Constrictive Pericarditis: An Update on Noninvasive Multimodal Diagnosis

Constrictive pericarditis (CP) is a rare condition that can affect the pericardium after every pericardial disease process and has been described even after SARS-CoV-2 infection or vaccine. In CP, the affected pericardium, usually the inner layer, is noncompliant, constraining the heart to a fixed maximum volume and impairing the diastolic function. This leads to several clinical features, that, however, can be pleomorphic. In its difficult diagnostic workup, noninvasive multimodal imaging plays a central role, providing important morphological and functional data, like the enhanced ventricular interdependence and the dissociation between intrathoracic and intracardiac pressures. An early and proper diagnosis is crucial to set an appropriate therapy, changing the prognosis of patients affected by CP. In this review, we cover in detail the main elements of each imaging technique, after a reminder of pathophysiology useful for understanding the diagnostic findings.

Cardiac Magnetic Resonance in HCM Phenocopies: From Diagnosis to Risk Stratification and Therapeutic Management

Hypertrophic cardiomyopathy (HCM) is a genetic heart disease characterized by the thickening of the heart muscle, which can lead to symptoms such as chest pain, shortness of breath, and an increased risk of sudden cardiac death. However, not all patients with HCM have the same underlying genetic mutations, and some have conditions that resemble HCM but have different genetic or pathophysiological mechanisms, referred to as phenocopies. Cardiac magnetic resonance (CMR) imaging has emerged as a powerful tool for the non-invasive assessment of HCM and its phenocopies. CMR can accurately quantify the extent and distribution of hypertrophy, assess the presence and severity of myocardial fibrosis, and detect associated abnormalities. In the context of phenocopies, CMR can aid in the differentiation between HCM and other diseases that present with HCM-like features, such as cardiac amyloidosis (CA), Anderson-Fabry disease (AFD), and mitochondrial cardiomyopathies. CMR can provide important diagnostic and prognostic information that can guide clinical decision-making and management strategies. This review aims to describe the available evidence of the role of CMR in the assessment of hypertrophic phenotype and its diagnostic and prognostic implications.

61 LEFT ATRIAL RESERVOIR AND STIFFNESS IN PATIENTS WITH WILD-TYPE TRANSTHYRETIN AMYLOID VS HYPERTROPHIC CARDIOMYOPATHY

Objectives

Left atrial (LA) function can be investigated by advanced ultrasound speckle tracking modality, much better than in the past. Modern ultrasound technology allows attaining myocardial deformation profiles from both ventricular and atrial chambers. Each of the 3 components of LA function [reservoir, also known as peak longitudinal strain (PALS); conduit and pump] can be impaired in various chronic diseases. We previously demonstrated that PALS (reservoir) and pump function weaken in patients with cardiac transthyretin amyloidosis (ATTR) and hypertrophic cardiomyopathy (HCM). In the present study we sought to recognize LA stiffness (LAst), a relatively novel marker of atrial dysfunction, in the same clinical settings.

Methods

17 patients, 9 with ATTR wild-type (wt) and 8 with non-obstructive HCM, mean aged 67±12 years, were investigated by using transthoracic color-Doppler and strain ultrasound equipment. LV mass index (LVMI), LA area index (LAAI), LV ejection fraction (LVEF), E/E’ ratio, LV global longitudinal strain (GLS), PALS and LAst were assessed in both groups. LAst was calculated by PALS/E/E’ ratio, as suggested by studies.

Results

LVMI and LAAI were similar in the 2 groups: 171±40 vs 161±51 g/m2.7 and 14±3 vs 16±4 cm/m2.7 in ATTRwt vs HCM, respectively (p=NS). However, patients in the former group showed poorer LV diastolic and systolic function (LVEF was 47±9 vs 58±5%, respectively, p<0.01), as well as GLS (9.5±2.2 vs 12.6±2.8, respectively, p=0.02). PALS and LAst were more impaired in ATTRwt compared to HCM patients (Figure), despite similar LA chamber size. Considering that LAst value >0.65 has been reported as a predictor of adverse LA morphofunctional remodeling, both groups were considered at risk for atrial dysfunction, but mainly the former one.

