Study of the efficacy of low-level laser in myocardial perfusion of patients with chronic stable angina

A sizable portion of patients with angina pectoris secondary to underlying coronary artery disease [CAD] can be effectively treated. Anti-anginal medication has proven efficacious in most patients, and percutaneous coronary revascularization or coronary artery bypass grafting can successfully treat the rest. Low-level laser therapy [LLLT] via its direct, heat-independent effect on the process of tissue repair may play a significant role in the treatment of patients with advanced CAD. We aimed at assessing the safety and efficacy of LLLT in advanced multi-vessel CAD patients not suitable for myocardial revascularization. We evaluated various clinical parameters as well as the results of laboratory tests to seek the indices of the potential impact of laser therapy on the study population. Twenty-two patients [mean age, 61 years old and male gender, 68.1%] with advanced CAD and a history of myocardial infarction underwent two series of irradiation therapy, each series comprising 10 sessions of LLLT and conducted with a three-month interval. In each series, LLLT was administered every other day for 20 minutes per session [excluding one session that lasted only 10 minutes]. The pre-laser evaluation consisted of blood pressure, heart rate, basic biochemical test, electrocardiogram [ECG], six-minute walk test, transthoracic echocardiography, and ECG-gated single photon emission computed tomography [SPECT] perfusion imaging. Three months later, the pre-laser evaluation was repeated. No side effects associated with laser biostimulation or performed clinical tests were noted. An improvement in functional class, and distance covered in the six-minute walk test and decrease in systolic blood pressure was observed. There was also a significant change in the myocardial perfusion of most anterior segments of the heart according to SPECT [visually and by computer software, P<0.05]. There was no significant change in diastolic blood pressure, heart rate, left ventricular ejection fraction by transthoracic echocardiography, and ECG gated SPECT. LLLT resulted in an improvement in functional capacity and myocardial perfusion as well as a reduction in the frequency of angina symptoms during the six-minute walk test. There were no significant changes, however, in the left ventricular function according to transthoracic echocardiography and ECG-gated SPECT. In the short term, LLLT proved to be a safe method. These encouraging results should be confirmed by larger, placebo-controlled studies

Primary synovial sarcoma of the right atrium

A 27-year-old man presented with exertional dyspnea and productive cough as well as weight gain. Transthoracic echocardiography revealed severe right ventricular enlargement with moderate systolic dysfunction and a large right atrial mass protruding into the right ventricular cavity with severe functional tricuspid stenosis. An urgent surgical operation was done, and the tumor was totally excised. The histological findings were those of a biphasic tumor, consistent with synovial sarcoma. This was also confirmed by an immunohistochemistry panel. The patient's chest CT scan showed multiple small peripheral nodules, suggestive of lung metastases. Chemotherapy was administered and several months afterwards, the patient was asymptomatic with no residual mass on echocardiography

Assessment of statistical relationship of ejection time and acceleration time with the severity of valvular aortic stenosis

Valvular aortic stenosis is a relatively common disease among valvular heart diseases and can be rheumatic, degenerative or congenital. Evaluation of the severity of the disease is sometimes challenging and problematic. Besides, the use of more parameters of non-invasive methods for the assessment of valvular disease and its severity seems attractive and helpful. Transthoracic echocardiography [TTE] is an appropriate modality for the evaluation of the aortic valve. In this study, TTE was performed for 80 patients with valvular aortic stenosis. The goals were to assess the statistical relationships between ejection time [ET] and acceleration time [AT] and their ratio [AT/ET] with the four traditional parameters of the echocardiographic severity of aortic valvular stenosis [aortic jet velocity, aortic valve area, mean pressure gradient and LVOT VTI/aortic VTI ratio]. There was a meaningful relationship between adjusted ET with the four above-mentioned parameters, d. ET [ET-adjusted ET according to heart rate and stroke volume] was inversely related with the aortic valve area [calculated with continuity equation]. AT/ET was significantly correlated with the four mentioned parameters. The regression equations were calculated. The cut-off value of AT/ET for the echocardiographic diagnosis of severe valvular stenosis was 0.36 [with 95% level of confidence]

