TY - JOUR
AB -   P1653 Discrete dissection of descending thoracic aorta confused with penetrating ulcer C Evdoridis C Evdoridis Elpis General Hospital, Athens, Greece C Grigoriou C Grigoriou Elpis General Hospital, Athens, Greece G Michas G Michas Elpis General Hospital, Athens, Greece V Mountaki V Mountaki Elpis General Hospital, Athens, Greece A Trikas A Trikas Elpis General Hospital, Athens, Greece Elpis General Hospital, Athens, Greece Introduction: Subtle or discrete dissection (DAD) is the most neglected variant of aortic dissection observed almost exclusively in the ascending aorta. Purpose: We describe the case of a 55- year-old man old man presented with typical chest pain Results: CT angiography (CTA) apparently showed a penetrating ulcer of the descending thoracic aorta with a floating linear mass at the ulcer borders (panel 1) but 3D reconstruction showed an eccentric bulging of the aortic wall (panel 2). Transesophageal echocardiography (TEE) revealed a DAD with a small intimal tear at the base of the bulging area and a false lumen under it as showed by color Doppler (panels 3-4). The previous described linear mass was in continuity with the intimal tear and gave the impression of a sheared intimal flap. The patient was successfully treated with thoracic endovascular repair Conclusion: Compared with other aortic syndromes, TEE in our case provided unique diagnostic information on (1) subtle intimal discontinuity/sheared intimal flap (2) false lumen flow and (3) aortic wall bulging not seen on 2D-CTA images. View largeDownload slide Abstract P1653 Figure. View largeDownload slide Abstract P1653 Figure. P1654 Aortic regurgitation as risk factor for coronary embolization from complex atheromatous aortic plaques. A clinical case VM Parato VM Parato Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy MC Di Saverio MC Di Saverio Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy M Scarano M Scarano Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy Funding Acknowledgements: NA OnBehalf: NA The Case The case is about a 68 y-o man with dyslipidemia, hypertension, aortic valve bioprosthesis with a significant intraprosthetic regurgitation. A TEE was performed because of a fever started two weeks before and a suspicious of endocarditis. He was on aspirin, ACEi, statin, b-blockers, antibiotics. TEE demonstrated a large atherosclerotic plaque in aortic arch with 2 mobile lesions (debris). There was no vegetations evidence on native or prosthetic valves. Double Anti-Platelet Theraphy (DAPT) with aspirin and clopidogrel was started. TEE was repeated at 2 months follow-up. It demonstrated a clear increase in sizing of aortic mobile lesions indicating a superimposed thrombosis. Four weeks after, patient was taken to Emergency Department (ED) because of chest pain with the ECG demostrating a infero-lateral acute STEMI. L-Cx coronary thrombectomy with aspiration catheter was performed and solid material (thrombus) was collected. There was no atherosclerotic coronary stenosis on LCx. Coronary embolism in this case may have been caused by flaked aortic plaque and/or superimposed thrombus, which was possibly carried by aortic regurgitation flow. Discussion: The prevalence of arch/descending aorta complex atheromatous plaques is 6.1% in unselected patients undergoing TEE for various reasons; it is 25% in patients with embolic episodes (Katzanos AH et al. Stroke, 2014;45:1764-1770). Atherosclerotic lesions of the thoracic aorta, especially complex plaques with superimposed thrombi and/or thickness >4 mm, are thought to be a risk factor for both cerebral and peripheral embolization. Retrograde embolization from complex plaques of the proximal descending aorta to all brain territories in early diastole is theoretically possible and could provide an alternative embolic source that should be taken into consideration especially in patients with cryptogenic stroke. Patients with mobile aortic arch atheroma and severe aortic regurgitation may be at higher risk of coronary embolism. View largeDownload slide Abstract P1654 Figure 1 View largeDownload slide Abstract P1654 Figure 1 P1655 Severe complications of unexpected staphylococcus aureus mitral valve endocarditis in a previously healthy 22-year-old T Thottakara T Thottakara University Heart Center Hamburg, Department of General and Interventional Cardiology, Hamburg, Germany J Starekova J Starekova University Medical Center Hamburg Eppendorf, Diagnostic and Interventional Radiology and Nuclear Medicine, Hamburg, Germany I Lettow I Lettow University Medical Center Hamburg Eppendorf, Department of Neurology , Hamburg, Germany E Tahir E Tahir University Medical Center Hamburg Eppendorf, Diagnostic and Interventional Radiology and Nuclear Medicine, Hamburg, Germany C Sinning C Sinning University Heart Center Hamburg, Department of General and Interventional Cardiology, Hamburg, Germany S Blankenberg S Blankenberg University Heart Center Hamburg, Department of General and Interventional Cardiology, Hamburg, Germany University Heart Center Hamburg, Department of General and Interventional Cardiology, Hamburg, Germany University Medical Center Hamburg Eppendorf, Diagnostic and Interventional Radiology and Nuclear Medicine, Hamburg, Germany University Medical Center Hamburg Eppendorf, Department of Neurology , Hamburg, Germany Severe complications of unexpected Staphylococcus aureus mitral valve endocarditis in a previously healthy 22-year-old Introduction: Staphylococcus bacteremia is considered a risk factor for endocarditis. The current guidelines require an echocardiographic examination in the presence of an according bacteremia. Up to 30% of patients have endocarditis in a positive blood culture. Despite an initially negative echocardiographic finding, a control examination after 7-10 days is recommended. Case Presentation: A previously healthy 22-year-old patient was introduced to the emergency room with fever, confusion and spontaneous wetting. No drug abuse was known. Meningism and cutaneous hemorrhagic lesions were observed. A high-grade inflammatory constellation with an evolving sepsis was present. CCT was inconspicuous. Initially suspected meningitis was ruled out. MRI showed cerebral septic emboli. Blood culture revealed Staphylococcus aureus, which rose suspicion of endocarditis. Immediate transesophageal echocardiography (TEE) was inconspicuous except for a previously known mild mitral regurgitation. PET-CT was negative. Because of continuing high clinical suspicion, endocarditis therapy was initiated. Follow-up TEE 5 days later, revealed posterior mitral leaflet perforation with severe mitral regurgitation and mobile vegetation. Sepsis led to disseminated intravasal coagulation (DIC) with thrombocytopenia. Intracerebral hemorrhage (ICH) occurred due to septic emboli and trepanation was performed. Urgent cardiac surgery had to be postponed due to the ICH. Recurrent cardiopulmonary edema occurred due to the destructed mitral valve. Pleural effusion was positive for S.aureus. Finally, biological mitral valve replacement took place after 3 weeks of treatment. S.aureus was detected on the removed valve even after weeks of antibiotic treatment. On the 6th postoperative day headache and vigilance disturbance occurred due to subarachnoid bleeding in perforated de-novo mycotic basilar tip aneurysm. Due to difficult vascular conditions, the aneurysm was coiled stent-supported. Cerebral vasospasm were treated with nimodipine and ventriculoperitoneal shunt was necessary du to persistent non obstructive hydrocephalus. Due to aneurysm re-perfusion, re-coiling took place. Antibiotic therapy continued throughout the entire inpatient stay. Limb palsy diminished progressively, but motor aphasia remained. The case shows that imaging may not always confirm the diagnosis, especially in early stage of endocarditis. Therefore, start of empirical therapy with high clinical suspicion is of paramount importance. Systemic infections with S.aureus are associated with high mortality. Common embolic complications usually occur around diagnosis, after which the risk of embolization decreases significantly with adequate therapy. Treatment of a severe form should be carried out in a center of maximum care where all complications can be treated accordingly in multidisciplinary team. P1656 17 y old tall boy with marphonoid physique presented with respiratory distress dicovered having flail MV with severe MR,huge TV vegetation at atypical side and dilated aortic root with retracted RCC A Khalil A Khalil international medical center(IMC), Adult cardiology, Jeddah, Saudi Arabia international medical center(IMC), Adult cardiology, Jeddah, Saudi Arabia Have you seen a case like this ??? • A tall statured 17 Y old previously healthy boy was transferred to our hospital from another facility on ventilator with diagnosis of Septic shock , ARDS and presumed infective endocarditis. bed side echo there, revealed a mass attached to TV and MVP with severe MR • His family denied history of any high-risk behavior for sexually transmitted diseases, alcohol abuse, intravenous drug abuse, recent dental procedures , persisting skin infections, congenital heart disease , or rheumatic fever. • At our institution, the physical exam was remarkable for pan-systolic murmur over the apex, bilateral basal to mid-zone lung crackles. His physique was remarkable for disproportionate ration of the lower extremities to torso and very large upper extremities span, he has a high arched palate and the thumb wrist test was positive all suggested marfanoid habitus. His initial laboratory data showed significant leukocytosis and elevated inflammatory markers and microscopic hematuria. Blood, respiratory and urine cultures were negative. Chest imaging showed pulmonary edema like picture/ARDS. TTE and TEE revealed large sessile cauliflower like mass attached to ventricular side of TV annulus and septal leaflet with highly mobile sphere like mass attached to its tip without hemodynamic compromise, Flail anterior MV leaflets with ruptured chordi at A2,A3 scallops and severe MR, Aortic valve showed retraction of RCC with triangular gape causing severe AR • The consensus was for surgery to remove the mass and send for C/S and histopathology ,repair/replacement of valvular lesions. Vegetations were removed and sent for culture and histopathology. All culture specimens were negative,Aortic valve specimen revealed No evidence of IE ,only myxoid changes ( C/W connective tissue diseases).Both aortic and mitral valves were replaced by mechanical valves. • We did a literature review about native TV Endocarditis with atypical vegetation at ventricular side and if there any relation to connective tissue disorder like Marfan syndrome , we found no single case report in the literature with combination of those rare findings . P1657 Late Toronto prosthesis dysfunction causing severe deterioration and cardiogenic shock JP Dias Ferreira Reis JP Dias Ferreira Reis Hospital de Santa Marta, Lisbon, Portugal TB Mano TB Mano Hospital de Santa Marta, Lisbon, Portugal S Aguiar Rosa S Aguiar Rosa Hospital de Santa Marta, Lisbon, Portugal LA Morais LA Morais Hospital de Santa Marta, Lisbon, Portugal L Branco L Branco Hospital de Santa Marta, Lisbon, Portugal P Rio P Rio Hospital de Santa Marta, Lisbon, Portugal A Agapito A Agapito Hospital de Santa Marta, Lisbon, Portugal A Laranjeira A Laranjeira Hospital de Santa Marta, Lisbon, Portugal J Fragata J Fragata Hospital de Santa Marta, Lisbon, Portugal R Cruz Ferreira R Cruz Ferreira Hospital de Santa Marta, Lisbon, Portugal Hospital de Santa Marta, Lisbon, Portugal Introduction: Prosthetic heart valve dysfunction can be potentially life-threatening. Its timely diagnosis and appropriate management, although challenging, is essential to determine the patient"s prognosis. We present a case of a 52 years old patient with aortic bioprosthesis dysfunction secondary to probable previous infective endocarditis (IE). Case Report: A 52 years-old man with underlying medical history of aortic valve replacement due to IE 16 years ago (St Jude Medical Toronto stentless porcine aortic valve), HIV-1 infection under highly active antiretroviral therapy, untreated chronic hepatitis C infection and chronic kidney disease stage 3a. He reported an hospital admission in the previous year for heart failure in his homecountry. The patient presented to the Emergency Room due to complaints of a constant vague chest discomfort non related to exertion and progressively worsening exertion dyspnoea (New York Heart Association class III) and was then admitted to the Cardiology Department. The transthoracic echocardiogram revealed an hyperechogenic longilineal and very mobile structure (17mm of length) adjacent to a dysfunctional bioprosthesis, severe aortic transprosthetic regurgitation and a markedly dilated left ventricle (end diastolic diameter - 79mm, end-diastolic volume - 333.5mL) with a depressed systolic function (Ejection Fraction - 40%), with no segmental wall motion abnormality. A transesophageal echocardiogram was performed and showed three hyperechogenic, calcified and mobile structures in close relation to the coronary ostia and one large mobile "vegetation" of 17x9mm, compatible with a previous IE. The patient remained apyretic, with no elevation of systemic inflammatory markers and negative serial blood cultures. Blood culture-negative infective endocarditis was excluded, thus no antibiotic therapy was initiated at this time. Later on, there was a sudden clinical worsening with progression to overt congestive heart failure (C clinical profile - "cold and wet"), significant kidney dysfunction (AKIN 3) and ischemic hepatitis, requiring inotropic and vasodilatory support. The patient was submitted to emergent bioprosthesis replacement with a Carpentier-Edwards Perimount prosthesis, experiencing a quick clinical improvement and a steady return of liver function tests and renal function to baseline values. Intra-operatively, it was noted an impressive prosthesis deterioration with complete leaflet destruction, that were almost inexistent. Its microbiological analysis was negative. It was assumed prosthesis dysfunction resulted from a past IE. Conclusion: This case emphasizes the possibility of severe deterioration of Toronto stentless prosthesis on an immunocompromised patient with a possible previous IE. View largeDownload slide Abstract P1657 Figure. Aortic bioprosthesis dysfunction View largeDownload slide Abstract P1657 Figure. Aortic bioprosthesis dysfunction P1658 Hypertrophic obstructive cardiomyopathy associated with secundum type atrial septal defect, mitral valve prolapse and pulmonary hypertension A Siama A Siama Asclepion Voulas Hospital, Athens, Greece A Tsoukas A Tsoukas Asclepion Voulas Hospital, Athens, Greece AJ Manolis AJ Manolis Asclepion Voulas Hospital, Athens, Greece Asclepion Voulas Hospital, Athens, Greece Hypetrophic cardiomyopathy is a genetically and phenotypically heterogeneous disease that manifests itself as left ventricular hypertrophy not solely explained by abnormal loading conditions. Related pathology involves the left ventricular outflow tract, the mitral valve apparatus, the left atrium, the right chambers and the diastolic function. In the present case report we describe a rare incident of a 70 year old woman