Minimal Mitral Regurgitation Research Articles

Isolated anterior mitral valve leaflet cleft repair with minimally invasive cardiac surgery using ORBEYETM

The cleft mitral valve leaflet is a common cause of congenital mitral regurgitation and is most often associated with other congenital heart defects, usually endocardial cushion defects. Cases in which cleft mitral valve leaflet is found without an associated defect are called isolated mitral valve clefts. We report a case of mitral valve repair for severe MR due to an isolated cleft with minimally invasive cardiac surgery using ORBEYETM in a 16-year-old male patient. Mitral regurgitation caused due to a defect in the anterior leaflet of the isolated mitral valve was observed on echocardiography. Minimally invasive cardiac surgery was performed using ORBEYETM, a newly developed surgical microscope, and the cleft was closed using interrupted sutures. The postoperative course was uneventful, with minimal mitral regurgitation observed. Therefore, early intervention should be considered for severe mitral regurgitation due to a mitral valve leaflet cleft.

EARLY DIAGNOSIS OF HYPERTENSIVE DISEASE IN YOUTH WITH NORMAL SYSTOLIC AND DIASTOLIC BLOOD PRESSURE LEVELS

Objective: Hypertensive cardiovascular disease can develop functional and/or structural organ damage by the increase of the volume/pressure and arterial stiffness, even before the current cut-off level of the systolic/diastolic blood pressure. The aim of this study was to evaluate in a young population with normal blood pressure levels if they presented any cardiovascular risk factors, arterial stiffness, signs, and symptoms of hypertensive disease. Design and method: This is a retrospective cross-sectional study developed between the years 2007/2022 from 9,600 non-invasive applanation tonometry, females-males 200-103 were entered, with an age range of 18 and 30 years old, and an average age of 24 years. Patients made their first cardiology visit without a previous diagnosis of arterial hypertension or decompensated associated diseases with a blood pressure not higher than 130/80 mmHg. Anthropological data, systolic/diastolic blood pressure, and heart rate were registered. Central Haemodynamics Parameters were measured with a SphygmoCor-PVX device (AtCor, Australia), a validated system employing the high-fidelity technique of applanation tonometry according to established protocols. Results: The average systolic/diastolic blood pressure among female-male was 112.9/72.4 mmHg-119.8/73.9 mmHg, respectively. Also, the Central Aortic Pressure in the female-male groups was 100.0 mmHg/103.7 mmHg, while the maximum values are 101.5 mmHg/106.0 mmHg, but the differences between the observed values and the normal levels of the Augmentation Index (a surrogate measure of arterial stiffness) were higher than normal in female-male 3.6%-4.6% indicating an incipient arterial stiffness. Into the female-male groups, were observed hyperlipidemia 10%-10%, smoking 26%-20%, minimal-mitral regurgitation 5%-8%, headache 46%-26%, palpitations 33%-25%, asthenia 22%-14%, sweating 9%-14%, and chest-pain 16%-27%, respectively. The percentage of women who had a history the polycystic ovarian syndrome was 19%, and the women in current or former estrogen-progesterone therapy were 17%-12%, respectively. Among the female-male groups that do not register any risk factor, symptoms, signs, or arterial stiffness were 8.5%-10%. Conclusions: In young people with normal blood pressure values, it is important to know the risk factors, symptoms, signs, and arterial stiffness of hypertensive disease for early diagnosis and to be able to optimize the time to start therapy.

WHAT IS THE MEANING OF FINDING A WANDERING ATRIAL RHYTHM?

