Significant Calcification Research Articles

Balloon-expandable transcatheter heart valves for treatment of aortic valve stenosis in patients with large aortic annuli: Evaluation of deployment balloon overfilling strategies.

Transcatheter aortic valve implantation (TAVI) using balloon-expandable (BE) transcatheter heart valves (THV) in aortic annuli above 29 mm includes particular procedural steps, mainly involving overfilling of the deployment balloon. Data on overfilling strategies in clinical daily practice is scarce. We herein aimed for a retrospective description of utilized overfilling strategies in those patients. Between January 2016 and December 2022, 45 patients (100% male, 76.9 ± 6.1 years) received TAVI in aortic annuli above 29 mm using a BE THV. Overfilling volumina of the deployment balloon were left to operators' discretion. Clinical and multislice computed tomography data were retrospectively collected. Clinical endpoints were adjudicated in accordance with the updated standardized VARC-3 definitions. Profound overfilling (+4/5 mL) was used in patients with a mild calcium burden (˂750 mm³) even in aortic annuli of 29.0-30.0 mm. Nominal/slight overfilling (+1 mL) was used in aortic annuli up to 32.5 mm but an intermediate to severe calcific burden (>750-3200 mm³). Accordingly, a low calcification group (˂750 mm³, n = 17) compared to a significant calcification group (≥750 mm³, n = 28), presented with higher overfilling volumina (2.1 ± 1.4 vs. 0.8 ± 1.0; p ˂ 0.001), although aortic annulus diameter was not different (29.8 ± 0.8 vs. 29.9 ± 0.9 mm; p = 0.7). All-cause 30-day mortality was 0%. Device success was 97.8%. Transvalvular mean pressure gradient at discharge was 9.5 ± 3.6 mmHg. No case of PVL >mild was documented. Extent of overfilling of the deployment balloon largely depends on calcification burden in addition to aortic annulus diameter with significant and profound overfilling particularly in patients with a calcification burden of the aortic valve complex ˂750 mm³.

Eveningness is associated with coronary artery calcification in a middle-aged Swedish population

Coronary artery calcification (CAC) is an established imaging biomarker of subclinical atherosclerosis, but its relationship to diurnal preference is not well studied. We investigated the association between chronotype and CAC in the Swedish CArdioPulmonary bioImage Study (SCAPIS) pilot cohort. Participants aged 50–64 years were randomly recruited and underwent extensive examination including imaging and accelerometry-assessed physical activity. 771 participants (47.3 % male, 57.6 ± 4.4 years) were included in this cross-sectional analysis. CAC was assessed by non-contrast computed tomography, and a CAC score > 10 was considered significant calcification. Self-assessed chronotype was classified as extreme morning, moderate morning, intermediate, moderate evening, or extreme evening. 10-year risk of first-onset cardiovascular disease was estimated by the Systemic Coronary Risk Evaluation 2 (SCORE2). Significant CAC was present in 29 % of the cohort. CAC prevalence increased from extreme morning to extreme evening type (22 %, 28 %, 29 %, 27 %, 41 % respectively, p = 0.018). In a multivariate logistic regression model controlling for confounders, extreme evening chronotype was independently associated with increased CAC prevalence compared to extreme morning type (OR 1.90, [95%CI 1.04–3.46], p = 0.037). When stratified by SCORE2 risk category (low: <5 %; moderate: 5 to <10 %; high: ≥10 %), significant CAC was most prevalent among extreme evening chronotypes in the low and moderate-risk groups, while chronotype seemed less important in the high-risk group (p = 0.011, p = 0.023, p = 0.86, respectively). Our findings suggest circadian factors may play an important role in atherosclerosis and should be considered in early cardiovascular prevention.

THU375 A Case Of Right Eye VI Nerve Palsy In A Patient With Uncontrolled Type 2 Diabetes Mellitus