with hypertrophic cardiomyopathy that is accompanied by severe mitral valve abnormalities resulting in eccentric mitral regurgitation that may have transformed a preexisting patent foramen ovale to secundum type atrial septal defect complicated by pulmonary hypertension. Transthoracic echocardiography was performed and demonstrated the following: left ventricular end diastolic and end systolic diameters were within normal limits accompanied by symmetric left ventricular wall hypetrophy, severe left atrial dilatation and a normal left ventricular ejection fraction. Complete systolic anterior motion (SAM) of the anterior mitral valve leaflet was observed causing left ventricular outflow tract (LVOT) obstruction with a maximum recorded velocity of 4.13 m/sec and a peak gradient measured across the LVOT of 68 mmHg at rest and of 80 mmHg upon provocation with Valsalva maneuver. The posterior mitral valve leaflet appeared elongated with holosystolic prolapse causing severe mitral regurgitation. An E/E" >15 was calculated in the lateral mitral annulus, indicative of increased left ventricular filling pressures. Moderate tricuspid regurgitation was recorded and systolic pulmonary artery pressure was estimated to be 50 mmHg. A suspected view of a secundum type ASD was obtained on transthoracic echocardiography demonstrating left to right flow at the atrial level. Transesophageal echocardiography confirmed the findings of the tranthoracic study, in particular a secundum type ASD was documented at the foramen ovale area. The morphology of the lesion was not typical of secundum ASD, instead the appearance of the defect could be attributed to reopening of a large patent foramen ovale with depiction of a membrane flap at the edge of the interatrial septal defect. Saline bubble contrast was administered and has demonstrated lack of opacification in the right atrium close to the ASD. Few bubbles could be visualized in the left cavities upon Valsalva manoeuver.We consider the ASD not necessarily to be an accompanying congenital defect. Rather, we hypothesize that the eccentricity of the mitral regurgitant jet with direction towards to the interatrial septum and increased left ventricular end diastolic and increased left atrial mean pressures and atrial dilatation, has resulted in excessive load at the area of fossa ovalis contributing to the distention of a preexisting patent foramen ovale transforming it to a secundum type atrial septal defect. View largeDownload slide Abstract P1658 Figure. Left to right shunt at the atrial level. View largeDownload slide Abstract P1658 Figure. Left to right shunt at the atrial level. P1659 Aortic valve endocarditis and root abscess: multimodality imaging & management S Suhail S Suhail Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates G Bhatnagar G Bhatnagar Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates J Bonatti J Bonatti Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates L Noor L Noor Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates S Sanger S Sanger Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates M Fernanda-Bonilla M Fernanda-Bonilla Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates S Adigopula S Adigopula Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates J Grapsa J Grapsa Cleveland Clinic Foundation, Cardiology, Cleveland, United States of America Cleveland Clinic Abu Dhabi, Cardiology, Abu Dhabi, United Arab Emirates Cleveland Clinic Foundation, Cardiology, Cleveland, United States of America Background: Surgical management of aortic valve endocarditis can be guided with appropriate multimodality and perioperative imaging. We present the case of a 69 years old female patient who was admitted with aortic valve endocarditis and aortic root abscess. Case description: A 69 years old female patient was admitted with fever for 4 weeks and cachexia. She had blood culture positive for streptococcus pasteurianus and positive urine cultures for Enterobacter. The patient had a transthoracic echocardiogram which demonstrated a moderate aortic valve stenosis with an estimated aortic valve area 1.21 cm2 (indexed 0.69 cm2/m2). Dimensionless index was 0.54. Peak aortic valve gradient was 38 mmHg and mean 19 mmHg. There was a small linear mobile vegetation attached to the non-coronary cusp. 3-dimensional transesophageal echocardiogram was crucial in the anatomic description of the aortic valve vegetation and its complications. The patient had severe aortic regurgitation with dehiscenced aortic valve. There was a mobile mass attached to the coronary cusp, measuring 1.3 cm is prolapsing between left ventricular outflow tract and aortic root. There was an active aortic abscess noted at the level of sinuses of Valsalva at the level of the non-coronary cusp, which filled with color. The best way to evaluate the coronary arteries prior to surgery was a CT coronary angiogram which demonstrated normal coronary arteries with no significant calcification. Carotid Doppler also did not demonstrate any significant disease. Surgical management: With the heart arrested, the ascending aorta, coronary ostia and aortic root were carefully assessed, and pathology was confirmed. The aortic tissue was resected in full until the level of the cross clamp, leaving a rim for the distal suture line. Aortic tissue was resected in a way that the two coronary ostia were left in two corresponding aortic buttons for coronary reimplantation. There was a large infection site within the non-coronary artery with intrusion of annulus from the left coronary artery and non-coronary artery – the two surgeons performed extensive debridement with a cardiopulmonary bypass time of 104 minutes and aortic cross clamp time of 127 minutes. The patient had aortic valve replacement and Bentall procedure with a homograft. The patient had an uncomplicated post-operative period with 6 weeks of intravenous antibiotics and she was discharged home Conclusions: We describe a patient who was admitted with aortic valve endocarditis and aortic root abscess, where multimodality imaging is crucial in the correct timing of surgical intervention and success of operation. View largeDownload slide Abstract P1659 Figure. Aortic valve endocarditis and abscess View largeDownload slide Abstract P1659 Figure. Aortic valve endocarditis and abscess P1660 Simultaneous imaging of a right ventricular apical thrombus and adjacent septal scar by contrast ultrasound in a patient with a previous anterior myocardial infarction S Suma S Suma University Hospital of Parma, Cardiology Deparment, Parma, Italy G Benatti G Benatti University Hospital of Parma, Cardiology Deparment, Parma, Italy N Gaibazzi N Gaibazzi University Hospital of Parma, Cardiology Deparment, Parma, Italy A Palumbo A Palumbo University Hospital of Parma, Radiology Department, Parma, Italy F De Rosa F De Rosa University Hospital of Parma, Cardiology Deparment, Parma, Italy S Coli S Coli University Hospital of Parma, Cardiology Deparment, Parma, Italy University Hospital of Parma, Cardiology Deparment, Parma, Italy University Hospital of Parma, Radiology Department, Parma, Italy A 44-year old man with a previous large anterior myocardial infarction was admitted to our hospital for dyspnea, peripheral oedema and abdominal distension. Upon arrival, given his critical conditions and abdominal complaints, an abdomen and chest Computed Tomography (CT) was also performed, which showed hepatic venous congestion, ascites, pulmonary congestion and a filling defect of the right ventricle (panel A, non gated thoracic contrast CT), but no signs of pulmonary embolism. The patient was treated for severe acute heart failure and after clinical stabilization a complete echocardiogram was performed, showing severe left ventricular systolic dysfunction with extensive apical akinesia, moderate right ventricular (RV) hypokinesia without clear RV masses (panel B). An ultrasound enhancing agent (SonoVue) with a left ventricular opacification setting (LVO) were employed, which clearly depicted the presence of large oval mass in the RV apex (panel C), attached to the inferior distal septum, where the myocardium appeared strongly echogenic in spite of the LVO setting (which should suppress tissue signal), indicating the presence of a scar. Cardiac Magnetic Resonance confirmed the presence of RV thrombus adjacent to a septal scar (panel D). Development of a thrombus within the RV is exceedingly rare and has usually been associated with RV infarction; in our case it was probably the result of extensive anterior myocardial infarction with transmural involvement of the distal septum and RV dysfunction. Interestingly, contrast ultrasound allowed to appreciate simultaneously the presence of RV thrombus and adjacent septal scar. View largeDownload slide Abstract P1660 Figure. View largeDownload slide Abstract P1660 Figure. P1662 Multiple intracardiac thrombi complicated with acute peripheral arterial ischemia TM Matajira Chia TM Matajira Chia Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain A Martin-Garcia A Martin-Garcia Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain AC Martin-Garcia AC Martin-Garcia Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain E Diaz Pelaez E Diaz Pelaez Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain M Gallego Delgado M Gallego Delgado Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain M Barreiro Perez M Barreiro Perez Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain C Avila Escribano C Avila Escribano Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain V Vallejo Garcia V Vallejo Garcia Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain M Gonzalez Ruiz M Gonzalez Ruiz Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain M Lopez Serna M Lopez Serna Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain S Merchan Gomez S Merchan Gomez Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain L Alvarez Rodriguez L Alvarez Rodriguez Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain M Bastos Fernandez M Bastos Fernandez Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain Hospital Clínico Universitario, Cardiology Unit -IBSAL-CIBER-CV, Salamanca, Spain We present the case of a 58-year-old male admitted due to an acute peripheral arterial ischemia undergoing emerging femorotibial bypass treatment. He did not referred known cardiovascular risk factors or previous heart disease. In order to rule out a cardioembolic origin of this episode, a transthoracic echocardiogram was requested. It showed severe left ventricular systolic dysfunction with generalized hypokinesia and lower apical segment akinesia as well as an apical mass. No coronary lesions were observed in left catheterization. Cardiac magnetic resonance revealed biventricular systolic dysfunction (LVEF = 24%;RVEF = 28%) with extensive intramyocardial late gadolinium enhancement (LGE) pattern and lower apical ischemic subendocardial pattern. Native and postcontrast T1 values of the myocardium were increased. T2 value was in the normal range. Pedicled and mobile mass of 37 x 17 mm was attached to the akinetic region. It was hypointense in T1-weighted imaging (T1WI) and T2-weighted imaging (T2WI), not perfused in the first step of gadolinium compatible with apical thrombus (high emboligenic risk). Moreover, two masses with the same characteristics as those previously described, i.e. compatible with thrombi, were observed in the left (LAA) and right atrial (RA) appendages. No evidence of valve diseases were found. Figure. Transesophageal echocardiogram confirmed the presence of thrombi in the appendages. Treatment with sodium heparin and acenocoumarol was started. Genetic testing of the factor V Leiden and prothrombin 2010 mutations were negative. After two months of treatment, the apical thrombus has disappeared and the size of the atrial thrombi have reduced. Biventricular systolic function has improved slightly. Moreover, his mother and a brother died suddenly at an early age. His father suffered a stroke when he was young. Because of high suspicion of cardiomyopathy (extensive LGE, systolic dysfunction, and a family history of sudden death), blood samples were collected for genetic test whose result is still pending . The incidence of multiple intracardiac mass is rare. The relevance of our clinical case is the finding of multiple thrombi in a patient without thrombophilia, cancer or known myocarditis. CMR imaging allows tissue characterization of myocardium and intracardiac masses. It is an useful non-invasive tool for a comprehensive diagnosis and follow-up. Figure A) Transthoracic echocardiogram: (*) apical left ventricular mass and arrow: RA mass B). Thrombus in RA (SSFP CMR) C ).Non perfused mass in first step of gadolinium in LAA D). LGE with long inversion time E). Perfusion image in four chamber F). LGE with long inversion time G). Native T1 mapping H). Extracellular volume (thombus, ECV:11%) I). Nonischemic delayed myocardial enhancement pattern J). Myocardium T1 mapping (1035 ms +/- 56 ms) K). Postcontrast T1 mapping (308 ms +/- 47 ms) L). Myocardium ECV (40.4 %) View largeDownload slide Abstract P1662 Figure. CMR Study.Multiple intracardiac thrombi View largeDownload slide Abstract P1662 Figure. CMR Study.Multiple intracardiac thrombi P1663 A challenging diagnosis of valvular heart disease A Xavier Fontes A Xavier Fontes Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal L Oliveira L Oliveira Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal C Serena C Serena Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal S Moura-Ferreira S Moura-Ferreira Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal C Almeida C Almeida Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal C Machado C Machado Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal R Dourado R Dourado Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal E Santos E Santos Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal N Pelicano N Pelicano Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal A Tavares A Tavares Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal D Martins D Martins Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal Hospital Divino Espirito Santo, Cardiology, Ponta Delgada, Portugal 75-year-old male, was accompanied in our department due to asymptomatic moderate aortic regurgitation. His past medical history included hypertension, dyslipidemia and diabetes. His last echocardiographic assessment showed mild dilated left ventricle (LV), LV ejection fraction of 50% and moderate aortic regurgitation. 