Successful simultaneous retrieval of two dislodged and entangled intracoronary stents using distal balloon inflating technique.

Stent loss in coronary arteries is a rare complication of coronary intervention. Furthermore, the entanglement of a lost stent with a second previously deployed stent leading to a very complicated scenario has not been reported previously. In this case, we are presenting the first case report of a stent loss due to the entanglement of a stent with the ostial part of the second already deployed side branch stent leading to distortions of the second stent and entrapment. This is also the first case report describing the successful and simultaneous retrieval of both the lost and entangled deployed stents percutaneously using the distal inflating balloon technique.

The Outcome of Patients with Pulmonary Arterial Hypertension and Chronic Thromboembolic Pulmonary Hypertension during the COVID-19 Pandemic.

BACKGROUND: The coronavirus 2019 (COVID-19) has affected the lives of many people worldwide. Patients with chronic underlying morbidities are vulnerable to get the severe form of the infection. The goal of this study was to evaluate the outcome of patients with pulmonary arterial hypertension during the COVID-19 pandemic in Iran. METHODS: This cross-sectional study was conducted at a large tertiary center for pulmonary artery hypertension (PAH) patients. The primary end point was the prevalence of SARS-CoV-2 infection in PAH patients. The secondary end points were investigating the severity and mortality of COVID-19 infection in PAH patients during the COVID-19 pandemic. RESULTS: Totally 75 patients were enrolled in the study from December 2019 to October 2021 and 64% were female. The mean ± SD age was 49 ± 16 years. The prevalence of COVID-19 in PAH/chronic thromboembolic pulmonary hypertension patients was 44%. About 66.7% of patients had comorbidities, which was a prognostic factor for COVID-19 infection in PAH patients (P < 0.001). Fifty-six percent of infected patients were asymptomatic. The most reported symptoms in symptomatic patients were fever (28%) and malaise (29%). Twelve percent of patients were admitted with severe symptoms. The mortality rate in infected individuals was 3.7%. CONCLUSIONS: COVID-19 infection in PAH/chronic thromboembolic pulmonary hypertension patients seems to be associated with high mortality and morbidity. More scientific proof is needed to clarify different aspect of COVID-19 infection in this population.

A preliminary study on the radiation dose reduction during catheterization procedures using simple partial patient shielding.

Reduction in X-ray exposure during cardiac catheterization is important to reduce radiation risks to operators and personnel. Reducing scattered radiation from the patient can achieve this goal. The goal of this study was to evaluate the reduction in radiation using simple partial shielding of patients undergoing cardiac catheterization. By putting a lead-based apron on the lower extremities of patients undergoing cardiac catheterization, we analyzed the reduction in total radiation dose with and without this shielding. One hundred and twelve patients were divided into two groups. In one group, the protective lead-based apron was put on the lower extremities of patients. Another group did not have any shielding. Total duration of angiography was 332 minutes and 45 seconds in the first group and 269 minutes and 10 seconds in the second group. The total radiation exposure was 33 µGy in the first group vs 606 µGy in the second group. Despite higher exposure time, total radiation dose was 22 times lower in the simple shielded group. Our simple method without any additional cost can significantly reduce radiation exposure in the cardiac catheterization laboratory.

Curable Syncope in Primary Pulmonary Hypertension with Novel Atrial Flow Regulator.

Pulmonary artery hypertension (PAH) occurs when mean pulmonary artery pressure (PAP) is higher than 25 mmHg in rest or 30 mmHg during activity. Idiopathic pulmonary artery hypertension (IPAH) is defined as PAH without a definite reason. The IPAH is a rare disease with a high mortality rate if left untreated. To date, there has been no definite cure for this entity, and most treatments are for symptom relief or improvement in the quality of life. For many years, decompressing the right heart through a hole in the interatrial septum has been advised to alleviate some of their symptoms, specifically syncope. Atrial flow regulator (AFR) is a device to make an iatrogenic interatrial hole and finally a unidirectional shunt. It has been used for some PAH patients for symptom relief. Herein, we report a 36-year-old female case with diagnosed IPAH for 6 years. In the last 3 years, the case had frequent syncope with shortening intervals. The AFR was implanted for her without any complications. Then, within 6 months of follow-up, she had only one syncope episode. A significant change was observed in her 6-minute walk and PAP.

Coronary dissection with ST elevation myocardial infarction responding to thrombolytic and conservative therapy alone.

