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Introduction The left atrial appendage occlusion (LAAO) procedure is a therapeutic option for stroke prevention in patients with atrial fibrillation (AF) which have contraindication to oral anticoagulants or still develop embolic events despite therapeutic anticoagulation. Transesophageal echocardiography (TEE) has been the gold standard to guide this procedure, with the intracardiac echocardiography (ICE) emerging as an alternative because of the advantage of reducing the general anesthesia burden compared to TEE. Objectives This study aims to compare the safety, procedure-related parameters and outcomes between TEE-guided LAAO and ICE-guided LAAO. Methods In a tertiary center, patients who underwent TEE-guided LAAO and ICE-guided LAAO were compared retrospectively regarding technical success, procedure-related events, procedure-related parameters (fluoroscopy time, dose of radiation and contrast volume), 45 days-transthoracic echocardiography (TTE) and 1-year outcomes (mortality, stroke and major bleeding). Results 88 patients underwent LAAO between 2009 and 2020 (n=43 with TEE, n=45 with ICE). Baseline characteristics were similar. Success was achieved in 95.3% (n=41) and 95.6% (n=43) of the patients in the TEE and ICE groups, respectively (OR 0.95, p=0.96). Procedure-related complications (major vascular complications, perforation, device embolization) didn't show significant differences (14.0% vs 8.9%, OR 1.66, p=0.46) in the TEE and ICE groups, respectively. Fluoroscopy time was inferior in the TEE group (29.1±13.6 vs 44.1±17.4 minutes, p=0.001), while radiation dose (2761±1555 vs 3397±2118 mGy, p=0.113) and contrast volume (220.3±104.1 vs 204.0±100.9mL, p=0.469) showed no significant differences. 45 days-TTE showed no significant differences between the TEE and ICE groups regarding peri-device leaks (14.0% vs 24.4%, p=0.212), device thrombus (2.3% vs 0%, p=0.990) and iatrogenic atrial septal defects, all mild (4.7% vs 13.3%, p=0.174). 1-year outcomes showed no significant differences regarding stroke (9.3% vs 4.4%, p=0.186), major bleeding (9.3% vs 2.2%, p=0.78) and all-cause mortality (9.3% vs 11.1%, p=0.38) between the TEE and ICE groups, respectively. Conclusions ICE-guided LAAO is associated with similar results, procedure-related events, procedure related-parameters (fluoroscopy time being the only exception) and 1-year outcomes, compared with TEE-guided LAAO. Funding Acknowledgement Type of funding sources: None.

Background Despite the continuous developments of transcatheter aortic valve implantation (TAVI), around 15% of the patients (P) who undergo this procedure require permanent pacemaker (PM). Right ventricular pacing (RVP), particularly with a cumulative percentage of ventricular pacing (CVp) above 40%, has been associated with detrimental effects on ventricular function and an increased risk of cardiovascular events in non-TAVI patients. Aim To evaluate the long-term prognostic significance of RVP, regarding overall mortality and the combined endpoint of overall mortality/heart failure hospitalization in P requiring a PM after TAVI. Methods We retrospectively examined P who underwent TAVI with a self-expanding valve from 2009 to 2020 at our institution. All P had pre-procedural clinical evaluation, cardiac computed tomographic angiography, transthoracic echocardiography and electrocardiography performed. CVp was determined from stored PM data. P with previous PM were excluded. Post-TAVI PM implantation was defined as a device implantation during hospital stay or during the first month after discharge. Results 474P, 57% male, mean age 81.7±6.5 years with a mean left ventricular ejection fraction of 51.5±14.6% were analysed. Mean follow-up was 18.7 months. Mean STS score and mean Euroscore II were, respectively, 6.89% and 5.76%. Mean gradient was 51.67 mmHg and mean aortic valve area 0.71 cm2. After TAVI, 104P (21.9%) required PM implantation, with a mean CVp of 65.3±43.4%. Post-TAVI PM was not associated with a worse outcome - overall mortality: HR 1.13, 95% CI 0.72 – 1.78, p=0.57; combined mortality/heart failure hospitalization: HR 1.22, 95% CI 0.87 – 1.70, p=0.24. The follow-up Kaplan-Meier curves according to the need for PM post-TAVI were similar: log rank p=0.24. A CVp cut-off of 40% was not associated with any of the study endpoints - overall mortality: HR 1.72, 95% CI 0.38–7.86, p=0.48; combined mortality/heart failure hospitalization: HR 1.32, 95% CI 0.45–3.91, p=0.61. Also, a CVp cut-off of 40% did not provide an accurate risk stratification as survival free of events was similar between these P and those below this cut-off (log rank p=0.11) and in comparison, with P without PM (log rank p=0.65). Conclusions In P submitted to TAVI with a self-expanding valve, the need for PM implantation is common, but not associated with increased risk of total mortality or heart failure hospitalization during a 18 months follow-up period. A CVp cut-off of 40% showed poor discriminative ability regarding long-term events in this population. Funding Acknowledgement Type of funding sources: None.

