Normal Global Systolic Function Research Articles

WELLENS SYNDROME OR PNEUMONIA?

Abstract Background Wellens syndrome, also known as "left anterior descending coronary syndrome," is characterized by the appearance of T–wave changes recorded on the ECG and it is an ECG manifestation of critical proximal left anterior descending artery stenosis. Case Report A 65–year–old man from Bangladesh with a history of chronic ischemic heart disease and trivessel coronary artery disease following surgical revascularization (CABG 2007). Recent admission for NSTEMI (June 2022) with unchanged coronary angiography compared to the previous one. Comorbidities include peripheral arterial disease, type II diabetes with organ damage, and COPD with recent exacerbations. Last myocardial scintigraphy (2021) was positive for inducible myocardial ischemia in the posterolateral region. Admission due to fever, productive cough, and severe chest pain. Initial instrumental assessments revealed ST–segment alterations in inferior leads and V1–V2 with negative/isodiphasic T–waves, not present in previous ECG tracings. A slight troponin elevation with ischemic curve (101 → 303 → 277 → 155 pg/dl, normal range < 50 pg/dl) led to the diagnosis of NSTEMI. Echocardiogram showed concentric remodeling of the left ventricle with normal global systolic function and hypokinesia of the mid–basal inferior wall (noted). Additionally, chest CT revealed pulmonary consolidations in the right middle lobe and upper left lobe, prompting antibiotic therapy and bronchodilator inhalation. Arterial blood gas analysis: pH 7.45, pO2 83, Lactate 0.8, HCO3– 24, P/F 360. Coronary angiography showed an unchanged picture compared to the previous one (patent AMIS and AMID, good run–off in native branches, no distal stenosis at the anastomosis). Clinical symptoms, inflammatory indices, and myocardial damage markers clinically improved during hospitalization. Discharged after optimization of anti–ischemic therapy with DAPT and diagnosis of NSTEMI. However, ECG abnormalities persisted at discharge (negative T–waves in DI–aVL–V1–V2). Post–discharge cardiac MRI was requested. Conclusions Diagnostic hypotheses include, primarily, a possible type II myocardial infarction due to an ongoing pneumonia (although hypoxia/hypovolemia/hypotension sufficient to cause MI was never documented during hospitalization), MINOCA, or microcirculatory disease (functional tests such as iFR/FFR, ACh, IMR were not performed during coronary angiography), or a possible myocarditic outcome (pending MRI).

Cardiac structure, function, and coronary anatomy 10 years after isolated contemporary adjuvant radiotherapy in breast cancer patients with low cardiovascular baseline risk.

The effects of isolated contemporary low-dose breast cancer (BC) radiotherapy (RT) on the heart remain poorly understood. This study aims to assess the long-term impacts of BC-RT on cardiac structure and function. Seventy-six women (62 ± 7 years) without history of prior heart disease, who had undergone RT for either first left (n = 36) or right (n = 40) BC, without additional medical oncology therapy apart from hormonal treatment 11 ± 1 years earlier, underwent transthoracic echocardiography, cardiac magnetic resonance imaging (CMR), computed tomography coronary angiography (CTCA), NT-proBNP, and a 6-min walk test (6MWT). They were compared with 54 age-matched healthy female controls. By CTCA, 68% of BC patients exhibited no or very mild coronary disease, while only 11% had moderate stenosis (50-69%) and 3% had significant stenosis (>70%). Despite slightly reduced regional echocardiographic midventricular strains, BC patients exhibited similar global left and right ventricular volumes, ejection fractions, and global strains by echocardiography and CMR as controls. Mitral E/e' ratios were slightly higher, and mitral deceleration times were slightly lower, but NT-proBNP was similar to controls. Also, 6MWT was normal. None had late gadolinium enhancement, and extracellular volume fraction was similar in BC (28 ± 3 vs. 29 ± 3, P = 0.15) and controls. No differences were observed relative to dose or side of RT. Aside from minor alterations of regional strains and diastolic parameters, women who received isolated RT for BC had low prevalence of coronary disease, normal global systolic function, NT-proBNP, and exercise capacity and showed no structural changes by CMR, refuting significant long-term cardiotoxicity in such low-risk patients.

Relative dilatation of left ventricle and left atrium in patients with Parkinson disease

