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Introduction: Multiple studies have shown the relationship between heart failure (HF) and development ofdepression. Several studies have demonstrated worse perception of quality of life among patients with type 2diabetes mellitus (T2DM). We aimed to assess the association between glycated hemoglobin (HbA1c) levelsand depression severity in patients with diabetic HF.Patients and Methods: Between July 2015 and June 2016, 179 patients with HF (left ventricular ejectionfraction < 35%) and T2DM were included in the study. Blood samples for HbA1c were obtained from patientswith T2DM. The severity of depression was assessed using the Beck Depression Inventory (BDI). Patientswith depression were classified as follows: minimal with score 0-13 (group I), mild with score 14-19 (groupII), moderate with score 20-28 (group III), and severe with score 29-63 (group IV).Results: The median age of the study population was 64 (57-75) years (98 females and 81 males). There wasno significant difference between the groups regarding the frequency of hypertension and gender. There wasa significant positive correlation between BDI and HbA1c levels in patients with HF (r= 0.488, p< 0.001).According to the analysis performed between the groups, HbA1c values were found to be significantly higher ingroup IV than in groups I, II, and III (6.0 ± 1.47, 6.4 ± 0.6, 7.03 ± 0.7, and 7.6 ± 1.23, respectively; p< 0.001),which indicate the association between severity of depression and HbA1c level.Conclusion: We detected a significant association between BDI and HbA1c level in patients with chronic HFwith T2DM. Therefore, more strict control of blood glucose level may improve quality of life and decreasedepressive symptoms in patients with diabetic HF., Giriş: Birçok çalışma kalp yetmezliği ile depresyon gelişimi arasındaki ilişkiyi göstermiştir. Bazı çalışmalartip 2 diabetes mellitus (DM) olanlarda yaşam kalitesinin bozulduğunu göstermiştir. Diyabetik kalp yetmezliklihastalarda HbA1c düzeyleri ile depresyon arasındaki ilişkiyi değerlendirmeyi amaçladık.Hastalar ve Yöntem: Temmuz 2015 ve Haziran 2016 tarihleri arasında, 179 Tip 2 DM’li kalp yetmezliğiolan (LV-EF < %35) hastalar çalışmaya dahil edildi. Tip 2 DM’li hastalardan HbA1c için kan örneklerialındı. Depresyonun şiddeti Beck Depresyon Envanteri (BDE) kullanılarak değerlendirildi. Depresyonuolan hastalar aşağıdaki gibi sınıflandırıldı: minimal skor 0-13 (grup I), hafif skor 14-19 (grup II), orta skor20-28 (grup III) ve şiddetli skor 29-63 (grup IV).Bulgular: Çalışma popülasyonunun medyan yaşı 64 (57-75) idi (kadın: 98, erkek: 81). Hipertansiyon ve cinsiyetsıklığı açısından gruplar arasında anlamlı fark yoktu. BDE skorlama sistemine göre sınıflandırılan hastalarınsayısı, I ila IV. gruplarda sırasıyla 42, 45, 46 ve 46 idi. Kalp yetmezliği olan hastalarda BDE ve HbA1c düzeyleriarasında anlamlı pozitif korelasyon vardı (r= 0.488, p< 0.001). Gruplar arasında yapılan analizlere göre HbA1cdeğerleri grup 4 te grup I, II ve III’e göre anlamlı olarak yüksek bulundu (6.0 ± 1.47, 6.4 ± 0.6, 7.03 ± 0.7, 7.6 ±1.23, sırasıyla, p< 0.001).Sonuç: Tip 2 DM’li kronik kalp yetmezlikli hastalarda BDE ve HbA1c düzeyleri arasında anlamlı ilişki saptadık. Bu nedenle, kan glukoz seviyesinindaha sıkı kontrolü, diyabetik kalp yetmezlikli hastalarda yaşam kalitesini artırabilir ve depresif belirtileri azaltabilir.

