The Prevention and Cardiac Rehabilitation Group of the Saudi Heart Association Recommendations Regarding Establishing a Cardiac Rehabilitation Service.

Cardiac rehabilitation (CR) is a cornerstone in the secondary prevention of cardiovascular disease (CVD). Comprehensive cardiac rehabilitation has obtained the highest class of recommendation and the level of evidence for the treatment of patients with ST-segment elevation myocardial infarction, after myocardial revascularization, with chronic coronary syndromes, and in patients with heart failure (HF). Comprehensive cardiac rehabilitation should be implemented as soon as possible, be multi-phasic, and adjusted to the individual needs of the patient. CR is still suboptimally used, and many cardiac centers do not have such services (2). The provision of CR services should be based on standards and key performance indicators, and guidelines containing a minimum standard of cardiac rehabilitation utilization should be published to improve the quality of the CR program. This document presents an expert opinion that summarizes the current medical knowledge concerning the goals, target population, organization, clinical indications, and implementation methods of the CR program in the Kingdom of Saudi Arabia.

Association Between COVID-19 Infection and Cardiac Biomarkers in Hospitalized Patients at a Tertiary Care Center.

Background The effects of coronavirus disease 2019 (COVID-19) on the cardiovascular system are well established. However, knowledge gaps in the clinical implications of cardiac involvement in COVID-19 patients are yet to be addressed. This study aimed to investigate acute cardiac injury (ACI) risk factors and outcomes associated with COVID-19 infection with cardiac involvement. Methodology In this retrospective study, we included hospitalized patients between March 2020 and May 2022 with confirmed COVID-19 infection and evidence of cardiac involvement. Results In total, 501 patients were included, of whom 396 (79%) had evidence of ACI. The median troponin level was 25.8 (interquartile range (IQR) = 10.8-71). Patients with evidence of ACI were significantly more likely to have diabetes mellitus (75% vs. 60%), cardiovascular disease (48% vs. 37%), chronic lung disease (22.2% vs. 12.4%), and chronic kidney disease (32.3% vs. 16.2%). Additionally, patients with ACI were significantly more likely to have cardiomegaly (60.6% vs. 44.8%) and bilateral lobe infiltrates (77.8% vs. 60%) on X-ray. Patients with ACI were significantly more likely to suffer from complications such as cardiogenic shock (5.3% vs. 0%), pneumonia (80.1% vs. 65.7%), sepsis (24.2% vs. 9.5%), and acute respiratory distress syndrome (33.1% vs. 8.6%). Patients with ACI were also significantly more likely to be admitted to the intensive care unit (ICU) (57% vs. 26.7%) and significantly more likely to die (38.1% vs. 11.4%). The results of the multivariate regression analysis indicated that mortality was significantly higher in patients with elevated troponin levels (adjusted odds ratio = 4.73; 95% confidence interval = 2.49-8.98). Conclusions In COVID-19-infected patients, old age, diabetes mellitus, cardiovascular disease, chronic lung disease, and chronic kidney disease were associated with an increased risk of ACI. The presence of ACI in the context of COVID-19 infection was noted to increase the risk for severe complications, such as cardiogenic shock, ICU admission, sepsis, and death.

The Gulf Achievement of Cholesterol Targets in Out-Patients Study (GULF ACTION): Design, Rationale, and Preliminary Results.

