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To investigate the clinical and echocardiographic predictors of echocardiographic super-response to cardiac resynchronization therapy (CRT) in heart failure patients.We retrospectively collected data from 97 patients, who underwent CRT and were followed up (median time = 20.33 months). All had left ventricular ejection fraction (LVEF) ≤35%, New-York-Heart-Association class 3 or 4, and Q wave, R wave and S wave (QRS) duration120 ms. Time-to-peak systolic velocity was measured for individual LV segments by tissue Doppler imaging prior to CRT. Two-dimensional echocardiography was carried out before and at follow-up, and ≥12.5% increase in LVEF was defined as super-response.From the 97 patients, 23 (23.7%) were super-responders. Super-responders were more frequently female (52.2% vs. 24.3%, respectively; p value = 0.012). Among super-responders, the mean of LV end-diastolic and end-systolic volumes were significantly lower. According to dyssynchrony indices, time delay between anteroseptal and posterior wall and SD of all LV segments timing showed significantly higher values in super-responders. By multivariate analysis, LV end-systolic volume and anteroseptal-to-posterior wall delay remained independently associated with echocardiographic super-response to CRT.About one-fourth of our patients with CRT were super-responder in that they had ≥12.5% increase in LVEF by echocardiography. Among all the clinical and echocardiographic measures, only lower LV end-systolic volume and higher anteroseptal-to-posterior wall delay predicted super-response.

Background: Usefulness of echocardiogram-associated markers for prediction of the response of the patients with cardiomyopathy to Cardiac Resynchronization Therapy (CRT) is under debate. Method: In a cross sectional retrospective design, we analyzed data from 69 cardiomyopathy patients (mean age = 57.59 ± 11.17 years, 69.6% male) with New-York-Heart-Association class ≥ III, left ventricular ejection fraction (LVEF) ≤ 35%, and QRS duration > 120 ms who underwent CRT. Transthoracic echocardiography and tissue Doppler imaging were performed before CRT and transthoracic echocardiography was repeated after CRT. More than 5% increase in the LVEF within 48 hours post CRT was considered as acute response. Results: After CRT, 36 (52.2%) patients were acute responders. Before CRT, responders had a remarkably higher frequency of diabetes mellitus (36.1% vs.15.2%, p = 0.048), lower left ventricular end systolic volume (125.82 ± 179.73 vs. 179.73 ± 77.51 ml, p = 0.002) and end diastolic volume (165.03 ± 67.09 vs. 236.06 ± 93.24 ml, p < 0.001) compared to none responders. Other echocardiography characteristics were not significantly different. In multivariable analysis, left ventricular end systolic volume remained the sole independent predictor of acute response. A cut-off of 135 ml for left ventricular end systolic volume had a good sensitivity (67.65%) and specificity (72.73%) to distinguish responders from non-responders. Conclusion: More than half of the cardiomyopathy patients had improvement ≥ 5% in LVEF within 48 hours after CRT. No relationship was found between formerly defined pre-CRT echocardiographic dyssynchrony markers and acute response. Left ventricular end systolic volume was the sole independent predictor of acute response and a threshold of 135 ml could discriminate acute responders to CRT.

Pulmonary hypertension (PH), a chronic and complex medical condition affecting 1% of the global population, requires clinical evaluation of right ventricular maladaptation patterns under various conditions. A particular challenge for clinicians is a proper quantitative assessment of the right ventricle (RV) owing to its intimate coupling to the left ventricle (LV). We, thus, proposed a patient-specific computational approach to simulate PH caused by left heart disease and its main adverse functional and structural effects on the whole heart. Information obtained from both prospective and retrospective studies of two patients with severe PH, a 72-year-old female and a 61-year-old male, is used to present patient-specific versions of the Living Heart Human Model (LHHM) for the pre-operative and post-operative cardiac surgery. Our findings suggest that before mitral and tricuspid valve repair, the patients were at risk of right ventricular dilatation which may progress to right ventricular failure secondary to their mitral valve disease and left ventricular dysfunction. Our analysis provides detailed evidence that mitral valve replacement and subsequent chamber pressure unloading are associated with a significant decrease in failure risk post-operatively in the context of pulmonary hypertension. In particular, right-sided strain markers, such as tricuspid annular plane systolic excursion (TAPSE) and circumferential and longitudinal strains, indicate a transition from a range representative of disease to within typical values after surgery. Furthermore, the wall stresses across the RV and the interventricular septum showed a notable decrease during the systolic phase after surgery, lessening the drive for further RV maladaptation and significantly reducing the risk of RV failure.

