azin alizadehasl

Cyclophosphamide-induced cardiotoxicity, associated with its toxic metabolite acrolein, is a significant concern and unresolved issue, especially when cyclophosphamide is administrated in high doses. However, cardiotoxicity following low-dose cyclophosphamide has been also documented, especially in post-hematopoietic stem cell transplantation (post-HSCT) settings. Despite the involvement of multiple signaling pathways in cyclophosphamide-induced cardiomyopathy, the exact underlying mechanisms remain to be fully elucidated. This review outlines the current challenges of cyclophosphamide therapy in HSCT recipients. In addition, the promising therapeutic approaches by targeting acrolein’s anti-angiogenic effect were thoroughly discussed to better manage post-HSCT cyclophosphamide-induced cardiotoxicity.

This case report presents the clinical findings and management of an 18yearold female patient with a known history of Crohn’s disease who developed right ventricular (RV) thrombosis. Despite presenting with prolonged fever and inconclusive initial evaluations, subsequent cardiac imaging confirmed the presence of a mobile RV mass. The patient’s complex medical history, including a history of gastrointestinal bleeding, necessitated a multidisciplinary approach to treatment. This case underscores the importance of considering atypical cardiac complications in patients with chronic inflammatory conditions like Crohn’s disease and highlights the challenges and choices in managing RV thrombosis in such cases.

Dual antiplatelet therapy (DAPT) following coronary stenting is used to prevent thromboembolic events. Dual antiplatelet therapy discontinuation and poor compliance to the antiplatelet drugs are common and results in various complication, most importantly cardiovascular events.

Here, we designated a cross-sectional study to evaluate the association of DAPT adherence and post-angioplasty cardiovascular events.

A total of 150 adult patients from Modarres Hospital undergoing successful stent implantation were included and adherence to DAPT following angioplasty were determined via telephone at 6 and 12 months by Persian version of the 8-item Morisky Medication Adherence Scale (MMAS-8). We also recorded the occurrence of ST segment elevation myocardial infarction (STEMI), acute coronary syndrome (ACS), coronary artery bypass grafting (CABG) and re-angioplasty 6- and 12-months following discharge.

During the trial, 50 patients were lost to follow-up due to failure to complete the MMAS-8 check list. We analyzed the association of STEMI, ACS, CABG and re-angioplasty with the level of DAPT adherence 6 and 12-month post-angioplasty. Our data suggested an important association of low and high DAPT adherence with lower cardiovascular events at 12 months post- Percutaneous Coronary intervention (PCI). However, at 6 months post-PCI, there was a minor cardiovascular event in patients with moderate DAPT adherence.

Here, we observed a significant association of drug adherence along with patient’s risk factors in a course of antiplatelet therapy following coronary stenting.

Cardiac hemangioma is a rare cardiac tumor which may have a spectrum of signs and symptoms; here we would like to present a case of asymptomatic cardiac hemangioma that was discovered by an ECG.

Most cases of congenital coronary artery fistula (CAF) resolve spontaneously, symptomatic patients with severe shunting require surgical intervention. Our aim is to evaluate success rate and outcome of CAFs treatment using transcatheter interventional methods.This retrospective study conducted on 28 CAF patients who were referred to Rajaie Cardiovascular Medical and Research Center in Tehran between 2015 and 2020. Baseline characteristics were collected by assessing hospital records, and patients were followed up annually for long-term evaluation. All of 28 patients gone throughtranscatheter closure of CAF. In 23 patient’s it was proximal type (82.1%) and in 5 patients was distal type (17.9%). In 11 patients, the fistula originated from the RCA (39.3%) and in 11 patients, it originated from the LAD and Diagonal. Most common drainage site was the pulmonary artery (82.1%). Coil used in 23 patients(82.1%). PDA occluder (7.1%) for 2 patients. VSD occluder for one patient (3.6%) and VSD+PDA occluder combination was used for one patient (3.6%). Procedure failure was in only one patient. Non-significant remaining shunt in the injection immediately after the procedure was seen in 4 patients (14.3%), which was reduced during the follow-up. None of the patients had significant shunt or clinical symptoms during long-term follow-up. As for complications, fistula dissection occurred in only one patient.The transcatheter interventional approach for the treatment of CAFs leads to favorable long-term results.

