%KOKARDIYOGRAFI /LGUî4EMELLIî9AKLAëÃM Garvan C. Kane, M.D Co-Director,Echocardiography Laboratory Consultant, Division of Cardiovascular Diease Assistant Professor of Medicine Mayo Clinic Rochester, Minnesota
Jae K.Oh M.D Cardiology Co-Director, Integrated Cardiac Imaging Consultant, Division of Medicine Professor of Medicine Mayo Clinic Rochester, Minnesota Co-Director, Cardiac and Vascular Center Samsung Medical Center Seoul, South Korea Çeviri Editörleri
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Kaynaklar 1. Spirito P, Bellone P, Harris KM, et al. Magnitude of left ventricular hypertrophy and risk of sudden death in hypertrophic cardiomyopathy. New Engl J Med. 2000;342:1778-1785. 2. McKenna WJ, Behr ER. Hypertrophic cardiomyopathy: PDQDJHPHQW ULVN VWUDWLÃ&#x20AC;FDWLRQ DQG SUHYHQWLRQ RI VXGGHQ death. Heart. 2002;87:169. 3. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am Coll Cardiol. 2003;42:1687. 4. McLeod CJ, Ommen SR, Ackerman MJ, et al. Surgical septal myectomy decreases the risk for appropriate implantable FDUGLRYHUWHU GHÃ&#x20AC;EULOODWRU GLVFKDUJH LQ REVWUXFWLYH K\SHUWrophic cardiomyopathy. Eur Heart J. 2007;28:2583-2588. 5. Ommen SR, Maron BJ, Olivotto I, et al. Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol. 2005;46:470â&#x20AC;&#x201D;476.
6. Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery. J Am Coll Cardiol. 2001;38:1994-2000. 7. Sorajja P, Valeti U, Nishimura RA, et al. Outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Circulation. 2008;118:131-139. 8. Talreja DR, Nishimura RA, Edwards WD, et al. Alcohol septal ablation versus surgical septal myectomy: comparison of effects on atrioventricular conduction tissue. / Am Coll Cardiol. 2004;44:2329-2332. 9. Woo A, Williams WG, Choi R, et al. Clinical and echocardiographic determinants of long-term survival after surgical myectomy in obstructive hypertrophic cardiomyopathy. Circulation. 2005;111:2033-2038. 10. Bax JJ, Raphael D, Bernard X, et al. Echocardiographic detection and long-term outcome of coronary artery-left ventricOH Ã&#x20AC;VWXOD DIWHU VHSWDO P\HFWRP\ LQ K\SHUWURSKLF REVWUXFWLYH cardiomyopathy. J Am Soc Echocardiogr. 2001;14:308-310.
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Kaynaklar 1. Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterization of aortic valve in valvular stenosis: a prospective, randomized study. Lancet. 2003;361:1241-1246.
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update on infective endocarditis: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2008;52:676-685.
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Kaynaklar 1. Brown SL, Gropler RJ, Harris KM. Distinguishing left ventricular aneurysm from pseudoaneurysm. A review of the literature. Chest. 1997;111:1403-1409. 2. Ohlow MA. Congenital left ventricular aneurysms and diYHUWLFXOD GHÃ&#x20AC;QLWLRQ SDWKRSK\VLRORJ\ FOLQLFDO UHOHYDQFH and treatment. Cardiology. 2006;106:63-72. 3. Brodie BR, Stuckey TD, Hansen CJ, et al. Importance of a patent infarctrelated artery for hospital and Iate survival after direct coronary angioplasty for acute myocardial infarction. Am J Cardiol. 1992;69:1113-1119. 4. Nijland F, Kamp O, Karreman AJ, et al. Prognostic implicaWLRQV RI UHVWULFWLYH OHIW YHQWULFXODU Ã&#x20AC;OOLQJ LQ DFXWH P\RFDU-
dial infarction: a serial Doppler echocardiographic study. J Am Coll Cardiol. 1997:30:1618. 5. Hillis GS, Moller JE, Pellikka PA, et al. Noninvasive estimation of left ventricular fîlling pressure by E/eâ&#x20AC;&#x2122; is a powerful predictor of survival after acute myocardial infarction. J Am Coll Cardiol. 2004;43:360-367. 6. Moller JE, Hillis GS, Oh JK, et al. Wall motion score index DQG HMHFWLRQ IUDFWLRQ IRU ULVN VWUDWLÃ&#x20AC;FDWLRQ DIWHU P\RFDUGLDO infarction. Am Heart J. 2006;151:419-425. 7. Moller JE, Hillis GS, Oh JK, et al. Left atrial volume: a powerful predictor of survival after acute myocardial infarction. Circulation. 2003;107:2207-2212.
