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Background: The use of cardiac resynchronization therapy (CRT) in heart failure patients with right bundle branch block (RBBB) is under debate. We present early and late echocardiographic characteristics of a series of heart failure patients with RBBB who underwent CRT. Methods: In this retrospective descriptive study, 18 patients with RBBB in the surface electrocardiogram underwent CRT between 2005 and 2015. All the patients had the New York Heart Association functional class III/IV, a left ventricular ejection fraction (LVEF) ≤35%, and a QRS duration ≥120 milliseconds. The median follow-up duration was 19 months. The echocardiographic response was based on a ≥5% increase in LVEF. Results: Within 48 hours after CRT implantation, LVEF increased from 24.58%±7.08% before to 28.46±8.91% after CRT (P=0.005) and to 30.00±9.44% at follow-up (P=0.008). Among the 18 patients, 12 (66.7%) were responders within 48 hours after CRT. The following baseline echocardiographic parameters were higher in the responders than in those without an increased LVEF, although the difference did not reach statistical significance: septal-to-lateral wall delay (48.33±33.53 vs 43.33±38.82 ms), anteroseptal-to-posterior wall delay (41.7±1.75 vs 38.33±18.35 ms), and interventricular mechanical delay (48.50±21.13 vs 31.17±19.93 ms). The mean QRS duration was higher in the responders than in the non-responders (183.58±40.69 vs 169.00±27.36 ms). Death was reported in 3 out of the 18 patients (16.7%) at follow-up. The 3 deceased patients had a higher baseline interventricular mechanical delay than those who survived. Conclusion: Our results indicated that patients with RBBB might benefit from CRT. Further, patients with higher intra and interventricular dyssynchrony and a wider QRS may show better responses.

Injuries to the heart and great vessels should always be considered after blunt chest trauma. Valvular damage rarely occurs after blunt trauma, but symptoms may be delayed. A 58-year-old woman was referred to our hospital with exertional dyspnea (functional class III) and palpitations for elective transesophageal echocardiography. Her symptoms had exacerbated in the preceding 2 or 3 months. Physical examination showed holosystolic murmurs (IV/VI) at the lower sternal border with extension to the apex. Transesophageal echocardiography revealed avulsion of the base of the posterior mitral valve leaflet (P3) from the annulus. In the past medical history, there was a history of a motor vehicle accident 9 months earlier. The patient was recommended for mitral valve surgery. Mitral valve replacement was performed, and the diagnosis was confirmed by surgery. The patient was discharged without any complications.

Mucopolysaccharidosis (MPS) syndrome is an inherited metabolic disorder. In more than half of the patients with MPS syndrome, heart valve involvement is reported; however, combined aortic and mitral valve stenosis in MPS syndrome type I-S is very rare. We describe a 39-year-old man with severe mitral and aortic valve stenosis due to MPS syndrome type I-S. Transthoracic and transesophageal echocardiography revealed severe thickening and calcification in the aortic and mitral valves with severe left ventricular hypertrophy. The coronary arteries were normal in angiography.

Introdution: Ischemic mitral regurgitation (IMR) remains one of the most complex and unresolved aspects of ischemic heart disease that the impact of percutaneous coronary intervention (PCI) on improvement of intensity of ischemic mitral regurgitation is not well clarified. Patients with coronary artery diseases and ischemic mitral regurgitation have a worse prognosis than the patients with coronary artery disease (CAD) and those without ischemic mitral regurgitation. We sought to investigate the impact of complete revascularization by percutaneous coronary intervention PCI on improvement of IMR in patients with CAD and comparisons of echocardiography indices in patients with and without improvement of ischemic mitral regurgitation. Methods: In this cross sectional retrospective study, echocardiographic reports in pre- percutaneous coronary intervention time and 12 months after PCI of patients with moderate (≥2+) ischemic mitral regurgitation who underwent complete revascularization by percutaneous coronary intervention from Farvardin 1391 to Esfand 1393 were included in the study. Then, echocardiographic data of the patients with improved ischemic mitral regurgitation compared with the patients with non-improved ischemic mitral regurgitation. Results: Comparison of echocardiographic indices before and after percutaneous coronary intervention revealed that after percutaneous coronary intervention (P = 0.002) in 15 patients (16%), improvement in ischemic mitral regurgitation was occurred. Also, left ventricular ejection fraction (P = 0.010), left ventricular end- diastolic (P = 0.003) and end-systolic diameters (P < 0.001), wall motion score index (P = 0.003), left atrial area (P = 0.001) and systolic pulmonary artery pressure (P = 0.046) in pre- percutaneous coronary intervention echocardiography were different between improved and none-improved IMR group. Conclusion: Although, percutaneous coronary intervention can lead to improvement of ischemic mitral regurgitation but most patients did not show improvement of ischemic mitral regurgitation after percutaneous coronary intervention. The structural abnormality of left ventricle and atrium were different between improved and none-improved IMR group

