P117 INCIDENTAL FINDING OF A PAPILLARY FIBROELASTOMA WITH UNCOMMON LOCATION: CASE REPORT

 

A 64–year old man with no cardiological history came to our laboratory to perform a transthoracic echocardiogram because of increased blood pressure. Patient was asymptomatic. Echocardiogram revealed the presence of a small mass attached to the proximal part of the interventricular septum (IVS) (Fig. 1), characterized by high mobility within the left ventricular outflow tract (LVOT). Transesophageal echocardiogram confirmed the presence of a 8 mm pedunculated mass with implant base on IVS, 2 cm below the aortic valve and oscillating in LVOT (Fig. 2). The high risk of peripheral embolization led the Heart team to propose cardiac surgery. The operation was conducted through a J–ministernotomy on a fourth intercostal space, cannulation of ascending aorta and right atrium, transverse aortotomy and identification of the mass via the transaortic route. The appearance of the mass, glossy brown and with a gelatinous consistency, first appeared to be attributable to papillary fibroelastoma. The histological investigation (Fig. 3) confirmed the diagnosis. Postoperative course was regular and the patient was discharged on fifth postoperative day.

Discussion

Papillary fibroelastoma is the third most common primary cardiac tumour, after myxoma and lipoma, with an incidence of around 10%. In 90% of the cases the origin is from the valvular endocardium (the aortic and mitral valve surfaces are the most affected sites), while the origin from the endocardium of left ventricle, as in the case of our patient, is much more rare (less than 10% of cases). Atypical locations, in addition to IVS, are papillary muscles, tendinous chords and atrial endocardium. Although most patients are asymptomatic, consequences related to peripheral embolization can be very serious (neurological complications, acute coronary sindrome, peripheral ischaemia, pulmonary embolism). Mobility rather than size appears to be an indipendent predictor of death and non fatal embolization; for this reason, in the presence of mobile and pedunculated mass, surgical intervention is always reccomended. Surgical excision is associated with a low operative risk and the minimally invasive approach, as in our case, allows for a rapid recovery.

P161 INCIDENTAL FINDING OF QUADRICUSPID AORTIC VALVE IN A YOUNG ASYMPTOMATIC PATIENT

Background

Quadricuspid aortic valve (QAV) is a rare congenital heart disease, eventually leading to aortic regurgitation (AR) and heart failure. In up to one–third of patients, QAV is associated with other coexisting cardiac defects, particularly aortic dilation and coronary arteries abnormalities.

Case Report

A 48–years old man without significant past medical history was referred to the Cardiologist for newly diagnosed arterial hypertension. The patient was asymptomatic and no abnormal findings were noticed on physical examination. Transthoracic echocardiography showed normal end–diastolic volume and diameter of the left ventricle and preserved systolic function. However, a mild dilation of the aortic root (40 mm) and ascending aorta (38 mm) with concomitant moderate–to–severe AR were described. Transoesophageal echocardiogram (TOE) was performed to better visualize the aortic valve anatomy and to define the exact mechanism of the AR. 2D–TOE revealed a QAV with equal–sized cusps (type A according to the Hurwitz–Roberts classification), with a central quadrangular coaptation defect and a moderate AR (vena contracta width: 4 mm) [Fig. 1–2]. The regurgitant jet conditioned a pseudo–prolapse of anterior mitral leaflet with consequent mild–to–moderate mitral regurgitation. 3D–TOE allowed a better characterization of valve morphology and the individuation of the sole left coronary artery ostium. A coronary artery computed tomography was requested to investigate a probable abnormal origin of the right coronary artery. The patients was subsequently addressed to a regular clinic and echocardiographic follow–up for the surveillance of AR and aortic dimensions and a prompt management of an eventual symptoms onset.

Discussion

We describe a rare case of type A QAV with moderate AR, mild dilation of aortic root and ascending aorta and suspected anomalous origin of the right coronary ostium. The broad diffusion of imaging techniques has recently led to an increase of incidental diagnosis, even in asymptomatic patients. The complex valve anatomy, with many possible morphologies of the supernumerary cusp, and the association with other congenital defects, particularly anomalous coronary ostia location, pose many technical issues in case of valve replacement. A multimodality imaging approach is essential for a clear description of valve morphology and coronary anatomy to avoid intraoperative complications in both surgical and percutaneous valve replacement procedures.

