Cytokine elimination in suspected COVID-19 perymyocarditis

Background: Only recently studies have been able to demonstrate the safety and efficacy of purification therapies in inflammatory diseases. Here we present the management of a young (21y) male patient in severe cardiogenic shock due to COVID-19 perymyocarditis admitted to the ICU at Bolzano Central Hospital. November 30th 2020 the patient developed high fever (>40 C) and diarrhea. After unsuccessfully being treated orally with a macrolide he was admitted to a peripheral hospital the 4th of December. The day after he deteriorated, required transfer to the ICU, endotracheal intubation and pharmacological cardiovascular support (Norepinephrine, Levosimendan). Antimicrobial treatment was started with piperacillin/tazobactam, linezolid and metronidazole. Despite multiple radiological and microbiological diagnostic attempts the origin of this severe septic shock remained unclear. December 6th the patient was transferred to Bolzano Central Hospital for VA-ECMO evaluation. Method(s): The transesophageal echocardiography revealed 15-20% of EF, lactate (5,2 mmol/l), cardiac enzymes (TropT 1400 mcg/l) and inflammatory parameters (PCT 35 ng/ml, IL-6 685 pg/ml) were elevated. We performed cardiac monitoring via Swan-Ganz catheter. The cardiac index was 1,6 l/min/m2. The peak dosage for Norepinephrine reached 7,5mg/h (1,47 mcg/kg/min). At Bolzano ICU we facilitate the pharmacological therapy with milrinone, vasopressin and low dose epinephrine. Furthermore, we impost continuous hemodiafiltration with CytoSorb filter. Result(s): Only hours after the start of filtration therapy the patient improved and we were able to gradually reduce catecholamine therapy, lactate values decreased. A VA-ECMO implantation was no more necessary. December 10th, we saw a stable patient without ventilatory or cardiovascular support, at echocardiography we revealed a normal EF. Conclusion(s): Clinically we saw a young patient in severe septic/cardiogenic shock due to perimyocarditis. Yet diagnostic attempts (CT-scan, multiple blood/urinary/liquor cultures) remained negative. Despite multiple negative PCR tests for SARS-CoV2 infection we performed specific immunoglobulin analysis and received a positive result for IgM. We therefore conclude on a COVID-19 associated perymyocarditis. Furthermore, this case illustrates the potential benefit of cytokine filtration and elimination in COVID-19 patients with altered IL6 levels.

Unexpected effects of new covid-19 infection in arrhythmia surgery

The article presents two clinical cases of patients with a fatal outcome after a coronavirus infection. The first patient had sepsis and purulonecrotic phlegmon complication after radiofrequency ablation of the cavatricuspid isthmus. The second one had a complication in the form of the esophageal rupture in the middle third after transesophageal echocardiography.Copyright © 2021, NJSC Institute of Cardiological Technology (INCART). All rights reserved.

Paravalvular aortic abscess with aorto-left atrial fistula in infective endocarditis of the native aortic valve: a case report

Introduction: Infective endocarditis (IE) is a life-threatening disease with poor prognosis and high mortality if not diagnosed promptly and intervened early1. Perianullary extension accounts for nearly 40% of all native valves IE, most commonly the aortic valve, but formation of an intracardiac fistula occurs in less than 1% of all cases2. Case report: We report the case of a 64-year-old man admitted to the intensive care unit because of acute respiratory failure with high fever, high inflammatory blood reactants and electrolyte disbalance. He had previously been extensively evaluated for microcytic anemia due to hemorrhoids, and had also suffered from epilepsy since his youth. A series of blood cultures were obtained and Streptococcus oralis was positive. Because of systolic-diastolic murmur and second-degree atrioventricular conduction disturbance on electrocardiography, transthoracic echocardiography (TTE) was performed. TTE showed the aortic valve with a hyperechogenic mass and severe aortic regurgitation with a jet directed toward the septum and moderate aortic stenosis. However, a 1.5 x 2.2 cm hyperechogenic mass was noted in the right atrium adjacent to the aortic annulus (Figure 1). Transesophageal echocardiography (TOE) showed a deformed aortic valve with three degenerative leaflets and hyperechogenic mobile vegetations, a circumferential abscess of the aortic annulus with extension of infection toward the right atrium just above the tricuspid septal leaflet and extension of infection toward the left atrium with formation of a fistula detected by color Doppler flow (Figure 2). The patient was treated with vancomycin and benzilpenciline and referred to cardiac surgery, where the aortic valve was replaced with a biological prosthesis and the aortic root was patched. The postoperative course was complicated by the COVID-19 infection. A series of control blood cultures were sterile. After two months of treatment, the patient was discharged home with normal TTE function of the biological aortic valve (Figure 3). Conclusion: TTE and TOE are invaluable for rapid and accurate diagnosis of the anatomic involvement of IE and its extent, leading to appropriate treatment and thus a better prognosis. [ FROM AUTHOR] Copyright of Cardiologia Croatica is the property of Croatian Cardiac Society and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

