The evaluation of bariatric surgery effect on cardiac structure and function using transthoracic echocardiography: a cohort study.

BACKGROUND: Obesity is a pathology and a leading cause of death worldwide. Obesity can harm multiple organs, including the heart. In this study, we aim to investigate the effect of bariatric surgery and following weight loss on cardiac structure and functions using echocardiography parameters in patients with morbid obesity. METHODS: In this cohort study, 30 patients older than 18 with BMI > 40 or BMI > 35 and comorbidity between March 2020 to March 2021 were studied. The patients underwent transthoracic echocardiography before and after six months of the bariatric surgery. RESULTS: In total, 30 patients (28 women, 93.3%) with a mean age of 38.70 ± 9.19 were studied. Nine (30%) were diabetic, and 9 (30%) had hypertension. After six months of bariatric surgery, all physical measurements, including weight, Body mass index, and Body surface area, decreased significantly (p < 0.001). After bariatric surgery, all parameters regarding left ventricular morphology, including left ventricular mass, interventricular septal thickness, left ventricular posterior wall thickness, left ventricular end-systolic diameter, and left ventricular end-diastolic diameter, improved significantly (p < 0.001). Also, LVEF rose post-bariatric surgery (p < 0.001). TAPSE parameter indicating right ventricular function also improved (p < 0.001). Right ventricular diameter, left atrium volume, and mitral inflow E/e' decreased significantly (p < 0.001). CONCLUSION: Systolic and diastolic parameters refine significantly after bariatric surgery in patients with obesity. Bariatric surgery lead to significant cardiac structure and function improvement.

The potential of HEART score to detect the severity of coronary artery disease according to SYNTAX score.

Clinical scoring systems such as the HEART score can predict major adverse cardiovascular events, but they cannot be used to demonstrate the degree and severity of coronary artery disease. We investigated the potential of HEART Score in detecting the existence and severity of coronary artery disease based on SYNTAX score. This multi-centric cross-sectional study investigated patients referred to the cardiac emergency departments of three hospitals between January 2018 and January 2020. Data including age, gender, risk factors, comorbidities, 12-lead ECG, blood pressure and echocardiogram were recorded for all the participants. Serum troponin I level was measured on admission and 6 h later. Coronary angiography was done via the femoral or radial route. HEART and SYNTAX scores were calculated for all patients and their association was assessed. 300 patients (65% female) with mean age of 58.42 ± 12.42 years were included. mean HEART Score was 5.76 ± 1.56 (min = 3, max = 9), and mean SYNTAX score was 14.82 ± 11.42 (min = 0, max = 44.5). Pearson correlation coefficient was 0.493 between HEART Score and SYNTAX score which was statistically significant (P < 0.001). We found that HEART Score of more than 6 is 52% sensitive and 74.7% specific to detect extensive coronary artery involvement (SNTAX score ≥ 23). The present study showed that the HEART score has a moderate and positive correlation with the SYNTAX score and HEART score with a cut-off value of 6 is a predictor for SYNTAX score of ≥ 23.

Adherence to American Heart Association and American College of Cardiology guidelines for exercise tolerance test in cardiovascular clinics.

Introduction: Considering the increased expenditure in public health sector, especially the increased cost in hospitals and clinics, there is an urgent need to control these costs mainly by ensuring adherence to clinical guidelines for diagnostic procedures. In this study we aim to investigate the adherence of heart clinics to guideline for exercise tolerance test. Methods: This cross-sectional study was performed on 308 patients who were referred for ECG exercise test in 3 clinics located in the city of Shiraz, Iran in 2018. Demographic and clinical data were recorded and the indications of exercise test for each patient was reviewed according to the ACC/AHA guideline for exercise tolerance test. Results: Exercise tests were found to be inappropriately done in 121 (39.3%) participants. Among the patients for whom the test was done without indication 79 (65.3%) were women and the gender difference was statistically significant (P < 0.01); women were 18.5% more likely to undergo exercise test without indication. There was more inappropriate tests among nonanginal pain subsets comparing to other presenting symptoms (P < 0.001). Age, coronary risk factors, reason for performing exercise tests and private health system were not predictors of inappropriate use (P > 0.05). Conclusion: This study confirms that more than one third of exercise tests done in the participants are inappropriate. Wide availability of exercise test makes it vulnerable to overuse and additional unnecessary cost to health care systems.

Pulmonary artery stenosis caused by a large aortic arch pseudoaneurysm detected 10 years after a minor trauma.

Pseudoaneurysm of aorta is a rare condition usually seen after aortic surgeries or serious accidents. Here we report a 60 years old man without any previous medical condition who presented with non-specific symptoms and underwent different investigations for more than 1 year, until the presence of a continuous murmur raised suspicion toward his cardiovascular system. In echocardiographic and computed tomography (CT) angiographic studies a large pseudoaneurysm of aortic arch with compression effect on pulmonary artery was detected. At this stage he remembered having suffered a minor trauma 10 years ago. He finally underwent operation and his aortic wall was repaired successfully with a patch. This case highlights the importance of thorough history taking and physical examination in patients irrespective of symptoms and high index of suspicion to detect this life-threatening condition.