Conclusions

Although present findings were achieved by a small patient population, LA reservoir and stiffness were impaired in patients with ATTRwt more than in those with HCM. Left atrial dysfunction may not be strictly related with LVMI or LA size, but with LV-GLS, confirming an atrio-ventricular functional interplay in cardiac amyloidosis. Further larger study is needed to corroborate present results.

230 ANOMALOUS ORIGIN OF LEFT CIRCUMFLEX ARTERY FROM RIGHT SINUS OF VALSALVA: A RARE CASE BUT WITH GREAT CLINICAL RELEVANCE

Introduction

The anomalous connection of the left circumflex artery (LCx) to the right coronary artery (RCA) or sinus is the most frequent coronary artery (CA) anomaly. Among them, only those with an interarterial course are regarded as hidden conditions at risk of myocardial ischemia (MI) and sudden cardiac death (SCD). We report an uncommon of anomalous origin of LCx from the right sinus of Valsalva and a retroaortic path causing MI.

Case presentation

A 61-year-old man presented to the emergency department complaining palpitations and chest discomfort for an hour. He only had history of hypertension. Physical examination was unremarkable. The ECG demonstrated atrial flutter with a 2:1 conduction ratio and a ventricular rate of 157 bpm and ST segment depression in leads V4-6. Transthoracic echocardiography did not reveal segmental kinetic anomalies but a five-chamber apical view showed a “RAC sign”, typical of anomalous retroaortic course of the left coronary artery. The patient was treated with intravenous infusion of amiodarone. He restored sinus rhythm and symptoms regressed completely, but the ECG taken after conversion showed flattened T waves in leads V5-6 and negative T waves in I and aVL. Cardiac enzymes had transient increase. After the acute episode ended the patient underwent cardiac computed tomography angiography (CTA) with evidence of anomalous origin of LCx from the right sinus with a retroaortic course. A coronary angiography excluded obstructive atherosclerotic coronary lesions. Nuclear myocardial perfusion imaging revealed reversible small subsegmental perfusion defects in mid inferolateral wall and apical lateral wall. We established a medical treatment with beta-blocker.

Discussion

Our patient had anomalous connection of the LCx branch to the right sinus of Valsalva with a retroaortic course. Although this anomaly is usually considered benign, cases of association with SCD and MI have been reported. The factor responsible for this pathogenicity could be high orifice, ostial stenosis, slit-like/fish-mouth-shaped orifice and acute-angle take-off. As cardiac CTA did not reveal any of these characteristics, we hypothesized that the increased cardiac output and expansion of the great vessels during tachycardia could cause compression of the retroaortic segment or angling at its origin and generate ischemia. Repolarization abnormalities at ECG are well documented during supraventricular tachycardia as a response to pacing-induced stress. These changes are usually diffused and disappear after conversion to sinus rhythm. In this case they appeared hours later, accompanied by cardiac enzyme buildup. As the epicardial coronary arteries did not show any pathology, we suggest that the patient had transient ischemia due to LCx anomaly. We confirmed it by myocardial perfusion imaging. As for the management of this anomaly in adults, surgery is recommended as class IC in patients with typical angina symptoms who present with evidence of stress-induced myocardial ischemia in a matching territory or high-risk anatomy. Our patient has never had clear manifestations of angina. All these elements together with the age of our patient motivated us to use a conservative approach.

Conclusions

We report a case of anomalous origin of LCx from right sinus of Valsalva causing transient myocardial ischemia in a patient that has always been asymptomatic. This anomaly has been and continues to be considered benign, nevertheless we suggest to judge the clinical significance of this kind of CA anomaly on a case-by-case integrated approach.

1033 A STRANGE CASE OF PULMONARY EMBOLISM IN A YOUNG PATIENT WITH CARDIAC RESYNCHRONIZATION THERAPY

Introduction

Clinically relevant pulmonary embolism (PE) related to pacemaker leads is reported in up to 3.5% of cases of implantations. We reported a particular case of acute massive PE in a patient bearer of a Cardiac Resynchronization Therapy-Defibrillator (CRT-D).

