bluuebunny/crossref_metadata_2025_split huggingface dataset:
P219 The role of color-coded duplex sonography in evaluating coronary-subclavian steal syndrome
Authors: Antova P , Tsvetanov T S , Gelev V , Staneva M 
Published: January 2020

Abstract

Background
Coronary-subclavian steal syndrome is a rare phenomenon leading to dysfunction of left internal mammary artery (LIMA)-graft after coronary artery grafting with the occurrence of proximal stenosis of the left subclavian artery (LSA), which causes myocardial ischemia due to a blood-steal phenomenon through a fully patent LIMA-graft.

Purpose
To evaluate the role of color-coded duplex sonography (CCDS) in follow-up of all symptomatic patients with LIMA-graft after aorto-coronary bypass grafting (ACBG).

Methods
Two men and one woman with recurrence of angina pectoris symptoms and vertigo after ACBG with LIMA-LAD graft. Patients were hospitalized in cardiology for coronary graft assessment via selective coronary arteriography. Due to the discovery of fully patent grafts with a combination of varying degrees of proximal stenosis of the LSA, CCDS with a high-frequency linear probe was used to evaluate cervical arteries, LSA and the LIMA-graft flow rate applying functional probe for hyperemia (PH) of the left upper limb for hemodynamic assessment of significance of the steal syndrome.

Results
One woman at age 72 after ACBG – LIMA-LAD; RM1; RCA -s.v.g. Selective coronary arteriography showed patent bypass grafts with 70% proximal stenosis of LSA. The performed CCDS showed a LIMA-graft blood flow reduction from 36 ml/min to 12 ml/min in a sample for left upper limb hyperemia. There was a difference in the blood pressure of the upper limbs within 20 mmHg. Dobutamine stress echocardiography was performed, confirming ischemic zones in the LAD- peak segments.
A 63 year old man after ACBG x 4 with a difference in blood pressure of upper limbs within 40 mmHg. The performed CCDS showed thrombosis of the left internal carotid artery, high-grade stenosis of the right internal carotid artery, high-grade stenosis of LSA, alternating blood flow in the left vertebral artery – a sign of hemodynamically significant steal syndrome.
A 65 year old male after ACBG x 3 (LIMA-LAD, RCA, OM1 -s.v.g.). The selective coronary arteriography showed patent LIMA-graft with 50% proximal stenosis of LSA with a trans-stenotic pressure gradient of 20 mmHg. To identify the steal phenomenon we used CCDS, which showed a blood flow reduction into the LIMA-graft from 14.2 ml/min to 7.5 ml/ min - data of hemodynamically significant steal syndrome.
Patients were treated with percutaneous transluminal angioplasty and stenting of the LSA with postprocedure reduction of angina pectoris complaints, no difference in the blood pressure of upper limbs and no reduction of LIMA-graft blood flow during the probe for hyperemia of the upper limb.
Conclusion(s) Color-coded duplex sonography is an important and indispensable technique, part of the overall assessment of hemodynamics in case of coronary-subclavian steal syndrome and probably may prove to be a first method of choice in follow-up of all symptomatic patients with LIMA-LAD graft.
P229 Primary cardiac angiosarcoma of the right atrium: a rare entity presenting with an atrial arrhythmia
Authors: Garcia Bras P , Aguiar Rosa S , Ferreira L , Moura Branco L , Castelo A , Vaz Ferreira V , Branco Ferrao J , Martins F , Sousa L , Fiarresga A , Pinto E , Ferreira R C 
Published: January 2020

Abstract

Introduction
Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor.
We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia.

Clinical case
A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain.
Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute.
Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L).
A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia.
The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed:
- Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus).
- Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava.
Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression.
Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped.
The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization.
During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism.
After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month.
Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor.
Abstract P229 Figure. Echocardiogram: right atrium mass
P232 A cardiac thrombus... or maybe not
Authors: Oliveira C C , Quina C , Campos I , Rodrigues C , Medeiros P , Braga C , Costeira A , Marques J , Pinho P 
Published: January 2020

