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This applied altmetric study aimed to analyze the presence of highly-cited documents on diabetes mellitus in online social media and correlate their altmetric attention scores with their received citation counts. Twenty thousand highly-cited documents on diabetes mellitus were identified in Scopus and their altmetric attention scores (ASSs) were extracted from Altmetric Explorer (Altmetric LLP, London, UK). Received citation rates of the documents were extracted from Google Scholar, Scopus, Web of Science and Dimensions. Excell 2016 and SPSS 22 were used for data statistical description and analysis. Out of 19,383 DOI-owner highly-cited documents on diabetes mellitus, 16,076 (82.94%) were shared at least once in social media and had an altmetric attention score. Mendeley ranked first in sharing documents with 16,868 documents (87.02%). Six hundred forty-six thousand one hundred eighty-four tweets were tweeted on the studied documents from 222 countries, with the United States as first-ranked country (17,453 tweets, 18.2%). The highest-mentioned journal was the Lancet, and the highest-mentioned research institute was Harvard University. A significantly positive correlation was found between the altmetric attention scores of the studied documents and their citation counts in Google scholar (r= .842, p

هدف: هدف از این پژوهش بررسی و شناسایی چالش‌های پیاده‌سازی سیستم‌های خدمات محصول هوشمند و ارزیابی و اولویت‌بندی این چالش‌ها، به‌عنوان یکی از اقدام‌های اساسی اولیه برای اجرای این سیستم است. روش: در این مقاله ابتدا چالش‌های پیاده‌سازی سیستم‌های خدمات محصول هوشمند، از طریق مرور ادبیات، بررسی اسناد، مصاحبه با صاحب‌نظران و روش دلفی فازی شناسایی شد. در ادامه با استفاده از روش بهترین بدترین راف ـ فازی، چالش‌های شناسایی‌شده اولویت‌بندی شدند. یافته­ها: بیست چالش پیاده‌سازی سیستم‌های خدمات ـ محصول هوشمند، در هفت گروه اصلی طبقه‌بندی و به‌روش بهترین بدترین راف ـ فازی ارزیابی شدند. بر اساس نتایج، چالش‌های مالی و فرایندی، مهم‌ترین گروه شناخته شد. روش بهترین بدترین راف ـ فازی با بررسی هم‌زمان عدم قطعیت درون‌فردی و بین‌فردی باعث می‌شود که ارزیابی به‌دست‌آمده، دقت و عینیت بیشتری را در مقایسه با روش بهترین بدترین مبتنی بر منطق فازی یا مبتنی بر تئوری راف ارائه دهد. نتیجه­گیری: با استفاده از نتایج این پژوهش شرکت‌های تولیدی و خدماتی، می‌توانند چالش‌های پیش‌ِرو در مسیر پیاده‌سازی سیستم‌های خدمات محصول هوشمند را دقیق‌تر ارزیابی کنند و به‌نحوی مناسب،­ منابع محدود سازمانی را برای رفع چالش‌های شناسایی‌شده اختصاص دهند.

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: Vasoplegia or vasoplegic syndrome is a type of vasodilator shock that occurs in a large number of patients after cardiac surgery under a cardiac pulmonary pump, which can increase the incidence of complications and mortality in patients. Therefore, it is necessary to find a way to treat this disease. So, the aim of this study was to evaluate the effect of two doses of alpha-agonist midodrine on the prevention of vasoplegic syndrome induced by cardiopulmonary bypass. Methods: This study was performed on 135 patients undergoing cardiac surgery (45 cases in midodrine 5 mg, 45 cases in midodrine 10 mg, and 45 cases in control group) in Chamran hospital, Isfahan, Iran, in 2016. Patients were randomly assigned into three groups, the drugs were prescribed one hour before surgery, and the vital sign and complications were recorded in patients. Chi-square and ANOVA tests were used to compare the data. Findings: The mean blood pressure during the pump was higher in the midodrine 10 mg group than the other groups (5 mg midodrine and control) (P = 0.021); and the mean ephedrine administration in this group (15.33 mg) was also less than 5 mg midodrine (21.55 mg) and control (29.77 mg) groups (P = 0.012). Conclusion: Considering the high incidence of vasoplegic syndrome after cardiac surgery, administrating 10 mg of midodrine can improve clinical symptoms during the pump and reduce the need for vasopressor drugs, which can make better surgical results.