Case presentation

A 49-year-old man presented to our ER reporting dyspnea and localized pain to the left hemithorax. Past medical history included HFrEF due to idiopathic dilated cardiomyopathy complicated by apical thrombosis, CRT-D, Charcot-Marie-Tooth syndrome, dyslipidemia, and a hepatic nodule undergoing diagnosis. Recently, he reported COVID-19 and successive pleuropneumonia requiring hospitalization. At home, he was taking Acenocoumarin, Sacubitril/Valsartan 97/103mg bid, Carvedilol 6.25mg bid, Digoxin 0.0625mg, and Canrenon 50mg with questionable adherence. On physical examination, he was pyretic, mildly hypotensive and hypoxemic. An ECG showed atrio-guided biventricular stimulation at 110 bpm. A transthoracic echocardiogram (TTE) revealed biventricular disfunction and dilation, mitral and tricuspid regurgitation, PAPs 60 mmHg, and a thrombotic formation in the left ventricle apex. Blood tests found elevated D-Dimer and infection markers, INR 1.1. A CT angiography confirmed a bilateral acute massive PE associated with lung consolidations and left pleural effusion. We excluded deep vein thrombosis in the lower limbs. Patient was admitted to CCU and treated with intravenous heparin, antibiotics, and support therapy. After one week, we performed a transesophageal echocardiogram that confirmed the previous TTE except for a minor PAPs and unknown thrombotic formations on the atrial side of the tricuspid valve, adhering to CRT-D leads, pedunculated, highly mobile, the largest with an area of 1.9cm2. Cardiac surgery wasn't indicated; we excluded thrombophilia and thoracic cancer. Patient is still hospitalized, asymptomatic and with a precarious cardiovascular status.

Discussion

The incidence of asymptomatic clot adhering to cardiac device's leads found by echocardiography is 1.4%, and thromboembolic complications are even rarer, especially after years from the implant. In our patient, the right atrium thrombosis is probably the cause of PE, and possible precipitating factors were pneumonia or unknown hepatic neoplasm. In the diagnostic workup, TTE probably wasn't sensitive enough to detect those thrombi.

Conclusions

We presented a particular case of PE in a relatively young patient affected with HFrEF. Even if thrombosis related to pacemaker leads is rare, it should be considered as a possible cause of PE in a patient bearer of a cardiac stimulating device.

783 RELATIONSHIP BETWEEN PULSE WAVE VELOCITY AND MYOCARDIAL WORK IN UNTREATED HYPERTENSIVE PATIENTS WITH PRESERVED LVEF

Introduction

Hemodynamic interaction between left ventricular (LV) and arterial system is a key determinant of cardiovascular performance. The non-invasive carotid-femoral Pulse Wave Velocity (PWV), obtained with applanation tonometry, is considered the most precise way of estimating arterial stiffness. The LV myocardial work (MW), based on non-invasive LV pressure-strain loop (PSL), is a new promising tool to assess LV function.

Aims

The aim of the study was to evaluate the correlation between PWV and MW parameters in a population of non-hypertensive and newly diagnosed untreated hypertensive people.

Materials and methods

80 people (M=48), divided in hypertensive (group 1 n=40, 45±10 years) and non-hypertensive (group 2 n=40, 40±12 years), were prospectively enrolled. All underwent conventional transthoracic echocardiogram and at the same day carotid femoral PWV was calculated with applanation tonometry (SphygmoCor® XCEL). MW parameters were obtained using 2D Speckle-tracking technique.

