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espanolLa insuficiencia cardiaca con fraccion de eyeccion del ventriculo izquierdo reducida (FEVIr) es una entidad al alza, dada su incidencia creciente y el aumento de su supervivencia, lo que hace que cada vez sea una entidad mas frecuente en cualquier consulta. Es importante realizar un adecuado estudio etiologico que permita detectar causas reversibles de disfuncion sistolica. Hoy en dia, la gran mayoria de los casos son secundarios a cardiopatia isquemica, patologia que siempre se debe descartar adecuadamente en este tipo de pacientes. El ecocardiograma sigue siendo la prueba de referencia, si bien la resonancia magnetica, por su precision y por la capacidad de realizar un estudio de caracterizacion tisular, es la prueba mas exacta y que mas informacion aporta. El tratamiento de la IC con FEVIr comprende una compleja medida de terapias no farmacologicas, farmacologicas y de dispositivos implantables. A diferencia de la IC con FEVI preservada, en estos pacientes hay tratamientos que han demostrado mejorar el pronostico de estos en ensayos aleatorizados. Surge entonces la necesidad de realizar un tratamiento individualizado y optimo para cada paciente. A su vez, es importante el adecuado tratamiento de todas las comorbilidades que presentan estos pacientes, ya que pueden influir en una mala evolucion clinica. EnglishHeart failure with reduced left ventricular ejection fraction (rLVEF) is on the increase, given its increasing incidence and improved survival, and is therefore an entity that is increasingly seen in any consultation. An adequate aetiological study is important to detect reversible causes of systolic dysfunction. At present most cases are secondary to ischaemic heart disease, which must always be appropriately ruled out in these types of patients. The echocardiogram is still the benchmark test, although magnetic resonance imaging, due to its precision and ability to provide tissue characterisation, is the most exact test and offers the most information. Treatment of HF with rLVEF comprises a complex array of non-pharmacological, pharmacological, and implantable device therapies. Unlike HF with preserved LVEF, there are treatments that have been shown to improve the prognosis of these patients in randomised clinical trials. The need arises, therefore, for optimal treatment tailored to each patient. In turn, it is important to treat all comorbidities appropriately in these patients, as they could contribute to a poor clinical outcome.

espanolLa insuficiencia cardiaca cronica (ICC) constituye un problema de salud de gran relevancia en nuestro medio, afectando al 1%-2% de la poblacion adulta en paises desarrollados, y cuya prevalencia aumenta por encima del 10% en mayores de 70 anos. El tratamiento de la ICC pretende mejorar la clase funcional, la calidad de vida, prevenir la hospitalizacion y reducir la mortalidad. Es necesaria una distincion importante entre los pacientes con ICC y fraccion de eyeccion del ventriculo izquierdo reducida (ICFEVIr) menor del 40% y aquellos con FEVI en rango medio (ICFEVIm) del 40%-50% o preservada (ICFEVIp) mayor del 50, pues tiene importantes connotaciones en lo referente al tratamiento farmacologico. El abordaje de estos pacientes, particularmente aquellos con una FEVI reducida, es complejo y con frecuencia es necesario el enfoque multidisciplinar en unidades de ICC que aunan distintas especialidades como cardiologia, medicina interna, nefrologia, cirugia cardiaca, rehabilitacion, geriatria y cuidados paliativos. EnglishChronic heart failure (CHF) is a major problem in our setting, affecting 1%-2% of the adult population in developed countries, and whose prevalence exceeds 10% in those over the age of 70. Treatment of CHF aims to improve functional class, quality of life, prevent hospitalisation and reduce mortality. It is important to distinguish patients with CHF and reduced left ventricular ejection fraction (HF with rLVEF less than 40%) from those with mid-range (HF with mLVEF, 40%-50%) or preserved left ventricular ejection fraction (pLVEF, greater than 50%), as there are significant implications for pharmacological treatment. Management of these patients is complex, especially those with reduced LVEF, and often requires a multidisciplinary approach in CHF units that combine different specialties such as cardiology, internal medicine, nephrology, cardiac surgery, rehabilitation, geriatrics, and palliative care.

