Heart surgery over two decades: what we have learned about results and changing risks

OBJECTIVES

Using the cardiac surgery database is of high importance in referral centers and can lead to a better quality of care for patients. Tehran Heart Center (THC) is a cardiovascular referral center that was inaugurated in 2001. In this report, we aimed to present the third report of trends in patients' cardiovascular risk factors and surgical procedures from 2002 to 2021 that have been gathered for all THC patients.

METHODS

This serial cross-sectional study was conducted at Tehran Heart Center from 2002 to 2021. All patients undergoing cardiac surgeries were eligible to enter the study (N = 63,974). Those with miscellaneous types of surgeries were excluded (N = 9556). The distribution of cardiac surgeries (including isolated coronary artery bypass graft (CABG), isolated valve, and CABG + valve surgeries) and their respective in-hospital mortality were recorded. Furthermore, 20-year trends in the prevalence of various cardiovascular risk factors (CVRFs) among the following groups were evaluated: a) isolated CABG, b) aortic valve replacement/repair for aortic stenosis (AS/AVR/r), and c) isolated other valve surgeries (IVS).

RESULTS

A total of 54,418 patients (male: 70.7%, age: 62.7 ± 10.8 years) comprised the final study population, with 84.5% prevalence of isolated CABG. Overall, the AS/AVR/r group was in between the CABG and IVS groups concerning CVRFs distribution. Excluding some exceptions for the AS/AVR/r group (in which the small sample size (N = 909) precluded observing a clear trend), all studied CVRFs demonstrated an overall rising trend from 2002 to 2021 in all three groups. Regarding in-hospital mortality, the highest rate was recorded as 4.0% in 2020, while the lowest rate was 2.0% in 2001.

CONCLUSIONS

Isolated CABG remained the most frequent procedure in THC. Notable, increasing trends in CVRFs were observed during this 20-year period and across various types of cardiac surgeries, which highlights the clinical and policy-making implications of our findings.

Short and mid-term outcomes of valve-sparing, aortic root reimplantation (David's procedure)

BACKGROUND

In the current study, we aimed to report the short- and mid-term outcomes of patients undergoing valve-sparing aortic root reimplantation (VSARR) and our center's experience with the procedure.

METHODS

Forty patients with aortic root aneurysms underwent VSARR at our center from 2010 until 2022. We retrospectively reviewed the medical records of these patients and extracted the relevant data. After carefully examining the aortic valve, the surgeon decided to perform Bentall or David's procedure during the operation.

RESULTS

The study population comprised 31 (77.5%) men and nine (22.5%) women, with a mean age of 55.35 ± 15.40. One patient developed hemodynamic instability post-surgery in the hospital and died from multi-organ failure. Another patient had severe AI in the intraoperative echocardiography, and aortic valve replacement with a prosthetic graft was performed during the same operation. In pre-operation echocardiography, 25 (62.5%) patients had severe, nine (22.5%) had moderate, and six (15%) had mild AI. In the in-hospital post-operation follow-up echo, AI was improved, and no patients had severe AI (P < 0.001). Only eight patients had moderate AI in post-one-year follow-up echo exams, while the rest had mild AI.

CONCLUSION

David's procedure showed excellent mid-term results in our center, with only one in-hospital mortality.

Papillary Muscle Lipoma in a Teenage Patient With Review of the Literature

•Cardiac lipoma is exceedingly rare in both adult and pediatric populations. •Only a few cases of papillary muscle lipoma have been reported. •TTE is the first step in detecting a cardiac mass. •CMR contributes to the diagnosis of cardiac lipoma. •There are no specific guidelines for the treatment of papillary muscle lipoma.

Comparison of 1-year Follow-up Echocardiographic Outcomes of Sapien 3 Versus Evolut R Bioprosthetic Transcatheter Aortic Valves: A Single-center Retrospective Iranian Cohort Study

OBJECTIVE

The current study aimed to compare 1-year echocardiographic outcomes of the new generations of self-expanding (Evolut R) versus balloon-expandable (Sapien 3) bioprosthetic transcatheter aortic valves.

METHODS

In this study, gradients and flow velocities obtained from transthoracic Doppler-echocardiography were retrospectively collected from patients who underwent 2 new generations of transcatheter aortic valve implantation interventions with Sapien 3 and Evolut R valves. Patients underwent echocardiography before the procedure and at discharge, 6 months, and 1-year follow-up.

RESULTS

Of the 66 patients, 28 received Sapien 3 and 38 received Evolut R valves. Evolut R valve presented a lower mean gradient at all follow-up time points compared with Sapien 3 valves (14.4 mm Hg, 14.9 mm Hg, 15.5 mm Hg compared with 10.1 mm Hg, 11.6 mm Hg, 11.8 mm Hg, respectively; all P -values <0.001). Small valve sizes of Evolut R, including 23 and 26, had higher echocardiographic mean gradient or peak gradient at the time of discharge compared with larger valves, including sizes 29 and 34 (11.1 mm Hg and 11.2 mm Hg vs. 10.2 mm Hg, 9.1 mm Hg) and 1-year follow-up (11.0 mm Hg, 11.0 mm Hg vs. 9.9 mm Hg, 8.4 mm Hg; all P -values = 0.001). Although Sapien 3 valves demonstrated a higher peak gradient in smaller sizes at discharge (18.44 mm Hg in size 23 vs. 17.9 mm Hg, 16.5 mm Hg in size 26 and 29, respectively; P = 0.001), the peak gradients did not show a statistically significant difference in the 1-year follow-up.

CONCLUSIONS

The current study detected significantly lower mean and peak gradients in Evolut R compared with Sapien 3 at all follow-up time points. Furthermore, smaller valve sizes were associated with significantly higher gradients at all follow-ups, regardless of the valve type.

