Background-Controversy exists as to whether secundum atrial septal defects (ASDs) in asymptomatic or mildly symptomatic New York Heart Association (NYHA) class I or II adult patients should be closed.

Background: To determine the rate of progression of dilation of the aortic root in adults with a bicuspid aortic valve. Methods: We reviewed retrospectively the transthoracic echocardiograms of 50 adults with a bicuspid aortic valve. Each patient had had at least two examinations made 12 months apart. Measurements were taken at four levels: at the basal attachment of the leaflets of the valve within the left ventricular outflow tract, at the widest point of the sinuses of Valsalva, at the sinutubular junction, and in the ascending aorta 1 cm beyond the sinutubular junction. Results: Progressive dilation occurred at all levels, ranging from 0.3 mm/yr at the basal attachment within the left ventricular outflow tract to 1.0 mm/yr, 1 cm beyond sinutubular junction. These rates of dilation were greater than the reported rate of 0.8 mm per decade in the normal population. The rate of dilation found in the ascending aorta 1 cm beyond the sinutubular junction was significantly greater than at the other sites (p = 0.005). The 21 patients with baseline measurements greater than 34 mm had a significantly higher rate of progression (p = 0.007). Sex, age, and the degree of valvar obstruction or regurgitation did not significantly influence the rate of progression of dilation. Conclusion: There is a significantly higher rate of dilation of the aortic root in adults with a bicuspid aortic valve when compared to the normal population. Periodic evaluation of the ascending aorta is essential in these patients, even after replacement of the aortic valve. Other imaging modalities should be considered if the region beyond the sinutubular junction is not well visualized by transthoracic echocardiography.

(Cardiol J 2013; 20, 5: 513-518)

A neurysm of the coronary sinus of Valsalva (ASV) is rare. It may be congenital, sometimes in association with other cardiac defects (most commonly ventricular septal defect or coarctation), or it may be acquired. The first manifestation of ASV is most often related to rupture, whereas unruptured ASVs are rare. Although unruptured aneurysms are frequently asymptomatic without physical findings, they can be associated with complications and can compress adjacent structures. We present a case of a familial unruptured right ASV causing obstruction of the right ventricular outflow tract (RVOT) and subsequent evolution following repair. CASE PRESENTATIONA 77-year-old woman presented with stable dyspnea on exertion (New York Heart Association [NYHA] class III), which she had been experiencing for the past year. Her medical history revealed only hypothyroidism and hysterectomy with bilateral salpingooophorectomy. A transthoracic echocardiography performed five years earlier was normal except for a mild increase in peak transvalvular pulmonary velocities (1.3 m/s). Examination revealed normal blood pressure and a systolic heart murmur (grade 3/6) best heard along the left sternal border. Further examination showed distension of the jugular veins and mild ankle edema. Recorded electrocardiogram alterations were a mild Q wave with inversion of the T wave in inferior leads. Computed tomography angiography of the chest showed no pulmonary embolism but revealed moderate proximal thoracic aorta ectasia. Pulmonary function tests were normal. Controlled transthoracic echocardiography (Figure 1) showed a right ASV and RVOT obstruction with a subvalvular pulmonary systolic gradient of 45 mmHg. Left ventricular contractility was normal on echocardiography with moderate aortic regurgitation (grade 3/4). Aortic angiography (Figure 2) confirmed a right ASV while cardiac catheterization confirmed RVOT obstruction with no shunt. Coronary angiography was normal. The patient was unable to undergo magnetic resonance imaging due to claustrophobia.The decision was made to repair the aneurysm because the patient's symptoms were likely related to RVOT obstruction and there was evidence of aneurysm progression on serial echocardiography. It was also known from the pathology report that the patient's younger brother had died 24 years earlier at 48 years of age from a ruptured ASV. The ASV was repaired with a pericardial patch. The aortic valve was also replaced with a Carpentier-Edwards porcine case report ©2009 Pulsus Group Inc. All rights reserved A case demonstrating compression of the right ventricular outflow tract by an unruptured coronary sinus of Valsalva aneurysm in which repair resulted in symptomatic improvement is presented. The pathology report revealed that the patient's younger brother had died from a ruptured aneurysm of the coronary sinus of Valsalva. The present report is the first to describe a familial unruptured coronary sinus of Valsalva aneurysm raising questions regarding the screening of relatives of patients with sinus...

