TY - JOUR
AU - Galasso,, Gennaro
AB - Abstract Aims Paravalvular leaks (PVL) and conduction disorders requiring permanent pacemaker implantation (PPI) in patients with severe Aortic Valvular Stenosis (SA) undergoing percutaneous aortic valve prosthesis (TAVI) still have a significant and unacceptable incidence for patients at medium and low surgical risk, who represent, with increasing scientific evidence, the prevalent population. The appearance of these complications seems to be related to clinical, anatomical and procedural factors, which influence the decision-making process of the type and size of bioprosthesis to be implanted. Particular attention has been paid to the role of the volume of calcium present at the native aortic valve (VCA) as a predictor of these complications, in order to optimize the percutaneous procedure. The VCA can be quantified using algorithms derived from Multilayer Computed Computed Axial Tomography (MSCT), an examination that has become a pivotal element in the evaluation of the patient's eligibility for TAVI.The aim of our study was to document the pre-procedural added value of VCA in terms of possible containment of adverse events and how much it may affect the choice of the type of bioprosthesis to be implanted. Methods and results 111 patients underwent TAVIs at the Interventional Cardiology Unit of the AOU S. Giovanni di Dio and Ruggi D'Aragona, between 2017 and 2020, subsequently divided into 2 groups: group A (self-expandable bioprosthesis, Medtronic Evolut R or Evolut Pro) and group B (balloon expandable bioprosthesis, Edward Sapien 3).The clinical, electrocardiographic, echocardiographic and anatomical parameters of the enrolled patients were analyzed, and the VCA in the preprocedural phase was quantified for each of them, using an algorithm extracted from the MSCT reading software, OsiriX (OsiriX-MD v.2.8.2 64-bit). A univariate logistic regression analysis was performed for the risk of developing the composite event of significant PVL and IPP.In Group B, no significant variables were found, while in Group A, the VCA (OR: 1.001; 95% CI, 1.000-1.002; p < 0.043) and incomplete left branch block (OR: 5.781; 95% CI, 0.013-32.988; p < 0.048) were significant. Subsequently, these two variables were tested in a multivariate regression model according to which only the VCA emerged as an independent predictor for the composite event (OR: 1.001; 95% CI, 1.000-1.002; p < 0.039). Conclusion VCA is significantly associated with the risk of moderate to severe PVL and rhythm disturbances requiring PPI, in the group of patients in whom a self-expandable bioprosthesis was implanted, unlike patients who received a balloon-expandable bioprosthesis where this association is not significant.   498 High-risk percutaneous coronary intervention in three-vessel coronary artery disease and aortic stenosis with Impella support Alice Bendetti Alice Bendetti Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Livio D´Angelo Livio D´Angelo Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Giulia Masiero Giulia Masiero Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Chiara Fraccaro Chiara Fraccaro Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Andrea Pavei Andrea Pavei Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Massimo Napodano Massimo Napodano Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Giuseppe Tarantini Giuseppe Tarantini Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua Medical School , Italy, Padua A 73-years-old male patient with hypertension, type 2 diabetes mellitus, and smoking habit was admitted to our institution complaining of new-onset typical chest pain and exertional dyspnoea (New York Heart Association functional class II). He had a history of positive stress test without evidence of severe coronary artery disease (CAD) at coronary angiography ten years before. Moreover, he was affected by severe chronic obstructive pulmonary emphysema with pulmonary hypertension. His physical examination revealed a systolic ejection murmur and the electrocardiogram showed a right bundle branch block with non-specific repolarization disorders. High sensitivity cardiac troponin I was 250 ng/L. Transthoracic basal echocardiography revealed normal left ventricular ejection fraction and end-diastolic volume (EF 60%, EDV 50 ml/mq) with normal kinetics, right ventricular chamber dilation and dysfunction, systolic pulmonary pressure of 54 mmHg and moderate aortic valve stenosis with a mean gradient of 20 mmHg and a valve area of 1.4 cm2. Coronary angiography showed a three-vessel coronary artery disease with severe stenosis (70%) of distal left main coronary artery (LM) involving left anterior descending (LAD) and circumflex (LCx) coronary ostia, severe stenosis (85%) at the mid tract of the LAD, chronic total occlusion (100%) of a small diagonal branch, severe stenosis (90%) of the first tract of the obtuse marginal branch (OM) and tandem severe stenosis (70% and 90%) of the posterolateral branch of the right coronary artery (RCA) (Fig 1). Left and right heart catheterization confirmed the presence of a moderate aortic valve stenosis (with a peak to peak gradient of 25 mmHg and a valve area of 1.4 cm2) with normal wedge pressure and mild pulmonary hypertension (with a mean pulmonary artery pressure of 28 mmHg). During the Heart Team discussion, percutaneous myocardial revascularization with Impella support was planned considering the patient comorbidities and the diffuse coronary artery disease. Although aortic stenosis is considered a contraindication to Impella implantation, the assist device acts as a bypass of the stenotic valve increasing cardiac output and reducing left ventricular end-diastolic pressure, thus improving coronary perfusion. After Impella CP insertion across the aortic valve into the left ventricle, through a femoral artery access, the patient underwent a high-risk PCI. T and protrusion double stenting technique on LM bifurcation was performed and two overlapping stents on the first tract of LCx-OM and the first tract of LAD were implanted. Final kissing balloon dilation and proximal optimization technique of the LM stent was done without complications (Fig 2). During the procedure with multiple long stents implantation in coronary bifurcation, hemodynamic parameters were stable. The post-procedural phase was uneventful, and the patient was discharge on day three. Dual antiplatelet therapy (DAPT) with Aspirin and Ticagrelor was prescribed for 12 months as indicated in acute coronary syndromes. After 12 months of DAPT without bleeding complications and considering the diffuse coronary artery disease, a long DAPT with Aspirin and Ticagrelor 60 mg was considered. Currently, the patient has been continuing DAPT for 18 months without complications. 253 Duration of dual antiplatelet therapy and subsequent monotherapy type in patients undergoing drug-eluting stent implantation: a network Meta-analysis Stefano Benenati Stefano Benenati Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Gabriele Crimi Gabriele Crimi IRCCS Ospedale Policlinico San Martino, Genova, Italia—IRCCS Cardiovascular Network Claudia Canale Claudia Canale Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Fabio Pescetelli Fabio Pescetelli Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Vincenzo De Marzo Vincenzo De Marzo Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Rocco Vergallo Rocco Vergallo Università Cattolica del Sacro Cuore, Roma , Italia Mattia Galli Mattia Galli Università Cattolica del Sacro Cuore, Roma , Italia Roberta Della Bona Roberta Della Bona IRCCS Ospedale Policlinico San Martino, Genova, Italia—IRCCS Cardiovascular Network Marco Canepa Marco Canepa Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Pietro Ameri Pietro Ameri Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Filippo Crea Filippo Crea Università Cattolica del Sacro Cuore, Roma , Italia Italo Porto Italo Porto Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova Università di Genova, Dipartimento di Medicina Interna e Specialità Mediche (Dimi , Italia ), Genova IRCCS Ospedale Policlinico San Martino, Genova, Italia—IRCCS Cardiovascular Network Università Cattolica del Sacro Cuore, Roma , Italia Aims To compare safety and efficacy of very short (≤3 months), short (6 months), standard (12 months) and extended (>12 months) DAPT, and subsequent monotherapies, after DES. Methods and results Twenty-two RCT (n = 110059 patients/year) were selected and included in a network meta-analysis, conducted according to both the Bayesian and Frequentist approaches. The primary efficacy endpoint was a composite of cardiac death, myocardial infarction (MI) and stent thrombosis (ST), the primary safety endpoint was major bleeding. Odds ratios (OR) and 95% confidence intervals (CI) were estimated. Compared to standard, we found lower rate of MI (OR 0.56, 95% CI 0.44-0.77) and, only in the frequentist analysis, ST (OR 0.42, 95% CI 0.28-0.64) in extended DAPT; lower rate of major bleeding (OR 0.61, 95% CI 0.39-0.87) in very short and lower rate of any bleeding (OR 0.61, 95% CI 0.38-0.90) in short DAPT. All DAPT durations were comparable regarding the secondary efficacy endpoints. Very short followed by P2Y12 inhibition was the treatment of choice to reduce both major bleeding and myocardial infarction. In the ACS subgroup, extended (as compared to standard DAPT) reduced PEP and ST (but not MI). Conclusion The efficacy of short and very short is comparable with that of standard DAPT after DES implantation, whereas extended DAPT reduces MI and ST rates. Very short DAPT reduces haemorrhagic events and, followed by a P2Y12 inhibitor monotherapy, may be preferred in order to pursue a trade-off in between major bleeding and ischemia. 40 Predictors of pacemaker implantation after TAVI according to kind of prostheses and risk profile: a contemporary meta-analysis Francesco Bruno Francesco Bruno A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Fabrizio D´Ascenzo Fabrizio D´Ascenzo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Matteo Pio Vaira Matteo Pio Vaira A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Elia Edoardo Elia Edoardo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Pierluigi Omedè Pierluigi Omedè A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Carlo Budano Carlo Budano A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Antonio Montefusco Antonio Montefusco A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Guglielmo Gallone Guglielmo Gallone A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Ovidio De Filippo Ovidio De Filippo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Mauro Rinaldi Mauro Rinaldi A.O.U. Città Della Salute e della Scienza, Torino, Divisione di Cardiochirurgia Michele La Torre Michele La Torre A.O.U. Città Della Salute e della Scienza, Torino, Divisione di Cardiochirurgia Francesco Atzeni Francesco Atzeni A.O.U. Città Della Salute e della Scienza, Torino, Divisione di Cardiochirurgia Stefano Salizzoni Stefano Salizzoni A.O.U. Città Della Salute e della Scienza, Torino, Divisione di Cardiochirurgia Federico Conrotto Federico Conrotto A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Carla Giustetto Carla Giustetto A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Gaetano Maria De Ferrari Gaetano Maria De Ferrari A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia A.O.U. Città Della Salute e della Scienza, Torino, Divisione di Cardiochirurgia 41 Aortic valve replacement vs balloon-expandable and self-expandable transcatheter implantation: a network meta-analysis Francesco Bruno Francesco Bruno A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Fabrizio D´Ascenzo Fabrizio D´Ascenzo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Luca Baldetti Luca Baldetti IRCCS San Raffaele Scientif Institute Milan, Divisione di Cardiologia Luca Franchin Luca Franchin A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Giorgio Marengo Giorgio Marengo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Susanna Beviario Susanna Beviario A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Francesco Melillo Francesco Melillo IRCCS San Raffaele Scientif Institute Milan, Divisione di Cardiologia Guglielmo Gallone Guglielmo Gallone A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Ovidio De Filippo Ovidio De Filippo A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Michele La Torre Michele La Torre A.O.U. Citta Della Salute e Della Scienza Torino, Divisione di Cardiochirurgia Mauro Rinaldi Mauro Rinaldi A.O.U. Citta Della Salute e Della Scienza Torino, Divisione di Cardiochirurgia Pierluigi Omedè Pierluigi Omedè A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Federico Conrotto Federico Conrotto A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Stefano Salizzoni Stefano Salizzoni A.O.U. Citta Della Salute e Della Scienza Torino, Divisione di Cardiochirurgia Carla Giustetto Carla Giustetto A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia Gaetano Maria De Ferrari Gaetano Maria De Ferrari A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia A.O.U. Citta della Salute e della Scienza Torino, Divisione di Cardiologia A.O.U. Citta Della Salute e Della Scienza Torino, Divisione di Cardiochirurgia IRCCS San Raffaele Scientif Institute Milan, Divisione di Cardiologia Aims While clinical equipoise has been demonstrated for surgery and transcatheter aortic valve interventions (TAVI) in appropriate candidates with severe aortic stenosis, observational data have raised concerns about safety of self-expandable (SE) compared to balloon-expandable (BE) valves in TAVI, although potentially limited by patient selection bias. Methods and results All Randomized Controlled Trials (RCTs) comparing BE vs. SE TAVI or/and vs. aortic valve replacement (AVR) were included and compared through Network Meta Analysis (NMA). All-cause and cardiovascular (CV) mortality during Follow-up were the primary endpoints, while stroke, rates of permanent pacemaker implantation (PPI), moderate/severe paravalvular leak (PVL) and re-intervention were the secondary endpoints. We obtained data from 11 RCTs, encompassing 9752 patients (3 with patients at low, 3 with patients at intermediate and 5 with patients at high surgical risk). After one and two years, no significant differences were noted for all-cause and CV mortality between BE, SE and surgical bioprosthetic valves. Compared to surgical bioprostheses, both BE and SE TAVI reduced the risk of acute kidney injury (OR 0.42; CI 95% 0.30-0.60 and OR 0.44; CI 95% 0.32-0.60), new-onset atrial fibrillation (OR 0.24; CI 95% 0.14-0.42 and OR 0.21; CI 95% 0.13-0.34) and major bleedings (OR 0.32; CI 95% 0.16-0.65 and OR 0.47; CI 95% 0.25-0.89) but were associated with increased risk of vascular complications (OR 2.29; CI 95% 1.37-3.85 for BE and OR 2.76; CI 95% 1.66-4.61 for SE). The BE prostheses reduced the risk of moderate/severe PVL at 30-day (OR 0.31; CI 95% 0.17-0.55) and of PPI both at 30-day (OR 0.51; CI 95% 0.33-0.79) and 1 year (OR 0.40; CI 95% 0.30-0.55) as compared to SE TAVI. Aortic valve reintervention was increased in SE prostheses compared to surgery (OR 3.13; CI 95% 1.47-6.64), while in BE prostheses were not (OR 2.26; CI 95% 0.93-5.47). Conclusion A TAVI strategy, independently from BE or SE prostheses, offers a survival benefits comparable to AVR. The BE prostheses are associated with a reduction of PPI and PVL compared to SE prostheses without any differences in all-cause and CV mortality during two years of Follow-up. 465 Transcatheter aortic valve replacement and complex coronary stenosis: a single centre experience of PCI with intravascular lithotripsy Myriam Carpenito Myriam Carpenito Campus Biomedico University of Rome Elisabetta Ricottini Elisabetta Ricottini Campus Biomedico University of Rome Annunziata Nusca Annunziata Nusca Campus Biomedico University of Rome Sara Giannone Sara Giannone Campus Biomedico University of Rome Rosetta Melfi Rosetta Melfi Campus Biomedico University of Rome Fabio Mangiacapra Fabio Mangiacapra Campus Biomedico University of Rome Paolo Gallo Paolo Gallo Campus Biomedico University of Rome Nino Cocco Nino Cocco Campus Biomedico University of Rome Raffaele Rinaldi Raffaele Rinaldi Campus Biomedico University of Rome Francesco Grigioni Francesco Grigioni Campus Biomedico University of Rome Gian Paolo Ussia Gian Paolo Ussia Campus Biomedico University of Rome Campus Biomedico University of Rome Aims Patients with severe aortic stenosis undergoing TAVI often present a significant coronary artery disease (CAD) with complex lesions and extensive calcification, requiring PCI. Recently intravascular lithotripsy has been introduced for PCI of calcified lesions through a balloon catheter using pulsatile mechanical energy. Limited data exist on the outcome of patients undergoing combined TAVI and complex PCI. We present a case series based on the experience of our centre with the aim to provide support to the feasibility of combined procedure of TAVI and intravascular lithotripsy -assisted PCI. Methods and results We analyzed data from patients with complex coronary lesions undergoing PCI and TAVI between January 2019 to December 2019. When indicated PCI with intravascular lithotripsy (Shockwave, Medical Inc) was performed in the same procedure of TAVI. Procedural time, amount of contrast medium and length of intensive care unit and in-hospital stay were collected and compared with mean results of TAVI alone procedures in our centre. In-hospital and 30-day major adverse cardiac events were also evaluated. A total of 34 consecutive patients (38% male; age 83 ± 7 years) underwent transfemoral TAVI procedure during the index timeframe. 3 patients (9%) received TAVI and intravascular lithotripsy - assisted PCI during the same procedure. Those patients presented at least one high-risk features, as reduced left ventricle ejection fraction (LVEF) (N = 1), chronic kidney disease (N = 1), multivessel coronary artery disease (N = 1), left main lesion (N = 1). Complete revascularization was achieved in all cases. No procedural complications were recorded. Procedural time was 83 ± 16 min, with no significant increase compared to mean of TAVI procedure in our centre (62 ± 22 min; P = 0.11). Use of contrast medium did not differ among the only TAVI group patients (169 ± 75.5) and those who received combined procedure (165 ± 100; P = 0.93). Patients treated with combined procedure did not present a longer intensive care unit (1 vs 1.54 ± 1.47; P = 0.53) o in-hospital length of stay (9.6 ± 3.6 vs 6.9 ± 3.2; P = 0.17). No major adverse cardiac events were recorded during in-hospital stay and at 30-day follow-up. Conclusion Our early experience suggests that a strategy of combined treatment with TAVI and intravascular lithotripsy - assisted PCI is feasible for treatment of patients with both severe aortic stenosis and severe calcified coronary artery disease without increasing procedural time and complexity. Further studies are needed to validate this treatment strategy in larger population. 194 A bomb on left ventricular wall: percutaneous treatment of a left ventricular pseudoaneurysm Paolo Vitillo Paolo Vitillo Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Giuseppe Santoro Giuseppe Santoro Ospedale del Cuore G. Pasquinucci , Massa Giuseppe Iuliano Giuseppe Iuliano Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Cesare Baldi Cesare Baldi Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Michele Bellino Michele Bellino Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Angelo Silverio Angelo Silverio Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Michele Ciccarelli Michele Ciccarelli Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Gennaro Galasso Gennaro Galasso Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Carmine Vecchione Carmine Vecchione Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Rodolfo Citro Rodolfo Citro Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Scuola di Specializzazione in Malattie Dell’Apparato Cardiovascolare, Universita’ Degli Studi di Salerno Azienda Ospedaliera Universitaria San Giovanni di Dio E Ruggi D’aragona , Salerno Ospedale del Cuore G. Pasquinucci , Massa Aims Left ventricular pseudoaneurysm (LVP) is a saccular structure communicating with ventricular cavity through neck entrance. LVP is generally related to contained cardiac rupture enclosed by adherent pericardium and scar tissue. Surgical repair is still considered the standard therapy such treatment is associated to high risk. In fact, repair of LVP is technically challenging due to tissue friability and the difficulty in the hemostasis achievement. In the recent years percutaneous closure for pseudoaneurysms with occluder devices emerged as an alternative strategy, however its systematic use is still controversial. Methods and results A 70 years-old male patient was referred to our institution for an abnormal cardiac mass detected as incidental finding at transthoracic echocardiography. Cardiac magnetic resonance revealed a large cavity (depth= 67 mm; max. longitudinal diameter= 88 mm), with characteristics for pseudoaneurysm, communicating with left ventricle through a neck (11 mm) in lateral wall. Coronary angiography showed diffuse coronary ectasia with chronic total occlusion of right coronary artery. Due to the high-risk profile of the patient, the Heart Team opted for percutaneous closure of the ventricular wall defect with an Amplatzer septal occluder (AGA Medical Corporation, 682 Mendelssohn Avenue, Golden Valley, MN 55427 USA). The closing procedure was performed under intraoperative transesophageal echocardiography (TEE) monitoring. TEE and subsequent left ventriculography confirmed the absence of communication between ventricular cavity and the pseudoaneurysm. After one-week, despite the normal post-procedure course, cardiac arrest due to ventricular tachycardia occurred. It was promptly treated with a single 250 DC shock. Subsequently internal cardioverter defibrillator was implanted. The patient is in good general conditions after six months Follow-up. Conclusion Left ventricular pseudoaneurysm is a saccular structure in communication with ventricular cavity generating after contained cardiac rupture which is enclosed by adherent pericardium and scar tissue commonly caused by myocardial infarction and cardiac surgery. The most important complication associated to LVP is rupture leading to a sudden fatal bleeding. Other possible complications are related to thrombus formation with risk of systemic embolization and compressive phenomenon due to the progressively increasing of the mass sizing. Due to the coexistence of several comorbidities’ patient was considered at high-risk for surgery and a less invasive approach was preferred. In recent years small series of percutaneous closure of LVP with occluder devices have been described, but further data about middle-long term outcome are lacking. Intraoperative TEE, together with left ventriculography, is a useful tool to guide the procedure and monitor the adequate release of the device. The occurrence of ventricular arrhythmias after percutaneous closure of interventricular septal defect with the same device have been already reported, but further data to identify patients at higher risk for such complication are needed. For this reason, prolonged ECG monitoring and/or intracardiac electrophysiological study could be useful in this patient cohort to identify those requiring a cardiac defibrillator in primary prevention. 271 Coronary cannulation after TAVR: the REACCESS study (reobtain coronary ostia cannulation beyond transcatheter aortic valve stent) Giuliano Costa Giuliano Costa Aou Policlinico Rodolico-San Marco , Catania Marco Barbanti Marco Barbanti Aou Policlinico Rodolico-San Marco , Catania Andrea Picci Andrea Picci Aou Policlinico Rodolico-San Marco , Catania Enrico Criscione Enrico Criscione Aou Policlinico Rodolico-San Marco , Catania Roberto Valvo Roberto Valvo Aou Policlinico Rodolico-San Marco , Catania Claudia Reddavid Claudia Reddavid Aou Policlinico Rodolico-San Marco , Catania Carmelo Sgroi Carmelo Sgroi Aou Policlinico Rodolico-San Marco , Catania Corrado Tamburino Corrado Tamburino Aou Policlinico Rodolico-San Marco , Catania Aou Policlinico Rodolico-San Marco , Catania Aims To investigate the feasibility of coronary ostia cannulation after transcatheter aortic valve replacement (TAVR), and to assess potential predictors of coronary access impairment. Certain data concerning the feasibility and reproducibility of coronary cannulation after TAVR are lacking. Methods and results This is an investigator-driven, single-centre, prospective, registry-based study that enrolled consecutive patients undergoing TAVR using all commercially available devices. All patients performed coronary angiography before and after TAVR. The primary endpoint was the rate of unsuccessful coronary ostia cannulation after TAVR. Secondary endpoints were the identification of factors associated with the inability to selectively cannulate coronary ostia after TAVR. Among 300 patients enrolled in the RE-ACCESS study from December 2018 to January 2020, a total of 23(7.7%) cases of unsuccessful coronary cannulation after TAVR were documented. This issue occurred in 22 of 23 cases with the use of Evolut R/PRO transcatheter aortic valves (TAVs) (17.9% vs. 0.4%,p < 0.01). At multivariate analysis, the use of Evolut R/PRO TAVs (OR : 29.6; 95%CI : 2.6-335.0; p < 0.01], the TAV/sinus of Valsalva (SoV) relation (OR : 1.1 per 1 mm increase; 95%CI : 1.0-1.2; p < 0.01) and the mean TAV implant depth (OR : 1.7 per 1 mm decrease; 95%CI : 1.3-2.3; p < 0.01) were found independent predictors of unsuccessful coronary cannulation after TAVR. A model combining these factors demonstrated to predict with very high accuracy the risk of unsuccessful coronary cannulation after TAVR (area under the curve 0.94; p < 0.01). Conclusion Unsuccessful coronary cannulation following TAVR was observed in 7.7% of patients, and occurred almost exclusively in patients receiving Evolut TAV. The combination of Evolut TAV, a higher TAV/SoV relation and implantation depth predicts with high accuracy the risk of unsuccessful coronary cannulation after TAVR. (ClinicalTrials.gov: NCT04026204) 187 When the wire within the yin and yang makes a difference - complex coronary dissection sealing Pierluigi Demola Pierluigi Demola Cardiologia Interventistica Strutturale—Azienda Ospedaliera Universitaria Careggi di Firenze Universita’ Degli Studi di Firenze Riccardo Colombi Riccardo Colombi Universita’ Degli Studi di Firenze Virginia Fossi Virginia Fossi Universita’ Degli Studi di Firenze Carlotta Romano Carlotta Romano Universita’ Degli Studi di Firenze Francesco Meucci Francesco Meucci Cardiologia Interventistica Strutturale—Azienda Ospedaliera Universitaria Careggi di Firenze