Hypoplastic posterior mitral valve leaflet: A case report and review of the literature.

Hypoplasia of the mitral leaflets is rarely reported in adults. We reported a 45-year-old man presented to us with palpitation, dyspnea, and severe mitral regurgitation. In echocardiographic examination, an immobile hypoplastic posterior mitral leaflet (PML) was detected. A review of clinical and echocardiographic findings of all reported cases revealed that mitral regurgitation was the most common finding associated with PML hypoplasia/uni-leaflet mitral valve. PML hypoplasia is rare and often an incidental diagnosis during echocardiography, which could be relatively well tolerated since adulthood and carries a good prognosis.

Epiaortic fat pad area: A novel index for the dimensions of the ascending aorta.

We sought to investigate the possible association between the area of the epiaortic fat pad (EAFP) and dimensions of the ascending aorta. A total of 193 individuals underwent transthoracic echocardiography (TTE) prospectively. The area of the EAFP was traced anterior to the aortic root and correlated with the diameter of the aorta. The mean area of the EAFP was 5.16 ± 2.28 cm(2) Absolute and indexed dimensions of the ascending aorta had a significant correlation with the area of the EAFP (p <0.001 for all). In a multivariate linear regression model, age >65 (p <0.001), body mass index >30 kg/m(2) (p = 0.02) and a history of hyperlipidemia (p = 0.003) were identified as independent predictors of the area for EAFP. In conclusion, both the absolute and indexed diameters of the ascending aorta at the different segments that directly come into contact with the EAFP linearly correlate with the area of the EAFP measured by TTE.

Correlation between Pulmonary Artery Pressure Measured by Echocardiography and Right Heart Catheterization in Patients with Rheumatic Mitral Valve Stenosis (A Prospective Study).

INTRODUCTION: Right heart catheterization (RHC) remains the gold standard for hemodynamic assessment of the right heart and pulmonary artery. However, this is an invasive tool, and noninvasive alternatives such as transthoracic echocardiography (TTE) are preferable. Nonetheless, the correlation between measurements by TTE and RHC are debated. In this study, we prospectively examined the correlation between systolic and mean pulmonary artery pressures (sPAP and mPAP) measured by RHC and TTE in patients with hemodynamically significant rheumatic mitral stenosis (MS). MATERIAL AND METHODS: Three hundred patients with hemodynamically significant MS undergoing TTE who were scheduled to undergo RHC within 24 hours were analyzed. PAP measurements were taken for all patients by RHC (sPAP(RHC), mPAP(RHC)). Maximum velocity of tricuspid regurgitation (TR) jet obtained by continuous-wave Doppler with adding right atrial (RA) pressure was used for measuring sPAP by TTE (sPAP(TRVmax)). Mean PAP was measured using either pulmonary artery acceleration time (mPAP(PAAT)) method or by adding RA pressure to velocity-time integral of TR jet (mPAP(TRVTI)). RESULTS: A good correlation between sPAP(RHC) and sPAP(TRVmax) (r = 0.89, P < 0.001), between mPAP(RHC) and mPAP(PAAT) (r = 0.9, P < 0.001), and between mPAP(RHC) and mPAP(TRVTI) (r = 0.92, P < 0.001) was found. Sensitivity and specificity of sPAP(TRV) max in detecting pulmonary hypertension (PH) were 92.8% and 86.6% and of mPAP(PAAT) were 94.1% and 73.3%, respectively. CONCLUSION: The noninvasive assessment of sPAP and mPAP by TTE correlates well with invasive measurements and has an acceptable specificity and sensitivity in detecting PH in patients with hemodynamically significant MS.

Relation between exhaled nitric oxide and left ventricular performance in chronic hemodialysis patients.

INTRODUCTION: End-stage renal disease is the most debilitating condition for patients with renal diseases. Cardiovascular disease is the leading cause of death in these patients. It has been shown that nitric oxide (NO) increases in renal failure and hemodialysis patients and could be correlated with cardiovascular diseases in this population. OBJECTIVES: To investigate the relation between exhaled nitric oxide (eNO) and left ventricular performance in chronic hemodialysis patients. METHODS: In this prospective study, eNO was measured in 20 chronic hemodialysis patients (13 males and 7 females with the mean age of 45.20 ± 14.99 years). Left ventricular findings were studied by conventional and Doppler echocardiography. eNO correlation with the echocardiographic parameters was evaluated. RESULTS: The median eNO was 11.65 ppb (range: 1.9-29.9 ppb). eNO was positively correlated with left ventricular ejection fraction (ρ = 0.561, p = 0.01) and negatively correlated with left ventricular end systolic volume (ρ = -0.451, p = 0.046), isovolumic relaxation time (ρ = -0.448, p = 0.047) and myocardial performance index (ρ = -0.587, p = 0.007). CONCLUSION: There is a positive correlation between eNO and left ventricular performance in chronic hemodialysis patients. Therefore, eNO may play an important role in pathophysiology of cardiac involvement in these patients.

