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AB -   P1212 Assessment of left ventricular function by two-dimensional speckle tracking analysis in youth with masked hypertension XX Luo XX Luo Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of YQ Sun YQ Sun Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of QR Ge QR Ge Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of J Su J Su Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of HK So HK So The University of Hong Kong, Department of Paediatrics and Adolescent Medicine, Hong Kong, Hong Kong SAR People"s Republic of China MC Yam MC Yam The Chinese University of Hong Kong, Department of Paediatrics, Prince of Wales Hospital, Hong Kong, Hong Kong SAR People"s Republic of China F Fang F Fang Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China People"s Republic of YS Zhu YS Zhu Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of Shenzhen Hospital, Southern Medical University, Department of Ultrasonography, Shenzhen, China People"s Republic of The University of Hong Kong, Department of Paediatrics and Adolescent Medicine, Hong Kong, Hong Kong SAR People"s Republic of China The Chinese University of Hong Kong, Department of Paediatrics, Prince of Wales Hospital, Hong Kong, Hong Kong SAR People"s Republic of China Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, China People"s Republic of Funding Acknowledgements: This project was supported by the Health and Medical Research Fund (Ref no: 12131351), Food and Health Bureau, Hong Kong SAR Government. Background: Masked hypertension (MH) is not rare in youths and it may increase risks of long-term cardiovascular impairment. However, little attention has been given to the association of this blood pressure phenotype with subclinical cardiac damage in this young group. The aim of this study was to assess the myocardial deformation and function in the youth with MH using advanced echocardiography. Methods: Forty young patients with MH (age 18 ± 3 years, 73% males) and 40 age-, sex- and race-matched normotensive volunteers were recruited in our study. MH was diagnosed if daytime or night-time ambulatory blood pressure (ABP) ≥ 95th percentile for gender and height according to the local reference. All study subjects underwent 24-hour ABP monitoring and completed two-dimensional echocardiography (2DE) including speckle-tracking analysis (2D-STE). Quantitative data were determined for left ventricular (LV) ejection fraction (EF), global circumferential strain (CS), longitudinal strain (LS) as well as strain rate. Results: Ventricular volumes and LVEF were similar between the study groups. However, 2D-STE derived LV global LS and CS were significantly decreased in youth with MH when compared to true normotensives (all P < 0.05, Figure 1). Moreover, LV systolic and early diastolic longitudinal strain rates in MH subjects were lower than in control group (all P < 0.05, Figure 1), while late diastolic strain rates tended to increase in MH, although without statistically significance. Conclusion: Youths with MH have evidence of subclinical LV systolic impairment evaluated by speckle-tracking analysis, despite of short disease course. Thus, MH in youth should be no longer considered an entirely benign entity. View largeDownload slide Abstract P1212 Figure 1. Echocardiographic Data View largeDownload slide Abstract P1212 Figure 1. Echocardiographic Data P1213 Newly breathless patient with ongoing chest pain VK Le VK Le Northern Ontario School of Medicine, Department of Medicine, Thunder Bay, Canada I Amhalhal I Amhalhal Northern Ontario School of Medicine, Department of Medicine, Thunder Bay, Canada M Sadreddini M Sadreddini Northern Ontario School of Medicine, Department of Medicine, Thunder Bay, Canada Northern Ontario School of Medicine, Department of Medicine, Thunder Bay, Canada Introduction and case report description: A 57-year-old male with no past cardiac disease presented to the emergency department (ED) after experiencing chest pain for 6 days. The chest pain worsened until it persisted even at rest and was associated with significant dyspnea. The initial electrocardiogram (ECG) showed q waves and ST segment elevation in the inferior leads (II, III, and aVF), ST depression in leads I, aVL, V1-3, and a tall R wave in V2-V3, consistent with late presentation of an inferoposterior ST-elevation myocardial infarction (STEMI). Description of the problem and procedures: He underwent emergent coronary angiography, which showed a right dominant system with a completely occluded proximal right coronary artery (RCA). There was no significant flow-limiting disease in the left system. Primary percutaneous intervention to the proximal RCA was successful with placement of 2 drug eluting stents. A few hours after the procedure, he was developed cardiogenic shock and fulminant pulmonary edema. Possible differential diagnosis: In patients who develop acute hypotension and hypoxia after a myocardial infarction (MI), there are three catastrophic mechanical complications of a MI that must be considered on the differential diagnosis: mitral regurgitation (MR) from papillary muscle rupture or rupture of the chordae, ventricular septal rupture, and left ventricular free wall rupture. Answers and discussion: The rupture of the posteromedial papillary muscle is more common than a rupture of the anterolateral papillary muscle since the posteromedial papillary muscle only has blood supply from the posterior descending artery, whereas the anterolateral papillary muscle has blood supply from both the left anterior descending and left circumflex arteries. A transthoracic echo was done which was suggestive of a mitral valve (MV) papillary muscle rupture. This was followed by a transesophageal echocardiogram (TEE), which confirmed the suspicion and showed a posteromedial MV papillary muscle rupture with severe MR. Figure 1 shows images from a TEE in the midesophageal long-axis view (A), midesophageal 2-chamber view (B), and the midesophageal 4-chamber view (C and D). The blue arrows indicate the flail anterior leaflet and the green arrows show the stump of the ruptured posteromedial papillary muscle. Cardiac surgery was urgently arranged for replacement of the MV. In this case, the patient had ongoing chest pain prior to presenting to the ED. His initial ECG was suggestive of late