Signs Of Congestion Research Articles

Spontaneous middle meningeal arteriovenous fistula without cortical venous reflux presenting with acute subdural hematoma: illustrative case.

Dural arteriovenous fistula (AVF) without cortical venous reflux (CVR) has a relatively benign course. Here, the authors describe a patient presenting with subdural hematoma due to a middle meningeal AVF without CVR. A 17-year-old male was admitted to the emergency department with acute headache without an episode of head trauma. Computed tomography demonstrated a left acute subdural hematoma (SDH). Because the nontraumatic SDH raised the suspicion of vascular pathology, emergent angiography was performed, which demonstrated an AVF fed by the middle meningeal artery and draining to the diploic vein via the serpentine meningeal vein without CVR. T2-weighted magnetic resonance imaging (MRI) revealed no signs of venous congestion. Given the proximity of the AVF to the SDH and the MRI findings, we suspected that the serpentine meningeal vein was responsible for the SDH. The patient was successfully treated with transarterial Onyx embolization. During the injection, Onyx migrated to the extravascular space following its penetration into the serpentine meningeal vein, suggesting the meningeal vein was a bleeding source of the subdural hematoma. Despite the absence of cortical venous reflux, serpentine meningeal venous drainage of middle meningeal AVF can be a source of subdural hemorrhage.

Quantitative fluid overload in severe aortic stenosis refines cardiac damage and associates with worse outcomes.

Cardiac decompensation in aortic stenosis (AS) involves extra-valvular cardiac damage and progressive fluid overload (FO). FO can be objectively quantified using bioimpedance spectroscopy. We aimed to assess the prognostic value of FO beyond established damage markers to guide risk stratification. Consecutive patients with severe AS scheduled for transcatheter aortic valve implantation (TAVI) underwent prospective risk assessment with bioimpedance spectroscopy (BIS) and echocardiography. FO by BIS was defined as ≥1.0 L (0.0 L = euvolaemia). The extent of cardiac damage was assessed by echocardiography according to an established staging classification. Right-sided cardiac damage (rCD) was defined as pulmonary vasculature/tricuspid/right ventricular damage. Hospitalization for heart failure (HHF) and/or death served as primary endpoint. In total, 880 patients (81 ± 7 years, 47% female) undergoing TAVI were included and 360 (41%) had FO. Clinical examination in patients with FO was unremarkable for congestion signs in >50%. A quarter had FO but no rCD (FO+/rCD-). FO+/rCD+ had the highest damage markers, including N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. After 2.4 ± 1.0 years of follow-up, 236 patients (27%) had reached the primary endpoint (29 HHF, 194 deaths, 13 both). Quantitatively, every 1.0 L increase in bioimpedance was associated with a 13% increase in event hazard (adjusted hazard ratio 1.13, 95% confidence interval 1.06-1.22, p < 0.001). FO provided incremental prognostic value to traditional risk markers (NT-proBNP, EuroSCORE II, damage on echocardiography). Stratification according to FO and rCD yielded worse outcomes for FO+/rCD+ and FO+/rCD-, but not FO-/rCD+, compared to FO-/rCD-. Quantitative FO in patients with severe AS improves risk prediction of worse post-interventional outcomes compared to traditional risk assessment.

Case Report: Heart failure in the puerperium

BACKGROUND: Cardiomyopathies that occur de novo in relation to pregnancy or childbirth have diverse etiologies, although they are uncommon, they contribute substantially to maternal morbidity and mortality. In addition, during gestation there are hemodynamic changes that could make hidden heart disease manifest and produce ventricular remodeling with the consequent appearance of persistent or transient structural heart disease. Currently, there is little data on the prevalence of heart disease that occurs during or after pregnancy; for this reason it is of utmost importance to know the cardiovascular diseases related to this period. CASE REPORT: A 26-year-old female patient, who during her late puerperium, after her first pregnancy, terminated by cesarean section due to preeclampsia with severity criteria, presented signs and symptoms of heart failure. After evaluation, ischemic causes were ruled out, maintaining a high diagnostic suspicion of peripartum cardiomyopathy, based on the absence of a history of heart disease prior to pregnancy, the presence of preeclampsia during gestation and the clinical presentation associated with the puerperium; however, after searching for the etiology by cardiac imaging studies, suggestive data of left ventricular non-compaction cardiomyopathy was reported. EVOLUTION: After definitive diagnosis was made, optimal medical therapy for heart failure with reduced ejection fraction was established. The patient presented a favorable evolution, with symptomatic improvement and decrease of clinical and radiological signs of pulmonary congestion and was discharged with the same pharmacotherapy and indications for outpatient monitoring. CONCLUSION: In this case we are dealing with a patient with no cardiac pathology prior to pregnancy, who debuted with symptoms of heart failure in the late puerperium. Although imaging studies confirmed the diagnosis of left ventricular non-compaction cardiomyopathy, the case should be closely followed up due to the probability of reversible ventricular trabeculations associated with pregnancy and not a noncompacted left ventricular cardiomyopathy per se. Given the difficulty for diagnosis and identification of the etiology, the pathology should be studied exhaustively, especially in patients with a high probability of presenting trabeculations as part of adaptive remodeling.