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OLGU 11
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OLGU 12
!SEMPTOMATIKî3ISTOLIKîeF~R~M
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Kaynaklar 1. Enriquez-Sarano M, Dujardin KS, Tribouilloy CM, et al. 'HWHUPLQDQWV RI SXOPRQDU\ YHQRXV ÁRZ UHYHUVDO LQ PLWUDO regurgitation and its usefulness in determining the severity of regurgitation. Am J Cardiol. 1999;83:535-541.
2. Tice FD, Heinle SK, Harrison JK, et al. Transesophageal echocardiographic assessment of reversal of systolic SXOPRQDU\ YHQRXV ÁRZ LQ PLWUDO VWHQRVLV Am J Cardiol. 1995;75:58-60.
OLGU 13
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OLGU 14
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Kaynaklar 1. Keogh KA, Specks U. Churg-Strauss syndrome: clinical presentation, antineutrophil cytoplasmic antibodies, and leukotriene receptor antagonists. Am J Med. 2003;115:284-290.
2. Kane GC, Keogh KA. Involvement of the heart by small and medium vasculitis. Curr Opin Rheumatol. 2009;21:29-34.
OLGU 16
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Kaynaklar 1. Oh JK, Hatle LK, Seward JB, et al. Diagnostic role of Doppler echocardiography in constrictive pericarditis. J Am Coll Cardiol. 1994;23(1):154-162. 2. Oh JK, Tajik AJ, Appleton CP, et al. Preload reduction to unmask the characteristic Doppler features of constrictive pericarditis. A new observation. Circulation. 1997;95(4):796-799. 3. Ha JW, Ommen SR, Tajik AJ, et al. Differentiation of constrictive pericarditis from restrictive cardiomyopathy using mitral annular velocity by tissue Doppler echocardiography. Am J Cardiol. 2004;94(3):316-319. 4. Reuss CS, Wilansky SM, Lester SJ, et al. Using mitral â&#x20AC;&#x153;annulus reversusâ&#x20AC;? to diagnose constrictive pericarditis. Eur J Echocardiogr. 2009;10(30):372-375. 5. Veress G, Ling LH, Kim KH, et al. Mitral and tricuspid annular velocities before and arter pericardiectomy in pa-
tients with constrictive pericarditis. Circ Cardiovasc Imaging. 2011;4(4):399-407. Epub 2011 May 4. 6. Choi JH, Choi JO, Ryu DR, et al. Mitral and tricuspid annular velocities in constrictive pericarditis and restrictive cardiomyopathy: correlation with pericardial thickness on computed tomogra-phy. JACC Cardiovasc Imaging. 2011;4(6):567-575. 7. Ling LH, Oh JK, Tei C, et al. Pericardial thickness measured with transesophageal echocardiography: feasibility and potential clini-cal usefulness. J Am Coll Cardiol. 1997;29:1317. 8. Talreja DR, Edvvards WD, Danielson GK, et al. Constrictive pericarditis in 26 patients with histologically normal pericardial thickness. Circulation. 2003;108:1852-1857.
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62 / %+/+!2$ĂŞ9/'2!&ĂŞ ĂŽ/,'5ĂŽ4%-%,,ĂŞĂŽ9!+,!ĂŹ)Kaynaklar 1. Pellikka PA, Sarano ME, Nishimura RA, et al. Outcome of DGXOWV ZLWK DV\PSWRPDWLF KHPRG\QDPLFDOO\ VLJQLĂ&#x20AC;cant aortic ste-nosis during prolonged follow-up. Circulation. 2005:111:3290-3295. 2. Rosenhek R, Binder T, Porenta G, et al. Predictors of outcome in severe asymptomatic aortic valve stenosis. N Engl J Med. 2000;343:611-617. 3. Douglas P, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Ă&#x2021;are Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011;24:229-267.
%DGGRXU /0 :LOVRP :5 %D\HU $6 HW DO $+$ 6FLHQWLĂ&#x20AC;F Statement. Infective endocarditis: diagnosis, antimicrobial therapy, and management of complications: a statement for healthcare professionals from the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease in the Young, and the Councils on Clinical Cardiology, Stroke, and Cardiovascular Surgery and Anesthesia, American Heart Associationâ&#x20AC;&#x201D;Executive Summary: Endorsed by the Infectious Diseases Society of America. Circulation. 2005:111:3167. 5. Karalis DG, Bansal RC, Hauck AJ, et al. Transesophageal echocardiographic recognition of subaortic complications in aortic valve endocarditis. Clinical and surgical implications. Circulation. 1992;86:353-362. 6. Daniel WG, MĂźgge A, Martin RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med. 1991;324:795800.