Correlation of left atrial strain with invasively measured left ventricular end-diastolic pressure; determining LA strain cut-off value.

Left atrium longitudinal strain (LAS) with speckle tracking method has been proposed as a non-invasive method for the assessment of left ventricular filling pressure and diastolic dysfunction. This study aimed to investigate left atrial strain compared to invasively measured left ventricular filling pressure. All Patients candidates for coronary angiography were consecutively recruited. LAS measured by transthoracic echocardiography. Left ventricular end-diastolic pressure (LVEDP) pressure was invasively measured. Current echocardiographic modalities for diastolic function evaluated. A total of 125 people were included. 45 patients had preserved ejection fraction (EF ≥ 50%) and 85 patients had reduced EF (EF < 50%) and compared two groups. LVEDP was significantly higher in reduced EF compared to preserved EF (p-value < 0.001). LA-reservoir and LA-booster strains were significantly lower in patients with reduced EF compared to preserved EF (p-value = 0.008, mean Reservoir = 16.4% ± 6.4, mean Reservoir = 19.5% ± 5.6, respectively) and (p-value = 0.009, mean Booster = 9.09% ± 4.0, mean Booster =11. 9% ± 4.3, respectively). LA 4ch-reservoir strain <14.4%, and LA 2ch-reservoir strain <14.1% were related to LVEDP≥20 mmHg (sensitivity 63.5% and specificity 75%) (sensitivity 77.9% and specificity of 60%) respectively. LAS is significantly lower in patients with elevated LVEDP (≥ 20mmHg). LAS is significantly lower in patients with reduced EF. Both LA-reservoir and LA-booster strains have a significant relation to predicting LVFP but LA-reservoir strain is more accurate. The mean LA-reservoir strain less than 12.4% is associated with LVEDP ≥ 20mmHg.

Comparative effects of surgical and percutaneous repair on P-wave and atrioventricular conduction in patients with atrial septal defect--ostium secundum type.

Both surgical and percutaneous closures of atrial septal defects have been successful in reversal of atrial dilatation. We compared the effects of surgical and percutaneous transvenous device closure of atrial septal defect on post-operative changes of P-wave duration, PR segment, and PR interval. Electrocardiographic data were prospectively collected from 30 patients following either surgical (n equal to 16) or percutaneous (n equal to 16) repair of atrial septal defects between 2004 and 2010. A cardiologist blinded to the closure technique performed the electrocardiographic analyses. P-wave duration (98.5 plus or minus 15.4 to 86.4 plus or minus 13.2 milliseconds, p-value less than 0.05) and PR interval (162.9 plus or minus 18.5 to 140.6 plus or minus 15.2 milliseconds, p-value less than 0.05) were reduced after percutaneous transvenous device closure. P-wave duration (104.5 plus or minus 24.7 versus 83.2 plus or minus 13.3 milliseconds, p-value less than 0.05) and PR interval (173.2 plus or minus 38.7 versus 144.3 plus or minus 32.0 milliseconds, p-value less than 0.05) were also reduced after surgical closure. PR segment in the percutaneous group was significantly reduced (63.4 plus or minus 14.5 to 52.1 plus or minus 10.8 milliseconds, p-value less than 0.05), but not in the surgical group (68.6 plus or minus 18.7 versus 61.1 plus or minus 24.7 milliseconds). However, the difference in PR segment changes between the two groups was not significant (-11.3 plus or minus 15.0 versus -7.6 plus or minus 20.5 milliseconds, p-value equal to 0.18). Our analysis demonstrates that the changes between the two groups were not different and that both closure techniques reduce P-wave duration, PR segment, and PR interval within 6 months.

Two-dimensional-Wilkins and real-time transesophageal three-dimensional scoring systems: Which one is preferred to mitral valve morphological assessment?

