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Abstract Unroofed coronary sinus (UCS) is an uncommon congenital heart anomaly and the most unusual type of atrial septal defect. This report presents a 71‐year‐old female with palpitation and dyspnea following an emotional stress, who was referred for ablation of typical atrial flutter. Finally diagnosed with a partially unroofed CS causing a bidirectional shunt.

PurposeInfective endocarditis (IE) remains a disease with high morbidity and mortality. The aim of this study was to determine the clinical characteristics and echocardiographic features of patients with IE.MethodsWe analyzed patients with either definitive or probable diagnosis of IE who were hospitalized in a teaching hospital in Mashhad, Iran between June 2011 and January 2020. Patients who survived were followed up by echocardiography for at least 6-month after hospital discharge.ResultsA total of 82 cases with IE were included of which 62 (75.6%) received definitive diagnosis. The mean age was 39.7 ± 18.7 years and 52 (63.4%) were male. The most common preexisting structural cardiac abnormality that predispose patients to IE were congenital heart diseases (28 %) of which bicuspid aortic valve was more common (n = 12, 14.6%), followed by ventricular septal defect (n = 9, 11%) and Tetralogy of Fallot (TOF) (n = 2, 2.4%). Three (3.6 %) cases had rheumatic heart disease and 12 (14.6 %) were injecting drug users. The most common causative pathogen was Staphylococcus aureus, detected in 7 (19.4%) cases. Follow-up echocardiography revealed right or left ventricular failure in 10 (12.1%) cases. Cardiac complications occurred in 41 (50%) cases and systemic complications in 63 (76.8%). All-cause mortality was 41.5% (n = 34) and 6 (18.1%) patients died due to cardiovascular complications.ConclusionsThe short- and long-term prognosis in IE was poor and the predictors for in-hospital and 1-year mortality were defined as heart failure and septic shock. Congenital heart disease and intravenous illicit drug using (IVDU) were the most common predisposing condition which may necessitate a revision in the IE prophylaxis recommendations.

Introduction: The pathophysiology of ischemia involves the cellular effect of myocardial ischemia, reactive oxygen species, and reactive inflammatory enzymes. Left atrial (LA) ischemia has been shown to have several mechanisms through which it can lead to abnormalities in left ventricular filling in early diastole and thus reduces LA passive functional reserve. In this review, we evaluated the physiological mechanisms of LA during myocardial ischemia, as previously demonstrated in experimental and clinical studies.Methods: Several databases were searched in order to find related articles. The outcome of interest included LA function measurements (measurement of LA volume) during ischemia. By applying a standardized protocol, reviewers independently extracted and assessed the studies.Results: The literature review indicated 50 publications, among which 15 studies were eligible for analysis. Assessment of LA dimension and function is essential for clinical evaluation and prognostic purposes. Conclusion: The present article revealed that LA passive emptying volume and LA emptying volume significantly increased in myocardial ischemia. Further researches could provide a better understanding of pathophysiological mechanisms behind LA enlargement and help to predict clinical outcomes in many cardiovascular disorders.

Situs inversus with levocardia and congenitally corrected transposition of the great arteries represents a relatively very rare congenital condition and most patients are diagnosed in infancy or early age. This case report describes a 35-year old man with congenitally corrected transposition of the great arteries which presented with a five month history of exertional dyspnea. A diagnosis was confirmed by transesophageal echocardiogram, showing situs inversus, levocardia, atrioventricular and ventriculoarterial discordance. He underwent physiologic repair, and was discharged thirty five days after the operation, in a good general condition. Although management of the corrected transposition of the great arteries patients remains controversial, the recommendation is that physiologic repair may be the procedure of choice for some patients, particularly complicated cases.