5 months later patient had an episode of syncope and was admitted to the emergency room. He also referred effort dyspnea in the last 3 months. Echocardiogram was performed and revealed mild dilated LV and eccentric hypertrophy, moderate reduced LV ejection fraction (38%) due to global wall hypokinesis, moderate to severe aortic regurgitation (eccentric jet, holodiastolic reverse of flow in descending thoracic aorta but with terminal velocity of 12cm/s, effective regurgitant orifice area = 0,26cm2, regurgitant volume of 30mL) and thickened mitral leaflets with oscillating intracardiac structure suggestive of ruptured chordae, causing mild regurgitation. With these findings we suspected of an asymptomatic coronary event in the last months, once cardiac enzymes and the electrocardiogram did not show any change after the syncope. We performed an transesophageal echocardiography that did not confirm chordae rupture of mitral valve but showed right coronary leaflet prolapse of the aortic valve. The coronary angiogram did not show any lesion. In order to understand the reduction of ejection fraction we performed a cardiac magnetic resonance that found severe aortic regurgitation (regurgitant fraction = 50%). This case reveals the importance of multimodality imaging when we are evaluating heart failure due to valvular disease, especially when we are facing eccentric jects. Patient was treated with surgical valve replacement and the echocardiogram performed 1 month later showed a mild prosthetic leak and LV ejection fraction of 60%. P1664 Bilateral absence of the superior vena cava R Sirbu Prisecaru R Sirbu Prisecaru Lucian Blaga University Sibiu, Sibiu, Romania L Riahi L Riahi Military Hospital of Tunis, Tunis, Tunisia Y De Greef Y De Greef ZNA Middelheim Hospital, Cardiology Department, Antwerp, Belgium D Stockman D Stockman ZNA Middelheim Hospital, Cardiology Department, Antwerp, Belgium B Schwagten B Schwagten ZNA Middelheim Hospital, Cardiology Department, Antwerp, Belgium Lucian Blaga University Sibiu, Sibiu, Romania Military Hospital of Tunis, Tunis, Tunisia ZNA Middelheim Hospital, Cardiology Department, Antwerp, Belgium We report the case of a 49 years old man scheduled for a CRT D implantation. The left subclavian vein was accessed through an introducer needle and then, the guide wire was inserted through the needle into the vein, but access to the SVC was not successful. Radio-iodinated contrast material was injected in order to obtain a venogram: no contrast was going into SVC and the anomalous venous drainage was suspected to be an hemiazygos vein. Injection of contrast material in the right brachialis vein revealed the absence of right SVC and anomalous venous drainage into azygos vein with subsequent drainage into the inferior vena cava (IVC). Access to the right ventricle and coronary sinus did not seem possible because of the anomalous venous drainage and procedure was abandoned. MRI angiography confirmed this anomalous venous drainage with subsequent discharge into the left renal vein. The patient underwent successful epicardial implantation of a right and left ventricular leads together with a subcutaneous array electrode sutured to the pericardium. Isolated bilateral absence of SVC makes routinely approaches in device implantation impossible. The real incidence of this anomaly may be higher than reported, due to the asymptomatic character and the fact that the majority of cases reports were discovered in adults at the time of device implantation. P1665 Residual mediastinal mass in releapsed Hodgkin"s disease: multiparametric MR imaging techniques TM Matajira Chia TM Matajira Chia Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain R Garcia Sanz R Garcia Sanz Hospital Clínico Universitario, Haematologic Department , Salamanca, Spain A Martin-Garcia A Martin-Garcia Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain AC Martin- Garcia AC Martin- Garcia Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain M Gonzalez Ruiz M Gonzalez Ruiz Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain E Diaz Pelaez E Diaz Pelaez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain M Barreiro Perez M Barreiro Perez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain M Gallego Delgado M Gallego Delgado Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain M Lopez Serna M Lopez Serna Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain S Merchan Gomez S Merchan Gomez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain L Alvarez Rodriguez L Alvarez Rodriguez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain M Bastos Fernandez M Bastos Fernandez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain PL Sanchez PL Sanchez Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain Hospital Clínico Universitario, Cardiology Department.IBSAL-CIBER-CV, Salamanca, Spain Hospital Clínico Universitario, Haematologic Department , Salamanca, Spain We present the case of a 26-year-old woman with history of nodular sclerosis Hodgkin lymphoma treated with chemotherapy and radiotherapy one year ago. The patient was referred to the cardiac-hematology consultation for persistence of anterior mediastinal mass in the follow-up tomographic study. She had no cardiac symptoms. Transthoracic echocardiogram showed normal biventricular function, absence of valvular heart disease, no pericardial effusion or signs of pericardial constriction. Cardiac magnetic resonance was performed. It revealed normal biventricular systolic function without edema or late enhancement gadolinium. It reported an anterior mediastinal mass (38*51.5 mm), not perfused in first pass or late gadolinium enhanced. It had low signal intensity on T2-weighted sequences similar to that of muscle (homogeneous inactive pattern). Moreover, parametric imaging techniques tissue characterization were performed to study the mass: native T1 time: 1145ms, and T2 time of 58 ms. Multiple nodules were evidenced in both pulmonary fields. Figure1. FDG PET-CT scan showed progressive metabolic disease (bilateral pulmonary and bilateral renal infiltration). Mediastinal mass had no metabolic activity. A new chemotherapy schedule treatment was initiated. Three month later a PET TC scan was performed and showed a metabolic response with disappearance of lung and kidney lesions and persistence of anterior mediastinal residual mass. A residual mediastinal mass is frequently observed after successful treatment of Hodgkin’s disease (up to 80%) and can cause both diagnostic and therapeutic problems. Cardiac magnetic resonance imaging is an excellent diagnostic tool and heps to differentiate active tumour from a residual mass. Figure 1. Classic Hodgkin"s lymphoma type nodular sclerosis: Extracardiac mass (EM) (38 x 51.5 mm) in anterior mediastinum(*). A-B. FDG PET-CT EM without inflamatory activity. CMR study : C. Cine images D. STIR images E. EM is not perfused F. EM without Late gadolinium enhancement G. T1 Mapping H. T2 mapping, I. T2* mapping View largeDownload slide Abstract P1665 Figure. Residual Mediastinal Mass . CMR View largeDownload slide Abstract P1665 Figure. Residual Mediastinal Mass . CMR P1666 Diagnostic discriminatory power of multiparametric cardiac magnetic resonance in diagnosing the cause of ventricular fibrillation in left ventricular dysfunction with competing aetiologies T Ntoskas T Ntoskas New Cross Hospital, Heart and Lung Centre, Wolverhampton, United Kingdom E Mcalindon E Mcalindon New Cross Hospital, Heart and Lung Centre, Wolverhampton, United Kingdom S Petkar S Petkar New Cross Hospital, Heart and Lung Centre, Wolverhampton, United Kingdom SS Hothi SS Hothi New Cross Hospital, Heart and Lung Centre, Wolverhampton, United Kingdom New Cross Hospital, Heart and Lung Centre, Wolverhampton, United Kingdom Funding Acknowledgements: Nothing to declare Background: We report a case of syncope and cardiac arrest due to ventricular fibrillation and demonstrate the powerful diagnostic utility of multiparametric cardiac MRI (CMR) imaging in differentiating between competing causes for left ventricular systolic dysfunction (LVSD) and cardiac arrest. This case adds to the debate that tissue characterisation techniques over and beyond late gadolinium enhancement (LGE) imaging have clinical utility and should not be confined purely to the research arena. Clinical Case A 28-year-old Caucasian male with no known medical history presented with chest pain, palpitations and syncope. He consumed cocaine for the past 10 years, 30 units of alcohol per week and 15 cigarettes per day. A maternal grandfather had premature sudden cardiac death. Cardiovascular examination was normal. Electrocardiography showed sinus rhythm, intermittent right bundle branch block and QTc 404–443ms. High-sensitivity troponin was elevated. He was initially treated for possible acute coronary syndrome. Twelve hours after admission he developed ventricular fibrillation (VF) and was successfully resuscitated. Transthoracic echocardiography revealed mild, global LVSD and a normal right heart. Coronary angiography was normal. The causes of LVSD, ACS and VF arrest remained uncertain with at least 3 potential causes (infarct, cardiomyopathy or primary arrhythmia). He therefore underwent CMR for further assessment, demonstrating mild LV dilatation with mild, global LVSD and basal anterolateral oedema evidenced by T2w and T2 STIR imaging (Figure). LGE imaging correspondingly revealed near-transmurally increased basal anterolateral signal consistent with acute infarction of this segment. In addition, there was striking, coarse, widespread mid-wall LGE consistent with a non-ischaemic dilated cardiomyopathy (DCM). An adenosine challenge did not reveal pre- excitation and a flecainide test was negative for Brugada syndrome. Toxicology was positive for cocaine. The differential diagnosis was atypical infarction that could be cocaine-induced vasospasm, and an underlying non-ischaemic DCM (familial, alcohol, cocaine-induced or a combination). Following multidisciplinary advice the patient underwent subcutaneous secondary prevention ICD implantation, screening for causes of DCM and drug rehabilitation. The case illustrates cardiac considerations for cocaine use, including atypical infarction, cardiomyopathy and arrhythmia. Conclusion: The triad of VF, myocardial infarction and LVSD can be multifactorial within a given patient and diagnosis can therefore be challenging. Many CMR studies continue to be confined to LGE for tissue characterisation. This case describes the powerful diagnostic discrimination afforded by multiparametric (LGE, T2 imaging and T2 STIR) CMR for tissue characterisation in establishing acute and chronic cardiac tissue diagnoses and its readiness for the clinical arena in challenging diagnostic cardiac cases. View largeDownload slide Abstract P1666 Figure View largeDownload slide Abstract P1666 Figure P1667 A matter of arteries and veins I Duraes Campos I Duraes Campos Hospital de Braga, Cardiology, Braga, Portugal C Vieira C Vieira Hospital de Braga, Cardiology, Braga, Portugal N Salome N Salome Hospital de Braga, Cardiology, Braga, Portugal A Costeria-Pereira A Costeria-Pereira Hospital de Braga, Cardiology, Braga, Portugal VH Pereira VH Pereira Hospital de Braga, Cardiology, Braga, Portugal N Bettencourt N Bettencourt Hospital de Braga, Cardiology, Braga, Portugal J Costa J Costa Hospital de Braga, Cardiology, Braga, Portugal C Quina-Rodrigues C Quina-Rodrigues Hospital de Braga, Cardiology, Braga, Portugal C Oliveira C Oliveira Hospital de Braga, Cardiology, Braga, Portugal J Marques J Marques Hospital de Braga, Cardiology, Braga, Portugal Hospital de Braga, Cardiology, Braga, Portugal Introduction: Pulmonary arteriovenous malformations are caused by the abnormal connection between pulmonary arteries and venous systems. Although these lesions are a relatively rare clinical problem, they are an important part of the differential diagnosis of common pulmonary problems such as pulmonary nodules. Case Report Description: A 25 year-old male without any relevant previous medical history was admitted at the emergency department of our hospital with a suspicion of complicated pyelonephritis. As part of the diagnostic work-up the patient performed a chest roentgenogram that showed the presence of multiple pulmonary nodules associated with cardiomegaly. The cardiovascular physical examination was unremarkable and the ECG had no alterations. In this context the patient was submitted to a complete echocardiography study that displayed a mild dilatation of the left cardiac chambers and an eccentric hypertrophy of the left ventricle with preserved ejection fraction. The patient was later referred to the Cardiology department for further study. The cardiac magnetic resonance showed a dilatation of all the cardiac chambers and a normal ejection fraction without late-gadolinium enhancement. The cardiac output was significantly elevated and the Qp/Qs was normal. The anatomic sequences confirmed the presence of several nodular images on both lungs that revealed to be arteriovenous malformations. These findings were complemented with a thoracic-abdominal-pelvic computed tomography scan that exposed the presence of multiple arteriovenous malformations in the lung, liver and left kidney. Discussion: These studies were suggestive of a high output state provoked by an increase in the systemic and pulmonary blood pool. The presence of a normal Qp/Qs excluded the presence of a significant shunt between the systemic and pulmonary circulations. The prognosis of our patient is affected by two main factors: the number and size of these malformations which are prone to rupture and the presence of a high cardiac output state that may lead to symptomatic heart failure. So far only an embolization of the renal malformation was performed without complications. The patient is currently asymptomatic. A genetic testing is ongoing to determine the underlying cause for this condition. Conclusion: This case report illustrates a patient with multiple large pulmonary arteriovenous malformations associated with multi-organs arteriovenous malformations (renal and liver) and, according to available literature, is one of the cases described with greater multi-organs involvement. View largeDownload slide Abstract P1667 Figure. Pulmonary arteriovenous malformation View largeDownload slide Abstract P1667 Figure. Pulmonary arteriovenous malformation P1668 Takotsubo cardiomiopathy in a 12 years old female suffering of asthma C Paolini C Paolini West Vicenza General Hospitals, Cardiology, Arzignano, Italy S Casella S Casella Ospedale Civile Cazzavillan, Emergency, Arzignano, Italy C Dalla Valle C Dalla Valle West Vicenza General Hospitals, Cardiology, Arzignano, Italy I Lobascio I Lobascio West Vicenza General Hospitals, Cardiology, Arzignano, Italy R Malago R Malago University Hospital, Verona, Italy A Mecenero A Mecenero West Vicenza General Hospitals, Cardiology, Arzignano, Italy C Bilato C Bilato West Vicenza General Hospitals, Cardiology, Arzignano, Italy West Vicenza General Hospitals, Cardiology, Arzignano, Italy Ospedale Civile Cazzavillan, Emergency, Arzignano, Italy University Hospital, Verona, Italy A 12-year-old black girl, with a history of bronchial asthma, was admitted to our hospital because of a scheduled operation of flat foot and bilateral valgus knee. Immediately after the induction of general anesthesia, she developed bronchospasm with transient desaturation, resolved after administration of corticosteroids. By the end of the surgery, after extubation, she developed acute pulmonary edema, requiring re-intubation ad admission to ICU. EKG showed sinus tachycardia, with ST-segment depression in inferior and V1 leads. Transthoracic echocardiogram showed dilated left ventricle (LV) with akinesia of the mid and apical segments, resulting in severe impairment of the LV systolic function and reduced ejection fraction (25%), suggesting Takotsubo cardiomiopathy (TTC). Cardiac biomarkers resulted elevated. The patient was treated with amines and intravenous diuretics with gradual improvement