Acute Left Ventricular Dysfunction Research Articles

Association between speckle tracking echocardiography and pressure-volume loops during cardiogenic shock development

BackgroundThe relationship between speckle tracking assessed global longitudinal strain (GLS) and Doppler-based echocardiography with basic physiological markers of cardiac function derived from pressure-volume loops is poorly elucidated.ObjectiveWe aimed to describe...

Anesthetic management in a patient with acute aortic dissection and severe left ventricular systolic dysfunction.

Anesthetic management in a patient with acute aortic dissection and severe left ventricular systolic dysfunction.

Streamlining same-day discharge for percutaneous coronary intervention: A single-center experience

Introduction and objectivesSame-day discharge (SDD) can be considered for patients who traditionally required overnight stay (ONS) after percutaneous coronary intervention (PCI). The authors aimed to evaluate viability of SDD-PCI. MethodsRetrospective single-center observational study of patients who underwent elective PCI. SDD patients were selected based on clinical, angiographic, and sociodemographic characteristics. Patient and procedure characteristics were collected from local databases, and SDD-PCI adverse events (all-cause mortality, acute coronary syndrome, stent thrombosis, reintervention, major bleeding, stroke, contrast-induced renal failure, vascular access complications) at 30-days were analyzed. ResultsThis study included 147 patients, 76% males with a mean age of 66±10, that underwent elective PCI during the first year after implementation of SDD protocol. Most patients undergoing elective PCI were discharged the same day (n=94, 64%). ONS group, when compared to SDD, had higher rates of acute coronary syndrome (38% vs 19%, P=.01) and left ventricular dysfunction (17% vs 6%, P=.04), higher Syntax I score (10 points [6–16] vs 8 points [5–12]; P=.01), more cases of multivessel PCI (24% vs 6%, P<.01) and a surrogate for longer procedures – fluoroscopy time (11min [7–15] vs 8min [5–13]; P=.02). There were no adverse events during the 30-day follow-up period of the patients treated in ambulatory regimen. ConclusionsSDD-PCI is a safe procedure. Protocol implementation is key to guide interventional cardiologists in low-risk patient selection. The potential role in decreasing bed-shortage, hospital overcrowding, and healthcare costs is pivotal.

Rethinking Tako-tsubo Cardiomyopathy: The Contribution of Myocardial Pathology and Molecular Imaging.

Despite substantial research, the mechanisms behind stress Tako-tsubo cardiomyopathy (TTC) remain rather elusive. The purpose of this paper was to provide a detailed review of the mainstream factors underlying the pathophysiology of TTC, highlighting the novel contributions of molecular pathology and in-vivo molecular imaging. A careful literature review selected all papers discussing TTC, specifically those providing novel insights from myocardial pathology and cardiac molecular imaging. Results concerning myocardial pathology, defect extension, sites and relationships between functional parameters underline the existence of a causal relationship between a determinant (e.g., the release of catecholamines induced by stress) and an outcome for TTC, which is not limited to a reversible contractile cardiomyopathy, but it includes reversible changes in myocardial perfusion and a long-lasting residual deficit in sympathetic function. Besides, they reinforce the hypothesis that sympathetic nerves may exert a complex control on cardiac contractile function, which is likely to be direct or indirect through metabolism and microvascular perfusion changes during anaerobic and aerobic conditions. TTC is characterized by acute transient left ventricular systolic dysfunction, which can be challenging to distinguish from myocardial infarction at presentation. Catecholamineinduced myocardial injury is the most established theory, but other factors, including myocardial metabolism and perfusion, should be considered of utmost importance. Each effort to clarify the numerous pathways and emerging abnormalities may provide novel approaches to treat the acute episode, avoid recurrences, and prevent major adverse cardiovascular events.

Incidence of Left Ventricular Thrombus and Embolic Phenomena in Patients with Acute Myocardial Infarction and Severe Left Ventricular Dysfunction

Incidence of Left Ventricular Thrombus and Embolic Phenomena in Patients with Acute Myocardial Infarction and Severe Left Ventricular Dysfunction

Association between speckle tracking echocardiography and pressure-volume loop derived parameters at increasing levels of myocardial damage in a porcine model of acute cardiogenic shock