Cancer is the second leading cause of death worldwide, and pericardial effusion is relatively common in these patients. What constitutes the best therapeutic method for treating pericardial effusion in patients with cancer is controversial. Recent decades have witnessed the introduction of percutaneous balloon pericardiotomy, an effective and less-invasive method with lower recurrence rates than pericardiocentesis for draining pericardial effusion in patients with cancer who have a poor prognosis.We herein describe 2 patients with a history of metastatic melanoma and metastatic breast cancer, presenting with symptomatic massive pericardial effusions. The patients had experienced 2 episodes of cardiac tamponade in the preceding 4 to 5 months, treated via surgical drainage. In their current episode, they were both successfully treated via percutaneous balloon pericardiotomy, and there was no recurrence of significant pericardial effusion reported during the follow-up.

Ischemic disorders, including myocardial infarction, cerebral ischemia, and peripheral vascular impairment, are the main common reasons for debilitating diseases and death in Western cultures. Ischemia occurs when blood circulation is reduced in tissues. Reperfusion, although commanded to return oxygen to ischemic tissues, generates paradoxical tissue responses. The responses include generating reactive oxygen species (ROS), stimulating inflammatory responses in ischemic organs, endoplasmic reticulum stress, and the expansion of postischemic capillary no-reflow, which intensifies organ damage. Multiple pathologic processes contribute to ischemia/reperfusion; therefore, targeting different pathologic processes may yield an effective therapeutic approach. Transient Receptor Potential A1 (TRPA1) belongs to the TRP family of ion channels, detects a broad range of chemicals, and promotes the transduction of noxious stimuli, e.g., methylglyoxal, ROS, and acrolein effects are attributed to the channel’s sensitivity to intracellular calcium elevation or phosphoinositol phosphate modulation. Hypoxia and ischemia are associated with oxidative stress, which activates the TRPA1 channel. This review describes the role of TRPA1 and its related mechanisms that contribute to ischemia/reperfusion. Relevant articles were searched from PubMed, Scopus, Web of Sciences, and Google Scholar electronic databases, up to the end of August 2023. Based on the evidence presented here, TRPA1 may have protective or deteriorative functions during the ischemia/reperfusion process. Its function depends on the activation level, the ischemic region, the extent of lesions, and the duration of ischemia.

Investigating the source of fever of unknown origin (FUO) is usually one of the diagnostic challenges for clinicians. Furthermore, it is one of the most important causes that should always be considered is cardiac causes. In this case, we evaluated a patient with a cardiogenic cause of FUO; despite all the studies, no definite cause was found, but it responded to empiric treatment.

Thyroid hormones play an important role in cardiac tissue function. Therefore, it is important to understand the relationship between thyroid hormone levels and cardiac disorders.

The present study aimed to assess the relationship between normal serum level of thyroid hormones and left ventricular systolic and diastolic dysfunction.

In this cross sectional descriptive retrospective study, 391 patients were selected. They were referred to the Rajaie Cardiovascular Research Center, Tehran, Iran from 2019 to 2021. After extracting echocardiographic and laboratory data from the clinical records, the parameters affecting the left ventricular systolic and diastolic dysfunction were analyzed using statistical software.

The mean age of patients was 41 ± 12.8 years. Among them 58.1% of all patients were female. Tricuspid regurgitation (TR) severity had a significant relationship with thyroid stimulating hormone (TSH) level (P = 0.02). End diastolic interventricular septum thickness (IVSD) was inversely associated with thyroxin4 (T4) level (P = 0.04). Mitral valve inflow deceleration time (MVDT) was inversely correlated with thyroxin3 (T3) (P = 0.04). Left ventricular ejection fraction (LVEF) was inversely related to TSH level and end diastolic right ventricular internal diameter (RVIDd) was directly related to TSH (P = 0.05).

Thyroid hormone levels in the normal range can be associated with the tricuspid regurgitation severity, end diastolic right ventricular internal diameter (RVIDd), mitral valve inflow deceleration time (MVDT), and. end diastolic interventricular septum thickness (IVSD). Due to the high prevalence of heart disorders, information on thyroid hormone levels can be helpful in the identification and timely treatment of these disorders.

