bluuebunny/crossref_metadata_2025_split huggingface dataset:
363 TRICUSPID ANNULUS DISJUNCTION: THE MISSING PIECE IN THE ARRHYTHMIC MITRAL VALVE PROLAPSE?
Authors: Cecere Annagrazia , Cipriani Alberto , De Lazzari Manuel , Graziano Francesca , Brunetti Giulia , Conti Giorgio De , Motta Raffaella , Iliceto Sabino , Marra Martina Perazzolo 
Published: December 2022

Abstract

Background
Arrhythmic mitral valve prolapse (MVP) is characterized by left ventricular (LV) fibrosis, due to an excessive myocardial stretch on the LV basal-mid inferolateral wall. Mitral annulus disjunction (MAD) and curling are common findings in arrhythmic MVP patients, thus representing the excessive traction of mitral apparatus on myocardium. Cardiac magnetic resonance (CMR) demonstrated to clearly identify these typical morpho-functional alterations, as well as LV fibrosis, in MVP patients. The involvement of right-sided annulus disease recently emerged as an interesting missing piece in the natural history of MVP patients. However, its role in a population of arrhythmic MVP patients in absence of significant mitral regurgitation (MR) has not been evaluated.

Purpose
The primary aim of the study was to evaluate the prevalence and the role of tricuspid annulus disjunction (TAD) in the arrhythmic MVP patients. Secondly, we evaluated the role of TAD in the prevalence and severity of the common morpho-functional alterations of MVP, MAD and curling.

Methods
Consecutive MVP patients with normal systolic function and without significant MR, referred for palpitations, were enrolled. Morpho-biventricular evaluations, including MAD and curling assessment, as well as LV fibrosis were evaluated using CMR.

Results
66 patients met the inclusion criteria (29% male, median age 44 years). TAD was identified in 22 MVP patients (27% male, median age 52 years). No differences for ventricular arrhythmias (p: 0.459) between MVP patients without (n: 44) and with TAD (n: 22) were identified. MVP patients with TAD were older (52 vs 42 years, p: 0.009) and presented reduced biventricular end-diastolic volumes, despite normal, in comparison with those without TAD (left ventricle: 80.5 vs 93.5 ml/m2, p: 0.002; right ventricle: 72.5 vs 85.5 ml/m2, p: 0.018). MAD and curling were more common in patients without TAD (respectively, 25 vs 19, p:0.014 and 24 vs 20, p: 0.002) than in those with TAD. Conversely, MAD and curling are more severe in patients with TAD (respectively, 5.9 vs 4.7 mm and 4 vs 3 mm, both p: 0.034) than in those without TAD. No differences for LGE distribution were identified in the two groups (p: 0.062).

Conclusion
In arrhythmic MVP patients, presence of TAD was associated with a great severity of MAD and curling. So, despite uncommon, the contextual presence of TAD and MAD in arrhythmic MVP patients suggests a more severe biannular disease, characterized by an increased biventricular myocardial stretch. Conversely to MAD, TAD wasn't associated with ventricular arrhythmias. Thus, its role in ventricular arrhythmogenesis in MVP patients appeared limited.
1000 THE EFFECT OF RIGHT VENTRICULAR SIZE AND FUNCTION ON TRICUSPID REGURGITATION SEVERITY
Authors: Niro Lorenzo , Iseppi Manuela , Tafciu Elvin , Maffeis Caterina , Bergamini Corinna , Rossi Andrea , Benfari Giovanni , Luciano Ribichini Flavio 
Published: December 2022

Abstract

Background
Tricuspid regurgitation (TR) is a relatively common echocardiographic finding and its proportional influence on prognosis and quality of life has been well described. A bidirectional relationship connects TR severity and its volume overload with right ventricular (RV) dilation and dysfunction.

Purpose
to assess the impact of RV size and function on TR severity.

Material and Methods
116 stable patients with TR were enrolled at the time of echocardiography (43 men, 37%; mean age 74±13 years). TR severity was quantified by means of proximal isovelocity surface area (PISA) derived effective regurgitant orifice area (EROA) and regurgitant volume (RVol). RV size was assessed by RV End Diastolic Area (EDA) and RV function by RV Free Wall Longitudinal Strain (FWLS).

