242 PRIMARY CARDIAC LYMPHOMA: A CASE REPORT

Introduction

Primary cardiac lymphomas in immunocompetent patients are an uncommon malignancy, accounting for 1.3% of primary cardiac tumors, while metastases secondaries to extracardiac lymphomas are more common. Mean age at diagnosis is 63 years old. They mainly involve the right side of the heart, particularly right atrium. Symptoms of primary cardiac lymphoma are non-specific. Cardiac lymphoma typically follows an aggressive clinical course and the prognosis is poor, with more than 60% of patients dying within 2 months of diagnosis. Predictors of worse outcome are immune status, left ventricular involvement, arrhythmias and the presence of an extracardiac disease.

Case report

48-year-old obese and hypertensive man, in therapy for OSAS. In February 2022 admission to the emergency department due to jugular pressure and mild exertion dyspnoea. Neck CT excluded inflammatory collections; echocardiography showed normal cavitary dimensions and biventricular systolic function, absence of major valvulopathies and circumferential pericardial effusion of n.d.d. with TD max 2.5 cm and partial collapse of the right atrium, for which started corticosteroid therapy. Chest CT showed mediastinal lymphadenopathy and persistence of pericardial effusion. In April, due to worsening dyspnoea, cardiac CT demonstated a solid mass at the passage from the superior vena cava to the right atrium (50×37×67 mm), leading to compression-infiltration phenomena on the superior vena cava, and thrombosis of the right mammary vein. Cardiac MR confirmed a voluminous expansive-infiltrative lesion, with an irregular lobular profile, projecting into the superior vena cava and extended to the right atrium. This mass appears very iperintensive in T2 stir sequences with an early contrast impregnation and uneven intralesional late enhancement (picture 1). With suspicion of lymphoma, after collegial discussion between thoracic surgeons, cardiologists, interventional radiologists and cardiac surgeons, a right transjugular radio- and echo-guided biopsy was performed to complete diagnostic iter; biopsy was positive for peripheral B lymphocyte-derived large-cell diffuse lymphoma with large necrotic and subnecrotic areas. Chemotherapy showed initial benefit,with a clear reduction in size of the cardiac mass and mediastinal lymphnodes at 2 months follow up, with regression of dyspnoea.

Conclusions

In our patient, despite an early lymphoma onset and a typical poor prognosis compared to literature, an early diagnostic-therapeutic iter, an immunocompetent status, the absence of extracardiac disease and a preserved left ventricular ejection fraction, ensured an immediate clinical benefit with an improvement of his quality of life.

560 A RARE CASE OF PERICARDIAL SARCOMA

A 47 years old man, with no previous medical history, presented to the emergency department for dyspnea increased over the prior weeks. The echocardiographic evaluation revealed a severe pericardial effusion. Moreover, a round-shaped, indeterminate mass was detected into the pericardium, partially enhanced after injection SonoVue R contrast. After the pericardiocentesis, to exclude a severe dilatation of the coronary sinus, the patient underwent to a coronary angiography that showed a diffuse vascularization of the region of the mass. A CT-scan were then performed, and confirmed the presence of a well-defined mass placed near to the left atrial-ventricular junction into the pericardium. The magnetic resonance revealed a limited area of infiltration of the lesion into the myocardium. Finally the patient underwent surgical asportation, and the biopsy showed an high-grade sarcoma. Primary cardiac tumors are rare diseases and in the majority of the cases are of benign nature. Among malignant tumor of the heart sarcoma is the most common. Despite their rarity, malignant heart cancers are associated with high mortality and the prognosis is mostly influenced by the localization of the tumor, its biological aggressiveness, and the difficulty in obtaining surgical radicality. Cardiac sarcomas are most likely to arise from the right atrium followed by right ventricle and less often from the epicardium. In these cases, the asportation of the mass can be challenging, and the risk of myocardial narrowing can affect the area of resection.

We reported a rare case of primary cardiac sarcoma mainly localized into the pericardium. Due to its position, the surgical asportation of the tumor was considered complete and our patient was discharge from the hospital without further complication and with a program of chemotherapy.

At six months follow-up no recurrence of disease was observed.