P331 IMPLANT OF THE BALLOON EXPANDABLE BIOLOGICAL PROSTHESIS FOR TAVI (EDWARDS SAPIEN 3 ULTRA) PRE–ASSEMBLED ON EXPANSION BALLOON, IN “OPEN” SITUATION WITH PATIENT IN CEC

The biological valve prostheses malfunctioning often leads to severe forms of heart failure, whose treatment requires surgical or percutaneous re–intervention. We report the case of a 77–year–old man with a biological aortic prosthesis since 2009 (Elan stentless–21), hospitalized for acute cardiac decompensation related to severe aortic prosthetic insufficiency (likely infective endocarditis with periprosthesis abscess involving the perivalvular fibrous lamina) and coexistence of severe mitral insufficiency. After 25 days of therapy, in stable haemodynamic conditions, surgery was scheduled to replace the aortic prosthesis and the mitral valve, in CEC. The exposure of the aortic valve plane highlighted the rupture of the prosthetic coronary cusp in the absence of prosthetic detachment and perivalvular abscess. After removal of the degenerated cusps, the preparation and implantation of the new biological prosthesis (perimount–Magna–19) was hindered by the excessive presence of calcium–fibrosis in the suture site of the valve ring which did not allow adequate sealing, with multiple peri–prosthetics leaks; the possibility of sutureless prostheses implantation was made impossible by lack of adequate anatomical conditions. In these conditions, the possibility of implanting a biological prosthesis for TAVI, pre–mounted on the expansion balloon (Ewards–Sapien3–Ultra–23mm), in an “open” situation and in CEC, was considered. The implantation of the balloon–expandable prosthesis was performed with direct vision of the aortic annulus and coronary ostia; the insertion of the prosthesis was performed on a standard “J” guide wire positioned in the ventricle; the expansion of the prosthesis was performed in two balloon inflation steps. The intraoperative ecotransophageal echo demonstrated the correct positioning of the biological aortic prosthesis with minimal periprosthetic leak. The presence of severe residual mitral insufficiency suggested a replacement of the mitral valve with biological prosthesis. On day 4 the patient was clinically stable; the transesophageal echocardiogram showed normal functioning of the prostheses. The direct implantation of the expandable biological prosthesis in the cardiac surgery room, in “open” and CEC, after excluding active endocarditic processes and infectious complications, allowed the implantation of a larger prosthesis and to avoid significant perivalvular leaks.

P130 A RARE CASE OF LARGE POST INFARCTION LEFT VENTRICULAR PSEUDOANEURYSM UNDERGOING CONSERVATIVE MANAGEMENT

Introduction

Left ventricular pseudoaneurysm is a rare complication of myocardial infarction and its natural history is still unclear. Non invasive imaging improves detection ability and differential diagnosis with aneurysm. We present the case of large post infarction left ventricular pseudoaneurysm undergoing conservative management.

Case Report

A 81–years–old woman presented to emergency room complaining dyspnea and epigastric and right hemithoracic pain. Her past medical history included: chronic coronary syndrome, already undergoing CABG; recent inferior STEMI complicated with complete AVB, with ineffective RCA reperfusion attempt and bicameral pacemaker implantation; Paroxysmal AF in antithrombotic prophylaxis with DOAC. The ECG showed sinus tachycardia, HR 114 bpm, electro–induced ventricular complexes. Objectively, fine bilateral basal crackles were detected. Chest x–ray showed pulmonary congestion. The echocardiographic examination revealed: left ventricle with eccentric remodeling and severe depression of the contractile function (EF 35%), coarse neochamber in communication with the basal segment of the lower wall (D: 6.4 cm x 4.9 cm). The narrow neck, with a ratio <0.5 between inlet orifice diameter / neochamber diameter, suggested pseudoaneurysm. Working diagnosis of NSTEMI–ACS was made (usTnT peak: 344 pg / mL, NV: 0–15 pg / mL) complicated by heart failure. Progressive improvement in compensation was achieved through diuretic therapy. To improve diagnostic definition, cardio–synchronized chest CT with contrast medium was performed. The examination confirmed the voluminous neochamber, consistent with pseudoaneurysm, in correspondence with the mid–basal segments of the lower and inferior septal wall, with thinned walls and mass effect on the great cardiac vein, and highlighted the patency of the bypasses. The venous graft to OM was 5 mm distant from the posterior sternal surface. The case was discussed collectively in Heart Team, due to the high operative risk, the surgical option was rejected and a decision was made for conservative therapy. It was titled beta–blocker, ranolazine was introduced, heart failure therapy was implemented, introducing ARNI. The patient was discharged at home and is in follow–up at the outpatient clinic for heart failure. One month after discharge, she is in NYHA functional class II and she is asymptomatic for angor. The pseudoaneurysmatic dimensions are unchanged on echocardiographic control.

