bluuebunny/crossref_metadata_2025 huggingface dataset:
P633 Murmuring the diagnosis
Authors: Tiucu G , Ait Yahia F
Published: January 2020

INTRODUCTION

Coronary-cameral fistulas (CCF) are mostly congenital, rarely acquired malformations that create a communication between one or more coronary arteries and one of the cardiac chambers resulting in arterio-venous or arterio-arterial connections, giving rise to left-right or left-left shunts.

CASE REPORT

A 64 year-old man with history of heart transplant in September 2018 for severe post-ischemic heart failure, was transferred in our cardiology service after a three months cardiac reeducation program. The patient was to be discharged on the same day but the accidental discovery of a myocardial septo-apical infarction with ST segment elevation motivated his admission for urgent coronary angiography. The patient did not present any thoracic pain, only a slight numbness in his right shoulder. Troponin T value was 1735pg/ml. The coronary angiography showed a recent occlusion in the distal segment of the left anterior descending artery presenting with an aneurismal dilatation and CCF.

Further we completed the exam with a transthoracic echocardiography showing an akinetic apex in the presence of a fistula between the left anterior descending artery and the apex of the right ventricle with a high velocity flowing (Vmax = 1.8m/s) preferentially directional to the right ventricle.

Reviewing the medical history we found out that the patient had had a endomyocardial biopsy three days before this episode. Clinically a continuous cardiac murmur could be heard and the patient presented NYHA II dyspnea. Following this clinical presentation we decided to discuss the case within a heart team reunion and the decision taken was to place a covered stent in the distal segment of the left descending artery so as to permit the occlusion of the fistula. The evolution was favorable and the patient was discharged five days later.

DISCUSSION

Diagnosis of acquired CCF is suspected by clinical history and recurrence of symptoms, occurrence of a new continuous machinery cardiac murmur and a palpable thrill. Normally conservative medical management is sufficient to relieve symptoms in these acquired fistulas and spontaneous resolution is very common in CCF acquired following endomyocardial biopsy.

In our case report we noted the occurrence of a systolo-diastolic murmur following endomyocardial biopsy with a patient who was symptomatic of myocardial infraction. The literature describes report cases of symptomatic patients who needed a surgical or endovascular occlusion of the acquired CCF following endomyocardial biopsy by implanting a covered stent or with a covered balloon.

CONCLUSION

The termination site of acquired iatrogenic CCF following endomyocardial biopsy in the heart transplant population is usually the right ventricle with an elevated ratio of spontaneous resolution of this coronary-cameral communications. However in sysmptomatic patients a surgical or endo-vascular occlusion may be needed.

Abstract P633 Figure. Transthoracic echography findings
P643 A case of Fabry cardiomyopathy refractory to enzyme replacement therapy; the importance of early diagnosis and treatment in Fabry cardiomyopathy
Authors: Park S H , Jung K T , Choi Y J , Kim W H , Chin J Y , Kang K W
Published: January 2020

A 56-year-old male was referred in order to identify Fabry disease after his older brother was confirmed as Fabry disease of cardiac variant type. He had been treated with hypertrophic cardiomyopathy (HCMP) five years ago. He didn’t have a history of hypertension. Blood pressure was 118/65 mmHg and pulse rate was 75 beats per minute. Serum creatinine was 1.07 mg/dl and estimated glomerular filtration rate was 75.2 ml/min. Cardiac enzymes including CK-MB and troponin-T were normal. There was no proteinuria on urinalysis. A 12-leads electrocardiogram revealed normal sinus rhythm with severe left ventricular hypertrophy (LVH) and strain pattern. Transthoracic echocardiogram (TTE) showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 17 mm with normal systolic function (left ventricular ejection fraction (LVEF), 56%). TTE also revealed left ventricular outflow tract obstruction with systolic anterior motion of mitral valve. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 7mm). Also, echocardiography revealed findings of diastolic dysfunction; left atrial enlargement, mitral inflow of a pseudo-normal pattern on pulsed wave Doppler image and an increased left ventricular filling pressure on tissue Doppler image (E/e’=20). Cardiac magnetic resonance imaging (MRI) revealed diffuse LV and RV hypertrophy and preserved LV systolic function with hypokinesia of mid-septal LV wall. Delayed hyper-enhancement (DHE) was not found within entire myocardium. A coronary CT angiography was performed because of regional wall motion abnormality but did not show any significant stenoses. He was confirmed as Fabry disease with the same genetic mutation as his brother. He did not present symptoms and signs of any other organs besides only myocardial hypertrophy. He received enzyme replacement therapy (ERT) with intravenous agalsidase-beta every other week via outpatient department for 3 years. Recently, TTE was performed and showed diffuse severe concentric LVH of an average ventricular wall thickness increased to 19 mm despite regularly ERT. Focal intramural and subepicardial DHE was newly developed at LV basal lateral and septal wall on cardiac MRI. Neutralizing antibody against agalsidase -beta was not found in serum.

Fabry disease of cardiac variant type can be delayed in diagnostic aspect because of absence of typical symptoms and signs. Despite the absence of neutralizing antibody, ERT did not prevent both further myocardial hypertrophy and myocardial fibrosis in patient with advanced myocardial hypertrophy caused by delayed diagnosis of Fabry disease. Suspicion of Fabry disease through detailed history taking including family history in patients with diffuse ventricular hypertrophy on an echocardiography can lead to early diagnosis and treatment and can result in improvement in a clinical outcome.
P646 Cardiac tamponade as initial manifestation of small cell lung carcinoma
Authors: Murdila M-C-T , Zamfirescu B , Popescu A C
Published: January 2020