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Kaynaklar 1. deFilippi CR, Willet DL, Brickner ME, et al. Usefulness of dobutamine echocardiography in distinguishing severe from nonsevere valvular aortic srenosis in patients with depressed left ventricular function and low transvalvular gradients. Am J Cardiol. 1995;75:191-194. 2. Nishimura RA, Grantham JA, Connolly HM, Schaff HV, Hi-gano ST, Holmes DR Jr. Low-output, low-gradient aortic stenosis in patients with depressed left ventricular systolic function: the clinical utility of the dobutamine challenge in the catheterization laboratory. Circulation. 2002;106:809-813. 3. Omran H, Schmidt H, Hackenbroch M, et al. Silent and apparent cerebral embolism after retrograde catheterisation of the aortic valve in valvular stenosis: a prospective, randomized study. Lancet. 2003;361:1241-1246. 4. Monin JL, Quere JP, Monchi M, et al. Low-gradient aorWLF VWHQRVLV RSHUDWLYH ULVN VWUDWLĂ&#x20AC;FDWLRQ DQG SUHGLFWRUV IRU long-term outcome: a multicenter study using dobutamine stress hemodynamics. Circulation. 2003;108:319-324. Epub 2003 Jun 30.
5. Schwammenthal E, Vered Z, Moshkovvitz Y, et al. Dobutamine echocardiography in patients with aortic stenosis and left ventricular dysfunction: predicting outcome as a function of management strategy. Chest. 2001;119:1766-1777. 6. Pereira JJ, Lauer MS, Bashir M, et al. Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction. J Am Coll Cardiol. 2002;39:1356-1363. 7. Malouf JF, Enriquez-Sarano M, Pellikka PA, et al. Severe pulmonary hypertension in patients with severe aortic valYH VWHQRVLV FOLQLFDO SURĂ&#x20AC;OH DQG SURJQRVWLF LPSOLFDWLRQV J Am Coll Cardiol. 2002;40:789-795. 8. Hachicha Z, Dumesnil JG, Bogaty P, Pibarot P. Paradoxical ORZ Ă RZ ORZ JUDGLHQW VHYHUH DRUWLF VWHQRVLV GHVSLWH SUHserved ejection fraction is associated with higher afterload and reduced survival. Circulation. 2007 Jun 5;115(22):285664.
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Kaynaklar 1. Mahapatra S, Nishimura RA, Oh JK, et al. The prognostic value of pulmonary vascular capacitance determined by Doppler echocardiography in patients with pulmonary arterial hypertension. J Am Soc Echocardiogr. 2006;19:10451050.
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OLGU 22
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OLGU 23
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OLGU 24
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Kaynaklar 1. O’Murchu B, Seward JB. Images in cardiovascular medicine. Adult congenital heart disease. Obstructive and nonobstructive cor triatriatum. Circulation. 1995;92:3574. %XFKKRO] 6 -HQQL 5 'RSSOHU HFKRFDUGLRJUDSKLF ÀQGLQJV in 2 identical variants of a rare cardiac anomaly, “subtotal”
cor triatriatum: a critical review of the literature. J Am Soc Echocardiogr. 2001;14:846-849. 3. van Son JA, Danielson GK, Schaff HV, et al. Cor triatriatum: diagnosis, operative approach, and late results. Mayo Clin Proc. 1993;68:854-859.
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102 / %+/+!2$ĂŞ9/'2!&ĂŞ ĂŽ/,'5ĂŽ4%-%,,ĂŞĂŽ9!+,!ĂŹ)Kaynaklar 1. Tei C, Dujardin KS, Hodge DO, et al. Doppler echocardiographic index for assessment of global right ventricular function. J Am Soc Echocardiogr. 1996:9;838-847. 5XGVNL /* /DL :: $Ă&#x20AC;ODOR - HW DO *XLGHOLQHV IRU WKH echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography: endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010:23:685-713. 3. Grifoni S, Olivotto I, Cecchini P, et al. Short-term clinical outcome of patients with acute pulmonary embolism, normal blood pressure, and echocardiographic right ventricular dysfunction. Circulation. 2000; 101:2817-2822.
4. JaffMR, McMurtry MS, Archer SL, et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis and chronic thromboembolic pulmonary hypertension. Circulation. 2011;123:1788-1830. 5. Sanchez O, Trinquart L, Colombet I, et al. Prognostic value of right ventricular dysfunction in patients with haemodynamically stable pulmonary embolism: a systematic review. Eur Heart J. 2008;29:1569-1577. 6. Pengo V, Lensing AW, Prins MH, et al. Incidence of chronic thromboembolic pulmonary hypertension after pulmonary embolism. N Engl J Med. 2004;350:2257-2264.
