Distal Septum Research Articles

AUTOIMMUNE MYOCARDITIS IN MELANOMA IMMUNOTHERAPY–COMPLEX CLINICA PRESENTATION AND ADVERSE THERAPEUTIC RESPONSE

Abstract A 68–year–old Caucasian female presented to the ED with cardiac chest pain and dyspnea. The patient had a history of arterial hypertension and was equipped with a biventricular pacemaker due to atrial fibrillation with low ventricular response. She had recently been diagnosed with metastatic melanoma and initiated treatment with nivolumab and ipilimumab two weeks prior. Troponin levels were elevated (700 ng/ml), and no ST–segment elevation was observed on the electrocardiogram (ECG). In suspicion of NSTEMI–ACS, coronary angiography was performed, revealing an intact epicardial coronary circulation without stenotic lesions. The echocardiogram showed borderline left ventricular systolic function (EF 50%), and the right ventricle exhibited initial signs of reduced systolic function (TAPSE, 15 mm; S RV, 9.5 m/s). The following day, there was a deterioration in hemodynamics and respiratory exchange, with evidence of apical and mid–distal interventricular septum hypokinesia of the left ventricle (EF 40%) and dilated right ventricle (BD 4.8 cm; MD 4 cm) with severely reduced systolic function (TAPSE 10 mm, S RV 7 m/s, FAC, 20%), and severe tricuspid regurgitation. Urgent computed tomography pulmonary angiography (CTPA) excluded pulmonary embolism. Additionally, there was a new troponin increase (5000 ng/ml) and elevated hepatic biomarkers. The clinical picture raised suspicion of myocarditis related to immune checkpoint inhibitor therapy. Corticosteroid therapy was initiated with a daily administration of methylprednisolone 1000 mg. Diagnostic confirmation was sought through autoimmune panel and viral marker assessments, which yielded negative results. Endomyocardial biopsy (EMB) revealed CD4 and CD8–positive lymphocytic infiltration and myocardial necrosis. Despite initial clinical improvement, an arrhythmic storm developed. Despite treatment with a defibrillator, intravenous antiarrhythmic therapy (beta–blocker, amiodarone, and lidocaine), and sedation, the patient unfortunately succumbed. Immune checkpoint inhibitors (ICIs) have been revolutionary in the treatment of many solid tumors. However, the dysregulation of immune mechanisms can rarely (2%) lead to autoimmune events involving multiple organs. Myocarditis, despite optimal treatment, is characterized by a mortality rate exceeding 50%, representing a significant challenge in the Intensive Care Unit.

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 (>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.

WELLENS SYNDROME: TIMELY RECOGNITION AND SUCCESSFUL REVASCULARIZATION

Abstract Wellens syndrome is a condition characterized by clinical and instrumental signs suggestive of a critical proximal left anterior descending (LAD) coronary artery stenosis and requires early revascularization. Diagnostic criteria include T–wave changes in ECG during asymptomatic periods in patients with a history of chest pain, absence of significant cardiac enzyme movement, no ST–segment elevation, preserved R–wave, and no pathological Q waves. Early recognition of this syndrome is crucial, due to its 10–15% prevalence, allowing proper management and myocardial function recovery, avoiding potentially catastrophic outcomes. A 64–year–old male, with hypertension, undiagnosed diabetes, and family history of CAD, presented to our ER with sudden, brief chest pain radiating to the left upper limb. Similar episodes had occurred in the past week. The patient denied previous cardiovascular events and home therapy. ECG conducted by the attending cardiologist, during free chest pain period, showed biphasic T–wave in V1–V3 (a). Admission ECG resembled the ambulatory one. Lab results: Hb 14.7 g/dl, Troponin I 0.059 ng/ml (cut–off 0.034). Echocardiogram indicated distal septum akinesia. Urgent coronary angiography was performed, detecting subocclusive stenosis in the proximal–mid LAD. Successful revascularization was achieved by PTCA and implantation of 1 DES. (b) Subsequently, the patient was admitted to the Cardiac Intensive Care Unit for multiparametric monitoring. The ECG showed deeply negative T waves from V1 to V6. (c) No complications during hospitalization. Discharge ECG showed repolarization anomalies improvement. Echocardiography revealed preserved systolic function, without global or segmental anomalies in wall motion. Wellens syndrome is a manifestation of acute coronary syndrome that precedes an anterior wall MI. This condition can be identified by its characteristic T–wave patterns on ECG. Patients with this syndrome have severe LAD occlusion and require early coronary intervention. In chest pain episodes, the ECG appears normal, and troponin levels often remain within the normal range, which can potentially provide false reassurance. Wellens syndrome is a cardiac emergency requiring immediate attention; it is crucial for the physician to promptly identify the typical ECG signs of Wellens Syndrome, facilitating early coronary revascularization to prevent adverse patient outcomes.

