valuation of the Proximal Isovelocity Surface Area Method and Vena Contracta Width in Mitral Regurgitation with Transthoracic and Transesophageal Echocardiography To compare the proximal isovelocity surface area (PISA) method and vena contracta width (VCW) which are some of the color Doppler methods that we use in the evaluation of mitral regurgitation (MR) with transthoracic (TTE) and multiplane transesophageal echocardiography (TEE) and to determine the reliability of the TTE measurements that we use routinely for the evaluation of MR. Included were 52 patients with MR of which 25 rheumatic disease, 10 mitral valve prolapse, 12 prosthetic valve having paravalvular leakage and 5 chordal rupture (26 male, mean age: 44.2 ±16.6 years). The effective orifice area (EOA) calculated by the PISA method at TEE was chosen as the reference method. The MR area, the proportion of jet area to the left atrium area (MR area/LA), the EOA and MR volume calculated by the PISA method and VCW were used as Doppler echocardiographic parameters while evaluating the MR at TTE. The PISA and VCW were measured by TTE from parasternal long axis, apical two-and four-chamber views and by TEE from 0º, 30º-60º, 90º and 120º. The proximal isovelocity surface area and VCW have been displayed optimally at TTE and TEE 94% and 98% of the cases, respectively, and the 90% and 94% of the VCW cases. Significant correlations existed between the MR area (r =0.34, p <0.02), MR area / LA (r = 0.38, p<0.009), VCW parasternal (r=0.78, p<0.0001), VCW four chamber (r=0.72, p<0.0001), VCW two chamber (r= 0.68, p<0.001), PISA-MR volume (r=0.83, p<0.0001) and PISA-EOA (r=0.95, p<0.0001) with the reference method. It has been found that PISA-EOA, PISA-MR volume and parasternal long axis VCW were determinants of the reference method by multivariate stepwise regression analysis of the parameters measured at TTE. It was ascertained that the EOA (52 mm2) calculated by the PISA method at TTE was able to predict the estimate value of the EOA (50 mm2) calculated by the same method at TEE with a high sensitivity and specificity, the MR volume (45 ml) with a high sensitivity and the VCW at the parasternal long axis chamber (5.2 mm) with a high specificity. The regurgitant orifice area and the regurgitant volume calculated by TTE are reliable and simple parameters in the quantitative evaluation of MR. VCW must be measured on axial planes, this method can be used secondarily as a semi-quantitative method auxiliary to the PISA method since it has mediocre sensitivity for the determination of the orifice area quantitatively. Other semiquantitative methods, which are used rather frequently in routine practice, are not reliable especially in the evaluation of the degree of eccentric jets.

Left Atrial Functions in Rheumatic Chronic Mitral Regurgitation Left atrial (LA) functions are affected in several cardiac pathologies. This study was planned to assess left atrial mechanical function in patients with rheumatic chronic mitral regurgitation (MR).18 patients (mean age 43 ±16 years) with isolated MR in sinus rhythm and 18 healthy controls (mean age 33 ±6 years) were included in this study. The severity of MR was estimated by color Doppler echocardiography. The ratio of MR jet area to left atrial area was calculated. With this method a ratio less than 0.20 was registered as mild, 0.20-0.39 as moderate, and 0.40 or greater as severe MR. LA volumes were measured echocardiographically at the time of mitral valve opening (LAVmax), at the onset of atrial systole (p wave on electrocardiography = LAVp) and at the mitral valve closure (LAVmin) according to the biplane area-length method in apical 4-chamber and 2-chamber view. All volumes corrected for body surface area, and following LA emptying functions were calculated. LA passive emptying volume (LAPEV)= LAVmax - LAVp, LA passive emptying fraction (LAPEF)= LAPEV/ LAVmax. Conduit volume (CV) =LV stroke volume-( LAVp- LAVmin), LA active emptying volume (LAAEV)= LAVp- LAVmin , LA active emptying fraction (LAAEF)= LAAEV/ LAVp , LA total emptying volume (LATEV)= (LAVmax -LAVmin), LA total emptying fraction (LATEF)= LATEV/LAmax. All measurements were averaged over three cardiac cycles.There were no significant differences in mean age, body surface area, and heart rate between patients and controls (p>0.05). Left ventricular end-diastolic and systolic diameters were significantly greater in patients with MR than in controls (p<0.001), whereas ejection fraction was not significantly different. A mean ratio of MR jet area to left atrial area were 0.37 ±10. LA dimension was significantly greater in patients with MR than in controls (p<0.001). LA volume indexes; Vmax, Vmin, and Vp were greater in patients with MR than in controls (p<0.001). Although LA passive emptying volume (p<0.01), LA active emptying volume (p<0.001), LA total emptying volume (p<0.001), conduit volume (p<0.005) were found significantly greater in patients with MR than in controls, LA passive emptying fraction (p<0.001), LA active emptying fraction (p<0.001), LA total emptying fraction (p<0.01) were significantly lower in patients with MR than in controls. The results of this study have indicated that LA maximal, minimal volumes and the one at onset of atrial systolie are increased, whereas LA mechanical functions are deteriorated in patients with rheumatic chronic MR

