The Journal of Tehran University Heart Center
Volume:12 Issue: 3, Jul 2017

Radiation risk allied to invasive cardiology is relatively high, and protecting both patients and cardiologists is necessary. The aim of this review is to discuss how to better protect patients and cardiologists against radiation exposure. We performed a global search on PubMed, Science Direct, and Scopus databases via keywords of “interventional cardiologist”, “patient”, “radiation”, and “exposure” and then performed an overview of the main strategies for risk reduction among interventional cardiologists and exposed patients. The 1st line for protection is awareness of both radiation risk factors and exposure doses and how to manage and minimize exposure levels. In conclusion, radiation-attenuating techniques can effectively reduce occupational/treatment radiation exposure to both operators and patients in cardiology interventions.

Several studies have emphasized the importance of cardiovascular disease (CVD) prevention. However, there is a dearth of data on the prevention of cardiovascular disease recurrence. The present study was the 1st in Iran to evaluate factors associated with CVD recurrence.
This prospective cohort study was conducted on 483 subjects (> 30 years old) with a history of CVD who participated in the Tehran Lipid and Glucose Study and were followed up for 12 years (1999–2012). The relationships between the most important established risk factors for CVD and CVD recurrence were evaluated.
Totally, 258 (53.4%) men and 225(46.5%) women at a mean age of 59.2 ± 10.7 years were recruited in the study. Our results showed that over the 12-year follow-up, the incidence of a recurrent event (per 100 person-years) was 48.5. Further, after controlling the possible confounding factors, the following variables had a significant relationship with CVD recurrence: age (HR = 1.02; p value = 0. 001), male sex (HR = 1.4; p value = 0.012), smoking (HR = 1.7; p value = 0.004), and increased fasting blood sugar (HR = 2.1; p value = 0.001).
We found that the established variables in the development of CVD (i.e., age, sex, and smoking) played an important role in the risk of CVD recurrence.

There are only a few reports concerning the genetic risk factors for coronary artery disease (CAD). However, 2 polymorphisms of rs10757274 and rs2383206 on chromosome 9p21.3 have been shown recently to be associated with CAD in certain populations. This is the 1st study to investigate their validity and association with CAD in a sample of the Iranian population.
Genomic DNA was extracted from the peripheral blood of all participants, consisting of 111 cases with CAD and 100 normal controls with normal coronary angiographies. Genotyping of rs10757274 and rs2383206 was performed in the cases and controls using designed mismatch primers via the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method.
Statistical analysis presented a significant association between the rs10757274 GG (p value = 0.029, χ2 = 7.078) and rs2383206 GG (p value = 0.036, χ2 =6.658) genotypes and CAD among the cases as compared with the normal controls. Haplotype analysis of rs10757274 and rs2383206 polymorphisms showed 43% GG/GG haplotype with a significant association with CAD (p value = 0.014, χ² = 6.058).
The results of this study provide an insight into the underlying molecular mechanism of CAD pathogenesis and pave the way for future functional studies on these variants.

Hepatic lipase (HL) plays a crucial role in lipid metabolism, but there is debate about whether HL acts in a more pro- or more anti-atherogenic fashion. We aimed to examine the relationship between the -514 C/T polymorphism within the HL gene (LIPC) and the risk of angiographically determined premature coronary artery disease (CAD).
Four hundred seventy-one patients with newly diagnosed angiographically documented (≥ 50% luminal stenosis of any coronary vessel) premature CAD were compared to 503 controls (subjects with no luminal stenosis in coronary arteries). A real-time polymerase chain reaction and high-resolution melting analysis was used to distinguish between the genotypes.
There was no significant difference in the distribution of -514 C/T genotypes between the 2 groups in the whole population or in the men, but the examined polymorphism was found to be associated with the presence of CAD in the women (p value = 0.029). After the application of a multiple logistic regression model, the minor T allele of the LIPC gene was not found to be independently associated with the presence of CAD either in the total population (adjusted OR = 0.97, 95% CI = 0.75-1.25; p value = 0.807) or in the women (adjusted OR = 0.91, 95% CI = 0.59-1.40; p value = 0.650) and in the men (adjusted OR = 1.15, 95% CI = 0.81-1.64; p value = 0.437) separately.
Our findings suggest that there is no relationship between the LIPC -514 C/T and the risk of premature CAD or its severity in patients undergoing coronary angiography.

The anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly. The usual clinical course is severe left-sided heart failure and mitral valve insufficiency presenting during the first months of life. However, in some cases, the collateral blood supply from the right coronary artery is sufficient and symptoms may be subtle or even absent. We describe a 49-year-old woman presenting with atypical chest pain during physical exertion. The exercise tolerance test and then coronary angiography by indication revealed an anomalous origin of the left coronary artery. The patient underwent surgical treatment, whereby a pulmonary artery tube graft from the aorta to the left coronary artery was created and the main pulmonary artery was reconstructed with a bovine pericardial patch. The patient was discharged from the hospital without any chest pain and dyspnea and was symptom free during a follow-up period of 18 months. Clinicians should consider ALCAPA as a differential diagnosis in adults with presentations similar to exercise-related asthma.

