Purpose: Cardiac resynchronization therapy (CRT) has a positive effect on the improvement of functional mitral regurgitation in patients with heart failure with reduced ejection fraction. However geometric changes in the mitral valve apparatus, subvalvular structures and their contribution to the improvement of mitral regurgitation after CRT have not been clearly defined. The aim of our study was to evaluate the geometric parameters of mitral valve apparatus measured with 3Dimensional (3D) transesophageal echocardiography (TEE) before CRT implantation and to determine the parameters predicting the improvement of mitral regurgitation after CRT. Methods: In this prospective study thirty patients with moderate or severe mitral regurgitation with low EF heart failure planned for CRT implantation and had an indication for TEE were included. Effective regurgitant orifice (ERO) and regurgitant volume (RV) measurements were performed before CRT implantation. Detailed quantitative measurements of mitral valve were done from recorded images by 3D TEE. ERO, RV measurements were repeated to evaluate mitral regurgitation at the end of 3rd month. Results: There were no significant changes in left ventricular EF and left ventricular diameters at third month follow-up, whereas ERO and RV values were decreased. posterior leaflet angle was found higher in non-responder group compared to responder group. (28,93 ± 8,41 vs 41,25 ± 10,90, p = 0,006). Conclusion: Heart failure patients with moderate or severe functional mitral regurgitation who underwent CRT implantation were found lower posterior leaflet angle which was measured by 3D TEE in the patient group whose mitral regurgitation improved after CRT.

Left atrial intramural hematoma (LAIH) is an uncommon entity for which a timely diagnosis is critical for decision making. Cardiac surgical or catheter-based procedures are potential causing factors. Though cardiac computerized tomography and magnetic resonance are highly accurate diagnostic modalities, their role is limited by the lack of widespread availability. The present clinical case illustrates the diagnostic features of LAIH that can be obtained using echocardiography at the bedside in critically ill patients. We report a case of LAIH, that followed a catheter ablation procedure and was complicated by cardiac and cerebral ischemia. Cardiac surgical management was required.

In case of valvular infective endocarditis, the infection is mainly localized on the flow side of the valves or at damaged valvular endothelium. We describe a rare case of an aortic valvular inefctive endocarditis with an aortic-valve vegetation situated on the aortic side of the valve. We believe this is the first description of this unusual localization of vegetations in a native aortic valve.

Pulmonary artery and pulmonary valve sarcoma are malignant and very rare vascular tumors with aggressive clinical course and very poor outcomes. Patients affected by coronavirus disease of 2019 (COVID-19) are at higher risk for thromboembolism complication. we describe young woman with history of corona virus pneumonia and progressive dyspnea, hemodynamic disturbance, edema with initial evaluation and clinical diagnosis of pulmonary thromboembolism. But further imaging study and pathology demonstrated, Giant sarcoma of pulmonary valve, obstructing pulmonary valve and extending to right ventricular outflow tract and main of pulmonary artery.

BACKGROUND. Multiple Doppler Echocardiography (DE) algorithms have been proposed to estimate mean pulmonary artery pressure (PAPM) and assess pulmonary hypertension (PH) likelihood. We assessed the accuracy of 4 different DE approaches to estimate PAPM in patients with heart failure (HF) undergoing near-simultaneous right heart catheterization (RHC), and compared their diagnostic performance to identify PH with recommendation-advised tricuspid regurgitation peak velocity (TRVmax). METHODS. PAPM was retrospectively assessed in 112 HF patients employing 4 previously validated DE algorithms. Association and agreement with invasive PAPM were assessed. Diagnostic performance of DE methods vs. TRVmax=2.8m/sec to identify invasive PAPM ≥ 25mmHg were compared. RESULTS. All DE algorithms demonstrated reasonable association (r = 0.41 to 0.65; p<0.001) and good agreement with invasive PAPM, with relatively lower mean bias and higher precision observed in algorithms that included TRVmax or velocity time integral. All methods demonstrated strong ability (AUC=0.70-0.80; p<0.001) to identify PH but did not outperform TRVmax (AUC=0.84; p<0.001). Echocardiographic estimates of right atrial pressure were considered in 3 of 4 DE algorithms and falsely elevated in as many as 30% of patients. CONCLUSIONS. Echocardiographic estimates of PAPM demonstrate reasonable accuracy to represent invasive PAPM and strong ability to identify PH in HF. However, even the best performing algorithm did not outperform recommendation-advised TRVmax. The additional value of echocardiographic estimates of right atrial pressure may need to be re-evaluated.