espanolLas tecnicas de imagen y la medicion de biomarcadores tienen un papel fundamental tanto en el diagnostico inicial del paciente con disnea, en el que se contempla el diagnostico de insuficiencia cardiaca, como en aquellos pacientes ya diagnosticados, en los que se busca identificar la etiologia, establecer un valor pronostico y seleccionar las mejores alternativas terapeuticas de acuerdo con la evidencia actual. EnglishImaging techniques and the measurement of biomarkers play a key role in both the initial diagnosis of the patient with dyspnoea, in which a diagnosis of heart failure is considered, and those already diagnosed with the condition, where the aim is to identify the aetiology, establish a prognostic value, and select the best therapeutic alternatives according to current evidence.

espanolLa insuficiencia cardiaca (IC) con fraccion de eyeccion del ventriculo izquierdo preservada (FEVIp) constituye una causa importante de morbimortalidad en nuestro medio, y su prevalencia esta aumentando a causa del envejecimiento de la poblacion y del aumento de las comorbilidades, con influencia sobre el sistema cardiovascular. Las tasas de mortalidad son cercanas a las de los pacientes con IC y fraccion de eyeccion reducida (FEVIr). La disfuncion diastolica por aumento de la rigidez miocardica constituye la base de esta entidad, al producirse una transmision retrograda de las presiones de llenado al circuito vascular pulmonar y a las camaras derechas. A nivel molecular, se ha descrito un aumento del estado proinflamatorio y protrombotico como origen del problema. El diagnostico supone un autentico reto y no existe un unico metodo validado, habiendose propuesto varias tablas de puntuacion en base a hallazgos clinicos, analiticos, ecocardiograficos y de medicion invasiva de la presion diastolica del ventriculo izquierdo. No existe ningun farmaco que haya demostrado mejorias en la supervivencia o en la disminucion de la tasa de ingresos por IC. El tratamiento se centra en la mejoria de la capacidad funcional y de la calidad de vida, incidiendo en el manejo de las comorbilidades y del estado de volemia. EnglishHeart failure (HF) with preserved left ventricular ejection fraction (PLVEF) is a major cause of morbidity and mortality in our setting, and its prevalence is rising due to the ageing population and increased comorbidities that impact the cardiovascular system. Mortality rates are close to those of patients with reduced ejection fraction (rLVEF). Diastolic dysfunction due to increased myocardial stiffness is the basis of this condition, as there is retrograde transmission of filling pressures to the pulmonary vascular circuit and right chambers. An increased proinflammatory and prothrombotic state has been described as the origin of the problem at the molecular level. Diagnosis is very challenging, and there is no single validated method, several score tables have been proposed based on clinical, laboratory, echocardiographic findings, and invasive measurement of the left ventricle diastolic pressure. No drug has been shown to improve survival or decrease the rate of admissions due to HF. Treatment focusses on improving functional capacity and quality of life, with emphasis on the management of comorbidities and blood volume status.

espanolLa insuficiencia cardiaca aguda descompensada es uno de los motivos mas frecuentes de consulta en urgencias. Dada la situacion de compromiso vital que puede llegar a suponer, es importante que se instaure un tratamiento eficaz de la misma de manera paralela al proceso diagnostico. El tratamiento de la congestion es uno de los pilares fundamentales de la misma, ya que esta se encuentra presente en la mayoria de los pacientes. Un adecuado tratamiento diuretico ayudara a mejor la sintomatologia y el pronostico de los pacientes con insuficiencia cardiaca. La hipoperfusion puede aparecer de manera mucho menos frecuente, pero empeora las cifras de mortalidad y el pronostico cuando esta presente, por lo que debe diagnosticarse y tratarse de manera precoz. Otras medidas no farmacologicas, fundamentalmente la oxigenoterapia en todas sus modalidades, son tambien basicas en el tratamiento de estos pacientes. EnglishAcute decompensated heart failure is one of the most frequent reasons for consultation in the emergency department. Because it can be a life-threatening situation, it is important that effective treatment is implemented in tandem with the diagnostic process. Treatment of congestion is one of the mainstays of its treatment, as it is present in most of these patients. Adequate diuretic treatment will help to improve the symptoms and prognosis of patients with heart failure. Hypoperfusion may develop much less frequently, but worsens mortality and prognosis when present, and therefore should be diagnosed and treated promptly. Other non-pharmacological measures, primarily oxygen therapy in all its modalities, are also key in the treatment of these patients.

