Implantable cardioverter-defibrillator in patients with inherited arrhythmia syndromes: A systematic review

BACKGROUND

The potential benefit of implantable cardioverter-defibrillator (ICD) therapy in individuals with inherited arrhythmia syndromes is well known. However, it is not deprived of morbidity, in the form of inappropriate therapies and other ICD-related complications.

OBJECTIVE

The aim of this systematic review is to estimate the rate of appropriate and inappropriate therapy, as well as other ICD-related complications, in individuals with inherited arrhythmia syndromes.

METHODS

A systematic review was performed, regarding appropriate and inappropriate therapy, and other ICD-related complications, in individuals with inherited arrhythmia syndromes (Brugada Syndrome, Catecholaminergic Polymorphic Ventricular Tachycardia, Early Repolarization Syndrome, Long QT Syndrome and Short QT syndrome). Studies were identified by searching published papers in PubMed and Embase up to August 23rd, 2022.

RESULTS

From data gathered of 36 studies, with a total of 2750 individuals, during a mean follow-up time of 69 months, appropriate therapies occurred in 21% of the individuals and inappropriate therapies in 20% of the individuals. Concerning the other ICD-related complications, 456 complications were observed, amongst 2084 individuals (22%), with the most frequent being lead malfunction (46%), followed by infectious complications (13%).

CONCLUSIONS

ICD-related complications are not uncommon, especially when one considers the exposure time of young individuals. The incidence of inappropriate therapies was 20%, although lower rates were reported in recent publications. S-ICD is an effective alternative to transvenous ICD for sudden death prevention. The decision to implant an ICD should be individualized, taking into account the risk profile of each patient, as well as the possibility of complications.

The Effect of Sacubitril-Valsartan on Ventricular Arrhythmia Burden in Patients With Heart Failure With Reduced Ejection Fraction

Introduction Heart failure with reduced ejection fraction (HFrEF) patients are prone to developing ventricular arrhythmias. In the PARADIGM-HF trial, sacubitril-valsartan (SV) showed a reduction in the composite endpoint of death and HF hospitalization in HFrEF patients; subgroup analysis of this trial revealed a reduction in both sudden death and deaths from worsening HF. The mechanism by which SV may affect the incidence of ventricular arrhythmias is currently under debate, and the literature provides conflicting results. The aim of our study was to evaluate the potential antiarrhythmic effect of this drug in patients with HFrEF carrying an implantable cardiac defibrillator (ICD) or a cardiac resynchronization therapy with a defibrillator (CRT-D). Methods This was a single-center, observational and retrospective study. Inclusion criteria were implantation of an ICD or CRT-D device between 2009 and 2019, age ≥18 years, left ventricle ejection fraction (LVEF) ≤40%, New York Heart Association (NYHA) functional class ≥II, and treatment with an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker for at least 12 months, followed by replacement with SV. Exclusion criteria were NYHA class IV, frequent alterations in chronic medication for HFrEF, and implantation of an ICD or CRT-D after the introduction of SV. The primary outcome was the occurrence of ventricular arrhythmias in the form of appropriate device shocks, ventricular fibrillation, or ventricular tachycardia. The comparisons were performed between two periods of time (12 months before and 12 months after SV) in the same group of patients. Results Fifty-four patients met the inclusion criteria. The mean age was 69.5 ± 1.65 years, and 74.1% of patients were male. The number of patients experiencing appropriate shocks was significantly lower after SV initiation (2% vs. 18%; p=0.016). The percentage of VT (13 vs. 20%; p=0.549) and VF episodes (4% vs. 13% for VF; p=0.289) were also lower, but these differences were not statistically significant. There were no significant differences in the value of NT-proBNP (1128 vs. 775 pg/mL; p=0.858), LVEF (28.4 vs. 29.6%; p=0.315), and left ventricular end-diastolic diameter (65.0 vs. 66.0 mm; p=0.5492). Conclusion SV seems to reduce the risk of arrhythmic events requiring appropriate shock therapy.

A simple interactive robot to promote computational thinking

This paper described the functionalities of a simple robot adopted in the classroom to promote computational thinking (CT) in the context of the project PeCOT—computational thinking with tangible objects. This robot, similar to some commercial educational robots, was developed to be used in primary education classroom contexts (second, third, and fourth grades) by children between 8 and 10 years old. PeCOT is a pedagogical intervention project and research project that will run over the next 2 years. The aim of this paper is to present the robot, how it works, and some activities that can be implemented in the educational context to promote CT skills, including learning in different subject areas, such as mathematics or natural science. Thus, we begin by presenting a general description of the robot. Next, we identify activities and formalize the programming steps for each of the activities. Finally, we discuss the potential that the robot and the proposed activities may have to promote the development of CT skills.

Clinical Case 13—An unusual culprit: challenging diagnosis, easy solution

Presentation

A 59-year-old woman, with multiple cardiovascular risk factors, a history of CABG (left internal mammary artery—obtuse marginal artery; right internal mammary artery—left anterior descending artery) and PAD; presented to the emergency department with prolonged thoracic pain (3 hours) associated with dyspnea. She was hypertense at admission, but the remaining physical exam was unremarkable. Initial electrocardiogram showed descendent segment ST depression in the lateral leads (DI, aVL and V4-V6). Blood test showed a rise in troponin I 0.6 → 8.3 ng/mL). Cardiac catheterization demonstrated patency of both bypasses. However, a calcified stenosis (70–80%) of the left subclavian artery proximal to the emergence of the left internal mammary artery was observed.

Diagnosis

The findings suggested a possible coronary subclavian steal syndrome (CSSS).

Management

The patient was reevaluated and was found to have a systolic blood pressure differential of 18mmHg between the two arms. Despite anti-anginal therapeutic optimization, episodes of angina upon minimal exertion continued. Consequently, she was submitted to percutaneous subclavian artery angioplasty with symptom resolution and was discharged under dual antiplatelet therapy and high-intensity statin.

Learning points

CSSS complicates 0.2–6.8% of the patients who have undergone CABG with a left internal mammary graft. Peripheral artery disease is its strongest predictor and atherosclerosis is the main pathogenic mechanism. In patients with suspected CSSS, physical examination is paramount, often showing a systolic blood pressure differential. Subclavian artery angiography should be performed, whenever it is relevant, during the coronary angiography. First-line therapy includes percutaneous angioplasty and optimal medical therapy.

On- vs off-hours primary percutaneous coronary intervention: a single-centre experience

Introduction

In ST-segment elevation myocardial infarction (STEMI) patients, emergency medical system delays importantly affect outcomes. The effect of admission time in STEMI patients is dubious when percutaneous coronary intervention (PCI) is the preferred reperfusion strategy.

Aims

The authors aimed to retrospectively describe the association between admission time and STEMI patient's care standards and outcomes.

Methods

Characteristics and outcomes of 1222 consecutive STEMI patients treated in a PCI-centre were collected. On-hours were defined as admission on non-national-holidays from Monday to Friday from 8 AM to 6 PM. Time delays, in-hospital and one-year all-cause mortality were assessed.

Results

A total of 439 patients (36%) were admitted on-hours and 783 patients (64%) were admitted off-hours. Baseline characteristics were well-balanced between groups, including the percentage of patients admitted in cardiogenic shock (on-hours: 4.6% vs off-hours 4%; p=0.62).

Median emergency system dependent time to reperfusion (i.e. first-medical contact to reperfusion) did not differ between the two groups (on-hours: 120 min vs. off-hours 123 min, p=0.54). The authors observed no association between admission time and in-hospital mortality (on-hours: 5% vs. off-hours 4.9%, p=0.90) or 1-year mortality (on-hours: 10% vs. off-hours 10%, p=0.97).

In patients admitted directly in the PCI-centre, median time from first-medical contact to reperfusion (on-hours: 87 min vs off-hours: 88 min, p=0.54), in-hospital mortality (on-hours: 4% vs off-hours: 7%, p=0.30) and 1 year mortality (on-hours: 9% vs off-hours: 13%, p=0.27) did not differ between the two groups.

Survival analysis showed no survival benefit of on-hours PCI over off-hours PCI (HR 1.01; 95% CI [0.77–1.46], p=0.95).

Conclusion

In a contemporary well-organized emergency network, STEMI patients admission time in the PCI-centre was not associated with reperfusion delays or increased mortality.

Funding Acknowledgement

Type of funding sources: None. Kaplan-Meier curve

ST-segment elevation myocardial infarction: are women being discriminated?