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Kaynaklar 1. Antoni ML, Scherptong RW, Atary JZ, et al. Prognostic value of right ventricular function in patients after acute myocardial in-farction treated with primary percutaneous coronary intervention. Circ Cardiovasc Imaging. 2010;3:264-271.
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êEKILî Kaynaklar 1. Douglas PS, Khandheria B, Stainback RF, et al. ACCF/ASE/ACEP/AHA/ASNC/SCAI/SCCT/SCMR 2008 appropriateness criteria for stress echocardiography. J Am Coll Cardiol. 2008;18:1127-1147.
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Kaynaklar 1. SchafF HV, Brown ML, Dearani JA, et al. Apical myectomy: a new surgical technique for management of severely symptomatic patients with apical hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg. 2010; 139:634-640. 2. Grewal KS, Malkowski MJ, Piracha AR, et al. Effect of general anesthesia on the severity of mitral regurgitation by transesophageal echocardiography. Am J Cardiol. 2000;85:199-203.
3. Mihalatos DG, Gopal AS, Kates R, et al. Intraoperative assessment of mitral regurgitation: role of phenylephrine challenge. J Am Soc Echocardiogr. 2006; 19:1158-1164.
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118 / %+/+!2$ê9/'2!&ê î/,'5î4%-%,,êî9!+,!ì)Kaynaklar 1. Sliwa K, Blauvvet L, Tibazanva K, et al. Evaluation of bromocriptine in the treatment of acute severe peripartum cardiomyopathy: a proof-of-concept pilot study. Circulation. 2010;121:1465-73.
OLGU 35
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Kaynaklar 1. Bybee KA, Kara T, Prasad A, et al. Systemic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004:141(11):858-865.
2. Madhavan M, Rihal CS, Lerman A, Prasad A. Acute heart failure in apical ballooning syndrome (TakoTsubo/stress cardiomyopathy): clinical correlates and Mayo Clinic risk score. J Am Coll Cardiol 2011;57(12):1400-01.
OLGU 36
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Kaynaklar 1. Varess G, Bruce CJ, Andreen K, et al. Acute thrombus formation as a complication of right ventricular biopsy. J Am Soc Echocardiogr. 2010;23:1039-1044.
2. Gujjs P, Rosing DR, Tripodi DJ, et al. Iron overload cardiomyopathy. J Am Coll Cardiol. 2010;56:1-12.
OLGU 37
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126 / %+/+!2$ĂŞ9/'2!&ĂŞ ĂŽ/,'5ĂŽ4%-%,,ĂŞĂŽ9!+,!ĂŹ)Kaynaklar %HOODYLD ' 3HOOLNND 3$ $O =DKUDQL *% HW DO ĂşQGHSHQGHQW predictors of survival in primary systemic (Al) amyloidosis, including cardiac biomarkers and left ventricular strain imaging: an observational cohort study. J Am Soc Echocardiogr. 2010;23:643-652. 2. Dispenzieri A, Gertz MA, Kyle RA, et al. Prognostication of survival using cardiac troponins and N-terminal pro-brain natriuretic peptide in patients with primary systemic amyloidosis undergoing peripheral blood stem cell transplantation. Blood. 2004;104:1881-1887. 3. Dispenzieri A, Lacy MQ, Katzmann JA, et al. Absolute values of immunoglobulin free light chains are prognos-
tic in patients with primary systemic amyloidosis undergoing peripheral blood stem cell transplantation. Blood. 2006;107:3378-3383. 4. Gertz M, Lacy M, Dispenzieri A, et al. Troponin T level as an exclusion criterion for stem cell transplantation in light-chain amyloidosis. Leuk Lymphoma. 2008;49:36-41. 5. Feng D, Syed IS, Martinez M, et al. Intracardiac thrombosis and anticoagulation therapy in cardiac amyloidosis. Circulation. 2009;119:2490-2497.
OLGU 38
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Kaynaklar 1. Kyle RA, Spittell PC, Gertz MA, et al. The premortem recognition of systemic senile amyloidosis with cardiac involvement. Am J Med. 1996; 101:395^00.
2. Ng B, Connors LH, Davidoff R, et al. Senile systemic amyloidosis presenting with heart failure: a comparison with light chain-associated amyloidosis. Arch Intern Med. 2005;165:1425-1429.
OLGU 39
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OLGU 40
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Kaynaklar 1. Ahn YK, Park JC, Park WS, et al. A case of prominent epicardial fat mimicking a tumor on echocardiography. J Korean Med Sci. 1999;14:571-574. 2. Pressman G, Verma N. Pericardial fat masquerading as tumor. Echocardiography. 2010;27:E18-E20.
