Effort Dyspnea Research Articles

"Hot phase" clinical presentation of biventricular arrhythmogenic cardiomyopathy: when the perfect electrical storm spontaneously stops.

An 18-year-old male presented with syncope during a training break. Post-syncope, he developed effort dyspnea, which he associated with the Pfizer-BioNTech COVID-19 vaccine received a week earlier. Electrocardiogram showed T inversion in V1-V3, III, and aVF, while 24-hour Holter monitoring revealed frequent ventricular premature beats. A transthoracic echocardiogram showed severe biventricular dilation and mild left ventricular (LV) dysfunction. Cardiac magnetic resonance (CMR) imaging confirmed these findings, showing moderate right ventricular (RV) systolic dysfunction with akinesia of the inferior and inferolateral walls. T2 hypersignal in the middle segment of the inferior inferior interventricular septum suggested myocardial edema. Extensive transmural late gadolinium enhancement was noted in the RV and LV walls. An implantable loop recorder was implanted. Three months later, the patient was admitted with palpitations, fever, and a positive SARS-CoV-2 test. Sustained ventricular tachycardia (VT) episodes were documented and managed with amiodarone and β-blockers. Follow-up CMR showed a slight improvement in LV ejection fraction and resolution of edema. A single-chamber implantable cardioverter-defibrillator (ICD) was implanted. Genetic testing for arrhythmogenic RV cardiomyopathy (ARVC) was negative, and family screening was normal. Two years later, pre-syncope episodes occurred, and ICD interrogation revealed nonsustained VT. The patient is awaiting VT ablation. This case highlights the diagnostic and therapeutic challenges of ARVC, particularly in differentiating it from myocarditis. The "hot-phase" presentation, vaccine association, and subsequent SARS-CoV-2 infection added complexity. CMR was crucial for diagnosis, and VT management required a combination of medical therapy and invasive procedures.

Atrial septal defect and platypnea-orthodeoxia syndrome: usefulness of the balloon occlusion test.

A 37-year-old man was referred to our medical center with a diagnosis of Eisenmenger syndrome due to an atrial septal defect (ASD). At admission he had central cyanosis, acrocyanosis, and progressive effort dyspnea; his symptoms improved during lying position.

Starry Sky Appearance of an Amyloid Heart in Plasma Cell Dyscrasias

We report an extremely rare case of amyloid heart with classical “Starry Sky” appearance in echocardiography in a 52-year-old male presenting with systemic amyloidosis secondary to plasma cell dyscrasias. Interestingly, patient presented with diffuse myalgia unresponsive to traditional nonsteroidal anti-inflammatory drugs with effort dyspnea New York Heart Association Class II secondary to Grade II diastolic dysfunction of stiff myocardium infiltrated with amyloid protein. A starry sky pattern of an amyloid heart led to the retrospective diagnosis of plasma cell dyscrasias with presence of 30% plasma cells in bone marrow biopsy without the presence of M band in serum electrophoresis.

The Current Role of Cardiopulmonary Exercise Test in the Diagnosis and Management of Pulmonary Hypertension.

Pulmonary arterial hypertension (PAH) is a progressive disease with a poor prognosis if left untreated. Despite remarkable achievements in understanding disease pathophysiology, specific treatments, and therapeutic strategies, we are still far from a definitive cure for the disease, and numerous evidences have underlined the importance of early diagnosis and treatment to improve the prognosis. Cardiopulmonary exercise testing (CPET) is the gold standard for assessing functional capacity and evaluating the pathophysiological mechanisms underlying exercise limitation. As effort dyspnea is the earliest and one of the main clinical manifestations of PAH, CPET has been shown to provide valid support in early detection, differential diagnosis, and prognostic stratification of PAH patients, being a useful tool in both the first approach to patients and follow-up. The purpose of this review is to present the current applications of CPET in pulmonary hypertension and to propose possible future utilization to be further investigated.