Background

Although outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary interventions (PCI) have improved, a gender disparity exists, with women showing higher mortality.

Objectives

To assess gender differences in presentation, management and in-hospital, at 30-days, 6-months and 1-year after STEMI mortality.

Methods

We collected data from 809 consecutive patients treated with primary PCI and compared the females versus males.

Results

Women were older than man (69,1±14,6 vs. 58,5±12,7 years; p<0.001) with higher prevalence of age over 75 years (36.7% vs. 11.7%; p<0.001), diabetes (30,6% vs. 18,5%; p=0.001), hypertension (60.5% vs. 45.9%; p=0.001), chronic kidney disease (3.4% vs. 0.6%; p=0.010) and acute ischemic stroke (6.8% vs. 3.0%; p=0.021). At presentation, women had more atypical symptoms, less chest pain (90.3% vs. 95.6%; p=0.014) and greater clinical severity (cardiogenic shock (10.7% vs. 5.4%; p=0.011). There were no differences in the symptom-first medical contact me (95.0 min vs. 80.5 min; p=0.215); however, women had longer time until reperfusion (264.0 min vs. 212.5 min; p=0.001) and were less likely to receive optimal medical therapy (aspirin-93.1% vs. 99.2%; p<0.001; P2Y12 inhibitors 91.9% vs. 98.2%; p<0.001; beta-blockers-90.8% vs. 95.1%; p=0.032; ACEIs- 88.1% vs. 94.8%; p=0.003). In-hospital mortality (9.6% vs. 3.5%; p=0.001), at 30-days (11.3% vs. 4.0%; p<0.001), 6-months (14.1% vs. 4.7%; p<0.001) and 1-year (16.4% vs. 6.3%; p<0.001) was significantly higher in women. The multivariate analysis identified age over 75 years (HR=4.25; 95% CI [1.67–10.77]; p=0.002), Killip class II (HR=8.80; 95% CI [2.72–28.41]; p<0.001), III (HR=5.88; 95% CI [0.99–34.80]; p=0.051) and IV (HR=9.60; 95% CI [1.86–48.59]; p=0.007), acute kidney injury (HR=2.47; 95% CI [1.00–6.13]; p=0.051) and days of hospitalization (HR=1.04; 95% CI [1.01–1.08]; p=0.030) but not female gender (HR=0.83; 95% CI [0.33–2.10]; p=0.690) as independent prognostic factors of mortality.

Conclusions

Compared to men, women with STEMI undergoing primary PCI have higher mortality rates. Our results suggest that this is not due to the gender itself, but due to the women worse risk profile, the higher reperfusion time related with system delays and the minor probability of receiving the recommended therapy. Efforts should be made to reduce these gender differences.

Funding Acknowledgement

Type of funding sources: None.

The Predictive role of speckle-tracking and left ventricular ejection fraction estimation using 2D and 3D echocardiography in the detection of chemotherapy related cardiotoxicity

Background

2D left ventricular ejection fraction (LVEF) estimation through echocardiography has been the classic parameter for cancer therapy–related cardiac dysfunction (CTrCD) detection. However, it is hypothesized that other parameters can be used in order to detect early stages of subclinical cardiotoxicity when LVEF is still preserved. Therefore, 3D LVEF and 2D and 3D strain parameters assessments have been evaluated in patients submitted to anthracyclines treatment.

Objectives

To compare 2D and 3D LVEF and strain parameters estimation using echocardiography regarding its ability to predict and detect subclinical and clinical cardiotoxicity during and after anthracyclines treatment.

Search methods and criteria

A systematic review was done and search was performed on PubMed and EMBASE from January 1st of 2000 to October 31th of 2020. Observational studies comparing 2D and 3D echocardiographic exams performed in adult patients submitted to anthracyclines were analyzed. Studies that evaluated survivors of pediatric cancer were excluded. 11 studies were included (n=844 patients).

Main results

2D and 3D LVEF decreased throughout the echocardiographic assessments of 7 studies, but 2D LVEF drops were not statistically significant in 4 studies and 3 studies showed that 3D LVEF detected a superior number of patients with abnormal LVEF. Compared to 3D LVEF,

2D GLS decreased at an earlier point of treatment and detected a superior number of patients with subclinical LV dysfunction. Despite 2D and 3D GLS decreased throughout treatment, 3D GLS measurements were consistently lower and had higher relative variation. All 3D strain parameters decreased during and after the treatment and have higher relative variations than 2D GLS, with the exception of 1 study. 3D GLS reference values are not yet recognized by guidelines, so subclinical LV dysfunction was not evaluated.

Conclusions

LVEF estimation through 3D proved to be a better parameter for CTrCD detection vs 2D imaging. GLS is superior to 3D LVEF in detecting earlier LV changes, even if calculated using 2D echocardiography. Moreover, GLS reduction can be a predictor of subsequent LVEF decrease. 3DE is a growing potential technique and may be superior to 2DE in detecting and predicting subclinical LVEF dysfunction and CTrCD, respectively. Though 3D strain parameters presented promising results, more studies are needed to prove its incremental value over 2D strain echocardiography

Funding Acknowledgement

Type of funding sources: None.

Impact of a cardio-oncology rehabilitation program in patients with breast cancer undergoing cardiotoxic treatment

Background

Cancer treatment–related cardiotoxicity (CTrCD) is commonly associated with anthracyclines and anti-HER2 agents which are widely used for the treatment of breast cancer. In order to mitgate CTrCD, exercise-based cardio-oncology rehabilitation (COR) involving a structured exercise program has been proposed.

Objectives

To evaluate the impact of a cardiac-rehabilitation program in breast cancer patients submitted to chemotherapy with known cardiotoxicity.

Methods

A systematic review was performed. Two databases were searched, PubMed and SCOPUS. All randomized or controlled trials and other prospective studies published between 2000 and March 2020 which evaluate the impact of an aerobic exercise program on cardiorespiratory fitness (CRF), health-related quality of life (QOL), vascular/endothelial function as well as cardiac assessment namely through the evaluation of left ventricular function and cardiac biomarkers in patients undergoing anthracycline and/or anti-HER2 treatments were included.

Main results

Fourteen studies were included enrolling 578 breast cancer patients with a mean age of 48.80 years. Regarding the impact of exercise in CRF, 5 studies (n=176) reported a significant improvement of VO2 max. and 4 studies of VO2max./kg (n=137). The peak power output was also improved in 4 studies (n=95) in the exercise-group. Considering the assessment of QOL, 3 studies (n=180) revealed significant differences favoring the exercise-group. The results regarding the evaluation of the LVEF were not clear: 2 studies (n=48) reported a significant decrease on LVEF when compared to baseline at the end of the intervention in both groups, despite the exercise program. However, 2 studies (n=97) showed a significant increase on LVEF in the exercise-group. Three studies (n=82) did not found significant differences in global longitudinal strain between groups. Limited evidence was found in vascular and endothelial functon. In 2 studies (n=50), endothelial function measured by brachial artery flow-mediated dilatation significantly improved in the exercise-group. Two studies (n=98) reported no significant impact of exercise on atenuating the increase of cTnI and BNP levels in the course of chemotherapy. On the other hand, when considering NT-proBNP, an increase in its levels was attenuated in the exercise-group.

Conclusions

This study confirms that exercise-based COR seems to be an effective approach to improve several cardiovascular outcomes and quality of life in breast cancer patients.

Funding Acknowledgement

Type of funding sources: None.

Temporal characterization of ventricular function and deformation after Takotsubo syndrome using cardiovascular magnetic resonance imaging

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

The time course of ventricular recovery in Takotsubo Syndrome (TS) patients(pts) is still not well characterized. Quantification of myocardial deformation using Cardiovascular Magnetic Resonance Feature-Tracking (CMR-FT) may be a useful method to better characterize ventricular recovery during TS.

AIM

To assess the time course of ventricular function using CMR-FT myocardial strain in patients (pts) with an episode of TS.

METHODS

We performed a single-center, retrospective cohort study including 130 pts admitted with TS over a 10-year period. From this cohort, 39 (30%) pts were selected and age and sex-matched with 16 healthy controls for a comparative analysis of myocardial strain using CMR-FT. TS pts were divided in 3 homogeneous subgroups according to the time from index-event and the CMR acquisition: Group 1(G1): <8 days; Group 2(G2): 8 to 30 days; Group 3 (G3): >30 days.

