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Improved cancer survivorship has led to an increase in cardiovascular (CV) complications in the oncologic population, mainly associated with therapeutic regimens. Hence, cardio-oncology has grown toward unifying the cancer care process in which the best prevention, early detection, treatment, and CV surveillance are offered to patients. This multidisciplinary approach allows us to optimize and agree upon clinical decisions to enhance clinical outcomes. Atrial fibrillation is one of the hot topics in the field because it is still challenging in cancer patients. The optimal antithrombotic therapy remains unclear. Nevertheless, evidence supports that specific recommendations are needed due to a hemorrhagic/thrombotic disbalance present within this subgroup of patients and a low rate of anticoagulation treatments compared with the general population. Further, cardiotoxicity management is currently transforming. Increasingly, early detection of subclinical alterations is raising awareness. When medical therapy is initiated early, fewer patients progress to ventricular dysfunction and the rate of patients completing cancer therapy gradually increases. New approaches are demonstrating better outcomes and these strategies will expectedly be established in clinical practice. Cardio-oncology enables us to find the best balance between cancer treatment and CV health protection. Nowadays, more and more physicians are being instructed in this discipline, which gradually exhibits a greater presence in conferences and scientific journals. However, given the need for physicians thoroughly trained in cardio-oncology, this subspecialty must be promoted further.

Introduction and objectives Despite advances in treatment, patients with acute myocardial infarction (AMI) still exhibit unfavorable short- and long-term prognoses. In addition, there is scant evidence about the clinical outcomes of patients with AMI and coronavirus disease 2019 (COVID-19). The objective of this study was to describe the clinical presentation, complications, and risk factors for mortality in patients admitted for AMI during the COVID-19 pandemic. Methods This prospective, multicenter, cohort study included all consecutive patients with AMI who underwent coronary angiography in a 30-day period corresponding chronologically with the COVID-19 outbreak (March 15 to April 15, 2020). Clinical presentations and outcomes were compared between COVID-19 and non-COVID-19 patients. The effect of COVID-19 on mortality was assessed by propensity score matching and with a multivariate logistic regression model. Results In total, 187 patients were admitted for AMI, 111 with ST-segment elevation AMI and 76 with non-ST-segment elevation AMI. Of these, 32 (17%) were diagnosed with COVID-19. GRACE score, Killip-Kimball classification, and several inflammatory markers were significantly higher in COVID-19-positive patients. Total and cardiovascular mortality were also significantly higher in COVID-19-positive patients (25% vs 3.8% [P 140 (OR, 23.45; 95%CI, 2.52–62.51; P = .005) and COVID-19 (OR, 6.61; 95%CI, 1.82-24.43; P = .02) were independent predictors of in-hospital death. Conclusions During this pandemic, a high GRACE score and COVID-19 were independent risk factors associated with higher in-hospital mortality.

Aortic intramural hematoma (AIH) is an entity within the acute aortic syndrome. Combination of a priori probability, clinical history, laboratory blood test and imaging techniques are the basis for diagnosis of AIH. This review is focused on all aspects related to diagnosis of patients with AIH, from clinical to imaging and analytical.

Objective Balance between embolic and bleeding risk is challenging among patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer. Methods and results The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1,237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years. Both groups were similar in age, embolic risk and bleeding risk. Lack of guidelines-recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04–2.35]), whereas bleeding rates remained similar (1.25 [0.95–1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42–1.99]) or severe bleedings (1.53 [0.93–2.53]). Conclusions Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.

We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti-cancer therapies. This includes an increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways. We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti-cancer therapies. The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients. We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio-oncology. This article is protected by copyright. All rights reserved.

Introduction: Limited data are available regarding the evaluation of right ventricular (RV) performance in patients with aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI). Objective: To evaluate the prevalence of RV dysfunction in patients with severe AS undergoing TAVI and long-term changes. Methods: Consecutive patients with severe AS undergoing TAVI from January 2016 to July 2017 were included. RV anatomical and functional parameters were analyzed: RV diameters, fractional area change, tricuspid annular plane systolic excursion (TAPSE), S-wave tissue Doppler of the tricuspid annulus (RV-S'TDI), global longitudinal strain (RV-GLS), and free wall strain (RV-FWS). Preprocedure and 1-year echo were analyzed. Results: Final population included 114 patients, mean age 83.63 ± 6.31 years, and 38.2% women. The prevalence of abnormal RV function was high, variable depending on the parameter that we analyzed, and it showed a significant reduction 1 year after TAVI implantation: 13.9% vs 6.8% (TAPSE [20]), P =.049; and 48.7% vs 28.9% (RV-FWS > [20]), P =.03. Significant differences were noted between patients with low-flow (LF) vs normal-flow (NF) AS in RV dysfunction prevalence as well as in RV function recovery which is less evident in LF compared with NF patients. Conclusions: RV dysfunction is high among symptomatic AS patients undergoing TAVI, with variable prevalence depending on the echocardiographic parameter used.

