Motion Of Mitral Valve Research Articles

Abstract 16368: Opioid Withdrawal-Induced Takotsubo Cardiomyopathy in Hypertrophic Cardiomyopathy

Introduction: This case highlights opioid withdrawal-induced Takotsubo cardiomyopathy (TCM) in a patient with pre-existing hypertrophic cardiomyopathy (HCM) and discusses the concurrent management. Clinical Presentation: An 85-year-old female with HCM, depression, and chronic back pain presented with generalized weakness five days after opioid discontinuation. She exhibited elevated troponin levels and ST elevation in anteroseptal leads, concerning for STEMI. Coronary angiogram revealed nonobstructive coronary artery disease. Transthoracic echocardiogram revealed newly reduced EF 45%, hyperdynamic basal left ventricle, and akinetic mid-distal left ventricle, consistent with TCM. Notably, marked basal anteroseptum thickness and systolic anterior mitral valve motion with left ventricular outflow tract obstruction (LVOTO) and a peak gradient of 92 mmHg. Presentation was complicated by hypotension, pulmonary edema and cardiorenal syndrome. β-blocker use initially deferred, opting for phenylephrine and diuresis until stabilization permitted β-blocker introduction. Discussion: We present a unique case of TCM precipitated by opioid withdrawal in a patient with existing HCM. Standard critical care management for TCM involves hemodynamic support until cardiac function recovers, though the use of vasopressors and inotropes remains controversial. Importantly, this case demonstrates severe provoked LVOTO, mimicking acute myocardial ischemia. Recognizing such scenarios is vital, as inappropriate use of vasodilators or inotropes can be fatal. Class I-IIa recommendations endorse β-blockers and vasoconstrictors for severe provoked LVOTO with hypotension and pulmonary edema. Phenylephrine, a selective α-agonist, maintains LVOT turgidity through preload enhancement, while β-blockers facilitate ventricular filling and reduce LVOT pressure gradient. Further research is warranted as current evidence level remains class C.

Cardiac masses and the role of imaging in their diagnostic

Abstract Objectives Myxomas are the most common primary tumors of the adult heart and should be considered in the differential diagnosis of intracavitary cardiac masses, along with thrombi and vegetations. Methods We report a case of a 64-year-old obese, hypertensive woman, who presented with dyspnea on moderate exertion as well as fatigue. The patient was admitted to our hospital after the discovery on transthoracic echocardiography of an intracardiac mass, which was highly suggestive for a left atrial myxoma. Results On admission, the patient presents no abnormalities on physical exam, with blood tests showing only slight deviations in the lipid profile. The ECG presents a normal sinus rhythm of 80/min with two premature ventricular contractions and a premature atrial contraction. Transthoracic echocardiography revealed the presence of a well-defined, pediculated, left atrial mass attached to the interatrial septum, measuring 25/17 mm, with no apparent interference in mitral valve motion. We supplemented our investigations with the use of transesophageal echocardiography which further defined the dimensions and location of the tumor, while also showing the presence of an atrial septal aneurysm associated to two small atrial septal defects measuring 6 mm and 7 mm respectively, with a left to right shunt. Cardiac CT examination confirmed the benign aspect of the mass and offered important anatomical elements, useful in preoperative planning. The patient was, therefore, admitted to our Cardiovascular Surgery department, where a successful surgical resection of the tumor was performed, without any local or systemic complications. The differential diagnosis of this mass included intracavitary thrombi, vegetations, as well as other histological subtypes of benign or malignant tumors, while the presence of an atrial septal defect, which represents a possible source of paradoxical emboli, provided an additional challenge. Conclusions This complicated case stands out due to its particular echocardiographic appearance and emphasizes the importance of a comprehensive evaluation in both the differential diagnosis and preoperative assessment.

A Pilot Study Evaluating LV Diastolic Function with M-Mode Measurement of Mitral Valve Movement in the Parasternal Long Axis View.

This pilot study aimed to develop a new, reliable, and easy-to-use method for the evaluation of diastolic function through the M-mode measurement of mitral valve (MV) movement in the parasternal long axis (PSLA), similar to E-point septal separation (EPSS) used for systolic function estimation. Thirty healthy volunteers from a tertiary emergency department (ED) underwent M-mode measurements of the MV anterior leaflet in the PSLA view. EPSS, A-point septal separation (APSS), A-point opening length (APOL), and E-point opening length (EPOL) were measured in the PSLA view, along with the E and A velocities and e' velocity in the apical four-chamber view. Correlation analyses were performed to assess the relationship between M-mode and Doppler measurements, and the measurement time was evaluated. No significant correlations were found between M-mode and Doppler measurements in the study. However, M-mode measurements exhibited high reproducibility and faster acquisition, and the EPOL value consistently exceeded the APOL value, resembling the E and A pattern. These findings suggest that visually assessing the M-mode pattern on the MV anterior leaflet in the PSLA view may be a practical approach to estimating diastolic function in the ED. Further investigations with a larger and more diverse patient population are needed to validate these findings.

