bluuebunny/crossref_metadata_2025_split huggingface dataset:
P707 Positive rest and negative adenosine stress perfusion in typical angina
Authors: Mitrousi K , Moharem-Elgamal S , Manghat N , Hamilton M 
Published: January 2020

Abstract

Clinical Presentation
A 45 year old gentleman seen in Rapid Access Chest Pain Clinic with typical angina (exertional chest pain). No risk factors for CAD. Normal ECG. Pre-test probability of significant CAD 51% .
Diagnostic techniques and findings
The patient was referred for adenosine stress CMR. CMR was performed on a 1.5 Tesla scanner. Cine was performed first, followed by stress perfusion, gadolinium enhance images and finally rest perfusion images. LV systolic function was normal. A significant perfusion defect of the LAD territory was noted on the rest but not on the stress perfusion images. The radiographers confirmed that stress and rest perfusion images were performed normally (stress first). A good physiological response was obtained during the assumed vasodilator stress with &gt; 20% in the HR (from 65-75bpm to 91-107bpm respectively). During the presumed rest perfusion acquisition, HR was similar to the previously recorded resting HR. The spleen was not adequately visible to comment on splenic switch off.
This type of perfusion defect (normal stress/abnormal rest) had not been described before, and there is no evidence that it was due to acquisition error.
A coronary CT was advised to assess the LAD. CT coronary angiogram showed mild coronary calcification. A severe (80%), focal, non-calcified mid LAD stenosis was identified. A mild proximal OM1 stenosis was also noted.
The patient subsequently underwent an invasive angiogram which confirmed the presence of a severe mid LAD stenosis. PCI was performed in the same setting with deployment of a single 4x18mm XIENCE drug eluting stent. The successful procedure was optimised with OCT guidance.

Learning points
Resting perfusion is often considered an integral part of adenosine perfusion imaging in order to overcome dark ring artefact, but it requires an additional contrast injection, prolongs imaging time and adds to cost. Some experts suggest that resting perfusion does not add to clinical interpretation and is not required.
Our case is interesting, showing a previously unreported phenomenon. We cannot explain the reason for it but do not believe that the stress/rest order was reversed (as this would require two radiographers to go off protocol, and they and the supervising physician to be lying) and the physiological response is as expected. It therefore suggests that a rest study may occasionally provide helpful diagnostic information.
Abstract P707 Figure.
P722 Unrepaired complex severe aortic coarctation determining restrictive cardiomyopathy with pulmonary hypertension in adulthood
Authors: Graziani F , Panaioli E , Lillo R , Delogu A B , Perri G , Grandinetti M , Burzotta F , Cialdella P , Lanzillo C , Massetti M , Crea F 
Published: January 2020

Abstract
A 54-year-old female presented to our Emergency Department with acute pulmonary edema. On physical examination she was tachypneic with arterial oxygen saturation of 91% and a grade 3/6 systolic murmur in the apex and left second intercostal space that was irradiated to the intrascapular area. Bilateral femoral and pedal pulses were quite faint on palpation. The blood pressure was 260/120 mmHg. Results of routine blood chemistry were normal with the exception of increased NT-proBNP (2746 pg/mL). Twelve-lead electrocardiogram revealed left ventricular hypertrophy with repolarization abnormalities and left atrial enlargement. The two dimensional (2D) echocardiography showed significant left ventricular hypertrophy (RWT 0.6; LVmass index 150 g/m2), no wall-motion abnormalities and normal left ventricular ejection fraction (EF 60%) but with reduced longitudinal components at TDI evaluation (6 cm/s). Severe ventricular diastolic dysfunction was detected with E/A 2,11 and E/e" 26 with a significant left atrial dilatation (LAVi 73 ml/m2) and severe pulmonary arterial hypertension ( PASP of 85 mmHg) . We were unable to visualize the aortic arch but reduced/absent pulsatile wall motion of abdominal aorta was identified. The patient reported to be affected by unrepaired aortic coarctation diagnosed at the age of 32 during pregnancy. She refused the surgical treatment twice and the she did not undergo any specific follow up but she had several admissions in emergency department for uncontrolled arterial hypertension. Our further evaluation with CT angiography showed a severe narrowing of the post isthmic aortic lumen with significant development collateral vessels (Figure 1). The patient was discharged after resolution of pulmonary edema and titration of hypertension treatment with a planning of hybrid approach to treat the aortic coarctation. The case shows a restrictive cardiomyopathy with post-capillary pulmonary hypertension due to severe unrepaired aortic coarctation.
Abstract P722 Figure. CT angiography,echo, right heart cath
P725 An unexpected direction: a case report of a double aortic arch in an asymptomatic woman in adulthood
Authors: Campos I , Vieira C , Salome N , Pereira V H , Costeira Pereira A , Bettencourt N , Costa Oliveira C , Marques Pires C , Medeiros P , Flores R , Mane F , Marques J 
Published: January 2020

