bluuebunny/crossref_metadata_2025_split huggingface dataset:
P277 SECRET BEYOND THE DOOR. TRIAGE ANALYSIS AND RECOGNITION AT THE DOOR OF ELDERLY PATIENTS WITH PULMONARY EMBOLISM WHO ARRIVE IN THE EMERGENCY ROOM. THE REAL–LIFE EXPERIENCE OF 5 YEARS IN THE EMERGENCY ROOM
Authors: Savioli G , Ceresa I , Novelli V , Pagani M , Belliato M , Grulli F , Fumoso F , Lapia F , Brattoli M , Bressan M 
Published: May 2022

Abstract

Background
The range of symptoms of pulmonary embolism is wide and its recognition difficult.

Purpose
to analyze the efficiency of triage in the EP.

Methods
Single–center retrospective observational study, on all geriatric patients (&gt;75 years) who entered our ED, where they were diagnosed with acute PE. Enrollment began in 2015 and ended in 2019. We analyzed means of presentation, priority codes for medical examination, exit code, hospitalization needs. We collected data from medical history, physical examination, laboratory tests, imaging, outcomes.

Results
We enrolled 247 patients, all in need of hospitalization. 44% came for dyspnea, 17% for chest pain, 16% for signs of DVT, 8% for syncope. 5% had only atypical symptoms (dizziness, general malaise, low–grade fever, neurological symptoms …). 45% had concomitant deep vein thrombosis. 50% showed alteration of the ECG tracing, 49% alteration of the shock index. Only 4% showed hypotension, 13% tachycardia and 8% desaturation. 39% arrived with their own vehicle. 32% was allocated to the area with low intensity of care, 68% to the area with medium–high intensity of care. As regards the priority code for the visit, 0% received a non–urgency code (white code or code 5), 27.9% a minor urgency code (green code or code 4) and 3.6% a high priority to the visit with assignment to low intensity of care (low intensity yellow or code 3). 63.15% received an emergency code (urgency or code 2) and 5.3% an emergency code (red code or code 1). The severity code at discharge, given on clinical criteria, was a low severity code (white or green) in 18% of cases, while 76% was considered high severity (urgency, yellow code) and in 6% for very high gravity (red code). 34% showed massive PE, 32% showed organ damage. 41% were considered to be at high risk of short–term mortality according to European guidelines, 8% required intensive care and in–hospital mortality was 7.7%. Under triage is 32%.

Conclusions
The population that arrives in ED due to pulmonary embolism presents extremely varied symptomatological pictures, and an overall high degree of clinical risk and care and therapeutic complexity in spite of the symptoms complained of and vital parameters. Under–riage remains a real problem for ED for this category of patients.
P281 A CASE OF ACUTE PULMONARY EMBOLISM IN A PATIENT WITH CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION MISSED: PROFITABLE COLLABORATION BETWEEN A SPOKE CENTER AND A HUB
Authors: Bongarzoni A , Marini C , Tassinario G , Garagiola M , D’armini A 
Published: May 2022

Abstract

The case of one patient is described: 78–year–old, obese, suffering from type II diabetes mellitus and arterial hypertension who complained of mild exertional dyspnea for one year. On ECG sinus rhythm 80 bpm, negative T wave from V1 to V4, right bundle branch block. He was sent to the emergency unit for further investigations.

Here the blood chemistry results: D–dimer 1761 (normal &lt;250 ng / ml), NT pro–BNP 9312 (normal &lt;93 ng / l), troponin 21 (normal &lt;14 ng / ml); pulmonary CT angiography demonstrated filling defects referable to bilateral lobar, segmental and subsegmental bilateral thromboembolism. The estimated PASP was 90 mmHg with AcT 55 msec and the presence of a mid–systolic notch on the pulmonary flow profile. A diagnosis of intermediate–high risk PE was made and, according to the local PDTA, written informed consent was obtained, the patient underwent treatment with percutaneous thrombectomy with loco–regional ultrasound–assisted thrombolysis (USAT–rtPA 24 mg in 12 hours). The RV / LV ratio was slightly reduced (1.1) and so was the estimated PASP (60 mmHg). He performed a lung perfusion scan with the detection of areas of diffuse pulmonary hypoperfusion. He was discharged on February 28, 2021, on therapy with Dabigatran 150 mg BID. 3 months later he carried out a cardiological check–up: he was in NYHA II class; the echocardiogram showed RV hypokinesia, TAPSE 15 mm, PASP 76 mmHg. In the suspicion of chronic thromboembolic pulmonary hypertension (CTEPH), he was sent to a HUB centre (Pavia) for a clinical assessment. Several tests were carried out to confirm the diagnosis of CTEPH and on 29 September 2021, the patient underwent bilateral pulmonary endarterectomy.

