Moderate Systolic Dysfunction Research Articles

Abnormal spirometry is a predictor of exercise capacity in patients with tetralogy of Fallot

<p>We investigated the association between cardiac factors, spirometry, and exercise testing in patients with tetralogy of Fallot (TOF). Clinical data from patients with TOF performing a cardiopulmonary exercise test (CPET) was collected retrospectively over a 10-year period. 122 patients with TOF were identified, 52 excluded for incomplete exercise, spirometry, or cardiac data for 70 total patients included in the study. There was a male predominance 39 (56%), a mean age of 25 ± 12 years, with 28 (40%) < 18 years of age. The mean number of cardiac surgeries was 2.1 ± 1.2. Most, 46 (69%) had moderate to severe pulmonary valve insufficiency (PI) and 34 (51%) had moderate to severe right ventricular (RV) dilation. Mean forced vital capacity (FVC) was low at 81.8% predicted, and 32 (46%) with low FVC (< 80% predicted). Overall peak VO<sub>2</sub>/kg was low with a mean of 58.2 ± 13.2 % predicted. Using multiple regression analysis, a higher number of cardiac surgeries was an independent predictor of lower FVC (<em>p</em> = 0.01). Lower FVC was itself an independent predictor of lower peak VO<sub>2</sub>/kg and O<sub>2</sub> pulse (<em>p</em> < 0.05). Moderate or severe RV systolic dysfunction was an independent predictor of stroke volume response (<em>p</em> = 0.03).<strong> </strong>Higher body mass index (BMI) was an independent predictor of all exercise measures being worse (<em>p</em> < 0.05). Low FVC and reduced exercise capacity were common in our population of TOF patients. Low FVC was predictive of low exercise capacity while, of the cardiac measures only RV systolic dysfunction was significant and predictive of stroke volume response. Spirometry may be a valuable screening tool in evaluation of TOF patients.</p>

Large Right Atrial Size on Cardiac MRI is Associated with Post-operative Right Ventricular Dysfunction After the Cone Operation for Ebstein Anomaly.

The cone operation has revolutionized care for patients with Ebstein anomaly; however, acute post-operative right ventricular dysfunction (RVD) is common in this patient population. A single-center, retrospective review of 28 patients with Ebstein anomaly who underwent cardiac MRI (CMR) prior to cone reconstruction of the tricuspid valve was conducted. Measurements of atrial and ventricular size/function were assessed. Post-operative RVD was defined as the presence of moderate or severe systolic dysfunction on discharge echo. A two-tail t test was employed to compare the two groups. The average age at operation was 21.4years (range 1.6-57.8) and 14 (50%) had RVD at discharge. Patients with post-operative RVD had significantly larger pre-operative right atrial (RA) maximum volume (p = 0.016) and RA minimum volume (p = 0.030). Patients with RVD had smaller pre-operative left atrial (LA) minimum volume (p = 0.012). Larger pre-operative right ventricular (RV) end-systolic volume (p = 0.046), lower RV ejection fraction (0.029), and smaller left ventricular (LV) end-diastolic volume (p = 0.049) were significantly associated with post-operative RVD. Post-operative RVD was associated with longer milrinone duration (p = 0.009) and higher maximum milrinone dose (p = 0.005) but was not associated with intensive care or hospital length of stay (p = 0.19 and 0.67, respectively). Increased RA and RV dilation and decreased LA and LV volumes are associated with the development of post-operative RVD following cone operation for Ebstein anomaly. Post-operative RVD affects milrinone dose and duration but is not associated with increased length of stay.

Case of Hypertrophic Cardiomyopathy with Clinical Progression to Restrictive Physiology