Results
TR was quantified mild in 23 patients, moderate in 53 and severe in 40 patients, with higher predominance of functional rather than organic etiology (101 vs 15 patients); median EROA was 31 mm2 and median RVol was 30 mL. Mean RV-FWLS was -25.9±7%, -21.4±7.4% and -18.4±6.4% respectively in mild, moderate and severe TR with a statistically significant difference between the groups (p=0.001). Mean RV-EDA was 19±7.7 cm2 in mild TR, 21.7±8.5 cm2 and 26.2±7 cm2 in moderate and severe TR respectively (p=0.002).
In univariate analysis both RV-FWLS and RV-EDA were predictor of TR grade estimated by TR-EROA (p=0.012 and p&lt;0.0001 respectively). In linear multivariable analysis only RV-EDA was an independent predictor of TR-EROA (p=0.001).
A ROC curve analysis confirmed the better ability of RV-EDA to identify severe TR (sTR) compared to RV-FWLS (AUC=0.738 vs AUC=0.669).

Conclusions
RV remodeling in terms of chamber dilation seems to better predict a higher TR severity compared to RV dysfunction.
945 TRANSIENT LEFT VENTRICULAR THROMBOSIS TAKOTSUBO-RELATED
Authors: Lofrumento Francesca , Mancinelli Anna , Trio Olimpia , Cusmà-piccione Maurizio , Di Bella Gianluca , Micari Antonio , Carerj Scipione , Zito Concetta 
Published: December 2022

Abstract

Background
Takotsubo syndrome (TTS) is an increasingly widespread syndrome characterized by an acute and usually transient left ventricular (LV) dysfunction. Despite its transient nature, the acute phase can be characterized by serious complications such as LV thrombosis, as occurred in this case.

Case description
A 93-year-old woman was admitted to our emergency department due to a recent and self-limiting episode of acute chest pain. The ECG showed ST-elevation in leads V2, V3 and V4 (Fig.1), with cardiac biomarkers elevation. Transthoracic echocardiography (TTE) revealed apical akinesia and hypokinesia of the other LV segments with a severely reduced ejection fraction (EF 35%). Emergency coronary angiography showed normal epicardial coronary vessels. So, Takotsubo cardiomyopathy was hypothesized as diagnosis. A mass suspect for a thrombus was detected into the apex on day 3, despite a mild improvement of the other segments contraction (EF 40%), and clearly confirmed with the contrast echocardiography on day 5 (Fig.2). Unexpectedly, any LV thrombus was identified with cardiac MRI study performed on day 7 (Fig.3). Meanwhile, the patient never showed neurological disorders or other signs of thromboembolic complications. Echocardiography performed on day 11, before discharge, showed a great improvement of regional wall motion with residual LV apical hypokinesia (EF 55%) and no apical masses.

Discussion
This case emphasizes the need of frequent echocardiographic follow up in stress-induced cardiomyopathy, not only during the akinetic phase but also during the period of wall motion recovery, in order to diagnose and treat as soon as possible a LV apical thrombosis avoiding thromboembolic complications. We hypothesized that the early anticoagulation therapy combined with the initial improvement in LV wall motion facilitated the process of thrombosis resolution. Cardiac MRI played a relevant role in the comprehensive assessment of the functional and structural LV changes; the absence of late gadolinium enhancement (LGE) can be considered as a positive prognostic factor, indicating a complete resolution without residual fibrosis.

Conclusion
A multimodality imaging approach, based on a frequent echocardiographic follow up combined with cardiac MRI, is fundamental for an early diagnosis and a rapid treatment of LV thrombosis Takotsubo-related.
271 AUTOMATED REAL TIME ECHOCARDIOGRAPHIC TOOL FOR EDGE TRACKING OF INFERIOR VENA CAVA AND NON-INVASIVE ESTIMATION OF RIGHT ATRIAL PRESSURE
Authors: Mesin Luca , Policastro Piero , Re Andrea , Sanson Cristian , Albani Stefano , Petersen Christina , Sciarrone Paolo , Taddei Claudia , Giannoni Alberto 
Published: December 2022