Conclusion
The case describes a patient with an episode of acute pulmonary embolism on a pre–existing unrecognized thromboembolic pulmonary hypertension, which partially benefited from percutaneous thrombectomy. Cases of CTEPH are infrequent; however, they must be recognized and sent, for a thorough evaluation, to an expert centre, to start the appropriate diagnostic therapeutic path, as in the case reported.
P284 THE RIGHT HEART ADAPTATS TO EXERCISE MORE EFFICIENTLY IN PULMONARY ARTERIAL HYPERTENSION THAN IN PULMONARY HYPERTENSION DUE TO HEART FAILURE WITH PRESERVED EJECTION FRACTION
Authors: Baratto C , Caravita S , Dewachter C , Faini A , Villella F , Perego G , Muraru D , Badano L , Parati G , Vachiéry J 
Published: May 2022

Abstract

Background
Right heart failure (RHF) represents the final step of distinct diseases, differently involving the pulmonary circulation, such as pulmonary arterial hypertension (PAH) and pulmonary hypertension (PH) due to heart failure with preserved ejection fraction (HFpEF). Exercise may unmask right heart maladaptation as a sign of RHF, but cut–offs for right atrial pressure (RAP) rise during exercise remain to be defined. We hypothesized that PH–HFpEF may present with worse right heart adaptation to exercise than PAH due to increased chamber stiffness and dysfunctional preload.

Aim
We sought to describe the behavior of RAP during exercise in PAH and in PH–HFpEF, and the mechanisms underlying right heart maladaptation.

Methods
We performed a retrospective analysis of data (2007–2021) obtained from patients with either PAH or PH–HFpEF who underwent a right heart catheterization at rest and during exercise. Right heart adaptation to exercise was described using either absolute or cardiac output (CO)–normalized RAP increase during exercise (RAP/CO slope). Patients with non–cardiac dyspnea (NCD) served to define RAP limits of normality. Estimated stressed blood volume (eSBV), as a measure of effective preload, was computed based on hemodynamics using a commercially–available software.

Results
Ninety–four patients were included (32 PH–HFpEF, 32 PAH and 30 NCD). The upper limit of normal for absolute peak RAP and RAP/CO slope were 12 mmHg and 1.55 mmHg/L/min. Compared with PH–HFpEF, PAH patients showed higher systolic, diastolic and mean pulmonary artery pressure (PAP) as well as higher indices of right ventricular afterload both at rest and during exercise, but lower filling pressures and similar CO (Figure 1).In particular, PH–HFpEF had higher peak RAP and higher RAP/CO slope than PAH (Figure 1,2). Additionally, 78% and 91% of PH–HFpEF, as compared with 47% and 44% of PAH had a RAP/CO slope and a peak RAP above normal, respectively (p &lt; 0.001). PH–HFpEF presented with higher increase in eSBV, and higher peak eSBV values than PAH (p &lt; 0.05), despite similar resting levels. RAP/eSBV slope was upward shifted (at a given effective preload, RAP was higher) while CO/eSBV slope was flatter (at a given effective preload, CO was lower) in PH–HFpEF as compared with PAH (Figure 3).

Conclusions
PH–HFpEF display worse right heart maladaptation to exercise than PAH, likely due to a combination of increased right heart stiffness and a more exhausted Frank–Starling reserve.
P285 PROGNOSTIC ROLE OF ELECTROCARDIOGRAPHIC TEMPORAL CHANGES IN PATIENTS WITH ACUTE PULMONARY EMBOLISM. DATA FROM THE ITALIAN PULMONARY EMBOLISM REGISTRY (IPER)
Authors: Zuin M , Bilato C , Bongarzoni A , Zonzin P , Casazza F , Roncon L 
Published: May 2022

Abstract

Background
The potential prognostic role of ECG changes during the course of acute pulmonary embolism (PE) has been poorly investigated over the years.

Methods
Data of patients prospectively enrolled in the IPER registry, having three ECGs (the first perfromed on admission, the second after three days of hospitalization and the third at discharge) were extracted and analyzed.

