Background: Early diagnosis of atherosclerosis, particularly in subclinical status, can play a remarkable role in reducing mortality and morbidity. According to previous studies, the elevation of oxidative stress markers may affect the progression of coronary artery calcification (CAC) and future cardiovascular diseases (CVD). we focused on the association of oxidative stress markers and CAC to achieve insight into the nature of CAC pathophysiology.

Methods: In October 2022, we systematically searched Web of Science, Scopus, PubMed, and Embase databases with no language or time restrictions. We included the eligible human observational studies which have investigated the association of CAC with oxidative stress markers. To appraise the included articles, we used the Newcastle Ottawa scale (NOS).

Results: Out of 557 records, 42 studies were included in our systematic review. Oxidative stress markers including serum uric acid (UA), gamma-glutamyl transferase (GGT), and 8- isoprostane were correlated with the incidence of CAC and its severity.

Conclusions: Indicators of oxidative stress may have a positive correlation with the CAC score. This systematic review would provide clinical evidence for further studies of identifying individuals exposed to enhanced risk of CAC which may assist in early diagnosis of CVD complications and could establish innovative targets for pharmacological therapy.

Background: Noninvasive estimation of elevated left ventricular end-diastolic pressure (LVEDP) is a necessary step in evaluating left ventricular diastolic dysfunction (LVDD). Most echocardiographic parameters used for this purpose have limitations. Left atrial (LA) strain was recently found useful for noninvasive estimation of LVEDP. Therefore, this study aimed to investigate the correlations between LA deformation parameters assessed by speckle-tracking echocardiography (STE) and invasively obtained LVEDP.

Methods: This study was prospectively performed on 82 patients in sinus rhythm who underwent left heart catheterization at our center. All the patients underwent complete transthoracic echocardiography and peak atrial longitudinal strain (PALS) evaluation by STE within 12 hours before catheterization.

Results: LVEDP was elevated in 45 patients (54.9%) and normal in 37 (45.1%). PALS, LA ejection fraction, and septal E’ had moderate inverse correlations with LVEDP (r= −0.590, P=0.001, r= −0.463, P=0.001, and r= −0.449, P=0.001, respectively). The E/E` ratio also had a moderate correlation with LVEDP (r= 0.567, P=0.001). Lateral E’ and the E/A ratio demonstrated a rather weak inverse correlation with LVEDP (r= −0.231, P=0.037 and r= −0.229, P=0.038, respectively). In multivariate logistic regression, age (OR, 1.14; 95% CI, 1.02 to 1.27), PALS (OR, 0.77; 95% CI, 0.65 to 0.91), and the E/E` ratio (OR, 1.36; 95% CI, 1.11 to 1.89) were independent predictors of an LVEDP≥12 mm Hg. PALS demonstrated the highest diagnostic accuracy 0.849 (0.764–0.935, P<0.001) to predict an LVEDP≥12 mm Hg. A cutoff of 35% had sensitivity =81.1%, and specificity =81.4% for prediction of increased LVEDP.

Conclusions: PALS proved to be a suitable noninvasive parameter to predict elevated LVEDP. It can potentially be used as a measure for earlier identification of LVDD.

Background: Sarcopenia is a predictor of mortality in multiple conditions but the potential prognostic value of indices of sarcopenia in pulmonary hypertension (PH) is not clarified. The aim of this study was to determine if there is an association between CT scan-measured pectoralis muscle area (PMA) and density (PMD) and adverse clinical outcomes in patients with PH.
Methods: In a cross-sectional study, medical records of PH patients (clinical class I and IV) referred to Rajaie Cardiovascular Center from March 2016 to March 2021 were retrospectively screened. CT scan-measured PMA and PMD were compared between survivors and non-survivors in addition to blood biomarkers and right heart catheterization variables. A binary logistic regression analysis was performed to determine the potential predictors of mortality.
Results: A total of 45 patients with PH (34 patients in survivor and 11 in non-survivor group) were included for data analysis. PMA was not significantly different between the two groups (p=0.124) whereas difference of PMD measures was weakly significant between survivors and non survivors (survivor: 45 HU (25.8-51.3), non-survivors: 31 HU (23-36); p=0.062)). In logistic regression analysis, none of the sarcopenia indices could predict mortality (p>0.05), although phosphodiesterase-5 (PDE-5) inhibitors, right atrial pressure (RAP), and systemic arterial oxygen saturation could serve as potential predictors (p<0.05).
Conclusion: Although CT scan-measured area and density of pectoralis muscle showed a weak correlation with prognosis of PH, there is a possibility that these factors could serve as potential markers for mortality in patients with idiopathic and chronic thromboembolic PH. Further confirmation is required through future studies with larger sample sizes.

