Cross-cultural validity of the Pulmonary Embolism Quality of Life questionnaire in the quality of life survey after pulmonary embolism: A Persian-speaking cohort.

Background: The Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire is the first disease-specific scale for assessing the quality of life in patients with a history of pulmonary embolism (PE). Objectives: To assess the cross-cultural validity and reliability of the disease-specific PEmb-QoL questionnaire. Methods: The Persian version was prepared through the forward and backward translation of the English questionnaire. Six months after the diagnosis of acute PE, consecutive Persian-speaking patients were asked to complete the PEmb-QoL, the generic 36-item Short Form (SF-36) questionnaires and undertake a 6-minute walk test (6MWT). Acceptability was assessed via item missing rate, reproducibility by the test-retest method, and internal consistency reliability by Cronbach's α and McDonald's ω coefficients. Convergence validity was assessed using the Spearman rank correlation between scores of PEmb-QoL, SF-36, and 6MWT. The questionnaire structure was evaluated through exploratory factor analysis. Results: Ninety-six patients with a confirmed diagnosis of PE completed the questionnaires. The Persian version of PEmb-QoL had good internal consistency (α = 0.95, 3-factor ω = 0.96), inter-item correlation (0.3-0.62), item-total correlation (0.38-0.71), reproducibility (test-retest ICC with 25 participants = 0.92-0.99), and good discriminant validity. Convergence validity was confirmed by the moderate-to-high correlations between PEmb-QoL and SF-36 scores, and a good correlation between the "limitation in daily activities" dimension of the PEmb-QoL questionnaire and 6MWT results. Exploratory factor analysis suggested a 3-component structure with functional (items 1h, 4b-5d, 6, 8, 9i, and 9j), symptoms (1b-h, 7, and 8), and emotional (5a, 6, and 9a-h) components. Conclusion: The Persian version of the PEmb-QoL questionnaire is valid and reliable for measuring the disease-specific quality of life in patients with PE.

Post-Pulmonary Embolism Impairment Six Months after Acute Pulmonary Embolism: A Prospective Registry.

BACKGROUND: Little evidence is available on post-pulmonary embolism impairment (PPEI), a recently defined complication of pulmonary embolism (PE) encompassing dysfunctional clinical and imaging parameters. In the present study, we sought to evaluate its frequency with a focus on the main components. METHODS: In this prospective registry, we included patients with a confirmed diagnosis of acute PE and focused on those with initial right ventricular (RV) dysfunction. Their baseline, pre-discharge, and 6 month follow-up clinical and imaging characteristics were recorded. The main study outcomes were incomplete RV functional recovery, exercise capacity limitations (based on the 6 minute walk test), and their combination, which defines PPEI, within six months of acute PE. RESULTS: Of 170 consecutive patients with a confirmed diagnosis of acute PE, 123 accepted to participate in the follow-up study, of whom 87 had initial RV dysfunction. The 6 month rates of incomplete RV functional recovery, signs of an intermediate-to-high echocardiographic probability of PH, and exercise limitations were observed in 58.6, 32.1, and 45.9%, respectively. A total of 22 (25.2%; 95% CI 15.5-34.4%) patients had PPEI. The RV/LV ratio and the fractional area change on discharge after acute PE were more often impaired among patients with incomplete RV recovery, exercise limitations, and a high probability of PH at 6 months. In contrast, an initial impaired RV diastolic function indices appeared to characterize patients with a limited exercise capacity at 6 months. DISCUSSION: PPEI affects one fourth of patients surviving acute PE with half of them presenting with RV dysfunction or exercise limitations.

Catheter-Directed Thrombolysis vs Anticoagulation in Patients With Acute Intermediate-High-risk Pulmonary Embolism: The CANARY Randomized Clinical Trial.