Similarities and Distinctions Between Acetazolamide and SGLT2 Inhibitors in Patients With Acute Heart Failure: Key Insights Into ADVOR and EMPULSE.

Both acetazolamide and sodium-glucose cotransporter 2 (SGLT2) inhibitors block sodium reabsorption in the proximal renal tubule primarily through inhibition of sodium hydrogen exchanger isoform 3 (NHE3), but neither SGLT2 inhibitors nor acetazolamide produce a sustained natriuresis due to compensatory upregulation of sodium reabsorption at distal nephron sites. Nevertheless, acetazolamide and SGLT2 inhibitors have been used as adjunctive therapy to loop diuretics in states where NHE3 is upregulated, e.g., acute heart failure. Two randomized controlled trials have been carried out with acetazolamide in acute heart failure (DIURESIS-CHF and ADVOR). In ADVOR, acetazolamide improved physical signs of fluid retention, but this finding could not be explained by the modest observed diuretic effect. Acetazolamide did not produce a natriuresis in the DIURESIS-CHF trial, and in ADVOR, immediate effects on symptoms and body weight were not reported, and the drug had no effect on morbidity or mortality after 90 days. Three randomized controlled trials have been carried out with empagliflozin (EMPAG-HF, EMPA-RESPONSE-AHF and EMPULSE in acute heart failure. The EMPULSE trial did not report effects on diuresis or in changes in physical signs of congestion during the first week of treatment, but in EMPAG-HF and EMPA-RESPONSE-AHF, empagliflozin had no effect of dyspnea, urinary sodium excretion or body weight during the first 4 days. In the EMPULSE trial, empagliflozin improved health status at 15 days and reduced the risk of worsening heart failure events at 90 days, but these effects are similar in magnitude and time course to the early statistical significance on the risk of heart failure hospitalizations achieved within 14-30 days in the major trials of SGLT2 inhibitors in patients with chronic heart failure. Neurohormonal inhibitors produce this early effect in the absence of a diuresis. Additionally, in numerous randomized controlled trials, in-hospital diuretic intensification has not reduced the risk of major heart failure events, even when treatment is sustained. These findings, taken collectively, suggest that any immediate diuretic effects of acetazolamide and SGLT2 inhibitors in acute heart failure are not likely to influence the short- or long-term clinical course of patients This article is protected by copyright. All rights reserved.

Scrub Typhus in Children: A Prospective Observational Study in a Tertiary Care Hospital in Eastern India.

Background Scrub typhus is a reemerging, acute, undifferentiating febrile illness and one of the most neglected tropical diseases, calling for an in-depth investigation into its clinical diversity, complications, and mortality, which drives us to carry out this research work. Methods Over a year, prospective observational research was carried out after gaining parental consent and institutional ethical clearance, 206 children of either gender aged between one month and 12 years who had been hospitalized with a fever for at least five days and subsequently tested positive forOrientia​​​​tsutsugamushiwere included in the study. Basic demographic information, clinical characteristics, laboratory findings, complications, related coinfections, and results were gathered and analyzed.A P-value of 0.05 was set as the statistical benchmark. Results The current study found that boys outnumbered girls. The ratio of boys to girls was 1.22:1, and the average age was 5.18 years. All had a fever (100%), and the other most frequently occurring clinical signs and symptoms were abdominal pain (16.99%), vomiting (22.33%), hepatosplenomegaly (49.51%), facial puffiness (39.32%), edema (27.18%), lymphadenopathy (19.90%), eschar (19.90%), macular-erythematous rash (17.96%), cough (21.84%), conjunctival congestion (25.24%), and headache (13.59%). Anemia (81.55%), leucocytosis (20.39%), leucopenia (6.8%), thrombocytopenia (49.51%), thrombocytosis (2.43%), and elevated serum levels of alanine aminotransferase (ALT, 57.28%) and aspartate aminotransferase (AST, 63.59%) were characteristic laboratory results. The coinfections were dengue, enteric fever, urinary tract infections, and malaria.Children who also had dengue were more likely to develop thrombocytopenia, which was statistically significant (P-value = 0.008). With doxycycline medication, early defervescence of fever occurred earlier than with azithromycin, and it was statistically significant (P-value = 0.000). The complications were hepatitis (63.59%), lower respiratory tract infections (LRTIs, 22.82%),scrub typhus meningoencephalitis (STME, 3.88%), acute kidney injury (AKI, 2.91%), myocarditis (1.46%), and acute disseminated encephalomyelitis (ADEM, 0.49%). Except for one who had ADEM, everyone was sent back home after receiving the best care possible. The average duration of hospital stay was 6.89 days. Conclusions Even in the absence of eschar, scrub typhus should be suspected in any febrile child who experiences clinical signs of meningoencephalitis syndrome, capillary leakage, skin rash, conjunctival congestion, LRTI, AKI, lymphadenopathy, hepatosplenomegaly, thrombocytopenia, and liver dysfunction in the post-monsoon season. Strong clinical suspicion and prompt anti-scrub drug administration go a long way in preventing or decreasing the morbidity and mortality of the same.

