The Journal of Tehran University Heart Center
Volume:12 Issue: 2, Apr 2017

Heart failure (HF) is one of the main causes of death and disability in the world.
The prevalence of HF in developed countries is between 1% and 2% of the adult population and approximately between 6% and 10% in the elderly, giving rise to high costs of care and treatment. Indeed, in the United States, the direct and indirect costs exceeded 23 billion dollars in 2002. HF is typically characterized by periods of acute symptoms followed by returns to nearly asymptomatic periods. As dyspnea and fatigue are considered the signature symptoms of HF, other symptoms such as pain go unnoticed. Awareness of the burden of pain, however, is growing in patients with chronic HF. The past 2 decades have witnessed remarkable technical headway in cardiology and many patients have survived despite the progressive impairment of their cardiovascular function. It is, therefore, of great value to investigate the prevalence and management of pain in patients with HF. To that end, we undertook a comprehensive search using the MEDLINE database for studies and guidelines on the subject of pain and HF and the complications and considerations and finally selected 65 studies for review.

L-carnitine may prevent the incidence of AKI by its antioxidant effects and improving circulation in ischemic conditions. The goal of this trial was to evaluate the impact of L-carnitine on contrast-induced nephropathy in patients undergoing elective PCI.
Totally, the patients were randomly allocated to 2 groups. The treatment group received 1 g of L-carnitine orally 3 times a day, 24 hours before the procedure (3 g before PCI) and 2 g after PCI, whereas the control group did not receive L-carnitine. In both groups, the plasma level of neutrophil gelatinase-associated lipocalin (NGAL) was measured at baseline and 12 hours after PCI.
Our study was conducted on 202 patients (including 91 vs. 111 patients in the treatment and the control group; 31 (34.1%) vs 33 (29.7%) female in carnitine and control group; and ages include 62.0 ± 9.0 vs 57.0 ± 11.2 years). The median plasma levels of NGAL were not different between the carnitine and control groups at baseline (57 [IQR: 22 – 255] vs. 54 [IQR: 29 – 324]; p value = 0.155) and 12 hours after PCI (71 [IQR: 52 – 129] vs. 70 [IQR: 46 – 153]; p value = 0.925), but the changes in the plasma NGAL from baseline to 12 hours after PCI were different between the 2 groups (5 [IQR:-147 – 30] vs. 17 [IQR: -21 – 41]; p value = 0.010).
Our results showed that oral L-carnitine was able to prevent an increase in NGAL following contrast medium administration in patients undergoing PCI. More studies should be performed to fully elucidate the nephroprotective effects of L-carnitine.

Myocardial infarction is the main cause of death worldwide. Angiogenesis, a promising new therapy for the treatment of diffuse coronary artery disease, shows a poor response to conventional revascularization techniques. This study focused on improving myocardial function using endothelial cells (ECs) and mesenchymal stem cells (MSCs) in a sheep animal model.
Acute myocardial infarction was induced in 18 sheep (12 treated cases and 6 controls). Autologous MSCs and ECs were injected in the infarcted area and the border zone. Two months after transplantation, echocardiography, electron microscopy, and immunohistochemistry were performed.
Echocardiography in both MSC and EC groups revealed a significant improvement in the ejection fraction compared with the control group (p value Both ECs and MSCs were able to promote angiogenesis and improve cardiac function. Presumably, MSCs differentiate into ECs and cause angiogenesis as it occurs for ECs.

The C1019T polymorphism of the connexin-37 (GJA4) gene is a single-nucleotide polymorphisms involved in atherosclerotic plaque rupture and atherosclerosis predisposition. We examined the association between the C1019T polymorphism of the GJA4 gene and the occurrence of myocardial infarction (MI) in patients with premature coronary artery disease (CAD).
Our study recruited 1000 patients with the final diagnosis of premature CAD and classified them into 2 groups: with a history of MI (n = 461) and without it (n = 539). The polymorphism variants were determined via the PCR–RFLP, and then genotyping was conducted through the high-resolution melting method. From a total of 1000 patients, 554 patients, who had been previously followed-up with a median follow-up time of 45.74 months vis-à-vis long-term major adverse cardiac events, were enrolled in this retrospective cohort phase.
The frequencies of the wild, heterozygous, and mutant genotypes of the C1019T polymorphism were 54.0%, 40.6%, and 5.4% in the MI group and 49.2%, 43.2%, and 7.6% in the non-MI group (p value = 0.187). After adjustment for the baseline covariates, no difference was found between the MI and non-MI groups apropos the frequency of the heterozygous genotype (p value = 0.625) and the mutant genotype (p value = 0.452). Regarding the level of human connexin-37, the serum level of this marker was not different between the MI and non-MI groups.
The C1019T polymorphism of the GJA4 gene may not be useful for predicting the occurrence of MI in patients with premature CAD. The presence of this polymorphism in such patients may also have a low value for predicting long-term CAD complications.

