echocardiography

Group A streptococcus (GAS) remains a global burden, particularly in developing countries, with long-term morbidity and mortality complications. Different strains and immune responses to GAS can lead to various disease patterns, from predominantly throat and skin manifestations to renal and cardiac involvement. Myocarditis associated with glomerulonephritis can progress to carditis, which may present with signs and symptoms similar to rheumatic heart disease. Although uncommon, this condition can deteriorate into dilated cardiomyopathy, potentially leading to cardiogenic shock and death, necessitating early recognition, intervention, and preventive measures.

We report three pediatric cases of post-streptococcal infection with cardiac manifestations. The first case involves an 8-year-old female with palpitations and a recurring cough, diagnosed with acute rheumatic carditis. The second case is a 10-year-old female presenting with hemoptysis and edema in the lungs and extremities due to acute rheumatic carditis and prior suspected vegetation. The third case is a 9-year-old male initially diagnosed with post-streptococcal glomerulonephritis (PSGN), who deteriorated into dilated cardiomyopathy with an ejection fraction of 32% and multiple organ dysfunction syndrome. All three patients recovered well, received prophylactic management, and were referred for further investigation.

Identifying specific features on echocardiography can help differentiate between rheumatic heart disease (RHD) and PSGN-associated cardiac involvement. Additionally, echocardiography is a more readily available and cost-effective screening method, especially in endemic populations. Early recognition and management of post-streptococcal cardiac complications may prevent long-term morbidity and mortality.

This study aimed to compare the time-to-peak systolic contraction time (Tc) by color-coded anatomical M-mode (AMM), the time-to-peak systolic strain (Tst) by strain rate imaging (SRI), and the time-to-peak systolic velocity (Ts) by tissue Doppler imaging (TDI) in the left (LV) and right (RV) ventricular segments of normal subjects. We also sought to determine the relationship between these methods for defining asynchrony indices in normal subjects.

Conventional echocardiography, color-coded AMM, SRI, and TDI were performed on 44 healthy adult volunteers (at the Tehran Heart Center and Shariati Hospital) to measure Tc, Tst, and Ts for 12 LV and 2 RV segments at mid and basal levels. Additionally, delays and standard deviations (SDs) were measured in all 12 LV segments.

In the assessed segments, Tc by AMM and Tst by SRI were significantly greater than Ts by TDI (P<0.001). No significant differences were noted between Tc and Tst in 8 LV and 2 RV segments (P<0.05). For the septal basal segment, the respective values were Ts=170.43±36.76 ms, Tst=372.34±72.21 ms, and Tc=374.19±42.76 ms. A moderate correlation was observed between AMM and SRI in assessing asynchrony and SD for all LV segments, but no correlation existed between AMM and TDI.

Tc by AMM and Tst by SRI were significantly higher than Ts by TDI in the LV and RV segments. There was no correlation between AMM and TDI in defining asynchrony indices.

Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is a vasculitis that primarily affects young children and results in coronary artery abnormalities. Echocardiography is the standard imaging modality for monitoring KD patients; however, this method does not detect some coronary artery anomalies. This case report demonstrates the significance of computed tomography (CT) angiography in identifying previously undiagnosed coronary abnormalities in a KD patient. We herein describe a 7-year-old male who presented with symptoms consistent with KD and was treated subsequently with intravenous immune globulin (IVIG). Follow-up echocardiography showed no significant coronary artery abnormalities. Three years later, the patient presented with flu-like symptoms, and an ECG revealed anterolateral ischemic changes. Echocardiography showed normal coronary arteries. Nonetheless, a CT angiogram was performed due to the ischemic changes on ECG, and it identified a myocardial bridge in the left anterior descending artery, which had not been detected by echocardiography or ECG. This case report emphasizes the importance of considering CT angiography as an adjunct imaging modality in the evaluation and follow-up of KD patients, particularly when echocardiographic findings are inconclusive or when clinical presentation raises concerns for potential coronary artery abnormalities. Further research is needed to establish evidence-based guidelines for the optimal timing and clinical indications for CT angiography in KD patients.

