Hemodialysis Patients with High-Flow Arteriovenous Fistulas: An Evaluation of the Impact on Cardiac Function.

Purpose: : Patients undergoing hemodialysis often experience changes in cardiac function when they have a high-flow arteriovenous fistula (AVF). This study aimed to assess the effect of high-flow AVFs on cardiac function in patients undergoing hemodialysis. Materials and Methods: : A longitudinal study was conducted on hemodialysis patients with high-flow AVFs. Echocardiographic parameters, such as left ventricular ejection fraction (LVEF), left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), right ventricular end-diastolic dimension (RVEDD), inferior vena cava diameter (IVCD), systolic blood pressure, and diastolic blood pressure, were measured and compared before and after AVF creation. Results: : One hundred hemodialysis patients with high-flow AVFs (mean age: 55.95±13.39 years, mean body mass index: 24.71±3.43 kg/m²) were studied. LVEF significantly decreased (51.10%±5.39% to 47.50%±5.79%), while LAD, LVEDD, and IVCD significantly increased after AVF creation (P<0.05). Systolic (132.49±16.42 mmHg to 146.60±17.43 mmHg) and diastolic (79.98±8.40 mmHg to 83.33±9.68 mmHg) blood pressure substantially rose post-fistularization (P<0.001). Notably, LVEF reduction was more significant in brachio-cephalic AVFs (46.29%±4.24%) compared to distal radio-cephalic or snuffbox AVFs (49.17%±7.15%) (P=0.014). Conclusion: : High-flow AVFs can significantly affect echocardiographic parameters in hemodialysis patients, thereby increasing the risk of cardiac failure. Close cardiac monitoring may be necessary for early intervention. Distal AVFs may be preferable in patients with decreased cardiac function.

Chemotherapy Port Peal Away Sheath Embolisation and Removal With Endovascular Snaring.

Chemotherapy port implantation is a common procedure for long-term intravenous access in cancer patients. While generally safe, complications can occasionally occur. This case report describes a rare complication of chemotherapy port placement, specifically peel away sheath embolisation, and its successful endovascular removal using snaring techniques. The purpose of this report is to highlight this uncommon complication and discuss the management strategy employed in our case.

Correlation of plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) with radiographic features of congestion in chest CT scan of patients with COVID-19.

BACKGROUND: Given the importance of chest computed tomography (CT) to differentiate congestion from COVID-19 pneumonia, and considering the association of chest CT findings with cardiac biomarkers in patients with concomitant COVID-19 and heart failure, this study was conducted to identify the correlation between plasma NT-proBNP level and radiographic features of congestion in patients with COVID-19. This retrospective cohort research was carried out on adult hospitalized patients with COVID-19 and the plasma concentration of NT-proBNP was measured. The most important findings in chest CT have been considered to differentiate COVID-19 pneumonia from congestion. The study population was divided into two groups based on the presence of these imaging characteristics. RESULTS: Totally, 180 patients with a mean age of 59.6 ± 14.6 years were included in the research. The radiographic findings related to congestion have been found in chest CT of 107 (59.4%) patients. Mean plasma concentration of NT-proBNP in patients with and without radiographic features of congestion was 9886.5 ± 12,676 and 2079.9 ± 4209.3 pg/mL, respectively (p < 0.001). The area under the curve of plasma levels of NT-proBNP for identification of patients with COVID-19 who had pulmonary vein enlargement in chest CT was 0.765 (95% CI 0.688-0.842) and 0.731 (95% CI 0.648-0.813) for the individuals who had interlobar fissure thickening (p < 0.001). CONCLUSIONS: The diagnostic accuracy of plasma NT-proBNP and its positive correlation with radiographic features of congestion in chest CT scan of patients with COVID-19 can be helpful for administering appropriate medications to prevent blood volume overload.

Impact of Negative Fluid Balance on Mortality and Outcome of Patients with Confirmed COVID-19.

