P381 A CHALLENGING PACEMAKER IMPLANTATION IN THE PRESENCE OF A GIANT RIGHT CORONARY ANEURYSM COMPRESSING THE RIGHT ATRIUM

Giant coronary artery aneurysm is an uncommon disease, treated with surgerical intervention or percutaneous coil embolization. A thrombosed aneurysm can cause extrinsic compression on the cardiac chambers, with potential haemodynamic effects and may cause problems when we need to implant a cardiac device. We present a 85–year–old patient, with a previous myocardial infarction and double coronary artery bypass graft in 1995. In 2013 he was hospitalized for heart failure and severe mitral insufficiency, with cardiac surgery indication. Preoperative coronary angiography revealed a giant right coronary aneurysm (65x75mm). The aneurysm was partially thrombosed and in close contact with the posterior sternal wall; it was decided to treat it by coil embolization in order to avoid damage during the initial stages of cardiac surgery (sternotomy and isolation of the pericardium). Subsequently, the replacement of the mitral valve with a bioprosthesis was performed without complications. In 2019 a chest CT scan, in an asymptomatic patient, showed an enlarged coronary aneurysm (85x90mm), completely thrombosed, compressing the right atrium, for which a conservative approach was maintained. The patient was hospitalized in May 2021 following 3 syncopes, with cranial trauma. The EKG shows sinus rhythm with first degree AV block and complete left bundle branch block. Chest CT confirmed the aneurysm, unchanged from 2019 (Fig 1). Transthoracic and transesophageal echocardiography confirmed compression of the mass on the right atrium, reduced to a very small cavity (Fig 2). A stress echocardiogram with dobutamine, performed to evaluate a possible hemodynamic effect of atrial compression, showed no changes in diastolic ventricular filling, arrhythmias, pressure drops, or significant symptoms. Based on these assessments, the syncopes and EKG changes, we implanted a VVIR ventricular pacemaker. The procedure was hampered by the difficulty of passing the lead through the compressed right atrium in order to reach the tricuspid plane and then enter the right ventricle; only after numerous attempts, and with the help of simultaneous echocardiographic and fluoroscopic guidance, was it possible to complete the procedure without complications (Fig 3). This case demonstrates the usefulness of the echocardiogram, in particular contexts, in cardiac electro–stimulation procedure

P188 MANAGEMENT OF ANTICOAGULANT AND ANTIPLATELET THERAPY IN THE GREAT ELDERLY: A REAL LIFE CLINICAL CASE

In daily clinical practice we have often to manage great elderly people with multiple comorbidities. In these cases it is not always easy to apply the guidelines, which must sometimes be adapted to the patient we are treating. We present the case of a 99–year–old hypertensive patient in therapy with oncocarbide and acetylsalicylic acid for polycythemia vera. No cardiological history. It came to our attention for NSTEMI during an episode of persistent atrial fibrillation (AF) with a high ventricular rate. Subsequent spontaneous restoration of sinus rhythm. Significant increase in troponin on blood tests. On the echocardiogram, normal biventricular kinetics and systolic function, no significant valvulopathies. Given the age and hemodynamic stability, a conservative approach was chosen. Therefore, antiplatelet therapy was started with acetylsalicylic acid (ASA) and anticoagulant therapy, initially with low molecular weight heparin and then with oral anticoagulant (NOAC); being the patient over 75 we chose Apixaban 2.5 mg bid, in accordance with weight and renal function (Consensus ESC 2016). At 1 month follow up the patient month was stable in good compensation, the 24h–Holter ECG showed stable sinus rhythm. At this point the question was how to proceed with the therapy: maintain the NOAC, as indicated in the NSTEMI guidelines, or continue with ASA alone, also considering that the risk scores usually used in patients with AF to determine the bleeding and cardioembolic risk (HASBLED and CHADS–VASC) are not validated in such elderly patients. We also hypothesized that the short AF paroxysm was related to ongoing myocardial ischemia (and not vice versa); in the literature, however, the indication for anticoagulant therapy does not take these extreme situations into account. Polycythemia vera also contributes to complicating the situation, exposing the patient to an increased risk of thrombotic events in the absence of antiplatelet therapy. After discussing the case with the haematologist, we decided to suspend the NOAC, also considering the absence of new arrhythmic episodes, and to continue with ASA alone. For now, with a follow–up of 6 months, we have not registered thrombotic / haemorrhagic problems or arrhythmic recurrences. The management of the elderly is always complex and will frequently lead us to adapt and customize the treatments on every single patient.

