bluuebunny/crossref_metadata_2025 huggingface dataset:
P3 EXERTIONAL SYNCOPE AND VENTRICULAR ARRHYTHMIA IN A PATIENT WITH CARDIAC AMYLOIDOSIS
Authors: Fede G , Guccione N , Abate G , Belluardo P , Scollo V , Sulsenti G , Ficili S
Published: May 2023

Systemic amyloidosis is a multisystem disorder caused by the misfolding, aggregation, and deposition of certain proteins in various organs and tissues. Cardiac involvement is common and worsens the prognosis. Atrial fibrillation is the most frequent arrhythmia in cardiac amiloidosis (CA), but many cases of ventricular arrhythmias (VA) and sudden cardiac death (SCD) have been described. We present a case of a 64–year–old man admitted following exertional syncope occurred after climbing a flight of stairs. His medical history included left gonarthrosis and surgery for right carpal tunnel syndrome one year before. Physical examination did not revealed signs of heart failure. A 12–lead electrocardiogram (ECG) showed a pseudoinfarction pattern with QS waves in V2 and V3 leads and low voltage in all limb leads. Routine blood tests revealed NT–pro–BNP 3436 pg/ml(n.v.0–125) and high–sensitive troponin T 67 pg/ml(n.v.< 58). A trans–thoracic echocardiogram showed left ventricle (LV) concentric thickening wall with granular and sparkling pat[1]tern, mild reduced ejection fraction, reduced global longitudinal strain with apical sparing, grade 3 diastolic disfunction, biatrial enlargement, mild mitral regurgitation, right ventricle free wall thickening (8 mm), mild reduced TAPSE, and mild pericardial effusion. Cardiac magnetic resonance (CMR) confirmed ventricular wall thickening with evidence at T1 mapping of interstitial infiltration more evident in the septum and inferior–lateral wall with apical savings. A total body 99mTc–HDP scintigraphy showed cardiac uptake with intensity similar to bone signal (Perugini Score 2) suggesting ATTR cardiac amyloidosis. Both kappa and lambda concentrations were normal. The genetic testing did not reveled mutations in the TTR gene. We concluded for a diagnosis of ATTR wild–type CA. The Holter ECG monitoring registered numerous ventricular ectopic beats and an episode of non–sustained ventricular tachycardia. A coronary angiography ruled out coronary artery disease. In consideration of the clinical–instrumental picture an ICD was implanted.

Conclusions

CA is still underdiagnosed. VA and SCD may further complicate the prognosis. Early diagnosis and adequate stratification of the arrhythmic risk are essential to ensure patients the best therapeutic strategies.
P6 A HEART OF STONE: A CASE OF APOLIPOPROTEIN A–I CARDIAC AMYLOIDOSIS TREATED WITH HEART TRANSPLANT
Authors: Abete R , Iacovoni A , Vittori C , Sebastiani R , Terzi A , Grazioli L , Lorini F , Arbustini E , Senni M
Published: May 2023

A 56–year–old woman was referred to our Unit for advanced heart failure refractory to pharmacological therapy with poor functional status (NYHA class IV, INTERMACS profile 4–5). She had a history of restrictive and hypokinetic cardiomyopathy secondary to autosomal dominant hereditary Apolipoprotein A–I (APOA1) amylodosis caused by Leu75Pro mutation, detected both in her sister and brother. An ICD was placed for cardiac arrest due to ventricular fibrillation. She was hospitalized in our unit to evaluate non–conventional heart failure therapies. ECG showed a sinus rhythm with low QRS voltages and pseudo–infarct pattern with QS waves in V1 towards V3. Laboratory testing revealed a BNP of 625 ng/L, creatinine of 1.47 mg/dL with an estimated GFR of 40 ml/min/1.73m2. Transthoracic echocardiography showed a non–dilated left ventricle (LVEDD 50 mm, LVEDV 70 ml/m2) with concentric hypertrophy (IVS/PW 15/15 mm) and granular sparkling myocardium, global hypokinesia with severely reduced left ventricular ejection fraction (LVEF 28%) and restrictive filling. The right ventricle was dilated with reduced function (TAPSE 12 mm). Moderate mitral and tricuspid regurgitation were also reported, with estimated systolic pulmonary pressure of 40 mmHg. Right heart catheterization showed a RAP of 14 mmHg, mPAP of 31 mmHg, PCWP of 25 mmHg, PVR of 2.2 wood units and a CI of 1.49 l/min/m2; after reversibility testing with intravenous nitrate, mPAP fell to 25 mmHg, PCWP was 18 mmHg, PVR 1.86 WU and CI improved to 1.94 l/min/m2. She was dependent on inotropes (dobutamine 4 mcg/Kg/min). In multidisciplinary team, LVAD placement as a bridge was excluded for severe right ventricular dysfunction and she was listed for heart transplant in 2A emergency status. Notably, screening colonoscopy showed polypoid amyloid deposition in the bowel. Macroscopic examination of explanted heart showed thickening of both ventricles, valves and papillary muscles; histopathologic examination revealed intramural amyloid accumulation. Immunohistochemistry confirmed that amyloid deposits were specifically stained with an anti–APOA1 antibody. Postoperative course was characterized by necessity of hemodialysis, which was stopped in day 26. No amyloidosis recurrence was detected at endomyocardial biopsies up to 6 months. In selected patients with cardiac amyloidosis, heart transplantation can be an effective therapeutic option with outcomes similar to those transplanted for other causes of heart failure.
P8 INTERMUSCULAR TWO–INCISION TECHNIQUE FOR IMPLANTATION OF THE SUBCUTANEOUS IMPLANTABLE CARDIOVERTER DEFIBRILLATOR: 3–YEAR FOLLOW–UP
Authors: Migliore F , Pittorru R , Giacomin E , De Lazzari M , Bertaglia E , Sottini S , Iliceto S
Published: May 2023

Purpose

The aim of the present study was to evaluate the outcome of patients underwent subcutaneous implantable cardioverter defibrillator (S–ICD) implantation with the intermuscular (IM) two-incision technique during 3–year followup.

