bluuebunny/crossref_metadata_2025_split huggingface dataset:
P849 An uncommon reason for transient ischemic attack: nonbacterial thrombotic endocarditis
Authors: Babur Guler G , Kilicgedik A , Zencirkiran Agus H , Kahveci G 
Published: January 2020

Abstract

Introduction
Non-bacterial thrombotic endocarditis (NBTE) is a rare condition which is usually associated with embolic complications. The exclusion of culture positive and negative infective endocarditis and the clinician"s suspicion of NBTE are the most important steps in the diagnosis.

Purpose
Illustrative echocardiographic images of NBTE in a patient with lung adenocarcinoma.

Case Report
A 48-year-old male patient was followed up in oncology clinic for known metastatic lung adeno carcinoma. The patient was referred to cardiology after a transient ischemic attack. Transthoracic echocardiography showed significant thickening of the mitral valve tips. In contrast to the rheumatic mitral disease valve opening was well preserved, signs of calcification and doming of anterior leaflet were absent. Transesophageal echocardiography was performed. Hypoechogenous thickening was observed at the mitral valve tips, measuring 1.39x1.33 cm in diameter. On the atrial side of the P2 scalllop, a mass with a diameter of 3.47 cm was seen. Central mitral regurgitation was observed. Aortic valve was structurally and functionally normal. The patient had no fever, serology and blood cultures were negative. Cranial magnetic resonans imaging showed multiple ischemic foci in the brain. The patient was considered NBTE in the light of these findings. Anticoagulation with warfarin was recommended. After 1 months patient deceased because of cancer.
Conclusion(s): NBTE is a condition that should be included in the differentials when the valve pathology is seen in patients with associated diseases (systemic lupus erythematosus, malignancy, disseminated intravascular coagulation, non-bacterial sepsis). Sterile vegetations seen at the contact surfaces of the mitral and aortic valves are typical lesions. They tend to involve the atrial side of the mitral and ventricular side for the aortic valve. Clinical suspicion is critical in the diagnosis of NBTE. The detection of vegetations on echocardiography without signs of infection and in patients with predisposing conditions leads to diagnosis.
Abstract P849 Figure.
P851 Carney"s complex: a rare cause of Atrial myxoma
Authors: Kasouridis I , Sargent R , Ghani S 
Published: January 2020

Abstract

Funding Acknowledgements
Nil
We present the case of a 53 year old lady who presented to the cardiology services with palpitations. She denied any symptoms of syncope or chest pain but described frequent short episodes of palpitations. Her background medical history at this point included a pituitary macroadenoma with panhypopituitarism requiring transphenoidal hypophysectomy, a follicular adenoma with left thyroid lobectomy and peripheral neuropathy. An echocardiogram was arranged and this showed a large left atrial mobile myxoma with good LV function and no other structural abnormalities. Her ECG showed sinus rhythm with no ischaemic changes and normal electrical intervals. She was admitted and transferred to a tertiary centre where the myxoma was successfuly excised. Her palpitations settled post procedure and holter monitoring didn"t pick up any malignant dysrrhythmias. She was referred to a genetics centre for investigation for Carneys complex which can predispose patient to endocrine and nonendrocrine tumours including pituitary, thyroid and as in our case a cardiac myxoma. This was confirmed on genetic testing and as her mother was found to also have a cardiac myxoma it raised the suspicion of an inherited mutation. Follow-up echo at 2 years post-op showed no recurrence of atria myxoma and patient was stable from a cardiovascular perspective.
P862 A conservative strategy for a frequently fatal post-myocardial infarction mechanical complication
Authors: Ferreira J , Freitas A , Loureiro J , Beringuilho M , Faria D , Roque D , Morais C 
Published: January 2020