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This study was supported by Czech Health Research Council AZV NU21-04-00445 and by the European Regional Development Fund - project ENOCH (No. CZ.02.1.01/0.0/0.0/16_019/0000868) Introduction Morbus Parkinson (MP) is the second most common neurodegenerative disease that progressively affects the nervous system. Accompanying heart problems may include mainly cardiovascular autonomic dysfunction. So far, very little is known about structural and functional cardiac changes in patients with MP. Purpose This pilot study aimed to analyse left ventricular (LV) and left atrial (LA) function and volumes using cardiovascular magnetic resonance (CMR). Methods In this study, 37 patients with MP (mean age 59,0 ± 8,0 years) without a history of cardiac disease or symptoms were compared to 37 sex- and age-matched control subjects without any heart disease history (mean age 54,5 ± 11,4 years). All patients underwent CMR examination at 1,5 MR scanner, including cine images for assessment of LV and LA volumetric and functional parameters. LA volumes (LAV) were measured at LV end-systole (maximum LAV - LAVmax), before the atrial contraction (pre-atrial contraction volume - LAVpac), and at late LV diastole (minimum LAV - LAVmin) and indexed (I) to the body surface area. LA strains were analysed for all LA phases: reservoir strain (LSr), conduit strain (LScd), and contractile strain (LSct). Descriptive statistics are reported as the mean (SD) or median (IQR) for normally and non-normally distributed continuous variables. All the p-values were adjusted using a false discovery rate for multiple comparisons. Results MP patients had normal global and regional systolic LV function – LV ejection fraction (EF) 65,9 ± 6,8% vs 68,9 ± 7,0% (p = NS). On the contrary, all indexed LV volumes were significantly higher in comparison to controls: LV end-diastolic volume index was 67,3 ± 12,1 ml/m2 vs 58,3 ± 11,7 ml/m2 (p = 0,013), LV end-systolic volume index was 22,0 (17,8 to 27,5) ml/m2 vs 18,9 (13,2 to 21,9) ml/m2 (p = 0,027), and LV stroke volume index was 43,8 ± 7,2 ml/m2 vs 39,8 ± 6,3 ml/m2 (p = 0,035). Similarly, indexed LAVmax and LAVpac were also relatively increased: LAVImax 42,7 ± 9,0 ml/m2 vs 35,7 ± 10,3 ml/m2 (p = 0,014), LAVIpac 29,8 ± 7,1 vs 23,8 ± 7,6 ml/m2 (p = 0,012). LAVImin was similar in both groups: 17,3 ± 5,5 ml/m2 vs 14,3 ± 6,7 ml/m2 (p = NS). LA strains were slightly lower in the MP cohort during the reservoir and conduit phase, and slightly higher in the contractile one. However, the difference did not reach statistical significance in any phase. Conclusion Patients with Parkinson´s disease have enlarged LV and LA compared to controls.

P30 A STONE ON THE HEART

Abstract We report a case of a 71–year–old female patient presented to our observation with worsening episodes of chest pain associated with cold sweat and spontaneous regression. Seven months earlier, the patient had undergone mitral valve replacement surgery with bioprosthesis for severe insufficiency. Pre–operative coronary angiography had documented the absence of significant lesions of the coronary arteries. Four months after the operation, hospitalisation was necessary due to an infective endocarditis on the prosthetic valve, effectively treated with specific antibiotic therapy. The patient came to the Emergency Department reporting episodes of stress related angina, lasting for a few days. The ECG documented sinus rhythm and non–specific anomalies of the ventricular repolarization phase. The haematochemical tests showed a minimal increase in the HS troponine values. Ultrasound documented normal left ventricular dimensions, no regional kinetic abnormalities with normal global systolic function and good functioning of the mitral bioprosthesis. The patient was admitted in our department of cardiology for further investigations. The next day the patient complained of severe oppressive chest pain with ECG evidence of diffuse ST–T segment depression and elevation in aVR and V1. Blood pressure was 170/90 mmHg and ultrasound showed apex hypokinesia with severely reduced systolic function. Nitrate s.l was administered with gradual improvement of symptoms and normalisation of the ECG. The patient underwent coronary angiography but during the first injection of contrast test, an anomalous stagnation of the contrast was highlighted in the aorta. It was urgently decided to perform aortic CT scan. The examination showed the presence of a voluminous pseudoaneurysm starting from the aortic bulb, partially thrombosed, which compressed the left main and the origin of the circumflex artery. The patient was therefore subjected to cardiac surgery the following day, with a good follow–up result one month after discharge.

Spatial and Temporal Non-Uniform Changes in Left Ventricular Myocardial Strain in Dogs with Duchenne Muscular Dystrophy

Understanding and effectively treating dystrophin-deficient cardiomyopathy is of high importance for Duchenne muscular dystrophy (DMD) patients due to their prolonged lifespan. We used two-dimensional speckle tracking echocardiography to analyze more deeply the non-uniformity of myocardial strain within the left ventricle during the progression of cardiomyopathy in golden retriever muscular dystrophy (GRMD) dogs. The circumferential strain (CS) and longitudinal strain (LS) of left ventricular (LV) endocardial, middle and epicardial layers were analyzed from three parasternal short-axis views and three apical views, respectively, in GRMD (n = 22) and healthy control dogs (n = 7) from 2 to 24 months of age. In GRMD dogs, despite normal global systolic function (normal LV fractional shortening and ejection fraction), a reduction in systolic CS was detected in the three layers of the LV apex but not in the LV middle-chamber and base at 2 months of age. This spatial heterogeneity in CS progressed with age, whereas a decrease in systolic LS could be detected early at 2 months of age in the three layers of the LV wall from three apical views. Analyzing the evolution of myocardial CS and LS in GRMD dogs reveals spatial and temporal non-uniform alterations of LV myocardial strain, providing new insights into the progression of dystrophin-deficient cardiomyopathy in this relevant model of DMD.

