bluuebunny/crossref_metadata_2025_split huggingface dataset:
P627 Step by step valve destruction in infective endocarditis with no apparent vegetations
Authors: Skafar M , Ovsenik A , Toplisek J , Berlot B , Bervar M 
Published: January 2020

Abstract

Background
Infective endocarditis can present without evident vegetation, diagnosis is challenging and prognosis very poor. We present an illustrative case where natural evolution of the mitral valve destruction with no evident vegetations was followed with frequent consecutive transthoracic (TTE) and transesophageal echocardiography (TOE).

Case presentation
71-year old male with known dilated cardiomyopathy presented with dyspnoea, ankle swelling and severe kidney failure with hyperkalemia. During short hospitalization he was recompensated with haemodialysis, parenteral diuretics and inotropes. TTE showed dilated left ventricle with severe systolic dysfunction and no evidence of valvular disease. Few days after discharge he was readmitted with malaise and febrile state with no obvious site of infection. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated immediately. Weekly TTEs and TOEs were performed (Figure 1, column A-D):
Week 1: TTE was performed due to congestive heart failure. There was no suspicion on disease and TTE showed no obvious mitral valve pathology.
Week 3: Second TTE showed only light thickening of posterior mitral leaflet with mild mitral regurgitation.
Week 4: Follow-up TOE was performed showing posterior leaflet discontinuity with small eccentric regurgitation jet and no vegetation.
Week 6: Symptoms of congestive heart failure persisted despite antibiotic treatment. A progressive destruction of posterior leaflet with evident perforation of P1 scallop and consequent severe mitral regurgitation. Patient was referred for urgent mitral valve replacement.

Conclusions
Staphylococcus aureus is a destructive pathogen and can cause severe destruction of native valve even without obvious vegetations. This case presents echocardiographic features of natural course of infective endocarditis on mitral valve. Despite antibiotic therapy progressive valve destruction is possible.
Abstract P627 Figure.
P634 Right atrial mechanics determined by speckle tracking strain as a more physiologic correlation in pulmonary hypertension
Authors: Ramirez P , Orihuela C , Alvarez M , Ayala M 
Published: January 2020

Abstract

Introduction
Right atrial dilation has also been established as a marker of adverse outcomes in pulmonary hypertension (PH), while right atrial mechanics remain relatively understudied.

Purpose
Transthoracic echocardiography is a practical and widely used tool for risk stratification in PH. We hypothesized that right atrial (RA) strain components [RA reservoir function (ƐR), peak RA contraction (ƐCT) and RA conduit function (ƐCD)] correlates better with strong prognostic parameters as 3D right ventricle ejection fraction (3D RV EF), 6 minutes walking test, systolic pulmonary artery pressure (SPAP) and B-type natriuretic peptide (BNP).

Methods
19 patients with diagnostic PH, type 2 patients were excluded. RA strain was analyzed and determined a correlation with right ventricle function and pulmonary variables.

Results
Morphology correlation was poor with all the variables as SPAP, 6 Minutes walking test, BNP, only RA/LA index has a good correlation with BNP (R = 0.76, P = 0.0004). Right atrial mechanics with strain has good correlation: ƐR correlates with BNP (R= -0.70, P = 0.001) and with SPAP (R= -0.68, P = 0.001). ƐCD correlates with BNP (R=-0.75;P = 0,0002) and with SPAP (R=-0.68, P = 0.001). ƐCT has no correlation with E/e, 3D RV EF, SPAP, pulmonary vascular resistance (PVR), 6 minutes walking test neither BNP. Right atrial deformation sum correlations with 3D RV EF (R= -0.70, P = 0.001), with SPAP (R= -0.72, P = 0.0005), with PVR (R= -0.68, P = 0.001) and with BNP (R=-0.71, P = 0.001).

Conclusion
Right atrium morphological characteristics have poor correlation with variables that evaluate right ventricle function and with variables that predicts outcomes, as BNP, in this patients population. Only RA/LA index as morphology parameter has good correlation with BNP level. Meanwhile right atrial mechanics analyzed by strain has strong correlation with other variables of severity at PH. Right atrial deformation sum has better correlation than other strain parameters in our study.
Abstract P634 Figure. RIGHT ATRIAL DEFORMATION SUM CORRELATION
P640 Multimodality imaging of an asymptomatic aortic fibroelastoma successfully treated with a surgical valve-sparing technique
Authors: Cocco D , Gonzalez Vargas T , Cossu L , Matta G , Cossa S , Manieli C , Locci G , Cirio E M 
Published: January 2020

