Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2016

doi:10.1093/ehjci/jew257

CLINICAL CASES: ISCHAEMIC HEART DISEASE

899 900
Asymptomatic very late presentation of ALCAPA Usefulness of 3-dimensional contrast echocardiography in the diagnosis of a
E. Cambronero Cortinas1; AE. Gonzalez Garcia2; M. Bret Zurita3; D. Garcia Hamilton2; left ventricular pseudoaneurysm after acute myocardial infarction
MJ. Corbi Pascual4; J. Ruiz Cantador2; JM. Oliver Ruiz5

Downloaded from https://academic.oup.com/ehjcimaging/article/17/suppl_2/ii167/2963216 by guest on 02 April 2024

C. Marini1; F. Ancona1; S. Stella1; I. Rosa1; M. Spartera1; G. Melisurgo2;
1
Royal Brompton Hospital, Cardiology, London, United Kingdom; 2University Hospital F. Pappalardo2; A. Margonato1; E. Agricola1
La Paz, Cardiology, Madrid, Spain; 3University Hospital La Paz, Radiology, Madrid, 1
San Raffaele Hospital of Milan (IRCCS), Echocardiography Laboratory,
Spain; 4Albacete University Hospital, Cardiology, Albacete, Spain; 5University Hospital Cardiothoracic Department, Milan, Italy; 2San Raffaele Hospital of Milan (IRCCS),
Gregorio Maranon, Cardiology, Madrid, Spain Anesthesia and Intensive Care Department, Milan, Italy
Anomalous origin of the left coronary artery arising from the pulmonary artery A 62-year-old man presented at the Emergency Department of our Institution with an
(ALCAPA Syndrome) is a rare congenital heart defect that affects approximately 1 in evolving anterior ST-elevation myocardial infarction. Transthoracic echocardiogram
300,000 live births and accounts for 0.5% of all congenital heart disease and approxi- (TTE) revealed a severe left ventricular (LV) systolic dysfunction (ejection fraction
mately 10% of patients are adults. We present a rare case of 67-years old woman (EF) 20%) with akinesia of the anterolateral wall, interventricular septum and apex,
who presented in our outpatients clinic pretty asymptomatic. and evidence of apical thrombosis. He underwent an urgent coronary angiography
A female patient, 67 years old, was referred to our cardiovascular outpatient depart- that showed an ostial left anterior descending (LAD) coronary occlusion interpreted as
ment for presenting occasional episode of palpitations. She was ex-smoker. Physical the culprit lesion. Critical stenosis of the first obtuse marginal branch and posterior
examination revealed no stigmata of right or left heart failure and a 3/6 holosystolic interventricular artery were observed and, upon an Intra Aortic Balloon Pump (IABP)
murmur was present. Electrocardiogram showed sinus rhythm at 65 bpm, normal axis placement, treated during the same procedure with angioplasty and drug eluted stent
and thin QRS and inverted T wave at V1 to V3. Chest X-ray revealed cardiomegaly placement. He was admitted to the Intensive Care Unit (ICU) where he was treated
(cardiothoracic ratio, 55%). Routine laboratory tests were irrelevant. 2-dimensional with dual antiplatelet therapy, unfractionated heparin (UFH) and anti-remodeling ther-
and colour Doppler imaging transthoracic echocardiography (TTE) demonstrated a apy with a progressive improvement in hemodynamic parameters. A myocardial viabil-
dilated right coronary artery (RCA, 1.5 cm in diameter), aneurysmatic LMA originated ity Positron Emission Tomography study and Single-Photon Emission Computerized
in dilated main pulmonary artery (MPA) with multitude of collaterals between left coro- Tomography perfusion study revealed extended apical necrosis, therefore it was
nary artery (LCA) and right coronary artery (RCA). Mitral valve was mixoid with mild decided not to revascularize the LAD territory. An implantable cardioverter defibrillator
to moderate regurgitation and LV was mildly dilated with normal overall ejection frac- was implanted. Given the apparent resolution of LV thrombosis at a control TTE, anti-