Abstract
A 61 years old female with history of rheumatic arthritis and Sjogren Syndrom resorted to the emergency room in December of 2017 for pleuritic chest pain and dyspnea. An angioCT showed a luminal filling defect at the left inferior pulmonary artery with extension to the segmentar vessels. A pulmonary embolism (PE) was diagnosed and the patient was admitted. The study performed, including transthoracic echocardiogram (TTE) was unremarkable. Patient was discharged after 15 days treated with a direct oral anticoagulant. Six months later she returned to the emergency room with the same complaints. A new angioCT showed reduction of the previous luminal filling defects, but a focal defect in the filling of the right atrium (RA) was visualized. A TTE showed a mass (17 mm) at the RA with apparent origin at the superior vena cava. A presumptive diagnostic of atrial thrombus was done and patient started therapy with vitamin K antagonist. Three months later, TTE was repeated and the mass was still present (19 mm). Five months later, the mass was still visualized at TTE (17 mm). A transesophagic echocardiogram confirmed the presence of a RA mass with 30x22 mm of major dimensions, with close relation with the interatrial septum suggestive of a tumor. A cardiac magnetic resonance revealed a RA mass without vascularization. A cardiac gated CT showed at the RA a low density nodular image of 26x22 mm at the axial plan, with an extension of 28 mm, adjacent to the posterior wall of the RA. After contrast administration, some areas did not had significant captation while some did, aspects compatible with a "pseudoenhancement" aspect. A positron tomography showed mild to moderate FDG captation at the RA. Meanwhile, patient was under anticoagulation for 2 years with no regression of the mass. For this reason, patient was oriented to cardiac surgery. The mass was resected and the histology revealed a RA myxoma.
Cardiac masses can be due to tumour, thrombus or vegetation. In this case, the mass was highly considered to be a thrombus due to the presence of multiple risk factors: prothrombotic disease and pulmonary embolism. However, the fact that the mass did not reduce with therapy raised suspicion of other diagnosis. Although rare, myxomas can be found in the RA, and should be included in the differential diagnosis of right-sided intracardiac masses. Although myxomas are histologically benign, potential for embolization and sudden death make surgical resection a priority. Its diagnosis has now increased with the use of echocardiogradiography, and has made it the main modality for the evaluation of myxomas. PE is the most dreaded and devastating complication of right-sided myxoma. In cases of RA myxomas, clinically evident PE events are uncommon. Nevertheless, there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right in approximately 3.2% of myxoma patients.
P234 Giant right atrial myxoma presenting as right heart failure
Authors: Carazo Vargas G , Fuentes Mendoza J A , Ruiz Esparza M E 
Published: January 2020

Abstract

Introduction
Myxomas are the most frequent primary cardiac neoplasms. It is currently believed that myxomas are derived from multipotent mesenchymal cells capable of both neural and epithelial differentiation Histologically, these tumors are composed of dispersed cells within a stroma of mucopolysaccharides Myxomas produce vascular endothelial growth factor, which probably contributes to the growth induction at the initial stages of tumor growth. Tumors vary widely in size, ranging from 1 to 15 cm in diameter and weighing between 15 and 180 g. About 35 percent of myxomas are friable, and they tend to present emboli. The clinical characteristics of these tumors are closely related to their location, size, and mobility; there are no specific signs and symptoms that suggest the presence of a myxoma. There are several mechanisms by which cardiac tumors can cause symptoms. The blockage of circulation through the heart or heart valves produces symptoms of heart failure. Atrial myxoma can interfere with the valves of the heart and cause regurgitation. They can also produce systemic embolisms and constitutional signs.
Clinical Case
We present a 29-year-old female patient who started with fatigue, weight loss, increased abdominal perimeter and dyspnea of one month"s effort that progressed to dyspnea at rest in the last week associated with syncope, so she decided to go to the emergency department of our institution. Upon arrival at the emergency room, the patient was found with vital signs within normal parameters, however with dyspnea at rest, jugular plethora and important lower limb edema. On auscultation, a systolic-diastolic murmur was found with an increase in the Rivero Carvallo maneuver, with reinforcement of the pulmonary component of the second noise and parasternal high-left rise. In clinical analysis, NT-proBNP 5698pg/mL, AST 34, INR 1.65 and serum lactate of 4.2 was found. A Transthoracic Echocardiogram (TTE) was performed, where a 10cm mass effusion was documented that occupied the entire right atrium and protruded into the right ventricular outflow tract. With these findings, medical treatment was started for right heart failure and it was to cardiac surgery for resection of the right atrium where it had been performed, however during the immediate postoperative state, presented biventricular failure and later asystole without achieving a return of spontaneous circulation despite resuscitation maneuvers.