Evaluating the pure effect of weight on cardiac function in patients with cardiac syndrome X

BACKGROUND

Obese patients have more coronary artery disease (CAD) risk factors that may affect myocardial function. We aimed to assess the ability of echocardiography-derived conventional parameters, left atrial strain, and global longitudinal strain to detect early diastolic and systolic dysfunction in obese individuals with almost no CAD risk factors.

METHOD

We studied 100 participants with structurally normal hearts, ejection fractions above 50%, almost normal coronary arteries in coronary angiogram (syndrome X), and no cardiovascular risk factor except dyslipidemia. Participants were classified as normal-weight (BMI < 25.0 kg/m² , n = 28) and high-weight (BMI ≥ 25.0 kg/m² , n = 72). Conventional echocardiographic parameters and two-dimensional speckle tracking (2DSTE) were used to measure peak LA strain and global longitudinal strain to evaluate diastolic and systolic function, respectively.

RESULT

There was no significant difference in the standard and conventional echocardiographic parameters between the two groups. 2DSTE echocardiographic parameters of the longitudinal deformation of the LV myocardium were not significantly different within the two groups. However, there were significant differences between the subjects with normal-weight and high-weight in terms of LA strain (34.51 ± 8.98% vs. 39.06 ± 8.62%, p = .021). The normal-weight group had lower LA strain, in compression with the high-weight group. All echocardiographic parameters were in the normal range.

CONCLUSION

In the present study we demonstrated that global longitudinal subendocardial deformations, for the evaluation of systolic function, and conventional echocardiographic parameters, for the evaluation of diastolic function, were not significantly different between normal- and high-weight groups. Although LA strain was higher among overweight patients, it was not above the normal range of diastolic dysfunction.

Cardiac imaging findings in anomalous origin of the coronary arteries from the pulmonary artery; narrative review of the literature

INTRODUCTION

Anomalous origin of the right coronary artery from the pulmonary artery (ARCAPA) is a rare coronary artery malformation with an incidence of 0.002% in patients undergoing coronary angiography. It can lead to an increased risk of myocardial infarction (MI) and sudden cardiac death, even in asymptomatic patients.

METHODS

We conducted a review of published cases of ARCAPA using PubMed and Scopus databases and included patients over 18 years old with adequate echocardiographic data.

RESULTS

We evaluated 28 patients with ARCAPA with a mean age of 42.8 from 1979 to 2021. Patients were diagnosed mostly by angiography and echocardiography, the most performed treatment was reimplantation (15, 53.6%) and the main echocardiographic findings were dilated coronary arteries (9, 32.1%), coronary collaterals (8, 28.6%), and retrograde flow from right coronary arteries to main pulmonary trunk (7, 25%).

CONCLUSION

Although ARCAPA is rare and not as deadly as the anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) still there is a chance of serious outcomes, therefore surgical treatment should be performed upon diagnosis. Angiography is the gold standard for diagnosis, but echocardiography can be a convenient, non-invasive, and most reliable method as the primary step whenever ARCAPA is suspected.

Mid to Long-Term Echocardiographic Follow-up of Patients Undergoing Transcatheter Tricuspid Valve-in-Valve Replacement for Degenerated Bioprosthetic Valves: First Single-Center Report from Iran

Background

Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran.

Methods

Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17±1.75 years.

Results

All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25±2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08±1.98 mm Hg to 5.29±1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00±49.46 ms to 158.64±57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91±7.31 mm Hg to 26.72±8.99 mm Hg, and left ventricular ejection fraction increased from 47.71±4.70% to 49.79±4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up.

Conclusion

This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results.

Transcatheter tricuspid valve-in-valve implantation with bioprosthetic balloon expandable valve

OBJECTIVES

This study was conducted to evaluate the outcome of the transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves with transcatheter aortic valves.

METHODS

This retrospective study enrolled all consecutive patients who were considered high risk for reoperations by the heart team and who underwent transcatheter valve-in-valve implantation for degenerated tricuspid bioprosthetic valves in Tehran Heart Center, Tehran, Iran. All the procedures were performed via the transfemoral venous route under echocardiography and fluoroscopy guidance with Edwards SAPIEN transcatheter heart valves (Edwards Lifesciences, Irvine, CA).

RESULTS

Ten patients underwent successful transcatheter valve-in-valve implantation in the tricuspid position without any major complications or need for emergency surgical interventions. The mean age was 54.1 ± 17.1 years, and 8 patients were female. The median follow-up was 19.5 months (16-32.25 mon). The mean period between the last tricuspid valve replacement and transcatheter valve-in-valve implantation was 4.9 ± 2.2 years. The bioprosthetic valves were Hancock in three patients, Mosaic in the other three patients, and Biocor, Pericarbon, Perimount, and Epic in the other patients. After the procedure, the clinical and functional status improved significantly in all the patients. The mean transvalvular gradient decreased from 6.75 ± 2.66 mm Hg to 2.85 ± 0.89 (P < 0.001), and the postoperative tricuspid regurgitation severity decreased significantly in almost all the patients. The hospitalization period after the procedure was 4.4 ± 1.7 days.

CONCLUSIONS

In high-risk patients, transcatheter valve-in-valve implantation seems to be a safe and minimally invasive alternative to reoperations for degenerated tricuspid bioprosthetic valves.

Assessment of Left Ventricular Function and Mitral Regurgitation Severity Early After Percutaneous Device Closure of the Atrial Septal Defect

BACKGROUND

Atrial septal defect (ASD) is one the most prevalent forms of congenital heart disease in adults. Closure of ASDs eliminates left-to-right shunt and reduces right heart volumes, but the effects of ASD closure, on the left ventricle (LV) and mitral valve competence are somewhat inconsistent. Therefore, we designed this study to evaluate the early effect of percutaneous closure of ASD on LV function and mitral regurgitation (MR) severity.

