Prevalence of Thromboembolic Events, Including Venous Thromboembolism and Arterial Thrombosis, in Patients with COVID-19: A Systematic Review with Meta-Analysis.

Background: Many studies have evaluated thromboembolic events in COVID-19 patients, and most of them have reported a high estimation of the prevalence of such events. The present study sought to evaluate the prevalence of thromboembolic events in patients with COVID-19. Methods: This study is a systematic review with meta-analysis that investigated thromboembolic events in patients with COVID-19 from the start of the pandemic to August 31, 2021. The 4 main databases for collecting articles were Medline, Scopus, Google Scholar, and Web of Science. Deep vein thrombosis, pulmonary embolism, arterial thrombosis, and the overall rate of thromboembolic events were considered primary outcomes. Results: In a total of 63 studies (104 920 patients with COVID-19), the overall thrombosis rate was 21% (95% CI, 18% to 25%), the rate of deep vein thrombosis was 20% (95% Cl, 16% to 25%), the rate of pulmonary embolism was 8% (95% Cl, 6% to 10%), and the rate of arterial thrombosis was 5% (95% Cl, 3% to 7%). The prevalence of all primary outcomes in critically ill patients admitted to the intensive care unit (ICU) was significantly higher (P<0.05). In older patients, the prevalence of overall thrombosis, pulmonary embolism, or deep vein thrombosis was significantly higher (P<0.05). Conclusion: This study showed that COVID-19 increases the risk of thromboembolic events, especially in elderly and critically ill patients admitted to the ICU. Therefore, more strategies are needed to prevent thromboembolic events in patients with COVID-19, especially in ICU-admitted and elderly patients.

A fatal Candida albicans pericarditis presenting with cardiac tamponade after COVID-19 infection and cardiothoracic surgery.

BACKGROUND: Candida pericardial infection is a rare clinical entity usually related to recent cardiothoracic surgery and chronic debilitating conditions. During the COVID-19 pandemic, invasive fungal infections have been on the rise, likely due to a combination of factors such as immunosuppression, underlying conditions like diabetes, and surgical procedures. CASE PRESENTATION: Herein, we report a 67-year-old diabetic woman with a history of COVID-19 infection who received a high dose of corticosteroids a few months before admission, and previous myocardial infarction for more than 12 years. The patient had a positive cardiac tamponade with signs of dyspnea, chest pain, and low blood pressure. Echocardiographic data were more in favor of constrictive pericarditis. The patient underwent urgent echocardiography-guided pericardiocentesis and then broad-spectrum antibiotic treatment was prescribed. Repeated echocardiography implied a persistent pericardial effusion 10 days later. Subxiphoid aspirates and biopsied tissues showed budding yeast cells and yeast colonies grew on culture media identified as Candida albicans. CONCLUSION: This report should bring to the attention of physicians toward the possibility of Candida pericardial infection presenting with cardiac tamponade after COVID-19 infection and cardiothoracic surgery. Echocardiographic assessment, prompt pericardiotomy, molecular-based identification of causative agent, and early administration of appropriate antifungal treatment should improve the patient's survival.

Acute fibrinous constrictive pericarditis and large pericardial effusion as the first manifestation of systemic lupus erythematsous disease in an adult male patient.

Systemic lupus erythematosus (SLE) can have various manifestations. Although cardiac involvement is very common in SLE patients, a severe acute pericarditis as the first manifestation of SLE in a male patient is relatively rare. A 36-year-old male was admitted to our hospital with acute pericarditis, large circumferential fibrinous pericarditis, and major criteria of a high-risk case of acute pericarditis. After a complete investigation, the underlying disease was revealed to be SLE. All of his symptoms were completely resolved after 6 weeks of treatment with non-steroidal anti-inflammatory drugs and corticosteroids with no need for a pericardiocentesis. Patients with acute fibrinous pericarditis should be considered and precisely investigated for multiorgan autoimmune process such as SLE, to avoid unnecessary intervention, and minimize the risk of recurrence and chronicity of the condition.