Background and aim: Effects of atrial fibrillation (AF) and its ablative treatment on LV torsion have not yet been fully investigated. This study aimed to examine whether AF patterns of LV contraction and its ablative correction can exert a significant impact on LV torsion by velocity vector imaging (VVI). Methods: This case-control study conducted in Rajaie Cardiovascular, Medical and Research Center between October 2012 and June 2013. Study participants were 30 consecutive patients with symptomatic paroxysmal AF who met the inclusion criteria. The control group included 24 healthy participants with no history of cardiovascular disease. All individuals were in sinus rhythm at the time of echocardiography before and after the ablation procedure. Two-dimensional (2D) and Doppler echocardiography on a commercially available ultrasound system was performed for all the patients. Scanning was done by a wide-band ultrasound transducer with the frequency range between 2.5-3.5 MHz. The two short-axis views at basal and apical levels were http://www.ephysician.ir Page 5396 subsequently processed off-line by VVI XStrain software. In order for data analysis, SPSS 16 utilized using paired and independent t-test. p-value ≤0.05 was considered significant. Results: LV torsion (°/cm) mean ± SD was significantly lower in paroxysmal AF patients before ablation (0.8±0.3) than the control group (1.5±0.4) (p

Introduction: An increased accumulation of fat in the intra-abdominal cavity is highly correlated with adverse coronary risk profiles. Cardiac rehabilitation (CR) produces a host of health benefits related to modifiable cardiovascular risk factors. Further research is needed to define better program for weight loss and risk improvement in coronary patients. The aim of this study was to determine the effect of supervised and unsupervised cardiac rehabilitation program on body composition and body fat distribution in a population with coronary artery disease. Methods: The study investigated 167 patients with coronary artery disease (73% males; mean age = 52.67±9.11 years) before and after a supervised protocol cardiac rehabilitation program, and 12-months later. Target variables included body fat distribution indices (waist and hip circumference and waist to hip ratio), weight and body mass index. Results: Weight, waist circumference, waist to hip ratio and body mass index significantly decreased with 2 month supervised program (P

Background: Tissue Doppler imaging is used routinely to quantify both left and right ventricular function. However, normal reference values of echocardiography parameters of the right ventricle in Iranian population are still unknown. Objectives: Accordingly, we conducted a study to determine the normal values of echocardiography parameters of right ventricular function in a healthy Iranian population. Patients and Methods: One hundred and eighty seven healthy volunteer subjects enrolled. Normal subjects were chosen by taking into account history, physical examination, ECG and echocardiography. Results: Reference ranges (5th and 95th percentile values) for tricuspid E velocity, A velocity, E/A ratio, deceleration time, annular Sa velocity, Ea velocity, and E/Ea ratio were derived for the whole individuals and for each of the three age groups (< 30, 30–39, 40-49). The deceleration time, E/ Ea ratio and acceleration time of the iso-volumetric contraction time (IVA) were greater in male than in female. All measured parameters were bigger but not statistically significant in the 40-49 year-old group in comparison with the < 30 year-old group. Comparison of data between different groups showed no significant differences between the majority of data when they have been adjusted to body surface area, age and sex. Conclusions: The reference ranges presented for the echocardiography parameters of right ventricular function, albeit not conducted in a sizable sample of normal cases, will help to standardize the assessment of RV functions, particularly by tissue Doppler imaging.

Echocardiography is a non-invasive diagnostic technique which provides information on cardiac morphology, function, and hemodynamics. It is the most frequently used cardiovascular diagnostic test only after electrocardiography. In less than five decades, the evolution in this technique has made it the basic part of cardiovascular medicine. Herein, the evolution of various forms of echocardiography is briefly described.

We present a very rare case of partially unroofed coronary sinus without persistent left superior vena cava in a 74 years old female with a history of hypertension, severe myxomatous bileaflet mitral valve prolapse with severe eccentric mitral regurgitation which was diagnosed during cardiac surgery.