Background Since the introduction of cardiac resynchronization therapy (CRT) to improve left ventricular function, the effect of CRT on the right ventricle in patients with heart failure has not been well described. Methods We evaluated the effect of CRT on right ventricular systolic function in 20 patients (80% men; mean [SD] age, 58.5 [9.8] y) with cardiomyopathy and right ventricular systolic dysfunction (New York Heart Association class III or IV, left ventricular ejection fraction ≤35%, and QRS interval ≥120 ms). The median follow-up time was 15 months. Right ventricular systolic function, defined as a tricuspid annular plane systolic excursion (TAPSE) index of 16 mm or less, was evaluated in patients before and after CRT. Results Twelve (60%) patients had ischemic cardiomyopathy, and 12 (60%) patients had left bundle branch block detected using surface electrocardiogram. The mean (SD) QRS duration was 160.5 (24.4) ms. From before CRT to the time of follow-up after CRT, the mean (SD) ejection fraction increased significantly from 22.5% (5.6%) to 29.4% (7.4%) (P < .001). The mean (SD) TAPSE index also increased significantly from 13.70 (1.78) mm to 16.50 (4.77) mm (P = .018). Eleven (55%) patients showed improved right ventricular systolic function (TAPSE ≥16 mm) after CRT. Patients with a favorable right ventricular response to CRT were significantly older (64.6 [8.2] y vs 53.6 [8.4] y, respectively) and more likely to have nonischemic origin of cardiomyopathy than were patients with unimproved right ventricular function (66.7% vs 18.2%, respectively). Conclusion Our findings indicate that CRT is associated with improved right ventricular systolic function in patients with heart failure and right ventricular systolic dysfunction. Patients with nonischemic heart disease more often show improved right ventricular function after CRT.

Background:Usefulness of echocardiogram-associated markers for prediction of the response of the patients with cardiomyopathy to Cardiac Resynchronization Therapy (CRT) is under debate. Method:In a cross sectional retrospective design, we analyzed data from 69 cardiomyopathy patients (mean age = 57.59 ± 11.17 years, 69.6% male) with New-York-Heart-Association class ≥ III, left ventricular ejection fraction (LVEF) ≤ 35%, and QRS duration > 120 ms who underwent CRT. Transthoracic echocardiography and tissue Doppler imaging were performed before CRT and transthoracic echocardiography was repeated after CRT. More than 5% increase in the LVEF within 48 hours post CRT was considered as acute response. Results:After CRT, 36 (52.2%) patients were acute responders. Before CRT, responders had a remarkably higher frequency of diabetes mellitus (36.1% vs.15.2%, p = 0.048), lower left ventricular end systolic volume (125.82 ± 179.73 vs. 179.73 ± 77.51 ml, p = 0.002) and end diastolic volume (165.03 ± 67.09 vs. 236.06 ± 93.24 ml, p < 0.001) compared to none responders. Other echocardiography characteristics were not significantly different. In multivariable analysis, left ventricular end systolic volume remained the sole independent predictor of acute response. A cut-off of 135 ml for left ventricular end systolic volume had a good sensitivity (67.65%) and specificity (72.73%) to distinguish responders from non-responders. Conclusion:More than half of the cardiomyopathy patients had improvement ≥ 5% in LVEF within 48 hours after CRT. No relationship was found between formerly defined pre-CRT echocardiographic dyssynchrony markers and acute response. Left ventricular end systolic volume was the sole independent predictor of acute response and a threshold of 135 ml could discriminate acute responders to CRT. &nbsp

Background: It has been identified that aortic annulus (AA) is not completely round in normal and stenotic aortic valves and some studies invesigated the eccentricity of AA by some modalities. Aims: To compare size of aortic valve annulus in different views via transesophageal (TEE) 3D echocardiography in patients without aortic stenosis (AS). Method: 31 patients underwent TEE3D without AS. Full-volume of aortic valve was saved by TEE in short and long-axis views in single beat. AA was measured in 3 planes: two orthogonal lines in short-axis plane(D1 & D2), sagittal(D3) and coronal(D4)planes ,diameter of left ventricular outflow tract 5-10 mm below AA was measured in sagittal and coronal views (D5 and D6) . Area and perimeter of AA were measured in short-axis plane in hing points of aortic cusps and the annulus according to area and perimeter was calculated. These different AA sizes were compared. Distance of left main (LM) and right coronary arteries (RCA) from adjacent aortic leaflets and length of left coronary cusp were measured. All measurements were done in mid-systole. Results: From, 31 patients(51.5% F), age 50.61 ±10.78, median Left Ventricular Ejection Fraction (LVEF) was 55%. AA in sagittal is smaller than coronal view, mean difference=1.97mm, P=0.002.D1 is smaller than D3, D2 is not different with D4. D perimeter is larger than D area and D sagittal, mean difference=0.7 and 0.9mm respectively, P

