bluuebunny/crossref_metadata_2025 huggingface dataset:
P96 ACUTE CORONARY SYNDROME AND CORONARY ARTERY KINK
Authors: Viele A , Trivisonno A , Porchetta N , Cuzzola B , Giannotti G , Colavita A
Published: May 2022

Coronary artery kink is a variant of anomalous coronary artery, not related to vessel disease. Often it is associated with coronary artery tortuosity (CAT) and fibromuscular dysplasia. The pathogenesis and clinical implications are not fully understood. Kinks are hypothesized to cause coronary blood flow alterations that can results in ischemia and even in acute coronary syndrome. It is speculated that coronary artery kinks are most often caused by guide wire straightening and seen after wiring the artery, but that is not always the case. We describe the case of a 55 years old woman, with familiar history of CAD. In 2019 she had percutaneous Patent Foramen Ovale closure intervention. She presented to the Emergency Department complaining chest pain radiating into the neck. The ECG was normal, but Troponin I levels were mildly elevated (2,1 ng/ml) and ipokinesia of basal and mid segment of the anterior intraventricular spetum was found at the ecoscopy. The patient was admitted to Cardiology department with diagnosis of unstable angina and urgent coronary angiography was performed. At a first glance the coronary arteries did not exhibit significant arteriosclerotic or thrombotic changes. However, upon a closer review, a focal kink of the mid left descending coronary artery was found. This coronary kink folded the LAD during systole causing a transient stenosis that resolved during diastole. Management of coronary kinks is controversial. In the past, literature suggested treatment with coronary stenting as one of the management options. However there are reported cases of adverse outcomes, such as shifting of kink proximally, requiring an additional stenting. We decided to treat patient with medical approach: beta–blockers at the tolerated doses was initiated, in addition to ACE–Inibithor, Aspirin and statin. Stenting of the coronary artery was not a choice, due to the possibility of shifting (as described in literature) and stent fracture. At a one month follow up the patient presented asymptomatic for angina, palpitation or dyspnea. Even if rarely coronary artery kink is a potential cause of myocardial ischemia and its treatment is often challenging to improve patient quality of life and to prevent adverse cardiac event.
P111 CLINICAL PROFILE AND CORONARY ANGIOGRAPHIC FINDINGS IN A PATIENT POPULATION WITH NORMAL STRESS ECHOCARDIOGRAPHY AND ANGINAL SYMPTOMS AND/OR ELECTROCARDIOGRAM ABNORMALITIES INDUCED BY THE STRESS TEST
Authors: Spinelli A , Cianfrocca C , Di Fusco S , Di Michele S , Speciale G , Auriti A , Imperoli G , Colivicchi F
Published: May 2022

Patients with normal pharmacologic stress echocardiography (SE) imaging but anginal symptoms and/or electrocardiographic (ECG) abnormalities induced by the stress test are commonly encountered in clinical practice.

The aim of this study

was to report the clinical profile of these patients and the coronary angiographic findings observed in this setting.

Methods

We analysed pharmacologic SE results of all patients who underwent this examination at our centre between 2015 and 2020. 34 (74%) patients performed pharmacological SE with dipyridamole and 11 (24%) with dobutamine. All patients with normal SE imaging and anginal symptoms and/or ECG abnormalities triggered by this examination who required further diagnostics using coronary angiography were enrolled in this study. Patient data were retrospectively collected from hospital records.

Results

1553 SEs were performed from 2015 to 2020. Forty–five patients met the inclusion criteria of our study (62% female, mean age 67 years). The majority of included patients 37 (82%) had hypertension, 22 (49%) dyslipidemia, 13 (29%) diabetes and 7 (16%) were smokers. Thirteen patients (29%) had anginal symptoms induced by SE and positive coronary angiography. Six patients (13%) had ECG abnormalities and positive coronary angiography. Only two patients (4%) had both ECG abnormalities, anginal symptoms, and positive coronary angiography. Overall, 47% of patients had positive coronary angiography, half of whom had a history of ischemic heart disease. Seventeen patients (38%) had anginal symptoms and negative CVG. Two patients (4%) had ECG abnormalities and negative CVG. Five patients (11%) had both ECG abnormalities and anginal symptoms (Table 1). Overall, 53% of patients had negative CVG.

Conclusion

In our centre, more than half of patients with normal SE imaging associated with ECG abnormalities and anginal symptoms induced by the stress test had negative coronary angiography. Hypertension was the most common risk factor in this patient population.
P112 REPRODUCIBILITY AND AGREEMENT OF 2D VS M–MODE ECHOCARDIOGRAPHIC LINEAR MEASUREMENTS IN ESTIMATION OF LEFT VENTRICLE MASS IN NORMAL ADULT SUBJECTS
Authors: Rossi D , Alessi F , Campanile C , Pinna G , Forni G
Published: May 2022

Background:

Left ventricle (LV) mass is one of the echocardiographic parameters, essentials to define the LV remodeling
P123 PERCUTANEOUS CLOSURE OF PATENT FORAME OVALE IN PATIENT WITH FORME FRUSTE COR TRIATRIATUM DEXTER: A CASE REPORT
Authors: Barca L , Gil Ad V , Masoero G , Bezante G , Porto I , Crimi G
Published: May 2022

