Challenging in pulmonary thromboembolism diagnosis in patients with disproportionate pulmonary hypertension and severe mitral stenosis: Report of two cases.

Key Clinical Message: Before valvular interventions, echocardiography, especially the TEE or the ventilation/perfusion scan, should be performed to detect silent PTE and set a more accurate treatment and surgical plan. Abstract: Pulmonary hypertension (PH) is a progressive and critical disease that can be caused by mitral stenosis (MS). Some of these patients present with disproportionate PH, which is an uncommon phenomenon and is considered a challenging diagnostic and treatment process. In these patients, other causes may also play a role in developing PH. This report presented two cases with disproportionate PH and severe MS who were scheduled for percutaneous mitral valvuloplasty (PMV). The pre-procedural echocardiography revealed systolic pulmonary artery pressure (sPAP) of 90 and 120 mmHg, mitral valve area of 0.80 and 0.55 cm2 by three-dimensional (3D) planimetry, and diastolic pressure gradient (DPG) of 13 and 18.8 mmHg, respectively. Furthermore, in the first patient, 3D transesophageal echocardiography (TEE) revealed multiple saddle-type organized thrombi in the proximal parts of the right and left pulmonary arteries, extending to the distal branches. In the second patient, 3D TEE revealed a large, relatively fresh, flow-limiting thrombosis in the proximal part of the right pulmonary artery. The diagnosis of pulmonary thromboembolism (PTE) in both patients was confirmed by CT angiography. In both patients, the valves were surgically repaired, while all thrombi were removed from the cardiac chambers and pulmonary vessels during surgery. In addition, patients underwent warfarin therapy orally. They were followed up 6 months after the intervention, and their clinical symptoms had improved significantly.

Determining whether LV filling time contributes to HF symptoms in different widths of QRS in LBBB patients: A clinical study.

OBJECTIVES: Accurate assessment of left ventricular (LV) function is essential for managing patients with left bundle branch block (LBBB). This study aimed to evaluate the relationship between LV systolic function, left ventricular diastolic filling time (LVFT), QRS duration, and heart failure symptoms in patients with LBBB. METHODS: This study was conducted between June 2021 and June 2022. Patients with LBBB and sinus rhythm who were referred to the echocardiography department were included in the study. All the patients underwent electrocardiogram-gated echocardiography using the same machine. In this study, the LVFT value was measured in absolute terms and as a ratio to the R-R interval (LVFT/RR). RESULTS: A total of sixty-five patients were included, forty-two (64.6%) were women, and the mean age was 60.71 ± 8.72. We performed three one-way ANOVA tests that showed that LV filling time/RR ratio, QRS duration, and ejection fraction were significantly different between heart failure classes (p = 0.008, p = 0.001, and p < 0.001, respectively). A weak correlation was observed between LVEF and LVFT/RR (r = 0.349, p = 0.004). Additionally, QRS duration was negatively correlated with LVEF (r =  - 0.395, p = 0.004) and LVFT/RR (r =  - 0.350, p = 0.004), although these correlations were weak. CONCLUSION: We showed that LVFT/RR ratio differed significantly between HF functional classes and was lower in patients with more severe HF symptoms. Additionally, QRS duration was negatively correlated with LVEF and LVFT/RR, and patients with more severe HF symptoms had longer QRS durations.

Assessing cardiac power output values in a healthy adult population.

Cardiac power output (CPO), which combines pressure and flow capacities, directly measures the heart's pumping capability. It is proposed as a superior alternative to ejection fraction in assessing cardiac function. However, there is a lack of data on CPO in healthy individuals, prompting a study to determine the cardiac power output in healthy adults in the Iranian population. This cross-sectional descriptive study investigated cardiac power in a sample of healthy individuals. Participants were recruited from healthy individuals referred to the Echocardiography department using convenience sampling. In this study, we examined the echocardiographic parameters in 173 individuals, of which 52% were men. Men exhibited significantly higher values for stroke volume, cardiac output, and cardiac power output (CPO) in both ventricles, as well as larger body surface area (BSA) and systemic mean arterial pressure (MAP), compared to women. Individuals under the age of 40 had significantly higher BSA and right ventricular cardiac output compared to those aged 40 or above. Multivariate analysis revealed that MAP, left ventricular (LV) cardiac output, LVCPO, pulmonary MAP, right ventricular (RV) CPO, and RV cardiac power index (CPI) were significant predictors of LVCPI changes. Our findings emphasize the importance of cardiac power output as a comprehensive measure of cardiac function, complementing the traditional use of ejection fraction. Further research is warranted to validate these results, establish accurate reference ranges, and explore the clinical implications of cardiac power output in various patient populations.