AIM: To assess the current dyslipidemia management in the Arabian Gulf region by describing the demographics, study design, and preliminary results of out-patients who achieved low-density lipoprotein cholesterol (LDL-C) goals at the time of the survey. BACKGROUND: The Arabian Gulf population is at high risk for atherosclerotic cardiovascular disease at younger ages. There is no up-to-date study regarding dyslipidemia management in this region, especially given the recent guideline-recommended LDL-C targets. OBJECTIVE: Up-to-date comprehensive assessment of the current dyslipidemia management in the Arabian Gulf region, particularly in view of the recent evidence of the additive beneficial effects of ezetimibe and proprotein convertase subtilisin/kexin-9 (PCSK-9) inhibitors on LDL-C levels and cardiovascular outcomes. METHODS: The Gulf Achievement of Cholesterol Targets in Out-Patients (GULF ACTION) is an ongoing national observational longitudinal registry of 3000 patients. In this study, adults ≥18 years on lipidlowering drugs for over three months from out-patients of five Gulf countries were enrolled between January 2020 and May 2022 with planned six-month and one-year follow-ups. RESULTS: Of the 1015 patients enrolled, 71% were male, aged 57.9±12 years. In addition, 68% had atherosclerotic cardiovascular disease (ASCVD), 25% of these patients achieved the LDL-C target, and 26% of the cohort were treated using combined lipid-lowering drugs, including statins. CONCLUSION: The preliminary results of this cohort revealed that only one-fourth of ASCVD patients achieved LDL-C targets. Therefore, GULF ACTION shall improve our understanding of current dyslipidemia management and "guideline gaps" in the Arabian Gulf region.

Correlation Between Different Parameters of Acute Myocardial Infarction and Obesity.

OBJECTIVE: To study if obesity had a detrimental effect on troponin after acute coronary syndrome. We investigated the effects of the body mass index (BMI) in post-myocardial infarction (MI) patients, and see the difference in troponin levels and other parameters between normal and overweight patients. METHODOLOGY: A retrospective cohort study was conducted. Data were extracted from the electronic medical files of patients hospitalized due to acute ST-elevation MI to examine the association between BMI and MI. Sixty-one patients were categorized into normal BMI category, overweight, and obese/morbid obesity groups using the baseline measurements, to assess the independent factors associated with a patient with a high BMI who had a MI. RESULTS: In total, 61 post-myocardial infarction patients with a mean age of 56.9 ± 11.2 years were included in the study. The average BMI was 28.5 ± 6.5 kg/m2. Just more than a third (37.4%, n=23) were in the normal BMI category, 19 (31.2%) overweight, and 19 (31.2%) obese/morbid obesity. The mean left ventricle mass was 93.74 ± 32.69 gram and the mean left ventricular ejection fraction was 44.02% ± 10.02. A significant difference in the mean level of troponin and mean heart rate between the body mass index groups (normal vs. overweight groups) was noted. A fair correlation was noted between BMI and left ventricle mass. No statistically significant relation could be linked to high BMI with total cholesterol, low-density lipoprotein (LDL), or aspartate transferase/alanine transaminase (AST/ALT) levels. CONCLUSIONS: In this pilot study, the group with a high BMI had a statistically significant lower troponin level and higher mean heart rate. Such data need to be considered when assessing a patient's risk. In addition, obese persons with a MI had a higher left ventricle mass.

Right-sided infective endocarditis and pulmonary embolism: a multicenter study.

The incidence of right-sided infective endocarditis (RSIE) is steadily increasing and it has been reported to be associated with high risk of embolic events (EE). Aim of our study was to identify the clinical characteristics of patients with RSIE complicated by PE. Indeed, the identification of patients at high risk of significant PE who will benefit from a more aggressive therapeutic strategy may improve the prognosis. From January 2015 to September 2020, 176 patients (Pts) in 6 centers were found to have definite RSIE complicated by PE. Advanced imaging for PE including computed tomography pulmonary angiography (CTPA) was performed in 28 pts (16%) who represent our study group (24 male, mean age 50.6 ±18.29 years). They all underwent transesophageal echocardiography (TEE), in 12 cases (43%) also three-dimensional (3D) TEE, and 27 patients (99%) had both TEE and transthoracic echocardiography (TTE). A total of 53 vegetations (V) were detected. In 18 pts (64%) two or more vegetations were found. Native tricuspid valve was the most frequently involved valve (38 V, 71.7%), followed by catheter (5 V, 9.4%), tricuspid valve prosthesis (4 V, 7.5%), chordae and papillary muscle (2 V, 3.8%) and one vegetation (9%) in each of the following: pulmonic valve, inferior vena cava, eustachian valve, and right atrium. The most common location for vegetations was the anterior leaflet of the tricuspid valve (19 V, 35.8 %) followed by the posterior leaflet (11 V, 20.8%). The most common vegetations morphology was raceme-like shaped (35.8%). Staphylococcus aureus (S. aureus) was the most common causative pathogen (14 pts, 50%). The incidence of PE was very high in patients with vegetation length above 1.5 cm (median 17.6±6.5 mm by TEE). Our results suggest that a routine CTPA should be advised in the presence of vegetations larger than 1.5 cm and with S. aureus infection. This behavior would identify patients at high risk of PE who will benefit from a more aggressive therapeutic strategy, leading to an improvement in the prognosis. Further prospective studies are required to better confirm our hypothesis.