Objective: To know if the presence of a Wandering Atrial Rhythm (WAR), from childhood, is a pathophysiological condition that should be interpreted as an early sign of hypertension. Design and method: For this cross-sectional retrospective study, data were collected from 251 patients with episodes of WAR, registered during 24hs-Holter monitoring. Female-male (F-M) 126–125 mean age (SD) 56 (18.4) - 52 (18.3) from 6 to 89 years. Some patients were unaware of having hypertension, others with and without antihypertensive therapy. Was registered the anthropomorphic measures, systolic and diastolic blood pressure (S-DBP), heart rate, Central Haemodynamics Parameters, and difference of augmentation index (Diff-AIx) between observed values and normal levels, evaluated by applanation tonometry according to established protocols (SphygmoCor System-PVX AtCor-Medical Australia). Results: In the sample of males who were overweight from the 30 s, in females overweight/obese from the 40 s. In this study, the average of S-DBP before 20 years was registered in F-M 113.9/69–113.9/67.9 mmHg, and from 20 years to octogenarians in F-M was 140/82.5–136.8/84.2 mmHg. Among the groups of the F-M from 40–20 years, the average BP was higher than 120/80 mmHg. In all groups, the Central Haemodynamics Parameters (principally end-systolic pressure) and Diff-AIx (surrogate value of arterial stiffness) were higher than normal. A minimal mitral regurgitation was found in a female-male 38%-33.6% after 18–11 years, and brief phases of atrial fibrillation were found in 23%-19.2% from 35–48 years, respectively. Conclusions: Wandering Atrial Rhythm appearance is more early in life than minimal mitral regurgitation, it was observed during life even in octogenarians, which is correlated with an increase of S-DBP and Central Haemodynamics Parameters, and the frequent presence of atrial fibrillation. It could be interpreted as an early sign of hypertension from childhood.

Is the minimal mitral regurgitation a marker of high blood pressure, and can predispose to the appearance of atrial fibrillation?

Abstract Background Leonardo da Vinci intuited that the cardiac valves were the key to the functioning of the heart. Minimal mitral regurgitation (MMR) in young's is often interpreted as haemodynamically insignificant, it is attributed that it starts from birth or named para-physiologic effect. Pathophysiological changes in the arterial wall can lead to mitral regurgitation, left atrial enlargement, and atrial fibrillation (AF). Purpose The aim of this study is to know if the presence of MMR is a consequence of the High Blood Pressure (BP), and whether in the own evolution can contribute to the appearance of the AF. Methods For this cross-sectional retrospective study, data were collected from 436 patients. Female-Male: 249–187 from the 20 to the 89 years old, mean age (±SD) 59.6 (16.5) – 59.7 (16.1), divided and analyzed in each one of them all 7 decades. All patients had MMR. Some patients were unaware of having hypertension, others with and without antihypertensive therapy. The measures of BP were registered in mmHg. The finding of AF was confirmed with the presence of brief phases in the 24hs-Holter monitoring. The Central Haemodynamic Parameters (CHP) were measured with a SphygmoCor System PVX (AtCor-Medical Australia), a validated device employing the high-fidelity technique of applanation tonometry according to established protocols. Also, the difference of Augmentation Index (between the normal levels and the observed values) was assessed according to the normal range by age. Results In all patients female - male, the mean (±SD) of SBP/DBP 142.7 (24.5)/83.7 (13.6) – 137.7 (20.2)/82.4 (11.3) was higher than normal levels of BP accepted by ESC/ESH. All measures of CHP and SBP/DBP increased with age in each decade, in female from the 20s 120.3 (18.9)/76.7 (14.1) to the 80s 160.4 (21.1)/86.0 (25), and in male from the 20s 133.7 (16.7)/78.9 (6.4) to the 70s 142.8 (23.5)/78.8 (12.4), but slightly decreased in the 80s 138.4 (20.4)/76.6 (8.0). The difference of Augmentation index (surrogate value of arterial stiffness) in all decades was higher too, for both genders. In the adult total sample, in female - male the AF reached 26.5% - 27.8%, beginning after 33 years old, and strongly increased its prevalence after the 60s to a top of 50.0% - 43.8% at 80s. Conclusions MMR can be an early marker of high BP levels, the prevalence increasing with age, and it would be a predisposing condition to evolving to AF. The appearance of MMR principally among younger can indicate that the brachial BP found is higher than “normal”, needing any time to modify the original ventricular geometry toward myocardial remodelling, Therefore, it should be reassessed the optimal levels of BP to avoid its complication. Funding Acknowledgement Type of funding sources: None.

