Previous Embolization Research Articles

Initial single-center experience with transapical beating heart mitral valve chordal repair of primary mitral regurgitation

Abstract Introduction Ten patients underwent off-pump transapical mitral valve repair with chordal implantation for the treatment of primary mitral valve regurgitation (MR) between 01.2023 and 03.2024 in our tertiary referral center. Purpose Our aim was to examine the safety, feasibility and effectivity of the surgical method. Methods We fulfilled the retrospective analysis of the patients’ preoperative, operative and postoperative data. Results Median age was 75.5 years [IQR: 74; 80], Euroscore II 2.8 [IQR: 2; 3], and STS Score 3.8 [IQR: 2; 4]. Three patients were in NYHA II, four patients in NYHA III and three patients in NYHA IV functional stage. The patients had severe co-morbidities as congestive heart failure (n=9), pulmonary hypertension (n=10), chronic renal failure (n=4), more than mild coronary artery disease (n=4), peripheral arterial disease (n=4), previous pulmonary embolism (n=4), atrial fibrillation (n=3), chronic obstructive pulmonary disease (n=2), previous stroke (n=1). All the patients had posterior mitral leaflet prolapse ± chordal rupture, causing severe mitral regurgitation. Six patients had isolated P2 disease and four had more complex pathology. Median MR PISA radius was 14 mm [12-15.8], 3-dimension vena contracta area 0.56 cm2 [IQR: 0.56-0.57], effective regurgitant orifice 0.61 cm2 [IQR: 0.5-0.84], regurgitant volume 83 ml [IQR: 65-111], leaflet-to-annulus index 1.23 [IQR: 1.2-1.3] and coaptation index 5 mm [IQR: 4.5-5]. All the surgeries were successful, with median 90 minutes [IQR: 75; 100] surgery time, 2-5 chordal implantations. The intra-operative echocardiography showed trace or mild MR in seven cases, and mild-to-moderate MR in three cases. There was no operative/early postoperative mortality, or early valvular/chordal failure. One case of postoperative bleeding occurred with successful surgical revision. There was one case of 30-days-mortality in a critically ill patient with severe heart failure. Mild left-sided pleural effusions and postoperative atrial arrhythmias were detected in five and three patients, respectively. Median ICU stay was 27 hours [IQR: 23.5; 27.8], and postoperative in-hospital stay was 8 days [IQR: 7; 9]. Predischarge transthoracic echocardiography showed trace-to-mild MR in eight patients, and mild-to-moderate MR in two patients, while three months postoperatively we detected four cases of mild, four cases of mild-moderate or moderate and one case of moderate-to-severe MR. In comparison to the baseline values, five patients were in NYHA I, two in NYHA II and two in NYHA III functional stage three months after surgery. Conclusion In summary, transapical beating heart mitral valve chordal repair seems a relatively safe and effective option for high-risk patients, however, we emphasize the significance of judicious preoperative risk and echocardiographic eligibility assessment and the need for further studies to examine the durability and long-time efficacy of the method.

Endovascular Treatment of Spetzler-Martin Grade III Arteriovenous Malformations: A Single-Center 12 years' Experience Stratified by the Spetzler-Martin Modified Scale.

Limited evidence exists for endovascular first-line treatment of Spetzler-Martin (SM) grade III brain arteriovenous malformations (AVMs). In this article, we sought to evaluate advanced endovascular techniques for treating SM III AVMs across different sizes, eloquence, and patterns of venous drainage. Data from AVMs SM III treated between January 2010 and January 2022 were collected: size (S), eloquence (E), drainage (V), angioarchitecture features (arterial and venous aneurysms, venous drainage, and venous stenosis), treatment strategy (single arterial, double arterial, venous, both arterial and venous, and transvenous endovascular embolization with selective temporary flow arrest [TFATVE]), neoadjuvant treatment, and number of previous embolization sessions. AVMs were classified according to the modified SM grade as follows: small (S1V1E1/III-), medium/deep (S2V1E0/III), medium/eloquent (S2V0E1/III+), and large (S3V0E0). Treatment complications (hemorrhagic and ischemic), clinical discharge and 6-month outcomes (modified Rankin Scale 0-2, mRS), and angiographic occlusion rates were recorded. A total of 91 AVMs (62.6% ruptured, 72.5% S1V1E1, 7% S2V1E0, 19.7% S2V0E1, and 0% S3V0E0) in 91 patients (mean age 37 ± 15.8 years) were included. Treatment techniques included single arterial approach (28.6%), double arterial technique (30.8%), single venous strategy (9.9%), TFATVE (10.9%), and arterial and venous combined (19.8%). The angiographic occlusion rate was 91.2% (90.9% S1V1E1, 100% S2V1E0, and 88.9% S2V0E1) for all techniques, and 100% for the transvenous technique, isolated or combined with transarterial embolization. Minor complication (mRS 0-2), major complication (mRS >2), and mortality rate were 16.5%, 2.2%, and 3.4%, respectively. Overall, treatment morbimortality (mRS >2) was 3% (2/66) for S1V1E1, 0% for S2V1E0, and 16.7% (3/18) for S2V0E1. Although morbidity is non-negligible , endovascular treatment of SM grade III lesions with advanced techniques offers up to 100% rates of cure, which is of high interest, especially for ruptured deep-seated eloquent AVMs with high reruptured rates, and less amenable to microsurgery techniques.

