Anterior Septum Research Articles

An out-of-season cold: filler-induced vascular occlusion of the columellar artery causing necrosis of the cartilaginous anterior nasal septum case report and a literature review

In their recent publication, George Kroumpouzos et al. provided a comprehensive update on the complications caused by filler procedures in the lips and perioral area. These injections have been associated with various arterial accidents and an incidence of vision loss mainly when such procedures are performed at the level of the central facial massif. Among the various cases of vascular involvement reported in the literature, we have found what we believe to be a rare occurrence of columellar artery occlusion with a noteworthy discrepancy between the expected symptoms and the actual described vascular effects. The necrosis of the columellar artery following hyaluronic acid injections showed some peculiarities: its frequency is unknown, and recognition can be troublesome due to the presentation of subtle symptoms. We want to exemplify these characteristics in this case, which, fortunately, optimally resolved itself, underscoring its unique nature.

Severe stress cardiomyopathy following spinal corrective surgery for scoliosis complicated with pectus excavatum: a case report

BackgroundStress cardiomyopathy (SCM) is an acute heart failure syndrome characterized by transient, usually reversible left ventricular systolic dysfunction with normal or enhanced basal compensatory wall motion abnormalities involving the left ventricular anterior septum and apex, resulting in a “ballooning” appearance. However, it has rarely been reported in patients undergoing spinal surgery.Case presentationWe report a case of severe stress cardiomyopathy in a scoliosis patient with pectus excavatum who underwent spinal corrective surgery. During the wake-up period, circulatory collapse occurred. After multidisciplinary consultation, the patient was diagnosed with stress cardiomyopathy. At last, she had a good prognosis after a series of treatments including ECMO.ConclusionStress cardiomyopathy is a reversible but uncommon condition. It can cause death if it is not diagnosed in time. Consequently, this report should improve the awareness of orthopedists and anesthesiologists for timely identification and management. For patients with potential risk factors, timely preoperative intervention should be performed to reduce the occurrence of stress cardiomyopathy.

Pediatric Intranasal Lobular Capillary Hemangioma: A Scoping Review and Multimedia Case Presentation.

Systematic, scoping literature review and case presentation. The goal of this study is to review current literature on management trends and outcomes of pediatric intranasal lobular capillary hemangioma (ILCH). A 14-year-old male patient presented with a 15-month history of unilateral epistaxis, nasal congestion, and mouth breathing. Further workup revealed a pale nasal mass obstructing the right nasal cavity. The patient was successfully treated using a minimally invasive endoscopic endonasal approach for mass resection and nasal floor free mucosal graft for septal reconstruction. Independent queries of the PubMed Central, MEDLINE, and Bookshelf databases were performed; articles from 1990 to 2023 were abstracted. All studies that described pediatric ILCH using the Boolean method and relevant search term combinations, including "Intranasal," "Lobular capillary hemangioma," "Pyogenic granuloma," "Pediatric," "Outcome," and "Management," were collected for subsequent analysis. A total of 407 relevant unique articles were identified for analysis. Of these, 19 articles were deemed appropriate for inclusion in this literature review. Twenty-two pediatric ILCH cases were identified with a mean age at diagnosis of 10.5 years. The majority of cases occurred in males and presented with recurrent epistaxis and nasal obstruction. Most lesions originated from the anterior nasal septum and were resected using an endoscopic endonasal approach with no recurrence at last follow-up. Pediatric ILCH, a benign vascular neoplasm, often presents with unilateral nasal obstruction and severe, refractory epistaxis. This comprehensive review aims to highlight the importance of including this lesion in the differential diagnosis for unilateral nasal obstruction and epistaxis in young children.

Hot topic: Mapping of the human intranasal mucosal thermal sensitivity: A clinical study on thermal threshold and trigeminal receptors.

