bluuebunny/crossref_metadata_2025_split huggingface dataset:
P209 HUGE AND OCCLUDING LAA THROMBUS DISSOLUTION IN A CASE OF SEVERE TACHI–CARDIOMYOPATHY
Authors: Maurizi K , Ianni U , D'Agostino S , Gizzi G , Molisana M , Parato V 
Published: May 2023

Abstract
A 62–year–old man was admitted to our emergency department for worsening nocturnal dyspnea and orthopnea for 15 days. Finding of Acute Pulmonary Edema in a setting of non datable high ventricular response atrial fibrillation (AF) associated with severe LV dysfunction. NT–proBNP 8.252 pg/ml. ECG: atrial fibrillation with high ventricular response (120/bpm). TTE: Severe left ventricular systolic disfunction (EF 20%). TOE/3D TOE: evidence of voluminous oval–shaped thrombotic formation (10 x 17 mm) protruding in LA and completely occluding the left atrial appendage (LAA). LA thrombosis in patients with AF is relatively rare and represents a contraindication to rhythm control strategies. Once an LAA thrombus is identified, effective anticoagulation is recommended for at least three weeks or until LAA thrombus resolution is detected. Available evidence on left atrial thrombus dissolution largely refers to the use of vitamin K antagonist oral anticoagulant (VKAs), but their effectiveness may be influenced by variability in the level of anticoagulant activity obtained, wich may be suboptimal. In a recent prospective observational study has been evaluated the effectiveness of Edoxaban for the resolution of LA thrombosis in 25 patients with AF: it has been demonstrated a complete thrombus resolution in 56% of patients at 4 weeks, similar to studies using VKAs and the other NOACs. Use of NOACs in this setting represents a great field of interest for the near future. In our experience, indeed, after confirmed diagnosis of LAA thrombus, we started anticoagulant therapy with warfarin (currently the first choice), however due to poor INR control, we switched to continuous infusion of unfractionated heparin (UFH), wich represents, in a hospital setting, a safe and effective method for thrombus dissolution, allowing continuous monitoring of efficacy and a rapid cessation of effect in case of major bleeding. In this way we obtained complete thrombus dissolution in about 3 weeks. At the meantime we initiate a rate control therapy, an optimized treatment for HFrEF and intravenous diuretics. Our experience highlights the need of great ductility in the choice of anticoagulant therapy in patients with evidence of voluminous LAA thrombus, monitoring treatment’s efficacy parameters and being ready to change strategy if necessary and it reminds that auricular thrombosis is often inserted in a wider picture of heart disease wich requires multiple other specifics treatments.
P224 THE SHARK–FIN THAT EMERGES AND IMMERGES: A CASE REPORT OF TRANSIENT AND REPETITIVE TRIANGULAR QRS–ST–T
Authors: Valcher S , Villaschi A , Bertoldi L , Briani M , Corrada E , Chiarito M , Condorelli G 
Published: May 2023

Abstract

Introduction
Shark fin sign, also known as triangular QRS–ST–T waveform (TW), is characterized by a giant R wave (amplitude ≥ 1 mV) resulting from the fusion of the QRS complex, the ST–segment and the T wave and showing triangular morphology. TW pattern is quite uncommon and reveals a life–threatening condition that needs aggressive management. Case presentation: A 45–year–old black man with history of arterial hypertension and without known comorbidities arrived at our emergency department (ED) with out–of–hospital cardiac arrest (OHCA). Return of spontaneous circulation occurred after 11 minutes and 2 direct current shocks. At arrival in the ED, he was hemodynamically stable, electrocardiogram showed atrial fibrillation without repolarization abnormalities, and echocardiogram revealed left ventricular hypertrophy and hypokinesia of the mid–basal inferior wall. Plasma level of electrolytes and high–sensitivity troponin were in range. Sedation in the ED was needed due to psychomotor agitation. He was transferred to the cardiac intensive care unit; no arrhythmias were noted. During the night, electrocardiogram monitoring revealed a progressive ST segment elevation in inferior leads up to a triangular QRS–ST–T giant waveform (“Shark fin sign”), confirmed at 12–lead electrocardiogram. After 3 minutes the electrocardiogram showed a progressive and complete resolution of ST–elevation. Akinesia of the inferior wall was confirmed at echocardiogram. The episode repeated 5 more times in the following 40 minutes, while waiting for the arrival of the Cath lab personnel. Coronary angiography revealed a sub–occlusive mid right coronary artery (RCA) stenosis. Percutaneous coronary intervention with the implantation of one drug eluting stent was performed. After the procedure the patient was hemodynamically stable, and the ECG did not show any other abnormality and no episodes of recurrent ST–elevation occurred.