Intrarenal Venous Doppler as a novel marker for optimal decongestion, management and prognosis in acute heart failure patients.

An increase in right atrial pressure is a common feature of acute decompensated heart failure (ADHF). Such increased pressure leads to persistent kidney congestion. A marker to guide optimal diuretic therapy is missing. We aim to correlate intrarenal Doppler ultrasound (IRD) in ADHF patients with clinical outcomes to assess whether renal hemodynamic parameter changes are useful for monitoring kidney congestion. Between December 2018 and January 2020, ADHF patients requiring intravenous diuretic therapy for at least 48 hours were considered for study selection. IRD blinded examination was performed day on 1, 3, 5 and clinical and laboratory parameters were recorded. Venous Doppler profile (VDP) were classified as continuous (C), pulsatile (P), biphasic (B), or monophasic (M) according to congestion degree; B and M profiles were considered deranged. VDP improvement (VDPimp) was defined as a change of ≥ 1 pattern degree or maintenance of C or P patterns. Arterial resistive index (RI) > 0.8 was considered elevated. Outcomes of death and rehospitalization were gathered at 60 days. Data were assessed by regression and Kaplain Meier analyses. All 177 ADHF patients admitted were screened and 72 were enrolled (27 females - median age 81 [76-87] years - median EF 40% [30-52]). VDP derangement decreased from 79.2% on day 1 to 51.4% on day 5 (p < 0.05). RI elevation decreased from 60.6% on day 1 to 43.1% on day 5 (p < 0.05). At day 5, VDPimp was registered in over half of the patients (59.7%). At day 5, signs of congestion (dyspnea/edema/rales), fluid accumulation (pleural/peritoneal fluid), hematocrit, and BNP improved (p > 0.05).After 60 days, 12 (16.7%) patients were readmitted and 9 (12.5%) died. VDPimp was identified as the unique independent factor associated with readmission (OR 0.22 CI 95% 0.05-0.94, p = 0.04) and death (OR 0.07, CI 95% 0.01-0.68, p = 0.02), with significantly better outcomes identified in VDPimp patients (Log Rank test p < 0.05). Decongestion may be associated with improvements in many clinical and instrumental parameters, but only VDPimp was associated with better clinical outcome. VDPimp should be incorporated in ad hoc AHF clinical trials to better define its role in everyday practice.

Symplified pulmonary ultrasound in heart failure patients with preserved systolic function

Abstract Funding Acknowledgements Type of funding sources: None. Background About 1/3 of patients with heart failure (HF) have normal Ejection Fraction (HFpEF). Pulmonary congestion and Oedema is useful marker of HFpEF. The aim of this study was to determine the place of pulmonary ultrasound in patients with DHF. Methods We studied 250 patients with II-IV NYHA class HF from which 70 patients had HFpEF (I gr) and 100 patients Left Ventricular Diastolic Dysfunction but without signs of HF (control, II gr). All participants undergone standard EchoCG examination. Sonographic evaluation of a lung was done in horizontal or vertical positions of patient, from 10 points of thoracic wall (5 points from each side), which corresponded to the projection of lower, middle and upper lobes of a right lung and upper and lower lobes of left lung. Results In patients with HF we significantly often found multiple (3 or more) B-lines or "Comet tail Phenomenon" (CTPh), which was registered in 91.1%. In 40.0% of control group patients we also registered B-lines, but the count of them in was less than 3 lines per each registration point (the difference between control an HF groups was significant). The count of points from where the CTPh was registered was 6.8 in HFpEF gr. and 0.7 in control gr. The B-lines where registered from 3 or more points of thoracic wall in 82.86% of patients of I gr and only 5% in II gr participants. In HF groups CTPh was prominent, protracted and multiple while in the control group it was single and short lasting, like lightening. There was good correlation between the count of B-line registration points from the thoracic wall and the heart failure NYHA class (r=0.56), left ventricular systolic (r=0.40) and diastolic (r=0.32) diameters and negative MAPS and TAPS (r=-0.42 and 0.41 respectively). Conclusion Thoracic US is sensitive and accurate method for evaluation pulmonary congestion in patients with HFpEF. The US sign of pulmonary congestion in HF are B-lines or "Comet tail phenomenon", which is protracted, prominent, multiple and registered from larger area of thoracic wall (3 points or more).