METHODS

In this prospective study, we enrolled 32 patients with ASD secundum who underwent percutaneous device closure in Tehran Heart Center. We used transthoracic and transesophageal echocardiography (TEE) before the procedure and TTE 24 hours after the procedure, then compared obtained LV parameters before and after the procedure.

RESULTS

LV end-diastolic diameter (LVEDD) increased significantly from 44.8 ± 2.4 to 45.8 ± 2.8 (P < 0.001). LV end-systolic diameter (LVESD) also increased but was statistically insignificant (P = 0.063) and LV ejection fraction (LVEF) remained nearly unchanged. Highest alteration was in right ventricular systolic pressure (12.4% decrease; P < 0.001) and mitral early Doppler/tissue Doppler velocity ratio (E/E') (9.7% increase; P = 0.010). The change in MR severity was insignificant using Wilcoxon signed-rank test (P = 0.157).

CONCLUSIONS

We concluded that systolic functions do not change immediately. However, LVEDD and E/E' will increase immediately, resulting from the passage of all blood from the LA into the LV in the early diastole just after closure. We also observed the positive effect of device closure on reducing right ventricular systolic pressure, and at least it does not worsen MR early after the procedure.

A Case of Isolated Bicuspid Pulmonic Valve and Pulmonary Artery Aneurysm

A 33-year-old woman with a history of thyroid surgery for thyroid cancer and radioactive iodine therapy was referred for echocardiography due to dyspnea on exertion. Transthoracic echocardiography showed normal left ventricular size and function (the ejection fraction = 55%), a prolapsing mitral valve with redundant chordae, mild mitral regurgitation, a tricuspid aortic valve, mild aortic insufficiency, and mild tricuspid regurgitation. The most remarkable echocardiographic findings were moderate right ventricular dilation with mild systolic dysfunction, moderate right atrial dilation, an aneurysmal pulmonary artery (the main pulmonary artery = 47 mm), mild pulmonary stenosis (the peak gradient = 22 mmHg), and severe pulmonary regurgitation (the vena contracta = 6–7 mm and the pressure half time = 105 ms). Transesophageal echocardiography with the use of 3D modalities demonstrated a bicuspid pulmonic valve with doming and poor coaptation of the pulmonic valve leaflets (Figure 1). Additionally, a large patent foramen ovale was visualized in color Doppler (the flap separation = 2 mm and the tunnel length = 11 mm) with bubble passage in agitated saline injection. Bicuspid pulmonic valves constitute a rare finding, and they are most often associated with other congenital heart diseases. Isolated bicuspid pulmonic valves are extremely rare, with an incidence rate of about 0.1% in clinical practice.1 Pulmonary artery aneurysms also comprise a rare abnormality, with an incidence rate of approximately 1 in 14 000 cases in most studies.2 The association between bicuspid pulmonic valves and pulmonary artery aneurysms has been reported, and the pathophysiologic causes of this association include hemodynamic alterations due to bicuspid pulmonic valves and most likely the abnormal migration of neural crest cells.3  The diagnosis of a bicuspid pulmonic valve by 2D imaging is challenging and sometimes impossible. Using 3D echocardiography and reconstruction confers a better assessment of the pulmonic valve morphology and identification of bicuspid pulmonic valves.

Epicardial and transverse sinus fat pad near left atrium appendage; role of 3D echocardiography

Pericardial fat pad in transverse sinus adjacent to left atrial appendage (LAA) is a rare condition that may resemble LAA thrombosis especially in suspected cases. More Trans-esophageal echocardiography (TEE) angulations and also 3D TEE images are helpful tools to confirm the diagnosis.

A pseudoaneurysm of the left atrium as a rare source of coronary artery embolization

A 67 years old woman with history of surgical Mitral valve replacement underwent transoesophageal echocardiography for evaluation of mild dyspnoea. It revealed a large narrow-necked outpouching from medial portion of the inferior wall of the left atrium (LA) that was extended to the interatrial septum. A diagnosis of the LA pseudoaneurysm was made. It contained a fresh clot. Five days later, the patient presented with an acute inferior ST-elevation myocardial infarction. Coronary angiography revealed an occluded right coronary artery at its distal part by a large thrombus. Thromboaspiration was done and resulted in restoration of a Thrombolysis in Myocardial Infarction Score (TIMI) flow 3 without underlying stenosis.

Prognostic role of moderate functional tricuspid regurgitation in length of hospitalization in patients undergoing isolated coronary artery bypass grafting

Functional tricuspid regurgitation (FTR) is defined as abnormal systolic tricuspid leakage with normal valve structures, and its prognostic role and management in patients with left-heart valve disease is well known. Due to paucity of data on FTR in patients with ischemic heart disease, the aim of our prospective study was to compare the prognostic effect of FTR between patients with moderate FTR and those with less-than-moderate FTR undergoing isolated coronary artery bypass graft (CABG) surgery. This prospective cohort study included all the patients who were candidate for isolated CABG and were referred for preoperative transthoracic echocardiography between April 2018 and November 2018. Patients were categorized into two groups: less-than-moderate FTR and moderate FTR. The endpoints of the study were the prognostic effect of FTR on short-term mortality and morbidities as a composite endpoint, as well as length of hospitalization, length of intensive care unit (ICU) stay, and ventilation time. Of a total of 410 patients, 363 patients (mean age = 62.4 years, 63.7% men) entered our final analysis. Logistic regression analysis demonstrated that composite endpoints of short-term mortality and morbidities was not significantly different between the two groups, but moderate FTR had a statistically significant effect on length of hospitalization (P = 0.002) and the ventilation time (P = 0.048). This effect, however, did not persist after adjustments for probable known confounders. Our study indicated no significant prognostic effect for preoperative FTR versus less-than-moderate FTR on short-term mortality and morbidities, as well as length of hospitalization, length of ICU stay, and the ventilation time.

