CLINICAL CASE POSTER SESSION 4 P1046 An unexpected finding R. Ilhao Moreira; L. Moura Branco; M. Coutinho Cruz; P. Pinto Teixeira; L. Almeida Morais; A. Viveiros Monteiro; M. Oliveira; R. Ramos; A. Agapito; R. Cruz Ferreira Hospital de Santa Marta, Cardiology, Lisbon, Portugal A 50-years-old man, with previous history of patient ductus arteriosus submitted to surgical therapy in 1972, aortic valve replacement with mechanical prosthetic valve in 2008 due to aortic stenosis in a bicuspid valve and persistent atrial fibrillation, was electively admitted for left atrium atrial fibrillation catheter ablation. Three months before admission, a cardiac computed tomography was performed which showed no intracavitary thrombus nor other significant pathological change. During hospitalization, a transoesophageal echocardiogram showed a filiform image very mobile in the left atrium, compatible with a thrombus, 20 mm, attached to a for- eign body which crossed the interauricular septum. This exam was repeated after two weeks and the size and mobility of the thrombus remained the same. A cardiac computed tomography angiogram was performed and showed a filiform material (3 mm caliber range) that originated in the right atrial appendage, travelled posterior and inferiorly passing posterior to superior vena cava and then anterior to right superior pulmonary vein, entering through the interauricular septum to become apparently free on the left atrium cavity. The patient underwent cranial computed tomography that excluded the presence of ischemic lesions. After reviewing the surgical protocol of the aortic valve replacement, there was no reference to a possible foreign body, eventually a catheter, which could have been left during surgery. Therefore, there is no possibility to assess the origin of this foreign body that looks very much like a catheter. The patient refused surgery and was discharged maintaining oral anticoagulation. After nine months, the patient continued to be asymptomatic and in the control trans- oesophageal echocardiogram, the thrombus had disappeared and the foreign struc- ture remained in the same position. Had the patient been submitted to left atrial catheter ablation without previous trans- oesophageal echocardiogram, the possible complications could have been disastrous. P1047 Coronary artery ectasia in the setting of subacute Inferior STEMI E. Cambronero Cortinas 1 ; P. Racugno 2 ; D. Escribano 2 ; J. Mendez 2 ; A. Paya 2 ; C. Bonanad 2 ; A. Valle Munoz 3 ; MJ. Corbi Pascual 4 ; FJ. Chorro 2 ; V. Bodi 2 1 Royal Brompton Hospital, Cardiology, London, United Kingdom; 2 University Hospital Clinic of Valencia, Cardiology, Valencia, Spain; 3 Denia Marina Salud Hospital, Cardiology, Alicante, Spain; 4 Albacete University Hospital, Cardiology, Albacete, Spain Coronary artery aneurysms (CAAs) are defined as a localized area of dilatation exceeding the diameter of the adjacent normal arterial segment by 50%. The CAAs are uncommon entities seen in a small percentage of coronary angiograms. We present a case with right coronary artery aneurysms (RCA) and myocardial infarction. A male patient, 69 years ago, with history of hypertension. He was admitted our hos- pital for episode of chest pain two week ago in relation with subacute inferior STEMI. On physical examination, his blood pressure was 120/90mmHg. His heart rate was 75 bpm and regular. The JVP was not elevated without sings of heart failure. Cardiac auscultation was normal. The lung auscultation was clear and there was no peripheral oedema present. The ECG showed sinus rhythm with a normal PR and QRS interval and elevated ST segment on inferior leads, with T inversion. Chest X-ray was normal. Routine laboratory tests showed elevated troponin. Coronary angiogram was per- formed 24 hours later and showed large aneurysmal dilatation of the RCA filled with a thrombus (Figure 1E). Due the complexity of the lesion and the high risk of emboliza- tion of thrombotic material in the context of evolutional inferior STEMI. The general consensus was evaluated viability of the affected segments before decided percuta- neous angioplasty. Cardiac magnetic resonance (CMR) was performed and exposed a large aneurysmal dilatation of the RCA as well. The left ventricular ejection fraction was in the lower limits of normal with inferior akinetic and no viable segments (Figure 1D). Cardiac CT angiogram confirmed a large mostly thrombosed aneurysm of the proximal right coronary artery and showed normal dimension of ascending aorta (Image A,B and C). Medical treatment was continued with double antiaggregation and anticoagulation, beta-blockers, ARE inhibitors and statins. The patient is been fol- lowed in our outpatient clinic and he is not referred other cardiovascular symptomatology. Coronary artery aneurysms are seen only in a small percentage of coronary angio- grams. Differential diagnosis should cover different causes of aneurysmal coronary artery dilatation: Kawasaki disease, atherosclerosis, autoimmune diseases such as polyarteritis nodosa, systemic lupus erythematous, scleroderma, trauma (including coronary angioplasty), coronary artery dissection, mycotic coronary emboli and syphi- lis, among others. CMR was especially helpful in our patient in order to chose the best therapeutic option. So far, this imaging technique showed no viable RCA territory Abstract P1047 Figure. P1048 Diagnosis through the back door: the utility of the subscapular acoustic window G. Giannakopoulos; H. Mueller Geneva University Hospitals, Division of Cardiology, Geneva, Switzerland Introduction: Calcific aortic stenosis (AS) is the most common valvular heart disease in the devel- oped world. Symptomatic severe AS is associated with a high mortality rate. Accurate diagnosis is thus important for timely valve replacement, currently the only treatment option. Description of the problem: Case 1: A 54-year-old woman with unremarkable past medical history was admitted to the hospital due to severe abdominal pain and under- went urgent saplingectomy for bilateral tubo-ovarian abscesses. Soon after the sur- gery she developed shortness of breath, hypoxemia and bilateral pleural effusions (PE). Clinical examination revealed a 4/6 systolic ejection murmur radiating to both carotid arteries. Transthoracic echocardiography showed a thickened and heavily cal- cified aortic valve. Using both apical and right parasteranal window the AS was quan- tified as moderate with a peak velocity of 3.6 m/s. When the patient was placed in the sitting position, the left PE offered an additional acoustic window that allowed a better Doppler-aortic jet alignment and a peak velocity recording of 4.3 m/s. Case 2: A 57-year-old man with a remote history of Hodgkin’s lymphoma for which he received chemotherapy and radiation therapy was admitted to the intensive care unit due to refractory pulmonary edema. Initial echocardiographic assessment was challenging due to pectus excavatum that resulted in poor Doppler alignment in both apical and right parasternal windows and a heavily artefacted Doppler spectral trace. Subsequent echocardiogram performed in the sitting position, taking advantage of the left PE, allowed optimal beam-jet alignment with a peak velocity recording of approxi- mately 4 m/s. Discussion: In the first case, AS quantification using anterior thoracic acoustic win- dows underestimated disease severity as assessed by peak velocity and mean gra- dient, but interestingly not by aortic valve area calculated by the continuity equation as both prestenotic and maximal velocity jet were intercepted at the same angle. In the second case, reliable measurement of peak aortic velocity and mean gradient was not feasible using the anterior acoustic windows due to poor Doppler signal and left subscapular window was the only available access. Conclusion: In the presence of left pleural effusion subscapular acoustic window offers a valuable access for AS evaluation. Eur Heart J Cardiovasc Imaging Abstracts Supplement, December 2016 doi:10.1093/ehjci/jew261 Published on behalf of the European Society of Cardiology. All rights reserved. V C The Author 2016. For permissions please email: Journals.permissions@oup.com. 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