Background: Despite the positive impact of cardiac rehabilitation (CR) on quality of life and mortality, the majority of people who could benefit from this program fail to participate in it. The lack of referral from the physician is a common reason that patients give for not seeking CR. The objective of this study was to compare factors affecting CR referral by cardiologists. Methods: A cross-sectional survey of 122 cardiologists, including 89 general cardiac specialists and 33 fellows in cardiology from 11 major cardiology training centers in Iran, was done in 2010. They responded to the 14- item investigator-generated survey, examining the physician’s attitudinal and knowledge factors affecting CR referral. Results: 47.9% of the subjects reported having available CR centers but only 6.6% reported continuous medical education on the topic. 90.7% of the physicians reported that less than 15% of patients are referred to CR centers. The main factor affecting the low referral rate was limited general knowledge about CR programs (79.5%) such as program attributes and benefits, methods of reimbursement. Lack of insurance coverage, unavailability of CR centers in the community and low physicians’ fee were other factors reported by the physicians. Conclusion: Cardiologists’ inadequate general knowledge of and attitude toward CR programs seem to be a potential threat for cardiac prevention and rehabilitation in some societies.

The anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital cardiac malformation. It presents predominantly in infancy and its main presenting feature is myocardial ischemia or heart failure. Survival to adulthood is quite uncommon. If untreated, mortality from ALCAPA approaches 90% in infancy; early recognition and surgical correction are, therefore, essential. With early surgical correction, the prognosis is good. There are two types of ALCAPA syndrome: the infant type and the adult type, each of which has different manifestations and outcomes. Infants experience myocardial infarction and congestive heart failure, and approximately 90% die within the first year of life. A literature review regarding this anomaly in teenagers and adults show that only 25 cases have been diagnosed during life and 18 additional cases of ALCAPA in these age groups have been diagnosed post mortem. We present a rare case of a 60-year-old man, who referred to our center due to dyspnea on exertion from the previous year without any history of chest pain and diagnosed as ALCAPA. Given the absence of ischemia and the patient’s age, only medical therapy was recommended.

Background: The right ventricular (RV) dyssynchrony has not been studied extensively and the existing literature has established the effect of cardiac resynchronization therapy (CRT) on the left ventricular (LV) dyssynchrony, but there is a dearth of data on the effect of CRT on the forgotten ventricle. We sought to evaluate the presence of mechanical right ventricular dyssynchrony in patients with systolic heart failure, selected for CRT, and track the changes early afterward utilizing the longitudinal strain analysis.Methods: Thirty-six patients with severe left ventricular systolic dysfunction, candidated for CRT, were enrolled in this study. Mechanical dyssynchrony was assessed using tissue Doppler echocardiography. The time interval between the onset of the QRS to the peak systolic longitudinal strain at the RV free wall and the septum was obtained. The RV mechanical delay was calculated as the absolute value of the difference in the time-to-peak measurements between the RV and septum. The RV dyssynchrony was defined as the calculated delay in strain imaging, which was ± 2 SD above the mean value for the control subjects (20 cases). The RV function was evaluated using the RV fractional area change (RVFAC), tricuspid annulus plane systolic excursion (TAPSE), and peak systolic strain values of the RV free wall. Four to 7 days after CRT implantation, echocardiographic reevaluations were done.Results: The calculated cut-off value for the RV dyssynchrony was 41.5 msec, according to which the pre-CRT analysis specified two patient groups: Group 1 (16 cases) with RV dyssynchrony and Group 2 (20 patients) without RV dyssynchrony. Significant improvement in the RV dyssynchrony was noted in Group 1 after CRT (30 ± 28.9 msec vs. 68.8 ± 21 msec; p value < 0.01 vs. 14 ± 10 msec vs. 19 ± 16.5 msec; p value = 0.18 respectively). A significant correlation was found between the severity of the RV dyssynchrony and peak systolic strain in the RV free wall (r = -0.5; p value < 0.05). No significant relation was found between the RV dyssynchrony and right ventricle fractional area change (RVFAC), LV mechanical dyssynchrony, time-to-peak systolic strain in the RV free wall, QRS width, or morphology. In Group 1, the peak systolic strain increased insignificantly (p value = 0.15 for the basal segment; p value = 0.20 for the mid segment). A moderately significant correlation was found between the RV mechanical delay before CRT vs. the post-CRT values (r = 0.4; p value = 0.01).Conclusion: Early after CRT, the RV mechanical delay can improve and the significant improvement is seen in patients with baseline RV mechanical dyssynchrony.