We report the case of a 69 years old woman, ex-smoker, with a history of hypertension, dyslipidemia, diabetes and right leg partial amputation after childhood osteomyelitis, presented at the emergency department for dyspnoea, posterior thoracic pain and progressive distention of the abdomen. She was tachycardic, slightly hypoxemic but normotensive. Electrocardiography: sinus tachycardia, normal axis, diffuse microvoltage and electric alternans. Chest X-ray showed enlarged cardiac silouhette, bilateral pleural effusion and upper right pulmonary lobe consolidation. Transthoracic echocardiography revealed large pericardial effusion, swinging heart, right atrial and right ventricular colapse, significant respiratory variation of transmitral and transtricuspidian flow, dilated inferior vena cava without respiratory variation, all suggesting cardiac tamponade. Computed tomography showed a mediastinal and pulmonary mass in the upper right pulmonary lobe, invading the posterior right thoracic wall and multiple mediastinal voluminous lymphadenopaty and ascites. She became hypotensive and was transferred to a tertiary hospital for urgent drainage of pericardial effusion. Over 1200 mL of serohematic fluid was evacuated with the removal of the drainage catheter in the following 48 hours. A biopsy was performed through bronchoscopy and small cell carcinoma of the lung was diagnosed. Considering the advanced stage of the carcinoma the option of pallative treatment was pursued.

Discussions

Chronic accumulation of large amounts of pericardial fluid is well tolerated, especially in patients that have limited physical activity. Ecocardiography allows early detection of cardiac tamponade. Development of cardiac tamponade in the evolution of malignancy confers a poor prognosis.

The particularity of the case

Cardiac tamponade as initial manifestation of lung cancer is a very rare occurrence and only limited data exist in literature.

Conclusion

Simultaneous presence of ascites, pleural and pericardial effusion should rise the suspicion of malignancy.

Abstract P646 Figure.
P648 Right heart volume overload after surgical correction of atrial septal defect sinus venosus type with partial anomalous pulmonary veins drainage
Authors: Ruiz-Zamora I , Alvarez-Roy L , Pinillos-Francia G , Gutierrez-Fernandez A , Gomez-Llorente M , Alonso-Perez L , Bastarrika-Aleman G , Azcarate-Aguero P
Published: January 2020

40 year-old male with history of congenital heart disease. Atrial septal defect (ASD) sinus venosus type associated with partial anomalous pulmonary venous drainage (PAPVD) was diagnosed during childhood and surgically repaired at the age of three.

Since then the patient was asymptomatic and he was lost to follow up when reached adulthood. A transthorathic echocardiogram was performed during a hospitalization because of a complicated pneumonia. A severe dilatation of right chambers and main pulmonary artery was observed. The estimated Qp:Qs by this technique was 2.0 but the atrial septum seemed to be intact. Agitated saline was administered in this procedure and no passage of microbubbles was observed. A cardiac MRI was performed because of suspicion of anomalous pulmonary venous drainage. The findings observed in the echocardiogram were confirmed and an uncommon PAPVD was demonstrated by this technique: the superior left pulmonary vein drainaged into a dilated innominated vein. Also, a small pulmonary vein from the right upper lobe emptied into a "venous conduct" (yellow circle) located posterior to the superior cava vein (SCV) that later drainaged into the right atrium under the mouth of the SVC, posterior to the interatrial septum. Surgically correctioin of the PAPVD was performed.

Discussion

PAPVD is a congenital heart disease characterized by the drainage of one or several pulmonary veins –but not all of them- into the right atrium or systemic veins, which leads to left-to-right shunting. The estimated incidence of this disease ranges between 0.1 and 0.2% of the general population. The right superior pulmonary vein is the most frequently involved and is commonly associated to ASD sinus venosus type. Bilateral anomalous drainage, as occurred in this case, is exceptional.

Furhermore, this case highlights the importance of long-term follow-up in patients with congenital heart disease due to the fact that, even when the disease is considered to be cured, long term complications could appear compromising the prognosis of the patient.

Abstract P648 Figure. Unusual PAPVD
P654 Prognostic evaluation of simplified echocardiographic parameters in acute myocardial infarction
Authors: Fonseca Goncalves F , Guimaraes J P , Borges S C , Monteiro J J , Mateus P S , Moreira J I
Published: January 2020

Introduction

In an era where prognostic evaluation is increasingly being improved by echocardiography in acute myocardial infarction (MI), there are also classic 2D echocardiographic parameters that may have potential and practical utility in this area. The aim of this study was to evaluate the prognostic impact of left ventricular end-diastolic diameter (LVEDD), indexed left atrium volume (VOL) and indexed left ventricular mass (LVM) in ST-segment elevation myocardial infarction (STEMI) patients.

Methods

Retrospective study of consecutive patients with nonfatal STEMI who underwent percutaneous coronary intervention between January/2015 and December/2017. VOL was calculated by the "Area-Length" and LVM by "Cube formula", both indexed to the body surface area. High parameters were considered when: LVEDD >58mm in man or >52mm in woman; VOL >34mL/m2; LVM >115g/m2 in man or >95g/m2 in woman. At a median follow-up of 46 months (IQR 38-58), the endpoints evaluated were acute myocardial infarction (AMI), decompensated heart failure (DHF), and overall mortality. The analysis of events was adjusted for possible confounding factors.

Results

A total of 200 patients were identified, 72% of whom were men and the mean age was 63.7 ± 13.0 years. There was an increase of the LVEDD in 17.5%, VOL in 42% and LVM in 16.5%.

In the multivariate analysis, LVEDD was able to predict significant DHF (HR 2.4, 95% CI 1.2-4.9) and AMI (HR 6.4, CI 95% 1.6-26.0) and VOL only AMI (HR 6.1, 95% CI 1.2-30.1), but not DHF (HR 1.3, 95% CI 0.7-2.6). The presence of increased LVM was not associated with more events of DHF (HR 1.4, IC95% 0.7-3.0) or AMI (HR 3.7, 95% CI 0.9-14.5). None of these parameters reached statistical significance for mortality (LVEDD: HR 1.0, 95% CI 0.3-3.0, VOL: HR 1.9, 95% CI 0.8-4.4, LVM: HR 1.3, 95% CI 0.5-3.5).