Cortriatriatum Dexter (CTD) is an uncommon congenital cardiac anomaly defined by the presence of abnormal septation within the right atrium due to incomplete reabsorption of the right venous valve. While Cor triatriatum with obstructive membranous is often found in early infancy, the non–obstructive forme (“forme fruste”, ff–CTD) usually remain asymptomatic until late adulthood. Non–obstructive forms, in fact, generally have a modest clinical impact, but in some clinical situations, they may represent a significant obstacle. CTD and ff–CTD are commonly associated with other congenital heart anomalies, e.g. atrial septal defects (ASDs), and a few cases of extreme difficulties in percutaneous procedures like ASD or patent foramen ovale (PFO) closure have been described.

We present a case of a 51–year–old male patient with a recent diagnosis of paradoxical cardioembolic stoke that during the procedure of percutaneous PFO closure, ff–CTD was detected. Multifenestrated Amplatzer septal occluder 18 mm device was successfully deployed under TEE monitoring, confirming optimal positioning and no distortion of the device, particularly of the right disk.

Conclusion

cc–CTD is generally a benign condition but may represent a challenge and should be searched prior to percutaneous heart procedures.
P133 UTILITÀ DEL MYOCARDIAL WORK NELLA VALUTAZIONE ECOCARDIOGRAFICA MULTIPARAMETRICA DI PAZIENTI CON CARCINOMA MAMMARIO
Authors: Di Lisi D , Madaudo C , Rossetto L , Di Palermo A , Gambino G , Buccheri G , Damerino G , Di Leo G , Galassi A , Novo G
Published: May 2022

Background

The aim of our study was to assess subclinical cardiac effects of anthracyclines (ANTs) in women treated for breast cancer (BC).

Methods

We enrolled 46 female patients with BC undergoing adjuvant treatment with anthracycline–containing chemotherapy (CT) followed by taxane (paclitaxel/docetaxel). Patients underwent physical examination, electrocardiogram (ECG) and standard transthoracic echocardiography (TTE) including evaluation of diastolic and systolic function, measured as left ventricular ejection fraction (LVEF), left ventricular global longitudinal strain (GLS) and myocardial work (MW) expressed as global work index (GWI), global constructive work (GCW), global work waste (GWW), and global work efficiency (GWE). The parameters were measured at baseline (T0) and at 3 months (T1) and 6 months (T2) follow up.

Results

All patients completed the chemotherapy cycles. No significant cardiovascular adverse events were observed during treatment. Neither 2D left ventricular ejection fraction (LVEF) nor E/e’ ratio evaluation at TDI were significantly changed after treatment. Conversely, GLS was significantly reduced at T1 and T2 since baseline (GLS – 19,99 % IQR –20,6 –19,3 % at T0 vs –17,88 % IQR –18,8 –16,9 % at T1, p < 0,00 1 and –16,71 % IQR 17,6 –15,7 % at T2, p < 0,001). Consensually, a significant reduction in myocardial work was also measured (GWI 2115 mmHg% IQR 1888 – 2342 mmHg% at T0 vs 1714 mmHg% IQR 1557 – 1870 mmHg% at T1, p < 0,0001 and 1694 mmHg% IQR 1482 – 1907 mmHg% at T2, p < 0,0001).

Conclusion

Our study demonstrates that evaluation of myocardial work allows very early detection of subclinical cardiac damage induced by chemotherapy, consensually to the reduction of the GLS. A multiparametric assessment of the myocardial function, including myocardial work and GLS, could improve the accuracy of risk stratification of cardiotoxicity in patients undergoing ANTs treatment.
P134 A RARE CASE OF CARDIAC DIFFUSE LARGE CELL B LYMPHOMA: ECHOCARDIOGRAPHIC RESPONSE TO CHEMOTHERAPY
Authors: Morgagni R , Parato A , Zizzari G , Martuscelli E , Cantonetti M
Published: May 2022

Introduction

Diffuse large B–cell lymphoma (DLBCL) is the most common subtype of non–Hodgkin‘s lymphoma in adults. Rituximab and Anthracycline–based chemotherapy are the standard treatment, complete remission (CR) is achived in approximately 67% of patients. About one third of patients have refractory disease or relapse after standard therapy, mostly within 5 years of achieving CR.

Clinical Case

A 62–year–old patient, current smoker, without previous cardiovascular diseases presented to our ER for dyspnea and asthenia. Medical history showed GBC–DLBCL at third stage that achieved CR with R–CHOP therapy and intrathecal prophylaxis. The ECG documented sinus tachycardia with normal ventricular repolarization. Arterial blood gas analysis showed a condition of respiratory distress (pO2 71 mmHg, pCO2 27 mmHg). For suspicion of pulmonary embolism, chest CT with contrast was done showing a bulky mass extending from the right atrium to the right ventricle, also involving the pericardial sac (image 1). Transthoracic echocardiography showed a bulky mass (area 31 cm2) occupying almost the entire right atrium (5.9 x 4.4 cm) and extended, through the tricuspid valve, into the right ventricle, displacing the interventricular septum (image 2). Endomyocardial biopsy confirmed the diagnosis of GBC–DLBCL cardiac recurrence. Assumed the good systolic function of the left ventricle and the age of the patient, chemotherapy debulking was performed with Gemcitabine, followed by R–CHOP and MTX. One month after therapy post–treatment Total Body CT shows a good response with no evidence on echocardiogram of pathological tissue in the right ventricle (image 3).

