Redo surgery for a type A aortic dissection in a pregnant woman with Marfan syndrome: a complex clinical case

Aortic dissection during pregnancy is a very rare event in the general population but can be fatal to both the mother and the fetus. A rate of dissection as high as 10% was observed in pregnant patients affected by Marfan syndrome. Facing this kind of disease can represent a challenge for the involved physicians because of its rarity. Here we present the case of an aortic dissection in a pregnant woman with Marfan syndrome who previously underwent an open heart surgery for a mitral prolapse. The diagnosis and the treatment of this case, given the mid-term gestational age combined with an increased surgical risk due to the reintervention, required a particular effort by our team. A multidisciplinary approach to the management of this patient was the key to achieve a favorable outcome both for the mother and for the baby.

How accurate is cardiac magnetic resonance in quantitation of primary mitral regurgitation?

Background Since evaluation of mitral regurgitation (MR) in patients with mitral prolapse by echo may be challenging, cardiac MRI (CMR) has been used for identification of patients with severe valve disease. Little is known about potential factors influencing accuracy of this approach. Purpose To study the impact of left ventricular (LV) contouring methods and interobserver variability on quantitation of MR severity. Methods A total of 50 asymptomatic patients with echocardiographically moderate or severe MR were included to LV-REGURGE study and evaluated with CMR by two independent reviewers. LV volumes were calculated on SSFP short axis stack including or excluding intracavitary myocardium into/from the LV volume (“including” or “excluding” method, respectively). Aortic flow volumes were obtained using phase contrast method. Mitral regurgitant volume (RegVol) was calculated by subtracting forward aortic volume from LV stroke volume. Severe MR was diagnosed when RegVol >60mL and/or RegVol/LV stroke volume (RF) >40%. Agreement between MR grading into severe and non-severe, obtained by different tracing methods and different reviewers was assessed using kappa coefficient. Results Left ventricular and mitral regurgitant volumes obtained by “including” method were significantly larger as compared with “excluding” method, see table. “Including” method identified severe MR in 68% while “excluding” method in 57% of cases. Overall agreement between the methods was present in 84% of cases, meaning a substantial rate of agreement (κ 0.67). Within respective methods, interobserver agreement was present in 77% of cases, interpreted as a moderate rate of agreement (κ 0.48–0.54) Conclusion “Including” trabeculae and papillary muscles into the LV cavity volume substantially increases rate of recognizing severe MR, due to larger LV volumes, particularly LV ESV, comparing with the “excluding” method. Moreover, inter-observer variability in similar extent as tracing method seems to impact differentiation between severe and non-severe MR. Funding Acknowledgement Type of funding source: None

Human disease caused by Streptococcus alactolyticus: a case report of native valve infective endocarditis and review of the literature

Streptococcus alactolyticus, a member of the Streptococcus bovis/Streptoccus equinus complex, is primarily hosted in the gastrointestinal tract of animals and rarely of humans, with only scarce reports relating to human disease. We herein present a case of subacute infective endocarditis (IE) caused by S. alactolyticus in a 64-year old male with pre-existing mitral prolapse. Despite a 10-month history of low-grade fever and weight loss, the diagnosis of IE was triggered by left quadrant abdominal pain which revealed splenic infarcts on computed tomography. A definitive diagnosis of IE was subsequently established by four consecutive blood cultures positive for S.alactolyticus plus demonstration of a vegetation on the mitral valve by trans-esophageal ultrasound. Further workup revealed multiple embolic phenomena including brain and spine. A dental abscess was identified as the most probable origin of the bacteraemia, while colonoscopy revealed no evidence of cancer. The patient recovered uneventfully with antibiotic treatment and underwent successful cardiac surgery post-discharge. Although rare, IE caused by S. alactolyticus may be severe and of obscure origin; oral cavity should not be overlooked as a possible origin. Attention should be given in patients with preexisting risk factors.