Simultaneous Delivery of Wharton's Jelly Mesenchymal Stem Cells and Insulin-Like Growth Factor-1 in Acute Myocardial Infarction

Wharton's jelly mesenchymal stem cells (HWJMSCs) hold promise for myocardial regeneration, but optimal treatment regimen (preferably with a growth factor) is required to maximize functional benefits. The aim of this study was to explore the cardioprotective and angiogenesis effects of HWJMSCs combined with insulin-like growth factor-1 (IGF-1) in the treatment of acute myocardial infarction. The hydrogel consisted of Polyethylene glycol (PEG) and hyaluronic acid was prepared and characterized with regards to rheology, morphology, swelling, degradation, and release behaviors. To examine in-vivo effects, the hydrogels containing HWJMSCs either alone (Cells/hydrogel group) or with IGF-1 (Cells/hydrogel/IGF-1 group) were intra-myocardially injected into a rabbit myocardial infarction model. In-vivo efficacy was evaluated histological, immunohistochemical, echocardiography, scanning electron microscopy, and SPECT analyses. Eight weeks after infusion, the Cells/hydrogel and Cells/hydrogel/IGF-1 groups exhibited significantly increased left ventricular ejection fraction by echocardiography. Percent of ejection fraction was respectively 18.5% and 40% greater than control (P < 0.01). Vascular density (CD31 positive cells) of both treatment groups were more than the control group and this superiority was more remarkable in Cells/hydrogel/IGF-1 group. Cells/hydrogel/IGF-1 group showed the least defect size in SPECT analysis. Combinatory therapy with HWJMSCs and IGF-1 may additionally improve cardiac function and promote angiogenesis.

Regenerating Heart Using a Novel Compound and Human Wharton Jelly Mesenchymal Stem Cells

BACKGROUND

Myocardial infarction is a major problem in health system and most conventional therapy is not led to restoration of the health. Stem cell therapy is a method to regenerate the heart but today appropriate cell source and scaffold selection as extracellular matrix to achieve the best effect is disputing.

AIM OF THE STUDY

In this study a combination of human Wharton jelly mesenchymal stem cells (HWJMSCs) with a novel compound consisting polyethylene glycol (PEG), hyaluronic acid and chitosan is presented to heart regeneration.

METHODS

After proliferation and expansion of HWJMSCs, these cells were mixed with scaffold and injected into the infarcted rabbit myocardium. After two months cardiac function and infarcted area were evaluated. Immunohistochemistry performed for vessel count and demonstrating of differentiation ability into cardiomyocytes. To confirm this ability PCR was done. Scanning electron microscope was used to evaluate angiogenesis.

RESULTS

Improving cardiac function was higher in cell/scaffold group than the others and it was confirmed by SPECT results which showed least defect size in the myocardium. There were a lot of neoangiogenesis in the target group and also cardiomyogenesis observed in cell/scaffold group. PCR results confirmed the presence of differentiated cardiomyocytes and SEM showed well developed vessel in this group.

CONCLUSIONS

Comparing macroscopic and microscopic results between all groups revealed that HWJMSC in combination with this scaffold led to brilliant results regarding cardiac function, angiogenesis and cardiogenesis. It is recommended using these cells and materials for cardiac tissue engineering and regeneration therapy.

Early Improvement in Mitral Regurgitation after Cardiac Resynchronization Therapy in Cardiomyopathy Patients

BACKGROUND

The study aim was to investigate factors affecting the improvement of mitral regurgitation (MR) severity within 48 hours after cardiac resynchronization therapy (CRT) in patients with cardiomyopathy.

METHODS

Sixty-nine cardiomyopathy patients (48 males, 21 females; mean age 59.12 ± 9.66 years) in NYHA functional class ≥III, with left ventricular ejection fraction (LVEF) ≤35%, and QRS duration >120 ms, with MR ≥moderate, were included in the study. Conventional echocardiography was performed before and within 48 h after CRT, and all patients underwent tissue Doppler imaging prior to CRT. Improved MR was defined as a reduction of at least one grade in MR severity.

RESULTS

After CRT, 49 patients (71%) showed MR improvement but 20 (29%) had no MR improvement. The mean MR severity grade was reduced significantly, from 2.70 ± 0.77 before CRT to 1.90 ± 0.94 after CRT (p<0.001). The group with improved MR had a significantly higher rate of left bundle branch block (75.5% versus 45%; p = 0.015), a higher QRS duration (172.00 ± 31.98 versus 147.25 ± 28.75 ms; p = 0.001), a higher median septal lateral delay (70 versus 35 ms, p = 0.035), and a higher median anteroseptal to posterior-wall delay by M mode (200 versus 130 ms, p = 0.041). Older age, longer QRS duration, and septallateral delay remained significant independent predictors of MR improvement. A greater proportion of patients with improved MR showed ≥5% increase in LVEF (55.1% versus 30.0%, p = 0.058).

CONCLUSIONS

CRT acutely reduced the severity of functional MR in the majority of cardiomyopathy patients. Those patients with improved MR showed a higher frequency of ≥5% increase in LVEF after CRT. Older age, longer QRS duration, and septallateral delay were independent predictors of MR improvement after CRT.