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: The evaluation of prosthetic valves is very difficult with two-dimensional transthoracic echocardiography alone. Doppler and color flow imaging as well as transesophageal echocardiography are more reliable to detect prosthetic valve dysfunction. However, Doppler study sometimes tends to be misleading due to the load-depending characteristics of peak and mean pressure gradients. The peak-to-mean pressure decrease ratio is a load-independent measure, which was previously used for the detecting and grading of aortic valve stenosis. We assessed the usefulness of this method for the evaluation of aortic valve prosthesis obstruction.Methods: One hundred fifty-four patients with aortic valve prostheses were included in this study. Transthoracic and transesophageal echocardiographic examinations were performed in all the patients. Peak velocity and velocity time integral of the aortic valve and left ventricular outflow tract, peak and mean aortic valve pressure gradients, peak-to-mean pressure gradient ratio, and time velocity integral (TVI) index were measured.Results: There was a significant relation between the TVI index (p value < 0.001) and aortic prosthesis obstruction. A TVI index < 0.2 had a sensitivity of 71% and specificity of 100% for the detection of aortic valve prosthesis obstruction. However, no significant relation was found between the peak-to-mean pressure ratio and aortic valve prosthesis obstruction (p value = 0.09).Conclusion: Although the peak-to-mean pressure gradient (PG/MG) ratio is a simple, quick, and load-independent method which may be useful for the grading of aortic valve stenosis, it is poorly associated with aortic valve prosthesis obstruction.The TVI index is a useful measure for the detection of aortic prosthesis obstruction.

Background: There is some evidence indicating improvement in myocardial performance after atrial septal defect closure, either device closure or surgical, but ventricular dyssynchrony has not been evaluated before and after surgical closure. The aim of this study was to evaluate ventricular mechanical dyssynchrony in patients with atrial septal defect before and after surgical closure.Methods: Twenty patients (mean age: 23±11years) with isolated secundum or sinus venosus type atrial septal defect, unsuitable for device closure, were evaluated before and after successful surgical closure. Interventricular and intraventricular dyssynchrony (using 6 basal and 6 mid-segmental models) were determined.Results: A significant reduction in the right atrial and right ventricular dimensions and the tricuspid regurgitation peak gradient was noted after atrial septal defect closure (3.6±0.54 cm versus 4.2±0.7, P=0.009; 3.5±0.29 cm versus 4.3±0.41, P=0.02; and 20.4±10.5 mmHg versus 35.3±6.5, P

Background: Echocardiography is the most common test used for the evaluation of aortic regurgitation (AR). However, the role of echocardiography as an available and inexpensive method in the quantification of AR by the left ventricle to right ventricle stroke volume ratio (LV/RV SV ratio) has not been completely investigated. Methods: Between June 2005 and December 2007, 132 consecutive patients with AR (mean age: 44.7±14.6 years, 52.3% male) were enrolled in the study. All the patients underwent echocardiography; and aortography, if indicated, was performed as well.Results: Fifty-two percent of the patients had severe AR. There was almost a perfect agreement between echocardiography and cardiac catheterization in determining the severity of AR (Kappa=0.81). Associated valvular disease was found in 81.8% of the patients, the most common disease being mitral regurgitation (61%). The results of our bivariate and multivariate analyses showed a significant relation between the LV/RV SV ratio and the AR severity via either echocardiography or cardiac catheterization (both P=0.001). The receiver operating characteristic (ROC) curve analysis showed that the LV/RV SV ratio was very accurate in the detection of severe AR utilizing cardiac catheterization as the gold standard (AUC=0.71). The cut point value of the LV/RV SV ratio ≤1.5 had a sensitivity of 56% and specificity of 75% for the differentiation of non-severe from severe AR. Conclusion: Our study demonstrated that the LV/RV SV ratio was a simple and reliable method for the assessment of the severity of AR. This method is more accurate in the absence of a significant involvement of the other valves.

Echocardiography plays a fundamental role in the evaluation of patients with an intracardiac mass. The ability to distinguish tissue characteristics, location, attachment, shape, size, and mobility non-invasively, quickly, and without the use of ionizing radiation makes echocardiography the ideal diagnostic modality. With careful attention to mass location and morphology, and appropriate application of clinical information, echocardiography can usually distinguish between the three principal intracardiac masses: tumor, thrombus, and vegetation. Equivocal transthoracic findings typically indicate the need for a transesophageal evaluation, during which the atria and great vessels might be better imaged. Surgical intervention is often indicated based on possible echocardiographic findings, without the need for additional time-consuming procedures. This review will focus on cardiac tumors.