766 Distal embolization protection systems. A rare complication

Abstract Aims The no reflow phenomenon is a not rare complication that occurs in up to 30% of patients with acute coronary syndrome undergoing myocardial reperfusion by percutaneous coronary intervention. The use of coronary artery thrombus aspiration or distal embolization protection systems has reduced the risk of distal embolization and no-reflow phenomenon. Methods and results We describe the case of a 77 year old female suffering from hypertension presented at our emergency department for inferior STEMI. An urgent coronary angiography was performed, showing a three-vessel coronary artery disease with right coronary artery sub-occluded in the middle segment (culprit lesion), with a voluminous endoluminal minus image, as intracoronary thrombosis. Before performing the coronary angioplasty, a Spider FX3 filter was placed on the distal segment of the right coronary artery; thrombus aspiration was performed, which was ineffective, then angioplasty and Zotarolimus eluting stent implantation in the mid segment of the right coronary artery. After stent implantation, an image of minus was highlighted inside the basket of the filter, as a migrated and incarcerated thrombotic formation; then, the filter was removed. During the removal of the filter, longitudinal crush of the distal portion of the stent is caused, with limitation of the downstream flow, in the absence of haemodynamic instability. The stent was recrossed with Fielder XT guidewire supported by Turnpike LP Microcatheter. Multiple dilations werenperformed with semi-compliant and non-compliant increasing-caliber balloons and then Zotarolimus eluting stent implantation, in partial overlap with the distal portion of the previously implanted stent, with TIMI flow 3. The echocardiogram showed a normal global systolic function, with alterations in regional kinetics. On the 6th day, angioplasty and Zotarolimus eluting stent implantation was performed on the mid-proximal segment of the left anterior descending artery. During the hospitalization the patient was stable and has been discharged in good condition on the ninth day. Conclusions The interest of this case is the evidence of a rare complication related to the use of distal embolization protection system, probably due to an incomplete closure of the filter before removal, due to the high amount of thrombotic material inside it. The rapid recrossing of the stent after the longitudinal crush, the angioplasty and the second stent implantation, led to a quick flow restoration, without haemodynamic and clinical consequences on the patient's outcome.

BIRD FANCIER'S DISEASE: A CASE OF HYPERSENSITIVITY PNEUMONITIS

TOPIC: Occupational and Environmental Lung Diseases TYPE: Medical Student/Resident Case Reports INTRODUCTION: The immunologic lung disease through inhalation and sensitization of an aerosolized antigen is termed hypersensitivity pneumonitis (HP). Here we describe a case of HP from exposure to avian antigen. CASE PRESENTATION: A 42 y/o F presented with progressively worsening dyspnea at rest & exertion, pleuritic chest pain, dry cough for past 2 months. She denied sick contacts or recent travel. On exam BP: 122/76mmHg, HR 107bpm, RR 30bpm, SpO2 82% on room air. Physical exam, significant for b/l crackles. Labs: WBC 16.33 k/mm3, ABG PaO2 of 45mmHg. CXR showed b/l airspace opacities & CT-thorax showed b/l diffuse GGO. ECHO showed LVEF 55% with normal global systolic function with mildly elevated PASP. Treatment was initiated with hi-flo oxygen and her SpO2 improved to 97%. QuantiFERON Gold, urine legionella, Mycoplasma IgM, and respiratory multiplex viral panel were negative. Cardiac CT revealed patent coronaries. Spirometry revealed severe restrictive ventilatory defect. Further questioning revealed that patient got parakeets a few months prior to onset of symptoms. She was then started on methylprednisolone for possible HP. Bronchoscopy with BAL and transbronchial biopsies showed no bacterial/fungal/viral growth. Cytology was unremarkable and biopsies revealed mild inflammatory changes with lymphocytes and aggregates of intralaveolar foamy macrophages. The CD4:CD8 ratio was 0.89. Patient clinically improved with steroid therapy and gradually weaned from supplemental oxygen. She was discharged on oral prednisone with close follow up where she continued to improve after removal of her parakeets DISCUSSION: HP an immune-mediated response from repeated inhalation, sensitization, & hyperresponsiveness to various organic particles which can be mammalian or avian proteins, fungi, bacterial, or chemicals. Based on duration of exposure & symptoms onset, HP can be divided into acute, subacute, or chronic. Acute HP presents as flu-like illness, subacute HP has insidious onset of symptoms, dyspnea on exertion or reduced exercise capacity. Physical exam reveals inspiratory crackles. Imaging usually demonstrates GGO, mosaic attenuation and centrilobular nodules. BAL reveals lymphocytic predominant cells with CD8 alveolitis. Histopathology usually demonstrates cellular bronchiolitis with predominant lymphocytic or plasmocytic infiltrates. It can also present as interstitial mononuclear infiltrates or loosely-formed granulomas. Treatment for HP is avoidance of antigen exposure. Role of steroids in treating HP is not well known, however general practice is slow tapering steroid regimen for about 3-6 months duration. Prognosis is usually good with complete recovery in most patients; a few may progress to chronic fibrosing HP. CONCLUSIONS: A high level of suspicion should be present in diagnosing HP with a thorough history and prompt management must be initiated to prevent progression of disease. REFERENCE #1: Selman M, Pardo A, King TE Jr. Hypersensitivity pneumonitis: insights in diagnosis and pathobiology. Is J Respir Crit Care Med. 2012; 186:314-24. REFERENCE #2: Costabel U, Bonella F, Guzman J. Chronic hypersensitivity pneumonitis. Clin Chest Med. 012; 33:15163. REFERENCE #3: Camarena A, Juárez A, Mejía M, Estrada A, Carrillo G, Falfán R, Zuñiga J, Navarro C, Granados J, Selman M. Major histocompatibility complex and tumor necrosis factor-alpha polymorphisms in pigeon breeder's disease. Am J Respir Crit Care Med. 2001;163:1528-33. DISCLOSURES: no disclosure on file for Jagadish Akella; No relevant relationships by Alex Diaz, source=Web Response no disclosure on file for Iqbal Javed; No relevant relationships by Raghavendra Sanivarapu, source=Web Response

