bluuebunny/crossref_metadata_2025_split huggingface dataset:
P1266 Infectious endocarditis- still a diagnostic dilemma
Authors: Mocan R A , Muresan C , Schiau S , Jacquemin L 
Published: January 2020

Abstract

INTRODUCTION
Infectious endocarditis is still a challenge with a high mortality and complication rate despite the progress made in its management.
DESCRIPTION OF CLINICAL CASE
A 58 years old female, with a history of mitral and aortic mechanical prosthesis for rheumatic valvular disease and mitral infectious endocarditis with Aggregatibacter Actinomycetemcomita due to an apical abscess was referred to our service for persistent fever.
The clinical examination revealed irregular mechanical prosthesis beats, with no heart murmurs and no signs of heart failure, but with a tender splenomegaly.
The laboratory tests showed an inflammatory syndrome, but no positive blood cultures. An extensive panel for endocarditis was negative for Coxiella burnetii, Brucella Spp, Legionella Spp, Mycoplasma Spp and for the immunology markers (rheumatoid factor, antinuclear antibodies and anti-cardiolipin antibodies)

ECG
AF, 88 bpm, PVC bigeminy, LBBB.
Infectious endocarditis was the most likely diagnosis considering the fever, the inflammatory syndrome, the presence of the mechanical valves and the history of endocarditis.
An echocardiography was performed that showed a non-dilated left ventricle with a preserved EF, no aortic prosthesis dysfunction, nor mitral; a dilated RV with normal function, moderate tricuspid regurgitation, no intracardiac masses and no pericardial effusion.
The TEE revealed no vegetation, no abscess or pseudoaneurysms and no dehiscence of the prosthetic valves.
The Endocarditis Team was reunited and empirical antimicrobial therapies with Amoxiciline, Gentamicine and Cloxaciline for 6 weeks, as well as a PET scan were recommended.
The PET-CT revealed abnormal fixation in the posterior-inferior part of the aortic valve.
As we had only one major criterion and two minor criteria for the diagnosis of endocarditis a radiolabeled leukocytes SPECT CT that showed no pathological fixation was realised. The result was inconclusive as it was performed at the end of the antimicrobial treatment.
A computed tomography of the brain, thorax, abdomen and pelvis didn’t reveal any vascular phenomena. The tender splenomegaly was secondary to two hemangiomas.
Also a dental computed tomography revealed an apical abscess of 1.2 that was treated after discharge with antibiotic prophylaxis.

DISCUSSION
This clinical case confirms that the diagnosis on infectious endocarditis can be challenging in patients with prosthetic valves. The multimodality imaging is of major importance for the diagnosis of these patients.
Additionally the microbiological criteria was not met in this case as it was a blood culture-negative endocarditis with a history of previous antibiotic therapy.

CONCLUSION
Our knowledge of infectious endocarditis is constantly evolving. Blood culture negative endocarditis accounts for one third of cases and is still a challenge. The Endocarditis Team and multimodality imaging play a central role in the diagnosis and treatment of these patients.
Abstract P1266 Figure. PET-CT showing AV abnormal fixation
P1270 Systolic blood pressure at age 40 is associated with left atrial volumes at age 64
Authors: Selmer Roenningen P , Berge T , Solberg M G , Enger S , Nygaard S , Pervez O , Orstad E B , Kvisvik B A , Aagaard E N , Lyngbakken M N , Ariansen I , Rosjo H , Steine K , Tveit A 
Published: January 2020

Abstract

Funding Acknowledgements
Vestre Viken Hospital Trust

Background
Left atrial (LA) enlargement is associated with elevated blood pressure (BP) and with cardiovascular morbidity and mortality. In the assessment of LA size, echocardiographic guidelines recommend the use of LA end-systolic volume (LAVmax). LA end-diastolic volume (LAVmin) and LA emptying fraction (LAEF) may add valuable information in risk assessment. The knowledge of early adulthood BP and its association to LA volumes and LAEF later in life is limited.

Purpose
To explore the association between systolic BP at age 40 and LA volumes and LAEF at age 64.

Methods
We linked data from subjects who had participated in both a nationwide cardiovascular screening survey (1990-1991) at the age of 40, and the Akershus Cardiac Examination (ACE) 1950 Study (2012-2015) at the age of 64 (n = 2,597). In the ACE 1950 Study, LAVmax and LAVmin were measured with echocardiography according to the summation of discs method. LAEF was calculated as (LAVmax-LAVmin/LAVmax)x100%. The association between systolic BP at age 40 and LA volumes and LAEF at age 64 was assessed in univariate and multivariate linear regression analyses.

