P125 CORONARY REVASCULARIZATION GUIDED BY STRESS ECHOCARDIOGRAPHY WITH ULTRASOUND CONTRAST: A CASE

Echocontrastography is an echocardiography method that involves the intravenous administration of a particular contrast medium, formed by microbubbles capable of crossing the pulmonary circulation and distributing themselves in the left sections. These micro bubbles hit by ultrasound break or oscillate emitting ultrasound waves with a different frequency than the beam that hit them, generating a series of harmonic signals that can be processed to observe, for example, the opacification of the left cavities. An 82–year–old diabetic hypertensive man with a strong family history of coronary artery disease underwent routine cardiac evaluation. At the time of the visit, sporadic episodes of non–specific chest pain (localized in the right breast), of an intermittent nature, and not related to physical exertion, were reported. On the ECG, finding of sinus rhythm and q waves in V1–V3 (not present at a previous in 2019). On echocardiography (patient with poor acoustic window): Left ventricle of normal size with mild concentric parietal hypertrophy. Slight reduction in global systolic function due to alterations in district kinetics. Akinesia of the apex and middle segment of the septum and anterior wall. FE 48%. Doubtful apical iso–hyperechoicity (artifact?). Urgent hospitalization for coronary angiography was indicated in the suspicion of subacute anterior AMI. Coronary angiography revealed occlusion of anterior interventricular artery (IVA) in the proximal tract, partially re–inhabited downstream by homocoronary circulation (figure 1). Before proceeding with revascularization, given the absence of movement of the myocardiocitonecrosis indices, it was decided to perform myocardial viability tests. In consideration of the suspected apical thrombotic formation, as well as the patient‘s poor acoustic window, echo contrast was necessary (Figure 2). Once the complete opacification of the left ventricular cavity was highlighted by the contrast agent, suggestive of the absence of apex thrombi, we proceeded to ecostress with dobutamine to evaluate myocardial viability. At the explored dosages (5 – 10 and 20 ug/kg/ min) recovery of the apex kinetics was observed, but not of the mid–apical septum, which remained akinetic. We then proceeded to angioplasty on proximal IVA with a good angiographic result and the patient was discharged on the third day from revascularization in excellent clinical conditions.

P406 UNMASKING A PATTERN OF BRUGADA: FLECAINIDE VS AJMALINA

Brugada syndrome mainly affects men in the third and fourth decade of life. It presents with a typical electrocardiographic pattern, unmasked by sodium channel blocking drugs or hyperpyrexia. A 36–year–old young man, with no reported cardiovascular risk factors or family history of sudden death, had convulsions and loss of consciousness during hyperpyrexia, for which family members alerted the local emergency service. During transport to the hospital, the vital parameters and heart rhythm were normal, but, due to the onset of seizures, the patient was sedated, intubated and hospitalized in intensive care unit (ICU). The ECG performed at the entrance (in the course of hyperpyrexia) showed a dubious type 1 Brugada pattern (Figure 1). The echocardiogram (as well as the subsequent cardiac resonance) showed the absence of cardiac structural alterations. Prompt treatment of hyperpyrexia was recommended, the use of drugs listed on brugadadrugs.org was contraindicated and careful ECG monitoring was recommended. Non–sustained ventricular tachycardia was documented during the hospitalization in ICU. When the clinical picture stabilized with resumption of spontaneous breathing, the patient was transferred to our ICU for continuation of the diagnostic and therapeutic process (Figure 2). From the interview with the patient, a previous paroxysmal tachycardia from atrio–ventricular reentry emerged in antiarrhythmic prophylaxis for several years with Propafenone and subsequently treated with catheter ablation of the right lateral accessory path. Considering the lack of documentation of complex ventricular arrhythmias by the 118 during transport to the hospital and during the stay in the UTIC, the long antiarrhythmic therapy with sodium channel inhibitors, as well as the absence of a typical Brugada pattern during fever, we decide to perform a Flecainide test (2 mg / Kg in 10 ‘), negative result for Brugada type 1 pattern (Figure 2) In the following days, considering the absolute negativity of all the neuroradiological and EEG investigations, not having found the cause of the loss of consciousness during hyperpyrexia, we performed ajmaline test (1 mg / kg in 100 cc of SG5% in 10 ‘) with the identification of the diagnostic pattern type 1 (Figure 3). Finally, the implantation of a subcutaneous cardioverting defibrillator (S–ICD) was performed.