presentation of a STEMI, and thus he was at higher risk for a mechanical complication of the MI. Conclusions and implications for clinical practice: It is important that clinicians assess for potential catastrophic mechanical complications during management of a patient with a MI, such as a posteromedial papillary muscle rupture, especially in patients with late presentation of a STEMI and significant dyspnea or in patients who develop cardiogenic shock. View largeDownload slide Abstract P1213 Figure 1 View largeDownload slide Abstract P1213 Figure 1 P1214 Flow reversal in pulmonary vein caused by anomalous pulmonary vein opening to both left atrium and superior vena cava M Toki M Toki The Sakakibara Heart Institute of Okayama, Department of Clinical Laboratory, Okayama, Japan N Kagiyama N Kagiyama Washington University in St. Louis, Division of Cardiology, St. Louis, United States of America A Hayashida A Hayashida The Sakakibara Heart Institute of Okayama, Department Of Cardiology, Okayama, Japan T Kawamoto T Kawamoto The Sakakibara Heart Institute of Okayama, Department Of Cardiology, Okayama, Japan T Sakaguchi T Sakaguchi The Sakakibara Heart Institute of Okayama, Department of Cardiovascular Surgery, Okayama, Japan S Aritaka S Aritaka The Sakakibara Heart Institute of Okayama, Department of Clinical Laboratory, Okayama, Japan K Yoshida K Yoshida The Sakakibara Heart Institute of Okayama, Department Of Cardiology, Okayama, Japan The Sakakibara Heart Institute of Okayama, Department of Clinical Laboratory, Okayama, Japan Washington University in St. Louis, Division of Cardiology, St. Louis, United States of America The Sakakibara Heart Institute of Okayama, Department Of Cardiology, Okayama, Japan The Sakakibara Heart Institute of Okayama, Department of Cardiovascular Surgery, Okayama, Japan A 75-year-old lady was presented to our hospital with shortness of breath. She had no medical history of cardiovascular disease. Her oxygen saturation was 98 % and no crackles or rales were heard. However, chest X-ray showed cardiomegaly and her BNP level was significantly elevated (163.1 pg/mL). Transthoracic echocardiography (TTE) revealed dilated right heart, and normal-size left heart. She had moderate to severe tricuspid regurgitation with pulmonary hypertension (peak systolic pressure 44 mmHg). Pulmonary to systemic blood flow ratio (Qp/Qs) derived by TTE was 3.5. Although these results strongly suggested left to right shunt, the evidence of intra-cardiac shunt was not detected by TTE. Accordingly, transesophageal echocardiography was performed. First, secundum atrial septal defect (ASD) was not detected. Further examination revealed reversal of late systolic, diastolic and atrial flow in right superior pulmonary vein (RSPV). Flow in the other three pulmonary veins was normal. Considering the high Qp/Qs in this patient, the RSPV was suspected to drain blood from left atrium to right heart. CT angiography confirmed that the RSPV opened to both left atrium and superior vena cava. Surgery was performed and the connection of the RSPV with superior vena cava was closed. Hemodynamics of partial anomalous pulmonary venous connection (PAPVC) is similar to that of ASD. Because PAPVC is often accompanied by ASD, it is important pay attention to pulmonary veins to avoid overlooking PAPVC during echocardiography. In this extremely rare case, all the pulmonary veins opened to left atrium, and the flow reversal in the pulmonary vein was an important clue for the diagnosis. View largeDownload slide Abstract P1214 Figure. The RSPV Opened to Both LA and SVC View largeDownload slide Abstract P1214 Figure. The RSPV Opened to Both LA and SVC P1215 A very rare case of endocarditis DH Neves Sebaiti DH Neves Sebaiti Hospital Garcia de Orta, Cardiology, Almada, Portugal PF Paula Fazendas PF Paula Fazendas Hospital Garcia de Orta, Cardiology, Almada, Portugal DR Helder Pereira DR Helder Pereira Hospital Garcia de Orta, Cardiology, Almada, Portugal TÉC Ana Francisco TÉC Ana Francisco Hospital Garcia de Orta, Cardiology, Almada, Portugal Hospital Garcia de Orta, Cardiology, Almada, Portugal Fungal endocarditis is a rare and fatal condition (about 50% mortality rate). It usually develops in immunosuppressed patients. The diagnosis is challenging, and diagnosis of prosthetic valve fungal endocarditis is extremely difficult. The etiologic fungi more commonly seen are the Candida and Aspergillus species. This is a 64-year-old female, Caucasian, with hypertension, diabetes and stage 5 chronic kidney disease, chronic pulmonary obstructive disease, pulmonary thromboembolism with pulmonary hypertension and a recent 21 days hospital stay for pneumonia, started dialysis due to worsening of renal failure and being on corticoids for allopurinol induced Dress Syndrome, was discharge one week ago. The patient came back to the hospital with a 24 hours onset of fever, shivering and vomiting, with a worsen of fatigue and onset of orthopnea. Initial physical assessment was unremarkable. Serum test showed elevation of leukocytes count 37^9/L, Neutrophil 94%, C-reactive protein 13 mg/dl. Started empirical antibiotics just after collecting samples for blood and urine cultures (respiratory Vs urinary tract infection) with resolution of fever. Two weeks later, onset of abdominal pain, and rectal hemorrhage. Colonoscopy showed multiple ulcers at the rectum portion, negative biopsies and culture. After cytomegalovirus positive protein chain reaction test (>100.000 viral copies), colitis due to cytomegalovirus was admitted and started antiviral therapy with resolution of symptoms. Six weeks after admission, new onset of fever and recurrence of leucocytes and elevated PCR with signs of infection (inflammatory signs and exudate) at the site of catheter dialysis insertion (internal right jugular vein) and catheter was replaced. New blood culture and culture of the exudate were positive for multi-sensitive Candida Albicans and started intravenous anti-fungal therapy. Transesophageal echocardiography (TEE) was performed, that showed a mobile mass formation (> 50X17 mm) starting at superior vena cava (SVC), occupying 50% of the lumen of the SVC, and protruding into the right atrium and didn´t appear to be related to the new central catheter. The image seemed to match "ghost" image characteristic (post-removal tubular mobile mass following