Background Coronary sinus Reducer device (CSF) implantation is a novel therapeutic option to relieve symptoms in patients with refractory angina (RA). There is limited real-world data describing its use outside of clinical trials. Aim To assess the safety and efficacy of this procedure in a real-world setting. Methods This is a report of a single centre prospective registry of consecutive patients with RA (CCS II-IV) deemed unsuitable for revascularization. Between May 2017 and August 2019, 17 patients were referred to CSF implantation. Baseline and follow-up evaluation consisted of clinical assessment, including completion of the short version of the Seattle Angina Questionnaire (SAQ-7) and CCS class evaluation and objective evaluation by transthoracic echocardiography and cardiopulmonary exercise test (CPET). Results A total of 13 patients (70,6±6,5 years, 76,9% male) underwent CSF implantation with a procedural success of 84.6%. No cases of periprocedural serious adverse events were reported. At 12-month follow-up, any reduction in CCS Class was achieved in 72.7% of cases, with 27.2% reducing 2 CCS classes. Baseline CCS score was reduced from 2.8±0.4 to 1.7±0.8 (p=0.009). Quality of life (QoL) was significantly improved as assessed by the improvement seen in all items of SAQ-7 (p Conclusion CSF implantation in patients with RA was safe and led to a significant reduction of the angina burden and improvement of QoL at 12-month follow-up. Funding Acknowledgement Type of funding sources: None.