The olfactory and trigeminal system are closely interlinked. Existing literature has primarily focused on characterizing trigeminal stimulation through mechanical and chemical stimulation, neglecting thermal stimulation thus far. The present study aimed to characterize the intranasal sensitivity to heat and the expression of trigeminal receptors (transient receptor potential channels, TRP). A total of 20 healthy participants (aged 21-27 years, 11 women) were screened for olfactory function and trigeminal sensitivity using several tests. Under endoscopic control, a thermal stimulator was placed in 7 intranasal locations: anterior septum, lateral vestibulum, interior nose tip, lower turbinate, middle septum, middle turbinate, and olfactory cleft to determine the thermal threshold. Nasal swabs were obtained in 3 different locations (anterior septum, middle turbinate, olfactory cleft) to analyze the expression of trigeminal receptors TRP: TRPV1, TRPV3, TRPA1, TRPM8. The thermal threshold differed between locations (p = 0.018), with a trend for a higher threshold at the anterior septum (p = 0.092). There were no differences in quantitative receptor expression (p = 0.46) at the different sites. The highest overall receptor RNA expression was detected for TRPV1 over all sites (p<0.001). The expression of TRPV3 was highest at the anterior septum compared to the middle turbinate or the olfactory cleft. The thermal sensitivity correlated with olfactory sensitivity and results from tests were related to trigeminal function like intensity ratings of ammonium, a questionnaire regarding trigeminal function, nasal patency, and CO2 thresholds. However, no correlation was found between receptor expression and psychophysical measures of trigeminal function. This study provided the first insights about intranasal thermal sensitivity and suggested the presence of topographical differences in thermal thresholds. There was no correlation between thermal sensitivity and trigeminal mRNA receptor expression. However, thermal sensitivity was found to be associated with psychophysical measures of trigeminal and olfactory function.

Pediatric Sinonasal Pleomorphic Adenoma: A Case Report

While primarily observed in adults, this case contributes valuable insights into the manifestation and management of this benign salivary gland tumor within the pediatric population. This paper reports the first documented case of sinonasal pleomorphic adenoma in pediatric otolaryngology, presenting a unique perspective on this rare nasal tumor in a 9-year-old boy. The patient presented with progressive nasal obstruction and epistaxis and underwent a smooth endoscopic resection of a 2-cm pleomorphic adenoma on the right anterior nasal septum. The subsequent discussion covered background, histology, imaging, and management strategies. Surgical removal with clear margins, particularly through the endoscopic approach, emerged as the primary and successful treatment method, minimizing morbidity and reducing recurrence risk. Long-term clinical surveillance is recommended due to an estimated 8.8% recurrence rate. In conclusion, this paper explains the challenges and solutions in diagnosing and treating sinonasal pleomorphic adenomas in children. It emphasizes the critical importance of early diagnosis, precise surgical intervention, and continuous monitoring, which are essential for achieving optimal patient outcomes.

Specific and comprehensive genetic targeting reveals brain-wide distribution and synaptic input patterns of GABAergic axo-axonic interneurons.

Axo-axonic cells (AACs), also called chandelier cells (ChCs) in the cerebral cortex, are the most distinctive type of GABAergic interneurons described in the neocortex, hippocampus, and basolateral amygdala (BLA). AACs selectively innervate glutamatergic projection neurons (PNs) at their axon initial segment (AIS), thus may exert decisive control over PN spiking and regulate PN functional ensembles. However, the brain-wide distribution, synaptic connectivity, and circuit function of AACs remain poorly understood, largely due to the lack of specific and reliable experimental tools. Here, we have established an intersectional genetic strategy that achieves specific and comprehensive targeting of AACs throughout the mouse brain based on their lineage (Nkx2.1) and molecular (Unc5b, Pthlh) markers. We discovered that AACs are deployed across essentially all the pallium-derived brain structures, including not only the dorsal pallium-derived neocortex and medial pallium-derived hippocampal formation, but also the lateral pallium-derived claustrum-insular complex, and the ventral pallium-derived extended amygdaloid complex and olfactory centers. AACs are also abundant in anterior olfactory nucleus, taenia tecta, and lateral septum. AACs show characteristic variations in density across neocortical areas and layers and across subregions of the hippocampal formation. Neocortical AACs comprise multiple laminar subtypes with distinct dendritic and axonal arborization patterns. Retrograde monosynaptic tracing from AACs across neocortical, hippocampal, and BLA regions reveal shared as well as distinct patterns of synaptic input. Specific and comprehensive targeting of AACs facilitates the study of their developmental genetic program and circuit function across brain structures, providing a ground truth platform for understanding the conservation and variation of a bona fide cell type across brain regions and species.