Methods

The study population consisted of 105 consecutive patients (79 male; median 50 [13-77] years) underwent S–ICD implantation with the IM two-incision technique. The composite primary end point of the study consisted of device–related complications and inappropriate shocks (IAS). Secondary end points included the individual components of the primary end point, death from any cause, appropriate therapy, major adverse cardiac events, hospitalization for heart failure, heart transplantation.

Results

According to the PRAETORIAN score, the risk of conversion failure was classified as low in 99 patients (94.3%), intermediate in 6 (5.7%).Ventricular fibrillation was successfully converted at ≤65 J in 97.4% of patients. During a median follow–up of 39 (16–53) months, 10 patients (9.5%) experienced device–related complications and 9 (8.5%) patients reported inappropriate shocks (IAS). Leadassociated complications were the most common (5 patients, 4.7%), including 2 cases of lead failure (1.9%). Pocket complications were reported in 2 patients (1.9%). Extra–cardiac oversensing (3.8%) represented the leading cause of IAS. No T–wave oversensing episodes were recorded. Twelve patients (11.4%) experienced appropriate shocks. Eight patients (7.6%) died during follow–up. IAS or device–related complications did not impact on mortality.

Conclusions

The overall device–related complications and IAS rates over 3 years of follow–up were 9.5% and 8.5%, respectively. According to our findings, the IM two–incision technique allows for optimal positioning of the device achieving a low PRAETORIAN score with a high conversion rate. IM two–incision technique allows low incidence of pocket complications, shifting the type of complications towards lead–related complications, which represent the most common complications. The IM two–incision technique would not seem to impact the occurrence of IAS. Management of complications are safe without impact on the outcome.
P10 REAL–WORLD SINGLE CENTER EXPERIENCE WITH THE WEARABLE CARDIOVERTER DEFIBRILLATOR: SEX DIFFERENCES IN RISK STRATIFICATION FOR SUDDEN CARDIAC DEATH
Authors: Bolognesi M , Rossi L , Biagi A , Bricoli S , Sticozzi C , Comastri G , Aschieri D
Published: May 2023

Background

Previous studies established a role for the wearable cardioverter defibrillator (WCD) in patients with transient risk os sudden cardiac death (SCD). The WEARIT–II Registry highlighted an higher burden of ventricular and atrial arrhythmic events in women than in men, in spite of a similar ICD implantation rates.

Objectives

We aimed to describe the sex differences in WCD use and compliance. Moreover we reviewed the rate of cardiac events detected with WCD and the rate of ICD implantation in women in a real–world single center experience.

Methods and results

Between August 2017 and June 2022, 60 consecutive patients receiving a WCD at Piacenza Hospitals were retrospectively included in this analysis: mean age 66.9±11.9 years, 56.6% with ischaemic cardiomyopathy, 38.3% with dilated cardiomyopathy, 5% after implantable cardioverter–defibrillator explant. 8 patients were women (13.3%). Women and men presented similar clinical characteristics. Median WCD usage period and median daily wear time were not different between women and men (49.6±25.3 vs 51.8±32.8 days, 23.6±0.3 vs 23.1±1.7 hours, respectively). No ventricular fibrillation was detected in the monitoring period. Non–sustained ventricular tachycardia and atrial arrhythmias were similar between women and men. However, ICD implantation rate at the end of WCD use was significantly lower in women than and men (25% vs 61.5%; p< 0.01).

Conclusions

In this real word analysis WCD was underused in women despite a nice compliance. A similar burden of ventricular and atrial arrhythmic events were detected, with a lower ICD implantation rate at the end of WCD use in women than in men.
P11 RISK STRATIFICATION IN ATHLETES: AN "IRREDUCIBLE" MASTER ATHLETE
Authors: Pescatore V , Brugin E , Compagno S , Zanella C , Giada F
Published: May 2023

We describe the clinical case of a 48–year–old master athlete, runner (marathon runner), always asymptomatic at rest and during effort, with a family history of ischemic heart disease and no other known cardiovascular risk factors. On the occasion of the pre–partecipation screening visit, he presented an altered baseline electrocardiogram with low peripheral voltages and T wave inversion in V1–V5 leads and inferior leads. The echocardiogram documented morphofunctional alterations in the right ventricle and raises the suspicion of arrhythmogenic cardiomyopathy, later confirmed by cardiac magnetic resonance with Gadolinium. During effort, even repetitive premature ventricular beats LBBB with superior axis morphology appeared. Also, torsade de pointes episode with presyncopal sensation. He was hospitalized with a diagnosis of threatening arrhythmias in right ventricular arrhythmogenic heart disease. Coronary angiography was negative. We recommend beta–blocker therapy, genetic analysis, screening of family members. A subcutaneus defibrillator has been placed. The patient, against the advice of the Physicians, continued to train even at high intensity until he has a syncopal episode with correct intervention of the device on ventricular fibrillation. Since the patient has requested specific indications to continue training independently, an exercise test in beta–blocker therapy is repeated and the training thresholds are calculated. The case of this master athlete highlights the issue of the difficulty of screening the master athlete with frequent omission of symptoms (the patient already had syncopal/presyncopal episodes at home which he had omitted), poor adherence to therapeutic indications, possible negative effects of high intensity physical training on the evolution of arrhythmogenic cardiomyopathy.
P14 CT SCAN DERIVED PARAMETERS PREDICT LEFT VENTRICLE OBSTRUCTION AFTER TAVI
Authors: Vella C , Ferri L , Ancona M , Bellini B , Russo F , Romano V , Ghizzoni G , Gentile D , Paci G , Esposito A , Montorfano M
Published: May 2023

Introduction

Mid Ventricular (MVO) and Left Ventricular Outflow Tract Obstruction (LVOTO) after Trans–catheter Aortic Valve Implantation (TAVI) have been previously described and are associated with adverse outcome. Pre–procedural identification of patient at risk of MVO and LVOTO after TAVI may help pre–operative risk stratification and patient selection and facilitate intra–operative management, finally improving clinical outcomes. This study aims to identify CT–scan and Echocardiographic predictors of Left Ventricular Obstruction (LVO), defined as the composite of MVO and LVOTO.

