Iranian Heart Journal
Volume:24 Issue: 1, Winter 2023

Data are scarce regarding the association between a positive T wave in the precordial lead V1 (TV1) and the severity of coronary artery disease (CAD) and long-term mortality in patients with suspected CAD and otherwise normal electrocardiograms (ECGs). The present study aimed to assess the association between a positive TV1 and the severity of coronary artery stenosis and 1-year mortality in patients with normal ECGs undergoing elective coronary angiography.

The present retrospective study enrolled 500 patients referred for elective coronary angiography and normal ECGs. We excluded patients with a history of myocardial infarction and acute coronary syndromes, bundle branch blocks, left ventricular hypertrophy, intraventricular conduction delays, significant valvular heart diseases, and permanent pacemakers. The patients were divided into 2 groups based on their ECG: patients with a positive TV1 and those with a negative or flat TV1.

Out of 500 patients, 139 (27.8%) had a positive TV1. Multivessel CAD was more frequent in the patients with a positive TV1 than in those with a negative or flat TV1 (40.3% vs 28.5%; P=0.012). The 1-year mortality rate was significantly higher in the patients with a positive TV1 (9.4% vs 2.8%; P=0.003). A positive TV1 was an independent predictor of 1-year mortality (OR, 4.07; 95% CI, 2.16 to 7.62; P<0.001).

The findings of the present study suggest that a positive TV1 in patients with normal ECGs and suspected CAD is associated with advanced CAD and is an independent predictor of 1-year mortality. 

Remote ischemic preconditioning (RIPC) may improve outcomes in ischemia/reperfusion injury (IRI) by improving antioxidant defense. We investigated total antioxidant capacity (TAC) and malondialdehyde (MDA) content as markers of lipid peroxidation.

The present randomized clinical trial allocated 50 coronary artery bypass graft (CABG) patients with cardiopulmonary bypass at Tehran Heart Center to 2 groups: RIPC and control (25 patients each). Clinical biochemistry parameters, TAC, and MDA were measured at 3 time points: post-anesthesia induction (before skin incision), immediately post-CPB, and 24 hours post-ICU admission.

Increased transfusions of packed cells in the ICU and higher plasma MDA levels at post-CPB were observed in the control group. Additionally, significantly higher plasma TAC levels were observed at 24 hours post-ICU in the RIPC group.

RIPC protects against IRI in CABG on CPB by reducing lipid peroxidation and elevating antioxidant defense. RIPC could be integrated into CABG to reduce IRI adverse outcomes. 

Open-heart surgery is usually done in 2 ways. The first and most common method is done with cardiac arrest after aortic clamping and the perfusion of the cardioplegic solution into the coronary arteries. The second method is the on-pump beating heart, done usually for the right-heart chambers. In this study, we sought to compare these 2 methods concerning cardiac muscle damage, kidney and liver parameters, and clinical outcomes in patients with isolated pulmonary valve repair.

Forty-three patients that underwent cardiopulmonary bypass were randomly assigned to 2 on-pump non-beating (n=20) and beating (n=23) heart groups. We assessed between-group hemodynamics and arterial blood gasses.

The operation time was shorter in the beating-heart group than in the non-beating heart group (P=0.003). The ejection fraction (EF) at discharge in the non-beating group was significantly lower than that in the beating-heart group (44.25±6.12 vs 50.00±5.56). Cardiac troponin I and creatine phosphokinase levels showed significant decreases at the preoperative time in both groups; the levels were better in the beating-heart group. No changes were observed in arterial blood gasses before surgery, postoperatively, at intensive care unit admission, and 24 hours after surgery in the 2 groups. The potassium level after the operation was significantly lower in the beating-heart group (4.18 [± 0.85]).

The beating-heart surgical procedure conferred a better EF at discharge. Additionally, cardiac troponin I and creatine phosphokinase levels decreased after the preoperative time.

Cardioplegia is used to protect the heart from ischemic injury during cardiovascular bypass. We randomly selected candidates for coronary artery bypass surgery undergoing either microplegia or del Nido cardioplegia.