Photon-Counting CT Iodine Maps for Diagnosing Chronic Pulmonary Thromboembolism: A Pilot Study.

The aim of this study was to evaluate the feasibility and efficacy of chronic pulmonary thromboembolism assessment using photon-counting detector computed tomography (PCD-CT) iodine maps of the lung parenchyma. This institutional review board-approved retrospective study included 83 subjects (49.4% male, aged 62.4 ± 13.4 years; 50.6% female, aged 59.9 ± 17.1 years) who underwent clinically indicated PCD-CT scan to rule out chronic thromboembolic pulmonary hypertension (CTEPH). Two blinded readers used iodine maps and corresponding sharp-kernel CT reconstructions in the lung window to evaluate perfusion defects and identify patients with chronic pulmonary thromboembolism (CTEPH, CTEPH overlap with other causes of pulmonary hypertension [PH], chronic thromboembolic disease [CTED]). No other clinical or imaging information was given. Discordance was resolved in a subsequent consensus read. The clinical diagnosis was reviewed in an interdisciplinary clinical setting. The accuracy, sensitivity, and specificity of radiologic evaluation and clinical diagnosis were calculated. Of the 83 subjects included, 32 were diagnosed with CTEPH, CTEPH overlap, or CTED, 35 were diagnosed with PH caused by other pathologic mechanisms, 10 had no PH, and 6 had suffered previous acute pulmonary embolism, which resolved. The interreader agreement was good (Cohen κ = 0.74). The consensus reached high accuracy (0.88), sensitivity (0.94), and specificity (0.84), as well as good agreement with interdisciplinary clinical diagnosis (Cohen κ = 0.75). No cases with confirmed CTEPH as the primary cause of PH or CTED were missed. Patients with pulmonary arterial hypertension were most frequently rated false-positive. The mean effective dose (±standard deviation) was 1.3 (±0.76) mSv. Accurate, sensitive, and specific diagnosis of pulmonary chronic thromboembolism at low radiation dose is possible using iodine maps reconstructed from PCD-CT scans.

Clinical characteristics, resource use, and diagnostic accuracy of natriuretic peptides in cancer patients presenting with acute dyspnea to the Emergency Department

Abstract Background Previous studies suggest that dyspnea is a common presenting symptom in cancer patients and 6% of patients hospitalized for acute heart failure (AHF) have a history of cancer [1]. However, the clinical characteristics and diagnostic accuracy of natriuretic peptides in patients with active or past cancer presenting to the emergency department (ED) with acute dyspnea is largely unknown. Purpose We aimed to evaluate (1) the characteristics of patients presenting with acute dyspnea, (2) the prevalence of AHF, (3) the time to discharge and hospitalization rate, and (4) the diagnostic accuracy of natriuretic peptides (BNP and NT-proBNP) and the recommended algorithm to diagnose AHF in patients with and without cancer [2]. Methods Patients presenting with acute dyspnea to the ED were prospectively enrolled in a multicenter diagnostic study. Patient characteristics, including cancer status was prospectively assessed. Final diagnosis was centrally adjudicated by two independent cardiologists using all individual patient information including cardiac imaging, natriuretic peptides and follow-up data. Discrimination was assessed using the area under the curve (AUC). Results Among 2153 patients, 474 (22.0%) had cancer. Cancer patients were older, more frequently smokers, presented more often with productive cough and less often with paroxysmal nocturnal dyspnea, and had a higher prevalence of previous pulmonary embolism. Prevalence of AHF was 44.9% vs 51.0% in patients with and without cancer, respectively (P = 0.02), although it was the most frequent final adjudicated diagnosis for both groups. Cancer patients had a higher prevalence of pneumonia (18.1% vs 14.4%, P = 0.046) and lower prevalence of psychogenic hyperventilation (1.9% vs 5.2%, P = 0.002). Cancer-related dyspnea accounted for up to 30.4% of final diagnoses. Length of stay in the ED was similar in the two groups, although cancer patients had a higher hospitalization rate (85.0% vs 79.0%, P = 0.004) and the hospitalization was longer (median 9 vs 7 days, P<0.001). The diagnostic accuracy of NT-proBNP was high in cancer patients, but significantly lower compared to non-cancer patients (AUC 0.90 vs 0.93; P=0.02). The diagnostic accuracy of BNP was very high and comparable between groups (0.94 vs 0.95. P=0.40, Figure 1). In cancer patients, the AHF NT-proBNP algorithm maintained a very high safety for ruling out AHF but had lower efficacy with more patients remaining in the gray zone compared with patients without cancer (28.9% vs 18.9%, respectively; P<0.01, Figure 2). Conclusions Patients with cancer presenting with dyspnea have lower prevalence of AHF. Hospitalization rates are increased. The diagnostic performance of NT-proBNP, but not of BNP, is reduced. The efficacy of the NT-proBNP algorithm is reduced with more patients triaged to the grey zone and so is rule-in performance, possibly leading to overdiagnosis and mistreatment.Diagnostic accuracy of BNP and NT-proBNPNT-proBNP ESC algorithm