Specific and comprehensive genetic targeting reveals brain-wide distribution and synaptic input patterns of GABAergic axo-axonic interneurons

Axo-axonic cells (AACs), also called chandelier cells (ChCs) in the cerebral cortex, are the most distinctive type of GABAergic interneurons described in the neocortex, hippocampus, and basolateral amygdala (BLA). AACs selectively innervate glutamatergic projection neurons (PNs) at their axon initial segment (AIS), thus may exert decisive control over PN spiking and regulate PN functional ensembles. However, the brain-wide distribution, synaptic connectivity, and circuit function of AACs remain poorly understood, largely due to the lack of specific and reliable experimental tools. Here, we have established an intersectional genetic strategy that achieves specific and comprehensive targeting of AACs throughout the mouse brain based on their lineage (Nkx2.1) and molecular (Unc5b, Pthlh) markers. We discovered that AACs are deployed across essentially all the pallium-derived brain structures, including not only the dorsal pallium-derived neocortex and medial pallium-derived hippocampal formation, but also the lateral pallium-derived claustrum–insular complex, and the ventral pallium-derived extended amygdaloid complex and olfactory centers. AACs are also abundant in anterior olfactory nucleus, taenia tecta, and lateral septum. AACs show characteristic variations in density across neocortical areas and layers and across subregions of the hippocampal formation. Neocortical AACs comprise multiple laminar subtypes with distinct dendritic and axonal arborization patterns. Retrograde monosynaptic tracing from AACs across neocortical, hippocampal, and BLA regions reveal shared as well as distinct patterns of synaptic input. Specific and comprehensive targeting of AACs facilitates the study of their developmental genetic program and circuit function across brain structures, providing a ground truth platform for understanding the conservation and variation of a bona fide cell type across brain regions and species.

Double-Flap Elevation From the Ipsilateral Lower Extremity: The Anterior Approach to Fibula Osteo-Cutaneous Flap Elevation.

The free fibular flap has been elevated by a "lateral approach" from the posterior edge of the peroneal muscle for more than 40 years. However, in this approach, the surgical view is limited because flap elevation in mandibular reconstruction is performed simultaneously with tumor resection in the supine position, even when using positioning pillows. We herein propose an "anterior approach" as a new surgical method. We retrospectively investigated free fibular flap surgeries performed using the anterior approach, which consists of three anterior approaches, over a seven-year period. First, to avoid the course of the superficial peroneal nerve, the crural fascia was incised 1-2 cm posterior to the anterior edge of the peroneal muscle. The anterior edge of the peroneus muscle is detached from the anterior intermuscular septum. After performing osteotomies distal and proximal to the fibula, the interosseous membrane was incised from the anterior view. Pulling out the fibula to the anterior space between the anterior intermuscular septum and the peroneal muscle made the surgical field shallow. No postoperative superficial or deep peroneal nerve palsies were found in the 55 patients. Only one tourniquet was used in 31 of the 55 cases (56.4%), with an average of 95 min. Twenty-four patients (43.6%) required a second tourniquet 38 min after an interval. Only one tourniquet was used in 25 of the 30 (83.3%) cases in the last 3 years. Moreover, double flaps were used in 21 cases (38.2%), all of which involved ipsilateral ALT flaps. In 18 cases, double-flap elevation and prefabrication were successfully finished before the completion of tumor resection by otorhinolaryngologists.

Atraumatic Infected Septal Hematoma in a Pediatric Patient.

We present a case of a 10-year-old male who developed an atraumatic, nasal septal hematoma with abscess following several days of rhinorrhea and cough. His chief complaint to the emergency department was a two-day history of nasal swelling and discomfort, associated with difficulty breathing through his nose. The patient was well-appearing with swelling and tenderness along the external nasal ridge and nasal septal swelling that occluded both nares. Contrast-enhanced maxillofacial computed tomography revealed a rim-enhancing, fluid-filled collection to the anterior nasal septum. The patient underwent successful incision and drainage by otolaryngology. Infected septal hematomas are rare but important to recognize as they can result in septal deformity and potentially life-threatening sequelae, such as intracranial infections. Most are secondary to nasal trauma in adult patients. This case highlights a unique presentation of atraumatic septal hematoma with abscess formation in an immunocompetent pediatric patient.