AB1074 FEATURES OF COMBINED USE OF BIOMARKERS AND VISUALIZATION METHODS FOR DIAGNOSIS OF HEART DAMAGE IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background:In rheumatoid arthritis (RA), the endocardium is involved in the inflammatory process, which is caused by immunopathogenetic mechanisms involving CD4 +, T-cells and proinflammatory macrophages. Minor changes in the cardiovascular system can be successfully detected by ultrasound in patients with RA.Objectives:to improve the quality of non-invasive diagnostics of heart disease in patients with RA.Methods:57 patients with RA were under observation: 7 men and 50 women aged from 26 to 70 years; mean age 50.45 ± 10.12 years; activity (according to DAS28) was low for 3.5%, medium for 86%, and high for 10.5%. Immunological examination included determination of serum IgM-RF, CRP, antibodies to cyclic citrulline peptide (anti-CCP), antibodies to modified vimentin (anti-MCV), antibodies to antigen RA33, levels of angiopoietin-like proteins 3 (ANGPTL3) and 4 (ANGPTL4) types (classical ELISA test), as well as the detection of IgG antibodies to 5’-nucleotidase (5’-NT) and xanthine oxidase (XO) (modified ELISA test). Data from ultrasound, magnetic resonance (MRT) and computer (CT) tomography were used in assessing the state of the heart structures.Results:The pathology of cardiovascular system was diagnosed in 28 (49.1%) patients with RA. Signs of the heart damage were noted in 33.3% of cases (pericarditis and valvular heart disease were most often detected). In groups of patients with RA with elevated levels of antibodies to 5’-NT and XO (compared with RA patients with normal parameters), there was a significantly more frequent heart damage (for antibodies to 5’-NT: χ2= 3.8, p = 0.047; for antibodies to XO: χ2= 3.92, p = 0.041). It was discovered that in all patients with an increased level of antibodies to XO, one of the lesions of the heart valvular apparatus of varying severity was noted. According to ultrasound data (usually confirmed by CT and / or MRT), signs of valvular dysfunction were found in 21 (36.8%) patients with RA. The high frequency of mitral prolapse (28.6%) may be associated with the presence of a chronic inflammatory process that is able to accelerate the development of atherosclerosis and heart disease in RA patients. A tendency to an increase in the prevalence of mitral prolapse in patients with a longer duration of the disease (p = 0.062) and with high levels of serum ANGPTL4 (p = 0.058) was found.One of the main factors leading to the development of vascular pathology in RA is the accumulation of reactive oxygen intermediate. Antibodies to XO can affect the biochemical activity of the enzyme in the serum of patients with RA, stimulating the increased formation of O-form XO, which has a pronounced prooxidant effect (especially to lipids). ANGPTL4, acting as a potent inhibitor of endothelial lipoprotein lipase, can suppress the release of non-esterified fatty acids and their transfer to the heart muscle.Conclusion:To identify subclinical signs of involvement of cardiovascular system in the pathological process in the early asymptomatic stages of RA, it is advisable to use imaging techniques in combination with immunological markers of heart damage, which can be especially useful for screening, diagnostic evaluation and determining cardiovascular risk.Disclosure of Interests:None declared

Clinical Study of Chronic Heredofamilial Migraine with Aura

Sixteen patients ranging from 19 to 68 years-old were studied with Chronic Heredofamilial Migraine with Aura. The following symptoms were associated to chronic heredofamilial migraine: dizziness, vertigo, syncope, redness eye, photophobia, blurred vision and reduced and loss of vision, scintillant scotomas, dizziness, ears noise, temporospatial disorientation, memory disorders, effort dyspnea, asthenia, son phobia, nausea, vomits, and social, labor and home stress. The followings symptoms were interpreted as migraine auras: Blurred vision and reduced and loss of vision, scintillant scotomas, dizziness, ears noise. The following comorbidities were found: syncope, bradycardia, mitral prolapse and tachycardia, effort dyspnea, asthenia, seizures, environment, labor and home stress, sleep disorders or insomnia and constipation. The followings aspects were discussed: migraine and prodroms, migraine and vascular diseases, migrainous vertigo and dizziness, symptoms related to the visual system in migraine, migraine and sleep disorders, hemiplegic migraine, neural correlates of migraine, histamine and migraine, the calcitonin gene-related peptide in migraine and its role in migraine physiopathology, and migraine genetic