Introduction Pregnancy is a process that causes several physiological changes including all systems as well as cardiovascular system. Ventricular hypertrophy and dilation of cardiac chambers are seen as a result of these changes. Although there are studies about pregnancy-related changes in echocardiographic examination; there is no data about the long-term effects of parity on these alterations. Therefore, we have evaluated the long-term effect of pregnancy on right ventricular (RV) dilation and RV hypertrophy and their relation to the parity number. Methods This prospective study included a total of 600 women (200 consecutive women who had no parity, 200 women who had a parity number of 1 to 4 and 200 women who had a parity number of more than 4). Right chambers’ measurements were compared between the groups. Results In echocardiographic analysis, RV and right atrial dimensions and areas and RV wall thickness were higher in parous women. On the other hand, RV systolic function parameters were significantly lower in parous women. These significant changes showed a gradual increase or decrease by increasing parity number. There were also independent relationship between the number of parity and RV hypertrophy even after adjustment for several confounders. Conclusion Pregnancy-related physiological changes mostly resolve after delivery. This study about long-term effects of pregnancy on RV has demonstrated that there is a significant relation between the number of parity and either RV dilation or RV hypertrophy. Each parity had also additive effect on these changes.

Kawasaki disease (KD) is a self-limited vasculitis with significant morbidity and even mortality if not treated early. The diagnosis and timely treatment in children younger than 3 months is challenging, most of them have an incomplete or atypical presentation. Coronary artery abnormalities are frequent in this type of patients. We present a 6-week-old female infant with Kawasaki disease who developed a giant coronary aneurysm. The timely diagnosis and promptly treatment as well as the echocardiographic and multimodality follow-up allowed us to improve our clinical approach and management.

Abnormal pulmonary venous flow patterns on fetal echocardiography and a nutmeg lung pattern on fetal magnetic resonance imaging are seen in patients with pulmonary venous stenosis. The association between these findings and the degree of pulmonary venous stenosis remains unknown. We report an extremely rare case of a fetus diagnosed with hypoplastic left heart syndrome complicated by an absent atrial septum and supracardiac total anomalous pulmonary venous connection with left pulmonary venous congestion. This case suggests that compared to non-pulsatile continuous pulmonary venous flow, the nutmeg lung pattern can only be observed with severe pulmonary congestion and advanced pulmonary lymphangiectasia.

BACKGROUND: Systemic thromboembolism is a known complication of rheumatic mitral stenosis (RMS) in sinus rhythm (SR). Left atrial appendage (LAA), the commonest site of thrombus formation is usually hypocontractile (inactive) in such patients. We aimed to study the prevalence of LAA inactivity (LAAI) in severe RMS and assess its independent predictors. METHODS: The study population consisted of 100 patients of severe RMS in sinus rhythm. Transthoracic and transesophageal echocardiography were done to assess LAA contractile function. Patients with LAA-peak emptying velocity <25 cm/sec were defined as having LAAI. RESULTS: The mean age of study subjects was 31.66±8.69 years and 56% were females. 73% patients had LAAI (Group A), while remaining 27% had normal LAA function (Group B). Mitral-valve area (MVA) and lateral annulus systolic velocity (Sa-wave) were significantly lower while mean pressure gradient across mitral valve (MGMV) and serum fibrinogen were significantly higher (all p-values <0.001) in group A patients. On multivariate regression analysis, MGMV (p<0.001), Sa-wave (p=0.02) and serum fibrinogen (p=0.005) were independent predictors of LAAI. Optimal cut-off values of MGMV, Sa-wave and serum fibrinogen for predicting LAAI were 11.5mmHg, 6.8cm/sec and 300mg/dL respectively.67(90.55%) patients in group A compared to 13(48.1%) in group B had LA/LAA smoke. LAAI was the only independent predictor of left atrium (LA)/LAA smoke and associated thrombus. CONCLUSION: There is high prevalence of LAAI in patients of severe MS in SR. MGMV, Sa-wave and serum fibrinogen levels are independent predictors of LAAI. LAAI is an independent predictor of LA/LAA smoke and associated thrombus.

