P255 A fall from the tractor: a case report

Introduction

Pulmonary artery aneurysms (PAAs) are rare and infrequently diagnosed clinical conditions. They can have congenital, acquired or idiopathic causes. PAAs can be asymptomatic or present with non-specific manifestations even at large diameters up to 70 mm. Rupture and dissection are the main life threating complications. The optimal treatment remains uncertain. There are no clear guidelines regarding the therapeutical approach.

Case presentation

A 78-year-old male presented at our medical facility to investigate further a pulmonary artery aneurysm discovered accidentally after a traumatic fall from a farmer tractor. He had no important chronic diseases, but in his medical history it was reported that he was excluded from the military service on top of a cardiac murmur, never investigated with an echocardiography exam. The fall from the tractor caused a fracture of the second and third costal ribs with hematoma and a commotional cranial trauma. At the thoraco-abdominal computed tomography (CT) scan conducted after the fall emerged an important fusiform dilatation of the principal pulmonary trunk and the left pulmonary artery (3.8 cm and 5 cm respectively). There was also a mild dilatation of the right pulmonary artery (3 cm), thickening of the pulmonary valve cusps and dilatation of the right cardiac chambers with flattening of the interventricular septum. Pulmonary embolism was excluded.

Transthoracic and transesophageal echocardiography revealed a dysplastic pulmonary valve, with thickened cusps and moderate stenosis with insufficiency. The jet of the right ventricular outflow tract was eccentric with an anterolateral direction and a correlated dilatation of the common pulmonary trunk (3.8 cm) and the left pulmonary artery (5 cm). The right ventricle appeared not dilated and the tricuspid regurgitation was mild with a normal systolic pulmonary artery pressure. The dilated pulmonary artery did not interfere with the flow in the left main coronary artery. We concluded that the pulmonary artery aneurysm was mainly due to the congenital pulmonary valvulopathy. The patient underwent successful pulmonary trunk, left pulmonary artery and pulmonary valve replacement with a bioprosthetic valved conduit.

Conclusion

Congenital pulmonary valvulopathy can remain clinically silent lifelong and is commonly discovered during exams performed due to other clinical circumstances. The eccentric jet caused by the valvulopathy can be the reason for dilatation of the pulmonary trunk and pulmonary arteries. Transthoracic and transesophageal echocardiography are competent tools for clarifying the cause of the pulmonary artery aneurysm and therefore are essential in the decision making regarding the treatment strategy.

Abstract P255 Figure. Transesophageal echocardiography images

P839 The lucky unlucky patient: a case report

Introduction

Carcinoid tumors are rare neuroendocrine malignancies arising from the neural crest amine precursor uptake decarboxylation cells and are most commonly (90%) located in the gastrointestinal system, the most malignant arising from the ileum. Approximately 50% of patients with carcinoid syndrome will develop carcinoid heart disease, which is commonly characterized by the thickening and retraction of the tricuspid ± the pulmonary valves resulting in significant regurgitation ± stenosis. Hepatic metastasis must be present for the carcinoid heart disease to develop. In order to develop left-sided heart valve lesions, communication between the left and right heart chambers must be present.

Case presentation

A 50-year-old female patient with a known neuroendocrine tumor of the ileum with hepatic and peritoneal metastasis presented at our facility for evaluation of the heart valves. She was diagnosed with the neuroendocrine tumor in 2017, a resection of the intestinal ileocecal segment and peritoneal nodules was done in the same year (stadium pT3N1M1b ki 67 2%), the tumor was angio and neuroinvasive. The disease was treated with somatostatin analogues with minimal regression of the disease. She started peptide receptor radionuclide therapy and completed 3 cycles. In October 2018 an increment of one of the hepatic lesions was documented, with other hepatic lesions remaining of stable dimensions. Due to the recent appearance of dyspnea in mild to moderate physical activities she was sent to our facility for echocardiography.

The transthoracic and transesophageal echocardiography revealed severe tricuspid regurgitation with mild stenosis (tricuspid anatomic area 3.5 cm², max gradient 7 mmHg, mean gradient 4 mmHg) caused by thickened and retracted cusps with a significant coaptation deficit. Severe stenosis and insufficiency of the pulmonary valve was also noted (maximum gradient 22 mmHg, mean gradient 15 mmHg, pulmonary valve area 0.5 cm²), with a rapid deceleration regurgitation jet limited to protodiastole, caused by thickened and retracted pulmonary valve leaflets. The interatrial septum exhibited an aneurysm with a patent foramen ovale (PFO) and mild left-to-right shunt. Despite the shunt left-sided heart valves were not affected, therefore we recommended a replacement of the tricuspid and pulmonary valves with an intraoperative closure of PFO and intraoperative verification of the efficacy of the surgical closure.

Conclusion

Carcinoid heart disease is an important cardiac complication of the neuroendocrine neoplasms. Communication between the right and left heart chambers (for example a PFO) must be present for the development of left heart valve lesions. Our patient had a PFO with a mild left to right shunt, but fortunately no left sided lesions were found.

Abstract P839 Figure. Carcinoid heart disease

The Importance of Consistent Global Forest Aboveground Biomass Product Validation

Several upcoming satellite missions have core science requirements to produce data for accurate forest aboveground biomass mapping. Largely because of these mission datasets, the number of available biomass products is expected to greatly increase over the coming decade. Despite the recognized importance of biomass mapping for a wide range of science, policy and management applications, there remains no community accepted standard for satellite-based biomass map validation. The Committee on Earth Observing Satellites (CEOS) is developing a protocol to fill this need in advance of the next generation of biomass-relevant satellites, and this paper presents a review of biomass validation practices from a CEOS perspective. We outline the wide range of anticipated user requirements for product accuracy assessment and provide recommendations for the validation of biomass products. These recommendations include the collection of new, high-quality in situ data and the use of airborne lidar biomass maps as tools toward transparent multi-resolution validation. Adoption of community-vetted validation standards and practices will facilitate the uptake of the next generation of biomass products.

REDD+ and climate smart agriculture in landscapes: A case study in Vietnam using companion modelling

Finding land use strategies that merge land-based climate change mitigation measures and adaptation strategies is still an open issue in climate discourse. This article explores synergies and trade-offs between REDD+, a scheme that focuses mainly on mitigation through forest conservation, with "Climate Smart Agriculture", an approach that emphasizes adaptive agriculture. We introduce a framework for ex-ante assessment of the impact of land management policies and interventions and for quantifying their impacts on land-based mitigation and adaptation goals. The framework includes a companion modelling (ComMod) process informed by interviews with policymakers, local experts and local farmers. The ComMod process consists of a Role-Playing Game with local farmers and an Agent Based Model. The game provided a participatory means to develop policy and climate change scenarios. These scenarios were then used as inputs to the Agent Based Model, a spatially explicit model to simulate landscape dynamics and the associated carbon emissions over decades. We applied the framework using as case study a community in central Vietnam, characterized by deforestation for subsistence agriculture and cultivation of acacias as a cash crop. The main findings show that the framework is useful in guiding consideration of local stakeholders' goals, needs and constraints. Additionally the framework provided beneficial information to policymakers, pointing to ways that policies might be re-designed to make them better tailored to local circumstances and therefore more effective in addressing synergistically climate change mitigation and adaptation objectives.