In the ROC curve analysis, LVEDD showed an area under the curve (AUC) of 0.7 (95% CI 0.6-0.8) for DHF and 0.6 (95% CI 0.5-0.8) for AMI, whereas VOL demonstrated an AUC of 0.7 (95% CI 0.5-0.9) for AMI.

CONCLUSION

In patients with nonfatal STEMI who underwent percutaneous coronary intervention, LVEDD and VOL are echocardiographic parameters that may still play some role in prognostic evaluation. The presence of elevated LVM was not associated with a significant increase in cardiovascular events.
P657 Deterioration of left ventricular performance in response to pulmonary hypertension, in patients with scleroderma versus patients with coronary artery disease
Authors: Marton E , Hodas R , Blendea C , Cucuruzac R , Pirvu M , Benedek T , Benedek I
Published: January 2020

Funding Acknowledgements

PlaqueImage

Background

The relationship between the degree of pulmonary hypertension (PH) and left ventricular performance in patients with systemic sclerosis is still a controversial issue in the literature. We aimed to conduct a comparative analysis of indexes characterizing left ventricular systolic and diastolic function, in two etiological types of pulmonary hypertension involving different pathophysiological mechanisms: PH caused by systemic sclerosis and PH caused by myocardial ischemia.

Material and method

We performed a prospective study on 83 patients (36 patients with documented PAH with a systolic pulmonary arterial pressure – sPAP of >35 mmHg and 47 subjects with normal sPAP), out of which group 1 – with systemic sclerosis (n = 48); group 2 – significant coronary artery disease - CAD (n = 35). Patients of each group were divided in two subgroups based on the diagnosis of PH: group 1A - subjects with scleroderma and associated PH (n = 20), group 1B - subjects with scleroderma without PH (n = 28), group 2A - ischemic patients with associated PH (n = 16) and subgroup 2B - patients with ischemic disease without PH (n = 19).

Results

Patients in group 1 presented a significantly higher number of female subjects (p = 0.001) and a higher mean age (p = 0.009) compared to group 2. Patients with associated PH presented a significantly lower left ventricular ejection fraction (LVEF) compared to those without PH within the ischemic group (p = 0.023). There was a significant inverse correlation between the sPAP and LVEF in ischemic patients (r=-0.52, p = 0.001) as well as for scleroderma patients without PH (r=-0.51, p = 0.04). Tissue Doppler analysis of the left ventricular function indicated a significant negative correlation between the septal E’ value versus the sPAP and lateral E’ value versus the sPAP (r=-0.49, p = 0.002; r=-0.43, p = 0,008).

Conclusions

Intrinsic myocardial damage plays an important role in left ventricular systolic function even in the absence of PAH. Scleroderma patients present a less pronounced deterioration of the LVEF in response to pulmonary hypertension, indicating that in this group, additional compensatory mechanisms could be involved in the complex response of myocardium to elevated pulmonary pressures.
P679 Subpulmonary left ventricular dysfunction is associated with severity of heart failure in patients with systemic right ventricle
Authors: Surkova E , Segura T , Dimopoulos K , Flick C , West C , Senior R , Gatzoulis M , Li W
Published: January 2020

Background

Dysfunction of systemic right ventricle (SRV) in patients with congenitally corrected transposition of great arteries (ccTGA) or simple transposition (TGA) is commonly associated with exercise intolerance, heart failure and death. However, the relevance of subpulmonary left ventricular (LV) function in these settings is unknown.

Purpose

To examine the relation between severity of heart failure and echocardiographic parameters of subpulmonary LV size and function in patients with SRV.

Methods

We identified all patients with SRV from our digital echocardiographic database between 2014 and 2018. The size and function of SRV and subpulmonary LV were assessed in the most recent examination. Clinical data were collected from electronic patient records.

Results

We included 157 patients with SRV, median age 40.6 [33.1; 46.8] years, 57% male. 133 (85%) patients had NYHA functional class 1-2 and 24 (15%) NYHA class 3-4.

Patients with NYHA class 3-4 were older, had larger SRV and subpulmonary LV with poorer function and higher BNP level (Table, Figure A).

LV fractional area change (FAC) had higher sensitivity and specificity in differentiation of patients with severe heart failure than SRV FAC (Figurel B) with LV FAC cut-off value <39.2% showing the highest accuracy in prediction of NYHA class 3-4 (Se 83% and Sp 88%) and 86% Sp in predicting BNP > 100 ng/l.

LV end-diastolic diameter and area, MAPSE and FAC significantly correlated with BNP level (p < 0.0001; p = 0.001; p = 0.007; and p = 0.0002, respectively).

In Multivariate Cox regression analysis LV FAC and RV FAC were the only independent associates of NYHA class 3-4 (HR 0.69 [95%CI 0.55-0.86], p = 0.001 and HR 0.71 [95%CI 0.55-0.93], p = 0.012, respectively), while age, degree of tricuspid regurgitation and BNP were not.

Conclusions

Subpulmonary LV dysfunction is strongly associated with NYHA class 3-4 heart failure in patients with SRV. LV FAC is more accurate than SRV FAC in predicting heart failure symptoms. Subpulmonary LV should be accurately assessed in all SRV patients and be taken into account in clinical decision making and timing for interventions.

