Comparative outcomes of percutaneous transvenous mitral commissurotomy between low and high Wilkins score.

BACKGROUND: Percutaneous transvenous mitral commissurotomy (PTMC) is one of the non-surgical methods for patients with significant mitral stenosis. It is less invasive, less complicating with better outcomes compared to surgery. The Wilkins score ≤8 is used to select patients for PTMC, but the results of several studies suggest that PTMC can also be successful in a higher Wilkins score. The aim of this study is to compare the outcomes of PTMC between two groups. METHODS: In this retrospective study, patients who underwent PTMC between April 2011 and December 2019 were included. Patients were divided into two groups based on Wilkins score: 196 patients (57.64%) with a Wilkins score ≤8 (group I) and 134 patients (39.4%) with a Wilkins score >8 (group II). RESULTS: There was no difference in demographic characteristics between two groups except for age (p = 0.04). Pre and post-interventional echocardiographic and catheterization measurements including left atrial pressure, pulmonary artery pressure, mitral valve area, mitral valve mean, and peak gradient were measured, and there was no difference between the two groups (p > 0.05). The most common complication was mitral regurgitation (MR). Serious complications such as stroke and arrhythmias were rare in both groups (<1%). There was no difference between MR, ASD (atrial septal defect) and serious complications between the two groups. CONCLUSION: This study shows that the Wilkins score with a cutoff value of 8 is not suitable for patient selection and novel criteria including both mitral valve features and other variables affecting the PTMC outcomes is needed.

Evaluation of the Causes of Door-to-Balloon Time Delays in Patients with ST-Elevation Myocardial Infarction at Tehran Heart Center.

Background: Coronary artery disease (CAD) is the leading cause of cardiovascular death globally, and the most severe form of CAD, ST-elevation myocardial infarction (STEMI), needs immediate treatment. This study aimed to report patient characteristics and the causes of door-to-balloon time (D2BT) delays in STEMI patients admitted to Tehran Heart Center with a D2BT exceeding 90 minutes. Methods: This cross-sectional study was conducted at Tehran Heart Center, Iran, from March 20th, 2020, through March 20th, 2022. Variables consisted of age, sex, diabetes mellitus, hypertension, dyslipidemia, smoking, opium, family history of CAD, in-hospital mortality, primary percutaneous coronary intervention results, culprit vessels, causes of delays, the ejection fraction, triglycerides, and low and high-density lipoprotein levels. Results: The study population was composed of 363 patients (272 males [74.9]) at a mean (SD) age of 60±11.47 years. The leading causes of D2BT delays were the catheterization lab used in 95 patients (26.2) and misdiagnosis in 90 (24.8). Other causes were ST-elevation less than 2 mm in electrocardiograms in 50 patients (13.8) and referral from other hospitals in 40 (11.0). Conclusion: The catheterization lab in use and misdiagnosis were the leading causes of D2BT delays. We recommend that high-volume centers allocate an additional catheterization lab with an on-call cardiologist. Improved resident training and supervision in hospitals with many residents are also necessary.

One-Month Clinical Outcomes of ST-Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention at a High-volume Cardiac Tertiary Center: Routine Hours Versus Off-hours.

Primary percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-elevation myocardial infarction (STEMI). We aimed to compare 1-month major adverse cardiac events (MACE) of patients undergoing primary PCI between 2 routine-hour and off-hour working shifts. In this cross-sectional study, 1791 STEMI patients were retrospectively evaluated who underwent primary PCI. The patients were classified into 2 groups of routine and off-hour according to the PCI start time and date [495 patients (27.7%) in routine-hour group; 1296 patients (72.3%) in off-hour group]. Cardiovascular risk factor, angiographic, procedural data, door-to-device time, and 1-month follow-up data of patients were compared between 2 groups. There was a statistical difference in door-to-device time between routine-hour and off-hour group [55 minutes (40-100 minutes) in off-hour group vs. 49 minutes (35-73 minutes) in routine-hour group; P ≤ 0.001]. However, most of the patients in both groups had door-to-device time ≤60 minutes. The frequency of 1-month MACE was 8.5% in off-hour group and 6.9% in routine-hour group (P = 0.260). After adjustment for possible confounders, the procedure result, in-hospital death, and 1-month MACE were not significantly different between both study groups. We found that STEMI patients treated with primary angioplasty during off-hour shifts had similar 1-month clinical outcomes to routine-hour shifts. Considering the high number of patients requiring primary PCI during off-hours, the importance of early revascularization in acute myocardial infarction, and the comparable clinical outcomes and procedural success, full-time provision of primary PCI services seems to be beneficial.