P297 PERICARDIAL EFFUSION WITHOUT HEMODYNAMIC INSTABILITY: WHEN AND TO WHOM THE PERICARDIOCENTESIS?

Cardiac tamponade is traditionally considered a clinical diagnosis, but there are pre–tamponating effusions that occur without signs of cardiogenic shock, and in these situations it can be complex to determine when and which patient treat with pericardiocentesis. The clinical case concerns a 90–year–old woman who comes to the emergency room for exertional dyspnea. Upon arrival blood pressure was 150/90 mmhg, heart rate 70 bpm. On chest x–ray, enlargement of the cardiac silhouette was evident (Fig 1). The echocardiogram showed a circumferential pericardial effusion of 2 centimeters with signs of right cardiac chambers compression (Fig 2). Hospitalized in ICU, the clinical situation was complicated by the onset of atrial fibrillation with a high ventricular response (Fig 3) and immediate cardiogenic shock (BP 70/40 mmHg, tachypnea, altered mental status). We proceed with emergency electrical cardioversion, effective in restoring sinus rhythm with almost immediate arrhythmic recurrence; therefore we perform a pericardiocentesis, with regression of the shock status after aspiration of a few cc of serum–haematic pericardial fluid (total 750 cc); spontaneous restoration of sinus rhythm after the procedure. Neoplastic problems were excluded, IgM positivity for influenza A and B on blood tests. The patient presented no further complication, was discharged at home, in sinus rhythm, with negative follow–up so far. This clinical case focuses the question of the indication and timing of pericardiocentesis. We managed a pericardial effusion with ultrasound signs of compression of the right sections, but in the absence of clinical signs of cardiogenic shock / Beck‘s triad. Given the clinical evolution, should we have perform the pericardiocentesis as soon as the patient arrived, in conditions of hemodynamic stability? Interesting are the score index proposed by Halpern et al. and an ESC position statement that serves to identify patients to undergo urgent pericardiocentesis based not only on clinical factors, but also on imaging evaluation. The total score of our case would have been indicative for an immediate pericardiocentesis. In our opinion, the formulation of a triage system for patients with pericardial effusion and hemodynamic stability that can be routinely implemented in clinical practice would be extremely useful.

C3 A RARE AND ATYPICAL CASE OF ICD POCKET HEMATOMA CONTAINING PSEUDOCHYLOUS

Subcutaneous hematoma is a complication in 2–9% of cardiac device implants.In most cases, it is drained or spontaneously reabsorbed; if untreated, there is a risk of infection.While cases of chylothorax and pseudochylothorax are rare, no previous cases of accumulation of chyliform material in the subcutaneous pockets of cardiac devices have ever been documented.We present the case of a 60–year–old man with antibody syndrome antiphospholipids, rheumatoid arthritis, previous acute anterior myocardial infarction and aorto–coronary by–pass surgery, paroxysmal atrial fibrillation, in oral anticoagulant therapy. In 2020, the patient underwent primary prophylactic dual–chamber ICD implantation (EF 33%) at another center, complicated by the formation of a large pocket hematoma, which required drainage and evacuation. In the following weeks, the patient noticed the reappearance of a large swelling in the ICD pocket; however, as it was painless and not troublesome, he did not seek medical attention. After 7 months he came to our observation with signs of heart failure. Clinical examination revealed a large swelling in the left pectoral area (Fig. 1), extending to the nipple, soft, not painful, not hot or red.The patient had no signs of infection (normal ESR, CRP, procalcitonin and WBC). We decided to drain the hematoma, given the size. At the level of the defibrillator pocket, we made a small incision, from wich 100ml of gold–colored, odorless liquid leaked out (Fig. 2), with no evidence of blood material in the pocket. The ICD–case was then wrapped in a rifampicin–releasing antibacterial bag and reinserted into the subcutaneous pocket, without further complications. The chemical–physical examination revealed a cloudy, gold–colored liquid, density of 1020, pH 8.5, high protein content (>400g/l), absence of glucose.Microscopic examination shows isolated leukocytes, rare erythrocytes immersed in mucoid material; this was not pus, as culture testing was negative for bacterial growth. The cholesterol concentration was 704mg/dl, triglycerides 80mg/dl (plasma cholesterol values were 91mg/dl, triglycerides 48mg/dl). The cytological analysis showed a carpet of foamy macrophages filled with cholesterol crystals (Fig. 3). Such evidence supports the diagnosis of pseudochilous, formed from the evolution of an untouched hematoma in a fibrous subcutaneous pocket for more than 6 months.This is the first case in which the presence of chyliform material is documented in an ICD pocket.

