P304 CASE OF MYOCARDITIS AFTER COVID 19 VACCINATION

COVID 19 has so far found the only barrier in the use of mRNA and viral vector vaccines. Among the rare adverse effects related to mRNA vaccines is myocarditis (4.8 cases per million doses) a disease already found in COVID 19 infection but not in the safety studies of the vaccines. Males not older than 30 years (40% of the total), subjected to the second dose inoculation, are most affected. During our recent clinical practice there was a case of a patient with myocarditis, attributable to vaccination for COVID 19. It was a male, twenty–year–old, non–allergic smoker, subjected to second dose of Pfizer–BioNTech vaccine (BNT162b2). On the fifth day after the inoculation, the patient, already asthenic from the previous days, complained of an episode of oppressive chest pain, which lasted about 15 minutes, which returned, more intense the following night, associated with dyspnea, lasted for hours. When the patient went to the emergency room the pain was in regression and there was good hemodynamic compensation. EKG: sinus rhythm, slight diffuse ST segment elevation, more pronounced in the inferior–lateral leads, slight lowering of the P–R segment. Blood tests: troponin, CKMB and PCR increase, negativity of the molecular test for COVID 19. Echocardiography: normal left ventricle, non–dilated right sections, normokinetic right ventricle, normal valves, pericardial hyper–refraction without effusion, normal diastolic relaxation. In the suspicion of myocarditis, the patient was admitted to our intensive cardiological care. With the high–dose anti–inflammatory and beta–blocker therapy the pain gradually disappeared; never fever; EKG showed progressive ST segment improvement and T wave negativization. Never arrhythmic events. Negativity for all infections with common viral pathogens. MRI: hyperintensity (T2 STIR sequences and late enhancement) in the infero–lateral area. Patient discharged in therapy with lysine acetylsalicylate, to be reduced, associated with pantoprazole, and metoprolol and indicated for outpatient checks. In conclusion, the case presented reflects the scientific literature in the type of patient and in the favorable evolution of the disease.

P172 AN ACCESSORY PATHWAY WITHOUT REENTRANT TACHYCARDIA

A 65–year–old patient, hypertensive, dyslipidemic, strong smoker. He has heart disease with hypokinetic evolution EF 47%, mild MI. Negative Dipyridamole–stress echocardiography dated January 2008. Recently atrial fibrillation (AF) is found and anticoagulant therapy was started. Dyspnea and weight loss occurred in past two months. Detected keratinizing squamous pulmonary Ca with negative markers. This injury was judged to be inoperable, and the patient get indications for chemotherapy and radiotherapy. The patient also starts complaining of dyspnea and chest pain on exertion: Not serological modification, not ischemic ECG. Echocardiogram LVEF 47–50% highlights diffuse hypokinesia, regular valves. Ergometric test was not evaluable for ischemia. Coronary angiography shows stenosis of proximal and middle anterior interventricular coronary and non–critical lesions of circumflex and right coronary. Ecodobutamine test was positive for ischemia and arrhythmias (AF and wide QRS tachycardias in recovery phase), but negative for angor. The patient was treated with CT and IVA I – II. angioplasty Monitoring shows AF with high penetrance, wide QRS tachycardia runs and very short TVNS. ECG 1: During atrial tachycardia, show broad QRS conduction to BBSX alternating with narrow QRS with the same RR interval. ECG 2. show fusion between the wavefront conducted with narrow QRS and that with wide QRS. These are supraventricular arrhythmias that run along the atrioventricular nodal pathway (NAV) in the narrow QRS tracts and take an accessory pathway in the wide QRS run.

The Mahaim fibers have decremental conductivities like the AV node, therefore high ventricular frequencies does not occur AF appeared during ecodobutamine, but some beats were conducted by an anomalous path in a discontinuous way); they are generally directed from the atrium or the NAV, towards another part of the right ventricular conduction system, with atrium wave or NAV – RB, therefore the early activation of the RB generates a widened QRS, with a LBB morphology. ECG 3 Re–entry on Mahaim pathway, ventricular activation widened through Mahaim fiber, which generate LBB morphology with retrograde atrial depolarization. In this case there is no reentry, but we have an atrial tachycardia conducted alternately on an accessory pathway and across the NAV. Given the patient‘s clinical problems and the total absence of symptoms, the patient remains asymptomatic during therapy with amiodarone and beta–blocker.

