Quantitative assessment of left atrial functions by speckle tracking echocardiography in hypertensive patients with and without retinopathy.

PURPOSE: The association between hypertensive retinopathy and left atrial (LA) impairment is unknown. Accordingly, it was aimed to investigate the possible relationship between hypertensive retinopathy and LA phasic functions by means of two-dimensional speckle-tracking echocardiography (2D-STE). METHODS: A total of 124 hypertensive patients and 27 control subjects were included in the study. LA reservoir strain (LAS-S ), LA conduit strain (LAS-E ), and LA booster strain (LAS-A ) parameters were used to evaluate LA myocardial functions. RESULTS: Hypertensive patients (with and without retinopathy) displayed an obvious reduction in the LA reservoir strain (LAS-S ), and LA conduit strain (LAS-E ). Moreover, further impairment in LA reservoir and conduit strain was found in patients with hypertensive retinopathy than in the isolated hypertensive patients. There were no significant differences in LA booster strain (LAS-A ) among the three groups. Impaired LAS-S (OR: 0.764, CI: 0.657-0.888, and p < 0.001), LAS-E (OR: 0.754, CI: 0.634-0.897, and p = 0.001), and hypertension (HT) duration (OR: 2.345, CI: 1.568-3.507, and p < 0.001) were shown to be independent predictors of hypertensive retinopathy. CONCLUSION: Impaired LA reservoir and conduit strain may be used to predict hypertensive patients at higher risk of developing hypertensive retinopathy, and to determine which patients should be followed more closely for hypertensive retinopathy.

Role of the oxidative stress index, myeloperoxidase, catalase activity for cardiac allograft vasculopathy in heart transplant recipients.

BACKGROUND: The aim of this study was to explore the role of oxidative stress index (OSI), myeloperoxidase (MPO), and catalase (CAT) activity in cardiac allograft vasculopathy (CAV) in heart transplant recipients (HTRs). METHODS: The study enrolled a median age of 41 ± 9 years 47 recipients. The HTx patients were divided into two groups based on the presence CAV as follows: CAV(+) and CAV(-) group. Also, CAV(+) group were divided into two groups as mild/moderate to severe CAV. The OSI, MPO, and CAT activity were analyzed in both groups. RESULTS: The mean total antioxidant capacity (0.79 ± 0.46 vs 1.03 ± 0.33 µmol H2 O2 equiv/L) P = .043 was significantly lower and OSI, MPO, CAT activity were significantly higher in CAV(+) group (63 ± 38 vs 20 ± 16 arbitrary unit, P = .001; 398 ± 242 vs 139  ± 112 µg/L, P = .001; 51 ± 42 vs 26 ± 23 pmol/mg protein, P = .013, respectively). Also, mean OSI (38 ± 41 vs 93 ± 75, P = .05) were significantly higher in severe CAV(+) group. Recipient age, male gender, and low density lipoprotein-cholesterol were significantly higher in CAV(+) group. There was a moderate correlation between the CAV grade and OSI, MPO, and CAT levels in univariate analysis (r = .560, P = .002; r = .643, P = .007; r = .681, P = .001, respectively). CONCLUSION: An increase in the serum level of OSI, MPO, and CAT was associated with CAV in HTRs.

Evaluation of Tp-e Interval, Tp-e/QT Ratio, and Tp-e/QTc Ratio in Patients with Asymptomatic Arrhythmogenic Right Ventricular Cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate repolarization dispersion measured from the 12-lead surface electrocardiogram (including Tp-e interval, Tp-e/QT, and Tp-e/QTc ratio) in asymptomatic ARVD patients METHODS: We selected 27 patients with asymptomatic ARVD and 27 age- and gender-match young, healthy volunteers. RESULTS: Tp-e interval, Tp-e/QT and Tp-e/QTc ratio were also significantly higher in ARVD group compared to the control group (all P < 0.001). There were negative correlation between S global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.57, P = 0.02; r = -0.85, P = 0.02; r = -0.63, P < 0.01; respectively). There were also negative correlation between Sm global and Tp-e, Tp-e/QT, Tp-e/QTc ration (r = -0.61, P < 0.01; r = -0.67, P < 0.01; r = -0.68, P < 0.01; respectively). Moreover, Em global were negative correlation between Tp-e, Tp-e/QT, and Tp-e/QTc (r = - 0.64, P < 0.001, r = - 0.75, P < 0.01; r = -0,69, P < 0.01; respectively) CONCLUSION: In conclusion, we have presented strong evidence suggesting that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were increased in asymptomatic ARVD patients.