This study was conducted with the aim of evaluating the prevalence and severity of tricuspid regurgitation in children referred to the Echocardiography Department of Hazrat Masoumeh Hospital in Qom in 2021.

An observational study was conducted at Hazrat Masoumeh Pediatrics Clinic in Qom, Iran, involving 284 healthy children aged 1 day to 18 years old with no previous diseases. The study excluded patients with congenital disorders and those with symptoms of cardiac or pulmonary disease. The severity of tricuspid regurgitation was assessed using Transthoracic Echocardiography (TTE) based on recent guidelines. Data analysis was performed using SPSS 26.0 software, and statistical tests were used to compare the data. The study was approved by the Medical Ethics Committee of the Qom of Medical Sciences and obtained informed consent from all parents.

Our study included 284 patients, with 164 boys and 120 girls (57.7% Vs. 42.3%). The youngest participant was 2 days old and the oldest was 18 years old, with a mean age of 4.07±4.02 years. Most children (90.2%) had mild to moderate signs of TR, while 8.8% had no signs. Overall, 82.3% of boys and 80% of girls had TR, with no significant association between TR severity and sex. There was also no significant difference in TR severity among different age groups (P-value>0.05).

The study found that over 90% of healthy children have some degree of tricuspid regurgitation (TR). The presence of mild TR should not be considered pathological, as it does not worsen with age and does not require further follow-up or investigation. Furthermore, over 80% of adults have been reported to have mild TR.

Research has shown that maternal diabetes is an important factor in increasing the risk of various congenital heart defects. This research investigated the presence of cardiovascular abnormalities in infants born to diabetic mothers.

This cross-sectional study was conducted on pregnant women who were referred to Hazrat Masoumeh (PBUH) Hospital in Qom City, Iran, for echocardiography from 2021 to 2022. Sampling was done among diabetic and healthy pregnant women using a simple random method. First, the necessary information was collected through echocardiography findings in the patients’ files, and the data were analyzed using SPSS software, version 26, and related tests.

In this study, 13 infants (14.4%) had a cardiac abnormality, of whom six infants (6.7%) were born to mothers with type 1 diabetes and seven infants (7.8%) were born to mothers with type 2 diabetes. No significant difference was found between the average age of the mothers (P=0.648), the gender of the infants (P=0.733), the weight of the infants (P=0.143), gestational status (P=0.229), maternal occupation (P=0.077), type of delivery (P=0.675), the Apgar score at one minute (P=0.709), and Apgar score at five minutes (P=0.736) between the two groups of type 1 and type 2 diabetes.

Babies born to mothers with diabetes are more likely to have congenital heart diseases (CHDs). It is recommended to use transthoracic echocardiography as a screening tool to diagnose CHDs in infants born to diabetic mothers.

Acute lymphoblastic leukemia (ALL) is the most prevalent malignancy in pediatrics. ALL blood cancer causes excessive production of immature white blood cells called lymphoblasts or leukemic blasts. Therefore, the present study evaluates the effect of chemotherapy on echocardiography, uric acid (UA) and lactate dehydrogenase (LDH) in ALL children.

A quasi-experimental study was designed for 53 ALL patients who referred to Shahid Beqaei 2 in Ahvaz from 2022 to 2023. The inclusion criteria for the studied ALL children aged 2 to 16 years were the maintenance phase of chemotherapy and lack of symptoms of cardiomyopathy. The levels of LDH, UA and echocardiographic parameters were compared before and after chemotherapy through paired sample t-tests. P-values<0.05 were considered significant.

The mean age of the ALL patients was 6.28 ± 4.13 years. Of all the patients, 64% were male. The mean levels of LDH before and after chemotherapy were 1443.36 ± 1373.26 and 534.51 ± 236.61 U/L, and the LDH levels decreased significantly after chemotherapy (P < 0.001).  The mean U.A levels before and after chemotherapy were 6.67 ± 6.80 and 5.30 ± 6.15 mg/dl, respectively (P = 0.30). Abnormal echocardiography before and after chemotherapy was observed in 3.76% and 22.64% of the patients, respectively, but the difference was not markedly significant (P = 0.44). The relative risk was estimated to be 0.16, suggesting that the probability of cardiac dysfunction after chemotherapy reduced to approximately 16% of the baseline risk observed before chemotherapy.