the intracardiac route of the previous permanent catheter, on the superior vena cava) but could also correspond to vegetation or even thrombus. Transesophageal echocardiography was repeated 20 days after, with 21 days of antifungal therapy with clinical improvement. TEE showed bigger sized mass, that occupied all the lumen of the SVC and the protrusion got near the tricuspid valve. The patient was submitted to surgical removal of the vegetation (fungal endocarditis). The patient was discharged 4 weeks after surgery with long lasting anti-fungal therapy. View largeDownload slide Abstract P1215 Figure. Fungal Endocarditis View largeDownload slide Abstract P1215 Figure. Fungal Endocarditis P1216 Deformation Imaging for diagnosis of myocarditis - Comparison with MR findings: a case report S Stoebe S Stoebe Leipzig University Hospital, Department of Cardiology, Leipzig, Germany B Tayal B Tayal Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark K Solty K Solty Leipzig University Hospital, Department of Radiology, Leipzig, Germany M Gutberlet M Gutberlet Heart Center of Leipzig, Department of Radiology, Leipzig, Germany D Lavall D Lavall Leipzig University Hospital, Department of Cardiology, Leipzig, Germany U Laufs U Laufs Leipzig University Hospital, Department of Cardiology, Leipzig, Germany A Hagendorff A Hagendorff Leipzig University Hospital, Department of Cardiology, Leipzig, Germany Leipzig University Hospital, Department of Cardiology, Leipzig, Germany Aalborg University Hospital, Department of Cardiology, Aalborg, Denmark Leipzig University Hospital, Department of Radiology, Leipzig, Germany Heart Center of Leipzig, Department of Radiology, Leipzig, Germany A 60 years old female patient presented at the emergency department because of chest pain and dyspnoea. The patient also had flu-like symptoms over the past few days before the onset of chest pain. In the initial electrocardiogram no signs of acute ischemia could be observed and coronary enzymes were normal. Emergency transthoracic echocardiography showed a normal left ventricular (LV) ejection fraction. Further, global longitudinal strain (< -20%) and radial strain were normal (> 40%), but layered circumferential strain showed decreased values in the subepimyocardial region of the LV wall (posterior and inferior segments) at both base and apex. In addition, myocardial work was analysed by a novel, non-invasive method, which quantifies constructive work by segmental information about positive work in the ventricle. The assessment of myocardial work resulted in a regional increase in or near the segments with reduced circumferential strain values, which correspond to the pathological findings in cardiac magnet resonance imaging (cMRI). cMRI was performed due to persistent symptoms of the patient and confirmed the diagnosis of infective myocarditis by fulfilling the Lake Louis consensus criteria showing edema in the inferior - inferoseptal segments, hyperaemia by early gadolinium enhancement and late gadolinium enhancement in the corresponding segments. The patient stayed in hospital for monitoring for a few days and recovered completely of symptoms. Conclusion: Acute infective myocarditis documented by cMRI also causes impairment of layered circumferential strain involving the subepimyocardium in the corresponding areas. A simple procedure, e.g. the assessment of layered circumferential strain could be of diagnostic value in clinical routine - specifically in patients with suspected myocarditis. In addition, changes of regional myocardial work index could be found in the infected areas indicating possibly compensatory regional increase of longitudinal deformation. Figure 1 - Deformation Imaging by by Speckle Tracking: a-b: Analysis of circumferential strain showing transmural pathological values in the apical inferior-inferoseptal ventricular regions (a) and pronounced subepimyocardial in the basal inferior-posterior ventricular regions (b). c: Bull`s eye of regional myocardial work index showing increased regional longitudinal work index in the apical inferoseptal as well as in the basal posterior regions (red arrows). d-e: Pressure-strain diagram of the basal inferior region (d) documenting less constructive work than the average constructive work of the apical inferior region (e) documenting more than average constructive work. View largeDownload slide Abstract P1216 Figure 1 View largeDownload slide Abstract P1216 Figure 1 P1217 Added value of three-dimensional echocardiography in the evaluation of grown-up congenital heart disease patients after congenital cardiac surgery M Previtero M Previtero University of Padova, Dpt of Cardiac, Thoracic and Vascular Sciences, Padua, Italy D Muraru D Muraru University of Padova, Dpt of Cardiac, Thoracic and Vascular Sciences, Padua, Italy S Iliceto S Iliceto University of Padova, Dpt of Cardiac, Thoracic and Vascular Sciences, Padua, Italy LP Badano LP Badano University of Padova, Dpt of Cardiac, Thoracic and Vascular Sciences, Padua, Italy University of Padova, Dpt of Cardiac, Thoracic and Vascular Sciences, Padua, Italy A 40-year-old man with previous (1984) surgical repair of a partial atrioventricular canal [anterior leaflet cleft of the mitral valve (MV) and ostium primum atrial septal defect], was admitted to our department because of worsening dyspnea (NYHA class III). For two years, he had complained of shortness of breath and fatigue. In March 2017, because of persistent atrial flutter (AF), he underwent transthoracic echocardiogram (TTE) that revealed normal size and mild systolic dysfunction of the left ventricle (LV), a dilated right ventricle (RV) with normal systolic function, and moderate mitral and tricuspid valve regurgitation. A left-to-right shunt at the level of interatrial septum (AS) was suspected. However, a 2D transesophageal (TOE) study confirmed a good result of the surgical repair of the interatrial septal defect (ASD). Despite a successful electric cardioversion, the patient was still symptomatic. Later, AF relapsed. At admission, physical examination revealed a clear chest, no peripheral oedema and an apical holosystolic murmur. The ECG showed AF (95 bpm) with incomplete right bundle branch block. TTE confirmed RV enlargement, but showed an abnormal color flow passage through the AS. A focused 2D and 3DTOE revealed surgical patch detachment