A Case of Demons-Meigs Syndrome Observed at the Markala Reference Health Center

DEMONS-MEIGS syndrome is defined by a pathological triad associating ascites, hydrothorax (Both can sometimes be associated) and an ovarian tumor, most often solid and benign but possibly cystic. Objective: To describe a case of Demons-Meigs syndrome observed at the Health Center of Reference of Markala. Clinical observation: We report the medical file of a 64-year-old postmenopausal lady, G11P7V6A0D1, IIG=2 years old without surgical history but poorly monitored hypertension. She was conducted in our department on 08/25/2020 in a picture of paroxysmal abdominal-pelvic pain with gravity type associated with an alteration of the general condition. It is associated with a productive cough with dyspnea of effort and previous chest pains. After the physical examination, there was a voluminous rounded pelvic mass going from the epigastric region to the pubic hair, the ultrasound examination having objectified an ascites of medium abundance and a voluminous left pelvic mass of 191mm / 120 mm then the chest X-ray from the front showing a right basal pleural effusion, the diagnosis of Demons-Meigs syndrome was evoked. After a preoperative assessment and a pre-anesthetic consultation, an exploratory laparotomy was performed. At the celiotomy, a serohematic ascites of 1.5 l is discovered, a large ovoid and pediculated ovarian tumor of the left ovary, not bumpy, overhanging the uterus, not twisted and not adhered but easily mobilizable. Conclusion: The Demons-Meigs syndrome which essentially comprises a benign ovarian tumor, ascites and a recurrent pleural effusion, characterized by healing without sequelae with drying of the effusions (Ascites and pleurisy) after removal of the ovarian tumor still retains a rather obscure etiology and pathophysiology.

ONGOING ANTI-HYPERTENSIVE TREATMENT DOESN’T IMPACT ON OUTCOME ON MEDIUM-LONG TERM SEQUELAE OF PATIENTS WITH MODERATE TO SEVERE COVID-19 PNEUMONIA

Objective: One “hot” topic that remains to be elucidated is the possible role of anti-hypertensive drugs on middle and long term outcome of COVID-19 pneumonia. Namely, ACE2 receptor is highly expressed on the surface of cardiac and pulmonary cells, and it is used by coronaviruses, to enter host cells; specifically, the interaction between the “spike” protein of coronaviruses and ACE2 has been identified as a key factor for the virus transmission. This makes the role of ACE-inhibitors and Angiotensin Receptor Blockers (ARBs) drugs extremely controversial and their role – if any – is still to be elucidated. Moreover, it is still unclear whether these drugs may have any impact on SARS-CoV-2 sequelae. Design and method: In this retrospective study, we analysed a group of 70 hypertensive unvaccinated patients treated in our Medicine ward for moderate to severe COVID-19 pneumonia during pandemic who survived and accepted to undergo a follow-up visit after a mean of 260 days including phone interview, standard laboratory tests, chest x-ray and/or chest computed tomography, spirometry with evaluation of DLCO. Patients were divided in three groups according to hypertensive treatment: ACE-inhibitors (n. 27) or ARBs (n. 21) or other anti-hypertensive medication. The considered groups where homogeneous (see table) Results: As shown in the table, biochemical, radiological and respiratory data were not significantly different. Again, we did not find any significant difference in terms of number of non-specific radiological alterations (i.e. ground-glass opacities, irregular linear/reticular opacities), lung fibrosis, spirometry data, DLCO diffusion, persisting effort dyspnoea. Biochemical data were, once more, substantially super-imposable in the two groups Conclusions: In conclusion, in our study, we could not detect any difference in middle-long term outcome nor in complication type or number in the groups of hypertensive patients undergoing different treatments. This result seems to support and to strengthen the idea that ACE-inhibitors and ARBs do not play a significant role on onset, evolution and middle-long term outcome of moderate to severe COVID-19 pneumoniae: although the number of follow-up patients is very small, we did not find any difference in sequelae in both groups.

Immediate right chambers remodelling after orthotopic transcatheter valve tricuspid replacement.