PMID:31674928 Objective: Normal reference values for the cardiac chambers are widely based on cohorts from European or American populations. In this study, we aimed to obtain normal echocardiographic measurements of healthy Turkish volunteers to reveal the age, gender, and geographical region dependent differences between Turkish populations and other populations. Methods: Among 31 collaborating institutions from all regions of Turkey, 1154 healthy volunteers were enrolled in this study. Predefined protocols were used for all participants during echocardiographic examination. Blood biochemical parameters were also obtained for all patients on admission. The American Society of Echocardiography and European Association of Cardiovascular Imaging recommendations were used to assess the echocardiographic cardiac chamber quantification. Results: The study included 1154 volunteers (men: 609; women: 545), with a mean age of 33.5±11 years. Compared to men, women had a smaller body surface area, lower blood pressure and heart rate, lower hemoglobin, total cholesterol, lower low-density lipoprotein (LDL) levels, and higher high density lipoprotein (HDL) levels. Cardiac chambers were also smaller in women and their size varied with age. When we compared the regions in Turkey, the lowest values of left cardiac chamber indices were seen in the Marmara region and the highest values were observed in the Mediterranean region. Regarding the right cardiac indices, the Mediterranean region reported the lowest values, while the Black Sea region and the Eastern Anatolia region reported the highest values. Conclusion: This is the first study that evaluates the normal echocardiographic reference values for a healthy Turkish population. These results may provide important reference values that could be useful in routine clinical practice as well as in further clinical trials.

Objective: The ambulatory arterial stiffness index has been proposed as an indicator of arterial stiffness. The aim of this study was to test the hypothesis that increased ambulatory arterial stiffness index might be related with impaired left atrial function in hypertensive diabetic patients with no previous history of cardiovascular disease. Methods: Inclusion criteria included office systolic BP> 130 mm Hg or diastolic BP> 80 mm Hg and absence of secondary causes of HT, whereas exclusion criteria LV ejection fraction

Pannus formation is an infrequent but serious complication of prosthetic heart valve surgery. The cause of pannus is recognized as a bioreaction to the prostheses; histological investigations have shown that pannus comprises collagen and elastic tissues containing endothelial cells, chronic inflammatory cells, and myofibroblasts. However, the detailed mechanism of its formation has not been fully demonstrated. We aimed to evaluate the potential role of vascular endothelial growth factor (VEGF) and matrix metalloproteinase-2 (MMP-2) in the pathogenesis of pannus formation in three patients with mechanical prosthetic heart valves. Pannus specimens removed from the prostheses were fixed in 10% neutral-buffered formalin for 24 hours after surgical removal and paraffin-embedded using standard procedures. Serial sections were cut at 4 μm for immunohistochemistry analysis. Hematoxylin and eosin (HE) was used in the histological analysis. VEGF and MMP- 2 were studied in the immunohistochemistry analysis. Three patients with mechanical prosthetic obstruction due to pannus overgrowth underwent redo valve surgery. In the first and second patients, the mitral prosthesis was explanted along with the pannus overgrowth. The third patient had both aortic and mitral prostheses; the aortic prosthesis was explanted with obstructive pannus formation, whereas the mitral valve was spared with excision of the nonobstructive pannus. The immunohistochemical study demonstrated the expressions of MMP-2 and VEGF in all of the pannus specimens acquired from these cases. VEGF and MMP-2 may play a role in the mechanism of pannus formation as the elements of the chronic active inflammatory process.

Background— Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. Methods and Results— Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25–100mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. Conclusions— Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Objectives The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies. Background The best treatment strategies for prosthetic valve thrombosis have been controversial. Methods Transesophageal echocardiography–guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates. Results The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p > 0.05 for each comparison), it was significantly lower in Group V (10.5%, p Conclusions Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320 )

Objectives: The aim of this study was to evaluate real-time 3-dimensional transesophageal echocardiography (RT-3D TEE) in the assessment of mitral paravalvular leakage curtaining surgery with a Dacron patch. Methods: RT-3D TEE was used before and after the operation. Results: Repairing a mitral paravalvular leak with Dacron patch curtaining was a useful, simple and new technique with promising feasibility and durability. Conclusions: In selected patients in whom the mitral paravalvular defect is relatively large, and may thus not be suitable for closing with primary suture, Dacron patch curtaining may be feasible for repair guided with RT-3D TEE; both are described for the first time.