Hypospadias with Intact Prepuce: A Spectrum of Anomalies and their Reconstruction.

The aim of the study was to perform a detailed analysis of the clinical characteristics of megameatus with intact prepuce (MIP) and to audit our results of reconstructive surgeries on MIP. Design: Retrospective analysis. Setting: Pediatric surgery department of tertiary level. Subjects, methods: Hospital records and pictures of MIP operated over a 9-year period. Age, size of penis, circumcised or not, shape of glans, external urethral meatus (EUM), urethral plate (UP), chordee, distal urethra, reconstructive surgery, and complications were analyzed. Postoperative result was objectively assessed by Hypospadias Objective Scoring Evaluation (HOSE). Twelve of 254 hypospadias were MIP (incidence = 4.72%). The mean age at operation was 38.25 months (12-87 m). Patients sought circumcision or surgical correction of anomaly. Two patients were precircumcised. MIP was coronal 7, subcoronal 3, and glanular 2. Meatus was wide in 10 and normal in 2. Glans penis was wide in 9 and conical in 3. UP was wide (9), moderately wide (2), or narrow and shallow (1). In two cases of wide deep UP, distal septum was present. Distal urethra was nondilated in all but 1, which had megalourethra. Reconstructive surgery was Tubularized Urethral Plate Urethroplasty (7 cases) or classical Snodgrass (Tubularised incised plate urethroplasty (TIPU), with superimposed vascular dartos flap (5 cases). The megalourethra underwent partial excision and TIPU. Distal UP-septum was incised. Urethral injury (2 cases) and UP injury (1 case) were intraoperative complications. One postoperative complication (ventral glans necrosis) resulted. The mean follow-up period was 4.79 months (1-12 m). In the postoperative follow-up, 11 (92%) had HOSE score 14-16, whereas one had HOSE 13. Some hypospadias cases which have intact prepuce have no megameatus; hence, they cannot be termed MIP. All cases of hypospadias having intact prepuce can be covered by the umbrella term "Hypospadias with Intact Prepuce (HIP);" MIP is a large subgroup under HIP. HIP presents with a spectrum of anomalies of glans, EUM, and UP. Repair by tubularization of UP without or with midline incision gives excellent results.

Abstract 18676: Aneurysmectomy or No Aneurysmectomy - An Unknown Heart Failure Terrain

Case Report: A 40-year male with a history of traumatic inferoapical ventricular septal rupture after a motor vehicle accident status post patch repair and left ventricular thrombus on Rivaroxaban presented to the ED with hemoptysis. The patient on arrival was hemodynamically stable. CTA revealed a new 6.9 cm left ventricular pseudoaneurysm and an echocardiogram revealed an EF of 30% with a pseudoaneurysm involving the entire distal septum, lateral wall, and apex and a ventricular septal rupture into the intraventricular septum. Cardiac MRI revealed a pseudoaneurysm from the inferoseptal wall measuring 9.6 x 6.9 x 10.0 cm and a stroke volume of 123 mL. A right heart catheterization revealed no evidence of left-to-right shunting. Given heart failure with reduced ejection fraction in the setting of a pseudoaneurysm and the complexity of aneurysm repair, advanced heart failure and cardiothoracic surgery teams were consulted for conventional surgical and transplant evaluation. Due to social barriers, the patient was declined from transplant and ultimately proceeded with patch repair. Intraoperative echocardiography revealed a post-operative EF of 25%. Discussion: This case highlights the need for further data on pseudoaneurysms that are confounded with concurrent heart failure. For this patient, the concerns were for adequate stroke volume given the extent of the pseudoaneurysm and whether improvement in systolic function could be seen with repair or result in further decline. It was postulated that surgical repair would raise his effective stroke volume, and thus improve cardiac function. Postoperative EF changes could have been further explained by myocardial stunning during anesthesia or rapid changes in end-diastolic volume with aneurysmectomy altering Frank-Starling hemodynamics. With isolated case report data, further aneurysmectomy outcome characterization is thus imperative to guide advanced heart failure treatment and improve patient mortality.

Echocardiographic Study of Ventricular Septal Defect in 1- to 12-Year-Old Children Visiting a Tertiary Care Center in Patna, India.