Abstract
The non-invasive estimation of right atrial pressure (RAP) would be a key advancement in several clinical scenarios, in which the knowledge of central venous filling pressure is vital for patients’ management. The echocardiographic estimation of RAP proposed by Guidelines, based on inferior vena cava (IVC) size and respirophasic collapsibility, is exposed to operator and patient dependent variability.
We introduce an automated real time method to process ultrasound scans of IVC and to measure pulsatility indexes, which are then used, together with other non-invasive measurements, to estimate RAP. Specifically, our method is based on the cardiac collapsibility (cardiac caval index - CCI), tested in a monocentric retrospective cohort of patients undergoing echocardiography and right heart catheterization (RHC) within 24 hour in condition of clinical and therapeutic stability (170 patients, age 64±14, male 45%, with pulmonary arterial hypertension, heart failure, valvular heart disease, dyspnea or other pathologies). IVC size and CCI were integrated with other standard echocardiographic features using machine-learning approaches. Three RAP classes (low &lt;5 mmHg, intermediate 5-10 mmHg and high &gt;10 mmHg) were generated and RHC values used as comparator.
Our classifications showed a higher accuracy than Guidelines (71% and 61% for our machine-learning method and Guidelines, respectively), promoting the integration of IVC and echocardiographic features for an improved non-invasive estimation of RAP.
241 LEFT ATRIAL SEPTAL POUCH THROMBOSIS AFTER COVID19 INFECTION: IS IMMUNOTHROMBOSIS THE CULPRIT MECHANISM?
Authors: Morello Matteo , Maestroni Alerto , Matteo Federica , Tavano Elisa , Rossetti Giuseppe , Franzoni Irene , Crenna Marco , Sgaria Riccardo , Golino Michele , De Ponti Roberto 
Published: December 2022

Abstract

Aims
The atrial septal pouch (ASP) is an incomplete fusion between septum primum (SP) and septum secundum (SS), resulting in a kangaroo pouch, that has a high prevalence in general populations (47%) and it is a potential site of blood stasis and thrombosis. After the novel coronavirus disease (COVID19) -related thrombotic complications, immunothrombosis has been widely investigated and proposed as key pathogenic mechanism linking coagulation and inflammation, leading sometimes to intracardiac thrombosis. In this paper we describe a case of thrombus in the ASP interestingly developed after COVID19 and made a literature review.

Methods and Results
A 85 years old woman with a history of hypertension and chronic atrial fibrillation (AF) in therapy with dabigatran, was admitted to our hospital for dyspnea, atypical chest pain and fever. Laboratory exams showed only mild leukocytosis and elevated levels of d-dimer; EKG confirmed AF with a normal ventricular rate and CT scan excluded pulmonary embolism.
Transthoracic and transesophageal echocardiogram (TEE) (Figure 1) showed a mobile ovoid mass (13×26 mm) attached to a left-sided ASP mimicking a myxoma, no mass was seen in the left atrial appendage (LAA). Four months earlier she had been hospitalized for idiopathic thrombocytopenia and concurrent COVID19 infection with mild symptoms, therefore dabigatran was discontinued for a month. The patient underwent surgery and histopathology confirmed it was a thrombus. In the PubMed search we conducted for reports demonstrating ASP masses, or alleged thromboembolism (TE) from this site, we found 25 reports, whose characteristics are briefly summarized in Table 1. Interestingly mild thrombocytopenia was described just in one case.

Conclusions
In addition to the LAA, the atrial septal pouch is a newly described, common anatomic entity of the interatrial septum, that potentially serves as a site of stasis and thrombus formation. Despite its high prevalence, the finding of a thrombus in this site is very rare. According to Virchow triad, we assume that in this case an endothelial injury and hypercoagulability could have played a pivotal role, since the concomitant thrombocytopenia and high levels of d-dimer. This could be the first case of a thrombus in the ASP associated with COVID19-immunothrombosis.
795 MYOCARDIAL WORK AND LEFT HEART DEFORMATION PARAMETERS ACROSS MITRAL REGURGITATION SEVERITY
Authors: Pastore Maria Concetta , Mandoli Giulia Elena , Lisi Matteo , Iuliano Maria Alma , Paolo Niglio Francesco , Santoro Alfonso , Barilli Maria , Focardi Marta , Cavigli Luna , D´ascenzi Flavio , Valente Serafina , Cameli Matteo 
Published: December 2022

Abstract

Background
Myocardial work (MW) estimation by pressure-strain loops using an implemented speckle tracking software has showed to estimate LV contractile properties overcoming the load-dependency limit of left ventricular (LV) global longitudinal strain (GLS). This has proved useful particularly in clinical setting characterized by frequent hemodynamic variations, such as heart failure and valvular heart disease. However, the variation of MW parameters across different stages of mitral regurgitation (MR) and its impact on symptoms has never been investigated.

Objective
The aim of this observational study was to assess the variations of MW and deformation parameters of left heart chambers in mild, moderate and severe MR.

