P726 Cardiac amyloidosis: unmasking the simulator

Introduction

A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis.

Case

We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier.

Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis.

Discussion

This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach.

Abstract P726 Figure. Images of the case

P816 Right Ventricular assessment using Advanced Cardiac Imaging in Mid-Range patients: Keys to detect the risk

Background

Patients with mid-range ejection fraction heart failure (HFmrEF) are a new category defined in actual guidelines. The aim of this study was to establish the prognostic value of several parameters obtained by Cardiac Magnetic Resonance (CMR) and Transthoracic Echocardiography (TTE) in patients with HFmrEF.

Methods

Thirty patients, defined as HFmrEF by TTE and CMR, were included between 2012-2018. Patients with structural heart disease different from Left Ventricular (LV) dysfunction were excluded. Cine sequences in CMR (SSFP) were used to obtain atrial and ventricular volumes and mass. Myocardial fibrosis was quantified by late gadolinium enhancement. TTE was used to obtain anatomical and functional parameters as LV and Right Ventricular (RV) ejection-fraction, LV and RV global longitudinal strain, and RV free-wall longitudinal strain.

The primary endpoint was the combination of all-cause death or heart failure admission. The median follow-up was 1.9 (0.5-3.3) years.

Results

Mean age was 59.3 ± 12.4 years, and 67.9% patients were male. The aetiology of LV dysfunction was mainly ischemic (n = 16, 53.3%). Results are shown in Table1. Patients who presented the primary endpoint had a lower RV ejection-fraction by CMR and a lower absolute value of RV free-wall longitudinal strain by TTE(Figure 1).

Conclusions

In HFmrEF patients, worse RV function (by CMR and TTE-Speckle Tracking) may be associated with a worse prognosis. Larger studies are needed to confirm this hypothesis.

Table1 All-cause death or HF admission (n = 5; 16.7%) No all-cause death of HF admission (n = 25; 83.3%) p iRVEDV (ml/m2) by CMR 65.5 ± 13.5 66.2 ± 12.3 0.906 iRVESV (ml/m2) by CMR 30.4 ± 7.5 24.4 ± 6.2 0.065 iLVEDV (ml/m2) by CMR 85.8 ± 23.7 98 ± 19.5 0.225 iLVESV (ml/m2) by CMR 47.8 ± 15.3 54.9 ± 11.7 0.246 Indexed LA Volume (ml/m2) by CMR 42.8 (36.5 - 49) 48.4 (42 - 63.5) 0.386 LVEF (%) by CMR 44.9 ± 3.3 44 ± 2.6 0.506 RVEF (%) by CMR 52.2 ± 7.2 61.7 ± 7.2 0.012 RV-FAC (%) by TTE 43.4 ± 4.4 44.7 ±7.5 0.378 TAPSE by TTE 2.1 ± 0.3 2.5 ± 0.1 0.032 LV Longitudinal Global Strain by TTE -14.3 ± 3.3 -15.5 ± 4.9 0.663 RV Longitudinal Global Strain by TTE -11.3 (-13.2 - -7.0) -19.5 (-23.7 - -10) 0.089 RV Free-Wall Longitudinal Strain by TTE -11.5 (-14.2 - -8.2) -20 (-26 - -13.7) 0.043 HF: Heart Failure; CMR: Cardio Magnetic Resonance; LV: Left Ventricle; RV: Right Ventricle; iRVEDV: Indexed RV End-Diastolic Volume; iRVESV: Indexed RV End-Systolic Volume; iLVEDV: Indexed LV End-Diastolic Volume; iLVESV: Indexed LV End-Systolic Volume; LA: Left Atrium; LVEF: LV Ejection Fraction; RVEF: RV Ejection Fraction; RV-FAC: RV Fractional Area Change; TAPSE: Tricuspid Annular Plane Systolic Excursion

Abstract P816 Figure 1

P288 Prognostic role of hemoglobin levels in patients with severe tricuspid regurgitation

Background

Patients with severe tricuspid regurgitation (TR) frequently develop heart failure (HF) and their surgical therapeutic options are limited because of very high or prohibitive risk. According to the 2016 ESC guidelines for HF, anaemia and iron deficiency are associated with worse prognosis and intravenous iron therapy should be considered in symptomatic patients with HF reduced ejection fraction (HFrEF) in order to alleviate symptoms, improve exercise capacity and quality of life. The effect of treating iron deficiency in HF preserved ejection fraction (HFpEF) is unknown. The purpose of this study was to analyze the correlation between levels of hemoglobin (Hb) and the prognosis in patients with severe TR and preserve EF.

