedure were on average younger (mean age =80.7 in No CVG, 69.0 in CORO and 72.3 in PCI), with a lower percentage of women (58.8% in No CVG, 37.0% in CORO and 27.6% in PCI) and with fewer comorbidities than untreated. After adjusting for gender, age, and comorbidities, coronary angiography was protective versus no treatment whether performed alone (HR=0.57; p<0.0001) or followed by PCI (HR=0.67; p<0.0001). 0.0001).

Conclusions

In this cohort of consecutive patients with new–onset HF, coronary angiography and/or PCI was associated with a significant reduction in 1–year mortality.
P82 SAFETY AND FEASIBILITY OF ANGIONTENSIN RECEPTOR NEPRILYSIN INHIBITOR IN REAL– WORLD PATIENTS WITH ACUTE DECOMPENSATED HEART FAILURE
Authors: Rossini R , Angelini F , Giordana F , Coppini L , Ferraro I , Ruffino E , Varbella F , Tizzani E , Coletta G , Musumeci G
Published: May 2023

Background

To determine the safety and feasibility of in–hospital sacubitril/valsartan initiation after clinical stabilization in patients with acute decompensated heart failure (ADHF) and reduced ejection fraction (EF).

Methods

This retrospective, multicenter observational study included patients admitted for ADHF in 2 Italian centers between February 2017 and January 2022. Feasibility was evaluated by assessing the proportion of patients discharged on sacubitril/valsartan. Key safety endpoints were the incidences of adverse events during hospitalization and during follow–up planned at 1 month, 3 6 months and 12–18 months after discharge.

Results

One hundred and twenty–two patients were included. Median age was 71 (60–78) years, 78% male, 63% New York Heart Association (NYHA) class III at admission with a median left ventricular ejection fraction (EF) of 25% (20–30). During hospitalization, 94 (77%) patients were treated with intravenous diuretics, 39 (32%) with inotrope/vasopressor, 51 (42%) with continuous positive airway pressure ventilation and 7 (6%) were assisted with an intra–aortic balloon pump. Median time from hospitalization to sacubitril/valsartan initiation was 4 (2–7) days. Sacubitril/valsartan was started at a dosage of 12 mg/13 mg in 52 (43%) patients, 24 mg/26 mg in 61 (50%) patients and 49 mg/51 mg in 8 (7%) patients. Overall, 111 (91%) of patients were discharged on sacubitril/valsartan. At 12–18 months follow–up, the vast majority of patients were still on sacubitril/valsartan therapy.

Conclusions

In–hospital initiation of sacubitril/valsartan treatment in real–world ADHF patients may be a safe and feasible treatment option.
P86 WHEN THE HEMATOLOGIST HAS THE SOLUTION – A RARE CASE OF HEART FAILURE
Authors: Biolé C , Bianco M , Ulisciani S , Nangeroni G , Chinaglia A
Published: May 2023

Introduction

Cardiologists are confident with heart failure due to cardiac etiology, but sometimes this may be due to other organs‘ dysfunction (e.g. endocrine problems); in this case we report a very rare cause of anasarca due to hematologic disease.

Case report

A 33 year old man with a known complete left bundle branch block and without other pathologies is admitted to the ED for sickness and abdominal pain. Low platelet count, splenomegaly and an anterior mediastinal mass (53x54mm) are found. A Positron Emission Tomography (PET) reveals multiple lymphnodes captation above and under the diaphragm and at mediastinal level. Bone marrow biopsy is consistent with myelofibrosis. During the hospitalization the patient experiences an important weight gain (14 kg) with edema and worsening renal function suspected for heart failure; echocardiogram shows a globally hypokinetic left ventricle with moderately reduced ejection fraction (EF 37%), mild pericardial effusion, no relevant valve anomalies; cardiac MRI confirmed moderately depressed EF with global hypokinesia and no LGE anomalies of the myocardial wall; a clinical benefit is noted with high dose i.v. diuretics, and echocardiogram findings rapidly improve with therapy, EF 49% after decongestion; a discrepancy is noted between the severity of anasarca and echocardiographic data; ultimately, lymph node biopsy is performed, which is consistent with Castleman disease, HHV 8 negative. TAFRO (Thrombocytopenia, Anasarca, Fever, Reticulin myelofibrosis/Renal dysfunction, Organomegaly) syndrome is therefore diagnosed. Therapy with siltuximab (anti IL–6) is started with good clinical response on lymph nodes enlargement and on anasarca, and the patient is currently followed–up by the hematologists of our institution.

Discussion

TAFRO syndrome is a very rare hematologic disease that can manifest with severe anasarca; usually it presents with non–cardiac features, but cardiologists should be aware of this disease as they could be involved in the management of this condition, especially in the fist stages when the diagnosis has not yet been made.
P96 NO PATIENT SELECTION IN TOTALLY ENDOSCOPIC ISOLATED MITRAL VALVE SURGERY: OPERATIVE AND EARLY RESULTS IN DEGENERATIVE MITRAL VALVE REGURGITATION
Authors: Zoni D , Cresce G , Hinna–Danesi T , Salvador L
Published: May 2023

Background and aim

In high–volume centers MICS can be offered to any patient affected by degenerative mitral valve surgery (MVS). Aim of this study was to evaluate early outcomes in patients undergoing isolated MVS for degenerative mitral regurgitation (MR) using a totally endoscopic technique.