Background— Distinguishing pannus and thrombus in patients with prosthetic valve dysfunction is essential for the selection of proper treatment. We have investigated the utility of 64-slice multidetector computed tomography (MDCT) in distinguishing between pannus and thrombus, the latter amenable to thrombolysis. Methods and Results— Sixty-two (23 men, mean age 44±14 years) patients with suspected mechanical prosthetic valve dysfunction assessed by transesophageal echocardiography were included in this prospective observational trial. Subsequently, MDCT was performed before any treatment was started. Periprosthetic masses were detected by MDCT in 46 patients, and their attenuation values were measured as Hounsfield Units (HU). Patients underwent thrombolysis unless contraindicated, and those with a contraindication or failed thrombolysis underwent surgery. A mass which was completely lysed or surgically detected as a clot was classified as thrombus, whereas a mass which was surgically detected as tissue overgrowth was classified as pannus. A definitive diagnosis could be achieved in 37 patients with 39 MDCT masses (22 thrombus and 17 pannus). The mean attenuation value of 22 thrombotic masses was significantly lower than that in 17 pannus (87±59 versus 322±122; P P P =0.007). Conclusions— Sixty-four slice MDCT is helpful in identifying masses amenable to thrombolysis in patients with prosthetic valve dysfunction. A high (HU≥145) attenuation suggests pannus overgrowth, whereas a lower value is associated with thrombus formation. A higher attenuation (HU>90) is associated with reduced lysis rates.

This case report describes the use of low-dose prolonged infusion of tissue-typed plasminogen activator in the treatment of renal artery thromboembolism secondary to prosthetic valve thrombosis, under the guidance of multimodality imaging. Thromboembolic occlusion of renal arteries is a rare disorder with serious consequences. It is generally associated with cardiac diseases and arrhytmias. Four consecutive doses of low-dose prolonged infusion of tissue-typed plasminogen activator [25 mg tissue-typed plasminogen activator (tpa) in 6 h] were administered to the patient. This case of renal artery thromboembolism secondary to mitral mechanical prosthetic valve thrombosis was successfully treated with low-dose prolonged infusion of tPA under the guidance of multimodality imaging with renal artery Doppler ultrasonography, multislice computerized tomographic angiography, renal angiography, two-dimensional and real-time three-dimensional transesophageal echocardiography. This case has demonstrated that low-dose prolonged infusion of tissue-typed plasminogen activator may be effective and well tolerated in the treatment of renal embolism.

WOS: 000352651800008, PubMed: 25662695, The Ceraflex atrial septal defect occluder is an alternative device to the Amplatzer septal occluder with some structural innovations including flexible connection, increased flexibility, and minimized amount of implant material. We evaluated the efficiency and safety of the Ceraflex septal occluder device in percutaneous closure of secundum atrial septal defects. This was a prospective, nonrandomized, multicenter study of patients undergoing transcatheter closure for an atrial septal defect with the Ceraflex and the Amplatzer septal occluder devices. A clinical evaluation and follow-up transthoracic echocardiography were performed at 1, 6, and 12 months. Between 2010 and 2014, 125 patients underwent atrial septal defect closure with the Ceraflex septal occluder (n = 58) and the Amplatzer septal occluder (n = 67) under transesophageal echocardiography guidance. Patient characteristics, the stretched size of the defect, device size, and fluoroscopy time were similar between the groups. The immediate and follow-up complete occlusion rates for both groups were 100%. There was no device embolization, procedure-related stroke, or pericardial effusion. The Ceraflex septal occluder is a safe and efficient device for closure of secundum atrial septal defects with no procedural complications. The Ceraflex has similar outcomes when compared with the Amplatzer septal occluder device. The advantage of the Ceraflex septal occluder device is that it can be deployed without the tension of the delivery catheter.

OBJECTIVE This study was designed to investigate the effects of dipper and nondipper patterns on global longitudinal systolic functions of left ventricle (LV) by means of two-dimensional speckle tracking echocardiography in treated hypertensive diabetic patients with preserved left ventricular ejection fraction. PATIENTS AND METHODS We enrolled 86 hypertensive diabetic patients. Twenty-four hour ambulatory blood pressure monitoring and echocardiography were performed in each patient. The relationship between dipper/nondipper patterns and global longitudinal strain (GLS) was analyzed. RESULTS Fifty-one (59.3%) patients had a nondipper pattern. GLS and average global longitudinal strain rate systolic (GLSRs) were significantly decreased (-17.8±1.5, -19.6±1.9; P

