Compare CPM-RMI trial: intramyocardial transplantation of autologous bone marrow-derived cd133+ cells and mononuclear cells during coronary artery bypass grafting in patients with recent myocardial infarction: a phase II/III, multicenter, placebo-controlled, randomized, double-blind clinical trial

Objective: The regenerative potential of bone marrow-derived mononuclear cells [MNCs] and CD133+ stem cells in the heart varies in terms of their pro-angiogenic effects. This phase II/III, multicenter and double-blind trial is designed to compare the functional effects of intramyocardial autologous transplantation of both cell types and placebo in patients with recent myocardial infarction [RMI] post-coronary artery bypass graft

Materials and Methods: This was a phase II/III, randomized, double-blind, placebo-controlled trial COMPARE CPM-RMI [CD133, Placebo, MNCs - recent myocardial infarction] conducted in accordance with the Declaration of Helsinki that assessed the safety and efficacy of CD133 and MNCs compared to placebo in patients with RMI. We randomly assigned 77 eligible RMI patients selected from 5 hospitals to receive CD133+ cells, MNC, or a placebo. Patients underwent gated single photon emission computed tomography assessments at 6 and 18 months post-intramyocardial transplantation. We tested the normally distributed efficacy outcomes with a mixed analysis of variance model that used the entire data set of baseline and between-group comparisons as well as within subject [time] and group×time interaction terms

Results: There were no related serious adverse events reported. The intramyocardial transplantation of both cell types increased left ventricular ejection fraction by 9% [95% confidence intervals [CI]: 2.14% to 15.78%, P=0.01] and improved decreased systolic wall thickening by -3.7 [95% CI: -7.07 to -0.42, P=0.03]. The CD133 group showed significantly decreased non-viable segments by 75% [P=0.001] compared to the placebo and 60% [P=0.01] compared to the MNC group. We observed this improvement at both the 6- and 18-month time points

Conclusion: Intramyocardial injections of CD133+ cells or MNCs appeared to be safe and efficient with superiority of CD133+ cells for patients with RMI. Although the sample size precluded a definitive statement about clinical outcomes, these results have provided the basis for larger studies to confirm definitive evidence about the efficacy of these cell types

Assessment of subclinical left ventricular dysfunction in patients with chronic mitral regurgitation using torsional parameters described by tissue doppler imaging

Left ventricular [LV] twist is due to oppositely directed apical and basal rotation and has been proposed as a sensitive marker of LV function. We sought to assess the impact of chronic pure mitral regurgitation [MR] on the torsional mechanics of the left human ventricle using tissue Doppler imaging. Nineteen severe MR patients with a normal LV ejection fraction and 16 non-MR controls underwent conventional echocardiography and apical and basal short-axis color Doppler myocardial imaging [CDMI]. LV rotation at the apical and basal short-axis levels was calculated from the averaged tangential velocities of the septal and lateral regions, corrected for the LV radius over time. LV twist was defined as the difference in LV rotation between the two levels, and the LV twist and twisting/untwisting rate profiles were analyzed throughout the cardiac cycle. LV twist and LV torsion were significantly lower in the MR group than in the non-MR group [10.38° +/- 4.04° vs. 13.95° +/- 4.27°; p value = 0.020; and 1.29 +/- 0.54 °/cm vs. 1.76 +/- 0.56 °/cm; p value = 0.021, respectively], both suggesting incipient LV dysfunction in the MR group. Similarly, the untwisting rate was lower in the MR group [-79.74 +/- 35.97 °/s vs.-110.96 +/- 34.65 °/s; p value = 0.020], but there was statistically no significant difference in the LV twist rate. The evaluation of LV torsional parameters in MR patients with a normal LV ejection fraction suggests the potential role of these sensitive variables in assessing the early signs of ventricular dysfunction in asymptomatic patients

rare case of congenital heart disease with bifid cardiac apex: a unique finding in left ventricle

