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Cardiac amyloidosis (CA) results from cardiac infiltration with systemic light chains (AL) or the transthyretin amyloid (ATTR) protein. Diffuse increase in left ventricular (LV) wall thickness often with ground glass appearance, preserved LV ejection fraction, small LV volumes, and restrictive

INTRODUCTION Patients with apical myocardial infarction are at higher risk of developing left ventricular (LV) thrombi. Standard transesophageal echocardiography (TEE) is commonly used in assessing cardiac source of embolic cerebrovascular accident (CVA). Contrast-enhanced transthoracic echocardiography (TTE) improves sensitivity for thrombus detection compared with noncontrast TTE, and however for LV apical thrombi, contrast-enhanced magnetic resonance imaging (MRI) and/or contrast-enhanced computed tomography (CT) outperform both TTE and TEE in some studies. CASE A 67-year-old man with history of prior myocardial infarction (MI), four-vessel coronary artery bypass surgery, congestive heart failure with LV ejection fraction of 30%, and diabetes mellitus presented to our facility with acute right occipital-parietal stroke and recent history of left lower extremity ischemia. Head and neck MRI and MR angiography found multiple posterior circulation infarcts suggestive of cardio-embolic etiology. TTE image quality was suboptimal even after contrast use to evaluate for LV thrombus, and due to renal insufficiency, MRI or CT was precluded and 3DTEE identified large LV apical thrombus with mobile components. CONCLUSION 3DTEE may increase the detection of LV apical thrombi as well as evaluating its characteristics by live imaging as well as by offline reconstruction. TEE may be a useful diagnostic modality, especially in patients with decreased renal function, where iodinated contrast for cardiac CT or Gadolinium for MRI may be contraindicated. Multimodality imaging studies may further prove the utility of 3D echocardiographic imaging in the detection of LV apical thrombus.

Background: Arrhythmia is the foremost cause of sudden death after myocardial infarction (MI). Animal models have recently shown that erythropoietin (EPO) can reduce the incidence of arrhythmia after MI. Methods: We investigated the effects of administrating 33,000 IU EPO on the occurrence of post-MI arrhythmia in 40 patients with ST-elevation MI who were randomly assigned in either EPO or placebo groups. Arrhythmias were blindly documented using full 12-lead configuration during 24 hours after percutaneous coronary intervention (PCI) by a cardiologist. Afterward, CK-MB, hematologic, and hemodynamic data were examined within 2 weeks after MI. Results: A comparison made between the 2 groups showed significant differences in the incidence of arrhythmias (20% in EPO group and 35% in placebo group, P = 0.043). However, no significant differences in type of arrhythmias were observed between the groups. There was no significant difference between levels of CK-MB in the 2 groups during 24 hours (P = 0.186). Hematologic and hemodynamic data showed no significant changes 2 weeks after PCI. Conclusion: High-dose administration of EPO in patients with ST-elevation MI who have been treated by primary PCI and standard antiplatelet therapy reduces the occurrence of arrhythmias. For clinical interpretation of the results, further well-designed trials are required.

Background: Pulmonary arterial hypertension (PAH) is a leading cause of death in systemic sclerosis (SSc) patients. Early detection of systolic failure in SSc patients will facilitate early treatment and improve the survival rate of these patients. Objectives: In this study, besides studying the RV function in SSC patients, attempts have beenmade to find a new possible nonin- vasive echocardiographic test for early diagnosis of systolic failure as a PAH complication. Methods: 30 patientswith at least a 2-year history of diffuse SSc confirmed by an expert rheumatologistwere enrolled in this study. All the patients underwent transthoracic echocardiography by an echocardiologist. Fractional area change (FAC) of the right ven- tricle (RV), tricuspid annular plane systolic excursion (TAPSE), RV lateralwall strain and strain rate (Base,Mid, Apex), RV-EDD and RV pressure with respect to inferior vena cava (IVC) diameter as well as Left Ventricle’s Ejection Fraction (LVEF) were evaluated. Results: The prevalence rate of PAH was reported 36.6% in this study. There was no significant relationship between LVEF and RV parameters. LVEF was found to be significantly higher in women whereas RV strain turned out to be higher inmen. Besides, there was a significant relation between pulmonary arterial pressure (PAP) and Basal (P = 0.03),mid RV strain (P = 0.002), RV strain rate (P = 0.001) and RV diameter (P = 0.02). Also, an inverse relationwas observed between RV systolic (P = 0.01) and diastolic functions (P = 0.007) with PAP. In addition, no significant relationship was found between LVEF and bodymass index (BMI) and RV parameters (P > 0.05). Moreover, Apical RV strain and LVEF were found to be higher inmales and females respectively. Furthermore, a significant relationshipwas found between RV strain and age (P = 0.027). Finally, the results did not show any relationship between RV systolic and diastolic functions and gender. Conclusions: This paper states the likely advantages of strain and strain rate echocardiography in identifying patients withmore diffused and severe SSc and the need for further longitudinal studies based on thementionedmethod for early diagnosis ofmyocar- dial impairment.