Context: 

It seems that the threat of death increases among diabetic patients with coronavirus infection disease-2019 (COVID-19). Statins have anti-inflammatory and anti-thrombogenic properties along with lowering blood cholesterol. Therefore, statins could be considered as an important factor in reducing the mortality rates in diabetic patients with COVID-19. This systematic review and meta-analysis study was performed to investigate the effect of statin on mortality in diabetic patients with COVID-19.

Evidence Acquisition: 

This study was done based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Electronic databases such as PubMed, Embase, Scopus, Web of Science, and Cochrane Library were searched from December 2019 until the end of September 2022. Meta-analysis was used by the comprehensive meta-analysis software to combine the results. A funnel plot and Egger’s regression test were used to investigate the publication bias.

 Six studies were included in the meta-analysis. Nine thousand five hundred and thirty-three diabetic patients with COVID-19 were studied. The heterogeneity between studies was significant. According to the meta-analysis, using the random-effects model, we found that the rate of mortality due to COVID-19 in diabetic patients who used statins was 9% lower than other patients. Publication bias between studies included in the meta-analysis was not significant.

 In this study, there was no significant difference between the mortality rates of diabetic people with COVID-19 who used statins and individuals who did not consume statins – this difference was just 9%. Therefore, it could be said that more clinical trials are needed to ensure the clinical efficacy of statins among diabetic patients with COVID-19.

The crisscross heart is a rare congenital heart abnormality often associated with other cardiac anomalies. Echocardiography is the first-line diagnostic tool, whereas magnetic resonance imaging and catheterization are used for complementary assessments. In the absence of significant pulmonary valve stenosis or hypoplasia in the tricuspid valve or the right ventricle, total repair or, otherwise, the Fontan procedure is recommended. (Iranian Heart Journal 2023; 24(3): 85-88)

Using echocardiographic parameters, we sought to predict cardiotoxicity in patients with breast cancer before treatment.
 
The study recruited 53 left-sided breast cancer patients with no previous history of heart failure or cancer treatment. The patients underwent 2D and 3D echocardiography before and 6 months after the end of treatment. The main criterion for cardiotoxicity was a reduction in posttreatment LVEF exceeding 10% compared with pretreatment. Systolic and diastolic parameters were compared between 2 groups: complicated and noncomplicated. Binary logistic regression was used to predict cardiotoxicity.
 
The patients’ mean age was 49 ± 11.2 years. No statistical differences existed between the groups in demographics and cardiac risk factors at study commencement. Posttreatment, 4 echocardiographic parameters (E/A ratio, sPAP, LVEF, and LVGLS) were significantly changed compared with pretreatment echocardiography. The regression analysis showed that E/A ratio was effective in predicting cardiotoxicity (sensitivity = 68%, specificity = 76%, AUC =77%; and P <0.001).
 
Echocardiography, aside from its usefulness in diagnosing cardiotoxicity, can be valuable in predicting complications, especially in patients with breast cancer at higher risk of cardiotoxicity due to chemotherapy and radiotherapy in the chest wall area. (Iranian Heart Journal 2023; 24(3): 62-69)

Burned-out hypertrophic cardiomyopathy (BO-HCM) is complicated by substantial adverse events. However, few studies have focused on clinical or echocardiographic features and their prognostic values among patients with BO-HCM.

This study evaluated the clinical manifestations and prognostic value of echocardiography in patients with BO-HCM.

The present retrospective study evaluated 401 consecutive patients referred to the echocardiography ward of Rajaie Cardiovascular Center for evaluation of HCM during the period from January 2010 to February 2018. Three hundred six patients who completed the follow-up were included: 78 (25.4%) had BO-HCM and an EF of < 50% (group 1), and 228 (74.5%) had a normal EF in their baseline TTE (group 2). Among the group 2 population, 183 patients had a preserved EF of > 50% (group 2B), and 45 became BO-HCM at the end of their follow-up (group 2A). Clinical data were analyzed, including medical history, electrocardiography, and echocardiography. Generalized estimating equation (GEE) regression was performed to assess the association between patient characteristics and burned-out HCM.