Accessory mitral valve tissue in mirror-image dextrocardia

A 20-year-old man was referred to us for further evaluation due to infective endocarditis. He had mirror-image dextrocardia with visceral situs inversus. He had a history of dyspnea on exertion [NYHA class II] of several years' duration with no new onset symptoms. On physical examination, he had no peripheral stigmata of infective endocarditis. Laboratory examination showed a normal erythrocyte sedimentation rate with normal hemoglobin. Three separate sets of blood cultures obtained over a 24-hour period and cultures were negative in aerobic and anaerobic media. Transthoracic and transesophageal echocardiographic studies showed mirror-image dextrocardia with total situs inversus as well as accessory mitral valve tissue with chordal attachment to the posteromedial papillary muscle with no significant LVOT obstruction [Figs. 1,2] but resulting in mild to moderate aortic insufficiency [Fig.3]. There was also aneurysmal dilation of the membranous part of the interventricular septum with a residual pouch and no residual ventricular septal defect according to computational fluid dynamics and contrast studies [Fig 4]. There was no other concomitant abnormality. The patient was discharged in good physical condition

In-hospital course of early invasive strategy in acute coronary syndromes

Unstable angina is emerging as a major public health problem worldwide. Two approaches - an early invasive strategy or a conservative strategy - are used of the management of non-ST elevation acute coronary syndrome [MSTE-ACS]. An early invasive strategy involves the use of early coronary angiography and revascularization with percutaneous coronary intervention [PCI] or coronary artery bypass graft surgery [CABG]. A conservative strategy involves initial treatment with aggressive pharmacologic treatment, and coronary angiography with revascularization is used if there is evidence of spontaneous or provoked ischemia within the hospital stay. Two hundred sixty-one patients coronary syndrome were enrolled in this study for early invasive strategy. Patients received aspirin, heparin, clopidogrel, and lipid-lowering therapy. The primary endpoint was a composite of death, non-fatal myocardial infarction, cerebrivascular accident, and recurrent chest pain. Angiograms were assessed qualitatively by two expert invasive cardiologists. Sixty-seven percent of the patients underwent percutaneous [33%] or surgical [34%] revascularization. The overall death rate was 1.1%. In-hospital major adverse cardiac event [MACE] rate was 3.2% in the revascularization groups. According to the favorable in-hospital course in patients referred for PCI or CABG, it seems that accurate selection of patients who may be candidates for early invasive strategies is of paramount importance. We found that diabetes, cardiac enzyme elevations [Troponin T], ST/T changes, and the presence of two or more risk factors besides diabetes are powerful predictors of the patients who will undergo revascularization. Proper selection of patients admitted with ACS for invasive strategy is warranted. Positive cardiac enzymes [Troponin T], diabetes mellitus, and presence of two or more major CAD risk factors are helpful for patient selection

Prevalence of left ventricular diastolic asynchrony in patient with systolic heart failure

To study the occurence of left ventricular [LV] diastolic asynchrony in patients with systolic heart failure [HP] and its relationship to diastolic function regardless of QRS duration. Recent work has demonstrated that intraventricular asynchrony is a common finding in patients with systolic heart failure. Little attention has been paid to diastolic asynchrony in patients with systolic heart failure. We have therefore decided to determine the extent to whuch patients with systolic heart failure have evidence of diastolic asynchrony and wheather or not diastolic asynchrony is correlated with diastolic dycfunction. Tissue Doppler echocardiography was performed in 50 HF patients [LV EF=23 +/- 8%]. Diastolic and systolic asynchrony was determined by tissue synchronization imaging using a 6 basal, 6 mid-segmental model. Systolic and diastolic asynchrony were assessed by the maximal difference in time to peak systolic and early diastolic velocities between any two of 12 LV segments, and the standard deviation of time to peak systolic and early diastolic velocities of the 12 LV segments. The mean +/- SD maximal difference in time to peak systolic velocity [controls: 17.2 +/- 9.6 ms versus narrow QRS: 66.7 +/- 38.0 ms versus wide QRS: 76.5 +/- 34.6 ms, both P<0.05 versus controls] and in standard deviation of time to peak systolic velocity of 12 LV segments [controls: 15 +/- 6.1 ms versus narrow QRS: 25.9 +/- 15.3 ms versus wide QRS: 28.6 +/- 14.4ms, both P<0.05 versus controls] was prolonged in both the narrow and wide QRS groups compared with normal controls. Similarly, the maximal difference in time to peak diastolic velocity [controls: 39 +/- 16.8 ms versus narrow QRS: 73.1 +/- 58ms versus wide QRS: 108.5 +/- 168 ms, both P<0.05 versus controls] and in standard deviation of time to peak early diastolic velocity of 12 LV segments [controls: 15.3 +/- 5.8ms versus narrow QRS: 25.1 +/- .13.8ms versus wide QRS: 25.5 +/- 14.9ms, both P<0.05 versus controls] was prolonged in both the narrow and wide QRS groups. The respective prevalence of systolic and diastolic asynchrony was 31.4% and 20%, in the narrow QRS group, and 40% and 28.6%, in the wide QRS group respectively.Stepwise multiple regression analysis showed that low ejection fraction and low mitral annular early diastolic velocity were independent predictors of both systolic and diastolic asynchrony. QRS complex duration was found to correlate only with diastolic asynchrony. LV systolic and diastolic mechanical asynchrony is common in patients with HF regardless of QRS duration. Selection for cardiac resynchronization treatment should also be based on information about systolic and diastolic synchronicity

