Congenital absence of the pericardium is a rare condition. Diagnosis and management of this condition remain a dilemma for clinicians. Here, we report a case of 15-year-old boy who had complaint of palpitation. Considering the echocardiographic features, pericardial agenesis associated with atrial septal defect (ASD) was suspected and multimodality imaging was performed for subsequent confirmation. Mal-aligned septum leads to failure in ASD device closure; therefore, the defect was repaired surgically by using a Dacron patch. Physicians need to be aware of this disorder and its associated congenital abnormalities, to enable them to make a correct diagnosis and treatment plan.

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Background: Diastolic function abnormalities contribute to symptoms of heart failure (HF). However, data in this regard are limited. We, therefore, sought the association of sensitive new markers of filling pressure and diastolic function with functional capacity in patients with congested HF. Materials and Methods: This case-series study was conducted from December 2017 to December 2018 in the Department of Heart, Modarres university hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Patients with moderately reduced systolic ejection fraction (EF) (30%-40%) were included in the study. Thirty patients were included in the study and underwent Doppler echocardiography following the exercise tolerance test. All patients had stable systolic HF and were stable on therapy for at least 1 month before testing. The primary endpoint was maximal exercise tolerance defined by the achieved metabolic equivalents (METs). Results: There were 27 (90%) males in the study. Mild diastolic dysfunction presented in 13 (43.3%) patients and moderate/severe diastolic dysfunction in 17 (56.7%) patients. In Pearson analysis, data showed systolic pulmonary arterial pressure (SPAP), left atrial volume index (LAVI), peak early diastolic mitral annulus velocity (E/Ea), left atrial pressure (LAP), and tricuspid annular plane systolic excursion (TAPSE) which were significantly higher in patients with higher age (P < 0.05). Increasing in E/Ea was significantly related to higher SPAP (P < 0.001), lower METs (P < 0.001), higher LAVI (P < 0.001), higher LAP (P < 0.001), higher TAPSE (P < 0.001), and higher S tissue (P = 0.02). LAP and E/Ea were conversely correlating with METs significantly (P < 0.001). Conclusion: In the present study, it was found that the diastolic function and high-LA pressure apart from the left ventricular EF (LVEF) are associated with exercise tolerance in patients with stable functional Class I-III HF and reduced LVEF.

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A 33-year-old male presented with dry cough for 6 months and dyspnea on exertion for 3 months for which he was treated symptomatically by nearby physicians. On two-dimensional echocardiography, it revealed large left atrial mass occupying 2/3^rd of the left atrium (LA) extending into the left lower pulmonary vein (PV). Then, his computed tomography of the chest was done, which revealed posterior mediastinal mass invading the left upper and lower lobe of the lung through the left main bronchus. The lesion also invaded the LA through the left PV. Biopsy was suggestive of nonseminomatous germ-cell tumor. This case is presented to demonstrate uncommon cardiac manifestations of secondary spread of testicular malignancy.

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Purpose: Evaluation of cardiac valve morphology has not been considered an indication for cardiac magnetic resonance imaging (MRI) due to suboptimal imaging quality. Our study aims to evaluate cine of cardiac magnetic resonance-steady-state free precession (CMR-SSFP) imaging quality and diagnostic accuracy in the assessment of cardiac valve morphology for congenital heart disease. Materials and Methods: We retrospectively reviewed consecutive pediatric/congenital cardiac MRI cases. A 5-grade diagnostic clarity score was assigned to the aortic valve annulus and leaflets, tricuspid valve and mitral valve annuli, leaflets, chordae, and papillary muscles by examination of standard cine CMR-SSFP imaging. Among patients with aortic valve imaging, we compared morphologic diagnosis by CMR-SSFP to echocardiography. High-quality diagnostic imaging was defined as a clarity score of 1 or 2. Results: There were a total of 234 cardiac MRI studies evaluated with a total of 1892 valve components. The majority of valve annuli, leaflets, and papillary muscles had high diagnostic clarity score 64%-80% of the time - the tricuspid valve papillary muscles had a high diagnostic clarity score 53% of the time. Among the 39 cases with aortic valve imaging, CMR-SSFP correctly identified the aortic valve morphology including the affected commissure. Conclusions: CMR-SSFP produces high diagnostic quality imaging of cardiac valve morphology in congenital/pediatric cardiac MRI. The valve components with the highest diagnostic clarity score are tricuspid and mitral valve annuli, leaflets and papillary muscles, and aortic valve annuli and leaflets. Aortic valve morphology can be diagnosed with a high degree of reliability.