The Effect of Covid-19 Pandemic on Cardiologists and the Practice of Cardiology: A Survey Based Study

Background The Coronavirus disease (COVID) pandemic had a devastating effect on physician practices across the globe resulting in lost revenue. In this study, we aimed to determine the impact of the pandemic on cardiologists across the United States. Cardiologists account for 5.8% of physicians in the US but are estimated to be the 2nd most revenue generating specialty ($3.5 million/year). Methods The subjects for the study were Cardiologists with membership to either medical societies American College of Cardiology, Society of Cardiovascular Angiography and Interventions, Heart Rhythm Society, or American Society of Echocardiography. The participants were emailed a survey link with information regarding the study objective, potential risks, and benefits of participation. (Proportional Reporting Ratio) PRR was calculated to compare various characteristics of the responders, exposures, disease impact on self and practice. Results 91%(448) of the cardiologists who responded(n=493) reported some disruption in practice and 46%(226) reported delay in planned elective procedures. Nearly all (92%, 453) reported incorporating telemedicine into their practice. Cardiologists working?>55 hours/week (PRR=1.296, 95% CI =1.023-1.643), urban and semi-urban areas (PRR=1.802, 95% CI=1.468-2.211) and in academic settings (PRR=1.345, 95% CI=1.096-1.652) were at increased risk of developing COVID infection compared to others. Cardiologists performing transesophageal echo had reduced risk of contracting COVID (PRR=0.721,95% CI=0.604-0.861) compared to those performing catheter ablation (PRR=1.382, 95% CI=1.150-1.661) and device placement (PRR=1.208, 95 %CI=1.012-1.442). Conclusion Cardiologists who worked longer hours, practiced in urban/academic settings, worked in centers not requiring preoperative COVID testing and were exposed to COVID positive patients without a Personal Protective Equipment(PPE) were at higher risk of getting infected. Albeit derived from a self-reported physician survey of a small cohort of cardiologists, the patterns of exposure and infection offer insight into practice changes and precautions that might protect physicians in future pandemics.Copyright © 2023 American College of Cardiology Foundation

Left atrial thrombus exclusion before atrial fibrillation ablation: Reconsidering the role of cardiac computed tomography

Objectives: Considering the risk of aerosolization during the COVID-19 pandemic associated with transesophageal echocardiography (TEE), we evaluated the diagnostic performance of cardiac computed tomography (CCT) before pulmonary vein isolation (PVI) in comparison to semi-invasive TEE in excluding left atrial (LA)/LA appendage (LAA) thrombus, limiting the need for TEE to only patients with possible thrombus on CCT. Material(s) and Method(s): We included a total of 145 consecutive patients with atrial fibrillation (AF) (age 52.4 +/- 10.3 years;63% males;89 paroxysmal AF) referred for radiofrequency ablation in National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. All patients underwent preprocedural single-phase 128-slice multidetector CT and subsequent TEE as the reference standard with a mean time interval of 6.5 +/- 5.3 days between the two procedures. Result(s): CCT identified 30 patients (20.7%) with a filling defect in the LA/LAA, 8 of which were confirmed by TEE as thrombi (22 false positives and 8 true positives), whereas 9 true thrombi (6.2%) were detected by TEE (1 false negative by CCT). The sensitivity and specificity of CCT were 88.9% and 83.8%, respectively, with a positive predictive value of 26.8% and a negative predictive value of 99.1%. The overall accuracy was 84.1%. Conclusion(s): Apart from being a planned preparation modality before PVI, CCT is sufficient and could be used as an initial step to exclude the presence of LA/LAA thrombus, limiting the invasive TEE only for confirmation of the thrombus if detected by CCT.