Abstract Hypertrophic cardiomyopathy (HCM) is defined as an unexplained left ventricular (LV) hypertrophy ≥15 mm (13 mm if family history present) occurring in the absence of identifiable factor that may account for LV wall thickening, including pressure overload and infiltrative or storage disorder. Restrictive physiology is a pattern of ventricular filling with increased myocardial stiffness leading to elevation of ventricular pressure, causing diastolic dysfunction. A 60-year-old man was brought to the hospital with progressive worsening breathlessness for 2 days and bilateral lower limb swelling. The patient was a known case of HCM, ischemic heart disease (IHD) with single-vessel disease – ostial D1 70% stenosis, atrial fibrillation (AF), status post radiofrequency ablation, moderate LV systolic dysfunction (ejection fraction [EF] – 30%), with recurrent admission due to heart failure. The patient presented with hypotension and bilateral lower limb swelling, and systemic examination showed bilateral crepitations. The patient was diagnosed with acute decompensated heart failure, heart failure with reduced EF, HCM, old IHD, and AF with controlled ventricular rate. Serial two-dimensional echocardiography showed the progression of HCM to restrictive physiology. The patient deteriorated and was planned for a heart transplant with bridging LV assist device therapy. The transition is not usually reported, and literature related to this is scarce; hence, this case is being reported.

Patient Outcomes by Ventricular Systolic and Diastolic Function.

Left ventricular dysfunction is characterized by systolic and diastolic parameters, leading to heart failure (HF) with reduced or preserved ejection fraction (EF), respectively. The goal of this study is to examine the impact of left ventricular systolic and diastolic dysfunction (DD) on patient outcomes. Two cohorts were used in this analysis: Cohort A included 136 455 patients with EF ≥50%, stratified by the presence and grade of DD. Cohort B included 16 850 patients with EF <50%, stratified by EF quartiles. Patients were followed to the end points of all-cause death and cardiovascular, HF, or cardiac arrest hospitalizations. Over a median follow-up of 3.42 years, 23 946 (16%) patients died and 31 113 (20%), 13 305 (9%), and 1269 (1%) were hospitalized for cardiovascular, HF, or cardiac arrest causes, respectively. With adjustment for comorbidities, the risk of all-cause mortality and of cardiovascular and HF hospitalizations increased steadily with increasing grade of DD in patients with normal EF, and even more so in patients with worsening EF. The risk of hospitalization for cardiac arrest in patients with grade III DD, however, was comparable to that of patients with EF <25% (hazard ratio, 1.00 [95% CI, 0.98-1.01]) and worse than that of patients in better EF quartiles. Although systolic dysfunction is associated with a greater risk of overall death and HF hospitalizations than DD, the risk of cardiac arrest in patients with grade II and III DD is comparable to that of patients with moderate and severe systolic dysfunction, respectively. Future studies are needed to examine treatment strategies than can improve these outcomes.

Cardiac Catheterization in Adults with Ebstein Anomaly: Pathophysiologic Insights Regarding Surgical Repair and Prognosis.

The underlying invasive hemodynamics and physiology in Ebstein anomaly (EA) are poorly understood. Moreover, the hemodynamic impact of tricuspid valve intervention in EA has not been well studied. Retrospective cohort of 52 adults with repaired and 36 with unrepaired EA undergoing right heart catheterization at Mayo Clinic, MN between 1993 and 2021. "Repaired" EA was defined as prior tricuspid valve repair and/or replacement (83% post-tricuspid valve replacement). Repaired patients were younger than those with unrepaired EA (41.3 ± 16.0 versus 50.6 ± 15.6years, p = 0.008) and had a lower prevalence of ≥ moderate native or prosthetic tricuspid regurgitation (67% versus 81%, p = 0.01). Right atrial (RA) pressure was higher among patients with repaired EA than in unrepaired disease [13 (11; 18) versus 10 (8; 15) mmHg; p = 0.02], but these differences were no longer present when adjusting for ≥ moderate right ventricular systolic dysfunction and ≥ moderate tricuspid regurgitation. Cardiac index (Qs) was lower among those with unrepaired EA than in repaired EA (1.9 ± 0.7 versus 2.3 ± 0.6 l/min/m2, p = 0.01), even after adjusting for similar confounders. During a follow-up of 8.6 (3.2-13.3) years, 16 (18%) patients died. Systolic pulmonary artery pressure was independently associated with all-cause mortality. In summary, highercardiac indices were found in those with repaired EA compared to those with unrepaired disease. RA hypertension was prevalent in both groups and no differences in right filling pressures were found between groups after adjusting for potential confounders. Elevation in pulmonary pressures was independently associated with survival. The use of pulmonary vasomodulators in EA requires further investigation.