Objective: The regenerative potential of bone marrow-derived mononuclear cells (MNCs) and CD133+ stem cells in the heart varies in terms of their pro-angiogenic effects. This phase II/III, multicenter and double-blind trial is designed to compare the functional effects of intramyocardial autologous transplantation of both cell types and placebo in patients with recent myocardial infarction (RMI) post-coronary artery bypass graft. Materials and Methods: This was a phase II/III, randomized, double-blind, placebo-controlled trial COMPARE CPM-RMI (CD133, Placebo, MNCs - recent myocardial infarction) conducted in accordance with the Declaration of Helsinki that assessed the safety and efficacy of CD133 and MNCs compared to placebo in patients with RMI. We randomly assigned 77 eligible RMI patients selected from 5 hospitals to receive CD133+ cells, MNC, or a placebo. Patients underwent gated single photon emission computed tomography assessments at 6 and 18 months post-intramyocardial transplantation. We tested the normally distributed efficacy outcomes with a mixed analysis of variance model that used the entire data set of baseline and between-group comparisons as well as within subject (time) and group×time interaction terms. Results: There were no related serious adverse events reported. The intramyocardial transplantation of both cell types increased left ventricular ejection fraction by 9% [95% confidence intervals (CI): 2.14% to 15.78%, P=0.01] and improved decreased systolic wall thickening by -3.7 (95% CI: -7.07 to -0.42, P=0.03). The CD133 group showed significantly decreased non-viable segments by 75% (P=0.001) compared to the placebo and 60% (P=0.01) compared to the MNC group. We observed this improvement at both the 6- and 18-month time points. Conclusion: Intramyocardial injections of CD133+ cells or MNCs appeared to be safe and efficient with superiority of CD133+ cells for patients with RMI. Although the sample size precluded a definitive statement about clinical outcomes, these results have provided the basis for larger studies to confirm definitive evidence about the efficacy of these cell types (Registration Number: NCT01167751).

Background: Enhanced external counterpulsation (EECP) reduces angina pectoris, extends time to exercise-induced ischemia, and improves quality of life in patients with symptomatic stable angina. We aimed to evaluate the effects of EECP on heart rate recovery in patients with coronary artery disease (CAD). Methods: Between January 2011 and March 2013, a total of 34 consecutive patients (24 male, 70.6%) with symptomatic CAD, who were candidated for EECP, prospectively received 35 sessions of 1-hour EECP therapy per day, 6 days per week. The patients underwent echocardiography and a symptom-limited modified Bruce exercise test before and after EECP. Left ventricular ejection fraction (LVEF), resting and peak exercise heart rates, systolic blood pressure, heart rate at 1 and 2 minutes of recovery, exercise duration, workload, and first- and second-minute heart rate recovery were measured before EECP and compared with those after EECP. Results: The mean age of the patients (70.6% men) was 64.82 ± 8.28 years. After EECP, exercise duration increased significantly from 6.48 ± 2.76 minutes to 9.20 ± 2.71 minutes (p value < 0.001). Maximum workload increased significantly (4.44 ± 1.28 vs. 5.65 ± 1.77 METS; p value < 0.001). The LVEF increased from 42.65 ± 11.82% to 44.26 ± 11.86% (p value < 0.001). The resting systolic blood pressure decreased significantly from 125.59 ± 22.35 mmHg to 116.26 ± 14.93 mmHg (p value = 0.013). The increase in the first- and second-minute heart rate recovery after EECP was not statistically significant. Conclusion: The results of the present study showed that exercise duration, maximum workload, and the LVEF might increase significantly after EECP. The increase in the first- and second-minute heart rate recovery after EECP was not statistically significant.

BACKGROUND: Cardiomyopathies are myocardial disorders in which the heart muscle is structurally and functionally abnormal. Several mutations in sarcomere protein coding genes are responsible for different types of cardiomyopathies. ACTC1 is one of the main sarcomere components in heart muscle. Two mutations of E101K and M123V in this gene are shown to be associated with cardiomyopathies. METHODS: In this case and control study, a sample of contains 30 hypertrophic cardiomyopathy and 100 dilated cardiomyopathy patients, as well as 130 healthy individuals were screened for two mutations of E101K and M123V. The genotypes of samples were determined in whole blood genomic DNA by restriction fragment length polymorphism polymerase chain reaction (RFLP-PCR) and mismatched-PCR-RLFP techniques. RESULTS: All patients and healthy peoples had wild type genotype for both locations and even no heterozygous was detected. CONCLUSION: Despite previous reports, no association was observed between both mutations with cardiomyopathy. Our results indicated that two mutations of E101K and M123V of ACTC1 gene may are not associated with cardiomyopathy in Iranian population.

Background: It is not clear whether the latest activation sites in the left ventricle (LV) are matched with infracted regions in patients with ischemic cardiomyopathy (ICM). We aimed to investigate whether the latest activation sites in the LV are in agreement with the region of akinesia in patients with ICM. Methods: Data were analyzed in 106 patients (age = 60.5 ± 12.1 y, male = 88.7%) with ICM (ejection fraction ≤ 35%) who were refractory to pharmacological therapy and were referred to the echocardiography department for an evaluation of the feasibility of cardiac resynchronization therapy. Wall motion abnormalities, time to peak systolic myocardial velocity (Ts) of 6 basal and 6 mid-portion segments of the LV, and 4 frequently used dyssynchrony indices were measured using 2-dimensional echocardiography and tissue Doppler imaging (TDI). To evaluate the influence of the electrocardiographic pattern, we categorized the patients into 2 groups: patients with QRS ≤ 120 ms and those with QRS >120 ms. Results: A total of 1 272 segments were studied. The latest activation sites (with longest Ts) were most frequently located in the mid-anterior (n = 32, 30.2%) and basal-anterior segments (n = 29, 27.4%), while the most common sites of akinesia were the mid-anteroseptal (n = 65, 61.3%) and mid-septal (n = 51, 48.1%) segments. Generally, no significant concordance was found between the latest activated segments and akinesia either in all the patients or in the QRS groups. Detailed analysis within the segments indicated a good agreement between akinesia and delayed activation in the basal-lateral segment solely in the patients with QRS duration ≤ 120 ms (Φ = 0.707; p value ≤ 0.001). Conclusion: The akinetic segment on 2-dimensional echocardiogram was not matched with the latest activation sites in the LV determined by TDI in patients with ICM.