The initial evaluation of serum LDH can be beneficial in knowing the response to chemotherapy. So, it is of importance to determine the prognostic value of this biological marker. On the other hand, chemotherapy does not seem to have a significant effect on the mean values of echocardiographic parameters and the level of uric acid.

Right ventricle failure is a well-known complication following pulmonary thromboembolism. Although Computed Tomography Pulmonary Angiography (CTPA) findings are supposed to be a surrogate for patients’ outcome, investigations based on this issue is not still elucidated. Thus, in the current study, we assessed patients’ CTPA findings and compared the result with echocardiographic findings.

A total of 36 patients with proven pulmonary thromboembolism were enrolled and a comparison was made between indices in CTPA (interventricular septal deviation to the right side, inferior vena cava contrast reflux, and right ventricle diameter to left ventricle diameter ratio) and echocardiographic findings for detecting right ventricular failure. Also, the reliability of the aforementioned indices was sought for predicting mortality.

No significant correlation was found between CTPA indices and echocardiographic findings. The highest sensitivity and positive predictive value in CT pulmonary angiography for detecting right ventricle dysfunction were revealed to be for Right Ventricle Diameter (RVD) / Left Ventricle Diameter (LVD) > 1 (63.64%), abnormal septal deviation (75.00%), respectively.

Our results revealed that CTPA indices can reliably predict the upcoming mortality risk. On the other hand, these indices were not well-correlated with echocardiographic findings.

Aortic valve stenosis (AS) is the most common valvular heart disease in developed countries, with its prevalence on the rise due to aging populations. While severe AS has long been recognized as high-risk, recent studies have shed light on the significant association between moderate AS and cardiovascular morbidity and mortality. Yet, the data are still inconclusive. With noninvasive multi-modality imaging techniques advancing rapidly, we now have more insight into the underlying biology of AS. Echocardiography continues to serve as the primary noninvasive imaging modality for diagnosing and grading AS. This comprehensive review delves into the role of echocardiography in diagnosing moderate AS and how the findings can support clinicians in making well-informed decisions that impact patients’ prognoses.

A 72-year-old man presenting with progressive dyspnea was evaluated. Transthoracic and consequently transesophageal echocardiography verified severe mitral regurgitation (MR) caused by hypoplasia of the posterior mitral leaflet (PML) and flail of A2 scallop. Areview of reported cases reveals that PML hypoplasia is an uncommon diagnosis among the adult population which can be tolerated relatively well and carries a good prognosis. Our patient had a unique course of the disease. Previously presenting with a bicuspid aortic valve and a nonsignificant MR in spite of the severely hypoplastic PML. Eventually, he became symptomatic years later as severe MR developed due to chordal rupture and flail of the anterior mitral leaflet.

Assessing right ventricular performance using twodimensional (2D) echocardiography has been difficult due to its complex shape. Tissue Doppler imaging was used as a noninvasive method in this study to evaluate right ventricular function in patients with acute inferior wall ST-elevation myocardial infarction (IWMI) treated with primary percutaneous coronary intervention (PCI).

Forty patients with IWMI admitted to a tertiary care hospital in India were included in this prospective, observational study. The patient’s detailed history, physical examination along with laboratory parameters, electrocardiogram, echocardiogram, and coronary angiogram profile were recorded from which the decision for PCI was made. The followup period for each patient was 6 weeks, during which 2D color Doppler and pulse-wave echocardiographic parameters were assessed.

