bluuebunny/crossref_metadata_2025_split huggingface dataset:
P332 A CASE OF METABOLIC ACIDOSIS AFTER INITIATION OF SGLT2–I THERAPY IN HEART FAILURE WITH REDUCED EJECTION FRACTION
Authors: D’Errico G , Orso F , Verga F , Salucci C , Perini E , Vatri M , Poletti E , Cagnoni C , Corti G , Di Bari M , Ungar A , Baldasseroni S 
Published: May 2023

Abstract
In July 2022 C.M., a 58–year–old woman, was admitted to our Heart Failure Outpatient Clinic. Patient with permanent AF undergoing DOAC therapy, previous double mitral and tricuspid valve replacement with bioprosthesis. As comorbidities she had stage IIIb CKD, previous ischemic stroke without outcome, multifactorial anaemia, asthma, ulcerative rectocolitis non–responsive to biological therapy. Since April 2022 progressive reduction in exercise tolerance with dyspnoea for previously well–tolerated exertion, with finding of severe left ventricular systolic dysfunction (FE 25%) due to widespread hypokinesia previously unknown. In September angiographic control confirmed the absence of coronary artery disease. Amiodarone therapy was started for frequent runs of VT. Cardiac MRI confirmed FE 27% with fibrosis of the interventricular septum and lower basal wall of non–ischemic appearance. In view of the clinical–instrumental findings, a single–chamber ICD pacemaker was implanted and the therapy for heart failure with reduced FE was optimised with the introduction of Sacubitril/Valsartan (later discontinued due to hypotension), MRA and SGLT2–I (Empagliflozin). Due to the persistence of labile haemodynamic compensation, an indication was given to perform three cycles of Levosimendan infusion at our Day Hospital. The routine EGA taken during the first infusion cycle showed metabolic acidosis in the absence of significant worsening of renal function (Fig. 1) with mild hypobicarbonatemia and electrolytes in the normal range. On the assumption that the acidosis was secondary to the introduction of SGLT2–I (about two months earlier), Empagliflozin was discontinued. One week after discontinuation, the control EGA (Fig. 1) showed resolution of the acidosis, with a substantially stable glomerular filtrate, so that discontinuation of the drug was confirmed.

Conclusions
In the literature there are reviews and case reports of euglycaemic diabetic ketoacidosis (euDKA) in DM2 patients on SGLT2–I therapy although there are currently only hypotheses regarding the pathophysiological mechanism. The possibility of inducing acidosis with hypobicarbonatemia in the absence of worsening renal function is unclear. A ‘Fanconi–like‘ mechanism could be hypothesised with induction of type 2 tubular acidosis with bicarbonate loss due to glycosuria.
P382 TEAMWORK IS SUCCESSFUL (2): PATIENT WITH DIFFUSE LARGE B–CELL LYMPHOMA (DLBCL) AND MULTIPLE HEART MASSES
Authors: Pennacchioni A , Nizzoli M , Roncali M , Alvarez De Celis M , Turina C , Laurito M , Merli F , Navazio A , Luminari S , Tarantini L 
Published: May 2023

Abstract

Introduction
Patients (Pts) with lymphoma are at high risk of cardiovascular events for the cardiotoxic effects of therapies and direct involvement of the heart. Autopsy series, indeed, indicate that cardiac localization may be observed in 10 – 25% of DLBCL Pts. The presence of cardiac mass, in DLBCL poses further complexity to the management beyond myocardial chemotherapy–related cardiotoxicity for the possible unfavorable/unpredictable evolution of the lymphoma mass (arrhythmias, AV block, myocardial ischemia, pericardial effusion and cardiac tamponade). We report the case of pt. with diffuse DLBCL, and multiple cardiac locations discovered, incidentally, on total body PET performed for disease stratification.