C81 CORRECTION OF MASSIVE TRICUSPIDAL INSUFFICIENCY WITH PERCUTANEOUS TRICLIP SYSTEM IN WOMAN WITH MARFAN‘S SYNDROME

The interventional–percutaneous therapy of valve pathologies has undergone, in recent years, an enormous technological development in traditional surgery. In particular, the recent introduction for the percutaneous treatment of tricusp insufficiency allows you to correct forms otherwise not surgically treatable. We report a case of a 58–year–old woman suffering from Marfan‘s Sd with massive tricuspidal insufficiency in relation to valve leaf prolapse, complicated by retrograde heart failure and recurrent episodes of atriale flutter, Anamnestic cardiovascular hystory began at the age of 38 (2000) when patient underwent to the first cardiac surgery in emergency contest, with replacement of the ascending aorta and aorto–coronary bypass for acute dissection (type A); after one year (2002) perform surgery to replace the aortic arch with reimplantation of the neck vessels; at the age of 45 (2009) she underwent aortic valve replacement surgery with mechanical prosthesis, for severe aortic valve insufficiency; finally, at the age of 48 (2012) she underwent surgery to replace the thoraco–abdominal aorta and reimplantation of the abdominal vessels for chronic dissecting aneurysm. Given the high risk of re–surgery for tricuspid valve repair/replacement, the Heart–Team has indicated the percutaneous correction of tricuspid insufficiency using the valve clip. The procedure was performed under general anesthesia, ultrasound–guided with transesophageal; three clips were placed at the level of the commissure between the anterior flap and septal flap with the final result of an 80% reduction in the degree of tricuspid insufficiency, absence of peri and post procedural complications; discharge of the patient on day 3. The follow–up was completed at six months: asymptomatic patient, significant reduction of arrhythmic episodes, absence of peripheral venous stasis, reduction of hepatomegaly; echocardiographic control showed persistence of optimal alignment of the clips in the closing rim of the anterior and septal tricuspid flap; normal volume and function of the right ventricle, absence of indirect signs of hypertension in the small circulation, to report a significant reduction in arrhythmic events (two episodes of atrial flutter treated effectively with drug therapy).

P5 ACCESSORY PATHWAYS HIGH–DENSITY MAPPING IN WOLFF–PARKINSON–WHITE SYNDROME

Wolff–Parkinson–White syndrome is a common condition characterized by atrioventricular accessory pathways (AP), which can be asymptomatic or can be responsible for atrioventricular reentrant tachycardia or rapid conduction of atrial fibrillation to the ventricles: for this reason, patients are referred for catheter ablation procedures. Although success rates of ablation are >95%, late recurrences can occur in 2–21% of cases mainly depending on the anatomical position. Current approaches remain suboptimal, and when failures occur, they may be due to technical difficulties such as poor contact or catheter stability, inability to access the target site as well as mapping errors resulting in inaccurate location of the AP itself. High–density mapping represents an alternative approach to mapping arrhythmias since the collection of a high density of points allows pathway conduction to be mapped more efficiently. The use of a new software called open–window mapping proved to be reliable in the localization of AP and therefore in the determination of the effective ablation site. A 41–year–old male patient was referred to our Centre following the ECG finding of manifest ventricular preexcitation and short–lasting paroxysmal palpitations. In the Electrophysiology Lab, the diagnostic catheters were inserted with the “fluoroless” technique using the EnSite Precision™ mapping system (Abbott): the ECG and the endocavitary electrograms were indicative of a right Parahissian accessory pathway. The mapping was performed with a multipolar catheter (Advisor™ HD Grid). Once the location of the pathway had been estimated, the roving acquisition interval (RAI) was set according to the expected position of atrial and ventricular electrogram. The RAI window was centered at this point and was opened in both directions (open window mapping) to fully include signals leading up to and traveling away from the AP. It accurately showed the location of the pathway just few millimeters from the Hissian potential. The baseline electrophysiological study revealed an effective antegrade refractory period (PREAP) of 320 msec. In isoproterenol, antegrade PREAP was reduced to 300 msec and inducibility of arrhythmias was not observed. Therefore, in consideration of the poor conductive properties and the non–inducibility of arrhythmias, as well as the anatomical site near the conduction system, it was decided not to proceed with the ablation due to the significant risk of atrio–ventricular block.