Results
Systolic BP at age 40 was associated with LAVmax and LAVmin but not with LAEF at age 64. In our multivariate model, a 10 mm Hg higher systolic BP at age 40 was associated with a 0.9 ml greater LA end-systolic volume and a 0.5 ml greater LA end-diastolic volume at age 64.

Conclusion
Early adulthood systolic BP is associated with LA volumes 24 years later in life.
Table. Association of systolic blood pressure at age 40 to left atrial (LA) volumes and LAEF at age 64 Univariate Multivariate* Dependent variable B (95% CI) p-value B (95% CI) p-value LAVmax (ml) 2.4 (2.0, 2.9) &lt;0.001 0.9 (0.4, 1.4) 0.001 LAVmin (ml) 1.5 (1.1, 1.8) &lt;0.001 0.5 (0.1, 0.9) 0.015 LAEF (%) -0.01 (-0.3, 0.3) 0.938 0.2 (-0.2, 0.5) 0.294 *Adjusted for gender, body mass index, smoking, resting heart rate and antihypertensive treatment, all assessed at age 40. B (95% CI), regression coefficient for systolic blood pressure (per 10 mm Hg) with 95% confidence interval; LAVmax, LA end-systolic volume; LAVmin LA end-diastolic volume; LAEF, LA emptying fraction
P1275 In-hospital outcome of patients with infective endocarditis: is echocardiography enough?
Authors: Motoc A , Kessels J , Roosens B , Lacor P , Van De Veire N , De Sutter J , Droogmans S , Cosyns B 
Published: January 2020

Abstract

Background
Despite improvements in medical and surgical therapy, infective endocarditis (IE) remains a deadly disease. Echocardiography is the first-line diagnostic tool. However, data regarding its role in the prognostic assessment of in-hospital clinical outcome of IE are scarce.

Purpose
We sought to assess the role of echocardiography to predict the in-hospital outcome in a large cohort of patients diagnosed with definite IE and its association with clinical presentation and microorganisms.

Methods
We retrospectively included patients from two centers between 2006 and 2018. Transthoracic and transesophageal echocardiography were performed in all patients. The clinical endpoints were in-hospital death, embolic events (cerebrovascular and non-cerebrovascular), shock (septic shock and cardiogenic shock) and cardiac surgery.

Results
183 patients with definite IE (age 68.9 ± 14.2 years old, 68.9% male) were evaluated. Ninety three (50.8%) patients had aortic valve IE and 81 (44.3%) patients presented with mitral valve IE. Twenty three patients had multivalvular IE. The in-hospital mortality rate was 22.4%. Sixty patients (32.8%) had embolic events and 42 (23%) patients developed shock during hospitalization. Surgery was performed in 103 (56.3%) patients. Mitral valve IE on echocardiography was an independent predictor of in-hospital mortality (p = 0.038, OR 0.38, 95% CI 0.15 – 0.94) and aortic valve IE on echocardiography was an independent predictor of embolic events (p = 0.018, OR 0.36, 95% 0.16-0.84). The presence of a new cardiac murmur upon admission was predictive for the need of cardiac surgery (p = 0.042, OR 0.51, 95% CI 0.22- 1.09) and correlated with the severity of valvular regurgitation identified by echocardiography (p = 0.024). Methicillin resistant Staphylococcus aureus (MRSA) as the causative microorganism was an independent predictor for in - hospital mortality and for the development of shock during hospitalization (p = 0.010, OR 0.13 95% CI 0.30 - 0.62 and p = 0.027, OR 6.11, 95% CI 1.22 – 30.37, respectively). No correlation was found between MRSA and echocardiographic parameters.

Conclusion
Mitral valve IE was an independent predictor of in - hospital mortality. Furthermore, aortic valve IE was an independent predictor of embolic events. The presence of a new cardiac murmur was predictive for the need of cardiac surgery and correlated with the severity of valvular regurgitation by echocardiography. Our findings suggest that a thorough physical examination upon admission is required in combination with a comprehensive echocardiographic exam for early identification of patients with IE at high - risk for in-hospital death and complications.
P1277 Cardiac remodeling in secondary tricuspid regurgitation: should we just look at the tricuspid annulus diameter?
Authors: Guerin A , Dreyfus J , Vabret E , Le Tourneau T , Lavie-Badie Y , Sportouch C , Eicher J C , Marechaux S , Donal E 
Published: January 2020

Abstract

Funding Acknowledgements
Financial support: French society of cardiovascular imaging.