Vegetation Formation and Aortitis as a Possible Sequela of COVID-19 in a Patient with an Aortic Stent: A Case Report.

Bacteria, especially staphylococcal groups, cause aortic graft infection. Infection stems from synthetic materials that repair aneurysms or artery blockages. Aortic stent infection and vegetation formation are rare, and heterogeneous presentations and ambiguous findings in routine diagnostic modalities render the diagnosis challenging. A 25-year-old man with a history of catheter-based aortic stenting for hypertension associated with severe aortic coarctation was referred to our tertiary care hospital. Five months before the presentation, the patient had been infected with COVID-19, but he recovered after mild symptoms. Nevertheless, 3 months later, he developed erythematous lesions, progressive anorexia, epigastric pain, fever, and weakness. The results of blood tests, blood cultures, transthoracic echocardiography, plain chest radiography, computed tomography angiography, and electrocardiography were unremarkable. We found severe infectious aortitis, crescent thickness surrounding the aorta, pseudoaneurysm development, and a mass with dimensions of 17 mm×8 mm within the aortic stent on transesophageal echocardiography (TEE). Broad-spectrum antibiotic therapy was initiated, and the patient was transferred to the operating room, where the infected stent and adhesive vegetation were removed. The patient recovered remarkably after the surgery and was discharged. At 6 months' follow-up, he was in good condition. Our findings highlight the significance of maintaining vigilance and a high level of clinical suspicion for the possibility of vegetation formation and aortitis as the possible sequelae of COVID-19, particularly in patients with an implanted stent. Furthermore, we strongly suggest TEE in patients with implanted stents to detect vegetation and aortitis.

Conventional and two-dimensional strain echocardiography in predicting postoperative atrial fibrillation after coronary artery bypass grafting surgery.

Background: Atrial fibrillation (AF) is a common complication after heart surgeries. Advances in imaging technologies and an understanding of the pathophysiology of preoperative left atrial (LA) dysfunction can lead to more definitive potential therapeutic approaches. This study aimed to determine the role of conventional echocardiography and LA two-dimensional (2D) strain echocardiography in assessing LA function and predicting POAF after CABG surgery. Methods: All patients with sinus rhythm who underwent CABG surgery were enrolled. All the patients had undergone conventional echocardiography and LA 2D-strain echocardiography 24 hours before surgery. In addition to demographic, clinical, and perioperative features, electrocardiogram (ECG) and Holter monitoring were recorded. Results: Of the 105 patients included, 85 patients (81%) were men with a mean age of 60.26±10.61 years. POAF was seen in 22.9% of patients during hospitalization, and AF duration was 10 hours (median; IQR: 2.0-19.5). AF patients had a higher LA volume index (LAVI) than patients with sinus rhythm (p=0.018). Patients with sinus rhythm had higher rates of LA reservoir (26.97±6.87 VS. 20.46±4.27, p<0.001), LA contractile (14.98±3.68 VS. 12.76±3.72, p =0.012) and LA global strain (24.28±6.57 VS. 17.71±4.11, p<0.001) than AF patients. The results of the multivariate logistic regression showed that LAVI (p=0.014) and LA global strain (p=0.027) were independent predictors of AF detection. Conclusion: Compared to conventional echocardiography, 2D-strain echocardiography is a more effective diagnostic method to predict the possibility of post-CABG AF.

