TY - JOUR
AB - P1102From hepatic carcinoma to heart failure: a rare late complication with a devastating cascading effect B A Popescu B A Popescu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania C Ginghina C Ginghina Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania M Croitoru M Croitoru Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania M Rosca M Rosca Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania A Burducea A Burducea Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania D M Dorobantu D M Dorobantu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania A Calin A Calin Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania A Guta A Guta Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania Introduction: The association between hepatocellular carcinoma and inferior vena cava (IVC) and right atrium (RA) thrombosis is rare, carries a poor prognosis and is usually a sign of advanced stage disease. Surgical treatment is an option, but satisfactory results are limited to early stage cancer. A multimodality imaging and multidisciplinary approach can help identify patients who might benefit from surgical treatment, rather than palliation. Case description: We present the case of a 69 year old male, with many cardiovascular risk factors, a history of coronary artery disease and intermittent claudication, referred to our clinic for treatment. He had been increasingly dyspneic in the three months preceding his hospitalization, with an episode of aggravated congestive heart failure, poorly responsive to maximal diuretic treatment one month prior. He also had a known hepatic nodule, which he neglected to follow-up. At admission he was in NYHA class III, had signs of right cardiac failure, otherwise an unremarkable examination. The brain-natriuretic peptide was increased (356 pg/ml), he had a mild hepatic cytolysis and simple chronic anemia with a modestly increased C reactive protein; the ECG showed atrial flutter. Due to the patient history, the symptoms were initially considered to be due to the untreated ischemic heart disease. The transthoracic echocardiography showed a large mass (59/38 mm) in the RA, with an irregular surface and hypermobile segments (A), mild tricuspid regurgitation and an estimated systolic pulmonary artery pressure of 48 mmHg, otherwise normal biventricular systolic function. The transesophageal echocardiography confirmed the presence of a large, multilobulated tumor in the RA, extended into the IVC (B). The thoraco-abdominal CT scan revealed a tumoral thrombosis extending from the hepatic veins through the IVC into the RA (C), multiple images suggestive of pulmonary thromboembolism, micronodules and adenopathies, several hepatic tumors (D) and a suprarenal mass. Since this is a patient with known arterial disease we performed an angiographic study which showed an 80% LAD stenosis, a diffusely infiltrated RCA with multiple significant stenosis and multiple femuro-tibial bilateral lesions. The case was presented in the multidisciplinary meeting where it was concluded that the extension of the neoplastic process, with multiple secondary lesions, was prohibitive for surgical treatment or chemotherapy, due to the severe coronary lesions. As such, palliation was recommended and the patient was started on oral anticoagulant, diuretics and ACE inhibitors, being referred to an oncological clinic for specialty care. Discussions: Extended central venous thrombosis secondary to a neoplastic process is often an incidental finding, many times with unspecific symptoms. Echocardiography remains the diagnostic option of choice, offering valuable data on size, extension and often can differentiate thrombi from other tumoral formations based on aspect, mobility and extension into the IVC/SVC. A complete, multimodality imaging study is mandatory, in order to diagnose the primary lesion, its extension and the presence of metastases, all important factors in deciding between aggressive therapy and palliation. Surgical care is usually associated with poor outcomes, dictated by the staging of the oncological disease, and less so by the nature and size of the thrombus. Conclusion: This case highlights the "cascade effect" going from a neglected hepatic nodular lesion to venous thromboses, eventually extended into the RA, causing heart failure, finally becoming apparent on echocardiography, with multimodality imaging, both cardiac and non-cardiac, having an important role in the treatment decision. Open in new tabDownload slide Abstract P1102 Figure. Multimodal imaging Open in new tabDownload slide Abstract P1102 Figure. Multimodal imaging P1103A clinical case of pulmonary artery sarcoma D Tarasov D Tarasov Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation O Kondrat'eva O Kondrat'eva Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation I Chernov I Chernov Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation N Ilov N Ilov Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation I Arkhipova I Arkhipova Federal Center of Cardiovascular Surgery, Astrakhan, Russian Federation Background: According to the literature data cardio-vascular tumors are rare with an incidence of 0.001–0.03%. Since symptoms and imaging of pulmonary arterial (PA) intimal sarcomas (PAS) mimic pulmonary thromboembolism (PTE), the differential diagnosis of a patient presenting with chest pain, dyspnea, and filling defect within the pulmonary arteries should include intimal sarcoma. We present a case of malignant non-differentiated PAS with palliative surgery underwent. Case presentation: A 55 year old female patient admitted to the hospital with dyspnea and shortness of breath upon exertion. On physical examination, her lungs were clear to auscultation and her heart had a normal rate and rhythm. Systolic pulmonic murmur was heard. Biochemical analysis showed: hemoglobin - 89 г/л, erythrocytes - 3,4 x1012/L, leucocytes - 6,7 x109/L; aspartate transaminase, bilirubin and creatinine levels were slightly increased. TTE revealed enlarged PA diameter and right chambers with severe tricuspid regurgitation. There was a non-homogeneous neoplasm in the PA trunk with significant obturation of its lumen (PG = 65 mm Hg). Systolic PA pressure was 88 mm Hg. At this point, the differential diagnosis included lung cancer, arterial tumor, tumor embolus, and a thrombus/embolism. Ultrasound study showed that the lower extremity veins were free of any thrombus. A CT scan with contrast revealed a large saddle filling defect extending into the right and left pulmonary arteries without extension to lobe pulmonary artery branches. An additional mass with sizes 3.2x1.5 sm was found in RVOT. Because of PA obstruction a patient was taken for surgical treatment. A tumor of PA trunk with extension to the posterior wall of RVOT and intraventicular septum was found. Due to the extensive disease, only the palliative tumor resection with PA trunk prosthesis implantion were performed. Histological study verified that it was a non-differentiated sarcoma. There were no postoperative complications. A repeat CT chest scan showed an additional mass with sizes 3.2x1.5 sm the posterior wall of RVOT. A patient was directed to the treatment at the oncological hospital. Discussion: Described first by Mandelstamm1 in 1923, PAS is a rare and often lethal tumor which is usually diagnosed only during surgery or autopsy. They are thought to arise from the mesenchymal cells of the intima of pulmonary artery trunk or the bulbous cordis. PAS is often misdiagnosed as PTE, as both of the diseases initially appear as intraluminal ‘filling defects’ in the PA system on contrast enhanced CT scans. The differentiation between these two disease entities is very important to avoid misdiagnosis of a potentially fatal malignancy and unnecessary anticoagulation therapy. Conclusion: PAS often presents with symptoms mimicking pulmonary hypertension, heart failure or thromboembolic disease. Due to the presence of pulmonary arterial occlusion and the acute symptoms associated with this, surgical resection is usually the mainstay of therapy. Clinicians should maintain high clinical suspicion of PAS in patients with a filling defect in the PA without any underlying risk factors for PTE. P1105Intracardiac mass from hepatocellular carcinoma mimicking right heart failure J Okafor J Okafor Royal Surrey County Hospital, Cardiology, Guildford, United Kingdom Royal Surrey County Hospital, Cardiology, Guildford, United Kingdom Introduction: Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and third leading cancer-related cause of death. However HCC with tumour thrombus extending into the right heart is rare and signals advanced disease. It’s presence has been reported in 0.67% - 4.1% of autopsies. Recognition and diagnosis of this stage of disease can be complicated by a varied clinical presentation. The ensuing physiological changes caused by mass effect within the heart as well as the hepatic inferior vena cava (IVC) may lead to convincing signs of acute right heart failure. Case Presentation: This case presents a 69-year-old female with advanced hepatocellular carcinoma who developed gross bilateral lower extremity oedema and ascites. She had no history of cardiac disease. Jugular venous pressure was mildly elevated at 5cm and a pan-systolic murmur was heard radiating to the apex. There were no pulmonary symptoms. Aggressive intravenous diuresis was instituted with a presumed diagnosis of acute right heart failure but this worsened the clinical picture with new-onset light-headedness, hypotension and a harsher murmur. Echocardiography revealed normal right ventricular size with borderline function (TAPSE 1.9cm) and normal left ventricular function (LVEF 55-60%). Furthermore, the presence of a large mass within a fixed, dilated IVC (3.1cm) and ascending into the right atrial cavity was described (image 1, red arrow). There was visible systolic anterior motion of the anterior leaflet of the mitral valve (SAM) causing a dynamic left ventricular outflow tract obstruction (LVOTO) with astonishing gradients of 192mmHg with valsalva manoeuvre (image 2, white arrow). Diuresis was promptly discontinued on the 3rd post admission day (PAD). Cardiac Magnetic Resonance, performed on the 7th PAD, characterised the mass as avascular with no late myocardial enhancement. The aetiology was tumour extension from the known HCC. The SAM had now resolved. The patient was deemed a poor candidate for systemic therapy and palliated. Differential diagnosis and discussion Initially the peripheral oedema was thought to be from right heart failure secondary to mitral valve disease or chronic liver disease. The low normal albumin level counted against reduced oncotic pressure as a primary cause. The preserved right heart longitudinal function made right heart failure unlikely while the lack of pulmonary oedema in conjunction with normal LVEF counted against left sided failure. After the echocardiogram demonstrated a mass filling the IVC and subsequent CMR confirmed the mass as tumour, it was then clear that the patient’s gross peripheral oedema was due to IVC obstruction and hence the poor response to diuresis. A hypovolemic state by the treatment was the main cause of the SAM and subsequent LVOTO. This would account for the progression in the murmur. The picture was complicated by the raised JVP, which can be attributed to elevated right atrial pressures from the proximal IVC obstruction. Conclusion: Peripheral oedema has a wide differential and further investigations are always required. The need to consider IVC obstruction in patients with a history of malignancy is paramount. There should be wariness in labeling a patient as acute or decompensated heart failure with no previous proven evidence of myocardial dysfunction. Open in new tabDownload slide Abstract P1105 Figure. Image 1. RA mass Image 2. LVOT gradients Open in new tabDownload slide Abstract P1105 Figure. Image 1. RA mass Image 2. LVOT gradients P1106Two problems, one cause C Iorgulescu C Iorgulescu Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania N M Fotea N M Fotea Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Description: The case presents a 62-year-old man complaining of intense pain in the right upper limb, functional impairment for 3h and progressive dyspnea in the last 2 months. Clinical examination: HR 110 bpm, BP 135/75 mmHg, cyanotic, cold skin of the forearm, absent pulse distally to brachial artery, right ventricular gallop. ECG: sinus tachycardia, northwest axis, S1Q3T3, minor right bundle block. Doppler ultrasound of the right arm revealed thrombotic material in the brachial artery occluding the lumen with no Doppler signal distally. Echocardiography showed dilated right cavities, hypokinesis of RV free wall and severe pulmonary hypertension. CT pointed bilateral thrombi in both main pulmonary arteries, extension on the lobar branches and chronic thrombi distally. Urgent Fogarty thromboembolectomy was performed and immediatly after surgery anticoagulation therapy initiated. Questions: Taking into account that the patient presented with acute limb ischemia potential embolic source was searched and proved to be a right popliteal vein trombosis. The presence of deep venous thrombosis in such a patient prompted the evaluation for patent foramen oval (PFO). A careful review by echocardiography divulged PFO with intermittent right-left shunt. Even if there was an explanation for the clinical case, multiple thromboembolic risk factors may be encountered. Considering patient’s symptoms of weight loss, an abdomino-pelvic CT examination was realized indicating cecal assymetric thickening. A subsequent colonic biopsy excluded neoplasia. Supplementary investigations disclosed heterozygous MTHFR and PAI-1 mutations. Answers and discussion: The pacient was discharged at home with oral anticoagulation. The exact time of anticoagulation in the presence of one unprovoked pulmonary thromboembolic event should be of at least 3 months. Heterozygous mutations for MTHFR and PAI-1 are not among the thrombophilic conditions that raise the risk of embolism and according to this the anticoagulant therapy will not be prolonged after 3 months. The PFO was not closed due to reduced dimensions and absence of shunt after clinical stability and lysis of the thrombus at one month control. Learning objectives: 1. The importance of screening frequent causes of thromboembolism (DVT, thrombofilia, neoplasia) 2. The importance of searching a PFO in front of a possible paradoxial embolism 3. Cuantification of all thromboembolic risk factors (PFO size, degree of functional shunting, hypercoagulable state, neoplasia) to decide treatment 4. Duration of anticoagulation treatment after the first unprovoked thromboembolic episode 5. The risk of embolic events in pacients with heterozygous mutations in genes associated with thrombophilic status 6. Medical vs interventional treatment in PFO. P1107A thrombus straddling a patent foramen ovale: Quo