Urgent Cardiac Catheterization Research Articles

Delayed closure of ventricular septal defect with prolonged mechanical support

Introduction: Ventricular septal defect (VSD) is a severe complication following acute myocardial infarction (MI) resulting from mechanical disruption of the interventricular septum due to extensive myocardial necrosis. Despite advances in management, the mortality rate approaches 50%. We report a case of a 58-year-old male with VSD following MI who was successfully treated with a delayed surgical approach after haemodynamic support using Impella. Case description: A 58-year-old man with type 2 diabetes mellitus and hypertension presented with three days of chest pain. Testing revealed late presenting acute anterior ischaemic infarction and left-to-right shunt in the apical ventricular septum. Urgent cardiac catheterisation showed near-total occlusion of the left anterior descending artery. An Impella CP® was placed before angioplasty with a drug-eluting stent to optimise haemodynamics. After a multidisciplinary discussion, the Impella CP® was upgraded to Impella 5.5®, and surgery was delayed allowing for scar formation. The patient remained in the intensive care unit, where he underwent physical therapy, showing improvements in exercise tolerance by the time of surgery. He underwent a left ventriculotomy with a successful repair via an endocardial patch 28 days after initial presentation. Post-operative recovery was uneventful, with the patient discharged five days later, reporting no physical limitations one month post-discharge. Conclusion: The successful management of VSD post-MI relies on interdisciplinary collaboration, careful timing of surgical intervention and the strategic use of mechanical support devices such as the Impella. This case highlights the potential for favourable outcomes when tailored treatment approaches are employed.

A novel case of yamaguchi syndrome in the Saudi population

Background: Apical hypertrophic cardiomyopathy (ApHCM) known as Yamaguchi syndrome, is an uncommon variant of hypertrophic cardiomyopathy, with higher incidence reported in the Asian populations. The clinical presentation of ApHCM is vague thus can mimic other conditions, which can lead to a delayed or a missed diagnosis. Only a few reports have described the incidence of Yamaguchi syndrome in other populations other than Asians. Case Presentation: A 46-year-old male, heavy smoker, with unremarkable past medical history was presented to the emergency department with severe central chest pain that radiates to the left side, exacerbated by excretion, and relived by rest not associated with shortness of breath or palpitation. Additionally, the patient reported two similar episodes that occurred the past 4 days. However, physical examination was unremarkable. Initially the patient was labeled as high-risk acute coronary syndrome (unstable angina vs non-ST segment myocardial infarction). Cardiac markers including troponin I and Creatine kinase-MB were within normal range. ECG revealed deep T wave inversion in the inferior limb leads and pericardial leads suggestive of right coronary and left anterior descending artery or left main coronary lesion. The patient underwent for urgent cardiac catheterization which revealed normal coronary arteries. Transthoracic echocardiograph (TTE) showed isolated apical hypertrophy with preserved LV function, suggestive of ApHCM. The patient was advised on smoking cessation and discharged on beta blocker. Conclusion: There is an imminent need to establish further research investigating the prevalence of Yamaguchi syndrome among the Saudi population.

Abstract 15836: Paraganglioma Presenting as Myocardial Infarction With Decompensated Heart Failure

Description of Case: Paragangliomas are extra-adrenal catecholamine secreting tumors, classically presenting with paroxysmal hypertension, headache, and diaphoresis. However, presentations vary significantly, and can mimic cardiac pathologies including myocardial infarction and aortic dissection. A 52-year-old male with history of hypertension and 1 year of palpitations presented for substernal chest pressure with associated dyspnea, nausea and diaphoresis. He reported two days of cough and nasal congestion, and recent addition of metoprolol for palpitations. His family history was notable for early ACS. On examination, he was tachycardic (140 bpm), hypertensive (220/140 mmHg), and hypoxic requiring non-rebreather mask. EKG revealed sinus tachycardia with 1mm J point elevations in V2 and V3. Chest X-Ray and bedside ultrasound indicated pulmonary edema and reduced systolic function. Nitroglycerin infusion was initiated and he was admitted to the Cardiac ICU. Laboratory testing showed a Troponin-T of 0.15 ng/L (normal <0.01 ng/L), ntPro-BNP 2764 pg/mL, lactic acid 3.2 mmol/L, and respiratory swab positive for Influenza A. A CT Aorta ruled out acute dissection but identified several large retroperitoneal masses. Urgent cardiac catheterization demonstrated non-obstructive CAD. Echocardiography noted severely reduced ejection fraction of 30-35%. With diuresis and alpha blockade, he clinically improved and was discharged. Plasma and urine studies revealed elevated metanephrines. He underwent open paraaortic mass resection and pathology later confirmed paraganglioma. Discussion: With angina, elevated troponins, and acute decompensated heart failure, this presentation was initially concerning for ACS. However, the absence of obstructive CAD warranted further investigation. While concomitant Influenza A infection raised concern for viral myocarditis, abdominal imaging proved crucial in diagnosing paraganglioma.