One operator blinded for the study group performed the analysis. Left ventricle (LV) radial strain (RS), longitudinal strain (LS) and right ventricle (RV) LS were quantified.

RESULTS

The mean age of TS group was 66 years and 90% were female. The median ejection fraction (EF) at admission was 38%; 82% displayed an apical ballooning (AB) pattern. Around 19% had at least 1 in-hospital complication and 1.5% died during hospitalization. A significant increase use of CMR was observed over the years (p = 0.001).

Myocardial deformation analysis showed a significant group interaction for LV LS and RS. Specifically, the global values of G1 LV LS and RS were significantly decreased when compared with G3 (LS:-15vs-20%;p = 0.002; RS:40vs61%; p < 0.001) and controls (LS:-15vs-22%;p < 0.001; RS: 40vs70; p < 0.001). There were no significant differences in the RV LS across groups.

The CMR-quantified EF was significantly decreased in G1 when compared with G3 (52vs64%; p < 0.003) and controls (52vs64%; p < 0.001). Differences between G1 and G2 were found in LV RS (LS:40vs57%; p < 0.001) and EF (52vs62%; p < 0.001). No differences were observed for any parameters between G3 and controls.

This study showed that global LV LS (r=-0.6, p < 0.001) and RS (r = 0.7, p < 0.001) had a significant correlation with the CMR-quantified EF.

A comparison between the different patterns of TS was also performed (Figure 1). Pts with AB pattern in G1 displayed lower global RS (P = 0.014), although there were no differences regarding global LS. As expected, in the AB group the reduction in myocardial strain was limited to the apical segments.

Despite not being significantly different across groups RV LS was the only CMR-derived predictor of complications during follow-up (OR = 1.17; p = 0.026).

CONCLUSION

This study revealed that after an episode of TS myocardial function quantified either by EF or CMR-FT strain fully recovers between the 8th and 30th day of the event. RV strain was a predictor of complications during follow-up.

Cannabidiol in the prelimbic cortex modulates the comorbid condition between the chronic neuropathic pain and depression-like behaviour in rats: The role of medial prefrontal cortex 5-HT1A and CB1 receptors

The prelimbic division (PrL) of the medial prefrontal cortex (mPFC) is a cerebral division that is putatively implicated in the chronic pain and depression. We investigated the activity of PrL cortex neurons in Wistar rats that underwent chronic constriction injury (CCI) of sciatic nerve and were further subjected to the forced swimming (FS) test and mechanical allodynia (by von Frey test). The effect of blockade of synapses with cobalt chloride (CoCl₂), and the treatment of the PrL cortex with cannabidiol (CBD), the CB₁ receptor antagonist AM251 and the 5-HT_1A receptor antagonist WAY-100635 were also investigated. Our results showed that CoCl₂ decreased the time spent immobile during the FS test but did not alter mechanical allodynia. CBD (at 15, 30 and 60 nmol) in the PrL cortex also decreased the frequency and duration of immobility; however, only the dose of 30 nmol of CBD attenuated mechanical allodynia in rats with chronic NP. AM251 and WAY-100635 in the PrL cortex attenuated the antidepressive and analgesic effect caused by CBD but did not alter the immobility and the mechanical allodynia when administered alone. These data show that the PrL cortex is part of the neural substrate underlying the comorbidity between NP and depression. Also, the previous blockade of CB₁ cannabinoid receptors and 5-HT_1A serotonergic receptors in the PrL cortex attenuated the antidepressive and analgesics effect of the CBD. They also suggest that CBD could be a potential medicine for the treatment of depressive and pain symptoms in patients with chronic NP/depression comorbidity.

Infective endocarditis by a rare and fastidious agent: Abiotrophia defectiva

Abiotrophia defectiva is a nutritional variant streptococcus, with affinity for endovascular structures that cannot be cultured on non-supplemented media, leading to a delay in diagnosis. This case describes a 36-year-old woman with a previously known bicuspid aortic valve that presented with asthenia, myalgias and anorexia with 2-month onset. On admission, we documented fever and a systolic murmur. Transthoracic echocardiography revealed an oscillating mass attached to the aortic valve. The patient was admitted with a possible diagnosis of infective endocarditis. Later, blood cultures were positive for A. defectiva Due to severe aortic regurgitation and congestive heart failure, she underwent surgical aortic valve replacement. After 6 weeks of antimicrobial therapy, the patient experienced full recovery. Despite of its rarity, A. defectiva endocarditis is associated with significant morbidity with mortality and physicians must have a high level of suspicion to ensure a prompt diagnosis and provide the appropriate treatment.

Video-Endoscopic Mobilization of the Gracilis Muscle for Rectourinary Fistula Repair

INTRODUCTION

Transposition of the gracilis has been used in a large number of reconstructive procedures. Its advantage is its proximity to these defects and a good blood supply. Traditionally, the gracilis mobilization is performed by open surgery with one or more incisions. We describe our initial experience with the video-endoscopic mobilization of gracilis.

METHOD

We described a retrospective review of all patients who underwent gracilis muscle mobilization for treatment of rectourethral fistula, performed by video-endoscopy, between March 2013 and September 2017, for treatment of rectourethral fistula. Also, our surgical technique is described in detail.

RESULTS

Three patients, with a mean age of 66.6 years, underwent the procedures. The mean time for mobilization of the gracilis was 107 min (range 60-145). There was no case of donor area infection, no change in the sensitivity of the medial aspect of the thigh or chronic pain. Conversion to open surgery was not necessary in any case. The hospital discharge occurred in average after 4 days. The bladder catheter was removed after 4 weeks after cystography was performed without evidence of leakage. One patient had a recurrence of the fistula.

DISCUSSION

The gracilis is an excellent choice of tissue to be interposed in reconstructive procedures of the perineal region, especially in the treatment of rectourinary fistulas. However, endoscopic harvest of the gracilis muscle has not yet found its way into everyday practice. The results in the treatment of rectourinary fistulas are excellent, with a success rate of 87.7%. Our rate of 67% is below, probably due to the small number of cases. In open surgery, complications are uncommon; however, approximately half of the patients expressed concern about the painful scar, which can be reduced by minimally invasive access.

CONCLUSION

Video-endoscopic mobilization of gracilis muscle for the treatment of rectourethral fistula is feasible and safe. Studies comparing this technique with the conventional mobilization are required.

Impact of Atrial Fibrillation type in Acute Coronary Syndrome and the antithrombotic strategy

Funding Acknowledgements

Type of funding sources: None.

INTRODUCTION

Atrial fibrillation (AF) is an adverse prognostic factor during acute coronary syndrome (ACS). Current evidence recommends dual antithrombotic therapy (DAT), 1 antiplatelet drug and 1 anticoagulant drug, as the default strategy after nonST elevation ACS.

AIM

To identify the clinical differences and prognosis of AF type-new onset (nAF) or pre-existing (pFA)- during ACS, to evaluate antithrombotic strategy at hospital discharge (HD) and its impact on haemorrhagic and ischemic events.

METHODS

We performed a retrospective observational cohort study including 3241 patients (pts) with ACS (mean age 64 years, 77.5% male) admitted to a single center over a 6-year period, with 12-months follow-up.

RESULTS

AF rhythm was identified in 11.2% pts, of whom 63.2% presented nAF and 36.8% pAF.

When AF types where compared, pts with pAF had a higher prevalence of cardiovascular (Cv) comorbidities, including hypertension (p < 0.001), previous ACS (p = 0.03), valvular disease (p = 0.01) or stroke (p = 0.05), had greater left atrial diameter (p < 0.001) and were less likely to have significant coronary lesions (p = 0.05). Pts with nAF more frequently presented with STelevation ACS (p < 0.001) and had a lower Hemoglobin nadir (p < 0.001). The independent predictors of nAF in ACS were age (OR 1.1, p< =0.001), LVEF ≤ 40% (OR 2.2, p = 0.001), STelevation ACS (OR 2.6, p< =0.001) and previous valvular disease (OR 3.5, p< =0.01). Compared with the population without AF, nAF was a predictor of in-hospital death (OR 2.9, p = 0.027) and in-hospital composite endpoint (death, stroke, reinfarction and cardiogenic shock) (OR 2.5, p = 0.001) in multivariate analysis, but pAF wasn’t. During 12-months follow-up of pts with ACS and AF, there was no difference regarding death or follow-up composite endpoint (death, stroke and ACS) between the AF types.Regarding antithrombotic therapy, nAF pts were less often anticoagulated (p < 0.001) and pAF pts where more often treated with triple antithrombotic therapy (TAT) at HD (<0.001). Most of the pts with TAT stopped the second antiplatelet at agent 6-months (43.8%) or 12 months (25.5%) after HD. During 12-months follow-up, pts discharged with TAT had trend towards more haemorrhagic events (TAT 6.2% vs DAT2.7%,p = 0.69) and both groups had similar ischaemic events (death, ACS, stroke) (TAT 20.9% vs DAT23.7%,p = 0.714). In multivariate analysis the choice of TAT or DAT wasn’t a predictor of ischaemic events.

