Luís, A S

Abstract Background Transthoracic echocardiography is the primary modality used for the assessment of the pericardial space. Guidelines recommend semi-qualitative assessment of the size of a pericardial effusion with characterization as trace, small, moderate or large. The reproducibility and association of this characterization is variable. Whether simple 2D-based quantitative measures of effusion size better associate with pericardial volumes is unclear. An accurate measure of pericardial volume would be helpful for tracking patients over time. Purpose To test whether 2D-based measures of the pericardial space could accurately predict pericardial volumes. Methods We retrospectively assessed a series of echos performed immediately prior to pericardiocentesis. 2D-based area tracings from the parasternal long and short axis at the papillary muscle level as well as 2D volumetric tracings from the apical 4 chamber view using the Simpson's method were tested with the operator blinded to the true pericardial volume (recorded at pericardiocentesis). Patients who underwent pericardiocentesis in setting of acute perforation were excluded as were patients where pericardiocentesis was unsuccessful or incomplete. Pericardial fluid area or volume was calculated by taking the difference between the measures obtained by tracing the epicardial border of the heart and pericardium (figure 1). Results The median pericardiocentesis (n=118) fluid volume was 500 mL (IQR 350 – 750 mL) with a range, 95–2300 mL. The pericardial fluid was serous (22%), sero-sanguineous (37%) and sanguineous in 41%. The effusion was malignant in 24 cases and due to inflammation in 42 cases. Pericardial area traces from either the parasternal short (r=0.56, p<.0001) or long axis (r=0.62, p<.0001) correlated modestly with measured pericardial volume. The average volume estimated echocardiographically by the Simpson’s method was 580 ± 359 mL (range, 85.8–2419 mL). There was stronger linear correlation between echocardiographic (apical 4-chamber measurement) and pericardiocentesis-derived volumes (r=0.92, p < 0.0001; figure 2A). Etiology of the pericardial effusion was not associated with estimates of pericardial volumes. There was a large overlap in pericardial volume amongst the reading physician qualitative grading of effusion size (figure 2B). Categorization of pericardial effusion size was improved when based on volumetric estimates (Kappa 0.65) rather than physician estimates (Kappa 0.32; Figure 2B). Variation between measured pericardial volume and actual pericardial volume was most related to the quality of the image and the likely extent to which the pericardial fluid was not entirely captured in the image window. Conclusion Two-dimensional transthoracic echocardiography using biplane Simpson’s method of disks can simply and reasonably accurately estimate the pericardial effusion volume. This technique may add value in the serial assessment of pericardial effusions. Figure 2

Abstract Background Cardiac metastasis from neuroendocrine tumors (NET) is rare and has been thought to potentially result in life threatening sequalae. Peptide receptor radionucleotide therapy (PRRT), such as Lutetium-177 (Lu-177) DOTATATE, has been validated as effective treatment for patients with NET who have progressed on somatostatin analogue (SSA) therapy and more recently suggested for use in SAA-naïve higher risk grade 2 and grade 3 NETs. However, Lu-177 DOTATATE therapy has been found to have potentially serious adverse effects both locally and systemically. Overall, the clinical significance of cardiac metastasis of NET, as well as the safety and efficacy of Lu-177 DOTATATE in this cohort, has not been thoroughly evaluated. Purpose This study assessed the outcomes and clinical consequences of cardiac metastatic involvement in patients with NET. Furthermore, this study investigated the safety of Lu-177 DOTATATE therapy in patients with cardiac metastases from NET. Methods All patients who underwent 68Ga-DOTATATE positron emission tomography for evaluation of NET across three tertiary centers between 2016 and 2022 were retrospectively evaluated. Patients with evidence of cardiac metastasis were further evaluated. Baseline characteristics, treatment modality, and clinical outcomes including mortality, arrhythmia or conduction disease, carcinoid heart disease, and heart failure admissions were recorded. Patients with cardiac metastases were grouped and compared based on therapeutic modality (conservative therapy with surveillance or SSA, Lu-177 DOTATATE therapy, or surgical resection of metastases). Results From 3253 patients with NET, 51 patients were identified to have cardiac metastases (mean age 66.7 ± 12.2 years, 54% male). Three patients underwent surgical resection of cardiac metastases, and in two of whom this was concomitant while undergoing valve surgery for carcinoid heart disease. Patients with cardiac metastasis had significantly higher mortality than patients without cardiac metastasis (HR 2.12, 95%CI 1.00 – 4.52, p = 0.049, Figure 1A). Median follow-up from diagnosis of cardiac metastasis was 3.64 years [IQR 1.59 – 5.64]. There was no significant difference in clinical outcomes between patients that received Lu-177 DOTATATE therapy (n = 27) and conservative therapy (n = 21). Specifically, there was no significant difference in mortality risk at five years post the diagnosis of cardiac metastasis between these groups (p = 0.47, Figure 1B). Conclusion Patients with cardiac metastasis from NETs have worse clinical outcomes than NET patients without cardiac metastatic involvement. Lu-177 DOTATATE therapy appears to be safe in patients with cardiac metastasis from NET.Figure 1AFigure 1B

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND Detection of immobile leaflets immediately following bioprosthetic valve implantation is a rare but important intraoperative finding. Restriction of leaflet movement can occur in the closed or open position, leading to abnormal prosthesis function. We sought to determine the clinical implications of immobile leaflets seen on intraoperative echocardiography. METHODS Patients with immobile leaflets identified on intra-operative/procedure echocardiography immediately post implantation between 2009-2020 were identified from an institutional database. All echocardiograms were reviewed de-novo to confirm immobile leaflets in the immediate post-implantation period. Identified cases were matched 1:2 to controls for age; sex; prosthesis position, model and size; and implantation approach (surgical vs. transcatheter). Nominal logistic regression and proportional hazards were used to analyze outcomes. RESULTS Thirty patients with immobile leaflets immediately post-bioprosthesis implantation were included. Clinical characteristics are summarized in the Table. Immobile leaflets were documented in procedural reports in only 18 (60%) patients. Moderate stenosis was present intraoperatively in 1 patient, none demonstrated ≥moderate regurgitation, and none resulted in immediate corrective action. In 3 (10%), valve re-intervention was required within 30 days due to symptomatic prosthesis dysfunction. Presence of restricted leaflet motion was associated with higher need for post-operative extracorporeal membrane oxygenation use (odds-ratio 7.3, p = 0.02) and composite end-point of death, valve re-replacement, prosthesis thrombosis, or cardiac hospitalizations (risk ratio 2.1, p = 0.03, Figure). CONCLUSION Immobile leaflet(s) immediately post-bioprosthetic valve implantation is an uncommon, under-reported, and under-treated phenomenon. Even in the absence of significant prosthetic valve dysfunction, it can be associated with worse post-operative course as well as worse outcomes. Baseline characteristics Age 76 (67-84) Sex, male 10 (33%) Surgical approach 25 (83%) Aortic 5 (17%) Mitral 12 (40%) Tricuspid 12 (40%) Pulmonary 1 (3%) Re-intervention within 10 days 3 (10%) Numbers are presented as median (interquartile range) or number (percentage). Abstract Figure. Clinical outcome of stuck leaflets