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Introduction: We present three cases of ruptured sinus of Valsalva aneurysm concomitant with a cardiac lesion in 2 cases of ventricular septal defect and 1 case of bicuspid aortic valve with mild aortic insufficiency. Case presentation: In 2/3 cases, the site of ruptured sinus of Valsalva aneurysm originated from right coronary cusps and one from non-coronary cusps. Both ruptured sinus of Valsalva aneurysm from right coronary cusps communicated to right ventricle, and one that originated from non-coronary cusps ruptured to right atrium. All cases were diagnosed by transthoracic echocardiography and confirmed by transesophageal echocardiography. Two underwent the surgery, while one did not want to continue treatment. Conclusion: ruptured sinus of Valsalva aneurysm is a rare cardiac anomaly. In the Eastern countries, the most common associated anomalies with ruptured sinus of Valsalva aneurysm are ventricular septal defect and aortic regurgitation. Ruptured sinus of Valsalva aneurysm mainly originates from right coronary cusps and is ruptured into right ventricle. Transthoracic echocardiography and transesophageal echocardiography are employed to confirm the diagnosis. In this cohort, the coexistences of ruptured sinus of Valsalva aneurysm with ventricular septal defect and aortic regurgitation (case 1), ventricular septal defect (case 2), aortic regurgitation and bicuspid aortic valve (case 3) are observed.

I ntroduction: Myocardial longitudinal tissue velocity imaging and strain rate imaging indices may have a role in the prediction of significant proximal stenosis of left anterior descending by echocardiography. Materials and Methods: Total 20 patients with proximal left anterior descending stenosis >70% by angiography and ejection fraction ≥50%, without wall motion abnormality at resting echo (stenotic group) and 20 angiographically normal coronaries subjects with normal echocardiography (non-stenotic group) were included in the study. Strain rate imaging and tissue velocity imaging were performed in nine segments of the left anterior descending territory at rest. Parameters of interest included: peak systolic strain (%), strain rate (Second -1 ), and peak systolic velocity (Sm, cm/s). Results : Overal mean systolic strain and strain rate showed a significant reduction in the stenotic group compared to non-stenotic group ( P

Background Strain rate imaging (SRI) is proposed for assessing atrial function. There are limited studies on the role of SRI in assessing the left atrial (LA) function in patients with mitral stenosis (MS). We decided to assess LA early diastolic strain to evaluate LA conduit function in two groups of patients with MS. Methods A total of 49 patients with moderate to severe MS, scheduled for percutaneous transluminal mitral commissurotomy, were categorized into two groups: normal sinus rhythm (NSR, n=24) and persistent atrial fibrillation (AF, n=25). Early diastolic strain was measured via SRI in four mid-left atrial walls by transthoracic echocardiography. Results Left atrial volume was significantly higher in AF group. LA early diastolic strain was significantly reduced in AF patients in three walls: interatrial septum (−6.78±6.22% vs −11.44±6.35%, P=.016), anterior wall (−4.47±4.30% vs −12.52±10.62%, P=.002), and inferior wall (−2.87±3.23% vs −9.73±9.67%, P=.003). After adjustment for age, heart rate, LA volume, LA thrombus, and LAA emptying velocity, there was a significant correlation between the presence of AF and left atrial average early diastolic strain. This correlation was also remarkable between existence of AF and two LA walls (i.e., anterior and inferior walls of the LA). Conclusion There was reduced average early diastolic strain in the presence of AF compared to NSR in MS patients regardless of LA volume and age. In AF patients, there is not only a loss of atrial late diastolic contraction, but also there is a reduction in early diastolic shortening of LA myocardium.

Objective To determine normal values for tissue velocity imaging (TVI) and strain rate imaging (SRI) in the left atrium (LA) and right atrium (RA) in normal subjects. Methods A total of 63 healthy volunteers (50.8% male, age: 20-50 years) prospectively underwent TVI and SRI. The peak systolic velocity (TVs), strain (STs) and strain rate (SRs), peak early and late diastolic velocities (TVe and TVa), strain (STe and STa), and strain rate (SRe and SRa) were measured in the base and mid of the LA and RA walls and roofs. Results By TVI, TVs and TVe of LA walls decreased significantly from basal to mid-level and from mid to the roof. Mean Tva of LA walls reduced significantly from basal to mid-level and to the roof. By SRI, mean STs and STe of LA walls increased remarkably from basal to mid-level and to the roof and also mean SRs, SRe and SRa increased significantly from basal to mid-level and to the roof. For SRe, the changes were also significant from mid-LA wall to the roof. Mean Tvs, Tve, and Tva of the RA walls reduced significantly from base to mid and then to the RA roof. RA systolic, early, and late diastolic ST and SR increased from base to mid and to the roof. Conclusion Peak systolic and diastolic velocities of the LA and RA decreased from the base to the mid and to the roof, while systolic and diastolic ST and SR increased from the base to the mid to the roof.

