Ultrasound Accelerated Thrombolysis May Be an Effective and Safe Treatment Modality for Intermediate Risk/Submassive Pulmonary Embolism.

Pulmonary embolism (PE) is a potentially life-threatening condition and the fact that 90% of PE originate from lower limb veins highlights the significance of early detection and treatment of deep vein thrombosis. Massive/high risk PE involving circulatory collapse or systemic arterial hypotension is associated with an early mortality rate of approximately 50%, in part from right ventricular (RV) failure. Intermediate risk/submassive PE, on the other hand, is defined as PE-related RV dysfunction, troponin and/or B-type natriuretic peptide elevation despite normal arterial pressure. Without prompt treatment, patients with intermediate risk PE may progress to the massive category with a potentially fatal outcome. In patients with PE and right ventricular dysfunction (RVD), in hospital mortality ranges from 5% to 17%, significantly higher than in patients without RVD.

The effect of different atrioventricular delays on left atrium and left atrial appendage function in patients with DDD pacemaker.

BACKGROUND: Although it has been known that optimization of atrioventricular delay (AVD) has favorable effect on the left ventricular functions in patients with DDD pacemaker, the effect of different AVDs on left atrium (LA) and left atrial appendage (LAA) functions has not been exactly evaluated. The aim of the present study was to assess the effect of different AVDs on LA and LAA functions in DDD pacemaker implanted patients with atrioventricular block. METHODS: Forty-eight patients with DDD pacemaker were enrolled into the study. Patients were divided into two groups according to the echocardiographic diastolic function: Group I (normal diastolic function) and Group II (diastolic dysfunction). LAA emptying velocity on pulsed wave Doppler and LAA late systolic wave velocity by using tissue Doppler were recorded. Patients were paced for five successive continuous pacing periods of 10 minutes duration using five selective AVDs (80-250 ms). RESULTS: Significant effect on LA and LAA functions has not been observed by the setting of AVD in Group I. However, when the AVD was gradually shortened form 150 ms to 80 ms, LA and LAA functions gradually decreased in Group II patients. When AVD increased to 200 ms, LA and LAA functions were improved. Further increase in AVD resulted in decreased LA and LAA functions. CONCLUSION: Setting of AVD has not significant effect on the LA and LAA functions in patients with normal diastolic function, but moderate prolongation of AVD in physiological limits improved LA and LAA functions in DDD pacemaker implanted patients with diastolic dysfunction.

Prognostic performance of copeptin among patients with acute decompensated heart failure.

BACKGROUND: In heart failure (HF), various biomarkers have been established for prognosis. However, little is known about the relevance of copeptin measurements to HF. This study aimed to explore the prognostic value of copeptin for predicting cardiovascular (CV) death or HF-related re-hospitalisation in patients with acute decompensated HF. MATERIALS AND METHODS: We prospectively enrolled 155 consecutive patients with acute signs and symptoms of HF. Plasma copeptin and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were measured at admission. Patients were monitored for 90 days regarding the composite endpoint of CV death or acute HF-related re-hospitalisation. RESULTS: Of the 155 patients enrolled, 40 reached the endpoint, and 115 were in a stable condition during follow-up. Patients who reached an adverse endpoint showed higher NT-proBNP and copeptin levels compared to patients in stable condition. Receiver operating characteristic curve analysis revealed that the area under curve of copeptin 0.844 (95% CI, 0.753-0.935) was superior to that of NT-proBNP 0.809 (95% CI, 0.729-0.890) for the prediction of adverse events within 90 days. Meanwhile, compared to the group with lower copeptin levels (<34 pmol/L), patients with higher copeptin levels (≥34 pmol/L) were at a 10.672-times higher risk of CV death or acute HF-related re-hospitalisation. Multivariate Cox proportional hazards regression analysis revealed that increased copeptin level was a significantly independent predictor of adverse events (risk ratio, 1.051; 95% CI, 1.020-1.083; p < 0.001). CONCLUSION: Copeptin was found to be a strong, novel marker for predicting CV death or HF-related re-hospitalisation in patients with acute decompensated HF.

A case of myocarditis mimicking acute coronary syndrome associated with H1N1 influenza A virus infection.