Methods

We retrospectively reviewed pre–operative CT scans and Trans–Thoracic Echocardiography of 349 patients treated with TAVI at our Centre between January 2019 and December 2021. Correlations between post–operative development of MVO and LVOTO and pre–operative Echocardiographic and CT scan measurements were tested.

Results

LVO occurred in 16.3% of patients after TAVI. At univariate analysis clinical factors associated to LVO were female gender (OR=2.2, p=0.006) and body surface area (OR=0.19, p=0.006); pre–procedural echocardiographic parameters identified were end–diastolic–diameter (OR=0.89, p<0.001) and left ventricular ejections fraction (OR=1.09, p<0.001), whereas pre–procedural CT scan measurements associated to LVO were intraventricular septum to leaflet coaptation length (SLCL; OR=0.87, p<0.001) and left ventricular systolic area (OR=0.9, p<0.001). After multivariate analysis, only left ventricular ejection fraction (OR=1.1, p<0.001) and the CT scan derived parameters SLCL (OR=0.9, p<0.001) and left ventricular area (OR=0.9; p<0.001) were able to predict LVO after TAVI.

Conclusions

Left ventricle obstruction (LVOTO + MVO) after TAVI can be predicted by CT scan derived parameters. Pre–procedural identification of patients at risk may help intraprocedural and postprocedural management, thus improving clinical outcomes.
P17 MITRAL ANNULUS CALCIFICATION IN TRANSCATHETER AORTIC VALVE IMPLANTS
Authors: Nardi B , Cammelli T , Zoppi F , Grippo G , Maioli M , Di Mario C , Toso A
Published: May 2023

Background

Mitral annular calcium (MAC) is a common finding in patients undergoing transcatheter aortic valve implantation (TAVI). However, assessment of MAC in the pre–TAVI diagnostic pathway is not among the procedures routinely performed.

Aim of the study

In this retrospective study conducted in patients undergoing TAVI, we evaluated (1) the presence and extent of MAC using a multimodal imaging approach; (2) the clinical and structural factors associated with it; and (3) the possible prognostic role of MAC.

Methods

Between 2016 and 2022, 62 patients with severe aortic stenosis underwent TAVI at the Cardiovascular Department of A.O.U. Careggi (Florence, Italy). Baseline and post–TAVI clinical and echocardiographic data were collected at Santo Stefano Hospital (Prato, Italy). MAC assessment was performed by quantitative analysis on echocardiographic and computed tomography (CT) images, obtaining a MAC severity score. A clinical follow–up was conducted at 30–day intervals in all patients.

Results

MAC was detected in 48 patients (77%), a severe MAC in 16 patients (26%). CT analysis was more accurate in defining the presence and extent of MAC. Patients with MAC were more female, older in age, with greater cardiovascular risk profile and comorbidities; they presented more frequently mitral valvulopathy and arrhythmias. These differences were amplified by stratifying the population according to MAC severity score. Patients with severe MAC had a pattern of ventricular remodeling with predominantly concentric hypertrophy. Post–TAVI, patients with severe MAC had less hemodynamic benefit and a greater need for pacemaker implantation. A trend of increasing all–cause mortality as MAC score increased was noted.

Conclusions

Assessment of mitral annular calcium and its extension should become an integral part of the patient‘s pre–TAVI risk stratification process. A phenotypic pattern of concentric left ventricular hypertrophy, mainly associated with patients with severe MAC, identifies a category with lower post procedural recovery.
P20 LOOK BEYOND APPEARANCES:NOT ONLY A SIMPLE AORTIC ENDOCARDITIS
Authors: Verrengia E , Pezzi L , Addari M , Caprio M , Genovesi E , D’Alleva A , Magnano R , Forlani D , Fulgenzi F , Vitulli P , Di Marco M , Paloscia L
Published: May 2023

Infective endocarditis (IE) refers to the colonization of cardiac valve endocardium by virulent microorganisms. It is the fourth leading cause of life–threatening infectious disease syndrome, if not efficiently diagnosed and treated. The three most common causes of IE on native valves (from the most to the least frequent) are Staphylococci, Streptococci and Enterococci. Enterococcus related IE are often associated to endoscopic procedures involving the digestive tract. The most remarkable structural complications associated with IE are: cusp or leaflet rupture, perforation, aneurysm/pseudoaneurysm, fistula, abscess, embolization. The usual final consequences of these lesions are severe valve regurgitation and heart failure.A 74 years old male patient with no history of heart disease, presented to the hospital with orthopnoea and periferal edema, consistent with acute heart failure.Few months before he underwent a routine colonscopy. Transthoracic echocardiography revealed a mildly reduced ejection fraction and the presence of a little, mobile mass on the aortic valve, suggestive of vegetation, associated with a severe aortic regurgitation. The diagnosis was confirmed thanks to a transesophageal echocardiogram that represents the technique of choice for the diagnosis of endocarditis and for detecting eventual perivalvular extention; it documented the presence of an endocarditic vegetation protruting in the LVOT, complicated by a pseudoaneurysm, identified as a pulsatile perivalvular echo free–space with colour doppler flow inside. Successively, a specific antibiotic therapy was started because of the positivity of blood cultures for Enterococcus Faecalis. After performing a thoracic computed tomography that showed the presence of “plus image" at the level of aortic valvular plane, particularly between the right coronary and non–coronary cusp, consistent firstly with a pseudoaneurysm, the patient underwent urgent cardiac surgery with the removal of the vegetations and the implantion of an aortic valve bioprosthesis after the apposition of bovine pericardial patches for repairing aortic wall’s lacerations. A post–operative transesophageal echocardiogram revealed a good result with a mild paravalvular leak. Pseudoaneurysm and severe valvular regurgitation are among the major causes of acute heart failure in the setting of infective endocarditis. In such cases, surgery should be considered to decrease mortality.
P22 AN UNEXPECTED DIAGNOSIS; GEMELLA MORBILLORUM, A POORLY KNOWN KILLER
Authors: Cozza E , Bellin A , Videsott L , Cutolo A , Temistoclakis S
Published: May 2023