Echocardiography is a non-invasive diagnostic technique which provides information regarding cardiac function and hemodynamics. It is the most frequently used cardiovascular diagnostic test after electrocardiography and chest X-ray. However, in a patient with acute chest pain, Transthoracic Echocardiography is essential both for diagnosing acute coronary syndrome, zeroing on the evaluation of ventricular function and the presence of regional wall motion abnormalities, and for ruling out other etiologies of acute chest pain or dyspnea, including aortic dissection and pericardial effusion. Echocardiography is a versatile imaging modality for the management of patients with chest pain and assessment of left ventricular systolic function, diastolic function, and even myocardial and coronary perfusion and is, therefore, useful in the diagnosis and triage of patients with acute chest pain or dyspnea. This review has focused on the current applications of echocardiography in patients with coronary artery disease and myocardial infarction

Bifid cardiac apex is a rare anomaly of human hearts. We report of the case of a 34-year-old man with a previous history of ventricular septal defect (VSD) and subvalvular pulmonary stenosis. He had undergone pulmonary commissurotomy and VSD closure 22 years before he was referred to our center for evaluation of progressive dyspnea. Transthoracic echocardiography revealed atrial septal defect (ASD), multiple VSDs, severe pulmonary regurgitation, and a bifid cardiac apex. The patient was referred for re-do surgery for ASD and VSD closure along with pulmonary valve replacement, but he refused the surgery.

Background: Left ventricular (LV) twist is due to oppositely directed apical and basal rotation and has been proposed as a sensitive marker of LV function. We sought to assess the impact of chronic pure mitral regurgitation (MR) on the torsional mechanics of the left human ventricle using tissue Doppler imaging. Methods: Nineteen severe MR patients with a normal LV ejection fraction and 16 non-MR controls underwent conventional echocardiography and apical and basal short-axis color Doppler myocardial imaging (CDMI). LV rotation at the apical and basal short-axis levels was calculated from the averaged tangential velocities of the septal and lateral regions, corrected for the LV radius over time. LV twist was defined as the difference in LV rotation between the two levels, and the LV twist and twisting/untwisting rate profiles were analyzed throughout the cardiac cycle. Results: LV twist and LV torsion were significantly lower in the MR group than in the non-MR group (10.38˚ ± 4.04˚ vs.13.95˚ ± 4.27˚; p value = 0.020; and 1.29 ± 0.54 ˚/cm vs. 1.76 ± 0.56 ˚/cm; p value = 0.021, respectively), both suggesting incipient LV dysfunction in the MR group. Similarly, the untwisting rate was lower in the MR group (-79.74 ± 35.97 ˚/s vs.-110.96 ± 34.65 ˚/s; p value = 0.020), but there was statistically no significant difference in the LV twist rate. Conclusion: The evaluation of LV torsional parameters in MR patients with a normal LV ejection fraction suggests the potential role of these sensitive variables in assessing the early signs of ventricular dysfunction in asymptomatic patients

Background: Noninvasive techniques for the localization of the accessory pathways (APs) might help guide mapping procedures and ablation techniques. We sought to examine the diagnostic accuracy of strain imaging for the localization of the APs in Wolff-Parkinson-White syndrome. Methods: We prospectively studied 25 patients (mean age = 32 ± 17 years, 58.3% men) with evidence of pre-excitation on electrocardiography (ECG). Electromechanical interval was defined as the time difference between the onset of delta wave and the onset of regional myocardial contraction. Time differences between the onset of delta wave (δ) and the onset of regional myocardial contraction (δ-So), peak systolic motion (δ-Sm), regional strain (δ-ε), peak strain (δ-εp), and peak strain rate (δ-SRp) were measured. Results: There was a significant difference between time to onset of delta wave to onset of peak systolic motion (mean ± SD) in the AP location (A) and normal segments (B) versus that in the normal volunteers (C) [A: (57.08 ± 23.88 msec) vs. B: (75.20 ± 14.75) vs. C: (72.9 0 ± 11.16); p value (A vs. B) = 0.004 and p value (A vs. C) = 0.18] and [A: (49.17 ± 35.79) vs. B: (67.60 ± 14.51) vs. C: (67.40 ± 6.06 msec); p value ( A vs. B) < 0.001 and p value (A vs. C) = 0.12, respectively]. Conclusion: Our study showed that strain imaging parameters [(δ-So) and (δ-Strain)] are superior to the ECG in the localization of the APs (84% vs. 76%).