vadis? T Santos T Santos 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal J Sa J Sa 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal P Raimundo P Raimundo 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal V Carmelo V Carmelo 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal J Toste J Toste 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal D Ferreira D Ferreira 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal N Cardim N Cardim 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal A Toste A Toste 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal R A Guerreiro R A Guerreiro 1Hospital Espirito Santo de Evora, Cardiology, Evora, Portugal F Machado F Machado 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal 1Hospital Espirito Santo de Evora, Cardiology, Evora, Portugal 2Hospital Luz, Centro Cardiovascular, Lisbon, Portugal We report a case of an 85-year-old female patient, with a past medical history of chronic bronchitis with cor pulmonale who presented with worsening dyspnoea and syncope. On physical examination, she was dyspnoeic, tachycardic and slightly hypotensive. There were no signs of heart failure. Arterial blood gases showed hypoxemia (PaO2 49mmHg) without hypercapnia. The ECG showed sinus tachycardia and the chest CT scan detected bilateral pulmonary embolism (PE) with signs of right ventricular pressure overload. Despite the suboptimal acoustic window in a critically ill patient, transthoracic echocardiogram (TTE) followed by transoesophageal echocardiogram (TEE) showed a mobile mass in the right atrium straddling the patent foramen ovale (PFO) into the left atrium (Figure). Given the patient's age and co morbidities, we started anticoagulation (enoxaparin, 1 mg/kg subcutaneously every 12 hours), with clinical and echocardiographic improvement and no clinically detected episodes of systemic embolism. In a second TTE (performed 3 days later), the image previously seen in the right atrium was absent while right chambers remained dilated despite a lower pulmonary artery systolic pressure (PASP) (52 mmHg). The case is associated with rare images that capture a mobile thrombus straddling a PFO extending into the left atrium. The literature review shows that, despite surgical therapy seems to be the first option in most cases, anticoagulation alone is a good alternative, especially in elderly patients with significant co morbidities or when the thrombus is small and fixed. Thrombolysis is linked to the highest mortality, which can be explained by the worse prognosis of patients with haemodynamically unstable pulmonary embolism or by haemorrhagic complications. Open in new tabDownload slide Abstract P1107 Figure. Transesophageal echocardiogram Open in new tabDownload slide Abstract P1107 Figure. Transesophageal echocardiogram P1108When there is more than meets the eye: a challenging case of myocardial infarction C C Neagu C C Neagu Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania D Zamfir D Zamfir Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania L Calmac L Calmac Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania C Mihai C Mihai Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania M Dorobantu M Dorobantu Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Introduction: Myxomas represent the most common primary cardiac tumors, usually arising in the left atrium and, more rarely, in other locations such as the right atrium, ventricles, blood vessels. Symptoms can be determined by the obstruction of blood flow, thromboembolic events or by the production of interleukin-6. Case report. A 52-year old man was admitted for acute onset of anterior chest pain. He was a smoker, known dyslipidemic and hypertensive, with no history of chest pain but with progressive dyspnea and fatigue on mild exertion for the past 6 months. On physical examination, his heart rate was 77 bpm, regular, BP 170/100 mmHg, with no other remarkable findings. The ECG was consistent with inferior and posterior STEMI. Emergency coronary angiography was performed and revealed two vessel disease (distal occlusion of the left anterior descending (LAD) and 70% stenosis of the mid circumflex artery (LCX). Intracoronary thrombus aspiration from the LAD did not remove any material, and simple balloon angioplasty of the distal LAD was performed, with TIMI 3 flow. Echocardiography showed an EF 50%, hipokinesia in the apical LAD territory and a large mobile right atrial (RA) mass of 41 mm, attached by a pedicle to the atrial septum, in the proximity of fossa ovalis, compatible with a myxoma. Detailed medical history revealed involuntary weight loss, recurrent low grade fever and arthralgia for the past 6 months. To aid the differential diagnosis between a tumor and a possible thrombus, comprehensive tumor analysis was performed by transesophageal echocardiography. This revealed a right, irregular, avascular mobile atrial mass, with a cross-sectional area of 6 cm2, attached by a 7/8 mm pedicle to the interatrial septum, in the proximity of the tricuspid valve, without interfering with its mobility; no interatrial communication was revealed. A brain and thoracic CT scan were performed to rule out cryptogenic thromboembolic complications. Given the symptomatic right atrial myxoma and the increased levels of CRP and interleukin-6, the patient was referred to cardiac surgery for tumor extraction. Discussion. We present a case of STEMI in a male patient with cardiovascular risk factors and an incidental, but symptomatic RA myxoma. The mechanism of acute myocardial infarction in this young male patient is atherosclerosis, secondary to the common risk factors, which was undoubtedly influenced and accelerated by the persistent systemic inflammation due to the production of interleukin-6 by the atrial myxoma. With this case report, we emphasize the rarity of RA myxoma, especially in men, the fact that it can induce inflammatory abnormalities associated with coronary artery disease and the importance of echocardiography performed before emergency coronary angiography in STEMI patients, to identify other comorbidities that can influence the acute and medium to long term medical management and prognosis. P1109Giant left atrial appendage thrombus J Rigueira J Rigueira Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal A Magalhaes A Magalhaes Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal A Nunes Ferreira A Nunes Ferreira Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal I A Ricardo I A Ricardo Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal R Santos R Santos Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal A G Almeida A G Almeida Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal R Goncalves R Goncalves Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal F J Pinto F J Pinto Hospital Universitário de Santa Maria/CHLN, CAML, CCUL,Faculdade de Medicina, Universidade de Lisboa, Cardiology Department, Lisbon, Portugal Introduction: Thrombi, particularly those located on the left atrial appendage (LAA), are frequently associated with atrial fibrillation (AF) and may cause systemic thromboembolic complications. Therefore, patients with AF, particularly those at high risk of thromboembolism, should receive anticoagulant therapy. Non-vitamin K antagonist oral anticoagulants (NOAC) are recommended for stroke prevention in high risk patients with nonvalvular AF due to their efficacy and safety profile. However, care must be taken in prescribing the appropriate dose and ensuring the compliance of the patient. In fact, recent studies have shown that a significant proportion of patients are medicated with the lowest doses of NOACs. Case report/Discussion: We present a case of a 75 year-old man, with permanent AF (CHA2DS2-VASc score=4) with an episode of acute lower limb ischemia two months before. This patient was referred to our hospital following the detection of an intracardiac mass on a transthoracic echocardiogram performed after the ischemic event. He was on treatment with dabigatran 110 mg twice daily, but with low compliance. Additionally, he was medicated with diltiazem for hypertension, alfuzosin for benign prostatic hyperplasia and cilostazol for peripheral arterial disease. On admission, physical examination was globally normal, with exception of irregular heart sounds. We underwent transthoracic echocardiography that showed a preserved left ventricle ejection fraction (LVEF=58%), biatrial dilation and an echogenic mobile mass with 22x19mm on the left atrium (figure 1). Transesophageal echo (TEE) confirmed the presence of a large and highly mobile hyperechogenic mass, pediculated, with 37mm of maximum dimension, located in the LAA, that protruded to the left atrium and to the mitral valvular apparatus (figure 2). Taking into account the clinical context and the location of the mass, thrombus was assumed as the most likely diagnosis and the patient was started on parenteral anticoagulation. The patient was carefully monitored and progressed favorably without evidence of embolic complications. After five days on low molecular weight heparin (LMWH), a TEE showed that the mass was significantly smaller, presenting as a small oval image inside the LAA with 9x8mm (figure 3). Given the good response to anticoagulant therapy, we assumed that the final diagnosis was LAA thrombus as a consequence of an incorrect anticoagulation scheme, and no further investigation was taken. After 10 days of parenteral anticoagulation, the patient was discharged on dabigatran 150 mg twice daily. The patient was educated about AF and anticoagulant therapy. This patient, with a high thrombotic risk, was poorly anticoagulated because he had no criteria for dose reduction (age >80 years, eGFR<50ml/min, ongoing treatment with verapamil, high bleeding risk and age between 75-80 years, gastroesophageal reflux disease or gastritis) of dabigatran and frequently failed to take the drug. This was the most likely cause of LAA thrombus formation and the ischemic event. Conclusion: The above case highlights some key issues related to stroke prevention in non-valvular AF, namely the importance of knowing the dose reduction factors in each of the NOACs and providing adequate patient education in an attempt to increase adherence to therapy. Open in new tabDownload slide Abstract P1109 Figure. Thrombus evolution Open in new tabDownload slide Abstract P1109 Figure. Thrombus evolution P1110Assessment of coronary artery flow during routine echocardiography can reveal significant stenosis in an asymptomatic patient A Zagatina A Zagatina Cardiocenter Medika, Saint Petersburg, Russian Federation N Zhuravskaya N Zhuravskaya Cardiocenter Medika, Saint Petersburg, Russian Federation Cardiocenter Medika, Saint Petersburg, Russian Federation Introduction: Coronary artery disease is a high prevalence nosology. Diagnosis is based on clinical symptoms and often requires tests to induce ischemia. Some patients have a silent ischemia without clearly marked symptoms, in these cases stress tests are often not performed and the disease could be underestimated or undiscovered, which was also seen in patients with diabetes or young people. Case report: A 39-year-old man, with a long history of smoking, without diabetes mellitus, during examination had mild arterial hypertension. His blood level of cholesterol was 5.9 mmol/l. He denied any chest pain or shortness of breath during physical activity. Following current recommendations, we performed an echocardiography. During the examination, we additionally assessed the coronary artery flow in the left main artery and proximal parts of the left anterior descending (LAD) and left circumflex arteries (LCx). A short local spot of high diastolic velocity in the proximal part of LAD (Figure 1) was visualized, which was more than twice as high as commonly observed in healthy subjects by our data or other authors. Suspecting significant stenosis in LAD, we performed a supine bicycle echocardiography test. The large area of ischemia at the apex, septum, anterior wall, and lateral wall was observed at 75 W and was the reason for stopping the test. There were no symptoms or ECG changes during exercise. A coronary angiography was performed a month later revealing: left main - without stenoses, LAD - 70% in proximal part, 80% in the middle part, LCx main – without significant stenoses, the first marginal branch – 90%, right coronary artery – 95-100% of proximal part. The patient was successfully revascularized. Discussion: By recent guidelines, it was not required to perform a stress test for this patient, as he had not experienced any chest pain. Only the additional information of the coronary artery flow at rest helped to recognize coronary artery disease. Often it is a problem to discover asymptomatic or mild symptomatic coronary artery disease that can occasionally be observed, especially in patients with diabetes mellitus or among young people. We know that about 25% of all heart attacks occur without any previous warning signs. Likely, some of these people could be detected by transthoracic Doppler coronary artery assessment at rest. Open in new tabDownload slide Abstract P1110 Figure. Open in new tabDownload slide Abstract P1110 Figure. P1111The silent complications A Almaghraby A Almaghraby 1Alexandria University, Alexandria, Egypt M Abdelnaby M Abdelnaby 2Alexandria University, Medical Research Institute, Alexandria, Egypt B Hammad B Hammad 3Massachusetts General Hospital, Boston, United States of America S Elfawal S Elfawal 1Alexandria University, Alexandria, Egypt R Laymouna R Laymouna 4International Cardiac Center Hospital, Alexandria, Egypt E Selim E Selim 4International Cardiac Center Hospital, Alexandria, Egypt A Zeid A Zeid 4International Cardiac Center Hospital, Alexandria, Egypt M Seleem M Seleem 1Alexandria University, Alexandria, Egypt A Ghoneem A Ghoneem 1Alexandria University, Alexandria, Egypt Y Saleh Y Saleh 1Alexandria University, Alexandria, Egypt 1Alexandria University, Alexandria, Egypt 2Alexandria University, Medical Research Institute, Alexandria, Egypt 3Massachusetts General Hospital, Boston, United States of America 4International Cardiac Center Hospital, Alexandria, Egypt Introduction: Mechanical complications of acute myocardial infarction (AMI) are mainly ventricular septal rupture (VSR), free wall rupture, and ischemic mitral regurgitation. If the patient survives the acute phase, negative remodeling starts to occur leading to aneurysm formation. Despite their rareness, our case showed two of those mechanical complications at the same setting. Case Report: A 72-year-old male patient, a smoker with a past medical history of hypertension but no diabetes, presented to our out-patient clinic complaining of dyspnea grade III that had started 3 months ago and progressed gradually with no history of any acute event in the past. On examination he was hemodynamically stable with a systolic murmur heard over the parasternal area. Transthoracic echocardiography showed a large inferior wall true aneurysm with a large ventricular septal defect located at the basal inferoseptal segment with left to right shunt, left ventricular ejection fraction was 35-40% with no thrombi or masses seen. As another moality to confirm the diagnosis, cardiac magnetic resonance (CMR) revealed the same echocardiography data. To complete the management of the patient, invasive coronary angiography was done and revealed a 70% stenotic lesion in the proximal part of the left anterior descending (LAD) coronary artery with normal left circumflex and right coronary arteries and thus he was sent for surgery with left internal mammary artery (LIMA) graft to the LAD, aneurysmectomy and closure of the ventricular septal defect. Post-operatively, the patient was doing well on anti-ischemic and anti-failure treatment. Conclusions: Bedside echocardiography is still the mainstay procedure for diagnosis of mechanical complications following AMI and CMR is a new diagnostic tool for confirming the diagnosis and planning for further interventions. Although rare, mechanical complications of acute myocardial infarction should always be considered in every ischemic patient. Open in new tabDownload slide Abstract P1111 Figure. 