bluuebunny/crossref_metadata_2025 huggingface dataset:
P73 ANGIOGRAPHY–DERIVED INDEX OF MICROVASCULAR RESISTANCE (IMR–ANGIO) IN TAKOTSUBO SYNDROME
Authors: Castaldi G , Fezzi S , Widmann M , Mammone C , Rizzetto F , Lia M , Prati D , Pighi M , Pesarini G , Tavella D , Scarsini R , Ribichini F
Published: May 2022

Introduction

Coronary microvascular dysfunction (CMD) has been proposed as a key driver in the etiopathogenesis of Takotsubo syndrome (TTS), likely related to an “adrenergic storm” upon a susceptible microvascular circulation. The aim of our manuscript was to assess and quantify CMD in patients with TTS through non–invasive angio–derived index of microcirculation (IMRangio) and evaluate its correlation with clinical and instrumental presentation.

Methods

41 consecutive TTS patients were retrospectively analyzed. Three different formulas for compute Non–Hyperemic IMRangio (NH–IMRangio) derived by 3D–Quantitative Coronary Angiography (3D–QCA) and Quantitative Flow Reserve (QFR) analysis were used according to each fluidodynamic mathematical expression as reported by respective authors. CMD was deﬁned as an IMRangio ≥ 25. The correlation between NH–IMRangio and clinical presentation and the comparation between the three formulas were provided.

Results

Median age was 76 years, 85.7% were women and mean left ventricular ejection fraction (LVEF) at first echocardiogram was 41.2%. NH–IMRangio was higher in Left Anterior Descending artery (LAD) than Circumflex artery (CX) and Right Coronary artery (RCA) with either NH–IMRangio 1 (52.7 vs 35.3 vs 41.4), NH–IMRangio 2 (47.2 vs 31.8 vs 37.3) or NH–IMRangio 3 (52.7 vs 36.1 vs 41.8). All patients presented CMD with NH–IMR angio ≥ 25 in at least one territory with each formula. NH–IMRangio in LAD territory was significantly higher in patients presenting with LVEF impairment (≤40%) than in those with preserved ventricular global function (NH–IMRangio LAD 1: 59.3 vs 46.3, p. value=0.030; NH–IMRangio LAD 2: 52.9 vs 41.4, p–value=0.037; NH–IMRangio LAD 3: 59.2 vs 46.3, p–value=0–035). Association between NH–IMRangio computed in LAD and LVEF showed a moderate correlation (NH–IMRangio 1: r = –0,3485, Rho = 0,1214, p = 0,0256; NH–IMRangio 2: r = –0,3513; Rho = 0,1234, p = 0,0256; NH–IMRangio 3: r = –0,3326, Rho = 0,1106, p = 0,0336). Finally, Bland–Altman plot analysis showed good agreement between NH–IMRangio 1 and 3, while NH–IMRangio 2 showed a consistent bias of –5 units against both NH–IMRangio 1 and NH–IMRangio 2 with increasing difference at higher absolute values.

Conclusion

CMD, assessed with NH–IMRangio, is a common finding in TTS and it is inversely correlate with LVEF dysfunction. The available formulas for NH–IMRangio computation have a substantial superimposable diagnostic performance in assessing CMD.
P76 A ‘PARACHUTE EFFECT’ MOCKINGLY SEALING A SPONTANEOUS CORONARY ARTERY DISSECTION
Authors: Buccheri D , Priolo L , Vinci D , Lombardo R
Published: May 2022

We present a case of a 38–year–old female admitted for Non ST–Elevation Myocardial Infarction. 15 days before the patient experienced an inferior ST–Elevation Myocardial Infarction and underwent primary Percutaneous Coronary Intervention with 2 drug–eluting stent (DES) in the mid–Right Coronary Artery (RCA). At presentation ECG and echocardiogram was negative for myocardial ischemia. For the typical chest pain, an urgent coronary angiography (CA) was performed. The previously stented RCA did not show any significant stenosis but a posterolateral branch appeared occluded at the ostium, with a retrograde flow from the left anterior descending artery. However, suspecting a dissection distally to the stents previously implanted, an Optical Coherence Tomography (OCT) was performed after 2 guidewires placement. The presence of two guidewires and the contrast medium pushing from inside–out caused a ‘sealing effect’ of the intima to the media, hence hiding the presence of dissection. The day after, a new chest pain episode associated with transient ST–segment elevation in the inferior leads warranted a new CA. Another OCT of the RCA was performed, this time using a single guidewire: a clear imaging confirmed the spontaneous coronary artery dissection (SCAD) presence. To have a better understanding of the vessel morphology an Intravascular Ultrasound (IVUS) analysis was carried out and even this imaging modality confirmed the presence of a true and false lumen. The interventional cardiologist decided to treat the dissection with two overlapping drug–eluting stents and a TIMI–3 flow was restored, with the complete resolution of the symptoms The patient was discharged after 5 days with dual antiplatelet therapy and statin. At the 24 month follow–up she was still asymptomatic. SCAD expertise is of utmost importance in recognizing this entity and, perhaps, this is the reason why it is still underdiagnosed, also in view of the frequent absence of hallmarks at CA. This is a case in which a complete imaging evaluation (CA + OCT + IVUS) has discovered and documented a SCAD after a recent stent implantation and in which the exclusive acquisition of angiograms by inexperienced operators could have missed the dissection.
P81 SIMULTANEOUS TRANS–APICAL AORTIC AND MITRAL VALVE IMPLANTATION IN A PATIENT WITH A DEGENERATED MITRAL BIOPROSTHESIS AND SEVERE AORTIC STENOSIS
Authors: D‘Ascoli R , Manzan E , Prestipino F , Innelli P , Cristiano A , Costantino M , Stabile E , Luzi G
Published: May 2022

