Heart surgery over two decades: what we have learned about results and changing risks.

OBJECTIVES: Using the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients. METHODS: This serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS). RESULTS: A total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001. CONCLUSIONS: Isolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings.

Three-dimensional transesophageal echocardiography measurements of ASD sizing parameters in comparison to balloon sizing method in percutaneous ASD closure.

BACKGROUND: Balloon sizing (BS) has been used for device size selection in percutaneous atrial septal defect (ASD) closure. Due to its limitations, alternative imaging techniques like three-dimensional transesophageal echocardiography (3D-TEE) are valuable for guiding ASD device size selection during ASD closure procedures. The purpose of this study was to compare ASD sizing using measurements obtained from 3D-TEE to those utilizing the standard balloon sizing method. METHODS: We identified 53 patients with single secundum type ASD without PFO who underwent percutaneous closure at the Tehran Heart Center between 2019 and 2022. Balloon sizing was performed in all patients with the stop-flow technique, and the choice of device size was determined based on the sizing derived from BS. 3D-TEE imaging was performed before the intervention, and the ASD shape and quality of ASD rims were assessed. RESULTS: Among the 53 patients who underwent single ASD device closure, multiple 3D TEE measurements significantly correlated with balloon sizing results. This included defect area, perimeter, and diameter obtained from 3D-TEE images multi-planar reconstruction. ASD perimeter detected by 3D TEE had the best correlation with BS results. When divided by the shape of ASD, there was no significant difference between our 3D-images data and BS in round or oval-shaped ASDs. CONCLUSION: The 3D-TEE study is reliable for assessing ASD configurational characteristics in percutaneous device closure candidates. 3D-TEE has the potential to accurately determine the appropriate device size and reduce complications, costs, and procedural duration. Further research is needed to validate these findings and establish the role of 3D-TEE measurements in guiding the best treatment decisions for ASD closure.

Evaluating the pure effect of weight on cardiac function in patients with cardiac syndrome X.

BACKGROUND: Obese patients have more coronary artery disease (CAD) risk factors that may affect myocardial function. We aimed to assess the ability of echocardiography-derived conventional parameters, left atrial strain, and global longitudinal strain to detect early diastolic and systolic dysfunction in obese individuals with almost no CAD risk factors. METHOD: We studied 100 participants with structurally normal hearts, ejection fractions above 50%, almost normal coronary arteries in coronary angiogram (syndrome X), and no cardiovascular risk factor except dyslipidemia. Participants were classified as normal-weight (BMI < 25.0 kg/m2 , n = 28) and high-weight (BMI ≥ 25.0 kg/m2 , n = 72). Conventional echocardiographic parameters and two-dimensional speckle tracking (2DSTE) were used to measure peak LA strain and global longitudinal strain to evaluate diastolic and systolic function, respectively. RESULT: There was no significant difference in the standard and conventional echocardiographic parameters between the two groups. 2DSTE echocardiographic parameters of the longitudinal deformation of the LV myocardium were not significantly different within the two groups. However, there were significant differences between the subjects with normal-weight and high-weight in terms of LA strain (34.51 ± 8.98% vs. 39.06 ± 8.62%, p = .021). The normal-weight group had lower LA strain, in compression with the high-weight group. All echocardiographic parameters were in the normal range. CONCLUSION: In the present study we demonstrated that global longitudinal subendocardial deformations, for the evaluation of systolic function, and conventional echocardiographic parameters, for the evaluation of diastolic function, were not significantly different between normal- and high-weight groups. Although LA strain was higher among overweight patients, it was not above the normal range of diastolic dysfunction.

A pseudoaneurysm of the left atrium as a rare source of coronary artery embolization.

A 67 years old woman with history of surgical Mitral valve replacement underwent transoesophageal echocardiography for evaluation of mild dyspnoea. It revealed a large narrow-necked outpouching from medial portion of the inferior wall of the left atrium (LA) that was extended to the interatrial septum. A diagnosis of the LA pseudoaneurysm was made. It contained a fresh clot. Five days later, the patient presented with an acute inferior ST-elevation myocardial infarction. Coronary angiography revealed an occluded right coronary artery at its distal part by a large thrombus. Thromboaspiration was done and resulted in restoration of a Thrombolysis in Myocardial Infarction Score (TIMI) flow 3 without underlying stenosis.