Left ventricular myocardial deformation assessment in asymptomatic patients with recently diagnosed sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis

BackgroundSarcoidosis is a systemic granulomatous disease affecting different organs including the heart. Myocardial strain analysis could potentially detect the early stages of cardiac dysfunction in sarcoidosis patients. The present study aims to assess the use of cardiac magnetic resonance (CMR) strain analysis using feature tracking (FT) in the detection of early cardiac involvement in asymptomatic patients with sarcoidosis.MethodsOne hundred and thirteen CMR studies of patients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis without pre-existing known cardiovascular disease were included in the study and analysed using FT and compared to 22 age and gender-matched controls. Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) of the left ventricle (LV) were measured.ResultsThe sarcoidosis patients did not significantly differ from the controls in basic demographic data and had normal global and regional systolic LV function—LV ejection fraction (EF) 66 ± 7% vs 65 ± 5% in the controls (p = NS). No statistically significant differences were found in all strain parameters between patients and controls: GLS (− 13.9 ± 3.1 vs. − 14.2 ± 2.5), GCS (− 23.4 ± 4.0 vs. − 22.2 ± 2.9) and GRS (53.4 ± 13.5 vs. 51.2 ± 13.6%) (p = NS).ConclusionPatients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis had normal myocardial deformation measured by CMR-FT derived global strain

Cardiac Fibrosis and Changes in Left Ventricle Function in Patients with Chronic Chagas Heart Disease.

ResumoFundamento A cardiopatia chagásica (CC) é uma condição de progressão lenta, cujo principal achado histopatológico é fibrose.Objetivos Avaliar se a fibrose cardíaca aumenta ao longo do tempo e se correlaciona com aumento no tamanho do ventrículo esquerdo (CE) e redução na fração de ejeção (FE) na CC crônica.Métodos Estudo retrospectivo que incluiu 20 indivíduos (50% homens; 60±10 anos) com CC crônica que se submeteram a dois exames de ressonância magnética cardíaca (RMC) com realce tardio com gadolínio em um intervalo mínimo de quatro anos entre os exames. Volume, FE e massa de fibrose do ventrículo esquerdo (VE) foram determinados por RMC. Associações da massa de fibrose na primeira RMC com alterações no volume do VE e FE ventricular esquerda na segunda RMC foram testadas por análise de regressão logística. Valores p<0,05 foram considerados significativos.Resultados Os pacientes foram classificados em: A (n=13; alterações típicas de CC no eletrocardiograma e função sistólica global e segmentar do VE normal) e B1 (n=7; alteração na motilidade da parede do VE e FE ≥45%). O tempo médio entre os dois estudos de RMC foi de 5,4±0,5 anos. Fibrose do VE (em % massa do VE) aumentou de 12,6±7.9% para 18,0±14,1% entre os exames de RMC (p=0,02). A massa de fibrose cardíaca no basal associou-se com uma diminuição > cinco unidades absolutas na FE ventricular esquerda da primeira para a segunda RMC (OR 1,48; IC95% 1,03-2,13; p=0,03). A massa de fibrose do VE foi maior e aumentou entre os dois estudos de RMC no grupo de pacientes que apresentaram diminuição na FE entre os testes.Conclusões Mesmo pacientes em estágios iniciais da CC apresentam um aumento na fibrose do miocárdio ao longo do tempo, e a presença de fibrose do VE no basal está associada a uma diminuição da função sistólica do VE.