Abstract Disclosure: C. Musurakis: None. A. Havrylyan: None. J.L. Gilden: None. Background: Uncontrolled type 2 diabetes is one of the most common etiologies of acquired VI nerve palsy. Clinical Case: A 40-year-old Mexican female with uncontrolled type 2 diabetes mellitus (DM), diabetic retinopathy and hypertension was admitted to the hospital due to the new onset of diplopia, headache, and right eye pain. Her symptoms started 2 weeks before seeking medical care and had worsened when she looked towards the right. Duration of DM was more than 10 years, with long-standing history of diet and medication non-compliance. She had never taken the prescribed metformin and insulin, nor did she monitor her blood glucose levels at home. Four years previously, she had received laser therapy to both eyes for diabetic retinopathy. Although she denied numbness or tingling of her extremities, she had a left 4th toe amputation in the past, due to infection, which was complicated by chronic osteomyelitis. There was no prior history of cerebrovascular or cardiac disease. Family history was positive for type 2 DM in both parents. Upon hospital admission, HbA1c was 13.2% (n&amp;lt;5.7). BMI 23.7. Vitals: BP 184/104, HR 110. Labs: blood glucose was 439 mg/dL (n=70-99), CO2 23 mEq/L (n=21-31), AG 12 mmol/L (n=4-11), Beta-Hydroxybutyrate/Acetate 2.0 mmol/L (n=0.1-0.3), venous pH 7.36 (n=7.35-7.45). Physical exam: no conjunctival redness, discharge or swelling around the eye, but inability to abduct the right eye laterally. CT head wo contrast: significant atherosclerotic calcifications within the intracranial segment of right vertebral artery and no acute intracranial abnormality. CTA brain w/wo contrast: no obvious mass effect on 6th cranial nerve territories. MRI of brain and orbit w/wo contrast showed no macroscopic anatomic abnormality or impingement on right abducens nerve but showed minimal white matter changes on the centrum bilaterally. She was diagnosed with an isolated VI facial nerve palsy in the setting of longstanding uncontrolled diabetes mellitus and hypertension. She was started with basal-bolus insulin and antihypertensive therapies and recommended to continue this medication regimen after discharge. She was also advised that gradual recovery of vision may be achieved with glycemic control of DM and hypertension. Conclusion: Although the etiology of acquired VI nerve palsy may be idiopathic, or result from hypertension, trauma, multiple sclerosis, neoplasm, CVA, postsurgical complication, or aneurysm, it is also caused by uncontrolled diabetes mellitus combined with hypertension. It is to be noted that when neoplasm or aneurysm is the cause, the history and examination often reveals the presence of other neurologic symptoms or signs. Reference: Patel SV, Holmes JM, Hodge DO, Burke JP. Diabetes and hypertension in isolated sixth nerve palsy: a population-based study. Ophthalmology. 2005 May;112(5):760-3. doi: 10.1016/j.ophtha.2004.11.057. PMID: 15878054. Presentation: Thursday, June 15, 2023

Multinodular intraventricular lymphoplasmacyte-rich meningioma with significant calcification: a case description.

Multinodular intraventricular lymphoplasmacyte-rich meningioma with significant calcification: a case description.

Femoral or Axillary Cannulation for Extracorporeal Circulation during Minimally Invasive Heart Valve Surgery (FAMI): Protocol for a Multi-Center Prospective Randomized Trial.

Minimally invasive heart valve surgery via anterolateral mini-thoracotomy with full endoscopic 3D visualization (MIS) has become the standard treatment of patients with valvular heart disease and low operative risk over the past two decades. It requires extracorporeal circulation and cardioplegic arrest. The most established form of arterial cannulation for MIS is through the femoral artery and is used by most surgeons, but it is suspected to increase the risk of stroke through retrograde blood flow. An alternative route of cannulation is the axillary artery, producing antegrade blood flow during extracorporeal circulation. Femoral or axillary cannulation for extracorporeal circulation during minimally invasive heart valve surgery (FAMI) is a multicenter randomized controlled trial designed to determine whether axillary cannulation is superior to femoral cannulation for the outcome of a manifest stroke within 7 days postoperatively. The target sample size was 848 participants. Patients ≥ 18 years of age, with valvular regurgitation or stenosis scheduled for minimally invasive surgery via anterolateral mini-thoracotomy, were randomized to axillary cannulation (treatment group) or to femoral cannulation (standard care). Patients were followed up for seven days postoperatively. A CT scan was performed pre-operatively to screen patients for vascular calcifications and to assess the safety of femoral cannulation. The standard of care is femoral artery cannulation, but is performed only in patients without significant vascular calcifications or severe kinking of the iliac arteries and in patients with sufficient vessel diameter. The cannulation is performed via Seldinger's technique, and the vessel closed percutaneously using a plug-based vascular closure device. Only patients without significant vascular calcifications are considered for femoral cannulation, as an increased risk of stroke is assumed. In patients with vascular calcifications, axillary cannulation is the standard of care to avoid these risks. Retrospective studies have hinted that, even in patients without vascular calcifications, there may be a lower stroke risk with axillary cannulation compared to femoral cannulation. We present a protocol for a multi-center randomized trial to investigate this hypothesis. To date, evidence on the best access for peripheral artery cannulation during minimally invasive heart valve surgery has been scarce. Patients may benefit from axillary cannulation for extracorporeal circulation in terms of stroke risk and other neurological and vascular complications, though femoral cannulation is the gold standard. The aim of this study is to determine the risks of peri-operative stroke in a prospective randomized comparison of femoral vs. axillary cannulation.