Bifid cardiac apex is a rare anomaly of human hearts. We report of the case of a 34-year-old man with a previous history of ventricular septal defect [VSD] and subvalvular pulmonary stenosis. He had undergone pulmonary commissurotomy and VSD closure 22 years before he was referred to our center for evaluation of progressive dyspnea. Transthoracic echocardiography revealed atrial septal defect [ASD], multiple VSDs, severe pulmonary regurgitation, and a bifid cardiac apex. The patient was referred for re-do surgery for ASD and VSD closure along with pulmonary valve replacement, but he refused the surgery

Noninvasive localization of accessory pathways in patients with Wolff-Parkinson-White syndrome: a strain imaging study

Noninvasive techniques for the localization of the accessory pathways [APs] might help guide mapping procedures and ablation techniques. We sought to examine the diagnostic accuracy of strain imaging for the localization of the APs in Wolff-Parkinson-White syndrome. We prospectively studied 25 patients [mean age = 32 +/- 17 years, 58.3% men] with evidence of pre-excitation on electrocardiography [ECG]. Electromechanical interval was defined as the time difference between the onset of delta wave and the onset of regional myocardial contraction. Time differences between the onset of delta wave [delta] and the onset of regional myocardial contraction [delta-So], peak systolic motion [delta-Sm], regional strain [delta-epsilon], peak strain [delta-epsilonp], and peak strain rate [delta-SRp] were measured. There was a significant difference between time to onset of delta wave to onset of peak systolic motion [mean +/- SD] in the AP location [A] and normal segments [B] versus that in the normal volunteers [C] [A: [57.08 +/- 23.88 msec] vs. B: [75.20 +/- 14.75] vs. C: [72.9 0 +/- 11.16]; p value [A vs. B] = 0.004 and p value [A vs. C] = 0.18] and [A: [49.17 +/- 35.79] vs. B: [67.60 +/- 14.51] vs. C: [67.40 +/- 6.06 msec]; p value [A vs. B] < 0.001 and p value [A vs. C] = 0.12, respectively]. Our study showed that strain imaging parameters [[delta-So] and [delta-Strain]] are superior to the ECG in the localization of the APs [84% vs. 76%]

role of echocardiography in coronary artery disease and acute myocardial infarction

Echocardiography is a non-invasive diagnostic technique which provides information regarding cardiac function and hemodynamics. It is the most frequently used cardiovascular diagnostic test after electrocardiography and chest X-ray. However, in a patient with acute chest pain, Transthoracic Echocardiography is essential both for diagnosing acute coronary syndrome, zeroing on the evaluation of ventricular function and the presence of regional wall motion abnormalities, and for ruling out other etiologies of acute chest pain or dyspnea, including aortic dissection and pericardia! effusion. Echocardiography is a versatile imaging modality for the management of patients with chest pain and assessment of left ventricular systolic function, diastolic function, and even myocardial and coronary per fusion and is, therefore, useful in the diagnosis and triage of patients with acute chest pain or dyspnea. This review has focused on the current applications of echocardiography in patients with coronary artery disease and myocardial infarction

Partially unroofed coronary sinus with intact atrial septum in an elderly patient

We present a very rare case of partially unroofed coronary sinus without persistent left superior vena cava in a 74 years old female with a history of hypertension, severe myxomatous bileaflet mitral valve prolapse with severe eccentric mitral regurgitation which was diagnosed during cardiac surgery

Obvious or subclinical right ventricular dysfunction in diabetes mellitus [type II]: an echocardiographic tissue deformation study