In this report, we describe a case of spontaneous coronary dissection involving left anterior descending artery presenting with acute anterior myocardial infarction successfully treated with thrombolytic and conservative therapy with a suggestion that spontaneous resolution of thrombus occurred before coronary intervention could be performed. As we did not have initial angiogram due to patient's refusal, this assumption is speculative. However, this case suggests that dissections may heal spontaneously and could be treated with conservative approach in selected cases based on best clinical judgment. It is important to realize that the clinical course of a major coronary artery dissection remains unpredictable. Therefore, cardiologists should always treat each case individually and consider coronary interventions if conservative treatment is not leading to resolution of ST elevation or in patients with hemodynamic compromise. This case is followed by discussion about conservative versus invasive management of spontaneous coronary dissections.

Differences in right ventricular dysfunction in patients with idiopathic pulmonary hypertension versus secondary pulmonary hypertension.

INTRODUCTION: Right ventricular (RV) function in the setting of pulmonary hypertension based on different etiologies has not been well studied. In this study, we evaluated the RV function in patients with idiopathic pulmonary hypertension (IPH) versus secon-dary pulmonary hypertension (SPH) due to congestive heart failure. MATERIAL AND METHOD: Forty-five patients with pulmonary hypertension and New York Heart Association (NYHA) functional class II or III were enrolled. Of these, 22 were diagnosed with IPH and 23 with SPH. Echocardiographic data, including Doppler and Doppler based strain, were assessed according to the American Society of Echocardiography (ASE) guidelines for detailed evaluation of RV function in these two groups. RESULTS: Mean PAP was 60 ± 14.5 mm Hg in patients with IPH versus 43 ± 11.5 mm Hg in patients with SPH (p = 0.001). Considering conventional indexes of RV function, only Sm and dp/dt were significantly better in the first group compared with the second group (p-value for Sm = 0.042 and for dp/dt = 0.039). RV end diastolic dimension was significantly higher in the IPH group (p = 0.013). Using deformation indexes of RV function, the basal and mid portion of RV free wall strain and basal RV strain rates were significantly worse in the chronic systolic heart failure (PH-HF) group in comparison to the IPH group (p < 0.001 in basal RV strain, p = 0.034 in mid RV strain and p = 0.046 in basal RV strain rate respectively). CONCLUSION: IPH has less impact on RV function in comparison to PH-HF. Considering both entities are in the category of RV pressure overload, we conclude that the etiology of pulmonary hypertension also plays an important role in RV function in addition to pressure overload.

Removing an Entrapped Pigtail Catheter by Re-enforcing a Traditional Method.

Right heart catheterization is the main step in the evaluation of pulmonary hypertension including Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and is considered a relatively safe procedure. Complications can occur including perforation, tamponade, bleeding, etc. requiring different types of interventions such as manipulation or surgery. Here, we have described a case of pigtail catheter entrapment and the method we used to free it without invasive measures.

Detection of a Rare Complication of Endovascular Treatment for Brain Arteriovenous Malformation with Echocardiography.

A brain arteriovenous malformation (AVM) is a congenital malformation of the vascular system, in which an abnormal short circuit (vascular malformation) connects cerebral arteries and veins. When the brain AVMs are diagnosed, the majority of them must be closed with surgical or endovascular treatment, because only a small portion of the brain AVMs remain asymptomatic during the patient's life. Endovascular transarterial embolization using Onyx Liquid Embolic System is a suitable method for treating brain AVMs. Previously known complications of Onyx usage are bleeding and neurologic deficits. We report a young man with a rare complication of Onyx injection, clinically silent distal embolization to the heart chamber and pulmonary circulation, discovered incidentally with echocardiography.

Acute ST-segment elevation myocardial infarction as the first manifestation of essential thrombocytosis successfully treated with thrombectomy alone.

A patient with no conventional cardiovascular risk factors presented with inferior ST-elevation myocardial infarction which was finally diagnosed as a case of essential thrombocytosis. This case demonstrated that thrombectomy alone was sufficient for the treatment of his coronary occlusion. Furthermore, this case report highlights the importance of evaluating rare causes of myocardial infarction other than atherosclerosis and that internists and cardiologists should be aware of essential thrombocytosis as a known cause of myocardial infarction, particularly in patients with no underlying cardiovascular risk factors.