3. Ommen SR, Nishimura RA, Hurrell DG, et al. Assessment of right atrial pressure with 2-dimensional and Doppler echocardiography: a simultaneous catheterization and echocardiographic study. Mayo Clin Proc. 2000;75:24-29.
OLGU 42
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Kaynaklar 1. ElBardissi AW, Dearani JA, Daly RC, et al. Analysis of benign ventricular tumors: long-term outcome after resection. J Thorac Cardiovasc Surg. 2008; 135:1061 -1068.
2. ElBardissi AW, Dearani JA, Daly RC, et al. Survival after resection of primary cardiac tumors: a 48-year experience. Circulation. 2008;118(14)(suppl):S7-S15.
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Kaynaklar 1. Price S, Prout J, Jaggar SI, et al. “Tamponade” following cardiac surgery: terminology and echocardiography may both mislead. Eur J Cardiothoracic Surg. 2004;26:1156-1160.
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160 / %+/+!2$ê9/'2!&ê î/,'5î4%-%,,êî9!+,!ì)Kaynaklar 1. Ommen SR, Maron BJ, Olivotto I, et al. Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy. J Am Coll Cardiol Aú
4. Talreja DR, Nishimura RA, Edwards WD, et al. Alcohol septal ablation versus surgical septal myectomy: comparison of effects on atrioventricular conduction tissue. J Am Coll Cardiol. 2004;44:2329-2332.
2. Qin JX, Shiota T, Lever HM, et al. Outcome of patients with hypertrophic obstructive cardiomyopathy after percutaneous transluminal septal myocardial ablation and septal myectomy surgery. J Am Coll Cardiol. 2001;38:1994-2000.
5. Shah PM, Gramiak R, Kramer DH. Ultrasound localization RI OHIW YHQWULFXODU RXWÁRZ REVWUXFWLRQ LQ K\SHUWURSKLF REVWructive cardiomyopathy. Circulation. 1969;40:3-11.
3. Sorajja P, Valeti U, Nishimura RA, et al. Outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy. Circulation. 2008;! 18:131-139.
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Kaynaklar 1. Attenhofer Jost CH, Connolly HM, Dearani JA, et al. Ebsteinâ&#x20AC;&#x2122;s anomaly. Circulation. 2007;115:277-285.
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OLGU 50
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Kaynaklar 1. Eysmann SB, Palevsky HL, Reichek N, et al. Two-dimensional and Doppler-echocardiographic and cardiac catheterization correlates of survival in primary pulmonary hypertension. Circulation. 1989;80:353-360.
2. Plotnick GD, Rubin DC, Feliciano Z, et al. Pulmonary hypertension decreases the predictive accuracy of echocardiographic clues for cardiac tamponade. Chest. 1995;107:919.
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Kaynaklar 1. Goldhaber SZ. Thrombolysis for pulmonary embolism. N Engl J Med. 2002;347:1131-1132. 2. Sadeghi HM, Kimura BJ, Raisinghani A, et al. Does lowering pulmonary arterial pressure eliminate severe functional tricuspid regurgitation? Insights from pulmonary thromboendarterectomy. J Am CollCardiol. 2004;44:126-132. 3. Konstantinides S, Geibel A, Heusel G, et al. Management strategies and prognosis of pulmonary embolism-3 trial in-
vestigators. Heparin plus alteplase compared with heparin alone in patients with submassive pulmonary embolism. N Engl J Med. 2002;347:1143-1150. 4. Tapson VF. Acute pulmonary embolism. Engl J Med. 2008:358:1037.
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Kaynaklar 1. Ommen SR, Seward JB, Tajik AJ. Clinical and echocardiographic features of hypereosinophilic syndromes. Am J Cardiol. 2000;86:110-113.
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Kaynaklar 1. Aduen JF, Castello R, Daniels JT, et al. Accuracy and precision of three echocardiographic methods for estimating mean pulmonary artery pressure. Chest. 2011;139:347-352. 5XGVNL /* /DL :: $Ã&#x20AC;ODOR - HW DO *XLGHOLQHV IRU WKH echocardiographic assessment of the right heart in adults: a repon from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713.
3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation. 2008; 118:e523-e661.
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Kaynaklar 1. Cannegieter SC, Torn M, Rosendaal FR. Oral anticoagulant treatment in patients with mechanical heart valves: how to reduce the risk of thromboembolic and bleeding complicanons. J Intern Med. 1999;245:369-374. 2. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines
for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2008;52:el-el42.