Diabetes mellitus is capable of impairing the myocardial function. Several studies have documented the influential impact of diabetes mellitus on the left ventricular function. The right ventricular function plays a significant role in the overall myocardial contractility; hence, this study was undertaken to evaluate the effect of diabetes mellitus type II on the right ventricular function. Twenty-two diabetic patients without any coronary artery disease, hypertension, or left ventricular dysfunction were studied. The right ventricular end diastolic diameter, tricuspid plane systolic excursion, right ventricular inflow Doppler parameters, longitudinal myocardial velocities, and deformation indices from the basal and apical segments of the right ventricular free wall of the case group were measured. The control group consisted of 22 healthy individuals. The tricuspid annular plane systolic excursion [TAPSE] and tricuspid peak early to peak late diastolic flow velocities ratio [E/A] in the diabetic patients were significantly lower than those of the control group patients [18.9 vs. 23.2, p value < 0.001 and 0.96 vs. 1.21, p value = 0.012], but there were no significant differences in the right ventricular end diastolic diameter and the right ventricular Tei index between the two groups [p value = 0.72]. The right ventricular basal peak myocardial systolic velocity [SM] [12 cm/sec vs. 13.4 cm/sec; p value = 0.03], basal and apical right ventricular free wall systolic strain [-13.3% and -18.7% vs. -20.2% and -25.7%; p value = 0.001], and apical strain rate [-1.2 1/s vs. -1.6 1/s; p value = 0.008] were significantly lower in the study group. There was a weak correlation between the right ventricular function and HbA1c as well as the duration of diabetes mellitus and C-reactive protein. Our results suggest that diabetes mellitus type II can influence the right ventricular function in the absence of coronary artery disease, diastolic dysfunction, and pulmonary hypertension

evolutionary development of echocardiography

Echocardiography is a non-invasive diagnostic technique which provides information on cardiac morphology, function, and hemodynamics. It is the most frequently used cardiovascular diagnostic test only after electrocardiography. In less than five decades, the evolution in this technique has made it the basic part of cardiovascular medicine. Herein, the evolution of various forms of echocardiography is briefly described

Physician-related factors affecting cardiac rehabilitation referral

Despite the positive impact of cardiac rehabilitation [CR] on quality of life and mortality, the majority of people who could benefit from this program fail to participate in it. The lack of referral from the physician is a common reason that patients give for not seeking CR. The objective of this study was to compare factors affecting CR referral by cardiologists. A cross-sectional survey of 122 cardiologists, including 89 general cardiac specialists and 33 fellows in cardiology from 11 major cardiology training centers in Iran, was done in 2010. They responded to the 14- item investigatorgenerated survey, examining the physician's attitudinal and knowledge factors affecting CR referral. 47.9% of the subjects reported having available CR centers but only 6.6% reported continuous medical education on the topic. 90.7% of the physicians reported that less than 15% of patients are referred to CR centers. The main factor affecting the low referral rate was limited general knowledge about CR programs [79.5%] such as program attributes and benefits, methods of reimbursement. Lack of insurance coverage, unavailability of CR centers in the community and low physicians' fee were other factors reported by the physicians. Cardiologists' inadequate general knowledge of and attitude toward CR programs seem to be a potential threat for cardiac prevention and rehabilitation in some societies

Factors associated with failure to complete phase ii cardiac rehabilitation: survey registry in rajaie cardiovascular medical and research center

A significant proportion of patients who begin CR [cardiac rehabilitation] do not complete the program. The purpose of this study was to determine the predicting factors that interfere with adherence and completion of an outpatient CR program. A cross-sectional survey was conducted with all 128 patients who entered the CR program at the Rajaie Cardiovascular Medical and Research Center in Tehran, IR Iran, from March 2009 to March 2010. The demographic variables included age, sex, education, employment status, insurance status, and return to work. These variables were compared in patients who completed and did not complete phase II CR. The reason for CRincompletion was asked in follow-up phone interviews. The most frequent clinical diagnosis among the patients enrolled in the CR program was coronary artery disease. 83.6% of patients who participated had a CABG or PCI procedure during the last year. CR participation increased when cardiac revasculariza-tion procedures were performed during the first hospitalization. 88 of the 128 patients dropped out, yielding a dropout rate of 68.7%, which was significantly [P < 0.01] higher than the same study in other countries. Sex and age did not predict the completion rate. As education increased, cardiac rehabilitation utilization and completion increased. Unemployed patients were less likely than employed patients to complete the program. Our data indicate a low rate of CR completion, with lower rates among unemployed, uninsured, and less educated patients

