52nd ANMCO Congress Abstracts e-Posters
European Heart Journal, Supplement
A 59 year-old male underwent an outpatient pacemaker check in February 2020 because of several recurrences of syncope at rest. His past medical history included permanent bicameral pacing in 2013 for atrioventricular block and a recent mechanical aortic valve replacement in October 2019. Pacemaker check resulted satisfactory; blood pressure was 80/60 mmHg. Chest auscultation revealed signs of congestions and a diastolic heart murmur and in the weeks before he had a mild fever. He was
... d for heart failure; BNP value was 4128 pg/L. Hepato-renal dysfunction was revealed by spontaneous INR of 9.21, serum creatinine 2.33 mg/dl and blood cultures revealed Staphylococcus epidermidis sepsis. Transthoracic echocardiography revealed severe aortic regurgitation (Image A) consistent with paravalvular aortic leak. Transesophageal echocardiography showed a lobulated echo-free space adjacent to aortic root consistent with paravalvular abscess extending to ascending aorta (image B) and a vegetation in left ventricular outflow tract (Image B, white arrow). Severe regurgitation from paravalvular leak was observed (image C) due to dehiscence of sewing ring from 7 to 14 o'clock (image D), without rocking motion of valve. Patient was urgently referred to redo cardiac surgery for removal of infected mechanical valve and biological valve implantation. In patients with high suspicious characteristics for cardiac syncope, it is mandatory to provide further investigations for diagnosis and treatment. Patient: 69-year-old male, no cardiovascular risk factors, two hospital admissions for accidental falls (one of them during alcohol intoxication), psoriasiform dermatitis localized to the inferior limbs. Recent hospital admission due to cachectic state, anaemia due to haemorrhagic gastric ulcer and esophageal Mallory-Weiss lesions treated with medical therapy, E.faecalis urosepsis and blood cultures positive for S.aureus treated with levofloxacin. The day after hospital discharge he developed fever and was readmitted to the hospital. Haematochemical exams documented chronic macrocytic anaemia, elevated inflammatory markers (PCR 66 mg/dL), mildly reduced renal function, reduced albumin and prealbumin levels. ECG showed new onset atrial fibrillation, heart rate 140 bpm, low voltages in peripheral leads, nonspecific ST-T changes. Chest X-ray documented bilateral pleural effusion. Transthoracic echocardiography showed mobile hyperechogenic endocardial mass (6 x 7 mm) localized on the aortic face of the non-coronary aortic valve leaflet without aortic regurgitation and severe pericardial effusion with initial echocardiographic signs of hemodynamic compromise. The patient was traeted with antibiotic therapy. Pericardial effusion was treated with NSAIDs and colchicine. Atrial fibrillation was characterized by high heart rate episodes treated with amiodarone and digoxin. Transesophageal echocardiography revealed periaortic psuedoaneurism near the left coronary aortic cusp, diastolic flow towards LVOT compatible with fistulization. Fundus oculi, abdominal ultrasound, contrast enhanced thoracic, abdominal and cerebral CT didn't show septic embolization. Contrast enhanced cardio CT documented pseudoaneurism (20 x 16 x 13 mm) localized along the aortic root near the left coronary cusp under the left main and the first tract of anterior descending and circumflex coronary arteries and communicating with Valsalva sinus and LVOT, evidence of a second pseudoaneurism smaller than the first one (5 x 5 mm) and localized in subvalvular posterior position, absence of significant coronary artery disease. A sudden episode of dyspnoea associated with echocardiographic documentation of acute severe aortic regurgitation required prompt Heart Team discussion. The patient was urgently treated with aortic valve replacement with bioprosthetic valve, obliteration of the abscess with bovine pericardial patch and pericardial drainage. P2 Figure 1 P2 Figure 2 Published on behalf of the Mechanisms leading to mitral regurgitation can be multiple and have different etiologies. On the other hand, the continence of the mitral valve depends on the coordinated functioning of all its components. We present the case of a young man, symptomatic for exertional dyspnea for several weeks. Due to a chest CT scan suggestive for acute inflammation of the respiratory tract, he had already practiced an antibiotic therapy, without benefit. At the time of our evaluation a severe mitral insufficiency due to flail of the anterior mitral leaflet with indication for surgical repair, in the absence of symptoms or signs of myocardial ischemia. Coronary angiography performed before cardiac surgery documented a subocclusion of the right coronary artery for which the patient was subjected to myocardial revascularization surgery by means of a single bypass with autologous saphenous vein on the posterior interventricular branch of the right coronary artery associated with mitral valve plastic two pairs of artificial tendon cords on the LAM and implantation of Memo 4D ring n.34. Analysis of the anatomy of the mitral valve documented a rupture of one of the