Methods

From January 2018 to December 2022, 1124 consecutive unselected patients underwent endoscopic MVS at our institution. Among them, 399 patients underwent isolated MVS for degenerative valve pathology. Concomitant surgery and different etiology were excluded. All patients were approached with peripheral cannulation, limited skin incision (peri–areolar/sub–mammary/anterior axillary line) and 5 mm 30° endoscope. Neo–chordae implantation plus annuloplasty ring was the preferred technique for mitral repair.

Results

Endoscopic MVS was achieved in all patients and no conversion to sternotomy was needed. Median Cross–Clamp and CPB Time were respectively 93 [75 – 11] and 143 minutes [115 – 171]. Overall in hospital mortality was 0.75%. Major Stroke occurred in 1.6%. Replacement for unsuccessful repair occurred in 4 patients (1%). Repeated cross–clamp for residual MR in 13 patients (3,3%). Median intubation time was 5 h [3 – 7], ICU time was 18 h [15 – 21], bleeding requiring revision occurred in 21 patients (5.3%) always through the same access. PM implantation occurred in 3%, vascular complications in 1%. We had 1 case of endocarditis, 1 case of early failure, 1.3% mitral redo.

Conclusions

In high volume centers isolated endoscopic MVS without preoperative patient selection has proven to be safe with optimal mortality, good fast–track and low incidence of complications.
P101 HIGH–DENSITY MAPPING OF KOCH‘S TRIANGLE DURING SINUS RHYTHM AND TYPICAL AV NODAL REENTRANT TACHYCARDIA INTEGRATED WITH THE DIRECT RECORDING OF ATRIOVENTRICULAR NODE STRUCTURES POTENTIAL: A MULTICENTER NON–RANDOMIZED STUDY
Authors: Matteucci A , Russo M , Galeazzi M , Botto G , Castro A , Zingarini G , Del Giorno G , Papa A , Di Belardino N , Segreti L , Pepi P , Casale M , Treglia S , Nicolis D , Carbone A , Lavalle C , Malacrida M , Pandozi C , Colivicchi F
Published: May 2023

Background

Atrioventricular nodal re–entrant tachycardia (AVNRT) is humans‘ most frequent regular tachycardia. Nevertheless, understanding the exact mechanism and pathways involved in the circuit that sustains the arrhythmia is still incomplete. Also, the recording of nodal potential was performed previously in animals with relative success, but not in humans. The aim of our study is to identify the potential of the compact atrioventricular node (AVN) and inferior extensions by using an electroanatomic mapping of the right atrium and the Koch‘s triangle in sinus rhythm and during AVNRT.

Methods

From March 2021 to July 2022, 79 patients with AVNRT underwent high–resolution mapping and complete ablation in 12 Italian Hospitals. No patients with atrial fibrillation or sustained ventricular tachycardia were included. The diagnosis of AVNRT was established according to standard criteria and diagnostic pacing manoeuvres. The presence and location of SP potentials, i.e., Jackman potential (JP) and Haïssaguerre potential (HP) were evaluated in each patient. The electroanatomic mapping obtained were merged with cardiac computerized tomography (CT) scan.

Results

Forty–five cases of successful AVNRT ablation were included in the analysis. The AVN potential has been demonstrated to be a very low frequency signal distinct from atrial, His bundle or ventricular activations, that can be recorded from electrodes overlying the region of the compact AVN by using a non–conventional bipolar electrogram filtering both during sinus rhythm and slow fast AVNRT. AVN potential was identified in all cases in the mid–septal region (#5) in both sinus rhythm and tachycardia. The mid–septal region and the postero–septal regions (#7) bounded anteriorly by the tricuspid annulus and posteriorly by the lateral wall toward the crista terminalis showed a higher prevalence of HP than other regions (46.7% in region #5 and 51.1% in region #7, p<0.0001 vs other regions, respectively). JPs seemed to have a converse distribution across the KT and they were mainly observed in the mid–postero–septal region (73.3%). After 359±121 days of follow–up, no patients had a recurrence of AVNRT.

Conclusion

The exact anatomical site and pathways involved in AVNRT are still unclear as well as the analysis and characterisation of the AVN potential. Our results represent the first evidence of the recording of AVN potential. Further studies and technological improvements are needed to confirm our results.
P102 DIFFERENCES IN HIGH–DENSITY MAPPING OF KOCH‘S TRIANGLE DURING TYPICAL AV NODAL REENTRANT TACHYCARDIA INTEGRATED AND NOT INTEGRATED WITH DIRECT RECORDING OF ATRIOVENTRICULAR NODE STRUCTURES POTENTIAL: A MULTICENTER NON–RANDOMIZED STUDY
Authors: Matteucci A , Galeazzi M , Russo M , Botto G , Castro A , Zingarini G , Del Giorno G , Papa A , Di Belardino N , Segreti L , Pepi P , Nicolis D , Carbone A , Lavalle C , Casale M , Treglia S , Malacrida M , Pandozi C , Colivicchi F
Published: May 2023

Background

Despite the sustained efforts and advances in the fields of anatomy, histology, immunohistochemistry and cardiac mapping, the definition of the AVNRT circuit in humans is still incomplete. This discouraging result can be explained by many reasons, but the most important one has been the impossibility to map the AVNRT circuit without recording the electrical activity of the AVN and its extensions, which represent the diastolic interval in the tachycardia cycle. The aim of this study was to compare high density activation mapping integrated and not integrated with AV node potential recordings to establish the importance of annotation of AV nodal structure electrical activity in defining Koch’s triangle activation during AVNRT.