Turbulent blood dynamics in the left heart in the presence of mitral regurgitation: a computational study based on multi-series cine-MRI.

In this work, we performed a computational image-based study of blood dynamics in the whole left heart, both in a healthy subject and in a patient with mitral valve regurgitation. We elaborated multi-series cine-MRI with the aim of reconstructing the geometry and the corresponding motion of left ventricle, left atrium, mitral and aortic valves, and aortic root of the subjects. This allowed us to prescribe such motion to computational blood dynamics simulations where, for the first time, the whole left heart motion of the subject is considered, allowing us to obtain reliable subject-specific information. The final aim is to investigate and compare between the subjects the occurrence of turbulence and the risk of hemolysis and of thrombi formation. In particular, we modeled blood with the Navier-Stokes equations in the arbitrary Lagrangian-Eulerian framework, with a large eddy simulation model to describe the transition to turbulence and a resistive method to manage the valve dynamics, and we used a finite element discretization implemented in an in-house code for the numerical solution.

786 SYSTOLIC ANTERIOR MOVEMENT OF MITRAL VALVE: NOT ONLY HYPERTROPHIC CARDIOMYOPATHY, BUT ALSO CARDIAC AMYLOIDOSIS

Abstract A 71 years-old man was diagnosed with lambda light chain multiple myeloma evolving from monoclonal gammopathy of unknown significance during hematological follow-up. Serum creatinine and blood urea were normal, but proteinuria was significant. A subsequent renal biopsy showed amyloid deposits in renal glomeruli. He had no comorbidities or previous cardiologic history. To provide a complete diagnostic work-up, an echocardiogram was performed, showing marked and asymmetric left ventricular hypertrophy (interventricular septum diastolic thickness IVSd 15 mm) with dynamic left ventricular outflow tract obstruction (LVOTO) due to an incomplete systolic anterior motion (SAM) of mitral valve. ECG showed sinus rhythm with 1st degree atrio-ventricular block; notably, there was no electrocardiographic sign of left ventricular hypertrophy. Therefore, a Cardiac Magnetic Resonance (CMR) was performed, showing left ventricular hypertrophy (interventricular septum thickness 15 mm) with normal contractility. Mild left atrial enlargement and thickening of the interatrial septum were found, together with mild circumferential pericardial effusion. No perfusion defects were recorded, but late gadolinium enhancement (LGE) pattern was not assessable because of difficult myocardial signal nulling point. These findings were consistent with cardiac amyloidosis (CA). By the time, histological demonstration of amyloid was mandatory, so an endomyocardial biopsy was performed. Amyloid deposits were found to be in the myocardial interstitial space and into the myocardial vessel walls. Immunohistochemical staining revealed diffuse and high reactivity for lambda free light chains and moderate reactivity for kappa chains. No transthyretin was found in the specimens. Finally, a diagnosis of AL amyloidosis with cardiac and renal involvement associated with lambda light chain multiple myeloma was made and chemotherapy with bortezomib, thalidomide and dexamethasone (VTD) was started. During the cardiologic follow-up, three syncope with prodromal symptoms have occurred. In all these circumstances, no arrhythmias were found at prolonged ECG Holter monitoring. Echocardiogram showed a progression of the dynamic outflow obstruction to 80 mmHg and increasing mitral regurgitation associated with complete systolic anterior motion of the valve. Given the echocardiographic features and the clinical events, we performed a genetic blood test which excluded sarcomeric genes mutations. Also, familial screening with ECG and echocardiogram was negative. A better management of pharmacological therapy, together with avoidance of hypovolemia and supportive treatment of anemia finally relieved patient's symptoms. Conclusions we presented this case to underline that, although rare, cardiac amyloidosis can resemble other hypertrophic cardiomyopathies with left ventricular outflow tract obstruction due to SAM of the mitral valve and irregular septal hypertrophy, caused by amyloid deposits. Most of these cases are seen in the senile transthyretin type, but sometimes they are observed in AL patients. Nowadays, it is crucial to diagnose these patients correctly as early treatment is critical for survival in this population.