Acute heart failure (AHF) is an increasingly frequent clinical syndrome in our setting. The heterogeneity of this syndrome, a consequence of multiple pathophysiological mechanisms, makes it difficult to create a consensus protocol for its treatment. There are multiple triggers and hormone amplification mechanisms that can act on a basic anatomical substrate, both of which must be adequately explored to reach an accurate diagnosis that will affect the patient's management and prognosis. As part of diagnosis, the clinical history and physical examination, aimed at detecting signs of congestion (most frequent) or hypoperfusion, remain fundamental tools. In turn, there are traditional complementary tests (plain x-ray, electrocardiogram) and other more advanced tools (heart and lung ultrasound, computed tomography, natriuretic peptides) that are very useful to establish a diagnosis, guide treatment and determine these patients’ prognosis.

espanolLa insuficiencia cardiaca (IC) es un sindrome complejo y heterogeneo, cada vez mas prevalente en la poblacion. Para clasificar el mismo, podemos seguir distintos criterios que posteriormente son importantes a la hora de realizar estudios de investigacion, y que pueden incluir variables clinicas, analiticas y de imagen. Si bien la incidencia de esta enfermedad se encuentra estable o en leve descenso, la prevalencia se muestra al alza por factores como el envejecimiento y la mejora de los tratamientos medicos disponibles. Es importante conocer los distintos factores de riesgo que aumentan la probabilidad de padecerla, asi como las comorbilidades asociadas mas frecuentes, que muchas veces tienen origen y mecanismo fisiopatologicos comunes. Independientemente del origen y de la clasificacion, los pacientes con IC presentan una expectativa de vida y unos indices de calidad disminuida que deben alertarnos sobre la necesidad de una adecuada prevencion, asi como de su diagnostico precoz. EnglishHeart failure (HF) is a complex and heterogenous syndrome that is increasingly prevalent in the population. We can use different criteria to classify it, which are important for subsequent research studies and may include clinical, laboratory and imaging variables. Although the incidence of the disease is stable or slightly declining, its prevalence is rising due to factors such as ageing and the improved medical treatment available. It is important to be aware of the different risk factors that increase the likelihood of developing the disease, and its most common associated comorbidities, which often have a common pathological origin and mechanism. Regardless of the origin and classification, patients with HF have reduced life expectancy and quality indices, which should highlight the need for adequate prevention, and early diagnosis.

Background Left ventricular thrombus (LVT) is a potential complication of acute myocardial infarction and is associated with a high rate of thromboembolic events. With the advent of more potent antithrombotic medications and quicker reperfusion strategies, the incidence of LVT has been reduced. However, current guidelines recommendations are based on older evidence and some aspects of the treatment are being questioned, such as the optimal duration of anticoagulation. Purpose To determine how length of anticoagulation influences the risk of thromboembolic events and mortality in a tertiary-care cardiac center with primary percutaneous coronary intervention (PCI) capability. Methods A cohort of consecutive cases of patients with IVT diagnosed by transthoracic echocardiography between 2014 and 2020 was retrospectively analyzed. Results A total of 72 cases of LVT were identified. Etiology was ischemic cardiomyopathy in 60 (82.0%) patients and 13 (20.0%) were female. LVT was diagnosed in the setting of acute myocardial infarction in 23 (32.0%) of cases. Prolonged anticoagulation regimes were significantly associated with fewer systemic thromboembolic events (21.4% vs 6.1%; p=0.04), without a significant effect on mortality (Figure 1). Conclusion Clinical manifestations and epidemiology of LVT has recently changed after the advent of improved treatments. In our cohort, an indefinite anticoagulation strategy was significantly associated with fewer thromboembolic events, suggesting that future investigations should clarify these issues. Funding Acknowledgement Type of funding sources: None.