Background
The respective strength of the different mechanisms that could lead to significant secondary TR occurrence remains debated.

Purpose
The main objective of our study was to characterize the determinants of tricuspid regurgitation (TR) severity in stable patients with preserved left ventricle ejection fractionand without significant left valvular heart disease. Patients were classified into 5 groups according to echocardiographic TR severity assessment: mild / moderate / severe / massive / torrential. Secondary objectives were to describe the evolution of the dimensions of the right cavities and the right ventricle (RV) function parameters according to the severity of the TR.

Methods
This is a prospective observational and multicentric study. Criteria for inclusion were: age ≥ 18 years; at least moderate TR; euvolemic status. We excluded patients with organic TR. All patients underwent standard trans-thoracic echocardiographyat distance from initial diagnosis and after stable optimized medical treatment. All exams were analysed in a Core Laboratory.

Results
100 patients (12 presented mild TR, 31 moderate, 18 severe, 17 massive and 22 torrential) were enrolled and we used effective regurgitant orifice area (EROA) to quantify the severity of TR. To explain TR severity in multivariate analysis, right atrium (RA) indexed volume and tethering area were statistically significant (p &lt; 0.001). For an increase of 10 mL/m2of RA volume, EROA increases by 4.2 mm2and for an increase of 0.1 cm2of tethering area, EROA increases by 2.2 mm2. The right heart dilation and the degree of restriction of tricuspid apparatus change significantly according to the severity of the TR (p &lt; 0.001). RV function parameters did not differ significantly according to the degree of TR.

Conclusion
Early TA enlargement is present in secondary isolated TR. Then, increase in tethering area and RA indexed volume are associated with increase in TR severity. All right heart cavities dilate progressively without clear impact on RV-function parameters when TR increase.
Factor determining increase in EROA coefficient SD p value RA volume (mL/m2) 0.42 0.09 &lt; 0.001 Tethering area (cm2) 22.1 3.9 &lt; 0.001 Multivariate linear regression model. EROA: Effective Regurgitant Orifice Area; SD: Standard Deviation; RA: Right Atrium.
Abstract P1277 Figure. RV-EDA: probability of TR class severity
P1286 A retrospective clinical and anatomical characteristics study of transaortic extended left ventricular myectomy for obstructive hypertrophic cardiomyopathy
Authors: Furugen A , Doi H D , Mitsube K M , Hashimoto M H , Koshima R K 
Published: January 2020

Abstract

Objective
Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM). The aims of our study are to investigate anatomical characteristics and make clear effectiveness of transaortic extended left ventricular (LV) myectomy for HOCM.

Methods
This study enrolled 28 consecutive patients (age 66.7 ± 12.1 years, 46% Female) from 2012 to 2018 who met the following inclusion criteria: symptoms of heart failure persisting despite optimal medical therapy including beta blockers and Class I anti-arrhythmic agent, LV outflow tract gradient (LVOTG) &gt; 50mmHg at rest or with provocation using stress echo (exercise TTE or low-dose dobutamine stress echo). We evaluated LV dimension, LVOTG, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM), Mitral complex morphology, high echoic region of endocardium and appearance of abnormal muscle bundles including apical-basal muscle bundle. These parameters were evaluated based on changes in LVOTG, MR and SAM at after LV myectomy. Also, intraoperative findings and cardiomyocytes pathological findings were evaluated. Stress echo were performed to investigate sustained reduction of LVOTG at medium term.

Results
All patients were successfully underwent transaortic extended LV myectomy. SAM was identified in all and moderate MR in 14 patients. The anterior mitral valve leaflet height was large in all patients and 16 patients had LV abnormal muscle bundles.
Postoperative LVOTG were controlled in 10mmHg or less. SAM disappeared completely in all patients and MR were decreased mild or less. LVOTG were sustained good control in 10mmHg or less under stress echo at medium term.

