Abstract

ID: 1: S TUDY OF M YOCARDIAL W ORK D URING E XCERCISE E CHOCARDIOGRAPHY IN H YPERTENSIVE -D YSLIPIDEMIC P ATIENTS

Ajello Manuela

Cardiology Unit, University of Messina, Messina Italy

Background: Concentric hypertrophy is frequently associated with arterial hypertension. Myocardial Work (MW) indices, calculated from echocardiographic speckle tracking and non-invasive blood pressure data, enable detailed assessment of function in distinct myocardial segments.

Aim: to assess the performance of diverse MW indices across successive phases of exercise echocardiography in patients afflicted by hypertension, both with and without the presence of dyslipidemia.

Materials and Methods: 23 patients (88.9 % M) affected by grade 1 hypertension were enrolled. 5 were excluded due to high acoustic impedance of the chest. The mean age was 61 ± 11 years. Of the remaining 10 (55.6%) were also dyslipidemic. Patients underwent stress echocardiography with eBike EL Ergometer (GE), pressure measurement, ECG and MW parameter acquisition during each phase of the exercise.

Results: GCW in the peak phase was significantly higher in patients without dyslipidemia (3413.00 mmHg% vs 2736.44 mmHg%; p=0.033) (Fig. 1A); GWE in the recovery phase was significantly higher in patients without dyslipidemia (95.25 mmHg% vs 88.60 mmHg%; p=0.007) (Fig. 1B). GWW in the recovery phase was significantly lower in patients without dyslipidemia (109.50 mmHg% vs 277.10 mmHg%; p=0.005) (Fig. 1C).

Conclusions: Using Myocardial Work indices during exercise echocardiography may provide a new method to evaluate heart function and uncover exercise-induced pathophysiological changes in patients with varying cardiovascular risk factors.

ID: 2: A R ARE C ASE OF I NFECTIOUS A ORTITIS

Amato Filippo 1 , Pergola Valeria 1

1 Padua University Hospital - Padua Italy

Aortitis is an inflammatory process affecting the arterial wall. There are infectious and non-infectious forms. While the non-infectious forms can be linked to arteritis of the large vessels, the infectious forms are a rare but fearful complication of infective endocarditis. An 81-year-old patient subjected to previous aortic valve replacement (with Intuity 27 mm bioprosthesis for severe stenosis in 2016), was admitted to emergency department for oliguria and worsening ankle swelling in December 2022. A transthoracic echocardiography was performed, which highlighted a vegetation of about 2 cm on the aortic bioprosthesis with mild stenosis and negligible intraprosthesis regurgitation. A cerebral and thoraco-abdominal CT angiography showed multiple thromboembolic outcomes involving the splanchnic vessels, kidney and spleen. The patient was then subjected to transesophageal echocardiography which highlighted the presence of vegetation on the bioprosthesis with diameters of 12x12 mm; moreover, aneurysmal dilatation of the aortic root was found with the presence, both anteriorly and posteriorly of the wall, of a thickening of about 1 cm which extended up to the sino-tubular junction. The patient’s hospitalization was also complicated by intestinal subocclusion without urgent surgical indications. The patient’s case was discussed collectively and it was decided, in the light of the high risk of intestinal ischemia (linked to the thromboembolic occlusion of the splanchnic vessels) not to subject the patient to cardiac surgery. In a recent publication of a case report with literature review, 12 cases were reported, all treated surgically, of which 2 died. Our patient, unable to undergo surgical therapy, represents the first case treated with medical therapy alone.

ID: 3: M OBITZ 1 A SSOCIATED WITH K INKING OF THE R IGHT C ORONARY A RTERY IN A Y OUNG B ASKETBALL A THLETE

Ammendolea Carlo 1 , Tosi Alberto 1 , Madalosso Michela 1 , Sartor Riccardo 1 , Arrigoni Paola 1 , Sirico Domenico 2 , Balestriero Giovanni 1 , Truong Stella 1 , Pergola Valeria 2 , De Leo Alessandro 1

1 S. MARTINO Hospital, ULSS1 DOLOMITI - Belluno Italy, 2 Padua University Hospital - Padua Italy

A 10-year-old boy, a competitive basketball player for the local team, came to our attention with a known asymptomatic Mobitz type 1 AV block and phases of junctional rhythm during the night hours (Holter ECG). The atrioventricular block regressed during the ergometric test at the highest frequencies.

During an echocardiographic check-up, an anomalous origin of the right coronary artery was identified, along with normal biventricular function and normal diastole. Subsequent coronary CT scan revealed an anomalous origin of the right coronary artery, with a rather cranial ostium in the right coronary sinus and a proximal section that presented angled kinking, running posterior to the outflow tract of the right ventricle. This kinking caused significant stenosis at the origin of the artery itself.

The case was discussed collegially with pediatric cardiology and pediatric cardiac surgery (UNIPD), and a decision for follow-up was made due to the absence of inducible ischemia in the subsequent ergometric test and the asymptomatic nature of the condition. According to the COCIS guidelines (Italian guidelines for sports medicine), competitive physical activity was not contraindicated.

Conclusions: We report a rare case of Mobitz type 1 AV block associated with the anomalous origin and kinking of the right coronary artery. However, this anomaly has no clinical implications and does not limit competitive activity.

ID: 4: A C ASE OF S EVERE L EFT A TRIAL T HROMBOTIC C OMPLICATION A FTER E MERGENCY R ECOAGULATION WITH A DMINISTRATION OF PCC AND V ITAMIN K

Ammendolea Carlo 1 , Sartor Riccardo 1 , Mario Luca 1 , Mantoan Pierluigi 1 , Tarantini Luigi 1 , Franceschini 1

1 S. MARTINO Hospital, ULSS1 DOLOMITI - Belluno Italy, 2 Padua University Hospital - Padua Italy

An 84-year-old woman with a medical history encompassing hypertensive heart disease, chronic AF under therapeutic anticoagulation (TAO), LBBB. CKD at stage III, along with a previous TIA. In August 2016 when she was hospitalized for cholangitis, leading to an indication for ERCP. INR was elevated to 6, marking a critical point in her medical journey. 08-22 she exhibited general clinical deterioration, including dizziness, dyspnea, and reduced urine output, suggestive of an initial septic state. Echocardiography uncovered FE of 45%, bilateral atrial enlargement, and no signs of left atrial thrombosis, MI grade of 3+. The subsequent an urgent ERCP after correcting coagulation parameters (INR 2.8) with vitamin K and PCC (Kedcom®) at 30 IU/kg, successfully placing the biliary prosthesis. O8-23 the patient developed dyspnea, prompting another EcoTT, revealed an image consistent with a left atrial intracavitary thrombus with an associated smoke effect in the atrial septum (Asn). UFH infusion was initiated, followed by TAO therapy. EcoTE on August 29 confirmed a 44 x 38 mm thrombotic formation occluding the left atrial appendage, accompanied by a 1.9 cm floating fragment, localized only in the atrial septum. Progressive reduction of the thrombus to echocardiographic follow-up.

Conclusions: Thrombosis is an exceptionally rare and potentially fatal complication of rapid recoagulation with PCC. The actual incidence is uncertain but is estimated between 4 and 20 cases per 100,000 infusions according to FDA monitoring.

The case is unique, with a rapid formation of the thrombotic mass, and its persistence despite well-managed TAO. We recommend echocardiography post PCC.

ID: 5: A P ECULIAR C OMPLICATION A FTER C ATHETER A BLATION OF A TRIAL F IBRILLATION . T HE R OLE OF M ULTIMODALITY I MAGING TO I DENTIFY THE D IAGNOSIS AND A DDRESS M ANAGEMENT

Andolina Giulia 1 , Niero Alice 2 , Grolla Elisabetta 2 , Giannattasio Alessia 2 , Previato Martina 2 , Ruozi Nicolò 2

1 Cardiology Unit University of Padua - Padua Italy, 2 Dell’Angelo Hospital, Cardiology Unit - Mestre-Venice Italy

Background. Catheter ablation (CA) is a well-established treatment modality in atrial fibrillation (AF) refractory to antiarrhythmic drugs, with approximately 4-14% complication rate. We report on a patient with a very rare and insidious complication after CA.

Case presentation. Our patient is a 46-yo woman with a long history of recurrent AF who was referred to our centre for CA. The procedure was complicated by an anaphylactoid allergic reaction to protamine (not previously known in anamnesis), promptly treated with antihistamines and corticosteroids. After the procedure there were no complications, the patient complained only of atypical retrosternal pain.

A routine transthoracic echocardiography (TTE) performed after 48h showed a 31 x 41 mm mass (image A, B, C) located posteriorly the left atrium, not present in the pre-procedure TTE. An urgent contrast CT (D, E) was performed, which ruled out active bleeding or a wall pseudo-aneurism. A cardiac magnetic resonance (F) subsequently confirmed the presence of an intramural haematoma extending over the left atrium posterior wall.

The patient was transferred in ICU for close clinical monitoring and anticoagulation was temporarily suspended. Serial echos demonstrated a progressive improvement and, due to the haemodynamic stability, no surgery was necessary. The patient was discharged 20 days after ablation.

Discussion. Intramural atrial haematoma is a rare complication of CA. In our case the early administration of high dose of corticosteroids may have played a causative role. This case highlights the importance of performing TTE after an invasive procedure and the relevance of multi-modality imaging for differential diagnosis.

ID: 6: C LINICAL C ASES OF M ETASTATIC T UMORS TO THE H EART

Andreassi Dal Ben Nicoletta, Urban Michele, Bulgari Sara, Cicciò Carmelo, Molon Giulio, Bonapace Stefano, Lanzoni Laura

IRCCS Sacro Cuore Don Calabria Hospital - Negrar di Valpolicella (VR) Italy

Metastatic cardiac tumor is more prevalent than previously recognized, which is likely attributable to the increased ability to detect disease of the myocardium in vivo and improved survival of oncological patients. The term cardiac metastasis is used to describe when cancer elsewhere in the body spreads to the heart and involves any of its structures, the pericardium, great vessels, myocardium or producing intracavitary tumor thrombi.

We present 4 different cases of cardiac metastasis:

Case 1 (Panel A): a 79-year-old-male with lung neoformation and sospected apical thrombus in left ventricle (LV). Transthoracic echocardiography (TTE) demonstrated a 34x28 mm pedunculated mass originate from the LV apex with echodensity similar to the myocardium. Non-invasive imaging tools confirmed the origin of the hypovascularized mass as infiltrating metastasis.

Case 2 (Panel B): a 63-year-old-male with tonsil cancer developed multiple metastases also engaging the heart. F-FDG PET/TC detected a hypermetabolic lesion in the cardiac apex. The lesion was later confirmed by TTE: 22x25 mm oval-shaped, homogeneous, infiltrative mass in the right ventricle apex-free wall.

Case 3 (Panel C): a 53-year-old female with history of surgical resection and now in follow up for thymoma. TTE showed a multi-lobulated and mobile mass in the right atrium arising from the coronary sinus. The patient underwent cardiac surgery: histopathological examination confirmed the diagnosis of metastatic thymoma.

Case 4 (Panel D): a 79-year-old male with lung carcinoma. TTE and transeophageal echocardiography demostrated a 18x19 mm non-homogenous mass protruding into the left atrium arising from left inferior pulmonary vein as infiltrating metastasis.

ID: 7: A CUTE T RICUSPID V ALVE A NNULUS R EMODELING A FTER T RANSCATHETER E DGE - TO -E DGE R EPAIR WITH T RICLIP

Antonelli Giorgio, De Luca Valeria Maria, Cammalleri Valeria, Carpenito Myriam, Nobile Edoardo, De Filippis Aurelio, Mega Simona, Grigioni Francesco, Ussia Gian Paolo

CAMPUS BIO-MEDICO University of Rome – Rome Italy

Background: Right ventricular (RV) adverse remodeling together with RV dysfunction, and not only tricuspid regurgitation (TR) severity, are independently associated with survival in patients with medically treated significant TR. Nevertheless, tricuspid valve annulus (TVA) reverse remodeling after transcatheter tricuspid valve intervention and their association with outcomes remain largely unexplored.

Aim: Aim of our study is to assess acute remodeling of TVA after tricuspid transcatheter edge-to-edge repair (T-TEER) with TriClip using intraprocedural trans-esophageal echocardiography (TEE).

Materials and methods: This prospective, single-center study, conducted at Campus Bio-Medico of Rome, enrolled 35 consecutive symptomatic patients with the diagnosis of at least severe TR who underwent T-TEER from March 2021 to August 2023. Intraprocedural TEE was performed using Siemens Acuson. All the measures were performed during the procedure.

Results: The mean age of the study cohort was 78,77 ± 6,15 years, and 77% were female. Sixteen patients (46%) had severe (3+), fourteen patients (40%) massive (4+) and four patients (11%) torrential (5+) (TR). The majority had atrial functional tricuspid regurgitation, due to annular dilatation. Procedural success was achieved in all patient, with a TR reduction of at least 1-grade. We observed a significative reduction of TVA three-dimensional measurements immediately after the procedure.

Conclusions: In our study we observed that the reduction of TVA happened after clip positioning, proving that T-TEER is effective in reducing TR and in inducing reverse remodeling of the TV.

ID: 9: S HORT - TERM E FFECT OF SGLT2 I ON C OMPREHENSIVE G ERIATRIC A SSESSMENT IN R LDERLY WITH C HRONIC HF ( FROM MAGIC-HF)

Armentaro Giuseppe 1 , Cassano Velia 2 , Miceli Sofia 1 , Severini Giandomenico 2 , Divino Marcello 2 , Panza Alberto 2 , Panza Marilisa 2 , Riillo Federica 2 , Condoleo Valentino 2 , Maio Raffaele 10 , Perticone Maria 3 , Sciacqua Angela 3

1 University Hospital “Renato Dulbecco” of Catanzaro - Geriatrics Department - Catanzaro Italy, 2 Department of Medical and Surgical Sciences - Magna Graecia University of Catanzaro - Catanzaro Italy, 3 University Hospital “Renato Dulbecco” of Catanzaro - Geriatrics Department; Department of Medical and Surgical Sciences - Magna Graecia University of Catanzaro - Catanzaro, Italy

Introduction: SGLT2i had improved clinical prognosis in patients with heart failure (HF). Cognitive impairment, depression and poor physical functional performance resulting in a worse prognosis. Aim: The aim of this study was to evaluate the potential gender differences in the effects of SGLT2i on oxidative stress and platelets activation biomarkers and on comprehensive geriatric assessment (CGA) scales, in HFrEF elderly patients with type 2 diabetes mellitus (T2DM). Matherials and Methods: We enrolled 134 patients (82 men/52 women, 72.6±6.6 years) in the MAGIC-HF study. Results: After six months a significant improvement in CGA, NT-pro-BNP levels and echocardiographic parameters were observed. Changes (Δ) in echocardiographic, cognitive and functional parameters are greater in men, while changes in depressive symptoms and oxidative stress biomarkers levels are greater in women. In the whole population, multivariate analysis shows that ΔCI, Nox-2, Homeostatic-model-assessment (HOMA), Sp-Selectin and NT-pro-BNP contributed for a 53.8% of ΔMMSE (p<0.05); moreover, Δ of CI, Nox-2, Sp-Selectina and HbA1c accounted for a 33.0% of ΔMoCA (p<0.05). In addition, Δ of HOMA, CI and Sp-Selectin contributed for 29.5% of ΔGDS (p<0.05); and Δ of HOMA, CI, Sp-Selectin, Global longitudinal strain and NT-pro-BNP contributed for 49.7% of ΔSPPB (p<0.05). Conclusion: This study shows that the effect of SGLT2i on echocardiographic, cognitive and functional improvements are greater in men than in women, while mood-related, and oxidative stress biomarkers levels improvements are greater in women.

ID: 10: A S IMPLE F EVER R EVEALS A F AIRLY C OMPLEX C ASE

Barbara Keti, Miceli Sofia, Riillo Federica, Clausi Elvira, Monaco Vittoria, Crescibene Daniele, Rosa Maria, Condoleo Valentino, Armentaro Giuseppe, Maio Raffaele, Perticone Maria, Sciacqua Angela

Geriatriac Medicine Division, Department of Medical and Surgical Science, University Magna Graecia of Catanzaro - Catanzaro Italy

A male with aortic stenosis came to our attention after experiencing fever, asthenia, constipation, and weight loss. No significant physical abnormalities were noted, except for abdominal pulsation and mild abdominal pain. Laboratory tests demonstrated an increase in inflammatory indices and sideropenic anemia. Three sets of blood cultures were performed at febrile elevation and a TTE which showed significant fibro-calcifications only on the aortic valve. Due to abdominal symptoms, an abdominal CT scan was carried out, revealing an unspecified thickening of the bowel and an extensive subrenal abdominal aortic aneurysm (5.2x5.2x6.0 cm), currently untreatable due to the infectious state. After three days, S. Gallolyticus was isolated. Based on the antibiogram, Ceftriaxone 2 g/day IV was started. A colonoscopy was scheduled but could not be performed due to the clinical condition. We performed a TEE, identifying vegetations on the mitro-aortic valves. After five weeks of antibiotic therapy, were performed a control TEE, showing the resolution of the endocarditis; a colonoscopy highlighting the presence of intestinal adenocarcinoma (ascending colon) and multiple capillary angiectasias. The diagnosis of Heyde-Syndrome was made. A whole-body CT scan was performed for neoplastic staging, ruled out metastasis. After consulting with vascular surgeons, it was decided to prioritize oncologic disease. The patient underwent a right hemicolectomy, and the aneurysm will be closely monitored, due to the high risk of dissection.

S. Gallolyticus is the main causative agent of septicemia and infective endocarditis in elderly, frail persons, it is also strongly associated to colorectal cancer.

ID: 11: C ARDIAC M AGNETIC R ESONANCE U SEFULNESS IN D ETECTION OF P ULMONARY V ALVE I NVOLVEMENT AND C ARDIOTOXICITY IN N EUROENDOCRINE T UMOR

Barbati Giovanni, Giarraputo Leonardo, Iurilli Vincenzo, Caprioglio Francesco

San Bortolo Hospital - Vicenza Italy

Introduction: Carcinoid heart disease (CHD) is a rare manifestation of advanced neuroendocrine tumors. Serotonin and other vasoactive tumoral substances can lead to right heart valves fibrosis, thus causing tricuspid and pulmonic regurgitation and stenosis. Echocardiography is the diagnostic mainstay in CHD, but cardiac magnetic resonance (CMR) may be a valid alternative.

Case Report: A 52-year-old man affected by neuroendocrine tumor with bone and liver metastases and CHD, in treatment with capecitabine and temozolomide, came to our hospital for an outpatient CMR. Echocardiography showed moderate tricuspid regurgitation but failed to clearly visualize pulmonic valve. Using phase-contrast techniques, CMR demonstrated moderate stenosis and severe regurgitation of pulmonic valve (figure 1A). In addition, unlike echocardiography, CMR showed new onset left ventricular dilation and systolic dysfunction, anterior wall and left ventricular apex edema with elevated T2 mapping value, and septum late gadolinium enhancement with elevated T1 mapping and extracellular volume values (figure 1B, 1C). Combination of capecitabine and temozolomide is one of the few options to treat advanced neuroendocrine tumors with high response rate and long progression-free survival, but capecitabine may also be cardiotoxic, causing, among the others, coronary vasospasm, direct myocardial toxicity and myocarditis.

Conclusions: Our case underlines the important role that CMR can play in assessment of CHD in advanced neuroendocrine tumor patients. CMR is very useful to evaluate the degree of right valves dysfunction, especially of pulmonic valve, often difficult to visualize by echocardiography, but it can also provide a unique opportunity for tissue characterization and detection of cardiotoxicity.

ID: 12: L EFT V ENTRICLE F REE W ALL R UPTURE : A B REAKTHROUGH FROM C ARDIAC M AGNETIC R ESONANCE

Barbato Maria Grazia, Iuliano Giuseppe, Prota Costantina, Cannavaro Gianpio, Grossi Alma, Guerriero Antonio, Romei Stefano, Brenca Davide, D’Elia Debora, Campanile Alfonso, Ravera Amelia

SAN GIOVANNI DI DIO E RUGGI D’ARAGONA University Hospital - Salerno Italy

A 47-year-old man presented at our emergency department with typical chest pain.

A baseline electrocardiogram (ECG) showed normal sinus rhythm with profound ST-segment elevation in the anterolateral leads, leading to a diagnosis of anterolateral ST-segment elevation myocardial infarction (STEMI). Indeed, a bed-side fast echocardiogram confirmed akinesis of the apex in toto and of anterior wall, without evidence of severe valvulopathy or pericardial effusion. Emergency coronary angiography revealed complete occlusion of the proximal left anterior descending coronary artery, treated with primary PCI and DES implantation (pre-coronary time <1h).

Forty-eight hours later, a new echo surprisingly revealed a very thin aneurismatic left ventricular inferolateral apex with pericardial effusion (Fig. 1A). Suspecting a possible, even if unlikely considering the short precoronary time, contained LV rupture, cardiac magnetic resonance (CMR) was immediately performed. Of note, CMR (Fig. 1B) confirmed the evidence of a large myocardial infarction involving the LV apex with poor enhancement (signs of no reflow). In addiction, a lower thickness of the inferolateral apical segment was detected, with spillage of contrast medium into the pericardiumc onfirming thw hypothesis of a contained rupture of the LV apex.

Immediately, surgical repair of the LV was performed with a Dacron patch. The patient had an uneventful hospital course and was discharged in stable condition.

In this case, echocardiography confirm its important role in the quickly recognition of possiblecomplicationsin myocardial infarction; anyway, CMR has a pivotal role in confirming, in order to consent the best possible therapeutic strategy as soon as possible.

ID: 13: T HE O LD N EW FOR A B ETTER W ORK : T HE R OLE OF A TRIAL E LECTRO -M ECHANICAL C OUPLING AS P REDICTOR OF C ATHETER A BLATION E FFICIENCY

Barletta Valentina, Parollo Matteo, Canu Antonio Maria, De Lucia Raffaele, Segreti Luca, Di Cori Andrea, Carluccio Marisa, Branchitta Giulia, Sbragi Sara, Cellamaro Tea, Grifoni Gino, Zucchelli Giulio

Pisana University Hospital - Pisa Italy

Atrial fibrillation results in electrical and structural remodeling of the atria, and the extent of remodeling has been found to be associated with higher AF recurrence rate after catheter ablation (CA). A novel echocardiographic parameter derived from tissue Doppler imaging (TDI), PA-TDI, has been introduced to assess the total atrial activation time, as a non-invasive surrogate of fibrosis and atrial cardiomyopathy.

AIM: to investigate the role of PA-TDI interval as predictor of AF ablation efficacy.

METHODS: Consecutive patients with persistent or paroxysmal symptomatic AF referred to perform ablation procedures were prospectively enrolled. A complete transthoracic echocardiogram was performed before and after the ablation procedure, including assessment of the PA-TDI interval.

RESULTS:From October 2018 to May 2020, 221 consecutive patients (mean age 61 ± 9 years, 74% male, mean BMI 26.5 ± 3.6, mean EF 61 ± 6%) symptomatic for AF, undergoing the procedure ablation were enrolled. In a 3 years FU, 25% of patients experienced recurrence of arrhythmia. Compared to patients who did not relapse, patients with AF recurrence have a generally longer post-procedural PA-TDI interval (139.6 ± 22.1 msec vs 153.9 ± 33 msec, respectively). In the multivariable analysis only post-procedure PA-TDI and re-do interventions were found to be independent predictors of AF recurrence. A PA-TDI cut-off>144msec identifies patients at risk of post ablation AF recurrence with sensitivity 58.7% and specificity 73.5% (AUC 0.697).

Conclusions The PA-TDI interval is an independent predictor of AF recurrence. This parameter is easily obtainable and accessibile, low-cost, reproducible

ID: 14: A T RICKY C ARDIAC L ESION

Baroni Giulia, Cucchini Umberto, Peluso Diletta, Nguyen Kim Anh, Alderighi Chiara, Chirillo Fabio

San Bassiano Hospital - Bassano del Grappa (VI) Italy

A 56-year-old man without any prior cardiovascular or systemic disorder was admitted to the emergency department for chest pain, dyspnea and palpitation. Blood tests revealed a raised level of Troponin I and D-dimer. Chest-X-ray showed cardiomegaly.

A transthoracic echocardiogram showed a cardiac mass occupying the right atrium and partially infiltrating the interatrial septum and the left atrium. Partially, it also partly obstructed the superior cava vein as demonstrated by color Doppler and high continuous wave Doppler velocities.

The patient underwent a cardiac computed tomography that confirmed the presence of a solid amorphous lesion, spreading from the interatrial septum, with irregular surface and inhomogeneous contrast enhancement, findings supportive of malignancy.

To better define the tissue characterization a cardiac magnetic resonance was performed: the mass presented with multi-lobar morphology and appeared to be isointense in T1 weighted images, isointense/minimally hyperintense in T2 weighted images and had a patchy late gadolinium enhancement. These elements were considered as possibly suggestive of sarcomas or lymphomas.

The trans-jugular endomyocardial biopsy confirmed a diffuse large B cell lymphoma (CD20+, CD45+, CD79a+, Bcl2+, MIB160%).

Patient was finally attended by hematological ward to start chemotherapy.

Comment: Multimodality imaging is a necessary strategy in the diagnostic work-up of cardiac masses. Echocardiogram, cardiac magnetic resonance and computed tomography have complementary roles: they provide important information about morphology, localization, relations with surrounding structures and tissue characterization, getting closer to the histological definition, that is mandatory for the following therapeutic program.

ID: 15: T HE H EART S URGEON ’ S N IGHTMARE

Baroni Michele, Gherbesi Elisa, Santangelo Gloria, Carugo Stefano

Department of Cardio-Thoracic-Vascular disease, Foundation IRCCS Ca’ Granda Maggiore Hospital - Milan Italy

We present the clinical case of a 72-year-old man admitted to the intensive care unit for acute pulmonary edema in October 2023. In April of the same year he had placed a biological aortic valve (CE Magna Ease type No. 23) and performed a coronary artery bypass.

Transesophageal echocardiogram, as well Computed tomography of the heart documented periprosthetic abscess (picture D and B, star) described as large vacuolized thickening up to 4 cm extending toward the ascending aorta, with pulsatile and flow-supplied portion, communicating with the left ventricular outflow tract in partial detachment, conditioning severe paraprosthetic insufficiency (Picture B, white arrow). Further communication with right atrium (8 o’clock in course axis) as per fistulization (of about 6-7 mm) was visualized, too (Picture A, harrowhead). Extensive endocarditic process of the aortic prosthetic cusps with adherent mobile vegetation was present, too. On velocimetric analysis, there was an increase in anterograde gradients (G max/median 47/24 mmHg in transgastric view). The mitral valve and the tricuspid valve presented severe regurgitation.

After a challenging 8-hour surgical intervention, involving the replacement of the aortic bioprosthesis, closure of the recess by a pericardial patch, placement of the aortic counterpulsator, and administration of maximal drug therapy, it was impossible to successfully discontinue the extracorporeal circulation. Unfortunately, this resulted in an unfavorable outcome, and the patient succumbed.

ID: 16: A ORTIC S TENOSIS AND A TRIAL F IBRILLATION , A C OMPLEX C OMBINATION

Barresi Roberta, Tosto Giuseppe, Passaniti Giula, Torrisi Tito, Deste Wanda, Tamburino Corrado

University Hospital “G. Rodolico - San Marco” - Catania Italy

Introduction: Aortic stenosis (AS) and atrial fibrillation (AF) are commonly found together in elderly patients, due to the fact that their incidence increases with age and the fact that atrial fibrillation may be a consequence of congestive heart failure, exacerbated by AS. It has been shown in the literature that these patients have a higher overall mortality. Furthermore, in this cohort, it is difficult to make a diagnosis of symptomatic AS, because the symptoms of AS and AF are usually the same and echocardiographic evaluation usually underestimates the severity of AS.

SCOPE: Our goal is to reconsider the echocardiographic evaluation: we found that gradients related to a longer RR interval are those that indicate more severe AS. In our study this evaluation is statistically significant and not inferior to the guide methods, which require the average of 5 beats.

Material and methods: 30 patients were included in our study. Different patient characteristics can be found in Figure 1, Table 1.

All patients underwent a complete echocardiographic evaluation with two experienced echocardiographers and cardiac CT with an experienced cardio-radiologist.

Results: As shown in Figure 1, Table 2, we found that the results for maximum gradient, mean gradient, maximum velocity, and stroke volume are statistically significant while there is no significant change in EOA.

Conclusions: In patients with atrial fibrillation, the single long cycle method can be used to calculate EOA instead of averaging multiple cardiac cycles. Naturally, further studies will be necessary in the future.

ID: 17: M ITRAL M ECHANICAL P ROSTHESIS D YSFUNCTION AND P REGNANCY

Bentivegna Agnese

GIOVANNI PAOLO II Hospital- Ragusa Italy

A 26-year-old female patient had undergone mechanical mitral valve replacement when she was a child. Because of the pregnancy, acenocoumarol was replaced with LMWH.

On April 2023 (16th week of pregnancy) she had an episode of paroxysmal AF. The TTE showed increased transmitral gradients (mean gradient 22 mmHg) with normal disc motion and without signs of thrombosis. On April 28th she was admitted to the emergency department because of dyspnea, and the TTE revealed a possible hypomobile disc, intra-prosthetic regurgitation, prosthetic dysfunction (mean gradient 23 mmHg, PHT 290 ms), and signs of heart failure (dilated and hypo-collapsed IVC, sPAP 60 mmHg, diffuse B-lines). They decided not to perform the fluoroscopy considering that she was at 18th week of pregnancy.

The TEE showed a mobile mass, likely thrombotic in nature, and a blocked medial disc, causing moderate intraprosthetic regurgitation and severe stenosis.

This clinical case was discussed with the Heart Team and her family via telemedicine. They decided to attempt the therapy with intravenous UFH, without success. Therefore, they opted for the abortion and, then, cardiac surgery.

The patient underwent replacement of the mechanical mitral valve with bioprosthesis.

During the cardiac surgery, a thrombus and pannus were found on the prosthetic valve blocking the opening of a disc.

This case underlines the importance of the echocardiography for the diagnosis and management of prosthetic dysfunction, especially when other imaging options (CT, fluoroscopy) are not possible. Telemedicine allows a management of complex patients in the Heart Team in cardiovascular departments without cardiac surgery.

ID: 18: A R ARE C ASE OF M ITRAL V ALVE R EPLACEMENT IN P EDIATRIC M UCOPOLYSACCHARIDOSIS -L IKE S YNDROME

Bianchi Janetti Maria 1 , Boffi Lucia 1 , Trocino Giuseppe 1 , Seddio Francesco 2 , Gasperini Serena 1 , Soffici Federica 1 , Cesana Francesca 1 , Lofrano Luca 1

1 IRCCS San Gerardo dei Tintori Hospital - Monza Italy, 2 Papa Giovanni XXIII Hospital - Bergamo Italy

We report the case of a 10 yr old male known for OSAS in nocturnal cPAP, subclinical hypothyroidism, renal tubulopathy and chronic steroid therapy for macrophage activation syndrome.

Genetic diagnosis of mucopolysaccharidosis like syndrome by p. Aeg498Trp homozygosity mutation in the VPS33A gene was performed by exome sequencing. This mutation involves glycosaminoglycan metabolism and is characterized by severe multisystemic and rapidly progressive phenotype not treatable with enzymatic therapy.

At age 21 month he’s been diagnosed a hypertrophic heart disease with mitral regurgitation (MR) due to posterior mitral leaflet thickening and prolapse. It was first described during hospitalization for diagnostic workup complicated by cardiopulmonary arrest during sedation for invasive examination. It has rapidly evolved to severe MR with left chambers dilatation despite optimized medical therapy (diuretic, ACE-inhibitor, beta-blocker, antialdosteronic). In the following years he underwent multiple hospitalizations for respiratory infections and congestive heart failure treated with cPAP, sometimes requiring IOT and aminic support for evolution to septic shock with ARDS.

We document concomitant progressive neuromotor improvement with independent ambulation, absence of speech but expressiveness mediated by effective gestures and good interpersonal interaction.

Collegial evaluation (CCH, Pediatric Cardiologist, Anesthesiologist, Pediatric Metabolist) on risk/benefit profile was assessed at 5 yr old and he was referred for surgical correction based on anatomical and functional status.

A Surgical valve repair was attempted; after intraoperative failure, a Carbomedics No. 21 mechanical mitral prosthesis was successful implanted. The following 4 years there were no more need of hospitalizations demonstrating that MR was the major determinant of clinical instability.

ID: 19: N ON -I NFERIORITY OF L EFT A TRIAL A PPENDAGE C LOSURE WITH I NTRA -C ARDIAC E CHOGRAPHY G UIDANCE

Binno Simone Maurizio, Moderato Luca, Rusticali Guido, Rossi Luca, Monello Alberto, Gioacchino Valenti, Perrino Felice, Vermi Annachiara, Aschieri Daniela

Guglielmo da Saliceto Hospital - Piacenza Italy

The percutaneousleft atrial appendage closure (LAAC) represents an alternative to oral anticoagulant therapy in patients at high thrombotic risk and contraindications to anticoagulation. LAAC is usually performed with transesophageal echocardiography (TEE) guidance, and consequently, patientsneeds to be intubated and anaesthetized, with an increase in costs and complexity of procedure. An alternative approach, utilizing awake patient monitoring with intracardiac echocardiography (ICE), is now available.

Aim: Investigate the efficacy and safety of ICE-guided LAAC without anesthesia support.

Materials and Methods:Atrial fibrillation patients with CHA2DS2-VASc scores ≥2 and clinical indications for LAAC were eligible. The primary outcome was the rate of peri-device leaks(>5 mm) at 45-day TEE.

Results: Between July2022 and July2023, 23 patients (mean age 81±6,4 years, CHA2DS2-VASc score 4±1.5) underwent LAAC. Two procedures were performed with TEE and general anaesthesia, while 21 utilized ICE.

All procedures were completed, without any conversion to TEE. The incidence of significant peridevice leak was 0%. No differences in fluoroscopy time was noted (11,5 min±4,5min for ICE vs 13,1 min±4,5 min for TEE, p=0,6).

There was one periprocedural complication (cardiac tamponade) in the ICE group, managed through pericardial drainage. In 13 patients the Amulet device was used while in 10 patients the Watchman device was preferred. All patients evaluated by TEE at 45 days had effective LAAC and showed mild interatrial shunt, due to the procedural trans-septal puncture.

Conclusions: ICE can be used to successfully guide LAAC with the Watchman and Amulet devices, excellent procedural success, a high rate of effective LAAC, and minimal periprocedural complications.

ID: 20: M ULTIMODALITY I MAGING AND C ARDIAC M ASSES : D IAGNOSIS B ETWEEN P AST AND P RESENT

Bonelli Andrea, Guasti Serena, Sormani Paola, Di Marco Daniela, Spanò Francesca Maria, Santambrogio Gloria Maria

Niguarda Hospital- Milan Italy

A 65-year-old man with hypercholesterolemia and family history of coronary artery disease came to our attention to perform a routine transthoracic echocardiography. The exam showed an increased thickness of the basal interventricular septum with hyperechoic spots, suspicious for cardiac mass. No bi-ventricular outflow tract obstruction was detected and other cardiac structures were normal. In that occasion, contrast echocardiography was performed and showed an inhomogeneous perfusion of the mass.

The clinical assessment of the patient revealed good functional status and absence of symptoms. The laboratory tests displayed normal blood count, normal renal function and normal values of cardiac troponin. The electrocardiogram (ECG) showed sinus rhythm with first-degree atrio-ventricular block without significant alterations of ventricular repolarization. No arrhythmias were detected during the 24-hour ECG monitoring.

To characterize the mass, cardiac magnetic resonance was performed. The presence of an oval mass with clear margins, measuring 30x34x48 mm APxLLxCC, located in the interventricular septum, was confirmed. The mass was hypointense in T1 and T2-weighted sequences. After administration of gadolinium, it showed an inhomogeneous late enhancement with an hyperintense capsule. Lastly, the cardiac computed tomography revealed the presence of calcifications without evidence of vascularization in the arterial phase. These characteristics lead towards the diagnosis of fibroma.

The case was evaluated by a multidisciplinary team, including a cardiac surgeon. Given the absence of symptoms, bi-ventricular outflow tract obstruction or arrhythmias there was no a compelling indication to surgery. Moreover, the patient exhibited an echocardiogram from 1989 which demonstrated the presence of the mass of unchanged dimensions.

ID: 21: F EASIBILITY IN T RANSTHORACIC D OPPLER S AMPLING OF THE P ROXIMAL S EGMENT OF THE L EFT A NTERIOR D ESCENDING C ORONARY A RTERY F LOW : E CHOCARDIOGRAPHER C ARDIOLOGIST V ERSUS C ARDIOLOGY R ESIDENT

Calabrò Ylenia, Miglierina Emilio, Tanzi Lorenzo, Zoli Laura, Meregalli Guglielmo, Pozzoli Marco

Di Circolo Hospital and Macchi Foundation- Varese Italy

Introduction: A critical stenosis of the proximal segment of the left anterior descending coronary artery (LAD) has a high prognostic value. Setting aside invasive procedures, sampling of the proximal LAD flow through transthoracic echocardiography (TTE) has been proposed with results unclearly defined regarding feasibility.

Aim: To evaluate the feasibility of flow sampling of proximal LAD with TTE, comparing the echocardiographer cardiologist (EC) with the first-year cardiology resident (CR).

Materials and Methods: The population consisted of 92 patients: 33.6% female, 67+15 mean years, 1.86+0.19 mean BSA. Images were collected using GE Vivid E80/E95 echocardiographs; to visualize proximal LAD we used an unusual extreme apical 5-chambers view. The sampling success rate of the two groups was calculated.

Results: proximal LAD coronary flow was visualized and sampled in 82 patients (feasibility 89%) by EC and in 41 patients (feasibility 44.5%) by CR. Patients in whom proximal LAD was successfully sampled by CR were the same as those by EC. The average of the peak diastolic velocity flow was overlapping in EC and CR (0.50+0.30 m/sec). The main reason of failure was poor acoustic window for EC and poor technical experience for CR.

Conclusions: proximal segment of the LAD coronary flow were sampling with high feasibility by EC comparing to the first-year CR. However, it cannot be ignored that there was a valid amount of feasibility even in young physichans, so that with an appropriate learning curve, it is possible to anticipate a wider adoption of this useful diagnostic technique in clinical practice.

ID: 22: S EVERE M ITRAL R EGURGITATION IN M IDLY S YMPTOMATIC P ATIENT : T HE R OLE OF E XERCISE S TRESS E CHOCARDIOGRAPHY AND T HERAPY

Campagnano Ettore, Cerracchio Emma, Bologna Ada, Villari Bruno, Ciampi Quirino

Fatebenefratelli Hospital of Benevento, Cardiology Division - Benevento Italy

Background: Evaluation of severe mitral regurgitation needs to take into account symptoms, therapy and serial assessments with advanced imaging as exercise stress echocardiography (ESE).

Case summary: A 62-years old woman presented to our division with dyspnea for about a month. Trans-thoracic and trans-esophageal echocardiography showed pulmonary B-Lines, pulmonary hypertension (PAPs: 47 mmHg) and a severe mitral regurgitation (E-wave velocity: 136 cm/s, EROA: 0.47 cm2, Vena Contracta 8.2 mm) (Figure 1A). Left ventricle (LV) dimensions and ejection fraction (EF) were normal (End Diastolic Volume: 67 ml, End Sistolic Volume: 23 ml, EF 67 %), as right ventricle function (TAPSE 27 mm), while left atrium was dilated (LAVI 58 ml/m2). She started medical therapy (bisoprolol 2.5 mg, ramipril 2,5 mg, furosemide 25 mg, canrenone 50 mg). Symptoms improved with therapy and after 3 months she underwent ESE without symptoms, with moderate mitral regurgitation and no B-Lines at rest and at peak stress (Figure 1B), normal LV contractile reserve (2.42) based on LV force (ratio between stress and rest of systolic pressure/end systolic volume), no significant increase of PAPs (19 mmHg at rest and 27 mmHg at peak stress). ESE confirmed the indication to medical therapy, postponing surgery. The patient continues follow-up since 5 years with stable rest and ESE, without symptoms.

Conclusions: Multi-parametric approach to mitral regurgitation plays an important role in the therapeutic decision. Exercise stress echocardiography is an excellent pathophysiological tool to evaluate the haemodynamic significance and stress change in mitral severity, left ventricular function and pulmonary congestion.

ID: 23: P ROGNOSTIC V ALUE OF C ORONARY F LOW AND M YOCARDIAL V IABILITY IN H EART F AILURE WITH R EDUCED E JECTION F RACTION

Campagnano Ettore 1 , Ciampi Quirino 1 , Cortigiani Lauro 2 , Gaibazzi Nicola 3 , Rigo Fausto 4 , Zagatina Angela 5 , Djordjevic-Dikic Ana 6 , Barbieri Andrea 7 , Bartolacelli Ylenia 8 , Pepi Mauro 9 , Carerj Scipione 10 , Villari Bruno 1 , Picano Eugenio 11

1 Fatebenefratelli Hospital of Benevento, Cardiology Division - Benevento Italy, 2 San Luca Hospital, Cardiology - Lucca Italy, 3 University of Parma, Cardiology Department - Parma Italy, 4 Villa Salus Foundation/IRCCS San Camillo Hospital - Venice Italy, 5 Cardiology Department, Research Cardiology Center “Medika” - Saint Petersburg Russian Federation, 6 Clinical Center of Serbia and School of Medicine University of Belgrade, Cardiology Clinic - Belgrade Serbia, 7 Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena - Modena Italy, 8 Paediatric Cardiology and Adult Congenital Heart Disease Unit, S. Orsola-Malpighi Hospital - Bologna Italy, 9 Cardiology Division, Centro Cardiologico Monzino, IRCCS - Milano Italy, 10 Cardiology Division, University Hospital Polyclinic G. Martino, University of Messina - Messina, Italy 11 CNR, Institute of Clinical Physiology - Pisa, Italy

Background. Patients with heart failure (HF) with reduced ejection fraction (EF) have heterogeneous prognosis. We evaluated coronary flow velocity (CFV) and coronary flow velocity reserve (CFVR) in HF

Methods and results. We enrolled 1,408 HF patients (age 66±12 years), with EF ≤49%, 743 (53%) with coronary artery disease, and 665 (47%) with normal coronary arteries. We analyzed at rest CFV (abnormal value >31 cm/s) and CFVR with exercise (n=99), dobutamine (n=100), and vasodilator stress (dipyridamole in 1,149, adenosine in 60). Inducible myocardial ischemia was identified with wall motion score index (WMSI, stress> rest) and LV contractile reserve (CR) with WMSI stress30%, CFV >31 cm/s, CFVR≤ 2.0, LVCR present, ischemia absent) to score 5 (all steps abnormal). All-cause death was the only end-point.

Results. The mean CFV was 34±16 cm/s and CFVR was 2.02±0.53. During a median follow-up of 990 days, 253 patients died. Independent predictors of death were EF (HR: 0.956, 95% CI: 0.943-0.968, p<0.0001), CFV (HR: 2.407, 95% CI: 1.871-3.096, p<0.001), CFVR (HR: 3.908, 95% CI: 2.903-5.260, p<0.001), stress-induced ischemia (HR: 2.223, 95% CI: 1.642-3.009, p<0.001), and LVCR (HR: 0.524, 95% CI: 0.324-.647, p=0.008). The annual mortality rate was lowest (1.2%) in patients with a score of 0 (n=61) and highest (31.9%) in patients with a score of 5 (n=15, p<0.001) (figure).

Conclusion. High resting CFV predicts worse survival in ischemic and nonischemic HF with reduced EF. The value is independent and additive to resting EF, CFVR, LVCR, and inducible ischemia.

ID: 24: H OT S EPTUM AND S TRAIN R EVERSUS : A DDITIONAL E CHOCARDIOGRAPHIC S IGNS A SSOCIATED WITH C ONSTRICTIVE P ERICARDITIS D ETECTED BY CMR

Cannata Francesco, Fazzari Fabio, Milanese Romina, Baggiano Andrea, Fusini Laura, Gripari Paola, Mushtaq Saima, Mantegazza Valentina, Maragna Riccardo, Muratori Manuela, Pepi Mauro, Pontone Gianluca

Monzino Hospital IRCCS - Milan Italy

Introduction: A typical echocardiographic global longitudinal strain (GLS) pattern has been described in patients with constrictive pericarditis (CP): a reduction in regional longitudinal strain of the left ventricular free wall and relative sparing of the septal longitudinal strain called “hot-septum (HSS)”, described by some authors as “strain reversus (SR)”.

Aims: The aim of this study was to evaluate the diagnostic role of HSS or SR among pericardial diseases and their correlation with pericardial involvement assessed by cardiac magnetic resonance (CMR).

Material and methods: This is a retrospective, single centre cohort study including consecutive patients admitted for pericardial diseases with both echocardiographic and CMR assessments. HSS was visually assessed, while SR was defined as the ratio between basal septal LS and lateral LS <1.

Results: After screening of 385 patients, 85 were included. The study population was divided in CP (24) and non-constrictive pericarditis (NCP, 61). The prevalence of HSS was higher in CP (79% vs 8%, p<0.001). SR was significantly lower in CP patients (0.81±0.50 vs 1.36±0.79, p<0.001). Logistic regression model showed an association between CP and reduced SR (OR:1.64, CI:0.55-2.74; p:0.003); the best cut-point for CP prediction was 0.96 (c-statistic:0.73, sensitivity 0.79, specificity 0.64). HSS was mainly associated to pericardial thickening (OR:2.30, CI:1.21-3.41; p:0.001), less to pericardial LGE (OR:1.06, CI:0.07–2.04; p:0.036), while it was unrelated to pericardial oedema (OR:0.87, CI:0.11–1.84; p:0.079).

Conclusion: Hot septum and strain reversus are echocardiographic signs associated with constrictive pericarditis and pericardial involvement detected by cardiac magnetic resonance.

ID: 25: P ERIPARTUM C ARDIOMYOPATHY : A R ARE C OMPLICATION OF P REGNANCY -R ELATED H EMOLYTIC U REMIC S YNDROME

Cannavaro Gianpio, Prota Costantina, Grossi Alma, Barbato Maria Grazia, Guerriero Antonio, Brenca Davide, Romei Stefano, D’Elia Debora, Procaccini Cinzia, Iuliano Giuseppe, Campanile Alfonso, Ravera Amelia, Citro Rodolfo

SAN GIOVANNI DI DIO E RUGGI D’ARAGONA University Hospital - Salerno Italy

A 37-year-old pluripara woman, with no history of chronic disease, was admitted to our intensive care unit at the 25th week of pregnancy due to placental abruption, undergoing an emergent cesarean. At her admission, serum creatinine and platelet values measurements were 2,81 mg/dL, and 17000/lL, respectively. Hemodialysis was immediately started due to the progression of renal failure. Since she was not hypertensive during her pregnancy and her liver enzymes did not exceed the upper limit, preeclampsia/Eclampsia and HELLP syndrome were not considered as diagnoses; thrombotic thrombocytopenic purpura was ruled out due to the patient’s normal ADAMTS-13; therefore, pregnancy-related atypical hemolytic uremic syndrome (aHUS) was accepted as the diagnosis. Indeed, therapy with complement inhibitor ravulizumab was started. Five weeks after diagnosis, she presented progressive dyspnea, with severe respiratory failure. An echocardiogram demonstrated an acute drop in left ventricular ejection fraction (from 60 to 30%) with global hypokinesis; massive pulmonary effusion was seen at lung ultrasound.

CPAP therapy to support ventilation and optimal heart failure medications were started. After one week, clinical and laboratory data improved, with echocardiographic finding of substantial improvement in LV systolic function. A cardiac magnetic resonance was performed, showing a preserved LVEF 50% without signs of fibrosis or edema. Her physical examination was now completely normal, with a normal serum creatinine and normal blood count test.

In conclusion, peripartum cardiomyopathy occurred during atypical pregnancy-related hemolytic uremic syndrome was diagnosed; a completely recovery through target therapy was obtained, underlying the importance of a correct and timely diagnosis.

ID: 26: F ATAL C ONSPIRACY : M IDVENTRICULAR O BSTRUCTIVE H YPERTROPHIC C ARDIOMYOPATHY C OMPLICATED BY G IANT A PICAL A NEURYSM AND S EVERE M ITRAL R EGURGITATION

Capodaglio Irene, Tofoni Paolo, Brugiatelli Leonardo, Nazziconi Marco, Maurizi Kevin, Pietrucci Francesca, Gioacchini Simona, Schicchi Nicolò, Patani Francesca, Lofiego Carla, Di Eusanio Marco, Dello Russo Antonio, Perna Gian Piero, Vagnarelli Fabio

Marche University Hospital - Ancona Italy

This case refers to a 69 y/o woman with a history of hypertrophic cardiomyopathy with severe mid-ventricular obstruction complicated by apical aneurysm and restrictive phenotype. This patient had no left ventricular outflow tract obstruction and previous examinations showed moderate mitral regurgitation (MR) with suboptimal echocardiographic follow-up. ICD was previously implanted. Disease progression was complicated by episodes of acute HF caused by AF with rapid ventricular response despite pharmacological therapy and a transcatheter ablation attempt.

The patient was admitted to our cardiac ICU with acute pulmonary oedema and extreme frailty. EKG showed AF with high ventricular rate. TTE and TEE gave evidence of severe hypertrophy of left ventricular (LV) mid-cavity segments (mid IVS 26 mm) with mid-ventricular systolic obliteration and a large apical aneurysm (37x35 mm) resulting in an “hourglass” shaped LV cavity. In addition the examinations highlighted systolic dysfunction with severe stroke volume reduction and severe MR.

TEE and cardiac CT (Figure 1) were analyzed by the Heart Team. Surgery with aneurysmectomy and mitral valve repair/replacement was excluded due to patient’s frailty. Percutaneous valve repair with MitraClip was considered, despite suboptimal anatomy, but it was postponed owing to hemodynamic instability. Further hemodynamic deterioration led to the patient’s exitus.

Discussion: Large apical aneurysms can reduce LV contractile efficiency and the combination with severe MR can cause further loss of anterograde cardiac output leading to a progressive and fatal deterioration. A better outcome can only be achieved through careful follow-up and early detection and management of disease complications.

ID: 27: A C HALLENGING C ASE OF P ERCUTANEOUS A TRIAL S EPTAL D EFECT C LOSURE

Carluccio Raffaele 1 , Riegler Lucia 1 , Forni Alberto 1 , Molinari Riccardo 2 , Parlati Antonio Luca Maria 3 , Quaranta Gaetano 1 , Pastore Fabio 1 , Zambrano Aniello 1 , Santoro Giuseppe 4 , D’Andrea Antonello 1

1 ”Umberto I” Hospital - Nocera Inferiore (SA) Italy, 2 ”Monaldi” Hospital - Naples Italy, 3 ”Federico II” University of Naples - Naples Italy, 4 Fondazione Toscana “Gabriele Monasterio” CNR, Institute of Clinical Physiology - Massa Italy,

ASDs account for 13% of all congenital heart diagnoses at birth but remain asymptomatic until adulthood, when atrial arrhythmias, paradoxical embolization or pulmonary hypertension can develop. A 46-year-old woman, without significant cardiovascular history, was admitted to Cardiology Department for dyspnea at exertion. TTE showed an ASD OS type with large left-to-right shunt (Qp/Qs >1.5) and right heart volume overload, dilated right chambers (RVD0: 50 mm) with good longitudinal ventricular function (TAPSE: 29 mm), moderate tricuspid regurgitation with PAPs estimated of 45 mmHg (TAPSE/PAPs: 0.64). TEE confirmed the presence of a 2 cm circular defect (2.01 cm at 61°, 1.98 cm at 91°, 1.92 cm at 98°), posterior and with a small IVC rim (PS rim: 0.571 cm at 0°, PI rim: 0.670 cm at 59°, IVC rim: 0.466 cm at 112°) but eligible to percutaneous closure. ASD was intra-procedure measured in 3 different TEE planes (0°, 45° and 90°) estimating the device size by adding 30% to the largest measurement (2.53 cm considering an ASD of 1.95 cm). With sizing balloon ASD balloon-stretched diameter resulted 2.25 cm at fluoroscopy and 2.56 cm with stop-flow CDUS technique. The procedure was therefore performed with the implantation of a 2.6 cm device, with good angiographic and echocardiographic final result. At 1-month follow-up TTE, device resulted in proper position without trivial leak, right chambers were less dilated (RVD0: 42 mm) with good longitudinal ventricular function (TAPSE: 32 mm), residual mild tricuspid regurgitation with PAPs estimated of 42 mmHg (TRV: 3.06 m/s, TAPSE/PAPs: 0.76).

ID: 28: E FFECT OF S EMAGLUTIDE ON G LOBAL L ONGITUDINAL S TRAIN AND G LOBAL M YOCARDIAL W ORK E FFICIENCY IN P ATIENTS W ITH U NCONTROLLED T YPE 2 D IABETES AND O BESITY

Cassano Velia 1 , Armentaro Giuseppe 1 , Crescibene Daniele 1 , Divino Marcello 1 , Pastura Carlo Alberto 1 , Condoleo Valentino 1 , Miceli Sofia 1 , Maio Raffaele 1 , Perticone Maria 1 , Arturi Franco 1 , Sesti Giorgio 2 , Sciacqua Angela 1

1 Magna Graecia University Hospital- Catanzaro Italy, 2 La Sapienza University- Roma, Italy

Introduction: Cardiovascular outcome trials (CVOTs) demonstrated that GLP1-RAs have effectively reduced CV risk in T2DM patients, so their use is recommended by guidelines

Aim: The objective of our work is to evaluate the effect of Semaglutide, in a cohort of uncontrolled diabetic patients, on oxidative stress, platelet activation and myocardial deformation and efficiency parameters, obtained by speckle tracking echocardiography (STE).

Materials and Methods: We enrolled 70 patients with T2DM and obesity. All clinical evaluation and laboratory tests were performed at baseline and after 6 months of treatment. Results: At follow-up, data showed significant improvement in heart rate, NT-ProBNP and metabolic parameters. Moreover, there was an improvement in creatinine and eGFR, a significant reduction in oxidative stress biomarkers such as 8-isoprostane (p<0.0001), Nox-2 (p<0.0001), and platelet activation such as sP-selectin (p<0.0001). We observed a significant improvement in left ventricular myocardial deformation parameters such as GLS (p<0.0001), GLS endo/epi (p<0.0001) and GWE (p<0.0001). The linear correlation analysis showed that ΔGLS endo-epi was inversely correlated with ΔHOMA (p=0.001), Δuric acid (p=0.012), ΔNox-2 (p=0.016), ΔSp-selectin (p=0.010); ΔGLS was inversely correlated with ΔHOMA (p=0.011), Δuric acid (p=0.025) and ΔSp-selectin (p<0.0001); ΔGWE was inversely correlated with ΔHOMA (p=0.011), Δuric acid (p=0.025) and ΔSp-selectin (p<0.0001). From stepwise multivariate linear regression model, ΔSp-selectin, Δuric acid and ΔHOMA justifying 27.8%, 4.4% and 5.6% of ΔGLS variation.

Conclusion: Our results demonstrated that 6 months treatment with Semaglutide, improved GLS, GLS endo-epi ratio and GWE, due to reduced levels of oxidative stress, platelet activation, probably acting on the microcirculation.