Death after smoking of fentanyl, 5F-ADB, 5F-MDMB-P7AICA and other synthetic cannabinoids with a bucket bong

PurposeWe report a case of a polydrug user who consumed various synthetic cannabinoids and fentanyl from a transdermal patch via a bucket bong. Toxicological results from postmortem matrices with special focus on synthetic cannabinoids are discussed in terms of their relevance to the death.MethodsThe samples were analyzed by toxicological screening procedures involving immunoassays and gas chromatography–mass spectrometry (GC–MS) as well as quantitative analyses by means of GC–MS and high-performance liquid chromatography–tandem mass spectrometry (LC–MS/MS).ResultsAt the autopsy, coronary artery disease and signs of liver congestion were noted, in the absence of acute myocardial ischemic changes. Femoral blood concentrations of fentanyl and pregabalin were 14 ng/mL and 3,200 ng/mL, respectively. In addition, 2.7 ng/mL 5F-ADB and 13 ng/mL 5F-MDMB-P7AICA were detected together with relatively low amounts of 5 other synthetic cannabinoids in cardiac blood. A total number of up to 17 synthetic cannabinoids were detected in kidney, liver, urine and hair. Fentanyl and 5F-ADB were also detected in the water of the bucket bong.ConclusionsThe cause of death could be attributed to an acute mixed intoxication by fentanyl and 5F-ADB (both Toxicological Significance Score (TSS) = 3) with a contribution of pregabalin and 5F-MDMB-P7AICA (TSS = 2), in a subject suffering from pre-existing heart damage. The most plausible mechanism of death consists in a respiratory depression. This case report demonstrates that use of opioids in combination with synthetic cannabinoids might be particularly dangerous.

The Role of Congestion Biomarkers in Heart Failure with Reduced Ejection Fraction.

In heart failure with reduced ejection fraction, edema and congestion are related to reduced cardiac function. Edema and congestion are further aggravated by chronic kidney failure and pulmonary abnormalities. Furthermore, together with edema/congestion, sodium/water retention is an important sign of the progression of heart failure. Edema/congestion often anticipates clinical symptoms, such as dyspnea and hospitalization; it is associated with a reduced quality of life and a major risk of mortality. It is very important for clinicians to predict the signs of congestion with biomarkers and, mainly, to understand the pathophysiological findings that underlie edema. Not all congestions are secondary to heart failure, as in nephrotic syndrome. This review summarizes the principal evidence on the possible roles of the old and new congestion biomarkers in HFrEF patients (diagnostic, prognostic, and therapeutic roles). Furthermore, we provide a description of conditions other than congestion with increased congestion biomarkers, in order to aid in reaching a differential diagnosis. To conclude, the review focuses on how congestion biomarkers may be affected by new HF drugs (gliflozins, vericiguat, etc.) approved for HFrEF.

Cardiotoxicity after autologous hematopoietic stem cell transplantation (AHSCT): longitudinal and observational study

Objectives: To assess incidence and extent of early cardiotoxicity after autologous hematopoietic stem cell transplantation (AHSCT).&#x0D; Methods: Study carried out in two bone marrow transplant centers, in public and private hospital, located in interior of Minas Gerais, Brazil. All patients who underwent AHSCT at centers between March 2018 and May 2019 and October 2019 were included. Altered results were classified according to Brazilian Cardio-Oncology Guidelines.&#x0D; Results: Of the 36 patients evaluated, seven (21.2%) had cardiotoxicity on echocardiography, with mean left ventricular ejection fraction decreasing from 71.53 to 64.75% before and after conditioning (p = 0.00013). Clinical cardiovascular alterations were associated with advanced staging and time of more than one year between diagnosis and AHSCT (p=0.01 in both cases). Specific clinical signs of congestion were correlated with radiotherapy to the mediastinum and a dose &gt;400 mg of doxorubicin before AHSCT (p=0.02 and p=0.01, respectively).&#x0D; Conclusions: Thus, higher incidence of cardiac injury was observed after AHSCT, which was related to type of pre-transplant therapy. This fact reflects our limitations and leads us to seek improvements in cardiovascular assessment of patients undergoing AHSCT, in order to reduce morbidity and mortality associated with myocardial injuries in these patients.