Transcatheter Valve–in–Valve implantation has shown promising results in high–risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. This is a case of a 82–year–old man, with history of multiple previous mitral valve replacement, admitted to the hospital for heart failure. During diagnostic work out he was diagnosed with a severe aortic stenosis and structural degeneration of a mitral valve bioprostheses Epic 29mm, St Jude Medical, (Inc, St Paul, Minn, USA). The heart team defined the patient at high surgical risk profile and was therefore scheduled for a simultaneous mitral and aortic transcatheter valve implantation. Through a double trans–apical approach (Figure A and B), the patient underwent two balloon expandable valves (Sapien 3, Edwards Lifesciences, Irvine, CA, USA) deployment in native aortic (Figure C) and mitral bioprosthesis (Figure D), respectively. Final angiography showed lack of aortic (Figure E) and left atrial (Figure E) regurgitation. The procedure was uneventful as well as the following hospital stay. Post–procedural transesophageal echocardiography confirmed the absence of paravalvular leakage nor aortic or mitral regurgitation. The patient was discharged at home on day 7. Simultaneous transapical transcatheter aortic and mitral valve replacement is technically feasible with the current available technology and can be a possible alternative in patients with high surgical risk.
P86 IN–HOSPITAL OUTCOMES OF PORTICO TRANSCATHETER AORTIC VALVE IMPLANTATION WITH THE FLEXNAV AS COMPARED TO THE FIRST–GENERATION DELIVERY SYSTEM
Authors: Marino G , Rigattieri S , Giovannelli F , Tommasino A , Berni A , Volpe M
Published: May 2022

Introduction

technological advancements in transcatheter heart valve platforms, along with increasing operator experience and careful patient selection, are essential to reach high standards of efficacy and safety in transcatheter aortic valve replacement (TAVR). Aim of this study was to evaluate the performance of the new version of the Portico valve delivery system (FlexNav) as compared to the first–generation device.

Materials and Methods

we report the results of a single–center, observational study on patients with severe aortic valve stenosis undergoing TAVR with the Portico valve at our Institution. Consecutive patients treated with the new FlexNav delivery system (DS), available since May, 2020, were compared with patients treated with the first–generation delivery system (1st Gen–DS). In–hospital outcomes were self–adjudicated according to the Valve Academic Research Consortium–3 definition.

Results

50 patients were included in this study; 22 were treated with the FlexNav–DS and the remaining with the 1st Gen–DS. Clinical characteristics were similar between group, expect for older age (82.6 ± 3.6 vs 80.7 ± 3.8; p = 0.07) and higher prevalence of female gender (68.2% vs 39.3%; p = 0.04) in FlexNav–DS group as compared to 1st Gen–DS group, respectively. We observed similar rates of procedural success but higher rate of moderate–to–severe paravalvular leak in 1st Gen–DS as compared to FlexNav–DS group (28.6% vs 4.6%; p = 0.03); major vascular complications were reduced, although not significantly, in the FlexNav–DS as compared to 1st Gen–DS group (4.5% vs 10.7%; p = 0.64).

Conclusion

Our data suggest that the FlexNav DS, thanks to lower profile and enhanced stability during valve deployment, has the potential to allow for to better procedural and clinical results of TAVR with the Portico valve as compared to the 1st Gen–DS.
P90 LEFT ATRIAL APPENDAGE OCCLUSION AND RIGHT CARDIAC CATHETERIZATION IN PATIENT WITH PORTO–PULMONARY HYPERTENSION AND PERSISTENT ATRIAL FIBRILLATION WITH GASTRO–INTESTINAL BLEEDING IN ORAL ANTICOAGULANT TREATMENT
Authors: Cacciola G , Serra W , Vignali L , Niccoli G , Lina D , Cattabiani M
Published: May 2022

62–year–old male with multiple cardiovascular risk factors.Known pre–capillary porto–pulmonary hypertension treated with Macitentan 10 mg per day, in the context of serum–negative liver disease complicated by portal hypertension and congestive gastropathy.Persistent atrial fibrillation in AVK due to high thromboembolic risk (CHA2DS2VAsc 3).At the last echocardium–TT evidence of worsening of right ventricular systolic function (TAPSE from 20 to 16 mm) and estimated pulmonary hypertension (PAPS from 45 to 65 mmHg). Subsequent hospitalization for severe anemia (Hb 6.5 g/dl), with diagnosis of bleeding angiodysplasias.In consideration of high bleeding risk (HAS–BLED 3), left atrial appendage occlusion has been indicated.The patient underwent right cardiac catheterization, via right femoral vein, with confirmation of severe pulmonary pre–capillary hypertension (mean PAP 45 mmHg, PCWP 14 mmHg); during the same session, left atrial appendage was occluded percutaneously using a Watchman device. At discharge, combination therapy with Riociguat plus Macitentan and single antiplatelet therapy with Clopidogrel 75 mg per day were undertaken. Shortly thereafter, recurrence of gastro–enteric bleeding occurred; after cardiac evaluation, Clopidogrel was discontinued and anticoagulant therapy with Edoxaban 30 mg od was started.The choice of shifting from Clopidogrel to low dose NOAC was guided by the unclear evidence of efficacy and safety of single or dual antiplatelet therapy in a population of patients with both high thrombotic and bleeding risk, such as in this case.Given that NOACs can be considered as an alternative to Warfarin after Watchman implantation (class IIB), after the second recurrence of bleeding, we opted for long–term antithrombotic strategy using a direct oral anticoagulant at reduced dose, making bleeding risk more acceptable instead of the administration of full dosage of NOAC, matter of major importance in candidates for left appendage closure, in whom long–term anticoagulant therapy itself is contraindicated; on the other hand, aiming for a better protection against thromboembolic events compared to standard antiplatelet therapy.
P100 HYNOTIC COMMUNICATION IN INTERVENTIONAL CARDIOLOGY: OUR REALITY…………
Authors: Benigni M , Civalleri M , Sartelli S
Published: May 2022