Abstract Background Echocardiography is a diagnostic cornerstone in acute cardiovascular care. However, the relationship between speckle tracking assessed global longitudinal strain (LS) and Doppler-based echocardiography with basic physiological markers of cardiac function derived from pressure-volume loops remains poorly elucidated, especially with increasing levels of myocardial damage. Objectives We aimed to describe the association between LS and Doppler-based echocardiography and direct measurements of central hemodynamic parameters from conductance catheter-based pressure-volume loops in an animal model with increasing left ventricular (LV) dysfunction. Methods Twelve Danish landrace pigs weighing 75-80 kg were used. All instrumentations were performed percutaneously, including placement of a conductance catheter in the LV. Progressive LV dysfunction was induced by stepwise embolization trough the left main coronary artery every three minutes until a 50% reduction in cardiac output or mixed venous saturation, compared to baseline, or a mixed venous saturation &amp;lt;30%. Echocardiography was performed through a subxiphoid midline incision, and was done at baseline and 90 seconds after each injection. Results With progressive LV dysfunction, mean cardiac output decreased from 5.6 l/min (SD: 0.9) to 2.1 l/min (SD: 0.9) and mean mixed venous saturation deteriorated from 61.1%(SD: 7.9) to 35.3% (SD: 6.1). Mean LS and LV outflow tract velocity time integral (LVOT VTI) declined from -13.8% (SD 3.0) to -6.1% (SD: 2.0) and 16.9 cm (SD: 2.6) to 7.8 cm (SD: 1.8), respectively (Figure 1). LS and LVOT VTI showed the strongest correlation to stroke work in unadjusted univariate regression (r2=0.53 and r2=0.49, respectively. p&amp;lt;0.01 for both). LS correlated significantly, but modest, with stroke volume (r2=0.46, p&amp;lt;0.01), end-systolic elastance (r2=0.32, p&amp;lt;0.01), systolic blood pressure (r2=0.37, p&amp;lt;0.01), ventriculo-arterial coupling(r2=0.34, p&amp;lt;0.01), and arterial elastance (r2=0.23, p&amp;lt;0.01) (Figure 2). In a multivariate regression analysis, LS showed significant correlation with stroke work, systolic blood pressure, and end-diastolic wall stress (r2=0.60, p&amp;lt;0.01). Conclusion In an animal model of acute progressive LV dysfunction, echocardiographic and conductance catheter-based measurements changed significantly. LS and LVOT VTI displayed the earliest and the largest alterations with increased myocardial damage and LS showed moderate correlations with contractility, arterial elastance and ventriculo-arterial coupling. This indicates that LS is a marker of overall ventricular performance.Echocardiographic changes from baselineScatter plot of LS and hemodynamics

Abstract 17123: Opioid Withdrawal Causing a Broken Heart!

Introduction: Takotsubo syndrome is a condition characterized by transient acute left ventricular systolic dysfunction. Although it was previously thought of as a benign self-limiting condition, it is now known to be associated with significant morbidity and mortality. Case: A 26-year-old male patient with past medical history of Fentanyl abuse now on methadone, presented with features of opioid withdrawal. ECG on arrival was normal sinus rhythm with QTc 488 ms. with a troponin of 2.63. Due to excessive agitation and vomiting, he was given IV haloperidol and ondansetron. The patient then became unresponsive and sustained a cardiac arrest. He was found to be in polymorphic ventricular tachycardia and was able to be resuscitated. ECG after resuscitation demonstrated new yamaguchi T waves with a QTc 597 ms and troponin of 6.60. Transthoracic echocardiography subsequently revealed a reduced ejection fraction of 35% with apical hypokinesis, and he was referred for an ischemic evaluation with CTA coronary that showed normal coronary arteries. He was diagnosed with takotsubo cardiomyopathy and was initiated on dapagliflozin, metoprolol succinate and losartan. For opioid dependence, he was prescribed buprenorphine/naloxone being mindful of his QTc and was provided a wearable cardioverter defibrillator on discharge. Final ECG demonstrated QTc of 465 ms. Discussion: Opioid withdrawal is known to cause a high adrenergic state and this catecholamine excess can result in cardiac stunning, creating transient left ventricular dysfunction along with wall motion abnormalities. Patients with takotsubo cardiomyopathy typically have normal coronary arteries. Approximately 4.5% of these patients can die during their hospitalization and 4% can die within 30 days of discharge. So, clinicians must keep a high index of suspicion for this syndrome in patients with history of substance use disorder, especially in the setting of troponin elevation.

