A multicentre survey of knowledge and implementation of radiation protection techniques in cardiac cath-lab medical personnel.

BACKGROUND: Awareness of radiation hazards and methods to reduce radiation dose is a sine qua non for all staff working in the cath-lab for their own safety and their patient's safety. RESULTS: There were large variations in the implementation of radiation protection techniques with overall inadequate radiation risk knowledge. Some members of the cath-lab team are at higher risk of radiation-induced side effects, including the fellows, nurses, technicians, and anaesthesiologists because they spent longer time in the cath-lab and/or their position in relation to the source of radiation. About 10% of the participants have reported different health problems potentially induced by radiation exposure. CONCLUSIONS: There is lack of radiation risks knowledge with inadequate radiation protection practice among cath-lab team. Some members such as fellows, nurse, technicians, and cardiac anaesthesiologist are at higher risks. They represent the forgotten members of the Cath-Lab team.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review.

Transcatheter aortic valve replacement (TAVR) has proven to be a safe, effective, and less invasive approach to aortic valve replacement in patients with aortic stenosis. In patients who underwent prior aortic valve replacement, transcatheter and surgical bioprosthetic valve dysfunction may occur as a result of structural deterioration or nonstructural causes such as prosthesis-patient mismatch (PPM) and paravalvular regurgitation. Valve-in-Valve (ViV) TAVR is a procedure that is being increasingly utilized for the replacement of failed transcatheter or surgical bioprosthetic aortic valves. Data regarding long-term outcomes are limited due to the recency of the procedure's approval, but available data regarding the short- and long-term outcomes of ViV TAVR are promising. Studies have shown a reduction in perioperative and 30-day mortality with ViV TAVR procedures compared to redo surgical repair of failed bioprosthetic aortic valves, but 1-year and 5-year mortality rates are more controversial and lack sufficient data. Despite the reduction in 30-day mortality, PPM and rates of coronary obstruction are higher in ViV TAVR as compared to both redo surgical valve repair and native TAVR procedures. New transcatheter heart valve designs and new procedural techniques have been developed to reduce the risk of PPM and coronary obstruction. Newer generation valves, new procedural techniques, and increased operator experience with ViV TAVR may improve patient outcomes; however, further studies are needed to better understand the safety, efficacy, and durability of ViV TAVR.

New insights into amiodarone induced retinal and optic nerve toxicity: functional and structural changes.

Background: Amiodarone is widely used for heart arrhytmia. Previous studies have suggested the possibility of optic neuropathy with the chronic use of this drug. Objectives: To identify structural or functional changes in the retina and optic nerve in patients on chronic amiodarone therapy without visual complaints. Methods: This observational study included 15 eyes of 15 patients with cardiac arrythmia on chronic amiodarone treatment and 15 healthy matched subjects as a control group. All subjects underwent electrophysiological tests [pattern visual evoked potential (PVEP), pattern electroretinogram (PERG), multifocal electroretinogram (mfERG), and optical coherence tomography (OCT) and angiography (OCTA)]. Results: There were no statistically significant differences between the two groups regarding the PVEP, PERG, and the mfERG parameters. Macular and optic nerve head OCT and OCTA have not shown statistically significant differences except for the morphological parameters of the optic disc (p = 0.008 for the horizontal and p = 0.013 for vertical cup/disc ratio and p = 0.045 for rim area). Conclusion: Patients on chronic amiodarone therapy have not shown evident structural or functional changes in the retinal or optic nerve as demonstrated by electrophysiological tests, OCT, and OCTA results compared to controls.

Effect of taurolidine citrate and unfractionated heparin on inflammatory state and dialysis adequacy in hemodialysis patients.

BACKGROUND AND AIM: HD patients using dialysis catheters have been associated with chronic inflammatory state. In Egypt 6.6% of HD patients use catheters, of which short term catheters represent 59.6% and 40.4% with long-term catheters. In this study, we aimed to assess the effect of Taurolidine citrate and unfractionated heparin combination (Taurolock-hep500™) as a lock solution compared to unfractionated heparin alone on inflammatory markers, incidence of catheter related blood stream infections (CRBSI) and dialysis adequacy in HD patients with temporary HD catheters only, for 4 weeks duration. METHODS: Sixty ESRD patients from hemodialysis units in Ain-Shams University hospitals (ASUH) at the time of catheter insertion we enrolled in our study. They were randomized into two groups: Group 1: Thirty patients received Taurolock-hep500™ as a catheter lock solution at the end of each hemodialysis session. Group 2: Thirty patients received unfractionated heparin as a catheter lock solution. hsCRP and IL-6 were measured at baseline and 1 month after using the lock solutions. Blood cultures were done in patients who developed symptoms of catheter related infections. RESULTS: At the end of the study, Inflammatory markers were significantly higher in group 2 (p-value: 0.045, 0.001, and 0.018 for WBCs, hsCRP and IL-6, respectively). Group 1 had better dialysis adequacy assessed by URR (p-value: 0.007 and 0.001, respectively). CRBSI were demonstrated in nine patients in group 2 (30%) in contrast to one patient only in group 1(3.3%) (p-value: 0.006) with pseudomonas being the most common isolated organism (27.7%). CONCLUSION: Use of (Taurolock-hep500™) for temporary hemodialysis catheters was associated with lower levels of inflammation markers and lower incidence of CRBSI and better catheter performance.