Introduction: The use of tissue velocity and strain rate imaging is proposed for the quantification of non-viable myocardium. This study is aimed at investigating the differences in tissue velocity and strain rate imaging indices between non-viable left ventricular apical segments and the normal segments using segment-by-segment comparison.Materials and Method: Thirty-two patients with akinetic left ventricular apical segments and without viability were selected using two-dimensional echocardiography and dobutamine stress echocardiography; 32 individuals with normal echocardiography and coronary angiography formed the normal group. Peak systolic velocity, peak systolic strain, and strain rate were measured in the four left ventricular apical segments and the apex 17th segment.Results: The patient group had a significantly lower ejection fraction (26.88±6.06% vs. 56.56±2.36%; p

Atrial septal defect (ASD) is the defect of interatrial septum, there are four types of ASD: 1. ASD ostium secundum type, 2. ASD ostium primum type, 3. ASD sinus venosus, 4. Unroofing coronary sinus.

Ventricular septal defect (VSD) is one of the most common congenital heart diseases. In fetal life, there may be muscular or perimembranous VSD in septum, most of them are closed until birth or in early life or until puberty.

Pulmonary stenosis is often a congenital heart disease; involvement of pulmonary valve due to acquired disease like carcinoid is rare.

There is a spectrum of degenerative mitral valve disease from fibroelastic deficiency to Barlow disease [1].

Mitral stenosis (MS) is often due to rheumatic fever; about 25% of patients with rheumatic heart disease have isolated MS, 40% have MS and MR, and 38% have multivalve involvement; involvement of pulmonary valve is rare [1].

The most common cause of aortic stenosis (AS) in developing countries is rheumatismal involvement of aortic valve often in association with involvement of other valves, while in developed countries, AS is often due to senile degenerative changes.

There are two categories of tricuspid valve involvement: 1. Congenital, like Ebstein disease 2. Acquired

Paravalvular leak of prosthetic valve occurs between 5–17% [1] in some studies and 3–6% in other reports [2]. Most of paravalvular leaks are mild and do not need interventions. If paravalvular leak produces symptoms of heart failure or hemolysis, it needs intervention.

A 55-year-old woman presented with fatigue of 1-month duration. She underwent MVR with bileaflet prosthetic valve and TVR with bioprosthetic valve 8 years ago and 3 months after her first operation; the second surgery was performed on her due to infective endocarditis and fistula between LA and LV.

Objectives: Transcatheter closure of a secundum atrial septal defect (ASD II) has become an effective alternative for surgical treatment. In this study we evaluated the correlation between the two-dimensional transoesophageal echocardiographic (2D TEE) sizing of ASDs and the actual diameter of occluders in patients undergoing device closure. Methods: The records of 54 patients who underwent transcatheter ASD closure were reviewed. ASD characteristics and maximum defect diameter were evaluated using preprocedure 2D TEE images. Appropriate device size was determined by the balloon sizing method, which measures the balloon occlusive diameter (BOD) via TEE and fluoroscopy. ASD closure was performed under continuous TEE monitoring using the Amplatzer occluder in all patients. Results: The mean of the TEE-derived maximum defect diameter was significantly lower than the mean of the BOD (17.8 ± 4.5 vs 22.1 ± 5.1 mm; p < 0.001) and the mean size of the implanted occluder device (17.8 ± 4.5 vs 23.3 ± 5.1 mm; p < 0.001). However, a good correlation was found between the TEE-derived defect size and the BOD (BOD = 0.898 × TEE defect size + 6.212, R = 0.824; p < 0.001) and between the TEE measurement and the final size of the implanted Amplatzer (device size = 0.928 × TEE defect size + 6.853, R = 0.822; p < 0.001). Conclusions: 2D TEE may provide a good equation to predict the BOD or the size of the occluder device; however, further studies are needed to investigate whether it is feasible to perform transcatheter ASD occlusion without balloon sizing.

