Systolic Murmur Due to Systolic Gradient Across Moderator Band.

A 14 years asymptomatic male was evaluated for a grade 3/6 systolic murmur along lower left parasternal region. Color Doppler evaluation revealed turbulent systolic flow across moderator band with a peak systolic gradient of 127.2 mm hg. There was no other abnormality. This anomaly should be considered in differential diagnosis of systolic murmur in tricuspid area.

Rhythmic pulsations in inferior vena cava in pericardial constriction.

A case of pericardial constriction with rhythmic, nonrespiratory pulsations in inferior vena cava is presented. Hepatic vein flow showed wave form classical of pericardial constriction. Backward transmission of changes in right atrial pressure resulted in rhythmic, nonrespiratory pulsations in inferior vena cava. This echocardiographic finding could help in diagnosis of pericardial constriction.

Diagnosis of coronary microvascular dysfunction - Present status.

Definite clinical diagnosis of microvascular angina is not possible with the existing knowledge. Resting electrocardiogram may be normal, and exercise electrocardiogram may be unremarkable. Echocardiography usually does not show regional wall motion abnormalities. Transthoracic Doppler echocardiography can satisfactorily evaluate only left anterior descending coronary artery and that too in some patients. Radio-isotope imaging can detect only severe localized disease. Noninvasive diagnosis needs high index of suspicion. At present, definite diagnosis is based on documentation of normal epicardial coronaries, coronary flow reserve less than 2.5 on adenosine induced hyperemia, and absence of spasm of epicardial coronaries on acetylcholine provocation. Invasive evaluation is costly, needs sophisticated equipments and expertise. Therapeutic and prognostic implications of various parameters remains to be evaluated. At present invasive evaluation is recommended only for patients with intractable symptoms with unconfirmed diagnosis, requiring repeated hospitalization and evaluation with failure of empirical therapy.

Presystolic flow in ascending aorta in a case of left ventricular diastolic dysfunction.

A 65 years old hypertensive presented with effort breathlessness. Echocardiography revealed significant concentric remodeling of left ventricle. (relative wall thickness - 0.86) with significantly impaired relaxation (E/A - 0.54 and Ea/Aa - 0.52). Doppler evaluation of flow in ascending aorta revealed a presystolic flow which coincided with P wave of ECG and A wave of mitral flow. This finding suggests increased stiffness of left ventricle resulting in significant increase in left ventricular pressure during left atrial contraction and presystolic flow in aorta. Our case shows that all cases of grade 1 diastolic dysfunction are not alike. Presystolic flow in ascending aorta suggests greater degree of diastolic dysfunction than what is apparent from conventional criteria.

Superdominant right coronary artery with double posterior descending artery.

Coronary artery anomalies are rare entities. All angiographers and cardiac surgeons need to be familiar with these anatomic variants for proper surgical revasularisation in the presence of coronary artery disease. We report here an interesting case of superdominant right coronary artery with double posterior descending artery.

Slow junctional rhythm, QTc prolongation and transient torsades de-pointes following combined use of Ivabradine, Diltiazem and Ranolazine.

A case of unstable angina developed slow junctional rhythm with QTc prolongation and transient Torsades de pointes following simultaneous use of Ivabradine, Diltiazem and Ranolazine. Effect of Diltiazem on hepatic isoenzyme CYP 3A could be responsible. Such a combination should be avoided.

Post stress tissue Doppler imaging can identify false positive exercise electrocardiogram.

Post stress tissue Doppler imaging can diagnose false positive response on exercise electrocardiography. Tissue Doppler imaging thus provides additional useful parameter to increase specificity of stress testing for evaluation of coronary artery disease.

Occult constrictive pericarditis.

Four cases of occult pericardial constriction are presented. This condition is not uncommon, but needs high index of suspicion. Integration of detailed echocardiographic evaluation in a given patient with diseases known to cause pericardial involvement can clinch the diagnosis.

Etiopathogenesis of microvascular angina: caveats in our knowledge.