Purpose: Maintaining the proper fluid balance is a fundamental step in the management of hospitalized patients. The current study evaluated the impact of negative fluid balance on outcomes of patients with confirmed COVID-19. Methods: We considered the negative fluid balance as a higher output fluid compared to the input fluid. The fluid balance was categorized into four groups (group 4: -850 to -500 ml/day; group 3: -499 to -200 ml/day, group 2: -199 to 0 ml/day, and group 1 : 1 to 1000 ml/day) and included ordinally in the model. The outcomes were all-cause mortality, length of hospitalization, and improvement in oxygen saturation. Results: The fluid balance differed significantly among nonsurvivors and survivors (MD: -317.93, 95% CI: -410.21, -225.69, and p < 0.001). After adjusting for potential confounders, there was a significantly lower frequency of mortality in patients with negative fluid balance compared to the controls (aRR: 0.69, 95% CI: 0.57, 0.84, and p < 0.001). Similarly, the length of hospitalization was significantly shorter in the negative fluid balance group in comparison to the control group (aMD: -1.01, 95% CI: -1.74, -0.28, and p=0.006). Conclusion: We determined that the negative fluid balance was associated with favorable outcomes in COVID-19 patients. The negative fluid balance was associated with the reduced mortality rate and length of hospitalization as well as improvement in oxygen saturation. Moreover, the NT-proBNP >781 pg/mL and fluid balance >-430 mL might be the predictors for positive fluid balance and mortality, respectively.

Optimal cut points of N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) in patients with COVID-19.

BACKGROUND: COVID19 patients may suffer from multiple cardiovascular complications. Recently, N-terminal of the prohormone brain natriuretic peptide (NT-proBNP) was a potentially independent risk factor for COVID-19 in-hospital death. The present study aimed to find new optimal cut points for NT-proBNP across censored survival failure time outcomes in hospitalized COVID-19 patients. RESULTS: This cohort study was conducted on 272 patients with COVID-19 whose initial records were recorded from March 2020 to July 2020. Demographic characteristics, clinical examinations, and laboratory measurements were collected at the beginning of the admission registered in the patient record system located in the hospital. We used the maximally selected rank statistics to determine the optimal cut points for NT-proBNP (the most significant split based on the standardized log-rank test). Survival time was defined as the days from hospital admission to discharge day. In this cohort study, two optimal cut points for NT-proBNP were 331 (pg/mL) and 11,126 (pg/mL) based on a survival model. The adjusted HR of NT-proBNP for in-hospital death was 3.41 (95% CI: 1.22-9.51, P = 0.02) for medium against low category, and 3.84 (95% CI: 1.30-11.57, P = 0.01) for high in comparison with low group. CONCLUSIONS: We reported a dramatically increased concentration of NT-proBNP among COVID-19 patients without heart failure in both severe and non-severe cases. Moreover, our study showed that a high level of NT-proBNP was highly associated with the prolonged survival time of patients with COVID-19. NT-proBNP is a strong prognostic indicator of in-hospital death in the second week of admission.

The relationship between N-terminal pro-brain natriuretic peptide (NT-proBNP) levels and diastolic heart failure in patients with COVID-19.

Diastolic dysfunction has been reported in patients with COVID-19. Due to the role of N-terminal pro-brain natriuretic peptide (NT-proBNP) in the diagnosis of heart failure, this study investigated the relationship between serum NT-proBNP levels and diastolic heart failure in patients with COVID-19. This descriptive-analytical study was performed at Ayatollah Rouhani Hospital in Babol. Fifty-two patients with confirmed COVID-19 diagnosis, who were admitted to the ICU, were included in this study. The primary outcome was about the relationship and predictive role of NT-proBNP and diastolic heart failure in patients with severe SARS-CoV-2 infection. Patients with pro BNP > 125 pg/ml underwent echocardiography, and the relationship between echocardiographic indices and NT-proBNP was assessed as the secondary outcome. Our study showed that plasma NT-proBNP levels in patients with increased diastolic dysfunction were associated with disease severity. It was also found that the cut-off point of NT-proBNP = 799 pg/ml could be a predictor of diastolic dysfunction grades two and three. In this study, patients with a serum NT-proBNP level > 799 had 37 times higher chance of having diastolic dysfunction than those with a serum NT-proBNP < 799. Patients with NT-proBNP > 556 had RV_EA > 2 in echocardiography, indicating increased right-sided filling pressures. Despite the confounding factors in the interpretation of the NT-proBNP level in COVID-19, its level can be used to estimate the presence of high-grade diastolic heart failure on the left side and the right side of the heart and the presence of high filling pressures. Lower levels of NT-proBNP are associated with right-sided diastolic failure.

