bluuebunny/crossref_metadata_2025_split huggingface dataset:
473 Chloroma: an unusual case with extensive cardiac involvement detected by echocardiography
Authors: Oliveira Da Silva C , Eliasson S , Sequeira C , Bernardes A , Gunyeli E , Manouras A 
Published: January 2020

Abstract

Introduction
Chloroma, also known as myeloid sarcoma, is a localized extramedullary tumour composed of malignant cells of the myeloid cell line, most frequently occurring in myelogenous leukemia. Heart involvement is exceptional, only about 20 cases have been reported in the literature.

Case presentation
A 38-year-old woman presenting with fatigue and pre-syncope was admitted to the hospital. The patient had a history of acute myeloid leukaemia diagnosed 2017, treated with chemotherapy and transplanted with allogenic bone-marrow the same year, remaining thereafter in clinical remission. Initial electrocardiogram showed sinus bradycardia and recurrent sinus arrests and therefore a pacemaker was implanted. An echocardiogram was performed which revealed multiple infiltrative masses with involvement of the superior vena cava extending to the right atrium, atrial septum, left atrium, mitral valve and aortic root. Magnetic resonance imaging was done confirming the echocardiographic results and showing even involvement of pulmonary veins, coronary arteries and myocardial infiltration. Chemoradiation was administered with initial response, however, disease progression led to the patients´death.

Conclusion
To our knowledge, this is the first case describing a chloroma with extensive involvement of cardiac walls, vessels and valves. This case also illustrates the value of echocardiography as a tool for early detection of cardiac masses.
Abstract 473 Figure. Echo with contrast
475 A rare cause of right ventricular mass
Authors: Briosa A , Almeida A R , Gomes A C , Pereira A R , Marques A , Alegria S , Sebaiti D , Santos J , Carrington M , Miranda R , Joao I , Sousa S , Pereira H 
Published: January 2020

Abstract

Introduction
Intracardiac masses are always a challenging diagnosis, especially when it involves the right side of the heart. There are multiples etiologies that can be responsible for these masses, namely thrombosis, neoplasm or vegetations. Occasionally, these may be related to an autoimmune process not yet discovered.

Case Report
17-year-old male, with a previous history of genital ulcers, medicated with penicillin with complete resolution of symptoms.
In January 2019, he started an history of recurrent fever, associated with right anterior thoracalgia, weight loss and oral afthosis. He went to the emergency department several times, where he was medicated with antibiotic, with partial symptom relief.
Three months later, he returned to medical attention due to an episode of abundant hemoptysis, followed by hematemesis and cough. At hospital admission, he was hemodynamically stable, tachycardic (100/min) and with occasional episodes of cough. Cardiac and pulmonary auscultation were unremarkable. Thoracic CT revealed the presence of pulmonary thromboembolism (PTE) and a large mass in the right ventricle (RV). It was performed an echocardiogram (echo) that confirmed the presence of a large mass in the RV (50x53mm) from which a projecting hypermobile mass appeared to prolapse into the right atrium.
Taking into account the diagnosis of PTE and the presence of a right ventricular mass, the patient was hospitalized and started anticoagulation. The case was immediately discussed with cardiac surgery, that confirmed that there was no surgical indication. During hospitalization, there were no more episodes of hemoptysis or hematemesis.Consecutive echos were performed, that did not reveal a significant decrease in mass dimensions despite anticoagulation. Viral serologies and autoimmunity panel were all negative. Cardiac RMI was performed raising the suspicion of a possible mass covered with thrombus.
After discussion with rheumatology, and according to clinical signs, the hypothesis of vasculitis was placed, and the patient started treatment with steroids. This treatment had to be suspended after a few days due to an infectious intercurrence. After a course of antibiotic therapy, the patient started therapy with cyclophosphamide with good clinical and echocardiographic response (reduced mass dimensions).
It was admitted Behçet’s disease with cardiac complications, and the patient was referred to the rheumatology consultation.

Conclusion
Behçet’s disease is a multi-system, chronic disorder that behaves like vasculitis.There are some typical clinical manifestations associated with this disease, such as oral and genital afthosis, uveitis, arthritis, skin lesions and nervous system involvement.Presentations with cardiac symptoms are one of the extremely rare manifestations of this disease, posing a challenge for the treating physician.
Abstract 475 Figure. Right ventricular mass
476 An unusual location and size of a papillary fibroelastoma
Authors: Valentim Goncalves A A , Sousa M J , Matos P , Pinto E , Banazol N , Branco L , Cruz Ferreira R 
Published: January 2020