with an inferior and posterior ASD (Figure panel B and C) resulting in massive left-to-right shunt. Volume rendered 3DE imaging showed position, shape and size of the defect, presence of double superior venae cavaes draining in the right atrium and surgically-closed MV cleft (panel D). By right heart catheterization, the ratio between pulmonary and systemic output (QP/QS) was 3.1. There was mild pulmonary artery hypertension (mean pulmonary artery pressure = 26 mm Hg) with normal pulmonary vascular resistences (1.5 UW). The patient has been scheduled for surgical repair. Learning points: Evaluation of grown-up congenital heart disease patients after congenital cardiac surgery requires complete knowledge of the past medical history and a detailed focused assessment. The first 2D TOE failed to identify the persistent shunt because its 5-chamber and bicaval views showed just the anterior and the middle part of the AS, thus missing the defect that was located posteriorly and inferiorly. A 2DE study provides just "thin slices of the heart" that are limited in number and orientation and the operator assumes that those slices are representative of the whole heart. 3DE provides comprehensive and anatomically sound imaging of cardiac structures. Particularly, the en face view of cardiac structures like AS (not possible with 2DE) allows a comprehensive anatomical assessment of structures, improving diagnostic accuracy and helping to plan surgery. Due to suboptimal spatial resolution of current 3DE systems and the thin ASD, drop-out artifacts may occur and they can be confused for true defects. To avoid misdiagnoses, 3DE color-flow data sets should always be acquired to document the presence of shunt. View largeDownload slide Abstract P1217 Figure. View largeDownload slide Abstract P1217 Figure. P1218 From bad to worst case scenario: left ventricular pseudoaneurysm after surgery for prosthetic mitral valve obstruction D Ciuperca D Ciuperca University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania DC Calin DC Calin University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania A Calin A Calin University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania M Rosca M Rosca University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania C Ginghina C Ginghina University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania BA Popescu BA Popescu University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania University of Medicine and Pharmacy Carol Davila, Euroecolab, Bucharest, Romania A 57-year old man was admitted with dyspnea at mild exertion, progressively worsened over the last two weeks. He had a history of mitral valve replacement (MVR) with a mechanical bileaflet prosthesis 14 months before admission. He had stopped the anticoagulant therapy without the physician’s advice, one month before, when he had a dental extraction (unknown antibiotic prophylaxis). The transthoracic (TTE) and transesophageal echocardiography (TEE) revealed a dysfunctional mitral valve prosthesis (MVP) with severe stenosis and moderate regurgitation, caused by a large mass attached to the atrial side of the ring and the leaflets, to the left atrial wall, with soft echo density, suggesting thrombosis, obstructing the anterior leaflet (A, B). Considering the clinical presentation, the echocardiographic features, the negative blood cultures (and no other clinical or imaging criteria for endocarditis), the patient was transferred to a cardiac surgery department for dysfunctional MVP replacement. After two months of good initial recovery following surgery, he returned to our clinic for rest dyspnea, cough with sanguinolent sputum, aggravated a week before admission. The physical exam showed signs of left and right heart failure. The TTE revealed an anechoic mass of approximately 3.5/5.5 cm adjacent to the basal lateral left ventricular (LV) wall (C). On color Doppler flow the cavity communicated with the LV through an apparent free wall defect (D), suggesting a LV posterolateral wall pseudoaneurysm (PA). The evaluation of the MVP showed no signs of obstruction. A paravalvular leak was suspected, caused by a possible disjunction of the mitral prosthetic ring. The clinical state of the patient deteriorated rapidly into cardiogenic shock and he was transferred to the intensive care unit (ICU) for ventilatory and inotropic support. The TEE performed in the ICU confirmed the presence of the PA in the posterolateral LV wall, a moderate paravalvular leak and did not reveal images suggestive of vegetations. The blood cultures were positive for Streptococcus pneumoniae, leading to the diagnosis of possible endocarditis (using the modified Duke criteria). The case was discussed by the Heart Team, but due to a high operative risk and technical difficulties, urgent surgery was declined. Unfortunately, the patient also developed septic shock, unresponsive to medical treatment, and died of multiple organ failure a few days later. The gold standard treatment in patients with a LV pseudoaneurysm, a rare complication following MVR, is the surgical closure of the LV wall defect and excision of the PA. Our patient had a very high operative risk, so the surgical team considered that a new intervention is not an option. Replacement of MVP due to thrombosis, excess removal of annular tissue and a possible endocarditis were considered causes that led to the PA and the unfavorable outcome. View largeDownload slide Abstract P1218 Figure. View largeDownload slide Abstract P1218 Figure. P1219 Risk of misdiagnosis in children with left ventricular non-compaction - potential benefit of magnetic resonance imaging T Jurko T Jurko Clinic of Neonatology JFM CU,University Hospital Martin,Slovak republic, Neonatology Clinic, Martin, Slovak Republic A Jurko A Jurko Pediatric cardiology clinic Martin, Pediatric cardiology, Martin, Slovak Republic M Mistinova M Mistinova 2Radiology Clinic, Medical Faculty, Comenius University, Bratislava, Departmen Radiology, Bratislava, Slovak Republic A Jurko A Jurko Jessenius medicine faculty UK Martin,Slovakia, Pediatric Clinic, Martin, Slovak Republic M Minarik M Minarik Cinic of Anestesiology JFM CU Martin,University Hospital Martin,Slovakia, Department of Anestesiology, Martin, Slovak Republic M Mestanik M Mestanik Department of Physiology JFMCU and Biomedical center Martin JFMCU,Slovak