Prosthetic valve thrombosis is a life-threatening complication that is seen most commonly in patients with left-sided prosthetic valves. However, mechanical tricuspid valves carry the highest risk of thrombosis of any cardiac valve. Thrombolysis has been performed successfully in right-sided prosthetic valve thrombosis and has been recommended as the first-line treatment in these patients. Although two-dimensional and real-time three-dimensional transesophageal echocardiography are the gold standard imaging modalities for the diagnosis of prosthetic valve thrombosis, right-sided prosthetic valves may not be evaluated precisely. This is a serious problem during the follow-up of patients who receive thrombolytic therapy for tricuspid valve thrombosis. Fluoroscopy is an alternative noninvasive imaging method that provides valuable information about leaflet motion and may be used for such cases with restricted leaflets. Herein, we report a case of tricuspid valve thrombosis who was managed with low-dose (25 mg) and ultra-slow (25 hours) infusion of tissue-type plasminogen activator under the guidance of serial fluoroscopy.

Mitral valve aneurysms (MVAs) are rarely encountered in echocardiography laboratories. Although they are commonly associated with endocarditis of the aortic valve, various mechanisms have been suggested for the etiopathogenesis of MVAs associated with non-infectious conditions. 5,887 patients who underwent transesophageal echocardiography (TEE) between 2007 and 2012 were evaluated retrospectively for MVA. Mitral valve aneurysm is defined as a localized saccular bulging of the mitral leaflet towards the left atrium with systolic expansion and diastolic collapse. The color flow Doppler image of a perforation was described as a high-velocity turbulent jet traversing a valve leaflet in systole. We found that 12 of 5,887 patients (0.204 %) had MVA in TEE examinations. The mean age of patients with MVA was 53 years (range 21–80 years), including four females and eight males. Nine patients presented with symptoms of endocarditis. On TEE, aneurysms were located in the anterior mitral leaflet in 11 patients, and in the posterior mitral leaflet in one patient. Eight patients had severe, three had moderate, and one had trace mitral regurgitation. Of the nine patients with perforated leaflets, eight patients had severe and one patient had moderate mitral regurgitation. Aortic regurgitation was present in nine patients, being severe in three, moderate in two, mild in two, and trace in two patients. Two patients without severe mitral regurgitation were followed-up conservatively, while nine patients underwent surgery. Two patients died from septic shock, one in the postoperative period and the other one prior to surgery. Although MVAs occur during the course of aortic valve endocarditis and, in particular, due to aortic regurgitation jet, it should be borne in mind that they may develop as an isolated valvular pathology and may be misdiagnosed as chordal rupture, other cardiac masses, or vegetation. Thus, MVAs may not be so infrequent as they are thought; they may justify to be considered in the differential diagnosis of masses seen on the mitral valve on echocardiographic examination.

Prosthetic valve thrombosis (PVT) is a life-threatening complication. Neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) have been studied as inflammatory biomarkers in atherosclerosis, but data regarding valvular disease are lacking. The study population included patients with mitral PVT (n = 152) versus control subjects (n = 164) with functional mitral prosthesis. Transesophageal echocardiography was performed to diagnose PVT. NLR and PLR were calculated using complete blood count. C-reactive protein (CRP) levels were also analyzed. Neutrophil and platelet levels did not differ between the groups (4.9 ± 2.0 vs 4.7 ± 1.5, p = 0.84 and 254.8 ± 89.7 vs 241.5 ± 62.8 p = 0.36, respectively), but lymphocyte levels were significantly lower in patients with PVT than the controls (1.8 ± 0.7 vs 2.2 ± 0.6, p0.001). NLR, PLR, and CRP levels were significantly higher in patients with PVT than in controls (3.2 ± 2.1 vs 2.2 ± 0.8, p0.001; 163 ± 77.5 vs 114.9 ± 37.3, p0.001; and 1.97 ± 3.02 vs 1.02 ± 1.22, p = 0.01, respectively). A positive correlation was observed between NLR and PLR (r = 528, p0.001). NLR level of2.23, measured on admission, yielded an area under the curve value of 0.659 (95% confidence interval 0.582 to 0.736, sensitivity 66%, specificity 60%, p0.001) and PLR level of117.78 yielded an area under the curve value of 0.707 (95% confidence interval 0.636 to 0.777, sensitivity 70%, specificity 58%, p0.001). Multivariate analysis showed that increased PLR and inadequate anticoagulation were independent predictors of thrombosis in patients with PVT. In conclusion, patients with PVT had increased NLR, PLR, and CRP levels compared with subjects with normofunctional prosthesis, and increased PLR was an independent predictor of mitral PVT.