Funding Acknowledgements Type of funding sources: None. Introduction Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of arrhythmias and sudden cardiac death (SCD). The Late gadolinium enhancement (LGE) in cardiovascular magnetic resonance (CMR) has been associated with the occurrence of arrhythmic events. Purpose The aim was to analyze the association between LGE burden and location and arrhythmic events in HCM patients (P). Methods Retrospective analysis of P with HCM in a single tertiary center. Baseline clinical, echocardiographic and CMR characteristics were collected. On follow up arrhythmias (ventricular fibrillation (VF), sustained ventricular tachycardia (SVT), non-sustained ventricular tachycardia (NSVT), paroxysmal supraventricular tachycardia (PSVT), atrial fibrillation (AF) and atrial flutter (AFL)) were identified. LGE on CMR was compared between patients with and without arrhythmias. Results 61P (59% male) were included, with a mean age of 58 ± 2 years. The HCM risk-SCD score was 3.35 ± 0.28%. On echocardiography mean left ventricle ejection fraction was 62.16 ± 1.36% and maximum wall thickness 20.59 ± 0.596mm. 31.1% had systolic anterior movement of mitral valve and 26.7% had left ventricle outflow tract obstruction. LGE was present in 88.5% P with a median number of 5 ± 7 segments involved. Interventricular septum (IVS) was involved in 78.7% P, anterior wall in 57.4%, inferior wall in 54.1%, lateral wall in 52.5%, posterior wall in 9.8%, basal segments in 62.3%, median segments in 68.9% and apical segments in 63.9%. On follow up 3.3%P died, 45.8% had hospitalizations (22,2% because of an arrhythmia) and 75% had arrhythmias (1.6% VF, 6.6% SVT, 50% NSVT, 9.8% PSVT, 37.7% AF and 6.6% AFL). The number of segments with LGE correlated with arrhythmias (p = 0.05 for arrhythmias, p = 0.03 for SVT, p = 0.008 for NSVT and p = 0.042 for PSVT). A cut off of 5 segments involved was a good predictor of arrhythmias (p = 0.002), NSVT (p= 0.006), PSVT (p = 0.024) and AF (p = 0.0029). For SVT the best cut off was 9 (p = 0.003). Considering the LGE location, we found an association between the segments involved and the occurrence of different arrhythmias (table 1). Conclusion Supraventricular and ventricular Arrhythmias are frequent in patients with HCM, with the most frequents being NSVT and AF. The LGE burden (>5 segments) and location (median inferior IVS, median anterior IVS, median anterior wall, basal anterior IVS, apical anterior wall, median inferior wall, apical anterior wall and basal inferior IVS) were correlated with arrhythmic events. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. Introduction Percutaneous mitral valve repair has shown to prevent and even reverse adverse LV remodelling in most patients with moderate to severe mitral regurgitation (MR). This effect is, however, highly variable and may differ according to the MR etiology. Objectives The aim of the present study is to evaluate cardiac remodelling patterns and clinical outcomes after MitraClip implantation (MI) in ischemic and non-ischemic patients (P). Methods A standardized registry was prospectively performed between 2013 and 2019 for all P who underwent MitraClip insertion in a single terciary care centre. Transthoracic echocardiographic information was assessed at baseline and 1, 6, 12 and 18 months after MI. Student’s t-test was used to assess the procedure’s effect on several variables. Clinical outcomes were compared with the use of Fisher’s exact test or the chi-square test, as appropriate. Results 46 P, 61% male, mean age 65 ± 14 years. 39% had ischemic MR. Dyslipidemia was more frequent in ischemic P (52% versus 93%, p= 0.002) as well as history of smoking (32% versus 67%, p= 0.022). Atrial fibrillation was significantly associated with non-ischemic etiology (75% versus 44%, p= 0.036). MI success rate was 87% (proper placement and reduction in MR to grade 2 or less), with an average of 1.5 clips. Considering the 37 P that completed 18 months of follow-up (FU), the echocardiographic parameters at baseline were: left ventricular ejection fraction (LVEF) 36 ± 12%, LV end-diastolic dimeter (LVEDD) 68.2 ± 10.2mm, LV end-systolic diameter (LVESD) 52.2 ± 13.5mm and left atrial diameter (LAD) 53.1 ± 6.7mm; there were no significant differences between groups. After MI, a compelling difference in LVEDD was noticeable early in the first month, with significant lower dimensions in non-ischemic P (66.6 ± 11.4 versus 72.8 ± 5.4, p= 0.039). Sustained differences in LVEDD were consistent at 6, 12 and 18 months (62.4 ± 12.3 versus 73.5 ± 7.4, p= 0.025). There was also a reduction in LVESD that became apparent in the sixth month (45.5 ± 15.1 versus 55.3 ± 9.8mm, p= 0.047) and that was sustained after 18 months from MI (45.4 ± 11.7 versus 58.3± 8.9, p= 0.012). No significant differences in LVEF or LAD were noticed over time. Regarding clinical outcomes at 18 months, overall mortality (M) was 24% (9P) and 51% (19P) died or were hospitalized due to heart failure (MH). No difference was found between groups: M (p= 0.119), MH (p= 0.091). Conclusion This study reports better LV reshape effects after MI in P with non-ischemic etiology, with sustained improvement over time. However, no differences regarding mortality or hospitalization due to HF were apparent at the 18-month FU. Larger long-term studies are required to evaluate these results. Abstract Figure. LV remodelling pattern

Funding Acknowledgements Type of funding sources: None. Objective To analyze the relationship between coronary microvascular dysfunction (MCD) and left ventricular (LV) myocardial deformation in hypertrophic cardiomyopathy (HCM). Methods Prospectively inclusion of HCM patients (P). MCD was assessed by CMR, during regadenoson-induced hyperemia. For perfusion assessment, the myocardium was divided into 32 subsegments (16 AHA segments subdivided into an endocardial and epicardial layer). Ischemic burden was calculated as the number of involved subsegments, assigning 3% of myocardium to each subsegment. Epicardial coronary artery disease was excluded by computed tomography or invasive coronary angiography. LV myocardial deformation was evaluated by 2D and 3D speckle-tracking echocardiography (STE), including global longitudinal strain (GLS), peak systolic dispersion (PDS), global circumferential strain (GCS), global radial strain (GRS), area strain, twist and torsion. Results 31 P enrolled (51%male,age57.8 ± 15.5years). Asymmetric septal hypertrophy was seen in 55%, apical in 29%, concentric in 16%,maximal wall thickness (MWT) of 20.5 ± 4.9mm; 26% with LVOT obstruction; LV ejection fraction 67.9 ± 7.9%. In 2DSTE analysis, P with more ischemia (>20%of LV) presented more severe impaired GLS and greater PDS, comparing with patients with ≤20% of ischemia. Similarly, 3DSTE imaging showed worse LV performance in P with greater ischemic burden, expressed by significant difference in GLS, GRS and area strain. GCS also trended to be worse in the presence of >20% of ischemia. The stronger correlation was found between 2D GLS and ischemic burden (Pearson correlation factor 0.545; p = 0.002). Conclusion In HCM, the severity of ischemia secondary to MCD was associated with impairment in LV myocardial deformation evaluated by 2D and 3D STE. Table 1. Echocardiography Ischemic burden (% of LV) 2D parameters ≤ 20% (n = 15) > 20% (n = 16) p-value GLS (%) -15.6 ± 2.7 -12.1 ± 4.7 0.016 PSD (ms) 73.2 ± 25.6 102.1 ± 57.6 0.150 3D parameters GLS (%) -10.3 ± 4.5 -7.3 ± 3.0 0.010 GCS (%) -12.6 ± 3.0 -10.1 ± 4.5 0.079 GRS (%) 30.8 ± 8.5 22.8 ± 11.4 0.035 Area strain(%) -20.8 ± 4.9 -15.8 ± 6.3 0.020 Twist (deg) 6.0 ± 4.8 4.1 ± 4.0 0.175 Torsion (deg/cm) 1.2 ± 0.9 0.8 ± 0.7 0.232