Comparative prognostic value of different echocardiographic parameters of the subpulmonary left ventricle in adults with a systemic right ventricle

Abstract Introduction Adults with complex congenital heart disease and a systemic right ventricle (SRV) are at increased risk of SRV dysfunction, heart failure, and premature death. In the systemic left ventricle (LV), impaired global longitudinal strain (GLS) is a strong predictor of adverse outcome. In the subpulmonary LV, however, echocardiographic assessment lacks standardisation and the relative prognostic significance of metrics of subpulmonary LV function remain unknown. Purpose To assess the correlation and relative prognostic power of quantitative metrics of subpulmonary LV function in adults with an SRV. Methods All adults with an SRV who underwent echocardiography in 2011-2019 at our specialist centre and had sufficient data for quantitative multiparametric subpulmonary LV assessment were included. LV systolic function was assessed by fractional area change (FAC), 4-chamber global longitudinal strain (GLS) and free wall longitudinal strain (FWLS). Linear regression was used to assess the correlation between echocardiographic variables of subpulmonary LV function. Cox regression analysis was used to assess the relation between echocardiographic predictors and the combined endpoint of death or transplantation. TimeROC analysis was performed to assess risk variable performance. Results In total, 120 patients (43.5±12.1 years, 60.0% male, 37.5% congenitally corrected transposition of the great arteries) were included. Most patients (94, 79.0%) were in NYHA functional class I/II and two-thirds (79, 66.4%) were receiving ≥1 heart failure therapy. One half of patients (63, 52.5%) had at least moderate systolic SRV dysfunction at baseline assessment with a median SRV FAC of 27[22-32]%. Subpulmonary LV function was visually preserved in most patients (98, 81.7%), with a LV FAC of 47.0[40.0-52.9]%. Median GLS was -15.2[-19.7–11.8]% and LV FWLS -19.9[-24.4–12.8]%. There was a weak correlation between LV FAC and GLS (r=0.25). During a median follow-up of 4.9[3.4-5.6] years, 24(20.0%) patients died and 3(2.5%) underwent heart or heart-lung transplantation. The 5-year transplant-free survival was 78.9%, (95%CI: 71.7-86.8%). On univariable Cox analysis, LV FAC (/5%, HR 0.55, 95%CI:0.47-0.65, p&amp;lt;0.0001) and GLS (/5%, HR 1.6, 95%CI:1.1-2.31, p=0.01), but not LV FWLS (/5%, HR 1.25, 95%CI:0.99-1.58, p=0.06) emerged as predictors of death or transplantation. LV GLS did not remain predictive in a bivariable model including LV FAC. LV FAC outperformed GLS on timeROC analysis (5-year AUC 0.87 vs. 0.64, p&amp;lt;0.0001; Figure). Conclusions Impaired systolic function of the subpulmonary LV strongly associated with mortality and heart or heart-lung transplantation in adults with an SRV. Both LV FAC and GLS are related to outcomes and should be a part of comprehensive echo assessment. LV FAC, a marker longitudinal and radial contraction, may better reflect pathophysiological mechanisms of subpulmonary LV failure and has greater prognostic significance in SRV patients.5-year ROC curves of LV FAC and GLS

Novel uses for implanted haemodynamic monitoring in adults with subaortic right ventricles

BackgroundPulmonary hypertension (PH) is a common complication in patients with complete dextro-transposition of the great arteries (TGA) after atrial switch (D-TGA/AS) and congenitally corrected TGA (ccTGA). In this population with...

Abstract 12632: Clinical Outcomes Across Groups of Ejection Fraction and Grades of Diastolic Dysfunction