Identification of Novel and Known LDLR Variants Triggering Severe Familial Hypercholesterolemia in Saudi Families.

BACKGROUND: Familial hypercholesterolemia (FH) is a common illness mainly caused by variants occurring in the low-density lipoprotein receptor (LDLR) gene. FH is a leading cause of coronary artery disease. OBJECTIVE: This study aims to determine genetic defect(s) in homozygous and heterozygous FH index patients and their first-degree blood relatives and understand the genotype-phenotype correlation. METHODS: This study employed the genetic screening of FH-related genes by next-generation sequencing and cascade screening by capillary sequencing. RESULTS: We identified the presence of a novel frameshift variant [c.335_336insCGAG, p.(F114Rfs*17)] and three known missense variants [c.622G>A, p.(E208K)], [c.1474G>A, p.(D492N)], [c.1429G>A, p.(D477N)] in the LDLR gene of four unrelated Saudi families with FH. In proband 1, a nonsense variant c.1421C>G, p.(S474*) was also detected at exon 9 of the lipoprotein lipase gene. The segregation arrangement of the identified variants corresponded with the clinical characteristics. In this study, all the detected variants were confined in the ligand-binding domain and epidermal growth factor (EGF)-precursor homology domain of the LDLR protein, which portrayed severe clinical phenotypes of FH. Moreover, these LDLR variants were in a highly conserved residue of the proteins. CONCLUSION: In addition to the finding of the novel variant in the LDLR gene that extends the spectrum of variants causing FH, the results of this study also support the need for diagnostic screening and cascade genetic testing of this high-risk condition and to understand the genotype-phenotype correlation, which could lead to better prevention of coronary artery disease.

Loss of engagement in controlling chronic anticoagulation therapy during Covid-19 stringency measures. A single center experience of disproportioned increase of stuck mechanical valves.

Stuck valve is a very rare and severe complication that occurs in mechanical valve replacement patients with ineffective anticoagulation. However, with COVID-19 restriction measures, it became challenging to regularly assess INR to make sure it falls within the target therapeutic range to prevent this complication. We present a series of 10 patients who either underwent transthoracic echocardiography for a suspected stuck valve or were seen at the outpatient valve clinic with the residual consequences of a stuck valve during the COVID-19 restriction measures in our institute. Stuck prosthetic valves incident has increased significantly during this period, particularly those in the mitral position for which urgent replacement and prolonged hospitalization were necessary. Particularly with the COVID-19 restrictions in place, these cases highlight the need for physicians to be aware of the dramatic increase in the incidence of stuck prosthetic valves in patients on chronic warfarin therapy.

A Community-Based, Cross-Sectional Study Assessing the Level of Awareness and Insight Related to Cardiovascular Diseases.