This study comprised 40 patients, among which 16 patients had right ventricular myocardial infarction (RVMI), and the mean age of RVMI patients was 56.65 ± 12.03 years. In RVMI patients, tricuspid annular plane systolic excursion (mm) and RV FAC (%) values were lower than in IWMI patients, and a surge in its respective value to 15.66 ± 1.20 and 32.64 ± 3.17 (P = 0.03) was observed post-PCIs. Furthermore, an inclination in tissue annular systolic velocity (Sm; cm/s) to 11.24 ± 1.55, P = 0.02, and early diastolic tissue annular velocity (Em; cm/s) to 10.98 ± 1.27, P = 0.003, from the baseline was observed after revascularization. The myocardial performance index value accounted to be higher in RVMI patients; however, after PCI, a change from 0.73 ± 0.06 to 0.61 ± 0.12 was noted (P = 0.002).

In this study, a significant difference in the echocardiographic parameters assessing RV function in RVMI and IWMI patients was noted, and hence, it can be considered a reliable diagnostic tool to predict the RV performance.

The relationship between diastolic function parameters and the severity of coronary artery disease (CAD) is controversial. This study aimed to determine the relationship between left ventricular diastolic function and the severity of CAD. This cross-sectional study included 63 patients with Ischemic heart disease (IHD) or those suspected of having IHD, who underwent angiography. The study was conducted in Shafa Hospital, Kerman, Iran, from 2021 to 2022. Two-dimensional (2D) strain echocardiography was used to assess left ventricular (LV) function parameters, followed by coronary angiography. Based on the severity of the disease, patients with significant CAD were placed in the case group, and patients with insignificant CAD were placed in the control group. The correlation between the CAD severity and the severity of LV diastolic dysfunction was computed. Descriptive tests, independent t tests, and Spearman correlation coefficients were used. P<0.05 was considered statistically significant. The results indicated that there was no correlation between E/e′ (P=0.103), left atrial volume index (LAVI) (P=0.168), tricuspid regurgitation velocity (TRV) (P=0.217), myocardial performance index (MPI) (P=0.106), E wave deceleration time (dt) (P=0.644), and late diastolic strain rate (P=0.502) with CAD severity based on SYNTAX score. However, there was a correlation between left atrial (LA) strain (P=0.017), global longitudinal strain (GLS) (P<0.001), early diastolic strain rate (P<0.001), and systolic strain rate (P=0.047) with SYNTAX score. Besides, there was a correlation between LA strain (P=0.017), GLS (P<0.001), early diastolic strain rate (P<0.001), and late diastolic strain rate (P=0.035) with numbers of epicardial coronary arteries with significant lesions. In contrast with 2D strain echocardiography, this study showed that conventional echocardiography parameters had no significant relationship with CAD severity. GLS had the strongest correlation with CAD severity, and diastolic strain rates had a weaker correlation with CAD severity.

Hydatid disease is a parasitic infestation caused by larvae of the Echinococcus tapeworm. It mainly affects the liver and lungs. Cardiac hydatid cyst is uncommon and involvement of the interventricular septum is even rarer. It may lead to various complications because of rupture and embolization. We report the case of a 24-year-old man who was diagnosed to have a large interventricular hydatid cyst associated with cysts in the liver which mimics like acute coronary syndrome. This case is of particular interest because of the rarity of septal localization of a hydatid cyst, and concurrent involvement of the liver and cardiac is uncommon.

Despite growing evidence linking Vitamin D (Vit-D) deficiency with heart dysfunction, objective evidence such as echocardiographic findings remains limited and inconclusive.

This study aims to investigate the association between Vit-D levels and both systolic and diastolic function of the ventricles in patients with normal coronary arteries using echocardiography.

This study, conducted between 2019 and 2020, examined individuals without apparent coronary artery disease (CAD). The researchers measured the participants' Vit-D levels and divided them into two groups based on a 30 ng/dL cut-off point. All patients underwent echocardiography, and the researchers analyzed and compared their ventricular systolic function characteristics.