The correlation between conventional echocardiography and two-dimensional speckle strain imaging for evaluating left atrial function in patients with moderate to severe mitral stenosis.

AIM: We intended to assess the left atrial deformation parameters, using two-dimensional speckle tracking (2DSTE) and transesophageal echocardiography (TEE), and determine the correlation between these two techniques in order to recognize the patients at risk for cardioembolic events. METHOD: Strain and strain rate were measured using 2DSTE among 26 patients in sinus rhythm, with isolated moderate to severe mitral stenosis. Left atrial (LA) volume parameters (maximum, minimum and preatrial contraction) were measured. Among 26 patients, TEE was performed to detect left atrial thrombosis or spontaneous echo contrast. Left atrial appendage velocity (LAAV) was also assessed. RESULTS: A significant correlation was observed between LAAV and the average value of left atrial peak systolic strain (LA-RES) (r = 0.638, P = 0.001). The sensitivity and specificity of mean LA-RES (cutoff = 16.75%) for detecting LAAV < 25 cm/s were 88.9% and 80%, respectively. The sensitivity and specificity of mean LA-RES (cutoff = 18.14%) for detecting LAAV < 25 cm/s and/or dense smoky pattern were 77.8% and 83.3%, respectively, and those of left atrial maximum volume indexed for body surface area(cutoff = 50.75 cc/m2 ), for discriminating LAAV < 25 cm/s and/or dense smoky pattern, were 73.3% and 83.3%, respectively. A meaningful correlation was witnessed between mean LA-RES and left atrial ejection fraction (r = 0.736, P < 0.001), and left atrial expansion index (r = 0.743, P < 0.001). CONCLUSION: The average value of left atrial reservoir function using 2DSTE can be used as a predictive factor for detecting LAAV < 25 cm/s and/or dense SEC and thus recognizing high-risk patients for cardioembolic events with moderate to severe mitral stenosis. In addition, assessment of LA function and LA volume can also be helpful.

Early Improvement in Mitral Regurgitation after Cardiac Resynchronization Therapy in Cardiomyopathy Patients.

BACKGROUND: The study aim was to investigate factors affecting the improvement of mitral regurgitation (MR) severity within 48 hours after cardiac resynchronization therapy (CRT) in patients with cardiomyopathy. METHODS: Sixty-nine cardiomyopathy patients (48 males, 21 females; mean age 59.12 ± 9.66 years) in NYHA functional class ≥III, with left ventricular ejection fraction (LVEF) ≤35%, and QRS duration >120 ms, with MR ≥moderate, were included in the study. Conventional echocardiography was performed before and within 48 h after CRT, and all patients underwent tissue Doppler imaging prior to CRT. Improved MR was defined as a reduction of at least one grade in MR severity. RESULTS: After CRT, 49 patients (71%) showed MR improvement but 20 (29%) had no MR improvement. The mean MR severity grade was reduced significantly, from 2.70 ± 0.77 before CRT to 1.90 ± 0.94 after CRT (p<0.001). The group with improved MR had a significantly higher rate of left bundle branch block (75.5% versus 45%; p = 0.015), a higher QRS duration (172.00 ± 31.98 versus 147.25 ± 28.75 ms; p = 0.001), a higher median septal lateral delay (70 versus 35 ms, p = 0.035), and a higher median anteroseptal to posterior-wall delay by M mode (200 versus 130 ms, p = 0.041). Older age, longer QRS duration, and septallateral delay remained significant independent predictors of MR improvement. A greater proportion of patients with improved MR showed ≥5% increase in LVEF (55.1% versus 30.0%, p = 0.058). CONCLUSIONS: CRT acutely reduced the severity of functional MR in the majority of cardiomyopathy patients. Those patients with improved MR showed a higher frequency of ≥5% increase in LVEF after CRT. Older age, longer QRS duration, and septallateral delay were independent predictors of MR improvement after CRT.

