Poster No. 137 A very evident pulmonary thrombus

Clinical case

Female patient, 78 years-old, that complained of epigastric pain and intense fatigue for a week. While waiting in the urgency department, she became hypotensive, with refractory shock. Electrocardiogram showed sinus rhythm, 90 bpm, de novo right bundle block and infraST in the right precordial leads. The echocardiogram showed a dilated right ventricle (ratio RV/LV > 1), with depressed function and major tricuspid regurgitation, RV/RA gradient of at least 55 mmHg. Left ventricle presented “D-shape”, preserved function and no segmental kinetic changes. The pulmonary artery was dilated and a serpentiform mass was visible, protruding through the pulmonary valve; similar masses were also visible in its branches. The diagnosis of pulmonary embolism (PE) was assumed and fibrinolysis was started, given there were no contra-indications.

One year before, she had an intermediate-risk PE in the context of COVID-19, with a similar echocardiographic presentation. She recovered RV function in the following months and stopped anticoagulation 3 months after that episode.

Discussion

PE can present with varying degrees of severity. Bedside echocardiography can be of major help in its diagnosis, especially in critical patients. The visualization of a thrombus in the pulmonary artery is rare, particularly in transthoracic echocardiogram. Echocardiogram is also useful for risk stratification and prognostic evaluation. This patient developed obstructive shock due to massive PE and the fibrinolytic treatment was paramount for her survival. A good echocardiogram helped in the differential diagnosis and enabled the Cardiologist to assist the patient in the best way.

Multimodality imaging for the assessment of left ventricular dynsfunction in cardio-oncology

Funding Acknowledgements

Type of funding sources: None.

Introduction

Left ventricular systolic dysfunction (LVD) is a key concern in the context of cardio-oncology (CO). Usually, referral for suspected Cancer therapy-related cardiac dysfunction (CTRCD) is the main challenge, but heart failure with other more common causes, such as ischemic cardiomyopathy can also decompensate during cancer treatment or be diagnosed incidentally during cardiotoxicity echocardiographic (echo) surveillance. Multimodality imaging is essential in these patients in order to better establish aetiology and assure the most appropriate clinical management.

Purpose

evaluate clinical impact of multimodality imaging in the clinical management of CO patients.

Methods

retrospective study of a population followed in CO consultation. Statistical analysis of demographic, clinical, transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) data was made.

Results

we included 115 pts, mean age 66.3 ± 10.2 years, 67,8% female, with mean follow-up of 16.1 ± 12.8 months. About half (56.5%) had breast cancer, followed by gastrointestinal tract (16.5%) and haematological (8,7%) malignancies, with a significant proportion (32,2%) with advanced disease. Prevalence of cardiovascular risk factors was high (hypertension in 74.8%, dyslipidaemia in 47%, type 2 diabetes mellitus in 17.4%), but also coronary artery disease (18,3%) and atrial fibrillation (18.3%). All of them were treated with different types of chemotherapy and 53,9% of pts with radiotherapy.  At baseline, 13% of pts had a left ventricular ejection fraction (LVEF) under 50% (LVD) assessed by TTE, which increased to 26,9% (n = 31) after oncological treatment initiation. Of these (n = 31), an ischemic aetiology was found in 32,3% and non-ischemic in 54,8%, which was significantly more frequent in patients with CTRCD (OR 2,7, p = 0,001). CMR was performed in 45,2%, mostly in CTRCD cases (p = 0,012, OR 8,4), which, apart from LVD, did not show any tissue changes in most patients (p = 0,026, OR 35). Only one patient with CTRCD (under treatment with trastuzumab and anthracyclines) had subepicardial late gadolinium enhancement, with wall motion abnormalities, suggesting a myocarditis-like mechanism for cardiotoxicity.

Conclusion

LVD has a major impact in patients" prognosis, particularly in CO context, where effective oncological treatments can be compromised due heart failure decompensation. Therefore, a thorough clinical evaluation should encompass etiological study in order to provide the most appropriate treatment strategies. Moreover, CTRCD can develop through different physiopathological mechanisms. Thus, multimodality imaging, particularly including CMR evaluation, can have a major role ensuring a good clinical outcome for these patients.

