Systolic Murmur Due to Systolic Gradient Across Moderator Band.

A 14 years asymptomatic male was evaluated for a grade 3/6 systolic murmur along lower left parasternal region. Color Doppler evaluation revealed turbulent systolic flow across moderator band with a peak systolic gradient of 127.2 mm hg. There was no other abnormality. This anomaly should be considered in differential diagnosis of systolic murmur in tricuspid area.

Slow junctional rhythm, QTc prolongation and transient torsades de-pointes following combined use of Ivabradine, Diltiazem and Ranolazine.

A case of unstable angina developed slow junctional rhythm with QTc prolongation and transient Torsades de pointes following simultaneous use of Ivabradine, Diltiazem and Ranolazine. Effect of Diltiazem on hepatic isoenzyme CYP 3A could be responsible. Such a combination should be avoided.

Post stress tissue Doppler imaging can identify false positive exercise electrocardiogram.

Post stress tissue Doppler imaging can diagnose false positive response on exercise electrocardiography. Tissue Doppler imaging thus provides additional useful parameter to increase specificity of stress testing for evaluation of coronary artery disease.

Occult constrictive pericarditis.

Four cases of occult pericardial constriction are presented. This condition is not uncommon, but needs high index of suspicion. Integration of detailed echocardiographic evaluation in a given patient with diseases known to cause pericardial involvement can clinch the diagnosis.

Mild mitral and tricuspid regurgitation secondary to pericardial constriction.

A 26 years female presented with pericardial effusion. On follow up she developed pericardial constriction with new appearance of mild mitral and tricuspid regurgitation without any other pathology. Fibrosis along posterior atrioventricular groove could be responsible for regurgitation.

Efficacy of post exercise pulsed wave tissue velocity imaging in diagnosing more than 70% coronary artery stenosis.

BACKGROUND: To evaluate efficacy of post exercise tissue velocity imaging in diagnosing more than 70% coronary artery stenosis. METHOD: Twenty patients with angiographically proved significant coronary artery disease and 26 healthy controls were evaluated. Pulsed wave tissue velocity imaging was performed at rest and immediately after treadmill stress test. Medial and lateral part of mitral annulus and medial and lateral part of tricuspid annulus were evaluated. RESULT: No change or reduction in systolic annular velocity after exercise at any of the four sites identified patients of significant coronary artery disease with 75% sensitivity and 73% specificity. Rise in the ratio of early diastolic inflow velocity to the corresponding early diastolic annular velocity above the identified site-specific cut-off value had sensitivity of 85% but specificity of 34.6%. A combination of no change or decrease in late diastolic annular velocity and no change or decrease in systolic annular velocity at any of the four sites had sensitivity of 75% and specificity of 88.46%. CONCLUSION: Post exercise tissue velocity imaging can provide a useful, objective parameter for detection of ischemic heart disease on stress testing.

Inferior sinus venosus atrial septal defect.

One case of inferior vena cava type sinus venosus defect is reported. It is likely to be missed on transthoracic echocardiography. Transesophageal echocardiography is useful. Unlike superior sinus venosus defect which are easily visible on transesophageal echocardiography, a careful search is needed to detect inferior sinus venosus defects. All patients with unexplained right ventricular volume overload on transthoracic echocardiography should have transesophageal echocardiography to see for sinus venosus atrial septal defects.

Radial pseudoaneurysm following trans-radial coronary angiography.

A case of pseudoaneurysm of right radial artery following transradial coronary angiography is reported. Adequate hemostasis is the key to prevention. Prolonged ultrasonography guided compression of neck of pseudoaneurysm or injection of procoagulants in the cavity of pseudoaneurysm can help non surgical closure.

Transient pericardial constriction.

A patient with idiopathic pericardial effusion is reported. Patient developed transient constrictive hemodynamics which recovered with continued empirical use of antitubercular drugs and prednisolone.

Presystolic mitral regurgitation.

A case of mild to moderate aortic regurgitation with presystolic closure of mitral valve and presystolic mitral regurgitation is reported. This echocardiographic finding is a reliable marker of significantly increased LV end-diastolic pressure.

Acute myocardial infarction in a 20 year pregnant female with prosthetic mitral valve.

Myocardial infarction is very uncommon in young females. We are reporting a case of acute myocardial infarction in a 20 year pregnant female with prosthetic mitral valve. Embolism from mitral valve prosthesis, in-situ thrombosis due to hypercoagulable state of pregnancy or coronary spasm could be responsible.

Mean arterial pressure may affect LV mass even when clinic BP is 120/80 mmHg or less.

Detailed echocardiographic evaluation was performed on sixty-four normal persons without any cardiovascular risk factor and clinic blood pressure of 120/80 mm of Hg or less with an aim to find, if there are subclinical echocardiographic changes even in this population. There was significant positive linear correlation between mean arterial pressure and LV mass index. On dividing the patients according to mean arterial pressure, those with mean arterial pressure of more than 85 had significantly higher LV mass index (P <0.01).There may be a relationship between mean arterial pressure and LV mass index in this population, but this needs to be further explored in a larger study.

Tetralogy of Fallot with quadricuspid aortic valve.

We describe herein a 54 year female who had tetralogy of Fallot with quadricuspid aortic valve. This combination is very uncommon. Hence it was worth reporting this interesting case.

Effect of treadmill exercise on tricuspid inflow and tissue Doppler velocity of tricuspid annulus in healthy persons.

Effect of treadmill stress test on tricuspid flow and tissue Doppler imaging of tricuspid annulus were evaluated in 26 healthy persons. Exercise resulted in significant increase in A-wave velocity and significant reduction in E-wave deceleration time and E/A ratio. On tissue Doppler imaging Aa-wave increased significantly with decrease in isovolumic relaxation time and Ea/Aa ratio.