Utility of speckle tracking echocardiography imaging in patients with asymptomatic and symptomatic arrhythmogenic right ventricular cardiomyopathy.

BACKGROUND: Arrhythmogenic right ventricular dysplasia (ARVD) is characterized by the progressive replacement of ventricular myocytes with variable amounts of fibrous and adipose tissue. Several studies have suggested that speckle tracking echocardiographic (STE) parameters such as strain (S) and strain rate (SR) may prove useful in the early detection of right ventricular (RV) dysfunction. Therefore, the aim of this study was to evaluate RV myocardial function using the STE method in both asymptomatic and symptomatic patients with ARVD and to assess its potential role in the differential diagnosis of these two presentations. METHODS: We recruited 34 patients with ARVD. Seventeen patients were symptomatic, and seventeen were asymptomatic. RESULTS: The RV free wall global longitudinal S and SR were significantly lower in symptomatic patients with ARVD than in asymptomatic patients. According to a cutoff value of 1.35 per seconds for RV global SR, the sensitivity and specificity for predicting ARVD were 88% and 77%, respectively. According to a cutoff value of 17.3% for RV S, the sensitivity and specificity for predicting ARVD were 82% and 77%, respectively. CONCLUSION: In conclusion, we present strong evidence that STE-derived global S and SR in the RV free wall are decreased in symptomatic patients with ARVD compared with asymptomatic patients.

Comparison of Right Ventricle Systolic Function between Long-Term Anabolic-Androgenic Steroid User and Nonuser Bodybuilder Athletes: A Study of Two-Dimensional Speckle Tracking Echocardiography.

BACKGROUND: Right ventricular (RV) effects of long-term use of anabolic-androgenic steroids (AAS) are not clearly known. The aim of this study was to assess RV systolic functions by two-dimensional speckle tracking echocardiography (2DSTE) in AAS user and nonuser bodybuilders. METHODS: A total of 33 competitive male bodybuilders (15 AAS users, 18 AAS nonusers) were assessed. To assess RV systolic functions, all participants underwent standard two-dimensional and Doppler echocardiography, and 2DSTE. RESULTS: Interventricular septal thickness, left ventricle posterior wall thickness, relative wall thickness, and left ventricle mass index were significantly higher in AAS users than nonusers. While standard diastolic parameters were not statistically different between the groups, tissue Doppler parameters including RV E' and E'/A' were lower in AAS users than nonusers (10.1 ± 2.0 vs. 12.7 ± 2.1; P = 0.001, 1.1 ± 0.1 vs. 1.5 ± 0.4; P = 0.009, respectively). Tricuspid annular plane systolic excursion, RV fractional area change, and RV S' were in normal ranges. However, RV S' was found to be lower in users than nonusers (12.2 ± 2.2 vs. 14.6 ± 2.8, P = 0.011). RV free wall longitudinal strain and strain rate were decreased in AAS users in comparison with nonusers (-20.2 ± 3.1 vs. -23.3 ± 3.5; P = 0.012, -3.2 ± 0.1 vs. -3.4 ± 0.1; P = 0.022, respectively). In addition, there were good correlations between 2DSTE parameters and RV S', E', and E'/A'. CONCLUSION: Despite normal standard systolic echo parameters, peak systolic RV free wall strain and strain rate were reduced in AAS user bodybuilders in comparison with nonusers. Strain and strain rate by 2DSTE may be useful for early determination of subclinical RV dysfunction in AAS user bodybuilders.

The Effect of Chronic Anabolic-Androgenic Steroid Use on Tp-E Interval, Tp-E/Qt Ratio, and Tp-E/Qtc Ratio in Male Bodybuilders.