Adverse in-hospital prognosis in patients with non-ST-segment elevation myocardial infarction with right bundle branch block – red flag ECG and sicker patients

Introduction

Recent recommendations regarding myocardial infarction (MI) underline the adverse prognosis associated with right bundle branch block (RBBB), suggesting that, in some cases of non-ST-segment elevation MI (NSTEMI) with RBBB a primary percutaneous coronary intervention (PCI) strategy should be considered. However, it is unclear if this is due to a more difficult and late diagnosis or to the clinical severity inherent to these patients (pts).

Purposes

To characterize the NSTEMI with RBBB population and find predictors of worse prognosis.

Methods

Retrospective analysis of pts included in the Portuguese Registry of Acute Coronary Syndromes with NSTEMI, comparing pts with RBBB (group A) vs without RBBB (group B), regarding clinical and demographic variables, diagnostic and therapeutic approaches. Primary endpoint was heart failure, electrical and mechanical complications and death in the in-hospital period.

Results

We included 9375 pts, 686 in group A and 8689 in group B. Pts in group A were more likely to be male (p<0.001) and over 75 years old (p<0.001). Also, they were more prone to have cardiovascular risk factors (hypertension - p<0.001, diabetes – p<0.001) and history of coronary artery disease (stable angina p=0.007, previous MI p=0.002 and revascularization, either PCI – p=0.016 or surgery – p<0.001), stroke (p<0.001), chronic kidney disease (p<0.001) and cancer (p=0.025), comparing to pts in group B. There were no differences between time from onset of symptoms and first medical contact or hospital admission between groups. Upon admission, these pts presented more frequently with hypotension (p=0.026), Killip class>II (p<0.001) and atrial fibrillation (p<0.001) than pts in group B. There were statiscally significant differences between groups, regarding the use of inotropes (p<0.001), non-invasive (p=0.008) and invasive ventilation (p=0.018) and temporary pacing (p=0.001), all of them higher in group A.

Pts with RBBB were less likely to undergo coronary angiography (CA) (p<0.001). However, among those who did, there were no differences in CA timing (p=0.091), but pts from group A had more frequently multivessel disease (p=0.044) and no revascularization was undertaken (p=0.012).

About 16.64% of all pts reached the endpoint, but unfavourable in-hospital outcome was significantly more common in group A (p<0.001). RBBB remained an independent predictor of the endpoint (p=0.032) in a multivariate regression analysis, controlled for other variables (namely gender, age, cardiovascular risk factors, previous evidence of cardiovascular disease, and clinical and coronary anatomy data) – AUC of 0.833.

Conclusion

Although pts with NSTEMI and RBBB have a poorer in-hospital prognosis, partly due to their bigger clinical complexity (older age, multiple comorbidities and complex coronary anatomy), RBBB itself still remains an independent predictor of worse outcome.

Funding Acknowledgement

Type of funding sources: None.

P887 Two sides of the same mass

Echocardiography (echo) remains the first-line imaging modality for the evaluation of cardiac masses. Three-dimensional (3D) echo, either transthoracic or transesophageal (TTE and TEE respectively), has allowed for better definition imaging, providing more information about the size, mobility, attachment and relation of these lesions with cardiac structures. Nevertheless, due to its superior tissue characterization capability, other imaging techniques, such as cardiac magnetic resonance (CMR), are very helpful in the differential diagnosis, making multimodality imaging the most attractive option for the study of intracardiac masses.

We present the case of a 85 year-old male, with paroxysmal atrial fibrillation (under effective anticoagulation), type 2 diabetes mellitus, hypertension, referred for the study of an asymptomatic cardiac mass found in a routine TTE. There were no relevant findings on physical examination. The TTE showed a bilobar spheroid mass, in the right atrium, attached to the interatrial septum, with 33x23mm and regular edges. A 3D TEE was performed confirming the previous findings, but also showing extension of this mass through the fossa ovalis membrane, reaching the left atrium; this aspect raised the doubt about either protrusion or invasion of the left atrium and, respectively, a benign (like a myxoma) versus malignant behaviour (such as a sarcoma). To better characterize this lesion, a CMR was ordered, which revealed a bilobar heterogeneous mass, attached to the right side of the interatrial septum, at the fossa ovalis membrane, without signs of adjacent tissue invasion, namely unequivocal invasion of the left atrium; it presented with intermediate T1 signal, hyperintense T2 signal and heterogeneous pattern of gadolinium enhancement, features mostly in favour of a right atrial myxoma. The complimentary study found no other relevant changes, namely no findings suggestive of endocarditis (negative blood cultures), autoimmune disease or malignancy. The patient refused undergoing heart surgery and, therefore, kept follow-up with clinical and echocardiographic stability.

