The Journal of Tehran University Heart Center

Integrating Echocardiographic Findings to Improve Diagnostic and Prognostic Assessments in Moderate Aortic Valve Stenosis: A Comprehensive Review

Mohammad Sahebjam — 2024-07-31

Aortic valve stenosis (AS) is the most common valvular heart disease in developed countries, with its prevalence on the rise due to aging populations. While severe AS has long been recognized as high-risk, recent studies have shed light on the significant association between moderate AS and cardiovascular morbidity and mortality. Yet, the data are still inconclusive. With noninvasive multi-modality imaging techniques advancing rapidly, we now have more insight into the underlying biology of AS. Echocardiography continues to serve as the primary noninvasive imaging modality for diagnosing and grading AS. This comprehensive review delves into the role of echocardiography in diagnosing moderate AS and how the findings can support clinicians in making well-informed decisions that impact patients’ prognoses.

The Effects of Albumin 20% and Hydroxyethyl Starch 6% on Bleeding and Interleukin-6 Levels as Priming Solutions for Cardiopulmonary Bypass: A Randomized Controlled Trial

Alireza Hosseini — 2024-07-31

Background: Cardiopulmonary bypass (CPB) can adversely affect coagulation and systemic inflammatory response. Given that the optimal strategy for priming CPB in cardiac surgery remains a matter of debate, this study aimed to investigate the effects of albumin 20% and hydroxyethyl starch 6% as priming solutions on bleeding and interleukin-6 (IL-6) levels during CPB.
Methods: This randomized clinical trial involved 40 patients undergoing coronary artery bypass surgery at Shahid Chamran Hospital between July 2021 and July 2022. Participants were assigned to 2 groups: the first group received 50 mL of albumin 20% as the priming solution for the CPB circuit, while the second group received 500 mL of hydroxyethyl starch 6%. Bleeding and IL-6 levels were assessed before and after the intervention.
Results: The albumin group comprised 80.0% men and 20.0% women, with a mean age of 66.45±5.84 years. The hydroxyethyl starch 6% group consisted of 85.0% men and 15.0% women, with a mean age of 63.05±5.92 years (P>0.05). The findings revealed that 12 hours after CPB, the IL-6 level in the hydroxyethyl starch 6% group (mean: 171.6±77.71 pg/mL) was significantly higher than that in the albumin group (mean: 105.8±36.45 pg/mL; P=0.002). At 48 hours after CPB, the mean bleeding was not significantly different between the groups (P=0.950).
Conclusion: Albumin 20% was more effective than hydroxyethyl starch 6% concerning IL-6 levels. However, no significant differences in bleeding were observed between the groups at 48 hours post-CPB.

Protocol for a Randomized Controlled Trial on the Development and Effectiveness of an Educational Mobile Application Using an Integrated Change Model to Prevent Atherosclerotic Cardiovascular Disease Risk Factors

Afsaneh Aein — 2024-07-31

Background: An effective approach to preventing cardiovascular issues is the use of mobile health applications to improve modifiable risk factors. This protocol for a randomized controlled trial aims to evaluate the development and effectiveness of an educational mobile app that employs an integrated change model to reduce risk factors for atherosclerotic cardiovascular disease (ASCVD) among individuals aged 20 to 69 years.
Methods: This study will be a parallel, randomized, single-blind clinical trial utilizing the randomized block design involving 430 participants. The participants will be divided into a control group receiving standard clinical care and an intervention group receiving standard clinical care along with app-based education, over approximately 6 months.
Conclusion: This application has been designed to enhance motivation, awareness, and positive habits to reduce risk factors in individuals at increased risk of ASCVD. Consequently, the results could improve cardiovascular health knowledge, manage biological risk factors, and modify cardiac behaviors through mobile applications. This research is expected to present a promising approach to utilizing mobile apps for managing cardiovascular health and contribute to the growing body of research on digital health interventions.