BACKGROUNDThere is an ongoing controversy about harms and benefits of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in hypertensive patients with coronavirus disease 2019 (COVID-19). Given the unresolved debate, we investigated the association of ARBs with in-hospital outcomes of these patients.METHODSIn this retrospective observational study, we studied patients with COVID-19 who referred to Sina Hospital in Tehran, Iran, from 20 February to 29 May 2020. Patients with either positive real-time reverse-transcriptase polymerase-chain-reaction test of swab specimens, or high clinical suspicion according to the World Health Organization’s interim guidance were included. We followed-up patients for incurring death, severe COVID-19, and in-hospital complications.RESULTSWe evaluated 681 patients with COVID-19 of whom 37 patients were excluded due to incomplete medical records and 8 patients who used ACEIs which left 636 patients in the analysis. In this cohort, 108 (17.0%) patients expired and 407 (64.0%) patients incurred severe COVID-19. Of 254 (39.9%) patients with hypertension, 122 (48.0%) patients were receiving an ARB. After adjustment for possible confounders, we found no independent association between taking ARBs and in-hospital outcomes except for acute kidney injury (AKI), in patients with confirmed or clinically suspected COVID-19, either hypertensive or not-hypertensive. We found that discontinuation of ARBs during hospitalization was associated with a greater risk of mortality, invasive ventilation, and AKI (all P ˂ 0.002).CONCLUSIONSWe found that taking ARBs by patients with hypertension and confirmed or clinically suspected COVID-19 is not associated with poorer in-hospital outcomes after adjustment for possible confounders.

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.

BACKGROUND Measurement of the mitral valve area (MVA) in patients with mitral stenosis (MS) by 3D echocardiography (3DE) is usually done via 3D quantification (3DQ). The present study on patients with severe MS sought to evaluate the agreement regarding the MVA measurement between 3DQ and direct planimetry on 3D zoom and also between 3DE and 2DE. METHODS Twenty-six patients (22 female, mean age:34.5 ± 14.0 years) with severe MS diagnosed by 2D transthoracic echocardiography(2DTTE) underwent 3D transesophageal echocardiography (3DTEE). Direct planimetry, the pressure half-time (PTH), and the continuity equation(CE) constituted 3 conventional 2DTTE methods, and 3DQ and direct planimetry on 3D zoom comprised two 3DTEE methods applied for the MVA measurement. Agreement between the 2D and 3D methods was assessed using the Bland-Altman plot and measuring the intra-class correlation coefficient (ICC). RESULTS The mean MVA measured by 3DQ was significantly larger than that derived by direct planimetry on 3D zoom (0.935 ± 0.23 cm2 vs 0.846 ± 0.22 cm2 , respectively; P = 0.026). The agreement between 3DQ and 3D zoom for the MVA measurement was moderate to good by the Bland-Altman plot (ICC = 0.67). The mean MVA measured by 2DE (all 3 methods of direct planimetry, the PTH, and the CE) was significantly larger than that derived by 3DE (both methods of 3DQ and direct planimetry on 3D zoom) (all Ps