Background Two-dimensional speckle-tracking echocardiography (STE) may help detect coronary artery disease (CAD) when combined with dobutamine stress echocardiography. However, few studies have explored STE with exercise stress echocardiography (ESE). We aimed to evaluate the feasibility, reliability, and incremental value of STE combined with treadmill ESE compared to treadmill ESE alone to detect CAD. Methods We conducted a case–control study of all consecutive patients with abnormal ESE in 2018–2020 who subsequently underwent coronary angiography within a six-month interval. We 1:1 propensity score-matched these patients to those with a normal ESE. Two blinded operators generated a 17-segment bull's-eye map of longitudinal strain (LS). We utilized the mean differences between stress and baseline LS values in segments 13–17, segment 17, and segments 15–16 to create receiver operator curves for the overall examination, the left anterior descending artery (LAD), and the non-LAD territories, respectively. Results We excluded 61 STEs from 201 (30.3%) eligible ESEs; 47 (23.4%) because of suboptimal image quality and 14 (7.0%) because of excessive heart rate variability precluding the calculation of a bull's-eye map. After matching, a total of 102 patients were included (51 patients in each group). In the group with abnormal ESE patients (mean age 66.4 years, 39.2% female), 64.7% had significant CAD (> 70% stenosis) at coronary angiogram. In the group with normal ESE patients (mean age 65.1 years, 35.3% female), 3.9% were diagnosed with a new significant coronary stenosis within one year. The intra-class correlation for global LS was 0.87 at rest and 0.92 at stress, and 0.84 at rest, and 0.89 at stress for the apical segments. The diagnostic accuracy of combining ESE and STE was superior to visual assessment alone for the overall examination (area under the curve (AUC) = 0.89 vs. 0.84, p = 0.025), the non-LAD territory (AUC = 0.83 vs. 0.70, p = 0.006), but not the LAD territory (AUC = 0.79 vs. 0.73, p = 0.11). Conclusions Two-dimensional speckle-tracking combined with treadmill ESE is relatively feasible, reliable, and may provide incremental diagnostic value for the detection and localization of significant CAD.

A 73-year-old woman presented with dyspnea on exertion (New York Heart Association [NYHA class II]) without angina, which she had been experiencing for two years. Twenty-three years earlier, the patient had venous conduit coronary artery bypass graft surgery on the left anterior descending artery. Examination revealed normal blood pressure and no heart murmur. The parasternal long-axis view of a routine transthoracic echocardiography (Figure 1) showed marked enlargement of the coronary sinus (23 mm × 48 mm) and mild right chamber dilation. Transcatheter bypass graft angiography (Figure 2) and magnetic resonance angiography (Figure 3) revealed a pseudoaneurysm at the distal portion of the venous conduit bypass graft, with graft occlusion near the distal anastomosis. A slow-flow fistula between the pseudoaneurysm and the dilated coronary sinus was identified. Coronary angiography showed native left anterior descending artery occlusion with perfusion from collateral pathways. No intervention was performed at that time because the patient refused the recommended surgery. Two years later, the patient presented with acute coronary syndrome and a left hemothorax confirmed by pleural fluid analysis. Computed tomography angiography and bypass graft contrast angiography revealed thrombosis of the bypass graft and pseudoaneurysm with no residual fistula and no extravasation. No intervention was performed and the patient had no complaints at the two-month follow-up.

Good hematology and hemodynamics, along with remarkably low complication rates, demonstrate that the Omnicarbon valve meets contemporary performance expectations.

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