Abstract

A 88-year-old female was admitted for an anterior ST-segment elevation myocardial infarction (STEMI). Patient had a history of intermittent chest pain for 2 days with worsening on the day of admission. Electrocardiogram (ECG) at admission showed ST-segment elevation on leads from V2 to V6 and leads DI and aVL. Initial observation on the emergency department was described as unremarkable apart from the chest pain. Aspirin and Ticagrelor loading doses were administered and patient underwent emergent coronary angiography, which showed left anterior descendent artery occlusion after the emergence of second diagonal branch. Coronary angioplasty of this lesion was tried, with a total of 3 drug-eluted stents implantation but with no success as in the end there was no reflow of the artery.
Patient was then admitted on cardiac intensive care unit, and on observation at that time there was a remarking holosystolic murmur. Transthoracic echocardiogram showed (apart from left ventricle systolic disfunction with akinesia of the apical segments as well as middle segments of the interventricular septum (IVS) and anterior wall) an apical IVS defect with a left to right shunt with a gradient of around 50mmHg evaluated by Doppler, and no signs of right ventricle overload. Case was promptly discussed with cardiothoracic surgery and it was decided that she was not a candidate to urgent surgical intervention. Patient had an initial evolution in Killip class II, and remained hemodynamically stable for the rest of the admission, having no signs of heart failure on discharge at 17 days later. Serial ETTs during admission and at discharge were similar to the evaluation performed at admission.
In the meanwhile, during admission, case was discussed in multidisciplinary heart team with cardiothoracic surgery and interventional cardiology. Given the favourable evolution and comorbidities and frailty of the patient it was decided to adopt a conservative strategy with medical follow-up, only considering intervention if there was worsening of heart failure. Until now, with 4 months follow-up, patient remains in New York Heart Association (NYHA) functional class I.

Discussion
Post-myocardial infarction ventricular septal defect (VSD) is a complication that, regardless of the treatment strategy has a high mortality rate, especially when patient presents in cardiogenic shock. However, when patient is stable and especially when comorbidities imposes a high interventional risk medical treatment can be an option. So far, this is a successful case of a medically managed post-myocardial infarction VSD.
Abstract P862 Figure. Ventricular Septal Defect
P865 Ecstasy s use an unusual cause of dilated cardiomyopathy a case report
Authors: Mouadili M , Elqadi M , Goulehcen A , Echarai N , Elhattaoui M 
Published: January 2020

Abstract
Background
3,4-methylenedioxymethamphetamine is a stimulant used illegally around the world, including Morocco. Cardiomyopathy and heart failure may occur following chronic MDMA use and may cause many other acute cardiac complications.
Case report
A 30-year-old man, with a history of MDMA use, 2 tablets/week since 2 months, and 6 tablets the week before admission, presentedwith severe dyspnea at rest. The first evaluation shows a sinus tachycardia with tachypnea and signs of global heart failure, loud systolic murmur heard over the apex andcrackles at the base of the lungs were observed.
The blood tests performed, including erythrocyte sedimentation rate, blood picture, liver function and kidney function tests, protein, iron, phosphocalcic balance, glucose, and thyroid hormones,were within normal range. Moreover, immunological assays [immunoglobulin M (IgM) and immunoglobulin G (IgG) anti-Epstein–Barr virus] and toxoplasmosis were negative. Cytomegalovirus IgM was also absent, and IgG titer value was also absent.
Electrocardiogram (ECG) tracing showed a complete left bundle branch block (LBBB)with a regular sinus rhythm (100 bpm). Transthoracic echocardiography showed dilated cardiomyopathy with severe systolic dysfunction (12% by Simpson’s method) (Fig. 1).
Additional evaluation in the hospital excluded other etiologies of the cardiomyopathy. Thus, his condition was referred to the MDMA use.
The patient now is a heart transplant candidate.

Conclusion
There are several reports that show an increase in frequency of MDMA use, suggesting that cardiomyopathy and acute heart failure secondary to the Ecstasy use may be a new medical concern. Thus, proper history of illicit drug intake is crucial in the diagnosis of unexplained cardiomyopathies.
P868 Dissecting myocardium
Authors: Laymouna R , Samoka A , Haggag A , Almaghraby A , Hassan Y , El-Sharkawy E , Zaki A 
Published: January 2020

Abstract

Introduction
Incomplete rupture is a relatively uncommon type of free-wall rupture. It is found in 10% to 15% of total free-wall ruptures.