Transcatheter aortic valve implantation (TAVI) with zero contrast in patients with impairment of renal function. A single centre experience

Abstract Transcatheter aortic valve implantation (TAVI) represents nowaday a safe and effective alternative to traditional surgery for patients with high and intermediate surgical risk. However, the risk of contrast induced nephropathy still remains a major concern and a real challenge in patients with baseline chronic kidney disease (CKD). Aim of our new approach, has been to find a solution capable to reduce or contain the incidence of acute renal damage after TAVI caused by the use of contrast dye in CKD patients. In the last twelve months, out of 85 patients admitted to our Center for severe symptomatic aortic stenosis, addressed to TAVI, 18 patients (mean age: 81.8 years, NYHA class III) presented CKD with mean creatinine value: 2.39 mg/dl; GFR: 24.46 ml/min/1.73 m2. Three patients had previously undergone surgical revascularization with coronary artery bypass graft and in 3 cases we performed a valve-in-valve procedure for degeneration of valvular bioprostheses.They were selected for our zero contrast protocol; all these patients underwent pre-procedural chest and abdomen CT scan without dye, together with a Lower Limb Eco-Color Doppler scan.Coronary angiography had been carried out in a previous hospitalization. The valve size choice was determined after measurements of the CT scan and echo images (both two- and three-dimensions) were compared. Data obtained (valve perimeter, area and the two main valve diameters) were strongly similar with the two techniques, without significant differences. The new valve deployment was monitored under constant fluoroscopy and transesophageal (TOE) visualization. A single pig tail catheter was placed in the non coronary sinus to facilitate valve annulus localization on fluoroscopy. The TOE selected view for TAVI deployment was the mid esophageal long axis. Proper prosthesis positioning was determined by measuring the protruding portion through the left ventricle outflow tract, and prevent possible impairment of diastolic mitral valve movement. In 17 cases a transfemoral percutaneous approach was used and only in one case surgical isolation of the right carotid artery was necessary due to the occlusion of every other peripheral access. Four patients needed a post implant dilatation for significant residual left ventricle/aortic gradient. All patients underwent the TAVI procedure successfully. In the post-TAVI phase, two patients underwent definitive PM implantation for third degree atrioventricular block despite adequately high implantation of the valve.At discharge, mean creatinine value was 1.9 mg/dl and mean GFR was 32.2 ml/min/1.73 m2. All patients survived the procedure and were discharged alive, after a further mean Hospital stay of four days. In conclusion, TAVI zero contrast is a safe, feasible and winning procedure to consider in patients with severely impaired renal function. Funding Acknowledgement Type of funding sources: None.

Fluid structure computational model of simulating mitral valve motion in a contracting left ventricle

Background:Fluid structure interaction simulations h hold promise in studying normal and abnormal cardiac function, including the effect of fluid dynamics on mitral valve (MV) leaflet motion. The goal of this study was to develop a 3D fluid structure interaction computational model to simulate bileaflet MV when interacting with blood motion in left ventricle (LV). Methods:The model consists of ideal geometric-shaped MV leaflets and the LV, with MV dimensions based on human anatomical measurements. An experimentally-based hyperelastic isotropic material was used to model the mechanical behaviour of the MV leaflets, with chordae tendineae and papillary muscle tips also incorporated. LV myocardial tissue was prescribed using a transverse isotropic hyperelastic formulation. Incompressible Navier–Stokes fluid formulations were used to govern the blood motion, and the Arbitrary Lagrangian Eulerian (ALE) method was employed to determine the mesh deformation of the fluid and solid domains due to trans-valvular pressure on MV boundaries and the resulting leaflet movement. Results:The LV–MV generic model was able to reproduce physiological MV leaflet opening and closing profiles resulting from the time-varying atrial and ventricular pressures, as well as simulating normal and prolapsed MV states. Additionally, the model was able to simulate blood flow patterns after insertion of a prosthetic MV with and without left ventricular outflow tract flow obstruction. In the MV–LV normal model, the regurgitant blood flow fraction was 10.1 %, with no abnormality in cardiac function according to the mitral regurgitation severity grades reported by the American Society of Echocardiography. Conclusion:Our simulation approach provides insights into intraventricular fluid dynamics in a contracting LV with normal and prolapsed MV function, as well as aiding in the understanding of possible complications after transcatheter MV implantation prior to clinical trials.

Ecocardiographic comprehensive evaluation of OHCM patients treated with percutaneous ASA