Background: We aim to investigate prognostic effects of carotid strain (CS) and strain rate (CSR) in hypertension. Methods: We prospectively recruited 120 patients being treated for hypertension (65.8 ± 11.8 years, 58% male) in this observational study. Peak circumferential CS and peak CSR after ejection were identified using two-dimensional speckle tracking ultrasound. Major cardiovascular events were any admission for stroke, acute coronary syndrome, and heart failure. Results: After a mean follow-up period of 63.6 ± 14.5 months, 14 (12%) patients had cardiovascular events. Age (75.3 ± 9.2 vs. 64.6 ± 11.6 years; p = 0.001), systolic blood pressure (131.8 ± 15.5 vs. 143.1 ± 16.6 mmHg; p = 0.021), diastolic blood pressure (74.6 ±11.4 vs. 82.1 ± 12.2 mmHg; p = 0.039), use of diuretics (71 vs. 92 %; p = 0.014), carotid CS (2.17 ± 1.02 vs. 3.28 ± 1.14 %; p = 0.001), and CSR (0.28 ± 0.17 vs. 0.51 ± 0.18 1/s; p <0.001) were significantly different between the patients who did and did not reach the end-points. Multivariate Cox regression analysis controlling for age, systolic blood pressure, diastolic blood pressure, and use of diuretics showed that CS (HR 0.425, 95%CI 0.223-0.811, p = 0.009) and CSR (HR 0.001, 95%CI 0.000-0.072, p = 0.001) were independent predictors for cardiovascular events. Conclusion: In conclusions, decreased CS and CSR were associated with cardiovascular events in hypertension.

Objectives: Myocardial injury during active coronavirus disease-2019 (COVID-19) infection is well described however, its persistence during recovery is unclear. We assessed left ventricle (LV) global longitudinal strain (GLS) using speckle tracking echocardiography (STE) in COVID-19 recovered patients and studied its correlation with various parameters.Methods: A total of 134 subjects within 30-45 days post recovery from COVID-19 infection and normal LV ejection fraction were enrolled. Routine blood investigations, inflammatory markers (on admission) and comprehensive echocardiography including STE were done for all. Results: Of the 134 subjects, 121 (90.3%) were symptomatic during COVID-19 illness and were categorized as mild: 61 (45.5%), moderate: 50 (37.3%) and severe: 10 (7.5%) COVID-19 illness. Asymptomatic COVID-19 infection was reported in 13 (9.7%) patients. Subclinical LV and right ventricle (RV) dysfunction were seen in 40 (29.9%) and 14 (10.5%) patients respectively. Impaired LVGLS was reported in 1 (7.7%), 8 (13.1%), 22 (44%) and 9 (90%) subjects with asymptomatic, mild, moderate and severe disease respectively. LVGLS was significantly lower in patients recovered from severe illness (mild: -21 ± 3.4%; moderate: -18.1 ± 6.9%; severe: -15.5 ± 3.1%; P < 0.0001). Subjects with reduced LVGLS had significantly higher interleukin-6 (P < 0.0001), C-reactive protein (P = 0.001), lactate dehydrogenase (P = 0.009) and serum ferritin (P = 0.03) levels during index admission. Conclusions: Subclinical LV dysfunction was seen in nearly a third of recovered COVID-19 patients while 10.5% had RV dysfunction. Our study suggests a need for closer follow-up among COVID-19 recovered subjects to elucidate long-term cardiovascular outcomes.

Objective: Predicting postoperative atrial fibrillation (PoAF) in the preoperative period will provide a serious advantage in preventing the morbidity and mortality associated with this arrhythmia and in planning the treatment. In this study, we investigated the value of atrial electromechanical delay (AEMD) in predicting the development of PoAF. Methods: A total of 93 patients who underwent isolated coronary artery bypass grafting (CABG) operation were included in this prospective study. Patients’ demographic characteristics, laboratory parameters, echocardiographic data, and AEMD durations that could be measured by the co-use of electrocardiography and echocardiography were recorded. The patients at sinus rhythm during the postoperative period were identified as “Group 1”, and those who developed PoAF were identified as “Group 2”. Results: PoAF incidence was 26.88% (n=25). Left ventricle (LV) lateral AEMD, LV medial AEMD, right ventricle lateral AEMD, and left atrium (LA) lateral AEMD durations of Group 2 were significantly higher than Group 1 (p<0.001, p=0.004, p=0.004, p<0.001; respectively). In Univariate Logistic Regression Analysis, the age, hypertension, LA maximum volume, LA lateral AEMD and pulmonary artery pressure were significantly associated with PoAF development (p=0.01, p=0.004, p=0.004, p=0.001, p=0.01; respectively). However, only LA lateral AEMD was found as an independent predictive factor for the development of PoAF in the Multivariate Logistic Regression Analysis (OR:1.03, 95% CI:1,001-1.06, p=0.04). AUC was 0.741 for LA lateral AEMD in ROC Curve Analysis (95% CI:0.633-0.849, p<0.001). Conclusions: The development of PoAF can be predicted by AEMD durations measured in the preoperative period in patients undergoing isolated CABG.