WHEN AND WHERE DOES A CARRIER OF HEREDITARY TRANSTHYRETIN AMYLOIDOSIS (ILE88LEU) SHOW THE FIRST SIGNS OF THE DISEASE? DIAGNOSTIC CHALLENGES OF A NOT ONLY CARDIOGENIC MUTATION

Abstract We present the case of a 58–year–old man with a familiar history (mother affected) positive for ATTR–v (Ile88Leu) amyloidosis. The mother initially had a pure cardiac phenotype and was firstly treated with tafamidis, but progression of the disease to the nervous system warranted a switch to patisiran. Our patient carried the Ile88Leu mutation and had a medical history notable for surgically treated left carpal tunnel syndrome (CTS) and untreated right CTS. Furthermore, he was affected by systemic arterial hypertension and was a habitual smoker. He has been followed at our Institution since 2018. His first echocardiogram showed normal left ventricular ejection fraction (LVEF 65%), mild hypertrophy (anterior septum: 12 mm), and borderline values of GLS (– 16%) without any specific pattern. Further exams were executed: Bone scintigraphy (BS): negative (Perugini score 0); Coronary artery ct scan: moderate stenosis of proximal LAD; Neurologic evaluation: no signs of peripheral neuropathy. The clinical picture remained unaltered in 2020 and 2021. However, during November 2022 the patient developed atrial fibrillation (AF) and presented to the ED for dyspnea and palpitations. Electrical cardioversion was performed with success but subsequent recurrences warranted AF ablation in April 2023. At that moment, the patient was re–evaluated. Basal ECG did not show any significant alteration (FIg.1)This time, echocardiogram showed mild worsening of hypertrophy (13 mm septum), GLS – 16% with apical sparing pattern, no other major variations (Fig.2). BS was repeated and revealed grade 1 Perugini score (Fig.3). Hence, a series of clinical question arose: Should we begin a specific treatment or is the disease in an excessively early stage that does not warrant treatment? Is AF linked to concomitant arterial hypertension or might it be an early marker of disease? We questioned the usefulness of endomyocardial biopsy in this specific setting. In this case, we repeated electromyography that showed mild axonal sensitive–motor polyneuropathy. Finally, we concluded for initial signs of systemic amyloidosis ATTR–v (Ile88Leu) type with mixed phenotype (neurological+cardiac). The neurological involvement allowed us to start a gene–silencer (Patisiran). In conclusion, a periodic neurological evaluation is necessary and has crucial therapeutic implications in all genotypes. Indeed, there is increasing evidence that Ile88Leu is a not only cardiogenic mutation.

VASOSPASTIC INFARCTION STARTED WITH PULSELESS ELECTRICAL ACTIVITY CARDIAC ARREST

Abstract We report the case of a 48–year–old female with a special history of ischemic heart disease. It started in 2021 with an acute anterior ST myocardial infarction: the coronary angiography showed subocclusive stenosis at the first tract of the left anterior descending (LAD), without other coronary stenoses. The patient was treated with primary PCI + DES; the echocardiogram showed EF 30% and akinesia of apex, intermediate segments of anterior wall and interventricular septum. During the same hospitalization the patient experienced recurrence of angina with transient ST elevation in the anterior and inferior leads; a control coronary angiography was unchanged. She was started on therapy with nitrates and diltiazem up to the tolerated dose, statin as well as antiplatelet and anticoagulant therapy due to apical thrombus. She underwent ICD implantation in primary prevention in January 2022. During 2022, there were several accesses to the ED for vasospastic angina despite medical therapy at the maximum tolerated dose. In October 2023 the patient experienced an acute chest pain followed by cardiac arrest, pulseless electrical activity and acute cardiogenic shock. After resuscitation procedures, she underwent an emergency coronary angiography which showed excellent result of the previous PCI, as well as stenosis of the distal edge of the stent resolving after injection of i.c. nitrates. No arrhythmic events at ICD recording and continuous electrocardiographic monitoring in ICU were observed. Cardiac MRI showed areas of subendocardial LGE involving the apex, anterior, anterolateral and septal segments due to ischemic scar; we also observed areas of edema and LGE with an ischemic pattern at the infero–septal and inferior wall in toto, suggesting recent ischemia; EF was 31%. During hospitalization the patient experienced episodes of typical angina with poor response to medical therapy at the maximum tolerated dose. The current clinical case most likely points to acute myocardial infarction due to vasospasm of the right coronary artery with acute pump failure resulting in cardiac arrest and no specific recommendations exist in recent cardiologic guidelines on the strategy to adopt for this acute clinical setting. In the hypothesis of a vasospastic pathogenesis of the problem, counseling for modulation of the stellate ganglion was requested.