Results

Comparing the two groups, PWV and Global Work Wasted (GWW) were significantly higher in the hypertensives group (9,73±2,4 vs 7,79±1,1; p=0,001 and 146±50 vs 85±27, p=0,001), as shown in Figure 1, whereas Global Work Efficiency (GWE) and Global Work Constructive (GWC) were significantly lower (93,6±2,5 vs 95,6±1,2, p=0,001 and 2410±122 vs 2167±65, p=0,002). We found a linear and positive correlation of PWV with GWW (r=0,271, p=0,016), as seen in Figure 2, and a linear and negative correlation of PWV with GWE (r=-0,282, p=0,012).

Conclusion

This study highlights the role of PWV and MW evaluation in hypertensives. Higher PWV and GWW could be considered as red flags of myocardial damage suggesting the need of an early appropriate antihypertensive therapy.

57 ISCHEMIC HEART SCOMBROID SYNDROME: FURTHER EVIDENCE FROM ALL OVER THE WORLD

Objective

Scombroid syndrome (SS) is a long-standing poisoning illness caused by ingestion of improperly stored fish food (usually tuna fish) contaminated by Gram-negative bacteria. The main pathogenetic feature is toxicity by the high histamine (and/or other toxin) levels within the fish muscle. Scombroid syndrome accounts for approximately 5% of food toxicities at emergency department in the USA. It consists of gastrointestinal symptoms, sickness, at times (head) rash or flushing, peppery taste, hypotension, and other symptoms. Cardiovascular complications are infrequent, but acute coronary syndromes (ACSs) have been described in some patients on admission to hospital. We identified those cases as with ischemic heart scombroid syndrome (IHSS).

Methods

An accurate literature search for IHSS in case series and single reports, published as by the end of July 2022, was performed. Herein main clinical features are summarized.

Results

From 1997 to 2022, 18 studies were found describing 25 patients aged 42±15 years, 14 women (56%), likely to have IHSS. Countries of origin are depicted in the Figure nearby. Apart from typical clinical presentation of SS, chest pain, oppression and hypotension were complained by almost all patents. Symptoms and signs of ACS started 10 to 180 minutes from the meal. Four patients (mostly before 2015) required advanced life support or mechanical ventilation. Widespread ST-depression (first in the inferior leads) was the most frequently reported ECG feature (approximately in 90% of cases). Hospitalization was required for unstable patients or those admitted for coronary angiography. However, this latter was performed only in 10 cases (40%), and only in 3 (12%) a culprit lesion was identified and treated. Therapy consisted with antihistamine drugs, fluids and circulatory support, symptomatic drugs, and steroids in some cases. All patients were discharged from hospital with uneventful follow-up.

Conclusions

To date, 25 published cases of IHSS have been recognized, mostly from Italy, but reports are from all over the world. As in typical SS, myocardial ischemia begins shortly after raw or cocked (tuna) fish ingestion. However, due to unfamiliarity with the syndrome, diagnostic misinterpretation is possible. IHSS can be classified as a transient (usually benign) ACS, caused by coronary vasospasm in response to a nitroxide-mediated histamine-induced tissue hypoperfusion, in a similar way to type-I Kounis syndrome. Based on current knowledge, coronary angiography is mandatory in patients with a history of coronary artery disease and/or allergic diathesis, persistent symptoms or unresponsive to emergency treatment.

221 NONBACTERIAL THROMBOTIC ENDOCARDITIS WITH ATYPICAL PRESENTATION AS OVERT CONGESTIVE HEART FAILURE

Introduction

Non-Bacterial Thrombotic Endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or, rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography.

Case presentation

An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep vein thrombosis. On physical examination, he was apyretic, mildly hypotensive and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed “thrombotic” thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed in the diagnostic workup and prescribed palliative care.

Discussion

Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo-density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about treatment of NBTE and the only role of anticoagulation to prevent systemic embolism.

Conclusions

We report a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging played a crucial role for the final diagnosis.

746 DAL COMPASS AI DATI DI REAL LIFE: UNO STUDIO CASO-CONTROLLO

Background

The COMPASS trial showed that rivaroxaban plus aspirin was associated with fewer adverse cardiovascular events, but more major bleeding events, as compared with aspirin alone in patients with chronic vascular disease. The clinical benefit was particularly favorable in high-risk subgroups, who are frequently undertreated because of the fear of severe bleeding events.