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Background: Echocardiography is usually the first imaging modality for the evaluation of the structural and functional disorders of the heart and the great vessels. Color flow and Doppler images can provide hemodynamic and bloodstream assessment. The goal of this study was to investigate the function of the right ventricular (RV) using echocardiography in patients with an increased mean pulmonary artery pressure (PAP) (>25 mmHg). Methods: This cross-sectional study recruited patients with an elevated mean PAP (>25 mmHg) according to echocardiography. The RV function was evaluated in terms of the fractional area change (FAC), pulmonary vascular resistance (PVR), the myocardial performance index (Tei index), and the S-wave velocity. The data were analyzed using SPSS software, version 16, as well as the Chi-square test, the Pearson correlation coefficient, and the t-test. P< 0.05 was considered as statistically significant. Results: The mean FAC and the mean tricuspid annular plane systolic excursion (TAPSE) in the group with a mean PVR value of <2 WU were significantly higher than the mean FAC and the mean TAPSE in the group with a minimum mean PVR value of 2 WU (P = 0.006 andc P = 0.04, respectively). Conclusions: The RV function measured in terms of some basic echocardiographic parameters - namely the FAC, the S-wave velocity, the Tie index, and TAPSE - had a significant correlation with the mean PAP. In addition, the FAC value was more sensitive to an abnormal PVR value owing to the high frequency of the abnormal FAC values in the range of abnormal PVR values.

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Introduction: Measurement of the left ventricular ejection fraction (LVEF) is a common tool for evaluating the left ventricle (LV) systolic function. The aim of this study was to evaluate and compare the LVEF and mitral regurgitation (MR) severity as estimated by angiography and echocardiography in patients with coronary artery disease (CAD) and LV systolic dysfunction. Methods: In this observational study, 39 men and 11 women at a mean age of 60 years were recruited. The patients underwent catheterization and echocardiography, and the data on the LVEF and MR by both methods were registered. Results: The mean LVEF by echocardiography and angiography was significantly correlated (correlation coefficient = 0.698; P < 0.0001). Although there was agreement between these methods in the estimation of the mean EF (mean difference in the LVEF = 1.23 ± 7.63% and 95% limit of agreement = −12.5-19) and the κ coefficient was 45.7% (P = 0.001), the estimated mean EF was 32.6 ± 10.25% by echocardiography and 29.8 ± 8.2% by angiography (P = 0.007). Furthermore, there was a statistically significant difference in the estimated MR severity between the two methods (P = 0.0001), with echocardiography reporting higher degrees of severity than angiography. Conclusions: In our patients with CAD and LV systolic dysfunction, after the exclusion of age, sex, number of diseased coronary arteries, and myocardial infarction history from the analysis, although the mean LVEF by echocardiography and angiography was significantly correlated, echocardiography estimated higher LVEF values than angiography, especially in the patients with triple-vessel disease. Moreover, echocardiography showed higher degrees of MR severity than angiography.

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Background: Iron overload is a common problem in beta-thalassemia major. Finding a reliable and available modality to determine the presence of iron overload in the initial stages might decrease the risk of cardiomyopathy. We sought a reliable echocardiographic index to assess the extent of iron overload. Methods: This cross-sectional study was conducted on patients with beta-thalassemia major from June 2016 to May 2017. All the patients underwent T2* magnetic resonance imaging, conventional echocardiography, tissue Doppler study, and strain imaging for the measurement of ventricular systolic function indices including the left ventricular global longitudinal strain (LVGLS). The echocardiographic findings were compared between those with myocardial iron overload (T2* ≤20 ms) and those without it (T2* >20 ms) and in the second phase between those with nonsevere overload (20 ms >T2* >10 ms) and those with severe overload (T2* ≤10 ms). Results: Forty-four patients, comprising 23 (52.35%) males and 21 (47.7%) females, were enrolled. All the patients were receiving chelating drugs. The LVGLS showed a significant difference between those with myocardial iron overload and those without it (P = 0.012). Accordingly, a cutoff value of −17.5 for the LVGLS had 100% specificity and 43.8% sensitivity. Concerning the distinction between nonsevere and severe iron overload states, the average LVGLS (P < 0.001), LV end-diastolic volume index (P = 0.016), and LV end-systolic index (P = 0.016) showed significant differences between the groups. Conclusions: The LVGLS might be used as a reliable echocardiographic index for defining myocardial iron overload.