Case report
A 68-year-old male patient, heavy smoker, with medical history of diabetes mellitus and hypertension, had experienced an attack of acute retrosternal chest pain associated with dyspnea grade II-III one week before presentation.
He presented to our facility complaining acute chest pain. Upon examination, the patient had stable vital signs and an unremarkable clinical examination except for distant heart sounds on auscultation. Electrocardiogram showed deep Q waves in V1 to V4 with residual ST segment elevation. Routine lab investigations were unremarkable including a negative troponin.
A Chest X-ray showed an enlarged cardiac shadow. Echocardiography revealed a poor left ventricular systolic function due to an akinetic anterior wall and a dyskinetic apical cap containing a large highly mobile thread like mass which was suspected to be a thrombus.
Coronary angiography revealed proximal 85% stenosis followed by mid segment total occlusion of the Left anterior descending (LAD) artery, proximal 75% stenosis of the left circumflex (LCX) artery and a tight lesion in the mid segment of the right coronary artery (RCA).
The patient was diagnosed to have multi-vessel coronary artery disease and was maintained on medical treatment. Cardiac MRI was requested to detect myocardial viability before revascularization.
Subsequently, cardiac magnetic resonance (CMR) revealed a dilated left ventricle with very poor systolic function, akinetic inferior wall, aneurysmally dilated apex and anterior wall with the same large highly mobile mass. Late gadolinium enhancement revealed scarred anterior, septal and inferior walls including all apical segments and surprisingly the mobile intra-ventricular mass also contained a scar tissue continuous with the anterior myocardial scar which means it is a part of the myocardium which was dissected or partially ruptured.
Unfortunately, the patient suddenly experienced an attack of ventricular arrhythmia which was not resuscitated successfully.

Conclusion
Incomplete rupture is a rare type of free-wall rupture. It is thought that the infarcted myocardium wall is made weak in part by activation of metalloproteinases, which degrade the myocardial matrix. Structural weakness is associated with increased intra-cavitary pressure which predisposes the myocardial wall to rupture.
Although Echocardiography is a good method of diagnosis but CMR is superior due to its high spatial resolution and good tissue characterization, plus the use of late gadolinium enhancement helps in identifying the location and the extent of prior infarctions guiding us to the next step in management.
Abstract P868 Figure. Myocardial dissection with scarred flap
P885 Pulmonary artery stent implantation in an adult with chronic thromboembolic pulmonary stenosis
Authors: Khalifa E A , Helmy S , Elallus F , Mohamed S F , Alkuwari M 
Published: January 2020

Abstract

Introduction
Pulmonary artery stenosis presenting in adults is rare. Chronic thromboembolic pulmonary hypertension (CTEPH) is by far the most common cause of pulmonary artery stenosis. Stenosis in these patients are not caused by an abnormality of the arterial wall itself, but by intraluminal narrowing as a result of the only partially resolved and organized thromboembolism. In contrast to paediatric patients, in adults with pulmonary artery stenosis, pulmonary stenting is not routinely performed.

Case report
A 51-year male, smoker, diabetic, hypertensive, and with chronic kidney disease. He was diagnosed two years earlier with bilateral multiple pulmonary emboli and was maintained on oral anticoagulation therapy. Recently, he presented with gradually progressive shortness of breath and signs of right ventricular failure.
Diagnostic imaging: 1-Transthoracic and transesophageal echocardiography showed normal global systolic left ventricular function with no regional wall motion abnormalities, dilated right ventricle (RV) with moderately impaired function, severe pulmonic valve incompetence, mild tricuspid incompetence and a severely elevated right ventricular systolic pressure (RVSP) of 82 mmHg. In addition, a small rounded mass (6 x 11 mm) was visualized attached to the posterior wall of the RV outflow tract (RVOT) about 15mm proximal to the pulmonary valve annulus, (figure A). 2- Computed tomography pulmonary angiography showed a right main pulmonary artery (RPA) with circumferential narrowing, which was highly suggestive of chronic thrombosis. There was an abrupt tapering noted in the segmental branches of the right lower lobar pulmonary artery, with non-opacification of the distal arteries. No contrast opacification was noted in the right upper lobe pulmonary arteries. The left main pulmonary artery showed thickening of its bifurcation, again suggestive of chronic thrombosis, with narrowing of its left upper lobar branch, (figures B&C). 3-Cardiac magnetic resonance (CMR) showed a non enhancing RVOT mass protruding through the incompetent pulmonary valve during systole with features suggestive of a thrombus.

