Intracavitary Thrombus Research Articles

Prevalence of atrial fibrillation in patients with ischemic stroke older than 55 years at the Alberto Antranik Eurnekian Hospital in Ezeiza, Buenos Aires, Argentina

Background: A stroke is a neurological disorder that occurs when the blood supply to (part of) the brain is Interrupted. 87 % of the cases are caused by an Ischemia (Ischemic stroke). One of the principal causes is Atrial fibrillation (AF) being the most frequent sustained arrhythmia represented by 160 000 patients who develop it annually in the United States. AF generates a turbulent flow within the left atrial appendage, which causes the formation of intracavitary thrombus with the risk that they are expelled into the systemic circulation, possibly causing a stroke as a complication. The purpose of this research study is to establish the prevalence of AF in patients with ischemic stroke older than 55 years old in the clinic service of the Hospital Alberto Antranik Eurknekian from January through September 2022. Material and methods: This research study was conducted following a non- experimental, descriptive, quantitative, transversal and retrospective approach. Data were gathered upon the clinical records of patients older than 55 years old, who had an admission electrocardiogram (ECG) and had ischemic stroke evidenced in topographies of the brain in Hospital de Ezeiza. The following variables were analysed: age and sex, arterial hypertension, diabetes, obesity, dyslipidaemia, smoking, history of previous stroke or transient ischemic attack, as well as AF and AF under treatment. Results: The final sample of this study consisted of 49 patients, of whom 55, 1 % were male (N=27) and 44, 9 % female (N=22). 8, 2 % (N=4) of them had associated atrial fibrillation, among them, 75 % (N=3) were anticoagulated. 77,6 % (N=38) had hypertension, 40, 8 % (N=20) diabetes, 6, 1 % (N=3) used tobacco and 4,1 % (N=2) had obesity and dyslipidaemia. 16,3 % (N=8) suffered an ischemic stroke previously and 2 % (N=1) had a transient ischemic attack. Conclusion: It was found a high prevalence of AF in patients diagnosed with a stroke. Of these, 75 % were anticoagulated, but still developed the ischemic event. Regarding cardiovascular risk factors, the entire sample had a high prevalence of comorbidities, the most common being hypertension and diabetes

Congenital giant right atrial aneurysm.

Right atrial aneurysm is a rare congenital heart condition defined as a dilation of the right atrium in the absence of an underlying cause [1]. The clinical presentation varies; most patients are asymptomatic, while others may experience arrhythmias or intracavitary thrombi [1, 2]. We report a case.

Anatomical factors of intracavitary thrombus formation in the pathogenesis of cardioembolic stroke

Cardioembolic stroke, like other types of acute cerebrovascular disorders, is a global priority medical and social problem. This review analyzes the role of anatomical factors, which, along with other factors of thrombus formation in the heart chambers, may represent an important and yet insufficiently studied link in the pathogenesis of this disease.

Diagnosis and Outcome of Patients with Idiopathic Hypereosinophilic Syndrome and Cardiac Involvement