The Effect of Traditional Iranian Music on Anxiety and Physiological Parameters of Patients before Coronary Artery Bypass Graft (CABG): A Randomized Controlled Trial

Samereh Rasoli — 2024-07-31

Background: Coronary artery bypass graft (CABG) surgery is a primary treatment for coronary artery occlusion. Anxiety is a common preoperative concern among patients undergoing this procedure. This study aimed to investigate the effect of listening to traditional Iranian music on anxiety in patients before CABG surgery. Methods: This randomized controlled trial involved 66 patients scheduled for CABG surgery. Patients were randomly assigned to either the control or intervention group, with 33 patients in each group. The intervention group listened to traditional music on an MP3 player for 20 minutes, while the control group received an MP3 player without music. Anxiety levels were measured using the Spielberger Anxiety Questionnaire before and after the intervention. Data were analyzed using the Student’s t-test, the paired t-test, and the Mann-Whitney U-test with SPSS software version 21.
Results: There was no significant difference in anxiety severity between the 2 groups before the intervention (music group: 106.45±10.67 and control group: 116.36±9.78; P=0.798). However, after the intervention, there was a significant difference between the groups (music group: 65.82±7.54 vs control group: 113.72±13.04; P=0.001). There were no significant differences in physiological parameters (blood pressure, heart rate, and respiration rate) between the groups before the intervention (P<0.078). Following the intervention, systolic (P<0.013) and diastolic (P<0.003) blood pressure significantly decreased in the intervention group compared with the control group.
Conclusion: Traditional Iranian music therapy can be a noninvasive, low-cost, and accessible tool to reduce anxiety in patients undergoing CABG surgery.

The Demographic and Lifestyle Char-acteristics of Patients with Familial Hypercholesterolemia Referred to a Dyslipidemia Clinic: A Cross-Sectional Single-Center Study

Maryam Moshkani Farahani — 2024-07-31

Background: Familial hypercholesterolemia (FH) is one of the most prevalent dyslipidemia disorders. This study investigated the demographic and lifestyle characteristics of patients with FH referred to a dyslipidemia clinic.
Methods: This 5-year, single-center cross-sectional study focused on patients with low-density lipoprotein cholesterol (LDL-C) levels higher than 190 mg/dL referred to a dyslipidemia clinic in Tehran, Iran, between 2017 and 2022. The study examined their demographics, physical activity, and anxiety within the FH cohort.
Results: A total of 1724 patients were referred to the dyslipidemia clinic. Of these patients, 44 were diagnosed with definite FH. The mean age and LDL-C level of the FH cohort were 38.84±16.85 years and 315.95±81.73 mg/dL, respectively. A significant correlation was found between LDL-C and body mass index (BMI) (correlation coefficient = -0.31, P=0.031) and total sleep duration (correlation coefficient = -0.40, P<0.000). No correlation was observed between age and physical activity or LDL-C levels. Additionally, no significant correlation was detected between the Dutch score and patients’ LDL-C, BMI, age, or physical activity. Regression analysis indicated that BMI and total sleep duration were independent predictors of LDL-C in the FH cohort.
Conclusion: Investigating and identifying patients’ demographic and lifestyle characteristics is the first step in planning efficient and effective management strategies for chronic diseases, such as FH. Establishing a patient registry for chronic diseases enhances understanding of the target population and enables healthcare providers to design and implement appropriate preventive and control strategies.

Conditioned Medium from Human Amniotic Membrane-Derived Mesenchymal Stem Cells Modulates Inflammatory and Myofibrotic Factors in Vivo

Gazaleh Asgharnezhad — 2024-07-31

Background: Heart failure (HF) is a prevalent diagnosis with a significant mortality rate. Various therapeutic approaches exist for treating HF, and human adipose-derived mesenchymal stem cells-conditioned medium (hAMSCs-CM) therapy has emerged as a promising option. Despite its potential efficacy, the precise mechanism of action underlying hAMSCs-CM treatment remains unclear. To address this knowledge gap, we conducted a novel animal study to investigate the mechanism of action of hAMSCs-CM in an HF model, with a specific focus on transforming growth factor-β (TGF-β)/galectin-3, monocyte chemoattractant protein-1 (MCP1), B-type natriuretic peptide (BNP), and aldosterone (ALD).
Methods: Forty adult male Wistar rats were divided into 4 groups: control, HF, culture medium, and CM. All rats, except those in the control group, received an injection of isoproterenol to induce an animal model of HF. The CM group was administered the CM, while those in the culture medium group received standard culture media. Subsequently, serum levels of fibrotic factors, including TGF-β/galectin-3, MCP1, BNP, and ALD, were measured using ELISA. Statistical analysis was performed using one-way analysis of variance and the Tukey test.
Results: Serum levels of TGF-β/galectin-3, MCP1, BNP, and ALD were significantly elevated in the HF, CM, and culture medium groups compared with the control group (P<0.001). Additionally, these fibrotic factors were significantly reduced in the CM group compared with the HF group (P<0.001). Notably, CM therapy could not restore TGF-β/galectin-3, MCP1, BNP, or ALD levels to the normal range observed in the control group.
Conclusion: Our findings indicate that hAMSCs-CM modulates the expression of inflammatory and fibrotic cytokines, such as TGF-β/galectin-3, MCP1, BNP, and ALD, in isoproterenol-induced HF in male rats. These results contribute to a better understanding of the therapeutic mechanisms underlying hAMSCs-CM treatment for HF.