Aortic regurgitation in bicuspid aortic valve: know to decide

Abstract Funding Acknowledgements Type of funding sources: None. Chronic aortic regurgitation (AR) is the second cause of valve surgery in patients with bicuspid aortic valve (BAV) and has distinctive characteristics of trileaflet regurgitation. The quantification variables of aortic regurgitation do not take into account the unique characteristics of bicuspid regurgitation. Recognition of the mechanisms that lead to bicuspid AR is relevant as it allows correct treatment planning and valve repair in candidate patients. Objective a prospective study was designed to identify the mechanisms of AR and the factors (clinical and anatomical) associated with the development of significant AR (moderate/severe) in adult patients with BAV. Materials and methods We included consecutive adult patients with a confirmed diagnosis of BAV evaluated between 2014 and 2021 with at least 3 years of follow-up by the Structural Heart Disease group of our institution. Valve disease was evaluated by echocardiography and complementary methods. It was classified as mild, moderate (Mod), and severe (Sev) aortic regurgitation, according to current criteria (integral approach with quantitative and semi-quantitative criteria). The prevalence of regurgitation mechanisms, the progression of aortic regurgitation, and predictive variables of significant AR and major cardiovascular events (death, surgery) were analyzed using univariate and multivariate analyses. A p&amp;lt;0.05 was considered significant. Surgery was indicated following international recommendations (ESC guidelines): symptoms development or ventricular dysfunction. Results We included 300 patients (39.7 ± 14.9 years, 72.6% men). Regarding valvular phenotype 84% (257p) presented fused BAV (coronary leaflets) and the majority with raphe (87.5%). 71.7% of the patients had some degree of aortic regurgitation at the start of follow-up (24.1% Mod/Sev AR). Among the patients with significant AR, 50% had cusp prolapse (86% prolapse of the fused leaflet), 39.18% dilatation of the aortic root, 26.6% significant calcification of the valve, 1.3% valve perforation and 29.4% restriction of valve movement. 43% with Mod/Sev AR had mixed mechanisms of regurgitation and the combination, half represented by the combination of aortic root dilatation and cusp prolapse (Fig 2). During follow-up 18–6% of patients with Mod AR showed progression to Sev AR and 4.7% underwent surgery. On the other hand, 34.1% of patients with baseline Sev AR required aortic valve surgery (p&amp;lt;0.01). Conclusions In our cohort, AR was highly prevalent: 1 out of 4 patients had significant AR at the start of follow-up. Eccentric jets and the presence of valve prolapse were frequent in patients with significant AR. 43% of BAV patients with Mod/Sev AR exhibited mixed regurgitating mechanisms. Because mechanism affects the choice of surgical technique, comprehensive mechanism description is critical in patients with BAV and AR.

#3986 THE ROLE AND MECHANISM OF EZH2 IN VASCULAR CALCIFICATION ASSOCIATED WITH CHRONIC KIDNEY DISEASE

Abstract Background and Aims Vascular calcification (VC) is a prevalent complication in chronic kidney disease and contributes to increased cardiovascular morbidity and mortality. EZH2 (Enhancer of zeste 2 homolog-2) is reported as a key epigenetic regulator involved in various kidney diseases such as acute kidney injury, renal fibrosis, diabetic nephropathy, and lupus nephritis. In this study, we aimed to investigated the role of EZH2 in chronic kidney disease associated vascular calcification. Method 1. Patients and Radial Artery Analysis Radial arteries with or without calcification from patients with end-stage renal disease that underwent arterial venous fistular surgery were collected for Von Kossa staining and immunohistochemical (IHC) staining. 2. Animal model of Chronic renal failure-Vascular Calcification (CRF-VC) (in vivo) An adenine and phosphate (1.2%) diet-induced CRF mouse model was designed following an 8-week program. The thoracoabdominal arteries of mice and rats were dissected to assay Ca deposition and histological analysis. Plasma levels of Alkaline phosphate (ALP), and phosphate (Pi) were measured. The transcription level of EZH2 and Runt-related transcription factor 2 (Runx2) were measured by real-time PCR and IHC staining. 3. Aortic ring calcification (ex vivo) Thoracic aortas were dissected from SD rat. To induce calcification, Pi (NaH2PO4/Na2HPO4 [pH = 7.4]) was added to HG-DMEM at a final concentration of 2.6 mmol/l. After the indicated incubation periods (3, 5, 7 days), samples were taken for Calcium deposition assay, Western blotting and histological analysis. 4. Cell culture and treatment (in vitro) Calcification of rat smooth muscle embryonic thoracic aorta cell line A7r5 (VSMC) was induced by incubation in calcifying media. 3-deazaneplanocin A (3-DZNeP), a carbocyclic analog of adenosine was added right after Pi to block EZH2 activation. After the indicated incubation periods, samples were collected for Calcium deposition assay and Western blotting analysis. Results 1. In vivo, EZH2 protein level was increased in calcified radial arteries from patients with end-stage renal disease that underwent arterial venous fistular operation. In CRF-VC mice model, the aortic calcium deposition markedly aggravated in the group induced by adenine diet. Severe vascular calcification was also induced as shown by increased intensity of von Kossa. Moreover, IHC and q-PCR results showed that the protein and transcriptional levels of EZH2 expression were upregulated in calcified aortas of CRF mice, in paralleled with the increased expression Runx2 in protein and transcriptional levels. 2. Ex vivo, histological analysis revealed significant medial vascular calcification in the aortic ring culture with this calcifying medium for 7 days. Similarly, WB results showed that the expression of EZH2 and its downstream, methylation of Histone H3 at lysine 27 (H3K27me3), were significantly enhanced after high Pi medium stimulation while the osteogenic markers Runx2, Osteopontin (OPN) and Msh homeobox 2 (Msx2) protein levels were upregulated and the expression of VSMC differentiation markers α-Smooth muscle actin (α-SMA), Calponin (CNN) and Smooth muscle protein 22 (SM22) were downregulated. 3. In vitro, the osteogenic markers Runx2, OPN and Msx2 were significantly upregulated in high Pi treated VSMCs compared to control VSMCs. Moreover, the epigenetic markers EZH2 and H3K27me3a were markedly repressed in calcifying VSMCs by time. 4. 3-DZNep treatment reduced the calcium deposition in a concentration dependent manner. Western blotting showed that 3-DZNep treatment blocked the increased expression of osteogenic markers Runx2, Bone morphogenetic protein 2 (BMP2) as well as epigenetic markers EZH2 and H3K27me3a by high Pi treatment, indicating that inhibition of EZH2 attenuates VSMCs Calcification. Conclusion Our study revealed that EZH2 is highly expressed in calcified vascular tissues of CRF patients and CRF mice, rat aorta culture and VSMCs calcification models, and EZH2 inhibitor 3-DZNep attenuated calcification of VSMCs. EZH2 could be a promising target for treatment of vascular calcification in CRF patients.