We performed a controlled randomized double-blind study to evaluate 60 patients undergoing coronary artery bypass surgery in Rajaie Cardiovascular Medical and Research Center during a 3-month period. During surgery, the case group received microplegia, and the control group received del Nido cardioplegia. Preoperative, intraoperative, and postoperative personal information was collected from the patients’ records, and the data were analyzed using the SPSS software, version 22, using appropriate statistical tests.

Out of 60 patients under study, 28 patients underwent microplegia, and 32 patients received del Nido cardioplegia. The patients, randomly assigned to the groups, did not significantly differ concerning height, weight, and body surface area. No significant differences existed between the 2 groups. The levels of postoperative decreases in hemoglobin and hematocrit were significant in the microplegia group and led to an increase in the number of blood transfusions in the intensive care unit. A significant increase in CK-MB was observed in the del Nido group 24 hours after surgery.

Microplegia, compared with del Nido cardioplegia, conferred proper myocardial protection. However, the use of the microplegia technique was associated with more significant decreases in hemoglobin and hematocrit postoperatively, and the beneficial effects of microplegia in reducing hemodilution were not well-reflected. 

Ischemic heart disease (IHD) is the most common cause of mortality, and prompt treatment can be life-saving. Cardiogoniometry (CGM) is a noninvasive method that seems reliable for IHD diagnosis. This study aimed to determine the accuracy of CGM in IHD diagnosis in patients with suspected acute coronary syndrome (ACS), especially those with unstable angina or non–ST-elevation myocardial infarction (NSTEMI), whose diagnosis may be challenging.

This cross-sectional study was performed at Rajaie Cardiovascular Medical and Research Center, a tertiary public hospital. Forty-five patients with ACS in the emergency ward were enrolled. The patients underwent CGM about 24 hours before catheterization, and the results were compared with angiography as the gold standard for IHD diagnosis. The data were analyzed using the SPSS software and were reported separately for age, sex, and hypertension.

The sensitivity and specificity of this method were 96.7% and 55.3%, respectively. The positive and negative predictive values were 80.6% and 88.9%, respectively. 

CGM is a sensitive method for confirming or ruling out ACS. It is useful when the diagnosis is challenging, especially when ACS is suspected and electrocardiography or laboratory test results are unremarkable. Other studies are needed to confirm our conclusion.

Changes and increases in blood glucose and lactate during and after cardiac surgery in the intensive care unit (ICU) can be associated with complications. Recognizing these changes during and after surgery can be significant.

The present prospective observational case-series study assessed 163 children aged between 1 and 170 months undergoing open-heart surgery on cardiopulmonary bypass (CPB) over a 3-month period. Blood glucose and lactate were assessed using arterial blood samples before surgery, during surgery (at 15 and 45 minutes on CPB, after warm-up, and after sternum closure), and at 1, 6, 12, 24, and 48 hours after admission to the ICU.

In the first hour following ICU admission, a significant number of patients needed inotropes. Also at this time point, the percentage of patients with lactate levels >2.5 mmol/L was higher than that at the other time points. Further, most changes in blood glucose and lactate occurred in the first 6 hours following ICU admission. A significant relationship existed between changes in blood sugar and serum lactate in the first 6 hours post-ICU admission (P<0.001).

The results demonstrated a significant relationship between changes in blood glucose and serum lactate in the first 6 hours following ICU admission.

Phase analysis assesses left ventricular (LV) dyssynchrony from gated single-photon emission computed tomography myocardial perfusion imaging (GSPECT-MPI). This study aimed to determine the impact of diabetes mellitus (DM) on phase parameters.

The study population consisted of 121 diabetic patients with no history of coronary artery disease, hypertension, or dyslipidemia and no evidence of perfusion abnormalities or systolic dysfunction in GSPECT-MPI. The resting-state images of MPI were further analyzed using the Cedar–Sinai quantitative GSPECT, and LV phase parameters, including phase histogram bandwidth (PHB), phase standard deviation (PSD), and entropy, were derived. The results were compared with the corresponding figures previously defined in a control group, consisting of 100 subjects with low likelihoods of coronary artery disease, in our center.