of the clinical status and subsequent extubation. Then, she was admitted to cardiology ward. Serial echocardiograms showed a gradual normalization of the LV contractile function while negative T waves in precordial, lateral and inferior leads were observed at the EKG. Cardiac MRI, performed 2 weeks after admission, showed hypokinesia of the LV apical and anterolateral walls with minimal paradoxical telesystolic bulging, no delayed enhancement and normal ejection fraction, confirming the hypothesis of Takotsubo cardiomiopathy. Takotsubo cardiomyopathy in pediatric population is a rare occurrence. In the literature are reported few cases in young patients, none as consequence of orthopedic intervention and/or asthma (and asthma medications). View largeDownload slide Abstract P1668 Figure. View largeDownload slide Abstract P1668 Figure. P1669 Arrhythmogenic cardiomyopathy with isolated left ventricle involvement and heart failure in a 38-year old male patient. Role of CMR VM Parato VM Parato Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy MC Di Saverio MC Di Saverio Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy M Scarano M Scarano Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy Cardiology Unit of emergency Department, San Benedetto del Tronto, Italy Funding Acknowledgements: NA OnBehalf: NA The Case A 38-year old male patient, competitive athlete, presented with signs and symptoms of heart failure and palpitations. Electrocardiography showed atrial fibrillation with T wave inversion in infero-lateral leads. Holter monitoring showed frequent ventricular premature beats of right bundle branch block morphology. Echocardiographic examination revealed a normal right ventricle. Left ventricle (LV) had normal volumes togheter with a slightly reduced ejection fraction (45%). A clear hypokinesia of LV inferolateral wall was also detected. Holter monitoring showed frequent isolated ventricular ectopies but no evidence of sustained ventricular tachycardia. No information was available about the family history, as the child was adopted by the family from an orphan house. Neither parent was alive and the cause of death was not known. After electrical cardioversion, the athlete was referred for cardiac magnetic resonance (CMR), which was done on a Siemens Avanto 1.5 T machine (Siemens, Munich, Germany). Image sequences acquired included: black blood T1-weighted turbo spin echo images with and without fat suppression; steady-state free precession or cine images; and late gadolinium images after gadolinium injection. RV was completely normal. Left ventricular (LV) volumes were normal with wall motion abnormalities involving the inferolateral wall and apex and mildly reduced systolic function (ejection fraction 44%). There was two findings: 1) a hyperenhancement involving the inferolateral segments and apex of the LV; 2) fatty replacement of myocardium in the mid to distal lateral wall of the LV (figure 1). Patient underwent ICD implantation. Discussion: LV involvement has been reported in ARVC patients, with the majority having advanced right ventricle disease. LV involvement in ARVC may manifest as late gadolinium enhancement, often involving the inferior and lateral walls. Arrhthmogenic Cardiomyopathy (AC) with an isolated involvement of LV is very rare. CMR has now emerged as the imaging modality of choice in AC. CMR allows not only the morphological and functional evaluation but also the tissue characterization of the myocardium. RV abnormalities in AC have been extensively described in the literature while LV abnormalities are to date still elusive. In our patient a hyperenhancement involving the inferolateral segments and apex of the LV togheter with a fatty replacement of myocardium in the mid to distal lateral wall of the LV allowed the diagnosis. View largeDownload slide Abstract P1669 Figure 1 View largeDownload slide Abstract P1669 Figure 1 P1670 A rare cause of cardiac constriction I Bravo Martinez I Bravo Martinez Hospital de Basurto, Department of Cardiology, Bilbao, Spain N Garcia N Garcia Hospital de Basurto, Department of Cardiology, Bilbao, Spain M Codina M Codina Hospital de Basurto, Department of Cardiology, Bilbao, Spain A Manzanal A Manzanal Hospital de Basurto, Department of Cardiology, Bilbao, Spain G Aurrekoetxea G Aurrekoetxea Hospital de Basurto, Department of Cardiology, Bilbao, Spain P Mendoza P Mendoza Hospital de Basurto, Department of Cardiology, Bilbao, Spain C Asla C Asla Hospital de Basurto, Department of Cardiology, Bilbao, Spain M Castellanos M Castellanos Hospital de Basurto, Department of Cardiology, Bilbao, Spain R Martinez De Bourio R Martinez De Bourio Hospital de Basurto, Department of Cardiology, Bilbao, Spain A Ullate A Ullate Hospital de Basurto, Department of Cardiology, Bilbao, Spain L Ruiz L Ruiz Hospital de Basurto, Department of Cardiology, Bilbao, Spain Hospital de Basurto, Department of Cardiology, Bilbao, Spain We present the case of a 70 year-old woman that presented in hospital with shortness of breath on mild exertion. In 1986 she had surgery for breast cancer with total left mastectomy and adjuvant oncological therapy consisting on local radiotherapy. She had presented no recurrence since then. She developed a post-radiotherapy sternal osteonecrosis and secondary osteomyelitis colonized by Methicillin Sensible Staphylococcus Aureus. Previous thoracic cardiac tomography and magnetic resonance studies showed the chronic osteomyelitis affecting the sternum and the left side of the chest wall with extension in depth towards anterior mediastinum. She received several antibiotic treatments and underwent thoracic surgery to remove the infected bone and tissues without success. Physical examination revealed congestive sings with elevated jugular pressure, oedema in lower limbs but without pulmonary rales. The ultrasound window for the transthoracic echocardiography was compromised because of thoracic postsurgical changes. It showed a non-dilated left ventricle (LV) with mild depressed global systolic function and non-dilated right ventricle (RV) with mild to moderate tricuspid regurgitation and calculated systolic pulmonary artery pressure of 60mmHg. A cardiac magnetic resonance was then performed to complete the study showing a myocardial thickening at the level of the anterior wall of the RV, right ventricle outflow tract, anterior septum and anterior wall of the LV, with no contraction of these segments and which seem to be attached to the chest wall. There were also seen areas with perfusion defect in these segments, which correspond to intramyocardial calcifications. In the sequences of late enhancement (Figure 1) , a heterogeneous intramyocardial uptake was observed in the segments affected by the infiltration, as well as diffuse pericardial uptake. There were sings suggesting pericardial constriction such as a marked septal flattening with forced inspiration, dilation of both atria, inferior vena cava and suprahepatic veins. In the sequences with gadolinium for assessment of the thoracic wall, a heterogeneous enhancement was visualized affecting all the sternum and left anterior thoracic wall below the pectoral muscle. These findings match with changes of chronic osteomyelitis. The patient was rejected for cardiac surgery. She has progressively developed severe pulmonary hypertension and she is now in the New York Heart Association (NYHA )III/IV functional class. This case represents a rare case of pericardial constriction due to post-radiotherapy chronic sternum osteomyelitis that infiltrates mediastinum, pericardium and anterior walls of left and right ventricles. There is no treatment despite of control of the infection. View largeDownload slide Abstract P1670 Figure1. CMR: Late gadolinium enhacement View largeDownload slide Abstract P1670 Figure1. CMR: Late gadolinium enhacement P1671 An unexpected finding in a routine echocardiogram I Duraes Campos I Duraes Campos Hospital de Braga, Cardiology, Braga, Portugal J Martins J Martins Hospital de Braga, Cardiology, Braga, Portugal AS Matos AS Matos Centro Hospitalar do Alto Minho, Internal Medicine, Viana do Castelo, Portugal L Basto L Basto Hospital de Braga, Cardiology, Braga, Portugal C Vieira C Vieira Hospital de Braga, Cardiology, Braga, Portugal VH Pereira VH Pereira Hospital de Braga, Cardiology, Braga, Portugal N Bettencourt N Bettencourt Hospital de Braga, Cardiology, Braga, Portugal A Costeira-Pereira A Costeira-Pereira Hospital de Braga, Cardiology, Braga, Portugal N Salome N Salome Hospital de Braga, Cardiology, Braga, Portugal J Marques J Marques Hospital de Braga, Cardiology, Braga, Portugal Hospital de Braga, Cardiology, Braga, Portugal Centro Hospitalar do Alto Minho, Internal Medicine, Viana do Castelo, Portugal Introduction: Primary intimal sarcoma is a rare tumor, more commonly encountered in large arterial blood vessels but extremely unusual in the heart. The aim of this report is to describe a rare disease entity, and to underline its presentation and pathological findings. Case Report Description: A 72-year-old woman with a history of atrial flutter and breast cancer (submitted to radiotherapy and chemotherapy in 2000) was referred to our hospital for complaints of dyspnea and orthopnea with 15 days of evolution and a mass in the left atrium on a routine transthoracic echocardiography. At admission, pulmonary auscultation showed bilateral crackles and bilateral ankle edema was observed. No other changes were observed. The patient’s electrocardiogram showed sinus rhythm, and her blood tests showed pro-BNP increase of 562 pg/mL. Description of the Procedures: During hospitalization the patient underwent transesophageal echocardiography, which showed the presence of an heterogeneous space-occupying lesion (7.6 × 2.8cm), arising from the lateral wall of the left atrium, infiltrating the wall and with continuity through the pericardial space, of probable neoplastic etiology. A moderate pericardial effusion was also observed. Cardiac magnetic resonance (CMR) was performed to better characterize the mass, providing complementary findings and identifying the mass as tumor. In particular, perfusion CMR demonstrated blood flow in the mass, and late contrast-enhanced CMR revealed high- and low-signal territories in the tumor suggesting heterogenous cell-rich and cell-depleted components of the mass. Differential Diagnosis: Differential diagnosis included a secondary cardiac tumor, a primary cardiac tumor (benign or malignant), or less likely, a thrombus. In order to exclude a secondary cardiac tumour, the patient underwent a thoraco-abdomino-pelvic CT, bilateral mammography, and upper and lower gastrointestinal endoscopy that showed no evidence of neoplastic disease. An excision of a suspected left axillary skin lesion was made, showing that it is a benign lesion. Pleural fluid was collected and cytological smears were made. Pleural fluid was categorized as transudative and was negative for malignant cells. Diagnostic pericardiocentesis was performed revealing exudate characteristics but the cytology was negative. Therefore, faced with the suspicion of primary cardiac tumor (without identification of primary extracardiac neoplasia), the patient was guided to biopsy of the cardiac mass. Histology of the mass confirmed an primary intimal sarcoma. Discussion: Primary cardiac tumours are exceedingly rare (0.001–0.03% of all cardiac tumours). Although cardiac intimal sarcoma is an uncommon entity, it is an aggressive disease with poor prognosis, which makes early diagnosis and treatment extremely important. Conclusion: The report of this case is of paramount importance in order to reinforce clinical awareness regarding such aggressive tumors. View largeDownload slide Abstract P1671 Figure. Late contrast-enhanced CMR View largeDownload slide Abstract P1671 Figure. Late contrast-enhanced CMR P1672 Behind the acute coronary syndrome: the use of cardiac MRI L Filippetti L Filippetti Hospital Brabois of Nancy, cardiology, Vandoeuvre les Nancy, France C Venner C Venner Hospital Brabois of Nancy, cardiology, Vandoeuvre les Nancy, France O Huttin O Huttin Hospital Brabois of Nancy, cardiology, Vandoeuvre les Nancy, France C Selton Suty C Selton Suty Hospital Brabois of Nancy, cardiology, Vandoeuvre les Nancy, France Hospital Brabois of Nancy, cardiology, Vandoeuvre les Nancy, France Introduction: Acute Myocarditis (AM) refers to heterogeneous clinical manifestations. Initial risk stratification is crucial for the management especially in case of AM with preserved left ventricular ejection fraction (LVEF). Case: We report the case of a 21 year old presenting with acute chest pain. He had no medical history and no cardiovascular risk factors. ECG showed lateral ST-segment elevation and inferior mirror. Coronary angiography was performed in emergency and showed a non-significant lesion involving the anterior interventricular artery. The transthoracic echocardiography (TTE) demonstrated a preserved LVEF and isolated lateral wall abnormal movement. Global longitudinal strain reached -21%, and only basal lateral and inferior wall strain was reduced (figure 1). Biology revealed a peak value of troponin I >78ng/mL without inflammatory syndrome. Cardiac MRI (CMR) was performed 2 days later and showed important circumferential myocardial edema at T2-weighted sequences, sparing septal wall (figure 2). In the same territory, edema and capillary leakage were confirmed by the presence of diffuse early gadolinium enhancement at spin echo T1-weighted sequences and the increase of T2 mapping value (52ms) (figure3). We reported supepicardial late gadolinium enhancement (LGE) with intense signal, involving all segments, except the septal wall (figure 4). LVEF was preserved. According to the Lake Louise Criteria, we confirmed the diagnostic of acute myocarditis. The patient did not present any hemodynamic or rhythmic complications and he was treated by Beta Blocker and Angiotensin-Converting-Enzyme inhibitors. Questions and problems: CMR is crucial in the diagnosis approach of acute coronary syndrome (ACS) with normal coronary arteries. Clinical, biological and electrical data are not sufficient and the role of TTE is also limited too, as findings are not specific for myocarditis. CMR is helpful to differentiate ischemic disease and acute myocarditis, in particular presenting with infarct-like pattern. This case is remarkable because of the striking contrast between the severity of cardiac involvement highlighted on CMR and the non-threatening clinical status. CMR provides new insights about myocardial tissue characterization. Previous studies have demonstrated the relationship between LGE patterns and prognosis, in particular in case of acute myocarditis with preserved LVEF and have identified non infero-lateral LGE distribution as a predictive factor of worse prognosis. This case contributes to emphasize the growing value of LGE distribution , in comparison with LGE extent or intensity, as initial and middle-term prognostic factor. The treatment still remains controversial. According to ESC guidelines, treatment is recommended in case of acute myocarditis with heart failure, LV dysfunction or rhythmic complications. Up to day, Inflammatory process and fibrosis estimated by CMR are not considered in the choice of treatment. View largeDownload