Assessment of subclinical left ventricular dysfunction in patients with chronic mitral regurgitation using torsional parameters described by tissue doppler imaging

Left ventricular [LV] twist is due to oppositely directed apical and basal rotation and has been proposed as a sensitive marker of LV function. We sought to assess the impact of chronic pure mitral regurgitation [MR] on the torsional mechanics of the left human ventricle using tissue Doppler imaging. Nineteen severe MR patients with a normal LV ejection fraction and 16 non-MR controls underwent conventional echocardiography and apical and basal short-axis color Doppler myocardial imaging [CDMI]. LV rotation at the apical and basal short-axis levels was calculated from the averaged tangential velocities of the septal and lateral regions, corrected for the LV radius over time. LV twist was defined as the difference in LV rotation between the two levels, and the LV twist and twisting/untwisting rate profiles were analyzed throughout the cardiac cycle. LV twist and LV torsion were significantly lower in the MR group than in the non-MR group [10.38° +/- 4.04° vs. 13.95° +/- 4.27°; p value = 0.020; and 1.29 +/- 0.54 °/cm vs. 1.76 +/- 0.56 °/cm; p value = 0.021, respectively], both suggesting incipient LV dysfunction in the MR group. Similarly, the untwisting rate was lower in the MR group [-79.74 +/- 35.97 °/s vs.-110.96 +/- 34.65 °/s; p value = 0.020], but there was statistically no significant difference in the LV twist rate. The evaluation of LV torsional parameters in MR patients with a normal LV ejection fraction suggests the potential role of these sensitive variables in assessing the early signs of ventricular dysfunction in asymptomatic patients

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%]

Tissue doppler imaging and doppler studies in patients with transmural and non-transmural myocardial infarction

Myocardial longitudinal shortening play an important role in cardiac contraction [1,2]. Tissue velocity imaging [TVI] is an ultrasonographic technique that measure myocardial motion and providing a quantitative agreement of left ventricular regional myocardial function in different modalities [3]. The present review discusses the most recent development in the application of TDI in coronary artery disease. Seventy patients with myocardial infarction [transmural and nontransmural] were included in the study. These subjects were diagnosed with recent myocardial infarction wall [septal side of mitral annulus] and basal segment of base of RV free wall were examined for tissue Doppler study with complete transthoracic echocardiography study. Mean age in group of inferior MI, anterior MI and non Q wave MI are as follows: 61.87 +/- 10.7, 57.04 +/- 10.7, 58.45 +/- 9.2. Sm was significantly reduced in anterior MI groups than non Q wave MI [PV=0.01]. In patients with inferior myocardial infarction 88% of patients had left ventricular ejection fraction [LVEF]>45% and in patients with anterior MI 18.2% patients had EF>45%. In non Q wave MI groups 60% patients had LVEF>45%. Except for Sm, other TDI parameters had no significant difference between two groups [transmural and nontransmural infarction] but it has significant changes in reduced left ventricle function and could be of determinants for prognosis

Right ventricular strain predicts functional capacity in patients with repaired tetralogy of Fallot

Echocardiography-derived strain rate and strain may provide new insights into right ventricular [RV] function in repaired tetralogy of Fallot [rTOF] patients in whom evaluation of RV function and functional capacity has an important role in further management. In 45 rTOF patients with severe pulmonary regurgitation. the routine echocardiography-derived indices for evaluation of RV function [TAPSE. RVOT Excursion and eyeball method] and longitudinal strain rate and strain were acquired from basal, mid and apical segments of RV free wall [RVFW] and interventricular septum; functional capacity was measured by standard Bruce protocol exercise testing. All patients had some degrees of RV dysfunction with no correlations between results of routine indices and functional capacity. Reduced RVFW average systolic strain was correlated directly with reduced functional capacity [r = 0.86[P <0.001], this was also true for peak systolic strain of basal and mid segments of RVFW. Derivation of ROC curves showed that a cut-off value of 15.8% for average RVFW systolic strain predicts good exercise capacity [>/= 10 METs] with a sensitivity of 91.2% and a specificity of 100%. Although routine echocardiography indices are not accurate tools in rTOF patients, systolic strain of RVFW seems to be reliable in estimation of RV function and functional capacity

Hydatid cyst mimicking heart tumor

We present two women who lived in a rural community. The presence of a semi-solid mass, a hydatid cyst or tumor, in the heart was diagnosed by echocardiography, computed tomography, and Magnetic Resonance Imaging. The hydatid cyst was seen during surgery. Pathological examination confirmed an infected hydatid cyst

Anomalous origin of the left coronary artery from the pulmonary artery [ALCAPA] in an old adult

The anomalous origin of the left coronary artery from the pulmonary artery [ALCAPA] is a rare congenital cardiac malformation. It presents predominantly in infancy and its main presenting feature is myocardial ischemia or heart failure. Survival to adulthood is quite uncommon. If untreated, mortality from ALCAPA approaches 90% in infancy; early recognition and surgical correction are, therefore, essential. With early surgical correction, the prognosis is good. There are two types of ALCAPA syndrome: the infant type and the adult type, each of which has different manifestations and outcomes. Infants experience myocardial infarction and congestive heart failure, and approximately 90% die within the first year of life. A literature review regarding this anomaly in teenagers and adults show that only 25 cases have been diagnosed during life and 18 additional cases of ALCAPA in these age groups have been diagnosed post mortem. We present a rare case of a 60-year-old man, who referred to our center due to dyspnea on exertion from the previous year without any history of chest pain and diagnosed as ALCAPA. Given the absence of ischemia and the patient's age, only medical therapy was recommended

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

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

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 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