P176 MITRAL FISTULA IN PATIENT WITH OUTCOMES OF TRANSCATHETER AORTIC VALVE IMPLANTATION: A CASE REPORT

Infective endocarditis (IE) following transcatheter aortic valve replacement (TAVR) has been associated with a poor prognosis. The development of an aorto–atrial fistula (AAF) is a rare but problematic complication of IE, which can be confirmed with transesophageal echocardiography. A 55–year–old man, asthmatic and allergic (Penicillin and ASA) went to the emergency room for therapy–resistant hyperpyrexia and was admitted to Medicine Department for the necessary investigations and treatment. In remote pathological history: ischemic heart disease with dilated–hypokinetic evolution, already revascularized by CABG in 1996 and by PTCA in 2006 and in 2016; transcatheter aortic valve replacement with biological prosthesis in 2018. In the next medical history: admission to neurosurgery about 9 months before for cerebral haemorrhage and implantation of CRT– ICD about 6 months before On the echocardiogram performed at the entrance, evidence of isoechoic formation on the mitral flap for which further study with TEE was recommended. Blood cultures performed during hospitalization were positive for S. Epidermidis Oxacillin resistant. Few days after the admission, due to a sudden worsening of the respiratory picture, the patient was subjected to oro–tracheal intubation and transferred to Intensive Care Unit. The transesophageal echocardiogram (figure) performed in urgency documented: “fistula on the anterior flap of the mitral with medium–severe flow directed from the outflow tract of the left ventricle to the posterolateral wall of the left atrium.” On the recommendation of the infectious disease consultant, intravenous antibiotic therapy with Vancomycin and Gentamicin was started. In the following days, there was a progressive improvement in hemodynamics and the respiratory picture, for which the patient was transferred to Cardiac Surgery to undergo mitral valve replacement surgery. In literature, patients with perivalvular extension of infective endocarditis show very high early and late mortality rates, and surgery during hospitalization for IE appeared to be associated with better outcomes.

Early prognostic stratification and identification of irreversibly shocked patients despite primary percutaneous coronary intervention

BACKGROUND

Despite prognostic improvements in ST-elevation myocardial infarction (STEMI), patients presenting with cardiogenic shock (CS) have still high mortality. Which are the relevant early prognostic factors despite revascularization in this high-risk population is poorly investigated.

METHODS

We analyzed STEMI patients treated with primary percutaneous coronary intervention (PCI) and enrolled at the University Hospital of Trieste between 2012 and 2018. A decision tree based on data available at first medical contact (FMC) was built to stratify patients for 30-day mortality. Multivariate analysis was used to explore independent factors associated with 30-day mortality.

RESULTS

Among 1222 STEMI patients consecutively enrolled, 7.5% presented with CS. CS compared with no-CS patients had worse 30-day mortality (33% vs 3%, P < 0.01). Considering data available at FMC, CS patients with a combination of age ≥76 years, anterior STEMI and an expected ischemia time > 3 h and 21 min were at the highest mortality risk, with a 30-day mortality of 85.7%. In CS, age (OR 1.246; 95% CI 1.045-1,141; P = 0.003), final TIMI flow 2-3 (OR 0.058; 95% CI 0.004-0.785; P = 0.032) and Ischemia Time (OR = 1.269; 95% CI 1.001-1.609; P = 0.049) were independently associated with 30-day mortality.

CONCLUSIONS

In a contemporary real-world population presenting with CS due to STEMI, age is a relevant negative factor whereas an early and successful PCI is positively correlated with survival. However, a subgroup of elderly patients had severe prognosis despite revascularization. Whether pPCI may have an impact on survival in a very limited number of irreversibly critically ill patients remains uncertain and the identification of irreversibly shocked patients remains nowadays challenging.

Prevalence and predictors of persistent sinus rhythm after elective electrical cardioversion for atrial fibrillation

AIMS

To evaluate the prevalence and predictors of persistent sinus rhythm in a recent cohort of unselected patients undergoing electrical cardioversion for atrial fibrillation.

METHODS

We enrolled all consecutive patients undergoing elective electrical cardioversion for atrial fibrillation between January 2017 and December 2018. We analysed baseline clinical and echocardiographic data as well as pharmacological antiarrhythmic therapy. Primary endpoint was the maintenance of sinus rhythm at 12 months after electrical cardioversion.