A CASE REPORT OF AN ASYMPTOMATIC PATIENT WITH TYPE 2 WELLENS’ SYNDROME AND RENAL CARCINOMA

Abstract A 65–year–old male with renal cell carcinoma, previously treated with nephrectomy and recently diagnosed with lung metastases, presented to the cardiology clinic for investigations before starting chemotherapy. He reported a history of ischemic heart disease, a non–ST–elevation myocardial infarction for which he refused coronary angiography in 2005, and a negative maximal stress test for ischemia in 2017. Additionally, the patient reported insulin–dependent type 2 diabetes mellitus and well–controlled arterial hypertension. The patient was referred for a cardiological evaluation due to a reported short–term rhythmic heartbeat without other cardiological symptoms. Cardiological parameters were stable (blood pressure: 140/95 mmHg; heart rate: 42 bpm, and oxygen saturation without oxygen supplementation: 98%). Physical examination was normal. Laboratory investigations did not show elevated levels of high–sensitivity troponin I, and only signs of mild chronic kidney disease were observed. The initial ECG showed sinus bradycardia with deeply inverted T–waves in the extended anterior area (Fig. 1), which were not present in an ECG performed one month earlier. There was no reported chest pain. An echocardiogram examination demonstrated hypertensive heart disease with marked hypokinesia of the mid–apical portion of the anterior wall and anterior interventricular septum, together with a moderate reduction in global systolic function (LV ejection fraction: 40%). The patient was hospitalized, and underwent coronary angiography the following day. He had a low–risk score (GRACE: 95 pts) As shown in Fig. 2, there was evidence of long sub–occlusive stenosis of the proximal part of the anterior descending coronary artery that was treated with angioplasty and a single drug–eluted stent placement, resulting in a good angiographic result. After the procedure, there was a rapid recovery of regional kinetics but a slower normalization of the electrocardiographic morphology (Fig. 3). Comment Wellens‘ syndrome identifies a particular subtype of unstable angina characterized by the appearance of ischemic changes on the ECG,. The clinical risk assessment of this subgroup of patients with ACS, apparently having a more benign prognosis due to their definition as unstable angina with a low GRACE risk score, potentially has an evolution toward a large myocardial infarction if not promptly diagnosed.

UNPREDICTABLE IDENTIFICATION OF A TITIN MUTATION IN A YOUNG PATIENT PRESENTING WITH INFLAMMATORY CARDIOMYOPATHY

Abstract Case Presentation A 23 years old patient, affected by type 1 diabetes, presented with fever, dyspnea and bilateral peripheral edemas. In the last week he received antibiotic treatment for a persistent dry cough and sore throat, and became symptomatic for exertional dyspnea from three days. His mother died at the age of 40 for sudden cardiac death. Blood pressure and oxygen saturation were normal: the ECG showed sinus tachycardia with symmetric negative T waves in all precordial leads. High sensitivity troponin T was 0.01 mcg/L (normal value &amp;lt; 0.014 mcg/L). All remaining blood tests were normal, except for CRP that was slightly elevated. His echocardiogram revealed left ventricular (LV) remodelling and dilation, severely reduced LV ejection fraction (LVEF 20%) with global hypokinesia, more pronounced at the level of the anterior wall, interventricular septum and apex and a dilated right ventricle (RV) with reduced systolic function. Cardiac magnetic resonance (CMR) confirmed severe biventricular disfunction (LVEF 19%; RVEF 23%) and showed a small area of subepicardial inferior junctional late gadolinium enhancement (LGE). The patient underwent an endomyocardial biopsy that showed a lymphocytic virus–negative myocarditis. Given his known type 1 diabetes, steroid treatment was not considered and anakinra was started. The patient was discharged after two weeks with a slight amelioration of the LV function (LVEF 27%), on optimal heart failure therapy and anakinra. At six months he was in NYHA class II and CMR showed slight reduction in LV dimensions and improvement of the LV and RV function (LVEF 39%; RVEF 45%), with no changes in the LGE pattern. A genetic test was performed and revealed two titin gene mutations, both categorized as likely pathogenic (TTN c.[11831T&amp;gt;A]; c.[72510_72517delGACAAATG]), responsible for a genetic form of dilated cardiomyopathy. Conclusion The present case suggests that in young patients presenting with clinical or histological diagnosis of myocarditis, genetic testing for cardiomyopathies should be considered especially in presence of a positive family history for sudden death or an incomplete recovery of the LV function at follow–up. Identification of a gene mutation in these patients allows a more tailored risk stratification of the index case and a proper management of the entire family.