BACKGROUND: To quantify valvular morphological assessment, some two-dimensional (2D) and three-dimensional (3D) scoring systems have been developed to target the patients for balloon mitral valvuloplasty; however, each scoring system has some potential limitations. To achieve the best scoring system with the most features and the least restrictions, it is necessary to check the degree of overlap of these systems. Also the factors related to the accuracy of these systems should be studied. We aimed to determine the correlation between the 2D Wilkins and real-time transesophageal three-dimensional (RT3D-TEE) scoring systems. METHODS: This cross-sectional study was performed on 156 patients with moderate to severe mitral stenosis who were candidates for percutaneous balloon valvuloplasty. To morphologic assessment of mitral valve, patients were examined by 2D-transthoracic echocardiography and RT3D-TEE techniques on the same day. RESULTS: A strong association was found between total Wilkins and total RT3D-TEE scores (r = 0.809, p < 0.001). The mean mitral valve area assessed by the 2D and 3D was 1.07 ± 0.25 and 1.03 ± 0.26, respectively, indicating a mean difference of 0.037 cm2 (p = 0.001). We found a strong correlation between the values of mitral valve area assessed by 2D and 3D techniques (r = 0.846, p < 0.001). CONCLUSION: There is a high correlation between the two scoring systems in terms of evaluating dominant morphological features. Partially, mitral valve area overestimation in the 2D-transthoracic echocardiography and its inability to assess commissural involvement as well as its dependence on patient age were exceptions in this study.

Giant descending aortic pseudo-aneurysm in an adult man with uncorrected aortic coarctation.

BACKGROUND: Aortic coarctation (CoAo) accounts for 6 to 8% of all congenital heart diseases and occurs two to five times more often in males. The uncorrected aortic coarctation is complicated by hypertension, ascending and descending aortic aneurysms, endarteritis, and heart failure. The aortic pseudo-aneurysm (APD) usually occurs in patients with endarteritis. We report an adult man with bicuspid aortic valve, perimembranous ventricular septal defect, and uncorrected aortic coarctation complicated by descending aortic pseudo-aneurysm without aortic endarteritis. CASE PRESENTATION: A 40-year-old man was referred to our division for hemoptysis and severe aortic coarctation. Echocardiography confirmed the aortic coarctation diagnosis and showed a large aortic pseudo-aneurysm at the coarctation site with intra-cavity mural thrombus. Subsequently, the patient underwent contrast-enhanced computed tomography angiography, and diagnosis of coarctation and APD was confirmed. Due to various malformations and considering that the patient had become unstable due to hemoptysis, it was discussed in the heart team, and it was decided that the patient would undergo staged surgery. CONCLUSIONS: The aortic pseudo-aneurysm is a rare complication in patients with untreated coarctation that requires prompt surgery, and this complication should be considered in patients with untreated aortic coarctation who present with hemoptysis.

Biatrial Myxoma with a Shared Stalk: A Case Report.

Myxomas are rare cardiac neoplasms and may present as single or multiple tumors. Only a few cases of single biatrial myxomas have been reported. We report a very rare case of this condition in a middle-aged woman, presenting with exertional dyspnea and cough. The patient had a resting tachycardia of 105 beats per minute, and cardiac auscultation discovered a mid-diastolic murmur across the mitral valve, followed by a tumor plop focused on the apex and elevated levels of C-reactive protein (1+) and creatine phosphokinase in lab data. The diagnosis was made via transesophageal and transthoracic echocardiographic examinations, showing the tumor extension through a patent foramen ovale (PFO). The operation was undertaken, the myxoma was excised, and the PFO was repaired. She was discharged with no further complications. Although myxomas are rare, considering this condition before surgery is significant. The involvement of both atria via a PFO is possible.

Isolated cardiac hydatidosis--a case report.

Cardiac hydatidosis is rarely encountered. A case of isolated cardiac hydatid cyst of the left ventricle in a young woman is described. The diagnosis was suggested by echocardiography and was confirmed later by pathological evaluation. Serological tests were negative. The patient underwent a successful operation for cyst resection.

Left ventricular non-compaction in a patient with Shone's complex.

Shone's complex is a rare congenital cardiac malformation characterized by serial obstructive lesions of the left heart at multiple levels. Presently described is an unusual case of an adult male patient who presented with palpitations and worsening dyspnea. An echocardiographic evaluation revealed Shone's complex associated with left ventricular non-compaction cardiomyopathy (NCC). To our knowledge, an association between NCC and Shone's complex has not been previously described.

