Left pulmonary artery stenting with glenn shunt: in-troducing a hybrid procedure

Complexity of some congenital heart diseases sometimes necessitates a combination of interventional procedures and surgery, amongst which intraoperative stent implantation is one of the most common. We herein report a successful hybrid procedure in a cyanotic adult patient who had undergone no procedure in childhood. The patient was a 24-year-old cyanotic male [oxygen saturation in the room air was 65%] who presented with dyspnea. According to echocardiography, catheterization, and cardiac magnetic resonance imaging data, the patient was amenable to the Fontan surgery. However, because of significant left pulmonary stenosis and his age, he first underwent a hybrid procedure [Glenn shunt and left pulmonary artery [LPA] stenting]. After the procedure, oxygen saturation rose to 83%. At six months follow-up of the patient, exercise capacity and cyanosis had improved significantly, with o[2] saturation having reached near 85% by pulse oximetry

Noninvasive localization of accessory pathways in patients with Wolff-Parkinson-White syndrome: a strain imaging study

Noninvasive techniques for the localization of the accessory pathways [APs] might help guide mapping procedures and ablation techniques. We sought to examine the diagnostic accuracy of strain imaging for the localization of the APs in Wolff-Parkinson-White syndrome. We prospectively studied 25 patients [mean age = 32 +/- 17 years, 58.3% men] with evidence of pre-excitation on electrocardiography [ECG]. Electromechanical interval was defined as the time difference between the onset of delta wave and the onset of regional myocardial contraction. Time differences between the onset of delta wave [delta] and the onset of regional myocardial contraction [delta-So], peak systolic motion [delta-Sm], regional strain [delta-epsilon], peak strain [delta-epsilonp], and peak strain rate [delta-SRp] were measured. There was a significant difference between time to onset of delta wave to onset of peak systolic motion [mean +/- SD] in the AP location [A] and normal segments [B] versus that in the normal volunteers [C] [A: [57.08 +/- 23.88 msec] vs. B: [75.20 +/- 14.75] vs. C: [72.9 0 +/- 11.16]; p value [A vs. B] = 0.004 and p value [A vs. C] = 0.18] and [A: [49.17 +/- 35.79] vs. B: [67.60 +/- 14.51] vs. C: [67.40 +/- 6.06 msec]; p value [A vs. B] < 0.001 and p value [A vs. C] = 0.12, respectively]. Our study showed that strain imaging parameters [[delta-So] and [delta-Strain]] are superior to the ECG in the localization of the APs [84% vs. 76%]

Echocardiographic findings in thalassemia major: a case report and literature review

We introduce a 28-year-old woman with Thalassemia major whose clinical assessment, including two-dimensional Doppler echocardiography demonstrated severe left ventricular hypertrophy with severe biventricular enlargement and systolic dysfunction as well as severe diastolic dysfunction. We hereby address these issues from an echocardiographic point of view.

Apical hypertrophic cardiomyopathy in association with pulmonaryartery hypertension

Apical Hypertrophic Cardiomyopathy is an uncommon condition constituting 1% -2% of the cases with Hypertrophic Cardiomyopathy [HCM] diagnosis. We interestingly report two patients with apical hypertrophic cardiomyopathy in association with significant pulmonary artery hypertension without any other underlying reason for pulmonary hypertension. The patients were assessed by echocardiography, cardiac catheterization and pulmonary function parameters study.

Isolated right sided anomalous pulmonary venous connection associated with significant right ventricular enlargement and intact interatrial septum

Partial anomalous pulmonary venous connection [PAPVC] is a very rare congenital heart disease where one or more of the pulmonary veins are connected to the venous circulation. Although initially suspected with inexplicable right ventricular enlargement on transthoracic echocardiography, other modalities such as transesophageal echocardiography, CT angiography or cardiac Magnetic resonance [CMR] imaging are able to diagnosis the anatomical abnormalities. We present a 29-year-old female with moderate right ventricular enlargement and isolated right upper and middle pulmonary vein anomalous return to superior vena cava

Percutaneous mitral balloon valvotomy; single center experience: a review of outcome