Objective The disease outcome had been shown to improve with improving patient knowledge. The study had two objectives, firstly to assess the level of knowledge about cardiovascular diseases (CVDs) in the general population, and secondly, to provide written educational material regarding the risk factors, major symptoms, and the prevention of CVDs. Method The target population was the residents living in the Western region of Saudi Arabia, aged 18 years and above. All were invited to participate voluntarily. A pre-structured questionnaire was designed to collect data related to age, gender, marital status, education level, occupation, lifestyle habits, and a history of heart diseases, as well as cardiac symptoms, and risk factors. The educational material was provided after the questionnaire. Results The majority of the participants were female (74.8%). The risk factors most frequently identified were lack of exercise, stress, and obesity. Chest pain was recognized as a major symptom (87.6%). Other symptoms included dyspnea, syncope, and excessive sweating. The level of knowledge regarding the risk factors for cardiovascular disease was poor. Only 18.5% were knowledgeable about the risk factors. The majority (60%) could identify the preventable factors, including smoking cessation (92.2%), a high level of cholesterol (88.6%), and hypertension (78.7%). The majority (83.7%) read the educational material and 99% reported that the lecture increased their knowledge about cardiovascular disease. Conclusion Although cardiovascular risk factors are common, there is a big gap in the knowledge in our population. Further, alarming symptoms that bring the patients to medical care are also deficient. A call for action at different levels is urgent. Simple educational material in a basic language and virtual education are useful and cheap tools that must be practiced wherever possible. Education is welcomed by the participants.

A Field-Based Study of the Magnitude of Risk Factors and Health Habits in Young Volunteers in the Community.

Objective A field study is more informative in terms of epidemiological data than a hospital-based study. Undiagnosed risk factors may be discovered in an asymptomatic group. This study aimed to estimate if the community was well informed about the risk factors for coronary artery disease and if that affected the prevalence and the anthropometric among those who participated in the study. Materials and methods A cross-sectional study was conducted, using a consecutive sampling technique. Individuals were interviewed in terms of the risk factors and clinical signs and symptoms. The anthropometric measurements were done on-site to identify asymptomatic risk factors. The survey was utilized to increase the awareness among the participants. Results In total, 193 individuals participated in this study. The mean age of the sample was 36.3 ± 12.4 years, with 53% male. Smoking was the most frequent risk factor (31.6%), followed by dyslipidemia (22.5%), hypertension (16.6%), and diabetes mellitus (14.5%). Almost half of the sample participated in sports for one to two hours per week (40%). Almost all consumed fast food at least once a week, and 16.6% consumed fast food more than four times a week. The average systolic blood pressure was 129.41 ± 22.5 mmHg and the average body mass index (BMI) 27.6 ± 7.2 kg/m2. Conclusion Dyslipidemia was the most prevalent risk factor. Hypertension and diabetes mellitus are on top of the risk factor pyramid in commonality. An early diagnosis is important to decrease the incidence of cardiovascular disease. The consumption of fast food and obesity are relatively high and require educational interventions and more available healthy food. Screening through social media and primary health care centers may avert a negative outcome.

Familial Hypercholesterolemia in the Arabian Gulf Region: Clinical results of the Gulf FH Registry.

BACKGROUND AND AIMS: Familial hypercholesterolemia (FH) is a common autosomal dominant disorder that can result in premature atherosclerotic cardiovascular disease (ASCVD). Limited data are available worldwide about the prevalence and management of FH. Here, we aimed to estimate the prevalence and management of patients with FH in five Arabian Gulf countries (Saudi Arabia, Oman, United Arab Emirates, Kuwait, and Bahrain). METHODS: The multicentre, multinational Gulf FH registry included adults (≥18 years old) recruited from outpatient clinics in 14 tertiary-care centres across five Arabian Gulf countries over the last five years. The Gulf FH registry had four phases: 1- screening, 2- classification based on the Dutch Lipid Clinic Network, 3- genetic testing, and 4- follow-up. RESULTS: Among 34,366 screened patient records, 3713 patients had suspected FH (mean age: 49±15 years; 52% women) and 306 patients had definite or probable FH. Thus, the estimated FH prevalence was 0.9% (1:112). Treatments included high-intensity statin therapy (34%), ezetimibe (10%), and proprotein convertase subtilisin/kexin type 9 inhibitors (0.4%). Targets for low-density lipoprotein cholesterol (LDL-C) and non-high-density lipoprotein cholesterol were achieved by 12% and 30%, respectively, of patients at high ASCVD risk, and by 3% and 6%, respectively, of patients at very high ASCVD risk (p <0.001; for both comparisons). CONCLUSIONS: This snap-shot study was the first to show the high estimated prevalence of FH in the Arabian Gulf region (about 3-fold the estimated prevalence worldwide), and is a "call-to-action" for further confirmation in future population studies. The small proportions of patients that achieved target LDL-C values implied that health care policies need to implement nation-wide screening, raise FH awareness, and improve management strategies for FH.

