Transthorasic Echocardiography Research Articles

Does speckle tracking transthorasic echocardiography show subtle changes in left ventricular function in patient with heart failure with reduced ejection fraction treated by Sacubitril-Valsartan

Abstract Introduction Pathophysiology of HF involves a maladaptive response during which the (RAAS) is activated. RAAS activation leads to VC, HT, increased aldosterone levels, increased sympathetic tone, and eventually, cardiac remodeling, all of which are detrimental to the progression of the disease. By blocking these maladaptive elements, ACEIs or ARBs play a major role in reducing morbidity and mortality due to HF, Simultaneously, the NP system is also activated, hence the elevated BNP and NT-pro BNP seen in HF exacerbations. This is a Compensatory mechanism that leads to VD, natriuresis and diuresis, lowers BP, lowers sympathetic tone, and reduces aldosterone levels. The NP system works antagonistically to the RAAS and has favorable effects on the pathogenesis of HF NP are broken down by an enzyme called neprilysin and blocking of its action by neprilysin inhibitor prevent the breakdown of NP leading to prolonged duration of the favorable effects of these peptides. Sacubitril/valsartan is a first-in-class medicine that contains a neprilysin (NEP) inhibitor (sacubitril) and (Ang-II) receptor blocker (valsartan). STE is a sensitive tool for assessing ventricular function, even subclinical myocardial alterations that traditional imaging techniques are not able to detect. Sub endocardial function is powered mostly by longitudinal contraction, it is impaired earlier than circumferential or radial component's. Therefore, Longitudinal function is in most cases the best early marker of LV dysfunction. Objective The aim of our study is to retrospectively detect if the patients treated by sacubitril/valsartan showed no improvement in LVEF assessed by TTE, is the same patient will shows improvement in LVEF assessed by 2D STE? Methods Our study will include 200 patients with HFrEF. All participants were subjected to the following: History taking, Physical examination, Serial 12-lead ECG, 2D echo to assess: -LVEDD, LVESD and LVEF%, LVEDVI (ml/m2), LVESVI (ml/m2), (LAVI) ml/m2, E/e′ ratio. 2D STE was done before and after 6 months of sacubitril/valsartan. Results Age 48 ± 9 years, 63% females, 9 (4.5%) were in NYHA FC I, 120 (60%) NYHA FC II, 64 (32%) of patients were in NYHA FC III & 7 (3.5%) were in FC IV. improved to NYHA FC I, 82 (41%) NYHA FC II 118 (59%), LVEDV, LVESV, LVEF, E/e′ were 139.3 ± 7.3, 89.7 ± 4.7, 34.9 ± 2.8, 11.2 ± 2.7, that all improved to 139.1 ± 10.5, 89.0 ± 4.4, 35.6 ± 2.6, 9.1 ± 2.3. 82 (41%) patient showed improvement in LVEF either by traditional TTE or STE, 118 (59%) patients showed no improvement of EF by traditional TTE, of them 74 (37%) patients was improved detected by STE while 44 (22%) patients showed no improvement in EF neither by TTE nor by STE. Conclusion STE is more accurate diagnostic tool for detecting early improvment in LVEF that not detected by traditional TTE in patient with HFREF treated by scubitril/valsartan. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Comparison of Cardiopulmonary Exercise Capacity in Patients with Atrial Septal Defect Treated with Minimally Invasive Cardiac Surgery or Transcatheter Closure