Background: Although several studies have examined patients who have undergone transcatheter fenestration closure, comprehensive evaluations of its long-term outcomes remain scarce. Therefore, this study aimed to evaluate the clinical status of these patients after a long-term follow-up period.
Methods: This cross-sectional analytical study evaluated the records of all children with congenital heart diseases admitted for transcatheter fenestration closure at Rajaie Cardiovascular Medical and Research Center, a tertiary care hospital specializing in congenital heart diseases in Tehran, Iran. We included patients with a history of fenestration following Fontan surgery who required fenestration closure between January 2012 and August 2020. Cardiac function data, such as ejection fraction (EF), pulmonary artery pressure (PAP), and O₂ saturation, were extracted from electronic medical records.
Results: We assessed 26 patients (11 female and 15 male) with a mean age of 13.88±3.73 years. Comparing EF before and after fenestration closure revealed a significant difference (P=0.011), with only 2 patients (7.7%) experiencing a slight reduction (5.0%) in EF. No significant difference was observed in PAP before and after closure (P=0.068), although most patients (n=16, 61.5%) had a postprocedural reduction. Our results demonstrated a significant difference before and after the procedure (P<0.001), with all patients exhibiting increased O₂ saturation after closure.
Conclusion: Our study demonstrated improvements in cardiovascular function and desirable organ function among patients. These findings suggest that transcatheter fenestration closure could serve as a beneficial complementary approach for patients with patent fenestration.

Background: Maternal diabetes is the most common causes of hypertrophic cardiomyopathy, which significantly increases the risk of fetal heart dysfunction. In this study, the effect of overt maternal diabetes on fetal cardiac function was performed.

Methods: In this case-control study, twenty-six pregnant women with overt diabetes (case group) and 26 women with uncomplicated pregnancies (control group) were examined using tissue Doppler echocardiography. Cardiac function was assessed twice in the fetal period (18-22 weeks and 28 weeks of gestation) and once in the neonatal period (one week of postnatal). Fetal cardiac function was assessed using early-diastolic maximum velocity index (Em), end-diastolic maximum velocity index (Am), Em / Am ratio, left ventricular myocardial function index (LVMPI) and inter-ventricular mechanical delay index (IVMDI).

Results: The case and control groups were not significantly different in terms of maternal age and gestational age at the time of fetal Doppler evaluation. Em (P = 0.007), Am (P <0.001), LVMPI (P = 0.003), and IVMDI (P = 0.026) were significantly higher in fetuses of diabetic mothers than control group, while there was no significant difference in Em / Am ratio (P = 0.264). Eight fetuses (30.8%) of diabetic mothers had dyssynchrony, while no cases of dyssynchrony were seen in fetuses of non-diabetic mothers (P = 0.004). Infants of diabetic mothers were 8.8 times more likely to develop adverse neonatal outcomes than infants of healthy mothers (RR = 8.8, 95% CI: 1.71-45.31, P = 0.009). Regarding the predictive value of cardiac indices for adverse neonatal outcome, IVMDI had the area under curve of 0.887 (P = 0.001) and LVMPI had area under the curve of 0.762 (P = 0.024).

Conclusion: The findings of the current study revealed significant cardiac dysfunction and dyssynchrony in fetuses of diabetic pregnant women. We also found that the IVMDI and the LVMPI index can be used to predict adverse neonatal outcomes in pregnancies complicated with overt diabetes.

Purpose: The aim of the study was to compare the time to peak systolic contraction time (Tc) by color-coded anatomical M-mode (AMM), time to peak systolic strain (Tst) by strain rate imaging (SRI), and the time to peak systolic velocity (Ts) by tissue Doppler imaging (TDI) in the left ventricular (LV) and right ventricular (RV) segments of normal subjects. We also sought to determine the relationship between these methods for defining asynchrony indices in normal subjects.

Methods: Conventional echocardiography, color-coded AMM, SRI, and TDI were performed on 44 healthy adult volunteers (in Tehran heart center and Dr. Shariati hospital) to measure Tc, Tst, and Ts for 12 LV and 2 RV segments in the mid and basal levels. Additionally, the delay and the standard deviation (SD) were measured in all 12 and basal LV segments.

Results: In 12 LV and 2 RV segments, Tc by AMM and Tst by SRI were significantly higher than Ts by TDI (P < 0.001). Tc and Tst had no significant differences in 8 LV and 2 RV segments (P < 0.05); however, there were meaningful differences between Tc and Tst only in the anterior and inferior walls. There was a moderate correlation between AMM and SRI for asynchrony in all and basal LV segments and the SD of all and basal LV segments. There was no correlation between AMM and TDI in defining asynchrony indices. There was a weak correlation between TDI and SRI apropos of asynchrony in all and basal LV segments and the SD of all and basal LV segments.