SAT472 A Case of Contrast Induced Thyrotoxicosis in a Patient Newly Diagnosed with Hyperthyroidism

Abstract Disclosure: E. Askar: None. B. Reddy: None. Background: It is quite uncommon for thyrotoxicosis to manifest itself after the administration of iodinated contrast. Although the actual prevalence has not yet been identified, estimates showed that the prevalence in areas with iodine deficiency is 0.25 to 0.5% and 0.025% in non-iodine-deficient areas with higher risk in elderly patients. Clinical Case: A 68-year-old female presented to the emergency department for 2 weeks of intermittent substernal chest pain associated with diaphoresis. She was diagnosed with hyperthyroidism by an outside clinic approximately one week prior to her presentation and was prescribed methimazole but did not start it. Her physical examination was significant for mild exophthalmos. EKG showed ST depression in anterolateral leads. Laboratory data showed a troponin of 0.328 ng/ml (0.0.015-0.45) which trended up to 4.830 after 3 hours and TSH of <0.005 mIU/L (0.358-3.74), otherwise BMP and CBC were within normal limits. Patient was started on aspirin, statin and heparin infusion along with methimazole. Patient was transferred to tertiary hospital for urgent cardiac catheterization that showed 90 % stenosis of left anterior descending artery (LAD) and 95 % stenosis in distal right coronary artery (RCA). A successful drug eluting stent was deployed in LAD with a plan of staged PCI in RCA. An hour after the procedure, Patient complained of palpitations and diaphoresis. Laboratory findings at that time revealed Free T4 of 17.5 ng/dl (0.9-1.8), Free T3 of 12.3 pg/ml (1.8-4.6) with positive Thyroperoxidase antibody, TSI and TSH Receptor Antibody. Thyroid ultrasound revealed diffusely heterogeneous thyroid gland with increased vascularity, consistent with Graves’ disease. The patient was diagnosed with thyrotoxicosis secondary to contrast administration. She was treated with methimazole 20 mg TID, metoprolol tartrate 25mg BID and hydrocortisone 25 mg BID. Decision was made to postpone the second procedure until trending down of thyroid hormones and improvement of symptoms. A successful staged RCA PCI was performed eight days later and patient did not experience any complications despite exposure to the same dose of iodinated contrast. Conclusion: Rarely, hyperthyroid patients may experience chest discomfort and EKG abnormalities that are consistent with cardiac ischemia. This usually happens in older patients with known underlying coronary artery disease in response to the rise in cardiac contractility and strain caused by thyrotoxicosis. Our case did not have any history or risk factors of coronary artery disease other than hyperthyroidism. This case highlights how recognition of hyperthyroidism may alter management, because the use of some procedures or treatments may acutely exacerbate the condition of the patient. Presentation Date: Saturday, June 17, 2023