Aim. The main aim of our study was to compare the results of transcatheter atrial septal defect (ASD) closure versus minimally invasive cardiac surgery (MICS) focusing on cardiopulmonary exercise capacity and echocardiographic findings preoperatively and 1 month after defect closure.Material and methods. 54 patients with ASD and finally 43 patients who were followed up were included in the study. 21 patients were in MICS (robotic or endoscopic approach) and 22 patients were in transcatheter closure arm. All patients investigated in detail by transesophageal echocardiography and underwent cardiopulmonary exercise test (CPET). At the end of first month, CPET and transthorasic echocardiography were reperformed.Results. There was significant improvement of physical capacity after 1 month following the transcatheter closure procedure documented by exercise time and VO 2 max. Tricuspid annular plane systolic excursion (TAPSE) and tricuspid lateral annular systolic velocity (Tri S) were not changed. In surgery group right heart diameters declined significantly; but VO 2 max, TAPSE and Tri S significantly decreased.Conclusion. Cardiopulmonary exercise function is increased in transcatheter closure group 1 month after closure and contrary not in MICS group. This may be caused by long recovery time of the right ventricle after surgery. Device closure of ASD is preferable to surgical closure if the anatomy is suitable. However, MICS for ASD closure is safe, with short recovery period and less scarring.

Pulmonary hypertension screening in patients with systemic sclerosis, in a tertiary center, in Turkey; a cross-sectional original study

Aim: Development of Pulmonary Hypertension (PH) in Systemic Sclerosis (SS) significantly reduces the survival of the disease and early diagnosis and treatment is very important.The aim of this study was to investigate the presence of PH in patients who were followed and treated by rheumatology clinic with the diagnosis of SS and who did not have a known diagnosis of PH.Materials and Methods: This cross-sectional study was completed with 51 patients with SS and a control group of 51 volunteers with similar characteristics in terms of gender and comorbidity. Demographic, laboratory and echocardiographic data were recorded.Results: The median age of the patients with systemic sclerosis was 53 (46-60) years and the control group was 50 (45-55) years. 42 (82.4%) of the SS patients were female and 39 (76.5%) of the control group were female. Right heart catheterization was performed to 3 patients with high pulmonary artery pressure (>40 mmHg) on transthorasic echocardiography. Group 1 PH was diagnosed in two of three patients (3.9%); group 2 PH was diagnosed in one of three patients (1.9%).Conclusion: In our study, we detected pulmonary hypertension in 5.8% of 51 patients with systemic sclerosis in a tertiary center. Although these patients have undergone PH screening at certain frequencies, it is noteworthy that we achieved this finding. We believe that we have detected patients with pulmonary systolic pressure at the border and showing rapid progression. Our study supports the more frequent screening of SS patients with borderline pulmonary artery pressure elevation.

Akut iskemik inmeli hastalarda miyokard fonksiyonunun doku Doppler miyokardiyal performans indeksi ile değerlendirilmesi

Purpose: The aim of this study is to investigate the relationship between myocardial function assessed by tissue Doppler imaging myocardial performance index (TDI-MPI) and National Institutes of Health Stroke Scale (NIHSS) score in patients with acute ischemic stroke. Materials and Methods: The study comprised 128 patients (males, 55; females, 73; 68 ± 19 years) with acute ischemic stroke. 20 patients were excluded. Patients were divided into two groups based on the calculated NIHSS score (Group 1, NIHSS score < 16; Group 2, NIHSS score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac function was evaluated by transthorasic echocardiography within 48 hours of admission to the neurology care unit.Results: There were no significant differences among demographic parameters of patients. Tissue Doppler myocardial performance index was significantly higher in Group 2 patients than in Group 1 patients (0.62±0.28 vs 0.46±0.16).Conclusion: Our results suggest that TDI-MPI is associated with stroke severity on admission in patients with acute ischemic stroke. TDI-MPI is an indicator of global myocardial dysfunction with a different from LVEF. TDI-MPI, which includes both systolic and diastolic time intervals to assess the global cardiac dysfunction.