P48: A Single Center Early Experience With DCD Heart Transplantation: Lessons Learned On A New Journey

Intro Heart transplantation remains the gold standard for end stage heart failure refractory to medical therapies. Methods to expand the donor pool continue to highlight the need to increase the supply of hearts to meet the demand. We aim to describe our experience with DCD (donor cardiac death) heart transplantation. Methods: We obtained the total number of DCD attempts at our institution since enactment of our DCD program from our OPO administrator from February 1, 2022 through September, 30, 2022. Our OPO is through Donor Network of Arizona and serves communities across the Southwestern United States. Results: Out of the 11 DCD procurements, 3 hearts were successfully procured, 5 donors did not progress to circulatory death, and 3 donor hearts were turned down due to quality issues. Average age and sex of DCD donors that were used: 22 years, 2 male and 1 female, unused: 30 years, 5 male, and 3 female. Cause of death in the DCD donors that were used included head trauma (2) and anoxia (1). Cause of death in the DCD donors that were not used: head trauma (2), anoxia (5), CVA (1). For the organs that were turned down due to quality, 2 had significant coronary calcifications and 1 had a cardiac contusion. Forty-five percent of our DCD donors did not progress to donor circulatory death. We were able to successfully utilize 27% of DCD offers. Conclusion: More data are required for successful procurement of DCD hearts and further studies are needed to optimize resource utilization. Specifically, predictive models of which hearts are suitable quality and which donors will progress to circulatory death are needed.

Aspirin and statin use in primary prevention after coronary artery calcium score

Abstract Funding Acknowledgements Type of funding sources: None. Introduction A coronary artery calcium (CAC) score of more than 100 places the 10-year cardiovascular risk above 7.5%, justifying the initiation of pharmacological measures in primary prevention. Purpose The present study explores the level of implementation of a primary prevention strategy after CAC score in patients without obstructive coronary disease. Methods The study cohort included all patients from the health area of our city (Galicia, Spain) who underwent a coronary computed tomography (CT) scan between July 2021 and February 2022. Subjects with obstructive coronary disease (CADRADS 3 or higher), atrial fibrillation patients and inconclusive studies were excluded. The final population of the study consisted of 209 patients. The sample was classified according to Agatston Score into three groups: no calcification (CAC=0), non-significant (CAC 1-100), and significant calcification (CAC &amp;gt;101). Multinomial and binomial logistic regression were performed to identify the predictors associated with the prescription of statin and aspirin, respectively. Results 41 patients (19.62%) had significant calcification (CAC &amp;gt;101). Of those, 16 (39.02%) started aspirin and 21 (51.22%) started statin (Figure 1). The CAC score allowed to increase the percentage of patients who benefited from lipid-lowering treatment, from 31.70% to 82.92% (Figure 2). Significant differences were observed in the proportion of patients who initiated aspirin and statins according to the degree of coronary calcification (Chi2 18.76; p=0.000), (Chi2 48.42; p=0.000) respectively. After multivariate adjustment, a CAC score &amp;gt;100 (OR 5.88 (2.29-15.07; p=0.000) and the presence of vulnerable plaque (OR 6.78 (1.01-47.46; p=0.050) were the only predictos which led clinicians to start antiplatelet therapy. Neither age, nor SIS (segment involvement score) were associated. Regarding to lipid-lowering therapy, CAC score 1-100 (OR 5.87 (1.68-20.51; p=0.006) and CAC score &amp;gt;100 (OR 30.78 (5.08-186.47; p=0.000) were independently associated with statin prescription. Conclusions The use of coronary CT allows optimization of the therapeutic strategy in primary prevention, increasing the percentage of patients who may benefit from statins. In this setting, aspirin is little established in our cohort. Therefore, we should transmit to the clinician the possibility of starting antiplatelet therapy, individualizing the indication.