Characteristics of 157 patients with SRV Parameter NYHA Class 1-2 (N = 133) NYHA Class 3-4 (N = 24) P value Age, years 39.1 (31.9; 45.7) 46.5 (43.9; 58.1) <0.0001 RV EDAi, cm2/m2 17.4 (15.2; 20.1) 21.8 (17.5; 25.6) 0.0002 RV FAC, % 29.5 (23; 35) 22 (20; 27) <0.0001 LV EDAi, cm2/m2 12.0 (10.1; 14.1) 16.4 (11.6; 19.1) 0.0008 Reduced LV function by eyeballing 3 (2%) 18 (75%) <0.0001 BNP, ng/l 66 (35; 109) 356 (196; 512) <0.0001 Data presented as median (25th; 75th percentiles)

Abstract P679 Figure.
P685 Isolated Large Cardiac Hydatid Cyst in the Interventricular Septum
Authors: Tunca C , Pamukcu H
Published: January 2020

Hydatidosis or cystic echinococcosis is caused by infection with the metacestode stage of the tapeworm Echinococcus . Cardiac hydatid cyst is a rare disease (%0.5-%2) and its symptom is depending on the size and site of infection. The growth of hydatid cyst is usually slow and asymptomatic and just about 10% of patients with cardiac hydatid cyst are symptomatic . The left ventricle is the site of cardiac hydatid cysts in 55% to 60% of cases.Involvement of the interventricular septum is quite rarer.Surgical excision is the preferred treatment. We are reporting a patient with cardiac hydatidosis who was medically treated mass cause of refused the surgery.A 27-year-old woman presented with atypical chest pain and dyspnea. Transthoracic echocardiography revealed a large cyst in the interventricular septum. Thoracic computed tomography showed a cystic lesion in that site, and magnetic resonance imaging confirmed the presence of a 32× 34-mm mass. The patient was treated with albendazole 10 mg/kg for 6 months. After a 6-month follow-up, echocardiography revealed reduction in the size of the cyst. We consider this is the infrequent documented case of cardiac hydatid cyst which regressed with only medical treatment

Abstract P685 Figure. Hydatid Cyst in the IVS
P687 Left atrial mass - a potential pitfall
Authors: Skarlovnik A , Erzen B
Published: January 2020

Background.

Echocardiography is an important diagnostic tool in differential diagnosis of retrosternal pain. Despite the high prevalence of hiatus hernia, a relatively small number of echocardiographically manifested cases have been reported.

Case summary.

A 75 y old female patient with rheumatic polymialgia and diabetes was admitted for progressive weakness, retrosternal pain and dyspnoea. Due to elevated levels of D-dimer and troponin I an urgent CT angiography was performed and a diagnosis of pulmonary embolism was confirmed in the ER. Echocardiography showed a mildly hypertrophied left ventricle with normal EF, a mildly dilated right ventricle, moderate pulmonary hypertension 45 mmHg, and an apparent mass in the left atrium (picture).

To further characterize the left atrial mass a cardiac MR angiography was made, that excluded potential cardiac tumor and confirmed that the suspected mass was a large hiatus hernia impressing the left atrium. Patient was treated with anticoagulant therapy due to PE and corticosteroids due to polymialgia and was discharged in improved condition. We also consulted thoracic surgeons regarding hernia and did not decide to operate on the hernia urgently but opted for conservative reflux measures and an outpatient follow up with barium contrast oesophagus imaging.

Discussion.

Hiatal hernia may exert a wide spectrum of manifestations mimicking acute cardiovascular events, from ECG changes to angina, dyspnoea and even syncope as a consequence of total compression of the left atrium. A history of known hiatus hernia and aforementioned clinical correlates postprandially may shed some clues. Echocardiographic features that may suggest a hiatus hernia include:

1. A large ill-defined mass filling the left atrial chamber from posteriorly, with its maximal size seen when imaged in a posterior plane.

2. Respiratory variation in the degree of encroachment of the mass on the left atrium.

3. Loss of the normal sharply defined sonolucency of the descending thoracic aorta in the apical 4-chamber and long-axis views due to superimposition of the hiatus hernia.

4. A swirling motion seen within the mass after consumption of effervescent fluids.

5. Occasionaly, identification of an inner lining reminiscent of gastric mucosa is possible.

Various intracardiac or extrinsic lesions can resemble the echocardiographic appearance of hiatus hernia. Other potential causes of extracardiac masses that could encroach on the left atrium include structures such as aneurysm or dissection of the aorta, dilation of coronary sinus, abcesses, oesophageal carcinoma and other mediastinal space occupying structures.

Conclusion.

Hiatus hernia can simulate clinical and sonographic characteristics of cardiac disorders. Its echocardiographic manifestation may mimic a left atrial mass and must therefore be differentiated from such lesions.

Abstract P687 Figure. Hiatal hernia mimicking LA mass(PLAX)
P694 Late shunt closure: is it the only cause of pulmonary hypertension after surgical repair?
Authors: Almeida I , Ferreira F , Almeida A R , Repolho D , Joao I , Pereira H
Published: January 2020

Introduction

Atrial septal defects (ASD) may be a cause of pulmonary hypertension (PH) specially when they are only detected in adulthood. Sinus venosus type ASD are rare, with an estimated prevalence of 4-11%, and frequently they are associated with anomalous venous return of the right superior pulmonary vein (RSPV). Surgical closure is safe and effective, and it is associated with normal life expectancy when performed before age 25; the risk of PH is higher in untreated defects or late closure.

Clinical case

The authors present the case of a 74-years old female patient with previous diagnosis of a sinus venosus type ASD. Closure of the shunt and correction of venous return was performed when the patient was 36. Follow up in the following years was normal, and the patient was discharged from the congenital surgical center. The patient was referred to our PH unit due to symptomatic PH for etiological investigation (PSAP of 70 mmHg in transthoracic echocardiogram). After excluding PH related to left heart disease and lung disease, the most likely cause was pulmonary arterial hypertension due to late closure of left to right shunt, but complete investigation was performed. A transesophageal echocardiogram showed dilatation of right heart chambers and a communication of 36 mm at the high atrial septum between the RSPV and superior vena cava entrance with spontaneous left to right shunt. A severe dilation of coronary sinus (maximal dimension 33.4mm) suggestive of persistent left superior vena cava (PLSVC) was also found. A cardiac magnetic resonance was performed showing dilated right chambers, abnormal drainage of right superior pulmonary vein to right atrium, a dilated coronary sinus with a PLSVC and Qp/Qs 1.7. Right heart catheterization showed a mean pulmonary artery pressure of 25 mmHg with normal pulmonary vascular resistance (2.4 UWood) suggesting that the intracardiac shunt is the responsible for the PH with reversible pulmonary vascular disease. The patient was proposed to surgical repair.