Multi-organ sonographic assessment of congestion has incremental prognostic value in outpatients with heart failure irrespective of left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Congestion is a key driver of symptoms, disease progression and prognosis for patients with heart failure (HF), irrespective of left ventricular ejection fraction (LVEF). However, clinically overt congestion is often undiagnosed unless severe. Recent research has shown that ultrasonographic quantification of systemic venous (i.e. inferior vena cava), renal venous and lung (B-lines) congestion is feasible and identifies HF patients with a worse prognosis. Purpose Whether a simultaneous multi-organ evaluation of congestion by ultrasound may improve risk stratification in HF is unknown. In the present study, we assessed signs of ultrasonographic congestion in the inferior vena cava, lungs and kidneys in HF patients across the LVEF spectrum and investigated their association with pathophysiology, clinical characteristics and prognosis. Methods We prospectively enrolled 326 patients with a prior clinical diagnosis of HF attending a routine follow-up visit. We also enrolled 102 consecutive patients with cardiovascular risk factors (including hypertension, type II diabetes mellitus or chronic ischaemic heart disease) and no history of HF; these latter patients had NT-proBNP levels &amp;lt;125 ng/L, LVEF &amp;gt;50%, and were not taking loop diuretics. All patients underwent a complete clinical assessment, blood and urine tests, and an ultrasound evaluation. Ultrasound congestion was defined as inferior vena cava ≥21 mm, highest tertile of lung B-lines or discontinuous renal venous flow. Results The final population consisted of 310 HF patients (median age 77 years, median NT-proBNP 1037 ng/L, 51% with LVEF &amp;lt;50%), and 101 subjects without HF. Among the 224 HF patients (72%) with no clinical signs of congestion, 95 (42%) had at least one sign of congestion by ultrasound (p&amp;lt;0.0001). HF patients with ≥2 ultrasound signs were older, had greater neurohormonal activation (i.e., higher NT-proBNP; Figure 1), lower urinary sodium concentration, and larger left atria despite similar LVEF. During a median follow-up of 13 (interquartile range 6–15) months, 77 HF patients (19%) died or were hospitalized for HF. HF patients without ultrasonographic evidence of congestion had a similar outcome to subjects without HF (reference; HR 1.02, 95% CI 0.86 – 1.35), while those with ≥2 ultrasound signs had the worst outcome (HR 26.7, 95% CI 12.4–63.6), even after adjusting for multiple clinical variables and NT-proBNP (Figure 2). Adding multi-organ assessment of congestion by ultrasound to a clinical model, including NT-proBNP, provided a 28% net reclassification improvement (p=0.03). Conclusion Simultaneous assessment of pulmonary, systemic venous and kidney congestion by ultrasound identifies a high prevalence of sub-clinical congestion associated with poor outcomes in HF, irrespective of LVEF. The speed of investigation, along with the widespread availability and relatively low cost of ultrasound, makes this protocol easy to implement for real-time assessment of congestion.

P289 HEART FAILURE DUE TO HIGH OUTPUT ARTERIOVENOUS FISTULA IN A DIALYSIS PATIENT AFFECTED BY AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE

Abstract Autosomal dominant polycystic kidney disease (ADPKD) can determine end stage renal disease (ESRD) which require haemodialysis. Surgical creation of arteriovenous fistula (AVF) has been associated with development of left ventricular (LV) dilatation and high output heart failure (HF) and right ventricle (RV) dysfunction at long term follow–up. Databases show an association between ADPKD and idiopathic dilated cardiomyopathy, suggesting that PKD mutations contribute to development of heart failure. 36 ys old female patient affected by ADPKD who required in 2018 bilateral nephrectomy, due to a relapse of severe urinary tract bleeding, and then put in thrice–weekly hemodialysis. Before the procedure in 2016 an echocardiogram showed normal biventricular function, with valvular defects. An AVF, between left humeral artery and the perforator vein of the elbow, was employed as vascular access. 6 months later she was referred to our center for atypical chest pain and palpitations. A transthoracic echocardiogram showed a diffuse hypokinesia with severe left ventricular dysfunction and dilation (EF 25%, VTDi 90ml/mq), a cardiac output of 6,5 l/min, moderate mitral insufficiency, hypokinetic RV, pulmonary artery systolic pressure (PASP) of 56mmHg, severe biatrial dilatation. No signs of congestion. She was admitted to our service. The coronary angiogram was normal, ruling out an underlying ischemic cardiomyopathy. Therapy with b–blocker and ACE–I was started. Doppler ultrasonography of the AVF was performed and showed an high output fistula. Two weeks later at Hospital discharge with medical therapy only, EF improved to 43%. Five months later, the AVF was ligated, after the creation of another more distal one. Echocardiographic re–evaluation one month after the intervention showed a normalization of left ventricular function and volumes ( EF 55%, VDTi 54ml/mq)and of PASP. In 2020 she underwent renaltransplant without complications. The patient is nowadays stable only on beta–blocker for some PVCs, with ongoing annual follow–up. Even if dilated cardiomyopathy and HF in patients affected by APDKD can be caused by genetic predisposition, in our case the main factor was a high output AVF, as showed by complete reversion of left ventricular dysfunction after its ligation.

