1 ORGANIZING COMMITTEE

International Committee International President: Prof. Navin Nanda Members: Navin C. Nanda, MD (USA) Hanumanth Reddy, MD (USA) Ming C. Hsiung, MD (Taiwan) Satish Parashar, MD (India) Robert Gatewood, MD (USA) Zvi Vered, MD (Israel) Jaroslaw Kasprzak, MD (Poland) Vadim A. Kuznetsov, MD (Russia) Piotr Lipiec, MD (Poland) Serdar Kucukoglu, MD (Turkey) Kul Aggarwal, MD (USA) Pedro Armendariz, MD (Peru) Vincent Sorrell, MD (USA) Nilda Espinola Zavaleta (Mexico ) Lidiette Esquivel (Costa Rica) C. N. Manjunath, MD (India)

Local Organizing Committee National President: Assoc. Prof. Krasimira Hristova Secretary General: Assoc. Prof. Elena Kinova Secretary General- HIT: Dr. Svetlin Tsonev

National Scientific Committee Krasimira Hristova, MD Arman Postadzhiyan, MD Elena Kinova, MD Tzvetana Katova, MD Temenuga Donova, MD Naidenka Zlatareva, MD Nina Gocheva, MD Maria Tokmakova, MD Ludmila Vladimirova-Kitova, MD Yoto Yotov, MD Pencho Kratunkov, MD Sotir Marchev, MD Iana Simova, MD Valentina Mincheva, MD Elina Trendafilova, MD Rabhat Shabani, MD Ivo Petrov, MD Ivan Gruev, MD Assen Goudev, MD Svetlin Tsonev, MD Dobrin Vassilev, MD Emil Manov, MD Vera Yotova, MD Rumen Marinov, MD

HOST The event is hosted by the Foundation of Cardiovascular Imaging www.fcibg.com

2 3 WELCOME ADDRESSES

Dear Friends and Colleagues, Dear Faculty and Attendees, On behalf of the Local Organizing Committee, it is my greatest On behalf of the International Society of Cardiovascular Ultrasound pleasure to welcome you to the XXIV World Congress of (ISCU), I most heartily welcome you to the XXIV World Congress of and Cardiovascular Imaging on 17-20 May, Echocardiography and Cardiovascular Imaging which is being 2018, here in Albena Resort. held May 17-20, 2018 in the picturesque seaside Albena Resort, Varna, Bulgaria. The XXIVth World Congress has brought together world-class researchers and clinicians numbering 600 participants from It is most gratifying to know that as busy as you are with your 19 countries and 3 continents. work in your own country, you have still taken precious time off to come all the way to Bulgaria to lend your expertise and knowledge to this Congress. I am most grateful to you We truly believe that the Congress will provide a wonderful forum for you to refresh your for doing this and for enthusiastically supporting not only this Congress but also many knowledge base and explore the innovations in every aspect of echocardiography and other World Congresses and International Conferences sponsored or co-sponsored by cardiovascular imaging. The forum will strive to offer plenty of networking opportunities, ISCU over the past several years. providing you with the opportunity to meet and interact with the leading scientists and researchers, friends and colleagues as well as sponsors and exhibitors. The Bulgarian Society of Echocardiography needs to be highly commended for undertaking the onerous task of organizing this Congress and appointing no other I would like to extend sincere gratitude for the valuable support to the International and than Professor Krasimira Hristova, the pioneer of echocardiography in Bulgaria and a Bulgarian eminent experts for joining our forum to share with us their broad experience, nationally renowned cardiologist, as the Congress President. to all sponsors and exhibitors for contributing to the high level of this forum and to all attendees dedicating time and expressing insatiable thirst for knowledge. She has been working extremely hard and tirelessly for over three years to make this Congress a great success and all the credit for this fantastically successful Congress I am delighted to welcome you to the XXIV World Congress of Echocardiography and goes personally to her for her capable leadership and to her great team which includes Cardiovascular Imaging as with your attendance you do become part of its ultimate aim Associate Professor Elena Kinova, the Congress Vice President, Dr. Svetlin Tsonev, the of keeping a healthy heart. Congress Secretary and many others. We are also grateful to Daniela Radulova, the We hope you will enjoy the symphony of outstanding science, taking a little extra time to Congress Event Manager for all the meticulous arrangements she has made in regards enjoy also the spectacular and unique beauty of the Bulgarian seaside. to housing, transportation and accommodation facilities for the faculty and attendees. She has been on top of everything! Thank you very much! Again, a very welcome and I am sure you will remember and cherish the Bulgarian Best Regards, hospitality you enjoyed in Albena for a long time. Sincerely,

Assoc. Prof. Krasimira Hristova, Prof. Navin C. Nanda, MD, PhD, FESC MD, DSc(Hon), DSc(Med)(Hon), FACC, FAHA, FISCU(D) National President, Local Organizing Committee, International President, XXIV World Congress of XXIV World Congress of Echocardiography and Cardiovascular Imaging, Bulgaria 2018 Echocardiography and Cardiovascular Imaging President of the Foundation of Cardiovascular Imaging President, International Society of Cardiovascular Ultrasound (ISCU) President of the Bulgarian Working Group on Cardiovascular Imaging Distinguished Professor of Medicine and , University of Alabama at Birmingham, Birmingham, Alabama, USA 4 5 SCHEDULE Thursday, 17 May PROGRAM Thursday, 17 May

SEA HALL WIND & SKY HALL FLAMINGO GRAND HALL Sea Hall /Paradise Blue Hotel/ /Paradise Blue Hotel/ /Flamingo Grand Hotel/ /Paradise Blue Hotel/ 08:00 - 20:00 Registration /Main lobby of Paradise Blue Hotel/ 08:00 - 10:00 Registration /lobby of Paradise Blue Hotel/ 10:00 - 12:00 ECHO IN CRITICAL CLINICAL FOCUS: 10:00 - 12:00 ECHO IN CRITICAL ILL PATIENTS ILL PATIENTS AND Chairmen: E.Kinova, H. Soliman PERICARDIAL DISEASES 10:00 - 10:20 Integrated cardiac imaging in 12:00 - 13:30 Lunch Symposium BAYER /Paradise Blue Hotel/ G. Elkilany /UAE/ 13:30-15:30 VALVULAR HEART BASIC OF CARDIAC ASSESSMENT OF 10:20 - 10:40 Role of imaging in patients with shock DISEASES I part ULTRASOUND I DIASTOLIC FUNCTION H. Soliman /UK/ Coffee Break and visit to the exhibition 15:30 - 16:00 10:40 - 11:00 Acute pulmonary embolism or /lobby of Paradise Blue Hotel, Sea Hall/ L. Vladimirova /Bulgaria/ 16:00 - 18:00 DIASTOLIC BASIC OF CARDIAC CONGENITAL HEART FUNCTION ULTRASOUND II DISSEASE SESSION I 11:00 - 11:20 Acute and echo imaging E. Srbinovska /FYROM/ 18:00 - 18:30 1. Presidential lecture K. Hristova /Bulgaria/ 11:20 - 11:40 Echo in sudden cardiac death N. Cardim /Portugal/ 2. Presidential Lecture - Echo from 50’s to 2018 N. Nanda /USA/ 11:40 - 12:00 Ultrasound 19:00 Opening Ceremony /Sea Hall/ H. Soliman /UK/ Welcome Reception /lobby of Paradise Blue Hotel/ 12:00 – 13:30 Lunch Symposium BAYER in Paradise Blue Hotel, Sea Hall News in Practical guidelines: How to choose NOAC in different patients I. Savelieva /UK/ 13:30 – 15:30 VALVULAR HEART DISEASES I part Chairmen: I. Gruev, R. Pai 13:30 - 13:50 Echocardiographic assessment of mitral stenosis R. Shabani /Bulgaria/ 13:50 - 14:10 Echo evaluation of mitral regurgitation R. Pai /USA/ 6 7 PROGRAM Thursday, 17 May PROGRAM Thursday, 17 May

14:10 - 14:30 3D for valvular intervention Wind & Sky Hall M. Saric /USA/ /Paradise Blue Hotel/ 14:30 - 14:50 Assesing valvular regurgitations from genetics to 08:00 - 10:00 Registration /lobby of Paradise Blue Hotel/ intervention N. Nanda /USA/ 10:00 - 12:00 CLINICAL FOCUS: Endocarditis Chairmen: K. Hristova, E. Plonska 14:50 - 15:10 Role of CV imaging in the assessment of right heart structure and function in TR patients. 10:00-10:18 Inside from the new ESC guidelines JB. Park /South Korea/ E. Plonska /Poland/ 15:10 - 15:30 Malignant prolapse 10:18-10:36 Endocarditis and its complications V. M. Parato /Italy/ V. M. Parato /Italy/ 15:30 – 16:00 Coffee Break and visit to the exhibition in the lobby 10:36-10:54 Prostetic valve endocarditis of Paradise Blue Hotel A. Aleksiev /Bulgaria/ 16:00 – 18:00 DIASTOLIC FUNCTION 10:54-11:12 Right side endocarditis Chairmen: E. Kinova, F. Sozzi K. Hristova /Bulgaria/ 16:00 - 16-20 Mitral inflow, LA volumes, Tissue Doppler velocities 11:12-11:30 Echocardiography for diagnosis of submasive and PA pressure pulmonary embolism F. Sozzi /Italy/ R. Tandon /India/ 16:20 - 16:40 LV strain and twist, LA strain 11:30-11:40 Clinical case 1 A. Gopal /USA/ The hidden endocarditis D. Gnanam /Netherlands/ 16:40 - 17:00 Diastolic function on right heart P. Manoria /India/ 11:40-11:50 Clinical case 2 Aspergillus endocarditis 17:00 - 17:10 Clinical case: Breathlessness R. Tandon /India/ J. Nesser /Austria/ 11:50-12:00 Clinical case 3 17:10 - 17:30 The European experience: insight from Q- fever endocarditis Eurofilling study R. Ilieva /Bulgaria/ K. Hristova /Bulgaria/ 12:00 – 13:30 Lunch Symposium BAYER in Paradise Blue Hotel, 18:00 - 18: 30 Presidential lecture Sea Hall K. Hristova /Bulgaria/ News in Practical guidelines: How to choose NOAC in Presidential Lecture - Echo from 50’s to 2018 different patients N. Nanda /USA/ I. Savelieva /UK/ 8 9 PROGRAM Thursday, 17 May PROGRAM Thursday, 17 May

13:30 – 15:30 BASIC OF CARDIAC UTRASOUND I: Flamingo Grand Hall Chairmen: M. Gospidinova, J. Nesser /Flamingo Grand Hotel/ 13:30-13:50 Physics, instrumentation and machine settings 08:00 - 10:00 Registration /lobby of Paradise Blue Hotel / P. Malhotra /India/ 10:00 - 12:00 CARDIOMYOPATHY AND PERICARDIAL DISEASES 13:50-14:10 The complete standard echo study Chairmen: Sv. Tsonev, V. M. Parato R. Shabani /Bulgaria/ 10:00-10:20 LV hyperthrophy: athletes vs. hypertensive vs. 14:10-14:30 Common mistakes and pitfalls in 2D: how to avoid them hypertrophic cardiomyopathy N. Nanda /USA/ N. Cardim /Portugal/ 14:30-14:50 Facts or artifacts in 3D echocardiography 10:20-10:40 Restrictive CMP vs. constrictive . R. Janardhanan /USA/ Transient constrictive pericarditis 14:50-15:10 Advance in non – invasive assessment of cardiac I. Simova /Bulgaria/ mechanics 10:40-11:00 How to use imaging in acute and chronic J. Nesser /Austria/ pericardial diseases? 15:10-15:30 Determination of myocardial viability by echocardiography R. Shabani /Bulgaria/ R. Senior /UK/ 11:00-11:20 Management of pericardial diseases in era of 15:30 – 16:00 Coffee Break and visit to the exhibition in the lobby multimodality imaging of Paradise Blue Hotel Sv. Tsonev /Bulgaria/ 16:00 – 18:00 BASIC OF CARDIAC UTRASOUND II 11:20-11:40 Stress CMP and noncompaction: echo in context of Chairmen: I. Gruev, P. Claus multimodality imaging V. M. Parato /Italy/ 16:00-16:20 Stretch -strain relations: a new non-invasive approach to myocardial contractility 11:40-12:00 Apical HCP – a challenge in diagnosis P. Claus /Belgium/ N. Espinola-Zavaleta /Mexico/ 16:20-16:40 2D and 3D strain in clinical practice 12:00 – 13:30 Lunch Symposium BAYER in Paradise Blue Hotel, J. Nesser /Austria/ Sea Hall News in Practical guidelines: How to choose NOAC 16:40-17:00 3D in valvular diseases in different patients S. Shrivastava /India/ I. Savelieva /UK/ 17:00-17:20 Intraoperative echocardiography P. Malhotra /India/ 17:20-17:40 Moderator band – what does in moderate? 10 M. Saric /USA/ 11 PROGRAM Thursday, 17 May PROGRAM Thursday, 17 May

13:30 – 15:30 ASSESSMENT OF DIASTOLIC FUNCTION 17:20-17:40 Mechanical deformation in adults with unrepaired Chairmen: I. Simova, S. E. Catirli aortic coarctation N. Espinola-Zavaleta /Mexico/ 13:30-13:50 Guidelines for patients with HFrEF E. Kinova /Bulgaria/ 17:40-17:50 Atrial related to isolated persistent left superior vena cava- clinical case 13:50-14:10 Diastolic stress echo S. Slavcheva /Bulgaria/ I. Simova /Bulgaria/ 14:10-14:30 Assessment of LV filling pressure in primary pulmonary hypertension S. Kücükoğlu /Turkey/ 14:30-14:50 LV vortex intensity and LV diastolic function R. Gupta /India/ 14:50-15:10 Guidelines for patients with HFpEF R. Shabani /Bulgaria/ 15:10-15:30 Right ventricle function in HFpEF S. E. Catirli /Turkey/ 15:30 – 16:00 Coffee Break and visit to the exhibition in the lobby of Paradise Blue Hotel 16:00 – 18:00 CONGENITAL HEART DISSEASE SESSION I Chairmen: P. Kratunkov, W. Budts 16:00-16:20 and aortic arch in CHD W. Budts /Belgium/ 16:20-16:40 Arch abnormalities – imaging in children and adults G. Elkilany /UAE/ 16:40-17:00 Patent foramen ovale –shunt quantification as a prerequisite for transcatheter closure M. Saric /USA/ 17:00-17:20 How to image normal venous return and atria G. Di Salvo /USA/

12 13 SCHEDULE Friday, 18 May PROGRAM Friday, 18 May

SEA HALL WIND & SKY HALL FLAMINGO GRAND HALL Sea Hall /Paradise Blue Hotel/ /Paradise Blue Hotel/ /Flamingo Grand Hotel/ /Paradise Blue Hotel/ 08:00 - 10:00 Valvular heart CLINICAL USE OT CONGENITAL HEART 8:00 - 10:00 Valvular heart diseases II diseases II - Aortic 2D SPEACKLE DISEASES II – from natural history stenosis – from TRACKING to intervention natural history to intervention Chairmen: Y. Yotov, M. Saric 10:00- 10:30 Coffee Break and visit to the exhibition 08:00-08:20 Natural history, and current concept of AS /lobby of Paradise Blue Hotel/ S. Shrivastava /India/ 10:30 - 13:00 JOINT SESSION LEFT VENTRICULAR ADVANCE ECHO 08:20-08:40 Doppler imaging of AS – tips and tricks WITH KOREAN FUNCTION TECHIQUES – R. Pai /USA/ SOCIETY OF ECHO- BASICS, INDICATIONS, CARDIOGRAPHY, PROTOCOLS 08:40-09:00 Role of 3D and Multimodality imaging for assessing of AS BWG OF CVI AND AND INTERPRETATIONS K. Aggarwal /USA/ ISCU - UP TO DATE RESEARCH ON LV 09:00-09:20 Issue of transcatheter AVR – TAVR FUNCTION M. Saric /USA/ 13:00 - 14:00 Lunch Satellite Symposium Berlin Chemie /Paradise Blue Hotel, Sea Hall/ 09:20-09:40 Cardiac reverse remodeling after heart valve surgery L. Vladimirova /Bulgaria/ 13:00 - 14:00 Moderated poster session I /lobby of Paradise Blue Hotel/ 09:40-10:00 Three challenges clinical cases 14:30 - 16:30 THE COMMONS: ORAL ABSTRACTS DISCOVERING EARLY R. Pai /USA/ DIABETIC AND SESSION I HEART FAILURE HYPERTENSIVE IN CARDIOMYOPATIES 10:00 - 10:30 Coffee Break and visit to the exhibition in the lobby HEART DISEASE of Paradise Blue Hotel 16:30 - 17:00 Coffee Break and visit to the exhibition /lobby of Paradise Blue Hotel/ 10:30 - 13:00 JOINT SESSION WITH Korean Society of 17:00 - 19:00 HEART FAILURE Transesophageal CARDIOONCOLOGY Echocardiography, BWG of CVI and ISCU - /TOE/ ECHOCAR- Up to date research on LV function DIOGRAPHY – Chairmen: K. Hristova, JB. Park from basic to the advance 10:30-10:50 Assessment of Central Hemodynamics using 19:00 - 19:30 SATELLITE SATELLITE Noninvasive Cardiovascular Imaging SYMPOSIUM KRKA SYMPOSIUM W. I. Yang /South Korea/ SANDOZ 10:50-11:10 Echocardiography and multimodality imaging in 20:30 - 22:30 Sponsor’s evening patient with HFpEF JB. Park /South Korea/ 14 15 PROGRAM Friday, 18 May PROGRAM Friday, 18 May

11:10-11:30 Treatment and prevention of cardiotoxiticity from 15:50-16:10 Appropriate Echo Evaluation Follow-up for the cancer treatment Diabetic and/or Hypertensive Patient E. Kinova /Bulgaria/ I. Gruev /Bulgaria/ 11:30-11:50 Dyspnea in HCMP – a complex cardiac and 16:10-16:30 How to avoid pitfalls in interpretation of perfusion ventilatory interactions – based on cardiopulmonary imaging? test and stress echocardiography A. Singh /USA/ K. Hristova /Bulgaria/ 16:30 - 17:00 Coffee Break and visit to the exhibition in the lobby 11:50-12:10 An usual case of LV apex involvement in HCMP of Paradise Blue Hotel V. M. Parato /Italy/ 17:00 - 19:00 HEART FAILURE 12:10-12:30 Clinical case of involvement of LV function by FMF Chairmen: L. Vladimirova-Kitova, V. M. Parato L. Andreeva /Bulgaria/ 17:00-17:20 Incorporating guidelines in the clinical practice 12:30-12:45 Discussion V. M. Parato /Italy/ 13:00 - 14:00 Lunch Satellite Symposium by Berlin Chemie in 17:20-17:40 Systolic function in 2018 – role of twisting and Paradise Blue Hotel, Sea Hall deformation Echocardiographic assessment of the clinical E. Donal /France/ effects of the therapy in patients with Cardiovascular diseases. 17:40-18:00 Diastolic function in 2018 – suction and relaxation K. Hristova /Bulgaria/, E. Kinova /Bulgaria/, F. Sozzi /Italy/ V. Mincheva /Bulgaria/ 18:00-18:20 What are the best prognostics markers in heart 14:30 - 16:30 The Commons: Diabetic and Hypertensive failure – imaging vs biomarkers Heart Disease S. Parashar /India/ Chairmen: L. Vadimirova-Kitova, E. Srbinovska 18:20-18:40 Stress echo in heart failure patients 14:30-14:50 The Diabetic Heart A. Salustri /Qatar/ S. Jovanova /FYROM/ 18:40-19:00 Myocardial dyssinchrony in HF 14:50-15:10 The Hypertensive Heart M. Vadalazhkaya /Belarus/ R. Ivanova /Bulgaria/ 19:00 - 19:30 Satellite Symposium KRKA 15:10-15:30 Ischemic Disease: Microvascular and Coronary Flow Chairman: A. Gudev /Bulgaria/ Reserve A step further in treatment of CV diseases I. Simova /Bulgaria/ M. Sabovic /Slovenia/ 15:30-15:50 Vascular: Carotid Intima-Media Thickness 20:30 - 22:30 Sponsor’s evening M. Staneva /Bulgaria/ /lobby of Paradise Blue Hotel/ 16 17 PROGRAM Friday, 18 May PROGRAM Friday, 18 May

Wind & Sky Hall 11:10-11:30 Guidelines based selection of cardiac /Paradise Blue Hotel/ resynchronization therapy recipients. I. Simova /Bulgaria/ 8:00 - 10:00 CLINICAL USE OT 2D SPECKLE TRACKING Chairmen: L. Vladimirova-Kitova, P. Claus 11:30-11:50 LV haemodinamics in heart failure P. Manoria /India/ 08:00-08:20 Deformation lmaging with tracking techniques, echo versus MRI. 11:50-12:10 Assessment of left atrial function- predictors of P. Claus /Belgium/ clinical success after PVI R. Radoslavova /Bulgaria/ 08:20-08:40 Assessment of the layer strain A. Gopal /USA/ 12:10-12:30 Multimodality imaging for diastolic function D. Neglia /Italy/ 08:40-09:00 Right ventricle strain – better than classical parameters 13:00 - 14:00 Lunch Satellite Symposium by Berlin Chemie in K. Hristova /Bulgaria/ Paradise Blue Hotel, Sea Hall Echocardiographic assessment of the clinical 09:00-09:20 Evidence matter – when and how to use 2D and 3D effects of the therapy in patients with speckle tracking today? Cardiovascular diseases. A. Gopal /USA/ K. Hristova /Bulgaria/, E. Kinova /Bulgaria/, V. Mincheva /Bulgaria/ 09:20-09:40 Lessons from the EACVI/ASE intervendor study J. Kasprzak /Poland/ 14:30 - 16:30 Oral Abstracts session I Chairmen: R. Shabani, E. Plonska 09:40-10:00 Right ventricular afterload and ventricular interdependency 14:30-14:40 Pulmonary artery pressure before and after Mitraclip P. Claus /Belgium/ I. Tonchev /Israel/ 10:00 - 10:30 Coffee Break and visit to the exhibition in the lobby 14:40-14:50 Correlation between LAA spontaneous echo of Paradise Blue Hotel contrast and fractional change of its orifice area L. Mihov /Bulgaria/ 10:30 - 13:00 LEFT VENTRICULAR FUNCTION Chairmen: R. Radoslavova, J. Nesser 14:50-15:00 Pregnancy-associated presenting as a peripartal cardiomyopathy in a 10:30-10:50 Cardiac chamber quantifications according to the 37-year-old woman guidelines D. Gencheva /Bulgaria/ St. Goldstein /USA/ 15:00-15:10 CLIP THE STITCH: Mitraclip techniques 5 years after 10:50-11:10 3D echocardiography in LV assessment Alfieri stitch mitral valve repair J. Nesser /Austria/ I. Tonchev /Israel/ 18 19 PROGRAM Friday, 18 May PROGRAM Friday, 18 May