A Case of Fatal Acute Lung Injury after Balloon Valvuloplasty of Pulmonary Stenosis: Case Report and Review of Literature.

A newly described immediate complication after percutaneous pulmonary valvuloplasty isacute lung injury. Here we report a case of fatal acute lung injury after pulmonary valvuloplasty.The patient was a 26-year-old woman, referred to a general hospital with the diagnosis of livercirrhosis. In her work-ups severe pulmonary stenosis was detected and so a decision was madeto relieve the valve stenosis. Despite the procedural success, the patient developed severe dyspneaand desaturation a few hours later and died within 3 days due to shock state. Although thedefinition, incidence or severity of acute lung injury after pulmonary balloon valvuloplasty is notyet clear, this is as far as we know the first mortality reported in literature. This presentation inour patient should prompt clinicians to consider a more aggressive approach at the first sight ofthis previously considered innocent complication.

Procedural Outcome and One Year Follow up of Patients Undergoing Endovascular Stenting for Coarctation of Aorta: A Single Center Study.

INTRODUCTION: Coarctation of aorta is the fourth most common cardiac lesion requiring intervention. While surgery used to be the only treatment option, endovascular intervention is now considered the first option in simple coarctation lesions. Despite increased popularity, there are currently no FDA approved stents for use in coarctation of aorta and data on the outcome of this procedure is still sparse. METHODS: Between October 2004 and June 2010, 33 patients who underwent treatment with Cheatham-Platinum stents for coarctation of aorta were retrospectively studied. All the patients underwent control CT scans at 6 month and echocardiography at 1 year follow-up. RESULTS: There were 17 females and 16 males with a mean age of 26.64 ± 16.30 years (range 2-71 years). The mean stent length and balloon diameter were 3.18 ± 0.56 mm and 15.7 ± 3.12 mm respectively. We achieved an immediate success rate of 96.9% with the only complication of aortic rupture which led to our single mortality in this series. At 6 month follow up no complications were noted in the CT scans. The mean echocardiographic aortic arch gradient at one year follow up was 21.73 ± 11.06 mmHg. CONCLUSION: This study is one of the few cohorts of patients with stenting for coarctation of aorta in Iranian population which comprised a diverse group of patients from early childhood to elderly. It was demonstrated in this study that stenting for coarctation of aorta is a safe and effective procedure if done carefully and performed in selected patients.

The effect of metoprolol succinate on the cardiac function of patients with thalassaemia cardiomyopathy: a double-blind randomised study.

BACKGROUND: Heart failure is the most common cause of mortality in ß-thalassaemia major. However, the management of this disease, apart from chelation therapy, is largely empirical. Therefore, we decided to evaluate the effect of metoprolol succinate on patients with thalassaemia cardiomyopathy (TCM). MATERIALS AND METHODS: In this clinical trial, 45 patients with TCM were randomised to receive either metoprolol (n=26) or placebo (n=19). Echocardiography and a 6 min walk test were performed at baseline and repeated after 6 months and the values compared. RESULTS: In the metoprolol group, left ventricular ejection fraction (LVEF) rose from 38.65% to 42.84% (p<0.001), while it decreased in the placebo group from 37.89% to 35.84% (p=0.01); the difference between the two groups was significant (p<0.001). Left ventricular (LV) mass in the metoprolol group decreased from 154.31 to 144.26 g (p=0.02), while in the placebo group it increased from 174.32 to 200.15 g (p=0.68); the difference between the two groups was significant (p<0.001). End systolic volume (ESV) decreased in the metoprolol group from 42.19 to 36.73 cm(3) (p<0.001) but increased from 47.37 to 57.42 cm(3) in the placebo group (p=0.144); the difference between the groups was significant (p<0.001). No differences in exercise capacity or pulmonary capillary wedge pressure were seen between the two groups (p=0.268 and p=0.535, respectively). CONCLUSIONS: Metoprolol succinate as a ß-blocker may have the potential to significantly improve systolic function in patients with TCM and reverse LV remodelling to the same extent as in other types of cardiomyopathy. TRIAL REGISTRATION NUMBER: NCT01863173.

Successful percutaneous intervention of proximal left anterior descending artery in a case of single coronary artery trunk.

Congenital coronary anomalies are mostly asymptomatic, detected accidentally during invasive or non-invasive imaging. One of the least encountered of such anomalies is single coronary ostium. Considering the fact that the whole myocardium is perfused by a single coronary vessel, performing percutaneous coronary stenting is a challenge for interventional cardiologists with some authors even considering it as a contraindication. Here we present a rare case of single coronary artery as a result of terminal extension of right coronary artery from left circumflex artery, for whom successful balloon angioplasty and stenting of left anterior descending artery after myocardial infarction was done. .

Residual pulmonary hypertension after retrograde pulmonary embolectomy: long-term follow-up of 30 patients with massive and submassive pulmonary embolism.