A total of 27 patients with normal Vit-D levels and 47 patients with Vit-D deficiency were included in the study. There was no significant difference between the left ventricle (LV) and right ventricle (RV) systolic function parameters, including left ventricular ejection fraction (LVEF), LV end-systolic/diastolic volume, and tricuspid annular plane systolic excursion. The mean LVEF between the patients with normal Vit-D levels (53%) and those with Vit-D deficiency (57%) did not show a significant difference (P = 0.420). Right ventricle diastolic parameters, such as A, E, E', deceleration time (DT), and Right Atrial Volume Index (RAVi), also did not show a significant difference between the two groups. However, patients with Vit-D deficiency had higher diastolic blood pressure (DBP) (P = 0.019).

The results of this study indicate that there is no significant correlation between Vit-D levels and systolic dysfunction in the right and LV s of individuals with normal coronary arteries. However, it is important to note that this is a complex area of study, and further research is needed.

 Previous studies have investigated the potential influence of prior aspirin use on cardiac function in patients with ST-elevation myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PPCI). However, the results from these studies have been conflicting. This study aimed to investigate whether prior aspirin use affects left ventricular (LV) function in these patients using echocardiography.

 The study included 260 consecutive STEMI patients, who were divided into two groups based on the presence or absence of prior aspirin use. Echocardiographic parameters, such as maximal left atrial (LA) size, LV ejection fraction (LVEF), early diastolic velocity (e’), E/A ratio, and E/e’ ratio, were assessed within 72 hours of admission.

 Aspirin users had an older age compared to non-users, as well as lower body mass index and renal function. They also had a greater history of hypertension and were more likely to be taking statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and calcium channel blockers. There were no significant differences in LVEF, maximal LA size, E/A ratio, E/e’ ratio, and deceleration time between aspirin users and non-users. e’ wave was marginally lower in aspirin users (P=0.054). After controlling for confounding variables, the previous use of aspirin did not show a significant impact.

 Prior aspirin use in STEMI patients does not have a significant impact on LV echocardiographic parameters. Our conclusions remained consistent even after adjusting for potential confounders.

The staging of Heart Failure (HF) in the population at risk of progression emphasizes early identification and prevention of HF. Therefore, this study aims to evaluate the prevalence of various stages of HF in individuals over 40 years old within a large population of Iranian adults. In this descriptive cross-sectional study, a random sub sample of Yazd Health Study (YaHS) participants aged 40-70 years was evaluated. History and clinical examination of the patients was conducted by a cardiologist and then, the participants underwent echocardiography to determine the stages of heart failure. Among 410 Yazd population -the representative sample with mean age 58.0±9.2 years, 183 patients (44.6%) were in stage 0, 121 (29.5%) in stage A, 77(18.8%) in stage B, and 29 (7.1%) in stage C heart failure. No individuals were in stage D. There was a significant difference between the frequency of individuals with different stages of HF in terms of diabetes, hypertension, obesity, and history of ischemic heart disease (p<0.05). In addition, the frequency of HF increased in the age group >60 years and the obesity group (p<0.05).  According to these, about half of the patients with HF were in stage A and B. Therefore, appropriate measures are needed to identify these groups of patients, especially individuals with risk factors of diabetes, hypertension, obesity and those over 60 years to prevent the progression of the disease to higher stages which lead to poorer outcome.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acid-fast, rod-shaped bacillus. The disease predominantly affects the skin, the peripheral nerves, the mucosa of the upper respiratory tract, and the eyes. 1 The diagnosis of leprosy is based on the presence of at least 1 of 3 cardinal signs: definite loss of sensation in a pale or reddish skin patch, a thickened or enlarged peripheral nerve with loss of sensation, and/or weakness of the muscles supplied by the nerve, and the presence of acid-fast bacilli in a slit-skin smear. However, there are no reports that describe the link between leprosy and pulmonary hypertension (PH). Here, we describe a 22-year-old man who was first diagnosed with leprosy and subsequently developed PH, confirmed by echocardiography. To our knowledge, this is the first case of leprosy associated with PH with a detailed clinical description. We recommend that physicians be aware of this rare comorbidity in patients with leprosy. Early echocardiographic screening is necessary for symptomatic patients. (Iranian Heart Journal 2024; 25(4): 100-104)

Type 2 myocardial infarction (MI) is caused by myocardial ischemia resulting from an imbalance between oxygen supply and demand in the heart. This study aimed to assess the incidence, variations in clinical characteristics, current therapeutic approaches, and overall prognosis in patients with type 2 MI compared to those with type 1 MI.
 