Conclusion
LV myectomy provides excellent relief from LVOT obstruction. The appearance of mitral valve anterior leaflet and abnormal band may be important keys of LVOT obstruction.
P1303 Pseudo-severe aortic stenosis due to mechanical dyssynchrony in a patient with low contractile reserve
Authors: Breskvar U , Mrak M , Zupan Meznar A , Zizek D 
Published: January 2020

Abstract

Introduction
Aortic stenosis characterization in patients with low flow – low gradient stenosis (LF-LG) and reduced left ventricular (LV) ejection fraction (EF) is challenging. In this subgroup, pseudo- severe stenosis should be properly identified, as these patients are treated conservatively with heart failure therapy. Its identification relies mainly on preserved contractile reserve seen during dobutamine echocardiography. We present a patient with low contractile reserve and pseudo-severe stenosis due to mechanical dyssynchrony.

Case presentation
83-years old patient with ischemic heart disease and chronic kidney disease was admitted to our department due to progressive exertional dyspnea. In 2014 he underwent dual-chamber pacemaker (PM) implantation due to sick sinus syndrome and was programmed to asynchronous pacing mode (VVI mode) in 2016 as atrial electrode dysfunction was observed. Coronary angiogram was normal. Echocardiography showed enlarged left ventricle (LV EDV 180 ml), reduced EF (33%) and signs of mechanical dyssynchrony. Peak aortic valve velocity was 2.5 m/s, mean pressure gradient (MPG) 13 mmHg and AVA 1.0 cm2. Stroke volume was reduced (SVI 28 ml/m2). LF-LG aortic stenosis was suspected. Stress echocardiography using dobutamine at peak infusion of 15 mcg/kg/min showed low contractile reserve (EF 37%, SVI 33 ml/m2) with no significant changes in aortic valve parameters (MPG 29 mmHg, AVA 0.9 cm2). However, significant masurement disparity was noted and at least partly contributed to atrio-ventricular (A-V) and inter-ventricular dyssynchrony because of asynchronous VVI pacing. To overcome A-V and intraventricular dyssynchrony we decided for atrial lead reposition and upgrade to cardiac resynchronization therapy (CRT-P). After six months of CRT, normalization of EF and improvement of exercise capacity were observed. Furthermore, additional evaluation of aortic valve showed only moderate stenosis (peak velocity 2,8 m/s, MPG 18 mmHg and AVA 1.4 cm2). Stroke volume was normal (SVI 48 ml/m2). Consequently, we postponed potential surgical or interventional treatment of the aortic valve.

Conclusion
Considerable LV mechanical dyssynchrony could interfere with determining the severity of aortic stenosis. As demonstrated in the present case report, special considerations should be taken in patients with notable LV dyssynchrony and low contractile reserve as it may not be overcome with dobutamine stress echocardiography as recommended by the current guidelines.
P1309 A jellyfish in the sea
Authors: Tong J , Lee E , Joseph Francis P 
Published: January 2020

Abstract

Background
The unexpected presence of a left ventricular (LV) mass is always a cause of concern for physicians. This is especially so in the presence of a cerebrovascular accident and a recent cardiac event, where the hunt for a cardioembolic source begins. We describe a case of an unusual presentation of a LV thrombus masquerading as a cystic mass, where diagnosis was confirmed with multimodality imaging tools.

Purpose
A 58 year old Thai male first presented to the emergency department with left brachio-facial syndrome secondary to a right pre-central gyrus stroke. He had chest pain 2 days prior, and was pain free on admission. An electrocardiogram done showed an evolved anterior myocardial infarction.
Methods and Results
A transthoracic echocardiogram performed on the 4th day of admission revealed a mildly impaired left ventricular systolic function with an ejection fraction of 45%, and wall motion abnormalities in the left anterior descending artery territory. There was an apical gelatinous-like, cystic and mobile mass with soft flexible walls, measuring 2.4 X 2.1cm. Differentials at this point included cystic thrombus, hydatid cyst, capillary haemangioma and intracardiac tumour.
A cardiac MRI was performed which showed an irregular apical mass with features suggestive of fresh thrombus. The mass demonstrates hyperintensity T1-w FSE sequences (with and without fat sat), increased hyperintensity in T2-w triple IR FSE, with no increased uptake in first pass perfusion, T1-w post contrast, or early and late gadolinium enhancement images.
A repeat transthoracic echocardiogram done 11 days after anticoagulation showed a 50% reduction in the size of the mass.
See images below for more information.

