Search

Background: Aficamten, a next-in-class cardiac myosin inhibitor, improved peak oxygen uptake (pVO 2 ) and lowered resting and Valsalva left ventricular outflow (LVOT) gradients in adults with symptomatic obstructive hypertrophic cardiomyopathy (oHCM) in SEQUOIA-HCM (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults With Symptomatic oHCM), a phase 3, multicenter, randomized, double-blinded, placebo-controlled study., Objectives: The authors sought to evaluate the effect of aficamten on echocardiographic measures of cardiac structure and function in SEQUOIA-HCM., Methods: Serial echocardiograms were performed over 28 weeks in patients randomized to receive placebo or aficamten in up to 4 individually titrated escalating doses (5-20 mg daily) over 24 weeks based on Valsalva LVOT gradients and left ventricular ejection fraction (LVEF)., Results: Among 282 patients (mean age 59 ± 13 years; 41% female, 79% White, 19% Asian), mean LVEF was 75% ± 6% with resting and Valsalva LVOT gradients of 55 ± 30 mm Hg and 83 ± 32 mm Hg, respectively. Over 24 weeks, aficamten significantly lowered resting and Valsalva LVOT gradients, and improved left atrial volume index, lateral and septal e' velocities, and lateral and septal E/e' (all P ≤ 0.001). LV end-systolic volume increased and wall thickness decreased (all P ≤ 0.003). Aficamten resulted in a mild reversible decrease in LVEF (-4.8% [95% CI: -6.4% to -3.3%]; P < 0.001) and absolute LV global circumferential strain (-3.7% [95% CI: 1.8%-5.6%]; P < 0.0010), whereas LV global longitudinal strain was unchanged. Several measures, including LVEF, LVOT gradients, and E/e' returned to baseline following washout. Among those treated with aficamten, improved pVO 2 and reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP) were associated with improvement in lateral e' velocity and septal and lateral E/e' (all P < 0.03), whereas improvement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (KCCQ-CSS) was associated with a decrease in both LVOT gradients (all P < 0.001)., Conclusions: Compared with placebo, patients receiving aficamten demonstrated significant improvement in LVOT gradients and measures of LV diastolic function, and several of these measures were associated with improvements in pVO 2 , KCCQ-CSS, and NT-proBNP. A modest decrease in LVEF occurred yet remained within normal range. These findings suggest aficamten improved multiple structural and physiological parameters in oHCM without significant adverse changes in LV systolic function. (Phase 3 Trial to Evaluate the Efficacy and Safety of Aficamten Compared to Placebo in Adults With Symptomatic oHCM [SEQUOIA-HCM]; NCT05186818)., Competing Interests: Funding Support and Author Disclosures The SEQUOIA-HCM trial is funded by Cytokinetics, Incorporated. Representatives of Cytokinetics have been involved in the design and conduct of the study reported in this paper. Study design and data analysis was supported by the funder and aided by coauthors. Manuscript drafting was completed independently but reviewed by the funder. Dr Wang is supported by a ACC/Merck Research Fellowship. Dr Hegde’s and Dr Wang’s institutions have received fees for core lab services from Cytokinetics and Bristol Myers Squibb. Dr Masri has received research grants from Pfizer, Ionis, Attralus, and Cytokinetics; and has received fees from Cytokinetics, BMS, Eidos/BridgeBio, Pfizer, Ionis, Lexicon, Attralus, Alnylam, Haya, Alexion, Akros, Prothena, BioMarin, AstraZeneca, and Tenaya. Dr Nassif has received research and grant support from AstraZeneca and Cytokinetics; and has received consulting/advisory fees from Vifor and Cytokinetics. Dr Barriales-Villa has received consultant/advisor fees from MyoKardia/Bristol Myers Squibb. Dr Cardim has received speaker fees from Cytokinetics and Bristol Myers Squibb. Dr Coats has received speaker fees from Alnylam and Pfizer; and has received advisory fees from Cytokinetics and Roche Diagnostics. Dr Kramer has received research grants from Cytokinetics, BMS, and Eli Lilly; and is a consultant for Eli Lilly. Dr Maron has received consultant/advisor fees from Imbria and Takeda; and has received steering committee fees for SEQUOIA-HCM from