An 84-year-old man with atrial fibrillation, ischemic heart disease with surgical and percutaneous revascularization, complained about effort abdominal pain and dyspnoea (NYHA III), with asthenia and peripheral oedema. Transoesophageal echocardiography showed torrential atrial tricuspid regurgitation and dilated right ventricle with preserved ejection fraction (Panels A–C). Invasive systolic pulmonary pressure was 30 mmHg. The TRI-SCORE was 30%. Considering the symptoms and signs of right heart failure despite optimal medical treatment and the prohibitive surgical risk, the patient was selected for tricuspid transcatheter valve replacement with Cardiovalve (VenusMedtech, Hangzhou, China) according to Heart Team evaluation. Repair percutaneous techniques were rejected, transcatheter annuloplasty due to right coronary artery proximity and thin tissue, and edge-to-edge approach because of the gap of 1 cm. The 32-F Large Cardiovalve system was inserted via surgically exposed femoral vein and was advanced into the right atrium. Under transesophageal echocardiographic and fluoroscopic guidance, the device legs were opened in the atrium and advanced into ventricle and grasp the 3 native leaflets by pulling the system (Panel D). Finally, the atrial followed the ventricular flanges that were released (Panel E). There was a posterior mild paravalvular regurgitation (Panels F and G, Supplementary data online, Videos S1 and S2). After 1 month, the patient is NYHA class I, neither having effort abdominal pain nor peripheral oedema. CT scan showed a significant reduction of the right ventricular diastolic volume from 256 to 216 mL, and the right atrium from 89 to 71 mL, even persisting atrial fibrillation (Panel H, Supplementary data online, Video S3).

P24 AN UNSUAL ENDOCARDITIS

Abstract In February 2021 a 28 years old woman presented with effort dyspnea. She refers a history of post caesarean section sepsis treated with antibiotic therapy. At TTE and following TEE: thickening of the interatrial septum, protruding neoformation in the left atrium as well as mitral valve steno–insufficency related to infiltration of the neoformation. The patient was then referred for cardiac surgery in Vicenza. The resection of the neoformation infiltrating the left atrium, interatrial septum, leaflet, annulus and papillary muscles of the mitral valve was performed (minithoracotomy). Finally valve replacement with Hanckock bioprosthesis no. 27 was performed. Extemporaneous histological examination showed a possible intimal sarcoma, which was subsequently confirmed (G3, IV stadium, MDM2+). At CT angiography evidence of vascular involvement (VCI and pulmonary vein) and possible secondary sites. The patient was referred to the regional reference centre (C.R.O. Aviano) where she was treated with six cycles of chemotherapy with EpiADM and Ifofosfamide, resulting in excellent remission of the tumour. At control PET/CT with FDG (01/22) substantial absence of disease. Intimal sarcoma (ISA) is an exceedingly rare undifferentiated sarcoma that arises in the pulmonary artery and less frequently in the aorta or its branches. ISAs behave highly aggressive with a mean patients’ survival ranging from 5 to 18 months. Patients with ISA are mostly of middle age at diagnosis and typically present with non–specific symptoms, which sometimes masquerades as thromboembolic disease. Thus, patients are often diagnosed in an advanced disease stage. Furthermore, ISAs are often reported to be resistant to conventional chemotherapy.

P29 LVOTO IN HCM: HYBRID TREATMENT MAY STILL NOT SOLVE CHALLENGING CASES

Abstract MA, a 28 years old male with a diagnosis of OHCM since 2008, came to our attention for effort dyspnea (NYHA II) and fatigue limiting his greengrocer activity. Decompensated T1DM (HbA1C 12%), HTN, obesity (BMI 37). In 2017 he implanted a bicameral ICD in primary prevention, later extracted for sepsis and replaced with S–ICD. In the last 2 years he had 3–4 episodes of FAP, the latter causing an AHF requiring hospitalization in ICU. CV therapy: metoprolol 100 mg bid; disopyramide 100 mg x 3; rivaroxaban 20 mg die, insulin. Resting ECG: sinus bradycardia, HR 50 bpm, LVH with secondary repolarization abnormalities, long QTc (>500 ms). At basal and stress echocardiography (Fig. 1) he had a maximum wall thickness at medium IVS of 21 mm and severe dynamic obstruction due to complete SAM (Gmax 50 –> 135 mmHg); moderate mitral regurgitation, secondary to SAM, with eccentric jet; worsening of obstruction and MR at peak of stress (Gmax 145 mmHg; MR 3+); absence of pulmonary hypertension; severe left atrial dilatation (53ml/mq). He was considered not eligible for Morrow myectomy due to unfavorable anatomy (basal IVS of 11–14 mm, maximum thickness at medium IVS). Mitral valve area was > 4cmq. After Heart Team evaluation the patient was proposed for a reparative approach of mitral valve, and TEER was preferred to open surgery for favorable anatomy and to avoid an increased peri–operative risk in a patient with different comorbidities. The procedure was successfully conducted with the implantation of 1 MitraClip (MITRACLIP® Evalve – Abbott) in central position, with echocardiographic evidence (Fig. 2) of complete SAM resolution, reduction of MR to 1+ and gradient abolition (13 mmHg post–Valsalva maneuver). MVA at intraoperative TEE: >2 cmq. At six–months follow–up the patient reported a satisfactory reduction of symptoms without limitations in non–agonist physical activity and work, yet he still was not asymptomatic. Although on best medical treatment and after TEER, transthoracic echocardiographic control showed a recurrence of SAM and LVOTO (40 mmHg at basal, 70 mm Hg post – Valsalva maneuver). He is still candidate to myosin inhibition treatment. This case highlights the multiple challenges of LVOTO in HCM patients. Although a hybrid approach may be a promising treatment of OHCM, especially in youngers, an increase of expertise in this field and further research is needed, focusing on predictors of procedural failure and success.