Association of mean platelet volume with echocardiographic findings in patients with severe rheumatic mitral stenosis.

Introduction: Rheumatic heart disease (RHD) is a relatively common cause of mortality among patients in the developing countries, and pure mitral valve failure is the most common form of RHD. An increase in the mean platelet volume (MPV) is considered as an independent risk factor for many cardiovascular diseases. This study aimed to evaluate the association of MPV with echocardiographic findings in patients with severe rheumatic mitral stenosis. Methods: In a descriptive, analytical study, 100 patients with severe rheumatic mitral stenosis referred to Shahid Madani hospital of Tabriz University of Medical Sciences and 100 age & sex-matched healthy individuals were included the study. MPV and echocardiographic findings including Wilkins score, left ventricular ejection fraction (LVEF), pulmonary artery systolic pressure, and left atrial spontaneous echo contrast (LASEC) were evaluated in both groups. Results: MPV in the case group was 10.45±0.98 and in the control group was 9.88±0.83. MPV in the patient's groups was significantly higher than the control group (P = 0.001). Also, MPV in patients with positive LASEC findings was 10.69 ± 1.01 and in patients with negative LASEC findings was 10.25 ± 0.91. The difference was found to be statistically significant (P = 0.028). Conclusion: Patients with rheumatic mitral stenosis has a higher MPV compared to the healthy individuals, and it is associated with LASEC sign seen in echocardiography.

Correlation between echocardiographic severity of ischemic mitral valve regurgitation following acute myocardial infarction and its electrocardiographic location.

Introduction: Ischemic mitral regurgitation (IMR) is common after acute myocardial infarction (AMI) which is associated with long-term cardiovascular mortality. Size, transmurality and location of the myocardial infarction (MI) has role on the development of IMR. In this study we evaluated the severity of IMR after different types of MI. Methods: One-hundred patients with the first AMI were recruited and according to echocardiographic findings were categorized to have moderate to severe IMR (case group, n=50) or trivial or no IMR (control group, n=50). Demographic and echocardiographic findings and MI location were compared between groups. Results: Case group compared to control group had significantly higher Killip class, more cases with left ventricular ejection fraction (LVEF) <30% and inferolateral STEMI. They had significantly higher left ventricular (LV) and right ventricular (RV) diastolic dysfunction. Mechanism of IMR was mono leaflet tethering in 88%, both leaflets tethering in 12% and ring dilatation in 62%. MR jet origin-direction was medial commisure-posterior in 66%, lateral commisure-anterior in 11 22% and both commisure-central direction in 12%. Conclusion: IMR is common after AMI, especially in cases with inferior MI. The echocardiographic findings are indicative of left ventricular remodeling and abnormality of mitral valve apparatus.

Serendipitous diagnosis of aortic coarctation by bilateral parvus et tardus renal Doppler flow pattern.

BACKGROUND: Aorta Coarctation (AC) is uncommon condition that in most adult patients is asymptomatic. Diagnosis of AC is made during routine physical examination by detection of Blood Pressure (BP) difference between arm and leg. AIM: To describe a novel renal artery Doppler flow pattern pathognomonic of aortic coarctation. METHODS: We enrolled 4 consecutive patients referred to renal artery Doppler Ultrasonography (DU) for diagnostic work-up of secondary arterial hypertension. All met the following inclusion criteria: 1) arterial hypertension at age <30 years; 2) referred for renal DU to rule out renovascular hypertension. RESULTS: We found in all 4 patients (age range 10 to 27 years) a bilateral "parvus-tardus" renal Doppler flow pattern. In all, echocardiographic and angiographic work-ups showed aortic coarctation. CONCLUSION: Careful physical examination should be performed in all hypertensive patients. Furthermore, the suspicion of AC can be raised by a bilateral renal arteries "parvus-tardus" Doppler flow pattern in young hypertensive patients screened for secondary hypertension.

Measurement of coronary sinus blood flow after first anterior myocardial infarction with transthoracic echocardiography and its correlation with wall motion scoring index.