Abstract
Papillary fibroelastoma is an uncommon cardiac tumour. It is usually attached to the chordae tendineae or to the papillary muscles, while the involvement of the valves or the LVOT is rarely seen. The diagnosis is often due to incidental finding because the tumor is often asymptomatic, even though structural cardiac damages or dramatic embolization may occur. We present the case of a 66 year old woman affected by arterial hypertension and dyslipidemia. During a routine cardiologic visit a transthoracic echocardiogram unexpectedly revealed the presence of a extremely mobile peduncolate mass (11x5mm) with a homogenous speckle pattern, apparently settled on the aortic side of the right cusp of the aortic valve. No further pathological elements were detected. A diagnosis of suspected fibroelastoma was made and the patient was transferred to the cardiac surgery department. On admission clinical examination and vital signs were unremarkable. No symptoms suggestive of TIA or amaurosis were reported by the patient, hence the tumor was considered as an asymptomatic incidental finding. Since the mass did not seem to be firmly attached, based on the high risk of embolization and the possibility of coronary ostia impingement with the manipulation of the catheters, the Heart Team decided to omit a pre-interventional coronary angiography. A coronary CT scan excluded significant coronary artery disease and the patient was offered a surgical resection of the mass. After anterior mini-sternotomy, during extracorporeal circulation, the ascending aorta was opened with a transversal incision and the aortic valve was exposed. A pedunculated tumour of 1.5x2 cm implanted in the edge of the right cusp was observed and completely excised with a valve-sparing resection. Macroscopically, the tumour looked whitish and filamentous, suggestive of fibroelastoma. At the end of the procedure transesophageal echocardiography guaranteed the competence of the aortic valve was preserved. The patient recovered successfully and was discharged one week after the intervention. The control transthoracic echocardiography excluded tumoral residual and the histological examination confirmed the diagnosis of fibroelastoma. The patient was discharged after an uneventful course. This report singularly shows a rare case of aortic location of an asymptomatic fibroelastoma treated with an early surgical approach in order to avoid embolic complications. Multimodality imaging provides clear and exemplary information about this rare entity. Nowadays, the optimal management of challenging cases requires a multidisciplinary team with a discrete familiarity with the common imaging techniques, which play a pivotal role in the diagnostic, pre-procedural and interventional setting.
Abstract P640 Figure. Multimodality imaging: fibroelastoma
P642 Coronary arteriovenous fistulas
Authors: Ciuca C , Balducci A , Lovato L , Niro F , Angeli E , Cesaretti S , Bonfiglioli R , Gargiulo G , Donti A 
Published: January 2020

Abstract

Clinical case
A 53 years woman in good health and un uneventful clinical history except for a mild hypercholesteremia was evaluated for palpitations. At the clinical examination she had a systolic murmur 3/6 Levine, with no signs of heart failure.
The ECG showed normal sinus rhythm with a normal heart rate (62bpm), normal atrio-ventricular and intraventricular conduction and normal repolarisation, one supraventricular premature beat. The echocardiography showed normal biventricular dimension and function, no valvular heart diseases, no septal defects, regular aortic dimensions. A giant right coronary was evidenced (Figure, panel a) with an arteriovenous fistula originating from the right coronary artery and draining through the coronary sinus into the right atrium (Figure, panel b). The CT coronary angiogram evidenced an dilated right coronary artery communicating with the coronary sinus (arteriovenous fistula) draining into the right atrium. A smaller arteriovenous fistula was evidenced between the circumflex artery (slightly dilated) and the great cardiac vein. (Figure, panel c-e)
The Treadmill test didn’t evidence an induced ischemia; however the patient didn’t perform a maximal exercise (double product 20400mmHb*bpm). Moreover, during the first steps of recovery frequent supraventricular premature beats were registered with phases of bigeminies followed by a junctional rhythm phase. Thus, a Gated myocardial Perfusion SPECT was performed evidenced a mild stress induced ischemia of the inferolateral and apical left ventricle wall with normal rest perfusion and normal left ventricle volumes (125ml during exercise and 134ml at rest) with a normal ejection fraction ( &gt; 65%). (Figure, panel f)An elective coronarography was planned. The patient is on therapy with beta-blockers and aspirin. The patient is asymptomatic for angina. Antibiotic prophylaxis was recommended for dental, gastrointestinal, or urologic procedures. Discussion: Coronary arteriovenous ﬁstula (CAVF), first described in 1865 by Krausein (1), are a rare congenital heart disease representing less than 0.5% of all congenital heart diseases with an extremely rare prevalence 0.002% in the general population (2). Moreover, therapy of CAVF is still controversial with previous data showing a relatively high rate of myocardial infarction after surgical repair (3). The recent AHA/ACC guideline for the management of adults with Congenital heart disease recommend a review by a knowledgeable team that may include congenital or noncongenital cardiologists and surgeons to determine the role of medical therapy and/or percutaneous or surgical closure (4) Conclusion: CAVF is a very rare congenital heart defect and might be asymptomatic and evidenced by hazard in adults patients. Therapy strategy demands a multidisciplinary team evaluation and should be be individualized according to the clinic presentation, the presence or absence of myocardial ischemia or ventricular dysfunction.
Abstract P642 Figure.
P645 Familial restrictive cardiomyopathy and Noonan"s syndrome: a rare association
Authors: Surkova E , Barradas-Pires A , Li W 
Published: January 2020

