bluuebunny/crossref_metadata_2025_split huggingface dataset:
92 Aortopulmonary fistula complicating native aortic valve endocarditis
Authors: Kapelios C , Bonou M , Papadimitraki E D , Skouloudi M , Masoura K , Moyssakis I , Barbetseas J 
Published: January 2020

Abstract
A 41-yo male with history of bicuspid aortic valve and dilatation of ascending aorta (49 mm), was transferred from a peripheral hospital with staphylococcus aureus endocarditis. On day 4 he developed fulminant pulmonary edema with a continuous murmur best heard at the left second intercostal space and impressive cardiothoracic index augmentation. TTE revealed the presence of a large aorto-pulmonary fistula (A-PF), (figure 1, left), with left to right shunt during systole and diastole (figure 1, right), between the ascending aorta and the main pulmonary artery. Despite diuretic and antibiotic therapy with cloxacillin, gentamicin and cefazolin, the patient remained in class NYHA IV, soon became inotrope dependent and he progressively developed renal dysfunction. In the ICU unit he had an episode of ventricular fibrillation and was successfully defibrillated. He underwent emergent surgery with aortic valve and ascending aorta replacement. The fistula was closed using pericardial patch. Three years postoperatively he remains well. Aortopulmonary fistula is an uncommon but highly lethal condition if untreated. The etiology of acquired A-PFs includes aneurysm rupture, trauma, aortic dissections and infective endocarditis, most commonly of a prosthetic valve. Chest pain, dyspnea and intermittent hemoptysis are frequent symptoms whereas fulminant heart failure and low cardiac output syndrome may predominate the clinical picture as in our patient. Aortopulmonary fistula is an extremely rare complication of native valve endocarditis.
Abstract 92 Figure 1
94 When the gut affects the heart
Authors: Elmaghraby A , Kumar N , Lengyel Z , Francis W , Al Kuwari M , Chinnakaruppan S , Petkar M , Salustri A 
Published: January 2020

Abstract
A 59-year-old man came to our attention with progressive shortness of breath associated with lower limb oedema. He complained also of recurrent malar flushing, diarrhea and weight loss (14 kg in the last 8 months). At physical examination, a holosystolic murmur best heard over the fourth left sternal border, intensified upon inspiration, and a palpable tender liver with irregular surface were noted.
Transthoracic and transesophageal echocardiogram revealed dilated right chambers. The tricuspid annulus was dilated and the leaflets thickened, shortened and retracted with restricted mobility and incomplete coaptation, leading to severe tricuspid regurgitation (Panels A-B). Moderate pulmonary regurgitation was also detected (Panel C). Cardiac MR confirmed the morphology of the tricuspid valve (Panels D-E, arrows) and the severity of the tricuspid regurgitation (regurgitant fraction 66%). The pulmonary valve leaflets were also thickened and fixed (Panel F, arrow), with moderate pulmonary regurgitation (regurgitant fraction 21%).
With the suspicion of carcinoid syndrome, 5-hydroxyindoleacetic acid (5-HITT) was tested by 24-hour urine sample and a value of 929.5 µmol/24h was found (n.v. 10.5-47.1).
Whole body 18-F DOPA PET was performed. Axial views and reconstructed images revealed a short segment of mural thickening (2.4 cm and 1.1 cm) in the jejunum with a moderate/high uptake (Panels G, arrow). Adjacent to this lesion, a mesenteric spiculated mass (4.0 x 2.8 cm) with moderate uptake was visible (Panels H, arrow). Multiple enhancing nodules with high uptake were present in the liver (Panel I).
One of the liver nodules was biopsied. The biopsy revealed extensive infiltration by well differentiated neuroendocrine tumor (Panel J, blue arrow). The tumor cells were arranged in nests and were composed of cells with round to oval nuclei and eosinophilic cytoplasm (Panel K). The neuroendocrine nature of the tumor was confirmed by strong diffuse positivity with synaptophysin (Panel L), chromogranin and CD 56. Ki-67 showed a proliferative index of less than 3%. The tumor morphology, combined with the immunohistochemical features, was in keeping with a well differentiated neuroendocrine tumor.
Carcinoid heart disease is a rare cause of primary tricuspid and pulmonary valve disease leading to significant morbidity and mortality caused by right heart failure. The characteristic pathological findings are endocardial plaques of fibrous tissue that may involve the tricuspid valve and, rarely, the pulmonary valve. The fibrous tissue in the plaques results in distortion of the valves leading to either stenosis, regurgitation, or both.
Abstract 94 Figure.
108 Uncommon cardiac fatty distribution: a case report
Authors: Redondo Bermejo B , De La Torre Carpente M M , Munoz San Jose J C , Escudero Caro T , Acuna Lorenzo M , Guillem Ares E , Revilla Martinez M , Rollan Gomez M J 
Published: January 2020