Introduction: Pulmonary vein stenosis includes narrowing of one or more pulmonary veins that may have congenital or acquired causes. Con- genital pulmonary vein stenosis is a rare condition and also a rare cause for pulmonary hypertension. Since identifying the etiology of pulmonary hypertension plays a crucial role in medical and surgical planning, we decided to introduce a rare case of pulmonary hypertension due to pulmonary vein stenosis. Case Presentation: A 29 year-old white female patient who was suering from exertional dyspnea was referred to our center for further evaluation. Our findings in transthoracic and transesophageal echocardiography showed pulmonary arterial hypertension with maximum gradient of 65 - 70 mmHg and moderate to large size secondom type oval shaped atrial septal defect (2 cm - 1.2 cm) with bidirectional shunt, in a predominantly left to right direction. Atrial septal defect rims were suitable for device closure. Due to out of proportional pulmonary hypertension with atrial septal defect, further evaluations were conducted and pulmonary vein stenosis was confirmed. In this case, the echocardiography findings were consistent with right upper pulmonary vein stenosis and justified severe pulmonary hypertension with the anomaly of atrial septal defect. Device closure of atrial septal defect and balloon angioplasty of pulmonary vein stenosis were performed for our patients. Three months later, in a follow up evaluation, it was revealed that the severity of pulmonary hypertension was declined from 65 - 70 mmHg to 40 mmHg. Conclusions: Only few cases of pulmonary hypertension secondary to congenital pulmonary vein stenosis in infancy were reported until now, and it is very uncommon in adult patients without any prior history of surgery. Patients with pulmonary vein stenosis often present with shortness of breath and may mimic symptoms of Chronic Lung Disease or pneumonia which result in misdiagnosis and treatment. Therefore, in patients with underlying congenital heart disease and out of proportional pulmonary hypertension, other potential and rare causes for pulmonary hypertension such as pulmonary vein stenosis should be considered and evaluated. It is recommended that cardiologists do not directly attribute pulmonary hypertension to the underlying heart disease without sucient assessment to rule out other possible causes for it.

Background: One of the inclusion criteria for applying atrial septal defect (ASD) closing procedure is an increased pulmonary-to- systemic blood flow ratio (Qp/Qs). Eccentricity index (EI) is associated with ventricular dysfunction in patients with pulmonary hypertension. Objectives: As ASDpatients have overload volume and pressure in their pulmonary arteries,we tried to test this hypothesis if EI and Qp/Qs ratio are possibly associated. Patients andMethods: This study is a correlation study. 64 patientswith primary diagnosis of secundumtype ASD enrolled in this study and echocardiography was performed for all of them. Data were analyzed by SPSS as well as descriptive and statistical tests. Results: Bivariate correlation test showed that therewas a positive and significant association betweenQp/Qs ratio and EI (r = 0.502, P = 0.001). Linear regression analysis showed that there was a linear association between Qp/Qs ratio and EI (Beta = 1.765, P = 0.001). Conclusions: We found that EI and Qp/Qs ratio are significantly and positively associated and Qp/Qs ratio can be easily estimated bymeasuring EI in secundumtype ASD patients.

Introduction Absence of the posterior mitral leaflet is usually fatal for fetus in utero. Although hypoplasia of the posterior mitral leaflet is usually present in children with symptomatic mitral regurgitation, it is usually evident in a few cases of asymptomatic adults. We decided to introduce a rare case with hypoplasia of the posterior mitral valve leaflet associated with aortic stenosis. Case Presentation A 24-year-old man was admitted with a history of atypical chest pain. The patient had a normal psychophysical growth. The physical examination showed 4/6 mid- systolic ejection murmurs over the left sternal border. Chest roentgenogram was normal and the electrocardiogram showed sinus rhythm with mild LVH. Meanwhile, the echocardiography revealed severe elongated sail- like anterior leaflet and hypoplasia of the posterior mitral leaflet with moderate valvular aortic stenosis. MR grade was mild due to the complete coverage of anterior mitral leaflet. Moreover, LV function and pulmonary arterial pressure were reported normal. Conclusions This abnormality was tolerated since adulthood and mitral regurgitation was gradually developed due to annulus dilation. Therefore, the posterior mitral leaflet did not have a significant impact on mitral valve performance.