Aims Late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) adds prognostic information in patients with hypertrophic cardiomyopathy (HCM). Whether Myocardial work (MW), a new parameter on transthoracic echocardiographic (TTE), can predict significant fibrosis in HCM patients is unknown. Methods Single-centre evaluation of consecutively recruited HCM patients in which TTE and CMR were performed. MW and related indices were calculated from global longitudinal strain (GLS) and from estimated left ventricular pressure curves. The extent of LGE was quantitatively assessed. LGE ≥15% was chosen to define significant fibrosis. Logistic regression analysis was used to find the variables associated with LGE ≥15% and cut-off values were determined. Results Among the thirty-two patients analysed mean age was 57±16 years, 18 (56%) were male patients and the mean left ventricular ejection fraction by TTE was 67±8%. Global constructive work (GCW), global work index and GLS were significant predictors of LGE ≥15%. A cut-off ≤1550 mmHg% of GCW was able to predict significant fibrosis with a sensitivity of 92% and a specificity of 79%, while the best cut-off for GLS (>−15%) had a sensitivity of 86% and a specificity of 72%. Conclusion GCW was the best parameter to predict significant left ventricular myocardial fibrosis in CMR, suggesting its utility in patients who may not be able to have a CMR study. Myocardial Work and LGE in CMR in HCM Funding Acknowledgement Type of funding source: None

Background Percutaneous Patent Foramen Ovale (pPFO) closure benefits for secondary prevention after cardio-embolic stroke have recently been proved. With the increasing number of cases and procedures, a concern with new onset atrial fibrillation (NOAF) has been raised. Purpose To evaluate long-term outcome regarding NOAF rate and to identify its predictors and clinical impact, in a real population submitted to pPFO closure. Methods From 2000 to 2017, consecutive patients (P) submitted to pPFO closure in a tertiary centre were prospectively enrolled. The primary endpoint was NOAF rate and secondary endpoints were all-cause, neurologic and cardiac mortality rates and recurrent ischemic events. Previous and follow-up electrocardiographic, echocardiographic and 24-hour heart rhythm monitoring data were analysed. Follow-up was performed through medical visits, medical charts consultation and a phone call based system, in order to assess clinical status, on-going treatment and events. Results 496 patients were submitted to pPFO. Immediate success was achieved in 98.8% and 9.1% presented a residual shunt on the 1st year TEE. Mean age was 45.0±11.2 years-old with 50.2% of males. The prevalence of hypertension, hypercholesterolemia and atrial septum aneurysm (ASA) was 25.7%, 45.0% and 46.3%, respectively. Pre-procedural mean left atrial (LA) diameter was 36.0±5.3 mm. FU data was available for 490 (98.6%), for a mean FU time of 7.41±3.51 years. 34 P (6.9%) presented ischemic events recurrence (26 strokes and 8 TIA). The primary endpoint was observed in 21 P (4.3%) during the FU period. Median time to 1st AF episode since PFO closure was 5.90±5.53 years. 11 P (52.3%) initiated oral anticoagulation. In univariate analysis, age (44.6±11.3 vs 51.8±6.0 years, p=0.005) and hypertension (24.7% vs 47.6%, p=0.019) were predictors of NOAF in this population. In multivariated analysis, only age remained a predictor of NOAF (OR 1.05 (1.007–1.101), p=0.025). LA pre pPFO closure dimensions, ASA, device type or size and the presence of residual shunt in TEE were not determinants of AF occurrence. The incidence of NOAF was associated with the need for hospitalization due to cardiac causes (19% vs 3.2%, p=0.001) and a trend towards higher rate of recurrent stroke (4.9% vs 14.3%, p=0.06). Conclusion Despite being a highly successful and safe procedure in most patients, pPFO closure was associated with a non-negligenciable rate of NOAF during long-term follow-up. NOAF predictors were related with classical cardiovascular risk factors, such as age and hypertension. None of the procedure or device features were associated with NOAF. Yet, a clinical impact was attributed to NOAF, with more hospitalizations and a trend towards ischemic events recurrence. As young patients submitted to pPFO closure grow older, prevention strategies to diagnose and treat NOAF should be endeavoured. Funding Acknowledgement Type of funding source: None