58–year–old woman, previous smoking habit. In medical history holosystolic murmur since childhood. At echocardiogram performed in 2019: "VS with preserved FE, mild–to–moderate IA, likely perimembranous DIV." No major comorbidities. In June 2021, she was admitted to the Mestre NICU for paroxysmal complete atrioventricular block. On echocardiogram, mild worsening of IA was described, with a sub–valvular shunt and doubtful aortic bicuspidia. At 24 hours after admission, the patient underwent definitive bicameral PM implantation. In light of the clinical and echocardiographic suspicious, we began to think of a possible organic genesis of the event; a hypothesis supported by the finding of serotin fever and a dental examination with dental hygiene that the patient reported having performed a month earlier. So, on suspicion of an infectious genesis, cold blood cultures were requested and found to be positive for Gemella Morbillorum. The endocarditis hypothesis was confirmed by performing a TE echo and PET/CT scan. Antibiotic therapy was then set up, and an infectious source was subsequently searched for, through a CT scan of the dental arches, which was positive for foci of periodontopathy, and through a rectosigmoidocolonoscopy finding an adenoma with high–grade dysplasia. HOT TOPIC: infective endocarditis is a disease with a high risk of mortality and complications. Among the complications, conduction disturbances are relatively rare. A–V block is often paroxysmal, driven by inflammation, and therefore potentially reversible. Hence, the paramount importance of performing a thorough echocardiogram and resolving any suspicions before referring the patient for definitive device implantation. The case also turns out to be particularly interesting not only for the onset of symptomatology but also for the etiology of the latter. In fact, the microorganism responsible is not among the most frequent germs but represents a rare cause of which there are few cases described in the literature. The main infectious source in humans is the dental system, but several studies have shown a correlation between Gemella morbillorum and rectal colon cancer. Ultimately, the above case represents a typical example of how a "easy" hospitalization for a conduction disorder can actually reveal a much more complex pathology.
P27 DOPPLER ULTRASOUND SELECTION AND FOLLOW–UP OF THE INTERNAL MAMMARY ARTERY AS CORONARY GRAFT
Authors: Scicchitano P , De Palo M , Gesualdo M , Trotta F , Sanasi M , Piscopo A , Pignatelli A , Pinto M , Caldarola P , Ciccone M
Published: May 2023

The impact of coronary artery disease (CAD) on all–cause mortality and overall disabilities is well–established. Percutaneous and/or surgical coronary revascularization procedures dramatically reduced the occurrence of adverse cardiovascular events in patients suffering with atherosclerosis. Specifically, guidelines from the European Society of Cardiology on the management of myocardial revascularization promoted coronary artery by–pass graft (CABG) intervention in patients with specific alterations in coronary tree due to higher beneficial effects of this procedure as compared to percutaneous one. Left internal mammary artery (LIMA) is one of the best–performing vessels in CABG procedures due to its location and its own structural characteristics. Nevertheless, non–invasive assessment of its patency is challenging. Doppler Ultrasonography (DU) might perform as a reliable technique for non–invasive evaluation of the patency of LIMA. Data from literature revealed that DU may detect severe (>70%) stenosis of the LIMA graft. In this case, pulsed–wave Doppler might show peak diastolic velocity/peak systolic velocity < 0.5 and diastolic fraction < 50%). Stress test might also be adopted for the evaluation of patency of LIMA through DU. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow–up after CABG intervention. The aim of this narrative review is to evaluate the impact of DU on the evaluation of the patency of LIMA graft in patients who undergo follow–up after CABG intervention.
P28 CONVERSION TO OPEN SURGERY FOR COMPLICATED TAVI: STILL FUTILE?
Authors: Petrini F , Paduvakis I , Cerillo A , Stefano P
Published: May 2023

Background and aim

Mechanical complications of TAVI may be catastrophic, and conversion to open surgery in this context has been associated with an extremely poor prognosis, with a mortality close to 50%. We report our recent experience on 9 patients requiring cardiac surgery during TAVI. Patients and methods: 9 patients undergoing various transcatheter procedures at a high volume centre required cardiac surgery for valve misplacement (2), valve embolization (2), annular rupture (3), acute coronary occlusion (1) and aortic dissection (1). Four patients were initially treated by a hybrid team including a cardiac surgeon performing transcatheter procedures (3 TAVI in NAVR and one transseptal Mitral VIV), while five were performed by an interventional cardiology team (all TAVI).