BACKGROUND: Although isolated left ventricular noncompaction (ILVNC) has been described almost two decades ago, our knowledge about its diagnosis, presentation, echocardiographic features and clinical outcome is sparse. We aimed to assess the echocardiographic and clinical characteristics of ILVNC in a group of patients referred to our center. METHODS: Patients who were referred to a tertiary referral center, affiliated with Mashhad University of Medical Sciences, with primary diagnosis of dilated cardiomyopathy underwent comprehensive echocardiographic evaluation. The diagnosis of ILVNC was made based on the presence of two-structural layer in myocardium; ratio of noncompacted to compacted layers more than 2, and excessive trabeculation in the left ventricle. RESULTS: Final diagnoses of ILVNC were made in 42 patients. Mean age of patients was 32.9 ± 15.6 years (ranging from 9 to 70 years). Females comprised a higher proportion of patients (61.9%) and shortness of breath was the most reported symptom among patients (47.6%). Non-compacted layers were detected in inferior and lateral segments of apex in 97.6% of patients. A total of 26 (61.9%) patients had left ventricle (LV) dysfunction (defined as ejection fraction less than 50%). The only factor that showed significant association with LV dysfunction was the number of affected segments with noncompaction (P = 0.008). Reduced ejection fraction was not associated with either age or sex (P = 0.437 and P = 0.206, respectively). CONCLUSION: Based on the result of the current study, it can be suggested that apex of the heart is the most common site of noncompaction and increasing numbers of affected segments might be associated with LV dysfunction.

BACKGROUND: Parachute tricuspid valve is a rare congenital malformations explained in the literature. In most cases, this malformation coexists with other congenital defects. The importance of this condition depends on its functional consequences. CASE REPORT: First case was a 52-year-old female patient presented with palpitation. She had a history of paroxysmal supraventricular tachycardia. Transthoracic echocardiography revealed large secundum type atrial septal defect and all the tricuspid valve leaflets appeared to be connected to a single calcified papillary muscle in right ventricle suggestive of parachute tricuspid valve. Echocardiography showed severe right ventricle and right atrial enlargement, and moderate to severe tricuspid regurgitation without significant tricuspid stenosis. Another case was a 30-year-old female patient referred for echocardiography prior to her breast cancer chemotherapy. Transthoracic echocardiography revealed a right ventricle with an unusual fusion of papillary muscles resulting in a single calcified head for the attachment of all tricuspid leaflets. These findings were suggestive of a parachute-like tricuspid valve. Other data were mild to moderate tricuspid regurgitation without any stenosis, and normal right ventricle size and function. In both cases, parachute tricuspid valve was confirmed by three dimensional echocardiograph. CONCLUSION: In our first case, parachute tricuspid valve was associated with atrial septal defect, although in the second case, no associated anomaly was detected, a condition not previously reported in the literature. In both cases, parachute tricuspid valve was not associated with tricuspid stenosis. Based on other published cases, parachute involvement of the tricuspid valve is less often reported than cases involving the mitral valve. Additionally, the associated consequences in tricuspid valve position such as tricuspid stenosis seem to be less significant than cases involving mitral valve. It is recommended that in patients with tricuspid valve involvement, parachute anomaly should be considered as a possible rare cause.

BACKGROUND: This study was performed to determine the size of left ventricular thrombus (LVT), risk of systemic embolization and response to medical treatment during 18 months of follow up in the patients with anterior-ST elevation myocardial infarction (aSTEMI). METHODS: This cross-sectional study was performed on thirty-five patients with anterior myocardial infarction (MI), in Emam Reza Hospital and Ghaem Hospital, Mashhad, Iran, from August 2008 to January 2011. Warfarin was prescribed for all the patients. Transthoracic echocardiographic study was performed on the 1st, 2nd, 4th, 6th, 12th and 18th months. Outcomes included rate of death, MI, stroke, systemic embolization, major bleeding and change in thrombus size following treatment. RESULTS: The resolve rate of clot on the 2nd, 4th, 6th, 12th and 18th months was 64.7, 86.6, 81.4, 81.4 and 100 percent, respectively. In five patients with complete clot resolution, clot reformation occurred after warfarin discontinuation. In these patients, left ventricular ejection fraction (LVEF) improvement was poor. During the study period, five patients died due to severe heart failure. One patient developed hematuria whereas non-experienced thromboembolic events. The mean LVEF at study initiation was 30.8 ± 0.92%, which improved to 42 ± 0.84% (P < 0.05) at the end. CONCLUSION: All LVT was resolved with a combination therapy of antiplatelet and warfarin without any thromboembolic event. In patients with a poor improvement in the LV function, due to the risk of LVT reformation, lifelong warfarin therapy was recommended.