VERY MOBILE LEFT VENTRICULAR PAPILLARY FIBROELASTOMA PRESENTING WITH ISCHEMIC STROKE

Abstract Papillary fibroelastomas are small and pedunculated left side valves associated mass, that frequently causing cerebral embolization; they are composed of collagen and elastic fibers and are usually connected with a pedicle to the endocardial layer. Differential diagnosis with endocarditis can rely on the side of attachement: Papillary fibroelastomas are more frequently found downstream the valves, instead, endocarditis are mostly found upstream the valves. They are mostly located (&amp;gt;80%) on valvular surfaces, more commonly on left side cardiac valves (44% on the aortic valve and 35% on the mitral valve); therefore, in the present knowledge, papillary fibroelastomas arising from left ventricular myiocardial wall are rare and mostly anecdotally descripted. We present the case of a 78–year–old man, diabetic, with no cardiac history, hospitalized with a right capsulo–lenticular stroke. Symptomatic due to left hemiparesis, he did not undergo thrombolysis due to a delay in hospitalization of almost 24 hours. The transthoracic and then transesophageal echocardiogram showed the presence of a hyperechogenic, floating mass of approximately 3 cm at the level of the left ventricle, separate from the mitral valve and attached to the mid–distal anterior septum and the ventricular apex (Figure 1). Cardiac MRI confirmed the presence of a peduncolate left ventricular mass, isointense on cine sequences, without myocardial infiltration, isointense on T1–weighted images and mildy hyperintense on T2–weighted images, with mild uniform late–gadolinium enhancement (Figure 2). The patient underwent surgical removal of the mass: histological analysis showed multiple, branching fronds of paucicellular, avascular fibroelastic tissue lined by a single layer of endocardium, with positive stains at Weigert coloration for elastic fibers (Figure 3). Histomorphological analysis was compatible with papillary fibroelastoma. This is a very atypical case of papillary fibroelastoma, due to the large size of the mass and the intraventricular and not–valvular location, which determined its emboligenicity and which, if not removed, would have exposed the patient to an enormous risk of recurrence of stroke.

Case report: Para Hisian Atrial Tachycardia

Case report: Para Hisian Atrial Tachycardia

Acute Myocardial Infarction or Broken Heart with Takotsubo Cardiomyopathy? Realm of Mystification after Suicidal Hanging

Abstract Takotsubo cardiomyopathy is a rare immune-endocrinologic cause of acute and rapidly reversible left ventricular dysfunction, usually resembling acute myocardial infarction (AMI) and triggered by emotional or physical stress. We described a case of such syndrome in a 27-year-old female after an attempted suicidal hanging, whose initial clinical symptoms and electrocardiography (ECG) findings were misleading to AMI. On admission, the patient was unconscious and hypoxic. Echocardiography demonstrated a severe left ventricular systolic dysfunction with akinesis in the mid and anterior septum and apex (a typical ballooning pattern), which raised suspicion of takotsubo cardiomyopathy. Our patient developed chest pain, a day after the suicidal attempt. Emergent coronary angiography revealed no evidence of occlusion, confirmed diagnosis of takotsubo cardiomyopathy was made. The patient was managed with medical therapy. On a week later follow-up, the patient was totally asymptomatic with a reversal of ECG changes, and the left ventricular contractility was improved within 30 days.