ID: 29: A N U NUSUAL C AUSE OF C OMPLETE A TRIOVENTRICULAR B LOCK

Caterino Anna Laura, Pantano Paola, Gasparetto Nicola, Squasi Paolo M., Menegon Vittoria, Cernetti Carlo

Ca’ Foncello Hospital - Treviso Italy

Caseous calcification of mitral annulus represents a rare form of intra-cardiac mass preferentially involving mitral posterior leaflet. Aortic cusp localization has been anecdotally reported, instead.

Incidental asymptomatic imaging finding is often described. Anyway, mass content could be drained into the blood stream with embolic risk or compress on coronary cusps and interventricular septum causing advanced atrioventricular block and impairment of valve functionality.

Despite lack of consensus on the optimal management, current evidence supports conservative strategy in case of certain imaging diagnosis and no valve dysfunction.

The case reported concerns 59-year-old women admitted to cardiac intensive care unit for syncope in underlying third grade atrioventricular block.

Cardiac transthoracic ultrasound showed calcified multiple masses involving posterior mitral annulus and right aortic cusp, respectively resulting in moderate mitral regurgitation and mildly increased aortic gradients. No infective signs were reported.

Infusion of isoprenaline was instituted with rapid achievement of hemodynamic stability.

Laboratory tests excluded septic sources with negative blood culture results.

Chest contrast-enhanced computed tomography confirmed calcified masses with low-density materials both on the mitral annulus and interventricular septum, features consistent with caseous calcification.

Transesophageal echocardiography was performed ascertaining abovementioned findings and showing at interventricular septum a calcified mass protruding into tricuspid valve and continuing into a sleeve-like thickening around aortic cusp. No perivalvular abscesses were detected.

After heart team discussion, patient received pacemaker implantation. A conservative management was pursued since lack of embolic localizations and absence of severe valvular impairment. Finally, a confident imaging diagnosis was easily achieved making cardiac surgery sampling unnecessary.

ID: 30: I NTEGRATING THE S ONOGRAPHER T ECHNICIAN INTO THE E CHOCARDIOGRAPHY L AB : A T RAINING P LAN FOR F UNDAMENTAL AND A DVANCED L EVELS

Cerone Elisa 1 , Trimarchi Giancarlo 2 , Mariani Massimiliano 1 , D’Agostino Andreina 1 , Benedetti Giovanni 1 , Marchi Federica 1 , Pizzino Fausto 1 , Paradossi Umberto 1 , Sorbo Simone 1 , Lilli Alessio 1 , Baratta Stefania 1 , Berti Sergio 1

1 Heart Hospital “G. Pasquinucci” - Fondazione Toscana “Gabriele Monasterio” - Massa Italy, 2 University Hospital “G. Martino” - Messina Italy

Background: The Sonographer Technician, specialized in Cardiovascular Physiopathology and Cardiovascular Perfusion Techniques, is essential in echocardiography, contributing to the entire diagnostic process. Rigorous and practical training, under expert guidance, prepares them for subspecialties like transesophageal and stress echocardiography, essential for advanced cardiology care.

Aim: Implementation of a theoretical-practical training program for beginner Sonographers in cardiothoracic echocardiography, with medical supervision and shared responsibility in examinations.

Methods: Two training plans have been developed, one for the acquisition of basic technical skills and one for the acquisition of advanced technical skills. The acquisition of skills and the integration of the sonographer into the work context have been planned through the use of a Gantt chart (Figure 1). The costs associated with the training and inclusion of sonographers in the echocardiography clinics have been evaluated.

Results: To qualify as independent at the basic level, a trainee sonographer (TS) must conduct 500 supervised and 500 independent exams, which are reviewed before reporting. The basic training duration is 6 months, while advanced training takes 12 months. Trainees mostly perform routine exams and receive digital educational materials. Material consumption is unaffected by trainee presence. The Health Company covers the distance learning platform costs, and trainer costs are approximately €25.82 per hour. Table I outlines the training course’s projected expenses.

Conclusions: The initiative to incorporate a Sonographer Technician into the Echocardiography Lab equips students with skills for proficient task execution and resource utilization during hands-on training, ensuring that educational aims, methodologies, and assessments align with professional competencies.

ID: 31: S UPRANORMAL V ALUES OF R ESTING L EFT V ENTRICULAR S YSTOLIC F UNCTION N EGATIVELY A FFECT S URVIVAL

Cerracchio Emma 1 , Ciampi Quirino 1 , Cortigiani Lauro 2 , Zagatina Angela 3 , Kasprzak Jaroslaw D. 4 , Wierzbowska-Drabik Karina 5 , Djordjevic-Dikic Ana 6 , Rigo Fausto 7 , D’Andrea Antonello 8 , Gaibazzi Nicola 9 , Merli Elisa 10 , Barbieri Andrea 11 , Carerj Scipione 12 , Pepi Mauro 13 , Picano Eugenio 14

1 Cardiology Division, Fatebenefratelli Hospital - Benevento Italy, 2 Cardiology Department, San Luca Hospital - Lucca Italy, 3 Cardiology Department, Cardiocenter Medika - St. Petersburg Russian Federation, 4 Chair of Cardiology, Bieganski Hospital Medical University - Lodz Poland, 5 Department of Internal Disease and Clinical Pharmacology, Bieganski Hospital Medical University - Lodz Poland, 6 Cardiology Clinic, University Center Serbia, Medical School, University of Belgrade - Belgrade Serbia, 7 Cardiology Department Villa Salus Foundation, IRCCS San Camillo Hospital - Venice Italy, 8 Cardiology Department, Umberto I° Hospital - Nocera Inferiore (SA) Italy, 9 Cardiology Department, Parma University Hospital - Parma Italy, 10 Department of Cardiology, Ospedale per gli Infermi - Faenza (RA),Italy, 11 Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena - Modena, Italy, 12 Cardiology Division, University Hospital Polyclinic G. Martino, University of Messina - Messina, Italy, 13 Centro Cardiologico Monzino, IRCCS, Milano - Milano, Italy, 14 CNR, Institute of Clinical Physiology - Pisa Italy

Background: Hyper-contractile phenotype of the left ventricle (LV) is generally considered prognostically benign.

Aim: assess the effects of resting LV function on survival.

Methods: We recruited 5,122 patients (age 65± 11.1 years, 2974 males, 58%) with chronic coronary syndromes in 14 accredited laboratories. LV force was estimated as systolic blood pressure by cuff sphygmomanometer/end-systolic volume (ESV). All-cause death was the only considered outcome end-point.

Results: Ejection fraction (EF) was 59±11% (normal reference sextile= 58.0-59.9%). Force was 4.51±2.11 mmHg/ml (normal reference sextile= 3.50-4.27 mmHg/ml). The correlation between EF and force was linear (r=0.585, p67%) and significantly higher in the lowest sextile (EF< 52%, Figure, left panel). A U-shaped curve was found with force, with mortality values being lowest in the middle sextile and significantly higher in the lowest sextile (6.36 mmHg/ml, Figure, right panel). At multivariable analysis, both the highest sextile of force (HR 1.84, 95%, CI: 1.12-3.03 p=0.015), and the lowest sextile of force (HR 1.77, 95%, CI: 1.08-2.90 p=0.024) were associated with decreased survival.

Conclusion: Sub-normal values of resting ejection fraction and super- and sub-normal values of the force are associated with worse survival. This U-shaped curve of mortality is detectable only with the force, a load independent index of LV contractility: too much of a good thing such as LV contractility can be dangerous on the long-run

ID: 32: A C OMPLICATED C ASE OF A P ROSTHETIC V ALVE E NDOCARDITIS : T HE I MPORTANT R OLE OF A DVANCED I MAGING

Cerracchio Emma 1 , Santo Felicita 2 , Campagnano Ettore 1 , Bologna Ada 1 , Caccavale Francesco 2 , Cusano Maria 2 , Villari Bruno 1 , Ciampi Quirino 1

1 Cardiology Division, Fatebenefratelli Hospital - Benevento Italy, 2 Anesthesia Division, Fatebenefratelli Hospital - Benevento Italy

Background: Prosthetic valve endocarditis (PVE) is associated with high morbidity and mortality. Three-dimensional transoesophageal echocardiography (3D-TOE) is the key imaging technique to diagnose of PVE and its complications.

Case summary:A 52-year-old man presented to our hospital with fever for about two weeks, elevated C-reactive protein and procalcitonin, with blood and urine cultures both negative. Ten years ago he underwent aortic valve replacement with mechanical prosthesis (AVR), and a year later a PVE caused by Staphylococcus Haemolyticus complicated by perivalvular abscess with fistula to the right atrium. A redo mechanical AVR and a tricuspid annuloplasty were performed. A 3D-TOE showed a vegetation attached to the aortic prosthesis without valve dysfunction (Figure 1A). A diagnosis of PVE was made and an empirical antibiotic therapy started. After 16 days of hospital stay, the patient presented a sudden septic shock, requiring inotropic support, tracheal intubation and continuous renal replacement therapy using oXiris filter. The new blood cultures isolated Klebsiella Pneumoniae, and targeted therapy was administered. Serial blood cultures subsequently led to isolation Enterococcus Faecium and Candida. An antifungal therapy and a combination of ampicillin and daptomycin were adopted. After eight weeks of prolonged antimicrobial treatment, a complete eradication of the infection was reached. A 3D-TOE showed a complete resolution of aortic prosthesis vegetation (Figure 1B).

Conclusion: In PVE, 3D-TOE is a very useful tool providing additional information and multidisciplinary approach plays a crucial role for rapid treatment of sudden and unexpected complications that may occur in such condition.

ID: 33: R EDUCTION IN E JECTION AND P RE -E JECTION T IME ARE P REDICTIVE OF M ORTALITY IN H EART A MYLOIDOSIS

Cicco Sebastiano, De Fazio Giuditta, Marozzi Marialuisa Sveva, Corvasce Francesco, Melaccio Assunta, Desantis Vanessa, Solimando Antonio Giovanni, Ria Roberto, Vacca Angelo

Unit of Internal Medicine “Guido Baccelli” and Unit of Hypertension “A. M. Pirrelli”, Department of Precision and Regenerative Medicine and Ionian Area- (DiMePRe-J), University of Bari “Aldo Moro”, AUOC Policlinico di Bari - Bari Italy

Introduction: Cardiac involvement is the leading cause of death in Amyloidosis. Echocardiography is the most used imaging technique. Heart stiffness is the main issue leading heart dysfunction. However, few data are available on the possible connection between heart and vessels alterations. Aim is to evaluate heart stiffness using Ventricular–arterial coupling (VAC) in Amyloidosis.

Methods: We evaluate 58 patients (22F/36M, aged 67.14± 12.49) at diagnosis. They were 42 AL and 16 ATTR patients. Among all amyloidosis, 18 died with a mean survival of 12 months [IQR 1-24 months].

Results: At baseline, VAC was increased in dead patients (p=0.09) but was ineffective to predict risk of mortality (AUC 0.54, p=0.57). Ejection and pre-Ejection time were both increased in alive (p<0.007). Moreover, they were effective in prediction of death (Ejection time AUC 0.81, cut-off 239msec, Sensitivity 61.54%,specificity 88.24%; pre-Ejection time AUC 0.75, cut-off 82msec, Sensitivity 84.62%,specificity 58.82%). Ejection time, but not pre-ejection, relates directly to GLS (r=0.68), while VAC (r=-0.44) inversely does. No difference in studied parameters were found comparing AL to ATTR.

Conclusion: Amyloidosis induces an increase in heart stiffness and a reduction of heart contractility. We demonstrated that this mechanism effects the capacity to pump blood in vessels due the reduction in time for loading during systole. It is also able to a prediction of mortality with a good sensitivity and specificity, regardless of the type of amyloidosis evaluated.

ID: 34: TAPSE/PAP S R ATIO R ELATES TO L EFT H EART D YSFUNCTION AND C LINICAL W ORSENING IN C ARDIAC A MYLOIDOSIS

Cicco Sebastiano, Marozzi Marialuisa Sveva, De Fazio Giuditta, Corvasce Francesco, Solimando Antonio Giovanni, Desantis Vanessa, Ria Roberto, Vacca Angelo

Unit of Internal Medicine “Guido Baccelli” and Unit of Hypertension “A. M. Pirrelli”, Department of Precision and Regenerative Medicine and Ionian Area- (DiMePRe-J), University of Bari “Aldo Moro”, AUOC Policlinico di Bari - Bari Italy

Background: Cardiac Amyloidosis (CA) is the main determinant in clinical worsening and death. Parameters useful to evaluate clinical evolution are still in debate. Useful tools may help to stratify this disease in patients in particular at diagnosis.

Aim is to evaluate TAPSE/PAPs ratio as a possible marker for clinical worsening and its relationship with left heart alterations.

Methods: We evaluate 58 patients (22F/36M, aged 67.14±12.49) at diagnosis. There were 42 AL and 16 ATTR patients. Among all amyloidosis, 18 died with a mean survival of 12 months [IQR 1-24 months].

Results: PAPs was significantly increased in died patients (alive 30.38±12.23 vs died 50.14±27.84, p=0.0005) as well as TAPSE was reduced (alive 20.05±8.08 vs died 16.13±7.01, p=0.09) despite it do not reach statistical significance. TAPSE/PAPs ratio was significantly reduced in died (alive 0.85±0.64 vs died 0.43±0.38, p=0.02). TAPSE and TAPSE/PAPs directly correlated to mean GLS-LV evaluation (r=0.82 and 0.70, respectively) while PAPs inversely did (r=-0.71).

Despite a good AUC, TAPSE was ineffective to predict risk of mortality (AUC 0.64, p=0.11). On the contrary, PAPs AUC was 0.72 and using 38 mmHg as cut-off, it has a good specificity (71.4%) and sensitivity (66.67%). TAPSE/PAPs AUC was 0.71, but using cut-off 0.42 mm/mmHg, there was a better sensitivity (Sensitivity 71.4%,specificity 71.4%).

Conclusion: Amyloidosis induces an increase in heart stiffness and a reduction of heart contractility. We demonstrated that this mechanism also affects the right ventricle and its coupling with the pulmonary artery, relating also to LV contractility loss. It is also able to predict mortality with good sensitivity/specificity.

ID: 35: M ULTIMODAL A PPROACH TO A D IFFERENTIAL D IAGNOSIS OF P ULMONARY H YPERTENSION A SSOCIATED WITH C ONGENITAL H EART D ISEASE

Cipollone Enea, De Michele Lucrezia, Civino Fabio, Fratini Nicolò, De Tommasi Elisabetta, D’Agostino Carlo

University Hospital GIOVANNI XXIII - Bari Italy

A 23 years old female patient was admitted to our cardiology lab for dyspnea. She suffered from recurrent bronchitis in childhood and asthma during adolescence. However, the spirometry was always normal.

In 2022 she accused worsening of dyspnea and lower limbs edema.

In April 2023 her first EKG and echocardiography showed a right bundle branch block with signs of right heart overload, a distortion of the interventricular septum (eccentricity index 1.9), wide Atrial septal defect (ASD) with left-right shunt and a right chambers enlargement.

The right cardiac catheterization confirmed precapillary pulmonary hypertension (PAH: mPAP:65 mmHg; PVR 8.2 wu; Qp/Qs: 1.3), associated with small/coincidental defects (type 3). The patient started therapy with Macitentan 10 mg/day, Tadalafil 40 mg/day, Selexipag 1200 mcg /day.

Significant amelioration, was observed, in the symptomatology and after six months proBNP levels went from 1987pg/ml to 496 pg/ml. A 6mwt showed an increase of the distance performed by the patient (from 477 m to 583 m). A new catheterization in June 2023 showed lower values of mPAP 49 mmHg; PVR 4.4 wu and an increase of Qp/Qs: 2.8.

The absence at DNA analysis of pathogenetic mutations for PAH allowed to edit the diagnosis towards PAH associated with prevalent systemic-to-pulmonary shunts (type3), eligible for a fenestrated ASD closure. The integrated clinical, genetic, instrumental management give a therapeutic opportunity otherwise precluded.

ID: 36: A DJUSTING R IGHT V ENTRICULAR E JECTION F RACTION BY THE R EGURGITANT V OLUME IN P ATIENTS WITH S ECONDARY T RICUSPID R EGURGITATION

Clement Alexandra 1 , Tomaselli Michele 1 , Badano Luigi Paolo 1 , Hadareanu Diana 2 , Radu Noela 3 , Penso Marco 1 , Fisicaro Samantha 1 , Caravita Sergio 1 , Baratto Claudia 1 , Delcea Caterina 1 , Gavazonni Mara 1 , Cascella Andrea 1 , Benzoni Giorgia 1 , Muraru Denisa 1

1 Istituto Auxologico Italiano, IRCCS, Ospedale San Luca - Milan Italy, 2 Clinical Emergency County Hospital of Craiova - Craiova Romania, 3 Emergency Institute of Cardiovascular Diseases “Prof. Dr. C. C. Iliescu” - Bucharest Romania

INTRODUCTION: In the presence of secondary tricuspid regurgitation (STR) the chronic volume overload determined by the regurgitant volume (RegVol) may lead to an overestimation of right ventricular (RV) systolic function assessed by conventional echocardiographic parameters.

AIM: To overcome this, we sought to assess whether, in patients with STR, effective RV ejection fraction (eRVEF) is better associated with outcome than tricuspid annular plane systolic excursion (TAPSE), RVEF, fractional area change (FAC) and RV free-wall strain (RV-FWS).

METHODS: We included consecutive patients with STR (ranging from mild to severe) undergoing complete echocardiography. eRVEF was calculated as forward RV stroke volume (RVSV)/RV end-diastolic volume, where forward RVSV was obtained by subtracting the STR RegVol from the total RVSV. The endpoint was a composite of heart failure hospitalization and all-cause death.

RESULTS: 513 patients (mean age 75±13 years, 53% female) were included in the final cohort. After a mean follow-up of 18±15 months, 195 patients (38%) reached the composite endpoint. At receiver operating characteristic analysis, eRVEF (AUC 0.72, 95%CI 0.68-0.77) showed a stronger association with outcomes than RVEF (AUC 0.65, 95%CI 0.59-0.70, p=0.006), TAPSE (AUC 0.64, 95%CI 0.59-0.69, p= 0.01), RV-FWS (AUC 0.63, 95%CI 0.58-0.68, p= 0.003), and FAC (AUC 0.55, 95%CI 0.50-0.60, p<0.001). The spline curve of mortality risk showed that the value of eRVEF, where the excess events rate started to grow, was at the threshold of 20%.

CONCLUSIONS: In patients with STR, eRVEF was more closely associated with all-cause mortality and heart failure hospitalizations than conventional echocardiographic indices of RV function.

ID: 37: H YPOGLICEMIA S ENDS Y OU TO P SICHIATRY

Cola Maria

CAZZAVILLAN Hospital - Arzignano (VI) Italy

Premises:IGF2 plays a foindamental role in hypoglycemia, especially with regard to its production by neoplastic cells. In Doege-Potter syndrome, paraneoplastic condition involving ectopic secretion of IGF2 by solitary fibrous tumor cells of the lung, hypoglycemia is further aggravated by glucose consumption by the neoplasm.

Description of case report:Caucasian woman admitted to psychiatric ward for relapse of major depressive disorder, inappetence and asthenia. During hospitalization finding of persistent marked hypoglycemia, poorly responsive to corrections with glucose solution, with insulin, C-peptide and cortisolemia levels in range. To investigate the etiology of the hypoglycemia, she underwent CT chest/abdomen with evidence of expansive lesion of the entire right thoracic cavity in the absence of lymph node repeats. CT-guided biopsy was promptly performed, documenting the presence of soft tissue, compatible with lung solitary fibrous tumor. We hypothesized that the repeated hypoglycemic seizures could be attributed to ectopic secretion of paraneoplastic IGF2 as well as increased glycid consumption by the cancer.

Conclusions:In the absence of effective correction of hypoglycemia, the patient underwent thoracotomy surgery and excision of the neoplasm, subsequently the patient’s glycemic values improved after a few hours and remained within normal ranges throughout the subsequent follow-up. Thus suggesting that the only treatment effective in resolving symptomatic hypoglycemia in the patient with Doege Potter’s sdr is surgical removal of the tumor mass.

ID: 38: M YOCARDIAL W ORK IN I DENTIFYING C ANCER T HERAPY –R ELATED C ARDIOTOXICITY

Contaldi Carla 1 , Catapano Dario 1 , Falco Luigi 1 , Bombace Marco 1 , Di Sivo Domenico 1 , Verrengia Marina 1 , Masarone Daniele 1 , Montesarchio Vincenzo 1 , Pacileo Giuseppe 1 , Calabrò Paolo 2 , Bonow Robert O 3

1 AORN DEI COLLI- MONALDI HOSPITAL - Naples Italy, 2 Sant’Anna e San Sebastiano’ Hospital, University of Campania “Luigi Vanvitelli” - Naples Italy, 3 Northwestern University Feinberg School of Medicine - Chicago, USA

Introduction:The current role of global longitudinal strain (GLS) in diagnosing subclinical cardiac damage caused by anticancer drugs is consilated.

Aim: Given the GLS dependence on hemodynamic loading conditions, our study aimed to explore the effectiveness of myocardial work indices (MWI) derived from pressure–strain analysis for early cardiotoxicity diagnosis.

Materials and Methods: We included 40 consecutive patients (mean age: 54 ± 9 years; 91% female) undergoing anthracycline ± trastuzumab ± paclitaxel chemotherapy. Patients underwent evaluation by 2D/3D echocardiography, measuring left ventricular ejection fraction (LVEF), GLS and MWI [global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE)] at baseline and after one, three and six months post chemotherapy initiation.

Results:20% of patients developed subclinical cardiac dysfunction, defined as a relative decrease ≥15% in GLS from baseline, without significant reduction in LVEF. In all patients after starting chemotherapy, GWE decreased and GWW increased significantly during follow-up (p value <0.05). Patients exhibiting LV subclinical dysfunction displayed lower GWE at baseline and during follow-up, before developing decrease ≥15% in GLS from baseline (p value <0.05). At the time of developing LV subclinical dysfunction, patients demonstrated a significant reduction in GWE and GCW compared to baseline values (p value <0.05).

Conclusion: MWI change significately during chemotherapy and alter early. GWE appeared to reduce early in patients who develop cancer therapy –related subclinical cardiotoxicity. More patients might be helpful in identifying a possible cutoff of MWI that predicts earlier than GLS subclinical cardiotoxicity.

ID: 39: S EVERE S YMPTOMATIC M ITRAL R EGURGITATION A FTER A NNULOPLASTY F AILURE : S UCCESSFUL T RANSCATHETER E DGE - TO -E DGE R EPAIR

Coradello Elena, D’Onghia Giovanni, Saraò Emanuele, Tedoldi Francesca, Videsott Lodovica, Saltori Michela, Fanti Diego, Dallago Michele, Zilio Filippo, Bonmassari Roberto

Santa Chiara Hospital- Trento Italy

Surgical mitral valve repair is the most common, feasible and preferred procedure to treat primary and secondary mitral regurgitation (MR). However, 30% of patients suffer from residue severe regurgitation 10 years after surgical intervention, resulting in a considerable number of Redo procedures. In elderly and high-risk patients with major comorbidities medical treatment is the only and often insufficient option for symptoms’ relief. Percutaneous Transcatheter Edge to Edge Repair technique (TEER) with MitraClip system is emerging as a valid alternative to successfully treat severe MR after surgical valvuloplasty failure.

In failed annuloplasty, with small residual valve area, the main risk is the creation of a gradient across the mitral valve. Transesophageal echocardiography (TEE) is essential in diagnosis, planning, intraprocedural device placement, and follow up.

We present two cases of severe MR after surgical annuloplasty with ring placement, successfully treated with TEER:

1) a 79-year-old man with exertional dyspnea and orthopnea in the setting of previous surgical mitral Annuloplasty (2003) with a 32-mm Carpentier Ring. At TEE severe MR due to P2 prolapse and mean diastolic gradient 1.8 mmHg.

2) a 83 year-old woman with dyspnea (NYHA III) and severe MR after previous Annuloplasty with a 34-mm Edwards Ring and placement of Goretex artificial Chordae (2016). At TEE prolapse of P2 and P3 leaflets, mean diastolic gradient 2.17 mmHg, valvular area 3.5 cm2.

Both patients underwent transfemoral and transseptal implantation of one MitraClip device under TEE guidance with successful reduction of MR to mild level and symptoms relief, without significant postprocedural stenosis.

ID: 40: A N I NDEPENDENT M ARKER OF M YOCARDIAL F UNCTION IN A THLETE ’ S H EART : R OLE OF V ORTEX A NALYSIS

Corsi Marco, Stefani Laura

Careggi Univeristy Hospital- Firenze Italy

Introduction: Athlete’s heart has been extensively studied, particularly regarding global myocardial remodeling in the presence of normal systo-diastolic function and supernormal deformation reserve. It is commonly classified as eccentric and concentric remodeling based on specific morphological characteristics; however, the recent interest in echocardiography lies in the dynamicity of the vorticity flow inside the LV chamber, primarily correlated with diastolic function.

Aim: This study aims to verify the potential additional contribution of vortex analysis in the athlete’s heart.

Materials and Methods: A group of 24 highly trained athletes was studied using 2D standard and deformation echo parameters, along with vortex examination. A dedicated software (Hyperdoppler-ESAOTE) was used to define geometrical and dynamic vortex parameters (area, length, depth, Energy Dissipation, Vorticity Fluctuation, Kinetic Energy fluctuation). The data obtained were compared with a group of 26 active non-athletes and a group of 23 normal subjects.

Results: BMI differed among the three groups, with higher values in normal subjects (normal=27.2±5.7; active=22.9±2.6; triathletes=22.1±1.8; p=0.01). iLV mass was significantly higher in triathletes (triathletes=96.9±14.9; active=87.6±15; normal=79.5±15.7; p=0.003) as twist (triathletes=12.3±3.9; active=9.8±3.7; normal=8.1±3.1; p=0.001), expressing a supernormal apical reserve. Diastolic function was normal in both groups. In the presence of normal geometrical vortex data, vortex energetic parameters were significantly higher in triathletes (energy dissipation= 1.10±0.41, p<0.001; vorticity fluctuation= 0.89±0.04, p<0.001; kinetic energy fluctuation= 1.01±0.08, p<0.001).

Conclusions: Vortex analysis complements the morphological remodeling of athlete's heart. It can contribute to defining the effects of training intensity and energy consumption. Future research will focus on potential modifications in different sports.

ID: 41: A N A TYPICAL C ASE OF S EVERE T RICUSPID R EGURGITATION

Cortese Francesca 1 , Costantino Marco Fabio 2 , Magnante Antonio 1 , D’Addeo Gianpaolo 2 , Stolfi Luisiana 2

1 Cardiology Unit - “Madonna delle Grazie” Hospital - Matera Italy, 2 Cardiovascular Department - “San Carlo” Hospital - Potenza Italy

62-year-old patient with an unremarkable medical history comes to our attention during a normal routine check-up. Patient presents with exertional dyspnea, sense of fatigue, weakness, asthenia, turgor of the jugular veins, peripheral edema. During transthoracic echocardiography, there was evidence of dilatation of the right heart, no anomalies of the left heart, normal continence of the aortic and mitral valves, and eccentric regurgitation towards the interatrial septum (IAS) of the tricuspid valve. To support the diagnosis of severe tricuspid regurgitation, the patient underwent transesophageal echocardiography.

The examination highlights: atrial appendage free from thrombotic formations, right ventricle dilated but normokinetic (Fraction of variation of areas FAC > 0,40), right atrium dilated (volume > 20 cm2), absence of pericardial effusion.

There is also mild left ventricular diastolic dysfunction, left atrium volume < 34 ml/m2, maximum speed of tricuspid regurgitation < 2.8 m/s.

The mitral valve has normal geometry and it is continent (annulus < 40 mm), the subvalvular apparatus is preserved.

The aortic valve is continent, the aortic root is within the limits (30 mm), without evidence of aneurysms, Sino-Tubular Junction (STJ) 21 mm, STJ/annulus: 1, tubular tract 30 mm.

The tricuspid valve presents eccentric regurgitation directed towards the IAS due to prolapse of the posterior leaflet, grade 4+/4 insufficiency, annulus 50 mm, it shows no signs of fissuring, there are no electrocatheters, no Ebstein anomaly is detected. Jet originate between the posterior and septal leaflets.

The diagnosis is non-congenital severe secondary tricuspid regurgitation and the patient is directed towards percutaneous repair.

ID: 42: LCAT D EFICIENCY L EADS TO S EVERE M YOCARDIAL H YPERTROPHY AND M ITRAL S TENOSIS

Corvasce Francesco, Fiorentino Marco, Marozzi Marialuisa Sveva, Ria Roberto, Gesualdo Loreto, Vacca Angelo, Cicco Sebastiano

Unit of Internal Medicine “Guido Baccelli” and Unit of Hypertension “A. M. Pirrelli”, Department of Precision and Regenerative Medicine and Ionian Area- (DiMePRe-J), University of Bari “Aldo Moro”, AUOC Policlinico di Bari - Bari Italy

Introduction: LCAT (lecithin-cholesterol acyltransferase) deficiency is a rare genetic disorder characterized by a deficiency or malfunction of the enzyme involved in cholesterol esterification. The impaired or absent activity of this enzyme leads to the accumulation of free cholesterol and phospholipids in blood, due to undosable HDL and ApoA.

Case report: A 54-year-old patient with chronic kidney disease, history of two kidney transplants, familiar deficiency of LCAT, corneal opacities, atrial fibrillation and hypertrophic cardiomyopathy was admitted to our hospital. The patient underwent a series of tests, particularly focusing on his renal and cardiovascular conditions, such as blood tests, including complete blood count, metabolic panel, lipid profile, proteinuria levels (>1g/die), immunologic tests that detected the presence of antibodies anti-DSA (DQ7, DQ8, and DQ9). Moreover, eye examination revealed corneal opacities. HDL was indosable and ApoA was strongly under laboratory reference value as normal. Echocardiography showed severe concentric hypertrophy of the left ventricle, suspected for infiltrative cardiomyopathy, post-capillary pulmonary hypertension. Right heart catheterization (RHC) confirmed the value. The patient underwent Cardiac Magnetic Resonance Imaging (MRI) that confirmed the diagnosis of hypertrophic cardiomyopathy with obstructive features. Extensive calcification was described including posterior mitral leaflet down to papillary muscle with severe transmitral gradient. Furthermore, dynamic severe subaortic stenosis was foudn.

Myocardial byopsy showed focal sarcoplasmic vacuolizations and mild increase in myocellular size but no sign of infiltrative material. Renal biopsy described glomerular sclerosis.

Conclusion:Lcat patients may have a complex medical history with multi-organ involvement. Cardiovascular and Kidney complications are challenging management and they need a multidisciplinary care.

ID: 43: C ARDIAC R EMODELING AND O UTCOME A FTER S URGICAL I NTERVENTION FOR A TRIAL F UNCTIONAL M ITRAL R EGURGITATION

Costantino Marco Fabio 1 , Stolfi Luisiana 1 , Cortese Francesca 2 , D’Addeo Gianpaolo 1 , Gerardi Donato 1 , Polizzi Vincenzo 3 , Parato Maurizio 4 , De Luca Leonardo 5 , Luzi Giampaolo 1

1 Cardiovascular Department - “San Carlo” Hospital - Potenza Italy, 2 Cardiology Unit - “Madonna delle Grazie” Hospital - Matera Italy, 3 Cardiology Unit - “Villa Sofia Cervello” Hospital - Palermo Italy, 4 Cardiology Unit - “Madonna del Soccorso” Hospital - San Benedetto del Tronto (AP) Italy, 5 Cardiology Unit - “San Matteo” General Hospital - Pavia Italy

The atrial functional mitral regurgitation refers to a newly recognized disease entity in which mitral regurgitation occurs secondary to left atrial disease, without left ventricular dilatation and intrinsic mitral valve disease.

To better define this new entity and understand the benefits of surgery in patients with severe regurgitation, we conducted an observational analysis on subjects with atrial functional mitral regurgitation who underwent surgical treatment between 2020 and 2022.

Twenty-eight subjects (11 males, 39.3%), mean age ± standard deviation 72.7 ± 8.4 years were evaluated at the Cardiosurgery Center of “San Carlo” Hospital in Potenza.

Subjects were assessed at enrollment and at one-year follow-up. We evaluated clinical and echocardiographic parameters.

The demographic and clinical characteristics are shown in Table 1.

Table 2 shows NYHA class and echocardiographic parameters of patients at baseline and follow-up.

Results highlight a significant improvement of the quality of life of patients after mitral repair surgery inversely related to NYHA class.

As regards echocardiographic parameters, results showed a reduction of left ventricular end diastolic volume [110 ml (95-148 ml)] vs. (55 ml (48-59 ml), z: -0,7, p<0.001] of left atrial volume [83.5 ml (63.2-96.5 ml) vs. 63 ml (45.5-78.7 ml), z: -3.2, p: <0.01] and of pulmonary artery systolic pressure [35 mmHg (30-43) vs. 25 (22-32.7), z: -3.9, p< 0.001]. Non-significant differences were found as regards values of left ventricular end diastolic diameter, interventricular septum, posterior wall thickness and ejection fraction, table 3. The results were independent from the presence or absence of atrial fibrillation.

ID: 44: E CHOCARDIOGRAPHIC P REDICTORS OF R ESIDUAL MR ≥ 2+ AND C LINICAL O UTCOMES O NE Y EAR A FTER M ITRACLIP I MPLANTATION

Costantino Marco Fabio 1 , Stolfi Luisiana 1 , D’Addeo Gianpaolo 1 , Cortese Francesca 2

1 Cardiovascular Department - “San Carlo” Hospital - Potenza Italy, 2 Cardiology Unit - “Madonna delle Grazie” Hospital - Matera Italy

Introduction: The extent of residual mitral regurgitation (MR) (1+ vs ≥ 2+) has a notable impact on the outcome of MitraClip (MC) repair of significant functional MR.

Aim: The aim of the study was to analyze the one-year results in our series of patients with functional MR treated with MC.

Materials and methods: Between 2020 and 2022, 58 consecutive patients underwent percutaneous mitral valve repair with MC technology. All patients had moderate-severe MR on a functional basis.

Results: At one year 10 patients died (mortality 17.2%). The remaining 48 patients had complete follow-up for up to one year and were included in the statistical analysis:

1. The incidence of new hospitalizations was 8.3%;

2. The incidence of grade 1+ and ≥ 2+ MR was 54.1% (26) and 45.9% (22), respectively;

3. In patients with MR ≥ 2+ the clinical and instrumental outcomes were worse than in patients with MR 1+;

4. Posterior leaflet height and extent of immediate postprocedural MR were independent predictors of MR ≥ 2+.

In multivariable analysis, preprocedural posterior leaflet height (PLH) (OR 0.16, p = 0.02) and immediate postprocedural MR degree (IPOMR) (OR 12.4, p = 0.03) were predictive; preprocedural Ejection Fraction (EF) was almost significant (OR 0.87, p = 0.08) (Figure 1).

Conclusions: Percutaneous repair with MC of moderate/severe functional MR has favorable one-year outcomes in terms of mortality and rehospitalizations.

The best results are obtained in cases with residual MR 1+. Echocardiographic parameters are independent predictors of residual MR ≥ 2+.

ID: 45: VAL VE – IN –V ALVE T RANSCATHETER A ORTIC V ALVE R EPLACEMENT : E L D ORADO OR E XIT –S TRATEGY ?

Costantino Marco Fabio 1 , Stolfi Luisiana 1 , D’Addeo Gianpaolo 1 , Pietrafesa Davide 2 , Cortese Francesca 3 , Veglia Giusy 3 , Morea Costanza 3 , Tucci Maria Luigia 4 , Magnante Antonio 3

1 Cardiovascular Department - “San Carlo” Hospital - Potenza Italy, 2 Department of Biology - University of Rome “Tor Vergata” - Rome Italy, 3 Cardiology Unit - “Madonna delle Grazie” Hospital - Matera Italy, 4 Cardiology Department “Ospedali Riuniti” - University Hospital - Foggia Italy

Introduction: The Valve–in–Valve Transcatheter Aortic Valve Replacement (ViV–TAVR) procedure is a valid alternative treatment to surgery. Aim: This study evaluates, from a clinical and echocardiographic point of view, the immediate and one–year postprocedural outcome of the ViV–TAVR in case of dysfunction of a biological prosthesis at the aortic site. Materials and methods: Between 2021 and 2022, 17 consecutive patients with stenosis (64.71%) or aortic valve insufficiency (35.29%) underwent ViV–TAVR procedure and we evaluated them echocardiographically for 12 months. Results: The implanted valves (10 of 20 mm, 5 of 23 mm, 1 of 26 mm and one of 29 mm in diameter) were Sapien XT type in 4 patients and Sapien 3 in 13 cases (of which 3 Ultra). We reported the Kaplan–Meier curve referring to one–year mortality in the presence/absence of coronary heart disease. Degeneration of bioprostheses in patients aged ≤ 70 years at the time of implantation occurred on average in 10.89±2.98 years, in patients aged >70 years in 7.88±2.23 years after implantation intervention. For all patients we calculated the mean change in end–diastolic volume (EDV) between the value at baseline, immediately after ViV–TAVR and at one–year follow–up. On patients who had bioprosthesis dysfunction with stenosis, we calculated the change in the mean transvalvular gradient (Gm) and Doppler Velocity Index (DVi) at baseline, immediately after ViV–TAVR and at follow–up. Conclusions: The analyzed echocardiographic parameters were improved after ViV–TAVR both in the immediate post–procedural and in the follow–up period.

ID: 46: U TILITY OF CCTA IN E VALUATING CAV A FTER H EART T RANSPLANTATION

Cozza Elena, Pergola Valeria, Mattesi Giulia, Pradegan Nicola, Tessari Chiara, Motta Raffaella, Gerosa Gino, De Conti Giorgio, Iliceto Sabino

Cardiology Unit, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua - Padua Italy

Introduction: Coronary Computed Tomography Angiography (CCTA) represents a promising non-invasive alternative for evaluating Coronary Allograft Vasculopathy (CAV) in patients undergoing orthotopic heart transplantation (OHT), offering clinical and economic advantages over traditional invasive techniques.

Aim: 1) Assess the non-inferiority of CCTA compared to invasive coronary angiography (ICA); 2) Analyze the benefits of a CCTA-guided strategy versus ICA in terms of costs, hospitalization time (HT), radiation dose (RD), fluoroscopy time (FT), and contrast medium administered (CM).

Materials and Methods: From March 2021 to February 2023, we performed CAV monitoring using CCTA alone in approximately 50% of OHT patients. Therefore, we retrospectively analyzed data from 260 heart transplant patients; 115 underwent CCTA, and 145 underwent ICA. Preferably, patients who had undergone their first post-OHT angiographic control with ISHLT-CAV < 2 were subjected to CCTA. From these two patient groups, we compared RD, CM usage, FT, HT, admission costs, and diagnostic accuracy.

Results: None of the CCTAs were considered uninterpretable and visualization of distal segments and main branches of the epicardial arteries was not significantly different. Diagnostic accuracy was similar between CCTA and ICA (95% versus 100%; p=0.169). CCTA and ICA did not show significant differences in vascular complications (0 versus 3; p 0.116). Compared to ICA, CCTA required less HT, had lower costs, lower CM usage, significantly shorter FT and emitted lower levels of RD.

Conclusions: CCTA has proven to be an effective and advantageous method for the follow-up of OHT patients in evaluating CAV.

ID: 47: R IGHT V ENTRICULAR D YSFUNCTION IN P ATIENTS WITH S EVERE L OW -F LOW -L OW -G RADIENT A ORTIC S TENOSIS U NDERGOING TAVR

Cristiano Mario 1 , Bellino Michele 1 , Lionetti Noemi 1 , Migliaino Serena 1 , Caliendo Giuseppe 1 , Nigro Emanuele 1 , Giordano Arturo 2 , Galasso Gennaro1 1 , Citro Rodolfo 1

1 San Giovanni di Dio e Ruggi d’Aragona University Hospital- Salerno Italy, 2 Pineta Grande Hospital- Castel Volturno (CE) Italy

Aims: to determine the prevalence and the prognostic implication of right ventricular (RV) dysfunction on one-year mortality in patients with low-flow, low-gradient aortic stenosis (LFLG-AS) undergoing transcatheter aortic valve replacement (TAVR).

Methods: all consecutive patients with severe LFLG-AS undergoing TAVR from 2018 to 2023 at two Italian high-volume centers (Salerno and Castel Volturno) were enrolled. Study population was divided into two groups according to the presence or not of RV dysfunction defined by tricuspid annular plane excursion (TAPSE) value TAPSE <17 mm. The primary outcome of this study was one-year mortality.

Results: The study included 392 patients (mean 81±10 years, 52.3% females); of them, 97 (24.7%) patients showed RV dysfunction at hospital admission.

NYHA class at admission (p=0.001) and the EuroSCORE II (p<0.001) were higher among patients with RV dysfunction compared with those without. Moreover, patients with RV dysfunction had lower left ventricular ejection fraction (p<0.001) and a higher prevalence of classical LFLG-AS (p<0.001).

At one-year, death was reported in 51 (13.0%) patients, cardiovascular death in 43 (11.0%) patients. The propensity score-weighted adjusted regression analysis showed a significantly higher risk for the primary outcome (adjusted HR: 3.11; 95% CI: 1.58-6.13; p=0.001) and for cardiovascular death (adjusted HR: 3.26; 95% CI: 1.58-6.72; p=0.001) in patients with RV dysfunction compared to those without. These results were also consistent between patients with classical and paradoxical LFLG-AS, with no significant interaction between subgroups.

Conclusions: RV dysfunction is a common echocardiographic finding in LFLG-AS patients undergoing TAVR and is associated with a poorer one-year outcome.

ID: 48: A C ASE OF U NUSUAL A SCENDING A ORTA A NEURYSM – S YSTEMIC D ISEASES IN THE D IFFERENTIAL D IAGNOSIS

Croci Riccardo, Boffi Lucia, Trocino Giuseppe, Soffici Federica, Lofrano Luca, Bianchi Janetti Maria, Cesana Francesca, Pozzi Maria Rosa

IRCCS San Gerardo dei Tintori Hospital- Monza Italy

A 29-year-old patient with suspected lymphadenopathy underwent a CT scan of the chest, abdomen and neck which found pathological supra-, sub clavicular and mediastinal lymph nodes and an ascending aortic aneurysm with proximal dissection. Ectasia of the arch (42mm) and of the suprarenal aorta (35mm) was also reported, while the origin of the left renal artery was poorly recognizable, significantly stenotic, with suspected intimal hyperplasia conditioning an irregular wall thickening (Fig. 1A). The patient underwent replacement of the ascending aorta with a prosthetic tube.

Given the aforementioned findings, compatible with vasculitis, the patient was evaluated by an immunorheumatologist specialist who hypothesized Takayasu arteritis or, in the differential diagnosis, Systemic Lupus Erythematosus (SLE).

The histology on the aortic wall did not highlight typical alterations of Takayasu and the autoantibody picture, although not typical, and the lymphadenomegaly suggested SLE although large vessel vasculitis is rare in SLE.

An FDG-PET scan was performed 40 days after the operation and confirmed and highlighted accumulations of tracer at moderate signal intensity in the lateral-cervical area, in particular at the II level bilaterally, more intense right supra-retroclavicular uptake with a non-homogeneous appearance in correspondence with voluminous adenopathy confirming the hypothesis of SLE.

Conclusions: This is a rare case of aortitis with aortic dissection in SLE. The peculiar appearance of the thoracic and abdominal aorta and the widespread adenopathy have made it possible to hypothesize and diagnose SLE, excluding other forms that more frequently involve the large vessels such as Takayasu disease.

ID: 49: A N U NUSUAL C ASE OF L UTEMBACHER ’ S S YNDROME D UE TO A L ARGE PFO WITHOUT M ITRAL S TENOSIS

D’Agostino Simone, Ianni Umberto, Gizzi Germana, Molisana Michela, Parato Vito Maurizio

“Madonna del Soccorso” Hospital - San Benedetto del Tronto (AP) Italy

Lutembacher’s syndrome, first described by the anatomist Johann Friedrich Meckel in 1750, is a combination of interatrial septal (IAS) defect or patent foramen ovale (PFO), associated with mitral stenosis. High left atrial (LA) pressure in mitral stenosis increases left-to-right shunt in patients with interatrial communication.

We present a case of a 77 y-o man affected by heart failure with preserved ejection fraction. Echocardiography revealed normal left ventricular systolic function without mitral stenosis and a turbulent left-to-right shunt through the IAS. 2D/3-D Transesophageal Echocardiography demonstrated an interatrial aneurysm with high mobility of fossa ovalis membrane. A large patent foramen ovale (PFO), with a gap of 6 mm, was evident through the aneurism. The left to right shunt through PFO had a peak velocity flow of 2.3 m/s with an estimated pressure gradient of 22 mmHg, indicating high LA pressure. Patient had an aortic valve stenosis with a planimetric area of 1,2 cm2.

In conclusion Lutembacher’s syndrome may exist also with a PFO and without mitral stenosis. The presence of turbulent left-to-right shunt through the IAS is helpful for detecting high LA pressure. Other situations different than mitral stenosis may leading to a LA pressure increase.

ID: 50: C ONTRAST -E NHANCED U LTRASOUND (CEUS) AS P REDICTOR OF R ECURRENCE FOR TIA/ STROKE IN L OW -G RADE I NTERNAL C AROTID A RTERY S TENOSIS

D’Auria Francesca 1 , Santo Danilo Flavio 2

1 San Giovanni di Dio e Ruggi d’Aragona University Hospital, Schola Medica Salernitana - Salerno Italy, 2 Santagostino Medical Center - Milan Italy

Introduction: Contrast-enhanced ultrasound (CEUS) allows to visualize atherosclerotic plaque neo-vessels which are the hallmark of carotid plaque instability.

Aim: Our prospective study check the correlation between carotid CEUS findings and recurrence of TIA/minor-stroke in patients with previous recent TIA/minor-stroke and neurological impairment (congruent with the carotid stenosis).

Materials and Methods: From November 2021 to May 2023, 62 consecutive patients (mean age 73.8 +/- 12.2, female 51) with TIA/minor-stroke in the previous 30 days, underwent carotid ultrasound and CEUS in outpatients setting after 15 days from the acute event. Inclusion criteria was one atherosclerotic plaque inside the internal carotid artery, congruent with symptoms, which was causing a stenosis less than 50% (low-grade stenosis). Carotid plaque neovascularization scoring method was: score 0: no visible microbubbles within the plaque (A); score 1: minimal microbubbles confined to periadventitial (B); and score 2: microbubbles present throughout the plaque core (C). During the six-month follow-up, we checked TIA/stroke recurrences. A multivariable Cox regression analysis was performed.

Results: In our series, 22% of patients have CEUS score 0; 35% CEUS score 1; 43% CEUS score 2. At six-month follow-up we found 21% TIA/minor stroke recurrences in CEUS score 2, despite of the ongoing best medical therapy as per guidelines. In Cox regression analysis, CEUS-detected neovascularization was independently associated with TIA/minor-stroke recurrence (hazard ratio, 5.37; 95% confidence interval, 1.36–2.31).

Conclusions: Plaque neovascularization, detected by CEUS, is an independent predictor of TIA/stroke recurrence at six-month follow-up in patients with carotid atherosclerosis despite of low-grade stenosis.

ID: 51: L EFT V ENTRICULAR P SEUDOANEURYSM F OLLOWING A CUTE M YOCARDIAL I NFARCTION

De Feo Daniele

University Hospital «Aldo Moro» - Bari Italy

Left ventricular (LV) pseudoaneurysm is a cavity characterized by a narrow neck, freely communicating to the left ventricle by localized pericardial adhesions.

Herein, we describe a case of 59-year-old male patient who was admitted to hospital care due to dyspnea, fatigue, and inferior limbs oedema, whose ECG showed signs of inferior leads necrosis and the presence of ST-elevation in the inferior-lateral site. Troponin level was increased, so we performed urgent coronarography that showed critical left circumflex coronary stenosis treated with PCI and chronic right coronary stenosis. Echocardiography was carried out, detecting akinesia, and scarring of the posterior mid-basal interventricular septum and of the mid-basal inferolateral wall.

Surprisingly, in the LV inferior wall we also observed a cavity with large neck, devoid of contracting myocardium, highly suggestive of pseudoaneurysm (6.5 x 3.5 mm) that extended up to the apex determining severe mitral insufficiency, likely derived from a rupture of the LV inferior wall, made up of pericardium in its distal wall portion. The patient was promptly transferred to the cardiac surgery department where they confirmed the diagnosis and performed the exclusion of left ventricular pseudoaneurysm by closure with bovine pericardium patch together with mitral valve repair and reimplantation of papillary muscle.

LV pseudoaneurysm is a rare (0.2-0.5%), potentially lethal mechanical - complication in patients with myocardial infarction, due to its high risk of rupture determining a sudden death.

Although difficult and tricky, only echocardiography may allow a timely suspicion and diagnosis, leading to the right treatment and management, improving patient’s prognosis.

ID: 52: E DGE - TO -E DGE R EPAIR FOR T RICUSPID V ALVE R EGURGITATION . P RELIMINARY E CHO -D ATA FROM THE TR- I NTERVENTIONAL S TUDY

De Luca Valeria Maria, Cammalleri Valeria, Antonelli Giorgio, Carpenito Myriam, De Filippis Aurelio, Piscione Maria Grazia, Nobile Edoardo, Di Pumpo Anna Laura, Carassiti Massimiliano, Sarubbi Domenico, Grigioni Francesco, Ussia Gian Paolo

Campus Bio-Medico Univeristy of Rome – Rome Italy

Introduction: Tricuspid regurgitation (TR) is a widespread valvular disease. Even while TR was long thought to be an incidental finding with few clinical effects, evidence-based studies revealed the clinical impact of untreated TR. As a result, less invasive percutaneous repair techniques have developed in recent years, including the TriClipTM system. Aim:We aim to highlight right ventricular remodeling after TriClip. Also, describe the echocardiographic and clinical changes in a prospective cohort of “real-life” patients. Materials and Methods:This is a prospective, monocentric study. From March 2021 to October 2023, we enrolled consecutive symptomatic patients. All patients underwent preoperative evaluation, using 2D transthoracic echocardiography(TTE). We performed TTE at 30 days and 1 year follow-up. Results: 40 subjects—75 % women—were enrolled. The mean age was 79±6 years with an average TRISCORE of 5±1.99. 40% had massive TR and 13% torrential. TR etiology included functional (45%), degenerative (12.5%), lead-induced (15%), and mixed (27.5%). The mean device time was 43 ± 23 min. TR severity at discharge was moderate or less in 82% of treated patients. 80% of enrolled patients had moderate or less TR at 30 days and 82% at one year. 30-day TTE performed for follow-up highlights notable improvements in right heart chamber sizes with stable results at 1 year. Conclusions: In our experience, the Triclip system is a durable and safe therapeutic option for symptomatic patients suffering by TR. We have shown significant improvement in functional status and quality of life associated with right-heart reverse remodelling.

ID: 53: D YSFUNCIONAL G REEN H EART OF U MBRIA

De Paolis Marcella, Mezzetti Paola, Camilli Giulia, Caterina Milici, Dominici Marcello

Santa Maria di Terni Hospital, Division of Cardiology - Terni Italy

We report the case of a 45-year-old male admitted in hospital for right hypochondrium/thoracic pain for about 1 week and dyspnoea for the last 2 days; due to fever, he had been treated with amoxicillin for almost 2 weeks. At physical examination: blood pressure 80/50 mmHG, heart rate 90/min. Laboratory analysis showed neutrophil leucocytosis, C-reactive protein, AST and ALT elevated levels. Under suspicion of sepsis due to abdominal injury, abdomen-thorax CT was performed: stasis in the lungs, pleuric effusion, left ventricular enlargement with apical thrombosis were detected. Then, electrocardiogram showed PR = 200 msec, anterior left hemiblock and right bundle branch block; hsTroponin and NTproBNP were elevated. Transthoracic echocardiogram confirmed severely reduced left ventricular ejection fraction (LVEF=20%) with multiple apical thrombi. The patient was transferred to ICU in cardiogenic shock SCAI C. The coronarography showed no obstructions; circulatory support with intraortic balloon counterpulsation (IABP) was performed in addition to inotropes, vasopressor, anticoagulant, empiric antibiotics (ceftriaxone 2g die). Immunological testing revealed a positive ELISA for anti-Borrelia immunoglobulin M antibodies. The patient had no clinically apparent tick-borne infection but self-reported history of a suspected tick bite about one month before. Antibiotic therapy with ceftriaxone was continued. At 12-day, cardiac magnetic resonance showed moderate LVEF recovering (40%), extensive intramyocardial oedema and mid-myocardial LGE. Patient could be discharged with a life vest at 20-day (betablocker therapy to control ventricular tachycardia) in a clinically improved condition and nearly normal LVEF (50%). Lyme disease very rarely manifests in myocarditis, in Europe, only 0.3–4% of all cases.

ID: 54: P ROGNOSTIC V ALUE OF L EFT A TRIAL S TRAIN IN P EDIATRIC C ARDIOMYOPATHIES : A M ULTI -C ENTRE S TUDY

De Sarro Rosalba 1 , Avesani Martina 2 , Moscatelli Sara 3 , Borrelli Nunzia 4 , Pelaia Giulia 1 , Leo Isabella 1 , De Rosa Salvatore 1 , Concolino Daniela 1 , Torella Daniele 1 , Di Salvo Giovanni 2 , Sabatino Jolanda 1

1 R. Dulbecco Univeristy Hospital- Catanzaro Italy, 2 University Hospital of Padua- Padua Italy, 3 Royal Brompton Hospital- London UK, 4 Monaldi Hospital - Napoli Italy

INTRODUCTION: The prognostic significance of left atrial (LA) function, in children with dilated cardiomyopathy (DCM), hypertrophic cardiomyopathy(HCM), and restrictive cardiomyopathy (RCM) has not been well established.

Aims: To assess the prognostic value of LA strain, measured using 2-D echocardiographic speckle-tracking analyses (2D-STE), in cardiomyopathies (CMP).

Materials and Methods: This retrospective study involved children with cardiomyopathies, who had undergone standard TTE and 2-D speckle-tracking analyses.

The primary endpoint was a combination of cardiac death, hospitalization due to heart failure, or life-threatening arrhythmias.

Results: 155 children (8.8 ± 6years) were enrolled, comprising 50 with DCM, 50 with HCM, 10 with RCM, and 45 healthy controls (CTRL).

Twenty-two patients (14%) experienced the primary endpoint during 5 years FU.

LA peak systolic strain and strain rate values displayed a consistent and significant decrease with the severity of diastolic dysfunction.

Left ventricular ejection fraction (LVEF), left atrial volume index (LAVI), LV global longitudinal strain (GLS), and LA reservoir strain were associated with the outcome in univariate analysis (P<0.05).

LA reservoir strain emerged as a more robust predictor of the outcome compared to the otherechocardiographic variables.

In the multivariable model, LA reservoir strain remained significantly associated with the outcome (HR: 3.05; P< 0.05).

Conclusions: 2D-STE-derived LA reservoir strain serves as a independent prognostic predictor in children with cardiomyopathies, surpassing the predictive capacity of LV GLS, LVEF, and LAVI. Therefore, considering LA strain in the management of children with CMP may enhance the risk stratification of the disease and facilitate the planning for early clinical intervention.