Objectives It is not clear whether the presence and degree of chronic ischemic mitral regurgitation (IMR) in patients with left ventricular (LV) dysfunction are related to LV dysfunction, local LV remodeling or mitral valve deformation. We sought to establish the strongest determinants of IMR severity in patients with LV dysfunction and IMR. Methods We prospectively performed transthoracic echocardiography for 135 patients (mean age = 60.76 ± 9.69 years, 71.9% male) with LV dysfunction (ejection fraction ≤ 50%) and coronary artery disease (70% stenosis in ≥1 coronary artery and no myocardial infarction during the previous 16 days). Global and local LV remodeling and mitral deformity indices were measured. Using the vena contracta, MR severity was graded as no regurgitation; mild; moderate; and severe. Results Mild regurgitation was found in 45 (33.3%) patients, moderate in 71 (52.6%), severe in 6 (4.4%), and no regurgitation in 13 (9.6%). By linear logistic multivariable analysis, the major echocardiographic determinants of MR severity were tenting area (TA), sphericity index (LV systolic length/width), and C-septal (distance between the leaflet coaptation and the septum). TA was best related to coaptation depth and annulus diameter. Mitral annular diameter was best correlated with left atrial surface area (r = 0.630, p

Background: Assessment of left ventricular (LV) dyssynchrony has an important role in optimizing the selection of cardiac resynchronization therapy (CRT) candidates. We compared a new semiautomatic echocardiographic modality, tissue synchronization imaging (TSI) with a manual method, color-coded tissue Doppler imaging (TDI), in the assessment of LV dyssynchrony in patients with heart failure (HF). Methods: Ninety-five patients (age = 54.5 ± 17.1 years, 66.3% male) with advanced HF (NYHA functional class ≥III and ejection-fraction ≤35%) were included in the study and evaluated echocardiographically. The time to regional peak systolic velocity (Ts) in six basal and six middle segments of the LV was measured manually using velocity curves from TDI and semiautomatically using TSI and seven parameters of systolic dyssynchrony were computed. Results: Overall, a moderate-to-good association was found between Ts derived by these two modalities, whereas the mean of Ts via TSI was significantly lower than that measured by TDI in many LV segments. The agreement between these two modalities in identifying LV dyssynchrony varied from weak to moderate according to various dyssynchrony indices. In comparison to the TDI-derived dyssynchrony indices, TSI showed a high sensitivity of more than 90% using Ts delay at the basal/all LV segments and the indices for their standard deviations (SD) for identifying LV dyssynchrony, whereas the highest specificity of 80% was achieved using the septal-lateral dyssynchrony index in the prediction of LV dyssynchrony. Conclusion: With the aid of selected LV dyssynchrony indices, the TSI method may confer enough sensitivity for a speedy evaluation and initial screening of LV dyssynchrony in HF patients; however, the current technology of TSI does not seem specific enough to replace TDI in the evaluation of dyssynchrony. (Echocardiography 2012;29:7-12)

Background: Echocardiographic measurements of time-to-peak systolic velocities (Ts) are helpful for assessing the degree of cardiac asynchrony. We assessed the degree of ventricular asynchrony in structurally normal heart according to Ts by tissue Doppler imaging. Methods: We performed conventional echocardiography and tissue velocity imaging for 65 healthy adult volunteers to measure the Ts of 12 left ventricular segments in the mid and basal levels delay of Ts and standard deviation (SD) of Ts in all and basal segments. Six frequently used markers of dyssynchrony were measured and were also compared between men and women. Data are presented as median (25th and 75th percentile). Results: Septal-lateral and anteroseptal-posterior delays were 50 (20, 90) and 20 (0, 55) ms. The delay between the longest and the shortest Ts in basal and all segments were 100 (80, 120) and 110 (83, 128) ms, respectively. SD of Ts was 39 (24, 52) ms for basal and 41 (28, 51) ms for all segments. Overall, 76.9% of cases had at least one marker of dyssynchrony. Frequencies of dyssynchrony markers were almost significantly higher in women compared to men. The most frequently observed dyssynchrony marker was SD of Ts of all segments (70.8%) and the lowest was anteroseptal-posterior delay (21.5%). Conclusions: Normal population almost had dyssynchrony by previously described markers and many of these markers were more frequent in women. Conducting more studies on normal population by other tissue Doppler modalities may give better description of cardiac synchronicity. (Echocardiography 2010;27:823-830)

