bluuebunny/crossref_metadata_2025_split huggingface dataset:
P132 A CASE REPORT OF A STEMI MIMICKER IN A PATIENT WITH TUMORAL MYOCARDIAL INFILTRATION AND LITERATURE REVIEW
Authors: Carmina M , Pieri E , Romano G , Geraci G , Minà C , Bonnì E , Polizzi V 
Published: May 2023

Abstract

Introduction
We report a case of ‘STEMI–like’ presentation, with marked STE on ECG in a patient with lung cancer and cardiac catheterization showing no significant coronary obstruction. A 76y woman presented in the emergency room with dyspnea and chest pain.She had a history of hypertension, obesity, previous cerebellar ischemia and pulmonary neoplasia with involvement of left upper lobe and stenosis of main left bronchus and mediastinal infiltration, on palliative treatment.First ECG showed atrial fibrillation (AF) 150 bpm and marked convex STE in I and aVL leads with reciprocal changes, so urgent coronary angiography (CA) was performed. Initial therapy was BB, ASA and UFH. CA surprisingly showed no significant coronary obstruction. Transthoracic echo (TTE) showed a large mass involving pericardium and left atrium, with infiltration of left myocardial lateral wall with a fingernail shape. HS troponin reached 10xN. The STE persisted on subsequent ECGs. In conclusion the ECG changes are due to neoplastic infiltration of left ventricle lateral wall, while AF is due to atrial infiltration. Discharged on day3, the patient was maintained on palliative care plus BB but no antithrombotic therapy due to very high risk of pulmonary bleeding and hemorrhagic infarction of ventricular wall. In our case no Thoracic CT Scan was performed, so we cannot differentiate between cardiac muscular involvement by pericardial metastasis and infiltration by the primary tumor, which is more likely because of the anatomic relationship between left upper lobe and the heart.

Discussion
Cardiac metastases varies in incidence (2.3 –18.3%), decrease with age, and most frequently origin from respiratory system. They can involve any heart chambers, clinical patterns depend on degree and site of myocardial infiltration.When ventricular wall is infiltrated pseudo–ischemic ECG changes may be induced;persistency of STE suggests tumour compression and/or myocardial infiltration. Patients with known malignancy with chest pain and STE should be screened for cardiac metastases and treated with a single (and not double) antiplatelet agent until coronary stenosis are confirmed. If systemic thrombolysis is considered, a bedside TTE should be performed before therapy.
P146 PERIPHERALLY INSERTED CENTRAL VENOUS CATHETER AND PERSISTENT LEFT SUPERIOR VENA CAVA: WHAT SHOULD WE KNOW?
Authors: Gatto M , Celli E , Ferrari I , Biava G , Nicastri E , Antinori A 
Published: May 2023

Abstract
Peripherally inserted central catheters (PICCs) are widely used medical devices to provide medium to long–term infusion treatment and therapy. PICC placement is contraindicated in cases of deep–vein thrombosis, end–stage renal disease or if deep venous access is compromised. Among the possible complications there are some related to the interventional procedure (e.g. accidental puncture of an arterial vessel, injury to peripheral nerves, misplacement, arrhythmias, haematoma) and others related to the post–implantation phase (e.g. thrombosis, infection, gas emboli, phlebitis). One of the possible intra–procedural complications is the occasional finding of a persistent left superior vena cava (PLSVC). PLSVC is an anatomical variant present in at least 0.5% of the general population and its occurrence during interventional procedures is not uncommon. Clinical case description An 82–year–old woman was admitted to our Institute following a diagnosis of herpetic encephalitis (HSV1). She had a history of hypothyroidism undergoing substitution treatment. Cause the poor peripheral venous patrimony and the need of infusion therapy with acyclovir, levetiracetam and ceftriaxone, the indication for PICC implantation was given. After antibiotic prophylaxis and sterile field preparation, the procedure was performed with ultrasound–guided Seldinger technique by puncturing the left basilic vein. A successive X–ray showed the PICC running unusually parallel to the right sternum (Fig. 1). The echoscopy with bubble test allowed to visualize the agitated saline solution in the right atrium. In view of the suspected venous abnormality, the PICC was removed and a single–lumen MiniMidline 4F of 11 cm length was placed in the right basilic vein (4 mm). A subsequent chest CT scan visualised the PLSVC and its intrathoracic course, the presence of the right superior vena cava was also observed (Fig. 2). The PLSVC is an anatomical variant encountered during interventional procedures involving peripherally inserted central venous catheters. It is important to recognise this variant to avoid possible procedural and/or post–procedural related surgical complications.
P164 PERCUTANEOUS LEFT STELLATE GANGLION BLOCK IN REFRACTORY LEFT ATRIAL TACHYCARDIA
Authors: Morena A , Gravinese C , Frea S , Angelini F , Bocchino P , Bruno F , Saglietto A , Toscano A , Anselmino M , De Ferrari G , Dusi V 
Published: May 2023