Background Symptoms of serious heart problems present at birthoften appear during the first few days, weeks, or months of a child's life. Shunt formation between the left and right ventricle is a crucial component of the pathophysiology of ventral septal defects. Objectives We aim to determine the most frequent types of ventricular septal defect (VSD) by echocardiography and whether there is any gender variation in the type of ventricular septal defect. Material and methods A total of 100 children who were clinically suspected of or diagnosed with VSD at the age of 1-12 years were enrolled in this study. The septum of the atrioventricular (AV) canal, the muscular septum, and the parietal band of the distal conal septum were evaluated by color Doppler. Ventricular septal defect (VSD) size and kind are similarly impacted by the 2D echo mode. The size and site of the VSD, associated congenital anomaly, and significant morphological changes in ventricular cavities, gender discrimination, and relation-specific types of ventricular septal defect were observed. Results A total of 100 VSD children presentedwith clinical symptoms of fast breathing, retraction of the chest, cough, cyanosis, fever, difficulty during feeding, cyanotic spell, chest pain, and edema at 65%, 62%, 54%, 52%, 54%, 29%, 9%, 11%, and 4%, respectively. Conclusion Early diagnosis is essential for effective medical care of diseases such as infective endocarditis (IE), which is present in some cases of VSD, and the avoidance of persistent pulmonary veno-occlusive disease (PVOD).

High and Low Septal Strip Excision on Dorsal Preservation Rhinoplasty to Fix Septal Deviation.

Rhinoplasty is one of the leading procedures among aesthetic and plastic surgery interventions. Dorsal hump and nasal deviation deformities are prevalent among the general population. Patients who have both dorsal hump and nasal deviation deformities can be considered challenging for rhinosurgeons. Dorsal preservation techniques are of great interest for obtaining better and more satisfactory aesthetic and functional results. Dorsal strip excision plays a considerable part in dorsal preservation techniques. In this study, the author defines a new method that includes excisions of low and high septal strips in the subdorsal area to straighten deviation in the lower part of the distal septum and fix it on the middle line. The present study was designed as retrospective. Sixty-nine patients met the inclusion and exclusion criteria, and their records were assessed (49 females and 20 males). The patients who were included in the study have undergone surgery with high and low septal strip excision through either push-down or let-down techniques. Patients were evaluated using the "Rhinoplasty Outcome Evaluation" (ROE) questionnaire before and 12 months after surgery. The follow-up period ranged between 12 and 20 months (median, 16.3 months). All procedures were performed by the same surgeon between October 1, 2018, and April 1, 2020. The ROE scores ranged between 82 and 100 points after 1 year. The initial median ROE score was 56.5, and it increased to 93.00 points 12 months after surgery (P < 0.001). Patient satisfaction was excellent in 88.76% of the included patients. The combination of let- and push-down methods with low to high septal strip excision resulted in favorable outcomes in patients who had concomitant hump and septal deviation deformities. This new approach presents a suitable and easy method to the surgeons who are interested in dorsal preservation rhinoplasty.

837 COMPLETE MAGNESIUM BIORESORBABLE SCAFFOLD ABSORPTION AT 1-YEAR OF INTRACORONARY IMAGING FOLLOW UP

Abstract Background the development of bioresorbable scaffolds (BRSs) has been conceived as revolution in interventional cardiology for the prospective improvements in the treatment of coronary artery disease. However, metallic drug eluting stent (DES) demonstrated greater safety and efficacy than bioresorbable vascular scaffold (BVS) Absorb in dedicated trials culminating in the commercial withdrawal of Absorb device in 2017. Nevertheless, the progressive absorption of the scaffold and the restoration of physiological coronary artery characteristics attracted attention, so currently research on BRSs is in progress. Case presentation a 58-year-old woman was admitted in our department after an episode of typical angina at rest without significant troponin elevation. The electrocardiogram showed T wave inversion in lateral leads. Hypokinesia of distal septum and anterior wall and mildly reduced left ventricular ejection fraction (LVEF 50%) were observed on echocardiography. Her cardiovascular risk factors included obesity, arterial hypertension, dyslipidaemia, family history of ischemic heart disease and former smoking. Her past medical history was remarkable for chronic kidney disease (CKD EPI eGFR 50 ml/min) and previous connective tissue disease. Coronary angiography highlighted a critical stenosis in the middle segment of left anterior descending artery (LAD). Optical coherence tomography (OCT) imaging showed recanalized and organized throumbus and calcific plaques. After adequate predilatation and stent sizing by OCT, a 3×25 mm Magnesium-based BVS (Magmaris, Biotronik AG, Buelach, Switzerland) was implanted. OCT confirmed good expansion and apposition of the stent after postdilatation. Patient was discharged on dual antiplatelet therapy (DAPT) for 12 months, anti-remodeling cardiac and lipid-lowering therapy. One year later, the patient underwent and elective coronary angiography and OCT control showing a complete reabsorption of the Magmaris BVS with positive remodelling and luminal enlargement of the vessel. The patient was asymptomatic throughout the year with a good performance status. Conclusion The present case illustrates an example of imaging-based revascularization with BVS Magmaris and optimal intracoronary imaging result at 1 year follow up in agreement with the last available evidence. The last European Society of Cardiology/European Association for Cardio-Thoracic Surgery Guidelines on myocardial revascularization recommends the use of BVS only in the context of clinical controlled studies. However, encouraging results obtained and what expected from the current studies with Magmaris scaffolds, might change indications considering the potential benefit about the restoration of natural vasomotion, the reduced risk of neoatherosclerosis and the positive vascular remodelling following the scaffold absorption.