Over the years, different techniques have been introduced for the repair of sinus venosus atrial septal defect (ASD) with anomalous right-sided pulmonary venous connection to the superior vena cava. We report the case of a 9- year-old girl, who presented with dyspnea and peripheral cyanosis. Preoperative echocardiography and angiography findings suggested a partial anomalous pulmonary venous connection. On cardiopulmonary bypass, the ASD was dilated, and the anomalous pulmonary vein was anastomosed to the right atrium and redirected to the left atrium using an intraatrial baffle and a tube graft. The intraoperative and postoperative periods were uneventful, and the patient is currently in good health at 4.5 years’ follow-up.

Background: Left ventricular (LV) dyssynchrony is a prevalent feature in heart failure (HF) patients. The current study aimed to evaluate the prevalence of inter and intraventricular dyssynchrony in HF patients with regard to the QRS duration and etiology. Methods: The available data on the tissue Doppler imaging (TDI) of 230 patients with refractory HF were analyzed. The patients were divided into three groups according to the QRS duration: QRS duration < 120 ms; 120-150 ms; and ≥ 150 ms and the patients were re-categorized into two subgroups depending on the underlying etiology: ischemic cardiomyopathy (ICM) or dilated cardiomyopathy (DCM). The time-to-peak myocardial sustained systolic velocity (Ts) in six basal and six middle segments of the LV was measured manually using the velocity curves from TDI. LV dyssynchrony was defined as interventricular mechanical delay ≥ 40 ms and tissue Doppler velocity all segments delay ≥ 105 ms; standard deviation (SD) of all segments ≥ 34.4 ms; basal segments delay ≥ 78 ms; SD of basal segments ≥ 34.5 ms; and opposing wall delay ≥ 65 ms. Results: After adjustment for the possible confounders, interventricular dyssynchrony was more prevalent in the patients with QRS duration ≥ 150 ms than in those with QRS duration 120-150 ms and < 120 ms. The patients with DCM also had a higher percentage of interventricular dyssynchrony than those with ICM in the wide QRS groups. Turning to the intraventricular dyssynchrony indices, the patients with QRS duration ≥ 150 ms and 120-150 ms revealed a significantly greater delay between Ts at the basal and all segments than did those with QRS duration < 120 ms, while etiology did not influence the frequency of these indices in each QRS group. Conclusion: The prevalence of both inter and intraventricular dyssynchrony indices was greater in the patients with wide QRS than in those with narrow QRS duration. The underlying etiology may affect the frequency of interventricular but not intraventricular dyssynchrony indices.

Background: The location of acute myocardial infarction (MI) is an important prognostic factor for risk stratification of patients with first ST-segment elevation MI (STEMI). The main goal of this study was to compare the severity and extension of coronary involvement in inferior and anterior MI. Methods: This study reviewed angiographic reports of 579 patients with a first anterior wall STEMI and 690 with a first inferior STEMI that were referred to Tehran Heart Center between March 2004 and September 2007. The number of coronary vessels involvement and the presence of left main lesion were determined based on angiography reports. The Gensini score was also calculated for each patient from the coronary arteriogram. Results: Incidence of left main lesion was similar between the two groups. Although coronary arteries involvement according to Gensini score was more severe in anterior wall MI group compared with inferior wall MI group, the number of involved coronary arteries was significantly higher in the inferior MI patients. Recommendation of coronary artery bypass grafting, percutaneous coronary intervention (PCI) or medical treatment were the same for both groups; however, patients with anterior MI were treated more with primary PCI. Conclusions: According to our angiography database, despite anterior wall MI is associated with more severity of coronary artery disease; inferior wall MI is more extent with regard to the number of involved coronary vessels. Location of MI can predict the severity and extension of infarction.

This article published in Cell J (Yakhteh), Vol 20, No 2, Jul-Sep 2018, on pages 267-277, four affiliations (1, 4, 5, and 10) were changed based on authors request.

Background: Transcatheter closure of atrial septal defect secundum (ASD-II) has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography (TEE) method for measuring atrial septal defect with balloon occlusive diameter (BOD) in transcatheter ASD-II closure.Methods: A total of 39 patients (71.1% female, mean age: 35.31 ± 15.37 years) who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography (TTE) and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1 – 2 mm larger than the BOD of the defect.Results: The mean defect size obtained by TEE and BOD was 18.50 ± 5.08 mm and 22.86 ± 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 ± 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD = 0.773 × ASD size by TEE+8.562; r2 = 67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values (r = -0.394, p value = 0.013).Conclusion: In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure.

Background: Moderate non-organic tricuspid regurgitation (TR) concomitant with coronary artery disease is not uncommon. Whether or not TR improves after pure coronary artery bypass grafting (CABG), however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR.Methods: This study recruited 50 patients (40% female, mean age: 65.38±8.01 years, mean left ventricular ejection fraction (LVEF): 45.74±13.05%) with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure (PAPs)>30mmHg and LVEF

Background: Given the dearth of data in the existing literature on the size and morphologic variability of secundumtype atrial-septal defect (ASD-II) in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophageal echocardiography (TEE).Methods: A total of 50 patients (68.0% female) with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of the defect were evaluated, and the largest defect size was measured. The ASD rim wasdivided into 6 sectors: the superior-anterior, superior-posterior, superior, inferior-anterior, inferior-posterior, and inferior.The minimal length of the defect rims was determined.Results: Mean age at the time of evaluation was 33.62±14.48 years. Mean defect diameter in the all the study patients was 20.80±8.17 mm. Thirteen morphological variations were detected. Deficiency of one rim was detected in 14 (28%) patients,two in 16 (32%), three in 2 (4%), and four in 2 (4%). Deficiency of the superior anterior rim was found in 24% of the patients as the most frequent morphology. There was a significant correlation between the defect size and number of deficient rims (γ=0.558, P value