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Kaynaklar 1. Eriksson MJ, Sonnenberg B, Woo A, et al. Long-term outcome in patients with apical hypertrophic cardiomyopathy. J Am Coll Cardiol. 2002:20;39:638-645. 2. Maron MS, Finley JJ, Bos JM, et al. Prevalence, clinical VLJQLÃ&#x20AC;FDQFH DQG QDWXUDO KLVWRU\ RI OHIW YHQWULFXODU DSLFDO aneurysms in hypertrophic cardiomyopathy. Circulation. 2008; 118:1541-1549.
3. Schaff HV, Brown ML, Dearani JA, et al. Apical myectomy: a new surgical technique for management of severely symptomatic patients with apical hypertrophic cardiomyopathy. J Thorac Cardiovasc Surg. 2010; 139:634-640.
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Kaynaklar 1. Li W, Davlouros PA, Kilner PJ, et al. Doppler-echocardiographic assessment of pulmonary regurgitation in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance imaging. Am Heart J. 2004;147(1):165-172.
2. Ammash NM, Dearani JA, Burkhart HM, et al. Pulmonary regurgitation after tetralogy of Fallot repair: clinical features, sequelae, and timing of pulmonary valve replacement. Congenital Heart Dis. 2007;2(6):386-403.
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Kaynaklar 1. Pieroni M, Chimenti C, De Cobelli F, et al. Fabry s disease cardiomyopathy: echocardiographic detection of endomyocardial glycosphingolipid compartmentalization. J Am Coll Cardiol. 2006;47:1663-1671.
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Kaynaklar 1. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the mana-
gement of patients with valvular heart disease). J Am Coll Cardiol. 2008;52:el-el42. /L -6 6H[WRQ '- 0LFN 1 HW DO 3URSRVHG PRGLÃ&#x20AC;FDWLRQV WR the Duke criteria for the diagnosis of infective endocarditis. Clin Infect Dis. 2000;30:633-638.
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Kaynaklar 1. Kollum A, Desai D, Cohen GI. The etiology of the atrial myxoma tumor plop. JAm Coll Cardiol. 201 l;57:e371.
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Kaynaklar 1. Libman E, Sacks B. A hitherto undescribed form of valvular and mural endocarditis. Arch Intern Med. 1924;33:701-737.
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Kaynaklar 1. Hurst RT, Askew JW, Reuss CS, et al. Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol. 2006;48:579-583. 2. Dhoble A, Abdelmoneim SS, Bernier M, et al. Transient left ventricular apical ballooning and exercise induced
hypertension during treadmill exercise testing: is there a common hypersympa thetic mechanism? Cardiovasc Ultrasound. 2008;6:37.
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Kaynaklar 1. Warnes CA, Williams RG, Bashore TM, et al. ACC/AHA guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines on the management of adults with congenital heart disease). Circulation. 2008;118;e714-e833.
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Kaynaklar 1. Lembo NJ, Dell’Italia LJ, Crawford MH, et al. Bedside diagnosis of systolic murmurs. N Engl J Med. 1988;318:15721578.
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aARPíNTíîVEî$ISPNE
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OLGU 67
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OLGU 68
3OèUKî3OLî!YAK
6
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/,'5î î / 217 Kaynaklar 1. Nagueh S, Mikati I, Kopelen HA, et al. Doppler estimatiRQ RI OHIW YHQWULFXODU ÀOOLQJ SUHVVXUH LQ VLQ V WDFK\FDUGLD A new application of tissue Doppler imaging. Circulation. 1998;98:1644-1650. 2. Sohn DW, Kim YJ, Kim HC, et al. Evaluation of left ventricular diastolic function when mitral E and A waves are completely fused: role of assessing mitral annulus velocity. J Am Soc Echocardiogr. 1999;12:203-208. 3. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/ SCMR 2011 Appropriate Use Criteria for Echocardi-
ography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011 ;24:229-267.
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Kaynaklar 1. Beghetti M, Galie N. Eisenmenger syndrome a clinical perspective in a new therapeutic era of pulmonary arterial hypertension. J Am Coll Cardiol. 2009;53:733-740.
2. Dimopoulos K, Inuzuka R, Goletto S, et al. Improved survival among patients with Eisenmenger syndrome receiving advance therapy for pulmonary arterial hypertension. Circulation. 2010;121:20-25.
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Kaynaklar 1. Abascal VM, Wilkins GT, Choong CY, et al. Echocardiographic evaluation of mitral valve structure and function in patients followed for at least 6 months after percutaneous balloon mitral valvuloplasty. J Am Coll Cardiol. 1988;12:606615.