ID: 55: E VALUATION OF S ERUM L EVELS OF L IPOCALIN -2 AND C ORRELATIONS WITH M MSE AND WITH S URROGATE M ARKERS OF C ARDIOVASCULAR R ISK S UCH AS RHI, IMT, MMEE IN A P OPULATION OF NAFLD

Del Cuore Alessandro

San Vito e Santo Spirito Alcamo Hospital - Alcamo (TP) Italy

Introduction: Non-alcoholic fatty liver disease (NAFLD) is an emerging liver disease with a validated cardio-cerebrovascular risk.

Aim: We purposed to evaluate in patients with NAFLD, serum levels of Lipocalin 2 and MMSE correlating them with the presence of endothelial dysfunction (RHI), IMT and myocardial mechano-energetic efficiency (MMEE) assessed by De Simone’s formula.

Matherial and methods: Between Dicember 2022 and June 2023, a cohort of 40 patients with NAFLD was compared to a control group of 40 healthy patients.

All subjects underwent to serological sampling for the dosage of markers of adipo-neuro-inflammation (Lipocalin-2), assessment of cognitive abilities by MMSE, assessment of endothelial function by means of the endothelial release index (RHI) using Endopat2000, assessment of mid-intimal thickening on vascular ultrasound, assessment of MEE on echocardiography according to De Simone’s formula.

Results: We found that patients with NAFLD compared to healthy controls had higher serological levels of LCN-2 (148,54 ± 78,64 ng/mL vs 85,29 ± 44,55 ng/mL; p < 0.001) and lower RHI values (1.76 ± 0,59 vs 2,24 ± 0,38; p < 0.001), MMEE values (43.15 ± 11,58 vs 48,59 ± 13,82; p = 0.058), and MMSE scores (28,52 ± 1,65 vs 29,30 ± 0,86; p = 0.020).

Conclusion: In conclusion LCN-2 and MMSE, can be considered as early markers of adipose-neuro-inflammation, whereas RHI and MMEE identify a worse cardiovascular risk profile in patients with NAFLD. However, only new and future works can support and confirm our data and show us new clinical and therapeutic scenarios in the study of NAFLD.

ID: 56: A SSOCIATION OF E FFECTIVE L EFT V ENTRICULAR E JECTION F RACTION WITH A LL -C AUSE M ORTALITY IN V ENTRICULAR S ECONDARY M ITRAL R EGURGITATION

Delcea Caterina 1 , Tomaselli Michele 1 , Oliverio Giorgio 1 , Gavazzoni Mara 1 , Curti Emanuele 1 , Pece Cinzia 1 , Springhetti Paolo 2 , Clement Alexandra 1 , Penso Marco 1 , Pugliesi Giordano 1 , Benzoni Giorgia 1 , Camarda Emmanuele 1 , Muraru Denisa 1 , Badano Luigi 1

1 Department of Cardiology, Istituto Auxologico Italiano, IRCCS - Milan Italy, 2 Department of Medicine, Division of Cardiology, University of Verona - Verona Italy,

Introduction: Left ventricular (LV) systolic function is crucial for determining prognosis of patients with ventricular secondary mitral regurgitation (VsMR). However, both the LV ejection fraction (LVEF) and global longitudinal strain are influenced by the volume overload associated with MR. Effective LVEF (eLVEF) is a novel parameter that accounts for mitral regurgitant volumes and overcomes the load-dependency of LVEF.

Aim: We sought to explore the association of eLVEF measured by three-dimensional echocardiography (3DE) with mortality in patients with VsMR.

Materials and Methods: We enrolled 212 VsMR patients (mean age 70±13 years, 26% female) from January 2015 to March 2022. eLVEF was calculated by dividing forward LV stroke volume (SV), measured by 2D-Doppler echocardiography by the LV end-diastolic volume measured by 3DE. The primary outcome was all-cause mortality.

Results: During a mean follow-up of 22±11 months, 22% VsMR patients died. In multivariable Cox regression. eLVEF was independently associated with all-cause mortality (HR 0.93, 95%CI 0.89-0.97, p<0.001), In ROC analysis, cut-off values associated with all-cause mortality were eLVEF≤24% (77% sensitivity, 61% specificity, AUC 0.74, 95%CI 0.67-0.79, p<0.0001), LVEF≤40% (87% sensitivity, 44% specificity, AUC 0.69, 95%CI 0.62-0.75, p<0.0001).

Kaplan-Meier analysis demonstrated increasing event rate with eLVEF≤24% independent of LVEF higher or lower than 40% (log-rank, p40% had a worse prognosis than patients with LVEF≤40% and eLVEF>24%.

Conclusions: In patients with VsMR, eLVEF was independently associated with all-cause mortality. eLVEF≤24% was more strongly associated with mortality than LVEF.

ID: 57: P ULMONARY H YPERTENSION AND C ONGENITAL H EART D ISEASE : T HE C LINIC B EYOND T HE E VIDENCE

Di Fonzo Rosanna, Ferrara Alfonso, Vigorito Francesco, Galasso Gennaro, Vecchione Carmine, Soriente Lucia

Univeristy Hospital of Salerno - Salerno Italy

Eisenmenger syndrome was defined by Paul Wood as “pulmonary hypertension (PH) at systemic level, caused by a high pulmonary vascular resistance (PVR), with reversed or bidirectional shunt at aorto-pulmonary, ventricular, or atrial level. The clinical case we describe is that of a 44-year-old patient, suffering from Down syndrome, with ES due to subaortic VSD and a a patency of Botallo duct, followed in our PH clinic of the “Ruggi D’Aragona” University Hospital for about 9 years. The patient, on dual therapy with Macitentan 10 mg and Sildenafil 60 mg, was in the intermediate-high risk class, stationary. During the last two checks, there was a progressive worsening of the hemodynamic parameters, walking distance of only 100 meters at 6 mwt, with SpO2 at baseline 90%. On cardiac color Doppler ultrasound evidence of TAPSE 18 mm, PAPS 100 mmHg, RAA 20 cm²; TAPSE/PAPS 0.18. The patient presented in WHO class 3.

The only RCTs currently available concern the use of bosentan, but in clinical practice, initial monotherapy with ERA or PD5i for symptomatic patients is proposed. Consider escalation to a double combination therapy in case of clinical worsening or inadequate clinical response and uptitration with prostanoids when inadequate response and timely assess the eligibility for transplantation. For our patient, in consideration of the impossibility of surgery, although there is little evidence on prospective observational studies, we added selexipag to therapy. This case opens the door to still unclear scenarios in which the only weapon available remains the clinician’s judgment and experience.

ID: 58: E VALUATION OF A TRIAL AND L EFT V ENTRICULAR F UNCTION IN B REAST C ANCER P ATIENTS U NDERGOING A NTINEOPLASTIC T REATMENT : A P ROSPECTIVE S TUDY

Di Lisi Daniela, Triolo Oreste Fabio, Rossetto Ludovico, Madaudo Cristina, Rubino Luigi, Sinagra Paolo, Gambino Grazia, Manfrè Federica, Ortello Antonella, Vullo Celeste, Comparato Francesco, Li Manni Rosalia, Galassi Alfredo Ruggero, Novo Giuseppina

Division of Cardiology, University Hospital “Paolo Giaccone”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo. - Palermo Italy

Introduction: Cancer therapy-related cardiac dysfunction (CTRCD) diagnosis relies on reduced left ventricular ejection fraction (LVEF), global longitudinal strain (GLS), and elevated myocardial necrosis markers.

Aim: This study aimed to evaluate antineoplastic drug toxicity on atrial and left ventricular function using the global atrio-ventricular strain (GAVS), a novel echocardiographic index considering atrial-left ventricular correlation.

Material and Methods: A prospective study involved 131 breast cancer patients (mean age 51.4 ± 10.4 years) undergoing anthracycline, trastuzumab, and/or taxane therapy. Evaluations at baseline (T0), 3 (T1), 6 (T2), and 12 months (T3) included electrocardiograms, echocardiograms assessing GLS, atrial strain (PALS), atrial stiffness (PALS to average E/e’ ratio), LVEF/GLS ratio, and GAVS. CTRCD, based on 2022 ESC Cardio-Oncology guidelines, was tracked. Patients were grouped into CTRCD development (Group A) and non-CTRCD (Group B).

Results: CTRCD occurred in 44 patients, with 10% developing moderate CTRCD at T2. LVEF reduction was significant only at T2 (p = 0.04), while E/e’ increased at T3. Conversely, GLS, PALS, LASI, GAVS, and LVEF/GLS ratio significantly decreased at various time points (p 0.18 had the highest sensitivity and specificity in predicting CTRCD (p = 0.085). GAVS < 57.5 also associated with CTRCD but not significantly (p = 0.76).

Conclusions: PALS, LASI, and GAVS, alongside GLS, are crucial parameters during antineoplastic treatment for early CTRCD detection. Long-term data are vital for further validation.

ID: 59: P ROGNOSTIC R ISK S TRATIFICATION IN M YOCARDITIS : T HE M YOCARDITIS P ROGNOSTIC S CORE

Di Lisi Daniela, Macaione Francesca, Balasus Fabio, Madaudo Cristina, Marotta Antonia, Alaimo Chiara, Gargano Marta, Damerino Giuseppe, Giardina Ottavia, Scelfo Domenico, Castro Francesca, Galassi Alfredo Ruggero, Novo Giuseppina

Division of Cardiology, University Hospital “Paolo Giaccone”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (ProMISE), University of Palermo. - Palermo Italy

Introduction: Myocarditis exhibits diverse causes, clinical presentations, and prognosis. Prognostic factors such as complicated clinical onset, reduced global longitudinal strain (GLS) and septal delayed enhancement (DE) on cardiac magnetic resonance imaging (MRI) are recognized.

Aim: This study aimed to develop a prognostic score based on multiparametric factors to predict events in myocarditis patients.

Material and Methods: 98 patients with confirmed or suspected acute myocarditis participated in a multicenter study. Assessments included admission electrocardiogram, echocardiogram with GLS evaluation, troponin measurement, and cardiac MRI for DE assessment. Follow-up evaluations at 6 months gauged DE changes. Adverse cardiovascular events (death, heart failure hospitalization, heart transplant, recurrent myocarditis, ICD implantation, dilated cardiomyopathy, ventricular arrhythmias) were monitored over a mean 3-year follow-up.

Results: Of the 98 patients, 31 had complicated onset, correlating with a higher incidence of adverse events. Patients with events exhibited impaired left ventricular ejection fraction (LVEF) and GLS, higher septal DE prevalence, prolonged troponin elevation, and persistent/increased DE at 6 months. Linear logistic regression identified parameters as significantly associated with adverse events. Different scores were assigned to these parameters, leading to the “myocarditis prognostic score”. A score ≥ 5 correlated with higher event probability, while ≤ 2 indicated a low probability. LVEF ≤ 45%, GLS > -15.3%, and troponin increase > 6.9 days had the highest diagnostic accuracy.

Conclusions: Myocarditis prognosis varies, and adverse events are more frequent in complicated cases. This study introduces a novel prognostic score integrating echocardiographic, MRI, and laboratory data to identify high-risk patients necessitating closer follow-up.

ID: 60: A CUTE C ORONARY S YNDROMEN R ESULTING FROM E NDOCARDITIS ON A B IOPROSTHESTIC V ALVE

Di Marino Mario 1 , Genovesi Eugenio 2 , Corazzini Alessandro 2 , Vitulli Piergiusto 2 , Magnano Roberta 2 , Pezzi Laura 2 , Verrengia Elvira 2 , D’Alleva Alberto 2 , Gallina Sabina Gallina 1 , Di Marco Massimo 2

1 Santissima Annunziata Hospital- Chieti (CH) Italy, 2 Santo Spirito Hospital - Pescara Italy

Male, 79 years old, presented to the ED with chest pain and hemodynamically instability. One month prior, he underwent aortic bioprosthesis implantation for severe aortic stenosis. Pre-intervention coronary angiography revealed diffuse atheromatous plaques. The medical history included paroxysmal atrial fibrillation and hypertension. Upon admission: NIBP 80/50 mmHg, HR 150 bpm, and oxygen saturation was 85%. EKG showed atrial fibrillation with ST-segment elevation from V1 to V5. Arterial blood gas analysis revealed pH 7.25 and lactate 6 mmol/L. He received inotropic and vasopressor support, and prompt coronary angiography was performed, revealing 99% stenosis of the left anterior descending artery, treated with angioplasty and coronary stent placement. Transthoracic echocardiography demonstrated the presence of the aortic bioprosthesis with diffusely thickened leaflets consistent with multiple vegetations. Transesophageal echocardiography (TOE) confirmed a nosocomial infectious endocarditis, with mild-to-moderate stenosis, and evidence of peri-prosthetic abscess directed towards the left atrium. The patient reported low-grade fever and asthenia in the weeks prior. The systemic and local inflammatory state of the endocarditis contributed to an accelerated atherosclerotic process. Blood cultures identified multidrug-resistant Staphylococcus hemolyticus. The patient declined cardiac surgery. Follow-up TOE, after six weeks of intravenous antibiotic therapy, showed reduced vegetations on the bioprosthetic valve leaflets, with evolution of the large echolucent cavity, along with two similar peri-prosthetic lesions, confirmed by contrast-enhanced CT. The patient, achieving hemodynamic stability, was discharged home, continuing intravenous antibiotic therapy (OPAT protocol). At the one-month post-discharge follow-up, the follow-up TOE showed normally mobile bioprosthetic valve leaflets without vegetations, and cleansed abscess.

ID: 61: E CHOCARDIOGRAPHIC E VALUATION IN T RANSFUSION -D EPENDENT T HALASSEMIA B EFORE A TRIAL F IBRILLATION : T HE F ATHAL S TUDY

Di Stefano Valeria 1 , Gianesin Barbara 2 , Bertini Matteo 3 , Pisaniello Marco 4 , Culcasi Martina 5 , Denotti Anna Rita 6 , Giuditta Marianna 1 , Longo Filomena 7 , Manca Maria Regina 8 , Orecchia Valeria 6 , Origa Raffaella 6 , Motta Irene 1

1 Unit of Medicine and Metabolic Disease, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Milan Italy, 2 Fondazione For Anemia - Genoa Italy, 3 Cardiology Unit, Ferrara University Hospital - Cona (FE) Italy, 4 Departmen of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda

Maggiore Hospital - Milan Italy, 5 Day Hospital Thalassemia and Hemoglobinopathies, Ferrara University Hospital- Cona Italy, 6 Centro Microcitemie e Anemie Rare, Pediatrico Microcitemico ‘A. Cao’ - Cagliari Italy, 7 Day Hospital Thalassemia and Hemoglobinopathies, Ferrara University Hospital- Cona (FE) Italy

Atrial fibrillation (AF) is an emerging issue in transfusion-dependent thalassemia (TDT) due to increased life expectancy; however, data in the literature are limited.

The aim of our study was to analyze echocardiographic features in adult TDT before the first AF episode.

TDT pts followed between June 2003 and May 2023 with at least one episode of AF were included in a multicentric retrospective Italian study. Clinical data have been collected with digital CRF.

Three Italian centers participated, recruiting 130 pts, with a prevalence of AF of 13.8%. The mean age at the first AF episode was 39.7 yr.

At the last available echocardiogram before AF, the most common alteration was left atrial dilatation (LAD), present in 58% (36/62) of pts. Only 8 pts had moderate/severe valvulopathy (6 mitral insufficiency, 2 aortic insufficiency, and 4 tricuspid insufficiency). Diastolic function was normal in most cases (46/58, 79%), and in only 6 pts left ejection fraction was less than 40%. The majority of pts did not have hypertension (98%) or a prior history of heart failure (77%). Cardiac iron overload was present in 48.7% at any time before AF and in 29% of pts at the time of the first event. Thirty-eight patients (29.2%) did not show cardiac iron overload before or at the time of the first episode.

In this chronically anemic population, LAD, in the absence of other evident common causes, is most likely related to chronic high output due to anemia, which requires appropriate correction through transfusions or new therapy.

ID: 62: A C ASE OF L EFT V ENTRICULAR H YPERTROPHY : W HEN D IFFERENTIAL D IAGNOSIS M AKES THE D IFFERENCE

Dominioni Irene, Caparvi Camilla, Mengoni Marco, Dell’Uomo Marco, Pace Vincenzo, Martinelli Marco, Khoury Georgette, Pucci Giacomo, Dominici Marcello, Conti Serenella

Santa Maria di Terni Hospital - Terni Italy

A 34-year-old patient with a history of IAS was hospitalized for cerebellar ataxia. She performed brain CT and MR angiography with evidence of occlusion of the left vertebral artery and multiple areas of altered signal intensity. The ECG showed short PR interval, increased QRS duration, R wave in aVL>11mV and depression of the ST segment in the inferior leads. To evaluate emboligenic sources of cardiac origin, an echocardiogram was performed which documented hypertrophic heart disease (EDV 39 mm, IVSd 18 mm and PWd 18 mm), with slightly depressed systolic function due to hypokinesia of the lateral wall and first degree diastolic dysfunction with increased filling pressure (E/e'13). This was suggestive of hypertensive heart disease, for which a complete screening was performed for secondary hypertension tested negative, symmetric hypertrophic cardiomyopathy and Fabry disease. Cardiac MRI confirmed marked thickening of the LV and multiple focal areas of LGE with patchy morphology at the level of the middle and basal portion of the lateral wall with a mesocardial and subepicardial distribution; furthermore, gross area of LGE with transmural distribution at the level of the anterolateral papillary muscle of the left ventricle. No signs of LVOT obstruction, no SAM. Therefore, female sex and age of the patient, the ECG and instrumental evidence indicated Fabry disease with primordial neurological manifestations. The diagnosis was further supported by genetic test which confirmed the mutation of the GLA gene coding for the lysosomal enzyme alpha-galactosidase A.

ID: 63: A C ASE OF Q UADRICUPID A ORTIC V ALVE

Donato Domenica 1 , Leonetti Stefania 2 , Romeo Maria Grazia 3 , Bellieni Luca 1 , Scigliano Fabio 1 , Comi Maria Caterina 1

1 ”BIANCHI-MELACRINO-MORELLI” Hospital, Cardiac surgery Department - Reggio Calabria Italy, 2 SANT’EUGENIO Hospital, Division of Cardiology - Roma Italy, 3 DEPARTMENT OF CARDIAC SURGERY, UNIVERSITY “FEDERICO II” - Napoli Italy

We describe a case of 66-year-old man with family history of sudden death and thyroid goiter. In follow-up for moderate regurgitation in bicuspid aortic valve. The patient was symptomatic for dyspnea. During endocrinological hospitalization for thyroid goiter, transthoracic echocardiogram showed severe aortic regurgitation and ascending aorta aneurysm. The transesophageal echocardiogram showed also dilatation of the aortic root, aortic valve with normal right coronary cusp, normal left coronary cusp and two smaller non-coronary cusps and a central coaptation defect. Coronary arteries were normal. The patient underwent aortic valve replacement with a bioprosthesis implantation and ascending replacement with a vascular prosthesis. Intraoperative anatomical finding showed quadricuspid aortic valve: the supernumerary cusp was the smallest and located between the non-coronary and the right coronary cusps. Quadricuspid aortic valve is a rare malformation. It can be isolated or associated with other anomalies. aortic regurgitation is predominat than stenosis due to reduced coaptation. Transesophagealechocardiogram is important for an accurate morphological description. In relation to the dimensions of the cusps and the position of the supernumerary cusp there are several classifications: Hurwitz and Roberts (type A-G) and Nakamura et al. (type I-IV). A clear correlation between the type of quadricuspid and the extent of valvulopathy is not described, while the asymmetry of the cusps can increase the risk of endocarditis. In our case the quadricuspid fell into TYPE C (two equal cusps and two smaller ones, especially the supernumerary) and TYPE II (the smallest cusp was placed between the non-coronary and right coronary cusps).

ID: 64: T HROMBOCYTOPENIA : N EVER U NDERESTIMATE I T

Donato Domenica 1 , Leonetti Stefania 2

1 ”BIANCHI-MELACRINO-MORELLI” Hospital, Cardiac surgery Department - Reggio Calabria Italy, 2 SANT’EUGENIO Hospital, Division of Cardiology - Roma Italy

We report the case of a 79-year-old gentleman who was diagnosed with mitral and tricuspid valve disease and underwent a tissue MVR and tricuspid valve repair. Following surgery, he developed sepsis with a positive blood culture for Klebsiella and severe thrombocytopenia (PLT count 18.000µL). He was treated with antibiotics successfully. He was initiated with Warfarin and at discharge, his platelet count was 84.000 µL.

One month after he was re-admitted with dyspnoea. 7days before admission he was treated with Warfarin given a non-therapeutic INR. During admission, He underwent a transthoracic echocardiogram which showed a large thrombus in the left atrium. His platelet count was 43.000 µL. The Warfarin was discontinued and he was commenced with Direct thrombin inhibitors (DTIs). A transoesophageal echocardiogram confirmed a severe smoke effect and a large, soft and irregular thrombus occluding the mitral valve prosthesis. The case was discussed in the multidisciplinary meeting and the consensus was to remove the clot surgically using Direct thrombin inhibitors (DTIs) to support extracorporeal circulation.

The patient underwent uneventful surgical resection of an left atrium clot.

During the admission, He was detected with HIT antibodies and he was diagnosed with Heparin-induced thrombocytopenia in light of the clinical presentation, 4T scoring and evidence of Heparin antibodies.

The challenges in this case were related to an early identification of HIT which is based on the clinical scoring and immunological assay as well as the management.

ID: 65: E XAMINING G ENDER D ISCREPANCIES AND P ROGNOSTIC I MPLICATIONS IN M ODERATE A ORTIC S TENOSIS : I NSIGHTS FROM A R ETROSPECTIVE A NALYSIS

Donisi Luca 1 , Guareschi Alessandro 1 , Pasero Guido 1 , Mallardi Giulio 1 , Faggiano Andrea 1 , Faggiano Pompilio 2 , Bursi Francesca 3 , Carugo Stefano 1 , Santangelo Gloria 1

1 Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico - Milan Italy, 2 Fondazione Poliambulanza, Cardiothoracic Department Unit, Brescia, Italy - Milano Italy, 3 Division of Cardiology, Department of Health Sciences, San Paolo Hospital - Milano Italy

Aortic stenosis (AS) is a prominent valvular heart disease, with severe cases posing a threat to survival. Recent studies note concerning outcomes in moderate AS, challenging optimal intervention timing. This retrospective study at IRCCS Fondazione Ca’ Granda Ospedale Maggiore Policlinico (July 2022–October 2023) investigated 150 moderate AS patients (median age 79±13 years, 48% female) in order to explore sex-related pathophysiological variations. Men, younger on average, exhibited distinct echocardiographic differences, including lower left ventricular ejection fraction, larger left ventricular end-systolic volume, and smaller aortic valve area index than women (54±7% vs. 59±10%, p=0.028; 55±36 ml vs. 31±13 ml, p<0.001; 83±18 ml vs. 75±18 ml, p=0.030, respectively). Male patients had significantly smaller aortic valve area index to body surface area (0.6±0.09 cmq/mq vs. 0.7±0.1 cmq/mq, p<0.001) and lower Doppler velocity index (0.32±0.07 vs. 0.38±0.11, p<0.001). Coronary artery disease and smoking were also more prevalent in men (53.3% vs. 46.7%, p=0.002; 52.6% vs. 47.4%, p<0.001). Survival analysis revealed that male sex independently correlated with the composite outcome (all-cause mortality and aortic valve replacement) during a mean 200±133 days follow-up, with median survival being 244±16 vs. 255±15 days (p=0.025). In a multivariable analysis, considering variables like hemoglobin and aortic valve index to BSA value, male sex remained independently associated with the composite outcome (hazard ratio: 2.01, CI 1.0-4.17, p=0.05). Intriguingly, women with moderate AS exhibited a lower incidence of aortic valve replacement and all-cause mortality, suggesting potential different clinical and echocardiographic phenotypes among AS patients.

ID: 66: M ULTIMODAL I MAGING FOR E VALUATION OF G IANT C ORONARY A NEURYSM R ELATED TO K AWASAKI D ISEASE : A C ASE R EPORT

Esposito Arianna, Surace Francesca Chiara, Bianco Francesco, Baldinelli Alessandra, Capestro Alessandro, Bucciarelli Valentina, Baldoni Monica, Berton Emanuela, Raffaelli Elena, Fogante Marco

Marche University Hospital- Ancona Italy

BACKGROUND: Kawasaki disease (KD) is an acute systemic vasculitic illness of childhood that leads to coronary artery aneurysms (CAAs) in about 25% of untreated cases. Transthoracic echocardiography (TTE) is the primary imaging modality for cardiac assessment and should be performed as soon as the diagnosis is suspected. However, TTE alone may not be sufficient to fully evaluate the extent of disease. Computed tomography angiography (CTA) is particularly useful for detecting distal lesions and coronary artery stenosis.

CASE SUMMARY: Our present case concerns a 3-year-old boy who presented with persistent high fever associated with cervical lymphadenopathy and bilateral nonexudative conjunctivitis and was subsequently diagnosed with Kawasaki disease. Echocardiography performed in the acute phase of illness showed medium aneurysms of the right coronary artery and a giant aneurysm of the left anterior descending artery (9 mm, Z-score 20). Moderate mitral regurgitation and a small pericardial effusion were also detected. Thus, he underwent CTA, which confirmed the echocardiographic findings and revealed no significant coronary artery stenosis. Repeat echocardiograms were performed to monitor for thrombus formation at least once weekly during the acute phase, then monthly until the third month of disease.

DISCUSSION: We discuss the challenges of diagnosis and risk stratification of coronary artery abnormalities in paediatric patients with KD. A multimodal non-invasive approach is crucial to obtain high-resolution coronary images, especially in patients with clinically significant CAAs. Accurate evaluation of coronary artery involvement is indeed essential for driving subsequent follow-up and anticipating the best therapeutic choice for each patient.

ID: 67: E PICARDIAL A DIPOSE T ISSUE A CROSS HF P HENOTYPES

Fabiani Iacopo 1 , Diotalevi Luca 2 , Osmenaj Benisa 3 , Castiglione Vincenzo 1 , Barison Andrea 1 , Emdin Michele 1 , Giannoni Alberto 1

1 SANT’ANNA SCHOOL OF ADVANCED STUDIES SAN CATALDO HOSPITAL - FONDAZIONE TOSCANA GABRIELE MONASTERIO - CARDIOLOGY AND CARDIOVASCULAR DIVISION UNIT - Pisa Italy, 2 ALMA MATER STUDIORUM Univeristy of Bologna - Bologna Italy, 3 PISA University- Pisa Italy

INTRODUCTION: Cardiac amyloidosis (due to light-chain deposition - AL or transthyretin - TTR) is now acknowledged as a relevant driver for Heart failure (HF). In CA, misfolded proteins are usually ubiquitous involving both ventricles and atria, cardiac valves and potentially also the epicardial adipose tissue (EAT). EAT has important paracrine functions, including cardiac metabolism and cell signals.

AIM: To evaluate EAT thickness in different HF phenotypes, including CA.

MATERIALS AND METHODS: We retrospectively included 301 patients admitted at Fondazione Toscana Gabriele Monasterio (Pisa, PI, Italy) Hospital with an acute HF diagnosis. Patients were grouped into 3 different categories according to primary diagnosis and EF based classification of HF: CA (ATTR and AL), patients with HF across all EF classes (HFpEF, HFrEF/mEF). EAT was measured on the parasternal long axis view, as the thickness of the epicardial fat at the end of the systole on the right ventricle.

RESULTS: EAT was found to be thinner in CA patients than patients with HFpEF, especially in AL-CA (all p<0.01). At multivariate analysis, dyslipidaemia, NT-proBNP, high sensitivity troponin-T and left ventricular ejection fraction (LVEF) resulted independent predictors of EAT thickness (the lower the LVEF, the thinner the EAT). C-reactive protein was the only predictor of EAT thickness in patient with AL-CA.

CONCLUSIONS: EAT might is a potential red flag of CA, independently from other potential confounders.

ID: 68: I NTEGRATED A SSESSMENT OF F UNCTIONAL L IMITATION IN P ATIENTS WITH C ARDIAC T RANSTHYRETIN A MYLOIDOSIS BY C OMBINED E CHOCARDIOGRAPHY AND C ARDIOPULMONARY E XERCISE T EST

Fabiani Iacopo 1 , Mondello Giovanni 2 , Arzilli Chiara 1 , Benelli Eleonora 1 , Vergaro Giuseppe 1 , Castiglione Vincenzo 1 , Aimo Alberto 1 , Passino Claudio 1 , Emdin Michele 1 , Giannoni Alberto 1

1 SANT’ANNA SCHOOL OF HIGHER STUDIES - SAN CATALDO HOSPITAL UO CARDIOLOGIA E MEDCINA CARDIOVASCOLARE FONDAZIONE TOSCANA GABRIELE MONASTERIO - Pisa Italy, 2 PISA UNIVERSITY - Pisa Italy

Background: Transthyretin cardiac amyloidosis (ATTR-CA) is characterized by progressive left ventricular diastolic and systolic dysfunction associated with the autonomic nervous system and ventilatory impairment, responsible for reduced effort tolerance. Cardiopulmonary exercise testing (CPET) is the gold standard to assess exercise capacity. Its combination with exercise echocardiography (eCPET) allows further clarification of the mechanisms of exercise limitation.

Aim: To define the primary determinants of functional impairment in ATTR-CA patients, compared to a sex and age-matched population of patients with heart failure with preserved ejection fraction (HFpEF) and hypertrophic phenotype.

Methods and results: 15 ATTR-CA patients and 9 HFpEF patients with HFpEF were evaluated. A significantly worse diastolic dysfunction was observed in the study group, with higher median values of peak E/e’ (10.9 [9.4, 13.8] vs 7.4 [5.9, 10.5], p 0.043). There were no statistically significant differences in most of the variables analyzed, including peak VO2. ATTR-CA patients showed a lower increase in stroke volume from rest to peak effort (∆SV: 29 [19, 36.5]% vs. 37 [33, 45]%, p 0.073) and lower ∆TAPSE (22.22 [18.82, 31.22]% vs. 32.14 [15, 44.44]% p 0.591). History of AF and β-blocker therapy were the main clinical predictors of limited functional capacity in ATTR-CA patients.

Conclusions: The functional limitation of ATTR-CA patients is mainly driven by lower CO during effort. History of AF, β-blockers and circulatory levels of Tn-Hs and peak VO2 might influence exercise capacity.

ID: 69: R EVIEW OF THE O RGANIZATIONAL M ODELS FOR T ECHNICAL S TAFF IN THE D EPARTMENT OF C ARDIOLOGY AT T RENTO ’ S H OSPITAL

Falco Piero, Curzel Mauro

Santa Chiara Hospital - Trento Italy

Introduction: Over the past few years, positions such as Cardiac Sonographer had increased technician’s working activity, boosting working offer and opening the doors wide to ultrasound diagnostic, which for years has been a medical prerogative.

Aim: In order to optimize the staff organization according to acquired skills and to give a better response to the request for diagnosis and treatment of cardiovascular diseases, it was necessary to activate a review of the organizational models and relocation of the technical staff based on skills and professional profiles.

Materials and methods: An organizational-structural analysis was carried out, evaluating the diagnostic request of users and the response that the service is able to provide.

Finally, on the basis of the data obtained, it was simulated an organizational model that could optimize the productivity and quality of the service provided; moreover it was calculated the need for staff integration to bring this model into operation.

Results: The results suggest that the inclusion of new professional figures such as Cardiac Sonographer, who already contribute significantly to the productivity of the echocardiography laboratory (57% of the exams carried out in 2018), if correctly integrated into a functional organizational model can almost double the number of examination provided, also allowing Echocardiographers Cardiologist to provide a greater number of advanced echocardiograms.

Conclusions: It has been demonstrated that a reorganization and integration of the technical staff is necessary in order to provide a greater response to user’s diagnostic requests.

ID: 70: L EFT A TRIAL F UNCTION A FTER T OTALLY T HORACOSCOPIC L EFT A TRIAL A PPENDAGE E XCLUSION AS S TANDALONE AND AS C OMBINED WITH E PICARDIAL M AZE P ROCEDURE IN P ATIENTS WITH A TRIAL F IBRILLATION ; C LINICAL , S EROLOGICAL AND E CHOCARDIOGRAPHIC F INDINGS AT O NE -Y EAR F OLLOW U P

Fanti Diego, D’Onghia Giovanni, Marini Massimiliano, Branzoli Stefano, Tedoldi Francesca, Saraò Emanuele, Casagranda Giulia, Mochen Marianna, Saltori Michela, Videsott Lodovica, Corradello Elena, Coser Alessio, Quintarelli Silvia, Guarracini Fabrizio, Bonmassari Roberto

S Chiara Hospital Trento - Trento Italy

Introduction: Left atrial appendage (LAA) is the most common source of thrombi in patients with atrial fibrillation (AF). The Totally Thoracoscopic (TT)-LAA exclusion with epicardial clip is a safe and effective procedure, yet the effects on left atrial (LA) mechanics remain unknown. The aim of this study was to assess the impact of TT-LAA exclusion on the LA function.

Methods: 39 patients with AF and contraindication to oral anticoagulation (OAC) underwent standalone TT-LAA exclusion with the Atriclip device. All patients were screened preoperatively with 3D CT scan, transthoracic and trans-esophageal echocardiography. To evaluate LA function, standard transthoracic echocardiography and 2D strain of LA were performed before surgery, at discharge, at 3-month and at 1 year. Routine blood tests and BNP levels were measured.

Results: There were no major complications during the procedure. At median follow-up of 13 months, 1 non cardiovascular death, 1 ischemic stroke and 4 cardiovascular hospitalizations occurred. At 2D strain of LA, the reservoir function decreased significantly after Clip implant and recovered at 3- months follow-up; at 1 year it remained stable. Furthermore, NT-proBNP increased significantly after LAA exclusion with a return to baseline after 3 months. Changes in E/A occurred at predischarge and did not persist at follow up.

Conclusion: TT-LAA exclusion with clip device is a safe and effective procedure in preventing AF related stroke in patients with contraindication to OAC. LAA epicardial clip impairs the reservoir LA reservoir function with a recovery over time.

ID: 71: A R ARE C OMPLICATION OF A CUTE M YOCARDIAL I NFARCTION

Fantini Enrico 1 , Pantano Paola 2 , Gasparetto Nicola 2 , Barbisan Davide 2 , Cernetti Carlo 2

1 Univeristy Hospital of Padua – Padua Italy, 2 Ca’ Foncello Hospital - Treviso Italy

Background: Late-presenting myocardial infarction may often develop mechanical complications, especially in elderly patients.

Case summary: a 94-year-old woman presented to the Emergency Department for fatigue, dizziness and loss of appetite; she accused chest pain approximately four days before, lasting for forty-five minutes. She was hemodynamically stable; electrocardiogram showed a 2:1 atrioventricular block and inferior Q waves with coexistent ST segment elevation. The echocardiogram revealed akinesis of the inferior wall and inferior interventricular septum. The right ventricle was mildly dilated with reduced systolic function. The patient was therefore admitted to our Intensive Cardiac Care Unit with the diagnosis of late presenting inferior myocardial infarction with advanced atrioventricular block. Given the delayed presentation, emergent coronary angiography was excluded. The day after, a single-chamber pacemaker was implanted.

A subsequent echocardiogram identified an intramyocardial dissecting hematoma extended from the inferior interventricular septum towards the right ventricle. Furthermore, a communication between the dissecting hematoma and the right ventricle cavity itself was noticed, realizing a left-to-right shunt. This finding was confirmed by a cardiac computed tomography. After multidisciplinary team discussion, a conservative approach was chosen. After few hours the patient died because of pulseless electrical activity.

Discussion: besides physical examination, echocardiography is the first diagnostic technique for the assessment of mechanical complications of myocardial infarction, among which the intramyocardial dissecting hematoma is one of the rarest and most challenging to diagnose.

ID: 72: I NADVERTENT I MPLANTATION OF T EMPORARY P ACEMAKER L EAD IN THE L EFT V ENTRICLE T HROUGH I NTERVENTRICULAR S EPTUM

Ferraro Daniel, Aquila Iolanda, Mascaro Giuseppina, Mongiardo Annalisa, Ventura Ettore, Giordano Salvatore, Passafaro Francesco, Santarpia Giuseppe, Curcio Antonio, Indolfi Ciro

Division of Cardiology, Department of Medical and Surgical Science, Magna Graecia University - Catanzaro Italy

Introduction: Inadvertent lead malposition in the left heart (ILMLH) is a rare complication, which occurs during implantation of cardiac electronic devices. This may result in complications like loss of capture, cardiac perforation, valvular damage, thrombus formation. The diagnosis is simple but requires careful analysis of the post pacing electrocardiography. Malposition is confirmed through transthoracic echocardiography, chest x-ray or transesophageal echocardiography in the majority of cases.

Clinical case: a 62 years old male was admitted to the local emergency room because of cardiac arrest occurred to hyperkalemia. An intravenous temporary pacemaker was implanted and the patient was transferred to our institution. At his arrival the EKG showed a ventricular-paced rhythm with RBBB morphology. Thus, a chest x-ray was performed demonstrating the tip of the lead in the left chambers (Fig. A). To better define the path of the lead, a TEE was performed. The images showed the presence of the lead in the left ventricle, passing through the IVS, pointing towards the infero-lateral wall, confirming lead malposition (Fig. B).

At this point, the Heart-Team decided to remove the temporary pacemaker. The procedure occurred without complications and without evidence of residual interventricular shunt (Fig. C). In consideration of previous syncopal episodes, the decision to switch to permanent pacemaker implantation was made (Fig D).

Conclusions: ILMLH is a known complication of cardiac electrophysiology procedures. In this case multimodality imaging allowed accurate identification of site perforation, lead path and presence of an active leak into the pericardial space.

ID: 73: A H UGE F LOATING A SCENDING A ORTA T HROMBUS IN A T RIPLE R ULE - IN CT

Finori Luca 1 , Barbarossa Alessandro 1 , Berretta Paolo 1 , Guerra Federico 1 , Casella Michela 1 , Dello Russo Antonio 1 , Di Eusanio Marco 1

1 Marche University Hospital - Ancona Italy

A 50-year-old man with no prior cardiological history presented to the ED with chest pain radiating to the right shoulder. High D-dimer levels prompted a “triple-rule-out” CT, confirming segmental-PE, revealing a 3cm pedunculated aortic mass, and a proximal stenosis in the left anterior descending artery (LAD). The case was discussed in “Heart-team,” and given the mass size ant its likely thrombotic nature, cardiac surgery was performed via aortotomy with extracorporeal circulation in order to avoid life-threatening embolization and to diagnose the nature of the mass. Intraoperatively, the mass was pedunculated, attached above the right coronary ostium, with no aortic wall abnormalities. Histological analysis confirmed its thrombotic nature.

Aortic mural thrombi in a normal ascending aorta are extremely rare and are often discovered incidentally due to systemic embolization or CTA scan. When pedunculated, they carry higher risk of systemic embolization and mortality. CTA is a valuable tool to rule out PE, ACS, and aortic diseases in ED patients.

In literature, there is no established treatment for ascending aorta thrombi, each case is managed individually, typically through direct surgery or anticoagulation. In our case, the “Heart team” discussion led to aortotomy and mass resection due to the mass’s uncertain nature within a normal aortic wall and the high risk of life-threatening systemic embolization. Anticoagulation therapy for PE was initiated promptly, considering the risk of bleeding.

Regarding LAD stenosis, we chose not to perform aorto-coronary bypass due to a normal ECG, negative troponins, and the prohibitory risk of coronary angiography before mass resection.

ID: 74: P ROGNOSTIC A CCURACY OF L UNG U LTRASOUND COMPARED TO C HEST -X-R AY IN COVID-19 P NEUMONIA

Fiorelli Elisa Maria

Fondazione IRCCS Ca’ Granda Maggiore Hospital - Milan Italy

BACKGROUND: Lung ultrasound (LUS) and chest radiography (CXR) have been used as first evaluation tools in COVID-19 pneumonia. Several studies evaluated their prognostic role as they may represent a more affordable alternative to chest CT scan. Our aim was to compare the prognostic accuracy of CXR and LUS in predicting adverse events in patients with COVID-19 pneumonia.

MATERIALS AND METHODS: Patients admitted for COVID-19 pneumonia into two COVID19 units were enrolled. CXR and LUS were evaluated by Brixia and LUS score. Prognostic value of both techniques was evaluated together with clinical variables. The primary outcome was a composite of non invasive mechanical ventilation, admission to ICU and death. Secondary outcome was the composite of death and admission to ICU.

RESULTS: 140 patients were included in the analysis. The primary outcome occurred in 49 (35%). At multivariate regression only dyspnoea, PaO2/FiO2 and Brixia score were associated with the primary outcome. The ROC analysis for the primary outcome demonstrated an AUC of 0.783 and 0.876 for LUS and Brixia score (p=0.0169). For the secondary outcome AUC was 0.789 for LUS and 0.805 for Brixia score. The inter-observer reliability for Brixia score demonstrated a weighted Cohen’s Kappa of 0.59.

CONCLUSIONS: Both LUS and CXR demonstrated a good prognostic accuracy; CXR appears to perform slightly better for the primary outcome. LUS could be useful to identify patients at risk of worse outcomes in settings where CXR is not immediately available.

ID: 75: E CHOCARDIOGRAPHIC M EASUREMENT OF M YOCARDIAL W ORK . E FFECTS OF T IMING AND P ATIENTS ’ P OSITION D URING B LOOD P RESSURE M EASUREMENT

Fisicaro Samantha 1 , Clement Alexandra 2 , Tomaselli Michele 1 , Penso Marco 1 , Rota Alessandra 3 , Menna Alessandro 3 , Muraru Denisa 1 , Badano Luigi 1

1 Department of Cardiology, Istituto Auxologico Italiano, IRCCS - Milan Italy, 2 Internal Medicine Department, “Grigore T. Popa”, University of Medicine and Pharmacy - Iasi Romania, 3 Department of Medicine and Surgery, University Milano-Bicocca - Milan Italy

INTRODUCTION. Although cuff blood pressure measurement is a critical parameter to calculate myocardial work (MW) noninvasively, there is no recommendation about when and how to measure it.

AIMS. To evaluate the effects of the timing during the echo study and the patient’s position on the scanning bed during the cuff blood pressure measurement on MW parameter calculations.

METHODS. 101 patients were prospectively enrolled. During the echocardiographic study, we measured the cuff blood pressure four times: BP1 before the start of the echo study, with the patient supine; BP2, after positioning the patients on his/her left side to start the echo study; BP3, at the time of the acquisition of the apical views used to measured left ventricular global longitudinal strain; and BP4, at the end of the echo study with the patient supine.

RESULTS. Systolic blood pressure (SBP) at BP1 was 147±21 mm Hg. Between BP1 and BP2, it dropped by 17±9 mm Hg (p<0.05). SBP at BP3 was significantly lower than BP2 (130±20 mm Hg vs. 122±18 mm Hg, p<0.05), and at BP4 was significantly lower than at BP1 (-9±13 mm Hg, p<0.05). The average GLS was -16±3%. Accordingly, the global work index was 1929±441 mmHg% at BP1, dropped to 1717±421 at BP2, decreased to 1602±351 mm Hg% at BP3, and increased to 1815±386 mmHg% at BP4 (p<0.001).

CONCLUSIONS. The timing during the echocardiography study and the patient's position on the scanning bed are critical determinants of the measured cuff SPB and the resulting values of MW parameters.

ID: 76: R EGRESSION OF E XTRA -V ALVULAR C ARDIAC D AMAGE A FTER TAVI AND S HORT -T ERM O UTCOMES IN A R EAL -W ORLD S ETTING

Fortuni Federico 1 , Myagmardorj Rinchyenkhand 2 , Nabeta Takeru 2 , Stassen Jan 2 , Galloo Xavier 2 , Meucci Maria Chiara 2 , Butcher Steel 2 , Van Der Kley Frank 2 , Reeger Madelien 2 , Delgado Victoria 3 , Bax Jeroen 2 , Ajmone Marsan Nina 2

1 San Giovanni Battista Hospital, Department of Cardiology - Foligno Italy, 2 Leiden University Medical Center - Leiden The Netherlands, 3 Hospital University Germans Trias i Pujol - Badalona Spain

Introduction: Aortic stenosis (AS) is the most common valvular heart disease in the elderly. Recently, a staging system based on the extent of cardiac damage was proposed.

Aim: This study aimed to evaluate the change in cardiac damage in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI) 6 months after the procedure and to assess its prognostic value.

Materials and Methods: Patients with severe AS undergoing TAVI were retrospectively analyzed. An echocardiographic 5-stage system based on the presence and extent of cardiac damage (Figure) was applied before TAVI and 6 months after the procedure. Multivariable Cox regression models were used to investigate the independent prognostic value of the change in cardiac damage.

Results: A total of 734 patients with severe AS (mean age 79.8±7.4 years, 54.5% male) were included. Before TAVI, 32(4%) patients did not show any sign of cardiac damage (Stage 0), 85(12%) patients had left ventricular damage (Stage 1), 220(30%) left atrial and/or mitral damage (Stage 2), 227(31%) pulmonary vasculature and/or tricuspid damage (Stage 3), and 170(23%) right ventricular damage (Stage 4). Six months after TAVI, 38% of patients improved at least 1 stage in cardiac damage. Cardiac damage staging 6 months after TAVI (HR per 1-stage-increase 1.422;95%CI 1.038-1.948;p=0.029) and, most importantly, improvement in cardiac damage during follow-up (HR 0.526;95%CI 0.285-0.969;p=0.013) were independently associated with 2-year all-cause mortality (Figure).

Conclusions: More than one third of patients undergoing TAVI showed an improvement in cardiac damage 6 months after the procedure which was associated with better outcomes.

ID: 77: L ONG -T ERM F OLLOW -U P OF I SOLATED L EFT V ENTRICULAR A PICAL H YPOPLASIA . A C ASE R EPORT

Franco Erica 1 , Conti Valentina 1 , Rovera Chiara 1 , Mazzanti Andrea 2 , Moretti Claudio 1

1 Civico Hospital - Chivasso, Turin Italy, 2 DEPARTMENT OF MOLECULAR CARDIOLOGY, IRCCS ICS Maugeri - Pavia Italy

Isolated left ventricular apical hypoplasia (ILVAH) is a rare cardiac malformation consisting of a truncated left ventricle (LV), an elongated right ventricle (RV) and apical fat infiltration.

The cause is unknown but may be related to inadequate LV–RV dilatation during partitioning.

We report a case of an asymptomatic 31-year-old athlete, who was referred to our Echo lab in January 2020, after the finding of anterior q wave on ECG. He was a mild smoker without other cardiovascular risk factors, in particular there was no familial history of any cardiac disease.

Echocardiography demonstrated a dilated and unusually shortened left ventricle (LV) with a severe systolic impairment (EF 40%), a stretched but normal functioning right ventricle (RV), no valvular anomalies, no signs of pulmonary hypertension, normal pericardium.

Coronary computed tomography excluded coronary artery disease.

Myocarditis laboratory screening was negative for autoimmune disease or recent viral infection.

Genetic testing did not detect any of the about 40 already known gene mutations. ECG monitoring did not register ventricular arrhythmias.

CMR supported the diagnosis of ILVAH.

The patient, treated with ACE inhibitors, beta-blockers, MRA, without symptoms or ventricular arrhythmias, received a wearable defibrillator life vest for three months and subsequently a loop recorder was implanted.

After about four years, no significant ventricular arrhythmias have been detected and no heart failure episodes occurred.

This case highlights the importance of considering unconventional etiologies of heart disease when investigating anomalous ECG even in completely asymptomatic sportsmen.

ID: 78: P ERMANENT P ACEMAKER V ENTRICULAR L EAD P OSITION : 3D ECHOCARDIOGRAPHIC E VALUATION A CCORDING TO T YPE OF V ENTRICULAR P ACING

Fusini Laura 1 , Marongiu Alessandro 1 , Maranzano Gaspare 1 , Arcudi Alessandra 2 , Dell’Era Gabriele 3 , Tundo Fabrizio 1 , Erbetta Riccardo 3 , Provenzano Enza 3 , Rondinara Giulia 3 , Garlasche’ Anna 1 , Pepi Mauro 1 , Muratori Manuela 1 , Pontone Gianluca 1 , Patti Giuseppe 3

1 Centro Cardiologico Monzino IRCCS - Milan Italy, 2 Cattolica University - Rome Italy, 3 Maggiore della Carità Hospital- Novara Italy

Introduction. The use of permanent pacemakers (PPM) has dramatically increased in recent years. The endocardial leads can cause tricuspid regurgitation (TR) when they interfere with tricuspid valve (TV) leaflet motion. Moreover, worsening of TR and mitral regurgitation (MR) can also be a consequence of ventricular pacing.

Aim. We sought to determine: 1) the feasibility of using 3D transthoracic echocardiography (TTE) to visualize the PPM leads, 2) the prevalence of different lead positions, 3) the early echocardiographic outcome according to the type of ventricular pacing (right ventricular apical pacing, RVAP, and left bundle branch area pacing, LBBAP).

Materials and Methods. A total of 48 patients who underwent PPM implantation with RVAP and LBBAP was prospectively enrolled. 2D and 3D TTE were performed in all patient at baseline and at 3-months follow-up.

Results. 3D TTE is feasible in 94% of patients. The posteroseptal commissure is the most frequent lead location regardless of the ventricular pacing modalities (65% RVAP vs 60% LBBAP, p = 0.761). Similar TV diameters were found using 2D and 3D dataset in both groups. Whereas higher distance between TV plane and lead tip insertion was found in the RVAP compare with LBBAP. At short-term follow-up, no differences were found in MR and TR severity according to type of ventricular pacing.

Conclusions. 3DTTE allows precise PPM-lead localization at the level of the tricuspid valve. Accordingly, this imaging modality should be routinely used to facilitate the timely detection of TV interference and early progression of TR that could potentially affect the prognosis.

ID: 79: R ECURRENT I NFECTIVE E NDOCARDITIS IN H YPERTROPHIC O BSTRUCTIVE C ARDIOMYOPATHY

Gaido Luca 1 , Piovano Elena 2 , Ballocca Flavia 2

1 MARTINI Hospital - Turin Italy, 2 MARIA VITTORIA Hospital- Turin Italy

A 53-year-old man with obstructive hypertrophic cardiomyopathy presented with pulmonary edema, atrial fibrillation and evidence of severe mitral valve regurgitation caused by perforation of anterior leaflet. Blood cultures were positive for Enterococcus faecalis and targeted antibiotic therapy was performed. After hemodynamic stabilization, patient underwent mitral valve repair with enlargement patch, annuloplasty ring insertion and Morrow septal myectomy. Native valve cultures resulted positive for Extended-spectrum β-lactamase-producing Escherichia coli. After long targeted antibiotic therapy and rehabilitation, blood cultures were negative and echocardiographic signs of endocarditis were absent. Two months later, patient presented with acute heart failure, fever and evidence of large vegetation involving anterior leaflet with patch detachment and severe mitral valve regurgitation. The patient underwent urgent mitral valve replacement with bioprostetic valve. Native valve cultures resulted positive for Candida albicans, instead blood cultures were positive for Enterococcus faecium. After long targeted antibiotic therapy and rehabilitation, blood cultures were negative and echocardiographic signs of endocarditis were absent. Three months later, patient presented with further recurrence of endocarditis with evidence of large vegetation involving posterior bioprosthetic valve annulus determining valve detachment, severe regurgitation and prosthesis rocking. Computed tomography showed splenic embolization and blood cultures resulted positive for Candida albicans, Staphylococcus pettenkoferi and Staphylococcus epidermidis. The patient underwent emergency mitral valve replacement with bioprostetic valve, complicated by perioperative left main embolization. Despite immediate thrombus aspiration and combined Intra-Aortic Balloon Pump and Extra-Corporeal Membrane Oxygenation support, patient developed mixed shock and died 15 days later.

ID: 80: A H UGE S TRING - L IKE M ASS ON N ORMAL N ATIVE A ORTIC V ALVE

Galzerano Domenico 1 , Alamro Bandar 1 , Pergola Valeria 2 , Di Michele Sara 3 , Elmahi Isra 4 , Hamad Alaa 4 , Aljheish Saif 1 , Mohammed Shamayel 5 , Khaliel Feras 1

1 Heart Centre, King Faisal Specialist Hospital & Research Center, College of Medicine, Alfaisal University - Riyadh Saudi Arabia, 2 Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua - Riyadh Italy, 3 Divisione di Cardiologia, Ospedale San Filippo Neri – Rome, Italy, 4 College of Medicine, Alfaisal University - Riyadh Saudi Arabia, 5 Department of Pathology and Laboratory Medicine, King Faisal Specialist Hospital & Research Center – Riyadh, Saudi Arabia

A 43 years old male known case of Polycythemia Vera, JAK-2 positive mutation, history of venous thrombosis, with renal and splenic infarcts one year before. In therapy with hydroxyurea and rivaroxaban, underwent a routine transthoracic echocardiography (E). It showed a large (0.8 x 1.6 cm), multilobed, mass attached to right(R) coronary cusp (CC) with homogeneous, myocardial like texture. Trace aortic regurgitation. Normal ventricular size and function, Further transesophageal (TE) E found a sessile mobile thick string-like mass (3 x 0.8 cm) attached to the commissural areas between and left (L) and RCC (Panel A, B transgastric view, C 3D TEE long axis). The large size, the attachment on a very mobile structure and the absence of clinical findings of infective endocarditis raised the suspicion of a tumor more than clot or vegetation. For the high risk of embolism the patient was sent for emergent surgery; a reddish mass attached by a stump in the commissural areas between R and L CC (size 1 x 0.65 cm) (panel D, specimen) was easily excided from the LCC but severely attached to a necrotic RCC. Anatomical features of the mass gave the surgeon the impression of a tumor. It was decided to replace the valve with a biological prosthesis. Unexpectedly it was found to be a clot at pathology. Native aortic valve thrombosis is a rare and challenging pathology often misdiagnosed. However, it has to be considered in the differential diagnosis to better choose the therapeutic strategy and surgical planning.

ID: 81: F ROM M ULTIMODALITY I MAGING TO THE M ICROSCOPE , A R IGHT A TRIAL M ASS D IAGNOSIS

Gamberini Giacomo, Santangelo Gloria, Carugo Stefano

Department of Cardio-Thoracic-Vascular disease, Foundation IRCCS Ca’ Granda Maggiore Hospital, Italy – Milano, Italy

Right atrial masses present a diagnostic challenge due to heterogeneous differential diagnosis.

We present a case of a woman with a history of a kidney transplant for nephronophthisis at age 18, complicated by post-transplant linfoproliferative disorder followed by graft failure. Subsequently, the patient underwent a second kidney transplant at age 22, and after two years, experienced cellular graft rejection leading to graft failure. In this circumstance, a Tesio catheter was positioned to perform hemodialysis. The patient was admitted to our hospital due to an infection at the venous catheter exit site and for the embolization and explantation of the graft, in preparation for another kidney transplant.