Burden of In-Hospital Admissions and Outcomes of Thoracic Outlet Compression Syndrome in the United States From 2010 to 2021.

Introduction Despite advancements in medical and surgical management, thoracic outlet syndrome (TOS) remains a complex and often understudied condition with variable outcomes.This study assessed hospitalization rates and outcomes, including patient characteristics, mortality risks, and healthcare costs associated with TOS hospitalizations. Methods We analyzed elective and nonelective hospitalization data for TOS between 2010 and 2021 from the National Inpatient Sample (NIS) and National Readmission Databases (NEDS) and classified the data into neurogenic, venous, and arterial subtypes using the International Classification of Diseases (ICD) diagnostic and procedural codes. The primary endpoint of this study was hospital-related all-cause mortality. Secondary outcomes included hospitalization costs, length of hospital stay, in-hospital complications, and 30-day readmissions. The odds of primary and secondary outcomes were assessed using multivariate hierarchical logistic regression analysis. Cox proportional hazard models were used to assess predictors of 30-day readmission. Results A total of 37,174 hospitalizations for TOSwere identified in the NIS datasets included in our study. Of these, 7,397 (19.9%) were for venous TOS, 3,346 (9.0%) were for arterial TOS, and 26,430 (71.1%) were for neurogenic TOS. Patients with arterial TOS were significantly older (median age: 66; interquartile range (IQR): 54-77 years) compared with venous (63 years; IQR: 50-74) or neurogenic TOS (58 years; IQR: 53-73; P < 0.001). Scalenectomy, with or without first rib resection, was performed in 18% (6,692) of TOS hospitalizations, mainly in neurogenic TOS (16.7%, 4,405 cases) compared to venous (13%, 964 cases) and arterial TOS (38.1%, 1,273 cases). The median duration of hospitalization for TOS was three days (IQR: two to six days). The mean cost of care for all TOS hospitalizations was $107,481 (standard deviation (SD): $4,158). The mean cost of hospitalization was significantly higher for vascular TOS than neurogenic TOS ($114,824 vs. $98,278; P < 0.001) and for venous TOS than arterial TOS ($119,042 vs. $110,606; P = 0.041). Overall, in-hospital mortality was 446 (1.2%). Mortality rates were significantly higher in venous TOS compared to arterial TOS (263 (59.1%) vs. 182 (40.7%); adjusted hazards ratio (AHR): 1.56; 95% confidence interval (CI): 1.26-3.56; P = 0.041). Black race (adjusted Odds ratio (aOR): 3.86, 95% CI: 8.80-16.90; P = 0.043), deep vein thrombosis(aOR: 1.68, 95% CI: 1.18-2.03; P = 0.018), previous coronary artery bypass graft(aOR: 2.37, 95% CI: 1.84-3.92; P = 0.003), pulmonary embolism (aOR: 2.63, 95% CI: 1.23-3.45; P < 0.001), and postoperative sepsis with multiorgan failure (aOR: 3.33, 95% CI: 2.13-6.40; P = 0.032) were correlated with mortality. Conclusion Hospitalization duration and mortality rates for TOS are generally low, though vascular TOS has a longer length of stay and higher mortality than neurogenic TOS. Mortality was significantly associated with Black race, deep vein thrombosis, previous coronary artery bypass grafting (CABG), pulmonary embolism, and postoperative septicemia.

Exercise pulmonary hypertension in chronic thromboembolic pulmonary disease: A right heart catheterization study.