Correlation between systolic deformation and dyssynchrony indices and the grade of left ventricular hypertrophy in hypertensive patients with a preserved systolic ejection fraction undergoing coronary angiography, based on tissue Doppler imaging.

OBJECTIVES: The purpose of this study was to investigate whether systolic mechanical dyssynchrony occurs in hypertensive patients with a normal coronary artery and a normal ejection fraction and its relationship with different degrees of left ventricular (LV) hypertrophy. METHODS: A total of 125 angiographically normal coronary patients (42.4% male; mean age ± SD, 57.16 ± 8.26 years) with an ejection fraction greater than 50% were included, of which 84 were hypertensive and 41 normotensive. The hypertensive patients were categorized into 3 groups: no, mild, and moderate LV hypertrophy. Tissue Doppler and deformation imaging parameters were measured in the 6 LV basal segments at peak systole. RESULTS: The frequency of dyssynchrony was 40.5% in the hypertensive patients compared to 19.5% in the control patients (P = .020). Among the hypertensive patients, LV dyssynchrony was found in 5 patients (20%) with no hypertrophy, 20 (42.6%) with mild hypertrophy, and 9 (75%) with moderate hypertrophy. There was a moderate correlation between the grade of hypertrophy and septal-lateral wall delay (r = 0.497), 6-basal segment delay (r = 0.454), overall strain (r = 0.453), overall peak systolic velocity (r = -0.430), and standard deviation of the time to peak systolic velocity in the basal segments (r = 0.429). After adjustment for the LV end-systolic diameter and body surface area, overall strain was the best correlate of the hypertrophy grade (odds ratio, 7.043; 95% confidence interval, 1.839-26.980; P = .0044). CONCLUSIONS: Among tissue Doppler and deformation indices, overall peak systolic strain was the strongest correlate of the LV hypertrophy grade. Therefore, in hypertensive patients with normal cardiac systolic function, a reduction in overall strain in the 6 basal LV segments may be a good indicator of progression of the LV hypertrophy grade and systolic dysfunction.

Mechanical prosthetic valve thrombosis: A literature review of treatment strategies.

Mechanical prosthetic valve thrombosis (MPVT) is a common complication of valvular implantations. This study compared the efficacy and safety of different treatments for MPVT. A systematic search of electronic databases identified studies evaluating surgical, anticoagulant, and thrombolytic therapies. Although several studies of different types have been conducted to evaluate the efficacy of these treatment strategies the lack of randomized controlled trials has resulted in the inability to make a definitive conclusion about the pros and cons of these treatments. Recent treatments, such as slow and ultraslow infusion of thrombolytics, showed comparable efficacy and lower complication rates than traditional methods. Inadequate anticoagulant use is a major risk factor for MPVT, highlighting the importance of prevention. Treatment selection should be individualized based on patient factors and available expertise. Overall, slow and ultraslow infusion of thrombolytics may be a promising treatment option for MPVT.

Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David's procedure).

BACKGROUND: In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's experience with the procedure. METHODS: Forty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David's procedure during the operation. RESULTS: The study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI. CONCLUSION: David's procedure showed excellent mid-term results in our center, with only one in-hospital mortality.

Relationship between left atrial function and size and level of left ventricular dyssynchrony in heart failure patients.

AIM: To study whether there is any relation between left atrial (LA) size or function and the level of left ventricular dyssynchrony (LV) in patients with heart failure. METHOD: Fifty-two patients (male 34, mean age = 65.77 ± 8.69 years) with ejection fraction (EF) <35%, who were candidates for cardiac resynchronization therapy (CRT), underwent conventional transthoracic echocardiography and tissue Doppler imaging (TDI). Intra-ventricular dyssynchrony, inter-ventricular mechanical dyssynchrony (IVMD), and related time intervals were measured. The LA size and function were evaluated by transthoracic echocardiography and deformation imaging using LA lateral wall strain (ST) and strain rate (SR), and the septal wall ST. RESULTS: The LA volume showed severe dilation in 41 (78.8%) patients. 44 (84.6%) cases had intra-ventricular dyssynchrony and 33 (63.5%) had IVMD. In univariable analysis, the LA lateral wall ST and SR as well as the LA septal wall ST had significant but poor correlation with IVMD. There were also poor to moderate correlation between these parameters and the LV end diastolic diameter and mitral annulus tissue velocity at early and late diastole. However, after adjustment for all the related factors, IVMD remained a significant independent correlate for the LA lateral wall ST and SR. This correlation for the LA septal wall ST was not statistically significant. CONCLUSION: IVMD was a significant independent correlate for the LA lateral wall ST and SR. This correlation for the LA septal wall ST was nonsignificant. Future studies are needed to examine whether the correction of inter-ventricular dyssynchrony by CRT in patients with concomitant LA dysfunction can have an independent role in the improvement of the LA function.