Conclusion: Tc by AMM and Tst by SRI were significantly higher than Ts by TDI in LV and RV segments. There was no correlation between AMM and TDI in defining asynchrony indices.

Background: Adopting healthy nutritional behavior in patients with Heart Failure (HF) can play a crucial role in controlling symptoms of the disease. To develop effective interventions, it is recommended to recognize significant determinants of nutritional behavior based on theoretical frameworks in behavioral sciences and utilize valid instruments. The aim of this study was to develop and validate measurement tools for assessing the determinants of nutritional behavior among patients with HF based on the Theory of Planned Behavior (TPB) variables.

Methods: In this psychometrics study, a preliminary instrument based on the TPB with five subscales was created. Additionally, an instrument for measuring the nutritional behavior of HF patients was developed. The face validity and content validity of the instruments were assessed using both quantitative and qualitative methods. The factor structure of the instrument for assessing TPB variables was examined through Exploratory Factor Analysis (EFA) using a sample of 330 patients with HF. Furthermore, the reliability of the instruments was evaluated.

Results: In the stages of face validity and content validity assessment, 13 items were removed from the TBP instrument, and 14 items were modified in the two instruments. The EFA revealed that the 12 items of the TPB variables could be classified into 4 subscales, namely behavioral intention, attitude, and perceived behavioral control. The results of the EFA indicated that the Kaiser-Meyer-Olkin and Bartlett’s test of sphericity of the instrument were acceptable. These factors accounted for 87.03% of the variance. The TPB instrument subscales demonstrated acceptable levels of reliability, as indicated by Cronbach's alpha. Both instruments had acceptable levels of intraclass correlation coefficient.

Conclusions: The results showed that the developed instruments were two valid and reliable tools for assessing the determinants of adopting nutritional behavior among patients with HF, utilizing TPB variables. These instruments can be used in conducting needs assessments and developing education intervention efforts for patients with HF.

Background: Complete heart block (CHB) is a known complication following congenital heart disease (CHD) corrections in children, yet data on its prevalence and short-term outcomes is limited. This study investigates the prevalence and short-term outcomes of post-procedural CHB in pediatric patients undergoing surgical or transcatheter procedures for CHD.

Method: A retrospective cohort study was conducted on pediatric patients who underwent CHD corrections between 2019 and 2020 at a tertiary cardiac center in Isfahan, Iran. Patients with a history of arrhythmia or heart block before surgery were excluded. The medical records were reviewed to identify cases of post-procedural CHB. The prevalence, risk factors and short-term outcome of post-procedural CHB were analyzed.

Result: A total of 840 patients were included in the study, with a mean age of 3.41±4.30 years and 47.8% being male. CHB was identified in 22 patients (2.6%) during the post-procedural period, with a prevalence of 0.6% in the transcatheter group and 4.7% in the surgical group. Patients with post-procedural CHB were younger than non-CHB patients. Regression analyses indicated that the type of procedure and type of CHD were associated with post-procedural CHB. Patients who developed post-procedural CHB had a longer mean stay in the pediatric cardiac critical care unit than non-CHB patients. The in-hospital mortality rate was 5.2%, with no correlation to CHB occurrence.

Conclusion: The findings highlight the importance of attentive monitoring for post-procedural CHB, particularly in younger patients, to facilitate timely intervention and improve the patient’s outcome.

Background and objectives: Diazinon (DZN), an organophosphate insecticide, used in households and agriculture for several decades, has a variety of adverse effects on different organs of humans. In this study, we studied the possible cardiotoxicity effects of flaxseed oil (FS oil) on Diazinon (DZN) caused oxidative stress in the heart tissue of rats.

Method: Totally thirty male Wistar rats (60-200 g) were allocated into five groups: The control group (received 1 ml normal saline orally), flaxseed oil group (received 200 mg/kg/day FS oil, p.o.), Diazinon group (received 70 mg/kg/day DZN, p.o.), and co-treatment groups (received DZN 70 mg/kg/day plus flaxseed oil at doses of 100 and 200 mg/kg/day). Oxidative stress biomarkers including malondialdehyde (MDA), total oxidant status (TOS), catalase (CAT), Superoxide dismutase (SOD), and total thiol group (TTG) were investigated in heart tissue. Moreover, the hematoxylin and eosin (H&E) staining method was used for the evaluation of morphology and pathology of heart tissue.

Results and conclusion: DZN significantly increased the levels of MDA and TOS and also decreased the content of CAT, SOD, and TTG in heart tissue. Flaxseed oil supplement consumption significantly reversed oxidative stress status, so these effects were dose-dependent. Furthermore, FS oil ameliorates heart histopathological alterations induced by DZN. Our findings confirmed DZN-induced heart toxicity and flaxseed oil had protective effects by decreasing oxidative stress markers and improving anti-oxidative status. It was shown that FS oil supplementation has protective effects on the heart against toxicity induced by DZN.