Multidetector computed tomography for patients with congenital heart disease: a multi-center registry from Africa and Middle East; patients' characteristics and procedural safety.

BACKGROUND: We aimed to establish a clinical registry for patients with congenital heart disease who referred to multidetector computed tomography in our country, to describe the pattern and clinical profile of such patients and document the safety and efficacy of the procedure in our daily practice. RESULTS: A total 2310 studies were analyzed after excluding studies with missed, and lost data. Half of our study population-1215 patients-52.5% were males. The median age of the patients was 12 months (IQR 37 months), and the youngest patient was 3 days old. The eldest patient was 50 years old. 68.27% of the patients were less than 2 years old, and two-third of the whole studied population 66.7% had cyanotic heart disease. Minor local access complications, complications related to anesthetic drugs, and allergic reactions were the most commonly encountered complications, with only single mortality mainly due to multiple associated multisystem congenital malformation. CONCLUSIONS: Most of our patients with congenital heart disease referred for MDCT study were infants and young children. The majority of them had complex cyanotic heart disease. The study is safe, with excellent diagnostic yield and safe with very low incidence of complications.

Veno-arterial rail and over the wire technique for atrial septal defect closure in a patient with interrupted inferior venae cava.

Transcatheter closure of secundum atrial septal defect (ASD II) is considered the treatment of choice when anatomically suitable and clinically indicated. This is routinely done through the inferior vena cava via a femoral venous approach; however, certain anatomical anomalies, such as congenital interruption of inferior vena cava with azygos continuation, render the delivery of the device either difficult or not possible. When this anomaly is also associated with dextrocardia, the technical challenge increases further due to the unusual orientation of the interatrial septum. We describe a case of transcatheter closure of ASD II via left internal jugular vein approach with some modification of the standard technique. We used a combination of veno-arterial rail by parking the super-stiff wire in the descending aorta instead of the usual method of parking it in the pulmonary vein for better support, and over the wire technique during device deployment to maintain the delivery sheath position during device deployment. Changing the vascular access with the modification of the standard technique of closure was the key to success in this patient. .

Comparison of the early cardiac electromechanical remodeling following transcatheter and surgical secundum atrial septal defect closure in adults.

BACKGROUND: Secundum atrial septal defect (ASD) closure leads to electrical and mechanical remodeling that occurs early after shunt disappearance. The relationship between electromechanical remodeling using electrocardiogram (ECG) and cardiac magnetic resonance (CMR) after percutaneous and surgical closure has not yet been recorded in prospective studies. OBJECTIVE: We thought to study right atrium (RA) and right ventricle (RV) changes by CMR 3 months after transcatheter and surgical closure and their comparison with electrical remodeling by ECG. RESULTS: We prospectively evaluated 30 consecutive adult patients with isolated secundum ASD who were referred for (transcatheter and surgical) ASD closure. There was significant reduction in all of the electrical parameters within the same group as compared to the baseline values, except P wave dispersion (Pd). (P max was 97.33 ± 16.67 (pre closure) to 76 ± 15.49 (post closure) in the device group and 97.33 ± 12.79 (preclosure) to 73.33 ± 16.32 (post closure) in the surgical group, QRS complex was 104 ± 18.82 (preclosure) to 80 ± 18.51 (post closure) in the device group and 106.67 ± 14.47 (preclosure) to 86.67 ± 17.99 (post closure) in the surgical group. QTc maximum was 478.53 ± 36.79 (preclosure) to 412.53 ± 38.03 (post closure) in the device group and 470.53 ± 65.70 (preclosure) to 405.93 ± 63.08 (post closure) in the surgical group, and QTc dispersion was 70.33 ± 24.04 (preclosure) to 60.26 ± 28.56 (post closure) in the device group and 80.73 ± 30.38 (preclosure) to 60.27 ± 28.57 (post closure) in the surgical group).There was no significant difference between two groups indicating that transcatheter and surgical closure had led to equivalent value of electrical remodeling. In CMR study, we measured RA maximal volume and right ventricle end diastolic volume (RVEDV), RA maximal volume decreased significantly as compared to the base line values post closure in both groups (P value < 0.001). The reduction in RA max volume was more in the transcatheter closure group; however, this difference was not statistically significant when compared with the surgical arm (P value = 0.5).RVEDV decreased significantly in both groups as compared to the baseline values (P value < 0.001). Transcatheter closure resulted in more significant reduction in the RVEDV than the surgical closure (P value = 0.03). CONCLUSION: Our study showed early significant electromechanical reverse remodeling in most of the study parameters from the baseline values after ASD closure. We found no significant differences in all of the electrical and RA mechanical remodeling parameters with significantly better mechanical remodeling of RV in the device group.