Background: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to a paradigm shift in healthcare worldwide. Little is known about the impact on the cardiovascular system, and the incidence and consequences of new onset of atrial fibrillation (AF) in infected patients remain unclear. The aim of this study was to analyze the cardiovascular outcomes of patients with newonset AF and coronavirus disease 2019 (COVID-19) infection. Methods: This observational study analyzed a sample of 160 consecutive patients hospitalized due to COVID-19. A group with new-onset AF (n = 12) was compared with a control group (total: n = 148, sinus rhythm: n = 118, previous AF: n = 30). New-onset AF patients were significantly older and hypertensive, as well as presenting more frequently with a history of acute coronary syndrome and renal dysfunction. This group showed a higher incidence of thromboembolic events (41.7% vs. 4.1%; p < 0.001), bleeding (33.3% vs. 4.7%, p = 0.005), a combined endpoint of thrombosis and death (58.3% vs. 19.6%, p = 0.006) and longer hospital stays (16.4 vs. 8.6 days, p < 0.001), with no differences in all-cause mortality. Results: In multivariate analysis, adjusted by potential confounding factors, new-onset AF demonstrated a 14.26 odds ratio for thromboembolism (95% confidence interval 2.86–71.10, p < 0.001). Conclusions: New-onset AF in COVID-19 patients presumably has a notable impact on prognosis. The appearance of new-onset AF is related to worse cardiovascular outcomes, considering it as an independent predictor of embolic events. Further studies are needed to identify patients with COVID-19 at high risk of developing “de novo” AF, provide early anticoagulation and minimize the embolic risk of both entities.

Many patients with recurrent/metastatic squamous cell cancer of the head and neck (SCCHN) are old or fragile and, despite deserving rapid and deep responses due to symptoms or a high tumor burden, they are not candidates for the current standard in the first-line setting of pembrolizumab plus platinum-5-FU. Other chemoimmunotherapy combinations substituting the 5-FU infusion by a taxane, may allow for less toxic effects without the need for a central venous catheter placement while maintaining efficacy. We present the case of an oral cavity cancer progressing with bulky disease to first-line cetuximab-paclitaxel in a frail and malnourished patient, where second-line treatment with pembrolizumab and reduced-dose 3-weekly carboplatin-paclitaxel achieved a deep and durable response. This is, to our knowledge, the first reported case of such combination being used in the R/M setting of SCCHN. Clinical trials should try to investigate the feasibility of this potentially less toxic and convenient combination in patients with SCCHN.

This was the case of a 61-year-old woman with a medical history significant for hypertension and rheumatoid arthritis treated with chloroquine for the last 10 years. She was admitted to our hospital for heart failure symptoms. Echocardiography revealed severe concentric left ventricular hypertrophy. Serum and urine immunofixation electrophoresis and serum light chain assay were negative. No late gadolinium enhancement was observed on cardiovascular magnetic resonance. 99mTc-99mTc-DPD (3,3-diphosphono-1,2-propanodicarboxylic acid) scintigraphy showed myocardial uptake (Perugini score 2/3). Genetic testing excluded hereditary transthyretin cardiac amyloidosis. Endomyocardial biopsy analysis did not show findings suggestive of amyloidosis but consistent with chloroquine toxicity. Chloroquine-mediated cardiotoxicity is rare, and there are very few reports about bone scintigraphy imaging features.