Electrocardiographic changes in young patients with spontaneous pneumothorax: A retrospective study.

Primary spontaneous pneumothorax (PSP) commonly occurs in adolescents. PSP symptoms can mimic cardiac event. We aimed to examine electrocardiography (ECG) changes that accompanied PSP in relation to side and size of pneumothorax.A retrospectively reviewed 57 adolescents presented with PSP and underwent a cardiac evaluation.Overall, 49 patients (86%) were male, median age of 16 years. Of these, 1 patient had a known mitral valve prolapse. In 56 patients the initial episode of PSP was unilateral (16 left sided and 40 right sided), and 1 was bilateral. The main initial symptom was chest pain or dyspnea and chest pain 66.6% and 33.3% respectively. Small pneumothorax was right and left sided in 1and 8 patients respectively, medium right (n = 8) medium left (n = 22), large right (n = 7) and large left (n = 10). One additional patient had medium bilateral pneumothorax. ECG findings were abnormal in 12 patients (21%) and included ST elevation in 5 patients, inverted T wave in 2 patients, incomplete right bundle branch block in 2 patients, poor R wave progression, left axis deviation and low QRS voltage in 1 patient each. Only 2 patients had abnormal echocardiography findings, MPV (n = 1) and minimal mitral and tricuspid regurgitation (n = 1). Serum troponin-T levels were normal in all patients.ECG changes were found in 21% among pediatric patients with PSP. No correlation was observed between ECG changes and side/size of pneumothorax. It is important to rule out pneumothorax among children presented with chest pain, dyspnea and ECG changes.

Interdisciplinary approach to surgical treatment for patients with hypertrophic obstructive cardiomyopathy

Hypertrophic cardiomyopathy (HCM) – is the most common genetically determined heart disease, characterized by symmetrical or asymmetrical myocardial thickening (≥15 mm), leading to progressive heart failure and a high risk of sudden cardiac death (SCD). Diagnosis, natural course and treatment of HCM have become sources of uncertainty, misunderstanding and debate due to the increasing complexity of diagnosis in clinical practice, international differences in strategic approaches, advances in the treatment of genetic diseases and cardiac imaging. The aim. To amplify the current concept of HCM pathogenesis and mechanisms of the left ventricular outflow tract (LVOT) obstruction as well as to highlight our own results of HCM surgical correction. Materials and methods. A total of 330 HCM patients underwent surgical correction (septal myectomy) in the National M. Amosov Institute of Cardiovascular Surgery affiliated to National Academy of Medical Sciences of Ukraine. The mean age of the patients was 49.7 ± 15.0 years, median – 53; 168 (50.9 %) were male. Results. Surgical correction of HCM significantly improves the quality of life (80 % of patients were in NYHA II functional class after correction), reduces the symptoms of heart failure (93 % of patients had minimal mitral regurgitation after septal myectomy), decreases LVOT systolic pressure gradient (SPG) (the mean SPG was 18.9 ± 8.5 mmHg versus preoperative 93.6 ± 23.2 mmHg) and lowers the high-risk for SCD in the patients (the mean percentage of high-risk group was 3.78 % after correction). Routine CT planning and intraoperative transesophageal echocardiography helps to avoid severe iatrogenic complications and resect the interventricular septum as accurately as possible, completely eliminating LVOT obstruction. Conclusions. Secondary abnormal chordal attachment cutting, papillary muscle realignment and anterior mitral leaflet plication along with septal myectomy allows to fully correct all phenotype of HCM, is the safe and effective procedure as well as the definitive method of this pathology treatment minimizing the risk of disease recurrence.

WHAT DOES THE FINDING OF MINIMAL MITRAL REGURGITATION MEAN?

