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Background and aim of the study There is a rising interest in cardio-oncology as an holistic approach to oncological patients with established cardiovascular comorbidities or at increased cardiovascular risk. Symptoms of potential cardiovascular significance are a common cause of cardiologic consultation in patients with active cancer. Moving from this perspective, we analyzed the proportion of cardiovascular conditions underpinning potentially cardiologic presenting symptoms in a cohort of patients with active malignancy referred to the Emergency Department (ER) of a tertiary oncological centre. Methods and Results The study included 250 consecutive patients (median age 69 years [IQR 59.7-77.4], 50% female) presenting to the oncologic ER from September 1st 2021 to May 31st 2022. The most common presenting symptoms were fever (26.9%), gastrointestinal symptoms (24.9%), dyspnea (10.4%), hypotension and hypertension (1.6%), syncope (1.2%) and other (11.2%). We considered as symptoms of potential cardiologic significance the following: dyspnea, lipothymia and syncope, palpitations, fever, chest pain, hypotension and hypertension. We found that 101 of 250 patients (40%) presented with symptoms of potential cardiologic significance. Out of them, 14 patients (13.9%) had confirmed cardiologic diseases: pulmonary embolism (21.4%), heart failure (21.4%), pericardial effusion (21.4%), reflex syncope (14.2%), pericarditis (14.2%) and new onset atrial fibrillation (7.1%). As reported in the table, no significant difference was reported in terms of risk profile or history of cardiac diseases when comparing patients with and without cardiovascular cause of presenting symptoms (CV cause vs non-CV cause). Conclusions Cardiovascular conditions are not common causes of ER presentation among oncologic patients with active cancer. Nevertheless, when a cardiologic condition is diagnosed, it could be potentially life-threatening. The cardiovascular risk profile and the history of cardiac disease is not a good discriminator to identify a cardiac cause of presenting symptoms in this specific setting. Table. Characteristics of patients with potentially cardiologic presenting symptoms.

A 85-year-old lady with severe dyspnea presented in emergency dept. of our institution in Reggio Emilia last July. Typical signs and symptoms of heart failure were associated with high voltage at ECG and echocardiographic findings show a reduced EF (40%) with trans-aortic mean gradient of 42 mmHg, aortic valvular area of 0.8 cm2 and moderate aortic regurgitation. At CT scan analysis, a dismorphic quadricuspid aortic valve (QAV) was detected. This is a rare congenital heart disease generally unrelated to other cardiac abnormalities and usually diagnosed incidentally. Due to QAV stenosis rarity, many considerations in Trans Aortic Valve Implantation (TAVI) in QAV are unclear. Some individuals with QAV develop aortic regurgitation and rarely other cardiovascular complications such as aortic aneurysm. Because of its infrequency, it is difficult to characterize these patients and standardize their management. Tailored therapy is more than ever necessary. Our patient also had bicameral pacemaker for grade II Mobitz 2 atrioventricular blockage. At coronarography angiography mild atheromasia was detected; AngioCT reconstructions in figure 1 panel A and B show the presence of QAV. Severe wall atheromasia along the entire course of the aorta was also detected. A few days later the patient underwent the TAVI procedure. A coronary guidewire was positioned in right coronary artery in order to protect its ostium that was slightly lower and, as known from literature, QAV has a longer leaflet height and a shallower cusp depth. After implantation of a Balloon Expandable Valve, a chimney stenting was also performed. An excellent final result was achieved with a safe deployment and a 90/10 final position (last aortography frame in Figure 2, where both coronary arteries are well visible). Post-procedural echo follow-up showed a well functioning aortic prosthesis (with mean gradient of 9 mmHg). The case presented is particularly interesting mainly for three reasons: Extreme rarity of this condition that can be challenging especially in the elderly people with calcific valve affected by stenosis and regurgitation;Paucity of procedural data in literature on QAV;It is a real life management example with subsequent successful implantation of the BEV and chimney stenting in QAV

Eosinophilic myocarditis is an inflammatory disease of the heart, even if rare, it could be a life-threatening condition, characterized by eosinophils infiltration of the myocardial tissue. First report of this type of endocarditis was reported by Löffler in 1935 and was described as an eosinophilic filling of endocardial cells with consequent myocardial fibrosis. Etiologically, viral infections are the prominent cause of myocarditis, especially the Coxsackie-B virus, drugs such as sumatriptan and canine Toxoplasma infections have been associated with eosinophilic myocarditis. Eosinophilia indeed (increase in eosinophils count in blood sample) has a similar etiology to eosinophilic myocarditis. However, as known from the literature, the relationship between myocardial damage and eosinophilia can have multiple etiologies, from hypersensitivity to autoimmune diseases but also malignancies. Clinically, its signs and symptoms present a wide spectrum of manifestations such as chest pain, dyspnea, rhythm disturbances, until sudden cardiac death. Diagnostic gold standard is endomyocardial biopsy, but cardiac magnetic resonance is a valid option in such scenarios following Lewis Lake criteria and suggestive laboratory results. We present the case of a 78-year-old lady, affected by arterial hypertension and dyslipidemia. Among her main comorbidities she complained late-onset asthma and hypothyroidism. The patient went to the emergency department of our hospital for onset of dyspnea associated with chest pain. An echocardiogram showed a dilated and diffusely hypokinetic left ventricle, severely reduced systolic function (EF 30%) and atrial fibrillation with high ventricular response. The patient presented with acute pulmonary edema and oliguria, for which non-invasive ventilation, diuretics therapy and inotropic therapy were needed. Invasive coronary angiography was negative, excluding any kind of coronary syndrome. HS-troponin peak detected was very high (73.170 ng/L). CMR was performed that showed images indicative of myocarditis (as shown in the picture A and B) with typical distribution of late gadolinium enhancement and reduced left ventricular function: The finding of hypereosinophilia was highly suspicious, so the endomyocardial biopsy performed confirmed the histotype of eosinophilic myocarditis. Hypereosinophilic myeloproliferative syndrome was ruled out after genetic testing. Therefore, a final diagnosis of eosinophilic granulomatosis with ANCA-negative polyangiotis with predominantly hematologic (peripheral hypereosinophilia), cardiac (multifocal myocarditis with inflammatory infiltrate with predominantly eosinophilic component), pulmonary (late-onset asthma) and peripheral neurologic (sciatic mononeuropathy) involvement was made. The patient underwent corticosteroid therapy, to which mepolizumab and cyclophosphamide were added. This case enlightens the rarity of this pathology, enhancing the appropriate indication of CMR in complex settings. We also remark the importance of close team collaboration with rheumatologists and CMR-expert radiologists for the resolution of the case and its proper therapeutic management.