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Alcohol septal ablation (ASA) has been widely accepted as an alternative to surgical myectomy in patients with symptomatic obstructive hypertrophic cardiomyopathy (OHCM) despite optimal medical treatment. The aim of this study was to analyse the effect of ASA on anatomical and functional features analysed by echocardiography, as well as its clinical impact. We further evaluated the safety of procedure. Methods and results Retrospective analysis of consecutive patients submitted to ASA (2009 – 2019) in a single tertiary centre. A dedicated echocardiogram was performed at 3 and 6 months after procedure. Echocardiographic primary endpoint was a > 50% reduction in left ventricular outflow tract (LVOT) gradient (the definition used for successful procedure). Echocardiographic secondary endpoint was improvement in mitral regurgitation. Clinical primary endpoint was defined as a combined endpoint of cardiac death or hospitalization during follow-up (FU). 110 patients were included, 66.4% women, mean age 65.1 ± 12.2 years. Functional class NHYA class III/IV, angina CCS class II/III and syncope were present in 87.3%, 52.7% and 10.0%, respectively. Baseline LVOT gradients at rest and at Valsalva manoeuvre were 93.6 ± 39.8 mmHg and 118.9 ± 44.2 mmHg. Maximum septal thickness was 21.0 ± 3.3 mm, 24.5% had moderate mitral regurgitation and 52.7% showed systolic anterior motion of mitral valve. During hospitalization for ASA, peak creatine kinase after procedure was 1306 ± 816 U/l. 17 (17.1%) patients required permanent PM due to induction of permanent complete heart block. There was one case of inferior myocardial infarction and one case of cardiac tamponade. Echocardiographic primary endpoint was achieved by 83.6% of patients. At 3 and 6-months follow up, LVOT gradients was significantly decreased in successful comparing with unsuccessful procedure group (24.6 ± 23.9 vs 82.0 ± 28.7 mmHg, p = 0.003 and 31.8 ± 34.5 vs 68.6 ± 27.8 mmHg, p = 0.027, respectively). There was no difference in baseline clinical or echocardiographic parameters between both groups. Regarding the echocardiographic secondary endpoint, among patients with moderate mitral regurgitation, 80% improved to mild regurgitation. A significant reduction in basal septal thickness was achieved in most patients, from 21.0 ± 3.3mm to 16.4 ± 2.7 mm after ASA (p = 0.001). During mean FU of 3.4 ± 2.1 years, clinical primary endpoint occurred in 25.5%, mainly in unsuccessful procedure group (50.0% vs 20.7%, p = 0.013). Reintervention was performed for recurrence of symptoms in 14 (12.7%) patients, surgical myectomy in 3 (3.6%) and repeated ASA in 10 (9.1%). Conclusion ASA allows a significant reduction in LVOT gradient and improvement of mitral regurgitation in the majority of patients with OHCM. Systematic and comprehensive echocardiographic evaluation assumes a paramount importance for the evaluation of procedural success. Abstract Figure.

Magnitude of mitral valve closure plays a pivotal role in enhancing the forward blood flow during cardiac massage in dogs with ventricular fibrillation.

Motion of mitral valve during cardiac massage was examined using beagle dogs with ventricular fibrillation (n=4). Active compression-decompression cardiac massage (ACD-CM) exhibited greater peak aortic pressure than standard cardiac massage (S-CM), reverse of which was true for peak pulmonary capillary wedge pressure in each animal. Accordingly, peak aortic pressure was greater than peak pulmonary capillary wedge pressure with ACD-CM, whereas its reverse was true with S-CM. Transesophageal echocardiography revealed that mitral valve was incompletely closed with S-CM with showing regurgitation. The valve was more effectively closed during ACD-CM. These results indicate that effective closure of mitral valve during cardiac massage may increase forward blood flow, supporting “cardiac pump theory” rather than “thoracic pump theory” as a principle in dogs.

Mid-Diastolic Events (L Events): A Critical Review.

Mid-diastolic events (L events) include three phenomena appreciable on echocardiography occurring during diastasis: mid-diastolic transmitral flow velocity (L wave), mid-diastolic mitral valve motion (L motion), and mid-diastolic mitral annular velocity (L’ wave). L wave is a known marker of advanced diastolic dysfunction in different pathological clinical settings such as left ventricle and atrial remodeling, overloaded states, and cardiomyopathies. Patients with L events have poor outcomes with a higher risk of developing heart failure symptoms and arrhythmic complications, including sudden cardiac death. The exact mechanism underlying the genesis of mid-diastolic events is not fully understood, just as the significance of these events in healthy young people or their presence at the tricuspid valve level. We also report an explicative case of a patient with L events studied using speckle tracking imaging of the left atrium and ventricle at the same reference heartbeat supporting the hypothesis of a post-early diastolic relaxation or a “two-step” ventricular relaxation for L wave genesis. Our paper seeks to extend knowledge about the pathophysiological mechanisms on mid-diastolic events and summarizes the current knowledge.