RESULTS

Of the 300 patients enrolled, 270 (90%) had successful electrical cardioversion and among them, 201 patients have 12-month follow-up data (mean age 70 ± 10 years; 74% men). At 12 months, only 45.7% were in sinus rhythm. Patients without sinus rhythm compared with persistent sinus rhythm at 12 months had a lower baseline left ventricle ejection fraction (LVEF) (49.1 ± 16 vs. 59.7 ± 9%, P = 0.02) and had more frequently a history of atrial fibrillation more than 12 months (55 vs. 34% P = 0.003). At the multivariate analysis, only the duration of the disease beyond 12 months (OR 0.26, 95% CI: 0.08-0.88, P = 0.032), LVEF (OR 1.06, 95% CI: 1.01-1.12, P = 0.012) and the presence of sinus rhythm at 1-month follow-up (OR 18.28, 95% CI: 3.3-100, P = 0.001) were associated with the probability of maintaining sinus rhythm at 12 months.

CONCLUSION

In unselected patients with atrial fibrillation undergoing elective electrical cardioversion, only 45.7% were in sinus rhythm at 12 months. The presence of sinus rhythm at 1-month follow-up emerged as an independent predictor of maintenance of sinus rhythm. This highlights that early re-evaluation of these patients appears useful for assessing longer term outcomes also from the perspective of a possible selective approach to ablation strategies.

P1133Impact of mid-septal versus apical pacing on the right ventricle performance of patients with right bundle branch block undergoing pacemaker implantation

Background

pacemaker induced cardiomyopathy or transient impairment of the left ventricle (LV) function could be common collateral effects of the prolonged right ventricle (RV) pacing in patients with a pacemaker (PM) and pre-existing intra-ventricular conduction disturbances. However, the impact of RV pacing-site on RV performance of patients with right bundle branch block(RBBB) is still under-investigated.

Purpose

to study the effects of RV pacing in the mid-septal versus apical site on the morpho-functional performance of RV in patients undergoing permanent PM implantation.

Methods

We prospectively enrolled consecutive patients with a pre-existent complete RBBB and undergoing dual-chamber PM implantation in our institution. We randomized the patients 1:1 to receive the RV catheter fixed either in the apex or in the mid-septal position. Patients with LV systolic dysfunction (LVEF &lt;50%), severe valvulopathies, left bundle branch block (LBBB), or preserved intraventricular conduction were excluded. Patients who received PM implantation were evaluated both at baseline and after two months with a 12-lead ECG, 2D, and 3D echocardiogram with analysis focused on RV performance according to the guidelines of the European Association of Cardiovascular Imaging.

Results

a total of 22 patients were randomized in the study, 11 (50%) received RV catheter positioned in the apex and 11 (50%) in the mid-septum, respectively. No baseline differences were recorded between the two groups in clinical characteristics, ECG and echocardiographic parameters. At 2 months follow up, there were no statistically significant difference in the % of RV pacing between the two groups. Nonetheless, RV mid-septal group showed significantly shorter duration of the stimulated QRS (146 ± 12 msec vs. 161 ± 20 msec, p = 0.05), significantly reductions in the RV dimensions (pre: 42 ± 8 mm vs. post: 37 ± 7 mm, p = 0.05) telediastolic area (pre: 12 ± 3 cm2/m2 vs post: 9 ± 4 cm2/ m2, p = 0.02) telediastolic volume (pre: 55 ± 16 ml/m2 vs post: 50 ± 17 ml/m2, p = 0.02) and a significant improvement of RV ejection fraction (pre: 54 ± 9% vs post: 57 ± 11%, p = 0.02) than patients in the RV-apical group. Moreover, patients in the RV-apical group showed significant lowering in the GLS of the LV (pre: -16 ± 3% vs post: -11.7 ± 3%, p &lt;0.001) and in the TAPSE (pre: 23 ± 5 mm vs post: 21 ± 2, p = 0.07) at follow up.

Conclusions

In this study, mid-septal pacing seems associated with a better morpho-functional RV performance than apical pacing in patients with pre-existent RBBB undergoing permanent PM implantation.

A life-threatening manifestation of tachycardia-induced cardiomyopathy

A 74-year-old man was referred to hospital for sustained dyspnea. The patient was normotensive (110/70 mmHg) with clinical evidence of congestive heart failure. ECG showed atrial flutter (145 bpm). Transthoracic echocardiography demonstrated a mildly dilated left ventricle with severe systolic dysfunction and a big irregular mobile mass, a mildly dilated right ventricle with moderate systolic dysfunction and a large mass protruding into the cavity. The patient was treated surgically for high embolic and sudden death risk after coronarography, which showed a single stenosis (70%) of the left anterior descending coronary. Myocardial biopsy demonstrated interstitial and endocardial fibrosis, no inflammatory pattern. After 6 months of follow-up echocardiography was normal.

