bluuebunny/crossref_metadata_2025 huggingface dataset:
102 Different mechanics of septal and lateral walls and their effects on left ventricular ejection fraction in patients with left bundle-branch block
Authors: Kupczynska K , Nguyen K A , Surkova E , Palermo C H , Sambugaro F , Previtero M , Badano L P , Muraru D
Published: January 2020

Funding Acknowledgements

Karolina Kupczynska was supported by research grant awarded by the Club 30 of the Polish Cardiac Society

Background

Left bundle branch block (LBBB) impairs left ventricular (LV) mechanics and can lead to systolic dysfunction. However, LV mechanical changes that differentiate LBBB patients with preserved and reduced LV ejection fraction (LVEF) remain to be clarified.

Purpose

To measure myocardial work (MWI) and myocardial work efficiency (MWE) of the septal and LV lateral wall in patients with LBBB and various degrees of LV dysfunction using non-invasive strain-derived method.

Methods

Fifty-eight LBBB patients without coronary artery disease (mean age 65 ± 13 years, 60% male) were divided into 4 groups based on their LVEF according to current recommendations for cardiac chamber quantification (figure A): normal (n= 25), mildly (n= 16), moderately (n= 11), and severely (n= 6) reduced LVEF. Septal and lateral wall MWI and MWE were estimated by LV pressure-strain loop obtained by echocardiography.

Results

Both MWI (787 mmHg%, 95% CI 651-924 vs 1956 mmHg%, 95% CI 1758-2154; p < 0.0001) and MWE (71%, 95% CI 66-76 vs 85%, 95% CI 82-87; p = 0.0001) were lower in the septum than in the lateral wall. There was a progressive decrease in septal MWI and MWE with the worsening of LVEF (figure B). Conversely, MWI and MWE of the lateral wall were preserved in patients with normal, mildly and moderately reduced LVEF groups. A significant reduction of MWI and MWE in the lateral wall was detected only in patients with severely reduced LVEF (figure C).

Conclusion

In patients with LBBB, impairment in septal myocardial work escalates according to LVEF loss. Septal dysfunction was compensated by the effective myocardial work of the lateral wall in patients with normal, mildly and moderately reduced LVEF. Mechanical dysfunction of the lateral wall was associated with severe reduction of LVEF.

Abstract 102 Figure.
P172 Uncommon reason for right-sided heart failure
Authors: Mladenovic Z , Obradovic S O , Ilic I R , Djenic D J L J , Vranes V D , Djuric D J P , Jovic J Z
Published: January 2020

This paper outlines a case study 57 year old, female patient who was admitted in our institution due to severe sign and symptoms of right-sided heart failure. She complained on progressive fatigue, a shortness of breath and oedema of cruris for three months before. Initially she was hospitalized in regional hospital due to pericardial effusion and they excluded any malignancy and systemic tissue disease in that moment. Immediately after admission we have performed 2D transthoracic echocardiography which showed a large (6.7x4.9cm), oval tumours soft tissue formation in right atrium which compromise flow in Vena cava inferior and across tricuspid valve and make a gradient of 35 mmHg above it. Left and right ventricles had preserved dimensions and function, without pericardial effusion. 3D transoesophageal echocardiography (TEE) imaged confirmed huge, oval tumorous formation (8.2x7.9cm), which originated from lateral wall of right atrium and almost occupied it, compromising flow towards superior and inferior vena cava. We had detected an irregular free space, probably due to necrosis, in the middle part of that tumorous formation.

Thorax MSCT revealed heterogeneous expansive mass (19x8x8 cm) in projection of right atrium with signs of active bleeding its central part, although MSCT couldn’t exclude extra cardiac origin. There were no signs of dissemination. Cardiac MR indicated that we had extra cardiac mass (12x9x10cm) close to lateral right atrial wall and basal part of lateral wall of right ventricle which compromise flow towards superior and inferior vena cava, with no changes on surrounding structures.

The patient underwent almost complete tumour surgical resection, with a lot of bleeding complications due to its local invasiveness and central necrosis. Surgical findings completely were concordant with 3D TEE imagining which provided us very precise information about size, location and extension of tumour. Severe systemic inflammatory response syndrome (SIRS) occurred in the postoperative period, and the patient died due to multiple organ dysfunction. Patohistological analyses were conclusive of undifferentiated pleomorphic sarcoma diagnosis.

Abstract P172 Figure.
P199 Mitral valve annular disjunction prevalence and significance amongst patients with mitral valve prolapse
Authors: Faia Carvalho Dias G , Faria B , Von Hafe P , Cardoso A F , Azevedo O , Fernandes M , Leite S , Cordeiro F , Castro F , Lourenco M , Almeida F , Lourenco A
Published: January 2020

Background

Mitral valve prolapse (MVP) is a common and usually benign entity. Occasionally, patients with MVP present with mitral annular disjunction (MAD), whose prevalence and clinical significance are still not clearly established.

Purpose

This study aimed to define the prevalence of MAD in a population of patients with MVP and study its echocardiographic and clinical implication.

Methods

A total of 31 patients with MVP who underwent echocardiographic evaluation in our laboratory were retrospectively evaluated. Echocardiographic, demographic and clinical variables were assessed. Disjunction amplitude (DA) was measured in parasternal long axis view (PLAX) and MAD was considered present if a separation of ≥ 5mm was verified. Annular diameter was measured in PLAX and apical four chamber view (A4C) both in systole and diastole.