Republic, Department Physiology, Martin, Slovak Republic I Tonhajzerova I Tonhajzerova Department of Physiology JFMCU and Biomedical center Martin JFMCU,Slovak Republic, Department Physiology, Martin, Slovak Republic Clinic of Neonatology JFM CU,University Hospital Martin,Slovak republic, Neonatology Clinic, Martin, Slovak Republic Pediatric cardiology clinic Martin, Pediatric cardiology, Martin, Slovak Republic 2Radiology Clinic, Medical Faculty, Comenius University, Bratislava, Departmen Radiology, Bratislava, Slovak Republic Jessenius medicine faculty UK Martin,Slovakia, Pediatric Clinic, Martin, Slovak Republic Cinic of Anestesiology JFM CU Martin,University Hospital Martin,Slovakia, Department of Anestesiology, Martin, Slovak Republic Department of Physiology JFMCU and Biomedical center Martin JFMCU,Slovak Republic, Department Physiology, Martin, Slovak Republic Left ventricular non-compaction (LVNC) is a rare form of cardiomyopathy resulting from a disorder of endomyocardial morphogenesis associated with significantly increased risk of cardiovascular morbidity and premature mortality. Despite the widespread use of echocardiography, LVNC is commonly misdiagnosed, often due to lack of knowledge about this disorder. This study was aimed to provide a detailed summary of complex diagnostic process and follow-up in 24 children (16 boys, 8 girls, 9 - 18 years old) diagnosed with LVNC. 17 patients were initially misdiagnosed and followed-up for different diagnoses. After retrospective evaluation by a senior specialist in pediatric cardiology, LVNC was identified in 3 patients initially diagnosed with dilated cardiomyopathy, 11 patients followed-up with various forms of arrhythmias, and 3 patients with congenital heart disease. The diagnosis of LVNC was confirmed using magnetic resonance imaging (MRI) in all the patients. The classical triad of complications - heart failure, ventricular arrhythmias and systemic embolic events - was not confirmed in this study, ECG findings were abnormal in 87.5% of patients. Isolated non-compaction of the left ventricular myocardium was a dominant form of non-compaction. The high variability of morphological findings and clinical manifestations of LVNC results in frequent misdiagnosis of this disorder. It is important to make the cardiologists more familiar with this condition and its pathology. MRI represents a conducive method to make a correct diagnosis of LVNC under several specific conditions, particularly in case of non-conclusive echocardiographic finding. P1220 Severe tricuspid regurgitation induced by permanent pacing lead- imaging approach R Sosdean R Sosdean "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania F Goanta F Goanta "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania L Maries L Maries "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania RL Ianos RL Ianos Timisoara Institute of Cardiovascular Medicine, Timisoara, Romania IR Macarie IR Macarie Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania C Mornos C Mornos "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania A Ionac A Ionac "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania S Pescariu S Pescariu "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania "Victor Babes" University of Medicine and Pharmacy, Clinic of Cardiology, Timisoara, Romania Timisoara Institute of Cardiovascular Medicine, Timisoara, Romania Clinical Hospital of Infectious Diseases and Pneumophtisiology, Timisoara, Romania Background. Severe permanent pacemaker induced tricuspid regurgitation is an under- diagnosed entity with deleterious consequences. Several mechanisms have been described including dyssynchrony, lead impingement on the tricuspid valve leaflets, lead adherence to the tricuspid valve. 3D echo imaging is beginning to gain ground in its diagnosis. Purpose. Our aim is to report a case of severe permanent pacing lead tricuspid regurgitation describing the imaging techniques implied in its diagnosis. Reporting a valid diagnostic pathway in these cases is worthwhile for an appropriate management. Methods. A 69 year-old patient came to our clinic with decompensated right heart failure symptomatology (peripheral edema, ascites, pericardial and pleural effusion) for which he had had multiple hospitalizations, under maximal heart failure therapy. He underwent a two chamber VDD pacemaker for complete atrioventricular block 10 years ago, up-graded to biventricular 2 years ago. He was diagnosed with cardiac cirrhosis after excluding other causes and/or collagen diseases by specific investigations. The ECG and device interrogation revealed atrial fibrillation with appropriate biventricular pacing in VVI mode. We combined 2D and 3D transthoracic echocardiography as well as fluoroscopy in order to better evaluate and understand the problem. Results. Transthoracic 2D echocardiography revealed a normal sized left ventricle with an ejection fraction of 50%, with mild mitral regurgitation. The right ventricle (RV) on the other hand was enlarged but with a preserved systolic function (TAPSE 1.7cm, tricuspid ring S" 0,11m/s, RV free wall speckle tracking strain -19%). Tricuspid regurgitation was now severe with a dilated ring and tethering. There seemed to be no other problem with the valve"s cusps, and the regurgitation seemed to be functional. On the other hand the pressure gradient corresponded with only a light pulmonary hypertension. Additional findings included biatrial dilation, small amount of pericardial and left pleural fluid and a significantly dilated inferior vena cava. 3D echocardiographic evaluation of the tricuspid valve properly diagnosed the problem, by exposing all three cusps entirely. The pacing lead was impinging on the septal leaflet partly alterating it"s movement. Fluoroscopy showed the distal third of the pacing lead lacking it"s normal movement, suggesting adherences with the RV wall. Surgical intervention for lead removal and tricuspid valve repair was proposed but the patient refused for the moment. For now, the evolution was favorable with intravenous loop diuretic supplemmentation. Conclusions. Severe pacing lead induced TR is likely to be misdiagnosed by 2D echocardiography because of the impossibility to evaluate properly the entire valve apparatus. 