Sex-related changes in tissue Doppler imaging parameters among patients with acute pulmonary thromboembolism.

OBJECTIVES: There are few studies evaluating serial changes in tissue Doppler imaging parameters in acute pulmonary thromboembolism. We aimed to compare these changes in male and female patients separately. METHODS: Between September 2010 and September 2011, 41 of 64 hemodynamically stable acute patients with pulmonary thromboembolism were included in the study. Twenty-two healthy individuals served as a control group. RESULTS: Compared to the control group, the acute pulmonary thromboembolism group had a lower tricuspid annular plane systolic excursion, basal peak systolic velocity of the tricuspid valvular annulus, right ventricular (RV) peak systolic strain, and RV peak systolic strain rate and a higher RV diameter, peak systolic pulmonary artery pressure, and RV myocardial performance index (P < .05). Values for these parameters were not different between men and women in the patient group. In men, compared to admission, predischarge echocardiography showed significant improvement in the tricuspid annular plane systolic excursion (mean ± SD, 16.08 ± 4.33 versus 19.29 ± 3.74 mm; P = .002), basal tricuspid annular peak systolic velocity (10.11 ± 3.66 versus 11.66 ± 3.38 cm/s; P = .007), and peak systolic strain (-13.00% ± 14.99% versus -23.20% ± 10.23%; P = .001), whereas in women, predischarge and 3-month follow-up echocardiography showed marked improvement in the tricuspid annular plane systolic excursion (17.50 ± 4.88 versus 19.79 ± 5.58 mm; P = .021) and peak systolic strain (-15.70% ± 13.52% versus -21.01% ± 10.57%, respectively; P= .045). Female patients did not show improvement in these parameters during hospitalization. CONCLUSIONS: Patterns of changes in the RV function over time during a 3-month follow-up might differ between male and female patients with acute pulmonary thromboembolism, and the recovery process could be slower in women. Moreover, the midventricular peak systolic strain might be useful for serial evaluation of the recovery process.

Comparison of 1-year Follow-up Echocardiographic Outcomes of Sapien 3 Versus Evolut R Bioprosthetic Transcatheter Aortic Valves: A Single-center Retrospective Iranian Cohort Study.

OBJECTIVE: The current study aimed to compare 1-year echocardiographic outcomes of the new generations of self-expanding (Evolut R) versus balloon-expandable (Sapien 3) bioprosthetic transcatheter aortic valves. METHODS: In this study, gradients and flow velocities obtained from transthoracic Doppler-echocardiography were retrospectively collected from patients who underwent 2 new generations of transcatheter aortic valve implantation interventions with Sapien 3 and Evolut R valves. Patients underwent echocardiography before the procedure and at discharge, 6 months, and 1-year follow-up. RESULTS: Of the 66 patients, 28 received Sapien 3 and 38 received Evolut R valves. Evolut R valve presented a lower mean gradient at all follow-up time points compared with Sapien 3 valves (14.4 mm Hg, 14.9 mm Hg, 15.5 mm Hg compared with 10.1 mm Hg, 11.6 mm Hg, 11.8 mm Hg, respectively; all P -values <0.001). Small valve sizes of Evolut R, including 23 and 26, had higher echocardiographic mean gradient or peak gradient at the time of discharge compared with larger valves, including sizes 29 and 34 (11.1 mm Hg and 11.2 mm Hg vs. 10.2 mm Hg, 9.1 mm Hg) and 1-year follow-up (11.0 mm Hg, 11.0 mm Hg vs. 9.9 mm Hg, 8.4 mm Hg; all P -values = 0.001). Although Sapien 3 valves demonstrated a higher peak gradient in smaller sizes at discharge (18.44 mm Hg in size 23 vs. 17.9 mm Hg, 16.5 mm Hg in size 26 and 29, respectively; P = 0.001), the peak gradients did not show a statistically significant difference in the 1-year follow-up. CONCLUSIONS: The current study detected significantly lower mean and peak gradients in Evolut R compared with Sapien 3 at all follow-up time points. Furthermore, smaller valve sizes were associated with significantly higher gradients at all follow-ups, regardless of the valve type.