C15 PERCUTANEOUS EDGE–TO–EDGE REPAIR USING EDWARDS PASCAL SYSTEM FOR SEVERE TRICUSPID REGURGITATION IN CONGENITALLY CORRECTED TRANSPOSITION OF THE GREAT ARTERIES

Abstract Introduction Congenitally corrected transposition of the great arteries (ccTGA) is a rare cardiac malformation characterized by ‘double’ discordance of atrioventricular and ventriculo–arterial connections, resulting in a systemic tricuspid atrioventricular valve and a systemic right ventricle. Clinical case We describe a case report of 54 years–old male patient with ccTGA, diagnosed when he was 3 years–old. Patient performed regular follow–up. Since December 2019, the patient reported onset of effort dyspnoea (NYHA III), fatigue and exercise intolerance. Despite medication optimization, his symptoms persisted. He was referred at our Centre for specialist evaluation. Transthoracic echocardiography showed mild dilatation and dysfunction of right ventricle, massive systemic tricuspid valve regurgitation (EROA 42 mm2), due to multiple jets and systolic pulmonary artery pressure of 45 mmHg. As reported by most recent guidelines, indication was given for surgical replacement of the systemic tricuspid valve. However, the patient refused the cardiac surgery option. Transesophageal echocardiography (TEE) screening showed feasibility of percutaneous approach to tricuspid regurgitation. Being the jet central, the strategy was to place one device implant between the septal and the anterior leaflet (9–3 oriented), as central as possible. Following simultaneous leaflet capture and further optimization of leaflet, the result was excellent. Post–implant deployment TEE revealed only mild–to–moderate residual tricuspid regurgitation, with no tricuspid stenosis (mean gradient 2 mm Hg). The result was a percutaneous bicuspidization of a tricuspid systemic valve. The patient recovered quickly and was discharged to home 2 days after the procedure. Patient experienced significant improvement in functional status (NYHA I), exercise capacity and quality of life at 6 months follow–up. Conclusions In ccTGA patients, treatment of severe tricuspid regurgitation and improvement of the systemic ventricle’s systolic function is critical since progression of dysfunction of the RV and tricuspid regurgitation are considered key determinants for morbidity and mortality in these patients. Based on the results obtained in our case, percutaneous edge–to edge repair seems to be a reasonable alternative to the surgical approach and three–dimensional transesophageal echocardiography is imperative for the proper visualization of the leaflets outcome of the procedure and his durability.

A Young Patient Presenting with Dilated Cardiomyopathy and Renal Infarction during Treatment with Isotretinoin: Mere Coincidence or Serious Side Effect of a Drug Commonly Used in Adolescence?

Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drugs for the treatment of severe acne vulgaris. Despite being deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We report a case of heart failure due to dilated cardiomyopathy (DCM) and concomitant renal infarction occurring after 5 months of isotretinoin use in a previously healthy 18-year-old male. The patient, with a history of acne vulgaris, presented to our emergency department with left iliac fossa pain and effort dyspnea. A trans-thoracic echocardiogram showed DCM and severely reduced left ventricle ejection fraction (LVEF: 29%). During hospitalization, a total body computed tomography (CT) showed an ischemic lesion in the left kidney. Ischemic, autoimmune, infective, and heritable causes of DCM were ruled out. Cardiac magnetic resonance (CMR) evidenced LV circumferential mid-wall late gadolinium enhancement. Heart failure therapy was promptly started and up-titrated, but only poor LVEF improvement was detected overtime. Our case aims to raise awareness on rare life-threatening cardiovascular events possibly associated with isotretinoin use. To the best of our knowledge, this is the first described case of renal thromboembolism and severe DCM leading to implantable cardioverter-defibrillator (ICD) implantation occurring during isotretinoin treatment.