Effects of Endothelial and Mesenchymal Stem Cells on Improving Myocardial Function in a Sheep Animal Model

Background: Myocardial infarction is the main cause of death worldwide. Angiogenesis, a promising new therapy for the treatment of diffuse coronary artery disease, shows a poor response to conventional revascularization techniques. This study focused on improving myocardial function using endothelial cells (ECs) and mesenchymal stem cells (MSCs) in a sheep animal model. Methods: Acute myocardial infarction was induced in 18 sheep (12 treated cases and 6 controls). Autologous MSCs and ECs were injected in the infarcted area and the border zone. Two months after transplantation, echocardiography, electron microscopy, and immunohistochemistry were performed. Results: Echocardiography in both MSC and EC groups revealed a significant improvement in the ejection fraction compared with the control group (p value < 0.05). Vascular density, estimated by antibodies against the von Willebrand factor and smooth muscle actin, increased in both study groups. The pattern of vascularity in the MSC and EC groups was diffused. The electron microscopic evaluation of the infracted areas revealed cardiomyocytes in variable stages of development in the border zone in both EC and MSC groups. Conclusion: Both ECs and MSCs were able to promote angiogenesis and improve cardiac function. Presumably, MSCs differentiate into ECs and cause angiogenesis as it occurs for ECs.

Association between Latest Activated Sites in the Left Ventricle and Akinetic Segments in Patients with Ischemic Cardiomyopathy

Background: It is not clear whether the latest activation sites in the left ventricle (LV) are matched with infracted regions in patients with ischemic cardiomyopathy (ICM). We aimed to investigate whether the latest activation sites in the LV are in agreement with the region of akinesia in patients with ICM. Methods: Data were analyzed in 106 patients (age = 60.5 ± 12.1 y, male = 88.7%) with ICM (ejection fraction ≤ 35%) who were refractory to pharmacological therapy and were referred to the echocardiography department for an evaluation of the feasibility of cardiac resynchronization therapy. Wall motion abnormalities, time to peak systolic myocardial velocity (Ts) of 6 basal and 6 mid-portion segments of the LV, and 4 frequently used dyssynchrony indices were measured using 2-dimensional echocardiography and tissue Doppler imaging (TDI). To evaluate the influence of the electrocardiographic pattern, we categorized the patients into 2 groups: patients with QRS ≤ 120 ms and those with QRS >120 ms. Results: A total of 1 272 segments were studied. The latest activation sites (with longest Ts) were most frequently located in the mid-anterior (n = 32, 30.2%) and basal-anterior segments (n = 29, 27.4%), while the most common sites of akinesia were the mid-anteroseptal (n = 65, 61.3%) and mid-septal (n = 51, 48.1%) segments. Generally, no significant concordance was found between the latest activated segments and akinesia either in all the patients or in the QRS groups. Detailed analysis within the segments indicated a good agreement between akinesia and delayed activation in the basal-lateral segment solely in the patients with QRS duration ≤ 120 ms (Φ = 0.707; p value ≤ 0.001). Conclusion: The akinetic segment on 2-dimensional echocardiogram was not matched with the latest activation sites in the LV determined by TDI in patients with ICM.

Percutaneous aortic valve implantation in bicuspid aortic valve: A case report

BACKGROUND

Transcatheter aortic valve implantation (TAVI) was known as an alternative technique for treatment of severe aortic stenosis (AS). This technique is controversial in bicuspid aortic valve (BAV). Here, we report TAVI for severe AS in a BAV setting in a patient with serious lung disease.

CASE REPORT

A 68-year-old woman with a history of coronary artery bypass graft, BAV and severe AS, asthma, who had repeatedly denied any suggestion for open heart surgery, was our volunteer candidate for TAVI. The peak and mean pressure gradient decreased from 53 and 43 mm Hg to 13and 6 mm Hg respectively.

CONCLUSION

TAVI could be a viable option for highly selected patients with AS and BAV who have a prohibitive risk for open heart surgery.

Percutaneous Mitral Valve Repair with the Edge-to-Edge Technique: Case Series of First Iranian Experience

Mitral regurgitation (MR) is a common valvular lesion in the general population with considerable impact on mortality and morbidity. The MitraClip System (Abbot Laboratories, Abbot Park, IL, USA) is a novel percutaneous approach for treating MR which involves mechanical edge-to-edge coaptation of the mitral leaflets. We present our initial experience with the MitraClip System in 5 patients. In our series, the cause of MR was both degenerative and functional. Two patients received two MitraClips due to unsatisfactory results after the implantation of the first clip. Acute procedural success was seen in 4 patients. Blood transfusion was required for 2 patients. All the patients, except one, reported improvement in functional status during a 2-month follow-up period. Our initial experience with MitraClip implantation indicates that the technique seems feasible and promising with acceptable results and that it could be offered to a broader group of patients in the near future.

Evaluation of in-hospital NT-proBNP changes in heart failure patients to identify the six-month clinical response following cardiac resynchronization therapy

N-terminal pro β-type natriuretic peptide (NT-proBNP) is a valuable marker for monitoring the response to treatment in patients with heart failure. Based on the clinically observed improvement of heart failure symptoms early after cardiac resynchronization therapy (CRT), we sought to investigate whether CRT induce any significant reduction in the plasma level of NT-proBNP in three days after implantation and whether it is correlated with patients' response at six months. In this prospective study, 21 consecutive patients with severe heart failure (New York Heart Association class 3.19±0.40) who underwent CRT were enrolled. Being alive, no hospitalization due to decompensated heart failure, and improvement of at least one NYHA functional class at six months were classified as clinical responsiveness. The plasma level of NT-proBNP was measured before, three days, and six months after CRT. Clinical evaluation, echocardiographic study, and six-minute walking test were performed before and six months after the procedure. At six months' follow-up, 16 (76.2%) patients were responders. The plasma level of NT-proBNP at three days after CRT increased almost equally in both responder and non-responder groups of patients (∆NT-proBNP was 40.94±135.74 vs. 54.80±88.98); however, at six months' follow-up, the NT-proBNP changes statistically differed across the two groups of patients (P=0.005). According to our findings, NT-proBNP percent deviation from baseline to three days after CRT appears to be not correlated with the patients' clinical response after six months, which was incongruent to the patients' clinical improvement after CRT.