Background: Diabetes mellitus is capable of impairing the myocardial function. Several studies have documented the influential impact of diabetes mellitus on the left ventricular function. The right ventricular function plays a significant role in the overall myocardial contractility; hence, this study was undertaken to evaluate the effect of diabetes mellitus type II on the right ventricular function. Methods: Twenty-two diabetic patients without any coronary artery disease, hypertension, or left ventricular dysfunction were studied. The right ventricular end diastolic diameter, tricuspid plane systolic excursion, right ventricular inflow Doppler parameters, longitudinal myocardial velocities, and deformation indices from the basal and apical segments of the right ventricular free wall of the case group were measured. The control group consisted of 22 healthy individuals. Results: The tricuspid annular plane systolic excursion (TAPSE) and tricuspid peak early to peak late diastolic flow velocities ratio (E/A) in the diabetic patients were significantly lower than those of the control group patients (18.9 vs. 23.2, p value < 0.001 and 0.96 vs. 1.21, p value = 0.012), but there were no significant differences in the right ventricular end diastolic diameter and the right ventricular Tei index between the two groups (p value = 0.72). The right ventricular basal peak myocardial systolic velocity (SM) (12 cm/sec vs. 13.4 cm/sec; p value = 0.03), basal and apical right ventricular free wall systolic strain (-13.3% and -18.7% vs. -20.2% and -25.7%; p value = 0.001), and apical strain rate (-1.2 1/s vs. -1.6 1/s; p value = 0.008 ) were significantly lower in the study group. There was a weak correlation between the right ventricular function and HbA1c as well as the duration of diabetes mellitus and C-reactive protein. Conclusion: Our results suggest that diabetes mellitus type II can influence the right ventricular function in the absence ofcoronary artery disease, diastolic dysfunction, and pulmonary hypertension.

Background: The aim of this study was to echocardiographically assess the effects of EECP (Enhanced External Counterpulsation Therapy) therapy on systolic and diastolic cardiac function. Methods: LVEF (left ventricular ejection fraction), ESV (end-systolic volume), EDV (end-diastolic volume), Sm (myocardial systolic wave), Ea (myocardial early diastolic wave), Vp (propagation velocity), E/Ea (peak early diastolic transmitral flow velocity/Ea), E/Vp and diastolic function grade were studied in twenty-five patients before and after 35 hours of EECP. Results: EECP reduced ESV and EDV and increased EF significantly (p=0.018, 0.013, 0.002, respectively) in patients with baseline LVEF≤50%, but not in patients with baseline LVEF>50%. Patients with E/Ea≥14 had a significant reduction in EDV and ESV (p=0.038 and 0.32, respectively) and an increase in LVEF (p=0.007) after EECP, whereas patients with baseline E/Ea

Noncompaction of the ventricular myocardium is an embryonic cardiomyopathy that is increasingly being recognized. Noncompaction of LV myocardium, right ventricular myocardium, or both can occur in isolation, in congenital heart diseases, in valvular heart diseases, in neuromuscular disorders, skeletal abnormalities and in endocrinologic abnormalities. Clinical manifestations of ventricular non-compaction include congestive heart failure, arrhythmia, sudden cardiac death and embolic events. This report is illustrative of non-compaction left ventricle associated with WPW syndrome in a 12-year-old girl presented with aborted sudden cardiac death and heart failure.

We reported a case of patent ductus arteriosus (PDA) with congenital anomaly of coronary arteries as abnormal origin of right coronary artery (RCA) and left coronary artery (LCA) from a single ostium of the right coronary sinus. A 21-year-old man referred to our institution for evaluation of cardiac murmur. He has suffered from palpitation and atypical chest pain for three months. On physical examination, a continuous murmur was heard in the second left parasternal space. Transthoracic echocardiography showed normal left and right ventricular size and systolic function (LVEF = 55%). Main pulmonary artery (PA) and left pulmonary artery (LPA) branch were considerably dilated. Considering normal coronary flow, lack of clinical evidence of myocardial ischemia and echocardiography findings, patient underwent surgical closure of PDA via left thoracotomy and after five days discharged uneventfully.

Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made.One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction.We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamicdecompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardialeffusion with tamponade, containing a large elongated mass measuring 1 × 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured.