Introduction: Diagnostic criteria of idiopathic hypereosinophilic syndrome (iHES) comprise persisting reactive/non-clonal eosinophilia ≥1.5 G/l and associated organ infiltration/dysfunction. The pattern and extent of organ involvement is most relevant for symptoms, quality of life, complications, response to treatment and prognosis. Of note, the potentially life-threatening cardiac involvement (CI) is frequently underrecognized. Patients and Methods: Based on the ´German Registry on Disorders of Eosinophils and Mast Cells (GREM)', we sought to investigate CI in 62 patients (pts) with iHES and predominantly multifocal organ involvement (sinus [n=26], lungs [n=36, including asthma, n=23], abdominal organs [n=15], skin [n=15] and lymph nodes [n=9]) by cardiac magnetic resonance imaging (MRI, 62/62 pts), echocardiography (30/62 pts), myocardial biopsy (10/62 pts) and the cardiac biomarkers troponin I (TNI, 49/62 pts) and N-terminal prohormone B-type natriuretic peptide (NT-proBNP, 38/62 pts). Clonal eosinophilia, e.g. FIP1L1::PDGFRA, alternative tyrosine kinase fusion genes and point mutations, e.g. KIT D816V, was excluded by the combination of cytogenetic/molecular analyses, bone marrow histology and immunohistochemistry. Myeloid peroxidase (MPO)-ANCA antibodies as characteristic marker of eosinophilic granulomatosis with polyangiitis (EGPA) were absent in all 62/62 (100%) pts and no evaluable patient had histologic evidence of vasculitis. Results: Cardiac MRI was pathologic in 34/62 (55%) pts with overlapping presence of late gadolinium enhancement (LGE, 31/34, 91%), pericardial effusion (11/34, 32%), involvement of heart valves/conduction system (9/34, 26%), impaired left-ventricular ejection fraction (LVEF <50%, 9/34, 26%) and presence of intracavitary thrombus (6/34, 18%). Concomitant echocardiography revealed pathological findings only in 10/24 (42%) pts with a pathologic MRI. Myocardial biopsy unveiled fibrosis (4/10, 40%) or eosinophilic infiltration (2/10, 20%) but was also non-informative (4/10, 40%). CI was rather associated with involvement of lungs (24/34, 71%) and sinus (23/34, 68%) than of abdominal organs (8/34, 24%) and skin (5/34, 15%). The combination of CI and asthma, potentially suggestive of ANCA-negative EGPA, was observed in 16/34 (47%) pts, but an indistinguishable pattern of multifocal organ involvement was also present in 18/34 (53%) pts with CI and absence of asthma. All 10/49 (20%) pts with an elevated vs. 0/49 (0%) pts with a normal troponin I (<0.045µg/l) and 20/38 (53%) pts with an elevated vs. 7/38 (18%) pts with a normal NT-proBNP (<125ng/l) revealed a pathologic cardiac MRI (Table). During a median follow-up of 108 months (range 3-470), the occurrence of cardiac events (n=15; death, n=3; cerebral embolism, n=4; worsening of LVEF, n=2; arrhythmias, n=2; valve surgery, n=2; pericardial effusion, n=1; coronary artery aneurysm, n=1) was strongly associated with a pathologic cardiac MRI in 15/15 (100%) pts (prior to MRI, n=6; after MRI, n=9) and an elevated troponin I and/or elevated NT-proBNP in 14/15 (93%) or 12/15 (80%) pts, respectively. During a median follow-up of 7.6 years (range 0.3-29.2), glucocorticoid-based immunosuppressive treatment resulted in improved MRI findings in 9/20 (45%) pts (improved LGE, n=7; regression of thrombus, n=1; improved LVEF, n=1) and a median NT-proBNP decrease of 48%. In pts with a pathologic MRI and elevated biomarkers, 9/13 (69%) and 5/19 (26%) pts, respectively, had a normalization of troponin I or NT-proBNP. Conclusions: In pts with iHES, i) the incidence of CI is high, particularly in pts with multifocal organ involvement, ii) it is questionable whether absence or presence of asthma in pts with multiple organ involvement is qualified for the challenging differentiation between iHES and ANCA-negative EGPA, iii) CI should be assessed by troponin I/NT-proBNP and cardiac MRI as they are superior to echocardiography, iv) the combination of elevated troponin I and to a lesser extent also elevated NT-proBNP with a pathologic cardiac MRI is associated with retrospective and subsequent, potentially life threatening cardiac events, and v) cardiac biomarkers and cardiac MRI are useful for monitoring response to treatment.

Тромбоутворення в порожнині лівого шлуночка. Частина 2. Можливості лікування

Попри давню проблему внутрішньопорожнинного тромбоутворення питання його лікування і сьогодні досить складне для будь-якого клініциста. На початку лікування перед лікарем постає вибір, якому з антикоагулянтів надати перевагу. Помилки щодо вибору препарату та його дозування збільшують ризик у хворого, з одного боку, виникнення кровотечі, а, з другого боку, ризик розвитку ускладнень за наявності тромбоутворення в порожнині лівого шлуночка. Стаття присвячена проблемі тромбоутворення в порожнині лівого шлуночка з огляду на аналіз даних реєстрів, метааналізів, пілотних та рандомізованих багатоцентрових клінічних досліджень.

Giant right ventricular thrombus as the revealing form of Behçet's disease

BackgroundBehçet's disease BD is a rare multisystemic disease, with rare cardiac involvement. This case illustrates a rare cardiac involvement as a giant intracavitary thrombus which was the revealing form of Behçet disease.Case presentationAn 15-year-old male admitted to the emergency department for progressive dyspnoea, hemoptysis for which an echocardiogram displayed a large echogenic mass in the right ventricle and angio CT revealed associated bilateral pulmonary embolism. The patient was then proposed for surgery for removal and pathological study the later confirmed its fibrin thrombotic nature. Behçet disease was suspected based on past history of recurrent oral aphthosis and confirmed with a positive pathergy test. Further management by anticoagulants, immunosuppressants and corticosteroids seemed effective to avoid relapse.ConclusionsCardiac involvement during BD can be life-threatening as it is not always diagnosed in timely manner. However, intracardiac thrombus is uncommon with only few case reports. Echocardiography is the key tool for the diagnosis of intracardiac thrombus.