Methods
consecutive patients with mild, moderate and severe MR were prospectively enrolled. Exclusion criteria were: chronic atrial fibrillation, valvular heart prosthesis, previous cardiac surgery.Clinical evaluation, blood sample tests, ECG and echocardiography were performed. Speckle tracking analysis completed by myocardial work were performed offline. Patients were then divided into groups first according to MR severity. Differences among the groups were analyzed by student T test (or non-parametric tests for non-normally distributed variables) and predictors of symptoms (as NYHA class ≥ 2) were explored by logistic regression analysis.

Results
overall, 120 patients were enrolled (40 mild, 40 moderate, 40 severe MR). LV GLS improved according to severity, while Global PALS reduced according to MR severity. Global constructive work (GCW) and global wasted work (GWW) significantly improved in patients with moderate and severe MR, while global work efficiency (GWE) showed a trend towards reduction in patients with higher grades of MR. Global work index did not changed significantly in the three groups (Fig.1). Among strain parameters, global PALS emerged as a predictor of NYHA class (R2=0.2, p&lt;0.001) These results are explained by the pathophysiology of MR, characterized by a mechanism of attempted LV compensation to volume overload with increased contractility parallel to the disease progress, although with low efficacy on increasing LV stroke volume and increased wasted work; while LA and diastolic function have an early reduction which is associated with the occurrence of symptoms.

Conclusions
myocardial deformation parameters of the left heart chambers accurately reflect the pathophysiologic mechanisms of MR stages and are associated with the burden of symptoms.
Fig. 1
Fig. 2
517 RIGHT ATRIAL THROMBUS IN A PATIENT WITH CARDIAC AMYLOIDOSIS: A MULTIMODALITY IMAGING APPROACH
Authors: Pece Cinzia , Tomaselli Michele , Radu Noela , Perelli Francesco , Muscogiuri Giuseppe , Castelletti Silvia , Torlasco Camilla , Giorgio Oliverio , Heilbron Francesca , Rella Valeria , Gavazzoni Mara , Caravita Sergio , Baratto Claudia , Parati Gianfranco , Muraru Denisa , Crotti Lia , Paolo Badano Luigi 
Published: December 2022

Abstract

Case Presentation
A 47-year-old man was referred to our outpatient clinic for dyspnea and chest pain. His past medical history was remarkable for an admission of acute congestive heart failure, occurred two weeks before presentation. On that occasion, the patient was discharged after a few days of diuretic therapy.

Diagnostic Workup
at presentation, the patient was symptomatic for dyspnea with signs of systemic congestion. The ECG showed sinus rhythm, inferolateral negative T waves and absent progression of R wave in precordial leads. Transthoracic echocardiography revealed markedly thickened left ventricular (LV) walls (maximum interventricular septum dimension 19 mm) with a granular-sparkling appearance of the myocardium, bi-atrial enlargement, preserved LV ejection fraction, restrictive mitral flow pattern thickened interatrial septum and atrio-ventricular valves. No significant valvular regurgitations were detected. Global LV longitudinal strain was significantly reduced (-9.4%), with relative apical sparing. Given the high suspicion for infiltrative disease we performed further investigations. The cardiac computed tomography (CCT) excluded significant coronary artery disease, but it raised the suspicion of a thrombus at the level of the right atrial appendage, that was confirmed by a transesophageal echocardiography showing a mobile round mass of 14×12 mm. Finally, tissue characterization by cardiac magnetic resonance exhibit a diffuse myocardial delayed enhancement, with a dark blood pool and, an increase in extracellular volume and T1 mapping values (1266.3 ms). Laboratory tests showed increased levels of creatinine, BNP and, lambda light chains. Bone scintigraphy imaging didn't identify any uptake of radiotracers at myocardial level. These findings were suggestive for cardiac light-chain (AL) amyloidosis. Accordingly, a treatment with warfarin, beta-blockers, steroid, and diuretics was initiated.

Conclusions
cardiac amyloidosis is an infiltrative disease characterized by the deposition of aggregates of amyloid fibrils in the myocardium. Multimodality imaging is pivotal to determine the diagnosis, assess the potential complications, and stratify the patients’ prognosis. Our case demonstrates that cardiac AL amyloidosis is associated with an increased thromboembolic risk, irrespective of the presence of atrial fibrillation. Moreover, although the left atrial appendage is most frequently the site of thrombus formation, it is advised to look for them also in uncommon sites as the right atrial appendage.
506 TECHNIQUES OF ARTIFICIAL INTELLIGENCE FOR THE DETERMINATION OF THE OPTIMAL INVERSION TIME: THE THAITI PROJECT
Authors: Torlasco Camilla , Papetti Daniele M , Sabatini Maria , Muscogiuri Giuseppe , Castelletti Silvia , Xue Hui , Kellman Peter , Parati Gianfranco , Badano Luigi P , Nobile Marco S , Besozzi Daniela 
Published: December 2022

Abstract

Introduction
Identifying the optimal Inversion Time (TI) is pivotal to null the myocardium and obtain high quality cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) imaging. Setting the optimal TI can be challenging in some diseases and for less experienced operators. We propose an Artificial Intelligence (AI) tool to automatically predict the optimal TI in CMR-LGE imaging.