4 in 1 picture Open in new tabDownload slide Abstract P1111 Figure. 4 in 1 picture P1112Peculiar evolution of an acute myocardial infarction complicated with left ventricular apical rupture M L Luchian M L Luchian 1University Emergency Hospital, Bucharest, Romania C L Gherghinescu C L Gherghinescu 2Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital Bucharest, Cardiology Department, Bucharest, Romania I Corlan I Corlan 2Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital Bucharest, Cardiology Department, Bucharest, Romania C Udroiu C Udroiu 1University Emergency Hospital, Bucharest, Romania D Vinereanu D Vinereanu 2Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital Bucharest, Cardiology Department, Bucharest, Romania 1University Emergency Hospital, Bucharest, Romania 2Carol Davila University of Medicine and Pharmacy, University and Emergency Hospital Bucharest, Cardiology Department, Bucharest, Romania The mechanical complications, such as free wall rupture of the left ventricle are rare (2-4%), and mortality is up to 50% in different series .Emergency detection using transthoracic echocardiography (TTE) is vital and imperative for urgent treatment. We report a case of a 67 years old woman admitted with ST-elevation anterior myocardial infarction (MI). Coronary angiography showed proximal left anterior descending coronary artery stenosis. Primary percutaneous coronary intervention (PCI) with implantation of a drug eluting stent was performed, with optimal result and no complications. TTE performed after PCI showed severe left ventricular (LV) systolic dysfunction, with apical akynesia, and no pericardial effusion. After five hours, patient developed low blood pressure and significant bradycardia. Repeated TTE showed increasing pericardial effusion, with instant clot formation, and with moderate compression of the right heart cavities. LV wall rupture was suspected, however, site of rupture using TTE was not identified. Patient was put on colloid fluids, Dobutamine and Dopamine infusion, with normalization of the blood pressure. Consequently, patient was not referred for emergency surgery. Computer tomography performed during the admission described hemorrhagic pericardial effusion, with apical rupture at the level of the superior part of ventricular septum. Unfortunately, she developed contrast nephropathy, followed by pulmonary infection and, therefore, surgical procedure was postponed. She was constantly evaluated by TTE, showing developing of an apical pseudo-aneurysm, with thrombus formation, that covered the apical rupture. After two months of hospitalization she was discharged. At one month follow-up, TTE showed improvement of the LV ejection fraction, only minimal pericardial effusion, and apical thrombus with no visible rupture. Thus, oral anticoagulation therapy was initiated. This case demonstrates that LV apical rupture might have a favorable outcome, even when the risk of surgery is considered too high. Imaging assessment and close echocardiographical follow-up allow medical management of the patient, including continuation of the dual anti-platelet therapy and further initiation of anticoagulation therapy, as soon as the risk of two-step rupture was considered low. Open in new tabDownload slide Abstract P1112 Figure. left ventricle wall rupture Open in new tabDownload slide Abstract P1112 Figure. left ventricle wall rupture P1113Acute coronary artery occlusion - is it enough to rely on ECG and troponin values? H S Schroer H S Schroer UKB Berlin, cardiology, Berlin, Germany S W Winkler S W Winkler UKB Berlin, cardiology, Berlin, Germany L B Bruch L B Bruch UKB Berlin, cardiology, Berlin, Germany M S Seidel M S Seidel UKB Berlin, cardiology, Berlin, Germany UKB Berlin, cardiology, Berlin, Germany Introduction: Acute coronary artery occlusion (ACO) occurs in approximately 30% of patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). The diagnosis ACO can only be made in the cath lab many hours after first medical contact. Copeptin as a novel and early vascular stress marker shows an immediate increase after myocardial infarction and presents with higher values in ST-elevation acute coronary syndrome (STE-ACS) compared to NSTE-ACS. Copeptin in contrast to troponin is not cardiospecific. 2D speckle tracking echocardiography as a cardiospecific diagnostic procedure has been rapidly adopted into the clinical routine. A correlation between impaired regional longitudinal strain and coronary occlusion has already been shown. Clinical course A 56-year-old previously healthy male presented to the emergency department with acute chest pain. Onset of symptoms was about 2 hours prior to hospital arrival. The initial ECG showed no ST-elevation. The first laboratory results showed no relevant increase in high-sensitive troponin. The novel biomarker copeptin instead was highly elevated. Serial biomarker tests over time were performed resulting in the diagnosis of NSTE-ACS as a significant rise in the high-sensitive troponin level was detected. The copeptin level on the other hand decreased over the time course. A speckle tracking echocardiography was performed and showed a preserved ejection fraction but an impaired longitudinal strain in 6 adjacent segments with a longitudinal strain value of more than -15% (global longitudinal strain -17,1%). The main findings were located in the mid-inferior, basal-inferoseptal and mid-inferoseptal segments (17-segment model). The calculated GRACE-score (Global Registry of Acute Coronary Events) was below 140. According to current guidelines the invasive examination was scheduled for the next day. The coronary angiography performed the next day showed a mid-sectional occlusion of the right coronary artery which was treated accordingly. The coronary findings correlated well with the functionally impaired regions detected by speckle tracking echocardiography. Conclusion: In patients with NSTE-ACS the novel and early biomarker copeptin in combination with 2D speckle tracking echocardiography can help to determine high-risk patients with acute coronary artery occlusion in need of immediate invasive treatment. Cardiac enzymes Time (hh:mm) . 15:51 . 18:05 . 21:09 . post-interv. . post-interv. . CK mkat/l <3.20 4.59 + 3.99 + 6.21 + 24.21 + 20.66 + CK MB mkat/l <0.42 2.86 + 2.03 + CK-MB (%) 11.8 + 9.8 + Troponin T-hs ng/l <14.0 (Elycsys) 8.2 21.3 + 104.6 + Copeptin pmol/l <10.0 210.4 + 67.6 + 49.7 + Time (hh:mm) . 15:51 . 18:05 . 21:09 . post-interv. . post-interv. . CK mkat/l <3.20 4.59 + 3.99 + 6.21 + 24.21 + 20.66 + CK MB mkat/l <0.42 2.86 + 2.03 + CK-MB (%) 11.8 + 9.8 + Troponin T-hs ng/l <14.0 (Elycsys) 8.2 21.3 + 104.6 + Copeptin pmol/l <10.0 210.4 + 67.6 + 49.7 + CK = creatine kinase; CK MB = creatine kinase myocardial band; post-interv. = post-intervention Cardiac enzymes Time (hh:mm) . 15:51 . 18:05 . 21:09 . post-interv. . post-interv. . CK mkat/l <3.20 4.59 + 3.99 + 6.21 + 24.21 + 20.66 + CK MB mkat/l <0.42 2.86 + 2.03 + CK-MB (%) 11.8 + 9.8 + Troponin T-hs ng/l <14.0 (Elycsys) 8.2 21.3 + 104.6 + Copeptin pmol/l <10.0 210.4 + 67.6 + 49.7 + Time (hh:mm) . 15:51 . 18:05 . 21:09 . post-interv. . post-interv. . CK mkat/l <3.20 4.59 + 3.99 + 6.21 + 24.21 + 20.66 + CK MB mkat/l <0.42 2.86 + 2.03 + CK-MB (%) 11.8 + 9.8 + Troponin T-hs ng/l <14.0 (Elycsys) 8.2 21.3 + 104.6 + Copeptin pmol/l <10.0 210.4 + 67.6 + 49.7 + CK = creatine kinase; CK MB = creatine kinase myocardial band; post-interv. = post-intervention Open in new tabDownload slide Abstract P1113 Figure. Open in new tabDownload slide Abstract P1113 Figure. P1114Portrait of a complex mitral valve leak B Carbonell Prat B Carbonell Prat Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain E Flores E Flores Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain G Mendieta G Mendieta Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain R San Antonio R San Antonio Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain M Mimbrero M Mimbrero Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain S Vazquez S Vazquez Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain L Tirapu L Tirapu Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain S Prat S Prat Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain M Azqueta M Azqueta Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain B Vidal B Vidal Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain Hospital Clinic de Barcelona, Cardiology, Barcelona, Spain Heart failure secondary to paravalvular leaks is a relatively common cause of hospital readmission after surgical valve replacement, with prosthetic mitral valve involvement encompassing 7-17% of total cases. Paravalvular leaks can easily be diagnosed and characterized using real-time 3D transesophageal echocardiography, which provides useful anatomic information prior to intervention. When associated to infective endocarditis, mechanical hemolytic anemia requiring multiple transfusions or congestive heart failure, surgical management is required. A 66 year-old woman with multiple comorbidities and rheumatic valve stenosis presented to our center with new onset dyspnea and signs of pulmonary and systemic congestion. Her past medical history revealed multiple surgical mitral valve replacements due to recurrent episodes of prosthetic endocarditis. Transthoracic echocardiography revealed a mitral leak with normal prosthetic gradients, mild left atrial dilatation with right displacement of the inter-atrial septum, causing severe pulmonary hypertension with secondary severe tricuspid regurgitation. The transoesophageal study showed an intra-auricular displacement of mitral septal suture, probably due to septal dissection resulting in septum primum aneurysm and the leak aforementioned. Also, a second severe lateral leak directed at the left atrial appendage was detected. Despite medical therapy adjustment and initial appropriate clinical improvement, she was readmitted on several occasions for biventricular cardiac failure and haemolytic anaemia requiring multiple blood transfusions. Therefore, she underwent direct structural interrupted surgical repair anchoring the "rocking" valve to basal native myocardium and a tricuspid annuloplasty. No relevant incidences were registered post-operatively, and the pre-discharge transoesophageal ecochardiogram ruled out any residual mitral regurgitation, demonstrating reduction of pulmonary hypertension reduction and no residual tricuspid regurgitation Transoesophageal echocardiography is a non-invasive diagnostic technique with relatively low rates of major complications (0.2-0.5%). Its application is pivotal in the surgical procedure and the peri-operative haemodynamic management. In this case, mitral valve desinsertion due to native tissue frailty was optimally characterized by transoesophageal echocardiography. Open in new tabDownload slide Abstract P1114 Figure. PARAVALVULAR MITRAL LEAK Open in new tabDownload slide Abstract P1114 Figure. PARAVALVULAR MITRAL LEAK P1115Torrential tricuspid regurgitation improved with coronary intervention: An insight from three-dimensional echocardiography N Hamid N Hamid National Heart Centre Singapore, Cardiology, Singapore, Singapore J W Tan J W Tan National Heart Centre Singapore, Cardiology, Singapore, Singapore S H Ewe S H Ewe National Heart Centre Singapore, Cardiology, Singapore, Singapore Z P Ding Z P Ding National Heart Centre Singapore, Cardiology, Singapore, Singapore Y L Chua Y L Chua National Heart Centre Singapore, Cardiology, Singapore, Singapore National Heart Centre Singapore, Cardiology, Singapore, Singapore Interest in the tricuspid valve (TV) has increased over recent years with recognition of its progressive nature of the disease and the impact of secondary tricuspid regurgitation on outcomes. Accurate assessment with echocardiographic imaging is essential for diagnosis. We describe a case report of symptomatic acute torrential functional tricuspid regurgitation, which was incidentally found on transthoracic echocardiography (TTE). Diagnosis was confirmed with angiography and symptoms improved after percutaneous intervention. 73 year-old gentleman with past medical history of enterococcus aortic bioprosthetic valve endocarditis in 2014 (treated medically) with residual moderate to severe aortic regurgitation, asymptomatic moderate to severe functional tricuspid regurgitation, SVT in 2005 (treated medically) and previous colon cancer treated with anterior resection and chemotherapy, presented to our institution with syncope. Electrocardiogram (ECG) confirmed supraventricular tachycardia (SVT). This was difficult to terminate with anti-arrhythmic medications. TTE revealed dilated, worsened right ventricular function (TAPSE 1cm and fractional area change = 23%) with marked incomplete coaptation of the tricuspid valve (Figure A and D). Compared to previous echocardiograms, there was significant dilatation of the tricuspid annulus (TV annulus 4.6cm), leading to torrential tricuspid regurgitation (Figure B and C). The patient was already on oral anti-coagulation and his international normalized ratio (INR) has been therapeutic prior admission. Left heart catheterization revealed a new proximal right coronary artery (RCA) thrombus. A multi-disciplinary team decision was made for ablation and percutaneous intervention (PCI) to the RCA due to his high surgical risk. Electrophysiology study revealed a typical slow-fast atria-ventricular nodal re-entry tachycardia (AVNRT) and was successfully ablated. Successful PCI was performed with a drug-eluting stent to the RCA. He improved and was discharged 2 days later. He was seen in clinic 1 month post discharge and remained asymptomatic. Repeat transthoracic echocardiography showed improvement in RV function and RV dimensions (TAPSE 1.7cm, fractional area change = 47%). The coaptation and annulus of the tricuspid valve improved (Figure E and F) with reduction in the tricuspid regurgitation effective orifice area (EROA) from 3.24cm2 to 1.19cm2 (Figure G). He remained on optimal medical therapy and will continue follow up. This case highlights the role of imaging and the utility of both 2D and 3D TTE in describing the tricuspid anatomy, morphology, function and assessment of residual disease. 