Methods

Electroanatomic 3–D reconstruction and propagation automated mapping of atrial activation during both sinus rhythm and tachycardia was performed using a basket catheter (64 electrodes of 0.4–mm2 area; 2.5–mm spacing, Orion, Boston Scientific, Natick, MA) and the Rhythmia electroanatomic mapping system in group 1 patients (X). In group 2 patients (45) the AV node potential (a very low frequency signal distinct from atrial, His bundle or ventricular activations, recorded from electrodes overlying the region of the compact AV node and its extensions by using a non–conventional bipolar electrogram filtering of [0.05/1 – 250] Hz) were also recorded both during slow fast AVNRT.

Results

The integrated map showed that during AVNRT, the activation wavefront descends from the Tendon of Todaro region (fast pathway area) and rises along the septal leaflet of the tricuspid valve through the RINE and reaches the AV bundle probably via the LNB bypassing the compact AV node almost completely. This kind of activation of the Koch’s triangle was not reconstructed by the non–integrated map. Moreover, the recording of the potentials of the AV node structures makes it possible to obtain a 100% coverage of the tachycardia cycle which was only 32% in the non–integrated maps (p < 0.0001).

Conclusion

The recording of the electrical activity of AV nodal structures allows a better definition of the circuit of typical slow–fast AVNRT which, in the majority of the cases, is completely localised in the right atrium.
P104 LASER BALLOON APPROACH FOR PULMONARY VEIN ISOLATION IN MARFAN SYNDROME
Authors: Bernardini A , Sciara P , Paoletti Perini A , Signorini U , Milli M , Giomi A
Published: May 2023

Background

Marfan syndrome (MFS) is an autosomal dominant disorder of the connective tissue and it’s associated with an increased incidence of atrial fibrillation (AF), due to scar–mediated processes and sites of atrial ectopy. Limited data exist regarding ablation techniques in these patients. The frailty of atrial walls correlated to connective disease makes the ablation challenging with an increased risk of complications. Laser–balloon (LB) approach for pulmonary vein isolation (PVI) could be a promising strategy due to the possibility to ablate a large volume of tissue with a single application of energy, short procedure times, and real–time monitoring of balloon–tissue contact. We present a case in which LB technology was applied for PVI in an MFS patient

Clinical case

A 44–year–old woman with MFS and paroxysmal AF underwent PVI. The echocardiographic examination showed mild aortic and mitral valve regurgitation, the first due to a slight dilation of the aortic root, the latter associated with mitral valve prolapse. Atrial volume was normal. No other comorbidities were present. The procedure was executed in general anesthesia. A decapolar catheter was inserted in the coronary sinus and used later to stimulate the phrenic nerve during the ablation of the right pulmonary veins (Fig.1C). Left atria (LA) was reached after an ultrasound–guided transeptal puncture. High–density mapping of the LA was performed to assess the number and geometry of PVs (Fig.1A). A LB catheter was used to perform laser ablation at the level of PV antrum, delivering 13 W in automatic rapid mode in regions with optimal contact and 5.5 W in areas with more represented blood–tissue interface. LA mapping after ablation assessed the effective isolation of pulmonary veins (Fig.1B). No complications occurred during the procedure.

Conclusion

a laser–balloon approach for PVI in MFS patients seems feasible and safe. To our knowledge, this is the first application of this technology on MFS patients. Larger data are needed to confirm our findings.
P110 INTRAVASCULAR LITHOTRIPSY FOR THE TREATMENT OF SEVERELY CALCIFIED LEFT MAIN CORONARY STENOSIS
Authors: Pavani M , Giacobbe F , Zanda G , Sagazio E , Vadalà P , Galiffa V , Taglialatela V , De Filippo O , Annibali G , Abdirashid M , Bernardi A , Benenati S , Arena M , Ferrari F , Cordone S , Piedimonte G , Rolfo C , Cerrato E , Varbella F
Published: May 2023

Background

Even if pilot studies have been conducted to validate Intravascular Lithotripsy, most challenging cases were excluded, including unprotected Left Main (LM) coronary stenosis.

Methods

We retrospectively enrolled patients treated with IVL in a real–world multicenter registry from 21 centers among Italy and Spain from January 2020 to November 2021. The primary safety endpoint was freedom from major adverse cardiovascular events (cardiac death, target vessel revascularization, stent thrombosis) at 30 days. The primary effectiveness endpoint was procedural success (defined as stent delivery with a residual stenosis <20% and without intra–procedural MACE). Secondary endpoint were 6–months and 12–months MACE rates.