Measurement of mitral valve area by direct three dimensional planimetry compared to multiplanar reconstruction in patients with rheumatic mitral stenosis.

Mitral valve area (MVA) measurement by three-dimensional transesophageal echocardiography (3D-TEE) has a crucial role in the evaluation of mitral stenosis (MS) severity. Three-dimensional direct (3D-direct) planimetry has been proposed as a new technique to measure mitral valve area. This study aimed to compare the 3D-direct mitral valve planimetry to conventional three-dimensional multiplanar reconstruction (3D-MPR) in severe MS using 3D-TEE. In this cross-sectional, prospective study; 149 patients with severe MS who were referred for transesophageal echocardiography in Shahid Madani Hospital (Tabriz Iran), just before percutaneous transmitral commissurotomy (PTMC), recruited consecutively. All patients underwent 2D transthoracic echocardiography (2D-TTE) and 3D-TEE in a single session before PTMC. During 2D-TTE planimetry, pressure half time (PHT), and proximal isovelocity surface area (PISA) were applied to measure the MVA. Transmitral mean pressure gradient (MPG) was measured. During 3D-TEE, MVA planimetry was carried out with both 3D-direct and 3D-MPR methods. 3D-direct was applied from both atrial and ventricular views. The consistency of MVA measurements with 3D-direct, 3D-MPR, and 2D-TTE methods was statistically investigated. Our sample consisted of 109 (73.2%) women and 40 (26.8%) men. The mean age was 51.75 ± 9.81 years. The agreement between 3D-direct and 3D-MPR planimetry was significant and moderate (0.99 ± 0.29 cm2 vs. 1.12 ± 0.26 cm2, intraclass correlation = 0.716, p value = 0.001).The accuracy of the 3D-direct method reduced significantly compared to the MPR method at MVA > 1.5 cm2. The maximum difference between two methods was observed in cases with MVAs larger than 1.5 cm2. MVA measured with the 3D-MPR method was significantly correlated with a 2D-TTE method, with a moderate agreement (intraclass correlation = 0.644, p value = 0.001). Also, 2D-TTE and 3D-direct TEE techniques yielded significantly consistent measurements of the MVA (1.06 ± 0.026 cm2 vs. 0.99 ± 0.29 cm2, intraclass correlation = 0.787, p value = 0.001); however, with a slight overestimation of the MVA by the former with a net difference of 0.06 ± 0.013 cm2. Mitral valve pressure gradient (MPG) had no significant correlation with planimetry results. A significant inverse correlation was seen between the MVA and pulmonary arterial systolic pressure. 3D-direct planimetry has an acceptable agreement with 3D-MPR planimetry at MVA less than 1.5 cm2, but their correlation decreases significantly at MVA above 1.5 cm2. 3D-direct planimetry underestimates MVA compared to 3D-MPR, especially at MVA above 1.5 cm2. It seems that the saddle shape of mitral valve, interferes with 3D-direct measurement of commissures at moderate MS. The 2D-TTE planimetry has generally acceptable accuracy, but its correlation to the 3D-TEE methods is significantly reduced in cases with moderate to severe MS (i.e. MVA > 1.0 cm2).

New solution for old challenge: Device closure of non-centrally positioned atrial septal defect.

Multiple interatrial defects, termed fenestrated ASDs that require closure are not uncommon. The problem arises when a centrally located defect or a patent foramen oval (PFO) is associated with another peripherally located defect. In cases like this, all attempts at crossing the true defect might totally fail or might be difficult because the wire or the catheter crosses the central defect repeatedly despite the use of a sizing balloon. In order to overcome such an issue, we introduce a new technique by which not only the procedure and the fluoroscopy time will be reduced, but also it ceases the mistakes about the number of defects, their size and location.

Aortic shelf as a normal variant diagnosed primarily as the aortic dissection: A case report.