Background: A sinus venous atrial septal defect (SVASD) is a type of congenital heart defect that predominantly involves an opening between the Superior Vena Cava (SVC) and the Right Upper Pulmonary Vein (RUPV). Surgical closure of SVASD has been the standard treatment; however, the surgical closure of SVASD is far more complex than mere ASD secundum reconstruction, and complications are more likely. Transcatheter closure of SVASD is an emerging alternative for surgical repair.

Methods: We report five cases of successful transcatheter closure of SVASD and one case of failure that required surgical intervention. All patients underwent pre-procedure Computed Tomography Angiography (CTA) to determine the size and location of the defect and the optimal stent size and position. The SVC stenting was performed using balloon-expandable stents, followed by RUPV angioplasty if needed.

Results:  Final angiograms and pressure measurements in the SVC, RUPV, and Right Atrium (RA) confirmed the absence of residual shunt and pulmonary venous obstruction. One patient experienced stent migration to the pulmonary artery, which necessitated surgical retrieval and defect closure.

Conclusion: The balloon expansion test is not mandatory before stent implantation, as in the case of RUPV obstruction, its flow could be reestablished by ballooning and/or stent implantation within the RUPV with a mild residual shunt which might resolve spontaneously.

Background
Heart rate variability (HRV) plays an important role in predicting poor prognosis after acute myocardial infarction, but whether this parameter is able to predict long-term adverse outcomes following revascularization procedures is still not clear. We investigated the value of HRV in predicting post- procedural adverse outcome (mortality and major adverse cardiovascular event or MACE) in patients undergoing coronary artery bypass grafting (CABG) surgery and referred to intensive care unit.

Methods

This prospective cohort study was performed on 258 consecutive patients underwent elective isolated CABG. All patients required intensive care unit referring before discharge from the hospital. All patients were planned for a 3-week cardiac rehabilitation program with a 24-hour electrocardiogram Holter monitoring. HRV was analyzed by computer and over-read manually. Within a follow-up period ranged 1 to 3 years, the patients were asked by phone for long-term outcome including death and MACE (including myocardial infarction, reoperation, or brain stroke).

Results

overall, 4.3% of patients died due to cardiovascular events and 15.1% suffered from long-term MACE. Comparing HRV indicators between non-survived and survived subgroups showed significantly lower mean RR, lower mean SDNN, lower LF and lower HF in former group. However, the comparison of HRV between the subgroups with and without long-term MACE showed no difference in HRV indicators between the two groups. Using Cox proportional hazard analysis, lowering HRV (SDNN) could effectively predict long-term death in patients underwent CABG.

Conclusion
Lower postoperative HRV can effectively predict long-term death after CABG in patients admitted to intensive care unit.

Background: Chronic inflammation of RHD occurs and releasing proinflammatory cytokines, including Transforming Growth Factor β1 (TGF-β1) which induces myofibroblast differentiation. This differentiation plays crucial role on resulting fibrosis and calcification of the heart valve. This cascade of inflammation presents an opportunity for the use of antifibrotic agents such as angiotensin-converting enzyme (ACE) Inhibitor. However, no study provided an optimum dose nor comparison of various Lisinopril doses.

Methods: This study is an in vitro posttest-only control group study. Valvular Interstitial Cell (VIC) were obtained from New Zealand rabbit (Oryctolagus cuniculus) heart valves. Valve interstitial cells were divided into five groups of exposure TGF-β1 and various Lisinopril doses (1 µM, 10 µM, 100 µM). The effect of Lisinopril on myofibroblastic differentiation was evaluated by measuring αSMA expression using immunocytochemical methods. Statistical significance was determined using an independent T-test with a p-value < 0.05.

Results: The result of independent T test indicated a significantly lower αSMA expression in the group given Lisinopril at various doses compared to the group only induced by TGF-β1 (Lisinopril dose 1 µM, 10 µM, 100 µM; p<0.05). The lowest and most significant amount of αSMA expression was found in Lisinopril at a dose of 100 µM.

Conclusion: Lisinopril inhibited TGF-β1-induced myofibroblast development in rabbit valve interstitial cells at dosages of 1 µM, 10 µM, and 100 µM. The lowest fibrosis marker was observed with Lisinopril 100 µM.

Background and Objective: Myocardial infarction (MI) presents one of the most common cardiovascular disorders and a progressive debilitating condition. Patients with MI experience low quality of life (QoL) mainly due to the devastating complications of this condition, and it is necessary to upgrade QoL and self-care among these patients. Self-care training is one of the ways to improve QoL in these patients. Therefore, the present study aimed to investigate the effects of implementing Orem’s self-care model on the QoL of patients experiencing MI hospitalized in the intensive care unit (ICU).