Importance: The optimal treatment of intermediate-high-risk pulmonary embolism (PE) remains unknown. Objective: To assess the effect of conventional catheter-directed thrombolysis (cCDT) plus anticoagulation vs anticoagulation monotherapy in improving echocardiographic measures of right ventricle (RV) to left ventricle (LV) ratio in acute intermediate-high-risk PE. Design, Setting, and Participants: The Catheter-Directed Thrombolysis vs Anticoagulation in Patients with Acute Intermediate-High-Risk Pulmonary Embolism (CANARY) trial was an open-label, randomized clinical trial of patients with intermediate-high-risk PE, conducted in 2 large cardiovascular centers in Tehran, Iran, between December 22, 2018, through February 2, 2020. Interventions: Patients were randomly assigned to cCDT (alteplase, 0.5 mg/catheter/h for 24 hours) plus heparin vs anticoagulation monotherapy. Main Outcomes and Measures: The proportion of patients with a 3-month echocardiographic RV/LV ratio greater than 0.9, assessed by a core laboratory, was the primary outcome. The proportion of patients with an RV/LV ratio greater than 0.9 at 72 hours after randomization and the 3-month all-cause mortality were among secondary outcomes. Major bleeding (Bleeding Academic Research Consortium type 3 or 5) was the main safety outcome. A clinical events committee, masked to the treatment assignment, adjudicated clinical outcomes. Results: The study was prematurely stopped due to the COVID-19 pandemic after recruiting 94 patients (mean [SD] age, 58.4 [2.5] years; 27 women [29%]), of whom 85 patients completed the 3-month echocardiographic follow-up. Overall, 2 of 46 patients (4.3%) in the cCDT group and 5 of 39 patients (12.8%) in the anticoagulation monotherapy group met the primary outcome (odds ratio [OR], 0.31; 95% CI, 0.06-1.69; P = .24). The median (IQR) 3-month RV/LV ratio was significantly lower with cCDT (0.7 [0.6-0.7]) than with anticoagulation (0.8 [0.7-0.9); P = .01). An RV/LV ratio greater than 0.9 at 72 hours after randomization was observed in fewer patients treated with cCDT (13 of 48 [27.0%]) than anticoagulation (24 of 46 [52.1%]; OR, 0.34; 95% CI, 0.14-0.80; P = .01). Fewer patients assigned to cCDT experienced a 3-month composite of death or RV/LV greater than 0.9 (2 of 48 [4.3%] vs 8 of 46 [17.3%]; OR, 0.20; 95% CI, 0.04-1.03; P = .048). One case of nonfatal major gastrointestinal bleeding occurred in the cCDT group. Conclusions and Relevance: This prematurely terminated randomized clinical trial of patients with intermediate-high-risk PE was hypothesis-generating for improvement in some efficacy outcomes and acceptable rate of major bleeding for cCDT compared with anticoagulation monotherapy and provided support for a definitive clinical outcomes trial. Trial Registration: ClinicalTrials.gov Identifier: NCT05172115.

Right ventricular peak systolic free wall longitudinal strain as a practical tool to detect right ventricular dysfunction in acute myocarditis.

INTRODUCTION: Acute myocarditis is one of the etiologies of acute heart failure, chronic dilated cardiomyopathy, and cardiac mortality. The extent of right ventricular (RV) involvement and its impact on the course of the disease have been scarcely studied. This study aimed to evaluate both the prevalence of RV dysfunction in acute myocarditis and echocardiographic measures as a diagnostic tool for RV dysfunction compared with cardiac magnetic resonance imaging (CMR) findings. METHODS: This retrospective study enrolled patients with a definite or probable acute myocarditis diagnosis based on the Lake Louise criteria in CMR and evaluated the diagnostic accuracy of echocardiographic measures in predicting RV dysfunction in CMR. RESULTS: The study population consisted of 71 patients, including 54 men (76%), at a median (Q1-Q3) age of 33 (26-46) years. CMR detected RV dysfunction in 53.5% of the patients. The RV free wall peak systolic longitudinal strain showed the highest correlation (r = -.786, p < .001) and area under the curve (.919) with the RV ejection fraction in CMR, followed by the RV global peak systolic longitudinal strain and the RV fractional area change. The RV-free wall peak systolic longitudinal strain had a sensitivity of 92% and a specificity of 73% for the diagnosis of RV dysfunction in myocarditis. A cutoff value of -17.9% was 100% specific for RV systolic dysfunction. CONCLUSIONS: Echocardiography, as a readily available tool, was predictive of and had acceptable accuracy for RV dysfunction in acute myocarditis compared with CMR.

Prevalence of Structural Heart Diseases Detected by Handheld Echocardiographic Device in School-Age Children in Iran: The SHED LIGHT Study.

