Murat Atalay

The CHA2DS2-VASc score as a predictor of left atrial thrombus in patients with non-valvular atrial fibrillation.

Objective: To investigate whether or not the CHA2DS2-VASc score predicts left atrial (LA) thrombus detected on pre-cardioversion transoesophageal echocardiography (TEE). Materials and Methods: The medical records of patients who had undergone TEE were reviewed to assess the presence of LA thrombus prior to direct-current cardioversion for atrial fibrillation (AF). The CHA2DS2-VASc score was calculated for each patient. Clinical TEE reports were reviewed for the presence of LA thrombus. Patients with a valve prosthesis or rheumatic mitral valve disease were excluded from this study. Results: A total of 309 patients were identified. The mean age was 70.1 ± 9.8 years and 151 (49%) patients were males and 158 (51%) were females. LA thrombus was seen in 32 (10.3%) of the 309 patients. Fifty (16.2%) patients had a low CHA2DS2-VASc score (0-1), 230 (74.4%) had an intermediate score (2-4) and 29 (9.4%) had a high score (5-9). The incidence of LA thrombus in the low, intermediate and high CHA2DS2-VASc score groups was 0, 4.4 and 68.7%, respectively. The LA thrombus risk increased with increasing CHA2DS2-VASc scores. On multivariate logistic analysis, the CHA2DS2-VASc score (OR 3.26, 95% CI 2.3-4.65; p = 0.001) and age (OR 0.93, 95% CI 0.88-0.98; p = 0.004) were independent risk factors for LA thrombus in patients with non-valvular AF. Conclusion: A high CHA2DS2-VASc score was independently associated with the presence of LA thrombus in patients with non-valvular AF.

Echocardiographic assessment of Lutembacher syndrome.

A 59-year-old woman was a candidate for lumbar disc hernia surgery. She was complaining of shortness of breath on mild exertion. Preoperative cardiac assessment was performed. On physical examination, her blood pressure was 110/60 mm Hg and heart rate was 75 bpm. A grade II/VI holosystolic murmur and a diastolic rumble were heard at the cardiac apex. Electrocardiography (ECG) showed normal sinus rhythm with normal axis (Fig. 1A). Chest X-ray showed prominent hilar vasculature (Fig. 1B — red arrow), right atrial enlargement (Fig. 1B — black arrow), and absence of left atrial enlargement (Fig. 1B). Evaluation by two-dimensional (2D) transthoracic echocardiography (TTE) revealed coexistence of ostium secundum atrial septal defect (ASD) and rheumatic mitral stenosis. Mitral valve leaflets appeared thickened and restricted in motion but calcification and subvalvular involvement could not be defined exactly (Figs. 2A, B). Planimetric mitral valve area (MVA) was 2.1 cm2, maximum diastolic gradient was 9 mm Hg, and mean gradient was 3 mm Hg. Also there was a mild-to-moderate mitral regurgitation. The diameter of ASD was estimated to be 2.2 cm2 and colour flow mapping revealed left-to-right shunt across the defect (Figs. 2C, D). Subsequently, 3D TTE study was performed in order to achieve more accurate assessment of mitral valve apparatus. By 3D echocardiography (Figs. 2E, F), planimetric MVA was 1.7 cm2 and subvalvular thickening including calcification was seen, indicating that limitations of 2D echocardiography should be recognised and determination of planimetric MVA should be performed accurately by 3D echocardiography before treatment. Soon after, the patient was referred for open-heart surgery. Lutembacher syndrome is a rare combination of congenital ASD and acquired mitral stenosis. Due to the limitations of 2D echocardiography, particularly for distinguishing calcification and subvalvular involvement and for accurate determination of planimetric MVA, mitral valve apparatus should be assessed by 3D echocardiography before treatment.

Aortic interruption in an adult female

Murat Yalcin, Murat Atalay, Zafer Isilak, Cahit Kafadar, Murat Eroglu 1Department of Cardiology, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey 2Department of Cardiology, Merzifon Military Hospital, Amasya, Turkey 3Department of Radiology, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey 4Department of Emergency Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey

eComment. An unusual cause of aortic mural thrombus in non-atherosclerotic vessel

terial wall can show quite often an uneven surface or local calcifications and these could be, at least in part, the origin for thrombi formation. A limitation of this case report is that, as the vascular surgery was not necessary, we cannot surely exclude a local cause as the origin of the thrombi formation. Owing to its rarity, actually no definitive consensus on treatment exists. In patients with embolic complications anticoagulant therapy is indicated, with or without a subsequent surgical approach [1]. When feasible, endovascular coverage of the aortic thrombus with stents appears to be an effective and safe procedure but, in case of atypical localization or a very large thrombus, it could be better managed with vascular thromboembolectomy, although it has been associated with significant morbidity and mortality. In our asymptomatic patient, the thrombus was rather small, thus an endovascular or a surgical approach would not have been indicated. Two previous reports of aortic thrombus in the absence of peripheral embolism have shown a good outcome with anticoagulation therapy without surgical procedures [4, 5]. We can speculate on the possibility that such a small thrombus may resolve even independently of anticoagulant therapy.

Hypertrophic cardiomyopathy associated with abnormal origin of right coronary artery.