Objective: bjective: Leonardo da Vinci intuited that the cardiac valves were key to the functioning of the heart. Minimal mitral regurgitation in young's is often interpreted as haemodynamically insignificant. Morphological changes in the arterial wall can lead to mitral regurgitation, left atrial enlargement, and atrial fibrillation (AF). The aim is to know the measures of the central haemodynamic parameters (CHPs), brachial blood pressure (BP) values, and the prevalence of headache and AF, in both genders with minimal mitral regurgitation. Design and method: Design and Methods: For this cross-sectional retrospective study, data were collected from 323 patients: Female/Male 189/134, from 20 to 89 years old, divided and analyzed in each one of the 7 decades. Some patients were unaware of having hypertension, others with and without antihypertensive therapy. The finding of AF was confirmed with the presence of brief phases in the 24hs-Holter monitoring. The CHPs were measured with a SphygmoCor System PVX (AtCor-Medical Australia), a validated device employing the high-fidelity technique of applanation tonometry according to established protocols. Also, the difference of Augmentation Index (Diff-AIx) between the normal levels and the observed values was assessed according to normal range by age. Results: Results: Average BP was higher than normal: Female- Male 141/83–137/82 mmHg. CHPs and BP values increased in each one of the 7 decades, both genders. Frequently, the patients were symptomatic, among the female/male the headache was found in 61%/25%, with a high prevalence of up to 69 years old in 85%/88% of them. Also, they presented symptoms such as sweating, asthenia, thoracalgia, palpitations. Hypertension would not be silent chronic disease. AF was found in 49 patients (15%), female/male 22/ 27 (12%/20%), increasing the prevalence with age, after 50/60 years old was observed in 68/78%. Conclusions: Conclusions: Minimal mitral regurgitation would not be a bystander, it can be the consequence of the higher values of the brachial BP, the central haemodynamic parameters and the Diff-AIx. The appearance of minimal mitral regurgitation principally among younger can indicate that the brachial BP found is higher than normal and the optimal levels should be reassessed.

PIMS-a new pediatric challenge

Der Fall eines 9 Jahre alten Patienten, der im Rahmen eines septischen Schocks an unsere Intensivstation transferiert wurde, wird beschrieben. Neben der Differenzialdiagnose eines „Toxic-shock“-Syndroms wurde auch die Verdachtsdiagnose eines „pediatric inflammatory multisystem syndrome“ gestellt, welche sich laborchemisch bestätigte. Er erhielt eine Therapie mit IVIG, Methylprednisolon, ASS sowie hämodynamischen Support (u. a. Katecholamine). Aufgrund der Schwere der Symptomatik mit Schock und kardialer Einschränkung ist die Betreuung dieser Patienten in einem Zentrum mit PICU-Hintergrund essenziell.