Introduction The indication of valve replacement surgery in patients with severe aortic regurgitation (AR) is mainly based on the presence of symptoms or dilatation/dysfunction of the left ventricle (LV). However, diastolic function and natriuretic peptides have not been related to adverse outcomes in these patients. The aim of this study was to evaluate the prognosis impact of different diastolic function parameters as well as type-B natriuretic peptide (BNP). Methods Patients with moderate to severe or severe AR evaluated in the Heart Valve Clinic between 2013–2019 were evaluated. Those patients with classical indications for surgical aortic valve replacement (SAVR) at the moment of inclusion were excluded, as well as those patients with atrial fibrillation. Echocardiographic and analytical data were obtained from the medical history. End-point included cardiovascular mortality, SAVR and heart failure. Results A total of 126 patients were included. Median age was 65.0±17.7 years. Among them, 75 (59.5%) were men, 78 (62.4%) hypertensive, 44 (35.3%) suffered from dyslipidemia and 11 (9,6%) had ischaemic cardiomyopathy. During a median follow up of 31±17 months, 24.6% of the patients reached the combined end-point (n=5 developed heart failure, n=28 underwent SAVR, and n=4 died). Among the diastolic parameters [E wave, A wave, E/A, E/e', left atrial volume and diameter, tricuspid regurgitation (TR) degree and pulmonary systolic pressure (PSP)], only TR degree and PSP were associated with a higher incidence of the combined endpoint: TR degree HR=2,08, p=0,039 and PSP HR= 1,1, p=0,007. BNP also showed prognostic impact for the combined endpoint (HR= 1,002, p=0,011). Conclusions In patients with asymptomatic significant AR, severity of TR, PSP and BNP levels are associated with worst prognosis. However, classical echocardiographic diastolic parameters do not show prognosis impact, probably due to the limitations of such parameters to identify diastolic dysfunction and high filling pressures in this population. Our findings support the use of PSP and TR over diastolic function parameters to better stratify left valvular patient risk in clinical practice. Funding Acknowledgement Type of funding source: None

Introduction In previous studies the risk of stroke recurrence has been associated with the left atrial appendage (LAA) morphology (non-chicken wing (NCW)), knowing those with a greater risk as malignant LAA. Recently, a simpler morphological classification has been suggested with two categories: Low-risk (LAA-L) and High-risk (LAA-H); which could be easier to apply and may correlate better with the risk of embolic stroke. Methods Retrospective analysis from a registry of patients with recurrent cardioembolic strokes despite appropriate anticoagulant therapy, in which LAA morphology was studied with cardiac CT scan. LAA morphology was classified according to the four current categories and H-L morphology by the same cardiologist. Other variables associated with a high risk of stroke were also assessed, such as CHA2DS2-VASc score and left atrial (LA) size. Results Twenty-six cases were included in the analysis. We identified 22 (84.6%) chicken wing (CW), 1 (3.8%) windsock and 3 (11.5%) cactus by the current classification system, while 15 (57.7%) were classified as LAA-H and 11 (42.3%) as LAA-L by the new system. Half of the 22 cases with CW morphology were considered LAA-H, whereas all NCW were also classified as LAA-H. LA diameter and area were significantly higher in cases with LAA-H morphology (p=0.03 and 0.014), and also in those CW and LAA-H, compared to those CW with LAA-L (p=0.035). Conclusions With this new classification system more than half of the cases of our malignant LAAs were classified as high-risk morphology. This morphology was also associated with an increased LA size.

The distinction between reactive mesothelium and carcinoma in serous effusions can be very difficult. Immunocytochemistry (ICC) is the most widely used tool to improve the diagnostic accuracy of body fluid cytology, with several ICC markers being proposed. Ber-EP4 antibody has shown high sensitivity and specificity rates for diagnosing metastatic carcinoma. In our department, we have detected Ber-EP4 positivity in mesothelium in some cytological specimens. We reviewed all articles on Ber-EP4 staining in effusion cytology, summarized current findings and analyzed the staining pattern of all cases expressing Ber-EP4. Some cases showing Ber-EP4 positivity in mesothelium have been reported, most of which showed only weak Ber-EP4 staining or staining of less than 50% of mesothelial cells. However, some cases may show strong positivity both in cytological and histological specimens. Clinicians and pathologists should be aware of this source of misdiagnosis, and ICC results in mesothelium should be always interpreted cautiously and correlated with clinical tests, other ICC markers and patient's previous history.