Results

MAD was identified in 9 patients (29%), having a mean DA of 12.3 ± 3.2 mm. The group of patients with MAD was significantly younger than the group without MAD (mean age of 54 ± 18 vs 67 ± 15 years; p = 0.001), but there were no significant differences regarding gender, height, weight or cardiovascular risk factors. DA was inversely correlated with body surface area (r=-0.8, p = 0.009). Systolic annular diameters in PLAX and A4C views were increased in patients with MAD (4.2 ± 0.6 vs 3.6 ± 0.7 mm, p= 0.04 and 4.8 ± 0.7 vs 4.1 ± 0.7 mm, p = 0.025, respectively). The difference between systolic and diastolic diameters in PLAX was also greater in MAD (0.5 ± 0.2 vs 0.1 ± 0.3 mm, p = 0.007). Posterior wall thickness (8.5 ± 1.1 vs 9.7 ± 1.4 mm, p = 0.035), indexed left ventricular mass (89.0 ± 15.8 vs 110.6 ± 40,2 g/m2, p = 0.04) and ascending aortic dimensions (28.7 ± 6.7 vs 37.4 ± 3.6 mm, p = 0.018) were notably inferior in MAD patients, as was left ventricle ejection fraction (LVEF) (57.5 ± 5.8 vs 62.6 ± 4.9 %, p = 0.0023). No differences were found in chamber volumes. Similarly, eletrocardiographic parameters were identical in both groups. Five patients (56%) in the group with MAD had documentation of events (palpitations, dizziness, syncope or sudden cardiac death), in contrast with just 3 (21%) in the group without MAD, although statistical significance was not achieved (p = 0.078).

Conclusion

This study revealed that MAD is common among patients with MVP and is associated with altered annulus dynamics during the cardiac cycle. Its association with younger individuals, lower LVEF and, apparently, more clinical events highlight the importance of this entity.
P216 Cardiac amyloidosis is not a single disease: an echocardiographic study of light chain vs transthyretin forms
Authors: Adam R D , Jercan A , Badelita S , Coriu D , Stan C , Serban M , Beladan C , Rosca M , Balahura A M , Ginghina C , Popescu B A , Jurcut R
Published: January 2020

Background

Cardiac amyloidosis (CA) is described as one entity. However, several subtypes of amyloid can infiltrate the heart: light chain (AL) and tranthyretin (ATTR) are the most common.

Purpose

To characterize the specific findings of the CA subtypes as a tool to aid differential diagnosis between AL and ATTR CA.

Material and methods: Consecutive patients with CA were evaluated by clinical examination, ECG, cardiac biomarkers and echocardiography with both conventional and myocardial deformation study of the left ventricle (LV), left atrium (LA) and right ventricle (RV). Amyloid subtype was described using light chain assessment for AL-CA and 99Tc-HMPD scintigraphy and TTR gene sequencing for ATTR-CA.

Results

32 patients with CA were included, 13 with ATTR and 19 with AL. Patients in AL group were significantly older, with higher levels of cardiac biomarkers. At similar LV EF and wall thickness, they had lower GLS. LA function parameters were also lower in AL pts (table). Using ROC curves, the best predictors for AL diagnosis were NTproBNP (AUC 0.937) and Tn levels (AUC 0.958), as well as LV GLS and pericardial fluid presence (both AUC 0.750).

Conclusions

At similar LV wall thickness and ejection fraction, cardiac dysfunction appears to be more severe in AL pts, with lower global LV longitudinal strain, worse LA function, higher sPAP and NTproBNP.

ATTR (13 pts) AL (19 pts) p Age (years) 50 ± 12 60 ± 8 0.01 NTproBNP (pg/mL) 3066 ± 3720 11755 ± 9114 0.02 hsTnI (ng/mL) 0.005 ± 0.008 0.147 ± 0.161 0.04 Pericardial fluid (%) 53% 100% 0.002 LVEDV (mL) 88 ± 25 75 ± 38 NS LVMi (g/m2) 166 ± 47 168 ± 41 NS LVEF (%) 50 ± 8 49 ± 16 NS LV GLS (%) -12.1 ± 3.8 -8.9 ± 4.5 0.04 Septal Basal/Apical LS 0.33 ± 0.17 0.25 ± 0.27 NS LAVi (mL/m2) 46 ± 21 45 ± 14 NS LAEF 4CV (%) 35 ± 21 24 ± 8 0.05 LA systolic strain (%) 17.4 ± 11.9 10.5 ± 5.0 0.02 RV free wall thickness (mm) 7.0 ± 1.5 7.6 ± 1.4 NS RV 6-segments strain (%) -15 ± 4 -10 ± 8 0.09 sPAP (mmHg) 36.6 ± 12.0 48.6 ± 17.2 0.04
P220 Behcet"s disease with right ventricular aneurysm
Authors: Stoodley P , Tanous D
Published: January 2020

Funding Acknowledgements

Nil

Introduction

Behcet’s disease (BD) is a rare inflammatory disorder, which predominantly impacts people of Mediterranean and East Asian origin. While the aetiology is unknown, the prevailing disorder is vasculitis. Oral, skin and ocular lesions are common: cardiac involvement is rare.

Case description

A sixty-three year old male with Behcet’s disease (BD) presented for review. On clinical examination, atrial fibrillation, prominent V waves, mild pedal oedema and a ‘to and fro’ murmur were noted. Marked elevation of right ventricular (RV) end diastolic pressure was measured by cardiac catheter.

Echocardiography and magnetic resonance imaging revealed significant RV abnormalities. The mid and apical RV regions were heavily trabeculated, and an anterior aneurysm was identified (see 2D image in abstract picture). A prominent horizontal muscular ridge in the basal RV was noted, and the RV outflow tract was narrowed. While the tricuspid valve was not apically displaced, leaflet coaptation was absent with subsequent severe tricuspid regurgitation into a grossly enlarged right atrium (see colour image in abstract picture). Management included diuretics and continuing immunosuppressives.