Edge-to-edge mitral valve repair in the surgical treatment of hypertrophic cardiomyopathy

Septal myectomy is the method of choice for treating symptomatic left ventricular outlet obstruction in patients with hypertrophic cardiomyopathy who are resistant to drug therapy. An important role in persistence, residual obstruction, mitral valve abnormalities and anterior systolic mitral valve movement is systolic anterior motion. Several authors have reported the use of edge-to-edge mitral valve repair in addition to septal myectomy in patients with mild septal hypertrophy. We performed a literature review on the surgical treatment of obstructive hypertrophic cardiomyopathy—mitral valve repair using the edge-to-edge technique with septal myectomy. Four retrospective studies and three clinical cases were analysed. The data of patients who underwent mitral valve repair surgery using the edge-to-edge technique with septal myectomy and had satisfactory long-term clinical and hemodynamic results were studied. This treatment technique should be considered in cases of unexpressed hypertrophy when isolated limited myectomy is insufficient to eliminate the left ventricular outlet or when there is a hemodynamically significant mitral insufficiency caused by anterior systolic movement of the mitral valve that increases the need for intervention on interventricular hypertrophy of the associated disease. Septal defect, plastic mitral valve, surgically significant residual mitral regurgitation and high residual left ventricular outflow gradients in long-term follow-up are feasible, safe and effective for anterior systolic mitral valve movement. Received 28 September 2020. Revised 23 March 2021. Accepted 25 March 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and study design: S.A. Budagaev, A.V. Afanasyev, A.V. Bogachev-ProkophievData collection and analysis: S.A. Budagaev, M.A. Ovchinnikova, A.N. Pivkin, I.I. DeminDrafting the article: S.A. Budagaev, A.V. AfanasyevCritical revision of the article: A.V. Bogachev-Prokophiev, D.A. AstapovFinal approval of the version to be published: S.A. Budagaev, A.V. Afanasyev, A.V. Bogachev-Prokophiev, M.A. Ovchinnikova, A.N. Pivkin, D.A. Astapov, I.I. Demin

MO079SOY PROTEINS PREVENT HEART REMODELING IN WISTAR RATS ON HIGH SODIUM CHLORIDE DIET

Abstract Background and Aims Increased salt intake has been linked to a number of poor effects, such as myocardial remodeling [1], independently of blood pressure level. Yet, many aspects of this remodeling are not well understood. The aim of the study was to find echocardiographic myocardial changes in Wistar rats on high sodium chloride (NaCl) diet, as well as to prove protective effects of diet, containing soy proteins. Method 28 male Wistar rats (age of 2.5-3.0 months) were enrolled in the observational prospective study (4 month) and subdivided into several groups. 1) Standard diet-Control group (C, n = 8, 20.16% protein of animal origin and 0.34% NaCl); 2) High salt diet (n = 10, 8% NaCl); 3) Low-protein diet (n=10, 10% soy protein (SUPRO 760) and 8% NaCl). Tail systolic blood pressure (BP) measurement, as well as echocardiographic examination were performed in anesthetized rats. Statistical analysis was performed with STATISTICA 10 software package. Fisher's LSD test was used. The significance level was <0.05. All data are presented as mean ± SEM. Results Keeping rats on a diet with 8% NaCl did not lead to significant changes in blood pressure (group 2 - 138.0 + 5.0, group 3 - 134.0 + 5.0 mm Hg), compared to C (135.0 + 5.0 mm Hg). On the contrary, left ventricle back wall width in rats of group 2 was significantly higher (1.83 ± 0.09 mm, p <0.02), than in C (1.49 ± 0.10 mm) or animals from group 3 (1, 47 ± 0.09mm). The values of end systolic left ventricle size, interventricular septum width, mitral valve systolic movement and tricuspid valve systolic movement in group 3 were significantly lower (1.67 ± 0.08 mm, 2.18 ± 0.13 mm, 2.70 ± 0.23 mm), than in group 2 (3.26 ± 0.33mm, p <0.037; 2.00 ± 0.12mm, p <0.043; 2.67mm ± 0.15, p <0.0124; 3.56 ± 0.34mm , p <0.0148, respectively). At the same time, left ventricular chamber size and thickness of interventricular septum did not differ significantly. In C animals, mitral valve movement (1.96 ± 0.09 mm; p <0.0008) and tricuspid valve movement (2.35 ± 0.07 mm; p<0.0012) were significantly lower than in rats of group 2 but not differed much from the values found in group 3. Conclusion High sodium containing diet does not necessarily lead to the development of arterial hypertension in Wistar rats, but may cause heart remodeling, while soy proteins counteracts the development of left ventricle hypertrophy, even in case of high sodium consumption.

