bluuebunny/crossref_metadata_2025_split huggingface dataset:
P299 WATCHMAN DEVICE THROMBOSIS FOLLOWING THE PERCUTANEOUS CLOSURE OF THE LEFT ATRIUM APPENDAGE: A "CUL–DE–SAC" IN THE ANTITHROMBOTIC STRATEGY
Authors: Zanarelli L , Lapolla D , Marchini F , Tonet E , Guardigli G , Campo G , Passarini G , Pavasini R 
Published: May 2023

Abstract

Background
The percutaneous closure of the left atrium appendage (LAA) is a valuable therapeutic tool in patients with atrial fibrillation (AF) who have contraindications to anticoagulant drugs. However, the procedure can lead to complications and the device positioning determines a risk of thrombosis that can‘t be underestimated, especially during the first period from the intervention.

Clinical Case
In this report we propose the case of a 72 years old man in chronic therapy with NOAC (non–vitamin K antagonist oral anticoagulants) for a paroxysmal AF (CHA2DS2–VASC = 3), that presented intracranial hemorrhage after 3 years due to a cerebral arteriovenous malformation. This condition represents an absolute contraindication to anticoagulant therapy, because of the high hemorrhagic risk, and led to the percutaneous device positioning (WATCHMAN 24 mm) for LAA closure. After the implantation procedure we started a single antiplatelet therapy (SAPT) with clopidogrel 75 mg for 6 months. At one month follow–up a trans–esophageal echocardiogram (TEE) showed the presence of a swinging samll trombotic formation (4x2,5 mm) attached to the device. At that time antithrombotic therapy with enoxaparin 6000 IU was started, in addition to SAPT. Ten days later, another TEE showed the thrombus resolution and we decided to continue with clopidogrel alone. No relevant clinical events were observed to the subsequent follow–up.

Discussion
Current recommendations suggest double antiplatelet therapy (DAPT) for 1–6 months followed by SAPT, in patients who have absolute contraindication to anticoagulant drugs, or SAPT for at least 1 month in those who have an extreme hemorrhagic risk. LAA closure device thrombosis affects 3% of patients and represents an independent predictor of cerebral ischemic events, according to various registers and meta–analyses. This event determines an indication to anticoagulant therapy in patients who would have an absolute contraindication, creating a difficult management that assume clinical relevance. In our experience a 10 days therapy with heparin added to SAPT led to thrombosis resolution. However the therapeutic management of these complications is currently not standardized and more studies are needed.
P307 "REAL WORLD" EVALUATION OF LONG–TERM OUTCOMES RELATED TO FIRST AND SECOND GENERATION BIORESORBABLE AVASCULAR SCAFFOLDS
Authors: Berlier N , Albani S , Bernardi A , Amato G , Biava L , Bonino C , Pisano F , Scacciatella P 
Published: May 2023

Abstract

Introduction
The studies currently available in the literature support worse outcomes in first generation bioresorbable scaffold (Absorb; Abbott USA) compared to second generation devices (Magmaris; Biotronik CHF); the proposed retrospective study aims to analyze and compare long–term adverse events in the two groups and to estimate any predictors.

Methods and Results
236 consecutive cases selected between 2012 and 2018 from the hemodynamic registers of the Aosta valley health authority (VdA) and subjected to an average follow–up of 72.0 months, the composite endopint (Mortality, Target Lesion Revascularization, Target Vessel Myocardial Infarction, Stent Thrombosis) involved 38 patients (16.1%) in the Absorb group and 7 subjects (9.1%) treated with the Magmaris stent (p=0.058), with a lower number of ST and TVMI in the second group. The total mortality rate was very low in both populations, and it appears to be linked mainly to non–cardiac causes. The duration of DAPT seems to confirm a protective role against adverse events (HR 0.79; p = 0.14).