A 7-year-old female presented with a 6- to 7-mm restrictive perimembranous ventricular septal defect with posterior extension, moderate dilatation of the left atrium and left ventricle and moderate tricuspid regurgitation. Diagnostic cardiac catheterization and transoesophageal echocardiography (TEE) were performed, and a left to right shunt (oximetric shunt of 12.6%) at the ventricular level was found with a QP/Qs of 1.83. Pressure assessment revealed moderate hyperkinetic pulmonary hypertension and pulmonary vascular resistances of 2.9 WU·m 2 . A Nit-Occlud® Le VSD was implanted. Immediate control angiography and TEE revealed a residual VSD of 2,5 mm and an increase in the degree of tricuspid regurgitation that increased to grade II-III/IV. Twelve hours after device implantation, the EKG revealed a complete AV block. Based on the residual shunt, tricuspid regurgitation, and the cAVB, surgical explantation of the device was decided. The device was removed, and the VSD was closed with a patch. Twenty-four hours after the surgery and still on corticosteroid treatment, the patient recovered sinus rhythm with a normal PR interval. The appearance of a complete AV block hours after the procedure was likely related with an inflammatory process related to the device. cAVB can be a serious complication of perimembranous VSD closure that to date seems possible with any perimembranous VSD device, as the anatomy of the conducting tissue is highly variable. This risk should be considered in the selection of candidates for this procedure.

Background Balance between embolic and bleeding risk is challenging in patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We aimed to evaluate the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with breast cancer. We also compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. Methods It is an ambispective observational multicentric study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain in the period 2011–2018. A total of 1237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. The incidence of thromboembolic and major bleeding events according to the antithrombotic strategy with VKAs or DOACs was evaluated in the cohort of 637 patients with cancer. Analysis were conducted using SPSS software V.22.0 and R V.3.5.1, with a two-tailed significance value of 0.05. Results Mean follow-up was 3.1 years. Both groups were similar in age, CHA2DS2-VASc and HASB-LED scores. There was no evidence that the incidence of ischemic stroke/systemic embolism differed between patients with cancer treated with AVK and DOAC after CHA2DS2-VASc adjustment: HR 0.91 (95% CI, 0.42–1.99). In addition, no significant differences in the incidence of major bleeding events were found between DOACs and VKA after adjustment for HAS-BLED score: HR 1.53 (95% CI, 0.93–2.53) (Figure 3). Gastrointestinal bleeding was the main source of haemorrhages in both groups (45% of bleedings among patients treated with DOACs and, 37% in VKAs group). Metastatic disease or active chemotherapy were studied as potential covariates but none of them posed any relevant change in the result. Kaplan-Meier analysis Conclusions Cancer patients treated with DOACs did not differ versus those treated with VKAs with regards to stroke or systemic embolism in a model adjusted for CHA2DS2-VASc. Neither significant differences were found for bleeding events in a model adjusted for baseline HASBLED.

Aims Balance between embolic and bleeding risk is challenging in patients with cancer. There is a lack of specific recommendations for the use of antithrombotic therapy in oncologic patients with atrial fibrillation (AF). We compared the embolic and bleeding risk, the preventive management and the incidence of events between patients with and without cancer. We further evaluated the effectiveness and safety of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) within patients with cancer. Methods The AMBER-AF registry is an observational multicentre study that analysed patients with non-valvular AF treated in Oncology and Cardiology Departments in Spain. 1237 female patients with AF were enrolled: 637 with breast cancer and 599 without cancer. Mean follow-up was 3.1 years. Results Both groups were similar in age, CHA2DS2-VASc and HASB-LED scores. Lack of guidelines recommended therapies was more frequent among patients with cancer. Compared with patients without cancer, adjusted rates of stroke (hazard ratio [95% confidence interval]) in cancer patients were higher (1.56 [1.04–2.35]), whereas bleeding rates remained similar (1.25 [0.95–1.64]). Within the group of patients with cancer, the use of DOACs vs VKAs did not entail differences in the adjusted rates of stroke (0.91 [0.42–1.99]) or severe bleedings (1.53 [0.93–2.53]). Follow-up events Conclusions Antithrombotic management of AF frequently differs in patients with breast cancer. While breast cancer is associated with a higher risk of incident stroke, bleeding events remained similar. Patients with cancer treated with DOACs experienced similar rates of stroke and bleeding as those with VKAs.

Bleeding in ACS patients is an independent marker of adverse outcomes. Its prognostic impact is even worse in elderly population. Current bleeding risk scores include chronological age but do not consider biologic vulnerability. No studies have assessed the effect of frailty on major bleeding. The aim of this study is to determine whether frailty status increases bleeding risk in patients with ACS.This prospective and observational study included patients aged ≥75years admitted due to type 1 myocardial infarction. Exclusion criteria were severe cognitive impairment, impossibility to measure handgrip strength, cardiogenic shock and limited life expectancy due to oncologic diseases. The primary endpoint was 30-day major bleeding defined as a decrease of ≥3g/dl of haemoglobin or need of transfusion.A total of 190 patients were included. Frail patients (72, 37.9%) were older, with higher comorbidity features and with a higher CRUSADE score at admission. On univariate analysis, frailty predicted major bleeding during 30-day follow-up despite less frequent use of a P2Y12 inhibitor (66.2% vs 83.6%, p=0.007) and decreased catheterisation rate (69.4% vs 94.1%, p0.001). Major bleeding was associated with increased all-cause mortality at day 30 (18.2% vs 2.5%, p0.001). On multivariate analysis, frailty was an independent predictor for major bleeding.Frailty phenotype, as a marker of biological vulnerability, is an independent predictor of major bleeding in elderly patients with ACS. Frailty can play an important role in bleeding risk stratification and objective indices should be integrated into routine initial evaluation of these patients.