Previous studies have demonstrated that inflammation, neurohormonal process and cardiovascular risk factors are associated with the development of coronary artery ectasia (CAE). However, the underlying mechanisms responsible for ectasia formation are not fully understood. The neutrophil to lymphocyte (N/L) ratio has recently emerged as a new inflammation marker for cardiovascular disease.In this study, we hypothesised that CAE could be associated with more severe inflammation compared to obstructive coronary artery disease (O-CAD) with regard to N/L ratio values.A total of 405 patients with isolated CAE, O-CAD and insignificant CAD (controls) were enrolled. Severity of isolated CAE was determined according to the Markis classification. N/L ratio values were compared between the three groups.We determined that the patients with isolated CAE had significantly elevated N/L ratio values compared to O-CAD and control groups (2.5 vs. 1.9, p0.001 and vs. 1.6, p0.001, respectively). In multivariate analysis adjusted for age, sex, diabetes mellitus (DM) and hypertension, N/L ratio was independently associated with the presence (N/L ratio, OR = 2.48, 95% CI 2.03-3.02, p0. 001) and severity (DM, OR = 2.90, 95% CI 1.02-8.18, p = 0.044, N/L ratio, OR = 1.88, 95% CI 1.47-2.41, p = 0.004) of isolated CAE. ROC curve analysis revealed that a N/L ratio value of2.06 identified the patients with isolated CAE.We showed that patients with isolated CAE had a significantly higher N/L ratio than patients with O-CAD and control groups. This finding suggests that a more severe inflammatory process could be involved in the development of CAE.

Paravalvular leaks (PVLs) commonly occur in mitral prostheses. Real-time 3-dimensional transesophageal echocardiography (RT-3D TEE) may provide invaluable information about complex 3D anatomy of mitral PVLs compared to two-dimensional (2D) TEE findings. We, herein, aimed to evaluate the detailed description of anatomical characteristics of severe mitral PVLs using RT-3D TEE.Patients with diagnosis of severe mitral PVLs were simultaneously examined with 2D transthoracic echocardiography (TTE), 2D TEE, and RT-3D TEE. 3D characteristics of PVLs (localization, number, size, shape, etc.) were recorded and compared to 2D findings. Results were also compared with surgical findings.The study comprised 47 cases (3 bioprosthesis, 44 mechanical) with 61 severe mitral PVLs. The most common PVL localizations were anterolateral commissure, posteromedial commissures and posterolateral region. The mean PVL width measured by 2D TEE was 3.1±1.3 (range; 2-7) mm and the mean width of defect measured by 3D TEE was 3.1±1.1 (range; 2-7) mm (p=0.7). The mean length of defect measured by 3D TEE was 11.1±6.5 mm. The most common defect type was 'oval/round' shaped (n=29; 48%). There were also 19 'crescentic' (31%), 9 'slit like' (15%), and 2 tunnel-like shaped defects. In 22 patients, the site and dimension of the PVLs were all confirmed surgically.RT-3D TEE permits detailed structural evaluation of the prosthesis and description of paravalvular leak morphology compared to 2D TEE. It may provide more accurate information to the clinician in decision making and may contribute to the success of the potential corrective procedures.AMAÇ: Paravalvüler kaçaklar (PVK) genellikle mitral protez kapaklarda görülür. Gerçek zamanlı üç-boyutlu transözofageal ekokardiyografi (GZ-3B TÖE) iki boyutlu transözofageal ekokardiyografi (2B TÖE) ile kıyaslandığında mitral protez kapağın kompleks 3B anatomisi hakkında paha biçilmez bilgiler sunar. Bu çalışmada GZ-3B TÖE'yi kullanarak ileri mitral PVK'ların detaylı anatomik özelliklerini incelemeyi hedefledik. YÖNTEMLER: İleri PVK'sı olan hastalar eş zamanlı 2B transtorasik ekokardiyografi, 2B TÖE ve GZ-3B TÖE ile incelendi. PVK'ların 3B özellikleri (yerleşimi, boyutları, şekilleri, sayıları vs.) kaydedildi ve 2B görüntülerle kıyaslandı. Sonuçlar cerrahi bulgularla da kıyaslandı.Çalışma 47 mitral protez kapak hastasını (3 biyoprotez, 44 mekanik) ve toplam 61 PVK'yı kapsıyordu. En sık PVK yerleşimi anterolateral komissür, posteromediyal komissür ve posterolateral bölge idi. 2B TÖE ve 3B ile ölçülen ortalama defekt eni sırasıyla 3,1±1,3 (aralık; 2-7) mm ve 3,1±1,1 (aralık; 2-7) mm idi (p=0,7). 3B TÖE ile ölçülen defekt uzunluğu ise 11,1±6,5 mm idi. En sık defekt türü 'oval/yuvarlak' (n=29; %48) idi. Ayrıca 19 hilal şekilli (%31), 9 kesik şekilli (%15) ve 2 tünel-tipi şekil saptandı. PVK yeri ve boyutları 22 hastada cerrahi ile doğrulandı. SONUÇ: GZ-3B TÖE, 2B TÖE'e nazaran protez kapağın yapısal özelliklerinin ve defekt morfolojisinin detaylı incelenmesine olanak tanır. Klinisyene klinik karar verme aşamasında daha doğru bilgiler sunabilir ve olası girişimsel işlemlerin başarısını arttırabilir.