A 20-year-old man was admitted to our clinic with prolonged chest pain and shortness of breath. His physical examination was normal and myocardial enzymes were not elevated. Electrocardiography showed T-wave inversion in precordial leads. His transthoracic echocardiography (TTE) demonstrated hypertrophy of the interventricular septum and left ventricle posterior wall (Fig. 1A). There were no detectable gradients with Doppler echocardiography on left ventricular outflow tract, neither at rest nor with provocation. There were no other pathological findings on TTE. Syncope or family history of sudden cardiac death were not identified. 24 hour Holter ECG monitoring was normal. He underwent multidetector computed tomography coronary angiography (MCTCA) to exclude obstructive coronary artery disease. MCTCA revealed normal left coronary arteries and abnormal origin of right coronary artery (RCA) with an interarterial course between the aorta and pulmonary artery (Fig. 1B–D). There was no luminal stenosis in coronary arteries. Myocardial perfusion scintigraphy (MPS) with 99 mTc sestamibi was performed to investigate any effect of the interarterial course of RCA. After MPS, no myocardial perfusion defect or ischaemia was detected. Beta-blocker therapy was initiated and the patient was discharged. The association of hypertrophic cardiomyopathy and interarterial course of RCA is not common in the literature. Theoretically, myocardial ischaemia can develop in these patients due to abnormal supply-demand balance. Supply-demand imbalance should be kept in mind as a possible cause of chest pain in young individuals.

Heterotaxy syndrome associated with left ventricular non-compaction

A 20-year-old asymptomatic man was referred to our clinic for the evaluation of a 2/6 grade systolic cardiac murmur. The ECG was normal. On his transthoracic echocardiography (TTE), subaortic membrane causing peak 25 mm Hg gradient on left ventricular outflow tract as the cause of the murmur (Fig. 1A) and an enlarged coronary sinus (CS) (Fig. 1B) were detected. We also suspected left ventricular non-compaction (Fig. 1C, D). We performed agitated saline injection via left antecubital vein for diagnosis of persistent left superior vena cava (PLSVC) and bubbles reached to CS before right atrium, indicating PLSVC. The injection was repeated via right antecubital vein to evaluate the right superior vena cava (RSVC) because of that the absence of RSVC may be associated with PLSVC. After the injection, the coronary sinus was opacified before right atrium, indicating the absence of RSVC. Left ventricular non-compaction was confirmed with cardiac magnetic resonance imaging (Fig. 2A, B). Thoracal computed tomographic (CT) venography was performed, and it confirmed the PLSVC and also revealed the absence of RSVC (Fig. 3A). Surprisingly, it also demonstrated absent inferior vena cava (IVC). Therefore, it forced us to perform abdominal CT angiography. It revealed the venous return of lower limbs and abdomen maintaining with dilated hemiazygous vein, indicating absent IVC. His abdominal CT faced us to another interesting findings, polysplenia (Fig. 3B). Subsequently, all findings in the entire story reached us to diagnose heterotaxy syndrome (HS). Coexistence of HS, subaortic membrane and left ventricular non-compaction has not been reported in the literature.

PP-133 AN EXTREMELY RARE CASE; ISOLATED RIGHT VENTRICULAR HYPERTROPHIC CARDIOMYOPATHY

the periaortic area and localized hyper echogenity was observed in the paravalvular region. Left and right atrial dimension and pulmonary artery systolic pressure were increased. The analysis of thoracentesis material revealed Ph+ cells and flow cytometry confirmed blastic transformation. As the bone marrow analysis was still in hematological and molecular remission the final diagnosis was extramedullary blastic transformation of CML presenting with pleura-pericardial involvement. An acute leukemia induction treatment with tyrosine kinase inhibitor initiated, complicated with bacterial and fungal infections. He recovered in remission. The pleura-pericardial effusion dissolved completely. The underlying arrhythmias disappeared. Chest CT and echocardigraphic control exam showed us complete recovery of left and right ventricular wall motions, and normalization of both atrium dimensions. Conclusion: This is a rare case of extramedullary blastic transformation of CML, who had received allo HSCT. The pleura-pericardial effusion which disappeared completely after chemotherapy and TKI, and resolution of underlying arrhythmias and cardiac insufficiency was demonstrative for the efficient treatment of extramedullary CML relapse.

Symptomatic giant cardiac cyst hydatid in an adult woman.

A 56-year-old woman presented to our hospital with shortness of breath and chest pain. On physical examination heart and lung auscultation were normal. The ECG showed normal sinusal rhythm. The two-dimensional echocardiography revealed 5.65×2.81 mm size unilocular giant cystic mass at the basal segment of lateral wall (figure 1A–C). There was no other abnormality on echocardiography examination. MRI revealed cyst hydatid (CH) at the same location (figure 1D–F). She …

Ventricular septal defect with bidirectional shunting in a patient with congenitally corrected transposition

Congenitally corrected transposition of the great arteries (CCTGA) is a rare cardiac malformation characterized by the combination of discordant atrioventricular and ventriculoarterial connections. Most of the cases with CCTGA are diagnosed in childhood because of concomitant cardiac malformation. Relevant concomitant cardiac defects such as ventricular septal defect (VSD), atrial septal defect, tricuspid regurgitation and pulmonary stenosis were reported previously. We report an asymptomatic patient with CCTGA and coexisting VSD with bidirectional shunting. A 22-year-old asymptomatic male in the army was seen in our department during his periodical examination. He had a grade 3/6 mesocardiac systolic murmur on cardiac auscultation. Electrocardiogram (ECG) showed normal sinus rhythm with right bundle branch block. Transthoracic echocardiography showed CCTGA with VSD with left to right shunt (Fig.1, Video 1. See corresponding video/movie images at www.anakarder.com) and moderate tricuspid and aortic regurgitation in apical four-chamber view. The pulmonary valve was moderately stenotic with a peak pressure gradient of 49 mm Hg. For identifying the direction of shunt flow in VSD contrast echocardiographic examination with agitated saline was carried out. Contrast echocardiography demonstrated positive contrast effect in the left ventricular in diastole confirming a right-to-left shunt at the ventricular septum (Video 2. See corresponding video/movie images at www.anakarder.com). According to our knowledge, our case is the first reported CCTGA with VSD with bidirectional shunting in an asymptomatic patient.