Introduction: Retinal vein occlusion is a common vascular disorder disrupting vision. Two basic types of RVO are branch retinal vein occlusion and central retinal vein occlusion (CRVO). Retinal vein occlusion is a multifactor process including systemic illness and local retinal factors.RVO may be associated with atherosclerotic risk factors. We analyzed the role of 2 dimensional transthoracic echocardiography (TTE) for detecting the cardiac disease in patients with retinal veins occlusion. Materials and Methods:In this cross-sectional study 70 recently diagnosed patients with RVO enrolled in the study. The clinical diagnosis of retinal vein occlusion and its type was confirmed by a vitreoretinal specialist. The Patients were then referred for performing complete TTE. Results: The prevalence of RVO increased with age, but did not vary by sex. The most frequent cardiovascular risk factor was hypertension. The findings of our study revealed that a variety of echocardiographic abnormalities may be presented in patients with RVO. Diastolic dysfunction was the most frequent echocardiographic finding and we found positive correlation between diastolic dysfunction with increasing age and the presence of hypertension. Other findings included mitral regurgitation (52.9%), mitral stenosis (2.9%), mitral annulus calcification (1.4%), mitral valve prolapse (8.6%), aortic insufficiency (22.9%), sclerotic aortic valve (27.1%), tricuspid regurgitation (45.7%), pulmonary insufficiency (8.6%), mild pulmonary hypertension (8.6%), and moderate to severe pulmonary hypertension (4.3%) Mild LVH (11.4%), Moderate LVH (8.6%). Abnormality on IAS was defined in these patients, including paten foramen ovale, lipomatosis IAS, exaggerated motion of IAS, and aneurysm of IAS. Conclusion: In our study, the most common echocardiographic finding was diastolic dysfunction which was compatible with the patients' age and the fact that the most prevalent risk factor was hypertension. Other findings were not more prevalent than general population.We think that a routine workup for structural heart diseases is unwarranted in these patients.

Introduction: Retinal vein occlusion is a common vascular disorder disrupting vision. Two basic types of RVO are branch retinal vein occlusion and central retinal vein occlusion (CRVO). Retinal vein occlusion is a multifactor process including systemic illness and local retinal factors.RVO may be associated with atherosclerotic risk factors. We analyzed the role of 2 dimensional transthoracic echocardiography (TTE) for detecting the cardiac disease in patients with retinal veins occlusion. Materials and Methods:In this cross-sectional study 70 recently diagnosed patients with RVO enrolled in the study. The clinical diagnosis of retinal vein occlusion and its type was confirmed by a vitreoretinal specialist. The Patients were then referred for performing complete TTE. Results: The prevalence of RVO increased with age, but did not vary by sex. The most frequent cardiovascular risk factor was hypertension. The findings of our study revealed that a variety of echocardiographic abnormalities may be presented in patients with RVO. Diastolic dysfunction was the most frequent echocardiographic finding and we found positive correlation between diastolic dysfunction with increasing age and the presence of hypertension. Other findings included mitral regurgitation (52.9%), mitral stenosis (2.9%), mitral annulus calcification (1.4%), mitral valve prolapse (8.6%), aortic insufficiency (22.9%), sclerotic aortic valve (27.1%), tricuspid regurgitation (45.7%), pulmonary insufficiency (8.6%), mild pulmonary hypertension (8.6%), and moderate to severe pulmonary hypertension (4.3%) Mild LVH (11.4%), Moderate LVH (8.6%). Abnormality on IAS was defined in these patients, including paten foramen ovale, lipomatosis IAS, exaggerated motion of IAS, and aneurysm of IAS. Conclusion: In our study, the most common echocardiographic finding was diastolic dysfunction which was compatible with the patients' age and the fact that the most prevalent risk factor was hypertension. Other findings were not more prevalent than general population.We think that a routine workup for structural heart diseases is unwarranted in these patients.