BACKGROUND: The chronic consumption of androgenic anabolic steroids has shown to cause atrial arrhythmias. Several studies have suggested that the interval from the peak to the end of the electrocardiographic T wave (Tp-e) may correspond to the transmural dispersion of repolarization and that increased Tp-e interval and Tp-e/QT ratio are associated with malignant ventricular arrhythmias. The aim of this study was to evaluate repolarization dispersion measured from the 12-lead surface electrocardiogram (including Tp-e interval, Tp-e/QT ratio, and Tp-e/cQT ratio) in bodybuilders who are using anabolic androgenic steroids (AAS). METHODS: We selected a population of 33 competitive bodybuilders, including 15 actively using AAS for ≥ 2 years (users) and 18 who had never used AAS (nonusers), all men. RESULTS: QT, cQT, QTd, cQTd, JT, and cJT were significantly increased in AAS users bodybulders compared to the nonusers (all P < 0.001). Tp-e interval, Tp-e/QT ratio, and Tp-e/cQT ratio were also significantly higher in AAS user group compared to the nonuser group (all P < 0.001). QRS duration was not different between the groups. There were negative correlation between E(m) and Tp-e, Tp-e/QT ratio, Tp-e/cQT ration (r = -0.657, P < 0.01; r = -0.607, P = 0.02; r = -0.583, P = 0.02; respectively).There were also negative correlation between S(m) and Tp-e, Tp-e/QT ratio, Tp-e/cQT ration (r = -0.681, P < 0.01; r = -0.549, P = 0.03; r = -0.544, P = 0.023; respectively). CONCLUSION: In conclusion, we have presented a strong evidence suggesting that Tp-e interval, Tp-e/QT ratio, and Tp-e/QTc ratio were increased in AAS users, which suggest that there might be a link between AAS use and ventricular arrthymias and sudden death.

Relation of epicardial fat thickness to the severity of heart failure in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: The aim of this study was to assess whether epicardial fat thickness (EFT) is associated with the severity of heart failure in patients with nonischemic dilated cardiomyopathy (NICMP). METHODS: The study group was composed of 93 patients with NICMP and38 age- and sex-matched healty individuals as the control group. The EFT was identified during end-systole at the point on the free wall of the right ventricle. RESULTS: Patients with NICMP had significantly lower mean EFT than those in the control group (4.1 ± 0.8 vs. 6.1 ± 1.8 mm, P < 0.001). EFT was thinnest in patients with New York Heart Association (NYHA) functional class III or IV (3.5 ± 0.5, P < 0.001). There was a significant correlation between EFT, left ventricle EF (r = 0.540 P < 0.001), and B-type natriuretic peptide (BNP) (r = -0.695, P < 0.001) values in patients with NICMP. In addition, when EFT was corrected for BMI, EFT/BMI was lower in patients with NYHA functional class III-IV than patients with NYHA class I-II and control group (0.13 ± 0.01, 0.16 ± 0.02, 0.23 ± 0.04, respectively; P < 0.001). There was a significant correlation between EFT/BMI, left ventricle EF (r = 0.489, P < 0.001), and BNP (r = -0.549, P < 0.001) in patients with NICMP. In multivariate regression analysis, EFT (P = 0.009), BNP (P = 0.039), and left atrium volume index (P = 0.039) were independently associated with impaired functional status. CONCLUSION: Echocardiographic EFT is an inexpensive, simple, and readily available marker that may be used to asses the severity of chronic heart failure in patients with NICMP.

Two-dimensional strain and strain rate imaging of the left atrium and left ventricle in adult patients with atrial septal defects before and after the later stage of percutaneous device closure.

AIM: Atrial septal defect (ASD) causes chronic volume overload of the right heart. The potential adverse effects of this long-standing volume overload to left atrium (LA) and left ventricle (LV) and their response to ASD closure has been poorly studied. METHODS: We studied 20 ASD patients before the procedure, at the 24-hour and 1 month following the percutaneous closure. Twenty age-matched controls served as the control group. The analysis for atrial deformation was performed on the lateral wall, mid segment of the LA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during LA reservoir, passive emptying, atrial contraction phases and LV global longitudinal systolic S and SR were measured. RESULTS: Peak S and SR at LA reservoir, conduit and late contraction phases in ASD patients were similar to controls. All of these parameters increased immediately after the closure of the defect. Similarly, SLV and SRLV in ASD patients were not significantly different from the controls and significantly increased after the closure. But LA S, SR and LV S, SR results decreased in 1 month after the closure. SLV in ASD patients was significantly correlated with echocardiographic findings and the invasively measured defect size. CONCLUSION: LA and LV S and SR are not significantly affected in ASD patients. However, correction of the long-standing volume overload by percutaneous closure causes an early increase in LA and LV longitudinal deformation that correlates with the magnitude of the atrial septal defect. But this increase decreased in 1 month after closure.