Alessio Mattesini Alessio Mattesini Cardiologia Interventistica Strutturale—Azienda Ospedaliera Universitaria Careggi di Firenze Carlo Di Mario Carlo Di Mario Cardiologia Interventistica Strutturale—Azienda Ospedaliera Universitaria Careggi di Firenze Universita’ Degli Studi di Firenze Cardiologia Interventistica Strutturale—Azienda Ospedaliera Universitaria Careggi di Firenze Universita’ Degli Studi di Firenze Left main (LM) dissection is a rare complication of cardiac surgery but it is associated to a high peri-procedural mortality. Hemodynamic instability with ST elevation after cardiac surgery requires urgent coronary angiography and revascularization by percutaneous coronary intervention (PCI) or redo coronary artery bypass surgery. PCI has a high complication rate in patients with LM coronary dissection, especially in difficult settings such as after aortic valve cardiac surgery. Coronary imaging has a critical role for guidance of PCI in these challenging scenarios. We herein describe a case of a 78 years old man suffering from severe symptomatic aortic valve stenosis and hypertension who underwent surgical aortic valve replacement through mid-sternotomy. During the immediate post-operative course in Intensive Care Unit, reintervention was necessary due to sudden bleeding from chest drainages. Concomitantly, ST segment elevation developed in the antero-lateral leads. Transesophageal echocardiography revealed severe left ventricular dysfunction (30% ejection fraction) with akinesia of the whole cardiac apex and hypokinesia of anterior and lateral walls. The patient was therefore immediately transferred to catheterization laboratory where coronary angiography revealed a long dissection with TIMI flow grade 1, extending from the origin of the LM towards the left anterior descending coronary artery up to the third segment and involving the first diagonal branch (Figure 1). We performed intravascular ultrasound (IVUS) that delineated the sharp contours of a “Yin and Yang” sign (Figure 2) confirming the longitudinal extent of the dissection and the presence of the wire in the true lumen. Thanks to IVUS we could confidently deploy two 3.5 x 23 mm and 3.0 x 18 mm everolimus eluting stents with a successful final result (Figure 3) and TIMI 3 flow. At the end of the procedure, intraortic balloon pump was positioned in view of persistent hypotension. This case confirms the pivotal role of intracoronary imaging in complex left main disease scenarios even in high-risk patient. PCI in left main coronary dissection is technically challenging, mainly for the uncertainties rising from wiring into the real true lumen and danger of extending the dissection by catheter tip deep intubation and contrast injection into the false lumen. Once IVUS imaging confirmed that the wire (we preferred the non polymer jacketed guidewire Asahi Sion) passed through the real true lumen of the left main we were able to safely complete stenting. 143 Long term outcome of PCI of unprotected coronary artery. Preliminary data from gravity Edoardo Elia Edoardo Elia Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Giorgio Marengo Giorgio Marengo Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Fabrizio D´Ascenzo Fabrizio D´Ascenzo Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Gianni Casella Gianni Casella Dipartimento di Cardiologia, Ospedale Maggiore di Bologna Daniela Trabattoni Daniela Trabattoni Dipartimento di Cardiologia Centro Cardiologico Monzino Emad Abu-Assi Emad Abu-Assi Dipartimento di Cardiologia, Presidio Alvaro Conqueiro , Vigo Giulio Stefanini Giulio Stefanini Dipartimento di Cardiologia, Istituto Humanitas , Milano Fabrizio Ugo Fabrizio Ugo Dipartimento di Cardiologia Ospedale Sant’andrea , Vercelli Sebastiano Gili Sebastiano Gili Dipartimento di Cardiologia Centro Cardiologico Monzino Carla Giustetto Carla Giustetto Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Roberto Manfredi Roberto Manfredi Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Gulgiemo Gallone Gulgiemo Gallone Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Francesco Bruno Francesco Bruno Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Roberto Verardi Roberto Verardi Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Dipartimento di Cardiologia Centro Cardiologico Monzino Imad Sheiban Imad Sheiban Dipartimento di Cardiologia, Clinica Pederzoli, Peschiera del Garda Sergio Raposeiras-Roubín Sergio Raposeiras-Roubín Dipartimento di Cardiologia, Presidio Alvaro Conqueiro , Vigo Gaetano Maria De Ferrari Gaetano Maria De Ferrari Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Dipartimento di Cardiologia, Città Della Salute e Della Scienza—Università di Torino Dipartimento di Cardiologia Centro Cardiologico Monzino Dipartimento di Cardiologia, Presidio Alvaro Conqueiro , Vigo Dipartimento di Cardiologia, Ospedale Maggiore di Bologna Dipartimento di Cardiologia Ospedale Sant’andrea , Vercelli Dipartimento di Cardiologia, Clinica Pederzoli, Peschiera del Garda Dipartimento di Cardiologia, Istituto Humanitas , Milano Aims Long-term outcome after percutaneous treatment (PCI) of unprotected left main coronary artery (ULMCA) disease is still uncertain despite the widespread this therapeutic option. Indeed there is no data regarding survival after 15 years and how repeated revascularization on target lesion (TVR) or not-target lesion can influence patients’ prognosis. Consequently, we performed an European multicenter collection of PCI on ULMCAD to describe 15 years outcomes of patients and their potential clinical and procedural determinants. Methods and results GRAVITY is a multicenter retrospective registry including consecutive patients underwent PCI of ULMCAD between June 2002 and 2005 at nine European centers. At this moment, data from only seven centers were received and consequently included in this preliminary analysis. The chosen primary Endpoint is cardiovascular (CV) mortality, the secondary Endpoint are overall mortality, freedom from myocardial infarction and stent thrombosis. 200 patients were included with a mean age of 67 years (±12), of which 98% hypertensive, 22% diabetics, 72% dyslipidemic and 39% smokers. The mean SYNTAX score was 24 (±10), mean percentage of stenosis 73% (±17), lesion length 13.2 mm (± 6.4 mm), medina class 1,1,1 and 0,1,1 occurred in 33% and 4% respectively. Regarding procedural characteristics provisional strategy was more common that two-stents strategy (74% vs 26%) and were more used DES compared to BMS (91% vs 9%). The mean LVEF at discharge was 42% (±12). After 15 (13-17) years, 23.5% of patients underwent rePCI of ULMCA, the majority during the first year (58%). RePCI on ULMCA did not modify the CV mortality (6%vs 12%; p = 0.372), overall mortality (36% vs 27%; p = 0.156) and stent thrombosis (4% vs 5%; p = 0.817) but myocardial infarction was more common in who underwent rePCI on ULMCA (17% vs 4%; p = 0.006). At multivariate analysis only diabetes mellitus was found to predict CV death (HR 1.56, 95% CI 1.15-2.11, p = 0.004) Conclusion Percutaneous treatment of atherosclerotic disease of left main coronary artery is a safe therapeutic option and repeat revascularization on TVR does not influence cardiovascular and overall mortality. CV death Overall death Myocardial Infarction 69 Emergent aortic valvuloplasty in patient with Takotsubo cardiomiopathy and aortic stenosis presenting with cardiogenic shock Andrea Gratta Andrea Gratta Università Degli Studi di Verona Simone Fezzi Simone Fezzi Università Degli Studi di Verona Elvin Tafciu Elvin Tafciu Università Degli Studi di Verona Gabriele Pesarini Gabriele Pesarini Università Degli Studi di Verona Flavio Ribichini Flavio Ribichini Università Degli Studi di Verona Università Degli Studi di Verona A 84 years old woman contacts EMR for chest pain and dyspnoea whose onset followed an anxious nightmare that had awakened her from sleeping. In her clinical history arterial hypertension in therapy with ACE inhibitors and a known aortic valve stenosis in echocardiographic follow-up (last Eco-doppler of 4 months earlier with evidence of normal left ventricular function and a moderate aortic valve stenosis). At the arrival of emergency team the patient was in shock (TA 75/50 mmHg) and in respiratory failure. A prompt intubation was performed and an EKG was obtained with evidence of diffuse alteration of the repolarization and a slight elevation of ST segment in the anterior leads. The patient was transferred directly to the cath-lab and a coronary angiography was performed. No significant coronary obstructions were found and the patient was transferred to the Coronary Care. Despite inotropic support with Dobutamine 8 mcg/kg/min and Norephinephrine 0,08 mcg/kg/min no hemodynamic improvement was observed. At the echocardiography a severe left ventricle dysfunction with an apical balloon shape consistent with a Takotsubo syndrome (TTS) was observed. The aortic valve appeared heavily calcified and the movement of the cuspids was severely reduced. The aortic doppler confirmed a severe low-flow low-gradient aortic stenosis with an aortic valve area (AVA) less than 1 cmq. However, given the low stroke volume a pseudo-severe aortic stenosis caused by the abrupt decrease in left ventricle systolic function couldn’t be excluded. Moreover, a dynamic left ventricular outflow tract obstruction (LVOTO) has been reported in 20% of TTS (typically in patients with pre-existing septal bulge) and could precipitate the scenario. Inotropic support response was poor and given the echocardiographic presentation Dobutamine was suspended. The choice of inotropes was limited since increasing exogenous catecholaminergic inotropes in a highly suspected Takotsubo cardiomyopathy was useless and even dangerous and levosimendan or milrinone use was precluded because of their important vasodilators effects. So we thought a mechanical support, but in the context of LVOTO also intra-aortic balloon pump should be avoided. For the persistency of severe cardiogenic shock and the worsening of the clinical scenario, we decided to perform an urgent valvuloplasty. After the procedure arterial pressure progressively improved and Norephineprine support was progressively suspended in the same day. In the following days a complete recovery of left ventricle function was observed, with a complete recovery of systolic function (LVEF 55%), an improvement of the aortic valve area at the control echocardiography (Mean gradient 22 mmHg, AVA 1.1 cmq). Aortic valvuloplasty in patients affected by severe aortic stenosis is a known therapeutic weapon in patients in critical situations. However the most important limit of the procedure is connected to the low persistency of the result obtained. In the context of temporary decrease of the left systolic function and an hemodynamically relevant aortic stenosis, valvuloplasty could be an useful therapeutic tool to overcome critical situation. In this case was particularly useful because of the abrupt decrease and the fast recovery of the left ventricle function. However after 6 months, for the progression of the aortic valve disease, the patient successfully underwent transcatheter aortic valve implantation (TAVI) with an Edwards Sapien 3 26 mm valve. The following 12-months ambulatory follow-up was uneventful. 495 Thermodilution-derived resting coronary flow measurement: “a reverse dose finding study” Emanuele Gallinoro Emanuele Gallinoro Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Department of Translational Medical Sciences, University of Campania” Luigi Vanvitelli”, Naples , IT Iginio Colaiori Iginio Colaiori Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Giuseppe Di Gioia Giuseppe Di Gioia Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Department of Advanced Biomedical Sciences, Federico II University, Naples , IT Stephane Fournier Stephane Fournier Department of Translational Medical Sciences, University of Campania” Luigi Vanvitelli”, Naples , IT Department of Cardiology, Lausanne University Hospital , CH Monika Kodeboina Monika Kodeboina Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Alessandro Candreva Alessandro Candreva Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Jeroen Sonck Jeroen Sonck Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Department of Advanced Biomedical Sciences, Federico II University, Naples , IT Nico H J Pijls Nico H J Pijls Department of Cardiology, Catharina Hospital , Eindhoven, NL Carlos Collet Carlos Collet Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Bernard De Bruyne Bernard De Bruyne Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Department of Cardiology, Lausanne University Hospital , CH Cardiovascular Center Aalst, Olv Clinic, Aalst , BE Department of Translational Medical Sciences, University of Campania” Luigi Vanvitelli”, Naples , IT Department of Advanced Biomedical Sciences, Federico II University, Naples , IT Department of Cardiology, Lausanne University Hospital , CH Department of Cardiology, Catharina Hospital , Eindhoven, NL Aims Hyperemic absolute coronary blood flow (in mL/min) can be safely and reproducibly measured with intracoronary continuous thermodilution of saline at room temperature at an infusion rate of 20 mL/min. This study aims at assessing the best infusion rate to measure resting flow by thermodilution, I.e. low enough to avoid microvascular dilation but high enough to allow reliable thermodilution tracings