Results

From a total amount of 470 patients enrolled in our registry, 41 underwent IVL to LM stenosis. Most of them were males (78.0%). The clinical presentation was acute coronary syndrome (ACS) in 41.4% of cases. Mechanical circulatory support was necessary in 4 cases (9.7%). IVL before stent implantation was planned in 90% of cases. The primary safety endpoint occurred in 97.6%. of patients. The primary effectiveness endpoint was achieved in 97.6% of cases. Interestingly, at 6 months and 12 months, no MACE was recorded.

Conclusions

Intravascular lithotripsy for the treatment of severely calcified Left Main stenosis seems to be a safe and effective option with very high procedural success rate and low MACE rate at follow–up.
P111 RADIAL ACCESS FOR THE PERCUTANEOUS TREATMENT OF CHRONIC CORONARY OCCLUSIONS: A SINGLE CENTER EXPERIENCE
Authors: Salvi N , Fedele S , Di Russo C , Sciahbasi A , Patrizi R , Cera M , Boncompagni D , Renda M , Minardi S , Granatelli A
Published: May 2023

Background

In the last years the improvement of interventional techniques for the treatment of coronary total occlusions (CTO) trough percutaneous coronary intervention (PCI) allowed a significant increase of the number and success rate of these procedures. At the same time, transradial access is increasingly being used for CTO–PCI even though there are concerns about its efficacy in this setting because of the higher procedural complexity. Aim of our study was to review the procedural success of all the CTO–PCI performed in our center according to the vascular access utilized.

Methods

We retrospectively evaluated all the CTO–PCI performed in our center from January 2018 to December 2019. These procedures were divided in two groups according to the vascular access employed: all femoral access procedures (Group 1) or procedures with at least one radial access (Group 2). The primary end–point of the study was the procedural success. Major procedural complications, the duration of the procedure and the volume of contrast used were also evaluated.

Results

A total of 66 CTO procedures have been performed: 15 procedures in Group 1 (66 ± 14 years, 80% males) and 51 in Group 2 (66 ± 9 years; 80% males, P= NS). In Group 2, 14 procedures were performed using only radial access whereas in 38 procedures a combination of radial and femoral access have been utilized. There were no significant differences in the main cardiovascular risk factors between the two groups. In Group 2, 5 procedures were performed by retrograde approach while in Group 1 all procedures were performed by antegrade approach. There were no significant differences between Group 1 and Group 2 in terms of contrast volume used (376 ± 137 mL and 345 ± 101 mL respectively, P=0.40) or in terms of procedure time duration (132 ± 49 min and 149 ± 71 min respectively, p=0.13). Procedural success was similar in the two groups: 86% in Group 1 and 80% in Group 2 ( P=0.86). There was one only major clinical complications in group 1 ( one stroke) and no complications in Group 2.

Conclusion

In our experience, the use of radial access alone or in combination with a single femoral access is safe and effective to perform CTO–PCI.
P115 "WHEN THE GOING GETS TOUGH, THE TOUGH GET GOING": LARGE THROMBOSIS ASPIRATION DURING PERCUTANEOUS APPENDAGE OCCLUSION
Authors: Scarpino T , Pascale V , Alessandro F , Gerbasi E , Ciconte V
Published: May 2023

Background

An 83–year–old woman with permanent atrial fibrillation was referred for percutaneous left atrial appendage closure (LAAC) following a spontaneous intracranial hemorrhage caused by pituitary macroadenomas that the patient refused to excise. Pre–procedural EET revealed no formed thrombus. Intravenous unfractionated heparin (UFH) was administered. After multiple attempts, the device (Amplatzer Amulet) was correctly positioned but before final release, a large thrombus was noted within the left atrium, attached to delivery system. A further 4000 IU of UFH and 300 mg of salicylic acid were administrated, and a subsequent 300 s activated clotting time was recorded. Under continuous negative pressure in the delivery sheath via a 50 mL Luer–Lock syringe, suction of the thrombus was performed. Similarly, the device was released and the delivery system withdrawn into the delivery sheath and removed. Final EET revealed no residual thrombus within the left atrium with adequate device compression and no peri–device leaks. No further aspiration through the sheath was possible, indicating successful thrombus retrieval into the delivery sheath.

Discussion

Device–related thrombus (DRT) is a possible and terrible complication of percutaneous LAAC due to patient–specific (hypercoagulability disorders, renal insufficiency, nonparoxysmal AF) and/or procedural factors (LAAO depth of implantation >10 mm from the pulmonary vein limbus, pericardial effusion). For this patient, potential causes could be both the long intervention time required for correct positioning of the device and non–optimal pre interventional medical therapy and procedural options included either recapturing the device into the delivery sheath and abandoning the procedure or surgical thrombectomy. Both options would increase the risk of clot dislodgement and embolization. An off–label device deployment under continuous negative pressure was performed reducing embolic risk by minimizing both mechanical forces on the thrombus as well as procedural time.