Assessment of dyspnea, ADL, and QOL in the perioperative period in lung cancer patients treated with minimally invasive surgery.

Patients with lung cancer generally undergo minimally invasive surgery, such as video-assisted thoracoscopic surgery (VATS). This study examined the changes in health conditions and symptoms of patients with lung cancer using the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC QLQ) C-30 questionnaires after surgery. This was a longitudinal descriptive study. One hundred and three patients with lung cancer who underwent lung resection at Tokushima University Hospital between 2012 and 2021 were eligible. They completed EORTC QLQ-C30, QLQ-LC13, the Cancer Dyspnea scale (CDS), and pulmonary-ADL (P-ADL) before and 1, 3, and 6 months after surgery. Regarding functional scale scores, impairments in physical and role functions persisted for 6 months after surgery. In symptom scale scores, fatigue, pain, dyspnea, and appetite loss continued for 6 months after surgery. In CDS, sense of effort, discomfort, and total dyspnea scale scores were elevated for 6 months after surgery. In P-ADL, most ADL were impaired 1 month after surgery, but recovered by 3 months. The dyspnea index of ADL was lower for 6 months after surgery. Impairments in health conditions and symptoms persisted for 6 months after surgery despite its minimally invasive nature. J. Med. Invest. 70 : 388-402, August, 2023.

15 THE HEAVY BURDEN OF SARS-COV-2 RELATED PNEUMONIA REQUIRING HIGH-OXYGEN FLOW

Abstract Aim there is evidence of significant clinical sequelae of COVID-19 that may impair both life length and its quality. Aim of this study was to assess the long-term consequences of moderate to severe SARS-CoV-2-related pneumonia in patients requiring high-flow oxygen treatment. Methods This prospective follow-up study included 45 patients with confirmed COVID-19 admitted to a medical ward at the Montichiari Hospital, Brescia, Italy from November 2020 to April 2021 Patients had COVID-19 related pneumonia with respiratory failure and needed at least treatment with an inspired fraction of oxygen of 40% (of them, 59% were treated with Venturi mask and 41% needed non-invasive ventilation). Patients underwent a clinical assessment with standard laboratory testing, chest CT scan, lung function tests with DLCO, and evaluation of vital parameters after a mean of 382 days after hospital discharge. A quality-of-life questionnaire was administered to each willing patient. Results See table for details. While standard laboratory testing showed a substantial normalization, we found persistence of radiological alterations (i.e. ground-glass opacities, irregular linear/reticular opacities) in 61% of patients; mean Tiffenau index (FEV1/FVC) was reduced, although not clearly pathologic (79%) and 38% of patients showed a mild to moderate reduction in CO lung diffusion (DLCO). Interestingly, 54% of subjects showed concomitant presence of radiologic alterations AND persistence of dyspnea OR reduction in CO lung diffusion, while 21% had all three concomitant conditions, compatible with the diagnosis of lung fibrosis. Overall, a total of 75% patients had some degree of functional or structural alteration of respiratory apparatus. We also evaluated quality of life thorough a structured questionnaire: after more than one year 62% of the patients still lamented fatigue, 62% effort dyspnea, 12% anorexia, 29% dysgeusia or anosmia, 31% insomnia and 43% anxiety. Conclusions these data seem to demonstrate that SARS-CoV-2-related pneumonia requiring high flow oxygen has a heavy long-term burden, both in terms of persistence of functional and structural pulmonary damage (which may be progressive and evolve to a more severe degree) and of burden on overall quality daily life.

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<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.