slide Abstract P1672 Figure. abstract jpeg View largeDownload slide Abstract P1672 Figure. abstract jpeg P1673 An unexpected cardiac magnetic resonance imaging finding A Marques A Marques Hospital Garcia de Orta, Cardiology, Almada, Portugal D Caldeira D Caldeira Hospital Garcia de Orta, Cardiology, Almada, Portugal I Cruz I Cruz Hospital Garcia de Orta, Cardiology, Almada, Portugal S Alegria S Alegria Hospital Garcia de Orta, Cardiology, Almada, Portugal AR Pereira AR Pereira Hospital Garcia de Orta, Cardiology, Almada, Portugal AC Gomes AC Gomes Hospital Garcia de Orta, Cardiology, Almada, Portugal A Briosa A Briosa Hospital Garcia de Orta, Cardiology, Almada, Portugal D Sebaiti D Sebaiti Hospital Garcia de Orta, Cardiology, Almada, Portugal AR Almeida AR Almeida Hospital Garcia de Orta, Cardiology, Almada, Portugal I Joao I Joao Hospital Garcia de Orta, Cardiology, Almada, Portugal H Pereira H Pereira Hospital Garcia de Orta, Cardiology, Almada, Portugal Hospital Garcia de Orta, Cardiology, Almada, Portugal We present a case of a 61-year-old black male, diabetic and former smoker, with past medical history of inferior myocardial infarction with 3-vessel coronary artery disease, complicated by left ventricular free wall rupture, submitted to cardiac surgery in his origin country, 6 years before, that presented with a 1-month history of new complaints of dyspnea, orthopnea and fatigue. Observation was remarkable for the presence of lower limbs edema, with normal cardiac and pulmonary auscultation. The transthoracic echocardiography revealed left ventricle dilatation with hypokinesis of septal and posterior walls, left ventricle ejection fraction of 35% and signs of surgical correction of inferior left ventricle free wall rupture. For better assessment of cardiac anatomy and function, a cardiac magnetic resonance imaging (MRI) was performed. At medial and basal segments of inferior left ventricle wall it was observed free wall rupture associated with the presence of a large pseudoaneurysm (11cm x 9cm x 7cm), with systolic expansion. Adherent to pseudoaneurysm wall, it was visualized a large and organized thrombus. Left ventricle ejection fraction was 34%. The patient was referred to cardiac surgery to pseudoaneurysm exclusion and correction of the rupture. Left ventricular pseudoaneurysm formation typically results in the early period following myocardial infarction and is consequent to rupture of the myocardial free wall. Most cases of left ventricular pseudoaneurysm were related to myocardial infarction (particularly inferior wall myocardial infarction) and cardiac surgery. Congestive heart failure, chest pain and dyspnea were the most frequently reported symptoms. Regardless of treatment, patients with left ventricular pseudoaneurysms had a high mortality rate, especially those who did not undergo surgery. The authors would like to emphasize with this case the role of cardiac MRI in the diagnosis and the long period since myocardial infarction and the diagnosis assumption. View largeDownload slide Abstract P1673 Figure. View largeDownload slide Abstract P1673 Figure. P1675 Hidden behind the radical treatment of an invasive thymoma - a case report M Horumba M Horumba Coltea Clinical Hospital, Internal Medicine, Bucharest, Romania G Cristea G Cristea Coltea Clinical Hospital, Cardiology, Bucharest, Romania R Ilie R Ilie Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania DV Spataru DV Spataru University of Medicine and Pharmacy Carol Davila, Bucharest, Romania AL Gurghean AL Gurghean University of Medicine and Pharmacy Carol Davila, Bucharest, Romania AM Vintila AM Vintila University of Medicine and Pharmacy Carol Davila, Bucharest, Romania R Siliste R Siliste University of Medicine and Pharmacy Carol Davila, Bucharest, Romania C Homentcovschi C Homentcovschi University of Medicine and Pharmacy Carol Davila, Bucharest, Romania R Ciomag R Ciomag University of Medicine and Pharmacy Carol Davila, Bucharest, Romania Coltea Clinical Hospital, Internal Medicine, Bucharest, Romania Coltea Clinical Hospital, Cardiology, Bucharest, Romania Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania University of Medicine and Pharmacy Carol Davila, Bucharest, Romania Funding Acknowledgements: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Radiation therapy is an accelerator of atherosclerosis and may give rise, if aimed at the thorax, to coronary heart disease (CAD), valve disease, pericardial disease or conduction disorders. The factors behind the higher risk of ischemic heart disease are TGF-beta1 and IL-1 that induce fibroblast and endothelial proliferation, promote collagen production and deposition with subsequent fibrosis. While CAD is due to intimal proliferation, valve thickening and conduction abnormalities are due to fibrosis of the adjacent myocardium. A 73-year-old woman with a history of aortic stenosis, hypertension, paroxysmal atrial flutter was referred for transaortic valve replacement (TAVR). The patient had been diagnosed 24 years prior with an invasive thymoma (without myasthenia gravis) with associated left and right brachiocephalic vein (BCV) thrombosis and had undergone surgical excision and radiation therapy for the tumor with implantation of a Gore-Tex vascular graft linking the right BCV and superior vena cava. The physical examination was unremarkable except for a systolic murmur over the aortic area radiating to both carotid arteries. Temperature, blood pressure and heart rate were 36.5 C, 100/60 mmHg and 60 bpm respectively. The electrocardiogram revealed sinus rhythm and a major left bundle branch block. Laboratory assays revealed therapeutic INR (2.13) under antivitamin K (AVK). Echocardiography showed moderate-severe aortic stenosis with moderate regurgitation and pulmonary hypertension. Coronary angiogram revealed extensive non-obstructive atherosclerosis with 80% stenosis of a diagonal branch of the left descending artery and a posterior-lateral branch of the right coronary artery without indication for revascularization. Computed tomography angiogram was performed for accurate valve measurements in addition to several non-stenotic atherosclerotic lesions along the aorta, bilateral renal and common iliac arteries. The patient underwent successful TAVR with an Edwards SAPIEN 3 no. 23 prosthesis. Post-operatively, the patient developed complete heart block which was resolved through the implantation of a DDDR. However, implantation proved impossible through the brachiocephalic left vein as venography revealed left brachiocephalic vein occlusion and the right BCV was preferred. We present the case of a patient with a history of radical treatment for thymoma who developed diffuse, ungraftable coronary artery disease, severe aortic stenosis and a complete heart block following TAVR. It is a well known fact that coronary artery disease is a direct, long-term consequence of radiation therapy. Moreover, beyond the clinical consequences of arterial stenosis, venous bed occlusion may also pose difficulties in terms of implantation of intracardiac devices. P1676 Bicuspid severe aortic stenosis in pregnancy: when life struggles with physiopathology LF Trasca LF Trasca University of Bucharest Carol Davila, Bucharest, Romania N Patrascu N Patrascu University of Bucharest Carol Davila, Bucharest, Romania MS Neagu MS Neagu University of Bucharest Carol Davila, Bucharest, Romania D Vinereanu D Vinereanu University of Bucharest Carol Davila, Bucharest, Romania University of Bucharest Carol Davila, Bucharest, Romania Introduction. Bicuspid aortic valve is the main cause of aortic stenosis among women of childbearing age, its prevalence being almost 2% of all congenital heart diseases. In WHO classification of cardiovascular risk in pregnancy, severe aortic stenosis is included in Class IV risk which comprises extremely high risk for maternal morbidity and mortality. Case description. We report the case of a 29 years old woman with known severe aortic stenosis on the background of a bicuspid aortic valve diagnosed in childhood. The patient presented for cardiovascular evaluation at 15 weeks of pregnancy, being completely asymptomatic. The first echo assessment showed severe aortic stenosis with a mean trans-valvular gradient (MVG) of 44 mmHg and a maximal aortic velocity of 4.6 m/s with normal left ventricle ejection fraction (LVEF) but with Tissue Doppler Imaging (TDI) velocities of the left ventricle (LV) at the lower range of normality with an S’ wave of the lateral mitral annulus of 7 cm/s. The LV strain assessed by TDI showed normal global values but with disparity along left ventricle walls with differences for the lateral and anterior ones which had lower deformation. During the evaluations from the second semester of pregnancy there was an augmentation of the MVG up to 61 mmHg and of the maximal velocity up to 4.9 m/s with a 3D LVEF calculated of 58%, but with increased disparity at the TDI assessment. Woman had no signs or symptoms of heart failure. In the last semester of pregnancy 3D LVEF decreased significantly up to 48% with a slight decrease in gradients and velocity (64 mmHg for the MG and 4.5 m/s for velocity). Even so the patient remained asymptomatic, with normal and specific for every pregnancy stage systolic blood pressure and heart rates, no symptoms of heart failure and she gave birth at the 39 weeks of pregnancy to a normally developed baby breastfeeding him. Discussions. Pregnancy implies an increased hemodynamic stress and can result in decompensation in women with valvular disease. The main problem is that stenotic valve lesions cannot be tolerated because of the fixed obtructive lesion which is not always adaptable to the increase in stroke volume occuring as pregnancy progresses. Moreover arrhythmias, myocardial infarction, stroke of mother, but also preterm delivery and intrauterine growth restriction may occur and remain the main risk events during a severe aortic stenosis pregnancy. Conclusion. Even a severe pathology with a high aggravation potential in the presence of a volume overload condition like pregnancy, can be well tolerated and successful let to the end thanks to an individual adaptability who does not allow a generalization for this pathology. P1677 How many lives does one have in Marfan syndrome? B Fetecau B Fetecau Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania M Rotareasa M Rotareasa Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania C Banescu C Banescu County Emergency Hospital of Targu Mures, Targu Mures, Romania H Moldovan H Moldovan Sanador Hospital, Bucharest, Romania D Deleanu D Deleanu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania R Jurcut R Jurcut Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania County Emergency Hospital of Targu Mures, Targu Mures, Romania Sanador Hospital, Bucharest, Romania Introduction: Marfan disease is an autosomal dominant genetic disorder caused by mutations of the fibrillin-1 gene (FBN-1) - 15q21.1, with multisystemic implications, associated with cardiovascular, musculoskeletal, ocular, cutaneous, pulmonary, neurological abnormalities. The estimated prevalence of Marfan syndrome varies from 1 to 5,000- 10,000 individuals, with no predilection for race or gender. Marfan syndrome is one of the most common, potentially fatal diseases inherited in a mendelian manner, given the risk of aortic dissection and valvular complications in this patients. Purpose The purpose of this case report is to show how several of the possible facets of this disease can occur in the same patient and need serial interventions due to their stepwise progression in a single individual. Case presentation: We present the case of a 67 year old patient, diagnosed with Marfan syndrome at the time of an aortic dissection in 1997, with Bentall surgery (Carboseal 25 conduct) for dissected ascending aortic aneurysm, with mechanic prosthesis in aortic position (now normofunctional), needing at that time a percutaneous catheter drainage with Vaskutek 12 graft (actually thrombosed – CT scan march 2015), who also needed VVIR pacing for complete AV block after surgery (implantable pulse generators replaced in 2006 and 2015). After an eventless evolution until 2015, she developed symptoms due to mitral prolapse with severe mitral regurgitation and underwent MitraClip implantation. Of note, our patient had mild skeletal features of Marfan syndrome (mild scoliosis and reduced upper segment/lower segment amplitude – 0.75), but no thumb and/or wrist sign, as well as no ocular changes. The systemic score was 2. The diagnosis of the patient as Marfan proband allowed also timely diagnosis in 2 nephews, of whom 1 already underwent preventive aortic root surgery for aneurysmal dilation beyond 45 mm. Conclusions: The present case reflects the complex evolution of Marfan disease patients, for whom life can be a continuous challenge due to the evolution of cardiovascular, but also ocular or skeletal symptoms. Therefore close and continuous follow- up is essential, taking into consideration the fact that both vascular and valvular manifestations are possible, both of which can manifest in a severe form at different life moments. Although the systemic score usually reflects the phenotype, the outside doesn’t always embody the inside. View largeDownload slide Abstract P1677 Figure. View largeDownload slide Abstract P1677 Figure. P1678 Longitudinal strain in a young patient with laminopathy UD Breskvar UD Breskvar University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia N Kajdic N Kajdic University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia G Zemljic G Zemljic University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia R Zbacnik R Zbacnik University Medical Centre of Ljubljana, Department of Radiology, Ljubljana, Slovenia A Cerne Cercek A Cerne Cercek University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia D Zizek D Zizek University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia University Medical Centre of Ljubljana, Department of cardiology, Ljubljana, Slovenia University Medical Centre of Ljubljana, Department of Radiology, Ljubljana, Slovenia Introduction: Dilated cardiomyopathy (DCM) is the third most common cause of heart failure (HF) and is the commonest type of cardiomyopathy. The phenotype of ventricular dilatation and abnormal contractile dysfunction is relevant, since specific management strategies can be different, particularly with regard to primary prevention of sudden cardiac death (SCD). We present a case of a young patient initially diagnosed with idiopathic DCM and moderately reduced ejection fraction (EF). However, as additional longitudinal strain was indicative of cardiolaminopathy, implantable cardioverter-defibrillator (ICD) was considered outside practice guidelines. Case presentation: A 37-year-old active sportsman with a 2-year history of mild HF symptoms and family history of SCD was hospitalized due to worsening physical performance, occasional palpitations and syncope. Echocardiography showed mildly enlarged left ventricle (LV) and global hypokinesia with moderately reduced EF of 45 %. Right ventricle and valves were normal. Cardiac magnetic resonance (CMR) with late gadolinium enhancement was consistent with echo findings, however specific aetiology could not be determined. Due