Conclusion

Therefore, shorter procedural times and optimized preoperative medical therapy could reduce DRT risk. The evidence for the use of cerebral protection devices in the setting of LAAO insertion is limited to a small single case series. Randomized multicentric studies are necessary to approve routine use of these devices when the patient is deemed to be at high risk of thromboembolism based on clinical or intraprocedural factors.
P123 TRANSCATHETER ABLATION OF SUPRAVENTRICULAR ARRHYTHMIAS IN PATIENTS SUFFERING FROM HYPERTROPHIC CARDIOMYOPATHY: A PROPENSITY SCORE–BASED ANALYSIS
Authors: Pierri A , Albani S , Buongiorno A , Ricotti A , Grossi S , De Rosa C , Mabritto B , Bongioanni S , Luceri S , Negri F , Grilli G , Barbisan D , Burelli M , Biondi F , Cireddu M , Berg J , Musumeci M , Di Donna P , Vianello P , Del Franco A , Scaglione M , Barbati G , Berchialla P , Russo V , Imazio M , Porto I , Canepa M , Peretto G , Francia P , Autore C , Castagno D , Gaita F , Olivotto I , Merlo M , Sinagra G , Musumeci G
Published: May 2023

Background

To date, the prognostic impact of transcatheter ablation (T–Abl) of supraventricular arrhythmias (SA) in HCM patients has not been satisfactorily elucidated.

Objectives

To assess the impact of T–Abl on clinical outcomes in a large cohort of HCM patients.

Methods

In this retrospective multicenter study, 570 consecutive HCM patients with SA were enrolled, 425 receiving medical therapy and 145 undergoing T–Abl. 1:1 propensity score matching (PSM) led to the inclusion of 234 patients (117 intervention group, 117 medical group) in the final analysis for endpoint evaluation. The primary outcome was a composite of all–cause mortality, heart transplantation (HT) and worsening heart failure (HF). Additionally, an inverse probability weighted (IPW) model was elaborated.

Results

At PSM analysis, after a median follow-up of 57.3 months, the primary endpoint occurred in 31 (26.5%) patients in the intervention group vs 38 (32.5%) in the medical group (p=0.871). Thromboembolic strokes and major arrhythmic events in the intervention vs the medical group were 9.4% vs 9.4% (p=0.367) and 5.1 vs 7.7% (p=0.741), respectively. Fewer patients in the intervention vs medical group experienced SA recurrences (64.1% vs 84.6%, p<0.001) and transition to permanent SA patterns (21.4% vs 37.6%, p=0.007). IPW analysis showed consistent results. Severe complications related to T–Abl were uncommon (0.7%).

Conclusions

At 5–year follow–up, T–Abl does not improve major clinical outcomes in a large cohort of HCM patients. Nevertheless, T–Abl seems to facilitate the maintenance of sinus rhythm and decelerate the progression to permanent SA. Lastly, T–Abl is usually safe in HCM.
P128 CTLA–4 AND PD–1 BLOCKING AGENTS AFFECTS LONGITUDINAL AND RADIAL STRAIN IN PRECLINICAL MODELS, INCREASES SYSTEMIC CXCL12, CARDIAC FIBRONECTIN EDA, S–100 CALGRANULIN, GALECTINE–3 AND NLRP–3/MYD–88/CHEMOKINE PATHWAYS
Authors: Quagliariello V , De Lorenzo C , Passariello M , Di Mauro A , Cipullo C , Paccone A , Iovine M , Bruzzese F , Palma G , Luciano A , Maurea N
Published: May 2023

Background

Immune checkpoint inhibitors (ICIs) have significantly changed the oncology clinic in recent years, improving survival expectations in cancer patients. ICI therapy have a broad spectrum of side effects from endocrinopathies to cardiovascular diseases. In this study, pro–inflammatory and pro–fibrotic effects of short–term ICIs therapy in preclinical models were analyzed.

Methods

Firstly, in a human in vitro model, human cardiomyocytes co–cultured with hPBMC were exposed to ICIs (with CTLA–4 or PD–1 blocking agents, at 200 nM) for 72h. After treatment, production of DAMPs and 12 cytokines were analyzed in the supernatant through colorimetric and enzymatic assays. C57/Bl6 mice were treated with CTLA–4 or PD–1 blocking agents (15 mg/kg) for 10 days. Before (T0), after three days (T3) and after treatments (T10), ejection fraction, fractional shortening, radial and longitudinal strain were calculated by using bidimensional echocardiography (Vevo 2100,Fujfilm). Fibrosis, necrosis, hypertrophy and vascular NF–kB expression were analyzed through Immunohistochemistry. Myocardial expression of DAMPs (S100– Calgranulin, Fibronectin and Galectine–3), MyD88, NLRP3 and twelve cytokines have been analyzed. Systemic levels of SDF–1, IL–1β and IL–6 were analyzed before, during and after ICIs therapy.

Results

Radial and longitudinal strain were decreased after 10 days of ICIs therapy. Histological analysis of NF–kB expression shows that short–term anti–CTLA–4 or anti–PD–1 treatment increased vascular and myocardial inflammation. No myocardial hypertrophy was seen with the exception of the pembrolizumab group. Myocardial fibrosis and expression of galectin–3, pro–collagen 1–α and MMP–9 were increased after treatment with all ICIs. Both anti–CTLA–4 or anti–PD–1 treatments increased the expression of DAMPs, NLRP3 inflammasome and MyD88 and induced both in vitro and in vivo the secretion of IL–1β, TNF–α and IL–6. Systemic levels of SDF–1, IL–1β and IL–6 were increased during and after treatment with ICIs.