Introduction: Previous studies have examined the association of diastolic dysfunction (DD) with cardiovascular (CV) outcomes. Understanding how clinical outcomes for those with a normal ejection fraction (EF) and DD compared to those with reduced EF is important in mitigating CV risk and optimizing management. Methods: 153,305 patients with echocardiograms performed at our institution between 2009 and 2022 were included in this analysis and divided into 2 cohorts: A) Normal EF patients (n=136,455) who were further stratified by grade of DD; and B) low EF (EF&lt;50%, n=16,850) patients who were further stratified by EF into four groups. Patients were followed for CV hospitalization or death. Results: Over a median follow up of 3.42 years, 23,946 (16%) patients died. There were 31,113 (20%), 13,305 (9%), and 1,269 (1%) hospitalizations for any CV diagnosis, heart failure (HF), or cardiac arrest (CA), respectively. After adjustment for age, CAD, HF, DM, hypertension, AF and CKD, the risk of all-cause mortality and of CV or HF hospitalizations increased steadily with increasing grade of DD in patients with normal EF (Table). The same was observed in cohort B with worsening EF, to greater extent than in patients with preserved EF (Table). The risk of hospitalization for CA in patients with grade III DD, however, was comparable to that of patients with an EF &lt;25% (HR=0.97, 95% CI 0.58-1.62, p=0.90) and worse than patients in better EF quartiles (p&lt;0.001). Patients with grade II DD had a CA hospitalization risk comparable to those with EF between 36-40% (HR=1.11, 95% CI 0.79-1.57, p=0.54). Conclusions: Although systolic dysfunction is associated with worse overall death and HF hospitalizations than DD, the risk of CA in patients with grade II and III DD is comparable to that of patients with moderate and severe systolic dysfunction, respectively. Future studies are needed to examine the mechanisms of CA in DD, and optimal treatment strategies for these patients.

A case report: anteroseptal ST elevation due to acute isolated right ventricular infarction

BackgroundElectrocardiogram (ECG) is the first diagnostic tool physicians use in diagnosing acute myocardial infarction (MI). In this case report, we present a case where the initial ECG diagnosis was that of an acute anteroseptal MI but emergency coronary angiography showed that the infarct-related artery was a small non-dominant right coronary artery (RCA) instead of the anticipated left anterior descending artery (LAD). Isolated right ventricular (RV) infarction from a non-dominant RCA is rarely seen in clinical practice, and it may exhibit ECG changes that can be confused with an acute anteroseptal MI. It is important to appreciate the subtle differences in the ECG changes that occur in either of these two types of MI for appropriate diagnosis and treatment.Case presentationA 49-year-old non-smoking male with prior coronary stent implantation in LAD presented with acute chest pain and his pre-hospital ECG indicated an anteroseptal STEMI possibly due to stent thrombosis, but an emergency angiogram showed patent LAD and Circumflex arteries. There was however thrombotic occlusion of the right, non-dominant coronary artery, which was revascularized with a drug-eluting stent. The patient’s chest pain and ST elevations resolved, and subsequent echo showed moderate RV systolic dysfunction in keeping with RV myocardial infarction.DiscussionRV myocardial infarction is usually due to an occlusion of the dominant RCA proximal to the origin of its RV wall branch, which often results in inferior ST elevation with reciprocal anterior ST depression. The ST elevation over V1 which would accompany RV infarction is often masked due to the more dominant electrical forces of inferior and posterior LV wall infarction. Our case demonstrates that in isolated RV infarction due to non-dominant proximal RCA occlusion, anterior ST elevation can be seen over V1-3, being most prominent in V1, which overlies the right ventricle, and resolved after restoring flow to the RCA. Spatial vector analysis of the ECG or right-sided ECG leads would be helpful to aid the diagnosis of RV infarction when clinical suspicion is present, for example when there is significant hypotension, raised jugular venous pressure but clear lung fields or deterioration after nitrate administration.