Assessment of Myocardial Function by Myocardial Performance Index in Patients with Acute Ischemic Stroke

Objective: Acute stroke is an important cause of morbidity and mortality. Myocardial injury is an important complication of acute cerebrovascular events. In this study, we aimed to investigate the relationship between myocardial function assessed by myocardial performance index (MPI) and National Institutes of Health Stroke Scale (NIHSS) score in patients with acute ischemic stroke. Method: The study comprised 97 patients (males, 42; females, 55; 65 ± 16 years) diagnosed with acute ischemic stroke. 17 patients were excluded. Patients were divided into two groups based on the calculated NIHSS score (Group 1, NIHSS score < 16; Group 2, NIHSS score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac function was evaluated by transthorasic echocardiography within 48 hours of admission to the neurology care unit. Results: There were no significant differences among demographic parameters of patients. MPI was significantly higher in Group 2 patients than in Group 1 patients (0.59±0.25 vs 0.48±0.20, p=0.004). Conclusion: Our results suggest that MPI is associated with stroke severity on admission in patients with acute ischemic stroke. MPI is an indicator of global myocardial dysfunction with a different from LVEF. MPI, which includes both systolic and diastolic time intervals is an option to assess the global cardiac dysfunction.

The Most Accurate Method for Measurement of Mitral Valve Area in Mitral Stenosis by Direct Planimetery Three Dimensional Transesophageal Echocardiography (3D TEE)

DEAR EDITOR,Three-dimensional (3D) transesophageal echocardiography (TEE) is a powerful tool for assessment of mitral valve area with multiplanar reconstruction (MPR) or direct planimetery in patients with rheumatic mitral valve stenosis. Two dimensional transthorasic echocardiography (2D TTE) is a well-known conventional method in these patients which is used routinely. This method is less accurate than 3D TEE because mitral valve is saddle shaped and 2D images cannot image this valve correctly [1-7]. Exact method for 3D mitral valve area measurement is not determined yet and MPR was used as an accurate method. Direct planimetery by 3D TEE emerged as a novel method to evaluate mitral valve area with least variability [8].

The prognostic value of cardiac ultrasonography in patients with cardiac arrest

Introduction: Echocardiography or cardiac imaging is proposed as a gold standard method for identifying high risk patients for cardiac arrest. In this systematic review, we studied the prognostic value of cardiac sonography in patients with cardiac arrest. Methods: PubMed was searched for the relevant articles. Case reports were not included. Inclusion criteria were all the studies applied transthorasic echocardiography in patients with cardiac arrest arrived at emergency department that studied the efficacy of this modality on patients survived to emergency discharge and returned to spontaneous circulation.Result: Overall, 870 articles were obtained through initial search and only nine articles were included after the evaluation of the title, abstract, and the full text. Echocardiography has high sensitivity and specificity in predicting the return of spontaneous circulation.Conclusion: Cardiac sonography is a fairly effective (not definitive) modality in predicting death in patients with lack of cardiac activity during resuscitation. Echocardiography should not be the sole basis for the decision to cease resuscitative efforts.

The Effects of Fetuin-A Levels on Aortic Stenosis

Aim: We aimed to investigate the relation between fetuin-A and calcific aor tic stenosis in non diabetic patients whose renal function were normal. Material and Method: 26 patients followed for aortic stenosis by our cardiology clinic for outpatients and 25 voluntary healthy subjects were included in the study. The fetuin–A levels were measured from the venous blood samples of the study population. All patients underwent transthorasic echocardiography, the aortic valvular area and left ventricular parameters of the patients were measured. Results: The average age of the patients in degenerative aortic stenosis group was significantly higher than the control group. The param eters related to aortic valve were naturally higher in patients with dejenerative aortic valve. There was no significant difference between two groups about fetuin-A levels. Further more there was no significant relation between fetuin-a levels and aortic stenosis severity. Discussion: In conclusion fetuin-A is a multifunctional glycoprotein that plays important role in systemic calcifi cation inhibition and valvular calcification. Finally aortic stenosis is an active process and larger studies that investigate the relation between fetuin-a and the progression and prognosis of aortic stenosis are needed.