Background: The right ventricular (RV) dyssynchrony has not been studied extensively and the existing literature has established the effect of cardiac resynchronization therapy (CRT) on the left ventricular (LV) dyssynchrony, but there is a dearth of data on the effect of CRT on the forgotten ventricle. We sought to evaluate the presence of mechanical right ventricular dyssynchrony in patients with systolic heart failure, selected for CRT, and track the changes early afterward utilizing the longitudinal strain analysis. Methods: Thirty-six patients with severe left ventricular systolic dysfunction, candidated for CRT, were enrolled in this study. Mechanical dyssynchrony was assessed using tissue Doppler echocardiography. The time interval between the onset of the QRS to the peak systolic longitudinal strain at the RV free wall and the septum was obtained. The RV mechanical delay was calculated as the absolute value of the difference in the time-to-peak measurements between the RV and septum. The RV dyssynchrony was defined as the calculated delay in strain imaging, which was ± 2 SD above the mean value for the control subjects (20 cases). The RV function was evaluated using the RV fractional area change (RVFAC), tricuspid annulus plane systolic excursion (TAPSE), and peak systolic strain values of the RV free wall. Four to 7 days after CRT implantation, echocardiographic reevaluations were done. Results: The calculated cut-off value for the RV dyssynchrony was 41.5 msec, according to which the pre-CRT analysis specified two patient groups: Group 1 (16 cases) with RV dyssynchrony and Group 2 (20 patients) without RV dyssynchrony. Significant improvement in the RV dyssynchrony was noted in Group 1 after CRT (30 ± 28.9 msec vs. 68.8 ± 21 msec; p value < 0.01 vs. 14 ± 10 msec vs. 19 ± 16.5 msec; p value = 0.18 respectively). A significant correlation was found between the severity of the RV dyssynchrony and peak systolic strain in the RV free wall (r = -0.5; p value < 0.05). No significant relation was found between the RV dyssynchrony and right ventricle fractional area change (RVFAC), LV mechanical dyssynchrony, time-to-peak systolic strain in the RV free wall, QRS width, or morphology. In Group 1, the peak systolic strain increased insignificantly (p value = 0.15 for the basal segment; p value = 0.20 for the mid segment). A moderately significant correlation was found between the RV mechanical delay before CRT vs. the post-CRT values (r = 0.4; p value = 0.01). Conclusion: Early after CRT, the RV mechanical delay can improve and the significant improvement is seen in patients with baseline RV mechanical dyssynchrony.

Background: The evaluation of prosthetic valves is very difficult with two-dimensional transthoracic echocardiography alone. Doppler and color flow imaging as well as transesophageal echocardiography are more reliable to detect prosthetic valve dysfunction. However, Doppler study sometimes tends to be misleading due to the load-depending characteristics of peak and mean pressure gradients. The peak-to-mean pressure decrease ratio is a load-independent measure, which was previously used for the detecting and grading of aortic valve stenosis. We assessed the usefulness of this method for the evaluation of aortic valve prosthesis obstruction. Methods: One hundred fifty-four patients with aortic valve prostheses were included in this study. Transthoracic and transesophageal echocardiographic examinations were performed in all the patients. Peak velocity and velocity time integral of the aortic valve and left ventricular outflow tract, peak and mean aortic valve pressure gradients, peak-to-mean pressure gradient ratio, and time velocity integral (TVI) index were measured. Results: There was a significant relation between the TVI index (p value < 0.001) and aortic prosthesis obstruction. A TVI index < 0.2 had a sensitivity of 71% and specificity of 100% for the detection of aortic valve prosthesis obstruction. However, no significant relation was found between the peak-to-mean pressure ratio and aortic valve prosthesis obstruction (p value = 0.09). Conclusion: Although the peak-to-mean pressure gradient (PG/MG) ratio is a simple, quick, and load-independent method which may be useful for the grading of aortic valve stenosis, it is poorly associated with aortic valve prosthesis obstruction. The TVI index is a useful measure for the detection of aortic prosthesis obstruction.

Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made. One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction. We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamic decompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardial effusion with tamponade, containing a large elongated mass measuring 1 × 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured.