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Percutaneous coronary intervention (PCI), despite its remarkable efficacy in the treatment of coronary artery disease, has some complications such as coronary artery perforations, which are uncommon but may lead to pericardial effusion and progress to cardiac tamponade, myocardial infarction, and death. A 76-year-old woman with a history of exertional angina was admitted to our hospital for PCI. The angiographic feature of the patient's PCI was a major dye leakage into the pericardial sac with a frank perforation, representing Type III Ellis classification. Given her unstable hemodynamic state and a high risk for perforation, immediate pericardiocentesis was performed and a JoStent GraftMaster Stent was used. In addition, a decision was made to perform a covered stent implantation, as an alternative to surgery, because balloon dilation failed to stop the leakage. The perforation was sealed successfully. After the pericardiocentesis and the emergency covered stent implantation, the patient was stable and her hemodynamic state improved gradually. Coronary artery perforations with sequelae during the intervention, albeit a rare event, may lead to serious complications and even death. While prompt surgical intervention may be life-saving, expertise in the use of covered stents may provide a valuable rescue option for this serious complication.

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A patent ductus arteriosus (PDA) is a common congenital malformation in pediatric patients and accounts for 7%-10% of congenital heart diseases. The PDA is a posttricuspid shunt resulting from an arterial communication between the upper descending aorta and the distal pulmonary artery, is an important part of a normal fetal cardiac anatomy and usually closes spontaneously within 1 week after birth. Closure is indicated in patients with significant related symptoms, history of endarteritis, or dilation of the left atrium and/or the left ventricle (LV). Before the development of percutaneous PDA closure, surgical closure was recommended as the main routine treatment. An occasional occurrence is the recanalization of a surgically ligated ductus arteriosus, which may be associated with the serious complication of aneurysm formation. Herein, we report a rare case of a longstanding neglected PDA aneurysm as a complication of postsurgical PDA closure and discuss the weaknesses and strengths of cardiac imaging in this regard. A 31-year-old man with a history of surgical ligation of the PDA 20 years ago was referred to us for preoperative evaluation before elective noncardiac surgery. Electrocardiography revealed a normal sinus rhythm and an LV volume-overload pattern. Severe LV enlargement and moderate systolic dysfunction associated with a large residual PDA were found on transthoracic echocardiography. Cardiac catheterization and cardiac computed tomography angiography confirmed the presence of a calcified aneurysm of PDA, which was not suitable for percutaneous PDA closure. The patient underwent successful surgical closure without any residue or complications.

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Background: Given the high capability of dobutamine stress echocardiography (DSE) in the actual estimation of the ventricular function and the prediction of the intraoperative or postoperative outcomes of revascularization, especially following coronary artery bypass grafting (CABG), we aimed to assess the relationship between DSE findings and CABG outcomes. Methods: This retrospective case-control study was conducted on forty patients with left ventricular (LV) systolic dysfunction who underwent CABG during an 8-year period. All the patients were assessed with DSE to determine their ventricular functional status. Checklists containing DSE findings based on the latest guideline, demographics, and the outcomes of revascularization were filled out for the participants. Telephone follow-up was done for all the participants after 6 months. The data were analyzed using SPSS, version 16. Results: Resting LV ejection fraction (LVEF) ≤25%, peak DSE LVEF ≤35%, absolute increase in the LVEF (LVEF change) <8%, a minimum resting wall motion score index (WMSI) of 2, a post-DSE WMSI >2.25, a minimum pulmonary artery pressure (PAP) of 30 mmHg, and nonviable myocardium had positive correlations with the short- and long-term complications of CABG. These correlations were statistically significant between a maximum pre-DSE LVEF of 25% and an LVEF change of < 8% and the operating room complications (P < 0.001) and between nonviable myocardium and the complications in the intensive care unit (ICU; P < 0.001). However, our results did not show that the peak DSE LVEF, WMSI, PAP, and nonviable myocardium were the significant predictors of death due to CABG. It appears that only a pre-LVEF of <25% is a significant predictor of death after CABG (P < 0.001). Conclusions: DSE findings were able to predict complications in the operating room and in the ICU, especially in the participants with low LVEFs.