Purpose: Although nonobstructive prosthetic valve thrombosis (PVT) does not develop hemodynamic compromise, it carries potential risk for thromboembolism. Real time three-dimensional transesophageal echocardiography (RT-3DTEE), has emerged as a complementary tool in depicting “en face” views of prosthesis compared with two-dimensional transesophageal echocardiography (2DTEE). We aimed to evaluate the utility of RT-3DTEE in assessment of mitral ring-located thrombosis. Method: We present 3 cases of mechanical mitral valve thrombosis complicated by thromboembolism, who were all examined and followed-up by 2D transthoracic echocardiography (TTE), 2DTEE, and RT-3DTEE. Result: The consequencies of thromboembolism in the patients were coronary embolism, transient ischemic attack, and ischemic stroke, respectively. They were all inadequately anticoagulated at the time of admission. 2DTTE and TEE examination was unsatisfactory; RT-3DTEE depicted nonobstructive mitral ring thrombosis in each of the patients. The patients were followed up under effective anticoagulation and antiplatelet therapy. RT-3DTEE was able to demonstrate the evolution of thrombus size in each of the patients. Conclusion: Nonobstructive ring-located PVT which poses risk for thromboembolism, may be diagnosed with certainty and imaged with clarity utilizing RT-3DTEE. (Echocardiography 2013;0:E1-E5)

Although 2-dimensional (2D) transesophageal echocardiography (TEE) is the gold standard for the diagnosis of prosthetic valve thrombosis, nonobstructive clots located on mitral valve rings can be missed. Real-time 3-dimensional (3D) TEE has incremental value in the visualization of mitral prosthesis. The aim of this study was to investigate the utility of real-time 3D TEE in the diagnosis of mitral prosthetic ring thrombosis. The clinical outcomes of these patients in relation to real-time 3D transesophageal echocardiographic findings were analyzed. Of 1,263 patients who underwent echocardiographic studies, 174 patients (37 men, 137 women) with mitral ring thrombosis detected by real-time 3D TEE constituted the main study population. Patients were followed prospectively on oral anticoagulation for 25 ± 7 months. Eighty-nine patients (51%) had thrombi that were missed on 2D TEE and depicted only on real-time 3D TEE. The remaining cases were partially visualized with 2D TEE but completely visualized with real-time 3D TEE. Thirty-seven patients (21%) had thromboembolism. The mean thickness of the ring thrombosis in patients with thromboembolism was greater than that in patients without thromboembolism (3.8 ± 0.9 vs 2.8 ± 0.7 mm, p0.001). One hundred fifty-five patients (89%) underwent real-time 3D TEE during follow-up. There were no thrombi in 39 patients (25%); 45 (29%) had regression of thrombi, and there was no change in thrombus size in 68 patients (44%). Thrombus size increased in 3 patients (2%). Thrombosis was confirmed surgically and histopathologically in 12 patients (7%). In conclusion, real-time 3D TEE can detect prosthetic mitral ring thrombosis that could be missed on 2D TEE and cause thromboembolic events.