Clinical case
A 72–year–old woman with worsening asthenia and advanced stage non–GCB DLBCL presented multiple cardiac radiotracer uptake at 18FDG PET. The basal echocardiogram evidenced a roundish pedunculated mass at the level of the outflow tract of the right ventricle (24 x 22 mm) with significant obstruction of the RVOT, an oval formation at right ventricular apex with possible myocardial infiltration and a further mass in the right atrial site. Mild (&lt; 1 mm) circumferential pericardial effusion, finally, was appreciated. No other notable alterations . After multi–disciplinary discussion, the patient underwent R–COMP based induction regimen, thus substituting conventional doxorubicin (R–CHOP) with non–pegylated liposomal doxorubicin in order to reduce the risk of acute cardiotoxicity. The first cycle was administered as inpatient under close cardiac monitoring, that was subsequently carried on before each cycle. No embolic and/or mechanical complications occurred. The response to chemotherapy was excellent: after the first cycle a substantial reduction in size of the cardiac masses was observed and after 3 cycles a complete resolution of the same was observed. Interim response evaluation by 18FDG PET after cycle 3 upheld early ultrasound observations by displaying a complete disappearance of pathological uptake.

Conclusions
In the case of patients with advanced DLBCL, multi–imaging evaluation enable appropriate assessment of cardiac conditions, including possible cardiac location and nature of masses. The personalized multidisciplinary management allows a tailored management of complex cases that enables both the achievement of treatment goals and the avoidance of acute complications.
P403 MITRAL VALVE PROLAPSE AND RISK OF SUDDEN CARDIAC DEATH IN A PATIENT WITH VENTRICULAR ARRHYTHMIAS: THE PROGNOSTIC ROLE OF CARDIAC MAGNETIC RESONANCE IMAGING
Authors: Mazza T , D’Ambrosi A , Lukic V , Fina P , Trambaiolo P , Romano S , Granatelli A 
Published: May 2023

Abstract

Introduction
in most cases mitral valve prolapse is a benign condition, however in 2% of cases it has been associated with the risk of sudden cardiac death (SCD). Basso et al have demonstrated papillary muscle’s and left ventricle’s inferolateral wall fibrosis on cardiac magnetic resonance imaging (MRI), in patients who died from SCD with mitral valve prolapse.

Clinical case
A 59–year–old patient was admitted to the Cardiology Department of Pertini Hospital (Rome, Italy) for episodes of vertigo and not sustained ventricular tachycardia in two morphologies at 24–hour ECG monitoring. The patient had negative history for cardiovascular risk factors, but an echocardiogram had demonstrated a moderate mitral valve regurgitation, secondary to valve prolapse with mitral annular disjunction (MAD) (Fig.1). Considering patient‘s age associated with low pre–test probability of coronary artery disease, the patient underwent coronary CT that showed a coronary artery tree free from injury. Cardiac MRI showed increased volumes in the left ventricle and slightly reduced systolic function and valve prolapse of both mitral leaflets determining moderate regurgitation. In addition, intra–myocardial Late Gadolinium Enhancement (LGE) showed fibrosis of the inferior and inferolateral wall with extension to the proximal portion of the inferior papillary muscle (Fig.2). Considering such findings, an intracavitary electrophysiological study (EPS) was performed for an evaluation of the arhythmic burden, by administrating the patient a double extra stimulus from the outflow tract of the right ventricle; the treatment induced a polymorphic ventricular tachycardia, starting from the inferior papillary muscle and degenerating into ventricular fibrillation (Fig.3).

Discussion
considering all the above findings, a mitral valve prolapse at high risk of malignant arrhythmias has been diagnosed and a subcutaneous cardiac defibrillator was implanted.

Conclusions
in mitral valve prolapse associated with complex ventricular arrhythmias, evaluation with cardiac MRI increasingly plays a crucial role in prognostic stratification for defibrillator implantation in primary prevention.
P427 IMPACT OF THE WAR IN UKRAINE ON CARDIOLOGY HEALTH CARE: A SINGLE CENTRE EXPERIENCE
Authors: Alonzo A , Castello L , Matteucci A , Di Fusco S , Colivicchi F 
Published: May 2023

Abstract

Background
Since the start of the conflict in Ukraine, a progressive migration flow from war regions to many European countries has been observed, with an unavoidable impact on health care systems of the individual host states. With this work, we aimed to evaluate the trend over time in the demand of cardiological services of Ukrainian patients in our centre.

Methods
We performed a retrospective analysis of the medical records of our Cardiology Department from January 2015 to December 2022. All cardiological services provided to Ukrainian patients, both in outpatient and inpatient setting, were counted. The average number of services performed annually from 2015 to 2021 was then compared with that observed in 2022.