ODP148 GENDER AFFIRMING HORMONE THERAPY AND SPONTANEOUS CORONARY ARTERY DISSECTION

Abstract Introduction Spontaneous coronary artery dissection (SCAD) is an important and underreported cause of acute coronary syndrome in women. SCAD has been linked to arteriopathy, pregnancy, as well as hormone replacement therapy in cisgender patients. There is a scarcity of data on the long-term cardiovascular effects of gender affirming hormonal therapy (GAHT) with estrogen. Observational studies have shown increased thromboembolic disease and cardiovascular events in transwomen on estrogen, with oral synthetic or oral combined equine estrogens showing a higher association versus transdermal formulations, however there had been no reports of SCAD in transgender patients on GAHT. Clinical Case A 37-year old transwoman with a history of gender affirming orchiectomy on GAHT with sublingual estradiol 2 mg BID presented with typical symptoms of acute coronary syndrome. No prior history of chest pain. No personal history or family history of cardiovascular disease or risk factors. Initial Troponin I was 9.52 ng/dl (<0. 04 ng/dl), ECG with non-specific ST-changes. A transthoracic echocardiogram showed hypokinesis of the mid anterior and lateral wall. She underwent urgent cardiac catheterization, found to have SCAD of her ramus intermedius. Given the size of the lesion and wall motion abnormalities, a cutting balloon was used to inflate the lesion, and she remained chest pain free during the hospitalization. She was started on Aspirin, Clopidogrel, and Metoprolol. Sublingual estradiol was determined to be her only predisposing risk factor and therefore it was held during her hospitalization and during the lesion healing period, with plans to change to a constant transdermal estrogen patch in the primary care setting. Discussion This is the first case report showing an association of estrogen GAHT and SCAD in a transwoman. SCAD has been observed to occur more often in cisgender women during the late luteal phase and post-partum period, raising the hypothesis that estrogen level fluctuations could potentially play a role. Sublingual estradiol has been shown to have higher peak and trough serum concentration compared to oral estradiol. Research is needed in this area and on the potential adverse cardiovascular effects of GAHT and whether route of estrogen administration plays a role. We support transdermal estradiol in transwomen with or at risk of cardiovascular disease, and close monitoring of serum levels, as well as aggressive treatment of cardiovascular risk factors. Presentation: No date and time listed

VENTRICULAR FIBRILLATION AS PRESENTATION FOR TAKOTSUBO CARDIOMYOPATHY

VENTRICULAR FIBRILLATION AS PRESENTATION FOR TAKOTSUBO CARDIOMYOPATHY

Coronary Angiographic Findings in Survivors of Sudden Cardiac Arrest at Nicvd Karachi

Background: The most recent guidelines advocate an immediate coronary angiography [1] for those who have survived a cardiac arrest and are still exhibiting electrocardiographic indications of ischemia. Recovered cardiac patients who don't show signs of ongoing ischemia may nonetheless need an emergency angiography, according to the same recommendations. Conventional ECG is ineffective in diagnosing if coronary culprit lesions are present during an angiography, according to earlier study [2]. As a result, some believe that all patients who are resuscitated after a cardiac arrest should undergo an urgent cardiac catheterization. [3]. Objective: To determine the frequency of coronary angiographic findings in survivors of sudden cardiac arrest. Materials and methods: We included all patients who satisfied the study's criteria and visited the NICVD in Karachi for treatment. After a thorough explanation of the study's procedures, risks, and benefits, participants agreed to participate. The results of coronary angiography were recorded for each patient. The form at the end contained all of the information that had been acquired and was used electronically for research purposes. Results: Mean ± SD of age was 51.4±10.6 years. In distribution of gender, 142 (67.6%) were male while 68 (32.4%) were female. left anterior descending (LAD) as noted in 104 (49.5%) patients, left circumflex artery (LCX) in 31 (14.8%), 52 (24.8%) had right coronary artery (RCA) while left main artery (LMA) was found in 23 (10.9%) patients. Conclusion: It is to be concluded that left anterior descending noted as most common coronary angiographic finding followed by right coronary artery and left circumflex artery. Epidemiological and research data should be expanded by further studies to validate the current findings. Keywords: Acute Coronary Syndrome, Angiographic Findings, CABG, Cardiac, Arrest, Survivors, Percutaneous Coronary Intervention

Chest Pain After Cesarean Section

We present a case report of a 35-year-old multiparous female who presented to the emergency department with acute-onset chest pain. She had an uncomplicated cesarean delivery 2 weeks before presentation. Her physical exam, electrocardiogram, laboratory analysis, and bedside echocardiogram findings are presented. Her findings prompted urgent cardiac catheterization to reveal the diagnosis and adjudicate proper therapy. This case highlights a potentially serious etiology of chest pain in an otherwise healthy peripartum female.

