compared with non-khat chewers. Khat chewers weremore likely to be smokers and smokeless tobacco (sham-ma) users. Obesity and overweight was more prevalentin khat chewers. Left ventricular contractility (LVEF %)was lower in khat chewers compared with non-khatchewers. Anatomically significant coronary artery lesions(P50%) were more prevalent in khat chewers (74% vs.26%, odds ratio, 4.3; 95% confidence interval, 1.5–12;P = 0.005) and physiologically significant lesions (P70%)were also more prevalent in khat chewers (55% vs. 22%;odds ratio, 4.3; 95% confidence interval, 1.4–12;

P = 0.008) compared with non-khat chewers. Further-more, the extent of coronary artery disease (CAD) washigher in khat chewers. The previous observationsremained significant even after restriction of the tradi-tional risk factors for CAD like diabetes mellitus, hyper-tension, smoking, family history of CAD, and obesity.

Conclusion: Khat chewing was prevalent amongheart failure patients and was associated with more sig-nificant and higher extent of CAD and could be consid-ered as independent risk factor for CAD in patientswith heart failure.

http://dx.doi:10.1016/j.jsha.2013.03.126

Echocardiographic pearl a rare complication ofinfective endocarditis one of the rarest complica-tion of infective endocarditis being diagnosed byechocardiography

Mona Rayan, Mona Aboulsoud, Marawan Saad,Azza Elfiky

Our patient is a 41 years old male, born and living inCairo, working as a constructor worker and has 3 childrenthe older of which is 13 years old. He was admitted to theinternal medicine department by fever and shortness ofbreath for about 1 week associated with weakness ofhis right upper limb for 12 h before his presentationwhich made him sought medical advice. He was notknown to be hypertensive nor diabetic.He was a heavyCigarette and Shesha smoker for about 17 years .Hedenied history of any substance abuse. He has no familyhistory of any cardiac disease O/E: The patient appearedpale, toxic, orthopenic, a little confused however he wasoriented to time, place and persons.There was mildweakness of his right upper limb with intact sensation.BP: 100/70 bilaterally, HR: 110, regular, of average vol-ume, peripherally felt, Temp: 38.8 �C, RR: 20/min. Bilat-eral fine basal rales on deep inspiration, Normalabdominal examination.

Cardiac examination: The cardiac impulse was hyper-dynamic at the 5th intercostal space just outside the mid-clavicular line with no palpable thrill. Auscultationrevealed S3 gallop apically with grade III–IV pan systolicmurmur radiating to the anterior axillary line.

Investigations: Hgb: 11.2,WBC’s: 13,000, Plateletcount: 270,000. Total billirubin: 1.1, BUN: 17, Creat: 1.4,Na: 135, K: 3.9, SGOT: 45, SGPT: 37.

Discussion: Left atrial dissection (LAD) is a rarecomplication and the literature reveals only a small num-ber of cases. LAD is by Gallego et al. as a gap from themitral or tricuspid annular area to interatrial septum orleft atrial wall, creating a new chamber with or withoutcommunications into the true left or right atrium. Themost common etiology of LAD is mitral valve surgery.

Debridement of much calcified valves annulus, impro-per suturing of the annulus to the prosthetic cuff, exces-sive traction on sutures in the posterior annulus, and thehemodynamic influence of the paraprosthetic leakextended the dissection into the left atrial wall, develop-ing a false cavity. Also left atrial thrombectomy can beassociated with injury to the left atrial endocardium asa mechanism of primary tear.A rare case of left atrial dis-section as a consequence of infectious endocarditis wasreported. They present a patient with infectious endocar-ditis with involvement of mitral and aortic valves; inwhom the trans-esophageal echocardiography was ableto visualize the left atrial dissection.

The LA has a venous component that receives the PVs,a fingerlike atrial appendage, and shares the septum withthe right atrium. The major part of the atrium, includingthe septal component, is relatively smooth-walledwhereas the appendage is rough with pectinate muscles.The smoothest parts are the superior and posterior wallsthat make up the pulmonary venous component, and thevestibule. Seemingly uniform, the walls are composed ofone to three or more overlapping layers of differentlyaligned myocardial fibers, with marked regional varia-tions in thickness. Why the posterior wall of the leftatrium:A sagittal section through the left atrium of acadaver shows the proximity of the esophagus to the pos-terior wall of the left atrium The wall is particularly thinat the level of the superior pulmonary veins. Clinical pre-sentation may be the appearance of a new systolic mur-mur, associated with or without symptoms of heartfailure and low-output manifestations, hours to daysafter the operation but there were patients in whom clin-ical onset occurs years after surgery. Rarely, LAD can bean incidental finding on TEE in an asymptomatic patient.

LA dissection typically appears as a hypoechoic spacefrom the mitral/tricuspid origin extending along theinteratrial septum or LA wall. M-mode is excellent at dis-tinguishing subtle movement of the intima or the endo-cardium in relation to the cardiac cycle. Similar to whatis seen in aortic dissections, the false cavity is com-pressed during systole as the LA is being filled.

Other entities that should be considered when an LAmass is visualized are:

Thrombi most common left atrial myxoma, cysts, cor-onary aneurysms. Pericardial blood impinging on theLA wall may mimic these findings.