During the pre-operative screening, the patient underwent a transthoracic echocardiogram, which revealed a mass in the right atrium measuring 15 x 13 mm which appeared isoechoic and homogeneous, with regular borders. It exhibited a sextile shape and was firmly adherent to the atrial free wall. Despite investigations using cardiac magnetic resonance (D, E), computed tomography (C), and 2D and 3D transesophageal echocardiograms (A, B) with contrast agent, diagnostic ambiguity persisted. Histopathological examination of the tissues was deemed necessary to determine the etiological diagnosis. The mass was then surgically resected, and the histological examination revealed a thrombus.

Despite the broad armamentarium of noninvasive imaging that offers detailed morphologic delineation and tissue characterization, the correct diagnosis may remain elusive. Only tissue biopsy eventually provides the answer.

ID: 82: C RUCIAL R OLE OF T RANSTHORACIC E CHOCARDIOGRAPHY IN I SOLATED D OUBLE -C HAMBERED R IGHT V ENTRICLE IN AN A DULT P ATIENT

Gattari Bianca Maria 1 , Pantano Paola 2 , Rugolotto Matteo 2 , Caterino Anna Laura 2 , Martire Paola 2 , Terlizzi Raffaele 3 , Pellizzari Nicola 3 , Pradegan Nicola 1 , Cernetti Carlo 2

1 Padua University Hospital - Padua Italy, 2 Ca’ Foncello Hospital - Treviso Italy, 3 Castelfranco Veneto Hospital - Castelfranco Veneto (TV) Italy,

CASE REPORT: A 62-year-old female was admitted to the Medicine Department for infective pneumonia. Transthoracic echocardiography showed indirect signs of severe pulmonary hypertension. CT angiography excluded pulmonary thromboembolism. A first right heart catheterization showed normal pressures and resistance in the pulmonary circulation. Because of persistent clinical signs of right heart overload, another transthoracic echocardiogram was performed, showing a muscle band protruding from the interventricular septum towards the right ventricular free wall, dividing the ventricle into two cavities. A turbulent jet was seen through the stenotic mid-right ventricle, with a flow acceleration of 5,2 m/s, corresponding to a pressure gradient of 108 mmHg. Hence, a presumptive diagnosis of a double-chambered right ventricle (DCRV) was made. A cardiac MRI confirmed the diagnosis and raised suspicion of ventricular septal defect, which was ruled out by a second cardiac catheterization. Therefore, the patient underwent successful muscle bundle resection through right atriotomy.

DISCUSSION: DCRV is a rare congenital heart disease wherein a mid-cavitary obstruction divides the right ventricle into a high-pressure proximal portion and a low-pressure distal portion. Transthoracic echocardiography is the first diagnostic technique, but it is limited by the right ventricle’s irregular shape and retrosternal location. Turbulent mid-cavitary jets may also be confused with intracardiac shunts or high right ventricular pressures could be mistaken for pulmonary hypertension. However, these issues can be overcome: the obstruction is better visualized in parasternal short-axis and subcostal views, while the turbulent jet can be better directed using the subcostal view.

ID: 83: A SSESSING R IGHT A TRIAL S IZE IN P ATIENTS W ITH T RICUSPID R EGURGITATION : I MPORTANCE OF THE R IGHT V ENTRICULAR -F OCUSED V IEW

Gavazzoni Mara 1 , Cascella Andrea 1 , Badano Luigi P 1 , Pugliesi Giordano 1 , Penso Marco 1 , Hădăreanu Diana-Ruxandra 2 , Tomaselli Michele 1 , Oliverio Giorgio 1 , Heilbron Francesca 1 , Ciambellotti Francesca 1 , Fisicaro Samantha 1 , Muraru Denisa 1

1 IRCCS Istituto Auxologico Italiano, San Luca Hospital - Milan Italy, 2 Clinical Emergency County Hospital of Craiova - Craiova Romania

INTRODUCTION: Assessment of right atrial volume (RAV) in patients with secondary tricuspid regurgitation (STR) still relies on two-dimensional echocardiography (2DE) with a conventional apical 4-chamber (4Ch) view.

AIM: To investigate the clinical application of an apical right ventricular-focused (RVF) view for measuring RAV in patients with STR.

MATERIALS AND METHODS: We compared the RAV measures obtained using the 4Ch versus RVF views using three-dimensional echocardiography (3DE) as a reference. The outcome of the study was a composite of heart failure or death for any cause.

RESULTS. We included 384 patients (34% had mild STR, 36% moderate, and 30% severe). RAVs obtained from the 4Ch were significantly smaller than the RAV measured by 3DE compared with those obtained from RVF (-24% vs. -14%, respectively, p<0.001). The underestimation of RAVs was larger in lower grades of STR, with a difference of 28% vs. 17% in mild, 23% vs. 14% in moderate, and 19% vs. 11% in severe STR (p=0.001). Furthermore, the underestimation was significantly larger in the atrial STR (28% compared to 13%; p=0.002) than in the ventricular STR (22% compared to 14%; p=0.413). RAVs measured by 3DE and RVF showed a similar association with the composite outcome (area under curve, AUC respectively: (0.671·CI95% :0.590-0.752· vs 0.641·CI95%:0.558-0.724·, p=0.051). Conversely, RAVs obtained from the 4Ch showed a weaker association with the composite outcome (AUC: 0.607 ·CI95%:0.522-0.692·, p=0.021 vs RVF).

CONCLUSIONS. In patients with STR, RAV obtained from RVF is more accurate than 4Ch, and it is more closely associated with clinical outcomes.

ID: 84: M ASSIVE P ULMONARY E MBOLISM AND R IGHT H EART T HROMBUS

Ghiraldin Daniele, Grigolato Michele, Paris Sara, Garyfallidis Polyxeni

Spedali Civili Hospital - Brescia, Italy

Recent surgery is a risk factor for pulmonary embolism. Pulmonary embolism with related haemodynamic instability is a clinical condition characterized by a high risk of early death.

The case presented shows a 52 years old male hospitalized for acute pancreatitis treated with surgery. During the hospital stay after 25 days from surgery he developed persistent hypotension (BP 80/60 mmHg): at the urgent transthoracic echocardiography we found a dilated and hypokinetic right ventricle, septal flattening and a floating mass between right atrium and right ventricle suspected for thrombosis. An urgent computer tomography showed massive pulmonary embolism. The patient was transferred to the intensive care unit and treated with systemic thrombolysis. We performed a transthoracic/transesophageal echocardiography a week later showing no signs of floating masses in the right chambers; right ventricle was not dilated and normokinetic.

This case underlines the role of echocardiography in detecting right ventricle overload signs and potentially right-heart thrombi in the high-risk pulmonary embolism setting.

ID: 85: T RICUSPID V ALVE I NTERVENTION : E ARLY P ATIENT S ELECTION

Gibiino Vincenzo

University Hospital of Catania – Catania, Italy

Tricuspid regurgitation is a frequently encountered condition in the population, and the prevalence of significant regurgitation increases with the age of patients. Tricuspid regurgitation causes symptoms of both right and left heart failure, significantly impacting life expectancy and quality of life. Today, there are various interventional and minimally invasive techniques available to address the tricuspid valve.

However, the accurate identification of the structural characteristics that would make a patient a candidate for intervention, even in the early stages, has not been adequately determined.

ID: 86: L AY L ADY L AY : A T RICKY C ASE OF P LATIPNEA O RTODEOXYA S INDROME

Gironella Pier Paolo, Coraducci Francesca, Luciani Lara, Barbarossa Alessandro, Manca Carla

Riuniti Hospital – Ancona, Italy

A patent foramen ovale (PFO) with right to left shunt does not occur unless there are clinical conditions that raise right atrial pressure. In the platipnea-ortodeoxya sindrome (POS) R-L shunt occurs due to anatomical alteration of the interatrial septum that happens only in the upright position causing the direct venous flow from inferior vena cava through PFO or an atrial septal defect into left atrium, particularly in presence of an extremely mobile septum and right atrial pressure overload.

We present a case of a woman of 77 y.o. with no relevant past medical history that was admitted to hospital care for mild pulmonary embolism (PE). She was treated with direct oral anticoagulation promptly achieving the resolution of the embolism. However her dyspnoea did not improve and laboratory tests showed a normocapnic hypoxiemic respiratory insufficiency with a suspicious lowering of oxygen saturation levels manteining upright position while improved in supine position. She also had a transient episode of dysarthria and hypostenia to right upper limb, suggestive of transient ischemic attack (TIA). A pulmonary scintigraphy showed arterious renal perfusion as in a right to left shunt while transoesophageal echocardiography recorded an hypermobile interatrial septum with evidence of PFO with left to right shunt in the supine position. Because of this records, the severity of shunt and the transient ischemic attack, she underwent PFO closure positioning an Amplatzer PFO Occluder 25 mm, with no complications and complete resolution of symptoms and signs characterized POS.

ID: 87: I NFECTIVE OR N OT ? T HAT WAS THE Q UESTION : A C HALLENGING C ASE OF M ITRAL V ALVE M ASS

Gironella Pier Paolo, Torselletti Lorenzo, Luciani Lara, Manca Carla

Riuniti Hospital – Ancona, Italy

We present a case of a man, 60 y.o. with several cardiovascular risk factors (diabetes mellitus, sistemic arterial hypertension, smoking), previous history of ischemic stroke and advanced renal desease, admitted to emergency department for lipothymia associated with fever lasting two weeks.

Laboratory tests showed anemia, increased white blood cell count and markers of inflammation while chest radiography revealed diffuse lung interstitial desease.

At the same time nasopharyngeal swab resulted positive for Sars-Cov-2 virus so the patient was hospitalized with diagnosis of viral pneumonia, complicated by bacterial and fungal superinfection in the following weeks requiring administration of antibacterial agents.

Because of these records, a transtoracic echocardiography was requested and showed an adherent hyperechogenic mass to posterior mitral anulus, with high suspicion of infective endocarditis.

So a transesophageal ecocardiography was carried out and revealed a mass with few characteristics of infective vegetation. On the other hand a PET was performed and the lesion appeared to adsorbe the radiotracer, meaning that there was an acute process.

Infective or not? That was the question. A specific antibacterial treatment was introduced but the theory of bacterial endocarditis did not convinced many of us, that thought should be a case of mitral anular calcification or a tumoral mass.

As a consequence (and last chance) we requested a cardiac magnetic resonance that rejected hypothesis of bacterial endocarditis and tumoral mass in favour of isolated mitral anular calcification.

Antibiotic therapies were stopped and lesion appeared stable in the following echocardiographic checks

ID: 88: M YOCARDIAL W ORK AND A TRIAL F UNCTION D URING E XERCISE IN P ATIENTS WITH M ID -R ANGE E JECTION F RACTION H EART F AILURE

Gismondi Alessandro, D’Antoni Valentino, Morsella Valentina, Catena Matteo, Vadalà Sara, Di Biasio Deborah, Silvestrini Marco, Cascelli Giovanna, Caminiti Giuseppe, Marazzi Giuseppe

IRCCS San Raffaele Roma - Pisana - Rome Italy

Introduction: changes occurring in myocardial work and left atrial function during incremental exercise in in patients with heart failure with mid-range ejection fraction (HFmrEF) have been poorly studied. Aims: to assess cardiac adaptations occurring in HFmrEF during incremental exercise. Methods: twelwe patients with established HFmrEF were compared with age-matched healthy controls. All subjects performed a stepwise exercise test on cyclette. Echocardiography was performed at baseline, during submaximal effort (SE), at peak of exercise (PE), and during recovery. Results: the two groups obtained similar METs at PE; heart rate and systolic blood pressure were higher in the control group than in the HFmrEF (between-groups p 0.006 and p 0.003 respectively). Global constructive work increased significantly in both groups at submaximal exercise; it further increased at peak exercise in HFmrEF while it tended to decrease in controls. Global waste work increased in both groups in a similar way at SE while it presented a greater increase in the control group than in HFmrEF at PE. At SE, LA reservoir strain (LARS) and conduit strain (CS) increased in both groups. At PE, LARS and CS remained unchanged in HFmrEF while returned at baseline values in controls. At PE stroke volume remained constant in the HFmrEF while decreased in controls (p 0.002); cardiac output increased in both groups. Conclusions: HFmrEF were able to properly increase their cardiac output, during incremental exercise, by relying on their atrial reserve

ID: 89: C HANGES IN L EFT A TRIAL F UNCTION A FTER T WO M ODALITIES OF E XERCISE IN C ORONARY H EART D ISEASE

Gismondi Alessandro, D’Antoni Valentino, Marazzi Giuseppe, Morsella Valentina, Catena Matteo, Silvestrini Marco, Vadalà Sara, Di Biasio Deborah, Di Carlo Roberto, Caminiti Giuseppe

IRCCS San Raffaele Roma - Pisana - Rome Italy

Introduction: left atrial function is impaired in patients with coronary heart disease (CHD) and reflects a rising left ventricular diastolic pressure. The effects of exercise training on atrial function are poorly understood. Aim: investigating the effects of two regimes of combined training (CT) program on left atrial function in patients with CHD. Methods: the study included 45 stable patients, who were randomly assigned to three groups: fifteen patients were assigned to a supervised CT with low frequency (two session/week) (CTLF); fifteen to supervised CT with high frequency (three session/week) (CTHF); a third group to follow contemporary exercise preventive guidelines at home (Control). The protocols lasted 12-weeks. Before and after training, all patients performed a symptoms-limited exercise test and an echocardiography. The training included aerobic continuous at moderate intensity, and resistance exercise performed at 60% of 1 repetition maximum. Results: at 12-weeks, exercise duration at ergometric test presented a significant greater increase in the CTLF and CTHF groups compared to control (p 0.002). Peak atrial longitudinal strain (PALS) and conduit phase presented a significant increase in the CTHF and were unchanged in CTLF and control (p 0.008). Peak atrial contraction strain (PACS) presented a greater increase in CTHF than control. Left ventricular global longitudinal strain, increased significantly in both CTHF and CTLF compared to control (p 0.004). No adverse effects were observed. Conclusions: a regimen of CT at high frequency was more effective than low frequency in improving atrial function in CHD patients.

ID: 90: M ULTIMODALITY I MAGING IN D IFFERENTIAL D IAGNOSIS OF T WO R ARE C ARDIAC M ASSES IN THE S AME P ATIENT

Giubertoni Elisa, Conti Massimo, Guerri Elisa, Navazio Alessandro

Civil Hospital - Guastalla (RE) Italy

BACKGROUND: Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification (MAC). It involves mainly the posterior annulus and is more common in elderly women; it’s associated with abnormalities of calcium metabolism. Usually an incidental finding, may be complicated with valvular dysfunction, systemic embolization or conduction abnormalities. Lipomatous hypertrophy of the interatrial septum (LASH) is a benign lesion characterized by massive accumulation of fat, typically sparing the fossa ovalis. It’s associated with obesity, advanced age and chronic corticosteroid therapy; the relationship with supraventricular arrhythmias is uncertain. Differential diagnosis includes other intracardiac masses, such as tumors, abscesses or vegetations.

CASE DESCRIPTION: 78 years old female patient, with multiple comorbidities (severe asthma, obesity and hyperparathyroidism with hypercalcemia) had repeated accesses to emergency department for paroxysmal supraventricular tachycardia. She refused ablation and was under treatment with verapamil. During cardiology consultation, transthoracic echocardiography has been performed and highlighted two intracardiac masses: one on the interatrial septum and the other under the mitral anterior leaflet.

TEST AND RESULTS: We decided to perform cardiac MRI. The one on the interatrial septum showed homogeneous high signal intensity in T1-weighted images and low signal in T2 fat-suppressed, therefore compatible with lipomatous hypertrophy. The other appeared as roundish and well-defined mass with hyperintense center and hypointense rim, as well as consensual movement with mitral valve apparatus: compatible with CCMA, determining moderate regurgitation without stenosis.

CONCLUSIONS: Both the incidental masses resulted benign and without clinical implications: we avoided further invasive approach in our frail patient.

ID: 91: R ECURRENT I NFECTIVE E NDOCARDITIS ON B IOLOGICAL M ITRAL P ROSTHESIS IN A R ENDU O SLER P ATIENT

Gizzi Germana, D’Agostino Simone, Ianni Umberto, Molisana Michela, Parato Vito Maurizio

“Madonna del Soccorso” Hospital - San Benedetto del Tronto (AP) Italy

A 75-year-old woman suffering from Rendu-Osler syndrome came to our observation in December 2023 for fever and septic shock: she had history of previous hospitalization in 2018 for infective endocarditis from S.aureus on a native mitral valve treated with a bioprosthesis implant; after one year there was a recurrence of endocarditis with the need for reoperation and replacement of the bioprosthesis with a mechanical prosthesis; in June 2023 she was hospitalized for a third recurrence of S.aureus endocarditis with echocardiographic evidence of partial detachment of the prosthesis and severe perioprosthetic mitral insufficiency and underwent surgery to replace the mechanical prosthesis with a biological valve prosthesis Epic n.31 and mitral subvalvular pseudoaneurysm repair with heterologous pericardial patch. The patient was initially treated with vasopressors and empiric antibiotic therapy with meropenem, daptomycin and gentamicin with partial clinical response. Following isolation of S.aureus from blood cultures, targeted antibiotic therapy was introduced according to the antibiogram with oxacillin IV. with progressive clinical and laboratory improvement. A transesophageal echocardiogram was performed which documented normal positioning and functioning of the mitral bioprosthesis, absence of periprosthetic leaks and evidence on 3D-reconstruction of circumferential thickening of the prosthetic ring with hyperechoic material suggestive of infectious-inflammatory localization, in the absence of clear endocarditic vegetations. CT-PET was performed which confirmed the presence of hyperfixation of the radiopharmaceutical in correspondence with the periprosthetic region, compatible with phlogistic-septic localization. Cardiac surgical evaluation was performed with a negative opinion on reoperation and indication for conservative treatment with continued antibiotic therapy and echocardiographic follow-up.

ID: 92: D IAGNOSTIC D IFFICULTIES IN S EVERE L EFT V ENTRICULAR H YPERTROPHY WITH E XTENSIVE F IBROSIS

Gnan Eleonora, Pandolfi Andrea, Calcagnino Margherita, Santangelo Gloria, Carugo Stefano

Foundation IRCCS Ca’ Granda Maggiore Hospital, - Milan Italy

A 49-year-old man presented to the Emergency Department with acute pulmonary oedema and systemic congestion during hypertensive emergency.

Echocardiography showed severe concentric left ventricular hypertrophy (LVH) and a left ventricular ejection fraction of 50%, without any other abnormalities.

The severe LVH was felt to be excessive to be solely explained by long-lasting pressure overload. Hence, we performed a cardiac magnetic resonance (CMR) that confirmed the severe concentric LVH and showed extensive and diffuse late gadolinium enhancement (LGE), with non-ischemic distribution, in nearly all cardiac segments except for relative sparing of the LV septum.

Further investigations were performed to exclude hypertrophic cardiomyopathy (HCM) phenocopies.

Cardiac amyloidosis was ruled out by a negative bone scintigraphy and by normal immunological examinations. Fabry disease and hemochromatosis were excluded by a negative enzyme assay test and normal Iron metabolism levels, respectively.

Two relatively common conditions, i.e. hypertensive heart disease and HCM, and two rarer ones, i.e. Danon disease and Carnitine Palmitoyl transferase 1 (CPT1) deficiency, were still in play as differentials. Therefore, we performed genetic testing with a tailored gene panel, whose results are not yet available.

This case shows how extensive clinical and radiological work-up may not be enough to reach a definitive etiological diagnosis of cardiac hypertrophy. In this scenario, genetic testing and endomyocardial biopsy, the latter not performed in our patient, may assume a pivotal role. Indeed, the lack of a clear etiologic diagnosis carries along significative therapeutic implications such as a different consideration of arrhythmic and SCD risk.

ID: 93: TAPSE/PASP R ATIO AND IN -H OSPITAL O UTCOMES IN P ATIENTS W ITH S EVERE P RIMARY M ITRAL R EGURGITATION U NDERGOING C ARDIAC S URGERY

Grieco Martina 1 , Bonelli Andrea 2 , Guasti Serena 2 , De Sanctis Giorgio Maria 3 , Cerrito Luca Felice 4 , Musca Francesco 2 , Belli Oriana 2 , Casadei Francesca 2 , Spanò Francesca Maria 2 , Russo Claudio Francesco 2 , Giannattasio Cristina 2 , Moreo Antonella 2

1 Roccasaspide Hospital - Roccadaspide (SA) Italy, 2 ASST Niguarda Hospital - Milano Italy, 3 San Giovanni Evangelista Hospital - Tivoli Italy, 4 San Bortolo Hospital - Vicenza Italy,

Introduction: Recent data suggests that right ventricular to pulmonary artery (RV-PA) uncoupling negatively influences prognosis in several clinical conditions.

Aim: Our study aimed to investigate the role of RV-PA coupling in patients with chronic severe primary MR (PMR).

Materials and Methods: We retrospectively assessed patients with severe PMR undergoing surgical repair or replacement. Patients underwent preoperative transthoracic echocardiography. RV-PA coupling was assessed by the ratio of tricuspid annular plane systolic excursion (TAPSE) and pulmonary artery systolic pressure (PASP). We studied the association between TAPSE/PASP and the length of stay in the intensive care unit (ICU), the length of hospitalization and NYHA class at discharge.

Results: 144 patients were included in the study. Patients with lower TAPSE/PASP had lower left ventricular ejection fraction (58.6±10.0% vs. 60.9±6.1% vs. 63.5±6.3%,p=0.009) and more dilated left atrial volume (LAV: 69.3±24.1 vs 65.4±25.6 vs 54.9±20.2 ml/m2, p=0.009). Patients with lower TAPSE/PASP had longer hospital stay(11.2±3.8 vs 10.1±3.0 vs 9.0±2.9 days, p=0.045) and stay in ICU (3.4±2.0 vs 2.9±2.4 vs 1.9±1.2 days, p<0.001). There was a significant inverse association between TAPSE/PASP and length of stay in ICU and hospital stay [respectively β= -0.32(-0.46;-0.19), p<0.001 and β=-0.42(-0.65;-0.19), p =0.001] and between TAPSE/PASP and the probability of having a NYHA class ≥ 2 at discharge [OR 0.68(0.55;0.85),p=0.001]. These relationships were confirmed after adjustment for other variables.

Conclusions: In patients with PMR undergoing cardiac surgery RV-PA coupling may identify a more compromised group of patients and it is related to clinical outcomes in the very short-term after surgery.

ID: 94: A B IG H UGE H OLE

Grimaldi Emilia, Fico Vera, D’Alfonso Maria Grazia, Oddo Andrea, Mori Fabio

Careggi Univeristy Hospital– Florence, Italy

Introduction: Persistent left superior vena cava (PLSVC) is a rare embryologic anomaly of the systemic venous circulation and results from the absence of involution of the left anterior cardinal vein. It is increased in patients with congenital cardiovascular disease, such as atrial septal defect (ASD); the clinical significance of a PLSVC will vary from asymptomatic to severe symptom.

Case report: A 65 years old female without cardiovascular risk factors and completely asymptomatic for angor, dyspnea. During follow-up for melanoma, chest X-ray revealed enlargement of right sections, which led to a cardiology referral. Electrocardiography revealed signs of right ventricular enlargement. Transthoracic echocardiography (TTE) unveils a dilated right ventricle and shows a coronary sinus (CS) dilation and suspected ASD. The dilatation of the CS raised suspicion of PLSVC. Transesophageal echocardiography drop out a large ASD (41x 31 mm). Then saline contrast echocardiography was performed and showed the bubbles traveling from the CS and then into right atrium (RA) shortly after the contrast was injected.

This finding was diagnostic for the existence of a PLSVC. Cardiac Nuclear Magnetic Resonance Imaging confirmed the diagnosis. The patient is therefore now awaiting surgical closure of ASD.

Conclusion: Our case confirms the possible association between ASD and PLSVC. PLSVC should be suspected if we find dilatation of CS. Sophisticated imaging is not always available in each health care provider. TTE with agitated saline injections through the left and right antecubital veins provides a simple, and inexpensive, but effective study for a rapid bedside diagnosis of PSLVC.

ID: 95: T RICUSPID V ALVE G EOMETRY AND R EGURGITATION A FTER P ERCUTANEOUS E DGE - TO -E DGE V ALVE R EPAIR : A 3D T RANSESOPHAGEAL S TUDY

Gripari Paola, Maranzano Gaspare, Mantegazza Valentina, Fusini Laura, Garlaschè Anna, Marongiu Alessandro, Fazzari Fabio, Ferrari, De Marco Federico, Pepi Mauro, Pontone Gianluca, Muratori Manuela

Monzino Cardiological Center, IRCCS – Milan, Italy

Introduction: Tricuspid transcatheter edge-to-edge repair (T-TEER) is an emerging treatment for significant tricuspid regurgitation (TR) in symptomatic patients at high risk for convetional surgery.

Aim: Aims of the study were to evaluate immediate changes in the tricuspid valve (TV) geometry induced by T-TEER and correlations between baseline geometry and residual intraoperative TR.

Materials and Methods: 25 patients with symptomatic severe TR (≥ grade 4) who underwent T-TEER were enrolled. Intraoperative transesophageal echocardiographic 2D and 3D images were acquired immediately before and after the procedure. 3Ddatasets were processed offline using a dedicated software for 3D analysis of the TV morphology.

Results: All patients were successfully treated: 18 patients reached an optimal result with a residual regurgitation ≤ 2 and 7 patients showed grade 3 or 4. 3D datasets were adequate for analysis in 19 patients. Anatomic TV parameters obtained with intraoperative transesophageal echocardiography immediately before and after T-TEER are showed in Table 1. 2D and 3D area, perimeter, diameter in 2-chamber view and minor diameter of the tricuspid annulus significantly reduced after the procedure. A significant reduction in TR was observed irrespective of annulus changes.

Conclusions: T-TEER is associated with significant reduction in TR and remarkable changes in TV geometry, especially with a significant reduction in annulus area and perimeter. These variations seem to be mainly attributed to a reduction in the minor axis (antero-posterior). This may play a role in the effectiveness of T-TEER in reducing TR.

ID: 96: C ANCER T HERAPY -R ELATED M ODERATE AND R EVERSIBLE C ARDIAC D YSFUNCTION : A C ASE R EPORT

Guarino Simona, Giaimo Valerio, Barbanti Marco

Umberto I Hospital – Enna, Italy

A 57-year-old woman was diagnosed with ductal carcinoma in her left breast (pT1cpN0SN). The treatment consisted of a quadrantectomy followed by adjuvant treatment with four cycles of doxorubicin and cyclophosphamide, 12 times weekly paclitaxel and trastuzumab. She had no medical history and her only cardiovascular risk factors were hypertension, dyslipidemia and familial history of ischemic heart disease. Before treatment, her blood pressure was normal (110/70 mmHg), the electrocardiogram (ECG) showed left bundle branch block (LBBB) and the echocardiography displayed a normal left ventricle (LV) with a normal left ventricular ejection fraction (LVEF) of 58% and global longitudinal strain (GLS) of 19.8%. During the first 2 months of follow-up, the echocardiography displayed a LVEF moderately reduced of 40% and GLS of 14%; the patient remained symptom-free. She was treated with heart failure medication including ramipril (5 mg once a day) and bisoprolol (5 mg once a day) and canrenone (50 mg once a daily) titrated up to the maximum tolerated dosage. The patient underwent coronary computed tomography angiography (CCTA) which showed no coronary artery disease. Cardiac magnetic resonance imaging (MRI) displayed a normal LV with EF of 43% without edema and delayed enhancement. At a 2-months follow-up, echocardiogram showed recovery of the LV function to a LVEF of 52% and a GLS of 17%. Troponin T (TropHS T) was slightly high (24 pg/ml). Thus, after a short interruption of trastuzumab therapy, she is resuming therapy under close clinical and laboratory monitoring.

ID: 97: A SYMPTOMATIC A CUTE M ITRAL I NSUFFICIENCY : A C ASE R EPORT

Idone Gaetano, Oro Pietro , Onorato Federica, Pugliese Giulia, Imbriglio Gian Marco, Desimone Pietro, Ricci Giulia, Barillà Francesco

Tor Vergata University Hospital – Rome, Italy,

Acute mitral insufficiency(AMI) is a life-threatening medical and surgical emergency that is rarer than chronic MI and often associated with severe hemodynamic impairment. The most frequent causes of AMI are spontaneous rupture of a chord tendon, rupture of the mitral flap during infective endocarditis and post-ischemic rupture of a papillary muscle. It generally presents as acute pulmonary edema due to the sudden increase in the filling pressures of the pulmonary circulation or as cardiogenic shock. Clinical case:A 60-year-old-male patient, who came to the ER for a syncopal episode at rest, in the absence of symptoms and signs of pulmonary congestion and reduced flow rate and with normal vital signs. Asymptomatic. He was a former employee of the Air Force and he underwent frequent cardiological check-ups, which were always found to be normal. On the entrance ECG:sinus rhythm, monomorphic ventricular bigeminism, blood chemistry in the normal range except PCR. TTE:normal systolic function, mild left atrial dilatation, severe mitral insufficiency, large eccentric jet with Coanda effect directed towards the anterior wall of the left atrium, evident rupture of chorda tendinous with flail of the posterior flap of the mitral valve, myxomatous in appearance(Carpentier’s type II). Mild to moderate aortic insufficiency. The patient underwent ETE and was sent to Cardiac Surgery for urgent repair surgery. Conclusions:The uniqueness of the case depends mainly on the complete absence of symptoms or objective signs in the patient. In case of syncope associated with ventricular extrasystole, the TTE should be performed immediately in the ER to rule out myocardial disease and/or valvulopathies, even in young patients.

ID: 98: M ULTIMODALITY I MAGING FOR THE D IAGNOSIS OF M ITRAL V ALVE B LOOD CYST

Ielapi Jessica 1 , Volpe Lorenzo 1 , Carbone Andrea 1 , Petullà Maria 2 , Mascaro Giuseppina 2 , Indolfi Ciro 1 , Aquila Iolanda 2

1 Magna Graecia University of Catanzaro - Catanzaro Italy, 2 R. Dulbecco University Hospital- Catanzaro Italy

Introduction. Blood cysts of the heart are rarely seen in adults because they are congenital abnormalities that typically resolve before adulthood.

Case presentation. A 59-year-old good-health female was referred to the cardiology unit for palpitations and dizziness for 3 days. The electrocardiogram showed atrial fibrillation. The transthoracic echocardiogram revealed a mass attached to the mitral valve (MV), with clear hyperechogenic walls and hypoechogenic content, adherent to the ventricular side of the anterior MV leaflet and chordae. The administration of eco potentiator hadn’t evidence contrast impregnation. The color Doppler examination showed mitral regurgitation of a moderate degree. The transesophageal echocardiogram confirmed the presence of a round cystic mass (approximately 1.3x1.1x1.6 cm), that didn’t create functional inflow and outflow obstruction. To make differential diagnosis with other cardiac masses, a cardiac TC was performed and it confirmed the presence of a round and solid mass (1.4x1.8 cm) adherent to the anterior leaflet of the MV and projecting into the left ventricle. The mass was hypodense in the arterial phase, in the absence of contrastographic impregnation, and slightly hypodense in the venous and late phases. After the diagnosis of a blood cyst with MV dysfunction the patient was referred for cardiac surgery evaluation and the decision was made to valve replacement with a biological valve.

Conclusions. Intracardiac blood cysts are rarely seen in adults and for this reason, they could be misdiagnosed with other common cardiac masses (vegetation, thrombus, myxoma, fibroelastoma). It is essential the use multimodality imaging to reach the correct diagnosis.

ID: 99: I DENTIFICATION AND C HARACTERIZATION OF A Q UADRICUSPID A ORTIC V ALVE C OMBINING T RANSTHORACIC AND T RANSESOPHAGEAL E CHOCARDIOGRAPHY

Labriola Antonio Raffaele, Santillo Vincenza

S. Giuseppe Moscati Hospital - Aversa (CE) Italy

A 30-year-old white man was referred to our Division of Cardiology with dyspnea on exertion, fatigue, dizziness and increase in the systolic blood pressure. His physical examination demonstrated wide pulse pressures with diastolic murmur. Transthoracic echocardiography revealed preserved left ventricular systolic function and possible quadricuspid aortic valve with moderate aortic regurgitation. Transesophageal echocardiography detected a quadricuspid aortic valve characterized by four cusps of equal size and confirmed moderate aortic valvular regurgitation, without any further anomalies. He underwent to annual clinical and transthoracic echocardiography checkup.

Quadricuspid aortic valve (QAV) is a rare form of congenital malformation. It was first described by Balington by autopsy study in 1862. Aortic regurgitation is the predominant valvular dysfunction associated with QAV, whereas valvular stenosis is very rare. QAV may also be diagnosed as a lonely lesion without other malformation, but QAV could be associated with patent ductus arteriosus, anomalies of coronary arteries, ventricular septal defect and pulmonary artery stenosis, subaortic fibromuscular stenosis, and hypoplasia of anterior mitral leaflet.

Conclusions: Quadricuspid aortic valve anomaly is a rare congenital cardiac defect that can be well diagnosed combining transthoracic and transesophageal echocardiography.

ID: 100: C ARDIAC CT I DENTIFICATION OF F IBRO -A DIPOSE T ISSUE I NFILTRATION IN A P ATIENT WITH C ONTRAINDICATION FOR CMR

Lassandro Eleonora, Motta Raffaella, Mattesi Giulia, Rigato Ilaria, Bauce Barbara, Iliceto Sabino, Pergola Valeria

Padua University Hospital – Padua, Italy

A 57 years old man was referred to our Center because of asymptomatic recurrent ventricular extrasystoles. The cardiological history was not significant, except for dyslipidemia treated with statin and ezetimibe. Rest ECG showed alterations of the repolarization phase in the left-sided leads (T wave inversion). Transthoracic echocardiograph did not show relevant structural alterations and routine blood examination was normal. Furthermore the patient underwent a previous cardiac CT exam at another hospital, which shown the presence of suspected epicardial fibrosis.

As the patient was claustrophobic, cardiac magnetic resonance was contraindicated and so cardiac CT was chosen as the main imaging technique. The exam was aimed at myocardial tissue characterization (MDCT 320 slices, prospective protocol and LE).

Cardiac CT showed hypodense areas with sub-epicardial distribution in the lateral, infero-lateral and anterior medium apical walls of the left ventricle. The characteristics of these areas were highly suspicious for fibro-adipose tissue infiltration. In addition, in the late contrast phase, it was possible to detect a sub-epicardial late enhancement stria in the left ventricular medium apical antero-lateral wall (non-ischemic pattern).

It was finally possible to rule out significant coronary artery disease as the exam only documented two focal eccentric plaques in the first tract of the LAD (CAD-RADS 2).

All these findings, together with the history of ventricular extrasystoles and the ECG abnormalities, were highly suspicious for left dominant arrhythmogenic cardiomyopathy.

The patient underwent genetic testing and the results will be available soon.

ID: 101: T HE S WORD T HAT D OES N OT H URT

Laurito Marianna 1 , Nassar Ashraf 2 , Grossule Francesca 2 , Turina Maria Cristina 1 , Grimaldi Teresa 1 , Mantovani Francesca 1 , Copelli Silvia 1 , Farì Antonio 3 , Navazio Alessandro 1

1 S. Maria Nuova Hospital- Cardiology Unit - Reggio Emilia, Italy, 2 Modena-Reggio Emilia University - Modena Italy, 3 S. Maria Nuova Hospital - Radiology Department - Reggio Emilia Italy

Introduction: A multidisciplinary approach and the use of multimodal imaging are crucial in diagnosing congenital heart disease (CHD) even in adulthood.

Case history: a 58-year-old female with no known cardiovascular risk factors and no significant cardiac history, presented to the emergency room with dyspnea, cough and fever.

Chest X-ray revealed parenchymal consolidation in the right lung; the cardiac shadow was deviated towards the right side. Chest CT showed a single right lung lobe and an anomalous vascular structure, seemingly originating from the inferior vena cava (IVC). Additionally, bilateral consolidations were noted, leading to admission with a diagnosis of pneumonia.

A 2D echocardiogram revealed a rightward displacement of the heart, a hypoplastic right pulmonary artery branch and a vessel entering the IVC at the junction with the right atrium. However, the right heart chambers showed no dilation, and there were no signs of pulmonary hypertension. An angio-CT confirmed the presence of a vertical venous collector along with distinctive pulmonary anomalies, including right lung hypoplasia and a horseshoe lung. These findings raised suspicion of vascular anomaly of venous pulmonary return: the Scimitar Syndrome. In this specific case, due to the absence of signs of right ventricular overload and pulmonary hypertension, an annual clinical and instrumental follow-up was recommended.

Conclusions: Scimitar syndrome, a rare CHD, is a variant of partial anomalous pulmonary venous return causing a left-to-right shunt. Named for its distinctive anatomical resemblance to a Turkish sword, it also involves specific alterations in pulmonary anatomy.

ID: 102: 3D-A UTOMATED , M ACHINE -L EARNING V ERSUS S TANDARD 2D-E CHOCARDIOGRAPHY : A SSOCIATIONS OF O UTCOMES IN P ATIENTS R EFERRED FOR C LINICALLY I NDICATED S TUDIES

Laus Vera, Barbieri Andrea, Bonini Niccolò, Bartolomei Mario, Torlai Triglia Laura, Chiusolo Simona, Stuani Marco, Mari Chiara, Muto Federico, Righelli Ilaria, Malaguti Mattia, Gerra Luigi, Boriani Giuseppe

Modena University Hospital, University of Modena and Reggio Emilia – Modena, Italy

Introduction. Artificial intelligence-powered three-dimensional (3D) transthoracic echocardiography offers precise left chamber measurement in line with cardiac magnetic resonance. However, its ability to refine prognostic assessment over standard two-dimensional (2D) echocardiography has not yet been demonstrated.

Aim. We tested the association of the 3D and the standard 2D parameters with the clinical outcomes collected during the same study.

Materials and Methods. 3D metrics were quantified by the Dynamic Heart Model (DHM: end-diastolic position=60/60; end-systolic position = 30/30). The outcome was a composite of all-cause mortality and cardiovascular hospitalizations. In a multivariate binary logistic regression analysis, we identified independent echocardiographic events’ predictors using variables associated with the outcome at the univariate analysis and excluding multicollinearity.

Results. We evaluated 872 consecutive patients (49% females, 64 ± 16 years) referred for clinically indicated studies. During follow-up (3.0 ± 2.0 years), 192 (22%) composite outcome events occurred. In the multivariate analysis, left ventricular end-diastolic volume indexed (LVEDVi) 3D (OR 0.97, IC95% 0.96-0.99), LV mass indexed (LV MASSi) 3D (OR 1.02, IC95% 1.03-1.04), left atrial ejection fraction (LAEF) 3D (OR 0.97, IC95% 0.96-0.99) and LA maximum volume indexed (LAVi max) 3D (OR 1.02, IC95% 1.00-1.05) were independently associated with the composite outcomes, while LVEF 3D and myocardial contraction fraction (MCF) 3D showed a trend toward significance. In contrast, none of the 2D parameters were associated with the composite outcome in the multivariate analysis (Figure).

Conclusions: In patients who underwent clinically indicated echocardiography, 3D-DHM parameters showed a more robust association with outcome than conventional 2D parameters.

ID: 103: P REVALENCE OF L OW -F LOW S TATE BY A UTOMATED M ACHINE -L EARNING 3D ECHOCARDIOGRAPHY IN A ORTIC S TENOSIS AND N ORMAL E JECTION -F RACTION

Laus Vera, Barbieri Andrea, Bonini Niccolò, Torlai Triglia Laura, Chiusolo Simona, Stuani Marco, Mari Chiara, Muto Federico, Boriani Giuseppe

Modena University Hospital, University of Modena and Reggio Emilia – Modena, Italy

Introduction. In aortic valve stenosis (AS), measurement of stroke volume index (SVi) is required to calculate the aortic valve area (AVA) and determine flow status. The 2D Doppler-derived technique is prone to potential errors. An accurate LV volumetric method without geometric assumptions may overcome the constraints of the 2D Doppler SVi calculations.

Aim. To investigate the prevalence of low-flow (LF) state (SVi ≤35 ml/m2) in patients with AS and preserved ejection fraction (EF) by automated machine-learning 3D echocardiography and its repercussions on flow status reclassification in patients with AVA≤1cm2.

Materials and Methods. Consecutive patients with AS (peak velocity >2.5 m/s) and EF>50% underwent Dynamic Heart Model (DHM) evaluation with larger settings of the boundary detection sliders (end‐diastolic position= 60/60; end‐systolic position= 30/30).

Results. We included 101 patients (mean 75,+-13 years; 42% females). Based on DHM, 17% had LF and 26% by the 2D Doppler method. The correlation between SVi by DHM and the 2D Doppler method was poor (Pearson coeff.=0.483, p50%, the prevalence of LF state may be significantly lower when the LV metrics by DHM are employed, posing the question of how better to describe LF in the modern 3D era.

ID: 104: A N U NUSUAL C ASE OF I SCHEMIC S TROKE

Lavanco Vincenzo, Vitale Carolina, Felis Salvatore

Garibaldi Hospital – Catania, Italy

BACKGROUND: Left atrial appendage (LAA) closure represents an alternative to anticoagulation therapy for stroke prevention in selected patients with atrial fibrillation (AF). Mitral valve repair with MitraClip system is nowadays a specific therapy for patients who are not eligible for surgery.

CASE SUMMARY: G. G. 71 years old, F, admitted in the neurology ward of our hospital with diagnosis of ischemic stroke. Recent discharge from cardiology unit after mitral valve repair with MitraClip system and left atrial appendage (LAA) closure with Amplatzer device.

A 3D transoesophageal echocardiography (TEE) was performed. The TEE showed good position of the LAA closure device with no leaks and the presence of a thrombotic formations (0.9 X 0.7 cm) on the atrial surface of the LAA closure device (fig. 1a). Anticoagulant therapy with LMWH 6000 UI X2 was started. A follow-up 3D TEE was performed one month after discharge showing the complete disappearance of the thrombotic formation (fig. 1B).

DISCUSSION: LAA closure is a safe and effective procedure with a low rate of complications. Device related thrombosis occurred in a minority of cases (2.8 %). Combined MitraClip and LAA closure is deemed feasible and safe, even though there are not large specific trials on this topic. In our case we assume that the rapid reduction in mitral regurgitation and the rapid increase of AV gradient, even if of little entity, could have caused a prothrombotic state that have caused the LAA device thrombosis.

CONCLUSION: a device related thrombosis must be taken into account in patients presenting with ischemic stroke without a cause.

ID: 105: A C ASE OF C OMPLICATED P ERCUTANEOUS C LOSURE OF A P ARAVALVULAR L EAK G UIDED WITH 3DTOE

Limatola Mirella, Pagnano Gianpiero, Salerno Gemma, Caso Ilaria, Palmiero Giuseppe, Merenda Raffaele, Golino Paolo

Monaldi Hospital – Napoli, Italy

Percutaneous closure represents an alternative to surgery to repair large paravalvular leaks in cases with high risk of intraprocedural mortality. Transoesophageal echocardiogram (TOE) is crucial for the diagnosis and to guide the percutaneous procedure. We describe the case of a 68-year-old female patient admitted for acute heart failure. The patient underwent two mitral valve replacements in 1981 and in 1987 using a tilting disk mechanical valve (Sorin Allcarbon 27mm). Laboratory tests revealed anemia (haemoglobin 8.2 g/dL) and increased LDH (1120 U/L), INR (5.26), unconjugated bilirubin (5.3 mg/dL), NT-proBNP (11461 pg/mL). TOE showed a large paravalvular leak due to partial detachment of the prosthetic mitral valve, moderate aortic stenosis, severe tricuspid regurgitation associated with severe pulmonary hypertension. The extension of the leak was evaluated with 3DTOE (figure 1a). The evaluation of cardiac surgery risk with EUROSCORE II and STS score showed a predicted mortality of 22.67 and 32%, respectively. The patient declined surgery and an attempt of percutaneous closure of the paravalvular leak was performed under 3DTOE and fluoroscopic guidance. An attempt of positioning of an Amplatzer vascular plug II and III was performed but 3DTOE showed that the plugs interfered with the opening of the mechanical valve causing severe increase of transprosthesis gradients (mean gradient 24mmHg) (Figure 1b). The procedure was abandoned after several failed attempts of releasing the devices in the right position and avoiding obstruction of the tilting disk movement. This case confirms the crucial role of 3DTOE in the percutaneous closure of paravalvular leaks.

ID: 106: H ISTOLOGIC T HROMBUS C OMPOSITION AND E CHOCARDIOGRAPHIC LEFT A TRIAL P ARAMETERS IN S TROKE P ATIENT

Lionetti Noemi Erminia, Migliarino Serena, Palumbo Rossana, Sasso Cristina, Nigro Emanuele, Caliendo Giuseppe, Nocilla Alessandra, Provenza Gennaro, D’Ambrosio Liliana, Napoletano Rosa, Citro Rodolfo

San Giovanni di Dio e Ruggi D’Aragona Univeristy Hospital – Salerno, Italy

Objectives: To analyze the correlation between histologic thrombus composition and echocardiographic morphologic and functional parameters of the left atrium in stroke patients treated with mechanical thrombectomy.

Methods: 52 patients who underwent mechanical thrombectomy from January 2022 to January 2023 were included. The sampled thrombi were classified into “white” (WC) and “red” (RC) based on the prevalence of platelets/fibrin and emazies, respectively. All patients underwent transthoracic echocardiographic examination within 72 hours after the event, and atrial volumes indexed by body surface area (LAVi) and peak atrial longitudinal strain (PACS) values were acquired by speckle tracking method. Patients with atrial fibrillation were excluded from the study.

Results: Patients were divided into two groups according to thrombus composition: 27 with white thrombus (WC group) and 24 with red thrombus (RC group). The WC group had significantly higher values of LAVi (39.8+/- 6.4 vs. 29.8+/- 6.8 mL/m2, p=0.015) and significantly lower values of PACS than the RC group (9.4+/- 1.9 vs. 15.3+/-2.6%, p<0.049). No significant differences were found in left ventricular ejection fraction and severity of mitral insufficiency.

Conclusions Our results suggest a correlation between histologic thrombus composition and echocardiographic values of left atrial volume and peak atrial longitudinal strain. Larger atrial volumes and reduced atrial reservoir function might suggest a more likely cardioembolic etiology of stroke. Further studies are needed to confirm our findings.

ID: 107: A V ERY L ATE A TRIAL S EPTAL E ROSION A FTER AN O STIUM S ECUNDUM P ERCUTANEOUS C LOSURE

Lofrumento Francesca

Univeristy Hospital G. Martino, Cardiology Unit, Messina, Italy

History of presentation: A 37-year-old woman was referred to her cardiologist for a recent history of headache and palpitations. At age of 25, she underwent a percutaneous closure of an ostium secundum defect. Two events need to be reported: a recent pregnancy and a strong, long-lasting cough Covid-19 related.

Investigations: A transthoracic echocardiogram was performed: the device appeared more prominent in the left atrium with a suspected left-to-right shunt. Then, transesophageal echocardiography (TEE) shown a paper-thin atrial septal aneurysm waving incessantly between the two disks with a severe left-to-right shunt at the lower rim of the device, where an atrial septal erosion was detected (Fig. 1).

Management: Considering shunt severity and initial device instability, a surgical approach was successfully performed (device removal + pericardial patch).

Discussion: Iatrogenic erosion of the septum primum after percutaneous closure of an atrial septal defect (ASD) is a very rare event. Device instability could be associated to a theoretical risk of device embolization, as well as paradoxical embolism recurrences and long-term hemodynamic impairment. In this case, the anatomical characteristics of the interatrial septum combined with potential cause of volume (pregnancy) and pressure (cough) cardiac overload, might have been a trigger for a very late erosion of the septum primum.

Conclusion: Iatrogenic erosion of the septum primum after a percutaneous ASD closure is a very rare but potentially relevant complication which can also occur very late. So, a longer-term echocardiographic follow up is essential for a timely diagnosis and treatment of this condition.

ID: 108: “T HE N EW G REAT I MPOSTER ”

Lopreiato Mariarosaria 1 , Buralli Simona 2 , Bacca Alessandra Violet 3 , Mengozzi Alessandro 4 , Maremmani Davide 5 , Masi Stefano 6 , Virdis Agostino 7

1 Santa Chiara Univerisity Hospital - Pisa Italy, 2 Santa Chiara Hospital, Division of Medicine 1 - Pisa Italy, 3 Univerisity Hospital, Division of Medicine 1 4 Pisana University Hospital- Pisa Italy, 5 Santa Chiara Hospital, Pisa, Italy 6 Santa Chiara Hospital- Pisa Italy, 7 Santa Chiara Hospital, Cisanello Hospital- Pisa Italy

BACKGROUND:The New Great Imposter” so was named Fabry’s S., by the French Observatoire in Internal Medicine Departments, which recognizes an X-linked inheritance with mutation of the GLA gene mapped to the long arm (region Xq22.1) leading to a GalA deficiency/defect with Gb3 accumulation. Sex M is more severely affected than sex F. The diagnosis is confirmed by genetic testing, although incidental findings on parenchymal biopsies, skin findings, ocular findings can also lead to the diagnosis. Recombinant DNA enzyme therapy is currently the only one that can slow the progression of the disease that would lead to exitus.

CASE: Patient C. C., 46 years old, recently diagnosed with hypertension in good pharmacological control (Olmesartan/ Amlodipine 20/5 mg), S. depressive in psychotherapy, accessed the PS (BP 193/100mmHg, HR, 101bpm) for appearance of paresthesias in hands and feet and palpitations. EE(within normal range). ECG(IV signs). 10 Gtt of Nifedipine was administered with normalization of BP values. Cardiac ECD: picture of concentric hypertrophy, SIV 22mm, PW14 mm, ASx 52 mm. On further investigation performed: cardiac MRI (LVM increased, SIV 16mm, Fundus Oculi in normal, reported cornea verticillata. On molecular investigation of GLA gene found mutation in heterozygosity of intron 3: c547+IG>A.

LysoGb3 biomarker assay: 6 ng/ml. Formulated diagnosis of S.di Fabry, enzyme replacement therapy with agalsidase Alpha was undertaken.

At Family Screening: first cousins maternal branch and daughter affected by the same mutation.

ID: 109: A N U NUSUAL C ASE OF P APILLARY F IBROELASTOMA

Losanno Francesco, Servoli Chiara, Mori Fabio, D’Alfonso Maria Grazia, Oddo Andrea, Stefàno Pierluigi

Careggi University Hospital – Florence, Italy

A 67 year-old man underwent a cardiological examination, after SarsCoV2 symptomatic infection requiring hospitalization, with echocardiographic detection of neoformation at the tricuspid valve (TV) level.

He had a personal history of high blood pressure, previous smoking habit and dyslipidemia. He practiced physical activity regularly without symptoms.

The second level transthoracic echocardiography performed at our Institute confirmed the presence of a round formation in the right side of the heart, which seemed directly attached to the atrial surface of the TV posterior leaflet, 14 × 15 mm in size, not floating freely but synchronized with the movement of the valve leaflet. Minimal tricuspid regurgitation was detected.

Subsequently, transesophageal echocardiography and cardiac magnetic resonance were performed confirming a roundish and solid lesion, hyperechoic and hyperintense respectively, suggestive of right-sided heart fibroelastoma.

Based on multi-modality imaging, the Heart Team recommended surgical removal of the lesion.

The preoperative coronary angiography showed a subcritical stenosis at the level of the I-II segment of a dual left anterior descending artery (LAD) and a subcritical stenosis at the level of the first diagonal branch (D1).

The surgery was performed with a valve sparing technique and a gelatinous lesion of 20 x 20 mm was resected through median sternotomy. Moreover coronary artery bypass graft of D1 and LAD was performed. The postoperative course was uneventful and no worsening of tricuspid regurgitation was found.

A Microscopic analysis of the tumor confirmed the diagnosis of papillary fibroelastoma.

ID: 110: U SEFULNESS OF R ECOVERY P ERIOD D URING E XERCISE S TRESS E CHOCARDIOGRAPHY IN E LICITATING I NTRA -V ENTRICULAR O BSTRUCTION IN H YPERTROPHIC C ARDIOMYOPATHY

Luciani Lara 1 , Dottori Melissa 1 , Ianni Umberto 2 , Molisana Michela 2 , Gizzi Germana 2 , Parato Vito Maurizio 2

1 Riuniti Hospital– Ancona, Italy, 2 Madonna del Soccorso Hospital - San Benedetto del Tronto (AP) Italy

Background: Intra-Ventricular Obstruction (IVO) in Hypertrophic Cardiomyopathy (HCM) should be routinely assessed at rest and during Valsalva manoeuvre, in the sitting and semi-supine positions and then on standing if no gradient is provoked. In symptomatic patients in whom classic provocative manoeuvres fail to induce a gradient of 50 mmHg or higher, exercise stress echocardiography is recommended.

Case presentation: We report a case of 62 years-old man with an apparently non obstructive HCM. Transthoracic echocardiography revealed predominantly septal hypertrophy, normal systolic function, diastolic disfunction grade 2, mild mitral regurgitation and severe left atrium dilatation. Cardiac magnetic resonance confirmed asymmetric hypertrophy with anterobasal interventricular septum of 20 mm and late gadolinium enhancement in the same location (2.6% of cardiac mass). Apparently no significant left ventricle outflow tract obstruction (LVOTO) was found at resting and during Valsalva manouvre (25 mmHg). Exercise stress echocardiography showed only a mild increase in gradient (40 mmHg) during effort, but evidenced significant LVOTO (145 mmHg) in the period of late recovery (more than 90 seconds) due to mitral systolic anterior motion (SAM) associated to severe mitral regurgitation. Transesophageal echocardiography clarified the mechanism of obstruction (basal septum hypertrophy, hyperdynamic left ventricle and anomalous anterior mitral leaflet chordae) and better evaluated the mitral apparatus in view of a possible septal reduction procedure, in case of failure of medical therapy.

Conclusion: Exercise stress echocardiography is essential to detect provocable LVOTO and exercise-induced mitral regurgitation. In particular, the recovery period, when preloading decreases and SAM increases, is very important to slatentize IVO.

ID: 111: A R ARE C ASE OF C ARDIAC L YMPHOMA : F ROM E CHOCARDIOGRAPHIC S USPICION TO B IOPSY D IAGNOSTIC C ONFIRMATION

Luciani Lara 1 , Manca Carla 2 , Gironella Pier Paolo 3 , Casella Michela 4

Riuniti Hospital – Ancona, Italy

Case presentation: 69-years-old man with history of recurrent venous thromboembolism complicated by acute pulmonary embolism (2018) came to our attention for worsening of dyspnoea, loss of appetite and weight loss. Electrocardiogram showed sinus rhythm with first degree atrioventricular block. Echocardiography evidenced a big hypoechoic mass that affected the right ventricle and atrium involving the tricuspid annulus with significant tricuspid stenosis and moderate regurgitation. Severe dilatation of right sections and systolic dysfunction of the right ventricle were also present. Of note, the mass was not present on the computer tomography (CT) scan of the chest performed nine months before. Laboratory examination revealed hemoglobin 12 g/dl, NT-proBNP 3304 pg/dl, high-sensitivity cardiac troponin 639 ng/l, LDH 298 U/l. The patient underwent an endomyocardial biopsy that made diagnosis of high-grade peripheral B-cell- derived lymphoma. Immunohistochemical analysis showed that CD20, CD79a, Bcl-2 and Bcl-6 were positive, CD3, CD5, CD10, CD23, Bcl-1 and CD30 were negative, K-67 was > 95%. Fluorescence in situ hybridization is in progress. CT scan total body showed lymphadenomegaly in the upper mediastinum, no thromboembolism defects in the pulmonary artery, no abdominal-pelvic lymphadenopathy. The mass was considered inoperable due to its size and the relation with the ascending aorta and the right coronary cusp. Bone marrow biopsy was performed but the results are not yet available. Corticosteroid therapy and chemotherapy were promptly started.