Myocarditis due to H1N1 influenza infection has not been previously described. We report on a case of acute fulminant myocarditis caused by H1N1 influenza A virus infection that mimicked acute coronary syndrome. A 50-year-old man was admitted with dyspnea, fever, cough, vomiting, and atypical chest pain of three-day history. His body temperature, pulse rate, and blood pressure were 39.2 °C, 115 beats/min, and 80/40 mmHg, respectively. Electrocardiography showed sinus tachycardia, 1-mm ST-segment elevation, and absence of R wave progression in anterior leads, and ST depression in anterolateral leads. The chest radiogram revealed diffuse bilateral alveolar infiltrates. Cardiac enzymes were elevated. Despite treatment with aspirin, clopidogrel, low-molecular weight heparin, metoprolol, and an ACE inhibitor, he developed hemodynamic instability on the first day of admission. Echocardiographic examination showed anteroseptal, apical, and lateral wall hypokinesia, left ventricular diastolic dysfunction, and dilatation of all the chambers. There was no abnormal finding on coronary angiography. The diagnosis was considered to be myocarditis; thus, anticoagulant and antiaggregant therapies were discontinued, and empirical broad-spectrum antimicrobial treatment was initiated together with antiviral oseltamivir (2x75 mg/day). The patient's clinical condition significantly improved. Nasopharyngeal samples were positive for H1N1 influenza A virus. He was discharged on the 15th in good medical condition.

Predictive value of plasma copeptin level for diagnosis and mortality of pulmonary embolism.

OBJECTIVE: Early diagnosis and risk stratification may provide a better prognosis in pulmonary embolism (PE). Copeptin has emerged as a valuable predictive biomarker in various cardiovascular diseases. The aim of this study was to determine the levels of copeptin in patients with acute PE and to evaluate its relationship with disease severity and PE-related death. METHODS: Fifty-four patients and 60 healthy individuals were included in this study. Copeptin concentrations and right ventricular dysfunction were analyzed. The correlation between copeptin levels and hemodynamic and echocardiographic parameters was examined. After these first measurements, patients were evaluated with PE-related mortality at the one-year follow-up. RESULTS: The copeptin levels were higher in PE patients than in the control group (8.3 ng/mL vs 3.8 ng/mL, p<0.001). Copeptin levels were found to be significantly higher in patients with PE-related death and right ventricular dysfunction (10.2 vs 7.5 ng/ml, p=0.001; 10.5 vs 7.5 ng/ml, p=0.002, respectively). When the cut-off value of copeptin was ≥5.85, its sensitivity and specificity for predicting PE were 71.9% and 85.0%, respectively (AUC=0.762, 95% CI=0.635-0.889, p<0.001). CONCLUSIONS: The copeptin measurement had moderate sensitivity and specificity in predicting the diagnosis of PE, and the copeptin level was significantly higher in patients with PE-related death at the one-year follow-up. Copeptin may be a useful new biomarker in predicting diagnosis, risk stratification, and prognosis of PE.

Frailty Significantly Associated with a Risk for Mid-term Outcomes in Elderly Chronic Coronary Syndrome Patients: a Prospective Study.

INTRODUCTION: Frailty is a condition of elderly characterized by increased vulnerability to stressful events. Frail patients are more likely to have adverse events. The purposes of this study were to define frailty in patients aged ≥ 70 years with chronic coronary syndrome (CCS) and to evaluate mortality and prognostic significance of frailty in these patients. METHODS: We included 99 patients, ≥ 70 years old (mean age 74±5.3 years), with diagnosis of CCS. They were followed-up for up to 12 months. The frailty score was evaluated according to the Canadian Study of Health and Aging (CSHA). All patients were divided as frail or non-frail. The groups were compared for their characteristics and clinical outcomes. RESULTS: Fifty patients were classified as frail, and 49 patients as non-frail. The 12-month Major Adverse Cardiac Events (MACE) rate was 69.4% in frail patients and 20% in non-frail patients. Frailty increases the risk for MACE as much as 3.48 times. Two patients died in the non-frail group and 11 patients died in the frail group. Frailty increases the risk for death as much as 6.05 times. When we compared the aforementioned risk factors by multivariate analysis, higher CSHA frailty score was associated with increased MACE and death (relative risk [RR] = 22.94, 95% confidence interval [CI] 3.33-158.19, P=0.001, for MACE; RR = 7.41, 95% CI 1.44-38.03, P=0.016, for death). CONCLUSION: Being a frail elderly CCS patient is associated with worse outcomes. Therefore, frailty score should be evaluated for elderly CCS patients as a prognostic marker.