Is TIMI Frame Count Correlated with Left Ventricular Hypertrophy? The TIMI frame count (TFC) has been proposed as a simple, reproducible, objective, and quantitative method to assess coronary blood flow. The TFC reflects coronary flow reserve. Cardiac hypertrophy is associated with a decrease in coronary reserve. Several factors have been shown to relate with TFC, but the relation between left ventricular hypertrophy (LVH) and TFC has not yet been investigated. The aim of this study was to determine whether LVH affects TFC. The TFC was measured in 68 subjects without history of myocardial infarction and significant coronary stenosis. Determination of left ventricular mass index (LVMI) according to the formula of Devereux was performed, and LVH was defined by LVMI >134 g/m2 in men and >110 g/m2 in women. The patients were divided into 2 groups according to presence of LVH: group 1 with LVH (n = 31; aged 53 ± 13 years; 16 women), and group 2 without LVH (n = 37; aged 50 ±8 years; 16 women). The mean TFC in the right coronary artery (RCA) was significantly higher in group1 (24,1 ±4,9 frames) than in group 2 (20,9 ±5,4 frames, p = 0.01). The TFC in the RCA was significantly correlated with interventricular septum thickness (r = 0,36; p = 0,004) and left ventricular posterior wall thickness (r = 0,33; p = 0,007), but not with LVMI (r = 0.18; p = 0.17). The mean TFC in the left anterior descending (LAD) and left circumflex (Cx) arteries were not different between the two groups. No correlation existed between TFC in the LAD or Cx and echocardiographic parameters. Left ventricular hypertrophy has significant effect on the TFC in the RCA. Therefore, studies comparing TFC need to consider LVH.

The aim of this study was to evaluate left ventricular (LV) diastolic parameters in patients with chronic cor pulmonale (CCP), and to compare these with healthy volunteers by using Doppler echocardiography and tissue Doppler imaging (TDI). In this study, 33 patients (mean age: 60.1 ±12.0 years) with CCP and good echocardiographic image quality were examined, and 20 age-matched healthy volunteers constituted the control group. All patients and control group were in sinus rhythm. Patients and the controls underwent Doppler echocardiography and TDI examinations. All patients had a respiratory test and blood gas analyses. Additionally, systolic pulmonary artery pressure (PAP) was calculated in all patients. Pulmonary hypertension (PH) was defined as peak systolic pressure greater than 30 mmHg. Patients in CCP group had lower mitral E wave (p<0.05), higher A (p<0.01), lower E/A (p<0.0001), longer EDT (p<0.05) and isovolumetric relaxation time (IVRT) (p<0.01), lower mitral anular Em velocity (p<0.0001) and Em/Am ratio (p<0.001) than the control group. In addition, there was a significant correlation between PAP and the following parameters: Mitral E/A ratio (r=-0.422, p<0.05), IVRT (r=0.472, p<0.01) and mitral anular Em (r=-0.575, p<0.001). There were no significant differences between the groups in terms of age, gender, heart rate and systemic blood pressure. Patients with CCP have LV diastolic dysfunction, which is correlated to PH levels. We concluded that the combination of standard Doppler echocardiography and diastolic myocardial velocities measured by TDI may contribute to determining LV diastolic dysfunction in patients with CCP.