Abstract
Percutaneous left stellate ganglion block (PLSGB) has been recently implemented for the acute treatment of refractory ventricular arrhythmias (VAs). The beneficial effect on supraventricular arrhythmias susceptibility and their ventricular response is well characterized in animal models, less so in humans. Available data suggest a significant prolongation of atrial refractory period, a reduction in inducibility and duration of atrial fibrillation and of all spontaneous intra– and postoperative atrial arrhythmias after thoracic and cardiac surgery. Here we describe a case of PLSGB for focal atrial tachycardia (AT). Case: we present a 68–year–old men with hypertension, obesity, OSAS and previous anterior myocardial infarction in the setting of a trivessel coronary disease, treated with PCI and complicated by apical aneurysm, with a LVEF of 38% and a moderate mitral and aortic regurgitation. He was on chronic antiarrhythmic therapy with bisoprolol 1.25 mg and ranolazine. He presented in the ED due to palpitations, pre–syncopal episodes, and worsening dyspnea. The ECG showed very frequent, self–limiting episodes of AT with a 1:1 atrioventricular (AV) conduction and a variable heart rate (HR) between 100 and 160 bpm, alternating with sinus rhythm at 45–50 bpm, sometimes conducted with aberrancy. Isolated and repetitive premature ventricular beats (PVB, maximum 8 beats) were also documented. Amiodarone, lidocaine, and intravenous unloading therapy were tried, without benefit. Coronary angiography was negative. PLSGB with an ultrasound–guided lateral approach (local bolus of lidocaine 100 mg+ropivacaine 20 mg) was performed, without complications, inducing palpebral ptosis. Over the next 15 hours we observed the disappearance of non–sustained VAs, the reduction of PVBs, and a progressive reduction of AT burden, of mean hourly HR (from 84 to 50 bpm, –40%) and of mean HR during AT (from 158 to 84 bpm, –47%, with AV 1:1 conduction). The patient subsequently underwent ablation of an extra systolic focus found near the ostium of the right inferior pulmonary vein, with no recurrences after 18 months.

Conclusions
This case highlights the potential efficacy of PLSGB in the acute treatment of supraventricular arrhythmias refractory to medical therapy. Prospective studies will help us to identify the extent, time of onset, and duration of its benefit depending on the type and mechanism of the underlying arrhythmia and the clinical characteristics of the patient.
P170 WHICH DIAGNOSTIC PROCEDURE IN CANCER SURVIVORS WITH CHEST PAIN? DESCRIPTION OF A CLINICAL CASE
Authors: Ferretti M , Demola P , Farì R , Pignatelli G , Grimaldi T , Menzà G , Mantovani F , Guiducci V , Navazio A , Tarantini L 
Published: May 2023

Abstract

Introduction
Cancer and CVD often share common risk factors and pathophysiological mechanisms, the relationship can be amplified by oncological treatment. In the case of aromatase inhibitors (AIs), used for a long time in breast cancer (BC) expressing the estrogen receptor there is a significant association with dyslipidemia, metabolic syndrome, ischemic heart disease and heart failure. For this reason the ESC guidelines on Cardio–oncology (LG–CO) recommend the evaluation of the baseline CV risk using SCORE2 or SCORE2–OP and aggressive control of CV risk factors (RF) to be integrated with the management of cancer. In case of suspicion of coronary artery disease (CAD), ESC LG–CO recommended the adoption of ESC 2019 guidelines for CAD. We present a case of atypical chest pain (LG 2019 ESC CAD pre–test probability &lt; 15%) in a woman at very high CV risk and in adjuvant therapy with AI for BC