Background: Studies on the prognosis of ST elevation myocardial infarction (STEMI) versus non-ST elevation myocardial infarction (non-STEMI) have shown different results. The present study was designed to compare the early outcome and left ventricular systolic function of patients with ST and non-ST elevation myocardial infarction. Methods: The patients' information was derived from 10,065 consecutive patients hospitalized in Tehran Heart Center with acute MI (2007 patients with STEMI and 8058 with non-STEMI). The baseline clinical characteristics, post-MI complications, left ventricular systolic functions, and 30-day mortality rates were compared. Results: A history of current cigarette smoking, opium addiction, and brain stroke was more frequent in the STEMI patients, whereas hyperlipidemia, hypertension, and obesity were found more in the non-STEMI group. Ejection fraction was higher in the non-STEMI patients than that in the STEMI group, and anterior wall infarction was detected more frequently in the STEMI cases. A history of coronary artery bypass grafting and also percutaneous coronary intervention was observed more in the non-STEMI group. Amongst the in-hospital complications, ventricular arrhythmias (1.4 vs. 0.5, P

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study.

Objective- To determine the range of systolic times intervals using Pulsed-wave Doppler and m-mode echocardiography in normal, healthy Great Dane dogs. Design- Descriptive study. Animals- Thirty healthy Great Dane dogs. Procedures- This study examined 30 clinically healthy Great Dane dogs by the two-dimensional, M-mode and Pulsed-wave Doppler echocardiography. The dogs were awake and unsedated. The following parameters were measured on the both Pulsed-wave Doppler and M-mode echocardiographic images: pre-ejection period (PEP), left ventricular ejection time (LVET), ratio of PEP to LVET (PEP/LVET) and the total electrical-mechanical systole (QAVC). Acceleration time of aortic flow (AT) was also measured by Doppler mode. Results- The following values have been acquired: PEP = 0.067 ± 0.010 s; LVET = 0.188 ± 0.011 s; QAVC = 0.254 ± 0.016 s and PEP/LVET = 0.354 ± 0.054 measured by Mmode echocardiography and PEP = 0.062 ± 0.009 s; LVET = 0.193 ± 0.007 s; QAVC = 0.256 ± 0.011s; PEP/LVET = 0.323 ± 0.051 and AT = 0.080 ± 0.107 s measured by Doppler echocardiography. Conclusion and Clinical Relevance- On Doppler mode, there was a significant correlation between the body weight and PEP and PEP/LVET. M-mode echocardiography showed significant correlation between the body weight and body surface area and QAVC. Results of this study revealed the importance of determination of breed-specific echocardiographic parameters and indices, and evaluating of measured values with range using same method for accurate diagnosis.

Background: Discrete subaortic stenosis (DSS) is a progressive condition. Controversy still rumbles on as to whether the subaortic membrane causes aortic regurgitation (AR) and whether membrane resection reduces AR severity. We investigated the association between the left ventricular outflow tract peak gradient (LVOT-PG) and AR severity preoperatively and changes in AR severity and obstruction recurrence after surgery in DSS patients.Methods: Twenty patients were evaluated before and after surgery for DSS (mean follow-up time: 13.60±9.61 months). The patients were evaluated via transthoracic echocardiography and transesophageal echocardiography, if necessary. The cut-off point for surgery was LVOT-PG ≥50 mmHg or the presence of progressive AR.Results: The mean age of the patients was 28.55±15.23 years, and 35% of them were male. LVOT-PG decreased from a mean of 80.83±42.72 mmHg preoperatively to 19.14±14.03 mmHg postoperatively and to 25.47±16.10 at follow-up. AR was identified in 15 (75%) patients preoperatively: mild in 8 (40%) and moderate in 7 (35%). The postoperative change in AR severity was insignificant. The correlation between preoperative LVOT-PG and the incidence and severity of preoperative AR was not significant. AR severity had no correlation with age. Membrane recurrence occurred in 25% of the patients. Conclusion: Our results indicated no relationship between AR severity and LVOT-PG and the patient’s age. Patient selection for surgery can, therefore, be carried out on the basis of LVOT-PG or AR severity separately. Subaortic resection may reduce AR severity in some patients, but this reduction is not significant. Future studies are required to elucidate whether or not the presence of the AR is an indication for surgery.

Background: We compared the outcomes in patients with a low ejection fraction (EF) and multivessel coronary artery disease (CAD) who either underwent coronary artery bypass grafting (CABG) or received medical treatment (MT) after a viability study via dobutamine stress echocardiography (DSE).Methods: We considered patients with CAD and left ventricular ejection fraction (LVEF) 25% (100% vs. 40%, P< 0.05). Conclusion: The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium.

Background: This study was undertaken to compare the outcome in patients with moderate to severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with either mitral valve repair or mitral valve replacement.Methods: Between March 2002 and February 2005, 49 consecutive patients (mean age: 62.84±8.42 years; mean EuroSCORE: 10.03±3.12) with coronary artery disease and moderate to severe IMR underwent CABG plus mitral valve replacement or mitral valve repair. The patients with annulus dilatation were more likely to undergo repair. The mean follow-up period was 18.89±2.1 months.Results: 40.8% of the patients underwent CABG plus mitral valve replacement, and 59.2% had CABG concomitant with mitral valve repair. The total rate of mortality in our population was 14.9% (7 patients) including 10.3% (3 patients) early mortalities; all the deceased patients were in the repair group. Both groups had a similar EuroSCORE, but more patients in the repair group had a recent episode of unstable angina (65.5% vs. 35.0%, respectively; P=0.035) and diabetes mellitus (44.8% vs. 10.0%, respectively; P=0.009). After the follow-up period, in the repair group, 11.5% had no features of Mitral regurgitation (MR); while 50% had mild MR, 23.1% moderate MR, 11.5% moderately severe MR, and 3.8% severe MR. Overall, 68.9% had no or mild MR, which we defined as successful repair, and 31.1% had moderate to severe MR. Success of repair and mortality were not statistically related to preoperative ejection fraction (39.2±7.8% vs. 32.5±8.5%; P=0.057). Conclusion: Early mortality was higher in the repair group than that in the replacement group, but this may have been due to the higher frequency of diabetes mellitus and unstable angina in the former group. Future studies are required to determine the benefit of repair versus replacement concomitant with CABG in IMR patients.