3D TTE not only provides mechanistic insights into the underlying pathology, but also allows for accurate assessment and quantification of secondary tricuspid regurgitation on serial follow-up. Open in new tabDownload slide Abstract P1115 Figure. Figure A - G Open in new tabDownload slide Abstract P1115 Figure. Figure A - G P1117Right sided infective endocarditis: don't miss the Eustachian valve V Ostuni V Ostuni 2Polyclinic Hospital of Bari, Cardiology Hospital, Bari, Italy I Dentamaro I Dentamaro 1Polyclinic Hospital of Bari, Cardiology Department, DETO, Bari, Italy C Girasoli C Girasoli 1Polyclinic Hospital of Bari, Cardiology Department, DETO, Bari, Italy C D'agostino C D'agostino 2Polyclinic Hospital of Bari, Cardiology Hospital, Bari, Italy P Colonna P Colonna 2Polyclinic Hospital of Bari, Cardiology Hospital, Bari, Italy 1Polyclinic Hospital of Bari, Cardiology Department, DETO, Bari, Italy 2Polyclinic Hospital of Bari, Cardiology Hospital, Bari, Italy Introduction: The Eustachian valve (EV) is an embryonic structure redirecting the blood flow from the inferior vena cava through the foramen ovale. It may persist in adults as a floating membrane in the right atrium. A large EV can be associated with thrombosis, embolization and bacterial endocarditis. Case: A 70-year-old man who was admitted with fever, chills, and nausea. His medical history included no recent dental work, no human immunodeficiency viral infection, and no history of intravenous drug use, but a previous ischemic heart disease. Investigations revealed an elevated WBC with a neutrophilia and an elevated C-reactive protein. Subsequently blood cultures grew Streptococcus viridans and intravenous gentamicin was started. No abnormalities were detected on transtoracic echocardiogram (TTE). On transoesophageal echocardiogram (TOE), the native valves were normal, but there was a 1 × 0.6 cm independently mobile, echo dense mass within the right atrium. This mass was attached to the superior aspect of the eustachian valve (EV). Furthermore a patent foramen oval was identified, innocent bystander. The initial treatment for this condition is appropriate antibiotic therapy; surgery is indicated in non-responsive cases. Our patient presented remission of the infectious process after four-week treatment with specific antibiotics and required no surgical intervention. Discussion: The presence of a large EV is usually an innocent echo finding. Infective endocarditis is a major issue and the most common cause in right heart structures is percutaneous introduction of Staphylococcus aureus by intravenous drug use. Endocarditis of Eustachian valve is a rare and under diagnosed entity. It should be strongly considered when a patient has the clinical syndrome of right-sided endocarditis, but no vegetations are identified on TTE. Multiplanar TOE remains the diagnostic tool of choice for detecting vegetations of EV. Although EV endocarditis is rare, it may be unwise to rule out this diagnosis based solely on TTE, especially in the setting of persistent bacteremia or pulmonary emboli. If a patent foramen ovale coexists, the EV may also be a risk factor for paradoxical embolization. In the literature, small samples of patients with brain embolism and increased prevalence of EV in comparison with a control group have been described. It must be recognized, however, that a systematic searching of EV vegetations during the echocardiographic examination is not routinely performed in a patient suspected of having endocarditis. That the EV is an unfrequent site of vegetation attachment can be explained by its different hemodynamic situation compared with that of the other cardiac valves. Given that the joining of the superior vena cava with the right atrial chamber does not support high-velocity jets nor pressure gradients, the endothelium at the level of the eustachian valve is usually intact; thus thrombogenesis, which is the first stage in the formation of infected vegetations, does not occur. When endocarditis at that level presents, its clinical characteristics mirror those of tricuspid endocarditis. Conclusion: The present report describes a novel case of EV endocarditis diagnosed by transesophageal echocardiogram in which the causative organism was determined to be S viridans. Appropriate treatment with antibiotics resulted in resolution of the vegetations, which was confirmed by an additional transesophageal echocardiogram. Unique to this case were the lack of history of intravenous drug use and an uncommon causative organism, which has not been previously reported to involve the eustachian valve. P1118A very rare case report: left atrial wall vegetation after dental procedure Seda Tan Kurklu Seda Tan Kurklu Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey İrem Dincer İrem Dincer Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Demet Gerede Uludag Demet Gerede Uludag Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Nazli Turan Nazli Turan Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Nil Ozyuncu Nil Ozyuncu Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey M Kilickap M Kilickap Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey H Goksuluk H Goksuluk Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Cetin Erol Cetin Erol Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Ankara University Faculty of Medicine, Cardiology Department, Ankara, Turkey Summary: Infective endocarditis (IE) is a mortal disease. Despite improvements in its management, IE remains associated with high mortality and severe complications. Antibiotic prophylaxis is highly recommended for patients with any prosthetic valve, including a trans catheter valve, those in whom any prosthetic material was used for cardiac valve repair, the ones with a previous episode of IE with congenital heart disease (CHD), or any type of cyanotic CHD. Introduction: Infective endocarditis is a common disease with high mortality and morbidity. Generally, cyanotic heart disease or mechanic valve structure (high risk patients) increase the risk of infective endocarditis. 2015 infective endocarditis guideline recommends prophylaxis for high risk patients for a guideline specified procedure. But infective endocarditis prophylaxis is not recommended for functional valve diseases such as mitral valve prolapses. Case: A 33-year-old patient was admitted to our hospital with lost weight and persistant fever for two months. He is controlled annually for mitral valve prolapses with moderate mitral regurgitation. The patient had reciewed dental root canal procedures two months ago. After these procedures, his symptoms had begun. Transthoracic echocardiography demonstrated vegetation near the mitral valve but could not show the exact place. So, we examined trans oesophageal echocardiography. TEE demonstrated mobile vegetation held on the lateral left atrium through the anterior mitral leaflet. (figure-1) And also, we examined eccentric mitral regurgitation through the lateral left atrium which is the same place as vegetation. (figure-2) Six blood culture bottles on presentation all grew S. sanguinis (alfa haemolytic streptococcus) which is a member of the strep. viridans family associated with normal oral flora. IV gentamicin and ceftriaxone were administered. Concurrently, due to DVT he was given subcutaneous anticoagulant therapy. All blood tests for searching hematologic diseases and rheumatologic diseases were checked but nothing else was found. After 3 days, his fever stopped but he felt some weakness on his left arm. After neurology consultation, he had a cranial MRG. MRG demonstrated a haemorrhagic embolic area (septic emboli?). After that anticoagulant therapy was stopped. Through the haemorrhagic cranial area cardiac surgery was found highly risky because of using intraoperative anticoagulation therapy. A week later the patient felt left epigastric pain. After abdominal CT examinations, splenic infarction was demonstrated. Emergency TEE was found and neither vegetation nor mass was seen. Six weeks later we decided to finish the antibiotic therapy. After last TEE control the patient was discharged from the hospital. Discussion: High risk patients for Infective endocarditis are specified and procedures for prophylaxis are listed at 2015 ESC guideline. Infective endocarditis prophylaxis isn’t recommended for structural valve disease such as mitral valve prolapse. Our patient has MVP and wasn’t given prophylaxis before the dental procedure. He had neither immunodeficiency nor hematologic malignity. And also, any immunologic disease was found. A population based study has shown that, MVP patients with moderate mitral regurgitation or flail leaflet are notable risk of developing infective endocarditis as compared to those without mitral regurgitation. Our case has MVP with moderate mitral regurgitation accordingly he has high risk within MVP patients. Our case is rare infective endocarditis case due to low risk for infective endocarditis And also, a rare case for vegetation area. Open in new tabDownload slide Abstract P1118 Figure. mobile vegetation Open in new tabDownload slide Abstract P1118 Figure. mobile vegetation P1119Relapsing Q fever infective endocarditis R Ilhao Moreira R Ilhao Moreira Hospital de Santa Marta, Cardiology, Lisbon, Portugal L Moura Branco L Moura Branco Hospital de Santa Marta, Cardiology, Lisbon, Portugal A Galrinho A Galrinho Hospital de Santa Marta, Cardiology, Lisbon, Portugal T Mendonca T Mendonca Hospital de Santa Marta, Cardiology, Lisbon, Portugal A Goncalves A Goncalves Hospital de Santa Marta, Cardiology, Lisbon, Portugal M Cruz Coutinho M Cruz Coutinho Hospital de Santa Marta, Cardiology, Lisbon, Portugal M Cruz Coutinho M Cruz Coutinho Hospital de Santa Marta, Cardiology, Lisbon, Portugal R Cruz Ferreira R Cruz Ferreira Hospital de Santa Marta, Cardiology, Lisbon, Portugal Hospital de Santa Marta, Cardiology, Lisbon, Portugal This case reports a 19-year old Angolan women migrated to Portugal two months before. The patient had a history of acute rheumatic fever which led to mitral valve replacement with bioprothesis at 12 years old and multiple admissions in Angola due to infective endocarditis (IE) with two re-operations (mitral replacement for bioprothesis at 16 and again at 17 years old), without clear microorganism identification on medical records. She was hospitalized after complaints of fever and progressive dyspnoea for 1 month. On admission she was febrile (40.3ºC), pallid and tachycardic. Blood analysis was evident for anaemia (haemoglobin 9.8 g/L) and increased inflammatory parameters (high-sensitivity reactive C-protein 45.9 mg/L). A transesophageal echocardiogram (TOE) showed large vegetations on both leaflets of mitral bioprothesis without significant regurgitation. Three blood cultures were negative and investigation for fastidious organisms and intracellular bacteria revealed elevated titres for antibodies against Coxiella Burnetti (phase I IgG 1/16224 and IgM 1/6144). Once the serological results were known, the patient was placed on a regimen of oral medication with a combination of hydroxychloroquine and doxycycline. She remained clinically and hemodynamically stable and afebrile and inflammatory parameters decreased. A TOE was repeated which revealed complete resolution of mitral valve vegetations. She was discharge with antimicrobial therapy (to be maintained for at least 18 months) and periodic assessments of antibodies against C. burnetti. Eight months later, she presented to the cardiology consult with shortness of breath, followed by the development of intermittent fever for 2 weeks. A TOE was repeated which revealed two small vegetation on posterior leaflet of mitral valve associated to leaflet rupture which was responsible for severe valvular regurgitation. After questioned, she admitted noncompliance to antimicrobial therapy for the last month. Phase I antibodies for C. burnetti were increased (IgG 1/12800 and IgM 1/6.400). Hydroxychloroquine and doxycycline were started again and the patient underwent mitral valve replacement for mechanical prosthesis (being this the 4th mitral valve replacement). Pathological examination of resected valvular tissue was positive for C. burnetti by polymerase chain reaction. Four months later, the patient is in good general condition and continues to take the above antimicrobial treatment. This case illustrates the difficulties of diagnosing fastidious bacteria IE that are treated often as blood culture-negative IE due to previous antimicrobial therapy. Furthermore, C. burnetti is a resistant microorganism that is associated with an increased rate of relapse, especially when long-term antimicrobial therapy is not strictly adhered to, demanding a regular cardiological and pathological monitoring of these patients for prompt detection of relapses. P1120Immediate effect of a successful MitraClip procedure on mitral annulus geometry in a patient with secondary severe mitral regurgitation S Cimino S Cimino Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy V Maestrini V Maestrini Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy M Pagliaro M Pagliaro Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy M Reali M Reali Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy M Mancone M Mancone Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy D Filomena D Filomena Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy G Sardella G Sardella Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy L Agati L Agati Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy Sapienza University of Rome, Department of Cardiov. & Respiratory Sciences, Nephrology & Geriatrics, Rome, Italy Percutaneous treatment of mitral regurgitation (MR) is able to reduce MR severity and to improve functional and clinical outcomes. While the success of MR surgical treatment is related to mitral annulus reduction, the influence of MitraClip system on annulus geometry is still unclear. We presented a case of severe MR, successfully treated with double Mitraclip implantation, analyzed by the software QLAB 10 MV Navigator, Philips, before and immediately after the procedure, in order to evaluate acute changes in mitral annulus’ shape and dimensions. We report a case of an 80-year-old man with ischemic severe functional MR, atrial fibrillation, and chronic renal failure. Left ventricular ejection fraction was moderately reduced, but despite optimal medical therapy, patient was in New York Heart Association (NYHA) functional class III-IV. Because the high surgical risk, the patient was