Methods and results In 26 coronary arteries (24 patients) with angiographic non-significant stenoses, absolute flow was assessed by continuous saline thermodilution at infusion rates of 10 mL/min and 20 mL/min using a pressure/temperature sensored guide wire, a dedicated infusion catheter (RayFlowTM, Hexacath, Paris, France) and a dedicated software (CoroFlow™ System, Uppsala, Sweden). Average peak velocity (APV) was measured simultaneously using an intracoronary Doppler-wire (FloWire, Volcano/Philips). In addition, in a subgroup of 10 arteries, absolute flow and APV were also measured during saline infusion at 6 ml/min and 8 ml/min. In 26 coronary arteries there was no significance difference in the Pd/Pa and in the APV at baseline and during the infusion of saline at 10 ml/min (Pd/Pa: 0.94 ± 0.057 vs 0.94 ± 0.059, p = 0.82; APV: 22.2 ± 8.40 vs 23.2 ± 8.39 cm/s, p = 0.63). In contrast, at an infusion rate of 20 mL/min, we observed a significant decrease in Pd/Pa compared to baseline (0.85 ± 0.089 vs 0.95 ± 0.053 vs, respectively, p < 0.001) and a significant increase in APV (22.2 ± 8.4 cm/s to 57.8 ± 25.5 cm/s, respectively, p < 0.001). The coronary flow reserve (CFR) evaluated by Doppler and intracoronary continuous thermodilution correlated well (r = 0.87, 95% CI = 0.72-0.94, p < 0.001) and Bland-Altman analysis documented a mean bias of -0.003 (limit of agreement -1.05 to 1.04) thus indicating the presence of resting coronary blood flow during the infusion of 10 mL/min of saline. In 10 coronary arteries saline infusions at 6 and 8 ml/min did not produce any significant changes in the Pd/Pa and in the APV compared to baseline and both Doppler and Thermodilution derived CFR correlated well at each infusion rate (6 ml/min: r = 0.71, 95%CI 0.14-0.92, p = 0.02; 8 ml/min: r = 0.78, 95%CI = 0.31-0.95, p = 0.007). However, with an infusion rate of 6 mL/min, an unstable thermodilution tracing was observed. Accordingly, Bland Altman analysis showed a significantly larger dispersion of the CFR values when 6 ml/min was used to measure resting coronary flow (as compared with 8 m/min): mean bias at 6 ml/min: -0.53, limits of agreement: -2.25 to 1.20: mean bias at 8 ml/min: 0.004, limits of agreement: -0.72 to 0.73. Conclusion Absolute resting coronary flow can be measured by intracoronary continuous thermodilution of saline at infusion rate of 8-10 ml/min. 537 Hyperemic hemodynamic characteristics of serial coronary lesions assessed by pressure pullbacks gradient (PPG) index Emanuele Gallinoro Emanuele Gallinoro Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Department of Translational Medical Sciences, University of Campania” Luigi Vanvitelli”, Monaldi Hospital, Naples , IT Alessandro Candreva Alessandro Candreva Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Jeroen Sonck Jeroen Sonck Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Takuya Mizukami Takuya Mizukami Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Sakura Nagumo Sakura Nagumo Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Giuseppe Di Gioia Giuseppe Di Gioia Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Department of Advanced Biomedical Sciences, University of Naples” Federico Ii”, Naples , IT Giovanni Monizzi Giovanni Monizzi Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Monika Kodeboina Monika Kodeboina Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Bernard De Bruyne Bernard De Bruyne Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Department of Cardiology, Lausanne University Hospital , Lausanne, CH Carlos Collet Carlos Collet Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Cardiovascular Center Aalst—Olv-Clinic , Aalst, BE Department of Translational Medical Sciences, University of Campania” Luigi Vanvitelli”, Monaldi Hospital, Naples , IT Department of Advanced Biomedical Sciences, University of Naples” Federico Ii”, Naples , IT Department of Cardiology, Lausanne University Hospital , Lausanne, CH Aims To describe the functional characteristics of angiography-defined serial coronary lesions using fractional flow reserve (FFR)-derived motorized pullback tracings, and to describe the Pullback Pressure Gradients (PPG) index—in these lesions. Methods and results Prospective, multicenter study with independent core laboratory analysis. Patients undergoing coronary angiography due to stable angina were enrolled. Serial lesions were defined angiographically as the presence of 2 or more narrowings with visual diameter stenosis >50% separated at least by 3 times the reference vessel diameter in the same coronary vessel. Continuous IV adenosine-FFR measurements were obtained using a motorized-pullback device at a speed of 1 mm/s. Pullback curves were assessed to determine the presence of focal stepups (FFR >0.05 units over 20 mm). In addition, the PPGindex was computed for all vessels. PPGindex values close to 0 define functional diffuse disease whereas values close to 1 define focal disease. From a total of 159 vessels (117 patients), 25 vessels were adjudicated as presenting serial lesions (mean PPGindex 0.48 ± 0.17, range 0.26—0.87). Two focal pressure step-ups were observed in 40% of the cases (n = 10; mean PPGindex 0.59 ± 0.17), whereas 8% of the vessels presented a progressive pressure losses (n = 2; mean PPGindex 0.27 ± 0.01). In the remaining 52% of the cases, a single pressure step-up was recorded (n = 13; mean PPGindex 0.44 ± 0.12; ANOVA p-value = 0.01). The PPGindex independently predicted the presence of two focal pressure step ups. Conclusion Hyperemic FFR curves in tandem stenoses revealed high prevance of functional diffuse CAD. Two pressure step-ups occurred in less than half of the vessels. High PPG-Index identified vessels with two focal pressure drops. FFR tracings and the PPGindex provide a more objective CAD evaluation, which can lead to changes in the therapeutic approach. 540 Vessel fractional flow reserve and graft vascuopathy in heart transplant recipients Emanuele Gallinoro Emanuele Gallinoro Cardivascular Center Aalst, Olv Clinic, Aalst , BE Department of Translational Medical Sciences, University Of Campania” Luigi Vanvitelli”, Naples , IT Sakura Nagumo Sakura Nagumo Cardivascular Center Aalst, Olv Clinic, Aalst , BE Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama , Kanagawa Alessandro Candreva Alessandro Candreva Cardivascular Center Aalst, Olv Clinic, Aalst , BE Takuya Mizukami Takuya Mizukami Cardivascular Center Aalst, Olv Clinic, Aalst , BE Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama , Kanagawa Giovanni Monizzi Giovanni Monizzi Cardivascular Center Aalst, Olv Clinic, Aalst , BE Monika Kodeboina Monika Kodeboina Cardivascular Center Aalst, Olv Clinic, Aalst , BE Bernard De Bruyne Bernard De Bruyne Cardivascular Center Aalst, Olv Clinic, Aalst , BE Department of Cardiology, Lausanne University Hospital , Lausanne, CH Jeroen Sonck Jeroen Sonck Cardivascular Center Aalst, Olv Clinic, Aalst , BE Department of Advanced Biomedical Sciences, Federico II University, Naples , IT Carlos Collet Carlos Collet Cardivascular Center Aalst, Olv Clinic, Aalst , BE Marc Vanderheyden Marc Vanderheyden Cardivascular Center Aalst, Olv Clinic, Aalst , BE Cardivascular Center Aalst, Olv Clinic, Aalst , BE Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama , Kanagawa Department of Translational Medical Sciences, University Of Campania” Luigi Vanvitelli”, Naples , IT Department of Advanced Biomedical Sciences, Federico II University, Naples , IT Department of Cardiology, Lausanne University Hospital , Lausanne, CH Aims Cardiac allograft vasculopathy (CAV) remains the Achilles' heel of long-term survival after heart transplantation (HTx). The severity and extent of CAV is graded with conventional coronary angiography (COR) which has several limitations. Recently, vessel fractional flow reserve (vFFR) derived from COR has emerged as a diagnostic computational tool to quantify the functional severity of coronary artery disease. The present study assessed the usefulness of vFFR to detect CAV in HTx recipients. Methods and results In HTx patients referred for annual check-up, undergoing surveillance COR, the extent of CAV was graded according to the criteria proposed by the international society of heart and lung transplantation (ISHLT). In addition, three-dimensional coronary geometries were constructed from COR to calculate pressure losses using vFFR. In 65 HTx patients with a mean age of 53.7 ± 10.1 years, 8.5 years (IQR 1.90, 15.2) years after HTx, a total number of 173 vessels (59 LAD, 61 LCX, and 53 RCA) were analyzed. The mean vFFR was 0.84 ± 0.15 and median was 0.88 (IQR 0.79, 0.94). A vFFR ≤ 0.80 was present in 24 patients (48 vessels). HTx patients with a history of ischaemic cardiomyopathy (ICMP) had numerically lower vFFR as compared to those with non-ICMP (0.70 ± 0.22 vs. 0.79 ± 0.13, p = 0.06). The use of vFFR reclassified 31.9% of patients compared to the anatomical ISHLT criteria. Despite a CAV score of 0, a pathological vFFR ≤ 0.80 was detected in 8 patients (34.8%). Conclusion The impairment in epicardial conductance assessed by vFFR in a subgroup of patients without CAV according to standard ISHLT criteria suggests the presence of a diffuse vasculopathy undetectable by conventional angiography. Therefore, we speculate that vFFR may be useful in risk stratification after HTx. 616 Predictors of outcomes in patients with mitral regurgitation undergoing percutaneous valve repair Alberto Polimeni Alberto Polimeni Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Michele Albanese Michele Albanese Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Nadia Salerno Nadia Salerno Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Iolanda Aquila Iolanda Aquila Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Jolanda Sabatino Jolanda Sabatino Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Sabato Sorrentino Sabato Sorrentino Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Isabella Leo Isabella Leo Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Michele Cacia Michele Cacia Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Vincenzo Signorile Vincenzo Signorile Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Annalisa Mongiardo Annalisa Mongiardo Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Carmen Spaccarotella Carmen Spaccarotella Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Salvatore De Rosa Salvatore De Rosa Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Ciro Indolfi Ciro Indolfi Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Division of Cardiology, Department of Medical and Surgical Sciences, “Magna Graecia “University, Catanzaro Research Center for Cardiovascular Diseases, “Magna Graecia “University , Catanzaro Aims We sought to investigate predictors of clinical outcomes in patients with mitral regurgitation undergoing percutaneous valve repair. Percutaneous mitral valve repair has been increasingly performed worldwide after approval. Methods and results The MITRA-UMG registry retrospectively collected data from consecutive patients with symptomatic moderate-to-severe or severe mitral regurgitation who underwent MitraClip implantation. The primary endpoint of interest was the composite of cardiovascular death or rehospitalization for heart failure. Between March 2012 and July 2018, a total of 150 consecutive patients admitted to our institution were included. Acute procedural success was obtained in 95.4% of patients, with no intraprocedural death. The composite primary endpoint of cardiovascular death or rehospitalization for heart failure was met in 50 patients (38%) with cumulative incidences of 7%, 25%, at 30 days and 1 year, respectively (Table I). In the Cox multivariate model, NYHA functional class IV, left ventricular end-diastolic volume index (LVEDVi), Euroscore II, independently increased the risk of the primary endpoint at long-term follow-up (Table II). At Kaplan-Meier analysis, a LVEDVi >92 ml/m2 was associated with an increased incidence of the primary endpoint (Figure 1). Conclusion In this study, patients presenting with dilated ventricles (LVEDVi >92 ml/m2), high operative risk (EUROSCORE II > 7%) or advanced heart failure symptoms (NYHA IV) at baseline carried the worst prognosis after percutaneous mitral valve repair. 