Detection of moderate and severe coronary artery stenosis with technetium-99m tetrofosmin myocardial single-photon emission tomography

The aim of this study was to determine the diagnostic accuracy of technetium-99m tetrofosmin myocardial imaging for the localization of coronary artery stenoses of different degrees of severity. Stress-rest single-photon emission tomography (SPET) was performed on separate days in 80 patients (64 males, 16 females; mean age 61 years; 43 patients with previous myocardial infarction; 18 patients with pharmacological stress), within 6 months of coronary angiography. Scintigraphic images were blindly and independently evaluated by three observers. Coronary stenosis was defined as a >50% narrowing in luminal diameter; severe stenosis was defined as a proximal stenosis of >75% or a peripheral stenosis of >90%. Coronary angiography revealed normal coronary arteries or insignificant coronary stenosis in 13 patients and significant coronary stenoses in 67 patients. The sensitivity and specificity of 99mTc-tetrofosmin SPET in respect of severely stenosed vessels were, respectively, 80% and 65% for the left anterior descending artery (LAD), 100% and 46% for the right coronary artery (RCA) and 58 and 78% for the left circumflex artery (LCx) territories. Considering all the significantly stenosed vessels, a significant decrease in sensitivity was observed for LAD territories (to 59%, P=0.05), and a nonsignificant decrease for RCA (88%) and LCx (47%) territories while specificity values remained essentially unchanged. No significant changes in sensitivity or specificity were observed when regions with previous myocardial infarction were excluded. In conclusion, the sensitivity of 99mTc-tetrofosmin SPET for the localization of individual stenosed vessels is only moderate when all significant stenoses are considered, but the ability of this technique to predict the location of severe coronary artery stenoses seems satisfactory, with the exception of the low specificity in respect of RCA territories.

[Short and intermediate term clinical outcome in patients with cardiogenic shock treated with aortic counterpulsation]

BACKGROUND

Despite improvements in coronary care, cardiogenic shock (CS) remains the leading cause of death in patients with dramatic cardiac diseases of which acute myocardial infarction (AMI) is the most frequent event. Conventional therapy for CS with coronary care unit (CCU) monitoring and vasopressor agents to support blood pressure has historically been associated with an 80% to 90% mortality rate in large series. Intra-aortic balloon pump (IABP) therapy for shock results in initial favourable clinical and haemodynamic responses, but ultimately, in most patients, death is merely delayed and hospital mortality still exceeds 80%. In several recent non-randomised series, coronary revascularisation performed early in the course of CS with the use of coronary artery by-pass grafting (CABG) or coronary angioplasty (PTCA) resulted in an apparent reduction in the hospital mortality rate to less than 50% in selected patients with shock.

OBJECTIVES

This study reviews our experience of cardiogenic shock treatment at a time when standard care included aggressive use of the intra-aortic balloon pump counterpulsation, cardiac catheterisation, coronary angioplasty and/or coronary artery by-pass grafting, ventricular septal defect and mitral incompetence repair.