In the past two years we have progressively introduced the practice of hypnotic communication in our hemodynamics and electrofisiology laboratory in S. Paolo Hospital, Savona. The objective of hypnotic communication is to support patients during procedures electrophysiology in particular but also in hemodynamics, and help them in managing, if possible eliminate, fear, anxiety and pain while reducing the use of drugs to achieve this result. Hypnotic communication applies to relaxation phase and, if require, analgesia which can affect one or more areas of the body. We use this practice in a team of four: two doctors and two nurses. We all have successfully attended a one–year training course in clinical hypnosis and hypnotic communication at the CIIS (Italian Center for Experimental Clinical Hypnosis) Franco Granone Institute in Turin. The area in which we generally use hypnotic communication is electrophysiology: atrial fibrillation ablations, atrial flutter ablations, supraventricular tachycardia (TPSV), during pacemakers implants (ICD). In Hemodynamics we use it with patients affect by Acute myocardial infarction (AMI), and during patent foramen ovale (PFO). It is essential to always make contact with the patient and even more important to use all representational channels ( when possible): verbal, visual and tactile to stimulate suggestions of change in the patient. To achieve this, every member of the team uses his/her own schedule that changes according to the type of intervention. Almost all patienrs approched the procedure expressing concern, fear and anguish; on the contrary, patients treated with a hypnotic approach are calm, relaxed and do not feel pain. Upon their return to the “ here” their feedback backup is summed up in one “ I was fine and I did not notice the time passed”.
P102 NEW THREE–DIMENSIONAL ECHOCARDIOGRAPHIC PREDICTING PARAMETERS IN TRANS–VENTRICULAR HEART–BEATING MITRAL VALVE REPAIR WITH NEOCHORDAE: A MONOCENTRIC RETROSPECTIVE STUDY
Authors: Gaiero L , Vairo A , Fioravanti F , Piroli F , Gallone G , D‘Ascenzo F , Desalvo P , Marro M , Sebastiano V , Alunni G , De Ferrari G , Rinaldi M , Salizzoni S
Published: May 2022

Background

Trans–ventricular off pump mitral valve (MV) repair with neochordae implantation (Neochord procedure) is a minimally invasive surgical technique for correction of degenerative mitral regurgitation (MR) due to prolapse or flail. The aim of this study was to evaluate mid–term results of patients undergoing this procedure and find new three–dimensional pre–operative echocardiographic parameters to predict MR recurrence at follow–up.

Methods

We performed a retrospective analysis of 72 consecutive patients with severe MR due to prolapse or flail who underwent Neochord procedure at our hospital from March 2015 to February 2021. MV pre–operative anatomical parameters were assessed using 2D TEE, 3D TEE and dedicated three–dimensional (3D) post–processing analysis with dedicated software (QLAB, Philips). TTE follow–up and clinical evaluation were performed at 3 months, 6 months, 1 year and then annually.

Results

Twenty–seven patients were female (37.5%), mean age was 77±9 years. The average preoperative EuroSCORE II was 2.2%±1.5%. Twenty–three patients (32%) had an history of paroxysmal or persistent atrial fibrillation. Procedural success at discharge was achieved in sixty–eight patients (94.5%). Mean follow–up was 30±16 months. Three years follow–up was completed by fifty patients. At three years thirteen patients (26%) presented with recurrence of severe MR or underwent new surgical operation. Prevalence of mild or trace MR at three years follow–up visit was 70%. End–systolic annulus area (12.5±2.5 cm2 vs 14.1±2.6 cm2; p = 0.038), end–systolic annulus diameter (13.2±1.2 cm vs 14±1.3 cm; p = 0.042) and indexed left atrial volume (59±17 ml/m2 vs 76±37 ml/m2; p = 0.041) were lower in patients with residual MR less than moderate (MR < 3+/4+). Three–dimensional indexes specifically focused on coaptation reserve and annular disfunction were the best predictors of MR < 3+/4+ at follow–up, in particular diastolic sum of the leaflets/end–systolic annulus area ([AUC] 0.74; p = 0.029) and systo–diastolic annulus area fractional change ([AUC] 0.743; p = 0.035). Furthermore, each of these annular parameters, calculated using dedicated 3D software, were predictive of residual MR, whereas annular 2D dimensions were not (p = 0.347).

Conclusion

In patients with degenerative MR treated with Neochord procedure, 3D analysis focused on annular measures and coaptation indexes, that included 3D annular dimensions, predicts better MR relapse than conventional 2D parameters.
P104 FEASIBILITY AND ROLE OF ECHOCONTRAST EVALUATION IN PATIENTS WITH LVAD
Authors: Baroni G , Pergola V , Dellino C , Aruta P , Cecchetto A , Baritussio A , Fiorencis A , Di Michele S , Mastro F , Tarzia V , Gerosa G , Iliceto S , Mele D
Published: May 2022

Background

Advanced heart failure is a clinical syndrome characterized by persistent or progressive symptoms of heart failure despite optimal medical therapy. Left ventricular assist device (LVAD) brings survival benefits and improvement in quality of life, compared with conventional medical treatments. Development of Right ventricle failure in patients with LVAD has a direct effect on mortality and hospitalization.