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Background: Coronary computed tomography angiography (CTA) has recently been shown to enjoy a high negative predictive value for ruling out coronary heart disease and risk stratifying patients with acute coronary syndrome (ACS). Hence, we assessed the 1-year outcome associated with a CTA-guided strategy in patients presenting to the emergency department with low to intermediate risk for ACS graded according to the GRACE score. Methods: In this case-series study, 77 consecutive patients (mean age = 49.7 ± 10.1 and 53.2% female) who presented to the emergency department with ischemic-type chest pain and low to intermediate risk for ACS were evaluated prospectively. The patients underwent coronary CTA after the measurement of troponin I. Those with nonobstructive plaques and mild stenoses (<50% luminal narrowing) were discharged with optimal treatment without further evaluations, those with moderate stenoses (50%-70% narrowing) were discharged with optimal treatment and close follow-ups, and those with severe stenoses (>70% narrowing) underwent coronary angiography. The discharged patients were contacted and their medical records were reviewed to determine the rates of major adverse cardiovascular events (MACE)—comprising death, myocardial infarction, stroke, hospital admission, and revascularization. Results: A total of 89.6% of the patients were in the low-risk ACS group. There was no significant association between MACE and the subscales and the GRACE score (P > 0.05). There was no relationship between the GRACE score and the severity of coronary stenosis (P > 0.05) and the high-severity plaques (P > 0.05). However, the severity of stenoses in the proximal part of the left anterior descending artery (LAD) (P = 0.00), the mid part of the LAD (P = 0.004), and the first part of the obtuse marginal artery (P = 0.004) was associated with MACE. Furthermore, there were no relationships between MACE and the high-risk plaques and the risk factors (P > 0.05). Conclusions: CTA ruled out significant lesions and optimal treatment was accompanied by good prognoses in our patients. CTA may, therefore, be an optimal cost-benefit modality for the determination of the diagnosis and the therapeutic modality in patients at low to intermediate risk for ACS presenting to the emergency department.

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Arteriovenous fistula could be traumatic with one manifestation as high-output heart failure. We present a 29-year-old male, referred for unexplained right-sided enlargement and the symptoms of right ventricular failure for 8 months ago. Considering right-sided dilatation, marked inferior vena cava plethora, and increased pulmonary passage of flow in the absence of intracardiac shunts, arteriovenous shunt was suspected. He had a history of penetrating abdominal trauma which raised the suspicion for further evaluation. Abdominal sonography and contrast-enhanced computed tomography revealed a large arteriovenous fistula between the left common iliac artery and vein. The patient underwent successful percutaneous repair with a stent graft and dramatic improvement in symptoms and resolution of flushing and edema.

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Coarctation of the aorta (COA) is a congenital disease with significant stenosis of the aorta which is associated with some complications such as hypertension. A 37-year-old pregnant woman was referred to our Cardiology Department for control of hypertension. She was in the 26^th week of her gestation and she had another uneventful pregnancy 4 years ago. Echocardiography before delivery showed significant coarctation with pressure gradient (PG)= 120 mmHg and cesarean section was done without any abnormal event. Six months later, stenting of aortic stenosis was done with a patient in a good condition. Coarctation (repaired or nonrepaired) is an important clinical condition during pregnancy which needs full investigation.

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Ventricular diverticula are a rare congenital abnormality characterized by synchronized contractility. Isolated diverticula mostly remain asymptomatic until adulthood. In this case report, we describe a 22-year-old woman with a history of pain in her arms and cold-induced skin discoloration. She was evaluated with echocardiography and cardiac magnetic resonance imaging, which illustrated a muscular basal diverticulum in the left ventricle.

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Tumors that involve the heart are more likely to represent metastatic disease than do primary cardiac neoplasms. Cardiac metastases from a renal cell carcinoma are rare and would be unique when there is no contiguous vena caval involvement such as the case that will be described here.

