bluuebunny/crossref_metadata_2025_split huggingface dataset:
P1472 Concealed thrombus in a 12-year-old boy diagnosed by disappearance of intricate comb-like pectinate muscle form in the left atrial appendage
Authors: Takeuchi Y , Suzuki S , Tsuneyoshi H , Sakamoto H , Shimada T 
Published: January 2020

Abstract

Background
As previously known, patients with prolonged atrial fibrillation often have atrial thrombus. However, in children, cardiogenic embolism due to atrial fibrillation is rare. Also, the diagnosis of residual thrombus in the left atrial appendage is sometimes difficult even by transesophageal echocardiography (TEE). We have obtained a meaningful comparison between TEE findings and surgical specimen of bilateral atrial appendage.

Case report
A 12-year-old boy admitted to the nearby hospital, because of sudden onset of right-side hemiplegia. Till then, he was born at normal weight and grew up without any problem. The electrocardiogram indicated atrial fibrillation. He was transferred to the pediatric cardiology department of a hospital with higher function for the treatment of cardiogenic thromboembolism.
After 72 hours from the onset of first thromboembolism, a new embolic event happened in his left brachial artery. The contrast-enhanced computed tomography (CT) showed thrombus of bilateral atrium and coronary sinus. Consequently, residual thrombus led to the potential risk of additional embolization. Therefore, catheter cerebral thrombectomy was performed, and then surgical thrombectomy for the bilateral atrium was planned. Preoperative CT showed thrombus in the left atrial appendage (LAA). However, intraoperative TEE showed no obvious thrombus in the LAA. Intricate pectinate muscle formation in the left atrial appendage almost disappeared (figure1A), which suspected remaining thrombus. In addition, massive thrombus was seen in the right atrium and coronary sinus. Coronary sinus thrombus was removed as far as possible, and bilateral atrial appendage resection and myocardial biopsy were performed. Simultaneously, modified-Maze was also done. Heart rhythm returned into sinus rhythm after surgery. Pathological findings did not show specific findings of myocarditis or pericarditis.
Until now, the cause of thrombotic factors has not been fully clarified. Although the time of onset is unknown, probably, heart failure was triggered by atrial fibrillation, and consequently thromboembolism occurred. In the resected left atrial appendage, small thrombus remained among pectinate muscle (figure1B); therefore, postoperative anticoagulation should be needed.

Conclusion
We experienced a boy with thrombus in bilateral atrial appendages. In the resected left atrial appendage, multiple small thrombi remained in the pectinate muscle. From our experience, the disappearance of comb-like form in pectinate muscle by TEE suspects the residual thrombus, especially in the case of cardiogenic embolism.
Abstract P1472 Figure.
P1480 A case of triple left ventricular aneurysms diagnosed by CT and echocardiography
Authors: Makino K , Hashimoto G , Ide S , Hayama H , Isekame Y , Otsuka T , Iijima R , Hara H , Moroi M , Suzuki M , Nakamura M 
Published: January 2020

Abstract
【Background】
Left ventricular aneurysms is complication of myocardial infarction (MI) that can lead to death or serious morbidity. False aneurysm is rare complications of myocardial infarction or iatrogenic perforation and represent a contained myocardial rupture. False aneurysm does not contain all the three layers of the myocardium and is frequently lined by pericardium and mural thrombus. Definitive diagnosis is achieved by echocardiography, computed tomography (CT), angiography, or magnetic resonance imaging. Coexistence of true and false aneurysms is rare.
【Case】 A 58 years old man with a history of hypertension and MI was referred to our hospital for aneurysmectomy. During the course of prior MI, he got fever and pericardial effusion.
CT revealed that three left ventricular aneurysms were present. Also, three aneurysms were connected by narrow ducts each other. Transthoracic echocardiography (TTE) revealed that three ventricular aneurysms were connected via acceleration blood flow which swirling in the spherical aneurysm. We determined that this triple ventricular aneurysms were at high risk for rupture, so we performed surgery.
The postoperative course was good and he was discharged without any complications.
【Discussion】
False aneurysms occur after hemorrhagic dissection into an area of transmural infarction and most commonly result in free intrapericardial rupture of the heart, cardiac tamponade, and death. Rarely, if the overlying pericardium becomes adherent to the epicardium along the surface of the infarct, it can contain the rupture.
We were able to evaluate the mechanism of development with triple left ventricular aneurysms using CT and TTE. We could know about spatial comprehension of triple aneurysms using CT. False aneurysms were restricted enlargement due to stiff pericardium because of complicating Dressler syndrome. We hypothesis that aneurysms were enlarging in the direction of the base of heart in the adhered pericardium space.
We were able to evaluate the thickness of aneurysms and blood flow condition using TTE. TTE revealed that the wall of aneurysm was fragile. Multimodality imaging like TTE or cardiac CT are useful diagnostic methods in this case.
Abstract P1480 Figure. Triple aneurysms
P1482 Surviving free wall rupture
Authors: Pomiato E , Milewski P , Comunello A , Schoepf E , Oberhollenzer R , Cemin R 
Published: January 2020