Mid to Long-Term Echocardiographic Follow-up of Patients Undergoing Transcatheter Tricuspid Valve-in-Valve Replacement for Degenerated Bioprosthetic Valves: First Single-Center Report from Iran.

Background: Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran. Methods: Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17±1.75 years. Results: All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25±2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08±1.98 mm Hg to 5.29±1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00±49.46 ms to 158.64±57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91±7.31 mm Hg to 26.72±8.99 mm Hg, and left ventricular ejection fraction increased from 47.71±4.70% to 49.79±4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up. Conclusion: This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results.

Transcatheter tricuspid valve-in-valve implantation with bioprosthetic balloon expandable valve.

OBJECTIVES: This study was conducted to evaluate the outcome of the transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves with transcatheter aortic valves. METHODS: This retrospective study enrolled all consecutive patients who were considered high risk for reoperations by the heart team and who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves in Tehran Heart Center, Tehran, Iran. All the procedures were performed via the transfemoral venous route under echocardiography and fluoroscopy guidance with Edwards SAPIEN transcatheter heart valves (Edwards Lifesciences, Irvine, CA). RESULTS: Ten patients underwent successful transcatheter valve-in-valve implantation in the tricuspid position without any major complications or need for emergency surgical interventions. The mean age was 54.1 ± 17.1 years, and 8 patients were female. The median follow-up was 19.5 months (16-32.25 mon). The mean period between the last tricuspid valve replacement and transcatheter valve-in-valve implantation was 4.9 ± 2.2 years. The bioprosthetic valves were Hancock in three patients, Mosaic in the other three patients, and Biocor, Pericarbon, Perimount, and Epic in the other patients. After the procedure, the clinical and functional status improved significantly in all the patients. The mean transvalvular gradient decreased from 6.75 ± 2.66 mm Hg to 2.85 ± 0.89 (P < 0.001), and the postoperative tricuspid regurgitation severity decreased significantly in almost all the patients. The hospitalization period after the procedure was 4.4 ± 1.7 days. CONCLUSIONS: In high-risk patients, transcatheter valve-in-valve implantation seems to be a safe and minimally invasive alternative to reoperations for degenerated tricuspid bioprosthetic valves.

Cardiac imaging findings in anomalous origin of the coronary arteries from the pulmonary artery; narrative review of the literature.

INTRODUCTION: Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare coronary artery malformation with an incidence of 0.002% in patients undergoing coronary angiography. It can lead to an increased risk of myocardial infarction (MI) and sudden cardiac death, even in asymptomatic patients. METHODS: We conducted a review of published cases of ARCAPA using PubMed and Scopus databases and included patients over 18 years old with adequate echocardiographic data. RESULTS: We evaluated 28 patients with ARCAPA with a mean age of 42.8 from 1979 to 2021. Patients were diagnosed mostly by angiography and echocardiography, the most performed treatment was reimplantation (15, 53.6%) and the main echocardiographic findings were dilated coronary arteries (9, 32.1%), coronary collaterals (8, 28.6%), and retrograde flow from right coronary arteries to main pulmonary trunk (7, 25%). CONCLUSION: Although ARCAPA is rare and not as deadly as the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) still there is a chance of serious outcomes, therefore surgical treatment should be performed upon diagnosis. Angiography is the gold standard for diagnosis, but echocardiography can be a convenient, non-invasive, and most reliable method as the primary step whenever ARCAPA is suspected.

Assessment of Left Ventricular Function and Mitral Regurgitation Severity Early After Percutaneous Device Closure of the Atrial Septal Defect.