Clinically suspected myocarditis in COVID-19 patients: Case series and review of the literature.

This Study describes eleven patients positive for severe acute respiratory syndrome coronavirus 2. In our cases, females and younger patients developed more severe disease. In contrast, improvement in left ventricular ejection fraction and N-terminal prohormone brain natriuretic peptide within the first week of treatment contributed to promising outcomes.

A case of cardiac angiosarcoma and pulmonary tuberculosis; diagnostic challenges and review of literature.

BACKGROUND: Patient symptoms and primary investigational methods may be misleading at some points in patient management and can consume a lot of time. Sarcomas are rare malignancies and contribute 1% of all cancers of adult. CASE PRESENTATION: A rare case of primary cardiac angiosarcoma is presented, who was first treated because of lung tuberculosis and then with only slight improvement in symptoms, further investigations were done showing right ventricular enlargement and pericardial effusion. Eventually, after ruling out pulmonary embolism and constrictive pericarditis, investigations lead to the diagnosis of primary cardiac angiosarcoma. The patient went under surgery to remove the tumor but he still had residual mass left, leading to chemotherapy and then radiotherapy. Although the tumor has a poor prognosis, our patient has managed to survive a year by now and is doing good for 6 months after radiotherapy. CONCLUSION: The case describes the importance of having in mind different differential diagnosis in managing patients and the role of multi-modality imaging in guiding diagnosis and treatment.

Transient left ventricular clot in COVID-19-related myocarditis is associated with hypereosinophilic syndrome: a case report.

Frequent clinical presentations have been reported in patients with Coronavirus disease 2019 (COVID-19). It may be associated with multi-organ and cardiovascular involvements such as myocarditis and clot formation. Hypereosinophilic syndrome (HES) is a rare disease diagnosed with idiopathic eosinophilia and organ involvement. Here, we report a patient with COVID-19 who presented with clot formation and myocarditis. One month after discharge, regarding persistent peripheral/bone marrow hypereosinophilia and clot in echocardiography, fluorescent in situ hybridization (FISH) analysis was done that showed FIP1L1-CHIC2 fusion (PDGFRɑ rearrangement) in 18% of scored cells and PDGFRß rearrangement in 12% of scored cells, which confirmed HES diagnosis. Clot formation may be a late manifestation of COVID-19 or myocarditis due to COVID-19, or the first manifestation of HES that COVID-19 might provoke in this rare syndrome.

Heart failure with preserved ejection fraction in coronavirus disease 2019 patients: the promising role of diuretic therapy in critically ill patients.

The impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) on diastolic function is less known. We describe a 46-year-old man with a history of mild hypertension who presented to the emergency department with fever, cough, and myalgia for 2 days. The patient was tested positive for SARS-CoV-2. He was admitted and started on a combination of antiviral and antimicrobial therapy. He developed respiratory distress 2 days later, and O2 saturation declined. Blood tests showed an increased N-terminal pro-B type natriuretic peptide (NT-proBNP) level, and echocardiography showed normal left ventricular ejection fraction and E/e' ratio of 16. Computed tomography scan showed interstitial pulmonary oedema and prominent peripheral pulmonary vascular markings. Given these findings, heart failure with preserved ejection fraction (HFpEF) was considered. Low-dose diuretic was started, and fluid administration was restricted, resulting in a decrease in NT-proBNP level, clinical and haemodynamic stabilization, and improved oxygenation. This case highlights the occurrence of HFpEF in coronavirus disease 2019.

Characteristics and outcomes of hospitalized patients with cardiovascular complications of COVID-19.

