Saudi Heart Association Position Statement on the Use of Biomarkers for the Management of Heart Failure and Acute Coronary Syndrome.

Background: The burden of acute coronary syndrome (ACS) and heart failure (HF) remains high in Saudi Arabia. Biomarkers can greatly improve the management and outcomes of these conditions, but no official guidance is available on their use in Saudi Arabia. Consensus panel: An expert panel of cardiologists, interventional cardiologists and cardiac surgeon reviewed available evidence and formulated recommendations relevant to clinical practice in Saudi Arabia. Consensus findings: high-sensitivity cardiac troponins play a major role in the diagnosis of ACS and the exclusion of myocardial infarction in patients with HF. Natriuretic Peptides are recommended to determine the likelihood of a diagnosis of HF in a chronic setting and rapidly exclude HF in an acute setting. High-sensitivity cardiac troponins and NT-proBNP have good prognostic ability in ACS and HF. These biomarkers could also facilitate discharge planning and reduce unnecessary hospital admissions and resource wastage. The use of biomarkers should not be excessive and should abide by appropriateness criteria. High-sensitivity assays and NT-proBNP measurements are preferred. Conclusion: By outlining expert recommendations on the best practices in the use of biomarkers, the panel hopes to contribute towards a recognized updated guidance for all healthcare providers in Saudi Arabia on the evidence-based management of HF and ACS.

Self-Expandable Transcatheter Aortic Valve Implantation Outcomes: Findings From the Western Region of Saudi Arabia.

Background and objective The prevalence of aortic stenosis in Saudi Arabia is expected to increase owing to the rise in the life expectancy of the population. Such increase is expected to be met with higher demand for interventions including transcatheter aortic valve implantation (TAVI). In this study, we aimed to identify the outcomes of this procedure among the population of the Western region of Saudi Arabia. Methods This was a retrospective observational study involving patients who underwent TAVI at the King Faisal Cardiac Center (KFCC), Jeddah, Saudi Arabia from June 2018 to January 2020. All patients who had undergone TAVI were included, and patients who were lost to follow-up for more than 90 days were excluded. The collected data included sociodemographic characteristics, peri-procedural assessment, and outcomes within 90 days. Results The study included a total of 52 patients. There were 28 males (53.8%) and 24 females (46.2%). The mean age of the cohort was 78 years. Type two diabetes mellitus was present in 67.3%, and hypertension and dyslipidemia were seen in 80.8% of patients. Coronary diseases were seen in 55.8%. The majority had prior percutaneous coronary intervention (PCI) (53.8%) and 3.8% had coronary artery bypass grafting (CABG). Twenty patients (38.5%) had heart failure. Atrial fibrillation was encountered in 13 patients (25%). Chronic kidney disease was described in nine (17.3%) patients, and four (7.7%) were on regular hemodialysis. The median Society of Thoracic Surgery (STS) risk score was 2.4 (IQR: 1.97-5). High STS scores (>8) were only seen in 9% of the patients. The success rate was 98%, and the in-hospital mortality rate was 3.8%. Vascular complications were seen in eight patients (15.4%), and the majority of them were minor. One patient (1.9%) had a major vascular complication. There was a tendency toward high blood transfusions (19.2%). Clinically manifest stroke was seen in three patients (5.8%). Eight patients (15.4%) had post-procedure complete heart block (CHB). Endocarditis was seen in two patients (3.8%). Thirty-day cardiac readmission was observed in 17.3% of patients, and acute kidney injury was seen in eight patients (15.4%). Mild aortic regurgitation was seen in 51.9% of the patients, but moderate or severe aortic insufficiency (AI) was not encountered. Conclusion Transfemoral TAVI using a self-expandable valve is a safe and feasible procedure at KFCC, an intermediate-sized center. Our data is comparable to local and international centers of similar size. Program sustainability depends on the development of robust referral networks and implementing regulatory quality and patient safety standards.

Late Complications After Previous Surgical Repair for Coarctation With Extra-Anatomic Bypass Graft: Report on Two Cases.

Surgical correction of aortic coarctation (CoA) has been the standard treatment in infants and adolescents to prevent late consequences related to obstruction and distal hypoperfusion. Several surgical techniques for CoA repair have traditionally been applied. However, late complications, including re-CoA and pseudoaneurysm formation, are not uncommon. The incidence of complications is highly related to the type of initial surgery. Here, we are reporting two cases of late complications related to an infrequently used surgical technique, the extra-anatomical aortic bypass graft (EABG). The first case presented with pseudoaneurysm at the distal anastomosis site with the descending aorta and treated by endovascular stent graft. The second case presented with stenosis at the proximal anastomosis site with the left subclavian artery (LSCA) and treated medically upon the request of the patient.

Abnormal mitral flow, what is the cause?

Diastolic mitral regurgitation is a unique Doppler finding that can be missed if special attention is not paid to it. There are a few causes of such abnormal flow, ranging from a conduction abnormality to abnormal valvular and left ventricle function. Failure to recognize it might lead to unnecessary investigations and delay the primary diagnosis. We are presenting a teaching case and discuss the associated pathology.