Conclusions

Cardiac DLBCL is a rare tumor with few cases reported in the literature. There is currently no standard therapy, particularly for those who are unsuitable for high–dose chemotherapy a/o autologous stem cell transplantation. The multidisciplinary cardiological and hematological approach has proved to be fundamental these patient‘s therapeutic management.
P135 NEOPLASTIC DISEASE LONG AFTER ACUTE CORONARY SYNDROME. THE ABC–4* STUDY ON HEARTDISEASE
Authors: Berton G , Mahmoud H , Cavuto F , Bagato F , Palmieri R , Stocchero L , Selvestrel E , Allocca G , Lorenzon E , Merotto D
Published: May 2022

Background

Non cardiac outcomes after ACS are seldom reported specially on the long term. In the literature, aspects of parallelism between the atherosclerotic, inflammatory, and neoplastic process have been observed. However, there is a lack of prospective studies looking for potential association between ACS and future neoplasia.

Aim

To describe the presence, incidence of malignant neoplasia long after ACS. Comparison with the general population registries incidence rate worldwide and in Italy was also considered. Methods This prospective study included 541 patients who were discharged alive after index hospitalization with ACS in three hospitals and followed for 22 years.

Results

All but 3 patients completed the follow–up or were followed until death. Pre–existing malignancy was noted in 15 patients, whereas 106 patients developed cancer during the follow–up period, which represented 6232 person–years. The most common sites were the lungs (22%), colorectal (19%), and prostate (15%), as well as the pancreas (5%), breast (5%), and leukaemia (5%). A total of 99 (18%) patients died due to malignancy (Figure 1). The risk of malignancy after ACS in the present study, appears higher than that of general population; as we observed a cancer incidence rate approximating 17.8 case per 1000 person–year, while in general population estimates carried out globally, in Europe, Italy and in Veneto Region, the age standardized cancer incidence rate was reported to be 3.27, 4.64, 4.73 and 4.70 cases per 1000 person–years, respectively [according to GLOBOCAN 2020].

Conclusions

In this prospective, long–term study, we observed an increase in the risk of malignant neoplasia in patients who survived ACS, notably higher than the risk observed in the general population globally, in Europe, in Italy and in Veneto region. Further understanding of the delicate interaction between CV disease and cancer may lead to better prevention, earlier detection, and safer treatment strategies.
P138 CARDIAC LIPOMA IN PATIENT WITH SYSTEMIC LIPOMATOSIS
Authors: Parato A , Morgagni R , Martuscelli E
Published: May 2022

Introduction

Primary adipose cardiac tumors are divided into two different entities: lipomatous hypertrophy of the interatrial septum (LHIS) and lipomas. Lipomas are usually benign masses of unknown pathogenesis. Currently few cases are reported in literature, with no differences in gender distribution.

Clinical Case

A 63–year–old patient presented to our emergency room complaining chest pain and dyspnea on exercise. Her medical history shows severe obesity, hypertention, past surgical removal of several systemic lipomas (uterus lipoma, right ovary lipoma, right thigh and leg lipoma, right forearm and wrist lipoma). A coronary angiography was performed showing the lack of angiographically significant lesions. On suspicion of microvascular angina, she began therapy with Ranolazine and Beta–blockers. Echocardiographic examination showed a lipomatous interatrial septum in the postero–superior tract with a maximum of 22.5mm thickness (image 1). At 12 months, chest CT and MRI scan showed a hyperintense mass on interatrial septum measuring 32x34mm. The formation, mainly protruding in the right atrium, does not obstruct the outlet of the hollow veins, nor the outlet of the pulmonary veins. No hemodynamic compromise and compression were detected. Last follow–up visit our patient presented dyspnea and chest pain, the echocardiogram showed a slight increase of the mass size (see image), with unchanged thicknesses and biventricular pump function.

Conclusions

In literature there is no evidence of malignant transformation of cardiac lipomas, however well–differentiated cell tumors can coexist with liposarcomas. There are no guidelines for the treatment of cardiac lipomas, radical resection is practiced in the majority of symptomatic patients and should be considered in all patients with cardiac lipoma. Asymptomatic lipomas can excessively grow up and infiltrate into the myocardium, resulting in negative outcomes to a possible subsequent resection. According to the worsening of the clinical course, the patient under consideration was referred for lipoma resection surgery.
P155 SINGLE CENTER EXPERIENCE ICD IMPLANTATION IN PEDIATRIC AGE
Authors: Fumanelli J , Elhyka A , Rotella M , Ferretto S , Di Salvo G , Iliceto S , Leoni L
Published: May 2022

Background

Despite sudden cardiac death (SCD) is a rare phenomenon in pediatric age, the use of the implantable defibrillator (ICD) is progressively increasing in consideration of its life–saving role. Our work aims at evaluating our pediatric population to verify the protective role of the device in terms of SCD prevention, acute and chronic complications and to evaluate the role played by the device as a bridge to transplantation.