Results

The complications and the surgical procedures performed are reported in the table. Four patients underwent immediate conversion in the hybrid room, 3 underwent delayed conversion and two were managed conservatively. Eight patients survived and were discharged from the hospital. The only patient dying was a TAVI patient having aortic valve embolization. A second transcatheter valve was deployed too ventricular. The patient had cardiac arrest needing CRP and the surgical team was called to start ECMO assistance several minutes after the initial complication. Comment: Our small series suggests that prompt conversion to open surgery, especially if performed immediately by surgeons that were initially involved in the transcatheter procedure, might offer excellent results. We believe that hybrid teams may offer a significant benefit, especially in low–risk patients and during complex or off–label procedures.
P29 LVOTO IN HCM: HYBRID TREATMENT MAY STILL NOT SOLVE CHALLENGING CASES
Authors: Federico F , Marcolin C , Stella S , Biondi F , Ancona F , Ingallina G , Tavernese A , Margonato D , Belli M , Agricola E , Slavich M , Buzzatti N , Belluschi I , Maisano F
Published: May 2023

MA, a 28 years old male with a diagnosis of OHCM since 2008, came to our attention for effort dyspnea (NYHA II) and fatigue limiting his greengrocer activity. Decompensated T1DM (HbA1C 12%), HTN, obesity (BMI 37). In 2017 he implanted a bicameral ICD in primary prevention, later extracted for sepsis and replaced with S–ICD. In the last 2 years he had 3–4 episodes of FAP, the latter causing an AHF requiring hospitalization in ICU. CV therapy: metoprolol 100 mg bid; disopyramide 100 mg x 3; rivaroxaban 20 mg die, insulin. Resting ECG: sinus bradycardia, HR 50 bpm, LVH with secondary repolarization abnormalities, long QTc (>500 ms). At basal and stress echocardiography (Fig. 1) he had a maximum wall thickness at medium IVS of 21 mm and severe dynamic obstruction due to complete SAM (Gmax 50 –> 135 mmHg); moderate mitral regurgitation, secondary to SAM, with eccentric jet; worsening of obstruction and MR at peak of stress (Gmax 145 mmHg; MR 3+); absence of pulmonary hypertension; severe left atrial dilatation (53ml/mq). He was considered not eligible for Morrow myectomy due to unfavorable anatomy (basal IVS of 11–14 mm, maximum thickness at medium IVS). Mitral valve area was > 4cmq. After Heart Team evaluation the patient was proposed for a reparative approach of mitral valve, and TEER was preferred to open surgery for favorable anatomy and to avoid an increased peri–operative risk in a patient with different comorbidities. The procedure was successfully conducted with the implantation of 1 MitraClip (MITRACLIP® Evalve – Abbott) in central position, with echocardiographic evidence (Fig. 2) of complete SAM resolution, reduction of MR to 1+ and gradient abolition (13 mmHg post–Valsalva maneuver). MVA at intraoperative TEE: >2 cmq. At six–months follow–up the patient reported a satisfactory reduction of symptoms without limitations in non–agonist physical activity and work, yet he still was not asymptomatic. Although on best medical treatment and after TEER, transthoracic echocardiographic control showed a recurrence of SAM and LVOTO (40 mmHg at basal, 70 mm Hg post – Valsalva maneuver). He is still candidate to myosin inhibition treatment. This case highlights the multiple challenges of LVOTO in HCM patients. Although a hybrid approach may be a promising treatment of OHCM, especially in youngers, an increase of expertise in this field and further research is needed, focusing on predictors of procedural failure and success.
P31 A RARE CASE OF PERSISTENT ECG CHANGES AT STRESS TEST
Authors: Guerri E , Navazio A , Quinto S , Conti M
Published: May 2023

Background

Cardiac lipomas are rare benign tumors. They carry usually a good prognosis and are often an incidental finding of cardiovascular imaging exams for cardiac evaluations.

Methods

We present a case of left ventricular intramyocardial lipoma detected during the work–up for a positive stress test.

Results

This case report involves a 55–year–old male, light smoker, with a history of glucose intolerance. Height 190 cm; weight 90 kg; BMI 24.93 kg/m2 He has always played sports and since the age of 16 he performed serial cardiological assessments and stress test for competitive fitness. Already from the first evaluation the ergometric test was markedly pathological (ST segment depression greater than 1 mm in leads V3 to V6), in absence of symptoms. The subsequent diagnostic exams performed (including an exercise myocardial scintigraphy) excluded ischemic aetiology. Competitive fitness has always been reconfirmed for many years. He also performed repeated holter–ECG in absence of any arrhythmias. He was admitted because of a routine check–up. A new stress test (ECG stress test) resulted positive for ECG changes and clinically negative (fig 1) Cardiac MRI demonstrated a small intramyocardial "round like" mass of about 7 mm, located on the middle–distal segment of the left ventricle lateral wall; MRI signals were consistent with a lipom: no evidenced of delayed enanchement (fig 2) and T1 weighted scans assessed perfusion lack of the mass (fig 3). Computed tomography confirmed this diagnosis; the coronary angiography excluded significant coronary artery stenosis.

Conclusion

We hypnotize that cardiac lipoma in our patient caused persistent ST changes at stress ECG since young age
P32 PERSISTENT ISOLATED LEFT SUPERIOR VENA CAVA ASSOCIATED WITH BICUSPID AORTIC VALVE
Authors: Faleburle A , Cosmi D , Pagnotta F , Buccolieri M , Capponi E , Cardona A , Cardile M , Di Pasquale T , Martinelli S , Ray L , Piccioni N , Murrone A , Cappannelli S
Published: May 2023

Persistent left superior vena cava (VCSSP) is the most frequent systemic venous return anomaly. It often occurs during right heart catheterization (0.1%) and is associated with right superior vena cava aplasia in 10 to 33%. It can lead to the development of a left superior venous system mirroring the normal right return. It runs between the pulmonary veins and the left auricle, to join the coronary sinus. Sometimes the coronary sinus does not communicate directly with the right atrium but drains into the VCSS. An increased incidence of arrhythmias has also been reported in the presence of venous drainage abnormalities. Its discovery has implications as it can create difficulties in the insertion of central venous catheters, cardiac surgery, thoracic and PMK implantation.VCSSP in the absence of the right superior vena cava (VCSD) is a rare congenital anomaly.