Conclusion
In the era of early primary percutaneous coronary intervention and anticoagulation following an acute myocardial infarction (AMI), LV thrombus is an uncommon complication. It can occur within 2 weeks after an AMI, where increased blood stasis from dyskinesia or akinesia of associated wall segments, and a hypercoagulable state increases the risk of thrombus formation. A literature search has shown that presentation of the thrombus as a cystic mass is rare as well. As such, early diagnosis allowing for early treatment, especially when systemic embolism of thrombus is suspected, is important. Other causes of cystic LV thrombus do need to be considered in the relevant clinical context. These include infectious causes such as hydatid cyst, capillary hemangioma or intracardiac tumour, which are less likely given the history and investigation results. In this case, a trial of therapy with anticoagulation reduced the size of the cystic mass, and along with imaging findings, confirmed the diagnosis of a cystic LV thrombus.
Abstract P1309 Figure. TTE and MRI heart
P1320 Percutaneous mitral valve leaflet plication to reduce systolic anterior motion and mitral regurgitation using the transcatheter mitral clip system
Authors: Drakopoulou M , Soulaidopoulos S , Oikonomou G , Stathogiannis K , Aggeli K , Toutouzas K , Tousoulis D 
Published: January 2020

Abstract
A 72-year-old female patient with a past medical history of severe mitral regurgitation, atrial fibrillation and embolic cerebrovascular events was admitted to our institution. The patient was under optimal medical therapy and complained for progressive worsening of activity-related dyspnea with limitation of physical activity (NYHA III).
Transthoracic echocardiography showed the presence of severe mitral regurgitation with a central jet. There was prolapse of both mitral valve leaflets and interestingly the anterior leaflet presented systolic anterior motion (SAM) at the same time. There was no significant left ventricular outflow tract obstruction (LVOT). Further evaluation of the regurgitant mitral valve with a transesophageal echocardiography (TOE) confirmed the above findings and the mechanism of MV regurgitation was attributed to prolapse in addition to SAM of an elongated anterior leaflet. Laboratory test showed elevated NT-pro-BNP levels. A coronary angiography was performed and excluded significant coronary artery disease.
The findings were assessed by our institution’s HEART TEAM and, in the presence of high surgical risk (LogEuroscore 32,76%), a decision for transcatheter mitral valve repair with a Mitral Clip implantation was taken. The Mitral Clip was succesfully implanted with immediate significant reduction of the regurgitant jet and no signs of stenotic behavior of the repaired valve. There was only mild mitral valve regurgitation. Notably, after the procedure there was elimination of the SAM and no LVOT obstruction (Figure). In accordance to the echocardiography findings, the patient demonstrated a significant clinical improvement and was discharged home 1 day after the procedure. Mitral clip implantation in this case showed improvement of the MR by reducing the SAM of the mitral valve.
Abstract P1320 Figure.
P1329 An unexpected finding in a patient wth previous coronary artery bypass grafts and atypical chest pain
Authors: Karanikas S , Pavlidis A , Hamid S , Wasan B , Shakespeare C , Papamichael N 
Published: January 2020

Abstract
A 79-year-old male with a previous history of ischaemic heart disease and previous coronary artery bypass grafting (CABG) in 2005 presented with atypical chest pain. He also had past medical history of hypertension, hyperlipidaemia and bladder diverticulum which has been previously investigated by an abdominal CT. The latter had showed an incidental finding of what was reported to be a large pericardial cyst. Despite poor acoustic window, transthoracic echocardiography revealed a spherical echo–free structure in the area of the right atrioventricular groove (Figure 1, panel A white arrow). As the patient was too claustrophobic to undergo cardiac MRI, he was subsequently referred for a cardiac CT in order to further investigate the cystic mass and assess graft patency. The CT revealed an occluded left internal mammary artery (LIMA) to the LAD, severe left main (LM) and proximal LAD disease, a patent vein graft to an obtuse marginal (OM) branch and identified a largely thrombosed giant aneurysm (62x65x89 mm) of an otherwise patent vein graft to the RCA (Figure 1, panels B–E, white arrows point to the thrombosed and yellow arrows point to the non-thrombosed segments of the vein graft aneurysm). Coronary angiography confirmed occlusion of the LIMA, patency of the OM vein graft and identified only the non-thrombosed segment of the RCA vein graft aneurysm (Figure 1, panel F). The case was discussed at an MDT meeting and it was decided to proceed with LM and LAD stenting, and initially conservative management and close surveillance of the RCA vein graft aneurysm as the patient was high–risk for repeat CABG due to age, frailty and other comorbidities.
Abstract P1329 Figure 1