heads of the posterior papillary muscle from a probable ischemic cause. The initial finding on the echocardiogram of severe mitral insufficiency due to flail of the anterior mitral flap did not find an underlying morphological and/or structural justification (there were no signs of degenerative valvulopathy, nor of endocarditic vegetations). On the other hand, the patient reported having been permanently asymptomatic for angor and did not have any clinical and laboratory signs (Troponin HS) of acute ischemic heart disease. However, coronary angiography examination, documenting a sub-occlusion of the right coronary artery, suggested an ischemic etiology of severe valve insufficiency. Papillary muscle rupture is a rare complication of myocardial infarction which, however, should be considered in patients with severe mitral insufficiency in the absence of clear underlying etiopathogenetic mechanisms. Despite advances in diagnosis and treatment, infective endocarditis still shows considerable morbidity and mortality rates. The dermatological examination in patients with infective endocarditis may prove very useful, as it might reveal suggestive abnormalities of this disease, such as Osler's nodes and Janeway lesions. These cutaneous manifestations of infective endocarditis are currently found only in about 20% of endocarditis cases, their presence, expression of an immune-mediated response C50 Abstracts Downloaded from https://academic.oup.com/eurheartjsupp/article/23/Supplement_C/C49/6357815 by guest on 30 August 2021 and septic microembolism is associated with poor outcome. We report a case of a woman with infective endocarditis and the typical cutaneous manifestations. A 47year-old woman with a history of intravenous drug use, came to our observation for fever for a few days now. The arterial blood pressure and the heart rate were in normal range. The physical examination showed the presence of cutaneous lesions in the nail beds and palms that were typical for splinter hemorrhages associated with endocarditis, painful lesions consistent with Osler nodes and painless Janeway lesions, see figure. The cardiac examination revealed a diastolic murmur grade III/IV near the heart's base. The laboratory biomarkers showed the elevation of C-reactive protein, erythrocyte sedimentation rate and procalcitonin, leucocytosis. and an increase in the indices of hepatocyte necrosis. The echocardiographic evaluation showed the presence of an endocarditis vegetation on the left cusp of the aortic valve determining a severe regurgitation. The subjects had a staphylococcus aureus endocarditis. She underwent aortic valve replacement with biological prosthesis, see figure, intra-operatory view. Cutaneous manifestations of infective endocarditis, very common in the pre-antibiotic era, are currently found only in about 20% of endocarditis cases.Osler's nodes are typically painful lesions that occur on fingers and toes and are attributed to an immune-mediated response. In contrast, splinter hemorrhages (involving the distal nail bed) and Janeway lesions (involving the palms and soles) are painless and secondary to septic microembolism. Osler's nodes are painful, purple nodular lesions, usually found on the tips of fingers and toes. Janeway lesions, in turn, are painless erythematous macules that usually affect palms and soles. Early recognition of these clinical signs is important as they indicate the presence of systemic embolization and are associated with poor outcomes. Background: Coronary CT is an effective method in the study of coronary artery disease; however, it has limitations in the study of stents. The advent of bioabsorbable magnesium alloy stents (Magmaris, Biotronik AG), with less burden of artifacts, has made the CT a potentially useful method in their evaluation. Objective: The objective of this study is to evaluate with coronary CT, the state of the Magmaris stents and identify any neointimal hyperplasia after more than 1 year from the index event. Methods: Among all patients treated with Magmaris at the Ferrara's Hospital between 2018 and 2019, 37 of them will be evaluated with CT. Cardiovascular risk factors (FRCV) and cardiovascular events were collected. Adverse events were collected at 30 days, 6 months and 1 year. Coronary CT was taken at 18 months median from the index procedure. The examination was carried out with prospectively-gated coronary computed tomography using 256-slice. Ten over thirty seven patients have already did CT. Results: these ten patients (8 M; 2 F) had an age of 61 6 3 years and at the time of the heart attack, they did not experienced any previous cardiovascular disease. For six of them, the index event was a STEMI. Seven of them were treated with a single Magmaris, while three with more than one Margamris and in one of them, they were in overlap. The analysis of FRCV showed that in 50% of the cases, the subjects were hypertensive patients, 60% were dyslipidemic, 30% smokers and one patient was diabetic. No event occurred between the index procedure and the execution of the CT. The CT analysis gave excellent quality images in all cases. At 18 months median follow up, only in 2 cases there was a complete reabsorption