Background Previous studies have shown that prophylactic implantable cardioverter-defibrillators (ICD) in patients with symptomatic severe systolic dysfunction reduce all-cause mortality. However, their benefit in patients with severe systolic dysfunction of non-ischemic origin is not so clear, and is currently under debate. Methods/Aim We retrospectively reviewed all consecutive patients with nonischemic dilated cardiomyopathy (NICM) who underwent prophylactic ICD implantation between 2008 and 2020 in two tertiary centers. Our main goal was to identify predictors of appropriate ICD therapies (ATP and/or shocks) in this cohort of patients. Results A total of 224 patients were included, median age 62.7 years, 73.7% men. During a median follow-up of 51 months, 61 patients (27.2%) required appropriate ICD intervention, 7 patients (3.1%) presented inappropriate shocks and 11 (4.9%) had device infection. Patients that received appropriate ICD therapies, as compared to those who did not, were more frequently men (86.9% vs 68.7%, p=0.006) and were significantly younger (median age 58.7 years, IQR 53.0–64.8 vs 63.7, IQR 57.0–69.8; p=0.02). Left ventricular end diastolic volume (LV-EDV) and left ventricular end systolic volume (LV-ESV) were both significantly higher in this subgroup of patients (median LVEDV 100 ml/m2 vs 86, p=0.0106; median LVESV 72.2 ml/m2 vs 60.9, p=0.0467). A trend towards lower LVEF was also noted, but it did not reach statistical significance (26% vs 29%, p=0.077). Regarding ECG previous to implant, patients that required ICD intervention presented more frequently complete right bundle branch block (RBBB) (14.8% vs 4.3%, p=0.007). On the other hand, left bundle branch block (LBBB) was more frequent in those patients who did not receive ICD intervention during follow-up (47.2% vs 26.2%, p=0.005). Table 1 summarizes baseline characteristics and results. In a multivariate Cox regression analysis, RBBB (HR 3.9, CI 95% 1.9–8.0, p Conclusion RBBB and male sex may help identify patients with NICM at high-risk of ventricular arrhythmias requiring ICD intervention. Funding Acknowledgement Type of funding sources: None. Baseline characteristics and resultsKaplan-Meier curves

Background The HeartLogic algorithm combines multiple implantable cardioverter-defibrillator (ICD)-based sensors into an index for prediction of impending heart failure (HF) decompensation. In patients with ICD and cardiac resynchronization therapy ICD remotely monitored at 13 Spanish centers, we analyzed the association between clinical events and HeartLogic alerts and we described the use of the algorithm for the remote management of HF. Methods The association between clinical events and HeartLogic alerts was studied in the blinded phase (from ICD implantation to alert activation – no clinical actions taken in response to alerts) and in the following active phase (after alert activation – clinicians automatically notified in case of alert). Results We enrolled a total of 215 patients (67±13 years old, 77% male, 53% with ischemic cardiomyopathy) with ICD (19%) or CRT-D (81%). The median duration of the blinded phase was 8 [3–12] months. In this phase, the HeartLogic index crossed the threshold value (set by default to 16) 34 times in 20 patients. HeartLogic alerts were associated with 6 HF hospitalizations and 5 unplanned in-office visits for HF. Five additional HeartLogic threshold crossings were not associated with overt HF events, but occurred at the time of changes in drug therapy or of other clinical events. The rate of unexplained alerts was 0.25 alert-patient/year. The median time spent in alert was longer in the case of HF hospitalizations than of in-office visits (75 [min-max: 30–155] days versus 39 [min-max: 5–105] days). The maximum HeartLogic index value was 38±15 in the case of hospitalizations and 24±7 in that of minor HF events. The median duration of the following active phase was 5 [2–10] months. After HeartLogic activation, 40 alerts were reported in 26 patients. Twenty-seven (68%) alerts were associated with multiple HF- or non-HF related conditions or changes in prescribed HF therapy. Multiple actions were triggered by these alerts: HF hospitalization (4), unscheduled in-office visits (8), diuretics increase (8), change in other cardiovascular drugs (5), device reprogramming (2), atrial fibrillation ablation (1), patient education on therapy adherence (2). The rate of unexplained alerts not followed by any clinical action was 0.13 alert-patient/year. These alerts were managed remotely (device data review and phone contact), except for one alert that generated an unscheduled in-office visit. Conclusions HeartLogic index was frequently associated with HF-related clinical events. The activation of the associated alert allowed to remotely detect relevant clinical conditions and to implement clinical actions. The rate of unexplained alerts was low, and the work required in order to exclude any impending decompensation did not constitute a significant burden for the centers. Funding Acknowledgement Type of funding source: None