Conclusion

The authors present a rare clinical case of an undiagnosed persisting sinus venous ASD after surgical repair. Failure of shunt closure led to the development of PH, emphasizing the need to maintain lifelong follow up of these patients in specialized centers.

Abstract P694 Figure.
P697 Left ventricular non compaction highlighted by three-dimensional and speckle tracking echocardiography
Authors: Hotta V T , Martinelli L M B , Fernandes F , Moises V A , Vieira M L C , Mady C
Published: January 2020

Introduction

Left ventricular non-compaction (LVNC) is a relatively new cardiomyopathy, first reported by Chin et al. in 1990. Since then, much has been learned about this entity, but until now, there are some limitations for the diagnosis of this disease. Cardiac Magnetic Resonance Imaging is considered the gold standard for the diagnosis of LVNC, but echocardiography remains the first line imaging modality due to its availability and cost efficacy.

Case report

In this case, we report a case of an asymptomatic 21 years old young male with no personal or familiar history of cardiomyopathies. Two dimensional echocardiography (2D Echo) evidenced increased left ventricular trabeculation in the apical segments of lateral and anterior walls and a non compacted myocardium/ (compacted + non compacted myocardium) ratio of 0,33, compatible with LVNC according to Chin´s criteria. 3D Echo provided more detailed LV morphology analysis and 3D Echo Color Doppler evidenced ventricular flow within the intraventricular recesses. Strain analysis by speckle tracking (STE) evidenced global longitudinal strain = - 17% (Normal values < -18%), probably related to an incipient systolic dysfunction not evidenced by the evaluation of left ventricular ejection fraction by 2D Echo.

Conclusions

This case illustrates new echocardiographic modalities for LVNC diagnosis. 3D Echo and STE are new technologies that may play an incremental role in the evaluation of LVNC but need further investigation and validation.

Abstract P697 Figure.
P710 Nivolumab-induced takotsubo syndrome: a case report
Authors: Prevedello F , Dolci G , Tenaglia R M , Lobascio I , Paolini C , Bilato C
Published: January 2020

Background

Nivolumab is a monoclonal antibody targeting programmed cell death protein 1 (PD-1), with a demonstrated clinical efficacy against metastatic cancer. Immunotherapy cardiovascular toxicity is rare, but recent scientific literature demonstrated possible and different cardiovascular side effects. Nivolumab was found to be associated with fatal acute myocarditis with diffuse myocardial necrosis and heart failure. To our knowledge no case of Nivolumab induced Tako-tsubo syndrome has ever been reported.

Case presentation

A 76-year-old woman was admitted to the emergency department for dyspnoea with electrocardiographic evidence of extensive anterior ST segment elevation (Figure 1A); the patient was hemodynamically unstable with increasing shortness of breath and oxygen desaturation (arterial blood pressure 90/50 mmHg, heart rate 120 beats/min, O2 Sat. 87%). She was scheduled for urgent coronary angiography which eventually demonstrated no significant coronary artery disease. The ventriculography revealed dyskinesis of the left apex and peri-apical segments and basal hyperkinesis (Figure 1B). The final diagnosis was stress cardiomyopathy or Tako-tsubo syndrome. The echocardiogram performed in the acute setting revealed severe left ventricular impairment (ejection fraction, EF = 30%) confirming the typical apical ballooning pattern of the syndrome (Figure 1C). Left ventricular outflow tract obstruction was not found. At admission, the level of TroponinT was mildly elevated (745 ng/L) and NT-proBNP was 35 000 pg/ml. The patient was treated with optimal heart failure medical therapy with gradual and complete left ventricular function recovery (EF at discharge = 55%). Of note, the patient had a history of primary lung adenocarcinoma firstly treated in 2017 with carboplatin; due to cancer progression she had undergone Nivolumab therapy in October 2018 with a total of three cycles, the last one interrupted one month before the cardiovascular event due to ipokaliemia and mild renal impairment. At that time the patient was defined as having a good functional status. Apart from the oncologic treatment, patient’s history did not reveal any "acute" stressful event.

Conclusions

To the best of our knowledge this is the first Takotsubo cardiomyopathy ever detected after Nivolumab therapy. Stress cardiomyopathy is a rare but possibly severe complication that could appear in the course of oncological treatment and, in this backdrop, its aetiology is not well understood. As a matter of fact, cardiac function monitoring and strict clinical follow-up for early detection of complications is mandatory in these patients. Favourable outcomes may be achieved with early diagnosis and prompt treatment introduction.