273 “Primary” TAVI in a patient with cardiogenic shock: the future is now Pasquale De Vico Pasquale De Vico Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Dalgisio Lecis Dalgisio Lecis Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Marco Di Luozzo Marco Di Luozzo Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Massimo Marchei Massimo Marchei Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Saverio Muscoli Saverio Muscoli Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Valeria Cammalleri Valeria Cammalleri Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Francesca Romana Prandi Francesca Romana Prandi Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Marcello Chiocchi Marcello Chiocchi Department of Diagnostic Imaging, University of Rome” Tor Vergata” , Rome, Italy Francesco Romeo Francesco Romeo Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Department of Cardiology, University Of Rome” Tor Vergata”, Rome , Italy Department of Diagnostic Imaging, University of Rome” Tor Vergata” , Rome, Italy Aims The introduction of TAVI (transcatheter aortic valve implantation) has revolutioned the way to treat patients with severe aortic stenosis (AS) and high-intermediate surgical risk. TAVI is often performed in the elective setting. We describe the case of a 85 years old woman with severe AS developing cardiogenic shock and treated with “primary” TAVI. During the procedure the patient has been assisted with non-invasive ventilation (NIV) and analgo-sedation. We want to highlight the mini-invasiveness and the feasibility of a procedure like TAVI, which is already spreading its indication to low and intermediate risk population, and it could be even performed as a life-saving intervention in the emergency setting of severe AS with cardiogenic shock. Methods and results A 85 years old woman with diabetes mellitus type II and hypertension was admitted to our CICU for the occurrance of hypertensive pulmonary oedema. On her arrival the patient was sent to the cathlab where coronary artery disease was ruled out. The echocardiography revealed severe AS. Because of the high surgical risk (Logistic euroSCORE 37.77; STS mortality and morbidity 20.5) the Heart Team contraindicated surgical aortica valve replacement (SAVR) and addressed the patient to TAVI. While the patient was in the Radiology Department to take an angio-CT for the evaluation of the vascular access and the assessment of valvular planimetry, she developed pulmonary oedema and cardiogenic shock. Skin rush and other allergic manifestations were ruled out. The anesthesiologist promptly started NIV with an inotropic support provided by the administration of i.v. Norepinephrine. The patient’s unstable condition led us to send her straight to the cathlab: every minute could be important to save her life. Percutaneous balloon aortic valvuloplasty (PBAV) was performed with a Nucleus 22 mm balloon. Subsequently, a CoreValve R23 mm (Medtronic) was implanted. The positioning of the valve (Device Time) took 20 minutes and the residual gradient was not significant without periprosthetic leaks. During the whole procedure the patient, after the induction of analgo-sedation, has been assisted by NIV using a facial mask (FlexiFit 431). The weaning from NIV occurred after few hours the patient came back to the CICU because of the evidence of a net improvement of the respiratory parameters. Before discharging, we optimized the diuretic therapy and set a dual antiplatelet therapy with cardioaspirin and clopidogrel (one-month duration). At 30 days’ follow-up the patient was well and in good general condition. Several case series suggest PBAV in patients with heart failure due to severe AS as a bridge therapy to SAVR or TAVI. As reported from Masha et al. in patients presenting with severe AS and acute cardiogenic shock, TAVI appears to be a viable treatment option although such patients population remains at elevated risk of death. TAVI might be the best strategy in selected patients with cardiogenic shock and aortic stenosis while PBAV should be performed as a bridge to a definitive therapy in the sickest patients yet to avoid futility. Whether primary PCI is the milestone for the treatment of the acute coronary sindrome, “primary” TAVI could become a procedure to be performed in patients with severe AS developing cardiogenic shock, thus becoming a life-saving procedure. Conclusion We present a case where a successful emergency TAVI was performed in a patient with cardiogenic shock. This is the first reported case in which an emergency TAVI has been performed using NIV and analgo-sedation further reducing the invasiveness of such procedure into an emergency setting. 274 Predictors and clinical impact of prosthesis-patient mismatch after self-expandable TAVI in small annuli—from TAVI small registry Pier Pasquale Leone Pier Pasquale Leone Humanitas Research Hospital Damiano Regazzoli Damiano Regazzoli Humanitas Research Hospital Mauro Chiarito Mauro Chiarito Humanitas Research Hospital Matteo Pagnesi Matteo Pagnesi San Raffaele Scientific Institute Francesco Cannata Francesco Cannata Humanitas Research Hospital Nicholas M Van Mieghem Nicholas M Van Mieghem Erasmus Medical Center Corrado Tamburino Corrado Tamburino Policlinico Vittorio Emanuele Rui Campante Teles Rui Campante Teles Centro Hospitalar de Lisboa Ocidental Salvatore Curello Salvatore Curello Civil Hospital of Brescia Francesco Maisano Francesco Maisano Zurich University Hospital Won-Keun Kim Won-Keun Kim Kerckoff Heart and Lung Center Francesco Bedogni Francesco Bedogni Policlinico San Donato Giulio Stefanini Giulio Stefanini Humanitas Research Hospital Paolo Pagnotta Paolo Pagnotta Humanitas Research Hospital Bernhard Reimers Bernhard Reimers Humanitas Research Hospital Antonio Colombo Antonio Colombo Maria Cecilia Hospital Azeem Latib Azeem Latib Montefiore Medical Center Humanitas Research Hospital San Raffaele Scientific Institute Montefiore Medical Center Zurich University Hospital Erasmus Medical Center Policlinico Vittorio Emanuele Kerckoff Heart and Lung Center Policlinico San Donato Civil Hospital of Brescia Centro Hospitalar de Lisboa Ocidental Maria Cecilia Hospital Aims Define predictors of prosthesis-patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI) with self-expandable valve (SEV) in patients with small annuli, and compare outcomes in patients with and without PPM. TAVI seemed to reduce the risk of PPM incidence as compared with surgical aortic valve replacement, especially in patients with small aortic annuli. Nevertheless, predictors and outcomes of PPM in this population have not been clarified yet. Methods and results A total of four-hundred forty-five patients with (n = 129) and without PPM (n = 316) were included from TAVI-SMALL study, a retrospective registry of patients with severe aortic stenosis and small annuli treated with transcatheter SEV. Predictors of PPM and all-cause death were investigated. Intra-annular valves were found to confer an augmented risk of PPM (odds ratio [OR] 2.36, 95% confidence interval (CI) 1.16-4.81), while postdilation (OR 0.46, 95% CI 0.25-0.84), and valve oversizing (OR 0.53, 95% CI 0.28-1.00), seemed to protect against PPM occurrence. Patients with severe PPM suffered a higher all-cause mortality when compared to those without PPM (14.6% vs 6.6%, p = 0.069), and severe PPM resulted to be independent predictor of all-cause death (OR 12.5, 95% CI 2.48-62.6). Conclusion Patients with small aortic annuli undergoing TAVI are at higher risk of PPM, especially if implanted with intra-annular valves; conversely, postdilation and valve oversizing are protective factor against PPM occurrence. Severe PPM is an independent predictor of all-cause death. 456 A case report of coronary artery spasm and Tako-Tsubo syndrome: exploring the hidden side of the moon Marco Lombardi Marco Lombardi Universita’ Cattolica del Sacro Cuore Rocco Vergallo Rocco Vergallo Universita’ Cattolica del Sacro Cuore Alfredo Ricchiuto Alfredo Ricchiuto Universita’ Cattolica del Sacro Cuore Alessandro Maino Alessandro Maino Universita’ Cattolica del Sacro Cuore Giovanna Liuzzo Giovanna Liuzzo Universita’ Cattolica del Sacro Cuore Filippo Crea Filippo Crea Universita’ Cattolica del Sacro Cuore Universita’ Cattolica del Sacro Cuore Aims Tako-Tsubo syndrome (TTS) is a disease characterized by an acute and reversible myocardial injury typically precipitated by stressful and/or emotional triggers. Despite extensive research, its pathogenesis remains incompletely understood. Spasm of epicardial coronary arteries has been proposed as a potential pathogenic factor in TTS. Methods and results Herein we report the case of a 68-years old female admitted to the emergency department after developing chest pain in concomitance with an intense emotional stress. A diagnosis of non-ST-segment elevation myocardial infarction (NSTEMI) was made. Coronary angiography disclosed normal coronary arteries, and left ventriculography showed an inferior focal akinesia with basal and apical hyperkinesis, so that a diagnosis of focal TTS was made. Two months later, the patient was re-admitted with NSTEMI, and repeat coronary angiography showed an irregular subocclusive stenosis of a well-developed first obtuse marginal branch. After intracoronary nitroglycerine infusion, a complete recover of the vessel patency was noted, and a diagnosis of epicardial spasm was made. Intracoronary optical coherence tomography was performed to assess a residual “hazy” region, which confirmed a normal vessel morphology and a residual focal area of spasm without signs of instability. Conclusion Whether TTS and coronary artery spasm are two expressions of the same disease, or rather two separate entities with overlapping mechanisms remains unknown, and further research is warranted to solve this issue. Meanwhile, the opportunity of performing provocative tests for coronary spasm in patients with suspected TTS might be considered to gain more insights into this hypothesis. 457 Thrombotic volume assessed by dual quantitative coronary angiography predicts microvascular obstruction after primary percutaneous coronary intervention Marco Lombardi Marco Lombardi Universita’ Cattolica del Sacro Cuore Rocco Vergallo Rocco Vergallo Universita’ Cattolica del Sacro Cuore Alfredo Ricchiuto Alfredo Ricchiuto Universita’ Cattolica del Sacro Cuore Alessandro Maino Alessandro Maino Universita’ Cattolica del Sacro Cuore Domenico D´Amario Domenico D´Amario Universita’ Cattolica del Sacro Cuore Antonino Buffon Antonino Buffon Universita’ Cattolica del Sacro Cuore Cristina Aurigemma Cristina Aurigemma Universita’ Cattolica del Sacro Cuore Enrico Romagnoli Enrico Romagnoli Universita’ Cattolica del Sacro Cuore Rocco Montone Rocco Montone Universita’ Cattolica del Sacro Cuore Giampaolo Niccoli Giampaolo Niccoli Universita’ Cattolica del Sacro Cuore Antonio Maria Leone Antonio Maria Leone Universita’ Cattolica del Sacro Cuore Francesco Burzotta Francesco Burzotta Universita’ Cattolica del Sacro Cuore Italo Porto Italo Porto IRCCS Ospedale San Martino , Genova Carlo Trani Carlo Trani Universita’ Cattolica del Sacro Cuore Filippo Crea Filippo Crea Universita’ Cattolica del Sacro Cuore Universita’ Cattolica del Sacro Cuore IRCCS Ospedale San Martino , Genova Aims To investigate the relation between the thrombotic volume detected by dual quantitative coronary angiography (QCA) and the occurrence of microvascular obstruction (MVO) assessed by cardiac magnetic resonance (CMR) in patients with ST-segment elevation myocardial infarction (STEMI). Methods and results Forty-eight patients with STEMI undergoing primary percutaneous coronary intervention and receiving CMR within 7 days from admission were included. Pre-stenting thrombus volume at the site of the culprit lesion was measured by applying automated edge detection and video-assisted densitometry techniques (i.e., dual-QCA), and patients were categorized into tertiles of thrombus volume. The presence of delayed-enhancement MVO, as well as its extent (MVO mass), were assessed by CMR. Pre-stenting dual-QCA thrombus volume was significantly greater in patients with MVO than in those without (5.85 mm3 [2.05–16.71] vs. 1.88 mm3 [1.03–6.92], p = 0.009). Patients in the highest tertile showed greater MVO mass compared to those in the mid and lowest tertiles (113.3 gr [0.0–203.8] vs. 58.5 gr [0.00–144.4] vs. 0.0 gr [0.0–60.225], respectively; p = 0.031). The best cut-off value of dual-QCA thrombus volume for predicting the presence of MVO was 2.07 mm3 (AUC: 0.720). The addition of dual-QCA thrombus volume to the traditional angiographic indices of no-reflow enhanced the prediction of MVO by CMR (R = 0.752). Conclusion Pre-stenting dual-QCA thrombus volume predicts the presence of MVO assessed by CMR in patients with STEMI. This methodology may aid the identification of patients at higher risk of MVO and guide adoption of preventive strategies. 239 Acute heart failure events increase the level of frailty in elderly patients affected by severe aortic stenosis and CHFPEF. A pre TAVR evaluation by multidisciplinary heart team Annamaria Mazzone Annamaria Mazzone Ospedale del Cuore Ftgm, MASSA/PISA Silverio Sbrana Silverio Sbrana Istituto Fisiologia Clinica CNR, MASSA/PISA Giuseppe Trianni Giuseppe Trianni Ospedale del Cuore Ftgm, MASSA/PISA Paola Quadrelli Paola Quadrelli Ospedale del Cuore Ftgm, MASSA/PISA Marco Marotta Marco Marotta Ospedale del Cuore Ftgm, MASSA/PISA Tommaso Gasbarri Tommaso Gasbarri Ospedale del Cuore Ftgm, MASSA/PISA Marcello Ravani Marcello Ravani Ospedale del Cuore Ftgm, MASSA/PISA Alberto Clemente Alberto Clemente Ospedale del Cuore Ftgm, MASSA/PISA Simona Storti Simona Storti Ospedale del Cuore Ftgm, MASSA/PISA Cristina Vassalle Cristina Vassalle Ospedale del Cuore Ftgm, MASSA/PISA Paolo Del Sarto Paolo Del Sarto Ospedale del Cuore Ftgm, MASSA/PISA Marco Solinas Marco Solinas Ospedale del Cuore Ftgm, MASSA/PISA Sergio Berti Sergio Berti Ospedale del Cuore Ftgm, MASSA/PISA Ospedale del Cuore Ftgm, MASSA/PISA Istituto Fisiologia Clinica CNR, MASSA/PISA Aims Frailty is prevalent in elderly patients (pts) with severe symptomatic aortic valve stenosis (AS) and heart failure; it associates with poor outcomes and mortality after trans-catheter aortic valve replacement (TAVR). To measure, by a comprehensive pre-TAVR assessment of elderly high risk pts with AS, the frailty level and its relation with Chronic Heart Failure (CHF) and Acute Heart Failure (AHF) to identify in advance a tailored treatment with TAVR, balloon aortic dilation (AVD), or medical therapy (MT). Methods and results In a pre-TAVR assessment of 53 pts (70% F; mean age 82.7 ± 5.7) affected by severe AS and CHFpEF (EF = 57%), we considered two groups for occurrence of AHF (average time 55 days). We evaluated Frailty (Fried score), Comorbidity (Charlson Index), disability (ADL, IADL), depression (GDS), nutritional status (MNA), cognitive impairment (MMSE) in addition to clinical features, STS score, imaging and laboratory data. AHF pts (n = 20) were mainly females (85%), with higher STS score (P = 0.013), NYHA III-IV (P = 0.0002), EF = 50% (P < 0.0001), higher PAPs (P = 0.008) and tricuspid valve regurgitation > 2 (P = 0.008). They were at risk of malnutrition (P = 0.006), depression (P = 0.03), with higher comorbidity (P = 0.02) and disability (P = 0.04). 