Background Patients with severe tricuspid regurgitation (TR) frequently develop heart failure (HF) and their surgical therapeutic options are limited because of very high or prohibitive risk. According to the 2016 ESC guidelines for HF, anaemia and iron deficiency are associated with worse prognosis and intravenous iron therapy should be considered in symptomatic patients with HF reduced ejection fraction (HFrEF) in order to alleviate symptoms, improve exercise capacity and quality of life. The effect of treating iron deficiency in HF preserved ejection fraction (HFpEF) is unknown. The purpose of this study was to analyze the correlation between levels of hemoglobin (Hb) and the prognosis in patients with severe TR and preserve EF. Methods Consecutive patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015-2018 were included. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure. Results A total of 70 patients were included (mean age was 74± 8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). Mean left ventricular ejection fraction was 56,5% ±6,7%. During a median follow up of 18 months [IQR: 4-28], 35% of the patients reached the combined end-point (n = 16 developed right HF, n = 17 underwent tricuspid valve surgery, and n = 3 died). Patients with events showed lower Hb values (p = 0.04). The level of anaemia was a prognostic factor of the combined endpoint (per gr/dl, HR 0.77 [0-61-0.98], p = 0.036). Conclusion Hemoglobin is predictive of poor outcomes in patients with significant TR. According to these preliminary results, iron deficiency could be a therapeutic target in this subgroup of patients with limited therapeutic options.

Introduction Primary cardiac tumors are a relatively uncommon condition, which may appear both in asymptomatic patients or in a myriad of clinical presentations. Imaging techniques are crucial for its diagnosis, and a multi-modality approach may be useful in the evaluation of this masses. Case description A 57 year-old man with history of hypertension presented in the emergency department with acute pulmonary edema and cardiogenic shock. He was admitted to the coronary care unit, and on bedside echocardiography a mass on the tricuspid valve was observed. Upon clinical improvement, a cardiac CT and cardiac MRI was performed (figure 1). A solid mass with no calcium content and dependent exclusively on the anterior leaflet of the tricuspid valve was seen on CT-scan (fig 1, A and B). Thrombus on the right atrial appendage could also be appreciated. MRI confirmed the presence of a 18x19 mm mass with isointense signal on T1-turbo spin echo black-blood (fig 1, C) and cine steady-state free precession sequences, whereas an hyperintense signal was evident on T2 weighted images (T2-STIR; fig 1 D). In first pass sequences the central core was hypointense and late gadolinium enhancement showed peripheral enhancement with a non captating central core (fig 1, E). The patient underwent surgery and the anatomopathological results showed a tumor constituted by dense connective tissue, scarce cellular content and an avascular matrix of mucopolysaccharides, elastic fibers and fusiform cells consistent with the diagnosis of papillary fibroelastoma. Discussion The imaging characteristics of papillary fibroelastoma are not commonly reported on MRI. We present an unusually large right-sided fibroelastoma with a characteristic distribution of late gadolinium enhancement, which has not been consistently described on a fibroelastoma. Cardiac tumors are rare, and a non-invasive differential diagnosis is always a challenge. A multi-modality approach (echocardiography, cardiac-CT and cardiac MRI) as well as integration of relevant morphological information, including the location of the lesion and tissue characteristics was essential to the orientate the most plausible diagnosis. The distinctive images are presented. Abstract P729 Figure 1.