Purpose

evaluation of clinical safety and feasibility of echocontrast in patients implanted with 3 different types of LVAD; improvement in the visualization of heart structures; intra and inter–operator agreement of RV assesement with and without contrast. Methods 43 patients were implanted with LVAD, 7 patients (16%) with Jarvik 2000, 31 (72%) with HeartMAte 3, 5 (12%) with (HeartWAre HVAD). Nine patients (21%) had contraindication or refused contrast. In 3 (7%) patients was technically challenging to obtain apical images at all levels. Two (5%) patients lost their follow–up. Our final population was of 29 (67%) patients (mean age 65±7 y; 100% Male). We assessed the reproducibility of these measurements between two different expert blind operators

Results

Total 329 (64%) of 516 RV wall segments were available for qualitative analysis without contrast vs 451 (87%) with contrast (p < 0.001) with a significant improvement of the evaluability of regional contractility (especially due to the better evaluation of medial and apical segments of lateral and anterior walls) and FAC (41% vs 90%, p < 0.001). Evaluation of TAPSE, TR and sPAP was similar with and without contrast (p=NS). All the RV parameters showed little inter–operator variability when measured with contrast. TAPSE, FAC, and RWMA showed an excellent reproducibility (ICC >0.86) while it was good for 2D–baseline derived parameters (ICC = 0.74) showing improvement of inter operator reproducibility in the evaluation of regional contractility in the contrast echocardiography modality.

Conclusion

EC is safe with all the types of LVAD examined. Accurate and reproducible visualization of RV is imperative for reliability of information, a routine use of EC could play a pivotal role in interpreting RV features. EC improves RV morphologic and functional judgment allowing greater accuracy and precision in the assessment of both global and regional RV functions. This finding may have important clinical improvement, especially in the future for analysis focused in RV prognostic role in LVAD patients.
P106 A LEFT GIANT MYXOMA WITH A NOTABLE NEOVASCULARIZATION
Authors: Cortese F , Costantino M , Prestipino F , Manzan E , D‘Ascoli R , D‘Addeo G , Cristiano A , Lopizzo A , Bochicchio A , Luzi G
Published: May 2022

A 73–year–old asymptomatic woman came to our observation to perform a routine echocardiographic examination. The patient suffered from arterial hypertension, dyslipidemia, hypothyroidism, paroxysmal atrial fibrillation. She underwent a bilateral mastectomy for breast cancer about 5 years ago, and she was undergoing chemotherapy and radiation therapy for a stage IV lung adenocarcinoma. The clinical evaluation was normal, as was the electrocardiogram. Transthoracic echocardiographic evaluation showed the presence of a rounded formation with variable echogenicity, with an irregular surface (4 x 3 cm), adherent to the interatrial septum at the level of the fossa ovalis, which did not hinder the excursion of the mitral valve. No other significant cardiac abnormalities were detected. Tansesophageal echocardiography confirmed the presence of atrial mass adhered to the oval fossa (panels A, B). of coarsely rounded shape, and variable echogenicity, in the absence of interference with the movement of the valve leaflets and of anomalies of the interatrial septum (panel C). Coronary angiography showed a right–dominant coronary circulation (panel D) and a mild stenosis of the mid left anterior descending artery. An abundant arterial perfusion of the atrial mass, with several vessels originating from the circumflex artery was also evident at the coronary angiography (panels E, F). The patient underwent cardiac surgery; the surgical exeresis of the left atrial mass was performed through right mini thoracotomy. Because the neo–formation was adherent not only to the atrial septum but also to the left atrial roof, to obtain a radical excision, a large portion of the atrial wall and the septum were removed and totally reconstructed with the pericardium. The main artery supplied the mass related vascular network was ligated. The post–operative course was uneventful, and the patient was discharged at home on day six. The pre–discharge echocardiography showed absence of any residual mass in left atrium that appear anatomically reshaped, no shunt at level of interatrial septum, preserved ventricular function of both ventricles. Histological analysis confirmed the diagnosis of atrial myxoma. At six–month follow–up the patient was asymptomatic and the echocardiography was superimposable to discharge.
P108 PLEURAL EFFUSION AND THE POSTERIOR THORACIC WINDOW: ONE MORE CHANCE TO IMAGE THE AORTIC VALVE
Authors: Mantovani F , Monari D , Guiducci V , Manca F , Navazio A
Published: May 2022

A 85–year–old woman was admitted to our institution with acute respiratory distress. Clinical examination revealed a 5/6 systo–diastolic murmur radiating to both carotid arteries and bilateral lung crackles. Laboratory workup was notable for a N–terminal pro–brain natriuretic peptide (NT–proBNP) of 15.000 ng/L (normal range: < 300 ng/L) and a moderate high–sensitive troponin T elevation of 245 ng/L (normal range: < 14 ng/L) with no increase on serial testing. The hemoglobin and renal function was normal. Evaluation by chest X–ray showed bilateral diffuse pulmonary infiltrates consistent with pulmonary edema and bilateral pleural effusion. The patient was admitted in CCU. A transthoracic echocardiogram was performed bedside, but it was extremely difficult to obtain good quality images from standard view given the ortopnoic decubitus of the patient. However, the aortic valve was heavily calcified and severe aortic stenosis was documented with a mean gradient of 42 mmHg from apical 5 chambers view; 35 mmHg from right parasternal view, with an functional aortic valve area ≈0.6 cm2 (figure, upper panel). Left ventricle shows eccentric hypertrophy and a moderate diffuse reduction of ejection fraction (EF 35–40%). Then, the patient was positioned sitting upright, because the left pleural effusion offered an additional acoustic window—the posterior thoracic window (PTW)—that allowed better alignment of the ultrasound beam with the aortic jet. Mean gradient was recorded definitely higher than from standard view at 50 mm Hg. Moreover, aortic regurgitation that appeared mild from standard view was documented as significant from PTW. In fact, a proper alignment of the aortic regurgitation jet was feasible from this view with a quantification of severity with multiparameter criteria as suggested from the guidelines (PHT 166 ms, Vena contracta 8 mm; Rvol 60 ml). (Figure, lower panel)