Background Mitral regurgitation (MR) is a marker of bad prognosis in heart failure (HF) patients (pts). Mitraclip implantation (MI) leads to a clinical improvement. Purpose To characterize the adult population submitted to MI and evaluate its mid-term results. Methods Prospective analysis of 40 pts with moderate to severe MR (grades III-IV) submitted to MI between 2013 and 2018. Paired sample t-test to assess the procedure’s effect on several variables. P-values Results 40pts, 60% male, with a mean age of 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months (M), of which 67.5% presented with grade IV MR (mean regurgitant volume - 43.5 ± 29 ml; mean EROA - 34.8 ± 13 mm2 ) and 75% with functional MR. Mean LVEF of 35%±10.3, with 55% presenting a LVEF Conclusion MI is a safe procedure with a low rate of periprocedural complications. It’s associated with a functional class improvement and a significant reverse left ventricular remodeling.

Introduction Primary cardiac tumors are rare entities and 75% are benign. Angiosarcoma is the most common malignant primary cardiac tumor. We report the case of cardiac angiosarcoma presenting with an atrial arrhythmia. Clinical case A 39-year-old female patient with no past medical history presented to the emergency department with heart palpitations and atypical chest pain. Electrocardiogram on admission showed atrial flutter with a heart rate of 153 beats per minute. Laboratory analysis were performed showing elevated D-dimer levels (2210 ug/L). A thoracic CT scan was performed, which ruled out pulmonary embolism, but showed multiple pulmonary nodules and a right atrial (RA) mass measuring 48 mm that could correspond to a thrombus or neoplasia. The patient was admitted in the Cardiology ICU of our hospital and was started on beta-blocker and amiodarone with conversion to sinus rhythm. Additional exams were performed: - Transthoracic echocardiogram (TTE) revealed an heterogenous 32,6 x 17,7 mm mass in the lateral wall of the RA with an adherent mobile mass near the tricuspid valve with 28 mm diameter (possible adherent thrombus). - Cardiac magnetic resonance imaging confirmed a RA tumor with invasion of the atrial free wall and compression of the superior vena cava. Due to the unclear etiology of the RA mass, ultrasound-guided intracardiac biopsy was performed. Pathological examination revealed spindle cell proliferation, consistent with the diagnosis of angiosarcoma. Immunohistochemical staining was positive for Vimentin, CD34 and CD31, with 70% Ki67 expression. Later on, the patient developed melena with significant drop of hemoglobin levels, requiring daily red blood cell transfusions and anticoagulation had to be stopped. The patient was transferred to the Internal Medicine ward and thoracic-abdomen-pelvis staging computed tomography (CT) scan showed a significant increase in the number of pulmonary nodules, bilateral ovarian masses, 4 hepatic nodules and ileum metastization. During hospitalization, the patient developed right leg deep venous thrombosis and thoracic CT scan revealed bilateral pulmonary embolism. After improvement of the clinical status, palliative chemotherapy was started and the patient was discharged, maintaining regular outpatient follow-up in the Oncology Department for 1 month. Cardiac angiosarcoma generally presents in a late stage of the disease with metastatic involvement. When surgical treatment is not possible, despite agressive chemotherapy, the prognosis remains poor. Abstract P229 Figure. Echocardiogram: right atrium mass

Introduction Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome and is now being identified more frequently, in part because of increased awareness. Case report We present the case of a 63-year-old female, without cardiovascular risk factors or relevant past medical history. She complained of atypical chest pain in the last year. The patient was admitted due to acute chest pain at rest, hemodynamically stable, with unremarkable physical examination, including absence of heart failure signs. The EKG revealed a dynamic ST depression in leads V4-V6. The peak of high sensitivity troponin I was 13744pg/mL (ULN< 15.6) and CK 874U/l (ULN Discussion and conclusion The recognition of spontaneous coronary artery dissection is essential to the correct management of these cases because, unlike acute coronary syndrome due to atherosclerotic disease, the results of revascularization in these patients are suboptimal and conservative management is probably the best option. Abstract P715 Figure. angio-CT

Introduction Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR. Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms. Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic. Conclusion Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.