Feature tracking cardiovascular magnetic resonance in asymptomatic patients with extracardiac sarcoidosis

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): European Regional Development Fund - Project ENOCH (No. CZ.02.1.01/0.0/0.0/16_019/0000868) and the Specific University Research (MUNI/A/1685/2020) provided by the Ministry of Education, Youth and Sports of the Czech Republic (MEYS CR) in the year 2020. Introduction Sarcoidosis is a systemic granulomatous disease affecting many organs including heart. Myocardial strain analysis could potentially detect early stadia of cardiac dysfunction in sarcoidosis patients. Purpose The study aims to assess use cardiac magnetic resonance (CMR) strain analysis using feature tracking (FT) in the detection of early cardiac involvement in asymptomatic patients with sarcoidosis. Methods One hundred thirteen CMR studies of patients with extracardiac sarcoidosis without pre-existing known cardiovascular disease were included into the study and analysed using FT and compared to 22 age and gender matched controls. Global longitudinal strain (GLS), global circumferential strain (GCS) and global radial strain (GRS) of left ventricle (LV) were measured. Results The sarcoidosis patients did not significantly differ from controls in basic demographic data and had normal global and regional systolic LV function – LV ejection fraction (EF) 66 ± 7% vs 65 ± 5% in controls (p = NS). No statistically significant differences were found in all strain parameters between patients and controls: GLS (-13.9 ± 3.1 vs. -14.2 ± 2.5), GCS (-23.4 ± 4.0 vs. -22.2 ± 2.9) and GRS (53.4 ± 13.5 vs. 51.2 ± 13.6%) (p = NS). Conclusion Asymptomatic patients with extracardiac sarcoidosis had normal myocardial deformation measured by CMR-FT derived global strain.

Successful Multiorgan Donation From a Brain-dead Donor Following Liquid Nicotine Voluntary Intoxication: A Case Report.

Successful Multiorgan Donation From a Brain-dead Donor Following Liquid Nicotine Voluntary Intoxication: A Case Report.

Acute Severe Functional Mitral Regurgitation After Non-Mitral Valve Cardiac Surgery—Left Ventricular Dyssynchrony as a Potential Mechanism

Functional mitral regurgitation (MR) describes valve leakage in the absence of disease or damage to the mitral leaflets or subvalvular apparatus. Significant, new functional MR after cardiopulmonary bypass (CPB) may result from a number of intraoperative processes, including left ventricular (LV) ischemia and enlargement, left atrial enlargement secondary to increased filling pressure, and systolic anterior motion of the mitral valve after mitral repair. Assessment of new MR after CPB is important because it may direct hemodynamic maneuvers or prompt reinitiation of CPB if surgical intervention is deemed necessary. Described extensively in the electrophysiology literature but underreported as a cause of MR after CPB, LV dyssynchrony represents another possible mechanism of functional MR, in which resynchronization of conduction via pacing maneuvers may prove beneficial. Herein, a series of 4 patients in whom new MR was found after non-mitral valve cardiac surgery in the setting of normal LV systolic function is presented, and LV dyssynchrony is proposed as a major contributing factor. The findings suggested that the concomitant observation of new or worsened functional MR, together with normal global and regional LV systolic function, should lead the clinician to consider ventricular dyssynchrony as a possible cause. Attempts to improve or alter ventricular conduction should be considered before contemplating a return to CPB for mitral valve intervention.

Myocardial Function Following Repair of Anomalous Origin of Left Coronary Artery from the Pulmonary Artery in Children

We aimed to assess the change in global and regional myocardial function before and after surgical revascularization and their added value when compared with conventional measures in children with anomalous left coronary artery from the pulmonary artery (ALCAPA). Advanced echocardiographic assessment was performed pre- and postoperatively in 22 children with ALCAPA (eight male; median surgery age, 0.4years; interquartile range, 0.21-1.05) and 22 healthy controls. Measurements included global and segmental longitudinal, radial, and circumferential two-dimensional speckle-tracking strain and postsystolic index. Global strains were lower in preoperative patients than in controls (longitudinal: -9% vs -21%; P<.001; circumferential: -11% vs -21%; P<.001; radial: 18% vs 60%; P<.001) and improved postoperatively when compared with preoperative findings (longitudinal: -9% pre vs -16% post; P=.002, circumferential:-11% pre vs -17% post; P=.012, radial: 18% pre vs 53% post; P=.001). Preoperatively, patients with normal global systolic function on conventional echocardiography had significantly impaired global longitudinal and radial strain compared with healthy controls. Global mechanical dyssynchrony improved significantly postoperatively (longitudinal postsystolic index 43 pre vs 6 post, P<.001; circumferential 15 pre vs 2 post, P=.001; radial 48 pre vs 5 post, P=.003). Despite overall improvement in most segments, global longitudinal and circumferential and segmental peak strain in some of the segments supplied by the ALCAPA remained postoperatively abnormal. This study shows that myocardial deformation indices were a more sensitive measure of LV dysfunction in patients before and after ALCAPA repair than conventional echocardiographic measures. We believe, therefore, they should be added to routine preoperative and serial postoperative follow-up assessment.