Conclusions

Short therapy with PD–1 and CTLA–4 blocking agents increases vascular expression of NF–kB, systemic SDF–1, IL–1β, IL–6 levels and myocardial NLRP3, MyD88 and DAMPs expression in preclinical models. A pro–inflammatory cytokine storm was induced in myocardial tissues and in cultured cardiac cells after ICIs therapy.
P129 RARE CASE OF A GIANT THYMIC CYST: A CHALLENGING DIFFERENTIAL DIAGNOSIS OF A PARACARDIAC CYSTIC LESION
Authors: Schiavo M , Foroni M , Coccolo F , Graziosi M , Attinà D , Dolci G , Galiè N
Published: May 2023

Background

Benign thymic cysts are a rare clinical entity, representing approximately 3% of all mediastinal masses and can be congenital or acquired. We report a case of a 58–year–old female with a giant benign thymic cyst which entered in differential diagnosis with pericardial cyst and pericardial effusion. Case presentation: A 58–year–old female was brought to our hospital due to new onset dyspnoea and fatigue. She had a history of a mediastinal liquid mass incidentally discovered 9 years before which was interpreted at that time as a loculated pericardial effusion (Fig. 1). An echocardiogram was performed and it revealed increased size of the known lesion without any signs of hemodynamic compromise (Fig. 2). A magnetic resonance showed a voluminous liquid lesion that originated from the anterior mediastinum, extending caudally to the diaphragm with maximum dimension on the right hemithorax of 16 x 12 x 9 cm and on the left hemithorax of 10 x 5 x 13 cm (antero–posteriorly, transversely and cranio–caudally respectively) (Fig. 3). It was initially interpreted as a pericardial cyst. All the findings were then collegially reviewed and it was suspected of being a giant thymic cyst especially due to its rapid growth and spatial evolution over time. The cyst was surgically removed using a thoracoscopic approach. Histological examination confirmed the thymic origin of the cyst and excluded malignancy. At three month follow up, the patient presented no symptoms, and the echocardiogram was normal.

Discussion

The echocardiographic features of mediastinal cysts are not specific for the type of cystic lesion, so the origin and location of the cyst can be used for differential diagnosis. Computed tomography has the best spatial resolution, while the magnetic resonance has better capacity to differentiate the content of the cyst, especially when it is not a homogeneous liquid lesion. In our case, the growth over nine years was a crucial hint to suspect the thymic origin of the lesion. On the other hand, the sole evaluation of the last imaging exam would have made the diagnosis more challenging because of its huge dimensions, which made the exact site of origin almost impossible to identify.

Conclusion

Our case is a rare example of a giant thymic cyst which was extremely difficult to differentiate from other paracardiac cystic lesions and required integrated imaging and discussion by a team of experts of different specialties to make the correct diagnosis.
P138 ST–SEGMENT ELEVATION, QTC PROLONGATION AND BRUGADA LIKE PATTERN IN THE EMERGENCY DEPARTMENT: A NEW ENTITY FOR US TO KNOW? CASE 1
Authors: Carmina M , Bellavia D , Pieri D , Donzelli M , Vaccaro P , Panzarella G , Bonomo V , Polizzi V , Geraci G
Published: May 2023

Introduction

ST elevation (STE) usually means acute transmural ischemia by epicardial coronary artery occlusion by a blood clot,so Guidelines recommend rapid reperfusion therapy, possibly within the first hour. Nevertheless,STE due to non–ischemic etiologies has been reported in up to 15% of the general population.We report a case of ‘likely STEMI’ presenting with marked STE,QTc prolongation and Brugada like pattern on ECG but no significant coronary obstruction on angiography.Case 1A 74y woman presented in the ER with syncope and chest pain.History of pulmonary emphysema and Crohn‘s disease previously operated on. On admission:apyretic,BP 80/40, HR130 bpm, SO2 98% on mask O2 12 l/min.WBC 20,000, 84% neut, high D–Dimer 36091 and HS–TnI 99. On transthoracic echo (TTE) akinesis in apical, apical lateral, anteroseptal, and anterior wall and EF 25%.On Chest CT bilateral emphysema,no pulmonary embolism.On ECG sinus tachycardia,frequent PVCs,diffuse deep negative waves and prolonged QTc.While in ER,a new she syncope occurred,and tachycardia with large complex,with spontaneous resolution,was observed.On ICU admission ECG diffuse STE with coved pattern in V1 and prolonged QTc 641 ms;treated with magnesium sulfate,calcium gluconate,metoprolol,ASA,heparin;on urgent coronary angiography subcritical stenosis of left anterior descending artery without blood clot:PCI with drug–eluting stent was performed. Nevertheless,ECG did not change while multiple ventricular fibrillations occurred later, requiring electric shock.Later on, after prolonged treatment with magnesium sulfate, Calcium gluconate, antibiotic, electrolytes correction,QTc,ECG and EF progressively normalized.