Methods

Consecutive patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015-2018 were included. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 70 patients were included (mean age was 74± 8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean left ventricular ejection fraction was 56,5% ±6,7%. During a median follow up of 18 months [IQR: 4-28], 35% of the patients reached the combined end-point (n = 16 developed right HF, n = 17 underwent tricuspid valve surgery, and n = 3 died). Patients with events showed lower Hb values (p = 0.04). The level of anaemia was a prognostic factor of the combined endpoint (per gr/dl, HR 0.77 [0-61-0.98], p = 0.036).

Conclusion

Hemoglobin is predictive of poor outcomes in patients with significant TR. According to these preliminary results, iron deficiency could be a therapeutic target in this subgroup of patients with limited therapeutic options.

P1400 Improving ischemia diagnosis: 3D speckle-tracking stress echocardiography

Background

2D stress echocardiography (SE) is based in the visual analysis of wall motion abnormalities and it requires a trained operator. This operator-dependence has promoted the search for a semiautomatic method to reduce SE limitations and improve test accuracy. The aim of this study was to evaluate the value of 3D speckle tracking (3DSTE) in SE in patients with chest pain.

Methods

44 consecutive patients with chest pain and pathological findings on CCTA (>50% stenosis or high calcium score (>400 HU) with undetermined severity) were included. These patients underwent SE with acquisition of 3DSTE at rest and at peak stress.

Results

Mean age was 63.9 ± 9.9 years. 90% were men. The images of the 44 patients were processed with automatic tracking and manual corrections. 11 patients developed inducible ischaemia during SE. Patients with ischaemic response showed significant reductions in 3D area strain (AS) compared to resting values. The 33 patients without inducible ischaemia showed, however, a significant increase in this parameter. Results are shown in table 1.

Conclusion

3D area strain SE could help to identify patients with inducible ischemia. However, further studies are need to confirm these data.

Ischemia + (n = 11) Ischemia - (n = 33) P 2D LVEF rest 57.2; 5.5 61.4; 6.0 0.04 2D LVEF peak stress 56.9; 11.7 70.0; 9.0 <0.01 3D LVEF at rest 54.3; 6.9 64.3; 9.7 0.17 3D LVEF peak stress 51.9; 22.5 66.0; 8.6 0.17 AS rest 38.3; 5.1 40.4; 5.7 0.29 AS peak stress 37.2; 11.3 43.6; 7.2 0.03 LVEF: left ventricle ejection fracion; AS: area strain.

1645 Unexpected aortic bioprosthetic valve thrombosis

Introduction

Prosthetic valve thrombosis (PVT) is a rare but feared complication of cardiac valve replacement which usually represents a difficult diagnostic challenge. Although PVT is not frequent in bioprosthetic valves, the advent of transcatheter heart valves and the advances in computed tomography, allowing the detection of subclinical thrombosis, have yielded growing interest in that field, specially taking into account that there is no consensus on optimal antithrombotic approach in these patients.

Clinical Case

A 74-year-old male with prior cardiac antecedents of aortic valve replacement (April 2010) with a bovine pericardial bioprosthesis (Mitroflow 25, Sorin group Inc.), ischemic dilated cardiomyopathy with moderately depressed left ventricle ejection fraction (33%) and carrier of VDD pacemaker due to third degree atrioventricular block was admitted to advanced heart failure unit. During routine follow-up echocardiograms, prosthetic valve presented no signs of dysfunction except slightly increased gradients (image C): max 38 mmHg (normal <36), med 23 mmHg (normal <20). Because of left ventricle dysfunction, high pacing rate (>95%) and dyspnea NYHA class III the patient was referred for upgrade to cardiac resynchronization therapy (CRT).

Computed tomography to asses epicardial venous anatomy prior to CRT implant was performed. In addition to venous distribution, it was described a repletion defect in aortic bioprosthetic valve suggestive of leaflet thrombosis (image A). To complete the study the patient underwent a transesophageal echocardiography (TOE) revealing a swallow’s nest shaped hypoechoic occupation of non-coronary and left aortic leaflets (image B), and 3D effective orifice area of 0,9 cm2.

Oral anticoagulation was started in association to previously taken acetylsalicylic acid (ASA). Control TOE was performed 3 months after diagnosis showing almost complete resolution of thrombi.