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Background: Curcumin, a yellow substance found in turmeric, has not only antioxidative features and beneficial effects in the treatment of cancer, liver, heart, and pulmonary diseases but also anti-inflammatory and anticoagulative effects. This chemical has cardioprotective effects too. Objectives: In this study, we examined the effects of curcumin on left ventricular (LV) function in patients receiving dialysis for chronic renal failure. Methods: This study is a double-blind, placebo-controlled trial conducted on 35 patients with chronic renal failure undergoing dialysis in the dialysis center of Baqiyatallah hospital. The patients were randomly divided into 2 groups: the curcumin group (n = 20) and the control group (n = 15). The curcumin group received curcumin capsules at a dose of 500 mg every 8 hours for 6 weeks (1500 mg/d) and the control group received a placebo for 6 weeks at the same dose. Echocardiography was done before the use of the drug and once after the 6th week. Also, the ejection fraction (EF), representing LV function and size, was measured in both groups. Results: Themeanage was 44.2±13.4 years for the curcumin group and 45.4±6.2 years for the placebo group. The study population comprised 22 male and 13 female patients. There were no significant differences regarding demographic variables such as age, sex, and body mass index between the 2 groups. In the curcumin group, LVEF based on the volume changed from 50.6% ±7.1% to 51.5% ± 6.8% (P = 0.130). In the curcumin group, LVEF based on the diameter changed from 51.8% ± 3.8% to 52.4% ± 3.5% (P = 0.112). The changes in the mean EF before and after the intervention were not significant in each group. The EF, based on ventricular volume and diameter, was not significantly different between the 2 groups. In addition, the pulmonary artery pressuremeanin both groups did not significantly change after the intervention (P > 0.05). Conclusions: The administration of curcumin in patients undergoing dialysis had no positive effects on enhancing LVEF and LV function. Further research is required to shed sufficient light on this issue.

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The right ventricle (RV) is a complex structure with abstruse function that reveals important differences when compared to the left ventricle (LV), so it cannot be described as a simple geometric form and achromatic physiology. As an inference from this fact, in the present review, weaim to describe RV structure including theembryology, anatomy, and physiology and present a functional, hemodynamic, and imaging assessment of the normal and failing RV. So that, we conducted a thorough review based on the database sources such as MEDLINE, PubMed, Cochrane and Google scholar. No restrictions were placed on study date, study design, or language of publication. We searched all valuable and relevant information considering the anatomy, physiology, mechanics, hemodynamic and imaging evaluation of RV.

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Postpartum Takotsubo cardiomyopathy is mainly induced by drugs that enhance sympathetic nervous activity. We report a novel case of postpartum inverted Takotsubo cardiomyopathy triggered by intravenous atropine administration resulting in acute pulmonary edema. Cardiac troponin I and beta-type natriuretic peptide were elevated. Transthoracic color Doppler echocardiography demonstrated a nondilated left ventricle with mid-basal akinesis, a hyperdynamic apex, and moderate-to-severe mitral regurgitation likely linked to papillary muscle dysfunction. Coronary computed tomography angiography revealed normal coronary arteries. Atropine inhibits the parasympathetic nervous system, alters the autonomic system balance, and, thus, leads to increased sympathetic nervous activity, which seems to have been the cause of Takotsubo cardiomyopathy in this patient. Atropine should be listed among the drugs triggering Takotsubo cardiomyopathy.

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Introduction: Takotsubo syndrome (TKS) is generally caused by a stressful condition, and it usually has a good prognosis after the recovery of left ventricular function. About 70% of the cases of hypertrophic cardiomyopathy may develop obstruction in the left ventricular outflow tract (LVOT), which is responsible for heart failure. Case Presentation: We present a unique case where TKS occurred in a middle-aged male patient with hypertrophic obstructive cardiomyopathy (HOCM) without a clearly identifiable initial stress trigger. Conclusions: In the setting of acute left ventricular function depression in HOCM, a comprehensive differential diagnosis should be established. Treatment should be based on hemodynamic changes. After recovery, the prognosis is related to HOCM.