Abstract

Background
The incidence of primary cardiac tumours is low. Although histologically benign, left-sided, larger sized (≥ 1 cm) and highly mobile tumors have a higher risk of embolization.
Papillary fibroelastomas frequently occur on the aortic or mitral valves, with only 10% arising from nonvalvular surfaces. Since they are small and usually attached to moving valves, CT and MRI technique modalities have more difficulty in detecting them, with echocardiography remaining the most common exam for the diagnosis.
Clinical case description:
A 69-year-old woman, with known history of breast cancer treated with chest radiation ten years ago. She was completely asymptomatic, but in a routine echocardiography a left ventricular heterogeneous round mass with 22x25mm with a likely pedunculated attachment in the apical region was diagnosed. The remaining exam was remarkably normal, namely with normal left ventricular size and function with no wall motion abnormalities.
Because the wall motion appeared normal, the mass was interpreted as a tumour. However, a thrombus could not be excluded. After four weeks of therapy with Warfarin and aspirin, a MRI was performed. The apical mass had similar dimensions (22x23mm) and the exam was inconclusive (myxoma? fibroma? thrombus?) despite no signs of left ventricular fibrosis with late gadolinium enhancement.
Since the risk of embolization was high and there was no reduction in size with anticoagulation therapy, surgery was performed. Using a transaortic valve route, a 28x30mm mass with a pedunculated attachment in the apical region was removed. The mass had a macroscopic appearance of a sea anemone with gelatinous material. Histological examination made the final diagnosis of a papillary fibroelastoma.

Conclusion
Large, left-sided mobile tumors should be excised to prevent sudden death and embolization. Here we present the case of a papillary fibroelastoma with a rare localization and an unusual size. Some clinical cases have raised the question for a relation between previous chest radiotherapy and the occurrence of papillary fibroelastomas.
Abstract 476 Figure.
481 Mass compromising left atrium
Authors: Rodrigo Carbonero D , Estandia U , Perez P M , Perez C , Voces R , Cortes A , Panera E 
Published: January 2020

Abstract

A 47-year-old woman presented to the ER with a sudden-onset left side chest pain of less than one hour in duration that started at rest. The pain was severe and radiated to the left shoulder. This was accompanied with symptoms of shortness of breath and sweating but no similar episodes in the past. There was no significant history of coronary artery disease or any other illness in the family. She had dyslipidemia and a smoking habit of 1 pack/day for the previous 10years.
In the ERt, she was hemodynamically stable and her physical examination was within normal limits. ECG showed ST-segment elevation in the inferior leads. No prior ECG was available for comparison. She underwent emergent PCI which showed spontaneous proximal segment circumflex (dominant) artery dissection with TIMI angiographic flow grade 0. All other coronaries were patent with TIMI III flow and no atherosclerotic changes. PCI was carried out, but unfortunately, it was complicated with coronary rupture having to implant a drug eluting stent in order to seal the vessel rupture, with optimal final result (TIMI 3).
An urgent TTE was performed for evaluation of the patient due to persistence of chest pain after coronariography, revealing an echogenic mass at the left atrium suggesting extracardiac hematoma vs. left atrium dissection. TC scan confirmed space compromise of the left atrium by a mass, without being able to rule out active bleeding. The patient was transferred to our center for emergent CABG surgery.
Upon arrival, the patient had persistent chest pain, sinus tachycardia, and hypertension. Intraoperative TOE findings consisted of a mass compromising left atrium and minimal pericardium effusion. Comprehensive study identified a mobile intimal flap of the atrial wall that was creating a false chamber.
Intraoperative surgery findings were compatible with a huge left atrial desiccant hematoma . Two orifices were performed on the epicardium of the inferior and lateral border of the left atrium, in order to drain the retained blood and lavage. No active bleeding was evidenced.
TTE control evidenced disappearance of the left atrium mass a The patient had a satisfactory evolution and discharged without complications.
Even though left atrial desiccant hematoma is a rare STEMI complication , in this patient, we concluded the etiology was iatrogenic due to the performance of PCI.

Conclusion
Left atrial dissection is an uncommon entity. It is generally associated with mitral valve replacement, but other predisposing factors should be considered in pathogenesis. Its diagnosis requires a high index of suspicion.
Predisposing factors and catheterization, surgical or pathologic findings should be reviewed in order to identify the pathogenic mechanism . Dissection of the coronary sinus secondary to retrograde cardioplegia, endocarditis, cardiac rupture after myocardial infarction, blunt chest trauma and iatrogenic PCI are related to its development.
Abstract 481 Figure. MASS COMPROMISIN LEFT ATRIUM
507 Heat failure in restrictive ventricular septal defect
Authors: Lam L T , Tam C M , Fan K Y Y 
Published: January 2020

Abstract

Introduction
Patients with small restrictive ventricular septal defect are usually asymptomatic. This case report presented a case of shortness of breath in a patient with known restrictive ventricular septal defect.