CARDIAC MANIFESTATIONS OF EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS

SESSION TITLE: Airways Function Measurement and Treatment OutcomesSESSION TYPE: Rapid Fire Original InvPRESENTED ON: 10/19/2022 11:15 am - 12:15 pmPURPOSE: Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare systemic disease characterized by asthma, peripheral & tissue eosinophilia & systemic vasculitis. Cardiovascular manifestations have been reported in prior studies, but the prevalence & spectrum of cardiac and vascular disease in EGPA is poorly understood.METHODS: The medical records were reviewed of a series of patients with EGPA who were evaluated from 1990-2021. For inclusion, patients had to fulfill standardized criteria for EGPA. Cardiac involvement was attributed to EGPA if findings could not be explained by other coexisting conditions.RESULTS: Two hundred and nineteen patients with EGPA were identified. The mean age at diagnosis was 52.16 years. 108 (49.3%) were female. Eighty-three (38%) had evidence of cardiac involvement. 49 (22.4%) had myocardial dysfunction. 6 (3%) with intra-cavitary cardiac thrombus; 22 (10%) with valvular involvement. 42 (19.2%) had pericardial disease (8 with tamponade and 1 with chronic constrictive pericarditis). Myocardial & pericardial involvement was also associated with greater degrees of peripheral eosinophilia -myocardial: 47, 18% vs no myocardial: 34, 20% of total WCC; p=0.0002 & pericardial: 47, 16% vs no pericardial 34, 20% of total WCC; p=0.0004. Patients with myocardial involvement with EGPA were less likely to be ANCA positive (24.5% versus 48.3%; p=0.002). ANCA positivity in those with pericardial involvement was 31.0% versus those without pericardial involvement 46.0%, p=0.077). Patients with myocardial involvement were less likely to have peripheral nerve involvement (a vasculitic manifestation) (52.1%) than those without cardiac involvement (77.7%; p=0.0008) but more likely to have pulmonary infiltrates/eosinophilic pneumonia (likely an eosinophilic manifestation) (70.8%) versus (49.4; p=0.0008). Cardiac involvement was associated with lower all-cause mortality over 10 years of follow-up (Hazard ratio 0.38 (0.15-0.98); p=0.03).CONCLUSIONS: In a large single-center series, both myocardial and pericardial involvement was common in EGPA and was associated with higher degrees of peripheral eosinophilia and the prevalence of eosinophilic pneumonia. A positive ANCA and peripheral nerve involvement were less common in those with myocardial and pericardial involvement.CLINICAL IMPLICATIONS: These findings may have implications for diagnosis, management including targeted treatment strategies of EGPA patients with cardiac involvement.DISCLOSURES: no disclosure on file for alvise berti;No relevant relationships by Garvan Kanepharmaceutical drug trial site invest. relationship with GSK Please note: $1-$1000 by Karina Keogh, value=Travelmonograph relationship with BMJ Please note: $1-$1000 by Karina Keogh, value=Honoraria SESSION TITLE: Airways Function Measurement and Treatment Outcomes SESSION TYPE: Rapid Fire Original Inv PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm PURPOSE: Eosinophilic Granulomatosis with Polyangiitis (EGPA) is a rare systemic disease characterized by asthma, peripheral & tissue eosinophilia & systemic vasculitis. Cardiovascular manifestations have been reported in prior studies, but the prevalence & spectrum of cardiac and vascular disease in EGPA is poorly understood. METHODS: The medical records were reviewed of a series of patients with EGPA who were evaluated from 1990-2021. For inclusion, patients had to fulfill standardized criteria for EGPA. Cardiac involvement was attributed to EGPA if findings could not be explained by other coexisting conditions. RESULTS: Two hundred and nineteen patients with EGPA were identified. The mean age at diagnosis was 52.16 years. 108 (49.3%) were female. Eighty-three (38%) had evidence of cardiac involvement. 49 (22.4%) had myocardial dysfunction. 6 (3%) with intra-cavitary cardiac thrombus; 22 (10%) with valvular involvement. 42 (19.2%) had pericardial disease (8 with tamponade and 1 with chronic constrictive pericarditis). Myocardial & pericardial involvement was also associated with greater degrees of peripheral eosinophilia -myocardial: 47, 18% vs no myocardial: 34, 20% of total WCC; p=0.0002 & pericardial: 47, 16% vs no pericardial 34, 20% of total WCC; p=0.0004. Patients with myocardial involvement with EGPA were less likely to be ANCA positive (24.5% versus 48.3%; p=0.002). ANCA positivity in those with pericardial involvement was 31.0% versus those without pericardial involvement 46.0%, p=0.077). Patients with myocardial involvement were less likely to have peripheral nerve involvement (a vasculitic manifestation) (52.1%) than those without cardiac involvement (77.7%; p=0.0008) but more likely to have pulmonary infiltrates/eosinophilic pneumonia (likely an eosinophilic manifestation) (70.8%) versus (49.4; p=0.0008). Cardiac involvement was associated with lower all-cause mortality over 10 years of follow-up (Hazard ratio 0.38 (0.15-0.98); p=0.03). CONCLUSIONS: In a large single-center series, both myocardial and pericardial involvement was common in EGPA and was associated with higher degrees of peripheral eosinophilia and the prevalence of eosinophilic pneumonia. A positive ANCA and peripheral nerve involvement were less common in those with myocardial and pericardial involvement. CLINICAL IMPLICATIONS: These findings may have implications for diagnosis, management including targeted treatment strategies of EGPA patients with cardiac involvement. DISCLOSURES: no disclosure on file for alvise berti; No relevant relationships by Garvan Kane pharmaceutical drug trial site invest. relationship with GSK Please note: $1-$1000 by Karina Keogh, value=Travel monograph relationship with BMJ Please note: $1-$1000 by Karina Keogh, value=Honoraria