P1 NEW TREATMENT STRATEGIES IN PATIENTS WITH SENILE CARDIAC AMYLOIDOSIS

Abstract We present the case of a 75 year–old man, diabetic, dyslipidemic, hypertensive, previous ischemic heart disease, AF, previous hospitalizations for heart failure, who underwent cardiology evaluation for worsening dyspnea (NYHA class II–III), swallen ankles and elevated BNP levels (900 pg/ml). The patient suffered from sensory–motor polyneuropathy diagnosed with EMG and ENG. Echocardiographic evaluation: severe concentric hypertrophy of the left ventricle (SIV 18 mm, PP 17 mm), granular sparkling and EF 50%, left atrium dilatation, light–moderate mitral regurgitation, moderate tricuspid regurgitation with PAPS 40–45 mmHg. Circumferential pericardial effusion (12 mm). Moreover, we noticed a decreased longitudinal contractive function of the left ventricle (TDI e‘, a’, e s’ &amp;lt;5 cm/s e absolute GLS &amp;lt; 15%), speckle–tracking ‘cherry on the top‘ and restrictive diastolic pattern. •ECG: low QRS voltage and increased wall thickness (&amp;gt;12 mm). •Laboratory: (SPIE and UPIE) no monoclonal protein present. •Bone scintigraphy: grade 3 cardiac uptake. •Cardiac MRI: asymmetric hypertrophy of the left ventricle with moderate biventricular systolic dysfunction. Subendocardial late gadolinium enhancement. •Genetic testing: no sarcomeric or TTS gene mutations. All findings were suggestive for senile cardiac amyloidosis (ATTR wt), the patient was discharged from the hospital with optimized medical therapy for heart failure and follow up was prescribed. After 3 months from the first diagnosis we added Tafamidis to the therapy (ESC indications class IB). ATTR–ACT, published on ‘New England Journal of Medicine’ showed that Tafamis is superior to placebo in reducing the combination of all–cause mortality and cardiovascular–related hospitalizations. Tafamidis was also associated with a significant reduction in the decline in functional capacity (as measured by the 6–minute walk test) and the decline in quality of life (as measured by the KCCQ–OS) at month 30, with differences first observed at 6 months. Tafamidis was well–tolerated, with a safety profile comparable to placebo. Follow–up: 6 months later the introduction of Tafamidis, the patient has not needed other hospitalizations for heart failure, well tolerates the drug with a subjective symptom reduction and remarkable improvement in quality of life.

Single Center Experience With Durable Continuous Flow Single Ventricle Assist Device: A Viable Option in Fontan Circulatory Failure.

Ventricular assist devices are increasingly used for patients with single ventricle physiology. We describe the use of durable, continuous flow, single ventricular assist device (SVAD) therapy in Fontan circulatory failure patients. Retrospective, single-center review of patients with Fontan circulation implanted with a SVAD between 2017 and 2022. Patient characteristics and outcomes were obtained by chart review. Nine patients underwent SVAD implantation (median age 24 years). Most patients had a total cavopulmonary connection; one had an atriopulmonary Fontan. Five patients had a systemic right ventricle. SVAD was most often utilized as bridge to candidacy (67%). Eight patients had at least moderate systemic ventricular systolic dysfunction. SVAD support continued for a median of 65 days (longest duration, 1,105 days) and one patient remains on support at time of submission. Of five patients discharged home, median length of stay after SVAD was 24 days. Six patients were transplanted (median 96 days from SVAD). Two patients died from pretransplant multisystem organ failure before transplant. All transplanted patients remain alive (median time since transplant 593 days). Continuous flow SVAD therapy can be effective for patients with Fontan circulatory failure and systolic dysfunction. Further studies should investigate feasibility and optimal SVAD timing with more advanced Fontan associated end-organ dysfunction.

Evaluation of echocardiographic abnormalities in children with end-stage renal disease (CKD stage 5): A single-center experience

BackgroundChronic Kidney disease (CKD) stage V might gradually induce the occurrence of morphological and functional cardiac disturbances; these cardiac disturbances make up supplementary risk factors. ObjectiveThe study aimed to describe electrocardiographic (ECG) and Echocardiographic (Echo) findings in dialysis patients. Also, to define the correlation between Echo findings and dialysis modality. MethodsWe studied 27 dialysis patients aged 3 years and one month to 25 years (163 ± 77 months. Boys accounted for 59.3 % of the patients. The modality of dialysis was peritoneal dialysis (PD) in 33.3 % and hemodialysis (HD) in 51.9 % of cases. Four patients (14.8 %) had undergone both modalities at different times. All patients were taken ECG and Doppler 2D echocardiography (Echo). Assessment of LV systolic function was done according to ejection fraction (EF) and categorized as normal (≥55 %), mild systolic dysfunction (45–54 %), moderate systolic dysfunction (30–44 %), and severe systolic dysfunction (<30 %) . ResultsThe most common abnormalities in ECG were left ventricular hypertrophy (70.4 %), prolonged QTC interval (33.3 %), and first-degree atrioventricular block (25.9 %), respectively. Based on the ejection fraction, 40.7 %, 33.3 %, and 26 % of the patients had normal systolic function, mild systolic dysfunction, and moderate systolic dysfunction, respectively. Also, left ventricular (LV) volume in both diastole and systole were significantly lower in PD compared to HD cases (P = 0.006 and 0.004). ConclusionsWe found that abnormal findings in ECG are common among pediatric dialysis patients. Additionally, Echo's assessment noted that systolic dysfunction was common. Significantly lower LV volume in diastole and systole in PD compared to HD cases may suggest that PD patients encounter less pressure and volume loads. These findings can be considered a positive point of PD modality.