OBJECTIVES: Pulmonary hypertension is a major cause of morbidity and mortality in patients following acute pulmonary embolism. Although thrombolytic therapy decreases pulmonary arterial pressure, compared with anticoagulation alone, it has the propensity for haemorrhagic complications, distal embolization and incomplete recanalization, with the potential risk of late pulmonary hypertension. Surgical embolectomy-once performed solely on critically-ill patients-has now gained favour in a wider range of patients. In this paper we present the outcomes of patients who underwent surgical embolectomy complemented with retrograde technique and follow-up systolic pulmonary arterial pressure (SPAP). METHODS: From January 2004 to December 2010, 30 consecutive patients with a mean age of 58±15 years underwent pulmonary embolectomy at our centre. The patients were followed for a mean period of 30.5±12 months. Their New York Heart Association (NYHA) classifications were assessed and their SPAPs were measured by echocardiography. RESULTS: The overall mortality rate was 13.2% (4/30). Of the remaining patients, 19 patients (73.1%) were in NYHA classes I and II, 7 patients (26.9%) in class III and no patient in class IV. The patients' preoperative and postoperative mean SPAPs were 44.9±5.7 and 34.9±7.1 mmHg, respectively, which showed a significant reduction (P<0.001). The mean SPAP in the follow-up was 29.4±11.5 mmHg, which again showed significant reduction compared with early postoperation values (P<0.001). No significant correlations were found between the level of SPAP reduction in patients' follow-up with age (P=0.727) and total days of ICU admission (P=0.700), but weak correlations with sex (P=0.016) and total intubation time were noticed (P=0.035). CONCLUSIONS: This is the first series reporting the long-term outcome of patients undergoing surgical embolectomy complemented by retrograde embolectomy technique, demonstrating the safety and favourable long-term outcome of this technique. It is also a new element in the growing body of evidence regarding the relevance of surgical embolectomy in patients with acute pulmonary embolism. We concluded that, following surgery, not only does the pulmonary arterial pressure drop immediately, but also the trend toward normalization continues long after operation.

Short-term results of retrograde pulmonary embolectomy in massive and submassive pulmonary embolism: a single-center study of 30 patients.

OBJECTIVE: Surgical pulmonary embolectomy is usually reserved for critically ill patients with pulmonary embolism. The conventional antegrade technique of embolectomy may miss peripheral clots, rendering the patient amenable to developing pulmonary hypertension. Here, we present our experience with a new retrograde pulmonary embolectomy supplementing the current antegrade technique. METHODS: From January 2004 through December 2010, 30 consecutive patients underwent pulmonary embolectomy in our center. The study included 15 men and 15 women whose age ranged from 28 to 80 years, with mean age of 58±15 years. All the patients except one were taken to the operating room with at least one imaging modality confirming the presence of a large thrombus in pulmonary-arterial vasculature. RESULTS: The most common presenting symptoms of patients was dyspnea (n=27, 90%). The major indications for surgery were severe hemodynamic or respiratory compromise (n=11, 36%). After performing antegrade embolectomy, retrograde flushing of the pulmonary veins was done. The in-hospital mortality in our study was 6.6% (2/30). Mean intubation time for the patients was 52.7±36.5 h, with a range of 12-120 h. Mean intensive care unit (ICU) admission for the patients was 7 days with a range of 2-60 days. CONCLUSIONS: As far as we know, this is the largest series of cases published so far regarding the immediate results of retrograde pulmonary embolectomy. This technique can successfully dislodge the remaining clots in distal pulmonary vasculature not directly visualized. Surgical pulmonary embolectomy is a safe method and should not be used as a last resort for patients with pulmonary embolism.

Vasculitis and rheumatologic diseases may play role in the pathogenesis of acute disseminated encephalomyelitis (ADEM).

Acute disseminated encephalomyelitis (ADEM) is defined as a multifocal, monophasic, demyelinating, and inflammatory disease involving the central nervous system. It typically begins within 6 weeks of an antigenic challenge such as infection or immunization. Perivenous inflammation, edema and demyelination are the pathological hallmarks of ADEM. Reactivity of T-cells against myelin components such as myelin basic protein has been found in children with ADEM. The triggers for immune responses in ADEM are not known, but the two most widely accepted hypotheses are molecular mimicry and self-sensitization secondary to CNS infection. Inflammatory cytokines including tumor necrosis factor alpha (TNFalpha), interleukin 2 (IL2) and interferon gamma (INFgamma) are thought to be important in lesion formation in ADEM. Due to the active role of inflammatory cytokines in the pathogenesis of ADEM, any disease contributing to systemic formation of inflammatory cytokines can potentially be an etiologic factor for the initiation of ADEM. In vasculitis and rheumatologic diseases the number of T-cells, T helper type 1 cytokines and other inflammatory cytokines such as TNFalpha increase substantially. We present this hypothesis that in such setting of inflammation, adhesion molecules are up-regulated on the brain capillary endothelium by cytokines and other inflammatory mediators, altering the permeability of the brain blood barrier and so allowing for inflammatory cell migration. The migratory cells attack the basic myelin protein and the final result is the demyelination seen in ADEM. So we propose that vasculitis and rheumatologic diseases may play role in the pathogenesis of ADEM.