of the scaffold (SR group), and among the 8 cases in which the stent was not reabsorbed (SNR group), CT showed intimal hyperplasia in 2 patients. In the two cases where scaffold was reabsorbed, those were located in the right coronary artery. SNR group showed a higher incidence of dyslipidemia (75% vs 0% in the SR group). Analysis of the characteristics of the lesion showed that 38% of patients in the SNR group had long lesions (> 20 mm). Conclusions: CT is a useful tool to assess the scaffold and to identify patients with an increased risk of neointimal hyperplasia. Finding the sweetest spot in balance between ischaemia and haemorragic risk is one of most interesting challenges in platelet aggregation setting in acute coronary syndrome (ACS). The treatment has to be tailored on a single patient, choosing very appropriately timing, antiplatelet agent and/or antithrombotic therapy. A.C., 71 years old, hypertension, hypercholesterolemia, was admitted to the gastroenterology department of another hospital because of epigastric pain with anemia and melena; an EGDS showed a gastric carcinoma with surgery indication. The day before surgery, the patient suffered of rest chest pain and EKG showed inferior STEMI, with akinesia of inferior midbasal myocardial wall at echo observation. Patient was then referred to our center to perform an urgent coronary angiography. In this clinical setting the challenge is to choose the best therapeutic and interventional treatment. Coronary angiography showed a stenosis of 95% of the right coronary artery. The patient was not pre-treated with any P2Y12: because of the high haemorragic risk we decided to use cangrelor with ev bolus and then two hours infusion, without acetylsalicylic acid. The culprit stenosis was dilated with a 3.0 mm semi-compliant balloon, obtaining a TIMI 3 antegrade flow with angiographic good result. After 5 minutes observation we decided to not stent the lesion, in order to avoid DAPT. The patient was subsequently transferred to ICU, without developing complications, hemodynamically stable and with pantoprazole 40 mg bid, ramipril 5 mg/die, atorvastatin 80 mg/die, ezetimibe 10 mg/die, enoxaparin 4000 IU bid. After 36 hrs a partial gastrectomy was done, obtaining optimal surgical haemostasis. At third day post-op, we introduced clopidogrel 75 mg/die and two weeks later, in absence of haemorrhages and changes in the blood count, the interventional management is completed implanting a drugeluting stent on the coronary right artery. Our choice of an off-label use of cangrelor takes into account the upper gastrointestinal bleeding risk linked to acetylsalicylic acid and the different pharmacokinetic and pharmacodynamic characteristics of the GpIIb/IIIa inhibitors compared to cangrelor. During the lockdown period due to COVID 19, total hospital admissions drastically decreased, mainly for the fear of contagion. In the first days of lockdown, our hospital decided to separate the pathway of COVID 19 positive/suspicious patients and COVID 19 free patients, to avoid the spread of the disease. After arriving in the pretriage camping tend, vital parameters and temperature were measured to all patients and a questionnaire was submitted to identify subjects at risk of COVID-19 contact. After the immediate pre-triage, patients were separated into suspected/ positive and negative, a rapid serological test (10 minutes) and oral-pharyngeal antigen swab (20 minutes) were executed, at the result of these two exams, the patients were sent on a COVID-free pathway or in dedicated area of hospitalization for COVID patients. To guarantee the best possible assistance for urgent pathologies, our hospital has equipped the COVID structure with the necessary diagnostic methods including CT and a dedicated angiograph for neuroradiology, vascular radiology and interventional cardiology, to allow the execution of coronary angiography and angioplasty in patients with STEMI and NSTEMI. A team dedicated to the COVID operating room consisting of a doctor, 2 nurses and a technician and was available 24/24 hours for any emergencies. From March 4 to today, the operating room has been used for a definitive pacemaker implant in a patient with complete AV block, 13 STEMI patients came from "Rete IMA ", our regional emergency medical system (our hospital is the provincial HUB) or in hospital with their own means of transport or transported by 118. Of these 13 patients, 4 died during the hospital stay. Since March 2020, the pathways for cardiological patients with acute pathologies have been differentiated, minimizing the possibility of contact between the two populations and always guaranteeing hospital users the best treatment indicated for the various emergency/ urgent pathologies. The reduction in the number of ACS is around 30% (the reduction for unstable angina and NSTEMI is greater), but the complexity of cases has increased, we have seen an increase in heart attacks with complications (cardiogenic shock, ruptures) compared to the same period of the last year. Probably the late presentation (sometimes even a few days after the onset of symptoms) makes these patients particularly at risk of complications, pre and post-procedural.