Abstract

Introduction
Complete vascular rings represent about 0.5-2% of all congenital cardiovascular malformations, with the double aortic arch (DAA) being the most common of the complete vascular rings, causing tracheoesophageal compression. The right (posterior) arch is usually dominant (70%), although the two arches can have the same size (5%). The left (anterior) arch is dominant in only approximately 25% of cases. In most cases, this anomaly is diagnosed during childhood due to symptoms caused by oesophageal or tracheal compression. For this reason, case reports of adults are rare. This report describes a case of a 61-year-old woman with DAA with dominant left arch, diagnosed accidentallyby thoracic CT angiography.

Case Report Description
A 61 years old woman with a previous story of hypertension and type 1 diabetes presented to the emergency service with dyspnoea and thoracic pain. She also referred a history of intermittent dysphagia and cough with at least 12 years of progression. All the parameters of the physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm with no evidence of acute ischemia and her blood analyses did not show any abnormalitie. She also performed a thoracic CT angiography, which excluded signs of pulmonary embolism, but revealed a vascular ring suggesting a double aortic arch with permeability in both right and left arches as well as their collaterals. The Cardiac MRI was performed with the purpose of excluding ischemia, confirming the double aortic arch with left dominance. The right arch, posterior to the oesophagus and trachea, and the left arch, in an anterior position, showed an anatomic compression of the oesophagus as well as the proximal trachea, capable of eliciting the symptoms mentioned. Other congenital anomalies were excluded. The echocardiography did not demonstrate any additional cardiac malformation. Endoscopy shows a pulsatile extrinsic compression of the esophagus (aortic ring). The patient is currently being studied and closely monitored in the Cardiology consultation.

Discussion
The most common type of complete vascular ring is the double aortic arch, which accounts for 70% of the complete rings. In most cases, there are two permeable arches, usually with right dominance (70% of the cases). Rarely, both arches are symmetrical. Symptoms usually appear in the fifth month of life. In most cases, only supportive treatment is required.

Conclusion
This case illustrates the atypical features of this congenital malformation, namely the diagnosis during adulthood as well as the left dominance.
Abstract P725 Figure. A double aortic arch
P727 Unexpected ventricular aneurysm: further ischemic aetiology
Authors: Vieitez Florez J M , Hinojar R , Pascual M , Ramos J , Jimenez Nacher J J , Sanchez D , Carvelli A , Esteban A , Kristo D , Moya J L , Abellas M , Lorente A , Zamorano J L , Fernandez-Golfin C 
Published: January 2020

Abstract

Introduction
Ventricular aneurysm is an infrequent complication of myocardial infarction. In absence of an ischemic event, alternative aetiologies include: thoracic trauma, hypertrophic cardiomyopathy, myocarditis, Chagas disease, cardiac sarcoidosis or arrythmogenic cardiomyopathy. In the absence of any of the previous, congenital aneurysm diagnosis is made.