Introduction: Aortic valve sclerosisis considered as a manifestation of coronary atherosclerosis. Recent studies demonstrated an association between aortic valve sclerosis and obstructive coronary artery disease. The purpose of this study was to evaluatethe correlation betweenaortic valve sclerosis andobstructive coronary artery disease and the extent of coronary artery disease in patients hospitalized for chest pain. Materials and Methods: A total of 230 consecutive patients were referred to the coronary angiography of GhaemMedical Center and were subjected to transthorasic echocardiography for screening of aortic valve sclerosis and coronary risk assessment. The diagnostic value of obstructive coronary artery disease for aortic valve sclerosis was calculated. Results: The patients with obstructive coronary artery disease had a higher prevalence of aortic valve sclerosis compared to those with no coronary artery disease (P< 0.05). Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease by multivariate analysis (P< 0.05). Aortic valve sclerosis had sensitivity of 47% and specificity of 79% and positive predictor value of 92%. Conclusions: Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease in patients with chest pain and was strongly interrelated with the extent of coronary artery disease in these patients.

Introduction: Aortic valve sclerosisis considered as a manifestation of coronary atherosclerosis. Recent studies demonstrated an association between aortic valve sclerosis and obstructive coronary artery disease. The purpose of this study was to evaluatethe correlation betweenaortic valve sclerosis andobstructive coronary artery disease and the extent of coronary artery disease in patients hospitalized for chest pain. Materials and Methods: A total of 230 consecutive patients were referred to the coronary angiography of GhaemMedical Center and were subjected to transthorasic echocardiography for screening of aortic valve sclerosis and coronary risk assessment. The diagnostic value of obstructive coronary artery disease for aortic valve sclerosis was calculated. Results: The patients with obstructive coronary artery disease had a higher prevalence of aortic valve sclerosis compared to those with no coronary artery disease (P< 0.05). Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease by multivariate analysis (P< 0.05). Aortic valve sclerosis had sensitivity of 47% and specificity of 79% and positive predictor value of 92%. Conclusions: Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease in patients with chest pain and was strongly interrelated with the extent of coronary artery disease in these patients.

Cor triatriatum sinistrum is a rare congenital cardiac malformation, accounting for about 0.1-0.4% of all congenital heart diseases and characterized by the presence of a fibromuscular membrane that subdivides the left atrium into two chambers in the classical form. While classic cor triatriatum in most patients can be observed during the neonatal period or early infancy, it is very rare in adults.We herein present an incidental finding of cor triatriatum sinistrum in a middle-aged man with coronary artery diseasescheduled for coronary artery bypass graft surgery. The patient was admitted for exertional dyspnea and chest pain of a three-month duration. He had a past medical history of mild hyperlipidemia and mild hypertension. Transthoracic two-D echocardiography (TTE) demonstrated a visible presence of a membranous band in the mid portion of the left atrium with obvious obstruction by color and Doppler flow measurements, confirmed by three-D echocardiography. Selective coronary angiography also revealed a severe ostioproximal stenosis of the left anterior descending artery of up to 99%.On-pump coronary artery bypass grafting was performed without complications, during which the anastomosis of the left internal mammary artery to the left anterior descending artery and the removal of the membrane were done.

Background: Stroke, one of the most important causes of morbidity and mortality in the world, is of great importance in young adults (15-45 years), amongst whom the causes of stroke and transient ischemic attack (TIA) are different from those in older ages and a significant portion of them have no known etiology. Patent foramen ovale (PFO) is considered a probable cause in this group.Methods: Patients between 15 and 45 years of age with TIA or stroke were examined and evaluated for causes of cerebrovascular accidents. Patients with no definite cause for stroke or TIA, except for PFO, despite our extensive evaluations were categorized as cryptogenic. The controls were comprised of those between 15 and 45 years old who underwent transesophageal echocardiography (TEE) for reasons other than stroke. The frequency of PFO and its characteristics were compared between the two groups.Results: The case group comprised 48 patients with cryptogenic stroke (n=31) and TIA (n=17), and the control group consisted of 57 patients. The age distribution of the groups was normal, and there was no significant difference between the age and gender of the two groups. The frequency of PFO in the case and control groups was 52% and 25%, respectively (p value=0.003, odds ratio=3.33, confidence interval=1.46-7.63). The exaggerated motion of the interatrial septum (IAS) in the case and control groups was 18.8% and 0%, respectively. Right-to-left shunt at rest in the case and control groups was 78% and 28%, respectively (significant differences). The differences in terms of PFO size, number of bubbles, and atrial septal aneurysm were not significant between the two groups.Conclusion: PFO had a relation with stroke and TIA in the young adults, and right-to-left shunt at rest and exaggerated motion of the IAS could increase the possibility of paradoxical emboli. It seems that the presence of atrial septal aneurysm, number of bubbles, and PFO size did not increase the risk of cerebrovascular accidents.