Background Coronary microvascular dysfunction has been described as an important pathophysiologic feature in hypertrophic cardiomyopathy (HCM). Objective To analyse the impact of coronary microcirculatory dysfunction on left ventricular (LV) deformation parameters obtained by 4D echocardiography in HCM. Methods HCM patients (P) prospectively underwent dedicated transthoracic echocardiogram for microcirculation study. The evaluation of coronary flow velocity reserve (CFVR) was performed in apical three chambers view for the left anterior descending (LAD) artery and in an apical two chambers view for the posterior descending (PD) artery. Diastolic coronary flow velocity (CFV) was measured at basal conditions and during hyperaemia, induced with adenosine perfusion (0.14 mg/kg/min intravenously, during 2 minutes). Absolute CFVR was calculated as the ratio of hyperaemic to basal peak diastolic flow velocities. By 4D TTE (GE E95 equipment) LV global longitudinal strain (GLS), global circumferential stain, global radial strain, area strain, twist and torsion were analysed. Results 23 P were enrolled (57% male, mean age 57.9 ± 13.7 years). Asymmetric septal hypertrophy was verified in 70% of patients, with maximal wall thickness of 21.6 ± 4.3mm. Obstructive HCM was documented in 35% of patients. CFV was successfully measured in the LAD in all patients, but only in 70% of patients in the PD due to technical issues related to poor acoustic window and anatomical constraints. 78% of P (n = 18) presented CFVR At baseline conditions, 4D GLS < -8% was associated with lower LAD flow (34.3 ± 8.3 vs 42.7 ± 9.7cm/s; p = 0.037), trend to lower PD flow (35.3 ± 17.8 vs 49.9 ±18.4 cm/s; p = 0.066). 4D GLS < -8% P presented higher CFVR PD (2.0 ± 0.8 vs 1.1 ± 0.2; p = 0.009), with no significant difference in CFVR LAD. Global circumferential stain 4deg presented higher CFV PD at baseline (49.6 ± 16.5 vs 33,8 ± 12.9 cm/s; p = 0.039) and during hyperemia (68.0 ± 12.2 vs 52.9 ± 12.1cm/s; p = 0.032). Conclusion HCM P with greater impairment in LV deformation parameters by 4D echocardiography presented increased basal diastolic CFV, which can be explained by increased coronary vascular resistance and a higher oxygen demand at baseline conditions. Worse LV performance was also associated with decreased CFVR, mainly in PD.

Background Mitraclip implantation (MI) is a well-established option for patients (P) with severe mitral regurgitation (MR) noneligible to surgery. Its impact on long term prognosis is being addressed by several recent studies. Purpose To identify predictors of morbidity and mortality in P undergoing MI and evaluate if the COAPT, Everest and MITRAFR exclusion criteria (EC) had any impact on the outcome of our population. Methods prospective study of P who underwent MI between 2013 and 2018 in one medical center. EC: COAPT: LVEF 70mm or pulmonary artery systolic pressure > 70mmHg; Everest: LVEF 55mm; MITRA-FR: LVEF 40% or primary MR. An univariate analysis was performed followed by a multivariate Cox analysis to evaluate overall mortality (M), overall mortality/ heart failure hospitalization (MH) and mortality in the first year post-MI(M1). Survival analysis using Kaplan-Meier plots. p Results 40P, 60% male, mean age 66 ± 12 years (Y) and mean follow-up time of 18 ± 15 months. 67.5% presented with MR grade IV and 75% had functional MR. Successful implantation in 97.5%, with 55% presenting mild MR post-procedure. Overall mortality was 30% (12P), mostly due to cardiovascular causes, with 9P dying in the first year (30%). There was no difference between pts with functional and primary MR: M- 33%vs20% (p = 0.6); MH– 53.3%vs30% (p = 0.5). P who met the COAPT exclusion criteria (N-22) presented an inferior 1Ysurvival (64.5%vs86.7%, p = 0.046). The overall outcome was comparable between P who matched and didn"t match Everest and MITRA-FR exclusion criteria. Basal BNP value (p = 0.037), mean preprocedural MAGGIC score (p = 0.040) and EROA (p = 0.039) were associated to M1. Multivariate Cox analysis revealed that basal BNP was an independent predictor of M (p = 0.017), whereas a higher distance in the pre-procedural 6 minute walk test (p = 0.008) and the "reduction in the MR severity and PASP" (p = 0.008) presented a protective effect. LVESD > 55mm was an independent predictor of MH (p = 0.017), but MR of grade 2 or less after procedure was protective (p = 0.006). Conclusion There was no M difference between P with functional and primary MR. P with COAPT exclusion criteria had worse 1Ysurvival. A higher distance in 6MWT and a reduction in MR severity and PASP were protective. An LVESD > 55 mm had a worse prognosis. Careful P selection may be crucial to improve MI"s results Abstract P198 Figure. Kaplan-Meier Plots