An atrial fibrillation (AF) rhythm was more common in the groups with BO-HCM (groups 1 and 2A) (32.8 vs. 14%; P = 0.002), as were Frequent premature ventricular contractions (PVCs) (13.98 vs. 5%; P = 0.040). Moderate or severe systolic anterior motion (SAM) was significantly more common in group 2B (LVEF > 50%) compared with group 1 and 2A, who had an EF of ≤ 50% (32.3% vs. 7.6%; P = 0.006). The S-wave of the right ventricle was significantly lower in groups 1 and 2A (9.73 vs. 11.8 cm/s; P < 0.001). Systolic pulmonary artery pressure (SPAP) was significantly higher in groups 1 and 2A (38.28 vs. 29.74 mmHg, P < 0.001). The differences in the prevalence of asymmetrical septal hypertrophy (ASH), left ventricular outlet (LVOT) obstruction, pericardial effusion (PE), diastolic dysfunction, and mitral regurgitation (MR) were insignificant between all groups.

Among the patients suffering from HCM, the presence of AF rhythm, frequent PVCs, significant RV dysfunction, and absence of systolic anterior motion (SAM) of mitral valve leaflets have prognostic value and might be considered predictors for progression to BO-HCM.

Left ventricular (LV) non-compaction is a genetic disease which might result in heart failure, arrhythmias, and thromboembolic events. Nonetheless, other diseases and drugs or toxins like chemotherapy agents can also simulate or exacerbate this phenotype and accelerate systolic dysfunction. Moreover, cancer and receiving chemotherapy agents are procoagulant states leading to venous, arterial, and intracardiac thromboses.

Case: 

A 62-year-old man with a history of lung squamous cell carcinoma from 4 months earlier and non-compacted LV presented with dyspnea, severe LV systolic dysfunction, and multiple large LV clots.

Non-compacted LV can be a risk factor to exacerbate the cardiotoxicity of cancer therapeutics and lead to severe LV systolic failure. Additionally, severe LV systolic dysfunction, advanced stages of the lung cancer, the hypercoagulable state of cancer, and chemotherapy drugs like platinum agents could result in the formation of multiple large clots in the LV. 

Cardiotoxicity, a common complication of chemotherapy, may have irreversible adverse effects on the heart. Anthracycline-based chemotherapy for breast cancer can lead to dilation-hypokinetic cardiomyopathy, eventuating in heart failure. As the primary diagnostic tool for cardiovascular toxicity, echocardiography may be essential in evaluating the heart function of such patients.

This study aimed to identify the most important echocardiography findings for proper and timely diagnosis of cardiotoxicity in patients with HER2-positive breast cancer undergoing anthracycline-based chemotherapy.

Our final analysis included 132 female patients who were HER2-positive and had breast cancer. All of these patients had one pre-chemotherapy echocardiography and at least one echocardiography after three episodes of anthracycline-based chemotherapy. The patients’ age, body mass index, and history of chemotherapy were recorded. Mean alterations from baseline echocardiography to echocardiography after three episodes of chemotherapy were calculated for all parameters evaluated. Data analysis was conducted using the Statistical Package for the Social Sciences v. 26.

Significant changes were seen in three-dimensional left ventricular ejection fraction (LVEF 3D), two-dimensional left ventricular ejection fraction (LVEF 2D), left ventricular global circumferential strain (LVGCS), left ventricular global longitudinal strain (LVGLS), left ventricular end-diastolic volume (LVEDV), stroke volume (SV), left ventricular end-systolic volume (LVESV), right ventricular end-systolic dimension (RVESD) in patients with breast cancer (P < 0.0001). RVESD, LVESV, LVEDV, and SV significantly increased after three chemotherapy episodes, but LVEF (3D and 2D), absolute LVGCS, and absolute LVGLS fell significantly.

LVEF (3D and 2D), LVGCS, LVGLS, LVEDV, LVESV, SV, and RVESD are important echocardiography parameters in diagnosing cardiotoxicity in patients with HER2-positive breast cancer.