Conclusion

Obtaining adequate echocardiographic images in critically ill patients is important for better diagnosis and treatment. For several reasons, this group of patients remains among the most challenging with regard to quality of echocardiographic images. In presence of pleural effusion and technically difficult echo exams, the PTW should be considered in the assessment of cardiac structures including aortic valve as a potentially useful option to provide further diagnostic information.
P113 HIDDEN POCKET. LEFT ATRIAL SEPTAL POUCH: VARIANT OF NORMALITY OR CARDIOEMBOLIC SOURCE?
Authors: Minardi S , Trambaiolo P , Tocci G , Renda M , De Matteis G , Mustilli M , Fina P , Romano S , Ferraiuolo G
Published: May 2022

During embryological period the blood flows from right to left atrium trought patent interatial septum. Embryon’s interatrial semptum consists on the apposition of Septum Secundum (SS) over Septum Primum (SP) that go to seal each other just afther birth. Sometimes this fusion doesn’t happen or partially happens, leading respectively to patent foramen ovale (PFO) or the less known eventuality of Atrial Septal Pouch (ASP).

48–year–old woman, history of chronic anemia treated with blood transfusions, underwent a routine transthoracic echocardiogram (TTE) as recommended by her transfusion center. The patients is asymptomatic, denies cardiovascular risk factors, denies any signs or symptoms suggestive of recent infectious or inflammatory disease. The TTE documented preserved left ventricular sistolic function, normal sized cardiac chembers, no valvular abnormalities, evidence of linear formation (10 x 5 mm), near foramen ovale, on the left side of interatrial septum, increased in echogenicity. It was performed a transesophageal echocardiogram (TEE) which confirmed the finding at SIA level. It was therefore recommended in depth study with cardiac magnetic resonance (CMR) which described the same mobile formation, characterized by the same signal strength as the atrial walls, both before and afther contrat administration, compatible in the first hypotesis with an embryonic residue (Left Atrial Septal Pouch, LASP).

There is still much uncertainty regarding the clinical significance of LASP, however, its large prevalence among general population suggests that its potential embolism requires other predisposing conditions in order to be of real clinical relevance. CMR represents a usefull test for cardiac structures analysis owing its better tissue characterization cormpared to other diagnostic tests. In the event of an occasional finding and in absence of any other indication for anticoagulant therapy, no therapeutic measures are currently indicated. These patients could be followed up in order to promptly identify the onset of prothrombotic conditions likely to expose them to higher risk compared with patients who do not have LASP.
P116 GIANT LEFT ATRIAL MYXOMA CAUSING ACUTE ISCHEMIC STROKE
Authors: Chiarello G , Garzya M , Donateo M , Marazia S , Cucurachi M , De Giorgi A , Colonna G
Published: May 2022

Aims

Primary cardiac tumours are rare; most are benign, and around half are myxomas, often located in the left atrium. Clinical presentation is variable. Ischaemic stroke is a rare, although real and potentially fatal, complications of cardiac myxomas.

Case Report

We present a case of a 51–year–old man, ex– smoker, obese, with history of hypertension and COPD, presented to our emergency department with right–sided hemiplegia and aphasia caused by ischaemic stroke. Brain CT revealed cerebral perfusion deficit. The patient was underwent intravenous thrombolytic strategy. TTE showed a large left atrial mass attached to the interatrial septum, with a friable appearance, suggestive of myxoma. The 2D and 3D TEE detected a giant space–occupying mass in the left atrium, coral–like, and the most apical portion prolapsed into the left ventricle during diastole, causing fixed obstruction to flow in the left ventricular inflow tract. In view of the risk of imminent embolization, the emergent surgical excision of the tumour was performed. Subsequent histopathological findings confirmed the diagnosis of myxoma. Symptomatic cardiac myxoma may present with one of the three classic clinical presentations of the Goodwin’s triad, which include intracardiac obstruction, constitutional symptoms, and embolism. The obstructive pattern mimics atrioventricular valve obstruction. Constitutional manifestations include fatigue, fever, weight loss. Systemic embolization from myxoma occurs in around a third of cases. Of these, the most serious is cerebrovascular embolism, which may result in cerebral stroke. The tumour size, location, and macroscopic appearance, along with mean platelet volume and platelet count, are closely associated with embolic events. Echocardiography remains the method of choice for diagnosis and morphological characterization of myxoma. Two patterns have been established by echocardiography: round, with a solid appearance and a firm surface, and polypoid, with an irregular outline and a friable surface. The incidence of systemic embolization is higher in those with an irregular and friable surface and those that prolapse into the ventricle. Once a diagnosis of myxoma is established, surgical resection is the only effective treatment and should be performed immediately, in view of the risk of embolization.