Conclusion
The shark fin sign refers to the abrupt total deprivation of blood flow in large areas of myocardium that are seen during coronary thrombotic occlusion or vasospasm. In our case we assisted to transient but repetitive inferior triangular ST–elevation, probably the expression of RCA plaque coronary vasospasm that cause the ECG shark fin sign and OHCA. This sign correlates with high risk of cardiogenic shock, electrical instability, and cardiac arrest, thus requiring prompt and aggressive management.
P232 CORONARY DISSECTION FROM AMMONIA INTOXICATION
Authors: Ossola P , Gualini E , Ciampi C , Gallone G , Santolamazza C , Pedrotti P , Quattrocchi G , Soriano F , Giannattasio C , Pirola R 
Published: May 2023

Abstract
Spontaneous coronary artery dissection is one of the possible causes of MINOCA defined by a separation of the intima or adventitia from the arterial wall and frequently related to a nontraumatic, noniatrogenic etiology. Coronary artery dissection often involves a single vessel most often represented by the anterior interventricular artery. Case report. An 82–year–old patient with a silent cardiology history presented to the emergency department after accidental ammonia inhalation reporting cough, epiphora, and chest pain. On admission ECG we show a normofrequent sinus rhythm with an EAS and a high lateral Q wave with a negative T wave. In view of the TnT values of 425 mg/dL, an indication for admission with a diagnosis of NSTEMI was posited. On echoscopy, a hypo–akinesis of the mid–distal portion of the anterolateral wall, posterior wall, and interventricular septum (SIV) with inspective left ventricular ejection fraction (FEVS) 35% was evident. In the face of persistence of modest angor, as well as further elevation of troponin values (1400 ng/L) and a significant change in electrocardiogram with development of right bundle branch block, the patient underwent urgent coronarography. Coronary angiography documented by IVUS analysis a spontaneous coronary artery dissection of the anterior descending artery (VAT) with the presence of a non–occlusive wall hematoma at the middle tract. In view of the patient‘s achieved asymptomaticity, hemodynamic stability, and ubiquitous TIMI 3 flow, a conservative approach was opted for, setting medical therapy with ASA + Clopidogrel "off–label" by virtue of the woman‘s low bleeding risk and high ischemic risk. Follow–up echocardiogram performed three days after the patient‘s arrival on the ward showed a fair recovery of biventricular systolic function with an FEVS of 50% with alterations in regional hypokinetic Chinese. Diagnosis was completed by cardiac MRI, which confirmed the ultrasound findings inherent in the kinesis and showed areas of edema at the anterior wall, anterior septum, and anterolateral wall in the absence of late ischemic myocardial enhancement. These findings were found to be suggestive of an associated TakoTsubo syndrome picture.
P234 IT IS TIME THAT ITALIAN AMI NETWORKS ARE BASED ON DIAGNOSTIC–THERAPEUTIC PATHWAYS INCLUDING BOTH TYPES OF ACS (STEMI AND NSTEMI)
Authors: Parato V , Berrettini U , Luzi M , Paci M , Grossi P , Principi T , Zamponi E , Ciucani A , Petrelli G , Curto R , Gabrielli D 
Published: May 2023

Abstract

Background
Nowadays AMI management represents one of the most challenging clinical scenarios. On 8 july 2022 ANMCO held a special event about the last 20 years of AMI networks in Italy. During this event it was highlighted how these networks – supported by ANMCO – led to mortality reduction in the last 20 years (till –57%). By the way, the networks are usually based on diagnostic–therapeutic (D–T) pathways that not include NSTEMI–ACS. At contrary, the prevalence of NSTEMI–ACS is increasing and it significantly contributes to whole mortality due to coronary heart disease in the world. Materials and

Methods
The Functional Cardiology Department of Marche Region (Italy) covers the territory of three provinces. This department provided a new diagnostic–therapeutic pathway for AMI–network on July 2022. Globally, the department provides heart diseases management to 500.000 subjects living in that area. Working group who proposed the new D–T pathway included: 1) all Cardiology Units Directors; 2) all Emergency System Directors; 3) all Emergency Rooms Directors. The diagnostic–therapeutic pathway was based on 1) latest ESC guidelines and whole medical licterature on the topic; 2) geographic area features; 3) logistic local criticisms; 4) multiple sharing meetings results.