Nasal Gouty Tophus

A 48-year-old, non-hypertensive, non diabetic man with uncontrolled gouty arthritis presented with a four-day swollen nasal mass. He was assessed to have a nasal abscess at the emergency room and was admitted for urgent management. Paranasal computed tomography (CT) scans showed a heterogeneously enhancing focus with areas of hypodensities in the nasal apex and dorsum extending into the right ala measuring 1.5 x 2.8 x 3.4 cm. with associated erosion of the cartilaginous part of the anterior nasal septum, soft tissue swelling and skin thickening in the nasal dorsum, nasal tip and right zygomatic region that was suspected to relate to an aggressive etiology. Tissue correlation was therefore recommended, and he underwent endoscopic-guided incision and drainage with biopsy and debridement of the nasal mass. The specimen submitted consisted of red to white, irregular, soft tissue fragments with an aggregate measurement of 1.5 x 1.5 x 0.5 cm. Microsections showed deposits of amorphous white to pink material with surrounding fibrosis and acute and chronic inflammatory cell infiltrates and foreign body giant cells. (Figures 1 and 2) Also seen in the background were fragments of sclerotic bone and bacterial colonies. These findings were consistent with gouty tophus with acute and chronic inflammation and bacterial colonization. The culture and sensitivity test of the nasal discharge showed growth of Enterobacter aerogenes (currently named Klebsiella aerogenes) which was identified by an automated mass spectrometry microbial identification system (VITEK® MS). Work-up also included uric acid levels which were within the reference interval at that time (6.57 mg/dL).

Is myocardial fibrosis appropriately assessed by 2D strain derived integrated backscatter?

Abstract Introduction Calibrated integrated backscatter (cIB) may be obtained from bidimensional (2D) strain echocardiography as a quantification measurement of myocardial ultrasound reflectivity. Increased collagen content of the myocardium modifies tissue reflectivity and cIB is suggested as a marker of left ventricular (LV) fibrosis. However, its diagnostic accuracy is not fully established. Aim To assess the correlation between cIB by 2D strain and LV myocardial fibrosis (MF), as evaluated by non-invasive imaging and histopathology. Methods Correlation study from a cohort of 157 patients with severe symptomatic aortic stenosis (AS) referred for surgical aortic valve replacement (AVR). Patients with complete preoperative transthoracic echocardiography, cardiac magnetic resonance (CMR) and endomyocardial biopsy (EMB) obtained from the anterior basal septum at the time of AVR were selected. Two groups of 30 patients were evaluated, with and without late gadolinium enhancement (LGE) at CMR. Integrated Backscatter was obtained at QRS peak in decibels (dB) from both parasternal long axis (PLAX) and apical-three-chamber (A3C) cine clips at Qanalysis. cIB was calculated by subtracting the pericardial intensity from the average of the anteroseptal and basal inferolateral wall values. Correlation analysis was performed for the whole group of patients with global and segmental (anterior basal septum) values of native T1 and extracellular volume (ECV), and EMB collagen volume fraction (CVF) from Masson´s Trichrome staining. IBS values were compared in both group of patients. Results 60 patients (74 [36-74] years, 45% male) with high gradient (mean gradient: 63±20mmHg), normal flow (45±10mL/m2), preserved ejection fraction (60±9%) AS were included. Basal septal cIB was –9.17±9.45dB and –17.45 (–31.2–10.95) dB from A3C and PLAX views, respectively. These indexes did not correlate with basal septum thickness or global LV mass. Absolute and cIB did not correlate neither with global and regional T1 and ECV values, nor with CVF at EMB. These were not significantly different in both groups of patients and there was no correlation between cIB values and mass of replacement MF in patients with LGE. Conclusion In these cohort of patients with classical severe AS, there was no correlation of cIB with imaging markers of both replacement and diffuse MF. cIB also didn´t correlate with CVF at histopathology. These findings suggest that reflectivity indexes are not suitable for myocardial tissue characterization in this setting.