15:10-15:20 Left atria phasic function in HCP versus 18:40-19:00 TOE and LAA closure hypertensive heart disease in middle ages patients. R. Janardhanan /USA/ A. Borizanova /Bulgaria/ 19:00 - 19:30 Satellite Symposium SANDOZ 15:20-15:30 Rare case of paradoxal embolism Benefits beyond the Anti-Hypertensive effect of D. Vassileva /Bulgaria/ Dipperam (Amlodipine / Valsartan) - favorable early Echocardiographic implications of subclinical 15:30-15:40 Echocardiography in petroleum workers A. Sarma /India/ Y. Simova /Bulgaria/ 15:40-15:50 A story with a sudden start and almost unexpected 20:30 - 22:30 Sponsor’s evening ending /lobby of Paradise Blue Hotel/ M. Vladova /Bulgaria/ 15:50-16:00 Non- bacterial thrombotic endocarditis in a patient with rheumatoid T. Kurteva /Bulgaria/ 16:00-16:30 Discussion 16:30 - 17:00 Coffee Break and visit to the exhibition in the lobby of Paradise Blue Hotel 17:00 - 19:00 Transesophageal /TOE/ echocardiography – from basic to the advance Chairmen: E. Kinova, N. Nanda 17:00-17:20 Basics of the 2D and 3D TEE Exam K. Aggarwal /USA/ 17:20-17:40 LV function assessment N. Nanda /USA/ 17:40-18:00 Prosthetic valves: echo challenges S. Laing /USA/ 18:00-18:20 3D TEE in cardiac surgery P. Malhotra /India/ 18:20-18:40 TOE in ASD/VSD closure K. Maganti /USA/

20 21 PROGRAM Friday, 18 May PROGRAM Friday, 18 May

Flamingo Grand Hall 10:50-11:10 Stress echocardiography 2020 /Flamingo Grand Hotel/ A. Salustri /Qatar/ 8:00 - 10:00 CONGENITAL HEART DISEASES II 11:10-11:30 Stress echocardiography in valvular diseases Chairmen: G. Elkilany, G. Di Salvo E. Plonska /Poland/ 08:00-08:20 Fethal echocardiography – to improve prenatal 11:30-11:50 Role of flow status by assessing aortic stenosis detection of CHD R. Senior /UK/ A. Bhat /USA/ 11:50-12:10 Stress Echo for Risk Stratification 08:20-08:40 Tetralogy of Fallot preoperative anatomy and J. Kasprzak /Poland/ variation 12:10-12:30 Value of incorporating contrast echo in stress – P. Shivachev /Bulgaria/ echocardiography 08:40-09:00 Tetralogy of Fallot – echo and multimodality imaging R. Senior /UK/ during follow up 13:00 - 14:00 Lunch Satellite Symposium by Berlin Chemie in G. Di Salvo /UK/ Paradise Blue Hotel, Sea Hall 09:00-09:20 Echo evaluation for ventricular septum for Echocardiographic assessment of the clinical intervention or surgery effects of the therapy in patients with A. Bhat /USA/ Cardiovascular diseases. K. Hristova /Bulgaria/, E. Kinova /Bulgaria/, 09:20-09:40 Diastolic Dysfunction in ACHD V. Mincheva /Bulgaria/ W. Budts /Belgium/ 14:30 - 16:30 DISCOVERING EARLY HEART FAILURE IN 09:40-10:00 Echo assessment of ACHD – from 2D to 3D CARDIOMYOPATIES W. Li /UK/ Chairmen: Y. Yotov, A. Varga 10:00-10:10 Clinical case – Cor triatriatum 14:30-14:48 HYPERTROPHIC CMP F. Sozzi /Italy/ G. Elkilany /UAE/ 10:00 - 10:30 Coffee Break and visit to the exhibition in the lobby 14:48-15:06 DILATED CMP of Paradise Blue Hotel Y. Yotov /Bulgaria/ 10:30 - 13:00 ADVANCE ECHO TECHIQUES – BASICS, 15:06-15:24 ARRHITMOGENIC CMP INDICATIONS, PROTOCOLS AND INTERPRETATIONS H. Reddy /USA/ Chairmen: J. Kasprzak, A. Varga 15:24-15:42 NON-COMPACTION CMP 10:30-10:50 Stress – echocardiography in CAD E. Kinova /Bulgaria/ A. Varga /Hungary/

22 23 PROGRAM Friday, 18 May MODERATED POSTER SESSION Friday, 18 May

15:42-16:00 INHERITANCE DISEASES AND CMP A. Varga /Hungary/ 13:00-14:00 Chairmen: N. Nanda, E. Kinova, A. Salustri, S. Kutty, V. Sorrell 16:00-16:18 Stress induced CMP T. Tak /USA/ 1. Anthropometric parameters as a predictors of myocardial dysfunction in patients with asymptomatic type 2 mellitus 16:18-16:36 Slavica Mitrovska, Silvana Jovanova /FYROM/ J. Nesser /Austria/ 2. CT assessment of normal variant of LAA anatomy -a case with diverticula and 16:30 - 17:00 Coffee Break and visit to the exhibition in the lobby accessory appendage. of Paradise Blue Hotel P. Popeski, B. Bogdanova, K. Genova /Bulgaria/ 17:00 - 19:00 CARDIOONCOLOGY 3. Hypertrophic CMP in infant Chairmen: K. Hristova, E. Plonska K. Ganeva, P. Shivachev /Bulgaria/ 17:00-17:18 ESC guidelines on cancer therapy and cardiotoxicity 4. Acute aortic syndrome – CT assessment E. Plonska /Poland/ B. Bogdanova, K. Genova, P. Popeski /Bulgaria/ 17:18-17:36 Can we still use EF for guiding oncology therapy? 5. related to isolated persistent left superior vena cava K. Hristova /Bulgaria/ S. Slavcheva, A. Angelov, G. Dimitrova /Bulgaria/ 6. What of type CMP? 17:36-17:54 Biomarkers and cardiac imaging – the right balance K. Gospodinov, S. Tisheva /Bulgaria/ for cardiotoxicity K. Maganti /USA/ 7. Ruptured sinus of Valsalva aneurism A. Nikolova, A. Peneva, A. Shaban, M. Milanova /Bulgaria/ 17:54-18:12 Heart masses – thrombus vs. tumors M. Vadalazhkaya /Belarus/ 8. Expect the unexpected A. Kisheva, Y. Yotov /Bulgaria/ 18:12-18:30 Tumors of the heart – 34 years of experience at the 9. Libman Sacks endocarditis of aortic valve in patients with SLED. National Institute of Cardiology Ignacio Chavez Somleva, E. Kinova, N. Spasova, B. Krastev, A. Goudev /Bulgaria/ N. E. Zavaleta /Mexico/ 10. Hypertrophic cardiomyopathy as a first presentation of Anderson-Fabry 18:30-18:48 Radiation Related Cardiovascular Diseases and disease, diagnosed with cardiac magnetic resonance Valve diseases K. Genova, M. Denev, H. Mateev /Bulgaria/ E. Srbinovska /FYROM/ 18:48-19:00 Misdiagnosis for right atrial mass – a case report N. Espinola-Zavaleta /Mexico/ 20:30 - 22:30 Sponsor’s evening /lobby of Paradise Blue Hotel/

24 25 SCHEDULE Saturday, 19 May PROGRAM Saturday, 19 May

SEA HALL WIND & SKY HALL FLAMINGO GRAND HALL Sea Hall /Paradise Blue Hotel/ /Paradise Blue Hotel/ /Flamingo Grand Hotel/ /Paradise Blue Hotel/ 8:30 - 10:00 MULTUMODALITY STRESS ECHO FOR ADVANCE IMAGING IN 08:30 - 10:00 MULTUMODALITY IMAGING IN ERA OF QUATIFICATION IMAGING IN ERA VALVULAR HEART ECHOCARDIOGRAPHY Chairmen: M. Gospodinova, G. Elkilany OF QUATIFICATION DISEASE: GO WITH THE FLOW 08:30-08:45 Techniques for Valve Regurgitation H. Reddy /USA/ 10:00-10:30 Coffee Break and visit to the exhibition /lobby of Paradise Blue Hotel/ 10:30 - 13:00 ADVANCE IN ISHEMIC HIT–HOT SESSION MULTIMODALITY IMAGING 08:45-09:00 Quantification of Left Ventricular Systolic Function HEARD DISEASE - MY CHALLENGES FOR VASCULAR DISEASES G. Elkilany /UAE/ READ WITH EXERTS CLINICAL CASE 09:00-09:15 Quantification of Right Ventricular Size and Function 13:00 - 14:00 Lunch Satellite Symposium Actavis /Paradise Blue Hotel, Sea Hall/ V. Sorrell /USA/ 13:00 - 14:00 Moderated poster session II /lobby of Paradise Blue Hotel/ 09:15-09:30 Quantification of Atrial Function 14:30 - 16:30 STRUCTURAL HEART THE RIGHT HEART RIGHT HEART: I. Vlasseros /Greece/ DISEASES THERE IS CONGENITAL 09:30-09:45 Utility of Right Ventricular Strain Compared to HEART DISEASES Conventional Echo Quantification for Assessment of 16:30 - 17:00 Coffee Break and visit to the exhibition /lobby of Paradise Blue Hotel/ Cardiac MRI Evidenced Right Ventricular Dysfunction 17:00 - 19:00 STRAIN IMAGING IN ECHO AND ACUTE CONTRAST ECHO E. Sade /Turkey/ HEART FAILURE MYOCARDIAL INFARCTION 09:45-10:00 Multimodality Imaging in Restrictive M. Gospodinova /Bulgaria/ 19:00 - 19:30 ESAOTE SATELLITE SYMPOSIUM 10:00 – 10:30 Coffee Break and visit to the exhibition in the lobby NOVARTIS of Paradise Blue Hotel 20:30 – 23:00 Gala Dinner /Albena Variete Theater/ 10:30 - 13:00 ADVANCE IN ISHEMIC HEART DISEASE - READ WITH EXERTS Chairmen: I. Simova, A. Singh 10:30-10:50 Echocardiographic assessment of patients with CAD- review of old and new techniques. K. Hristova /Bulgaria/ 10:50-11:10 Coronary assessment by non-invasive cardiac imaging I. Simova /Bulgaria/

26 27 PROGRAM Saturday, 19 May PROGRAM Saturday, 19 May

11:10-11:30 Role of CMR in diagnosis of CA 15:30-15:50 Echo Guidance for Paravalvular Leak Closure F. Sozzi /Italy/ K. Aggarwal /USA/ 11:30-11:50 Myocardial SPECT in the diagnosis of CAD 15:50-16:10 Percutaneous Treatment for Tricuspid Regurgitation G. Elkilany /UAE/ St. Goldstein /USA/ 11:50-12:10 New advances in percutaneous coronary 16:10-16:30 Balloon Mitral Valvuloplasty for Rheumatic Mitral Stenosis intervention: new device, new techniques and more K. Karamfilov /Bulgaria/ K. Karamfilov /Bulgaria/ 16:30-16:50 Percutaneous Mitral Valve Replacement 12:10-12:30 Imaging for assessment myocardial viability A. Gopal /USA/ A. Singh /USA/ 16:30 – 17:00 Coffee Break and visit to the exhibition in the lobby of 13:00 – 14:00 Lunch Satellite Symposium by Actavis in Paradise Paradise Blue Hotel Blue Hotel, Sea Hall Eplerenone in the treatment of heart failure 17:00 – 19:00 STRAIN IMAGING IN HEART FAILURE Chairman: I. Gruev /Bulgaria/ Chairmen: N. Nanda, E. Sade 13:00 - 13:30 Evaluation of the safety and tolerance profile of 17:00-17:20 Evaluation of Ischemic Cardiomyopathy: Insights from eplerenone and spironolactone in patients with Strain Imaging heart failure with reduced global ejection fraction - E. Sade /Turkey/ monocentric comparative study 17:20-17:40 Strain in the Evaluation of Nonischemic Cardiomyopathy E. Manov /Bulgaria/ I. Mikati /USA/ 13:40 - 13:50 Eplerenone – clinical case of patient with heart 17:40-18:00 Strain in the Evaluation of Hypertrophic failure with reduced ejection fraction Cardiomyopathy E. Donal /France/ D. Vasileva /Bulgaria/ 18:00-18:20 Cardiac Resynchronization Therapy: Echo Before, 13:50-14:00 Discussion During, and After Implantation 14:30 – 16:30 STRUCTURAL HEART DISEASES E. Sade /Turkey/ Chairmen: K. Karamfilov, M. Saric 18:20-18:40 Pressure strain loops in the evaluation of the LBBB. 14:30-14:50 TAVR: TTE and TEE Evaluation E. Donal /France/ K. Aggarwal /USA/ 18:40-19:00 2D and 4D X-strain technology – an incremental value 14:50-15:10 MitraClip: Basic Echo Imaging for Routine Clip in your everyday practice M. Saric /USA/ M. Maglione /Italy/ 15:10-15:30 Imaging for Left Atrial Appendage Occlusion 19:00 - 19:30 ESAOTE R. Janardhanan /USA/ 20:30 – 23:00 Gala Dinner /Albena Variete Theatre/ 28 29 PROGRAM Saturday, 19 May PROGRAM Saturday, 19 May

Wind & Sky Hall 10:50-11:00 Challenges in the management of a patients with /Paradise Blue Hotel/ NCLV and VT L. Zolumova /Bulgaria/ 08:30 - 10:00 Stress Echo for : Go with the Flow Chairmen: Y. Yotov, N. Kesser 11:00-11:10 RV noncompaction I. Gruev /Bulgaria/ 08:30-08:45 Low Gradient Aortic Stenosis with Depressed Ejection 11:10-11:20 Peripartal CMP Fraction I. Bayraktarova /Bulgaria/ A. Varga /Hungary/ 11:20-11:30 Patient with L/R shunt on three levels 08:45-09:00 Low Gradient Aortic Stenosis with Normal Ejection N. Marinov /Bulgaria/ Fraction A. Salustri /Italy/ 11:30-11:40 Tricuspid valvuloplasty I. Stanilov /Bulgaria/ 09:00-09:15 Mitral Stenosis R. Janardhanan /USA/ 11:40-12:00 Pulmonary embolism T. Tak /USA/ 09:15-09:30 Mitral Regurgitation N. Kesser /Turkey/ 12:00-12:20 Clinical cases of rheumatic heart diseases D. Roychoudhury /USA/ 09:30-09:45 Assessment of Pulmonary Hemodynamics V. Sorrell /USA/ 12:20-12:30 Fibroelastoma – clinical case D. Vassileva /Bulgaria/ 09:45-10:00 The role of echo in the timing of surgery/ intervention N. Kesser /Turkey/ 12:30-12:45 Discussion 10:00 – 10:30 Coffee Break and visit to the exhibition in the lobby 13:00 – 14:00 Lunch Satellite Symposium by Actavis in Paradise of Paradise Blue Hotel Blue Hotel, Sea Hall Eplerenone in the treatment of heart failure 10:30 - 13:00 HIT–HOT SESSION Chairman: I. Gruev /Bulgaria/ My challenges clinical case Chairmen: L. Vladimirova-Kitova, R. Shabani 13:00 - 13:30 Evaluation of the safety and tolerance profile of eplerenone and spironolactone in patients with 10:30-10:40 Granulomatosis with Polyangiitis (GPA) and an Acute heart failure with reduced global ejection fraction - Cardiovascular Event monocentric comparative study N. Spasova /Bulgaria/ E. Manov /Bulgaria/ 10:40-10:50 Challenges in the management of a patient with AF. 13:40 - 13:50 Eplerenone – clinical case of patient with heart V. Konstantinova /Bulgaria/ failure with reduced ejection fraction D. Vasileva /Bulgaria/

30 13:50-14:00 Discussion 31 PROGRAM Saturday, 19 May PROGRAM Saturday, 19 May

14:30 – 16:30 The Right Heart 17:40-17:50 RV infarction – clinical case Chairmen: L. Vladimirova-Kitova, V. Sorrell K. Hristova /Bulgaria/ 14:30-14:48 Right Ventricular Chamber Quantification Update 17:50-18:10 Right Ventricle Myocardial Infarction: Making the S. E. Catirli /Turkey/ Diagnosis R. Shabani /Bulgaria/ 14:48-15:06 Incorporating New Technologies: Strain and 3D for assessing right heart 18:10-18:20 Clinical Case 2 V. Sorrell /USA/ N. Spasova /Bulgaria/ 15:06-15:24 Assessing Pulmonary Hypertension 18:20-18:40 Post Myocardial Infarction Complications II: S. Goldstein /USA/ Ventricular Septal Defect and Left Ventricular Rupture/Pseudoaneurysm 15:24-15:42 Echo in pulmonary embolism I. Gruev /Bulgaria/ I. Mikati /USA/ 18:40- 18:55 Discussion 15:42-16:00 Right Ventricle Manifestations of Systemic Diseases E. Kinova /Bulgaria/ 19:00 – 19:30 Satellite Symposium Novartis Timely change for better results in treatment of 16:00-16:18 RV function in valvular diseases heart failure I. Vlasseros /Greece/ Y. Yotov /Bulgaria/ 16:18-16:36 When it’s NOT Right: Carcinoid, Ebstein’s and Complications K. Hristova /Bulgaria/ 16:30 – 17:00 Coffee Break and visit to the exhibition in the lobby of Paradise Blue Hotel 17:00 – 19:00 Echo and Acute Myocardial Infarction Chairmen: E. Kinova, K. Maganty 17:00-17:20 Prognostic Value of Echo/Doppler Findings Early After Myocardial Infarction G. Elkilany /UEA/ 17:20-17:40 Post Myocardial Infarction Complications I: Acute Mitral Regurgitation Post Myocardial Infarction K. Maganti /USA/

32 33 PROGRAM Saturday, 19 May PROGRAM Saturday, 19 May

Flamingo Grand Hall 11:50-12:10 Acute aortic syndrome and CTA /Flamingo Grand Hotel/ B. Bogdanova /Bulgaria/ 08:30 - 10:00 Advance imaging in echocardiography 12:10-12:30 Multumodality imaging in acute coronary syndrome Chairmen: E. Manov, I. Simova M. Nedevska /Bulgaria/ 08:30-08:45 Cardiac involvement and echocardiographic 12:30-12:50 Incremental value of multisliced coronary tompgraphy assessment in patients with neuro-muscular disorders over angiography for left main disease. M. Gospodinova /Bulgaria/ F. Ilgenli /Turkey/ 08:45-09:00 Athetes Heart 12:50-13:00 Clinical case: Multimodality imaging in vessel diseases Y. Simova /Bulgaria/ B. Kunev /Bulgaria / 09:00-09:15 RV function in pulmonary endarterectomy 13:00 – 14:00 Lunch Satellite Symposium by Actavis in Paradise Blue M. Kanchi /India/ Hotel, Sea Hall Eplerenone in the treatment of heart failure 09:15-09:30 Cardiac blood flow imaging in CAD Chairman: I. Gruev /Bulgaria/ K. Hristova /Bulgaria/ 13:00 - 13:30 Evaluation of the safety and tolerance profile of 09:30-09:45 Pulmonary Embolism vs. Right Ventricular Infarction eplerenone and spironolactone in patients with E. Srbinovska /FYROM/ heart failure with reduced global ejection fraction - 09:45-10:00 Dobutamin stress – echocardiography in CAD monocentric comparative study G. Litsova /Bulgaria/ E. Manov /Bulgaria/ 10:00 – 10:30 Coffee Break and visit to the exhibition in the lobby 13:40 - 13:50 Eplerenone – clinical case of patient with heart failure of Paradise Blue Hotel with reduced ejection fraction D. Vasileva /Bulgaria/ 10:30 - 13:00 Multimodality IMAGING FOR VASCULAR DISEASES Chairmen: E. Goranova, D. Vasilev 13:50-14:00 Discussion 10:30-10:50 Utility and Limitations of Stress Echo in Evaluating 14:30 – 16:30 Right heart: THERE IS CONGENITAL HEART DISEASES Chairmen: S. Kutty, W. Li A. Salustri /Italy/ 14:30-14:45 Role of prenatal echo for early detection of CHD 10:50-11:10 CTA and FFRct in the Diagnosis of Coronary Artery K. Chacheva /Bulgaria/ Disease 14:45-15:00 The Right Ventricle in the Repaired Tetralogy of Fallot D. Vasilev /Bulgaria/ G. Di Salvo /Italy/ 11:10-11:30 CMR in the Assessment of Ischemic Heart Disease 15:00-15:15 The Systemic Right Ventricle: Corrected and F. Sozzi /Italy/ Uncorrected Transposition 11:30-11:50 Can Echo Imaging Complete with Other Modalities? R. Marinov /Bulgaria/ D. Neglia /Italy/ 34 35 PROGRAM Saturday, 19 May MODERATED POSTER SESSION Saturday, 19 May