Determination of the effects of cryoablation for atrial fibrillation on esophageal functions.

OBJECTIVE: Periesophageal vagal plexus injury is a complication of cryoablation for atrial fibrillation (AF). The aim of this study is to investigate the effect of cryoablation on esophageal functions and to determine the relationship between esophageal temperature and esophageal motility. METHODS: Twenty patients with symptomatic paroxysmal AF who underwent cryoablation were included in this study. The lowest cryoballoon temperature for each pulmonary vein (PV) was recorded. Esophageal temperature was measured using an esophageal probe during each cryoapplication. Esophageal manometry was performed before the procedure and one day after the procedure for each patient in order to assess the esophageal functions. RESULTS: During the procedure, the highest esophageal temperature change was found in the left-side PVs in 13 patients (65%) and in the right-side PVs in seven patients (35%). No correlation was found between the lowest cryoballoon temperature and esophageal temperature change (r=0.22, p=0.05). It was detected that the lower esophageal sphincter pressure and esophageal contraction amplitude pressure decreased after the procedure (before: 19.7±9.3 mm Hg, after: 14.3±4.9 mm Hg, p=0.001; before: 84.5±28.3 mm Hg, after: 72.7±34.3 mm Hg, p=0.005, respectively). Five patients (25%) developed gastrointestinal symptoms after the procedure. CONCLUSION: During cryoablation, esophageal temperature measurement can be performed to reduce the probability of esophageal injury. Cryoablation affects esophageal motility, and esophageal manometry can be performed to detect esophageal motility impairments in patients with gastrointestinal symptoms.

Relationship between left ventricular geometry and left ventricular systolic and diastolic functions in patients with chronic severe aortic regurgitation.

BACKGROUND: Chronic aortic regurgitation (AR) is a form of volume overload inducing left ventricle (LV) dilatation. Myocardial fibrosis, apoptosis, progressive LV dilatation, and eventually LV dysfunction are seen with the progression of disease. The aim of the study was to assess the relation between LV geometry and LV systolic and diastolic functions in patients with chronic severe AR. METHODS: The study population consisted of 88 patients with chronic severe AR and 42 healthy controls. The LV ejection fraction (LVEF) was calculated. Subjects were divided as Group I (controls, n = 42), Group II (LVEF > 50%, n = 47), and Group III (LVEF < 50%, n = 41). Transmitral early and late diastolic velocities and deceleration time were measured. The annular systolic (Sa) and diastolic (Ea and Aa) velocities were recorded. Diastolic function was classified as normal, impaired relaxation (IR), pseudonormalization (PN), and restrictive pattern (RP). RESULTS: The LVEF was similar in Group I and II, while significantly lower in Group III. Sa velocity was progressively decreasing, but LV long- and short-axis diameters were increasing from Group I to Group III. Forty-six, 31 and 11 patients had IR, PN, and RP, respectively. LV long-axis systolic and diastolic diameters were significantly increasing, while LVEF and Sa velocity were significantly decreasing from patients with IR to patients with RP. The LV long-axis diastolic diameter is independently associated with LV systolic and diastolic functions. CONCLUSIONS: The LV long-axis diastolic diameter is closely related with LV systolic and diastolic functions in patients with chronic severe AR.

Frailty significantly impairs the short term prognosis in elderly patients with heart failure.

BACKGROUND: Frailty is a condition of elderly characterized by increased vulnerability to stressful events with high risk of adverse outcomes. The purpose of this study was to evaluate the association between frailty and adverse outcomes including death and hospitalization due to heart failure in elderly patients. METHODS: We included patients aged ≥ 65 years with the diagnosis of heart failure. The clinical and laboratory data, echocardiography and ECGs were recorded. Additionally, the frailty scores of the patients were evaluated according to Canadian Study of Health and Aging. All the patients were divided as frail or non-frail. The groups were compared for their characteristics and the occurrence of clinical outcomes. RESULTS: We included 86 eligible patients. The median follow-up time was four months. The mean age was 75 ± 6.5 years. Of these 86 patients, 17 (19.7%) patients encountered an event (death and/or hospitalization). Nine patients (10.4%) died during follow-up. Thirty patients (34.9%) were considered frail. Among the demographic, clinical and laboratory data, only total protein and albumin levels were found to be lower in frail patients (total protein level: 6.8 ± 0.6 g/dL in non-frails, 6.5 ± 0.9 g/dL in frails, P = 0.05; albumin level: 3.8 ± 0.4 g/dL in non-frails, 3.4 ± 0.6 g/dL in frails, P = 0.001). In multivariate analysis, frailty was found to be strongly associated with clinical outcomes in short term. CONCLUSIONS: Being frail in an elderly heart failure patient is associated with death and/or hospitalization due to heart failure in short term. Therefore, frailty score should be evaluated for all elderly heart failure patients as a prognostic marker.