We investigated predictors of spontaneous conversion of recent onset atrial fibrillation (AF) to sinus rhythm (SR) and the long-term efficacy of propafenone for maintaining SR after conversion in patients with the first episode of recent AF. This prospective study consisted of consecutive 102 patients with recent onset AF (?48 hours). Twenty-four patients were excluded due to acute coronary syndome (n:17), heart failure (n:5) and pulmonary disease (n:2). The remaining 78 patients constituted the main study population. After spontaneous conversion to SR within 12 hours, they were randomized to propafenone (n:21, mean age:59.9 ±11.4 years) or placebo groups (n:24, mean age: 62.7±9.5 years) and were followed up for long-term SR maintenance during 12 months. There was no withdrawal at follow-up. Clinical characteristics in both groups were comparable. The maintenenance of SR was analyzed by the Kaplan-Meier method. Spontaneous SR was observed in 45 (58%) of 78 patients. Among the variables of age, gender, underlying heart disese, AF duration, left atrial dimension (LAD) and left ventricular ejection fraction (LVEF), duration of AF ?24 hours was the only independent predictor of spontaneous conversion in multivariate analysis (OR:7.1, 95% CI:1.6-31.3; p=0.01). At 12 months, SR was maintained in 16 (76%) patients assigned to the propafenone group whereas it was so in those 10 (42%) assigned to placebo (p=0.02). By multivariate analysis, treatment with propafenone was the only predictor for maintenance of SR (p=0.02) in a model comprising age, gender, underlying heart disese, AF duration, LAD and LVEF had no predictive value. No major side effects occurred. Patients with recent onset AF should be monitored for at least 12 hours to observe spontaneous conversion as long as hemodynamics are stable. Propafenone seems to be superior to placebo for long-term maintenance of SR after spontaneous conversion.

The mechanisms of different hemodynamic and clinical responses to dobutamine infusion in mitral stenosis are not clearly established. The aim of this study was to evaluate the relation between left atrial (LA) function and hemodynamic response in patients with mitral stenosis to dobutamine infusion and to explain this response related to this parameter. Forty-two consecutive moderately symptomatic patients (33 women, 9 men; mean age 46 ±9, range from 26 to 66), New York Heart Association (NYHA) class II with mitral stenosis (mean mitral valve area 1.7 ±0.1cm2) were evaluated with dobutamine stress echocardiography. Hemodynamic measurements were obtained at rest and peak dobutamine infusion. LA fractional shortening at rest was used as an index of global LA function. Twelve patients with hemodynamically serious mitral stenosis consisted of Group II (pulmonary artery pressure >60mmHg, transmitral mean gradient >15 mmHg during dobutamine infusion). The remaining 30 patients whose hemodynamic data did not reach the same level formed of group I. LA fractional shortening was significantly lower in group II compared to group I (19 ±3 vs 32 ±5 %, p<0.0001). In addition, left atrial dimension was significantly larger in group II (43 ±5 mm in group I vs. 50 ±2mm in group II, p<0.0001). While baseline hemodynamic parameters and mitral valve characteristics were not different in both groups, an increase in mean transmitral gradient (8 ±3 vs 5 ±2 mmHg, p<0.0001) and pulmonary artery systolic pressure (24 ±3 vs 16 ±8 mmHg, p= 0.007) were significantly greater in group II compared to group I during dobutamine infusion. Left atrial fractional shortening was negatively related to the increase in transmitral mean gradient (r:-0.58, p<0.01). We that hemodynamic response during dobutamine stress echocardiography correlated with LA fractional shortening in patients with mitral stenosis. In some patients with mitral stenosis patients, manifest elevation in hemodynamic parameters may depend on impaired left atrial function accompanying left atrial enlargement.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVC) is a cardiomyopathy characterized pathologically by fibrofatty replacement primarily of the RV and clinically by life-threatening ventricular arrhythmias in apparently healthy young people. The disease is typically inherited as an autosomal dominant trait with variable penetrance. We report four siblings with ARVC in one family with different clinical features: Sibling A had developed sudden cardiac death 19 years ago, at age 18. Sibling B, a 14-year-old girl admitted with multiple congestive heart failure attacks over a two-year period, finally developed fatal ventricular fibrillation at age 16. In sibling C, a 16-year-old girl with fatigue, palpitation and prominent ascites recently, typical features of ARVC were noted on ECG and nonsustained ventricular tachycardia on Holter recording. Echocardiography revealed dilated cardiomyopathy with prominent right chamber dilatation and magnetic resonance showed fatty replacement of right and left ventricular myocardium. The patient, diagnosed as having ARVC with left ventricular involvement, is currently on sotalol and congestive heart failure medication. Sibling D, a 9-year-old girl, screened because of her elder sister, was asymptomatic but her ECG, TTE and MRI revealed early phase of ARVC. In summary, the natural history of ARVC can be asymptomatic, subclinical-resulting in sudden death, overt with life-threatening arrhythmias, or dominated by progressive congestive heart failure.