Endovascular Approach to Complex CTO Lesion in a Poor Surgical Candidate

Despite the various uses of endovascular and surgical techniques in management of patients with critical limb ischemia (CLI), traditional open bypass surgery with vein graft was shown to be more durable in the long term in long segment and heavily calcified lesions per the Best-CLI trial. However, patients with extensive cardiovascular risk factors and poor surgical candidates benefit from an endovascular approach. Endovascular revascularization of long segment lesions is complex and often requires the use of multiple unique techniques. Here, we present a case of a 76-year-old male with complex cardiovascular history with history of partial amputation of the right great toe and fifth toe who presented with non-healing ulcers overlying the right first and fifth distal metatarsals. A 76-year-old man with complex cardiovascular history presented with limited mobility, rest pain, and non-healing ulcers overlying the right first and fifth distal metatarsals. Bilateral common femoral artery (CFA) endarterectomy and lower left extremity angioplasty with stenting was done in the past. Doppler studies demonstrated dampened and flat pulses throughout the right lower extremity. Current computed tomography angiography (CTA) showed occlusion of the right superficial femoral artery (SFA) from the ostium to the P3 segment of the popliteal artery with significant calcification. Through ultrasound-guided left CFA access, a .035 guidewire and sheath were advanced into right distal CFA/proximal SFA and with angiogram confirming CTA results. Through the ultrasound-guided right PTA access and double flossing technique, retrograde V-18 guidewire was advanced into the antegrade Navicross catheter positioned within the right CFA. Subsequently, over the guidewire orbital atherectomy and balloon angioplasty were performed from the distal CFA to the proximal ATA region. With use of intravascular ultrasound for vessel diameter measurement, self-expanding stents were placed from the proximal SFA to the distal popliteal region. Final angiogram demonstrated an improvement of luminal diameter with less than 30% stenosis through the right lower extremity. Patient was started on Xarelto and aspirin. Multimodal endovascular technical approaches such as double-crossing flossing technique, controlled antegrade and retrograde tracking (CART) and reverse CART technique, and synapse rendezvous technique help with management of complex long segment occlusions. The case above demonstrates the use of double-crossing flossing technique in successful revascularization of a patient with end-stage CLI.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Peritoneal pre-conditioning impacts long-term vascular graft patency and remodeling.

There are questions about how well small-animal models for tissue-engineered vascular grafts (TEVGs) translate to clinical patients. Most TEVG studies used grafting times ≤6months where conduits from generally biocompatible materials like poly(ε-caprolactone) (PCL) perform well. However, longer grafting times can result in significant intimal hyperplasia and calcification. This study tests the hypothesis that differences in pro-inflammatory response from pure PCL conduits will be consequential after long-term grafting. It also tests the long-term benefits of a peritoneal pre-implantation strategy on rodent outcomes. Electrospun conduits with and without peritoneal pre-implantation, and with 0% and 10% (w/w) collagen/PCL, were grafted into abdominal aortae of rats for 10months. This study found that viability of control grafts without pre-implantation was reduced unlike prior studies with shorter grafting times, confirming the relevance of this model. Importantly, pre-implanted grafts had a 100% patency rate. Further, pre-implantation reduced intimal hyperplasia within the graft. Differences in response between pure PCL and collagen/PCL conduits were observed (e.g., fewer CD80+ and CD3+ cells for collagen/PCL), but only pre-implantation had an effect on the overall graft viability. This study demonstrates how long-term grafting in rodent models can better evaluate viability of different TEVGs, and the benefits of the peritoneal pre-implantation step.

A surgical case of solitary severe tricuspid regurgitation mimicking constrictive pericarditis

BackgroundIt has been reported that severe tricuspid regurgitation may demonstrate constrictive pericarditis-like hemodynamics. In this article, we report a surgical case of solitary severe tricuspid regurgitation in which the hemodynamic features are consistent with constrictive pericarditis.Case presentationThe patient was a 78-year-old man with chronic atrial fibrillation and tricuspid regurgitation. He was admitted to our hospital with complaints of edema and dyspnea, and transthoracic echocardiography showed severe tricuspid regurgitation and enlargement of the bilateral atrium. A right heart catheterization revealed “dip and plateau” patterns in the biventricular pressure waveforms, and both right and left ventricle endo-diastolic pressure had increased to 30 mmHg. Although there were no signs of calcification or thickening of the pericardium in computed tomography, we diagnosed the patient with constrictive pericarditis with severe tricuspid regurgitation and underwent surgical intervention since his heart failure symptoms were resistant to medication. The surgical findings did not show any pericardial thickening or adhesions either; therefore, we diagnosed the patient with solitary severe tricuspid regurgitation showing constrictive pericarditis-like hemodynamics. We performed tricuspid valve replacement with a bioprosthetic valve and his heart failure symptoms improved postoperatively.ConclusionsTo determine the best timing for surgery, it is essential to recognize the existence of severe tricuspid regurgitation mimicking constrictive pericarditis.