Abstract

Background
Fatty masses of the heart are relatively uncommon. This report is about a rare case of extensive fat infiltration along the apical interventricular septum that causes separation of the right ventricular apex from left ventricular apex, simulating a bifid cardiac apex.

Case summary
The patient was a 58-year-old female who was admitted to the hospital because of palpitations and chest pain. A trasnsthoracic echocardiogram was performed and it showed a thickenned anterior pericardium so a cardiovascular magnetic resonance (CMR) was performed. CMR revealed a large amount of epicardial and pericardial fat without adipose tissue inside the right ventricle wall. In the cardiac apex this fat seemed a lipoma however CMR demonstrated the fat was not capsulated and besides, it extended, as if it were an infiltrative disorder, in the cardiac apex between both ventricles.
Patient was discharged with an implantable loop recorder (ILR) in order to ruled out ventricular arrhythmia.
During a two year follow-up, ILR has shown several symptomatic supraventricular paroxysmal tachycardia episodes and no other arrhythmic events have been reported. Also, the CMR has been repeated and it has shown similar results.

Discussion
Fatty masses of the heart are relatively uncommon. Among those masses are included cardiac lipomas, lipomatous infiltration of the right ventricle, arrhythmogenic right ventricular dysplasia (ARVD) and lipomatous hypertrophy of the interatrial septum. The findings in the CMR of our patient do not fulfill the criteria of the aforementioned disorders.
Our patient shows a pattern of unusual fatty infiltration pattern of unclear etiology. The prognostic value of this type of heart disease is unknown. In our patient, although the follow-up has not been very long, it does not seem to have had any relevant consequences, so far.

Conclusion
This is a rare case of a patient with a large amount of epicardial and pericardial fat that seems to infiltrate between both ventricular apex, as a bifid cardiac apex. It is apparently asymptomatic.
Abstract 108 Figure. CMR-Cardiac-fatty_EECHO-2019
162 Right ventricular function: is longitudinal strain by speckle-tracking an option?
Authors: Azul Freitas A , Ferreira C , Milner J , Ferreira J , Alves P , Marinho V , Martins R , Baptista R , Jorge E , Goncalves L 
Published: January 2020

Abstract

Introduction
Estimation of right ventricular (RV) performance by echocardiography is challenging due to its anatomical and functional distinctiveness. RV longitudinal strain (RVLS) by speckle-tracking (STE) is an innovative tool and recent studies show that it can be used with prognostic significance, although it isn’t yet standardized.

Purpose
In this study, we aimed to evaluate global (G) and free wall (FW) RVLS-STE and its correlation with common RV evaluation methods.

Methods
We conducted a prospective observational study including 65 patients and 20 healthy controls. G and FW RVLS-STE were correlated to tricuspid annular plane systolic excursion (TAPSE), Doppler tissue tricuspid lateral annular systolic velocity (S`) and left ventricle ejection fraction (LVEF). Following current guidelines, a TAPSE higher than 17mm, a peak S` wave velocity higher than 9.5cm/s and a RVLS-STE inferior to -20% was considered normal.