Case
We present the case of 57-year-old man referred to cardiology department because a new onset of atrial fibrillation with left bundle branch block. Past medical history included high blood pressure and dyslipidaemia without any history or smoking, alcohol consumption or any other toxic abuse. No chest pain, shortness of breath or other significant symptoms were reported. Physical examination was unremarkable except for an arrhythmic pulse at 85-90 bpm.
Echocardiogram showed moderate dilated left ventricle with mild-moderate LV dysfunction (EF 40% ) with a septal aneurysm of 2.4x1cm (Picture A). A coronary CT was performed that ruled out coronary heart disease and confirmed the presence of the septal aneurysm (Picture B). To better characterize this image, a cardiac magnetic resonance (CMR) was performed. Moderate dilated LV with significant dysfunction (EF 31%) was reported. A septal aneurysm of 13 x 22 x 33 mm composed of a 2.8 m thin wall of true myocardial tissue was documented (picture C and D-late gadolinium enhance). No myocardial delayed enhancement was detected in any area of the LV. Moreover, no signs of myocardial non compaction, arrythmogenic cardiomyopathy, hypertrophic cardiomyopathy or myocarditis were seen. Chagas serology as well as sarcoidosis diagnosis work up were negative. Patient denied any thoracic traumatism. Congenital aneurysm diagnosis was finally established.
Electrical cardioversion was performed after 1 month of correct oral anticoagulation and heart failure treatment was started. Case was presented in the Heart Team session and a conservative management was decided based on asymptomatic status and absence of ventricular arrhythmias. After 3 years of clinical follow up, the patients is in good status, asymptomatic and in sinus rhythm. Discussion: Congenital ventricular aneurysm is a rare cardiac malformation that arises during the fourth embryonic week. Most frequently, left ventricular aneurysms are found in the apex and the perivalvular area, being the septal location an atypical one. Most patients are asymptomatic but when symptoms occur, they are mostly related to the presence of ventricular arrhythmias. Aneurysm rupture incidence is variable, ranging from 3.7% to 12 % according to the different series. For this reason, surgery is recommended in symptomatic patients. However, management of asymptomatic patients is not clear since prognosis studies are lacking.
Abstract P727 Figure. A.Echo B.-CT C.-CMR. D.-CMR gadolinium
P731 When cardiac imaging saves the day - a rare cause of embolic stroke
Authors: Demetriades P , Ahluwalia V , Speke L , Wilson L , Khan J N 
Published: January 2020

Abstract
INTRODUCTION
Hypereosinophilic syndrome (HES) is a rare disorder characterised by infiltration of tissues by eosinophils. Myocardial infiltration occurs in 50-60% of HES and leads to a condition called Loeffler’s endocarditis. Eosinophilic protein toxicity initiates endomyocardial necrosis. This is followed by a thrombotic stage and finally by endomyocardial fibrosis leading to a form of restrictive cardiomyopathy. Thrombosis is often located in the apical region of the ventricles and can result in stroke, which is the most devastating neurological consequence of hyperoesinophilia. We describe a case of a patient that presented with neurological symptoms and was found to have multiple embolic strokes secondary to Loeffler’s endocarditis.
CASE
A 57-year-old female presented to our institution with new onset confusion and reduced level of consciousness. Initial neurological assessment was consistent with encephalopathy. She had a 2-year history of eosinophilia that had been investigated by the haematology and rheumatology teams with no obvious aetiology identified.
Initial haematological investigations showed a raised eosinophil count at 13mmol/L. Her cerebral MRI scan showed multiple embolic infarcts and therefore a transthoracic echo (TTE) was booked. This did not show any obvious intracardiac cause of emboli although the appearances of the LV apex were suspicious of thrombus. This was confirmed later, on contrast imaging (Fig 1). Staphylococcus aureus was grown in a single blood culture specimen raising the suspicion of infective endocarditis and a transoeosophageal echocardiogram (TOE) ruled out vegetations but again illustrated the apical filling defect despite absence of wall motion abnormalities (Fig 2). Finally, a cardiac MRI was arranged and this confirmed the diagnosis of Loeffler’s endocarditis with endomyocardial fibrosis and superimposed LV thrombus (Fig 3). She was treated with anticoagulation and steroids and her eosinophil count normalised before discharge. She remains well with no recurrence at two months post-event.
DISCUSSION
The diagnosis of Loeffler’s endocarditis depends on the presence high eosinophil count in combination with cardiac involvement on imaging. Transthoracic echocardiography can provide useful information such as apical thickening and thrombus in the left ventricle. As in our case, contrast TTE often provides further detail however contrast-enhanced cardiac MRI remains a key tool in the diagnosis and monitoring of this condition. It provides an assessment of systolic and diastolic function, tissue characterisation and typical features notably endomyocardial fibrosis and thrombosis on late enhancement imaging.
CONCLUSIONS
We presented a case where cardiac imaging has revealed the diagnosis in a patient presenting with systemic symptoms. We encourage clinicians to use multi-modality cardiac imaging as this has an invaluable role in the diagnostic process of complex patients.
Abstract P731 Figure.
P765 Does detection of thrombus in left atrial appendage increase risk of ischemic stroke and mortality?
Authors: Kagawa E , Kato M , Oda N , Kunita E , Nagai M , Shiota H , Dote K 
Published: January 2020

Abstract

Background
Left atrial appendage (LAA) thrombus is one of causes of cardiogenic stroke and detection of LAA thrombus by transoesophageal echocardiography (TOE) strongly suggest cardiogenic stroke. It was reported that cardiogenic stroke patients had higher in-hospital mortality about 19%; however, little is known about LAA thrombus and mortality after indexed detection of LAA thrombus. We investigated LAA thrombus detection and their prognosis including ischemic stroke and survival.