Primary pericardial mesothelioma complicated by pericardial calcification

BackgroundPericardial calcification is usually a marker of chronic diseases, and its occurrence in rapidly progressing malignant primary pericardial mesothelioma (PPM) is extremely rare. Therefore, this atypical imaging appearance contributes to more frequent misdiagnosis of PPM. However, no systematic summary currently exists of the imaging characteristics of malignant pericardial calcification in PPM. In our report, its clinical characteristics are discussed in detail, to provide a reference to reduce the misdiagnosis rates of PPM.Case presentationA 50-year-old female patient was admitted to our hospital, presenting primarily with features suggestive of cardiac insufficiency. Chest computed tomography revealed significant pericardial thickening and localized calcification, suspicious of constrictive pericarditis. A chest examination performed through a midline incision showed a chronically inflamed and easily-ruptured pericardium that was closely adherent to the myocardium. Post-operative pathological examination confirmed a diagnosis of primary pericardial mesothelioma. Six weeks postoperatively, the patient experienced symptom recurrence and abandoned chemotherapy and radiation therapy. Nine months postoperatively, the patient died of heart failure.ConclusionWe report this case to highlight the rare finding of pericardial calcification in patients with primary pericardial mesothelioma. This case illustrated that confirmation of pericardial calcification cannot completely rule out rapidly developing PPM. Therefore, understanding the different radiological features of PPM can help to reduce its rate of early misdiagnosis.

Abstract Number ‐ 71: Management of Delayed Carotid Stent Fracture with an Overlapping Open Cell Design Stent: Case Report

Introduction Stent fracture after carotid angioplasty and stenting is rare. Risk factors include presence of angulation, calcification, and restenosis increasing the risk of stent fracture. Although literature indicates that not all carotid stent fractures are associated with adverse outcomes, there is limited details on successful endovascular management of this entity. We describe a unique case of carotid stent fracture with symptomatic restenosis treated with an overlapping open cell stent with no residual stenosis and resolution of symptomology. Methods Case Report. Results A 79‐year‐old man with medical history of right sided symptomatic carotid artery stenosis which had been previously treated with endarterectomy and subsequently carotid stenting after a follow up carotid ultrasound demonstrated recurrence of severe right internal carotid artery (RICA) stenosis. Approximately 2 years after this index procedure, the patient returned with acute onset of left‐hand numbness. Cerebral angiography was performed that demonstrated 85% stenosis with a fractured carotid stent at segment of stenosis (Figure 1A, B). Furthermore, the lesion was found to be heavily calcified. This was determined to be the primary contributing factor in resultant artery wall stress, which over time led to carotid stent fracture. Angioplasty with placement of a new open cell stent and distal embolic protective device was performed successfully. The open cell stent was chosen for this approach as closed cell stents have been associated with an increased odds of in‐hospital stroke/death for carotid lesions, attributable to the lower degree of conformability with closed cell stents. After our stent placement, there was no significant residual stenosis visualized (Figure 1C, D). The patient’s symptoms resolved without any subsequent complaints on follow‐up visit. Conclusions While carotid stent fractures are a rare occurrence, we report a case of symptomatic carotid artery restenosis with a fractured stent due to significant lesion calcification and wall stress. This case was successfully treated with angioplasty and new open cell stent placement due to its potential advantages over closed cell stents in carotid artery lesions. Current literature indicates that carotid stent fractures have a low prevalence. However, there is a paucity of studies on the mechanism of stent fracture as well as optimal management of these fractured stents, suggesting a need for further study and characterization.

Cardiovascular risk factors and pericardial fat volume as predictors of coronary atherosclerosis burden in postmenopausal women: A retrospective, single center study.

Little is known about the clinical relevance of pericardial fat volume (PFV), compared to other conventional cardiovascular risk factors, as predictors of coronary atherosclerosis severity among postmenopausal women. Our main aim was to assess the association of PFV and cardiovascular risk factors with coronary atherosclerosis burden, including occlusive coronary artery disease (CAD) (luminal stenosis >50%), coronary artery calcium score (CAC)>100, and plaque types in postmenopausal women. Patients who had chest pain of angina and referred for 64-slice multi-detector CT (MDCT) angiography examination to exclude occlusive CAD presence were enrolled in this retrospective study. A total of 241 women with absence of menses for more than 2 consecutive years and not taking hormone replacement therapy were enrolled in the present study. Increased PFV(OR[CI] = 1.1 [1-1.3],p = 0.004), age (OR [CI] = 1.1 [1-1.4],p = 0.002), and diabetes mellitus (OR [CI] = 2 [1-4],p = 0.025)were significant predictors of occlusive CAD presence. Increased PFV(OR [CI] = 1.1 [1-1.4],p = 0.017)and increased age (OR [CI] = 1.2 [1.1-1.4],p < 0.001)were better predictors of CAC>100 than other cardiovascular risk factors. Regarding coronary plaque types, increased age (OR [CI] = 1.1 [1.1-1.3],p = 0.001)showed a significant association with coronary calcified plaque presence while increased body mass index(OR [CI] = 1.2 [1-1.4],p = 0.018)showed a significant association with coronary non-calcified plaque presence. Higher PFV values showed an independent association with occlusive CAD and significant coronary calcification. This may imply that increased PFV is likely associated with the development of advanced and severe phenotype of coronary atherosclerosis among postmenopausal women with suspected CAD.