Cytokinetics, Incorporated. Dr Michels’ institution has received a research grant from Bristol Myers Squibb; has received consultant/ advisor fees from Cytokinetics and Bristol Myers Squibb/Myokardia and Alnylam; and has received speaker fees from Bristol Myers Squibb and Pfizer. Dr Olivotto has received research grants from Bristol Myers Squibb, Cytotinetics, Sanofi, Benzyme, Amicus, Bayer, Menarini International, Chiesi, and Boston Scientific; has received consulting fees from Bristol Myers Squibb, Amicus, Sanofi, and Genzyme; and has served as an Advisory Board member for Cytokinetics, Bristol Myers Squibb, Chiesi, and Rocket Pharma. Dr Saberi has received consultant/advisor fees from Bristol Myers Squibb; and has received research grants from Cytokinetics, Bristol Myers Squibb, Cytokinetics, Novartis, and Actelion Pharmaceuticals. Drs Jacoby, Heitner, Kupfer, Meng, and Malik, and Ms Wohltman are employees of and hold stock in Cytokinetics, Incorporated. Dr Solomon has received research grants from Alexion, Alnylam, Applied Therapeutics, AstraZeneca, Bellerophon, Bayer, BMS, Boston Scientific, Cytokinetics, Edgewise, Eidos/Bridgebio, Gossamer, GSK, Ionis, Lilly, NIH/NHLBI, Novartis, NovoNordisk, Respicardia, Sanofi Pasteur, Tenaya, Theracos, and US2.AI; and has consulted for Abbott, Action, Akros, Alexion, Alnylam, Amgen, Arena, AstraZeneca, Bayer, BMS, Cardior, Cardurion, Corvia, Cytokinetics, GSK, Lilly, Novartis, Roche, Theracos, Quantum Genomics, Tenaya, Sanofi-Pasteur, Dinaqor, Tremeau, CellProThera, Moderna, American Regent, Sarepta, Lexicon, Anacardio, Akros, and Valo. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of the present study was to ascertain whether the length of anterior mitral leaflet second-order chordae (SOC) could be considered as a predictor of the incidence of post-repair systolic anterior motion (SAM) and left ventricular outflow tract obstruction (LVOTO) in patients with myxomatous mitral valve disease., Methods: With the implementation of preoperative transoesophageal echocardiography (TEE), the length of anterior mitral leaflet SOC, anterior leaflet (AL) and posterior leaflet (PL) as well as the distance from the coaptation point to the septum (C-S distance) before and after mitral valve repair (MVR) surgery were measured in 190 patients, comprising 12 who developed SAM and 178 who did not., Results: The results revealed that, in patients who developed SAM, SOC were significantly higher (2.76 ± 0.15 vs 1.83 ± 0.32 mm, P < 0.001) and the C-S distance was significantly lower (2.18 ± 0.36 vs 2.91 ± 0.36 mm, P < 0.001) in comparison to the obtained results for those who did not develop SAM. SOC and the C-S distance were independent risk factors of developing SAM and had the largest area under the receiver operating characteristic (ROC) curve (P < 0.001). With application of a cut-off ROC curve analysis, the cut-offs selected for the two variables of C-S distance and SOC were 2.5 and 2.6, respectively. Sensitivity and specificity of SAM development were 100% [95% confidence interval (CI): 73.5-100] and 87.1% (95% CI: 81.0-91.4) for SOC ≥2.6 and 83.3% (95% CI: 51.6-97.9) and 73.6% (95% CI: 66.4-79.9) for the C-S distance ≤2.5., Conclusions: The two variables of the second-order chordae and the distance from the coaptation point to the septum were associated with an increased risk of the post-repair systolic anterior motion after mitral valve repair., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Left atrial intramural hematoma is a very rare complication of radiofrequency ablation procedures. A patient with tachyarrhythmia underwent radiofrequency catheter ablation. Echocardiography performed the following morning showed a large mass in the left atrium, suggestive of intramural hematoma formation. The patient was in a stable condition; therefore, it was decided that follow-up should be conservative and her anticoagulation therapy was continued. The size of the hematoma decreased significantly over the following 50 days. This case highlights a rare complication of a complex catheter ablation procedure in the left atrium that was managed via a noninvasive approach, with which all interventionists should be familiar.