Clinical case
August 2022: 63–year–old female with multiple RF (premature family history of CAD, smoke, hypertension and dyslipidemia) in adjuvant treatment with Exemestane (Letrozole not tolerated) for BC (2020: T2N0M0 ER 99%, PGr– HER2– Ki67 20%) presents in ER for chest pain typical for site, character and irradiation (constricting – burdening, retrosternal radiating to the neck and shoulders) mainly at rest, in the evening, very rarely induced by rapid efforts. Statin therapy was discontinued after initiation of letrozole therapy for arthralgias – myalgias. At the most recent evaluation of blood chemistry: LDL cholesterol 185 mg/dl, Hb, glycemia and thyroid hormones were normal. ECG and rest, troponin, echocardiogram and exercise ECG were normal. Non–synchronized CT with ECG, performed for tumor staging, showed the presence of multiple calcifications on DA, CX and CD (Figure 1). The CGF confirmed the presence of a critical stenosis on the right coronary artery (Figure 2) and a non–critical stenosis on the DA (Figure 3). Successfully performed PTCA with DES implant and started DAPT + high intensity statin with Ezetimibe in addition to antihypertensive therapy obtaining asymptomaticity and optimal control of CV risk factors (FR)

Conclusions
Aggressive control of CV RF is mandatory in women with BC on AI therapy and high CV risk; the onset of symptoms suggestive of CAD must not be overlooked and in this context coronary CT can be a valid tool for estimating the atherosclerotic burden and to establish the diagnosis.
P171 CARDIOTOXICITY IN A PATIENT WITH UROTHELIAL CARCINOMA TREATED WITH DURVALUMAB AND CARBOZANTINIB
Authors: Mautone F , Casavecchia G , Pesolo M , Brunetti N 
Published: May 2023

Abstract
We present the clinical case of a 53–year–old patient with urothelial carcinoma enrolled in the ARCADIA study since April 2020, in therapy with Durvalumab and Carbozantinib (24 cycles). Durvalumab was suspended in October 2022 due to the increase in pancreatic enzymes and the probable autoimmune genesis of pancreatitis. On 04/12/2022, due to the onset of epigastralgia with ECG finding of sinus tachycardia and ST elevation in the lower site with HS–TnI 18883.8, he performed emergency coronary angiography which was negative for significant stenosis. On the Echocardiogram: Severe left ventricular systolic dysfunction (FE 25%). The patient presented increased inflammation indices and acute renal failure with Exitus.
P289 HEART FAILURE DUE TO HIGH OUTPUT ARTERIOVENOUS FISTULA IN A DIALYSIS PATIENT AFFECTED BY AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE
Authors: Massa L , Buratti S , Guazzi M 
Published: May 2023

Abstract
Autosomal dominant polycystic kidney disease (ADPKD) can determine end stage renal disease (ESRD) which require haemodialysis. Surgical creation of arteriovenous fistula (AVF) has been associated with development of left ventricular (LV) dilatation and high output heart failure (HF) and right ventricle (RV) dysfunction at long term follow–up. Databases show an association between ADPKD and idiopathic dilated cardiomyopathy, suggesting that PKD mutations contribute to development of heart failure. 36 ys old female patient affected by ADPKD who required in 2018 bilateral nephrectomy, due to a relapse of severe urinary tract bleeding, and then put in thrice–weekly hemodialysis. Before the procedure in 2016 an echocardiogram showed normal biventricular function, with valvular defects. An AVF, between left humeral artery and the perforator vein of the elbow, was employed as vascular access. 6 months later she was referred to our center for atypical chest pain and palpitations. A transthoracic echocardiogram showed a diffuse hypokinesia with severe left ventricular dysfunction and dilation (EF 25%, VTDi 90ml/mq), a cardiac output of 6,5 l/min, moderate mitral insufficiency, hypokinetic RV, pulmonary artery systolic pressure (PASP) of 56mmHg, severe biatrial dilatation. No signs of congestion. She was admitted to our service. The coronary angiogram was normal, ruling out an underlying ischemic cardiomyopathy. Therapy with b–blocker and ACE–I was started. Doppler ultrasonography of the AVF was performed and showed an high output fistula. Two weeks later at Hospital discharge with medical therapy only, EF improved to 43%. Five months later, the AVF was ligated, after the creation of another more distal one. Echocardiographic re–evaluation one month after the intervention showed a normalization of left ventricular function and volumes ( EF 55%, VDTi 54ml/mq)and of PASP. In 2020 she underwent renaltransplant without complications. The patient is nowadays stable only on beta–blocker for some PVCs, with ongoing annual follow–up. Even if dilated cardiomyopathy and HF in patients affected by APDKD can be caused by genetic predisposition, in our case the main factor was a high output AVF, as showed by complete reversion of left ventricular dysfunction after its ligation.
P291 BUILDING UP A TRANSFEMORAL TAVI PROGRAM DONE BY CARDIAC SURGEONS: OUR EXPERIENCE IN 502 PATIENTS
Authors: Berretta P , Capeestro F , Galeazzi M , Bifulco O , Alfonsi J , Buratto B , Cefarelli M , Malvindi P , Di Eusanio M 
Published: May 2023

Abstract

Background
Current evidence on TAVI has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here we describe the development of our TAVI program and report the results of transfemoral TAVI done by cardiac surgeons on their own.