Impact of maintenance dose of eptifibatide in patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention.

BACKGROUND: ST-segment elevation myocardial infarction (STEMI) is usually caused by a rupture in the atherosclerotic plaque, followed by platelet aggregation which ultimately leads to acute coronary artery occlusion. So far, few studies have investigated the effect of maintenance dose of Eptifibatide (glycoprotein IIb/IIIa inhibitor) in STEMI patients who underwent primary percutaneous coronary intervention (PPCI). Therefore, in this study, we investigated the effect of maintenance dose of Eptifibatide in patients with STEMI who underwent PPCI. 264 patients who had acute chest pain suggestive of STEMI were entered in the study. All patients received the same dose of bolus dose of Eptifibatide in the cardiac catheterization laboratory. Then the patients were randomly divided into two groups, one group (n = 147) received a maintenance dose of intravenous Eptifibatide (infusion of 2 µg/kg/min) and the other group (n = 117) did not receive this treatment. Standard medical treatment of STEMI after PPCI was performed based on guidelines and the same in both groups. All patients were evaluated 1, 2, and 3 months after the start of treatment in terms of predicted outcomes. RESULTS: The occurrence of 3-month major adverse cardiovascular events (MACE) between the case and control groups did not have a statistically significant difference (28.6% versus 35.0%; P value: 0.286). Also, investigations showed that the rate of re-infarction (P value: 0.024) and target lesion revascularization (P value: 0.003) was significantly lower in the group that received Eptifibatide infusion. CONCLUSIONS: Eptifibatide maintenance dose infusion in patients who undergo PPCI in the context of STEMI, does not significantly reduce MACE, although it does significantly reduce re-infarction and target lesion revascularization. It also does not increase the risk of bleeding and cerebrovascular events.

Comparing the efficacy of N-acetylcysteine plus carvedilol versus carvedilol in the prevention of atrial fibrillation following coronary artery bypass graft surgery.

BACKGROUND: Atrial fibrillation (AF) is the most common arrhythmia following open-heart surgery. Agents with antioxidant properties may reduce postoperative complications like postoperative AF (POAF) in patients undergoing open-heart surgery. This study was conducted to assess the effect of N-acetylcysteine (NAC) in prevention of AF following coronary artery bypass graft (CABG) surgery. METHODS: Three hundred patients who underwent CABG surgery were entered in the study. Patients with contraindications for beta-blockers and patients were simultaneously replacing or repairing the valve with open-heart surgery were excluded. The patients were randomly divided into two groups (n = 150) and they were received NAC plus carvedilol or carvedilol. The patients were monitored for 5 days after surgery and the incidence of AF during hospitalization was recorded. RESULTS: AF was detected in 14 patients in the NAC with Carvedilol group (9.33%) and 23 patients in Carvedilol group (15.33%). There was no significant difference in the incidence of POAF between the two groups (p value = 0.112). The result of multivariable regression model represented that although the incidence of POAF was lower in NAC plus carvedilol group, it wasn't statistically significant (p value = 0.10). CONCLUSIONS: NAC was not associated with a decreased incidence of AF following CABG surgery.

Pulmonary valve sarcoma in patient with coronavirus disease of 2019 (COVID-19), mimicking pulmonary thromboembolism, a very rare case.

Pulmonary artery and pulmonary valve sarcoma are malignant and very rare vascular tumors with aggressive clinical course and very poor outcomes. Patients affected by coronavirus disease of 2019 (COVID-19) are at a higher risk for thromboembolism complication. We describe a young woman with a history of coronavirus pneumonia and progressive dyspnea, hemodynamic disturbance, edema with initial evaluation, and clinical diagnosis of pulmonary thromboembolism. But further imaging study and pathology demonstrated giant sarcoma of pulmonary valve, obstructing pulmonary valve and extending to right ventricular outflow tract and main of pulmonary artery.