Abstract 15188: Mid-Cavity Takotsubo Cardiomyopathy Post CAR T-cell Therapy

Introduction: CAR T-cell therapy has been reported to have cardiovascular (CV) adverse effects mostly in context of cytokine reconstitution syndrome (CRS). Although pathophysiology of CAR T-cell cardiotoxicity (CTCC) is not fully understood, it is thought to be IL-6 mediated which has been implicated as a mediator of myocardial depression in infectious and inflammatory states. Another mechanism is direct cardiotoxicity from potential cross-reactivity with unrelated peptides expressed by normal tissue. We present a case of Takotsubo cardiomyopathy following CAR T cells. Case: 61 year old male with h/o Waldenstrom's macroglobulinemia, DMT2, HLD was admitted for CAR T cell therapy. Following infusion, he developed chills, diaphoresis, tachypnea, tachycardia, chest tightness lasting several hours. EKG had dynamic ST depressions in inferolateral leads with elevated hstroponin (6000 pg/ml). Despite severe pancytopenia, heparin was started for acute coronary syndrome. Pain resolved with morphine and he received tocilizumab for CRS. Echo showed a mid-cavitary variant of Takotsubo involving right and left ventricles with depressed systolic function (LVEF 30-35%; Image). Coronary angiogram was deferred due to bleeding risk. Repeat echo in 2 days showed persistent mid-cavity hypokinesis with slight improvement in LVEF (40%) after initiating beta blocker. The temporal relation of acute mid-cavity dysfunction to CAR T-cells indicates most likely CTCC. Heparin was stopped and he was managed conservatively with plan to reassess LVEF in 2 months. Conclusion: Patients undergoing CAR T-cell therapy should be assessed for CV symptoms using biomarkers and imaging for early detection of cardiotoxicity and prompt initiation of supportive treatment. We present a case of acute mid-cavity left ventricular dysfunction (a Tako-tsubo variant) that was temporally related to CAR T cell infusion. Further studies are needed to determine the frequency of this acute form of CTCC.

Abstract 14399: Development of Heart Failure in High-Risk Post-Myocardial Infarction Patients: An Analysis of the Paradise-MI Trial

Objectives: The aims of this study were i) to examine the incidence, risk factors and subsequent mortality after high-risk acute myocardial infarction (AMI) and ii) compare the effects of sacubitril/valsartan with the ACE inhibitor ramipril across heart failure (HF) risk categories. Background: The contemporary risk of developing HF following AMI in the coronary reperfusion era is not well documented. Methods: We analyzed the 5661 patients enrolled in the PARADISE-MI trial which compared sacubitril-valsartan to ramipril after AMI. Patients were required to have acute pulmonary congestion and/or left ventricular systolic dysfunction at the time of AMI, but no history of HF. We analyzed a composite outcome of first occurrence of investigator-reported HF hospitalization or outpatient development of HF. Results: During a median follow up of 22 months, 734 patients (13%) developed a first episode of HF, of which 496 (68%) were a hospitalization and 238 (32%) an outpatient HF episode. Only 74 patients (10%) experienced another AMI prior to developing HF. Independent predictors for the development of HF were a lower baseline left ventricular ejection fraction (LVEF), pulmonary congestion, diabetes, older age, higher heart rate, previous MI, and renal dysfunction. A risk-score showed an exponential increased risk of developing HF with a higher score (Figure 1). The relative effect of sacubitril/valsartan compared to ramipril was similar across the HF risk spectrum (p-value for interaction=0.14). The hazard ratio for cardiovascular mortality after outpatient development of HF (in comparison to no event) was 3.9 (95% CI 2.5-6.2) and after an HF hospitalization was 10.0 (95% CI 7.8-12.8). Conclusion: New onset HF after high-risk AMI was common and resulted in a 10-fold higher cardiovascular mortality than no HF. Sacubitril/valsartan, compared to ramipril, showed similar efficacy across the HF risk spectrum.