The early presentation of atrial myxoma with acute myocardial infarction.

Atrial myxoma as a rare benign heart tumor can cause acute coronary syndrome via coronary embolization. In this report, we present a 54-year-old woman who presented with acute inferior myocardial infarction. In further evaluation a 2.5 x 3 x 4 cm mass was found in the left atrium. The mass was excised surgically and its pathology was compatible with myxoma. After resection, the patient was discharged with a favorable outcome.

The long-term immunity among health care workers vaccinated against hepatitis B virus in a large referral hospital in southern Iran.

BACKGROUND: Health care workers are at increased risk of occupational exposure to hepatitis B virus (HBV) infection. Reassessment for revaccination of such high-risk persons after 10 years may be appropriate if anti-HBs antibody titers declined below 10 mlU/mL. This study was conducted to evaluate the long-term efficacy of HBV vaccine in health care workers and the need for their reassessment for revaccination. METHODS: We interviewed 600 health care workers in a referral hospital in Shiraz, southern Iran. They were asked to complete a confidential questionnaire including information on their age, gender, vaccination date, number of doses of vaccine, their job description in hospital, previous history of needlestick injury, and educational level. Anti-HBs antibodies were determined by the ELISA method and titers of >10 mlU/mL were considered protective. Those with a positive HBsAg or anti-HBcAb were excluded from the study. RESULTS: Among 600 health care workers interviewed, 339 subjects who accepted to participate in the study, were vaccinated with three doses of HBV vaccine. Anti-HBsAb titers were >100 mlU/mL in 211 subjects (62.2%), 10 - 100 mlU/mL in 85 (25.1%), and <10 mlU/mL in 43 (12.7%) persons. Among 339 subjects who received three doses of vaccine, 273 were vaccinated less than 5 years, 47 cases between 5 - 10 years, and 19 cases were vaccinated more than 10 years before the study. The majority of them had an antibody concentration above the protective level (88.1%, 88.9%, and 60.9%, respectively, P = 0.001). CONCLUSION: Reassessment for revaccination in health care workers should be considered according to their anti-HBsAb levels 10 years after vaccination. In our health care workers, we think that due to the existence of low immunity against HBV, reassessment for revaccination after 10 years is mandatory.

Arteriovenous fistula thrombosis in patients on regular hemodialysis: a report of 171 patients.

BACKGROUND: Fistula thrombosis in patients on maintenance hemodialysis is an important morbidity factor. Arterial or venous thrombotic events have been described as complications in patients on regular hemodialysis. This study was designed to evaluate the risk factors for arteriovenous fistula thrombosis. METHODS: One hundred and seventy-one patients with arteriovenous fistula on maintenance hemodialysis were studied prospectively during a period of 14 months for any episode of arteriovenous fistula thrombosis, after anticardiolipin antibodies were assayed by ELISA. Other risk factors for thrombosis such as the presence of diabetes or hypertension, the use of erythropoietin (rhEPO), fistula site, gender, age, ultrafiltration, hypotension during dialysis, and the number of dialysis visits in a week were assessed. RESULTS: Fifty-six percent of patients had IgG-anticardiolipin antibodies > or = 10GPL, which was significantly correlated with dialysis duration (23.18 +/- 24.56 months in patients with anticardiolipin antibodies < or = 10GPL vs. 37.73 +/- 36.35 months in patients with 20 < or = IgG-anticardiolipin antibodies < 40GPL). Within the 14 months of follow-up, 36 episodes of arteriovenous fistula thrombosis occurred in 31 patients (18.1%). Considering anticardiolipin antibodies and other risk factors in a Cox proportional hazard model, only fistula site (P = 0.021, RR = 2.48, Cl = 1.14 - 5.37) and erythropoietin (Eprex) use (P = 0.021, RR = 10.92, Cl = 1.43 - 83.02) seemed to have an influence on fistula patency. According to fistula site, the survival of brachiocephalic fistulas were significantly (P = 0.007) better than radiocephalic ones (1- and 3-year survival were 95% and 87% for upper, and 88% and 72% for lower ones, respectively). CONCLUSION: Although the incidence of the anticardiolipin antibody was high in our patients, in the presence of other risk factors for thrombosis, we found no correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis. Instead, erythropoietin (Eprex) use and fistula site seem to have an important role in the correlation between IgG-anticardiolipin antibodies and arteriovenous fistula thrombosis.