Conclusion: cardiac lymphoma is a rare disease with poor prognosis. Early pathologic diagnosis and early treatment are of great importance. Currently, the most effective treatment is chemotherapy.

ID: 112: A S TRANGE C ASE OF V ERTIGO : A ORTIC V ALVE T UBE D ETACHMENT

Lupi Alessandro 1 , Trovarelli Eugenio 1 , Girella Elisabetta 1 , Mengoni Marco 2 , Borghetti Valentino 2 , Scarpignato Maurizio 3 , Fortuni Federico 3

1 Santa Maria della Misericordia Hospital – Perugia, Italy, 2 Santa Maria Hospital – Terni, Italy, 3 San Giovanni Battista Hospital - Foligno (PG) Italy

Combined aortic valve and ascending aorta replacement surgery is known as Bentall technique consisting in a single-block replacement with a prosthetic Dacron tube, to the end of which the artificial valve is attached. Coronary ostia are connected to the artificial aortic lumen at two openings, allowing coronary circulation.

We describe the case of a 58-year-old male admitted to the emergency department complaining of asthenia, vertigo and some episodes of paroxysmal dyspnoea. The patient had undergone Bentall surgery (Resilia 29 bioprosthesis and Gelweave 34 tubular prosthesis) with concomitant aorto-coronary-bypass-surgery (left-internal-mammary-artery for left anterior descending artery) 5 months ago. On clinical examination, an aortic systo-diastolic murmur 3/6 was noted. A transthoracic echocardiogram was performed and showed prosthetic tube detachment with severe paravalvular leak along with the formation of a voluminous pseudoaneurysm intermittently compressing the prosthetic tube (Panel A). Transesophageal examination confirmed the presence of a posterior paravalvular leak and voluminous pseudoaneurysm (Panel B-C). A pre-surgical computed-tomography-angiography was urgently performed and confirmed the presence of the voluminous pseudoaneurysm of the thoracic ascending aorta (Panel D-E) extending circumferentially around the valve plane to the upper mediastinum. The patient underwent urgent cardiac surgery with implantation of a new valve tube (Biointegral-Bioconduit n°27) with no post-operative complications. The present case underlines the importance of performing an urgent multimodality imaging work-up of patients who recently underwent complex cardiac surgery, as Bentall procedure, presenting at emergency department with complaints potentially related to impaired systemic perfusion, such as asthenia and vertigo, to promptly diagnose and manage potentially life-threatening complications.

ID: 113: B EYOND P ULMONARY A SPERGILLUS I NFECTION : M ULTIFACETED I MPLICATIONS

Mallardi Giulio Pio Federico 1 , Santangelo Gloria 2 , Carugo Stefano 1

1 Department of Clinical Sciences and Community Health, University of Milan - Milan Italy, 2 Policlinico Maggiore Ca’ Granda– Milan, Italy

Pneumopericardium is caused by either the presence of a communication between the pericardial sac and the lungs or by infection of the pericardium by gas-forming microorganisms. Pulmonary Aspergillosis occurs almost exclusively in immunocompromised patients; involvement of the pleura or pericardium is extremely rare. A 41 years old woman, was admitted to our hospital due to a severe autoimmune hepatitis, so an intensive immunosuppressive therapy was started. Few days later a severe pulmonary infection was assessed, characterized by widely cavitary bilateral lung consolidations. A bronchopulmonary aspirate culture was performed, revealing a pulmonary infection caused by Aspergillosis, so a therapy, with isavuconazole and caspofungin, was started. Clinical scenario was further complicated by subcutaneous emphysema and relapsing pneumothoraces, which have been drained many times. Moreover a pneumopericardium was assessed by chest-x-ray (Fig.1). A high resolution computed tomography scan confirmed the presence of a substantial pneumopericardium, measuring 3.8 centimeters (Fig.1). Due to the patient’s stable hemodynamic status, she underwent continuous clinical and chest-x-rays monitoring. Several days after, a reduction in the size of the pneumopericardium was observed, and the patient was discharge with a closed follow-up. Pneumopericardium is a rare but serious complication because is associated with significant mortality and morbility. In our case the prognosis seems to be related to the infection rather than pneumopericardium, which usually not require pericardiocentesis, but the treatment of underliyng disease.

ID: 114: A N I NCIDENT R IGHT A TRIAL M YXOMA T REATED WITH M INIMALLY I NVASIVE S URGERY

Mansour Davide 1 , Ricci Mirella 1 , Galanti Kristian 1 , Ricci Fabrizio 1 , Renda Giulia 1 , Benedetto Umberto 2 , Gallina Sabina 1

1 Department of Neuroscience, Imaging and Clinical Sciences, G. D’Annunzio University of Chieti-Pescara – Chieti, Italy, 2 Department of Cardiac Surgery, SS Annunziata Hospital – Chieti, Italy

Right atrial myxoma (RAM) is a rareprimary cardiac tumor, composed of abnormal connective tissue and cells, often described as gelatinous or mucoid in nature. This neoplasm can present with a spectrum of symptoms including dyspnea, chest pain, syncope, weight loss and fever. Echocardiography is the method of first choice for diagnosing RAM, allowing accurate assessment of tumor size/site of attachment/mobility/consistency. We present the case of a 74-year-old man with history of chronic ischemic heart disease already revascularized by angioplasty, who had been suffering from chest pain for 2 hours. The echocardiogram showed a normal sized left ventricle with preserved global systolic function(EF 60%); evidence of a pedunculated mass(7x5cm) with irregular edges, emerging from the interatrial septum and projecting into the right atrium. Also, there were no significant valvular pathologies, a normal-sized and collapsible inferior vena cava upon inspiration and an estimated PAPs of 25 mmHg. CT-angiography supported the suspected diagnosis. Surgical excision is the mainstay of treatment, with a generally favorable prognosis following complete resection. However, due to potential embolic events and hemodynamic compromise, early recognition and intervention are essential. The right anterolateral minithoracotomy (RALT) was chosen as compared to standard median sternotomy (SMS) for resection of RAM. The myxomatous nature of the mass was confirmed by surgery. Ongoing surveillance is recommended due to the rare risk of recurrence. This abstract underscore the importance of recognizing and appropriately managing RAM, necessitating a multidisciplinary approach. RALT approach for RAM resection can be performed safely with favorable cosmetic outcome and accepted clinical results, deserving additional study as a promising alternative to SMS

ID: 115: A UTOMATIC A LGORITHM MAY H ELP N ON -T RAINED S ONOGRAPHER IN A NALYSIS BUT NOT IN T IME S PARING FOR E XECUTION OF G LOBAL L ONGITUDINAL S TRAIN

Marozzi Marialuisa Sveva 1 , Corvasce Francesco 1 , Amodio Gianfranco 2 , Santoro Giuseppe 2 , Vacca Angelo 1 , Cicco Sebastiano 1

1 Unit of Internal Medicine “G. Baccelli” and Unit of Hypertension “A. M. Pirrelli”. Department of Precision and Regenerative Medicine and Ionian Area- (DiMePRe-J), University of Bari “Aldo Moro”, University Hospital - Bari Italy, 2 Unit of Hypertension “A. M. Pirrelli”. Department of Precision and Regenerative Medicine and Ionian Area- (DiMePRe-J), University of Bari “Aldo Moro”, University Hospital - Bari Italy

Introduction: Global longitudinal Strain (GLS) is useful to evaluate left ventricle function. New guidelines on arterial hypertension indicate 20% as a cut-off to indicate a hypertension mediated organ damage. Therefore, its evaluation may help in identifying less evident organ damage. However, GLS is time consuming and sometimes needs expertise in its performance.

Aim of this study is to evaluate if an automatic algorithm may help sonographer with different stage of echocardiography expertise in GLS use.

Methods: Four different physicians performed the same evaluation of GLS using an automatic algorithm. They evaluated 30 consecutive patients investigated for arterial hypertension. The same exam was evaluated in postprocessing. The four physicians had different expertise: one was a resident (Sub1) at the beginning of echocardiography course, one was a just certified echocardiographer (Sub2), while the remaining two were senior consultant with 10 (Sub3) and 20 (Sub4) year experience in echocardiography experience. Time in performing GLS and result variability were evaluated.

Results: There was a significant difference in time of evaluation, with a decrease in time of evaluation moving from Sub1 to Sub4 (p<0.05). The GLS results were mostly comparable in values between the four sonographers considering either average, A4C, A2C and LAx evaluation.

Conclusion: Automatic support for GLS evaluation may help in performing the exam also sonographer with a low or very low expertise in echocardiography but training is still necessary to have an adequate and fast evaluation.

ID: 116: C ASE R EPORT OF I NTRAMYOCARDIAL F IBROMA

Martinelli Marco, Mengoni Marco, Pace Vincenzo, Dominioni Irene, Caparvi Camilla, Dominici Marcello, Conti Serenella, Khoury Georgette

Santa Maria Hospital – Terni, Italy

A 80 years-old female was admitted to our hospital for a transient loss of consciousness after few seconds of dizziness, nausea and vomiting. In the suspicion of a cardiac syncope a transthoracic echocardiogram was performed, finding an isoechoic mass with thin hyperechoic edges in the left ventricular myocardial wall next to the atrioventricular junction, measuring 23x24 mm; it caused mild extrinsic compression of the mitral ring with a mild left ventricular inflow obstruction (average gradient was 3 mmHg), with apparently preserved movement of the mitral leaflets; coexisted mild mitral regurgitation and moderate left atrium dilatation; the remaining findings were normal. Cardiac MRI confirmed the mild thickening of the basal inferior-lateral left ventricular free wall caused by the intramyocardial mass, which was hypo-intense relative to muscle on T2-weighted and mildly iper-intense on T1-weighted images, with a thin peripheral rim of late gadolinium enhancement. Those findings made the diagnostic suspicion of cardiac fibroma. A 24 hours-ECG holter monitoring didn’t show arrhythmias. On the basis of the low the low-risk features before the TLOC, the lack of neither significant structural heart disease (the fibroma caused just mild left ventricular inflow obstruction) nor arrhythmic events, we agreed on the diagnosis of reflex syncope and decided to avoid the surgical resection. The patient was discharged in good heath conditions.

Fibroma is a primitive cardiac tumor which is extremely rare in adults, even if it’s the second most prevalent benign cardiac tumor in childhood. It is located more often in left ventricle in the myocardial wall.

ID: 117: C ASE R EPORT OF A TRIAL M YXOMA : A B ENIGN BUT NOT I NNOCUOUS T UMOR

Martinelli Marco, Mengoni Marco, Pace Vincenzo, Dominioni Irene, Caparvi Camilla, Dominici Marcello, Conti Serenella, Borghetti Valentino

Santa Maria Hospital – Terni, Italy

A 47-years old male with arterial hypertension, diabetes and former smoker, was admitted to our hospital for intermittent episodes of transient ischemic attack characterized by dysarthria, dizziness and ideomotor apraxia, with spontaneous gradual resolution. The brain CT scan showed a hypodense area in the left temporooccipital parenchyma like a subacute ischemic lesion. Carotid ultrasound was normal. ECG showed sinus rhythm with normal heart rate. In the suspicion of a cardioembolic event we performed a transthoracic echocardiogram witch documented a mass in left atrium, measuring 38x32 mm; it was mobile, fixed to the atrial septum in the fossa ovalis with a large implant site, located near the mitral valve but without hemodynamic compromise; the left atrium was enlarged; the other findings were normal. TEE allowed a more detailed evaluation of the the mass, that appeared with inhomogeneous echostructure and irregular edges. The first diagnostic hypothesis was a left atrial myxoma. After a collegial discussion with the heart surgeons, we agreed upon a surgical excision of the mass after performing a coronary angiography witch showed no evidence of coronary stenosis. The patient was discharged in good health conditions. The histological examination confirmed the diagnosis of atrial myxoma.

Atrial myxoma is the most common benign tumor in adults, more often located in left atrium. Even if it is a benign tumor, it can cause systemic and/or pumonary cardioembolic events or can obstruct the heart valves resulting in hemodynamic compromise. In these cases a surgical excision is recommended.

ID: 118: B ICUSPID A ORTIC V ALVE AND P ERSISTENT L EFT S UPERIOR V ENA C AVA IN A LAGILLE S YNDROME

Martinelli Marco, Mengoni Marco, Pace Vincenzo, Dominioni Irene, Caparvi Camilla, Dominici Marcello, Conti Serenella

Santa Maria Hospital – Terni, Italy

We met a 44-years-old male with Alagille syndrome and bicuspid aortic valve known since his childhood, for which he made regular cardiological follow up. As comorbidities he had chronic alterations of his bile ducts that caused him cholestasis in treatment with Ursodeoxycholic acid, and previous surgery for bilateral cataract and nasal septum deviation. At the last echocardiographic control was documented a severe dilatation of the aortic root, for which the cardiac surgeons decided to admit him to hospital to perform cardiac surgery. Before the surgery we performed a transthoracic and transesophageal echocardiogram, which confirmed the bicuspid aortic valve without rafe (type 0) antero-posterior, with origin of the coronary arteries from the anterior coronary sinus. The aortic root measured at the Valsalva sinus was dilated (60 mm in diameter) with a voluminous aneurysm of the posterior coronary sinus (measuring 35x 50 mm). The aortic valve was continent and had a normal opening. The ascending aorta and the aortic arch were normal. Collaterally we noticed that coronary sinus was enlarged; the diagnostic suspicion of a persistent left superior vena cava was confirmed after administration of an intravenous bolus of shaked saline solution from a peripheral vein of the left arm while performing echocardiogram, documenting the opacification of the coronary sinus before the right atrium. Thorax-abdomen CT-scan made before surgery didn’t show clearly this anatomical variant because it was performed without contrast medium. Cardiac surgeons thanked us for this diagnosis because it requires specific precautions during cardiac surgery.

ID: 119: C ORONARY E MBOLISM IN P ATIENT WITH P ROSTHETIC A ORTIC V ALVE : L OOKS CAN BE D ECEIVING

Mauriello Alfredo 1 , D’Arco Beatrice 2 , Desiderio Alfonso 3 , D’Andrea Antonello 3

1 Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli” – “V. Monaldi” Hospital, - Naples Italy, 2 Department of Medicine, Surgery and Dentistry, Neuroscience Section, University of Salerno - “Umberto I” Hospital - Nocera Inferiore (SA) Italy, 3 Department of Cardiology, “Umberto I” Hospital - Nocera Inferiore (SA) Italy

Case Presentation: a 68-year-old woman was admitted to the ED for chest pain. The ECG showed an aspect compatible with ACS-STEMI. Coronary angiography showed an embolic occlusion of the right coronary artery. The past medical history showed aortic valve replacement with bioprosthesis and prior atrial fibrillation ablation. The family history showed a thrombophilic trait.

No embolic sources was identified. TTE didn’t show alteration of the bioprosthesis. TEE did not show persistent FOP, left atrial appendage thrombosis or prosthetic valve thrombosis. The presence of extracardiac shunts with bubble study and Doppler and deep vein thrombosis was excluded. The test panel for inherited thrombophilias was perfomed. Finally, an implantable loop recorder was implanted.

Discussion: a procoagulant state wasn’t increased risk of arterial thromboembolism in long-term. The patient had acquired risk factors for thrombophilia: prior atrial fibrillation and prosthetic valve. Prosthetic thrombosis was excluded. There was no way to rule out an episode of AF, therefore it was decided to implant the ILR. The patient was discharged with DOAC associated with ASA and evaluation after 3 months, to decide based on the interrogation of the ILR whether or not to continue oral anticoagulant therapy.

Conclusion: coronary embolism represents a challenging clinical issue. A careful comprehensive evaluation aiming to identify embolic sources and thrombophilic risk factors should be considered in the care centered on patients with coronary embolism.

ID: 120: “N ARROW -W IDE -N ARROW ” QRS C OMPLEX T ACHYCARDIA — B EWARE THE S MARTWATCH M ONSTERS

Mauriello Alfredo, Ascrizzi Antonia, Russo Vincenzo

Department of Medical Translational Sciences, University of Campania “Luigi Vanvitelli,” Monaldi Hospital – Naples, Italy

A young adult patient was referred to our Arrhythmic Unit for palpitations associated with chest pain and lightheadedness. The patient’s smartwatch recorded a narrow QRS regular tachycardia triggering a nonsustained phase of wide complex irregular tachycardia; finally, the tachycardia again assumes a wide complex configuration until spontaneous termination occurs some beats later. The interpretation of the “narrow-wide-narrow” QRS complex tachycardia was not univocal, and its nature has been debated. The smartwatch-based single- lead ECG of the patient described was challenging because a concomitance of supraventricular and ventricular tachyarrhythmias has been suspected. A persistent embryonic conduction branch, the so-called dead- end tract, which forms a connection between the AV nodal region and the focus for idiopathic VT, may be the electrophysiological basis of this association. The presence of transition from narrow-complex to wide-complex tachycardia with different cycle lengths and different QRS morphology excluded the possibility of AVNRT conducted over a bystander accessory pathway. The restart of narrow QRS tachycardia with the same cycle length as that before wide complex tachycardia excluded the hypothesis of VT. The electrophysiology study confirmed the diagnosis of AVNRT, the absence of accessory pathway or aberrant conduction, and the non-inducibility of any VT. Finally, we considered the phase of wide irregular QRS tachycardia as an artifact. The present case suggests that attention should be paid to the ECG findings of smartwatches.

ID: 121: A N O DD C ASE OF G IANT I NTRAPERICARDIAL MASS

Maurizi Kevin, Lofiego Carla, Capodaglio Irene, Patani Francesca, Brugiatelli Leonardo, Tofoni Paolo, Nazziconi Marco, Pietrucci Francesca, Gioacchini Simona, Dottori Melissa, Dello Russo Antonio, Perna Gian Piero, Vagnarelli Fabio

GM Lancisi Hospital – Marche Univeristy Hospital – Ancona, Italy

A 70-year-old man was admitted to our emergency department (ED) for chest pain during the previous 3 days variable with breathing and chest movements.

At the ED an ECG showed atrial fibrillation (AF) with 100 bpm. Transthoracic echocardiogram (TTE, Fig.1a) and transesophageal echocardiogram (TEE) revealed a voluminous roundish iso-ipoechoic mass (“red star”) with regular and hyperechoic margin, apparently intrapericardial and close to the lateral wall of the left atrium, measuring 8 x 5.5 x 2 cm, without infiltrating the wall. On contrast TTE (Sonovue) there was no uptake of contrast agent (Fig.1b).

The MRI (Fig.1c) showed a heterogeneous formation with slight late contrast enhancement consistent with intrapericardial hematoma.

We submitted the case to cardiac surgeons who recommended close echocardiographic follow-up, given the absent hemodynamic impact of the mass.

Management of pericardial hematoma in this clinical setting is controversial, it has limited available evidence.

Due to AF, anticoagulant therapy with warfarin was initiated; anti-inflammatory treatment with ibuprofen and colchicine was prescribed. The patient was discharged in good conditions. One month later a clear volumetric reduction of the intrapericardial hematoma was documented (Fig. 1d) and the patient reported a complete disappearance of the symptoms.

We chose this case to highlight the importance of using all cardiac imaging techniques in the differential diagnosis of cardiac/pericardial masses; among others, MRI certainly represents the gold standard in these situations but the contribution of simple TTE with Sonovue is helpful.

ID: 122: T HE A PEX T ALKS …C ARDIAC M ETASTASIS M IMICKING S T S EGMENT E LEVATION M YOCARDIAL I NFARCTION

Maurizi Kevin, Lofiego Carla, Capodaglio Irene, Patani Francesca, Brugiatelli Leonardo, Tofoni Paolo, Nazziconi Marco, Pietrucci Francesca, Gioacchini Simona, Dottori Melissa , Dello Russo Antonio, Perna Gian Piero, Vagnarelli Fabio

GM Lancisi Hospital – Marche Univeristy Hospital – Ancona, Italy

A 78-year-old man with a recent diagnosis of lung squamous cell carcinoma was referred to our cardiology department for marked ECG abnormalities (ST segment elevation in V2-V4 and T waves inversion in the antero-lateral leads, Fig.1a) in the absence of ischemic symptoms and for the detection of an intramyocardial mass at the apical segments on the CT scan. A transthoracic echocardiogram (TTE) was performed and showed an isoechoic mass at the LV apical segments measuring 3 x 4 cm apparently incorporating the myocardial wall (Fig.1b). The echocardiography with Sonovue revealed a late uptake of the contrast (Fig.1c).

CMR showed an ovular image in the para-apical area of 40 x 23 cm consistent with a secondary lesion (Fig.1d). Due to infiltrative appearance of the mass and the oncology history, this formation was highly suspicious for metastasis.

Due to the marked EKG repolarization abnormalities the patient underwent coronary angiography which excluded significant stenosis.

Cardiac metastases are more common than primary cardiac malignancy. Typical presentation includes arrhythmias or conduction disturbances. Echocardiography is the initial imaging test for the detection of cardiac metastasis, although CMR, CT and PET/CT may be helpful.

Herein we described a case of cardiac metastasis with EKG mimicking acute coronary syndrome. This finding is not uncommon among these patients. EKG findings of myocardial ischemia or injury, particularly localized and prolonged ST elevation, in the absence of ischemic symptoms have been reported in previous studies as high specificity for cardiac metastasis in patients with malignancy.

ID: 123: A RITHMIC O NSET OF A MYLOID C ARDIOMYOPATHY

Mautone Francesco, Rugger Debora, Casavecchia Grazia, Gravina Matteo, Brunetti Natale Daniele

RIUNITI University Hospital – Foggia, Italy

A female patient of 36 yy was carried in ED after out-hospital cardiac arrest that was pharmacologically cardioverted. The collected medical records show the case of a young patient, smoker and overweight, suffering only from bilateral carpal tunnel syndrome. Unusual symptoms such as dyspnea, asthenia and palpitation in lasts months were reported by the patient onsite. A standard 12-lead ECG record show a sinusal rhythm, qS in V1-V2-V3 derivation and low QRS amplitudes in limb derivations. A plethora of echocardiographic findings are suspicious: a concentric hypertrophic pattern of ventricular chambers, sparkling myocardium aspect, mildly reduced ejection fraction at 3D (45%), a restrictive transmitral Doppler filling pattern. Severe reduction in GLS and an apical sparing pattern in the bulls-eye pattern werefound in speckle-tracking echocardiography. IWT score of 10 points directed to high probability of amyloidosis. Cardiac MRI results demonstrated in PSIR sequences the meso-subendocardical pattern of high signal and in mapping sequences ECV value exceeded 1000 points widely in myocardiac walls. To complete the framework, laboratory tests were performedwhich highlighted proBNP and hs-TNI out of range, and 99mTc scintigraphy, that shown Perugini score of 2. Hematocrit, renal and liver function were normal and serum free light chain and serum and urine immunofixation were also in range.

According to recent Guidelines, clinicians performed amyloidosis diagnoses and genetic analyses which revealed a mutation of TTR Ile69Leu associated with TTR amyloid cardiomyopathy.

Considering the arrhythmic onset, the cardiologist team proposed to implant of AICD in secondary prevention in addiction to pharmacological therapy with Tafamidis.

ID: 124: P ERFORATION OF THE R IGHT V ENTRICLE WITH C ARDIAC T AMPONADE A FTER P ACEMAKER I MPLANTATION

Mazzanti Camilla, Fiorentini Alessandra, Mercuri Silvia, Luciani Michelangelo, Marini Federico, Alberti Marcello

Belcolle Hospital – Viterbo, Italy

INTRODUCTION: Permanent cardiac pacemakers are medical devices used in the treatment of malignant arrhythmias. Rupture of the ventricle after implantation of a pacemaker or defibrillator is a rare event but associated with a high risk of cardiac tamponade and death. We present a clinical case of a 62-year-old patient with cardiogenic shock following cardiac tamponade due to perforation of the right ventricle after pacemaker implantation.

CASE: A 62-year-old-man was admitted in April to the emergency room for NSTEMI and atrial fibrillation with a post-ischemic dilated heart disease, for which ICD was implanted in primary prevention. In June he was admitted to our department for worsening chest pain and he underwent an echocardiogram with evidence of an electro-catheter in the right ventricle with the distal end perforating the apex of the ventricle penetrating the pericardial cavity with pericardial effusion of approximately 1 cm. A pericardiocentesis was performed with drainage of 1200 mL and the ICD was removed. Blood cultures from CVC were positive for MSSA for which therapy with daptomycin and cefazolin had been undertaken. Subsequently, a transesophageal echocardiogram was performed which showed massive tricuspid insufficiency. No evidence of formations referable to endocardial vegetations affecting the other valve systems. The patient then underwent surgery to replace the tricuspid valve. Regarding the infectious pathology, in order to investigate the presence of septic embolizations, a total body CT scan was performed which excluded septic emboli. Postoperatively, serial control TT echocardiograms were performed without evidence of abnormalities

ID: 125: M ACARONI S IGN : A C LUE TO T AKAYASU A RTERITIS D IAGNOSIS IN A P ATIENT WITH T UBERCOLOSIS

Mazzella Francesca, Guarino Angela, Verde Raffaele, Fele Nunzia, Weisz Sara, Sordelli Chiara, Severino Sergio

dei Colli Cotugno Hospital – Napoli, Italy

Takayasu arteritis (TKA) is an inflammation of the aorta and major branch vessels. Carotid artery (CA) lesion in TKA, known as the ‘macaroni sign’ (MS), is characterised by global thickening of the common CA wall and lumen narrowing. A possible link between TKA and tuberculosis is supposed. Both illnesses cause arterial wall changes that are similar in appearance.

We describe a TKA case diagnosed based on the presence of the MS in a young Asian women, 30 years old, with a concomitant diagnosis of latent tubercolosis. She presented with dyspnoea and carotidynia. Temperature, blood pressure and heart rate were 36.8°C, 112/60mm Hg on her right arm (left, 84/60mm Hg) and 76 beats/min, respectively. Blood test results demonstrated an elevated inflammatory response C-reactive protein, 8.0 mg/ dL; erythrocyte sedimentation rate (ESR), 120 mm/hour. ANA, ENA and ASMA profile were negative. Quantiferon tb gold was positive. We suspected TKA and performed a carotid ultrasound, which revealed marked thickening of the intimamedia of the bilateral common CAs and a positive MS (figure 1, figure 2). The patient was diagnosed with TKA Type I. The FDG-PET/CT demonstrated an increase in the glucose uptake(GU) in thoracic aorta, subclavian and rigth CA (SUV 4.5). The patient was treated with steroids and Isoniazide. After 6 months carotidynia and dyspnea disappear with a reduction in C-reactive protein, 1.5 mg/dL; ESR=39 mm/hour and a decrease in the GU at FDG-PET/CT (SUV 3.5).

TKA diagnosis based on the MS identified by ultrasound can be easily performed during hospital evaluation.

ID: 126: O NSET OF H EART F AILURE IN A P ATIENT WITH L YMPHOMA AND S EVERE M ALNUTRITION

Melfa Chiara Francesca Maria, Accurso Davide, Torrisi Tito, Tosto Giuseppe Giovanni, Passaniti Giulia, Inserra Maria Cristina, Cannizzaro Maria Teresa, Polizzi Gesualdo, Russo Giovanna, La Spina Milena, Samperi Piera, Deste Wanda, Tamburino Corrado

“G. Rodolico - San Marco” Univeristy Hospital – Catania, Italy

This clinical case involves a young boy (17) with Hodgkin’s lymphoma and acute heart failure.

Initial presentation included advanced malnutrition, behavioural changes, edema and compromised hemodynamic parameters. Laboratory tests showed severe anaemia and elevated inflammatory markers. A comprehensive total body CT scan confirmed nodal involvement and identified secondary localizations (IV° stage). Definitive diagnosis of nodular sclerosis Hodgkin lymphoma was established through a lymph node biopsy.

During cardiology consultation, echocardiography revealed severe left ventricular dysfunction (LVEF 21%), moderate mitral regurgitation, severe tricuspid regurgitation, pericardial and pleural effusions. An MRI, discontinued due to patient discomfort, highlighted native T1 interstitial fibrosis.

Chemotherapy was carried out based on echocardiography information and clinical improvement from cardiological therapy for heart failure.

Chemotherapy approach progressed step by step, considering patient’s clinical improvements, included the OEPA regimen (vincristine, etoposide, prednisolone, doxorubicin) excluding doxorubicin due to severe ventricular dysfunction.

Following first chemotherapy cycle and heart failure pharmacological treatment, the ejection fraction improved to 45%, with a mild reduction in global longitudinal strain and in pericardial effusion. Echocardiographic data, showing hemodynamic improvement, allowed the initiation of doxorubicin therapy, resulting in reduced metastases and improved biochemical parameters.

MRI showed a marked improvement in contractile function, with only a mild late gadolinium enhancement strip in the basal septum, indicating minimal myocardial fibrosis.

In conclusion, progressive heart failure presents initially without evidence of cardiac lymphoma infiltration. A lymphoma-induced cytokine storm is considered the cause of cardiac injury and subsequent heart failure. Echocardiography remains essential for defining therapy progression and clinical status.

ID: 127: A C ASE R EPORT OF P ANNUS -R ELATED P ROSTHETIC V ALVE D YSFUNCTION

Mengoni Marco, Pace Vincenzo, Martinelli Marco, Dominioni Irene, Caparvi Camilla, Sordi Martina, Borghetti Valentino, Migliano Francesco, Dominici Marcello, Conti Serenella

Santa Maria Hospital – Terni, Italy

We report the case of a 57-year-old patient who came to our Cardiology department for worsening dyspnea since 10 days ago. The patient had undergone mitralic valve replacement 10 years earlier with bileaflet mechanical prosthesis. On cardiac physical examination there was an appreciable diastolic rumble and a 3/6 systolic murmur at the tip, with wet sounds in the lower lung fields bilaterally; the electrocardiogram showed sinus tachycardia at 105 b/min and right bundle branch block, while the chest x-ray showed a diffuse accentuation of the interstitial pattern. The patient was taking warfarin chronically and the international normalized ratio (INR) value was 3.4, in full therapeutic range. The transthoracic echocardiogram showed a left ventricle of normal volumes with paradoxical movement of the SIV due to volume overload of the right ventricle (D-shape sign), slightly reduced global kinesis with ejection fraction 50%, mechanical prosthesis in the mitral site with very poor movement of the hemidiscs, severe stenosis (average gradient 24 mmHg) and severe regurgitation; furthermore, a dilated and severely hypokinetic right ventricle was documented with severe tricuspid regurgitation due to leaflet coaptation deficiency. The subsequent evaluation with transesophageal echocardiogram, although confirming the clinical features, did not provide further relevant information. After diuretic therapy, the patient underwent reoperation with replacement of the valve prosthesis with a bioprosthetic mitral valve with intraoperative evidence of significant fibrous pannus on the ventricular side of the leaflets.

ID: 128: E NDOCARDITIS ON A ORTIC P ROSTHESIS A FTER T RANSCATHETER I MPLANTATION

Mengoni Marco, Martinelli Marco, Pace Vincenzo, Dominioni Irene, Caparvi Camilla, Dell’Uomo Marco, Borghetti Valentino, Donzelli Stefano, Dominici Marcello, Conti Serenella

Santa Maria Hospital – Terni, Italy

We present the case of a 77-year-old male patient who underwent transcatheter aortic bioprosthesis implantation (TAVI) 6 months earlier for severe aortic stenosis and reguritation in aortic bicuspid valve with left ventricular dysfunction and dilatation. The patient was admitted to General Medicine for persistent fever with isolation of Enterococcus Faecalis from blood culture tests. He then came to our observation for a transthoracic echocardiogram integrated with transesophageal examination which highlighted a severely dilated left ventricle with severe hypokinesia and an ejection fraction of 20%, aortic bioprosthesis with a mobile and polylobed soft vegetation of at least 18 mm in length, with an traprosthetic mean gradient of 21 mmHg and slight perivalvular leak. He was then treated with antibiotic therapy guided by the antibiogram with negative culture tests in 10 days. At the subsequent control with transesophageal echocardiogram after 14 days of therapy, the vegetation appeared bilobed, the main one 23 mm long and the smaller one 14 mm long, mobile and with increased echogenicity compared to the previous control. Therefore, cardiac surgery was performed to replace the bioprosthesis with another biological aortic prosthesis. Due to the development of complete atrioventricular block during the post-operative hospital stay, he underwent cardiac resynchronization therapy-defibrillator (CRT-D) implantation. At the pre-discharge echocardiographic check we observed a good functioning of the aortic bioprosthesis and after 3 months was documented an excellent response to the resynchronization therapy with a significant increase in the ejection fraction (EF 45%).

ID: 129: U LTRASOUND TO V ERIFY P OSITIONING OF C ENTRAL V ENOUS C ATHETER AND TO EXCLUDE P NEUMOTHORAX : THE P ADUA E XPERIENCE

Menon Andrea, Barchitta Agatella, Dal Prà Chiara, Scarda Alessandro, Russo Lucia, Marchegiani Matteo, Lovisotto Marco, Sandri Sara, Purificati Chiara, Po’ Domenico, Martin Barbara, Vettor Roberto

Padua Univeristy Hospital– Padua, Italy

Introduction: Post-procedural chest x-ray (CXR) is usually obtained to confirm a Central Venous Catheter (CVC) position and to rule out pneumothorax (PTX). CXR can be time-consuming, causing delays in using CVC; bubble test ultrasound (US) is an alternative method for quick confirmation.

Aim: This study aimed to assess whether US could replace CXR to quickly verify the CVC placement.

Additionally, we investigated whether US could efficiently identify the presence of PTX.

Materials and Methods: The study included patients who underwent positioning of CVCs, subsequent CXR was performed. US was employed to assess the correct positioning of the CVC, confirmed by observing the microbubble artifacts arriving in the right atrium roof within 1 second after injecting agitated saline in the distal lumen. PTX was excluded evaluating pleural sliding in the anterior chest.

Results: 45 patients were enrolled, with 40 CVCs positioned in internal jugular vein (38 in the right, 5 in the left), 2 CVCs in the right subclavian vein. The mean US time to confirm positioning was 4.51 minutes; the mean time from CXR request to the execution of the exam was 33 minutes. Two catheters were misplaced: both cases were suspected with US (late detection of microbubbles) and subsequently confirmed by CXR. Furthermore in 11 cases US identified excessively deep CVC position, enabling immediate retraction. No cases of PTX were observed.

Conclusions: US is a rapid and effective method to confirm CVC placement and excluding PTX. This allows prompt utilization of CVCs in critically ill patients and emergency situations.

ID: 130: E VALUATION OF M IOCARDIAL W ORK I NDEX IN P ATIENTS WITH T AKOTSUBO S YNDROME

Migliarino Serena, Cristiano Mario, Iuliano Giuseppe, Lionetti Noemi Erminia, Prota Costantina, Bellino Michele, Silverio Angelo, Baldi Cesare, Galasso Gennaro, Citro Rodolfo

San Giovanni di Dio e Ruggi D’Aragona Univeristy Hospital – Salerno, Italy

Objective: To investigate the potential association of MW campared to standard echocardiography parameters in TTS patients.

Methods: Thyrty-eight patients (mean age 68 ±12 years, 35 women) with TTS dignosed were prospectively enrolled and underwent a transtoracic Doppler echocardiography within 24 hours from hospital admssion. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI),MW efficency (MWE), and wasted myocardial work (WMW) were measured. In hospital complication (HC) were defined as a composite of apical left ventricle (LV) thrombosis, Hypocinetic arrhythmia (HA), supraventricular tachicardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD).

Results: Hospital complication occurred in 16 TTS patient (26% with acute heart failure,10% with SVT, 8% with CS, 5% with apical LV thrombosis, 5% with HA, 2,6% with stroke, 2 % with VT/VF). The MWI and CMW parameters appear to have th best performance to predicting in-hospital complications, followed by ejection fraction(EF) and WMW. MWI has the same sensivity (94%) as CMW and EF, but higher specificity (41% vs 32%). Of note, the highest specificity was obtained by the WMW parameters (41%).

Conclusion: Limited by the low number of patients, these results suggest that myocardial work parameters have a good senvity and may have a better performance than the EF value in predictin intra-hospital complication.

ID: 131: D IAGNOSTIC V ALUE OF S TRESS G LOBAL L ONGITUDINAL S TRAIN TO D ETECT C ORONARY A RTERY D ISEASE

Moderato Luca 1 , Binno Simone Maurizio 2 , Mei Davide 3 , Lazzeroni Davide 4

1 Oglio Po Hospital – Parma, Italy, 2 Guglielmo da Saliceto Hospital – Piacenza, Italy, 3 Modena University Hospital – Modena, Italy, 4 Fondazione Don Gnocchi – Parma, Italy

Introduction: Dipyridamole Stress echocardiography (DSE) is a recommended diagnostic method in patients with suspected coronary artery disease (CAD). Coronary flow velocity reserve in the left anterior descending coronary artery (CFVR-LAD), delta wall motion score index (d-WMSI), Left Ventricle Contractile Reserve (LVCR) have proven diagnostic value.

Aim: This study aimed to compare the diagnostic accuracy of delta GLS to predict revascularization in comparison to conventional parameters such as WMSI, CFVR-LAD, (HRR) (LVCR)

Materials and Methods: We retrospectively enrolled 216 patients with known or suspected CAD undergoing DSE; all patients underwent coronary angiography within 1 month for clinical reasons. Revascularization was needed in 160 patients (73%) while in 58 patients(27%) there was no evidence of severe CAD. The Global longitudinal strain was measured at rest and at the peak of the stress (after 6 minutes of 0,84mg/kg of dipyridamole infusion), and a delta was calculated as peak GLS-Rest GLS

Results: Patients with CAD showed no improvement of GLS and consequently a more positive delta GLS (1,5 ± 2,7 vs -3 ± 2). No differences in risk factors were found in the population with normal and abnormal Dleta GLS. DeltaGLS was a better predictor of CAD (AUC = 0,902) than conventional parameters (Table 2) and a high significant predictive accuracy was found (AUC = 0,961, cut-off 0, Sensibility 76%, Specificity 96%).

Conclusions: Peak GLS and derived Delta GLS could improve diagnostic accuracy of DSE.

ID: 132: A S TRANGE V ALVE : W HEN N OTHING IS C ERTAIN

Monticelli Luigi Maria 1 , Manzara Carla 2 , Natale Enrico 3

San Camillo Forlanini Hospital – Rome, Italy

A 47-year-old woman affected by previous ischemic stroke, presented a posterior STEMI due to thrombotic occlusion of the OM I, treated with primary angioplasty and a drug-eluting stent. Transthoracic echocardiography revealed a moderate aortic stenosis and regurgitation, of unclear origin; in suspicion of a cardio-embolic origin, a transesophageal echocardiography was performed, a patent foramen ovale was excluded and was confirmed aortic valve pathology with a similar myxomatous appearance. Subsequently, she experienced acute lower limb ischemia due to external iliac artery occlusion, managed with embolectomy. Histological examination revealed thrombotic material without septic features. The hypothesis of endocarditis was ruled out with serial blood culture, a total body CT scan ruled out the presence of neoplastic disease, a thrombophilia screening was performed, resulting positive for antiphospholipid antibodies. Repeat echocardiography confirmed valve thickening, albeit appearing less pronounced, even the transvalvular gradient appeared reduced. Therefore, a thrombotic process on a degenerated valve was hypothesized. The patient underwent aortic valve replacement with a mechanical prosthesis (St Jude size 21), intraoperative findings did not show macroscopic features suggestive of thrombosis or endocarditis. Histology unexpectedly showed dense connective tissue with massive amyloid deposits. Further evaluation ruled out AL and ATTR cardiac amyloidosis, and the patient remains under close observation.

CONCLUSIONS: Typically, amyloidosis is a systemic disease that causes extracellular deposition of insoluble fibrils in various organs, including the heart. Isolated deposits of amyloid on a heart valve, on the other hand, represent an atypical and very rare nosological entity, often associated with cardioembolic phenomena.

ID: 133: T HE I MPORTANCE OF G LOBAL L ONGITUDINAL S TRAIN IN THE A MYLOIDOSIS D IAGNOSTIC P ROCESS

Mura Giulia 1 , Gioi Alesssandra 1 , Caggiari Ludovica 1 , Utzeri Elena 1 , Contini Francesca 1 , Nocco Silvio 2 , Cadeddu Dessalvi Christian 1

1 Monserrato, Cagliari Italy Univeristy Hospital D Casula, Department of Medical Sciences, Cagliari University - Monserrato, Cagliari Italy, 2 Cagliari University - Monserrato, Cagliari Italy

Case report: An 89-year-old female complains shortness of breath and edema of lower limbs.

Medical history included permanent atrial fibrillation, hypertension and dyslipidemia. She came to our echo lab after hospitalization for syncope and bradycardia due to beta-blockers overdose. At the transthoracic echocardiogram (TTE) we evidenced left ventricle concentric hypertrophy (maximum wall thickness of 12 mm) with mildly reduced ejection fraction (LVEF 49%) due to diffuse hypokinesia. Doppler signals revealed an impaired diastolic function with E-wave deceleration time 134 ms and E/E’ 19. Both atria dilated. Tricuspid leaflets appeared thickened with peak velocity of tricuspid regurgitation by CWD of 2,9 m/s. Aortic valve appeared fibrotic with hypomobile right cusp without significant stenosis. To complete the exam we performed Global Longitudinal Strain that showed reduced average left ventricle GLS (-10,4%) with apical sparing pattern. Therefore, we planned blood tests, which evidenced a monoclonal gammopathy. The patient was then addressed to hematologic consult on the suspect of monoclonal immunoglobulin light chains (AL) amyloidosis. She was also scheduled for total body scintigraphy to exclude overlap transthyretin (ATTR) amyloidosis on AL amyloidosis. The ematological consult confirmed a multiple myeloma.

Discussion: 2D speckle tracking myocardial strain is a highly useful tool in the diagnosis and evaluation of patients with cardiac amyloidosis. GLS is been fundamental in our case to make our echographic suspicion stronger and start a targeted diagnostic process. Furthermore GLS it has shown to be an independent predictor of outcome in patients with cardiac AL amyloidosis.

ID: 134: J OURNEY THROUGH A Y OUNG D ILATED C ARDIOMYOPATHY

Muscherà Francesca 1 , Lanzafame Lorena Gioia 2 , Giuseppe Cudemo 1

1 Federico II University – Naples, Italy, 2 Catania University – Catania, Italy

The patient, a 48-year-old female diagnosed with stage 2b Hodgkin’s lymphoma in 1997, underwent 12 cycles of VEBEP followed by 20 radiotherapy sessions. In August 2023, she presented at Hospital with chest pain, palpitations, and edema. CT revealed pleuro-pericardial effusion, and echocardiogram indicated hypocontractile cardiopathy with reduced systolic function (ejection fraction 35%) and a dilated left ventricle. Treatment with Furosemide and Canrenon was started.

After 30 days, she was admitted for persistent chest pain and dyspnea. On admission, BP was 95/60 mmHg, HR 72 bpm, and SpO2 98%. Blood tests releals elevated NT-proBNP. ECG: no specific ventricular repolarization disturbances. Echocardiography: dilated cardiopathy (EF 35%), tricuspid insufficiency, reduced global longitudinal strain (GLS= -14). Coronary angiography ruled out significant stenosis.

During hospitalization, SGLT2-i and ARNI were introduced, with symptomatic improvement. After hospitalization she performed cardiac magnetic resonance, that confirmed left dilated cardiomyopathy and reduced EF, excluding myocardial fibrosis. Subsequent genetic screening for major mutations associated with dilated cardiomyopathy showed negative results.

A clear cause for the cardiopathy onset, in this young patient, could not be identified. So It is plausible to attribute the cardiopathy onset to complications of chemo and radiotherapy. Literature describes cases of cardiopathies emerging years after such therapies, establishing them as independent cardiovascular risk factors like diabetes and hypertension. This case emphasizes the importance of extended cardiac follow-up, for patients undergoing chemo and radiotherapy in their youth. This is crucial for early diagnosis and management of potential abnormalities.

ID: 135: H OW TO S USPECT C ARDIAC A MYLOIDOSIS

Muscherà Francesca 1 , Cioffi Giuseppe 1 , Lorena Lanzafame 2

1 Federico II University – Naples, Italy, 2 Catania University – Catania, Italy

A 82-year-old female patient with a medical history hypertension, heart failure with preserved ejection fraction and bilateral carpal tunnel syndrome. Recently discharged after an episode of riacutization of heart failure. Presenting symptoms included fatigue, dyspnea on moderate exertion, and peripheral edema. Elettrocardiogram: sinus rhythm at 70 bpm, 1st degree AV block and left axis deviation. Echocardiogram:important left ventricle concentric hypertrophy [RWT= 0.68 IVS =20mm]preserved systolic function (EF 60%) moderate aortic sclerosis. Pseudonormal trans-mitralic pattern E/A= 1.3, E/E’ =20, E’=3 cm/s. Grade 2 diastolic dysfunction. Right ventricle thickness was normal with normal fuction (TAPSE 18mm), mild pulmonary hypertension [PAPs=35 mmHg] a dilated and not collapsing inferior vena cava (IVC=20mm) and a reduction of global longitudinal strain (-14) with apical sparing. According to guidelines we had the parameters to suspect cardiac amyloidosis. We performed (99mTc) scintigraphy that showed cardiac uptake of grade 2 (moderate cardiac uptake) and with negative free light chaing we was able to diagnosticate transthyretin cardiac amyloidosis.

After that, genetic testing excluded mutations, leading to a diagnosis of wild-type ATTR amyloidosis. This distinction is crucial for initiating Tafamidis therapy. The case underscores the importance of recognizing typical feature. Amyloidosis, indeed, is a rare but serious disease that is often complicated by delayed diagnosis. Morbidity and mortality can sometimes be limited with an earlier diagnosis. We hope our real life case will help to not understimate suspicious leading to an early diagnosis and better management.

ID: 136: P REDICTIVE R OLE OF L EFT V ENTRICULAR G LOBAL L ONGITUDINAL S TRAIN IN P ATIENTS U NDERGOING C AROTID A RTERY S TENTING

Nappa Dalila 1 , Ilardi Federica 1 , Manzo Rachele 1 , Immobile Molaro Maddalena 1 , Sgherzi Giulia 1 , Santoro Ciro 1 , Piccolo Raffale 1 , Stabile Eugenio 2 , Esposito Giovanni 1

1 Federico II University Hospital – Naples, Italy, 2 San Carlo Hospital – Potenza, Italy

Introduction: There is a strong correlation between carotid obstructive disease (COD) and coronary artery disease (CAD). Treatment of preclinical CAD in patients with COD may improve long-term outcomes and survival. Left ventricular (LV) global longitudinal strain (GLS) is a sensitive echocardiographic tool in the discrimination of significant CAD. However, the predictive role of reduced GLS in COD patients is still unknown.

Aim: This prospective study aims to investigate the utility of GLS to predict CAD in patients with preserved systolic function, without history of myocardial revascularization, undergoing carotid artery stenting (CAS).

Materials and Methods: All patients scheduled for CAS underwent complete echocardiographic assessment before coronary angiography (CA), including GLS analysis.

Results: Of 125 patients screened, 36 patients with COD and preserved LV ejection fraction (EF) were enrolled. After CA, CAD was detected in 18 patients. Significant lower GLS was observed in CAD patients, compared to those without CAD, despite similar values of LVEF. At ROC curve analysis, the best absolute GLS value associated with significant CAD was 19.8%. GLS >19.8% was able to discriminate 61.5% of patients with a normal coronary tree, while 80% of patients with impaired GLS had significant CAD at coronary angiography. Moreover, GLS reduction in CAD patients was progressive with increasing vessels affected.

Conclusions: A GLS value ≤19.8% identifies with 88% of specificity patients who should undergo CA before CAS because at high risk of CAD. Its non-invasiveness and high reproducibility make GLS a reliable tool for CAD screening in COD population.

ID: 137: P ROGNOSTIC I MPACT OF N ON -I NVASIVE M YOCARDIAL W ORK I NDICES IN P ATIENTS U NDERGOING T RANSCATHETER A ORTIC V ALVE I MPLANTATION

Nappa Dalila, Ilardi Federica, Franzone Anna, Manzo Rachele, Angellotti Domenico, Immobile Molaro Maddalena, Santoro Ciro, Cirillo Plinio, Spaccarotella Carmen, Piccolo Raffaele, Esposito Giovanni

Federico II University Hospital – Naples, Italy

Introduction: Transcatheter aortic valve implantation (TAVI) leads to functional recovery of left ventricle, demonstrated with myocardial work (MW). Integrating strain measurement with pressure, echocardiographic assessment of MW has emerged as a valuable tool for obtaining an objective evaluation of ventricular function.

Aim: This study aims to evaluate the impact of TAVI on non-invasive MW indices and their association with clinical outcomes at midterm follow-up.

Materials and Methods: We selected 88 patients scheduled for TAVI within the EffecTAVI registry. Global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE) were measured by echocardiography at baseline and at 30-day after. Accuracy of non-invasive measures was assessed by invasive evaluation of MW. Adjusted Cox-regression analysis was performed to assess the impact of MV indices on 1-year clinical outcomes.

Results: In the overall population, at 30-day after TAVI, a significant reduction of GWI, GCW and GWW was observed. GWE was improved only in patients that did not develop left ventricular dyssynchrony because of new onset LBBB or pacemaker implantation after TAVI. In a multivariable Cox‐regression analysis, adjusted for confounders, GWE after TAVI was the strongest predictor of adverse events (composite of all-cause death, endocarditis, worsening of dyspnea and re-hospitalization for cardiovascular events) at 1-year follow-up.

Conclusion: TAVI conveys significant changes of MV indices, consisting of an early reduction of GWI, GCW and GWW and an improvement of GWE only in patients without LV dyssynchrony. A value of GWE≤92% at 30-day predicts poor clinical outcomes after 1-year.

ID: 138: T HROMBOSIS V S E NDOCARDITIS : A D IAGNOSTIC O DYSSEY

Nappa Dalila, Ilardi Federica, Manzo Rachele, Sgherzi Giulia

Federico II University Hospital – Naples, Italy

A 86-year-old patient, suffering from permanent atrial fibrillation in therapy with NAO and rheumatic mitral stenosis, came to our clinic for routine follow-up. He reported recent hospitalization for ischemic stroke complicated by hemorrhagic infarction during NAO therapy (then interrupted) and nosocomial pneumonia. Our transthoracic echocardiogram (TTE) showed the presence of hyperechogenic mass (2.4x1.2 cm) attached to the posterior leaflet of mitral valve, determining severe mitral steno-insufficiency. The patient had recently undergone dental extraction without antibiotic prophylaxis, so he was hospitalized for endocarditis. Transesophageal echocardiogram was performed, which highlighted the presence of sessile hyperechogenic mass attached to both mitral leaflets, and of a thrombotic mass in left auricle. Inflammatory markers and blood cultures were negative, the patient was apiretic, PET-CT excluded the presence of areas with increased metabolic activity: endocarditis was ruled out and patient was discharged in NAO therapy. After 20 days we performed TTE: the mass on anterior mitral leaflet was modified both for size (2.0 x 1.0cm) and localization (attached to subvalvular apparatus) and it was compatible with thrombus. On the same day, embolization occurred in the left common iliac artery, treated by Fogarty catheter. The history of dental extraction without antibiotic prophylaxis in the presence of rheumatic valve disease and recent pneumonia suggested endocarditis, but apiressia and negative inflammatory markers made the suspicion of endocarditis disappear. Adequate performance of second-level imaging was therefore crucial for the definitive diagnosis of thrombosis. The patient was finally discharged in anticoagulant therapy with coumadin and is currently in good clinical condition.

ID: 139: G IANT P SEUDOANEURYSM OF M ITRAL -A ORTIC F IBROSA P RESENTING AS A NGINA AND C ARDIAC A RREST D UE TO V ENTRICULAR F IBRILLATION

Nazziconi Marco, Lofiego Carla, Capodaglio Irene, Patani Francesca, Brugiatelli Leonardo, Tofoni Paolo, Maurizi Kevin, Pietrucci Francesca, Gioacchini Simona, Dottori Melissa, Dello Russo Antonio, Perna Gian Piero, Di Eusanio Marco, Vagnarelli Fabio

GM Lancisi Hospital – Marche University Hospital – Ancona, Italy

A 66-year-old man was suddenly referred to the emergency department (ED) for an extra-hospital cardiac arrest due to ventricular fibrillation, promptly treated by a single DC shock. Four months prior, he had undergone aortic valve replacement with a biological prosthesis valve (BVP) for severe aortic stenosis. One month after, was hospitalized for acute cholecystitis requiring antibiotics and percutaneous cholecystostomy. On arrival to the ED the patient was completely asymptomatic; no fever during previous days. He complained of constricting chest pain during physical exertion for ten days. However, no signs of ischemia were seen on the EKG. Transthoracic echocardiography showed a very large pulsatile anaechogenic area posteriorly to the prosthesis. Transesophageal echocardiography (2D and 3D) highlighted a very large pseudoaneurysm of mitral-aortic interventricular fibrosa (P-MAIVF; Fig.1ABCD and Fig.1EFGH) with a very large cavity with thickened walls, extended for more than two-thirds of the prosthetic circumference and with multiple septa; a large communication between the left ventricular outflow tract and P-MAIVF (Fig.1A) with a to-and-fro flow into the cavity and a prominent systolic pulsation; no paraprosthetic leak and absence of any attached mass or intraprosthetic aortic regurgitation.

These findings suggested a prosthetic aortic valve endocarditis with an extensive periannular involvement and a possible “ab extrinseco” compression of the left coronary artery, involved in the genesis of chest pain and ventricular arrhythmia (in absence of significant CAD at preoperative coronary angiography). An empiric antibiotic therapy with daptomycin and piperacillin-tazobactam was started. The patients subsequently underwent Bentall surgery with a subannular implantation technique.

ID: 140: C HALLENGING T RIPLE C ARDIAC P ATHOLOGY : T RANSTHYRETIN A MYLOIDOSIS WITH H YPERTROPHIC O BSTRUCTIVE C ARDIOMYOPATHY A SPECTS AND A NOMALOUS C ORONARY A RTERY

Nazziconi Marco, Lofiego Carla, Capodaglio Irene, Patani Francesca, Brugiatelli Leonardo, Tofoni Paolo, Maurizi Kevin, Pietrucci Francesca, Gioacchini Simona, Dottori Melissa, Dello Russo Antonio, Perna Gian Piero, Di Eusanio Marco, Vagnarelli Fabio

GM Lancisi Hospital – Marche University Hospital – Ancona, Italy

A 70 years-old man with systemic hypertension and surgically treated bilateral carpal tunnel was referred for dyspnea on exertion. At physical examination a systolic heart murmur exacerbated by Valsalva maneuver was appreciated; no heart failure signs.