Purpose

Our aim is to evaluate objective effects of anticoagulation strategies with rivaroxaban among patients with stable cardiovascular disease.

Methods

We considered a population of patients with stable cardiovascular disease (coronary and/or peripheral artery disease) which has had dual antiplatelet therapy (DAPT) for 1 year. Between them we selected 65 patients (52 males and 13 females, mean age 59±7 years) with high risk of ischemic events and low bleeding risk. We used DAPT Score and HAS BLED Score to enroll patients. We stopped them DAPT and starting a dual therapy combining rivaroxaban 2,5 mg twice daily plus aspirin 100 mg. We excluded patients with high bleeding risk and heart failure with less than 35% ejection fraction. At baseline they underwent blood tests, transthoracic echocardiography, six minutes walking test (6MWT), Kansas City Cardiomyopathy Questionnaire (KCCQ) Score, evaluation of carotid– femoral pulse wave velocity (cf-PWV) and ankle brachial index (ABI). We established 3, 6 and 12 months follow-up.

Results

At 3 months follow-up we evaluated 41 patients (the study is going on) repeating those exams and comparing them with the baseline ones. We observed that 35% of population had reduction of cf-PWV values and in 40% of population ABI increased. 15% of patients had also improvement of more than 100 meters in 6MWT. Particularly, reduction of cf-PWV and improvement of ABI values suggest that rivaroxaban 2,5 mg twice daily may have effects on vascular protection and arterial stiffness through different mechanisms such as improvement of endothelial functionality and fibrinolytic activity at endothelium, anti-inflammatory properties and platelet-dependent thrombin generation. Nevertheless none of the patients experienced subjective clinical improvement and the KCCQ Score was unmodified. This element indicates that patients at 3 months follow-up have imperceptible changes that can be documented only by diagnostic imaging evaluation and not by anamnestic data. Finally, an important evidence was that none of the patients at 3 months follow-up reported major bleeding events.

Conclusion

Preliminary data suggest that the addiction of rivaroxaban 2,5 mg to aspirin exerts vascular protection and its effects can be primarly documented by evaluation of cf-PWV and ABI. The 6MWT seems to play a minor role at 3 months assessment. The KCCQ may not be useful to fill in at 3 months follow-up because patients seem not to perceive subjective clinical improvement in this phase. If confirmed on a large cohort these results may give rivaroxaban a higher relevance not only for the power but also for the immediacy of its effects. Anyway, we are continuing our check to give our data more statistical significance and to test any role of the other parameters at 6 and 12 months follow-up.

Relationship between Pulse Wave Velocity and Myocardial Work in untreated hypertensive patients with preserved LVEF

Introduction

Hemodynamic interaction between left ventricular (LV) and arterial system is a key determinant of cardiovascular performance. The non-invasive carotid-femoral Pulse Wave Velocity (PWV), obtained with applanation tonometry, is considered the most precise way of estimating arterial stiffness. The LV myocardial work (MW), based on non-invasive LV pressure-strain loop (PSL), is a new promising tool to assess LV function.

Purpose

The aim of the study was to evaluate the correlation between PWV and MW parameters in a population of non-hypertensive and newly diagnosed untreated hypertensive people.

Material and methods

50 people (M=30), divided in hypertensive (group 1: n=25, 40±8 years) and non-hypertensive (group 2: n=25, 38±9 years), were prospectively enrolled. All underwent conventional transthoracic echocardiography and at the same day carotid femoral PWV was calculated with applanation tonometry (SphygmoCor® XCEL). MW parameters were obtained using 2D Speckle-tracking technique.

Results

Comparing the two groups, PWV and Global Work Wasted (GWW) were significantly higher in the hypertensives group (9.44±2.4 vs 7.56±1.1; p=0.001 and 130±2.5 vs 80.60±1.5, p=0.002), as shown in Figure 1, whereas Global Work Efficiency (GWE) and Global Work Constructive (GWC) were significantly lower (94±2.5 vs 95.8±1.2, p=0.003 and 2393±20 vs 2166±18, p=0.02). We found a linear and positive correlation of PWV with GWW (r=0.315, p=0.026), as seen in Figure 2, and a linear and negative correlation of PWV with GWE (r=−0.315, p=0.026).