Efficacy of intravenous eptifibatide in primary percutaneous coronary intervention patients.

Early and complete restoration of blood flow in closed coronary arteries is the main goal in treating patients with myocardial infarction. Primary angioplasty is not always successful in establishing myocardial blood flow. Although the strategy of adding eptifibatide leads to better blood flow, its value as part of a routine strategy is questionable. Therefore, this study was performed to evaluate the efficacy of intravenous eptifibatide in primary percutaneous coronary intervention (PCI) patients. This clinical, randomized, double-blind trial was performed on patients aged 20-80 years undergoing primary PCI. The patients were selected for study by convenience sampling and were randomly divided into two equal groups. The first group was treated with intravenous eptifibatide immediately before angioplasty with heparin. The second group received only coronary angioplasty with heparin. After data collection, statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) software, version 16. A total of 104 patients were enrolled in the study, and there were no statistically significant differences in terms of age (P=0.188), gender (P=0.345), risk factor (P>0.05), or history of PCI (P=0.199). Mean thrombolysis in myocardial infarction (TIMI) score was not significant between the two groups after receiving the drug and performing angioplasty (P>0.05), and the rate of ejection fraction was 46.33±6.69 in patients receiving eptifibatide and 47.54±4.67 in the heparin group, which was not statistically significant (P=0.884). We found that eptifibatide improves clinical indexes in patients undergoing primary PCI, but these differences were not significant in the two groups.

Catastrophic Candida prosthetic valve endocarditis and COVID-19 comorbidity: A rare case.

BACKGROUND AND PURPOSE: Coronavirus disease 2019 (COVID-19) and Candida prostatic valve endocarditis present various clinical manifestations which may overlap; hence, discrimination between them is extremely difficult. CASE REPORT: The case was a 66-year-old man with a past medical history of mitral and aortic valves replacement one year before COVID-19 co-infection. He was admitted with fever (for 7 days), shortness of breath, cough, seizure, lethargy, headache, and 85% oxygen saturation. Transesophageal echocardiography revealed multiple large-sized, highly mobile masses on both sides of the mechanical mitral valve highly suggestive of vegetation. Chest computed tomography scanning showed simulating scattered COVID-19 peripheral ground-glass opacities confirmed by reverse-transcription polymerase chain reaction. The set of blood cultures yielded yeast colonies that were identified as Candida tropicalis. The patient died of septic shock shortly after receiving antifungal therapy. CONCLUSION: This case emphasized the importance of early diagnosis and implementation of antifungal treatment, particularly in patients with prosthetic cardiac valves, to reduce their unfavorable outcomes in COVID-19 patients.

Fatal Prosthetic Valve Endocarditis Due to Aspergillus flavus in a Diabetic Patient.

Aspergillus endocarditis (AE) accounts for a-quarter of all fungal endocarditis, mainly in immunocompromised hosts prior to heart-valve surgery with high mortality, even with treatment. Herein, we report a rare case of AE in a diabetic 60-year-old woman with a history of redo mitral valve prosthesis suspecious of acute endocarditis. She underwent second redo surgical mitral valve replacement in combination with mechanical aortic valve replacement. Blood cultures were negative. The explanted valve and vegetation were subjected to identification. Grown colonies were identified as Aspergillus flavus, based on conventional and molecular methods. Despite the administration of liposomal amphotericin B and improvement in her general condition shortly after initiation of therapy, the patient passed away. As AE is a late consequence of redo prosthetic valve replacement, extended follow-up, early diagnosis, repeating valve-replacement surgeries, and timely selective antifungal treatments are warranted.

Fractional Flow Reserve as a Standard of Reference for Ischemia Early After ST Elevation Myocardial Infarction.