Serum small dense low-density lipoprotein (sd-LDL) concentrations were measured in patients with angiographically defined coronary artery disease (CAD) and compared to concentrations in healthy subjects. Five hundred and seventy patients with stable CAD were divided into CAD- and CAD+ based on angiography. Patients in whom stenosis was50 % in diameter were classified as having a 'normal' angiogram (CAD-), otherwise the patients were allocated to the CAD+ group. The CAD+ group was further subcategorized into single-, double- and triple-vessel disease (VD). Serum sd-LDL concentrations were significantly lower in controls compared with CAD+ and CAD- patients (P 0.001). Moreover, CAD+ patients had higher concentrations of sd-LDL than CAD- patients (P 0.01). sd-LDL levels were not significantly associated with severity of CAD defined by the number of stenosed coronary arteries (P = 0.245). All participants were also categorized into subgroups with or without metabolic syndrome. Subjects with metabolic syndrome had higher levels of sd-LDL than subjects without metabolic syndrome (P 0.01). Multiple linear regressions showed that in CAD patients, triacylglycerol, total-cholesterol, body mass index, and waist circumferences were the most important determinants of serum sd-LDL concentrations. We found that sd-LDL levels were significantly higher in patients presenting with symptoms of CAD. Moreover, patients with significant stenosis of their coronary arteries (50 % stenosis) had higher levels of sd-LDL compared to patients without significant lesions.

Aims This study investigated the prognostic value of B type natriuretic peptide (BNP) in acute myocardial infarction (AMI) patients and its relation with left ventricular function and post-myocardial infarction complications. Methods In this cross-sectional study, plasma BNP level was measured for 42 consecutive patients (mean ± SD: 61.6 ± 10.85 years old) with acute ST elevation myocardial infarction (MI) and 42 healthy, age and gender matched subjects. Result BNP level in AMI patients were significantly higher than control group (@ P < 0.001). Regarding to infarct location, the highest BNP level measured in inferoposterior MI (BNP = 4436.63 ± 6188.159 pg/ml) and the lowest one indicated in standalone inferior MI (BNP = 598.83 ± 309.867 pg/ml ( P = 0.071). There was significant reverse relation between BNP and EF ( P = 0.006, OR = −0.47) and a significant relationship between BNP and killip classification ( P = 0.036). There was no significant relation between diastolic and right-ventricular function and BNP level ( P = 0.61, P = 0.21). The highest BNP level was detected in LV septal rupture and false aneurysm ( P = 0.02) and in ventricular tachycardia, but without significant relationship ( P = 0.25). Conclusion After the onset of AMI, BNP blood level can be used as an important predictor for left ventricular dysfunction, killip classification, early mechanical complications and cardiac death.

Background: Studies have shown that Glomerular Filtration Rate (GFR) and Hemoglobin (Hb) concentrations are two predictive values for ST-elevation Myocardial Infarction (MI) mortality.. Objectives: This study aimed to investigate the relationship between GFR and Hb concentrations and intra-hospital mortality and electrocardiographic (ECG) and echocardiographic abnormalities in ST-elevation MI patients admitted to a highly equipped hospital in Mashhad. The results will help define some factors to manage these patients more efficiently.. Patients and Methods: This descriptive study aimed to assess the relationship between Hb and GFR concentrations and mortality and morbidity among 294 randomly selected patients with ST-elevation MI. Echocardiography, ECG, and routine laboratory tests, including Hb and creatinine, were performed for all the patients. Then, the data were entered into the SPSS statistical software, version 16 and were analyzed using chi-square, t-test, and ANOVA. P < 0.05 was considered as statistically significant.. Results: Intra-hospital mortality rate was 10.5%. Besides, the results showed higher levels of serum blood sugar (P < 0.001), higher levels of creatinine (P < 0.001), lower levels of GFR (P < 0.001), lower ejection fraction (P < 0.001), higher grades of left ventricular diastolic dysfunction (P = 0.002), and lower mean Hb concentration (P = 0.022) in the dead compared to the alive cases. Besides, the patients with mechanical complications had lower Hb levels (P = 0.008). The results showed no significant relationship between creatinine level and mechanical and electrical complications (P = 0.430 and P = 0.095, respectively). However, ejection fraction was significantly associated with GFR (P = 0.016).. Conclusions: According to the results, low levels of Hb and GFR could predict mortality caused by ST-elevation MI and ECG abnormalities could notify intra-hospital death. Moreover, lower Hb levels were associated with mechanical complications and could be used as a parameter for diagnosis of high-risk patients..