During the follow-up a CRT-D was implanted, with significant response in systolic performance, reaching a LVEF of 45%. Interestingly, despite the increase in anterograde aortic flow, progressive decrease of aortic gradients (max 24 mmHg, med 15 mmHg) until normalization was found (image D). Clinical benefit was also patent, being the patient in NYHA class I at the moment.

Discusion

Valve thrombosis could be difficult to diagnose in the presence of left ventricle dysfunction as gradients shall remain low despite an important compromise in valve motion. We present a case of incidental diagnosis of non-obstructive leaflet thrombosis that was managed conservatively with oral anticoagulation and ASA. The descent in transaortic gradients, moreover taking into account the response to CRT increasing LVEF, indicates that gradients slightly increased or in the upper limit of normality should raise suspicion in valve dysfunction in the presence of decreased LVEF.

Abstract 1645 Figure.

P727 Unexpected ventricular aneurysm: further ischemic aetiology

Introduction

Ventricular aneurysm is an infrequent complication of myocardial infarction. In absence of an ischemic event, alternative aetiologies include: thoracic trauma, hypertrophic cardiomyopathy, myocarditis, Chagas disease, cardiac sarcoidosis or arrythmogenic cardiomyopathy. In the absence of any of the previous, congenital aneurysm diagnosis is made.

Case

We present the case of 57-year-old man referred to cardiology department because a new onset of atrial fibrillation with left bundle branch block. Past medical history included high blood pressure and dyslipidaemia without any history or smoking, alcohol consumption or any other toxic abuse. No chest pain, shortness of breath or other significant symptoms were reported. Physical examination was unremarkable except for an arrhythmic pulse at 85-90 bpm.

Echocardiogram showed moderate dilated left ventricle with mild-moderate LV dysfunction (EF 40% ) with a septal aneurysm of 2.4x1cm (Picture A). A coronary CT was performed that ruled out coronary heart disease and confirmed the presence of the septal aneurysm (Picture B). To better characterize this image, a cardiac magnetic resonance (CMR) was performed. Moderate dilated LV with significant dysfunction (EF 31%) was reported. A septal aneurysm of 13 x 22 x 33 mm composed of a 2.8 m thin wall of true myocardial tissue was documented (picture C and D-late gadolinium enhance). No myocardial delayed enhancement was detected in any area of the LV. Moreover, no signs of myocardial non compaction, arrythmogenic cardiomyopathy, hypertrophic cardiomyopathy or myocarditis were seen. Chagas serology as well as sarcoidosis diagnosis work up were negative. Patient denied any thoracic traumatism. Congenital aneurysm diagnosis was finally established.

Electrical cardioversion was performed after 1 month of correct oral anticoagulation and heart failure treatment was started. Case was presented in the Heart Team session and a conservative management was decided based on asymptomatic status and absence of ventricular arrhythmias. After 3 years of clinical follow up, the patients is in good status, asymptomatic and in sinus rhythm. Discussion: Congenital ventricular aneurysm is a rare cardiac malformation that arises during the fourth embryonic week. Most frequently, left ventricular aneurysms are found in the apex and the perivalvular area, being the septal location an atypical one. Most patients are asymptomatic but when symptoms occur, they are mostly related to the presence of ventricular arrhythmias. Aneurysm rupture incidence is variable, ranging from 3.7% to 12 % according to the different series. For this reason, surgery is recommended in symptomatic patients. However, management of asymptomatic patients is not clear since prognosis studies are lacking.

Abstract P727 Figure. A.Echo B.-CT C.-CMR. D.-CMR gadolinium

P729 A shocking tumor

Introduction

Primary cardiac tumors are a relatively uncommon condition, which may appear both in asymptomatic patients or in a myriad of clinical presentations. Imaging techniques are crucial for its diagnosis, and a multi-modality approach may be useful in the evaluation of this masses.

Case description

A 57 year-old man with history of hypertension presented in the emergency department with acute pulmonary edema and cardiogenic shock. He was admitted to the coronary care unit, and on bedside echocardiography a mass on the tricuspid valve was observed.

Upon clinical improvement, a cardiac CT and cardiac MRI was performed (figure 1). A solid mass with no calcium content and dependent exclusively on the anterior leaflet of the tricuspid valve was seen on CT-scan (fig 1, A and B). Thrombus on the right atrial appendage could also be appreciated.