Conclusions
The results obtained, with the limitations related to the low sample size and the nature of the study, confirm the lower long–term complication rate of new generation stents compared to first generation stents. Prolonging DAPT appears to be a reasonable choice in subjects treated with resorbable stents.
P312 TAKOTSUBO SYNDROME DURING INFECTIVE ENDOCARDITIS: AN UNUSUAL COMBINATION
Authors: Caldarella Y , Betta D , Possamai M , Carrer A , Favero L , Cernetti C , Iliceto S , Gasparetto N 
Published: May 2023

Abstract
A 66–year–old woman presented to medical attention for low back pain, weight loss and evening fever for about 2 weeks, with concomitant mood deflection. Blood cultures were positive for Streptococcus mutans. Lumbar spondylodiscitis was found on spinal MRI and splenic infarction on abdominal ultrasound. The echocardiogram revealed the presence of vegetations on the aortic valve, which was severely regurgitant, and on the tricuspid valve, which was moderately regurgitant, in a setting of preserved biventricular dimensions and function. The patient was diagnosed with infective endocarditis, complicated by systemic embolization. The hospital stay was complicated, despite the appropriate antibiotic therapy, with acute pulmonary edema and cardiogenic shock, with a sudden worsening of the left ventricular function which became severely reduced, in the presence of an "apical ballooning" appearance. Anterior T–wave inversion with prolongation of the QT interval was documented on the electrocardiogram. Coronary lesions were excluded by coronary CT scan. According to the InterTAK criteria, the patient achieved a score of 80, suggestive of a high probability of Takotsubo syndrome. In the following days, thanks to continuous infusion of diuretics and inotropic support, a hemodynamic compensation was obtained; there was a progressive recovery of the left ventricular function and of the apical wall motion abnormalities, with suspension of the inotropic support and reduction of the dosage of the diuretic. We concluded for Takotsubo syndrome in the setting of acute infective endocarditis. The patient, with a stabilized clinical picture, finally underwent cardiac surgery to replace the aortic and tricuspid valves without complications. Takotsubo syndrome (TS) is a condition characterized by a transient impairment of left ventricular function and kinetics, typically triggered by physical or emotional stress. In the literature only four cases of concomitant endocarditis and TS are reported, in which other triggers are recognizable (recent surgery, cerebral involvement with embolization or meningitis). In our case, there are no other apparent triggers other than endocarditis. Endocarditis could therefore represent in itself a new trigger for TS or even manifest, from the beginning, with a TS.
P316 CHEST PAIN: ONE, NONE AND A HUNDRED THOUSAND DIAGNOSES. A CASE REPORT
Authors: Piscione M , Bianco S , Castaldo G , Polito D , De Luca V , Nafisio V , Crispino S , Gatto L , Grigioni F , Prati F 
Published: May 2023

Abstract
A 62–year–old woman, with a history of systemic hypertension, smoking habit and paroxysmal atrial fibrillation treated with Flecainide, was admitted to the ER of our Hospital for chest pain. She reported that the symptoms appeared after an emotional stress at work. Troponin I was of 895 pg/mL. The electrocardiogram showed: negative T waves in the inferior leads and an early repolarization pattern/ ST elevated in the antero–lateral leads. The patient underwent transthoracic echocardiography which showed: EF 45%, akinesia of the posterior and inferior segments of the septum. Invasive coronary angiography showed absence of lesions. CMR presented: EF 51% and mild hypokinesia of the mid septum and inferior segment; signs of oedema affecting the left ventricular myocardium in the apex, the mid inferior segment and in the lower apical wall, with subendocardial hypoperfusion layer in the mid inferior septum (microvascular dysfunction?). The patient was dismissed with the diagnosis of M.I.N.O.C.A. A month later, she was admitted again to our ER suffering from a new episode of acute chest pain; she also reported a short episode of atrial fibrillation (documented by an EKG) lasting about 10 minutes occurred the day before. The EKG showed: negative T waves in anterolateral leads. TnI was of 2052,5 pg/ml. The patient underwent a transthoracic echocardiogram which demonstrated: reduced global systolic function (EF 35%), akinesia of the apex, mid–anterior septum and mid– anterior wall. The day after the echo was repeated and it demonstrated a gaining of Vsx EF which was of approximately of 50%. Invasive coronary angiography showed absence of lesions. A methylergometrine test was negative for vasospasm on anterior descending artery. The CMR showed: EF 58%, signs of oedema in the basal and mid anterior wall, mid–anterior septum. LGE intra wall of the apical septum and of the basal part of the anterior wall (coronary spasm? Vasculitis?) Absence of edema. The final diagnosis was of Tako Tsubo.