BACKGROUND: The purpose of the present study was to assess the value of the fractional flow reserve (FFR) of the infarct-related artery (IRA) early after ST elevation myocardial infarction (STEMI) in detecting reversible ischemia. METHODS: Single photon emission computed tomography (SPECT) at rest and after dipyridamole stress, and within 24 hour FFR of the IRA was performed on 69 patients 3 to 7 days after STEMI. FFR was 0.80 or less in 61 (88.4%) of them. In these patients, percutaneous coronary intervention (PCI) was performed, and a second SPECT study was repeated within 14 days. RESULTS: SPECT showed reversible ischemia in 36 (59%) of these 61 patients, and converted to negative in 29 of them. Thus, the SPECT results of these 29 patients were defined as true positive before angioplasty and true negative after angioplasty. Considering the true-positive and true-negative SPECT results as the gold standard, the sensitivity, specificity, and positive and negative predictive values of the FFR of 0.80 or less compared to this gold standard were 96.7%, 100%, 100%, and 96.6%, respectively (ĸ = 0.97, P < 0.001). CONCLUSIONS: In the early phase after STEMI, the reliability of FFR to determine residual ischemia in the IRA is very high in those patients with true-positive SPECT before and true-negative SPECT after PCI.

The relationship between Aldosterone level and various LV conditions in patients with End-stage renal disease.

BACKGROUND: Aldosterone has been assumed to be implicated in left ventricular hypertrophy (LVH). Preventing the progression of LVH in the early period of end-stage renal disease (ESRD) can increase patient survival. In this study, therefore, we analyzed the relationship between aldosterone level and LVH in ESRD patients who underwent hemodialysis at Fatemeh Zahra Hospital and Imam Khomeini Hospital in Sari, Iran from 2016 to 2017. METHODS: This research is a case-control study involving 69 patients, divided into the case group (n=52, exhibiting LVH) and the control group (n=17, no ventricular hypertrophy observed in the echocardiography). The relationship between the patients' serum aldosterone levels and LVH was evaluated on the basis of relative wall thickness (RWT). RESULTS: Among the patients, 20.3% had normal cardiac conditions, 53.6% eccentric hypertrophy (EH), 4.3% exhibited concentric remodeling (CR), and 21.7% had concentric hypertrophy (CH). In other words, 24.6% of the patients belonged to the control group, and 75.4% belonged to the case group. The results indicated a significant difference (P=0.006) in average aldosterone levels between the case (165.11±80.8) and control (115.76±72.47) groups and a significant difference in aldosterone levels among the four subgroups (P=0.03), with the levels of the CH group being higher than those of the EH group. CONCLUSION: Based on the results of the study, a significant relationship exists between plasma aldosterone level and LVH in ESRD patients. Serum aldosterone level is therefore a predictor of LVH.

TP53 single nucleotide polymorphism (rs1042522) in Iranian patients with coronary artery disease.

Chronic diseases including coronary artery disease (CAD) impose a high burden in terms of mortality and disability particularly in developing countries. Both genetic and environmental risk factors confer susceptibility to CAD. Meanwhile, a functional polymorphism in the tumor protein p53 (TP53) gene (codon 72, exon 4) has been reported to be associated with a wide range of cancers and inflammatory disorders. There are controversies regarding CAD and involvement of the TP53 codon 72 single nucleotide polymorphism; therefore, the present case-control study was conducted to evaluate the potential association between this TP53 polymorphism and CAD in an Iranian population. A total of 153 subjects (including 70 patients diagnosed with CAD and 83 subjects with normal coronary parameters, determined by angiography) were genotyped for the TP53 (rs1042522) polymorphism by the polymerase chain reaction-restriction fragment length polymorphism technique. Clinical and laboratory findings were also evaluated. The χ2 test and unpaired Student's t-test were applied to compare genotype and allele distributions and clinical characteristics between the two groups. Significant associations of the Pro72 allele [odds ratio (OR)=1.66, P=0.027] and Pro/Pro genotype (OR=2.91, P=0.022) with CAD were identified. No associations between patients' clinical findings and genotypes were apparent. Therefore, according to present findings, the TP53 Pro72 allele may be involved in the development of CAD along with conventional risk factors in patients from Northern Iran.