Anomalous origin of the left coronary artery from the pulmonary artery [ALCAPA] in an old adult

The anomalous origin of the left coronary artery from the pulmonary artery [ALCAPA] is a rare congenital cardiac malformation. It presents predominantly in infancy and its main presenting feature is myocardial ischemia or heart failure. Survival to adulthood is quite uncommon. If untreated, mortality from ALCAPA approaches 90% in infancy; early recognition and surgical correction are, therefore, essential. With early surgical correction, the prognosis is good. There are two types of ALCAPA syndrome: the infant type and the adult type, each of which has different manifestations and outcomes. Infants experience myocardial infarction and congestive heart failure, and approximately 90% die within the first year of life. A literature review regarding this anomaly in teenagers and adults show that only 25 cases have been diagnosed during life and 18 additional cases of ALCAPA in these age groups have been diagnosed post mortem. We present a rare case of a 60-year-old man, who referred to our center due to dyspnea on exertion from the previous year without any history of chest pain and diagnosed as ALCAPA. Given the absence of ischemia and the patient's age, only medical therapy was recommended

Percutaneous mitral balloon valvotomy; single center experience: a review of outcome

Percutaneous balloon mitral valvotomy [BMV] has been accepted as an alternative to surgical mitral commissurotomy in the treatment of patients with symptomatic rheumatic mitral stenosis. Despite the worldwide use of the BMV technique, no studies have been hitherto designed to assess the outcome of the patients undergoing BMV in Iran. The present study reports the outcome of 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center during a 15-year time period. A total of 2531 patients underwent 3138 BMV procedures at Shaheed Rajaei Cardiovascular, Medical and Research Center between 1992 and 2006. Seventy-three percent [2278] of the cases were followed for 48 +/- 41 months. Recurrent stenosis in 802 [25.8%], mitral valve replacement [MVR] in 213 [6.9%], immediate good result in 3110 [99.1%], and successful outcome in 2000 [72.9%] cases were the outcome of the BMV procedures in the current study. Concordant to the similar studies, we concluded that BMV produces a good clinical outcome in a high percentage of patients. The recent study demonstrated that the successful outcome of BMV was multi factorial and the selection of patients with rheumatic mitral stenosis is recommended to be based on both anatomic and clinical characteristics of the individuals. The procedure-related variables must also be considered in order to predict the outcome

Fragmented QRS complex in acute anterior myocardial infarction and coronary sinus blood flow: is there any relevance?

Patients with QRS fragmentation following myocardial infarction [MI] are at greater risk of cardiac death. Transthoracic echocardiography [TTE] can be used as a method for evaluating the coronary sinus blood flow [CSBF] and coronary sinus velocity time integral [CSVTI]. The present study reports measurement of CSBF and CSVTI by TTE in 100 acute anterior MI cases, half of them with fragmented QRS. Our study included 100 patients with acute anterior MI in whom CSBF and CSVTI were measured by the use of TTE. Fifty of all the patients had fragmented QRS complex and 50 patients were without fragmented QRS complex, while there was no difference in terms of LVEF in both groups of study. CSBF [303 +/- 126 ml/min vs. 258 +/- 121 ml/min; p-0.001] and CSVTI [14.45 +/- 2.85 ml vs. 10.85 +/- 2.69 ml; p=0.003] were significantly lower in the acute anterior MI patients with fragmented QRS in comparison with the patients with acute anterior MI without fragmented QRS. We conclude that CSBF and CSVTI can be measured by TTE in acute MI patients and these variables are reduced in acute anterior MI patients with fragmented QRS

Papillary muscle rupture after benttal operation: is it necessary to Do CABG in high-risk patients?