Background: Early clinical investigations indicate that an infusion of autologous bone-marrow cells into the infarct-related coronary artery is feasible after acute myocardial infarction. There is increasing evidence that cell transplantation may improve the perfusion and contractile function of the ischemic myocardium. The present study reports primarily the safety of intracoronary bone marrow mononuclear cell (BMMNC) injections and secondarily the hypothesis that intracoronary injections of autologous BMMNC in patients with acute myocardial infarction may have a favorable impact on tissue perfusion and contractile performance. Methods: Twelve patients with acute ST-elevation myocardial infarction of the anterior wall treated with percutaneous coronary intervention were enrolled in this prospective, nonrandomized, open-label study. Left ventricular function and number of nonviable segments were assessed with the use of echocardiography and Technetium-sestamibi single photon emission tomography respectively at baseline and after a 4-month follow-up.Results: At 4 months’ follow-up, global left ventricular ejection fraction in echocardiography increased from a mean of 31.78±7.56% at baseline to 38.89±6.97% (p=0.018). Mean wall motion score in rest echocardiography was 29.5±6.67 in basal and 26.75±5.44 at 4 months’ follow-up (p=0.05). Nuclear perfusion imaging studies in the patients for the mean number of nonviable segments were 6.5 at baseline and 6 in 4 months’ follow-up (p=0.17). Three patients were lost to follow-up and did not undergo the 4-month evaluations. Conclusion: This study is small and very preliminary. Data from large, randomized, controlled trials are needed to clarify the effect of stem-cell injection in myocardial function

Background: This study was designed to investigate the accuracy of dobutamine stress echocardiography (DSE) in detecting the post-revascularization recovery rate of contractile reserve (CR) in ischemic myocardium. Methods: A total of 112 segments from seven patients with low ejection fraction (

Background: Muscle fibers overlying the intramyocardial segment of an epicardial coronary artery are termed myocardial bridge (MB). The aim of this study was to analyze the mid-term outcome of MB and to examine its possible association with angiographic findings and concomitant cardiac pathologies such as hypertrophic cardiomyopathy (HCM). Methods: From a total of 3218 patients admitted for coronary angiography during 9 consecutive months, 28 (0.9%) were diagnosed with MBs with stenoses >=50%. Of these, 19 referred for follow-up with a median duration of 18 months. Results: HCM was present in 5 patients (26.3%), of whom 4 had MB as the sole finding in angiography. Of the 19 patients, 14 had diastolic dysfunction. In follow-up, 2 patients were treated with revascularization strategies due to the concomitant coronary artery disease and in 2, syncope occurred. For two patients, an intra-cardiac device and a permanent pacemaker were implanted. Three patients with MB as the sole finding in angiography were readmitted because of chest pain. Conclusion: Diastolic dysfunction may contribute to the presentation of symptoms of muscle bridging. Also, myocardial bridging as the only finding in coronary angiography is highly associated with hypertrophic cardiomyopathy and may help to detect this group of patients. The mid-term outcome of myocardial bridges is favorable.

Background: Several echocardiographic markers have been introduced to assess the left ventricular (LV) mechanical dyssynchrony. We studied dyssynchrony markers and the latest LV activation site in heart failure patients with and without left bundle branch block (LBBB). Methods: Conventional echocardiography and tissue velocity imaging were performed for 78 patients (LV ejection fraction ≤ 35%), who were divided into two groups: LBBB (n = 37) and non-LBBB (n = 41). Time-to-peak systolic velocity (Ts) was measured in 12 LV segments in the mid and basal levels. Seven dyssynchrony markers were defined: delay and standard deviation (SD) of Ts in all and basal segments, septal-lateral and anteroseptal-posterior wall delay (at the basal level), and interventricular mechanical delay (IVMD). Results: The LBBB patients had significantly higher QRS duration and IVMD. The posterior wall was the latest activated site in the LBBB and the inferior wall was the latest in the non-LBBB patients. The most common dyssynchrony marker in the LBBB group was the SD of Ts in all segments (73%), whereas it was Ts delay in the basal segments in the non-LBBB group (48.8%). Ts delay and SD of all LV segments, septal lateral delay, septal-to-posterior wall delay by M-mode, pre-ejection period of the aortic valve, and IVMD were significantly higher in the LBBB group than in the non-LBBB group. Also, 29.3% of the non-LBBB and 10.8% of the LBBB patients did not show dyssynchrony by any marker. The number of patients showing dyssynchrony by ≥ 3 markers was remarkably higher in the LBBB patients (73% vs. 43.9%, respectively; p value = 0.044). Conclusion: The LBBB patients presented with a higher prevalence of dyssynchrony according to the frequently used echocardiographic markers. The latest activation site was different between the groups.