Abstract P710 Figure. Diagnostic evaluation of Takotsubo Sdr
P712 When Popeye had shortness of breath
Authors: Kocabas U , Turk U O
Published: January 2020

A 61-year-old man presented to our clinic with progressive shortness-of-breath in the last 3 months. He had a history of hospitalization and endotracheal intubation due to acute pulmonary edema and type – I respiratory failure a week ago and discharged after diagnostic coronary angiography which demonstrating normal coronary arteries. Physical examination revealed bunching of the left biceps when he flexed his left arm which is consistent with rupture of distal biceps tendon (Panel A, Popeye Sign). A 12-lead electrocardiography (ECG) showed low QRS voltage in the limb leads and ST segment depression and asymmetrical T wave inversion in the anterolateral leads (Panel B). Transthoracic echocardiography (TTE) showed concentric left ventricular hypertrophy with left ventricular ejection fraction of 60% (Panel C). Pulsed wave-Doppler obtained from the mitral valve demonstrated restrictive filling pattern with high early diastolic velocity (E-wave) and low late diastolic filling (A-wave) peaks with E/A ratio > 2.0 and reduced lateral mitral annular diastolic velocities with E/e’ ratio > 15 which are compatible with impaired left ventricular diastolic function with elevated left ventricular filling pressures (Panel D-E). Biceps tendon rupture, low QRS voltage and left ventricular hypertrophy with restrictive filling pattern were considered suggestive of cardiac amyloidosis and patient was referred to hematology clinic for diagnostic work-up. Protein electrophoresis demonstrated monoclonal gammopathy in the serum and immunoelectrophoresis showed free lambda light chains. The patient diagnosed as AL amyloidosis with cardiac and musculoskeletal involvement.

Biceps tendon rupture is a rare finding of amyloidosis due to musculoskeletal involvement. In the setting of acute pulmonary edema and/or heart failure with preserved ejection fraction with massive left ventricular hypertrophy, restrictive filling pattern, low QRS voltage and spontaneous tendon rupture should raise clinical suspicion of amyloidosis with cardiac and musculoskeletal involvement.

Abstract P712 Figure.
P749 Echocardiographic risk factors of functional ischemic mitral regurgitation in patients with first acute myocardial infarction
Authors: Kochanowski J , Piatkowski R , Scislo P , Budnik M , Marchel M , Opolski G
Published: January 2020

Purpose

The aim of this study was to assess the correlation between the size of acute functional ischemic mitral regurgitation (FIMR) and selected left ventricle echocardiography measurements in patients (pts) with first ST-segment elevation myocardial infarction (STEMI) treated with effective primary angioplasty (PCI).

Methods

We analyzed 1578 consecutive hospitalized pts with STEMI (M-914; 66,4 ± 10,2 years) treated with PCI. The echocardiographic examination was performed at up to 3 days after admission. We assessed the frequency and size of FIMR, left ventricular end diastolic diameter (LVEDd), ejection fraction (EF), wall motion score index (WMSI) and systolic sphericity index (Sls). Effective regurgitation orifice area (EROA) was used for quantitative FIMR assessment (mild: <10 mm², moderate: ≥10 and < 20 mm², severe: ≥ 20mm²). The study population was divided into four groups depending on the size of FIMR. Correlation coefficient was used to determine correlations between data sets.

Results

We observed mild FIMR in 550 pts (34,9%) - group I, moderate in 356 pts (22,5%) - group II, severe in 57 pts (3,6%) - group III, no FIMR in 615 pts (39%) – group IV. Mean values of selected echocardiographic parameters in each analyzed group are shown in table 1. The positive good correlations between SIs and size of FIMR were found (r = 0,68) as well as weak correlations between LVEDd, WMSI and FIMR (ro = 0,25, ro = 0,34, respectively). The negative weak correlation between EF and size of IMR was present (ro = - 0,34).

Conclusions

1. FIMR is a common complication in pts with STEMI treated with PCI.

2. We found a statistically significant correlation between SIs and FIMR severity.

Table 1 Group I Group II Group III Group IV p LVEDd (cm) 5,22 ± 0,64 5,42 ± 0,56 5,72 ± 0,64 4,98 ± 0,58 NS EF (%) 48 ± 6 42 ± 8 35 ± 8 51 ± 8 NS WMSI 1,34 ± 0,28 1,42 ± 0,24 1,68 ± 0,32 1,32 ± 0,22 NS SIs 0,22 ± 0,1 0,32 ± 0,1 0,68 ± 0,1 0,18 ± 0,1 0,01 NS - non-significant
P772 Percutaneous transcatheter patent foramen ovale closure: does size really matter?
Authors: Ramis Barcelo M F , Mas Llado C , Rodriguez A , Valadron I , Noris M , Forteza J F , Pericas P , Pasamar L , Gonzalez R , Peral V
Published: January 2020

Introduction

Patent foramen ovale (PFO) has been associated with cryptogenic stroke. Percutaneous transcatheter PFO closure has been in development for the last years. In recent studies, it has shown a reduction of recurrent ischemic stroke events. Several manufactures of PFO device closure have developed guidelines for selection of device size based on anatomic measurements obtained through echocardiography. A study showed that according to the guidelines few patients had adequate tissue rim to allow device implantation, and yet almost all the patients had an effective closure.

Purpose and methods

The aim of this study was to evaluate the characteristics of PFO with transesophageal echocardiogram (TEE) (size, distance between foramen ovale-superior vena cava (FO-SVC) and distance between FO-aortic annulus (FO-AoAn)) and to determinate the correlation between the size of PFO device implanted and the theoretical device size according to the guidelines.

We performed a retrospective study among patients who underwent a PFO closure procedure between 2006 and 2018.

Results

42 patients were included, 55% male, mean age 56 years and mean BSA 1,83 m². The PFO mean diameter and length were 3 and 13 mm respectively. The majority of PFO were complex: 91% of patients had defects larger than 8mm and 36% had atrial septum aneurism. Characteristic of PFO were measured (Table). In older patients the distance between PFO-SVC and PFO-AoAn was larger and the septum secundum was thicker (p 0.02). The right-to-left shunt was moderated or severe in most cases (75%). The PFO closure device was successfully implanted in all patients. The majority of them received an Amplatzer PFO device (45%) followed by an Hyperion PFO device. The size of the device was 25mm in half of the patients followed by 30mm device. According to the guidelines, in 67% of the cases the wrong size was chosen and the mean size of the device should had been 30mm (SD ±5,2). TEE examination during follow up showed no residual or mild residual shunt in 80% of the patients. Residual shunt was more prevalent with larger devices (p 0.008)