Results
Mean age was 66.34 ± 15.45 years with 61.5% males in the patient group and 31.1 ± 7 years with 50% males in the control group. Echocardiographic findings in patient group included 44.6% with reduced LVEF (EF &lt; 50%), 26.2% with moderate to severe valvular disease, 23% with an elevated systolic pulmonary pressure (&gt; 35mmHg) and 36.9% without significant structural disease. The control group had no pathological signs on echocardiography. Peak S` wave and TAPSE showed a better correlation with FW RVLS-STE (r²=0.41, p &lt; 0.001 and r²=0.46, p &lt; 0.001) than G RVLS-STE (r²=0.27, p &lt; 0.001 and r²=0.30, p &lt; 0.001). A high absolute FW RVLS-STE (&lt; -20%) was a good marker of a normal TAPSE and a normal peak S` wave velocity, with a negative predictive value of 87% and 98% respectively. Comparing to control group, patients with reduced LVEF showed a reduction in TAPSE (27.6 mm vs 18.53 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.84 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -15.34%, p &lt; 0.001). Patients with moderate to severe valvular disease also showed a reduction in TAPSE (27.6 mm vs 18.4 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.3 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -16.04%, p &lt; 0.001). And finally, patients with elevated systolic pulmonary pressure also showed a reduction in TAPSE (27.6 mm vs 17.94 mm, p &lt; 0.001), S` (14.8 cm/s vs 10.47 cm/s, p &lt; 0.001) and FW RVLS-STE (-28.7% vs -16.7%, p &lt; 0.001).

Conclusion
FW RVLS-STE is better than G RVLS-STE as a RV evaluation method. RVLS-STE is correlated with TAPSE and peak S` wave velocity. It was the only parameter that showed reduction to abnormal values (&gt; -20%) in pathological groups and seems to be an accurate marker of RV function particularly detecting early dysfunction
P168 Non-bacterial endocarditis in patients with antiphospholipid syndrome treated with direct oral anticoagulants
Authors: Munoz Pousa I , Calvo Iglesias F E , Cespon Fernandez M , Lopez Rodriguez E , Pradas Montilla G , Legarra Calderon J J , Fernandez Martin J J 
Published: January 2020

Abstract

Introduction
Primary antiphospholipid syndrome (APS) is a hypercoagulability state of autoimmune origin. Vitamin K- antagonists remain the mainstay therapy though the difficulties in maintaining target therapeutic range contributed to prescriptions of direct oral anticoagulants (ACOD). A recent randomized trial reported an excess in thromboembolic events in patients under rivaroxaban therapy compared with warfarin.

Purpose
Description of two cases of Libman-Sacks endocarditis in APS patients on therapy with rivaroxaban due to poor control with coumadin.
Methods and results. Case 1 is a 47-year-old woman and case 2 a 69-yo man with APS with high antibody titers of 3 classes and previous thrombotic events (pulmonary embolism in case 1 and acute coronary syndrome in case 2). In both cases, coumadin was switched to rivaroxaban because of poor control. During follow-up the diagnosis of blood culture-negative endocarditis was stablished in both cases. Echo examinations in case 1 revealed a 12 mm mobile vegetation in the ventricular face of the non-coronary aortic cusp, which resolved after 2 months high-dose warfarin therapy. Case 2 was admitted to hospital because of heart failure. TTE and TOE revealed a 26 mm mass attached to the atrial face of posterior mitral leaflet and moderate mitral regurgitation. He underwent mitral valve replacement with a mechanical prosthesis and the final pathologic diagnosis was Libman-Sacks endocarditis.

Conclusions
Libman-Sacks endocarditis as a thrombotic feature of high-risk APS patients can occur under rivaroxaban therapy. In one of our 2 cases, high-dose coumadin therapy resolved this complication
Abstract P168 Figure. Cases
P173 When the heart doesn"t want to grow up
Authors: Carrer A , Civera S , Muraru D , Videsott L , Sambugaro F , Perazzolo Marra M , De Lazzari M , Iliceto S , Badano L P 
Published: January 2020