to palpitations he was referred for 24-hour Holter monitoring, which revealed moderate ventricular ectopy burden, nonsustained ventricular tachycardia during exertion and intermittent second-degree AV block type I at night. Ergospirometry was unremarkable. We up-titrated HF therapy and prescribed low-dose beta blocker. In few months he was again admitted to our department due to three syncope events. Telemetry confirmed ventricular ectopy, however causative relation with syncope could not be confirmed. Additional tilt test (TT) revealed cardioinhibitory vasovagal syncope with 13 seconds asystole emulating syncope. Due to family history of SCD, undetermined DCM and recorded arrhythmic events additional echo imaging and genetic testing were performed. Longitudinal strain was reduced in all segments with post-systolic deformation most prominent in the LV inferolateral segments, suggestive for genetic cardiomyopathies. We performed genetic testing with the specific analysis of the LMNA gene, which confirmed laminopathy. Due to diagnosis of laminopathy, family history of SCD, cardioinhibitory tilt test, intermittent second degree AV bloc, and recorded ventricular ectopy dual-chamber ICD was implanted outside practice guidelines for primary SCD prophylaxis in DCM. Conclusion: In our case thorough echocardiographic assessment with longitudinal strain proved to be pivotal to determine DCM aetiology. Comprehensive evaluation of patients with DCM is warranted for making the best clinical decisions. View largeDownload slide Abstract P1678 Figure. left ventricular longitudinal strain View largeDownload slide Abstract P1678 Figure. left ventricular longitudinal strain P1679 Effect of sacubitril/valsartan on pulmonary hypertension due to left heart disease: a case report A Giammarresi A Giammarresi IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy F Bandera F Bandera IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy M Losito M Losito IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy V Labate V Labate IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy E Alfonzetti E Alfonzetti IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy M Guazzi M Guazzi IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy IRCCS, Policlinico San Donato, Cardiology University department, San Donato Milanese, Italy Introduction: In heart failure (HF) syndrome development of pulmonary hypertension (PH) carries a relevant clinical and prognostic value. At present, there are not approved therapeutic strategies for the left-sided PH treatment. sacubitril/valsartan is the first of a new class of drugs (ARNIs), that relies on simultaneous blockade of the renin angiotensin aldosterone system and inhibition of neprilysin with significant additive impact on morbidity and mortality over ACE-inhibition . We report a case of a 50 years-old man who was followed at our clinic for heart failure due to ischemic heart disease over a period of 3 years. In May 2015 he experienced an anterior STEMI complicated by out-of-hospital cardiac arrest. He underwent a primary-PCI with implantation of a DES on proximal LAD, with the need of mechanical support with IABP and inotrope agents for cardiogenic shock. Methods: A complete evaluation by cardiopulmonary exercise testing (CPET) combined with exercise echocardiography using a tiltable ergometer was performed at baseline (March 2016) and after 2 years of follow-up. We observed a severe LV dysfunction (LVEF 30%), apical and anterior akinesia, mild MR, grade III diastolic dysfunction (E/A 2,5; average E/e’ 15; LAVI 38,5 ml/m2), severe PH (PASP 100 mmHg), a borderline RV longitudinal function (TAPSE 17 mm) and a unfavourable right ventricle-to-pulmonary circulation coupling (TAPSE/PASP 0,17) (see Figure). During exercise a further increase in PASP (114 mmHg) was observed despite no increase in MR. CPET showed an impaired exercise tolerance (peak VO2 44% of predicted), a moderate ventilatory inefficiency (VE/VCO2 slope 38,8, Ventilatory class III) with a maximum workload of 56 Watts. NT-pro-BNP level was 1503 ng/L. In December 2016, sacubitril/valsartan 49/51 mg bid was added to his therapy, according to Guidelines suggestions. Results: Clinical course and symptoms improved over time without any significant clinical event or therapeutic adjustement in the range of two years follow-up. In March 2018 the patient repeated a CPET combined with exercise-echo. LV systolic function was mildly improved (LVEF 35%), while diastolic function and MR were unchanged. Surprisingly, we observed a significant reduction in pulmonary arterial pressures (PASP 50 mmHg), with a more favourable RV-to-PC coupling (TASPE/PASP 0,38). Nonetheless, during exercise, an increase in PASP to 110 mmHg was detected (see Figure). Peak VO2 was improved (50% of predicted) as well as ventilatory efficiency (VE/VCO2 slope 33,3, Ventilatory class II) with a maximum workload of 79 Watts. NT-pro-BNP level was 435 ng/L. Conclusion: The potential effect of sacubitril/valsartan on pulmonary vasculature and its role on exercise gas exchange is underappreciated. The observed remarkable reduction in PASP and recoupling of RV to PC coupling points in favor of a large scale assessment of potential benefits on pulmonary hemodynamics with sacubitril/valsartan. View largeDownload slide Abstract P1679 Figure 1 View largeDownload slide Abstract P1679 Figure 1 P1680 A rare cause of acute left ventricular systolic dysfunction in the immediate postpartum period C Jozsa C Jozsa Croydon Health Services NHS Trust, Department of Cardiology, London, United Kingdom V Pergola V Pergola Croydon Health Services NHS Trust, Department of Cardiology, London, United Kingdom Croydon Health Services NHS Trust, Department of Cardiology, London, United Kingdom Introduction: the peripartum period predisposes women to a number of pathologies leading to shortness of breath, which has predominantly pulmonary or cardiovascular origin. The typical examples are infection, pulmonary embolism, acute coronary artery disease, spontaneous coronary artery dissection and peripartum cardiomyopathy. Case presentation: we present a case of a 31 years old white woman at 37 week of gestation who was admitted to hospital because of pre-eclamptic toxaemia. It was decided to deliver the twins by means of a Caesarian section. Following birth the mother became breathless, desaturated rapidly and the cardiology team was contacted. There was no evidence of infection either clinically or on the chest X-ray or in the lab results. The bedside transthoracic echocardiography showed severe left ventricular systolic dysfunction, ejection fraction of 20% with hypokinesia of the mid and basal segments and preserved contractility of the apical segments. During her evaluation, she was found to have elevated cardiac enzyme level in association with HELLP syndrome. She was commenced on an appropriate heart failure regimen and monitored in the cardiac care unit. Pulmonary embolism was excluded with V/Q scan. CT coronary angiography revealed unobstructed coronary arteries and no coronary artery dissection. One week later cardiac MRI was performed showing an improved left ventricular ejection fraction up to 44% without any evidence of myocardial inflammation, fibrosis, infiltration or infarction. The left ventricular systolic function returned back to the normal in one and half month. The most probable diagnosis of this patient was reverse Takotsubo cardiomyopathy, which was mainly based on the characteristic echocardiographic findings, sudden clinical and left ventricular systolic function deterioration and rapid improvement of the left ventricular ejection fraction. Conclusion: in the postpartum period only a few cases of reverse Takotsubo cardiomyopathy were published in the literature up to now. This case illustrates that we should consider even this rare cause of acute left ventricular systolic dysfunction during the differential diagnosis in the postpartum period, by using multimodality imaging (transthoracic echocardiography, cardiac CT and cardiac MRI) to establish the correct diagnosis. P1681 Acute left ventricle systolic dysfunction after chemoembolization with irinotecan in a 61-year-old patient with cholangiocarcinoma M Zechowicz M Zechowicz University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland L Gromadzinski L Gromadzinski University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland U Laczkowska U Laczkowska University Clinical Hospital, Clinic of Cardiology and Internal Medicine, Olsztyn, Poland B Moczulska B Moczulska University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland M Rucinska M Rucinska University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland University Clinical Hospital, Clinic of Cardiology and Internal Medicine, Olsztyn, Poland For patients with cholangiocarcinoma transarterial chemoembolization (TACE) with the use of drug-eluting beads with irinotecan (DEBIRI) represents a novel alternative to systemic chemotherapy or local treatments alone. Anticancer chemoembolization is considered safer than systemic therapy, but little is known about cardiotoxicity of such treatment. Aim of this case study is to present a rare cardiotoxic effect of chemoembolization with irinotecan in a 61-year-old patient with cholangiocarcinoma after palliative systemic treatment with gemcitabine and cisplatin. The male patient without cardiovascular risk factors, with no history of hypertension, dyslipidemia, smoking or diabetes, was admitted to cardiology clinic due to aggravating fatigue, slight dyspnea, tachycardia and retrosternal pain, which appeared directly after the procedure of DEBIRI. A month before, 6-months-long systemic therapy with gemcitabine and cisplatin was completed without any apparent cardiotoxic effects. Before chemoembolization the electrocardiogram (ECG) was normal. In following ECGs there was tachycardia 110/min observed, as well as 1mm ST elevation in leads V2-V3 and ST depression with negative T in leads: II, III, aVF, V4-V6. There was no typical coronary chest pain observed, but the patient complained about mainly upper abdominal and general pain. The blood pressure was tending to lower values with 90/60mmHg at the time of admission. There were no signs of congestion. Troponin T levels were stable but slightly increased (0.063 to 0.097ng/ml) and there was no dynamics typical for acute coronary syndrome. NT-pro-BNP was significantly elevated to 4773 pg/ml. Echocardiography confirmed the suspicion of cardiotoxicity: regional contractility was impaired with LVEF 45-48% (Simpson), global longitudinal strain was low (-12.9%), diastolic dysfunction type I was present with e’ m and e’ lat lowered to 4 cm/s and 6 cm/s respectively, there were no valve disorders present. Treatment with B-blocker and ACE-I was initiated with a good tolerance. Additional imaging diagnostics with magnetic resonance was scheduled. Cardiotoxic effects of irinotecan alone are rarely described in literature. In this case patient was treated with gemcitabine and cisplatin before, which are also reported with rare cardiac side effects. In some cases a multiple hit mechanism of myocyte damage due to consecutive use of many cardio-toxic agents during treatment was described. Such a complication significantly deteriorates the initially poor prognosis of the patient. Interestingly, the patient had no cardiovascular risk factors when qualified for the various methods of anticancer treatment. Although chemoembolization with irinotecan is known as little cardiotoxic, new symptoms of heart failure or coronary artery disease should draw attention to possible post-treatment cardiomyopathy. Echocardiography is of critical importance for the right diagnosis in time. View largeDownload slide Abstract P1681 Figure. View largeDownload slide Abstract P1681 Figure. P1682 Right ventricle failure as a consequence of a concrete lung and septic shock: mechanical circulatory support A Gambaro A Gambaro Royal Brompton Hospital, London, United Kingdom H Soliman H Soliman Royal Brompton Hospital, London, United Kingdom C Vanderbriele C Vanderbriele Royal Brompton Hospital, London, United Kingdom R Fisher R Fisher Royal Brompton Hospital, London, United Kingdom F Caetano F Caetano Royal Brompton Hospital, London, United Kingdom J Doyle J Doyle Royal Brompton Hospital, London, United Kingdom S Price S Price Royal Brompton Hospital, London, United Kingdom Royal Brompton Hospital, London, United Kingdom Funding Acknowledgements: No financial support OnBehalf: N/A Introduction: In myocardial dysfunction complicating septic shock, the usual pattern is of biventricular failure, however, in the presence of pneumonia, right ventricular dysfunction may predominate. Choice of appropriate mechanical circulatory support (MCS) depends upon careful echocardiographic evaluation. Description of the Problem: A 44-year-old man with pneumococcal pneumonia and septic shock was referred for venous-venous extracorporeal membrane oxygenation (VV ECMO).The patient was treated with broad spectrum antibiotic therapy and intravenous immunoglobulin and supported by protective lung ventilation, vasopressors and VV-ECMO. Admission echocardiography demonstrated preserved biventricular function, with evidence of high pulmonary hypertension pressure (RV systolic pressure 48mmHg). Over the next four hours the patient became profoundly shocked (MAP 60mmHg and rising lactate). Repeat echocardiography showed RV impairment associated with McConnell’s sign, plus significant LV impairment. Pulmonary embolism was excluded by Computed Tomography, and a diagnosis of septic cardiomyopathy plus acute cor pulmonale secondary to acute respiratory distress syndrome (ARDS) and pneumonia was made. The patient was commenced on milrinone and inhaled nitric oxide. Question and Problems: How will the patient respond to ‘upgrade’ of his extracorporeal support? Which type of mechanical circulatory is most appropriate in the context of his ventricular dysfunction and pulmonary hypertension? Answer/Discussion: In patients with isolated RV failure, the use of direct RV bypass system helps to reduce right atrium (RA) pressure, but increases mean pulmonary arterial (PA) pressure and LV preload. Conversely, veno-arterial ECMO (VA-ECMO) decreases RA and PA pressures and LV preload. LV afterload increases, but native CO may remain unchanged if LV function is preserved. In patients with biventricular failure, VA ECMO support decreases RA pressure and provides oxygenated blood support for the body, however, at the expense of increased LV afterload. This can translate into an increase in LV filling pressure, oxygen demand and PA pressure. In contrast, activation of direct RV bypass system decreases RA pressure, unload RV and increases LV preload. After multisciplinary team discussion, the patient received RV bypass system together with an oxygenator, however despite improving all haemodynamic and echocardiographic parameters, he died 3 days later from multi-organ dysfunction. Conclusion: Septic myocardial dysfunction is reportedly predominantly biventricular, however, in the context of severe pneumonia, ARDS and a very high pulmonary vascular resistance, RV dysfunction may predominate, with proposed mechanisms including RV distention as well as associated hypoxia, hypercarbia and