referred to transcatheter mitral valve repair. Echocardiography confirmed severe MR (Figs. 1A, B and C and Fig 2), mostly as a result of ischemic tethering of the posterior leaflet. The adopted strategy consisted of implanting 2 clips, the first one postero-medial and the second one following a medio-lateral direction (Figs. 3A and B) with an optimal final result (Figs 4 A, B and C). We performed 3-D TEE during the whole procedure and we analyzed both a complete 3D Volume of the mitral valve before and after the procedure, with QLAB 10 MV Navigator software. Our analysis showed a significant reduction of annulus dimensions (AP diameter, area), a significant change in annulus’ shape (more elliptical) and a significant reduction of the mitral-aortic angle (Figs. 5 A and B). No complication related to the procedure occurred, the patients was discharged in NYHA class II. Seven days follow up confirmed the significant reduction of MR, evaluated <2+. Significant acute changes in the annulus shape after a successful procedure should be predictors of good outcome at late follow-up. Further longitudinal studies are needed. Open in new tabDownload slide Abstract P1120 Figure. Open in new tabDownload slide Abstract P1120 Figure. P1121Alone Mitraclip mimicking commissural annuloplasty S Stella S Stella San Raffaele Hospital, Milan, Italy C Capogrosso C Capogrosso San Raffaele Hospital, Milan, Italy C Marini C Marini San Raffaele Hospital, Milan, Italy F Ancona F Ancona San Raffaele Hospital, Milan, Italy M B Ancona M B Ancona San Raffaele Hospital, Milan, Italy C Godino C Godino San Raffaele Hospital, Milan, Italy A Colombo A Colombo San Raffaele Hospital, Milan, Italy A Margonato A Margonato San Raffaele Hospital, Milan, Italy E Agricola E Agricola San Raffaele Hospital, Milan, Italy San Raffaele Hospital, Milan, Italy A 77 yrs old female patient was admitted to emergency department for pulmonary edema with prompt response to diuretic administration. She was affected by idiopathic dilated cardiomyopathy, diagnosed 5 years ago, with a story of progressive reduction of left ventricle ejection fraction (EF: 25%) leading to several hospitalizations for congestive heart failure episode, despite optimal medical therapy. The last echocardiogram reported an EF of 25%, diffuse hypokinesia and mild functional mitral regurgitation (MR). The transthoracic echocardiography performed in ICU showed the presence of moderate to severe MR and furthermore reduction of EF (18%). This picture did not change and the patient resulted to be difficult to wean from endovenous diuretic therapy. Given her clinical history and high surgical risk, the patient was discussed by the Haert Team, and the decision was to treat MR percutaneously. Transesophageal echocardiography was then performed, confirming functional mechanism of MR, presence of multiple regurgitant jets originating from the entire coaptation line and modest valve remodeling (coaptation depth 6 mm, coaptation length 4 mm, annular diameters 35x40 mm). No calcification was present at the level of mitral annulus. The echocardiographic features of mitral valve made it suitable for a percutaneous annuloplasty approach (Cardioband System, Valtech). However, CT scan evaluation demonstrated the circumflex artery to be very close to the mitral annulus, making the patient not eligible for Cardioband. Therefore, Mitraclip was then considered as alternative approach. As the regurgitant jets covered the entire coaptation line, multiple potential target lesions could be considered for the initial grasping. The planned strategy was to implant the 1th Clip in the medial region of A2-P2 (Fig 1 A, B) and then to proceed with further implantation laterally. The procedure was performed under EchoNavigator guidance. Despite the procedural steps were made correctly, while positioning the clip in the first target lesion, it got entrapped in posterior-medial commissure. Several unsuccessful attempts were made to disengage the clip, leading to the decision to proceed with the grasping and to release the clip in the commissure. Immediately after clip closure, we observed a significant reduction of MR with the complete abolishment of central and lateral jets with trace residual MR. Concomitant marked smoke effect in left atrium appeared, as indirect sign of efficacious grasping (Fig 2 A, B). No more clip implantation was needed. 3D en-face mitral valve view showed the absence of usual edge-to-edge double orifice, and more remarkably, the slightly changing in annular D shape, by the distortion of medial region of posterior mitral annulus, given the selected commissural clip implantation (Fig 3 A, B). The pre-discharge echocardiographic evaluation confirmed the stability of the clip and mild residual MR. Open in new tabDownload slide Abstract P1121 Figure. Open in new tabDownload slide Abstract P1121 Figure. P1122An unusual cause of dyspnea H M Osman H M Osman Almana General Hospital, cardiology, dammam, Saudi Arabia Almana General Hospital, cardiology, dammam, Saudi Arabia S M H El Tayeb S M H El Tayeb Almana General Hospital, cardiology, dammam, Saudi Arabia S M H Eltayeb S M H Eltayeb Almana General Hospital, cardiology, dammam, Saudi Arabia A Khamies A Khamies Almana General Hospital, cardiology, dammam, Saudi Arabia A 26 years old IT specialist presented to the A & E with large haemoptysis. He was aware of progressive shorness of breath on exersion which is limiting his regular sports. His past history was remarkable for a diagnosis of 'heart problem 'at the age of 14 but there where neither chronic medications, nor inervension. He did not return for a follow up since then .No family history of relevance. Fast track bronchoscopy following urgent chest CT failed to reveal a space occupying lesion or active bleeder. CT chest was remarkable for dilated pulmonary artery & cardio -megaly. Auscultation revealed no murmurs . Echocardiography ( TTE & TOE ) showed moderate concentric hypertrophy of the LV while the right ventricle was severly hypertrophied, including the moderator band. No RVOT obstruction niether at rest nor following excercise ( which didnot confirm oxygen drop during maximum effort) ..Agitatined saline with valsalva failed to reveal signifivant shift of bubbles . Cardiac magnetic resonance confirmed severe hypertrophic right ventricle, with less dramatic hypertrophy of the LV. There was accelerated flow across th RVOT but no obstruction. Pulmonary artery was dilated. We proposed to proceed for right heart cathetarization to rule out the possiblity of pulmonary hypertension but the patient refused . We present this patient with the diagnosis of hypertrophic non-obstructive right ventricular cardiomyopathy, with severe hypertrophy of the RVOT causing pulmonary artery dialtion & Haemoptysis. Open in new tabDownload slide Abstract P1122 Figure. cardiac MR, the extent of hypertrophy Open in new tabDownload slide Abstract P1122 Figure. cardiac MR, the extent of hypertrophy P1123An unusual endomyocardial fibrosis; case report Khalid M Ahmed Khalid M Ahmed University Hospital Limerick, cardiology, Limerick, Ireland V Voon V Voon University Hospital Limerick, cardiology, Limerick, Ireland T Kiernan T Kiernan University Hospital Limerick, cardiology, Limerick, Ireland University Hospital Limerick, cardiology, Limerick, Ireland Introduction: Endomyocardial fibrosis (EMF) is a rare idiopathic disorder of the tropical and subtropical regions of the world that is characterized by the development of restrictive cardiomyopathy. Case presentation: Mr. P.C is a 71 years old gentleman who was admitted to hospital on top of a sudden onset chest pain at home. Cardiology team was consulted in order to review his ischemic looking ECG with diffuse deep T- wave inversions through all precordial leads as well as small troponin leak of 23 mg/dl. His only background history was hypertension which is completely controlled by his medications. Furthermore, all other laboratory results were within normal range apart from mild esoniophilia. Mr. P.C is a Caucasian Irish born citizen and spent most of his life working in London and has never travelled outside Europe before. Initially, brain CT was done and reported as normal. Transthoracic echocardiography revealed mildly impaired systolic function EF of 45-50% and apical akinesis with attached LV mural thrombus. Ironically, Coronary angiogram only showed mild atheroma of the left circumflex artery. Anecdotally, cardiac MRI was performed and established the diagnosis of endomyocardial fibrosis (EMF) and confirmed the existence of LV thrombus ( see below). Eventually, he was discharged after excellent in hospital course and managed as a heart failure patient for lifelong anticoagulation. Repeated holter monitor as an outpatient to rule ventricular tachyarrhythmias. Conclusion: An accidentally diagnosed EMF in patient who never been to tropical or subtropical regions raises the concern that EMF might be underdiagnosed in Europe. Another question to be raised, should those patients offered an ICD on elective basis? Open in new tabDownload slide Abstract P1123 Figure. Open in new tabDownload slide Abstract P1123 Figure. P1124Atypical presentation of a rare systemic vasculitis M Trepa M Trepa Hospital Center of Porto, Cardiology, Porto, Portugal R B Santos R B Santos Hospital Center of Porto, Cardiology, Porto, Portugal I Silveira I Silveira Hospital Center of Porto, Cardiology, Porto, Portugal M F Oliveira M F Oliveira Hospital Center of Porto, Cardiology, Porto, Portugal P Rodrigues P Rodrigues Hospital Center of Porto, Cardiology, Porto, Portugal S Cabral S Cabral Hospital Center of Porto, Cardiology, Porto, Portugal V A Dias V A Dias Hospital Center of Porto, Cardiology, Porto, Portugal S Torres S Torres Hospital Center of Porto, Cardiology, Porto, Portugal Hospital Center of Porto, Cardiology, Porto, Portugal Churg-Strauss syndrome (CSS) is a rare form of systemic vasculitis usually occurring in atopic patients. The pathophysiology progresses through 3 major stages: asthma and allergic rhinitis, peripheral eosinophilia and tissue infiltration and, lastly, necrotizing vasculitis. Presentation with cardiac symptoms is unusual but it is a well-established adverse prognosis factor. We report the case of a 69 years old man who was admitted to our cardiology ward due to "de novo" heart failure (HF). At hospital admission he reported in his previous medical history hypertension, dyslipidemia and asthma since childhood. In the month preceding admittance he developed rapidly worsening dyspnea, orthopnea and had multiple episodes of paroxysmal nocturnal dyspnea and atypical chest pain. The physical exam was unremarkable. The blood count revealed lymphopenia and a significant increase in eosinophil count. He had a slight rise in high sensitivity T Troponin and the EKG showed T wave inversion in all precordial leads. Echocardiogram presented moderated left ventricular ejection fraction (LVEF) impairment with apex dyskinesia, posterior-basal akinesia and anterior-lateral hypokinesia. There was a mild pericardial effusion. The patient underwent coronary angiography which revealed no significant epicardial disease. We proceeded with cardiac magnetic resonance (CMR) showed transmural late gadolinium enhancement in the basal and median segments of the lateral and inferior left ventricular wall and STIR sequences were compatible with edema in the lateral wall. These findings were suggestive of myocarditis with possible associated vasculitis. Given this finding we decided to review thoroughly the patient’s previous medical history and records searching for diagnostic clues. We uncovered bronchiectasis, nasal polyps and seasonal chronic cough. This symptoms added to the evidence of myocarditis and persistent peripheral eosinophilia were compatible with the diagnosis of Churg-Strauss Syndrome (CSS). The endomyocardial biopsy that confirmed the eosinophilic infiltration in the myocardium. Additional studies excluded drug-related (hypersensitivity reaction), parasitic, neoplastic and idiopathic hypereosinophilic syndrome. The diagnosis of CSS with cardiac involvement was then confirmed as four out of six criteria (from the American College of Rheumatology) were met: Peripheral eosinophilia, asthma, paranasal sinus abnormality and extravascular eosinophils on biopsy. The patient was given symptomatic and prognosis modifying treatment drugs for HF, corticosteroids and immunosuppressants and presented significant clinical improvement. At 6 months follow-up he was in HF NYHA class II, had a decrease in eosinophil count, LVEF increased to 47% and CMR showed significant less areas compatible with ongoing myocardium inflammation. This case was remarkable because of three distinct important messages: A careful clinical history taking is essential to the adequate management of all heart failure patients. - Churg Strauss Syndrome presentation with heart failure is very rare. In the setting of heart involvement and eosinophilia is essential to consider this diagnosis. - Timely diagnosis and start of adequate therapy is crucial in modifying prognosis for this patients P1125Superior vena cava obstruction as a complication of pacemaker therapy- the role of echocardiography in diagnosis and follow up of the patient A Wojtkowska A Wojtkowska 1Medical University of Lublin, Cardiology Department, Lublin, Poland A Tomaszewski A Tomaszewski 1Medical University of Lublin, Cardiology Department, Lublin, Poland M Tomaszewski M Tomaszewski 1Medical University of Lublin, Cardiology Department, Lublin, Poland D Stettner-Leonkiewicz D Stettner-Leonkiewicz 1Medical University of Lublin, Cardiology Department, Lublin, Poland T Jargiello T Jargiello 2Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland 1Medical University of Lublin, Cardiology Department, Lublin, Poland 2Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Lublin, Poland A 22-year-old man with a dual-chamber pacemaker implanted 4 years earlier for symptomatic sick sinus syndrome, was admitted to our institution because of identified leads malfunction. The patient was qualified for a transvenous lead extraction (TLE). The procedure was performed without complications. After TLE the transesophageal echocardiography (TEE) was performed, which revealed additional irregular structure in the orifice of vena cava superior (SVC) with acceleration of blood flow in spectral doppler up to 2.3 m/sec. (maximum gradient 21 mmHg). Visible structures were fibrotic ghosts surrounding the leads formed as a result of excessive tissue reaction, which could remain after TLE. The patients vital signs were stable. Blood test results (morphology and biochemical analysis) were normal. Next the patient was undergone venography which confirmed essential narrowing in the orifice of SVC and the transluminal balloon venoplasty was performed with partial effect. Two months later control TEE and next venography revealed sustaining of narrowing. Another attempt of balloon dilatation was unsuccessful