The importance of intraoperative echocardiography in the early detection of mitral regurgitation as a postsurgical sequel of aortic valve replacement: a case report.

BACKGROUND: Mitral leaflet perforation (MLP) can rarely be a consequence of aortic valve replacement (AVR), resulting in mitral regurgitation (MR). Determining the cause and severity of MLP following AVR is crucial in preventing hemodynamic consequences, such as pulmonary hypertension and biventricular remodeling. However, the diagnosis of this rare complication requires detailed echocardiographic evaluations. CASE PRESENTATION: In this paper, we report a 37-year-old Persian male with progressive dyspnea on exertion diagnosed with severe MR caused by anterior MLP following AVR and discuss the importance of intraoperative transesophageal echocardiography (TEE) in the proper and on-time diagnosis of this rare complication. CONCLUSION: During AVR procedure, an evaluation with TEE could be beneficial for identifying and treating such condition. Echocardiography is beneficial in providing real-time guidance during surgery, early detection of potential complications, treatment of such complications if present, and prevention of adverse outcomes.

Evaluation of Systolic Function using Global Longitudinal Strain in Isolated Obese and Overweight People.

BACKGROUND: The association of obesity with left ventricular (LV) diastolic dysfunction is fully understood, but there are few investigations regarding its effect on LV systolic function in the absence of other risk factors. This study aimed to identify the global longitudinal strain (GLS) changes in isolated overweight and obese people in the absence of other risk factors. METHODS: A total of 120 individuals, including 60 obese, 30 overweight, and 30 healthy controls with no underlying disease and no history of hypertension, diabetes, CAD, or CKD were included in the study. Echocardiographic findings were measured, including apical 2-, 3- and 4-chamber GLS, GLS total, LV diameter, interventricular septum thickness, and PAP. These findings were then compared between the three groups (obese, overweight, and normal controls). RESULTS: Analyses showed that LV diameter in healthy controls was significantly lower compared to overweight (p = 0.02) and obese (p < 0.0001) participants. Also, the interventricular septal thickness was significantly increased in overweight (p = 0.007) and obese (p < 0.0001) individuals compared to healthy controls. The mean and standard deviation (Mean ± SD) of total GLS values were - 22.29% ± 1.89% for normal weight, -22.09% ± 1.91% for overweight, and -19.88% ± 2.34% for obese individuals. The total GLS of obese participants was significantly lower than overweight and normal controls (p < 0.0001). It was observed that the GLS values were significantly lower in people with BMI higher than 40. The mean ± SD of total GLS values were -20.68% (1.84%) for BMI ≤ 40 patients and -18.51% (2.52%) for BMI > 40 patients. CONCLUSION: Data revealed that all GLS values had a moderately strong correlation with BMI values. Also, subclinical LV dysfunction was detected in overweight and obese subjects.

Acute heart failure as an atypical presentation of Takayasu arteritis: The value of multi-modality imaging.

Takayasu arteritis (TA) is an inflammatory disease that affects the aorta and the major branch arteries. Here, we describe an atypical presentation of the disease with heart failure.

Early prediction of ventricular functional recovery after myocardial infarction by longitudinal strain study.

BACKGROUND: There are some suggestions that global myocardial strain (GLS) early after ST-elevation myocardial infarction (STEMI) is a predictor of improvement in left ventricular ejection fraction (LVEF). The goal of this study was to evaluate LV recovery after STEMI intervention based on GLS values. METHODS: The study population consists of 43 patients with acute STEMI and no history of prior coronary intervention treated with primary percutaneous coronary intervention. LVEF and myocardial strain indices were measured 48 hours and two months after STEMI by transthoracic echocardiography and speckle tracking method. More than 5% improvement in LVEF was considered significant. RESULTS: GLS values were significantly higher in patients with >5% improvement in LVEF 2 months after the STEMI (GLS=15.76% in patients with >5% improvement vs. 11.54% in the other group, P<0.05). ROC analysis suggested GLS values more than 13.5 to be a predictor of significant LVEF improvement 2 months after STEMI. Higher GLS was observed in patients with inferior, posterior and inferoseptal STEMI versus anterior, extensive or anteroseptal STEMI and in patients with right coronary occlusion versus occlusion of the left anterior descending or circumflex arteries. CONCLUSION: We have observed that early longitudinal LV strain after STEMI is a predictor of recovery after STEMI. This is a useful method to predict early LV recovery after STEMI. GLS values of more than 13.5% are a significant predictor of significant LVEF improvement.