Results
The average number of cardiology services annually provided to Ukrainian patients during 2015–2021 was 18.7 vs 60 in 2022. In 2022, compared to the previous period, the total number of services performed by our heart centre increased by 246% and the number of hospital admissions by 16.7%. In detail, we observed an increase in performed ECGs (+ 1125%), echocardiograms ( + 465%), Holter ECGs (+88%) and electrophysiological studies (+110%). The average age of Ukrainian patients referred to our centre in 2022 is similar to that of previous years (59.9±2.4 vs 59.8±2.3 years). Finally, an increase in the number of male subjects, who needed our cardiological services annually, was observed (74% vs 22.5%).

Conclusions
With the start of the war in Ukraine, compared to the previous six years, we observed an increase in the number of services provided to Ukrainian patients in our centre. These patients were mainly male, both in outpatient and inpatient settings. The NHS will have to cope with this demand, which is bound to increase over time, by promoting and facilitating the access to care for refugee patients not resident in Italy. These preliminary data can be a starting point for a larger multi–centre analysis, which may be helpful to understand the extent of this new challenge.
P428 NURSING AND AF: SIX YEARS EXPERIENCES OF THE DOAC CLINIC
Authors: Pagliani L , Magoga J , Colledan C , Denas G , Antonini–Canterin F , Bertoldo I 
Published: May 2023

Abstract
Oral anticoagulant therapy (OAT) is the treatment of choice in thromboembolic prevention in patients with AF. Starting from the indications of the regional laws that outline the Diagnostic Therapeutic Path, the need arose in our area to create a divisional clinic dedicated to the diagnosis and treatment of AF. The task of the team (Cardiologists, Nurses, GPs, secretariat) was to monitor the number of patients being treated with DOACs through AIFA PTs drawn up; Verify adherence to regional guidelines, analyze adherence to therapy; Prepare a protocol for the management of complications and emergencies; Ensure that the departments and services authorized to prescribe OACs take charge, in close collaboration with GPs who since June 2020 have become active prescribers and also actors in patient follow–up; Taking care of the training of the prescribers themselves and the education of patients through hospital meetings dedicated to guided counseling and, finally, monitoring the pharmaceutical expenditure of the OAC on the total prescriptions of the local health unit of competence in compliance with the regional indicators prepared. In our hospital, the pilot project started in 2017 (7632 patients currently in FU). In the three–year period 2017–19, an average of 700 therapeutic plans were collected for renewal/first prescription per year (58.3 plans/month) to be monitored in subsequent years. In the three–year period 2020–2022, which saw the difficulty of organizing activities due to the pandemic emergency, 903, 945 and 1090 PTs were analyzed respectively with an average of 89 plans/month, maintaining almost 75% of face–to–face visits compared to telemedical contacts set up in the pandemic context. As appears from the data, therefore, there is a strong need for diagnostic and therapeutic assistance pathways to be increasingly organised. Despite the emergency period and despite a framework in which local medicine could have assisted the clinical and bureaucratic effort, no reduction in the care burden has occurred and indeed the constant increase in patients intercepted makes the complexity and difficulty of a correct clinical classification understandable and management support of the patient with the need for OAT.
P450 ADVANCED ATRIOVENTRICULAR BLOCK AT LOOP RECORDER MONITORING IN A YOUNG PATIENT WITH BRUGADA SYNDROME AND CONDUCTION ABNORMALITIES: CAUSE OF SYNCOPE OR INCIDENTAL FINDING?
Authors: Martini N , Prete G , Sottini S , Porcelli G , D‘addazio M , De Lazzari M , Bertaglia E , Migliore F 
Published: May 2023