Abstract 13870: Ventricular Fibrillation Arrest in a 27-Year-Old Woman Due to Takotsubo Cardiomyopathy

Introduction: Sudden cardiac death in young patients may be due to coronary artery disease, primary electrical disease, cardiomyopathy, or congenital anomalies. We explore potential causes for sudden cardiac arrest in a young patient. Case Description: A 27-year-old woman was found unconscious. Initial rhythm showed ventricular fibrillation. Cardiopulmonary resuscitation was done for 5 minutes before return of spontaneous circulation. ECG showed ST elevations in aVL, V4, and V5. She was admitted for therapeutic temperature management. Troponin peaked at 1.86 ng/mL on the evening of arrival. Transthoracic echocardiography (TTE) demonstrated hypokinesis of the mid to distal septum, anterior wall, and apex (Figure 1). Repeat TTE 3 days later showed resolution of the wall motion abnormalities. She reported marijuana use and a domestic dispute with her significant other the night prior. Coronary CT angiography showed calcium score of 0 with normal coronary anatomy, no significant coronary artery stenosis, and incidental finding of bilateral pulmonary artery filling defects. Lower limb venous duplex was unremarkable. Therapeutic dose of enoxaparin was started. Cardiac MRI showed no myocardial infarction, scar, or infiltrative disease. An electrophysiology study revealed adequate QT shortening during epinephrine infusion and no inducible ventricular arrhythmias. Genetic testing was unremarkable. She was discharged with a wearable defibrillator before ultimately receiving a subcutaneous implantable cardioverter-defibrillator. Discussion: The presentation of transient regional wall motion abnormalities, with ST-segment elevations and negative ischemic workup, is highly suggestive of Takotsubo cardiomyopathy, mid-ventricular variant. Marijuana use is a risk factor, and the domestic dispute is a potential emotional trigger. This case highlights Takotsubo cardiomyopathy as a possible cause of sudden cardiac arrest in young patients.

Type X dual left anterior descending (LAD) artery masquerading as type 1 LAD \u2014 a case report

BackgroundDual left anterior descending (LAD) coronary artery is a rare congenital anomaly. To date, eleven variants of dual LAD have been described with three published reports of type X dual LAD. Here, we describe a new variant of type X dual LAD with a short LAD artery masquerading as type 1 LAD.Case presentationA 42-year hypertensive female presented with recent onset angina with a treadmill test positive for inducible ischemia. Coronary angiography showed a normal right coronary artery (RCA). The left main coronary artery (LMCA) originated from the left sinus of Valsalva (SOV), giving rise to a LAD and the left circumflex artery (LCX). Appearing a normal angiogram with type 1 LAD based on its length, the presence of a large bare area in LAD territory (especially at the apex) and lack of septal branches prompted a search for an additional vessel. Right SOV injection showed a vessel originating separately from RCA, which was confirmed to be a long LAD on selective injection, with a pre-pulmonic course and giving rise to septal branches exclusively before wrapping around the apex. Computed tomography coronary angiography (CTCA) confirmed the pre-pulmonic course of long LAD, defined its entry to the distal interventricular septum to the right of short LAD, and ruled out other coronary artery anomalies. In the absence of a stenotic lesion in the epicardial coronaries, angina in our case was presumed to be due to microvascular dysfunction. She was discharged on beta-blocker therapy for co-existing hypertension and is asymptomatic on follow-up at one year.ConclusionsA short LAD artery of type X Dual LAD could be potentially misdiagnosed as type 1 LAD based on its length. However, an active search for a long LAD could properly diagnose the case as a variant of type X dual LAD, which has important clinical implications. Its awareness is critical for cardiologists and cardiac surgeons to correctly interpret the coronary angiogram and plan proper management.

Transverse vaginal septum managed by simple flap surgery technique: A case report.