Triple leaflet perforation due to endocarditis in aortic valve complicated by pneumonia and exacerbation of chronic obstructive pulmonary disease

Valve perforation complicating infective endocarditis has been for decades a bad sign leading to severe valve destruction, intractable heart failure and even death if surgical therapy is not administered in time. Here we present a 57years old male patient inadvertently diagnosed with pneumonia and chronic obstructive pulmonary disease exacerbation in another hospital. After 20days of broad spectrum antibiotics and bronchodilator therapy no improvement was achieved. During examination a severe aortic regurgitation was recognized. Immediately after, patient was transferred to our hospital for aortic valve surgery evaluation. Transthorasic echocardiography (TTE) showed a severe aortic regurgitation and vegetation like echogenicity over the noncoronary leaflet. An aortic valve replacement surgical therapy was decided. During the aortic valve excision underneath the vegetations, multiple small perforations in all the three leaflets were noticed. The destructed valve was excised and a mechanical aortic prosthesis (St Jude No: 23, MN, USA) was successfully replaced. After 14days of treatment patient was healthily discharged.

A huge left ventricular pseudoaneurysm manifesting as acute dyspnea

Pseudoaneurysm of the left ventricle (LV) is one of the mechanic complications of myocardial infarction. This rare complication mostly stems from inferior wall of the LV. The wall of pseudoaneurysm contains pericardium and/or scar tissue but not myocardium. Transthorasic echocardiography is commonly used in clinical practice and is usually sufficient to make a diagnosis of LV pseudoaneurysm. It is important to differentiate pseudoaneurysm from true LV aneurysm. Pseudoaneursym does not contain myocardial tissue whereas true LV aneurysm does. Pseudoaneurysm also has narrow neck unlike true LV aneurysm. Urgent surgical approach is indicated because of fatal rupture. Here we report a case report of pseudoaneurysm manisfesting with acute dyspnea.

PP-053 Intervention to a Fistula Originating from Left Anterior Descending Artery (LAD) to Main Pulmonary Artery

Coronary artery fistula is a rare anomaly, either with congenital or acquired origin, which is characterized by blood flow from myocardial capillary network to any of the heart chambers, great vessels or other structures. A 54-year-old male complaining about chest pain was admitted to our hospital. The patient had history of hypertension and cigarette smoking. Initial blood pressure and heart rate were 144/89 mmHg, 75/min respectively. Physical examination and laboratory findings were unremarkable. Electrocardiography revealed a normal sinus rhythm with left anterior hemiblock. Transthorasic echocardiography showed left ventricular ejection fraction of 62% and left atrial enlargement. The patient underwent to diagnostic coronary angiogram as well as pulmonary angiogram with detection of a fistula originating from aneurysmatic part of proksimal left anterior descending artery to main pulmonary artery and stenotic lesions on LAD. (Panel A) The fistula was occluded with different size of coils (Panel B). 90 % stenotic lesion in distal part and aneurysmatic proximal part of LAD were stented in another session. (Panel C). The patient was discharged from the hospital without complications. Coronary artery fistula is a rare anomaly, and is mainly asymptomatic but may present with fatigue, dyspnea, angina, orthopnea, endocarditis, myocardial ischemia and arrythmias. Main indications of fistula closure are heart failure and symptoms of myocardial ischemia. Surgical or cathater based interventions are recommended for fistula closure. In our case, the fistula was successfully coiled and aneurysmatic part of proximal LAD was stented with cathater based intervention. The patient's symptoms were completely relieved after interventions.

Bioimpedance Analysis Reveals Graft Function in Renal Transplant Recipients.