Platypnea-Orthodeoxia Syndrome Due to Patent Foramen Ovale Shunt Caused by Aortic Root Dilation

Background Orthodeoxia syndrome (OS) is a rare clinical condition characterized by oxygen desaturation noted in the upright position (orthodeoxia). OS can originate in the heart, lungs, abdomen, or elsewhere due to either an intracardiac (cardiac OS) or intrapulmonary shunt, or a ventilation-perfusion mismatch. Anecdotal reports suggest that the enlargement of the aortic root could interfere with atrial septal mobility (ASM) and cause patent foramen ovale (PFO) shunt. Case A 77-year-old male patient was admitted to the ICU with pneumonia due to COVID-19. During the evaluation, the patient presented orthodeoxia detected by pulse oximetry, with oxygen saturation (SpO2) of 96% in supine and 70% in upright positions. COVID-19 was treated with remdesivir and corticosteroids without orthodeoxia improvement. Decision-making Pulmonary embolism was ruled out with CT Angiography. Transthoracic Echocardiogram was also normal. A microbubble contrast-enhanced Transesophageal echocardiography was done and confirmed an aortic root dilatation with atrial septal mobility leading to a significant patent foramen ovale (PFO) shunt. The patient was submitted to interventional closure of the patent foramen ovale with the resolution of orthodeoxia. Conclusion Increased Mobility of the Atrial Septum in Aortic Root Dilation can be a cause of PFO shunt and orthodeoxia [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Transesophageal Echocardiography-Guided Extracorporeal Membrane Oxygenation Cannulation in COVID-19 Patients.

OBJECTIVES: A paucity of data supports the use of transesophageal echocardiography (TEE) for bedside extracorporeal membrane oxygenation (ECMO) cannulation. Concerns have been raised about performing TEEs in patients with COVID-19. The authors describe the use and safety of TEE guidance for ECMO cannulation for COVID-19. DESIGN: Single-center retrospective cohort study. SETTING: The study took place in the intensive care unit of an academic tertiary center. PARTICIPANTS: The authors included 107 patients with confirmed SARS-CoV-2 infection who underwent bedside venovenous ECMO (VV ECMO) cannulation under TEE guidance between May 2020 and June 2021. INTERVENTIONS: TEE-guided bedside VV ECMO cannulation. MEASUREMENTS: Patient characteristics, physiologic and ventilatory parameters, and echocardiographic findings were analyzed. The primary outcome was the number of successful TEE-guided bedside cannulations without complications. The secondary outcomes were cannulation complications, frequency of cannula repositioning, and TEE-related complications. MAIN RESULTS: TEE-guided cannulation was successful in 99% of the patients. Initial cannula position was adequate in all but 1 patient. Fourteen patients (13%) required cannula repositioning during ECMO support. Forty-five patients (42%) had right ventricular systolic dysfunction, and 9 (8%) had left ventricular systolic dysfunction. Twelve patients (11%) had intracardiac thrombi. One superficial arterial injury and 1 pneumothorax occurred. No pericardial tamponade, hemothorax or intraabdominal bleeding occurred in the authors' cohort. No TEE-related complications or COVID-19 infection of healthcare providers were reported during this study. CONCLUSIONS: Bedside TEE guidance for VV ECMO cannulation is safe in patients with severe respiratory failure due to COVID-19. No tamponade or hemothorax, nor TEE-related complications were observed in the authors' cohort.

Cardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era

In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke Criteria. Seven cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was non-diagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision-making. Further prospective controlled trials of CMR Vs TEE are warranted. © 2022 Elsevier Inc.