Abstract 16506: Effect of COVID-19 on Outcomes of Patients Hospitalized With Takotsubo Cardiomyopathy

Introduction: Takotsubo Cardiomyopathy (TCM), commonly known as stress cardiomyopathy, is a condition characterized by the abrupt occurrence of acute left ventricular dysfunction, triggered by a variety of physical and psychosocial factors. The influence of COVID-19 on the outcomes of TCM hospitalizations remains relatively understudied. Thus, our objective was to investigate the impact of COVID-19 (COVID) on the outcomes of individuals hospitalized with TCM. Methods: The 2019-2020 National Inpatient Sample (NIS) was analyzed to identify adult hospitalizations admitted for TCM with a concurrent diagnosis of COVID-19 using International Classification of Disease 10 Clinical Modification (ICD-10-CM) codes. We compared baseline characteristics using T-test and Chi-square for continuous and categorical variables, respectively and multivariate regression analysis was used to adjust for potential confounders. Results: Out of the 41,324 TCM hospitalizations, 1,665 had a concurrent COVID infection. Hospitalizations with TCM and COVID had statistically significant difference in mortality (adjusted Odds Ratio (aOR) 2.30; Confidence Interval [CI] 1.2-4.5, p = 0.01), longer length of stay (LOS) 4.1 days (CI 2.8-5.5, p &lt; 0.001), and higher mean total hospital charges (THC) of $46,452 (CI 17,711-75203). Figure 1 shows the Forrest plot for multivariate analysis of in-hospital morbidities when adjusted for patient demographics, comorbidities and hospital characteristics. Conclusions: Patients hospitalized for TCM with concurrent COVID 19 infection had increased in-hospital mortality, longer LOS, higher THC and increased odds of cardiogenic shock, cardiac arrest, acute kidney injury (AKI), use of mechanical ventilation and use of vasopressor support.

Therapeutic S100A8/A9 blockade inhibits myocardial and systemic inflammation and mitigates sepsis-induced myocardial dysfunction

Background and AimsThe triggering factors of sepsis-induced myocardial dysfunction (SIMD) are poorly understood and are not addressed by current treatments. S100A8/A9 is a pro-inflammatory alarmin abundantly secreted by activated neutrophils during infection and inflammation. We investigated the efficacy of S100A8/A9 blockade as a potential new treatment in SIMD.MethodsThe relationship between plasma S100A8/A9 and cardiac dysfunction was assessed in a cohort of 62 patients with severe sepsis admitted to the intensive care unit of Linköping University Hospital, Sweden. We used S100A8/A9 blockade with the small-molecule inhibitor ABR-238901 and S100A9−/− mice for therapeutic and mechanistic studies on endotoxemia-induced cardiac dysfunction in mice.ResultsIn sepsis patients, elevated plasma S100A8/A9 was associated with left-ventricular (LV) systolic dysfunction and increased SOFA score. In wild-type mice, 5 mg/kg of bacterial lipopolysaccharide (LPS) induced rapid plasma S100A8/A9 increase and acute LV dysfunction. Two ABR-238901 doses (30 mg/kg) administered intraperitoneally with a 6 h interval, starting directly after LPS or at a later time-point when LV dysfunction is fully established, efficiently prevented and reversed the phenotype, respectively. In contrast, dexamethasone did not improve cardiac function compared to PBS-treated endotoxemic controls. S100A8/A9 inhibition potently reduced systemic levels of inflammatory mediators, prevented upregulation of inflammatory genes and restored mitochondrial function in the myocardium. The S100A9−/− mice were protected against LPS-induced LV dysfunction to an extent comparable with pharmacologic S100A8/A9 blockade. The ABR-238901 treatment did not induce an additional improvement of LV function in the S100A9−/− mice, confirming target specificity.ConclusionElevated S100A8/A9 is associated with the development of LV dysfunction in severe sepsis patients and in a mouse model of endotoxemia. Pharmacological blockade of S100A8/A9 with ABR-238901 has potent anti-inflammatory effects, mitigates myocardial dysfunction and might represent a novel therapeutic strategy for patients with severe sepsis.Graphical

Imaging Predictors of Left Ventricular Functional Recovery after Reperfusion Therapy of ST-Elevation Myocardial Infarction Assessed by Cardiac Magnetic Resonance.