Background Patients with mid-range ejection fraction heart failure (HFmrEF) are a new category defined in actual guidelines. The aim of this study was to establish the prognostic value of several parameters obtained by Cardiac Magnetic Resonance (CMR) and Transthoracic Echocardiography (TTE) in patients with HFmrEF. Methods Thirty patients, defined as HFmrEF by TTE and CMR, were included between 2012-2018. Patients with structural heart disease different from Left Ventricular (LV) dysfunction were excluded. Cine sequences in CMR (SSFP) were used to obtain atrial and ventricular volumes and mass. Myocardial fibrosis was quantified by late gadolinium enhancement. TTE was used to obtain anatomical and functional parameters as LV and Right Ventricular (RV) ejection-fraction, LV and RV global longitudinal strain, and RV free-wall longitudinal strain. The primary endpoint was the combination of all-cause death or heart failure admission. The median follow-up was 1.9 (0.5-3.3) years. Results Mean age was 59.3 ± 12.4 years, and 67.9% patients were male. The aetiology of LV dysfunction was mainly ischemic (n = 16, 53.3%). Results are shown in Table1. Patients who presented the primary endpoint had a lower RV ejection-fraction by CMR and a lower absolute value of RV free-wall longitudinal strain by TTE(Figure 1). Conclusions In HFmrEF patients, worse RV function (by CMR and TTE-Speckle Tracking) may be associated with a worse prognosis. Larger studies are needed to confirm this hypothesis. Table1 All-cause death or HF admission (n = 5; 16.7%) No all-cause death of HF admission (n = 25; 83.3%) p iRVEDV (ml/m2) by CMR 65.5 ± 13.5 66.2 ± 12.3 0.906 iRVESV (ml/m2) by CMR 30.4 ± 7.5 24.4 ± 6.2 0.065 iLVEDV (ml/m2) by CMR 85.8 ± 23.7 98 ± 19.5 0.225 iLVESV (ml/m2) by CMR 47.8 ± 15.3 54.9 ± 11.7 0.246 Indexed LA Volume (ml/m2) by CMR 42.8 (36.5 - 49) 48.4 (42 - 63.5) 0.386 LVEF (%) by CMR 44.9 ± 3.3 44 ± 2.6 0.506 RVEF (%) by CMR 52.2 ± 7.2 61.7 ± 7.2 0.012 RV-FAC (%) by TTE 43.4 ± 4.4 44.7 ±7.5 0.378 TAPSE by TTE 2.1 ± 0.3 2.5 ± 0.1 0.032 LV Longitudinal Global Strain by TTE -14.3 ± 3.3 -15.5 ± 4.9 0.663 RV Longitudinal Global Strain by TTE -11.3 (-13.2 - -7.0) -19.5 (-23.7 - -10) 0.089 RV Free-Wall Longitudinal Strain by TTE -11.5 (-14.2 - -8.2) -20 (-26 - -13.7) 0.043 HF: Heart Failure; CMR: Cardio Magnetic Resonance; LV: Left Ventricle; RV: Right Ventricle; iRVEDV: Indexed RV End-Diastolic Volume; iRVESV: Indexed RV End-Systolic Volume; iLVEDV: Indexed LV End-Diastolic Volume; iLVESV: Indexed LV End-Systolic Volume; LA: Left Atrium; LVEF: LV Ejection Fraction; RVEF: RV Ejection Fraction; RV-FAC: RV Fractional Area Change; TAPSE: Tricuspid Annular Plane Systolic Excursion Abstract P816 Figure 1