Utility of Multidetector Computed Tomographic Angiography as an Alternative to Transesophageal Echocardiogram for Preoperative Transcatheter Mitral Valve Repair Planning.

BACKGROUND: Three-dimensional (3D) transesophageal echocardiogram (TEE) is the gold standard for the diagnosis of degenerative mitral regurgitation (dMR) and preoperative planning for transcatheter mitral valve repair (TMVr). TEE is an invasive modality requiring anesthesia and esophageal intubation. The severe acute respiratory syndrome coronavirus 2 pandemic has limited the number of elective invasive procedures. Multi-detector computed tomographic angiography (MDCT) provides high-resolution images and 3D reconstructions to assess complex mitral anatomy. We hypothesized that MDCT would reveal similar information to TEE relevant to TMVr, thus deferring the need for a preoperative TEE in certain situations like during a pandemic. METHODS: We retrospectively analyzed data on patients who underwent or were evaluated for TMVr for dMR with preoperative MDCT and TEE between 2017 and 2019. Two TEE and 2 MDCT readers, blinded to patient outcome, analyzed: leaflet pathology (flail, degenerative, mixed), leaflet location, mitral valve area (MVA), flail width/gap, anterior-posterior (AP) and commissural diameters, posterior leaflet length, leaflet thickness, presence of mitral valve cleft and degree of mitral annular calcification (MAC). RESULTS: A total of 22 (out of 87) patients had preoperative MDCT. MDCT correctly identified the leaflet pathology in 77% (17/22), flail leaflet in 91% (10/11), MAC degree in 91% (10/11) and the dysfunctional leaflet location in 95% (21/22) of patients. There were no differences in the measurements for MVA, flail width, commissural or AP diameter, posterior leaflet length, and leaflet thickness. MDCT overestimated the measurements of flail gap. CONCLUSIONS: For preoperative TMVr planning, MDCT provided similar measurements to TEE in our study.

Septic arthritis caused by Brucella melitensis - An orthopedic chal-lenge (11194)

Introduction The zoonotic infection with Brucella melitensis can be acquired by inges-tion of unpasteurized goat's or sheep's milk. The infection is common in Eastern Mediterranean countries (EMC), but rare in western Europe (6 cases in Switzerland, 2021). When evaluating patients with symptoms of septic arthritis, brucellosis is not the foremost differential diagnosis. How-ever, with the increasing population of people from EMC in western Eu-rope, the incidence may be rising. We present a patient who was initially suspected to suffer from Long-COVID-Syndrome (LCS), which underscores the relevance of this case in a pandemic situation. Methods/Results A 58-year-old male patient was admitted to the emergency department with a painful right knee effusion after a minor trauma. Additionally, he suffered from fatigue, subfebrile temperatures, back pain and myalgias for more than two months. He was suspected to suffer from LCS after a mild COVID-19 three months earlier. The culture of the arthrocentesis (14.400 cells/mul with 61% polynuclear cells) unexpectedly turned positive for B. melitensis. The patient declared that he had been drinking three liters of unpasteurized goat's milk to cure the presumptive LCS. To ensure staff safety, arthroscopic lavage was postponed until brucella-active antibiotics had been administered for at least 24 hours. Surgery was performed under strict infection control measures to avoid generating aerosols. According to Duke, one major (continuous bacteremia over 14 days) and 2 minor criteria (fever, most probably septic embolic gonarthritis) were fulfilled. Therefore, possible endocarditis had to be assumed although transesophageal echocardiography was normal. Antibiotic treatment was escalated to a quadruple regimen (intravenous gentamicin for three weeks;as well as oral doxycycline, trimethoprim/sulfomethoxazole and rifampin for at least 3 months). The clinical recovery - still under treatment - is protracted with slowly improving knee pain and normalizing signs of inflammation. Conclusion Although B. melitensis is a rare pathogen in Switzerland, orthopedic sur-geons, rheumatologists and infectious disease specialists need to be aware of diseases with low incidence and non-specific symptoms espe-cially in times of a global pandemia. A high index of suspicion is needed in patients related to EMC. When brucellosis is confirmed, strict infection control measures to protect staff involved in aerosol generating proce-dures must be adopted.