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P13 COMPLETE ATRIOVENTRICULAR BLOCK IN A 52–YEAR–OLD MAN ASSOCIATED WITH LYMPHATIC CANCER WITH CARDIAC INVOLVEMENT

A 52–year–old man arrived at the local emergency room for worsening dyspnea and asthenia, present for about a month, but significantly worsening during the night of the access. The ECG (Figure 1) revealed complete AtrioVentricular Block (ABV) with a narrow–QRS junctional escape rhythm, with a heart rate of about 30 beats per minute (bpm). The other vital parameters were within the normal limits and no anomalies were detected on the physical examination. Medium–dose intravenous isoprenaline infusion was immediately started, with an increase in the junctional escape rate up to 50 bpm. The patient also underwent chest x–ray, which showed interstitial thickening in the pulmonary hilus, which was judged to be nonspecific. The blood chemistry was normal and the echocardiogram (Figure 2) did not show any abnormalities. Since there were no apparent reversible causes of the complete AV block, on the next day, a bicameral pacemaker was implanted via the left cephalic vein. The procedure was uneventful and the patient was discharged home two days later, in good general condition. Eight days after the discharge, surgical wound control and pacemaker control were performed, with completely normal parameters. About 15 days after the discharge the patient went back to the local emergency room for dyspnea and fever. Chest Computed Tomography (CT) without contrast medium was performed, which revealed the presence of widespread pathological mediastinal lymphadenopathy. Therefore, the patient was admitted to the internal medicine ward. An in–depth diagnostic was performed first with thoraco–abdominal angio–CT, then with Positron Emission Tomography (PET)–CT (see Figure 3), which revealed the presence of diffuse areas of fixation of the radio–drug (18F–Fluorodeoxyglucose –FDG–), at the ilo–mediastinal, hepatic, pulmonary, retrocrural, retrocaval, iliac, supra and subclavicular, and also cardiac area (activation of interatrial brown fat and between aortic root and the superior vena cava). The patient was therefore transferred to another hospital for diagnostic investigations and lymphoma therapy. In the light of the picture that emerged, the arrhythmological disease was considered to be referred to the cardiac involvement of the oncological disease; to date there are few similar cases described in the literature. Legend of the figures: Figure 1: ECG at the admission Figura 2: Echocardiogram at the admission Figura 3: PET / CT with myocardial areas of 18F–FDG fixation.

Anisakis pegreffii impacts differentiation and function of human dendritic cells

Human dendritic cells (DCs) show remarkable phenotypic changes when matured in the presence of helminth-derived products. These modifications frequently elicited a polarization towards Th2 cells and regulatory T cells thus contributing to immunological tolerance against these pathogens. In this study, the interaction between DCs and larvae of the zoonotic anisakid nematode Anisakis pegreffii was investigated. A. pegreffii larvae were collected from fish hosts, and monocyte-derived DCs were cocultured in the presence of the live larvae (L) or its crude extracts (CE). In both experimental conditions, A. pegreffii impacted DC viability, hampered DC maturation by reducing the expression of molecules involved in antigen presentation and migration (ie HLA-DR, CD86, CD83 and CCR7), increased the phagosomal radical oxygen species (ROS) levels and modulated the phosphorylation of ERK1,2 pathway. These biological changes were accompanied by the impairment of DCs to activate a T-cell-mediated IFNγ. Interestingly, live larvae appeared to differently modulate DC secretion of cytokines and chemokines as compared to CE. These results demonstrate, for the first time, the immunomodulatory role of A. pegreffii on DCs biology and functions. In addition, they suggest a dynamic contribution of DCs to the induction and maintenance of the inflammatory response against A. pegreffii.

Past, present and future strategies of immunotherapy in gynecological malignancies

Recently, the combining of different drugs has greatly improved response and survival rates in gynecological malignancies. Results are however far from being satisfactory. Treatments used in case of advanced or recurrent disease offer limited results in terms of long-term responses. The urgent need for new and more effective treatments has prompted researchers to investigate and propose new therapeutic strategies. One of the most interesting approaches that are being explored is constituted by immunotherapy. Currently, immunotherapeutic strategies include vaccination with peptide, viral vectors, carbohydrates and antiidiotypic antibodies. In addition, cell based immunotherapy has been adopted in vitro activated lymphocytes and dendritic cells. Most experience has been acquired in ovarian cancer and cervical cancer. Little has been investigated in endometrial and rare gynecologic neoplasms.The clinical experiences and results achieved with immunotherapy in this setting of patients have been reviewed and the future avenues that are currently being explored have also been discussed.