Discussion

BD is a rare (chronic) inflammatory disorder, which mainly affects people of Mediterranean and East Asian origin, and is often first diagnosed (in the third or fourth decades of life) following recurrent oral ulcerations, skin and ocular lesions. With BD, the prevailing disorder is vasculitis. Blood vessels of all sizes, both arteries and veins, are impacted: true or false aneurysms can occur.

BD rarely affects the heart. If there is cardiac involvement, pericarditis is the most common lesion - others include myocarditis, mitral valve prolapse, intra-cardiac thrombus and myocardial infarction. We present a rare (and possibly unique) cardiac manifestation of BD, anterior RV aneurysm.

Conclusion

In this case report we present a rare cardiac manifestation of BD, anterior RV aneurysm.

Abstract P220 Figure. Echocardiography Images
P221 Carcinoid heart disease
Authors: Tyminska A , Kaczmarska-Turek D , Kaplon-Cieslicka A , Kochanowski J , Scislo P , Bednarczuk T , Opolski G
Published: January 2020

Carcinoid heart disease is a rare disease, which develops in 20-50% of patients with carcinoid syndrome and is a main predictor of clinical outcome in those patients. Typical cardiac involvement of this disease presents as primary diseases of the tricuspid or pulmonary valves with a rare affection of left sided heart valves. The characteristic pathological findings are endocardial plaques of fibrous which may involve not only the valve leaflets, but also the subvalvar apparatus.Typical management of patients with this condition consist of the treatment of right heart failure (HF), pharmacotherapy to reduce the secretion of tumour products, and surgical valve replacement. Here we report a 56-year old male admitted to the Department of Endocrinology because of flushing with abdominal pain and diarrhea 2-3 times a week for 2 years. During hospitalization carcinoid syndrome with metastases to the liver and abdominal lymph nodes was diagnosed. Treatment with a long-acting somatostatin analog was initiated, resulting in a good control of the symptoms of the carcinoid syndrome. Trans-thoracic echocardiography revealed right atrial and right ventricular enlargement with degenerative lesions of tricuspid valve leaflets and its subvalvular apparatus, with leaflet stiffening, retraction and malcoaptation, resulting in severe tricuspid regurgitation (vena contracta [VC] width - 7 mm). Pulmonic valve was also involved with thickening of pulmonary valve cusps leading to mild pulmonary stenosis (peak gradient [PG] - 27 mmHg, mean gradient [MG] - 14 mmHg) and mild pulmonary regurgitation. Moreover, signs of pulmonary hypertension (with tricuspid regurgitation pressure gradient [TRPG] of 50 mmHg and estimated systolic pulmonary artery pressure [SPAP] of 50-55 mmHg) was observed. There were no signs of hemodynamically significant left-sided valve disease, nor of any abnormalities in segmental or global left ventricular function. After 12 months of treatment with a long-acting somatostatin analog, the patient was reassessed. Despite a good control of carcinoid syndrome symptoms and reduction in carcinoid syndrome marker (5-hydroxyindoloacetic acid), exacerbates the tricuspid regurgitation and worsens right HF was observed. Control echocardiographic examination showed significant progression of the pulmonary valve disease with severe pulmonary regurgitation (VC width - 10 mm) and mild pulmonary stenosis (PG 18 mmHg, MG 8 mmHg), a deterioration of tricuspid regurgitation (VC width - 11 mm, effective regurgitant orifice area - 0.94 cm2, regurgitant volume - 64 ml) with further enlargement of the right ventricle and right atrium, and with a consequent decrease in TRPG value (25 mmHg), despite well preserved right ventricular systolic function (TAPSE - 24 mm). Due to disease progression, treatment of HF and peptide receptor radionuclide therapy were initiated. The patient was presented for surgical valve replacement, however he did not agree to surgical treatment.

Abstract P221 Figure
P222 Pycnodysostosis and cardiac congenital defects: a rare association
Authors: Almeida I , Miranda H , Santos H , Santos M , Chin J , Almeida S , Tavares J
Published: January 2020

Introduction

Pycnodysostosis is a rare recessive autosomal hereditary disease associated with skeletal dysplasia, with no evidence of associated cardiac defects.

Clinical case

The authors report a case of a 29-years old male patient with previous diagnosis of pycnodysostosis and a corrected subaortic ventricular septal defect. He was admitted at the emergency room due to productive cough with purulent expectoration which started one week before, refractory to the first antimicrobial therapy. The patient evolved with respiratory failure and necessity of orotracheal intubation and invasive mechanical ventilation. Large spectrum antimicrobial therapy was initiated after blood cultures and serologies for atypical agents of pneumonia collection (all negative). Due to the persistence of fever and elevation of inflammatory parameters, a transthoracic echocardiogram was performed to evaluate the presence of vegetations or other complications of infective endocarditis, not excluding this hypothesis. A transesophageal echocardiogram (TEE) was then performed showing a severe dysplastic mitral valve with flail of both leaflets conditioning a torrential mitral regurgitation occupying all the left atrium; and a tricuspid valve also dysplastic with no significant regurgitation. The patient was proposed to cardiac surgery. Intraoperative TEE revealed mitral dysplastic leaflets both inserted in a single papillary muscle constituting a congenital abnormally designated parachute mitral valve presenting with torrential mitral regurgitation and no images suggestive of vegetations neither other complications. A mechanical prothesis was successfully implanted in mitral position with subsequent favorable clinical evolution.

Conclusion

In this case, the authors report two concomitant rare congenital abnormalities: one in the mitral valve and the other affecting the skeletal system, which are usually not associated.

Abstract P222 Figure.
P1596 Pulmonary hypertension in cardiology practice: clinical echocardiographic evaluation
Authors: Legkonogov A
Published: January 2020

Purpose

To study the clinical echocardiographic features of various variants of pulmonary hypertension (PH).