tion and RV was normal in size with good overall systolic function as well. Exercise coagulant therapy was stopped and the patient was transferred to cardiac rehabilita-
test was negative. Stress TTE showed no worsening of the wall motion or MR at peak tion. The hemodynamic state deteriorated progressively in few days. TTE showed a
stress. At peak stress there was 1mm ST depression in the inferior leads. severe spontaneous echo contrast and an elliptical mass attached to the mid segment
Multidetector-row computed tomography (MDCT, Image A and B) confirmed origin of of the lateral wall (3x4 mm), protruding into LV, highly suggestive for intraventricular
left main artery (LMA) in the pulmonary artery and enormous size epicardial arteries thrombus. Unfractionated heparin was started and the patient was sent back to ICU.
and very large collaterals across the anterior and diaphragmatic surface of the right He was in INTERMACS class 2, and epinephrine, IABP, levosimendan cycles were
ventricle (RV), collateralizing to the left system with no significant signs of atheroscle- used to sustain hemodynamics. Heart team decided for an LV assist device (LVAD)
rosis and no obstruction the coronary arteries. The RCA arose from the aorta runni- support as bridge to decision, upon intraventricular thrombosis resolution. At this point
ng?a normal course, and showed marked dilatation throughout its extent, with a diam- TTE images highly suspicious for a pseudoaneurysm at the basal anterolateral wall of
eter of up to 1.5 cm (near the origin). Cardiac magnetic resonance (CMR, Image C) LV, with a thrombotic apposition protruding into LV. Echocardiographic contrast along
showed a dilated LV with normal overall systolic function. Late gadolinium enhance- with 3-dimensional (3D) echocardiography were used to settle the diagnosis of a
ment sequences showed subtle mid septal enhancement. The calculated pulmonary post-acute myocardial infarction (AMI) pseudoaneurysm. A cardiac Computed
to systemic blood flow ratio (Qp:Qs ratio) was 1.8. Exercise stress myocardial perfu- Tomography confirmed the presence of a thrombosed pseudoaneurysm. This diagno-
sion scintigraphy did not demonstrate any perfusion defect. 24-hour Tape electrocar- sis changed significantly the therapeutic approach, shifted from LVAD to cardiac
diogram monitoring was carried out. Normal SR with a mean HR of 62 bpm was transplant. The patient was put on a waiting list for a heart transplant. An IABP was
recorded. There were frequent supraventricular ectopic including one run of five beats positioned surgically via right axillary artery, and the patient was discharged after a 5-
and no significant ventricular ectopic. Coronary angiography was not performed. month hospitalization with indication to a close follow-up. Three months later he
Although surgical correction is the usual treatment for such cases, medical treatment received a heart transplant, and the post-procedural course was uneventful.
was preferred for this patient because she was asymptomatic without clinical signs of
heart failure. The following medications was started: carvedilol and AAS. She is been
followed-up as an outpatient clinic since 5 years ago and she is still pretty
asymptomatic.
In the diagnosis of ALCAPA syndrome, CMR and MDCT were especially helpful tool
toward the better understanding of this complex cardiac arteries anatomy. Factors
that may lead to asymptomatic survival beyond the infancy in our patient can be
related to extensive development of collateral circulation between the right coronary
artery to the LCA and reversal flow from the pulmonary artery into the LCA, which
provided enough oxygenated blood to the myocardium.

Abstract 900 Figure.