Endovascular Treatment for Pseudoaneurysms After the Surgical Repair of Aortic Coarctation.

In this report, we describe the case of a 28-year-old male who presented to our hospital with shortness of breath and sudden, severe central chest pain that radiated across his chest and back. The patient had a history of coarctation of the aorta (CoA) repair using Dacron patch aortoplasty at the age of 10 years, and he had been lost to clinical follow-up. A chest X-ray (CXR) revealed the widening of the upper mediastinum. He underwent emergency CT angiography, which demonstrated extensive mediastinal hematoma and contrast leaking from a 4x12 cm complex pseudoaneurysm of the proximal thoracic descending aorta. After the heart-team meeting, the transcatheter approach was deemed more feasible and safer than a surgical approach. The patient was taken to cardiac catheterization laboratory and, under general anaesthesia, we successfully implanted a tapered (28 mm - 26 mm) x 150 mm Valiant Thoracic Stent Graft with the Captivia Delivery System (Medtronic Vascular, Santa Rosa, CA). In this case, we demonstrated the feasibility and safety of using a stent graft to treat late surgical complications after CoA repair, which are not uncommon.

Percutaneous Intervention With Balloon-Expandable Covered Stent for the Treatment of Traumatic Aortic Pseudoaneurysm in a Paediatric Patient.

In this report, we describe the case of a 13-year-old male who presented to our hospital after sustaining injuries from a motor vehicle accident (MVA). A full-body CT scan revealed multiple injuries, including subgaleal hematoma, hemorrhagic brain contusion, moderate-size aortic pseudoaneurysm with associated mediastinal hematoma, and multiple stable visceral organ lacerations. Additionally, there were numerous fractures, including in the right femur associated with large hematoma. The patient was deemed at high risk for systemic anticoagulation required for an urgent operative aortic repair. Available percutaneous endograft sizes were deemed too large for his descending aortic diameter, and the associated potential risk of vessel injury from the large sheath required to implant the endograft removed this option from consideration. The decision was made to use a balloon-expandable covered stent, which is routinely used to treat coarctation of the aorta (CoA) as a life-saving alternative. A BeGraft aortic stent (Bentley InnoMed, Hechingen, Germany) measuring 16x38 mm was successfully implanted percutaneously with complete exclusion of the pseudoaneurysm without any procedural complications.

Transcatheter Intervention For Severe Aortic Coarctation in a Patient With Uninterrupted Left-Sided Inferior Vena Cava Presenting With Recurrent Abdominal Pain.

We describe a case of a 17-year-old male patient who was admitted to the hospital for an evaluation of his recurrent postprandial abdominal pain and fatigue on exertion. He was discovered to have severe post-ductal aortic coarctation (CoA) and uninterrupted left-sided inferior vena cava (IVC) draining into the right atrium crossing anterior to the abdominal aorta. There were no signs of IVC compression. Patient symptoms improved dramatically after CoA stenting on follow up. The presence of uninterrupted left-sided IVC in this particular case created a diagnostic dilemma, and it was of great importance to know such anomaly before the procedure. This association of uninterrupted left-sided IVC with CoA is unusual, and to our knowledge, our case is the first to report such congenital association.

Transcatheter pulmonary valve replacement in pediatric patients.

INTRODUCTION: Right ventricular outflow tract (RVOT) dysfunction is common among individuals with congenital heart disease (CHD). Surgical intervention often carries prohibitive risks due to the need for sequential pulmonary valve (PV) replacements throughout their life in the majority of cases. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with RVOT dysfunction. AREAS COVERED: In this review, we examine the pathophysiology of RVOT dysfunction, indications for tPVR, and the procedural aspect. Advancements in clinical application and valve technology will also be covered. EXPERT OPINION: tPVR is widely accepted as an alternative to surgery to address RVOT dysfunction, but still significant numbers of patients with complex RVOT morphology deemed not suitable for tPVR. As the technology continues to evolve, new percutaneous valves will allow such complex RVOT patient to benefit from tPVR.

Current practice in atrial septal defect occlusion in children and adults.

INTRODUCTION: Atrial septal defect (ASD) is one of the most common congenital heart diseases (CHD) in children and adults. This group of malformations includes several types of atrial communications allowing shunting of blood between the systemic and the pulmonary circulations. Early diagnosis and treatment carries favorable outcomes. Patients diagnosed during adulthood often present with complications related to longstanding volume overload such as pulmonary artery hypertension (PAH), atrial dysrhythmias, and right (RV) and left (LV) ventricular dysfunction. AREA COVERED: This article intended to review all aspects of ASD; anatomy, pathophysiology, clinical presentation, natural history, and indication for treatment. Also, we covered the transcatheter therapy in detail, including the procedural aspect, available devices, and outcomes. EXPERT OPINION: There has been a remarkable improvement in the treatment strategy of ASD over the last few decades. Transcatheter closure of ASD is currently accepted as the treatment of choice in most patients with appropriately selected secundum ASDs. This review will focus on the most recent advances in diagnosis and treatment strategy of secundum ASD.

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.

An Adult Patient With a Tetralogy of Fallot Case.