Methods
The patients who were performed TOE between 2005 and 2016 in our hospital were enrolled in this study. Patients were divided into 2 groups based on thrombus detection in the LAA, and baseline characteristics and outcomes including prevalence of 5-y stroke-free and survival from the indexed TOE were compared.

Results
Among the 1260 study patients, the follow-up duration was median 971 d (interquartile range 345 d – 2017 d), and 67% of the patients were performing TOE for atrial fibrillation (AF), 20% for cerebral infarction, and 14% for valvular heart disease. Non-valvular AF was seen in 64% of the study patients and rheumatic AF was in 2%. The age (74 y [66 y – 79 y] vs 70 y [62 y – 76 y], p &lt; 0.001), the prevalence of male sex (67% vs 69%, p = 0.63), and hemoglobin level (13.9 g/dl [12.5 – 15.1 g/dl] vs 13.8 g/dl [12.4 – 14.9 g/dl], p = 0.49) were similar between the patients with LAA thrombus and those without. The CHA2DS2-VASc score (p = 0.008), the prevalence of receiving anticoagulation before TOA (34% vs 24%, p = 0.01), those of after TOA (98% vs 66%, p &lt; 0.001), serum creatinine (0.92 mg/dl [0.80 – 1.10 mg/dl] vs 0.85 mg/dl [0.71 – 1.00 mg/dl], p &lt; 0.001), d-dimer level (1.7 mcg/ml [0.9 – 3.5 mcg/ml] vs 0.8 mcg/ml [0.5 – 2.2 mcg/ml], p &lt; 0.001), and plasma brain natriuretic peptide (315 pg/ml [128 – 515 pg/ml] vs 126 pg/ml [47 – 284 pg/ml], p &lt; 0.001) were higher in the patients with LAA thrombus than those without. The 5-y ischemic stroke-free rate was lower in the patients with LAA thrombus than those without (p &lt; 0.001) (Figure, Panel A); however, the 5-y survival was similar between the 2 groups (p = 0.93) (Panel B).

Conclusions
The patients who were detected thrombus in the LAA had higher incidence of ischemic stroke, but the survival rate were similar. The higher rate of receiving anticoagulation therapy in the patients with LAA thrombus may be the cause of this discrepancy. Further studies are necessary to clarify this issue.
Abstract P765 Figure
P781 Role of serum biomarkers combined with two-dimensional speckle tracking echocardiography for screening of immunotherapy-induced cardiotoxicity
Authors: Fusco F , Scognamiglio G , Vitiello F , Gilli M , Piantedosi F , Colonna D , Palma M , Granata G , Sarubbi B 
Published: January 2020

Abstract

Background
Immune checkpoint inhibitors (ICIs) are a novel class of antineoplastic drugs which have dramatically changed the management of non-small cell lung cancer. ICI-associated cardiotoxicity is rare, but potentially fatal, presenting in most of cases as autoimmune acute myocarditis during the first phase of treatment. However, since an extensive cardiac monitoring is not routinely performed in most immunotherapy trials, the true incidence of ICIs related cardiac effects is largely unknown.
Aim
Aim of our study is to ascertain a possible subclinical cardiac involvement in patients with non-small cell lung cancer treated with ICIs.

Methods
We prospectively recruited 40 patients (13 males; mean age 64.3 ± 8.3 years) starting immunotherapy with PD-1/PDL-1 inhibitors for non-small lung cancer between January and August 2018. Demographic and clinical data were recorded and all patients underwent a standard 12-lead ECG and a transthoracic echocardiogram with assessment of left ventricular global longitudinal strain (LV GLS). Furthermore, blood samples for pro BNP-nt and high sensitivity Troponin T (hsTnT) measurements were collected. Serial assessments were performed before and 1 and 3 months after initiation of immunotherapy.