Lower intercostal spaces depicted better final r wave than V1 at left bundle branch pacing implant attempts

Abstract Background Left bundle pacing lead positioning implies screwing the lead until a final ‘r’ wave is seen in V1 ECG lead (unipolar pacing), depicting the left part of the septum has been reached. That final vector should be better seen if V1 is placed parallel rather than perpendicular to the lead tip, so we used lower intercostal spaces for V1, to test this hypothesis. Failure to see the 'r' wave could increase the screwing efforts owing to perforation. Methods Leads V1 to V5 were positioned from 2nd to 6th right sided intercostal spaces during implants. Fluoroscopy was used to ascertain the lead most parallel to the final tip position. Inferior leads were used to confirm anterior, mid or posterior implants. A ratio between the ‘r’ wave amplitude and the QRS amplitude was used to compare the intercostal space depicting better the final ‘r’ wave. Results 19 patients were implanted using this new set-up of precordial leads (see figure 1); 32% were female; mean age at implant was 77,6 +/-8,04 years (range 58,3-90,6 years old); all but two were Medtronic 3830 leads. Regarding the position 26%, 32% and 42% of the leads ended in the posterior, mid or anterior septum respectively. Mean unipolar pacing QRS was 126ms +/- 18,2ms and mead LVAT was 76ms +/-19ms. Only 31% of patients had the lead placed parallel to the 4th intercostal space; 13% had the lead parallel between the 4th and the 5th space; and 56% of implants, had the 5th or 6th space as the most parallel to the lead tip. Finally in a consistent way, mean ratios of ‘r’/QRS amplitude were increasing at every intercostal space from: 0,12/2nd; 0,24/3rd; 0,3/4th; 0,35/5th and 0,45/6th (except for most posterior implanted leads where ratios varied less); this finding was even greater for anterior implanted leads (see figure 2). Conclusion Final ‘r’ wave is better depicted when V1 is lowered to 5th or 6th intercostal space, as the leads are mostly implanted parallel to these observation sites; but the septum is also a 3-D structure and when the leads are implanted too anterior, there is almost no way to see the final ‘r’ wave in usual 4th space V1, as the vector is directed mostly in the opposite direction (posteriorly and downward), while a lower placed V1 allows some of that vector to be depicted anyways. Placing V1-V3 leads in 4th-6th intercostal spaces could prevent excessive screwing and reduced perforation rates specially in anterior implanted leads.LAO: V1 to V5 placed 2-6 R intercostal'r' not seen until 5th-6th R intercostal

Abstract 14201: Double the Trouble: Extremely Rare Incidental Finding of a Double Interatrial Septum With Atrial Septal Aneurysm and Coexisting Patent Foramen Ovale

Case: A 59-year-old&amp;nbsp;female with a past medical history of hypothyroidism and IgG deficiency presents to cardiology clinic due to palpitations and premature ventricular complexes (PVCs) noted at a recent urgent care visit. In-office vitals, physical exam, labs, and EKG were unremarkable. Ambulatory cardiac monitoring showed predominantly sinus rhythm with a PVC burden of 1.4%. Echocardiogram revealed an extremely rare structural anomaly – a double interatrial septum (DIAS) with atrial septal aneurysm. Cardiac MRI (cMRI) further confirmed the presence of a DIAS enclosing an interatrial space, along with blood flow within the interatrial space and a discontinuity in the anterior right lateral atrial septum suggestive of a patent foramen ovale (PFO). There was no evidence of thrombus within the interatrial or intracardiac spaces. Mild right atrial enlargement was seen. The patient was initiated on aspirin for cardioembolic stroke prophylaxis. Discussion: DIAS is a highly rare congenital cardiac anomaly with limited number of cases in literature. It has been described as a midline third atrium resulting in a “tri-atrial heart”. As of 2018, less than 20 cases have been cited. DIAS is characterized by two parallel interatrial septa along with a clear echo lucent midline space that expands in systole and collapses in diastole. This case is unique as it is one of the few to include additional characterization with cMRI. Patients with DIAS are usually asymptomatic but can experience cardioembolic events as the interatrial space is at risk for thrombus formation. Communication across the DIAS makes these events more likely. Unlike with atrial fibrillation/flutter, no current criteria for anticoagulation (AC) initiation exists for DIAS given the scarcity of cases. While some sources advocate for use of anti-platelet agents, others have indicated a preference for oral AC. Our patient had an interatrial space and a PFO but lacked communication across the DIAS, had low bleeding risk, and no other classic risk factors of Virchow’s triad. We determined her risk for thrombus formation to be relatively low, and thus initiated her on aspirin over oral AC. Percutaneous closure of the interatrial space was deferred as it has been dismissed as a viable treatment option in the literature.