15:15-15:30 Right Ventricle Response to Pressure Loads in Adults with Congenital Heart Disease 13:00-14:00 S. Kutty /USA/ Chairmen: St. Goldstein, K. Hristova, E. Donal, E. Sade, S. Laing. A. Bhat 15:30-16:00 Single Ventricle Fontan Circulation in the Adult 11. Emotional status of patients prior to echocardiography W. Li /UK/ A. Rasheva /Bulgaria/ 12. A rare case of Bland-White- Garland syndrome in 16:00-16:15 Echocardiography estimation of native preoperative a 60-year-old woman anatomy of pulmonal atresia with intact ventricular P. T. Hao /Vietnam/ septum 13. Pregnancy-associated myocardial infarction presenting as a peripartal B. Ganev /Bulgaria/ cardiomyopathy in a 37 year old woman L. Vladimirova-Kitova, F. Nikolov, D. Gencheva, N. Atanasov, 16:15-16:30 Rare congenital heart diseases S. Kitov /Bulgaria/ D. Roychoudhury /USA/ 14. A case of calcific chronic constrictive tuberculosis pericarditis 16:30 – 17:00 Coffee Break and visit to the exhibition in the lobby P. T. Hao /Vietnam/ of Paradise Blue Hotel 15. A case of haemorrhagic tamponade due to right atrium angiosarcoma P. T. Hao /Vietnam/ 17:00 – 19:00 CONTRAST ECHO 16. A case of arrhytmogenica right ventricular cardiomyopathy Chairmen: Y. Yotov, R. Senior P. T. Hao /Vietnam/ 17. Correlation between left atrial appendage spontaneous echocontrast and the 17:00-17:20 Using contrast in echocardiography – basic, fractional change of its orifice area principals, protocols L. Mihov, A. Aliev, V. Nedyalkova /Bulgaria/ Y. Yotov /Bulgaria/ 18. Impact of CRT on parameters of myocardial dyssynchrony in patients with chronic 17:20-17:40 EACVI guidelines on contrast echocardiography heart failure and arterial fibrillation T. Troyanova-Shchutskaia, A. Kurlainskaya, T. Denisevich, update – 2018 D. Goncharik, A. Chasnoyt, T. Asmalouskaya /Belarus/ R. Senior /UK/ 19. Patient with left to right shunt on three levels 17:40-18:00 Using contrast echo in CHD N. Marinov, Z. Stankov, I. Petrov, Y. Simova /Bulgaria/ S. Kutty /USA/ 20. Granulomatosis With Polyangiitis (GPA) and an Acute Cardiovascular Event 18:00-18:20 Contrast stress echo imaging – when and whom? N. Spasova, E. Kinova, D. Somleva, B. Krastev, A. Goudev /Bulgaria/ R. Senior /UK/ 18:20-18:40 Contrast вeyond еndocardial вorder definition - improving our diagnostic value S. Kutty /USA/ 18:40-19:00 Clinical cases illustrating the EACVI contrast echocardiography guidelines K. Hristova /Bulgaria/

36 37 SCHEDULE Sunday, 20 May PROGRAM Sunday, 20 May

SEA HALL WIND & SKY HALL Sea Hall /Paradise Blue Hotel/ /Paradise Blue Hotel/ /Paradise Blue Hotel/ 09:00 - 11:00 THE ROLE OF ECHO IN IMAGING THE AORTA AND GREAT 09:00 - 11:00 THE ROLE OF ECHO IN EVOLUTION OF STROKE EVOLUTION OF STROKE VESSELS Chairmen: P. Kratunkov, S. Laing 11:00 - 11:30 Coffee Break and visit to the exhibition 09:00-09:20 Complex atheromatous aortic plaques: risk factors /lobby of Paradise Blue Hotel/ for embolization 11:30 - 13:30 INTEGRATION OF 2D AND 3D HEART BREAKS – IMAGING IN V. M. Parato /Italy/ TEE AND MULTIMODALITY MYOCARDIAL DISEASES 09:20-09:40 Which Patients with Stroke Should Undergo TEE? IMAGING IN CURRENT S. Laing /USA/ PRACTICE 09:40-10:00 Transcranial Doppler: Role in Cryptogenic Stroke 13:30 - 14:00 Closing Ceremony /Paradise Blue Hotel, Sea Hall/ M. Staneva /Bulgaria/ 10:00-10:20 Patent Foramen Ovale Evaluation and the Role of Closure P. Kratunkov /Bulgaria/ 10:20-10:40 Left Atrial Appendage Occlusion Therapies: Answered and Unanswered Questions R. Janardhanan /USA/ 10:40-11:00 Clinical Cases of Unusual Causes of Stroke M. Staneva /Bulgaria/ 11:00 – 11:30 Coffee Break and visit to the exhibition in the lobby of Paradise Blue Hotel 11:30 - 13:30 Integration of 2D and 3D TEE and multimodality imaging in Current Practice Chairmen: L. Vladimirova-Kitova, A. Gopal 11:30-11:50 A comprehensive 2 D-3D study N. Nanda /USA/ 11:50-12:10 2D/3D TEE for assessing valvular diseases – an European experience E. Donal /France/

38 39 PROGRAM Sunday, 20 May PROGRAM Sunday, 20 May

12:10-12:30 2D/3D TEE in Guiding Valvular Interventions A. Gopal /USA/ 10:00-10:10 Clinical case 12:30-12:50 2D/3D TEE in Guiding Atrial Interventions S. Parashar /India/ M. Saric /USA/ 10:10-10:20 Clinical case coronary –cameral fistula 12:50-13:10 Echo and Multimodality imaging in Congenital Heart F. Sozzi /Italy/ Disease Interventions S. Kutty /USA/ 10:20-10:30 Clinical case - Pulmonal ectasia K. Hristova /Bulgaria 13:10-13:30 Echo assessment of rheumatic mitral stenosis before and after PTCM 11:00 – 11:30 Coffee Break and visit to the exhibition in the lobby A. Majumder /Bangladesh/ of Paradise Blue Hotel 13:30 – 14:00 Closing Ceremony in Paradise Blue Hotel, Sea Hall 11:30 - 13:30 HEART BREAKS – IMAGING IN MYOCARDIAL DISEASES Chairmen: E. Kinova, I. Vlasseros 11:30-11:50 Hypertensive Heart Disease E. Kinova /Bulgaria/ Wind & Sky Hall 11:50-12:10 Hypertrophic Cardiomyopathy /Paradise Blue Hotel/ N. Cardim /Portugal/ 09:00 - 11:00 Imaging the Aorta and Great Vessels 12:10-12:30 Novel modalities for early recognition of dilated Chairmen: E. Goranova, F. Sozzi echocardiography 09:00-09:15 Screening of Aortic Disease: Familial, Abdominal S. Jovanova /FYROM/ Aortic Aneurysm, and Dissection 12:30-12:50 Chemotherapy Induced Heart Failure I. Simova/ Bulgaria/ K. Hristova /Bulgaria/ 09:15-09:30 Arch Vessel Imaging for the Echocardiographers 12:50-13:10 Peripartal CMP A. Kisheva / Bulgaria/ S. Laing /USA/ 09:30-09:45 Aortopathy and Aortic Disease Management 13:10-13:30 Fabri disease Sv. Tsonev /Bulgaria/ I. Vlasseros /Greece/ 09:45-10:00 Role of MM Imaging for assessment aorta and 13:30 – 14:00 Closing Ceremony in Paradise Blue Hotel, Sea Hall great vesels R. Janardhanan /USA/

40 41

A_1. Percutaneous Treatment for Tricuspid Regurgitation Steven Goldstein Washington Hospital Center, Washington, DC, USA Due to its common association with left-sided heart valve disease or cardiomyopathy, functional tricuspid regurgitation (TR) was merely considered as an innocent bystander and a reversible condition for a long time and management focused primarily on correction of the left-sided pathology. However, more recent data indicates that TR does NOT resolve after correction of left-sided heart disease. Moreover, even moderate TR (a common problem in clinical cardiology) represents a significant risk factor for progression to severe TR and is associated with significant morbidity and reduced long-term survival. Surgical approaches consist of Kay annuloplasty, DeVega annuloplasty, and annuloplasty ring. However, many patients have advanced co-morbidities making surgery high-risk and/or undesirable. A variety of emerging transcatheter techniques are an attractive alternative to surgery for these patients that are deemed to be high-risk surgical candidates. These can be categorized as: (1) annular modification (e.g., Tricinch; Trialign; Cardioband; Millipede; Triapta) (2) Spacers (Forma device) (3) leaflet apposition (MitraClip) and (4) caval valve implantation (TricValve; SAPIEN valve implanted in the svc and IVC). Some of these preclinical and early clinical novel transcatheter treatment options for patients with symptomatic functional TR and high surgical risk will be presented.

A_2. A CASE OF Q FEVER ENDOCARDITI R. Ilieva, E. Kinova, A. Goudev Cardiology Department, UMHAT “Tsaritsa Yoanna- ISUL” Sofia, Bulgaria Q fever is endemic in Bulgaria. The most common clinical presentation of chronic Q fever is Q fever endocarditis. We describe the case of a 37-year-old woman diagnosed with Q fever endocarditis 5 months after acute Q fever. She presented with a new diastolic murmur, no signs of heart failure or other abnormalities apart from slightly elevated laboratory markers for inflammation. The transthoracic echocardiography demonstrated thickened aortic valve leaflets with no visible vegetations and moderate-to-severe aortic regurgitation with eccentric jet. The transoesophageal echocardiography visualized thickened aortic valve leaflets with focal nodular . Markedly positive serology established the diagnosis of Q fever endocarditis and prolonged antimicrobial treatment was started. CT with contrast was performed and paravalvular complications were excluded. Our case highlights the nonspecific nature of the presenting symptoms and echocardiographic findings of Q fever endocarditis and emphasizes the use of serology for its diagnosis.

A_3. A CASE OF CALCIFIC CHRONIC CONSTRICTIVE TUBERCULOUS PERICARDITIS 1Phan Thai Hao, M.D, Master of Internal Medicine 1Department of Internal Medicine, Pham Ngọc Thach University of Medicine Introduction: Chronic constrictive pericarditis is a chronic inflammatory process that involves both fibrous and serous layers of the in which fibrous thickening of the pericardium occur. Many etiological factors have been identified. Among them infection, idiopathic chronic pericarditis, post cardiac surgery, mediastinal radiotherapy are important. But pericarditis caused by Mycobacterium tuberculosis is the most common cause in endemic area. We reported a case of calcific chronic constrictive tuberculous pericarditis. Case Report: A 25-year-old Vietnamese, nonsmoker, nonalcoholic, non-diabetic, normotensive salesman from a province near our city presented with dyspnea on exertion, ankle edema, puffiness of face and abdominal distension, nonproductive cough, weight loss about 14kg for two months and a half. Night sweat, slight evening fever for about a week. General examination revealed generalized pitting edema, swelling of face, good build and nutritional status, elevated jugular venous pressure, Kussmaul’s sign. Physical examination revealed a high pitched early diastolic pericardial knock over the left sternal border, distended abdomen, shifting dullness positive, liver 3 cm from right costal margin. Patient was previously healthy, referring no prior cardiac surgery, chest radiotheray or tuberculosis. His family were normal. Results: Electrocardiogarphy showed sinus rhythm with left atrium enlargement and low voltages. Chest X-ray: frontal and lateral views showed calcified pericardium, cardiac shadow was within normal limits. Abdomen Ultrasonography: mild ascites and congestive hepatomegaly. Echocardiography: pericardial thickened (5mm), moderate (12mm), left atrium enlargement (LA=48mm), respiratory variation of the mitral peak E velocity of 29 %, EF: 55%, PASP: 20mmHg. cardiac MSCT: Left and right atrium enlargement. Total thickened and calcified pericardium. Normal coronary arteries. Moderate right pleural effusion (Fig 1) After 42 days of admission, surgical procedure pericardiectomy was done. Histopathological report of removed pericardium consistent with tuberculous pericarditis. After operation patient’s postoperative course was uneventful with improvement of heart function. Discussion: This case we diagnosed of constrictive pericarditis is based on 2015 ESC Guidelines for the diagnosis and management of pericardial diseases consist of the association of signs and symptoms of right heart failure and impaired diastolic filling due to pericardial constriction by one or more imaging methods including: Chest X-ray, Echocardiography, CT. Cause of this constrictive pericarditis was tuberculous pericarditis confirmed by histopathological report. Conclusion: Constrictive pericarditis, a disease with particularly high morbidity and mortality, remains a challenging clinical diagnosis. The commonest aetiologies are idiopathic pericarditis, prior cardiac surgery and chest radiotherapy in the developed world and tuberculosis pericarditis in the developing world. A high index of suspicion for constrictive pericarditis consist of the association of signs and symptoms of right heart failure and impaired diastolic filling due to pericardial constriction by one ormore imaging methods, including echocardiography, computed tomography, cardiac magnetic resonance, and cardiac catheterization. If pericardial fluid is not accessible, a diagnostic score ≥ 6 based on the following criteria is highly suggestive of tuberculous pericarditis in people living in endemic areas. The mainstay of treatment of chronic constrictive tuberculous pericarditis is pericardiectomy and tuberculosis chemotherapy for six months.

Figure 1 cardiac MSCT: Total thickened and calcified pericardiu

A_4. Aspergillus Fumigatus endocarditis diagnostic role of echocardiography

Rohit Tandon

DAYANAND MEDICAL COLLEGE LUDHIANA, INDIA

Incidence of fungal endocarditis is increasing globally and comprise 10% of all cases of . [6] Aspergillus species is second most frequent cause accounting for 25% of cases. During any surgical procedure, colonization of the surgical site by airborne Aspergillus conidia poses the patient for risk of endocarditis .Early diagnosis is elusive as blood cultures are negative and classic physical findings of endocarditis is rare. Diagnosis is confirmed using specialized stains from surgical specimen. Echocardiography is pivotal in early diagnosis of these cases. We discuss three cases of confirmed Aspergillus Fumigatus related infective endocarditis discuss their clinical features, mode of presentation and outcome.

A_5. CT assessment of normal variant of LAA anatomy -a case with diverticula and accessory appendage

P.Popeski , B.Bogdanova,K.Genova Department of Diagnostic Imaging and Interventional Radiology, National Heart Hospital, Sofia, Bulgaria

We present a routine retrospectively gated contrast-enhanced 64-MDCT angiography for assessment of morphology of left atrial appendage and potential cause of embolic stroke. During the routine investigation we founded rare anatomy variant of a diverticula and accessory LAA in a patient for cardiac ablation. In our poster we show their location, morphology and size. Diagnosis and recognition of diverticula or accessory LAA is of clinical importance, as it is very common place for generating thrombus formation in patients with atrial fibrillation and .

A_6. A rare case of Bland-White-Garland syndrome in a 60-year-old woman Phan Thai Hao Pham Ngoc Thach University of Medicine, Ho Chi Minh City, VietNam Background: Bland-White-Garland syndrome or Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. The usual clinical course is severe left sided heart failure and mitral valve insufficiency presenting during the first months of life. However, in some cases collateral blood supply from the right coronary artery is sufficient and symptoms may be subtle or even absent. We report A rare case of Bland-White- Garland syndrome in a 60-Year-Old Woman. Case presentation: A 60-year-old female patient presented with a 10-day history of shortness of breath and exertional , with ischemic heart disease, mitral regurgitation, heart failure 5 years ago. Her physical examination revealed a grade III/VI systolic murmur over the apex. Electrocardiogram showed normal sinus rhythm with left ventricular enlargement, poor R wave progression in the precordial leads. The patient’s echocardiographic imaging revealed dilated left-sided heart chambers, as well as reduced left ventricular ejection fraction (43%), severe mitral valve insufficiency and elevated systolic pulmonary artery pressure (60 mmHg). Multislice computed tomography with three dimensional reconstruction showed that the left main coronary artery originated from posterior side of the main pulmonary artery, confirming the diagnosis of ALCAPA (Fig 1). The patient was treated by ligation of the left coronary artery from the pulmonary artery combined with coronary artery bypass grafting and mitral valve repair. Discussion: 85% of all cases of ALCAPA present within the first two months of life. However, symptoms may be misinterpreted (as in our case) or even be absent. In adult life patients with ALCAPA could present with symptoms of heart failure, mitral valve insufficiency, angina or . Objective findings include on chest X-ray, and ECG may display an anterolateral infarct pattern. The diagnosis can often be made by two-dimensional echocardiography with direct visualization of the abnormal origin of the left coronary artery and retrograde flow into the pulmonary artery. In cases where the clinical suspicion is strong, a coronary angiography or CT-angiography should be performed. Conclusion: the diagnosis of ALCAPA should be considered in adults without evidence of ischemic heart disease presenting with arrhythmias, left sided heart failure with or without mitral valve dysfunction, since an early diagnosis and surgical treatment generally results in an excellent prognosis.

Figure 1 MS-CT showed that the left main coronary artery (LCA) originated from posterior side of the main pulmonary artery (PA) A_7. A CASE OF HEMORRHAGIC TAMPONADE DUE TO RIGHT ATRIUM ANGIOSARCOMA Phan Thai Hao, M.D Pham Ngoc Thach University of Medicine, Ho Chi Minh city, Viet Nam Background: Primary cardiac angiosarcoma is rare. It is typically located in the right atrium and manifests as right-sided heart failure or . Most patients are symptomatic at presentation and when disease is discovered, it is often late in its course, resulting in a poor prognosis. We describe a case of hemorrhagic tamponade due to right atrium angiosarcoma. Case presentation: A healthy 53-year-old man presented to lung diseases hosptital after one month of hemoptysis. He was started on antibiotics for suspected pneumonia. Over the next few weeks, the hemoptysis worsened and a chest computer tomography was performed.The result was a tumor in right atrium, then he was referred to our institution for further evaluation. Cardiac MS-CT showed a heterogeneous tumor in right atrium 6.5 x 8.0 x 8.0 cm in size suspected angiosarcoma, moderated pericardial effusion (Fig.1). PET-CT showed hypermetabolic tumor in right atrium, paratracheal lymph nodes and intrapulmonary nodes. Over one week he suddenly developed dyspneic, hypotensive, and . Examination revealed distended jugular veins, distant heart sounds, and diminished lung sounds at the bases. A transthoracic echocardiogram demonstrated a large circumferential pericardial effusion with evidence of cardiac tamponade. He was transfered to emergency surgery. A large amount of blood was found in the pericardial space. Direct invasion of the tumor to the pericardium detected. The tumor was located on the wall of the right atrium and extended over the epicardium. Bleeding from the tumor had ceased after sewing and blood drainage. A piece of tumor was resected and the pathological examination revealed primary cardiac angiosarcoma. Discussion: Primary cardiac angiosarcomas are rare. Most patients present with symptoms related to heart failure and tamponade.The patient described here had numerous extensive pulmonary metastases, hemoptysis and tamponade. The majority of the primary tumor site is located in the right atrium, and the most common site for metastasis is the lung or the pericardium. Computed tomography scanning confirms the diagnosis of a cardiac mass. Conclusion: Primary cardiac angiosarcomas-such as our patient's tumor-are highly aggressive and locally invasive. The tumor usually arises from the right atrium, with nonspecific symptoms and signs. Very rarely, the tumor presents with rupture, which leads to , cardiac tamponade, and a poor prognosis. In our patient, the surgery also controlled the bleeding and prevented death from cardiac tamponade; further, it provided a tissue specimen for diagnosis.

Figure 1. Cardiac MS-CT

A_7. Granulomatosis With Polyangiitis (GPA) and an Acute Cardiovascular Event – a Clinical Case

N. Spasova, E. Kinova, D. Somleva, B. Krastev, A. Goudev UMHAT ”Tsaritsa Yoanna – ISUL”Sofia, Bulgaria

GPA is a rare autoimmune disease which is characterized by granulomatous lesions in various tissues and organs and necrotizing vasculitis affecting small arteries and veins. We present a clinical case of a 53-year-old man with established GPA on corticosteroid therapy, who had acute chest pain, ECG abnormalities and significantly increased hs troponin levels. The patient had a history of coronary artery disease with coronary artery bypass grafting and diabetes mellitus on therapy. Despite clinical, ECG and laboratory data suggesting acute coronary syndrome, there were echocardiographic findings of acute pulmonary embolism. CT pulmoangiography was performed immediately to verify the diagnosis. Endothelial dysfunction, increased thrombin activity and other coagulation factors can explain the high prevalence of pulmonary embolism in patients with GPA.

A_8. Submassive Pulmonary embolism Rohit Tandon DAYANAND MEDICAL COLLEGE LUDHIANA, INDIA Sub massive PE is increasingly recognised emergency nowadays in ER. This could be due to easy widespread availability of bedside echocardiography. We discuss the clinical spectrum of acute sub massive pulmonary embolism along with discriminatory parameters on echocardiography which help in further categorisation of these patients relative to their in hospital risk for clinical deterioration. Concluding from a small single centre study results we recommend A risk stratification model based mainly on echocardiography variables is warranted for patients with sub-massive pulmonary embolism for expeditious management. Physicians should be aware that patients of acute sub-massive PE who have right ventricular strain and dysfunction above the cut off values mentioned require aggressive management with systemic/catheter based thrombolysis besides routine anticoagulation to prevent in-hospital clinical deterioration.