A 85 years old woman with shortness of breath and leg edema with proggresive intensity last three weeks is admited in the cardiology department. As significant comorbidities, the patient has arterial hypertension (although last months all the medication that she needed was discontinued due to tendency toward low blood pressure) and paroxysmal atrial fibrillation. As previous surgical background, the patient only refers a carpal tunnel syndrome surgery (in both sides). In the physical exam she has a blood pressure of 110/60 Hg mm, lung crackles in the lower third of both lungs and a systolic murmur in the aortic area with a very low second sound. After being admitted in the cardiology department an echocardiography was done, showing severe left ventricle hypertrophy. As seen in the image (picture A), the myocardium, showed a characteristic granular ang bright pattern. It also showed a moderate to severe aortic stenosis. Although she was in atrial fibrillation during the echocardiography, the transmitral Doppler showed signs of significantly elevated filling pressures as for example, the presence of L waves. Finally, the exam was completed with an analysis of longitudinal deformation of the left ventricle, showing a clearly depressed global longitudinal strain, with a base-apex gradient (preserved at the apex, picture D). With these findings a Tc-PYP scintigraphy was performed, showing moderate and difuse uptake of the radioactive tracer in both ventricles (as shown in the image C). To complete the diagnosis, a cardiac magnetic resonance was performed showing a subendocardial ring pattern of delayed enhancement (image B). The diagnosis of transthyretin cardiac amyloidosis was done. Cardiac amyloidosis is clearly underdiagnosed entity, and sometimes differential diagnosis is really hard. Patients with cardiac amyloidosis are not always so "typical" as in this case. In fact, even a 5% of patients with history of aortic stenosis surgery may have also a cardiac amyloidosis. Maybe the use of myocardial deformation study and nuclear imaging can be useful solving this problem. Several studies have shown that nuclear imaging may be useful in the early diagnosis of this disease, even before that with echocardiography or cardiac magnetic resonance. Besides, new sequences of cardiac magnetic resonance may be very useful solving the problem of the differential diagnosis in left ventricle hypertrophy: The extracellular volume mapping. In cardiac amyloidosis hypertrophy is due to the deposit of amiloid in extracellular space. Because of that, the extracellular space is significantly increased in comparison with almost every other cause of left ventricle hypertrophy, making this sequence very useful in differential diagnosis. CONCLUSION Transthyretin cardiac amyloidosis is a rare and very under-diagnosed disease. However these problems with the advance of cardiac imaging and the development of new treatments could change very soon. Abstract P874 Figure. Image 1

Introduction A non-invasive diagnosis of cardiac amyloidosis is a challenge, especially in cases of atypical phenotypic presentation. Differential diagnosis includes hypertrophic cardiomyopathy (HCM), hypertensive cardiomyopathy, and other infiltrative disorders. Multimodality imaging is essential to make a final diagnosis. Case We present the case of a 65 years old woman, with a personal history of resistant arterial hypertension and mild hypertensive cardiomyopathy. She was diagnosed 6 years earlier with multiple myeloma, treated with chemotherapy and allogeneic hematopoietic stem cell transplant, presenting with several relapses and in a stable situation at the moment of our first consult. The patient was referred for heart failure in context of acquired community pneumonia one month earlier. Transthoracic echocardiography showed severe asymmetric left ventricle (LV) hypertrophy (Image A), systolic anterior motion of the mitral valve and diastolic dysfunction suggestive of HCM, not present in the previous examination. Strain imaging of the LV showed a typical amyloid infiltration pattern, with lower longitudinal strain values in the base compared to the apical segments (Image D). Further characterization of the myocardial tissue established the diagnosis along with performing a cardiac magnetic nuclear imaging (MRI). It showed the presence of inferior septum severe LV hypertrophy along with extensive patchy late gadolinium enhancement (LGE) of the lateral wall involving the endocardium (Image C), with normal LV contractility. There was no pleural effusion, but a small pericardial effusion was seen (Image B). With the suspicion of infiltrative heart disease, probably amyloid with an atypical LGE pattern, an oral mucosal biopsy was performed confirming amyloid diagnosis (Images E1,E2). Heart failure treatment was continued, but clinical evolution was poor with the deceasement of the patient 3 years after diagnosis. Discussion This case represents an example of the variety of imaging patterns we can see in cardiac amyloidosis. Despite the classical pattern of cardiac amyloidosis, with concentric LV hypertrophy, up to 8% of cases may present with asymmetrical LV hypertrophy, mimicking HCM. LGE extension and pattern can shows this variability as well: global transmural or subendocardial LGE is the most common, but focal patterns (up to 6% of cases) are described. The complexity of the diagnosis in these cases require a clinical and multimodality image approach. Abstract P726 Figure. Images of the case