EKG with low-voltage QRS. Blood tests showed elevated NT-proBNP (1434 pg/ml). Transthoracic echo (ETT) revealed severe asymmetric hypertrophy, ‘granular sparkling’ appearance of myocardium, ‘apical sparing’ at GLS (Fig.1B). Moreover, elongated mitral leaflets, anomalies of mitral sub-valvular apparatus with apically displaced papillary muscles and systolic anterior motion of the mitral valve (SAM) with dynamic outflow tract obstruction (90-100 mmHg with Valsalva maneuver) were seen (Fig. 1E-F-G). For ETT suspicion of a coronary artery anomaly (Fig.1I), the patient underwent coronary CT angiography that confirmed a separate origin of LAD from right coronary sinus with a long intramyocardial bridge (Fig.1L-M). A 99mTC-HDP bone scintigraphy shows high-grade of cardiac uptake (Perugini Score 2, Fig.1C). Screening for monoclonal gammopathy and genetic testing resulted negative. Cardiac MRI revealed late gadolinium enhancement (LGE) in midwall septum, diffuse endocardial LGE in the LV basal inferior and posterolateral walls (Fig.1D) and confirmed the asymmetric hypertrophy with apically displaced papillary muscles (Fig.1H) and SAM.

These features led to a non-invasive diagnosis of wild-type transthyretin cardiac amyloidosis with aspects of hypertrophic obstructive cardiomyopathy. The patient started a disease-modifying therapy with Tafamidis and Metoprolol, with relevant reduction of LVOT obstruction at follow-up. Genetic testing for HCM was also performed. In conclusion, in rare cases hypertrophic phenotype may be challenging, showing features overlap between ATTR and HOCM.

ID: 141: A “R IGHT ” M ASS FOR THE “R IGHT ” H EART

Nese Alberto, Pantano Paola, Martire Paola, Gazzola Rachele, Minniti Giuseppe, Cernetti Carlo

Ca’ Foncello Hospital – Treviso, Italy

A 37 years old female with a family history of thrombo-embolic events had a recent diagnosis of breast cancer initially treated with neoadiuvant chemoteraphy and was then scheduled for surgery.

The first transthoracic echocardiogram, performed after 3 month the start of chemoteraphy, showed a mobile mass in the right atrium (with no other relevant echocardiographic findigs), which was than confirmed at the transoesophageal echocardiogram: it appeared isoechoic, attached to the roof of the right atrium, 20 x 10 mm dimensions, and without contrast enhancement after 5 minutes from echocontrast medium injection.

The initial suspicion was of a thrombotic formation, so a parental anticoagulation with low molecular weight heparin was started.

Routine blood tests were normal, trombophilic screening was also negative.

A total body computed tomography angiography excluded metastasis and a cardiac magnetic resonance with gadolinium medium contrast showed a mass attached to the infero-posterior wall of the right atrium, next to the outlet of inferior cava vena. However the nature of the mass was not clear: at first impression it seemed an Eustachian Valve but a thrombotic origin could not be excluded.

After Multi Disciplinary Team discussion a conservative approach was established due to the small dimensions of the mass and the absence of cardiac symptoms. A strict follow-up and continuation of the anticoagulation therapy were planned.

A month later, the patient was still asymptomatic, the transthoracic echocardiogram demonstrated a reduction of the mass: this finding strengthens the initial suspicion of a thrombotic formation attached to the Eustachian valve.:

ID: 143: S -ST2 P REDICTION OF R IGHT V ENTRICULAR /P ULMONARY A RTERY C OUPLING WITH TAPSE/PAP S IN P ATIENTS A FFECTED BY P ULMONARY H YPERTENSION

Novielli Maria Elena 1 , De Tommasi Elisabetta 2 , Guida Piero 1 , Camassa Nino 2 , De Michele Lucrezia 2 , Mannarini Antonella 2 , Tota Antonio 2 , Civino Fabio 2 , Cipollone Enea 2 , Fratini Nicolò 2 , Giorgio Alessio 2 , Di Serio Francesca 2 , Colonna Paolo 2 , D’Agostino Carlo 2

1 ”Miulli” University Hospital- Acquaviva delle Fonti (BA) Italy, 2 University Hospital – Bari, Italy

Introduction: Pulmonary hypertension is a disease with an unfavorable prognosis, characterized by increasing in pulmonary resistence and right heart failure. One of the most important prognostic factors is the adaptation of the right ventricle to increased pressure overload, which can be evaluated through tricuspid annular plane systolic excursion/systolic pulmonary arterial pressure (TAPSE/PAPs), index of right ventricle-pulmonary artery coupling. In this setting, NT-proBNP is the only prognostic biomarker, but it is influenced by age, body mass index, sex and comorbidities, such as anemia and renal failure. In previous studies soluble-Suppression of Tumorigenicity (s-ST2), a marker of myocardial stress, resulted a strong predictor of death in heart failure, acute coronary syndromes and pulmonary hypertension.

Aim: Our purpose is to study the possible correlation between sST2 and different echocardiographic parameters.

Methods: This is a prospective study on 45 PH patients undergoing echocardiography, right heart catheterization and venous sampling to measure s-ST2 levels which were followed for survival.

Results: During an average 18-month follow-up, 17 patients died, 76% of whom had pulmonary arterial hypertension. sST2>78 ng/ml represents a numerical value with the highest association with mortality in our study population: at 6-12 months patients with sST2>78 ng/ml showed statistically significant early higher mortality in comparison with sST278ng/ml had statistically significantly greater right atrial area and lower TAPSE/PAPs, compared with patients with sST2<78 ng/ml values. We showed a statistically significant inverse correlation between sST2 and TAPSE/PAPs.

Conclusion: s-ST2represents an useful and promising marker in noninvasive hemodynamic assessment of pulmonary hypertension.

ID: 144: A RARE C ASE OF C ARDIAC R ELAPSE OF D IFFUSE -L ARGE B C ELL L YMPHOMA : E CHOCARDIOGRAPHIC R ESPONSE TO C HEMOTHERAPY

Onorato Federica, Parato Andrea Giovanni, Michienzi Giuseppe, Morgagni Riccardo Morgagni, Barillà Francesco

Fondazione PTV - Tor Vergata University Hospital – Rome, Italy

INTRODUCTION: Diffuse large B-cell lymphoma is the most common subtype of non-Hodgkin’s lymphoma in adults. Standard chemotherapy treatment achieves Complete Remission in approximately 67% of patients. About one third of patients have refractory disease or relapse after standard therapy, mostly within 5 years of achieving CR. CLINICAL CASE:62-year-old patient without previous cardiovascular diseases came to our ER for dyspnea and asthenia. Medical history showed diagnosis of GBC-DLBCL at third stage that had achieved CR with R-CHOP therapy and intrathecal prophylaxis. At the ECG sinus tachycardia in absence of alterations in ventricular repolarization. At arterial EGA a condition of respiratory distress. The chest CT with contrast showed a bulky mass in the right chambers, also involving the pericardial sac. TTE showed a bulky mass (area 31cm2) that occupied the entire right atrium (5.9x4.4cm) and that extended, through the tricuspid, into the right ventricle, displacing the interventricular septum (image1). Endomyocardial biopsy confirmed the diagnosis of cardiac recurrence of GBC-DLBCL. A chemotherapy debulking has been performed with Gemcitabine, followed by R-CHOP and MTX. Three months after therapy post-treatment TTE showed a good response with no evidence of pathological tissue in the right ventricle (image2). CONCLUSIONS: Cardiac-DLBCL is a rare tumor with few cases reported in the literature. There is currently no standard therapy, particularly for those who are unsuitable for high-dose chemotherapy a/o autologous-stem-cell-transplantation. The multidisciplinary cardiological and hematological approach has proved to be fundamental in the therapeutic management of this patient.

ID: 145: P ERCUTANEOUS T REATMENT OF A CUTE -S EVERE -M ITRAL -I NSUFFICIENCY IN A P ATIENT IN C ARDIOGENIC S HOCK : A C ASE R EPORT

Oro Pietro, Onorato Federica, Idone Gaetano, Marsili Giorgia, Renga Emanuele Maria, Giamundo Domenico Mario, Ciarlitto Salvadori Alessia, Barillà Francesco

Fondazione PTV - Tor Vergata University Hospital – Rome, Italy

We report the case of a 65-year-old patient, hypertensive, dyslipidemic, smoker with a family history of CAD. History of FAP on apixaban therapy. In June 2021 anterior-STEMI underwent PPCI with implantation of 3 DES on DA with residual stenosis on CT(40%). In August 2021 hospitalization for EPA on hypertensive peak;on coronary artery study, critical stenosis of the ostial CT, confirmed on IVUS;stents previously implanted on IVA were pervious. The patient refused surgical myocardial revascularization with coronary-artery-bypass-grafting so percutaneous revascularization was opted for by PCI and implantation of 1 DES on CT-DA. On echocardiogram c/D, slightly reduced global systolic function(EF:50%) and moderate mitral insufficiency due to LMP retraction. In March 2022 NSTEMI underwent PTCA with PEBA on IVA at intrastent restenosis, DES implantation on CX and RMO and Kissing Balloon on TC-IVA-CX. The following day, the clinical picture worsened with EPA and cardiogenic shock with the need for inotropic support and IOT. On TTE severely reduced global systolic function(EF:30%),acute severe mitral insufficiency, and severe tricuspid insufficiency. A percutaneous implantation of a MitraClip device was indicated in an emergency. The procedure required the execution of unconventional manoeuvres for the release of the device in the presence of a left atrium of reduced volume. At the end of the procedure, residual mitral insufficiency was mild in the absence of significant transvalvular gradient. The reduction of mitral insufficiency in patients with cardiogenic shock allowed to reduce the overload in the left atrium and at the level of the pulmonary circulation, allowing progressive clinical improvement and suspension of IOT. The patient was discharged in good clinical condition and in good compensation, currently in instrumental clinical follow-up

ID: 146: S EVERE A CUTE A ORTIC I NSUFFICIENCY : A C ASE R EPORT

Pace Vincenzo, Mengoni Marco, Martinelli Marco, Dominioni Irene, Caparvi Camilla, Borghetti Valentino, Dionisi Dante, Dominici Marcello, Conti Serenella

Santa Maria Hospital – Terni, Italy

We present the case of a 29-year-old man who presented to the emergency department with worsening dyspnea over the past week, accompanied by fever, cough, and mild hemoptysis. Medical history revealed hepatitis C (HCV), a history of heroin and cocaine addiction. The electrocardiogram showed sinus tachycardia, and blood tests revealed neutrophilic leukocytosis. Pulmonary CT angiography revealed diffuse basal parenchymal consolidations and ruled out the presence of pulmonary embolism.

Initially admitted to the medical ward, the patient’s clinical and hemodynamic condition worsened, characterized by acute pulmonary edema. It was decided to transfer the patient to the intensive care unit. Endotracheal intubation and mechanical ventilation were administered. Transthoracic and subsequently transesophageal echocardiograms were performed, revealing a bicuspid aorta due to fusion of the right and left cusps, severe acute aortic insufficiency from cusp rupture; a rounded and mobile image exceeding 1.2 cm, attributable to endocardial vegetation, was observed. Additionally, there was a dilated left ventricle, moderate mitral insufficiency, and reverse flow in the abdominal aorta. The patient was urgently taken to the cardiothoracic operating room for aortic valve replacement with the placement of a biological prosthesis. Cultures previously obtained were positive for Abiotrophia Defectiva. Antibiotic therapy was adjusted based on the antibiogram. Subsequent follow-up blood cultures were negative. A. defectiva is part of the normal flora within human oropharyngeal, gastrointestinal, and urogenital tracts. When associated with IE though, this organism can cause significant morbidity and mortality. The patient was discharged with instructions to continue antibiotic therapy at home.

ID: 147: D IAGNOSIS OF I SOLATED R IGHT V ENTRICULAR D YSFUNCTION IN S YSTEMIC S CLEROSIS C OMPLICATED BY P ULMONARY E MBOLISM : S M ULTIMODALITY I MAGING A PPROACH

Palmieri Alessandro 1 , Lepre Veronica 2 , Barison Andrea 3 , Todiere Giancarlo 3 , Grigoratos Chrysanthos 3 , Gueli Ignazio Alessio 3

1 Careggi University Hospital– Florence, Italy, 2 Giuliano Isontina University Hospital – Trieste, Italy, 3 Fondazione G. Monasterio – Pisa, Italy

We report the case of a 72-year-old woman diagnosed with pulmonary (fibrosing interstitial disease) and esophageal systemic sclerosis. In 2022 an echocardiogram was performed due to worsening dyspnea, which showed a left ventricle of normal volumes and systolic function, with a D-shape IV septum (panel A); the right ventricle was severely dilated with moderate systolic dysfunction (FAC=25%; TDI S=8cm/s). A subsequent cardiac MRI (B) confirmed the severe dilatation of the RV (EDVI 166 ml/m2) with diaphragmatic wall hypokinesia. The bSSFP and CEMRA images documented dilatation of the main trunk of the pulmonary artery (44 x 45 mm) and right and left branches. T1 mapping was increased with myocardial ECV within the limits, in line with connective tissue disease with myocardial involvement. In T1-GRE-IR sequences acquired after gadolinium injection we detected junctional and midwall distal inferior wall LGE. In 2023 the patient was hospitalized due to progressive-worsening dyspnea: haemodynamic investigation revealed mild pulmonary hypertension and Sildenafil therapy was started. A control cardiac MRI (C) was performed, revealing a filling defect of the main branch of the left pulmonary artery and of the ipsilateral lower lobar branch which appears hypointense in the LGE images (D), as from endoluminal thrombosis. A lung scintigraphy then showed hypoperfusion of the left lung (E) and an Angio-TC (F) confirmed a partial filling defect of the distal portion of the left main pulmonary artery branch. Follow-up scintigraphy (G) after one week of LMWH therapy showed perfusion improvement of the left lung.

ID: 148: A S ILENT C ASE OF E NDOMYOCARDIAL F IBROSIS : P AY A TTENTION TO ECG (E VEN AT THESE L ATITUDES )

Palmieri Alessandro 1 , Lepre Veronica 2 , Barison Andrea 3 , Todiere Giancarlo 3 , Grigoratos Chrysanthos 3 , Gueli Ignazio Alessio 3

1 Careggi University Hospital– Florence, Italy, 2 Giuliano Isontina University Hospital – Trieste, Italy, 3 Fondazione G. Monasterio – Pisa, Italy

A 50-year-old Caucasian man with a history of allergic asthma, favism and eosinophilia on blood tests, and deep negative T waves from V2 to V6 (A), was referred to cardiac magnetic resonance. He presented obliteration of the LV apex (maximum thickness 18 mm (B)) and a subtle subendocardial hyperintensity in the distal segments of the LV in T2-weighted imaging (C), as signs of subendocardiac edema.

In EGE images, a subendocardial hypointensity was highlighted in the apical segments (D) and in the LGE T1-GRE-IR images, subendocardial enhancement was found at LV lateral wall and at level of all distal segments, compatible with fibrosis. A 6-mm hypointense formation adhering to the area of apical fibrosis compatible with apical thrombotic stratification was highlighted (E). In 2023 a control MRI showed overlapping findings but the thrombotic formation was no longer evident (F): the patient has never taken anticoagulant therapy and manifested no symptoms.

Even in non-tropical regions endomyocardial fibrosis should be suspected in case of apical hypertrophic phenotypes and characteristic ECG findings.

CMR can differentiate EMF and apical HCM, as the former shows typical abnormal subendocardial fibrosis on LGE and apical thrombi formation (three-layered “V sign”), while the latter shows LV apical myocardial thickening with heterogenous enhancement on LGE. Differentiation from advanced eosinophilic heart disease relies mostly on clinical history (exclusion of hematologic neoplasms, parasitic infections and vasculitis). Prognosis is usually poor, due to the increased risk of arrhythmias and sudden cardiac death.

ID: 149: S ECUNDUM A TRIAL S EPTAL D EFECT AS A R ARE C AUSE OF P ULMONARY A RTERY H YPERTENSION : A C ASE R EPORT

Pantano Paola 1 , Savo Maria Teresa 2 , Di Paolantonio Diana 2 , Rugolotto Matteo 1 , Caterino Anna Laura 1 , Martire Paola 1 , Cernetti Carlo 1

1 Ca’Foncello Hospital, Treviso – Treviso, Italy, 2 Padua University Hospital – Padua, Italy

Background: Pulmonary arterial hypertension (PAH) is a rare condition and congenital heart disease related PAH represents 10-23% of all cases in Western world.

Case summary: A 26-year-old female presented with dyspnea at minimal effort, worsened in the past year. She had two previous regular pregnancies and no history of cardiac disease.

At admission, EKG showed right axis deviation and right ventricular (RV) hypertrophy. A CT pulmonary angiogram, performed to rule out pulmonary embolism, revealed main pulmonary arteries and RV dilatation.

Transthoracic echocardiography demonstrated significant dilatation of the right chambers, RV hypertrophy with preserved systolic function, interventricular septum flattening and increased systolic peak tricuspid regurgitation velocity consistent with high probability of pulmonary hypertension. A bubble contrast study showed the presence of right to left shunting at rest. Transesophageal echocardiogram revealed the presence of a large secundum atrial septal defect (ASD) (24 mm across) extending superiorly toward the superior caval ostium, with bidirectional but prevalent systemic-pulmonary shunting. The patient underwent right heart catherization and PAH was diagnosed (mPAP 51 mmHg; PVR 7.9 WU; PWCP 8 mmHg) thus wasn’t eligible for device shunt closure. Therefore, she started sequential combination therapy, achieving a low-risk status at follow-up.

Discussion: This case highlights the role of early diagnosis of ASD to prevent PAH. In a minority of cases secundum ASD can cause significant left to right shunting with subsequent right chambers volume overload. If untreated, ASD can lead to irreversible PAH with worse outcomes.

ID: 150: C ARDIOVASCULAR E FFECTS OF B RUTON ’ S T YROSINE K INASE I NHIBITOR IN C HRONIC L YMPHOCYTIC L EUKEMIA : A N A DVANCED E CHOCARDIOGRAPHIC S TUDY

Paoletta Daniele 1 , Pucci Martina, Gammaldi Vittoria, Capece Luca Maria, Pontoriero Mariateresa, Iacono Marina, Esposito Roberta

Departement of clinical medicine and surgery, Federico II University Hospital, Naples – Naples, Italy

Introduction: Bruton’s tyrosine kinase (BTK) inhibitors have revolutionized treatment of chronic lymphocytic leukemia (CLL). However, ibrutinib, the first BTK inhibitor approved, is associated with serious cardiovascular toxicities. New echocardiographic technology as longitudinal strain and myocardial work can improve cardiac evaluation in patients’ setting.

Aim: we performed advanced echocardiographic evaluation of patients with CLL treated with Ibrutinib using during a six-months follow-up.

Materials and methods: Study population includes 26 patients who, before starting treatment and six months later, underwent standard and advanced echocardiographic evaluation including left ventricular global longitudinal strain (GLS), left atrial strain and myocardial work study: global work index (GWI), constructive work (GCW), wasted work (GWW) and work efficiency (GWE).

Results: At follow up evaluation there weren’t statistically significant differences of standard and advanced echocardiographic parameters evaluated, although two patients have developed atrial fibrillation.

Conclusions: The stability of myocardial work parameters with improvement of myocardial efficiency (91.57 vs 90.42) although not significant, allows us to hypothesize a potential beneficial effect of increased blood pressure on cardiac performance. The stability of the echocardiographic parameters of atrial strain allows us to hypothesize that Ibrutinib doesn’t worsen atrial remodeling, therefore it may not be necessary to interrupt this life-saving therapy, while the basal stratification of the patients before starting treatment remaining fundamental.

ID: 151: L OCALIZED NON -A NON -B A ORTIC D ISSECTION

Parato Andrea Giovanni 1 , D’Agostino Simone 2 , Gizzi Germana 2 , Sbaraglia Francesco 2 , Boni Maria Virginia 3 , Parato Vito Maurizio 2

1 Cardiology Chair, Tor Vergata University – Rome, Italy, 2 “Madonna del Soccorso” Hospital - San Benedetto del Tronto (AP) Italy, 3 ”G. Mazzoni” Hospital - Ascoli Piceno, Italy

Non-A Non-B aortic dissection is considered an unusual occurrence, representing a small percentage of the total number of aortic dissection cases. In this case report, we describe a 76 years-old polytraumatized male patient with an incidentally found, “localized” non-A non-B aortic dissection. Chest CT-angiography showed a unique intimal entry tear, located in the central portion of the aortic arch, without propagation or any re-entering second tear. No signs of malperfusion or clinical symptoms related to the aortic finding were evident. After surgical treatment of leg fracture, given the asymptomatic status without any hemodynamic compromise, the Aortic Team decided a conservative approach and patient was fully monitored in a semi-intensive setting where a medical therapy was started with the aim to controlling blood pressure and heart rate. The unchanged stable clinical condition and chest CT-scan picture at day 7 led to patient’s discharge in a stable hemodynamic condition. A very strict follow-up was planned.

ID: 152: N OVEL I NTEGRATED I MAGING P ARAMETERS FOR R ISK S TRATIFICATION OF A TRIAL F IBRILLATION IN P ATIENTS WITH H YPERTROPHIC C ARDIOMYOPATHY

Parisi Francesca 1 , La Franca Eluisa 2 , Pistelli Lorenzo 1 , Gentile Giovanni 3 , Bellavia Diego 4 , Zito Concetta 1 , Di Bella Gianluca 1 , Carerj Scipione 1 , Cipriani Manlio 2

1 Department of Clinical and Experimental Medicine, Cardiology Unit, University of Messina, Azienda Ospedaliera Universitaria “Policlinico G. Martino”, Messina, Italy. – Messina, Italy, 2 Clinical Cardiology and Heart Failure Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy – Palermo, Italy, 3 Department of Diagnostic and Therapeutic Services, Radiology Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT) - Palermo, Italy, 4 Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT) – Palermo, Italy

Abstract Background: Over the past years, several indexes and methods to predict AF among HCM patients have been proposed. However, they are limited by a lack of accuracy.

Aim: Aim of our study was to evaluate the role of new echocardiographic parameters in predicting new onset of AF and to validate them by cardiac magnetic resonance (CMR).

Methods and Results: We analyzed clinical and imaging data of 141 HCM patients in sinus rhythm (mean follow up 5.3±3 years). Main parameters analyzed were left atrium (LA) end-diastolic volume (LAVmin), end-systolic volume (LAVmax), LA ejection fraction (LAEF), left atrioventricular coupling index (LACI), and LA diameter (LAD). LACI was defined by the LAVmin divided by the LV end-diastolic volume (LVEDV); this parameter was assessed in previous studies as a good detector of early atrial remodeling.

Results: 35 patients developed new-onset AF (after 4±3.2 years). At the baseline evaluation, LACI, LAD, and LAVmin showed to be significantly greater in patients who developed AF. At CMR, LACI >44% accurately predicted new-onset AF. LACI by ETT showed similar accuracy and was superior to that shown by LAD(Figure1). Patients who did not develop AF had significantly higher LAEF at ETT (49.3±11% vs 37±9.6%; p43% was a good predictor of AF free survival (log rank<0.001). Conversely, at a multivariate analysis, LAFE<43% by ETT was independently associated with AF occurrence (OR 4.5, 95% CI 1.4-13.7).

Conclusions: Higher LACI and Lower LAEF (namely<43%) identify patients at higher risk of new onset AF, and, therefore, worthy of a strict follow-up.

ID: 153: A DVANCED M ULTIMODAL I MAGING IN THE L ONG -T ERM F OLLOW - UP OF A V ENTRICULAR P SEUDOANEURYSM

Passaniti Giulia, Deste Wanda, Cannizzaro Maria Teresa, Tosto Giuseppe, Torrisi Tito, Melfa Chiara, Fragapane Angelo, Tamburino Corrado

G. Rodolico- San Marco University Hospital – Catania, Italy

Introduction: Left ventricular pseudoaneurysm is a rare and often fatal complication of myocardial infarction. It has an incidence of 0,2-0,4% of all the STEMI and a very high mortality, particularly in the first month. It can present acutely, right after the myocardial injury or chronic, up to three months after the myocardial infarction and its diagnosis can easily be made with a transthoracic echocardiogram and more in depth with a CT scan and a cardiac MRI.

Its treatment is surgical, but the choice is up to the anesthesiologist and cardiothoracic surgeon, depending on patient’s comorbidity and surgery risk. Surgical treatment has a high rate of death, reaching even the 37%.

Aim: This case report illustrates the strategic and fundamental role of multimodal imaging approach, especially exhibited by the morphological and functional findings displayed by Angio-Ct scan and CMR.

Background: We present the case of a 74 year-old patient with a history of chronic hypertension and cerebral vasculopathy, who sustained a STEMI in 2017. and developed a left ventricular pseudoaneurysm.

Methods: From March 2018 to October 2022, we have followed the patient with complete echocardiographic follow-ups, done every three-six months.

Results and conclusions: Patient with left ventricle pseudoaneurysm due to a previous extensive myocardial infarction has been followed in our echo lab for more than 4 years. He has been stable during these years, NYHA II, in a good clinical and hemodynamic state.

ID: 154: G ERBODE D EFECT A CQUIRED FROM A ORTIC E NDOCARDITIS - D IAGNOSTIC AND T HERAPEUTIC A PPROACH

Passaro Mario

Monaldi Hospital – Naples, Italy

A 56 year old patient was admitted to the emergency department. for fever not responsive to antibiotic therapy and dyspnea for approximately 20 days.

On TT echocardiography, a hypoechoic formation measuring 4.1 cm x 2.5 cm was detected in the right atrium and a hypokinetic CMD (EF 35%).

Once in our center, atrial flutter is recorded on the ECG and a positive blood culture is reported for Abiotrophia defectiva. Repeated TT echo in our facility reported tricuspid aortic valve with sessile echodense images at the level of the vegetation-like leaflets that cause stenosis. The presence of vegetation measuring 4.5 x 2.5 cm is confirmed which, starting from the aortic valve, infiltrates the aortic wall and, through the membranous interventricular septum, the right atrium, reaching the atrial cavity and engaging the tricuspid in diastole. This is a Gerbode defect acquired from aortic endocarditis. MRI confirmed the suspected diagnosis, CT revealed ongoing embolization with hypodense areas of ischemic appearance on the hepatic IVs and V/VIs and an area of centroparenchymal ischemia at the splenic level. It was deemed necessary to intervene surgically. The operation, with Euroscore II of 13.43%, involved remediation of the right aortic and atrial endocarditic vegetations with closure of the Gerbode defect and subsequent aortic valve replacement with Inspiris Resilia bioprosthesis n.23. IABP implanted, then removed on the second day.

Post-operative therapy with inotropic support and Unasyn was established. 7 days after the operation, the patient is transferred to a rehabilitation clinic for the conclusion of the therapeutic process.

ID: 155: R ARE C ASE OF Q UADRICUSPID A ORTIC V ALVE IN Y OUNG P ATIENT WITH S EVERE A ORTIC I NSUFFICIENCY AND H YPERTENSION

Passaro Mario

Monaldi Hospital – Naples, Italy

A 51-year-old woman with arterial hypertension has been in cardiologic follow-up since 2010 for myocarditis likely viral with an episode of heart failure during the eighth month of the second gestation, for which she had undergone echocardiographic examination, which found markedly reduced FE, mild-to-moderate aortic insufficiency, and the presence of type F aortic valve quadricuspid, according to Hurwitz and Roberts classification.

For the past several weeks, the patient has been complaining of asthenia and chest tightness on moderate-to-severe exertion, so hospitalization at the Department of Cardiac Surgery was necessary.

At the TT echo performed in our facility reported quadricuspid valve with good opening, medium-to-major aortic regurgitation, ascending aorta in the normal range (cm 3.8), mild mitral regurgitation, FE 60%.

Preoperatively, he also performed a CT scan and coronarography to rule out

It was therefore deemed necessary to subject the patient to cardiac surgery for aortic valve replacement with Perceval Plus size L bioprosthesis implantation in minithoracotomy, through right breast periareolar incision. The procedure was performed in 40 minutes of aortic clamping and 60 minutes of extracorporeal circulation with St. Thomas Cardioplegia, with perioperative TEE control.

The postoperative period was free of complications. After 48 hours spent under observation in the ICU, she returned to the cardiac inpatient unit, where the ECG showed an RS with BBSx.

She performed a control echo TT on postoperative day 5, which showed a normofunctioning bioprosthesis, FE 55 %

At 6 days after surgery, the hemodynamically stable woman was discharged home surgically cured with medical therapy.

ID: 156: R ARE C ASE OF Y OUNG W OMAN WITH R IGHT V ENTRICULAR M ASS ON T RICUSPID

Passaro Mario

Monaldi Hospital – Naples, Italy

A 43-year-old woman is urgently admitted to the ICU following TT echocardiographic examination, performed at our facility, which showed echodense formation in the right ventricle at the level of the pulmonary infundibulum 3.1x2 cm, engaging the outflow tract of the right ventricle, implanted on the chords from the tricuspid valve. In history antiphospholipid antibody syndrome and previous deep vein thrombosis. Control Angio-CT is performed pending scheduling of surgery. Following an episode of cardiovascular arrest with subsequent resumption of ROSC after 30 seconds of cardiac massage, urgent cardiac surgery is performed by collegial decision. The patient underwent tricuspid valve replacement with Epic Supra 31 mm bioprosthesis with implantation of definitive tunneled epicardial electrode in left hypochondrium pocket.

The procedure was performed in 75 minutes of aortic clamping and 97 minutes of extracorporeal circulation with Del Nido Cardioplegia and perioperative TEE monitoring.

The immediate postoperative period was free of complications. After 48 hours spent under observation in the ICU, the patient returned to the cardiac inpatient unit, where she had a spike in fever, so no anti-infective therapy had to be administered.

She had a control echo TT on postoperative day 5, which showed a normofunctioning bioprosthesis, with cusps of normal appearance and mobility, FE 60 %, gradient 5 mmHg, PHT 90 msec.

At 6 days after surgery, the hemodynamically stable woman was discharged home surgically cured with medical therapy and prescription for outpatient follow-ups.

ID: 157: A N U NUSUAL C AUSE OF S YNCOPE : T HE K EY R OLE OF M ULTIMODALITY I MAGING

Pedone Chiara 1 , Sguazzotti Maurizio 1 , Perugini Enrica 1 , Coutsoumabas Gloria V 1 , Dattolo Giacomo 1 , Russo Vincenzo 2 , Di Giannuario Giovanna 3 , Casella Gianni 1

1 Maggiore Hospital – Bologna, Italy, 2 S. Orsola-Malpighi Hospital – Bologna, Italy, 3 Infermi Hospital – Rimini, Italy

BACKGROUND: Cardiac masses are rare cause of syncope and a diagnostic dilemma in clinical practice. Multimodality imaging (MMI) is needed but best approach standardization is still lacking. Transthoracic echocardiogram (TTE) is the first-line, often not conclusive technique. Cardiovascular magnetic resonance (CMR) is highly accurate test providing tissue characterization, multiplanar information on relation to surrounding structures and vascularization assessment. Cardiac computed tomography (CCT) could be a valid alternative due to spatial resolution, calcium and perfusion characterization. Metabolic activity assessment with 18F-FDG PET/CT plays a key role in selected cases.

CASE SUMMARY: A 47-year-old woman presented to emergency department with repeated effort syncope occurred in the last week and mild chest pain. Ten years before she underwent wide local excision of skin melanoma with negative follow-up. She had no previous cardiac history. Physical examination, vital parameters and electrocardiogram were normal. TTE revealed a bulky mass occupying mid-apical left ventricular cavity, hampering both inflow and outflow, with smooth surface, small implant base next to posteromedial papillary muscle. At CMR the mass appeared hyperintense both on T1w and T2w sequence; it had limited perfusion to implant base and minimum inhomogeneous LGE; findings were suggesting for thrombosis. PET/CT with FDG scan showed intense uptake (SUV 18) within the mass. Transapical biopsy confirmed diagnosis of metastatic melanoma with BRAFV600 mutations. The patient was treated with dabrafenib-trametinib combination and low weight molecular heparin for superimposed thrombosis. At 3 months multimodality imaging demonstrated a significant therapy response with more 50% volume reduction and uptake disappearance within the mass.

ID: 158: F ETAL A RRHYTHMIAS : D IAGNOSIS AND M ANAGEGEMENT ARE B ASED ON F ETAL E CHOCARDIOGRAPHY

Pelaggi Giuseppe 1 , Ceratti Simona 1 , De Luca Francesco Letterio 1 , Bruno Letteria 1 , Crea Pasquale 1 , Zito Concetta 1 , Gitto Placido 2 , Guccione Paolo 2 , Scimone Ignazio Massimo 3 , Carerj Scipione 1 , Oreto Lilia 1

1 G. Martino University Hospital – Messina, Italy, 2 Pediatric Cardiological Center of Mediterraneo, Bambin Gesù Hospital – Taormina, Italy, 3 Fetal Cardiology Service (Scilla Health House) – Scilla (RC) Italy

Introduction. Fetal arrhythmias cause significant morbidity and mortality in utero and in neonatal age. Fetal echocardiography is crucial for differential diagnosis between different arrhythmias, allowing identification of atrial and ventricular contractions by M-Mode, given that proper alignment is obtained with atrial and ventricular chambers simultaneously. We reviewed our cases of fetal arrhythmias, aiming at evaluating characteristics and clinical management.

Methods and Results. Since 2014 we identified retrospectively 56 pregnancies with fetal arrhythmias (extrasystoles, tachycardias, bradycardias and blocks). Mean gestational age at diagnosis was 27 weeks, 13 cases required transplacental antiarrhythmic drugs, severe heart failure occurred in 4 cases, urgent cesarean section was required in 21 cases.

Isolated extrasystoles (21 cases) were common, not associated with significant arrhythmias, except for one case initially diagnosed as isolated ventricular ectopy, which after birth evolved in persistent junctional tachycardia.

Bradycardia (3 cases) was associated with long QT syndrome diagnosed at birth in all 3 cases, requiring prophylactic beta-blockers, and one also pacemaker implantation. Two sudden deaths occurred during infancy.

Fetal tachycardia (23 cases) evolved in severe heart failure with hydrops in 4 cases: 1 atrial flutter requiring cesarean section at 32 weeks and 3 fetal resolution of heart failure with transplacental therapy.

Of 8 cases with complete heart block, 2 showed evolution from Wenckebach II to III degree. Six cases were associated with maternal autoimmunity, while 2 with congenital heart disease.

Conclusions. Fetal arrhythmias are relatively rare but represent a challenge for diagnosis and treatment. Accurate prenatal diagnosis is crucial for the appropriate treatment.

ID: 159: D ILATATION OF THE R IGHT H EART IN C HILDREN : N OT O NLY A TRIAL S EPTAL D EFECT

Pelaggi Giuseppe 1 , De Luca Francesco Letterio 1 , Bruno Letteria 1 , Solazzo Antonio 1 , Todaro Maria Chiara 2 , Ceratti Simona 1 , Miccichè Serena 1 , Trimarchi Giancarlo 1 , Scimone Ignazio Massimo 3 , Zito Concetta 1 , Carerj Scipione 1 , Oreto Lilia 1

1 G. Martino University Hospital – Messina, Italy, 2 Pappalardo Hospital – Palermo, Italy, 3 Fetal Cardiology Service (Scilla Health House) – Scilla (RC) Italy

Scimitar syndrome is a rare congenital condition characterized by partially anomalous pulmonary venous drainage of the right veins into the inferior vena cava, usually associated with hypoplastic right lung. We present the case of a 6-year-old girl, regularly followed-up at another center for bicuspid aortic valve. The patient came to our attention for preoperative assessment in preparation for tonsillectomy. During the interview, she complained of fatigue following mild to moderate exertion. Physical examination was unremarkable except for mildly short stature. The electrocardiogram was normal for patient’s age, except for the presence of positive T waves in leads V1-V2. The echocardiogram showed significant dilation of the right heart chambers, hepatic veins, and inferior vena cava (10.6 mm; normal range <7.65 mm), which had reduced collapsibility. The atrial septum was intact, but the right pulmonary veins did not enter the left atrium. However, from the subcostal view there was an abnormal vessel draining into the inferior vena cava. Suspecting “scimitar syndrome”, a chest X-ray was performed, showing the characteristic radiological sign, in the absence of pulmonary hypoplasia. Angiography CT confirmed the anomalous venous return of both right pulmonary veins into the right atrium, significantly enlarged right atrium and bilobed right lung. The case was then discussed between pediatric cardiologists and surgeons, and the patient is now awaiting cardiac catheterization and subsequent surgical correction of the defect. In case of dilation of the right heart chambers, cardiologists should always consider in the differential diagnosis pre-tricuspid shunts such as anomalous pulmonary venous returns.

ID: 160: A RTIFICIAL I NTELLIGENCE (HEART MODEL) IN E CHOCARDIOGRAPHY FOR THE S TUDY OF L EFT A TRIAL F UNCTION AND V OLUMETRY

Pelaggi Giuseppe, Trimarchi Giancarlo, Miccichè Serena, Lo Nigro Maria Claudia, Iuvara Giustina, Napoli Anna Rosa, Restelli Davide, Zito Concetta, Di Bella Gianluca, Micari Antonio, Carerj Scipione

G. Martino University Hospital – Messina, Italy

INTRODUCTION: The advent of technology has brought increasingly precise techniques for the assessment and stratification of cardiac patients. From monodimensional methods to the present, there have been remarkable advances with the introduction of three-dimensional reconstruction techniques and even programs integrated with artificial intelligence.

AIM: The aim of the study was to compare the values of left atrial volumetry and its ejection fraction obtained through 2D methodology, LA-strain algorithm for atrial ejection fraction alone, and volumetry and ejection fraction in 3D Heart Model (HM) technique. Additionally, the study aimed to compare the execution times among the various methods.

MATERIALS AND METHODS: Analysis was conducted on 25 healthy subjects (16 males) aged between 18 and 35 years. All subjects underwent a comprehensive assessment using 2D, standard 3D, and artificial intelligence-based HM techniques. Parameters were analyzed using the Student’s T-test.

RESULTS: There is no significant variability (P=0.091) in the evaluation of volumes between the two-dimensional technique and the 3D HM technique. There is no significant variability (P=0.195) in the evaluation of left atrial ejection fraction between LA-strain method and Heart Model method. Otherwise, there is a significant variation (P=0.001) in the execution times of volume and left atrial ejection fraction analysis using the 3D HM technique compared to the two-dimensional method.

CONCLUSIONS: Automated volumetric analysis of the left atrial chamber is an accurate alternative to conventional methodology, as it is highly reliable and significantly reduces execution times.

ID: 161: E FFECTS OF H IGH -F LOW N ASAL C ANNULA ON R IGHT H EART D YSFUNCTION IN P ATIENTS WITH A CUTE - ON -C HRONIC R ESPIRATORY F AILURE AND P ULMONARY H YPERTENSION

Pelaia Corrado 1 , Armentaro Giuseppe 1 , Lupia Chiara 1 , Maiorano Antonio 1 , Montenegro Nicola 1 , Miceli Sofia 1 , Condoleo Valentino 1 , Cassano Velia 1 , Bruni Andrea 1 , Garofalo Eugenio 1 , Crimi Claudia 2 , Vatrella Alessandro 3 , Pelaia Girolamo 1 , Longhini Federico 1 , Sciacqua Angela 1

1 University “Magna Græcia” of Catanzaro – Catanzaro, Italy, 2 University of Catania – Catania, Italy, 3 University of Salerno – Salerno, Italy

High-flow nasal cannula (HFNC) has several benefits in patients affected by different forms of acute respiratory failure, based on its own mechanisms. We postulated that HFNC may have some advantages over conventional oxygen therapy (COT) on the heart function in patients with acute-on-chronic respiratory failure with concomitant pulmonary hypertension (PH). We therefore designed this retrospective observational study to assess if HFNC improves the right and left ventricle functions and morphologies, arterial blood gases (ABGs), and patients’ dyspnea, compared to COT. We enrolled 17 hospitalized patients receiving HFNC, matched with 17 patients receiving COT. Echocardiographic evaluation was performed at the time of admission (baseline) and 10 days after (T10). HFNC showed significant improvements in right ventricular morphology and function, and a reduction in sPAP. However, there were no significant changes in the left heart measurements with HFNC application. Conversely, COT did not lead to any modifications in echocardiographic measurements. In both groups, oxygenation significantly improved from baseline to T10 (in the HFNC group, from 155 ± 47 to 204 ± 61 mmHg while in the COT group, from 157 ± 27 to 207 ± 27 mmHg; p < 0.0001 for both comparisons). In conclusion, these data suggest an improvement of oxygenation with both treatments; however, only HFNC was able to improve the right ventricular morphology and function after 10 days from the beginning of treatment in a small cohort of patients with acute-on-chronic respiratory failure with PH.

ID: 162: P ARAVALVULAR L EAK A FTER P ROSTHETIC V ALVE I MPLANTATION : P ERCUTANEOUS C LOSURE AS P REFERRED T REATMENT

Pellizzeri Bianca, Rizzo Sofia, Lombardo Luca Barbaro, Bellina Giovanni, Accurso Davide, Barbera Chiara, Scandura Salvatore, Castania Giuseppe, Sanfilippo Maria, De Santis Jessica, Greco Ylenia, Lentini Giuseppe, Tamburino Corrado

Catania University, “G. Rodolico” University Hospital – Catania, Italy

A 71-year-old female patient, suffering from hypertension, dyslipidemia, chronic renal failure and atrial fibrillation, undergone mitral valve replacement with biological prosthesis in August 2021. In November 2021 she referred dyspnea (New York Heart Association IV), asthenia, pallor and anemia which required blood transfusions. Computed Tomography (CT) Angiography excluded bleeding sites. Suspecting the presence of periprosthetic leak, on February 2022 transesophageal echocardiogram (TEE) was performed and confirmed severe mitral valve prosthesis regurgitation through a leak located at “10-11-o-clock” from the surgeon’s view. TEE also showed severe tricuspid regurgitation and elevated pulmonary hypertension.

Indications for percutaneous paravalvular leak (PVL) closure include the presence of symptoms as dyspnea or clinically significant hemolytic anemia and moderately severe or severe paravalvular prosthetic regurgitation. Considered the increased risk of morbidity and mortality if a second cardiac surgery was performed, percutaneous closure is the preferred treatment choice.

On March 2022 we performed percutaneous PVL closure. The procedure was done under general anesthesia; from the right femoral vein access, using TEE guidance trans-septal puncture, Amplatzer Vascular Plug III 5x14 mm was correctly positioned cross the leak. Post-deployment TEE showed completely resolution of regurgitation.

At 1 month follow up, patient has not required blood transfusion since PVL closure, and clinically her dyspnea as well as exercise tolerance are both much improved.

ID: 163: A N H OURGLASS IN A T INY H EART “COR TRIATRIATUM SINISTER” (CTS)

Petruccelli Enrica

San Giacomo Hospital - Monopoli (BA) Italy

I report on case of a child with “Cor triatriatum sinister” occasionally encountered. A 3 year old boy, arrives in Cardiology from Emergency Room for chest pain, increased with breathing actions and sore throat. The child, to observation was rosy and eupnoeic, with normal ecg and laboratory tests, lung ultrasound negative for pneumonia, but with a diastolic mumur to ausclutation. An echocardiogram, during first aid consultation allowed the identification of CTS. The left atrium was sepimented by a funnel-shaped membrane in the intermediate portion. In CTS, the left atrium is divided into two chambers by a fibromuscular septum, with the pulmonary veins entering a posterior-superior chamber separated from the anterior-inferior distal chamber containing the mitral valve. The embryologic origin of this defect remains controversial, with two different theories, the “Malincorporation” and “Entrapment”. The diagnosis of CTS is made by echocardiography, it is important to differentiate the CTS membrane from a supravalvular mitral ring, and the left atrial appendage is used as an anatomic landmark. In CTS, cyanosis is rare but can be present on the basis of associated lesion, in this case absent. The presentation of CTS is related to the degree of ostruction caused by the membrane, which allow the blood to pass through abnormally (medium grade mitral stenosis like). After oral anti-inflammatory (ibuprofen) the child showed rapid remission of symtoms. The child will undergo to angiography and cardiac catheterization. Treatment for CTS for higher gradients is surgical resection.

ID: 164: D IALYSIS C ENTRAL V ENOUS C ATHETER R ELATED R IGHT A TRIAL T HROMBOSIS WITH S UPER -I MPOSED E NDOCARDITIS

Pilan Matteo, Ciceri Luca, Cerrito Luca, Caprioglio Francesco, Barbati Giovanni

San Bortolo Hospital – Vicenza, Italy

Introduction: Right atrial thrombosis is a possible, potentially life threatening, complication related to the presence of central venous catheters (CVC). It is worth noting that this condition is probably underdiagnosed with some studies reporting a prevalence of right atrial thrombosis in up to 30% of patients with CVCs.

Case: A 40-year-old female patient, with a history of end-stage renal failure due to vesicoureteral reflux and recent placement of a central venous catheter to start hemodialysis, was referred to our attention for echocardiography because of persistent fever and positive blood cultures for Staphylococcus Aureus. Transthoracic echocardiography showed a mass attached to the posterolateral wall of the right atrium and extended to the base of the posterior tricuspid leaflet conditioning a mild to moderate regurgitation with no associated stenosis. Transesophageal echocardiography confirmed the presence of an isoechoic mass of 30 x 10 mm with two extremely mobile protrusions (9 x 3 mm and 10 x 3 mm) allowing to establish a diagnosis of CVC decubitus thrombosis with superimposed endocarditis. The patient was therefore evaluated by a multidisciplinary team, leading to the decision to pursue, in first instance, a conservative approach with appropriate anticoagulant and antibiotic therapies. One month after initiating medical treatment the patient underwent a re-evaluation with transthoracic echocardiography revealing a complete resolution of the lesion.

Conclusion: Our case shows that in selected patients with complicated CVC thrombosis, medical therapy may be a valuable alternative to thrombolysis or surgical thrombectomy, which could be used in non-responders as a rescue therapy.

ID: 165: W ET OR D RY ? T HAT IS THE Q UESTION

Piscione Mariagrazia, Polito Dajana, Frau Lorenzo, Ussia Gian Paolo, Grigioni Francesco

Policlinico Campus Biomedico – Rome, Italy

Background: In Intensive Care Unit, point-of-care ultrasound has to be considered a valuable tool for patient evaluation. If the assessment of the dimension and the collapsibility of the inferior vena cava (IVC) is the most common method, it is subject to numerous limitations.

Methods: We would examine two cases in which there is an evident disparity between IVC measurements and hepatic and renal Doppler pattern.

Results: The first case is that of a 50-years old woman with severe tricuspid regurgitation due to annulus dilation who exhibits a dilated IVC with no correlation with her fluid status. Actually, the portal vein flow and the intrarenal venous flow are monophasic and continuous. To confirm this datum, the abdominal objectivity does not show signs of parenchymal congestion. On the other hand, the second case shows a 65-years old acute right ventricle myocardial infarction caused by a complete occlusion of the right coronary artery. In this case, the IVC was mildy dilated but the portal and renal flow exhibit a pulsatile shape. What it may be suggested is that the right heart has behaved as a passive conduit between the venous system and the left heart. The LV has become hyperdynamic and the patient may have been volume-resposive, despite the IVC being significantly dilated.

Conclusions: Vena cava size and its respiratory variability may not always depend on volume status. In these occasions, portal and renal flow pulsatility might be more sensitive in detecting peripheral congestion.

ID: 166: S URVEY A MONG SIECVI M EMBERS ON THE U SE OF PACS

Pizzuti Alfredo 1 , Trocino Giuseppe 2 , Barchitta Agata 2 , Barletta Valentina 1 , De Chiara Benedetta 1 , Di Salvo Giovanni 1 , Giannini Danilo 1 , Giorgi Mauro 3 , Greco Cosimo Angelo 3 , Palmiero Giuseppe 1 , Polizzi Vincenzo 1 , Trambaiolo Paolo 3 , Merli Elisa 3 , De Amici Erica 4

1 SIECVI Education Sector – Milano, Italy, 2 SIECVI Board of Dirtectors - Milano, Italy, 3 SIECVI – Milano, Italy, 4 SIECVI Secretariat – Milano, Italy

Introduction: Picture Archiving and Communication System (PACS) has been implemented and developed in radiology departments.

Aim and Methods: To find out how much, and how, PACS is used in Italian echo-labs, we conducted a survey of SIECVI members in March 2023. The main questions were: 1. Is there a PACS in your facility and which methods flow into it? 2. Do you digitally archive echo images? 3. Is there an external workstation to review echo exams? 4. Are echo images of hospitalised patients available on the PCs of all wards? 5. Do you provide digital images to outpatients? 6. How do you rate your experience with PACS?

Results: We got 187 replies, for a total of 211 laboratories. A PACS is present in 90% of hospital echo-labs and 39% of outpatient labs. Among the 174 facilities with PACS this is available for cardiology imaging in 149 (86%), but in 26 of them (17%) it is not used. Echo images are available for consultation at the point of care in 36% of facilities with beds. Outpatients are always provided with digital images in 16% of laboratories; 83% of responders are only partially (79%) or not at all (4%) satisfied with their experience with PACS.

Conclusions: Echo-labs do not appear to be fully integrated with PACS. The decision-making process of choosing a PACS may be a difficult task. Clinicians may be focused on convenience in usage and workflow, administrators may be more interested in performance, monitoring tools, integration and compatibility. Some of these issues should be addressed at the selection stage and might be mitigated by a strict collaboration between the two professional groups

ID: 167: M ULTIMODALITY I MAGING IN A C ASE OF S EPTIC S HOCK S ECONDARY TO A B ACTERIAL A ORTITIS

Po’ Domenico, Barchitta Agatella, Dal Prà Chiara, Russo Lucia, Maiolino Giuseppe, Zabeo Eva, Barbato Beatrice, Trevisan Francesca, Vettor Roberto

Sub-Intensive Care Unit, Department of Medicine, Padua University Hospital – Padua, Italy

A 68-years-old man with no past medical history presented to the Emergency Department with persistent fever, pharyngodynia, arthralgia and oliguria in the last few days. His blood exams showed a neutrophilic leukocytosis, a huge increase of C-reactive protein (603 mg/L) and procalcitonin. Few hours after hospital admission, the patient developed severe septic shock and acute kidney failure with need of inotropic support and kidney replacement therapy. A chest X-ray, an echocardiography and a urinalysis excluded infectious foci, therefore a contrast-CT scan of abdomen and chest was performed. It showed a diffuse abdominal aortic wall thickening, an imbibition of periaortic tissue and an infrarenal aortic ectasia with thrombotic apposition and a penetrating ulcer. The patient underwent a broad-spectrum empiric antibiotic therapy with meropenem, daptomycin, levofloxacin and caspofungin. The hyperinflammatory condition was treated with anti-IL-1 therapy. Microbiological tests and autoimmune screening were negative, except for an increase of the antistreptolysin titre (1320 UI/mL). After 4 days of therapy, a PET-MRI (Fig.1) showed a ring-shaped hypermetabolism of infrarenal aortic region and excluded other foci of inflammation. In consideration of the elevated risk of rupture, the patient underwent percutaneous implant of vascular endoprosthesis as a bridge to an open surgery that will be performed at the conclusion of the acute event. He was discharged with long-life antibiotic therapy with moxifloxacin; after 3 months, PET-CT and blood exams showed a significant reduction of aortic parietal inflammation.

ID: 168: L EFT A TRIAL V OLUME , F UNCTION , AND B- LINES AT REST AND DURING V ASODILATOR S TRESS E CHOCARDIOGRAPHY

Prota Costantina 1 , Cortigiani Lauro 2 , Campagnano Ettore 3 , Wierzbowska-Drabik Karina 4 , Kasprzak Jaroslaw 5 , Colonna Paolo 6 , Merli Elisa 7 , Manganelli Fiore 8 , Gaibazzi Nicola 9 , D’Andrea Antonello 10 , Cerracchio Emma 3 , Meola Laura 2 , Citro Rodolfo 1 , Villari Bruno 3 , Ciampi Quirino 3

1 AOU San Giovanni Di Dio e Ruggi D’Aragona – Salerno, Italy, 2 San Luca Hospital – Lucca, Italy, 3 Fatebenefratelli Hospital – Benevento, Italy, 4 Bieganski Hospital, Medical University – Lodz, Poland, 5 Hospital Medical Univerity of Lodz – Lodz, Poland, 6 Policlinico Hospital – Bari, Italy, 7 Ospedale per gli Infermi – Faenza, Italy, 8 San Giuseppe Moscati Hospital – Avellino, Italy, 9 Parma University Hospital – Parma, Italy, 10 Umberto I Hospital - Nocera Inferiore (SA) Italy

Background: Left atrial volume index (LAVI), left atrial reservoir function assessed with global peak amplitude longitudinal strain (LASr), and B-lines at lung ultrasound are supplementary markers of left ventricular filling pressures.

Aim: To assess the relationship between LAVI, LASr and B-lines at rest and peak vasodilator stress.

Methods. A comprehensive dipyridamole stress echo (SE) was completed in 252 patients (180 male, 71%, age 65±10 years) with chronic coronary syndromes. LAVI was measured with the biplane disk summation method. LASr was measured with 2-dimensional speckle tracking echocardiography. B-lines were assessed with the simplified 4-site scan in the third intercostal space.

Results. During dipyridamole, LAVI decreased (rest= 26±14 ml/m2 vs stress= 24±12 ml/m2, p<0.001), LASr increased (rest= 33±8 vs stress= 38±10%, p<0.001), and B lines were more frequent, from 19, 7.5% at rest to 29, 11.5%, at peak stress (p<0.001). There was a significant, linear, inverse correlation between LAVI and LASR both at rest (r=-.301, p<0.001) and at peak stress (r=-.279, p<0.001). At group analysis, peak B-lines were directly correlated with peak LAVI (r=.151, p=0.017) and inversely correlated with peak LASR (r= -.234, p<0.001). At individual patient analysis, 20/207 patients (9.7%) showed stress B-lines with normal LAVI and preserved LASr and 9/45 (20%) showed stress B-lines with abnormality of both LAVI and LASr (Fig).

Conclusion: Vasodilator stress echocardiography with combined assessment of left atrial volume, function and pulmonary congestion is feasible with high success rate. Pulmonary congestion is more frequent with dilated left atrium with reduced atrial contractile reserve.

ID: 169: H EART I NVOLVEMENT IN H YPOTHYROIDISM : A M YOCARDIAL W ORK S TUDY

Pucci Martina, Gammaldi Vittoria, Paoletta Daniele, Capece Luca Maria, Pontoriero Mariateresa, Esposito Roberta

Department of Clinical Medicine and Surgery, Federico II University Hospital, - Naples, Italy

Introduction: From 2022 Guideline for Management of Heart Failure it’s known that hypothyroidism is a potential cause of heart failure. Aim: clarify the hemodynamic changes caused by thyroid dysfunctions in patients with hypothyroidism using myocardial work, an emerging tool in echocardiography that incorporates left ventricular afterload into global longitudinal strain analysis. Materials and methods: Study population includes 48 patients with hypothyroidism in absence of risk factors for cardiovascular diseases and 102 healthy controls with euthyroidism. Myocardial work assessment was performed with EchoPAC. Four values are calculated: global work index (GWI), global constructive work (GCW), global wasted work (GWW) and global work efficiency (GWE). Continuous normally distributed variables were compared by using the Student t-test. Probability value 10. Conclusions: This study highlights how thyroid function plays a central role in regulating cardiac performance. The importance of recognition of the effects of thyroid disease on the heart derives from the observation that restoration of normal thyroid function most often reverses the abnormal cardiovascular hemodynamics.