Spatiotemporal registration and fusion of transthoracic echocardiography and volumetric coronary artery tree.

PURPOSE: Cardiac multimodal image fusion can offer an image with various types of information in a single image. Many coronary stenosis, which are anatomically clear, are not functionally significant. The treatment of such kind of stenosis can cause irreversible effects on the patient. Thus, choosing the best treatment planning depend on anatomical and functional information is very beneficial. METHODS: An algorithm for the fusion of coronary computed tomography angiography (CCTA) as an anatomical and transthoracic echocardiography (TTE) as a functional modality is presented. CCTA and TTE are temporally registered using manifold learning. A pattern search optimization algorithm, using normalized mutual information, is used to find the best match slice to TTE frame from CCTA volume. By employing a free-form deformation, the heart's non-rigid deformations are modeled. The spatiotemporal registered TTE frame is embedded to achieve the fusion result. RESULTS: The accuracy is evaluated on CCTA and TTE data obtained from 10 patients. In temporal registration, mean absolute error of 1.97 [Formula: see text] 1.23 is resulted from comparing the output frame numbers from the algorithm and from manual assignment by an expert. In spatial registration, the accuracy of the similarity between the best match slice from CCTA volume and TTE frame is resulted in 1.82 [Formula: see text] 0.024 mm, 6.74 [Formula: see text] 0.013 mm, and 0.901 [Formula: see text] 0.0548 due to mean absolute distance, Hausdorff distance, and Dice similarity coefficient, respectively. CONCLUSION: Without the use of ECG and Optical tracking systems, a semiautomatic framework of spatiotemporal registration and fusion of CCTA volume and TTE frame is presented. The experimental results showed the effectiveness of our proposed method to create complementary information from TTE and CCTA, which may help in the early diagnosis and effective treatment of cardiovascular diseases (CVDs).

Large Tricuspid Valve Myxoma in an Asymptomatic Patient with Uterine Myoma: An Uncommon Case.

Tricuspid valve myxomas are very uncommon tumors that could be found after the occurrence of pulmonary thromboembolism, symptomatic tricuspid obstruction, and right-sided heart failure. Herein, we describe a 42-year-old woman evaluated for an abdominal mass. In preoperative consultation, a tricuspid valve mass was detected in echocardiography. She underwent the removal of a benign uterine myoma and a myxoma of the tricuspid valve. Tricuspid valve myxomas constitute a scarce diagnosis. They could be asymptomatic, occurring in unusual locations and in association with benign tumors in other organs. Our patient was asymptomatic, underscoring the significance of the early diagnosis of this type of tumor to prevent further catastrophic events.

Double orifice mitral valve in a patient with bicuspid aortic valve and coarctation of the aorta: A rare presentation.

Double orifice mitral valve is a rare condition and may be accompanied by a bicuspid aortic valve (sometimes normal functioning) and coarctation of the aorta. Echocardiography is valuable in detecting the accompanied anomalies. Management depends on the severity of mitral valve function and the severity of associated anomalies.

Effect of kidney transplantation on right ventricular function, assessment by 2- dimensional speckle tracking echocardiography.

BACKGROUND: Advanced chronic kidney disease often results in adverse cardiovascular outcomes and is the leading cause of mortality in patients with end stage renal diseases (ESRD). There is much information about the effect of chronic kidney diseases (CKD) on the left ventricle (LV) chamber, but the right ventricle (RV) as a neglected chamber had not been evaluated precisely, in spite of its importance. OBJECTIVES: The aim of this study was to evaluate the impact of successful kidney transplants on the RV systolic and diastolic function using the advanced method of 2D speckle tracking echocardiography and comparison with the conventional methods. METHOD: The study included 48 patients with CKD who were eligible for kidney transplantation and underwent successful kidney transplantations. Right ventricular indices were evaluated, while RV function was focused by conventional methods and 2D speckle tracking echocardiography before the successful kidney transplant and 1 week, 1 month, and 3 months after the successful kidney transplant. RESULTS: The results of the study showed that RV global longitudinal strain and RV free wall longitudinal strain improved over the time (P = 0.024, P < 0.001 respectively). It also represented that kidney transplantation did not have significant effect on the RV mid cavity diameter, tissue velocity, Myocardial performance index, RV longitudinal diameter, and Tricuspid annular plane systolic excursion indices, but for other indices this effect was significant. On the differences between the mean slope of regression line of the GLS variable in hypertensive subjects (1.0 ± 0.2) and non-hypertensive subjects (0.36 ± 0.32), an independent t-test showed that between the two groups in terms of the improvement of RVGLS, there was a significant statistical difference (P = 0.0067). CONCLUSION: Most of the ESRD patients had subtle RV dysfunction which could be better detected by recent echocardiography methods than conventional methods. Moreover, kidney transplantation led to considerable improvements in RV function in this population.