Correlation between blood levels of CRP, TNT-alpha [as inflammatory factors], and IL-10 [as anti-inflammatory factor] and coronary artery disease

The results of a great amount of research done the world over in recent years have indicated that atherosclerosis is an inflammatory disease. Most of these investigations were conducted on the correlation between inflammatory factors such as CRP, Il- and Il-1 and atherosclerosis. In this study, we evaluated inflammatory factors such as CRP and TNF-alpha as well as anti-inflammatory factor IL-10 and analyzed the correlation between the balance of these factors with atherosclerosis. In total, 135 patients between the ages of 45 and 70 years who were admitted for coronary angiography were selected. All of the selected patients met the inclusion criteria for the research. After recording personal information, medical history, and any previous treatment in the questionnaire, blood samples were collected and levels of CRP [high-sensitive quantitative test], TNF-alpha, and IL-10 were measured in all the samples. We entered the acquired results, the routine blood examination, and the angiography results in the patients' charts and analyzed the results using statistical methods. The angiography results in the 135 patients were as follows: 19 [14.1%] cases had normal coronary arteries, 6 [4.4%] had minimal CAD, 43 [31.8%] had single-vessel disease, 29 [21.5%] two-vessel, and 38 [28.1] had three-vessel disease. In the laboratory tests, the mean CRP level in patients with normal coronary arteries was 6 +/- 4 mg/l, however in patients with CAD it was 17 +/- 9 mg/l. Also, the mean IL=10 level in cases with normal coronary arteries was 4.4 pgr/mL, while in patients with CAD it was 2.6 pgr/mL, and serum level of TNF-alpha in patients with CAD was 6.2 +/- 3.8 pgr/mL, whereas in cases with normal coronary arteries, the average serum level of TNF-alpha was 4.5 +/- 2.2 pgr/mL. The obtained results in this research showed a direct correlation between the blood levels of CRP and TNF-alpha with the existence and intensity of coronary artery disease. In addition, we found a reverse significant correlation between blood levels of IL-10 and existence of coronary artery disease. Although we found a correlation between reduced levels of IL-10 and intensity of coronary artery disease, it was not statistically significant. Furthermore, in patients with elevated blood levels of inflammatory and antiinflammatory factors, the intensity of the coronary artery disease was far less than that in patients with high levels of inflammatory factors and reduced levels of antiinflammatory factors. Therefore, we concluded that high levels of CRP and TNF-alpha and low levels of IL-10 had a significant correlation with the intensity of coronary artery disease and also the balance between these factors had a significant correlation with the intensity of the coronary artery disease

Comparative study of pulmonary function tests before and after successful percutaneous transvenous mitral commissurotomy

Mitral stenosis [MS] causes elevation of left atrial and pulmonary venous pressures. Persistent elevation of pulmonary venous pressure causes anatomical and physiological changes in lung vasculature and tissue, and change in lung volumes thereafter. Studies showed improvement of lung function with improvement of mitral stenosis and decrease in left atrial pressure and pulmonary congestion. This study was performed to evaluate lung volumes before and after percutaneous transvenous mitral commissurotomy [PTMC], including FEV1, PVC, SVC, and their percent and FEF of 25, 50, 75, 25-27 percent and PEFR before and within 48 h after PTMC, and to evaluate correlation of each with valve area. 26 from 51 patients with inclusion criteria stayed in the study with non-random consequential selection and the others were excluded. All of the patients had moderate to severe MS, good mitral valve morphology, echo score below 11, and absence of clot in the left atrium. Spirometery was done in all of the patients before and after PTMC and FEV1, FCV, SVC, FEF25%, FEF59%, FEF75%, FEF25-75% FEF1/FVC, and PEFR were measured. There were 26 patients [12 female, 14 male] with a mean age of 38.38 years old, miral valve area was 0.88 cm2 before and 1.46 cm2 after PTMC [mean 0.58 cm2 increase [p<.000]. Mean value of lung volumes and flow changes were: SVC change= 100 ml [p<0.1], FVC= 230 ml [p<0.0005], FEV1= 250 ml [p<0.003], FEF50%= 0.85 [p<0.004], FEF25%= 0.98 [p<0.003], and FEF25-75%= 0.71 [p<0.01]. Values for SVC, PEFR, and FEF75% and PEFR had no significant improvement. This may suggest improvement of small airway function due to a decrease in lung congestion

