Incidental detection of a benign thymoma on Tc-99m MIBI myocardial perfusion study.

UNLABELLED: Technetium-99m methoxy-isobutylisonitrile (Tc-99m MIBI) is a routinely used radiopharmaceutical for myocardial perfusion scintigraphy (MPS). It is also a tumor seeking agent. Here, we present a case of 51 year old male who underwent Tc-99m MIBI myocardial perfusion study due to permanent chest pain after coronary angiography. Abnormal MIBI uptake in the thorax was detected in the raw images. This single finding led to further investigation and thoracotomy proved that the lesion was benign thymoma. Thymomas are often asymptomatic or have a non-specific presentation. They are often detected coincidentally on images performed for any other reasons. We wanted to emphasize that during of MPS, the raw data should always be reviewed as occasionally valuable additional information on noncardiac pathology could be recognized by extracardiac uptake, as in this case. CONFLICT OF INTEREST: None declared.

Tricuspid valve thrombus: a case report associated with gonadotropin-releasing hormone analogue therapy and review of the literature.

A 35-year-old woman with a previously repaired atrial septal defect was referred for preoperative evaluation before laparoscopic surgery. The patient was asymptomatic, and a transesophageal echocardiographic examination revealed a probable thrombus attached to the tricuspid valve. The patient's history included therapy with a gonadotropin-releasing hormone analogue and deep venous thrombosis five months earlier. The tricuspid valve thrombus disappeared after anticoagulant therapy. Warfarin was initiated for prophylaxis. During the follow-up, the patient was event-free during laparoscopic surgery and pregnancy (when warfarin was switched to acetylsalicylic acid) and gave birth to a healthy term baby. Because etiological investigations revealed no reason for the tricuspid valve thrombus, it was considered to be related to the procoagulant state induced by hormonal treatment. The patient was scheduled for close follow-up.

[Hemodynamic performance of mechanical aortic valves in narrow aortic annulus cases]. / Küçük aortik annuluslu olgularda mekanik aort kapaklarinin hemodinamik performansi.

OBJECTIVE: Small-sized prosthetic valves used in aortic valve position usually cause a high transvalvular gradient. This situation, especially in people with a high body surface area, causes a patient-prosthetic valve mismatch. In this study, hemodynamic performances of the two new generation bileaflet, small size mechanical valves were evaluated during rest and stress conditions. METHODS: Eighteen patients with implanted 21-mm St. Jude HP (11 cases) and Sorin Bicarbon (7 cases) prosthetic valves in aortic position were evaluated at rest and during dobutamine infusion, 16.3+/-5.5 months after the operation. Dobutamine infusion was started at a dose of 5 microg/kg/min. The infusion rate was increased every 15 minutes up to 10-20-30 microg/kg/min. Maximum gradient, mean gradient, effective valve area (EVA), effective valve area index (EVAI) and performance index (PI) were calculated during rest and maximum dobutamine infusion rate. RESULTS: When the rest and dobutamine infusion measurements were compared, the maximum and mean gradients were found to be increased moderately, but EVA, EVAI, PI values did not change with increasing heart rates. For St. Jude valve; maximum gradient increased from 30.5+/-6.5 mmHg to 74.7+/-33.6 mmHg (p=0.03) and mean gradient increased from 17.9+/-3.8 to 40.8+/-23.8 mmHg (p=0.03). For Sorin Bicarbon valve; maximum gradient increased from 31.7+/-13.3 mmHg to 52.0+/-11.2 mmHg (p=0.01), mean gradient increased from 16.1+/-6.4 mmHg to 28.8+/-1.0 mmHg (p=0.01). The difference was not significant between the two valves with respect to measured parameters during rest and maximum dobutamine infusion. CONCLUSION: According to our findings, 21-mm Sorin Bicarbon and St. Jude HP mechanical bileaflet valves have good hemodynamic performance during exercise and these types of valves seem to be appropriate for patients with small aortic annulus.

The effect of pentoxifylline on haemolysis in patients with double cardiac prosthetic valves.