Seizure-Induced Coma in Patient with Haemoglobin 1.3 gram per decilitre and MultiOrgan Dysfunction: A Rare Case Report

People of all ages are affected by anaemia which is a serious global health problem. Iron Deficiency Anaemia (IDA) seems to be the most commonly occurring type of anaemia in women. Elderly people with anaemia have higher morbidity and mortality. The purpose of treatment is to tackle the disorder’s underlying cause. Older people with persistent anaemia may need regular blood transfusions. The authors present a case report of a 55-year-old woman who visited the Emergency Department with primary complaints of convulsions and subsequent unconsciousness. She had generalised oedema and weakness since eight days. On examination she was afebrile with pulse 92 beats/min, Blood Pressure (BP) of 80 mmHg systolic. Laboratory results showed haemoglobin of 1.3 g/dL, increased White Blood Cells (WBC) and peripheral smear showed pencil-shaped cells and teardrop cells. Radiological investigation showed grade III renal parenchymal disease, cirrhosis of liver, gross ascites with bilateral pleural effusion, and splenic cyst. A 2D Echocardiography was done, which was suggestive of left ventricular hypertrophy, mild to moderate systolic dysfunction, along with dilated left ventricle. She was intubated in view of low Glasgow Coma Scale (GCS) and unconsciousness. On further stay in the hospital, she received blood transfusion. Hence, this case is a rare finding of severe anaemia.

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&amp;lt;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.

COVID-19 Vaccine-Induced Cardiac Concerns

Myocarditis has been increasingly recognized as a rare complication of COVID-19 mRNA vaccinations, especially in young adolescent males. According to the US Centers for Disease Control and Prevention, the incidence of myocarditis in males 16–29 years of age is approximately 10.7 cases per 100,000. Of those diagnosed with myocarditis, roughly 69% were diagnosed 3–5 days after their second vaccination. Most recent reports have shown clinical presentations consistent with chest pain, elevated cardiac enzymes, ST elevations on ECG, and further echocardiogram or cardiac MRI findings displaying mild to moderate left systolic dysfunction. Although mechanisms in the development of myocarditis are still not clear, a promising hypothesis is that myocarditis is exacerbated by a hyperimmune response to the second dose of the vaccine. Children have a robust immune response to COVID-19, which has been exemplified by increasing cases of multisystem inflammatory syndrome in children. This report will review trends seen in patients with vaccine-induced myocarditis and highlight the benefit to risk assessment of cardiovascular complications associated with COVID-19.

Abstract 9729: Pulling Out All the Stops (for a Diagnosis): A Case of Progressive Dyspnea