Background: Several competing geometric and hemodynamic factors are suggested as contributing mechanisms for functional mitral regurgitation (MR) in heart failure patients. We aimed to study the relationships between the severity of MR and the QRS duration and dyssynchrony markers in patients with ischemic or dilated cardiomyopathy. Methods: We prospectively evaluated 251 heart failure patients with indications for echocardiographic evaluation of possible cardiac resynchronization therapy. All the patients were subjected to transthoracic echocardiography and tissue Doppler imaging to evaluate the left ventricular (LV) synchronicity. The patients were divided into two groups according to the severity of MR: ≤ mild MR and ≥ moderate MR. The effects of different dyssynchrony indices were adjusted for global and regional left ventricular remodeling parameters. Results: From the 251 patients (74.5% male, mean age = 53.38 ± 16.68 years), 130 had ≤ mild MR and 121 had ≥ moderate MR. There were no differences between the groups regarding the mean age, frequency of sex, and etiology of cardiomyopathy. The LV systolic and diastolic dimensions were greater in the patients with ≥ moderate MR (all p values < 0.001). Among the different echocardiographic factors, the QRS duration (150.75 ± 34.66 vs. 126.77 ± 29.044 ms; p value =0.050) and interventricular mechanical delay (41.60 ± 29.50 vs. 35.00 ms ± 22.01; p value = 0.045) were significantly longer in the patients with ≤ mild MR in the univariate analysis. After adjusting the effect of these parameters on the severity of MR for the regional and global LV remodeling parameters, no significant impact of the QRS duration and dyssynchrony indices was observed. Conclusion: Our results showed that the degree of functional MR was not associated with the QRS duration and inter- and intraventricular dyssynchrony in our patients with cardiomyopathy. No association was found between the severity of MR and the ischemic or dilated etiology for cardiomyopathy

Background: Percutaneous transcatheter closure has been proposed as an alternative to surgical closure or long-term anticoagulation in patients with presumed paradoxical embolism and patent foramen ovale (PFO). Methods: There were two symptomatic patients (29 and 47 years old) who underwent percutaneous transcatheter closure of PFO after at least two events of cerebral ischemia; one embolic event had occurred under anti-platelet therapy. For both patients, Amplatzer PFO occluder measuring 25 mm in diameter were used. In both cases, complete occlusion by color Doppler and transesophageal contrast echocardiography investigation was achieved after the procedure and lasted at least up to 3 months after implantation as determined by our follow up. Mean fluoroscopy time was 16.7 minutes. Results: Percutaneous transcatheter closure was technically successful in both patients (100%). No residual shunt was seen at the end of the procedure or in follow-ups. In-hospital follow-up was uneventful. At a mean follow-up of 3 months, no recurrent embolic neurological events were observed. Conclusion: Transcatheter closure of PFO with Amplatzer PFO occluder devices is a safe and effective therapy for patients with previous paradoxical embolism PFO. Percutaneous closure is associated with a high success rate, low incidence of hospital complications, and freedom of cerebral ischemic events.

Cardiac hydatid cyst (CHC) is a rare disease that was endemic in some regions especially in sheep-raising areas. The most commonly accepted theory for the routes of heart involvement in hydatid cyst was infestation by the hexacanthus embryo through coronary arteries. Here, we describe a case with the primitive cardiac hydatid cyst located around the pulmonary valve (PV) and main pulmonary artery (mPA) extended to right and left pulmonary arteries and metastasized to both lungs. Could it be possible for the embryo to adhere PV and mPA directly?

Background: In cases of moderate(2 or 3+ on a scale of 0 to 4+) nonorganic mitral regurgitation (MR) and coronary artery disease, operative strategy continues to be debated between coronary artery bypass grafting alone (CABG) or concomitant valve repair. To clarify the optimal management of these patients, we evaluated the mid-term results of isolated CABG in the study group. Methods: From March 2002 to February 2005, 40 consecutive patients (57.5% male, mean age: 62.45±8.7 years, mean ejection fraction: 44.15±12.6%, mean New York Heart Association class 2.5±0.78) with coronary artery disease and moderate MR without organic mitral valve disease (prolapse, rheumatism, etc.) underwent CABG alone. Thirty one (77.5%) patients had either postoperative or follow-up transthoracic echocardiography with mean follow up time of 10.82±8.12 months. Patient's pre and postoperative data were compared to evaluate the results of isolated CABG on moderate MR. Results: MR was ischemic (with persistent wall motion abnormality) in 25(62.5%) patients and functional (without persistent wall motion abnormality) in 15(31.5%). Considering postoperative and follow up transthoracic echocardiography, 54.8% had no or mild MR (29% MR 1+, 25.8% no MR) and 45.2% had moderate MR (16.1% MR 3+, 29% MR 2+). Resolution of MR was significant (p

Background: Transcatheter occlusion of the patent ductus arteriosus (PDA) is a minimally invasive treatment. The appropriate device size is chosen based on the angiographic measurement of the PDA. The current study aimed to assess the relationship between the transthoracic echocardiographic (TTE) measurements of the PDA prior to the occlusion procedure and the actual size of the deployed device.Methods: We reviewed the available records of 7 patients (2 male) who underwent the procedure at our institution (mean age: 21 ± 12.7 years, range: 7 to 46 years). PDA closure was performed successfully using the Amplatzer Duct Occluder (n = 5) and its Chinese copycat, Cardi-O-Fix Occluder (n = 2).Results: The TTE measurement of the aortic end diameter of the PDA showed a good linear regression correlation with the size of the implanted duct occluder [duct occluder size = 0.543 + (0.941× TTE measured diameter), R = 0.907; p value ≤ 0.01].Conclusion: TTE can provide a good estimation of the size of the Amplatzer duct occluder.

Cor triatriatum is defined as a membrane within the left atrium, which might lead to restricted pulmonary venous return.Diagnosis is usually achieved by echocardiography in early infancy. Therapy of choice is the excision of the membrane.Herein, successful correction of cor triatriatum in a 4-year-old girl is presented, and the clinical features, echocardiographic findings, and the surgical treatment are discussed.