METHODS

We retrospectively analysed 20 patients (13 M and 7 F, with an average age of 62 years and a half) affected by cardiogenic shock consecutively admitted to our CCU between October 1, 1992 and April 1, 1995. Fifteen patients (pts) were hospitalised for AMI, shock and pump failure (2 of them with pulmonary oedema), all with admittance delay less than 24 hours. Five patients were hospitalised for AMI with shock and mechanical defects, of which 3 pts with AMI and ventricular septal rupture and 2 pts with AMI and mitral regurgitation. All patients underwent IABP, coronary angiography (CA) and then were treated with PTCA, CABG and cardiac surgery or medical treatment.

RESULTS

On the whole, 7 pts died (35%): 4 of shock, 1 of haemorrhagic complications, 1 of septic shock in the CCU, and 1 of heart failure after CABG in cardiosurgery. One more patient died of heart failure two months after discharge (late mortality 5%). Out of the 15 patients hospitalised with AMI, shock and pump failure, 13 patients with AMI and CS less than 24 hrs were treated as follows: 1 patient was successfully submitted to emergency CABG and 12 patients to PTCA of the infarct related artery (IRA). Eight patients enjoyed a good outcome, but 1 patient died of haemorrhagic complications and 4 with a persistently occluded IRA also died (3 in the CCU and 1 after CABG). Of the 2 remaining pts with AMI, shock and pulmonary oedema, 1 patient underwent CABG with success and 1 patient with the 3-vessel disease was submitted to PTCA with reperfusion of the IRA, but he died from reocclusion three days later. Out of the 5 patients with AMI, shock and mechanical defects, 3 patients with AMI and septal ventricular rupture underwent cardiac surgery and CABG with early and late success. One of the 2 patients with AMI, shock and mitral regurgitation underwent cardiac surgery with valve repair and CABG and had a good outcome, the other died from septic complications in the CCU.

CONCLUSIONS

IABP is an useful device for stabilising patients in cardiogenic shock and safely performing angiography as well as PTCA, CABG or surgical correction of all mechanical complications with a more stable haemodynamic balance. Therefore, IABP is an useful tool to improve successful coronary revascularisation after direct PTCA or direct CABG. These data also suggest that the combination of successful coronary revascularisation and intra-aortic balloon pumping can improve survival in pts with cardiogenic shock complicating AMI with early pump failure.

Prognostic value of left ventricular mass in uncomplicated acute myocardial infarction and one-vessel coronary artery disease

This study assesses the relative prognostic value of increased left ventricular (LV) mass compared with residual ischemic myocardium and angiographic characteristics of the diseased vessel in 76 patients with uncomplicated acute myocardial infarction associated with 1-vessel coronary artery disease (CAD). All patients underwent symptom-limited treadmill exercise testing, resting and dipyridamole echocardiography and coronary angiography before discharge, and were followed-up for 32 +/- 6 months. LV measurements were obtained in diastole according to the Penn convention. Measurements of LV mass were divided by body surface area to obtain LV mass index. A cut-off value of 135 g/m2 body surface area for men and 112 g/m2 for women was prospectively selected. The individual effects of clinical, stress testing and angiographic variables were evaluated by using the Cox regression model. Echocardiographic LV mass index was increased in 43 patients and normal in 33. There was no intergroup difference with respect to baseline clinical and angiographic variables, ejection fraction and prevalence of stress-induced ischemia. During follow-up there were 23 cardiac events in the 43 patients with increased LV mass index and only 5 in the 33 with normal LV mass index (p < 0.001). No patient died or had nonfatal reinfarction among patients with normal LV mass. Cox survival analysis identified an increased LV mass index as the only independent predictor of cardiac events (chi-square = 7.9; p < 0.005; RR = 5.4). Thus, these data suggest that LV mass is an important independent risk factor in patients with uncomplicated acute myocardial infarction associated with 1-vessel CAD.