SPONTANEOUS CORONARY ARTERY DISSECTION RESULTING IN MITRAL VALVE REPLACEMENT

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Spontaneous coronary artery dissection (SCAD) is a rare condition accounting for only 0.1%–4% of acute coronary syndromes and 0.4% of sudden cardiac deaths. It predominantly affects young women with few or no traditional cardiovascular risk factors and is commonly associated with fibromuscular dysplasia (FMD), connective tissue disorders, and recreational drug use. Herein, we report a rare case of Type 2A SCAD in a male patient further complicated by the development of severe mitral valve regurgitation requiring mitral valve replacement (MVR). CASE PRESENTATION: A 47-year-old male with a history of hypertension, hyperlipidemia, and renal artery stenosis presented with complaints of fatigue, dyspnea, and chest pain. The initial EKG showed nonspecific ST changes, and troponin was elevated to 10 ng/dL (normal: <0.49 ng/dL). An urgent cardiac catheterization demonstrated non-obstructive coronary artery disease. Computed tomography (CT) of the chest ruled out a pulmonary embolism. The patient's troponin following cardiac catheterization continued to trend up with a peak of 23 ng/dL, at which point a formal transthoracic echocardiogram (TTE) was found to be normal. He had one recurrence of chest pain which correlated with another troponin spike and was found to have a decreased ejection fraction on emergent repeat TTE (EF: 45-50%). A third TTE was performed due to a new systolic murmur which showed a further decrease in EF (40-45%) and new mild MR. At this point, our leading differential diagnosis was myocarditis. Cardiac MRI showed an area of transmural late gadolinium enhancement involving the mid left ventricular inferolateral wall with islands of sparing which raised suspicion for a myocardial infarction (Figure 1), however, on further retrospective review of the cardiac angiogram, the findings (in correlation with the MRI) were consistent with narrowing in the obtuse marginal (OM) 1, a branch of the left circumflex artery, concerning for SCAD type 2. The patient was discharged home in stable condition with the diagnosis of SCAD of the OM-1 branch. Unfortunately, the patient returned with worsening dyspnea and was found to have severe MR which had progressed rapidly from the prior TTE. Given the circumflex distribution, and rapidly progressive MR, the patient was emergently referred for cardiothoracic surgery evaluation and ultimately underwent MVR. DISCUSSION: Any epicardial artery can be involved in SCAD, the left anterior descending artery is the most commonly affected. In this case, the involvement of the OM-1 resulted in impaired perfusion of the lateral wall and the anterolateral papillary muscle, subsequently leading to papillary rupture and MR. CONCLUSIONS: Even though this condition most commonly affects the female population, and is further primarily associated with connective tissue disorders, our work up revealed no such underlying conditions. REFERENCE #1: https://www.ahajournals.org/doi/10.1161/CIR.0000000000000564 DISCLOSURES: No relevant relationships by Nicole Anthony, source=Web Response no disclosure on file for Erdal Cavusoglu; no disclosure on file for Muhammad Dogar; No relevant relationships by Dilpat Kumar, source=Web Response No relevant relationships by Kamal Preet Singh, source=Web Response

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

Interim Guidance for Emergency Medical Services Management of Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

Early head-to-pelvis computed tomography in out-of-hospital circulatory arrest without obvious etiology.