Prosthetic valve endocarditis caused by multidrug-resistant Candida albicans in a patient with myelodysplasia syndrome: A case report and literature review.

BACKGROUND AND PURPOSE: Candida endocarditis is an infrequent disease with a high mortality rate, which commonly occurs in immunosuppressed patients with cardiac valve replacement. We reported a 70-year-old woman diagnosed with Candida prosthetic valve endocarditis (PVE). This study also involved a review of all published cases of Candida PVE from 1970. CASE REPORT: Herein, we reported a 70-year-old woman with the history of severe mitral stenosis and myelodysplasia syndrome. She underwent mitral valve replacement for two times. The blood cultures were positive, and phenotypic identification of the isolates at the species level was performed based on microscopic and macroscopic characteristics. In the second prosthetic valve replacement, huge fungal white and creamy vegetation was observed which was identified as Candida albicans based on the conventional and molecular methods. Despite the administration of antifungal treatments, the patient passed away probably due to the multidrug-resistant Candida PVE. CONCLUSION: As PVE is a late consequence of prosthetic valve replacement, extended follow-up visits, early diagnosis, repeating valve replacement surgeries, and timely selective antifungal treatments are warranted.

Analysis of Two CDKN2B-AS Polymorphisms in Relation to Coronary Artery Disease Patients in North of Iran.

Coronary artery disease (CAD) including myocardial infarction (MI) as its complication, is one of the most common heart diseases worldwide and also in Iran, with extremely elevated mortality. CAD is a multifactorial disorder. Twin and family studies at different loci have demonstrated that genetic factors have an important role in the progression of CAD. Many studies have reported a significant association of CDKN2B-AS, also known as ANRIL which is located within the p15, p16, p14 gene cluster at 9p21 locus, with cardiovascular diseases as well as many other diseases like diabetes and cancers. This study investigated two polymorphisms rs10757274 and rs1333042 of CDKN2B-AS gene at 9p21 locus. 205 subjects, comprising 102 controls and 103 CAD patients were genotyped by TaqMan probe real time PCR technique and haplotypes were examined. This study confirmed the association of rs10757274 variants with CAD in Iranian patients (P= 0.003) but genotype and allele distributions of CAD and control groups showed no significant association for the rs1333042. However, frequency of the [G;G] haplotype of these two SNPs was significantly higher in CAD group (P= 0.0002, Odds Ratio = 3.1, 95% CI = 1.7-5.7). Our finding suggests that [G; G] haplotype of rs10757274 and rs1333042 may be considered as a genetic risk factor for susceptibility to CAD in Iranian patients.

Comparing the Efficacy of Tadalafil Versus Placebo on Pulmonary Artery Systolic Pressure and Right Ventricular Function in Patients with Beta-Thalassaemia Intermedia.

BACKGROUND: Conventional oral therapies in the management of pulmonary hypertension in people without haemoglobinopathies are of limited value in thalassaemia patients because of toxicity and poor effectiveness. This study was conducted to assess the effect of tadalafil on pulmonary artery pressure and right ventricular systolic function in patients with beta-thalassaemia intermedia. METHODS: Forty-four patients with beta-thalassaemia intermedia with pulmonary hypertension based on transthoracic echocardiography (TTE) were entered in the study. Patients with hepatic or renal insufficiency and also patients who were treated with organic nitrates or alpha-blockers were excluded. The patients were randomly divided into two groups (n=22) and they were treated for six weeks with tadalafil (40mg daily) or placebo. The pulmonary artery systolic pressure (PASP), tricuspid regurgitation velocity (TRV) and parameters related to systolic function of the right ventricle were measured by the TTE before and after treatment. RESULTS: Significant improvement in TRV (3.02±0.02 m/s-2.52±0.06 m/s), PASP (45.31±0.66 mmHg-34.26±1.15mmHg) and parameters related to systolic function of the right ventricle were observed in the group who received tadalafil compared to placebo (p< 0.05). CONCLUSIONS: Tadalafil significantly decreased PASP and TRV in patients with beta-thalassaemia intermedia. Likewise, tadalafil improved right ventricular systolic function in the patients.