75% of AHF pts had sarcopenia by handgrip test (P = 0.004) and CPK value (P = 0.002), higher N/L ratio (P = 0.01), higher creatinine (P = 0.02) and BNP (P = 0.02). 10% of AHF pts were pre-frail, 30% frail, 90% severely frail (Figure 1). After Heart Team evaluation, the 75% of pre-frail and 47% of early-frail pts have been referred to TAVR (P < 0.0001); they are mainly affected by CHF (75%). Instead, the 53% and 37% of late-frail pts were referred to medical therapy and AVD, respectively (P < 0.0001); they were mainly affected by AHF (60%). Conclusion Patients with AS and CHF+AHF become late frail so loosing indication for TAVR. Our data suggest the needed of a precocious evaluation of elderly pts with severe AS for elective TAVR treatment before the occurence of AHF, since this event associates with a worsening degree of individual frailty. 591 Intracoronary bolus of glycoprotein IIB/IIIA inhibitor as bridging or adjunctive strategy to oral P2Y12 inhibitor load in the modern setting of STEMI Mattia Galli Mattia Galli Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Stefano Migliaro Stefano Migliaro Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Daniele Rodolico Daniele Rodolico Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Felicita Andreotti Felicita Andreotti Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Rocco Vergallo Rocco Vergallo Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Rocco Antonio Montone Rocco Antonio Montone Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Carlo Trani Carlo Trani Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Filippo Crea Filippo Crea Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Domenico D´Amario Domenico D´Amario Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Dipartimento di Scienze Cardiovascolari e Toraciche Fondazione Policlinico Universitario a Gemelli IRCCS Roma Aims In the acute management of ST-elevation myocardial infarction (STEMI), glycoprotein IIb/IIIa inhibitors (GPIs) bolus not followed by intravenous infusion as adjunctive or bridging therapy to oral P2Y12 inhibitors is potentially advantageous given their fast onset and offset of action, but clinical evidence in their support is limited. Methods and results Out of 423 consecutive STEMI patients, 297 met the inclusion and exclusion criteria and were enrolled. Of them, 107/297 (36%) received an intracoronary GPI bolus-only during primary percutaneous coronary intervention (PPCI) not followed by intravenous infusion and 190/297 (64%) received standard antithrombotic therapy. Of the 107 GPI-treated, 22/107 (21%) had P2Y12 inhibitor pre-treatment (adjunctive strategy) and 85/107 (79%) did not (bridging strategy). During hospital staying, there was no difference in the primary safety endpoint of TIMI major+minor bleeding (p = 0.283), TIMI major (p = 0.267) or TIMI minor (p = 0.685) bleeding between groups. No stroke event occurred in the GPI group. Despite patients receiving GPI having a significantly higher intraprocedural ischaemic burden, no significant differences were found in the efficacy outcomes between groups. Consistent findings were observed for patients receiving GPIs bolus before (bridging strategy) or after (adjunctive strategy) P2Y12 inhibitors, compared to those receiving standard therapy. Multivariate logistic regression analyses did not find any independent predictors significantly associated to the primary and secondary composite endpoints. Conclusion In a contemporary real world population of STEMI patients undergoing PPCI, the use of intracoronary GPIs bolus-only in selected patients at high ischaemic risk is safe and could represent a useful antithrombotic strategy both in those pre-treated and in those naïve to P2Y12 inhibitors. Larger trials are warranted to test its efficacy. 460 Macrophage infiltrates in coronary plaque erosion in patients with acute coronary syndromes Vincenzo Vetrugno Vincenzo Vetrugno Universita’ Cattolica del Sacro Cuore , Roma Michele Russo Michele Russo Universita’ Cattolica del Sacro Cuore , Roma Massimiliano Camilli Massimiliano Camilli Universita’ Cattolica del Sacro Cuore , Roma Marco Giuseppe Del Buono Marco Giuseppe Del Buono Carlo Trani Carlo Trani Universita’ Cattolica del Sacro Cuore , Roma Giampaolo Niccoli Giampaolo Niccoli Universita’ Cattolica del Sacro Cuore , Roma Maria Chiara Meucci Maria Chiara Meucci Universita’ Cattolica del Sacro Cuore , Roma Riccardo Rinaladi Riccardo Rinaladi Universita’ Cattolica del Sacro Cuore , Roma Rocco Antonio Montone Rocco Antonio Montone Universita’ Cattolica del Sacro Cuore , Roma Filippo Crea Filippo Crea Universita’ Cattolica del Sacro Cuore , Roma Universita’ Cattolica del Sacro Cuore , Roma Aims Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS), and inflammation plays a key role in plaque instability. We assessed the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (M&Oslash;I) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value. Methods and results ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of M&Oslash;I at culprit site was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target-vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03–2.58) years]. We included 153 patients [median age (IQR) 64 (53–75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with M&Oslash;I and 102 (66.7%) PE without M&Oslash;I. Patients having PE with M&Oslash;I compared with PE patients without M&Oslash;I had more vulnerable plaque features both at culprit site and at non-culprit segments. MACEs were significantly more frequent in PE with M&Oslash;I patients compared with PE without M&Oslash;I [11 (21.6%) vs. 6 (5.9%), p = 0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression, PE with M&Oslash;I was an independent predictor of MACEs [HR = 2.95, 95% CI (1.09–8.02), p = 0.034]. Conclusion Our study demonstrates that among ACS patients with PE the presence of M&Oslash;I at culprit lesion is associated with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up. 570 Intravascular ultrasound and its applications in the Cath lab: a case report Giuseppe Panuccio Giuseppe Panuccio Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Salvatore De Rosa Salvatore De Rosa Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Sabrina La Bella Sabrina La Bella Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Alberto Polimeni Alberto Polimeni Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Sabato Sorrentino Sabato Sorrentino Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Carmen Spaccarotella Carmen Spaccarotella Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Annalisa Mongiardo Annalisa Mongiardo Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Daniele Torella Daniele Torella Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Concetta Procopio Concetta Procopio Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Adriano Signorelli Adriano Signorelli Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Ciro Indolfi Ciro Indolfi Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Magna Graecia University, Division of Cardiology, Department of Medical and Surgical Sciences , Catanzaro, Italy Aims Use of Intravascular Ultrasound (IVUS) can be very helpful in the catheterization laboratory, especially when coronary angiography alone leaves unresolved doubts. Among its possible applications, it can be fundamental to assist in three specific context: i) precise assessment of angiographical borderline or intermediate stenoses; ii) assessment of previously treated lesions; iii) PCI guidance and optimization. The present report exemplifies these three case-scenarios, underlying the synergic interaction between angiography and IVUS in case of synchronization and overlay of these two imaging modalities. Methods and results A 56-year-old male with hypertension and history of coronary artery disease (CAD) and previous PCI for NSTEMI one year back. At the 1-year follow-up, the patient reported progressively worsening effort angina over the previous weeks. A treadmill stress test revealed ischaemic EKG-modifications at peak exercise. The patient was thus referred to our hospital for coronary angiography which showed disease progression with an intermediate stenosis of the left anterior descending artery (LAD) and an irregular intimal profile of the intra-stent segment. The patient had normal left ventricular function without regional wall motion abnormalities. The lesion was then assessed by means of IVUS with the SyncVision modality (Philips Volcano, Ca, USA), that synchronizes IVUS frames with the coronary angiogram, revealing moderate neointimal proliferation with underexpansion of the previously implanted stent and a severe stenosis close to the proximal edge of the stent with slight calcification (Figure 1). Thus, optimization of the previously implaned stent was obtained through high-pressure non-compliant balloon dilation (3,5 x 14 mm, expanded at 8 ATM for 120”), while an additional stent (3,5 x 15 mm, expanded at 16 ATM for 20”) was implanted proximally to cover the severe stenosis close to the proximal edge of the stent. Thus we performed PCI of restenosis and stenting of proximal LAD, with a good angiographic result. Final assessment by means of IVUS showed an improved result within the previously implanted stent with an increase in lumen area and a good expansion of the newly implanted stent with proper apposition of stent struts (Figure 2). The patients was discharged asymptomatic the next day with dual antiplatelet treatment (ASA 100 mg o.d. and Ticagrelor 90 mg b.i.d.). Conclusion IVUS is a useful tool in evaluating in-stent restenosis and understanding the underlying mechanisms. In particular, the use of IVUS and its synchronization with the angiography was very useful to: i) assess in-stenosis neointimal proliferation and the under-expansion of the previously implanted stent; ii) characterize the intermediate stenosis and evaluate the distal landing zone in relation to the proximal edge of the previously implanted stent; iii) guide PCI, thus helping to select stent size and assess and to optimize PCI result. The usefulness of IVUS in guiding PCI is supported by a growing wealth of data. In fact, recent meta-analyses including about 30.000 patients showed that IVUS guidance is able to prevent major adverse cardiovascular events (MACE) including early and late ST and myocardial infarction and mortality at 1 year. 558 MINOCA: Ergonovine test for the diagnosis Fabrizio Nicolò Fabrizio Nicolò Stefano Perrone Stefano Perrone Policlinico tor Vergata Ospedale Sant’Eugenio Sofia Schino Sofia Schino Policlinico tor Vergata Ospedale Sant’Eugenio Debora Russo Debora Russo Policlinico tor Vergata Ospedale Sant’Eugenio Elisa Beggio Elisa Beggio Policlinico tor Vergata Ospedale Sant’Eugenio Antonio Giuseppe Posteraro Antonio Giuseppe Posteraro Ospedale Sant’Eugenio Benedetta Giannico Benedetta Giannico Ospedale Sant’Eugenio Roberto Scioli Roberto Scioli Ospedale Sant’Eugenio Maria Iamele Maria Iamele Ospedale Sant’Eugenio Francesco Romeo Francesco Romeo Policlinico tor Vergata Achille Gaspardone Achille Gaspardone Ospedale Sant’Eugenio Policlinico tor Vergata Ospedale Sant’Eugenio Aims Myocardial infarction with non-obstructive coronary arteries (MINOCA) is diagnosed when a patient meets the three MINOCA criteria: AMI criteria according to the Fourth Universal definition; obstructive coronary arteries as per angiographic guidelines, with no lesions > 50% in a major epicardial vessels; no other clinically overt specific cause that can serve an alternative cause. The diagnostic algorithm for MINOCA is based on several exams that need to be performed in order to detect the real cause of MINOCA, that could be detected in more than 75% of patients with chest pain, high-sensitive troponin I (hs-TnI) above 99% percentile and no obstructive lesions >50% of coronary vessels. Coronary artery vasospasm is a common and underestimated cause of MINOCA that required an intracoronary functional test for a correct diagnosis and proper management. Case report A 64-year-old man with a medical history of arterial hypertension presented to the emergency room because of a severe chest pain episode, radiating to the back and left arm, started 30 minutes previously. An electrocardiogram was performed and ST-segment elevation was recorded in I, aVL, V2-V6 leads and ST-segment depression was recorded in II, III, aVF leads. The time-0 hs-TnI was elevated at 941.840 pg/mL (normal value < 34.2). Because of the suspect of a ST-segment elevation myocardial infarction (STEMI), the patient was immediately transferred to the cardiac catheterization laboratory: the coronary angiography (CAG) showed a mild