Interleukin-10 and Transforming Growth Factor Beta1 Gene Polymorphisms in Chronic Heart Failure.

BACKGROUND: As cytokines, including interleukin-10 (IL-10) and transforming growth factor beta 1(TGF-ß1) seem to contribute towards the pathogenesis of chronic heart failure (CHF), this study was performed to assess the associations of certain single nucleotide polymorphisms (SNPs) of these genes in a case control study. METHODS: This investigation was carried out to determine the frequency of alleles, genotypes and haplotypes of TGF-ß1 and IL-10 single-nucleotide polymorphisms (SNPs) in 57 Iranian patients with CHF compared with 140 healthy subjects using polymerase chain reaction with sequence-specific primers method. RESULTS: Results of the analyzed data divulged a negative association for both TGF-ß1 GC genotype at codon 25 (P=0.047) and CT genotype at codon 10 (P=0.018) and CHF proneness. Although, TGF-ß1 CC genotype at codon 10 was found to be positively associated with CHF (P=0.011). Moreover, the frequency of IL-10 (-1082, -819, -592) ATA haplotype and TGF-ß1 (codon 10, codon 25) TG haplotype were significantly lower in the patients group (P=0.004 and P=0.040, respectively), while TGF-ß1 (codon 10, codon 25) CG haplotype was overrepresented in patients with CHF (P=0.007). CONCLUSIONS: Cytokine gene polymorphisms might affect vulnerability to CHF. Particular genotypes and haplotypes in IL-10 and TGF-ß1 genes could render individuals more susceptible to CHF.

Tumor Necrosis Factor-Alpha and Interleukin-6 Gene Polymorphisms in Iranian Patients with Ischemic Heart Failure.

BACKGROUND: Proinflammatory cytokines have been known to be elevated in patients with Chronic Heart Failure (CHF). Given the importance of proinflammatory cytokines in the context of the failing heart, the prevalence of Tumor Necrosis Factor-α (TNF-α), Interleukin (IL)-6 polymorphisms in patients with CHF was studied due to ischemic heart disease. METHODS: Forty three patients with ischemic heart failure were enrolled in this study and compared with 140 healthy individuals. The allele and genotype frequency of four Single Nucleotide Polymorphisms (SNPs) within the IL-6 (-174, nt565) and TNF-α (-308, -238) genes were determined, using Polymerase Chain Reaction with Sequence-Specific Primers (PCR-SSP) assay. RESULTS: The frequency of the TNF-α (-238) A/A genotype was significantly higher in patients comparing to controls (p=0.043), while TNF-α G/A genotype at the same position decreased significantly, in comparison with controls (p=0.018). The most frequent haplotype for TNF-α was A/A in the patient group in comparison with controls (p=0.003). There was no significant difference in allele and genotype frequencies of IL-6 at positions -174 and nt565, and TNF-α at position -308. CONCLUSION: Certain alleles, genotypes, and haplotypes in TNF-α, but not IL-6, gene were overrepresented in patients with ischemic heart failure, which may, in turn, predispose individuals to this disease.

Correlates of the "No-Reflow" or "Slow-Flow" Phenomenon in Patients Undergoing Primary Percutaneous Coronary Intervention.

Background: Despite recent advances in interventional equipment and techniques, the angiographic no-reflow phenomenon occurs in a considerable number of patients undergoing primary percutaneous coronary intervention (PCI). We investigated the clinical, angiographic, preprocedural, and procedural characteristics associated with the no-reflow phenomenon among patients undergoing primary PCI. Methods: Between March 2008 and April 2013, 530 patients (78.5% male, mean age=58.11±12.39 y) with ST-segment-elevation myocardial-infarction who underwent primary PCI were categorized in 2 groups according to their postprocedural thrombolysis-in-myocardial infarction (TIMI) flow grades: those with a maximum score of 2 (the no-reflow or slow-flow group) and the ones with a score of 3 (the reflow group). A multivariable logistic regression model was used to find the multiple correlates of the no-reflow phenomenon after PCI. Results: There were 166 (31.3%) patients in the no-reflow group and 364 (68.7%) in the reflow group. The no-reflow patients were older and had significantly longer target lesion lengths, higher SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery (SYNTAX) scores, higher infarct-related artery SYNTAX scores, more thrombus burden, and a higher frequency of initial TIMI flow grades of 2 or lower. Our multivariable logistic regression analysis demonstrated that older age, higher numbers of Q waves, not using statin, longer target lesion lengths, higher thrombus grades, and higher infarct-related artery SYNTAX scores remained the independent correlates of increased no-reflow rates after primary PCI (area under the ROC curve=0.784, 95% CI: 0.742-0.826; P<0.001). Conclusion: Clinical, angiographic, and procedural features of patients undergoing primary PCI may be correlated with the occurrence of the no-reflow phenomenon. The thrombus grade and the infarct-related artery SYNTAX score could be among these factors.