A 77-year-old woman who had severe symptomatic aortic stenosis and was a high risk for conventional surgery underwent transcatheter aortic valve implantation by means of the transfemoral approach. The prosthesis migrated and became embolized in the left ventricle after inflation, causing interference with the mitral valve and also partial outflow tract obstruction. The patient was emergently transferred to the operating room. Vertical aortotomy was performed under cardiopulmonary bypass, and the calcified native leaflets were removed. The migrated Edwards SAPIEN XT valve was extracted and subsequently successfully sewn into the annulus after examination for leaflet and stent competence. The hemodynamic performance of the implanted valve was surprisingly more favorable than that of the conventional tissue prosthesis., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: In this study, three-dimensional torsion angle of myocardium was extracted by two-dimensional images of the left ventricle at three levels of base, mid, and apex of interventricular septum wall., Methods: Two-dimensional echocardiography images of long- and short-axis views of healthy men were synchronized using an electrocardiogram of each individual and processed. Interventricular septum wall motion at three levels of base, mid, and apex were measured using a motion-detection algorithm throughout three cardiac cycles. Considering position vectors in long and short-axis views, the three-dimensional torsion angle is extracted throughout the cardiac cycle., Results: The average and standard deviation of Φ(M) during three cardiac cycles for interventricular septal wall in healthy individuals in this study are estimated as 16.3 ± 3.0° at base level, 22.8 ± 5.0° at mid level, and 14.6 ± 5.8° at apex level of septum wall, respectively., Conclusions: This angle suggested for examination of regional and global biomechanical behavior of myocardium in different pathologic conditions.

Background: The ideal management of ischemic mitral regurgitation (MR) remains a clinical dilemma because of the suboptimal available therapeutic options. Recently, new concepts have emerged, pointing to the benefits of a patient selection approach when debating the management of moderate ischemic MR. We investigated the predictability of low-dose dobutamine stress echocardiography (DSE) in selecting candidates for CABG with moderate MR for valve repair., Methods: From November 2002 to May 2010, 110 candidates for first-time CABG, who were admitted to the cardiac surgery department in Day General Hospital (Tehran, Iran), were enrolled in the present cross-sectional study. DSE was performed for each case before CABG. Those with positive findings underwent CABG alone and those with negative results underwent concomitant CABG and mitral valve repair. The patients were followed up for a minimum of 60 months., Results: Of the 110 patients, 47 (42.72%) had positive test results and underwent CABG alone and 63 (57.28%) had negative DSE results and underwent concomitant CABG and mitral valve repair. The MR degree had decreased from 2.8±0.3 preoperatively to 1.46±0.6 early during the hospital stay and 1.9±0.7 during late follow-up in the CABG group. It had decreased from 2.84±0.4 preoperatively to 0.93±0.65 postoperatively but then increased to 1.41±0.9 during late follow-up, for a significant decrease in the combined group (P<.05)., Conclusions: Despite its utility in selecting CABG patients with moderate ischemic MR for valve repair from a short-term perspective, the use of DSE cannot predict the long-term outcomes of these patients., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We used a modified technique of a composite graft by moving the valve prosthesis away from the end into the inside of the tube and compared the effectiveness of this surgical method with the standard valved conduits., Methods: Through a prospective nonrandomized clinical study between March 2011 and June 2012, we performed replacement of the aortic valve and ascending aorta in 30 consecutive patients using a valved composite graft with a mechanical valve prosthesis. A modified self-assembled valved composite graft was employed in 20 patients (Modified group), while the remaining 10 patients received the standard composite graft (Control group)., Results: There was significantly less bleeding in the patients with modified grafts (184 vs. 415 mL, p < 0.05). Moreover, the mean transvalvular gradient of the composite graft patients was lower in the modified group than in the control group (9 vs. 14 mmHg, respectively, p < 0.05)., Conclusions: The modified valve composite graft technique results in good hemodynamics and appears to limit blood loss., (© 2014 Wiley Periodicals, Inc.)