Multidisciplinary assessment of patients with ischemic stroke, the structure of a stroke team, and first Egyptian experience in adults undergoing transcatheter PFO closure for PFO-related stroke.

BACKGROUND: Patent foramen ovale closure in the setting of stroke was debatable until the recent data from the long-term follow-up of multiple randomized control trials. These recent data have led to increase the number of the procedure worldwide. To our knowledge, there was no previous formal structured program in Egypt between cardiologists and neurologists for investigation and management of patients with cryptogenic stroke. The first Egyptian-dedicated stroke team was created in two large tertiary centers with collaboration between cardiologists, dedicated cardiac imagers, and neurologists for investigation and management of patients with cryptogenic stroke. RESULTS: Sixty-three patients with cryptogenic stroke were identified from a total of 520 patients admitted to the stroke units between 2016 and 2019. Twenty-five patients had a proven PFO-related stroke. Three patients were referred for surgical closure, 19 patients underwent transcatheter PFO closure, and procedural success was met in 18 patients (94.7%). We did not experience any major procedure-related complication. Complete closure was achieved in 83.3% of patients at 6 months. One patient had a single attack TIA within the first 3 months after device closure; one patient had a device-related thrombosis; both were managed successfully. CONCLUSION: Our initial experience in collaboration between cardiologist and neurologist with the establishment of a dedicated cryptogenic stroke team added significantly to the management of patients with stroke. The results of the first Egyptian cohort who underwent transcatheter PFO closure demonstrated procedural feasibility, safety, and efficacy with very low incidence of major complications. A nationwide program is needed to reduce the ischemic stroke disease burden and the risk of recurrence.

Topsy-turvy heart: A first recorded case report with intracardiac anomaly.

Topsy-turvy heart is a rare congenital anomaly; it has a specific characteristic of cardiac malrotation and superior-inferior arrangement of right/left ventricles. A five-day-old patient was diagnosed antenatally with hypoplastic left heart and right hydronephrosis and had been admitted to the hospital with symptoms of respiratory distress. The postnatal imaging studies revealed an abnormal ventricular arrangement with a large aortopulmonary window, ventricular septal defect (VSD), and the upside-down orientation resulting in the posterior-inferior displacement of the common arterial confluence and, in turn, the left main bronchial stenosis. For the first time, the diagnosis of a topsy-turvy heart with the intracardiac anomaly (VSD) was confirmed.

A new borne with very complex aortic anatomy: diagnosis and treatment challenge-case report.

BACKGROUND: Interrupted aortic arch (IAA) is a congenital malformation of the aortic arch which involves 3 out of 1 million live births. This congenital anomaly rarely occurs as an isolated lesion and is often associated with other intracardiac malformations, most commonly ventricular septal defect and patent ductus arteriosus (PDA). The diagnosis and surgical treatment of aortic interruption is usually challenging and may require multiple operations throughout the patient's life. CASE PRESENTATION: This case represents a neonate with interrupted aortic arch (type B) and a very long segment of descending aorta hypoplasia and complex anatomy. The patient escaped early diagnosis at birth and presented few days later by a picture that mimicked severe sepsis and shock. His aortic anatomy was very complex and he was treated with long extra-anatomical aortic interposition graft. CONCLUSION: Aortic interruption is a rare congenital anomaly and is considered an extreme form of aortic coarctation. It sometimes escapes early diagnosis due to the presence of patent ductus arteriosus and present later with shock and lactic acidosis. Sometimes the aortic anatomy is very complex and requires unusual surgical techniques for its repair.

Mechanism of the right ventricular reverse remodeling after balloon pulmonary valvuloplasty in patients with congenital pulmonary stenosis: A three-dimensional echocardiographic study.