Many patients with chronic thromboembolic pulmonary disease (CTEPD) suffer from exertional dyspnea. It is unclear if CTEPD is associated with exercise pulmonary hypertension (ePH). This cross-sectional study aimed to determine the occurrence of ePH in patients with CTEPD and to identify the haemodynamic changes during exercise. We recruited 36 patients with persistent dyspnoea and residual perfusion defects by ventilation/perfusion scintigraphy from a large cohort of patients with previous pulmonary embolism. All patients underwent exercise right heart catheterization before being classified into the following groups: (1) CTEPD without ePH; comprising patients with normal mean pulmonary artery pressure (mPAP) of ≤20 mmHg, but with mPAP/cardiac output (CO) slope of ≤3 mmHg/L/min, (2) CTEPD with ePH (CTEPD-ePH); those with CTEPD with an mPAP/CO slope of >3 mmHg/L/min, (3) chronic thromboembolic pulmonary hypertension (CTEPH); those with mPAP >20 mmHg, pulmonary arterial wedge pressure (PAWP) ≤ 15 mmHg and pulmonary vascular resistance >2 WU. The postcapillary contribution during exercise was considered present if the PAWP/CO slope of >2 mmHg/L/min. CTEPD without resting pulmonary hypertension (PH) was present in 29 (81%) of the 36 patients, of whom six (21%) had ePH, while five (14%) had CTEPH. Two patients had unclassified PH. Two (33%) of the six patients with CTEPD-ePH had a PAWP/CO slope of >2 mmHg/L/min, compared with two (40%) of the five of those with CTEPH. In conclusion, about 20% of patients with CTEPD and exertional dyspnoea had ePH. Exercise right heart catheterization revealed a notable proportion of patients with postcapillary contribution.

Juvenile Nasopharyngeal Angiofibroma: A Series of 96 Surgical Cases.

Introduction Juvenile nasopharyngeal angiofibroma (JNA) is a benign vascularized tumor that affects almost exclusively male adolescents. Surgery is the treatment of choice for JNA. Objectives The present study is a 42-year retrospective review of a series of JNA cases treated surgically without previous embolization. Methods The present is a retrospective, descriptive study based on medical records of 96 patients with JNA who underwent microscopic or endoscopic excision without previous embolization from 1978 to 2020 in a single institution. The patients were categorized according to the Andrews et al. stage, and data were collected on age, gender, tumor staging, surgical approach, affected side, and outcome. Results All patients were male, with an average age of 17 years. The predominant tumor stage consisted of type II, with 52.1%. A total of 33.3% of the patients were submitted to the microscopic technique and 66.7%, to the endonasal technique. The rate of intraoperative blood transfusion was of 17.7%. Conclusion The present study reinforces that resection of JNA in various stages is viable without previous artery embolization.

Exploring the relationship between embolic acute stroke distribution and supra-aortic vessel patency: key findings from an in vitro model study

BackgroundWe investigated differences in intracranial embolus distribution through communicating arteries in relation to supra-aortic vessel (SAV) patency.MethodsFor this experimental analysis, we created a silicone model of the extracranial and intracranial...

Predictors of Reduced Left Ventricle Global Longitudinal Strain One Year After COVID-19 Pneumonia.

Aim To identify predictors of decreased left ventricular global longitudinal strain (LV GLS) using the method of speckle-tracking in gray scale one year after COVID-19-associated pneumonia in patients without ischemic heart disease (IHD), previous pulmonary embolism (PE), peripheral thrombosis, and atrial fibrillation (AF).Material and methods The study included 156 patients from the Prospective Registry of People After COVID-19-Associated Pneumonia, with optimal visualization quality according to echocardiography (EchoCG), without IHD, AF, history of pulmonary embolism (PE), and peripheral thrombosis. The patients underwent clinical examination in the hospital during the acute period and at 3 and 12 months after discharge from the hospital. To identify earlier predictors of LV GLS impairment, clinical, laboratory, and instrumental data obtained in the hospital and at 3 months of discharge were compared based on the presence of LV GLS impairment one year after discharge (43 patients with reduced LV GLS and 113 patients with normal LV GLS). An LV GLS value ≥18% was considered reduced.Results At 3 months after discharge from the hospital, LV GLS impairment was detected in 34 (21.8%) of 156 patients, and 12 months later, in 43 (27.6%; p=0.211) of 156 patients. In contrast to the group with normal LV GLS, the majority of the group with reduced LV GLS were men (74.4% vs. 37.2%; p=0.001). In this group, body mass index (BMI) was significantly higher (29.9±4.3 kg/m2 vs. 28.1±4.5 kg/m2; p=0.011), and biological (11.6% vs. 2.7%; p=0.024) and hormonal therapy was administered more frequently (38.1% vs. 22.3%; p=0.049). The final predictive model for LV GLS impairment included male gender (odds ratio (OR), 5.65; 95% confidence interval (CI), 1.22-14.37; p &lt;0.001), BMI (OR, 1.11; 95% CI, 1.01-1.23; p=0.040), left ventricular end-systolic volume index (LVESVI) (OR, 1.10; 95% CI, 1.01-1.22; p=0.046) and right ventricular outflow tract (RVOT) acceleration time (OR, 0.98; 95% CI, 0.95-0.99; p=0.027).Conclusion One year after COVID-19-associated pneumonia, a decrease in LV GLS was observed in 27.6% of patients without IHD, AF, history of PE, and peripheral thrombosis and was associated with male gender, increased BMI and LVESVI, and shortened RVOT acceleration time as measured 3 months after discharge from the hospital. The decrease in LV GLS one year after discharge was not associated with the severity of the disease, length of stay in the hospital, or biological and hormonal therapy.