ACUTE INTERSTITIAL NEPHRITIS AS A PRIMARY PRESENTATION OF CANDIDA INFECTIVE ENDOCARDITIS

Introduction: Acute Interstitial Nephritis (AIN) is an important cause of Acute Kidney Injury (AKI), and infections are the second most common etiology, after the drugs. However, AIN following fungal infections is rare. We describe two cases of AIN, which on the investigation turn out to be candidemia following fungal infective endocarditis. Methods: CASE 1: A 65-year-old man with hypertension and diabetes without diabetic or hypertensive retinopathy and prior normal renal function, presented to us with vague abdominal pain with steadily creeping creatinine to 2mg/dl within 2 weeks, and urine showed no albuminuria and sediments. There was no history of any specific drug intake. His hematological and other parameters were normal. Blood and urine cultures were sterile. He underwent a renal biopsy which revealed acute interstitial nephritis (Figure 1). He was started on prednisolone at 1mg/kg/day for 1-week following which he had a rapidly worsening azotemia requiring hemodialysis. Steroids were stopped. Repeat blood cultures were sent which grew candida albicans resistant to flucytosine. Re-evaluation of the fundus revealed macular infarct in the right eye with vitreoretinitis in the left eye suggestive of endophthalmitis. PET CT showed increased FDG uptake in both kidneys suggestive of pyelonephritis. Trans-esophageal echocardiography (TEE) showed aortic valve vegetations. He was treated with antifungals for 3 months. He was dialysis-dependent for 2 weeks. He gradually regained normal renal function 3 weeks after starting anti-fungal agents. CASE 2: A 57-years-old man with diabetic, hypertensive, and no diabetic retinopathy had severe covid pneumonia in June 2021 requiring oxygen and tocilizumab 80 mg for 4 days, recovered with normal renal function. He presented to us 1 month later with unexplained non-oliguric severe AKI requiring dialysis, with bland urine sediments. Renal biopsy showed lymphocytic infiltrates in the interstitium suggestive of AIN (Figure 2). Blood cultures were sterile, but serum beta-D-glucan was elevated at 333 pg/ml. He was Initiated on 1mg/kg of prednisolone, on the presumption of drug-induced AIN. Simultaneously workup for systemic infection revealed mitral anterior leaflet endocarditis. He was initiated on anti-fungal therapy on the advice of an infectious disease specialist and the steroid was stopped. He continued to be dialysis-dependent after 6 weeks, despite anti-fungal agents. Results: [Formula presented] Conclusions: AIN contributes a significant proportion of cases in unexplained AKI. Prompt evaluation with a renal biopsy is warranted. Acute interstitial nephritis particularly due to candidemia can be oligosymptomatic as seen in our two cases. Since steroids have a significant role in treating early AIN, a dedicated search for underlying silent endocarditis and candidemia is advisable before initiating steroid therapy. Ophthalmic fundus evaluation, TEE, and repeat blood culture may be necessary to identify hidden candidemia. We recommend an evaluation to exclude fungal endocarditis in patients with AIN who present with minimal or no symptoms and no definitive cause for AIN is present. No conflict of interest

Novel Method for Percutaneous ECMO Cannula Exchange

Purpose: Percutaneous cannulation for Veno-Venous (V-V) and Veno-Pulmonary Arterial (V-PA) ECMO has transformed our approach to extracorporeal support, particularly in the Covid-19 era. Along with the increase in percutaneous cannulation comes an increase in complications, some necessitating replacement of the cannula. We present a novel technique to exchange cannulas using the same site with minimal blood loss and time off support. Method: All procedures were performed in the hybrid OR with fluoroscopy and transesophageal echocardiography (TEE). A 4 Fr. dilator was placed posteromedial to the existing cannula with pressure directed toward the cannula to enter the vein. A wire was placed through the dilator to facilitate directing the wire into the PA or IVC, ultimately advancing the wire into the RPA (V-PA) or IVC (V-V). The ECMO circuit was clamped and both limbs transected. The existing cannula was removed simultaneously with the new cannula being placed over the wire into either PA or IVC (V-PA or V-V respectively). The cannula was deaired, reconnected to the ECMO circuit, and flow reestablished. Results: 8.1% (19/234) of our V-V or V-PA patients required replacement of the percutaneous cannula. 63% were due to RV failure diagnosed by echocardiography and 32% were for cannula migration below the pulmonary valve into the RV. Our technique was universally successful with a mean blood loss of 20cc, <1.5 minutes off ECMO, and no complications. Summary: The described technique is effective in replacing percutaneous V-V and V-PA ECMO cannulas using the original site with minimal time off support and blood loss. (Figure Presented).