Left ventricular global longitudinal strain (LV GLS) is a superior predictor of adverse cardiac events in patients with myocardial infarction and heart failure. We investigated the ability of morphological features of infarcted myocardium to detect acute left ventricular (LV) dysfunction and predict LV functional recovery after three months in patients with acute ST-segment elevation myocardial infarction (STEMI). Sixty-six STEMI patients were included in the C-reactive protein (CRP) apheresis in Acute Myocardial Infarction Study (CAMI-1). LV ejection fraction (LVEF), LV GLS, LV global circumferential strain (LV GCS), infarct size (IS), area-at-risk (AAR), and myocardial salvage index (MSI) were assessed by CMR 5 ± 3 days (baseline) and 12 ± 2 weeks after (follow-up) the diagnosis of first acute STEMI. Significant changes in myocardial injury parameters were identified after 12 weeks of STEMI diagnosis. IS decreased from 23.59 ± 11.69% at baseline to 18.29 ± 8.32% at follow-up (p < 0.001). AAR and MVO also significantly reduced after 12 weeks. At baseline, there were reasonably moderate correlations between IS and LVEF (r = -0.479, p < 0.001), LV GLS (r = 0.441, p < 0.001) and LV GCS (r = 0.396, p = 0.001) as well as between AAR and LVEF (r = -0.430, p = 0.003), LV GLS (r = 0.501, p < 0.001) and weak with LV GCS (r = 0.342, p = 0.020). At follow-up, only MSI and change in LV GCS over time showed a weak but significant correlation (r = -0.347, p = 0.021). Patients with larger AAR at baseline improved more in LVEF (p = 0.019) and LV GLS (p = 0.020) but not in LV GCS. The CMR tissue characteristics of myocardial injury correlate with the magnitude of LV dysfunction during the acute stage of STEMI. AAR predicts improvement in LVEF and LV GLS, while MSI is a sensitive marker of LV GCS recovery at three months follow-up after STEMI.

P189 WHEN A PACEMAKER CAN BE HARMFUL IN A PATIENT WITH COMPLETE AV BLOCK

Abstract The occurrence of complete AV block in patients with aortic valve stenosis is a frequent event and the implantation of a dual–chamber pacemaker is the therapy of choice for these cases. We present the case of an 84–year–old hypertensive diabetic patient hospitalized with heart failure during a severe anemia caused by bleeding duodenal ulcer (Hb &amp;lt; 7g/dl). The patient was treated with blood transfusions, proton pump inhibitors, and endoscopic ulcer treatment with clinical stabilization. However, he presented a third–degree AV block, with a narrow QRS escape rhythm of about 45 bpm. The echocardiogram showed a calcified aortic valve with severe stenosis (transvalvular flow 4m/s, valvular area 0.9 cm2) ( fig1–2), with moderate mitral regurgitation and preserved systolic function (EF 60%). He was therefore subjected to a dual–chamber pacemaker implant. In the hours following the procedure, with heart rate increased to 90 bpm and correct AV synchronism, the patient presented an episode of acute pulmonary edema, treated with diuretics, oxygen and nitrogliceryn. with initial clinical improvement but subsequent new instabilization. The echocardiogram showed worsening of systolic function with septal dyssynergia secondary to electrostimulation and a severe mitral regurgitation (fig 3). The clinical status definitively stabilized only after changing the pacemaker programming to VVI 40 bpm (sentinel mode). The patient repeatedly refused the indications for aortic valve replacement surgery, and was therefore discharged with medical supportive care, third–degree AV block at electrocardiogram and a dual–chamber pacemaker programmed in sentinel VVI to obtain a minimal ventricular pacing. After 24–month follow–up, the patient remains in good clinical conditions, he was never hospitalized again, the third–degree AV block persists with PM stimulation percentages of 5%. This clinical case shows how electrostimulation and increased heart rate, in the presence of aortic outflow obstruction and significant mitral valve disease, can cause very insidious acute left ventricular systolic dysfunction, while restoring correct AV synchrony.

Changes in CMR findings over time following acute Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTS) is characterized by acute reversible left ventricular dysfunction showing typical left ventricular apical ballooning in the absence of obstructive coronary artery disease. Cardiac magnetic resonance (CMR) provides functional and inflammatory findings in contrast with the absence of late gadolinium enhancement (LGE). TTS generally heals within the first two weeks after the onset of symptoms, with the ECG and echocardiogram normalizing. However, data on CMR dynamics are scarce. In the present study, we aimed to describe how CMR findings change over time in acute TTS. Between December 2008 and May 2021, we retrospectively included all the patients hospitalized in the tertiary University Hospital of Angers, France who underwent CMR and received a diagnosis of acute TTS. Sixty-two patients fulfilled the diagnostic criteria from the 2018 ESC international expert consensus and underwent CMR. Patients were classified into three groups based on the delay between their first day of hospitalization and their assessment using CMR: less than five days (n = 31, 50%), between 5 and 15 days (n = 16, 25.8%), and more than 15 days [median 27 days (IQR: 20–36)] (n = 15, 24.2%). Compared to the 0–5 d group, the patients in the > 15 d group showed resolution of the LVEF alterations (55.9 ± 10.7 vs. 44.8 ± 13.3, P = 0.07), less apical akinesia (40% vs. 83%, P = 0.01) and normalized apical T2 values (44.5 ± 3.5 vs. 57 ± 2, P = 0.049). T1 and T2 quantitative measurements showed a base-to-apex gradient in 88.2% and 85.7% of patients, irrespective of the delay (P = 0.12 and P = 0.88). When CMR cannot be performed early after the onset of a suspected TTS, wall motion abnormalities disappear, and LVEF alteration resolve. However, a parametric assessment searching for a base-to-apex gradient in T1 and T2 values with higher apical values may be helpful to confirm the diagnosis. Main CMR findings at different time points (Fig. 1).