Feasibility of blood speckle imaging parameters as predictors of intracavitary thrombus in apical aneurysm

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In patients with apical aneurysm, left ventricular thrombus (LVT) is a major complication associated with systemic embolism. Likely, abnormalities in apical wall contraction produce stagnant flow which leads to the thrombus formation. Currently, there is a lack of knowledge about predictors of thrombus in such patients. However, new imaging techniques might be able to identify flow properties useful for risk stratification. Specifically, blood speckle imaging (BSI), a technology based on high-frame rate ultrasound, is a promising pattern-matching technique that could allow a comprehensive assessment of blood flow in patients with apical aneurysms (1,2). Purpose The aim of the study was to demonstrate the feasibility of obtaining quantitative and qualitative measurements with BSI in patients with apical aneurysms and to explore which parameters may be associated with LVT. Methods We examined cases of patients with apical aneurysm and LVT studied in our tertiary center. In order to exclude from our analysis the pro-inflammatory effects of the acute event, patients with thrombus formation within the first month after the ischemic event were excluded. Patients with current presence of thrombus were also discarded. A control group of patients with apical aneurysm but without history of LVT was included. A basic 2-dimensional echocardiography study was obtained, along with BSI images. BSI acquisitions were performed with a 29 cm/s (2.5 mHz) scale. Data regarding vortex flow were collected, including its presence, area, length, besides area without BSI vectors (Image 1). All measures were indexed by telediastolic left ventricular volume. Results Eight patients with apical aneurysms were enrolled in the study, four of them with history of LVT. Although in patients with history of thrombus a larger vortex area was found (Table 1), none of the differences in the BSI parameters was statistically significant. Conclusion This study shows for the first time the feasibility of BSI for characterizing complex flow patterns such as vortex in patients with apical aneurysms. Explorations in larger cohorts of patients are needed to prove significant findings with this technology in the future. Abstract Figure. Image 1 Abstract TABLE 1

Association of left ventricular abnormalities with incident cerebrovascular events and sources of thromboembolism in patients with chronic Chagas cardiomyopathy

BackgroundAlthough Chagas cardiomyopathy is related to thromboembolic stroke, data on risk factors for cerebrovascular events in Chagas disease is limited. Thus, we assessed the relationship between left ventricular (LV) impairment and cerebrovascular events and sources of thromboembolism in patients with Chagas cardiomyopathy.MethodsThis retrospective cohort included patients with chronic Chagas cardiomyopathy who underwent cardiovascular magnetic resonance (CMR). CMR was performed with a 1.5 T scanner to provide LV volumes, mass, ejection fraction (LVEF), and myocardial fibrosis. The primary outcome was a composite of incident ischemic cerebrovascular events (stroke or transient ischemic attack—TIA) and potential thromboembolic sources (atrial fibrillation (AF), atrial flutter, or intracavitary thrombus) during the follow-up.ResultsA total of 113 patients were included. Median age was 56 years (IQR: 45–67), and 58 (51%) were women. The median LVEF was 53% (IQR: 41–62). LV aneurysms and LV fibrosis were present in 38 (34%) and 76 (67%) individuals, respectively. The median follow-up time was 6.9 years, with 29 events: 11 cerebrovascular events, 16 had AF or atrial flutter, and two had LV apical thrombosis. In the multivariable model, only lower LVEF remained significantly associated with the outcomes (HR: 0.96, 95% CI: 0.93–0.99). Patients with reduced LVEF lower than 40% had a much higher risk of cerebrovascular events and thromboembolic sources (HR: 3.16 95% CI: 1.38–7.25) than those with normal LVEF. The combined incidence rate of the combined events in chronic Chagas cardiomyopathy patients with reduced LVEF was 13.9 new cases per 100 persons-year.ConclusionsLV systolic dysfunction is an independent predictor of adverse cerebrovascular events and potential sources of thromboembolism in patients with chronic Chagas cardiomyopathy.