Methods of research. Clinical evaluation and analysis of the results of 45,000 Doppler echocardiographic studies were performed. Moderate PH corresponded to the mean pulmonary artery pressure (MPAP) level up to 50 mm Hg, severe PH was characterized by MPAP above 50 mm Hg.

Results

Clinically significant moderate and severe PH was established in 283 patients, which was 0.63% of the examined patients. Severe PH was detected in 106 patients, including 30 men and 76 women, whose average age was 43.1 ± 1.7 years in the age range of 14-75 years. Patients with congenital heart disease (CHD) represented the majority of the patients with severe pulmonary arterial hypertension (PAH) - 49 people (10 men and 39 women, mean age 43.0 ± 1.8 years in the age range of 14-69 years), including 16 with ventricular septal defect, 9 with an atrial septal defect, 7 with transposition of the great arteries, 6 with complete common atrioventricular canal defect, 3 with congenitally corrected transposition of the great arteries, 3 with a double outlet right ventricle, 3 with a common arterial trunk, 2 with the Ebstein anomaly. Severe PH was also established in 12 patients with idiopathic PAH, 21 patients with recurrent pulmonary embolism (PE), 10 with acquired valvular heart disease (AVHD) (in 7 cases with severe mitral stenosis, 3 with severe aortic stenosis), in 7 patients with postinfarction left ventricular aneurysm, 4 patients with chronic obstructive pulmonary disease (COPD), 3 with dilated cardiomyopathy. Moderate PH was diagnosed in 177 patients (97 men and 80 women, mean age 60.3 ± 1.3 years in the age range of 21-87 years), including 54 patients with dilated, 26 - ischemic cardiomyopathy, 38 with AVHD, 26 with PE, 17 post-MI patients, 9 with CHD, and 7 with COPD. PAH-specific therapy with bosentan and / or sildenafil was performed in 9 patients with idiopathic PAH and 7 patients with CHD without significant clinical effect; in other cases, nonspecific therapy was continued with diuretics, positive inotropic agents, and anticoagulants.

Conclusions

The most pronounced manifestations of PH were observed predominantly in CHD patients with advanced left-to-right and right-to-left shunting of blood, idiopathic PAH and thromboembolic PH. For prevailing venous PH, the less pronounced clinical manifestations were observed in patients with ischemic, non-coronary and valvular heart lesions, as well as with COPD accompanied by hypoxemia.
P1598 Ruptured Sinus of Valsalva: clinical and echocardiographic features at presentation and long-term results after surgical and percutaneous repair
Authors: Fusco F , Castro M , Rigby M , Shore D , Scognamiglio G , Gatzoulis M , Li W
Published: January 2020

Background

Rupture of Sinus of Valsalva (rSOV) is a rare and potentially life-threatening condition often misdiagnosed. Percutaneous device closure has been replacing surgical repair as a treatment of choice. However, long-term outcome is poorly documented.

Methods

Echo database (2001-2019) was searched for patients >16y with rSOV. Clinical data were collected from ACHD database. Marfan Syndrome patients were excluded.

Results

Fifteen patients (42.2y, 10M) were diagnosed with rSOVbetween 1979 and 2019. HF symptoms at initial presentation were reported in 50%. All cases were diagnosed by TTE with finding of high velocity continuous flow from SOV to right heart. Two were initially misdiagnosed as VSD. Digital imaging recordings of 10/15 were available. The aortic root was dilated in 8/10. Four had asymmetrical SOV dilatation. LV and LA were dilated in 7/10 and 9/10. Significant aortic regurgitation was in 4. Two had RVOTO. RVSP was always raised. Echo findings are summarised in the Table.

Mean FU after repair was 10,7y (0,9-39). Ten patients had surgical repair and 5 device closure. Seven had repair of concomitant lesions (4 VSD closure and 3 AVR) at the time of the procedure. One redo device closure was performed. During FU 1 died from Cardiomyopathy. At the latest FU significant improvement in functional class, LV and LA size and RVSP was found.

Conclusion

Patients with rSOV may present with acute HF. High velocity continuous flow from SOV to right heart on TTE is characteristic feature for diagnosis. Percutaneous closure is an attractive alternative to surgery in patients with isolated lesion. Significant haemodynamic improvement can be achieved with good long-term haemodynamic results

Tot = 15 Initial findings Latest FU NYHA class 4 class I 2 class II 2 class III 4 class IV 3 unknown 11 class I 2 class II 1 class III 0 class IV* SOV (mm) 38.2 (33-44) STJ (mm) 36.2 (26-42 Asc Ao (mm) 30.3 (25-34) rupture site 8 RC sinus, 2 NC sinus Shunt to 8 RVOT, 1 RA, 1 RVOT + RA LVEDV (ml) 169.7 (114-330) 120 (67-230)* LVESV (ml) 66(42-130) 46 (28-80)* LAVi (ml/m2) 53.1 (30-129) 35 (24-53)* LV EF% 61.2 (57-65) 60.4 (50-70) RVSP (mmHg) 53.2 (37-130) 24.06 (15-32)** Pre VS post procedure p-value: * P < 0,05 **P < 0,01

Abstract P1598 Figure. PLAX in patient with ruptured RC sinus
P1687 When the easiest answer is the right one
Authors: Olaru-Lego G , Predescu L , Achim C , Radu D N , Ginghina C , Enache R
Published: January 2020

A 42 year-old woman presented with moderate exertion dyspnea within the past months. She was hypertensive, with end stage-chronic kidney disease (CKD) on hemodialysis for 8 years, initially by arteriovenous fistula and then by central venous catheter. She associated thrombosis of both common femoral veins.