Expanding Heart Donor Pool With a Broken Heart: Cardiac Transplant From Donor Following Circulatory Death With Takotsubo Syndrome.

Owing to the growth of patients with advanced heart failure and limited potential for donation after brain death, expanding donor source with hearts from controlled donation after circulatory death (cDCD) and meeting extended criteria are essential strategies. We present the first case of a patient who successfully underwent cardiac transplant (CT) from cDCD with Takotsubo syndrome (TTS). The donor was a 49-y-old man without risk factors for coronary artery disease (CAD) and terminal amyotrophic lateral sclerosis with respiratory failure and mechanical ventilation support. A decision was made with patient’s family to withdraw life-sustaining therapies (WLSTs). Organ donation option was presented and consented, and cDCD Maastricht Classification III1 was considered suitable. He presented normal blood tests, electrocardiogram, and echocardiogram. The cDCD process was performed using an extracorporeal membrane oxygenation circuit to perform thoracoabdominal normothermic regional perfusion.2 During intraoperative evaluation, transesophageal echocardiography revealed normal left ventricular ejection fraction (LVEF). However, after WLST, moderate dysfunction (LVEF 37%) and apical ballooning suggestive of TTS were observed (Figure 1A), continuing present after thoracoabdominal normothermic regional perfusion withdrawal and organ extraction. Epicardial coronary arteries palpation did not reveal pathology.FIGURE 1.: A, Intraoperative transesophageal echocardiography evaluation that shows the left ventricle in diastole and systole with apical akinesia and preserved contractility of basal segments. B, The 12-lead electrocardiogram reveals T wave inversion and prolonged QT interval. C, A graph of heart recovery timeline based on the high-sensitivity troponin T levels, left ventricular ejection fraction, and inotrope support, correlated with the d after cardiac transplant. D, Normal right and left coronary arteries in the post cardiac transplant protocol–based coronary angiography. LVEF, left ventricular ejection fraction.The heart recipient was a 52-y-old man with severe, irreversible ischemic cardiomyopathy and 10 d with a ventricular assist device, listed for CT after excluding severe comorbidities and a multidisciplinary team discussion. An orthotopic transplant was performed using the bicaval technique, with spontaneous heartbeat and cold ischemia time of 86 min. He required minimal vasoactive support, withdrawn 48 h after CT. The electrocardiogram showed diffuse negative T waves and prolonged QTc interval (Figure 1B), and peak level of high-sensitivity troponin T was 2115 ng/L. Six days after CT, LVEF normalized. The timeline of heart recovery is represented in Figure 1C. The coronary angiography ruled out donor CAD (Figure 1D). The patient was discharged 30 d after CT and is doing well 43 wk after. Serial echocardiograms reveal normal wall motion and function. DISCUSSION Although TTS and CT have been indirectly associated, few cases have been published on donor hearts with TTS, these with no compromised survival3; none in cDCD. Similar pathophysiological aspects, present in TTS and cDCD, could be responsible for the phenomenon that occurred during CT. In the cDCD, the heart experiences a warm ischemia period during the WLST, cardiac arrest, and CT. This implies ischemia–reperfusion injury: activation of inflammatory and coagulation cascades and release of catecholamines.4 The mechanisms behind TTS, clinical condition characterized by acute transient left ventricular dysfunction, remain unknown. The most widely accepted theory is catecholamine-induced cardiotoxicity, and growing evidence is arising for myocardial inflammation, endothelial and microcirculation dysfunction, and neurohormonal alterations.5 Because of donor’s age, low-risk profile of CAD, and echocardiographic abnormalities, TTS was suspected. The post-CT protocol–based coronary angiography ruled out obstructive CAD or atherosclerotic plaque rupture. There was a rapid normalization of LVEF, negative T waves in the electrocardiogram, and elevated cardiac enzymes. This fulfilled the most widely used TTS diagnostic criteria.5 A pre-CT coronary angiography in patients >40 y or at risk of CAD could avoid ruling out hearts with left ventricular dysfunction. CONCLUSION The pathophysiological knowledge of cDCD and TTS could increase CT rates. This first experience in cDCD should be cautiously interpreted and analyzed individually in future cases.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry.