Biocompatibility of an apical ring plug for left ventricular assist device explantation: Results of a feasibility pre-clinical study.

Patients receiving left ventricle assist devices (LVADs) as bridge to recovery remain a minority with 1%-5% of LVADs explanted after improvement of myocardial function. Nevertheless, considering the growing population of patients supported with LVADs, an increasing demand of new explantation strategies is expected in the near future. A novel plug for LVAD explantation has been developed and its biocompatibility profile needs to be proved. This study tested the biocompatibility of this novel plug in an in vivo ovine model. Six adult Blackhead Persian female sheep received plug implantation on the cardiac apex via minimally invasive approach and were clinically observed up to 90days. Echocardiography was performed to detect thrombus formation or further plug-related complications. After the observation period, euthanasia was performed and samples including the plug and the surrounding tissues were obtained to be analyzed with correlative light and electron microscopy. Organ necrosis, ischemia and peripheral embolism were investigated. Three animals survived surgery and completed the follow-up time without experiencing clinical complications. Echocardiographic controls excluded the presence of an intracavitary thrombus in the left ventricle (LV). Autopsy confirmed no signs of local infection, LV thrombus or peripheral embolism. Light and electron microscopy revealed an intact epithelium covering a layer of connective tissue on the plug surface facing the heart lumen. This novel apical plug for LVAD explantation allows for endothelial and connective tissue growth on its ventricular side within 90days from surgery. Further studies are required to fully demonstrate the biocompatibility of this apical plug and investigate the optimal anticoagulation regimen to be applied after implantation.

453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Abstract Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

A New Vision at the Interface of Atrial Fibrillation and Stroke.

Introduction: Current evidence questions the linear sequence traditionally described in atrial fibrillation, blood stasis, intracavitary thrombus, and embolization to the central nervous system. Currently, new perspectives have been described based on questions from the linearly traditional chronology of events; it is within this scope that the article has its objective.Evidences: The association of the two entities is biologically plausible and supported by different cohorts with a higher risk of developing atrial fibrillation, especially in the cardioembolic form. Concepts (temporal dissociation, biological gradient, etc.) determine the existence of other factors associated with cardioembolism, not exclusively by atrial fibrillation. The entire cascade of events associated with myopathy and atrial remodeling can generate damage to the myocyte and amplify the prothrombotic status. It is important to clarify that atrial myopathy can present itself as atrial fibrillation initially or not, but should always be considered thrombogenic in all the contexts of their clinical presentation. Considering atrial heart disease as a cause of embolic stroke, it could explain that one-third of strokes are considered cryptogenic.Conclusions: The traditional model exclusively associating the presence of atrial fibrillation in the genesis of thromboembolism is incomplete. The concept of atrial cardiopathy where cardioembolism occurs in a non-atrial fibrillation dependent manner fits better with current data. The future challenge is to effectively detect the various manifestations of atrial heart disease, generating direct implications for the identification of patients at risk of stroke and also for better management after a cardioembolic event.

Successful systemic fibrinolysis in a patient with Covid- 19: Case report

The new coronavirus 2019-nCov or SARS-Cov-2 is responsible for the most important pandemic in the 21st century: the coronavirus disease (COVID-19).
 The 2019-nCov infection elicits a hyper-coagulable state, conditioning a worse outcome in these patients. The pathophysiology of the exaggerated coagulation activation in these patients is still unknown, and probably involves several mechanisms, different from those involved in sepsis-associated coagulopathy.
 This article discusses the case of a patient with no remarkable medical history, who after 7 days of fever, diarrhea and epigastric pain was diagnosed with COVID-19 bilateral pneumonia, further aggravated by severe Acute Respiratory Distress Syndrome. In this context, the patient experienced a massive acute pulmonary thromboembolism accompanied by an acute thrombus in the heart’s right ventricle, leading to hemodynamic instability. For the first time in our center in these patients, systemic fibrinolysis was successfully performed, with resolution of the intracavitary thrombus and the acute hemodynamic shock.