A 69-year-old woman presented with a 2-week history of chest pain and mitral and aortic valve replacement 15 and 5 years earlier. Transthoracic echocardiography revealed a well-seated monoleaflet mitral valve and a bileaflet aortic valve with normal function. Cardiac catheterization showed 3-vessel coronary artery disease and an abnormal cluster of new vessels derived from the left atrial circumflex and posterior ventricle branches. Two- and 3-dimensional transesophageal echocardiography identified a semi-mobile oval left atrial mass with multiple internal cystic spaces, attached to the fossa ovalis region in the interatrial septum. The mass was resected. The pathological diagnosis was atrial myxoma.

Background: Exercise echocardiography is a well-validated technique for the diagnosis of coronary artery disease. In addition to the diagnostic role, it also provides useful prognostic information. Objectives: The aim of this cross sectional study was to assess the prognosis of patients with negative exercise echocardiographic results over a one-year period follow-up. Patients and Methods: The outcomes of 336 patients who had normal exercise echocardiograms were examined. All clinical and exercise echocardiogram parameters were recorded. Patients were followed up for 1 year. End points were defined as cardiac death, non-fatal myocardial infarction, hospital admission for coronary artery disease, and coronary revascularization. Results: Mean age was 54.55 ± 10.34 years. 63.4 % were women. The most frequent risk factor was hypertension. There was no significant statistical difference between men and women regarding the prevalence of systemic hypertension, diabetes mellitus, and history of coronary artery bypass grafting. 5.67% of men and 8.9 % of women had positive exercise tolerance test for ischemia. Hemodynamic parameters, diastolic function, severity of mitral regurgitation, pulmonary artery pressures, peak strain rate were not significantly different between men and women, but rest strain rates were significantly lower in women. Total exercise times and exercise capacity were higher in men. After a 1-year follow-up there was no cardiac events and mortality. Conclusions: Patients with normal exercise echocardiogram results regardless of ischemia or chest pain during the test had excellent outcomes over a one-year follow-up.

Anomalous origin of the circumflex artery of the right sinus of Valsalva is a rare finding which may be present with other cardiac malformations. A 19-year-old man presented with syncope. A transthoracic echocardiogram revealed discrete subaortic stenosis with a small defect just below the aortic valve, suggesting a ventricular septal defect. Transesophageal echocardiography showed anomalous origin of the circumflex artery from the right sinus of Valsalva. This was confirmed by coronary angiography. The patient underwent successful web resection without concomitant coronary surgery. Failure to demonstrate a coronary artery anomaly can be misleading for surgeons and perilous for patients.

Background: Rheumatismal mitral stenosis is less common today than it was several decades ago, but it is a common cause of mitral stenosis (MS) in the developing world. Mitral valve stenosis symptoms include fatigue, palpitations, and Shortness of breath especially with exertion. Objectives: The purpose of this prospective study was to determine the incidence of left atrial (LA) thrombus and the predisposing factors predicting its developments in patients with symptomatic rheumatismal mitral stenosis who underwent transesophageal echocardiography (TEE) planed for percutaneous transvenous mitral commissurotomy (PTMC). Patients and Methods: Patients who were referred to perform TEE before mitral balloon valvuloplasty enrolled the study. Data were analyzed by SPSS. Results: Out of 92 patients, females were 68 (73.91%). Mean age was 43.35 ± 13.94. They were classified into two groups based on the presence or absence of LA thrombus. Group A consisted of 21 patients (seven men and 14 women) with LA thrombus (mean age of 53.00 ± 15.70 years). Group B consisted of 71 patients (17 men and 54 women) without LA thrombus. There were no statistically significant differences between the two groups regarding age, sex, LA diameter, LA area, LA smoke, Trans-mitral mean pressure gradient, systolic pulmonary artery pressure, left ventricular ejection fraction and right ventricular function, but patients with LA clot had more LA appendage dysfunction, more frequent atrial fibrillation rhythm, and smaller mitral valve area (P = 0.020, 0.005 and 0.020 respectively) and the prevalence of MR was also lower in this group (P = 0.049). In our evaluation there was no statistically significant difference regarding the LA diameter or LA area in patients with or without LA smoke. Conclusions: The frequency of left atrial clots increased with the presence of LAA dysfunction, atrial fibrillation rhythm, and smaller mitral valve area. Presence of MR had protective effects against LA clots.