P1754 Regional left ventricular longitudinal myocardial dysfunction in mitral valve prolapse could be primary

Abstract Background Regional left ventricular dysfunction in patients with mitral valve prolapse (MVP) and normal ejection fraction has been described by different Authors, and recent data point to a dysfunction (prevalently longitudinal strain) of the myocardium of the LV base secondary to dilatation of the mitral annulus. Purpose To investigate degree and extent of regional LV dysfunction and its mechanisms in patients with MVP, severe regurgitation and normal global systolic function, compared to patients with equivalent degree of regurgitation but functional etiology (FMR). Methods Speckle-tracking echocardiography was performed in 30 controls (N), and in severe primary (MVP, n= 50) or functional (FMR, n= 20) mitral regurgitation, to measure global, regional and segmental longitudinal peak systolic strain (LPSS, %), and time delay of peak maximum strain (TTPd, ms, calculated as time to peak maximum strain - time of aortic valve closure). Maximum and minimum mitral annulus diameters and area were measured with 3D echo. We also evaluated as recommended: LV end-diastolic volume index (EDVi, ml/m2), ejection fraction (EF, %), and left atrial end-systolic volume index (LAESVi, ml/m2) with 2D echo; LV stroke volume index, and non-invasive pulmonary systolic (PSP, mmHg) and diastolic pressures (PDP), mmHg) with Doppler echo. Results Age, heart rate, BSA and systolic blood pressure were similar between groups. Atrial fibrillation was present in 34% of MVP and 71% of FMR patients. LV EF was normal in MVP and reduced in FMR (43 ± 14 % vs N, p&amp;lt;.001). LV EDVi (MVP: 77 ± 20 ml/m2; FMR: 107 ± 35, both p&amp;lt;.001 vs N) and LAESVi (MVP: 91 ± 26 ml/m2; FMR: 80 ± 30, both p&amp;lt;.001 vs N) were similarly increased (volume overload) in MVP and FMR, as were PSP (MVP: 42 ± 23 ml/m2; FMR: 52 ± 25, both p&amp;lt;.001 vs N) and PDP (MVP: 16 ± 6 ml/m2; MVP: 15 ± 5, both p&amp;lt;.001 vs N). In FMR, LPSS was reduced globally (-12.8 ± 3.3, p&amp;lt;.001 vs N and MVP) and similarly at LV base, papillary and apical levels. In contrast, in MVP global (-19.4 ± 3.7%) and apical (-23.4 ± 4.5%) LPSS were normal, whereas LV base (-12.3 ± 5.8%, p=.003 vs N) and papillary (-17.1 ± 4%, p=.024 vs N) LPSS were reduced; further, LPSS reduction was localized to the anterior (-16 ± 4, p=.028 vs N), lateral (-17 ± 5, p=.006 vs N) and posterior (-16 ± 6, p=.007 vs N) segments, and was associated with an increased TTPd in the same segments in MVP but not in FMR patients. At multivariate analysis, degree and localisation of regional myocardial dysfunction in patients with MVP was not related to the prolapsing scallop, dimension of the mitral annulus, degree of volume overload or pulmonary pressures, or stroke volume index. Conclusions In patients with MVP, severe regurgitation and normal EF, there is a specific dysfunction pattern of regional LV longitudinal function which appears to be primary and not dependent on the degree of preload increase, mitral annulus dilatation, or localization of the prolapsing scallop.

P1604 T1 mapping in asymptomatic patients with extracardiac sarcoidosis

Abstract Funding Acknowledgements LQ1605 from the National Program of Sustainability II (MEYS CR) Introduction Sarcoidosis is a systemic granulomatous disease affecting in particular the respiratory tract. Estimated 5% of these patients have clinical symptoms of heart involvement. Real number of patients with cardiac sarcoidosis is thought to be higher (around 20-30%), because the granulomatous process is sometimes asymptomatic. Cardiac magnetic resonance (CMR) including T1 relaxation time measurement could potentially detect early asymptomatic stadia of sarcoidosis of the heart. Purpose The aim of this study was to assess T1 mapping in detection of early cardiac involvement in asymptomatic patients with sarcoidosis. Methods One hundred twenty patients with sarcoidosis of the respiratory tract and/or extrapulmonary sarcoidosis and without any heart disease history were included. One hundred thirteen of them underwent CMR examination at 3,0 MR scanner. Cine images for assessment of left ventricular (LV) volumetric and functional parameters, and pre- and post-contrast Saturation method using adaptive recovery times for cardiac T1 mapping (SMART1map) and Modified Look-Locker Inversion recovery (MOLLI) images were acquired for assessment of native T1 relaxation time and extracellular volume (ECV). The measured parameters were compared between sarcoidosis patients and 22 healthy controls. Results Sarcoidosis patients had not enlarged LV (end-diastolic volume 119 ± 24ml vs 97 ± 20ml, p = NS) and normal global and regional systolic LV function – LV ejection fraction (EF) 65 ± 5% vs 66 ± 7% (p = NS). Mean native T1 relaxation time was not prolonged - 1464 ± 93 msec vs 1482 ± 88msec (p = NS) measured by SMART1map and 1317 ± 60 msec vs 1313 ± 83msec (p = NS) measured using MOLLI sequence. Similarly, mean ECV value was not increased - 16,3 ± 3,4% vs 17,9 ± 3,7% (p = NS) measured by SMART1map and 30,9 ± 2,9msec vs 30,7 ± 5,0% (p = NS) measured using MOLLI sequence. Conclusion Myocardial native T1 relaxation time was not prolonged and ECV was not increased in asymptomatic patients with extracardiac sarcoidosis.