CARDIAC CT DIAGNOSTIC UTILITY IN THE ASSESSMENT OF BICUSPID AORTIC STENOSIS: A COMPARATIVE STUDY WITH ECHOCARDIOGRAPHY AND OPERATIONAL RESULTS

The bicuspid aortic valve is the most prevalent congenital cardiac abnormality, often leading to symptoms in middle-aged individuals. It is a significant determinant of aortic valve dysfunction in the young population. This study aimed to assess the diagnostic utility of cardiac CT in evaluating individuals with bicuspid aortic valve disease. Thirty consecutive individuals with aortic stenosis who underwent surgical valve repair from January 2021 to July 2022 at Chaudhary Pervez Ellahi Institute of Cardiology Multan, Pakistan, were included in the study. ECG-gated CT and echocardiography were performed utilising a 64-MDCT scanner. Imaging findings regarding the number of aortic valve leaflets (bicuspid or tricuspid) were compared with intraoperative observations. Statistical analysis was conducted using one-way univariate analysis of variance. The aortic valve area (AVA) was assessed using CT and echocardiography, and the results were statistically analysed using a paired Student's t-test.: Eleven 30 patients had bicuspid aortic valves, while nineteen had tricuspid aortic valves. Echocardiography failed to determine the type of aortic valve in five patients due to severe calcification. The sensitivity, specificity, positive predictive value, and negative predictive value for detecting a bicuspid aortic valve were 75.5%, 60.3%, 67.6%, and 93.5%, respectively, for echocardiography, and 93.7%, 100%, 100%, and 96.7%, respectively, for CT. CT findings were not significantly different from perioperative observations (p = 0.87), while echocardiographic results were (p &lt; 0.05). CT and echocardiography yielded AVA measurements of 0.931 ± 0.42 cm2 and 0.649 ± 0.241 cm2, respectively, with a significant difference (p &lt; 0.05). ECG-gated cardiac CT provides a reliable morphologic diagnosis of bicuspid aortic stenosis, especially in individuals with significant valve calcification.

Histomorphological evaluation of placenta in SARS-CoV-2 patients: A cross-sectional study.

SARS-CoV-2 has emerged as a major pandemic of the century and little is known about the impact of maternal infection on placental histopathology. Histopathologic examination of placental tissue can contribute to significant information regarding the pathophysiology of the disease and how it affects the fetal outcome. This was a cross-sectional study conducted at the Department of Pathology, Government Doon Medical College and Hospital, Dehradun, on the placenta of 50 coronavirus disease 2019 (COVID-19)-positive pregnant females confirmed by reverse transcriptase-polymerase chain reaction (RT-PCR) from August 2020 to October 2020. Fifty term historical placentas were taken as control. Placenta sections were fixed in formalin, processed into paraffin blocks, stained with hematoxylin and eosin (H and E) stain, and visualized for any abnormality. The most prominent histological finding in the placenta of pregnant women affected by COVID-19 was chorangiosis, which is a feature of fetal vascular malperfusion seen in 28 (56%) cases. Other features included maternal vascular malperfusions (MVM) such as villous crowding and agglutination in 12 (24%) cases. Tenney-Parker change was seen in 13 (26%) patients. Intervillous fibrinoid deposition and intervillous hemorrhage were seen in 37 (74%) patients and 7 (14%) patients showed significant calcification. Other findings observed were less common. Infection with SARS-CoV-2 may be associated with a significant impact on fetal and maternal circulation causing features of fetal and maternal malperfusion such as chorangiosis, villous crowding, and agglutination. Indicating that the infection could cause a potential rise in the risk of adverse perinatal outcomes such as intrauterine fetal growth retardation, preterm birth, or stillbirth.

Automatic Plaque Removal Using Dual-Energy Computed Tomography Angiography: Diagnostic Accuracy and Utility in Patients with Peripheral Artery Disease.