Conclusion

This study highlights the role of PWV and MW evaluation in hypertensives. Higher PWV and GWW could be considered as red flags of myocardial damage suggesting the need of an early appropriate antihypertensive therapy.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Ospital G. Martino - Messina

Nonbacterial Thrombotic Endocarditis with Atypical Presentation as Overt Congestive Heart Failure

Nonbacterial thrombotic endocarditis (NBTE) is a form of endocarditis associated with malignancy or autoimmune disorders. Diagnosis remains a challenge as patients are often asymptomatic up to embolic events or rarely, valve dysfunction. We report a case of NBTE with uncommon clinical presentation and identified with multimodal echocardiography. An 82-year-old man presented to our outpatient clinic reporting dyspnea. Past medical history included hypertension, diabetes, kidney disease, and unprovoked deep-vein thrombosis. On physical examination, he was apyretic, mildly hypotensive, and hypoxemic, had a systolic murmur and lower limbs edema. Transthoracic echocardiography revealed severe mitral regurgitation due to verrucous thickening of the free margin of both leaflets, increased pulmonary pressure, and dilated inferior vena cava. Multiple blood cultures were negative. Transesophageal echocardiography confirmed "thrombotic" thickening of mitral leaflets. Nuclear investigations were highly suggestive of multi-metastatic pulmonary cancer. We did not further proceed with the diagnostic workup and prescribed palliative care. Lesions seen on echocardiography were suggestive of NBTE: they involved both sides of mitral leaflets, close to the edges, had irregular shape and echo density, a broad base, and no independent motion. Criteria for infective endocarditis were not met and the final diagnosis was paraneoplastic NBTE due to underlying lung cancer. We remark the lack of definitive recommendations about the treatment of NBTE and the only role of anticoagulation to prevent systemic embolism. We have reported a case of NBTE presenting with atypical symptoms and likely related to the prothrombotic state induced by underlying lung cancer. Provided the unconclusive microbiological tests, multimodal imaging has played a crucial role in the final diagnosis.

P424 SMALL HEART AND SINGLE CORONARY ARTERY IN A YOUNG PATIENT WITH CHRONIC FATIGUE SYNDROME: A CASE REPORT

Introduction

Chronic fatigue syndrome/Myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by severe and disabling fatigue limiting normal daily activities for at least 6 months accompanied by multiple unexplained symptoms including self–reported impairments in concentration and short–term memory, sleep disturbances, and musculoskeletal pain. Although rarely considered to have cardiac dysfunction, CFS/ME patients frequently have reduced stroke volume with a significant inverse relation between cardiac output and post–exertional malaise severity. We describe a case of a young man affected by CFS/ME and small heart with incidental findings of anomalous origin of the left main coronary artery (LMCA).

Case Presentation

A 19–year–old Caucasian male presented to our clinic complaining weakness, lack of concentration and excessive daytime sleepiness. Medical history included CFS/ME, D hypovitaminosis, inflammatory bowel disease associated with pancreatic insufficiency. Physical examination including cardiovascular auscultation was unremarkable, with normal blood pressure and heart rate. Electrocardiogram showed sinus rhythm at 75 bpm without any repolarization abnormalities. Echocardiogram revealed reduced diameters of left ventricle (LV) (end–diastolic diameter 36 mm), normal aortic root dimensions and, in a five–chamber apical view, a binary structure that seemed to cross the aorta perpendicularly to its long axis. Cardiac magnetic resonance (CMR) found significantly reduced LV stroke volume (34 ml/m2; normal values 44–68 ml/m2) and end–diastolic volume (57 ml/m2; normal values 68–103 ml/m2) together with reduced end–diastolic wall mass (51 g/m2; normal values 59–93 g/m2). Also, right ventricle (RV) volumes were reduced: stroke volume (32 ml/m2; normal values 40–72 ml/m2), end–diastolic volume (62 ml/m2; normal values 68–114 ml/m2). In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro–aortic course.