P885 Pulmonary artery stent implantation in an adult with chronic thromboembolic pulmonary stenosis

Abstract Introduction Pulmonary artery stenosis presenting in adults is rare. Chronic thromboembolic pulmonary hypertension (CTEPH) is by far the most common cause of pulmonary artery stenosis. Stenosis in these patients are not caused by an abnormality of the arterial wall itself, but by intraluminal narrowing as a result of the only partially resolved and organized thromboembolism. In contrast to paediatric patients, in adults with pulmonary artery stenosis, pulmonary stenting is not routinely performed. Case report A 51-year male, smoker, diabetic, hypertensive, and with chronic kidney disease. He was diagnosed two years earlier with bilateral multiple pulmonary emboli and was maintained on oral anticoagulation therapy. Recently, he presented with gradually progressive shortness of breath and signs of right ventricular failure. Diagnostic imaging: 1-Transthoracic and transesophageal echocardiography showed normal global systolic left ventricular function with no regional wall motion abnormalities, dilated right ventricle (RV) with moderately impaired function, severe pulmonic valve incompetence, mild tricuspid incompetence and a severely elevated right ventricular systolic pressure (RVSP) of 82 mmHg. In addition, a small rounded mass (6 x 11 mm) was visualized attached to the posterior wall of the RV outflow tract (RVOT) about 15mm proximal to the pulmonary valve annulus, (figure A). 2- Computed tomography pulmonary angiography showed a right main pulmonary artery (RPA) with circumferential narrowing, which was highly suggestive of chronic thrombosis. There was an abrupt tapering noted in the segmental branches of the right lower lobar pulmonary artery, with non-opacification of the distal arteries. No contrast opacification was noted in the right upper lobe pulmonary arteries. The left main pulmonary artery showed thickening of its bifurcation, again suggestive of chronic thrombosis, with narrowing of its left upper lobar branch, (figures B&amp;C). 3-Cardiac magnetic resonance (CMR) showed a non enhancing RVOT mass protruding through the incompetent pulmonary valve during systole with features suggestive of a thrombus. Management In view of the clinical history, CTEPH was considered to be the most likely aetiology of the pulmonary hypertension. The decision was to perform balloon angioplasty and stent implantation in the RPA. Immediately after the procedure, RVSP was reduced from 80 to 50 mmHg. The clinical course after this procedure was uncomplicated and the patient showed significant clinical improvement. Follow up CMR showed patent stent with improvement of RV function ( fig D) Abstract P885 Figure.

P681 Surprise imaging findings in an asymptomatic patient with an ECG suggestive of apical hypertrophic cardiomyopathy

Abstract We present the case of a 55-year old woman with an unremarkable past medical history, allergic to eggs and cinnamon and without any clinical complaints, who presented for a routine ECG prior to a dental implant procedure. The ECG revealed signs of left ventricular (LV) hypertrophy with deep negative T waves in V2-V6 (Figure) suggesting apical hypertrophic cardiomyopathy. Her physical exam was unremarkable and a transthoracic echocardiography (TTE) was ordered. The TTE revealed normal LV dimensions, a normal global systolic function of both ventricles, but most remarkably, an isoechoic mass that occupied the whole apex and one third of the LV cavity (Figure), with a maximum thickness of 22 mm and a 2 mm hyperechogenic lining towards the LV, all these findings being suggestive of Loeffler endocarditis. The routine laboratory tests showed (apart from a slightly increased LDL-cholesterol and normal BNP values) hypereosinophilia: more than 10% of the white blood count. Chest X-Ray and the abdominal scan showed no signs of pulmonary or hepatic infiltration. Cardiac magnetic resonance imaging was scheduled, but the patient has claustrophobia and was unable to perform the exam. The aetiological workup included the investigation of allergic, hematologic, as well as parasitic causes of the hypereosinophilic syndrome. Consequently, serological tests for Coxiella, Chlamydia, Echinococcus and Toxocara were all performed. The IgG antibodies for Toxocara canii were found in a very high level, indicating a chronic parasitic infection as a possible cause of the hypereosinophilic syndrome. The hematologic exams were all within normal limits. The endomyocardial biopsy, the gold standard for diagnosis could not be performed for technical reasons. The first step in the management of hypereosinophilia (HE) is stopping exposure to the trigger, as well as specific treatment- albendazole. The patient received oral anticoagulant treatment in order to prevent thromboembolic complications, which are frequently reported in this clinical setting. Loeffler’s endocarditis is usually a late cardiac manifestation of the HE syndrome. This is a rare and surprising case of an incidental imaging diagnosis in a totally asymptomatic patient after a routine ECG that was suggestive of hypertrophic cardiomyopathy. The challenge consisted in finding the cause of HE in order to attempt an aetiological treatment. Although the allergic and parasitic causes were most likely, considering the patient’s history, a hematologic malignancy had to be excluded. HE associated with toxocariasis rarely causes cardiac manifestations, but it should not be excluded when the patient has a history of canine exposure. The most fearsome complication in this case is the embolization of the eosinophilic mass, but the prompt management and routine follow-up allow the prevention of a thromboembolic event. Abstract P681 Figure. ECG and TTE apical views