Late gadolinium enhancement as a predictor of arrhythmias in patients with hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of arrhythmias and sudden cardiac death (SCD). The Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) has been associated with the occurrence of arrhythmic events. Purpose The aim was to analyze the association between LGE burden and location and arrhythmic events in HCM patients (P). Methods Retrospective analysis of P with HCM in a single tertiary center. Baseline clinical, echocardiographic and CMR characteristics were collected. On follow up arrhythmias (ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), non-sustained ventricular tachycardia (NSVT), paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation (AF) and atrial flutter (AFL)) were identified. LGE on CMR was compared between patients with and without arrhythmias. Results 61P (59% male) were included, with a mean age of 58 ± 2 years. The HCM risk-SCD score was 3.35 ± 0.28%. On echocardiography mean left ventricle ejection fraction was 62.16 ± 1.36% and maximum wall thickness 20.59 ± 0.596mm. 31.1% had systolic anterior movement of mitral valve and 26.7% had left ventricle outflow tract obstruction. LGE was present in 88.5% P with a median number of 5 ± 7 segments involved. Interventricular septum (IVS) was involved in 78.7% P, anterior wall in 57.4%, inferior wall in 54.1%, lateral wall in 52.5%, posterior wall in 9.8%, basal segments in 62.3%, median segments in 68.9% and apical segments in 63.9%. On follow up 3.3%P died, 45.8% had hospitalizations (22,2% because of an arrhythmia) and 75% had arrhythmias (1.6% VF, 6.6% SVT, 50% NSVT, 9.8% PSVT, 37.7% AF and 6.6% AFL). The number of segments with LGE correlated with arrhythmias (p = 0.05 for arrhythmias, p = 0.03 for SVT, p = 0.008 for NSVT and p = 0.042 for PSVT). A cut off of 5 segments involved was a good predictor of arrhythmias (p = 0.002), NSVT (p= 0.006), PSVT (p = 0.024) and AF (p = 0.0029). For SVT the best cut off was 9 (p = 0.003). Considering the LGE location, we found an association between the segments involved and the occurrence of different arrhythmias (table 1). Conclusion Supraventricular and ventricular Arrhythmias are frequent in patients with HCM, with the most frequents being NSVT and AF. The LGE burden (>5 segments) and location (median inferior IVS, median anterior IVS, median anterior wall, basal anterior IVS, apical anterior wall, median inferior wall, apical anterior wall and basal inferior IVS) were correlated with arrhythmic events. Abstract Figure.

Vasopressin in Patients with Septic Shock and Dynamic Left Ventricular Outflow Tract Obstruction.

Left ventricular outflow tract obstruction (LVOTO) is a relatively uncommon but severe condition that may lead to hemodynamic impairment. It can be elicited by morphological (left ventricular hypertrophy, sigmoid septum, prominent papillary muscle, prolonged anterior mitral valve leaflet) and functional (hypovolemia, low afterload, hypercontractility, catecholamines) factors. We sought to determine the incidence of the most severe form of LVOTO in septic shock patients and describe the therapeutic effects of vasopressin. Over a period of 29months, 527 patients in septic shock were screened for LVOTO. All were mechanically ventilated and treated according to sepsis bundles, including pre-load optimization and norepinephrine infusion. Vasopressin was added in addition to norepinephrine to reduce the adrenergic burden and decrease LVOTO. Ten patients were diagnosed with the most severe form of LVOTO, including systolic anterior mitral valve motion (SAM) and severe mitral regurgitation (MR) with pulmonary oedema. The median norepinephrine dosage to obtain a mean arterial pressure of ≥70mmHg was 0.58 mcg/Kg/min (IQR 0.40-0.78). All patients had a hyper-contractile left ventricle, septal hypertrophy, significant LVOTO (peak gradient 78 [56-123] mmHg) associated with SAM and severe MR with pulmonary oedema. Vasopressin (median 4IU/h) allowed a significant reduction of norepinephrine (0.18 [0.14-0.30] mcg/kg/min; p = 0.01), LVOT gradient (35 [24-60] mmHg; p = 0.01) and MR with a significant paO2/FiO2 increase (174 [125-213] mmHg; p = 0.01). Vasopressin allowed a reduction of norepinephrine with subsequent LVOTO reduction and hemodynamic improvement of the most severe form of LVOTO, which represented 1.9% of all septic shock patients.

Pre-Operative Systolic Anterior Motion of the Mitral Valve in a Patient Undergoing Mitral Valve Replacement

Pre-Operative Systolic Anterior Motion of the Mitral Valve in a Patient Undergoing Mitral Valve Replacement

P1273 Effects of surgical septal myectomy on left ventricular function in patients with hypertrophic obstructive cardiomyopathy