Health state valuation in Iran: an exercise on cardiovascular diseases using visual analogue scale method

Disability Weights [DWs] are main components for computing summary measure of population health [SMPH] and economic studies. They are specific for each community, but there are no previous studies in Iran. In this study, we investigated the feasibility of health state valuation [HSV] in Iranian population. Twelve cardiologists in 3 sessions of expert panels, defined 25 states, related to cardiovascular diseases [3 major and 22 specific diseases]. From January to March 2008, 80 persons in 4 groups including: physicians, patients, patients' families and general publics [each group 20], were interviewed and valuated the states, using visual analogue scale [VAS] method. SPSS[Registered] 15 for window[Registered] [SPSS Corporation, Chicago, Illinois] was used for statistical analysis. Data showed that the defined health states had various severities. All the 4 groups ranked the "3 major-diseases" and "very-mild" and "very-severe" states, similarly. Non-physicians were not able to differentiate among "valvular-diseases" and "pacemakers" properly. The reliability of responses was acceptable. VAS is an appropriate and reliable method for HSV in Iranian population. Non-physicians' opinions can be consider in major cardiac diseases. Valuation of more specific situations must perform by physicians

Comparison of transesophageal echocardiographic assessment of right and left atrial appendage functions

To define right atrial appendage functional parameters and comparing them with those of left atrial appendage. A consecutive series of 154 patients [76 males and 78 females] with mean age of 42 years were referred for transesophageal echocardiography. Ejection and filling velocities of right and left atrial appendages were measured at 120 and 70 degrees respectively. The left and right ventricles size and function, right atrial size, tricuspid regurgitation severity, and pulmonary artery systolic pressure were prospectively measured and calculated during transthoracic echocardiography. Mean right and left atrial appendages velocities were 42 +/- 18 cm/s and 50 +/- 26 cm/s respectively [PV<0.001]. Statistically significant positive association [PV<0.001] was found between right atrial appendage velocity and right ventricle ejection fraction and statistically negative relationship was observed between right atrial appendage velocity and smoke pattern [PV<0.001]. Also, the results suggested marginally significant associations between right atrial appendage velocity and right atrium size [PV = 0.05] and pulmonary artery systolic pressure [PV = 0.07]. It was also found that right atrial appendage measures were relatively independent on right ventricle size and tricuspid regurgitation severity. Our study showed right atrial appendage measures were relatively dependent on right ventricle function, right atrium size and pulmonary artery systolic pressure and relatively independent on right ventricle size and tricuspid regurgitation severity. In patients with right atrium smoky pattern right atrial appendage velocity was significantly reduced

Correlation of right ventricular DP/DT with functional capacity and RV function in patients with mitral stenosis

Evaluation of right ventricular [RV] contractility and systolic function in patients with right sided heart disease is an essential component of clinical management. The aim of this study was to assess RV systolic function by qualitative and quantitative methods and compare it to rate of ventricular pressure change during the isovolumic contraction period [dP/dt] as RV contractility index in patients with rheumatic mitral stenosis. In 56 consecutive patients with moderate to severe mitral stenosis, RV systolic function, RV dP/dt and dP/dt/Pmax, were calculated and compared. There was significant correlation between RV dP/dt and RV function [P < 0.001] and between RV dP/dt and New York Heart Association [NYHA] functional capacity [P < .001]. The mean of dP/dt was decreased with increasing severity of RV dysfunction [mean dP/dt was 648 +/- 159 for normal RV function, 592 +/- 126 for mild RV dysfunction, 319 +/- 146 for moderate RV dysfunction and 166 +/- 150 for severe RV dysfunction] Severity of tricuspid regurgitation and pulmonary hypertension had no significant effect on RV dP/dt and RV function. RV dP/dt/Pmax had also significant relationship with RV function and functional capacity [P < 0.001]. Measurements of dP/dt and dP/dt/Pmax, are practical methods for estimating RV contractility and results have a good correlation with RV systolic function and functional capacity

