Decision making in Ischemic cardiomyopathy: variability in physicians’ approaches and patients’ adherence

Ischemic cardiomyopathy (ICM) is a common cardiovasculardisease with conflicting evidence regardingits management and a high risk profile for revascularizationprocedures that seems to have resulted invariable approach of physicians toward its management,and likewise, significant patient non-adherence to physicianrecommendation. We included patients with 3-vesseldisease and left ventricular ejection fraction (LVEF)<45%(ICM group; n=825), and patients with LM diseaseand LVEF ≥45% (LM group; n=162), detected by coronaryangiography at Tehran Heart Center. Variation of recommendationsamong cardiologists was evaluated. The rateof coronary artery bypass graft (CABG) non-adherencewas also determined, as well as its predictors and outcomein ICM group. Decision making was more variable inICM group, compared to LM group. CABG non-adherencewas significantly more common in ICM group (32.4%),compared to LM group (10.0%) (P<0.001). Advancedage, being female, absence of angina, creatinine >2mg/dl,severe left ventricular dysfunction, absence of LM diseaseand moderate or severe mitral regurgitation were predictorsof CABG non-adherence. ICM patients with CABGnon-adherence had significantly more all-cause mortality(Hazard Ratio [HR]: 1.97, 95% confidence interval [CI]:1.28-3.04), and more all-cause mortality, revascularizationor hospitalization due to cardiac disease (HR: 1.94, 95%CI: 1.41-2.67), than those who received CABG. WhileICM is a common disorder encountered frequently in dailypractice of cardiologists, there is a significant variability indecision making, as well as a significant non-adherencetolifesaving recommendations for these patients

Association of the high-sensitive cardiac troponin T levels and long-term mortality in patients with acute aortic dissection type A

Introduction: Acute aortic dissection type A is a life-threatening cardiovascular emergency necessitating rapid diagnosis and treatment. We sought a new prognostic tool with cardiac biomarkers and simple inflammatory factors. Methods: from 2003 to 2014, 50 patients with documented acute aortic dissection type A were entered to this study. These patients were followed up until December 2020; within median follow up of 93.6 months. The patients were evaluated on the association of the baseline characteristics, first laboratory investigation, echocardiographic findings, surgical approach, and long-term mortality. Results: Total number of mortality during the follow up was 29 (58%) patients, which was significantly higher in medical group (89.4% vs 38.7%, P value=0.001). Multivariable analysis showed only an increase in hs-cTnT levels was suggested as a predictor of mortality (95% CI: 1.06–1.38; HR=1.21; P=0.005), so that for every 100 units increase, patients were 21% more likely to have mortality in long term. Also, performing surgical treatment for aortic dissection was determined as the independent predictor of surviving, so that death was 74.6% less than those who received medical treatment (95% CI: 0.13–0.58; HR=0.27; P=0.001). Conclusion: hs-cTnT is a potential predictor of mortality in patients with acute aortic dissection type A

Case report: Thoracic endovascular aortic repair using a non-touch exclusion technique with a custom-made device for the treatment of a large patent ductus arteriosus

Patent ductus arteriosus (PDA) is a common congenital heart disease affecting roughly one in every 2,000 term births. Although most of the patients are diagnosed and treated during childhood, few cases may persist into adulthood. We presented a 27-year-old male patient with a 20.2 mm diameter PDA who was referred to our hospital with progressive fatigue and exertional dyspnea. Given the potential complications, usual techniques such as coil occlusion and duct occluders were deemed inappropriate for this patient. Thoracic endovascular aortic repair (TEVAR) using a non-touch exclusion technique was successfully performed for this patient. The patient was discharged with no major post-surgical complications. TEVAR could be a new, safe, and effective alternative treatment to other transcatheter procedures for complicated PDAs in some patients

Comparing the effect of cardiac biomarkers on the outcome of normotensive patients with acute pulmonary embolism

Acute pulmonary embolism (PE) is a cardiovascular challenge with potentially fatal consequences. This study was designed to observe the association of novel cardiac biomarkers with outcome in this setting. In this prospective study, from 86 patients with a confirmed diagnosis of PE, 59 patients met the inclusion criteria (22 men, 37 women; mean age, 63.36±15.04 y).The plasma concentrations of N-terminal pro-brain natriuretic peptide (NT-proBNP), growth differentiation factor-15 (GDF-15), heart-type fatty acid-binding protein (H-FABP), tenascin-C, and D-dimer were measured at the time of confirmed diagnosis. The endpoints of the study were defined as the short-term adverse outcome and long-term all-cause mortality. Totally, 11.8% (7/59) of the patients had the short-term adverse outcome. The mean value of logNT-proBNP was 6.40±1.66 pg/ml. Among all the examined biomarkers, only the mean value of logNT-proBNP was significantly higher in the patients with the short-term adverse outcome (7.88±0.67 vs. 6.22± 1.66 pg/ml; OR, 2.359; 95% CI, 1.037 to 5.367; P=0.041). After adjustment, a threefold increase in the short-term adverse outcome was identified (OR, 3.239; 95% CI, 0.877 to 11.967; P=0.078).Overall, 18.64% (11/59) of the patients had expired by the long-term follow-up. Moreover, adjustment revealed an evidence regarding association between increased logNT-proBNP levels and long-term mortality (HR, 2.163; 95%CI, 0.910 to 5.142; P=0.081). Our study could find evidences on association between increased level of NT-proBNP and short-term adverse outcome and/or long-term mortality in PE. This biomarker may be capable of improving prediction of outcome and clinical care in non-high-risk PE