Introduction: Renal transplantation (RT) is the best treatment of choice for patients with end-stage renal disease. Despite improving of renal dysfunction, patients are at risk for existing or new onset of conditions as hypertension and dyslipidemia after transplantation. In present study, we aimed to determine the hydration status by bioimpedance analysis (BIA) in RT recipients and to analyse the association of body fluid status, graft function, biochemical parameters and echocardiographic measurements. Methods: Eighty two (58 male, mean age: 38.7± 11.5 years) RT recipients being followed in our centre who were using at least one anti-hypertensive treatment were enrolled into the study. Biochemical parameters as lipid profile (total, HDL and LDL cholesterol, triglyseride), parathyroid hormone, 24 hour urinary protein loss, estimated glomerular filtration rate (eGFR); transthorasic echocardiography, bioimpedance analysis (BCM, Fresenius) as systolic blood pressure, total body weight (TBW), lean tissue index (LTI), extracellular volume (ECW), intracellular volume (ICW), lean tissue mass (LTM) and phase angle (phi50) levels and renal resistive index (RRI) were evaluated. Results: TBW and ECW were significantly correlated with RRI and systolic blood pressure (p:0.001). Patients with <70 ml/min of eGFR values were divided into five groups according to each 10 ml/min decline in eGFR. RRI, urinary protein loss, pulmonary artery pressure, frequency of over-hydration, systolic blood pressure, TBW, LTI, ECW,ICW, LTM and phi50 values were significantly higher in patients with 15-50 ml/min (p:0.000), however similar in patients with 50-70 ml/min (p:0.648). Conclusion: Hypertensive RT recipients have increased TBW, LTI, ICW, FTI, LTM and phi50 values. Graft function is positively correlated with systolic blood pressure, RRI and BIA parameters. Thus, hypertensive RT recipients should be closely follow-up with RRI and BIA for an early diagnosis of loss of graft function.

Does Gestational Diabetes History Increase Epicardial Fat and Carotid Intima Media Thickness?

Gestational diabetes mellitus (GDM) is defined as glucose intolerance that has begun during pregnancy. Recent studies have proven that development of atherosclerosis may be established in this population even without presence of type 2 diabetes. For assessment of atherosclerosis, epicardial fat thickness (EFT) is recently being used as a surrogate marker. In this study, we aimed to prove that women with GDM history are more inclined to have higher EFT levels than women without GDM history. Sixty-two patients with previous GDM and 33 age- and sex-matched controls were allocated. Epicardial fat thicknesses of the subjects were measured with transthorasic echocardiography and carotid intima media thickness (c-IMT) was measured with ultrasound. Insulin resistance (IR) of each subject was assessed with Homeostasis model of assessment-insulin resistance (HOMA-IR). Carotid IMT and EFT were significantly higher in previous GDM group than controls. Serum gamma-glutamyl transferase (GGT), uric acid, and high-sensitivity C-reactive protein (hs-CRP) levels were also found significantly higher in the patients with previous GDM as compared to the controls. We observed that carotid IMT (β = 310, P = 0.003), total cholesterol (β = 315, P = 0.002), BMI (β = 308, P = 0.002), HbA1c (β = 227, P = 0.018), and HOMA-IR (β = 184, P = 0.049) were independently correlated with EFT. Although the number of patients included in this study is limited, high EFT results may indicate presence of atherosclerosis in women with previous GDM.

PP-246 Quadricuspit Aortic Valve with Partial Pulmonary Venous Return Anomaly and Atrial Septal Defect

A 55-year-old man was admitted to the hospital because of palpitations and progressive dyspnea in the last 10 days. Electrocardiogram showed atrial flutter (120-130 beats/min). Transthorasic echocardiography demonstrated normal left ventricular function, mild aortic regurgitation, a volume–loaded right ventricle, mild tricuspid regurgitation, moderate pulmonary artery hypertension and suspected shunt across the atrial septum in colour flow Doppler in apical four chamber view. Transesophageal echocardiography delineated sinus venousus atrial septal defect (Figure A ), patent foramen ovale and quadricuspid aortic valve with mild aortic regurgitation (Figure B).

Transcatheter patent ductus arteriosus closure with echocardiographic guidance: can radiation exposure be reduced?