Management
In view of the clinical history, CTEPH was considered to be the most likely aetiology of the pulmonary hypertension. The decision was to perform balloon angioplasty and stent implantation in the RPA. Immediately after the procedure, RVSP was reduced from 80 to 50 mmHg. The clinical course after this procedure was uncomplicated and the patient showed significant clinical improvement.
Follow up CMR showed patent stent with improvement of RV function ( fig D)
Abstract P885 Figure.
P887 Two sides of the same mass
Authors: Saraiva M , Moura A , Craveiro N , Vieira M J , Abecassis J , Pitta M L , Martins V 
Published: January 2020

Abstract
Echocardiography (echo) remains the first-line imaging modality for the evaluation of cardiac masses. Three-dimensional (3D) echo, either transthoracic or transesophageal (TTE and TEE respectively), has allowed for better definition imaging, providing more information about the size, mobility, attachment and relation of these lesions with cardiac structures. Nevertheless, due to its superior tissue characterization capability, other imaging techniques, such as cardiac magnetic resonance (CMR), are very helpful in the differential diagnosis, making multimodality imaging the most attractive option for the study of intracardiac masses.
We present the case of a 85 year-old male, with paroxysmal atrial fibrillation (under effective anticoagulation), type 2 diabetes mellitus, hypertension, referred for the study of an asymptomatic cardiac mass found in a routine TTE. There were no relevant findings on physical examination. The TTE showed a bilobar spheroid mass, in the right atrium, attached to the interatrial septum, with 33x23mm and regular edges. A 3D TEE was performed confirming the previous findings, but also showing extension of this mass through the fossa ovalis membrane, reaching the left atrium; this aspect raised the doubt about either protrusion or invasion of the left atrium and, respectively, a benign (like a myxoma) versus malignant behaviour (such as a sarcoma). To better characterize this lesion, a CMR was ordered, which revealed a bilobar heterogeneous mass, attached to the right side of the interatrial septum, at the fossa ovalis membrane, without signs of adjacent tissue invasion, namely unequivocal invasion of the left atrium; it presented with intermediate T1 signal, hyperintense T2 signal and heterogeneous pattern of gadolinium enhancement, features mostly in favour of a right atrial myxoma. The complimentary study found no other relevant changes, namely no findings suggestive of endocarditis (negative blood cultures), autoimmune disease or malignancy. The patient refused undergoing heart surgery and, therefore, kept follow-up with clinical and echocardiographic stability.
Although histological examination remains the only tool for definitive diagnosis, multimodality imaging allows a quite comprehensive evaluation of intracardiac masses, enlightening the differential diagnosis. Here the imaging findings helped to establish a benign origin as the most likely, very important in this case of a probable right atrial myxoma, due to its peculiar protrusion to the left atrium through the fossa ovalis membrane.
Abstract P887 Figure. atrial myxoma
P889 3D guided CT assessment to define the right pulmonary vein on standard apical 4-chamber view
Authors: Chan J , Mehta O H , Mottram P , Tay I M , Teng J 
Published: January 2020

Abstract

Introduction
Pulmonary vein(PV) assessment is an integral component of the transthoracic echocardiogram(TTE) examination; typically assessed in the apical four-chamber view(A4Ch). There is disagreement in current textbooks and literature regarding which specific right pulmonary vein is visualised on A4Ch; as either the right superior(RSPV) or right inferior PV(RIPV).
Given the high reliability of cardiac CT for PV assessment, we aimed to characterize right PV anatomy on A4Ch by utilizing multi-modality comparison of echocardiography and a 3D-guided A4Ch on CT.
Methods
Retrospective analysis was performed on consecutive patients with TTE demonstrating PV flow(by colour or pulse-wave Doppler) and cardiac CT within 30days; studies not meeting image quality criteria excluded. To simulate the A4Ch on CT, multi-planar reconstruction was used to create an image plane including right PV ostia and LV apex. This image was rotated along the long-axis to achieve an A4Ch with both ventricles and atria, tricuspid and mitral valves in view without LVOT or aorta. This was attempted for right superior, inferior and middle(RMPV, if present) PV’s.