Percutaneous balloon mitral valvotomy [BMV] has been accepted as an alternative to surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. Despite the worldwide use of the BMV technique, no studies have been hitherto designed to assess the outcome of the patients undergoing BMV in Iran. The present study reports the outcome of 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center during a 15-year time period. A total of 2531 patients underwent 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center between 1992 and 2006. Seventy-three percent [2278] of the cases were followed for 48 +/- 41 months. Recurrent stenosis in 802 [25.8%], mitral valve replacement [MVR] in 213 [6.9%], immediate good result in 3110 [99.1%], and successful outcome in 2000 [72.9%] cases were the outcome of the BMV procedures in the current study. Concordant to the similar studies, we concluded that BMV produces a good clinical outcome in a high percentage of patients. The recent study demonstrated that the successful outcome of BMV was multi factorial and the selection of patients with rheumatic mitral stenosis is recommended to be based on both anatomic and clinical characteristics of the individuals. The procedure-related variables must also be considered in order to predict the outcome

Echocardiographic assessment of adults with repaired tetralogy of fallot: a cardiovascular magnetic resonance comparison study

Surgical management of the tetralogy of Fallot [TOP] results in anatomic and functional abnormalities in the majority of patients. Right ventricular [RV] dilation from pulmonary regurgitation [PR], residual atrial and/or ventricular septal defect, tricuspid regurgitation, right ventricular outflow tract [RVOT] aneurysm, and pulmonary artery peripheral stenosis are some of the abnormalities frequently encountered in patients with repaired TOP. Cardiovascular magnetic resonance [CMR] can provide assessments of anatomical connections, biventricular function, flow measurement, and more, without ionizing radiation. Echocardiography is the most frequently used modality for the initial assessment and follow-up of most patients with CHD. We sought to evaluate adult patients with repaired TOP by transthoracic echocardiography and compare them with CMR. 156 patients [52 women, mean age= 23 +/- 5.5 years] late after TOP repair with severe PR were evaluated. Ventricular size and function and TOP -associated anomalies such as patent ductus arteriosus [PDA], peripheral pulmonary stenosis [PPS], and persistent left superior vena cava [LSVC] were evaluated by transthoracic echocardiography and CMR separately. Mean of LV ejection fraction by CMR was 52 +/- 9% and by echocardiography was 47 +/- 5.1%. We found a significant correlation between LVEF assessed by CMR and 2D visual assessment in multiple views. Mean of RVEF by CMR was 37 +/- 8% and RV end diastolic volume index was 161 +/- 57.3 mm[3]. Linear correlation between CMR-RVEF and RVEF measured by echocardiography was weak. There was almost perfect agreement between CMR and echocardiography for the diagnosis of LSVC [99.2%]. Agreement was 88.3% in the diagnosis of PDA, 66.4% in the diagnosis of PPS, and 93% in the diagnosis of the right aortic arch was. Adults late after repaired TOF have significantly reduced biventricular systolic function. Despite abnormal LV geometry, visual assessment of LV systolic function by an expert echocardiologist has an acceptable agreement compared to the quantitative measurement of LV systolic function by CMR. However, the correlation between CMR-RVEF and RVEF measured by echocardiography is weak. We found incremental diagnostic value of CMR in PPS and PDA. Atrial septal defect and ventricular septal defect are found more frequently by echocardiography

Blue color vision as a rare sign of digitalis toxicity

We report a 73-year-old woman who had taken an amount of 0.25 mg/day of digoxin for an unknown period of time because of chronic congestive heart failure and chronic atrial fibrillation. She was admitted due to nausea, vomiting, abdominal pain, atrial fibrillation with a slow ventricular rate and with a short corrected Q-T interval in an electrocardiogram of 345 milliseconds, high serum digoxin level of 4.2 nmol/L, and interestingly color vision disturbances: blue colored vision. After discontinuation of the digitalis treatment, all signs of digitalis toxicity, including blue color vision, disappeared within five days

Cardiac MRI in a patient with coincident left ventricular non-compaction and hypertrophic cardiomyopathy

Left ventricular non-compaction cardiomyopathy is a rare congenital cardiomyopathy that affects both children and adults. Since the clinical manifestations are not sufficient to establish diagnosis, echocardiography is the diagnostic tool that makes it possible to document ventricular non-compaction and establish prognostic factors. We report a 47-year-old woman with a history of dilated cardiomyopathy with unknown etiology. Echocardiography showed mild left ventricular enlargement with severe systolic dysfunction [EF = 20-25%]. According to cardiac magnetic resonance imaging findings non-compaction left ventricle with hypertrophic cardiomyopathy was considered, and right ventricular septal biopsy was recommended. Right ventricular endomyocardial biopsy showed moderate hypertrophy of cardiac myocytes with foci of myocytolysis and moderate interstitial fibrosis. No evidence of infiltrative deposition was seen

Is the peak-to-mean pressure gradient ratio useful for assessment of aortic valve prosthesis obstruction?