Clinical examination revealed mild leg edema, hepatomegaly, III/VI systolic murmur, left brachiocephalic arteriovenous fistula with aneurismal dilation and subclavian central venous catheter. Resting ECG showed atrial flutter with variable block and biventricular hypertrophy. Lab studies highlighted mild anemia, glomerular filtration rate (MDRD) 13.5 ml/min/1.73m2, hyperhomocysteinemia.

Transthoracic echocardiography revealed left ventricle (LV) with normal diameters and mild concentric hypertrophy, mild systolic LV dysfunction and diastolic dysfunction (Fig A), dilation of both atria, mild mitral regurgitation, dilated RV with moderate global dysfunction, moderate tricuspid regurgitation and secondary pulmonary hypertension (PH) with estimated systolic pulmonary artery pressure of 79 mmHg (Fig C), moderate pulmonary regurgitation, moderate dilatation of pulmonary artery. Vascular Doppler ultrasonography showed thrombosis of the arteriovenous fistula and of right jugular vein. To confirm PH, right heart catheterization was necessary. The intervention could not be realized on femoral approach due to thrombosis of both common femoral veins. We considered the jugular approach, but weighing the risks/benefits balance, with one functional jugular vein, we decided not going for it, as the jugular approach was the only vascular approach for dialysis. We performed left catheterization right after a dialysis session and an LV end-diastolic pressure of 13 mmHg was measured. The possible causes of PH considered in this case were the CKD by itself, a pulmonary thromboembolic component in a patient with hyperhomocisteinemia and thrombosis of both femoral veins and a left heart component given the borderline value of LV end-diastolic pressure.

The patient received treatment with beta-blockers, blockers of the renin-angiotenins-aldosterone system, calcium channel blockers and oral anticoagulation. She was evaluated after two months describing improvement of symptoms. The resting ECG showed sinus rhythm and the echocardiography revealed improved parameters of LV diastolic function (Fig B), with reduction of systolic pulmonary artery pressure (Fig D) and improvement of right heart parameters.

PH is a frequent complication in patients with CKD on hemodialysis. Possible mechanism of its development include RV overload with increased pulmonary flow or creating a fistula with an increased flow through arteriovenous shunt. Thromboembolic complications and hyperhomocysteinemia are other frequent findings in these patients. Despite all the above, the left heart involvement with LV diastolic dysfunction remains a common and amendable cause of PH in this setting.

Abstract P1687 Figure.
P1699 A case of atrial myxoma presenting with acute stroke
Authors: Gray R , Brassil J , Jepson N
Published: January 2020

A 73-year-old female presented with sudden reduced level of consciousness on the background of rheumatoid arthritis and dyslipidaemia. On examination she had a Glascow Coma Score of 12 and an irregularly irregular pulse. The electrocardiograph confirmed atrial fibrillation and showed widespread T wave inversion. A computed tomography cerebral angiogram showed an acute basilar artery occlusion. She was transferred to a tertiary centre where she had successful endovascular clot retrieval. An urgent transthoracic echocardiogram (figure 1) showed apical hypertrophy, normal systolic function and a large right atrial mass. The left atrial size was normal. A transoesophageal echocardiogram (figure 3) confirmed a large pedunculated mobile mass with a hypermobile septum consistent with a patent foramen ovale. There was no right to left doppler flow, however the atrial mass obstructed the course, and a bubble study was positive. The cardiac magnetic resonance image (figure 2) showed a 47 x 48 mm pedunculated lesion within the right atrium, arising from the intraventricular septum, demonstrating moderate T2 signal intensity, and intermediate T1 signal intensity, with avid enhancement, consistent with a right atrial myxoma. There was increased apical wall thickening at 15mm which confirmed apical hypertrophic cardiomyopathy. An open surgical resection and left atrial appendage ligation was performed on day 11 of admission. Histopathology confirmed an atrial myxoma. She had an excellent neurological recovery with only mild diplopia. The mechanism of stroke was likely atrial fibrillation secondary to increased left atrial pressure from apical hypertrophic cardiomyopathy. However, the unexpected finding of a right atrial myxoma with a corresponding patent foramen ovale provides a second possible mechanism.

Abstract P1699 Figure. Right atrial Myxoma
P1709 Left atrial strain: a novel prognostic marker in patients with chronic kidney disease
Authors: Gan G , Kadappu K , Bhat A , Fernandez F , Gu K , Cai L , Eshoo S , Thomas L
Published: January 2020

Funding Acknowledgements

Nil

Background and objectives

Patients with chronic kidney disease (CKD) are at increased risk of adverse cardiovascular events that are underestimated by traditional risk stratification algorithms. We sought to determine clinical and echocardiographic predictors of adverse outcomes in CKD patients.

Methods

Stage 3 and 4 CKD patients without previous cardiac disease underwent a comprehensive transthoracic and stress echocardiogram, with left ventricular (LV) and left atrial (LA) strain analysis. Participants were followed for the primary end point of a composite of all-cause death and major adverse cardiovascular events (MACE). The secondary end point was a composite of cardiovascular death and MACE.

Results

243 patients (male 63%; mean age 59.2 ± 14.4 years) were followed for a median of 3.9 ± 2.7 years. 69 patients met the primary endpoint and 58 the secondary end point. Age (p < 0.01), history of diabetes mellitus (p < 0.01), indexed LV mass(LVMI) (p < 0.01), LV global longitudinal strain(GLS) (p < 0.01), indexed LA volume(LAVI) (p < 0.01), E/e’ ratio (p < 0.01) and LA strain (LAs) (p < 0.01) were independent predictors of death and MACE. On Cox proportional hazards regression analysis, LAs (p < 0.01) was the only independent predictor for the primary end point in a model accounting for age, diabetes mellitus, LVMI, LVGLS, E/e’ and LAVI. LAs remained an independent predictor for the secondary end point.