Methods
The “surgical” TAVI program was built from the ground up in October 2018. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. A multivariable logistic regression was used to study the association of preoperative clinical characteristics, the progression of the experience and the operators, with postoperative early outcomes.

Results
A total of 502 patients were included in the study. Mean patients’ age was 82 years and STS score was 3.1% (2.2 – 4.4). Eighty–five patients underwent transapical TAVI and 417 patients had a transfemoral approach. We progressively moved from TA TAVI towards TF procedures now routinely performed on conscious sedation and using a fully percutaneous approach (Figures 1–3). Both balloon expandable (60.3%) and self–expandable valves (39.6%) were used. After TF TAVI technical success (according to VARC 3 criteria) was achieved in 99.1% of cases. Thirty–day mortality rate was 1%, stroke occurred in 2% of the cases and permanent pacemaker implantation was necessary in 23% of the patients. A moderate or severe paravalvular leak was observed in 4.4% and 0.7% of patients, respectively.

Conclusions
The acquisition of catheter–based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with excellent early results.
P304 ACUTE ST–ELEVATION MYOCARDIAL INFARCTION DUE TO AORTIC DISSECTION: HISTORY OF A LATE DIAGNOSIS AFTER PRIMARY ANGIOPLASTY
Authors: Allievi L , Mircoli L , Colombo F , Barbieri L , Tumminello G , Carugo S 
Published: May 2023

Abstract

Introduction
We report a case of aortic type A dissection, involving the right coronary ostium, presented as an inferior STEMI. The aortic dissection diagnosis was formulated only after the coronary angioplasty on the right coronary was successfully done, leading to chest pain resolution. Dual antiplatelet therapy was administered. We want to underline how sometimes, mostly in emergencies, can be difficult to do the right diagnosis at the right time, even if some angiographic findings could help us to avoid life–threatening mistakes. Case presentation: 60 years–old man with typical angina chest pain started after an effort. The electrocardiogram showed ST elevation in inferior leads, while the echocardiogram akinesia of the inferior wall, a preserved EF, a normal diameter of the aortic root, no dissection signs, no pericardial effusion. The coronary angiography showed ostial RCA occlusion, critical stenosis in mid–distal LAD. Angioplasty on the RCA ostium with one drug–eluting stent (DES 3.5 x 18 mm) achieving reperfusion with TIMI 3 flow, complete resolution of ECG alteration and symptoms. Then PCI of LAD with DES was performed. During hospitalization in ICU recurrence of mild chest pain without ECG alterations. Routine echocardiogram performed the following day showed signs of aortic root dissection and moderate aortic valve regurgitation; an angio–CT scan was immediately performed confirming the aortic dissection, and cardiac surgery was immediately performed with good result. Reanalysis of the angiographic images showed some signs that should have made us think right away of an aortic dissection: abnormal convexity of the right coronary sinus, extravascular stagnation of contrast medium, and ostial RCA stent create a communication between the real and the false lumen, visible at the final injection.

Conclusion
Aortic root dissection, involving coronary ostium, could be a sneaky diagnosis since signs and symptoms could be very similar to myocardial infarction ones. A correct diagnosis is very important, leading to the right surgery treatment, the PCI and the dual antiplatelet therapy could lead to worsening outcomes. It is mandatory to pay attention to the signs that could help us doing the right diagnosis when we are performing coronary angiography. Always check the patient accurately during the ICU stay in order not to lose signs that can let us change the wrong to the correct diagnosis.
P318 A LETHAL SPASM
Authors: Bellin A , Cutolo A , Antonucci A , Gallo F , Themistoclakis S 
Published: May 2023