Conclusion
In this case, it is an unusual presentation of a rare cardiac pathology that started with symptoms of right heart failure due to the obstruction of the right ventricular outflow tract. We consider that it is an interesting clinical case and with important educational aspects to take into consideration the differential clinical diagnoses of a patient presenting to the emergency department with right heart failure.
Abstract P234 Figure. Giant Myxoma
P236 Pinball game over
Authors: Carvalho R , Antunes C , Miragaia A , Guardado J , Morais J 
Published: January 2020

Abstract

Introduction
Transthoracic echocardiogram (TTE) is recommended for the diagnosis of acute pulmonary embolism (PTE) only in unstable patients, as it lacks specificity and sensitivity in stable ones. However, the rare documentation of intracavitary thrombus confirms the diagnosis and is associated with right ventricular dysfunction and high mortality, up to 42%.
We report a 69year-old female patient with history of hypertension and obesity, presenting at the emergency department with hypothermia (35º C), cyanosis, tiredness and breathless to minimal efforts. At examination she had no measurable blood pressure, low peripheral perfusion, tachycardia, tachypneia and no other abnormalities. Arterial blood gases on 10L/min facemask showed an uncompensated metabolic acidosis with pCO2 27mmHg, HCO3 12mmol/L, hyperlactacidemia and hypoxemia (pO2 57mmHg). Lab results had leucocytosis and neutrophilia, CRP 30mg/L, serum creatinine 2.53mg/dL, K+ 5.1mmol/L and high sensitivity troponin I 305pg/ml. Chest X-ray showed enlargement of the right chambers with a nodular image next to the right hila.
Although sepsis complicating acute pneumonia was firstly assumed and intravenous antibiotics and fluids were rapidly started; persistent hypoxemia with hypocapnia and tachycardia lead to the suspicion of acute PTE and workup proceeded in that direction. A TTE was primarily done because of the renal injury, showing a dilated right ventricle with flattening of the interventricular septum and a large, long, mobile mass in the right atria, protruding to the right ventricle, consistent with a thrombus. As the patient was no more hemodynamic unstable, prompt anticoagulation with low molecular weight heparin (LMWH) was initiated. Lately performed thoracic angio-CT with no contrast showed mild dilation of pulmonary artery and scintigraphy confirmed extensive perfusion defects of the left lung, preserving only posterobasal segment, with normal ventilation.

Additional study revealed a deep venous thrombosis of left popliteal and right gemelar veins and a heterozygosity for two polymorphisms of methyltethahdrofolate reductase enzyme
C677T and A1298C, clinically relevant in the context of patient’s hyperhomocysteinemia.
The patient recovered initially, with compression stockings and anticoagulation. A follow-up TTE showed no remaining intracavitary mass and no signs of right side overload. In the day after, the patient evolved with sudden refractory hypotension and signs of hypoperfusion with cardiorespiratory collapse and death.

Conclusion
The incidence of intracardiac thrombus in the right chambers in a patient with PTE is low (3-23%) and probably underestimated by the absence of early echocardiography in all patients. This case highlights the lability of the clinical evolution of these patients, even tough disappearance of the right atrium thrombus, which is in line with their high early mortality.
Abstract P236 Figure. Imaging study
P1593 Myocardial work in a cohort of systemic sclerosis patients
Authors: Magda S L , Popa E C , Rimbas R , Gheorghiu A M , Ciobanu A C , Vinereanu D 
Published: January 2020

Abstract

Funding Acknowledgements
Grants 83/2018 and TE49/2018

Context
Myocardial strain analysis provides important information on cardiac performance adding to standard parameters of left ventricular (LV) systolic function. Myocardial work (MW) is emerging as an alternative tool for studying LV systolic function, because it isn’t influenced by changes in afterload that could alterate strain analysis.
Systemic sclerosis (SSc) is an autoimmune disease frequently associated with myocardial fibrosis determining diastolic and subclinical systolic dysfunction.

Aim
to assess parameters of myocardial work in patients with SSc and in age and cardiovascular risk factors matched controls.

Methods
60 subjects (51 ± 9 years, 53 women) were studied: 40 patients with SSc (75% limited, 25% generalized form, mean time since onset 5 ± 4 yrs, mean time since treatment start 2.5 ± 0.5 yrs), and 20 age and cardiovascular risk factors matched controls. A comprehensive echocardiographic examination was performed using EACVI recommended protocols. Myocardial work parameters were calculated during mechanical systole and isovolumetric relaxation (IVR), by 2DSTE: global constructive work (GCW), performed during shortening in systole adding negative work during lengthening in IVR; global wasted work (GWW), performed during lengthening in systole adding work performed during shortening in IVR; global work efficiency (GWE), as the constructive work divided by the sum of constructive and wasted work and global work index (GWI), as the GCW added to GWW.