Although histological examination remains the only tool for definitive diagnosis, multimodality imaging allows a quite comprehensive evaluation of intracardiac masses, enlightening the differential diagnosis. Here the imaging findings helped to establish a benign origin as the most likely, very important in this case of a probable right atrial myxoma, due to its peculiar protrusion to the left atrium through the fossa ovalis membrane.

Abstract P887 Figure. atrial myxoma

A systemic disease un…suspected by physical examination

A 73-year-old man was admitted to the cardiology department with unstable angina. He had a history of macroglossia with 3 years of development, attributed to hypothyroidism. On physical examination, he presented an exuberant macroglossia. The following diagnostic procedures were performed-ECG, in sinus rhythm with low voltage criteria, and transthoracic echocardiography, which revealed a left ventricle with preserved function and marked wall thickening, with low strain values in basal segments. The coronary angiography confirmed a lesion of 90% in the right coronary artery, treated with two stents. Suspecting a systemic infiltrative disease, additional tests were performed and these revealed the presence of systemic amyloid light-chain (AL) amyloidosis with cardiac involvement, associated with multiple myeloma. The patient was sent to a consult of haematology to begin chemotherapy.

Cardiomyopathy in Churg-Strauss syndrome

The authors present the case of a 56-year-old man, admitted to the hospital twice in ten days for acute coronary syndrome with normal coronary angiograms. In the second hospitalization, the patient had anginal crises that did not respond to anti-ischemic therapy, associated with cough and wheezing. The echocardiogram revealed worsening left ventricular systolic dysfunction. He had no cardiovascular risk factors but there was a history of bronchial asthma, allergic rhinitis and peripheral neuropathy of the left upper limb with paresthesias. Laboratory studies showed eosinophilia, detected in previous blood tests, although more marked than before. Chest X-rays showed non-fixed pulmonary infiltrates and bronchoalveolar lavage revealed increased lymphocytes and eosinophils, suggesting Churg-Strauss syndrome with the probable cardiac manifestation of coronary vasospasm. A cardiac MRI was also performed but was inconclusive due to the patient's intolerance of the exam.

[Clinical manifestations and therapeutic of isolated infective endocarditis of the tricuspid valve]

We reviewed the records of patients admitted to our centre with the diagnosis of isolated tricuspid valve infective endocarditis and analysed the clinical presentation, etiopathogenic agent, echocardiographic features and therapeutic approach, namely the indication for cardiac surgery. Between 1988 and 1996, 11 cases of confirmed tricuspid valve endocarditis were identified, corresponding to 5% of the cases of endocarditis admitted to our centre in the same period. A predisposing factor was found in ten of the patients, half of them intravenous drug addicts and Staphylococcus aureus was the most frequent agent isolated. Fever and pleuro-pulmonary manifestations were predominant clinical features. Transthoracic echocardiography had a crucial role in the diagnosis and transesophageal echocardiography was important to characterize vegetations. Four patients underwent cardiac surgery, for persistent infection. In two cases, excision of the vegetations and ring annuloplasty was performed. In two patients not addicted to drugs, the tricuspid valve was replaced with a bioprosthesis, since the extension of the damage to the valve did not allow repair. One patient, with early endocarditis of a tricuspid bioprosthesis died before surgery was attempted.

[A review of infectious endocarditis due to Candida]

OBJECTIVE

As fungal endocarditis is a serious disease, frequently requiring cardiac surgery, a review was made of the experience of our Departments in this pathology.

DESIGN

A retrospective analysis of clinical, echocardiographic and surgical data.

SETTING

Patients studied in a tertiary care Hospital with cardiac surgery available.

PATIENTS

Between 1984 and 1994 there were ten cases of candida endocarditis in nine patients, four male and five female, mean age--45 +/- 12 years (31-65).

INTERVENTIONS

The following parameters were analysed: clinical (predisposing factors, clinical evolution, complications, therapy and mortality), echocardiographic (presence of vegetations, abscesses, valvular regurgitations). Patients studied in other Centres and referred to our Department only for examination (echocardiograms) were excluded from this analysis.