BackgroundTransverse Vaginal Septum (TVS) is a rare congenital abnormality, classified as the Mullerian duct anomaly development.1,2 TVS incidence range from 1:2.000 to 1:72.000. Management of TVS may only requirement local excision with a simple end to end anastomosis of the vagina, and use of skin grafts, but this technique has been reported has common complications of secondary tissue contracture, which often lead to stenosis of the vagina.3 In this case we managed TVS with simple flap technique to avoid such postoperative complications and maintain caliber of vagina.CaseA 11 years old girl complained cyclical abdominal pain since a year ago without history of menstrual blood. Patient already had vaginal surgery for removing menstrual blood, but after vaginal surgery the menstrual blood cannot be removed, then referred to our hospital. Ultrasound examination revealed hematometra and hemocolpos. The septum location was 3,38 cm proximal distance from vaginal introitus with the thickness of 8.1 mm. We performed simple excision of the septum with formerly performed distal vaginal septum mucosa preparation creating lateral flaps, then approximating the flaps to the edge of the proximal vaginal mucosa with interrupted suture continued with hymenorraphy. The patient has no complaint 6 months after surgery with vaginal length 8 cm, and had regular menstrual cycle.ConclusionA simple flap surgery technique can be done in transverse vaginal septum, with no complication such as tissue contracture, vaginal stenosis, or insightly scarring. This is a simple technique and can be done with hymenorraphy to restore normal anatomy of hymen.

Traumatic deficient perineum: surgical management and outcome from a single center.

Deficient perineum is a disruption of the perineal body and distal rectovaginal septum presenting with anal incontinence and a range of urogenital symptoms. There is scarce reported outcome of this condition with management often delayed and with a variety of surgical alternatives. This study aims to determine faecal continence outcomes after long-term surgical repair. Patients were included for analysis after surgical repair between 1989 and 2012. Cases were preoperatively assessed by endosonography and anorectal manometry with a record of their continence with the Cleveland Clinic Incontinence Score (CCIS). Surgical repair comprised an overlapping repair of the external anal sphincter (EAS) with levatorplasty. There was selective use of internal anal sphincter (IAS) suture and/or advancement perineoplasty for soft tissue reconstruction. Patients were clinically evaluated for functional outcomes with comparison of their postoperative CCIS. There were 20 patients (median age 55.5years; range 29-81years) with a median duration of incontinence symptoms of 174 (range 1-540)months. All patients had an EAS and IAS defect with 14 (70%) undergoing an IAS suture and 10 (50%) a Corman-style anoplasty. Over a median follow-up of 137.2 (range 13-322)months, there was a significant decrease in the recorded median preoperative vs. postoperative CCIS 18, range 13-20 vs. 2, range 0-10, respectively; p < 0.001) with 18 (90%) satisfied with the functional outcome. Faecal diversion was not used in any of the patients. Experienced delayed repair of a traumatic cloaca is associated with an acceptable functional outcome at medium- to long-term follow-up.

Semi-Let-Down and Semi-Push-Down Preservation Techniques: Maintaining the Intactness of the Distal Region.

The nose is an important part of the face and plays a significant role in interpersonal communication and self-esteem. Dorsal preservation techniques, such as the push-down and let-down techniques, are employed for dorsal hump reductions. In this study, several approaches were defined in which the let-down and push-down techniques were applied depending on the patients' needs. The records of 64 patients were assessed retrospectively. The patients who underwent either the push-down or let-down technique for hump reduction and who were eligible for these new approaches were included. In this research, the distal part of the septum remained intact after both the push-down and let-down techniques. Patients were assessed before and 1 year after surgery employing the Rhinoplasty Outcome Evaluation (ROE). The follow-up period ranged from 16 to 25 months (median of 19.2 months). The median ROE score before surgery was 61.6 (minimum: 58; maximum: 64) and increased to 92.2 (minimum: 82; maximum: 96) points 12 months after surgery. This increase in the ROE score was statistically significant (P < 0.001). The excellent satisfaction rate was 93.75% according to the ROE scale. These approaches for the let-down and push-down techniques will lead to better results and present different choices to surgeons. The present study is also the first to the author's knowledge to demonstrate leaving behind an intact area of the distal septum in the push-down and let-down techniques.