[The recurrence of pulmonary embolism during heparin therapy after thrombolysis in the acute phase: a clinical case report]

We report a case of a 61-year-old woman admitted to our Coronary Care Unit for pulmonary embolism following cholecystectomy. After thrombolytic therapy, and during treatment with heparin (administered as a continuous intravenous infusion in the standard dose), the patient had a recurrence of pulmonary embolism and a subsequent implant of a Gianturco-Rohem vena cava filter. The patient presented an initial reduction in the number of platelets from 477 x 10(3)/microliters to 360 x 10(3)/microliters that was ascribed to a heparin side effect or to a blocking of the platelets in a massive pulmonary thrombosis. A predischarge platelet count, however, showed an elevated number of thrombocytes (944 x 10(3)/microliters) and hyperfibrinogenemia (fibrinogen = 750 mg/dl). Essential thrombocythemia was demonstrated and treated with interferon alpha-2b-recombinant 3,000,000 U.I. on alternate days with a reduction in platelets to 450 x 10(3)/microliters. This case demonstrates the necessity of exploring, during pulmonary embolism, all possible causes of hypercoagulability in the course of thrombolytic therapy.

Silent versus symptomatic dipyridamole-induced ischemia after myocardial infarction: clinical and prognostic significance

The prevalence and prognostic significance of silent myocardial ischemia were prospectively assessed in 217 patients (mean age 57 +/- 9 years, 83% male) recovering from a first uncomplicated acute myocardial infarction and undergoing a dipyridamole echocardiography test before hospital discharge. Clinical, angiographic, exercise electrocardiographic (ECG) and dipyridamole echocardiographic variables were also examined. Of the 217 patients, 89 had no echocardiographically proved dyssynergy after dipyridamole, whereas 128 had dipyridamole-induced wall motion abnormalities that were silent in 94 (Group I) and symptomatic in 34 (Group II). There was no intergroup difference with respect to dipyridamole time (i.e., the time from onset of the test to frank dyssynergy: 7 +/- 3 vs. 8 +/- 3 min; p = NS); prevalence of inferior myocardial infarction (69% vs. 71%; p = NS); ischemic ECG changes during the test (83% vs. 71%; p = NS); diabetes (8.5% vs. 6%; p = NS); ongoing medical therapy; multivessel disease (57% vs. 56%; p = NS); and baseline left ventricular ejection fraction (57 +/- 13% vs. 57 +/- 10%; p = NS). There was also no significant difference between Group I and Group II with respect to wall motion score index at peak dipyridamole effect (1.77 +/- 0.39 vs. 1.78 +/- 0.36; p = NS). Patients were followed up for 24 +/- 4 and 25 +/- 5 months, respectively (p = NS). Life table analysis revealed no difference in unstable angina, reinfarction and death between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Heart involvement in anorexia nervosa: an electrocardiographic, functional and morphological study]

Mental anorexia (MA) is the most frequent condition of malnutrition in industrialized countries. Sudden death in MA is not infrequent. Furthermore, the role of nutritional state as an important determinant of myocardial function is known. Cardiovascular function was studied in 9 patients with MA. Blood electrolytes and thyroid function were assessed, basal and dynamic ECG, chest roentgenogram, M-mode echocardiography, ergometric test, cardiac output measurement and, in two cases, magnetic nuclear resonance (MNR) were performed. Our data confirm the ECG changes which were preeminent in the clinical context, as predictors of possible major, life-threatening arrhythmic events. The correct QT interval was normal in all patients. In 4 cases with heart rate less than 40 b/min, Holter ECG showed ventricular and atrial extrasystolic beats. In one case S-A blocks with idioventricular substitutive beats were recorded; the normal performance under maximal strain stands for a normal functional reserve. Blood electrolytes were in the normal range. The hypothalamic-pituitary axis can be considered as a cocausal factor by means of autonomic nervous system modulations. Echocardiography revealed only a mild reduction of ventricular wall thickness. Scattered degenerative myocardial involvement as shown by MNR imaging, could be the anatomical counterpart of a clinically emerging cardiomyopathy with potentially severe arrhythmias.