Subclinical involvement of the heart and its associated factors in patients with sarcoidosis with normal systolic function using 2D speckle tracking.

BACKGROUND: Cardiac involvement by sarcoidosis may affect any part of the heart such as the pericardium, atriums, ventricles, and papillary muscles. In this regard, the use of two-dimensional speckle-tracking strain has been reported to be valuable in detecting heart sarcoidosis and its distinction from cardiomyopathy. The aim of this study was to investigate subclinical cardiac involvement using 2D speckle tracking and its associated factors in patients with normal systolic function by 2D transthoracic echocardiography (TTE). METHODS: In this study, 55 patients with extra-cardiac sarcoidosis and 21 normal people were evaluated by 2D speckle tracking. The mean longitudinal global strain for the left ventricle was calculated as an average of 16 segments per patient. RESULTS: The comparison of the mean 2D speckle-tracking indices including GCS (global circumferential strain) SAXA, GCSSAXM, Average GCS, AP2LS, AP3LS, AP4LS, and also Average GLS (global longitudinal strain) showed a significant difference between the two groups. Also, the evaluation of each of the above indices with a specific cutoff point as well as a high sensitivity and acceptable specificity predicted the presence of sarcoidosis. The occurrence of changes in the above indices was independent of ventricular function by 2D echocardiography in these patients. CONCLUSIONS: The marked changes in the 2D speckle-tracking parameters in patients with extra-cardiac sarcoidosis can be of great value in the prediction of cardiac involvement. The occurrence of the abovementioned cardiac changes can be completely independent of the involvement of left ventricular function and is therefore predictable in patients with normal ventricular function.

Huge aneurysmal fistula from left main artery to right atrium in a man with atypical chest pain and dyspnea on exertion.

We present a 33-year-old man with atypical chest pain and with no significant past medical history. The patient was finally diagnosed as a case of huge fistula from the left main coronary artery to the right atrium, a very rare condition with challenging diagnostic and therapeutic approaches. The majority of cases of coronary artery fistula are small, asymptomatic and clinically undetectable; they frequently do not cause any complications and can spontaneously resolve. However, larger fistulas are frequently three times the size of a typical caliber of a coronary artery and may or may not cause symptoms or complications.

Effects of Weight Loss on Echocardiographic Parameters 1 Year after Sleeve Gastrectomy.

Background: Bariatric surgery is efficiently associated with the long-term resolution of obesity and its related morbidities. Not only can this surgical modality improve the metabolic profile, diastolic and systolic cardiac functions, and the clinical symptoms of heart failure or cardiomyopathy, but it can also reduce the atherosclerosis risk, ventricular mass, and pericardial fat thickness. The aim of the present study was to evaluate the effects of weight loss on echocardiographic parameters 1 year after sleeve gastrectomy. Methods: This quasi-experimental study, conducted in Modarres Hospital, Tehran, Iran, from September 2016 to September 2017, recruited 101 patients. Those with morbid obesity (body mass index ≥40 kg/m2) had undergone surgery 1 year before the study commencement. All the patients underwent sleeve gastrectomy. The data of echocardiographic indices before and 1 year after surgery were recorded and analyzed. Results: The mean age of the participants was 37.11±9.81 years. The majority of the study participants were female (n=77, 76.2%). During the first postoperative year, the mean weight loss was 43.82±14.53 kg. The mean systolic blood pressure was 137.96±19.60 mmHg and 123.37±9.60 mmHg before sleeve gastrectomy and 1 year afterward, respectively (P<0.001). The mean left ventricular size was 48.22±4.04 mm and 44.97±5.70 mm before sleeve gastrectomy and 1 year postoperatively, correspondingly (P<0.001). The mean pulmonary artery pressure was 28.88±5.25 mmHg and 24.10±4.78 mmHg before sleeve gastrectomy and 1 year after surgery, respectively (P<0.001). The mean left atrial size was 35.72±3.32 mm and 33.12±3.52 mm before sleeve gastrectomy and 1 year thereafter, correspondingly (P<0.001). Conclusion: Weight loss resulting from sleeve gastrectomy may improve systolic blood pressure, left atrial and left ventricular size, and pulmonary artery pressure.