OBJECTIVE: Intravascular haemolysis frequently occurs in patients with mechanical heart valve prostheses. In this prospective study, we investigated whether pentoxifylline (PTX) has an effect on haemolysis following prosthetic valvular replacement in 40 patients who underwent double valve (mitral and aortic) replacement. METHODS AND RESULTS: The patients were randomly assigned to two groups as control (n = 20) and PTX group (n = 20). PTX was given in a daily oral dose of 1200 mg (3 times 400 mg) for 120 days. Laboratory tests for evidence of haemolysis namely, haemoglobin (Hb), haematocrit (Hct), plasma total bilirubin, indirect bilirubin and haptoglobin levels, corrected reticulocyte percent and serum lactic dehydrogenase activity (SLDH) were performed before and after the PTX treatment. PTX treatment caused significant increases in Hb, Htc, and haptoglobin levels (P < 0.05, P < 0.05 and P < 0.01, respectively). Additionally, there were significant decreases in SLDH, total and indirect bilirubin levels, and corrected reticulocyte percent in patients receiving PTX as compared with their respective control values (P < 0.01, for all). PTX treatment caused a significant improvement, to different extents, in signs of haemolysis in 60% of the patients. On the other hand, the response rate was 5% in the placebo-treated control group (P < 0.05). CONCLUSIONS: These findings suggest that PTX may be an effective agent in the management of haemolysis in patients with prosthetic heart valves.

[Noninvasive methods for the diagnosis of rejection after heart transplantation]. / Kalp Transplantasyonu Yapilan Olgularda Akut Rejeksiyon Tanisinda Kullanilan Noninvazif Yöntemler.

Acute rejection is a major complication after heart transplantation. Prognosis depends on early detection and effective treatment. Currently, the most reliable technique for the detection of acute cardiac rejection is endomyocardial biopsy (EMB). Because of invasive procedure, it is not suitable for daily monitoring. If the pattern of rejection shows a focal distribution, false-negative results can be expected. So far, many studies were performed to evaluate diagnostic value of noninvasive procedures in acute rejection, but none of them was found to be superior to EMB. Value of different noninvasive procedures in the diagnosis of acute rejection after heart transplantation is discussed in this review.

Echocardiographic predictors of hemodynamic response and significance of dyspnea development in patients with mitral stenosis during dobutamine stress echocardiography.

BACKGROUND AND AIM OF THE STUDY: In mitral stenosis (MS) patients, resting hemodynamic data do not always correlate with symptom severity. Stress tests may be carried out in these patients, but the mechanisms of different hemodynamic and clinical responses to stress are not clearly established. The study aim was to evaluate hemodynamic changes that correlate with dyspnea development during dobutamine infusion (DI) in patients with MS, and to assess determinants of transmitral gradient response. METHODS: Forty-five consecutive mild or moderately symptomatic patients (36 women, nine men; mean age 44 +/- 10 years; range: 26-66 years), in NYHA class II and with MS (mean mitral valve area (MVA) 1.6 +/- 0.1 cm2; range: 1.5-1.9 cm2) were evaluated with dobutamine stress echocardiography. RESULTS: During DI, dyspnea developed in 12 patients, and 33 patients remained asymptomatic. During infusion, both mean transmitral gradient (6 +/- 3 versus 11 +/- 6 mmHg, p = 0.01) and pulmonary artery systolic pressure (PASP) (13 +/- 4 versus 21 +/- 3 mmHg, p < 0.001) were significantly increased in patients who developed dyspnea compared to others. Hence, a subgroup of patients with more serious MS was identified using the hemodynamic response to dobutamine. Based on these clinical and hemodynamic results, management was changed in 12 patients (27%); five underwent percutaneous mitral balloon commissurotomy and seven received intensive medical treatment. In all patients, PASP at rest (p = 0.001), MVA (p < 0.0001) and subvalvular mitral score (p = 0.004), which is indicative of mitral valve damage, were significantly correlated with mean mitral valve gradient response. CONCLUSION: These results suggest that patients in whom dyspnea is provoked during DI show a greater increase in hemodynamic parameters than patients in whom provocation does not occur. The mean mitral valve gradient-response correlates with baseline pulmonary artery pressure, MVA and subvalvular echo score, and may be predicted by these parameters. Association between dyspnea and presence of severe mitral valve hemodynamics showed a high sensitivity and negative and positive predictive value. It is possible that dyspnea may be of value in identifying those patients with significant mitral valve obstruction.