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting. In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72). In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

383: MYOCARDITIS DUE TO LEGIONELLA: A CASE REPORT

Introduction: Legionnaires’ disease is pneumonia caused due to Legionella species. Among the rare extrapulmonary manifestations, cardiac involvement is most prevalent in myocarditis, pericarditis, post-cardiotomy syndrome, and prosthetic valve endocarditis. The morbidity and mortality associated with such an uncommon presentation of legionella myocarditis are quite high. We describe a rare case of Legionella myocarditis in a 35-year-old female associated with acute left ventricular dysfunction with sepsis and pneumonitis. Description: The patient presented with fever, headache, giddiness, chills, myalgias, generalized body aches, altered mental sensorium, acute onset dyspnea, hypoxemia (83%), low blood pressure (86/56 mm Hg), respiratory failure, renal failure, and ischemic hepatic injury. She was intubated and stabilized with multiple inotropes. Echocardiography (Echo) showed borderline increase in cardiac chambers with severe, and mild mitral regurgitation (MR), mild tricuspid regurgitation (TR). The estimated LV ejection fraction (LVEF) was 10-15% with grade III LV diastolic dysfunction. X-ray showed haziness in the right lower zone with blunting of the right CP angle. She was admitted in the intensive care unit for 8 days. Due to significantly raised cardiac biomarkers (Troponin), borderline dilated chambers, and severe LV dysfunction on echocardiogram, a provisional diagnosis of fulminant myocarditis was made. Legionella infection was diagnosed on the basis of a serum pneumoslide IgM test. Although the result from the biopsy would have strengthened the diagnosis, but it was too risky. After appropriate medication, the patient improved significantly and transferred to the floor. After 10 days of monitoring, the patient was discharged and was advised follow-up after 1 week. She recovered fully and follow-up echocardiography showed marked improvement in the cardiac function. Echo Images will be presented during poster presentation. Discussion: A high degree of clinical suspicion and a thorough history is needed to suspect legionella infection. The prognosis of Legionella myocarditis depends on systemic involvement, comorbidities, and the delay before beginning directed therapy.

285 BIVENTRICULAR TAKO-TSUBOSYNDROME ASSOCIATED WITH SYNCOPE AND UNCONSCIOUSNESS

Abstract A 58-years old woman came to the emergency department due to syncope; she had been found lying on the ground in her residence. At the admission the patient was unconscious but had preserved blood pressure 120/80 mmHg. CT brain scan was negative for hemorrhage. Admission ECG showed a 52 b/m sinus bradycardia, elevated antero-septal ST segment and prolonged QT interval. Diagnosis of antero-septal STEMI was made and a coronary angiogram performed via right femoral access showed mild atheromasia in the absence of angiographically significant lesions. Bedside echocardiogram showed severe left ventricular dysfunction (LVEF 35%) with akinesia of apical and mid-ventricular segments. The right ventricle presented a marked hypocontractility of the apical region and a preserved kinetics of the basal portion (TAPSE 22 mm). There was also a moderate mitral regurgitation and a mild tricuspid regurgitation with a sPAP of 50 mmHg (40+10). On blood sampling, high-sensitivity troponin was slightly elevated (3950 pg/ml) and marked hyponatriemia (117 mmol/l) and slight hypokalemia (3.1 mmol/l) were noted. The echocardiogram on the third day showed an improvement in global and segmental kinetics of left ventricle with an estimated EF of 45% and persistence of a mild hypocontractility of the apex of right ventricle. During her hospital stay, her cognitive state gradually improved and she remained asymptomatic without evidence of arrhythmic events on monitoring. The ECG evolved on days with normalization of the ST-T tract, negative T wave in the anterior region and prolonged QTc interval. The pre-discharge echocardiogram showed a recovery of biventricular kinetics with an estimated EF of 50%. The presence of a transient abnormality in biventricular wall motion beyond a single epicardial coronary artery perfusion territory with new electrocardiographic change met the diagnostic criteria of Tako-tsubo Syndrome defined by Mayo Clinic criteria. The electrocardiogram on the day of discharge showed a 55 b/m sinus bradycardia with a negative T wave from V1 to V4. Tako-tsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction that improves spontaneously within days or weeks and is often preceded by emotional or physical stress. Biventricular involvement in TTS is typically identified on imaging studies such as echocardiography and MRI. TTS with RV involvement is associated with a higher rate of in-hospital mortality and long-term adverse clinical events than isolated LV TTS. In our clinical case, biventricular involvement was associated with a severe clinical presentation (syncope and unconsciousness). This case shows that biventricular Tako-tsubo is a clinical scenario that requires intensive care monitoring and strict cardiological evaluation.