Significant differences existed in the derived values for PHB, PSD, and entropy between the DM and control groups concerning global whole LV synchrony (P>.05). Likewise, PHB and PSD demonstrated no significant differences between the 2 groups regarding the regional wall-based analysis (P>.05). In contrast, the entropy indices of the LV septum (P= .019) and anterior wall (P= .022) were significantly higher in the DM group.

It appears that except for the regional wall-based entropy of the septum and the anterior wall, DM does not inherently impose any significant alterations on the mechanical synchrony indices of GSPECT-MPI. Consequently, the provided normal databases for GSPECT-MPI-derived synchrony parameters could be utilized in DM patients. 

We compared the mitral regurgitation (MR) volume measured between 2

the 2D continuity equation transthoracic echocardiography (2D CE-TTE) and the 3D HeartModel transthoracic echocardiography (3D HM-TTE).

Thirty-five patients at a mean age of 53.31 years (SD=15.16) were enrolled. All the patients were diagnosed with severe MR via transesophageal echocardiography. For the comparison of the MR volumes yielded by the 2 methods, the Bland–Altman chart and linear regression analyses were conducted.

The Bland–Altman analysis showed a mean difference of −89.30 mL between the MR volume measurements of the 2 methods, and the linear regression resulted in a standardized coefficient β of −0.831 (P<0.001). Hence, the analysis showed a significant proportional bias between 2D CE-TTE and 3D HM-TTE.

Overall, we observed that 2D CE-TTE overestimated the MR volume measured by 3D HM-TTE by about 30%.

The results of the IABP-SHOCK II trial did not encourage the use of an intra-aortic balloon pump (IABP) in cardiogenic shock (CS) with ST-elevation myocardial infarction (STEMI). We aimed to determine whether these findings may be applicable to our population in the South Asian region, as there is a paucity of data.

In this prospective cohort study, 2 independent cohorts of STEMI patients with CS were recruited based on the utilization of IABP during revascularization. The primary endpoints of in-hospital and after 30 days of major adverse cardiac events (MACE) and the secondary endpoint of any major bleed were compared between the 2 cohorts.

In total, each cohort consisted of 130 patients. Demographic, clinical, and angiographic profiles were comparable in the 2 cohorts. In the IABP and non-IABP cohorts, the in-hospital and 30-day mortality rates were 19.2% vs 26.2%; P=0.183 and 30.8% vs 36.9%; P=0.358, respectively, while the MACE rates were 20.8% vs 26.2%; P=0.306 and 32.3% vs 36.9%; P=0.434, respectively. Cardiac catheterization laboratory death was 0.8% vs 5.4%; P=0.031 and the major bleed was 4.6% vs 3.8%; P=0.758, among patients managed with IABP and without IABP, respectively.

Our study concluded that while there was no significant difference in the overall outcome, there was a lower trend in in-hospital mortality and significantly lower cardiac catheterization laboratory death with the use of IABP. However, the in-hospital and 30-day MACE were comparable in both groups. 

Permanent cardiac pacing is the most efficient treatment for conduction disorders, but it leads to asynchronous left ventricular (LV) activation, predisposing to deleterious effects on LV function and ejection fraction (EF). The predictors of LV dysfunction remain unclear, so we investigated whether strain measurements could be used to identify patients at risk of developing pacing-induced ventricular dysfunction (PIVD).

The study included 50 patients >18 years with normal LVEF (≥55%) who underwent single-chamber pacemaker implantation for various conduction disturbances. LVEF and global longitudinal strain (GLS) measurements were assessed by 2D speckle-tracking echocardiography at baseline and then at 1-month and 12-month follow-ups. The exclusion criteria were pregnancy, diabetes mellitus, myocardial infarction, revascularization within the prior 6 months, ischemic heart disease, significant valvular disease (starting from moderate in severity), structural heart abnormalities (LV dilatation), and any other comorbidities that might cause LV remodeling.