Background: Longitudinal myocardial tissue velocity imaging (TVI) and strain rate imaging (SRI) quantify regional myocardial function. We aimed to measure TVI and SRI indices for inferobasal aneurysmal segments by echocardiography at rest. Method: Sixteen patients with inferobasal left ventricular (LV) aneurysm, LV ejection fraction (EF) ≤50%, and 14 normal coronaries with normal echocardiography (control group) were studied. In SRI, peak systolic strain (ST), strain rate (SR), and pattern of strain curves and in TVI, peak systolic inward motion (Sm) were evaluated all at rest. Ascending curve means systolic expansion and descending means shortening. Results: LVEF was significantly lower in the patient group. Mean ST, SR, and Sm of inferobasal segment showed significant difference between patient and control groups; for ST: 1.45 ± 7.18% versus −17.64 ± 7.45%, P < 0.0001; SR: −0.25 ± 0.26 versus −1.44 ± 0.64 sec−1, P < 0.0001; and Sm: 3.85 ± 1.26 versus 5.56 ± 1.28 cm/sec, P = 0.006, respectively. All inferobasal aneurysmal segments had ascending curve while normal segments showed a descending curve. In patient group, aneurysmal segments had significantly reduced ST and SR compared to normal segments. Normal functioning segments of patients showed significant reduction of ST and SR compared to normal LV segments in control subjects. The range of SR and ST for inferobasal aneurysmal segments did not overlap with that of the normal segments (−0.60, 0.19 and −3.00, −0.80 sec−1 for SR, and −8.30, 23.30 and −35.30, −10.00% for ST, respectively). Conclusion: SRI indices were significantly reduced in inferobasal aneurysmal segment in comparison with either the same segment in normal subjects or normal functioning segments in the same patients. SR and ST may be superior to Sm in the evaluation of inferobasal aneurysmal segments. (Echocardiography 2010;27:803-808)

AIM To study tissue velocity imaging (TVI) and strain rate imaging (SRI) indices in akinetic nonviable and normal left ventricular (LV) inferobasal segment and effect of dobutamine infusion on these indices in nonviable segments. METHODS The study population consisted of two groups: 25 patients (mean age 60.75 +/- 8.69 years) with left ventricular akinetic inferobasal nonviable segment determined by dobutamine stress echocardiography (DSE) and 14 normal coronaries (mean age 56.67 +/- 11.90 years) with normal echocardiography as control group. The following TVI and SRI parameters were measured in patient and control group: ejection phase velocity (Sm [cm/sec]), peak systolic strain (ST [%]), and strain rate (SR [per second])). RESULTS Ejection fraction was significantly lower in patient group (29.40%+/- 5.46% vs. 55.00%+/- 3.39%; P < 0.001). Several differences were observed in patients with nonviable inferobasal segments compared to control group: Sm was reduced (3.58 +/- 1.08 cm/sec vs. 5.56 +/- 1.28 cm/sec; P < 0.001); SR and ST were significantly decreased (-0.39 +/- 0.20/second vs. -1.44 +/- 0.64/second, and -3.86%+/- 4.12% vs. -17.64%+/- 7.44%, respectively; P < 0.001 in both). The range of SR for nonviable segments (-0.04 to -0.77/second) did not overlap with that of the normal segments (-0.80 to -3.0/second). This range for Sm and ST overlapped with those of the normal segments. CONCLUSION All TVI and SRI parameters are reduced in akinetic nonviable inferobasal compared with normal segments. According to findings of this study, resting strain rate has a potential to discriminate nonviable inferobasal from normal segments.

In 258 patients with left main tract disease, the atherosclerotic risk factors were compared between patients with ostial and nonostial lesions of the left main coronary artery. Also, it was done for patients with ostial right coronary artery. Women were more likely to have ostial left main coronary artery and/or ostial right coronary artery. A multivariate logistic regression analysis revealed that the female sex (odds ratio: 2.336) and hypertriglyceridemia (odds ratio: 1.004) were independent risk factors of ostial left main coronary artery lesion. For ostial right coronary artery lesion, the female sex and family history of coronary artery disease were independent predictors. Ostial left main coronary artery and right coronary artery lesions were strongly correlated. The demographic and clinical profiles of ostial stenosis suggest that this group may represent a distinct entity, different from the more common atherosclerotic left main trunk stenosis (LMTD). The female sex and serum triglyceride level can be considered as independent predictors of ostial left main tract disease.

A 17-year-old girl presented with dyspnea on exertion (functional class II) since childhood. Physical examination revealed a harsh holosystolic murmur at the left sternal border and apex. Electrocardiography showed normal sinus rhythm and left axis deviation.

A 35-year-old man presented with dyspnea on exertion (functional class II) of recent duration. Physical examination revealed a systolic murmur at the lower left sternal border and the apex.

A 32-year-old woman referred to our center because of dyspnea on exertion (functional class III). Physical examination revealed a faint systolic murmur, and the electrocardiogram showed a tall R in the right precordial leads. Chest X-ray demonstrated cardiomegaly, prominent pulmonary knob, and mild pulmonary congestion. She had given birth to two children and had experienced mild symptoms during the pregnancies.