Methods

The retrospective study includes patients under the age of 18 underwent ICD implantation, following the guidelines and recommendations currently in force, in the time period between March 2000 and July 2020. Each device has been programmed in a personalized way based on age and cardiac pathology. All patients were then followed–up by evaluating the appropriate shocks, the acute and chronic complications, especially the inappropriate shocks.

RESULTS

The study group includes 55 subjects (41 males and 12 females) with a mean age of 14±4 years (range 2–18) and a mean follow–up time of 6.2 years. Thirty subjects had cardiomyopathy (CM), 15 electrical disease (ED) and 10 congenital heart disease (CHD) respectively. We used three different implantation technique (endocavitary, subcutaneous and hybrid technique) depending on the size of the patient and the cardiac anatomy. CHD and CM are mostly implanted in primary prevention. The rate of appropriate shocks in secondary prevention is higher than that in the primary one regardless of the disease (67% vs 33%). Thirty–eight percent of patients received appropriate shock, of which 66.7% were patients who had received defibrillator as a bridge to heart transplant. Two patients (3.6%) received inappropriate shocks on supraventricular tachycardia. There were no acute post–implantation complications. None dysfunctions or ruptures of the shock catheter or episodes of T wave oversensing took place. Peri–procedural and post–transplant mortality is zero.

Conclusions

The study confirmed the protective role of the device, in terms of prevention of sudden cardiac death, and its relevance as bridge to heart transplantation in pediatric age. An implant technique adequate to the size, age and heart disease of the patient associated with an adequate programming of the device significantly reduced inappropriate shocks in our patients.
P157 THE UNFORESEEABLE LINK: A CASE OF CORONARY–PULMONARY ARTERY FISTULA BRIDGING THE RIGHT CORONARY AND FIRST SEPTAL BRANCH OF THE LEFT ANTERIOR DESCENDING ARTERY
Authors: Michele B , Bertozzi R , Bertolini D , Di Nicola F , Pizzi C , Galiè N
Published: May 2022

Coronary–pulmonary artery fistulas are a rare clinical entity with a variety of potential clinical manifestations. Albeit rare, such anomalies may in some instances involve multiple coronary arteries and go unnoticed until old age producing little to no clinical manifestations. We hereby present the case of an 83–year–old man, heavy smoker, with a history of cor pulmonale due to severe chronic obstructive pulmonary disease (COPD) who was recently diagnosed with metastatic lung adenocarcinoma. Incidentally, one of the ECGs performed revealed negative T waves in the precordial leads in the absence of symptoms and with a negative troponin curve. Echocardiography was thus performed and revealed severe left ventricular systolic dysfunction (EF 31%) with infero–postero–lateral akinesia. The patient underwent CT coronary angiogram, which ruled out any significant coronary stenosis but revealed a most surprising finding. An ectatic arterial branch running anteriorly and draining into the pulmonary artery connected the the proximal segment of the right coronary artery to the first septal branch of the left anterior descending (LAD) artery. Unfortunately, the severe left ventricular failure contraindicated any chemotherapy and the patient was discharged with a plan to start palliative radiotherapy. Three months later, the patient returned to our Hospital due to worsening weakness, cachexia and one episode of pre–sincope. During this hospital stay, he developed atypical chest pain with a significant troponin curve. A HRCT and pulmonary angiogram was performed, which revealed neoplastic progression with bilateral lung involvement and bone metastases, as well as bilateral segmental pulmonary emboli. Echocardiography demonstrated new segmental areas of akinesia (apical septum and mid–apical anteroseptal segment) suggestive of focal ischemic damage. Given the documented pulmonary embolism and the anomalous connection between pulmonary artery and coronary circulation, this event may have been caused by paradoxical embolism travelling from pulmonary to coronary circulation (most likely affecting the LAD artery territory). Due to the patient’s frailty however, this hypothesis could not be confirmed by coronary angiography. Despite their relative rarity, coronary–pulmonary artery fistulas involving multiple coronary arteries can occur in the elderly population with no previous clinical manifestations and may give rise to apparently unfathomable clinical constellations.
P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT
Authors: Ceriello L , Salvatore T , De Rosa M , Marrone G , Ruggieri B , Fabiani D , Napoletano C
Published: May 2022

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities.

Case Report

A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset.

Discussion

We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.
P163 BOTALLO ARTERIAL DUCT SURGICALLY TREATED IN URGENCY
Authors: Magnano R , D‘Alleva A , Forlani D , Di Marco M , Pezzi L , Vitulli P , Fulgenzi F , Verrengia E , Paloscia L
Published: May 2022

The Botallo arterial duct connects the pulmonary artery and the aorta during fetal life; after birth there is a progressive fall in pulmonary resistance mediated by the increase in oxygen concentration and the decrease in prostaglandins with a vasodilating action. In these physiological conditions, spontaneous closure of the duct is observed within the first 48–72 hours of life. In the preterm infant the patency of the Botallo duct is very frequent due to the peculiar anatomical and physiological characteristics of the preterm infant. The incidence of PDA is higher the lower the birth weight and gestational age are.