A 63-year-old woman with hypertension, diabetes mellitus, severe obesity, obstructive sleep apnea, and history of GATA3+/ER+ breast cancer treated 14 years prior with neoadjuvant anthracycline-based chemotherapy and subsequent lumpectomy, chest radiotherapy, and letrozole presented to the emergency department with three weeks of progressive cough and exertional dyspnea. Physical examination revealed tachypnea, hypoxemia, a prominent P2, and jugular venous distension with a Kussmaul sign. Further investigation showed moderate hemolytic anemia, severe thrombocytopenia, and elevated natriuretic peptides. Electrocardiography revealed normal sinus rhythm, an S1Q3T3 pattern, and diffuse T wave inversions. Computed tomography angiography of the chest was notable for few small pulmonary nodules and diffuse vertebral osteosclerosis, consistent with osteoblastic metastases. Transthoracic echocardiography exhibited a moderately dilated RV with moderate systolic dysfunction, moderate TR, and an estimated RVSP of 79 mm Hg. Lung perfusion scintigraphy disclosed subtle subsegmental defects. Right heart catheterization (RHC) showed elevated right-sided filling pressures and severe precapillary pulmonary hypertension (RA 12 mm Hg, mPAP 51 mm Hg, PCWP 6 mm Hg, and PVR 775 dynes-sec/cm 5 ). There was no discernable shunt. These findings, coupled with the patient’s history, rapidly progressive symptoms, and hematologic derangements, raised suspicion for pulmonary tumor thrombotic microangiopathy (PTTM). A pulmonary capillary wedge blood aspirate was sent for cytology. Her clinical status rapidly worsened despite inhaled pulmonary vasodilators, hemodynamic support, and systemic glucocorticoids, precluding candidacy for empirical chemotherapy. She was transitioned to comfort measures only and suffered a bradycardic PEA arrest on hospital day 8. Autopsy was declined. Cytological analysis of the wedge blood aspirate ultimately revealed clusters of neoplastic GATA3+ cells, consistent with PTTM associated with late recurrence of breast carcinoma. This case highlights the rare instance of PTTM diagnosis aided by wedge cytology, reinforcing the multidimensional role of RHC in this extremely uncommon and devastating clinical entity.

Abstract 15712: Imaging Conundrum: The Diagnosis of Unusual Partial Anomalous Pulmonary Venous Return With Dual Connections

Case: A 68 year old male with a past medical history of hypertension, hyperlipidemia and chronic kidney disease presented for progressive dyspnea on exertion and bilateral lower extremity edema over three weeks. He was found to be in decompensated heart failure and new onset Atrial Flutter with rapid ventricular rate. Transthoracic echocardiography revealed severely impaired left ventricular systolic function with ejection fraction &lt;20%, enlarged right ventricle, moderate right ventricular systolic dysfunction, biatrial enlargement, mild pulmonary hypertension. He was started on guideline directed medical therapy and referred for transesophageal echocardiogram (TEE) with cardioversion for new onset Atrial Flutter and possible tachycardia induced cardiomyopathy. Imaging findings: During TEE, routine doppler of right upper pulmonary vein showed markedly dilated superior vena cava (SVC) (3.6 cm) and unusual predominant outflow with brief mid late systolic inflow (Fig A and B), suggestive of partial anomalous pulmonary venous return (PAPVR). All three other pulmonary veins appeared normal. Also noted to have positive bubble study likely related to PAPVR. Subsequent right heart catheterization left to right shunt with Qp/Qs 1.6, step up noted between SVC and right atrium. CTA revealed partial anomalous right upper lobe pulmonary vein (RUPV) had dual connection to both SVC via window like communication and left atrium (Fig C), no sinus venosus defect seen. Conclusion: This case illustrates an unusual example of PAPVR with bidirectional flow, as well as the importance of thorough evaluation even on routine transesophageal echocardiograms especially for patients with right heart enlargement.

Abstract 12143: Ventricular Conduction Abnormality and Outcome of Patients With Mild to Moderate Systolic Dysfunction

Introduction: In the context of mild-to-moderate systolic dysfunction (ejection fraction (EF) 36-50%), cardiac resynchronization therapy (CRT) is indicated only in patients with expected high burden of pacing but not in those with intrinsic ventricular conduction abnormalities. Hypothesis: Ventricular conduction delay is associated with a higher risk of mortality and HF hospitalization in patients with mild to moderate systolic dysfunction. Methods: We analyzed 5,966 patients with mild-to-moderate systolic dysfunction. Of those, 1,741 (29%) had a QRS duration of ≥120 milliseconds (ms). In the latter group, 68 (4%) patients were implanted with a CRT device. Patients were followed to the endpoints of death and the composite outcome of death or heart failure (HF) hospitalization. Results: Of the 1,741 patients with mild-to-moderate cardiomyopathy and wide QRS duration, 849 (51%) died and 1,004 (58%) had a HF hospitalization over a median follow-up of 3.35 years. Compared to patients with QRS&lt;120 ms, patients with QRS&gt;120 ms were at a higher risk of all-cause mortality (HR 1.11, CI 1.00-1.23, P=0.046) and of the composite of mortality or HF hospitalization (HR 1.10, CI 1.01-1.20, P=0.037) (Figure 1). Among patients with QRS&gt;120 ms, those who underwent CRT implant, had a lower risk of all-cause mortality (HR 0.44, CI 0.45-0.89, P=0.02) and of mortality or HF hospitalization (HR 0.58, CI 0.39-0.87, P=0.008). Conclusions: Among patients with HF and intermediate EF, a wide QRS is associated with higher risk of mortality and heart failure hospitalization. CRT is associated with a reduction in these adverse outcomes. Randomized trials are needed to assess role of CRT in this patient population.

