Feasibility of blood speckle imaging parameters as predictors of intracavitary thrombus in apical aneurysm

Funding Acknowledgements

Type of funding sources: None.

Introduction

In patients with apical aneurysm, left ventricular thrombus (LVT) is a major complication associated with systemic embolism. Likely, abnormalities in apical wall contraction produce stagnant flow which leads to the thrombus formation. Currently, there is a lack of knowledge about predictors of thrombus in such patients. However, new imaging techniques might be able to identify flow properties useful for risk stratification. Specifically, blood speckle imaging (BSI), a technology based on high-frame rate ultrasound, is a promising pattern-matching technique that could allow a comprehensive assessment of blood flow in patients with apical aneurysms (1,2).

Purpose

The aim of the study was to demonstrate the feasibility of obtaining quantitative and qualitative measurements with BSI in patients with apical aneurysms and to explore which parameters may be associated with LVT.

Methods

We examined cases of patients with apical aneurysm and LVT studied in our tertiary center. In order to exclude from our analysis the pro-inflammatory effects of the acute event, patients with thrombus formation within the first month after the ischemic event were excluded. Patients with current presence of thrombus were also discarded. A control group of patients with apical aneurysm but without history of LVT was included.

A basic 2-dimensional echocardiography study was obtained, along with BSI images. BSI acquisitions were performed with a 29 cm/s (2.5 mHz) scale. Data regarding vortex flow were collected, including its presence, area, length, besides area without BSI vectors (Image 1). All measures were indexed by telediastolic left ventricular volume.

Results

Eight patients with apical aneurysms were enrolled in the study, four of them with history of LVT. Although in patients with history of thrombus a larger vortex area was found  (Table 1), none of the differences in the BSI parameters was statistically significant.

Conclusion

This study shows for the first time the feasibility of BSI for characterizing complex flow patterns such as vortex in patients with apical aneurysms. Explorations in larger cohorts of patients are needed to prove significant findings with this technology in the future. Abstract Figure. Image 1  Abstract TABLE 1

1640 Pulmonary valve in carcinoid disease: be suspicious of functional assessment

Carcinoid heart disease occurs in 50% of patients with carcinoid syndrome, especially on serotonin-secreting neuroendocrine tumors (NET) [1, 2]. Carcinoid heart disease"s typical findings are carcinoid plaques, composed of smooth muscle, myofibroblasts and endothelium. These plaques, most frequently localized on the right side valvular cusps and leaflets, produce fixation and retraction, causing regurgitation and/or stenosis [3, 4, 5]. Left-sided heart disease is rare (<10%), as serotonin is purified in the pulmonary circulation [3, 6, 7].

We present the case of a 67 year old female patient with previous history of right ovarian NET. She presented with dyspnea (II-III NYHA functional class), and slight edema in lower limbs. She denied symptoms of carcinoid syndrome before or after the ovarian surgery.

Examination showed an increased jugular venous pulse.

Transthoracic echocardiography (TTE) showed severely dilated right cavities and a rigid, immobile tricuspid valve, with massive tricuspid regurgitation (Panel A, 1). Anatomy of

pulmonary valve was not properly visualized but jet area of pulmonary regurgitation was small (Panel A, 2). Left cavities and valves were intact.

As TTE was not anatomically conclusive, a cardiac magnetic resonance (CMR) and a cardiac computed tomography (CCT) were performed to assess the carcinoid involvement of pulmonary valve.

CMR showed severely dilated right ventricle with mild impairment of systolic function (Panel A, 3). Based on phase contrast imaging, pulmonary regurgitation fraction was 14%,

suggestive of a mild grade. However, CCT showed a diffuse thickening of the pulmonary valve, with complete opening during diastole (Panel A, 4, arrowhead). Finally, the patient underwent replacement of tricuspid valve and pulmonary valve for biological prosthesis without complications.

Our case is remarkable because it highlights the limitations of the functional assessment of pulmonary regurgitation in the presence of a concomitant massive tricuspid valve regurgitation, since the rapid equalization of pressure between pulmonary artery and right ventricle reduces the expression of pulmonary regurgitation. For these reason, the anatomic assessment of the pulmonary valve is mandatory to stage the involvement of pulmonary valve in carcinoid disease.

Abstract 1640 Figure. Panel A

1095 Effective image-guided medical management in effusive constrictive pericarditis

A 59 year old man was admited to hospitalization for persistent chest pain related to acute pericarditis. Within the admision tests, a transthoracic echography was performed, showing a moderate pericardial effusion with ventricular septal bounce and significant respiratory variations in mitral and tricuspid inflows, all of it consistent with effusive-constrictive pericarditis (Panel A). Anti-inflammatory treatment with ibuprofen and colchicine was started.

During the first 48 hours of admission there was a clinical and hemodinamic worsening in the patient’s condition that forced the performance of a pericardial window, obtaining a very little quantity of dense pericardial fluid. Looking for a more accurate study of the pericardium, a cardiovascular magnetic resonance (CMR) was performed, revealing a thick heterogeneous pericardial effusion (Panel B) and a significant late gadolinium enhancement of both pericardial layers (Panel C). All these findings where consistent with an effusive constrictive pericarditis with persistent inflammatory activity despite high doses of conventional inflammatory treatment. Furthermore, the growth of Propionibacterium acnes in the pericardial fluid disclosed the etiology of this condition.