Successful Treatment of Massive Pulmonary Embolism with Rescue Fibrinolysis in Young Patient with Homocystinemia - Case Report

Abstract Pulmonary embolism (PE) is the most frequently missed diagnosis in the urgent clinical department with serious consequences. Patients with unprovoked PE have increased risk of recurrent PE. Approximately 5 to 8% of PE patients have inherited thrombophilias. A solated homocystinemia is a rare cause of unprovoked acute pulmonary embolism. Timely diagnosis and proper treatment can prevent complications, costs and mortality and provide patient better quality of life. We are presenting a 42-year-old woman was admitted to our emergency department with the first episode of severe dyspnea and chest pain. She had no history of previous cardiovascular or respiratory disease and no history of previous pulmonary embolism (PE) or deep vein thrombosis (DVT). Urgent echocardiography showed indirect signs of pulmonary embolism which was confirmed by the pulmonary artery CT angiography performed one day after the patient’s admission. After two days of heparin infusion, she developed a hemodynamic instability with cardiogenic shock and was treated successfully with fibrinolysis. After the clinical stabilization, she was put on the rivaroxaban therapy, which was recommended for additional six months. The thrombophilia profile was done two weeks after stopping the therapy with rivaroxaban. The thrombophilia panel came back positive for high levels of homocysteine (67 μmol/L), with other thrombophilia results within normal limits. The patient was stable during the follow-up period. Pulmonary embolism should be always suspected in younger patients with acute severe dyspnea even without provocable risk factors. High suspicion level and fast diagnosis are lifesaving. In younger patients presented with unprovoked pulmonary embolism, clinicians should consider inherited prothrombotic factors and homocystinemia as a potential cause. Rescue fibrinolysis is a lifesaving therapy in hemodynamic worsening in intermediate high-risk PE patients. A longer anticoagulation therapy should be considered in these cases with novel oral anticoagulants that are recommended as safer and superior therapy.

Symptomatic Inflammatory Reaction from Previous Uterine Artery Embolization Requiring Hysterectomy Twelve Years Later

Symptomatic Inflammatory Reaction from Previous Uterine Artery Embolization Requiring Hysterectomy Twelve Years Later

Abstract 17006: Clinical Characteristics and All-Cause Mortality After Non-Major Bleeding in Patients With Atrial Fibrillation Taking or Not Oral-Anticoagulant: The Fushimi AF Registry

Background: The use of oral anticoagulants (OAC) in atrial fibrillation (AF) patients increases the risk of bleeding. However, the relationship between OAC use before and after non-major bleeding and all-cause mortality remains unknown. Purpose: We aimed to investigate the association between OAC prescription before and after non-major bleeding and all-cause mortality in AF patients. Method: In the Fushimi AF Registry, follow-up data were available in 4,496 patients by the end of February 2022. Patients were divided into four groups based on OAC prescription before and after non-major bleeding: G1 (OAC prescribed both before and after), G2 (OAC prescribed before but not after), G3 (OAC not prescribed before but prescribed after), and G4 (OAC neither prescribed before nor after). Non-major bleeding was defined as all bleeding except for major bleeding according to the criteria of the International Society on Thrombosis and Haemostasis. Result: During the median follow-up of 1,448 days, 733 patients experienced non-major bleeding. G1 had 452 patients, G2 had 54, G3 had 63, and G4 had 164. G1 and G2 were more often non-paroxysmal AF and had significantly higher prevalence of previous stroke or systemic embolism, heart failure and dyslipidemia and had higher CHADS2 scores than G3 and G4. All-cause mortality after non-major bleeding occurred in 91 patients in G1, 54 in G2, 63 in G3, and 164 in G4. (G1: 5.1%, G2: 13.0%, G3: 7.1%, and G4: 6.8% per patient-year, p=0.0004). Multivariate analysis showed that the G2 group had a higher incidence of all-cause mortality as compared with G1 (HR 2.49, 95%CI 1.58-3.93; p&lt;0.0001), G3 (HR 2.44, 95%CI 1.23-4.84; p=0.011), and G4 (HR 1.71, 95%CI 1.00-2.93; p=0.0502) [Figure]. Conclusion: Discontinuation of OAC therapy after non-major bleeding in Japanese AF patients was associated with increased all-cause mortality.