Introduction: To address cardiovascular (CV) complications and their relationship to clinical outcomes in hospitalized patients with COVID-19. Methods: A total of 196 hospitalized patients with COVID-19 were enrolled in this retrospective single-center cohort study from September 10, 2020, to December 10, 2020, with a median age of 65 years (IQR, 52-77). Follow-up continued for 3 months after hospital discharge. Results: CV complication was observed in 54 (27.6%) patients, with arrhythmia being the most prevalent (14.8%) followed by myocarditis, acute coronary syndromes, ST-elevation myocardial infarction, cerebrovascular accident, and deep vein thrombosis in 15 (7.7%), 12 (6.1%), 10(5.1%), 8 (4.1%), and 4 (2%) patients, respectively. The proportion of patients with elevated high-sensitivity troponin I, N-terminal pro-B-type natriuretic peptide, left ventricular diastolic dysfunction, and heart failure with preserved ejection fraction was greater in the CV complication group. Severe forms of COVID-19 comprised nearly two-thirds (64.3%) of our study population and constituted a significantly higher share of the CV complication group members (75.9%vs 59.9%; P =0.036). Intensive care unit admission (64.8% vs 44.4%; P =0.011) and stay (5.5days vs 0 day; P =0.032) were notably higher in patients with CV complications. Among 196patients, 50 died during hospitalization and 10 died after discharge, yielding all-cause mortality of 30.8%. However, there were no between-group differences concerning mortality. Age, heart failure, cancer/autoimmune disease, disease severity, interferon beta-1a, and arrhythmia were the independent predictors of all-cause mortality during and after hospitalization. Conclusion: CV complications occurred widely among COVID-19 patients. Moreover,arrhythmia, as the most common complication, was associated with increased mortality.

Association of vitamin D deficiency and premature coronary artery disease.

BACKGROUND: Evidence suggests hypovitaminosis D is associated with increased risk of coronary artery disease (CAD) and its extent and related risk factors. However, some investigations have produced contrary results. Therefore, we aimed to evaluate the association between serum vitamin D levels and the severity of premature coronary artery involvement. METHODS: This randomized prospective, case-control study was conducted in Babol from April 2013 to June 2017. We collected the demographic data and measured serum 25-OH-D levels of 294 patients (age≤50 years) diagnosed with CAD with coronary angiography as case group as well as 438 age and sex-matched controls. CAD severity was assessed using the Gensini score. Statistical analyses were used to assess the associations and p<0.05 was considered as significant. RESULTS: The mean serum level of 25-OH-D was 13.12±11.13 and 18.28±8.34 in case and control groups, respectively (P=0.036). In the case group, mean serum vitamin D levels were significantly lower among hypertensives (P=0.018), those with a family history of CVD (P=0.016) and those who used aspirin (P=0.036). The mean Gensini score of patients in the case group was 45.02±23.62 and was higher among men (P=0.022). There was a weak significant correlation between the serum vitamin D levels and the Gensini score (P=0.001 & R=-0.543). The mean Gensini score was not significantly different between patients with deficient (47.02±22.78), insufficient (26.0±21.72) and sufficient (39.0±43.84) vitamin D levels (P>0.05). CONCLUSION: The results showed that the lower levels of vitamin D is associated with increased risk and extent of coronary artery involvement as well as some of the risk factors of CAD, including male gender, hypertension and positive family history for CVD.

Cytochrome P450 2C19 Polymorphism in Iranian Patients with Coronary Artery Disease.