Rendu-Osler-Weber (ROW) syndrome or hereditary hemorrhagic telangiectasia is a rare autossomic dominant disease characterized by vascular dysplasia involving multiple systems and associated with an increased bleeding risk. The presence of atrial fibrillation in this population becomes a challenge, regarding the evaluation of bleeding and thrombotic risks and the best approach for the patient management. A 72 years-old female with ROW syndrome, atrial fibrillation and a CHA2DS2-VASc risk score of four, was admitted to our hospital for left atrial appendage (LAA) closure after a period of novel oral anticoagulation crowed with multiple haemorrhagic events and blood transfusions. After the implantation of a Watchman LAA number 33 closure device (Image 1A), and because of the concomitant diagnose of chronic pulmonary embolism, she was restarted on anticoagulation therapy in lower doses, with initial tolerance. For evaluation of LAA closure device during follow-up, after an unsuccessful attempt of transoesophageal echocardiography (TEE) because of severe epistaxis subsequent to oropharyngeal anaesthesia, the patient underwent a Cardiac Computed Tomography (CT) that showed a moderate peri-device leak (4.4x11mm, 0.73cm2) – (Image 1B). For better characterization, the patient underwent a new attempt of TEE with the support of an anaesthesiologist and the need of local vasoconstrictor agents and tranexamic acid for epistaxis and oropharyngeal bleeding control. TEE confirmed a moderate posterior device-leak (7.1mm) with absence of cavitary thrombus (Image 1C). After a year of anticoagulation with new significant bleeding events, TEE was repeated with the anaesthetic and pharmacologic preparation. This TEE showed a decrease in peri-device leak ( Abstract P182 Figure. Image 1

Mesenchymal/stromal stem cells (MSC) have unique properties favorable to their future use in clinical practice and have been studied for cardiac repair. MSC are larger than coronary microvessels and there is controversy about the risk of embolization and microinfarctions, which could compromise the intracoronary route for their delivery. The index of microcirculatory resistance (IMR) is an invasive method for quantitatively assessing the coronary microcirculation status and could be applied for evaluation of the acute effects of MSC intracoronary infusion providing new insights for this open question. Our purpose was to examine heart microcirculation effects after MSC intracoronary injection with IMR. Methods and Results: Eighteen healthy swine were randomized to receive 30 x 106 MSC or saline by intracoronary infusion. In the heart catheterization laboratory hemodynamic, electrocardiographic and coronary flow parameters were monitored and there were no differences between groups. Thermodilution-derived coronary flow reserve (CFR) and IMR were assessed at baseline, 5 and 30 minutes post-delivery using a coronary pressure wire. CFR had a small although not significant decrease in animals receiving MSC. After cell infusion, IMR increased at 5 and 30 minutes with a significant difference from the control group at 30 minutes (Table). Conclusion: Intracoronary delivery of MSC is possible without a significant negative impact on hemodynamic parameters, electrical stability and epicardial coronary flow status. However, this study provides definitive evidence of microcirculatory disruption upon intracoronary administration of MSC, in a large animal model closely resembling human cardiac physiology, function and anatomy. | | CONTROL | MSC | p | || | Baseline CFR | 3.8 ± 1 | 4 ± 2 | 0.7 | | Baseline IMR (U) | 8.1 ± 1 | 6.7 ± 0.6 | 0.3 | | Post-delivery CFR - 5 min. | 3.6 ± 1 | 3 ± 2 | 0.5 | | Post-delivery CFR - 30 min. | 3.8 ± 2 | 2.3 ± 1.5 | 0.064 | | Post-delivery IMR - 5 min. (U) | 9.8 ± 1 | 15.3 ± 2.8 | 0.08 | | Post-delivery IMR - 30 min. (U) | 8.8 ± 1 | 13.2 ± 1.8 | 0.02 | * Coronary flow reserve (CFR), index of microcirculatory resistance (IMR) CFR and IMR mean values