P5 DISCOVERY OF A NEW HATTR GENETIC VARIANT: A CASE REPORT OF A PATIENT WITH CARDIAC UPTAKE AT 99–MTC–DIPHOSPHONATES SCINTIGRAPHY AND ABNORMAL MONOCLONAL PROTEINS TESTS

Abstract Introduction Cardiac amyloidosis is an infiltrative disease that remains an under–diagnosticated cause of heart failure. Diagnostic algorithms focus on identifying the two most frequent forms of the disease, light chains amyloidosis (AL) and transthyretin amyloidosis (ATTR), by the initial use of 99mTc–DPD scintigraphy coupled to assessment of monoclonal proteins. Etiological distinction is and of pivotal importance since the availability of specific disease modifying treatments. Case Description We report the case of a 61–year–old man hospitalized for new onset of heart failure. Past medical history highlights bilateral carpal tunnel syndrome and monoclonal gammopathy of undetermined significance (MGUS). Cardiovascular examination reveals clinical signs of pulmonary and peripheric congestion. ECG shows conduction disturbances and low QRS voltage. Transthoracic echocardiography reveals left ventricular hypertrophy, normal systolic function (LVEF 58%), 3rd degree LV diastolic disfunction and mild pericardial effusion. Laboratory tests shows abnormal levels of TnT and pro–BNP. A diagnosis of cardiac amyloidosis is considered, and further exams are executed: cardiac magnetic resonance, haematological laboratory tests and 99mTc–DPD scintigraphy (tab. 1). Since both bone scintigraphy and monoclonal proteins tests are positive, diagnosis of cardiac amyloidosis cannot be made without non–invasive modalities (fig.1) and the patient is referred to an Amyloidosis Centre. Haematological evaluation and abdominal fat pad biopsy show stability of haematological disease and confirms the deposition of amyloidogenic TTR both in wild–type and mutated Ile88Arg variants. The results of genetic analysis confirms the presence of a heterozygous mutation of TTR gene (p.Ile88Arg – c.263T&amp;gt;G) (fig. 2). This mutation is not reported in database ClinVar nor in gnomAD, but according to the ACMG criteria it can be considered likely pathogenic. Considering the final diagnosis of cardiac hATTR the patient is considered eligible for treatment with Tafamidis. Discussion and Conclusion Despite clinical history with cardiac conduction system abnormalities and bilateral carpal tunnel syndrome, some gene TTR variants can bring false negative results at 99mTc–DPD scintigraphy, so ATTR form should not be excluded basing on non–invasive modalities. Performing a compete diagnostic workup led us to discover a new TTR pathogenic variant and confirm ATTR form without performing endomyocardial biopsy.

P180 EXTREMELY WIDE QRS TACHYCARDIA IN SEVERE HYPERKALEMIA: THE IMPORTANCE OF MONITORING MRA THERAPY

Abstract Although uncommon in the general population, hyperkalemia can affect up to 50% of patients with heart failure who are receiving MRA and/or are affected by CKD . Since potassium is the most abundant intracellular cation, hyperkaliemia causes a profound change in action potential, which manifests as expected electrocardiographic changes (lower voltage P wave, AV block, wide QRS, high voltage T wave) and arrhythmias. Clinic case. A 77–year–old woman was admitted to ED for dyspnea. She had a medical history of stage 3 CKD and a HFrEF with a recent admission in medical department for worsening congestion, from which was dimitted with a supratherapeutic dose of MRA (canrenone 300 mg/die). Physical examination at the admission excluded signs of central or peripheral congestion . An EKG was performed and revealed an heart rate of 95 beats per minute and extremely wide QRS (280 ms). Contextually, a blood gas analysis showed high potassium level (K 9 mmol/l) and metabolic acidosis. Due to the inability to demonstrate the presence of P wave and a regular A–V conduction, a differential diagnosis between a VT and a SVT with a wide QRS was required. The presence of a fusion beat, a negative concordance of QRS in the precordials derivation, and an extreme right axis deviation led to a diagnosis of slow VT. Cuncurrently with the onset of hyperkalemia therapy, an ECV with sinus rhythm restoration was done. The following EKGs showed expected electrical changes based on the measured potassium level. After ECV with K 8 mmol/l: QRS remained wide (180ms) with an heart rate of 65 beats per minute in the presence of possible junctional rhythm or sino–ventricular rhythm, which is sometimes described in hyperkalemia as an expression of atrial inectability with the exception of the conduction fibers. After 1 hour with K 6.3 mmol/l: QRS of normal duration with an HR of 60 bpm and a sinus rhythm but with low voltage P wave and concomitant AV block of I grade that was gradually restored with the normalization of potassium levels after canrenone suspension. Because the numerous side effects of hyperkaliemia careful monitoring of MRA therapy and potassium level plays a critical role in the prevention and diagnosis of arrhythmias and EKG changes in patients with HFrEF.