Transcatheter closure of mitral prosthetic paravalvular leak (PVL) has been hampered by technical challenges and the lack of closure devices specifically designed for this purpose. The oblong cross-sectional shape of the Amplatzer Vascular Plug III device (AVP) may be a more appropriate choice to be deployed for mitral PVL's. Real-time three-dimensional transesophageal echocardiography (RT-3D TEE) has emerged as an efficient tool that provides essential information concerning leakage size, location, and shape as well as navigation of catheters and wires. We assessed the feasibility and short, mid, and long-term efficacy of transcatheter mitral PVL closure using AVP-III under the guidance of RT-3D TEE. Three patients with severe symptomatic mitral PVL at high risk for repeat surgery underwent transcatheter leak closure with AVP III. Transfemoral approaches were used under RT-3D TEE guidance. Transcatheter closure of mitral PVLs was performed successfully in 3 patients using 5 devices. The first patient with 2 devices deployed had residual mitral regurgitation resulting in re-operation at the sixth month. The second patient had improved normally with a functioning prosthesis after the deployment of two devices, but had progressively worsening mitral regurgitation for which re-operation at the sixteenth month of follow-up was necessary. The third patient had no residual leak, with normal prosthetic function. At 24 months follow-up, all patients were in satisfactory clinical status. Although RT-3D TEE plays an essential role in guidance of transcatheter closure of mitral PVLs with AVP III, the absence of a specific closure device limits mid and long-term success rates.

The aim of this prospective study was to identify the most effective and safest regimen among different thrombolytic treatment strategies.The best treatment strategies for prosthetic valve thrombosis have been controversial.Transesophageal echocardiography-guided thrombolytic treatment was administered to 182 consecutive patients with prosthetic valve thrombosis in 220 different episodes (156 women; mean age, 43.2 ± 13.06 years) between 1993 and 2009 at a single center. These regimens chronologically included rapid (Group I), slow (Group II) streptokinase, high-dose (100 mg) tissue plasminogen activator (t-PA) (Group III), a half-dose (50 mg) and slow infusion (6 h) of t-PA without bolus (Group IV), and a low dose (25 mg) and slow infusion (6 h) of t-PA without bolus (Group V). The endpoints were thrombolytic success, in-hospital mortality, and nonfatal complication rates.The overall success rate in the whole series was 83.2%; it did not differ significantly among Groups I through V (68.8%, 85.4%, 75%, 81.5%, and 85.5%, respectively; p = 0.46). The overall complication rate in the whole series was 18.6%. Although the overall complication rate was similar among Groups I through IV (37.5%, 24.4 %, 33.3%, and 29.6%, respectively; p0.05 for each comparison), it was significantly lower in Group V (10.5%, p0.05 for each). The combined rates of mortality and nonfatal major complications were also lower in Group V than in the other groups, with all differences significant except for comparison of Groups IV and V. By multivariate analysis, the predictors of combined mortality plus nonfatal major complications were any thrombolytic therapy regimen other than Group V (odds ratios for Groups I through IV: 8.2, 3.8, 8.1, and 4.1, respectively; p0.05 for each) and a history of stroke/transient ischemic attack (odds ratio: 3.5, p = 0.011). In addition, there was no mortality in Group V.Low-dose slow infusion of t-PA repeated as needed without a bolus provides effective and safe thrombolysis in patients with prosthetic valve thrombosis. (Comparison of Different TRansesophageal Echocardiography Guided thrOmbolytic Regimens for prosthetIc vAlve Thrombosis; NCT01451320).

