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Background Cardiac masses represent a major diagnostic challenge given the difficulty in assessing their nature through imaging examinations. Cardiac Magnetic Resonance (CMR) is a noninvasive key diagnostic tool that can provide important anatomical, functional, and tissue characteristic information. Objectives of the study analyze the clinical and CMR features of patients with benign and malignant tumors and thrombus; asses the accuracy of CMR in comparison with the histologic examination; evaluate the prognostic rule of clinical and CMR features in predicting the primary endpoint of all cause mortality. Methods 92 Patients undergoing CMR for suspected cardiac masses between June 2004 and January 2022 were retrospectively evaluated. Patients with no mass 8 (9%) or pseudomass 11 (12%) were excluded. Clinical, CMR and histological data were collected. Results 73 patients with masses were finally enrolled, 27 (37%) with a diagnosis at CMR of benign tumor, 22 (30%) with malignant tumor, and 24 (33%) with thrombus. Among clinical variables the history of malignancy and smoking were seen in patients with malignant tumors (p>0,02). Among CMR features high size, infiltration, pericardial repeats, pericardial effusion, signal inhomogeneity, First Pass Perfusion and Late Gadolinium Enhancement were associated with malignant masses (p Conclusions although CMR has high diagnostic accuracy, histologic examination remains the diagnostic gold standard in determining the type of cardiac mass. In addition to playing a key role in the diagnostic process, CMR is useful in predicting the outcome of patients with cardiac masses.

Background Heart transplanted patients are mainly monitored with invasive diagnostic techniques for detecting cardiac allograft vasculopathy (CAV). However coronary CT angiography (CCTA) is a new promising tool that brings clinical and economical benefits. Objectives primary aim: demonstrate the non-inferiority of CCTA in comparison to invasive coronary angiography (ICA), in terms of radiation and contrast dose, costs, in-hospital stay and complications. Other aims: analyse in the subgroup of patients undergoing CCTA the role of immunological and non-immunological risk factors and the role of pericoronary-fat-attenuation-index (pFAI) in predicting CAV. Methods Between March 2021 and May 2022, 179 consecutive heart transplanted patients underwent either CCTA (78 patients) or ICA (101 patients) based on medical preference to study CAV. The 78 patients who underwent CCTA were also divided in patients with no previous CAV (npCAV, previous ISHLTV=0) and patients with previous CAV (pCAV, ISHLTV≤1). CAV progression was considered if there was any progression in ISHLTV. Results CCTA delivered lower radiation doses in comparison with ICA (3,52 mSV [1.46-7.23] versus 10,8 mSV [8.8-20.3]; p=0.03) and required also less in-hospital stay (0.5 ± 0,2 hours versus 23.7 ± 12.31 hours; p-70.1HU) did not show a statistically significance in the progression of CAV (p=NS). Conclusions CCTA is superior to ICA in terms of radiation and contrast dose, costs and in-hospital stay. TNF was the only independent predictor related with the progression of CAV. PFAI, didn't reach statistically significance probably due to the small sample size. Further studies are necessary to understand the role of pFAI in this subset of patients.

Background Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) and sudden death (SD). This condition predominantly affects young women with a few or no conventional risk factors for CAD. Diagnosis is traditionally made with invasive coronary angiography (ICA); nevertheless, coronary computed tomography angiography (CCTA) is going to be a new useful tool in the acute diagnosis and at follow-up in these patients. Conventional treatment could involve a conservative approach with medical therapy or an invasive approach with percutaneous coronary intervention (PCI). Methods We retrospectively analyzed data of 57 SCAD patients followed up with Coronary CT angiography (CCTA) at our centre. Clinical and angiographic (invasive and non invasive) data were collected at baseline and at the follow-up. The primary outcome was a composite of all cause mortality and hospitalization for cardiovascular cause evaluated at 1690,7±1082,3 days; the secondary outcome was the evaluation of the vessels with CCTA at 777,9 ± 271,6 days. Results 57 patients were divided in 2 groups: 46 patients underwent a conservative treatment (80,7%) and 11 patients a PCI treatment (19,3%). The first group is composed of 15,2% male and the second of 27,3% male (p=0,387), mean age is 52,8±11,1 years vs 48,0±10,7 years (p=0,201). Patients treated with PCI has a significative higher incidence of smoking habits (45,5% vs 15,2%; p=0,042), peripheral arteriopathy (18,2% vs 0%; p=0,034), higher troponin peak (40425,8 vs 13436; p=0,011) and lower ejection fraction (51,4±11,0 vs 57,1±7,6; p=0,050). Moreover the PCI population has a more common involvement of 2 vessels (72,7% vs 6,5%; p0,05). Among patients treated with conservative therapy, there were a more frequent recurrence of SCAD in those treated with DAPT than in those treated with SAPT (33,3% vs 5,9%; p=0,033). Conclusions in patients with SCAD, conservative management is comparable to PCI treatment in terms of clinical and angiographic outcomes. Among patients treated with conservative therapy, DAPT at discharge was independently associated with a higher rate of SCAD recurrence at follow-up.