Patients resuscitated from an out-of-hospital circulatory arrest (OHCA) commonly present without an obvious etiology. We assessed the diagnostic capability and safety of early head-to-pelvis computed tomography (CT) imaging in such patients. From November 2015 to February 2018, we enrolled 104 patients resuscitated from OHCA without obvious cause (idiopathic OHCA) to an early sudden-death CT (SDCT)scan protocol within 6 h of hospital arrival. The SDCT protocol included a noncontrast CT head, an electrocardiogram-gated cardiac and thoracic CT angiogram, and a nongated venous-phase abdominopelvic CT angiogram. Patients needingurgent cardiac catheterizationor hemodynamically unable to tolerate SDCT were excluded. Cardiac CT analyses were blinded, but other SDCT findings were clinically available. Primary endpoints were the number of OHCA causes identified by SDCT compared tothe adjudicated cause and critical diagnoses identified by SDCT, including resuscitation complications. Safety endpoints were acute kidney injury (AKI) and inappropriate treatments based on SDCT findings. Acute coronary syndrome was the presumed etiology if any major coronary artery had a>50% stenosis without another OHCA cause. SDCT scans occurred within 1.9±1.0h of hospital arrival and identified 39% (41/104) of all OHCA causes and 95% (39/41) of causes potentiallyidentifiable by SDCT. Critical findings were identified by SDCT in 98% (43/44) of patients that included potentially life-threatening resuscitation complications of liver or spleen laceration (n=6); pneumothorax or thoracic organ laceration (n=8); and mediastinal, pericardial, or vascular hemorrhage (n=3). SDCT exclusively identified 13 (13%) OHCA causes that would otherwise not be identified without SDCT imaging. No inappropriate treatmentsresulted from SDCT findings. AKI was common (28%) but only one (1%) patient required new dialysis. This observational cohort study suggests that early SDCT scanning is safe, can expedite the diagnosis of potential causes, and can meaningfully change clinical management after idiopathic OHCA.

NON-ST-Segment Elevation Myocardial Infarction Associated with Inadvertent Thyroid Hormone Overdose.

Thyroid hormone has a major role in cardiovascular function and cardiac hemodynamics. A slight change in thyroid affects ventricular function, serum cholesterol levels, increases the risk of coronary artery disease as well as cardiovascular mortality. In this report, we present a 62-year-old female with history significant for ischemic heart disease who was admitted for acute coronary syndrome (ACS) with persistent tachycardia, requiring urgent cardiac catheterization. Complete cardiac workup revealed that the patient had most likely suffered from vasospastic angina secondary to inadvertent overdose of her prescribed levothyroxine. This report emphasizes the significant cardiac complications caused by a deluged hyperadrenergic state secondary to overt hyperthyroidism. We conclude that thyrotoxicosis is a significant risk factor for cardiovascular disease and should be considered as a cause of life-threatening myocardial ischemia, especially in patients with known ischemic heart disease and thyroid disorders.

Trajectory of Cardiac Catheterization for Acute Coronary Syndrome and Out-of-Hospital Cardiac Arrest During the COVID-19 Pandemic.

BackgroundWe sought to investigate the trajectory of cardiac catheterizations for acute coronary syndrome (ACS) and out-of-hospital cardiac arrest (OHCA) during the pre-isolation (PI), strict-isolation (SI), and relaxed-isolation (RI) periods of the coronavirus disease 2019 (COVID-19) pandemic at three hospitals in Los Angeles, CA, USA.MethodsA retrospective analysis was conducted on adult patients undergoing urgent or emergent cardiac catheterization for suspected ACS or OHCA between January 1, 2020 and June 2, 2020 at three hospitals in Los Angeles, CA, USA. We designated January 1, 2020 to March 17, 2020 as the PI COVID-19 period, March 18, 2020 to May 5, 2020 as the SI COVID-19 period, and May 6, 2020 to June 2, 2020 as the RI COVID-19 period.ResultsFrom PI to SI, there was a significant reduction in mean weekly cases of catheterizations for non-ST elevation myocardial infarction/unstable angina (NSTEMI/UA) (8.29 vs. 12.5, P = 0.019), with all other clinical categories trending downwards. From SI to RI, mean weekly cases of catheterizations for total ACS increased by 17%, NSTEMI/UA increased by 27%, and OHCA increased by 32%, demonstrating a “rebound effect”.ConclusionsCardiac catheterizations for ACS and NSTEMI/UA exhibited a “rebound effect” once social isolation was relaxed.

Lenalidomide-induced focal myocarditis mimicking acute ST segment elevation myocardial infarction

An 86-year-old woman with a history of hypertension and diabetes presented with left-sided chest pain and dyspnoea 2 weeks after her treatment for diffuse large B-cell lymphoma. She was treated...