A_9. EXPECT THE UNEXPECTED A.Kisheva, Y. Yotov Second cardiology clinic, University hospital “St Marina”, Medical University Varna, Bulgaria

Male, 68 was admitted to interventional cardiology because of angina. He was directed from hospital, not capable for PCI, where ECG, blood tests and echocardiography were made. The patient was hypertensive, dyslipidemia; nonsmoker. He was under treatment with ASA, low dose beta-blocker, ASE-inhibitor, diuretic, statin. The examination revealed regular heart rate 88 bpm, RR 120/90mmHg, systolic murmur 1/6, otherwise normal. ECG was with . Laboratory showed normal cardiac enzymes, LDL elevation. The coronary angiography found 75% stenosis in mid segment of LAD and drug eluting stent was implanted. After procedure echocardiography was made and systolic anterior motion (SAM) of the mitral valve without obstruction in left ventricular outflow tract (LVOT), concentric hypertrophy and mild mitral regurgitation were detected. One month later gradient in LVOT was 123 mmHg at rest and 140 mmHg with Valsalva. Because of syncopy24hourHolter ECG was performed and wide-complex tachycardia and atrial fibrillation were recorded. Amiodarone was started. One year after PCI gradient in LVOT was 227 mmHg and mitral regurgitation was severe. Heart Team decided to send the patient for septal myectomy. Treatment with vasodilators was stopped and high dose beta-blocker prescribed. Surprisingly one month later there was no pathologic gradient in LVOT. LAD stent was not compromised and there were no coronary stenoses. Dynamic gradient in LVOT is seen in hypercontractility states – dehydratation, sympathetic stimulation, strain physical activity, treatment with vasodilators. Therapy must be focused on optimal control of hemodynamics and intravascular blood volume. High doses beta- blockers may lead to dramatic attenuation of SAM.

A_10. LEFT ATRIAL PHASIC FUNCTION IN HYPERTROPHIC CARDIOMYOPATHY VERSUS HYPERTENSIVE HEART DISEASE IN MIDDLE- AGED PATIENTS A.Borizanova, E. Kinova, D. Somleva, A. Goudev Department of Cardiology, UMHAT “ Tsaritsa Yoanna- ISUL”, Medical University Sofia Background: Hypertrophic cardiomyopathy (HCMP) and systemic hypertension (HTN) are associated with structural and functional left ventricular (LV) abnormalities. The specific changes of the left atrial (LA) structure and mechanical function in both conditions remain unclear. Aim: To evaluate the specific changes of LA structure and mechanical function in middle-aged HCMP patients compared to HTN patients. Methods: Echocardiographic indices of LA and LV geometry and function were compared between: 22 middle-aged patients (49,64±6,3 years) with HCMP , 28 age- matched patients with HTN and 25 normal controls. LA and LV function have been assessed by volumetric and speckle tracking method. Results: LA volumes were increased in patients with HCMP compared to those with HTN and healthy controls. LA reservoir, conduit and booster pump function was significantly deteriorated in HCMP group, whereas those changes were not observed in HTN group- table.1. LA was stiffer in HCMP patients who had also thicker interventricular septum, lower LV EF and attenuated LV GLS, and high filling pressures compared to the other groups- table 2. Conclusion: Patients with HCMP have stiffer, dilated and dysfunctional LA compared to HTN and healthy controls. These changes could be explained by generalized myopathic process affecting both ventricular and atrial myocardium and high filling pressures observed in HCMP patients. Table 1. LA structural and functional indices Parameter HCMP (n=22) HTN (n=28) Healthy(n=25) P-value Maximal, ml 79.34±27.08*^ 40,02±12,30 37,33±7,70 0.0001 Minimal, ml 38,83±20,83*^ 13,12±6,01 11,72±5,23 0.0001 Pre- Atrial, ml 57,92±22,76*^ 24,60±8,89 22,88±7,13 0.0001 LATEF, % 53,88±12,52*^ 66,64±9,04* 72,19±7,44 0.0001 LAPEF, % 27,44±10,32*^ 36,65±8,22 42,77±9,23 0.0001 LAAEF, % 36,52±12,81*^ 45,29±10,67 51,48±10,20 0.0001 LA GLS % 25,09±8,63*^ 37,13±9,88* 47,51±6,43 0.0001 LA stiffness 0,55±0,31*^ 0,23±0,08* 0,16±0,04 0.0001 index Values are mean ± SD. Final column reflects overall group analysis of variance (ANOVA). Between group comparison: * p<0.05 vs Healthy; ^ p<0.05 vs HTN ). LA total emptying fraction (LATEF),LA passive emptying fraction (LAPEF), LA active emptying fraction (LAAEF), LA global longitudinal strain ( LA GLS)

A_11. PATIENT WITH LEFT TO RIGHT SHUNT ON THREE LEVELS N. Marinov, Z. Stankov, I. Petrov, Y. Simova Acibadem City Clinic University Hospital, Sofia, Bulgaria

A 69 year old patient with heart failure and atrial fibrillation, was referred to our clinic for cardiac catheterization due to diagnosed with echocardiography dilated right coronary artery and atrial septal defect (ASD) with left to right shunt. Up on the echocardiography at admission we discovered extremely dilated right coronary artery arising from right coronary sinus, dilated right ventricle with preserved systolic function. Small ASD with left to right shunt-Qp/Qs 1,6 and a structure adjacent to the right atrial free wall which was shunting blood in to the right atrium. We performed cardiac catheterization and established arterioarterial fistula between left anterior descending coronary artery and the pulmonary artery. Extremely dilated and malformed right coronary artery which was shunting blood in to the right atrium. We also assess the shunt with oximetry which appeared to be left to right with Qp/Qs-1,6. Coronary cameral fistulae or coronary artery or arteriovenous fistulae are extremely rare (less than 0.002% of the general population). The diagnostic approach includes angiography (main method used), echocardiography, and multiple detector computed tomography. According to the American College of Cardiology/ American Heart Association guidelines, “percutaneous or surgical closure is a Class I recommendation for large fistulae’’.

A_12 . NON-BACTERIAL THROMBOTIC ENDOCARDITIS IN A PATIENT WITH RHEUMATOID ARTHRITIS

T. Kurteva, S. Georgieva, G. Tinov, T. Galabov Acibadem City Clinic University Hospital, Sofia, Bulgaria

Introduction: In several systemic diseases, valvular involvement is one of the most prevalent and important forms of cardiac abnormalities. Echocardiography plays a valuable role in the assessment and clinical decision making of morphological and functional valvular abnormalities.

Case report: A 50-year-old female with a 13-year history of seropositive rheumatoid arthritis (RA), systemic sclerosis and ischemic stroke a month ago. She was refered to cardiologist to exclude cardioembolic stroke. Severe aortic and mitral valve insufficiencies were found. A large mobile structure of mitral valve was described. The patient was admitted in cardiac surgery department for mitral and aortic valve replacement. The initial laboratory tests revealed normal inflammatory marker values and absence of microbiological findings. The electrocardiogram showed normal sinus rhythm, incomplete right . The transthoracic and intraoperative transesophageal echocardiography showed a mitral valve leaflet thickening, 2.5×0.6 cm in size, mobile mass-like nodular lesion, attached to the mitral annulus from the atrial side of the valve. There was a severe mitral regurgitation. Aortic valve leaflets were thickened, severe aortic regurgitation has been reported. Left ventricular function was preserved. There was no atrial septal defect and left atrial appendage thrombosis. The histology confirmed the diagnosis chronic non-bacterial thrombotic endocarditis (NBTE). Conclusion: NBTE is the result of platelet and/or fibrin aggregation on a heart valve secondary to hypercoagulable state usually induced by a metastatic process or rheumatologic condition. An embolic stroke may be the initial presentation. Echocardiogram should be obtained to assess for valvular lesions.

A_13. Acute aortic syndrome (AAS) – CT assessment

B.Bogdanova, K.Genova, P.Popeski

Department of Diagnostic Imaging and Interventional Radiology, National Heart Hospital, Sofia Bulgaria

We present an assessment with multidetector CT (MDCT) as a modality of gold standard in acute thoracic aortic syndromes (ASS). This syndrome summarizes a wide spectrum of emergency settings as a life-threatening aortic pathologies with important consequences on diagnosis and therapy. Our focus is on MDCT investigation following a routine protocol, common and unusual findings of AAS. We describe cases of emergencies regarding classic aortic dissection, subtypes of AAS, intramural haematoma (IMH), penetrating atherosclerotic ulcer (PAU) and iatrogenic dissection due to interventional procedure – coronarography. Based on a correct CT imaging and interpretation we give guidance on a timely therapeutic approach. In the current review we also present aetiology, clinical presentation, different appearances and possible complications of AAS evaluated with computed tomography (CT) angiogram as a first line imaging for early diagnosis of AAS, which continues to be crucial to survival.

A_14. Apical hypertrophic cardiomyopathy: A challenge in diagnosis. Study in the Mexican population

Nilda Espinola-Zavaleta National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico

Background: Apical hypertrophic cardiomyopathy (AHCM) is a variant of hypertrophic cardiomyopathy affecting 25% of the Japanese population. Echocardiography is an essential method for the diagnosis and follow-up of this disease.

Aim: The main objective of this study is to describe the prevalence and characteristics of AHCM in the Mexican population, who attended the National Institute of Cardiology Ignacio Chávez

Material and methods: From 1994 to 2017, a total of 13 patients with AHCM diagnosis were included. All patients had complete medical history, electrocardiogram (ECG) and echocardiogram. In some patients, myocardial perfusion, cardiac magnetic resonance imaging (CMRI), pharmacological stress echocardiography, coronary angiotomography and cardiac catheterization were analyzed. Patients with other types of hypertrophic cardiomyopathy.

Results: The mean age was 67.5±9.5 years, 62% were men. The clinical diagnosis for AHCM was on first instance in only 23% of the cases, the remaining 77% had an initial diagnosis of ischemic heart disease. Negative was detected in 100% of the patients and 46.1% presented giant T-wave inversion. All of the patients were diagnosed by echocardiography, four patients presented a mixed form of AHMC and the rest of them pure AHMC.

Conclusions: The prevalence of AHCM in our institution is of 0.4% in general population and in relation to hypertrophic cardiomyopathy (HM) of 3%. The clinical and electrocardiographic characteristics of AHCM suggested data compatible with ischemic heart disease. In all patients echocardiography should be the first-choice non-invasive study. In cases of diagnostic doubt or presence of concomitant diseases, other non-invasive imaging studies, such as CMRI or nuclear medicine are recommended.

A_15. CLIP THE STITCH: MITRACLIP TECHNIQUE 5 YEARS AFTER ALFIERI STITCH MITRAL VALVE REPAIR.

I. R. Tonchev1, A. Turyan1, R. Beeri1, D. Gilon1, M.Shuvy1 The Heart Institute, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel.

Mitral regurgitation deterioration after the Alfieri stitch surgical repair is not a rare finding and often can leads to congestive heart failure exacerbation and poor clinical outcome. Certain patients are unresponsive to optimal medical treatment, and redo-surgery could represent a substantial risk. The Mitraclip has been shown as a safe option in high-surgical-risk patients. It has never been reported as a treatment option in late deterioration of mitral regurgitation after a successful Alfieri operation. We describe a case of an 88 years old, high-surgical-risk patient, five years after Alfieri stitch surgery with severe symptomatic mitral regurgitation and recurrent hospitalizations for congestive heart failure exacerbation. He was successfully treated with MitraCliptechnique and on 1 year follow-up after the procedure had no hospitalizations for congestive heart failure.

A_16. Pulmonary artery pressure before and after Mitraclip. I.Tonchev1, A. Turyan Medvedovsky1, I. Tahiroglu1, C. Lotan1, D. Gilon1, D. Planer1, H. D. Danenberg1, R.Beeri1, M. Shuvy1, 1The heart institute, Hadassah Medical Center, Ein Kerem, Jerusalem, Israel Background: MitraClip as a safe procedure used for treatment of high-surgical patient, with good results in reducing functional mitral regurgitation (MR). Many patients are presenting also with elevation pulmonary artery pressure. We assessed the impact of this technique on pulmonary hypertension (PHTN). Methods: We studied a cohort of 52 patients who underwent MitraClip implantation at the Hadassah Medical Center between October 2015 and December 2017. We evaluated (PHTN) by echocardiography and calculated the estimated pulmonary artery pressure (PAP), before and after Mitraclip procedure in patients with severe MR. Results: Patient’s mean age was 73.16 years, and 76.5% - were males. Reduction of MR severity from +4 to +1 was achieved in 34 patients (66.7%). Only 3 patients (5.8%) remained with severe MR after the procedure. 12 were excluded due to missing data. The average estimated (PAP) before procedure was 54.1 ± 16.6 and after procedure 48.8 ± 14 with p value of 0.021. The main reduction of PHTN was noted in the group of severe PHTN, from 17 to 8 patients (Fig. 1). Conclusions: Mitraclip therapy improved PHTN and showed decrease in PAP in patient with severe MR. This procedure might be considered in this population to improve PHNT that is secondary to elevated left-sided pressures.

Figure 1. Numbers of patients before and after Mitraclip procedure, divided by pulmonary hypertension grading.

60 severe 40 moderate- 20 severe 0 mild- before after moderate

A_17. A CASE OF ARRHYTHMOGENIC RIGHT VENTRICULAR CARDIOMYOPATHY Phan Thai Hao Pham Ngoc Thach University of Medicine, Ho Chi Minh city, Viet Nam Backgrounds:Arrhythmogenic right ventricular cardiomyopathy (ARVC), also known as arrhythmogenic right ventricular dysplasia, is a heritable heart-muscle disorder that predominantly affects the right ventricle. Progressive loss of right ventricular myocardium and its replacement by fibrofatty tissue is the pathological hallmark of the disease. ARVC is one of the leading causes of arrhythmic in young people and athletes. We present a clinical case of Arrhythmogenic right ventricular cardiomyopathy Case Presentation :A 25-year-old female presented with a one year dyspnea after being diagnosed as systemic lupus erythematosus by a hospital in our city one year ago. She was diagnosed with tumor 17 years ago at the age of 8. Her treatments for brain tumor were surgery, chemotherapy and radiation therapy And then her family history decided for her to stop taking medicine and did not to follow treatment plan. Since then she has noticed she has no period. Her symptoms include fatigue, weakness, inability to lose weight (or weight gain), puffiness, constipation, Physical examination may, periorbital puffiness, brittle hair and eyebrow loss. Other findings were normal. Results: Echocardiogram: EF 53%, normal size and wall thickness of the left ventricle, slightly dilated left atrium, enlargement of the right ventricular 50mm and RVOT 47mm with reduced contractile function TAPSE 11mm, apical, aneurysm-akinesia and endocardial ventricular hypertrabeculation especially at apex. Mild mitral regurgitation and severe tricuspid regurgitation. Medium pericardial effusion without right ventricular depression. Cardiac MRI showed normal volume and function of the left ventricle (EF 55%), right ventricle with 114 ml/m2 indexed end diastolic volume, reduced right ventricular function (EF 29.6%), areas of dyskinesia of the free wall at the mid and apex. Late gadolinium enhancement of the free wall right ventricular at the mid and apex. Hypertrabeculation of septal wall at the apex. Medium pericardial effusion, no cardiac tamponade (Fig.1) Discussion:Diagnosis of ARVC relies on a scoring system, formulated in 2010 by the revisited Task Force, with two major or one major and two minor criteria or four minor criteria based on the demonstration of a combination of defects in right ventricular morphology and function, characteristic depolarization/repolarization electrocardiogram abnormalities (negative T waves and/or “epsilon” waves in right precordial leads), characteristic tissue pathology, typical arrhythmias, family history, and the results of genetic testing. Conclusion: In ARVC symptoms usually appear between the ages of 30–50. Especially in young patients the most common clinical presentation of ARVC are palpitations and syncope due to with left bundle branch morphology. Cardiac magnetic resonance (MRI) is considered the best imaging modality in evaluating the RV in ARVC.

Figure 1. Cardiac MRI

A_18. Quantification of RV size and Function Vincent Sorrell UNIVERSITY OF KENTUCKY MEDICAL CENTER, USA The assessment of the right ventricle (RV) is valuable in many patients with heart disease. In patients with either RV volume overload (eg. repaired tetralogy of Fallot (TOF), atrial septal defect (ASD), anomalous pulmonary venous return, tricuspid regurgitation from any cause) or RV pressure overload (eg, pulmonary hypertension from any cause, pulmonary stenosis), management decisions increasingly rely on evaluation of the RV size and function. Their trends during serial follow-up examinations predict heart failure, arrhythmias, and death and must be reliable.1

The noninvasive diagnostic evaluation of RV size and function in normal and pathologic conditions is daunting due to its complex shape and nonsymmetrical regional contraction pattern (figure 1). The RV is shaped like a “pyramidal banana”. The inflow and outflow portions are separated. The normal RV shape varies depending on orientation: sagittal view (echo short axis) is triangular (curved); axial view (echo long axis) is crescent-shaped; and coronal view (with CT and MRI) is most similar to a teapot. The RV myocardial wall is highly trabeculated and barely 3mm thin. In summary, there is no convenient geometric model that accurately approximates the normal or the diseased RV shape. In addition to the variable shape, the regional contraction pattern is also unique to the right ventricle. The normal RV apex is virtually immobile and tethered to the LV apex, and therefore is dominated by the shape and function of the adjacent left ventricular apex. The global RV systolic function is strongly influenced by the normally concave interventricular septum and ventricular interdependence. Acute and chronic pathologic pressure and volume overload will greatly impact global and regional RV performance. Finally, global RV performance isuniquely influenced by volume shifts that occur with normal respiration. During inspiration, venous return increases, causing an increased RV preload, with a slight but detectable increase in RV stroke volume. Therefore, when quantifying RV volume and function with echo, one should consider whether data were acquired during inspiration, expiration, or apnea (preferred). These features result in highly variable interpretations and most clinical studies simply use the “eye-ball” qualitative assessment rather than resorting to quantitative, or even semi- quantitative, estimates of RV size and function. Unfortunately, compared with the reference standard (cardiac magnetic resonance imaging – CMR), the ability to accurately detect severely dilated RV size or moderate to severe RV dysfunction is low and the interobserver variability is extremely poor.2 The RV can be considered to be comprised of 3 individual and separate components: the apex, the inflow, and the outflow. These RV regions are commonly the initial sites involved in pathology and have been termed the “triangle of dysplasia”. These anatomic regions develop separately and at distinct embryologic time points and are consequently independently subjected to congenital malformations. Each anatomic region has been demonstrated to have unique responses to pathology as well as pharmacologic interventions. The RVOT has been demonstrated to be more reactive than the RV inflow tract to inotropic stimulation. The global RV systolic function is determined by the following individual RV contraction patterns: (1) movement of the basal free wall toward the apex (the “bellows effect”); (2) the contraction of the RVOT; (3) the contribution of the LV (tethering) at the interventricular insertion sites. Normally, the left ventricle is estimated to contribute between 20-60% of the function of the RV.3It remains unknown how best to include this region in calculation of LV and RV function. Echocardiography is and will likely remain a first-line diagnostic imaging modality for evaluating the RV structure and function because of its wide-spread availability and the fact that it isa noninvasive, rapid, and portable tool. Accurate evaluation of RV morphology and function requires integration of multiple echocardiographic views, including parasternal long and short axis, RV inflow, apical (RV modified) four-chamber, and subcostal views.4 The ASE guidelines on the echo evaluation of the right heart recognize that there are limitations in available published normal references and therefore, most categories are reported as normal or abnormal, rather than mild, moderate, or severe disease which is common in reporting the left heart.5

The myofibrillar arrangement of the RV consists of mainly subepicardialcircumferential fibers and subendocardial longitudinal fibers in the inflow region and both subepicardialand subendocardial longitudinal fibers in the outflow region. The majority of the RV myocardium lacks the middle circumferential myofiber array that is dominant in the LV and consequentlyis much more dependent on longitudinal shortening for global ejection than the LV. The longitudinal RV contraction at the base is important in understanding and estimating RV function. The total tricuspid annular descent or tricuspid annular plane systolic excursion (TAPSE) is an important marker of RV global systolic function. Combining the findings from 46 studies investigating this value (N=2320), the normal range can be reported as 22-24mm (95% CI 15-31mm). ASE recommends using 16mm as the lower limit of normal based on this data, but I have found that using 20mm as normal and 16-19mm as mildly reduced is better at identifying RV pathology. It is likely that the simplicity and relative reproducibility of this displacement parameter partially compensates for the single dimensional nature that lowers the accuracy when regional RV dysfunction is present. The RV is typically smaller than the LV when normal and normally viewed in the apical 4- chamber view using 2-dimensional echo (2DE). However, it may be difficult to confirm the optimal alignment of these ventricles. Therefore, using relative dimensions as the sole criterion to diagnose RV dilation is subject to significant potential error. Image acquisition should obtain the maximal diameter of the tricuspid valve annulus to ensure appropriate relative alignment and avoid cutting through the LV in a “non-center” trajectory. Global, systolic RV function can also be simply assessed quantitatively using 2DE as a percentage of change in the RV cavity area from end-diastole to end- in the apical four- chamber view. Endocardial borders of the RV free wall and septum are traced from base to apex and the RV fractional area change (RV FAC) is defined using the following formula: (end- diastolic area – end-systolic area)/(end-diastolic area) × 100. The percentage of RV FAC is a relatively simple parameter that is a surrogate marker of the RVEF and correlates well with CMR-derived RVEF (r = 0.80).6 The pulmonary circulation normally has a low vascular resistance, and consequently, a very short (or undetectable) isovolumic contraction time (IVCT) and isovolumic relaxation time (IVRT). Tissue Doppler can be used to record the peak systolic velocity of the tricuspid annulus (S′). In healthy individuals, the lower normal limit at the basal RV lateral wall is ≥14 ± 2 cm/s for DTI spectral displays and ≥10 ± 2 cm/s for DTI color displays. This velocity has been shown to correlate more closely with CMR-derived RVEF than the 2D fractional area change (FAC), DTI-derived tissue displacement, systolic strain, and strain rate.7 An S′ <9.5 cm/s identifies patients with an RVEF <40%. Thresholds of >12, 12 to 9, and <9 cm/s allow differentiation between normal (>55%), moderately reduced (30%-55%), and severely reduced (<30%) RVEF, respectively. The RV index of myocardial performance (RIMP; or Tei index) is defined as the sum of the ICT and IRT divided by the ejection time and is increased in either systolic or diastolic RV dysfunction. This parameter is relatively simple to obtain with high quality tissue Doppler or conventional PWD, is a marker of early disease in cardiac , and predicts symptoms in hypertrophic cardiomyopathy. A value <0.25 predicts an RVEF ≥0.50 (sensitivity 70%, specificity 89%) and ≥0.40 predicts an RVEF <35% (81%, 85%).8 When the transthoracic ultrasound window is suboptimal and CMR is not available, transesophageal echo (TEE) may be performed. In a study of 25 children operated on for atrial septal defects, 90% had adequate 3D TEE studies. RV volumes with this technique matched the direct surgical measures (r2 = 0.99) obtained by injecting saline solution through the tricuspid valve using a graduated syringe.9In the clinical setting of tricuspid or pulmonic valve pathology, TEE is a valuable complementary diagnostic tool.