Papillary muscle rupture following acute myocardial infarction [AMI], which rarely occurs, leads to catastrophic outcomes. A 56-year-old man with sudden dyspnea and palpitation, one episode syncope, and left sided hemiparesis was admitted to our hospital and diagnosed as type A dissection with extension to the aortic arch and descending aorta. The patient underwent the Benttal and hemi-arch procedure. On the 16[th] postoperative day, he suddenly developed hypotension and respiratory distress. Urgent echocardiography showed severe acute mitral regurgitation due to the rupture of the posteromedial papillary muscle. Urgent mitral valve replacement was done but unfortunately the patient died two weeks after the second surgery because of sepsis. We propose that during urgent cardiac surgery in a patient with coronary risk factors, concomitant coronary artery bypass graft be performed as thoroughly as possible

Prosthetic pulmonary valve malfunction

Prosthetic heart valve thrombosis is a serious complication in which systemic thrombolysis has emerged as a suitable alternative to surgery, especially for right-sided prosthetic valve thrombosis. We report the case of a thrombosed Carbomedics Medical prosthetic valve placed in the pulmonary position in a patient who had undergone total repair of tetralogy of Fallot, which was successfully treated with intravenous thrombolytic therapy with streptokinase

Fungal endocarditis: review of our cases over a four-year period

Over a 4-year period, we studied six cases of fungal endocarditis, four of which were caused by Aspergillus sp. And the other two were candidal in origin. Both sides of the heart showed involvement by these infections. The vegetations of infective endocarditis tend to vary in size, but fungal lesions are often large. Our youngest patient was four months old and the oldest one was 62 years old. A high index of clinical suspicion, together with histopathological and microbiological studies, can be used as tools to diagnose and treat such patient in due course. It is important to send fresh specimens for tissue culture studies in sterile normal saline and not in fixatives such as formaladehyde. Pathologically, not only are the special staining methods such as Periodic acid-Schiff useful in the demonstration of fungal elements in tissue or vegetation sections, but also the routine hematoxylin and eosin stain is capable of showing these structures clearly

Neglected inferior sinus venosus atrial septal defect diagnosed late after surgical closure of secundum ASD

We descried neglected inferior sinus venosus a trial septal defect in a patient with history of surgical repair of secundum type ASD nineteen years ago. The defect was in the inferior portion of the interatrial septum just at the orifice of the inferior vena cava, far from the previous surgical patch of the secundum ASD repair. Preoperative and/or intraoperative transesophageal echocardiography is necessary for detection of multiple ASDs and reveals the successful repair of sinus venosus defects

Evaluation of longitudinal right ventricular mechanical dyssynchrony before and early after cardiac resynchronization therapy: a strain imaging study

The right ventricular [RV] dyssynchrony has not been extensively and the existing literature has established the effect of cardiac resynchronization therapy [CRT] on the left ventricular [LV] dyssynchrony, but there is a death of data on the effect of CRT on the forgotten ventricle. We sought to evaluate the presence of mechanical right ventricular dyssynchrony in patients with systolic heart failure, selected for CRT, and track the changes early afterward utilizing the longitudinal strain analysis. Thirty-six patients with severe left ventricular systolic dysfunction, candidated for CRT, were enrolled in this study. Mechanical dyssynchrony was assessed using tissue Doppler echocardiography. The time interval between the onset delay was calculated as the absolute value of the difference in the time-to-peak measurements between the RV and spetum. The RV dyssynchrony was defined as the calculated delay in strain imaging, which was +/- 2 SD above the mean value for the control subjects [20 cases]. The RV function was evaluated using the RV fractional area change [RVFAC], tricuspid annulus plane systolic excursion [TAPSE], and peak systolic strain values of the RV free wall. Four to 7 days after CRT implantation, echocardiographic reevaluations were done. The calculated cut-off value for the RV dyssynchrony was 41.5 msec, according to which the pre-CRT analysis specified two patient groups: Group 1 [16 cases] with RV dyssynchrony and Group 2 [20 patients] without RV dyssynchrony. Significant improvement in the RV dyssynchrony was noted in Group 1 after CRT [30 +/- 28.9 msec vs. 68.8 +/- 21 msec; p value <0.01 vs. 14 +/- 10 msec vs. 19 +/- 16.5 msec; p value = 0.18 respectively]. A significant correlation was found between the severity of the RV dyssynchrony and peak systolic strain in the RV free wall [r = -0.5; p value <0.05]. No significant relation was found between the RV dyssynchrony and right ventricle fractional area change [RVFAC], LV mechanical dyssynchrony, time-to-peak systolic strain in the RV free wall, QRS width, or morphology. In group I, the peak systolic strain increased insignificantly [p value = 0.15 for the basal segment; p value = 0.20 for the mid segment]. A moderately significant correlation was found between the RV mechanical delay before CRT vs. the post-CRT values [r = 0.4; p value = 0.01]. Early after CRT, the RV mechanical delay can improve and the significant improvement is seen in patients with baseline RV mechanical dyssynchrony