Relationship between Body Mass Index and Outcome of Elective Percutaneous Coronary Intervention.

BACKGROUND: Studies have shown controversial effects of obesity on major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI). We sought to investigate the impact of the body mass index (BMI) on the mid-term outcome following successful PCI. METHODS: Between March 2006 and August 2008, 3948 patients underwent successful elective PCI in Tehran Heart Center, Tehran, Iran, and were retrospectively included in this study. Patients who underwent PCI on the same day as the occurrence of myocardial infarction were excluded. The demographic, procedural, in-hospital, and follow-up information of these patients was extracted from the PCI Data Registry of our institution. The patients were divided into three groups: normal weight (No. 1058, BMI < 25 kg/m(2) age = 58 ± 10 years); overweight (No. 1867, 25 ≤ BMI < 30 kg/m(2), age = 57 ± 10 years); and obese (No. 1023, BMI ≥ 30 kg/m(2), age = 56 ± 10 years). MACE included death, myocardial infarction, target vessel revascularization, and target lesion revascularization. RESULTS: Compared with the other patients, the obese individuals were significantly younger and more frequently female, had a higher ejection fraction, and more frequently presented with hypertension, diabetes, and hyperlipidemia. There was no association between the BMI and the angiographic and procedural findings in the univariate analysis. While no difference was found in the rate of in-hospital death between the groups, the number of the obese patients undergoing emergent cardiac surgery was marginally different in the univariate analysis (p value = 0.06). At 9 months' follow-up, MACE had occurred in 92 (2.3%) patients and cardiac mortality was 9 (0.2%). After adjustments for confounders, no significant difference was observed in terms of MACE between the BMI groups. CONCLUSION: The BMI had no significant effect on the rate of MACE at 9 months' follow-up in our study population. Interventionists' recommendations for patients undergoing PCI should, therefore, not be significantly influenced by the BMI status.

A Risk-Scoring Model to Predict One-year Major Adverse Cardiac Events after Percutaneous Coronary Intervention.

BACKGROUND: The aim of the present study was to develop a scoring system for predicting 1-year major adverse cardiac events (MACE), including mortality, target vessel or target lesion revascularization, coronary artery bypass graft surgery, and non-fatal myocardial infarction after percutaneous coronary intervention (PCI). METHODS: The data were extracted from a single center PCI registry. The score was created based on the clinical, procedural, and laboratory characteristics of 8206 patients who underwent PCI between April 2004 and October 2009. Consecutive patients undergoing PCI between November 2009 and February 2011 (n= 2875) were included as a validation data set. RESULTS: Diabetes mellitus, increase in the creatinine level, decrease in the left ventricular ejection fraction, presentation with the acute coronary syndrome, number of diseased vessels, primary PCI, PCI on the left anterior descending artery and saphenous vein graft, and stent type and diameter were identified as the predictors of the outcome and used to develop the score (R² = 0.795). The models had adequate goodness of fit (Hosmer-Lemeshow statistic; p value = 0.601) and acceptable ability of discrimination (c-statistics = 0.63). The score categorized the individual patients as low-, moderate-, and high-risk for the occurrence of MACE. The validation of the model indicated a good agreement between the observed and expected risks. CONCLUSION: An individual risk-scoring system based on both clinical and procedural variables can be used conveniently to predict 1-year MACE after PCI. Risk classification based on this score can assist physicians in decision-making and postprocedural health care.

Outcomes of percutaneous coronary intervention on saphenous vein graft and native coronary vessels.