Cardiac Magnetic Resonance Imaging for the Diagnosis of Infective Endocarditis in the COVID-19 Era

Introduction In the COVID-19 pandemic, to minimize aerosol-generating procedures, cardiac magnetic resonance imaging (CMR) was utilized at our institution as an alternative to transesophageal echocardiography (TEE) for diagnosing infective endocarditis (IE). Methods This retrospective study evaluated the clinical utility of CMR for detecting IE among 14 patients growing typical microorganisms on blood cultures or meeting modified Duke criteria. Results 7 cases were treated for IE. In 2 cases, CMR results were notable for possible leaflet vegetations and were clinically meaningful in guiding antibiotic therapy, obtaining further imaging, and/or pursuing surgical intervention. In 2 cases, vegetations were missed on CMR but detected on TEE. In 3 cases, CMR was nondiagnostic, but patients were treated empirically. There was no difference in antibiotic duration or outcomes over 1 year. Conclusion CMR demonstrated mixed results in diagnosing valvular vegetations and guiding clinical decision making. Further prospective controlled trials of CMR vs TEE are warranted.

A Case of COVID-19 ARDS with Unusual Refractory Hypoxia

Aim and background: Since the beginning of COVID-19 pandemic, we have come across a large number of ARDS patients with different presentations and clinical manifestations. The usual management is using a lung-protective ventilatory strategy followed by proning to improve oxygenation. Here, we present a case where the usual management failed to improve oxygenation which led us to think of co-existing alternative diagnosis. Case description: A 59-year-old male with a history of cardiovascular disease, presented with cough and breathing difficulty for 10 days and COVID RT PCR was positive. He was started on remdesivir, steroids, anti-coagulants, and other supportive measures but worsened and had to be intubated and mechanically ventilated. Lung-protective ventilation was initiated but the patient remained hypoxic even at 100% fiO2. Chest X-ray and HRCT did not show much severity and the measured lung compliance was also good. A transesophageal ECHO showed good LV function and no significant diastolic dysfunction. 2 sessions of proning were done and yet the oxygenation did not improve. Repeat HRCT + CTPA was done to look for pulmonary embolism but it instead revealed a pulmonary AV malformation. Coiling of the AV malformation was done. Oxygenation then substantially improved. Further sessions of proning were done and patient was gradually weaned off. Conclusion: There may be several co-existing causes of ventilation-perfusion mismatch which needs to be looked for. Pulmonary AV malformation, though rare, can cause shunting and hence persistent hypoxia.

CARDIAC PAPILLARY FIBROELASTOMA: A RARE CAUSE OF EMBOLIC STROKE

Background and aims: Cardiac primary tumours are extremely rare. The most frequently detected are myxoma and fibroelastoma. Papillary fibroelastoma (PF) is mainly found in aortic and mitral valves. It can be diagnosed based on transthoracic echocardiography, but transesophageal echocardiography increases sensitivity among smaller tumours. PF is generally detected as an incidental finding, although it can be presented as cardiac symptomatology or embolization, being the ischemic stroke the most common presentation. We describe two ischemic stroke cases due to PF. Methods: Case 1: a 38-year-old male presented an ischemic stroke in the left posterior cerebral artery territory. Transthoracic echocardiography showed a hyperechogenic mass in the mitral valve (image 1). The examination did not show other findings. Case 2: a 66-year old male suffered an ischemic stroke in the right cerebral posterior artery territory. Usual examination did not show any pathological results. Transesophageal echocardiography showed a subvalvular mitral hyperechogenic mobile mass (11x5.5 mm) (image 2). Results: Case 1: surgical intervention extracted a 12x14 mm tumour. Histopathologic examination confirmed a PF. Case 2: surgery was postponed due to CoVid-19 pandemic. Treated with DOAC until surgery was performed. No new events. Histopathology exam confirmed the diagnosis. Neither of the patients had complications during the follow-up. No medical treatment was needed for secondary prevention. Conclusion: PF should be considered among etiological diagnoses of embolic strokes, bearing in mind secondary prevention could vary, since surgery could be a reasonable option. Transesophageal echocardiography may be a suitable option when other causes are excluded. (Figure Presented).