Results
The D–T pathway was divided in two chapters: 1) STEMI–ACS; 2) NSTEMI–ACS. STEMI–ACS chapter included 7 steps: 1) Symptoms onset and Emergency System Alert; 2) out of hospital intervention; 3) emergency room (ER) intervention; 4) primary PCI; 5) in–hospital complications; 6) whole in–hospital management and back transfer to the spoke; 7) cardiac rehabilitation and secondary prevention programs. The novelties were represented by: 1) ECG trasmission to the ICUs; 2) detailed establishment of which HUB every town/city of the area is assigned to; 3) inclusion of cardiac rehabilitation and secondary prevention programs in the pathway; 4) inclusion of NSTEMI–ACS with the two revascularization arms cited by the ESC guidelines.

Conclusions
The reported D–T pathway appears very innovative in order to including both two types of ACSs (STEMI and NSTEMI). Considering the latest guidelines, it could be appropriate that new D–T pathways, promoted by AMI networks in Italy, include a specific chapter dedicated to NSTEMI–ACS, given that also this type of ACS may require a time–dependent revascularization therapy and the correct approach may affect mortality and the whole prognosis.
P235 THE ROLE OF BIOELECTRICAL PHASE ANGLE IN PATIENTS WITH HEART FAILURE
Authors: Scicchitano P , Potenza A , Basile M , Sasanelli P , Massari A , Landriscina R , Cannito A , Abruzzese S , Tangorra M , Caldarola P , Massari F 
Published: May 2023

Abstract
The most challenging feature of heart failure (HF) still remains the evaluation of congestion. Residual congestion at discharge and the difficulties in perfectly dosing therapies in order to balance the hydration status of the patient are the most worrisome issues when dealing with HF. The use of bioimpedance vector analysis (BIVA) might promote a different approach in the general management of patients with HF. BIVA is a reliable, fast, bedside tool able to assess the congestion status. It proved to be helpful to physicians for diagnosing congestive status, managing therapies, and providing prognostic information in the setting of HF. Bioelectrical Phase Angle (PhA) – as derived from equations related to the parameters of BIVA – recently surged as a possible biomarker for patients with HF. Studies provided data about the application of PhA in the clinical management and in the overall risk stratification of HF patients. Basically, the use of PhA might be considered as a holistic evaluation of patients with HF which includes the need for a multiparametric approach able to effectively depict the clinical status of patients. There is no definite biomarker able to comprehensively describe and identify all the features of HF patient, but scores based on molecules/techniques able to explore the different pathogenetic mechanisms of HF are desirable. The aim of this review was to provide a comprehensive evaluation of literature related to PhA role in HF and the impact of this biomarker on clinical management and risk stratification of HF patients.
P237 WORSENING OF RENAL FUNCTION AND INCREASE IN RENAL RESISTANCE INDEX AFTER CARDIAC SURGERY
Authors: Barone R , Goffredo G , Di Terlizzi V , Squiccimarro E , Margari V , Di Biase M , Brunetti N , Iacoviello M , Paparella D 
Published: May 2023

Abstract
Worsening of renal function (WRF) is frequently observed after cardiac surgery and it is associated with both short– and long–term worse outcome. Among the pathophysiological conditions favoring the occurrence of WRF, the abnormalities in renal blood flow could play a key role. The aim of this study was to evaluate the changes in renal resistance index (RRI), a parameter reflecting renal parenchymal and hemodynamic parameters, after cardiac surgery.

Methods
Thirty–one patients were enrolled (age 65±12 years, 29% males, mean left ventricular ejection fraction 55±5%, mean creatinine serum levels 0.89±0.18 mg/dl, mean eGFR 89±28 ml/min*1.73 m2). All patients underwent cardiac surgery. Before cardiac surgery, after 3 days and before discharge, RRI was evaluated according to Peurcelot’s formula by renal interlobular arteries pulsed Doppler. Worsening of renal function was defined as an increase in serum creatinine of &gt; 0.3 mg/dl associated with a change &gt; 25% or the need of renal replacement therapy due to severe acute kidney injury.

Results
As shown in the table 1, after cardiac surgery a significant increase in RRI was observed at 3 days after cardiac surgery but not before discharge. The significant increase in RRI was observed both in patients with and without WRF. However, in patients with WRF significant higher values of RRI were observed before as well as after cardiac surgery.

Conclusions
Among patients undergoing cardiac surgery a significant increase in RRI values is observed after surgery. Among patients with WRF a significant greater values of RRI are observed before as well as cardiac surgery thus suggesting that a critical increase in renal resistance could play a role in the cardiorenal syndrome worsening.
P238 THE HEART LOGIC EXPERIENCE IN OUR CENTER “SANTA MARIA DELLA MISERICORDIA” HOSPITAL, UDINE
Authors: Favaretto V , Fumarola F , Tioni C , Facchin D , Driussi M , Imazio M , Sinagra G 
Published: May 2023

Abstract

Background
Outpatient monitoring of patients with chronic heart failure (HF) may result in HF exacerbation and subsequent hospitalizations that may be avoided with an early recognition. The HeartLogic (HL) algorithm automatically calculates a daily HF index based on values including heart sounds, markers of ventilation, thoracic impedance, activity and heart rate and recognize an active alert state relative to a configurable threshold.