Abstract 494: Mitral to Meninges: Aspergillus Endocarditis With Septic Emboli

Introduction: Fungal endocarditis comprises less than 2% of infective endocarditis, with Aspergillus causing less than 28% of fungal endocarditis. Fungal endocarditis should be suspected in immunocompromised patients with persistent fevers, negative blood cultures, and vegetation on echocardiography. Invasive Aspergillus can affect any organ, but typically begins in the respiratory tract. Mortality rates climb to 90% with signs of hematogenous spread, such as cerebral abscesses. Case Presentation: Patient is a 53-year-old female with a past medical history of Sweet syndrome and chronic pancreatitis. Patient was admitted for persistent fevers and confusion. Patient was tachycardic but normotensive with a temperature of 102.5 F. Labs included significantly elevated serum LDH and Beta-D-Glucan. Blood cultures remained negative. Lumbar puncture cultures were negative; CSF cytology revealed pleocytosis with positive Aspergillus galactomannan serum antigen. Head MRI revealed multiple peripherally enhancing supratentorial lesions and intracranial abscesses (largest 8.4 mm) with ventriculitis of lateral ventricles, right greater than left. Transesophageal Echocardiogram (TEE) revealed mitral valve vegetation at A2 segment, no surrounding perivalvular abscess, minimal mitral regurgitation (MR). Management: Antibiotics were discontinued and patient was counseled on avoiding glucocorticoids. Patient was transferred to large tertiary center for Neurosurgery evaluation but was not candidate for biopsy/aspiration of the ring-enhancing lesions per Neurosurgery. Cardiothoracic Surgery was also consulted and patient was not a candidate for mitral valve replacement due to small size of vegetation without abscess and only mild MR. Voriconazole was continued and patient ultimately demonstrated a slow improvement in her strength and mental status over the next 6 months. Discussion: Mitral endocarditis from Aspergillus is rare but has a very high mortality rate. This case illustrates the importance of early recognition of systemic fungal infections in the setting of immunosuppression. Glucocorticoids and broad-spectrum antibiotics placed this patient at elevated risk for invasive Aspergillosis, which led to mitral endocarditis and subsequent cerebral abscesses from septic emboli.

Transesophageal guidance for trans-catheter trans-septal mitral valve in valve implantation

Introduction In patients with high surgical risks, transcatheter mitral valve-in-valve replacement (VIV-TMVR) offers a less invasive alternative to open surgical approach for failing mitral bioprosthetic valves (1). Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) in failing aortic valve bioprosthesis is already an established technique worldwide (2). Transesophageal echocardiography (TEE) plays a vital role in the intraoperative management of these cases. Here we describe the approach to TEE evaluation and guidance of VIV-TMVR. Methods TEE is used for full assessment of the heart pre-procedurally as well as throughout the procedure to guide the placement of the new mitral valve and at the end to assess the integrity of the placement and to detect any complications.Both 2D B and color doppler modes as well as real-time, zoom and full volume 3D TEE modalities can be used to serve different purposes. Results Successful placement of an Edward Sapien S3 Valve (29 mm) under TEE guidance Discussion Pre-procedurally, severity and etiology of the bioprosthetic mitral valve disease should be confirmed using TEE (Fig 1A) as well as identification of factors that would contraindicate a VIV-TMVR such as infective endocarditis, severe paravalvular leak, bioprosthetic valve dehiscence or significant prosthesis-patient mismatch. It is also imperative to complete a baseline assessment of the right and left ventricular size and function, left atrial size and look for any pericardial effusion. During the procedure, TEE may rarely be used for guidewire placement into the IVC by the interventional cardiologists. Next, a combination of bicaval (90-110°) and aortic short axis (30-45°) views are used to guide the cardiologist to puncture the interatrial septum. The ideal site for puncture in these cases is determined in mid systole to be posterior and superior on the septum about 3-4 cm above the mitral annular plane. (Fig 1B) The puncture and passing of guidewire into the left atrium is followed by the passing of the valve deployment system, all of which are easily visible on TEE toggling between 2D and live 3D modes. (Fig 1C,D&E) Post-deployment TEE assessment include confirmation of the stability of the new valve as well as ensuring leaflets are moving freely with no or minimal mitral regurgitation, no paravalvular leaks and no flow restriction across the valve. (Fig 1F) The size, severity and directionality of the interatrial shunt created by the iatrogenic atrial septal puncture site should be assessed using color and spectral doppler, (Figure 1G) which may require placement of an Amplatzer ASD percutaneous closure device (Figure 1H).