Purpose: This study aimed at comparing the development of tricuspid and mitral regurgitation between the right ventricular outflow tract (RVOT) and right ventricular apex (RVA) pacing., Methods: We prospectively enrolled 164 patients for permanent pacemaker implantation due to sick sinus syndrome or atrioventricular block and randomly divided them into two equal groups to receive either RVOT or RVA pacing. Patients with heart failure or valvular disease were excluded. The post-procedural echocardiographic evaluations were performed 1 year after the pre-procedural echocardiography, and the results were compared with respect to the development of mitral and tricuspid regurgitation and probable changes in the ejection fraction (EF)., Results: Age, gender, pacing mode, and baseline cardiac rhythm did not significantly differ between the RVOT and RVA pacing groups. The incidence of mitral regurgitation was significantly higher in the RVA group (p = 0.03), but the incidence of tricuspid regurgitation was similar in both groups. There was a trend toward less tricuspid regurgitation in the RVOT group; however, it was not statistically significant. The mean EF was not significantly different between the study groups., Conclusion: It seems that the incidence of mitral regurgitation in RVA pacing is significantly higher than that in RVOT pacing. The formation of tricuspid regurgitation needs to be discussed in the future., Clinical Trial Registration Number: IRCT201103146061N1.

Background: In this study, the angle of the myocardium's trajectory in three dimensions (ф) was estimated by simultaneous use of long-axis and short-axis views of left ventricle septum two-dimensional images. Then correlation of three-dimensional trajectory's angle with the rotation angle from the long (χ) and short (θ) axis views was estimated and compared at the three levels of base, mid and apex of the interventricular septum wall., Methods: Two-dimensional echocardiography images of long- and short-axis views of 19 healthy men were recorded and analyzed. Using an electrocardiogram of each individual, the images of the two views were synchronized. The interventricular septum wall motion at the three levels of base, mid and apex were estimated, using a block matching algorithm throughout three cardiac cycles. Considering the defined system of coordinates and the position vectors in long and short-axis views, the 3-dimensional angle of the trajectory was calculated., Results: Maxima of the ф, θ, and χ angles were extracted at 16.33 ± 3.01, 10.61 ± 3.38, and 15.11 ± 3.30 degrees at base level, 22.77 ± 4.95, 7.78 ± 2.96, and 16.72 ± 2.66 degrees at mid level and 14.60 ± 5.81, 10.37 ± 5.48, and 8.79 ± 3.32 degrees at apex level, respectively, of the septum wall, respectively. This study shows significant correlation between the angle of 3-dimensional trajectory (ф) with the angle in short axis view (θ) of the septum wall at the apex level; and also with the angle in long axis view (χ) of the septum wall at base and mid levels., Conclusion: Due to the motion of the wall of the left ventricle in three dimensions, and the non-isotropic structure of myofibers, the angle of 3-dimensional trajectory was estimated using the speckle tracking method of 2-dimentional echocardiography images.

Background: We prospectively studied a group of patients with myocardial infarction (MI), who were candidates for surgical revascularization, to compare the efficacy of dobutamine gated myocardial SPECT with dobutamine stress echocardiography (DSE) for the detection of myocardial viability., Materials and Methods: We investigated 224 segments from 14 patients with MI using resting echocardiography and low dose dobutamine stress echocardiography as well as resting, low and high dose dobutamine stress 99mTc-Sestamibi gated SPECT., Results: In total, 13 men and 1 women with a mean age 54.57 years (range, 43 to 71 years) entered the study. Of the 125 dysfunctional segments, as assessed by ECG-gated examination, 53 (23.66% of total) were hypokinetic at rest, 64 (28.57% of total) were akinetic, and 8 (3.57% of total) were dyskinetic. The number of segments with resting wall motion abnormality (considered viable by low dose dobutamine ECG-gated examination) was significantly greater than those showing a contractile improvement in response to dobutamine in echocardiography (39.2% versus 32.8%, respectively, p < 0.05). In addition, in high dose ECG-gated examination, 42 of the 125 dysfunctional segments (33.6%) were viable. In general, the methods were well correlated., Conclusion: We found a good agreement between low dose dobutamine gated SPECT and stress dobutamine echocardiography for the detection of inotropic reserve in infarcted areas.