RESULTS

Eight cases in seven patients were prosthetic valve endocarditis and two native valve endocarditis. No patient was drug addicted. Seven cases of prosthetic valve endocarditis developed less than one year after surgery and another had a gynecological fungal infection as the cause of the endocarditis. Four patients had had previous endocarditis. There were four embolic events and three developed heart failure. There were three perivalvular infections, six valvular regurgitations and only one case with huge vegetations on echocardiography. Nine patients were treated with amphotericin B, in five fluocytosin was added and in four ketoconazol, which was replaced by flukonazol in one patient. Therapy was continued for at least eight weeks. Six patients were operated during the acute stage and one died. One patient was operated on late after the infection. Three patients died during the active stage. In a follow up of 5.2 +/- 4.8 years (8 months to 8 years) there was one fatal candida endocarditis relapse, one fatal candida sepsis, one non cardiac death, one patient developed a periprosthetic leak and one had recurrent systemic embolization. Abscesses/pseudoaneurysms were found in five out of seven patients submitted to surgery.

CONCLUSION

Candida infective endocarditis has a bad prognosis, specially in those patients not operated early; it develops in patients with predisposing factors, which in our series were a previous infective endocarditis (four patients) and/or a prosthetic valve implantation less than one year before; it has important morbidity with multiple embolic events, perivalvular involvement, valvular regurgitation and heart failure.

A rare cause of late infective endocarditis after heart surgery

A case is reported of a male patient with rheumatic mitral valve disease and open mitral valve commissurotomy, performed 13 years before, who had fever and multiple septic embolic events. Serial blood cultures were positive for Pseudomonas aeruginosa. Transthoracic and transesophageal echocardiography demonstrated the presence of an irregular, round, very mobile mass inserted in the fossa ovalis region of the interatrial septum. After resolution of the infectious process, surgery was performed. The structure previously described corresponded to a elongated suture material covered by fibrin. It had been secondarily infected and it was the cause of the entire process.

[Mitral valve insufficiency caused by tendinous cord rupture and mitral valve aneurysm. Significance of the echocardiographic study]

Mitral valve aneurysm is a rare complication that may occur in a myxomatous valve. We report the case of a 73 year old male patient with severe mitral regurgitation and heart failure-class IV NYHA. Echocardiography showed perforation of an aneurysm of the anterior leaflet of the mitral valve associated with rupture of tendinous cords of the posterior mitral leaflet. Diagnosis was made by transthoracic echocardiography and confirmed by transesophageal echocardiography. The patient was urgently operated with success and a mitral valve prosthesis was implanted.

[Mitral prosthesis dysfunction--report of 3 clinical cases with unusual ultrasonography features]

Prosthetic valve obstruction is one of the most serious complications of mechanical cardiac valves. Clinicians must be aware of this diagnosis in patients with a worsening of functional NYHA class. Over the past years, echocardiography has imposed itself as the method of choice to diagnose and evaluate patients with suspected prosthetic valve obstruction. We present three clinical reports of prosthetic valve malfunction that have unusual echocardiographic features.

[Endocarditis in patients with endocardial catheters; role of transesophageal echocardiography for its detection (report of 4 clinical cases)]

To evaluate the usefulness of transesophageal echocardiography in the diagnosis of patients with non-prosthetic intracardiac material and clinical suspicion of endocarditis. A brief review of the literature was also made.

PATIENTS

All the clinical cases of patients with febril syndrome, clinical suspicion of endocarditis and non-prosthetic intracardiac material who were referred to our Department of Echocardiography for an echocardiographic examination - transthoracic and transesophageal approach.

RESULTS

Four patients were found from our revision, three of them had a permanent endocavitary pacing catheter and one had a central venous catheter. Transthoracic echocardiography confirmed the diagnosis in three patients, but did not provide accurate information in two cases due to deficient acoustic window. Transesophageal echocardiography confirmed the clinical suspicion of endocarditis in all four patients and gave more information about the size and site of vegetations, involvement of cardiac valves and existence or absence of abcesses.

CONCLUSIONS

Transesophageal echocardiography improves the diagnosis of right heart endocarditis in patients with non-prosthetic intracardiac material providing more accurate information, sometimes with prognostic and therapeutic importance.