Color flow Doppler can be used to examine the endo-cardium for a tear and point of communication with thechamber. Pulsed wave Doppler can also be used to iden-tify flow across a tear. TEE is the diagnostic modality ofchoice for LAD.

No definitive criteria exist to help guide managementof LAD. Prompt surgical repair is usually required

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150 ORAL AND POSTER ABSTRACTS J Saudi Heart Assoc2013;25:113–172

because of coexistent significant mitral regurgitation,intra-cardiac shunt, mycotic aneurysm, pseudo aneu-rysm or fistulous communication. However, in theabsence of these findings, surgery may not always benecessary and occasionally successful repair has beenperformed years after diagnosis.

http://dx.doi:10.1016/j.jsha.2013.03.127

The expression of the gene seems to determineseverity of cardiac involvement in geleophysicdysplasia

M.E. Elhoury, Eissa Faqeih, M.O. Galal

Background: Geleophysic dysplasia is an extremelyrare autosomal recessive acromelic skeletal dysplasiacharacterized by short stature and short limbs, jointcontracture and cardiac involvement. It has beendescribed worldwide in less than 40 patients. Wedescribe the cardiac involvement in three girls of aSaudi family who showed different severity of the car-diac involvement.

Clinical description: Three sisters referred fromgeneral pediatrics over a period 5 years, because of dys-morphic features and heart murmur. The parents are firstdegree cousins, they have a boy who is now 3 years oldand is quite normal in regard of his growth anddevelopment.

The older sister is 8 years old, the next is six years, andthe third is two years old. All three girls were born fullterm spontanous delivery and had history of respiratoryproblems with frequent hospital admissions. They areall short for their ages (less than 3rd centile). Furthermorethey share dysmorphic features in a form of small handsand feet, hypertelorism, depressed nasal bridge andanteverted narse. They all have contracture at bothelbows and knees with inability to flex all to full rangeof flexion. They are happy and very friendly children,mentally normal and seem to be intellectually appropri-ate for their age. Genetic studies were done which con-firmed the heterogenicity of the ADAMTSL2 gene inthe older child.

The three girls have associated cardiac lesions withdifferent expression. The older has a mild pulmonaryand aortic valve stenosis, the second has thicking ofmitral valve and the youngest moderate to severe aorticand pulmonary valve stenosis.

Discussion: Geleophysics dysplasia (GD) has beendescribed in 1960 as a form of atypical gargoylism byVanace et al. and described by Spranger et al 1971 as afocal mucopolysacchriodosis. The disease is now consid-ered as a severe form of acromelic skeletal dysplasiawhich is a rare form of dysplasia including three disor-ders: geleophysic dysplasia, Weill-Marchesani and acro-micric dysplasia. Up to date there are less than 40reported cases with GD. All of these patients have a com-bination of cardiac valve involvement. The most frequent

cardiac lesions described being the mitral valve, then theaortic valve followed by pulmonary valve and the least istricuspid valve. Spranger described one girl with atrialseptal defect(ASD) and patent arterial duct (PDA) with-out valvular involvement. Pontz and Santolaya seperatelydescribed 5 cases with normal cardiac structure. Untiltodate there is a believe that the valve involvement showprogression over time.

Conclusions: There are very few case reportsdescribing the cardiac involvement in this conditionbut none is from the Middle East. Almost most of thecardiac conditions affect the cardiac valves in a formof thickening leading to stenosis in one or more of thecardiac valves. Most of the cases suggest progressionof the disease. In our three cases the younger has themost severe form of valve involvement. This suggeststhat the expression of the gene could determine theseverity of the disease, rather than the suggested pro-gression with age.

http://dx.doi:10.1016/j.jsha.2013.03.128

The reproducibility of coronary calcium scoring onmultiple software platforms

Norah Faisal Abukhaled, Abdullah MohammedAlskaini, Hassan Alziadey, Ihab Suleiman,Ahmad Alsaileek, Mouaz H. Al-Mallah

Introduction: Coronary Artery Calcium (CAC) Scor-ing has been validated as an accurate tool to risk stratifypatients without known coronary artery disease. The aimof this analysis is to evaluate the reproducibility of CACcalculated on different commercial softwares.

Methods: We included 159 patients who underwentCAC scoring with use of 64- slice multidetector computedtomography (CT) with prospective electrocardiographicgating for clinical reasons. The data sets were evaluatedon two different commercially available softwares (4DMfrom INVIA, Ann Arbor, MI (software A) and Smart scorefrom General Electric, Milwaukee, WI (software B)) bytwo blinded independent readers using the method ofAgatston with a threshold of 130 Hounsfield units. Com-parative analysis of CAC scores between the differentsoftware was performed by using Spearman rank correla-tion and Bland Altman analysis.

Results: Each software produced different absolutenumeric results for Agatston score. CAC was detected on107 scan on both softwares. A total of 59 scans (37%) hadthe same reading of which 50 patients are without detectedcalcium. In contrast, CAC reading were within 10 units in86 scans (52%) There was excellent statistical correlationbetween the two softwares (r = 0.948, p < 0.001) for bothscoring software. Bland Altman analysis showed signifi-cant variability at high calcium score. When grouped inthe different prognostically validated CAC groups, (CACof 0, 1–9, 10–99, 100–300, >400), 132 (87%) of the scans werein the same group by both softwares.

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