Case report
A 51 years old woman was diagnosed to have a small supra-cristal ventricular septal defect in early twenties. She enjoyed good functional state since the diagnosis. Routine echocardiogram assessment one year ago found normal left ventricular size and systolic function. However, she presented with exertional shortness of breath and severe bilateral lower limbs edema for two weeks. Transthoracic echocardiogram found both left and right ventricles were dilated. Left ventricular ejection fraction was 50%. The right ventricular systolic pressure(RVSP) was 70mmHg from tricuspid regurgitation peak velocity estimation. It was significantly raised compared with the RVSP 35mmHg measured last year. This caused right ventricular pressure overload with systolic flattening of interventricular septum. On color doppler examination, apart from the known ventricular septal defect flow, there was an abnormal turbulent flow at the right ventricular outflow tract. The two jets was close to each other and the nature of the abnormal jet could not be clearly identified. During trans-esophageal echocardiogram, in order to differentiate the two different jets, the baseline of the color doppler was shifted towards the directions of the jets to look for the proximal isovelocity surface area (PISA). Finally there were two PISA could be clearly seen. One was the PISA of the ventricular septal defect while the other one was due to ruptured right coronary sinus with shunting from aorta to right ventricular outflow tract. The findings was supported by continuous wave doppler examination. The ventricular septal defect flow was predominantly systolic whereas the aorto-right ventricular shunting was a continuous flow. Moreover, three dimension echocardiogram also showed the two closely related holes. Finally the patient underwent percutaneous closure of the ruptured sinus of valsalva. And the patient recovered well afterwards.

Discussion
Small ventricular septal defect with restrictive physiology usually will not lead to heart failure. When patient presented with heart failure while having a small ventricular septal defect, other pathology should be carefully looked for. Ruptured sinus of valsalva was known to associate with ventricular septal defect. However, the jet of ruptured sinus of valsalva may be missed in view of the close proximity with the ventricular septal defect jet as in this case. Methods to better delineate the different jets including demonstration of double PSIA, continuous flow on continuous wave doppler and three dimension echocardiogram. Nowadays, ruptured sinus of valsalva could also be closed percutaneously with success.
Abstract 507 Figure.
539 Optimized multiparametric analysis of cardiac dyssynchrony: machine learning and prediction of response to cardiac resynchronization therapy based of the apical 4-chamber view
Authors: Gallard A , Donal E , Le Rolle V , Hubert A , Bidaut A , Leclercq C , Galli E , Hernandez A 
Published: January 2020

Abstract

Aims. We hypothesized that a multiparametric evaluation, based on the combination of electrocardiographic and echocardiographic parameters, could enhance the appraisal of the likelihood of reverse remodeling and prognosis of favorable clinical evolution after cardiac resynchronization therapy (CRT). Also, we sought to test the respective value of automatically extracted parameters from left ventricular (LV) strain curves recorded in apical 4-chamber view as compared to the other echocardiographic views.
Methods and results;
This is a machine learning study based on a dataset of 161 patients who were treated by CRT according to current ESC-guidelines. The longitudinal strain curves of the 6 LV-segments of the left ventricle were plot for the three different apical views. Several features as times or integrals were extracted as previously published. These features were classified by importance using the out-of-bag method(fig1). Half of the most important features come from the 4-chamber view and a third from the 2-chamber view. The correlation between the most important features was studied to determine the relationship between them. Almost all the features from the 2-chamber and apical long-axis views are correlated with others and generally with one acquired from the 4-chamber view.

Conclusion
The high number of important features indicate the relevance of the 4-chamber as unique view for applying machine learning approaches on strain curves. Optimizing selection of patients for CRT should be possible just on the dataset coming from one apical 4-chamber view.
Abstract 539 Figure. fig1
564 Cardiac magnetic resonance myocardial feature tracking for optimized risk assessment after acute myocardial infarction in patients with type 2 diabetes
Authors: Kowallick J T , Backhaus S J , Stiermaier T , Lange T , Navarra J L , Koschalka A , Rommel K P , Lotz J , Gutberlet M , Kutty S , Hasenfus G , Thiele H , Eitel I , Schuster A 
Published: January 2020

Abstract

Objective
Type 2 diabetes mellitus (T2DM) associates with worse cardiovascular outcome following acute myocardial infarction (AMI) as compared to non-diabetic patients. Since the mechanisms behind these observations are not fully understood we aimed to quantify the underlying pathophysiology on ventricular and atrial levels and study their prognostic implications using cardiovascular magnetic resonance (CMR) quantitative feature-tracking (FT) and tissue characterization.
Research Design and Methods:
A total of 1147 consecutive patients with AMI (n = 265 with diabetes; n = 882 without diabetes) undergoing cardiac magnetic resonance (CMR) imaging in median 3 days after AMI were included in this multicenter study. Left ventricular (LV) function and volumetry included LV ejection fraction (LV-EF), global longitudinal (GLS), radial (GRS) and circumferential strain (GCS) as well as left atrial (LA) strain and strain rate parameters of LA reservoir, conduit and booster pump function. LV damage assessment included infarct size (IS), edema and microvascular obstruction (MO). The clinical study endpoint was the rate of major adverse cardiovascular events (MACE) at 12 months.