Abstract

Introduction
Free wall cardiac rupture (CR) is a rare event accounting for 0.1–0.3% of the patients suffering acute myocardial infarction. Its outcome is very poor and it is the third most common cause of early mortality after hospitalization for ST Elevation Myocardial Infarction (STEMI).
Purpose
We report a case of a 63 years-old woman surviving a free wall rupture after ST Elevation
Myocardial Infarction.
Methods
The patient was referred to our cath-lab to undergo primary PCI in ST elevation myocardial infarction.
Results
Coronary angiography showed long thrombotic occlusion of left anterior descendent (LAD) artery and critical stenosis of posterior descending artery. The CULPRIT lesion on the anterior descending artery was treated with angioplasty and implantation of three drug eluting stents (3.0x31 mm; 2.75x15 mm; 2.5x30 mm).
Twenty four hours later the patient developed a double cardiac arrest with pulseless electrical activity, which were immediately managed with ALS protocol. The patient recovered both time within a couple of minutes and point-of-care transthoracic echocardiogram (TTE) showed a newly developed circumferential pericardial effusion (maximum diastolic diameter 9 mm), associated to a significant thinning of the anterior interventricular septum. A fibrin clot was tamponating a suspected free wall rupture. Emergent coronary angiography showed an in-stent thrombosis but failed to restore adequate blood flow in the LAD artery.
In the following days, the patients developed cardiogenic shock handled with i.v. dobutamine and intra-aortic balloon pump (IABP). Only after day 10 hemodynamic parameters started to improve gradually, allowing IABP removal and finally discharge on day 30.
A second TTE, performed on day 7, confirmed massive necrosis of the anterior wall with severely reduced ejection fraction (EF 22%), pericardial thrombus and aneurismatic evolution of the apex and the mid-anterior septum. To support our finding we performed a cardiac magnetic resonance which confirmed missing ventricular wall at the anterior apex. It also showed transmural late gadolinium enhancement (LGE) of the anterior mid-apical septum and of the apex and a huge pericardial thrombus encompassing the whole mid-anterior septum (Figure 1, a-f).
Before discharge the patient underwent two cardiac surgery visits which contraindicated surgical treatment in the acute phase. Therefore she was sent to cardiac rehabilitation program.
Six months later, the patient finally underwent cardiac surgery and the covered free wall rupture was confirmed in the operating theatre.

Conclusion
This is a very rare case of covered free wall rupture, treated 6 months after the acute event. Multimodality imaging was essential to confirm the diagnosis and to guide the following management.
Abstract P1482 Figure 1
P1494 Incidental finding of aortic aneurysm formation following 34 years of coarctation repair by dacron patch aortoplasty
Authors: Khalifa E A , Helmy S , Mohamed S F , Alkuwari M 
Published: January 2020

Abstract

Introduction
Aneurysms are found following all types of surgical repair of aortic coarctation, especially after Dacron patch aortoplasty.
We describe the finding of an aortic aneurysm in an asymptomatic 52-year-old male, who was managed by Dacron patch aortoplasty for native coarctation of the aorta 34 years earlier.

Case report
A 52-year male, smoker, hypertensive on medication He had previous history of surgical repair of aortic coarctation at age of 18 years .
Repair was by Dacron patch aortoplasty. Since then, his regular follow up was unremarkable. Recently, he was referred for cardiac evaluation as a part of pre-employment general check-up. He was asymptomatic with no history of shortness of breath or chest pain.
Physical examination revealed that the pulse in the left arm was reduced in volume in comparison to the right one. The heart sounds were essentially normal but a pericardial murmur was audible, perhaps reflecting residual collateral flow. Blood pressure was 156/83 mmHg in right arm and 142/81 in the left arm.
Transthoracic echocardiography revealed mild left ventricular hypertrophy with normal global and regional contractility and an ejection fraction of 58%. Supra sternal window images showed dilatation of the three aortic arch branches. The distal portion of aortic arch just distal to origin of left subclavian artery was narrowed with a peak systolic gradient across of 34 mmHg. A cystic structure (1.7 cm x 1.9 cm) was visualized attached to the narrowed segment of the aorta, suggestive of a saccular aneurysm, (figures A&B&C).
Computed tomography aortogram showed a narrow-necked aneurysm arising from the posterolateral aspect of the distal aortic arch (anticipated site of the coarctation repair graft anastomosis). A small laminated thrombus was also noted within. Aneurysm measured approximately 2.2 x 3.3 cm in its craniocaudal and anteroposterior dimensions respectively, with no evidence of aortic luminal compromise. (figures D&E&F).