Results
Overall, 687 patients (286 males, mean age 69.0 ± 15.5 years) were included in the study. The negativization of electrocardiographic signs of right ventricualr strain (RVS) (Right bundle branch block –RBBB), S1Q3T3 and negative T waves from V1 to V4) followed the same pattern in both non–high (i.e. hemodynamically stable) and high–risk (i.e. hemodynamically unstable) patients, showing firstly the normalization of the S1QT3 pattern followed by the resolution of the RBBB. Conversely, additional NTWs appeared between the first and second ECGs in about 20% of cases and then partially normalized at discharge. Persistence of RVS at the second ECG was associated with a higher risk of death within 30 days only in high–risk patients [HRa: 2.78 (95% CI: 1.05–7.31. P = 0.03), with a sensitivity, specificity, PPV and PPN of 90.0%, 94.1%, 85.7% and 96.0%, respectively. Furthermore, the lack of normalization of the RBBB [HRa: 2.78 (95% CI: 1.05–7.31, p = 0.003)], of the NTW [HRa: 1.63 (95% CI: 1.04–2.55), p &lt; 0.0001] and of the resolution of qR complex in V1 [HRa: 12.5 (95% CI: 3.39–46.4,) p &lt; 0.0001] were independent predictors of poor prognosis in the short term. High–risk patients showing at the second–ECG the persitence of RBBB and NTWs as well as disappearance of the qR complex in V1 had a higher 30–day increased risk of death [HR: 9.44, (95% CI: 5.22–17.05, p &lt; 0.0001]. The C–statistic confirmed in high–risk subjects an improvement in short–term prognostic power using the persistence of all three ECG signs (0.77, 95% CI: 0.51–0.94) or they single presence (0.61, 95% CI 0.42–0.79; 0.70; 95% CI: 0.52–0.88 and 0.74, 95% CI: 0.56–0.96, RBBB, NTWs and qR in V1, respectively).

Conclusions
The persistence of RBBB, NTWs, and qR pattern in V1 after 3 days from the hospitalization for acute PE represent an independent prognostic factors of death within 30 days in high–risk acute PE patients. In terms of prognostic power, the single evaluation of each ECG sign was lower compared to the overall or combined assessment.
P289 EYESHOT OF CARDIAC AMYLOIDOSIS CASES PRESENTED TO A CARDIOLOGY UO IN CENTRAL ITALY IN 2021
Authors: D'Agostino S , Gizzi G , Parato V 
Published: May 2022

Abstract

Introduction
ATTR–related cardiac amyloidosis, caused by the accumulation of insoluble fibrillar proteins derived from transthyretin misfolding, is an often underdiagnosed pathology, especially when neurological involvement is absent or minor. Transthoracic echocardiography represents the first fundamental step in the diagnostic process.

Abstract
During the year 2021, a total of 9 patients with an echocardiographic feature of hypertrophic heart disease suggestive of infiltrative pathology were referred to our Cardiology unit. Of these patients, 89% were male (8 out of 9), aged between 60 and 88 years (average age of 72 years). The clinic presentation was heart failure in 5 cases (55% of the total), arrhythmic storm in 1 case, history of amyloid polyneuropathy in 1 case and it was an occasional finding in 2 patients who required a cardiological evaluation for other reasons. The 12–lead ECG documented atrial fibrillation arrhythmia in 4 out of 9 cases (44%) and sinus rhythm in the remaining 5 cases (56%). Transthoracic echocardiography revealed left ventricular hypertrophy with granular sparkling aspect of the SIV in all patients, with indexes of global systolic function preserved in 4 out of 9 cases (44%), moderately reduced in 3 out of 9 cases (33%) and severely reduced in the remaining 2 cases (22%). Diastolic dysfunction was present in all patients, with a restrictive pattern in 4 of 9 cases (44%). Myocardial scintigraphy with DPD was performed in 7 patients, which confirmed the suspicion of aTTR amyloidosis in 6 cases (Perugini Score = 2), in the remaining 2 patients the diagnostic procedure was not performed due to severe comorbidities. At present, diagnostic confirmation of aTTR amyloidosis has been confirmed by biopsy in 2 patients; a patient‘s biopsy is currently under analysis; 1 patient is on Patisiran therapy.