acidaemia. Here, the reduction in forward stroke volume from the RV as well as septal flattening contribute to reduction in stroke volume from the left heart. View largeDownload slide Abstract P1682 Figure. Biventricular disfuction in septic shock View largeDownload slide Abstract P1682 Figure. Biventricular disfuction in septic shock P1683 Left ventricular aneurysm after myocardial infarction: the important contribution of detailed imaging modalities to decide on aneurismectomy C Brizido C Brizido Hospital de Santa Cruz, Lisbon, Portugal MJ Andrade MJ Andrade Hospital de Santa Cruz, Lisbon, Portugal AM Ferreira AM Ferreira Hospital de Santa Cruz, Lisbon, Portugal P Freitas P Freitas Hospital de Santa Cruz, Lisbon, Portugal D Matos D Matos Hospital de Santa Cruz, Lisbon, Portugal P Magro P Magro Hospital de Santa Cruz, Lisbon, Portugal FF Gama FF Gama Hospital de Santa Cruz, Lisbon, Portugal S Madeira S Madeira Hospital de Santa Cruz, Lisbon, Portugal M Trabulo M Trabulo Hospital de Santa Cruz, Lisbon, Portugal JP Neves JP Neves Hospital de Santa Cruz, Lisbon, Portugal M Mendes M Mendes Hospital de Santa Cruz, Lisbon, Portugal Hospital de Santa Cruz, Lisbon, Portugal We report the case of a 44-year-old male smoker with otherwise unremarkable clinical background, and 1-week long complaints of left pleuritic chest pain and cough, without angina or heart failure symptoms. The electrocardiogram showed pathological Q waves and ST-segment elevation from V1 to V5. High-sensitivity troponin T was repeatedly low, suggesting pericarditis after subacute/chronic anterior myocardial infarction. Echocardiogram (images A, B and C) showed a severely dilated left ventricle (LV), with end-diastolic and end-systolic volumes (EDV/ESV) of 290mL and 190mL respectively, and an ejection fraction (EF) of 32% by Simpson biplane, owing to septal and anterior wall akinesia and apical dyskinesia. Increased wall thickness at the apex raised suspicion of a large apical aneurism lined by a mural thrombus, which was confirmed by contrast-enhanced cardiac CT. On coronary angiography, left anterior descending artery was distally occluded and there was a 80% focal lesion on the proximal circumflex artery. Given the embolic risk associated with the large apical aneurism, Cardiac Magnetic Resonance (CMR) was performed to better delineate cardiac anatomy and feasibility of surgical aneurismectomy. On CMR, EF was 23%, EDV 289mL (168mL/m2) and ESV 222mL (129mL/m2). Contrast with late-gadolinium-enhancement showed transmural necrosis with lack of viability in all apical segment and mid anterior and inferior septum (images D, E, F). Virtual CMR simulation of LV geometry after a possible reconstructive surgery with aneurismectomy predicted a reasonable outcome, with expected decrease of EDV by nearly half and increase of EF around 16%. After Heart Team discussion the patient underwent surgical repair using the endoventricular circular patch plasty technique – the "Dor" procedure – and an arterial bypass graft to the first obtuse marginal artery. The procedure was uneventful, and post-operative recovery was favorable. Surgical result, as assessed by echocardiography (images G, H, I) was close to CMR prediction, showing significant LV volume reduction and improvement of EF (EDV 128 mL (78ml/m2), ESV 77mL (48ml/m2), EF of 40%). LV aneurysms and progressive remodeling/dysfunction is not uncommon after non-reperfused anterior myocardial infarctions. The paradoxical bulging of aneurysmal segment "steals" part of LV stroke volume, thereby decreasing effective cardiac output and inducing LV volume overload, LV dilation and end-diastolic pressure rise, generating a vicious cycle that dictates the progression to heart failure. The present case highlights the utility of multi-modality imaging for the diagnosis and management decisions of LV aneurysms complicating myocardial infarction. Image-guided treatment resulted in significant clinical improvement and favorably influenced conventional prognostic variables like end-diastolic volume and ejection fraction. View largeDownload slide Abstract P1683 Figure. View largeDownload slide Abstract P1683 Figure. P1684 An unusual case of ARCAPA in the elderly: role of multimodality imaging F Casadei F Casadei Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy P Pedrotti P Pedrotti Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy G Annoni G Annoni Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy G Vignati G Vignati Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy B De Chiara B De Chiara Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy P Sormani P Sormani Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy F Musca F Musca Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy F Spano" F Spano" Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy O Belli O Belli Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy G Santambrogio G Santambrogio Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy C Giannattasio C Giannattasio Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy A Moreo A Moreo Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy Niguarda Ca" Granda Hospital, Cardiology, Milan, Italy A 68 year-old man with frequent premature ventricular contractions (PVCs) despite normal transthoracic echocardiography (TTE), underwent cardiac magnetic resonance (CMR) showing mild left ventricle (LV) dilation with preserved ejection fraction (EF); no late gadolinium enhancement was present; diffuse ectasia of coronary arteries was described. Treadmill stress test was unremarkable. Antiarrhythmic therapy was started with reduction of PVCs. Five years later he underwent a routine TTE that evidenced preserved LVEF. Color Doppler evaluation showed turbolent flow along the interventricular septum and within the apex of the right ventricle. Invasive coronary angiogram (ICA) was performed: the origin of the right coronary artery (RCA) from the right coronary sinus could not be visualized, the left main stem (LM) arose from the left coronary sinus and blood flow from left anterior descending artery (LDA) and circumflex artery (Cx) filled retrogradely the RCA through collateral vessels and passed into the pulmonary artery (PA). Multislice computed tomography (MSCT) was performed to better depict the coronary circulation, and it confirmed anomalous RCA originating from the main PA (ARCAPA); LM, LDA and Cx were dilated; collateral vessels originating from LDA had serpiginous course anteriorly to the right ventricle. Stress single photon emission computed tomography was negative for myocardial ischemia, the patient was asymptomatic and had no arrhythmias on pharmacological therapy; the treatment was conservative and the patient is now in follow-up. ARCAPA is a rare congenital coronary anomaly (CAA). Increase in oxygen demand can lead to infarction or sudden death due to steal phenomenon, but the majority of patients remain asymptomatic and the finding can be incidental. TTE is usually the initial imaging investigation but, in adults, it is less accurate in the evaluation of the proximal part of the coronary arteries. In our patient TTE demonstrated abnormal flow but it was unable to delineate the exact coronary anatomy and to discriminate between CAA and coronary fistula. ICA allowed the diagnosis of ARCAPA. However in CAAs the course and origin of each vessel can be complex and not clearly represented with two-dimensional images. MSCT is currently the gold standard for identification and characterization of CAAs due to the ability to define the course of the arteries in relation to other cardiovascular structures. CMR is reported to be a good noninvasive modality to detect CAAs. In the case that we present, CMR was performed to exclude myocardial structural abnormalities but didn’t detect RCA origin anomaly due to poor image quality in presence of PVCs. Furthermore no dedicated sequences were performed since the anomaly had not been suspected during scan acquisition. In conclusion, in CAAs, multimodality imaging is necessary to integrate information on coronary anatomy with its consequences on cardiac function and myocardial tissue characteristics. View largeDownload slide Abstract P1684 Figure. Multimdality imaging in ARCAPA View largeDownload slide Abstract P1684 Figure. Multimdality imaging in ARCAPA P1685 Unexpected cause of chest pain with ST-elevation on ECG A Gomiscek A Gomiscek Izola General Hospital, Department of Internal Medicine, Izola, Slovenia S Korosec S Korosec Izola General Hospital, Department of Internal Medicine, Izola, Slovenia J Avramovic J Avramovic Izola General Hospital, Department of Internal Medicine, Izola, Slovenia G Plevnik G Plevnik Izola General Hospital, Department of Internal Medicine, Izola, Slovenia Izola General Hospital, Department of Internal Medicine, Izola, Slovenia A 51 years old male heavy smoker without previous medical history was referred to the emergency department (ED) by paramedics’ due to intermittent chest pain lasting for about one day and changes in the ECG (Fig. 1). He described the pain as a substernal burning sensation, with 7/10 on VAS, which was radiating to the neck. It started the evening before presentation, stopped during the night and reappeared in the morning. He felt similar pain, but less sever in the past, mostly during exercise. At the time of examination at the ED the pain was gone. ECG at ED showed sinus rhythm, T-wave inversion in aVL and biphasic T in V2. Clinical examination was insignificant. Laboratory work showed hyperlipidaemia and no other abnormalities. Troponin was negative twice. During bed side echocardiography hypokinesia of the apex was observed, which subsequently disappeared while performing the echo. The patient was admitted to the cardiology ward due to suspicion of unstable angina. During clinical work-up we found out that prior one year a stress/rest myocardial perfusion scintigraphy showed mild stress induced ischemia, viable myocardium without any regional motion disturbances (Fig 1). Due to data acquisition defects, the degree of ischemia was not reliable, therefore subsequently coronary computed tomography angiography was performed, which did not show any haemodynamically significant stenosis and LAD bridging. Coronary angiography performed during the hospitalisation showed left dominant system, dynamic narrowing of the mid LAD. After application of contrast the patient felt chest pain, dynamic constriction was visible, which resolved after application of nitro-glycerine (Fig. 1). The diagnosis of muscle bridge of the mid LAD was confirmed. Patient was dismissed home with medical therapy. For exclusion of any additional potentially dangerous nonobstructive coronary artery disease intravascular imaging or plaque morphology imaging techniques would be necessary. View largeDownload slide Abstract P1685 Figure 1 View largeDownload slide Abstract P1685 Figure 1 P1686 A very rare coronary anomaly case report M Hassan Abdelnabi M Hassan Abdelnabi Medical Research Institute, Alexandria University, Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria, Egypt A Almaghraby A Almaghraby Alexandria University, Department of Cardiology, Alexandria, Egypt M Sanhouri M Sanhouri Alexandria University, Department of Cardiology, Alexandria, Egypt Y Saleh Y Saleh Alexandria University, Department of Cardiology, Alexandria, Egypt E El Sharkawy E El Sharkawy Alexandria University, Department of Cardiology, Alexandria, Egypt M Hassanein M Hassanein Alexandria University, Department of Cardiology, Alexandria, Egypt Medical Research Institute, Alexandria University, Cardiology and Angiology Unit, Clinical and Experimental Internal Medicine Department, Alexandria, Egypt Alexandria University, Department of Cardiology, Alexandria, Egypt Background: Congenital coronary anomalies are defined as any coronary pattern with a feature (origin, course, or termination) rarely encountered in the general population. According to the literature, coronary anomalies are observed in 1 percent of the general population. Single coronary artery is a very rare anomaly. we present a case of a single coronary artery with origin from a single ostium in the right sinus of Valsalva with double left anterior descending arteries (LAD) arise from right coronary artery (RCA) with two different courses. case presentation: A 38-year-old female patient with no cardiovascular risk factors presented to our facility by acute chest pain that started 3 hours before presentation. She was hemodynamically stable and her clinical examination was unremarkable. Her ECG showed 0.5 mm ST segment depressions in the lateral leads. Her cardiac troponin was slightly positive. She received dual Antiplatelets and was sent for coronary angiography. A bed-side transthoracic echocardiography showed no regional wall motion abnormalities. Coronary angiography showed accidentally discovered single origin of the coronary tree from the right coronary sinus, the right coronary artery was normal, the left system arises directly from the right coronary sinus and gives a small circumflex and two long left anterior descending arteries that also showed no significant lesions. MSCT coronary angiography confirmed that diagnosis and showed a benign course of one of the left anterior descending arteries and a malignant course of the other LAD that was running between the aorta and the right ventricular outflow tract. The patient refused any surgery and she was treated conservatively and she is doing well up till now. Conclusion: The presence of a single coronary artery is a very rare congenital anomaly with a reported incidence of 0.024% to 0.06%. They are usually asymptomatic, but some variants have been reported to carry a risk for serious cardiac events such as sudden cardiac death and myocardial infarction. It can be diagnosed either by conventional coronary angiography or computed tomography coronary angiography which is extremely useful to identify congenital coronary artery anomalies, regarding both their origins, courses and also relationships with other cardiac structures. Dual LAD is a rare congenital anomaly with two LADs with a short LAD terminates in the proximal part of the interventricular septum and does not reach the cardiac apex. Long LAD arises from the right or left coronary system, and takes a variable course and enters the distal part of the anterior interventricular septum and reaches up to the cardiac apex. To our knowledge this is the first case to report dual LAD arising from single coronary artery originating from right sinus of valsalva. View largeDownload slide Abstract P1686 Figure. A single coronary with double LAD View largeDownload slide Abstract P1686 Figure. A single coronary with double LAD P1687 Prinzmetal angina - a life threatening diagnosis T Branco Mano T Branco Mano Hospital de Santa Marta, Cardiologia, Lisboa, Portugal L Moura Branco L Moura Branco Hospital de Santa Marta, Cardiologia, Lisboa, Portugal J Reis J Reis Hospital de Santa Marta, Cardiologia, Lisboa, Portugal S Aguiar Rosa S Aguiar Rosa Hospital de Santa Marta, Cardiologia, Lisboa, Portugal S Jardim S Jardim Hospital de São José, Internal Medicine, Lisbon, Portugal R Cruz Ferreira R Cruz Ferreira Hospital de Santa Marta, Cardiologia, Lisboa, Portugal Hospital de Santa Marta, Cardiologia, Lisboa, Portugal Hospital de São José, Internal