Quadricuspid aortic valve (QAV) is an uncommon congenital anomaly which was an incidental finding during surgery or autopsy in the past. We present the case of a 44-year-old woman with moderately severe aortic regurgitation due to unequal cusp size QAV diagnosed via transesophageal echocardiography. Due to echocardiographic imaging improvement, the diagnosis of QAV is now easier and earlier than the past.

Myocardial free wall rupture is a catastrophic complication of acute myocardial infarction, and prognosis will depend on the prompt diagnosis by echocardiography, extension of infarct size, and prompt surgical treatment. Free wall rupture concomitant with ventricular septal defect (VSD) may be more complicated for management. A case of a 69-year-old man with myocardial free wall rupture and VSD following acute anterior myocardial infarction is presented.

We report two cases of Tetralogy of Fallot with pulmonary valve bacterial endocarditis where one extended to the branch of pulmonary artery (PA). This is a rare occurrence. Aggressive supportive care plus early and radical surgery can be life saving.

Background: Transcatheter occlusion of the patent ductus arteriosus (PDA) is a minimally invasive treatment. The appropriate device size is chosen based on the angiographic measurement of the PDA. The current study aimed to assess the relationship between the transthoracic echocardiographic (TTE) measurements of the PDA prior to the occlusion procedure and the actual size of the deployed device. Methods: We reviewed the available records of 7 patients (2 male) who underwent the procedure at our institution (mean age: 21 ± 12.7 years, range: 7 to 46 years). PDA closure was performed successfully using the Amplatzer Duct Occluder (n = 5) and its Chinese copycat, Cardi-O-Fix Occluder (n = 2). Results: The TTE measurement of the aortic end diameter of the PDA showed a good linear regression correlation with the size of the implanted duct occluder [duct occluder size = 0.543 + (0.941× TTE measured diameter), R = 0.907; p value ≤ 0.01]. Conclusion: TTE can provide a good estimation of the size of the Amplatzer duct occluder.

Cor triatriatum is defined as a membrane within the left atrium, which might lead to restricted pulmonary venous return. Diagnosis is usually achieved by echocardiography in early infancy. Therapy of choice is the excision of the membrane. Herein, successful correction of cor triatriatum in a 4-year-old girl is presented, and the clinical features, echocardiographic findings, and the surgical treatment are discussed.

Quadricuspid aortic valve (QAV) is an uncommon congenital anomaly which was an incidental finding during surgery or autopsy in the past. We present the case of a 44-year-old woman with moderately severe aortic regurgitation due to unequal cusp size QAV diagnosed via transesophageal echocardiography. Due to echocardiographic imaging improvement, the diagnosis of QAV is now easier and earlier than the past.

Background: Moderate non-organic tricuspid regurgitation (TR) concomitant with coronary artery disease is not uncommon. Whether or not TR improves after pure coronary artery bypass grafting (CABG), however, is unclear. The aim of this study was to evaluate the effect of isolated CABG on moderate non-organic TR. Methods: This study recruited 50 patients (40% female, mean age: 65.38±8.01 years, mean left ventricular ejection fraction (LVEF): 45.74±13.05%) with moderate non-organic TR who underwent isolated CABG. TR severity before and after CABG was compared. Pulmonary arterial systolic pressure (PAPs)>30mmHg and LVEF

Background: Given the dearth of data in the existing literature on the size and morphologic variability of secundum-type atrial-septal defect (ASD-II) in adult patients, we aimed to address this issue in a series of consecutive adult patients evaluated by transesophageal echocardiography (TEE). Methods: A total of 50 patients (68.0% female) with isolated ASD-II underwent TEE for the evaluation of the defect. The morphological characteristics of the defect were evaluated, and the largest defect size was measured. The ASD rim was divided into 6 sectors: the superior-anterior, superior-posterior, superior, inferior-anterior, inferior-posterior, and inferior. The minimal length of the defect rims was determined. Results: Mean age at the time of evaluation was 33.62±14.48 years. Mean defect diameter in the all the study patients was 20.80±8.17 mm. Thirteen morphological variations were detected. Deficiency of one rim was detected in 14 (28%) patients, two in 16 (32%), three in 2 (4%), and four in 2 (4%). Deficiency of the superior anterior rim was found in 24% of the patients as the most frequent morphology. There was a significant correlation between the defect size and number of deficient rims (γ=0.558, P-value

Background: Studies on the prognosis of ST elevation myocardial infarction (STEMI) versus non-ST elevation myocardial infarction (non-STEMI) have shown different results. The present study was designed to compare the early outcome and left ventricular systolic function of patients with ST and non-ST elevation myocardial infarction. Methods: The patients' information was derived from 10,065 consecutive patients hospitalized in Tehran Heart Center with acute MI (2007 patients with STEMI and 8058 with non-STEMI). The baseline clinical characteristics, post-MI complications, left ventricular systolic functions, and 30-day mortality rates were compared. Results: A history of current cigarette smoking, opium addiction, and brain stroke was more frequent in the STEMI patients, whereas hyperlipidemia, hypertension, and obesity were found more in the non-STEMI group. Ejection fraction was higher in the non-STEMI patients than that in the STEMI group, and anterior wall infarction was detected more frequently in the STEMI cases. A history of coronary artery bypass grafting and also percutaneous coronary intervention was observed more in the non-STEMI group. Amongst the in-hospital complications, ventricular arrhythmias (1.4 vs. 0.5, P

The aim of this article is to review the application of current imaging techniques used for the detection of viable myocardium. Each technique is discussed briefly, and the more commonly used techniques are compared. The imaging techniques reviewed herein are dobutamine stress echocardiography, single photon emission tomography, magnetic resonance imaging, positron emission tomography with F-18 fluorodeoxyglucose, and recently introduced tissue Doppler imaging. The estimation of the amount of viable myocardium that could predict a better outcome after revascularization being a challenging issue, the present article also reviews a variety of cut-off points suggested by different investigators as adequate viable myocardium for revascularization and presents a summary of clinical, angiographical, and echocardiographic findings that could assist in selecting patients for viability study.