BACKGROUND AND OBJECTIVES: The main effect of pulmonary stenosis is a rise in right ventricular pressure. This pressure overload leads to multiple changes in the shape, dimensions, and volumes of the right ventricle (RV) that are reversed after the relieve of the valve obstruction. We thought to study the changes in the RV in patients undergoing balloon pulmonary valvuloplasty (BPV) using three-dimensional (3D) echocardiography. SUBJECTS AND METHODS: The study included 50 patients with isolated valvular pulmonary stenosis who underwent BPV at our hospital from December 2016 to August 2017; echocardiography was recorded preprocedural and 3 months after the procedural. RESULTS: The median age of the study group at the time of the procedure was 2.7 years. The indexed RV wall thickness, basal, and mid-right ventricular dimensions decreased significantly after the procedure (P < 0.005), and the longitudinal dimension increased significantly after the procedure (P < 0.005). The end-systolic and the end-diastolic volumes (EDVs) by 3D echocardiography increased insignificantly (P > 0.05), and the right ventricular function increased significantly (P < 0.05), indicating that the changes in the EDVs were more than the changes in the end-systolic volumes. CONCLUSIONS: There are several factors that interplay together and result in reverse remodeling of the RV after BPV including regression in the RV hypertrophy; changes in the interventricular septal morphology, bowing, and mobility; and changes in the ventricular geometry and dimensions, rather than changes in the ventricular volumes.

Noninvasive Predictors of Functional Capacity in Patients with Pulmonary Hypertension due to Congenital Heart Disease: A Pilot Echocardiography Single-Center Study.

BACKGROUND: Pulmonary hypertension (PH) with congenital heart disease (CHD) affects the functional capacity (FC), quality of life, and survival. However, the importance of different echocardiographic parameters and their correlation with FC is unclear. METHODS AND RESULTS: A custom-made sheet for 34 consecutive patients with PH due to CHD was made to include patient's demographic data, underlying cardiac disorder, and FC by 6-min walk test (6MWT). The patients were subdivided into Group 1 with 6MWT < 330 m and Group 2 with 6MWT > 330 m. A cutoff value of 330 m was selected because it reflected the survival and outcome of patients in many studies before. Left ventricle global radial strain, baseline saturation, and saturation after 6MWT showed a significant strong positive correlation with 6MWT (r = 0.755, 0.714, and 0.721, P = 0.001, 0.000, and 0.000, respectively). Multiple regression analysis using a multivariate model showed that the mean pulmonary artery pressure (MPAP) and baseline saturation are the most independent predictors of the FC (P = 0.028 and 0.049, respectively), with a cutoff point for MPAP > 30 mmHg (area under the curve [AUC]: 0.85) with a sensitivity and specificity of 69.23% and 95.24%, respectively, and cutoff point for saturation < 94% (AUC: 0.852) with a sensitivity and specificity of 92.31% and 76.19%, respectively. CONCLUSION: The MPAP and the baseline oxygen saturation were the most independent predictors of impaired FC. They can be used for risk stratification and as surrogate predictors of outcome in this group of patients.

Identification of Novel Molecular Network Expression in Acute Myocardial Infarction.

BACKGROUND: In the current study, we aimed to analyze the hypothesis that human myocardial-specific extracellular RNAs expression could be used for acute myocardial injury(AMI) diagnosis. METHODOLOGY: We used bioinformatics' analysis to identify RNAs linked to ubiquitin system and specific to AMI, named, (lncRNA-RP11-175K6.1), (LOC101927740), microRNA-106b-5p (miR-106b-5p) and Anaphase, promoting complex 11 (ANapc11mRNA). We measured the serum expression of the chosen RNAs in 69 individuals with acute coronary syndromes, 31 individuals with angina pectoris without MI and non-cardiac chest pain and 31 healthy control individuals by real-time reverse-transcription PCR. RESULTS: Our study revealed a significant decrease in both lncRNA-RP11-175K6.1 and ANapc11mRNA expression of in the sera samples of AMI patients compared to that of the two control groups alongside with significant upregulation of miR-106b-5p. CONCLUSION: Of note, the investigated serum RNAs decrease the false discovery rate of AMI to 3.2%.

Addition of Neostigmine and Atropine to Conventional Management of Postdural Puncture Headache: A Randomized Controlled Trial.