Paradoxical Embolism in a Patient with Patent Foramen Ovale; a Case Report.

Patent foramen ovale (PFO) is usually asymptomatic; however, it could be quite dangerous for patients with right side clot in which thrombus can transmit the PFO and paradoxically emboli to systemic circulation. Here we present a patient with ankle fracture and paradoxical embolus to the brain, who was successfully treated with emergent thrombectomy, inferior vena cava (IVC) filter placement and anticoagulation therapy. Despite the high rate of mortality in these patients, fortunately our patient survived with surgical treatment.

Left ventricular sphericity index analysis for the prediction of appropriate implantable cardioverter-defibrillator therapy.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) is the most effective therapy currently available to prevent sudden cardiac death (SCD) in patients with left ventricular (LV) dysfunction. Although LV ejection fraction (LVEF) is an excellent marker of SCD in these patients, determining other predictors might help to identify patients who will be benefit more from device implantation. The purpose of this study was to determine whether abnormal LV sphericity index (SI) in transthoracic echocardiography is associated with appropriate ICD therapy in these patients. METHODS: A total of 140 patients with primary ICD implantation (mean age 62.59 ± 11.36 years; 98 [70%] male) were included. The patients were classified into "no ICD therapy" or "ICD therapy" group according to the information of their devices for a maximum of 2 previous years. In four-chamber view image of transthoracic echocardiography, SI was calculated by dividing the major-axis dimension to minor-axis dimension of LV in both groups. RESULTS: Compared with patients with no ICD therapy, patients in ICD therapy group had lower LVEF (31.36 ± 9.58 vs 23.24 ± 6.03, P = 0.0001) and lower SI (1.79 ± 0.29 vs 1.57 ± 0.32, P = 0.0001). In multivariant logistic regression analysis, the SI of ≤1.58 was associated with fourfold increase of appropriate ICD therapy, even after adjusting for LVEF (odds ratio, 4.08; 95% confidence interval, 1.71-9.75; P = 0.02). CONCLUSION: Simple echocardiographic sphericity dimension index as a marker of cardiac remodeling may be an important predictor of appropriate ICD therapy in patients with primary prevention ICDs and may provide additive risk stratification in patients with LV systolic dysfunction.

Asymptomatic Giant Lipoma of the Right Ventricular Outflow Tract: A Case Report.

Cardiac lipomas are extremely rare tumors of the heart. They are usually symptomatic and rarely may be found incidentally in autopsies. Here we describe a 23-year-old healthy man, in whose physical examination for employment a murmur was found incidentally. Transthoracic and then transesophageal echocardiographic examination showed a 4-cm oval-shaped mass in the right ventricular outflow tract. He underwent elective surgery, during which the tumor was removed under cardiopulmonary bypass and aortic-cross clamping via right atriotomy. The postoperative course was uneventful, and the patient was in good condition at 1 year's follow-up.

The change in NT-pro-BNP and post-PTMC echocardiography parameters in patients with mitral stenosis. A pilot study.