ObjectiveThe incidence of aortitis in patients with thoracic aortic diseases is not well established. The aim of this study was to analyse the frequency and clinical course of patients with aortitis in a surgical series.Methods320 consecutive patients with ascending aorta/aortic arch aneurysm or acute aortic syndrome who underwent surgery from 2012 to 2017 in a single tertiary referral hospital were retrospectively reviewed. Epidemiological data, clinical course and variables related to diagnosis, treatment and follow-up were collected from patients with histologically proven aortitis.ResultsFrom 320 examined aortic samples, 279 (87.2%) thoracic aneurysms and 41 acute aortic syndromes (12.8%), 9 (2.8%) were aortitis: 3 cases of Takayasu’s arteritis, 3 of IgG4-related aortitis, 2 of giant cell, and 1 classified as idiopathic. Median age at surgery was 53.4 (51–69.2) years and six cases were female. Seven patients presented with non-specific symptoms and the diagnosis was made at pathology. Surgery was elective in eight patients and emergent in one case of IgG4-related aortitis. 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) was performed for disease extension study and as a monitoring technique during the follow-up of five patients, with just one case performed presurgically. All the patients with IgG4-related disease showed extrathoracic aortic involvement. There were no deaths, neither in-hospital nor during the 1.7 years of median follow-up.ConclusionsIn surgically treated thoracic aorta pathology, the frequency of aortitis is low; IgG4-related disease is among the most common aetiologies with a frequency similar to other types of aortitis, such as Takayasu’s and giant cell arteritis, and clinical manifestations are non-specific making presurgical diagnosis difficult. 18F-FDG PET/CT allows a better assessment of disease extension and therapeutic response. Surgery can be successfully performed and corticosteroid therapy ensures a good mid-term follow-up.

e17551 Background: Few studies have addressed the carcinogenic process of laryngeal cancer from its premalignant phases. Our aim was to compare mutational status of laryngeal dysplasias (LD) evolving to laryngeal cancer (ELC) and not evolving to LC (NELC). Methods: Retrospective study of LD diagnosed between 2007 and 2011. A customized 15-gene NGS panel (DICER, IRF6, NOTCH1, NOTCH2, NOTCH3, NOTCH2NLA, PIK3CA, PTEN, RB1, RIPK4, SYNE1, SYNE2, TP53, TP63, CASP8) was used for mutational analysis with Truseq Custom Amplicon (Illumina) performed in FFPE LD samples and results compared between LD-ELC and LD-NELC. Results: Sixty-four patients (pts) with LD were identified. LD-ELC (N = 23) and LD-NELC (N = 41) were scored as mild (N = 40; NELC: 32 / ELC:8), moderate (N = 8; NELC: 4/ ELC: 4) and severe (N = 16; NELC:5 / ELC: 11). Prior or current moderate-to-heavy tobacco smoking ( > 10 pack-year): 53/64 (83%). Males: N = 50 (ELC: 21; NELC: 29); Female: N = 14 (ELC: 2; NELC: 12). Median time to cancer among 23 LD-ELC: 8 m (range: 0-46). Forty-seven gene variants were detected in ELC not found in NELC, of which 27 were pathogenic/likely pathogenic: Frameshift: 8 (1 in NOTCH2, 1 in PTEN, 2 in RB1, 2 in SYNE1 y 2 in SYNE2); Stop-gained: 3 (1 in NOTCH2NL, 2 in SYNE2); Splicing: 3 (1 in RB1, 1 in RIPK4 y 1 in TP53); Missense: 12 (1 in IRF6, 2 in NOTCH1, 1 in RB1, 2 in RIPK4, 6 in SYNE1). Conclusions: LD from pts ELC showed a different mutational profile than LD-NELC. These results show promise for identifying pts at higher risk for developing LC and should be validated in a larger, prospective study.