3D echocardiography overcomes this problem. View largeDownload slide Abstract P1220 Figure. View largeDownload slide Abstract P1220 Figure. P1221 An accidental finding that changed everything SLJ Sara Lozano Jimenez SLJ Sara Lozano Jimenez Puerta de Hierro, Cardiology, Majadahonda, Spain JBH Jorge Baena Herrera JBH Jorge Baena Herrera Puerta de Hierro, Cardiology, Majadahonda, Spain EGI Eusebio Garcia-Izquierdo EGI Eusebio Garcia-Izquierdo Puerta de Hierro, Cardiology, Majadahonda, Spain JFOD Juan Francisco Oteo Dominguez JFOD Juan Francisco Oteo Dominguez Puerta de Hierro, Cardiology, Majadahonda, Spain SMS Susana Mingo Santos SMS Susana Mingo Santos Puerta de Hierro, Cardiology, Majadahonda, Spain JMEV Juan Manuel Escudier Villa JMEV Juan Manuel Escudier Villa Puerta de Hierro, Cardiology, Majadahonda, Spain LAP Luis Alonso Pulpon LAP Luis Alonso Pulpon Puerta de Hierro, Cardiology, Majadahonda, Spain Puerta de Hierro, Cardiology, Majadahonda, Spain One of the causes of transcatheter heart valve (THV) failure is thrombosis. Diagnostic criteria included a transthoracic echocardiography mean gradient increase from post-procedural value ≥20 mm Hg and mean gradient ≥40 mm Hg with reduced leaflet mobility and/or perileaflet hypodense mass consistent with thrombus by transesophageal echocardiogram or computed tomography We report a case of Lotus valve thrombosis, which occurred 14 months after implantation. A 86-year-old male patient was admitted to our hospital due to chest pain. He had prior history of coronary artery multivessel disease which required CABG. Since he developed symptomatic severe aortic stenosis, valvuloplasty and implantation of a 23 mm Lotus valve was performed in December of 2016. Aspirin and Clopidogrel were administered during 3 months, as initial antiplatelet therapy. After that, a maintenance treatment with Clopidogrel was indicated. During the last weeks, he started to suffer from minimal exertion retrosternal pain, radiated to both arms and jaw, lasting more than 10 minutes. Physical examination revealed a systolic murmur. ECG didn´t show any change. A serial increase in Troponin I value was appreciated (up to 4 ng/ml, being our laboratory cutpoint: 0,06). A transthoracic echocardiography showed a mean gradient >60 mmHg (more than 40 mmHg higher than the previous value obtained several months before). Computed tomography images confirmed the suspicion of valve thrombosis. An hypoattenuated mass, involving the three valves, was identified, resulting in decreased leaflet motion (Figure 1). After four days of unfractionated heparin infusion, thrombus almost disappeared and our patient´s clinical condition improved (Figure 2). Thrombosis vs Pannus Thrombosis Pannus Higher total mass volume and area Higher lesion density More commonly located on the atrial side for mitral prostheses and on the aortic side for aortic prostheses Greater leaflet motion restriction Lower total mass volume and area Lower lesion density More commonly located on the ventricular side for both mitral and aortic prostheses Less leaflet motion restriction Thrombosis Pannus Higher total mass volume and area Higher lesion density More commonly located on the atrial side for mitral prostheses and on the aortic side for aortic prostheses Greater leaflet motion restriction Lower total mass volume and area Lower lesion density More commonly located on the ventricular side for both mitral and aortic prostheses Less leaflet motion restriction There are some features that allows to distinguish between thrombosis and pannus View Large Thrombosis vs Pannus Thrombosis Pannus Higher total mass volume and area Higher lesion density More commonly located on the atrial side for mitral prostheses and on the aortic side for aortic prostheses Greater leaflet motion restriction Lower total mass volume and area Lower lesion density More commonly located on the ventricular side for both mitral and aortic prostheses Less leaflet motion restriction Thrombosis Pannus Higher total mass volume and area Higher lesion density More commonly located on the atrial side for mitral prostheses and on the aortic side for aortic prostheses Greater leaflet motion restriction Lower total mass volume and area Lower lesion density More commonly located on the ventricular side for both mitral and aortic prostheses Less leaflet motion restriction There are some features that allows to distinguish between thrombosis and pannus View Large View largeDownload slide Abstract P1221 Figure. Thrombosis View largeDownload slide Abstract P1221 Figure. Thrombosis P1222 A case of atypical clinical presentation of acute aortic syndrome U Kocabas U Kocabas Baskent University Faculty of Medicine, Cardiology, Istanbul, Turkey H Altay H Altay Baskent University Faculty of Medicine, Cardiology, Istanbul, Turkey I Isiklar I Isiklar Baskent University Faculty of Medicine, Radiology, Istanbul, Turkey B Saritas B Saritas Baskent University Faculty of Medicine, Cardiovascular Surgery, Istanbul, Turkey F Ozkalayci F Ozkalayci Baskent University Faculty of Medicine, Cardiology, Istanbul, Turkey S Pehlivanoglu S Pehlivanoglu Baskent University Faculty of Medicine, Cardiology, Istanbul, Turkey Baskent University Faculty of Medicine, Cardiology, Istanbul, Turkey Baskent University Faculty of Medicine, Radiology, Istanbul, Turkey Baskent University Faculty of Medicine, Cardiovascular Surgery, Istanbul, Turkey A 61-year-old woman with a history of uncontrolled hypertension presented to emergency room with symptoms of confusion, nausea, dizziness and recent recurrent syncopal episodes. Physical examination was unremarkable except for blood pressure 70/40 mmHg with a heart rate of 95 bpm. The 12-lead ECG demonstrated normal sinus rhythm without ischaemic changes. Transthoracic echocardiography showed normal left ventricular systolic function with mild pericardial effusion The initial laboratory analysis were within normal limits, including blood gas analysis and troponin levels. The patient underwent to the computed tomography angiography (CTA) to diagnose the etiology of persistent hypotension, syncope and pericardial effusion. CTA and its three-dimensional reconstruction images revealed irregular contrast collection in the arcus aortic wall which is consistent with penetrating aortic ulser and periaortic fluid collection of the ascending aorta and aortic arch without dissection flap which is not consistent with typical acute aortic