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis

AimA considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established.MethodsThis retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions.ResultsApproximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99–12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91–2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88–1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81–1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92–6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02–3.21, P: 0.008) than SMuRF+ women.ConclusionsAlmost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality

Broken Heart Syndrome: A Case Report

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is a recently increasing diagnosed disease manifested by transient apical or mid left ventricular dilation and dysfunction. This sign is similar to acute myocardial infarction but without significant coronary artery stenosis. There are important and essential differences between Takotsubo cardiomyopathy and acute myocardial infarction in terms of management, necessitating a good understanding of the pathophysiology, diagnosis, and treatment of the former. We report a case of Takotsubo cardiomyopathy which presented with dizziness and near syncope after an intense emotional stress. Electrocardiogram showed ST-T changes in V1-V3 and echocardiography revealed severe left ventricular systolic dysfunction with marked regional wall motion abnormalities. Coronary angiography demonstrated minimal coronary artery disease. The patient was treated with beta -blockers, angiotensin-converting enzyme inhibitors, Aspirin, Clopidogrel, and diuretics. At the follow-up visit, all the symptoms had disappeared and control echocardiography showed significant improvement in the left ventricular systolic function with a normal ejection fraction and normal wall motion

Recurrence of Takotsubo Cardiomyopathy: Role of Multi- Detector Computed Tomography Coronary Angiography

Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy, is a clinical syndrome of transient left ventricular (LV) apical wall motion abnormality with relative preservation of the basal heart segments in the absence of any significant atherosclerosis. Recurrence of this condition is rare. We report a postmenopausal woman, who experienced two episodes of TCM within 4 months following emotional and physical stress. In the first episode, she was admitted due to severe dyspnea, accompanied by sudden-onset, prolonged, burning chest pain and palpitation. Transthoracic echocardiography revealed akinesia of the LV, with the exception of the basal regions. Coronary angiography demonstrated no significant coronary artery disease, and follow-up echocardiography showed normalization of the LV wall motion abnormalities. In the second episode, she experienced similar symptoms and echocardiography revealed similar changes. Multi-detector computed tomography revealed normal coronary arteries. After 9 days, she was discharged in good condition; and at 3 months’ follow- up, she was symptom-free with normal echocardiography

Doppler Tissue Imaging: A Non-Invasive Technique for Estimation of Left Ventricular End Diastolic Pressure in Severe Mitral Regurgitation

Background: Conventional Doppler measurements, including mitral inflow and pulmonary venous flow, are used to estimate left ventricular end diastolic pressure (LVEDP). However, these parameters have limitations in predicting LVEDP among patients with mitral regurgitation. This study sought to establish whether the correlation between measurements derived from tissue Doppler echocardiography and LVEDP remains valid in the setting of severe mitral regurgitation.Methods: Thirty patients (mean age: 57.37 ± 13.29 years) with severe mitral regurgitation and a mean left ventricular ejection fraction (EF) of 46.0 ± 14.95 were enrolled; 16 (53.4%) patients were defined to have EF < 50% and 14 (46.6%) patients had EF ≥ 50%. Doppler signals from the mitral inflow, pulmonary venous flow, and Doppler tissue imaging indices were obtained, and LVEDP was measured invasively through cardiac catheterization.Results: The majority of the standard Doppler and Doppler tissue imaging indices were not significantly correlated with LVEDP in the univariate analysis. In the multiple linear regression, however, early (E) transmitral velocity to annular E' (E/E') ratio (ß = 1.09, p value < 0.01), E wave velocity to propagation velocity (E/Vp) ratio (ß = 7.87, p value < 0.01), and isovolumic relaxation time (ß = 0.21, p value = 0.01) were shown as independent predictors of LVEDP (R2 = 91.7%).Conclusion: The ratio of E/Vp and E/E' ratio and also the isovolumic relaxation time could be applied properly to estimate LVEDP in mitral regurgitation patients even in the setting of severe mitral regurgitation

Hematuria during the right heart catheterization procedure: Renal perforation as a very rare complication

Abstract The occurrence of hematuria during a right heart catheterization can be a sign of renal perforation, a rare but life‐threatening complication that could be developed due to the misdirection of wire into the abdominopelvic venous plexus. We showed this complication could be managed with venoplasty of the common iliac vein

Coronary Artery Fistula with Double Outlet Right Ventricle: a Case Report

The majority of coronary artery fistulas (CAFs) are congenital. The anomaly accounts for 0.4% of congenital heart defects and approximately 50% of pediatric coronary vasculature anomalies. Twenty percent of people with congenital CAFs have other concomitant cardiac anomalies, most frequently aortic and pulmonary atresia and patent ductus arteriosus. It is worthy of note that CAF with the tetralogy of Fallot has also been reported. Here we describe a patient with a double outlet right ventricle in association with a coronary artery fistula