ID: 170: I BRUTINIB R ELATED A TRIAL F IBRILLATION IN C HRONIC L YMPHOCYTIC L EUKEMIA : T HE R OLE OF S PECKLE T RACKING E CHOCARDIOGRAPHY

Pucci Martina, Gammaldi Vittoria, Paoletta Daniele, Pontoriero Mariateresa, Capece Luca Maria, Esposito Roberta

Department of Clinical Medicine and Surgery, Federico II University Hospital, - Naples, Italy

Introduction: Ibrutinib is a Bruton tyrosine kinase inhibitor, approved for treatment of chronic lymphocytic leukemia (CLL). Its use is associated with serious cardiovascular toxicities including atrial fibrillation, ventricular arrhythmias, hypertension and heart failure.

Aim: Determine if there are echocardiographic parameters that could identify patients at major risk of developing ibrutinib-related atrial fibrillation (IRAF).

Materials and methods: Study population includes 26 patients who, before starting treatment with Ibrutinib underwent echocardiographic evaluation measuring peak atrial longitudinal strain (PALS) and peak atrial contraction strain (PACS) on 4 and 2 chambers views.

Results: Six patients developed IRAF (23 %). There weren’t anthropometric differences between the two groups. IRAF’s group had lower ejection fraction (54,67±1,96 vs 60,90±4,35, p-value < 0,0001), higher left atrium volume index (48,95±16,31 vs 34,18±9,07, p-value: 0,009), higher pulmonary arterial pressure values (44,16±11,26 vs 32,89±8,44, p-value: 0,015). Furthermore, PALS and PACS were reduced in patients who developed IRAF (PALS 4Ch: 18,89±6,90 vs 29,40±9,79, p-value 0,06; PACS 4Ch: 10,56±5,66 vs 14,31±5,72, p-value: 0,25; PALS 2Ch: 23,36±5,02 vs 32,88±16,57, p-value: 0,28; PACS 2Ch: 13,61±8,16 vs 18,33±9,87, p-value: 0,39)

Conclusions: Use of speckle tracking echocardiography for baseline evaluation of patients candidates to Ibrutinib can help us to identify patients at major risk of developing IRAF in order to allow a pharmacological intervention that could preserve cardiac function and improve long-term outcome.

ID: 171: D EEP P HENOTYPE C HARACTERIZATION OF P ATIENTS WITH A ORTIC S TENOSIS AND P RESERVED E JECTION F RACTION

Pugliese Nicola Riccardo

Pisana University Hospital – Pisa, Italy

Background. Degenerative aortic valve stenosis with preserved left ventricular ejection fraction (ASpEF) and heart failure with preserved left ventricular ejection fraction (HFpEF) display intriguing similarities.

Methods and results. We prospectively enrolled 148 patients with HFpEF and 150 patients with degenerative moderate-to-severe ASpEF, together with 66 age- and sex-matched healthy controls. All subjects received a comprehensive evaluation at rest and 351/364 (96%) performed a combined cardiopulmonary-exercise stress echocardiography test. Patients with ASpEF eligible for transcatheter aortic valve replacement (n=125) also performed cardiac computed tomography (CT). HFpEF and ASpEF patients showed similar demographic distribution and biohumoral profiles. Most patients with ASpEF (134/150, 89%) had severe high-gradient aortic stenosis; 6/150 (4%) had normal-flow, low-gradient ASpEF, while 10/150 (7%) had low-flow, low-gradient ASpEF. Both patient groups displayed significantly lower peak oxygen consumption (VO2), peak cardiac output, and peak arteriovenous oxygen difference compared to controls (all p<0.01). ASpEF patients showed several extravalvular abnormalities at rest and during exercise, similar to HFpEF (all p<0.01 vs controls). Epicardial adipose tissue (EAT) thickness was significantly greater in ASpEF than HFpEF and was inversely correlated with peak VO2 in all groups. In ASpEF, EAT was directly related to echocardiography-derived disease severity and CT-derived aortic valve calcium burden.

Conclusions. Functional capacity is similarly impaired in ASpEF and HFpEF due to both peripheral and central components. Extravalvular alterations may affect disease progression and prognosis in ASpEF even after valve intervention, which could support the concept of ASpEF as a specific subphenotype of HFpEF.

ID: 172: M ASSIVE P ULMONARY E MBOLISM AND H EMORRHAGE T REATED WITH C ATHETER -D IRECTED T HROMBOLYSIS AND I NFERIOR V ENA C AVA F ILTER . A C ASE R EPORT

Purificati Chiara, Barchitta Agatella, Scarda Alessandro, Ferrari Alessia, Maggi Michael, Balasa Alina, Vettor Roberto

Padua University Hospital – Padua, Italy

A 77-years-old woman was admitted for traumatic right pertrochanteric fracture due to a syncope. In emergency department, vital signs were normal except a mild tachypnea and desaturation, ECG revealed negative T waves in the precordial leads and elevated plasma troponin. A CT-pulmonary angiography was performed in the suspect of pulmonary embolism (PE) that was confirmed as massive bilaterally; deep vein thrombosis (DVT) in right common femoral vein was detected with ultrasound. An echocardiography showed signs of acute right ventricular (RV) dysfunction and pulmonary hypertension (PAPS 55 mmHg). Anticoagulant therapy with i.v. unfractionated heparin was started immediately. Few hours later the patient developed hemodynamic instability, and a large hematoma was seen in the right hip. A CT angiography documented hemorrhagic infarction nearby the femur fracture with loss of 5 g/dl of hemoglobin. It was mandatory to suspend anticoagulation, and the patient received transfusion.

In consideration of the of the massive pulmonary embolism and of the hemorrhagic shock, the patient underwent a catheter-directed therapy (CDT) with bilateral removal of thrombi and pulmonary arteries reperfusion leading to improvement in RV function and PAPs reduction (35 mmHg).

Subsequently, the IVC filter was positioned. 24 hours later the surgical femoral osteosynthesis stabilized the fracture.

In conclusion even if CDT is indicated only for patients with high-risk PE, in whom thrombolysis is contraindicated or has failed, we suggest that it may be useful also in patient with intermediate-high risk PE who are at risk of developing hemorrhagic complication due to anticoagulation.

ID: 173: D IAGNOSTIC W ORK - UP OF V ASCULAR G RAFT I NFECTIONS : D ESCRIPTION OF A C LINICAL C ASE

Raffaelli Elena 1 , Surace Francesca Chiara 1 , Bordignon Linda 1 , Lofiego Carla 2 , Baldinelli Alessandra 1 , Baldoni Monica 1 , Berton Emanuela 1 , Bianco Francesco 1 , Bucciarelli Valentina 1 , Capestro Alessandro 1 , Esposito Arianna 1 , Iezzi Federica 1 , Santoro Gaetano 1 , Dottori Melissa 2 , Merlino Ettore 1

1 Division of Cardiac Surgery and Petriatic and Congenital Division” Riuniti Hospital “ University Hospital – Ancona, Italy, 1 Division of Cardiology “ Riuniti Hospital “ University Hospital – Ancona, Italy

Introduction: We describe the case of a patient who underwent a percutaneous repair of aortic coarctation and developed an infected pseudoaneurysm of the descending aorta some weeks later.

Clinical case: A 16 year-old boy with bicuspid aortic valve and systemic blood hypertension was diagnosed with coarctation of the aorta, which was corrected percutaneously with the implant of an isthmic stent. Two months after the procedure, we admitted him because of a seven-day history of high fever, malaise and mild chest pain. Blood cultures were positive for Methicillin-sensitive Staphylococcus aureus, while transthoracic echocardiography did not show any signs of infective endocarditis. Transesophageal echocardiography documented a 5.0x5.1cm aortic pseudoaneurysm, extending from the distal landing of the isthmic stent to the descending aorta (Figure 1A, 1B). Cardiac computed-tomography confirmed this finding, which was proximal to the origin of the intercostal arteries (Figure 1C) and had an inflammatory-infective component within it; no signs of evolution emerged at the 24-hour follow-up scan. A positron emission tomography demonstrated an increased metabolic activity, though in presence of the aortic stent. Thus, a targeted antibiotic regimen was promptly started as well as an appropriate surgical work-up.

Conclusion: The occurrence of graft infections presenting with pseudoaneurysms of the descending aorta is a rare but devastating complication following percutaneous or surgical repair of coarctation. Since clinical/laboratory findings are often non-specific, a multimodality imaging approach is paramount for early diagnosis, which is the cornerstone of the effective management of these cases.

ID: 174: 3D T RANSESOPHAGEAL E CHOCARDIOGRAPHY IN A C ASE OF O RGANIC E CCENTRIC M ITRAL R EGURGITATION

Rapisarda Ornella, Lavanco Vincenzo, Vitale Carolina, Felis Salvatore

Garibaldi Hospital – Catania, Italy

BACKGROUND: organic mitral regurgitation (MR) represents a common diagnostic query in echocardiography. MR with eccentric jet often requires transesophageal echocardiography to assess mitral valve anatomy and severity of MR, especially with 3D analysis (3DTEE).

CASE SUMMARY: G. F. 55 years old, M, admitted in the coronary care unit of our hospital with diagnosis of acute heart failure. A transthoracic echocardiography was performed showing the presence of a dilated left ventricle with systolic dysfunction and the presence of eccentric MR that crosses longitudinally the mitral valve valvular plane. On suspicion of severe MR as a cause of heart failure a 3DTEE was performed.

The TEE showed the presence of severe eccentric MR (fig 1A). 2D analysis with X-plane imaging showed the presence of a MV prolapse of lateral posterior leaflet scallop with no clear evidence of cordal rupture (fig 1B). Integration with 3D real time imaging was fundamental to understand the valve pathophysiology showing the presence of P1-lateral commissure flail caused by single cordal rupture (fig 1C).

DISCUSSION: eccentric MR can be challenging for imager to assess. When feasible 3D echocardiography provides in one single image the possibility to assess with high specificity the MV pathophysiology overtaking the limits of 2D imaging and abbreviating the scanning time. In our case 3D imaging solved our diagnostic doubts and allowed us to understand MR grading and anatomic origin of MR.

CONCLUSION: 3DTEE represents the cornerstone of echocardiographic assessment of organic MR, especially when complex anatomy needs to be evaluated.

ID: 175: S MALL H EART AND S INGLE C ORONARY A RTERY IN A Y OUNG P ATIENT WITH C HRONIC F ATIGUE S YNDROME

Restelli Davide, Poleggi Cristina, Perfetti Silvia, Perna Alessia, Donato Rocco, Di Bella Gianluca , Carerj Scipione

G. Martino University Hospital – Messina, Italy

INTRODUCTION: Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) is a clinical condition predominantly observed in adults and often associated with a reduced stroke volume, with an inverse relationship between cardiac output and symptom severity post-exertion. We describe a rare case of a young individual with CFS/ME, a small heart, and an anomalous origin of the left main coronary artery (LMCA).

CASE PRESENTATION: A 19-year-old Caucasian male presented to our hospital with complaints of weakness, lack of concentration, and drowsiness. The patient was diagnosed with CFS/ME, vitamin D deficiency, inflammatory bowel disease, and exocrine pancreatic insufficiency. Echocardiogram revealed reduced left ventricle diameters and a binary structure in the apical 5-chamber view. Cardiac magnetic resonance imaging detected reduced LV stroke volume, telediastolic volume, and cardiac mass, and anomalous origin of LMCA from the proximal segment of the right coronary artery, with a retro-aortic course.

DISCUSSION: The pathophysiological mechanism of CFS/ME remains uncertain: immune activation, chronic viral infections, and stress. A significant number of CFS patients exhibit a small heart, possibly contributing to the onset of CFS/ME. In fact, clinical manifestations could result from reduced venous return and cardiac output. Anomalies like a single coronary artery are rare.

CONCLUSIONS: There are no reported cases in the literature of a patient presenting with all three conditions. This case highlights that CFS/ME associated with small heart is a possible condition even in young individuals. Further studies are warranted to better define the potential association between congenital cardiac anomalies and CFS/ME.

ID: 176: I SOLATED P ULMONARY V ALVE I NFECTIVE E NDOCARDITIS

Ricci Mirella 1 , Testa Sabrina 1 , Di Fulvio Maria 2 , Ricci Fabrizio 1 , Renda Giulia 1 , Gallina Sabina 1

1 Department of Neuroscience, Imaging and Clinical Sciences, G. D’Annunzio University of Chieti-Pescara - Chieti Italy, 2 Cardiology - Cardiac ICU, SS. Annunziata – Chieti, Italy

A 76 years old male was admitted to the general medicine department with complaints of fever and malaise of 2-weeks duration. Blood cultures obtained during his hospital stay yielded Streptococcus Bovis. His past medical history included hepatic cirrhosis, esophageal varices, portal hypertension, splenomegaly, pancytopenia and chronic kidney disease. Patient’s cardiovascular risk factors: permanent atrial fibrillation, hypertension, dislipidemia and type2-diabetes. In the previous 3months he was hospitalized twice for sepsis caused by the same pathogen. In both cases he was treated successfully with antibiotics. TTE were always unremarkable. The physician ordered a TOE, which was not performed due to esophageal varices. Nonetheless, TTE was accurate enough to reveal the presence of a large vegetation on the pulmonary valve(13×9mm), causing a moderate pul¬monic regurgitation, without involvement of any other valve. Echocardiography also documented a dilation of the right ventricle, with normal longitudinal systolic function, normal geometry and systolic function of the left ventricle (EF60%) and bi-atrial dilation. The infectious disease consultant recommended a 2-week course of Ceftriaxon and if successful, the regimen would be switched from endovenous to oral therapy. This case is an example of how challenging could be to diagnose such a rare entity, which accounts for 1.5–2% of all cases of IE1. PV IE is less common, probably owing to lower pressure gradient through the valve, resulting in less shear stress than other ones, and lower incidence of valvular abnormalities. This abstract highlights the importance of being aware of this rare condition and the role of patients’ re-evaluation.

ID: 177: A C ASE OF C ARDIAC T AMPONADE D URING P REGNANCY

Romano Giuseppe, Carmina Maria Gabriella, Bonnì Enrico, Minà Chiara, Bellavia Diego, Prestera Rosa, Buffa Lucia, Polizzi Vincenzo

V. CERVELLO Hospital – Palermo, Italy

We present a 30-year-old female patient in pregnancy. She complained of chest discomfort on left shoulder and dyspnea which began one months prior. She had fever, leukocytosis, increased CRP. The hemodynamics have become unstable and unfortunately, a therapeutic abortion was performed. The echocardiogram revealed the presence of cardiac tamponade, so urgent pericardiocentesis was performed and approximately 800 ml of blood fluid was drained. The patient was subsequently transferred to ICU. However, the patient’s clinical condition continued to worsen. Chest X-ray revealed a right-sided para-pericardial mass. Subsequently, a chest CT was conducted and revealed an anterior mediastinal mass, extending to the right hemithorax, compressing the right lung, the inferior vena cava and the right atrium. It was composed of cystic spaces and discrete areas like soft tissue, calcification, air and fat. The surgical removal was carried out via a median sternotomy and tumor with a infiltrated pericardial tissue were excised with no complications. Teratomas are rare germ cell tumors usually found in the gonads. Extra-gonadal teratomas are especially rare, mostly occurring in the thorax. Histologically, the tumor was diagnosed as a mature teratoma. We suspect that alterations in hormone levels during pregnancy might be the cause of rapid tumor growth which leads to clinical manifestations.

ID: 178: T RICUSPID V ALVE AND I STHMIC T HORACIC A ORTIC R UPTURE A FTER B LUNT C HEST T RAUMA IN A Y OUNG M AN

Romeo Maria Grazia 1 , Pilato Emanuele 1 , Parisi Valentina 2 , Comentale Giuseppe 1 , Romeo Domenico 3 , Conte Maddalena 2 , Hamameh Shadi 1 , Caso Pio 4 , Di Tommaso Luigi 1

1 Department of Cardiac Surgery, University “Federico II” – Naples, Italy, 2 Department of Translational Medical Sciences, University “Federico II” – Naples, Italy, 3 Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina – Messina, Italy, 4 Department of Cardiology, AORN Ospedali dei Colli, Monaldi Hospital – Naples, Italy

Introduction: Traumatic tricuspid regurgitation is a rare cause of acute right ventricular dysfunction. Cardiac injury resulting from blunt chest trauma includes a large range of presentations and is usually found in combination with other organ injuries which tend to hide cardiac lesion. The right ventricle is vulnerable to injury as it is adjacent to the sternum, isthmic thoracic aorta is often involved in thoracic trauma as it has a “locus minoris resistentiae”.

Clinical Case: A 20-year-old man was admitted to the cardiac surgery department following a motor vehicle accident. The patient was in critical condition which required urgent abdominal surgery due to spleen rupture and intestinal perforation. The angio-CT highlighted the presence of isthmic aortic rupture. Transesophageal-echocardiography showed also severe tricuspid-regurgitation due to papillary rupture with prolapse of anterior leaflet and overload of the right sections. Having assessed the unstable hemodynamic conditions, an emergency TEVAR(thoracic-endovascular-aortic-repair) with coverage of the left subclavian artery was performed to repair the isthmic lesion. Hemodynamic instability caused by acute tricuspid regurgitation was treated pharmacologically, as the patient’s condition didn’t allow surgical-treatment. Indeed, there were several ribs and limbs fractures that required urgent orthopedic-surgery. The post-operative course was uneventful. After a long ICU-stay, the patient was discharged and is currently under follow-up for tricuspid regurgitation. Our program is to treat valve insufficiency with tricuspid annuloplasty when patient will be in optimal condition and eligible for elective-cardiac-surgery.

Conclusion: The management of traumatic-cardiovascular-ruptures is very complex; however, planning optimal surgical-timing, may be the winning strategy to improve outcome.

ID: 179: A S UBTLE C ASE OF D YSPNEA IN A Y OUNG W OMAN

Romeo Maria Grazia 1 , Parisi Valentina 2 , Romeo Domenico 3 , Conte Maddalena 2 , Severino Sergio 4 , Caso Pio 4 , Tripepi Giovanni Luigi 5 , Pilato Emanuele 1

1 Department of Cardiac Surgery, University “Federico II”, Naples, Italy - Naples Italy, 2 Department of Translational Medical Science, University of Naples Federico II - Naples Italy, 3 Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina -Messina Italy, 4 Department of Cardiology, AORN Ospedali dei Colli, Monaldi Hospital, Naples - Naples Italy, 5 CNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension - Reggio Calabria, Italy

Introduction: Myxoma is the most common cardiac tumor, is an insidious pathology as it presents with non-specific symptoms such as: chest tightness, dyspnea, fatigue. Although myxomas are typically located in the left atrium and involving the atrial septum.

Clinical Case: A 31-year-old woman without any pathology was admitted to the ER after two syncopal episodes and dyspnea on exertion occurred 10-days earlier. Blood tests showed normal hematocrit, electrolyte and white-blood-cells levels. No pathological sounds were present on chest examination, but there was a remarkable apical mid-diastolic murmur on cardiac-auscultation.

Therefore, a transthoracic-echocardiogram was requested which revealed a hyperechoic mass (44x33 mm) in the left atrium with a broad base, attached to the left atrial anterolateral wall, with high mobility, which occupied almost the entire atrial volume and involved the mitral valve during diastole. Due to the high embolic risk and mitral valve obstruction that the ball-like mass caused, cardiac-surgery became mandatory. An urgent excision surgery was planned; the mass was removed through a longitudinal atriotomy. Histological examinations confirmed cardiac myxoma diagnosis. Postoperative course was uneventful and on the 5th postoperative-day patient was discharged.

Conclusion: Diagnosis of myxoma can be difficult, predominantly in patients without comorbidities and who present non-specific symptoms. Because it’s a subtle pathology, its finding is often incidental, therefore it’s important not to underestimate non-specific symptoms, which apparently may seem unrelated to cardiac-pathologies. In our case the echocardiographic-examination was decisive in understanding the cause of dyspnea and avoiding catastrophic consequences related to the presence of the giant myxoma.

ID: 180: B OVINE A ORTIC A RCH : S IMPLE A NATOMICAL V ARIANT OR F ATAL P REDICTOR OF A ORTIC D ISEASE ?

Romeo Maria Grazia 1 , Pilato Emanuele 1 , Romeo Domenico 2 , Scimone Ignazio Massimo 3 , Severino Sergio 4 , Pinna Giovanni Battista 1 , Tripepi Giovanni Luigi 5 , Scigliano Fabio 6 , Simone D’Alessio 1 , Di Tommaso Luigi 1

1 Department of Cardiac Surgery, University “Federico II”, Naples, Italy - Naples Italy, 2 Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina - Messina Italy, 3 Department of Cardiology, Reggio Calabria - Reggio Calabria Italy, 4 Department of Cardiology, AORN Ospedali dei Colli, Monaldi Hospital, Naples - Naples Italy, 5 CNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension - Reggio Calabria Italy, 6 Department of Cardiac Surgery, GOM Reggio Calabria - Reggio Calabria Italy

Introduction: Bovine aortic arch (BA) is the most common variant of aortic-arch. Previously, this pattern was considered to be without any clinical impact and undiagnosed. Nowadays, the development of endovascular-surgery has led to a reevaluation of BA, for planning surgical-strategy and also relating it to aortic pathology (AP)

Methods: From July 2011 to July 2023, 1340 patients who performed Angio-CT were enrolled in our database. The patients were divided into two groups: one composed by patients with AP and the other free of AP, to assess the frequencies of BA in our facility. Within the group of patients with AP, the incidence of BA was evaluated. This population was divided into two others groups: one composed by patients with-BA and the other with patients without-BA. The groups (with-BA/without-BA) were compared to evaluate: association with AP including bicuspid aortic valve (BAV), age at disease onset and the need for surgical-treatment, postoperative outcome and incidence rate of traumatic rupture

Results: Among 670 patients with AP, 53.13% had BA. BA is predominantly expressed in the descending-aortic-pathologies (63.92%) and in the ascending-aortic-pathologies (55.49%). Patients with-BA presented AP at a mean-age approximately 6.2-years earlier and required surgery approximately 7-years earlier than patients without BA. BAV in association with BA was present in 54.2% of patients.

Conclusions: From our data, there is a strong correlation between the presence of BA and the AP manifestation, involving ascending-aorta, aortic-arch and descending-aorta. Therefore, BA can be considered a risk-factor for AP and traumatic rupture.

ID: 181: T YPE N ON -A/N ON -B A ORTIC D ISSECTION IN A Y OUNG P ATIENT : T HE D ECISIVE R OLE P LAYED BY T RANSESOPHAGEAL E CHOCARDIOGRAPHY

Romeo Maria Grazia 1 , Comentale Giuseppe 1 , Romeo Domenico 2 , Tripepi Giovanni Luigi 3 , Donato Domenica 4 , Bellieni Luca 4 , Scigliano Fabio 4 , Pilato Emanuele 1

1 Department of Cardiac Surgery, University “Federico II”, Naples, Italy - Naples Italy, 2 Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina - Messina Italy, 3 CNR-IBIM, Clinical Epidemiology and Physiopathology of Renal Diseases and Hypertension - Reggio Calabria Italy, 4 Department of Cardiac Surgery, GOM Reggio Calabria - Reggio Calabria Italy

Introduction: Aortic dissection is a high-mortality condition requiring immediate diagnostic/therapeutic approach. Surgical management depends on the entry tear location and dissection extension. Aortic arch dissection with a non-dissected ascending aorta has recently been described as Non-A/Non-B dissection.

Clinical Case: A 26-year-old man was transferred from ER to our cardiac-surgery department following chest pain. There were no cardiac-pathologies in his medical history. However, the patient presented monstrous obesity (BMI 56) in absence of other comorbidities. An urgent CT-angiography was performed, which presented many beam hardening artifacts, due to patient’s constitutional habitus, despite the high contrast dose used. The poor quality of Angio-CT didn’t allow assessment of correct site of dissection tear and thus the planning of a proper operative strategy. However, performing additional contrast-enhanced-angio-CT screening wasn’t recommended given the already compromised renal-functions. Therefore, evaluated worsening of patient’s conditions, a TEE was performed to settle doubts about the site of tear and plan a surgical strategy quickly. TEE revealed intimal flap with presence of tear in distal aortic arch (Zone 2, Ishimaru classification), allowing the pathology to be classified as Non-A/Non-B aortic dissection. Given the high surgical risks related to patient’s BMI and evaluated the anterograde attitude of dissection, patient underwent TEVAR with left subclavian artery coverage.

Conclusion: In aortic emergencies, bedside TEE represents the most readily performable examination, which allows not only a correct diagnosis of dissection, but can be, as in this case, diriment for the choice of surgical strategy in relation to the site of dissection tear.

ID: 182: T RANSESOPHAGEAL E CHOCARDIOGRAPHY - GUIDED A ORTIC A RCH R EPLACEMENT

Romeo Maria Grazia 1 , Parisi Valentina 2 , Comentale Giuseppe 2 , Conte Maddalena 2 , Pilato Emanuele 1

1 Department of Cardiac Surgery, University “Federico II”, Naples - Naples Italy, 2 Department of Translational Medical Science, University of Naples Federico II - Naples Italy

Introduction: Total aortic arch replacement using the frozen elephant trunk (FET) procedure has nowadays widely spread. However, spinal cord injury is one of the most important complications, which limits the use of FET. There are three key points to avoid spinal cord injury: the distal-end of stent-graft should be positioned up to the eighth thoracic vertebrae level, the time for circulatory arrest should be shortened within 60min, mean blood-pressure should be maintained above 70mmHg. The Adamkiewicz artery originates from the descending aorta below the eighth thoracic vertebrae level and supplies blood to the spinal cord. Therefore, it was assumed that the distal-end of stent-graft should be positioned upper this level. Aortic valve is usually located around the seventh thoracic vertebrae level, thus is an appropriate landmark

Methods: We performed 11 total arch replacement using FET for aortic arch aneurysm or dissection with TEE support. TEE-guide was used in the initial phase to determine the stent-graft size and position, during the introduction and release of the prosthesis, to evaluate the positioning into true lumen of guide and prosthesis and in the final phase to estimate the correct function.

Conclusion: Since there is no established implantation method to evaluate the distal-end of the FET during surgery, TEE-guidance can support the correct prosthesis distal-positioning, using the aortic valve as a landmark. Furthermore, TEE-support is useful for visualizing the guide catheter on which the prosthesis will be inserted, so that it’s positioned into true lumen in dissections and doesn’t cause iatrogenic lesions aneurysms.

ID: 183: P ROSTHETIC M YCOTIC E NDOCARDITIS A FTER C OVID -19: TEE “L IFTS T HE C URTAIN ”

Romeo Maria Grazia 1 , Comentale Giuseppe 1 , Severino Sergio 2 , Romeo Francesco 3 , Donato Domenica 4 , Bellieni Luca 4 , Palmiero Giuseppe 2 , Pagnano Gianpiero 2 , Caso Pio 2 , Pilato Emanuele 1

1 Department of Cardiac Surgery, University “Federico II”, Naples - Naples Italy, 2 Department of Cardiology, Monaldi Hospital, Naples - Naples Italy, 3 Department of Infectious Diseases, University of Catanzaro “Magna Graecia” - Catanzaro Italy, 4 Department of Cardiac Surgery, Grande Ospedale Metropolitano, Reggio Calabria - Reggio Calabria Italy

Introduction: Candida-Parapsilosis is an unusual agent of prosthetic-endocarditis in immunocompetent-individuals but Covid-19 can cause a transient-immunodeficiency that exposes patients to opportunistic-infections.

Clinical Case: A 55-year-old man with history of bicuspid-aortic-valve and ascending-aortic-aneurysm treated ten-years earlier with a Bentall procedure, suffered from a severe pattern of Covid-19, requiring hospitalization in ICU. During ICU-stay, patient was treated with corticosteroids, long broad-spectrum antibiotic-therapy and immunosuppressors to reduce the immune-dysregulation. A few days after its discharge, patient manifested high fever again and was re-hospitalized in infectious-disease-ward. Blood-culture tests were positive for Candida-Parapsilosis. Considering the previous pathologies, a TEE was performed, which showed good functioning of the valve-prosthesis, but revealed an endocarditic infiltration of the posterior-aortic-wall, and a pedunculated structure (12 x 30 mm) attached to the prosthetic-ring, protruding into the LVOT. Assessed the dimensions of vegetation and the non-response to anti-fungal-therapy, surgery became mandatory to avoid embolism. A redo-Bentall procedure was performed, with aortic-root replacement and coronary-ostia reimplantation, using a new mechanical-valve-graft. Intraoperatively, prosthesis was covered with a friable/yellowish vegetations. The dreadful infection was found also in the LVOT where caused erosive sub-annular abscess that required a patch reconstruction.

Conclusion: Since the symptoms of a cardiac-infection and those of Covid-19 may overlap and mask the symptoms of each other, our case suggests the importance of early diagnosis of endocarditis in patients with prosthetic-valve-graft and strengthens the need not to underestimate the non-specific symptoms common to both pathologies, because in patients with previous Covid-19, the presence of prosthetic material may act as an additional risk-factor.

ID: 184: I NCIDENTAL F INDING OF A H UGE A SCENDING A ORTIC A NEURYSM : A S ILENT B ICUSPID A ORTIC V ALVE A ORTOPATHY

Romeo Maria Grazia 1 , Romeo Domenico 2 , Parisi Valentina 3 , Conte Maddalena 3 , Comentale Giuseppe 1 , Palmiero Giuseppe 4 , Caso Pio 4 , Pilato Emanuele 1

1 Department of Cardiac Surgery, University “Federico II”, Naples - Naples Italy, 2 Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina, Messina - Messina Italy, 3 Department of Translational Medical Sciences, University “Federico II”, Naples - Naples Italy, 4 Department of Cardioly, Monaldi Hospital, Naples - Naples Italy

Introduction: Giant ascending aortic aneurysm is defined as an aneurysm greater than 10cm in diameter. It’s a life-threatening, but unusual entity, as in most cases complications such as dissection or rupture will occur before the aneurysm reaches this size.

Clinical Case: A 66-years-old patient presented to the ER due to onset of dyspnea. Blood tests were normal, no history of cardiovascular diseases or other comorbidity. Therefore, following chest pain, a transthoracic-echocardiogram was performed, which showed a large mediastinal mass. TEE confirmed the presence of a voluminous Ascending-Aortic-Aneurysm, in absence of dissection, with dimensions of 118 mm x 116 mm, BAV (type 0-lateral), with a 30mm dilated aortic-ring. Angio-CT confirmed, with three-dimensional-rendering, the real expansion of the fusiform aneurysm, involving the entire mediastinum and altering the normal anatomical relations. Assessing the life-threatening condition, an emergency surgical approach became mandatory. The choice of surgical technique was modified intraoperatively; aortic root was heavily calcified, coronary-artery-ostia were very dislocated, fixed and difficult to mobilized to perform a direct anastomosis on the aortic-valved-conduit. Hence, a modified-Cabrol-technique was adopted, in order to interpose two separate short 8 mm Dacron tubular-grafts between coronary-artery-ostia and aortic-valved-conduit.

Conclusion: This case highlights the importance of never underestimating seemingly harmless and non-specific symptoms and signs, which can reveal potentially catastrophic pathologies, also focusing on the technique used. The modified-Cabrol-procedure, while an underutilized technique, if it’s present in the cardiac surgeon’s “arsenal,” can be a life-saving strategy.

ID: 185: W HAT ’ S B EHIND A C ARDIAC A RREST ?

Ruggeri Debora 1 , Mautone Francesco 1 , Casavecchia Grazia 1 , Gravina Matteo 2 , Brunetti Natale Daniele 1

1 Foggia University – Foggia, Italy, 2 Riuniti University Hospital – Foggia, Italy

A 25-year-old male Ivorian patient, without any cardiac factor risks, was carried in Emergency Department after out-of-hospital cardiac arrest pharmacologically cardioverted. He referred only fever in the last month. Before the cardiac arrest, the ECG recorded during ventricular tachycardia showed a peculiar pattern of QRS: alternant morphology RBBB and LBBB. In ED, Echocardiography shows mild hypertrophic walls with smoke aspect, pericardial effusion, global reduced ejection fraction (15%) and severe regurgitations through atrio-ventricular valves. The patient’s condition worsens and a complete AV block occurs during ECG monitoring. Implantation of a temporary PM, endotracheal intubation and a transfer in intensive care were required. The clinicians start pharmacological treatment with amines to sustain the haemodynamic status and vital fuctions and meanwhile perform various diagnostic tests (blood test showed infection, elevated serum troponin levels, CPK out of range, T-SPOT-TB positive and CT chest showed suspicious nodulations). Gradually the haemodynamic condition seems more stable, echocardio improves (EF 40%, low mitralic regurgitation) and cardiac MRI is possible. In STIR-T2 sequences, transmural patchy areas of high signal are detected in left ventricle which are compatible with myocardial oedema. Also in PSIR sequences are detected meso-subepicardial patchy areas of high signal areas (equal 13% of total cardiac mass) compatible with necrosis. In mapping sequences, ECV is widely exceeded. Acute myocarditis was diagnosed. Acute myocarditis was diagnosed and antibiotic therapy for TBC in first line was given. This case highlights the possible arrhythmic presentation of acute myocarditis, which required antiarrhythmic drugs and an implant of CRTD in secondary prevention.

ID: 186: E XERCISE -I NDUCED T RICUSPID R EGURGITATION AND R IGHT V ENTRICULAR -A RTERIAL C OUPLING

Rusconi Irene 1 , Mondellini Giulio Maria 2 , Giustiniani Alessandro 2 , Landi Susanna 2 , Dinardo Giulia 2 , Serrantoni Violetta 1 , Torta Daniela 1 , Losito Maurizio 1 , Bursi Francesca 2 , Guazzi Marco 2

1 Santi Paolo e Carlo Hospital – Milan, Italy, 2 University of Milan – Milan, Italy

Background:RV-PA coupling is prognostic in cardiovascular disorders, but its interaction with exercise-induced TR is poorly understood

Aim:Investigate RV-PA coupling’s association with exercise-induced TR using CPET and imaging data

Methods:We studied dyspneic patients with underlying heart disease, regardless of left ventricular ejection fraction, undergoing cardiopulmonary exercise test (CPET) imaging, demographics, baseline characteristics, and parameters from echocardiography and were assessed in three sub-cohorts based on tricuspid regurgitation (TR) severity at rest and peak exercise. Right ventricular-pulmonary artery (RV-PA) coupling was evaluated using the TAPSE/PASP ratio. Dynamic TR was defined as at least moderate TR detected from rest to stress

Results:73 patients (mean age 67±13 years, 52% men, mean LVEF 50±14%), 69% had mild TR without stress-induced increase (Group 0), 15% showed dynamic TR during stress (Group 1), and 16% had significant TR at rest (Group 2). TAPSE/PASP at rest and peak exercise were lower in Groups 1 and 2 compared to Group 0, while mean PAP/CO ratio was higher. Gas exchange data indicated lower median peak VO2 in Groups 1 and 2, with Group 2 also having a higher median VE/VCO2 slope compared to Group 0

Conclusion:Patients showing dynamic TR pattern during CPET exercise exhibit a worse degree of RV-PA coupling, gas exchange and performance profile compared to those without significant exercise-induced TR. However more research is needed to further improve outcomes

ID: 187: R IGHT H EART M ORPHOLOGICAL AND F UNCTIONAL A DAPTATIONS IN E XERCISE -I NDUCED D YNAMIC T RICUSPID R EGURGITATION

Rusconi Irene 1 , Mondellini Giulio Maria 2 , Giustiniani Alessandro 2 , Landi Susanna 2 , Dinardo Giulia2 5 , Serrantoni Violetta 1 , Torta Daniela 1 , Losito Maurizio 1 , Bursi Francesca2 9 , Guazzi Marco 2

1 Santi Paolo e Carlo Hospital – Milan, Italy, 2 University of Milan – Milan, Italy

Introduction: functional tricuspid regurgitation (TR) is a condition often asymptomatic in early stages, leading to delayed presentation, right heart remodelling and worsening symptoms. Whether exercise-induced TR is associated with specific right heart morphology and functional profiles is still unknown.

Aim: phenotyping right heart pattern of exercise-induced TR at cardiopulmonary exercise test (CPET) combined with stress echocardiography.

Materials and Methods: we prospectively enrolled 73 patients, who underwent CPET for dyspnea and heart disease evaluation, excluding those with severe pulmonary disease or prior cardiac surgery. Patients were categorized into three sub-cohorts based on TR severity at rest and peak exercise. Dynamic TR was defined as onset of at least moderate TR grade from rest.

Results: this study evidenced that 69% had mild TR at rest (Controls), 15% developed at least moderate TR during exercise (Group 1), and 16% already had moderate TR at rest (Group 2). Group 1 exhibited higher right atrial indexed volume (RAVi), lower tricuspid annular plane systolic excursion at peak exercise and reduced exercise performance (peak VO2), compared to Controls. Group 2 patients were older, with increased RAVi, enlarged right ventricular basal diameter, higher pulmonary artery pressure at rest and during stress, and a higher VE/VCO2 slope.

Conclusions: careful morphological and functional evaluation of right heart can identify a concealed phenotype of exercise-induced dynamic TR. Detection of evolving stages of TR by combined CPET imaging may allow for early and personalized TR-focused therapeutic strategies.

ID: 188: R ESIDUAL S HUNT A FTER P ERCUTANEOUS P ATENT F ORAMEN O VALE (PFO) C LOSURE AND ITS L ONG -T ERM P ROGNOSTIC V ALUE

Saccinto Giuseppe Fabrizio, Miglerina Emilio, Grossale Ilaria, Lattanzio Mariangela, De Ponti Roberto, Castiglioni Battistina, Ermacora Niccolò, Piemonti Andrea, Lauri Chiara, Casiraghi Margherita, Arnò Carlo, Carpani Alessia, Pesenti Sara Stella, Tirloni Michele

Di Circolo Hospital, Macchi Foundation – Varese, Italy

Introduction: presence, magnitude and prognostic value of residual shunt after PFO closure are not well defined. Aim: to assess residual shunt and its magnitude after PFO closure. Secondary aims were to detect prognostic value and events related to shunt. Methods: 41 patients subjected to percutaneous PFO closure, were studied with saline contrast transesophageal echocardiography (c-TEE) immediately after PFO closure and with saline contrast transthoracic echocardiography (c-TTE) and transcranial Doppler ultrasonography (c-DTC) 6 months later. Clinical followed up was 8 years. Results: c-TEE detected mild residual shunt in 8 patients (19.5%) and 1 (2.4%) moderate shunt. c-TTE e c-DTC with Valsalva maneuver, were performed in all patients 6 months later. A residual shunt mild to moderate was detected in 4 patients (9.7%) in basal conditions and in 19 patients (46.3%) after Valsalva maneuver, 11 (26,8%) of which presenting moderate to severe residual shunt. Physio-pathologically related events were found in 5 patients (12%), 4 (9,7%) atrial fibrillation and 1 (2,4%) ischemic stroke. Excluding atrial fibrillation detected within the first month after PFO closure, incidence of events was 2 (4,87%) with moderate residual shunt in both cases. Conclusions: Incidence and severity of residual shunt after PFO closure seem to be greater than formerly considered and a correct diagnosis relies on the type of ultrasound method used. The long-term prognostic value of the presence and magnitude of residual shunt appears to be overall good although an enhanced surveillance should be useful in moderate to severe residual shunt.

ID: 189: A S TRANGE C ASE OF L EFT V ENTRICULAR O UTFLOW T RACT O BSTRUCTION

Santoru Alberto, Idini Chiara, Pillitteri Gianluca, Raccis Mario, Bandino Stefano, Casu Gavino

SS Annunziata Hospital – Sassari, Italy

Left ventricular outflow tract obstruction (LVOTO) can result from various abnormalities affecting cardiac structures. While hypertrophic cardiomyopathy (HCM) stands as the most prevalent cause, there are several others anomalies associated with LVOTO. In this particular case, the obstruction was caused by the abnormal insertion of a hypertrophic accessory papillary muscle (PM).

A 53-year-old patient underwent a cardiological assessment for dyspnea during moderate exertion and palpitations. His medical history included: arterial hypertension, treated with telmisartan, and overweight, in absence of family history of ischemic heart disease, cerebrovascular accidents or sudden cardiac death.

At physical examination, the presence of 3/6 Levine systolic murmur was detected on aortic focus with jugular radiation. Electrocardiogram didn’t show criteria indicative of left ventricular hypertrophy.

Transthoracic echocardiography showed concentric remodeling of the left ventricle (interventricular septum 13 mm; posterior wall 12 mm; LVMi 82.69 g/m2; RWT 0.55) with preserved systolic function. The aortic valve had a normal opening amplitude. Anterior displacement of the PM with elongation and protrusion of the anterior mitral leaflet into the left ventricular outflow tract (LVOT) was found, with evidence of systolic anterior motion (SAM) and a basal dynamic gradient of 30 mmHg, increasing to 90 mmHg after the Valsalva maneuver.

The cardiac MRI excluded HCM and aortic valvular stenosis, and confirmed a LVOT flow acceleration and the suspect of a subvalvular stenosis.

Medical therapy was optimized with athenolol with partial improvement in symptomatology. The patient was referred for cardiosurgery evaluation to additional assessment of the LVOTO.

ID: 190: C CT ’ S C RYSTAL B ALL : P REDICTING C ARDIOVASCULAR R ISK I N A ORTIC V ALVE S TENOSIS P ATIENTS U NDERGOING V ALVE R EPLACEMENT

Savo Maria Teresa, Pergola Valeria, Bariani Riccardo, De Amicis Morena, Cozza Elena, Amato Filippo, Martini Marika, Sonego Piero, De Conti Giorgio, Rigato Ilaria, Mattesi Giulia, Bauce Barbara, Illiceto Sabino, Raffaella Motta

Padua University Hospital, Padua, Italy

Introduction:Computed tomography cardiac imaging(CTCI)prognostic role before degenerative-calcific aortic stenosis(AS)valve replacement(VR) has not been investigated. AIM: Assess whether the presence and extent of coronary artery(CAC), mitral annular(MAC), aortic valve (AVC) and thoracic aorta calcifications(TAC)could influence non-cardiovascular mortality(NCM),cardiovascular mortality(CM)and major adverse cardiovascular events(MACE) in patients undergoing VR. Material and methods:We collected retrospectivelly clinical and instrumental data and reviewed CTCI using a semi-quantitative approach. CAC were classified according to the visual approach in 2022 CADRADS. MACs were defined following the Guerrero et al. study, CVAs according to the Win Registry and CATs were assessed in the ascending aorta, aortic arch(AA) and descending aorta according to Vos classification. Results:244 patients(59% male, mean age 80.1±6.6 years), with 91% undergoing transfemoral VR, were enrolled(2016-2018). CM was significantly higher in patients with hypertension, cerebro/peripheral vascular disease, stage IV-V renal insufficiency and history of atrial fibrillation (p=0.012, p7(p=0.051), moderate and severe AVC(p=0.029 and p=0.053)and TAC>270° in AA(p=0.019) were linked to CM. In multivariate analysis, a high MAC score and the presence of moderate AVC persisted as risk factors for CM. The presence of a MAC score >7(p=0.006) and the extension of descending TAC >1.5 mm (p=0.034) were associated with an increased risk of NCM. The presence of extensive TAC (≥270°) measured in the AA and descending aorta were associated with MACE (p=0.034 and p=0.0504 respectively). Conclusions:CTCI emerges as a crucial tool for evaluating prognostic risk in patients undergoing VR for AS.

ID: 191: C ARDIAC M AGNETIC R ESONANCE 4DF LOW A NALYSIS OF R ESIDUAL M ITRAL R EGURGITATION A FTER TEER AND C ARDIAC R EMODELLING C ORRELATION

Sbordone Francesco Paolo, Fazzari Fabio, Mushtaq Saima, Mancini Maria Elisabetta, Annoni Andrea Daniele, Pontone Gianluca

Centro Cardiologico Monzino IRCCS – Milan, Italy

1. Introduction: In recent years the expertise of cardiac magnetic resonance (CMR) to evaluate cardiac valves disease has also been improved thanks to the introduction of 4D Flow analysis.

2. Aim: Assess the role of CMR quantification of mitral regurgitation in patients undergoing to transcatheter edge-to-edge repair (TEER) and its relationship to reverse cardiac remodelling.

3. Materials and Methods: Prospective single-center study enrolled 25 patients with severe / moderate-to-severe mitral regurgitation candidates for TEER, who underwent pre and post-procedural CMR (at least 6 months apart). The evaluation of the mitral regurgitation volume was carried out using three methods: 1. classic indirect method (difference between stroke volume and forward aortic volume derived from phase contrast sequences); 2. indirect 4D Flow method (difference between stroke volume and forward aortic volume derived by analysis from 4D Flow sequences); 3. 4D Flow direct method (automated retrospective trans-mitral valve tracking).

4. Results: 14 patients showed positive reverse cardiac remodeling (56%). 11 patients showed adverse remodelling (44%). The main factors associated with reverse remodeling were the severity of pre-procedural mitral regurgitation and the entity of MR reduction. The classical method demonstrated the best diagnostic accuracy in the evaluation of residual mitral regurgitation; 4DFlow analysis represents a valid alternative.

5. Conclusions: Cardiac magnetic resonance, also through 4D Flow analysis, can play a pivotal role in assessing residual mitral regurgitation quantification and evaluating reverse cardiac remodeling.

ID: 192: M ULTIMODAL D IAGNOSIS O F U NKNOWN S CIMITAR S YNDROME IN A DULTHOOD : A C ASE R EPORT

Sciarretta Tommaso 1 , Pantano Paola 1 , Pradegan Nicola 2 , Cernetti Carlo 1

1 ”Ca’ Foncello” Hospital - Treviso Italy, 2 Padua University Hospital – Padua, Italy

Background: Scimitar syndrome is a rare congenital heart disorder characterized by unique anatomical abnormalities affecting the pulmonary vasculature. Named for its distinctive appearance on medical imaging—a curved sword—this syndrome involves anomalous pulmonary venous return from the right lung to the inferior vena cava, bypassing the left atrium.

Case Summary: During a routine annual checkup for non-agonistic physical activity, an asymptomatic 47-year-old female was found to have a previously unknown right bundle branch block on her EKG. She reported recurring respiratory infections in childhood. Transthoracic echocardiography revealed right chambers dilatation and right ventricle reduced systolic function. The patient underwent cardiac magnetic resonance that identified a partial anomalous pulmonary venous return, with two right pulmonary veins confluent in inferior vena cava. Dilatation of the right chambers was confirmed, along with evidence of a left-to-right shunt (Qp/Qs: 2.1). A diagnosis of scimitar syndrome was formulated. A computed tomography detailed the complex anomaly, also involving persistent left superior vena cava, pulmonary sequestration, and left pulmonary isomerism. A successful heart catheterization confirmed anatomical abnormalities, and permit intervention occluding the abnormal arterial collateral of pulmonary sequestration with vascular plugs. The patient in now awaiting surgical correction.

Discussion: This case emphasizes the challenge of diagnosing congenital heart diseases in adulthood and underscores the importance of vigilance in routine medical examinations. Scimitar syndrome, if undetected, can lead to progressive right chamber overload and irreversible pulmonary hypertension. This underscores the necessity for multimodal diagnostic approaches in managing complex CHD, ensuring timely interventions and improved outcomes for individuals.

ID: 193: P REMATURE R ESTRICTION /C LOSURE OF F ORAMEN O VALE IN F ETAL E CHOCARDIOGRAPHY : A NALYSIS OF D IAGNOSTIC C RITERIA

Scimone Ignazio Massimo 1 , Oreto Lilia 2 , Polimeni Caterina Patrizia 1 , Altavilla Federica 1 , Iannopollo Michele 1 , Scimone Benedetta 1

1 Fetal Cardiology Service (Scilla Health House) – Scilla (RC) Italy, 2 Pediatric Cardiology – University of Messina – Messina, Italy

Introduction: Restrictive foramen ovale (FO) is an under-recognized and largely underdiagnosed condition in pregnancy. Its incidence in literature ranges from 0.2 to 1.4%.

Aim: The aim of this study is to analyse the current diagnostic criteria used in fetal echocardiography for the diagnosis of premature restriction/closure of foramen ovale.

Materials and methods: In the last 12 months, we have examined approximately 600 pregnancies between the 22nd and the 38th weeks. There was suspect of restrictive foramen ovale in approximately 10 cases. In this group several points are analysed: 1) the width of the FO on the septum secundum with 2D technique in 4-chamber section. 2) The D-S Color shunt entering and exiting the system. 3) Morphology and dynamics of the septum primum in the left atrium.

Results: Restrictive FO was diagnosed in seven cases and premature closure in two cases. The restriction appeared more frequently related to anomalies of the septum primum in different ways/types: thickened membrane, exuberant membrane, short/hypomobile membrane, anomalous location/width of the ostium secundum.

Conclusions: Diagnosis of restrictive FO requires proper monitoring of the pregnancy. The restriction may be present on the septum secundum (properly called FO), on the septum primum, or on both. When it involves the septum primum with a foramen ovale which appears large, diagnosis can become counterintuitive. A careful choice of delivery timing plays a crucial role in this condition due to the risk of fetal oxygenation problems and/or related to right atrial hypertension.

ID: 194: A GENESIS OF D UCTUS VENOSUS A RANTII D ETECTED T HROUGH F ETAL E CHOCARDIOGRAPHY . I NCIDENCE AND P OST -N ATAL O UTCOME

Scimone Ignazio Massimo 1 , Altavilla Federica 1 , Careri Annalisa 1 , Oreto Lilia 2 , Polimeni Caterina Patrizia 1 , Scimone Benedetta 1

1 Fetal Cardiology Service (Scilla Health House) - Scilla (RC) Italy, 2 Pediatric Cardiology - University of Messina – Messina, Italy

Introduction: The ductus venosus (DV) Arantii is a characteristic vascular structure of fetal circulation. It connects the intrahepatic segment of the umbilical vein to the inferior vena cava system, allowing to 20-40% of oxygen-rich placental blood destined for the fetus to bypass the liver. Agenesis of the Ductus Venosus (ADV) is a rare congenital anomaly characterized by the absence of this vascular structure. Its reported incidence in the literature ranges from 1 in 256 to 1 in 2500 pregnancies.

Aim: The aim of this study is to assess during the execution of fetal echocardiography: 1) the occasional incidence of ADV. 2) Detection of any repercussions on cardiac hemodynamics and 3) analysis of the post-natal outcome.

Materials and Methods: In the last four years, in our Fetal Echocardiography Service we have systematically evaluated this vascular structure in approximately 2400 pregnancies, using the axial section of the fetal abdomen performed at the intrahepatic segment of the umbilical vein, with two-dimensional technique and Color Doppler.

Results: Two cases of ADV were identified. In both, the umbilical vein anastomosed exclusively with the portal system.

Conclusions: A review of the literature reveals that the majority of isolated ADV cases have a favorable post-natal outcome. However, given the known associations with cardiomegaly, atrioventricular valve insufficiency and fetal hydrops, the detection of this rare condition necessitates closer monitoring of the pregnancy. Due to the substantial lack of reference guidelines, further studies are required to verify the proper follow-up of fetuses diagnosed with isolated ADV.

ID: 195: A GENESIS OF L EFT D UCTUS . P ATHOGENETIC E LEMENT OF R IGHT A ORTIC A RCH IN THE N ORMAL H EART

Scimone Ignazio Massimo 1 , Guccione Paolo 2 , Oreto Lilia 3 , Iannopollo Michele 1 , Pelaggi Giuseppe 1 , Scimone Benedetta 1

1 Fetal Cardiology Service (Scilla Health House) – Scilla (RC) Italy, 2 Bambino Gesù Pediatric Hospital – Rome, Italy, 3 Pediatric Cardiology - University of Messina – Messina, Italy

Introduction: Left ductus agenesis is an infrequent condition during fetal echocardiography with an incidence of approximately 1/3000 pregnancies. According to Edwards’ description in the primitive double arch and double ductus system, the physiological interruption in the vascular ring occurs early in the distal section of the primitive right arch. Several observations suggest that agenesis of left ductus leads to distal interruption in the primitive left arch and to the formation of a right arch with mirror-image epiaortic vessels.

Aim: The aim of this work is to report two cases of isolated right aortic arch related to agenesis of left ductus.

Materials and methods: We retrospectively analyzed cases of right aortic arch, not associated with cyanogenic heart disease, diagnosed in our Fetal Cardiology Service in the last 10 years using two-dimensional echocardiographic section of three vessels with trachea.

Results: Out of approximately 6000 Fetal Ecocardiographies, 6 cases of isolated right arch have been identified. Among these, 4 cases presented left ductus, aberrant left subclavian and “U” image and two cases right aortic arch with absence of retroesophageal vascular component, agenesis of left ductus and functional right ductus. Both cases of right arch with absence of U-shaped image and agenesis of left ductus appeared to have mirror-image vessels.

Conclusions: Apart from cyanogenic conotruncal heart disease, right aortic arch with mirror-image vessels can be observed in the normal heart, associated with agenesis of left ductus, a condition in which agenesis appears to have a pathogenetic role.

ID: 196: P ERSISTENT L EFT S UPERIOR V ENA C AVA D RAINAGE INTO A ZYGOS V EIN D ETECTED WITH F ETAL E CHOCARDIOGRAPHY : A C ASE -R EPORT

Scimone Ignazio Massimo 1 , Oreto Lilia 2 , Scimone Benedetta 1 , Pelaggi Giuseppe 1 , Licordari Roberto 1 , Montemurro Vincenzo 1 , Iannopollo Michele 1

1 Fetal Cardiology Service (Scilla Health House) – Scilla (RC) Italy, 2 Pediatric Cardiology - University of Messina - Messina Italy

INTRODUCTION: Persistent left superior vena cava (PLSVC) represents the most common anomaly of systemic venous returns and is present in 0.3 to 0.5% of individuals in the general population. It is also known as Marshall vein, after the author who first described it. In the most frequent anatomical variant it is inferiorly connected to the coronary sinus. More rarely it can drain into the left atrium (in this case leading to systemic desaturation). The isolated persistence of the LSVC draining into azygos vein through hemiazygos is exceptional. CASE-REPORT We describe the case of a 37-year-old woman who came to our attention at 33 weeks of pregnancy in order to perform a fetal echocardiography. The examination highlighted, in three vessels and trachea view, a marked dilation of azygos vein. Furthermore, in a slightly lower axial section, the presence of a large posterior venous structure appeared. This structure, which crossed the midline from left to right, connected to azygos. The role of Marshall vein related to the hemiazygos system was clear not without difficulty. Indeed the lack of dilation of the coronary sinus did not lead in the first instance to search for a left superior vena cava. DISCUSSION Isolated persistence of LSVC draining into the azygos system through hemiazygos is an extremely rare entity. It does not alter cardiac hemodynamics but may make the placement of central cannulae/catheters from the left approach impossible throughout life. To our knowledge, this case represents the first description of this anomaly diagnosed with fetal echocardiography.