Tetralogy of Fallot (ToF) is considered the most frequent cyanotic congenital heart abnormality with a low adulthood survival rate if kept untreated. The majority of cases are symptomatic during infancy and mandate early treatment. Few instances of survival to asymptomatic middle-age patients have been reported, and they are decreasing due to early detection. We reported a case of a middle-aged man who was asymptomatic during his life and recently diagnosed with ToF. The patient underwent surgical repair with excellent outcomes. The case represents the possibility of diagnosing such cases in a relatively old patient despite medical development and advances.

Percutaneous Device Closure of Patent Ductus Arteriosus in Adult Patients with 10-Year Follow-up.

OBJECTIVES: We report our 10-year experience with transcatheter closure of patent ductus arteriosus (PDA) in adult using different closure devices. BACKGROUND: Transcatheter closure of PDA in adults can be challenging because of frequently associated comorbidities. Reports on immediate and intermediate-term results of PDA closure are excellent. This study aimed to provide the outcomes of PDA closure using different devices on long and very long term follow-up in adults. MATERIALS AND METHODS: Between September 2009 and December 2018, data were retrospectively reviewed from 27 patients who underwent transcatheter closure of PDA. Outcome parameters were procedural success, procedure-related complications, evidence of residual shunt, and improvement in the signs/symptoms for which the procedure was performed. The mean follow-up interval was 72 months. RESULTS: A device was successfully implanted in 27 of 27 patients (15 females). Median age and weight were 24 years (range: 18-57 years) and 69 kg (range: 53-102 kg), respectively. The mean PDA diameter was 4.1 ± 2.1 mm. Devices used were Amplatzer Duct Occluder (19/27), Occlutech Duct Occluder (6/27), and PFM Nit-Occlud (2/27). Doppler transthoracic echocardiography (TTE) demonstrated 92.6% of full occlusion at day 1, rising to 96.3% at 1 month. Three procedure-related complications occurred with no death. Among symptomatic 26 patients (96.3%), there was marked improvement in symptoms. Among 22 patients (81.5%) for whom the procedure was performed to address left ventricular (LV) enlargement, there was reduction or stabilization in LV size on serial TTEs. CONCLUSIONS: Transcatheter closure of PDA in the adult patient appears to be safe and effective.

Management of Coarctation of The Aorta in Adult Patients: State of The Art.

Coarctation of the aorta (CoA) is a common form of congenital heart disease. Adult patients with CoA may be asymptomatic or may present with hypertension. Over the last few years, endovascular management of adult patients with CoA emerged as the preferred strategy. Stent implantation, though technically challenging, offers the best and most lasting therapy. In this paper, we will review technical considerations and outcome of patients undergoing stent implantation for CoA.

Transcatheter Pulmonary Valve Replacement: Current State of Art.

PURPOSE OF REVIEW: The past couple of decades have brought tremendous advances to the field of pediatric and adult congenital heart disease (CHD). Percutaneous valve interventions are now a cornerstone of not just the congenital cardiologist treating patients with congenital heart disease, but also-and numerically more importantly-for adult interventional cardiologists treating patients with acquired heart valve disease. Transcatheter pulmonary valve replacement (tPVR) is one of the most exciting recent developments in the treatment of CHD and has evolved to become an attractive alternative to surgery in patients with right ventricular outflow tract (RVOT) dysfunction. This review aims to summarize (1) the current state of the art for tPVR, (2) the expanding indications, and (3) the technological obstacles to optimizing tPVR. RECENT FINDINGS: Since its introduction in 2000, more than ten thousands tPVR procedures have been performed worldwide. Although the indications for tPVR have been adapted earlier from those accepted for surgical intervention, they remain incompletely defined. The new imaging modalities give better assessment of cardiac anatomy and function and determine candidacy for the procedure. The procedure has been shown to be feasible and safe when performed in patients who received pulmonary conduit and or bioprosthetic valves between the right ventricle and the pulmonary artery. Fewer selected patients post trans-annular patch repair for tetralogy of Fallot may also be candidates for this technology. Size restrictions of the currently available valves limit deployment in the majority of patients post trans-annular patch repair. Newer valves and techniques are being developed that may help such patients. Refinements and further developments of this procedure hold promise for the extension of this technology to other patient populations.

Evolution of hybrid interventions for congenital heart disease.

INTRODUCTION: Surgical and transcatheter interventions have seen a tremendous evolution in last three decades. Hybrid technology combines the achievements of both disciplines to bring substantial hemodynamic benefit to patients with congenital heart disease (CHD) in a minimally invasive manner. This collaboration between surgeons and interventionalists will continue to grow as the technology evolves to meet the demands of CHD patients, potentially avoiding cardiopulmonary bypass and vascular access complications as well as optimizing immediate technical outcomes with exit angiography. Areas covered: This review covers application of such technology to initial palliation of infants with hypoplastic left heart syndrome, ventricular septal defect closure, pulmonary atresia with intact ventricular septum, pulmonary valve replacement, intra-operative pulmonary artery stenting and vascular cut-down in small neonates. Expert commentary: Careful planning and investment in infrastructure is necessary to optimize outcomes, however patients can benefit tremendously from integration of this approach into clinical practice.