BACKGROUND: The change in the level of NT-pro-BNP (N-terminal-pro-Brain Natriuretic Peptide) is now considered as a reflection of the hemodynamic alterations and its circulatory reductions reported early after successful PTMC (percutaneous transvenous mitral commissurotomy). The present study aims to assess the change in the level of NT-pro BNP following PTMC in patients with mitral stenosis and also to determine the association between circulatory NT-pro-BNP reduction and post-PTMC echocardiography parameters. METHODS: Twenty five symptomatic consecutive patients with severe MS undergoing elective PTMC were prospectively enrolled. All patients underwent echocardiography before and also 24 to 48 hours after PTMC. Peripheral blood samples were taken for measurement of NT-pro-BNP before as well as 24 to 48 hours after PTMC. The patients were also classified in group with normal sinus rhythm or having atrial fibrillation (AF) based on their 12-lead electrocardiogram. RESULTS: It was shown a significant decrease in the parameters of PPG (Peak Pressure Gradient), MPG (Mean Pressure Gradient), PHT (Pressure Half Time), PAP (Pulmonary Arterial Pressure), LAV (Left Atrial Volume), and also a significant increase in MVA (Mitral Valve Area) RVS (Right Ventricular S velocity), and strains of lateral, septal, inferior and anterior walls of LA following PTMC. The mean LVEF remained unchanged after PTMC. The mean NT-pro-BNP before PTMC was 309.20 ± 17.97 pg/lit that significantly diminished after PTMC to 235.72 ± 22.46 pg/lit (p = 0.009). Among all echocardiography parameters, only MPG was positively associated with the change in NT-pro-BNP after PTMC. Comparing the change in echocardiography indices between the patients with normal rhythm and those with AF, lower change in PAP was shown in the group with AF. However, more change in the level of NT-pro-BNP after PTMC was shown in the patients with AF compared to those without this arrhythmia. CONCLUSION: PTMC procedure leads to reduce the level of NT-pro-BNP. The change in NT-pro-BNP is an indicator for change in MS severity indicated by decreasing MPG parameter. Lower change in PAP as well as higher change in NT-pro-BNP is predicted following PTMC in the group with AF compared to those with normal sinus rhythm.

The effectiveness of risk management program on pediatric nurses' medication error.

BACKGROUND: Medication therapy is one of the most complex and high-risk clinical processes that nurses deal with. Medication error is the most common type of error that brings about damage and death to patients, especially pediatric ones. However, these errors are preventable. Identifying and preventing undesirable events leading to medication errors are the main risk management activities. The aim of this study was to investigate the effectiveness of a risk management program on the pediatric nurses' medication error rate. MATERIALS AND METHODS: This study is a quasi-experimental one with a comparison group. In this study, 200 nurses were recruited from two main pediatric hospitals in Tehran. In the experimental hospital, we applied the risk management program for a period of 6 months. Nurses of the control hospital did the hospital routine schedule. A pre- and post-test was performed to measure the frequency of the medication error events. SPSS software, t-test, and regression analysis were used for data analysis. RESULTS: After the intervention, the medication error rate of nurses at the experimental hospital was significantly lower (P < 0.001) and the error-reporting rate was higher (P < 0.007) compared to before the intervention and also in comparison to the nurses of the control hospital. CONCLUSIONS: Based on the results of this study and taking into account the high-risk nature of the medical environment, applying the quality-control programs such as risk management can effectively prevent the occurrence of the hospital undesirable events. Nursing mangers can reduce the medication error rate by applying risk management programs. However, this program cannot succeed without nurses' cooperation.

Comparison of the response of the right ventricle with endovascular occlusion and surgical closure in adults with atrial septal defect one year after intervention.

BACKGROUND: Use of the Amplatzer septal occluder (ASO) for the closure of secundum atrial septal defect (ASD) has recently become the procedure of choice, while earlier the only treatment for ASD was surgical closure. This study compares the right ventricular indices of the ASO group with the surgical closure group one year after intervention in adults. METHODS: From January 2008 to February 2010, 38 patients with isolated atrial septal defect of the secundum type one year after surgical (n = 20, age = 27 ± 4 years, 13 females, 7 males) or Amplatzer septal occluder closure (n = 18, age = 25 ± 4 years, 12 females, 6 males) were studied. At the same time, thirty-one age-matched normal subjects (age = 26 ± 6 years, 23 females, 9 males) were included as the control group. Strain and strain rate of the right ventricle were measured. RESULTS: The mean values of strain of the midportion were -26% ± 11.7%, -8.9% ± 4.2%, and 24.5% ± 7.4% (P < 0.001). Strain rates of the midportion were -2.19 ± 0.6 s(-1), -1.2 ± 0.4 s(-1), -1.9 ± 0.6 s(-1) (P < 0.001) in ASO, surgery, and control groups, respectively. CONCLUSION: This study showed that the right ventricle might show better performance in the ASO than the surgery group in adults with ASD in midterm follow-up.