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Subvalvular aortic stenosis manifesting as a subaortic membrane predisposes to bacterial endocarditis, which typically affects the aortic valve or, less frequently, the left ventricular outflow tract. We present the case of a 60-year-old woman expressing an odd form of a subvalvular aortic membrane in conjunction with a left Valsalva sinus pseudoaneurysm as a result of an endocarditis complication.

Funding Acknowledgements Type of funding sources: None. Introduction The optimal lead position for right ventricle (RV) pacing is still a matter of debate. Several studies compared 2D-echocardiography left ventricle ejection fraction (LVEF) and LV global longitudinal strain (LVGLS) by speckle-tracking imaging (STI). However, these parameters present limitations, such as load dependency. Recently, myocardial work (MW) has emerged as an alternative tool for myocardial systolic function assessment. Purpose To compare LV MW and LVGLS between patients with RV outflow tract/septum pacing (Group1) and RV apical pacing (Group2). Methods Prospective single-center study of patients with permanent pacemaker (PMK) followed at our cardiac device’s outpatient clinic between july and november of 2022. Patients were divided into two groups according to RV pacing site. Moderate/severe valvular disease, LVEF<50%, segmental wall-motion abnormalities, pulmonary hypertension, cardiomyopathies, or RV dysfunction were exclusion criteria. STI-based LVGLS analysis and MW parameters were obtained (GWI:Global Work Index; GCW:Global Constructive Work; GWW:Global Wasted Work; GWE:Global Work Efficiency). RV pacing was required at the moment of imaging. A 12-lead ECG was also performed. Blood pressure (BP) was simultaneously measured. Results Our cohort comprised 30 patients in group 1 and 25 patients in group 2. The 2 groups were well-matched, except for the median time since PMK implantation, which was significantly higher in Group2 (5.3years vs 0.9years, p<0.001). The QRS was significantly narrower in Group1 (Group1:129ms±9 vs Group2:165ms±15, p<0.001). LVEF was similar in both groups (Group1:58%±7.5 vs Group2:60%±7.5, p = NS). Likewise, both systolic and diastolic BP were comparable (p = NS), but LVGLS was significantly higher in Group1 (15±3.3 vs 13±3.7, p = 0.043). Except for GWI which was also significantly higher in Group1 (1553mmHg%±581 vs 1238mmHg%±516, p = 0.040), no significant differences were found in the other parameters of MW among the groups (all p = NS). Conclusion Our results point to LVGLS being significantly lower in the group of RV apical pacing. Despite most parameters of MW didn’t differ between groups, GWI also showed significant impairment. These findings should be regarded as preliminary and further larger studies are needed to ascertain the value of this new tool in understanding the impact of pacing depolarization site on LV mechanics.

Funding Acknowledgements Type of funding sources: None. Background and purpose Left anterior descending (LAD) coronary artery occlusion has been associated with worse short-term outcomes and overall worse prognosis, there is still unclear data about the long-term risk of reinfarction in relation to the index culprit vessel. Methods In this retrospective cohort study, between 2008 and 2013, a total of 584 patients were admitted with STEMI and were subject to emergent percutaneous coronary intervention (PCI). Of those, 535 (91.6%) were alive at hospital discharge, from which 532 were considered for the analysis, after excluding the missing cases. We stratified the individuals according to the culprit vessel in two groups: anterior myocardial infarction (MI) (LAD or left main stem (LM)), and non-anterior MI (circumflex (CX) or right coronary artery (RCA)). We followed the cases for a maximum of 8 years, censoring every event beyond. The primary endpoints were reinfarction and target vessel failure (TVF). Secondary endpoints included all-cause mortality, heart failure (HF) hospitalization and stroke. Mann-Whitney-U and Chi-square tests were used to compare baseline characteristics. Kaplan-Meyer survival analysis was used to obtain the survival curves. Univariate and multivariate analysis were done using Cox regression models. Results Of the 532 individuals included in the analysis, 395 (74.2%) were men and the median age was 61 (+/- 19.8) years. The most common culprit vessel was RCA (45.5%), followed by LAD (41.2%), CX (13.2%), and lastly LM (0.20%). The median follow-up time was 6.94 (+/- 2.38) years. Overall, the anterior MI group presented at a higher Killip class (20.0% vs 14.8% in Killip class II-IV; p = 0.046) and had higher peak plasma level of high-sensitivity troponin T (6.16 vs 3.66 ng/ml; p < 0.001), suggesting larger infarct area. Left ventricle ejection fraction (LVEF) at discharge was also lower in the anterior MI group (reduced in 78,3% vs 43.4%; p < 0.001). Multivessel disease was more common in the non-anterior MI group (49.5% vs 60.9%; p = 0.005), as was PCI of non-culprit vessels (15.5% vs 22.8%; p = 0.037) and the use of bare-metal stents (20.0 vs 51.6%; p < 0.001). There were no significant differences between the groups regarding the main comorbidities, except for peripheral artery disease, more common in the non-anterior MI group (4.10 vs 10.0%; p = 0.011). There was a higher risk of reinfarction in the non-anterior MI group which persisted after relevant variable adjustment (Adjusted hazard ratio 1.96; 95% CI [1.08 – 3.67]; p = 0.027) (Figure 1). There were no significant differences regarding the risk of TVF or any of the secondary outcomes. Conclusions Although LAD/LM occlusion is thought to carry a worse short-term prognosis, non-anterior STEMI appears to be associated with a higher long-term risk of reinfarction. Despite higher rates of reinfarction, non-anterior STEMI patients have not been shown to have an excess mortality of HF hospitalizations in this cohort.