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Introduction: Takayasu's arteritis (TA) is a chronic, idiopathic, inflammatory disease that affects large elastic arteries, including the aorta and its main branches. No consensus exists currently on the superiority of surgery over endovascular repair (angioplasty with or without stenting) for vascular lesions in TA. Case Presentation: A 54-year-old woman with an 11-year history of ankylosing spondylitis (AS) presented with left arm weakness and severe left arm claudication. Duplex ultrasonography of the left upper extremity showed vessel-wall edema of the subclavian, axillary, and brachial arteries. Aortic angiography demonstrated a 70 - 80% stenosis of the left subclavian artery and a long, high-grade stenotic segment of the axillary artery. Intravascular ultrasound (IVUS) of the stenotic subclavian segment showed extensive negative remodeling with minimal plaque formation. The patient responded well to balloon angioplasty on this segment with medical therapy for AS. Conclusions: Our case is the first report of IVUS imaging of subclavian stenosis resulting from Takayasu's arteritis and provides insight into the pathology behind such lesions.

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Background: High-intensity interval training (HIIT) is a time-efficient alternative to traditional prolonged training. In contrast to ample evidence describing the effects of prolonged training, there are few data describing cardiovascular adaptations arising from HIIT interventions. Objectives: The present study aimed to evaluate the effects of HIIT on heart morphology and function in untrained male subjects. Patients and Methods: Twenty-two young men (age = 23.34 ± 2.56 years, weight = 72.47 ± 12.01 kg, and height = 174.10 ± 5.75 cm) were recruited and randomly assigned into control (n = 10) and HIIT (n = 12) groups. Echocardiography was used to evaluate left ventricular mass (LVM), end-systolic volume (ESV), end-diastolic volume (EDV), interventricular septal wall thickness (IVSWT), stroke volume, and ejection fraction (EF). Also, the Bruce treadmill test was employed to estimate VO_2max. Results: The HIIT subjects showed a significant increase in EDV (P = 0.001), LVM (P = 0.002), stroke volume (P = 0.003), and EF (P = 0.001). However, there was no change in ESV due to HIIT (P = 0.916). Additionally, following HIIT, IVSWT (P = 0.227), despite exhibiting a slight increase, was not significantly different from pre-training levels. Conclusions: HIIT in previously untrained subjects led to a significant change in left ventricle (LV) morphology, correlating with improvement in aerobic power (VO_2max). Cardiac remodeling was characterized by an increased EDV and a similar increase in LVM.

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Introduction: Multimodality imaging can help rule in/out the diagnosis of hypertrophic cardiomyopathy (HCM) in patients with significant left ventricular (LV) hypertrophy. Case Presentation: We describe a 73-year-old woman referred to us for consultation because of a giant negative T wave on her electrocardiography. Echocardiography revealed diffuse severe hypertrophy associated with hypertrophied anterolateral papillary muscles with a bifid head and with extensive wall insertion into the apicolateral segment. Three-dimensional echocardiography and cardiac magnetic resonance confirmed these data. Importantly, automated function imaging determined the global longitudinal strain at -10.2%. Conclusions: According to our multimodality imaging approach, hypertrophic cardiomyopathy was the most probable diagnosis.

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Background: Abnormalities in the velocity and pattern of myocardial shortening on tissue Doppler imaging (TDI) have been proposed to aid in the noninvasive diagnosis of coronary artery disease (CAD). Objectives: We investigated the diagnostic value of post-systolic shortening (PSS), a delayed ejection velocity of the myocardium after the closure of the aortic valve, on TDI in the diagnosis of CAD among patients with chest pain and normal resting wall motion on standard 2D echocardiography. Methods: Eighty consecutive patients (49% female) with typical ischemic chest pain but without prior myocardial infarction, coronary revascularization, arrhythmia, or heart failure, who had no regional wall motion abnormalities on resting echocardiography revascularization, arrhythmia, or heart failure, who had no regional wall motion abnormalities on resting echocardiography at 2 levels (basal and mid left ventricle [LV]) in each of the 4 LV walls (i.e., septal, anterior, inferior, and lateral). Coronary angiography was performed and interpreted per standard clinical protocols. Results: Compared to the patients with normal coronaries, those with angiographic CAD showed significantly increased myocardial isovolumic relaxation time (IVRT) velocity (P < 0.001) and significantly prolonged IVRT (P < 0.001) at the septal, anterior, inferior, and lateral LV walls. With a cutoff value > 4.0 m/sec, a positive PSS velocity had about 65% sensitivity and 85% specificity with a positive predictive value > 90% in predicting angiographic CAD. Conclusions: Among patients with chest pain and normal LV wall motion on 2D echocardiography, a prominent and prolonged IVRT on TDI may help predict the presence of significant CAD.

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