Correlation between systolic deformation and dyssynchrony indices and the grade of left ventricular hypertrophy in hypertensive patients with a preserved systolic ejection fraction undergoing coronary angiography, based on tissue Doppler imaging

OBJECTIVES

The purpose of this study was to investigate whether systolic mechanical dyssynchrony occurs in hypertensive patients with a normal coronary artery and a normal ejection fraction and its relationship with different degrees of left ventricular (LV) hypertrophy.

METHODS

A total of 125 angiographically normal coronary patients (42.4% male; mean age ± SD, 57.16 ± 8.26 years) with an ejection fraction greater than 50% were included, of which 84 were hypertensive and 41 normotensive. The hypertensive patients were categorized into 3 groups: no, mild, and moderate LV hypertrophy. Tissue Doppler and deformation imaging parameters were measured in the 6 LV basal segments at peak systole.

RESULTS

The frequency of dyssynchrony was 40.5% in the hypertensive patients compared to 19.5% in the control patients (P = .020). Among the hypertensive patients, LV dyssynchrony was found in 5 patients (20%) with no hypertrophy, 20 (42.6%) with mild hypertrophy, and 9 (75%) with moderate hypertrophy. There was a moderate correlation between the grade of hypertrophy and septal-lateral wall delay (r = 0.497), 6-basal segment delay (r = 0.454), overall strain (r = 0.453), overall peak systolic velocity (r = -0.430), and standard deviation of the time to peak systolic velocity in the basal segments (r = 0.429). After adjustment for the LV end-systolic diameter and body surface area, overall strain was the best correlate of the hypertrophy grade (odds ratio, 7.043; 95% confidence interval, 1.839-26.980; P = .0044).

CONCLUSIONS

Among tissue Doppler and deformation indices, overall peak systolic strain was the strongest correlate of the LV hypertrophy grade. Therefore, in hypertensive patients with normal cardiac systolic function, a reduction in overall strain in the 6 basal LV segments may be a good indicator of progression of the LV hypertrophy grade and systolic dysfunction.

Correlation between Mitral Regurgitation and Myocardial Mechanical Dyssynchrony and QRS Duration in Patients with Cardiomyopathy

BACKGROUND

Several competing geometric and hemodynamic factors are suggested as contributing mechanisms for functional mitral regurgitation (MR) in heart failure patients. We aimed to study the relationships between the severity of MR and the QRS duration and dyssynchrony markers in patients with ischemic or dilated cardiomyopathy.

METHODS

We prospectively evaluated 251 heart failure patients with indications for echocardiographic evaluation of possible cardiac resynchronization therapy. All the patients were subjected to transthoracic echocardiography and tissue Doppler imaging to evaluate the left ventricular (LV) synchronicity. The patients were divided into two groups according to the severity of MR: ≤ mild MR and ≥ moderate MR. The effects of different dyssynchrony indices were adjusted for global and regional left ventricular remodeling parameters.

RESULTS

From the 251 patients (74.5% male, mean age = 53.38 ± 16.68 years), 130 had ≤ mild MR and 121 had ≥ moderate MR. There were no differences between the groups regarding the mean age, frequency of sex, and etiology of cardiomyopathy. The LV systolic and diastolic dimensions were greater in the patients with ≥ moderate MR (all p values < 0.001). Among the different echocardiographic factors, the QRS duration (150.75 ± 34.66 vs. 126.77 ± 29.044 ms; p value = 0.050) and interventricular mechanical delay (41.60 ± 29.50 vs. 35.00 ms ± 22.01; p value = 0.045) were significantly longer in the patients with ≤ mild MR in the univariate analysis. After adjusting the effect of these parameters on the severity of MR for the regional and global LV remodeling parameters, no significant impact of the QRS duration and dyssynchrony indices was observed.

CONCLUSION

Our results showed that the degree of functional MR was not associated with the QRS duration and inter- and intraventricular dyssynchrony in our patients with cardiomyopathy. No association was found between the severity of MR and the ischemic or dilated etiology for cardiomyopathy.

Sex-related changes in tissue Doppler imaging parameters among patients with acute pulmonary thromboembolism

OBJECTIVES

There are few studies evaluating serial changes in tissue Doppler imaging parameters in acute pulmonary thromboembolism. We aimed to compare these changes in male and female patients separately.

METHODS

Between September 2010 and September 2011, 41 of 64 hemodynamically stable acute patients with pulmonary thromboembolism were included in the study. Twenty-two healthy individuals served as a control group.

RESULTS

Compared to the control group, the acute pulmonary thromboembolism group had a lower tricuspid annular plane systolic excursion, basal peak systolic velocity of the tricuspid valvular annulus, right ventricular (RV) peak systolic strain, and RV peak systolic strain rate and a higher RV diameter, peak systolic pulmonary artery pressure, and RV myocardial performance index (P < .05). Values for these parameters were not different between men and women in the patient group. In men, compared to admission, predischarge echocardiography showed significant improvement in the tricuspid annular plane systolic excursion (mean ± SD, 16.08 ± 4.33 versus 19.29 ± 3.74 mm; P = .002), basal tricuspid annular peak systolic velocity (10.11 ± 3.66 versus 11.66 ± 3.38 cm/s; P = .007), and peak systolic strain (-13.00% ± 14.99% versus -23.20% ± 10.23%; P = .001), whereas in women, predischarge and 3-month follow-up echocardiography showed marked improvement in the tricuspid annular plane systolic excursion (17.50 ± 4.88 versus 19.79 ± 5.58 mm; P = .021) and peak systolic strain (-15.70% ± 13.52% versus -21.01% ± 10.57%, respectively; P= .045). Female patients did not show improvement in these parameters during hospitalization.