MRI confirmed the presence of a 18x19 mm mass with isointense signal on T1-turbo spin echo black-blood (fig 1, C) and cine steady-state free precession sequences, whereas an hyperintense signal was evident on T2 weighted images (T2-STIR; fig 1 D). In first pass sequences the central core was hypointense and late gadolinium enhancement showed peripheral enhancement with a non captating central core (fig 1, E).

The patient underwent surgery and the anatomopathological results showed a tumor constituted by dense connective tissue, scarce cellular content and an avascular matrix of mucopolysaccharides, elastic fibers and fusiform cells consistent with the diagnosis of papillary fibroelastoma.

Discussion

The imaging characteristics of papillary fibroelastoma are not commonly reported on MRI. We present an unusually large right-sided fibroelastoma with a characteristic distribution of late gadolinium enhancement, which has not been consistently described on a fibroelastoma.

Cardiac tumors are rare, and a non-invasive differential diagnosis is always a challenge. A multi-modality approach (echocardiography, cardiac-CT and cardiac MRI) as well as integration of relevant morphological information, including the location of the lesion and tissue characteristics was essential to the orientate the most plausible diagnosis. The distinctive images are presented.

Abstract P729 Figure 1.

P5569Effective regurgitant oriffice area vs vena contracta method as predictors of outcomes in severe tricuspid regurgitation

Background

There is no gold standard echocardiographic method to evaluate tricuspid regurgitation (TR) severity. ESC guidelines recommend using a combination of several methods. The purpose of this study was to compare the prognostic value of the two most commonly used methods for the evaluation of the TR: Effective regurgitant orifice area (EROA) method and biplane vena contracta (VC) method.

Methods

Consecutive asymptomatic patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015–2018 were included.

TR severity was evaluated by a combination of several methods, including EROA method and biplane VC method, using EPIQ system. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure.

Results

A total of 70 patients were included (mean age was 74±8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). During a median follow up of 18 months [IQR: 4–28], 35% of the patients reached the combined end-point (n=16 developed right heart failure, n=17 underwent tricuspid valve surgery, and n=3 died).

Patients with events showed a larger EROA (0.55 vs 0.40 p: 0.036) but no significance different was found in VC (8.03 vs 7.80 p: 0.27). Among both parameters, the tricuspid EROA was the only prognostic factor of the combined endpoint (EROA, HR 24.22 [1.54–380.86], p=0.023; VC, HR 1.022 [0.882–1.183]. A value of EROA of 0.42 reached the best accuracy to predicted poor outcomes (p<0.01).

Conclusion

Among the two most commonly used methods for the evaluation of the TR, EROA was the only method that obtained prognostic value during follow-up.

5942Clinical outcomes and prognostic implications of effective regurgitant orifice area. Defining severe mitral regurgitation

Background

Previous studies showed that the effective regurgitant orifice area (EROA) is a strong predictor of clinical outcomes. However, there is controversy over the optimal threshold that identifies patients at high-risk, especially in secondary mitral regurgitation (MR).

Purpose

To determine the optimal EROA threshold that identifies a subgroup patients with an increased risk of cardiac death and hospitalization for heart failure (HF), in both, primary and secondary MR.

Methods

A total of 6022 consecutive transthoracic echocardiograpic studies were analysed. Patients with significant MR were prospectively included. The EROA was calculated by the PISA method. Each patient was followed up for three years. Cox regression was performed to study predictors of the combined end-point. ROC curve analysis was performed to determine the optimal cut-off values of EROA.

Results

Significant primary MR was found in 115 patients (62%), whereas significant secondary MR was described in 71 studies (38%). In primary MR, the optimal threshold of EROA for predicting the combined end-point was 45mm2 (Sn=85.7%; Sp=82.2%). After adjusting for NYHA class, ejection fraction and chronic kidney disease, an EROA ≥45mm2 was strongly associated with cardiac death and admissions due to HF (HR 15.65, 95% CI 4.34–56.47, p<0.001). Regarding secondary MR, the optimal cut-off value was 21mm2 (Sn=75.0%; Sp=61.8%) and the adjusted HR was 2.57 (95% CI 1.03–6.37, p=0.042).

Sensitivity and specificity curves

Conclusions

Our study demonstrates that an EROA of at least 45mm2 in primary MR or of at least 21mm2 in secondary MR is independently associated with a significantly increased risk of cardiac death and hospitalization for HF.