CONCLUSIONS

In ACS, pts with nAF had worst in-hospital outcomes than pts with pAF. Regarding antithrombotic strategy at HD pts with nFA were less often anticoagulated and less often treated with TAT. In our study the choice between DAT or TAT had no statistical impact on follow-up outcomes.

Asymptomatic severe aortic stenosis: what is the current role of exercise stress test and NT-proBNP in patient risk stratification

Funding Acknowledgements

Type of funding sources: None.

Introduction

Aortic stenosis (AS) is prevalent in the elderly population. When severe and the patient is symptomatic or left ventricular dysfunction arises, the prognosis deteriorates and valve replacement (AVR) is recommended. During the asymptomatic phase regular clinical evaluation is advised to detect early onset of symptoms and/or signs of myocardial maladaptation. Due to the inherent difficulties in the evaluation of symptoms, especially in the elderly, as well as the change in prognosis when symptoms appear (even if not perceived), it is crucial to evaluate the behavior of patients with effort and signs of myocardial injury.

Methods

An observational and retrospective study that included 74 patients followed at the Cardiology Service by severe AS (aortic valve area ≤ 1cm2 and/or aortic transvalvular mean gradient ≥40mmHg), who underwent exercise stress test (EST) and NT-proBNP evaluation for risk stratification. The outcome studied was hospitalization for heart failure (HF), or referral to SV, or death during the follow-up period. Independent predictors were obtained using multivariate Cox regression.

Results

Non-progression or decrease in systolic blood pressure (SBP) in EST is the only independent predictor of a short-term adverse event (p = 0.025). This parameter, NT-proBNP levels and interventricular septal thickness (IVS) were independent predictors of a medium (two (p = 0.025; p = 0.014; p = <0.001), three (p = 0.015; p = 0.007; p = 0.001) and four years (p = 0.007; p = 0.049; p = 0.005)) and a long term adverse event (p = 0.006; p = 0.028; p = 0.005).

Conclusion

In asymptomatic patients with severe AS, no progression or decrease in SBP in EST, increased NT-proBNP levels and thickness of IVS were independent predictors of hospitalization for HF, need for VS or death in short, medium and long term.

Prognostic impact of severe anemia (hemoglobin <10g/dL) during treatment with dual antiplatelet therapy after hospital discharge for acute coronary syndrome

Introduction

In recent years, the use of invasive strategies has become the generalized approach in the management of patients with acute coronary syndrome (ACS), justified by the associated prognostic benefit due to reduced mortality and the evolution of percutaneous coronary intervention (PCI). However, the benefits of an invasive approach in ACS are unclear in the population with significant anemia, as anemia is strongly associated with increased risk of morbidity and mortality in these patients.

Aim

To determine the ischaemic vs. bleeding risks from patients with severe anemia (hemoglobin <10 g/dL) during treatment with Dual Antiplatelet Therapy (DAPT) after an ACS undergoing PCI.

Methods

From a national multicentre registry, we analyzed 17 370 ACS pts. Pts were divided into two groups: group 1 - pts with severe anemia (hemoglobin <10g/dL) (n=557, 3.2%); group 2 - pts without severe anemia (hemoglobin 10g/dL) (n=16813, 96.8%). Primary endpoint was the occurrence of a composite of death and adverse cardiovascular events (stroke, reinfarction, and rehospitalization of cardiovascular etiology) at 1 year.

Results

The sample consisted in 73.4% men and 26.6% women, with mean age of 66±14 years. The incidence of severe anemia was 3.2%. Group 1 pts were older (75±12 vs 66±14, p<0.001), had a higher proportion of women (47.6% vs 25.9%, p<0.001), diabetes (55% vs 30.6%, p<0.001), hypertension (81.8% vs 68.2%, p<0.001) and chronic kidney disease (29.2% vs 5.2%, p<0.001). During hospitalization, group 1 had more heart failure (35.3% vs 15.1%, p<0.001), worst LVEF (27.3% vs 17.3%, p<0,001), bleeding (7.6%% vs 1.3%, p<0.001) and transfusion (23.4% vs 1%, p<0.001). During hospitalization, group 2 pts were more likely to undergo revascularization (82.9% vs 89.4%, p<0.001) and double antiaggregation (82.5% vs 95%, p<0.001). A multivariate analysis identified age [OR 1.48, 95% CI 1.32 to 1.89; p<0.001] and feminine sex [OR 2.21, 95% CI 1.89 to 3.61; p<0.001] as independent predictors of severe anemia during hospitalization. Patients with severe anemia had longer hospital stay (9 days vs 6 days; p<0.001), and higher 6-month mortality (8.7% vs. 2.9%; p<0.001). In multivariate analysis and after adjusting for different baseline characteristics, pts with severe anemia had higher occurrence of a composite of death and adverse cardiovascular events at 1-year compared to those without severe anemia [OR 3.04, 95% CI 1.21 to 5.04; p=0.029].

Conclusion

We objected a low prevalence of ACS patients with severe anemia undergoing PCI (52.2%) but the incidence of ICP in these complex patients has increased in recent years, mainly due to the evolution of PCI over the last 40 years. Severe anemia was strongly associated with increased risk of morbidity and mortality in ACS pts.

Funding Acknowledgement

Type of funding source: None

What is the prognosis for patients who develop new-onset atrial fibrillation in the first 48 hours after an acute coronary syndrome?

 

Atrial fibrillation (AF) is a common complication in acute coronary syndrome (ACS). However, treating patients (pts) with new-onset AF (NOAF) after an ACS remains a challenge. Although it seems intuitive that pts who develop AF within the first 48h have increased morbidity and mortality, your prognosis is unclear because there are no robust studies in the literature to confirm this association.

Aim

To characterize the population of pts who developed NOAF in the first 48 hours after an ACS and to compare the prognosis between these pts and pts who didn't develop AF.

Methods

2916 ACS pts admitted consecutively in our coronary care unit during 6 years were analyzed retrospectively. Of these pts, 343 (11.7%) had AF within the first 48h, of which 99 (3.4%) had pre-existing AF and 243 (8.3%) presented NOAF. Pts were divided into two groups: group 1 -ACS pts who developed NOAF in the first 48h (n=243; 8.8%); group 2 – ACS pts who did not develop AF (n=2517; 91.2%). Pts with pre-existing AF were excluded (n=156; 5.4%). Primary endpoint were the occurrence of death at 6 months; follow-up was completed in 95.8% of pts.

Results

Group 1 pts were older (72±12 vs 62±13, p<0.001), with higher proportion of women (30,9% vs 20,9%, p<0.001), hypertensive (78,5% vs 60,7%, p<0.001), smokers (17,4% vs 32,6%, p<0.001), previous CABG (7,9% vs 3,8%, p=0.06) and stroke (10,7% vs 6,8%, p=0.035). Group 1 had a higher proportion of STEMI pts (58,5% vs 46,5%, p<0.001) and, during hospitalization, had more often respiratory infection (p<0.001), malignant arrhythmias (p<0.001), heart failure (p<0.001), stroke (p=0.001), higher values of NT-proBNP (p<0.001) increased C-reactive protein levels (p<0.001), leukocytes (p=0.020), peak of TropI (p=0.029) and creatinine (p<0.001). On echocardiography, group1 had greater LA diameter (45±6 VS 41±5mm, p<0.001), more frequent significant mitral regurgitation (13,9% vs 2,9%, p<0.001), worst LVEF (41±10% vs 46±10%, p<0.001) and a higher value of pulmonary artery pressure (39±12 vs 24±10, p<0.001). Group 1 were less likely to have undergone coronary revascularization (84% vs 74%, p=0.005). In multivariate analysis, age ≥75 (OR 1.05, p<0.001), LVEF ≤40% (OR 2.50, p<0.001), LA diameter (OR 1.59, p=0.027), more significant mitral regurgitation (OR 2.49, p=0.001) and Killip class >1 (OR 1.51, p=0.015) remained independent predictors of NOAF. In multivariate analysis and after adjusting for different baseline characteristics, pts with NOAF have the same risk of 6-months mortality compared to those who didn't develop AF [OR 1.03, p=0.91].