P311 PULSED INFUSIONS OF LEVOSIMENDAN IN OUTPATIENTS WITH ADVANCED HEART FAILURE

Abstract Background Several non–randomized studies and small registries showed the efficacy of pulsed levosimendan infusion in relief of symptoms and preventing hospitalization in patients with advanced heart failure excluded by age or comorbidity from heart transplant program Aim of the study to describe the experience of pulsed levosimendan infusion in patient with advanced heart failure followed by the Division of Cardiology at "Villa Sofia" Hospital in Palermo Materials and methods we collected data of patient with adavced heart failure (NYHA III–IV) with reduced ejection fraction, who underwent pulsed levosimendan infusione at Division of Cardiology at "Villa Sofia" Hospital. Reduction of NYHA class, body weight and Nt–pBNP were examined as outcome indicators Results Between July 2021 an December 2022, fifhteen levosimendan infusion were made in five patient with advanced heart failure. Levodimendan was adminestered for a 24–hours infusion, as therapeutic day–hospital regimen. in the population of analysis, the following mean parameters were recorded at admission: NYHA class 3.2, furosemide dose 390mg, Nt–pBNP 10710pg/ml, body weight 72.8Kg, glomerualr filtration rate (GFR MDRD) 44ml/min. At discharge, the following mean parameters were recorded: NYHA class 2.1, Nt–pBNP 9225pg/ml, body weight 70.7Kg. One patient dead of sudden cardiac death during follow–up, one patient refused to continue treatment, the remaining three patient are still on treatment. Conclusions In our center experience, pulsed levosimendan infusion in patient with advanced heart failure determined an improvement of clinical and instrumental signs of congestion. Patients treated reported a subjective improvement of symptoms and of quality of life, also as a consequence of the reduction of the hospitalizations for heart failure. Although data ara scarce, they can be considered representative of a pilot experience of an integrated modality of assistance for patient with advanced heart failure, in which the sinergy between cardiology ward, a strict follow–up at the heart failure outpatient clinic are essential to obtain a good outcome in patient with such high complexity and frailty.

Femoral vein pulsatility: a simple tool for venous congestion assessment

BackgroundFemoral vein Doppler (FVD) is simpler than the VExUS score which is a multimodal scoring system based on combination of IVC diameter, hepatic venous Doppler, portal vein pulsatility and renal vein Doppler, may be useful in assessing right ventricular overload and signs of venous congestion. There is limited data on the relationship between FVD and VExUS score.ResultsAdult post-cardiac surgery patients were assessed for venous congestion using the VExUS score and FVD. Agreement between VExUS and FVD was studied using Kappa test, sensitivity, specificity, PPV and NPV for VExUS and FVD was calculated keeping CVP as gold standard. In total, 107 patients were enrolled, with a mean age of 55.67 ± 12.76. The accuracy of VExUS and FVD for detecting venous congestion was 80.37 (95% CI of 71.5 to 87.4) and 74.7 (95% CI of 65.4 to 82.6), respectively. The level of agreement between FVD and VExUS was moderate (Kappa value of 0.62, P < 0.001) while the agreement between FVD and CVP was weak (Kappa value of 0.49, P < 0.001).ConclusionFVD has good accuracy for detecting venous congestion and shows moderate agreement with VExUS grading. With potentially easier physical accessibility and a shorter learning curve for novices, it may be a simple and valuable tool for assessing venous congestion.

Relationship of Vascular Endothelial Growth Factor C, a Lymphangiogenesis Modulator, With Edema Formation, Congestion and Outcomes in Acute Heart Failure

Although vascular endothelial growth factor C (VEGF-C) is a known lymphangiogenesis modulator, its relationship with congestion formation and outcomes in acute heart failure (AHF) is unknown. Serum VEGF-C levels were measured in 237 patients hospitalized for AHF. The population was stratified by VEGF-C levels and linked with clinical signs of congestion and outcomes. The study's population was divided in VEGF-C tertiles: low (median [Q25-Q75]: 33 [15-175]), medium (606 [468-741]) and high (1141 [968-1442] pg/mL). The group with low VEGF-C on admission presented with the highest prevalence of severe lower-extremity edema (low VEGF-C vs medium VEGF-C vs high VEGF-C): 30% vs 13% vs 20%; P = 0.02); the highest percentage of patients with ascites: 22% vs 9% vs 6%; P = 0.006; and the lowest proportion of patients with pulmonary congestion: 22% vs 30% vs 46%; P = 0.004. The 1-year mortality rate was the highest in the low VEGF-C tertile: 35% vs 28% vs 18%, respectively; P = 0.049. The same pattern was observed for the composite endpoint (death and AHF rehospitalization): 45% vs 43% vs 26%; P = 0.029. The risks of death at 1-year follow-up and composite endpoint were significantly lower in the high VEGF-C group. Low VEGF-C was associated with more severe signs of congestion (signs of fluid accumulation) and adverse clinical outcomes.