This prospective, cross-sectional study involved 350 Egyptian patients presenting with MI. Participants were categorized into type 1 MI (n = 262) and type 2 MI (n = 88) groups based on standard diagnostic criteria. Data regarding demographic characteristics, clinical presentations, management strategies, and outcomes, including in-hospital, 30-day, and 6-month mortality rates; major adverse cardiovascular events (MACE); and hospitalization for heart failure, were collected and analyzed.
 
Coronary angiography was performed more frequently in patients with type 2 MI than in those with type 1 MI. Primary percutaneous coronary intervention and coronary artery bypass grafting were more commonly performed in type 1 MI patients. A statistically significant difference was observed between type 1 MI and type 2 MI concerning echocardiographic findings and hospital stays. However, there was no significant difference in MACE at 1-month and 6-month follow-ups, except for mortality and stroke, where a statistically significant difference was found.
 
Type 1 MI is more common than type 2 MI. Nonetheless, type 2 MI is associated with higher mortality rates and longer hospital stays. Patients with type 1 MI typically present with chest pain, while those with type 2 MI predominantly present with dyspnea, syncope, and hemodynamic instability. Cardiac interventions are primarily performed in patients with type 1 MI. (Iranian Heart Journal 2024; 25(4): 51-58)

Various extracardiac disorders are associated with congenital heart defect (CHD) at varying prevalence rates (7%–50%). Over the years, numerous studies worldwide have investigated these associations. This study aimed to examine the prevalence of extracardiac anomalies in children with CHD in Isfahan, one of Iran’s largest cities. 

This cross-sectional study was conducted in Isfahan, Iran, from 2020 through 2022, involving 750 infants under 1 year old diagnosed with CHD. Pediatric cardiologists performed echocardiography to evaluate the cardiovascular system and detect CHD. Most participants were referred for cardiac examinations due to abnormalities detected during physical examinations of skin, cerebral, spinal cord, abdominal, and urinary tract regions. Patients exhibiting signs of a syndromic disorder were also referred for CHD evaluation. 

Out of 750 infants with confirmed CHD, 241 (32.13%) presented at least 1 extracardiac malformation. Ninety (37.7%) had craniofacial malformations, with 66.7% having cleft palate with or without cleft lip. Forty-eight patients (19.9%) had genetic syndromes, most commonly Down syndrome (56.5%), and 46 (19.8%) had gastrointestinal abnormalities, including intestinal or esophageal atresia. 

The prevalence of extracardiac anomalies in patients with CHD is significant, and these patients are at an increased risk of mortality and morbidity throughout their lives. Implementing a screening program could effectively prevent further complications associated with the late diagnosis of these anomalies. (Iranian Heart Journal 2024; 25(3): 6-12)

Obesity is a prevalent health issue associated with an increased risk of cardiovascular diseases. While obesity's link to various cardiovascular conditions is well-documented, its specific impact on global longitudinal strain (GLS) requires further investigation. This study aims to explore the relationship between obesity and GLS in an adult population.

This cross-sectional study included 91 adult participants, categorized into obese (n=59) and non-obese (n=32) groups based on body mass index (BMI). GLS was measured using speckle-tracking echocardiography. Chi-square tests and odds ratios (OR) were used to assess the association between obesity and abnormal GLS.

Among the non-obese group, 25.0% had abnormal GLS compared to 20.3% in the obese group. The chi-square test indicated no significant difference in the prevalence of abnormal GLS between the groups (p = 0.60). The odds ratio for abnormal GLS in obese versus non-obese participants was 1.3 (95% CI: 0.4-3.6), indicating no significant association.

The study found no significant association between obesity and abnormal GLS, suggesting that BMI alone may not be a reliable predictor of subclinical myocardial dysfunction. These findings highlight the need for a comprehensive approach to cardiovascular risk assessment that includes multiple factors beyond BMI.