We report a case of Manuel, a baby born at 32 weeks of gestational age from elective CT due to transverse presentation with difficulty in extraction and anhydrosis. 37–year–old mother hospitalized for reduction of amniotic fluid (AFI 85 index) with no apparent rupture of the membranes, for which she began a cycle of glucocorticoids 12mg twice a day. At birth, the weight of the child was 1,780 g, length 42 cm, skull circumference 28 cm, absence of valid respiratory activity, bradycardia (78 bpm) APGAR index of 4. At 5 ‘of life he was intubated with a 3 Fi rush tube fixed to 8 cm from the buccal rim with neopuff with PIP 20 cmH2O, PEEP 5 cmH2O, FiO2 0.40, transferred to the NICU, placed in the incubator, connected to the ventilator and ventilated with A/C mode with PIP 23 cmH2O, PEEP 5 cmH2O, FiO2 0, 40 –> 0.60, given surfactant alfa 200 mg/kg. Anemic, plasma and red blood cells were administered multiple times; infectious disease tests (aerobic–anaerobic haemocolutre, umbilical culture, culture of OT tubes, BAL, ear and throat swabs) were negative. After 3 days, systolic heart murmur appeared 2–3/6 radiated to the axilla. The echocardium showed the persistence of the Duct of Botallo, with a mosaic jet in the pulmonary artery and a “growing” ductal flow pattern. He started treatment with indomethacin 0.2 mg/kg every 12 hours x 3 doses, but on echocardiographic control the picture remained unchanged. At 16 days of age, the newborn was transferred to the Bambin Gesù in Rome and underwent cardiac surgery via the left posterolateral thoracotomy to close the arterial duct with a Weck clip. The post–operative course was regular. Manuel was discharged 2.5 months after birth in good general conditions, good growth–weight, with a weight of 2460 g.
P167 ECG ABNORMALITIES AND DOUBLE CORONARY FISTULA
Authors: Viele A , Trivisonno A , Porchetta N , Guerrera L , Giannotti G , Cuzzola B , Colavita A
Published: May 2022

Coronary artery fistula (CAF) is defined as anomalous communication between coronary arteries and cardiac chamber or a major thoracic vessel. CAF are a rare coronary anomaly, mostly congenital, first described by Krause in 1856. In literature the incidence in general population is approximately 0,002%. Detection of CAF during coronary angiography is usually accidental. In 50% of cases CAF originate from right coronary artery, in 30% they originate from LAD, while in the rest of the percentage CAF originate from left circumflex artery. CAF drain into low–pressure chamber (right ventricle or right atrium, superior Vena Cava or pulmonary artery). We can distinguish CAF into little or medium sized, usually with silent clinical course, and large sized CAF, with variable clinical signs, depending on the extent of the shunt and on the hemodynamic overload of the receiving chamber. We describe the case of a 57 y.o woman with hypertension, admitted for femur fracture. ECG showed bifasic T waves in the anterior leads, already described in a previous ECG. Normal systolic function and no valvular defect were found on the echocardiogram. Patient was asymptomatic. Coronary angiography documented normal coronary arteries, with a double coronary fistula: the first from a septal branch of posterior descending and the second one from distal branches of the first diagonal. Even if CAF have often a favorable clinical course with no relevant consequences for the patient, it’s crucial to obtain more information about their functional implication and their anatomic connections. Indeed, rare cases of sudden cardiac death have been described in patients with CAF involved in myocardial ischemia based on the theft syndrome mechanism. Echocardiographic evaluation of the patient to detect associated congenital abnormalities, pressure overload of the receiving chambers and the extent of the shunt on the coronary angiography are crucial for the proper management of CAF. In the case described above we decided to optimize therapy adding beta–blocker (to reduce the overload caused by the two coronary fistula).
P168 A RARE CASE OF HYPERTROPHIC CARDIOMYOPATHY WITH HIGH RISK OF SUDDEN CARDIAC DEATH: WHAT CAN WE DO UNTIL MIECTOMY?
Authors: Renda M , Iannucci L , Minardi S , Romano S
Published: May 2022