Mechanical complications following acute myocardial infarction (MI) are associated with very high morbidity and mortality. Left ventricular (LV) pseudoaneurysms constitute a rare complication after MI. Considered a contained rupture of the LV free wall, an LV pseudoaneurysm is more prevalent in older age, the female sex, hypertension, and inferior and lateral wall MI. Echocardiography, computed tomography, and cardiac magnetic resonance are considered good noninvasive imaging modalities for the diagnosis of LV pseudoaneurysms.

Case: 

A 39-year-old man with a history of anterolateral MI 18 months earlier, coronary stent insertion, and implantable cardioverter-defibrillator implantation presented for follow-up, but he was incidentally diagnosed with LV pseudoaneurysm in transthoracic echocardiography, which was confirmed by cardiac computed tomography.

Pseudoaneurysms must be diagnosed because of their high likelihood of rupture. However, as their clinical presentation is not specific, they are occasionally diagnosed incidentally. Clinicians should, therefore, always look for them in post-MI patients’ echocardiography.

Blunt aortic trauma is a relatively rare fatal event with a high acute mortality rate of more than 80% on the scene. If the patient survives the primary injury, high clinical suspicion is necessary for diagnosis. The main mechanism of the trauma is reported to be deceleration injury or falling from a height. Herein, we describe a 37-year-old healthy male on a heavy weight lifting job for many years with a left upper mediastinum calcified mass incidentally discovered 18 years after blunt chest trauma. Transthoracic echocardiography and contrast-enhanced chest computed tomography scan revealed an aortic pseudoaneurysm just after the isthmus without descending aortic flow limitation, which was subjected to endovascular repair. High clinical suspicion is necessary for the diagnosis of aortic injury during blunt chest trauma. Atypical symptoms late after a traumatic event may be a manifestation of missed traumatic aortic rupture. Surgical repair, percutaneous intervention, or hybrid approaches are proposed for the management of this ominous scenario. (Iranian Heart Journal 2022; 23(4): 115-119)

Cardiotoxicity is an unavoidable complication after chemotherapy. The present study investigated the effect of 12 weeks of aerobic exercise (high-intensity interval training or moderate-intensity continuous training) with and without blood flow restriction on some anthropometric indices in women with breast cancer who had chemotherapy-induced cardiotoxicity.

Twenty breast cancer patients with cardiotoxicity participated in this study (age: 21-34 years and body mass index: 26-57 kg/m2). Patients were randomly divided into groups of high-intensity interval training, moderate-intensity continuous aerobic exercise, high-intensity interval training with limited blood flow, and moderate-intensity aerobic training with limited blood flow. Patients then received the interventions for 12 weeks, three sessions per week. Before and after the intervention, data related to patients’ anthropometric indices were collected using a body composition analyzer (X-CONTACT 356) and analyzed using a MANCOVA test.

Weight, body mass index and final score of the body analyzer in the high-intensity interval training group with restricted blood flow improved significantly compared with the groups without restricting blood flow (P < 0.05). High-intensity interval training and restriction of blood flow reduced the percentage of body fat and age-appropriate body, increased muscle tissue, and the waist to hip ratio compared with moderate-intensity continuous training (P<0.05). Basal metabolic rate was not affected by exercise type but increased with blood flow restriction (P < 0.05).

The present study suggests the use of a combination of physical activity and restriction of blood flow as a solution for the recovery of breast cancer patients with treatment‑related cardiotoxicity (in the case of the components of the present study).

Apical Hypertrophic Cardiomyopathy (ApHCM) is a rare form of hypertrophic cardiomyopathy with sarcomere protein gene mutations, which predominantly affects the apex of the left ventricle. Sudden Cardiac Death (SCD) and cardiovascular morbidity are less likely to occur in patients with isolated ApHCM. However, recent data suggested annual cardiac death rates of 0.5 - 4%, approaching those for classic HCM.

The present study aimed to assess the prevalence of burned-out ApHCM and its predictors.