P355 THE HYPNOTIC COMUNICATION USE IN CARDIOLOGY SETTING

Between summer 2020 and the end of 2021 the Cardiology facility of the Savigliano hospital trained 2 doctors and 2 nurses in hypnotic communication (IC). IC is a communicative approach, which involves establishing a relationship with the patient and can allow carrying out the planned procedure by bringing the patient into a modified state of consciousness that reverberates on physical and sensory perceptions up to a trans hypnotic. This particular connection with the patient can be represented by a simple communication deepening up to the real trance and allows to overcome the procedures with a reduction in the use of anesthetics and analgesics, with a control of procedural anxiety, up to complete analgesia, but also the management of some particular procedural needs such as the prolonged maintenance of the supine position on an operating room table with the patient awake. All patient has an extremely positive experience. Hypnosis can also optimize the abilities and performances of those who use it. During this period, at the Cardiology facility of the Savigliano we started using IC to perform procedures in the hemodynamics, electrophysiology and transesophageal echocardiography. In the hemodynamics and electrophysiology room, IC has increasingly become the preferred communicative approach to the patient who are going to have a procedure. A total of 123 patients booked for coronary angioplasty were managed in IC, including 5 in emergency, 24 PM implants and defibrillators, 3 electrophysiological studies and a foramen ovale closure procedure. In recent months, an outpatient operator has started performing IC on 10 transesophageal echocardiogram exams. In 70 patients the session was concluded with an anchorage, which is a moment in which the patient is allowed to reproduce the modified state of consciousness independently, to face moments of anxiety, fatigue or other procedures. In the majority of patients, the ratification of the presence of a trance state was positive, in a smaller percentage of cases (about 15%) the ratification was sometimes not evident or if it was, the patient was expelled during the procedure, but in 100% of cases the patient‘s experience was extremely positive both in terms of perceived closeness of the healthcare staff, and in terms of tolerance to the procedure and positive experience of the latter.

Persistent Atrial Fibrillation And Atrial Flutter Complicated By Tachycardiomyopathy Because Of Intermittent Conduction Through Accessory Pathway

The term tachycardiomyopathy refers to a specific form of tachycardia-related cardiomyopathy caused by supraventricular or ventricular tachyarrhytmias that are both associated with ventricular rates higher than 120 bpm. The arrhythmias which are most frequently associated with these forms of heart disease are atrial fibrillation and atrial flutter, particularly found in the elderly population. The most frequent clinical manifestation is heart failure. In this case we are reporting a clinical case of a patient that came to our attention because of an episode of heart failure associated with atrial fibrillation and atrial flutter. The patient had also prolonged and repetitive strips of rapid conduction with wide QRS morphology. We don't know if the cause is pre excitation or ectopia. We showed that those strips of tachycardia with wide QRS, particularly when they were associated with atrial flutter, were so fast and consistent to determine the left ventricular contractile dysfunction; we showed also that those strips of wide complex tachycardia were caused by pre-excitation through an accessory right posteroseptal pathway and supported by the reentry circuit of common atrial flutter. The block of conduction through the accessory pathway and the elimination of atrial arrhythmia allowed the regression of left ventricular contractile dysfunction. We believe that this case is interesting because it shows that there is a strict continuity between sophisticated electrophysiological mechanisms and clinical manifestation.

Severe degenerative aortic stenosis: when a senile patient is a candidate for surgery

Senile aortic stenosis is characterized by calcific degeneration of the valve that prevents the full opening of the cusps in systole. The disease may be silent for many years despite the presence of severe flow obstruction and generally is associated with aortic regurgitation and calcification of the coronary arteries. The continuous increase of the aged population with aortic stenosis entails difficult decisions in selecting the candidates for aortic valve replacement in order to optimize the timing for surgery. Although clinical examination is still fundamental for the diagnosis of the disease and the screening of the population, noninvasive assessment by Doppler echocardiography has transformed the management of these patients. The procedure allows better identification of patients who may benefit from valve replacement in particular in the setting of a ''low output/low gradient'' state and permits a follow-up of the progression of the disease in patients who are not yet candidates for surgery. It also allows a decrease in the utilization of invasive hemodynamics becoming a cost benefit tool for the health system. When performed properly, it is relatively time consuming, needs experience but offers major anatomic and hemodynamic data. Under these circumstances, cardiac catheterization is required only in cases when there is discordance between the clinical assessment and cardiac ultrasound evaluation. In this review we summarize the prevalence and significance of the disease in the elderly population and the use of all recent echocardiographic data that may help select the true candidates for surgery.