A 61-year-old man suffering from myasthenia gravis with predominant bulbar involvement since 10 months before admission, was diagnosed with thymoma in April 2021. He had no relevant comorbidities except for history of polymorphic ventricular ectopic beats. In this regard, in 2019 he had undergone transthoracic echocardiogram and coronary computed tomography angiography, which resulted both normal. After 1 month, due to poor response to standard medical therapy with prednisone and pyridostigmine and in preparation for thymectomy, an intravenous immunoglobulins (IVIG) treatment was prescribed leading to mild clinical improvement (Myasthenia Gravis Foundation of America Clinical Classification IIIA—MGFA). Two weeks later, the patient underwent robotic-assisted thoracoscopic thymectomy without complications. Pathological findings were consistent with type B1 Thymoma classified as Masaoka Stage IIB (TNM Stage pT1a). After discharge the patient complained a rapid worsening of neurological symptoms (MGFA IIIB) leading to an urgent hospitalization for Myasthenia Gravis exacerbation in the middle of June. On admission Intravenous Immunoglobulins (IVIG) treatment was immediately started. After administration of the second IVIG dose, he had a myasthenic crisis complicated by refractory heart failure with significant increase of cardiac troponin up to 5.768 ng/L, requiring invasive ventilation, inotropic support and urgent transfer to the Cardiac Intensive Care Unit (CICU). The 2D echo showed severe left ventricular systolic dysfunction (LVEF 20%) with diffuse hypokinesis. The patient underwent cardiac catheterization and coronary angiography that confirmed severe reduction of the LVEF (LVEF 23%) with embolic occlusion of the distal posterior descending coronary artery (PDA) without other significant coronary artery stenosis. An endomyocardial biopsy was performed, which revealed cardiomyocytes of normal dimensions with sporadic cytoplasmic vacuolization and excluded signs of inflammation, fibrosis, necrosis and viral myocarditis. The day after the patient completed IVIG treatment. During the following days, despite persistence of severe left ventricular systolic dysfunction, he was successfully weaned form inotropic and ventilatory support. At neurological evaluation he reported persistence of severe bulbar involvement with upper and lower limbs weakness. Five days later, the patient had a sudden cardiac arrest for pulseless electrical activity. Advanced cardiac life support requiring inotropes and invasive ventilation was performed for 28 min before returning to spontaneous circulation. The echocardiogram excluded pulmonary embolism and mechanical complications but showed severe left ventricular systolic dysfunction. A new coronary angiography showed clear coronary arteries including PDA. Because of severe haemodynamic compromise, an Impella CP device was implanted and set at maximum support level (P8 flow, >3 L/min). A neurological exam revealed no severe neurological sequelae. As a result of the long CPR the patient had a massive left haemothorax, initially treated with multiple blood transfusions and pleural drainage. Two days later, due to persistence of haemodynamic instability and active pleural bleeding with incessant severe anaemia the case underwent a Heart Team discussion where it was decided to escalate Impella CP device to Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) and then perform a video-assisted thoracoscopic evacuation of the haemothorax. Both procedures were carried out without complications. The patient had an immediate haemodynamic improvement which led to rapid weaning from inotropic support. Haemoglobin was stable. The 2D echo showed significant improvement of the LVEF (40%). After 3 days, given the persistence of haemodynamic stability, ECMO device was removed and invasive ventilation stopped shortly afterwards. Eleven days later, another 2D echo demonstrated complete recovery of left ventricular systolic function (LVEF 59%). Notwithstanding, the patient reported a progressive worsening of neurological symptoms with generalized myasthenia and severe bulbar involvement (MGFA IVB) along with episodes of respiratory muscle fatigue requiring non-invasive ventilation. For this reason, the patient was transferred to Subintensive Respiratory Unit and the case underwent a new multidisciplinary discussion involving neurologists, cardiologists and haematologists. Specialists agreed upon potential causal role of IVIG treatment in transient left ventricular dysfunction and considered re-administration absolutely contraindicated. Thus, they prescribed five plasmapheresis treatments and up-titration of corticosteroid therapy (methylprednisolone up to 60 mg od). An immediate and outstanding improvement of neurological symptoms was obtained (MGFA IIIA) and the patient was discharged from hospital 1 week later.