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

The benefits of tricuspid valve (TV) repair in patients with moderate tricuspid regurgitation (TR) during left-sided valve surgery are under debate. We investigated independent predictors for reduction in TR severity following left-sided valve surgery in patients with moderate TR.In this study, we included 106 patients (male: 33%) with a mean age of 4.23 ± 12.61 years who had moderate TR and underwent mitral or aortic valve surgery between March 2012 and November 2016. Concomitant tricuspid annuloplasty was done for one group of patients based on surgeon's decision. Transthoracic echocardiography was done before and at a median followup of 4.71 months for all patients. The patients were divided into improved and unimproved TR groups, with the term "improved" signifying a reduction of at least one grade in TR severity.Tricuspid annuloplasty was performed on 65 (61.3%) patients. TR improvement was observed in 87.7% of patients in the TV repair group and 56.1% of patients in the no-TV repair group, indicating a significant difference (P0.001). Tricuspid annulus diameter was not significantly different between the two groups (32.41 ± 4.68 mm in no-TV repair group and 33.87 ± 4.34 mm in TV repair group, P = 0.128). At follow-up with echocardiography, 80 (75.5%) patients were placed in the improved group and the majority of patients (71.3% vs. 30.8%; P0.001) underwent tricuspid repair in the improved group. TV annuloplasty was correlated with reduced TR severity following left-sided valve surgery (odds ratio [OR]: 5.19, 95% CI: 1.70-15.85, P0.001). TR changed from moderate to severe in 17 (17.1%) patients with no concomitant tricuspid repair, while only one patient (1.5%) with tricuspid repair showed an increased TR severity.Tricuspid annuloplasty may be useful in patients who have moderate TR undergoing left-sided valve surgery regardless of the tricuspid annulus diameter, and it can play an effective role in the improvement of TR at mid-term follow-up.

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

The study aim was to investigate factors affecting the improvement of mitral regurgitation (MR) severity within 48 hours after cardiac resynchronization therapy (CRT) in patients with cardiomyopathy.Sixty-nine cardiomyopathy patients (48 males, 21 females; mean age 59.12 ± 9.66 years) in NYHA functional class ≥III, with left ventricular ejection fraction (LVEF) ≤35%, and QRS duration120 ms, with MR ≥moderate, were included in the study. Conventional echocardiography was performed before and within 48 h after CRT, and all patients underwent tissue Doppler imaging prior to CRT. Improved MR was defined as a reduction of at least one grade in MR severity.After CRT, 49 patients (71%) showed MR improvement but 20 (29%) had no MR improvement. The mean MR severity grade was reduced significantly, from 2.70 ± 0.77 before CRT to 1.90 ± 0.94 after CRT (p0.001). The group with improved MR had a significantly higher rate of left bundle branch block (75.5% versus 45%; p = 0.015), a higher QRS duration (172.00 ± 31.98 versus 147.25 ± 28.75 ms; p = 0.001), a higher median septal lateral delay (70 versus 35 ms, p = 0.035), and a higher median anteroseptal to posterior-wall delay by M mode (200 versus 130 ms, p = 0.041). Older age, longer QRS duration, and septallateral delay remained significant independent predictors of MR improvement. A greater proportion of patients with improved MR showed ≥5% increase in LVEF (55.1% versus 30.0%, p = 0.058).CRT acutely reduced the severity of functional MR in the majority of cardiomyopathy patients. Those patients with improved MR showed a higher frequency of ≥5% increase in LVEF after CRT. Older age, longer QRS duration, and septallateral delay were independent predictors of MR improvement after CRT.

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.

A 55-year-old woman presented by dyspnea on exertion functional class II–III of recent exacerbation.

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

OBJECTIVES To quantify the normal peak mean systolic velocities and strain rate parameters in the left ventricle (LV) and right ventricle (RV) and define their regional differences in normal adult hearts. METHODS Sixty-nine healthy volunteers (42% male; mean age ± SD, 30.03 ± 5.35 years) underwent color tissue Doppler and strain rate imaging. The first and second peak mean systolic velocities, peak strain, and strain rate in the systolic ejection phase were determined for 16 LV segments, the apex (17th segment), and 3 RV free wall segments. RESULTS The first peak mean systolic velocity was measurable in less than 50% of segments in the inferior and septal (-posterior) walls and RV free wall and in greater than 70% of segments of the other LV walls. The first and second peak mean systolic velocities of all LV walls and the RV free wall decreased significantly from the basal to apical region (P < .001).The strain and strain rate in the lateral and anterior walls decreased significantly from base to apex, whereas the anteroseptal and posterior walls were homogeneous. The strain rate in the inferior wall increased remarkably from base to apex, whereas it decreased significantly from the mid level to the apex. The strain in the RV was homogeneous, whereas the strain rate decreased significantly from the mid level to the apex. The apex (17th segment) showed the lowest value for each of the study parameters. CONCLUSIONS Longitudinal velocities decreased from base to apex, whereas deformation measurements did not show uniform patterns in LV walls and the RV free wall. In most cases, there are 1 peak systolic velocity in the inferior and septal (-posterior) walls and 2 peak systolic velocities in the other 4 LV walls.

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.