Methods: The present research employed a quasi-experimental randomized pre-post design conducted from February 2021 to August 2022. The research population included 70 patients with MI hospitalized in the ICU of the Shahid Mostafa Khomeini Hospital of Ilam City, Eligible patients according to entry and exit criteria were divided into the intervention and control groups. Data were gathered using a questionnaire consisting of three parts: 1-demographic information, 2- needs assessment based on the Orem model, and 3- the MacNew Heart Disease Health-related Quality of Life. The intervention group received 4 sessions of self-care training (30-45 minutes each session) via in-person, virtual, and phone-based methods and handed a self-care training booklet. Participants in both groups filled out the QoL and self-care questionnaires before and two weeks and two months after the intervention by face-to-face visits or phone/virtual interviews. The data collected were analyzed using SPSS v.26 software by calculating frequencies, means, and standard deviations. The repeated-measure analysis of covariance was utilized to compare the two study groups before and after the intervention.

Results: The results showed no significant difference in the mean QoL score between the intervention and control groups before the intervention (P-value = 0.05); however, after the intervention, the two groups showed a significant difference in terms of the mean score of QoL (P-value = 0.001).

Conclusion: The results of the present study showed that Orem self-care training could effectively improve the QoL of patients with MI, suggesting this approach as an effective non-pharmaceutical approach to upgrade QoL in these patients.

Background and objectives: Atrial Fibrillation (AF) is the most prevalent persistent arrhythmia with a great burden on people’s health and society. Due to associations between psychological factors and AF in previous studies, this study was conducted to investigate the association between perceived stress and arrhythmia.

Methods: In this case-control study, participants were recruited from the outpatient clinic of Rajaie Cardiovascular, Medical and Research Center in Tehran, Iran, between May 2021 and September 2021 based on eligible criteria. Data were collected through face-to-face interviews by trained research nurses using the appropriate checklists. The stress level of participants was evaluated using the Perceived Stress Scale (PSS). Data were analyzed by Chi-square, independent T-test, and logistic regression model in SPSS 16.

Results: One hundred fifty-five cases with arrhythmia and 144 controls were recruited for this study. The mean score of the perceived stress was 30.6 in cases and 25.07 in controls (P< 0.001). Stress-related symptoms including palpitation and chest discomfort were more common in patients with arrhythmia than healthy controls (P = 0.015 and P< 0.001 respectively). The risk of arrhythmia was independently associated with sex, diabetes mellitus, dyslipidemia, hypothyroidism, cardiomyopathy, concentration difficulty, chest discomfort, and stress score in the multivariate logistic regression model.

Interpretation and conclusions: The results of this study demonstrate that AF arrhythmia is strongly associated with psychological stress and higher perceived stress scores. Interventions targeting reducing stress in those who are at high risk of developing AF are beneficial.

The Fractals are a fascinating mathematical tool for modeling the roughness of nature and understanding the structure of such complex objects. They are considered a tool for understanding the world. In general, fractal objects are characterized by the fractal dimension. In this work, and in order to exploit the fractal dimension to analyze fractal signals, we have defined the notion of the fractal dimension by presenting the methods for calculating this dimension. In this paper; we have shown that the electrocardiogram (ECG) is a fractal signal. This allows us to classify heartbeats based on the fractal concept. The aim is to develop a digital technique to analyze ECG signals in order to make an accurate diagnosis of cardiovascular diseases

Background: Heart transplantation has emerged as the preferred treatment for selected individuals with advanced heart failure. However, the outcomes and complications of this procedure have not been evaluated thoroughly among the Iranian population. In the present study, we aimed to provide a comprehensive understanding of the epidemiological characteristics of patients who had HT, with a focus on indications for HT, early and late complications, mortality causes, and survival rate.

Methods: In this retrospective cohort study, we included all patients aged ³18 years who underwent HT from July 2013 up to June 2023 at academic hospitals at Shiraz University of Medical Sciences. A questionnaire of several variables was completed for each patient by reviewing medical records. The following outcomes were collected for the first 10 years after HT surgery: (1) mortality/survival: the incidence of death, cause of death, and length of survival; (2) rejection: the incidence of rejection, time, and type of rejection; and (3) the incidence of early and late post-transplant complications. 1-year, 2-year, and 10-year survival was reported using Kaplan-Meier method. Multivariate relation with survival was evaluated by Cox regression analysis.