901
Peri-procedural jailing of septal perforator branch retrospectively identified
using speckle tracking echocardiography
R. Sorrentino; F. Lo Iudice; T. Niglio; E. Stabile; M. Galderisi; B. Trimarco
Federico II University Hospital, Advanced biomedical science, Naples, Italy
Background: Jailing of septal perforator branches following percutaneous coronary
Abstract 899 Figure.
intervention (PCI) of left anterior descending artery (LAD) is a possible complication

Published on behalf of the European Society of Cardiology. All rights reserved. V

C The Author 2016. For permissions please email: [email protected].
ii168 Abstracts

that can lead to ECG ischemia-related changes, conduction disturbances, ventricular Conclusion: Anomalous left coronary artery from pulmonary artery (ALCAPA) is not
arrhythmias, peri-procedural myocardial infarction and even complete heart block. considered an inheritable congenital cardiac defect but is a rare congenital cardiac
The effect of septal branches jailing related occlusion on left ventricular (LV) function malformation. It presents predominantly in infancy or adulthood with features of myo-
and its relevant prognostic value is controversial. Speckle tracking echocardiography cardial ischemia, heart failure or sudden cardiac death. However, the prognosis is
(STE) derived longitudinal strain, a sensitive tool for diagnosis of myocardial ischemia, good with early surgical correction, but awareness of this condition is essential for
allows to highlight changes in ischemic area not otherwise detectable with visual eval- prompt diagnosis and referral to a tertiary cardiac center.
uation. Case Report: A 63–years old male with history of hypertension and smoke
habit referring for acute chest pain was admitted to cath lab with diagnosis of anterior
STEMI. Patient was hemodynamically stable, still symptomatic for angina, had no
signs of cardiac failure. Ultrasensitive troponine I was 191 pg/ml (cut-off point ¼0-34).
Coronary angiography revealed a critical long thrombotic stenosis of proximal LAD,
treated by balloon angioplasty and implantation of one drug eluting stent (3 x 34 mm)
obtaining TIMI 3 final flow. Circumflex coronary artery had a non-culprit critical steno-
sis (70%) with indication for staged PCI. Patient was transferred to coronary care unit
and underwent echo-Doppler including STE. Bull’s eye evaluation of LV longitudinal
strain identified a dysfunctional area involving mainly anterior septum and, with lesser
degree, posterior septum and anterior wall ;global longitudinal strain (GLS) was -

Downloaded from https://academic.oup.com/ehjcimaging/article/17/suppl_2/ii167/2963216 by guest on 02 April 2024

12.7% (Figure 1a). The day after, 14 hours post PCI, patient was hemodynamically
stable and asymptomatic. A new STE evaluation showed an enlargement of dysfunc-
tional area, involving entire septum. GLS was also worsened compared to the pre-
vious one (-9%) (Figure 1b). Accordingly, re-analyses of PCI procedure image records
showed a peri-procedural occlusion of proximal septal perforator branch likely respon-
sible for ischemic region identified by STE. However, patient had a good clinical
course during hospitalization, underwent subsequent staged-PCI on circumflex coro-
nary artery 4 days after and was discharged in good clinical conditions, asymptomatic
for chest pain and without symptoms/signs of congestive heart failure. Discussion:
The extension of ischemic area identified with STE induced a reanalysis of the inter-
ventional procedure. This allowed the disclosure of a procedure-related septal branch
occlusion, not pointed out during the urgency context of PCI. Our clinical case has
practical implications showing the usefulness of serial evaluation of longitudinal strain
in subacute settings, it being a very sensitive tool even in detection of minor complica-
tions of acute coronary syndromes. This kind of information could be utilized also to
drive clinical management of patients with residual side-branch jailing after PCI. Abstract 902 Figure.