Management
Aneurysmectomy was performed subsequently. Interposition polyester grafts were used to reconstruct the aortic arch and proximal descending aorta and to connect this aortic segment to the subclavian artery via a lateral thoracotomy. The postoperative course thereafter was uneventful. Conclusion: This is a rare insidious complication of Dacron patch aortoplasty that occurred after more than 3 decades, which highlights the importance of diagnostic imaging in the follow up of these patients
Abstract P1494 Figure.
P1495 Suddenly haunted by a turbulent heart beat in the right ear. Post-traumatic monolateral pulsatile tinnitus caused by cervical arteriovenous malformation: colour-Doppler ultrasound and angio-CT find
Authors: Silvestri V , Mele RITA 
Published: January 2020

Abstract

Funding Acknowledgements
No financial disclosure to be added

INTRODUCTION
Tinnitus, the perceived sensation of sound in absence of corresponding external acoustic stimulus, has a prevalence of 15% among adults [1]; it may impair quality of life in about 1-2% of cases. When pulsatile, objective and synchronous with heart beat, it may be secondary to vascular abnormalities [2]; in some patients a post-traumatic pathogenesis ( head and neck) has been reported, with a prevalence up to 10% .

CASE REPORT
We report the case of a 28 year old male patient with a history of a right side pulsatile tinnitus occurred three days after head trauma. Described as "hearing heart beat in the right ear as a turbulent sound", it corresponded with an audible bruit and palpable fremitus in latero-cervical region. History was negative for medical or surgical comorbidities as laboratory investigation; color Doppler ultrasound revealed an external carotid artery collateral- internal jugular vein fistula, resulting in a pulsatile turbulent flow, synchronic with heart beat.
Angio-CT scan of epiaortic vessels confirmed findings in the context of occipital articulation, near jugular foramen. Patient postponed further investigations for personal reasons.

DISCUSSION
Vascular post-traumatic lesions may cause post-traumatic pulsatile tinnitus. Symptom onset may be delayed from several days up to twelve weeks after trauma and it can be a sign of life-threatening disorders such as carotid cavernous fistulas, arteriovenous malformations, and carotid dissections [3 ] .
Clinical management includes basic diagnostic steps ( history, assessment of tinnitus severity, clinical ear examination, audiological and a neurovascular examination [2] . CT and MR with angiography, following colour-Doppler ultrasound , are used to determine the anatomical cause of vascular pulsatile tinnitus and to study surrounding structures. Angiography may be helpful for diagnosis and treatment planning [4].

CONCLUSIONS
Pulsatile tinnitus may occur after head and neck trauma, may affect quality of life and can be caused by live-threatening lesions. Arteriovenous fistulae between carotid artery branches and jugular vein may be treatable anatomical cause of symptoms, and have to be considered in differential diagnosis .
Abstract P1495 Figure. Pulsatile tinnitus:Imaging and Pathology
P1502 A clinical case of mitral annulus disjunction syndrome revealed by cardiac MRI
Authors: Mitrousi K , Hamilton M 
Published: January 2020