Results: 75 patients underwent Heart Transplant operation, among which, 48 were male and 27 were female. The most common underlying cause of Heart Transplant was dilated Cardiomyopathy accounting for 85.3% of surgeries. Following the surgery, fifteen (23.8%) patients had evidence of transplant rejection. Overall mortality was 29 deaths, 19 of which were male and 10 were female. Twelve patients (15.8%) died in the operating room and the overall survival of our patients was 129.41±14.94 months. By excluding the 12 in-OR expired patients, the survival rates at 1 year, 2 years, and 10 years improved to 80.7%, 71.1%, and 68.3%, respectively.

Conclusions: Overall, the findings of this study provide valuable insights into the demographic and clinical characteristics of patients who undergo HT, as well as their post-transplant outcomes. Additionally, our findings will contribute to the current body of knowledge on pre-heart transplant risk assessment and patient selection, as well as early post-heart transplant diagnosis and management of significant complications.

Background: Post Infarction Ventricular Septal Rupture (PIVSR) is a rare condition of mechanical complication of myocardial infarction (MI) with a high mortality rate. Deterioration of hemodynamics is inevitable during both its progression while waiting for a timely surgery and after the surgery itself. Continuous vigilance of hemodynamic may improve hemodynamic status observation, enable timely interventions that target specific problems, and ultimately improve patient prognosis.

Case Illustration: 65-year-old man with dyspnea, following 19 days after onset of MI. He was referred to our hospital with a presentation of acute heart failure, with pansystolic murmur grade IV/VI heard at the apex area. Echocardiogram showed a 14 mm IVS gap at the apex area, with left to right shunt. The patient was then stabilized in the CVCU and planned to undergo VSR closure and CABG. Procedure was done at 16^th day of hospitalization. Post operative period, he developed shock due to bleeding and cardiac tamponade that required him to underwent 2x redo surgery. After tremendous efforts for stabilizing the patient, he ultimately survived.

Conclusions: Hemodynamic monitoring and stabilization play a pivotal role in determining the prognosis in the case of PIVSR. Prompt diagnosis of post-operative complications that deteriorate hemodynamics, along with an interdisciplinary team approach, can improve treatment strategy and significantly reduce fatal complications and morbidity, which ultimately will improve the patient’s chances of survival.

Keywords: Myocardial Infarction, Ventricular Septal Rupture, Hemodynamic

Mixed atrial septal defects (ASDs) involving inferior vena cava (IVC)-type sinus venosus and secundum types, with mixed partial anomalous pulmonary, systemic, and hepatic venous drainage, are rare. We report a three-year-old acyanotic boy who presented with a large mixed inferior sinus venosus and secundum-type ASD. He had an abnormal connection between the right upper pulmonary vein and the right atrium. The IVC and a hepatic vein also drained abnormally into the left atrium. There was also valvar and supravalvar pulmonary stenosis and a small patent ductus arteriosus. The ASD was surgically closed with a pericardial patch, positioned lower than typical to reroute the IVC and hepatic vein flow into the right atrium. The surgery was successful without any residual lesions or complications, and the patient recovered uneventfully. Abnormal IVC and hepatic vein drainage into the left atrium may not result in systemic arterial desaturation when a large ASD is present. During the two-dimensional echocardiographic evaluation of mixed  ASDs, it is critical to meticulously address three key aspects: 1. a thorough examination of both the systemic and pulmonary venous connections and their drainage; 2. a detailed search for any associated congenital heart diseases; and 3. the extensive use of the sweeping technique to comprehensively assess the atrial septum, especially when three-dimensional echocardiography is not available. It is crucial to inform the cardiac surgeon about these findings before surgery to prevent unexpected post-operative hypoxemia due to the misdirection of the IVC and hepatic vein into the left atrium.

Ewing's sarcoma, a highly aggressive, round-cell neoplasm of unknown origin, rarely manifests as a primary occurrence in the heart. In this intriguing case, we present a report of primary Ewing sarcoma in the right ventricle of an adult patient.

The patient was a 27-year-old man who presented with epigastric pain, fever, tachycardia, nausea, vomiting, shortness of breath, and dry cough. CT scan and echocardiogram showed an anterior mediastinal mass originating from the free wall of the right ventricle and located in the pericardium. It was causing pressure on the right ventricular outflow tract (RVOT) and pulmonary artery.

Based on the clinical conditions and paraclinical findings, a decision was made for surgical treatment. The mass was carefully separated from the heart tissue, and the RVOT was resected along with the pulmonary valve and the main pulmonary artery. This was repaired with a Dacron composite graft and anastomized to the bifurcation of the main pulmonary artery. The mass near the superior vena cava and the area of the pulmonary vein was also meticulously removed.

The patient was successfully removed from the cardiopulmonary pump in a stable condition and transferred to the intensive care unit. Histopathology results confirmed the presence of small round cell sarcoma and Ewing sarcoma in the patient. The patient was discharged and scheduled for regular follow-up visits.