A 16-year-old pregnant woman was referred for fetal heart echocardiography. It was her first pregnancy (22 weeks of gestation). There was no history of congenital heart disease in the family and no mismatch blood groups.

A 26-year-old obese man presented with a history of multiple episodes of respiratory infections. Physical examination revealed a systolic ejection murmur in the aortic area. Echocardiography showed normal left and right ventricular sizes and functions.

A 24-year-old woman, who had a history of typical chest pain and one episode of ventricular tachycardia as well as a continuous murmur (grade II/VI) in the second right intercostal space, was referred to our clinic. Echocardiography revealed normal left and right ventricular sizes and functions.

A 46-year-old woman referred to our echocardiography laboratory because of recurrent pericardial effusion. She had a holosystolic murmur at the lower left sternal border. Electrocardiography showed right axis deviation.

A 17-year-old boy was referred to our echocardiography laboratory with a diagnosis of an unroofed coronary sinus. He had dyspnea on exertion (functional class I) since childhood.

A 35-year-old man presented with dyspnea on exertion (functional class II–III) of recent duration. Physical examination showed a systolic murmur at the apex and the lower left sternal border.

A 12-year-old girl, who had undergone surgery for an atrioventricular septal defect (AVSD) at infancy, was referred to our echocardiography laboratory. She had dyspnea functional class II symptoms and was underweight. Physical examination revealed a holosystolic murmur at the apex and the left sternal border.

A 40-year-old asymptomatic woman was referred to our echocardiography laboratory because of dextrocardia and a systolic ejection murmur at the upper right sternal border. Electrocardiography showed a negative P in leads I and AVL. Chest X-ray revealed that the stomach and the heart were located in their right positions.

A 12-year-old boy with a history of balloon dilation and stenting of the right pulmonary artery branch stenosis was referred to our echocardiography laboratory. Physical examination showed an ejection systolic murmur (grade II/VI) at the first and second left intercostal spaces.

A 12-year-old boy, who had undergone the Senning operation at 2 years old because of the transposition of the great arteries, was referred to our center due to dyspnea on exertion (functional class I). The systemic ventricle showed a mildly reduced ejection fraction.

A 26-year-old pregnant woman, who had undergone surgical atrial septal defect (ASD) closure 2 years previously, referred to our clinic for checkup. This was her second pregnancy. During her first pregnancy, she was diagnosed with an ASD (ostium secundum type) with pulmonary arterial hypertension. The first transthoracic echocardiography and transesophageal echocardiography (TEE) demonstrated that the size of the ostium secundum ASD was 36 mm; the systolic and mean pulmonary arterial pressures were 110 and 55 mmHg, respectively; and the pulmonary and systemic vascular resistance was 7 and 20 units, respectively. However, despite elevated pulmonary vascular resistance, the Qp/Qs was still 1.85. Therefore, she underwent termination of her first pregnancy before referral for cardiac surgery. Follow-up echocardiography after cardiac surgery revealed the following

A 30-year-old pregnant woman (24 weeks of pregnancy) was referred for fetal heart echocardiography.

A 17-year-old female, who had been followed up in our center for the previous 10 years, was referred to our echocardiography laboratory for follow-up echocardiography. She was asymptomatic with normal growth and development.

A 22-year-old man referred to our echocardiography laboratory due to exertional dyspnea (functional class III) with recent exacerbation.

A 27-year-old pregnant woman (gravida 2) was referred to our echocardiography laboratory for fetal heart echocardiography. Her first infant had died of unknown reason at 7 months.

A 20-year-old man with a history of a single ventricle and Fontan operation was referred to our echocardiography laboratory for the evaluation of the extracardiac conduit function.

A 22-year-old woman presented with dyspnea (functional class III) and cyanosis with clubbing. She was a known case of complex cardiac diseases from childhood and had undergone surgery at 6 months old. O2 saturation was 44 % in room air, which reached 77 % with oxygen.

A 46-year-old woman presented with dyspnea on exertion and frequent episodes of palpitations. Physical examination revealed a systolic–diastolic murmur (grade III/VI) in the aortic area. Echocardiography demonstrated a mild left ventricular dilation with a good systolic function as well as mild concentric left ventricular hypertrophy, normal aortic valve thickness, and no evidence of doming and calcification.

A 30-year-old pregnant woman (gestational age of 25 weeks) with a history of previous fetal cardiac anomaly was referred for fetal heart echocardiography.