Conclusion

The incidence of NOAF was 8.8% in our population, which is similar to the literature. Age, LVEF, LA diameter, a significant mitral regurgitation and Killip class >1 were independent predictors of NOAF after ACS. Pts with NOAF in the first 48h after an ACS had worse clinical manifestations during hospitalization but no higher 6-months mortality risk.

Funding Acknowledgement

Type of funding source: None

Indomethacin attenuates mechanical allodynia during the organization but not the maintenance of the peripheral neuropathic pain induced by nervus ischiadicus chronic constriction injury

The neurochemical mechanisms underlying neuropathic pain (NP) are related to peripheral and central sensitization caused by the release of inflammatory mediators in the peripheral damaged tissue and ectopic discharges from the injured nerve, leading to a hyperexcitable state of spinal dorsal horn neurons. The aim of this work was to clarify the role played by cyclooxygenase (COX) in the lesioned peripheral nerve in the development and maintenance of NP by evaluating at which moment the non-steroidal anti-inflammatory drug indomethacin, a non-selective COX inhibitor, attenuated mechanical allodynia after placing one loose ligature around the nervus ischiadicus, an adaptation of Bennett and Xie's model in rodents. NP was induced in male Wistar rats by subjecting them to chronic constriction injury (CCI) of the nervus ischiadicus, placing one loose ligature around the peripheral nerve, and a sham surgery (without CCI) was used as control. Indomethacin (2 mg/kg) or vehicle was intraperitoneally and acutely administered in each group of rats and at different time windows (1, 2, 4, 7, 14, 21, and 28 days) after the CCI or sham surgical procedures, followed by von Frey's test for 30 min. The data showed that indomethacin decreased the mechanical allodynia threshold of rats on the first, second, and fourth days after CCI (P<0.05). These findings suggested that inflammatory mechanisms are involved in the induction of NP and that COX-1 and COX-2 are involved in the induction but not in the maintenance of NP.

P1308 A peculiar case of an acute pulmonary embolism

CONCLUSION

We experienced a very uncommon case of a metastatic cardiac tumor from urothelial carcinoma. To the best of our knowledge, only a small number of cases were reported and the reason for the rarity of cardiac metastasis from urothelial carcinoma is unclear. Although the echocardiography has become the gold standard for the diagnosis of intracardiac masses, cardiac MRI plays an important role in the evaluation of cardiac masses of non-neoplastic and neoplastic origin, allowing a comprehensive characterization of such lesions.

Abstract P1308 Figure. pediculated and mobile mass (20x56mm) at

P232 A cardiac thrombus... or maybe not

A 61 years old female with history of rheumatic arthritis and Sjogren Syndrom resorted to the emergency room in December of 2017 for pleuritic chest pain and dyspnea. An angioCT showed a luminal filling defect at the left inferior pulmonary artery with extension to the segmentar vessels. A pulmonary embolism (PE) was diagnosed and the patient was admitted. The study performed, including transthoracic echocardiogram (TTE) was unremarkable. Patient was discharged after 15 days treated with a direct oral anticoagulant. Six months later she returned to the emergency room with the same complaints. A new angioCT showed reduction of the previous luminal filling defects, but a focal defect in the filling of the right atrium (RA) was visualized. A TTE showed a mass (17 mm) at the RA with apparent origin at the superior vena cava. A presumptive diagnostic of atrial thrombus was done and patient started therapy with vitamin K antagonist. Three months later, TTE was repeated and the mass was still present (19 mm). Five months later, the mass was still visualized at TTE (17 mm). A transesophagic echocardiogram confirmed the presence of a RA mass with 30x22 mm of major dimensions, with close relation with the interatrial septum suggestive of a tumor. A cardiac magnetic resonance revealed a RA mass without vascularization. A cardiac gated CT showed at the RA a low density nodular image of 26x22 mm at the axial plan, with an extension of 28 mm, adjacent to the posterior wall of the RA. After contrast administration, some areas did not had significant captation while some did, aspects compatible with a "pseudoenhancement" aspect. A positron tomography showed mild to moderate FDG captation at the RA. Meanwhile, patient was under anticoagulation for 2 years with no regression of the mass. For this reason, patient was oriented to cardiac surgery. The mass was resected and the histology revealed a RA myxoma.

Cardiac masses can be due to tumour, thrombus or vegetation. In this case, the mass was highly considered to be a thrombus due to the presence of multiple risk factors: prothrombotic disease and pulmonary embolism. However, the fact that the mass did not reduce with therapy raised suspicion of other diagnosis. Although rare, myxomas can be found in the RA, and should be included in the differential diagnosis of right-sided intracardiac masses. Although myxomas are histologically benign, potential for embolization and sudden death make surgical resection a priority. Its diagnosis has now increased with the use of echocardiogradiography, and has made it the main modality for the evaluation of myxomas. PE is the most dreaded and devastating complication of right-sided myxoma. In cases of RA myxomas, clinically evident PE events are uncommon. Nevertheless, there have been reports of embolization of thrombi or tumor fragments into the pulmonary vessels in cases of right in approximately 3.2% of myxoma patients.

P1314 A singular explanation of stroke in young adults

INTRODUCTION

Although primary cardiac tumors are rare, papillary fibroelastoma (PFE) is the most common benign neoplasm of cardiac valvular structures. Because patients are often asymptomatic the true prevalence is unknown, being most commonly recognized given the evolution of higher-resolution imaging technology. The clinical presentation of PFEs can diverge between being asymptomatic to symptomatic based on the serious complications that can occur, such as acute valve dysfunction or embolization, giving rise to a wide variety of presenting features including neurologic events, acute coronary syndrome, and distal embolic events. The location on the mitral valve does not occur frequently, with rare cases reported in the literature. Here, we present an unusual case of a 32-year-old male with an acute stroke secondary to a PFE in the mitral valve.

CASE REPORT DESCRIPTION

A 32-year-old male patient with a history of crohn"s disease was admitted to our emergency department with a transient sudden-onset aphasia associated with a right hemiparesis. At admission, these symptoms had completely resolved. On further questioning, the patient described another episode of transient right hemiparesis in the last year. On physical examination, the patient"s vital signs were stable. The patient was awake, alert, and oriented with full Glasgow Coma Scale. There was no focal neurological deficit on neurological examination and his cardiovascular examination was normal with no murmurs, added sounds or carotid bruit. A cranial CT showed no signs of acute intracranial disease. Head MRI showed multiple areas of restricted diffusion in the left frontal lobe consistent with acute stroke. As part of the workup to determine the cause of his embolic stroke, a transthoracic echocardiogram and transoesophageal echocardiography were performed, showing a spherical and highly mobilemass attached on the downstream side of the anterior mitral valve leaflet of approximately 1.1 cm in diameter, suggesting the diagnosis of PFE. A bubble study was negative which out ruled patent foramen ovale. After completing the rest of the workup, it was determined that PFE was likely the cause of his stroke. Cardiothoracic surgery was consulted and the patient underwent surgical resection. Histology confirmed the diagnosis of PFE. After 5 years the patient remains asymptomatic, without new embolic events.

DISCUSSION AND CONCLUSIONS

We present a special case that illustrates the importance of diagnosing primary cardiac tumours in a young patient presenting with acute stroke with minimal or no risk factors.Although primary cardiac tumours are rare, diagnosis and treatment at an early stage may prevent serious complications and reduce the morbidity and mortality of embolic stroke.

P226 Caseous calcification of the mitral annulus: a silent cause of intracardiac mass

INTRODUCTION

Caseous calcification of the mitral annulus (CCMA) is a very rare variant of mitral annular calcification with a central liquefaction necrosis, being an uncommon echocardiographic finding (0.5 to 1%) which may be mistaken for an intracardiac tumor, thrombus or vegetation. This chronic degenerative process can occurs at advanced ages, particularly in women, and patients with hypertension, chronic renal failure or calcium metabolism abnormalities. Since patients often remain asymptomatic, conservative treatment for this lesion is generally sufficient.