The evaluation of prosthetic valves is very difficult with two-dimensional transthoracic echocardiography alone. Doppler and color flow imaging as well as transesophageal echocardiography are more reliable to detect prosthetic valve dysfunction. However, Doppler study sometimes tends to be misleading due to the load-depending characteristics of peak and mean pressure gradients. The peak-to-mean pressure decrease ratio is a load-independent measure, which was previously used for the detecting and grading of aortic valve stenosis. We assessed the usefulness of this method for the evaluation of aortic valve prosthesis obstruction. One hundred fifty-four patients with aortic valve prostheses were included in this study. Transthoracic and transesophageal echocardiographic examinations were performed in all the patients. Peak velocity and velocity time integral of the aortic valve and left ventricular outflow tract, peak and mean aortic valve pressure gradients, peak-to-mean pressure gradient ratio, and time velocity integral [TVI] index were measured. There was a significant relation between the TVI index [p value<0.001] and aortic prosthesis obstruction. A TVI index<0.2 had a sensitivity of 71% and specificity of 100% for the detection of aortic valve prosthesis obstruction. However, no significant relation was found between the peak-to-mean pressure ratio and aortic valve prosthesis obstruction [p value=0.09]. Although the peak-to-mean pressure gradient [PG/MG] ratio is a simple, quick, and load-independent method which may be useful for the grading of aortic valve stenosis, it is poorly associated with aortic valve prosthesis obstruction. The TVI index is a useful measure for the detection of aortic prosthesis obstruction

Post-surgical right ventricular pseudoaneurysm presenting as and epigastric pulsatile mass

We report a case of right ventricular pseudoaneurysm three weeks after open mitral valve commissurotomy. Transthoracic echocardiography showed a cavity of approximately 5 x 3 cm contiguous to the right ventricular inflow, communicating with the right ventricle by a small neck. Doppler study showed the presence of systolic and diastolic flow at the site of the rupture. Pseudoaneurysm is an infrequent surgical complication involving right ventriculotomy and often increases progressively in size. The association with open mitral valve commissurotomy has not been previously reported

Evaluation of longitudinal right ventricular mechanical dyssynchrony before and early after cardiac resynchronization therapy: a strain imaging study

The right ventricular [RV] dyssynchrony has not been extensively and the existing literature has established the effect of cardiac resynchronization therapy [CRT] on the left ventricular [LV] dyssynchrony, but there is a death of data on the effect of CRT on the forgotten ventricle. We sought to evaluate the presence of mechanical right ventricular dyssynchrony in patients with systolic heart failure, selected for CRT, and track the changes early afterward utilizing the longitudinal strain analysis. Thirty-six patients with severe left ventricular systolic dysfunction, candidated for CRT, were enrolled in this study. Mechanical dyssynchrony was assessed using tissue Doppler echocardiography. The time interval between the onset delay was calculated as the absolute value of the difference in the time-to-peak measurements between the RV and spetum. The RV dyssynchrony was defined as the calculated delay in strain imaging, which was +/- 2 SD above the mean value for the control subjects [20 cases]. The RV function was evaluated using the RV fractional area change [RVFAC], tricuspid annulus plane systolic excursion [TAPSE], and peak systolic strain values of the RV free wall. Four to 7 days after CRT implantation, echocardiographic reevaluations were done. The calculated cut-off value for the RV dyssynchrony was 41.5 msec, according to which the pre-CRT analysis specified two patient groups: Group 1 [16 cases] with RV dyssynchrony and Group 2 [20 patients] without RV dyssynchrony. Significant improvement in the RV dyssynchrony was noted in Group 1 after CRT [30 +/- 28.9 msec vs. 68.8 +/- 21 msec; p value <0.01 vs. 14 +/- 10 msec vs. 19 +/- 16.5 msec; p value = 0.18 respectively]. A significant correlation was found between the severity of the RV dyssynchrony and peak systolic strain in the RV free wall [r = -0.5; p value <0.05]. No significant relation was found between the RV dyssynchrony and right ventricle fractional area change [RVFAC], LV mechanical dyssynchrony, time-to-peak systolic strain in the RV free wall, QRS width, or morphology. In group I, the peak systolic strain increased insignificantly [p value = 0.15 for the basal segment; p value = 0.20 for the mid segment]. A moderately significant correlation was found between the RV mechanical delay before CRT vs. the post-CRT values [r = 0.4; p value = 0.01]. Early after CRT, the RV mechanical delay can improve and the significant improvement is seen in patients with baseline RV mechanical dyssynchrony