Discussion and conclusions
This case offers the inspiration to reflect on differential diagnosis of chest pain with undamaged coronary arteries. In addition to this, it should be considered coronary emboli arisen through various mechanisms including left atrial appendage thrombi due to atrial fibrillation, so that also anticoagulation therapy is suggested as discharge treatment.
P317 A…TELL–TALE HEART
Authors: Fischetti S , Brunelli V , Schettini F , Varricchione N , Viati L , Capitelli L 
Published: May 2023

Abstract
We present the clinical case of a 67–year–old male. He was affected by hypertension, hypercholesterolemia; he was heavy smoker. He went to the ED for paresthesias and tremors in the left upper limb, which resolved spontaneously in a few minutes, to which there followed severe thoracic discomfort lasting more than 5 minutes, which resolved during the arrival at the hospital. Upon arrival, the ECG showed ST–segment elevation in leads V4 – V6. POCUS demonstrated akinesia of the apex in its entirety with hypercontractility of the basal segments and the EF was 35%. Blood tests showed an increase in cTI (0.89 ng/ml; vn &lt; 0.16) and CK–MB (57 U/L; vn &lt; 25 U/L). Complete blood count and PCR result in the norm. Coronary angiography showed &lt;50% circumflex artery stenosis, not hemodynamically significant, not treated. Over the next few days the ECG showed marked changes in repolarization, up to T wave inversion; normalized blood tests. During the 3rd day of hospitalization, the patient presented an episode of sensorimotor epileptic seizure in the left upper limb, lasting about 3 minutes, which resolved spontaneously. He underwent a brain CT scan which revealed multiple, edematous brain lesions, probably of a repetitive nature. A whole body CT scan diagnosed lung malignancy. After the oncological evaluation, the patient started chemotherapy. Subsequent follow–ups documented recovery of apical movement at two months. The patient presented a clinical–instrumental picture compatible with the diagnosis of MINOCA. In particular, the echocardiography was suggestive of takotsubo syndrome (TTS). TTS affects 1–2% of patients presenting to ED with ACS and positive troponins or suspected STEMI. It mostly affects women and elderly patients. The exact pathophysiology of TTS is still unknown, but there are numerous determining factors, such as physical and/or emotional stress, that are responsible for sharp increases in levels of circulating catecholamines. Also neurological pathologies, such as ischemic and above all haemorrhagic stroke are implicated. Recent evidence suggests that about one in six TTS patients also have cancer. In conclusion, we described a case where the first clinical manifestation of a lung metastatic cancer was a SCA. In the TTS there can be a "theory of everything", capable of bringing together the various specialists (emergency physician, cardiologist, pulmonologist, general internist, oncologist, etc.) to reach a single outcome, the patient–care.
P324 LEFT VENTRICULAR ISOLATED CARDIOMYOPATHY OR DILATED CARDIOMYOPATHY: THE ROLE OF GENETIC ANALYSIS
Authors: Dei L , Trambaiolo P , Loricchio M , Mustilli M , Castro A , Starnazzi F , Samperi S , Cioffi A , Renda M , Sciarra L , Romano S , Granatelli A 
Published: May 2023

Abstract

Introduction
arrhytmogenic cardiomyopathy (ACM) is a genetic heart muscle disease caracterized by substitution of the ventricular myocardium with fibrofatty tissue. The disease was originally termed “arrhytmogenic right ventricular (dysplasia)/cardiomyopathy” to define a condition which distinctively affected the right ventricle and predisposed to fatal ventricular arrhythmias. New insights led to comprehending that the left ventricle is also frequently affected.