Conclusions

LAs is an independent predictor of death and MACE in CKD patients, in whom the predominant cardiac abnormality is diastolic impairment. LAs is a prognostic biomarker, reflecting alterations in diastolic function in CKD.

Abstract P1709 Figure. Kaplan Meier curve of LAs
P1714 When the mechanism of mitral regurgitation is unclear, 3D Trans-esophageal echocardiography is the solution
Authors: Thabet N , Labib D , Nagy S , Mahmoud-Elsayed H
Published: January 2020

Introduction

Assessment of mitral regurgitation (MR) mechanism is not always easy and may require advanced imaging techniques.

A 28-year-old male presented with significant MR three years following surgical mitral valve repair for severe MR due to mitral valve prolapse. During surgery, he underwent artificial chordal implantation on A2 scallop and Gore-Tex posterior band annuloplasty. Early post-operative transthoracic echocardiography (TTE) showed mild to moderate eccentric, posteriorly directed MR of unknown mechanism. Since the patient was asymptomatic, only regular follow-up was advised. He missed his follow-up for three years after which presented complaining of exertional dyspnea NYHA class II.

TTE showed dilated left ventricular dimensions with moderate to severe MR of unknown mechanism.

2D trans-esophageal echocardiography (TEE) (figure 1, panel A& B) showed severe, posteriorly directed mitral regurgitation, with a mass (arrow head) at the level of the mitral annulus.

3D TEE (figure 1,panel C, 3D zoom mode and panel D, true view mode) showed dehiscence (arrow head) of the annuloplasty band from the posterior mitral annulus with a wide gap measuring 83 mm² in 3D planimetred area. The patient was referred for re-do surgery.

Conclusion

3D TEE has a great added value in elucidating the mechanism of MR in obscure cases and guiding the proper management strategy.

Abstract P1714 Figure 1
P1727 Large coronary artery to pulmonary artery fistula as primary source of pulmonary blood supply in tetralogy of fallot with pulmonary atresia
Authors: Aslam N , Rashid Z , Mohsin M , Chowdhury D , Sultan Hasan B
Published: January 2020

Funding Acknowledgements

Not Applicable

OnBehalf

Not Applicable

Introduction

Pulmonary blood supply in patients of Tetralogy of Fallot with pulmonary atresia is usually from patent arterial duct or major aortopulmonary collaterals (MAPCAs) arising from descending thoracic aorta. We describe a case in which large coronary to pulmonary artery fistula was the primary source of pulmonary blood supply.

Case Report

A 17 years old female was referred to our hospital for diagnostic workup of suspected congenital heart disease. She was previously undiagnosed and now complains of progressive shortness of breath for last few months.

On physical examination she was non-dysmorphic with oxygen saturation of ∼ 77 % in room air, blood pressure of ∼ 117/72 mmHg, pulse rate of ∼ 89 beats per minute and respiratory rate of ∼ 24 breaths per minute. She was clinically cyanosed with grade 3 clubbing and polycythemic. Cardiovascular examination revealed quiet precordium with normally placed apex beat, grade 2 parasternal heave with single second heart sound and grade 3/6 continuous murmur along left mid sternal border.

Twelve lead electrocardiogram (ECG) showed normal sinus rhythm, right axis deviation and right ventricular hypertrophy. There was no evidence of ischemia. Chest X-ray revealed "boat shaped heart" with oligaemic lung fields. Transthoracic echocardiography showed large conoventricular ventricular septal defect with bidirectional flow. There was aortic over-ride with dilated left main coronary artery. No forward flow was seen across right ventricular outflow tract. Considering hugely dilated left main coronary artery, suspicion of coronary to pulmonary artery fistula was made and cardiac computed tomography followed by conventional angiography was done, both confirmed the diagnosis of Tetralogy of Fallot with pulmonary atresia and large coronary artery to main pulmonary artery fistula as a primary pulmonary blood supply. Two small collaterals (MAPCAs) were also identified supplying small part of right and left lungs.

Conclusion

This case highlights unusual source of pulmonary blood supply in Tetralogy of Fallot with pulmonary atresia. Correct pre-operative diagnosis is essential for appropriate surgical planning and better outcome.

Abstract P1727 Figure. TOF-PA with CA to PA Fistula
P1311 A rare case of asymptomatic cyst in interatrial septum longterm observation
Authors: Lewek J , Bielecka-Dabrowa A , Banach M , Maciejewski M
Published: January 2020

Background

Incidental findings in echocardiography performed from other indications are not always able to explain the patient condition as well as the observed pathology. However, review of literature, helps to find the most possible explanation. We present a case study of a patient with our proposal of possible diagnosis.

Case report

28-year old female with hypothyroidism and no other concomitant diseases presented with easy fatigue. Exercise stress test was clinically and ECG negative with 12,8 METs. Transthoracic echocardiography showed normal size of heart structures with preserved systolic and diastolic function of both left and right chamber. The only abnormality was a cystic structure of 44x31x34 cm in interatrial septum which was protruding to both left and right atrium and was not affecting the blood flow with normal gradients. We did not find any signs of inflammation nor infiltration to the heart walls. There was no flow inside the cyst with the use of colour Doppler. The structure had homogenous echolucency with very thin walls and a septum inside. As we did not find any connection between the cyst and the atriums we considered it as not harmful in terms of a risk of embolization. Patient was hemodynamically stable, there was no history of neurological dysfunctions nor atrioventricular conduction disturbances. Taking into account possible diagnoses for that patient we decided to schedule the patient for follow-ups. Ten years observation period confirmed that that our approach was proper. Serial echocardiographic studies showed no change in the cyst. In this year we performed multimodality imaging with CT and MRI, which showed the same views as echocardiography.