Abstract
S.F.E.G., a 52–year–old woman of Filipino origin, with no previous cardiology except arterial hypertension under therapy, came to our attention for a witnessed episode of cardiac arrest at home. Rescued by the emergency medical team, who found ventricular fibrillation at presentation, and performed ACLS with ROSC obtained after 3 DC shocks. The first ECG was unremarkable (sinus rhythm, diffuse ST depression). Total body CT was negative. Admitted to the Coronary Unit, the echocardiogram was normal for cavity dimensions and kinetics, as well was coronary angiography except for “short intramyocardial course in the second segment of LAD with slight systolic "milking". In the following days, however, there was a significant rise in HsTnI (1,000 → 47,000 ng/L), with concomitant sudden ventricular bigeminy and negative anterior T waves, akinesia of the anterior apical segments of the LV at cardiac ultrasound (not present at admission), in a patient still intubated and therefore with a non–evaluable clinic. Coronary angiography was repeated, which highlighted this time significant vasospasm affecting the middle segment of the LAD, that regressed after intracoronary nitrates. She was extubated without neurological sequelae, and subjected to ICD implantation by secondary prevention. To treat the vasospastic angina she was discharged with calcium channel blockers at the maximum tolerated dosage, as per guidelines (diltiazem 120mg TID + nifedipine 60mg BID). One month later the patient returned to our attention due to worsening dyspnoea, abdominal pain and anasarca (ascites, bilateral pleural effusion, peripheral oedemas). Hospitalized in a medical setting and treated with diuretics for suspected heart failure, despite the echocardiogram showing preserved biventricular systolic function, normal diastolic function, no valve disease, no pericardial effusion. BNP was 359 pg/mL, subsequently decreasing to 148 pg/mL. After excluding every other possible causes even with total body CT, our hypothesis was that of calcium channel blocker collateral effect (vasodilatory edema). We tapered the dosage until only diltiazem 60mg TID was mainteined, obtaining a significant clinical improvement (weight loss by 10 kg), without further recurrence of coronary vasospasm. This clinical case demonstrates the potential lethality of coronary vasospasm, and a rare complication during therapy with high doses of calcium channel blockers, with very few cases described in the literature.
P321 NEOVASC REDUCER IMPLANTATION AS A USEFUL THERAPEUTIC CHANCE IN REFRACTORY ANGINA
Authors: Acerbo V , De Michele G , Raucci G , Scherillo G , Signore G , Rotolo F , Scialla F , Cesaro A , Calabrò P 
Published: May 2023

Abstract
Refractory angina is a clinical condition caused by myocardial ischemia inadequately controlled by medical therapy and coronary revascularization. Emblematic case of this condition concerns a 72–year–old man with chronic coronary syndrome (percutaneous transluminal coronary angioplasty [PTCA] + drug–eluting stent [DES] on the proximal portion of the left main coronary artery [LMCA] in 2009 and PTCA + 2 overlapping DES on the proximal portion of the right coronary artery [RCA] in 2017) who accessed in the emergency room for unstable angina. The patient‘s past medical history was positive for repeated hospitalizations for unstable angina: in particular, was registered an admission in 2019 with angiographic evidence of intermediate stenosis 30% at the mid–distal tract of LMCA and good distant outcome of previously implanted stents on LMCA and RCA, and a further admission in 2021 with coronary evidence overlapping the previous one. In both hospitalizations, medical therapy optimization was carried out by adding also 2nd–line drugs to the antianginal therapy with Bisoprolol 2.5 mg and Amlodipine 5 mg such as transdermal Nitroglycerin 15 mg, Ranolazine 750 mg bis in die, and subsequently Trimetazidine 20 mg ter in die during the first and second hospitalizations, respectively. In the context of this re–hospitalization, coronarography was repeated again with evidence of unchanged angiographic picture from the previous one (2021) and, in view of the refractoriness of the anginal symptoms, was placed an indication for Neovasc Reducer device implantation. This device creates a pressor gradient in the coronary sinus, determining a redistribution of blood flow from the subepicardial areas to the ischemic subendocardial areas. Therefore, by performing jugular venous access we engaged the coronary sinus with 6F diagnostic catheter then by mother and child technique we placed the 9F guide catheter advancing as distally as possible in the coronary sinus and finally we implanted the Neovasc Reducer device (4 atm for 60‘‘), obtaining a good final angiographic result. At 6–month follow–up, the patient experienced symptomatic improvement, in particular he improved by 2 Canadian Cardiovascular Society (CCS) angina classes. The Neovasc Reducer device, by improving quality of life and reducing the need for hospitalizations for unstable angina, is a viable therapeutic strategy in patients angina unresponsive to medical therapy and coronary revascularization.