Abstract Introduction and Purpose Surgical left ventricular (LV) septal myectomy in patients with obstructive hypertrophic cardiomyopathyhas been shown to reduce left ventricular outflow tract (LVOT) gradient and improve symptoms. We investigated changes in strain analysis, LA volume and LV systolic and diastolic function in patients with HOCM after surgical septal myectomy. Methods We enrolled consecutive 30 patients (age 63.7 ± 11.0 years, 47% Female), who underwent surgical LV septal myectomy for HOCM from 2012 to 2019. We evaluated LV dimension, LVOTG, LV-stroke volume, LV in flow pattern (E wave, A wave, Dct), e’(septal and lateral), LA volume, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM) and Global longitudinal strain. These parameters were evaluated at baseline and after LV myectomy at medium term (at least 6 months after surgery). Results They are followed for a mean of 3.4± 1.9 years after surgery. Eight patients underwent concomitant procedure; mitral valve repair and annuloplasty in 3 patients (10%), Maze surgery in 1 patient, LV aneurysmectomy in 2 patients and aortic valve replacement in 3 patients (10%). Patients with concomitant procedure were excluded from LV function analysis. Postoperative LVOTG were controlled in 10mmHg or less.Global longitudinal strain (GLS) improved but no significant change. Otherwise LA volume index decreased (from 52.5 ± 16.7 to 32.9 ± 14.6 ml/m2, p = 0.01) and LV diastolic function improved with an increase in lateral e" velocity (from 4.5 ± 2.8 to 9.2 ± 3.4 cm/sec, p = 0.001) and improved E/e’ (from 18.9 ± 5.6 to 10.6 ± 5.2, p <0.05). Symptoms of dyspnea, chest oppression and heart failure improved with reduction in the New York Heart Association functional class. Conclusion Excellent relief of LVOT obstruction in HOCM by surgical LV septal myectomy results in decreased LA volume and LV diastolic function with improved symptoms.

P184 Broken heart complications

Abstract Introduction Patients with persistent chest discomfort or other symptoms suggestive of ischaemia and ST segment elevation in two contiguous leads on electrocardiography should be prompt managed to revascularization and emergent angiography for percutaneous intervention in two hours is the preferred reperfusion strategy. Purpose Our aim is to show the importance of differential diagnosis in a patient with an initial diagnosis of ST segment elevation myocardial infarction (STEMI). Clinical case We present a case of 67 years old women with a past medical history of dyslipidemia and polymyalgia rheumatica, treated with rosuvastatin 10mg id and prednisolone 5 mg id. The patient was admitted to emergency department complaining of chest pain with 3 hours of evolution that started after a period of nausea and vomiting. Physical examination showed slight tachypnea with 22 breath per minute, blood pressure 93/40 mmHg, heart rate 110 beats per minute, oxygen saturation in room air 90%, heart sounds with a systolic murmur II/VI and lung crackles in inferior lobes, with no peripheral oedema. Electrocardiography showed sinus rhythm and ST segment elevation in DI, DII and V2-6. Patient was treated with aspirin 300mg, ticagrelor 180mg, furosemide 40mg, oxygen therapy and was scheduled for emergent coronariography. This procedure revealed no significant coronary lesions and ventriculography identified apical ballooning, diagnosing takotsubo myocardiopathy. Clinical condition starts to deteriorate, and an echocardiography identified akinetic apical and midventricular segments and hyperkinetic basal segments with systolic anterior motion of mitral valve, significant mitral regurgitation and left ventricular outflow tract obstruction (LVOTO) with an intraventricular gradient superior to 60 mmHg. Adequate hemodynamic monitoring and heart rate control allowed a substantial clinical improvement. Two days later a cardiac magnetic ressonance was done, confirmed the diagnosis and identified an apical thrombus. The patient was later discharged stable with oral hypocoagulation with anti-vitamin K antagonist. Discussion and Conclusion Takotsubo cardiomyopathy is a unique cardiac syndrome characterized by transient systolic dysfunction witch often mimics acute coronary syndromes (ACS). After exclusion of an ACS, echocardiography is of primordial importance in the assessment of these patients. Left heart failure with pulmonar oedema, mitral regurgitation, LVOTO and thrombus formation were all complications that were present in this clinical case and established the indication to proper therapeutic attitudes. Abstract P184 Figure.

P643 A case of Fabry cardiomyopathy refractory to enzyme replacement therapy; the importance of early diagnosis and treatment in Fabry cardiomyopathy

