Myopericarditis as an Extra-Intestinal Manifestation of Crohn’s Disease: A Case Report

Introduction: Myopericarditis is an uncommon manifestation of Crohn’s disease. Interestingly enough, it can present in a patient without any acute bowel symptoms. Case Presentation: A 21-year-old male with a medical history of Crohn’s disease and eosinophilic esophagitis presented to the hospital with chest pain and fever. Blood work revealed elevated troponin, C-reactive protein, and sedimentation rate levels. Electrocardiogram (EKG) showed diffuse ST elevation in all leads. Transthoracic echocardiogram (TTE) demonstrated a small pericardial effusion without valvular abnormalities. The patient was diagnosed with myopericarditis. Extensive etiological workup was negative, in the absence of other explanations, it was attributed to his Crohn’s disease. The patient was started on colchicine and ibuprofen. Out-patient follow-up revealed resolution of symptoms. Conclusion: This case reports the rare occurrence of myopericarditis and Crohn’s disease. Inflammatory bowel disease as a cause of myopericarditis has been reported in some cases within the literature; however, there is no definitive mechanism known.

Experience of transcatheter device closure of atrial septal defect in a tertiary care institute

Objective: To share our experience of transcatheter device closure of secundum atrial septal defect in children and adults. Methods: This descriptive cross-sectional study was conducted at department of Paediatric Cardiology Ch. Pervaiz Elahi Institute of Cardiology Multan from 2011 to September 2019. Patients with moderate to large ASD secundum without severe pulmonary hypertension were studied. All procedures were performed under general anaesthesia and trans-Oesophageal echo guidance. Success and safety of procedure were evaluated. Results: During study period, a total of 75 patients underwent ASD device closure. Mean age was 25 ± 1.53 (4 -54 years) and male to female ratio 1:2. Mean defect was 20.38 ± 0.58 (09 to 32 mm). Large defects (> 25 mm) were 17 (22.7 %). Significant PS (> 30 mm Hg) observed in three and valvuloplasty performed. Device size was selected on the basis of TOE measurement + 4-5 mm. Balloon sizing was performed in only three patients. Amplatzer septal occluder was used in 80 %. Balloon assisted technique was used in 09 (12 %) patients. All the procedures were successful except two (2.7 %) where device embolized and retrieved by surgery. Transient arrhythmias were observed in 05 (6.6 %) and small pericardial effusion which was managed conservatively in one patient. There was no procedure related mortality. Conclusion: Transcatheter closure of moderate to large ASD secundum in children and adults is a safe procedure. Among the major events, device embolizaion was common. Other complications were rare including small pericardial effusion and transient arrhythmias. Continuous...

Efficacy and safety of ethanol infusion into the vein of Marshall for mitral isthmus ablation

Introduction: Chemical ablation by retrograde infusion of ethanol into the vein of Marshall (VOM-EI) can facilitate achievement of mitral isthmus block. This study sought to describe efficacy and safety of this technique. Methods and Results: Twenty-two consecutive patients (14 male, median age 71 years) with attempted VOM-EI for mitral isthmus ablation were included in the study. VOM-EI was successfully performed with a median of 4 ml of 96% ethanol in 19 patients (86%) and mitral isthmus was successfully blocked in all (100%). Touch up endocardial and/or epicardial ablation after VOM-EI was necessary in 12 patients (63%). Perimitral flutter was present in 12 patients (63%) during VOM-EI and terminated or slowed by VOM-EI in four and three patients, respectively. Low-voltage area of the mitral isthmus region increased from 3.1 cm2 (IQR 0-7.9) before to 13.2 cm2 (IQR 8.2-15.0) after VOM-EI and correlated significantly with the volume of ethanol injected (P = 0.03). Median high-sensitive cardiac troponin-T increased significantly from 330 ng/L (IQR 221-516) the evening of the procedure to 598 ng/L (IQR 382-769; P=0.02) the following morning. A small pericardial effusion occurred in three patients (16%), mild pericarditis in one (5%) and uneventful VOM dissection in two (11%). After a median follow-up of 3.5 months (IQR 3.0-11.0), 10 of 18 patients (56%) with VOM-EI and available follow-up had arrhythmia recurrence. Repeat ablation was performed in five patients (50%) and peri-mitral flutter diagnosed in three (60%). Conclusion: VOM-EI is feasible, safe and effective to achieve acute mitral isthmus block

Safety of Transseptal Puncture for Access to the Left Atrium in Infants and Children

Transseptal puncture (TSP) is a standard procedure to obtain access to the left heart. However, data on TSP in infants and children particularly with congenital heart defects (CHD) is sparse. Safety and efficacy of TSP in infants and children < 18 years with normal cardiac anatomy and with CHD were assessed. 327 TSP were performed in a total of 300 individuals < 18 years from 10/2002 to 09/2018 in our tertiary pediatric referral center. Median age at TSP was 11.9 years (IQR 7.8–15; range: first day of life to 17.9 years). 13 subjects were < 1 year. Median body weight was 43.8 kg (IQR 26.9–60; range: 1.8–121 kg). CHD was present in 28/327 (8.6%) procedures. TSP could be successfully performed in 323/327 (98.8%) procedures and was abandoned in 4 procedures due to imminent or incurred complications. Major complications occurred in 4 patients. 3 of these 4 subjects were ≤ 1 year of age and required TSP for enlargement of a restrictive atrial septal defect in complex CHD. Two of these babies deceased within 48 h after TSP attempt. The third baby needed urgent surgery in the cath lab. Pericardial effusion requiring drainage was noted in the forth patient (> 1 year) who was discharged well later. Minor complications emerged in 5 patients. The youngest of these individuals (0.3 years, 5.8 kg) developed small pericardial effusion after anterograde ballon valvuloplasty for critical aortic stenosis. The remaining 4/5 patients developed small pericardial effusion after ablation of a left-sided accessory atrioventricular pathway (6.1–12.2 years, 15.6–34.0 kg). TSP for access to the left heart was safe and effective in children and adolescents > 1 year of age. However, TSP was a high-risk procedure in small infants with a restrictive interatrial septum with need for enlargement of interatrial communication.