A 43–year–old Indian man with obstructive hypertrophic cardiomyopathy (HCMO) and a family history of sudden death presented with heart palpitations associated with chest discomfort and syncope during moderate physical activity despite beta–blocker therapy at maximum dose (New York Heart Association–NYHA III). Transthoracic echocardiography demonstrated ejection fraction 55% and ventricular septum (SIV) (23 mm) and posterior wall hypertrophy (12 mm). There was evidence of dynamic left ventricular outflow tract obstruction (maximum LVOT gradient 30 mmHg at baseline and 45 mmHg after Valsalva) and systolic anterior movement of the amterior mitral flap responsible of moderate regurgitation. It also showed a bicuspid aortic valve with fusion of the right and left cusps and mild regurgitation. ECG Holter showed sporadic supraventricular premature ectopic beats and abnormality of the ventricular repolarization that were accentuated during exercise. Exercise stress test showed 3 mm ST depression in V4–V5 leads. Cardiac magnetic resonance (CMR) and Cardio–CT confirmed HCMO diagnosis and showed a junctional origin of the coronaries, a bifurcated interventricular artery, coronaries free from significant stenosis, intramural late gadolinium enhancement (LGE) of the mid–ventricular SIV and sub–endocardium LGE of the basal SIV. The high HCM– Sudden Cardiac Death Risk score and the presence of LGE on CMR identified a high–risk status and prompt consideration for primary prevention automatic implantable cardioverter defibrillator (AICD) therapy. Thus, in order to treat major life–threatening ventricular arrhythmias, AICD was placed (ESC guidelines 2014 Class IIa). Invasive treatment is indicated for symptomatic patients, NYHA class III and IV refractory to optimized medication and who have gradients in the LVOT. Aortic transvalvular–myectomy is the procedure with the longest experience and considered the gold standard. However, in this case surgical treatment was temporarily postponed. So a sequential rhythm pacing with reduced A–V delay was set up in order to induce a left bundle branch block and a “paradoxical” movement of the SIV with reduction of LVOT gradient. After 2 weeks the LVOT gradient was 20 mmHg and the symptoms were improved. This case suggests the usefulness of a single device for the treatment of different aspects in HCMO waiting to undergo surgical treatment: prevention of sudden cardiac death and improvement of symptoms refractory to medical therapy.
P176 MITRAL FISTULA IN PATIENT WITH OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT
Authors: Gioia M , Rinaldi A , Milo M , De Castro A , Ignone G
Published: May 2022

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.
P179 DYSFUNCTION OF A MITRAL VALVE BIOPROTESIS FROM FLAIL OF A LEAFLET
Authors: Gizzi G , D‘Agostino S , Parato V
Published: May 2022

Introduction

The degeneration of biological valve prostheses is an irreversible process determined by intrinsic factors (calcification, thickening, fibrosis of the leaflets) or extrinsic (prosthesis–patient mismatch, malapposition, prosthetic detachment, thrombosis, endocarditis) that determine hemodynamic dysfunction with frequent need for surgical re–intervention . The average life span of a valve bioprosthesis is around ten years but in some cases premature dysfunction can occur.

Clinical Case

In September 2021, an 83–year–old woman who was symptomatic of progressively worsening dyspnea entered the emergency care unit of our hospital. In medical history: mitral valve replacement surgery using bioprosthesis in 2016, hypothyroidism in medical therapy. At the entrance, the patient appeared alert, attentive and oriented. Tachypnoic and dyspnoic at rest. Objectively ss 3/6 was appreciated on mitral focus, ss 2/6 on tricuspid focus. Signs of pulmonary congestion. PA 120/80 mmHg. HR 100 bpm, SpO2 88%. Laboratory tests showed increased NTproBNP values. On the ECG: sinus rhythm, HR 96 / min, atrioventricular conduction within limits, narrow QRS, widespread alterations in repolarization as from overload. The echocardiogram performed during the cardiological consultation showed normal biventricular size and contractility. The mitral biological prosthesis appeared in place with an increased transprosthetic gradient (mean Gp 7mmHg) and evidence of severe intraprosthetic regurgitation. There was also moderate to severe tricuspid insufficiency with PAPs estimated at 38 mmHg; the VCI was dilated and non–collapsing. Admitted to cardiac intensive care unit, trans–esophageal echocardiogram was performed which confirmed the finding of bioprosthesis dysfunction caused by severe mitral valve insufficiency in relation to eversion of the posterior leaflet. The patient remained in conditions of haemodynamic instability despite medical therapy with respiratory failure therefore after consulting cardiac surgery she was intubated and transferred for trans–catheter intervention of valve–in valve in emergency.

Conclusions

Transesophageal echocardiography represents the reference method in the evaluation of valve bioprostheses: in this case it allowed to highlight an unusual mechanism of mitral bioprosthesis dysfunction due to complete eversion of a leaflet.
P181 CARDIAC PROTECTION BY PIRFENIDONE AFTER MYOCARDIAL INFARCTION: A BIOINFORMATIC ANALYSIS
Authors: Aimo A , Iborra–Egea O , Martini N , Galvez–monton C , Burchielli S , Panichella G , Passino C , Emdin M , Bayes–Genis A
Published: May 2022

Purpose

Left ventricular (LV) remodeling after myocardial infarction (MI) is promoted by an intense fibrotic response, which could be targeted by an anti–fibrotic drug such as pirfenidone.

Methods

We explored the relationship between protein modulation by pirfenidone and post–MI remodeling, based on publicly available molecular information and transcriptomic data from a swine model of MI. We also compared the effects of pirfenidone and angiotensin–converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), mineralocorticoid receptor blockers (MRA) and beta–blockers.