Background: Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction (AMI). We aimed to investigate the frequency of IMR following first-time AMI and its association with infarct location, in-hospital mortality, and complications. Methods: From September 2011 to November 2012, all patients with a diagnosis of first-time acute ST-elevation MI were enrolled in the study. Patients with previous MI and heart failure, organic mitral valve disorders, and previous mitral surgery were excluded from the study. The patients' baseline characteristic, echocardiographic parameters, and complications were recorded. The frequency of IMR after AMI and its relation to infarct location and in-hospital mortality were evaluated. Results: Altogether, 250 patients (180 male) at a mean age of 60.21 ± 12.90 years were studied. IMR was detected in 114 (45%) patients. There was no association between the presence of MR and gender, systemic hypertension, smoking, diabetes mellitus, or body mass index; however, serum LDL-cholesterol and triglyceride levels were significantly higher in the patients with IMR. The most frequent territory of MI was anterior in the patients without MR, while the anterolateral territory was the most common one in the patients with IMR. The patients with IMR had more reduced left ventricular ejection fraction, more elevated left ventricular end-diastolic pressure, and higher pulmonary arterial pressure (p values < 0.001, < 0.001, and < 0.001, respectively). Stage III diastolic dysfunction was more frequent in the patients with IMR. All the deaths occurred in the IMR patients, who also had more complicated AMI. Conclusion: IMR following AMI is highly prevalent, and it complicates about half of the patients. Regarding its relation to the AMI complications, assessment of the MR severity is necessary to make an appropriate decision for treatment.

Background: Considering suggested formula in the references and PCWP measured by catheterism, in the present study the relation between pulmonary capillary wedge pressure (PCWP) measured the flow velocity of mitral valve and mitral annulus motion through tissue doppler imaging is evaluated Methods: 52 cases of severe MS were admitted for Balloon Mitral Valvolotomy (BMV) are included in this study. Mean age was 35±5 years consisting of 40 females and 12 males. Valve area, Pulmonary artery systolic pressure (PAP), E (Maximum Velocity of mitral valve at the beginning of diastole) & Em (Maximum rate of mitral annular motion at the beginning of diastole which is recorded through septal or lateral wall annulus site) velocity and left atrial (LA) size were also measured by echocardiography and PCWP & PAP through catheterism. All patients had normal ejection fraction (EF) and coronary arteries; there was no other valvular diseases and shunts. Results: There was a significant correlation between PAP in echocardiography and catheterism. Mean PAP was 53±19 mmHg in echocardiography and 53.9±17.8mmHg in catheterism. There wasn't any correlation between PCWP in echocardiography and catheterism (P=0.33) and also no relation between PCWP and mitral valve area (MVA) or LA size (P=0.2). E/Em ratio increased in severe MS cases.Conclusion: E/Em ratio and suggested formula would overestimate the wedge pressure so echocardiography is not a reliable method for measuring PCWP in severe MS. Em velocity and E/Em ratio may be used for estimating MS severity.

BACKGROUND: Isolated pulmonic valve endocarditis is a rare condition. The clinical and laboratory finding are not specific and experiences about that are limited. Most cases of that occur in children with congenital heart disease or in intravenous drug abusers and the main predisposing factor in adults is intravenous drug abuse. The most common pathogens are staphylococcus aurous and coagulase negative staphylococcus. CASE REPORT: In this case report we present a 27 years old man with chronic fever (4 months) and a history of congenital ventral septal defect (VSD). Echocardiography revealed the pulmonic valve and pulmonary artery vegetations. He referred for surgery after 3 weeks of intravenous antibiotic therapy. CONCLUSION: Careful evaluation of pulmonic valve in echocardiography should be done, when ever vegetation is not detected in other valves, and clinical suspicion for infective endocarditis is high. Keywords: Infective endocarditis, Pulmonic valve, Vegetation, Endartritis.