Background: Dilated cardiomyopathy (DCM) is often complicated by the appearance of functional mitral regurgitation (FMR). Although mitral ring annuloplasty (MAP) is the most widely used surgical procedure for the surgical treatment of FMR, there are still reports of patients who suffer recurrent FMR at later follow-ups. We sought to investigate the efficacy of papillary muscle approximation (PMA) combined with MAP in preventing the recurrence of FMR in high-risk patients., Methods: One hundred patients with ischaemic (74%) or non-ischaemic (26%) DCM along with severe (4+/4+) or moderately severe (3+/4+) FMR were enrolled in this prospective, cross-sectional study. According to the interpapillary muscle distance (iPMD) and coaptation depth (CD), the patients were risk stratified as low (iPMD + CD 30 mm, n= 69) and high-risk (iPMD + CD > 30 mm, n= 31) groups. The low-risk patients underwent only MAP, whereas the high-risk patients underwent MAP plus PMA., Results: After a mean +/- SD follow-up of 40.8 +/- 12.5 months, recurrence of 3+ to 4+ MR was observed in 8 (8.7%) and 7 (11.1%) patients in the annuloplasty group (MAP-only) and one (3.4%) patient in the combination group (MAP plus PMA) (P= 0.428). At the final follow-up, the New York Heart Association (NYHA) function class was 1.57 +/- 0.62 in the annuloplasty group and 1.45 +/- 0.57 in the combination group; there was no significant difference in NYHA function class between the first and final follow-ups (P> 0.05)., Conclusion: iPMD is a valuable index in the riskstratification of the recurrence of post-MAP MR in patients with DCM complicated by FMR.The patients treated with MAP plus PMA had more favourable outcomes and lower recurrence rates than those treated via the traditional route of MAP only.

Introduction: Due to limitations in measuring the torsion angle in the short-axis view when studying through-plane motion and so it is dependent on reference levels, in this study, we follow myocardial movement along the long-axis of the left ventricle (LV). Then, LV torsion is estimated in the long-axis view and compared with LV torsion in the short-axis view., Materials and Methods: Two dimensional echocardiographic images of healthy persons were recorded in cine loop format position throughout four cardiac cycles at basal and apical levels in the long- and short-axis views. The motion vectors for reign of interest in the horizontal and vertical directions were obtained by block matching algorithm. Correlation between the values of automated analysis and manual tracing was performed by Pearson correlation analysis. Then, the maximum rotation angles of the short- and long-axis views at basal and apical levels were assessed. Left-ventricular torsion angles in short-axis and long-axis views were calculated and compared based on rotation angles., Results: There was a high correlation between the measured myocardial wall displacement of automated analysis (BM algorithm) and manual tracing (R=0.96, p<0.05). The maximum rotation angles of basal and apical levels in the short-axis view are 7.96±1.57° and 9.49±1.72° and so in the long-axis view are 18.51±3.41° and 14.74±2.91°, respectively. The LV torsion angles and the time to reach peak LV torsion angles in the short-axis views are 17.26±2.53°, 293±26ms and in the long-axis view are 32.26±5.60° and 290±22ms respectively. There was a high correlation between the left-ventricular torsion angle in the short-axis view and the long-axis view (R=0.92, p<0.05). There was also a high correlation between the time to reach peak left-ventricular torsion angle in the short-axis view as compared to the long-axis view (R=0.97, p<0.05)., Conclusion: This study suggested that the LVtorsion angles in the short- and long-axis views were significantly correlated. It is concluded that torsion and rotation angles in the long-axis view are similar to those determined using the short-axis view., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: Considering the importance of annular dynamics in the valvular and ventricular function, we sought to evaluate the effects of treated pericardial annuloplasty rings on mitral annular dynamics and left-ventricular (LV) function after mitral valve repair. The results were compared with the mitral annular dynamics and LV function in patients with rigid and flexible rings and also in those without any heart problems., Materials and Methods: One hundred and thirty-six consecutive patients with a myxomatous mitral valve and severe regurgitation were prospectively enrolled in this observational cohort study. The patients underwent comparable surgical mitral valve reconstruction; of these 100 received autologous pericardium rings (Group I), 20 were given flexible prosthetic rings (Group II), and 16 received rigid rings (Group III). Other repair modalities were also performed, depending on the involved segments. The patients were compared with 100 normal subjects in whom an evaluation of the coronary artery was not indicative of valvular or myocardial abnormalities (Group IV). At follow-up, LV systolic indices were assessed via two-dimensional echocardiography at rest and during dobutamine stress echocardiography. Mitral annular motion was examined through mitral annulus systolic excursion (MASE). Peak transmitral flow velocities (TMFV) and mitral valve area (MVA) were also evaluated by means of continuous-wave Doppler., Results: A postoperative echocardiographic study showed significant mitral regurgitation (>=2+) in one patient in Group I, one patient in Group II, and none in Group III. None of the patients died. There was a noteworthy increase in TMFV with stress in all the groups, the increase being more considerable in the prosthetic ring groups (Group I from 1.10 ± 0.08 to 1.36 ± 0.13 m/s, Group II from 1.30 ± 0.11 to 1.59 ± 0.19 m/s, Group III from 1.33 ± 0.09 to 1.69 ± 0.21 m/s, and Group IV from 1.08 ± 0.08 to 1.21 ± 0.12 m/s). Recruitment of LVEF reserve during stress was observed in the pericardial ring and normal groups (Group I from 54.6±6.2 to 64.6±7.3%, P<0.005; and Group IV from 55.3 ± 5.7 to 66 ± 6.2%, P<0.05), but no significant changes were detected in the prosthetic ring groups (Group II from 50.4 ± 5 to 55.0 ± 5.1, and Group III from 51.1 ± 6.6 to 53.8 ± 4.7). There was a significant MASE increase in both of the studied longitudinal segments at rest and during stress in Groups I and IV compared with the prosthetic ring groups. There was no calcification of the pericardial rings., Conclusions: The use of treated autologous pericardium rings for mitral valve annuloplasty yields excellent mitral annular dynamics, preserves LV function during stress conditions, and leaves no echocardiographic signs of degeneration.