Conclusions
Cardiac amyloidosis represents a frequent clinical condition especially in the elderly population. In the light of the most recent therapeutic strategies, a correct and early etiopathogenetic diagnosis is of fundamental importance.
P291 SUBVALVULAR MITRAL APPARATUS REMODELING DURING HYPERTROPHIC OBSTRUCTIVE CARDIOMYOPATHY SURGERY: A 15–YEARS OF EXPERIENCE
Authors: Raffa G , Pilato M 
Published: May 2022

Abstract

Background and Aims
To assess the role of the mitral valve apparatus (leaflets, chordae and papillary muscles (PM) in left ventricle outflow tract (LVOT) obstruction, and results of the surgical treatment for hypertrophic obstructive cardiomyopathy (HOCM) in a retrospective observational study.

Methods
Seventy consecutive patients (58±12 years, M/F ratio: 41/29) undergoing HOCM surgery from 2007 to 2021 at our institute were reviewed. End points included the involvement of the mitral valve in LVOT obstruction, mortality, and change in clinical and echocardiographic characteristics after HOCM surgery.

Results
Secondary chordae tendineae tractioning the anterior mitral leaflet to the interventricular septum were detected in the majority of the patients. Anomalous, hypertrophied, and fused PM with muscularis trabeculae hypertrophy were a common findings. Four patients had posterior leaflet redundancy. Secondary chordae (90%), PM and muscularis trabeculae resection and PM splitting and elongation (77%) were added variably to septal myectomy (100%). Nine procedures (6%) on mitral valve leaflets were performed, involving 6 posterior and 3 anterior mitral leaflets. Long–term follow up was 4.6±3.7 years. There was no hospital mortality, and NYHA was reduced from 3±0.6 to 1±0.7 (p &lt; 0.0001), the LVOT gradient from 91±35 to 21±17 mmHg (p &lt; 0.0001), mitral valve regurgitation from grade 3±1 to 1±0.6 (p &lt; 0.0001), and septum thickness from 19±3 to 14±2 mm (p &lt; 0.0001).

Conclusions
The mitral valve apparatus with all its components contribute variably to LVOT dynamic obstruction thus, surgical correction in addition to extended myectomy is recommended to achieve the best outcome.
P294 AN ECHOCARDIOGRAPHIC SCORE OF VALVE DISEASE IN PATIENTS WITH CARDIAC AMYLOIDOSIS
Authors: Aimo A , Fabiani I , Maccarana A , Fontana M , Vergaro G , Chubuchny V , Pasanisi E , Petersen C , Poggianti E , Giannoni A , Spini V , Taddei C , Castiglione V , Passino C , Emdin M , Venneri L 
Published: May 2022

Abstract

Background
Cardiac amyloidosis (CA) affects all cardiac structures, including the valves. We summarized the echocardiographic features of valve disease in a score.

Methods
From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR–) or light–chain (AL–) CA, and selected age– and sex–matched controls. The Amyloid VAlve (AVA) score included 31 items related to the mitral, aortic and tricuspid valves (which can be properly assessed in standard echocardiograms), with a value of 1 for each abnormal item.

Results
Patients with ATTR–CA displayed more often a shortened/hidden and retracted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL–CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (interquartile interval 13.6–17.4) in ATTR–CA, 11.0 (9.3–14.9) in AL–CA, 12.8 (11.1–14.4) in ATTR–CA controls, and 11.0 (9.1–13.0) in AL–CA controls (p = 0.004 for ATTR– vs. AL–CA, 0.009 for ATTR–CA vs. their controls, and 0.461 for AL–CA vs. controls). We compared the AVA and two validated diagnostic scores (IWT and AMYLI). AUC values for the diagnosis of ATTR–CA were 0.782, 0.846 and 0.902, respectively, in patients with ATTR–CA or matched controls, and 0.773, 0.706 and 0.679 in patients with LV hypertrophy (n = 67, 84%) (all non–significant p values).