Background Low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator (t-PA) with repetition as needed has been shown to provide effective and safer thrombolysis in patients with prosthetic valve thrombosis (PVT). Further prolonging the infusion time may be rational with regard to reducing complication rates without reducing success rates. We aimed to investigate the efficacy and safety of ultraslow (25 hours) infusion of low-dose (25 mg) alteplase (t-PA) for PVT. Methods and results Transesophageal echocardiography–guided thrombolytic therapy (TT) was administered to 114 patients with PVT in 120 different episodes between 2009 and 2013 in a single center. Prosthetic valve thrombosis was obstructive in 77 (64.2%) and nonobstructive in 43 (35.8%) episodes. Ultraslow infusion (25 hours) of low-dose (25 mg) t-PA, as the TT regimen, was used in all patients admitted with PVT. The end points were thrombolytic success, mortality, and complication rates. The overall success rate of TT was 90% (95% CI 0.85-0.95). The univariate predictors of an unsuccessful result were higher New York Heart Association (NYHA) class, thrombus cross-sectional area, duration of suboptimal anticoagulation, lower baseline valve area, and presence of atrial fibrillation. The NYHA class was the only independent predictor of TT failure by multiple variable analysis. The overall complication rate was 6.7% (3.3% nonfatal major, 2.5% minor, and 0.8% death). The predictors of complications were presence of atrial fibrillation, higher NYHA class, and thrombus area. Conclusion Ultraslow (25 hours) infusion of low-dose (25 mg) t-PA without bolus appears to be associated with quite low nonfatal complications and mortality for PVT patients without loss of effectiveness, except for those with NYHA class IV.

A 57-year-old woman was admitted to our hospital with tachycardia and progressive dyspnea. The patient had a DDDR permanent pacemaker that was implanted 10 years ago because of complete AV block. A procoagulant state and lower limb venous thrombosis were not reported. Twodimensional transthoracic echocardiography revealed a mobile mass in the right and left atria, attached to the atrial pacemaker lead. Two-dimensional transesophageal echocardiography (2D-TEE) visualized a vermicular thrombus trapped in the patent foramen ovale (PFO) with floating parts in both atria and partially prolapsing into both ventricles during diastole (Fig. 1, videos 1 and 2 in the Supplementary Material). There was no evidence of thrombus in the pulmonary arteries. Computed tomography (CT) scan showed no pulmonary embolism. Neurologic examination and lower venous Doppler ultrasound imaging showed no abnormality. Anticoagulation therapy with unfractionated heparin was started and the patient was referred to the cardiac surgery department. Biatrial thromboembolectomy and surgical removal of the endocardial lead were successfully performed, and the foramen ovale was closed by primary suture (Fig. 2). The patient’s postoperative course was uneventful. Since there was no history of atrial fibrillation and procoagulant disease, oral anticoagulation was initiated and prescribed for 6 months. Although atrial thrombi have previously been reported in the presence of PFO [1–4], this unusual occurrence of a pacemaker lead crossing a PFO is unique. This is the first example of thrombus originating from a pacemaker lead and extending to the left atrium via the PFO.

A 54-year-old woman who had undergone mitral valve surgery (29 No BiocorTM porcine prostheses) 21 years earlier was admitted to the emergency department complaining of transient loss of vision in the left eye for five minutes. The bioprosthetic valve had been preferred as the patient had desired pregnancy. On admission, her neurological and retinal fundus examinations were normal as well as cranial computed tomography. She had been complaining of progressive dyspnea for the past five years. Transthoracic echocardiography showed normal left ventricular systolic functions. Subsequently, two-dimensional (2D) transesophageal echocardiography (TEE) revealed increased transvalvular gradients (25/12 mmHg) with decreased valve area (1.1 cm2). Two mobile thrombi (5 mm and 3 mm) were detected on the left atrial side of the leaflets (Fig. A, Video 1*). Real-time (RT) three-dimensional (3D) TEE confirmed the presence of mobile thrombi on the left atrial side of the bioprosthetic valve (Fig. B, Video 2*). Doppler ultrasound revealed normal blood flow in carotid and vertebral arteries, which led us to consider that the thrombi on the bioprosthetic valve was likely to be the source of thromboembolism and transient ischemic attack. The patient underwent redo valve surgery, and the degenerated bioprosthetic valve was replaced with a mechanical valve (29 mm Carbomedics). The thrombi were observed on the atrial side of the valve during surgery (Fig. C), and pathological examination confirmed the diagnosis of thrombosis. Unlike mechanical prosthetic valves, bioprosthetic valves are associated with a very low rate of thrombosis. Thromboembolic complications may be associated with bioprosthetic valve thrombosis. RT-3D TEE permits detailed structural assessment of prosthetic valves and therefore has advantages over 2D TEE in terms of depiction of prosthetic valve thrombosis. 496