903
Coronary artery compression by aneurysmal pulmonary artery
RG. Badea; R. Enache; M. Serban; D. Gherasim; P. Platon; C. Ginghina
Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Cardiology, Bucharest,
Romania
Introduction. Coexistent congenital heart defects, CHD raise difficulties in manage-
ment of both pediatric and adult patients. Therapeutic mishandling in childhood is not
rare and it echoes in present times by implying a high risk surgical profile and by limit-
ing the benefit of medical and percutaneous intervention.
Case report. 43 year old male presents for evaluation having a medical history of
complex CHD: small subpulmonary ventricular septal defect (VSD), closure of persis-
tent ductus arteriosus, PDA and angioplasty for aortic coarctation, preoperatory pul-
monary to systemic pressure ratio of 0.75 and late postoperatory reevaluation showed
Abstract 901 Figure. a ratio of 0.49. Problem and procedures. 6 minute walk test: 399m, desaturation from
91% to 82%, 10 mmHg fall in BP. Echocardiography revealed small subpulmonary
902 VSD and aneurysmal pulmonary artery, PA (main PA 57mm); biventricular hypertro-
phy, right ventricle, RV with mild systolic dysfunction, estimated systolic PA pressure,
Anomalous origin of the left coronary artery from the pulmonary artery
sPAP of 96mmHg; moderate to severe pulmonary regurgitation, moderate subvalvular
(ALCAPA)
aortic stenosis, mild to moderate aortic regurgitation. Catheterisation showed severe
Y. Hassan1; E. Elsharkawy2; R. Laymouna1; M. Elgowelly2; A. Almaghraby2 pulmonary arterial hypertension, PH (mean PAP 91 mmHg), pulmonary arterial resist-
1
International Cardiac Center Hospital, cardiology, Alexandria, Egypt; 2Alexandria ance 12,1 Wood units, Qp:Qs 1,41. Coronarography revealed ostial stenosis of 50-
University, cardiology, Alexandria, Egypt 60% of the left main coronary artery, LMCA which had a 7 mm diameter.
Introduction: Anomalous origin of the left coronary artery from the pulmonary artery Cardiopulmonary testing defined Weber class B.
(ALCAPA) is a rare but serious congenital cardiac anomaly. Its occurrence is gener- Questions and problems. The double aortic valvulopathy generates low diastolic
ally similar between males and females. coronary perfusion insufficient for the biventricular hypertrophy. Moreover, LMCA suf-
fers from extrinsic compression. This scenario raises 3 problems: 1) repair of aortic
Case report: A 19-year-old male patient, with no history of diabetes mellitus nor?hy-
valvulopathy; 2) closure of VSD; 3) dilation of LMCA stenosis.
pertension. He did not experience any previous attacks of chest pain, dyspnea or syn-
Answers and discussions. 1) Correction of the aortic disease is to be reevaluated
cope. He presented to our facility after resuscitation from sudden cardiac?arrest?while
given its moderate grade and natural slow progression. 2) VSD is too small to close
playing football. Upon examination, the patient had stable vital signs and an?unre-
and also acts as pressure release valve, its correction would cause right ventricular
markable clinical examination. Electrocardiogram showed normal sinus rhythm with
no ST segment abnormalities. Routine lab investigations were unremarkable?except decompensation. 3) However we support either pulmonary arterioplasty if the dilation
for weak positive troponin test. A Chest X-ray showed an average cardiac shadow. is progressive, or stenting of LMCA, high risk lesion: ostial position, supplemental
Echocardiography revealed normal data including normal left ventricular dimensions sPAP rise with physical exercise, more cardiovascular risk factors in time. The wide
and function. Multi-detector computed tomography revealed that the left main coro- LMCA constitutes an anatomical advantage and for now he is on sildenafil with satis-
factory results.
nary artery arising from the main pulmonary trunk then bifurcating to give left anterior
Conclusions and implications. PH in adults with CHD is not rare, mainly because
descending artery (LAD) and left circumflex artery (LCX). The right coronary artery
overdue surgical interventions in childhood. We expect a decline in this phenomenon
was arising normally from the Aorta (from right sinus of Valsalva).
after years of implementing PH guidelines. This should be endorsed by detailed CHD
The patient was referred for surgery. The left main coronary artery was resected from
management standardisation. Another point is validation of previously described fac-
the pulmonary artery and implanted to the aortic root.
Follow up multi-detector computed tomography (one year later) showed that the left tors for extrinsic LMCA compression: PA>40 mm, PA:aorta ratio>1,21, presence of
main coronary artery arising from the aortic root with good distal flow. All coronary PH. Given the low pretest probability of atherosclerosis PH patients rarely undergo
arteries were healthy with good flow. coronarography, but we promote that even without manifest ischemia, those with
compression risk factors should be investigated accordingly.

Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2016

 Abstracts ii169

Conclusions and Implications for Clinical Practice

Pseudoaneurysm is an increasingly rare but lethal complication of AMI. The presence
of a murmur in the context of AMI should always prompt urgent echocardiographic
investigation. A knowledge of echocardiographic features of pseudoaneurysm are
needed to help differentiate from true aneurysm as the acute management can differ.
Cardiac CT and 3D echo are useful to aid diagnosis and define the anatomy.

Downloaded from https://academic.oup.com/ehjcimaging/article/17/suppl_2/ii167/2963216 by guest on 02 April 2024

Abstract 904 Figure.

905
Single coronary ostium from the right aortic sinus of valsalva
Abstract 903 Figure.
R. Laymouna1; E. Elsharkawy2; Y. Hassan1; M. Elgowelly2; A. Almaghraby2
1
International Cardiac Center Hospital, cardiology, Alexandria, Egypt; 2Alexandria
904 University, cardiology, Alexandria, Egypt
A rare complication of myocardial infarction: pseudoaneurysm leading to Introduction: Single coronary ostium anomalies are rare conditions found in less
ischaemic VSD than 0.03% of the general population. One of these rare anomalies is the left main
TD. Heseltine; E. Lima; JM. Cino-Polla coronary artery arising from the right coronary artery. Although these anomalies are
Whiston Hospital, Cardiology, Liverpool, United Kingdom present at birth they are not diagnosed until older age.
Case report: A 63-year-old female patient, non-smoker, with medical history of diabe-
Introduction: Pseudoaneurysm is an increasingly rare complication of acute myocar-
tes mellitus and hypertension. She started complaining of exertional chest pain in the
dial infarction (AMI). This is recognised as an acute surgical emergency. The modern
past six months, which was relieved spontaneously. She presented to our facility com-
era of early invasive strategy combined with new potent antiplatelet agents have
plaining acute retrosternal chest pain. Upon examination, the patient had stable vital
greatly reduced the incidence of this often lethal complication. Urgent echocardiogra-
signs and an unremarkable clinical examination. Electrocardiogram was unremark-
phy is an essential tool in the assessment of patients presenting with pseudoaneur-
able. Routine laboratory investigations were unremarkable (including negative tropo-
ysm. We describe a case of pseudoaneurysm associated with ischaemic ventricular
nin test). Echocardiography revealed normal left ventricular dimensions and function.
septal defect (VSD) following delayed presentation of inferior AMI.
128-multidetector Computed tomography coronary angiography showed a single ori-
Case Report: A 67 year old patient was admitted with increasing exertional shortness
gin coronary artery arising from the right aortic sinus of Valsalva. An anomalous left
of breath over a two week period. He had a medical background of gallstones. His
main coronary artery (LM) was noticed to arise from the right coronary artery (RCA)
cardiac risk factors included smoking and a positive family history of ischaemic heart
passing anterior to the pulmonary outflow trunk to reach the anterior inter-ventricular
disease.
groove to give the left anterior descending artery (LAD) and the left circumflex artery
His initial ECG showed inferior Q waves with borderline ST elevation in the inferior
(LCX). The left anterior descending artery (LAD) was a short vessel. The right coro-
leads (figure 1). His chest radiograph showed evidence of pulmonary oedema. The
nary artery was a very large vessel. All these coronary arteries were healthy with
troponin was borderline elevated. He was treated initially with dual antiplatelets, low
good flow.
molecular weight heparin and intravenous diuretics. Clinical examination revealed
The patient was assured that she had no coronary artery disease but all she had was
bilateral crepitations with a loud pansystolic murmur at the left sternal edge. He was
a rare variation of coronary artery origin with no specific disease.
haemodynamically stable throughout.
Conclusion: Single coronary origin is a rare type of coronary artery anomalies.
Urgent echocardiography revealed a large pseudoaneurysm involving the mid-inferior
Multidetector computed tomography is one of the best non-invasive modalities in diag-
posterior wall. The cavity of the pseudoaneurysm communicated with the right ven-
nosis of coronary artery anomalies.
tricle (figures 2 and 3). The right ventricle was non-dilated with good systolic function.
The pulmonary artery systolic pressure was elevated at 50mmHg. The left ventricular
function was hyperdynamic.
This finding was later confirmed on cardiac CT with VSD measurements calculated at
1.3cm x 2.1cm. The patient was subsequently transferred to our local tertiary centre
where he underwent angiography and intra-aortic balloon pump placement. Once sta-
bilized he underwent VSD closure with resection of the left ventricular pseudoaneur-
ysm with saphenous vein grafting to the mid-LAD. The patient was discharged and he
remained asymptomatic at three months follow up.
Questions, Problems and Differential Diagnosis
1) Which are the differential diagnoses in patients with a murmur in the setting of
AMI?
2) What are the echocardiographic clues to differentiate true aneurysm with false or
pseudoaneurysms? 4) 3) What are the treatment options for patients with pseudoa-
neurysms and true aneurysms post MI?
4) What is the mortality of patients with pseudoaneurysms?
Answers and Discussion: 1) Ischaemic mitral regurgitation (MR) which may be sec-
ondary to a large area of infarct or papillary muscle rupture. Acute VSD. Tricuspid
regurgitation in the setting of right ventricular infarct. The presence of a murmur in a
patient with AMI especially if clinically unstable should trigger an urgent Echo.
2) True Aneurysm: Wide neck, usually at apex (only 3% inferior). Pseudoaneurysm:
narrow neck (less than 50% aneurysm diameter), thrombus support, pericardial
effusion.
3) Surgical intervention is the treatment of choice in patients with pseudoaneurysm. In
true aneurysms the risk of surgery against medical treatment can be considered Abstract 905 Figure.
depending on symptoms, location of aneurysm, LV function, presence of arrhythmia.
4) 50% mortality with medical treatment and 10% with surgery.

Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2016

ii170 Abstracts

906 kinase and myoglobin were negative on several occasions. Transthoracic

Incremental value of regional longitudinal strain upon visual assessment for Echocardiography (TTE) showed a diffused hypokinesis of the left ventricle (LV) with
detection of ischemia during dobutamine stress echocardiography akinetic and aneurismal apex, with an ejection fraction (EF) of 28%. A large thrombus
C. Santoro; F. Ilardi; M. Lembo; F. Lo Iudice; P. Cirillo; G. Esposito; B. Trimarco; (4 cm x 1.7 cm) was visualized in the apex. The patient was transferred to Cardiology
M. Galderisi Department. Initially, the patient’s condition remained severe. He was hypotensive
Federico II University Hospital, Advanced biomedical science, Naples, Italy (systolic blood pressure was in 80 mmHg range) and required inotropic support. On
admission to Cardiology Department The Glasgow Coma Scale (GCS) was 15.
Background: In patients with left main (LM) or three-vessel coronary artery disease His condition improved gradually. At present he is fully mobile, in logical contact and
(CAD), the detection of myocardial ischemia is of pivotal importance for management. shows sings of retrograde amnesia.
In these patients, due to balanced ischemia, stress nuclear imaging may not show Cardiac computer tomography displayed the proximal occlusion of Left Anterior
any myocardial perfusion defect and wall-motion appear even normal at maximal Descending Artery (LAD) with partly collateral flow from marginal artery, severe hypo-
dobutamine stress echocardiography (DSE). Speckle tracking echocardiography kinesia of interventricular septum and akinesia of anterior wall, LV apex and apical
(STE) allows a quantitative evaluation of wall motion abnormalities (WMA) also during segments of LV. In addition, a significant thinning (down to 2.5 mm) and dyskinesia
stress. Application of STE to DSE is actually limited at the highest heart rates (HRs) was visualized in the apical segment of the anterior wall, consistent with LV pseudoa-
occurring at maximal dobutamine doses. Case Report: We present a case of a 69- neurysm (5.5 x 2.2 x 5.1cm, gate 1.9 x 2.7 cm), partly filled with a thrombus. Finally a
year old man, smoker, hypertensive and hypercholesterolemic, affected by chronic small ventricular septal defect (2 mm) with left-to-right flow was found.
CAD. Four years before our evaluation, he underwent a percutaneous coronary inter- Three weeks later the TTE was performed and revealed an unchanged EF (28%).