Methods
We included 35 patients with HF in optimized medical therapy; the investigational chronic ambulatory data collection was performed via implanted Boston pace–maker, defibrillator or cardiac resynchronization therapy and we analyzed these data since February 2021, ongoing. We established a cut off of HL index of 16 due to the confirmatory trial and we contacted the patients 2 weeks after the threshold exceeding to evaluate their clinical state.

Results
Preliminary data (until December 2021) showed us 24 alarms in total, of whom 7 were truly heart failure related alarms. These are independent from the values of the HL index reached and the best parameter resulted to be the chest impedance. Measurement of third heart sound was another sensitive but not very specific parameter. The main confounding factor was given by infections, especially related to Covid–19. The therapeutic strategy was predominantly increasing the doses of diuretics. There were no heart failure events in patients without the warning HL index.

Discussion
The preliminary data showed us how high is the negative predictor factor of the HL index based on our center parameters. We aim to analyze further data to be more accurate and to find the best way to detect heart failure.
P242 CARDIOGENIC SHOCK WITH ISCHEMIC PHENOTYPE SECONDARY TO INCESSANT VENTRICULAR TACHYCARDIA: A CALL FOR IMPLEMENTATION OF HUB–AND–SPOKE MODEL
Authors: Corticelli A , Centola M , Spina M , Spinelli M , De Carlini C , Moro C , Loffreno A , Ruggiero D , Provenzale G , Aurino L , Russo G , Achilli F 
Published: May 2023

Abstract
A 55–years–old patient presents to emergency room with extensive anterior STEMI, complicated by acute pulmonary edema. The ECG showed sinusal tachycardia, Q waves in V1–V3, ST elevation &gt;2mm V2–V6. The echocardiogram showed akinesia of the apex and anterolateral wall with severe reduction of contractile function (LVEF 30%). The patient was treated with CPAP, dual antiplatelet therapy and diuretics; the urgent coronary angiography showed three–vessel disease with occlusion of the proximal LAD, treated with PCI and two drug–eluting stents implantation. 48 after admission to ICU, the patient developed "combined" shock (IC↓ RVS↓ WP↑), sustained by both severe cardiac dysfunction and a septic complication, requiring inotropes and targeted antibiotic therapy (noradrenaline 0.02 gamma/Kg/min and piperacillin/tazobactam i.v). At 96 hours there was a recovery of contractile function and haemodynamics (CI from 1.8 to 2.7). Weaned from inotropes, he began therapy with low doses of ACE inhibitor, beta blocker, antialdosteronic. On the 7th day of hospitalization, without ischemic and/or electrolyte "triggers", the patient developed "arrhythmic storm" with incessant sustained ventricular tachycardias. Arrhythmias persisted despite antiarrhythmics (magnesium sulfate, amiodarone, lidocaine), IOT, sedation, mechanical ventilation. The temporary pacemaker for overdrive pacing was placed in. After placement of IABP, the patient underwent revascularization of residual coronary artery stenosis. Despite 1 hour of assistance (ABLS), incessant ventricular tachycardia persisted; a third–level center for VA–ECMO inside support was called. After positioning VA–ECMO there was progressive clinical stabilization and –concomitantly– a progressive reduction of ventricular tachycardias. ECMO support was needed for over 7 days due to persistence of arrhythmic storm; it was slowly weaned with stabilization of the patient; an AICD was implanted. Residual function of the left ventricle was mild reduced (LVEF40%) despite protracted CPR. There wasn’t residual cognitive impairment. Implementation of multidisciplinary teams in the spoke centers would improve protocols and early treatments in patients with cardiogenic shock; spoke centers would provide early access to life–saving therapies and safe transfer to hub centers.
P245 IMPLICATIONS IN PHARMACOLOGICAL AND ELECTRICAL OPTIMIZATION IN HEART FAILURE: A EMBLEMATIC CASE
Authors: Placci A , Notarangelo F , Crocamo A , Gonzi G , Bearzot L , Serra W 
Published: May 2023