Immunogenicity of allo-vesicle carrying ERBB2 tumor antigen for dendritic cell-based anti-tumor immunotherapy

Dendritic cells (DCs) are able to orchestrate innate and acquired immunity and can activate and sustain a long-lasting anti-tumor immune response in vivo when used as anti-tumor cell therapy. The selection of the antigen and the choice of its formulation are key points in designing anti-cancer DC-based vaccines. Cell released vesicles/exosomes have been shown to transfer antigens, HLAI/peptide complexes and co-stimulatory molecules to recipient cells. In this study we describe the generation of an allogenic microvesicle cell factory in which the expression of a specific tumor antigen was combined to the expression of co-stimulatory and allogeneic molecules. The DG75 lymphoblastoid cell line was selected as microvesicle producer and transfected with ErbB2, as tumor antigen prototype. The shed microvesicles transferred antigenic components to recipient DCs, increasing their immunogenicity. DC pulsing resulted in cross-presentation of ErbB2 both in HLAI and HLAII compartments, and ErbB2-specific CD8+ T cells from cancer patients were activated by DCs pulsed with vesicle-bound ErbB2. The microvesicle cell factory proposed may represent a source of cell free immunogen to be used for DC-based cancer therapy.

Immunology of gynecologic neoplasms: analysis of the prognostic significance of the immune status

Gynecologic Oncology has changed in the last few decades. An increasing proportion of patients is benefiting from long term survival although patients diagnosed with advanced disease suffer from a poor prognosis. Unfortunately, several recent studies are confirming that changing the combinations of "traditional" cytotoxic drugs is unlikely to obtain a real breakthrough in survival rates. Furthermore, there is discouraging data regarding consolidation therapies. It is, therefore, necessary to identify new target therapies with a minimal impact on quality of life. It is likely that new breakthroughs are only going to be achieved when changes in therapies are tailored to the entire natural history of the disease and on specific patient characteristic's. Since the discovery that tumor infiltrating lymphocytes represent an independent prognostic factor in ovarian cancer patients, several researchers have dedicated their attention to cancer immune response in order to identify prognostic factors and immunological targets. Analyses on immunophenotype at diagnosis and throughout the entire course of treatment are currently ongoing and are giving the new diagnostic, prognostic and therapeutic tools to the physicians. Furthermore new antigens and new vaccination strategies are being investigated. Encouraging data on selected patient populations have been observed recently. The objective of the present review is to define the immunology of women affected by gynecological malignancies and describe new immunological targets for prognostic and therapeutic use.

Osteoporosis: recent physiopatologic acquisitions and new therapeutic perspectives

The World Health Organization (WHO) declared osteoporosis "social disease". The present revision of the literature will focus on the recent acquisitions in bone pathophysiology and the efforts in the formulation of new molecules able to change successfully the course of the disease. Osteocyte cell is now thought to be the main biomechanical transducer of bones, able to release sclerostin that produces inhibition on osteosynthesis and on the other hand to release substances like nitrid oxide and prostaglandins that provide a stimulus to osteosynthesis through direct or indirect activation of osteoblasts. In this work the authors analyze the most important clinical trials involving the use of new molecules, like denosumab, integrin avb3 inhibitor, cathepsin k inhibitors, able to interfere in the new osteometabolic pathways. Two trials, phase I and II, have been conducted using denosumab. The endpoint of the first phase was the evaluation of the markers of resorption and bone formation, while the second phase II trial focused on the use of this molecule in double-blind matching placebo and open alendronate with the evaluation of bone mass density (BMD) over one year in lumbar area. Another clinical trial in double-blind versus placebo was carried on and published on the use of a competitive integrin avb3 inhibitor in various dosages for the evaluation of bone mass modification in the lumbar and femoral area and of bone markers modification. Many studies focus on the use of cathepsin k inhibitors. Odanacatib has demonstrated to have worked on dose-dependent increase of densitometric value and to have reduced the bone turnover.

Identification of some impurities in fenoprofen calcium

Some impurities in Fenoprofen calcium has been identified using mainly gas-mass method. These impurities are by-products of the synthesis.