Results
A history of previous coronary artery disease was documented in eight cases (20%). At follow-up no cardiovascular events were recorded. Compared with baseline, echocardiographic parameters of ventricular function did not significantly changed at 1 and 3 months (LVEF 61 ± 6% at baseline, 61 ± 5% at 1 month, 60,2 ± 5% at 3 months, p =0.1; E/E’at baseline 9.2 ± 3, 9.2 ± 2.8 at 1 month, 9.1 ±3,5 at 3 months, p = 0.2;TAPSE 20 ± 3.4 mm at baseline, 21.3 ± 2.8 mm at 1 month, 20 ± 3.8 mm at 3 months, p =0.1; LV GLS -20.3 ± 3.6% at baseline, -20.8 ± 2.3% at 1 month, -20.6 ± 3% at 3 months; p = 0.4). Analogously, no significant increase in circulating levels of cardiac biomarkers was found with hsTnT &lt;0.015 ng/ml in all patients at baseline, 1 month and 3 months and median proBNP-nt 118 pg/ml (IQR 47-200) at baseline, 171 pg/ml (IQR 91-520) at 1 month, and 182 pg/ml (IQR 78-470) at 3 months, p = 0.9.

Conclusions
In our study no significant clinical or subclinical evidence of myocardial involvement was detected during treatment with ICIs in patients with non-small cell lung cancer, thus suggesting the potential cardiovascular safety of this promising class of antineoplastic drugs.
P789 Reverse left atrial functional remodeling after surgical aortic valve replacement is dependent on impaired left atrial function and reverse left ventricular remodeling
Authors: Pessoa Amorim G , Vouga L , Gama V , Bettencourt N , Fontes-Carvalho R , Mancio J 
Published: January 2020

Abstract

Funding Acknowledgements
Fundação Portuguesa para a Ciência e Tecnologia (SFRH/BD/104369/2014) and Sociedade Portuguesa de Cardiologia (“Bolsa de investigação João Porto”)

OnBehalf
EPICHEART Study

Background
Left atrial (LA) functional remodeling is an important mechanism in the pathophysiology of aortic stenosis (AS), and readily-assessable using speckle-tracking echocardiography (STE). It is uncertain whether and how surgical aortic valve replacement (SAVR) affects reverse LA functional remodeling.

Aims
We aimed to evaluate LA functional remodeling post-SAVR using STE and to explore potential underlying mechanisms.

Methods
73 symptomatic severe AS patients (72.6 ± 8.14 years, 53.4% male) were assessed before and six months after SAVR (Fig.1-A). LA function was evaluated using STE-derived LA longitudinal strain during reservoir (LASr), conduit (LAScd) and contraction (LASct) phases (Fig1.-B); reverse LA remodeling was represented by their relative percentual changes. LA structure was assessed by LA area and indexed volume.

Results
LA structure and left ventricle (LV) indexed mass, end-diastolic diameter (LVEDD) and mean E/e" improved after SAVR (Table 1). Although paired-samples analysis did not show signiﬁcant changes in LA function, multiple linear regression revealed that preoperative LA strain parameters were the sole baseline predictors of reverse LA remodeling: lower baseline LASr, LAScd and LASct were related to improved LASr, LAScd and LASct, respectively (Fig.1-C); mean E/e’ decrease was associated with LAScd improvement (Fig.1-D2). LV mass and LVEDD decrease were not associated with LA functional recovery.

Conclusion
Reverse LA functional remodeling is compromised after SAVR, and increased in patients with impaired baseline LA function. LV diastolic function recovery was linked to improved LA conduit function. An optimal echocardiographic cut-off should be further explored in order to better adjudicate surgical timing, and foster LA functional recovery.
Echocardiographic assessment Baseline 6-months post-SAVR Paired t-test (p-value) Mean aortic gradient (mmHg) 49.6 ± 12.2 11.2 ± 5.1 &lt;0.0001 LA area (cm2) 20.9 ± 4.9 19.5 ± 4.1 0.02 LA indexed volume (mL/m2) 37.4 ± 12.4 30.7 ± 8.3 &lt;0.0001 LASr (%) 30.0 ± 10.4 29.3 ± 11.2 0.57 LAScd (%) 14.3 ± 7.4 14.3 ± 6.8 0.95 LASct (%) 15.6 ± 6.5 15.0 ± 7.2 0.50 LV indexed mass (g/m2) 128.6 ± 31.8 124.5 ± 30.0 &lt;0.0001 LV end-diastolic diameter (mm) 45.7 ± 5.19 44.7 ± 5.7 0.03 LV ejection fraction (%) 66.0 ± 6.0 64.6 ± 5.5 0.54 Mean E/e´ ratio 14.2 ± 5.5 11.2 ± 4.3 0.0004 Values are mean ± SD
Abstract P789 Figure. Left atrial remodeling after SAVR