atherosclerosis plaque of the left coronary angiography (LCA). In consideration of the clinical and laboratory presentation, an ergonovine test was performed, resulting positive for diffuse epicardial coronary spasm with a completely spasm of first and second diagonal arteries and distal portion of circumflex artery. The patient was subsequently transferred to the Intensive Care Unit (ICU) and an echocardiogram was performed showing an ejection fraction of 60% with a mild hypokinesis of the apical region. MINOCA on coronary arteries spasm was the final diagnosis and the patient was discarged home on a daily aspirin, statin, angiotensin-converting enzyme inhibitor (ACE-i), nitrates and calcium channel blocker (CCB). Methods and results With this case report, we described a possible diagnostic and therapeutic management of a patient with AMI criteria and no relevant coronary arteries obstruction. In evaluating MINOCA patient, the first step is to find the cause of myocardial injury during the coronary angiography: coronary artery thrombosis or spasm or plaque rupture should be considered at this level and intracoronary functional test with ergonovine or intravascular imaging (IVUS or OCT) should be performed. Once these conditions have been excluded, cardiac magnetic resonance (CRM) could help detecting ischaemic or non-ischaemic patterns related to myocarditis or Takotsubo. In the presented case, provocative test with ergonovine was fundamental for the diagnosis and the correct therapeutic management. When coronary artery spasms are diagnosed, CCB and nitrates are the first therapeutic choice, also reducing the risk of vasospastic angina episodes. Conclusion In conclusion, coronary artery spasm is a condition that can be underestimated and for this reason provocative test is crucial when a patient with suspect of STEMI has no lesions during the CAG. 559 Double anterograde and retrograde approach for large pulmonary arteriovenous malformation embolization Raffaele Rinaldi Raffaele Rinaldi Università Campus Bio Medico di Roma Annunziata Nusca Annunziata Nusca Università Campus Bio Medico di Roma Caterina Bono Caterina Bono Università Campus Bio Medico di Roma Elisabetta Ricottini Elisabetta Ricottini Università Campus Bio Medico di Roma Rosetta Melfi Rosetta Melfi Università Campus Bio Medico di Roma Fabio Mangiacapra Fabio Mangiacapra Università Campus Bio Medico di Roma Paolo Gallo Paolo Gallo Università Campus Bio Medico di Roma Francesco Grigioni Francesco Grigioni Università Campus Bio Medico di Roma Gian Paolo Ussia Gian Paolo Ussia Università Campus Bio Medico di Roma Università Campus Bio Medico di Roma Pulmonary arteriovenous malformations (PAVMs) are an underappreciated cause of respiratory failure and life-threatening neurological events. Recanalization represents a possible long-term complication of percutaneous treatment, associated with recurrence of embolic events. We present a clinical case of a successfully treated PAVM using a double access technique, transfermoral transseptal (retrograde) and transfemoral transpulmonary artery (anterograde) for contemporary percutaneous embolization of both arterial and venous branches to minimize subsequent recanalization, in a patient with systemic desaturation and thrombophilia, thus at high risk for paradoxical ischaemic stroke. 509 A challenging anomalous origin of the left coronary artery Maria Sabatini Maria Sabatini Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Gino Duronio Gino Duronio Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Stefania Uguccioni Stefania Uguccioni Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Giuseppe Ciliberti Giuseppe Ciliberti Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Giulia Stronati Giulia Stronati Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Alessandro Rosario Parisi Alessandro Rosario Parisi Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Francesca Mirabella Francesca Mirabella Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Alessia Urbinati Alessia Urbinati Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Lucia Uguccioni Lucia Uguccioni Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Michela Casella Michela Casella Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Lucia Marinucci Lucia Marinucci Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Federico Guerra Federico Guerra Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Antonio Dello Russo Antonio Dello Russo Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Aims anomalous aortic origin of a coronary artery (AAOCA) is a congenital condition in which a major coronary artery arises from the wrong sinus of Valsalva. It has an estimated incidence of 0,1-0,3% in the general population. Although the first-choice approach to AAOCA is currently surgery, some successful cases of stenting the right coronary artery (RCA) with an anomalous origin have been described in literature. Methods and results a 42-year old female presented to the emergency department complaining of exertional chest pain as well as some episodes of thoracic discomfort at rest. She underwent an exercise stress test which was positive for symptoms and ECG modifications. She then underwent a coronary angiography that showed an anomalous origin of the left coronary artery (LCA) from the non-coronary sinus (NCS) (figure 1). IVUS showed a dynamic compression of the proximal part of the LCA during heart systole (figure 2; 3). Such a finding suggested an intramural course. The LCA was studied with a CT coronary angiography (CTCA) (figure 4) and surgical management was established. After a few days, she had a sudden cardiac arrest for a ventricular fibrillation treated with DC shock and ventilation management. The coronary angiography was repeated, and the patient was treated with a new generation DES placed from the origin of the LCA along the axis of left descending artery. The circumflex artery was treated with POBA. A new CTCA confirmed the success of the percutaneous intervention (figure 5). Six days after, the patient underwent a second exercise test. She reached the maximum loading phase and the test was negative both for symptoms and ECG modifications. Conclusion The adverse event rate linked to the surgical correction of an AAOCA is reported to be 15%. Moreover, in the postoperative period, some patients continue to have evidence of ischemia. This case shows an effective and safe PCI of an extremely rare anomalous origin of the LCA in an acute setting. 560 ACS in the youth: could the Varicella-Zoster virus be one of the main players? Maria Sabatini Maria Sabatini Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Gino Duronio Gino Duronio Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Giuseppe Ciliberti Giuseppe Ciliberti Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Alessandro Rosario Parisi Alessandro Rosario Parisi Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Stefania Uguccioni Stefania Uguccioni Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Giulia Stronati Giulia Stronati Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Francesca Mirabella Francesca Mirabella Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Alessia Urbinati Alessia Urbinati Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Lucia Uguccioni Lucia Uguccioni Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Michela Casella Michela Casella Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Lucia Marinucci Lucia Marinucci Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Federico Guerra Federico Guerra Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Antonio Dello Russo Antonio Dello Russo Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Cardiology and Arrhythmology Clinic, University Hospital Marche Polytechnic University , Ancona Hemodynamics and Interventional Cardiology, North Marche United Hospitals , Pesaro Aims An association between the Varicella Zoster virus (VZV) and an increased risk of cardiovascular events can be found described in current literature. A possible mechanism seems to be related to the inflammatory response to the infection, based on pro thrombotic antibodies and cytokines. The virus itself can therefore lead to a vasculopathy. Methods and results A 22-year-old male with occasional smoking habit and without other cardiovascular risk factors presented to the emergency department complaining of acute chest pain while resting. The electrocardiogram showed an ST elevation in the inferior leads and in the precordial leads (V3-V4). He was brought in the emergency department and then into the Cath Lab. When he arrived, he presented a skin rash compatible with chickenpox. The patient underwent a coronary angiography which detected an eccentric plaque with borderline significance in the middle tract of the left anterior descending artery (LAD) with a TIMI 3 flow (figure 1). The ventriculography showed a pronounced apical hypokinesia (figure 2). The suspicion of a myopericarditis came out and needed to be urgently confirmed through a cardiac magnetic resonance (CMR). The CMR showed an apical transmural damage in line with an acute myocardial infarction (figure 3; 4). A PCI was performed with the support of the intravascular optical coherence tomography (OCT) which confirmed a thrombotic formation (figure 5). The LAD was treated with a bioabsorbable stent and the first diagonal with POBA for a shift of the thrombotic material in that branch (figure 6; 7). Conclusion In current literature, risk of experiencing cardiovascular events in the first year after the reactivation of VZV is 10 to 30% higher to those with no reactivation. Our case shows how the primary infection as well could be linked with the development of an acute coronary syndrome, even in patients with low cardiovascular risk. 598 A singular presentation of coronary fistula Anna Faleburle Anna Faleburle Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Leandro Sanesi Leandro Sanesi Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Alberto Cerasari Alberto Cerasari Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Edoardo Santoni Edoardo Santoni Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Irene Dominioni Irene Dominioni Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Sara Alessio Sara Alessio Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Antonio Russo Antonio Russo Centro Servizi Grocco, Riabilitazione Cardiologica , Perugia Lucia Filippucci Lucia Filippucci Centro Servizi Grocco, Riabilitazione Cardiologica , Perugia Giacomo Pucci Giacomo Pucci Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Gaetano Vaudo Gaetano Vaudo Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Dipartimento di Medicina, Struttura Complessa di Medicina Interna, Azienda Ospedaliera Santa Maria di Terni Università Degli Studi di Perugia Centro Servizi Grocco, Riabilitazione Cardiologica , Perugia Aims A 39-year-old runner was evaluated at the “Grocco Cardiac Rehabilitation Center” for the occurrence of dyspnoea and mild precordial discomfort during intense efforts. Such symptoms were attenuated with reducing the effort. Apart for being a former smoker, his previous disease history was unremarkable. At the physical examination of the heart, the cardiac impulse was palpable at the left fifth intercostal space; cardiac activity was rhythmic and normofrequent; a continuous systo-diastolic murmur with a trill was appreciated at the left sternal border in the third intercostal space, suggesting intra-cardiac shunt. There were no signs related to heart failure. Blood pressure and electrocardiography trace were within the normal limits. Methods and results A trans-thoracic echocardiography revealed enlarged right cardiac chambers: right superior-inferior x latero-lateral atrial diameters, evaluated at the four chambers view, were 52 x 47 mm, with a corresponding right atrial area of 21 cm2. The right ventricle was dilated (basal diameter 49 mm); the diameter of inferior vena cava (IVC) was enlarged (25 mm); the inferior cava index was reduced by 30%, suggesting elevated systolic pulmonary arterial pressure (47 mmHg). Based on the absence of clear signs revealing the source of the appreciated heart murmur, the diagnostic work-up was implemented with trans-oesophageal echocardiography, which revealed a continuum solution at the level of interatrial septum, of about 1 cm length. At the color-Doppler examination, a left-to-right interatrial shunt was demonstrated, suggesting inter-atrial defect. An indication to cardiac surgery consult was made, and a coronary angiography with right cardiac catheterization was planned in order to complete the diagnostic work-up. This exam revealed an ectasic right coronary artery with a fistula, and a significant interatrial shunt with elevated QP/QS ratio. The interventricular posterior artery originating from the fistula was vascularized by heterocoronary collateral circulation. To better define the anatomical boundaries of the right coronary artery and the fistula, a coronary CT scan was performed, that showed ectasic right coronary artery and the presence of distal fistula connecting the aforementioned artery with the right atrium and vena cardia magna, inducing significant shunt. Conclusion Coronary fistulas are rare abnormalities found in about 0,1% of patients undergoing cardiac catheterization. Fistulas may originate from any tract of the coronary arteries; in half of cases, the fistula originates from the right coronary artery, and often involves the right atrium, the right ventricle and the pulmonary arteries. Fistulas can be asymptomatic or not, being the symptoms related to the extent of the shunt. Asymptomatic forms are occasionally found, and generally occur in adult patients. Conversely, symptomatic forms can be detected due to the presence of angina, “coronary theft”, heart failure or ventricular overload, and are associated with higher morbidity and mortality In the American College of Cardiology guidelines, percutaneous or surgical closure represents a Class I recommendation for large fistulae regardless of symptoms and for small- to moderate-size fistulae with evidence of myocardial ischemia, arrhythmia, ventricular dysfunction, ventricular enlargement, or endarteritis. The conservative treatment is reserved for small fistulas accidentally discovered in asymptomatic patients, provided that a periodic echocardiographic evaluation is performed to quantify the possible growth and/or hemodynamic changes that may occur. 