Results
50 patients were analysed: mean age 66yrs, 48% female, mean LA volume(indexed) 43.5ml/m². A4Ch was feasible in 100%(n = 50) of CT simulations using the RIPV, only 24%(n = 12) were feasible using RSPV with all excluded cases due to LVOT/aorta persistently in view. RMPV was present in 6 cases with feasible A4ch in 67%.

Conclusion
This study demonstrates that the right PV on A4Ch is highly likely to be the RIPV due to the RSPV being anatomically impossible in the significant majority of cases.
Abstract P889 Figure. CT multiplanar reconstruction of A4Ch
P892 Accuracy of right atrial pressure estimation using a multi-parameter approach derived from Inferior vena cava semi-automated edge-tracking echocardiography
Authors: Albani S , Pinamonti B , De Scordilli M , Fabris E , Perkan A , Geri P , Gregori C , Barbati G , Sinagra G , Mesin L 
Published: January 2020

Abstract

Background
In clinical practice, as stated in the ASE guidelines, the echocardiographic estimation of right atrial pressure (RAP) is based on the size of the inferior vena cava (IVC) and its inspiratory collapse. However, this method has proven to have limits of reliability and reproducibility. The use of a recently developed software that with a semi-automatic technique highlight the edges of the IVC could help to standardize the echocardiographic assessment of RAP.
Aim of the study: The aim of the study was to assess feasibility and accuracy of a new semi-automated approach to estimate the RAP.
Standard acquired echocardiographic images were processed with a semi-automatic technique, indexes related to the collapsibility of the vessel during inspiration (Caval Index, CI), during the whole respiratory cycle (Respiratory Caval Index, RCI) and through the heart cycle transmitted movements’ (Cardiac Caval Index (CCI) were derived (figure 1).
Using these indexes, we developed two models:
a) the Binary Tree Model (BTM), further divided in BTM3 and BTM5 (RAP estimated in 3 and 5 classes, respectively);
b) the Regression Model (RM), further divided in RM linear (continuous model) and RM3 and RM5 (RAP estimated in 3 and 5 classes respectively).
RAP assessed using these innovative techniques were compared with two standard estimation (SE) echocardiographic methods A and B.
Direct RAP measurements obtained during a right heart catheterization (RHC), performed within 6 hours, were used as reference.

Results
62 consecutive ‘all-comers’ patients that had a RHC were enrolled; 13 patients were excluded for technical reasons. Therefore 49 patients were included in this study (26 males and 23 females; mean age of 62.2 ± 15.2 years, 75.5% pulmonary hypertension, 34.7% severe left ventricular dysfunction and 51% right ventricular dysfunction). The two SE methods showed poor accuracy for RAP estimation (method A: ME = 51%, R2= 0.22; method B: ME = 69%, R2= 0.26). Instead, the new semi-automatic methods BTM3 and BTM5 based on parameters derived from IVC edge tracking (mean IVC diameter, CI, CCI and RCI) had a misclassification error of only 14% (R2 = 0.47) and 22% (R2 = 0.61), respectively, to classify RAP. The accuracy was lower for RM than BTM (RM3: ME = 61%, R2 = 0.39; RM5: ME = 55%, R2 = 0.39). However, the RM showed the lowest mean bias in estimating RAP: 0.23 [-8.34; 8.81] mmHg.

Conclusions
A multi-parametric approach using the new indexes, such as CCI and RCI, derived from a semi-automated edge tracking of the IVC is a promising tool for a more accurate estimation of RAP. This study proposes an innovative method for the non-invasive estimation of the RAP, which requires confirmation on larger population.
Abstract P892 Figure 1