The Myth of Myocardial Infarction With Normal Coronary Angiography.

Myocardial infarction with no obstructive atherosclerosis is an increasingly recognized presentation of acute coronary syndrome (ACS). The disease has all the clinical features of an ACS, but the only exception is that the coronary angiogram indicates non-obstructive coronary artery disease. Although different pathophysiological mechanisms have been postulated, no definitive mechanism has been identified. Consequently, the treatment plan varies and depends on the more probable mechanism. Here, we review the current body of knowledge about this disease and discuss updated management strategies.

Transverse sinus mass misinterpreted as the source of cardiac emboli.

Due to the proximity of the transvers sinus (TS) to the left atrial appendage (LAA) and pulmonary veins (PV), a mass in the TS can be misinterpreted as a LAA or PV thrombus, and considered as a source of emboli in a patient with stroke or transient ischemic attack. The incorrect identification of a mass as a LAA thrombus would initiate unnecessary anticoagulation therapy or potentially, an evaluation for the excision of the mass if there is a concern about dislodgement. We are presenting a case illustrating this confusion and review the literature for similar cases.

The prevalence of masked hypertension in a group of young healthy soldiers.

BACKGROUND: To assess the prevalence of masked hypertension (MH) in young Saudi National Guard soldiers based on 24h ambulatory blood pressure monitoring (ABPM). METHODS: A prospective study of 196 soldiers, aged between 21-50 years, without a history of hypertension or antihypertensive medication use. Each participant was fitted with a 24h-ABPM. Patients were considered to have MH if the office blood pressure (OBP) was <140/90 mm Hg and the 24h-ABPM average was ≥130/80 mmHg. RESULTS: The mean age of the MH group was 34.5 years compared to 32.4 years of the normotensive group. By pairing the average OBP with the 24h-ABPM, the prevalence of MH was estimated to be 29/196 (14.8%), with the SBP (systolic blood pressure) and DPB MH (diastolic BP) prevalence 12.8% and 7.7%, respectively. For the systolic BP, the OBP compared with the 24h-ABPM was 120.0±8.1 vs. 134.7±4.5 (P<0.001) and for the diastolic BP, 70.7±7.0 vs. 79.9±4.2 (P<0.001). CONCLUSIONS: The prevalence of MH among this sample of healthy military soldiers was 14.8%. It is important not to rely solely on the OBP and to consider MH when screening for hypertension in apparently healthy individuals.

Infective Endocarditis Outcomes in Jeddah City, Saudi Arabia.

OBJECTIVES: This study aimed to analyze all the reported cases of definitive infective endocarditis, based on the modified Duke criteria in a tertiary hospital over the past five years, focusing on the causative organism/s, predisposing factors, and outcomes. METHODS: This is a cross-sectional retrospective study. Patients with a confirmed diagnosis of infective endocarditis using modified Duke criteria were included. The demographic data, predisposing factors, the causative microorganisms, laboratory and echocardiography results, and treatment were collected. RESULTS: In total, 37 patients were identified, 22 were male, and the median age was 59 years. Native valve endocarditis was found in 29 (78.3%) patients. The most frequently involved valves were the mitral valve in eight (42.1%) and aortic valve in six (31.6%) patients. Fever occurred in 22 patients (59.5%). The most frequent organisms were Staphylococcus aureus in 14 (37.4%) patients, coagulase-negative staphylococci in seven (18.9%) patients, and streptococci in seven (18.9%) patients. The majority (n=27) of the patients (72.97%) were treated medically, with 10 (27.02%) requiring in-hospital surgical intervention. The in-hospital mortality rate was 24.3%. Late presentation, reluctance to undergo surgery, and the past history of rheumatic fever were the contributing factors. CONCLUSION: Native valve endocarditis is the major type of infective endocarditis. The most frequent organisms were Staphylococcus aureus, Streptococcus, and coagulase-negative staphylococci. In our study, infective endocarditis was more common among males, surgical intervention was low, and a high in-hospital mortality rate was noted in our series.