We present a 17-year-old woman with a 5-year history of systemic lupus erythematosus (SLE). The patient referred to us with the rheumatic involvement of the mitral valve and was treated with mitral valve repair by ring annuloplasty and anterior leaflet augmentation with autologous pericardium. Follow-up, however, disclosed precocious calcification of the valve, necessitating mitral valve replacement.

We report the case of a 48-year-old woman with a history of transient ischaemic attacks (TIA). The patient was diagnosed with a large patent foramen ovale (PFO), for which she underwent percutaneous PFO closure. Two years postprocedurally, the patient suffered frequent TIA and assessment showed the displacement of the device. The device was surgically removed, and the septum was repaired with a pericardial patch. Afterward, however, the patient experienced repeat TIA. It was discovered that the patient had a pulmonary arteriovenous fistula (PAVF), and a diagnosis of a trauma was made. The PAVF was later coil embolised. This case illustrates the importance of evaluating PFO closure patients for the associated causes of right-to-left shunting.

A 21-year-old man who had suffered an episode of complete heart block 2 months earlier and thus undergone pacemaker implantation presented with syncope. Echocardiography showed cardiac tamponade and raised the suspicion of lead penetration. The effusion was drained. Multi-sliced CT scan confirmed that the right aspect of the pacemaker wire was extracardiac, causing the cardiac tamponade.

Transcatheter aortic valve implantation has become an established alternative treatment method for patients with symptomatic aortic stenosis who are at high risk for conventional aortic valve replacement. Problems, however, persist when using this technique in patients with associated coronary artery disease. We describe a successful case of valve implantation via the transaortic route with simultaneous full revascularization., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Coronary anomalies are easily detected on ECG gated multi-detector CT which has shown to be superior to conventional angiography is demonstrating their origin and course. We present an unusual case of posterior descending artery arising as the continuation of the left anterior descending artery (LAD) in the presence of a diminutive right coronary artery (RCA). The LAD crossed over the apex and continued its course to the base of the heart in the posterior interventricular groove as PDA. The RCA, although normal in origin, was diminutive and terminated on the lateral wall of the right ventricle. This anomaly has been rarely reported and the previous cases have all been conventional angiographic findings., (Copyright © 2011 Australasian Society of Cardiac and Thoracic Surgeons and the Cardiac Society of Australia and New Zealand. Published by Elsevier B.V. All rights reserved.)