Background and Objectives: This study aimed to evaluate the utility and accuracy of dual-energy automatic plaque removal (DE-APR) in patients with symptomatic peripheral arterial disease (PAD) using digital subtraction angiography (DSA) as the reference standard. Materials and Methods: We retrospectively analyzed 100 patients with PAD who underwent DE computed tomography angiography (DE-CTA) and DSA of the lower extremities. DE-CTA was used to generate APR subtracted images. In the three main arterial segments (aorto-iliac segment, femoro-popliteal segment, and below-the-knee segment), the presence or absence of hemodynamically significant stenosis (>50%) and calcification was assessed using the images. CTA data were analyzed using different imaging approaches (DE-standard reconstruction image (DE-SR), DE-APR maximum intensity projection image (APR), and DE-SR with APR). Results: For all segments evaluated, the sensitivity, specificity, and accuracy for detecting significant stenosis were 98.16%, 81.01%, and 89.58%, respectively, with DE-SR; 97.79%, 83.33%, and 90.56%, respectively, with APR; and 98.16%, 92.25%, and 95.20%, respectively, with DE-SR with APR. DE-SR with APR had greater accuracy than DE-SR or APR alone (p < 0.001 and p < 0.001, respectively). When analyzed based on vascular wall calcification, the accuracy of DE-SR with APR remained greater than 90% regardless of calcification severity, whereas DE-SR showed a considerable reduction in accuracy in moderate to severe calcification. In the case of APR, the degree of vascular wall calcification did not significantly influence the accuracy in the aorto-iliac and femoro-popliteal segments. DE-SR with APR achieved significantly higher diagnostic accuracy for all lower extremity segments in evaluating hemodynamically significant stenosis in patients with symptomatic PAD and transcended the impact of vascular wall calcification compared with DE-SR. Conclusions: APR demonstrated favorable diagnostic performance in the aorto-iliac and femoro-popliteal segments, exhibiting good agreement with DSA even in cases of moderate to severe vascular wall calcification.

Bilan tomodensitométrique thoracique et abdomino-pelvien chez les patients insuffisants rénaux candidats à une transplantation rénale : intérêts et indications

IntroductionScreening for neoplasms and vascular calcifications is a key step before kidney transplantation. American, European and French recommendations diverge on the imaging assessment to be carried out in this context. MethodWe carried out a retrospective single-center study including patients who underwent imaging for kidney transplantation between the 01/01/2011 and the 12/31/2018. The neoplastic pathologies and vascular calcifications discovered on this assessment were noted. ResultsWe included 579 patients: 293 performed a thoracic CT scan, 579 an abdominopelvic CT scan. The imaging work-up revealed 5 malignant thoracic tumors, 14 malignant abdominal tumors and 140 significant calcifications of the external iliac axes. All malignant chest tumors were found in patients with estimated smoking greater than or equal to 30 PY. DiscussionLike the American recommendations, our results are in favor of performing a chest computed tomography in patients with smoking greater than or equal to 30 PY. Contrary to American and European recommendations, our results are in favor of performing an abdominopelvic tomodensitometry in all patients. ConclusionScreening for vascular calcifications and neoplasms in kidney transplant candidates should include routine abdominopelvic CT and chest CT for smoking greater than or equal to 30 PY.

332.10: Pre-transplant Coronary Angiography Findings Based on Coronary or Aorto-Iliac Calcification on CT Imaging in Asymptomatic Patients With a Negative Cardiac Stress Test

Purpose: Cardiac events are now the leading cause of early mortality after kidney transplantation. Long term exposure to immunosuppression also increases cardiometabolic stress after transplantation. Several studies in general population have shown that the presence of coronary artery calcification increases the risk of future cardiovascular events. Among pre-kidney transplant candidates, there remains wide variation in cardiac risk assessment practices across transplant centers. We report coronary angiography findings in asymptomatic candidates undergoing Kidney transplant evaluation with negative stress test but with findings of coronary or aorto-iliac calcification on CT imaging. Methods: We conducted a retrospective single center study of 76 Pre-Kidney transplant recipients who had a negative stress test and underwent coronary angiography between 2010 to 2021. All patients underwent coronary angiography based on coronary or aortoiliac calcification on CT imaging. Mean age was 60 years in both groups. Demographics and results are listed in table 1. Results: Results at our academic center showed that 18 out of 76 patients (23.6%) had a 70% stenosis in one or more coronary vessels. 11 out of 76 patients (14.4%) underwent single or multiple vessels stent placement and one underwent CABG. 7 out of 76 patients (9%) had significant distal disease or vessels were too small for intervention. In CAD group, 13 out of 18 patients (72%) were diabetic. All patients underwent successful kidney transplantation. Post Operative hypotension was more common in non-CAD group, in 9 patients as compared to 3 patients in CAD group. 5 patients in non-CAD recipients had post-op Atrial fibrillation Vs 1 in CAD group. Conclusions: In addition to traditional risk factors and other cardiac risk stratification modalities, Coronary or aorto-iliac calcification on CT imaging is a predictor of significant coronary artery disease in patients undergoing evaluation for kidney transplant surgery. coronary angiography before transplantation should be considered for potential candidates for Kidney transplant with negative stress test but significant vascular calcification. Table 1 - N=76 CAD=18 No CAD=58 Stent 11 NA CABG 1 NA Male/Female 12/6 34/24 Dialysis/Preemptive 12/6 46/12 DM 13 34 Former Smoker/ Nonsmoker 9/9 19/39 Months onHD (Mean) 32.2 32.4