2. Cannan CR, Nishimura RA, Reeder GS, et al. Echocardiographic assessment of commissural calcium: a simple predictor of outcome after percutaneous mitral balloon valvotomy. J Am Coll Cardiol. 1997;29:175-180.
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/,'5î î / 233 Kaynaklar 1. Kane GC, Hepinstall MJ, Kidd GM, et al. Safety of stress echocardiography supervised by registered nurses: results of a 2-year audit of 15,404 patients. JAm Soc Echocardiogr. 2008;21:337.
4. Pellikka PA, Nagueh SF, Elhendy AA, et al. American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr. 2007:20:1021.
2. Mathias W Jr, Arruda A, Santos FC, et al. Safety of dobutamineatropine stress echocardiography: a prospective experience of 4,033 consecutive studies. J Am Soc Echocardiogr. 1999; 12:785.
5. Ling LH, PeUikka PA, Mahoney DW, et al. Atropine augmentation in dobutamine stress echocardiography: role and incremental value in a clinical practice setting. J Am Coll Cardiol. 1996;28:551-557.
3. Mertes H, Sawada SG, Ryan T, et al. Symptoms, adverse effects, and complications associated with dobutamine stress echocardiography. Experience in 1118 patients. Circulation. 1993:88:15.
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/,'5î î / 243 Kaynaklar 1. Klarich KW, Enriquez-Sarano M, Gura GM, et al. PapilODU\ ÀEURHODVWRPD HFKRFDUGLRJUDSKLF FKDUDFWHULVWLFV IRU diagnosis and pathologic correlation. J Am Coll Cardiol. 1997:30:785. 2. Gowda RM, Khan IA, Nair CK, et al. Cardiac papillary ÀEURHODVWRPD D FRPSUHKHQVLYH DQDO\VLV RI FDVHV Am Heart J. 2003:146:404.
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a registered branch of the European Society of Cardiology, and the Canadian Societyof Echocardiography. J Am Soc Echocardiogr. 2010;23:685-713.
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Kaynaklar 1. Hagl C, Ergin MA, Galla JD, et al. Delayed chronic type A dissection following CABG: implications for evolving techniques of revascularization. J Card Surg. 2000; 15:362-367.
2. Hirose H, Svensson LG, Lytle BW, et al. Aortic dissection after previous cardiovascular surgery. Ann Thorac Surg. 2004;78:2099-2105.
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Kaynaklar 1. Innelli P, Esposito R, Olibet M, et al. The impact of ageing on right ventticulat longitudinal function in healthy subjects: a pulsed tissue Doppler study. Eur J Ecbocardigr. 2009:10;491-498.
3. Wethal T, Lund MB, Edvardsen T, et al. Valvular dysfunction and left ventricular changes in Hodgkin’s lymphoma survivors. A longitudinal study. Br J Cancer. 2009;101:575581.
2. Heidenreich PA, Hancock SL, Lee BK, et al. Asymptomatic cardiac disease following mediastinal irradiation. J Am Coll Cardiol. 2003;42:743-749.
*DOSHU 6/ <X -% 0DXFK 30 HW DO &OLQLFDOO\ VLJQLÀFDQW cardiac disease in patients with Hodgkin lymphoma treated with mediastinal irradiation. Blood. 2011;117:412-418.
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Kaynaklar 1. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/ SCCT/ SCMR 2011 appropriate use criteria for echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance American College of Chest Physicians. J Am Soc Echocardiogr. 2011 ;24:229-267. 2. Mulvagh SL, Rakovvski H, Vannan MA, et al. American Society of Echocardiography Consensus Statement on the
Clinical Applications of Ultrasonic Contrast Agents in Echocardiography. J Am Soc Echocardiogr. 2008;21(11):11791201. 3. Abdelmoneim SS, Bernier M, Scott CG, et al. Safety of contrast agent use during stress echocardiography in patients with elevated right ventricular systolic pressure: a cohort study. Circ Cardiovasc Imaging. 2010;3(3):240-248. 4. Wuthiwaropas P, Wiste JA, McCully RB, et al. Neuropsychiatric symptoms during 24 hours after dobutamine-atropine stress test-ing: a prospective study in 1,006 patients. J Am Soc Echocardiogr. 2011;21(11):367-373.
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Kaynaklar 1. Syed M, Lesch M. Coronary aneurysm: a review. Prog Cardiovasc Dis. 1997;40(l):77-84.
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Kaynaklar 1. Thomas JD, Wilkins GT, Choong CY, et al. Inaccuracy of mitral pressure half-time immediately arter percutaneous mitral valvotomy. Dependence on transmitral gradient and left atrial and ventricular compliance. Circulation. 1988;78(4):980-993.