Cardiac troponin T as a prognostic marker in patients with heart failure : a 3-year outcome study.

Cardiac troponin T (cTnT), a highly sensitive and specific indicator of myocardial cell death, may be elevated in congestive heart failure (CHF). The aims of this study were to test the hypothesis that decompensated CHF may be associated with an increase in cTnT release and to correlate between cTnT levels and patient outcomes. The authors studied 55 patients aged between 38 and 86 years (30 women and 25 men) who were hospitalized for CHF. Left ventricular ejection fraction (EF) was calculated by using modified Simpson's rule by echocardiography. cTnT levels were assessed. Troponin T >or=0.1 ng/mL was considered as positive. All patients were contacted by phone annually during the next 3 years, and their history of subsequent hospital admissions and current health status were recorded. cTnT was negative in 44 (80%) and positive in 11 (20%) patients. EF was significantly lower and NYHA was higher in cTnT-positive patients. During the 3-year follow-up period, 25 patients died from CHF. The mortality rate was 8/11 (72.7%) among cTnT-positive patients, whereas the mortality rate was 17/44 (38.6%) among cTnT-negative patients. There were significant relationships among positivity of cTnT, NYHA, EF, and mortality rate. Multivariate regression analysis yielded an independent relationship between positivity of cTnT, NYHA classification, and mortality rate. The percent of hospital admissions due to CHF was also higher in patients with cTnT positive (63.6% versus, 27.3%, p <0.05). In conclusion, this study shows that cTnT positivity is an independent risk factor in predicting the long-term mortality and morbidity rate in patients with CHF. Patients with worsening CHF may possibly be identified early on the basis of their elevated serum cTnT levels.

Electrocardiographic markers of left ventricular systolic dysfunction in patients with left bundle branch block.

BACKGROUND: Although some patients with left bundle branch block (LBBB) have structural heart diseases, some patients with LBBB have "normal hearts". The electrocardiography (ECG) criteria of LBBB in reduced left ventricular ejection fraction (LVEF) have not been defined completely. AIM: The main purpose of this study was to differentiate patients with reduced LVEF from patients with normal left ventricular systolic function simply by analysing 12-lead ECG. METHODS: Subjects admitted to our hospital with LBBB in their ECG were included in the study. The patients were categorised according to their left ventricular systolic function as group 1 (LVEF ≥ 50%) and group 2 (LVEF < 50%). Duration of the QRS complex, residual conduction of left bundle branch, and concordance/discordance of T waves in leads V5, V6, or D1 were recorded. The ECG findings of the two groups were compared. RESULTS: One hundred consecutive patients with LBBB were included in the study (male/female: 56/44, age: 66 ± 15 years). In the whole group, there were 35 patients with normal left ventricular systolic function (LVEF ≥ 50%), and 65 patients had LVEF below 50%. 80% of male patients with LBBB and 45% of female patients with LBBB had their LVEF below 50% (p < 0.001). Mean QRS durations of group 1 and group 2 were 132 ± 10 ms vs. 152 ± 22 ms, respectively (p < 0.001). The QRS duration of 140 ms was found to be the cut-off value to differentiate group 1 from group 2, with sensitivity and specificity of 72% and 75%, respectively. Twenty-one per cent of patients in group 1 and 69% in group 2 had discordant LBBB (p < 0.001). Residual conduction of left bundle branch was more frequent in group 2 (29% in group 1 vs. 52% in group 2, p = 0.03). CONCLUSIONS: Male gender, QRS duration greater than 140 ms, discordant LBBB, and residual conduction in the left bundle branch seem to be markers of reduced LVEF in patients with LBBB.