Implantable cardioverter-defibrillator in a patient with dextrocardia situs inversus.

BACKGROUND: Dextrocardia is a congenital anomaly, which may have coexistent coronary artery disease (CAD), arrhythmias and conventional indications for device therapy. However, the implantation of transvenous leads can be technically challenging and the approach needs to be tailored to the patient's individual anatomy. CASE PRESENTATION: A 54-year-old male with dextrocardia situs inversus and ischemic left ventricular dysfunction developed ventricular tachycardia and fibrillation. Therefore, left- sided approach, dual chamber implantable cardioverter-defibrillator (ICD) was applied using a conventional method and standard equipment after complete evaluation of cardiac anatomy and vascular assessment. CONCLUSION: Electrical device implantation in patients with dextrocardia is possible after obtaining complete information about anatomy and/or coexisting congenital abnormalities, which helps in obtaining appropriate implantation approach.

Left Atrial Appendage Aneurysm.

Left atrial appendage aneurysms (LAAA) are extremely rare. This condition is usually diagnosed incidentally or after the occurrence of thrombotic events or cardiac tachyarrhythmias in the second to fourth decades of life. It can predispose to hazardous adverse events, including atrial fibrillation, myocardial infarction, and systemic thromboembolism. We report a case of LAAA in a 68-year-old woman presenting with atypical chest pain, exertional dyspnea, and episodes of sudden-onset palpitation. Aneurysmectomy with the patient under cardiac arrest with cardiopulmonary bypass was performed. In addition, we explore the diagnosis, management, and prognosis of this entity through a meticulous literature review.

Double-Orifice Tricuspid Valve: A Case Report and Literature Review.

Duplication of an atrioventricular valve is a rare congenital anomaly that usually involves the mitral rather than the tricuspid valve (TV). Isolated appearances of a double-orifice TV (DOTV) are extremely rare and in most cases are associated with other congenital anomalies. We report a rare case of an HIV-seropositive male with a DOTV, divided right atrium and Wolff-Parkinson-White syndrome admitted to our hospital with palpitations and dyspnea. After medical therapy, the patient's symptoms were alleviated. We summarized the characteristics of the DOTV and reviewed the literature.

Primary Cardiac Angiosarcoma in a Middle Aged Woman.

INTRODUCTION: Primary cardiac angiosarcoma is the most common primary sarcoma in adults between the 3rd and 4th decades of life. Nearly 90% of angiosarcomas occur in the right atrium, which is responsible for the late onset of symptoms. CASE PRESENTATION: We presented a 56-year-old woman admitted to our center with lung emboli symptoms. Transthoracic and transesophageal echocardiography (TTE and TEE) demonstrated very large size (more than 10 cm diameter) multilobulated mass with mobile particles extended from the right atrium to the right ventricle and the right ventricular outflow tract which destructed the right atrium (RA) wall and penetrated to the pericardial space. CONCLUSIONS: Unfortunately the tumor was unresectable and just an incisional biopsy was performed. She received chemotherapy as palliative care.

Anomalous origin of the right coronary artery from the left circumflex coronary artery: an extremely rare coronary anomaly.

Isolated single coronary artery is an extremely rare anomaly with an incidence of 0.024% to 0.066% which may be associated with other congenital anomalies. This report describes a 50-year-old woman who was referred with recurrent chest discomfort and was diagnosed with anomalous origin of the right coronary artery from the left circumflex coronary artery.