Systemic embolization in infective endocarditis.

Embolism is a common complication in infective endocarditis which may lead to serious complications, such as stroke, intestinal ischemia, and peripheral embolization. A comprehensive literature search was performed and the registry at our centre, including 390 cases of infective endocarditis, diagnosed between 2010 and 2020, was investigated. Large registries show that 20-40% of patients with infective endocarditis (IE) are affected by embolism. In many instances, embolism is present already at the time of diagnosis. The rate of embolism during the hospital stay in our data was 11%. However, only 2% developed clinical embolism during or following surgery. According to recent guidelines, previous embolism, and the presence of vegetations > 10mm present an indication for surgical treatment. Routine imaging revealed non-symptomatic cerebral embolism in 8.5% of surgical patients. However, it is not clear whether detection of non-symptomatic embolism and consecutive surgical treatment improves the prognosis of infective endocarditis.

Factors Influencing the Degree of Resection and Proposed Preoperative Scale for The Management of Skull Base Meningiomas

Objectives: to identify factors involved in the degree of resection of skull base meningiomas and to propose a scale to calculate the probability of total resection. Materials and methods: unicenter, observational, retrospective study of patients operated on in the period 06/2018 – 06/2022. The following variables were used: age, clinic, location, size, previous embolization, perilesional edema, intertumoral calcium, characteristics in T2 and T1 and bone invasion. The degree of resection was measured with the traditional Simpson classification and was also divided into total (Simpson I, II and III) and subtotal (Simpson IV and V) resection. With the results, a scale was proposed taking into account the variables with statistical significance (p &lt; 0.05). A literature review of the topic was conducted. Results: A total of 23 patients were operated. They were statistically significant associated with Simpson's grade, location (p 0.002) and size (p 0.001). Associated with total and subtotal resection, bone invasion (p 0.013). For the scale we use: location (anterior 1 point, posterior 2 points, medial 2 points and medial involving cavernous sinus 3 points), size (&lt;5 cm 1 point, &gt;5 cm 2 points) and bone invasion (not 1 point and if 2 points). We performed an inferential analysis and an association was observed between the scale performed and the degree of resection (p 0.005). Conclusion: In our study, an association was observed between bone size, location and invasion with the degree of resection achieved. We proposed a scale to measure the probability of total resection.

CPC07 Lupus comedonicus: a not so common entity

Abstract Lupus comedonicus (LC) is an exceedingly rare variant of chronic cutaneous lupus erythematosus (CCLE), with only 13 reported cases in the literature to date. While its aetiology remains unknown, hallmarks include the presence of comedones on erythematous plaques, particularly in seborrhoeic areas. We report a case of LC involving the scalp, concha bowl and upper back. A 53-year-old female smoker with a 20-pack-year history and previous unprovoked pulmonary embolism presented to dermatology with a 2-year history of alopecia and rash affecting her face and upper back. She was initially reviewed by oral medicine for ulcers, where erythematous buccal mucosal plaques with white striations were seen. The initial biopsy showed a patchy lichenoid inflammatory infiltrate, raising suspicions for lichen planus; however, repeat biopsy highlighted perivascular inflammation and keratin plugging suggestive of lupus. Full skin examination revealed patchy scarring alopecia with perifollicular scale and erythema. Erythematous infiltrated plaques were seen on the face with similar more indurated lesions on the upper back associated with open comedones. The eponymous Shuster sign was observed in the left conchal bowl, with associated follicular occlusion. Laboratory studies all returned within normal limits, including antinuclear antibody titres and complement levels. Differential diagnosis included lupus erythematosus tumidus, discoid lupus erythematosus and LC. Lesional biopsies taken from her back confirmed LC, highlighting lichenoid inflammation involving follicles and interfollicular skin, with superficial and deep perivascular infiltrate. We commenced oral hydroxychloroquine at 200 mg once daily for management, with topical mometasone furoate 0.1% to be used while awaiting its full effect. Smoking cessation has also been advised given the potentially antagonistic effect of smoking with lupus and hydroxychloroquine. Hypotheses of the pathogenesis of LC include the effect of sun exposure. Ultraviolet radiation is known to not only enhance the activity of CCLE but may also contribute to the formation of comedones. Actinic damage alters collagen of normal skin, promoting sebum retention and follicular plugging. Given its infrequency, LC could be mistaken for benign conditions, including acne vulgaris, naevus comedonicus and Favre–Racouchot disease. It is plausible that the small case numbers are due to current underdiagnoses. It is important for dermatologists to be aware of and accurately diagnose LC. Apart from its potentially destructive, scarring complications, especially in untreated and misdiagnosed cases, it is associated with systemic lupus in 30% of cases. Delay in diagnosis and therapeutic management can be associated with significant potential morbidity and even mortality.