Conclusions

With this case report, we stress the importance of echocardiography in new onset of neurological deficit to prevent potentially fatal outcomes.
P121 ECHOCARDIOGRAPHIC EXAMINATION ON AGONIST ATHLETES WITH RECENT PAUCISYMPTOMATIC SARS COV 2 INFECTION, FOR THE RENEWAL OF AGONIST SPORT ACTIVITY ELIGIBILITY: PLAUSIBLE ROLE AND UTILITY OF GLS ANALYSIS THROUGH SPECKLE TRACKING
Authors: De Masi De Luca G , Papadia P , Prete G , Nuccio F , De Masi De Luca G , Morciano P , De Blasi S
Published: May 2022

Background

The aim of this work is to highlight whether or not the methodical echocardiography done through the analysis of global and segmental longitudinal deformation (GLS–SLS) can be useful to identify subclinical myocardial lesions in paucisymptomatic young agonist athletes with recent SarsCov2 infection before they return to agonist practice.

Material and Methods

From 12/2020 to 12/2021 84 agonist athletes with previous SarsCov2 infection have been examined at “Cardiomed Center” Maglie (Lecce, IT), as part of screening for their return to sport practice; all of them under standard echocardiographic analysis associated to GLS analysis, Holter–ECG analysis with 24h on 12 derivations.

Results

The base echocardiographic examination didn’t show any myocardial cynesis anomalies in any patient. In 5 patients there was a presence of a light pericardial effusion, how it was supposed to be as an outcome of a previous inflammatory ingjury The GLS analysis, that resulted in reliability considering the optimal acoustic window, showed a slightly lower medium value compared to the values cited in the literature (19.4 ± 2.9) and particularly 4 patients show considerable deficit reductions of segmentary strain. In these patients Holter analysis showed the presence of a moderate non–complex extrasystolic arrhythmia. These elements–that are a reduced GLS with marked regional anomaly, coupled with the presence of ventricular arrhythmia even in absence of segmentary dissinergyes– led to cardiac RMN evaluation. In 2 out of 4 patients there have been flaws that were compatible to modest myocardial lesions, in one case it was observed a marked flaw in medium–apical–lateral region that was correlated to the described areas at the specle tracking.

Conclusion

Our experience at the Cardiology and Sports integrated clinic, although it relied on a meager population of patients, it still demonstrated how echocardiographic analysis through GLS evaluation and the highlighting of sectorial alterations even in absence of cynesis anomalies can be used as a parameter to suppose the presence of miocarditic lesions that might be sent to the next RMN examination for confirmation, in young athletes with recent paucisymptomatic Covid–19 infection.
P125 CORONARY REVASCULARIZATION GUIDED BY STRESS ECHOCARDIOGRAPHY WITH ULTRASOUND CONTRAST: A CASE
Authors: Gioia M , Milo M , Passero T , Rollo R , Ignone G
Published: May 2022

Echocontrastography is an echocardiography method that involves the intravenous administration of a particular contrast medium, formed by microbubbles capable of crossing the pulmonary circulation and distributing themselves in the left sections. These micro bubbles hit by ultrasound break or oscillate emitting ultrasound waves with a different frequency than the beam that hit them, generating a series of harmonic signals that can be processed to observe, for example, the opacification of the left cavities. An 82–year–old diabetic hypertensive man with a strong family history of coronary artery disease underwent routine cardiac evaluation. At the time of the visit, sporadic episodes of non–specific chest pain (localized in the right breast), of an intermittent nature, and not related to physical exertion, were reported. On the ECG, finding of sinus rhythm and q waves in V1–V3 (not present at a previous in 2019). On echocardiography (patient with poor acoustic window): Left ventricle of normal size with mild concentric parietal hypertrophy. Slight reduction in global systolic function due to alterations in district kinetics. Akinesia of the apex and middle segment of the septum and anterior wall. FE 48%. Doubtful apical iso–hyperechoicity (artifact?). Urgent hospitalization for coronary angiography was indicated in the suspicion of subacute anterior AMI. Coronary angiography revealed occlusion of anterior interventricular artery (IVA) in the proximal tract, partially re–inhabited downstream by homocoronary circulation (figure 1). Before proceeding with revascularization, given the absence of movement of the myocardiocitonecrosis indices, it was decided to perform myocardial viability tests. In consideration of the suspected apical thrombotic formation, as well as the patient‘s poor acoustic window, echo contrast was necessary (Figure 2). Once the complete opacification of the left ventricular cavity was highlighted by the contrast agent, suggestive of the absence of apex thrombi, we proceeded to ecostress with dobutamine to evaluate myocardial viability. At the explored dosages (5 – 10 and 20 ug/kg/ min) recovery of the apex kinetics was observed, but not of the mid–apical septum, which remained akinetic. We then proceeded to angioplasty on proximal IVA with a good angiographic result and the patient was discharged on the third day from revascularization in excellent clinical conditions.
P137 GEOGRAPHIC DIFFERENCES IN CANCER RISK LONG AFTER ACS. THE ABC 7–7A* STUDY ON HEART DISEASE
Authors: Mahmoud H , Berton G , Cordiano R , Cavuto F , Palmieri R , Mahmoud M , Sitta N , Pasquinucci M , Lorenzon E
Published: May 2022

Background

Increased risk of cancer and cancer death has been reported in patients with Acute Coronary Syndrome (ACS). We investigated the long–term geographic differences in those risks.

Methods

In this prospective study, we enrolled 586 ACS patients admitted to hospitals in three provinces in the Veneto region of Italy. The patients were classified as residing in urban or rural areas in each province.