Results
2DEF, 2D longitudinal strain, GWW, GWE and GWI were similar in both groups, with values expected for sex and age. GCW was significantly lower in SSc patients (Table).

Conclusion
Patients with treated SSc have lower myocardial constructive work (GCW) compared to matched controls, probably due to subtle myocardial fibrosis, persisting under adequate treatment. Longer follow up and larger cohorts are needed in order to establish the role of MW analysis in the serial assessment of patients with SSc at risk of developing overt cardiovascular disease.
Parameter Systemic sclerosis Controls p GCW (mmHg%) 2124.2 ± 449.5 3102.8 ± 337.5 0.02 GWW (mmHg%) 81.0 ± 51.3 73.5 ± 38.9 NS GWE (mmHg%) 95.0 ± 2.8 95.9 ± 2.1 NS GWI (mmHg%) 1869.9 ± 410.9 2023.2 ± 321.7 NS EF (%) 61.3 ± 6.5 60.4 ± 8.7 NS 2DLS (%) 22.9 ± 3.4 22.4 ± 4.1 NS
1637 Percutaneous treatment of severe tricuspid regurgitation in a "bicuspid" tricuspid valve
Authors: Safi L , Pasala T , Shah A , Dudiy Y , Ruiz C 
Published: January 2020

Abstract
A 72 year old female with a past medical history of bicuspid aortic valve with severe aortic regurgitation status post placement of a 21 mm Magna Ease aortic valve replacement on 6/1/16, chronic atrial fibrillation, diabetes mellitus, and severe mitral regurgitation presented with symptoms of dyspnea upon exertion.
Transesophageal echocardiogram (TEE) showed normal left ventricular function with severe mitral regurgitation, severe tricuspid regurgitation and severe pulmonary hypertension. Upon close interrogation of the tricuspid valve, there was evidence of fusion with a raphe present between the septal and anterior leaflets ("a bicuspid" tricuspid valve).
The patient was referred for surgical evaluation where she was deemed to be at increased surgical risk and referred for percutaneous treatment for both severe mitral and severe tricuspid regurgitation. After an uncomplicated transseptal puncture, she underwent a placement of a single MitraClip XT clip to the A2/P2 portions of the mitral valve leaflets leaving mild residual mitral regurgitation by color Doppler. Attention was then taken towards the tricuspid valve where using TEE guidance, a MitraClip XT was positioned over the central aspect of the "bicuspid" tricuspid valve with the opened clip arms perpendicular leaflet coaptation. The MitraClip XT was advanced into the right ventricle and slowly retracted to grab both TV leaflets. There was mild, residual tricuspid regurgitation by color Doppler. The mean gradient across the tricuspid valve was 1 mmHg obtained at a heart rate of 52 bpm.
This case describes the first known percutaneous treatment of severe tricuspid regurgitation from a "bicuspid" tricuspid valve with a MitraClip device.
Abstract 1637 Figure.
1639 Echocardiographic photorealistic imaging of leiomyomatosis intravascularis
Authors: Budnik M , Czub P , Majstrak F , Kochanowski J , Scislo P , Opolski G 
Published: January 2020

Abstract
39-years old female patient was admitted to the Department of Cardiac Surgery because of the suspicion of additional mass in the right atrium (RA). She had no symptoms. Two weeks before she underwent surgery because of the tumours of the uterus and the bladder. Moreover, she was treated for papillary thyroid carcinoma 1 year before. D-dimer levels, NTproBNP and markers of cardiac necrosis weren’t elevated. In histopathological examination leiomyomatosis intravascularis was diagnosed.
In the transthoracic echocardiography (TTE) we confirmed the presence of additional inhomogeneous, mobile mass in the RA with morphology corresponding to thrombus. Moreover the inferior vena cava (IVC) was also involved. We decided to perform transesophageal echocardiography (TEE). Bicaval view showed that the structure enters through the IVC to the RA and protrude across the tricuspid valve throughout the cardiac cycle. In the photorealistic imaging we could exactly see huge mass that was elongated, mobile, inhomogeneous, had no adhesion with the wall of heart and vein and waved along with the heartbeat (figure 1 A,B). The surgery was performed through median sternotomy. A huge mass with about 30cm length was excised through RA oblique incision, on beating heart with cardiopulmonary bypass (figure 1C).
Abstract 1639 Figure. Leiomyomatosis intravascularis