CONCLUSIONS

Patterns of changes in the RV function over time during a 3-month follow-up might differ between male and female patients with acute pulmonary thromboembolism, and the recovery process could be slower in women. Moreover, the midventricular peak systolic strain might be useful for serial evaluation of the recovery process.

Endovascular treatment of acute type B dissection complicating aortic coarctation

Surgical treatment poses a high risk to patients with concomitant aortic coarctation and dissection, and an interventional approach could be an alternative. We describe the case of a 52-year-old man with a long history of untreated hypertension and aortic coarctation who emergently presented at our institution with an acute Stanford type B dissection. The patient's elevated serum creatinine level, perfusion deficit in the right lower limb, and hypertension did not respond to medical therapy, and he did not consent to surgery. By endovascular means, we used a self-expandable stent-graft to cover the entry point of the dissection; then, we deployed a balloon-expandable bare-metal stent to correct residual stenosis. To our knowledge, this is the first report of the endovascular treatment of aortic coarctation complicated by type B dissection.

Late diagnosis of large left ventricular pseudoaneurysm after mitral valve replacement and coronary artery bypass surgery by real-time three-dimensional echocardiography

One of the most serious complications of mitral valve replacement is left ventricular rupture and pseudoaneurysm formation, which is rare but potentially lethal. We herein present a late type of post mitral valve replacement and coronary artery bypass surgery pseudoaneurysm in a 74-year-old female, who was admitted to our hospital with a recent history of exertional dyspnea. She had the above-mentioned operation 10 months before. The diagnosis was made via two-dimensional and real-time three-dimensional transthoracic echocardiography. The prosthetic mitral valve was removed, and the large orifice of the pseudoaneurysm was closed by surgery. At one year's follow-up, the patient was in good condition.

Post-traumatic chordae rupture of tricuspid valve

Blunt injury to the chest can affect any one or all components of the chest wall and thoracic cavity. The clinical presentation of patients with blunt chest trauma varies widely and ranges from minor reports of pain to florid shock. Traumatic tricuspid valve regurgitation is a rare cardiovascular complication of blunt chest trauma. Tricuspid valve regurgitation is usually begotten by disorders that cause the right ventricle to enlarge. Diagnosis is made by physical examination findings and is confirmed by echocardiography. We report two cases of severe tricuspid regurgitation secondary to the rupture of the chordae tendineae of the anterior leaflet following non-penetrating chest trauma. Both patients had uneventful postoperative courses.

Atrial standstill: a rare case

We introduce a 32-year-old man who was evaluated for a dizziness and headache of unknown origin for at least two months and was referred to our center after ECG findings. He was finally diagnosed as a case of idiopathic, familial, diffuse, persistent atrial standstill, which is a rare arrhythmogenic condition characterized by the absence of electrical and mechanical activity in the atria. He successfully received a single-chamber permanent pacemaker.

Measurement of Atrial Septal Defect Size: A Comparative Study between Transesophageal Echocardiography and Balloon Occlusive Diameter Method

BACKGROUND

Transcatheter closure of atrial septal defect secundum (ASD-II) has become an alternative method for surgery. We sought to compare the two-dimensional transesophageal echocardiography (TEE) method for measuring atrial septal defect with balloon occlusive diameter (BOD) in transcatheter ASD-II closure.

METHODS

A total of 39 patients (71.1% female, mean age: 35.31 ± 15.37 years) who underwent successful transcatheter closure of ASD-II between November 2005 and July 2008 were enrolled in this study. Transthoracic echocardiography (TTE) and TEE were performed to select suitable cases for device closure and measure the defect size before the procedure, and BOD measurement was performed during catheterization via TEE. The final size of the selected device was usually either equal to or 1 - 2 mm larger than the BOD of the defect.

RESULTS

The mean defect size obtained by TEE and BOD was 18.50 ± 5.08 mm and 22.86 ± 4.76 mm, respectively. The mean difference between the values of ASD size obtained by TEE and BOD was 4.36 ± 2.93 mm. In comparison with BOD, TEE underestimated the defect size in 94.9%, but TEE value being equal to BOD was observed in 5.1%. There was a good linear correlation between the two measurements: BOD = 0.773 × ASD size by TEE+8.562; r2 = 67.9.1%. A negative correlation was found between TEE sizing and the difference between BOD and TEE values (r = -0.394, p value = 0.013).

CONCLUSION

In this study, BOD was larger than ASD size obtained by two-dimensional TEE. However, TEE maximal defect sizing correlates with BOD and may provide credible information in device size selection for transcatheter ASD closure.

Tricuspid regurgitation improvement in relation to the amount of pulmonary artery pressure reduction

BACKGROUND

Given the common concomitance of tricuspid regurgitation (TR) with significant mitral stenosis, we aimed at exploring the relation between TR severity and pulmonary artery hypertension (PAH) in patients who underwent mitral balloon valvotomy (MBV).

METHODS

We analyzed the echocardiography data of 133 consecutive patients (82.0% female, mean age 44.68 ± 12.56 years) with different degrees of TR severity that underwent MBV between April 2006 and March 2008. The pulmonary artery systolic pressure (PAPs) > 35 mmHg was considered as PAH.