Results

With 3 exceptions, all patients completed the 22–year follow–up or were followed until death. Urban (46%) and rural (54%) residents shared most of their baseline demographic and clinical characteristics. Pre–existing malignancy was noted in 16 patients, whereas 106 patients developed cancer during follow–up and 99 patients died due to the malignancy. The urban/rural incidence rate of new malignancy per 1000 person–years was (9/32 in the north, 19/21 in the middle, and 18/13 in the southern province) and the urban/rural incidence rate of neoplastic death per 1000 person–years was (10/23 in the north, 16/17 in the middle, and 17/11 in the southern province). Unadjusted Cox regression analysis revealed increasing hazards ratios (HRs) for malignancy onset from urban to rural areas (HR = 3.0; 95%CI=1.5–6.2; p = 0.02). Also, we found a strong positive interaction between urban/rural areas and provinces with risk increasing from the urban to rural areas from southern to northern provinces (HR 2.1; 95% CI 1.3–3.5; p = 0.002), even with a fully adjusted model. Geographic areas, additionally, showed a strong positive interaction for the risk of cancer death, with risk increasing from the urban to rural areas from southern to northern provinces (HR = 1.9; 95%CI=1.1–3.0; p = 0.01) with the unadjusted Cox regression analysis. The fully adjusted Cox regression and Fine–Gray competing risk regression models provided similar results. We did not observe an urban/rural difference or an interaction between the geographic areas in non–neoplastic death risk.

Conclusion

This analysis reveals the significant urban/rural difference in the long–term risk of cancer onset and cancer death among unselected ACS patients. These results highlight the importance of implementing a preventive policy based on area–specific knowledge.
P140 EFFICACY AND SAFETY OF CHEMOTHERAPY CONTAINING NON–PEGYLATED LIPOSOMAL DOXORUBICIN IN PATIENTS AT HIGH CARDIOVASCULAR RISK: A SINGLE–CENTER EXPERIENCE
Authors: Bisceglia I , Camilli M , Mistrulli R , Cartoni D , Matera S , Canale M , Battistini R , Rigacci L , Petrolati S
Published: May 2022

Anthracyclines represent the most effective chemotherapeutic agent in the treatment of non–Hodgkin‘s lymphoma (NHL), although their use is limited due to the risk of cardiac toxicity. This occurs mainly in elderly patients, those with a history of cardiovascular (CV) disease and/or multiple concomitant risk factors. Liposomal doxorubicin has been shown to reduce this toxicity. The aim of this retrospective study is to investigate the use of non–pegylated liposomal doxorubicin in high–risk patients in terms of haematological response rate and CV events. In a single centre, 15 patients undergoing R–COMP regimen (Rituximab, Prednisone, Cyclophosphamide, Vincristine, Myocet liposomal doxorubicin) were consecutively collected from January 2020 to December 2021. The mean age of patients was 73.9 years and 60% were male. The baseline mean left ventricular ejection fraction (LVEF) was 55.9%; four patients had a baseline FE of < 50%, two of them had a severe reduction in LVEF. Among all patients, 86.7% had systemic hypertension, 40% diabetes mellitus, 46.7% dyslipidaemia and 20% a family history of CV disease. Moreover, 46.7% of patients had at least two concomitant risk factors and 20% at least three. 20% had a history of ischemic heart disease, 13.3% had previous exposure to anthracyclines and 20% with mediastinal radiotherapy; 26.7% had moderate to severe aortic valvulopathy. According to the joint Cardio–Oncology evaluation, 100% of patients had been considered unsuitable for conventional doxorubicin.. More than 85% of the cases were already on cardioactive therapy at baseline evaluation and 66.7% required titration or modification during chemotherapy. With R–COMP, the whole population was able to finish treatment achieved complete haematological remission. The mean LVEF at the end of treatment was 55.8% (p = 0.814).

Conclusions

Our results support the efficacy and safety of R–COMP in a population at high risk for cardiac events, otherwise excluded from anthracycline–containing therapy. Liposomal formulatio reduces doxorubicin cardiomyocyte accumulation and thus toxicity, providing the best possible treatment for the majority of the onco–haematological population.
P158 ELECTROANATOMIC MAPPING–GUIDED DEFIBRILLATOR IMPLANTATION WITH CARTO 3 IN YOUNG PATIENTS
Authors: Loira L , Fumanelli J , Elhyka A , Rotella M , Ferretto S , Di Salvo G , Iliceto S
Published: May 2022

Introduction

Defibrillator (ICD) implantation is generally performed under fluoroscopy guidance, allowing to place the leads in the correct positions within the heart. However, for young patients, fluoroscopy exposure should be reduced as much as possible due to their higher radiosensitivity. Three–dimensional (3D) electroanatomical mapping (EAM) is a technique extensively used in electrophysiology for the ablation of different arrythmia, reducing the fluoroscopy exposure. In this preliminary study 3D EAM was used to achieve ICD implantation in pediatric patients and in young patients with congenital heart disease targeting minimal fluoroscopy exposure. Data on procedure complications, fluoroscopy dose and time were compared to those achieved with the conventional approach without 3D EAM.

Methods

Using the EAM system CARTO 3 (Biosense Webster, Johnson & Johnson Medical, CA) ICD implantation was performed in 10 young patients: 8 had an age below 18 (mean 13 y ± 2) at the time of the implantation and 2 were adults with congenital heart disease (24 and 38 y). For comparison, 10 pediatric patients (mean 13 y ± 2) and 2 adults with congenital heart disease treated conventionally, without EAM, were considered. In the EAM group, the physician started by mapping the chambers of interest with a sensor–based catheter (Navistar Biosense Webster, Johnson & Johnson Medical, CA). Then the leads were advanced in the heart and visualized on the CARTO 3 system utilizing alligator clips attached to the distal part of each lead and connected to the EAM system. A final fluoroscopic snapshot image was taken to confirm the correct deployment of the leads.