BACKGROUND: The polymorphisms of cytochrome P450 2C19 (CYP2C19) gene are major prognostic factors for the response to clopidogrel therapy in patients with coronary artery diseases (CAD). The CYP2C19*2 is the most important allele responsible for resistance to clopidogrel therapy. This study examined CYP2C19 gene polymorphism (CYP2C19*1 and *2) in Iranian patients. METHODS: This cross-sectional study was performed on 43 Iranian patients with CAD who underwent percutaneous coronary intervention (PCI) and received drug-eluted stents (DES). CYP2C19 polymorphisms were assessed using real time PCR and frequency of CYP2C19*1 and CYP2C19*2 were determined, and then homo- or heterozygous state of genes was detected by Melt Curve Analysis method. RESULTS: Forty three patients (mean age = 58.8 ± 10.0 years, 79.1% male) participated in this study. CYP2C19*1/CYP2C19*1 genotype was observed in 31 (72.1%) of participates, CYP2C19*1/CYP2C19*2 genotype in 10 (23.3%), and CYP2C19*2/CYP2C19*2 genotype in 2 patients (4.7%). The frequency of CYP2C19*2 allele in the sample was 27.9%. CONCLUSION: This study demonstrated a high prevalence of CYP2C19*2 gene polymorphism in Iranian patients. Further studies with larger samples or longitudinal are required to determine the effects of this polymorphism on the prognosis of CAD patients in our population.

Nasal mucosal involvement in Behçet disease: a study of its incidence and characteristics in 400 patients.

Behçet disease is a multisystem vasculitis characterized by mucosal aphthosis, primarily in the oral and genital mucosa. Only a few cases of involvement of the nasal mucosa have been reported in the literature, and its true prevalence is not known. We conducted a cross-sectional study of 400 consecutively presenting patients with confirmed Behçet disease (according to classification-tree criteria) to determine the incidence of nasal mucosal involvement, to identify its particular characteristics, and to determine if there are any statistically significant differences in clinical and paraclinical parameters between Behçet disease patients with nasal involvement and those without. To the best of our knowledge, this is the first systematic evaluation of nasal involvement in patients with Behçet disease to be published in the literature. Data analysis was performed with Statistical Package for the Social Sciences software (SPSS), and a confidence interval (CI) at 95% was calculated for each finding. Involvement of the nasal mucosa was seen in 31 of the 400 patients (7.8%; CI: 5.1 to 10.5). Among those 31 patients, the most common nasal symptom was dysosmia, which was seen in 15 patients (3.8% of the total population; CI: 1.9 to 5.7); other nasal symptoms included obstruction in 10 patients (unilateral in 9), ulcers in 2, pain in 2, and a burning sensation and discharge in 1 each. No patient reported a history of epistaxis or nasal itching. Abnormal signs were present in only 16 patients (4.0%; CI: 2.1 to 5.9); they included nasal cartilage deformity in 6, unilateral nasal obstruction in 4, postnasal discharge in 3, nonaphthous ulcer in 3, and crusted ulcer in 2 (2 patients each had 2 abnormal signs). No case of aphthous ulcer, nasal discharge, nasal scar or deformity, septal perforation, or nodular or granulomatous cartilage lesion was found. There were no statistically significant differences in clinical and paraclinical disease manifestations between those patients who had nasal mucosal involvement and those who did not.

Comparison of existing disease activity indices in the follow-up of patients with Behçet's disease.

The objective of this study was to determine the concordance between the Iranian Behçet's disease dynamic activity measure (IBDDAM) or the Behçet's disease current activity form (BDCAF) and expert physician global assessment (PGA) in the evaluation of disease activity changes in Behçet's disease (BD). In a prospective study, 117 consecutive patients with BD were evaluated in their two consecutive follow-up visits by IBDDAM and BDCAF. The change in disease activity was determined (increased, unchanged or decreased) according to the PGA. We used receiver operating characteristic (ROC) curve to determine an appropriate cutoff point for disease activity change. Comparison was made by Stata and kappa analysis. Comparing the area under the ROC curve showed a significant difference between IBDDAM and BDCAF (p < 0.03). The difference was more significant between nonocular IBDDAM and BDCAF (p < 0.002). Better concordance was also observed for IBDDAM (nonocular and total) with PGA than BDCAF. The difference was not significant for ocular IBDDAM. The best cutoff point for nonocular IBDDAM was 0.45, for ocular IBDDAM was 3.5, and for BDCAF was 1 point. IBDDAM was the preferred method for the evaluation of disease activity change in patients with BD (without ocular involvement) considering a change of at least 0.45.