syndrome features (Panel A-D). During her 2 hours of ICU follow-up, the patient was hypotensive despite intravenous fluid and vasopressor therapy, and also hemoglobin decline was recorded from 15.7 g/dl to 13.2 g/dl. Follow-up CTA was performed which revealed progression of penetrating aortic ulcer and intramural aortic hematoma with distinct pleural effusion which was not present at the initial examination (Panel E-F). The patient was transferred to the cardiovascular surgery clinic with a diagnosis of progressive penetrating aortic ulser and intramural aortic hematoma and underwent replacement of ascending aorta with a 28-mm Dacron graft. Postoperatively, the patient recovered without any complication and discharged from the hospital. View largeDownload slide Abstract P1222 Figure View largeDownload slide Abstract P1222 Figure P1223 Management Challenges in a Case of Pulmonary Hypertension Associated with Adult Congenital Heart Disease and Hepatitis C R Badea R Badea Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania R Enache R Enache Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania P Platon P Platon Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania L Predescu L Predescu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania IM Coman IM Coman Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania C Ginghina C Ginghina Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania BA Popescu BA Popescu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania Funding Acknowledgements: no disclosures BACKGROUND. Pulmonary arterial hypertension (PH) is a syndrome with complex aetiology that requires multimodality imaging for complete diagnosis, especially in congenital heart disease (CHD). CHD–associated PH may benefit from pulmonary vasodilator drugs, but PH complications such as left main coronary artery compression may require Heart Team discussions for risk assessment and best management. CASE PRESENTATION. 54 year-old woman known with hepatitis C and class A liver cirrhosis on interferon and ribavirin but persistent viremia, describes low exercise tolerance, confirmed by the 6MWT (320 m). She has SatO2 94%, otherwise normal clinical exam and BNP. Echo shows signs of PH: dilated main PA, mPAP 38mmHg, short PAT with midsystolic notching, dilated right heart chambers, normal biventricular function, no left heart disease. Porto-PH is unlikely -no signs of portal hypertension at upper gastrointestinal endoscopy. Transesophageal echo reveals sinus venosus type atrial septal defect, ASD. ChestCT finds no signs of thrombembolic disease, but finds partial anomalous pulmonary venous return, PAPVR, the upper right pulmonary vein draining in the superior vena cava. Catheterisation confirms precapillary PH (mPAP 38 mmHg, PCWP 7 mmHg) with PVR 3.07 WU (5.15 WUi), PVR/SVR 0.14, Qp:Qs 2.89 consistent with ASD and PAPVR. Coronarography shows 60% left main coronary artery, LMCA stenosis with instant wave-free ratio (iFR) =1. We considered ASD surgical correction but given the patient’s age, cirrhosis, bidirectional shunt, PH, high PVR and the natural septostomy as pressure-release valve for the RV, we chose a brigde-to-decision strategy (PH medication and repeat cath). Bosentan is preferred for CHD–associated PH, but can cause hepatolysis and new antiviral therapy for hep.C was needed. Lacking data on co-administration and considering stable PH vs. persistent viremia, she received antivirals first and later bosentan, well tolerated. Repeat cath at 3 months showed similar parameters. Evolution on bosentan was favourable at 1-year follow-up. DISCUSSIONS. Our case is relevant from different standpoints. First, bosentan (class I recommendation in CHD-associated PH) was well tolerated on a cirrhosis and vice-versa, ombitasvir/paritaprevir/ritonavir was well tolerated in a PH patient (no literature data on the association). Second, PVR 5 WUi sets ASD correction in the grey guidelines zone, but repeat cath after bosentan confirmed irreversible PH. Third, in lack of evidence regarding an asymptomatic 60% LMCA compression, we performed an ischaemia test which allowed witholding a risky PCI. This is to our knowledge the first application of iFR in a case of LMCA compression and in a case of PH altogether. CONCLUSIONS. Challenges emerging from this case are a reminder that case reports are essential in shedding some light on rare associations - here, grown-up CHD and PH with complications (left main coronary artery compression) and comorbidities (liver cirrhosis). View largeDownload slide Abstract P1223 Figure. Dilated PA causes LMCA compression View largeDownload slide Abstract P1223 Figure. Dilated PA causes LMCA compression P1225 An incidental murmur in a pregnant lady - a breaking hourglass, awaiting to be shattered WJ Tiau WJ Tiau University Kebangsaan Malaysia (UKM), Cardiology, Kuala Lumpur, Malaysia KY Cynthia Tan KY Cynthia Tan Hospital Sultan Haji Ahmad Shah, Medical Department, Temerloh, Malaysia University Kebangsaan Malaysia (UKM), Cardiology, Kuala Lumpur, Malaysia Hospital Sultan Haji Ahmad Shah, Medical Department, Temerloh, Malaysia Case : A 30 year-old primigravida at 17 week of gestation, was referred from a health clinic due to an incidental murmur which was detected during an antenatal follow up. She was otherwise well and asymptomatic. Her antenatal check up was uneventful. Clinically, she was comfortable. Auscultation revealed a grade IV diastolic murmur at the left parasternal, suggestive of an aortic regurgitation. Her lungs field were clear on auscultation and her apex beat was not displaced. She was afebrile and there were no stigmata of infective endocarditis. However, her blood pressure showed a systolic pressure discrepancy of more than 20mmHg between both brachial pressure, which highly suggestive an Acute Aortic Syndrome. An urgent echocardiography was performed and showed a dilated aortic root of 5.3cm with severe aortic regurgitation. A visible dissecting flap was seen at aortic root extent into the ascending aorta, separating the true and false lumen. The dissecting flap was also seen in the right common carotid artery. Her left ventricular function was preserved and there was no pericardial effusion. Standard Type A - Aortic Dissection was confirmed by CT Aortogram involving the ascending thoracic aorta, aortic arch, descending aorta, brachiocephalic