Clinical case

An 18–year–old soccer player came to our observation for an episode of presyncope and palpitations during a soccer match. The ECG showed sinus rhythm and incomplete right bundle branch block. The echocardiogram showed a bicuspid aortic valve and significant dilatation of the coronary sinus, with suspicion of persistence of the left superior vena cava. Cardiac MRI showed an isolated persistent left superior vena cava along the left mediastinum and extending it connected with the coronary sinus, which in turn drained into the right atrium. There was no evidence of LGE in the late sequences.

Discussion

VCSSP does not constitute a hemodynamic problem if isolated. The presence of VCSSP in the absence of right superior vena cava (VCSD) is in itself an occurrence rarely described in the literature. The anomalies most frequently associated with the presence of a VCSSP are the Atrial septal defect of the sinus venosus type and tetralogy of Fallot. Rare cases of association with aortic valve bicuspid have also been reported.In patients with VCSSP and absence of VCSD, the coexistence of impulse formation and impulse conduction disorders associated with histological alterations such as fragmentation and stretching of the specific conduction tissue and of the atrioventricular node has been described. The abnormal development can also induce sinus node alterations resulting in sinus dysfunction. In our case, no conduction anomalies or arrhythmias were described
P34 TAKOTSUBO SYNDROME OR UNKNOWN MYOCARDIAL ISCHEMIA? THE ROLE OF CARDIAC MAGNETIC RESONANCE IN DIFFERENTIAL DIAGNOSIS
Authors: Citarelli G , De Feo D , D’ Alessandro M , De Laura D , De Gennaro L , Rutigliano D , Basso P , Locuratolo N , Ficco M , Grimaldi V , D’ Aprile P , Caldarola P
Published: May 2023

There are numerous clinical conditions in which symptoms and signs may overlap, among these myocardial Ischemia in the absence of obstructive coronaropathy (INOCA/MINOCA), gets into differential diagnosis with a plethora of clinical pictures such as Takotsubo syndrome, myocarditis and cardiomyopathies. In this setting, cardiac magnetic resonance has a critical discriminating role. Herein we report the clinical case of a 52–year old patient suffering from hypertension and dyslipidaemia, with a history of chest pain episodes and recent intense psychophysical stress. After symptoms exacerbation, ambulance was called, loss of conscience was witnessed, observing ventricular fibrillation, subjected to prompt DC shock. Once in Emergency room, ECG showed ST–elevation in V1, V2 and AVR for which urgent coronary angiography was performed. It surprisingly resulted negative for epicardial coronary artery disease. Moderate left ventricular dysfunction (LVEF 45%) was found on 2D ultrasound along with apex akinesia, while mild elevation myocardial necrosis enzymes was seen at blood tests. The clinical picture characterized by female sex, history of psychophysical stress, by association of chest pain, ischemic type alterations of repolarization at ECG, akinesia of the apex and the concomitant slight elevation of myocardial necrosis enzymes in the absence of epicardial coronary lesions, highly suggested Tako–Tsubo Syndrome. In order to confirm the diagnosis, cardiac MRI was performed which, unexpectedly, showed the presence of oedema on T2–weighted STIR sequences at the level of the left ventricular apex, associated to same site transmural fibrosis at post–contrast imaging sequences, thus eliciting the hypothesis of a MINOCA. After a new retrosternal pain with transient ST–elevation in V1, a IVUS – guided new coronary angiography examination was performed, resulting intoIVA diffuse coronary spasm, reduced after intravenous nitrate administration. Final diagnosis was “MINOCA complicated by primary VF‘‘ and a subcutaneous AICD implant CMR imaging by virtue of its ability to provide information about cardiac structure and function and simultaneously, to define the characterization of tissues, together with the data of dynamic coronary spasm, proved to be essential in this case to establish the diagnosis, often misunderstood, of MINOCA, hence allowing to define the best therapeutic strategy. ​
P44 IMPROVEMENT OF THE LEFT VENTRICULAR CONTRACTILE RESERVE IN PATIENTS UNDERGOING MITRAL VALVE PLASTIC CARDIAC SURGERY
Authors: Tassone E , Carullo G , Morabito G , Valiante G , Leonetti S , Maselli D
Published: May 2023

Mitral Regurgitation (MR) is a clinical condition characterized by a high morbidity and mortality in severe or moderate forms complicated by hemodynamic instability, that often finds a solution only in the reparative surgical treatment. MR is often caused the presence of myxomatous degeneration that affects one or more structures of the valve apparatus, causing the prolapse of one or both leaflets. Surgical treatment can improve the hemodynamic parameters and consequently the prognosis of the patients, even though there is not still data concerning the myocardial contractile reserve. The aim of the study was to evaluate the effect of MR reparative surgery on the left ventricular contractile reserve during physical stress echocardiography. We enrolled 12 patients, 8 females and 4 males, affected by MR candidate to cardiac surgery. We performed a physical stress–echo test by using the ABCDE protocol suggested by the Italian Society of Echocardiography and Cardiovascular Imaging (SIECVI), before and after approximately 12 weeks from cardiac surgery. After each test, the prognostic score deriving from the sum of the ABCDE criteria was calculated; in addition, we measured the left ventricular contractile reserve (C parameter of the score) that represents a parameter of the force deriving from the hemodynamic changes during the test. In all patients we observed a significant improvement in the ABCDE prognostic score after cardiac surgery (3.89 + 0.43 vs 3.18 + 0.37; p = 0.002). There were no significant changes in ejection fraction, indexed left atrial volume, wall motion score index–WMSI (A parameter), coronary reserve (D parameter), and heart rate reserve (E parameter). The most relevant data concerns the increase in the left ventricular contractile reserve at 3 months after cardiac surgery (1.77 mmHg/ml vs 2.44 mmHg/ml, p<0.0001). Furthermore, a significant reduction in pulmonary congestion during stress was observed (B parameter). These data demonstrate for the first time that mitral valve plastic surgery is able to improve the left ventricular contractile reserve in patients with severe MR. Furthermore, the surgical procedure determined both a reduction in the degree of pulmonary congestion and an improvement in the ABCDE prognostic score during physical stress echocardiography.
P56 ROLE OF CARDIAC TROPONINS IN THE EMERGENCY DEPARTMENT IN PATIENTS WITH ATRIAL FIBRILLATION
Authors: Mager R , Fontani D , Assanelli A , Morciano D , Morosato M , Ricchetti G , Agricola E , Margonato A , Slavich M
Published: May 2023