Background: Structural heart disease (SHD) has great impacts on healthcare systems, creating further public health concerns. Proper data are scant regarding the magnitude of the affected population by SHD. Objectives: This study aimed to determine the prevalence of SHD among children and adolescents in an Iranian population. Methods: In this population-based study, a multistage cluster-random sampling was used to choose schools from the Tehran urban area. All students were examined using a handheld Vscan device by echocardiographer, and the results were concurrently supervised and interpreted by cardiologists. All the major findings were reevaluated in hospital clinics. Results: Of 15,130 students (6-18 years, 52.2% boys) who were examined, the prevalence of individuals with congenital heart disease (CHD) and cardiomyopathy was 152 (10.046 per 1,000 persons) and 9 (0.595 per 1,000 persons), respectively. The prevalence of definite and borderline rheumatic heart disease (RHD) was 30 (2 per 1,000 persons) and 113 (7.5 per 1,000 persons), correspondingly. Non-rheumatic valvular heart disease (VHD) was also detected in 465 (30.7 per 1,000 persons) students. Of all the pathologies, only 39 (25.6%) cases with CHD and 1 (0.007%) cases with RHD had already been diagnosed. Parental consanguinity was the strongest predictor of CHD and SHD (odds ratio [OR]: 1.907, 95% CI, 1.358 to 2.680; P < 0.001 and OR, 1.855, 95% CI, 1.334 to 2.579; P < 0.001, respectively). The female sex (OR, 1.262, 95% CI, 1.013 to 1.573; P = 0.038) and fathers' low literacy (OR, 1.872, 95% CI, 1.068 to 3.281; P = 0.029) were the strongest predictors of non-rheumatic VHD and RHD, correspondingly. Conclusions: The implementation of echocardiographic examinations for detecting SHD among young population is feasible which detected SHD prevalence in our population comparable to previous reports. Further studies are required to delineate its economic aspects for community-based screening.

Dilated cardiomyopathy caused by a pathogenic nucleotide variant in RBM20 in an Iranian family.

INTRODUCTION: Dilated cardiomyopathy (DCM) is characterized by the dilation and impaired contraction of 1 or both ventricles and can be caused by a variety of disorders. Up to 50% of idiopathic DCM cases have heritable familial diseases, and the clinical screening of family members is recommended. Identifying a genetic cause that can explain the DCM risk in the family can help with better screening planning and clinical decision-making. Whole-exome sequencing (WES) has aided significantly in the detection of causative genes in many genetically heterogeneous diseases. In the present study, we applied WES to identify the causative genetic variant in a family with heritable DCM. METHODS: WES was applied to identify genetic variants on a 26-year-old man as the proband of a family with DCM. Subsequently, Sanger sequencing was performed to confirm the variant in the patient and all the available affected and unaffected family members. The pathogenicity of the variant was evaluated through co-segregation analysis in the family and employment of in silico predictive software. RESULTS: WES demonstrated the missense pathogenic heterozygous nucleotide variant, c.1907G > A, (p.Arg636His, rs267607004, NM_0011343), in exon 9 of the RBM20 gene in the proband. The variant was co-segregated in all the affected family members in a heterozygous form and the unaffected family members. The in silico analysis confirmed the variant as pathogenic. CONCLUSION: Pathogenic RBM20 nucleotide variants are associated with arrhythmogenic DCM. We believe that our report is the first to show an RBM20 variant in Iranian descent associated with DCM.

Reliability and validity of a satisfaction questionnaire on virtual education in the coronavirus disease 2019 pandemic era aimed at cardiology faculty members.

BACKGROUND: In the coronavirus disease 2019 pandemic era, clinical programs and mandatory hands-on activities have been supplanted by remote teaching to maintain the fundamental capabilities of medical training and to furnish medical students with quality education. Nonetheless, the satisfaction of faculty members with this training method in the current pandemic has yet to be assessed. The aim of this study was to design a Persian questionnaire with appropriate validity and reliability on cardiology professors' satisfaction level with virtual education. MATERIALS AND METHODS: In this cross-sectional study, a questionnaire was devised drawing upon scientific sources and Iranian medical educators' expertise. Seventeen faculty members in various specialties evaluated the questionnaire concerning face and content validity. Content validity was assessed through the calculation of the content validity ratio (CVR) (values >0.62 were considered acceptable) and the content validity index (CVI) (values >0.79 were considered acceptable), construct validity was evaluated through principal component factor analysis by the Kaiser-Meyer-Olkin (KMO) statistic and Bartlett's sphericity test, internal reliability was measured through the calculation of Cronbach's alpha coefficient, and consistency was appraised through the use of test-retest reliability at two different time points. RESULTS: The questionnaire had a reliability rate of 95%, indicating high internal validity. Concerning test-retest reliability, the intraclass correlation coefficient was 0.96 (P < 0.001), demonstrating relatively good stability. The CVI was 0.81, and the CVR was 0.85. The KMO measure of sampling adequacy was 0.954, indicating the acceptability of the degree of common variance among the all items. CONCLUSIONS: This Persian questionnaire on virtual education aimed at cardiology faculty members in the current pandemic with its low question count and appropriate domains had high reliability and validity. By knowing the level of professors' satisfaction with the new method of education, it is possible to take steps to better provide specialized medical education to cardiology residents.