Conclusions

Not sufficient consideration was given to cardiovascular involvement in patients with CFS/ME, although many of signs and symptoms are suggestive of cardiovascular dysfunction. This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association with cardiac congenital anomalies and CFS/ME.

770 Small heart and single coronary artery in a young patient with chronic fatigue syndrome: a case report

Aims

Chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is a clinically defined condition reported mostly in adults, characterized by fatigue and unexplained aspecifical symptoms. Patients with CFS/ME frequently have reduced stroke volume with an inverse relation between cardiac output and post-exertional malaise severity. We describe a rare case of a young man affected by CFS/ME, small heart, and anomalous anatomy of left main coronary artery (LMCA).

Methods and results

A 19-year-old Caucasian male referred to our clinic complaining weakness, lack of concentration, and sleepiness. He suffered by CFS/ME, D hypovitaminosis, inflammatory bowel disease, and exocrine pancreas insufficiency. Blood tests revealed no pathological findings. Faecal exams documented intestinal dysbiosis and low pancreatic elastase. He was treated with oxygen-ozone rectal insufflations and probiotics. Physical examination was unremarkable. Electrocardiogram showed normal sinus rhythm. Echocardiogram revealed reduced diameters of the left ventricle (LV), normal aortic root dimensions and, in a five-chamber apical view, a binary structure that seemed to cross the aorta perpendicularly. Cardiac magnetic resonance (CMR) found reduced LV stroke volume (34 ml/m2) and end-diastolic volume (57 ml/m2) together with reduced end-diastolic wall mass (51 g/m2). Right ventricle volumes were reduced too. In addition, the exam confirmed the anomalous origin of LMCA stemming from the proximal segment of right coronary artery and following a retro-aortic course. Mechanism of CFS/ME remains unknown, although various factors have been implicated, including immune activation, chronic viral infection, and emotional disorders. A considerable number of patients affected by CFS has an anatomically small heart. Small heart syndrome, in fact, may contribute to the onset of CFS/ME. Previous studies hypothesized that clinical manifestations of CMS/ME were caused by reduced venous return, cardiac output, and heart mass, together with decreased arterial oxygen saturation. Single coronary artery is an uncommon congenital anatomic abnormality identified by a single coronary ostium giving rise to all arteries supplying the heart. Thus, we reported a rare case of a very young man affected by chronic fatigue syndrome and small heart, investigated not only with echocardiogram but also with CMR, not often used in this clinical setting. More, we found an anomalous origin of LMCA. From literature, it’s not reported any cases of a patient including these three rare conditions (CFS/ME, small heart, and single coronary artery).

Conclusions

This case highlights that CFS/ME together with small heart is a condition possible also in young people. More studies and reports could be necessary to better define the association between cardiac congenital anomalies and CFS/ME.

739 Atypical presentation of Takotsubo syndrome early after pacemaker implantation

Aims

Takotsubo syndrome (TTS) is an acute stress-induced cardiomyopathy showing left ventricular (LV) dysfunction without obstructive coronary arteries disease. A sudden massive surge of circulatory catecholamines from an intense physical or emotional stress may play a central role in the pathogenesis of TTS. We report the case of an 87 years-old woman who developed TTS with uncommon presentation after permanent pacemaker (PM) implantation.