Transradial coronary angiography has been known as an alternative to the transfemoral approach with fewer serious complications. Radial artery pseudoaneurysms present as a rare complication of transradial catheterization. Although some methods have been applied for the obliteration of pseudoaneurysms, the use of radial bands such as the TR Band® (Terumo Medical Corporation, Somerset, NJ) is a novel efficient technique only suggested by a few reports. We describe a 34-year-old man, who underwent transradial primary coronary angiography due to ST-elevation myocardial infarction. Two months later, he noticed a pulsatile mass on his hand where the catheterization was done. Ultrasonography proved the diagnosis of a pseudoaneurysm. Consequently, a TR Band® was applied to compress the mass. Interestingly, 24 hours later, ultrasonography confirmed a thrombosed pseudoaneurysm and the pulsatile mass had completely disappeared gradually without recurrence at 2 months’ follow-up. Hence, this case report aims to propose the TR Band® as an effective noninvasive method for the treatment of pseudoaneurysms following catheterization.

The coronary slow flow phenomenon (CSFP) is characterized by a delayed coronary blood flow in the absence of an obstructive coronary artery disease. Although the relation between the CSFP and myocardial ischemia has been reported previously, there is no knowledge about the relationship between the CSFP and the conduction system disorder. In this case report, we describe a patient with the CSFP presenting with complete heart block (CHB). The patient was a middle-aged woman with a history of diabetes, hypertension, and prior Coronary Care Unit admission presenting with dizziness, lightheadedness, and presyncope. Electrocardiography revealed CHB with no significant ST-T change. Cardiac enzymes and other routine lab tests were normal. The patient underwent temporary pacemaker implantation. Due to persistent atrioventricular block and suspicion of ischemic heart disease, she underwent coronary angiography, which showed the CSFP and no significant stenosis. The patient was discharged after permanent pacemaker implantation and remained asymptomatic at 3 month's follow-up.

Traumatic injuries to the subclavian-axillary artery, although uncommon, are associated with high morbidity and mortality rates if not managed promptly. The emergence of endovascular techniques offers an alternative to the surgical management of these injuries. We herein present 4 cases of traumatic subclavian-axillary artery injury with limb ischemia successfully managed via the endovascular approach with non-covered self-expandable stents. We achieved excellent immediate results with limb salvage and without complications. At follow-up by duplex sonography, all the patients had good peripheral pulses and patent revascularized arteries.

Major complications of heart transplantation include graft rejection, infection, graft arteriosclerosis, malignancy, and drug toxicity. Among these complications, infections and thrombophilic disorders are of particular interest owing to their major contribution to morbidity and mortality among heart transplantation patients. Thrombophilic disorders are caused by imbalance between hypercoagulation and fibrinolytic states. In this report, we describe a 43-year-old man who had unusual complications of heart transplantation. We presume that the unusual postoperative complications of the patient might have been caused by a faulty surgical procedure, improper use of anticoagulant agents, and incomplete prophylaxis for infections. During the postoperative period, the patient suffered arterial obstruction three times, for which he underwent clot removal via embolectomy. In addition to arterial obstruction, the patient had a mobile mass in the left atrium that was removed by open cardiac surgery. The frozen sample of the cardiac mass was positive for Acinetobacter baumannii. After 7 days of observation in the hospital and proper antibiotic regimen, the patient was sent home with no additional complaints and normal physical examination. We conclude that in heart transplantation patients, the precise performance of the surgical procedure, postoperative care, and early removal of the embolus might reduce morbidities and mortality due to thrombophilic disorders.

Takotsubo or stress-induced cardiomyopathy is a cardiomyopathy in which the patient has a sudden onset, reversible left ventricular systolic dysfunction without any significant coronary artery disease. Four women, who were at a mean age of 64 years and suffered from chest pain exacerbated by emotional stress, were admitted as cases of acute coronary syndrome and were completely evaluated through precise history taking, physical examination, and ECG. Coronary angiography or coronary multidetector computed tomography was used to exclude significant coronary artery disease. In these patients with confirmed Takotsubo cardiomyopathy, in addition to the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV) criteria, a 71-item form of the Minnesota Multiphasic Personality Inventory (MMPI)-Mini-Mult-was employed for psychological assessment. The main common elevated scale was hypochondriasis. Individuals with high scores on this scale are obsessed with themselves, especially in regard to their body, and often use their disease symptoms in order to manipulate others. They are mainly passive aggressive, critical, and demanding, which stems from their lack of effective verbal abilities as a means of communication, specifically when it comes to anger or hostility expression. To the best of our knowledge, there is no available study evaluating patients with Takotsubo cardiomyopathy using the Mini-Mult questionnaire for psychological assessment.

A 48-year-old woman was admitted to the emergency department with complaints of typical chest pain, cold sweat, and dyspnea of 24 hours’ duration. She had a history of hypertension, hyperlipidemia, and diabetes mellitus for many years. On admission, her electrocardiogram (ECG) revealed normal sinus rhythm and dynamic T inversion in the precordial leads. Her enzyme levels were normal. Transthoracic echocardiography showed a left ventricular ejection fraction of 60%, with mild mitral regurgitation. Because of ST depression during the peak exercise test, cardiac catheterization was suggested and then performed. Coronary angiography demonstrated normal left main coronary artery courses with normal dominant left circumflex artery and left anterior descending artery (LAD). An anomalous right coronary artery (RCA) was seen, with a nondominant separate branch arising from the mid part of the LAD. It then coursed anteriorly down on the right atrioventricular groove (Figure 1). Attempts for the cannulation of the RCA were unsuccessful. Aortic root angiography did not show the presence of an independent-origin RCA from the ascending aorta (Figure 2 and Figure 3). We selected medical management of X syndrome (microvascular disease) and followed up the patient because of the nondominancy of the RCA. There was no need for revascularization or surgery. She was discharged in good condition.