Utility of 2-Dimensional Speckle-Tracking Echocardiography to Predict Severity of Coronary Artery Disease in Patients With Non ST-Elevation Acute Coronary Syndrome and Apparent Normal Global and Segmental Systolic Function

Utility of 2-Dimensional Speckle-Tracking Echocardiography to Predict Severity of Coronary Artery Disease in Patients With Non ST-Elevation Acute Coronary Syndrome and Apparent Normal Global and Segmental Systolic Function

Effects of Trypanocidal Treatment on Echocardiographic Parameters in Chagas Cardiomyopathy and Prognostic Value of Wall Motion Score Index: A BENEFIT Trial Echocardiographic Substudy

Serial echocardiographic studies in chronic Chagas cardiomyopathy are scarce. The aims of this study were to evaluate whether therapy with benznidazole modifies the progression of cardiac impairment and to identify baseline echocardiographic parameters related to prognosis. A prospective substudy was conducted in 1,508 patients with chronic Chagas cardiomyopathy randomized to benznidazole or placebo, who underwent two-dimensional echocardiography at enrollment, 2years, and final follow-up (5.4years). Left ventricular (LV) ejection fraction, LV wall motion score index (WMSI), indexed left atrial volume, and chamber dimensions were collected and correlated to all-cause death and a composite hard outcome using univariate and multivariate analyses. At enrollment, most patients had normal chamber dimensions, and 70.5% had preserved LV ejection fractions. During follow-up, all chamber dimensions increased similarly in both treatment arms. LV ejection fraction was comparably reduced (55.7±12.7% to 52.1±14.6% vs 56.3±12.7% to 52.8±14.1%) and LV WMSI similarly increased (1.31±0.41 to 1.49±0.03 and 1.27±0.38 to 1.51±0.03) for the benznidazole and placebo groups, respectively (P>.05). A higher baseline LV WMSI was identified in subjects who died compared with those alive at final echocardiography (1.76±0.517 vs 1.271±0.393, P<.0001). There was a significant (P<.0001) graded increase in the risk for the composite outcome with worsening LV WMSI (hazard ratios, 2.27 [95% CI, 1.69-3.06] and 6.42 [95% CI, 4.94-8.33]) and also of death (hazard ratios, 2.45 [95% CI, 1.62-3.71] and 8.99 [95% CI, 6.3-12.82]) for 1<LV WMSI<1.5 and LV WMSI>1.5, respectively. Both LV WMSI and indexed left atrial volume remained independent predictors in multivariate analysis. Trypanocidal treatment had no effect on echocardiographic progression of chronic Chagas cardiomyopathy over 5.4years. Despite normal global LV systolic function, regional wall motion abnormalities and indexed left atrial volume identified patients at higher risk for hard adverse clinical outcomes.

Sometimes Surgery is the Only Way to Make a Diagnosis and Treat the Patient: A Case of Congenital Partial Absence of Pericardium.

IntroductionA 47-year-old Caucasian woman with a past medical history of multiple ablative procedures for supraventricular arrhythmias and pacemaker implantation presented with increasing shortness of breath. The initial working diagnosis of the team treating her was ablation-induced pulmonary stenosis, especially after the recording of increased flow velocities through the right lower pulmonary vein.Case presentationThe patient was alert and oriented, but obviously dyspnoeic. The vital signs were normal. The physical examination revealed a soft cardiac systolic murmur and the lungs were clear on auscultation. The electrocardiogram showed a pacemaker rhythm. The echocardiogram showed borderline normal global systolic function of the left ventricle and severe mitral regurgitation. The transoesophageal echocardiogram confirmed the above findings and revealed increased velocities through the right lower pulmonary vein. The working diagnosis of ablation-induced pulmonary stenosis was reinforced by the cardiac CT angiography. The patient was subsequently referred for surgical intervention. The intra-operative findings were both unexpected and impressive: congenital partial absence of the pericardium was responsible for herniation of the right chambers into the pleural space. Mitral regurgitation was attributed to failure of coaptation due to the very short surface of the leaflets. Extensive external fibrosis around the pulmonary veins caused the pulmonary vein stenosis.ConclusionThe final diagnosis of a partial pericardial defect causing torsion and distortion of the heart chambers was made only at surgery. The consistent finding of pulmonary vein stenosis in the non-invasive modalities and the past medical history of ablations initially misleadingly led us to the assumption that they were related.LEARNING POINTSThe initial working diagnosis of ablation-induced pulmonary vein stenosis based on the patient’s shortness of breath, severe mitral regurgitation, right lower pulmonary vein stenosis and past medical history of multiple ablative procedures, was incorrect.The finding that the cardiac silhouette was borderline displaced to the right, the mildly hypoplastic right lung and the borderline impairment of the global systolic function of the left ventricle, especially after coronary artery disease was ruled out, should have been given greater consideration.Cardiac computer tomographic images taken 7 years ago were used to assess the severity of the right inferior pulmonary vein stenosis; new medical technologies will provide even better diagnostic techniques.