CASE REPORT

DESCRIPTION

We report a case of an 86-year-old female with a known history of hypertension and diabetes, who was referred to our department in order to investigate the diagnosis of an intracardiac mass visualized through a routine transthoracic echocardiography. She reported effort dyspnea, but refused to have other cardiovascular symptoms.

In order to study this intracardiac mass, the patient was submitted to a transthoracic echocardiogram that showed a rounded mass of 16 × 22 mm in the anterior mitral annulus, mainly in P1 scallop, not causing valve stenosis and with a mild mitral regurgitation. This prompted the need for transesophageal echocardiography which revealed a spheroid mass of heterogeneous content with calcification points, regular edges and with faint central echo-lucent area without acoustic shadowing, attached to the anterior mitral valve leaflet. No communication with any cardiac chamber could be detected. The mass did not determine any restriction to the opening of mitral valve cusps. A cardiac MRI was requested to complete the diagnostic evaluation revealing that the lesion was located at the base of the anterior leaflet. In the T1 and T2 sequences the mass was hypointense, whereas in the perfusion sequence, no contrast penetration was detected in the mass and in the late enhancement. These findings, as well as the presence of a calcified envelope in the cardiac computed tomography scan, confirmed the suspicion of caseous calcification of the mitral annulus.

DISCUSSION

AND CONCLUSIONS

We present an unusual case of caseous calcification of the mitral annulus in which the multi-modal approach was crucial to confirme the diagnosis. Although transthoracic echocardiography can be sensitive in the diagnosis of this entity, the diagnosis may sometimes still be inconclusive. Thus, multi-modality with transesophageal echocardiography, cardiac MRI or CT can lead to a definitive diagnosis, avoiding an mistaken diagnosis with the need of a surgical approach. Since this pathology is most frequently detected in asymptomatic patients, the patients should be treated medically and monitored clinically and echocardiographically for an early recognition of possible complications.

Abstract P226 Figure. Caseous calcification of mitral annulus

P725 An unexpected direction: a case report of a double aortic arch in an asymptomatic woman in adulthood

Introduction

Complete vascular rings represent about 0.5-2% of all congenital cardiovascular malformations, with the double aortic arch (DAA) being the most common of the complete vascular rings, causing tracheoesophageal compression. The right (posterior) arch is usually dominant (70%), although the two arches can have the same size (5%). The left (anterior) arch is dominant in only approximately 25% of cases. In most cases, this anomaly is diagnosed during childhood due to symptoms caused by oesophageal or tracheal compression. For this reason, case reports of adults are rare. This report describes a case of a 61-year-old woman with DAA with dominant left arch, diagnosed accidentallyby thoracic CT angiography.

Case Report Description

A 61 years old woman with a previous story of hypertension and type 1 diabetes presented to the emergency service with dyspnoea and thoracic pain. She also referred a history of intermittent dysphagia and cough with at least 12 years of progression. All the parameters of the physical examination were within normal limits. The electrocardiogram showed a normal sinus rhythm with no evidence of acute ischemia and her blood analyses did not show any abnormalitie. She also performed a thoracic CT angiography, which excluded signs of pulmonary embolism, but revealed a vascular ring suggesting a double aortic arch with permeability in both right and left arches as well as their collaterals. The Cardiac MRI was performed with the purpose of excluding ischemia, confirming the double aortic arch with left dominance. The right arch, posterior to the oesophagus and trachea, and the left arch, in an anterior position, showed an anatomic compression of the oesophagus as well as the proximal trachea, capable of eliciting the symptoms mentioned. Other congenital anomalies were excluded. The echocardiography did not demonstrate any additional cardiac malformation. Endoscopy shows a pulsatile extrinsic compression of the esophagus (aortic ring). The patient is currently being studied and closely monitored in the Cardiology consultation.

Discussion

The most common type of complete vascular ring is the double aortic arch, which accounts for 70% of the complete rings. In most cases, there are two permeable arches, usually with right dominance (70% of the cases). Rarely, both arches are symmetrical. Symptoms usually appear in the fifth month of life. In most cases, only supportive treatment is required.

Conclusion

This case illustrates the atypical features of this congenital malformation, namely the diagnosis during adulthood as well as the left dominance.

Abstract P725 Figure. A double aortic arch

P1313 A curious case of endocarditis

INTRODUCTION

Nonbacterial thrombotic endocarditis (NBTE) is a rare form ofnoninfectious endocarditis in which a small sterile vegetations deposited on the heart valves (mostly aortic and mitral).It has been reported in every age group, most commonly affecting patients between the fourth and eighth decades of life with no sex predilection. Patients with advanced malignancy and those with systemic lupus erythematosus are the most common populations affected by NBTE, and they are typically asymptomatic until embolization occurs. Here, we report a case of a female patient with rheumatoid arthritis whose diagnosis was made prior to any thromboembolic event.

CASE REPORT DESCRIPTION

An 83-year-old female patient with a 10-year history of rheumatoid arthritis, was admitted for urinary tract infection with exacerbation of chronic renal disease and decompensated heart failure of unknown etiology. On physical examination, she was febrile (38,3ºC) with a blood pressure of 130/70 and pulse rate of 90 beats/min. Cardiac auscultation revealed a sistolic murmur of grade 1/4 in the fifth left intercostal space. A joint deformities in the hands were noted, such as interosseous atrophy and ulnar deviation. To evaluate this new sistolic murmur,the transthoracic echocardiogramwas performed and showed a vegetation in the mitral valve. Then, a transesophageal echocardiogram(TEE) was requested to better characterize this vegetation, showing a vegetation of 19x4mm involving the posterior cusp of the mitral valve leaflet, with moderate mitral regurgitation,being the hypothesis of infective endocarditis (IE) proposed. There were no other significant abnormalities in the remaining echocardiogram. Empirical antibiotic therapy to IE was initiated. The TEE was repeated after 4 weeks of antibiotic therapy with maintenance of the referred vegetation and mention of a smaller one (10x2mm). Clinical investigation didn’t show any infectious process. Hence, the hypothesis of NBTE was established. Anti-coagulation therapy was started immediately. The NBTE lesion disappeared in the follow-up echocardiography three months post anti-coagulation treatment.

CONCLUSION

Although NBTE is an uncommon and difficult diagnosis that requires a high degree of suspicion, its timely diagnosis is essential since it allows the prevention of thromboembolic events, resulting in a positive impact on patients" quality of life. In addition, the existence of this clinical condition may allow the diagnosis of another underlying disease, such as a hidden neoplasia. Thus, the authors believe that the sharing of this clinical case will allow a reflection on this entity emphasizing the importance in the hypotheses of vegetation diagnosis. From the authors" knowledge, from the available medical literature, the clinical case presented is one of the few NBTEs described in patients with rheumatoid arthritis, with mitral valve involvement and whose diagnosis was made before any thromboembolic event.

Abstract P1313 Figure. A vegetation of mitral valve

P644 A not so innocent athlete"s heart

We report the case of a 17 years old athlete who resorted to the emergency service for palpitations and dizziness during exercising. He mentioned two episodes of syncope associated with exercise in the last 6 months. He was tachycardic (200 bpm) and hypotensive (85/56 mmHg). The electrocardiogram showed regular wide complex tachycardia with left bundle branch block morphology with superior axis restored to sinus rhythm after electrical cardioversion. In sinus rhythm, it showed T-wave inversion in V1-V5. Patient was admitted for study. Transthoracic echocardiography demonstrated mild enlargement and dysfunction of the right ventricle (RV) with global hypocontractility (FAC of 29%). The cardiac magnetic resonance (CMR revealed a RV end-diastolic volume indexed to surface body area of 180 mL/m2, global hypocinesia and RV dyssynchrony, subepicardial late enhancement in the distal septum and in the middle segment of the infero-septal wall. The patient underwent genetic study which showed a mutation in the gene that encodes the desmocolin-2 protein (DSC-2) involved in the pathogenesis of arrhythmogenic right ventricular cardiomyopathy (ARVC). According to the 2010 modified Task Force criteria for this diagnosis, the patient presented 4 major criteria for ARVC (characteristic ventricular tachycardia, repolarization and morphofunctional changes and the presence of pathogenic mutation) and the diagnosis was made. Thus, given the clinical presentation, it was implanted a subcutaneous cardioverter and patient is currently in follow-up at the Cardiology service.

ARVC is present in 1 to 1000-5000 people and is responsible for 20% of all sudden cardiac deaths, especially in athletes. Diagnosis is based on structural, functional, electrophysiological and genetic criteria reflecting underlying histological changes. This case shows and reviews the essential characteristics to the disease recognition and, therefore, to the prevention of its most feared complication: sudden cardiac death.