BACKGROUND: The optimal target for revascularization in patients with history of coronary artery bypass graft surgery (CABG) is unclear. This study was designed to compare the outcome of percutaneous coronary intervention (PCI) on saphenous vein grafts (SVG) and that on native vessels in patients with previous CABG in terms of major adverse cardiac events (MACE). METHODS: The study drew upon data on consecutive patients hospitalized for PCI and MACE rate during a nine-month follow-up period. The patients were divided according to the target vessel for PCI into two groups: SVG and native vessel. RESULTS: Between 2003 and 2007, 226 patients underwent PCI 6.57 ± 4.55 years after CABG. Their mean age was 59.52±9.38 years, and 176 (77.9%) were male. PCI was performed on the SVG in 63 (27.9%) patients and on the native coronary artery in the rest. During a nine-month follow-up period, 9 (4%) patients suffered MACE; the prevalence of MACE was not significantly different between the SVG group (4.8%) and the native vessel group (4.9%), (p value = 0.999). CONCLUSION: PCI on grafted and native vessels did not affect MACE in patients undergoing PCI after CABG.

Sodium bicarbonate in preventing contrast nephropathy in patients at risk for volume overload: a randomized controlled trial.

BACKGROUND: Sodium bicarbonate has been recently proposed as a prophylactic measure for the prevention of contrast-induced nephropathy (CIN). We aimed to compare the efficacy of the combination of sodium bicarbonate with half saline, and half saline alone in preventing CIN in patients having uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema. METHODS: Seventy-two patients undergoing elective coronary angiography with a serum creatinine level > or =1.5 mg/dL who had uncontrolled hypertension, compensated severe heart failure or a history of pulmonary edema were prospectively enrolled in a single-center, double-blind, randomized, controlled trial from August 2007 to July 2008 and were assigned to either an infusion of sodium bicarbonate plus half saline (n=36) or half saline alone (n=36). The primary end point was an absolute (> or =0.5 mg/dL) or relative (> or =25%) increase in serum creatinine 48 hours after the procedure (CIN). RESULTS: There were no significant differences between the groups regarding their baseline demographic and biochemical characteristics, as well as the underlying disease. A total of 6.1% of the patients receiving sodium bicarbonate plus half saline developed CIN as opposed to 6.3% of the patients in the half saline group, which was not statistically different (odds ratio = 0.97; 95% confidence interval, 0.13-7.3; p=1.0). CONCLUSION: The combination therapy of sodium bicarbonate plus half saline does not offer additional benefits over hydration with half saline alone in the prevention of CIN.

Relationship between myocardial viability and coronary run-off in jeopardized myocardium.

OBJECTIVE: The aim of this study was to evaluate the relationship between coronary run-off and myocardial viability in jeopardized regions. METHOD: We studied 50 patients (40 male, mean age: 55.63 +/- 10.54 years) with coronary artery stenosis >70% and ejection fraction <40% referred for viability study via dobutamine stress echocardiography. The relationship between coronary run-off and viability was evaluated. Good run-off demonstrates good or moderate and no run-off means poor or no run-off. RESULTS: In the apical region, 33% of the segments with good antegrade run-off were viable and 67% nonviable. Also, 72% of the segments with no run-off were nonviable and 28% viable. In the midportion region, 70% of the segments with good antegrade run-off were viable and 30% nonviable; 50% of the segments with no run-off were nonviable and 50% viable. In the basal region, 85% of the segments with good antegrade run-off were viable and 15% nonviable; 19% of the segments with no run-off were nonviable and 81% viable. The proportion of the nonviable segments increased significantly from the basal to apical regions either with good (p < 0.001) or no run-off (p = 0.004). From 239 viable segments, 58.6% had antegrade, 15.4% retrograde, and 25.5% no run-off. Of 181 nonviable segments, 44% had antegrade, 34% retrograde, and 34.8% no run-off. CONCLUSION: There was more susceptibility to nonviability in the apical regions despite good run-off, while the basal segments showed more viability in spite of having no run-off. The findings may be helpful for selecting patients with coronary artery disease and left ventricular systolic dysfunction that benefit from revascularization.

Unusual presentation and echocardiographic management of giant mural endocarditis occurring simultaneously with aneurysmatic aorta.

We describe a 32-year-old man who presented in a febrile, unconscious state with unusual staphylococcal endocarditis. We diagnosed the patient's illness by using transthoracic echocardiography (TTE), which revealed a giant vegetation on the left ventricular lateral wall. The patient had history of aortic valve replacement and coarctoplasty. Conservative treatment using repeated TTEs resulted in successful management of endocarditis and embolic brain abscess. After discharge, the patient underwent aortic reconstruction for the aneurysmatic dilatation of ascending aorta. This report confirms that chronic endocardial trauma may provide a fertile nidus for the development of bacterial vegetation. The clinical, echocardiographic, and laboratory findings contributed to therapeutic decision-making in the management of this case.