RIvaroxaban in mitral stenosis (RISE MS): A pilot randomized clinical trial.

BACKGROUND: Patients with moderate-to-severe mitral stenosis (MS) have bee excluded from all major randomized controlled trials (RCTs) comparing non-vitamin K antagonist oral anticoagulants (NOACs) with warfarin in patients with atrial fibrillation (AF). METHODS AND RESULTS: In this pilot RCT, 40 patients were randomized to rivaroxaban 20 mg daily or warfarin. No patients experienced symptomatic ischemic strokes and systemic embolic events (the primary composite study outcome) during a 12-month follow-up. No major bleeding was reported. During the follow-up, 18.2% of patients in both groups showed echocardiographic signs of increased thrombogenicity in the left atrial appendage. The rate of silent cerebral ischemia was 13.3% in the rivaroxaban group and 17.6% in the warfarin group at brain magnetic resonance imaging. CONCLUSION: Our results suggest acceptable efficacy and safety for rivaroxaban in patients with AF and moderate-to-severe MS and are encouraging for larger RCTs in this so far neglected setting (NCT03926156).

Fast vs. ultraslow thrombolytic infusion regimens in patients with obstructive mechanical prosthetic valve thrombosis: a pilot randomized clinical trial.

AIMS: Thrombolysis is an alternative to surgery for mechanical prosthetic valve thrombosis (MPVT). Randomized clinical trials have yet to test the safety and efficacy of a proposed ultraslow thrombolytic infusion regimen. METHODS AND RESULTS: This single-centre, open-label, pilot randomized clinical trial randomized adult patients with acute obstructive MPVT to an ultraslow thrombolytic regimen [25 mg of recombinant tissue-type plasminogen activator (rtPA) infused in 25 h] and a fast thrombolytic regimen (50 mg of rtPA infused in 6 h). If thrombolysis failed, a repeated dose of 25 mg of rtPA for 6 h was administered in both groups up to a cumulative dose of 150 mg or the occurrence of a complication. The primary outcome was a complete MPVT resolution (>75% fall in the obstructive gradient by transthoracic echocardiography, <10° limitation in opening and closing valve motion angles by fluoroscopy, and symptom improvement). The key safety outcome was a Bleeding Academic Research Consortium type III or V major bleeding. Overall, 120 patients, including 63 (52.5%) women, at a mean age of 36.3 ± 15.3 years, were randomized. Complete thrombolysis success was achieved in 51 patients (85.0%) in the ultraslow-regimen group and 47 patients (78.3%) in the fast-regimen group [odds ratio 1.58; 95% confidence interval (CI) 0.25-1.63; P = 0.34]. One case of transient ischaemic attack and three cases of intracranial haemorrhage (absolute risk difference -6.6%; 95%CI -12% -0.3%; P = 0.07) were observed only in the fast-regimen group. CONCLUSION: The ultraslow thrombolytic regimen conferred a high thrombosis resolution rate without major complications. Such findings should be replicated in more adequately powered trials.

Cardio-oncology discipline: focus on the necessities in developing countries.

Cardiovascular diseases constitute one of the main aetiologies of mortality among patients with cancer. Population ageing and cancer survival rate improvements have resulted in the coexistence of cardiovascular diseases and malignancies in an increasing number of patients. With the diversity in treatments and the introduction of new drug lines, multiple mechanisms of cardiovascular injury have been recognized in these patients. Cardio-oncology is an emerging entity introduced to provide a proper solution to the several challenges encountered in the management of patients with cancer and cardiac involvement. This review will assess the logical grounds for establishing a cardio-oncology unit, describe the main objectives and the detailed responsibilities in such systems, and outline the target population. Furthermore, the importance of research and appropriate data collection will be highlighted. Lastly, the special considerations and modifications required for setting up such centres in the developing countries are discussed.