Balloon Mitral Valvotomy in Indigenous Patients With Rheumatic Heart Disease

Background: Approximately 3% of young Indigenous Australians suffer from rheumatic heart disease (RHD) and it is also common in Asian and African migrants. Though percutaneous balloon mitral valvotomy (PBMV) is widely performed procedure throughout the world, it is sparingly done in Queensland as evidenced by the Qcor data which shows the total number of PBMV's in 2017 was only six. Results: Between 2015 to 2018, five patients were referred for a BMV procedure to The Townsville Hospital. Four patients were identified as Indigenous and one was of Philippines descent. Most of the Indigenous patients were females (75%) belonging to 34–39 years age group. All of them reside in remote areas, present to hospitals late as family and cultural factors play an important role in their health decisions. A detailed echocardiographic assessment showed severe mitral stenosis with Wilkins score of 8 or greater and moderate to severe pulmonary hypertension. All cases were performed under local anesthesia and fluoroscopic guidance except for one case which required intracardiac echocardiography. Brockenbrough needle was utilized for transeptal puncture and Inoue balloons for percutaneous mitral valvotomy. One patient was referred for surgery after two failed attempts. In successful patients, the mean transmitral resting gradients dropped from 15 mm Hg to 4 mm Hg. There were no complications during the procedures and the patients remained asymptomatic after one year of follow up. Conclusion: PBMV is a safe, cost-effective and possibly underutilized treatment option for RHD in the Indigenous population with pliable valves and minimal mitral regurgitation.

Pulmonary Autograft Mitral Valve Replacement (Ross II): Long-Term Follow-Up of a US Center.

Mitral valve replacement (MVR) with a pulmonary autograft (Ross II) may be a useful technique for pediatric and young adult patients who wish to avoid anticoagulation. Our aim was to evaluate the long-term outcomes of the Ross II procedure at our institution. Patients undergoing the Ross II procedure between June 2002 and April 2008 were included. Preoperative diagnoses included rheumatic disease (n = 5), congenital mitral valve (MV) pathology (partial atrioventricular canal defect [n = 2], complete atrioventricular canal defect [n = 1], Shone's complex [n = 1]), and myocarditis (n = 1). Ten patients (eight females and two males) between 7 months and 46 years were included. Mean age at surgery was 25.2 ± 15.7 years. There were no in-hospital deaths. Mean follow-up was 11.7 ± 5.2 years. There were three late deaths at 11 months, 5 years, and 11 years, respectively. Causes of death included right heart failure, sepsis, and sudden cardiac arrest. Three patients required subsequent mechanical MVR a median of two years after the Ross II procedure (range: 1-4 years). There was no mortality with reoperation. Echocardiographic follow-up demonstrated mean MV gradients ranging from 2.2 to 9.6 mm Hg. Two patients had greater than mild MV regurgitation postoperatively, and all others had minimal mitral regurgitation or less. Two patients developed moderate MV stenosis. The Ross II procedure is an option for select older children and young adults desiring a durable tissue MVR to avoid long-term anticoagulation.

Multimodality imaging assessment of a caseous calcification of the mitral valve annulus

Caseous calcification of the mitral annulus (CCMA) is a rare echocardiographic finding. It is commonly misdiagnosed as an abscess, tumor or infective vegetation on the mitral valve. Since it is a benign process, differentiating it from malignant intra-cardiac mass is primordial to avoid unnecessary surgery. Various imaging modalities can be complimentary for definitive diagnosis. We present a case of CCMA in a 71-year-old female patient. Her medical history revealed hypertension, diabetes mellitus, hyperlipidaemia and coronary artery disease. She was referred to our department for coronary catheterization because of angina symptoms upon minimal exertion. The lesion was detected during echocardiography and was defined as a mass of heterogeneous content with calcification points, located at the posterior side of the mitral valve annulus. Restricted motion of the posterior leaflet and the mass effect caused only minimal mitral regurgitation. To establish the correct diagnosis, we performed the full spectrum of noninvasive cardiac imaging modalities. Transesophageal echocardiography identified well-organized, composite lesion with regular edges, markedly calcified margins and more echolucent central portion. A computed tomography (CT) was performed, showing a hyperdense mass with hypodense center and a calcified peripheral rim located at the posterior mitral ring. Cardiac magnetic resonance imaging (MRI) showed that the mass was hypointense with respect to the myocardium in the T1 and T2-weighted sequences and only presented late-phase enhancement in the surrounding capsule. Based on the CT and MRI findings, the diagnosis of CCMA was established. The patient was managed conservatively.