Abstract
We describe the case of an 82–year–old man with permanent atrial fibrillation in oral anticoagulation therapy. Former smoker. Diabetes mellitus. In 2009, subacute MI with PTCA/DES of anterior descending artery and obtuse marginal branch, critical stenosis of circumflex artery, right coronary artery occluded. Infrarenal aorta occlusion. Echocardiography TT mild–moderate mitral regurgitation. Ejection fraction (EF) preserved. Inferior wall akinesia. In 2019 hospitalization for heart failure due to severe bradyarrhythmia in atrial fibrillation. In therapy with bisoprolol 10 mg/day Echocardiography FE 35%, moderate–severe functional mitral regurgitation, PAPs 55 mmHg. Arterial pressure 100/85 Sat 2O 90% Treatment at discharge: furosemide 75 mg/day, bisoprolol 7,5 mg/day, Metformina 500 mg/day, potassium canrenoate 50 mg/day atorvastatin 40 mgday and warfarin,Ramipril 2.5 mg/day, allopurinol 150 mg/day. In 2020 new hospitalization for heart failure. NYHA III–IV; BNP 1890 pg/ml. Beta–blocker therapy reduced to bisoprolol 3.75 day for pulmonary hypertension and bradycardia, furosemide increased to 100 mg/day, possibly further titratable on the basis of renal function, blood electrolytes and clinical response, maintaining restriction of daily liquids at about 1000 cc. Initiated Sacubitril/Valsartan 24/26 mgx 2 /day. Coronary angiography was not possible due to occlusion of the abdominal aorta and right radial artery (1,2,3). CT CORO performed with relief of the interventricular branch occluded in the middle section; patent obtuse marginal branch stent; right coronary artery occluded. Abdominal aorta occluded at the level of the renal arteries. The patient was submitted to CRT–D implant for bradycardia and wide QRS like left bundle branch block. Glyphozine associated with Metformin. Echocardiography TT LVEF 40%, moderate functional MR, PAPS 35 mmHg. NYHA II. Edema resolution No hospitalizations for decompensation. titrated ARNI at 49/51 mg x 2/day, and the beta blocker Cardicor 5mg/day. At remote monitoring decreased ventricular catheter impedance. What does the case tell us? The combination of Sacubitril/Valsartan and Glifozine determined an inverse remodeling of the heart. The combination of Sacubitril/Valsartan and Glifozine improved cardiac compensation and clinically stabilized the patient.
P249 INTRAMYOCARDIAL HAEMATOMA AS A COMPLICATION OF ACUTE MYOCARDIAL INFARCTION
Authors: Pennacchi M , Mistrulli R , Natale E , Scirpa R , De Luca L , De Felice F , Gabrielli D 
Published: May 2023

Abstract
A 72–year–old overweight man, with known hypertension and dyslipidaemia, had an episode of high intensity chest pain, which appeared at rest and lasted for several hours. A few days later, he underwent a cardiological examination and the electrocardiogram showed normofrequent sinus rhythm, ST elevation of 3 mm and Q waves formed in the anterior and lateral wall leads. The patient was diagnosed with late ST elevation myocardial infarction and was transported to our emergency department. On blood test, troponin levels were significantly elevated. He was treated with dual antiplatelet therapy (DAPT, aspirin and ticagrelor) and then underwent percutaneous coronary intervention (PCI). The mid segment of the LAD was suboccluded and two drug eluting stent (DES) were implanted. The right coronary artery also had a critical stenosis at the second segment treated with implantation of a DES. Final angiographic result was good (TIMI 3). The patient was admitted to our coronary unit where he continued to receive DAPT. During hospitalization a routine transthoracic echocardiogram (TTE) was performed which showed dilated left ventricle with a–dyskinesis of the apex and middle segment of the septum and the anterior wall and reduced ejection fraction (FE 35%). Within the apical segment of the septum and inferior wall, was noted an area of 40x14 mm with different echogenicity, probably referable to intramyocardial haematoma (IH) of the ventricular wall or a stratified thrombus. Both Colour Doppler and echo–contrast, using Sonovue, did not show a continuity between the suspected IH and one of the ventricular cavities. On cardiac MRI, this finding was considered of uncertain interpretation (whether IH or non–protundant mural thrombus). Late transmural enhancement was also observed at the same echocardiographic sites with subendocardial hypointensity bands consistent with areas of no–reflow. As the patient was clinically stable and TTE monitoring showed no progression of IH, a joint decision was made by cardiologists and cardiac surgeon to continue conservative management with DAPT without initiating anticoagulant therapy. At 1 month follow–up, TTE showed a reduction of the IH and an improvement of the EF to 45%. IH is a rare complication of myocardial infarction and revascularization treatments. The incidence is not well documented and the finding is usually occasional by TTE. Appropriate management is still controversial and a personalised approach is recommended.