An unexpected complication of the MitraClip device: one of the arms gets stuck inside the guide catheter in the left atrium.

Percutaneous edge-to-edge mitral valve repair using the MitraClip (Abbot Vascular, USA) system is a promising technique for mitral regurgitation treatment in select high-risk surgical patients. Although the safety and efficacy of the technique have been demonstrated, a few complications of the MitraClip device have been reported. In this report, we present a rare complication that recently occurred during the performance of a MitraClip procedure in a patient with severe functional mitral regurgitation. One MitraClip arm got stuck inside the guide catheter in the left atrium and a decision was made to discontinue percutaneous intervention because the problem could not be resolved.

An epidemiological study to evaluate the use of vitamin K antagonists and new oral anticoagulants among non-valvular atrial fibrillation patients in Turkey- AFTER-2 study design.

OBJECTIVES: Atrial fibrillation (AF) is one of the most common causes of preventable ischemic stroke and is related to increased cardiovascular morbidity and mortality. There is a lack of data in Turkey on the use of new oral anticoagulants (NOACs), and time in therapeutic INR range (TTR) in vitamin K antagonist users and AF management modality. In this multi-center trial, we aimed to analyze, follow and evaluate the epidemiological data in non-valvular AF patients. STUDY DESIGN: Four thousand one hundred consecutive adult patients from 42 centers with at least one AF attack identified on electrocardiography will be included in the study. Patients with rheumatic mitral valve stenosis and prosthetic valve disease will be excluded from the study. At the end of one year, the patients will be evaluated in terms of major cardiac end points (death, transient ischemic attack, stroke, systemic thromboembolism, major bleeding and hospitalization). RESULTS: First results are expected in June 2015. Data about major cardiovascular end-points will be available in January 2016. CONCLUSION: The rates and kind of oral anticoagulant use, TTR in vitamin K antagonist users and main management modality applied in non-valvular AF patients will be determined by AFTER-2 study. In addition, the rate of major adverse events (MACEs) and the independent predictors of these MACEs will be detected (AFTER-2 Study ClinicalTrials.gov number, NCT02354456.).

Neutrophil/lymphocyte ratio is related to the severity of idiopathic dilated cardiomyopathy.

OBJECTIVES: The aim of this study was to assess whether NLR levels are associated with echocardiographic parameters, New York Heart Association (NYHA) functional class, or B- type natriuretic peptide (BNP) levels in patients with idiopathic dilated cardiomyopathy (DCM). DESIGN: Eighty-seven patients with idiopathic DCM were included prospectively from 2009 to 2014. Patients with acute decompensated heart failure and conditions that alter the total or differential white blood cell counts were excluded. Blood samples were collected before echocardiographic investigation on admission. RESULTS: There was a statistically significant correlation between neutrophil/lymphocyte ratio (NLR) and NYHA functional class (r = 0.68, p < 0.001), BNP levels (r = 0.61, p < 0.001) and various echocardiographic parameters. NLR was significantly higher in patients in NYHA functional class III or IV (n = 39) than among those categorized as NYHA class I or II (n = 48), (3.3 ± 1.0 vs 2.1 ± 0.6; p < 0.001). The NLR cutoff value predicting severe chronic HF was 2.25 with 82% sensitivity and 65% specificity (p < 0.001). On multivariate linear regression analysis NLR (p = 0.025), left ventricular end-diastolic volume (p = 0.041) and left atrial volume index (LAVI) (p = 0.001) were found to be independent positive predictors of BNP levels. CONCLUSION: Neutrophil/Lymphocyte ratio is associated with the severity of chronic heart failure in patients with idiopathic DCM.

PE with ST-segment elevation in leads V1-3 and AVR treated successfully by catheter directed high-dose bolus thrombolytic therapy during CPR.