At the 12-month follow-up, PIVD was detected in 14 patients (28%), 4 of whom developed pacemaker-induced cardiomyopathy (PICM). At the 1-month follow-up, GLS was significantly reduced in the 14 patients who subsequently developed PIVD at 12 months, compared with those who did not show a significant decline in EF (n=38) (GLS= −12.46±2.77 vs −16.05±2.57, respectively; P=0.001). EF was also significantly reduced in this group at the 1-month follow-up compared with those without PIVD (EF=53.57±5.05 vs 61.28 ±4.67, respectively; P=0.001) When the 4 patients with PICMP were excluded, only GLS at 1 month was significantly reduced compared with the baseline.

GLS measurements shortly after pacemaker implantation provided valuable data for predicting patients who would subsequently develop PIVD. 

A 45-year-old woman presented to our cardiology clinic because of recent exertional chest discomfort. The patient had a history of the surgical repair of a secundum-type atrial septal defect in adolescence and the surgical repair of aortic regurgitation, followed by an emergent coronary artery bypass grafting operation due to electrocardiographic changes after aortic valve repair. Primarily, we evaluated the patient’s coronary tree with computed tomography angiography, which showed occluded grafts. Subsequently, coronary angiography revealed a chronic total occlusion in the left main with an aneurysmal formation and occluded grafts. Unfortunately, the surgical team refused to perform surgery. Accordingly, given her multiple prior surgeries, a percutaneous intervention was our last resort. We performed successful revascularization on the left main via the retrograde approach. Nonetheless, a year later, the patient needed another percutaneous intervention due to the progression of the left main aneurysm. The last follow-up demonstrated the patient’s acceptable clinical condition and physical activity without remarkable limitations. 

Mechanical complications following acute myocardial infarction (MI) are associated with very high morbidity and mortality. Left ventricular (LV) pseudoaneurysms constitute a rare complication after MI. Considered a contained rupture of the LV free wall, an LV pseudoaneurysm is more prevalent in older age, the female sex, hypertension, and inferior and lateral wall MI. Echocardiography, computed tomography, and cardiac magnetic resonance are considered good noninvasive imaging modalities for the diagnosis of LV pseudoaneurysms.

Case: 

A 39-year-old man with a history of anterolateral MI 18 months earlier, coronary stent insertion, and implantable cardioverter-defibrillator implantation presented for follow-up, but he was incidentally diagnosed with LV pseudoaneurysm in transthoracic echocardiography, which was confirmed by cardiac computed tomography.

Pseudoaneurysms must be diagnosed because of their high likelihood of rupture. However, as their clinical presentation is not specific, they are occasionally diagnosed incidentally. Clinicians should, therefore, always look for them in post-MI patients’ echocardiography.

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection.

COVID-19 is an infectious disease caused by SARS-CoV-2 that has significant potential cardiovascular implications for patients. Here, we describe a patient referred to Namazi Hospital, Shiraz, Iran, whose COVID-19 polymerase chain reaction test result was positive and developed paroxysmal supraventricular tachycardia.

The clinical features of acute rheumatic fever (ARF) are mainly the results of post-streptococcal mimicry. One of the major criteria to diagnose ARF is erythema marginatum. However, the involvement of erythema nodosum has not been reported yet. A middle-aged woman without comorbidities or addiction presented with breathlessness (NYHA-II) of 1 year’s duration with acute exacerbation in the preceding 7 days with fever, dry coughs, bilateral chest pain, orthopnea, paroxysmal nocturnal dyspnea, palpitations, bilateral leg swellings, and multiple tender faint red maculopapular rashes over bilateral shins and posterior ankle regions. Two-dimensional echocardiography confirmed rheumatic heart disease (RHD) and showed mild mitral stenosis, mild-to-moderate mitral regurgitation, severe tricuspid regurgitation, moderate pulmonary arterial hypertension, and an approximate left ventricular ejection fraction of 60%. A skin lesion biopsy showed chronic inflammatory lesions, suggesting erythema nodosum. The patient’s antistreptolysin O (ASO) titer was elevated, suggesting a prior streptococcal infection. Most of the major clinical criteria of ARF are the consequence of the molecular mimicry of Streptococci, especially such skin manifestations as erythema marginatum and subcutaneous nodules. Therefore, erythema nodosum, which also manifests itself as a delayed hypersensitivity reaction to Streptococci, can be considered a major criterion for diagnosing ARF/RHD.