Abstract
A 32–year–old man healthy man presented to the emergency department because of remittent fever. His past medical history, physical examination and chest X–ray were unremarkable except for a body temperature of 39 Celsius degrees. Laboratory exams showed a marked elevation of transaminases, cholestasis markers and C–reactive protein, while an abdomen ultrasound revealed hepatomegaly and diffuse hyperechogenicity of the liver. He was diagnosed with acute hepatitis and admitted to the Gastroenterology Unit. Due to the persistent hyperpyrexia despite antipyretics and antibiotics, he was successfully treated with intravenous diclofenac, resulting in temporary remission of fever. First electrocardiogram during apyrexia showed sinus rhythm, first–degree atrioventricular block (PR interval 240 milliseconds), and non–specific intraventricular conduction delay. In the following days, liver and cholestasis markers improved, but he underwent two syncopal episodes without prodromes, the former while he was walking and the latter during meal. A new electrocardiogram revealed a type 1 Brugada pattern. At the time of its recording, however, his body temperature was 38.6 Celsius degrees. He was then admitted to the Cardiology Unit for monitoring and further investigations. 2D–echocardiogram and cardiac magnetic resonance imaging were unremarkable. Telemetry monitoring showed nocturnal episodes of marked sinus bradycardia (up to 35 beats per minute), but no ventricular arrhythmias were documented. He also underwent an invasive electrophysiological study with programmed ventricular stimulation, but again no ventricular arrhythmias were induced. Recording of His bundle electrogram, however, revealed the prolongation of both AH and HV interval (190 and 76 milliseconds respectively). Given the syncopal episodes, an implantable cardioverter defibrillator implantation was proposed, but the patient refused, so he underwent an implantable loop recorder implantation. After three months, at remote monitoring, a nocturnal episode of complete atrioventricular block with a pause of 15 seconds was recorded, thus he was again admitted to the Cardiology Unit. This time he was apyretic, but his electrocardiogram showed a spontaneous type 1 Brugada pattern with “high arrhythmic risk” features as first–degree atrioventricular block and a prominent S wave in lead I. He then underwent a successful implantable cardioverter defibrillator implantation with still an uneventful follow up.
P456 SUBACUTE STEMI AND ISCHEMIC STROKE DURING SARS–COV2 INFECTION: A CASE REPORT
Authors: Sias E , Farina G , Fiori M , Polo F 
Published: May 2023

Abstract
A 71–year–old woman arrived in the ER for left hemiparesis and dysarthria. The Patient was oriented, collaborative. Stable hemodynamics. Left hemiparesis. Dysarthria. NIHSS 8, Ranking 2. Blood tests, EGA, swab for SARS–Cov2 were performed (hsTnI 9433 ng, PCR 15.6 mg/dl, Sars–Cov2 positive test). ECG showed evidence of inferolateral ST–segment elevation with Q waves in the inferior site and negative T waves in the inferolateral leads. An episode of chest pain radiating to the left upper limb two days ago was reported. The echocardiography showed non–dilated left ventricle with global systolic function at the lower limits. Inferior, infero–lateral and medio–basal akinesia with hyper–refractive wall and preserved thicknesses were found. Moreover, a slight layer of circumferential pericardial effusion, without any hemodynamic importance was showed. In order to exclude an aortic syndrome, a CT angiography of the brain, neck and chest was performed for recent lesions, with negative result. Angiography showed the left vertebral artery up to the V3 segment, suspected by dissection. Recommendations on performing fibrinolysis in adults, with concurrent ischemic stroke and subacute STEMI, are conflicting: according to ASA/AHA guidelines in recent 3–month infarction, treatment is reasonable if the inferior or right wall is involved. According to ESO guidelines, fibrinolysis is not recommended if the subacute STEMI is seven days old. The Italian guidelines consider the treatment of acute stroke with r–TPA with subsequent PTCA, with possible stent, and recognize a very low risk of consequent hemopericardium. Depending on the timing of the anginal symptoms, the presence of Q waves on the ECG and the echocardiographic alterations, the AMI was considered subacute with no indication for urgent coronary angiography. For the patient of this case report, a conservative attitude for both pathologies was decided, performing an antiplatelet therapy with ASA and continuous ECG monitoring. Despite the treatment, the patient suffered heart failure and exitus after 10 days hospitalization. The lack of unequivocal guidelines on the treatment of patients with simultaneous ischemic stroke and subacute STEMI, require careful evaluation of the individual case, searching for possible predisposing factors of a poor prognosis.
P458 AN UNUSUAL REINDEER–IS LEFT VENTRICULAR MASS
Authors: Galanti K , Genovesi E , Alberto D , Verrengia E , Magnano R , Di Marco M , Paloscia L 
Published: May 2023