Is myocardial fibrosis in patients with non-ischemic dilated cardiomyopathy associated with the whole-heart myocardial mechanics?

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Non-ischemic dilated cardiomyopathy (NIDCM) is a severe form of primary myocardial disease related with progressive heart failure (HF) and a poor prognosis. In patients with NIDCM, myocardial fibrosis (MF) is associated to adverse cardiovascular outcomes and should be evaluated quickly in each case of NIDCM [1,2]. Purpose To evaluate the relationships between the whole-heart myocardial strain parameters and presence of late gadolinium enhancement (LGE) in a prospective cohort of NIDCM patients. Methods The study group consisted of 101 patients with NIDCM who were referred for a cardiovascular magnetic resonance (CMR) and speckle tracking echocardiography examination. We analyzed MF by LGE, and the whole-heart (both ventricles and atria) myocardial mechanics were evaluated by speckle tracking. All patients underwent a comprehensive clinical evaluation, laboratory test assessment, electrocardiogram, Holter monitoring. The exclusion criteria were ischemic coronary disease, primary valvular heart disease, chronic kidney disease (eGFR &amp;lt;30 ml/min/1.73 m2), under the age of 18, a poor echocardiographic or CMR image quality, inflammatory myocardial disease, previous pulmonary embolism, peripartum cardiomyopathy and toxic damage. Results The study group was divided into two groups according to the presence of MF fibrosis. The presence of MF was associated to worse of the whole-heart myocardial strain parameters. Both ventricles or atria were more dilated in the group with MF. The strongest relationships were detected between presence of MF and mechanical strain parameters of the left side of the heart (left ventricle ejection fraction (LVEF) (r=0.662, 25 p&amp;lt;0.001), left ventricle global circumferential strain (LV GCS) (r=-0.609, p&amp;lt;0.001), left ventricle global longitudinal strain (LV GLS) (r=-0.586, p&amp;lt;0.001), left atrial reservoir strain (LASr) (r=0.588, p&amp;lt;0.001). Logistic regression analysis revealed that the last three mentioned strain parameters were independently associated with presence of MF. Conclusions In patients with NIDCM, the whole-heart myocardial mechanics are worse in patients‘ presence of MF. LV GLS, LV GCS, and LARs are the best 2D echocardiographic mechanical strain parameters to prognosticate the presence of MF.

P95 A RARE CASE OF INFECTIOUS AORTITIS

Abstract Aortitis is an inflammatory process affecting the arterial wall. There are infectious and non–infectious forms. While the non–infectious forms can be linked to arteritis of the large vessels, the infectious forms are a rare but fearful complication of infective endocarditis. In this case the most affected pathogenic species are gram positive bacteria such as streptococci and enterococci. An 81–year–old patient, hypertensive, with permanent atrial fibrillation, subjected to previous aortic valve replacement (with Intuity 27 mm bioprosthesis for severe stenosis in 2016) and with previous pulmonary embolism in 2021, was admitted to emergency department for oliguria and worsening ankle swelling in December 2022. The haemodynamic parameters at the hospital admission were stable. A transthoracic echocardiography was performed, which highlighted a vegetation of about 2 cm on the aortic bioprosthesis with mild stenosis and negligible intraprosthesis regurgitation. A cerebral and thoraco–abdominal CT angiography showed multiple thromboembolic outcomes involving the splanchnic vessels, kidney and spleen. The patient was then subjected to transesophageal echocardiography which highlighted the presence of vegetation on the bioprosthesis with diameters of 12x12 mm; moreover, aneurysmal dilatation of the aortic root was found with the presence, both anteriorly and posteriorly of the wall, of a thickening of about 1 cm which extended up to the sino–tubular junction. The patient‘s hospitalization was also complicated by intestinal subocclusion without urgent surgical indications.The patient‘s case was discussed collectively and it was decided, in the light of the high risk of intestinal ischemia (linked to the thromboembolic occlusion of the splanchnic vessels) not to subject the patient to cardiac surgery. In a recent publication of a case report with literature review, 12 cases were reported, all treated surgically, of which 2 died. Our patient, unable to undergo surgical therapy, represents the first case treated with medical therapy alone. To date, the patient is still hospitalized, in stable haemodynamic conditions, with a unfavorable long–term prognosis.