Objective: One of the mechanisms of development of functional mitral regurgitation after myocardial infarction is the increased papillary muscle distance which results due to ventricle remodeling. The aim of this study was to investigate the long-term effect of papillary muscle approximation (PMA) on the cardiac function of patients with ischemic cardiomyopathy and increased papillary muscle distance., Methods: Thirty patients (22 males; mean age: 57.0 ± 7.4 years) selected for coronary artery bypass grafting (CABG) underwent ventriculoplasty. Additionally, 50% of the study population also underwent PMA (group 1). All the patients had preoperative grade 3 or 4 mitral regurgitation with an inter-papillary muscle distance > 2.5 cm. In group 1, the papillary muscles were drawn together using an encircling loop. Mitral annuloplasty and the Dor procedure were performed in all the patients. Follow-up time was 41.5 ± 5.8 months and 42.7 ± 3.3 months in groups 1 and 2, respectively (p-value=0.49)., Results: The two groups had no significant difference regarding the annulus diameter, ring size, number of grafts, and concavity area. There was one case of in-hospital mortality in each group, and one patient in group 2 had expired by the last follow-up. Postoperative echocardiography revealed significant changes in the concavity area, ejection fraction, and sphericity index in the PMA group by comparison to group 2 (p-value < 0.05)., Conclusions: In patients with ischemic mitral regurgitation and increased papillary muscle distance, PMA as an adjunct to CABG results in better left ventricle function and shape, even at long-term follow-up., (Copyright © 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Background: The aim of this study was to investigate the feasibility of performing papillary muscle repositioning (PMR) for subvalvular-sparing mitral valve replacement procedures in patients with ischemic mitral regurgitation and to determine the early and late effects of this procedure on the clinical outcome and left ventricular mechanics., Methods: We prospectively randomly allocated 50 patients with severe ischemic mitral regurgitation and left ventricle dysfunction who were candidates for coronary artery bypass graft surgery and mitral valve replacement into a total chordal-sparing mitral valve replacement group or a PMR group. Echocardiography was performed preoperatively, at discharge, and after 3 years to determine the left ventricular dimensions, shape, and function., Results: The reduction in the left ventricle volumes and sphericity index in the PMR group was more significant than that in the other group. With regard to the left ventricular end-systolic and left ventricular end-diastolic volumes, sphericity index, and ejection fraction, the PMR group showed better results (p < 0.05), but the difference in New York Heart Association functional class after 3 years was not statistically significant between the two groups (p > 0.05)., Conclusions: The PMR technique described herein can dramatically help ischemic patients by affecting the left ventricular shape and function more efficiently compared with the complete retention of the mitral subvalvular apparatus if the mitral valve is to be replaced., (Copyright 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: The gold standard test in the diagnosis of heart transplant rejection is right ventricular (RV) myocardial biopsy, which is an invasive, time-consuming, expensive method. In an effort to find a reliable method to minimise the sequential use of myocardial biopsy, we assessed the main echocardiographic indices for the detection of allograft rejection., Materials and Methods: Fifty myocardial specimens were examined in this prospective study, which assessed the prominent echocardiographic parameters propounded by previous studies as indicators of rejection. Prior to biopsy, all the patients underwent preoperative transthoracic echocardiography. The accuracy of the echocardiographic indices was compared with that of myocardial biopsy indices as the gold standard. At three myocardial segments, namely, RV base, interventricular septal (Sep) base and lateral left ventricular (Lat) base, peak systolic strain (RV-S, Lat-S and Sep-S) was measured. In addition, time to systole (TS) was measured at the same three segments, yielding the three variables of RV-TS, Sep-TS and Lat-TS., Results: Our logistic regression model revealed that the four factors of Lat-S (%), Sep-TS (ms), posterior wall thickness (PWT; mm) and left ventricular mass index (LVMI; g m(-2)) could denote heart transplant rejection. We devised a new index, the echo rejection score, using the following formula: [(PWT+LVMI)-(Lat-S+Sep-TS)]. This new formula has an area under a curve of 0.932 and a cut-off point of 0; it yields a sensitivity of 100.0%, specificity of 71.0%, positive predictive value of 67.9% and a negative predictive value of 100.0%. If the echo rejection score is >0, there is a 67.9% possibility that a cardiac transplant patient is presenting with allograft rejection, while a score < or =0 denotes a 100% improbability of rejection., Conclusion: Our proposed method for screening patients at risk of acute cardiac rejection with echo rejection score showed a good sensitivity in detection of graft rejection. However, further study is required to determine if it can be used as an adjunct to the myocardial biopsy., (Copyright 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

A young man with a history of subvalvular aortic valve stenosis repair performed in childhood presented to our center with chest pain. Computed tomography and angiography demonstrated obstruction of the left main coronary artery. The obstruction was believed to result from the cannulation of coronary arteries during antegrade cardioplegia in his previous cardiac surgery.