Aorta-right atrial tunnel.

Aorta-right atrial tunnel is rare. We report a case of aorta-right atrial tunnel in which the right coronary artery arose from the tunnel. Successful surgical treatment was performed.

Left atrial function as a predictor of haemodynamic response in patients with mitral stenosis: a dobutamine stress echocardiographic study.

OBJECTIVE: The mechanisms of the different haemodynamic and clinical responses to dobutamine infusion in mitral stenosis (MS) are not clearly established. The aim of this study was to evaluate the relation between left atrial (LA) function and haemodynamic response in patients with MS during dobutamine infusion. METHODS AND RESULTS: Forty-two consecutive moderately symptomatic patients (33 women, 9 men; mean age 46+/-9, range from 26 to 66), New York Heart Association (NYHA) class II with MS (mean mitral valve area 1.7+/-0.1 cm2) were evaluated with dobutamine stress echocardiography. Haemodynamic measurements were obtained at rest and during peak dobutamine infusion. LA fractional shortening at rest was used as an index of global LA function. Group I consisting of patients with significantly elevated pulmonary artery pressure (> 60 mm Hg) and mean transmitral gradient (> 15 mm Hg) at peak dobutamine infusion were defined as haemodynamically serious MS. Group II consisted of the remaining 30 patients whose haemodynamic data were below these levels. While baseline haemodynamic parameters and mitral valve characteristics were not different between the two groups, LA fractional shortening was significantly lower (18.9+/-2.8 vs. 32.3+/-5.1%, p<0.0001) and left atrial dimension was significantly larger in group I (49.7+/-2.3 mm vs 43.6+/-5.3 mm, p<0.0001). Left atrial fractional shortening was negatively correlated with the increase in mean transmitral gradient (r:-0.58, p<0.01). When the patients were divided using a LA fractional shortening level of 25% as the cut-off point, we observed that the patients with low LA fractional shortening had a greater increase in mean transmitral gradient (7.3+/-3.1 mm Hg vs. 4.6+/-1.4 mm Hg), p = 0.005) and pulmonary artery pressure (22.4+/-3.5 mm Hg vs. 16.1+/-8.5 mm Hg, p = 0.001) compared to the patients with high LA fractional shortening. Based on these haemodynamic results, management was changed in 12 patients (28%): 5 underwent percutaneous mitral balloon commissurotomy and 7 received intensive medical treatment. CONCLUSIONS: The present study demonstrates that haemodynamic response during dobutamine stress echocardiography correlates with LA fractional shortening in patients with MS. The evaluation of left atrial function at rest in patients with ambiguous symptoms and mild mitral stenosis may be useful in clinical decision making. Atrial dysfunction at rest may predict the haemodynamic response during stress echo in these patients.

Cardiac relapse of squamous cell carcinoma of the maxillary sinus.

An unusual case of maxillary sinus carcinoma presenting with heart metastasis is reported. The epicardium, myocardium and endocardium were infiltrated with the tumor, but no evidence of recurrent maxillary sinus carcinoma and other organ metastasis was found. Surgical excision was not possible due to massive invasion of the heart by the tumor mass. The right ventricular inflow tract obstruction was relieved by surgical dilatation.

Successful transcatheter retrieval of an embolized stent from the left ventricle.

Systemic embolization complicating intracoronary stenting before deployment is a rare complication; although it was not associated with any clinical sequelae, great care should be taken to prevent this possibility. We report a case of the successful retrieval of an embolized stent from the left ventricle during percutaneous transluminal coronary angioplasty of a left anterior descending coronary artery.