because of high resilience of vessel. The patient was qualified to metallic stent implantation, which was performed with good effect. There were no complications related to the procedure. The adjuvant antithrombotic therapy remains difficult and it goes unanswered in the literature. We decided to treat the patient with clopidogrel for 6 months. The next control TEE examination showed no recurrence of narrowing. Now the patient is awaiting reimplantation a new pacemaker system through the stented vein. Superior vena cava syndrome (SVCS) in patients with transvenous pacing leads is a rare but serious complication, different reports reveal the incidence from 0.03 to 0.4 % of patients. Most patients develop symptoms progressively over the several weeks or longer, with some improvement as the collateral circulation develop. There are a few mechanisms describing the etiology of SVC obstruction. The mechanical stress which is induced by pacemaker wires may lead to vessel wall inflammation and fibrin deposition, thrombus formation, and finally could result in venous obstruction and occlusion. There are various ways of treatment which could be considered, such as long-term anticoagulation, thrombolytic therapy, surgical intervetion, percutaneous transluminal balloon angioplasty and metallic stent insertion. However, only small case series have been reported so far and there is no accepted, unequivocal standard care at present time. Although contrast venography is the gold standard for diagnosis of venous obstruction, we would like to highlight the role of TEE examination, as an accurate and useful first modality in diagnosis of SVC obstruction and next in follow-up of patients after percutaneous treatment. TEE examination should always be performed after transvenous lead extraction to evaluate structures which could remain after a procedure. Open in new tabDownload slide Abstract P1125 Figure. TEE- narrowing in the orfice of SVC Open in new tabDownload slide Abstract P1125 Figure. TEE- narrowing in the orfice of SVC P1126A 11 years old boy presenting with exertional intolerance and ankle edema I H Tai I H Tai Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC I C Lin I C Lin Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC M H Lo M H Lo Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC C F Huang C F Huang Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC Y J Lin Y J Lin Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC K S Hsieh K S Hsieh Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC Chang Gung Memorial Hospital Kaohsiung, Pediatrics, Kaohsiung, Taiwan ROC A 11 years old boy had apparently been healthy until 1 year previously, when he developed exertional dyspnea which gradually worsened. Physical examination indicated audible diastolic murmur, hepatomegaly and ankle edema. At rest, he did not have dyspnea with pulse oximetry in room air was 96%. With a short walk, however, he became dyspneic with SpO2 of 87%. Chest radiography showed marked engorged pulmonary conus without cardiomegaly or Kerley B lines. Cardiac echography demonstrated a medium-sized secumdum type ASD(size: 17mm) with bi-direction shunt and a compressed LV from the enlarged RV. At catheterization laboratory, selected RPA & LPA angiography showed dilated PAs without pulmonary embolism. The PCWP & LA pressure & LVEDP (LV end-diastolic pressure) were 4, 2, & 7 mm Hg, respectively. Mean arterial pressure of MPA was 64mm Hg and inhalation of iloprost for 10 minutes make the mean arterial pressure decrease to 59mm Hg. The differential diagnosis of secondary pulmonary hypertension(PH) consists of four categories: left heart disease, lung disease or hypoxia, chronic pulmonary artery obstructions, and congenital systemic-to-pulmonary shunts. If above impressions are all excluded, then group 1 PH (idiopathic or heritable BMPR2 mutation induced PH) should be considered. Echocardiography didn’t reveal the presence of systolic dysfunction (LVEF <50%) or significant left-sided valvular disease makes left heart disease unlikely. Pulmonary function test showed no evidence of obstruction lung disease, lung fibrosis, or chronic inflammation disorders. Right heart catheterization (RHC) disclosed no pulmonary thromboembolic disease and it also determined equal systemic-to-pulmonary shunt. Gene test shows no reduced bone morphogenetic protein receptor type II (BMPR2) gene expression. Open in new tabDownload slide Abstract P1126 Figure. figure1,2A,2B,3A,3B with legend Open in new tabDownload slide Abstract P1126 Figure. figure1,2A,2B,3A,3B with legend P1127Looking for comets, why cardiologists should do it in congestive HF L Gargani L Gargani 2National Council of Research, Pisa, Italy 1Careggi University Hospital (AOUC), Florence, Italy 2National Council of Research, Pisa, Italy C Piazzai C Piazzai 1Careggi University Hospital (AOUC), Florence, Italy A Moggi Pignone A Moggi Pignone 1Careggi University Hospital (AOUC), Florence, Italy Introduction and case report description: Pulmonary congestion is often not adequately investigated during hospitalization. Patients may experience symptoms’ improvement and may be free of clinical congestion but have persistent hemodynamic or pulmonary congestion. A 79-year-old man was admitted to our hospital for increased lower extremity edema and oliguria. He complained no dyspnea, no chest pain, no palpitations. His medical history reported chronic ischemic heart disease, severe peripheral artery disease, diabetes mellitus type-2, permanent atrial fibrillation on warfarin, hypertension, chronic kidney disease (stable GFR = 47 mL/min/1.73m2), COPD, Parkinson’s disease. He had 3 hospitalizations for congestive heart failure in the previous month. Recently, his general practitioner had increased furosemide dose from 75 mg to 125 mg a day. Physical examination revealed edema up to the upper third of the leg. On chest auscultation, basal crackles with reduced breath sounds were found on both sides. His BP was 125/70 mmHg, HR 61 beats/min, RR 22 breaths/min, body temperature 37.0°C, and oxygen saturation on room air 89%. Electrocardiography, troponins, and heart auscultation were normal. Arterial blood gas analysis showed hypoxemic respiratory failure. Standard lab exams were normal, except for elevated NT-proBNP (7616 pg/mL) and evidence of urinary tract infection. A Chest X-Rays was performed and revealed cardiomegaly and mild bilateral pleural effusion. Echocardiography showed an already known akinesia of the inferior wall and reduced EF (=40%). In addiction to antibiotic, antihypertensive, anticoagulation treatment and oxygen, bolus of furosemide at a dose of 40 mg intravenously twice a day was started, and progressively reduced. Over the following days the patient reported symptomatic improvement and the signs of congestion gradually subsided, so his discharge was planned for the sixth day of hospitalization. The day before discharge at 5.30 pm a LUS exam was performed, showing multiple bilateral B-lines, but no immediate optimization of the therapy was done. The same day at 9 pm the patient complained an acute onset of dyspnea. He was tachypnoic, oxygen saturation was 87% with FiO2 28%, BP 115/60 mmHg, HR 90 bpm, and widespread wheezes and crackles were found on auscultation. The day after NT-proBNP was 13000 pg/mL. The furosemide dosage was increased and discharge was delayed for four days. The day before discharge no B-lines were detected. The patient was not rehospitalized in the following three months. Conclusion/Implications to clinical practice: Pulmonary congestion quantification through physical examination is challenging, and it may persist even if the patient is free of congestion’s signs and reports symptoms’ improvement. Pulmonary congestion is often not adequately investigated during hospitalization, and is associated with poor prognosis and rehospitalization in HF patients. Recent studies have shown that presence of residual pulmonary congestion at discharge, as assessed by LUS, is a predictor of rehospitalization for HF at 3-months. Lung ultrasound may represent a useful, quick and easy tool to identify and monitor congestion and optimize therapy during hospitalization in HF patients. Open in new tabDownload slide Abstract P1127 Figure. Open in new tabDownload slide Abstract P1127 Figure. P1128Acute pericarditis as a possible complication of infliximab therapy C Dugo C Dugo 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy L Lanzoni L Lanzoni 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy A Chiampan A Chiampan 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy A Cecchetto A Cecchetto 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy L Albrigi L Albrigi 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy C Ciccio' C Ciccio' 2Ospedale Sacro Cuore - Don Calabria, Diagnostic Imaging, Negrar (Verona), Italy S Bonapace S Bonapace 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy E Barbieri E Barbieri 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy 1Ospedale Sacro Cuore - Don Calabria, Cardiology, Negrar (Verona), Italy 2Ospedale Sacro Cuore - Don Calabria, Diagnostic Imaging, Negrar (Verona), Italy A 75-years-old female was admitted to our Cardiology department due to chest pain radiating to the back and left arm. She had a similar episode two weeks before, occurring while she was resting and with spontaneous resolution. She had a history of hypertension, which required medical therapy in the past, smoking habitus, borderline dyslipidaemia and no previous hospital admission due to heart disease. She has been affected by Crohn’s disease since 2009 complicated by a ileocecal resection in 2010 and requiring therapy with infliximab in 2015 which was early discontinued due to pneumonia. A steroid therapy was then started and, due to the lack of its efficacy, in July 2016, a month before she was admitted to our department, she underwent infliximab administration for a second time. The ECG performed at the admission revealed diffuse deep negative T waves and the transthoracic echocardiography showed a mildly hypertrophic left ventricle (A) with no regional wall motion abnormalities and no pericardial effusion (B). No significant rise in troponin was detected while c-reactive protein (CRP) was mildly elevated (22 mg/l). Due to the clinical presentation, the ECG and the cardiovascular risk factors, a coronary angiography was performed but no coronary artery disease was found. She started to complain about chest pain being exacerbated with respiration and while lying down and she started to cough with sore throat and ears pain. A computed tomography (CT) chest scan was performed, which was negative for major findings. Thus, we proceed with a cardiac magnetic resonance (CMR) which showed a diffusely thickened pericardium on T1w-images (C) with oedema of the inflamed pericardial layers on T2-STIR (D), a significant enhancement of the pericardium which was detected after gadolinium administration in early and delayed phase (E) whereas there was not pericardial effusion. We concluded for an acute pericarditis without myocardial involvement. Colchicine, steroids and beta-blockers were started. At the follow up visit performed 2 months after the discharge, the ECG revealed completed normalization of the T waves while CPR was negative. Open in new tabDownload slide Abstract P1128 Figure. Acute pericarditis: TTE and CMR Open in new tabDownload slide Abstract P1128 Figure. Acute pericarditis: TTE and CMR P1129Purulent cardiac tamponade due to Acitenobacter pericarditis in patients with tuberculous pleural effusion and concurrent detection of lung tumor R Hamonangan R Hamonangan Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia M S Azizi M S Azizi Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia M Muhadi M Muhadi Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia S A Nasution S A Nasution Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia N N Dalimunthe N N Dalimunthe Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia N K Sandjaja N K Sandjaja Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia A Ratya A Ratya Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia A Sejati A Sejati Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia L Rusdi L Rusdi Universitas Indonesia-Cipto Mangunkusumo National General Hospital, Division of Cardiology, Departement of Internal Medicine, Faculty of Medicine, Jakarta, Indonesia Cardiac tamponade is a critical condition which needs immediate diagnosis and proper treatment. A 32-year-old woman admitted for worsening dyspnea. She was fully alert, hypotensive, tachycardia, tachypnea with no fever. Laboratory test showed anemia, infection and inflammation. Electrocardiography revealed sinus tachycardia with low voltages and chest X-Ray demonstrated enlarged cardiac silhouette, bilateral perihilar and pericardial infiltrates with pleural effusion (A). Transthoracic echocardiography showed large volume of pericardial effusion about 20 mm, swinging heart with abnormal motion confirmed tamponade (B, C). Urgent echocardiography-guided pericardiocentesis was performed which revealed 250 mL of purulent fluid that grew Acitenobacter baumanii (anitratus) (D), no malignant cells were found while pleural fluid analysis showed suggestive result of tuberculosis. Patient was treated with susceptible antibiotic, antituberculosis drugs and steroid. The amount of drained pericardial fluid decreased gradually. After two weeks of treatment patient showed significant clinical and laboratory improvement. Pericardial effusion was no longer productive which confirmed by transthoracic echocardiography (E, F). However, thoracic computed tomography (CT) scan showed lung tumor with metastatic appearances in both lungs and mediatinum lymphadenopathy (G). CT-guided lung biopsy was scheduled for further investigation. The incidence of purulent pericardial effusion has declined since the era of broad-spectrum antibiotics, however it may occur in individual whose immune system is compromised and those have undergone cardiothoracic surgery. Acitenobacter baumanii is a rare etiologic pathogen of purulent pericarditis which related to nosocomial infection and multiple antibiotic resistance. Cardiac tamponade as the most severe complication of purulent pericardial effusion is often fatal. Although cardiac tamponade is a clinical diagnosis, transthoracic echocardiography is extremely helpful for quick diagnostic confirmation. Unfortunately in developing countries like Indonesia, the availability of transthoracic echocardiography is still limited. Urgent pericardial drainage combined with intravenous antibacterial therapy is mandatory to avert devastating life threatening complication of cardiac tamponade. This case highlights clinical awareness of purulent pericarditis particularly in immunocompromised patients and important role of transthoracic echocardiography in rapid diagnosis, guided-pericardiocentesis and treatment evaluation of cardiac tamponade. Open