Results

We identified 6 causative motives of post–MI remodeling (cardiomyocyte cell death, impaired myocyte contractility, extracellular matrix remodeling and fibrosis, hypertrophy, renin–angiotensin–aldosterone system activation, and inflammation), 4 pirfenidone targets and 21 bioflags (indirect effectors). When considering both targets and bioflags, pirfenidone showed a broad relationship encompassing all 6 motives. p38γ–MAPK12 blockade inhibits cardiomyocyte apoptosis, cardiomyocyte hypertrophy and inflammation. Furthermore, pirfenidone can modulate extracellular matrix remodeling and cardiac fibrosis by targeting the TGFβ1–SMAD2/3 pathway and other effector proteins such as matrix metalloproteases 2 and 14, PDGFA/B, and IGF1, which promote myocardial fibrosis, cardiomyocyte hypertrophy and impaired contractility. All the gold standard drugs were found to be important for specific clinical motives, but pirfenidone had a more widespread action on the molecular pathways active in the post–MI setting.

Conclusion

A bioinformatic approach allowed to identify several possible mechanisms of action of pirfenidone with beneficial effects in the post–MI LV remodeling, and suggests additional effects over guideline–recommended therapies. These findings support clinical studies evaluating the beneficial effects of pirfenidone in patients with MI.
P184 DIASTOLIC FUNCTION IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION TREATED BY SACUBITRIL/VALSARTAN
Authors: Lamaida N , Cerciello A
Published: May 2022

Background

After the remarkable success of the PARADIGM.HF trial, SAC/VAL was approved by European Society of Cardiology (ESC2016) and the American Heart Association (AHA2017), for the treatment of adults with chronic heart failure with reduced ejection fraction (HFrEF) (NYHA class II–IV), to reduce the risk of cardiovascular death and hospitalization. CurrentlySAC/VAL is recommended in patients with a left ventricular ejection fraction (LVEF) <35% as a replacement for an ACEI or ARB to further reduce the risk of HF hospitalization and death in ambulatory patients who remain symptomatic despite optimal treatment with an ACE–I, a beta–blocker and an MRA. However, the real world HF population differ from patients in randomized controlled trials in many clinical aspects. AIM: The aim of our work was to evaluate the reversibility of diastolic dysfunction before and after sacubitril/valsartan administration in patients with HF REF.

Methods

A total of 30 patients in NYHA class II–III and treated by ACE inhibitor or AAR2, were prospectively commenced on SAC/VAL (one tablet 24/26 mg twice daily). To classify diastolic dysfunction according to the ASE/EACVI guidelines published in 2016, transmitral E and A waves velocities, septal and lateral E’ tissue velocities, indexed left atrium volume and peak velocity of tricuspid regurgitation were collected. From multiparametric approach, Patients were subsequently categorized as diastolic dysfunction grade 1, 2 or 3.

Results

Mean age was 64.5±15 yo and 74 % patients were males. Ejection fraction averaged 35.5±7.0. Overall, after 12±3.0 months of treatment with sacubitril/valsartan, E/A ratio decreased from 1.9±1.5 to 1.04±0.72 (P < 0.05), the E/Ea ratio decreased from 14±6.0 vs. 09.5±5.0 (P < 0.05), tricuspid regurgitation peak velocity decreased from 3.0±0.7 to 2.4 m/s (P = 0.03) and left atrial volume decreased from 51.3±27.5 to 40.4±13.7ml/m2 (P < 0.05). Subsequently, both left–ventricular diastolic function and filling pressure improved significantly (P < 0.05, ).

Conclusions

In patients with HFrEF, administration of sacubitril/valsartan was associated with improvement of diastolic dysfunction and filling pressure, as shown in many studies.
P188 MANAGEMENT OF ANTICOAGULANT AND ANTIPLATELET THERAPY IN THE GREAT ELDERLY: A REAL LIFE CLINICAL CASE
Authors: Prenna E , Maffè S , Facchini E , Bergamasco L , Paffoni P , Careri G , Franchetti Pardo N , Paino A , Dellavesa P
Published: May 2022

In daily clinical practice we have often to manage great elderly people with multiple comorbidities. In these cases it is not always easy to apply the guidelines, which must sometimes be adapted to the patient we are treating. We present the case of a 99–year–old hypertensive patient in therapy with oncocarbide and acetylsalicylic acid for polycythemia vera. No cardiological history. It came to our attention for NSTEMI during an episode of persistent atrial fibrillation (AF) with a high ventricular rate. Subsequent spontaneous restoration of sinus rhythm. Significant increase in troponin on blood tests. On the echocardiogram, normal biventricular kinetics and systolic function, no significant valvulopathies. Given the age and hemodynamic stability, a conservative approach was chosen. Therefore, antiplatelet therapy was started with acetylsalicylic acid (ASA) and anticoagulant therapy, initially with low molecular weight heparin and then with oral anticoagulant (NOAC); being the patient over 75 we chose Apixaban 2.5 mg bid, in accordance with weight and renal function (Consensus ESC 2016). At 1 month follow up the patient month was stable in good compensation, the 24h–Holter ECG showed stable sinus rhythm. At this point the question was how to proceed with the therapy: maintain the NOAC, as indicated in the NSTEMI guidelines, or continue with ASA alone, also considering that the risk scores usually used in patients with AF to determine the bleeding and cardioembolic risk (HASBLED and CHADS–VASC) are not validated in such elderly patients. We also hypothesized that the short AF paroxysm was related to ongoing myocardial ischemia (and not vice versa); in the literature, however, the indication for anticoagulant therapy does not take these extreme situations into account. Polycythemia vera also contributes to complicating the situation, exposing the patient to an increased risk of thrombotic events in the absence of antiplatelet therapy. After discussing the case with the haematologist, we decided to suspend the NOAC, also considering the absence of new arrhythmic episodes, and to continue with ASA alone. For now, with a follow–up of 6 months, we have not registered thrombotic / haemorrhagic problems or arrhythmic recurrences. The management of the elderly is always complex and will frequently lead us to adapt and customize the treatments on every single patient.
P191 CONTEMPORARY CHARACTERISTICS AND OUTCOMES OF PATIENTS WITH NON–ST ELEVATION MYOCARDIAL INFARCTION ACCORDING TO MANAGEMENT STRATEGIES
Authors: Orso F , Casolo G , Szasz C , Forni S , D‘Arienzo S , Gemmi F
Published: May 2022