BACKGROUND: Atrial septal defect (ASD) is one the most prevalent forms of congenital heart disease in adults. Closure of ASDs eliminates left-to-right shunt and reduces right heart volumes, but the effects of ASD closure, on the left ventricle (LV) and mitral valve competence are somewhat inconsistent. Therefore, we designed this study to evaluate the early effect of percutaneous closure of ASD on LV function and mitral regurgitation (MR) severity. METHODS: In this prospective study, we enrolled 32 patients with ASD secundum who underwent percutaneous device closure in Tehran Heart Center. We used transthoracic and transesophageal echocardiography (TEE) before the procedure and TTE 24 hours after the procedure, then compared obtained LV parameters before and after the procedure. RESULTS: LV end-diastolic diameter (LVEDD) increased significantly from 44.8 ± 2.4 to 45.8 ± 2.8 (P < 0.001). LV end-systolic diameter (LVESD) also increased but was statistically insignificant (P = 0.063) and LV ejection fraction (LVEF) remained nearly unchanged. Highest alteration was in right ventricular systolic pressure (12.4% decrease; P < 0.001) and mitral early Doppler/tissue Doppler velocity ratio (E/E') (9.7% increase; P = 0.010). The change in MR severity was insignificant using Wilcoxon signed-rank test (P = 0.157). CONCLUSIONS: We concluded that systolic functions do not change immediately. However, LVEDD and E/E' will increase immediately, resulting from the passage of all blood from the LA into the LV in the early diastole just after closure. We also observed the positive effect of device closure on reducing right ventricular systolic pressure, and at least it does not worsen MR early after the procedure.

Epicardial and transverse sinus fat pad near left atrium appendage; role of 3D echocardiography.

Pericardial fat pad in transverse sinus adjacent to left atrial appendage (LAA) is a rare condition that may resemble LAA thrombosis especially in suspected cases. More Trans-esophageal echocardiography (TEE) angulations and also 3D TEE images are helpful tools to confirm the diagnosis.

Prognostic role of moderate functional tricuspid regurgitation in length of hospitalization in patients undergoing isolated coronary artery bypass grafting.

Functional tricuspid regurgitation (FTR) is defined as abnormal systolic tricuspid leakage with normal valve structures, and its prognostic role and management in patients with left-heart valve disease is well known. Due to paucity of data on FTR in patients with ischemic heart disease, the aim of our prospective study was to compare the prognostic effect of FTR between patients with moderate FTR and those with less-than-moderate FTR undergoing isolated coronary artery bypass graft (CABG) surgery. This prospective cohort study included all the patients who were candidate for isolated CABG and were referred for preoperative transthoracic echocardiography between April 2018 and November 2018. Patients were categorized into two groups: less-than-moderate FTR and moderate FTR. The endpoints of the study were the prognostic effect of FTR on short-term mortality and morbidities as a composite endpoint, as well as length of hospitalization, length of intensive care unit (ICU) stay, and ventilation time. Of a total of 410 patients, 363 patients (mean age = 62.4 years, 63.7% men) entered our final analysis. Logistic regression analysis demonstrated that composite endpoints of short-term mortality and morbidities was not significantly different between the two groups, but moderate FTR had a statistically significant effect on length of hospitalization (P = 0.002) and the ventilation time (P = 0.048). This effect, however, did not persist after adjustments for probable known confounders. Our study indicated no significant prognostic effect for preoperative FTR versus less-than-moderate FTR on short-term mortality and morbidities, as well as length of hospitalization, length of ICU stay, and the ventilation time.

Hydatid cyst of the right ventricle in early pregnancy.

Although hydatic cyst disease rarely involves myocardium and endocardium, cardiac echinococcosis, a potentially life-threatening condition, should be managed promptly. We report a case of right ventricle hydatid cyst detected after syncopal attack in a pregnant woman by using echocardiography.

Floating thrombus in the aortic arch as an origin of simultaneous peripheral emboli.

Few cases of a floating thrombus in a normal aorta have been reported without other underlying reasons for the thrombus formation and its systemic embolic complications. We report a case in which a floating thrombus in the proximal aortic arch was detected after echocardiography and computed tomography angiography as an origin of upper extremities and ophthalmic embolism.