Background: Discrete subaortic stenosis (DSS) is a progressive condition. Controversy still rumbles on as to whether the subaortic membrane causes aortic regurgitation (AR) and whether membrane resection reduces AR severity. We investigated the association between the left ventricular outflow tract peak gradient (LVOT-PG) and AR severity preoperatively and changes in AR severity and obstruction recurrence after surgery in DSS patients. Methods: Twenty patients were evaluated before and after surgery for DSS (mean follow-up time: 13.60±9.61 months). The patients were evaluated via transthoracic echocardiography and transesophageal echocardiography, if necessary. The cut-off point for surgery was LVOT-PG ≥50 mmHg or the presence of progressive AR. Results: The mean age of the patients was 28.55±15.23 years, and 35% of them were male. LVOT-PG decreased from a mean of 80.83±42.72 mmHg preoperatively to 19.14±14.03 mmHg postoperatively and to 25.47±16.10 at follow-up. AR was identified in 15 (75%) patients preoperatively: mild in 8 (40%) and moderate in 7 (35%). The postoperative change in AR severity was insignificant. The correlation between preoperative LVOT-PG and the incidence and severity of preoperative AR was not significant. AR severity had no correlation with age. Membrane recurrence occurred in 25% of the patients. Conclusion: Our results indicated no relationship between AR severity and LVOT-PG and the patient’s age. Patient selection for surgery can, therefore, be carried out on the basis of LVOT-PG or AR severity separately. Subaortic resection may reduce AR severity in some patients, but this reduction is not significant. Future studies are required to elucidate whether or not the presence of the AR is an indication for surgery.

Background: We compared the outcomes in patients with a low ejection fraction (EF) and multivessel coronary artery disease (CAD) who either underwent coronary artery bypass grafting (CABG) or received medical treatment (MT) after a viability study via dobutamine stress echocardiography (DSE). Methods: We considered patients with CAD and left ventricular ejection fraction (LVEF) 25% (100% vs. 40%, P< 0.05). Conclusion: The patients with CAD and a low EF had the same survival rate after both CABG and MT at mid-term follow-up. Long-term follow-up is needed to show the survival benefit of CABG in such patients with an acceptable extent of viable myocardium.

Background: This study was undertaken to compare the outcome in patients with moderate to severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting (CABG) with either mitral valve repair or mitral valve replacement. Methods: Between March 2002 and February 2005, 49 consecutive patients (mean age: 62.84±8.42 years; mean EuroSCORE: 10.03±3.12) with coronary artery disease and moderate to severe IMR underwent CABG plus mitral valve replacement or mitral valve repair. The patients with annulus dilatation were more likely to undergo repair. The mean follow-up period was 18.89±2.1 months. Results: 40.8% of the patients underwent CABG plus mitral valve replacement, and 59.2% had CABG concomitant with mitral valve repair. The total rate of mortality in our population was 14.9% (7 patients) including 10.3% (3 patients) early mortalities; all the deceased patients were in the repair group. Both groups had a similar EuroSCORE, but more patients in the repair group had a recent episode of unstable angina (65.5% vs. 35.0%, respectively; P=0.035) and diabetes mellitus (44.8% vs. 10.0%, respectively; P=0.009). After the follow-up period, in the repair group, 11.5% had no features of Mitral regurgitation (MR); while 50% had mild MR, 23.1% moderate MR, 11.5% moderately severe MR, and 3.8% severe MR. Overall, 68.9% had no or mild MR, which we defined as successful repair, and 31.1% had moderate to severe MR. Success of repair and mortality were not statistically related to preoperative ejection fraction (39.2±7.8% vs. 32.5±8.5%; P=0.057). Conclusion: Early mortality was higher in the repair group than that in the replacement group, but this may have been due to the higher frequency of diabetes mellitus and unstable angina in the former group. Future studies are required to determine the benefit of repair versus replacement concomitant with CABG in IMR patients.

Background: Early clinical investigations indicate that an infusion of autologous bone-marrow cells into the infarct-related coronary artery is feasible after acute myocardial infarction. There is increasing evidence that cell transplantation may improve the perfusion and contractile function of the ischemic myocardium. The present study reports primarily the safety of intracoronary bone marrow mononuclear cell (BMMNC) injections and secondarily the hypothesis that intracoronary injections of autologous BMMNC in patients with acute myocardial infarction may have a favorable impact on tissue perfusion and contractile performance. Methods: Twelve patients with acute ST-elevation myocardial infarction of the anterior wall treated with percutaneous coronary intervention were enrolled in this prospective, nonrandomized, open-label study. Left ventricular function and number of nonviable segments were assessed with the use of echocardiography and Technetium-sestamibi single photon emission tomography respectively at baseline and after a 4-month follow-up. Results: At 4 months’ follow-up, global left ventricular ejection fraction in echocardiography increased from a mean of 31.78±7.56% at baseline to 38.89±6.97% (p=0.018). Mean wall motion score in rest echocardiography was 29.5±6.67 in basal and 26.75±5.44 at 4 months’ follow-up (p=0.05). Nuclear perfusion imaging studies in the patients for the mean number of nonviable segments were 6.5 at baseline and 6 in 4 months’ follow-up (p=0.17). Three patients were lost to follow-up and did not undergo the 4-month evaluations. Conclusion: This study is small and very preliminary. Data from large, randomized, controlled trials are needed to clarify the effect of stem-cell injection in myocardial function.