571 Combined two-steps procedure of MitraClip and left atrial appendage occlusion in the same patient: a clinical case Angela Sanseviero Angela Sanseviero Università di Roma tor Vergata Massimo Marchei Massimo Marchei Università di Roma tor Vergata Saverio Muscoli Saverio Muscoli Università di Roma tor Vergata Marco Di Luozzo Marco Di Luozzo Università di Roma tor Vergata Pasquale De Vico Pasquale De Vico Università di Roma tor Vergata Enrica Mariano Enrica Mariano Università di Roma tor Vergata Daniela Benedetto Daniela Benedetto Università di Roma tor Vergata Martina Belli Martina Belli Università di Roma tor Vergata Marialucia Milite Marialucia Milite Università di Roma tor Vergata Michela Bonanni Michela Bonanni Università di Roma tor Vergata Annamaria Tavernese Annamaria Tavernese Università di Roma tor Vergata Maria Stelitano Maria Stelitano Università di Roma tor Vergata Francesco Romeo Francesco Romeo Università di Roma tor Vergata Valeria Cammalleri Valeria Cammalleri Università di Roma tor Vergata Università di Roma tor Vergata Aims Percutaneous transcatheter mitral valve repair (MVR) using the MitraClip system is a consolidated procedure to treat selected patients with degenerative or functional mitral regurgitation (MR). Its safety and efficacy in high surgical risk-patients has been consistently demonstrated, both in clinical trials and in real-world settings. Atrial fibrillation is frequently observed in this setting, and the presence of contraindication to oral anticoagulant therapy is also common in these patients. In this context, percutaneous left atrial appendage occlusion (LAAO) may be a valid alternative. This clinical case shows the efficacy of a combined two steps procedure of percutaneous transcatheter MVR using the MitraClip system and LAAO in patients with contraindications to anticoagulant therapy. Methods and results We report the case of a patient with severe primary MR, symptomatic for heart failure despite optimal medical therapy and cardiac resynchronization, with atrial fibrillation and contraindication for anticoagulant therapy due to high bleeding risk. Therefore, it was decided to perform a combined two-steps transcatheter procedure of MVR and LAAO. A 78-year-old patient, previous smoking, affected by hypertension and permanent atrial fibrillation in treatment with oral anticoagulant therapy was hospitalized for progressive and severe dyspnoea. His comorbidities included chronic Kidney disease, chronic anaemia and previous kidney cancer. Trans-thoracic (TTE) and trans-oesophageal echocardiogram (ETE) showed normal left ventricular ejection fraction (LVEF 55%) and severe primary MR with eccentric jet due to P2 prolapse. The patient, deemed inoperable due to prohibitive surgical risk, symptomatic despite optimal medical therapy, underwent a percutaneous edge-to-edge procedure. A single XTR clip was implanted in A2-P2 position with residual mild moderate MR and mean transvalvular gradient of 3 mmHg without peri and post procedural complications. Six months after the procedure, the patient reported a functional improvement; TTE showed the persistence of a mild moderate MR but he referred several hospitalizations for melena anemization. Considered long-term oral anticoagulant therapy indication, concomitant high bleeding risk (HAS-BLED score 5) and clinical frailty, the patient underwent to percutaneous LAAO with Amplatzer device. During follow-up, the patient reported an improvement of quality of life with lower rates of hospitalizations. Conclusion In selected patients with high surgical risk, atrial fibrillation and increased bleeding risk, a combined two-steps procedure with MitraClip and LAAO is feasible, safe and effective. 543 Neutrophil to lymphocyte ratio predicts heart failure admissions after trancatheter aortic valve replacement Antonio Totaro Antonio Totaro Department of Cardiovascular Disease, Gemelli Molise Spa, Campobasso Gianluca Testa Gianluca Testa Department of Medicine and Health Sciences” V. Tiberio”, University of Molise , Campobasso Vincenzo Ienco Vincenzo Ienco Department of Cardiovascular Disease, Gemelli Molise Spa, Campobasso Andrea Busti Andrea Busti Department of Medicine and Health Sciences” V. Tiberio”, University of Molise , Campobasso Antonio Pierro Antonio Pierro Department of Radiology, Gemelli Molise Spa, Campobasso Cosimo Sacra Cosimo Sacra Department of Cardiovascular Disease, Gemelli Molise Spa, Campobasso Department of Cardiovascular Disease, Gemelli Molise Spa, Campobasso Department of Radiology, Gemelli Molise Spa, Campobasso Department of Medicine and Health Sciences” V. Tiberio”, University of Molise , Campobasso Aims Neutrophil-to-lymphocyte ratio (NLR) has prognostic value in cardiovascular disease. The role of NLR in predicting HF admissions in TAVR patients is not fully clarified. It is theorized to be two pronged: firstly, inflammatory reactions are known to contribute to the development of HF; and secondly, inflammatory stimuli lead to the release of cytokines and proteolytic enzymes causing destruction of the myocardium and decreased left ventricular function. In HF, the hypothalamic pituitary axis is activated leading to increased cortisol production resulting in decrease in the relative concentration of lymphocytes. Lymphopenia has also been associated with a poor prognosis in HF. In this study we have evaluated NLR as a predictor of HF admission in patients undergoing transcatheter aortic valve replacement (TAVR). Methods and results A total of 115 consecutive TAVR candidates, hospitalized at Gemelli Molise in Campobasso, were enrolled in this study. Baseline characteristics and laboratory tests were collected and analyzed. NLR was evaluated at admission, implantation day and discharge. Patients with HF hospitalization in 2 years Follow-up (n = 9) were compared to those without (n = 106). There were no differences between the two groups in patient baseline characteristics. Higher NLR at admission (4,62 ± 4,27 vs 3.13 ± 1,59, p = 0.003), was significantly associated with HF hospitalization during Follow-up in patients undergoing TAVR. Multivariate analysis, adjusted for EF, age, CRP, sex, CKD, moderate to severe paravalvular leak (PVL), revealed that NLR calculated at admission was an independent predictor of AHF (OR 1,435; 95% IC 1,038-1,894; p 0,029). Multivariate analysis – predicting factors for AHF . Factor . P value . OR . 95% CI for OR . NLR admission 0,029 1,435 1,038-1,984 EF 0,931 Age 0,805 Sex 0,828 CRP 0,863 CKD 0,960 PVL (mod to sev) 0,126 Multivariate analysis – predicting factors for AHF . Factor . P value . OR . 95% CI for OR . NLR admission 0,029 1,435 1,038-1,984 EF 0,931 Age 0,805 Sex 0,828 CRP 0,863 CKD 0,960 PVL (mod to sev) 0,126 Open in new tab Multivariate analysis – predicting factors for AHF . Factor . P value . OR . 95% CI for OR . NLR admission 0,029 1,435 1,038-1,984 EF 0,931 Age 0,805 Sex 0,828 CRP 0,863 CKD 0,960 PVL (mod to sev) 0,126 Multivariate analysis – predicting factors for AHF . Factor . P value . OR . 95% CI for OR . NLR admission 0,029 1,435 1,038-1,984 EF 0,931 Age 0,805 Sex 0,828 CRP 0,863 CKD 0,960 PVL (mod to sev) 0,126 Open in new tab Multivariate analysis Conclusion   In our patients, higher NLR at admission was significantly associated with HF hospitalization during Follow-up in patients undergoing TAVI. These preliminary results need to be elucidated with larger and more specifically designed studies. 231 Contrast-induced acute kidney injury in patients undergoing TAVI compared to coronary interventions Gabriele Venturi Gabriele Venturi Azienda Ospedaliera Universitaria Integrata —Verona Michele Pighi Michele Pighi Azienda Ospedaliera Universitaria Integrata —Verona Flavio Ribichini Flavio Ribichini Azienda Ospedaliera Universitaria Integrata —Verona Azienda Ospedaliera Universitaria Integrata —Verona Aims Differences in the impact of contrast medium on the development of contrast-induced acute kidney injury (CI-AKI) in patients undergoing trans-catheter aortic valve implantation (TAVI) or coronary angiography/percutaneous coronary interventions (CA/PCI) have not been previously investigated. Methods and results Patients treated with TAVI or elective CA/PCI were retrospectively analysed in terms of baseline and procedural characteristics including pre/post-procedural kidney function. CI-AKI was defined as a relative increase in SCr (serum creatinine) concentration of at least 0.3 mg/dL within 72 hours of contrast-medium administration compared with baseline. The incidence of CI-AKI in the TAVI vs CA/PCI group was compared. After the exclusion of patients in dialysis and emergency procedures, 977 patients were analysed: 489 TAVI (50.1%), 488 CA/PCI (49.9%). TAVI patients were older, presenting a higher rate of anaemia and chronic kidney disease (p < 0.001 for all comparisons). Consistently, they also had a significantly lower glomerular filtration rate and higher SCr (p < 0.001 for all). However, the occurrence of CI-AKI was significantly lower in these patients compared to CA/PCI (6.7% vs. 14.5%, p < 0.001). At multivariate analysis, TAVI procedure had an independent protective effect on CI-AKI incidence among total population (OR 0.334; 95% CI 0.193-0,579; p < 0.001). This observation was confirmed after propensity score matching among 360 patients (180 TAVI and 180 CA/PCI; p = 0.002). Conclusion CI-AKI occurred less frequently in patients undergoing TAVI than in CA/PCI subjects, despite a worse risk profile. The impact of contrast administration on kidney function in TAVI patients may be better tolerated because of the hemodynamic changes following aortic valve replacement. 232 Contrast-induced nephropathy in patients with aortic stenosis undergoing concomitant or staged coronary and valvular procedures Gabriele Venturi Gabriele Venturi Azienda Ospedaliera Universitaria Integrata —Verona Michele Pighi Michele Pighi Azienda Ospedaliera Universitaria Integrata —Verona Flavio Ribichini Flavio Ribichini Azienda Ospedaliera Universitaria Integrata —Verona Azienda Ospedaliera Universitaria Integrata —Verona Aims The impact of staged vs. concomitant coronary procedures on renal function in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) remains unclear. Methods and results Patients undergoing CA/PCI one week up to 4 months before TAVI (staged strategy), or during the same TAVI procedure (concomitant strategy), were retrospectively analyzed in terms of baseline, procedural characteristics and kidney function, both pre-and post-procedure. Contrast-induced acute kidney injury (CI-AKI) was defined as a relative increase in serum creatinine (SCr) concentration of at least 0.3 mg/dL, compared to baseline, within 72 hours after the index procedure (CA/PCI pre-TAVI for the staged group, TAVI, and CA/PCI for the concomitant group). Thirty-day follow-up data after TAVI were collected to assess the early safety outcomes of TAVI procedures. After the application of exclusion criteria, 334 patients were considered for this analysis: 151 (45.2%) underwent staged pre-TAVI coronary procedures, and 183 (54.8%) followed a concomitant strategy. CI-AKI occurred in 33 patients following pre-TAVI coronary procedures vs. 8 patients in the concomitant strategy group (21.9% vs. 4.4%, p < 0.001). Staged pre-TAVI coronary procedures caused a higher incidence of CI-AKI than concomitant TAVI and coronary procedures at univariate and multivariate analyses (p < 0.001). Furthermore, performing CA/PCI during the same TAVI procedure did not impact the overall early safety TAVI outcomes compared to the staged strategy (p = 0.609). Conclusion Performing staged pre TAVI coronary procedures yields a significantly higher risk of CI-AKI compared with concomitant strategy. Moreover, the concomitant strategy did not increase the risk of procedure-related complications. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2020. For permissions please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - 234 The role of preprocedural assessment of aortic valve calcium volume for the optimization of percutaneous aortic bioprosthesis implantation (TAVI)
JF - European Heart Journal Supplements
DO - 10.1093/eurheartj/suaa197
DA - 2020-12-01
UR - https://www.deepdyve.com/lp/oxford-university-press/234-the-role-of-preprocedural-assessment-of-aortic-valve-calcium-WqeRLimXD1
SP - N52
EP - N63
VL - 22
IS - Supplement_N
DP - DeepDyve
ER -