Predictive value of plasma copeptin level for diagnosis and mortality of pulmonary embolism

SUMMARY OBJECTIVE: Early diagnosis and risk stratification may provide a better prognosis in pulmonary embolism (PE). Copeptin has emerged as a valuable predictive biomarker in various cardiovascular diseases. The aim of this study was to determine the levels of copeptin in patients with acute PE and to evaluate its relationship with disease severity and PE-related death. METHODS: Fifty-four patients and 60 healthy individuals were included in this study. Copeptin concentrations and right ventricular dysfunction were analyzed. The correlation between copeptin levels and hemodynamic and echocardiographic parameters was examined. After these first measurements, patients were evaluated with PE-related mortality at the one-year follow-up. RESULTS: The copeptin levels were higher in PE patients than in the control group (8.3 ng/mL vs 3.8 ng/mL, p<0.001). Copeptin levels were found to be significantly higher in patients with PE-related death and right ventricular dysfunction (10.2 vs 7.5 ng/ml, p=0.001; 10.5 vs 7.5 ng/ml, p=0.002, respectively). When the cut-off value of copeptin was ≥5.85, its sensitivity and specificity for predicting PE were 71.9% and 85.0%, respectively (AUC=0.762, 95% CI=0.635-0.889, p<0.001). CONCLUSIONS: The copeptin measurement had moderate sensitivity and specificity in predicting the diagnosis of PE, and the copeptin level was significantly higher in patients with PE-related death at the one-year follow-up. Copeptin may be a useful new biomarker in predicting diagnosis, risk stratification, and prognosis of PE.

RESUMO OBJETIVO: O diagnóstico precoce e a estratificação de risco podem proporcionar um melhor prognóstico em casos de embolia pulmonar (EP). A copeptina surgiu como um valioso biomarcador preditivo de várias doenças cardiovasculares. O objetivo deste estudo é determinar os níveis de copeptina em pacientes com EP aguda e avaliar a sua relação com a severidade da doença e mortes relacionadas à EP. MÉTODOS: Um total de 54 pacientes e 60 indivíduos saudáveis foram incluídos neste estudo. As concentrações de copeptina e disfunções ventriculares direitas foram analisadas. A correlação entre os níveis de copeptina e parâmetros ecocardiográficos e hemodinâmicos foi examinada. Após essas primeiras medições, os pacientes foram avaliados em relação à mortalidade relacionada à EP após um ano. RESULTADOS: Os níveis de copeptina foram maiores em pacientes com EP do que no grupo de controle (8,3 ng/mL vs 3,8 ng/mL, p<0,001). Os níveis de copeptina eram significativamente maiores em pacientes com mortes relacionadas à EP e disfunção ventricular direita (10,2 vs 7,5 ng/ml, p=0,001; 10,5 vs 7,5 ng/ml, p=0,002, respectivamente). Com um valor de corte ≥5,85 para a copeptina, sua sensibilidade e especificidade preditivas para EP foram 71,9% e 85,0%, respectivamente (AUC=0,762, 95% IC=0,635 - 0,889, p<0,001). CONCLUSÃO: A medição da copeptina teve sensibilidade e especificidade preditivas moderadas para o diagnóstico de EP, e o nível de copeptina foi significativamente maior em pacientes com mortes relacionadas à EP após um ano. A copeptina pode ser um novo biomarcador preditivo útil para o diagnóstico, a estratificação de risco e o prognóstico de PE.

Frailty significantly associated with a risk for mid-term outcomes in elderly chronic coronary syndrome patients: a prospective study

Abstract Introduction: Frailty is a condition of elderly characterized by increased vulnerability to stressful events. Frail patients are more likely to have adverse events. The purposes of this study were to define frailty in patients aged ≥ 70 years with chronic coronary syndrome (CCS) and to evaluate mortality and prognostic significance of frailty in these patients. Methods: We included 99 patients, ≥ 70 years old (mean age 74±5.3 years), with diagnosis of CCS. They were followed-up for up to 12 months. The frailty score was evaluated according to the Canadian Study of Health and Aging (CSHA). All patients were divided as frail or non-frail. The groups were compared for their characteristics and clinical outcomes. Results: Fifty patients were classified as frail, and 49 patients as non-frail. The 12-month Major Adverse Cardiac Events (MACE) rate was 69.4% in frail patients and 20% in non-frail patients. Frailty increases the risk for MACE as much as 3.48 times. Two patients died in the non-frail group and 11 patients died in the frail group. Frailty increases the risk for death as much as 6.05 times. When we compared the aforementioned risk factors by multivariate analysis, higher CSHA frailty score was associated with increased MACE and death (relative risk [RR] = 22.94, 95% confidence interval [CI] 3.33-158.19, P=0.001, for MACE; RR = 7.41, 95% CI 1.44-38.03, P=0.016, for death). Conclusion: Being a frail elderly CCS patient is associated with worse outcomes. Therefore, frailty score should be evaluated for elderly CCS patients as a prognostic marker.