Discussion

The most possible diagnose for our patient is a bronchogenic cyst, a very rare congenital bronchopulmonary malformation of the foregut that is usually found incidentally with mostly asymptomatic benign course. Also the localization of the cyst confirms that diagnosis. Nevertheless the final diagnosis would be possible only in histopathological study.

The differential diagnosis should include a cystic myxoma and echinococcosis. However the structure is not polycystic and seems to have homogenous echolucency. We ruled out the blood cyst because of the lack of typical localization and connection to valves.

As long as the patient remains asymptomatic surgical resection remains controversial.
P268 Epicardial cyst in a three months old baby: a challenging decision
Authors: De Roberto A M , Del Pasqua A , Chinali M , Francalanci P , Esposito C , Iacomino M , Ciliberti P , Secinaro A , Galderisi M , Carotti A , Rinelli G
Published: January 2020

We report a case of a three months old baby, with no history of heart disease, referred to our center for cardiological screening. EKG was normal and a physiologic 1/6 systolic murmur was present. Conversely, echocardiography revealed a thin-walled, echo-free cystic intrapericardic structure adjacent to the posterior wall of the left ventricle; no signs of compression on cardiac structures were evident. CAT scan confirmed the presence of echo-free cystic over-diaphragmatic structure at the crux cordis level. The cyst was described as located between visceral pericardial layer and muscolar ventricular wall and appeared to cause compression on the midbasal wall of the left ventricle, of the interventricular septum and less extensively on the right ventricle. The dimension of the cyst was 2.7x2.5x1.8 cm. Worthy of note, posterior interventricular and posterolateral coronary arteries were very close to the cyst and partially pushed apart one from the other by the mass. Eight months after the diagnosis we detected an increase in mass size, confirmed also by cardiac MRI showing a mass of 4.5x3.4x3 cm with an extimated volume of 23 cm2. Because of significant increase of dimension of the cyst we decided for surgical excision of the mass. The cyst contained clear and translucent fluid and was successfully removed. Pleuropericardial window was created to prevent pericardial effusion. Histopathological report suggested the diagnosis of bronchogenic cyst because of the presence of smooth muscle.

Bronchogenic cyst are closed epithelial-lined sacs developed from the respiratory system as the result of an abnormal budding process during the early development of the foregut. These congenital malformations are usually located in the mediastinum or in the lung parenchyma, but atypical locations such as neck, intramedullary part of the spine, diaphragm or intraabdominal region have been reported. Only a few cases occurring in the heart have been described, but their location in the left ventricle is extremely rare. Bronchogenic cyst are usually asymptomatic: symptoms are related to the interaction with the adjacent structures and therefore depend on the dimensions and the localization of the mass. Surgical approach is mandatory if a complication occurs. Conversely there is not a unique approach for asymptomatic mass as in our case.

The young age of the baby and the absence of symptoms argued in favor of a "watchful waiting" strategy. Nevertheless, the particular localization of the cyst at the crux cordis level, its relatively rapid growth and above all the evidence of a close relationship with the coronary arteries, suggesting a concrete risk of compression with further enlargement, were determinant for the final decision for surgical excision.

Abstract P268 Figure 1
P273 The role of multimodality imaging in the evaluation of arteritis
Authors: Matajira Chia T M , Castineira Busto M , Cespon Fernandez M , Gimena Reyes B , Calvo Iglesias F , Ir A
Published: January 2020

A 61-year-old man was admitted to the hospital with an atypical pain lumbar with oligoanuria. Other comorbidities were: arterial hypertension, diabetes mellitus and smoking .On examination the patient was comfortable at rest, with a heart rate of 89 b.p.m. and a blood pressure of 147/2 mmHg. Normal S1 and S2 heart sounds were present. There were no signs of heart failure present. Patients complained of pain in hypogastrium on palpation. Creatinine 2.33 mg / dL. PCR 72. The immunological studies were normal (including IgG and IgA serological levels, antinuclear antibodies, extractable nuclear antigens, anti-neutrophil cytoplasmic antibodies.

An Body CT was performed, it shows mass that includes the ureters as well as the iliac arteries and parietal thickening in aorta wall.

The positron emission tomography–computed tomography (PET CT) scans was performed that evidences pathological hypermetabolism that surrounds both primitive iliac arteries with maximum SUV 12 g / ml. Pathological hypermetabolism in ascending aorta until reaching arch with maximum SUV of 9.1 mg / ml compatible with periaortitis in the ascending aorta. A study was completed with retroperitoneal mass biopsy that showed areas of retroperitoneal fibrosis with predominantly lymphoplasmacytic areas. IgG4 / IgG> 40% , Obliterative involvement of small venules suggestive of IgG4 disease. A transthoracic echocardiogram was performed which showed normal biventricular function, absence of significant valvular disease and thickening of the aortic wall compatible with periaortitis. The patient started glucocorticoid therapy with favorable response. A PET CT control was performed that showed disappearing retroperitoneal masses around iliac vessels and disappearance of activity in lateral wall of aorta and decrease activity about ascendent aorta.

DIAGNOSIS :

IgG4 -related aortitis

Abstract P273 Figure.
P280 Evaluation of right atrium in patients with gestational hypertension
Authors: Stojsic S , Ilic A , Tadic S , Grkovic D , Stojsic-Milosavljevic A
Published: January 2020

Introduction

Some authors have confirmed changes in function of the right hearth in different conditions with endothelial dissfunction, such as systemic hypertension and metabolic syndrome. During gestational hypertension (GH), endothelial disfunction is one of the main pathogenic causes of vasoconstriction and placental insuficiety and following intrauterine growth restriction. Few authors evaluated function of the right ventricle during gestational hypertension, but to our knoledge, there are no studies about right atrial function during gestational hypertension.