Concurrent Myocardial Bridging and Coronary Artery Disease: A Study of an Iranian Population

Danial Chaleshi — 2024-07-31

Background: Myocardial bridging (MB) has been associated with acute coronary syndrome, ischemia, arrhythmia, and even sudden death. This study investigated the prevalence of MB and its complications and manifestations.
Methods: This cross-sectional study was conducted on symptomatic coronary patients who underwent angiography between March 2022 and March 2023 at Afshar or Shahid Sadoughi hospitals in Yazd, Iran. The angiographic reports of all patients were evaluated. Cases with MB were selected, and their angiographic films were assessed by an interventional cardiologist for diagnostic accuracy. Baseline, radiological, and clinical characteristics were also evaluated. Data were collected and analyzed using SPSS, version 20.0. The dependent variable was stratified based on independent variables using the χ²test.
Results: Out of 3750 symptomatic patients, 165 (4.4%) were diagnosed with MB. Among these, 111 (67.3%) were male, and the mean age was 56.87±10.06 years. A total of 152 patients had MB in the left anterior descending artery, representing the highest occurrence proportion at 92.1%. The most common types of coronary artery disease (CAD) diagnosed included mono-vessel disease and slow flow, accounting for 35.1% and 25.8%, respectively. There was no significant frequency distribution of CAD co-occurrence based on baseline and radiological features (P>0.050).
Conclusion: This study provides valuable insights into the prevalence of MB in Iran and its co-occurrence with CAD. While some findings align with previous research, certain discrepancies warrant further investigation.

Interventional Management of a Rare Case of Complex Congenital Heart Disease in an Adult Patient: A Case Report

Maryam Favaedi — 2024-07-31

Congenital heart disease (CHD), which accounts for about one-third of all congenital birth defects and affects about 1% of all live births worldwide, has had a stable incidence rate and decreased mortality rate since 1990. Despite advances in fetal cardiac ultrasound examinations and routine pulse oximetry screening of newborns, a considerable proportion of patients with CHD may still be missed until adulthood, leading to major morbidity and mortality due to physical limitations and reduced quality of life.
We herein describe a 29-year-old woman who was mistaken as an inoperable case of CHD and referred to our center with palpitation and exertional dyspnea. During workups, she was diagnosed with severe pulmonary hypertension associated with patent ductus arteriosus (PDA), pre-ductal aortic coarctation, ventricular septal defect (VSD), and bicuspid aortic valve, all of which had been missed from infancy. After initial medical treatment for pulmonary hypertension, a simultaneous transcatheter approach was selected, whereby the PDA was closed with an occluder device, and the coarctation was repaired simultaneously with a self-expanding stent. Eight months later, her VSD was closed successfully via an interventional technique using a muscular VSD occluder device.
This case highlights the significance of adult CHD fellowship training. A cardiologist specialized in this field was able to properly diagnose and treat an adult with complex CHD, which had been overlooked since infancy. As a result, the patient experienced complete relief from her symptoms and was saved from developing Eisenmenger syndrome.

Tracheostomy Cuff Herniation Following Cardiac and Pulmonary Arrest

Yasmin Chaibakhsh — 2024-07-31

Tracheostomy is a widely used procedure for airway maintenance and long-term ventilation of critically ill patients in ICUs or operating rooms. Although several complications, such as bleeding, leakage, infection, and stenosis, have been previously reported due to tracheostomy, cuff herniation is a rare complication of this commonly performed procedure. The first sign of herniation is a sudden drop in oxygen saturation. Since cuff herniation is not among the first differential diagnoses for a drop in oxygen saturation, it should be considered in the absence of other common causative agents.
In this study, we delineate a case of tracheostomy cuff herniation after cardiac arrest in a 64-year-old woman who underwent coronary artery bypass graft surgery. The patient experienced a cerebrovascular accident and mediastinitis postoperatively, necessitating tracheostomy due to extended tracheal intubation, during which the cuff herniated for the first time. Furthermore, a repeat tracheostomy was performed; however, the patient ultimately expired due to complications from mediastinitis.