A Cross-Sectional Study of the Current Management of Hypertriglyceridemia.

Objectives To estimate the prevalence of hypertriglyceridemia (HTG), determine the association between HTG and the risk of ischemic heart disease and major adverse cardiovascular events. Lastly, to assess the management outcomes of HTG in terms of the different drugs in the treatment plan.  Methods A retrospective, longitudinal study at a tertiary hospital was conducted. All who came in were screened. Patients with HTG (TAG [triacylglyceride] 2.3 mmol/L) in the last five years were included in the study. The data included the demographic variables, potential causes, and the methods of management. All data were recorded in a standard data collection form and analyzed by an appropriate statistical tool, using the John Macintosh Project (JMP) software version 15 (Cary, NC: SAS Institute Inc.). Results Of 300 patients included, 174 (58.0%) were male, with a mean age of 57.8±13.4 years. Pre-treatment, the mean triglycerides (TG) was 3.2±2.3 mmol/L, low-density lipoprotein (LDL) 2.7±1.3 mmol/L, high-density lipoprotein (HDL) 0.93±0.30 mmol/L, and the total cholesterol (TC)was 5.2±1.3 mmol/L. All the patients have prescribed a statin, 144 (48.0%) received aspirin, six (2.0%) fenofibrate, and three (1.0%) gemfibrozil. At the follow-up, the level of the TG was 2.6±1.3 mmol/L (P=0.001), LDL 2.5±1.2 mmol/L (P=0.006) and total cholesterol (TC) 4.7±1.5 mmol/L (P=0.001). Almost a third (28.2%) developed cardiac complications, five (1.6%) presented with unstable angina, six (2.0%) as non-ST segment elevation myocardial infarction (NSTEMI), three (1.0%) had ST segment elevation myocardial infarction (STEMI), and 19 (6.3%) had heart failure. A small proportion (17.3%) had a percutaneous coronary intervention, 27 (9.0%) had single-vessel disease, 12 (4.0%) two-vessel disease, and 13 (4.3%) three-vessel disease. Conclusions Many physicians do not pay attention to HTG in everyday practice, although HTG contributes significantly to the occurrence of coronary heart disease. In our study, the majority had mixed hyperlipidemia. One-third of patients with high triglycerides developed ischemic heart disease. The use of fenofibrate and gemfibrozil was not high. A low occurrence of pancreatitis was noted in our series.

Contrast transesophageal three dimensional echocardiographic imaging for patent foramen ovale: a needful role?

We report a case of a 55-year-old male admitted for cardiogenic embolic ischemic stroke work up. A transesophageal (TE) echocardiography (E) with contrast study to rule out patent foramen ovale (PFO) was performed; two-dimensional (2D) analysis did not detect any bubbles passage during Valsalva manoeuvre in the standard 2D cross sectional planes; further real time three-dimensional (3D) TEE imaging revealed passage of bubbles in the left atrium (LA) by both real-time 3DTEE imaging and by the 2D unconventional cross-sectional planes allowed by 3DTEE imaging. Even though 2DTEE is considered to be the gold standard modality for diagnosing PFO, it has some limitations. It has never been reported about usefulness of 3DTEE in PFO imaging. Even in the presence of only a report, our case suggests that 3DE could have an additional value and will compliment 2D imaging in PFO assessment.

Transient ST Segment Elevation in a Patient with COVID-19 and a Normal Transthoracic Echocardiogram.