Abstract 16079: The Cusp of Life: Anomalous Origin of All Coronary Arteries From a Single Cusp

Introduction: Anomalous origin of coronary arteries has a prevalence of 1% in the population and is independently associated with a risk of sudden cardiac death. While an anomalous coronary artery arising from the opposite sinus is rare, all three coronary arteries arising from separate ostia in a single cusp is an extremely rare phenomenon. Case: A 48-year-old male with history of hypertension presented with fevers, cough and shortness of breath of 3 days duration. CXR demonstrated multi-lobar pneumonia and serology returned positive for Influenza A. Treatment was initiated with oseltamivir, vancomycin and piperacillin-tazobactam. Subcutaneous heparin was initiated for VTE prophylaxis. On day 3, the patient developed acute hypoxic respiratory failure from flash pulmonary edema necessitating intubation and mechanical ventilation. ECG revealed ST segment elevation in leads II, III, aVF, V5 and V6 (Fig. 1A). He was taken for urgent cardiac catheterization. Coronary angiography revealed anomalous origins of the left circumflex (LCX) and left anterior descending (LAD) arteries arising from the right coronary cusp (RCC) (Fig. 1B &amp; 1C). 99% thrombotic occlusion of the distal right coronary artery was identified as the culprit lesion (Fig 1D). Percutaneous coronary intervention with a 4 x 30 mm drug-eluting stent was performed. Discussion: Absence of the left coronary artery originating from the left coronary sinus should raise suspicion for a coronary anomaly. While an anomalous LCX artery originating from the RCC is seen in 0.7% individuals, the LAD artery arises from the RCC is seen in 0.15% of people. All three coronary arteries arising from the RCC is extremely rare. An abnormal take-off angle, compression between the aorta and the pulmonary trunk, slit-like ostia, coronary hypoplasia and accelerated atherosclerosis are responsible for the increased risk of coronary events in this population.

Cardiac presentations mimicking acute coronary syndrome of a giant pheochromocytoma case

Pheochromocytomas are benign tumors which originate from adrenal chromaffin cells. The classical triad of the pheochromocytoma includes headache, palpitations, and diaphoresis. Cardiac complications as arrhythmias, cardiomyopathy, ST elevated myocardial infarction, non-ST elevated myocardial infarction and myocardial infarction with non-obstructive coronary arteries (MINOCA) may be seen.&#x0D; Herein, we present a case of a 28-year-old male patient who admitted to an emergency department with chest pain and tachycardia one year ago. Coronary angiography was performed to diagnose a possible acute coronary syndrome. Urgent cardiac catheterization did not demonstrate an obstructive cardiac artery. Any intervention for revascularization was not needed. Nevertheless, the symptoms of the patient continued in the past year after this admission and he was admitted to the hospital a few times more with similar cardiac symptoms mimicking acute coronary syndrome. When the patient referred to our department, we determined that his plasma and urinary catecholamine levels were elevated. Magnetic resonance imaging (MRI) demonstrated a 167x70 mm sized heterogeneous mass including cystic components in the right adrenal gland, which pushes the right kidney towards inferior. After the pre-medication, a 170 mm in size 990-g weighted mass was successfully removed with open surgery. Histopathological findings confirmed the pheochromocytoma diagnosis. However, we presented a case of an exceptional giant pheochromocytoma mimicking acute coronary syndrome.