Boosted-Dose Yttrium-90 Radiation Segmentectomy or Lobectomy for Hepatocellular Carcinoma Refractory to Prior Transarterial Embolization or Chemoembolization: A Single Institution Retrospective Case Series.

To assess the tumor response rates and liver toxicity of boosted-dose transarterial radioembolization (TARE) for treatment of hepatocellular carcinoma (HCC) refractory to previous transarterial embolization (TAE) and/or chemoembolization (TACE). All patients were identified who had HCC treated between 2017 and 2020 that had been refractory to prior TAE or TACE, then treated with boosted-dose segmental or lobar TARE. Tumor response was assessed by multiphasic CT or MRI using localized mRECIST imaging criteria and serological alpha-fetoprotein levels at three and six months after TARE, if available. Liver toxicity was evaluated using serial serological liver function tests, platelet counts, and clinical Child-Pugh and MELD scores. Twenty-four patients met inclusion criteria. Mean age was 68.7years (54-89); 8 were females. Three (12.5%) patients had Barcelona Clinical Liver Cancer stage A, 4 (16.7%) stage B, and 17 (70.8%) stage C disease. Three months after TARE, 52% of patients had a complete response and 33% had a partial response. Mean AFP decreased from 33.2ng/mL at baseline to 17ng/mL at 3months (p = 0.782). The median MELD-Na score increased from 11 at baseline to 16 at 6months post-TARE (p = 0.044); the mean Child-Pugh score rose from 5 at baseline to 6 at 3months post-TARE (p < 0.01). Boosted-dose TARE resulted in statistically significant favorable tumor responses by imaging criteria in 85% of patients previously refractory to TAE or TACE. TARE resulted in transient but acceptable deterioration of liver function and clinical scores.

Isolated pulmonary embolism - a specific clinical entity?

Pulmonary embolism in classical meaning is a complication of deep vein thrombosis (usually in the leg veins), developing after a part of the thrombus dislodged and got wedged in pulmonary arteries. However, in half of the patients with pulmonary embolism, deep vein thrombosis is not found. One potential explanation is a different, less common location of the thrombus or previous complete embolization of the whole thrombotic mass. Another possibility is pulmonary artery thrombosis in situ, which is a specific clinical entity associated with some typical risk factors. It develops in the place of vascular injury, as a consequence of hypoxia, inflammatory changes, endothelial dysfunction and injury. Pulmonary artery thrombosis in situ can be a complication after lung resection, radiation therapy, chest trauma, in the patients with Behçet´s disease, sickle cell anemia, chronic obstructive pulmonary disease, tuberculosis or covid pneumonia. Pulmonary artery thrombosis in situ may differ from classical pulmonary embolism in prognosis as well as in therapeutic approach.

Intraoperative Visualization of Flow in Direct Cerebrospinal Fluid-Venous Fistulas Using Intrathecal Fluorescein.

Cerebrospinal fluid-venous fistulas (CVFs) are a rare cause of spontaneous intracranial hypotension. Intraoperatively, CVFs are not readily identifiable and difficult to differentiate from normal veins. To assess the utility of intrathecal fluorescein injection intraoperatively to visualize and identify the CVF. We report a case series of patients treated surgically for a CVF. After surgical exposure, we injected intrathecal fluorescein (5-10 mg) through a lumbar catheter, which we placed immediately before surgery. Four patients with spontaneous intracranial hypotension with a suspected CVF underwent surgical ligation with adjunctive intrathecal fluorescein application. Intraoperative fluorescein injection confirmed the presence of a CVF in 3 cases. In 2 cases, we observed rapid fluorescein filling of a single epidural vein constituting the CVF. Other epidural vessels did not fill with fluorescein. In 1 case, fluorescein helped to identify a residual CVF after previous incomplete embolization. In the fourth case, no CVF was found intraoperatively. By contrast, a meningeal nerve root diverticulum was visualized, wrapped, and clipped. We demonstrate for the first time the direct intraoperative visualization of CVF using intrathecal fluorescein. CVF can be identified intraoperatively using fluorescein dye, which can be a valuable adjunct for the surgeon confronted with this disease.