Abstract
A 90–year–old woman is brought to the closest emergency room after being found in a confusional state of mind, with lateral–sided sight deviation with normal cardiovascular findings. Her past medical history is characterized by the presence of systemic hypertension, moderate–to–severe chronic disease. The 12–lead electrocardiogram showed sinus rhythm and aspecific anomalies of the left ventricular repolarization. Lab tests showed normal white blood cells count with increased creatinine levels and quite normal flogosis indices. An initial transthoracic echocardiogram (TTE) showed mild left ventricular concentric hypertrophy with preserved systolic function, but also revealed the presence of a moving posterior mitral leaflet mass, determining mild mitral regurgitation. A head CT scan was performed, showing a right temporo–insular ischemic ipodensity. Considering the echocardiographic and neuronal findings, a transesophageal echocardiogram (TEE) was indicated to look for and better describe the suspicious mass, after beginning an antibiotic therapy in an empiric regimen. TEE revelead a multi–lobular mass characterized by inhomogeneous echogenicity, leaning on the annulus and the atrial side of the posterior mitral leaflet that was fissurated, leading to mild mitral regurgitation. The left appendage showed normal emptying velocity and absence of thrombi. It was not easy to describe this mass morphology and dimensions, but in some projections, it reminded us of a reindeer with various antlers. This case could resemble a classic mitral valve endocarditis, evolved into valve fissuration and arterial embolization leading to ischemic stroke, but the unusual fact is that the laboratory tests showed no white blood cells alteration during the whole hospitalization, with a really minimal CRP change and always negative procalcitonin. That is why we came into the idea that such a mass could also not represent a classical endocarditis. Considering that the echocardiographic characteristics of a thrombus were not encountered, the mass may be a tumor. The most frequent tumors involving the heart valves are papillary fibroelastomas. Considering the absence of clinic endocarditis, some hints led to consider this differential diagnosis: fibroelastomas mostly occur during older ages, they frequently have a mitral or aortic location and they can embolize, differently from vegetations, they are located mostly on the annulus and the basal posterior mitral leaflet.
P467 CHALLENGING MANAGEMENT OF ORAL ANTICOAGULANT THERAPY IN A OBESE PATIENT WITH DILATED CARDIOMYOPATHY, ATRIAL FIBRILLATION AND ICD LEAD THROMBUS
Authors: Massa L , Buratti S , Guazzi M , Garattini D 
Published: May 2023

Abstract
Obesity is a worldwide epidemic condition at high risk for AF development; nevertheless, obese patients are underrepresented in RCTs of anticoagulant agents. Robust evidence assessing efficacy of DOACs in these patients is lacking and, to date, major Associations do not recommend DOACs in patients &gt; 120 Kg (BMI&gt;40 Kg/m2). The use of implantable cardiac devices has substantially increased in recent years; among potential complications are sterile intracardiac clots on the leads, typically discovered as incidental echocardiographic findings. 46 ys old male patient, III degree obesity (160 Kg,BMI 51 Kg/m2), ex–smoker. In 2012, acute heart failure and diagnosis of non–ischemic dilated cardiomyopathy (EF 20%). During the follow–up by a tertiary Center, in 2021 he was implanted with single–chamber ICD in primary prevention. At presentation, HFrEF pharmacological therapy was optimal (ARNI,SLGT2i,MRA,B–blocker). He came to the ED complaining of weakness; ECG showed atrial fibrillation, mean ventricular rate 160 bpm. CHA2DS2–VASc was 1. Anticoagulation with subcutaneous enoxaparin 10000UI twice daily was started. He was admitted to the cardiology ward and remained hemodynamically stable, with persistence of AF. Transesophageal echocardiography excluded thrombus in the left atrial appendage; unexpectedly, a filamentous, floating formation of about 30mm on the atrial side of the ICD lead was observed, compatible with a thrombotic formation, since the patient, afebrile, didn’t show any suggestive sign of endocarditis nor past history of infection; blood cultures, CRP and Procalcitonin were negative. In the absence of any shunt at the level of interatrial septum, it was felt safe to proceed to electrical cardioversion, able to restore sinus rhythm with a single 250J biphasic synchronized shock. Oral anticoagulation with warfarin was started, since no DOAC was considered adequate for effective anticoagulation. The following in hospital course and post–discharge weeks were uneventful, despite unstable INR values. Follow–up is ongoing; the patient has not yet repeated imaging to check for mass resolution. Stroke prevention in severely obese patients with AF is challenging and points toward warfarin use, as the evidence of DOACs efficacy is sparse. In our case, anticoagulant choice was also motivated by concomitant presence of a lead thrombus, a scenario in which optimal management and anticoagulation regimen are not clearly established yet.