Methods and results

The patient was referred to our hospital for PM implantation because of advanced atrio-ventricular block (3:1). She suffered by rheumatoid arthritis (RA), arterial hypertension, and chronic kidney disease. Echocardiogram, performed before PM implantation, showed normal LV kinesis and normal ejection fraction (EF 60%). She was initially administered with infusion of Isoprenaline 2 mcg/min. The subsequent day, she underwent permanent dual-chamber pacemaker implantation without any complications. After 3 days, the patient complained severe asthenia and fever, together with increase of white blood cells and C reactive protein. Blood cultures were negative. We started antibiotic therapy and, suspecting a reactivation of RA, steroid therapy with infusion of methylprednisolone 40 mg/die. Electrocardiogram showed normal sinus rhythm and paced ventricular rhythm. PM interrogation showed normal function. Surprisingly, echocardiogram showed LV dysfunction with apical and medium segments akinesia, and severe EF reduction (35%). Coronary angiography documented absence of coronary obstructive lesions, assessing diagnosis of TTS. The patient was discharged 1 week after admission in good clinical condition. One week later, an echocardiogram showed apical akinesia, partial recovery of medium segments motility, and slight increase of EF (40%). The excess of catecholamines could lead to decreased cardiac muscular function and to spasm of coronary arteries: these events can lead to acute heart failure and decrease of LVEF. Furthermore, about 90% of patients with TTS are women, especially in postmenopausal period. Peculiarities of this case were the atypical symptoms of TTS and the combination of different predisposing stressors factors: female sex in postmenopausal period, anamnesis of chronic inflammatory disease, use of stress-inducing drugs (methylprednisolone and isoprenaline, the last associated with TTS after PM-implantation), atrio-ventricular block itself, and PM implantation procedure. Our findings remark that even a low-risk procedure could be a possible cause of TTS in patient with such risk factors. In our opinion, in this subset of patients, conscious sedation could be useful to reduce the stress load, together with an early procedure and consequently the minimal use of exogenous stress drugs like Isoprenaline, even if the patient is in a good clinical condition.

Conclusions

This case highlights TTS as a potential complication after PM implantation, especially in post-menopausal women with high pre-existing stress load.

609 Prognostic role of renal function in patients with previous myocardial infarction. A study with cardiac magnetic resonance

Aims

There is not strong evidence in literature about the impact of renal function on the prognosis of patients with ischaemic cardiomyopathy. Thus, the aim of the study was to investigate mild renal impairment [estimated glomerular filtration rate (eGFR): 60–89 ml/min] as an independent prognostic factor in patients with history of myocardial infarction (MI).

Methods and results

We studied 339 consecutive patients (65 ± 13 years old, female 13%) from 2001 and 2012 with previous MI. Patients with eGFR <60 ml/min were excluded. We performed cardiac magnetic resonance (CMR) in all patients to quantify left ventricular ejection fraction (LVEF), volumes, and wall motion score index (WMSI), and to measure the infarction extent by late gadolinium enhancement (LGE). Renal function was estimated by creatinine value with Cockcroft–Gault formula and patients were divided according to normal (≥90 ml/min) and reduced (60–89 ml/min) eGFR. Patients with normal eGFR were 106 (31%, 56.9 ± 10.5 years old), 233 (69%, 66.1 ± 9.9 years old) had renal impairment. During follow-up (median 3.5 years), cardiac events (cardiac death or appropriate intra-cardiac defibrillator shock) occurred in 28/233 (12%) of patients with eGFR <90 ml/min and in 4/106 (4%) of patients with eGFR ≥90 ml/min (P < 0.05). Furthermore, survival curve showed a significantly worst prognosis in patients with renal impairment (P < 0.03). In the group of patients with ejection fraction (EF) < 35% (121 patients), cardiac events were observed only in patients with eGFR <90 ml/min (23/99, 23%, P < 0.05). At multivariate stepwise analysis, age >65 years old, eGFR <90 ml/min and WMSI >1.7 turned out to be independent predictor of cardiac events (P < 0.05).

Conclusions

In patients with previous MI, a mild renal impairment (eGFR between 60 and 89 ml/min) was an independent predictor of prognosis, especially if combined with left ventricular disfunction.

[Hypersplenism from an aneurysm of the splenic artery. A clinical case]

Presentation of one case. Hypersplenism may be caused by a variety of pathological conditions. Rarely, it may be due to some vascular pathology. The Authors report on a patient with an hypersplenic syndrome, caused by the aneurysm of splenic artery, in whom splenectomy has been curative.