Introduction: Recent guidelines for antithrombotic strategy in patients with atrial fibrillation (AF) and acute coronary syndrome (ACS) were recently published. Purpose: To evaluate the impact of antithrombotic strategy in real-world AF patients with ACS, in the occurrence of adverse events at one-year follow-up (all-cause mortality, bleeding and thrombotic events). Methods: Analysis of consecutive patients admitted with ACS included in a single centre registry. We identified patients with AF. Patients were divided into 4 groups according to antithrombotic therapy strategy: group 1 - oral anticoagulation and dual antiplatelet therapy, Group 2 - dual antiplatelet therapy; group 3: oral anticoagulation and single antiplatelet therapy; group 4: single antiplatelet therapy. Baseline patients characteristics of the 4 groups were compared and Kaplan-Meier curves were performed to analysis the occurrence of events over a one-year follow-up. Results: We analysed 2216 patients with ACS, between 2005 and 2011, of which 140 had AF (mean age 72.7±10.6 years, 60.7% male). The in-hospital mortality was 5.8% (5.4% vs 12.1% in patients with AF, p = 0.002). In AF patients coronary angioplasty was performed in 54% patients, 38.2% with drug-eluting stent and 55.3% with bare-metal stent. The proportion of patients enrolled in groups 1, 2, 3 and 4 was 17%, 56%, 13% and 14%, respectively. Mortality was 28.6%, and there were 7.1% of haemorrhagic complications and 17.1% of thrombotic events, during one-year follow-up. There were no significant differences in baseline patient characteristics or in risk scores (GRACE, CRUSADE, CHADS2 and HAS-BLED). In groups 1 and 2 the presence of ST elevation myocardial infarction and stent implantation were more frequent. In-hospital mortality was significantly higher in group 2 (p = 0.021), with no significant differences regarding mortality, thromboembolic and haemorrhagic complications, over a period of one year. Although there was no statistical difference in outcome of groups over time (log-rank, p = 0.474), group 1 showed a trend toward lower mortality. Conclusions: Patients with AF have a substantially higher mortality compared to the global populations of ACS. Antithrombotic therapy strategy had no significant influence on the occurrence of adverse events during one-year follow-up. However, a study in a larger population is needed to confirm these results.

Objective: This study sought to assess long term incidence, timing and prognostic of stent thrombosis (ST) after drug-eluting stent (DES) or bare-metal stent (BMS) implantation in patients undergoing primary percutaneous coronary intervention (PPCI). Background: Although DES remarkably reduced the incidence of stent-restenosis and the need for target lesion revascularization (TLR) compared to BMS, its widespread use has raised concerns regarding the occurrence of very late ST (>1 year). The incidence and timing of ST remain unsettled, with consequent uncertainty about risk stratification and long-term recommendations for antiplatelet medications. Methods: From 2001 to 2007 consecutive patients undergoing PPCI single tertiary-care center were included and prospectively followed up for at least 5 years. We analyzed ST occurrence as defined by the Academic Research Consortium (ARC) and also assessed the cumulative incidence of major adverse cardiac events (MACE) defined as death, reinfarction or TLR at 5-year follow up. Results: There were 1156 STEMI patients undergoing PPCI in study period. Patients not receiving a stent (92, 7.9%) were excluded from the analysis. Forty patients (3.8%) were lost to follow up. Mean follow up time was 64.3 months. DES was used in 417 (39.2%). Patients receiving DES were more likely to be younger (61±10 vs 69±11, p=0.03) and have single vessel disease (56 vs 48%, p= 0.02). No other baseline characteristics were found to differ between the 2 groups (Diabetes 18.3%, Severe LV dysfunction 10.2%). Five-year definite ST was found in 6 patients (1.44%) in the DES group and in 4 (0.75%) in BMS group. Considering definite or probable ST the total events number raised to 11 (2.6%) in the DES group and to 22 (4.1%) in BMS group. There was also no difference in the timing of ST (very late ST for BMS 1.1% vs 1.4% for DES, p=ns). Interestingly, ST was associated with an increase in 5-year MACE as compared to pts with reinfarction not due to ST (33 vs 19.8%, p=ns). This was not driven by a mortality difference. Conclusion: Stent thrombosis is an infrequent event (3,38%) after PPCI at 5-year follow up. DES use in this setting was not associated with an increases risk of ST. Although ST is linked with dismal prognosis, this does not seem to be worse than a reinfartion unrelated to ST.