Traumatic aortic dissection is most commonly caused following sudden deceleration injury. It most commonly involves descending thoracic aorta (DTA) and is associated with high mortality and morbidity if not treated urgently. Confirmation of diagnosis often requires contrast-enhanced computed tomography (CECT) or magnetic resonance imaging (MRI), which is time consuming, expensive, and often not available at many health-care facility. Transesophageal echocardiography (TEE) is equally efficient to CECT and MRI in diagnosing aortic dissection. It may also provide additional information that can be very useful for the management of the patient. In some cases, the likelihood of error in the diagnosis of such a critical condition with normal cardiovascular variations is expected. Herein, we describe a case with primary diagnosis of aortic dissection that led to final diagnosis of an aortic shelf that medically managed with a good long-term prognosis. In patients suspected to aortic dissection due to any cause, the specialized evaluation using the most accurate and sensitive tools is strongly recommended to discriminate normal vascular variations from major vascular defects requiring emergent surgical interventions.

The Iranian Society of Echocardiography (ISE) Statement on Performing Echocardiography During the COVID-19 Pandemic.

Corona virus disease 2019(COVID-19) pandemic has caused a significant burden on the global health system. Considerable cardiovascular involvement has been reported among COVID-19 patients with higher ICU admission and mortality rates among patients with cardiovascular comorbidities. Consequently, diagnostic cardiovascular evaluations such as echocardiography are a crucial part of the disease management. On the other hand, providing safety for the patients and the healthcare personnel is a matter of great concern in the pandemic state. In this document, we have provided recommendations on performing echocardiography in hospital echocardiography labs and outpatient echocardiography clinics during the current COVID-19 (Coronavirus disease of 2019) outbreak.

Left Atrial Malignant Fibrous Histiocytoma with Right Atrium Invasion.

BACKGROUND: Primary cardiac tumors are rare (0.001 to 0.03%). Malignant tumors account for 25%, of which 75% are cardiac sarcomas. CASE PERSENTATION: Here, we report a case of a 57-year-old male with palpitation and history of left atrial (LA) myxoma resection presented to cardiology clinic for postsurgical follow up and transthoracic echocardiography revealed a large non-homogenous mass in LA with right atrium invasion, which was confirmed by trans-esophageal echocardiography. The patient underwent surgical resection of tumor and the pathological diagnosis was malignant fibrous histiocytoma (MFH). CONCLUSION: MFH could be asymptomatic and the diagnosis be established as a surgical or complementary examination. In patients with history of myxoma resection and cardiac masses, further evaluation is recommended.

Evaluation of relationship between bicuspid aortic valve phenotype with valve dysfunction and associated aortopathy.

Introduction: Morphology of bicuspid aortic valve (BAV) may have implication in the associated pathologies including aortic stenosis (AS), aortic insufficiency (AI) and aortic dilation. The aim of this study is to investigate the frequency and patterns of valvular dysfunction and aortopathy associated with different phenotypes of BAV in a referral center in northwest of Iran. Methods: In this prospective study patients who presented to our echocardiography lab between January 2014 and December 2015 and were diagnosed with BAV were assessed. Frequency of various BAV phenotypes and their association with valvular dysfunction and aortopathy was evaluated. A P value less than 0.05 was considered statistically significant. Results: The average age of the study patients was 40±16 years, with predominance of male sex (72%). Patients with anteroposteriorly located BAV (BAV-AP) phenotype constituted majority of our cases with prevalence of 62.7%, while 37.3% of cases had right-left (BAV-RL) located valves. BAV-RL patients when compared to BAV-AP patients had higher frequencies of dilated aortic arch (25% vs. 4.3%, P < 0.001), AS (56.3% vs. 31.4%, P < 0.001), mass or vegetation on aortic valve (14.3 vs. 6.4%, P = 0.023) and lower frequencies of dilated aortic root (42.9% vs. 57.4%, P = 0.01), aortic insufficiency (68.8% vs. 79.8%, P = 0.034) and co-arctation of aorta (3.6% vs. 11.7%, P = 0.01). Conclusion: There seems to be a relationship between various BAV phenotypes, and frequency and pattern of aortic valve dysfunction and aortopathy. These findings suggest that examining leaflet morphology in BAV might help in risk stratification of these patients.