S2317 ERCP-Associated Air Embolism, Bacteremia, and Septic Cerebral Infarction

INTRODUCTION: Rare complications of endoscopic retrograde cholangiopancreatography (ERCP) are duodenal perforation, necrotizing pancreatitis, systemic air embolism (AE), and septic cerebral infarction. We present a case of ERCP associated AE, bacteremia, and septic cerebral infarction in one patient that survived. CASE DESCRIPTION/METHODS: A 52-year-old female with a history of choledocholithiasis, ERCP lithotripsy and stent placement 1 month prior, presented for outpatient ERCP and underwent stent removal, duct dilation and removal of multiple stones. Immediately post procedure, she became unresponsive with supraventricular tachycardia and hypotension requiring ICU admission and intubation. A stat EKG showed diffuse ST elevations with near complete resolution on repeat EKG 20 minutes later. Additionally, a stat abdominal CT showed portal venous gas confirming the presence of an AE (Figure 1). However, troponins eventually rose to 17 ng/mL, thus heparin was started until NSTEMI could be ruled out. Empiric antibiotics were also started due to persistent hypotension and infectious workup ensued. Urgent cardiac catheterization showed non-occlusive disease, and heparin was stopped. Her blood cultures grew Enterobacter hormaechei, thought to have seeded during ERCP, and antibiotics were streamlined. Despite hemodynamic improvement, she had difficulty awakening from sedation and a subsequent brain MRI revealed bifrontal hemorrhagic emboli, likely septic due to involvement of various vascular territories and known ERCP-associated bacteremia. Furthermore, there was no pneumocephalus, ruling out cerebral AE, and no vegetation on transesophageal echo, ruling out endocarditis. DISCUSSION: AE may be confused with an anesthetic side effect or acute ischemic event. It should be considered with sudden clinical deterioration during or immediately after ERCP. The diagnosis is often made post-mortem, thus clinical suspicion is paramount and may be confirmed after visualizing air in the vena cava, portal vein, heart, or brain. Air can be absorbed rapidly thus diagnosis can be made on clinical suspicion alone. Air insufflation into the portal vein can occur during sphincterotomy and use of CO2 can minimize risk of AE. Anticoagulation is not indicated and treating NSTEMI may have allowed for hemorrhagic conversion of septic emboli, which are already prone to hemorrhage. Septic cerebral emboli from ERCP are exceedingly rare, with a handful of reported cases. Our case urges awareness of potential catastrophic sequela of ERCP.Figure 1.: Abdominal CT without contrast demonstrating the peripheral pattern of portal venous gas (arrows) as well as the central gas pattern of pneumobilia (ellipse).Figure 2.: Coronal abdominal CT demonstrating air in the portal venous system.

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Abstract Introduction Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR. Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms. Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic. Conclusion Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

P6155Early computed tomographic evaluation for out-of-hospital cardiac arrest survivors: the CT-FIRST trial

Abstract Background Patients surviving an out-of-hospital cardiac arrest (OHCA) commonly present without an obvious etiology, but computed tomography (CT) can provide rapid, comprehensive anatomic evaluation of potential OHCA causes. Purpose To assess the diagnostic capabilities of whole body CT imaging in OHCA survivors. Methods From 11/2015 to 2/2018, the CT-FIRST (CT Feasibility In Resuscitated patient for Sudden death Triage) protocol enrolled 104 OHCA survivors without obvious OHCA cause to an early (&lt;6 hours from hospital arrival) dual source Sudden Death CT (SDCT) scan protocol that included a non-contrast head, ECG-gated cardiac/thoracic angiography, and non-gated venous phase abdominal CT's. Cardiac CT analysis was blinded, but other SDCT findings were clinically available. Patients needing urgent cardiac catheterization or hemodynamically unable to tolerate CT were excluded. Primary endpoints were SDCT diagnosis compared to OHCA causes from adjudicated record review, and any significantly altered therapy based on SDCT. Acute coronary syndrome by SDCT was conservatively assumed if &gt;50% stenosis was identified in major coronary artery(ies). Results SDCT scans identified 39% (41/104) of all OHCA causes and 95% (41/43) of causes potentially identifiable with SDCT (Table). No inappropriate treatments resulted from SDCT findings. SDCT changed or expedited treatments in 21/23 (95%) patients, including antibiotics, anticoagulants, and invasive evaluations or treatments. SDCT found or confirmed resuscitation complications including liver/spleen laceration (n=5), pneumothorax (n=7), and hemopericardium (n=1). N=104 OHCA Cause SDCT Diagnosis of OHCA Cause N (%) N (%) Acute coronary syndrome 13 (13%) 13 (100%) Cardiomyopathy 8 (8%) 7 (88%) Pneumonia 11 (11%) 11 (100%) Hemorrhagic stroke 3 (3%) 3 (100%) Pulmonary embolism 4 (3%) 4 (100%) Perforated viscus 2 (2%) 2 (100%) Gut necrosis 1 (1%) 1 (100%) Pulmonary hemorrhage 1 (1%) 1 (100%) Substance use 22 (21%) 0 (0%) Unknown 7 (7%) 0 (0%) Other 32 (31%) 0 (0%) Conclusion This pilot study suggests the SDCT protocol has considerable promise to diagnose OHCA causes and complications of resuscitation, as well as change clinical treatment. Acknowledgement/Funding Medic One Foundation