Cardiac MRI (and to a lesser degree, ECG-gated cardiac CT) have become reference standards for RV volume and function. The development of CMR has advanced significantly over the past few decades. Since CMR is not limited by the ultrasound acquisition window, the entire right ventricle can be easily visualized (figure 2). This allows qualitative assessment of right ventricular wall motion and reproducible quantitative assessment of chamber size, mass and ejection fraction.10 CMR can also be used to evaluate vascular anatomy and quantify blood flow and is an important tool in the evaluation of patients with complex congenital heart disease.11Highly skilled technologists and interpreting physicians are as equally necessary for CMR studies as they are for echo studies. A vital aspect of CMR is the ability to evaluate tissue characteristics. RV infarction can be easily detected with late gadolinium contrast-enhancement imaging. This CMR sequence has also been demonstrated to be a reliable way to assess thrombus, not uncommonly found in the right ventricle. The assessment of global RV deformation is possible using techniques such as myocardial tagging or cine displacement encoding with stimulated echoes (DENSE).Despite these strengths, CMR is expensive, may be limited in pacemaker-dependent patients or those with severe claustrophobia. Cardiovascular computed tomographic (CCT) can also be valuable in the assessment of the right ventricle. With high spatial resolution (approximately 0.5mm), the right ventricular anatomy, chamber size and systolic function can be accurately determined. Since CCT obtains a volumetric dataset with isotropic voxels, images can be re-oriented in any plane for post- acquisition evaluation. In patients with congenital heart disease who are unable to undergo CMR, contrast-enhanced, ECG-gated CCT offers an alternative non-invasive imaging option. However, despite the high spatial resolution that can be acquired with CCT, this technique is limited by low temporal resolution (often >80ms unless using a dual-source scanner), need for ionizing radiation (significantly increased over conventional CCT due to inability to use dose- reduction strategies for function assessment) and nephrotoxic contrast agents. Lastly, invasive RV angiography could be considered the reference standard, but like all imaging modalities require specialized skills at acquiring adequate orientation and contrast filling of the RV. Some investigators have had success and creating quantitative off-line spline models of regional contraction patterns to help separate normal from abnormal motion patterns12. CONCLUSIONS: Continued investigation is warranted to improve our understanding of the RV and to obtain robust noninvasive diagnostic methods to assess this chamber which continues to be proven to predict clinical outcomes. Evolving clinical settings demonstrate the importance of evaluating the RV in an effort to predict RV failure such as prior to left ventricular assist device placement. Given the normally complex shape, the further distortion with pathology, and the intricate myofibrillar arrangement, it is likely that a combination of parameters (possibly imaging and clinical) will need to be used for optimal RV assessment rather than a single diagnostic parameter. It may also be necessary to combine diagnostic imaging tools, but for the foreseeable future, echo will be the initial first-line technique for this purpose and cardiovascular MRI will be the reference standard. Disclosure: Gadolinium contrast is not FDA approved for CMR.

Figure 1.

Figure 2.

A_ 19. Assessment of Pulmonary Hemodynamics

Vincent Sorrell UNIVERSITY OF KENTUCKY MEDICAL CENTER, USA

Although not a direct estimate of RV volume or function, the evaluation of right heart hemodynamics is exceedingly valuable when right heart pathology is suspected. The right atrial pressure (RAP) is readily estimated from the inferior vena cava (IVC) dynamics and the caval and hepatic vein flows. More recently, TDI has also been used to evaluate this parameter. Classically, a dilated IVC, lack of inspiratory collapse, E/e’ ratio >6, atrial septal leftward bulge, predominant diastolic flow patterns in the SVC or hepatic veins (HV) suggest an elevated RAP. However, these features may be normal in athletes, obese individuals, congenital narrowing of the IVC-RA junction (Budd-Chiari), cortriatriatumdexter, or mechanical ventilation. Importantly, IVC imaging should be performed in the supine (not left lateral decubitus) position. For specific RAP values, it is somewhat reliable to use 0-20mmHg range at 5mmHg intervals. If the IVC size is <21mm and the inspiratory narrowing is >50%, the RAP is 0 or 5mmHg. Use 5mmHg if any other signs of elevated RAP exist. If either one of these two parameters is abnormal, use 5-10mmHg (10mmHg if other signs exist). If both size and respiratory variation are abnormal, use 15mmHg (or 20mmHg if IVC plethora exists). The dynamic inspiratory change >50% is more important than the IVC size. In mechanically ventilated individuals, more complex assessment is necessary to estimate RAP, such as the HV systolic filling fraction (HVFF = VsVTI / VdVTI) <55% which has a sensitivity and specificity of 86% and 90%, respectively for diagnosing RAP >8mmHg.1 Another formula successfully used in mechanically ventilated patients incorporates the tricuspid inflow and TDI of the tricuspid annulus: 1.62 E/e’ + 2.13 = RAP (r=0.7).2 When apnea cannot be performed for these right-sided measurements, averaging multiple Doppler velocities appears to be an adequate alternative. Careful scrutiny of the transvalvular (when regurgitation exists) or transeptal (when shunts exist) gradients provide the means to determine pressure gradients across cardiac chambers. These gradients are then added to known pressures, such as the RAP or LV systolic pressure (cuff pressure in absence of outflow gradients), and provide an avenue to noninvasively estimate intracardiac pressures.3 In clinical practice, recognizing that there is no single parameter of RV function, at rest or with exercise, that routinely accurately predicts clinical outcomes, it is recommended that multiple parameters, and often multiple diagnostic modalities, are used to best assess patients with suspected RH disease. The right atrial pressure, RV end-diastolic pressure, cardiac index, pulmonary pressure, and mixed venous oxygen consumption can readily be measured invasively (and with less than optimal accuracy, noninvasively). With exercise, the 6 min walking distance (6MWD) and cardiopulmonary response to exercise can be simply measured. With echo, once should always assess for any tricuspid gradient, presence of pericardial effusions, LV eccentricity index (EI), RV ejection time, the Tei index, right atrial area, tricuspid regurgitant volume/area, RV diameters, change in fractional area, and estimated cardiac output. Many other measures have been proposed and given variable results. Pulmonary artery pressure is uniformly measured, but it is known that there is an inconsistent relationship between pressures, effort tolerance, and prognosis. In patients with Eisenmenger’s syndrome, prognosis is better despite higher pressures than idiopathic PAH. However, patients with systemic sclerosis and sickle cell anemia have a moreadverse prognosis at lower pressures. Another drawback of using pulmonary artery pressure as a guide to management is that the impact of drug therapy on effort tolerance and prognosis is disproportionate to the impact on pulmonary pressures. Pulmonary artery pressure remains pivotal, because one cannot get away from the simple observation that the primary cause of death in PAH patients is RV failure caused directly and indirectly by the elevated pulmonary pressures. Any therapeutic manoeuvre that reduces pulmonary pressure close to normal while maintaining cardiac output and blood oxygenation will ultimately permit reasonable RV recovery, as seen in lung transplantation, pulmonary endarterectomy, and the small proportion of patients who normalize pressures on drug therapy. Although the improvement in exercise capacity in patients treated with epoprostanolhas not been shown to relate to resting mean pulmonary artery pressure, it is related to a reduced rate of rise of pulmonary pressure with exercise, facilitating an increase in pulmonary blood flow with exercise. Despite its pivotal role, pulmonary artery pressure gives us little more information on RV function than systemic pressure tells us about LVfunction. Validated correlates of survival in PAHall have in common their dependence on the RV function to explain their predictive value(invasively determined RAP, mixed venous oxygen saturation, cardiac index, 6MWD at baseline and absolute level at 3 months, VO2max, the presence of pericardial effusion, RA size on echo, and serum BNP or NTproBNP levels at baseline, and direction and magnitude of change during follow up. In contrast, measures that do not depend on RV function, such as pulmonary artery pressure and pulmonary vascular resistance, are poor predictors of survival, even though afterload is the dominant cause of RV failure. It appears that there is a threshold level of afterload beyond which RV response becomes the main determinant of survival and quality of life. Ideally, one would assess RV function during exercise, as the preservation of contractile reserve cannot be measured at rest. As with LV systolic dysfunction, improvement during exercise confers a better prognosis and effort tolerance. Three-dimensional assessment of RV contractile function is difficult enough at rest, similarly complex measures such as the Tei index are not possible in most patients during exercise. In every day practice, the only available measure during exercise is the tricuspid gradient and the change in pressure during exercise has not yet been correlated with clinical outcome.4 Cardiopulmonary exercise testing provides many measures, the VO2max in particular correlates well with prognosis and quality of life. The 6MWD correlates roughly with the VO2max but should not be considered a measure of the anaerobic threshold but rather a measure of aerobic performance. In advanced pulmonary hypertension, RV contractile reserve is the dominant determinant of maximal cardiac output during exercise. Thus, for any individual, all other factors being equal (arthritis, leg ulceration, and training effects), the direction and magnitude of change of 6MWD should correlate with changes in RV contractile reserve. In this context, it is difficult to understand why changes in 6MWD in response to therapy do not correlate with survival. It is likely that contractile reserve underpins the effort tolerance and other factors in determining myocyte survival. Accurate evaluation of RV function is essential for developing logical patient-centred strategies in pulmonary hypertension and other conditions such as tricuspid valve surgery for carcinoid. Six-minute walk distance, 2D and Doppler echocardiography, and invasive haemodynamics, despite their obvious limitations, remain the cornerstone of RV assessment at present. The role of CMR has become the reference standard, but requires experts for reliable data.

A_20. Srtain and 3D Echocardiography for the Right Heart Vincent Sorrell UNIVERSITY OF KENTUCKY MEDICAL CENTER, USA

2D STRAIN (SPECKLE TRACKING): The RV myocardium is normally only 3-4-mm thin. Within this thin layer of myocardium resides a complex arrangement of circumferential (parallel to the AV groove and encircling the RVOT) and spiral (near the apex) myofibers. Unlike tissue Doppler analysis which is subject to error from cursor angle misalignment, 2D strain (speckle tracking) is angle independent allowing for the evaluation of regional function in all myocardial segments (including the apex).1 Ultrasound of the myocardium has natural small variations in decibels (speckles) that are inherent to the characterization of the RV wall and can be tracked throughout the cardiac cycle. These provide a detailed regional determination of frame-to-frame myocardial deformation. Peak systolic strain and strain rate, particularly of the basal RV free wall, are significantly impaired in patients with pulmonary arterial hypertension and have been used as an index of global RV function.2The longitudinal RV strain and strain rate values are higher and more inhomogeneous than values reported for the LV. Longitudinal strain and strain rate values are lowest in the RV base and increase toward the RV apex. Strain rate imaging is independent of overall motion. This technique has significant potential as the initial and serial diagnostic tool to assess patients with known or suspected RV pathology and correlates with invasive and noninvasive reference standards of RV performance.3 Moreover, strain rates are much less load dependent than strains, volumes or ejection fraction, which is particularly important in the RV where preload varies significantly with respiration.4 Tissue Doppler can be used to record the peak systolic velocity of the tricuspid annulus (S′). In healthy individuals, the lower normal limit at the basal RV lateral wall is ≥14 ± 2 cm/s for DTI spectral displays and ≥10 ± 2 cm/s for DTI color displays. This velocity has been shown to correlate more closely with CMR-derived RVEF than the 2D fractional area change (FAC), DTI-derived tissue displacement, systolic strain, and strain rate. An S′ <9.5 cm/s identifies patients with an RVEF <40%. Thresholds of >12, 12 to 9, and <9 cm/s allow differentiation between normal (>55%), moderately reduced (30%-55%), and severely reduced (<30%) RVEF, respectively.5 THREE DIMENSIONAL ECHOCARDGIORAPHY In the absence of cardiac shunting, the LV and RV have the same stroke volume, but the upper limit of normal RV volume is greater than the LV. This explains why the lower limit of anormal ejection fraction (EF) is lower for the RV than the LV (example: RV in diastole, 100 mL; RV in systole, 55 mL; RV stroke volume, 45 mL; RVEF = 45/100 = 45%; LV in diastole, 90 mL; LV in systole, 45 mL; LV stroke volume, 45 mL; LVEF = 45/90 = 50%). Three-dimensional (3D) echo analysis of the RV has recently been reported as a means to eliminate the geometric intricacies of the RV. Real-time 3D echo (RT3DE) has recently become a reliable, reproducible tool to measure the LV. Although less well reported, this technique provides an evaluation of the RV independent of geometric assumptions.6 The RV volumes and RVEF are determined by manual tracing of the endocardial borders and require adequate image quality for this purpose. However, due to the fact that the entire RV is acquired in a single pyramidal data set, any acoustic window may be used and this increases the likelihood that an adequate image is obtained. Head to head comparison of 3D techniques to 2D techniques consistently demonstrate larger volumes and closer agreement as well as higher reproducibility relative to CMR. Normal RT3DE values of the RV size and function have been reported (table 1).7The technique of RT3DE has been validated in phantoms, animals studies, adults with acquired RV pathology, and children with congenital heart diseases.8 Excellent correlation exists with magnetic resonance imaging (MRI) reference standards, although there is a common underestimation of RV volumes. Although additional data from RT3DE studies including a wider variety of RV pathologies are needed, this option appears to be the most cost-effective reference standard for quantitative RV volume and EF determination.

A_21. IMPACT OF CARDIAC RESYNCHRONIZATION THERAPY ON PARAMETERS OF MYOCARDIAL DISSYNCHRONY IN PATIENTS WITH CHRONIC HEART FAILURE AND ATRIAL FIBRILLATION

T. Troyanova-Shchutskaia, A. Kurlainskaya, T. Denisevich, D. Goncharik, A. Chasnoyt, T. Asmalouskaya

Republican Scientific and Practical Centre «Cardiology, Minsk, Belarus

Purpose: to study the impact of cardiac resynchronization therapy (CRT) on myocardial dissynchrony in patients with chronic heart failure (CHF) and permanent atrial fibrillation (AF). Methods. The study included 50 patients with CHF III NYHA, AF, ejection fraction<35%, QRS>130ms. Patients were divided into 2 groups (1 - QRS 130-150ms, 2 - QRS>150ms) and underwent CRT with atrioventricular node ablation. Echocardiography with determination of myocardial dissynchrony was performed at baseline, in 6 and 12 months after CRT. Results: At baseline presystolic aortic delay (PAD) was higher in group 2 (p=0.001). Association of PAD and QRS-duration was confirmed by a significant correlation (rs=0.51, p<0.001). In group 1 interventricular dissynchrony (IVD) was higher (p=0.002, figure 1). Moderate correlation of IVD and QRS-duration was revealed (rs=0.38, p=0.018). In 12 months after CRT the PAD disappeared in 23% of patients, remained in 57% and appeared in 8%. No PAD was observed before or after CRT in 12% of patients. In 12 months after CRT PAD decreased significantly from 161 (140, 168) ms to 147 (133, 155) ms (p = 0.014) despite a 57% of negative dynamics. In group 2 PAD decreased from 211 (183; 223) ms to 172 (155; 179)ms (р=0,028). Parameters of intraventricular dyssynchrony decreased insignificantly. Perhaps these changes are caused by different coefficients of variability. Conclusions: Inter- and intraventricular dyssynchrony increased in 12 months after CRT. The severity of mechanical dissynchrony depended on the width of the QRS complex. PAD, IVD and all segments maximum delay were higher in patients with QRS>150ms.

Figure 1.

A_ 22. CARDIAC INVOLVEMENT AND ECHOCARDIOGRAPHIC ASSESSMENT IN PATIENTS WITH NEURO-MUSCULAR DISORDERS M. Gospodinova Clinic of Cardiology, Medical Institute of Ministry of Interior Neuro-muscular disorders (NMD) are genetic diseases characterized by progressive skeletal muscle wasting. can also be affected. Cardiac involvement presents either with predominant cardiomyopathy or rhythm and conduction disorders and is a major cause of morbidity and mortality.Cardiac involvement in Duchenne and Becker muscular dystrophiesis characterized by (DCM). In patients with Duchenne muscular dystrophy, DCM occurs in nearly all cases if patients survive long enough and significantly determines the outcome. Cardiac involvement is very common in lamin A/C and sarcoglycan diseases and presents with atrial and ventricular arrhythmias, various degrees of , and cardiomyopathy (both dilated and hypertrophic). Emery-Dreifuss muscular dystrophy is characterized by early-onset joint contractures, slowly progressive muscle weakness, and cardiac conduction defects that increase the risk of sudden death. In 15% to 30% of the patients with myofibrillar myopathiesa cardiomyopathy is detected. In Friedreich Ataxiacardiac disease is the most frequent cause of death and may present with LV hypertrophy, fibrosis and scarring, arrhythmias, and progressive heart failure. Cardiac manifestations are present in about 80% of patients with Myotonic Dystrophy type 1, mainly progressive atrioventricular or intraventricular conduction defects and tachyarrhythmias (ventricular and supraventricular), but dilated cardiomyopathy has also been reported. Echocardiographic assessment plays a key role for the detection and follow up of cardiac involvement in patients with NMD. Cardiac magnetic resonance may be used in case of poor acoustic windows and for the assessment of fibrosis.

A_23. An overview of cardiac tumors in Latin America Nilda Espinola-Zavaleta National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico

Introduction: Cardiac tumors account for 0.002-0.2% of all tumors. At present, the diagnosis is made on the basis of clinical data and non-invasive imaging methods. Objective: To present an overview of cardiac tumors in Latin America (National Institute of Cardiology Ignacio Chavez, INCICH) compared to reference data. Methods: For this retrospective study we reviewed the clinical and pathological records of 238 cases reported as cardiac tumors from 1983 through 2017. Of these 21 were excluded because of incomplete information. From the study population of 217 it was possible to follow 156. Identification of tumor type was established by histopathology. All patients underwent transthoracic echocardiography. Results: 70% of all cardiac tumors were found in female patients. 86% were benign; myxomas made up 68% of these and rhabdomyomas with 5%. Primary malignant tumors accounted for 19 (12%) and metastatic tumors 10 (6.5%). The most frequent location was left atrium (63%). Eighty-one patients of 156 (52%) were asymptomatic. In symptomatic patients, dyspnea occurred in 29%. 79% underwent surgical treatment, 8.3% received only medical treatment and 12.8% received no treatment. The surgical survival of the final group was 78.9%. Fifteen (9.7%) died during follow-up. In the survival curve based on tumor type, the myxomas had the longest survival in the follow-up. Conclusions: This Mexican population represents an overview of cardiac tumors in Latin America, compared to reference data. The cardiac tumors in Latin America were more frequent in women with a female/male ratio of 2.19 to 1.0, and a predominance of primary cardiac tumors was found.

A_24. Echo in sudden death

Nuno Cardim Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal

Echocardiography is today and will be in the future the first line technique in sudden cardiac death (SCD)risk assessment, both in coronary and non-coronary heart diseases. In this presentation the role of conventional and advanced techniques and derived parameters in SCD risk assessment are described, from the time- honored left ventricular ejection fraction (LVEF) to the recent global longitudinal strain (GLS), at rest and during exercise. Beyond LVEF, the role of new echocardiographic parameters in the selection to implantable cardioverter defibrillators is also adressed. Besides echocardiography, the role od other imaging techniques (cardiac magnetic resonance, cardiac CT and nuclear cardiology methods) is likely to increase, providing answers to specific clinical questions unsolved by echocardiography.

A_25. Left : athletes, hypertension and hypertrophic cardiomyopathy

Nuno Cardim Professor de Medicina-Cardiologia- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal

Left ventricular hypertrophy (LVH)is an entity of many faces. The detection of LVH is not the end but the begining of the investigation of its etiology, as the correct diagnosis has important therapeutic and prognostic implications. An integrated step wise approach is recommended,with sequential clinical, laboratorial,electrocardiographic and imagiologic assessment (in which echocardiography plays a major role). In this presentation a special focus on the differential diagnosis between hypertrophic cardiomyopathy-athletes hearthypertensive heart disease will be provided.

A_26. Hypertrophic cardiomyopathy

Nuno Cardim Professor de Medicina-Cardiologia- Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Portugal

As a consequence of the intrinsic limitations of clinical assessment, imaging plays a major role in HCM, providing solutions and answers for clinical problems. A multimodality approach is encouraged in HCM and different imaging techniques must be seen as complementary and selected in an integrated and rational way, always taking into account its availability, benefits, risks and costs. Echocardiography is recommended in all HCM patients and should be repeated every 1-2 year in stable patients. CMR should be considered in all HCM patients at least once in the initial evaluation and may be repeated according to potential changes in clinical status. Cardiac CT and nuclear imaging tests have more limited indications and are only indicated in specific clinical situations.