Objective: Arterial stiffness refers to arterial wall rigidity, particularly in central vessels, and is an independent predictor of cardiovascular disease. 25-Hydroxy (OH) vitamin D has beneficial effects on blood pressure, vascular endothelial function, and arterial stiffness. Therefore, we aimed to elucidate the role of 25-OH vitamin D deficiency in arterial stiffness development and its relationship with arterial stiffness in healthy children. Methods: This study included 80 patients with low levels of 25-OH vitamin D and 40 healthy control. The study participants were then divided into three groups: group 1 consisted of patients with a deficient 25-OH D level of < 19.9 ng/mL, group 2 with an insufficient 25-OH D level between 20-29.9 ng/mL; group 3 were considered control group with a sufficient serum 25-OH vitamin D level of ≥30 ng/mL. Aortic strain, distensibility, stiffness index, and standard left ventricular measurements were calculated using M-mode echocardiographic data. Results: Left ventricular mass index (LVMI) and interventricular septal diastolic thickness (IVSTd) appeared to increase in group 1 compared to groups 2 and 3. Aortic strain and distensibility were significantly decreased in group 1, whereas aortic stiffness index and elastic modulus were significantly increased. The aortic stiffness index was negatively correlated with serum 25-OH vitamin D levels; however, aortic strain, aortic distensibility, and LVMI were positively correlated. Conclusions: Our study results revealed a significant relationship between 25-OH vitamin D levels indicative of a deficiency and aortic stiffness. We suggest that arterial stiffness may also occur in healthy children with a 25-OH vitamin D deficiency.

Aortico-left ventricular tunnel (ALVT) is a rare congenital cardiac anomaly and constitues of less than 0.1% of all congenital cardiac defects (1). ALVT is described as an abnormal connection between the ascending aorta and the left ventricul which originates commonly above the right sinus of valsalva. Most patients are diagnosed with an ALVT during early infancy (2). Although transthoracic echocardiography (TTE) is more effective in diagnosis of ALVT, misdiagnosis rate was 17.1% (3). Sinus of valsalva aneurysm (SVA) is frequently confused with ALVT (3). We report a term female newborn with SVA in echocardiographic examination but in surgery she was diagnosed with ALVT.

A congenital left atrial appendage aneurysm (LAAA) is a rare cardiac malformation that is usually diagnosed in adulthood. It is rarely diagnosed prenatally. In most cases, surgical resection is recommended soon after the diagnosis has been made due to the risk of arrhythmia and thrombotic events. The present report describes a case of LAAA which was prenatally diagnosed and was asymptomatic postnatally. Imaging revealed the relation of the cardiac and airway structures around the LAAA in detail. The patient underwent surgical resection of the LAAA successfully at 7 months of age and is currently healthy at 5 years of age.

Extramedullary involvement of the endocardium is rare in multiple myeloma. Here we describe a case of multiple myeloma (plasma cell) with extramedullary plasmablastic transformation and endocardial involvement, which resulted in partial superior vena cava obstruction. We also conducted a literature review and summary analysis of space-occupying lesions in the heart in 12 patients with multiple myeloma (including the current case) in the last 10 years. Echocardiography is the preferred radiologic examination method for diagnosis and follow-up in multiple myeloma, and surgical resection is effective for alleviating symptoms.

Prevalence of primary coronary cameral fistula (CCF) is extremely rare, especially for CCF with the drainage site into the left ventricle. We describe a 45-year-old patient with chest tightness in whom a giant aneurysm associated with proximal right coronary artery (RCA), and the distal end of RCA terminated into the left ventricle through a fistula was discovered by echocardiography. Dual-source computer tomography revealed the CCF-related giant RCA aneurysm. The drainage site and coexistent abnormality could not be visualized well by coronary artery angiography because of the severely diluted contrast medium into the aneurysm. Finally, the patient received surgical treatment and is asymptomatic now.

Intraprocedural transesophageal echocardiography (TEE) guidance plays an essential role in transcatheter repair therapy of the tricuspid valve (TV). So far, several different imaging concepts are in use. However, an imaging protocol that fully addresses the morphological complexity of the TV and further offers efficacious workarounds for the frequently occurring restrictions of TV imaging is still missing. As a tertiary referral center with a large experience of more than 250 cases of transcatheter edge-to-edge repair (TEER) of the TV performed at the Heart Valve Center in Mainz/Germany, we have constantly adapted our periinterventional echocardiographic approach to accomplish both. As a key measure for success, we intensely rely on the transgastric acoustic windows that not only delivers high-resolution information on the morphology of the TV and all relevant procedural steps but also help to avoid the frequent shadowing artefacts experienced in transesophageal imaging.