P110 ACCIDENTAL FINDING OF COR TRIATRIUM SINISTER IN AN ADULT: DIAGNOSIS MANAGMENT

A 45–year old woman presented at the emergency department for palpitations and fever. The EKG, thoracic x–ray and troponins were normal, only a neutrophil leucocytosis was found. The echocardiography showed a normal bi–ventricular and valvular function and a mobile, linear, mass in the left atrium. In order to exclude an infective vegetation the patient underwent to a 2D and 3D transesophageal echocardiography (Figure 1 and 2) which showed a left ventricle concentric remodelling (iLVmass 62 g/m2; RWT 0.45), preserved left and right ventricle function (LVEF according to Simpson 70%; FAC 50%) and valves function; inter–atrial septum defects were excluded, too. The mass was described as a mobile membrane in the left atrium at 2.11 cm from the mitral valve anular plane, which divided the atrium into two separate chambers with a large fenestration without trans–mitralic flow obstruction, supporting a cor triatrium sinister. We excluded endocarditis (the blood cultures were negative, too) and supra–valvular mitral ring (since the left appendage position in the antero–inferior side of the left atrium). The cardiac MRI showed (Figure 3) (SSFP–FIESTA, IR–GRE T1, STIR T2) confirmed the finding of a left atrium divided in two chamber by a iso–intense membraine from the coumadin ridge between the left upper pulmonary vein and the left appendage to the inter–atrial septum fossa ovalis, incomplete in the infero–lateral part. Venous drenaige and other congenital abnormalities were excluded. Miocarditis was excluded since no fibrosis in IR–GRE T1 and no edema in Triple T2 sequences. Since the non–obstructive cor triatrium sinister, grading IA according the Lucas classification, was confirmed, no surgical treatment was proposed and the patient was discharged without complications.

C46 A RARE CASE OF LANGERHANS CELLS HISTIOCYTOSIS CARDIO–VASCULAR INVOLVMENT

A 54–year–old woman presented at our department for clinical follow–up. She was affected by hypertension, hypercholesterolemia, diabetes insipidus and autoimmune hypotiroidism in substitutive therapy. She had chronic coronary syndrome treated by medical therapy after unsuccessfull left anterior descending artery percutaneous revascularization and underwent to left common iliac artery stenting. The echo–doppler study showed a thickening of both common and internal carotid. Moreover, the patients underwent a skin biopsy of nodular, purple lesions which showed a xanthomatous infiltration suggestive of Langherans cell histiocytosis (CD1A+ e S100+). A subsequent PET–TC total body demonstrated a FDG uptake tissue around the great vessels and a focal increased uptake in the proximal thirds of the left tibia and in the distal thirds of fibula. The patient underwent to a new skin biopsy which confirmed histiocytosis (S100+, langherin+, CD1a+, BRAFV600E negative) and to a negative bone biopsy. Since the diagnosis of histiocytosis was confirmed the association of mercaptopurine and steroid therapy was started. In our department we performed a follow–up echocardiography which showed normal left and right ventricle dimensions and a good bi–ventricular function (LVEF according to Simpson 55% and FAC 50%) and surprisingly a focal right atrial wall thinckening of 3 mm. Therefore, the cardiac MRI showed no oedema in triple T2, no late gadolinium enhancement inIR–GRE T1 and at the posteriori wall of the right ventricle a focal thickening of 2.3 x 2.4 cm of increased intensity and a disomogenous enhancement after contrast agent administration (Figure 1); the same non stenotic tissue was showed along the aortic arch and the discending aorta (Figure 2). The MRI characteristic of these cardio–vascular lesions are consistent with the diagnosis of Langeran’s cells histiocytosis.

Changes in CMR parameters and prediction of cardiac complications in thalassemia major: fibrosis tells us more than iron

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The MIOT project received “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and ApoPharma Inc.).

Background

Cardiovascular magnetic Resonance (CMR) has dramatically changed the clinical practice and improved the prognosis in thalassemia major (TM).

Aim

This is the first study evaluating the predictive value of changes in CMR parameters (myocardial iron, function, and fibrosis) for cardiac complications in TM.

Methods

We followed prospectively 709 TM patients (374 females; 29.77 ± 8.53 years) consecutively enrolled in the Myocardial Iron Overload in Thalassemia (MIOT) Network who performed a baseline and a 1st follow up CMR scan after 18 months.  Myocardial iron overload (MIO) was measured by multislice multiecho T2* technique and atrial dimensions and biventricular function by cine images. Macroscopic myocardial fibrosis was detected by late gadolinium enhancement technique.

Risk classes were defined based on  the 4 patterns of MIO from worst to normal. For patients with baseline MIO (at least one segmental T2*<20 ms), improvement was defined as a transition to a better risk class, stabilization as no change in risk class, and worsening as a transition to a worse risk class. For patients without baseline MIO, the worsening was the transition to a worse risk class.