A_27. RUPTURED SINUS OF VALSAVA ANEURYSM A.Nikolova,A. Peneva, A. Shaban, M. Milanova Cardiology department, UMHATEM ‘N. I. Pirogov’ Sofia, Bulgaria Introduction: Sinus of Valsalva aneurysm (SVA) is rare pathology that has two ethiological forms: congenital or acquired. Congenital form often is combined with other anomalies. Acquired form can be due to: endocarditis, inflammatory process, trauma, atherosclerosis. SVA is asymptomatic. However its complications have clinical manifestation. Case presentation: A 53-year-old female admitted in cardiology department with shortness of breath, fatigue and peripheral edema for 1 month. On examination she was hemodynamically stable with strong systolic-diastolic murmur. The patient is without history of heart disease.TTE showed dilated left ventricular with moderate systolic dysfunction, dilated and volume overloaded right ventricular, moderate tricuspid regurgitation, dilated right atrium. On A5C it is visualized high-velocity flow from RCS to RA going on the atrial surface of tricuspid valve leaflet and mixing with tricuspid regurgitation jet. Detailed examination with and without CD on A5Cand PSSA showed aneurysm of RCS with rupture and left-right shunt from aorta to RA with Qp/Qs=2:1. The patient was diagnosed with ruptured aneurysm of RCS with left-right shunt between RCS and RA and heart failure. She was transferred to cardiac surgery center where she had aortic valve replacement with mechanic valve SJM No 25, ringannuloplasty of tricuspid valve with ring No31, resection and patch plasty with pericardium of the aneurysm of RCS. Conclusion: ТТЕ, ТЕЕ are methods for express localization of SVA. CD visualizes the shunt, which shows the rupture of SVA. Therapeutic strategy for asymptomatic and symptomatic SVA is always surgery due to high risk of increase volume of the aneurysm, rupture, heart failure and death.

A_ 28. THE HIDDEN ENDOCARDITIS

D. Gnanam; B. Bartelds; W. A.Helbing; L. P.Koopman.

Erasmus Medical Center/Sophia Children’s Hospital, Department of Pediatric Cardiology

Infective endocarditis (IE) is a disease with high morbidity and mortality, often presented as a multisystem disease. Its heterogeneous features present a diagnostic challenge. Congenital heart disease (CHD) has become the predominant underlying condition for IE in children from the developed world >2 years of age. A vegetation can develop when a high- pressure jet enters a low-pressure cavity through a narrow orifice, for example: small VSD. In the presence of a VSD, a vegetation can be found on the right ventricular side of the VSD, on the tricuspid valve, or where the jet impinges on the right ventricular wall. Vegetations found in coarctation are rare and usually occur distal to the obstruction. History: A four year old, previously healthy boy was diagnosed with Henoch Schonlein purpura after an upper airway infection in January 2018. A week later he was admitted to a local hospital with fever and a painful right knee. In addition, on auscultation a systolic murmur was heard. Blood cultures showed a Streptococcus sanguinis. An echocardiogram revealed a coarctation of the aorta without Vegetations. Ultrasound and MRI of the right knee were normal. CRP at initial presentation was 40 mg/L. He was diagnosed with a low grade bacteremia and reactive arthritis and treated with Penicillin. Despite treatment with antibiotics his fever did not disappear and he developed abdominal pain. Blood cultures remained positive for Streptococcus sanguinis and CRP increased to 57 mg/ml. BSE was 58 mm/hr. Kidney function and urine sedimentation were normal. The abdominal ultrasound showed splenomegaly. Due to persisting bacteremia, abdominal pain, splenomegaly and recurrent fever he was referred to our tertiary center, approximately 6 weeks after the initial symptoms. Physical examination at admittance Erasmus MC: Normal heart sounds, systolic ejection murmur, normal respiratory sounds, no hepatosplenomegaly, no tenderness in abdomen, no lymphadenopathy, right leg limping. PET/CT scan: No suspicion of active endocarditis in heart and large vessels, no active inflammation in knee or dental structures. Increased levels of Immunoglobin G ( IgG) (22.3 G/L), C- reactive protein (124 mg/L), BSE (124 mm/h). Echocardiogram: Coarctation of aorta of the distal aorta descendens. A echo dense structure is seen in distal of the coarctation using non-standard echo views. Trans-esophageal echo confirmed a highly moveable vegetation in the distal aortic arch. Child is now treated with IV penicillin for six weeks and is doing clinically well. A coarctation repair will be scheduled after 6-8 weeks of treatment. Conclusion: This case study illustrates that endocarditis can occur not only in heart valves, prosthetic materials and small restrictive shunts, but also in blood arteries distal to obstruction. Echocardiography by experienced sonographers remains an important diagnostic tool.

A_29. CARDIAC MAGNETIC RESONANCE IMAGING FOR THE ASSESSMENT OF ISCHEMIC HEART DISEASE

Fabiola B Sozzi, MD, PhD, Ospedale Maggiore Policlinico, Milan, Italy

Stress cardiac magnetic resonance imaging (CMR), has been shown to have an excellent diagnostic accuracy for the detection of significant coronary artery disease (CAD). As a result, stress CMR is increasingly being used to assess chest pain in patients with known or suspected CAD. CMR potentials derive from its high-spatial resolution, image contrast, lack of ionizing radiation and excellent depiction of wall motion. An essential characteristic of stress modalities is the negative prognostic value. The detection of myocardial with stress CMR is typically based on first-pass perfusion imaging, to search for inducible perfusion defects, or on wall motion abnormality imaging. An important goal of any stress modality is to identify those patients with low cardiac event rate.

A_30. CORRELATION BETWEEN LEFT ATRAL APPENDAGE SPONTANEOUS ECHO CONTRAST AND THE FRACTIONAL CHANGE OF ITS OREFICE AREA L. Mihov, A. Aliev, V. Nedyalkova MHAT Trakia, Stara Zagora, Bulgaria The spontaneous echo contrast (SEC) of left atrial appendage (LAA) is deemed to be a predictor of thromboembolic events. We evaluated the relationship between the SEC of LAA and the fractional change of its orifice area (LAAOAF). One hundred consecutive patients with acceptable quality of transesophageal echocardiography were included in this study. Mean age was 67 (±8.8) years, 62 males and 38 females. Sixty two of them had nonvalvular atrial fibrillation (AFb), 28 had atrial flutter (AFt) and 10 were in sinus rhythm (SR). The left atrial appendage spontaneous opacification (LAASO) was assessed qualitatively (SEC graded 0 through 3) and quantitatively by the signal attenuation in a sample area 0.31 sm2, placed in the LAA ostium (Q-Analysis, GE Healthcare). LAAOAF was calculated as (Amax-Amin)/Amax, where Amin and Amax were the minimum and maximum area of the LAA orifice in the plane of its ostium. There weren’t significant differences between AFb, AFt and SR groups in respect to average LAASO (-0.49.6; -50.3; -52.0 dB) (p=0.54; 0.16; 0.17) as well in respect to LAAOAF (0.25; 0.29; 0.31) (p=0.09; 0.06; 0.49). Because we found a significant correlation between LAASO and LAAOAF (r=0.86, p=0.001) in a nonlinear regression model, we supposed nonlinearity of signal attenuation that was a machine dependent preset. Еexcluding the cases lying in the right side of the function’s local extremum we found a linear correlation between the two variables (r= 0.84, p=0.001). We concluded that LAAOAF can be a good quantitative analogue of SEC assessment but further studies are needed to evaluate the clinical benefits of this measure Fig.1 Measurement of left atrial appendage orifice area fraction (LAAOAF). In this case LAAOAF = (3.4-1.8)/3.4 = 0.47. The area is measured frame by frame in the plane of the LAA ostium.

A_31. Diabetic cardiomyopathy Silvana Jovanova University clinic of cardiology, Medical Faculty, University St Cyril and Methodius, Skopje, FYROM Diabetic cardiomyopathy, the concept first introduced by Rubler at all, is defined as a disease that directly affects the structure and the function of the myocardium, in the absence of other confounding factors such as coronary artery disease, valve disease or hypertension. The etiology of DCM is multifactorial. , hyperlipidemia, inflammation with high oxidative stress are the main factors that trigger distinct structural, functional, and metabolic changes of myocardium. These alterations lead to the development of diabetic cardiomyopathy and heart failure as a clinical manifestation of the disease. Diastolic dysfunction is an early alteration of heart function in diabetic cardiomyopathy. It is asymptomatic for long period and progressively lead to impairment of contractile function. Conventional echocardiography can provide useful diagnostic information but novel Doppler techniques such as tissue-Doppler imaging, strain analysis can provide additional information foraccurate and complete diagnosis. Recent studies emphasize the usefulness of novel echo- Doppler modalities in identification of DCM at early, asymptomatic stage of the disease that is very important in order to delay onset of heart failure with proper preventive and medical interventions. A_ 32. CLINICAL CASE OF PAPILLARY FIBROELASTOMA OF AORTIC VALVE D.Vasileva, R. Shabani, N. Runev, E. Manov Cardiology Department, Medical University- Sofia, UMHAT Aleksandrovska Papillary fibroelastomas are the most common benign neoplasms of the cardiac valvular structures, and they are being recognized more frequently because of higher-resolution imaging technology. Papillary fibroelastomas are associated with substantial complications that are secondary to systemic embolism. We discuss the clinical presentation of fibroelastomas of the aortic valve and treatment approaches to the management of these tumors when they are discovered incidentally. Herein, we present the case of a 57 years old female patient with aortic valve papillary fibroelastoma, which was discovered incidentally during routine transthoracic echocardiography. She was admitted in our department because of poor control of the blood pressure values (up to 160/100 mm Hg) and complains of headache and nonspecific precordial discomfort. Her concomitant diseases were dyslipidemia and obesity. During the routine transthoracic echocardiography, a pathological formation, attached to base of the posterior noncoronary cusp, with the size of 12/12 mm, homogenous, encircled, mobile, without prolapse from the aortic valve. Similar finding was described during transoesophageal ultrasound. To have a detailed description of the formation we administered her MRI, which confirmed the diagnosis of papillary fibroelastoma. The patient was referred to cardiothoracic surgery for further evaluation and treatment. Although papillary fibroelastoma is benign, it is increasingly considered a matter for surgery because of such potential complications as stroke, acute myocardial infarction, ventricular , and sudden death.

A_33. Diastolic Function in 2018 – Suction and Relaxation

Fabiola B Sozzi, MD, PhD, Ospedale Maggiore Policlinico, Milan, IT

There is growing evidence that the diastolic function analysis provides important findings that can be helpful in the management of patients presenting with dyspnea of an unclear etiology. Diastolic dysfunction is an early sign of cardiac disease. It precedes systolic dysfunction and it is associated with increased mortality. It exists as its own entity. The causes of diastolic dysfunction are variable depending on the aetiology of myocardial disease (i.e. dilated, restrictive, hypertrophic cardiomyopathy, secondary ventricular hypertrophy, ischemia and infarction, pericardial disease). Chronic dyspnea is associated with a variety of diseases and is also a major symptom of heart failure (HF). The differential diagnosis of dyspnea is of daily routine in every cardiology practice. Approximately one-half of patients with heart failure have a preserved ejection fraction (HFpEF). The diagnosis of HFpEF is challenging and relies largely on the demonstration of elevated cardiac filling pressures represented by the pulmonary wedge pressure. The concept of the diastolic stress test was introduced about 15 years ago. Subsequently, its value in detecting the noninvasive cardiac filling pressure was validated against invasive measurements.

A_34. Echocardiography and multimodality imaging in patient with HFpEF

Jun-Bean Park Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Korea

Nearly one-half of patients with heart failure (HF) have preserved left ventricular (LV) ejection fraction (EF), and the prevalence of this form of HF (i.e., HF with preserved EF [HFpEF]) appears to be steadily increasing. Particularly, HFpEF comprises nearly 90% of incident case of HF in elderly women. More importantly, although the patients with HFpEF experiences similar patterns of morbidity and functional impairment as do those with HF with reduced EF (HFrEF), there are few treatments currently available for HFpEF. Therefore, the prognosis of HFpEF is worsening whereas that of HFrEF is improving. Hence, there is a need for a better understanding of HFpEF pathophysiology which can lead to the improvement in treatment of HFpEF patients. Various mechanisms have been suggested to explain the pathophysiology of HFpEF, but many remain hypothetical due to the limited access to live human heart tissue and the lack of relevant experimental models. In this regard, recent advances in cardiovascular imaging, including echocardiography, computed tomography, cardiac magnetic resonance imaging, and positron emission tomography, have the potential to provide novel insights into the pathogenesis of HFpEF. While the current guidelines highlight the role of diastolic dysfunction by conventional echocardiography for the diagnosis of HFpEF, novel imaging technologies enable a more comprehensive assessment of HFpEF pathophysiology, such as the analysis of myocardial mechanics, quantification of extra-cellular matrix, evaluation of myocardial blood flow, and detection of metabolic derangements, potentially providing additional information to diagnose HFpEF more exactly.

A_35. Hypertrophic cardiomyopathy as a first presentation of Anderson-Fabry disease, diagnosed with cardiac magnetic resonance K. Genova1,2, M. Denev3, H. Mateev4 1. National cardiology hospital Sofia, Radiology department2. M-TEH Pirogov Sofia, MRI center 3. National cardiology hospital Sofia, Pathology department 3. National cardiology hospital Sofia, Interventional cardiology departme Anderson–Fabry disease is an X-linked lysosomal storage disorder resulting from a deficiency of the enzyme α-galactosidase A and subsequent cellular storage of the enzyme's substrate globotriaosylceramide and related glycosphingolipids. Thought cardiac involvement is a common feature of the disease its appearance as a first manifestation is quite rare. We present a case with hypertrophic cardiomyopathy as a first presentation of Anderson–Fabry. The patient was diagnosed with cardiac magnetic resonance and the diagnosis was confirmed by endomyocardial biopsy and genotyping.

A_36. How to Avoid Pitfallls in the Interpretation of Myocardial Perfusion Scintigraphy.

Amolak Singh, MD, FACP, FISCU, FACNM University of Missouri, Columbia, MO, USA Abstract: Myocardial perfusion stress scintigraphy (MPSS) is an important imaging modality in the management of the patients with coronary artery disease (CAD). MPSS plays a key role in the diagnosis of CAD, determining prognosis, viability and assessing the effectiveness of the therapy. However, MPSS is a complex procedure, subject to a variety of artifacts and pitfalls which must be understood and prevented to assure its usefulness in the management of CAD. The focus of this presentation is to elicit a practical approach to achieve this objective. The process starts with selecting an appropriate protocol for the MPSS. Only those who are capable of exercising and achieving 85% of the maximum predicted heart rate (MPHR) should be subjected to treadmill stress. All other patients are better served with pharmacological stress testing using Regadenoson (Lexiscan). In addition, in patients with (LBBB), pharmacological stress test is preferred over treadmill to decrease the likelihood of septal artifacts. Thallium-201 (Tl-201) an excellent radiotracer for patients with normal body weight; however, those who have morbid obesity should be subjected to imaging with Tc-99 labelled Sesta-MIBI or Tc-99m Tetrofosmin. Tl-201 has an imaging energy of 69-81 keV which is relatively low, thus increasing the likelihood of attenuation artifacts in patients with morbid obesity, and in female patients with large breasts. In such patients, Tc-99m labelled radiotracers offer an advantage over Tl-201 with lesser artifacts, and with additional value of wall motion analysis. The left ventricular ejection fraction is also calculated. Two-day protocol using Tc-99m S-MIBI or Tetrofosmin with full doses (30 mCi each) provide better images in patients with severe morbid obesity. Attenuation correction using CT is semi- useful in reducing artifacts in obese patients (BMI>40) but technique is imperfect in achieving this goal. After injection of the radiotracer, the technologist must wait for about 30 minutes before starting imaging to allow enough time for circulation and optimal extraction of the radiotracer by the myocardium. The first-pass extraction fraction of Tc-99m MIBI or Tetrofosmin is about 50% compared to 90% with Tl-201. Patient motion during image acquisition is a serious source of artifacts. Patients who cannot remain still for 20 minutes for imaging are better served with some other test. The patient motion can be easily identified on the workstation and corrected to some extent. However, re- acquisition of images remains the most reliable option. Patients with adjacent extra-cardiac GIT activity often have artifacts along the inferolateral wall. Repeat-delayed imaging after oral ingestion of water-load is helpful in clearing GIT activity and elimination of such artifacts. Images should be processed with iterative reconstruction, carefully matching long axis on the horizontal images, as well as matching slices on the rest and stress images for final display and interpretation.

A_37. Scintigraphic Identification of Myocardial Viability in Pts. with Multi-Vessel CAD and LV Dysfunction Amolak Singh University of Missouri, Columbia, MO, USA Abstract: Myocardial viability in patients with multivessel coronary artery disease (CAD) is deemed to be present in myocardial regions with good perfusion. Both Thallium-201 and Tc- 99m labeled agents such as Tetrofosmin and Sestamibi are useful for myocardial perfusion imaging (MPI). Tl-201 is actively transported across cell membrane under ATPase. Tc-99m labelled radiotracers are passively transported across cell membrane by lipophilicity. Reversible defects indicate viability. However, some patients with severe CAD and left ventricle (LV) dysfunction may present with fixed or non-reversible perfusion defects on MPI that may still be viable and represent (HM). About 20% of non-reversible defects may have viable or hibernating myocardium. Metabolic imaging with F-18 fluorodeoxyglucose (FDG) can be very useful in identifying viability or HM. Normal myocardium derived 95% of its energy from oxidation of long chain fatty acid (1). In regions of HM, oxidation of fatty acids is decreased. Myocardium is kept alive by switching metabolism to an-aerobic . F-18 FDG in the cells is converted to F-18 FDG-6 phosphate (by hexokinase) which cannot be metabolized. The findings are matched with findings on MPI. Areas with decreased perfusion but increased FDG uptake indicate viability and HM. Non-viable areas are associated matched defects with decreased perfusion and metabolism. The techniques for viability determination include Dobutamine Echocardiography (DE), Myocardial Perfusion Scintigraphy (MPI), Myocardial Metabolic Imaging with F-18 FDG (PET) and Contrast Magnetic Resonance Imaging (MRI). In general the choice of the technique depends upon local expertise, cost, and availability. More importantly, the choice should depend upon which particular test is able to identify reversible myocardial injury better whether it is HM from chronic injury or stunned myocardium from acute injury (1). The choice should also depends upon individual patient and severity of left LV dysfunction. While DE may be the preferred technique because of its simplicity, availability, and low cost; it may not be the best technique for viability determination in some patients with poor acoustic window or poor LV function. About 39% of all recovering LV segments failed to exhibit inotropic contractile reserve (2). In another study, DE failed to identify 45% of viable segments at 6-months followup (3). The scintigraphic methods appear to have a higher sensitivity and a higher negative predictive value, particularly in patients with poor ventricular function. The contrast MRI may also be useful (4) but is contraindicated in presence of cardiac pacemaker and/or defibrillator (ICD). Several studies (5, 6) have shown a better performance of scintigraphic techniques over DE in demonstrating improvement after revascularization when late (1-year) followup was made. In a recent multicenter trial, better outcome was observed at 1-year when viability and treatment was guided by the PET compared to the standard of care (7). Early identification of hibernating myocardium and early revascularization (RV) of blocked vessels has much better outcome than delayed RV. In absence of viability, RV offers no significant benefit over medical management (8-9).

A_38.Mitral regurgitation: Role of echocardiography in the timing of intervention

Nurgül Keser Faculty of Medicine at the University of Sakarya, Turkey

Mitral valve is a complex structure that needs careful evaluation while deciding the appropriate timing for intervention. Mitral valve leaflets with special emphasis on scallops and subvalvular apparatus including geometrical indexes should all be evaluated . Quantification of the mitral insufficiency needs careful grading. Differentiation between functional and organic mitral insufficieny together with searching the reasons underlying the organic cause should all be done. After Carpentier classification the effect of mitral insufficieny on cardiac chambers need assessment. Thereafter it is time to decide whether repair or replacement will be done.

A_39. ATRIAL FIBRILLATION RELATED TO ISOLATED PERSISTENT LEFT SUPERIOR VENA CAVA. A CASE REPORT

S.Slavcheva, A.Angelov, G. Dimitrova Cardiology Clinic I ,MHAT “St. Marina”/ Medical University Varna

Persistent left superior vena cava (PLSVC) is the most common thoracic venous anomaly and its incidence is estimated to be about 0.3-0.5% of the general population. The congenital variant of PLSVC with an absence of a right-sided superior vena cava, also known as isolated PLSVC, is very rare in adult patients. In most cases, the venous blood from the upper half of the body drains in the right atrium (RA) through a left vena cava and the coronary sinus (CS) causing dilatation of the latter. Apresence of an enlarged coronary sinus, discovered by transthoracic echocardiography (TTE) leads to a possible diagnosis - PLSVC. A 29-year old male has been referred to our Cardiology clinic for occasionally detected asymptomatic atrial fibrillation. An isolated PLSVC has been identified by TTE and computed tomographic (CT) angiography. TTE has revealed a huge CS, and the injected agitated saline via the left and right cubital veins has caused opacification of the CS before the RA –fig.1. The role of additional imaging modalities – transesophageal echocardiography and CT angiography - is to depict the remnant vessel and either to prove or exclude concomitant cardiovascular abnormalities that can be observed in about half of the cases. There is evidence of the relationship between anomalous venous return and various rhythm disturbances on the basis of impaired embryologic processes. This rare anomaly is important to be known, also because it may cause technical difficulties and complications when placing central venous catheters and pacing electrodes.