The radiation dose from interventional cardiac catheterization is particularly relevant when treating children because of their greater radiosensitivity compared to adults. The transcatheter closure of patent ductus arteriosus (PDA), as well as other more complex pediatric interventions, have raised concerns regarding radiation exposure, particularly relevant when treating children. The purpose of this study is to show how to perform the transcatheter closure of PDA in children while giving less ionized radiation and to prove that the amount of radiation and contrast material can be reduced. Following appropriate device selection based on PDA morphology and diameter, transthorasic echocardiography images and control aortography findings were analyzed. The following devices were used during the procedure: Gianturco coils (10/63), an Amplatzer Duct Occluder (ADO, 31/63), Flipper coils (19/63), and an Amplatzer vascular plug (3/63). The scopy time, radiation dose, and contrast were 12 ± 6.4 mins, 28.1 ± 14.7 cmGy/cm²/kg, and 4.2 ± 2.3 cc/kg, respectively. In the control aortography shortly after the procedure, residual shunt was detected at various levels in 39.7% of patients, and 9.5% demonstrated residual shunt in real-time echocardiography. In the control aortography, the exposure to radiation was 13.3% of the total, and the amount of infused contrast was 27.2% of the total. Patients may be exposed to less radiation and contrast material if an echocardiographic evaluation, instead of a final control aortography injection, is performed after the transcatheter closure of PDA.

Investigation of the relationship between non-alcoholic fatty liver disease and coronary artery disease.

The purpose of the study was to examine the association between visceral adiposity form of non-alcoholic fatty liver and coronary artery disease severity and also to investigate the relationship between the epicardial adipose tissue thickness and non-alcoholic fatty liver disease with clinical and anthropometric measurements. This study included 105 patients (mean age of patients were 57 ± 11, 82 of them male) who were hospitalized for coronary angiography because of chest pain. Nonalcoholic fatty liver disease was investigated by using ultrasonography. Thickness of the epicardial adipose tissue was measured by transthorasic echocardiography to right ventricular free wall adjacent to the parasternal long and short axis images. Gensini score was used for the severity of coronary artery disease. In patients with non-alcoholic fatty liver disease, right ventricular free wall epicardial adipose tissue thickness average of parasternal long and short axis were thicker than those who do not have non alcholic fatty liver disease (0,90 ± 0,19 cm; 0.58 ± 0.18 cm, p<0.001). Also, in patients with severe coronary artery disease, right ventricular free wall parasternal long and short axis average thickness of epicardial fat tissue was thicker than those of patients without severe coronary stenosis (0.86 ± 0.21 cm; 0,66 ± 0.26 cm, p=0.001). For predictability of coronary artery disease, Receiver Operating Characteristic analysis of the area under the curve was found to be 0.60 (50.2 to 74.7, 95% Confidence Limits). Not only the fatty tissue which surrounds the heart effects the coronary arteries but also other visceral organs adiposity effects the coronary arteries atherosclerotic process.

Correlation Between Aortic Valve Sclerosis and Coronary Artery Disease: A Cross - Sectional Study

Introduction: Aortic valve sclerosisis considered as a manifestation of coronary atherosclerosis. Recent studies demonstrated an association between aortic valve sclerosis and obstructive coronary artery disease. The purpose of this study was to evaluatethe correlation betweenaortic valve sclerosis andobstructive coronary artery disease and the extent of coronary artery disease in patients hospitalized for chest pain. Materials and Methods: A total of 230 consecutive patients were referred to the coronary angiography of GhaemMedical Center and were subjected to transthorasic echocardiography for screening of aortic valve sclerosis and coronary risk assessment. The diagnostic value of obstructive coronary artery disease for aortic valve sclerosis was calculated. Results: The patients with obstructive coronary artery disease had a higher prevalence of aortic valve sclerosis compared to those with no coronary artery disease (P< 0.05). Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease by multivariate analysis (P< 0.05). Aortic valve sclerosis had sensitivity of 47% and specificity of 79% and positive predictor value of 92%. Conclusions: Aortic valve sclerosis was an independent predictor for obstructive coronary artery disease in patients with chest pain and was strongly interrelated with the extent of coronary artery disease in these patients.