Frequency of Congenital Heart Diseases in Prelingual Sensory-Neural Deaf Children.

Hearing impairment is the most frequent sensorial congenital defect in newborns and has increased to 2-4 cases per 1,000 live births. Sensory-neural hearing loss (SNHL) accounts for more than 90% of all hearing loss. This disorder is associated with other congenital disorders such as renal, skeletal, ocular, and cardiac disorders. Given that congenital heart diseases are life-threatening, we decided to study the frequency of congenital heart diseases in children with congenital sensory-neural deafness. All children who had undergone cochlear implantation surgery due to SNHL and who had attended our hospital for speech therapy during 2008-2011 were evaluated by Doppler echocardiography. Thirty-one children (15 boys and 16 girls) with a mean age of 55.70 months were examined, and underwent electrocardiography (ECG) and echocardiography. None of the children had any signs of heart problems in their medical records. Most of their heart examinations were normal, one patient had expiratory wheeze, four (12%) had mid-systolic click, and four (12%) had an intensified S1 sound. In echocardiography, 15 children (46%) had mitral valve prolapse (MVP) and two (6%) had minimal mitral regurgitation (MR). Mean ejection fraction (EF) was 69% and the mean fractional shortening (FS) was 38%. This study indicates the need for echocardiography and heart examinations in children with SNHL.

Challenges of Percutaneous Balloon Mitral Valvuloplasty in Paediatric Patients with Rheumatic Mitral Stenosis: A Case Report

Rheumatic fever is still the commonest cause of mitral stenosis in developing countries. This is attributable to predominance of overcrowding, unhygienic lifestyle and poor socio-economic status. Usually rheumatic carditis sets in by 10-20 years after an attack of rheumatic fever. However juvenile rheumatic carditis has a fulminant course and requires prompt intervention [2]. In case of a pliable valve and minimal mitral regurgitation, percutaneous balloon mitral valvuloplasty has shown to produce good immediate and long term outcome in paediatric patients.

Androgenic-Anabolic Steroid (Boldenone) Abuse as a Cause of Dilated Cardiomyopathy

A 34-year old, previously healthy male, presented to the ER with worsening dyspnea over a period of three weeks and the appearance of blood tinged sputum. Soon after presentation, the patient was hypoxemic and required mechanical ventilation. Chest X-ray demonstrated bilateral infiltrates and he was admitted to the ICU with the tentative diagnosis of acute respiratory distress syndrome. Investigation by PICCO, Suggested the presence of heart failure were and the patient was transferred to the ICCU. On admission, the patient maintained normal blood pressure but still needed mechanical support with high FiO2 values to maintain adequate oxygenation. Physical examination was remarkable for his muscular appearance. The heart sounds were regular. The lungs were clear to auscultation, although chest X-ray revealed signs of pulmonary edema. Blood count was remarkable for hemoglobin of 21 gr/dl with hematocrite of 65%. His blood chemistry showed creatinine level on 1.74 mg/dL, with no electrolytes imbalance. LFT were normal, total protein and albumin levels were normal, elevated CK with normal TnT. CRP 10 mg/L (normal level <10 mg/L). Blood cultures and panel of common respiratory infections were all negative. ECG showed normal sinus rhythm, with p pulmonale, signs of hypertrophy and inverted T waves in chest leads. Swan-gantz Cather measurements revealed cardiac output (CO) 3.9, capillary wedge pressure 34 mmHg, SVR 2070 and CI 2.2 consistent with cardiogenic shock. Transthoracic echocardiography demonstrated severe global dysfunction (left ventricular ejection fraction = 20%) with severely dilated left ventricle 5.1 cm (end-systolic diameter), asymmetric hypertrophy (Septum 14 mm, Posterior wall 12 mm). Minimal mitral and tricuspid regurgitation were also noted (Table 1 and Figure 1).