Fig.1 Transthoracic echocardiography – huge coronary sinus (CS), through which the “bubble” contrast enters right atrium.

Fig. 2 Reconstructеdimage of contrast chest CT – persistent left superior vena cava (LSVC) drains in the coronary sinus (CS). Right subclavian vein drains in the LSVC via innominate vein (InV).

A_40. Mechanical deformation in adult patients with unrepaired aortic Coarctation.

N Espinola-Zavaleta. National Institute of Cardiology. Ignacio Chavez, Mexico City, Mexico

Background: Aortic coarctation is a congenital heart disease that causes an increased left ventricular afterload, resulting in increased systolic parietal tension, compensatory hypertrophy, and left ventricular systolic and diastolic dysfunction. The speckle tracking is a new echocardiographic technique that allows the detection of subclinic left ventricular systolic dysfunction.

Aim: The aim of this study was to detect early left ventricular dysfunction using mechanical deformation by echocardiography in adults with un-repaired aortic coarctation.

Material and Methods: A total of 41 subjects were studied, 20 patients with aortic coarctation and 21control subjects, 21 women (51.2%), with an average age of 30 ± 10 years.

Results: All patients with aortic coarctation had systemic arterial hypertension (p < 0.001). Seventy percent (14/20) of the patients had bicuspid aortic valve. Statistically significance (p < 0.005) were found in left ventricular mass index, E/e ratio, pulmonary artery systolic pressure and peak velocity and maximum gradient of the aortic valve. The global longitudinal deformation of the left ventricle in patients with aortic coarctation was significative decreased, p < 0.001. The ejection fraction and the global longitudinal deformation of the left ventricle were significantly lower in patients with aortic coarctation compared to the control group, p < 0.003, p < 0.001, respectively. The subgroup of patients with coarctation and left ventricular ejection fraction < 55% had a marked decrease in global longitudinal strain (− 15.9 ± 4%). The radial deformation was increased in patients with aortic coarctation and showed a trend to be significant (r = 0.421; p < 0.06). A significant negative correlation was observed between the global longitudinal deformation and left ventricular mass index (r = 0.54; p = 0.01) in the aortic coarctation group. Conclusions: The patients with aortic coarctation and left ventricular hypertrophy had marked reduction of left ventricular global longitudinal deformation (− 16%, p < 0.05). In our study patients with normal left ventricular ejection fraction had abnormal global longitudinal deformation and also the increased left ventricular mass was related with a decreased left ventricular global longitudinal deformation as a sign of subclinical systolic dysfunction.

A 41. Mitral inflow, LA volumes, Tissue Doppler Velocitiesand PA Pressure

Fabiola B Sozzi, MD, PhD Ospedale Maggiore Policlinico, Milan, IT

The mitral inflow velocity by pulsed Doppler echocardiography at the level of the mitral tips with the mitral annular velocities by spectral Doppler echocardiography, and tricuspid regurgitation jet by continuous-wave Doppler at baseline together with the left atrial volume are the major parameters for the evaluation of diastolic function. Those parameters are evaluated at rest and eventually during stress. Healthy individuals with normal relaxation are able to increase the rate of myocardial relaxation when there is a need for increased diastolic filling. Faster relaxation allows the achievement of a lower minimal left ventricular (LV) diastolic pressure at a shorter time interval than in the resting state. Hence, increased LV filling can occur even with a shortened diastolic filling time. When myocardial relaxation is reduced in the resting state, it cannot be increased as much as necessary to meet the demands of exertion or stress. In this situation with abnormal myocardial relaxation, a reduced diastolic filling period and a lack of atrial contraction compromise LV filling substantially, causing the increase in left atrial and LV diastolic pressures (hence, decreased diastolic reserve). The diastolic pressure-volume curve will have an acute slope in the left ventricular hypertrophy. It means that slight activity can cause a significant increase in left ventricular end-diastolic pressure. In patients with diastolic heart failure, left atrial pressure is increased, leading to an increase in mitral E velocity, whereas annular e’ velocity remains reduced given the limited preload effect on e’. Moreover, an increase in the pulmonary artery systolic pressure can be detected by the increase in peak velocity of the tricuspid regurgitation jet. On the other hand, in the absence of cardiac disease, e’ increases to a similar extent to the increase in mitral E velocity, and the normal E/e’ ratio essentially is unchanged with exercise.

A_42. Multimodality Imaging in Acute Coronary Syndrome Maria Nedevska University Hospital “St. Ekaterina”, Sofia, Bulgaria Acute chest pain suggestive of ischemic cardiac origin, with a normal or nondiagnostic electrocardiogram and negative initial cardiac markers for myocardial necrosis represent a significant diagnostic dilemma in emergency settings. Cardiovascular imaging procedures provide essential information for the detection, diagnosis, and management of these patients, and play an important role in risk stratification and clinical decision making. The relevant procedures include echocardiography, radionuclide imaging, cardiac magnetic resonance, cardiac computed tomography, and invasive coronary angiography. Clinical guidelines and performance measures have been successfully developed, and their positive impact on patient outcomes has been well demonstrated. In this presentation the current imaging modalities available for these patients will be discussed and compared including their diagnostic accuracy, feasibility, and cost effectiveness

A_43. MULTIMODALITY IMAGING IN RESTRICTIVE CARDIOMYOPATHIES

M. Gospodinova

Clinic of Cardiology, Medical Institute of Ministry of Interior, Sofia, Bulgaria

Restrictive cardiomyopathies (RCM) areheterogeneous group of myocardial diseases.They may be subclassified into idiopathic, infiltrative, storage, inflammatory, endomyocardialand radiation or drug induced.RCM are characterized by normal or small LV cavity size with preserved LV ejection fraction, bi-,anddiastolicdysfunction.Restrictive physiology is not an obligatory sign for RCM diagnosis. Patients may present with a Grade I diastolic dysfunction and move progressively to Grade II or III diastolic dysfunction.Imaging techniques play a central role for diagnostic and prognostic evaluation.Echocardiography is the first-line imaging modality for the recognition of RCM. Deformation imaging is useful for the assessment of LV longitudinal function, which is frequently impaired and may help differentiating RCM form constrictive pericarditis. Cardiovascular magnetic resonance (CMR) imaging can contribute importantly to the diagnosis of RCM and the differential diagnosis between the different myocardial diseases and pericardial constriction. CMR allows accurate measurement of chamber size and function. Tissue characterization with late gadolinium enhancement is most widely used.T1andT2 mapping provide complementary information.Nuclear imaging modalities have a potential role in two forms of RCM: amyloidosis and sarcoidosis.There are increasing data on the role of nuclear tracers 99mTc- DPD, 99mTc-PYP and 99mTc–HMDP for diagnosis and early identification of transthyretin- related cardiac amyloidosis and differentiating it from light chain amyloidosis. Cardiac sarcoidosis is an inflammatorydisease and positron emission tomographyis used for diagnosis and follow up. All these techniques give additional information and should frequently be used in combination. A_44. Novel modalities for early recognition of dilated echocardiography Silvana Jovanova University clinic of cardiology, Medical Faculty, University St Cyril and Methodius, Skopje, FYROM DCM is the most common cardiomyopathy, and is one of leading causes of heart failure and arrhythmia. Familial and sporadic forms of DCM are well described and genetic factors are important. This has important implications for screening of first-degree relatives. Dilated cardiomyopathy is defined as left ventricular dilatation and left ventricular systolic dysfunction in the absence of abnormal loading conditions (hypertension and valve disease) or ischemic heart disease. Echocardiography is the first-line imaging test in the assessment of patients with DCM. Conventional echocardiography and Doppler analysis in conjunction with novel techniques such as tissue-Doppler imaging, strain analysis and real-time 3D echocardiography provide sufficient information for accurate and complete diagnosis and comprehensive assessment of cardiac anatomy, pathophysiology, and haemodynamics. Furthermore, echocardiography plays valuable role in risk stratification and guiding therapeutic interventions in patients with DCMP and in screening family members.

A_45. PERICARDIAL DISEASES Rabhat Shabani University Hospital “Aleksandrovska”, Sofia, Bulgaria Over the past 40 years, echocardiography has become a ubiquitous, first line tool for evaluating the pericardium and other cardiac structures. The diagnosis and management of pericardial diseases remain challenging because of the vast spectrum of manifestations and the lack of clinical data on which to base guidelines. Echocardiography and Doppler ultrasound are useful in evaluating a variety of pathological conditions affecting the pericardium. Pericardial diseases can present clinically as , pericardial effusion, cardiac tamponade, and constrictive pericarditis. Structural abnormalities including congenitally absent pericardium and pericardial cysts are usually asymptomatic and are uncommon. Doppler ultrasound studies may be particularly useful in those patients in whom the characteristic echocardiographic abnormalities are absent. Both M-mode and two- dimensional echocardiography may be useful in diagnosing pericardial thickening. Cardiac tamponade results in right atrial collapse and right ventricular diastolic collapse detectable by echocardiography. Increased respiratory variation in transvalvular blood flow velocities detectable by Doppler ultrasound is found in cardiac tamponade. Echocardiography is also useful as a guide to performing pericardiocentesis and in the detection of pericardial adhesions and pericardial metastases.

A_45. PERIPARTUM CARDIOMYOPATHY I .Bayraktarova, D. Avramov, T. Katova National Heart Hospital, Sofia , Bulgaria Peripartum cardiomyopathy (PPCMP) is a serious cardiologic condition connected to pregnancy and the peripartum period. Despite being comparatively rare, there is evidence of serious geographic and ethnic differences in distribution. What is more, with improvement of complex medical care, PPCMP has emerged as a leading cause of maternal morbidity and mortality in the peripartum period in developed countries. The ethiological mechanisms of the condition are yet not fully elucidated, and despite the presence of some official position papers from the European Society of Cardiology, treatment is still highly dependent on individually applied sound clinical judgement and the availability of local medical resources. We present a case of PPCMP without typical maternal risk factors, but with a protracted and difficult clinical course. The patient achieved stabilization via the utilization of the full array of available heart failure therapies, without full recovery.

A_46. HYPERTROPHIC CARDIOMYOPATHY IN INFANT: RECOVERY OF CARDIAC FUNCTION FOLLOWING HIGH DOSE OF – UNEXPECTEDLY GOOD DEVELOPMENT K. Ganeva, P. Shivachev UMHAT “St. Marina” – Varna, Department of Pediatrics, Medical University – Varna, Bulgaria The distinctive mark of hypertrophic cardiomyopathy is increased left ventricular wall thickness that is not explained by abnormal loading conditions. In children diagnosis requires left ventricular wall thickness of more than two standard deviations (Z-score>2). The first case of experimental treatment of an infant with hypertrophic obstructive cardiomopathy with beta blocker was described in 1971. Since then, beta blockers are used as a leading treatment strategy.We present a clinical case of an 11-months old girl, who was admitted at our hospital with cardiorespiratory failure. Echocardiography showed a severe unobstructive hypertrophic cardiomyopathy with septal and left ventricular wall thickness up to 11mm (Z-score +9.54 and +10.52), with leading diastolic disfunction, evaluated by pulse and tissue Doppler. Other underlying conditions were ruled out. Genetic testing is under question because of financial difficulties. There were no cases of sudden cardiac death in the family. We started treatment with Propranolol and gradually increase the dose up to 5mg/kg/day. One year later we found out a normalization of left ventricular diastolic function with restored early diastolic tissue Doppler velocities at the lateral and septal mitral annuli, with reduction of E/E’ ratio. Surprisingly, a decrease of myocardial hypertrophy was also documented : Z- score for septal thickness +1.81. At present, the girl has no clinical symptoms or any rhythmology accidents under treatment with beta blocker.

A_47. Pregnancy-associated myocardial infarction presenting as a peripartal cardiomyopathy in a 37 year old woman L. Vladimirova-Kitova 1,2 , F. Nikolov 1,2 , D. Gencheva 1,2 , N. Atanasov 1,2 , S. Kitov 1 1. Medical University – Plovdiv, Bulgaria 2. Department of Cardiology, UMHAT “Sveti Georgi” Plovdiv, Bulgaria

We present the case of a 37 year old woman with an unremarkable past medical history, who suffered a seizure and cardiac arrest in the final month of her second pregnancy. During her stay in the Intensive care department she was consulted with a cardiologist and an echocardiography was done, which showed normal left ventricular ejection fraction (LVEF). A few days past dehospitalization she presented with signs and symptoms of heart failure and a significant reduction of LVEF was noted. A month later LVEF recovered to nearly normal with treatment, but some regional wall motion abnormalities appeared which prompted coronary angiography. The result was normal coronary anatomy and hence the diagnosis of PCMP was established. A cardiac magnetic resonance was performed almost a year later due to the patient’s wishes for another pregnancy, and it revealed a cicatrix consistent with a past transmural myocardial infarction. We believe this was a case of a pregnancy-associated myocardial infarction, presenting initially as the more common peripartal cadridomyopathy. Currently the patient is with borderline LVEF, no signs or symptoms of heart failure, but persistent complex ventricular arrhythmias, possibly related to the zone of the myocardial infarction.

A_ 48. Quantification of Left Atrium Function Ioannis Vlasseros Athens University Medical School, Hippokration Hospital, Greece

Functional remodeling of the left atrium is related to diastolic load and considered a prognstic factor of common cardiovascular diseases Detailed analyzis of the left atrium are made using the latest techniques of 3D echocardiogram and echo deformation study. 3D echocardiogram gives three dimensional incisions in real time recording the changes in the left atrium and calculating the ejection fraction The measurement of the volume has greater diagnostic accuracy than with 2D echo, in relation with MRI the echocardiogram degrades the volume. The function of the left atrium can be estimated with the 2D strain by measuring the peak atrial longitudinal strain (PALS) and the peak atrial contraction strain (PACS). The PALS decreases in the arterial hypertension, in diabetes even more for the co-existence of the diabetes and hypertension. The PALS decreases in atrial fibrillation and is gradually improved after electrical cardioversion .It is significantly reduced in severe mitral regurgitation more with paroxysmal atrial fibrillation

A_49. Misdiagnosis of right atrial mass. A case report N Espinola-Zavaleta National Institute of Cardiology Ignacio Chavez, Mexico City, Mexico

In patients with chronic kidney disease undergoing haemodialysis therapy, the morbidity and mortality is high, the main causes are cardiovascular followed by infectious. These infectious problems originate from the vascular access, mainly when it is through a central venous catheter. A 72-year-old man with end-stage renal disease, requiring HD, with fever and purulent discharge at the catheter insertion site is descibed. Transthoracic echocardiography revealed a mobile mass in the right atrium of 39x27mm. Magnetic resonance imaging showed a 53x45x36mm mass suggesting myxoma. The patient underwent surgery and a mass of approximately 50x60 mm was found attached to the floor of the right atrium, near to the inferior vena cava outlet, without affection of the tricuspid valve or the interatrial septum. Histopathology reported infected thrombus. This case confirms that sometimes, a differential diagnosis between intracardiac masses is difficult to establish. The patient showed full clinical recovery and was discharged. Actually, he is in good clinical condition and attends follow-up iregularly in the clinic of nephrology in his city. Discussion: In HD patients, a high index of suspicion is very important in the early recognition and management of infective endocarditis. Imaging studies are very useful for the diagnosis of intracardiac masses, but sometimes it is difficult to differentiate one mass from another.

A_50. RARE CASE OF PARADOXICAL EMBOLISM-WHAT COULD BE HIDDEN BEHIND CRYPTOGENIC STROKE? D.Vasileva1, G. Shabani3, N.Runev1, E.Manov1, R. Shabani1, V. Vutova2, M. Nedevska4, M.Eneva4 1Cardiology Department, UMHAT Aleksandrovska, 2Psychiatry Department, UMHAT Aleksandrovska, 3 Cardiology Department, UMHAT Saint Ekaterina, 4Radiology Department, UMHAT Saint Ekaterina

The Paradoxical embolism is a rarely seen condition, which refers to the clinical phenomenon of thromboembolism, originating in the venous vasculature and migrating through an intracardiac or pulmonary shunt into the systemic circulation. The clinical presentation is diverse and potentially life-threatening. Usually this condition is associated with patent foramen ovale (PFO). Here we represent a rare case of simultaneous systemic and pulmonary embolism, caused by a thrombogenic mass, entrapped in PFO. A 71 years old man was admitted in psychiatric department for a third consecutive time because of frequent episodes of depression and anxiety after he had undergone two ischaemic strokes. On the 10th day of his stay, patient complained of an attack of mild to moderate dyspnoea and palpitations. After clinical evaluation and cardiac ultrasound, performed by a cardiologist, a band-shaped structure was discovered, entrapped in the PFO. It was extended to both atria and part of it obstructed mitral and tricuspid valves. A subsequent CT of the chest and abdomen regions revealed: multiple thrombi in main, lobar and segment branches of pulmonary artery, besides the thrombus in PFO, and as an additional finding: several parenchymal spleen infarctions. After a precise clinical discussion cardiac surgery with thrombendarterectomy of the pulmonary artery, the left and right atria and closure of PFO was performed. Postsurgical period was without complications. This case demonstrates the importance of thorough evaluation of patients with cryptogenic stroke and unexplained pulmonary embolism-the undetected left to right atrial shunt can be accounted for these conditions.

A_51. Right ventricular chamber quantification update Sibel Catirli Enar Turkiye Hospital and Memorial Hospital, Istanbul, Turkey Right ventricle(RV) is thin walled and has crescent shape.It is highly trabeculated and is sensitive to changes in afterload. Because of its complex shape, it is usually assessed qualitatively by comparing with left ventricular (LV) size rather than quantatively. When RV is larger than LV, it is considered as severly enlarged. Use of contrast agents maybe helpful to image RV free wall visualization. RV dimensions are measured at end diastole of basal and midcavity diameters and longitudinal diameter. RV basal diameter>41 mm and RV midbasal diameter> 35mm is considered as RV dilatation. Recently three dimensional (3D) echocardiography seems as a promising method for RV assessment. Studies using special software have shown good correlation with CMR.

A_52. ROLE OF CMR IN THE DIAGNOSIS OF CORONARY ARTERY DISEASE

Fabiola B Sozzi, MD, PhD Ospedale Maggiore Policlinico, Milan, Italy

Cardiac magnetic resonance (CMR) provides valuable clinical data on the evaluation of structural, functional and valvular heart disease. An important potentiality of CMR relies on the evaluation of viability with late gadolinium enhancement (LGE) methods. The LGE differentiate viable myocardium from scar on the basis of differences in cell membrane integrity for acute myocardial infarction. In chronic infarction, the scarred tissue enhances much more than normal myocardium due to increases in extracellular volume. Beyond infarct size or infarct detection, LGE is a strong predictor of mortality and adverse cardiac events. CMR can also image microvascular obstruction and intracardiac thrombus. CMR can determine infarct size, area at risk, and thus estimate myocardial salvage after acute myocardial infaction.

A_53. Role of CV imaging in the assessment of right heart structure and function in TR patients Jun-Bean Park Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Korea Analogous with left ventricular (LV) systolic function in patients with severe mitral regurgitation, right ventricular (RV) systolic function likely yields prognostic information in patients with significant tricuspid regurgitation (TR). However, although echocardiography- based assessment of RV volume and systolic function showed some promise, comprehensive and quantitative RV assessment with echocardiography is challenging because of the complex geometry of the RV. Previous studies also showed that a large number of subjects could not be analyzed due to failure of tracing the RV . This limitation of echocardiography may be more critical in patients with dilated RV. Furthermore, even after obtaining optimal visualization of the RV, echocardiographic parameters of RV function still suffer from several inherent limitations, including an angle dependency. These considerations underscore the need for other imaging techniques to accurately and reproducibly evaluate RV volume and function. Cardiac magnetic resonance (CMR) has emerged as the reference modality for the assessment of RV function with better accuracy and reproducibility. CMR permits a modeling of the RV free of cardiac geometric assumptions and it can also overcome the aforementioned limitations of echocardiography. Thanks to these advantages, CMR is the currently accepted reference standard for assessing RV size and function in patients with congenital heart disease and pulmonary hypertension. A recent study also suggested that preoperative assessment of CMR-based RV ejection fraction provides independent and incremental prognostic information in patients undergoing corrective surgery for severe functional TR. However, CMR also has several disadvantages, including s its limited availability, high cost, and long image acquisition time, which are impediments to its wide use. Additionally, the diagnostic performance of CMR has been less validated in patients with atrial fibrillation, whose prevalence is continuously growing. Hence, recent advances in echocardiography technology, such as single-beat 3-dimensional echocardiography, may have clinically promising applications for assessing RV volumes and global systolic function in these patients.

A_54. RV function in pulmonary endarterectomy

Muralidhar Kanchi Narayana Institute of Medical Sciences, NH Health city, Bangalore, India.

Pulmonary hypertension (PH) in chronic pulmonary thromboembolism occurs as a result of partial or complete occlusion of the pulmonary vascular bed due to recurrent or residual intraluminal clot material. Chronic thromboembolic pulmonary hypertension (CTEPH) is associated with progressive increase in pulmonary vascular resistance (PVR ), RV dysfunction, RV failure and mortality. Assessment of RV function is intriguing and challenging because of complex geometry and anatomy of RV. RV ejection fraction (RVEF) is generally used as an index of RV function. However, RVEF is highly load dependent and does not reflect RV contractility. In view of this, parameters reflecting RV function, such as RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE), have been introduced into clinical practice. Additionally, several indexes have been proposed as surrogates of RV function and contractility, including the RV myocardial performance index (RVMPI, or Tei index) and the acceleration of the myocardiumduring isovolumetric contraction (IVA). Based on Doppler imaging, RVMPI is an established marker of myocardial performance and ventricular contractility that is independent of ventricular geometry. Myocardial deformation parameters of the RV free wall, such as strain and strain rate, have been proposed as load- and heart motion–independent measures of RV function. There is suggestion in the literature that echocardiographic indexes of RV function, including TAPSE, RVMPI, RVFAC, and IVA are related to RV-PV coupling (Ees/Ea) rather than to Ees alone. RV echocardiographic indexes, especially RVFAC and IVA, have been shown to correlate more strongly with Ees/Ea than with Ees in an experimental model of RV chronic pressure overload induced by pulmonary arterial ligation and recurrent embolization.