Instant Electrocardiographic Diagnosis of Neonatal Atrial Flutter Using Inter-QRS Segment Pattern Recognition

ELAHEH MALAKAN RAD — 2024-07-31

Neonatal atrial flutter (NAF) is a rare type of macroreentrant supraventricular tachycardia. In this report, we describe a case of atrial flutter in an 8-day-old neonate with a total anomalous pulmonary venous connection. Additionally, we introduce a diagnostic triad for ECG identification of this condition. This triad is composed of 3 components: similar shapes of inter-QRS segments (SIS) in leads II, III, and aVF, different shapes of inter-QRS segments (DIS) in lead I, and the occurrence of 1 or multiple stretched M or inverted V shapes in the inter-QRS (IQS) segment in leads II, III, and aVF. We assessed the effectiveness of this triad through a validation cohort, using previously reported cases of NAF from the literature. The sensitivity rates for detecting SIS and DIS patterns and the singular or multiple reversed W or V signs were 100%, 81%, and 100%, respectively. Furthermore, all 3 components of the triad were found in 81% of neonates diagnosed with atrial flutter. The emergence of this triad can be attributed to the elimination of the isoelectric segment in ECG, caused by the extended duration of flutter waves originating from macroreentry within the atrium and the rapid atrial rate characteristic of atrial flutter.

Pericardial Effusion in the Transverse Sinus

Neda Toofaninejad — 2024-07-31

A 51-year-old woman with dyspnea on exertion was referred for echocardiography. The patient’s heart rhythm was sinus. Transthoracic echocardiography (TTE) showed normal left ventricular size and systolic function (ejection fraction = 55%), normal right ventricular size and systolic function, severe rheumatic mitral stenosis (the orifice area by direct planimetry = 1.2 cm²), mild mitral regurgitation, mild-to-moderate aortic regurgitation, and mild tricuspid regurgitation with normal systolic pulmonary artery pressure (the estimated pulmonary artery pressure = 31 mm Hg). Transesophageal echocardiography, performed for a better assessment of the mitral valve, confirmed the TTE findings and the absence of a left atrial appendage (LAA) clot. It also demonstrated pericardial effusion around the LAA and a space between the left atrium (LA) in the posterior view, the ascending aorta in the anterior view, and the pulmonary artery in the anterolateral view, suggesting effusion in the transverse sinus (TS).

We present this case to emphasize the significance of recognizing this anatomy. Pericardial sinuses are formed by the reflection of the pericardium where the great vessels enter the pericardial sac. The TS is posterior to the aortic and pulmonary trunk and above the LA. (1) The anatomic recognition of the TS is crucial, specifically during interventional procedures because the first herald of complications can be a fluid collection in the TS. These procedures have a broad spectrum extending from intra-LA to great vessel ones. (2,3) Thus, a clinician who performs intraprocedural echocardiography should be familiar with the TS anatomy and know that the fat and parts of normal structures, such as the LAA, can mimic thrombi and masses in the TS. (1,4) Diagnosing these conditions can determine a physician’s decision-making ability. Furthermore, the occurrence of pericardial effusion in some systemic diseases has been reported as a first sign. (5) The significant differential diagnosis of effusion in the TS is the pseudoaneurysm of aortomitral intervalvular fibrosis owing to cardiac surgery or infective endocarditis. The absence of flow in the color Doppler study suggests effusion in the TS. (1) Clinicians should, therefore, be au fait with the TS anatomy to manage patients intraprocedurally and diagnose complications.

Comment on “The Impact of Mean Arterial Pressure during Cardiopulmonary Bypass on Postoperative Outcomes in Coronary Artery Bypass Graft Surgery"

Muhammet Hüseyin Erkan — 2024-07-31

We read with interest the article “The Impact of Mean Arterial Pressure during Cardiopulmonary Bypass on Postoperative Outcomes in Coronary Artery Bypass Graft Surgery” recently published in the Journal of Tehran University Heart Centre by Shamsi et al. We would like to express some concerns about this study.