The percentage change was used for continuous variables. For biventricular ejection fractions, improvement was a %change > 10%, stabilization a %change between -10% and 10%, and worsening a %change<-10%. For biventricular volumes, LV mass index, and atrial areas, improvement was a % change<-10%, stabilization a % change between -10% and 10%, and worsening a % change > 10%.

Myocardial fibrosis was considered absent if not detected in any of the two CMRs and present if detected in at least one examination.

Results

During a mean follow-up of 89.4 ± 33.3 months, cardiac events were recorded in 50 (7.1%) patients: 24 (48%) episodes of heart failure, 24 (48%) arrhythmias (23 supraventricular and 1 hypokinetic), and 2 (4.0%) pulmonary hypertension.  Mean time from the 1st follow up CMR to the development of a cardiac complication was 75.31 ± 35.35 months.

In the univariate Cox regression analysis, cardiac iron cleareance and myocardial fibrosis were identified as univariate prognosticators (Table 1). In the multivariate analysis only myocardial fibrosis remained an independent predictor factor.

Conclusion

The presence of myocardial fibrosis at the baseline CMR or developed within 18 months emerges as the strongest long-term predictor for cardiac complications in TM. Our data demonstrate the importance in using the contrast medium for CMR scans in thalassemia patients.

Impact of the COVID-19 pandemic in the MR availability for iron overloaded patients

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): The E-MIOT project receives “no-profit support” from industrial sponsorships (Chiesi Farmaceutici S.p.A. and Bayer).

Background

The T2* magnetic resonance imaging (MRI) technique for the noninvasive quantification of iron overload has significantly improved the survival of patients with hemoglobinopathies by tailoring the chelation therapy. In Italy, the E-MIOT (Extension-Myocardial Iron Overload in Thalassemia) Network, a collaborative project among MRI and hematological centers, has assured high-quality quantification of iron in vital organs such as heart, liver, and pancreas. The COVID-19 pandemic has disrupted healthcare services around the world, also leading to postpone  or delete deferable diagnostic evaluations.

Aim

  We evaluated the impact of the COVID-19 pandemic on MRI services for iron overload quantification in Italy.

Methods

The activity of the MRI centers of the E-MIOT Network in the year 2020 was compared to the activity in the same months of 2019. A specific survey was filled out by the MRI operators to evaluate if the availability of MRI slots for patients with hemoglobinothies was reduced and the reasons.

Results

In comparison with the year 2019, in 2020 there was a significant reduction in the number of T2* MRIs performed (350 vs 656; P < 0.0001). The comparison month by month between the two years highlighted a marked decline (86.9%) in the four-month period March-June 2020, a reduction in the gap between the two years in the three-month period July-September, and a new decline (41.4%) in the three-month period October-December (Figure 1). No patient with hemoglobinopathy could undergo an MRI scan during the Italian lockdown (9 March-10 May 2020).

Figure 2 shows the percentage of  decline (year 2020 vs 2019) in the number of T2*MRI scans for each MRI center. If no decline or an increase were present, the vertical axis was set at 0. All centers experienced a significant drop in the number of the T2* MRIs in the four-month period March-June (from 75 to 100%). In the three-month period July-September only the centers of Pisa and Taranto dropped the number of T2* MRIs due to the rescheduling of the other MRI appointments deleted during the lockdown. In the three-month period October-December a reduction of the T2* MRI scans was experienced by all centers, except for Campobasso. In the centers of Ferrara and Lamezia Terme the reduction was the consequence of the general reduction in the number of the total MRIs scheduled per day for the  sanitation procedures. In the other centers, the availability for T2* MRI scans was unchanged in comparison to 2019, but the patients refused the MRI follow up for fear of getting sick of COVID.

Conclusion

The COVID-19 pandemic is having a strong negative impact on the quantification of iron overload by MRI, which may seriously worsen the prognosis of patients with hemoglobinopathies. Strategies to ensure proved lifesaving MRI exam and to reassure patients about the health safety of the hospitals are recommended.

P5263Genotype and cardiac findings in non transfusion dependent thalassemia patients

Background

In non transfusion dependent thalassemia (NTDT) the lack of a clear genotype-phenotype relationship complicates the already complex and extensive scenario in clinical practice.

Purpose

Our aim was to detect if the presence of a β°/β° homozygous genotype was associated to different rate of cardiac findings by Cardiovascular Magnetic Resonance (CMR) and cardiac complications.

Methods

We considered 81 patients with thalassemia intermedia never transfused o who received occasional transfusions (37.7±11.4 years, 39 females) consecutively enrolled in the Myocardial Iron Overload in Thalassemia project. CMR was used to quantify iron overload (T2* technique), biventricular morphological and functional parameters (cine sequences), and the presence of myocardial fibrosis (late gadolinium enhancement-LGE technique). All cardiac complications were classified according to international guidelines.

Results

Two groups of patients were identified: non homozygous β°/β° genotype (N=61) and homozygous β°/β° genotype (N=20.) No significant differences for sex and age were found between the groups.