Abstract

Background
Blood cysts of heart valves are uncommon and, usually, incidental findings in pediatric population. Rarely seen in adults, blood cysts are normally asymptomatic, even though several cases of embolization, valvular disfunction and left ventricle outflow tract (LVOT) obstruction have been described. Clinical Presentation. We report the case of a 23 year-old woman, with history of a small nodular mass of the mitral valve, found on a previous cardiac magnetic resonance (CMR) at the age of thirteen, who was admitted to our emergency department complaining atypical chest pain. She denied shortness of breath, syncope, tachycardia and fever. She was hemodynamically stable and a fast regression of symptoms was observed. The physical examination was unremarkable. Both the electrocardiogram (ECG) and blood tests were normal. A chest radiography showed normal heart size, without other abnormalities. After having ruled out an acute coronary syndrome, the patient was discharged with the indication to undergo further cardiological assessments. Diagnostic techniques and their most important findings. Therefore, a trans-thoracic echocardiogram was performed revealing normal biventricular function, no aortic root dilation, no pericardial effusion, no valvular regurgitation or stenosis. A round (7x11 mm) mass with hyperechogenic borders and hypoechogenic content was detected on the ventricular side of the anterior mitral valve leaflet consistent with a valvular blood cyst (figure 1: a,b,c). Only trivial mitral valve regurgitation without LVOT obstruction was present. The 3D echo reconstruction allowed to confirm the suspicion of blood cyst and detect a cleft of the posterior mitral valve leaflet, located in the P2 scallop (figure 1: d,e). A repeated CMR showed no contrast enhancement of the mass. Due to the clinical stability and the absence of complications, the patient was suggested to continue an echocardiographic follow-up. Discussion. Cardiac blood cysts are a rare condition with uncertain origin, usually found in infants in the first six months of life. A natural regression after that age has been described, making this condition very unusual in adults. Despite its benign features, when persistent beyond the childhood, the blood cyst can grow and reach even huge dimensions, potentially impairing the valvular function and/or causing LVOT obstruction. Another potential complication of blood cysts may be the arterial embolization. In all these situations surgical resection must be considered. In our patient, the contribution of trans-thoracic echocardiogram and in particular the 3D reconstruction, were pivotal to address the correct diagnosis.
Abstract P173 Figure 1
P174 Left atrial myxoma presenting in a cystic form
Authors: Yagmur B , Simsek E , Ozbaran M , Soydas Cinar C 
Published: January 2020

Abstract

Background
Early diagnosis of atrial myxomas may be a challenge because of their synptoms are often nonspecific. Two-dimensional echocardiography is the diagnostic procedure of choice.

Case presentation
A 42-year-old woman presented with complaints of palpitation and fatigue. Physical examination revealed a diastolic murmur at the apex. Two-dimensional transthoracic echocardiography revealed an extremely mobile mass in the left atrium that consisted of multiple cystic and solid parts. Three-dimensional transesophageal echocardiography showed that the 4.3x3.3 cm mass was connected to the interatrial septum through a 0.7 cm pedincle, and it moved between the atrium and the ventricle through the mitral valve with each carciac cycle. Grade 1 mitral and aortic regurgitation and grade 3 tricuspid regurgitation was accompanied by a SPAP of 90 mmHG. The mass was surgically excised. Histopathologic diagnosis was myxoma.

Discussion
Types of cystic masses that can appear in the left atrium are myxomas, hydatid cysts and interatrial septal aneurysms. In our case report, echocardiographic findings of a mass that was connected to the IAS with a pedicle were supportive of cardiac myxoma. If not removed, myxomas may cause major complications like stroke, rupture, and hemodynamic problems. Surgery was indicated because the mass was cystic and highly mobile.
Abstract P174 Figure. mass
P175 Cardiac device infection: to extract or not to extract, that is the question
Authors: Dias Ferreira Reis J P , Mano T , Valente B , Monteiro A , Silva Cunha P , Oliveira M , Pereira Da Silva T , Soares R , Rio P , Moura Branco L , Ferreira R 
Published: January 2020

Abstract

Introduction
The incidence of infectious complications related to intracardiac devices has been increasing in recent year and is associated with a poor prognosis, which is determined not only by the infectious process but also by the severity of the underlying cardiac pathology and the spectrum of comorbidities presented. Appropriate antibiotic therapy and extraction of the devices are fundamental in the management of these patients.