Abstract 16542: Hypotension and Pericardial Effusion Associated With High Frequency Jet Ventilation

Introduction: High frequency jet ventilation (HFJV) is used to increase catheter stability and improve outcomes during pulmonary vein isolation (PVI) [1,2,4]. In studies, hemodynamic intolerance of HFJV was rare. [1,3]. Hypothesis: HFJV during PVI is well tolerated and vasopressor-resistant hypotension requiring return to conventional ventilation is rare. Methods: Retrospective observational analysis of hemodynamic, blood gas, and echocardiographic data of PVIs performed with HFJV by 2 operators (PT, JW) at our institution between February 2019 and June 2020. Results: Among 193 PVIs, 8 cases (4%) of rapid onset hypotension associated with HFJV were found (Table). In 7 of 8 cases, persistent hypotension and abnormal gas exchange required conversion to conventional ventilation and a new, small pericardial effusion without tamponade was noted just after HFJV initiation. In these cases, initiation of HFJV was associated with a decrease in systolic function. Both the hemodynamic changes and effusion resolved completely within minutes of stopping HFJV. Four of 8 patients were rechallenged with HFJV, and had recurrent hypotension and effusion which resolved immediately after return to conventional ventilation. Conclusions: HFJV-associated rapid onset hypotension, often accompanied by transient pericardial effusion, is more common than previously reported, and resolves with cessation of HFJV. The mechanism of these changes may occur via CO2 levels and warrants further study.

Graft-versus-host disease: a case report of a rare but reversible cause of constrictive pericarditis

Background Constrictive pericarditis (CP), although an uncommon cause of heart failure, requires specialist multidisciplinary input and multi-modality imaging to identify the underlying aetiology and treat potentially reversible causes. Case summary We report the case of a 74-year-old gentleman referred for assessment of progressive exertional dyspnoea and peripheral oedema, 30 months following treatment of acute myeloid leukaemia with high-dose chemotherapy and allogeneic stem cell transplantation. Clinical examination and cardiac imaging revealed a small pericardial effusion and pericardial thickening with constrictive physiology; however, no aetiology was identified despite diagnostic pericardiocentesis. The patient required recurrent hospital admissions for intravenous diuresis, therefore, following multidisciplinary discussions, surgical partial pericardectomy was performed. Histology suggested graft-vs.-host disease (GvHD) and post-operatively, the patient improved clinically. Following immunomodulatory therapy with ruxolitinib for both pericardial and pulmonary GvHD, his functional status improved further with no subsequent hospital admissions. Discussion Although pericardial disease in cancer patients is common, CP is unusual. Determining the underlying aetiology is important for subsequent management, and here, we describe the use of multi-modality imaging to diagnose a rare cause, GvHD, which responded to surgical treatment and immunomodulatory therapy.

P871 Giant left ventricular (pseudo?)aneurysm complicating anterior myocardial infarction

Introduction Clinical approach of cardiac aneurysms and pseudoaneurysms is significantly distinct. Therefore, it is crucial to accurately differentiate these two entities, which could be a real challenge. Case report We describe a case of a 55-year-old woman, with hypertension and previous smoking habits. She was admitted in our Cardiology Department with the diagnosis of anterior acute myocardial infarction, and was submitted to emergent coronariography, unveiling an occlusion of the middle segment of the anterior descending artery. She underwent successful primary percutaneous coronary intervention (PCI) 1h45 after the chest pain onset. Transthoracic echocardiogram (TTE) revealed depressed left ventricle ejection fraction (LVEF 30%), with akinesia of anterior and septal walls and all apical segments. She evolved in Killip-Kimbal class 2 and was discharged clinically stable. One week later, the patient performed a control TTE that showed an apical thrombus, with a small pericardial effusion, and she initiated warfarin. Three weeks later, a reevaluation TTE demonstrated a severe increase of the left ventricle dimensions, with LVEF 32%, and a small pericardial effusion. In apical 4-chambers incidence, it was visualized a linear structure (42 mm x 5 mm) attached to the endocardial border of the anterolateral apical segment and to the apical segment of the interventricular septum, of undefined nature. The apical segments were dyskinetic and had a very thin wall, which could correspond to aneurysm versus pseudoaneurysm. To clarify these findings, the patient performed a cardiac magnetic resonance revealing a large anterior myocardial infarction complicated with extensive myocardial necrosis, severe depression of LV systolic function (LVEF 25%) and septum rupture distal to the right ventricle apex (without connecting with it), compatible with a large apical pseudoaneurysm. The clinical case was discussed in the Heart Team and it was decided to perform cardiac surgery. However, surgical findings showed integrity of septal and free walls, and she underwent an aneurysmectomy, without further complications. Histological examination confirmed the presence of a thin myocardial wall with marked fibrosis and, consequently, the diagnosis of ventricular aneurysm. She was discharged clinically stable and maintains follow-up in Cardiology consultation of our Hospital. Conclusion In this patient, initially admitted with an anterior myocardial infarction submitted to primary PCI, follow-up with advanced imaging modalities pointed to the diagnosis of pseudoaneurysm. Despite the preoperative diagnosis, surgical findings were compatible with a giant left ventricular aneurysm. Even with high spatial resolution exams, postoperative evaluation of tissue layers remains the gold standard for this differential diagnosis. Abstract P871 Figure. Apical pseudoaneurysm vs aneurysm