Abstract A 56-year-old male was referred in order to identify Fabry disease after his older brother was confirmed as Fabry disease of cardiac variant type. He had been treated with hypertrophic cardiomyopathy (HCMP) five years ago. He didn’t have a history of hypertension. Blood pressure was 118/65 mmHg and pulse rate was 75 beats per minute. Serum creatinine was 1.07 mg/dl and estimated glomerular filtration rate was 75.2 ml/min. Cardiac enzymes including CK-MB and troponin-T were normal. There was no proteinuria on urinalysis. A 12-leads electrocardiogram revealed normal sinus rhythm with severe left ventricular hypertrophy (LVH) and strain pattern. Transthoracic echocardiogram (TTE) showed diffuse severe concentric hypertrophy of the left ventricle (LV) of an average ventricular wall thickness of 17 mm with normal systolic function (left ventricular ejection fraction (LVEF), 56%). TTE also revealed left ventricular outflow tract obstruction with systolic anterior motion of mitral valve. Right ventricle (RV) was also hypertrophied (RV free wall thickness, 7mm). Also, echocardiography revealed findings of diastolic dysfunction; left atrial enlargement, mitral inflow of a pseudo-normal pattern on pulsed wave Doppler image and an increased left ventricular filling pressure on tissue Doppler image (E/e’=20). Cardiac magnetic resonance imaging (MRI) revealed diffuse LV and RV hypertrophy and preserved LV systolic function with hypokinesia of mid-septal LV wall. Delayed hyper-enhancement (DHE) was not found within entire myocardium. A coronary CT angiography was performed because of regional wall motion abnormality but did not show any significant stenoses. He was confirmed as Fabry disease with the same genetic mutation as his brother. He did not present symptoms and signs of any other organs besides only myocardial hypertrophy. He received enzyme replacement therapy (ERT) with intravenous agalsidase-beta every other week via outpatient department for 3 years. Recently, TTE was performed and showed diffuse severe concentric LVH of an average ventricular wall thickness increased to 19 mm despite regularly ERT. Focal intramural and subepicardial DHE was newly developed at LV basal lateral and septal wall on cardiac MRI. Neutralizing antibody against agalsidase -beta was not found in serum. Fabry disease of cardiac variant type can be delayed in diagnostic aspect because of absence of typical symptoms and signs. Despite the absence of neutralizing antibody, ERT did not prevent both further myocardial hypertrophy and myocardial fibrosis in patient with advanced myocardial hypertrophy caused by delayed diagnosis of Fabry disease. Suspicion of Fabry disease through detailed history taking including family history in patients with diffuse ventricular hypertrophy on an echocardiography can lead to early diagnosis and treatment and can result in improvement in a clinical outcome.

P1286 A retrospective clinical and anatomical characteristics study of transaortic extended left ventricular myectomy for obstructive hypertrophic cardiomyopathy

Abstract Objective Surgical septal myectomy is the gold-standard therapy for hypertrophic obstructive cardiomyopathy (HOCM). The aims of our study are to investigate anatomical characteristics and make clear effectiveness of transaortic extended left ventricular (LV) myectomy for HOCM. Methods This study enrolled 28 consecutive patients (age 66.7 ± 12.1 years, 46% Female) from 2012 to 2018 who met the following inclusion criteria: symptoms of heart failure persisting despite optimal medical therapy including beta blockers and Class I anti-arrhythmic agent, LV outflow tract gradient (LVOTG) > 50mmHg at rest or with provocation using stress echo (exercise TTE or low-dose dobutamine stress echo). We evaluated LV dimension, LVOTG, mitral regurgitation (MR), systolic anterior motion of mitral valve (SAM), Mitral complex morphology, high echoic region of endocardium and appearance of abnormal muscle bundles including apical-basal muscle bundle. These parameters were evaluated based on changes in LVOTG, MR and SAM at after LV myectomy. Also, intraoperative findings and cardiomyocytes pathological findings were evaluated. Stress echo were performed to investigate sustained reduction of LVOTG at medium term. Results All patients were successfully underwent transaortic extended LV myectomy. SAM was identified in all and moderate MR in 14 patients. The anterior mitral valve leaflet height was large in all patients and 16 patients had LV abnormal muscle bundles. Postoperative LVOTG were controlled in 10mmHg or less. SAM disappeared completely in all patients and MR were decreased mild or less. LVOTG were sustained good control in 10mmHg or less under stress echo at medium term. Conclusion LV myectomy provides excellent relief from LVOT obstruction. The appearance of mitral valve anterior leaflet and abnormal band may be important keys of LVOT obstruction.

P859 Can we connect intraventricular exercise induced gradients to sudden cardiac death?

Abstract Background Some publications, on exercise induced intraventricular gradients, admit the possibility they can be related to some cases of unexplained sudden cardiac death (SCD). Clinical case We present the case of a young male athlete (16 years) that after winning a triathlon competition has sudden cardiac death. No cardiovascular risk factors. No family history of SCD A previous episode of dizziness, accompanied by nausea and vomiting related to intense training happens 6 months before. In September 2018 about 30 minutes after winning a triathlon competition has SCD episode having been resuscitated on site by the competition physician having been defibrillated and transported to intensive care unit. After discharge, cardiac MRI, Coronary AngioTC, complete genetic study for heart diseases, flecainid test, transthoracic echocardiogram, stress echocardiogram with hyperventilation and ergometrine. All have normal results (Figure) During 24 hours Holter ECG isolated premature ventricular complexes were detected and during exercise stress echocardiography a significant intraventricular gradient without systolic anterior movement of mitral valve was detected (Figure). The athlete was disqualified for sports practice, refuses CDI implantation and started bisoprolol 2,5 mg daily. To the best of our knowledge this is the first case of association between SCD and exercise induced intraventricular gradient. This possible association should be studied in the future. Abstract P859 Figure. Intraventricular gradient in SCD athlete