Atrial fibrillation (AF) is the most frequent arrhythmia among those encountered in the emergency department. It’s well known that elevated values ​​of cardiac troponin in "stable” conditions is generally indicative of myocardial cytonecrosis and is associated with a worse prognosis in various clinical conditions. The role of cardiac biomarkers in the context of an AF episode has not yet been fully understood and is a source of debate in the cardiology community. Recent studies suggest the association of elevated troponin values in the context of an AF episode with an increased incidence of major cardiovascular events. Consequently, its measurement could be extensively taken into consideration also in the Emergency Department and implemented for risk stratification. There is currently insufficient evidence to support the dosing of cardiac troponins in all AF patients for risk stratification. The aim of this study is to investigate the significance of elevated troponin values ​​during AF and whether these are related to an increased cardiovascular risk.

Methods and Results

This is a retrospective and observational study and focuses on a population of patients who arrived in the Emergency Department of San Raffaele Hospital in Milan between the 1st of January 2018 and 22nd May 2021 with atrial fibrillation. Data were collected for 625 patients of whom 232 were enrolled for statistical analysis. The population was stratified based on cardiovascular risk factors and prior AF ablation. At 12–month follow–up we found that elevated troponin values ​​during atrial fibrillation in the Emergency Department do not correlate with an increase of deaths from any cause, major cardiovascular events or hospitalizations for heart failure. The presence of elevated cardiac troponin was not associated with an increased rate of CAD at coronary CT nor coronaru angiography. A weak association was seen between non–elevated cTnT–hs and higher rate of AF ablation.

Conclusions

Our data reject the hypothesis according to which elevated levels of highly sensitive cardiac troponin measured during an atrial fibrillation episode could be correlated with an higher incidence of major adverse cardiovascular events at 1–year follow up.
P59 SPONTANEOUS RESTORATION OF STABLE SINUS RHYTHM FOLLOWING EDGE–TO–EDGE TRANSCATHETER MITRAL REPAIR PROCEDURE WITH MITRACLIP IN A PATIENT WITH CHRONIC ATRIAL FIBRILLATION
Authors: Molinari R , Falco L , Malvezzi M , Scognamiglio G , Salerno G , Russo V , Natale F , Cimmino G , Liccardo B , Golino P
Published: May 2023

Patients with history of atrial fibrillation (AF) undergoing mitral edge–to–edge repair procedure with Mitraclip tend to be relatively older, have more advanced valve disease, and suffer from more comorbidities than patients without AF [1;2]. Moreover, their all–cause mortality rate one year after the procedure and hospitalization rate for heart failure is higher than that of patients in sinus rhythm [3]. Therefore, managing patients with AF poses a greater challenge, and their prognosis is considerably worse. Improvement of mitral regurgitation following mitral edge–to–edge repair procedure with Mitraclip may reduce atrial volume overload positively impacting AF triggers. In this report, we present a case of spontaneous restoration of stable sinus rhythm in a patient with chronic AF undergoing mitral valve repair procedure with Mitraclip. The patient, 80 years old, underwent implantation of a clip on centro–lateral site of the mitral valve plane (A2–P2) with mild residual insufficiency and an optimal procedural result. The restoration of sinus rhythm, which occurred during the first hours after the procedure, proved to be stable at the 30th day control post–discharge. the indexed left atrial volume remained unchanged (LAVI 43–45 mL/m2). Literature on the frequency of spontaneous sinus rhythm restoration following edge–to–edge mitral repair with Mitraclip in patients with chronic AF is limited. In a sub–analysis of the COAPT study [4], in addition to the known benefits of the Mitraclip procedure, it was possible to highlight a significant reduction in the rate of stroke in patients with AF. This outcome could be attributed to the reduction of the AF burden associated with mitral valve insufficiency. More studies are although necessary to determine the procedure‘s impact in this specific clinical situation. Rreferences: [1] Velu JF, Am J Cardiol. 2017 Dec 1;120(11):2035–2040. [2] Saad AM, Catheter Cardiovasc Interv. 2021 May 1;97(6):1252–1256. [3] Shah S, Heart Fail Rev. 2021 May;26(3):531–543. [4] Gertz ZM, Circ Cardiovasc Interv. 2021 Apr;14(4):e010300.
P67 MYOCARDIAL INFARCTION IN COVID AND NON–COVID PATIENTS: DIFFERENT TWINS
Authors: Piemonte F , Carraturo A , Damiano S , De Angelis A , Forte R , Leccia A , Lirato C , Molaro M , Penna G , Petitto M , Piemonte M , Puzio E
Published: May 2023