Abstract
A 39year old female patient with a family history of probable sudden cardiac death/long QT syndrome (sister died aged 36) was referred to our Arrhythmia/inherited cardiac conditions clinic. Patient was fit and well. She described occasional postural presyncope and some chest pain with stress. Not on any medication that could prolong QT. On examination she appeared well with normal heart sounds and no clinical signs of heart failure.
Her ECG in clinic confirmed sinus rhythm with normal QTc at 418msec. There were U waves which may reflect late repolarisation of His Purkinje system.
Diagnostic techniques and findings
A 24-hour ECG tape to look at the average QT interval, an exercise tolerance test to look for appropriate shortening of QT interval with exercise and an echocardiogram to exclude significant structural abnormality were requested.
The 24-hour ECG tape confirmed underlying sinus rhythm with multi-focal aberrant beats &lt;1% of total. One symptom demonstrated short run of ventricular bigeminy.
During the exercise tolerance test, QT interval was not obviously prolonged. There were frequent bifocal ventricular ectopic beats in recovery.
The echocardiogram showed minor abnormality with mild left ventricular dilatation, otherwise normal findings.
Patient referred for cardiac MRI In order to rule out any cardiomyopathy.
Cardiac MRI did not show any prolapse on the 3 chamber cine. In addition, the inferior and inferolateral annulus showed thinning passing into the LV, which is a feature of some patients with mitral annulus disjunction syndrome.
We went through the echocardiogram and in one single frame images are suspicious of focal P2 prolapse.
Learning points:
Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral valve leaflet hinge point. It has been associated with mitral valve prolapse and sudden cardiac death.
MAD is usually revealed with echocardiogram.
In this case report we showed that CMR revealed a MAD previously missed by echo.
Abstract P1502 Figure.
P1515 Hemodynamic determinants of tricuspid annular pulmonary systolic excursion (TAPSE)/ systolic pulmonary arterial pressure (SPAP) ratio in Heart Failure with reduced Ejection Fraction
Authors: Bandera F , Ghizzardi G , Agnifili M , Pizzocri S , Boveri S , Alfonzetti E , Saviano M , D"alesio G , Bedogni F , Guazzi M 
Published: January 2020

Abstract

Background
the TAPSE/SPAP ratio has gained a role as an easy-to-use surrogate of right ventricle-to-pulmonary circulation (RV-PC) coupling, showing a strong prognostic significance in heart failure (HF) patients. The hemodynamic determinants of TAPSE/SPAP ratio, as assessed by invasive approach, have not been fully clarified.

Aim
To identify the right heart hemodynamic variables correlated with TAPSE/SPAP in a HF with reduced EF (HFrEF) cohort, both at rest and during exercise.

Methods
30 HFrEF patients (age 68 ± 10 years LV EF 28 ± 7) underwent to rest and exercise echocardiography and performed right heart catheterization within 24 hours. Bivariate correlations between TAPSE/SPAP ratio (at rest and during exercise), right heart hemodynamic variables, RV systolic function and NTproBNP have been explored.

Results
TAPSE/SPAP ratio at rest showed a moderate correlation with pulmonary artery wedge pressure (PAWP: r= 0.441; p= 0.039), pulmonary artery pressures (PAP systolic: r = 0.481; p= 0.026; PAP diastolic: r= 0.434; p= 0.043; mPAP: r= 0.476; p= 0.025), pulmonary vascular resistance and compliance (r= 0.475; p= 0.041). A stronger correlation was identified with right atrial (RAP systolic: r= 0.586; p= 0.017; RAP diastolic: r= 0.681; p= 0.006) and right ventricular pressures- in particular diastolic ones (RVP systolic: r= 0.584; p= 0.004; RAP diastolic: r= 0.652; p= 0.002). No significant correlation with NTproBNP and RV 3D EF emerged. Exercise TAPSE/SPAP ratio significantly correlated with right atrium (RAP systolic: r= 0.564; p= 0.036) and right ventricle systolic pressures only (RVP systolic: r= 0.789; p&lt; 0.001).

Conclusions
TAPSE/SPAP ratio at rest showed a stronger correlation with invasively derived diastolic right heart pressure rather than pulmonary vascular bed pressures. A similar correlation was also observed for exercise TAPSE/SPAP ratio. This tight correlation with RV, rather than with vascular pressures, supports the significance of this ratio as a marker of RV adaptation to vascular overload.
P1528 Prognostic impact of pulmonary arterial wave reflection in heart failure
Authors: Hayama H , Uejima T , Cho J , Takahashi L , Hara H , Hiroi Y , Hashimoto G , Masao M , Nakamura M 
Published: January 2020

Abstract

Background
Pulmonary hypertension (PH) is prevalent and is associated with adverse outcomes in heart failure. The pathophysiology of PH is heterogeneous, including pre-capillary PH and combined pre- and post-capillary PH. The latter PH has been reported in experimental studies to cause wave reflection in pulmonary circulation, putting additional burden on right ventricle. This study tested the hypothesis that separating wave reflection would enhance risk stratification in heart failure.

Methods
This study included 152 patients with clinical stable heart failure associated with PH who were referred to echocardiography for hemodynamic assessment (age = 72 ± 13 years old, ejection fraction = 49 ± 21%). Pulmonary arterial wave reflection was characterised by separating PA pressure waveform into forward (Pf) and backward pressure (Pb) waves, based on the concept of wave intensity. PA pressure waveform was estimated from continuous Doppler tracing of tricuspid regurgitation. Flow velocity was measured by pulse Doppler at right ventricular outflow tract. Outcome data was obtained by reviewing medical charts. The endpoint was hospitalization for worsening heart failure (WHF).