High-Sensitivity Cardiac Troponin Predicts Major Cardiovascular Events in Diabetic Patients With Critical Limb Ischemia and Foot Lesions

Background: Diabetic patients with critical limb ischemia (CLI) and foot lesions show a poor prognosis. Optimal risk stratification to guide tailored intervention is still uncertain. The aim of the present study was to assess the prognostic role of high-sensitivity cardiac troponin T (hs-TnT) in such a high-risk population. Methods and Results: Clinical, laboratory, and interventional data, as well as the SPINACH score, were collected. Hs-TnT was measured at hospital admission. All patients were followed up for at least 1 year. The primary endpoint was the cumulative occurrence of major cardiovascular events (MACEs, all-cause death, myocardial infarction, or stroke). The secondary endpoint was all-cause mortality. Overall, 618 patients were included and followed for a median of 981 (557-1,325) days. Diagnosis of coronary artery disease (CAD) was established in 270 (43.7%) patients. Median hs-TnT at admission was 31 (20-59) ng/L, with 525 (85%) patients over the upper reference limit. Hs-TnT values were significantly higher in patients with established CAD (39 vs. 29 ng/L, p < 0.01). Hs-TnT was an independent predictor of MACE (HR 2.440, 95% CI 1.706-3.489, p < 0.001). The best cut-offs were 40 ng/L (AUC 0.711) for patients with established CAD and 25 ng/L (AUC 0.725) for those without. Hs-TnT emerged also as an independent predictor of all-cause mortality. The addition of hs-TnT improved prognostic value of the SPINACH score. Conclusions: Hs-TnT is a powerful biomarker for prognostic stratification of diabetic CLI patients with foot lesions. This is confirmed independently to CAD diagnosis and permits the identification of higher risk patients requiring tailored intervention.

Practical guide to prevention of contrast-induced acute kidney injury after percutaneous coronary intervention

Contrast-induced acute kidney injury (CI-AKI) represents a common but serious complication of percutaneous coronary interventions (PCI)-and in general of all those examinations requiring iodinated contrast injection-which affects not only renal function but also long-term prognosis. While several prophylactic approaches were designed in order to prevent CI-AKI, most failed to demonstrate clear benefits in randomized trials, and their implementation is therefore discouraged in clinical practice. The most notorious examples include pre-procedural bicarbonate or N-acetylcysteine, and preprocedural withdrawal of ACE inhibitors/Angiotensin receptor blockers. Those strategies that were instead demonstrated effective include the appropriate use of preprocedural hydration, reduction in contrast volume utilization, adoption of techniques for zero- or ultra-low-contrast procedures, and pharmacological treatments with statins. In this brief review, we summarize the main preventive strategies into brief and pragmatic recommendations designed to improve everyday clinical practice.

Right Ventricle Function in Patients with Acute Coronary Syndrome and Concomitant Undiagnosed Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) is frequently undiagnosed in patients with ischemic heart disease. Nowadays, it is still unknown whether undiagnosed concomitant COPD is related to early structural changes of the heart, as detectable by trans-thoracic echocardiography (TTE). Starting from the study population of the Screening for COPD in ACS Patients (SCAP) trial, we sought to investigate potential differences in echocardiographic parameters in patients with acute coronary syndromes (ACS), with or without undiagnosed concomitant COPD. Overall, 137 patients were included. Undiagnosed COPD was detected by spirometry in 39 (29%) patients. TTE was performed at inclusion (before hospital discharge) and after six months. Several echocardiographic parameters including fractional area change (FAC) and RV strain (RVS), were measured. Patients with undiagnosed COPD, as compared to those without COPD, showed lower FAC and reduced RVS both at inclusion (37 ± 6% vs. 44 ± 9%, p < 0.001; -15 ± -4 vs. -20 ± -5, p < 0.001, respectively) and after six months (38 ± 7% vs. 45 ± 9%, p < 0.001; -16 ± -4 vs. -20 ± -5, p < 0.001, respectively). After multivariate analysis undiagnosed COPD was independently associated with lower FAC and reduced RVS at baseline and at TTE after six months. Early impairment of RV function can be detected in ACS patients with concomitant undiagnosed COPD. If these alterations may be changed by an early diagnosis and an early treatment, should be evaluated in future studies. Clinical trial registration: NCT02324660.