P314 WHEN TAKO–TSUBO TRAPS… NOT ONLY OCTOPUSES

The case we present involves a 75 years–old woman with no cardiological past medical history, who presented to our attention complaining of sudden onset thoracic pain associated with dyspnea, dry cough, nausea and an episode of vomit. She called 911 rapidly coming to our Hospital. In the Emergency room an EKG showed ST segment depression in the inferior leads and in the blood test a remarkable increase in HS–Troponin level was evident. An echocardiogram showed mid and apical left ventricle segments hypokinesia with moderately reduced Ejection Fraction (45%); notably, right ventricle was increased in dimension with moderate tricuspid regurgitation and mild pulmonary hypertension. Because of this last find, D–dimer was checked and a pulmonary angio– CT was performed which excluded active pulmonary embolism. Next day she underwent coronary angiography which showed no coronary lesion able to explain the clinical and echocardiographic presentation; left ventriculography was also performed showing an increase in end–systolic volume with hypokinesia of the anterolateral, apical and diaphragmatic walls and an Ejection Fraction (EF) of 30%. These findings allowed us to make the diagnosis of Tako–Tsubo syndrome, also known as stress–induced cardiomyopathy. Few days later, a cardiac magnetic resonance (CMR) was performed showing whole apical and antero–lateral mid ventricular hypokinesia with compensatory hyperkinesia of basal segments; T2–weighted sequences were positive at the hypokinetic segments with no specific Late Gadolinium Enhanced (LGE) images. What’s more, an atrial septal defect type “ostium secundum” was clearly evident, causing a left–to–right shunt hemodynamically significant (Qp/Qs of about 2,8) with right atrial and right ventricle dilatation. Pulmonary artery and its main branches were dilated too. After these findings, lady underwent right heart cardiac catheterization that reported a Qp/Qs of 3,24 and a shunt flow of 8,78 L/min, with a cardiac index of 2,5 L/min/m2 and normal pulmonary vascular resistance (0,7 Wood Units). Because of these measures the patient was discharged from our Cardiology Unit and referred to the Interventional Cardiology centre of our city for the percutaneous closure of the hemodynamically significant atrial septal defect.

This case is curious because it shows how things in Cardiology can be deeply and unpredictably connected.

P300 ACUTE MYOCARDITIS COMPLICATED BY VENTRICULAR ARRHYTHMIAS

Background

Many kinds of arrhythmias may occur in patients with myocarditis at any stage of the disease. However, as compared to the other clinical presentations, arrhythmic myocarditis has been poorly described in literature.

Case Report

A 20–year–old girl, without CVRF or comorbidities, presented at the ED because of palpitations and epigastric pain irradiated to left arm. 12–lead ECG evinced elevated HR and aspecific repolarization abnormalities. Blood samples showed high cTn value and normal PCR value. Echocardiography showed a preserved LVEF, without abnormalities. Patient was hospitalized with a diagnosis of suspect acute myocarditis. Following hospital stay has been complicated by recurrent episodes of chest pain with concomitant increase of cTn that finally had presented a sinusoidal trend (peak 12830ng/L). At the same time, continuous ECG monitoring has been showing frequent but short term ventricular extrasystole activity, so B–blocker therapy was optimized. On ECG monitoring, appearance of short runs of asymptomatic mono– and polymorphic NSVT and after a few days appearance of polymorphic NSVT “torsade de pointes” like, symptomatic for presyncope. New changes in kinetics appear on the echocardiogram: hypokinesia of medio–apical segments of lateral, anterior wall septum. Therapy with metoprolol and lidocaine iv was started with subsequent stabilization of the rhythm. CMR presented data suggestive of myocarditis. Patient performed several BEM at different time and centers: diagnostic signs of myocarditis were not be found. Autoimmune and infectious disease screening, abdominal echography and a PET TC total body were been performed to research a potential etiology, without positive result. Patient has been discharged with wearable defibrillator and we waited for the ICD implantation in secondary prevention. Follow–up CMR showed a resolution of inflammation and no signs of fibrosis. Blood samples did not demonstrate a rise of cTn. After discharged, she has not had news onset of ventricular arrhythmias.

Conclusion

The mechanisms underlying the occurrence of ventricular arrhythmias during myocardial inflammation are less clear. Arrhythmias usually being self–limited with no recurrences that follow the acute phase. Management of acute life–threatening arrhythmias is generally supportive and there is a lack of evidence to support the use of specific antiarrhythmic agents. Wearable life vest has been presented as a possible therapeutic option.

Do speed bumps really decrease traffic speed? An Italian experience

Italy introduced the extensive use of speed bumps only in 1990, in an attempt to limit the high number of fatalities involving pedestrians in urban streets caused by the high speed of vehicles. In many countries, such devices have been the subject of careful investigations (in order to assess their effectiveness and disadvantages for the traffic circulation) and this has resulted in a number of modifications in the design to improve their performance. On the contrary, no systematic and scientific studies have been carried out on Italian installations: moreover, the type of undulation adopted is known to produce a series of problems for some categories of users and is not so effective in reducing speed as larger devices such as 'speed humps' or 'speed cushions'. This paper proposes a study of the effectiveness of 23 speed bumps installed in the city of Cagliari; to this aim, a speed analysis was performed at speed bump locations, at the crosswalks protected by the devices and at sections of the streets where bumps are installed but far from them. The results show that in one third of the cases the 85th percentile of speed measured at the speed bumps is higher than the posted speed limit (50 km/h) and an equal percentage of vehicles travel at a speed in the range of 45-50 km/h. No statistically significant differences were found from the comparison of speed values observed in free, bump or crosswalk sections of the same streets, while speed profiles calculated at four sites, where a high percentage of braking vehicles was observed, showed a common trend from which it clearly emerges that the effect of the device on driver's behaviour is restricted to a short spatial range (about 20-30 m before and after the bump). The current situation thus suggests the use of more effective devices such as humps or cushions, or the integration of speed bumps with other traffic calming techniques.