First Report of Web Blight on Lavender Caused by Rhizoctonia solani AG-1-IB in Korea

Lavender (Lavandula officinalis L.) is an annual or short-lived perennial herb belonging to the mint family (Lamiaceae) that originates from eastern Africa, the Mediterranean, southwest Asia, to southeast India. Lavenders are cultivated extensively as ornamental plants for garden and landscape uses, for usage as culinary herbs, and commercially for the extraction of essential oils. In June 2017, approximately 5 to 10% of plants showed web blight symptoms in a private garden located near Gangneung, Gangwon Province, Korea. Specifically, leaf tissues were blighted, and white mycelial growth was seen on the stems. Symptomatic tissues were surface sterilized with 1% NaOCl, washed twice in sterilized water, blotted on sterile filter paper, and plated on 2% water agar at 25°C. After 2 days, hyphal tips were transferred to potato dextrose agar (PDA) to obtain pure cultures. A total of five morphologically similar fungal isolates (LWB001 to LWB005) were obtained from diseased samples; isolate LWB002 was selected for identification. The fungus produced a white mycelium when young but produced a brown mycelium with dark brown sclerotia on PDA at 20 ± 2°C for 10 days. Mature sclerotia (n = 20) were dark, spheroidal, with diameters ranging from 0.2 to 2.2 mm (average 0.7 mm). The young hyphae had acute angular branching near the distal septum of the multinucleated cells, and mature hyphal branches showed approximately 90° angles. Morphological characteristics were consistent with those of Rhizoctonia solani (Sneh et al. 1991). A representative isolate (LWB002) was deposited in the Korean Agricultural Culture Collection (KACC), National Institute of Agricultural Science, Rural Development Administration, Wanju, South Korea (KACC48671), to be used for further studies. The identification of the anastomosis group of the R. solani isolate was carried out on sterilized glass slides coated with 2% water agar medium placed on Petri dishes. The representative isolate was paired with tester strains of R. solani (AG-1-IA, AG-1-IB, AG-1-IC, AG 2-2-IIIB, AG 4, AG 7, and AG 11), which were collected from KACC (Ogoshi 1987) and examined microscopically. The fungal isolate anastomized only with tester strain AG-1-IB. To obtain a DNA sequence-based identification, a total DNA was extracted directly from the mycelium with a DNeasy Plant Mini Kit (Qiagen, Hilden, Germany). Following DNA extraction, the internal transcribed spacer (ITS) region of rDNA was amplified with primers ITS1/ITS4 and sequenced (White et al. 1990). BLASTn analysis of the 706 bp showed a 100, 99.71, and 99.86% similarity with sequences of R. solani AG-1-IB (teleomorph Thanatephorus cucumeris) in GenBank (JQ692293.1, GU585667.1, and KF907717.1, respectively). The nucleotide sequence has been assigned GenBank number MH122653. To confirm pathogenicity, three fungal mycelial discs (14 days old, 6.5 mm) were placed onto three wounded young plant stems on the soil line. Another three plants served as controls, for which only an agar plug was used on wounded plant stems. Then all the plants were incubated in a growth chamber (at 28 ± 2°C, 90% relative humidity, with 12/12-h light/dark). After 10 days, blight symptoms were similar to the original symptoms developed on inoculated plant leaves and stems, whereas no symptoms were observed on control plants. Five fungal isolates were reisolated from disease lesions of inoculated plants on PDA with the same morphological characters as before, and the identity was confirmed by microscopic studies, which fulfilled Koch’s postulates. Lavender web blight caused by R. solani AG-1-IB has been recorded in Italy (Garibaldi et al. 2013). To our knowledge, this is the first disease report of web blight on lavender caused by R. solani AG-1-IB in Korea, which poses a potential threat to lavender production, and our findings will be useful for the development of effective control strategies and further research.

P644 A not so innocent athlete"s heart

Abstract We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service. ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.

109 Anderson Fabry disease in CMR: twins by traditional tissue characterization, different by parametric mapping

Abstract Anderson Fabry disease (AFD) is an X-linked recessive lysosomal storage disease, caused by intracellular accumulation of glycosphingolipids due to deficiency of the enzyme α-galactosidase. The cardiac involvement carries a worse prognosis. Myocardial hypertrophy is the most common manifestation due to the intracellular accumulation of glycosphingolipids in myocytes. With disease progression the deposits are replaced by fibrosis although recent data suggest a chronic inflammation also independently to glycosphingolipids accumulation. Cardiac magnetic resonance (CMR) by tissue characterization using parametric mapping is a unique technique in evaluating AFD progression and in determining enzyme treatment indications and evolution under therapy. Heterozygous females are not asymptomatic carriers of the AFD mutation, they have a variable clinical presentation; disease expression in females is the result of random inactivation of the X chromosome. Female patients have a . This case provides an example of Fabry disease in a couple of sisters with a third sister with a diagnosis of AFD with cardiac, hepatic, and renal involvement. The youngest sister with a positive genetic test was symptomatic for chest pain, without any significant coronary arteries disease by coro CT. The ECG showed atrial fibrillation and sign for LVH confirmed by echocardiography. The traditional CMR study by SSFP cine images and LGE technique showed an increased thickness in the basal infero-lateral wall (15 mm) and the anterior interventricular septum (14 mm) with midwall fibrosis in the basal infero-lateral wall (Fig. 1 A, B). The oldest sister with a positive genetic test was asyntomatic in AF. ECG and ECOC were aspecific. The traditional CMR study by SSFP cine images and LGE technique showed the same finding of the youngest sister (Fig. 2 A, B) By T1 mapping based on the normal cut off values of the Lab the older sister reported a short T1 global value (915 ms) and short T1 values in all segment with exception of lateral wall, mid and distal inferior segments and distal septum (Figure 1 C). Despite the presence of positive LGE in the basal infero-lateral wall the T1 value was normal in this segment due to a pseudo normalization related to the sphingolipid accumulation. Based on the CMR report she started the enzyme replacement therapy and the CMR follow was planned at 1 year. Conversely, the younger woman reported a long T1 value only in the basal infero-lateral wall with normal T1 value in all the other segments (Figure 2 C). The positive LGE in the basal infero-later segment (oedema/fibrosis) justifies the long T1 value in this no thickness segment. Based on the CMR report she did not start enzyme replacement therapy. Conclusion The case of this family show how quantitative parametric mapping could be a unique tool for the clinicians to adjust the therapy and plan the follow up of patients affected by AFD with cardiac involvement. Abstract 109 Figure.