PP-212 ANTERIOR ACUTE MYOCARDIAL INFARCTION DUE TO CORONARY EMBOLISM IN A PATIENT WITH MECHANICAL AORTIC VALVE PROSTHESIS

Introduction: Myocardial infarction secondary to coronary artery embolism in the presence of mechanical aortic valve prosthesis is a rare condition. In this report we aimed to present a case of anterior acute myocardial infarction due to coronary embolism in a 46 year-old-man with mechanical aortic valve prosthesis. Case: A 46-year-old man presented with chest pain for 5 hours. He had undergone aortic valve replacement with St Jude mechanical valve 2 years before. The patient had been using warfarin since the operation. However, it was learnt that he suspended the use of warfarin for 15 days due to emotional stress. Systolic ejection murmur grade 3/6 on the second right parasternal space and a mechanical valve click were the cardiac auscultation findings of the patient. Electrocardiogram showed sinus rhythm and ST elevation in leads DI, aVL, V2-V5 and ST depression in DII, DIII and aVF. Transthorasic echocardiography showed akinesia of anterior and apical segments and ejection fraction was 35%. Maximum 80mmHg, mean 42mmHg gradient was measured on mechanical aortic bileaflet prosthesis. Moderate degree of aortic regurgitation was detected. Dysfunction due to trombus load was considered in aortic valve. The cardiac enzyme levels revealed troponin T level of 2.1 ng/ml and creatinine kinase-MB level of 138U/L. The patient’s INR level was 1.1 and reflecting prothrombotic state. Emergent coronary angiography showed a total occlusion of mid left anterior descending artery. After advancing a 0.014 inch floppy guidewire and passing through the lesion, we tried to aspirate the thrombus by using a thrombus aspiration catheter (Export Medtronic, Minneapolis, Minnesota). After aspiration, thrombus causing partial obstruction in distal was observed. The procedure was ceased. The patient was started intravenous tirofiban. Tirofiban was administered for 30 minutes 0.4m/kg/min intravenous and 0.10mg/kg/min 48 hours infusion. In transesofageal echocardiography in the follow-up valve maximum 30mmHg, mean 14mmHg gradient was taken on the valve. Aortic regurgitation was minimal and no thrombus was found on the valve. The patient was discarded from the hospital with optimal INR value (INR: 3.2). Conclusion: In conclusion, inpatients with prosthesis coronary valve, it should be considered that myocardial infraction due to coronary embolism can develop. The use of glycoprotein IIb/IIIa inhibitors together with catheter aspiration embolectomy to treat these patients can improve results in patients with suspected accompanying prosthetic valve thrombosis.

Unexplained Perioperative Hypotension in a Patient Treated with Pine Needle Extract

Pine needle-based products are popular dietary supplements in East Asia for health promotion. Pine needle extract (PNE) are especially known as potential anti-hypertensive and anti-lipidemic agents. We report a case of profound, long-lasting unexplained hypotension during and after anesthesia in a patient treated with PNE. Bedside transthorasic echocardiography (TTE) was used as a part of useful diagnostic modality.

Takotsubo cardiomyopathy resembling acute high lateral myocardial infarction

A 65-year-old female patient admitted to the emergency department was diagnosed with acute high lateral myocardial infarction, but later Takotsubo cardiomyopathy (TC) was discovered. She had squeezing chest pain that started shortly after an emotional stress. The electrocardiogram revealed a loss of R wave voltage in leads V1 to V4 and an ST-segment elevation in I and aVL. After an urgent coronary angiography and ventriculography, TC was considered, and supportive anti-ischemic treatment was started. The severe left ventricular systolic dysfunction improved and normalized during the follow-up. She was discharged without any complications. TC is a new entity of acute cardiac events, and patients usually recover completely without sequelae with proper diagnosis and management. An exact diagnosis may also prevent an inappropriate application in the setting of recurrences.