In January 2014 a 50 years old man without previous medical history experienced a syncopal episode. During evaluation at Emergency department (ED) a sustained ventricular tachycardia (VT) with haemodynamic compromise was found and successfully treated with DC shock. The patient was admitted to the Coronary Care Unit (CCU) where the ECG showed diffuse low QRS voltages and flattened T waves. Coronary angiography showed normal coronary arteries. 2-D echocardiogram documented the presence of a mildly dilated left ventricle (LV) with a mildly decreased systolic function (EF : 41%); the right ventricle (RV) was severely dilated (REDV : 41 cmq/mq) with a severe systolic dysfunction (fractional area change: 21%) with diffuse hypokinesia and akinesia of subtricuspid region. Cardiac magnetic resonance (CMR) confirmed ventricular dimensional and kinetic abnormalities and tissue characterization sequences demonstrated the presence of fatty infiltration of the epicardial segments of LV lateral wall and of RV free wall. After gadolinium injection, late gadolinium enhancement (LGE) presented the same distribution of the fatty infiltration. A diagnosis of arrhythmogenic cardiomyopathy (AC) was made and ICD in secondary prevention was implanted. The patient was treated with Sotalol (240 mg/daily) and remained asymptomatic and free from sustained ventricular arrhythmias for five years. In January 2019 he started to complain asthenia, dyspnoea (NYHA II) and anorexia and he was admitted to ED where a persistent slow VT was detected. Echocardiogram showed a severely dilated LV with severe systolic dysfunction (EF: 30%) with substantially unchanged RV features. One year later he experienced an heart failure (HF) episode with further reduction of LV systolic function (EF: 21%). Cardiopulmonary test documented a severe ventilation/perfusion mismatch (VE/VCO2 slope 50.6) and severe reduction of the exercise tolerance (VO2 peak 9.2 ml/kg/min). In March 2021 the patient started heart transplantation check list. Three weeks after the discharge he was transplanted. In conclusion, this clinical case highlights an infrequent late presentation of AC, with an initial high arrhythmic burden and a following rapid progression to refractory HF requiring heart transplantation.

Aims Right ventricular systolic dysfunction is considered an outcome predictor in various cardiac diseases, sometimes stronger than ejection fraction (EF). We assume that right ventricular dysfunction, calculated with echocardiography in patients candidate for trans-catheter aortic valve implantation (TAVI), could be an outcome predictor. To evaluate the prognostic value of pre-TAVI right ventricular free wall longitudinal strain (RVFWSL) in patients with severe aortic stenosis undergoing TAVI. Methods and results Retrospective analysis of 100 patients underwent transfemoral TAVI in our hospital from January 2015 to September 2019, with at least a pre-TAVI and post-TAVI echocardiography. For each patients we collected clinical and echo data before and after TAVI and during the follow-up; we measured RVFWSL off-line at the same time. We considered the value of [23.3]% the cut-off of normality for RVFWSL. The primary endpoint was a composite of death from any cause and hospitalization for heart failure. The median age of the patients was 81 years (79–83) and EF was preserved in most patients (median: 56%, 55–58.28%). At a median follow-up of 1023 days (630–1387), the univariate analysis demonstrated a predictive of a reduced RVFWSL before TAVI ( Conclusions Among patients with severe aortic stenosis undergoing TAVI, a reduced pre-implant RVFWSL is able to predict long-term outcome.