Ascending aorta and aortic arch thrombosis is rare in a young man with no risk factor. Here, we report the case of a young male patient with factor V Leiden mutation who developed ascending aorta and aortic arch thrombosis and subsequent emboli.

Objective: Commonly used procedures to repair functional tricuspid regurgitation have a high failure rate. The present study was designed to lower this failure rate by reducing leaflet tethering via pericardial patch augmentation when the preoperative probability of recurrence was high., Methods: Between 2001 and 2007, 210 patients with severe functional tricuspid regurgitation underwent tricuspid valve repair at the Day General Hospital. With respect to the type of repair, the patients were randomly divided into 4 groups: (1) De Vega in 52 patients; (2) ring annuloplasty in 53 patients; (3) De Vega and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 53 patients; and (4) ring annuloplasty and, if indicated by the preoperative tethering index (tethering distance > 8 mm or tethering area > 16 mm(2)), pericardial patch augmentation in 52 patients. The results of 1-month and 1-year postoperative tricuspid regurgitation were evaluated., Results: Fifteen patients in group 3 and 15 patients in group 4 met the criterion for the complementary procedure. Postoperative tricuspid regurgitation was different between the groups (P < .05): 16.0% and 28.0% of patients in the De Vega group, 8.0% and 14.0% of patients in the ring annuloplasty group, 4.0% and 10.0% of patients in the De Vega + pericardial patch augmentation group, and 2.0% and 8.0% of patients in the ring annuloplasty + pericardial patch augmentation group had postoperative tricuspid regurgitation at 1-month and 1-year follow-up, respectively., Conclusion: An assessment of preoperative tricuspid valve tethering to select patients suitable for augmentation contributes to a good surgical outcome in patients with severe functional tricuspid regurgitation., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

A young man presented to our center with dyspnea. Echocardiograpy showed a low ejection fraction and a connection between the ascending aorta and the pulmonary artery. Multislice computed tomography confirmed the diagnosis. He underwent successful repair of the connection.

The initial and long-term benefits of coronary artery bypass grafting depend upon maintaining the coronary blood flow supplied by the graft. In order to devise a scoring system for predicting graft patency, we evaluated presumptive correlations between saphenous vein graft patency and the characteristics of saphenous veins that were used as conduits in coronary revascularization.We prospectively evaluated 1,000 saphenous vein segments that were implanted in 403 consecutive patients who underwent on-pump coronary artery bypass grafting at our hospital from January 2006 through February 2009. Branches, varicosity, diameter, and wall thickness were evaluated, and a scoring system was created in order to obtain a value for each characteristic. The patients were postoperatively monitored for 1 year, and graft patency was then evaluated with the use of 64-slice multidetector computed tomography.Lesions were found in 12.3% of the grafts. All of the evaluated characteristics of the grafts had a significant correlation with saphenous vein graft flow (P <0.0001). Using the venous characteristics in our statistical analysis, we devised a formula to obtain a score (range, 4-12) to predict the patency of each graft. A cutoff score of 7 yielded 87.8% sensitivity and 82.8% specificity.Our scoring system has good prognostic value. We believe that it can assist surgeons in choosing the most appropriate conduit and target vessel for coronary artery bypass grafting, especially in high-risk patients who are particularly dependent on blood flow through saphenous vein grafts.

After cardiac operations, careful management substantially reduces the risks of negative complications during or after the removal of temporary epicardial pacing wires. Herein, we report the case of a 58-year-old man who, 4 days after undergoing aortic root replacement, developed pericardial tamponade after the removal of temporary epicardial pacing wires. Consequent to the tamponade, a right-to-left shunt developed through a previously undiagnosed patent foramen ovale. The patient underwent emergency surgery to repair myocardium that had ruptured due to the removal of the wires, and he recovered uneventfully.