For about 2 months (from 13 January to 15 March 2022) our CICU–Cardiology department (spoke for the AMI network) of the "San Giovanni di Dio" Hospital of Frattamaggiore (Napoli) has assumed the role of Covid–CICU for ASL Napoli 2 Nord. We analyzed the data regarding patients hospitalized for acute myocardial infarction in our department from January to August, selected on the basis of the presence of SARS–COV2 infection at admission, and we noted some substantial differences between the two populations, although in the small sample examined. 15 of the 44 patients hospitalized with Covid (34%) were discharged with a diagnosis of acute myocardial infarction, while among non–Covid patients 46.4% had acute myocardial infarction. The average age and days of hospitalization were higher in Covid patients (70 vs 67 years and 8.9 vs 6 days), and Covid patients with myocardial infarction and heart failure were 50% vs 24.7% of non–Covid patients. Diabetes was present in 31.5% of Covid patients and 15.7% in non–Covid. The number of STEMIs was higher in the Covids (53.3% vs 15.7% of the non–Covids), probably because being CICU–COVID we also accepted patients with STEMI who otherwise would have been hospitalized in the CICU HUB. Despite the difficulties in managing acute coronary syndromes in Covid patients, 60% of all Covid patients hospitalized for infarction underwent a haemodynamic study (73% in non–Covid patients) and primary PTCA was guaranteed for 87.5% of Covid patients with STEMI in a reasonable time in that context (< 9 hours from admission to hospital). However, in the face of this considerable organizational effort, the 6–month and intra–hospital mortality in Covid patients hospitalized for infarction was 31.5% and 12.5%, much higher than that of non–Covid patients (2.2% and 1.1% respectively ). The STEMi data from COVID patients is not comforting either: in fact, 25% of them died within 6 months and 12.5% in hospital, despite almost all of them were treated with primary PTCA, although not in the first 3 hours. But the mortality of the Covid patients in our department with a prevalent respiratory commitment is even higher than that of the Covid patients with AMI, reaching 40% at 6 months. In the light of our limited experience, we can hypothesize that the therapeutic protocols used in heart attacks, despite the inevitable delays due to Covid and although they are not as effective as in non–Covid patients, nevertheless can have impact on the prognosis.
P74 NIGHT SWEATS AND AN UNUSUAL RIGHT ATRIAL MASS
Authors: Cerrito L , Sembenini C , Varotto L , Basso C , Testolin L , Caprioglio F
Published: May 2023

Background

Primary cardiac tumors are infrequently, usually benign, and diagnosed incidentally. Among primary cardiac tumors, cardiac hemangiomas are exceptionally rare with only a 1–2% incidence. In most cases, histological diagnosis is made after surgical removal or at autopsy. Case presentation: A 36–year–old male patient is suffering from several months of bothering night sweats. He has no previous medical history and is not taking medication. After performing various exams, including an electrocardiogram and chest rx–ray that were unremarkable, the patient performed a chest TC scan that shows a large mass at right atrial level (Figure 1). Surprisingly, at transthoracic echocardiography the mass was not visible and moreover the exam was normal. To better visualize the mass, a transesophageal echocardiography was performed, showing a inhomogeneous, round–shape, intracavitary mass of 70x65 mm in size. The mass appear to be fixed, expansive, with no embolic–features and seem to be initially–obstructing the upper–cava blood flow (Figure 2), even the patient was hemodynamically stable. A diagnosis of lymphoma was initially suspected and an Total–body PET–TC was performed, showing that the heart mass was metabolically inactive and an intestinal metabolic active mass. Intestine mass biopsy, made by colonscopy, showed a non–malignous villous adenoma. Before undergoing heart surgery, to understand the nature of the mass, we performed a intracavitary ecocardiography (ICE)–guided percutaneous biopsy. Histologically, the heart tumor was composed of cavernous channels embedded in a loose fibrous stroma, compatible with Cavernous hemangioma. At heart surgery, the mass was localized inside the right atrium, at upper–front level, adhered to a small part of atrial myocardium, and was removed without complications. The right atrium was rebuilt with artificial patch. (Figure 3).

Conclusions

Cavernous cardiac Hemangioma is a rare tumor that may have an atypical clinical presentation. To our knowledge, this is the first case of cardiac hemangioma diagnosed by ICE–guided endomyocardial biopsy.
P76 RARE CASE OF CARDIAC TUBERCULOSIS WITH CONCOMITANT SPONDYLODSCITIS MEDIATED BY MYCOBACTERIUM BOVIS
Authors: De Feo D , Marica F , Napoli V , Ciccone M
Published: May 2023

Tuberculosis (TB) is usually clinically confined to the respiratory system; however, it can affect any organ. Cardiac tuberculosis, though, is a rare as extrapulmonary manifestation of TB, generally it is clinically silent, and it shows up as sudden death due to ventricular arrhythmias. TB, and in particular cardiac TB, is a disease with complex signs and symptoms that overlap with other disorders determining a diagnostic dilemma, especially in case of a blood culture–negative infective pancarditis. Herein we report a case of a 30–year–old patient (African immigrant, HIV negative, black) who presented with chest pain and heart pounding because of paroxysmal atrial fibrillation. He suddenly developed sustained ventricular tachycardia, for which he was underwent subcutaneous ICD implantation. He was submitted to echocardiography and magnetic resonance, and a large mass involving right atrium, right ventricle and apex was observed. Cardiac tuberculosis without active pulmonary disease, with a concomitant spondylodiscitis, was diagnosed thanks to bacterial cultures of specimens drained from vertebral abscesses. After Mycobacterium Bovis was isolated, the patient received anti–tubercular therapy with wide improvement of symptoms and neat reduction of the cardiac mass observed in months at echocardiographic follow – up. Although literature describes high rate of mortality and complications due to cardiac tuberculosis a favourable outcome occurred.