trunk and right common carotid artery. She was started with infusion labetalol and transferred to the National Heart Institute. She underwent a modified Bentall’s procedure with mechanical AV replacement on the next day, followed by termination of her pregnancy one week later. Post procedure, she recovered well and was advised against pregnancy in the future. Discussion : Aortic dissection in pregnancy is a rare but highly fatal condition. Most patients would presents with typical symptom-abrupt onset of severe tearing chest pain. However, patients with atypical presentation has been reported and the diagnosis in these patients is often challenging. Hence, a high index of suspicion is extremely crucial as the delay in diagnosis would lead to a devastating outcome. Non-invasive imaging - TTE is crucial here, not only to evaluate the severity, but also to identify the etiology of the aortic insufficiency, by visualising the anatomical structure of the aortic root. Her dissection which was proximally extending warrant an urgent surgical intervention as she would at extremely high risk of coronary dissection, cardiac tamponade or stroke, if the dissection progressed. In summary, this case illustrates a rare case of asymptomatic extensive aortic dissection in pregnancy, and the importance of having a high index of suspicion by the attending clinician, enabling a timely diagnosis and resulting in a favorable clinical outcome. View largeDownload slide Abstract P1225 Figure. TTE/CTA View largeDownload slide Abstract P1225 Figure. TTE/CTA P1226 Aortic pseudoaneurysm with aorto-cavitary fistula, two similar cases, multimodality approach E Iglesias Colino E Iglesias Colino University of Navarra, Cardiology, Pamplona, Spain A Riesgo Garcia A Riesgo Garcia University of Navarra, Cardiology, Pamplona, Spain R Eiros Bachiller R Eiros Bachiller University of Navarra, Cardiology, Pamplona, Spain M Palacio Solis M Palacio Solis University of Navarra, Cardiology, Pamplona, Spain A De La Fuente Villena A De La Fuente Villena University of Navarra, Cardiology, Pamplona, Spain A Diaz Dorronsoro A Diaz Dorronsoro University of Navarra, Cardiology, Pamplona, Spain J Barba Cosials J Barba Cosials University of Navarra, Cardiology, Pamplona, Spain E Sufrate Sorzano E Sufrate Sorzano Hospital San Pedro, Cardiology, Logroño, Spain M Gomez Llorente M Gomez Llorente Hospital San Pedro, Cardiology, Logroño, Spain G Bastarrika Aleman G Bastarrika Aleman University of Navarra, Cardiology, Pamplona, Spain O Shangutov O Shangutov University of Navarra, Cardiology, Pamplona, Spain L Alonso Perez L Alonso Perez Hospital San Pedro, Cardiology, Logroño, Spain JJ Gavira Gomez JJ Gavira Gomez University of Navarra, Cardiology, Pamplona, Spain PM Azcarate Aguero PM Azcarate Aguero Hospital San Pedro, Cardiology, Logroño, Spain University of Navarra, Cardiology, Pamplona, Spain Hospital San Pedro, Cardiology, Logroño, Spain INTRODUCTION: Cardiac imaging plays a key role in both the diagnosis and management of infective endocarditis (IE). The evaluation of patients with IE is no longer limited to conventional echocardiography, but should include other imaging techniques such as cardiac CT (ESC guidelines 2015). Perivalvular complications of IE include abscess, pseudoaneurysm and aortocavitary fistula, and are associated with worse clinical outcome. We report two clinical cases of this perivalvular complications where 3D echocardiography and cardiac CT played a central role. CASE REPORTS The first patient, aged 61, suffered acute postsurgical MRSA endocarditis after an aortic valve replacement for aortic stenosis, with partial destruction of the valve annulus. He was retaken to cardiac surgery for a new valve replacement. One year later he was readmitted with acute heart failure (pulmonary oedema). A new echocardiography was performed, revealing a posterior aortic pseudoaneurysm that included half of the aortic annulus, which connected with the left ventricular outflow tract, and caused severe periprosthetic aortic regurgitation. For further evaluation Cardiac CT was performed confirming a posterior aortic pseudoaneurysm (figure 1 upper part, green arrows), with an aortocavitary fistula (figure 1 upper part, red arrow). The patient was remitted once again to surgery for a new valve replacement and aortic root repair. He had all imaginable perioperative complications: aortic root dissection, stroke of the right middle cerebral artery, cardiac tamponade that required surgical treatment (complicated with laceration of the internal mammary artery) and sternal dehiscence that required sternal reconstruction. One month later a follow up TTE was performed showing a new pseudoaneurysm on the opposite side (anterior) that was causing again severe aortic regurgitation. Due to the dreadful evolution and the frailty of the patient, a conservative approach was taken. Our second patient was 85 years old, and had several comobidities. He was admitted to the hospital for fever of unknown origin with positive blood cultures. A 3D transoesophageal echocardiogram (TOE) was performed revealing an aortic pseudoaneurysm similar to the first described, with aortocavitary fistula as well (figure 1 bottom part, green and red arrows). Since he had a prohibitive surgical risk, he was treated conservatively. DISCUSSION: Aortic root pseudoaneurysm is a pulsatile cavity formed around the aortic valve that is usually connected to the left ventricular outflow tract and the aorta. The most frequently associated pathogen is Staphylococcus aureus. Transthoracic echocardiography has a low sensitivity for the diagnosis of this complications, therefore TOE, cardiac CT or PET/CT should be performed when complicated endocarditis is suspected. The treatment includes antimicrobial therapy and surgical repair. View largeDownload slide Abstract P1226 Figure 1 View largeDownload slide Abstract P1226 Figure 1 Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2019. For permissions please email: Journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Poster Session - HIT Clinical Case Poster session 3
JO - European Heart Journal – Cardiovascular Imaging
DO - 10.1093/ehjci/jey270
DA - 2019-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/poster-session-hit-clinical-case-poster-session-3-2eFPW45WIQ
SP - i794
VL - 20
IS - Supplement_1
DP - DeepDyve
ER -