ID: 197: C HANGES IN B ASAL C ORONARY F LOW D ETECTED BY T RANSTHORACIC D OPPLER E CHOCARDIOGRAPHY A FTER CRT IN N ON -I SCHEMIC C ARDIOMYOPATHY

Seganfreddo Francesca

di Circolo Hospital and Macchi Foundation – Varese, Italy

Introduction: The results of previous studies evaluating the effects of cardiac resynchronization therapy (CRT) on basal myocardial blood flow are conflicting. Aim: The present study was designed to investigate by transthoracic Doppler echocardiography the effects of CRT on basal coronary flow detected on distal portion of left anterior descending (LAD) artery. Materials and Methods: Eleven patients diagnosed with non-ischemic dilated cardiomyopathy, left bundle branch block and responders to CRT were enrolled in the study. We performed transthoracic echocardiography in basal condition during biventricular pacing and during spontaneous rhythm after cessation of pacing for 15 min. Results: During biventricular pacing, we recorded a significant increase in the mean peak diastolic and systolic velocity of distal LAD flow, VTI of diastolic LAD flow, and diastolic perfusion time. LV ejection fraction, septal S’ wave velocity at TDI, cardiac cycle-corrected diastolic filling time was significantly higher during CRT; also, LV end-diastolic and end-systolic volume, intraventricular delay between septum and lateral wall and mean isovolumetric contraction and release time was significantly lower during CRT. Conclusion Biventricular pacing in patients with non-ischemic dilated cardiomyopathy who respond favorably to CRT appears to be correlated with increased resting coronary flow assessed by transthoracic Doppler echocardiography. This, associated with reduced intraventricular dyssynchrony and prolonged diastolic filling time, may be an additional contribution in the analysis of mechanisms involved in the response to CRT.

ID: 198: G IVE A L OOK TO THE R IGHT S IDE : T RICUSPID V ALVE E NDOCARDITIS , A C ASE R EPORT

Sfredda Sara 1 , Molisana Michela 2 , Ianni Umberto 2 , Parato Vito Maurizio 2 , Guerra Federico 1 , Dello Russo Antonio 1

1 Cardiology and Arrhythmology Clinic, University Hospital “Ospedali Riuniti Torrette di Ancona” – Ancona, Italy, 2 Cardiology and Cardiac Rehabilitation Unit, Madonna del Soccorso Hospital - San Benedetto del Tronto (AP) Italy

Tricuspid valve infective endocarditis represents a challenge in terms of management and treatment, principally due to higher risk of recurrences and complications when compared to left sides endocarditis. A 33-years-old young patient accessed the emergency room after acute onset of chest pain and dyspnea. He admitted previous use of intravenous high dose cocaine. He was pyretic and laboratory tests showed marked procalcitonin raise with leukocytosis suggesting a systemic inflammatory disease. EKG showed sinus tachycardia without relevant repolarization abnormalities. Chest X-ray revealed patchy opacities confirmed after tomography axial scan, suggestive of inflammatory lung consolidations. Transthoracic echocardiography speculated possibility of right-sided vegetation ascribable to infective endocarditis but inconclusive due to poor acoustic window. Patient was admitted to the infectious diseases department and empirical antibiotic therapy was promptly started. To corroborate diagnosis TEE was performed and a large vegetation adhered to the anterior leaflet was revealed with mild tricuspid regurgitation. Urgent cardiothoracic surgical consultation was requested, delaying surgical treatment in absence of instable criteria. After 10 days, due to persistent signs of congestive heart failure and development of significant tricuspid regurgitation at TTE, a new TOE was performed revealing perforation of the anterior leaflet with right ventricular dilation and right ventricular systolic disfunction. After a careful shared evaluation in heart-team about risks and benefits patient undergo surgery. An edge-to-edge commissural tricuspid valve repair and annuloplasty was performed using a 3D contour hemi-ring. The procedure was conducted without complications and after a brief cardiac rehabilitation he was discharged.

ID: 199: S AFETY AND E FFICACY OF A S INGLE P ROCEDURE OF E XTRACTION AND R EIMPLANTATION OF I NFECTED CIED IN C OMPARISON WITH D EFERRAL T IMING

Sordelli Chiara 1 , Severino Sergio 1 , Fele Nunzia 1 , Verde Raffaele 1 , Weisz Sara Hana 1 , Guarino Angela 1 , Mazzella Francesca 1 , Severino Laura1 8 , Tascini Carlo 2

1 Cotugno Hospital – Napoli, Italy, 2 Friuli Centrale University Hospital – Udine, Italy

Infections are among the most frequent and life-threatening complications of cardiovascular implantable electronic device (CIED) implantation. The aim of this study is to compare the outcome and safety of a single-procedure device extraction and contralateral implantation versus the standard-of-care (SoC) two-stage replacement for infected CIEDs. Methods: We retrospectively included 66 patients with CIED infections who were treated at two Italian hospitals.

Of the 66 patients enrolled in the study, 27 underwent a single procedure, whereas 39 received SoC treatment. All patients were followed up for 12 months after the procedure. Results: Considering those lost to follow-up, there were no differences in the mortality rates between the two cohorts, with survival rates of 81.5% in the single-procedure group and 84.6% in the SoC group (p = 0.075).

Conclusions: Single-procedure reimplantation associated with an active antibiofilm therapy may be a feasible and effective therapeutic option in CIED-dependent and frail patients. Further studies are warranted to define the best treatment regimen and strategies to select patients suitable for the single-procedure reimplantation.

ID: 200: H UGE A ORTIC P SEUDO -A NEURYSM F OLLOWING A ORTIC B IO P ROSTHETIC E NDOCARDITIS : K EY R OLE O F 3D E CHOCARDIOGRAPHY

Sordelli Chiara 1 , Severino Sergio 1 , Fele Nunzia 1 , Verde Raffaele 1 , Weisz Sara Hana 1 , Guarino Angela 1 , Mazzella Francesca 1 , Severino Corrado 2

1 Cotugno Hospital – Naples, Italy, 2 Second University of Naples Naples, Italy

A 47 year old male with previous meccanic prosthetic aortic valve replacement was admitted to our department for evaluation of pyrexia. Lab-work was notable for leukocytosis with a white blood cell count of 13.000/mm3 and a hemoglobin level of 10.8 gr/dl. Blood cultures grew Staphylococcus Epidermidis. A transesophageal echocardiogram was performed showing a pulsatile perivalvular echo free-space with colour Doppler flow inside suggestive of an aortic pseudoaneurysm (fig 1).

3D-TEE imaging provides better morphological assessment of aortic pseudoaneurysm. 3D TEE clearly demarcates an irregularly shaped of perivalvular cavity and through multiplanar reconstruction allowed a correct evaluation of the area and circumference.

Conclusion: Decision making in IE is complex. The most common indications for early surgery are development of heart failure, uncontrolled infection or risk of embolism. In particular uncontrolled infection is commonly due to perivalvular abscess formation. 3D-TOE allows rapid, accurate, unique assessment of IE complication through un

ID: 201: A S TRANGE C ASE OF P ULMONARY H YPERTENSION …

Soriente Lucia, Ferrara Alfonso, Ardovino Pasquale, Aliberti Chiara, Di Fonzo Rosanna

San Giovanni di Dio Ruggi d’Aragona University Hospital - Salerno Italy

PH is a haemodinamic and pathophysiological state that can be found in multiple clinical conditions. Chronic hemolytic anemia as sickle cell disease (SCD) is complicated by PH with 30 % of prevalence and worse prognosis. PH in SCD is multifactorial including vasoconstriction, proliferation, obstructive remodelling of the pulmonary vessel wall; inflammation and thrombosis in situ play a role in the pulmonary vascular disease. We have observed a 44-yr old woman affected by sickle cell who developed dyspnoea (WHO-FC III) without chest pain or fever. Transthoracic ecocardiography revealed moderate-severe tricuspid with a gradient of 70 mmHg with an assumed right atrial pressure di 20 mmHg estimated by inferior vena cava, right atrial and ventricular dilatation, reduced TAPSE 16 mm, Ryan index 0.8 with normal size and ejection fraction of left ventricular. Electrocardiogram provided right axial deviation. Computed angiography was normal and ventilation /perfusion lung scan showed an elevated probability for CTEPH. BNP was 921 pg /ml and lung diffusion capacity for carbon monoxide was slight decreased. Prophylactic transfusion during crisis to decrease the frequency of these and new direct anticoagulants were started. After two weeks the patient was in WHO-FC II and transtoracic echocardiography showed a slight tricuspidal regurgitation with a pressure gradient of 40 mmHg with TAPSE of 20 mm and Ryan index was normal. In the new guidelines SCD is moved into Group 5 and our patient was not subjected to specific therapy for pulmonary hypertension. DOAC has showed a reasonable alternative to VKAs for VTE.

ID: 202: I NDEPENDENT E FFECT OF SGLT2 I ON D IASTOLIC F UNCTION IN HF R EF

Stracqualursi Marco 1 , Nemola Giulia 1 , Moscardelli Silvia 1 , Santangelo Gloria 2 , Buratti Stefano 3 , Losito Maurizio 3 , Bursi Francesca 1 , Guazzi Marco 1

1 University of Milan; San Paolo Hospital – Milan, Italy 2 Fondazione IRCCS Ca’ Granda Maggiore Hospital – Milan, Italy, 3 San Paolo Hospital – Milan, Italy

Introduction: Diastolic dysfunction is an independent prognostic indicator of all-cause mortality in patients with heart failure with reduced ejection fraction(HFrEF). In this context, E/e’ ratio plays a central role in diastolic dysfunction assessments. Despite the introduction of medical therapies for HFrEF that led to improvement in mortality and HF hospitalization, the effect of the combined treatment with Sacubitril/Valsartan(SV) and Sodium-Glucose cotransporter-2 inhibitors(SGLT2i) on E/e’ ratio has not been addressed yet.

Aim: Evaluate the effect of SV alone vs SV+SGLT2i on E/e’ ratio in a real-life population of HFrEF outpatients.

Methods: Observational monocentric study including patients treated with either SV alone or with SV+SGLT2i from 2018 to 2023. E/e’ ratio was measured at baseline, at 6 and 12 months.

Results: 178 HFrEF patients in optimal medical therapy were enrolled. 121 of them received SV and 58 received SV+SGLT2i. Baseline E/e’ ratio was similar in the two groups (median 11.2 and 10.9, respectively, p=0.45). At follow up, only SV+SGLT2i group showed a significative decrease in E/e’ ratio (median 8.5 [IQR7;12] in SV+SGLT2i vs 11.8 [IQR8;15] in SV group, p=0.035).

Moreover, after 12 months most patients receiving SV+SGLT2i didn’t require diuretic administration compared to those treated with only SV (43% vs16% respectively; p=0,0002).

Conclusions: Among patients with HFrEF, treatment with SGLT2i+SV was associated with a significative reduction of E/e’ ratio and of diuretic administration. This result might suggest a favorable independent effect of SGLT2i on diastolic function and myocytes relaxation and might provide new evidence on the positive results observed on hard endpoints.

ID: 203: E FFECT OF SGLT2 I ON S ECONDARY TR IN A R EAL -L IFE HF R EF O UPATIENTS P OPULATION : A N O BSERVATIONAL S TUDY

Stracqualursi Marco 1 , Nemola Giulia 1 , Moscardelli Silvia 1 , Valli Federica 2 , Toriello Filippo 2 , Faggiano Andrea 3 , Buratti Stefano 4 , Losito Maurizio 4 , Santangelo Gloria 5 , Carugo Stefano 3 , Bursi Francesca 1 , Guazzi Marco 1

1 University of Milan; San Paolo Hospital – Milan, Italy, 2 Fondazione IRCCS Ca’ Granda Maggiore Hospital – Milan, Italy, 3 Milan University; IRCCS Ca’ Granda Maggiore Hospital - Milano Italy, 4 San Paolo Hospital- Milano Italy, 5 IRCCS Ca’ Granda Maggiore Hospital - Milano Italy

There is consistent and increasing evidence on the benefits of novel pharmacological therapies, i.e. sacubitril-valsartan (SV) and sodium-glucose cotransporter-2 inhibitor (SGLT2i) in heart failure with reduced ejection fraction (HFrEF). Many mechanisms of action and target organ have been identified. However, few data have focused on the right heart hemodynamics and how this may impact on pulmonary hypertension (PH) and tricuspid regurgitation (TR).

We aimed to evaluate the effect of SV alone versus SV+SGLT2i on TRV in a real-life HFrEF outpatients population.

Observational monocentric study including patients treated with either SV alone or with SV+SGLT2i from 2017 to 2023. PH and TR were measured at baseline, at 6 and 12 months.

179 HFrEF patients were enrolled; 121 received SV and 58 SV+SGLT2i. Baseline PH and TR were similar (median 261cm/s and 273cm/s respectively, p=0,95). After a median 384 days follow up, TR decreased in both groups. Specifically, those treated with the combination of SV+SGLT2i showed a greater reduction of TR (median change -21[IQR14;-43] in SV group vs -65[IQR-10;-93] in SV+SGLT2i, p=0,04). Moreover, most patients receiving SV+SGLT2i after 12 months did not require diuretic administration compared to those treated only with SV (43% versus 16% respectively;p=0,0002).

Treatment with SV implies a significative reduction of TR and PH in HFrEF patients. These favourable effects on the right heart dynamics was even additive in patients treated with SV+SGLT2i. A significant but likely not exclusive role of the combinatory effects seems to be the lower need of diuretic treatment in patients receiving combination therapy.

ID: 204: A RRHYTHMOGENIC M ITRAL V ALVE P ROLAPSE P RESENTED WITH OUT - OF -H OSPITAL C ARDIAC A RREST

Tarantino Giacomo, Rodio Davide, Colonna Paolo, D’Agostino Carlo

Bari University Hospital – Bari, Italy

INTRODUCTION: Mitral valve prolapse (MVP) has usually an excellent prognosis, but a meta-analysis demonstrated a link with sudden cardiac death. The elements which constitute the arrhythmic mitral valve complex/phenotype are: 1) MVP 2) frequent or complex ventricular arrhythmias 3) absence of any other well-defined arrhythmic cause. Among the features that raise the risk of ventricular arrhythmias there is the mitral annular disjunction.

CASE PRESENTATION: A 32-year-old woman with no relevant medical history was admitted after resuscitated cardiac arrest due to ventricular fibrillation thanks to CPR and six DC shocks. Once in the Emergency Department, the patient underwent urgent coronary angiography resulted negative; a total body CT excluded secondary causes. The ECG showed sinus rhythm at 65 bpm and infero-lateral negative T waves. A transthoracic echocardiogram underlined a slightly depressed ventricular function, hypokinesia of the mid-apical septum and a mitral valve prolapse with moderate mitral regurgitation and MAD of 10mm, data concordant with the cardiac magnetic resonance and transoesophageal echocardiography thereafter performed. No oedema or fibrous scar were detected. Viral and autoimmune screenings resulted negative. The patient underwent dual chamber ICD implantation in secondary prevention and was discharged with beta-blocker and ACE-inhibitor therapy.

CONCLUSION: MVP is a challenging entity because of the need of early identification of the patients affected by the arrhythmic phenotype for whom is indicated a lifelong follow up and in selected cases ICD implantation in primary prevention.

ID: 205: E CHOCARDIOGRAPHIC M ARKERS OF L EFT A TRIAL R EVERSE R EMODELLING A FTER S UCCESSFUL A TRIAL F IBRILLATION E LECTRICAL C ARDIOVERSION

Tirloni Michele, Imporzani Andrea, Tosin Elena, Lauri Chiara, Ghirimoldi Elena, Pellitteri Alessia, Cinel Elena, Carelli Mattia, Vinco Valentina, Giuri Maria, Di Martino Sara Elena, Lodi Rizzini Simone, Ceriani Francesca, Lattanzio Mariangela, De Ponti Roberto

di Circolo Hospital e Macchi Foundation– Varese, Italy

Atrial fibrillation is the most common arrythmia in adults. Atrial fibrillation induces reversible electrical, structural and functional modifications, atrial remodelling; after successful electrical cardioversion patients experience a left atrial mechanical dysfunction with preserved electrical function, atrial stunning. Maintaining of sinusal rhythm allows complete or partial regression of atrial modifications, atrial reverse remodelling.

The aim of our study was to evaluate by transthoracic echocardiogram with two-dimensional spackle tracking structural and mechanical left atrial reverse remodelling after successful electrical cardioversion.

A total of 10 patients (mean age 66.8 years) with persistent atrial fibrillation underwent transthoracic echocardiography with two-dimensional spackle tracking within 24 hours after successful electrical cardioversion (Baseline); patients were echocardiographically re-evaluated after a mean of 7.5 ± 2.3 weeks (Follow-up).

During follow-up no patient suffered atrial fibrillation recurrence. Restoration and maintenance of sinus rhythm led to a significant reduction in left atrial maximum (Baseline vs follow-up 54.63 ± 13.86 vs 43.20 ± 9.56, p = 0.010) and minimum (34.36 ± 8.44 vs 25.11 ± 9.95 p = 0.013) volume index. Furthermore, after this period, patients exhibited a significant increase in left atrial reservoir (9.57 ± 4.02 vs 20.94 ± 7.45, p = 0.001) conduit (6.87 ± 3.16 vs 10.92 ± 4.22, p = 0.022) and contractile (2.72 ± 1.57 vs 10.02 ± 4.57, p < 0.001) strain values.

Transthoracic echocardiography with two-dimensional spackle tracking allows to evaluate atrial reverse remodelling, in particular reduction of left atrial volume and improvement of left atrial mechanical function, after successful atrial fibrillation electrical cardioversion.

ID: 206: T HE S IGN OF THE H ORNS : A R ARE C ASE OF D OUBLE P ERI -C OMMISSURAL M ITRAL F LAIL

Tofoni Paolo, Brugiatelli Leonardo, Maurizi Kevin, Nazziconi Marco, Capodaglio Irene, Patani Francesca, Pietrucci Francesca, Gioacchini Simona, Lofiego Carla, Di Eusanio Marco, Dello Russo Antonio, Perna Gian Piero, Vagnarelli Fabio

Marche University Hospital – Ancona, Italy

A 80 year old man with history of hypertension and dyslipidemia was admitted to our Cardiology Unit for exertional dyspnea (NYHA III) occurred during last days. Physical examination showed a systolic heart murmur and signs of pulmonary congestion. The transthoracic echocardiogram revealed a massive mitral regurgitation together with severe dilation of the left atrium, mild-to-moderate aortic regurgitation, high probability of pulmonary hypertension and normal biventricular systolic function. A transesophageal echocardiography (TEE) was performed to clarify mitral anatomy. A double flail of the posterior leaflet was present involving the peri-commissural portions due to a single chordal rupture on P1 scallop and a double chordal rupture on P3. P2 scallop was prolapsing and there was a billowing of the anterior leaflet. In addiction mitral annulus was dilated (antero-posterior diameter of 43 mm and intercommissural diameter of 45 mm). We named this finding “sign of the horns” for his 3D echocardiographic appearance (Fig.1) given the double flail resembling two fingers.

A surgical correction was performed with 3 GoreTex neochords implantation on the posterior leaflet and an annuloplasty ring (Physio II n. 34) implantation during extracorporeal circulation through right anterior minithoracotomy. Surgical and echocardiographic results were optimal. The patient was discharged after 7 days of hospitalization.

Conclusion: the coexistence of a double peri-commissural flail in the same leaflet is a very rare echocardiographic finding and we named it “double horn sign”. TEE is an essential examination in this scenario in order to understand the exact mechanism of the regurgitation for an optimal preoperative planning.

ID: 207: I MPACT OF R IGHT V ENTRICULAR F UNCTION ON O UTCOME IN L OW -R ISK S ECONDARY T RICUSPID R EGURGITATION A CCORDING TO E FFECTIVE R EGURGITANT O RIFICE A REA

Tomaselli Michele, Badano Luigi Paolo, Muraru Denisa, Penso Marco, Springhetti Paolo, Clement Alexandra, Oliverio Giorgio, Gavazzoni Mara, Cascella Andrea, Parati Gianfranco

San Luca Hospital – Milan, Italy

INTRODUCTION: The impact of right ventricular (RV) adverse remodeling in low-risk secondary tricuspid regurgitation (STR) remains unclear.

AIM: Our study aimed to evaluate the effect of right ventricular (RV) remodeling in modulating the outcome of low-risk STR patients according to the effective regurgitant orifice area (EROA).

MATERIALS AND METHODS: Five-hundred thirteen consecutive outpatients with STR were included. Using the threshold value derived by spline curves, we divided our cohort into two groups: low (EROA≤ 0.47cm2) and high (EROA> 0.47cm2) risk. The endpoint was a composite of heart failure hospitalization and death.

RESULTS: After 18±15 months, 195 patients (38%) reached the endpoint. Patients with EROA> 0.47 cm2 experienced a higher rate of events at 2 years (54±6% vs 30±7%, p <0.0001), with a 2-fold increased risk of experiencing the outcome (HR 2.08, 95% CI 1.56-2.77, p<0.0001). In multivariable analysis, EROA remained independently associated with the composite endpoint (adjusted HR: 1.01, 95% CI 1.00-1.02, p90 mL/m2, RV end-systolic volume (RV ESV) >46 mL/m2, RV ejection fraction <45% and RV forward stroke volume/RV ESV< 0.40 were respectively: 42±4%, 51±4%, 44±4%, and 47±4%).

CONCLUSIONS: Our results refine the independent association between STR severity assessed by EROA and outcome. In patients with low-risk STR, the assessment of RV function and RV-PA coupling may improve patient’s risk prediction.

ID: 208: P ROGNOSIS AND M ANAGEMENT OF O LDER A DULTS W ITH S USPECTED I NFECTIVE E NDOCARDITIS R EFERRED TO I NTERNAL M EDICINE D EPARTMENTS

Tonelli Francesca, Torzillo Daniela, Ceriani Elisa, Strada Silvia, Cogliati Chiara Beatrice

Luigi Sacco Hospital – Milan, Italy

Introduction. The landscape of infective endocarditis (IE) has undergone significant changes in recent years in terms of the affected population, which is increasingly elderly, and about the implicated pathogens, often identified as Staphylococci and Enterococci.

Aim. This retrospective observational study aimed to describe the clinical characteristics, evaluate the diagnostic management, and assess the 30- and 90-days prognosis of patients with suspected IE admitted in our Internal Medicine Department.

Materials and Methods. Patients with suspected IE referred to our echocardiography laboratory from September 2021 to June 2022 were enrolled. TTE results were analyzed.

Results. 159 TTEs were performed for suspected IE and 23 patients were discharged with diagnosis of IE. Predominant pathogens involved in IE were Streptococci (38%) and Enterococci (33%); no patient with blood culture positive for gram negative bacteria had IE. Risk factors significantly associated with IE included the absence of a recognized infectious focus, presence of intracardiac device, significant valvopathy and positive blood cultures. 8% (13/159) of performed TTE were positive, 60% (97/159) negative, and 32% (49/159) revealed indeterminate results; transesophageal echocardiography (TOE) was performed in only 25% of negative or indeterminate TTE cases. Mortality rates at 30 and 90 days were 26% and 35% respectively, higher in IE patients than in patients without IE.

Conclusion. IE in our population presents diagnostic challenges, with TTE often yielding indeterminate results and TOE being impractical due to patient frailty and comorbidities. Accurate diagnostic suspicion based on microorganism involvement and individual risk factors is crucial for effective management.

ID: 209: I MPACT OF L EFT V ENTRICULAR H EMODYNAMIC F ORCES IN ADULT P ATIENTS WITH T REATED A ORTIC C OARCTATION AND HF P EF

Toritto Paolo 1 , Faganello Giorgio 1 , Collia Dario 2 , Pagura Linda 1 , Croatto Elisa 1 , Tosoni Letizia Maria 1 , Pedrizzetti Gianni 2 , Di Lenarda Andrea 1

1 Cardiovascular Center, University Hospital and Health Services of Trieste – Trieste, Italy, 2 Department of Engineering and Architecture, University of Trieste – Trieste, Italy

Introduction. The LV myocardial strain and hemodynamic forces (HDFs) are innovative markers of LV function. Aortic coarctation is safely repaired in infancy; however, mortality and morbidity remain increased in later life. Aim. The study investigated the role of left ventricular myocardial deformation and HDFs in asymptomatic patients who underwent successful aortic coarctation repair.

Materials and Methods. Clinical and echocardiographic data were analyzed from 42 repaired CoA, 32 ± 20 years after surgery, 2D echocardiographic global longitudinal strain (GLS), circumferential strain (GCS) and HDFs were determined. CoA patients were compared with 42 patients affected by blood hypertension and 84 healthy controls; all matched for age and gender.

Results. All groups had normal LV ejection fraction (LVEF), dimensions, and volumes. CoA patients showed a significantly higher rate of LV mass indexed (p<0.001) and left atrial volumes indexed (p<0.001). LV myocardial and endocardial global longitudinal and circumferential strain were decreased in CoA patients (p<0.001, p<0.001; p= 0.032 and p<0.001, respectively). HDF parameters such as LV longitudinal force, LV systolic longitudinal force and LV impulse (LVim) were uniformly reduced (p = 0.006, p = 0.001; p = 0.001 and p<0.001, respectively). LV myocardial strain and HDF parameter values were independently associated with hospitalization for heart failure on univariable Cox regression analysis.

Conclusions. Despite preserved LVEF, patients with CoA had lower LV myocardial strain and HDF parameters values, independently associated with hospitalization for heart failure.

ID: 210: E PICARDIAL F AT T HICKNESS AND M YOCARDIAL W ORK A NALYSIS IN THE A SSESSMENT OF L EFT V ENTRICULAR F UNCTION IN N ORMAL W EIGHT AND O VERWEIGHT P ATIENTS WITH P RESERVED E JECTION F RACTION

Trimarchi Giancarlo, Lofrumento Francesca, Taverna Giovanni, Pistorio Saro, Bellocchi Paolo, Carerj Scipione, Zito Concetta

University Hospital G. Martino – Messina, Italy

Background: Assessing epicardial fat thickness (EFT) indicates cardiometabolic risk and is linked to multiple syndromes and coronary issues. A new echocardiographic tool, myocardial work (MW), enhances left ventricular (LV) function analysis for those with thickened epicardial fat.

Aim: To evaluate the impact of epicardial fat thickness on LV function, assessed by MW analysis, in normal weight and overweight patients.

Materials and Methods: 80 patients were enrolled: 31 pts with EFT > 5 mm and 49 pts with EFT 5 mm and those with EFT 5 mm had lower values of GWE and higher values of GWW. Regarding correlations, EFT directly correlates to GLS and GWW and it inversely correlates to GWE.

Conclusion: The diagnosis of early LV dysfunction in patients with increased epicardial fat thickness can be improved by incorporating advanced echocardiographic techniques like myocardial work.

ID: 211: S UCCESSFUL E CHO -G UIDED R ETRIVAL OF E MBOLIZED L EFT A TRIAL A PPENDAGE C LOSURE D EVICE

Trocino Giuseppe, Rovaris Giovanni, Calchera Ivan, Bianchi Janetti Maria, Lofrano Luca, Soffici Federica, Cesana Francesca, Boffi Lucia

IRCCS San Gerardo dei Tintori Hospital - Monza (MB) Italy

A 83 year-old with a surgical repair for mitral regurgitation (2019), atrial fibrillation since 2020, NSTEMI treated with PTCA (2023), in dual antiplatelet and anticoagulation with apixaban therapy was admitted on July 2023 for severe anemia requiring multiple blood transfusions. Percutaneous LAA closure was proposed and accepted by the patient. TEE showed a single side LAA, 2.0 x 2.3 cm orifice and no thrombus.

An Amulet 28 amplatzer occluder was successfully implanted with TEE monitoring and guidance. Lobe compression was > 25%, the device was stable in the traction test, without leaks. The echo performed 2 hours after the procedure showed the complete detachment of the device which appeared floating in the left atrium (Fig. 1A). Two goose necks (20 mm and 10 mm) with double transseptal puncture were used for the recapture procedure with TEE and radioscopic guidance (Fig. 1B-C-D). Using TEE monitor a Boston Watchman FLX 31 was implanted without complications as demonstrated at predischarge echo and at 3-month TEE.

Conclusions: Device embolization is rare but a serious complication. The capture was very difficult in this case for the complete mobility of the device that was non entrapped in mitral valve as in previously published case reports. A second implantation with a different and larger device was successful and demonstrated how is critical the choise of the correct size of the device.

ID: 212: E NTEROCOCCUS F AECALIS I SOLATED P ULMONARY V ALVE E NDOCARDITIS IN AN E LDERLY P ATIENT

Trovarelli Eugenio 1 , Lupi Alessandro 1 , Girella Elisabetta 1 , Serena Gianluca 2 , Scarpignato Maurizio 2 , Fortuni Federico 2

1 Santa Maria della Misericordia Hospital - Perugia Italy, 2 San Giovanni Battista Hospital - Foligno, Italy

Isolated pulmonary valve infective endocarditis (IE) is an extremely rare condition (< 2% of IE) that may manifest with non-specific symptoms leading to management delay and increase in complications.

We describe the case of an 85-year-old male admitted to the emergency department for fatigue, persistent back pain and fever, treated with antibiotics. Transthoracic echocardiogram, performed for a systolic murmur, showed a large mass on the pulmonary valve (Panel A) inducing mild stenosis (Panel B) and regurgitation without right ventricular (RV) pressure and/or volume overload (Panel C). Blood cultures isolated enterococcus faecalis. A transesophageal echocardiogram confirmed isolated pulmonary valve endocarditis (2 x 1 cm mass – Panel D) without local complications. Given the characteristics of this pathogen, a computed tomography of the abdomen and colonoscopy were performed and excluded the presence of abdominal lesions. Considering the clinical stability and high surgical risk, a conservative management with only targeted antibiotic therapy was started. During antibiotic therapy, the patient was readmitted to the hospital for bilateral multifocal pneumonia (Panel E) due to septic embolization and later developed heart failure. Considering the persistence of IE, despite targeted antibiotic therapy, pulmonary infiltrates and RV dilatation (Panel F), the patient underwent pulmonary valve replacement with a biological prosthesis (Panel G) leading to normalization of RV dimensions and improvement in heart failure symptoms. This case highlights the importance of considering atypical localization of IE to identify it and promptly guide patient management avoiding complications.

ID: 213: M ULTIPLE P HENOTYPES OF C HRONIC C ORONARY S YNDROMES I DENTIFIED BY ABCDE S TRESS E CHOCARDIOGRAPHY

Tuttolomondo Domenico 1 , Gaibazzi Nicola 1 , Ciampi Quirino 2 , Cortigiani Lauro 3 , Wierzbowska-Drabik Karina 4 , Zagatina Angela 5 , Djordjevic-Dikic Ana 6 , Manganelli Fiore 7 , Rigo Fausto 8 , D’Andrea Antonello 9 , Monte Ines 10 , Merli Elisa 11 , Pepi Mauro 12 , Pellikka Patricia 13 , Picano Eugenio 14

1 Department of Cardiology, Azienda Ospedaliero-Universitaria di Parma – Parma, Italy, 2 Division of Cardiology, Fatebenefratelli Hospital – Benevento, Italy, 3 Department of Cardiology, San Luca Hospital – Lucca, Italy, 4 Department of Internal Disease and Clinical Pharmacology, Medical University – Lodz, Poland, 5 Cardiology Department, Research Cardiology Center “Medika - Saint Petersburg, Russian Federation, 6 Clinical Center of Serbia and School of Medicine University of Belgrade, Cardiology Clinic - Belgrade Serbia, 7 Department of Cardiology, San Giuseppe Moscati Hospital - Avellino Italy, 8 Villa Salus Foundation/IRCCS San Camillo Hospital - Venice Italy, 9 Department of Cardiology, Umberto I Hospital - Nocera Inferiore (SA) Italy, 10 Department of Surgery and Medical-Surgical Specialties, University of Catania - Catania, Italy, 11 Department of Cardiology, Ospedale per gli Infermi, Faenza - Ravenna, Italy, 12 Cardiology Division, Centro Cardiologico Monzino, IRCCS - Milano, Italy, 13 Department of Cardiovascular Medicine, Mayo Clinic - Rochester, USA, 14 Institute of Clinical Physiology of the National Research Council, CNR - Pisa Italy

Introduction: Regional wall motion abnormality (RWMA) is considered a sensitive and specific marker of ischemia during stress echocardiography (SE). However, ischemia is associated with either coronary artery disease (CAD) or angina with normal coronary arteries (ANOCA), a distinction difficult to make using a single sign.

Aim: To evaluate the diagnostic potential of the ABCDE-SE protocol for CAD detection.

Materials and Methods: From the SE-2030 study data-bank, we selected 3229 patients

(age= 66±12 years, 65% males), with known CAD (n=1792) or ANOCA (n=1437). All patients were studied with both ABCDE-SE protocol and with coronary angiography, within 3 months. Step A assesses RWMA; step B, B-lines/diastolic function; step C, left ventricular contractile reserve; step D, coronary flow velocity reserve (CFVR) in the left anterior descending artery; step E, heart rate reserve.

Results: SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). In CAD, the rate of abnormal results was 347 for A (19.4%), 547 (30.5%) for B, 720 (40.2%) for C, 615 (34.3%) for D, and 633 (35.3%) for E step. In ANOCA, the rate of abnormal results was 81 (5.6%) for A, 429 (29.9%) for B, 432 (30.1%) for C, 354 (24.6%) for D, and 445 (31.0%) for E step. The dominant “solitary phenotype” was step B in 109 (9.1%) patients.

Conclusion: Stress-induced ischemia presents with a wide range of diagnostic phenotypes. Utilizing a comprehensive approach such as the advanced ABCDE score proves to be more valuable than relying on a single marker in isolation.

ID: 214: R EVERSIBLE I SCHAEMIA AND O UTCOME A FTER A DJUSTMENT F OR C ORONARY A RTERY D ISEASE S EVERITY : A M ULTICENTRE S TRESS -E CHOCARDIOGRAPHY R EGISTRY

Tuttolomondo Domenico 1 , Gaibazzi Nicola 1 , Cortigiani Lauro 2 , Rigo Fausto 3 , Porter Thomas 4 , Guerra Emiliano 5 , Ciampi Quirino 6

1 Department of Cardiology, Azienda Ospedaliero-Universitaria di Parma – Parma, Italy, 2 Department of Cardiology, San Luca Hospital – Lucca, Italy, 3 Villa Salus Foundation/IRCCS San Camillo Hospital – Venice, Italy, 4 Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Nebraska Medical Center – Omaha, USA, 5 Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena – Modena, Italy, 6 Division of Cardiology, Fatebenefratelli Hospital – Benevento, Italy

Introduction: Beyond reversible ischaemia, vasodilator stress echocardiography (SE) is able to measure Doppler coronary flow velocity reserve in the left anterior descending coronary artery (CFVR-LAD), a strong prognostic variable. This is capable of assessing the entire coronary circulation, including the microcirculatory compartment.

Aim: To assess the potential association of reversible ischaemia and CFVR-LAD during SE with all-cause mortality and non-fatal myocardial infarction (MI), after correction for anatomic coronary artery disease (CAD) burden and other significant clinical variables.

Materials and Methods: We selected 3191 patients (mean age 66 ± 12 years) from our multicentre SE registry, who underwent both high-dose dipyridamole SE (comprehensive of CFVR-LAD measurement) and coronary angiography within 2 months. All-cause mortality and non-fatal MI were the primary end points. The association of the primary end point with ischaemia severity and CFVR-LAD was assessed, after multivariable adjustment for all other significant variables, including anatomic CAD severity by the modified Duke Prognostic Index.

Results: The primary end point occurred in 767 (24%) patients (death in 409 and non-fatal MI in 375 patients) during a median follow-up of 42 months. Multivariable Cox regression analyses indicated that anatomic CAD severity, reversible ischaemia, and CFVR-LAD were all independently associated with the primary end point; reversible ischaemia was also associated with subsequent MI, while CFVR-LAD with mortality, independent of anatomic CAD severity.

Conclusion: Reversible ischaemia by wall motion assessment and CFVR-LAD on dipyridamole SE are independently associated with dismal outcome in patients with suspected or known stable CAD.

ID: 215: C ORONARY F LOW V ELOCITY R ESERVE R EDUCTION I S A SSOCIATED WITH C ARDIOVASCULAR , C ANCER , AND N ON - CANCER , N ON - CARDIOVASCULAR M ORTALITY

Tuttolomondo Domenico 1 , Picano Eugenio 2 , Porter Thomas 3 , Ciampi Quirino 4 , Suma Sergio 1 , Garibaldi Silvia 5 , Botti Andrea 1 , Tedeschi Andrea 6 , Gaibazzi Nicola 1

1 Department of Cardiology, Azienda Ospedaliero-Universitaria di Parma – Parma, Italy, 2 Institute of Clinical Physiology of the National Research Council, CNR – Pisa, Italy, 3 Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, Nebraska Medical Center – Omaha, USA, 4 Cardiology Division, Fatebenefratelli Hospital – Benevento, Italy, 5 Cardiology Division, Fondazione Toscana Gabriele Monasterio - Pisa Italy, 6 De Gasperis Cardio Center and Transplant Center, Niguarda Hospital - Milan Italy

Introduction: Coronary flow velocity reserve measured in the left anterior descending artery (CFVR-LAD) during stress echocardiography (SE) interrogates both epicardial and microcirculatory coronary function and has been inversely associated with chronic inflammation and microvascular dysfunction, as well as with the presence of obstructive coronary artery disease (CAD). Microvascular dysfunction and chronic inflammation are common mechanisms of disease in cardiovascular (CV) and non-CV conditions.

Aim: To assess whether CFVR-LAD is associated with all-cause death, but more specifically with CV, cancer, and non-CV and non-cancer (NCVNC) mortality.

Methods: 1002 patients who underwent stress echocardiography were followed for a median of 8.2 years. A prespecified subgroup of subjects with no regional wall motion abnormalities (RWMA) or revascularization procedures during follow-up was also analyzed (n=752), to exclude most participants with possible CAD and remove such confounding from the assessment of the potential association of CFVR-LAD and mortality.

Results: A total of 161 patients (16%) died, 63 deaths being CV (39%), 52 from cancer (32%), and 46 (29%) from NCVNC causes. In comparison to CV mortality, cancer and NCVNC mortality were not associated with an ischemic RWMA at univariable analysis, while a CFVR-LAD <2 was significantly associated with each category of cause-specific mortality. A CFVR <2 or ≥2 separated a group of patients with 8-year 14.6% versus 1.2% CV mortality, 10.3% versus 0.4% cancer mortality, and 9.5% versus 1.5% NCVNC mortality.

Conclusions: The reduction of CFVR-LAD is independently associated with CV, cancer, and NCVNC death in a population clinically referred for suspected/known coronary artery disease.

ID: 216: A SSOCIATION OF C ORONARY C OMPUTED T OMOGRAPHY A NGIOGRAPHY AND S TRESS E CHOCARDIOGRAPHY WITH L ONG -T ERM C ARDIAC O UTCOME : A C OMPARISON S TUDY

Tuttolomondo Domenico, Gaibazzi Nicola

Parma University Hospital – Parma, Italy

Aims: This study aimed to assess which variables on coronary computed tomography angiography (CTA) and vasodilator stress-echocardiography (SE) are best associated with long-term cardiac outcome in patients presenting for suspected chronic coronary syndrome (CCS) who performed both tests.

Methods: We identified 397 patients with suspected CCS who, between 2007 and 2019, underwent both SE and CTA within 30 days. Coronary artery calcium score (CACS) and the number of coronary arteries with diameter stenosis >50% were assessed on CTA. The presence of reversible regional wall motion abnormalities (RWMA) and reduced Doppler coronary flow velocity reserve in the left-anterior descending coronary artery (CFVR) were assessed on SE. The association of SE and CTA variables with cardiac outcome (cardiac death or myocardial infarction) was evaluated using Fine and Gray competing risk models.

Results: During a median follow-up of 10 years, 38 (9.6%) patients experienced a nonfatal myocardial infarction and 19 (4.8%) died from a cardiac cause. RWMA (HR 7.189, p < 0.001) and a lower CFVR (HR 0.034, p < 0.001) on SE, along with CACS (HR 1.004, p 50% stenosed coronary vessels (HR 1.975, p < 0.001) on CTA, were each associated with cardiac events. After adjusting for covariates, only CACS and CFVR remained associated (both p < 0.001) with cardiac outcome.

Conclusion: Our data suggest that only CFVR on vasodilatory SE and CACS on CTA are independently and strongly associated with long-term cardiac outcome, unlike RWMA or the number of stenosed coronary arteries, usually considered the hallmarks of c

ID: 217: C ARDIAC P APILLARY F IBROELASTOMAS : T HREE C ASES , T HREE D IFFERENT L OCATIONS

Urban Michele, Andreassi Dal Ben Nicoletta, Bulgari Sara, Rigamonti Antonio, Molon Giulio, Bonapace Stefano, Lanzoni Laura

IRCCS Sacro Cuore Don Calabria Hospital - Negrar di Valpolicella (VR) Italy

Papillary fibroelastoma (PFE) is a primary benign cardiac tumor usually located on valves.

PFE may be incidental findings on echo (pt C) or associated with neurological events (pt A-B).

PFE is described as “sea anemone” composed of multiple papillary fronds arising from a central stalk firmly attached to the valve. Echo appearance could be round or oval, generally well demarcated mass with high mobility. We describe three cases, two of them, at the level of the left heart. The other, much rarer, with right-sided localization.

CASE A: a 79-year-old woman was admitted to our hospital after hip replacement and acute ischemic stroke was detected. Transthoracic echocardiography (TTE) showed a mobile, pedunculated (17x5 mm) mass at the level of the posterior mitral ring (PANEL A, B). Attributing stroke to embolization from the mass, she was referred for surgical removal. Pathological exam confirmed PFE with negative culture.

CASE B: A 77 year-old referred for echo due to memory deficit and instability in walking. A TTE was performed, showing the presence at the aortic valve of a rounded structure, highly mobile, adherent to the coronary cusp overhanging the aortic slope (PANEL C). TEE confirmed the presence of this structure, referred to PFE (PANEL D). The patient is refused surgical treatment despite symptoms that could be attributable to embolization.

CASE C: A 87year-old woman hospitalized for complete atrio-ventricular block waiting for PM implantation. The TTE showed the presence of round formation, mobile, at the level of the tricuspid valve, meaning PFE (PANEL E, F).

ID: 218: S INUS OF V ALSALVA A NEURYSM : A T RICKY C ASE C OMPLICATED BY T HROMBOTIC F ORMATION

Urban Michele 1 , Chiampan Andrea 1 , Sala Giuseppe 1 , Onorati Francesco 2 , Andreassi Dal Ben Nicoletta 1 , Bulgari Sara 1 , Bonapace Stefano 1 , Lanzoni Laura 1 , Molon Giulio 1

1 IRCCS Sacro Cuore Don Calabria Hospital - Negrar di Valpolicella (VR) Italy, 2 Verona University Hospital - Verona Italy

We present a case of left aortic sinus and left main trunk aneurysm (SOVA) with stratified thrombosis.

A 61-yo man presented to the emergency department with dizziness, sweating and tachycardia.

The ECG showed an atrial flutter, with HR of 120 bpm.

At TTE we observed a large dilatation of left sinus of Valsalva with a hyperechoic image inside of unclear interpretation (thrombosis? flap?) (Panel A, B). A mild LVSD and bi-atrial dilatation was described.

At the CT scan the dilatation emerged to be a SOVA of the left trunk originating from the ostium and terminating in a trifurcation of anterior descending artery (DA), intermediate and circumflex artery (CX).

In its distal portion, the SOVA had calcified walls and the unclear image observed at TTE demonstrated to be a mural thrombotic stratification (4 mm, Panel C, D).

After multi-disciplinary discussion, surgery treatment was indicated after coronary angiography which confirmed the SOVA with no other relevant finding of coronary arteries.

Cardiac surgery was effectively performed by surgical exclusion of the aneurysm with a patch in its proximal portion and a binding of the distal part.

A SOVA is an uncommon condition, either congenital or acquired that can complicate with dissection, thrombus, arrhythmias or coronary obstruction.

TTE allows initial detection and description of its morphology.

A multimodality imaging approach is often necessary to better define its characteristics, like in our case to distinguish a thrombosis from other differential diagnosis.

ID: 219: C ASE R EPORT OF R ECURRENT D OUBLE -V ALVE L IBMAN -S ACKS E NDOCARDITIS

Ventura Ettore 1 , Messina Chiara 1 , Cacace Roberto 1 , Pasceri Eugenia 2 , Mascaro Giuseppina 2 , Aquila Iolanda 2 , Indolfi Ciro 1

1 University ‘Magna Graecia’– Catanzaro, Italy, 2 Renato Dulbecco University Hospital – Catanzaro, Italy

Introduction: Libman-Sacks (LS) endocarditis is a form of nonbacterial thrombotic endocarditis and may be associated with autoimmune diseases or malignancy.

Clinical Case: A 47-year-old woman with diagnosis of ulcerative colitis and spondyloarthritis was admitted to the hospital for dyspnea. Significant aortic and mitral regurgitation at transthoracic echocardiogram (TTE) was identified. Subsequently, the patient underwent mitro-aortic valve replacement with bioprosthetic valves. Intraoperative examination revealed an inflammatory aspect of the mitral valve annulus and sessile vegetations, indicative of an active inflammatory process (blood cultures and microscopic examination of the excised valves resulted negative).

One month after surgery, the patient was admitted to our department for fever with elevated C-reactive protein levels and a negative procalcitonin (PCT) value. TTE revealed vegetations, and subsequent a transesophageal echocardiography (TEE) showed multiple mobile formations in correspondence of the mitral annulus. PET scan indicated heightened glucose metabolism around the aortic root, especially at mitral valve planes and in the pericardial area.

Despite persistent negative findings in infectious investigations (blood cultures, serological test and blood PCT were persistently negative) and considering the patient’s history of inflammatory diseases, the diagnosis of non-infectious endocarditis was established. Meanwhile, the patient experienced several transient ischemic events and a splenic infarction. HFU was administered, according to PTT values, until a following control TTE and TEE showed the resolution of the condition. Further investigations established the diagnosis of polychondritis.

Conclusion: recognizing the distinct features of LS endocarditis is crucial for ensuring early and correct treatment and optimizing patient outcomes.

ID: 220: L EFT A TRIAL A PPENDAGE C LOSURE FOR R ECURRENT E MBOLISM IN A P ATIENT W ITH M ECHANICAL P ROSTHETIC V ALVES AND A TRIAL F IBRILLATION

Videsott Lodovica, D’Onghia Giovanni, Muraglia Simone, Guarracini Fabrizio, Saraò Emanuele, Saltori Michela, Tedoldi Francesca, Coradello Elena, Fanti Diego, Bonmassari Roberto

S. Chiara Hospital – Trento, Italy

The incidence of cardiac thromboembolism recurrences despite adequate oral anticoagulation in patients with mechanical prosthetic valves and atrial fibrillation is not negligible and the antithrombotic management of such patients may be challenging. Multimodality imaging plays a pivotal role in every step of the diagnostic-therapeutic process.

We present the case of a 75-year-old man with chronic ischaemic cardiomyopathy, atrial fibrillation, mitral and aortic mechanical prosthetic valves and ostium secundum atrial septal defect (ASD). The patient was evaluated in our unit for recurrent cerebral ischaemic cardioembolic events despite adequate oral anticoagulation.

A transthoracic echocardiography showed normal function of the prosthetic valves and moderate left ventricular systolic disfunction. Initially, a transoesophageal echocardiogram (TOE) revealed left atrial appendage (LAA) sludge with the suspect of LAA thrombosis and confirmed absence of prosthetic valve thrombosis and the presence of ASD; a cardiac computed tomography confirmed the presence of LAA thrombus. Percutaneous LAA closure was planned. A pre-procedural TOE, made more accurate by adding contrast media, demonstrated thrombus resolution. Nevertheless, in order to reduce the embolic risk, an intra-aortic filter was used during the procedure. Moreover, the interatrial septal puncture was not performed and the LAA closure device was pushed through the ASD into the left atrium. 3D TOE was essential for carrying out a successful procedure.

This case highlights the role of multimodality imaging in planning and guiding new interventional strategies to successfully overcome cardiac thromboembolic recurrences in selected patients with mechanical prosthetic valves, atrial fibrillation and therapeutical INR range.

ID: 221: T RIPLE V ALVE C ORRECTION : T RICUSPID T EER A FTER P RIOR A ORTIC V ALVE R EPLACEMENT S URGERY AND M ITRAL A NNULOPLASTY

Volpe Lorenzo 1 , Aquila Iolanda 2 , Ielapi Jessica 1 , Mascaro Giuseppina 2 , Mongiardo Annalisa 2 , Spaccarotella Carmen 3 , Indolfi Ciro 1

1 Cardiology Department, Magna Graecia University, Catanzaro, Italy – Catanzaro, Italy, 2 Cardiology Division, University Hospital, Renato Dulbecco, Catanzaro, Italy – Catanzaro, Italy, 3 Cardiology Department, Federico II University, Napoli, Italy – Napoli, Italy

We present the case of a 76-yo woman referred to our emergency department with dyspnea.

Previous medical history included: aortic valve replacement surgery with mechanical prosthesis and mitral annuloplasty, hypertension, dyslipidemia, atrial fibrillation and dysthyroidism.

At admission, TTE revealed normal dimensions of left ventricle, severe enlargement of left atrium, normal left ventricular systolic function indices, outcomes of mitral annuloplasty (no significant mitral regurgitation), mechanical valve prosthesis normally inserted in aortic position (with normal prosthetic function indices), increase in the diameter of IVC, slight increase in the dimensions of right sections, normal right ventricular systolic function indices, severe tricuspid regurgitation with PAPs values equal to 50-55 mmHg. TOE revealed torrential tricuspid regurgitation, with evidence of a large jet in anteroseptal commissure, technically favorable for percutaneous repair.

Because of the symptomatic significant tricuspid regurgitation in patient with high surgical risk, she was referred for transcatheter tricuspid valve repair. After positioning a guide in the superior vena cava, a guide catheter was inserted. Two TriClip XTW were implanted between the anterior and septal leaflets, one of which in the “mid” position and the other in the “central” position, immediately adjacent to the first. At the end of procedure, good final result with mild residual regurgitation and absence of transvalvular gradient.

At 30-day follow-up the patient reported improvement in clinical status with dyspnea on moderate or severe exertion only. TTE showed Triclip devices in place with mild residual valve regurgitation. These findings agree with the results of TRILUMINATE trial.

ID: 222: P ATIENTS C HARACTERISTICS IN C ARDIAC I MPLANTABLE E LECTRONIC D EVICES I NFECTION : S INGLE C ENTER E XPERIENCE AND F OLLOW UP

Weisz Sara Hana 1 , Sordelli Chiara 1 , Fele Nunzia 1 , Guarino Angela 1 , Mazzella Francesca 1 , Verde Raffaele 1 , Severino Laura 1 , Attanasio Vittorio 1 , De Vivo Stefano 1 , Tascini Carlo 2 , Severino Sergio 1

1 dei Colli Cotugno Hospital – Napoli, Italy, 2 Friuli Centrale University Hospital – Udine, Italy

Introduction: Cardiac implantable electronic devices infection (CIEDi) represents a serious complication with poor prognosis.

Aim: The aim of this study was to evaluate clinical and echocardiograhic characteristics of patients hospitalized for CIEDi.

Materials and Methods: We retrospectively evaluated patients hospitalized for CIEDi in our hospital during 2019.

Results: Twenty-nine patients (71±16years, 24males) were included. Pocket infection was present in 13 patients (45%), while combined with lead±tricuspid valve infection in 10 (34%). Lead±tricuspid valve involvement was present in 6 patients (21%). Eleven patients (38%) had admission positive blood culture (S. epidermidis 38%). Mean ejection fraction was 40±14%, 55% patients had one vegetation (13.0±7.0mm) and 14% had multiple. TTE failed to identify vegetations in 6 patients while TOE was diagnostic for them. In 9 patients (31%), we found pulmonary embolization before percutaneous extraction, with significantly higher procalcitonin (2.2±3.6vs0.1±0.2ng/mL; p=0.030). During follow up, mortality for cardiovascular causes was 24%. In 5 patients (17%) echocardiographic ghosts were found and 3 of them died during follow up (p=0.039). No reinfection was recorded and Kaplan-Meier analysis showed significant increased cardiovascular mortality risk (p-Log rank=0.016) in patients with reduced ejection fraction ≤40%.

Conclusions: TTE and TOE are fundamental for diagnosis and follow up of CIEDi. In our population, long term follow up showed cardiovascular mortality of 24% and was increased significantly in patients with reduced ejection fraction ≤40%.

ID: 223: A R EDUNDANT AND S ERPIGINOUS C HORDA T ENDINEA P ROLAPSING IN L EFT V ENTRICULAR O UTFLOW T RACT

Zema Domenica, Nucara Mariacarmela, Bellieni Luca, Cama Eliodoro, Benedetto Francesco Antonio

“Bianchi-Melacrino-Morelli” Hospital - Reggio Calabria, Italy

The rare congenital anomalies characterized by the presence of accessory tissue of the mitral valve are often an accidental finding during routine echocardiograms or in patients symptomatic for syncope/pre-syncope when the accessory tissue obstructs the left ventricular outflow tract, or arrhythmias. These anomalies may manifest themself either as an isolated valvular anomaly or in association with other cardiac congenital anomalies. The embryological explanation could be the incomplete separation of mitral tissue from the endocardial cushions during the delaminating phase of endocardial cushion development.

We report the case of a thirty-five years old Indian boy, referred to our hospital for persistent migraine. The 2D and 3D transthoracic and transesophageal echocardiography revealed the presence of a long redundant chorda tendinea, with a serpiginous appearance, highly mobile, originating from the posteromedial papillary muscle and inserted on the anterior mitral leaflet. The redundant chorda prolapsed into the left ventricular outflow tract without causing obstruction, not even interference with the mitral and aortic valve apparatus. Function and size of both ventricles were normal.

No intracardiac right-to-left shunt neither congenital cardiac anomalies were detected.

Considering the absence of syncope, the patient was advised to continue echocardiographic follow-up.

As in mitral prolapse syndrome where there is a significant association with migraine, in patient with mitral valve accessory tissue, like our young patient, enhanced platelet aggregability and increased serotonin release from damaged platelet may be the pathophysiologic mechanism of migraine.

ID: 225: D IFFERENT P HENOTYPES IN C ARDIOMYOPATHIES . T WO S IDES OF THE C OIN ?

Gonano Nicola

University of Trieste – Trieste, Italy

A 18-years-old woman without any risk factors nor family history was screened for sports activity with an EKG that showed subtle repolarization abnormalities. Ergometric test and HolterECG showed bimorphic ventricular extrasistolic burden and transthoracic echocardiography showed normal biventricular volumes and function. Cardiac magnetic resonance (CMR) revealed diffuse intra-myocardial (non-ischemic) LGE in the apex and in basal to mid-ventricular lateral and anterior segments. She underwent genetic testing that showed likely-pathogenic variant of LMNA and thus she was implanted with cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death. During follow-up she had no major arrhythmias, and she develop a progressive and constant dilatation and worsening of left ventricular ejection fraction until severe systolic disfunction of the left ventricle and mild systolic disfunction of the right ventricle despite optimized medical therapy. In the meantime her brother, a preaviously healthy 23-years-old man, underwent CMR due to dilated cardiomyopathy diagnosis of his sister. Diffuse LGE with the same pattern and segments involved of his sister was found, but he resulted negative at genetic testing and therefore he didn’t implant an ICD initially, also due to normal biventricular size and function at the first CMR and during follow-up. Two years later he experienced syncope after intense physical activity and ICD in secondary prevention was implanted. One year later, appropriate ICD shock interrupted a sustained ventricular tachycardia. Conclusion: As highlighted by the 2023 guidelines on cardiomyopathies, in the same family different phenotypes could be present and even in the same individual the phenotypic expression could change over time.