LV remodeling and/or diastolic dysfunction in normal persons with BP of 120/80 mm hg or less and no other cardiovascular risk factors.

AIM: To detect echocardiographic abnormalities in persons without cardiovascular risk factors and BP of 120/80 mm Hg or less. METHOD: Detailed echocardiographic evaluation was done in 65 persons fulfilling above mentioned criteria. RESULTS: Nearly 50% persons had cardiac remodeling and/or diastolic dysfunction. Pulmonary vein flow systolic velocity/diastolic velocity had significant negative correlation with systemic diastolic BP (P < .002) and mean arterial pressure (P < .05). CONCLUSION: Some persons with BP of 120/80 mm Hg or less and not having conventional cardiovascular risk factors have subclinical LV remodeling and/or evidence of diastolic dysfunction. These findings could be for e-runner of established cardiovascular risk factors and should be evaluated periodically.

Idiopathic dilatation of inferior vena cava.

A case of isolated dilation of inferior vena cava with diminished inspiratory collapse is reported. There was no other abnormality. Diameter and collapsibility of IVC should be interpreted in collaboration with other clinical and echocardiographic parameters before drawing any definative conclusion.

Left ventricular tissue Doppler imaging in normal adults with clinic BP of 120/80mmHg or less.

BACKGROUND: There is only scanty data on tissue Doppler imaging (TDI) of 'normal' adults. METHODS: Twenty eight asymptomatic adults (20-45 yrs) without cardiovascular risk factors, clinic BP < or = 120/80mmHg and normal echocardiographic examination were evaluated by tissue Doppler imaging to find normal reference values in this population. RESULTS: There was significant heterogeneity in TDI velocities and duration of different segments of left ventricle (LV). Sa and Ea velocities were lower at medial mitral annulus and middle part of interventricular septum (IVS) than at lateral mitral annulus and middle part of left ventricular lateral wall. Isovolumic contraction time (IVCT) was significantly less at lateral mitral annulus and mid part of lateral wall of LV. Isovolumic relaxation time (IVRT) was significantly less at lateral mitral annulus. Aa velocity was lower at middle part of IVS. E/Ea velocity ratio was significantly lower at lateral mitral annulus. Ea/Aa velocity ratio was always more than 1. Relatively higher values were recorded at lateral mitral annulus and mid part of left lateral wall. Myocardial performance index values were higher at mid segments than at annulus. CONCLUSION: Our data provides reference values of TDI for healthy normal adults and may help in the detection of onset of early diastolic dysfunction in this age group.

Right ventricular function in isolated occlusion of left anterior descending coronary artery.

BACKGROUND: Previous studies in this field have not excluded right coronary artery disease by coronary angiography and have included patients with co-morbid conditions that have independent impact on right ventricular function. METHODS: 14 patients with left ventricular (LV) anterior myocardial infarction (MI) due to isolated occlusion of left anterior descending coronary artery (LAD) on coronary angiography were studied. 14 normal persons matched for age, body mass index (BMI), pulse rate, systolic and diastolic blood pressure (SBP and DBP) were evaluated as controls. All conditions that could independently affect right ventricular (RV) function were strictly excluded. Detailed 2-Dimensional (2-D), M-mode, pulse wave Doppler and tissue Doppler evaluation (DTI) of LV and RV was performed. RESULTS: Patients of LV anterior MI due to isolated occlusion of LAD had impairment of diastolic DTI parameters in all segments of RV. Impairment of systolic DTI parameters was seen only along Tricuspid annulus, lateral and anterior wall of RV. There was significant linear correlation between systolic and diastolic function parameters of the two ventricles. CONCLUSION: Presence of common myocardial fibers encircling the two ventricles (Myofibril interaction) can explain these observations. More research is needed to find exact explanation of observed findings.

Radial arterio-venous fistula following transradial coronary angiography.

A case of clinically detectable arterio-venous fistula following coronary angiography by right radial approach is reported. It is a rare complication. It may be clinically detectable only days or weeks following the procedure.

"Simpson's right ventricle ejection fraction versus tricuspid annular plane systolic excursion in patients with isolated left ventricle anterior myocardial infarction".

BACKGROUND: Unlike left ventricular, right ventricular (RV) function has not been widely studied after anterior myocardial infarction. This is because standard 2 dimensional echocardiographic evaluation of RV volumes and ejection fraction is cumbersome due to difficulty in exact delineation of RV endocardial borders because of prominent trabeculations and crescentric shape of the chamber. METHODS AND RESULTS: 50 patients of isolated LV anterior myocardial infarction subdivided into two subgroups--Group-1 with stenosis of Left anterior descending artery (LAD) and Group-2 with stenosis of both LAD and left circumflex artery were studied. Any associated RV infarction was excluded in all patients by ECG, Echocardiography and Right Coronary Angiography .From apical four chamber view of echocardiography, right ventricular ejection fraction (RVEF) was measured by Simpson's method and the systolic motion of the tricuspid annulus (TAPSEx) was recorded with the use of 2 dimensional guided M-Mode tracings both at lateral and the septal side of annulus. There was no significant difference in RVEF between study patients and control subjects. (p > 0.05). However septal TAPSEx was significantly reduced in patients of anterior myocardial infarction as compared to healthy subjects. Reduction was more marked in subgroup-2 patients having stenosis of both LAD and LCx arteries.(p < 0.005). CONCLUSION: Our study results suggests that TAPSEx is simple, quick and better non geometric echocardiographic parameter than RVEF to assess RV functions in patients of anterior infarction.