Purpose

We hypothesized that there are changes in right atrial function durig gestational hypertension, and wondered if they are reversible.

Methods

Study included 45 pregnant women. 25 with GH (defined as blood pressure ≥140/90mmHg that appeared after 20th week of gestation and disappeared within six weeks postpartum) and 20 normotensivewomen,as control. Function of right atrium and right ventricle was evaluated according to the last guidelines for chamber quantification. Additionally, right atrial function was assessed with p-p cycle speckle tracking. Echo was performed in the third trimester of pregnancy and 6 weeks after delivery.

Results

Parameters showed impairment of RV diastolic function. Women with gestational hypertension had E/e" over the normal value and higher than healthy pregnants, althow difference was not significant. ( 6.46 +- 4.7 vs 5.16 +- 1.9, p =0.66). TDI derived E" from lateral tricuspid annulus was significantly lower in hypertensive group (0.11 +- 0.03 vs 0.14 +- 0.03 p= 0.023). Atv – right ventricle late filling velocity was significantly higher in patients with GH (0.61 +- 0.1 vs 0.51+-0.12, p= 0.08) .

All pregnant women had normal values of RA dimensions, RA endsystolic area, RA endsystolic volume (RAVs). RAVs was significantly larger in GH group (34.64 +-12 vs 27.9+- 9.89, p= 0.041) comparing to the controls, but when we indexed it to the BSA, difference disappeared. Peak longitudinal strain was signfificantly higher in hypertensive group (33.49+- 2.48 vs 28.05+- 4.52, p= 0.001). After Pearson correlation of peak longitudinal strain with parameters of right ventricle diastolic function was done, there was possitive correlation between peak longitudinal strain and Etv (right ventricle early filling velocity) in hypertensive group (r 0.646, p 0.017). Also RAVs positively correlated with LAVsI (r= 0.577, p= 0.019), and RAVsI positively correlated with LAVsI (r= 0.690, p = 0.019).

After delivery all changes disappeared.

Conclusion

Our study indicates that right atrium accommodates to the hemodynamic and functional changes during gestational hypertension. It changes because of modified right ventricle diastolic function and probably in the same mode as left atrium. RA peak longitudinal strain is high, so function of the right atrium is preserved, and we assume that short time of mentioned changes during pregnancy, is the reason why.
P282 Left ventricular diastolic dysfunction in asymptomatic type 2 diabetes mellitus with preserved systolic function
Authors: Mouadili M , Sebani M , Mbauchy C , El Hattaoui M , El Karimi S
Published: January 2020

The involvement of diabetes in the occurrence of an alteration of the diastolic function of LV is well established.

The objective of our study was to evaluate the prevalence of diastolic dysfunction in Type II diabetic patients in light of the latest 2016 recommendations of the American Society of Echocardiography and to identify its associated factors.

It was a cross-sectional observational study with a descriptive and analytic focus spread over a 6-month period from July to December 2017.The study included 66 asymptomatic type II diabetic patients, with a normal ECG and a negative stress test ischemia. All hypertensive subjects with an ejection fraction <50%, or those with myocardial, valvular or rhythm disorder, were excluded.

The mean age of our patients, was 42 years ± 9 years with extremes ranging from 39 to 84 years, we noted a female predominance (68%) with a sex ratio of 2.14. The prevalence of diastolic dysfunction was 27%. Factors associated with this change in diastolic function were advanced age (p <0.0001), age of diabetes> 10 years (p <0.0001), glycemic imbalance with HbA1c> 7% (p <0) , 0001) and elevated fasting glucose levels (p = 0.039), obesity (p <0.0001), dyslipidemia (p <0.0001) and menopause (p = 0.002).

Diastolic dysfunction affects a significant percentage of patients with type II diabetes. Therefore, we propose strict glycemic control in these patients, an early cardiographic echo screening in at-risk subjects, in order to improve their management, and to limit their progression to more serious complications.
P303 Characteristics and prognosis of patients with significant tricuspid regurgitation
Authors: Bohbot Y , Chadha G , Delabre J , Landemaine T , Beyls C , Tribouilloy C
Published: January 2020

Funding Acknowledgements

none

Background

Severe tricuspid regurgitation (TR) usually remains asymptomatic for a long period, and the diagnosis is often delayed, at an advanced stage of right heart failure (RHF). Only a minority of patients are referred to surgery.

Purpose

To describe the characteristics and prognosis according to aetiologies of patients with significant TR.

Methods

Two hundred and eight consecutive patients with moderate-to-severe (grade III) or severe (grade IV) TR were included from echocardiography reports between 2013 and 2017. Median follow-up was 18(6-38) months.

Results

Patients (mean age 75 years, 46.6% males) were divided into 4 groups according to TR aetiology, group 1: primary TR (15%), group 2: TR secondary to left heart or pulmonary disease with a history of left heart valve surgery (24.5%), group 3: TR secondary to left heart disease with no history of left valvular surgery (26.4%) and group 4: idiopathic TR (34.1%). During follow-up, 61 patients (29%) experienced at least one decompensation of RHF requiring hospitalization. Only 11 patients (5.3%) underwent tricuspid valve surgery during follow-up. The 4 years survival was much lower than the expected survival of age- and sex-matched individuals of the general population (56 ± 4%vs74%). After adjustment for outcome predictors, patients with idiopathic TR had a higher risk of mortality (adjusted HR = 1.83[1.05-3.21]; p = 0.034) compared to other groups.

Conclusions

Moderate-to-severe and severe TR is associated with a high risk of hospitalization for RHF and death at 4 years and a low rate of surgery. Idiopathic TR is associated with worse outcome than other etiologies

Abstract P303 Figure. SURVIVAL CURVES