Following discharge, the patient was referred to the radiotherapy center and underwent radiotherapy. In a re-examination after one year, the absence of any signs of disease recurrence or re-engagement provided a beacon of hope and optimism. This case suggests that timely referral and treatment of Ewing's sarcoma in the heart can lead to a better prognosis.

Background: Infective endocarditis (IE) uncommonly happens right-sided. Furthermore, Streptococcus agalactiae rarely causes IE, in which only 2-9% of bacteremia cases manifest as endocarditis. 

Case presentation: A 30-year-old Lebanese woman came to the emergency room (ER) with a high-grade fever and chills. Blood tests were drawn, urine analysis showed leukocytes in urine, and treatment for urinary tract infection was started accordingly. The patient was hospitalized three days later and transferred to the intensive care unit (ICU); severe right-sided cardiomegaly, flailed tricuspid leaflets with ruptured chordae, and large coaptation deflect were discovered during echocardiography. She was diagnosed with Streptococcus agalactiae right-sided infective endocarditis and underwent tricuspid valvular replacement. Unfortunately, the patient died after suffering from acute decompensated heart failure. 

Conclusion: This is an unusual S. agalactiae right-sided infective endocarditis case found in Lebanon, in which definitive treatment for IE caused by this agent is still limited.

Thrombotic manifestations refer to the formation of blood clots within blood vessels.These conditions can manifest unexpectedly in various locations and are associated with potentially life-threatening situations, posing challenges in terms of both diagnosis and treatment.

Case Presentation

We present a case of multi-site thrombosis observed in a patient suffering from a hypercoagulable state, as confirmed by a positive factor V Leiden (Factor V leiden) mutation. The patient's medical history includes hypertension, Chronic obstructive pulmonary disease (COPD), prior thrombotic episodes, and previous cessation of anticoagulant therapy.

 The case illustrates the challenges of the multisystem thrombosis and the need for various diagnostic methods including echocardiography, coronary computed tomography angiography (CCTA), and Doppler ultrasonography. In this case there was presence of previous unprovoked lower limb DVT and multiple arterial thrombosis. The patient's treatment plan included anticoagulants, antiplatelet medications, and vasodilators. While a reduction in thrombus size was observed, achieving complete revascularization remained elusive.

Conclusion: To effectively identify and manage venous and arterial thrombosis often multi-modality imaging is imperative. Screening by Selected blood tests can be valuable for diagnosing or identifying congenital or acquired defects related to thrombosis development.

Background: Kawasaki disease (KD) is a vasculitis that primarily affects young children and results coronary artery abnormalities. Echocardiography is the standard imaging modality for monitoring KD patients; however, some coronary artery anomalies are not detected by using this method. This case report demonstrates the significance of CT angiography in identifying previously undiagnosed coronary abnormalities in a KD patient.

Case Presentation: A 7-year-old male presented with symptoms consistent with KD was treated subsequently with intravenous immune globulin (IVIG). Follow-up echocardiography showed no significant coronary artery abnormalities. Three years later, the patient presented with flu-like symptoms, and an ECG revealed anterolateral ischemic changes. Echocardiography showed normal coronary arteries, but a CT angiogram was performed due to the ischemic changes on ECG. The CT angiogram identified a myocardial bridge in the left anterior descending artery (LAD), which had not been detected by echocardiography or ECG.

Conclusion: This case report emphasizes on importance of considering CT angiography as an adjunct imaging modality in the evaluation and follow-up of KD patients, particularly when echocardiography findings are inconclusive or when clinical presentation raises concerns for potential coronary artery abnormalities. Further research is needed to establish evidence-based guidelines for the optimal timing and clinical indications for CT angiography in Kawasaki disease patients.

Background: Pregnancy in pulmonary hypertensive female patients is strongly contraindicated because of the high mortality rate according to physiological changes, especially in peri- and postpartum periods, and in case of occurrence, termination at an early stage is recommended. Therefore, our experience with continued pregnancies in patients with pulmonary hypertension are scarce.

Case presentation: This case report presents a young woman diagnosed with multiple bilateral pulmonary hydatid cysts and right ventricular hydatid cyst, who underwent surgical and pharmacologic treatments, but developed pulmonary hypertension due to pulmonary artery obstruction eight years after. According to the unsuitable condition of the patient for surgery, she was a candidate for medical therapy, including Tadalafil, Bosentan, and Eplerenone. After 3 years, despite the advice to avoid pregnancy, the patient got pregnant and at 37 weeks underwent a successful emergent cesarean section due to maternal dyspnea and tachycardia.

Conclusions: We believe that prompt treatment and regular follow-ups in a tertiary care center with a multidisciplinary approach would be crucial in the management of pulmonary hypertensive patients who get pregnant.