A_55. Assessment of left atrial function: predictors of clinical success after PVI procedure R. Radoslavova,V.Traykov, V.Gelev Acibadem-Sity Clinic,TokudaHospital, Sofia, Bulgaria

Advancements in the tools used for CA have improved outcomes in patients with both paroxysmal and persistent forms of AF. Indications for PVI procedure are basically clinical but we need to characterize patients who are optimal candidates for ablation.

The Electrophysiological Laboratory in Tokuda Hospital can be qualified as high- volume as it performs over 200 procedures per year. For characterization of the clinically indicated patients and for follow up the LA reverse remodeling we use mainly echocardiographic parameters.

The announcement is a literary review and sharing of our personal experience with different parameters of functional assessment of the left atrium. The Volumetric parameters assessed by 2DE, 3DE and the deformation analyses by STE before the PVI procedure and the follow up provide important prognostic information about the expected effect.

A _56. The Clinical use of Dobutamine stress echocardiography in ischemic heart disease

G. Litsova, R.Radoslavova, I. Jeleva, V.Gelev

Acibadem City Clinic, Tokuda Hospital, Sofia , Bulgaria Echocardiographic Laboratory in Tokuda Hospital is a high-volume laboratory and performs over 350 Dobutamine Stress Tests per year. This is case based presentation to share our experience with various different DSE protocols. Accelerated DSE and Short DSE are safe, feasible and useful tests in busy laboratories with high volume of activity for the diagnostic imaging of myocardial ischemia in some subgroups of patients. Is recommended physicians to chose the most suitable test for each single patient. Our most common indications are unresolved Borderline stenosis for the functional evaluation of inducible ischemia and Myocardial viability, presence and extend of ischemic myocardium in patients with Chronic Total Occlusion. We also share our experience with the use of DSE in patients Follow-up after interventional or operative revascularization.

A_57. The Right Heart in heart failure with preserved ejection fraction Sibel Catirli Enar Turkiye Hospital and Memorial Hospital, Istanbul, Turkey Heart failure with preserved ejection fraction (HFpEF) affects nearly half of the patients with clinical signs of heart failure. HFpEF is considered to be a disease of the left ventricle (LV).It is characterized by impaired diastolic function due to abnormal relaxation and increased chamber stiffness. The role of right ventricle (RV) has not been well characterized in HFpEF. Recently several studies have described the role of RV in these patients by echocardiography, and few studies by CMR. In these studies, it has been found that addition of RV dysfunction is related with worse prognosis. The following explanation has been proposed: Impaired LV diastolic function causes passive rise in left atrial (LA) pressure and consecutively in PAWP and pulmonary artery (PA) pressure. Pulmonary artery compliance (PAC) decreases and adds to the increasing resistance against the right ventricle. RV fails to compensate pressure overload, dilates and finally RV failure occurs. Left atrial dilation is also present in these patients. Although HFpEF is considered as a disease of the left ventricle, RV dysfunction is also affected. Diabetes Mellitus and hypertension present with HFpEF predominantly, however RV dysfunction is also observed in these patients. Improvement of right heart imaging by echocardiography and CMR will be very helpful in the diagnosis and determining the prognosis.

A_58. АNTHROPOMETRIC PARAMETERS AS A PREDICTORS OF MYOCARDIAL DYSFUNCTION IN PATIENTS WITH ASYMPTOMATIC MELLITUS.

1 Slavica Mitrovska, 2 Silvana Jovanova

1 Public Health Institution, Skopje, 2 University Clinic for Cardiology, Skopje, FYROM

Objective: To investigate the role of the anthropometric parameters as predictors of myocardial dysfunction in patients with asymptomatic type 2 diabetes mellitus (T2DM). Background: Diabetes mellitus is an independent risk factor for cardiovascular diseases. Metabolic abnormalities are associated with changes of myocardial function and doubled the risk of heart failure. Methods: Target group was constituted of 72 asymptomatic normotensive patients with T2DM. The control group is composed of 65 subjects w/o T2DM. All participants underwent clinical/anthropometric investigations and echocardiographic analysis (2D, Tissue Doppler imaging-TDI and Speckle-Tracking Analysis-STA). We assessed the correlation of clinical/anthropometric parameters (age, gender, body mass index-BMI, waist to hip ratio- WHR, diabetes duration) with echocardiographic parameters by Pearson Product Moment of Correlation. A p-value of <0.05 indicates significance. Results: Diabetic patients have higher obesity parameters than individuals in control group (p=0.02). We found strong negative correlations of anthropometric parameters (age, gender, BMI, WHR) with LV function assessed with STA in target group (U=2.1, p=0.03; U=3.0, p=0.001; U=2.1, p=0.03, U=3.5, p=0.004) and in control group (U=1.9, p=0.04; U=1.9, p=0.04; U=2.4, p=0.01; U=2.3, p=0.01). The diagrams of dispersion show that elderly people, female, individuals with higher BMI and WHR have decreased E/A ratio, lower global longitudinal strain (GLS) and higher E/E’ ratio. Conclusion: Strong correlations of anthropometric parameters with myocardial dysfunction suggest their role as predictors of increased risk of heart failure in diabetic patients. A_59. Emotional status of patients prior to echocardiography

Aneta Rasheva

Faculty of Medicine, Sofia University “St.St. Kiril and Metodii”, Sofia, Bulgaria

Resume: Negative emotional states lead to an increased risk of cardiovascular disease, and their presence in patients with a previously diagnosed cardiovascular disease is associated with worse prognosis and lower quality of life.

The aim of this study is to demonstrate the emotional status of patients with and without a diagnosis of cardiovascular disease prior to echocardiography and the need for emotionally- supporting communication with specialists.

Material and methods of study: Female and male sexes were studied at the Medical Center for Cardiovascular Diseases in Sofia - Sofia. The following methodologies were used: 1. Scale of manifest fеar to Janet Taylor - MAS, 1984 2. Questionnaire for Assessment of Hospital Anxiety and Depression (HAD) Zigmond and R.P. Suatith, 1983- Bulgarian variant / SBTD /.

Knowing the predominant emotions caused by waiting to confirm or reject a diagnosis of cardiovascular disease or, in the presence of a trace, the progression of the disease allows the specialist to choose a suitable way of communicating with the patient.

A_60. TETRALOGY OF FALLOT – ECHOCARDIOGRAPHIC ASSESSMENT OF NATURAL, PREOPERATIVE ANATOMY

P. Shivachev, K. Ganeva UMHAT “St. Marina” – Varna, Department of Pediatrics., Medical University – Varna, Bulgaria Tetralogy of Fallot is the most common form of cyanotic heart disease in children. The patient assessment must be consistent with the anatomic variations of the anomaly. In the current presentation we discussed the possibilities of complex echocardiographic assessment of natural preoperative anatomy in children with Tetralogy of Fallot. Particular attention is paid to the severity of the obstruction of the right ventricular outflow tract and the pulmonary artery. We look through the different anomaly variations : tetralogy of Fallot with restrictive ventricular septal defect, atrioventricular septal defect, absent , or pulmonary valve atresia, as well as other congenital heart disease as part of the differential diagnosis. We also discuss the opportunities of the fetal echocardiography as a diagnostic tool. The comprehensive echocardiography evaluation most often provide sufficiently accurate information about natural preoperative cardiac anatomy and haemodynamics in patients with Tetralogy of Fallot.

A_61. FAMILIAL MEDITERANEAN FEVER –ROLE OF MYOCARDIAL DEFORMATION IMAGING

L. Andreeva1, K.Hristova2,3

1 Department of Cardiology, University Hospital ”St. Anna” , Sofia, Bulgaria 2National Heart Hospital, 3 Medical Center of Cardiovascular Diseases, Sofia, Bulgaria Familial Mediterranean Fever (FMF) is a hereditary inflammatory disease characterized by recurrent fever and serositis. We aimed to evaluate cardiac involvement in FMF patients by using strain and strain rate echocardiographic imaging method in this study. Materials and Methods: Echocardiographic evaluation was performed in 62 old woman. FMF diagnosis was based on Tell‐ Hashomer diagnostic criteria. Conventional echocardiography, tissue Doppler echocardiography and longitudinal two‐ dimensional (2D) strain and strain rate imaging were performed in patient. Results: Doppler velocities. Left ventricle strain value was significantly lower in. Mean left ventricle strain value was significantly lower in FMF patient than controls (–21.1 ± 2.2% vs. –23.8 ± 2.2%; P < 0.001). No significant difference was noted between FMF patient and controls in mean left ventricle strain rate value (–1.61 ± 0.23 vs. –1.58 ± 0.21; P = 0.48). Conclusion: We have shown that although conventional echocardiography and tissue Doppler velocity data were similar, strain, strain rate values were significantly lower in FMF patient than controls. We know that strain and strain rate imaging method might be useful for evaluating subclinical cardiac involvement in case of normal conventional and tissue Doppler velocity data in patients with FMF and engaged with amyloid myocardium.

A_62. INTEGRATED MULTIMODAITY IMAGING IN CARDIOLOGY

G. Elkylany

Gulf Medical University, UAE Previous extensions of two-dimensional ultrasonic imaging to three dimensions used lattice diagrams which give measurement information, but no anatomic detail. The authors conducted three sets of experiments to test the hypothesis that complete acoustic backscatter data should be retained to produce useful information about heart structure and function. First, in vitro compound B-scans were taken under ideal conditions; second, in vitro rotating conventional sector scans were taken to test clinically applicable methods; and third, clinical in vivo rotating conventional sector scans were taken of a human volunteer. It is concluded that the resulting images show details of cardiac anatomy and have great clinical promise. Interactive analysis and surface and volume displays give context and perspective information which should improve diagnostic accuracy, communication with noncardiologists and yield more precise measurements of anatomical structure and function.

A_63. Identification of acutely ischemic myocardium using a new ultrasonic deformation imaging technique in patients presented with acute chest pain.

Galal Eldin Nagib-Elkilany MD, PhD(1), Mary Anne Sacayanan Olpindo,M.B.Ch.B (2),Ibrahim Kabbash,MD (3), Ram B Singh MD(4). 1Gulf Medical University, Ajman, UAE, 2Dibba-Fujairah Hospital, UAE, 3Department of Public Health & Community Medicine, Faculty of Medicine, Tanta University, Egypt 4Halberg Hospital and Research Institute, Moradabad, India. Introduction: Chest pain unit (CPU), is an observation unit for the workup and management of patients with low to moderate risk chest pain suspected of acute coronary syndrome (ACS). Patients admitted to this unit are targeted to have early diagnosis via serial examination of cardiac biomarkers, electrocardiograms (ECGs), echocardiography; deformation imaging (new emerging imaging modality) apart from clinical observation and reexamination. A selective use of stress testing and/ or other imaging modalities (multi slice computed tomography-CTA and myocardial perfusion imaging-MPI) are also done to achieve early diagnosis and suitable treatment. Objective: Identification of high-risk patients of ACS in pre symptomatic phase with low to intermediate risk, suffering from acute chest pain. Subjects and Methods: CPU of the medical department emergency consists of physicians, nurses, and midlevel service providers with consultative services provided by cardiologist. This prospective study, included a total of 492 consecutive patients suspected with ACS, who were assessed for eligibility. Clinical evaluation revealed that 55% (n=278) had non-cardiac chest pain (55%) and 45% (n= 214) had ACS with low to intermediate risk who presented to CPU due to acute chest pain with normal or non specific changes in the electrocardiogram (ECG). The peaks of longitudinal systolic strain, strain rate and post systolic shortening from 3 of apical views were measured by 2 dimensional (D) and 3D echocardiography. The GLPSS [global longitudinal peak systolic strain] and the GLPSSR [global longitudinal peak systolic strain rate] were measured after tracing the endocardium in 3 apical projections ,then acoustic markers automatically drawn and global strain and strain rate balls eye could be constructed in automated way. The average length of stay in the hospital of these patients was 12 hours with 55 percent of patients discharged within the first 24 hours. Results: Peak SS and Peak SSR of regions of interests of left ventricle were significantly lower in the low-intermediate risk group (P<0.05 and P=0.004 , respectively). Receiver operating characteristics curve showed that the optimal values of GLS and GLSR for detecting the critical CAD were -15.0 % and – 0.8 s-1. The sensitivity, specificity , negative predictive value and positive predictive value of non invasive techniques for detection of acutely ischemic myocardium (Echocardiography-strain , strain rate imaging and PSS] as compared to invasive techniques coronary angiography [CAG] was; 98.5%, 91.5%, 99% and 97% respectively. Conclusion: Doppler, two and three dimensional echocardiographic– derived myocardial strain imaging represent exciting advances in the field of noninvasive cardiac imaging. Strain and SR are highly sensitive earliest manifestations which correlate and are consistent with other measures of cardiac function, and detect changes in myocardial contractility, both normal and abnormal, across a wide range of ACS. Our study confirms that establishment of a CPU improves the prognosis of patients with chest pain due to ACS and also saves financial resources. A_64. CLINICAL CASES WITH CARDIOVASCULAR ANOMALIES Boyan Kunev Department of Cardiology, National Heart Hospital, Sofia, Bulgaria

We present two unrelated cases with apparently normal hearts and cardiovascular anomalies that may have clinical significance in certain procedures.

The first case is 41 years old male referred for electrophysiology study for asymptomatic sinus . At the time of right heart catheterisation an abnormal course of the catheters was noted. After performing venography, and subsequent echocardiography and a CT scan the patient was diagnosed with complete transposition of the inferior vena cava, which drained like a hemiazygos vein in the persistent left superior vena cava.

The second case is 37 years old male admitted with chest pain, mild pericardial effusion and slightly elevated cardiac biomarkers after a viral infection. The coronary angiogram revealed dual LAD artery with short vessel arising in normal position and a longer vessel originating from the right sinus of Valsalva. The course of the abnormal LAD relative to the right ventricular outflow tract could not be delineated. After performing another echocardiography the course of the abnormal LAD artery was defined and confirmed with a CT scan. The patient was treated for myopericarditis and has been asymptomatic for 6 months.

Both cases illustrate the need for multimodality imaging in complicated vascular anomalies and highlight that transthoracic echocardiography may still have incremental value. USEFUL INFORMATION

Congress Dates and Venue Information for Speakers XXIV World Congress of Echocardiography and Cardiovascular Imaging Speakers are kindly requested to upload their will take place on 17- 20 May 2018 in Paradise Blue Hotel and Flamingo presentations a day in advance or at least three Grand Hotel, Albena Resort. hours before its start to the technical staff in the respective hall. Speakers are kindly requested to strictly follow their fixed time for presentation according to the program. OFFICIAL OPENING Speaker’s Corner with technical facilities available will operate from 17 to 20 May at Paradise Blue Hotel, 3rd floor. You are kindly invited to the official opening of the XXIV World Congress of Echocardiography and Cardiovascular Imaging which Poster Session will be held on 17 May, Thursday, at 19:00 h, Sea Hall, Paradise Blue Display boards for poster exhibition will be provided on- Hotel, Albena Resort. site. Adhesive materials will be available on spot to mount Welcome reception will be organized at 19:30 h, after the opening your poster. ceremony, at the central lobby of Paradise Blue Hotel. Each poster will be assigned a number according to its number in the After reception dinner will be provided for attendees at the program so that participants will know where to place their posters. respective hotel of their accommodation. Presenting authors will be expected to be present at their poster and give a short oral overview on their work to moderators with a focus on results. Posters could be mounted starting from 17 May, 9:00 h and should remain Registration Desk till the end of Congress. Congress Management and Events – CME Ltd. is in Posters display boards will be dismantled and removed by the vendor at charge of the event logistics. The Registration Desk will 14:00 h. on 20 May, Sunday, so please have your poster down by this time be located in Paradise Blue Hotel and will operate from if not, the congress organizers will not be responsible for lost or demanded 16 to 20 May from 8:00 till 20:00 h. posters removed by the display board vendor. You will receive your name tag and delegate’s kit upon registration. Please, make sure to wear your name tag during the Congress including Exhibition social events. An exhibition presenting the latest achievements of the Please, feel free to contact the Registration Desk for any questions you industry will be organized during the Congress. It will be may have during your stay in Albena Resort. placed in Paradise Blue Hotel on 17-20 May 2018. USEFUL INFORMATION

Hotel Accommodation and Meals coordinated by CME. A departure schedule with pick-up time will Hotel accommodation is provided for participants in be available at the Registration desk. the following hotels of Albena Resort: Paradise Blue Pick-up time will be scheduled approximately 3 hours before the Hotel (5 star), Flamingo Grand Hotel (5 star), flight hour. Flamingo Hotel (4 star), Amalia Hotel (4 star), Laguna Garden Hotel (4 star). TOURIST PROGRAM Accommodation is provided on full board basis (breakfast, lunch and dinner) for Paradise Blue Hotel, Flamingo Grand Hotel, Flamingo Hotel Half-day sightseeing tour of Varna and Aladja Monastery and Amalia Hotel and on All inclusive basis (breakfast, lunch, dinner /included in the accompanying persons’ registration fee/ and local drinks included) for Laguna Garden Hotel. Date: 18 May 2018, Friday, 9:00 – 13:00 h. Meals’ hours: Price: 36 euro per person, incl. transportation, museum fees, Breakfast: 07:00 - 09:00 h guide in English Lunch: 12:00 - 14:00 h Dinner: 19:00 - 22:00 h The bus for the tour will start at 9:00 h from Paradise Blue Hotel. Please, note that check-in time is 14:00 h and check-out time is 12:00 h. Half-day tour to Balchik /included in the accompanying persons’ registration fee/ Payments Date: 20 May 2018, Sunday 2018, 14:00 – 18:00 h. Costs for additional services such as telephone calls, Price: 25 euro per person, incl. transportation, museum fees, mini bar, laundry, room service, etc., are to be paid guide in English personally at the hotel reception desks. The bus for the tour will start at 14:00 h from Paradise Blue Hotel. Payments on spot for additional overnights, transfers, social and tourist programs are to be settled on spot at the Registration Desk in Paradise One-day tour to Nessebar Blue Hotel. Credit cards and cash euro are accepted. /optional excursion/ Date: 19 May 2018, Saturday, 9:00 –18:00 Transfers Price: 55 euro per person, incl. transportation, museum fees, CME Ltd. will arrange individual transfers upon guide in English, lunch departure /from Albena Resort to Varna Airport/ for all participants upon preliminary request. The bus for the tour will start at 9:00 h from Paradise Blue Hotel. Precise travel details should be given to CME Ltd. at least 2 days Tours should be booked and paid at least two days prior to the prior to departure. The organization of the departure transfers will be respective date of the excursion at the Registration Desk. USEFUL INFORMATION

ALBENA RESORT The charming Bulgarian coastal resort Albena is one of the Gala Dinner pearls of Bulgaria North Black Join us for a glamorous Bulgarian night with Sea coast. It is located a special performance of in a picturesque bay 30 km Bulgarian folk-style dances, away from Varna city. music and songs. Albena is a unique blend of breathtaking sceneries, great atmosphere, a peculiar charm and magnetism. It’s interesting to know that Albena has an active eco policy, focused on the preservation of the environment. It has been awarded with the prestigious prize “Blue Flag” which is a testimonial for the clear waters of Albena’s coasts. Albena disposes of first-rate hotels /3, 4 and 5 stars/. All rooms feature views of the sea or the Baltata National Reserve — a rare combination of dense wet forest and a seashore. The specific sea climate is mild and pleasant with clean air, rich in ozone and optimal humidity of 63-65%. The tourist season lasts from May till October, when the use of the sea and the beach is guaranteed. The resort offers visitors numerous sport & recreation activities including football pitches, multiple tennis courts, indoor stadium, golf courses, bowling, jet-ski, an equestrian base and Albena Variete Theater many more. 19 May 2018, Saturday, 20:30 h Most of the hotels offer large conference halls, all with daylight and For registered attendees: included in the registration fee equipped with modern technical equipment for hosting conferences, congresses, business forums and discussions. Albena hosts many Invitations required. An invitation is valid for one person only. cultural events and conferences. For purchasing additional invitations, please contact the Registration desk. Albena Variete Theater is located in 15 minute walking distance from Paradise Blue Hotel. Shuttle buses will be provided in 15 minutes from Paradise Blue Hotel to Albena Variete Theater and back. 46 The first shuttle will start from Paradise Blue Hotel to Albena Variete Theater at 20:15 h. USEFUL INFORMATION

BULGARIA Bulgaria is a part of the Balkan Peninsula in South Eastern Europe. The state of Bulgaria was first founded in 681 AD and has a long and varied history. Since January 2007 Bulgaria is a member of the European Union. Here are some facts about Bulgaria: • The oldest crafted gold in the history of mankind • Of the 300 cultural and natural sites in the UNESCO List of World Heritage, nine are in Bulgaria. • Bulgaria is the country of yoghourt – the food of the centenarians. • The world’s perfume and cosmetics industry could not do without the Bulgarian attar of roses – the Bulgarian oleaginous rose yields 80% of the world’s production. • Small Bulgaria is one of the world’s largest wine producers together with France, Spain, Italy and Greece. Bulgaria is a beautiful mountaintous country, with tourism opportunities being one of its biggest assets. Bulgaria possesses beautiful landscapes and beaches. The Black Sea Coast on its East border is famous for its fine sanded beaches, and perfect temperatures of water and air.