Clinical, electrical and echocardiographic profile of the association of stroke and congestive heart failure: About 344 cases

Congestive heart failure (CHF) is a leading cause of death and a major health problem accross the world. The incidence is increasing with the aging og population. CHF and stroke share the same risk factors, particularly hypertension and atrial fibrillation. The objective of this study is to investigate the clinical, electrical and echocardiographic profile of CHF patients with stroke. It is a transversal retrospective study conducted between May 2006 and June 2019 including all patients beyond the age of 14 with CHF and diabetes followed-up in the therapeutic unit of heart failure of our department. The data were collected on Excel and analyzed using SPSS 2.0 software. We studied the profile of CHF patients with stroke. 344 patients were collected (10% of all CHF patients). Mean age was 68,85 ± 12,60 years, male predominance (66,9%). The main cardiovascular risk factor was hypertension (46,5%), smoking in 40,1% and diabetes in 32,8%. The leading cause of CHF was ischemic heart disease in 76,4%, valvular heart disease in 15,5%, dilated cardiomyopathy in 5,5%. Permanent atrial fibrillation was present in 17,3% of cases. Mean LVEF was 36,27 ± 10,61% with no statistical difference with CHF patients without stroke (P = 0.057). The left ventricle was dilated in 76,7%, 2% of patients had an intra-cavitary thrombus. 53,8% of patients were anticoagulated. CHF and stroke share the same risk factors. CHF with reduced LVEF is at risk of stroke. Secondary prevention may improve the prognosis and the benefit of anticoagulation is still controversial.

Acute Pulmonary Embolism, Multiple Coronary Thrombosis, and Thrombi in the Left Ventricle and Ascending Aorta in a Patient with COVID-19 Infection

Both arterial and venous thromboembolic events are common in patients hospitalized in intensive care units with severe COVID-19. These patients often have laboratory findings consistent with a hypercoagulable state, suggesting widespread thrombosis and fibrinolysis, as well as elevated levels of D-dimer, von Willebrand factor (VWF), and factor VIII. There is increasing evidence that these thromboembolic events are associated with worse outcomes. We present the case of a 61-year-old man admitted for bilateral pneumonia due to COVID-19 infection, who developed during his hospitalization; Bilateral pulmonary thromboembolism, an acute myocardial infarction due to multiple coronary thrombosis, an intracavitary thrombus and thrombus in the ascending aorta. The patient was treated with systemic fibrinolysis and full doses of anticoagulation for pulmonary embolism, an emergency primary percutaneous coronary intervention (PCI) was performed with the implant of a drug eluting stent (DES) in the left anterior descending artery (LAD). Triple therapy with aspirin, clopidogrel and heparin was maintained until discharge. After the patient discharge, aspirin was stopped and treatment with clopidogrel and dabigatran was maintained for three months. In a subsequent outpatient control, the thrombi of the left ventricle and the ascending aorta resolved.

Prevalence of LAA thrombus in patients undergoing percutaneous ablation of atrial fibrillation

Abstract Introduction Computed tomography (CT) is often performed before atrial fibrillation (AF) ablation to assess the anatomy of the pulmonary veins and exclude left atrial (LA) and left atrial appendage (LAA) thrombus. With the growing use of new oral anticoagulants (NOACs), a reassessment of the need for systematic thrombus exclusion in this context seems warranted. Objective To evaluate the prevalence of thrombus in LA/LAA in pre-ablation CT in a contemporary cohort of patients predominantly anticoagulated with NOACs. Methods We evaluated 789 consecutive patients (mean age 61±12 years; 38% female; 84% with paroxysmal AF) who underwent pre-ablation CT between Oct/2015 and Oct/2019. ECG-gated CT-angiography was performed using a dual-source 64-slice CT after iodinated contrast injection. Whenever necessary, a second dedicated acquisition was made 60 seconds after the first set of images. Presence of thrombus was defined as a persistent opacification defect. For each patient, thromboembolic risk was assessed with the CHA2DS2-VASc score. Results The median interval between CT and AF ablation was 1 day (IQR 1 – 2 days). The median CHA2DS2-VASc was 2 points (IQR 0 – 3 points), with 590 patients (75%) having CHA2DS2-VASc ≥1. Among the 199 patients (25%) with CHA2DS2-VASc = 0, 118 (59,3%) were anticoagulated with a NOAC and 14 (7%) with a vitamin K antagonist; 67 (34%) were not anticoagulated. Conversely, amongst the 590 patients with CHA2DS2-VASc ≥1, 84% were anticoagulated with a NOAC (n=494), 11% used vitamin K antagonists (n=62), and 34 patients were not anticoagulated (23 with CHA2DS2-VASc = 1). On cardiac CT, 521 (66%) patients were in sinus rhythm. Overall, only one LAA thrombus was found (0.12% [1/789]; 95% CI: 0.0–0.7%) – in a patient with CHA2DS2-VASc = 0, anticoagulated with a NOAC. The median effective radiation dose was 3.2 mSv (IQR 2.1–4.8 mSv). There were 5 minor allergic reactions to iodinated contrast. No strokes were documented within the first 24 hours after ablation. Conclusion In this contemporary cohort of patients with predominantly paroxysmal AF and anticoagulated with NOAC, the prevalence of intracavitary thrombus was extremely low (0.12%). While these findings do not compromise the multipurpose role of pre-ablation CT, they should nevertheless inform future discussions on the risk/benefit and cost/benefit of performing systematic exclusion of LA/LAA thrombi prior to AF ablation. Funding Acknowledgement Type of funding source: None