Background: There is some evidence indicating improvement in myocardial performance after atrial septal defect closure, either device closure or surgical, but ventricular dyssynchrony has not been evaluated before and after surgical closure. The aim of this study was to evaluate ventricular mechanical dyssynchrony in patients with atrial septal defect before and after surgical closure. Methods: Twenty patients (mean age: 23±11years) with isolated secundum or sinus venosus type atrial septal defect, unsuitable for device closure, were evaluated before and after successful surgical closure. Interventricular and intraventricular dyssynchrony (using 6 basal and 6 mid-segmental models) were determined. Results: A significant reduction in the right atrial and right ventricular dimensions and the tricuspid regurgitation peak gradient was noted after atrial septal defect closure (3.6±0.54 cm versus 4.2±0.7, P=0.009; 3.5±0.29 cm versus 4.3±0.41, P=0.02; and 20.4±10.5 mmHg versus 35.3±6.5, P

Background: Echocardiography is the most common test used for the evaluation of aortic regurgitation (AR). However, the role of echocardiography as an available and inexpensive method in the quantification of AR by the left ventricle to right ventricle stroke volume ratio (LV/RV SV ratio) has not been completely investigated. Methods: Between June 2005 and December 2007, 132 consecutive patients with AR (mean age: 44.7±14.6 years, 52.3% male) were enrolled in the study. All the patients underwent echocardiography; and aortography, if indicated, was performed as well. Results: Fifty-two percent of the patients had severe AR. There was almost a perfect agreement between echocardiography and cardiac catheterization in determining the severity of AR (Kappa=0.81). Associated valvular disease was found in 81.8% of the patients, the most common disease being mitral regurgitation (61%). The results of our bivariate and multivariate analyses showed a significant relation between the LV/RV SV ratio and the AR severity via either echocardiography or cardiac catheterization (both P=0.001). The receiver operating characteristic (ROC) curve analysis showed that the LV/RV SV ratio was very accurate in the detection of severe AR utilizing cardiac catheterization as the gold standard (AUC=0.71). The cut point value of the LV/RV SV ratio ≤1.5 had a sensitivity of 56% and specificity of 75% for the differentiation of non-severe from severe AR. Conclusion: Our study demonstrated that the LV/RV SV ratio was a simple and reliable method for the assessment of the severity of AR. This method is more accurate in the absence of a significant involvement of the other valves.

Background: The aim of this study was to echocardiographically assess the effects of EECP (Enhanced External Counterpulsation Therapy) therapy on systolic and diastolic cardiac function. Methods: LVEF (left ventricular ejection fraction), ESV (end-systolic volume), EDV (end-diastolic volume), Sm (myocardial systolic wave), Ea (myocardial early diastolic wave), Vp (propagation velocity), E/Ea (peak early diastolic transmitral flow velocity/Ea), E/Vp and diastolic function grade were studied in twenty-five patients before and after 35 hours of EECP. Results: EECP reduced ESV and EDV and increased EF significantly (p=0.018, 0.013, 0.002, respectively) in patients with baseline LVEF≤50%, but not in patients with baseline LVEF>50%. Patients with E/Ea≥14 had a significant reduction in EDV and ESV (p=0.038 and 0.32, respectively) and an increase in LVEF (p=0.007) after EECP, whereas patients with baseline E/Ea

Noncompaction of the ventricular myocardium is an embryonic cardiomyopathy that is increasingly being recognized. Noncompaction of LV myocardium, right ventricular myocardium, or both can occur in isolation, in congenital heart diseases, in valvular heart diseases, in neuromuscular disorders, skeletal abnormalities and in endocrinologic abnormalities. Clinical manifestations of ventricular non-compaction include congestive heart failure, arrhythmia, sudden cardiac death and embolic events. This report is illustrative of non-compaction left ventricle associated with WPW syndrome in a 12-year-old girl presented with aborted sudden cardiac death and heart failure.

A 48-year-old male with a history of secundum type atrial septal defect (ASD) closure in childhood presented to our outpatient clinic complaining of palpitation for six months. Interestingly, transthoracic and transesophageal echocardiography exams showed an undiagnosed partially unroofed coronary sinus associated with persistent left superior vena cava (LSVC) and Cor triatriatum.

Introduction: Heart valve injury following blunt chest trauma of car accidents is increasing. Although aortic valve involvement is rare, however, in survivors of blunt cardiac trauma it is the most commonly involved valve and the most frequent valve lesion is isolated injury of the noncoronary cusp of aortic valve. Case Presentation: A 31-year-old man with a history of car accident (five months before) was referred to our clinic because of shortness of breath. A holo-diastolic blowing murmur was heard on physical examination. Transesophageal echocardiography demonstrated severe aortic insufficiency secondary to rupture of the left coronary cusp associated with avulsion of aortic valve commissure. Conclusions: Since the aortic valve is rarely affected in blunt cardiac injury, it will be generally undiagnosed during the primary evaluation of a patient with blunt chest trauma. However, any patient presenting dyspnea after chest trauma should be examined for suspected aortic valve injury.