Background There is no gold standard echocardiographic method to evaluate tricuspid regurgitation (TR) severity. ESC guidelines recommend using a combination of several methods. The purpose of this study was to compare the prognostic value of the two most commonly used methods for the evaluation of the TR: Effective regurgitant orifice area (EROA) method and biplane vena contracta (VC) method. Methods Consecutive asymptomatic patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015–2018 were included. TR severity was evaluated by a combination of several methods, including EROA method and biplane VC method, using EPIQ system. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure. Results A total of 70 patients were included (mean age was 74±8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). During a median follow up of 18 months [IQR: 4–28], 35% of the patients reached the combined end-point (n=16 developed right heart failure, n=17 underwent tricuspid valve surgery, and n=3 died). Patients with events showed a larger EROA (0.55 vs 0.40 p: 0.036) but no significance different was found in VC (8.03 vs 7.80 p: 0.27). Among both parameters, the tricuspid EROA was the only prognostic factor of the combined endpoint (EROA, HR 24.22 [1.54–380.86], p=0.023; VC, HR 1.022 [0.882–1.183]. A value of EROA of 0.42 reached the best accuracy to predicted poor outcomes (p Conclusion Among the two most commonly used methods for the evaluation of the TR, EROA was the only method that obtained prognostic value during follow-up.

Purpose According to current ESC guidelines, mid-range ejection fraction (mrEF) might represent a separate subgroup of patients with distinct underlying characteristics, prognosis and treatment response. Cardiac magnetic resonance (CMR) is the gold standard for measuring volumes, mass and ejection fraction of the heart. We aimed to find long-term prognostic value of various CMR parameters in patients mrEF. Methods 137 patients with mrEF underwent CMR (1.5T) between 2012 and 2018 and were consecutively included. Volumes, mass and ejection fraction were assessed using short axis SSFP images and the Simpson method (using commercially available software). Myocardial fibrosis was determined by late gadolinium enhancement (LGE). Clinical parameters after a median of 762 (230–1315 days) were recorded. Patients with other significant cardiac affection rather than mrEF were excluded (pre-capillary pulmonary hypertension and significant valve disease). The primary endpoint was defined as a combined outcome of all-cause death or heart failure decompensation requiring in-hospital admission. Results Mean age was 63.0±12.4 years. 76.6% were males. Mean left ventricle ejection fraction (LVEF) was 45±2.69%. Main aetiologies were ischemic (46%), idiopathic (32.12%), myocarditis (9.5%), tachycardiomyopathy (6.57%) enolic (2.2%) stress cardiomyopathy (0.7%) and others (2.9%). A combined model for predicting outcomes in patients with mrEF using CMR parameters was obtained. This model was able to predict 32.7% (coefficient of determination, R-squared) of the adverse events (p Combined model for predicting outcomes in patients with mrEF using CMR parameters Variable p value iRVEDV (indexed right ventricular end-diastolic volume) Conclusions In patients with mid-range ejection fraction, RV volumes and ejection fraction, as well as LV mass and LA volume, were significant predictors of worse outcomes in a combined model. If supported by further studies, these findings may help the clinician select the patients with higher risk of complications and in need of a closer follow-up.

The best treatment for chemotherapy-induced cardiotoxicity is prevention. The first step in this process should be a careful selection of candidates for chemotherapy since preexisting cardiac disease is often underestimated. Environmental and genetic factors determine susceptibility to develop cardiotoxicity, as does aging. Early stratification of high-risk patients should be a primary goal for oncologists in order to personalize the therapeutic strategies. Baseline cardiovascular examination and cardiovascular management could prevent adverse events from antineoplastic drugs or exclude their use in potentially high-risk individuals. Controlling cardiovascular risk factors can prevent serious problems during treatment and increase its effectiveness.

Angiotensin-converting enzyme inhibitors slow the progression of left ventricular dysfunction in several clinical settings, and may protect cardiotoxicity induced by chemotherapy. There has been recent suggestions that there is a potential cardioprotective effect, especially with enalapril. Angiotensin II receptor blockers are a crucial drug in hypertension treatment, especially if there is any kind of intolerance to angiotensin-converting enzyme inhibitors. Its angiotensin-inhibiting effect may be protective.

Beta-blockers (β-blockers) are one of the most commonly used heart failure medications. They are known to improve survival in patients with congestive heart failure, cardiac hypertrophy, and reperfusion abnormalities. Some recent data illustrate its role in preventing chemotherapy-induced cardiotoxicity. β-Blockers may be effective for cardiac dysfunction prevention. It has been described that some β-blockers may have improved benefit in comparison with others of the same family. Carvedilol is the most studied and seems to be the most effective.