BACKGROUND: Postdural puncture headache (PDPH) lacks a standard evidence-based treatment. A patient treated with neostigmine for severe PDPH prompted this study. METHODS: This randomized, controlled, double-blind study compared neostigmine and atropine (n = 41) versus a saline placebo (n = 44) for treating PDPH in addition to conservative management of 85 patients with hydration and analgesics. The primary outcome was a visual analog scale score of ≤3 at 6, 12, 24, 36, 48, and 72 hours after intervention. Secondary outcomes were the need for an epidural blood patch, neck stiffness, nausea, and vomiting. Patients received either neostigmine 20 µg/kg and atropine 10 µg/kg or an equal volume of saline. RESULTS: Visual analog scale scores were significantly better (P< .001) with neostigmine/atropine than with saline treatment at all time intervals after intervention. No patients in the neostigmine/atropine group needed epidural blood patch compared with 7 (15.9%) in the placebo group (P< .001). Patients required no >2 doses of neostigmine/atropine. There were no between-group differences in neck stiffness, nausea, or vomiting. Complications including abdominal cramps, muscle twitches, and urinary bladder hyperactivity occurred only in the neostigmine/atropine group (P< .001). CONCLUSIONS: Neostigmine/atropine was effective in treating PDPH after only 2 doses. Neostigmine can pass the choroid plexus but not the blood-brain barrier. The central effects of both drugs influence both cerebrospinal fluid secretion and cerebral vascular tone, which are the primary pathophysiological changes in PDPH. The results are consistent with previous studies and clinical reports of neostigmine activity.

An unusual cause of tachyarrhythmia in an otherwise healthy young man.

CLINICAL INTRODUCTION: A 32-year-old man referred to the cardiology clinic for palpitations was found to have paroxysmal supraventricular tachycardia (SVT) on 24-hour Holter monitoring. His general and cardiac examinations were unremarkable. A transthoracic echocardiographic study to exclude structural heart disease was performed and showed an abnormal structure in relation to the right ventricular (RV) free wall; however, poor echocardiographic windows precluded proper characterisation. Cardiac MR (CMR) was therefore performed. Cine images (figure 1 and online supplementary videos 1 and 2) demonstrated the abnormal structure. Dynamic pass of contrast (rest perfusion module) showed the sequence of intracavitary enhancement across different cardiac chambers in the horizontal long-axis plane (figure 1 and online supplementary video 3).heartjnl;103/18/1472/F1F1F1Figure 1Still frames from balanced steady state free precession images in the horizontal long-axis plane (A,B). Still frames from the dynamic pass of contrast in the horizontal long-axis and the short axis following contrast injection into the right arm (C,D). Images in the horizontal long-axis plane at the basal level using T2-weighted short-tau inversion recovery (E) and half Fourier single-shot turbo spin echo (F).DC1SP110.1136/heartjnl-2017-311485.supp1Supplementary data DC2SP210.1136/heartjnl-2017-311485.supp2Supplementary data DC3SP310.1136/heartjnl-2017-311485.supp3Supplementary data QUESTION: The abnormal structure is most likely which of the following?Pericardial cystRight atrial appendage aneurysmRight ventricular aneurysmJuxtaposed left atrial appendageAccessory right ventricular chamber.

Left ventricular torsion assessed by two-dimensional echocardiography speckle tracking as a predictor of left ventricular remodeling and short-term outcome following primary percutaneous coronary intervention for acute myocardial infarction: A single-center experience.

AIMS: Left ventricular (LV) torsion is a novel method to assess systolic LV function. This study aimed at exploring the utility of 2D speckle tracking-based assessment of left ventricular torsion in patients with acute myocardial infarction (AMI) undertaking primary percutaneous intervention (pPCI) in predicting left ventricular remodeling. METHODS AND RESULTS: The study included 115 patients (mean±SD, age 52.2±9.67, males 84.3%) who underwent pPCI for AMI. Echocardiographic assessment of LV torsion by two-dimensional speckle tracking was performed early after the index pPCI. Patients underwent repeat echocardiography at 6 months to detect remodeling. LV torsion in the acute setting was significantly lower in those who demonstrated LV remodeling at follow-up compared to those without remodeling (7.56±1.95 vs 15.16±4.65; P<.005). Multivariate analysis identified peak CK & CK-MB elevation (ß=-0.767 and -0.725; P<.001), SWMA index (ß=-0.843; P<.001), and Simpson's derived LV ejection fraction (LVEF; ß=0.802; P<.001) as independent predictors of baseline LV torsion. It also identified peak LV torsion (ß: 0.27; 95% CI: 0.15-0.5, P=.001) and SWMA index (ß: 1.07, 95% CI: 1.03-1.12, P=.005) as independent predictors of LV remodeling. Baseline Killip's grades II and higher (ß: 48.6; 95% CI 5.5-428, P<.001) and diabetes mellitus (ß: 29.7; 95% CI 1.1-763, P<.05) were independent predictors of mortality. CONCLUSION: Left ventricular torsion in acute MI setting is impaired and predicts subsequent LV remodeling at 6-month follow-up.