Metformin improves endothelial function in type 1 diabetic subjects: a pilot, placebo-controlled randomized study

AIMS

Several studies have investigated the effects of metformin treatment in patients with type 1 diabetes mellitus (T1DM). No study has hitherto examined its effects on endothelial function in these patients. In this study we sought to evaluate the effect of metformin on endothelial function in type 1 diabetic patients.

METHODS

Forty-two uncomplicated T1DM patients were randomized in a placebo-controlled, double-blind, 6-month trial to treatment with either metformin or placebo. Glycometabolic and clinical parameters as well as flow-mediated dilation (FMD) and nitrate-mediated dilation (NMD) of the right brachial artery were measured at baseline and at the end of the study. Glycaemic variability (GV, calculated from continuous glucose monitoring data) and a biomarker of oxidative stress [urinary 8-iso-prostaglandin F2α (PGF2α)] were also assessed.

RESULTS

Baseline data were similar in the two groups. Compared with placebo, metformin significantly reduced body weight [-2.27 kg (95% confidence interval: -3.99; -0.54); p = 0.012] whilst improved FMD [1.32% (0.30; 2.43); p = 0.013] and increased PGF2α [149 pg/mg creatinine (50; 248); p = 0.004]. Notably, the improvement of FMD did not correlate with the decrease of body weight (r(2)  < 1%). NMD, haemoglobin A1c, GV, daily insulin dose and other parameters did not significantly change after the treatment comparing the two groups.

CONCLUSIONS

Our pilot trial showed that, in uncomplicated type 1 diabetic subjects, metformin improved FMD and increased PGF2α, a marker of oxidative stress, irrespective of its effects on glycaemic control and body weight. Randomized, blinded clinical trials are needed to evaluate the benefits and risks of metformin added to insulin in type 1 diabetes.

[If heart failure or cardiac arrest complicate pregnancy and delivery]

Physiological adaptation to pregnancy exposes mother's cardiovascular system to relevant hemodynamic overload. These changes and other specific conditions of pregnancy, such as amniotic embolism, can point out unrecognized preexisting heart disease or, in the presence of some cofactors, be burdensome even for healthy hearts. Thus, tragic cases of heart failure or cardiac arrest may occur, whose management requires several considerations with respect of trying to save two lives at the same time, the need for drugs potentially harmful to the fetus, and assessment of emergent cesarean section.

Information for gene networks in inner ear development: a study centered on the transcription factor gata2

The search for molecular mechanisms to stimulate sensory regeneration in the mammalian inner ear is commonly based upon developmental studies. This has revealed many genes that regulate the differentiation of sensory cells. A major challenge is to place these genes into the context of functional networks that describe developmental processes more fully and increase the chances of identifying useful therapeutic targets. We used a novel approach to identify genes that are functionally related to the transcription factor gata2. Temporal profiles of gene expression were derived from three conditionally immortal cell lines and clustered to those of gata2 by applying the gamma model for oligonucleotide signals, a statistical method that allows quantitative analysis of oligonucleotide array data. We derived an objective list of 28 genes that clustered with gata2 in all three cell lines. A number of these genes have known functional links with gata2. Genes encoding CCAAT/enhancer binding proteins (C/EBP) and signal transducer and activation of transcription 3 (Stat3) are especially interesting as they are known to bind gata proteins directly. The results provide strong evidence that our experimental approach can reveal functional relationships between genes that regulate fundamental processes in the differentiation of sensory cells in the inner ear.

Ventral otic cell lines as developmental models of auditory epithelial and neural precursors

Conditionally immortal cell lines were established from the ventral otocyst of the Immortomouse at embryonic day 10.5 and selected to represent precursors of auditory sensory neural and epithelial cells. Selection was based upon dissection, tissue-specific markers, and expression of the transcription factor GATA3. Two cell lines expressed GATA3 but possessed intrinsically different genetic programs under differentiating conditions. US/VOT-E36 represented epithelial progenitors with potential to differentiate into sensory and nonsensory epithelial cells. US/VOT-N33 represented migrating neuroblasts. Under differentiating conditions in vitro the cell lines expressed very different gene expression profiles. Expression of several cell- and tissue-specific markers, including the transcription factors Pax2, GATA3, and NeuroD, differed between the cell lines in a pattern consistent with that observed between their counterparts in vivo. We suggest that these and other conditionally immortal cell lines can be used to study transient events in development against different backgrounds of cell competence.

A probabilistic model for the extraction of expression levels from oligonucleotide arrays

In this work we present a probabilistic model to estimate summaries of Affymetrix GeneChip probe level data. Comparisons with two different models were made both on a publicly available dataset and on a study performed in our laboratory, showing that our model performs better for consistency of fold change.