Anterior leaflet augmentation: an effective method to repair tricuspid valve regurgitation

As an invaluable surgical tool, autologous pericardium has been successfully used to repair many cardiac lesions. The encouraging results from its use in repairing heart valves have been applied to repair tricuspid valve regurgitation [TR]. In the present study, we report our preliminary results using autologous pericardium as an alternative surgical technique in repairing tricuspid valve insufficiency. From June 2002 to November 2006, 22 patients [mean age 39.7 years] with heart valve disease underwent tricuspid valve repair by anterior leaflet augmentation with glutaraldehydetreated autologous pericardium. Nineteen patients [86.4%] had pure tricuspid valve regurgitation [TR], while the remaining three patients [13.6%] had significant associated tricuspid valve stenos is in whomcommissurotomy was carried out. TR was considered severe in 18 patients and moderate to severe in four cases. All had associated left-sided heart valve surgery, except two patients. Concomitant adjustable tricuspid annuloplasty by pericardial band was performed in 12 patients. The mean follow-up period was 10.39 months [range 1 to 42 months]. There was one in-hospital death due to postoperative multiorgan failure. One patient developed partial detachment of the pericardial patch, which was successfully repaired. Echocardiography data showed a significant decrease in the severity of TR: trivial to mild in 68.2% [n=15], mild to moderate in 22.7% [n=5], and moderate to severe in 9.1% [n=2] of the patients. Anterior tricuspid leaflet augmentation is a safe, effective and appealing surgical technique in dealing with patients with tricuspid valve regurgitation. Further studies are, however, mandatory to evaluate its long-term outcome

Evaluation of the relation between anterior mitral valve leaflet motion based on height-to-length ratio and the immediate outcome of percutaneous balloon mitral valvuloplasty

The purpose of this study was to investigate whether there is any relation between mitral leaflet motion based on height-to-length ratio of the anterior mitral valve leaflet doming in diastole and the immediate outcome of balloon mitral valvuloplasty,. The study population consisted of 49 patients [47 women, mean age: 43.7 +/- 13.35 years] with symptomatic rheumatic mitral stenosis who underwent balloon valvuloplasty. Complete transthoracic and transesophageal studies were performed in all the patients before valvuloplasty, and transthoracic study was repeated 24-48 hours after valvuloplasty. The severity of the restriction of the mitral valve leaflet motion was classified based on the heightto- length ratio of the anterior mitral valve leaflet doming. Mitral valve thickness, calcification, subvalvular thickening, and mobility were scored according to the Wilkins system. Optimal immediate outcome of balloon mitral valvuloplasty was defined as a valve area improvement of 50% or more or a final mitral valve area of >/= 1.5 cm[2] and mitral regurgitation Sellers' grade >/= 2. There was a significant relation between the total mitral valve score and its thickness with the optimal immediate post-balloon mitral valvuloplasty results [p value=0.03 and 0.04, respectively], but no relation was found between the Wilkins score and its components with the anterior mitral valve leaflet height-to-length ratio. There was no significant relationship between the amount of increase in the mitral valve area, decrease in trans-mitral pressure gradients, decrease in pulmonary artery pressure, and anterior mitral leaflet height-to-length ratio [all p values>0.05; all the correlation coefficients<0.2]. Our study showed that post-balloon mitral valvuloplasty results are mainly affected by valve thickness and the total Wilkins score. In addition, the severity of mitral leaflet motion restriction in terms of the height-to-length ratio of the anterior mitral valve leaflet has no significant relation with the immediate result of balloon mitral valvuloplasty