Clinical and Radiographic Assessments of Tooth Socket Preservation Using Leukocyte Platelet-Rich Fibrin.

Leukocyte platelet-rich fibrin (L-PRF) has the potential to accelerate wound healing. Here, we assess clinical and radiographic outcomes of socket preservation using L-PRF. For this single-blind, randomized, split-mouth clinical trial, we selected 22 patients (15 males and seven females), who required extraction of single-rooted teeth. Subjects were randomly assigned to two groups. We used L-PRF in the extraction socket on one side and no material on the contralateral side. We obtained cone-beam computed tomographic images and diagnostic casts from tooth extraction sockets before surgery and 3 mo after the procedure. Changes in buccolingual diameter and height of bone at 3 mo after tooth extraction (compared to baseline) were determined and digitized data statistically analyzed using Statistical Package for the Social Sciences software, ver. 25.0 (IBM, Armonk, NY) via the paired t-test. In tooth sockets with/without L-PRF application 3 mo after extraction, bone buccolingual diameter significantly decreased at socket center to 0, 1, and 3 mm from the ridge crest, compared to baseline. A significant reduction occurred in sockets with/without L-PRF application in buccal and lingual bone height at the bony socket midbuccal portion of and mesial and distal septa (p < 0.0001). However, the Mann-Whitney U test showed changes to be significantly greater in controls than the case group (p < 0.0001). Taking into account study limitations, application of L-PRF in tooth extraction sockets significantly decreased reductions in bone height and buccolingual diameter compared to control sockets.

P1468 a rare cause of chest pain:sudden rupture of aortic valsalva sinus aneurysm

Abstract Introduction Sinus of Valsalva aneurysms (SOVAs) occur when there is a congenital defect in the aortic media and incomplete fusion of distal bulbar septum (primitive bulbus cordis) and truncal ridges. These aneurysms usually rupture into the right side of the heart, with the right ventricle being the most common. Case Presentation A 32 year old male patient who presented to our facility with an attack of ulcerative colitis activity ,elevated inflammatory markers and thrombocytosis. During hospital stay, he developed sudden onset of retrosternal compressing chest pain. On examination he was afebrile with a blood pressure of 130/80 mm Hg and pulse rate 110 beats per minute. He had soft systolic and early diastolic murmurs with normal chest auscultation; there was no haemodynamic discrepancy between left and right sides or stigmata of endocarditis. His ECG showed sinus rhythm with no ST segment changes, and chest x ray was normal. Full blood count revealed thrombocytosis &amp; normochromic normocytic anemia , cardiac enzymes were normal, blood cultures were sterile. A 2D transthoracic echocardiography (TTE) revealed dilated left ventricular dimensions , there is an aneurysm of the right sinus of Valsalva which is communicating with the right ventricle (RV)confirmed by color Doppler and negative contrast seen inside RV during bubble study. 3D TTE showed a small fistulous track between the right sinus and RV. The patient refused surgical or percutaneous closure. Conclusion Congenital RSVAs account for 0.1–3.5% of congenital heart defects.It has a higher incidence in Asian versus Western populations with male to female ratio 3:1. SOVAs arise from the right sinus of Valsalva in 80–85% of these cases and from the noncoronary sinus in 5–15%. They rarely arise from the left sinus, as the left coronary cusp embryologically is not derived from bulbar septum. This is distinct from acquired SOVAs, which can occur in any of the sinuses Traditionally, surgical closure has been the mainstay of treatment for RSOVAs, with an operative mortality rate of &amp;lt;5% and excellent long-term outcomes. Abstract P1468 Figure. RSOVA