A MULTIMODALITY IMAGING DIAGNOSIS OF A CHALLENGING CASE OF CONCOMITANT GROUP 1 PULMONARY HYPERTENSION AND PARADOXICALLY LOW- FLOW, LOW-GRADIENTAORTIC STENOSIS

A 76 year old woman was admitted to our hospital for self-limiting dyspnoea (NYHA class III) in oxygen dependence and frequent lipothymia following Valsalva manoeuvres. She was previously admitted to a Spoke Centre for heart failure (HF) with preserved ejection fraction (EF) and a new diagnosis of “pre-capillary pulmonary hypertension (PH)”. Despite a diagnosis of PH of unclear aetiology, she was started on macitentan without being reassessed for functional capacity due to Covid emergency;because of worsening symptoms, she was admitted to our Hub Centre. Resting ECG showed right axis deviation, right ventricle (RV) hypertrophy, first-degree atrioventricular block and right bundle branch block. Transthoracic echocardiography (TTE) showed reduced left ventricular (LV) volume with preserved EF (diastolic volume= 37 ml, EF=88%), severe right atrial and RV dilation with flattening of the interventricular septum, estimated pulmonary artery systolic pressure (PASP) of 124 mmHg, and moderate calcific aortic stenosis (peak aortic velocity 3.3 m/s, mean gradient 25 mmHg, valve area 1.1 cm2). Right and left heart catheterization showed severe pre-capillary PH (mean pulmonary pressure 60 mmHg, mean wedge 11 mmHg, pulmonary vascular resistance 14.41 WU), a severe aortic valve stenosis (aortic valve area 0.68 cmq and peak-to-peak gradient 25 mmHg, slight reduction of cardiac index 2.04 l/min/mq) and no significant coronary artery disease. The degree of aortic stenosis was considered as moderate-severe by integrating data of transesophageal echocardiography (planimetric area 1cm2) and assessment of calcium score (1615 Agatson units). Pneumological causes, chronic thromboembolic PH, rheumatologic diseases, HIV infection, paraneoplastic origin and veno-occlusive disease were all ruled out as potential PH causes and a diagnosis of Idiopathic pulmonary arterial hypertension (IPAH) was finally made. The Heart Team established the best therapeutic option was a transcatheter aortic valve replacement (TAVI) allowing better haemodynamic tolerability of PH therapy. The patient underwent TAVI and was started on PH therapy;a complete atrio-ventricular block developed after the procedure, requiring permanent pacemaker (PM) implantation. Unfortunately, few days later, the patient died following pacemaker's lead dislocation. Conclusion: PH has a diverse aetiology, and prognosis is generally poor, especially in patients with severe comorbidities. (Figure Presented).

Capabilities of transesophageal echocardiography in patients with atrial fibrillation