Medical treatment was enhanced with high doses of intravenous corticosteroid, ceftriaxone and doxycycline. During the following days, the patient showed an excellent response achieving the complete clinical and echocardiographic relief of constrictive signs (Panel D).

Effusive constrictive pericarditis is characterized by the presence of pericardial effusion and constriction secondary to an inflammatory process of the pericardium. Pericardiectomy might be necessary in case of failure of medical treatment, a very common scenario in this kind of .pericarditis.

Our case is remarkable because it demonstrates the value of CMR to detect persistent inflammation of pericardium despite high doses of conventional medical treatment for pericaricarditis guiding the successful escalation to intravenous corticosteroid and avoiding the risk of an unnecessary cardiac surgery.

Abstract 1095 Figure.

Phase II study of capecitabine (X) + docetaxel (T) as neoadjuvant treatment in patients (pts) with locally advanced breast cancer (LABC) including biological correlates

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Background: X and T have demonstrated synergy in preclinical studies and survival benefits in metastatic BC. We aimed to determine whether the high efficacy of XT could translate into the neoadjuvant setting. Methods: Expression levels (mRNA) of 3 enzymes involved in X intratumoral activation and metabolism (thymidylate synthase [TS], thymidine phosphorylase [TP] and dihydropyrimidine dehydrogenase [DPD]), were determined in tumor biopsies before treatment and their relationship with clinical and pathological response analyzed using Fisher’s Exact Test. Pts with stage IIIA/IIIB LABC, adequate organ function and KPS ≥80 received 4 cycles of X 1250mg/m2 (1000mg/m2 for age >60) bid d1–14 and T 75mg/m2 d1 q3w followed by surgery, adjuvant AC q3w × 4 ± tamoxifen according to ER and PR status. The primary endpoint was pCR. Results: We enrolled 34 pts with LABC IIIA (44%)/IIIB (56%): median age 52y (30–72); KPS ≥90 (76%); median tumor size 6.8cm (2–20); N0 (20%), N1 (41%), N2/3 (35%); ER+PR-/p53+/HER2+ (23/24/28%). 128 cycles of X and T were administered (median 4, range 1–5). Main G3/G4 toxicities were: HFS 32%, diarrhea 15%, asthenia 9%, stomatitis 6% and neutropenia 71%. There were no treatment-related deaths. 2 pts were withdrawn prematurely due to adverse events. The overall response in 32 evaluable pts was 78%, including 5 CRs and 20 PRs. 6/29 pts evaluable for pathological response had pCR (20%), and 10 (33%) had ≤10mm residual tumor (3 microscopic RD) in breast. Nodal involvement after chemotherapy was N0 (33%), N1 (33%), N2 (27%), N3 (7%), and the rate of breast-conserving surgery was 17%. High TP/DPD ratio was associated with CR (p=0.037) and both high TP/DPD and low TS/DPD ratio appeared to correlate with residual tumor ≤10 mm (p=0.028). Conclusions: Neoadjuvant XT appears to be highly active. Safety was similar to that reported in anthracycline-pretreated pts but with less stomatitis. In this small sample, a high TP/DPD ratio appears to correlate with clinical response and a favorable enzymatic profile (high TP/DPD and low TS/DPD ratio) may predict for high pCR. A further prospective study is required to validate this hypothesis.

No significant financial relationships to disclose.

Synthesis, X-ray crystallographic structures of thio substituted N-acetyl N'-methylamide alanine and evaluation of sp sulfur parameters of the CFF91 force field

Acetyl thioalanine N-methyl (Ac-Alat-NHMe) and thioacetyl alanine N-methyl (Act-Ala-NHMe) were synthesized, crystallized and their X-ray diffraction structures determined for the first time. Both molecules adopted beta-sheet conformations and showed similar hydrogen bonding patterns with one molecular surface forming two oxo hydrogen bonds and the other forming two thio hydrogen bonds. The crystal structure data for the two thioamides provided a validation of the thioamide parameters for the newly derived CFF91 force field because the observed crystal (phi, psi) angles were situated in the global minimum regions of the theoretical (phi, psi) map predicted using the parameters. In addition, the parameters were further validated because conformational energy minimization of the crystal structure produced low deviations in unit cell dimensions, bond lengths, bond angles and torsional angles, and a 120-ps molecular dynamics simulation also gave a low deviation for the most probable N-H...S=C bond distance.

Disseminated lymphatic tuberculosis in acquired immunodeficiency syndrome: computed tomography findings

There is an increased frequency of disseminated tuberculosis in patients with acquired immunodeficiency syndrome (AIDS). The authors reviewed 6 thoracic and 10 abdominal computed tomography scans from 11 patients who had AIDS and disseminated tuberculosis. All scans demonstrated multiple, large, mediastinal or retroperitoneal lymph nodes, or both; low-density centers within enlarged nodes were identified in seven patients (63%). The scans also showed a diffuse miliary pattern (three patients), pericardial effusion (three patients), mild hepatomegaly (six patients), moderate splenomegaly (seven patients), hypodense splenic lesions (one patient), peritoneal fluid (four patients), bowel involvement (two patients) and dilatation of the biliary tract (two patients). Infection with Mycobacterium tuberculosis was demonstrated in all cases. The findings of this study show that lymph-node enlargement and nodes with low-density centers in patients who have AIDS are suggestive of disseminated tuberculous infection.