The Clinical Value of no-Reflow Phenomenon in the Routing Operation of The Regional Vascular Center

Coronary no-reflow phenomenon (CNR) is a complication of primary percutaneous coronary intervention (PCI). According to different reports, CNR occurs in 10 to 60 % of cases. Despite the long history of studying this phenomenon many issues remain unsolved. This article presents a clinical case of electrocardiographically confirmed ST-segment elevation myocardial infarction. In this case, the CNR phenomenon occurred during PCI and was associated with heart rhythm disorders, left ventricular (LV) cavity dilatation with a decrease in LV contractility, and formation of intracavitary thrombus. The patient asked for medical care late, which could influence the development of CNR. This case demonstrates the clinical significance, diagnostic characteristics, and successful drug correction of the no-reflow phenomenon.

P1242 Giant right atrium aneurysm presenting as right heart failure

Abstract Introduction Idiopathic aneurysmal dilatations of the right atrium are rare anomalies. It can be diagnosed at any time between foetal and adult life. This exceptional condition can be confused with other conditions that involve enlargement of right atrium. We report a clinical case of a symptomatic adult who was diagnosed with giant right atrium aneurysm. Case report An 83-year-old female presented with complaints of fatigue, paroxysmal nocturnal dyspnoea, exertional dyspnoea, orthopnoea and cough since last week. There were no history of syncope, convulsions or evidence of thromboembolism. There were a medical history of diverticulosis and atrial fibrillation (warfarin therapy). The principal findings on physical examination included holosystolic murmur at the left middle sternal border, pulmonary rales, jugular venous distension, enlarged liver and peripheral oedema. An electrocardiogram showed an atrial fibrillation with a controlled heart rate response, right axis deviation, right bundle-branch block. A chest radiography posteroanterior view showed a markedly enlarged cardiac silhouette, increased pulmonary vascular congestion, and bilateral pleural effusions. Computed tomography (CT) scan showed aneurysmal dilated right atrium communicating with right ventricle. Right ventricle (RV) and RV outflow tract were dilated with normal pulmonary arteries. Two-dimensional transthoracic echocardiography revealed aneurysmal dilated right atrium measuring 398mL/m2. The tricuspid valve was no displaced. There was severe tricuspid regurgitation and no stenosis. The right atrium was kinetic without any intracavitary thrombus. The intertrial and interventricular septa were intact. The right ventricle and outflow tract were mildly dilated with preserved systolic function. The left atrium and left ventricle were normal. The patient was admitted to the cardiology department with the diagnosis of right heart failure. Conclusion Aneurysm of right atrium is an uncommon condition. It is diagnosed as a disproportionately enlarged right atrium compared to the other cardiac chambers in the absence of other cardiac or hemodynamic abnormalities and must be distinguished from other anomalies causing structural pathology of the right atrium. Approximately, one-half of the patients have no symptoms. Others presented with arrhythmia, palpitations, chest pain, shortness of breath, and fatigue. The major rhythm abnormality is atrial fibrillation or atrial flutter. Our patient presented with symptoms of right heart failure and atrial fibrillation. The right enlargement is usually associated with tricuspid annular dilatation responsible for functional regurgitation, which can be severe in some cases. The diagnosis of right atrium malformation can be established by echocardiography, CT or magnetic resonance imaging. Literature reports various ways to manage these patients. Treatment ranges from conservative to surgical resection specially in the presence of arrhythmias. Abstract P1242 Figure. Aneurysm of right atrium

P626 Peripartum cardiomyopathy with persistent ventricular dysfunction and intracavitary thrombosis despite treatment with dopamine receptors agonist. The role of the three-dimensional echocardiography