Evaluation of the ventricular mechanical dyssynchrony in patients with artrial septal detect

There is some evidence indicating improvement in myocardial performance after atrial septal defect closure, either device closure or surgical, but ventricular dyssynchrony has not been evaluated before and after surgical closure. The aim of this study was to evaluated ventricular mechanical dyssynchrony in patients with artrial septal defect before and after surgical closure. Twenty patients [mean age: 23 +/- 11 years] with isolated secundum or sinus venosus type artrial septal defect, unsuitable for device closure, were evaluated before and after successful surgical closure. Interventricular and intraventricular dyssynchrony [using 6 basal and 6 mid-segmental models] were determined. A significant reduction in the right atrial and right ventricular dimensions and the tricuspid regurgitation peak gradient was noted after atrial septal defect closure [3.6 +/- 0.54 cm versus 4.2 +/- 0.7, P=0.009; 3.5 +/- 0.29 cm versus 4.3 +/- 0.41, P=0.02; and 20.4 +/- 10.5 mmHg versus 35.3 +/- 6.5, P<0.002; respectively]. There was no significant difference in the maximum difference in time-to-peak systolic velocity and the standard deviation of time-to-peak systolic velocity of the 12 left ventricular myocardial segments in the patients with atrial septal defect before and after surgical closure in comparison with the normal subjects [normal; 26 +/- 10.64 ms versus before closure: 21.0 +/- 33.9 versus after closure: 27 +/- 29.5, both P=0.68] and the left ventricular asynchrony index after atrial septal defect closure [normal: 14.9 +/- 8.7 versus before closure: 11.46 +/- 8.5 versus after closure: 18.12 +/= 13.6, both P=0.2]. There was a significant positive relation between the tricuspid regurgitation peak gradient and the left ventricular asynchrony index [r= 0.67, P=0.03] and an insignificant negative relation between the left ventricular ejection fraction and the asynchrony index before atrial septal defect closure [r= -0.53, P= 0.11]. No significant relation was found between the total asynchrony index and the atrial septal defect size, the degree of left-to-right shunt, and the tricuspid regurgitation peak gradient. There was no significant ventricular dyssynchrony in the patients with atrial septal defect before and after surgical closure

Echocardiographic Characteristics Including Tissue Doppler Imaging After Enhanced External Counterpulsation Therapy

The aim of this study was to echocardiographically assess the effects of EECP [Enhanced External Counterpulsation Therapy] therapy on systolic and diastolic cardiac function. LVEF [left ventricular ejection fraction], ESV [end-systolic volume], EDV [end-diastolic volume], Sm [myocardial systolic wave], Ea [myocardial early diastolic wave], Vp [propagation velocity], E/Ea [peak early diastolic transmitral flow velocity/Ea], E/Vp and diastolic function grade were studied in twenty-five patients before and after 35 hours of EECP. EECP reduced ESV and EDV and increased EF significantly [p=0.018, 0.013, 0.002, respectively] in patients with baseline LVEF 50%. Patients with E/Ea >/= 14 had a significant reduction in EDV and ESV [p=0.038 and 0.32, respectively] and an increase in LVEF [p=0.007] after EECP, whereas patients with baseline E/Ea<14 had no significant change in these parameters. Similarly, EECP significantly improved ESV, EDV and LVEF [p=0.014, 0.032, 0.027 respectively] in patients with grades II and III of diastolic dysfunction [decreased compliance] at baseline, but not in patients with normal diastolic function or grade I diastolic dysfunction [impaired relaxation]. Patients with Ea<7 cm/sec prior to EECP showed significant improvement in EDV, ESV and LVEF after therapy [p=0.024, 0.015, 0.001], while patients with Ea >/= 7cm/sec showed no significant change. Similarly, patients with Sm<7cm/sec prior to EECP showed significant improvement in EDV, ESV and LVEF after EECP [p=0.016, 0.017, 0.006], while patients with Sm >/= 7 cm/sec did not. These results provide new insight into the hemodynamic effectiveness and potential clinical applications of EECP