806 BRIDGING COLLATERALS OF CHRONICALLY OCCLUDED LEFT INTERNAL MAMMARY ARTERY BYPASS GRAFT TO LEFT ANTERIOR DESCENDING ARTERY

Abstract Methods and results The internal mammary artery (IMA) is the conduit of choice to bypass the left anterior descending (LAD) coronary artery in patients eligible for coronary artery bypass grafting (CABG). In case of graft occlusion, it is still not clear whether it is better to revascularize the graft or the recipient native vessel, on top of optimal medical therapy. A 55-year-old man, with prior CABG, underwent urgent coronary angiography for an acute coronary syndrome. LAD CTO, severe proximal circumflex artery stenosis, and mild atherosclerosis of the right coronary artery were found. Moreover, a proximal occlusion of the venous graft to the obtuse marginal branch and LIMA CTO within the body of the graft were shown as well. Surprisingly, many well-developed bridging collaterals, arising close to the proximal cap of the LIMA occlusion, supplied the bloodstream circulation distal to the occlusion within the LIMA. At that time, a left main–proximal circumflex artery stenting was performed (3.5×24-mm Xience Sierra, Abbott) because that was judged the culprit lesion. One month later the patient still complained of effort angina and dyspnoea despite optimized antianginal medical therapy. The patient was scheduled for elective antegrade LIMA CTO PCI, considered the most appropriate treatment strategy. Indeed, the presence of a prior stent implanted in the left main– circumflex artery would have made difficult a proximal cap negotiation and its penetration by guidewires in case of antegrade LAD CTO PCI. Thus, the LIMA CTO negotiation was initially attempted with a Fielder FC guidewire (Asahi Intecc) and a supporting Corsair Pro (Asahi Intecc) microcatheter. The polymeric soft wire prolapsed preferentially into the bridging collaterals without the chance to engage the CTO proximal cap. Finally, a moderate-weight hydrophilic GAIA second (Asahi Intecc) succeeded in cap penetration and final CTO crossing. After lesion predilatation with a 2.0×15-mm balloon (Emerge, Boston Scientific), 2 overlapped stents, respectively 2.75×44 mm and 3.0×18 mm (VIVO ISAR, Translumina) were deployed and postdilated by a 3.0×15-mm non-compliant balloon (Accuforce, Terumo). The final result was deemed very satisfactory with a TIMI 3 flow. Conclusions Many studies showed that IMA has active biological functions, providing a sort of protection against atherosclerosis and self-reparative properties. These biological properties might justify the IMA high long-term patency rates as CABG conduits. The development of bridging collaterals in this patient, represents a clear proof of the LIMA self-reparative properties. Whereas bridging collaterals are a common feature of coronary CTO, their development in a LIMA bypass graft represents a unique finding which requires further investigation.

239 VASOSPASTIC ANGINA: A CASE OF COMPLETE FUNCTIONAL ASSESSMENT

Abstract Introduction Vasospastic angina is defined as a focal or diffuse spasm of the arterial wall of an epicardial coronary artery due to muscle cells hyperreactivity caused by an increased calcium sensitivity. Clinical presentation typically consists in chronic story of rest and/or effort typical chest pain, episodes of ST elevated or not ST elevated myocardial infarction, arrhythmias or cardiac arrest; an increased vagal tone, drugs, allergic reactions or the exposure to extreme cold also can trigger vasospasm. Clinical case 73 years old dyslipidemic woman; in past medical history thyroidectomy and radiotherapy for carcinoma and right quadrantectomy with radiotherapy and hormonal therapy for breast cancer. In 2017 admission to cath-lab for non-ST elevation myocardial infarction (NSTEMI) with the evidence of mild left coronary artery disease without critical obstructive stenosis (MINOCA). For the persisting of effort angina and dyspnea (NYHA and CCS II-III), started Diltiazem therapy (60 mg x3) with clinical benefit. In 2020, due to the onset of new episodes of angina, started Ranolazine therapy. In June 2022, for the worsening of clinical symptoms, was evaluated with a Coronary CT, that showed a 65% stenosis at right coronary-acute marginal bifurcation and mild disease on left coronary artery, and then was admitted for an elective coronary angiography, with no evidence of epicardial artery critical stenosis. At the functional evaluation FFR, CFR and IMR (>0.80, 2.5 and 18) demonstrated normal coronary flow reserve and good microcirculation function. For the suspicion of vasospastic angina, acetylcholine test was performed with the evidence of mid-distal left anterior descending artery total occlusion, angina onset and ECG changes, promptly regressed with nitrates administration (Figure 1). Patient was discharged with the optimization of medical therapy with Diltiazem 120 mg x3, with clinical benefit. Conclusions To date vasospastic angina remains underdiagnosed. Functional evaluation of coronary arteries plays a fundamental role in the diagnostic algorithm of the disease and should always be investigated in case of patients with typical symptoms and the absence of critical epicardial stenosis. Further investigations are required to better explain pathogenesis and to identify affected patients in shorter times to ensure early optimized medical therapy.