Downloaded from https://academic.oup.com/ehjcimaging/article/17/suppl_2/ii167/2963216 by guest on 02 April 2024

vention (PCI) with drug eluting stenting on obtuse marginal (OM) branch of circumflex The LV aneurysm was still present, however a pseudoaneurysm of 5.5 cm x 2.3 cm
coronary artery (CCA). At that time, a concomitant intermediate stenosis of left ante- with a gate of 1.7 cm, partly filled with parietal thrombus was found. The presence of
rior descending (LAD) artery, judged non "angiographically" significant, was not a small apical ventricular septal rupture with left-to-right shunt was confirmed.
treated. The patient referred for effort chest pain with spontaneous resolution after This case shows unparalleled numbers of complications in a survivor of a late
few minutes. DSE included quantification of regional and global longitudinal strain presentation of an extensive myocardial infarction: LV aneurysm, LV pseudoa-
(GLS) by a novel Automated Function Imaging (AFI) system which provides confocal neurysm, ventricular septal rupture and embolic cerebral stroke due to LV thrombus.
imaging, it allowing to achieve enhanced spatial resolution with higher frame rate, The presence of pseudoaneurism was not confirmed in the first TTE, however most
even during sinus tachycardia. At rest, although the absence of ECG alteration and likely it was already present at the time (most probably in the first TTE LV pseudoa-
visual WMA, a mild reduction of longitudinal strain (LS) in basal segments of anterior, neurysm was filled with thrombus and proper echocardiographic diagnosis was not
lateral and posterior walls was evidenced. Ejection fraction (67%) and GLS (-22.4%) possible at this time).
were normal. At maximal dobutamine dose, the patient referred chest pain, again The patient’s condition remain stable and he is awaiting a cardiac surgery in 3
without ECG alteration or visual WMA (Figure 1). Nevertheless, a reduction of LS in months.
basal segments of anterior, lateral and posterior walls was demonstrated, despite a
still normal GLS (25.7%) (Figure 1). Based on the pure AFI assessment, the patient
was scheduled for coronary angiography that showed right coronary artery without
stenosis, but also moderate LM stenosis involving either CCA, with 75% ostium
lesion, and LAD, with a critical ostium lesion; critical stenosis of second diagonal
branch, moderate stenosis of intermediate branch and significant marginal OM steno-
sis, distal to the previous implanted stent, were also found. The global sintax score
calculated was 35. Accordingly, the patient underwent cardiac surgery with successful
sequential grafting in left internal mammary artery to LAD and diagonal branch, and in
saphenous vein to OM and intermediate branch. Discussion: The main limitation of
STE DSE corresponded to a poor identification of speckles at the highest HRs occur-
ring at the highest dobutamine doses. The present clinical case demonstrates the
important incremental value of novel AFI-derived regional strain upon visual WMA
assessment during DSE, driving a better decision making of CAD patients.

907
One serious complication after myocardial infarction, isn’t that enough?
K. Sawicka; M. Prasal; M. Tomaszewski; A. Wojtkowska; A. Tomaszewski
Medical University of Lublin, Cardiology Department, Lublin, Poland
A 47-year- old man was admitted to the Neurology Department due to ischemic stroke
(involving thalamus and pons, due to embolism of basic artery). There was no pre-
vious medical history. After ECG cardiological consultation was performed. The ECG
demonstrated signs consistent with an extensive anterior myocardial infarction (QS Abstract 907 Figure.
V1-V6 and persistent ST –elevation). Cardiac markers, including troponin I, creatine-

Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2016