Conclusions

These results showed that the size of PFO closure device implanted in our population differed from the size recommended by guidelines. Smaller devices have been used. According to our results, larger devices are associated with more residual shunt, which suggests that a different approach may be necessary to establish new protocols for PFO device closure

Table Minimal Maximal Mean SD SVC (mm) 10 30 17.55 ±3,7 AoAn (mm) 9 23 14.1 ±3,5 Minimal and maximal distance between PFO-SVC and AoAn
P776 Stress ecocardiography and speckle tracking analysis in patients with heart failure and preserved ejection fraction
Authors: Di Lisi D , Lupo A , Castellano F , Nugara C , Triolo O F , Evola G , Trapani R , Novo S , Novo G
Published: January 2020

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is characterized by heart failure symptoms despite preserved LV systolic function together with at least one among left ventricle hypertrophy/left atrial enlargement plus diastolic dysfunction (DD) and increased brain natriuretic peptide levels. Rest echocardiography could still be normal despite patients experience HF symptoms. Speckle tracking analysis (STE) analyzes myocardial deformation and is able to identify subtle left ventricular dysfunction.

PURPOSE

to analyze the added value of stress echocardiography to improve diagnostic accuracy in patients with normal ejection fraction and unexplained dyspnoea by evaluating DD, lung B lines and STE.

METHODS

Main inclusion criteria were: suspected heart failure, EF > 40%, DD up to moderate at rest (E/e"<14), age < 85 and >18 years, satisfactory acoustic window. Exclusion criteria were: comorbidities limiting the prognosis, valvulopathy more than moderate, coronary artery disease, moderate to severe DD at rest (E/e"≥14; E/A≥2), pregnancy or lactation. Each patient underwent physical stress echo and STE by GE Vivid 7, (AFI).

RESULTS

After measuring diastolic function parameters variation with stress, HFpEF was diagnosed in 8 patients, who had baseline non-diagnostic echocardiogram (Table 1). In the remaining 20 patients a non-cardiac etiology of dyspnoea was diagnosed (NCD). EF did not significantly change from rest to stress either in HFpEF group (58 ± 6 vs 61 ± 8.7 p:0.62) or in DNC group (59 ± 8 vs 62.2 ± 7.4; p:0.26). GLS values tended to decrease in patients with HFpEF (-18.5 ± 2.2 at baseline vs -15.96 ± 6.67 at peak stress; p:0.33), and it was stable in DNC (-17.69 ± 1.15 at baseline vs - 18.04 ± 2.02 at peak stress; p:0.64).

CONCLUSIONS

Study of diastolic function during stress echocardiography is a useful diagnostic tool to reveal HFpEF in patients with dyspnea and unremarkable baseline echocardiogram. STE could offer useful adjunctive diagnostic information but further studies are needed to confirm its value.

Table 1 HFpEF NCD p HFpEF NCD p GLS -18,5 ± 2,2 -17,6 ± 1,15 0,23 -15,96 ± 6,67 18,04 ± 2,02 0,26 E/A 0,8 ± 0,1 1 ± 0,7 0,55 1,67 ± 0,7 1,26 ± 0,6 0,07 E/e’ 10,1 ± 2,2 9,9 ± 3,7 0,4 16,4 ± 0,9 13,8 ± 5 0,16 PAP 25,6 ± 4,1 22,33 ± 0,55 0,57 49,8 ± 9,65 28,27 ± 4,35 0,001 LA 35,5 ± 8,5 23,44 ± 4,9 0,001 34,45 ± 4,88 27,32 ± 7,33 0,018 EF 58 ± 6 59 ± 8 0,6 61 ± 8,7 62,2 ± 7,4 0,7 Echocardiographic parameters at baseline and at peak stress in patients with HFpEF and with NCD
P780 Left ventricular torsion in severe valvular disease
Authors: Azul Freitas A , Ferreira J , Ferreira C , Milner J , Alves P , Marinho V , Martins R , Baptista R , Jorge E , Goncalves L
Published: January 2020

Introduction

Left Ventricular (LV) torsion is an important component of LV performance. With the development of speckle tracking echocardiography, it became possible and feasible to measure rotation and twisting with a high degree of accuracy. No standard normal values are defined for peak torsion, although mean values around 10° are found in normal subjects with a slight increase with age.

Purpose

In this study we aimed to evaluate torsion in the different types of severe valvular disease.

Methods

We conducted a retrospective, observational study including patients with severe valvular disease with suitable images for torsion analysis. We included 61 patients (21 with severe aortic stenosis (AS), 20 with severe aortic regurgitation (AR) and 20 with severe mitral regurgitation (MR). Circumferential basal and apical strain was performed, and peak torsion was calculated. Results were compared between groups and were related with echocardiographic parameters, including left ventricle ejection fraction (LVEF).

Results

Mean age was 70.3 ± 13.6 years with a male preponderance (66%). Mean LVEF was within normal range in the aortic valve disease group; no significant difference was found in LVEF between AS and AR patients (57 ± 7.7% vs 55 ± 9.7%, p = 0.57). In comparison with the aortic disease group, MR patients had a reduced LVEF (48 ± 17.3% vs 56 ± 8.7%, p = 0.05). Mean peak torsion was 8.9 ± 5.1° in AS, 12.6 ± 4.9° in AR and 7.9 ± 3.2° in MR (p = 0.004). Comparing with aortic valve disease patients, MR patients had a reduced mean peak torsion (7.9 ± 3.2° vs 10.7 ± 5.3°, p = 0.03). In relation with patients with AS, those with AR had a higher peak torsion (12.6 ± 4.9° vs 8.9 ± 5.1°, p = 0.024) and a higher left ventricle end-diastolic volume (87.3 ± 29.1 mL.m-² vs 64.5 ± 24.9 mL.m-², p = 0.011). Circumferential apical strain showed a negative correlation with peak torsion (r²=0.203, p = 0.006) and with LVEF (r²=0.290, p < 0.001). Peak torsion did not demonstrate any significant correlation neither LVEF nor circumferential basal strain.