Medicine, Lisbon, Portugal Printzmetal angina is characterized by sudden chest pain due to epicardial coronary spasm, usually associated with transient myocardial ischemia. However, it can lead to myocardial infarction, left ventricular impairment, potentially fatal arrhythmias and sudden death. A caucasian 28-year-old man, with no known medical history except an episode of short duration of chest pain 1 month before, presented to the emergency room (ER) with chest pain initially without electrocardiographic alterations (fig.1) nor elevated troponins. He then developed a new episode of chest pain at the ER associated with very significant anterior-lateral ST-segment elevation (fig.1), which evolved to ventricular fibrillation and cardiorespiratory arrest. After circulatory recovery, he underwent coronary angiography that showed a multivessel spastic component (left main trunk, anterior descending and circumflex arteries) partially reversed by intracoronary nitrate administration. He was admitted to an intensive care unit for hypothermia therapy. For a few days he had fever first attributed to pneumonia, but later attributed to eventual infective endocarditis and he was started on empirical antibiotic therapy. He had seizures and several ischemic lesions in the cerebral CT, being with neurologic sequela for several weeks. The transthoracic echocardiogram performed demonstrated a mild left ventricular systolic dysfunction (53% ejection fraction and GLS -14.9%) with akinesia of apical septal segment and hipokinesia of mid anteroseptal, mid anterior, apical anterior and apical inferior segments. The aortic valve had a partially calcified nodule in the right coronary cusp (6.5x6.7mm), with peak and mean systolic gradient of 33 and 17mmHg, respectively, and moderate regurgitation. Myocardial perfusion scintigraphy (fig.1) confirmed an apical infarction and ischemia in circumflex artery territory. In subsequent coronary arteriography, he seemed to have an intermediate lesion in the proximal circumflex artery, which was not confirmed later on by computerized tomographic coronary angiogram (fig.1). After discussion in Heart Team, an ICD was implanted (secondary prevention), and, assuming a predominant vasospastic component, he was maintained on optimized medical therapy with nitrates and calcium channel blockers with regression of symptoms. We intend to bring this case to the discussion to emphasize the difficulties still inherent to this pathology, even with multiple imaging modalities and show how serious and life threatening a coronary spasm can be. View largeDownload slide Abstract P1687 Figure 1 View largeDownload slide Abstract P1687 Figure 1 P1688 Transverse sinus pericarditis causing a recurrent chest pain in a 61-year old woman with a suspicion of aortic inflammation and dissection M Zechowicz M Zechowicz University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland U Laczkowska U Laczkowska University Clinical Hospital, Clinic of Cardiology and Internal Medicine, Olsztyn, Poland A Zurada A Zurada University of Warmia and Mazury, Department of Radiology, Olsztyn, Poland B Moczulska B Moczulska University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland M Rucinska M Rucinska University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland L Gromadzinski L Gromadzinski University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland University of Warmia and Mazury, Department of Oncology, Olsztyn, Poland University Clinical Hospital, Clinic of Cardiology and Internal Medicine, Olsztyn, Poland University of Warmia and Mazury, Department of Radiology, Olsztyn, Poland University of Warmia and Mazury, Department of Cardiology and Cardiac Surgery, Olsztyn, Poland The transverse pericardial sinus with its associated recesses is a uniquely located structure posterior to the ascending aorta and pulmonary trunk above the left atrium. Its inflammation may result in symptoms suggesting an acute coronary syndrome or an aortic dissection. In the presented case report a 61-year old woman has suffered from a recurrent chest pain radiating to the back with a slight dyspnoea for some weeks. Based on electrocardiogram and Troponin T levels acute coronary syndromes (ACS) were excluded during repeating appearances in emergency departments. Angiographic computed tomography (CT) excluded also pulmonary embolism and aortic dissection, but revealed a slight contrast enhancement around the ascending aorta within pericardium. No additional pericardial effusion was observed. With a suspicion of aortic inflammation the patient was admitted to our cardiology clinic for further diagnostics and treatment. She complained about aggravating retrosternal pain, especially when inhaling and lying down. In physical examination no significant abnormalities were found. In laboratory tests only C-reactive protein (192mg/l), fibrinogen (670mg/dl), platelet number (663000/ul) and NT-pro-BNP (476pg/ml) were significantly elevated. Finally, transthoracic echocardiography (TTE) revealed hyperechogenic pericardial effusion in the vicinity of the ascending aorta and the left atrium. Treatment with colchicine and NSAIDs was initiated, but the patient required an addition of corticosteroids due to an inadequate clinical response and increasing pericardial effusion in following TTEs. Viral or bacterial background was excluded, as well as tuberculosis. There were no indices of neoplastic or autoimmune diseases in additional diagnostics. The patient was discharged after three weeks with no pericardial effusion or chest pain. Transverse pericardial sinus inflammation is a very rare presentation of pericarditis, but the unique structure should be thoroughly observed using modern imaging equipment. It can be now visualized with more clarity and precision using TTE, CT or magnetic resonance (MRI). Differentiation of normal from abnormal findings in this location is critical in echocardiography with the use of the other imaging modalities, as anatomic variants occurring in normal cardiac developments often simulate pathologic entities. The diagnostics in such pericarditis is also more difficult due to often sparse effusion and impossibility of diagnostic pericardiocentesis, when the background of the inflammation is uncertain. An adequate reaction to the therapy may be of importance in differential diagnosis, as it appeared in the presented case. The transverse sinus inflammation is a very rare presentation of pericarditis, but should be considered when other possible causes of retrosternal pain are excluded. Different imaging techniques are necessary, but echocardiography is of critical importance. View largeDownload slide Abstract P1688 Figure. Transverse sinus effusion View largeDownload slide Abstract P1688 Figure. Transverse sinus effusion P1689 Effusive-constrictive pericarditis in a patient with end-stage renal disease A Wojtkowska A Wojtkowska Medical University of Lublin, Cardiology Department, Lublin, Poland M Zakoscielna M Zakoscielna Medical University of Lublin, I st. Department of Radiology, Lublin, Poland A Wysokinski A Wysokinski Medical University of Lublin, Cardiology Department, Lublin, Poland E Czekajska-Chehab E Czekajska-Chehab Medical University of Lublin, I st. Department of Radiology, Lublin, Poland A Tomaszewski A Tomaszewski Medical University of Lublin, Cardiology Department, Lublin, Poland Medical University of Lublin, Cardiology Department, Lublin, Poland Medical University of Lublin, I st. Department of Radiology, Lublin, Poland End-stage-renal-disease (ESRD) is associated with possible pericardial involvement, which is manifested most commonly as acute pericarditis or chronic pericardial effusion and infrequently as chronic constrictive pericarditis. A 51-year-old patient with ESRD, in the course of glomerulonephritis, chronically dialyzed, initially with peritoneal dialysis, currently with hemodialysis, renal transplantation twice, after nephrectomy because of adenocarcinoma of transplanted kidney, he was admitted to the Clinic due to deterioration of effort tolerance, peripheral edema, elevation of inflammation parameters. In laboratory tests, initially CRP-137 mg/l, procalcitonin not elevated, negative blood cultures. ECG showed atrial fibrillation, low voltages of QRS. Echocardiographic examination (TTE) revealed pericardial fluid, normal left ventricular (LV) dimension, preserved systolic function (EF-58 %), restrictive filling patern of LV and RV, respiratory variability of mitral peak E velocity of > 25%, inspiratory ventricular septal motion toward LV- septal bounce, enlargement (2.3 cm) and absence of respiratory collapse of vena cava inferior (VCI). In the computed tomography (CT) of the chest and abdominal cavity, no process of neoplasia character was found. In the pericardial sac, a fluid of approx. 18 mm thickness and density 10-20 jH, thickening of pericardium layers to approx. 2.8-3 mm, contrast enhancement of pericardium layers, marked obliteration of adhering adipose tissue with the presence of higher densities and contrast reflux to inferior vena cava and hepatic veins are depicted. No specific etiology for pericarditis was found after numerous serological and bacteriological studies. In laboratory tests, non-increased cardiac enzymes (troponin, CK, CK-MB), negative tumor markers (AFP, CEA, CA 15-3, CA 19-9), non-reactive virological tests in the IgM class (CMV, EBV, Enterovirus, Coxackie) , Quantiferon-TB negative test. Due to the features of active exudative-constrictive pericarditis found in imaging studies and elevated inflammatory parameters in the patient, dialysis was optimized and anti-inflammatory treatment was initiated: ibuprofen initially at a dose of 3 x 600 mg, and it was decided to administer colchicine 0.5 mg 1 x 1 tablet. In a follow-up examination after one month, improvement of clinical status, in TTE reduction in the amount of pericardial fluid, normal size and respiratory mobility of the inferior vena cava, respiratory variation of the mitral peak E velocity was smaller. Although ESDR is a rare cause of exudative-constrictive pericarditis, if symptoms of this condition appear and in the presence of active inflammatory features (elevation of CRP, contrast enhancement of pericardium on CT), after the optimization of dialysis therapy and the inclusion of anti-inflammatory treatment, the features of pericardium constriction can be reversed. Such a management may prevent the need for pericardiectomy. View largeDownload slide Abstract P1689 Figure. respiratory variation of the mitral peak View largeDownload slide Abstract P1689 Figure. respiratory variation of the mitral peak P1690 Primary cardiac angiosarcoma presenting with recurrent pericardial effusions HS Ahn HS Ahn Uijeongbu St. Mary"s Hospital, Internal medicine, Uijeongbu, Korea Republic of SH Kim SH Kim Seoul National University Hospital, Health promotion center, Seoul, Korea Republic of CS Park CS Park Bucheon St. Mary"s hospital, Internal medicine, Bucheon, Korea Republic of SK Ryu SK Ryu Eulji University, Cardiology, Seoul, Korea Republic of HK Jeon HK Jeon Uijeongbu St. Mary"s Hospital, Internal medicine, Uijeongbu, Korea Republic of Uijeongbu St. Mary"s Hospital, Internal medicine, Uijeongbu, Korea Republic of Seoul National University Hospital, Health promotion center, Seoul, Korea Republic of Bucheon St. Mary"s hospital, Internal medicine, Bucheon, Korea Republic of Eulji University, Cardiology, Seoul, Korea Republic of Pericardial effusions may be due to an array of medical conditions including infection, malignancy, collagen vascular disease and chest radiation. Those of unclear etiology may represent a diagnostic challenge. Primary cardiac angiosarcoma is rare entities that may present as a recurrent pericardial effusion in a patient with nonspecific symptoms and no pertinent medical history. We report a case of 45-year-old man who presented with five months of recurrent pericardial effusions. He was referred to us for further evaluation. Primary cardiac angiosarcoma was confirmed by liver biopsy and multimodality imaging including echocardiography and chest CT. The case highlights the misdiagnosis in initial clinical presentation, current diagnostic modalities such as multiple image studies and pathological approach for cardiac angiosarcoma. View largeDownload slide Abstract P1690 Figure. chest CT View largeDownload slide Abstract P1690 Figure. chest CT P1691 Purulent pericarditis complicating aortic valve infective endocarditis CM Bulei CM Bulei Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania R Enache R Enache Carol Davila University of Medicine and Pharmacy, Euroecolab, Prof. Dr. C.C Iliescu Institute, Bucharest, Romania B Radulescu B Radulescu Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania C Ginghina C Ginghina Carol Davila University of Medicine and Pharmacy, Euroecolab, Prof. Dr. C.C Iliescu Institute, Bucharest, Romania BA Popescu BA Popescu Carol Davila University of Medicine and Pharmacy, Euroecolab, Prof. Dr. C.C Iliescu Institute, Bucharest, Romania Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest, Romania Carol Davila University of Medicine and Pharmacy, Euroecolab, Prof. Dr. C.C Iliescu Institute, Bucharest, Romania The complications of infective endocarditis can sometimes overshadow the culprit disease. We present the case of a 62 y/o man, who had been treated 3 months previously for meningoencephalitis, with recurrent fever despite completing several lengthy antibiotic regimens. On admission, the patient described shortness of breath on exertion, the transthoracic echocardiography revealed an intrathoracic tumor (5/8 cm in diameter) that compressed the right cardiac chambers and aortic valve disease with moderate to severe stenosis and mild regurgitation. During the transesophageal examination images suggestive for a drained aortic root abscess, an aortic valve vegetation on a bicuspid aortic valve and the heterogeneous nature of the tumor were noticed. A computed tomography scan revealed the pericardial location of the tumor, its fluid density and its compressing effect on the superior vena cava and the right atrium. Following these imaging examinations, the diagnosis of chronic infective endocarditis was established. The patient underwent surgery for aortic valve replacement, aortic root reconstruction and pericardial drainage which revealed purulent effusion (Streptococcus mitis was identified). The patient received prophylactic antibiotic therapy before and after surgery and recovered without complications. On reevaluation two months later, he described improved effort tolerance, presented normal left ventricular function and well-functioning aortic prosthesis. The insidious nature of the infective endocarditis led to a late diagnosis. View largeDownload slide Abstract P1691 Figure. View largeDownload slide Abstract P1691 Figure. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2019. For permissions please email: Journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Poster Session - Clinical case poster session 6
JF - European Heart Journal – Cardiovascular Imaging
DO - 10.1093/ehjci/jey275
DA - 2019-01-01
UR - https://www.deepdyve.com/lp/oxford-university-press/poster-session-clinical-case-poster-session-6-mDz5UCGO7u
SP - i1173
VL - 20
IS - Supplement_1
DP - DeepDyve
ER -