Patients with homozygous β°/β° genotype had lower mean haemoglobin levels (8.6±1.1g/dl vs 9.2±1.2 g/dl) but the difference did not reach the statistical significance (P=0.060).

No patient showed cardiac iron and global heart T2* values were comparable between the two groups. Left atrial area index, left ventricular (LV) end-diastolic, end-systolic and stroke volume indexes, LV mass index, right ventricular end-diastolic and end-systolic volume indexes were significantly higher in the homozygous β°/β° group (see Table).

Frequencies of heart failure and arrhythmias were comparable between the groups.

Non-β0/β0 homozygous genotype β0/β0 homozygous genotype P Left Atrial Area (cm2/m2) 13.87±2.59 16.63±2.59 0.001 LV EDVI (ml/m2) 94.88±15.59 112.94±21.52 0.003 LV ESVI (ml/m2) 35.22±9.55 41.88±9.70 0.018 LV SVI (ml/m2) 61.98±12.57 69.81±11.20 0.029 LV mass index (g/m2) 61.26±10.15 68.63±15.89 0.030 RV EDVI (ml/m2) 91.27±23.50 107.53±23.87 0.019 RV ESVI (ml/m2) 33.93±17.55 40.81±15.20 0.043

Conclusions

Heart remodelling related to a high cardiac output state cardiomyopathy was more pronounced in patients with homozygous β°/β° genotype. These data can support the knowledge of different phenotypic groups in the management of NTDT patients.

P601Heart disease and pancreatic iron in thalassemia major

Background

Some preliminary data have postulated a correlation between pancreatic iron overload and heart iron and function in thalassemia major (TM) patients.

Purpose

In the present multicenter study we explored systematically the link between pancreatic iron and heart disease in a large cohort of TM patients.

Methods

We considered 880 TM patients (467 M, mean age 37.83±10.05 years) enrolled in the E-MIOT (Extension-Myocardial Iron Overload in Thalassemia) project. T2* measurements were performed over pancreatic head, body and tail and global value was the mean. Myocardial iron overload (MIO) was quantified using a T2* segmental approach. Biventricular function parameters were assessed by cine images. Late gadolinium enhancement (LGE) images were acquired to detect myocardial fibrosis.

Results

A significant correlation between pancreatic and cardiac iron was reconfirmed in this more numerous population and a normal pancreas T2* showed negative predictive value of 100% for cardiac iron.

LGE sequences were acquired in 273 TM patients and 84 (30.77%) of them showed macroscopic myocardial fibrosis. Global pancreas T2* values were significantly lower in patients with fibrosis (7.38±6.19 ms vs 11.91±9.79 ms; P<0.0001).

Sixty-four patients had at least one cardiac complication (arrhythmias, heart failure, pulmonary hyperthension, vascular disease). Patients with cardiac complications showed a significant lower global pancreas T2* (7.83±5.61 ms vs 12.76±10.34 ms; P=0.024). Specifically, global pancreas T2* values were significantly lower in patients with heart failure as well as in patients with arrhythmias and all patients with one of these two diseases had a pathologic global pancreas T2* value (see Figure).

Conclusion

Pancreatic iron is a strong predictor not only for cardiac iron, but also for cardiac complications supporting a more profound link between pancreatic iron and heart disease in TM.

Fenbufen pretreatment potentiates the anticonvulsant activity of CPPene and NBQX in DBA/2 mice

The anticonvulsant activity of 3-((+/-)-2-carboxypiperazin-4-yl)-1-propenyl-1-phosphonic acid (CPPene) and 2,3-dihydroxy-6-nitro-7-sulphamoyl-benzo(F)quinoxoline (NBQX), two excitatory amino acid antagonists, was studied against audiogenic seizures in DBA/2 mice, following intraperitoneal (i.p.) or intracerebroventricular (i.c.v.) administration. Maximal anticonvulsant protection was observed 15-30 min following NBQX and 45-180 min after CPPene. Coadministration with fenbufen (20 mg kg-1, i.p.), a non-steroidal anti-inflammatory agent, enhanced and prolonged the anticonvulsant actions of CPPene and NBQX and also potentiated and prolonged the impairment of rotarod performance. The enhancement of the anticonvulsant activity and the prolonged impairment of rotarod performance suggests that fenbufen may have some pharmacokinetic interactions with CPPene and NBQX and that fenbufen is able to increase the brain levels of these excitatory amino acid antagonists. In particular, fenbufen was able to exert a major degree of potentiation of effects of NBQX rather than those of CPPene, suggesting that the chemical structures of these excitatory amino acid antagonists are responsible for the different degree of interactions between CPPene or NBQX and fenbufen. NBQX appears to have a notable similarity with quinolones whilst CPPene does not. Additionally fenbufen may displace CPPene and NBQX from plasma binding sites or inhibit the renal excretion. The present data are also consistent with previous studies showing pharmacokinetic interactions between fenbufen and quinolones.