The VACTERL association, co-occurrence of vertebral, anorectal, cardiac, tracheoesophageal, genitourinary, and limb malformations, is a rare congenital anomaly. Several cardiac anomalies have been reported as a part of the VACTERL association, particularly ventricular and atrial septal defects. Pulmonary artery sling is a rare congenital abnormality in which the left pulmonary artery arises from the right pulmonary artery. This anomaly is not frequently observed in the VACTERL association and has been rarely reported. A 20-month-old girl was admitted to our hospital due to pneumonia in the right lung, which had pulmonary artery sling as a part of the VACTERL association. Barium meal X-ray showed pressure effects on the esophagus, and computed tomography angiography revealed pulmonary artery sling. Pneumonia management was done. However, the parents of our patient refused to give consent for the surgical correction of this vascular anomaly. Three months after discharge from the hospital, the patient was visited, at which time the parents again refused surgery and treatment for their daughter despite our recommendations.

The pseudoaneurysm of the aorta is rarely due to trauma and infection but usually is a late complication of previous surgical procedures like coronary artery bypass graft surgery. We describe a 65-year-old woman with the pseudoaneurysm of the ascending aorta due to coronary artery bypass graft surgery. It was revealed in coronary artery angiography after nonspecific symptoms. It was confirmed by multidetector computed tomographic angiography. The patient refused open cardiac surgery, so we decided to use an atrial septal defect occluder device in off-label way to seal the pseudoaneurysm orifice. In a hybrid operating room setting, the procedure was done successfully and patient’s hospitalization course was eventless. In multidetector computed tomographic angiography after 3 months, the device was in the appropriate position without endoleak and in the yearly visit the patient was asymptomatic and healthy.

Ventricular septal defects (VSDs) are among the most common congenital cardiac lesions. Large defects at apicomuscular regions, especially in young patients, are far from accessible to surgeons for conventional surgery. Moreover, the transcatheter closure of VSDs in these patients is difficult and carries a high risk of complications because of the large sheath size relative to the patient’s size. The periventricular approach simplifies VSD closure and, thus, eliminates the potential complications of cardiac catheterization and fluoroscopy as it is performed under echocardiographic guidance. A 3-year-old girl with a body weight of 11 kg (failure to thrive) was referred to us. She had multiple adjacent apicomuscular VSDs, the largest one being about 19 mm in diameter, and subsystemic pulmonary artery pressure (PAP). The patient underwent periventricular apicomuscular VSD closure with a Lifetech muscular VSD occluder (size 22 mm) under epicardial echocardiography guidance without cardiopulmonary bypass. Post procedure, the PAP was decreased to mild level. The residual shunt was mild across the adjacent small defects. She was discharged after 7 days without complications. At 2 years’ follow-up, the patient was hemodynamically stable and had a normal PAP (PAP = about 16 mmHg) by transthoracic echocardiographic assessment.

Cardiac lipomas are extremely rare tumors of the heart. They are usually symptomatic and rarely may be found incidentally in autopsies. Here we describe a 23-year-old healthy man, in whose physical examination for employment a murmur was found incidentally. Transthoracic and then transesophageal echocardiographic examination showed a 4-cm oval-shaped mass in the right ventricular outflow tract. He underwent elective surgery, during which the tumor was removed under cardiopulmonary bypass and aortic-cross clamping via right atriotomy. The postoperative course was uneventful, and the patient was in good condition at 1 year’s follow-up.

Cardiac myxomas are the most common cardiac tumors with diverse nonspecific clinical manifestations. A 78-year-old man presented to the emergency department with complaints of pain and coldness of the left lower extremity. The left femoral artery pulse was detected, while the pulses of the left popliteal, dorsalis pedis, and posterior tibialis arteries were absent. No blood inflow was detected in the superficial and deep femoral, popliteal, and anterior and posterior tibialis arteries. Thrombectomy was performed, and a fatty-like mass from the bifurcation of the common femoral artery and a thrombotic mass from the proximal portion of the superficial and deep femoral arteries were removed. The pulsatile inflow and palpable pulses of the left femoral, popliteal, dorsalis pedis, and posterior tibialis arteries were restored after surgery. The histological findings of the embolus were suggestive of a cardiac myxoma. The patient’s consciousness and lower limb blood flow improved gradually. He was discharged from the hospital with full awareness and improved lower extremity muscle function 2 weeks after surgery.