Clinical case
62 yo, male, no cardiovascular risk factors, positive history for frequent ventricular premature beats treated with Sotalol 40 mg twice a day. No other previous cardiological events. Accesses the ER with suddenly occured dyspnea for minimal exertion, without palpitation, chest discomfort or loss of consciousness. EKG: synus rhythm, low voltages, negative V4–V6 T waves, fragmented QRS. Blood testing: TnI 0,532 ng/ml (n.v. 0–0.034) NTproBNP 3840. Echocardiography: dilated left ventricle. 20% EF due to infero–lateral wall akynesia. Coronary angiography was performed and showed no coronary stenosis. Considered the frequent NSVTs showed by the telemetry, he was admitted to ICU and treated with Amiodarone, Atenolol 100 mg, Sacubistril/Valsartan 24/26 mg, diuretic therapy showing good control of major arrhytmic events. To evaluate characterize heart tissue, a magnetic resonance was performed, which showed: scalloping of the mid and apical left ventricular lateral wall, with fibrofatty substitution. Subepicardial, mid–wall and transmural LGE of the LV anterior, lateral and inferior walls. No RV abnormalities. Considered the reduced EF and the presence of arrhytmic substratum, an ICD was implanted. Finally, a genetic evaluation was discussed with the patient, but was declined.

Discussion
in patients presenting with typical LV abnormalities, without RV involvement, the phenotipic Padua criterias are not enough for a certain diagnosis. This is because of the phenotipic overlap between ACM and other diseases, such as dilated cardiomyopathy, myocarditis and cardiac sarcoidosis. In the presence of LV involvement, consistent with ACM, the evidence of a pathogenetic mutation is key for the diagnosis.
P327 A STRANGE CASE OF ACUTE CORONARY SYNDROME
Authors: Cannillo M , Rahbari E , Lonni E , Suppo U , Grosso Marra W 
Published: May 2023

Abstract
We report a case of a 46–years–old man hypertensive, diabetic with dyslipidemia with a previous hospitalization for NSTEMI. The Coronary angiography highlighted right coronary artery vasospasm. Echocardiogram reported good left ventricular function with left ventricular hypertrophy. ECG showed Sinus Rhythm with HR 60 bpm, PR 110 msec and right bundle branch block (Figure 1). He was discharged in dual antiplatelet therapy and with Diltiazem and nitrates. Later the patients reported several events of worsening angina and required the ER access: his therapy was integrated with ranolazine. After that he was bring to our attention for a relapse of NSTEMI. ECG: Sinus Rhythm with HR 55 bpm, PR 110 msec and right bundle branch block. Echocardiogram showed LV with severe wall thickening (ventricular septum/posterior wall 17/14 mm), LVEF 55% in the absence of segmental kinetic alterations, no intraventricular and/or outflow obstruction. There was a first degree diastolic disfunction, and there was mild reduction in both systolic and diastolic velocities on TDI. The right ventricle was not dilated, with thickened free wall, and normal systolic function [figure 2]. A repeated coronary angiography excluded a critical coronary artery disease, but it reveals again evidence of right coronary artery vasospasm. Diltiazem was replaced with nifedipine.A careful anamnesis revealed a history of tinnitus, with right receptive hypoacusia as a result of vestibular neuritis. Blood tests revealed proteinuria with 1800 mg/24 h with glycated Hb 5.8%. Based on the clinical history and the ECG and echocardiographic findings screening for Fabry disease was performed: the results showed abnormal levels of alpha–galactosidase A and plasma lyso–Gb3. Further investigations included cardiac MRI, which confirmed interventricular septal hypertrophy but no late gadolinium enhancement, and ophthalmologic examination, which revealed cornea verticillata in the left eye. Electromyography showed signs of peripheral neuropathy, and renal biopsy was consistent with Fabry disease. Genetic analysis revealed a mutation in exon 1 of the GLA gene (c.62 T&gt;G) that results in the amino acid substitution p.L21R, which has been previously described in patients with Fabry disease. The final diagnosis was Fabry disease with cardiac, renal, and peripheral neuropathic involvement. Enzyme replacement therapy was started with regression of angina episodes.
P334 PHARMACOUTILIZATION AND ADHERENCE TO SACUBITRIL/VALSARTAN IN REAL–WORLD: THE REAL.IT STUDY IN HEART FAILURE WITH REDUCED EJECTION FRACTION
Authors: Iacoviello M , Di Gesaro G , Sarullo F , Miani D , Driussi M , Correale M , Bilato C , Passantino A , Carluccio E , Villani A , Degli Esposti L , D’Agostino C , Peruzzi E , Poli S , Di Lenarda A 
Published: May 2023

Abstract

Aims
The current European Society of Cardiology guidelines provide clear indication for the treatment of acute and chronic heart failure (HF).Nevertheless,there is the constant need of real–world evidence concerning the effectiveness,adherence and persistence to drug therapy.We investigated the use of sacubitril/valsartan for the treatment of HF with reduced ejection fraction in real–world clinical practice in Italy.