Nearly 50% of subjects of coronary artery disease suffer from coronary microvascular dysfunction. Various etiopathogenetic factors have been proposed by different workers but no hypothesis can explain the genesis of microvascular angina in all patients. We have made an attempt to review the literature to find caveats in our knowledge so that future studies can be better designed.

Mild mitral and tricuspid regurgitation secondary to pericardial constriction.

A 26 years female presented with pericardial effusion. On follow up she developed pericardial constriction with new appearance of mild mitral and tricuspid regurgitation without any other pathology. Fibrosis along posterior atrioventricular groove could be responsible for regurgitation.

Efficacy of post exercise pulsed wave tissue velocity imaging in diagnosing more than 70% coronary artery stenosis.

BACKGROUND: To evaluate efficacy of post exercise tissue velocity imaging in diagnosing more than 70% coronary artery stenosis. METHOD: Twenty patients with angiographically proved significant coronary artery disease and 26 healthy controls were evaluated. Pulsed wave tissue velocity imaging was performed at rest and immediately after treadmill stress test. Medial and lateral part of mitral annulus and medial and lateral part of tricuspid annulus were evaluated. RESULT: No change or reduction in systolic annular velocity after exercise at any of the four sites identified patients of significant coronary artery disease with 75% sensitivity and 73% specificity. Rise in the ratio of early diastolic inflow velocity to the corresponding early diastolic annular velocity above the identified site-specific cut-off value had sensitivity of 85% but specificity of 34.6%. A combination of no change or decrease in late diastolic annular velocity and no change or decrease in systolic annular velocity at any of the four sites had sensitivity of 75% and specificity of 88.46%. CONCLUSION: Post exercise tissue velocity imaging can provide a useful, objective parameter for detection of ischemic heart disease on stress testing.

Acute myocardial infarction in a 20 year pregnant female with prosthetic mitral valve.

Myocardial infarction is very uncommon in young females. We are reporting a case of acute myocardial infarction in a 20 year pregnant female with prosthetic mitral valve. Embolism from mitral valve prosthesis, in-situ thrombosis due to hypercoagulable state of pregnancy or coronary spasm could be responsible.

Mean arterial pressure may affect LV mass even when clinic BP is 120/80 mmHg or less.

Detailed echocardiographic evaluation was performed on sixty-four normal persons without any cardiovascular risk factor and clinic blood pressure of 120/80 mm of Hg or less with an aim to find, if there are subclinical echocardiographic changes even in this population. There was significant positive linear correlation between mean arterial pressure and LV mass index. On dividing the patients according to mean arterial pressure, those with mean arterial pressure of more than 85 had significantly higher LV mass index (P <0.01).There may be a relationship between mean arterial pressure and LV mass index in this population, but this needs to be further explored in a larger study.

Isolated calcification of tricuspid valve with severe low pressure tricuspid regurgitation in an infant.

A three-month-old asymptomatic male infant was evaluated for a systolic murmur. Echocardiography revealed calcification of tricuspid leaflets with severe low pressure tricuspid regurgitation. Pulmonary artery flow was normal. There was no other congenital anomaly.

Tetralogy of Fallot with quadricuspid aortic valve.

We describe herein a 54 year female who had tetralogy of Fallot with quadricuspid aortic valve. This combination is very uncommon. Hence it was worth reporting this interesting case.

Transient pericardial constriction.

A patient with idiopathic pericardial effusion is reported. Patient developed transient constrictive hemodynamics which recovered with continued empirical use of antitubercular drugs and prednisolone.

Inferior sinus venosus atrial septal defect.

One case of inferior vena cava type sinus venosus defect is reported. It is likely to be missed on transthoracic echocardiography. Transesophageal echocardiography is useful. Unlike superior sinus venosus defect which are easily visible on transesophageal echocardiography, a careful search is needed to detect inferior sinus venosus defects. All patients with unexplained right ventricular volume overload on transthoracic echocardiography should have transesophageal echocardiography to see for sinus venosus atrial septal defects.