Abstract Introduction Peripartum cardiomyopathy (MPP) is a type of cardiomyopathy characterized by heart failure secondary to left ventricular systolic dysfunction during the last month of pregnancy or in the first 5 months of puerperium without other apparent etiology, being a diagnosis of exclusion. The left ventricle is not always dilated, but the fraction of left ventricular ejection is always less than 45%. The natural history and prognosis of the disease is diverse. Ventricular dysfunction is usually transient and normalizes at 3-6 months in up to 60% of cases. Mortality is variable, with reports ranging from 0 to 28%, affecting more certain ethnic groups, in patients with persistent ventricular dysfunction, evidence of the efficacy of a specific treatment beyond optimal medical therapy for heart failure is limited. Clinical case We present the clinical case of a 22-year-old woman, who was referred to the our institute with an acute heart failure syndrome two months after the end of her first pregnancy. On admission to the hospital, dilated cardiomyopathy and intracavitary thrombi were documented by transthoracic echocardiography (TTE) with dilatation and eccentric left ventricular hypertrophy, generalized hypokinesia and mobile thrombi inside, the largest of 34x16mm with severe left ventricular dysfunction 3D LVEF of 28% and global longitudinal strain (GLS) of -5.8%, pulmonary hypertension and right ventricular dysfunction with severe functional tricuspid regurgitation. Other specific etiologies of dilated cardiomyopathy were investigated and discarded, finally establishing the diagnosis of peripartum cardiomyopathy. The support management was carried with inotropic, diuretic, supplemental oxygen and parenteral anticoagulation was initiated, with gradual improvement. Subsequently, optimal medical treatment was started for heart failure, cabergoline and vitamin K antagonist. He was released to his home on II NYHA. Two months later she presented with progressive dyspnea, increased abdominal perimeter. On March 14, 2018, a TTE was performed, with absence of improvement in conventional and advanced ventricular function parameters. Apical thrombi of smaller size compared with previous study, severe left ventricular dysfunction, which worsened with respect to the previous echocardiogram, with 3D LVEF of 25% and GLS 3.7% Discussion We present the case of a woman with MPP, in whom persistent left ventricular dysfunction after 6 months of diagnosis, although cabergoline scheme in addition to optimal medical management for heart failure, with no improvement. In patients who dont present an adequate response to the management, it is necessary to consider enlisting for heart transplantation. Abstract P626 Figure. TTE, severe ventricular dysfunction

P1373 Cardiac source of embolism diagnosed by transeophageal echocardiography - what to expect in nowadays clinical practice

Abstract Background Transeophageal echocardiography (TEE) is an essential tool to diagnose cardiac source of embolism (CSE) and to define treatment approach. Purpose: To review the identified CSE in 25 years experience in TEE at a tertiary centre. Methods: Retrospective study of consecutive patients (pts) who underwent TEE to search for CSE, from 1994 to 2019. Results: 2936 pts (55% males, mean age 53 ± 13 years). Ischemic cerebral event (96%) was the main location of embolism. TEE identified potential CSE in 41.5% and 7% had more than one diagnostic. The most frequent CSE were patnt foramen ovale (PFO) (16.3%) and atrial septal aneurysm (ASA), among these 65% had concomitant PFO or atrial septal defect (ASD) (14.1%). Aortic plaques ≥ 4mm were noted in 9.6%, followed by valve disease or prosthesis (5.4%), intracavitary thrombi (3.9%), vegetations (1.6%), ASD (1.5%), dilated cardiomyopathy (1.4%) and tumors (0.7%). In the last 15 years, the diagnostic effectiveness increased (35.6% vs 45.95%) and there was a shift in etiologies with an increased in the diagnose of PFO/ASD (26.8% vs 38.5%) and valve disease or prosthesis became less frequent (29.9% vs 3.7%). Overall, in elderly pts there was a preponderance of atherosclerotic plaques in the aorta, contrasting with younger pts who presented a predominance of PFO (Table1). The prevalence of spontaneous echo contrast increased with age. Pts with ischemic cerebral event were younger, mostly male and PFO was the main source of embolism (17%), while in pts with peripheral embolism the most frequent etiologies were intracavitary trombi (16%) and aortic plaques ≥ 4mm (14%). Conclusion: The main cause to perform a TEE to search for CSE was cerebral embolism, with a diagnostic effectiveness overall of 41.5%, that increased in the last 15years. Table 1 Characteristics <50 years (n = 1191) 50-75 years (n = 1569) ≥75 years (n = 171) Male (%) 601 (50%) 931 (59%) 80 (47%) Atrial septal defect (%) 23 (2%) 20 (1%) 0 Patent foramen ovale (%) 239 (20%) 226 (14%) 12 (7%) Atrial septal aneurysm (%) 70 (6%) 130 (8%) 13 (8%) Vegetations (%) 8 (0.7%) 29 (2%) 9 (5%) Tumors (%) 10 (0.8%) 8 (0.5%) 4 (2%) Intracavitary trombi (%) 28 (2%) 74 (5%) 14 (8%) Aortic plaque ≥4mm (%) 31 (3%) 203 (13%) 48 (28%) Valve disease or prothesis (%) 54 (4.5%) 109 (6%) 11 (6%) Spontaneous echo contrast (%) 36 (3%) 155 (10%) 32 (19%) Distribution of cardiac source embolism by age