in new tabDownload slide Abstract P1129 Figure. Open in new tabDownload slide Abstract P1129 Figure. P1130Barrier on wrong side R Parikh R Parikh Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India S Chaurasia S Chaurasia Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India A Tiwari A Tiwari Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India A Beedkar A Beedkar Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India M Maske M Maske Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India B Talaviya B Talaviya Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India I Pathan I Pathan Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India S Washimkar S Washimkar Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India P Deshmukh P Deshmukh Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India M Deshpande M Deshpande Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India Government Medical College & Super Speciality Hospital, Nagpur, Department of Cardiology, Nagpur, India Introduction: In patients of congenital heart disease with ventricular septal defect, an intriguing phenomenon of acquired right ventricular outflow obstruction has been described. Popularly called Gasul’s phenomenon is thought to be a spontaneously acquired mechanism to protect lungs from volume overload due to shunt lesion between ventricles. Such phenomena in shunt lesions of great arteries has never been mentioned. Description: We hereby describe a case of 38 years old women who presented to us with hemoptysis. She is a mother of two kids, both healthy, with last pregnancy 10 years back. She was the third child in the family with five children, with no history of hospital admission during childhood except for out-patient treatments for recurrent cough since adolescence which subsided spontaneously in past seven to eight years. She had started developing exercise intolerance during her routine household work since past five to six years. She developed dyspnoea on exertion associated with exertional giddiness which has progressed over past two to three years from New York Heart Association (NYHA) class II to class III. She had two episodes of hemoptysis since last month. On examination, differential cyanosis was apparent with otherwise normal built & weight. Her vitals were stable. Cardiovascular examination revealed right ventricular heave with loud and palpable P2 along with soft grade II/VI mid systolic murmur in left 3rd intercostal space. Her haemoglobin was 20 gm/dL with thrombocytopenia on peripheral smear examination. Electrocardiogram had right axis deviation with right ventricular pressure overload pattern suggested by monophasic R in V1 along with small preserved R wave in V5, V6 suggestive of prior left to right shunt. Chest roentgenogram AP view showed massively dilated right pulmonary descending artery with peripheral pruning along with infundibular hump along left heart border. Her echocardiography showed PDA (patent ductus arteriosus) with right to left shunt, dilated pulmonary trunk and dynamic subinfundibular right ventricular outflow tract obstruction. MRI confirmed the findings. Discussion: Benjamin Gasul, in 1957, first described the case of acquired right ventricular obstruction in case of ventricular septal defect. As per Weidman et al. and Corone et al. series studying natural history of ventricular septal defect, the prevalence of this phenomenon has been described to be around 3 – 7%. This is the first ever mention of acquired right ventricular outflow tract obstruction in PDA. Though there is no documented evidence of any medical investigation for the patient in past, typical history of small PDA growing large with age leading to pulmonary volume overload and ultimately curving into eisenmengerisation with reversal of shunt is obvious here. Dynamic obstruction in right ventricle what appears to be ‘Gasulisation’ phenomenon can also be right sided hypertrophic cardiomyopathy incidental with PDA. There were no known features to suggest any syndromic association. Conclusion: The case report is first ever mention of gasulisation in PDA with eisenmenger syndrome in a female with two successful pregnancies. P1131Ventricular septal defect associated with aortic regurgitation and aortic ascending aneurysm I Bytyci I Bytyci 1University Clinical Centre of Kosova, Clinic of Cardiology, Pristina, Kosovo Republic of E Haliti E Haliti 1University Clinical Centre of Kosova, Clinic of Cardiology, Pristina, Kosovo Republic of B Bytyci B Bytyci 2University Clinical Centre of Kosovo, Clinic of Rheumathology, Prishtina, Kosovo Republic of L Kamberi L Kamberi 1University Clinical Centre of Kosova, Clinic of Cardiology, Pristina, Kosovo Republic of G Bajraktari G Bajraktari 1University Clinical Centre of Kosova, Clinic of Cardiology, Pristina, Kosovo Republic of 1University Clinical Centre of Kosova, Clinic of Cardiology, Pristina, Kosovo Republic of 2University Clinical Centre of Kosovo, Clinic of Rheumathology, Prishtina, Kosovo Republic of Introduction: The aortic regurgitation (AR) was seen in patients with ventricular septal defect (VSD) in its perimembranous subtypes, caused by the secondary prolaps as a result of Venturi effect. Missing of adequate treatment in early age of these patients by its closure and continuous forced physical activity increases hemodynamic left ventricle load and cumulative stress effect that can lead to valvular and vascular lesion that may be complicated with aortic elongation and aortic aneurysm. Case presentation: We present a case of 23 years old male patient with VSD and AR, associated with aortic ascending aneurysm. The patient was admitted at Outpatient Clinic, complaining for weakness and breathlessness at physical effort. In clinical examination, hart auscultation revealed continuous very loud systolic-diastolic murmur on the precordium associated with paplatory trill. On ECG slight right axial deviation and the signs of bi ventricular hypertrophy were registered. Other clinical and laboratory findings were within normal range. Transthoracic echocardiography demonstrated the presence of perimembranous VSD, with moderate restrictive shunt (Qp/Qs=1.6), AR and aortic ascending aneurysm. Similar findings reveal also on transesophageal echocardiography. Conclusions: We present a young male patient with perimembranous VSD, associated with AR and aortic ascending aneurysm which are developed as secondary complication of the missing adequate treatment. The monitoring of these patients, for the proper VSD treatment by its closure may prevent the progression of hemodynamic stress and secondary complications that are present in our case. Open in new tabDownload slide Abstract P1131 Figure. Open in new tabDownload slide Abstract P1131 Figure. P1132Concomitant pulmonary and aortic thrombosis - which is the mechanism? C Stefan C Stefan Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania A Scafa-Udriste A Scafa-Udriste Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania A Alexandrescu A Alexandrescu Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania P Capraru P Capraru Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania M Dorobantu M Dorobantu Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania A M Pascal A M Pascal Emergency Clinical Hospital Floreasca, Cardiology, Bucharest, Romania Although the pulmonary embolism is a common cause of death from cardiovascular disease, the association of massive thrombosis both in the pulmonary arteries and in the aorta is a much more rare condition, especially in young, apparently healthy patients. We present the case of a 48 years old man with no known cardiovascular disease and risk factors, except smoking, who presented with shortness of breath at minimum effort and even at rest, suddenly installed 5 days before. The clinical examination revealed a dyspneic patient, with oxygen saturation in atmosphere of 88% corrected on mask oxygen to 96% with tachyarrhythmia and significant difference in the blood pressure between the two arms (149/94 mmHg; 103/66 mmHg). The 12-lead ECG showed sinusal tachycardia, HR-120/min and major right bundle branch block. The transthoracic echocardiography revealed enlarged right cavities of the heart (RV=50 mm, RA=45 mm) with systolic disfunction of the right ventricle (TAPSE=16 mm, S’t=0,07 m/s) and indirect signs of high filling pressures in the right cavities of the heart (lax interatrial septum with specific movement by the left atrium). Therefore, considering the suddenly installed dyspnea, the difference in the blood pressure between the arms, the ECG and the echocardiography aspects, even if the WELLS score revealed a moderate risk for pulmonary embolism and the D-dimers were in normal ranges, we have decided that a CT scan on thorax is essential. The CT scan images discovered massive thrombosis in the pulmonary arteries and a massive floating thrombus in the thoracal aorta extending to the subclavian artery. Because of the multiple localization of the thrombosis associated to the echocardiographic aspect of the atrial septum, a transesophageal echocardiography has been made – which discovered a patent foramen ovale. Forwards, the three-dimensional echocardiography images showed the tunneliform aspect of the gap, being visibile on both sides of the atrial septum. Shortly after the admission, the clinical state of the patient got worse, and we decided to adopt thrombolysis. It turned out to be a good decision because the post-thrombolysis evolution was favorable with the remission of the symptoms and a real improvement of the imaging aspects (the disappearance of the right bundle branch block, the normalization in dimensions of the right cavities, the disappearance of the aortic thrombus with no underlying plaque and the recanalization of the thrombi in the pulmonary arteries). Therefore, thrombolysis in such an unusual case proved to be the best decision leading to the improvement of the condition. The existence of the patent foramen ovale partially explained the two locations of the massive thrombosis. Further, it was important to investigate and to treat, as possible, the cause leading to such an important patology. Therefore, the patient had been adviced to investigate for thrombophilia and also to discuss with a cardiac surgeon the opportunity of closing the atrial septal defect. Open in new tabDownload slide Abstract P1132 Figure. Open in new tabDownload slide Abstract P1132 Figure. P1133Platypnea-orthodoxy syndrome J De Sousa Bispo J De Sousa Bispo Faro Hospital, Cardiology, Faro, Portugal I Ramires I Ramires Faro Hospital, Cardiology, Faro, Portugal P Azevedo P Azevedo Faro Hospital, Cardiology, Faro, Portugal J P Moura Guedes J P Moura Guedes Faro Hospital, Cardiology, Faro, Portugal D Carvalho Silva D Carvalho Silva Faro Hospital, Cardiology, Faro, Portugal D Bento D Bento Faro Hospital, Cardiology, Faro, Portugal H Cafe H Cafe Faro Hospital, Cardiology, Faro, Portugal J Pestana J Pestana Faro Hospital, Cardiology, Faro, Portugal A Santos A Santos Faro Hospital, Cardiology, Faro, Portugal I De Jesus I De Jesus Faro Hospital, Cardiology, Faro, Portugal Faro Hospital, Cardiology, Faro, Portugal Introduction: The Platypnea-Orthodoxy Syndrome (POS) is a rare condition which is becoming increasingly recognized, characterized by onset or worsening of dyspnea with orthostatism (platypnea) and arterial desaturation (orthodesoxy) that is relieved by returning to a recumbent position. The pathophysiologic mechanism responsible for this syndrome is not entirely understood, but probably derives from one of the following mechanisms: intra-cardiac shunt, pulmonary vascular shunt, ventilation/perfusion mismatch, or a combination of the three.The most common pathology associated with this syndrome is the Pantent Foramen Ovale (PFO), which usually remains asymptomatic for decades. In rare occasions, a shift in the right/left intra-cardiac pressure relationship (such as can happen in Pulmonary Embolism (PE)), or a change in the anatomy of adjoining structures causing a change in the direction of the venous blood inflow into the PFO (as can happen in Thoracic Kyphosis) can lead to POS. Clinical Case: An 80 year old woman, previously healthy, presented in our emergency department with sudden onset dysarthria and right side hemiparesis that had over 24 hours of evolution. She was admitted with the diagnosis of Ischemic Stroke, as confirmed by head Computed Tomography (CT) scan. Her 12-lead electrocardiogram on admission was in sinus rhythm, and the Transthoracic Ecocardiography (TTE) showed no structural changes besides a septal hypertrophy (17 mm). On the 19th day of hospital stay she started complaining of positional dyspnea that appeared whenever she sat up, and reverted on recumbent position, associated with arterial oxygen desaturation refractory to oxygen supplementation. An Angio-CT scan of her lungs that showed no signs of EP and excluded lung disease. A Ventilation/Perfusion (V/Q) scan showed several peripheral emboli in the pulmonary vascular bed. In another TTE, no significant changes were identified. Suspecting POS, a Transesophageal Echocardiography (TOE) was performed, showing an interauricular septum with and exuberant hyperdynamic movement, with abundant passage of contrast from the right atrium to the left, compatible with an important PFO.The patient was then referred for percutaneous closure of the PFO. At 1-month follow-up after the procedure, patient presented with no cardiovascular symptoms, with a peripheral oxygen saturation of 94% while sitting and with no oxygen supplementation. She performed a follow-up TOE, confirming the presence of the closing device in the right position, without any passage of contrast from the right to the left atrium. Patient still had some neurologic deficits but was autonomous, and was still in physical rehabilitation. Discussion: This case is an example of the diversity of the manifestations of PFO. For 80 years the patient was asymptomatic, as happens with most patients with PFO. However, she first presented with an ischemic stroke of sudden onset, possibly originated in a Paradoxical Embolism. This could mean that there was some degree of right-left shunt, without any symptoms. During her hospital stay she suffered a PE, possibly justifying the onset of POS, due to a pressure increase in the right atrium, increasing the right-left shunt.The TOE had a crucial role in the diagnosis, allowing the detection of the structural anomaly. Percutaneous closure of the anatomical defect allowed effective treatment, giving a definitive confirmation of the diagnosis of POS caused by PFO. Open in new tabDownload slide Abstract P1133 Figure. PFO with significant shunt (off-axis) Open in new tabDownload slide Abstract P1133 Figure. PFO with significant shunt (off-axis) P1134Circumferential strain in the diagnosis of acute myocarditis A Leme Neto A Leme Neto santa cruz hospital, curitiba, Brazil santa cruz hospital, curitiba, Brazil The diagnosis of