Transesophageal echocardiography is widely used in clinical practice in patients with atrial fibrillation and it is mainly applied to determine the morphology of the heart, the presence of intracardiac thrombi, quantify the structures of the heart, as well as to determine the tactics for surgical interventions. Transesophageal echocardiography has an advantage over transthoracic echocardiography in visualizing the left atrium and left atrial appendage, common sites of thrombus formation in patients with atrial fibrillation. Due to the anatomical proximity of the esophagus to the heart, the transesophageal access avoids signal fading and incorrect interpretation of the study results. The possibilities of transesophageal echocardiography in patients with atrial fibrillation have expanded with the development of medical technology, and three-dimensional transesophageal echocardiography has become widespread. In recent years, the studies on the use of the transesophageal echocardiography in patients with atrial fibrillation during the coronavirus pandemic have been published. The review presents the results of studies, meta-analyzes of pooled samples, as well as clinical cases, demonstrating capabilities of transesophageal echocardiography in patients with atrial fibrillation. A brief history of the development of the method, work on the study of the technology features and capabilities of transesophageal echocardiography for pulmonary vein ablation, cardioversion, occlusion of the left atrial appendage in patients with atrial fibrillation, as well as studies on disadvantages of the transesophageal echocardiography and possible options for their elimination are presented. Comparison of the transesophageal echocardiography with transthoracic and intracardial echocardiography is also highlighted. In preparing the review, the literature search method in PubMed databases for the period 2012–2021 was used, as well as data from an earlier period to indicate the history of the method development. © Eco-Vector, 2022. All rights reserved.

Focused Transesophageal Echocardiography in Critical Care: The COVID-19 Pandemic.

Background: The use of transesophageal echocardiography (TEE) is controversial in patients with COVID-19. The aim of this case series was to demonstrate the usefulness of transesophageal echocardiography in acute cardiovascular care settings in patients with COVID-19 infection. Materials and Methods: We enrolled 13 patients with confirmed SARS-CoV-2 infection admitted to the critical care unit of our center from April 1, 2020, to July 30, 2020, in which transesophageal echocardiography was performed. TOE was performed by three cardiologists with training in echocardiography. Results: The main indication was suspected infective endocarditis in four cases, venovenous extracorporeal membrane oxygenation cannulation in four cases, suspected prosthetic mitral valve dysfunction in two patients, suspected pulmonary embolism in two patients, and acute right ventricular dysfunction and prone position ventilation in one patient. The final diagnosis was confirmed in 11 patients and discarded in 2 patients. None of the operators result infected. Conclusions: TOE is safe in the context of COVID-19 infection; it must be performed in well-selected cases and in a targeted manner.

Accidental diagnosis of significant coronary artery disease by cardiac CT scan to rule out left atrial appendage thrombus in patients with atrial fibrillation during COVID19 pandemic

Introduction The exclusion of left atrial appendage (LAA) thrombus prior to urgent electrical cardioversion (DCCV) for atrial fibrillation (AF) is traditionally performed by transesophageal echocardiography (TEE). During the COVID19 pandemic, TEE was replaced by cardiac CT (CCT) due to its high aerosol generating property, which in addition to assessing the anatomy of the heart, can also be used to evaluate the coronary arteries at the same time. Methods In our retrospective study, we evaluated the cardiac CT scans of patients undergoing DCCV in our institution between January 1, 2020 and February 28, 2021 for coronary artery disease (CAD). The scans were performed by a GE Revolution 256-slice CT scanner. Results CCT scans were performed in 32 patients to rule out LAA thrombus (24 male;8 female;age: 61.8 ± 11.2 years;BMI: 29.2 ± 4.4;heart rate: 79.2 ± 24.4 1/min;CHA2DS2VASc score: 2.4 ± 1.5). The mean radiation exposure of the scans was DLP: 356.3 ± 130.1 mGy-cm;effective dose: 5.0 ±1.8 mSv, Ca-score: 361.4 ± 883.0. In 4 equivocal cases TEE was also performed with negative results. No CAD was confirmed in 7 cases, mild CAD in 14 patients. CCT was not diagnostic only in 4 cases. Significant (moderate or severe) CAD was detected in 7 cases, invasive coronary angiography (ICA) was also performed in 5 cases. In 2 cases significant one-vessel disease, in 2 other cases borderline (FFR: 0.81 and 0.84) stenosis and in 1 case only mild CAD was diagnosed by ICA. Conclusions: CCT scans performed by our 256-slice CT scanner for AF can identify patients, who require further invasive or invasive and functional coronary artery assessment with satisfactory accuracy. In terms of coronary artery disease, the non-diagnostic scan rate was low, despite the presence of arrhythmia, suboptimal heart rate and higher than usual Ca-score.