598 PREVALANCE AND PREDICTORS OF LONG-TERM CARDIAC SYMPTOMS IN PATIENTS WITH TAKOTSUBO SYNDROME

Abstract Background Takotsubo syndrome (TTS) is characterized by an acute and transient left ventricular dysfunction, usually involving the apical and midventricular segments, associated with troponin elevation and often triggered by either emotional or physical stressors. Once considered a benign condition, it is now clear that TTS patients have increased long-term mortality compared with the general population. Prevalence and the determinants of long-term cardiac symptoms in TTS patients have been scarcely investigated. Methods We enrolled consecutive patients admitted to our Centre with a diagnosis of TTS . All patients underwent invasive coronary angiography with left ventriculography at admission and only those fulfilling both the Mayo Clinic and Heart Failure Association criteria for a TTS diagnosis were selected for this study. Clinical, biochemical, and instrumental data were collected at admission and before discharge, and patients were followed-up for: symptoms recurrence (i.e., presence of effort angina and/or dyspnoea in the absence of other obvious causes) and all-cause mortality. The prevalence of long-term symptoms was further compared with a control group of unselected patients admitted for acute coronary syndromes (ACS) in the same period, matched for sex, age, and left ventricular ejection fraction (LVEF) at discharge. Results We eventually enrolled 118 patients (aged 73±10 years, 91% of whom were female). Acute chest pain was the most common presenting symptom (73%), followed by dyspnoea (32%), acute heart failure (16%), cardiogenic shock (9%), and syncope (8%). Most of cases (82%) were classified as having a typical (apical) LV dysfunction. Either a physical or an emotional stressor was identified in 37 (31%) and 31 (26%) of the patients, respectively. At admission, patients showed moderate systolic dysfunction (LVEF 40±9%), which was often improved at discharge (LVEF 52±8%). Over a median follow-up of 21 (interquartile interval 11-53) months, 35% of patients complained of some cardiac symptom: 32% of patients complained of effort dyspnoea and 7% (partially overlapping with the former) complained of effort angina. When compared with ACS patients (n=55, aged 71±10 years, 94% women, LVEF 53±9%), TTS patients featured a similar mortality rate, a lower (non-significant) prevalence of angina, and a significantly higher prevalence of dyspnoea (p=0.02). Notably, while a lower age at presentation (p=0.017) and a physical trigger (p=0.015) were significantly associated with the risk of recurrent angina, the absence of chest pain (p=0.044), a lower LVEF at admission (p=0.019), and a higher troponin T concentration at discharge (p=0.018) were associated with the presence of dyspnoea at follow-up. Finally, older age, male sex, renal dysfunction, cardiogenic shock, and concomitant coronary artery disease were all associated with a higher risk of death. Prescription of ACE-inhibitors and/or beta-blockers were associated with reduced risk (p&amp;lt;0.05, for all), in line with previous reports. Conclusion TTS is associated with a high risk of recurrent cardiac symptoms, mostly dyspnoea, over time. Selected clinical, biochemical, and instrumental characteristics may help identify patients more at risk, who may deserve a closer follow-up and potentially tailored therapies, to be investigated in future studies.

The reversible perfusion-metabolism pattern of radionuclide myocardial PET imaging in Takotsubo Cardiomyopathy: A case report

Background: Takotsubo Cardiomyopathy (TTC) is known as a syndrome of transient and acute left ventricular dysfunction caused by emotional and physiological stressors. Due to a variety of complications in the acute phase, recently, there has been increased attention to TTC