HEART BREAKS TO BREATHE: RECURRENT TAKOTSUBO CARDIOMYOPATHY IN COPD EXACERBATION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo syndrome (TTS) is defined as reversible stress-induced cardiomyopathy presenting as apical ballooning or mid-ventricular, basal, or focal wall motion abnormalities in the absence of coronary artery disease. It can be provoked by a stressful emotional situation or exposure to catecholamine surge. It’s a rare phenomenon to have a lung-heart axis leading to recurrent TTS. Here we present a rare case of recurrent TTS in the setting of COPD exacerbations also termed as bronchogenic TTS CASE PRESENTATION: 64 years old female with presented with dyspnea secondary to COPD exacerbation due to bacterial pneumonia was noted to have EKG changes with T-wave inversion, mild troponin elevation consistent with an ischemic lesion, elevated BNP 6103, followed by urgent cardiac catheterization noted to have non-significant coronary artery disease. Transthoracic echocardiogram (TTE) reported left ventricular ejection fraction (LVEF) of 25-29% with moderate sized apical, septal, posterior and anteroseptal wall motion abnormalities with akinesis of the segment consistent with TTS. Work up was negative for infective endocarditis, neurological and neuroendocrine tumor. She was treated with guideline-directed medical therapy (GDMT). LVEF normalized to 55%-59% in a follow up TTE. Seventeen months later she got readmitted with another episode of acute hypoxic hypercapnic respiratory failure requiring intubation with cardiac collapse. Patient had similar cardiac Catheterization findings but reduced LVEF of 30-34% consistent with TTS, again treated with GDMT, followed by a return of LVEF to normalization in a repeat TTE DISCUSSION: Recurrent TTS in the setting of COPD exacerbation is an extremely rare phenomenon exact cause of which remains unknown. Catecholamine surge causing microvascular dysfunction leading to cardiac stunning is a leading hypothesis. In COPD exacerbation adding beta 2 adrenergic agonists in management might potentiate worsening of cardiac stunning. Recurrent TTS has 19% overall risk for serious complications such as cardiogenic shock similar to acute coronary syndrome. The first step toward treatment is the removal of precipitating etiology like stress and in our case COPD exacerbation. ACE-inhibitors and angiotensin receptor blockers have a protective effect in reducing recurrent TTS while beta blockers have shown limited benefit. Even after recovery patient with TTS remains at high risk for electrical and mechanical complications CONCLUSIONS: Recurrent TTS in setting of COPD exacerbation has unknown incidence yet it highlights the intricate relationship of heart-lung axis. While TTS might be reversible, underlying pathophysiological insult might be permanent. We encourage physicians to not consider TTS as benign pathology and do every effort to reduce its recurrence. COPD exacerbation with TTS has worse prognosis with higher risk of hypoxic injury warranting improved COPD management. Reference #1: Rennyson, S. L., Parker, J. M., Symanski, J. D., & Littmann, L. (2010). Recurrent, severe, and rapidly reversible apical ballooning syndrome in status asthmaticus. Heart & Lung: The Journal of Acute and Critical Care, 39(6), 537-539. Reference #2: Manfredini, R., Fabbian, F., De Giorgi, A., Pala, M., Menegatti, A. M., Parisi, C., ... & Bossone, E. (2014). Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: a systematic review. World journal of cardiology, 6(5), 338. DISCLOSURES: No relevant relationships by Sreelatha Naik, source=Web Response No relevant relationships by Muhammad Pir, source=Web Response No relevant relationships by najam saqib, source=Web Response