OBJECTIVE: To measure the coronary sinus blood flow (CSBF) and coronary sinus velocity time integral (CSVTI) via transthoracic echocardiography (TTE) in patients with acute myocardial infarction (AMI) in association with the left ventricular ejection fraction (LVEF), and wall motion scoring index (WMSI). METHODS: In this case-control study, 20 patients with anterior AMI and 20 healthy individuals as the control group, were studied in 6 months period from March to September 2005 in Madani Heart Center, Tabriz, Iran. All patients received the same treatment for AMI (such as fibrinolytic). The CSBF, CSVTI, WMSI, and tissue Doppler imaging (TDI) data were obtained via TTE and compared between the 2 groups. RESULTS: Baseline variables were similar between the 2 groups (p>0.05). The CSBF in AMI group was 287.8 +/- 128 ml/min and in the control group was 415 +/- 127 ml/min (p=0.001). Also, CSVTI was significantly lower in AMI group than control group (11.16 +/- 2.85 and 17.56 +/- 2.72 mm, p=0.003). There was a significant correlation between CSBF and LVEF (r=0.52, p=0.01), WMSI (r=-0.77, p=0.0001) and CSBF and in-hospital mortality (r=0.58 p=0.03), also between CSVTI and LVEF (r=0.85, p=0.0001), WMSI (r=-0.57, p=0.0009) and in-hospital mortality rate (r=0.69, p=0.02). The CSBF and CSVTI had a good correlation with TDI findings: peak early diastolic velocity in the myocardium and peak systolic velocity in the myocardium). CONCLUSION: Our study demonstrated a good correlation between measured CSBF and CSVTI by 2D- Doppler TTE and LVEF, WMSI, in-hospital mortality and TDI findings.

The significance of the left atrial volume index in prediction of atrial fibrillation recurrence after electrical cardioversion.

Introduction: Electrical cardioversion (ECV) is a safe method for the treatment of atrial fibrillation. It seems that left atrial volume index (LAVI) could be a good marker in predicting the success of ECV. The purpose of this study is to assess of the significance of LAVI measurement before ECV in predicting the recurrence of the AF. Methods: Fifty-one patients with AF, selected for ECV were studied in the cardiology department of Tabriz University of medical sciences. The clinical and demographic data of all the patients were obtained. Echocardiography was performed before and also three months after ECV. Patients were separated into two groups: those who maintained SR and those with relapse of AF diagnosed by clinical manifestations and electrocardiography (ECG). Results: Sinus rhythm (SR) was maintained in 76.5 percent of the patients following the three months after ECV. The age, sex and the body mass index (BMI) were not significantly different between SR and AF groups. Two groups showed no significant differences considering pre-ECV medical history including medications and systemic diseases. The initial LAVI of SR group was 42.21±12.4 mL/m2 and AF group was 96.08±52.21 mL/m2, the initial LAVI was significantly different between two groups (P = 0.000). The LAVI of SR group decreased significantly (5.69±0.74 mL/m2) after three months, LAVI decreased from 42.21 ± 12.4 ml/m2 to 37.51 ± 10.52 mL/m2. (P = 0.000). The cut-off point of LAVI value in predicting the maintenance of SR was 55 mL/m2. Conclusion: The present study indicates that LAVI is a powerful forecaster of the recurrence of AF after ECV. The LAVI measurement could be a useful method in the selection of the patients with AF for ECV.

Two-dimensional strain echocardiography for detection of cardiotoxicity in breast cancer patients undergoing chemotherapy.

Introduction: Two-dimensional (2D) strain echocardiography has emerged as a novel method for early diagnosis of myocardial dysfunction in patients receiving anthracycline chemotherapy. Certain myocardial segments might be more vulnerable for development of dysfunction. Methods: Sixty-three patients with breast cancer who were deemed amenable for anthracycline chemotherapy were prospectively studied from March 2013 to March 2015 in University Hospital settings. Global left ventricular (LV) ejection fraction (EF), fractional shortening and the strain over 17 segments of the LV were examined using 2-dimensional transthoracic echocardiography (TTE) before and after chemotherapy. More than 15% reduction in longitudinal peak systolic strain (LPSS) was considered significant. Results: The mean age of patients was 47 ± 10 years. LVEF was 59.7 ± 6.5% at baseline. Significant reduction of global LPSS was detected in 13% of patients. A significant LPSS reduction occurred in 32.4% of 1071 segments examined following chemotherapy. LPSS significantly decreased in 28% of apical segments, 31% of mid segments and 37% of basal segments. LPSS reduction occurred more frequently over the basal segments than all other segments (P = 0.031). Conclusion: Segmental pattern appears to exist in LPSS reduction following anthracycline therapy. As significant segmental decreases can be seen in the setting of unchanged global LPSS, segmental evaluation of LPSS might be a more accurate way for assessment of myocardial function.