In this retrospective cross-sectional study, echocardiographic data and electrocardiography features of 230 patients with ApHCM including premature ventricular contraction and atrial fibrillation were gathered and analyzed at baseline and after a mean follow-up of five years. All data were obtained from the data registry of Rajaie Cardiovascular Medical and Research Center, Tehran, Iran. The data were included in a retrospective study, which was approved by the local Ethics Committee. The patients were divided into two groups as follows: 1- Left Ventricular Ejection Fraction (LVEF) ≥ 50% and 2- LVEF < 50% known as burned-out ApHCM. Data analysis was also based on LVEF. Generalized Estimating Equation (GEE) regression was performed to assess the association between the patients’ characteristics and burned-out ApHCM. The clinical features demonstrating P < 0.05 in the univariate GEE analysis were included in a multivariate model to identify the independent predictors.

The prevalence of burned-out ApHCM, defined as LVEF < 50%, was 13.9%. There was no significant difference between males and females in this regard (P = 0.48). After a mean follow-up of five years, atrial fibrillation was significantly more common in the patients with LVEF < 50% (48.7% vs. 24.4%, P = 0.007). Additionally, left atrial enlargement was identified as the most important predictor of BO-ApHCM (odds ratio = 2.4, P = 0.003). Moreover, right ventricular dysfunction was more severe in the patients with burned-out ApHCM (P < 0.001).

The prevalence of burned-out HCM was higher in the present study than in the previous studies (13.9%). Besides, right ventricular systolic dysfunction and left atrial enlargement were two main predictors of the ApHCM progression.

Advances in cancer treatment have resulted in a growing number of cancer survivors. However, powerful treatments such as chemotherapy, radiation treatments, and some cancer drugs are not without risks, including the potential for serious, long-term damage to the heart. Cardiology and oncology specialists often collaborate to mitigate these risks when treating cancer patients. This joining is known as cardio-oncology. The main goals of cardio-oncology are to screen for and actively manage modifiable cardiovascular risk factors and diseases in cancer patients. Cardio-oncology plays an increasingly active role at every stage of cancer therapy, including baseline risk assessment pretreatment, surveillance and prevention during treatment, response to acute complications, and assessment of survivors’ post-cardiotoxic treatments. Cancer treatment has been optimized through new treatment strategies. The first cardio-oncology clinic in Iran was instituted about 4 years ago (2017) at Shaheed Rajaei Cardiovascular Medical and Research Center in Tehran, which is the first cardio-oncology clinic in the Middle East. It provides care for cancer patients with a history of cardiovascular disease or risk for cardiotoxicity during cancer therapy. Also, all patients are enrolled in the multicenter cardio-oncology Toxicity Registry research database, and 13 other hospitals from different centers in the whole country are involved in the registry. The establishment of the cardio-oncology clinic with a focus on the patient registry is discussed in this article.

Around 20% of breast cancers (BCs) overexpress Human Epidermal Growth Factor Receptor 2 (HER-2). HER-2 overexpression is associated with increased tumor aggressiveness and poor prognosis. Trastuzumab (an anti-HER2 monoclonal antibody) has been reported to improve overall survival in early-stage and metastatic BCs, but at the expense of increasing cardiac morbidity. In the current review study, we aims to discuss the pathogenesis of trastuzumab-induced cardiotoxicity and the potential ameliorating role of spironolactone in this regard.

The search strategy aimed to identify both published and unpublished studies. First off, we identified keywords and index terms, including trastuzumab, cardiotoxicity, heart failure, and spironolactone to conduct a broad search in PubMed, Embase, Scopus, and Web of Science, using the aforementioned keywords either individually or in combination. Lastly, the reference list of all identified articles was also evaluated. Our study included observational and interventional studies, case-reports, and systematic reviews and meta-analyses.

Trastuzumab could deteriorate mitochondrial function and subsequently leads to the accumulation of Reactive Oxygen Species (ROS) in cardiomyocytes. Published clinical studies offered conflicting results regarding the efficacy of angiotensin-converting enzyme inhibitors and beta-blockers in respect of trastuzumab-induced cardiotoxicity. On the other hand, spironolactone was found to have both antioxidant and anti-inflammatory properties. Recent in-vivo studies supported the cardioprotective effect of spironolactone through maintaining mitochondrial ultrastructure and reducing ROS production.