myocarditis with preserved ventricular function is challenging and empirically based on clinical presentation, changes in ECG, elevation of markers of myocardial necrosis and absence of coronary artery disease. Focal myocarditis may mimic acute ischemic syndrome, with cardiac catheterization being performed frequently. Magnetic resonance imaging is the noninvasive methodology used for the diagnosis of myocarditis, but with a high cost and not widely available. In this article, we diagnose a case of acute myocarditis with normal ventricular function through the circumferential strain methodology. Case report: Patient L. F. B, male, 19 years old, entered our service with a retrosternal chest pain complaint of an oppressive nature that began after 2 days of gastroenterocolitis associated with upper airway infection. The previous history, family history and conditions of life habits with no relevant particularities. At the physical examination, he presented pain facies, hypnotized 1+ \ 4; Feverish 38.5 degrees c. PA 142/86 mmHg; FC 110 bpm. The heart rate was regular with normal-sounding murmurs. The other segments, on physical examination, without significant alterations. The electrocardiogram presented sinusal tachycardia with current of anterolateral subepicardial lesion (figure 1A). The echocardiogram showed contractility, preserved systolic and diastolic functions. Evidence of normal ejection fraction with preserved longitudinal global strain and obvious reduction of the circumferential strain in basal inferolateral segment of the left ventricle (arrow); Presence of basal inferolateral late enhancement on nuclear magnetic resonance (confirming the myocarditis process at this level). Endomyocardial biopsy was not performed because of the considerations weighted about procedure complications, limited sensitivity and specificity, and technical limitations of the service. Laboratory tests revealed leukocytosis with predominance of lymphocytes, elevation of inflammatory markers, and myocardial necrosis. Negative serologies for rubella, toxoplasmosis, hepatitis B, C and A, HIV and VDRL. Negative examinations for diseases of Churg-Strauss, hypereosinophilic syndrome, giant cells, sarcoidosis, rheumatoid arthritis, dermatomyositis and systemic lupus erythematosus. The standard treatment for heart failure was started with ramipril 2.5 mg / day and bisoprolol 2.5 mg / day, by determining the acute phase of the disease against clinical history and complementary examinations. After 1 day of hospitalization, with worsening of inflammatory activity, elevation of myocardial necrosis markers and symptoms of major chest pain, in spite of the analgesia implemented, a high dose of IVIG (2g / kg for 5 days) was administered as a treatment based In its mechanism of action with anti-viral and anti-inflammatory effects, obtaining reduction of inflammatory activity and reduction of markers of myocardial necrosis on the day after its infusion. Discussion Noninvasive tools to distinguish acute myocardial ischemia from other diseases mimicking acute coronary syndromes are clinically useful. Conventional echocardiography has limited role in the diagnostic for acute myocarditis. MRI has the limitation of being a high-cost examination and not all services have this technology. Myocardial deformation imaging, assessed by circumferential strain was a useful tool in the diagnostic process of acute myocarditis, adding important information that can support clinical and conventional echocardiographic evaluation. P1135Importance of 3D echocardiography in assessment of origin of mitral regurgitation M Z Mladenovic M Z Mladenovic Military Medical Academy Belgrade, Belgrade, Serbia V D Vranes V D Vranes Military Medical Academy Belgrade, Belgrade, Serbia A R Ristic A R Ristic Military Medical Academy Belgrade, Belgrade, Serbia O S Obradovic O S Obradovic Military Medical Academy Belgrade, Belgrade, Serbia R N Ratkovic R N Ratkovic Military Medical Academy Belgrade, Belgrade, Serbia J Z Jovic J Z Jovic Military Medical Academy Belgrade, Belgrade, Serbia D J P Djuric D J P Djuric Military Medical Academy Belgrade, Belgrade, Serbia S R Spasic S R Spasic Military Medical Academy Belgrade, Belgrade, Serbia D Z B Dzudovic D Z B Dzudovic Military Medical Academy Belgrade, Belgrade, Serbia M S Stanic M S Stanic Military Medical Academy Belgrade, Belgrade, Serbia Military Medical Academy Belgrade, Belgrade, Serbia A 60 years old man was admitted to our department due to episode of paroxysmal atrial fibrillation (Af) and cardiac decompensation. Eight months before this episode he underwent the complete noninvasive assessment, and on that occasion we had found an asymptomatic, moderate aortic stenosis (AS) 61/32mmHg with small aortic regurgitation (AR). We recommended further medicamentous therapy with regular follow up. Four months after he was hospitalized in Clinic for Infective disorders because of prolonged febrile state, transthoracic (TTE) and transesophageal echocardiography (TEE) were performed, but there were no signs of infective endocarditis. After consultation with rheumatologist, it was concluded that he had a polymyositis so they started with small doses of corticosteroids. On the day of his admission laboratory parameters were completely normal. ECG showed paroxysmal Af which was medically converted into sinus rhythm with no signs of ischemia. Chest radiography had revealed the presence of pulmonary congestion. Standard TTE showed no significant progression of AS and moderate to severe, eccentric Mitral regurgitation (MR). We have noticed a strange filamentous structure on the anterior mitral leaflet (AML) in projection of A2 segment. Furthermore, 2D TEE revealed one small, fluctuating, saccular formation in projection of A2 segment on AML that was in continuity with its fibrous tissue. Color Doppler showed two separated jets of mitral regurgitation, one small with a central position as a consequence of inadequate coaptation of mitral leaflets, and the second one moderate, eccentric and perpendicular to AML, which originated directly from that saccular formation. Only after use of 3D TEE we had been sure that there was a small, saccular aneurism on A2 segment of AML which had its own perforation hole on the top. Color 3D Echo confirmed that perforation hole on the top of aneurismatic formation on AML was the origin of that moderate regurgitant jet. Coronary angiography revealed no significant changes on coronary arteries. After all the diagnostics, we came to the conclusion that it was the unrecognized, subclinical episode of Infective endocarditis that resulted in formation of the small aneurism on A2 segment of AML and consequently its perforation with MR, therefore Cardio surgery was indicated Open in new tabDownload slide Abstract P1135 Figure. Aneurism on A2 segment of AML Open in new tabDownload slide Abstract P1135 Figure. Aneurism on A2 segment of AML P1136Cardiac magnetic resonance incidental diagnosis of pulmonary thromboembolism in a patient presenting with ventricular tachycardia in the setting of an acute myocardial infarction M E Palacio Solis M E Palacio Solis 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain M Jimenez Martin M Jimenez Martin 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain A De La Fuente Villena A De La Fuente Villena 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain R Eiros Bachiller R Eiros Bachiller 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain R Neglia Montes R Neglia Montes 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain G Bastarrika Aleman G Bastarrika Aleman 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain M T Barrio Lopez M T Barrio Lopez 2Hospital Universitario HM Montepríncipe, Madrid, Spain J Barba Cosials J Barba Cosials 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain I Diaz Dorronsoro I Diaz Dorronsoro 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain P Azcarate Aguero P Azcarate Aguero 3Hospital San Pedro, Logrono, Spain 1Clínica Universidad de Navarra, Cardiology and Cardiac Surgery, Pamplona, Spain 2Hospital Universitario HM Montepríncipe, Madrid, Spain 3Hospital San Pedro, Logrono, Spain A 63-year-old male was brought to the emergency department with a hemodynamically well-tolerated sustained ventricular tachycardia (VT) and history of epigastrial pain. Upon arrival, the tachycardia had ceased and a 12-lead electrocardiogram was performed showing inferior, posterior and lateral Q waves, associated to a slightly elevated cardiac Troponin T. Besides prior history of smoking and a well-controlled arterial hypertension, the patient had no further known cardiovascular risk factors. With the suspicion of acute coronary syndrome (ACS) complicated with recurrent life-threatening arrhythmias, an emergency coronariography was performed, which revealed a proximal occlusion of the circumflex coronary artery and two significant lesions in the right coronary artery. In total three drug-eluting stents were implanted. A few hours later the arrhythmias recurred associated to chest pain. Betablockers, Amiodarone and Tirofiban were started, resulting in a better control of the VT and symptoms. The echocardiogram showed a mild left ventricular systolic dysfunction associated to an inferolateral and inferior hypokinesia. At that point, the possible causes were thought to be either a new ACS complicated with recurrent life-threatening arrhythmias or a reentrant VT due to ventricular scar tissue of a prior myocardial infarction. A stress cardiac magnetic resonance (CMR) was chosen as the following diagnostic procedure, to study the scar tissue disposition and rule out new areas of ischaemia. The study revealed oedema in the inferior and lateral walls (STIR sequence), findings that were also seen after contrast infusion (early gadolinium enhancement sequence) in the same areas. Transmural late gadolinium enhancement with core-phenomenon was observed in the inferior and lateral walls associated to a non-reversible perfusion abnormality. As a volumetric interpolated breath-hold examination (VIBE) sequence is always performed in this type of cases, an incidental pulmonary thromboembolism (PTE), involving the left pulmonary artery and the segmental branches of the inferior pulmonary lobe, was diagnosed (Fig. 1A). No thoracic aortic disease was found. A thoracic computed tomography angiography was performed afterwards corroborating the previous findings (Fig. 1B). Finally, a central PTE was incidentally diagnosed and properly treated, in a patient with a prior myocardial infarction presenting with an ACS. In summary, this is a perfect example of the CMR versatility in the diagnostic approach of patients presenting with acute chest pain, making possible to perform a "quadruple rule-out": ACS, acute PTE, acute myocarditis and acute aortic disease, with a single diagnostic test. Considering the above, this case remarks the importance of a thorough CMR study including aorta and pulmonary vasculature using the VIBE sequence in the setting of acute chest pain. Open in new tabDownload slide Abstract P1136 Figure. PTE at CMR and CT-Angio Open in new tabDownload slide Abstract P1136 Figure. PTE at CMR and CT-Angio P1137Anomalous origin of the left anterior coronary descending artery from the right coronary sinus: a multimodality imaging approach S Bonapace S Bonapace 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy C Ciccio C Ciccio 2Ospedale Sacro Cuore Don Calabria, Department of Diagnostic Imaging, Negrar, Italy F Valbusa F Valbusa 3Ospedale Sacro Cuore Don Calabria, Division of Internal Medicine, Negrar, Italy L Lanzoni L Lanzoni 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy A Rossi A Rossi 4University of Verona, Department of Biomedical and Surgical Sciences, Section of Cardiology, Verona, Italy A Cecchetto A Cecchetto 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy C Dugo C Dugo 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy E Barbieri E Barbieri 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy 1Ospedale Sacro Cuore Don Calabria, Division of Cardiology, Negrar, Verona, Italy 2Ospedale Sacro Cuore Don Calabria, Department of Diagnostic Imaging, Negrar, Italy 3Ospedale Sacro Cuore Don Calabria, Division of Internal Medicine, Negrar, Italy 4University of Verona, Department of Biomedical and Surgical Sciences, Section of Cardiology, Verona, Italy 5University of Verona, Department of Biomedical and Surgical Sciences, Section of Endocrinology, Verona, Italy G Targher G Targher 5University of Verona, Department of Biomedical and Surgical Sciences, Section of Endocrinology, Verona, Italy A Mantovani A Mantovani 5University of Verona, Department of Biomedical and Surgical Sciences, Section of Endocrinology, Verona, Italy A 72-year-old man presented with frequent non-sustained ventricular tachycardia on 24-hours-ECG monitoring. A transthoracic echocardiogram showed an unusual double binary image along the anterior wall of the ascending aorta (AscAo) in parasternal long (Figure 1, Panel A, arrow) and short axis (Figure 1, Panel B, arrowhead) view consistent with a vessel at colour flow Doppler. Cardiac computed tomography (CT) scan volume rendering-technique (VRT) images revealed that the echocardiographic images corresponded to the vertical (Figure 1, Panel D, E, arrows) and then horizontal segments (Panel D, E, arrowheads) along the ascending aorta of an anomalous left anterior descending coronary artery (LAD) branching from a short common trunk (CT) with the right coronary artery (RCA) from the right coronary sinus. A coronary angiography confirmed the anomaly (Figure 1, Panel F). Anomalous origination of a coronary artery from the opposite sinus (ACAOS) is estimated to be present in 0.2–2.0% of the population. When the ACAOS takes an inter-arterial between the aorta and the pulmonary artery or an intramural course it can precipitate ischemia and sudden cardiac death. In this case the CT-scan showed not only the anomalous origin of LAD but also its "benign" course that was neither intramural nor inter-arterial to reach its correct myocardial territory. The patient was put on beta-blockers, underwent a bicycle stress test and an intracavitary electrophysiological study without life-threatening arrhythmias. These unusual echocardiographic findings should raise the suspicion of the presence of an anomalous coronary origin warranting more accurate evaluation with cardiac CT-scan which is able to clarify abnormalities in both the origin and course of coronary arteries. Open in new tabDownload slide Abstract P1137 Figure. Open in new tabDownload slide Abstract P1137 Figure. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions please email: Journals.permissions@oup.com.
TI - Clinical Case Poster session 4
JO - European Heart Journal - Cardiovascular Imaging
DO - 10.1093/ehjci/jex289
DA - 2017-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/clinical-case-poster-session-4-KlOQBOAzPb
SP - iii254
VL - 18
IS - suppl_3
DP - DeepDyve
ER -