Discussion

The patient reported was labelled as a “TakoTsubo syndrome“ diagnosis,but in fact we think the ECGs (persistent STE, prolonged QTc and Brugada pattern), the TTEs and clinical features can be explained by different nosological entity due to the dysregulated INa, and in particular by increased late sodium current INa late : it leads to impaired cardiac energetics and contractile dysfunction as well as cardiac arrhythmias; acidosis and hypoxia can also increases IN late.As for our patient, unlike Takotsubo syndrome, she had no emotional trigger, no characteristic apical balloon on TTE, while severe physical trigger like hypoxia and acidosis stand out.Patients presenting with these ECG features should not be treated with thrombolysis but referred to a HUB center for coronary angiography.
P141 ACUTE MYOCARDIAL INFARCTION OR SOMETHING MORE? CASE REPORT AND CHALLENGES ASSESSMENT OF GIANT CORONARY ANEURYSM MANAGEMENT
Authors: Pala B , Tifi P , Bruno N , Tocci G , Gabrielli D
Published: May 2023

Background

Coronary Artery Aneurysms (CAA) are defined as localized coronary artery dilations more than 1.5 times the diameter of the adjacent segments. Giant CAA (GCAAs) are rare coronary diseases and the presence of multiple CAAs, located in more than one coronary artery, is even more uncommon. The pathophysiology is unknown but the majority are due to atherosclerosis. There is currently no consensus concerning the management. Case presentation: We report the case of a 72–year–old man, referred to our emergency department due to chest pain. The patient’s electrocardiogram was consistent with myocardial infarction with inferior leads ST–segment elevation. Two-dimensional echocardiography showed hypertrophic Left Ventricle (LV) with akinesia of the infero–postero-lateral LV wall and hypokinesia of the remaining LV segments (LVEF = 40%). Coronary angiography and computed tomography revealed multiple CAAs, some of them giant, associated with significant coronary artery disease: two CAAs on the right coronary artery, including a giant one (Dmax 11 mm and Dmax 32 mm); one large aneurism on the circumflex artery (D max 20.5 mm) and one on the left main descendent artery (D max 8 mm). The patient had a previous history of hypertension, dyslipidemia and abdominal aortic aneurysm. He had no history of percutaneous coronary intervention or cardiac surgical procedures. Serological studies for vasculitis or connective tissue disease were all negative. The patient underwent surgical exclusion of the giant right CAA with ligation of the proximal and distal ends of the aneurysm and double bypass surgery to the obtuse marginal and right posterior descending coronary arteries.

Conclusions

CAAs’ treatment options include medical treatment, interventional or surgical management. No clear evidence about the better option exists, but it seems that surgical option should be favored in cases of bigger, more tortuous and more calcified CAAs. Based on these evidences and the anatomic lesions of our patient, we opted for surgery and he successfully underwent CAAs resection with coronary bypasses. We reported our experience and we examined the current knowledge on CAA/GCAA. Overall, management is hampered by lack of evidence. We need prospective studies and registries to further our knowledge in the management of this disorder and prognosis. From our attitude, surgical treatment should be performed for multiple GCAA to prevent fatal complications.
P142 EARLY MANAGEMENT OF STEMI PATIENTS DURING COVID–19 PANDEMIC: THE ROLE OF AN EMERGENCY DEPARTMENT–BASED CARDIOLOGY UNIT IN SAN RAFFAELE SCIENTIFIC INSTITUTE
Authors: Morciano D , Barki M , Mager R , Morosato M , Ricchetti G , Assanelli A , Agricola E , Margonato A , Slavich M
Published: May 2023

During COVID–19 pandemic, a critical issue for cardiologists was to provide early access to the standard of care for patients with time–dependent diseases such as ST–segment elevation myocardial infarction (STEMI), while making efforts to prevent their exposure to SARS CoV–2. Aims: The aim of our research project was to evaluate the role of an Emergency Department–based operative unit directly managed by the Cardiology Department in providing a prompt cardiological evaluation to STEMI patients at first medical contact, which we assumed might positively impact on the reperfusion strategy and timing and thus on the extent of myocardial salvage.

Methods

We retrospectively included a group of STEMI patients admitted by our ED with a definitive diagnosis of STEMI from March 2020 to November 2021 and a control group admitted from January 2019 to February 2020. The groups were compared in terms of critical time intervals, rate of PCI or initial non–invasive conservative management, pre–discharge characteristics and in–hospital clinical outcomes, including all cause mortality and complications.

Results

Throughout the study period, a total of 211 patients were admitted to our institution with a diagnosis of STEMI. The number of patients presenting late (at least twelve hours since symptoms onset) was significantly higher and time from symptoms onset to hospital admission was significantly longer during the first COVID–19 pandemic peak, compared with the previous year. Almost all patients in both cohorts underwent invasive coronary angiography with subsequent primary PCI. Remarkably, despite the time–consuming hygiene practices and policies necessary to prevent patients’ exposure to SARS CoV–2 virus, door–to–balloon time was comparable between the two cohorts. No statistically significant differences were found regarding the occurrence of STEMI–related complications. The in–hospital mortality was comparable between the two cohorts, as was predischarge LVEF. The high–sensitivity Troponin–T peak was significantly lower after the introduction of the ED–based cardiology unit. Total in–hospital stay was shorter after the introduction of the ED cardiology unit.