The effect of COVID-19 on the cardiovascular system still needs to be clarified. Patients can develop a spectrum of cardiac diseases, from mild myocarditis to acute coronary syndrome with an impaired systolic fraction. We describe an interesting case of transient ST segment elevation in a COVID-19 patient admitted to ICU for severe respiratory distress syndrome. During his stay in ICU, the patient developed transient ST segment elevation in inferior-lateral leads which promptly resolved without requiring any additional invasive and/or pharmacological treatment. Transthoracic echocardiography showed a preserved ejection fraction without any regional abnormalities and the rise in enzyme biomarkers was insignificant. The case highlights the importance of avoiding invasive procedures in this subset of patients to reduce both patient complications and medical staff exposure. Careful evaluation including echocardiogram and second-line examinations should be performed before invasive and aggressive treatment is undertaken. LEARNING POINTS: Transient ST elevation may occur in critically ill COVID-19 patients.Early recognition is important to avoid unnecessary intervention or thrombolytic therapy.

Pericardial Fluid in a COVID-19 Patient: Is It Exudate or Transudate?

BACKGROUND: Very limited information is available on pericardial effusion as a complication of COVID-19 infection. There are no reports regarding pericardial fluid findings in COVID-19 patients. CASE DESCRIPTION: We describe a 41-year-old woman, with confirmed COVID-19, who presented with a large pericardial effusion. The pericardial fluid was drained. We present the laboratory findings to improve knowledge of this virus. DISCUSSION: We believe this is the first such reported case. Findings suggested the fluid was exudative, with remarkably high lactate dehydrogenase and albumin levels. We hope our data provide additional insight into the diagnosis and therapeutic options for managing this infection.LEARNING POINTS: Laboratory findings of drained pericardial fluid in a patient with COVID-19 are presented.The clinical presentation of pericardial involvement in COVID-19 infection and the role of echocardiography in diagnosis and management are described.

Cavitation phenomenon in mechanical prosthetic valves: Not only microbubbles.

INTRODUCTION: Microbubbles (MBs) or cavitation is high-velocity, echo-bright findings present during the closing or opening of a mechanical valve (MVP). Cavitation bubble growth or gas emboli are less frequently described. We evaluated the hemodynamic parameters involved in the formation of gas emboli and the impact of gas emboli on requests for additional investigations. METHODS AND RESULTS: Transthoracic echocardiographic studies (TTE) of 57 patients (31 males, mean age 46.8 ± 13.8 years) with gas emboli were evaluated after heart valve replacement surgery. The majority (72%, n = 42) had a mitral or combined mitral/aortic MVP, with 28% (n = 16) an aortic MVP. The last TTE with and without gas emboli were considered for the same patient and the no emboli group was the control group (42 patients). The patient's blood pressure (BP) and heart rate (HR) were available for each TTE. Comparing the two TTEs, the systolic and diastolic BP, transmitral and aortic gradients, and left ventricular ejection fraction were similar but the HR (80.9 ± 18.7 vs 72.5 ± 13.9 bpm, P = .02) was significantly higher in the group with gas emboli. A TEE was performed 52 times in 27 patients, due to gas emboli, with one case positive for thrombus/vegetation. For 19 patients, a brain CT was requested. In two patients, the indication for the brain CT was gas emboli but the result was negative. CONCLUSION: Gas emboli are frequently present and associated to an increased HR. They can cause the misdiagnosis of endocarditis or thrombus formation with significant additional requests for diagnostic examinations.

In-stent Restenosis in an Anomalous Left Main Coronary Artery Arising from the Right Sinus of Valsalva After a Stenting Lesion with Acute Angle.

We describe a 38-year-old male who underwent percutaneous coronary intervention (PCI) using a third-generation drug-eluting stent (DES) with a thin stent for an anomalous left main coronary artery (LMCA) originating from the right coronary sinus with a retro-aortic course. Six months later, in-stent restenosis (ISR) occurred due to stent implantation in angled lesions with significant hinge motion. An intravascular ultrasound (IVUS) revealed significant neointimal hyperplasia. The vessel wall of an angled coronary artery lesion is exposed to mechanical stress from the deployed stent. It has been reported before in the major coronary arteries but not in an anomalous LMCA.