Which congestion presentation pattern on the physical findings is associated with future adverse events? A cluster analysis in the multicenter acute heart failure registry.

Clinical congestion is the most frequent reason for hospital admission in patients with acute heart failure (AHF). However, few studies have investigated the patterns and prognostic implication of the physical congestion using unbiased and robust statistical methods. A hierarchical agglomerative clustering analysis was performed in the multicenter Japanese AHF registry (N = 3151) with the distance calculated by Jaccard's distance for jugular vein distention (JVD), leg edema, S3, crackles, and orthopnea. The primary outcome was a composite of cardiac death and heart failure readmission within 1-year. At the time of admission, the median number of prevalent congestive signs was 2. We identified three phenogroups: 'no physical congestions' (N = 251); 'congestion without JVD' (N = 1415); and 'congestion with JVD' (N = 1495). Patients in 'no physical congestion' were the youngest (median 75 [62, 83] years) with the lowest systolic blood pressure (122 [106, 142] mmHg). Patients in 'congestion without JVD', and 'congestion with JVD' were similar in terms of age (77 [67, 84] vs. 78 [69, 84] years) and systolic blood pressure (138 [118, 160] vs. 137 [118, 158] mmHg). While 30-day mortality was similar (4.0%, 3.7%, and 4.3% in 'no physical congestion,' 'congestion without JVD,' and 'congestion with JVD', respectively), the patients in 'congestion with JVD' were at the highest risk for the primary outcome (adjusted hazard ratio 1.79, 95% CI 1.26-2.55 when 'no physical congestion' was a reference). Our clustering analysis demonstrated that congestion signs, particularly JVD, allowed identification of AHF phenogroups with distinct clinical characteristics and long-term outcomes.

Safety, Feasibility of Controllable Decrease of Vena Cava Pressure by Doraya Catheter in Heart Failure

Lowering elevated central venous pressure may reduce renal dysfunction in acute heart failure (AHF) patients. The Doraya catheter lowers renal venous pressure by creating a gradient in the inferior vena cava below the renal veins. Here, we present a first-in-human feasibility study of the Doraya catheter performed on 9 AHF patients. We assessed the safety, feasibility, and acute clinical (hemodynamic and renal) effects of transient Doraya catheter deployment when added to the standard diuretic-based regimen in AHF patients with a poor diuretic response. The procedures decreased central venous pressure from 18.4 ± 3.8 mm Hg to 12.4 ± 4.7mmHg (P< 0.001) and improved mean diuresis and clinical signs of congestion. No device-related serious adverse events were observed. Thus, Doraya catheter deployment was safe and feasible in AHF patients. (FirstIn Human Study of the Doraya Catheter for the Treatment of AHF Patients; NCT03234647).

Inferior vena cava diameter is associated with prognosis in patients with chronic heart failure independent of tricuspid regurgitation velocity

AimsA high, Doppler-derived, tricuspid regurgitation velocity (TRV) indicates pulmonary hypertension, which may contribute to right ventricular dysfunction and worsening tricuspid regurgitation leading to systemic venous congestion, reflected by an increase in inferior vena cava (IVC) diameter. We hypothesized that venous congestion rather than pulmonary hypertension would be more strongly associated with prognosis.Methods and results895 patients with chronic heart failure (CHF) (median (25th and 75th centile) age 75 (67–81) years, 69% men, LVEF 44 (34–55)% and NT-proBNP 1133 (423–2465) pg/ml) were enrolled. Compared to patients with normal IVC (< 21 mm) and TRV (≤ 2.8 m/s; n = 504, 56%), those with high TRV but normal IVC (n = 85, 9%) were older, more likely to be women and to have LVEF ≥ 50%, whilst those with dilated IVC but normal TRV (n = 142, 16%) had more signs of congestion and higher NT-proBNP. Patients (n = 164, 19%) with both dilated IVC and high TRV had the most signs of congestion and the highest NT-proBNP.During follow-up of 860 (435–1121) days, 239 patients died. Compared to those with both normal IVC and TRV (reference), patients with high TRV but normal IVC did not have a significantly increased mortality (HR: 1.41; CI: 0.87–2.29; P = 0.16). Risk was higher for patients with a dilated IVC but normal TRV (HR: 2.51; CI: 1.80–3.51; P < 0.001) or both a dilated IVC and elevated TRV (HR: 3.27; CI: 2.40–4.46; P < 0.001).ConclusionAmongst ambulatory patients with CHF, a dilated IVC is more closely associated with an adverse prognosis than an elevated TRV.Graphical