A 55-year-old man presented with the emergency department after having a short syncopal episode and angina during the exertion for 1 month. His initial electrocardiogram showed minimal ST-segment changes on precordial leads. While waiting for the laboratory tests, abruptly, the patient went into cardiopulmonary arrest. After a short resuscitation, a new electrocardiogram revealed ST-segment elevations in leads V1-3 and AVR, mimicking an anteroseptal myocardial infarction. Although, the angiography showed severe coronary artery disease, coronary flow was normal and main branches of pulmonary artery were almost fully occluded by large pulmonary emboli. Recombinant tissue plasminogen activator bolus (25 mg) was given 2 times at 5-minute intervals immediately into pulmonary artery by pig-tail catheter under the cardiopulmonary resuscitation. The patient had an excellent response to high-dose bolus thrombolytic therapy. We conclude that in the case of massive pulmonary embolism with small chance of resuscitation, the catheter-directed high-dose bolus injection of recombinant tissue plasminogen activator could enrich the therapeutical possibilities.

The relationship between neutrophil/lymphocyte ratio and calcific aortic stenosis.

BACKGROUND: The role of inflammation in fibrotic and calcific processes of atherosclerosis and aortic stenosis (AS) is similar. Furthermore, a relationship between systemic inflammation and heart failure has been well demonstrated. Recently, neutrophil/lymphocyte ratio (NLR) has been proposed as a predictive marker of systemic inflammation. We investigated the association of NLR with the severity of calcific AS and left ventricular (LV) systolic dysfunction in patients with severe calcific AS. METHODS: A total of 96 patients with calcific AS were included in this retrospective study from 2011 to 2013. The severity of AS was graded according to the transaortic mean pressure gradient. The patients were divided into 3 groups as mild-to-moderate AS, severe AS with normal left ventricular ejection fraction (LVEF), and severe AS with reduced LVEF (mean gradient >40 mmHg and LVEF <50%). RESULTS: Neutrophil/lymphocyte ratio was significantly higher in severe calcific AS with reduced LVEF group than the other 2 groups (3.94 ± 0.88, P < 0.001). In addition, NLR was higher in severe AS with normal LVEF group than mild-to-moderate AS group (2.69 ± 1.00 vs. 2.05 ± 0.64, P = 0.008). There was a statistically significant correlation between NLR and both transaortic mean pressure gradient and aortic valve peak velocity in patients with mild-to-severe AS with normal LVEF (n = 81; r = 0.369, P < 0.001; r = 0.290, P = 0.004; respectively). CONCLUSION: Increased NLR is related to the severity of calcific AS and LV systolic dysfunction in patients with severe calcific AS.

Acute sleep deprivation in healthy adults is associated with a reduction in left atrial early diastolic strain rate.

BACKGROUND: Sleep deprivation (SD) is known to be associated with adverse cardiovascular events. Strain and strain rate measure the local deformation of the myocardium and have been used to evaluate atrial phasic function in various disease states. The aim of the study was to investigate whether strain rate imaging enables the identification of left atrial dysfunction in otherwise healthy young adults with acute SD which has not been studied previously. METHODS: Adequate echocardiographic images of 27 healthy volunteers were obtained both after a night with regular sleep and after a night with SD. Tissue Doppler-derived strain and strain rate were measured from the apical four- and two-chamber views of the left atrium, and global values were calculated as the mean of all segments. Measurements included peak systolic strain, systolic strain rate (S-Sr), early diastolic (E-Sr) and late diastolic (A-Sr) strain rate. Phasic left atrial (LA) volumes and fractions were also calculated. RESULTS: There was no significant difference in the traditional parameters of atrial function and LA volumes. Subjects had similar S-Sr, A-Sr and global atrial strain values after the night of sleep debt when compared after regular sleep, whereas they had significantly reduced E-Sr values (mean (SD) 3.2 (0.7) s(-1) vs 3.7 (0.6) s(-1), p < 0.001). Moreover, global E-Sr showed a significant correlation with sleep time (r = 0.554, p < 0.001). CONCLUSION: Acute SD in healthy adults is associated with a reduction in LA early diastolic strain rate in the absence of geometric alterations or functional impairment of the left atrium, raising the possibility that chronic SD may more profoundly affect LA function and thereby promote the occurrence of atrial fibrillation.

The relationship between CHA2DS2VASc score and left ventricular apical thrombus formation in patients with acute anterior ST segment elevation myocardial infarction.