P1261 A heart with red flags

A 67 years old woman with a previous history of hypertension, atrial fibrillation (AF) and known severe concentric hypertrophy (more pronounced at the interventricular septum) with moderate pulmonary hypertension and diastolic dysfunction of the left ventricle (LV) resorted to the urgency service for weight loss, asthenia and dyspnea for minor efforts. Her physical examination was innocent. Her ECG showed AF and low voltage in limb and precordial leads. Patient was admitted at the Cardiology Department for investigation. A new TTE revealed fast progression of the hypertrophic pattern (IVS 26 mm, and posterior wall 18 mm) with a rest outflow tract gradient of 18 mmHg; free right ventricular wall was also hypertrophied with 12 mm and a type II diastolic dysfunction was present. A complete investigation for ventricular hypertrophy and constitutional syndrome was done. CMR demonstrated preserved biventricular systolic function, LV hypertrophy with septal predominance (24 mm) with elevated myocardial mass indexed to body mass (114 g/m2) and late difuse subendocardial gadolinium enhancement. (99m)Tc -DPD scintigraphy was negative for ATTR; Anderson-Fabry disease was excluded by genetic testing. Blood analysis revealed a normocytic/ normochromic anemia and a disproportional ratio of free light immunoglobulin chains K/λ, with a predominance of lambda chains. β2-microglobulin was also elevated. 24 hours urine analyses were normal. The hypothesis of non-secretor multiple myeloma (MM) with light chain immunoglobulin amyloidosis (AL) was then admitted. The patient underwent bone marrow and salivary gland biopsies which confirmed MM and deposition of amyloid, respectively. The FISH analyses demonstrated a delection of RB1 gene on 13q14.3 sequence and of TP53 on 17p13.1, both associated with a poorly prognosis in MM. The patient was referred for oncology where she is currently undergoing chemotherapy for MM and AL amyloidosis.

Amyloidosis represents a large spectrum of systemic diseases. Heart failure may be its first sign. This case reflects the diagnostic work-up in the presence of a hypertrophic LV pattern as well as the importance of high clinical suspicious and early diagnosis. While AL amyloidosis occurs in isolation, 10% of patients with multiple myeloma develop systemic AL amyloid with cardiac involvement. The distinction between these entities is not only semantic, but has extremely important prognosis and therapeutic considerations.

P6522Overcoming anatomic challenges to transradial access in STEMI patients

Background

Transradial access is associated with fewer access-related complications, earlier discharge and lower mortality, being the preferred route to perform coronary angiogram and interventions due to its safety and cost effectiveness in STEMI patients. However, the radial artery is smaller, more superficial and thinner than the femoral artery and a percentage of patients ranging from 14% to 27% have a radial artery that is smaller than a 6-French introducer, which sometimes makes angioplasty difficult.

Purpose

This study reports our initial experience with the 5F straight (STR) flush catheter, which can be used as a “child” type rapid exchange catheter inside the 6F guiding catheter, creating a distal tip transition, facilitating angioplasty in transradial coronary interventions when the radial artery is small, tortuous or as severe spasm that impedes advancement of guiding catheter after successful angiography with 5F catheter.

Methods

We analysed, retrospectively, 1510 STEMI patients (pts) admitted in our catheterization laboratory, from August of 2010 to October 2017. Of these patients, 95 (6.3%) pts with problems in advancing a 6F guiding catheter, were submitted to this technique and a direct crossover to a femoral approach was performed in 36 pts (2.4%). This technique consists in the use of longer 5F STR flush catheter in order to overcome the larger distal tip of the 6F guiding catheter through the radial access, employing a 5-in-6 F technique.

Results

In 89 of 95 patients (93.7%), this new technique was successful, with a mean reperfusion time since arrival to the catheterization laboratory of 24.5±9.9 minutes. Of the pts submitted to this technique the majority were female 51 (57.3%) and the mean age was 67±14.3 years. Angioplasties were performed in the left main (2; 2.3%), left anterior descending (36; 40.4%), left circumflex artery (8; 9.0%), right coronary artery (40; 44.9%), right posterior descending artery (1; 1.1%) and obtuse marginal branch (2; 2.3%). No complications in arterial access were seen. Throughout these years of study, the need for crossover to femoral approach has decreased with the learning of this technique. The time until reperfusion since catheterization laboratory arrival was 29.3±9.5 minutes when there was a crossover, being statistically higher than with the radial procedure with the STR technique (p<0.017).

Conclusion

This new technique may be a simple and useful approach to perform primary PCI through transradial access in patients with small diameter radial arteries, allowing a reduction of crossover to femoral access, which translates into a lower risk of vascular complications and shorter reperfusion time, that may influence the prognosis of STEMI patients.

P5521Door-to-balloon time and mortality of a PCI centre: how crucial can 30 minutes be for our STEMI patients?

Introduction

STEMI time delays have been presented as an indicator of quality of care. Considering the system delay, the guidelines of European Society of Cardiology (ESC) and American Heart Association (AHA) for the management of STEMI patients (pts) diverge regarding the maximum time from STEMI diagnosis to wire crossing in pts presenting at primary PCI (pPCI) hospitals (≤60min versus ≤90min, respectively).

Objective

To compare the prognosis between pts presenting at pPCI hospital with maximum time from STEMI diagnosis to wire crossing of ≤60min and patients with times between 61 and 90min.

Methods

The records of 1679 STEMI pts admitted consecutively in our coronary care unit during six years were analysed retrospectively. Of this pts, 341 (20%) were admitted directly in a PCI centre and 1338 (80%) were rescued by an emergency medical system or presented to a non-PCI centre. Pts that presented at PCI centre were divided into two groups: group 1 – STEMI pts with maximum time from STEMI diagnosis to wire crossing of ≤60min (n=202,69%); group 2 – STEMI pts with times 61–90 min (n=91,31%). Pts with time from STEMI diagnosis to wire crossing >90min were excluded. Primary endpoints were the occurrence of death at 6 months and 1 year; follow-up was completed in 98% of pts.

Results

Group 2 pts were older (60±14 vs 67±143, p<0.001), with higher proportion of women (14.9% vs 25.3%; p=0.026), hypertension (45.5% vs 61.5%, p=0.035), diabetes (17.1 vs 24.4%, p=0.005) and presented more frequently Killip 4 at admission (2.1% vs 12.5%, p=0.003). Group 1 pts had higher proportion of smokers (62.2% vs 49.4%, p=0.03). Patient delay was statistically higher in group 2 (Mdn (h) 3.8±3.5 vs 5±2, p<0.001), as was the system delay (Mdn (min) 45±9 vs 74±8, p<0.001). In-hospital mortality (3.8% vs 5.1%, p=0.42) wasn't different between groups, but at 1-month (3.8% vs 10.3%, p=0.05), 6-months (4.4% vs 12.8%, p=0.02) and 1-year mortality (5% vs 15.4%, p=0.008) was higher in group 2. In multivariate analysis and after adjusting for different baseline characteristics, pts who complied with the recommended times according to the 2017 ESC guidelines had lower risk mortality at 1 year compared to group 2 [HR 0.42, 95% CI (0.23–0.74), p=0.006].

Conclusion

In patients presenting at this PCI centre, complying with the 2017 ESC STEMI guidelines in order to reduce the system delay to ≤60min was crucial, since pts who were reperfused within this recommended time had lower mortality rates.

P1723Predictors of in-hospital mortality in STEMI patients complicated by cardiogenic shock treated with primary percutaneous coronary intervention

Introduction

Cardiogenic shock (CS) is an uncommon complex syndrome in patients (pts) with acute myocardial infarction (AMI). However, it remains the most serious complication and the most common cause of in-hospital mortality, with mortality rates ranging from 40% to 60%. The majority of pts are thought to develop CS after admission (late CS), but the incidence in a contemporary STEMI cohort admitted for percutaneous coronary intervention (PCI) remains unknown.

Objective

The aim of the present study was to evaluate pts with STEMI and cardiogenic shock undergoing pPCI, in order to establish the timing of CS onset, mortality rates and predictors of in-hospital mortality.

Methods

The records of 1679 STEMI pts admitted, consecutively, in our coronary care unit during six years were analysed retrospectively. Of this pts, 137 (8%) developed CS based on clinical criteria. Univariate and multivariate logistic regression analyses were used to identify independent predictors of in-hospital mortality. Primary endpoint was the occurrence of death at 30 days and 1 year; follow-up was completed in 100% of patients. Statistical analysis was performed using SPSS 20.0.