Del Nido Cardioplegia for patients of adult congenital heart disease.

Objective: To assess the efficacy of del Nido cardioplegia for patients of adult congenital heart diseases undergoing cardiac surgery. Study Design: Descriptive Observational Case Series. Setting: Department of Paediatric Cardiac Surgery, Faisalabad Institute of Cardiology, Faisalabad. Period: October 2019 to September 2021. Material &amp; Methods: All consecutive patients of age fifteen years or above who underwent open-heart surgery for congenital heart disease by using ante grade del Nido cardioplegia during the study period were included. Dedicated hospital database used to retrieve the data of patients regarding type of surgery for CHD and operative or postoperative outcome parameters. The data was entered in excel sheet and descriptive analysis done. Results: One hundred and twenty five patients underwent open heart bypass surgery for congenital heart disease by using del Nido cardioplegia during the study period. Majority of patients were male (n=83, 66.4%) with male to female ratio 1.97:1. Sixty eight percent were less than thirty years of age. Primary repair of TOF was the most frequently performed surgery (49.6%, n=62) while 28.8% had repair of VSD. Average bypass time was 136 ±57 minutes and average cross clamp time of 103 ± 44 minutes. Total duration of mechanical ventilation was 6.6 ±11.9 hours, ICU stay of 38 ±34 hours and stay in the hospital of 5.2 ± 2.6 days. Cardiac tamponade was seen in 0.8% of patients (n=1) while moderate LV systolic dysfunction in 1.6 % of patients. Conclusion: Del Nido cardioplegia solution is as safe as conventional blood cardioplegia with short ventilation time, ICU stay and lowest postoperative complications.

ANEMIA IN PATIENTS WITH HEART FAILURE AND ITS CORRELATION WITH NT-PRO BNP: A RETROSPECTIVE OBSERVATIONAL STUDY FROM A TERTIARY CARE HOSPITAL IN SOUTH INDIA

Objective: To assess the prevalence of nutritional of anemia in Heart Failure patients and its correlation with the serum levels of NT-pro BNP. Methods: This is a single-center retrospective observational study, conducted at a tertiary care hospital in south India. Patients admitted to hospital with clinical diagnosis of HF based on validated clinical criteria were included in the study. Anemia was dened as hemoglobin (Hb) &lt;13 g/dl for males and &lt;12 g/dl for females, based on World Health Organization denition. Anemia was classied based on complete Iron prole, including serum iron, serum ferritin, total iron binding capacity, and transferrin saturation (TSAT). Serum levels of Vit B12 and Folate also assayed. Plasma concentrations of NTpro-BNP levels were assessed and correlated with the above parameters. A total of 100 patients ofResults: HF (69% males and 31% females) were studied. Most of the patients were of high-functional NYHA class ( NYHA Class III 81%) and with Moderate LV systolic Dysfunction (44%). Iron Deciency (ID)anemia was present in 72% patients with 50.4% patients having absolute and 21.6% patients having functional ID. Females were having signicantly higher prevalence of ID than males (80.6% vs 68.1%; p = 0.002). The NTpro-BNP levels in patients with IDA were statistically signicant (with p&lt;0.01) when compared to patients with normal iron levels . Conclusion: This study concludes that ID is much more common in patients with Heart Failure compared to Vit B12 or Folic acid deciency. The NTpro- BNP levels are elevated to much higher values in patients of heart failure with comorbid iron deciency states. Treating ID along with the routine heart failure management may improve the Quality of Life in HF patients.