BACKGROUND: Left ventricular apical thrombus (LVAT) formation is a well-known complication of acute anterior myocardial infarction (AMI). The CHA2DS2VASc is a scoring system that has been used to estimate the risk of thromboembolism in patients with nonvalvular atrial fibrillation. This score has also been used for other clinical conditions. The aim of this study was to investigate the relationship between CHA2DS2VASc score and development of LVAT in patients with AMI. METHOD: The study population included 378 patients (mean age: 56.5 ± 12.3 years, male: 318) presenting with AMI between January 2016 and January 2020. Primary percutaneous coronary intervention procedure was performed in all patients. Initial echocardiogram was performed within 7 days of admission. All patients were evaluated with echocardiography at 3rd, 6th and 12th months. Patients were divided into two groups according to the presence of LVAT on echocardiography. RESULTS: The incidence of the LVAT was 8.5% (n = 32) during a mean follow-up time of 233.1 ± 66.7 days. The mean CHA2DS2VASc score was notably higher in patients with LVAT compared to patients in the control group (3.1 ± 1.9 vs. 1.9 ± 1.2, p < 0.001). In Cox regression analysis, high CHA2DS2VASc score, low left ventricular ejection fraction (LVEF) and the presence of LV apical akinesis/aneurysm were the independent predictors for LVAT formation. All of these parameters were associated with higher cumulative incidence of LVAT formation in Kaplan-Meier analyses (p < 0.001 for all). CONCLUSION: High CHA2DS2VASc score, low LVEF and the presence of LV apical akinesis/aneurysm may be used for LVAT risk prediction among patients presenting with AMI.

Impact of systemic sclerosis on electromechanical characteristics of the heart.

Primary myocardial involvement is common in systemic sclerosis (SSc). We evaluated the atrial and ventricular electromechanical characteristics by using tissue Doppler echocardiography in SSc patients with subclinical cardiac involvement. Twenty-seven consecutive patients (24 women; mean age +/- SD 49.9 +/- 11.3 years) presenting with SSc without pulmonary arterial hypertension or symptomatic heart failure were prospectively studied. Electrocardiographic P-wave dispersion (Pd), corrected QT dispersion (QTcd), interatrial, intra-atrial, interventricular, and intraventricular electromechanical delays were analyzed by tissue Doppler echocardiography, and brain natriuretic peptide levels were measured. Results were compared with 17 healthy controls. There was no difference in conventional and tissue Doppler parameters between the two groups. However, patients with SSc had higher mean Pd (mean [+/-SD] 46.8 +/- 15 and 36 +/- 8 ms, respectively, P = 0.004) and mean interatrial electromechanical delay time (DT) (mean [+/-SD] 32.2 +/- 9.2 and 24.7 +/- 9.7 ms, respectively, P = 0.01), mean electromechanical delay time for all segments (Mean Ts) (mean [+/-SD] 148.8 +/- 18.8 and 129.3 +/- 13.4 ms, respectively, P < 0.001), and intraventricular DT (mean [+/-SD] 27.6 +/- 12.5 and 16.2 +/- 7.2 ms, respectively, P < 0.001). Intraventricular DT was the only parameter that correlated significantly with the Mean Ts. Brain natriuretic peptide levels were within normal limits in both groups; however, they were higher in patients with SSc than in controls (mean [+/-SD] 37.5 +/- 28.5 and 23.1 +/- 16.0 pg/ml, respectively, P = 0.03). The evaluation of atrial and ventricular electromechanical parameters by using tissue Doppler echocardiography seems to be useful for detection of subclinical cardiac involvement in SSc patients with normal conventional echocardiographic findings.

Severe right ventricular outflow obstruction by right sinus of valsalva aneurysm.

Aneurysms of the sinus of Valsalva are rarely diagnosed cardiac anomalies, occurring in 0.14%-0.96% of patients who have undergone open heart surgical procedures. The most common congenital anomalies accompanying sinus of Valsalva aneurysm (SVA) are ventricular septal defect, bicuspid aortic valve, atrial septal defect, and coarctation of aorta. We report a patient with an unruptured right SVA presenting with severe right ventricular outflow tract (RVOT) obstruction, and coexisting patent foramen ovale (PFO) with a right to left shunt. It could be assumed that the increase in right atrial pressure due to RVOT obstruction had led to a right to left shunt across the patent foramen ovale.

Depicting of a cleft mitral valve by real time three-dimensional transesophageal echocardiography.

We report the usefulness of real time three-dimensional transesophageal echocardiography in comprehensive delineation of cleft mitral valve. This new technique may be a useful supplement to two-dimensional and three-dimensional transthoracic echocardiography in the assessment of this pathology.