Methods
An observational, retrospective,non–interventional cohort study based on electronic medical records from nine specialized hospital heart failure Centers in Italy was carried out on patients prescribed with sacubitril/valsartan.

Results
Overall,948 patients had a prescription of sacubitril/valsartan, 924 (mean age 64.5 years, 84.6% male) had 6 months of characterization and 12 months of follow–up. The initial dose was 24/26 mg for 548 (59.3%),49/51 mg for 333 (36.0%),97/103 mg for 43 (4.7).The final dose was available for 881 patients and it was:24/26 mg for 254 (28.8%),49/51 mg for 229 (26.0%),97/103 mgfor 398 (45.2).The time to maximal dose prescribed (weeks) was:for 97/103 mg 6.9 ± 6.2 weeks;for 49/51 mg 6.2 ± 6.7 weeks.Blood pressure and hypotension in 65% of the patients, and worsening of chronic kidney disease in 10.6% were the main reasons for not reaching target dose; fifty percent had a change in sacubitril/valsartan dose during follow–up and 70.2% patients were persistent with treatment during the last three months of follow–up, with a sensitivity analysis (persistence during the last four months of follow–up) showing 72.0% persistence. Adherence data, available for 387 patients, showed fully adherence for 53%.Discontinuation (102/387 patients) was mainly due to hypotension and occurred after a mean time of 34.3 ± 28.7 weeks. During follow–up, of the 606 patients with available data, 434 patients (71.6%) had an HF add–on drug or drugs concomitant to sacubitril/valsartan. Although not significantly (p=0.405), HF–related hospitalization during follow–up was higher in not persistent patients (23.9%) versus persistent (19%) to sacubitril/valsartan treatment.Pharmacoutilization data at 1–year expressed as medication possession ratio (MPR) are shown in the Figure.

Conclusions
Real–world data of sacubitril/valsartan use in clinical practice in Italy show a rapid titration of to target dose, high therapeutic adherence allowing a good level of therapeutic management in line with ESC guidelines in patients with reduced ejection fraction.
P343 WHAT IS HIDING BEHIND A ‘STEMI‘?
Authors: Foroni M , Schiavo M , Pagano V , Bendandi F , Saia F 
Published: May 2023

Abstract

Introduction
Stanford type A aortic dissection associated with ST–segment elevation myocardial infarction (STEMI) is a rare event with a high mortality rate. Emergency coronary angiography and antithrombotic therapy expose to a greater risk of complications and mortality. Case presentation: A 57–year–old heavy smoker gentleman with no previous medical history was admitted to the emergency department due to the sudden onset of severe oppressive chest pain. The ECG was suggestive of inferior STEMI and thus he was brought to the cath lab. During coronary angiography, there was spontaneous regression of the ST–segment alterations with persistence, however, of chest pain. The coronary angiography was unremarkable, but the cannulation of the right coronary artery was unexpectedly difficult. In light of the clinic and the suspicious fluoroscopic images (dilated aorta and severe valvular calcifications), an aortography was performed showing a type A aortic dissection. CT angiography confirmed the presence of dissection confined to the ascending aorta with origin of the right coronary artery from the false lumen. The supra–aortic trunks were not involved by the dissection. A bicuspid aortic valve and a bovine trunk were also found. The patient therefore underwent emergency cardiac surgery: a composite aortic valve conduit (Bentall procedure) was implanted and double aorto–coronary bypass surgery was performed, due to intraoperative evidence of complete detachment of the right coronary ostium and partial detachment of the left. The operation was successful and the following hospitalization was uneventful.

Conclusions
This case report exemplifies an important alternative diagnosis in patients referred for STEMI, particularly if with an inferior localization (the right coronary artery is the most frequently involved by the dissection). It is necessary to pay attention to the possible clues coming from the clinical findings and from the radioscopic and angiographic images obtained in the cath lab in order not to miss the diagnosis of a pathology on whose recognition and timely treatment the patient‘s life depends.