Case report
We describe the case of a 66-year-old patient on a waiting list for transplantation due to non-ischemic dilated cardiomyopathy with poor left ventricular systolic function (LVEF of 10%), with severe functional mitral regurgitation and severe pulmonary hypertension, who received a CRT-D for secondary prevention (non-responder). He was admitted for decompensated heart failure (NYHA functional class IV and "dry-cold" profile) requiring inotropic support becoming dependent on dobutamine. During hospitalization, there was a progressive increase in inflammatory markers accompanied by recurrent febrile peak and inflammatory signs of the central venous catheter, with catheter-tip and serial hemocultures positive for Morganella morganii. Piperacillin / tazobactam was started. Due to the lack of response to pathogen directed antibiotic therapy, he underwent a transesophageal echocardiogram (TEE) that revealed several filiform images associated with the electrodes, with no image of valvular vegetations, which led to the association of gentamicin and device extraction (DE), according to the Pisa technique, that occurred without complications. On the 7th day after DE, there was a progressive clinical deterioration in spite of increasing doses of inotropes and vasopressors. It was considered that patient would not be candidate for cardiac transplantation or mechanical ventricular assist, and died on the 118th day of hospitalization in refractory cardiogenic shock.

Conclusion
Device endocarditis is a class I indication for intracardiac DE and TEE is fundamental in its diagnosis. Despite being a considered a non-responder to cardiac resynchronization therapy based on clinical and echocardiographic criteria, this case illustrates how the loss of cardiac resynchronization may have contributed to the patient’s hemodynamic deterioration and have played a fundamental role in the clinical outcome.
P184 Broken heart complications
Authors: Azul Freitas A , Ferreira C , Milner J , Ferreira J , Marinho V , Alves P , Jorge E , Goncalves L 
Published: January 2020

Abstract

Introduction
Patients with persistent chest discomfort or other symptoms suggestive of ischaemia and ST segment elevation in two contiguous leads on electrocardiography should be prompt managed to revascularization and emergent angiography for percutaneous intervention in two hours is the preferred reperfusion strategy.

Purpose
Our aim is to show the importance of differential diagnosis in a patient with an initial diagnosis of ST segment elevation myocardial infarction (STEMI).

Clinical case
We present a case of 67 years old women with a past medical history of dyslipidemia and polymyalgia rheumatica, treated with rosuvastatin 10mg id and prednisolone 5 mg id. The patient was admitted to emergency department complaining of chest pain with 3 hours of evolution that started after a period of nausea and vomiting. Physical examination showed slight tachypnea with 22 breath per minute, blood pressure 93/40 mmHg, heart rate 110 beats per minute, oxygen saturation in room air 90%, heart sounds with a systolic murmur II/VI and lung crackles in inferior lobes, with no peripheral oedema. Electrocardiography showed sinus rhythm and ST segment elevation in DI, DII and V2-6. Patient was treated with aspirin 300mg, ticagrelor 180mg, furosemide 40mg, oxygen therapy and was scheduled for emergent coronariography. This procedure revealed no significant coronary lesions and ventriculography identified apical ballooning, diagnosing takotsubo myocardiopathy. Clinical condition starts to deteriorate, and an echocardiography identified akinetic apical and midventricular segments and hyperkinetic basal segments with systolic anterior motion of mitral valve, significant mitral regurgitation and left ventricular outflow tract obstruction (LVOTO) with an intraventricular gradient superior to 60 mmHg. Adequate hemodynamic monitoring and heart rate control allowed a substantial clinical improvement. Two days later a cardiac magnetic ressonance was done, confirmed the diagnosis and identified an apical thrombus. The patient was later discharged stable with oral hypocoagulation with anti-vitamin K antagonist.

Discussion and Conclusion
Takotsubo cardiomyopathy is a unique cardiac syndrome characterized by transient systolic dysfunction witch often mimics acute coronary syndromes (ACS). After exclusion of an ACS, echocardiography is of primordial importance in the assessment of these patients. Left heart failure with pulmonar oedema, mitral regurgitation, LVOTO and thrombus formation were all complications that were present in this clinical case and established the indication to proper therapeutic attitudes.
Abstract P184 Figure.