Purpose

The aim of the present study was to analyze, in a large administrative database, the clinical characteristics and prognosis of a contemporary population of patients with Non–ST elevation myocardial infarction (NSTEMI) according to the treatment strategy.

Methods

This retrospective observational study included patients residing in the Tuscany region, aged 18+ years, discharged from a regional hospital with a diagnosis of NSTEMI (main diagnosis ICD–9–CM codes 410.7 or 411.1 in HDA) between 2016 and 2018. Patients were classified into two main groups: a conservative strategy (CON) group and an invasive strategy (INV) group that was further classified into three subgroups: a PCI group, a CABG group, and a group where patients were managed invasively but not revascularized.

Results

The study population consisted of 15,208 patients. The median age was 76 ± 9 years, females were 38.5%. Groups composition according to management strategies is shown in Figure 1. Compared to INV patients, patients in the CON group were older (mean age 85 vs 72 years, p < 0.0001), more frequently female (54% vs 33%, p < 0.0001), had a higher cardiovascular and non–cardiovascular comorbidity burden. All–cause mortality rates in hospital and 1–year MACCE (Figure 2 and 3) were 3% and 24.1%, resulting significantly higher in the CON strategic management group than in the INV strategic group: 8.9% vs 1.1; 34.0 vs 21.1%; p = 0.0001. Between the three INV subgroups we found no differences in hospital mortality, while at 1 year there was a significant difference in MACCE with a higher rate in the CABG group compared to the PCI subgroups and in that of invasively managed but not revascularized patients: CABG: 42.8% vs 19.3% vs 18.2% respectively, p = 0.0001

Conclusions

Real–world data show that patients with NSTEMI have significantly different characteristics and prognosis according to treatment strategy. Patients managed non–invasively have more complex characteristics and worse prognosis both in the hospital and after discharge. Patients who have been managed invasively but treated with medical therapy represent an interesting subgroup worthy of further study.
P193 MECHANICAL COMPRESSION DEVICE (LUCAS®) IN THE CATHETERIZATION LABORATORY: RETROSPECTIVE ANALYSIS OF A SINGLE CENTER
Authors: Dal Passo B , Cardelli L , Capecchi A , Nobile G , Canovi L , Frascaro F , Zanarelli L , Piscitelli L , Casella G
Published: May 2022

Background

The survival of IHCA and OHCA depends on the timeliness and the quality of cardiopulmonary resuscitation (CPR). During transport, in the Cath Lab or when resuscitation is extended, the availability of chest compression systems increases the quality of CPR and it is recommended in these specific situations by the AHA 2020 Guidelines.

Methods

Retrospective analysis of patients who encountered cardiocirculatory arrest (CCA) in the Cath Lab or in ICU of the Maggiore Hospital managed with CPR and application of a chest compression device (LUCAS® 3) from 2020 to 2021.

Results

The study population consisted of 21 patients, all undergoing invasive procedure (coronary angiography, angioplasty or aortic valvuloplasty) in peri–arrest: 17 patients (81%) with CCA during STEMI, 3 (14%) during NSTEMI and one patient during acute pulmonary edema caused by severe aortic stenosis. In 6 cases (29%) the onset rhythm of CCA was shockable, the others were pulseless electrical activities. Considering patients admitted with STEMI, 4 (24%) have OHCA and LUCAS® had been applied by 118 operators before entering the Cath Lab. In the other cases LUCAS® was placed in the Cath Lab, before or during the procedure; in all but two cases, the procedure was concluded. The resuscitation maneuvers involved, in addition to LUCAS®, the use of an external defibrillator, orotracheal intubation, administration of inotropes and, in 2 cases (10%) the intra–aortic balloon pump (IABP). The average time between CCA and application of LUCAS® was 14 minutes – the device was always positioned after at least 2 manual ECM cycles without restoring the circulation – and the average CPR duration was 73 minutes. Any complications related to the implantation of the device were observed. The survival at the end of the procedure in the Cath Lab was 24% and on discharge 14%.

Conclusion

The use of chest compression devices during CCA allows a better management by medical personnel during long–term CPR and a completion of invasive procedure. Unfortunately, it doesn’t substantially changes the survival of patients as reported by the literature.