Abstract

Background
Noonan syndrome is a rare genetic disorder. Typical cardiac involvement include pulmonary stenosis and hypertrophic cardiomyopathy. We present the association of Noonan syndrome with familial non-hypertrophic cardiomyopathy with haemodynamic features of restrictive physiology.
Case description. A 30-year old male patient presented to the outpatient clinic with clinical symptoms of heart failure which was slowly progressive since age 20. He was found to have features of restrictive cardiomyopathy aged 12 years at the time when his mother was diagnosed with Noonan syndrome and restrictive cardiomyopathy.
On examination, his 1st and 2nd heart sounds were normal, however 3rd heart sound was present. Pulse was regular, 75 per minute, BP 110/70 mmHg. Chest was clear and saturation 98%.
Echocardiography showed small left ventricle (LV) with preserved ejection fraction (EF), borderline LV wall thickness (10-11 mm), restrictive filling pattern with mitral valve E/A ratio 4.2 and deceleration time 68 ms; dilated both atria; and pulmonary artery systolic pressure of 37 mmHg (Figure, panels A-C; F). Prominent late diastolic reversal flow was noted in hepatic veins (Panel D). LV longitudinal strain was borderline in absolute value (-18%) however demonstrated ‘apical sparing’ pattern (Panel E). The right ventricle was small in size with mild hypertrophy and dynamic function, but normal flow through pulmonary valve. Prominent diastolic reversal flow was also noted in superior vena cava.
Cardiac magnetic resonance confirmed echocardiographic findings and additionally demonstrated prominent trabeculations and myocardial crypts in the LV, small pericardial effusion; no signs of amyloidosis, myocardial infarction, infiltration or fibrosis.
Right heart catheterisation showed borderline pulmonary hypertension with a mean pressure of 25 mmHg, raised pulmonary artery wedge pressure 18 mmHg, normal pulmonary vascular resistance 1.9 WU, and a ‘square root sign’ (Panel G).
Patient underwent cardiopulmonary exercise testing, he stopped after 9 mins of Bruce protocol due to fatigue, reaching the Peak VO2 of 21.1ml/kg/min (49% of predicted value). No ST changes or arrhythmic events were noted.
Patient was diagnosed with primary (non-infiltrative) familial restrictive cardiomyopathy and discussed at multidisciplinary team meeting with recommendation of close follow-up for timing for heart transplantation. Meanwhile he was encouraged to continue treatment with ramipril and start regular physical activity.

Discussion
There are only few reports describing familial non-hypertrophic cardiomyopathy in patients with Noonan syndrome and none in their family members. We review typical clinical and diagnostic features of restrictive cardiomyopathy involving both ventricles and raise awareness of clinicians of primary familial restrictive cardiomyopathy as a possible cardiac manifestation in patients with Noonan syndrome and their immediate family members.
Abstract P645 Figure.
P647 Constrictive pericarditis - a rare entitiy, often missed
Authors: Banthia NILESH , Banthia D R 
Published: January 2020