[Heart failure due to a postlaminectomy arteriovenous fistula]

The authors report a case of congestive heart failure as a consequence of traumatic postlumbar laminectomy arteriovenous fistula. A 49 years old female with the diagnosis of atrial septal defect was admitted at the hospital, complaining of dyspnea and peripheral edema. A hemodynamic study was performed and an arteriovenous fistula was detected between the iliac artery and vein, and arterial septal defect was excluded. Surgery for fistula closure was performed with great clinical improvement.

[Cardiac involvement in dystrophia myotonica. Comments apropos a case]

Myotonic dystrophy may have several cardiovascular abnormalities. We report a case in which the cardiac changes that can be found in this disease. Finally, we make a revision of the cardiac changes that can be found in this disease.

[Myocardial infarct and coronary fistula. A rare combination]

We report an unusual case of a 39-years-old male patient, with previous inferior and anterior non Q wave myocardial infarctions, in whom the coronary arteriography showed an arteriovenous fistula between the left anterior descending coronary artery and the pulmonary artery, without any other coronary lesions. We make a revision of this disease and discuss the mechanisms of ischemia.

[Hemolytic anemia in the malfunction of a mitral bioprosthesis]

Valvular cardiac prosthesis have dramatically altered the prognosis of patients with valvular cardiac disease; however, they are not free of complications. Prosthesis disfunction and problems related to anticoagulation are the more common, but hemolytic anemia should also be considered. In this case, hemolytic anemia appears as the major complication of a mitral bioprosthesis; the decision concerning the presentation of this case report rests upon its rarity and peculiar circumstances of appearance. A brief revision of the diagnostic work-up is also made.

[Multiple aneurysms of the coronary arteries. Report of a case]

Multiple coronary aneurysms are rare. We report a case of a 56 year-old patient and make a state of the art on this subject, discussing etiologic and pathogenic considerations versus clinical and therapeutic aspects.

[Changes in coronary angiography in young patients with myocardial infarction]

OBJECTIVE

To assess the coronariographic changes and left ventricular function of a group of young patients (pts) (less than 40 years) with myocardial infarction.

DESIGN

Retrospective analysis on clinical data and cineangiography.

SETTING

Patients studied in the Cardiology Department and Cardiothoracic Department of the Santa Marta Hospital in Lisbon.

PATIENTS AND INTERVENTIONS

Sequential sample of 40 pts 39 male and one female submitted to coronariography after an acute myocardial infarction (mean age--34 +/- 3 years).

MEASUREMENTS AND RESULTS

Twenty one pts had one vessel disease, 6 pts two vessel disease, 3 pts three vessel disease, 1 left main disease (2.5%) and 9 normal coronary arteries. More than a half (22) had a lesion on the left anterior descending artery (proximal in 12-30%), 13 a lesion on the right coronary artery (proximal in 3) and 8 on the circunflex coronary artery. There were 22 (55%) total occlusions (3 of the circunflex, 9 of the left anterior descending artery and 10 of the right coronary artery). Of these 8 were proximal. We divided the pts according to the regional contractility score in three groups. Most of them had a moderate decrease in contractility. Three pts had an apical aneurysm and 8 pts had apical discinesia. Three of these 11 pts had no significant coronary lesions, six had one vessel disease and 6 had a proximal lesion of the left anterior descending artery. The mean ejection was 53% and none was less than 30%. There was a statistical difference of score and ejection fraction between anterior and inferior myocardial infarctions (6.5 +/- 1.8 versus 7.8 +/- 1.6 e 48 +/- 11.6 versus 55.4 +/- 10.8), p less than 0.05 and between those with and without a proximal lesion of the anterior descending coronary artery (5.5 +/- 1.5 versus 7.9 +/- 1.5 and 41.4 +/- 7.9 versus 56.3 +/- 9.9), p less than 0.0005. Neverthless, when we tried to separate the pts with or without atherosclerotic lesions (6.9 +/- 1.7 versus 7.9 +/- 2.2 and 50.4 +/- 11 versus 54.8 +/- 14.3) or with and without multivessel disease (7.2 +/- 1.8 versus 6.7 +/- 1.9 and 52.9 +/- 12.2 versus 46.6 +/- 8.7), no statistical difference of score and ejection fraction was found.

CONCLUSION

Young patients with myocardial infarction are predominantly males; - There is an important number of one vessel disease and in many patients no coronary significant lesions were found; - The functional changes depended more on the proximal location than on the number of diseased vessels.