Conclusions

Our experience has shed light on the potential advantages of an ED–based unit directly managed by the Cardiology Department: despite the confirmation of a longer time from symptoms onset to hospital admission, no significant differences were found in terms of hard outcomes between the groups.
P144 USE OF SACUBITRIL/VALSARTAN IN A GUCH PATIENT POPULATION. PRELIMINARY STUDY
Authors: Sanfilippo M , Morreale P , Scardino G , Comparato C
Published: May 2023

Sacubitril/Valsartan (S/V) is used with optimal results in the therapy of heart failure (HF); reduces mortality and hospitalizations by 20% compared to ACE inhibitor therapy. There is a little data on the use of S/V in adult patients with congenital or acquired pediatric heart disease (GUCH). In these patients, HF is a real challenge for the cardiologist. HF in GUCH often has a different pathophysiology than usual, and interesting univentricular hearts in Fontan circulation, systemic right ventricle and patients undergoing multiple cardiac surgical procedures. The literature is poor in information and the guidelines do not give clear indications. We report our experience on a GUCH population. Starting from November 2019 we started S/V therapy in 13 GUCH patients with severe ventricular dysfunction, all in NYHA class III and already in optimal therapy for HF. Median age was 42.7 years (27–79 years); 8 males and 5 females. Basic heart disease: 4 patients with Fontan circulation, 3 patients with systemic right ventricle (TGA, operated according to Mustard), n. 2 complete CAV operated, n. 1 Ebstein‘s disease, n.1 Patent ductus arteriosus, n. 2 pediatric onset dilated cardiomyopathy. Median duration of follow–up 11.6 months (2–26 months). In n. 1 patient it was necessary to suspend the S/V due to skin itching, which resolved on diuscontinuation. The dosage was reduced in tree patients due to symptomatic hypotension (1 of these was taking Sildenafil). In n. In 1 patient there was a reduction in the glomerular filtration rate, which did not require discontinuation of the drug. After treatment: 6 patients are in NYHA class I, n. 3 pts in NYHA II class and 4 pts remained in NYHA III class. In the year preceding the start of S/V therapy, all patients cumulatively had n. 15 hospitalizations; in the year following the first six months of treatment, the number of hospitalizations decreased to no. 5 (4 for HF and 1 for severe anemia) The ejection fraction, evaluated by Simpson‘s method, remained stable. However, the limitations of the echocardiographic method in patients with such complex anatomy must be considered

Conclusions

The use of S/V is safe and effective in GUCH patients. However, larger studies and longer follow–up are needed.
P145 IVABRADINE IN TETRALOGY OF FALLOT AND POSTOPERATIVE JUNCTIONAL ECTOPIC TACHYCARDIA
Authors: Catucci S , Lombardi M , Maiorano A , Pirolo T , Meliota G , Massari E , Vairo U
Published: May 2023

Introduction

Ivabradine is a selective inhibitor of sodium’s If current; it acts at the level of the sinus node causing a bradycardizing effect without effect on inotropism and atrioventricular conduction. In fact, the If channel, located in pacemaker cells, is activated in hyperpolarization and allows the membrane potential to become gradually more positive until the threshold potential is reached. Previous studies have actually shown the usefulness of ivabradine not only for slowing sinus rate but also in case of atrial tachycardia and ectopic junctional tachycardia. Case report: Our patient, suffering tetralogy of Fallot, undergoes transannular patch correction surgery at the age of 6 months. During the stay in postoperative intensive care presents numerous episodes of junctional tachycardia. Therapy with amiodarone ev is undertaken, with a discrete response; on the ECG, frequent isolated and repetitive supraventricular extrasystoles (pairs and triplets) are observed. After the infusion ev is undertaken, oral therapy with amiodarone and beta–blocker is associated, but not obtaining a good rhythm control. In addition, the presence of numerous and sustained episodes of high frequency arrhythmia affects the hemodynamic parameters of the child. For the persistence of arrhythmic episodes, ivabradine therapy is undertaken at a dose of 0.05 mg/kg orally twice a day. Stable sinus rhythm is observed, so amiodarone therapy is subsequently discontinued and ivabradine therapy continued. No arrhythmias are observed either during hospitalization or in the subsequent follow–up after discharge, carried out with seriated Holter ECGs. After about 3 months, therapy is discontinued, in the absence of supraventricular and ventricular arrhythmias.

Conclusions

Ivabradine is a selective inhibitor of the sodium channel at the level of pacemaker cells; born as a bradycardizing drug for its action on the sinus node, its usefulness has also been demonstrated in the treatment of supraventricular arrhythmias due to enhanced automatism and atrial reentry. It is, therefore, conceivable the presence of If channels also in ectopic foci, which would allow its use as a real antiarrhythmic drug, exploiting its peculiar action not interfering with inotropism and atrium and intraventricular conduction.