Conclusions
Patients with ATTR–CA have a prominent impairment of mitral valve structure and function, and higher score values. The AVA score is quite effective in identifying patients with ATTR–CA among patients with CA or with unexplained hypertrophy.
P297 PERICARDIAL EFFUSION WITHOUT HEMODYNAMIC INSTABILITY: WHEN AND TO WHOM THE PERICARDIOCENTESIS?
Authors: Facchini E , Maffè S , Paffoni P , Prenna E , Bergamasco L , Careri G , Franchetti Pardo N , Paino A , Dellavesa P 
Published: May 2022

Abstract
Cardiac tamponade is traditionally considered a clinical diagnosis, but there are pre–tamponating effusions that occur without signs of cardiogenic shock, and in these situations it can be complex to determine when and which patient treat with pericardiocentesis. The clinical case concerns a 90–year–old woman who comes to the emergency room for exertional dyspnea. Upon arrival blood pressure was 150/90 mmhg, heart rate 70 bpm. On chest x–ray, enlargement of the cardiac silhouette was evident (Fig 1). The echocardiogram showed a circumferential pericardial effusion of 2 centimeters with signs of right cardiac chambers compression (Fig 2). Hospitalized in ICU, the clinical situation was complicated by the onset of atrial fibrillation with a high ventricular response (Fig 3) and immediate cardiogenic shock (BP 70/40 mmHg, tachypnea, altered mental status). We proceed with emergency electrical cardioversion, effective in restoring sinus rhythm with almost immediate arrhythmic recurrence; therefore we perform a pericardiocentesis, with regression of the shock status after aspiration of a few cc of serum–haematic pericardial fluid (total 750 cc); spontaneous restoration of sinus rhythm after the procedure. Neoplastic problems were excluded, IgM positivity for influenza A and B on blood tests. The patient presented no further complication, was discharged at home, in sinus rhythm, with negative follow–up so far. This clinical case focuses the question of the indication and timing of pericardiocentesis. We managed a pericardial effusion with ultrasound signs of compression of the right sections, but in the absence of clinical signs of cardiogenic shock / Beck‘s triad. Given the clinical evolution, should we have perform the pericardiocentesis as soon as the patient arrived, in conditions of hemodynamic stability? Interesting are the score index proposed by Halpern et al. and an ESC position statement that serves to identify patients to undergo urgent pericardiocentesis based not only on clinical factors, but also on imaging evaluation. The total score of our case would have been indicative for an immediate pericardiocentesis. In our opinion, the formulation of a triage system for patients with pericardial effusion and hemodynamic stability that can be routinely implemented in clinical practice would be extremely useful.
P298 ACUTE PERICARDITIS AS FIRST MANIFESTATION OF AN EXTRACARDIAC NEOPLASM
Authors: Neglia L , Indennidate C , Narciso M , Cocciolo A , Lardieri G 
Published: May 2022

Abstract

Introduction
Acute pericarditis (AP) may be primary (idiopathic, often presuming a viral origin) or secondary. In secondary forms, the primary disorder (e.g. myocardial infarction, collagen disease, neoplasia) is usually already known when pericardial involvement becomes manifest. However, it has been observed that AP may be the first manifestation of extracardiac neoplastic disease.

Clinical Case
M. 35 yo. Tabagism. In ED for continuous thoracic pain since 4 days, exacerbated by deep breath and supine decubitus. Night sweats. ECG: mild PR depression in DII, mild diffuse ST–segment elevation. WBC 9080/mcL, PCR 129, HsTnI &lt; 2, D–dimer negative. Chest X–ray: swelling of the left hilum deforming the profile of the left arches and mediastinum. Echocardiogram:…hypoechogenic space of approx. 1 cm at the level of the left ventricle with contiguous isoechogenic mass of approx. 3 cm thickness. When AP was diagnosed, treatment with ibuprofen and colchicine was administered with regression of symptoms. CT chest with mdc:…solid mediastinal lesion on the left extended from the aortic arch surrounding the upper part of the left ventricle. PET scan: voluminous area of high and inhomogeneous metabolism corresponding to the known left mediastinal mass to be referred to oncological nature. A biopsy of the lesion was then performed.

Discussion
AP may be the first manifestation of an unknown extracardiac neoplasm in 4% to 7.3% of cases depending on the series (5% Permanyer–Miralda et al. 1985; 7% Zayas et al. 1995;4 % Imazio et al. 2005). The most frequently associated primary malignancies are lung, breast and lymphomas. The most frequently associated clinical features are a positive history of malignancy, onset with cardiac tamponade, no response to NSAID therapy, and recurrent or incessant course. Direct visualisation of mediastinal masses during transthoracic echocardiographic examinations has already been described. In the present case, AP was the first clinical manifestation of an extracardiac neoplasm, which could be already viewed during first transthoracic echocardiogram. Despite the neoplastic origin, no massive pericardial effusion was present at the time of diagnosis and the patient had a good response to NSAID therapy.