Methods
The AI tool, named THAITI, consists of a Random Forest regression model whose hyperparametrs were optimized by means of evolutionary computation. The model considers as input parameters patient-specific TI determinants, such as age, gender, weight, height, kidney function, heart rate, contrast dose, and time from injection to image acquisition. THAITI was trained on 155 patients (2588 CMR-LGE images) with mixed cardiac conditions who underwent CMR (1.5T Siemens AvantoFit; Gadovist; averaged, motion-corrected, free-breathing true-FISP IR). Clinical testing was performed on 55 matched patients, randomized to experimental (THAITI-set TI) vs control (experienced operator-set TI) group. A user interface was developed for clinical testing. Image quality was assessed blindly by 2 independent experienced operators.

Results
THAITI Mean Squared Error (MSE) in the validation set was 4.7 and percentage of mispredicted TI of 4.5%. During clinical testing, LGE quality did not differ between the experimental vs control group: quality was “optimal” or “good” in 96% vs 93%, “poor” in 4% vs 7%. The average number of LGE images acquired and LGE imaging duration were similar (experimental vs control group: 17 ± 3 vs 16 ± 3 LGE images per patient; 12:14 vs 12:20 mm:ss, respectively).

Conclusion
THAITI efficiently predicts optimal TI for CMR-LGE imaging. Further development is needed to increase generalizability (multi-vendor, multi-sequence, multi-contrast) and to test its potential to improve LGE image quality and reduce the need for repeated imaging for inexperienced operators. Figure 1. Top panel: THAITI interface. Bottom panel: examples of experimental group LGE imaging. Table 1. Control vs experimental group. Data expressed as absolute number (%), mean ±SD
105 A CASE OF RARE ATYPICAL ATRIAL STRUCTURE
Authors: Lalario Andrea , Maione Davide , Carriere Cosimo , Merlo Marco , De Luca Antonio , Sinagra Gianfranco 
Published: December 2022

Abstract
A 27-year-old woman, without previous cardiological history, was admitted at our emergency department in the clinical context of an acute pericarditis. Echocardiography documented mild pericardial effusion (8 mm) without any sign of hemodynamic impact.
The patient was then admitted at our Cardiology Unit. During the hospitalization a complete transthoracic echocardiogram showed a normal biventricular morphology and function, normal valvular function and found an anechoic structure on the postero-lateral left atrial wall (1.75×1.5 cm). To better characterize this accidental finding, a transesophageal echocardiography was performed unmasking a dilated coronary sinus with anomalous course.
A subsequent cardiac computed tomography was performed showing anomalous systemic venous return with the persistency of the left superior vena cava draining into the coronary sinus. No other congenital anomalies were found.
PLSVC is present in approximatively 0.5% of individuals in the general population and is the most frequent congenital malformation of the thoracic venous return.
In about 90% coexists with the right superior vena cava and co-occur in almost 40% of patients with other congenital heart abnormalities such as atrial septal defect, aortic coarctation, bicuspid aortic valve, tetralogy of Fallot, transposition of the great vessels, anomalous connections of the pulmonary veins, dextroversion and cor triatatum.
Patients usually are asymptomatic. Nevertheless, this congenital malformation may cause chest discomfort, cardiac arrhythmias, thromboembolic events, decreased exercise tolerance and syncope.
Moreover, the correct identification of this condition has important clinical implications. In fact, it is a relative contraindication to the administration of retrograde cardioplegia during cardiac surgery. Furthermore, the placement of central venous-access line, pulmonary artery catheterization or the implantation of pacemaker/resynchronization leads could be difficult or can result in incorrect positioning. In these cases, it is recommended to access to the right heart through the right subclavian vein instead the left one.
Legend: *: Anomalous course of coronary sinus; LA: Left Atrium; LV: Left Ventricle; Ao: Aorta; RA: Right Atrium; R-SVC: Right superior vena cava; L-SVC: Left superior vena cava; LSPV: Left superior pulmonary vein.