Results
Figure A compares PA pressure waveforms (total and separated waves) obtained from 2 patients with and without WHF event. The patient with event had higher total pressure associated with late peak than the patient without event. Pb appeared later than Pf; it was markedly higher in the patient with event than the patient without event, although Pf was similar between both patients. Kaplan-Meier analysis demonstrated a significant separation of survival curves stratified by Pb (chi-square = 25.1, p &lt; 0.001, figure B). During follow-up period of 1.5 ± 1.8 years, 65 patients (43%) experienced the endpoint. Sequential Cox analysis revealed that PASP remained significant after adjusted for left ventricular ejection fraction and E/e’ (hazard ratio = 1.017, p = 0.019). Pb also remained significant after the same adjustment (hazard ratio = 1.066, p = 0.003); the addition of Pb to a baseline model resulted in greater increase in predictive power than the addition of PASP (model chi-square: from 27.4 (baseline), to 37.6 (p = 0.004) for Pb, to 31.6 (p = 0.027) for PASP, figure C)

Conclusions
Pressure wave reflection in pulmonary artery is associated with early decompensation in heart failure.
Abstract P1528 Figure.
P1537 Myocardial work in patients with aortic stenosis before and short term after transcatheter aortic valve replacement
Authors: Jasaityte R , Thiele A , Ernst L P , Baldenhofer G , Spethmann S , Laule M , Dreger H , Stangl K , Knebel F 
Published: January 2020

Abstract

Objective
The newly introduced noninvasive myocardial work analysis could potentially be beneficial in predicting the best timing for aortic valve replacement as well as clinical outcomes in patients with high grade aortic valve stenosis (AS), which is the leading valvular disease in the modern aging society. However, to date there is little data on the applicability of the method in the setting of extremely increased left ventricular (LV) afterload.

Purpose
In this pilot study, we aimed to apply myocardial work analysis in patients with increased LV afterload due to severe AS and to investigate the differences of myocardial work parameters in patients with different AS entities. In addition, we analyzed the early changes of myocardial work after the afterload reduction by transcatheter aortic valve replacement (TAVR).

Methods
We retrospectively studied echocardiographic data of 28 consecutive patients with severe AS before and 7 days after TAVR. Global Work Index (GWI), Global Constructive Work (GCW), Global Wasted Work (GWW) and Global Work Efficiency (GWE) were calculated using commercially available software based on noninvasive pressure-strain loops. In order to correct for underestimation of intraventricular pressure, we added the mean aortic valve pressure gradient to the peripheral systolic blood pressure used by the software.

Results
From the included patients (mean age 76 ± 10 years) 13 were classified as having normal flow (NF) severe AS, 8 had low flow low gradient (LFLG) and 7 paradoxical low flow low gradient (PLFLG) AS. GWI and GCW were significantly lower in patients with LFLG AS compared to patients with NF or PLFLG AS (936 ± 528 mmHg% vs. 2493 ± 485 mmHg% vs. 1959 ± 469 mmHg% [p &lt; 0.005] and 1132 ± 477 mmHg% vs. 2770 ± 507 mmHg% vs. 2189 ± 603 mmHg%, [p &lt; 0.005], respectively). 7 days after TAVR, GCW and GWI decreased significantly in patients with NF AS. In other AS entities, a trend towards increased GWI and GCW was observed, but the difference did not reach statistical significance. GWI and GCW remained significantly lower in LFLG AS group when compared to NF and PLFLG groups (1069 ± 378 mmHg% vs. 1919 ± 310 mmHg% vs. 2064 ± 842 mmHg% [p &lt; 0.005] and 1286 ± 346 mmHg% vs. 2107 ± 258 mmHg% vs. 2227 ± 949 mmHg% [p &lt; 0.005]) early after TAVR. GWE and GWW did not differ between the groups and were not influenced by TAVR.

Conclusion
In this pilot study we applied the adapted myocardial work analysis in patients with increased afterload due to severe AS. We have shown that GCW and GWI are significantly higher in patients with NF AS when compared to LFLG and PLFLG AS. The differences between the groups persisted early after TAVR in spite of significant reduction of GWI and GWC in patients with NF AS. The clinical and prognostic importance of these findings are still to be investigated in a bigger cohort study.