Background: Pulmonary artery hypertension is the presentation of various types of cardiovascular and systematic diseases. There are different kinds of noninvasive methods to determine right ventricular function, pulmonary artery pressure, and effect of pulmonary hypertension on right ventricular function. These methods include the tissue Doppler imaging (TDI) of the tricuspid annulus and the longitudinal deformation indices of the right ventricular free wall. Objectives: In some patients, the echocardiogram cannot help estimate pulmonary artery pressure. In this study, we evaluated the effect of pulmonary hypertension on the TDI of the tricuspid annulus and the longitudinal strain and strain rate of the basal segment of the right ventricular free wall in patients with left-sided valvular heart disease and pulmonary hypertension. Indeed, we sought to investigate whether we can guess the presence of pulmonary hypertension through the measurement of the TDI of the tricuspid annulus and the deformity indices of the basal segment of the right ventricular free wall. Patients and Methods: Eighty consecutive patients with left-sided valvular disease and pulmonary artery hypertension (V/PH Group) and 80 healthy matched controls (H Group) were enrolled in this research. The TDI parameters were obtained in the tissue velocity imaging mode during systole (S, S VTI), early relaxation (E), atrial systole (A), and isovolemic relaxation time (IVRT). The deformation indices included peak systolic longitudinal strain and strain rate measured from the basal segment of the right ventricular free wall and were calculated as the relative magnitude of segmental deformation. Results: S, E, and S VTI were reduced significantly in the V/PH Group, and there was a significant negative correlation between S velocity, S VTI with pulmonary artery systolic pressure (PASP), and right ventricular diameter (RVD). According to the ROC curve, S velocity 40 ms had 78% sensitivity and 67% specificity for the prediction of pulmonary hypertension. In comparison with the H Group, RV longitudinal peak systolic strain (-14/35 ± 4%) and strain rate (-0.65 ± 0.12) at the basal segment of the right ventricular free wall were significantly lower in the V/PH Group (P < 0.001 and P < 0.001). Conclusions: We observed a significant reduction in S, E velocity, and S VTI of the tricuspid annulus. Moreover, the strain/strain rate of the basal segment of the right ventricular free wall had a marked decrease in the V/PH Group in comparison with the healthy subjects.

Hydatidosis is a parasitic infestation caused by Echinococcus granulosus . Although uncommon, cardiac involvement has serious consequences. The incidence, even in countries where it is endemic, is

The mitro-aortic intervalvular fibrosa (MAIVF) connects the anterior mitral leaflet to the posterior portion of the aortic annulus.The pseudoaneurysm of MAIVF is one of the uncommon but catastrophic complications of native or prosthetic aortic valve endocarditis or chest trauma.We report a case of infective endocarditis of mitral valve complicated by development of pseudoaneurysm of MAIVF, and fistulous formation causing massive shunt flow from the ascending aorta above the non-coronary cusp to the left ventricle outflow tract.

We have measured the pro-oxidant-antioxidant-balance (PAB) levels in patients with defined coronary artery disease (CAD) and compared them with concentrations in healthy subjects.Based on angiography results, 400 patients with stable CAD were divided into CAD- and CAD+, this being further subcategorized into groups with single-, double- and triple-vessel disease (VD).The mean PAB values in the healthy subjects, was significantly lower than for other groups (P0.001). In CAD- patients, PAB levels were 123.2 ± 43.9, which was not statistically different compared to groups with SVD, 2VD and 3VD (P0.05). In the CAD+ group, PAB values in 1VD, 2VD and 3VD were not significantly different among patients with SVD, 2VD and 3VD (P0.05).In conclusion, we found higher levels of oxidative stress in CAD+ patients compared to healthy subjects. The oxidation level was not related to measures of the extent of CAD such as number of stenosed vessels.