Conclusion

LV function and peak torsion are more associated with apical than basal circumferential movement. Aortic valve disease is responsible for LV torsion variations in patients with normal ejection fraction, showing an increase in AR and a reduction in AS. In MR patients a reduced LVEF could entails a decrease in peak torsion.
P782 Septal flash is a prevalent and early dyssynchrony marker in transcatheter aortic valve replacement-induced left bundle branch block
Authors: Calle S , Coeman M , Kamoen V , De Pooter J , Timmermans F
Published: January 2020

BACKGROUND

New-onset left bundle branch block (LBBB) is a frequent complication after transcutaneous aortic valve replacement (TAVR). LBBB is associated with echocardiographic dyssynchrony in heart failure patients, but this has not been thoroughly investigated in acute LBBB following TAVR.

PURPOSE

This study aims to assess the timing and incidence of echocardiographic dyssynchrony in acute TAVR-induced LBBB patients.

METHODS

The study enrolled all TAVR-induced LBBB patients at our Hospital between January 2013 and May 2019. Presence of LBBB was scored within 72 hours following TAVR. Dyssynchrony was assessed by: 1/ presence of septal flash (SF), 2/ interventricular mechanical delay (IVMD, the difference between left and right ventricular pre-ejection interval using pulsed wave Doppler; cut-off ≥40 ms) and 3/ presence of ‘classical dyssynchronous strain pattern’ assessed with speckle tracking (Figure 1). As a control, these three LBBB-related dyssynchrony markers were assessed and compared to LBBB patients without TAVR (non-TAVR patients) in normal ànd reduced EF, but all having SF.

RESULTS

Out of 134 consecutive TAVR procedures, 30 (22%) were complicated by acute LBBB. SF was present in 72% of TAVR-induced LBBB patients, with a median time from TAVR to SF diagnosis of 24 hours. However, only 1 (5%) of these TAVR patients exhibited a classical dyssynchronous contraction strain pattern (Figure 1), despite presence of SF. Finally, the IVMD values in these TAVR-LBBB patients did not meet the ‘dyssynchrony’ cut-off.

As a control, we compared these dyssynchrony parameters in patients with non-TAVR related LBBB with normal and reduced EF, all exhibiting SF. A classical strain pattern was present in 33% of non-TAVR LBBB patients with preserved left ventricular ejection fraction (LV EF) (p = 0.17), and in 80% of non-TAVR LBBB patients with reduced LV EF ≤30% (p < 0.001). The IVMD in non-TAVR LBBB patients with SF and preserved LV EF was 52 ms (p = 0.002) and 57 ms in non-TAVR LBBB patients with SF and LV EF ≤30% (p = 0.009).

CONCLUSION

SF as dyssynchrony marker develops early after TAVR-induced LBBB and is much more prevalent than the classical strain-based dyssynchrony pattern and IVMD.

Our findings from the control population suggest that progressive LBBB-induced LV remodeling (septal thinning and relative lateral thickening) may be required for a ‘classical dyssynchrony strain pattern’ or significant IVMD to occur in TAVR-LBBB patients, but longitudinal follow-up studies in TAVR-LBBB patients are required as proof-of-concept.

Abstract P782 Figure 1
P784 Cardiac remodelling in elite rowers - insights from novel echocardiographic techniques
Authors: Kleinnibbelink G , Panhuyzen-Goedkoop N M , Hulshof H G , Van Dijk A P J , George K P , Somauroo J D , Oxborough D L , Thijssen D H J
Published: January 2020

Funding Acknowledgements

No financial support

Background

Chronic exercise training leads to cardiac remodelling; the so-called Athlete’s Heart. Previous studies are often limited by a cross-sectional design whilst longitudinal training studies are often constrained to the assessment of non-athletes. Echocardiography provides comprehensive assessment of mechanics and may give additional insight into short-term changes in training volume in the elite athlete.

Purpose

To examine the impact of a short-term (9 months) increase in training volume on cardiac structure and mechanics in elite international competing rowers.

Methods

As part of the work-up to the 2012 Olympic Games, twenty-seven elite rowers (26.4 ± 3.7 years, 19 male) underwent baseline echocardiography prior to and post (9-months) a planned increase in training volume. Conventional echocardiographic indices including mechanics of all cardiac chambers were assessed.

Results

In response to increased training volume, there was a significant increase in left ventricular (LV) size (IVSd 9.2 ± 1.2 to 9.7 ± 1.1 mm, p = 0.001; PWd 8.3 ± 1.3 to 8.7 ± 1.4 mm, p = 0.013), LVIDd (56.5 ± 4.6 to 57.9 ± 4.2 mm, p = 0.001), and LVMi (90.2 ± 17.8 to 100.8 ± 17.1 g/m2, p = 0.000), see table. There was a significant increase in LV twist (9.2 ± 4.5 to 11.2 ± 4.7 °, p = 0.04; basal rotation -4.4 ± 3.1 to -4.5 ± 3.4 °, p = 0.84; apical rotation 5.8 ± 3.4 to 7.1 ± 3.7 °, p = 0.011), see figure, however, there were no changes in any other conventional indices of function or any other cardiac mechanics. There was a significant increase in left atrial (LA) volume (58.8 ± 15.2 to 65.3 ± 17.6 mm, p = 0.01) whilst no changes were observed in right heart structure.

Conclusion

An increase in exercise training volume in elite rowers across 9-months induced mild balanced structural remodelling of the LV and LA with a concomitant increase in LV twist. Contradictory to findings in non-athletes, there was no increase in right ventricular or atrial structure or function which may be representative of the elite athlete status and possibly already at threshold for physiological adaptation.

Abstract P784 Figure.