Abstract

Funding Acknowledgements
No funding

OnBehalf
no group
Case of a 14 yrs old girl, presenting with abdominal distension, odema feet and occasional dyspnoea.
Evaluated with USG abdomen s/o hepatomegaly, ascitis, and GB wall thickening, blood reports all normal, including LFT, CBC, creatinine, and TSH. Pt had no h/o fever, or cough, dyspnoea, loose motions, jaundice.
ECG and CXR were also normal.
Started on diuretic with some response but odema and abdominal distension persisted, so admitted to our hospital after 4-5 months of illness for complete work up of her disease.
We did echocardiography which showed dilated RA and LA, with septal bounce, and variation in Mitral Valve Doppler velocities with respiration, also annulus reverses, with Lateral MV tissue Doppler velocity being less than the medial Mitral Valve annulus , also there was Inferior Vena Cava plethora, with dilated hepatic veins, with flow reversal in it with expiration. Also the pericardium was thickened and measured 5mm in a small girl. All these findings went in favour of constrictive pericarditis.
We went ahead and did cardiac MRI, which confirmed our findings and showed pericardium being thickened, 5mm, and septal bounce. Also there were e/o mediastinal nodes.
All these went in favour of constrictive pericarditis, with Kochs as the cause.
This has been diagnosed recently on 13 th December only and now we have started the pt on steroids with Anti Tuberculosis Treatment and waiting for her response.
This is being presented for the rarity of the disease, and how we need to keep on doing investigations and keep our eyes open of a rare disorder, to be diagnosed and relieve the patient of its symptoms.
P649 Before and after: sinus venosus atrial septal defect
Authors: Marco Clement I , Eiros R , Dalmau R , Lopez T , Guzman G , Sanchez-Recalde A , Dominguez P , Valbuena S , Caro J , Rosillo S , Ruiz J , Gonzalez A , Merino C , Martin L , Lopez Sendon J L 
Published: January 2020

Abstract

Introduction
The diagnosis of sinus venosus atrial septal defect (SVASD) is complex and requires special imaging. Surgery is the conventional treatment; however, transcatheter repair may become an attractive option.

Case report
A 60 year-old woman was admitted to the cardiology department with several episodes of paroxysmal atrial flutter, atrial fibrillation and atrioventricular nodal reentrant tachycardia. She reported a 10-year history of occasional palpitations which had not been studied. A transthoracic echocardiography revealed severe right ventricle dilatation and moderate dysfunction. Right volume overload appeared to be secondary to a superior SVASD with partial anomalous pulmonary venous drainage. A transesophageal echocardiography confirmed the diagnosis revealing a large SVASD of 16x12 mm (Figure A) with left-right shunt (Qp/Qs 2,2) and two right pulmonary veins draining into the right superior vena cava. Additionally, it demonstrated coronary sinus dilatation secondary to persistent left superior vena cava. CMR and cardiac CT showed right superior and middle pulmonary veins draining into the right superior vena cava 18 mm above the septal defect (Figures B and C).
After discussion in clinical session, a percutaneous approach was planned to correct the septal defect and anomalous pulmonary drainage. For this purpose, anatomical data obtained from CMR and CT was needed to plan the procedure. During the intervention two stents graft were deployed in the right superior vena cava. The distal stent was flared at the septal defect level so as to occlude it while redirecting the anomalous pulmonary venous flow to the left atrium (Figure D). Control CT confirmed the complete occlusion of the SVASD without residual communication from pulmonary veins to the right superior vena cava or the right atrium (Figure E). Anomalous right superior and middle pulmonary veins drained into the left atrium below the stents. Transthoracic echocardiographies showed progressive reduction of right atrium and ventricle dilatation. The patient also underwent successful ablation of atrial flutter and intranodal tachycardia. She is currently asymptomatic, without dyspnea or arrhythmic recurrences.

Conclusions
In this case, multimodality imaging played a key role in every stage of the clinical process. First, it provided the diagnosis and enabled an accurate understanding of the patient’s anatomy, particularly of the anomalous pulmonary venous connections. Secondly, it allowed a transcatheter approach by supplying essential information to guide the procedure. Finally, it assessed the effectiveness of the intervention and the improvement in cardiac hemodynamics during follow-up.
Abstract P649 Figure.
P651 Left intraventricular mass. An exceptional finding
Authors: Alvarez Roy L , Ruiz Zamora I , Pinillos Francia G , Gutierrez Fernandez A , Leal Fernandez O , Sanchez Valenzuela D , Portero Perez P , Azcarate Aguero P , Alonso Perez L 
Published: January 2020