Emergency use of Physician-modified Fenestrated Endograft in a Symptomatic Patient Who was Waiting for a Manufactured Graft to Treat Chronic Post-dissection Thoracoabdominal Aneurysm

Introduction - Fenestrated-branched endovascular repair (F-BEVAR) using custom manufactured devices (CMDs) has been applied to treat post-dissection thoracoabdominal aortic aneurysms (TAAA), but the long wait period for device manufacturing limits its application in patients with symptomatic or contained ruptured aneurysms. Methods - A 59-year-old female patient who was waiting for CMD (Cook Medical, Brisbane, Australia) presented with a symptomatic post-dissection TAAA. The patient had undergone a successful first stage thoracic endovascular repair with creation of a fenestration in the distal aortic septum to perfuse the right kidney, which originated from the false lumen. Repeat computed tomography angiography revealed compression of the true lumen below the level of the fenestration with pressurization of the false lumen (Figure A). The patient was treated emergently using a physician-modified endovascular graft (PMEG) with four fenestrations and preloaded guidewires. The technique of PMEG using low-profile Zenith Alpha™ Thoracic stent graft (Cook Medical, Copenhagen Denmark) is presented with video and illustrations. Results - The thoracic stent-graft was modified onsite under strict sterile technique using the same measurements obtained for the original CMD request. The active fixation bards were removed to facilitate re-sheathing. Four fenestrations were created with ophthalmologic cautery and reinforced using a double layer of nitinol wire (Figure B). Radiopaque markers were added for orientation. Four 0.014-inch preloaded guidewires were added exiting via the top of the delivery system (Figure C). Diameter-reducing sutures were applied and the device was reintroduced into the original 18Fr sheath. Using bilateral femoral and right brachial approach, a long 5Fr sheath was introduced via the brachial approach exiting via the femoral approach. The PMEG was loaded into a through-and-through wire, while the four preloaded guidewires were loaded into a long 5Fr brachial sheath. The device and sheath were advanced into position and deployed in a stepwise fashion allowing sequential catheterization of the celiac axis, superior mesenteric artery and both renal arteries in the compressed true lumen (Figure D). Once all vessels were catheterized, the bifurcated device and iliac limbs were added and flow was restored to the lower extremities. Sequential renal-mesenteric stenting was done. A completion cone beam computed tomography revealed successful aneurysm exclusion. The repair was completed with a total endovascular time of 133 minutes and the patient was dismissed on postoperative day 10. Follow-up CTA showed patent stent-graft with type 2 endoleak. A total of 6 PMEG repairs with low profile Zenith Alpha™ Thoracic stent grafts were performed at our institution between 2016 and 2018, representing 2% of the 280 patients treated by F-BEVAR during this period. All six patients who had PMEGs did not meet inclusion criteria for an ongoing prospective study using CMDs Conclusion - PMEGs remain a valuable option to treat TAAAs, including chronic post-dissection aneurysms, in patients with symptoms or contained rupture who are not ideally suited for off-the-shelf devices. Compared to tighter stainless-steel Z stents, the widely spaced nitinol stents of the Zenith Alpha™ Thoracic endograft offer more space for fenestration placement.

A case report of heart transplant for ischaemic cardiomyopathy from lupus coronary vasculitis.

BackgroundCoronary vasculitis is a rare, life-threatening complication of systemic lupus erythematosus (SLE).Case summaryA 23-year-old woman with SLE presented with typical angina and worsening dyspnoea on exertion. Coronary angiography revealed severe triple vessel disease with a ‘string of beads’ appearance classic for coronary vasculitis. Transthoracic echocardiogram revealed ejection fraction of 25–30% with a severely hypokinetic distal septum and distal anterior wall and an akinetic apical wall. Despite vasculitis treatment with cyclophosphamide and pulse-dose steroids, her coronary vasculitis did not improve. She was refractory to anti-anginal and guideline-directed medical therapy for heart failure and successfully underwent orthotopic heart transplant (OHT).DiscussionThis is the first reported case of OHT in the case of SLE coronary vasculitis. Chronic SLE coronary vasculitis is caused by lymphocyic infiltration leading to inflammation and fibrosis of the major epicardial coronary arteries but can be successfully managed with OHT when refractory to medical SLE and heart failure therapies. It can affect patients of all ages with SLE, emphasizing the importance of thorough history taking and clinical evaluation in young patients presenting with cardiac symptoms to establish an appropriate diagnosis and treatment plan.