Evaluation of the relation between anterior mitral valve leaflet motion based on height-to-length ratio and the immediate outcome of percutaneous balloon mitral valvuloplasty

The purpose of this study was to investigate whether there is any relation between mitral leaflet motion based on height-to-length ratio of the anterior mitral valve leaflet doming in diastole and the immediate outcome of balloon mitral valvuloplasty,. The study population consisted of 49 patients [47 women, mean age: 43.7 +/- 13.35 years] with symptomatic rheumatic mitral stenosis who underwent balloon valvuloplasty. Complete transthoracic and transesophageal studies were performed in all the patients before valvuloplasty, and transthoracic study was repeated 24-48 hours after valvuloplasty. The severity of the restriction of the mitral valve leaflet motion was classified based on the heightto- length ratio of the anterior mitral valve leaflet doming. Mitral valve thickness, calcification, subvalvular thickening, and mobility were scored according to the Wilkins system. Optimal immediate outcome of balloon mitral valvuloplasty was defined as a valve area improvement of 50% or more or a final mitral valve area of >/= 1.5 cm[2] and mitral regurgitation Sellers' grade >/= 2. There was a significant relation between the total mitral valve score and its thickness with the optimal immediate post-balloon mitral valvuloplasty results [p value=0.03 and 0.04, respectively], but no relation was found between the Wilkins score and its components with the anterior mitral valve leaflet height-to-length ratio. There was no significant relationship between the amount of increase in the mitral valve area, decrease in trans-mitral pressure gradients, decrease in pulmonary artery pressure, and anterior mitral leaflet height-to-length ratio [all p values>0.05; all the correlation coefficients<0.2]. Our study showed that post-balloon mitral valvuloplasty results are mainly affected by valve thickness and the total Wilkins score. In addition, the severity of mitral leaflet motion restriction in terms of the height-to-length ratio of the anterior mitral valve leaflet has no significant relation with the immediate result of balloon mitral valvuloplasty

Timely diagnosis of left ventricular posterior wall rupture by echocardiography: a case report

Left ventricular free wall rupture is responsible for up to 10% of in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction, and its antemortem diagnosis is rarely made. One of the medical complications of myocardial infarction is the rupture of the free wall, which occurs more frequently in the anterolateral wall in hypertensives, women, and those with relatively large transmural myocardial infarction usually 1-4 days after myocardial infarction. We herein present the case of a 66-year-old man suffering inferior wall myocardial infarction with abrupt hemodynamic decompensation 9 days after myocardial infarction. Emergent transthoracic echocardiography revealed massive pericardial effusion with tamponade, containing a large elongated mass measuring 1 x 8cm suggestive of hematoma secondary to cardiac rupture. In urgent cardiac surgery, the posterior wall between the left coronary artery branches was ruptured