Cor triatriatum sinistrum is a rare congenital cardiac malformation, accounting for about 0.1-0.4% of all congenital heart diseases and characterized by the presence of a fibromuscular membrane that subdivides the left atrium into two chambers in the classical form. While classic cor triatriatum in most patients can be observed during the neonatal period or early infancy, it is very rare in adults. We herein present an incidental finding of cor triatriatum sinistrum in a middle-aged man with coronary artery disease scheduled for coronary artery bypass graft surgery. The patient was admitted for exertional dyspnea and chest pain of a three-month duration. He had a past medical history of mild hyperlipidemia and mild hypertension. Transthoracic two-D echocardiography (TTE) demonstrated a visible presence of a membranous band in the mid portion of the left atrium with obvious obstruction by color and Doppler flow measurements, confirmed by three-D echocardiography. Selective coronary angiography also revealed a severe ostioproximal stenosis of the left anterior descending artery of up to 99%. On-pump coronary artery bypass grafting was performed without complications, during which the anastomosis of the left internal mammary artery to the left anterior descending artery and the removal of the membrane were done.

Background: Stroke, one of the most important causes of morbidity and mortality in the world, is of great importance in young adults (15-45 years), amongst whom the causes of stroke and transient ischemic attack (TIA) are different from those in older ages and a significant portion of them have no known etiology. Patent foramen ovale (PFO) is considered a probable cause in this group. Methods: Patients between 15 and 45 years of age with TIA or stroke were examined and evaluated for causes of cerebrovascular accidents. Patients with no definite cause for stroke or TIA, except for PFO, despite our extensive evaluations were categorized as cryptogenic. The controls were comprised of those between 15 and 45 years old who underwent transesophageal echocardiography (TEE) for reasons other than stroke. The frequency of PFO and its characteristics were compared between the two groups. Results: The case group comprised 48 patients with cryptogenic stroke (n=31) and TIA (n=17), and the control group consisted of 57 patients. The age distribution of the groups was normal, and there was no significant difference between the age and gender of the two groups. The frequency of PFO in the case and control groups was 52% and 25%, respectively (p value=0.003, odds ratio=3.33, confidence interval=1.46-7.63). The exaggerated motion of the interatrial septum (IAS) in the case and control groups was 18.8% and 0%, respectively. Right-to-left shunt at rest in the case and control groups was 78% and 28%, respectively (significant differences). The differences in terms of PFO size, number of bubbles, and atrial septal aneurysm were not significant between the two groups. Conclusion: PFO had a relation with stroke and TIA in the young adults, and right-to-left shunt at rest and exaggerated motion of the IAS could increase the possibility of paradoxical emboli. It seems that the presence of atrial septal aneurysm, number of bubbles, and PFO size did not increase the risk of cerebrovascular accidents.

Background: Considering suggested formula in the references and PCWP measured by catheterism, in the present study the relation between pulmonary capillary wedge pressure (PCWP) measured the flow velocity of mitral valve and mitral annulus motion through tissue doppler imaging is evaluated Methods: 52 cases of severe MS were admitted for Balloon Mitral Valvolotomy (BMV) are included in this study. Mean age was 35±5 years consisting of 40 females and 12 males. Valve area, Pulmonary artery systolic pressure (PAP), E (Maximum Velocity of mitral valve at the beginning of diastole) & Em (Maximum rate of mitral annular motion at the beginning of diastole which is recorded through septal or lateral wall annulus site) velocity and left atrial (LA) size were also measured by echocardiography and PCWP & PAP through catheterism. All patients had normal ejection fraction (EF) and coronary arteries; there was no other valvular diseases and shunts. Results: There was a significant correlation between PAP in echocardiography and catheterism. Mean PAP was 53±19 mmHg in echocardiography and 53.9±17.8mmHg in catheterism. There wasn't any correlation between PCWP in echocardiography and catheterism (P=0.33) and also no relation between PCWP and mitral valve area (MVA) or LA size (P=0.2). E/Em ratio increased in severe MS cases. Conclusion: E/Em ratio and suggested formula would overestimate the wedge pressure so echocardiography is not a reliable method for measuring PCWP in severe MS. Em velocity and E/Em ratio may be used for estimating MS severity.