RESULTS

Before MBV, 36.20% of the patients had moderate to severe TR, 92.5% PAH, and 18.0% right ventricular (RV) dilation (RV dimension ≥ 33 mm). After MBV, TR severity improved in 41.4%, worsened in 8.3%, and did not change in 50.4%. Before and after MBV, PAPs was significantly correlated with TR severity, and the mean PAPs change in patients with improved TR was significantly more than that of patients without TR improvement (p value = 0.042). Tricuspid regurgitation severity and mean PAPs (from 52.83 ± 18.82 to 35.89 ± 9.39 mmHg) decreased significantly after MBV (both p values < 0.001); this reduction was significantly correlated to the amount of PAPs decrease. A cut-off point of ≥ 19 mmHg reduction in PAPs had a specificity of 71.79% and sensitivity of 52.73% to show TR severity improvement (by Receiver-Operative-Characteristics analysis). The mean of RV dimension decreased from 28.94 ± 5.43 to 27.95 ± 4.67 mm (p value < 0.001). In contrast to patients with RV dilation, TR reduced significantly in patients without RV dilation (p value < 0.001).

CONCLUSION

Improvement in TR severity was directly correlated with the amount of PAPs reduction after MBV. More studies are needed to better define a cut-off value for PAPs reduction related to TR severity improvement.

Floating thrombus in the aortic arch as an origin of simultaneous peripheral emboli

Few cases of a floating thrombus in a normal aorta have been reported without other underlying reasons for the thrombus formation and its systemic embolic complications. We report a case in which a floating thrombus in the proximal aortic arch was detected after echocardiography and computed tomography angiography as an origin of upper extremities and ophthalmic embolism.

Inflammatory myofibroblastic tumor of the right ventricle causing tricuspid valve regurgitation

Cardiac inflammatory myofibroblastic tumor is a rare lesion consisting of inflammatory cells and myofibroblastic spindle cells. We describe a case of inflammatory myofibroblastic tumor that involved the right ventricle, thereby causing tricuspid valve regurgitation in an 18-year-old man who presented with a fever of unknown origin and of 1 month's duration. With the patient on cardiopulmonary bypass, we excised the lesion and replaced the tricuspid valve without serious intraoperative or postoperative sequelae. The patient had a favorable outcome.

Development of an ovine model of myocardial infarction

BACKGROUND

We report experimental myocardial infarction by occluding coronary arteries in ovine models.

METHODS

Twelve ewes were included in the study. After the chest was opened by left lateral thoracotomy incision, the second diagonal branch of the left anterior descending coronary artery was ligated at a point approximately 40% distant from its base. Prophylactic anti-arrhythmics were given. Animals were mechanically ventilated during surgery and stayed in intensive care unit for 24 h postoperation. Experiments were then evaluated by echocardiographic, electrocardiographic, haemodynamic, serological and morphological investigations. Echocardiographic measurements were repeated after 2 months and animals were then killed for post-mortem cardiac examinations.

RESULTS

All animals survived the surgical procedure. Cyanotic discoloration and hypokinesia in the cardiac tissue in an area of (30 +/- 2) x (4 +/- 2) mm plus ST-segment elevations was detected immediately after vessel ligation. Moreover, there were pathological Q-waves 2 months later. Echocardiographic evaluations showed an average of 30% relative decrease in cardiac ejection fraction. Wall motion analysis showed anteroseptal hypokinesia and akinesia in all animals 1 day and 2 months after operation, respectively. Thin-walled infarcted areas with tissue fibrosis were evident in pathological investigations 2 months after surgery.

CONCLUSION

In conclusion, we developed a practical and safe method for producing myocardial infarction in large animal models.

A Rare Cause of Chronic Mitral Regurgitation: Perivalvular Ventriculoatrial Fistulous Communication from Remote Blunt Chest Trauma

We report a rare case of a 31-year-old man with chronic severe mitral regurgitation as a result of perivalvular ventriculoatrial fistulous communication with a history of remote blunt chest trauma at age 19 to 20 years who underwent successful surgical repair. Mitral regurgitation after blunt trauma is usually secondary to rupture of the chordae tendinae or papillary muscles and perivalvular regurgitation is a very rare event especially after remote blunt chest trauma. We present a case with severe mitral regurgitation secondary to remote blunt chest trauma as a result of perivalvular ventriculoatrial fistulous communication.

The similar effect of transplantation of marrow-derived mesenchymal stem cells with or without prior differentiation induction in experimental myocardial infarction

Marrow-derived mesenchymal stem cells (MSCs) have been heralded as a source of great promise for the regeneration of the infarcted heart. There is no clear data indicating whether or not in vitro differentiation of MSCs into major myocardial cells can increase the beneficial effects of MSCs. The aim of this study is to address this issue. To induce MSCs to transdifferentiate into cardiomyocyte-like and endothelial-like cells, 5-azacytidine and vascular endothelial growth factor (VEGF) were used, respectively. Myocardial infarction in rabbits was generated by ligating the left anterior descending coronary artery. Animals were divided into three experimental groups: I, control group; II, undifferentiated mesenchymal stem cell transplantation group; III, differentiated mesenchymal stem cell transplantation group; which respectively received peri-infarct injections of culture media, autologous undifferentiated MSCs and autologous differentiated MSCs. General pathology, immunohistochemistry, electron microscopy and echocardiography were performed in order to search for myocardial regeneration and improvement of cardiac function. In Groups II and III, implanted cells transdifferentiate into myocardial cells within 28 days post injection in a similar manner, and well-developed ultra structures formed within transplanted cells. Improvements in left ventricular function and reductions in infarcted area were observed in both cell-transplanted groups to the same degree. Vascular density was similar in Groups II and III and significantly higher in these groups compared with the control group. There is no need for prior differentiation induction of marrow-derived MSCs before transplantation and peri-infarct implantation of MSCs can efficiently regenerate the infarcted myocardium and improve cardiac function.