Results

The sample was formed by 90 (65.7%) men and 47 (34.3%) women, with mean age of 67±15 years. The incidence of CS was 8%. The majority of this pts (48%) were transferred from a non-PCI centre, 27% were rescued by an emergency medical system and 26% were admitted directly at a PCI centre. Around of 39% of pts had to be resuscitated before coronary intervention. Regarding the timing of CS onset, 66% of pts had CS on admission and 34% developed late CS. The left anterior descending artery was the most affected artery (47%), and 55% of the patients had multivessel disease. All-cause in-hospital and 1 year mortality was 45% and 53%, respectively. A multivariate analysis identified age >75 (HR 1.1, p=0.002), eGFR <60 ml/min/1.73 m2 (HR 2.2, p=0.02), left ventricular dysfunction (LVEF<40%) (HR 2.1, p=0.027), resuscitation before PCI (HR 1.2, p=0.045), and Intra-Aortic Balloon Pump (IABP) implantation after PCI (HR 4.4, p=0.026) as independent predictors of in-hospital mortality.

Conclusion

Despite the therapeutic advances and early revascularization have substantially improved the survival of pts with STEMI and CS, the in-hospital mortality is still significant. This study identified age, acute renal failure, left ventricular dysfunction, resuscitation before PCI, and IABP implantation after PCI as independent predictors of in-hospital mortality in patients with cardiogenic shock due to AMI. Consequently, only the timing of IABP insertion was the only modifiable factor predicting in-hospital mortality in our study, and its implantation before PCI can be considered to improve the outcome of these patients. These results should motivate the search for potentially modifiable factors that can lead to better results in the prognosis of these patients.

CB1 cannabinoid receptor-mediated anandamide signaling mechanisms of the inferior colliculus modulate the haloperidol-induced catalepsy

The inferior colliculus (IC), a midbrain structure that processes acoustic information of aversive nature, is distinguished from other auditory nuclei in the brainstem by its connections with structures of the motor system. Previous evidence relating the IC to motor behavior shows that glutamatergic and GABAergic mechanisms in the IC exert influence on systemic haloperidol-induced catalepsy. There is substantial evidence supporting a role played by the endocannabinoid system as a modulator of the glutamatergic neurotransmission, as well as the dopaminergic activity in the basal nuclei and therefore it may be considered as a potential pharmacological target for the treatment of movement disorders. The present study evaluated if the endocannabinoid system in the IC plays a role in the elaboration of systemic haloperidol-induced catalepsy. Male Wistar rats received intracollicular microinjection of either the endogenous cannabinoid anandamide (AEA) at different concentrations (5, 50 or 100pmol/0.2μl), the CB₁ cannabinoid receptor antagonist AM251 at 50, 100 or 200pmol/0.2μl or vehicle, followed by intraperitoneal (IP) administration of either haloperidol at 0.5 or 1mg/kg or physiological saline. Systemic injection of haloperidol at both doses (0.5 or 1mg/kg, IP) produced a cataleptic state, compared to vehicle/physiological saline-treated group, lasting 30 and 50min after systemic administration of the dopaminergic receptors non-selective antagonist. The midbrain microinjection of AEA at 50pmol/0.2μl increased the latency for stepping down from the horizontal bar after systemic administration of haloperidol. Moreover, the intracollicular administration of AEA at 50pmol/0.2μl was able to increase the duration of catalepsy as compared to AEA at 100pmol/0.2-μl-treated group. Intracollicular pretreatment with AM251 at the intermediate concentration (100pmol/0.2μl) was able to decrease the duration of catalepsy after systemic administration of haloperidol. However, neither the intracollicular microinjection of AM251 at the lowest (50pmol/0.2μl) nor at the highest (200pmol/0.2μl) concentration was able to block the systemic haloperidol-induced catalepsy. Furthermore, the intracollicular administration of AM251 at 100pmol/0.2μl was able to decrease the duration of catalepsy as compared to AM251 at 50pmol/0.2μl- and AM251 at 200pmol/0.2-μl-treated group. The latency for stepping down from the horizontal bar - induced by haloperidol administration - was decreased when microinjection of AEA at 50pmol/0.2μl was preceded with blockade of CB1 receptor with AM251 (100pmol/0.2μl). Our results strengthen the involvement of CB1-signaled endocannabinoid mechanisms of the IC in the neuromodulation of catalepsy induced by systemic administration of the dopaminergic receptors non-selective antagonist haloperidol.

Right ventricular bifocal stimulation in the treatment of dilated cardiomyopathy with heart failure

OBJECTIVE

To describe a new more efficient method of endocardial cardiac stimulation, which produces a narrower QRS without using the coronary sinus or cardiac veins.

METHODS

We studied 5 patients with severe dilated cardiomyopathy, chronic atrial fibrillation and AV block, who underwent definitive endocardial pacemaker implantation, with 2 leads, in the RV, one in the apex and the other in the interventricular septum (sub pulmonary), connected, respectively, to ventricular and atrial bicameral pacemaker outputs. Using Doppler echocardiography, we compared, in the same patient, conventional (VVI), high septal ("AAI") and bifocal ("DDT" with AV interval approximately 0) stimulation.

RESULTS

The RV bifocal stimulation had the best results with an increase in ejection fraction and cardiac output and reduction in QRS duration, mitral regurgitation and in the left atrium area (p </= 0.01). The conventional method of stimulation showed the worst result.

CONCLUSION

These results suggest that, when left ventricular stimulation is not possible, right ventricular bifocal stimulation should be used in patients with severe cardiomyopathy where a pacemaker is indicated.

De novo trisomy 22 due to an extra 22Q-chromosome

Trisomy 22 is the most frequent trisomy, after trisomy 16, of the trisomies present in miscarriages. The children born with trisomy 22 have usually unbalanced translocations 11; 22 or mosaicisms. In a recent review Bacino et al. [1] were able to find 17 cases of children born with trisomy 22 including only 3 cases confirmed by molecular cytogenetics. We report a patient with an extra chromosome 22q- without mosaicism. This chromosomal anomaly was defined with FISH studies. The phenotype include microcephaly, microtia with pre auricular tags, hypertelorism, epicanthus, palatal cleft, short neck, winging scapulae, hypoplasia of the distal phalanges, pulmonary stenosis and mental retardation.

[Infective endocarditis in patients with permanent pacemaker]

Five patients who had permanent pacemaker and infective endocarditis were analyzed. Diagnose was confirmed by a positive blood cultures in all patients and 2 of them had identifiable vegetation in the echocardiogram too. The etiologic agent was Staphylococcus aureus in 3, Staphylococcus epidermidis in 1 and Staphylococcus viridans in 1. Three patients were treated with antibiotics alone: one had no clinical conditions to be operated, one died before surgery and one had good response to antimicrobial therapy alone. Two patients were submitted to antibiotic therapy and surgical removal of the pacemaker system, without complications. It was concluded that the surgical removal of the pacemaker system, as soon as possible, is the choice's therapy.

[Research in child mental health]

Some considerations are made about current child psychiatry research and its future challenge. We analyse some studies about parental psychopathological influence in the early relationship, mentioning obstacles and advantages of some clinical and epidemiological research methods. We emphasize the value of interaction, observation and the use of videoscopy in infant clinical research. In Portugal, the lack of motivation to work in mental health research is an impediment to establishing clinical and training priorities.

[Sudden death in patients wearing pacemakers]

10 to 30 p. cent of patients with cardiac pacemakers die suddenly. In most cases, the cause of death can not be established. Racing of the pacemaker is a rare but definite cause of sudden death. In contrast, failure of the stimulation, which occurs much more frequently, and which is due to failure of the pacemaker or the wire or to an elevation of the threshold of stimulation, rarely causes sudden death because of the development of an idioventricular rhythm, leading to detection of the fault. Competitive rhythms do not appear to be more dangerous than accidental inhibition in sentinel pacemakers; both of these mechanisms can lead to ventricular tachycardia which may degenerate to ventricular fibrillation. Programmable pacemakers have certain advantages and disadvantages, in that the programming may prove to be inappropriate. In most cases, the ventricular fibrillation is spontaneous, occurring in the context of myocardial failure. The extension of the indications for pacemakers is certainly responsible for the relatively high incidence of sudden death.