The Iranian Society of Echocardiography (ISE) Statement on Performing Echocardiography During the COVID-19 Pandemic.

Corona virus disease 2019(COVID-19) pandemic has caused a significant burden on the global health system. Considerable cardiovascular involvement has been reported among COVID-19 patients with higher ICU admission and mortality rates among patients with cardiovascular comorbidities. Consequently, diagnostic cardiovascular evaluations such as echocardiography are a crucial part of the disease management. On the other hand, providing safety for the patients and the healthcare personnel is a matter of great concern in the pandemic state. In this document, we have provided recommendations on performing echocardiography in hospital echocardiography labs and outpatient echocardiography clinics during the current COVID-19 (Coronavirus disease of 2019) outbreak.

Rapid improvement in right ventricular free wall longitudinal strain measures after successful percutaneous mitral commissurotomy.

BACKGROUND: Percutaneous mitral commissurotomy (PMC) is currently the treatment of choice for patients with symptomatic mitral stenosis (MS) that have favorable valvular characteristics. We aimed to evaluate the effect of PMC on the longitudinal strain of the right ventricular (RV) free wall in patients with severe MS. METHODS: This prospective study recruited patients who underwent PMC. Transesophageal and transthoracic echocardiographic examinations were performed. The mitral valve area (MVA) was measured by three-dimensional evaluation. The RV longitudinal strain was measured via the speckle-tracking method. RESULTS: A total of 42 patients with a maximum MVA of 1.5 cm2 underwent PMC in our study. The MVA increased significantly after the procedure (pre-PMC MVA = 0.94 ± 0.20 cm2 vs post-PMC MVA = 1.45 ± 0.18 cm2 ; P < .01). Systolic pulmonary artery pressure decreased from 46.05 ± 14.08 mm Hg preprocedurally to 35.86 ± 7.53 mm Hg postprocedurally (P < .01). The mean RV free wall longitudinal strain was -19.00 ± 5.14%, which rose significantly after PMC to -20.97 ± 3.81 (P < .05). There were postprocedural increases, albeit nonsignificant, in the tricuspid annular peak systolic excursion, the peak systolic Doppler velocity of the RV free wall, and fractional area change. The improvement in the RV longitudinal strain was more prominent in the patients with an MVA of less than 1.0 cm2 . CONCLUSIONS: There was a significant post-PMC rise in the RV free wall longitudinal strain measures in our study population, demonstrating an immediate improvement in the RV systolic function of the patients.

The role of echocardiography in anomalous origin of coronary artery from pulmonary artery (ALCAPA): Simple tool for a complex diagnosis.

Anomalous origin of coronary artery from pulmonary artery (ALCAPA) is a rare coronary anomaly usually presenting in the first year of life. Adult presentation suggests a wide range of differential diagnosis such as myocarditis, dilated cardiomyopathy, and coronary artery disease. We have presented here the major distinctive echocardiographic features of ALCAPA through 4 cases. Since echocardiography is often used as the first imaging modality in these clinical scenarios, recognizing the characteristics of ALCAPA in a routine echocardiographic examination can transform a readily available, low-cost tool into a valuable discriminative modality.

Intracoronary versus Intravenous eptifibatide during percutaneous coronary intervention for acute ST-segment elevation myocardial infarction; a randomized controlled trial.

Although aspirin and clopidogrel seem to be quite enough during low risk percutaneous coronary intervention (PCI), the combination may need some reinforcement in complex situations such as primary PCI. By modifying the route and also the duration of administration, glycoprotein IIb/IIIa inhibitors might be a viable option. The aim of this study is to compare the benefits and disadvantages of three different methods of administration of eptifibatide in primary PCI population. Primary PCI candidates were randomized in three groups on which three different methods of administration of eptifibitide were tested: intravenous bolus injection followed by 12-h infusion (IV-IV), intracoronary bolus injection followed by intravenous infusion (IC-IV) and, only intracoronary bolus injection (IC). 99 patients were included in the present study. There was no significant difference among the three groups regarding all cause in hospital and one month mortality (p value = 0.99), re-myocardial infarction (p value = 0.89), post-PCI TIMI flow grade 3 (p value = 0.97), ST segment resolution (p value = 0.77) and peak troponin levels (p value = 0.82). The comparison of vascular access and major bleeding complications were not possible due to low events rate. By modifying the route of administration of eptifibitide, the clinical effect might be preserved without increasing the short-term mortality and procedural failure.