Results
T2DM patients had impaired LA reservoir (19.8 vs. 21.2%, p &lt; 0.01) and conduit strains 7.6 vs. 9.0%, p &lt; 0.01) but no differences in ventricular function or myocardial damage. They were at higher risk of MACE than non-diabetic patients (10.2% vs. 5.8%, p &lt; 0.01) with the majority of MACE occurring in patients with LVEF ≥ 35%. Whilst LVEF was an independent predictor of adverse events in non-diabetic patients (p = 0.04 on multivariable analysis), LV GLS as well as LA strain emerged as independent predictors of poor prognosis in patients with diabetes (p &lt; 0.02 on multivariable analysis). Considering patients with diabetes and LVEF ≥35% (n = 237), GLS and LA reservoir strain below median were significantly associated with higher 12-month event rates.

Conclusions
In patients with diabetes, LA and LV longitudinal strain permit optimized risk assessment early after reperfused AMI with incremental prognostic value over and above LVEF.
P629 An uncommon cause for a frequent problem
Authors: Miranda H , Santos H , Almeida I , Santos M , Sousa C , Almeida S , Santos L , Tavares J 
Published: January 2020

Abstract

Introduction
Libman-Sacks endocarditis is the most characteristic cardiac manifestation of the autoimmune disease systemic lupus erythematosus. Embolic phenomena, although uncommon, can also complicate valvular abnormalities and can cause neurologic and systemic complications.

Case Report
Man, 52 years old. Active smoker and with previous peptic ulcer history. Admitted to our emergency department due to sudden onset of confusion and incoherent speech. The physical examination showed only a Glasgow Coma Scale of 9 and the presence of expressive aphasia. Normal pulmonary and cardiac auscultation, without any other pathological findings on physical examination.
Investigations showed a normal EKG, chest X-Ray and arterial-blood gas test. Blood test showed only the presence of thrombocytopenia, leucocytosis and renal disfunction. Brain CT revealed left-sided thalamic lacunar lesion. We assumed an ischemic stroke and admitted the patient in our emergency department. Neurological deterioration in the first 24h. A new brain CT was performed and showed multiple lesions in the middle cerebral artery territory. The echocardiogram was performed and showed the presence of multiples vegetations in both mitral leaflets with moderate to severe mitral regurgitation associated. We assume an ischemic stroke in the context of possible infective endocarditis. Medical therapy was optimized and empirical antimicrobial therapy was started (ampicillin + gentamicin + flucoxacillin).
The patient never had fever during hospital stay. Duke criteria with only 1 major criteria. Persistent negative microbiological cultures with decreasing inflammatory parameters. Blood tests revealed a progressive increase level of INR (2-4) and renal function deterioration. Patient began with massive episodes of diarrhea and sudden decrease of haemoglobin level (sudden reduction of 3g/dl). Endoscopic studies were performed and multiple ischemic lesions of embolic etiology and small vessel disease had been described. Serology test revealed a positive IgG for Mycoplasma pneumoniae. Autoimmune lab tests showed positivity for lupus anticoagulant, anticardiolipin and anti–beta-2 glycoprotein I.
We discussed the clinical case with our autoimmune experts team and the diagnosis of Systemic Lupus Erythematosus + Antiphospholipid Syndrome + Libman-Sacks Endocarditis was assumed. The patient started immunosuppressive therapy (Azathioprine + Mycophenolate Mofetil + Prednisolone).
Despite the used therapy the size of vegetation persisted and mitral regurgitation didn’t improve.
In this context, the patient was presented to our cardiac surgery team and underwent surgical intervention (vegetation removal + mitral valve repair). Evaluation one year after surgery revealed progressive functional and echocardiographic improvement.
Conclusion
The authors presented a didactic clinical case where valvular surgery was required thanks to a hemodynamically significant valvular dysfunction and embolic events.
P644 A not so innocent athlete"s heart
Authors: Oliveira C C , Vieira C , Campos I , Rodrigues C , Medeiros P , Flores R , Mane F , Braga C , Rocha S , Marques J 
Published: January 2020

Abstract
We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service.
ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.