Funding Acknowledgements Type of funding sources: None. Background and purpose In ST-segment elevation myocardial infarction (STEMI) patients with multivessel coronary artery disease (MVCAD), remote-vessel percutaneous coronary intervention (PCI) has been associated with a reduction in the incidence of reinfarction when compared to a culprit-only revascularization strategy. Overall effects on long-term all-cause mortality are still unclear. Methods Between 2008 and 2013, a total of 584 consecutive patients were admitted with STEMI. 535 survived to discharge, from which 302 (56,5%) had MVCAD and were included in the analysis. We stratified the patients according to the revascularization strategy in two groups: culprit-lesion-only PCI and PCI of non-culprit vessels with angiographic significant stenosis. Patients were followed for 8 years. The primary endpoints were reinfarction in any vessel and all-cause death. Secondary endpoints included target vessel failure (TVF) (any repeat revascularization in the index culprit vessel), heart failure (HF) hospitalization and stroke. Results Of the 302 cases, 217 (74.2%) were men and the median age was 63 years. 150 (49.7%) had 2-vessel, 152 (50.3%) had 3-vessel disease and 104 (34.4%) underwent non-culprit vessel PCI. The mean follow-up time was 6.95 (± 2.29) years. Overall, the culprit-lesion-only group was older (median: 66 vs 59.5 years; p < 0.001) and had a lower proportion of smokers (41.9% vs 59.6%; p = 0.003). There were no significant differences between the groups’ other main comorbidities. The culprit-lesion-only group had a shorter hospital stay (median: 7.0 vs 7.5; p = 0.013), despite presenting at higher Killip class (24.4% vs 10.6% in Killip II-IV; p = 0.004). Regarding index PCI, no-reflow phenomenon was more common in the culprit-lesion-only group (7.1% vs 1.0%; p = 0.020), where the use of drug-eluted stents was more prevalent in the remote-vessel PCI group (69.2% vs 47.0%; p = 0.001). There was a higher risk of reinfarction (Adjusted hazard ratio (HR) 2.46; 95% CI [1.12 – 5.38]; p = 0.008) and TVF (Adjusted HR 2.37; 95% CI [1.02 – 5.48]; p = 0.044) in the culprit-lesion-only PCI group after relevant variable adjustment, with no significant differences in all-cause mortality. There were no significant differences in any of the remaining secondary outcomes. Conclusions Randomized trials and successive metanalysis have demonstrated benefit in complete revascularization after STEMI regarding the incidence of reinfarction and cardiovascular death. However, the long term impact on all-cause death is still unclear. This study corroborates the main findings in the literature, while suggesting lack of effect on overall mortality on a long-term follow-up.

Despite cardiac rehabilitation (CR) being a recommended treatment for patients with heart failure with reduced ejection fraction (HFrEF), it is still underused. This study investigated the clinical determinants and barriers to enrollment in a CR program for HFrEF patients. We conducted a cohort study using the Cardiac Rehabilitation Barriers Scale (CRBS) to assess the reason for non-enrollment. Of 214 HFrEF patients, 65% had not been enrolled in CR. Patients not enrolled in CR programs were older (63 vs. 58 years; p < 0.01) and were more likely to have chronic obstructive pulmonary disease (COPD) (20% vs. 5%; p < 0.01). Patients enrolled in CR were more likely to be treated with sacubitril/valsartan (34% vs. 19%; p = 0.01), mineralocorticoid receptor antagonists (84% vs. 72%; p = 0.04), an implantable cardioverter defibrillator (ICD) (41% vs. 20%; p < 0.01), and cardiac resynchronization therapy (21% vs. 10%; p = 0.03). Multivariate analysis revealed that age (adjusted OR 1.04; 95% CI 1.01–1.07), higher education level (adjusted OR 3.31; 95% CI 1.63–6.70), stroke (adjusted OR 3.29; 95% CI 1.06–10.27), COPD (adjusted OR 4.82; 95% CI 1.53–15.16), and no ICD status (adjusted OR 2.68; 95% CI 1.36–5.26) were independently associated with CR non-enrollment. The main reasons for not being enrolled in CR were no medical referral (31%), concomitant medical problems (28%), patient refusal (11%), and geographical distance to the hospital (9%). Despite the relatively high proportion (35%) of HFrEF patients who underwent CR, the enrollment rate can be further improved. Innovative multi-level strategies addressing physicians’ awareness, patients’ comorbidities, and geographical issues should be pursued.

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