Multidetector CT evaluation of congenital heart disease: a pictorial essay

Multidetector computed tomography [MDCT] with or without ECG-synchronized images can successfully evaluate cardiac morphology and congenital heart diseases which mainly involve great vessels. In this pictorial essay, we present the great capability of MDCT for the evaluation of complex congenital heart disease

Coronary flow reserve measurement in the coronary sinus in pre and post CABG status

Coronary flow reserve [CFR] is defined as a maximal [hyperemic] to resting ratio of coronary blood flow. It is a physiologic parameter of coronary circulation and depends on the patency of the epicardial coronary arteries and integrity of the microvascular circulation.CFR measurement has many clinical applications including functional assessment of intermediate stenosis, detection of critical stenosis monitoring of coronary flow in the post angioplasty period, assessment of post infarct blood flow and assessment of coronary graft patency. The aim of this study was to measure CFR in the coronary sinus through the transthoracic echocardiographic approach, in patients who were candidate for coronary artery bypass graft surgery [CABG] before and one month after operation. The present study included 19 patients [mean age=56 +/- 9.1] including 15 males and 4 females, admitted for CABG. All patients had a sinus rhythm, normal wall thickness, normal RV systolic pressure, and tricuspid valvular regurgitation equal or less than grade 2. The antegrade phase of coronary flow in the coronary sinus moving into the right atrium was analyzed in two phases [systolic and diastolic]. Each wave was determined considering the peak velocity and velocity time integral [VTI]. The volumetric blood flow in the coronary sinus calculated at the baseline and then in hyperemic phase was used for determination of CFR both before and after CABG. There was a significant increase in the diameter of the coronary sinus after CABG [9.4 +/- 1.2mm] compared with that of before CABG values [8.6 +/- 1.05mm]. Also there was a trend of increasing the diameter in the hyperemic phase before and after CABG. The absolute increase in mean coronary sinus diameter was 0.5 mm before and 1.5 mm after CABG. Coronary flow reserve [CFR] was significantly higher after surgery, despite a significant increase in systolic velocity ratio [hyperemic/baseline] after CABG. This is also true for systolic velocity time integral [VTI] and diastolic VTI ratios, but there was an insignificant increase in diastolic velocity ratio. Our study in accordance with previous studies, denotes that transthoracic measurement of the coronary flow reserve can be used as a feasible and reproducible method to monitor the changes in cardiac perfusion after revascularization

Antiphospholipid antibody syndrome, a case of aortic valve insufficiency

A 31yearold woman was hospitalized for evaluation of aortic valve insufficiency and her present cardiac status. Clinical and paraclinical findings strongly suggested the presence of a collagen vascular inflammatory process precisely, the antiphospholipid antibody syndrome [APS], with systemic lupus erythematosus as the underlying disease

Very rare case of foreign body in the coronary artery

A 56year old man was admitted to our center for further evaluation of typical chest pain of ten months' duration. Selective coronary angiography was done and showed a sewing needle-like foreign body which was lying in very close proximity to the anatomic location of the right coronary artery. At operation two pieces of sewing needles were removed, one from the coronary sinus and the other from the right coronary artery before the crux

Thallium-201 stress test in 156 patients with suspected coronary artery disease

Currently, myocardial Tl-201 scintigraphy is most often performed in conjunction with exercise stress testing in patients with suspected or known CAD. Stress thallium tests were performed for 156 patients with and without old myocardial infarctions complaining of chest pain. All of them underwent contrast coronary angiography. Perfusion defects were mostly manifested as reversible defects [R]. Sensitivity of visual detection was generally 93%. The anteroseptal wall and septum showed defects more often than the other segments in patients with LAD stenosis. The inferolateral walls showed the least defects in RCA involvement. There was a significant difference between mean stenosis of LADs [90 +/- 10%] and CXs [82 +/- 11%] [P

Pulmonary arterio-venous fistula associated with deep vein tortuosity

A right to left pulmonary arterio-venous fistula was suspected clinically in a 21-year-old cyanotic male and confirmed by angiography and contrast echo-cardiography. An associated deep vein tortuosity of the lower extremity was documented by contrast venography

Right ventricular fatty infiltration in mitral stenosis, a rare cause of surgical failure

A 47 year-old female died after mitral valve replacement. Post-cardio pulmonary bypass right ventricle was not able to pump despite good left ventricular contractility. At microscopic examination, diffuse right ventricular fatty infiltration was found. We found no previous report of this pathology in patients with mitral stenosis