254 DIFFERENT DEGREES OF DEGENERATION OF TRANSCATHETER VALVES IMPLANTED IN THE AORTIC POSITION OR EMBOLIZED DISTALLY: A CASE REPORT

Abstract While transcatheter aortic valve replacement (TAVR) gradually emerges as first line therapy for aortic disease in most surgical risk groups, structural prosthetic degeneration remains an issue that may must be considered when planning procedures in younger patients. We present the case of a 74 years old female who underwent a valve-in-valve TAVR following degeneration of a previously implanted TAVR which had initially been complicated by distal embolization of two prosthetic valves. The patient initially underwent TAVR in 2010 for severe aortic regurgitation and a porcelain aorta. The procedure was complicated by distal embolization of two prosthetic valves; firstly a 26 mm Sapien valve migrated to the pre-renal abdominal aorta. This was followed by the embolization of a 29 mm CoreValve to the descending thoracic aorta. Finally, on the third attempt, a 29 mm CoreValve was successfully implanted without complication. The patient remained clinically stable until February 2022 when she developed progressively worsening effort angina and dyspnea. Echocardiographic evaluation demonstrated prosthetic aortic valve degeneration with cusp fibrosis and calcification, with severe aortic regurgitation. Interestingly, neither of the embolized prosthetic valves showed signs of deterioration on CT imaging. The valve that had migrated to the abdominal aorta did not show any significant increase in gradient or regurgitation on Doppler evaluation. After careful evaluation and Heart Team discussion, a transfemoral valve-in-valve (ViV) procedure was performed uneventfully with a 23 mm Sapien Ultra implant, that resulted in complete abolition of regurgitation with mild prosthesis-patient mismatch (mean gradient 15 mmHg, EOA 0.8 cm2/m2). Post-procedural CT imaging confirmed a satisfactory result with no signs of dislocation of the previous valve prostheses (Figure 3). The patient was safely discharged on day 4 post-op on oral anticoagulation (due to a history of atrial fibrillation), and was asymptomatic at 30-day follow-up. This case report describes a challenging but successful ViV TAVR implantation.

1 ACE-INHIBITORS AND ANGIOTENSIN RECEPTOR BLOCKERS DO NOT IMPACT ON OUTCOME NOR IN LONG TERM CONSEQUENCES OF COVID-19

Abstract Introduction COVID-19 pandemic still represents a major clinical problem worldwide. Many studies are actively being carried out to better understand prognostic factors of outcome as well as optimal treatment. Aim ACE-2 receptor is highly expressed on the surface of cardiac and pulmonary cells, and it is used by coronaviruses to enter host cells; this makes the role of ACE-inhibitors and Angiotensin Receptor Blockers (ARBs) drugs controversial. Moreover, it is still unclear whether these drugs may have any impact on sequelae. Methods In this retrospective study, we analysed a group of 244 hypertensive unvaccinated patients (134 on ACE-inhibitors, 110 on ARBs) admitted for moderate to severe COVID-19 pneumonia. As shown in the table, the two groups where homogeneous. Of these patients, 46 (20 treated with ACE-I and 26 treated with ARBs) came to a follow-up visit after a mean of 260 days; they underwent a quality-of-life assessment, laboratory and radiologic tests and spirometry (with DLCO). Results A total of 20 of 110 (18%) patients under treatment with ARBs and 23 of 134 (17%) died during hospitalization (p=0.8, NS). At discharge, biochemical, radiological and respiratory data were not significantly different. We did not find any significant difference in terms of radiologic alterations, lung fibrosis, spirometry data, DLCO, persisting effort dyspnea. Biochemical data were substantially super-imposable in the two groups. Conclusions we could not detect any difference in outcome nor in complications type or number in the two groups undergoing treatment with ACE-inhibitor or ARBs. This result seems to support and to strengthen the idea that ACE-inhibitors and ARBs do not play a significant role in onset, evolution and outcome of moderate to severe COVID-19 pneumoniae. Although the number of follow-up patients is small, we did not find any difference in follow-up sequelae in both groups.