Abstract
74-year-old woman without cardiovascular risk factors. Se came to the out-paint clinic due to chest pain.
Normal ECG. Spherical, pedunculated, mobile, slightly hyper-echogenic mass at the level of the posterior papillary muscle by transthoracic echocardiography. Cardiac MR (CMR) was performed for further evaluation: mobile mass of 4 x 5mm, located in the mitral subvalvular apparatus was confirmed, with similar intensity to the myocardium in the SSFP sequences. In T2 TSE sequences, the mass was hyperintense and in the perfusion sequences marked hypoperfusion was found. In early late gad enhancement the mass was hypointense and in the late phase, hyper-intense. According to these findings papillary fibroelastoma was our first diagnostic choice.
The coronary angio showed a significant RCA stenosis. The tumor was surgically removed and aorto-coronary bypass was perfomed. Pathological anatomy confirmed the suspected diagnosis.
Papillary fibroelastoma is the second most frequent benign primary cardiac tumor, originated mainly in the valvular endocardium. The most frequent localization of these tumors is in the aortic valve. The vast majority are asymptomatic and their diagnosis is usually incidental (as in the case described), although severe symptoms may appear secondary to embolic phenomena such as cerebrovascular event, acute myocardial infarction or even sudden death by coronary embolization. The initial diagnosis is usually made by echocardiography. CMR is a reference diagnostic technique in the study of cardiac tumors: provides a better location and tissue characterization. Regarding the treatment, it is recommended the exeresis, in symptomatic patients with embolic phenomenon or in asymptomatic patients with a high risk of embolization (tumors&gt; 1cm or very mobile).
This case is of special interest since the location of a fibroelastoma in the mitral subvalvular apparatus is exceptional (there are very few cases described in the literature). In addition, although in the study of cardiac tumors pathological anatomy remains the reference diagnostic method, this case shows how cardio-MRI can correctly guide diagnosis even in small and mobile tumors.
Abstract P651 Figure. A.3D TOE B.Surgical image C.CMR D. PA
P656 Cardiac dysfunction in breast cancer patients treated with anthracyclines: a single-center experience
Authors: Cardoso Torres S , Sousa C , Simoes J , Maia Araujo P , Nunes A , Tavares Silva M , Pinto R , Paiva M , Macedo F , Maciel M J 
Published: January 2020

Abstract

Introduction
Cardiac dysfunction is a well-documented side effect of cancer treatment, with significant morbidity and mortality. Cardio-oncology units play a vital role in the early identification and management of cancer therapy related cardiovascular side effects and provide a multidisciplinary care for cancer patients.

Purpose
To describe the incidence of cancer treatment related cardiac dysfunction (CTRCD) in a population of breast cancer patients (pts) under chemotherapy in a single center cardio-oncology unit, and to assess its predictors.

Methods
We retrospectively evaluated 83 women on anthracycline therapy for breast cancer, with or without anti-HER2 therapy, followed-up between January 2017 and July 2018.
CTRCD was defined as more than 10% absolute reduction of LV ejection function (LVEF) to below 50%. Pts with &gt;15% relative percentage reduction from baseline Global longitudinal strain (GLS) or with elevation of high-sensitivity Troponin I (hsTI) levels were considered to be at high risk for developing CTRCD and started cardioprotective treatment with an ACE inhibitor/ARB and a beta-blocker, as did pts with confirmed CRTCD. Also, in pts under antihypertensive drug therapy, switching drugs to cardioprotective ones was performed in the index consultation.
Follow-up was organized in our cardio-oncology consultation at 0, 3, 6 and 12 months (or more frequently in selected high-risk cases). Interruption of chemotherapy was a joint decision of the oncology and cardiology teams.

Results
A total of 83 women with a mean age of 49 years (26-76) were included. 4 pts (4.8%) developed CTRCD. 28 pts (33.7%) were considered to be at high risk due to GLS reduction during follow-up and 17 pts (20.5%) were at high risk due to hsTI elevation.
From all the baseline characteristics, only basal BNP correlated with CTRCD (p = 0.033). Other characteristics such as age, presence of cardiovascular risk factors and the previously proposed Cardiotoxicity Risk Score (CRS) did not.
There was a high percentage of pts (51.8%; n = 43) under cardioprotective drugs. 37% of the pts initiated cardioprotective drugs following cardio-oncology consultation. Chemotherapy was discontinued in only 2 pts (2.4%).

Conclusion
CTRCD is difficult to predict by baseline clinical characteristics. Monitoring and management of CTRCD by a multidisciplinary cardio-oncology team resulted in a high rate of cardioprotective drugs use and low rate of permanent discontinuation of chemotherapy. Further studies are needed to further analyze the relationship between these two variables.