Results

The total procedure time was similar between the two groups with a mean time of 61 min in the EAM group and 72 min in the conventional group. The mean fluoroscopic time and dose were lower in the EAM group (22 sec, 6.6 Gy·cm2) compared to the conventional group (887 sec, 39 Gy·cm2). There were no peri–procedural or follow–up complications in either group. Within the EAM group, a decreasing trend is observed in total procedure time, fluoroscopic time and dose by increased number of procedures.

Conclusion

Implantation of ICD under EAM guidance in young patients is feasible and allows for reduced fluoroscopic exposure, without compromising safety.
P171 EVALUATION OF ARRHYTHMIC RISK IN THE PSYCHOPHARMACOLOGIC–TREATED PATIENT
Authors: Acierno D , Scarfò G , Franzoni F , Miniati M , Perugi G
Published: May 2022

Background

Neuroleptics (NRL) and Tricyclic Antidepressants (TCA) could be related to the QT prolongation although the risk of ventricular arrhythmias and sudden death caused by these drugs was not clearly described in literature. Corrected QT (QTc), is the major marker of arrhythmic risk; Qt dispersion (QTd) is defined as the dispersion of the QT interval on 12–lead electrocardiogram (ECG) and is predictive of mortality if > 58; the heart rate variability (HRV) is indicative of the sympathetic/vagal tone and of the arrhythmic risk. Aim of the study. Evaluation of the main effects of psychotropic drugs in psychiatric patients on the following parameters: QT interval, QTc using 4 formulas (Bazett, Fridericia, Framingham e Hodges), Qtd and HRV depending on time and heart rate.

Materials and Methods

Data from 167 patients treated with typical and atypical NRL, TCA, and mood stabilizers have been collected. The observational study consisted in these phases: 1) chart review of 84 patients admitted in day hospital to detect sex, age, diagnosis, therapy and Qtc; 2) evaluation of the same parameters in 83 of them, to whom an ECG was performed at the discharge; 3) ECG Holter in a subgroup of 17 patients who have given consent to the exam, to highlith the incidence of arrhythmias and to investigate the HRV.

Results

No significant QTc alterations related to therapy were detected at the admission or at the discharge. Moreover, no statistically significant differences emerged among NRL classes nor an increased arrhythmic risk in polypharmacy. The use of different formulas has confirmed an overestimation of the QTc according to the Bazett formula. QTd was altered in 67 patients ( QTd ≥50 in 51 subjects; QTd>60 in 12 subjects)and the HRV was lower compared to the general population regardless of the therapies.

Conclusions

The psychopharmacological therapy in a “real world setting” didn’t show a signiticative influence on the evaluated parameters of arrhythmic risk. The arrhythmic risk is low in absence of other risk factors or comorbidities. QT correction using FRI or HOD, the QTd if QTc >450–470 ms and the HRV in patients with arrhythmic risk factors, should be considered as parameters to evaluate in the clinic routine of follow–up of psychopharmacologic–treated patient.
P172 AN ACCESSORY PATHWAY WITHOUT REENTRANT TACHYCARDIA
Authors: Bricco G , Coppolino A , Valeri L , Amoroso G , Cavallero E , Iacovino C , Barbero U , Battisti A , Scaglione M , Correndo L , Bessignana A , De Benedictis M
Published: May 2022

A 65–year–old patient, hypertensive, dyslipidemic, strong smoker. He has heart disease with hypokinetic evolution EF 47%, mild MI. Negative Dipyridamole–stress echocardiography dated January 2008. Recently atrial fibrillation (AF) is found and anticoagulant therapy was started. Dyspnea and weight loss occurred in past two months. Detected keratinizing squamous pulmonary Ca with negative markers. This injury was judged to be inoperable, and the patient get indications for chemotherapy and radiotherapy. The patient also starts complaining of dyspnea and chest pain on exertion: Not serological modification, not ischemic ECG. Echocardiogram LVEF 47–50% highlights diffuse hypokinesia, regular valves. Ergometric test was not evaluable for ischemia. Coronary angiography shows stenosis of proximal and middle anterior interventricular coronary and non–critical lesions of circumflex and right coronary. Ecodobutamine test was positive for ischemia and arrhythmias (AF and wide QRS tachycardias in recovery phase), but negative for angor. The patient was treated with CT and IVA I – II. angioplasty Monitoring shows AF with high penetrance, wide QRS tachycardia runs and very short TVNS. ECG 1: During atrial tachycardia, show broad QRS conduction to BBSX alternating with narrow QRS with the same RR interval. ECG 2. show fusion between the wavefront conducted with narrow QRS and that with wide QRS. These are supraventricular arrhythmias that run along the atrioventricular nodal pathway (NAV) in the narrow QRS tracts and take an accessory pathway in the wide QRS run.

The Mahaim fibers have decremental conductivities like the AV node, therefore high ventricular frequencies does not occur AF appeared during ecodobutamine, but some beats were conducted by an anomalous path in a discontinuous way); they are generally directed from the atrium or the NAV, towards another part of the right ventricular conduction system, with atrium wave or NAV – RB, therefore the early activation of the RB generates a widened QRS, with a LBB morphology. ECG 3 Re–entry on Mahaim pathway, ventricular activation widened through Mahaim fiber, which generate LBB morphology with retrograde atrial depolarization. In this case there is no reentry, but we have an atrial tachycardia conducted alternately on an accessory pathway and across the NAV. Given the patient‘s clinical problems and the total absence of symptoms, the patient remains asymptomatic during therapy with amiodarone and beta–blocker.