Abstract 15052: A Young Patient Who Presented With Dilated Cardiomyopathy and Renal Infarction During Treatment With Isotretinoin

Background: Isotretinoin or 13-cis-retinoic acid (RA) is one of the most effective and widely used drug for the treatment of severe acne vulgaris. Despite deemed safe, no definite consensus has been reached on the cardiovascular risk of RA derivatives. We describe the first case of concomitant dilated cardiomyopathy (DCM) and renal infarction after 5 months of isotretinoin use in a previously healthy 18-years old man. Case Summary: An18-years-old man, with history of acne vulgaris, presented in August 2021 to our emergency department because of left iliac fossa pain and effort dyspnea. Computed tomography scan revealed left renal infarction and echocardiogram demonstrated global left ventricular (LV) dilatation with severely reduced LV-ejection fraction (LVEF: 29%). Coronary artery disease, autoimmune, infective, or heritable causes of DCM were ruled out. Cardiac magnetic resonance evidenced LV circumferential mid-wall late gadolinium enhancement and ECG monitoring revealed several non-sustained ventricular tachycardia episodes. Thus, Bisoprolol, Sacubitril/Valsartan, and Eplerenone were started and up titrated until maximum tolerated doses, with only poor LVEF improvement. Conclusion: Our case aims to raise awareness on rare life-threatening cardiovascular events associated with isotretinoin use for the treatment of severe acne in young patients. To the best of our knowledge, this is the first described case of renal thromboembolism and DCM requiring S-ICD implantation and cardiac transplant program listing occurring in the course of isotretinoin treatment.

Factors associated with health-related quality of life in heart failure in 23,000 patients from 40 countries: results of the global congestive heart failure research program

Abstract Background Poor health-related quality of life (HRQL) is common in heart failure (HF) and strongly predicts death and HF hospitalization in all regions of the world. Understanding facors associated with HRQL could therefore lead to improved prognosis in HF patients. Despite that the majority of HF occurs in low- and middle-income countries, there are limited data characterizing self-perceived health HRQL and its correlates in these settings. Purpose To examine clinical and social correlates of HRQL in patients with HF from high- (HIC), upper middle- (UMIC), lower middle-(LMIC) and low-income (LIC) countries. Methods Between 2017 and 2020, we enrolled 23,292 patients with HF (32% inpatients, 61% men) from 40 countries in the Global Congestive Heart Failure Study. We recorded HRQL at baseline using Kansas City Cardiomyopathy Questionnaire (KCCQ)-12. In a cross-sectional analysis, we compared age- and sex-adjusted mean KCCQ-12 summary scores (SS: 0–100, higher=better) between patients from different country income levels. We used multivariable linear regression examining correlations (estimates expressed as β-coefficients) of KCCQ-12-SS with sociodemographic-, comorbidity-, treatment- and symptom-covariates. The adjusted model (37 covariates) was informed by univariable findings, clinical importance and backward selection. We used partial R2-estimates to understand the contribution to the variability in KCCQ-12-SS of 4 different groups of covariates. (sociodemographic, comorbidities, treatments and signs and symptoms of congestion). Results Mean age was 63 years and 40% were in NYHA class III–IV. Average HRQL was 55± SD 0.5. It was 62.5 (95% CI 62.0–63.1) in HIC, 56.8 (56.1–57.4) in UMIC, 48.6 (48.0–49.3) in LMIC, and 38.5 (37.3–39.7) in LICs (p<0.0001). Strong correlates (β-coefficient [95% CI]) of KCCQ-12-SS were NYHA class III vs class I/II (−12.1 [−12.8 to −11.4] and class IV vs. class I/II (−16.5 [−17.7 to −15.3]), effort dyspnea (−9.5 [−10.2 to −8.8]) and living in LIC vs. HIC (−5.8 [−7.1 to −4.4]). Symptoms explained most of the KCCQ-12-SS variability (partial R2=0.32 of total adjusted R2=0.51), followed by sociodemographic factors (R2=0.12). Results were consistent in populations across income levels. Conclusion The most important correlates of HRQL in HF patients relate to HF symptom severity, irrespective of country-income level. Improved symptom control may have a big impact on HRQL, especially in LICs. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Bayer AG