A giant left ventricular pseudoaneurysm in Behçet's disease: a case report

Behçet's disease is a chronic autoimmune disease with vascular complications that are most frequently manifested as thromboembolism in veins and pseudoaneurysm in arteries. We report the case of a 13-year-old boy admitted for clinical and biological signs of rheumatic fever associated with chest pain. The clinical examination found heart sounds with a discrete systolic murmur of mitral regurgitation. The electrocardiogram showed a microvoltage with diffuse repolarisation disorder. Biologically, he had inflammatory syndrome. Transthoracic echocardiography showed circumferential pericardial effusion with anterosepto-apical hypokinesia of the left ventricle with systolic dysfunction, and a minimal mitral regurgitation. The patient was treated by corticotherapy and antibiotherapy. The outcome was marked by orogenital aphthous ulceration and decreased visual acuity related to intermediate uveitis. The retinal angiography showed a vasculitis. The late appearance of this symptom led to the right diagnosis of Behçet's syndrome. Transthoracic echocardiography showed a hypokinetic dilated cardiomyopathy left ventricular with septo apical and anterior akinesia and severe systolic dysfunction, with a defect of the inferior septal with a collar communicating the left ventricle with a giant pseudo aneurysm. Magnetic resonance imaging showed a giant pseudoaneurysm communicating with the left ventricle. The coronary computed tomography was normal. The patient had undergone surgical treatment for the pseudoaneurysm with good outcomes.

Cor triatrium presenting as mitral stenosis and severe anemia

Cor triatrium presenting as mitral stenosis and severe anemia

Pulmoner Arter Bifurkasyodan köken alan Sirkumfleks Coroner arter

came with complaints of chest pain that starting with exertion and ending with rest. Physical examination revealed a 1/6 systolic murmur. The electrocardiogram showed no signs of ischemia. The transthoracic echocardiogram at admission revealed no significant finding except that minimal mitral valve regurgitation. Treadmill showed significant horizontal ST-segment depression in D11-D111-aVF and V4–V5-V6 with accompanied by chest pain. Cardiac catheterization showed a fistuluzation from circumflex coronary artery to pulmonary artery (Figure 1, 2). Origin of the circumflex artery from the pulmonary artery has been proved by multislice computed tomography (Figure 3). Myocardial perfusion scintigraphy were performed to evaluate myocardial ischemia and ischemia was identified at the perfusion area of the circumflex coronary artery. As a result of this, the patient was advised surgery

Circulating cytokine concentrations in dogs with different degrees of myxomatous mitral valve disease

Cytokines have been associated with the progression of congestive heart failure (CHF) in humans and may be implicated in the pathophysiology of myxomatous mitral valve disease (MMVD) in dogs. The aim of this study was to determine the serum concentrations of cytokines in dogs with MMVD. The study included 16 Cairn terriers with no or minimal mitral regurgitation (MR), 41 Cavalier King Charles Spaniels (CKCS) with different degrees of MR and 11 dogs of different breeds with CHF due to MMVD. Granulocyte-macrophage colony-stimulating factor, interferon-γ, interleukin (IL)-2, IL-6, IL-7, IL-8, IL-10, IL-15, IL-18, keratinocyte-derived chemokine, interferon-γ-induced protein and monocyte chemoattractant protein-1 (MCP-1) were measured using a canine-specific multiplex immunoassay. CHF dogs had significantly higher MCP-1 concentrations than dogs with no or minimal MR. Among the CKCS, IL-2 and IL-7 decreased with increasing left atrial size and IL-7 also decreased with increasing MR. IL-8 decreased with increasing left ventricular end-systolic internal dimensions. MCP-1 was increased in CHF dogs compared to healthy control dogs and IL-2, IL-7 and IL-8 decreased with increasing indices of disease severity. The results suggest a role for these cytokines in canine MMVD and CHF.