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OLGU 84
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Kaynaklar 1. Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation. 1998;98:2936-2948. 2. Rohmann S, Erbel R, Görge G, et al. Clinical televance of vegetation localization by ttansoesophageal echocatdiography in infective endocarditis. Eur Heart J. 1992;13:446-452. 6DQÃ&#x20AC;OLSSR $- 3LFDUG 0+ 1HZHOO -% HW DO (FKRFDUGLRJraphic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol. 1991;18:1191-1199.
4. Thuny F, Di Salvo G, Belliard O, et al. Risk of embolism and death in infective endocarditis: prognostic value of echocardiography: a prospective multicenter study. Circulation. 2005;112:69-75. $QDYHNDU 16 7OH\MHK ú0 $QDYHNDU 16 HW DO ,PSDFW RI prior antiplatelet therapy on risk of embolism in infective endocarditis. Clin Infect Dis. 2007;44:1180-1186.
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Kaynaklar 1. Sorajja P, Cabalka AK, Hagler DJ, et al. Percutaneous repair of paravalvular prosthetic regurgitation: acute and 30-day outcomes in 115 patients. Circ Cardiovasc Interv. 2011;4(4):314â&#x20AC;&#x201D;321.
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Kaynaklar 1. Stein PD, Alpert JS, Bussey HI, et al. Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. Chest. 2001; 119(l)(suppl):220S-227S. 2. Bonow RO, Carabello BA, Chatterjee K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to develop guidelines for
the management of patients with valvular heart disease). American College of Cardiology Web Site. http://vvrww. acc.org/clinical/guidelines/valvular/index. pdf. Accessed. 3. Colli A, Verhoye J-P, Leguerrier A, et al. Anticoagulation or antiplatelet therapy of bioprosthetic heart valves recipients: an unresolved issue. Eur J Cardio Surg. 2007;31:573-577.
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echocardiography: a new diagnostic sign of hydropneumopericardium. J Am Soc Echocardigr. 1996;9(2):187—189.
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Kaynaklar 1. Merrer J, De Jonghe B, Golliot F, et al. French Catheter Study Group in Intensive Care. Complications of femoral and subclavian venous catheterization in critically ili patients: a randomized controlled triai. JAMA. 2001;286:700-707. 2. Timsit JF, Farkas JC, Boyer JM, et al. Central vein catheter-related thrombosis in intensive care patients: incidence, risks factors, and relationship with catheter-related sepsis. Chest. 1988;114:207-213.
3. Ghani MK, Boccalandro F, Denktas AE, et al. Right atrial thrombus formation associated with central venous catheters utilization in hemodialysis patients. Intensive Care Med. 2003;29:1829-1832.
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OLGU 93
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Kaynaklar 1. Spirito P, Bellone P, Harris KM, et al. Magnitude of left ventricular hypertrophy and risk of sudden death in hypertrophic cardiomyopathy. N Engl J Med. 2000;342:17781785. 2. McKenna WJ, Behr ER. Hypertrophic cardiomyopathy: PDQDJHPHQW ULVN VWUDWLÀFDWLRQ DQG SUHYHQWLRQ RI VXGGHQ death. Heart. 2002;87:169.
3. Maron BJ, McKenna WJ, Danielson GK, et al. American College of Cardiology/European Society of Cardiology clinical expert consensus document on hypertrophic cardiomyopathy. A report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents and the European Society of Cardiology Committee for Practice Guidelines. J Am CollCardiol. 2003:42:1687.
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Kaynaklar 1. Rossi A, Dujardin KS, Bailey KR, et al. Rapid estimation of regurgitant volume by the proximal isovelocity surface area method in mitral regurgitation: can continuous-wave Doppler echocardiography be omitted? J Am Soc Echocardiogr. 1998;11:138-148.
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Kaynaklar 1. Vida VL, Padalino MA, Boccuzzo G, et al. Scimitar syndrome. A European Congenital Heart Surgeons Association (ECHSA) multicentric study. Circulation. 2010; 122(12): 1159-1166.
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Kaynaklar 1. Rodriguez-Roisin R, Krowka MJ. Hepatopulmonary syndrome. N Engl J Med. 2008;358:2378-2387. 2. Farzaneh-Far R, McKeown BH, Dang D, et al. Accuracy of Doppler-estimated pulmonary vascular resistance in patients before liver transplantation. Am J Cardiol. 2008; 101 (2):259-262.
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Kaynaklar 1. Alazmi W, Bustamante M, O’Loughlin C, et al. The association of Streptococcus bovis bacteremia and gastrointestinal diseases: a retrospective analysis. Dig Dis Sci. 2006;51(4):732-736.
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