Diastolic function predicts outcome after aortic valve replacement in patients with chronic severe aortic regurgitation.

BACKGROUND: Due to eccentric hypertrophy and fibrosis, patients with severe aortic regurgitation (AR) have diastolic dysfunction. Increased fibrosis correlates with increased myocardial stiffness and worsening of diastolic function. Patients with irreversible left ventricular (LV) dysfunction have severe myocardial fibrosis and myocyte apoptosis and do not benefit from aortic valve replacement (AVR). HYPOTHESIS: To investigate whether diastolic properties of LV predicts outcome after AVR in patients with chronic severe AR and LV systolic dysfunction. METHODS: The study population consisted of 41 patients with chronic severe AR and LV systolic dysfunction. Preoperative echocardiographic examinations were repeated at the postoperative 6th month. Left ventricular ejection fraction (LVEF) was calculated. Diastolic function was evaluated with Doppler echocardiography. Patients were classified as Group 1 (impaired relaxation), Group 2 (pseudonormalization), and Group 3 (restrictive pattern). RESULTS: Postoperative LVEF was significantly increased in Group 1, whereas it tended to decrease in Group 3. Left ventricular size was significantly decreased in Group 1 and 2 during the postoperative period. Multivariate linear regression analysis showed that deceleration time and early/late ratio were independent predictors of postoperative changes in LVEF. CONCLUSIONS: Assessment of diastolic function is a reliable parameter in predicting outcome of AVR in patients with chronic AR and systolic dysfunction.

The effect of early statin treatment on inflammation and cardiac events in acute coronary syndrome patients with low-density lipoprotein cholesterol.

We investigated the effects of atorvastatin on inflammation and cardiac events during the inpatient period and initial 6-month follow-up in acute coronary syndrome (ACS) patients with low low-density lipoprotein (LDL) cholesterol level. One hundred and twelve consecutive ACS patients with LDL cholesterol less than 100 mg/dl were included in the study (mean 78.2+/-12.3 mg/dl). While 70 randomly selected patients received a dose of 40 mg atorvastatin within the first 24 h on top of their standard treatment as the atorvastatin group, the remaining 42 patients considered as the control group were given the standard treatment only, i.e., without any lipid-lowering drug therapy. Lipid profile, high-sensitivity C-reactive protein (hsCRP), and plasma amyloid A (SAA) levels were measured in all patients within the first 24 h of chest pain, on the 5th day, and in the 6th month. During the inpatient period and subsequent 6-month follow-up, all episodes of angina, reinfarction, revascularization, heart failure, rehospitalization, cardiac mortality, and total number of cardiac events were recorded. In the atorvastatin group, hsCRP and SAA values on the 5th day and in the 6th month compared to the first 24 h were significantly lower than those of the control group (P<0.0001). Mean LDL cholesterol level was significantly decreased in the atorvastatin group (55.7+/-17.7 mg/dl), but there was no significant change in the control group at the 6th month. The frequency of heart failure during the inpatient period and angina, unstable angina pectoris, heart failure, and revascularization in the first 6 months were also significantly reduced in the atorvastatin group. Atorvastatin started in the first 24 h reduces inflammation and improves the prognosis during both the inpatient period and the first 6 months of clinical follow-up in ACS patients with low LDL cholesterol levels.

'Natural Conduit' between two atria associated with atrial septal defect.

Herein, we present a case of 46 years old woman with an extracardiac venous connection between two atria associated with secundum type atrial septal defect (ASD). This interatrial tunnel was not recognized by both transthoracic and transesophageal echocardiographic examinations. Computed tomography suspected a blood flow from right inferior pulmonary vein to inferior caval vein. Consequently, the patient underwent cardiac catheterization. Angiography revealed a tunnel between left and right atrium. To our knowledge, this is the first report of a case with venous tunnel between two atria associated with secundum type ASD in the literature.