Infective endocarditis (IE) is an under-recognized cause of fever that is often missed in preliminary evaluation. This may stem from a lack of vigilance towards IE and using empirical antibiotic therapy to treat fever. As a result, patients often present with complications of IE that warrant surgical intervention. We hereby discuss a case of IE that remained undiagnosed for 2 years, receiving short courses of oral antibiotic therapy for recurrent fever, ultimately developing heart failure due to valve perforation.

Syncope, characterized by transient loss of consciousness, is among the most common reasons for emergency department visits worldwide and can be categorized into reflex syncope, orthostatic hypotension, and cardiac syncope. Situational syncope as one of the subtypes of reflex syncope is much less investigated than other types. Herein, we report three patients presented to the syncope unit of Tehran Heart Center with unusual situational syncope triggers, in addition to their diagnosis tools and treatment of them. The first case was a 62-year-old woman with five syncopal episodes in the last two years, all of which were at the airport and during the airplane take-off. With the prescription of midodrine before the flights, no further syncope occurred. The second was an 18-year-old man with two syncope episodes, both of which were after marijuana smoking. He was advised to quit smoking marijuana and no syncope episode was recorded in the one-year follow-up. The last case was a 42-year-old heavy-smoker man with a complaint of several syncopal episodes after bursting coughs. After the failure of cough suppressor medications, he was cured with gabapentin. In conclusion, due to the complicated nature of syncope diagnosis in some cases, rare syncope triggers should always be taken into consideration by physicians in the history taking of patients with unexplained syncope.

Gallbladder and biliary tract diseases may manifest as cardiac symptoms, ischemic ECG changes, and arrhythmias. Although rare, bradyarrhythmia cases induced by cardiobiliary reflex have been linked to acute cholecystitis. This case emphasizes the cardiobiliary reflex as a possible cause of bradyarrhythmia in patients with gallbladder and biliary tract diseases . 

Background: In-stent restenosis (ISR) following percutaneous coronary intervention (PCI) is an unwanted complication in some patients. The etiology is multifactorial, and identifying these factors may help improve long-term outcomes after PCI.

Case summary: We hereby describe two cases of recurrent ISR; case 1 describes the techniques of PCI used over 17 years to manage recurrent ISR of Left Main bifurcation disease, while case 2 highlights the role of coronary artery bypass grafting (CABG) as a treatment modality for recurrent ISR of the right coronary artery.

Discussion: Management of post-PCI recurrent ISR has witnessed multiple advancements over the past decade. Newer technologies like intravascular imaging, plaque or calcium modification techniques, and drug-eluting balloons enable effective management of recurrent ISR.  This article describes possible risk factors for recurrent ISR and discusses various treatment strategies for its management.

Myocarditis is an uncommon manifestation of tuberculosis, associated with significant morbidity and mortality. Cardiac MRI is an essential imaging modality for the evaluation of infiltrative myocardial pathologies.

HbD is a variant of hemoglobin mainly found in north-western parts of India like Punjab and Gujarat, Pakistan, Iran and other countries. HbD arises due to genetic mutation at 121^st aminoacid residue glutamic acid which is replaced with glutamine. HbD may exist in homozygous or heterozygous forms. Patients with HbD usually remain asymptomatic during their life time. However, HbD may sometimes coexist with sickle cell disease which exhibits clinical manifestations. However, coinheritance of HbD with thalassemia is a rare possibility and is believed to have clinical presentation which is not much reported in literature. In this article we have reported a case found in Bathinda district of Punjab with coexisting HbD and thalassemia trait showing severe cardiac presentation which could be late sequelae of hemoglobinopathy owing to underlying chronic anemia. We have also proposed an algorithm which might help the clinicians and diagnostic lab experts for easy work up of hemoglobinopathies considering that availability and affordability of genetic allele testing is a major limitation in majority of clinical settings.

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Accelerated idioventricular rhythm (AIVR) is a slow ventricular rhythm. It generally occurs during the reperfusion phase of acute myocardial infarction. It is usually regarded as a benign rhythm that does not require any treatment. But here we present a case where AIVR is a presenting arrhythmia in a 41 years old male patient with acute coronary syndrome. This rhythm might not be completely benign as regarded in literature. The patient presented to our institute underwent urgent coronary evaluation followed by revascularization, which led to the conversion of AIVR to normal sinus rhythm and improvement in the patient’s anginal symptoms.

Acute aortic dissection (AAD) is characterized by the rapid development of an intimal flap causing luminal compromise, and mal-perfusion. They can occur anywhere from coronary to iliac arteries. The combination of left main occlusion and extensive aortic dissection from the ascending aorta to the iliac artery is lethal, with a very high mortality rate. A high index of suspicion is the first key step in the management of aortic dissection in ACS.