Although spironolactone mitigates oxidative stress and mitochondrial dysfunction, there is a lack of clinical evidence to support the effectiveness of spironolactone in trastuzumab-induced cardiotoxicity. Design and implementation of clinical trials are recommended to determine the potential beneficial effects of spironolactone on trastuzumab-induced cardiotoxicity.

One of the conditions leading to hemolysis in patients with artificial metallic heart valves is valvular dysfunction. In case of symptomatic hemolysis, a blood transfusion may be needed along with standard treatments. Inattention to the differential diagnosis of hemolysis and making decisions based on causes that are more obvious can lead to incorrect approaches.

In this case report, we presented a case with a previously undiagnosed rare blood group (positive antibody anti-E, anti-c, anti-Kell), undergoing reoperation of mitral valve replacement (MVR), who developed severe hemolysis and subsequent acute renal failure secondary to incompatible blood transfusion and required hemodialysis.

In this patient, hemolysis was solely attributed to mitral valve dysfunction. By timely diagnosis of the subtype of her blood group and appropriate decision-making during surgery, adverse blood transfusion outcomes were prevented.

Some degrees of hemolysis are probable in pediatric patients receiving cardiopulmonary bypass. Nonetheless, severe hemolysis, even in premature infants undergoing cardiac surgeries, is rare. When hemolysis happens in a neonate or infant receiving cardiopulmonary bypass, numerous causes, including erythrocyte membrane defects, hemoglobinopathies, iso-immunization, undiagnosed enzyme abnormalities, and acquired conditions such as sepsis or drug interactions, should be considered. Urine discoloration may be considered a hemolytic reaction secondary to blood transfusion; still, in mild degrees of hemolysis due to mechanical trauma, this discoloration may not be noticed. One type of acute hemolytic reaction is immunological, which may happen secondary to the interaction between the recipient’s antibodies and the donor’s antigens, although most severe cases of hemolytic anemia are secondary to ABO incompatibility In this case report, we describe a 15-month-old infant undergoing surgical repair for tetralogy of Fallot, who developed hemolysis during cardiopulmonary bypass. We also discuss the case’s diagnostic workup and therapeutic management.  

Coronary microvascular function can predict the infarct size and Left Ventricular (LV) functional recovery in patients diagnosed with ST-Elevation Myocardial Infarction (STEMI). Multiple invasive and non-invasive methods are used to evaluate coronary microvascular function. The Non-invasive Index of Microvascular Resistance (NiMR) is a method to evaluate microvascular resistance.

This study aimed to assess the relationship between NiMR and Left Ventricular Ejection Fraction (LVEF) measured by Transthoracic Echocardiography (TTE) in patients with acute STEMI undergoing primary Percutaneous Coronary Intervention (PCI).

This prospective observational study was conducted on 39 patients with STEMI. NiMR was measured instantly after primary PCI. After that, the patients were divided into two groups based on their NiMR: Group 1 (n = 20) with slighter microvascular dysfunction (NiMR < 24) and Group 2 (n = 19) with more severe microvascular dysfunction (NiMR ≥ 24). In the first 24 hours (Echo1) and one month after primary PCI (Echo2), LVEF and the Global Longitudinal Strain (GLS) were measured by TTE.

The mean age of the patients was 58.0 ± 11.3 years, and 34 ones (87.1%) were male. In Echo1, there were no significant differences between the two groups regarding LVEF (39.6 ± 7.8% vs. 38.8 ± 8.6%; P = 0.761) and GLS (−10.2 ± 2.5 vs. −10.9 ± 3.2; P = 0.487). However, LVEF improvement was higher in Group 1 than in Group 2 (Δ LVEF = 5.8 ± 7.3% in Group 1 vs. Δ LVEF = 1.3 ± 8% in Group 2; P = 0.073), but the difference was not statistically significant (OR: 2.8, 95% CI: 0.72 - 10.7; P = 0.13). GLS also exhibited an improvement in both study groups after a month (Δ GLS = 5.4 ± 3.1 in Group 1 vs. Δ GLS = 2.4±3.2 in Group 2; P = 0.005), but this improvement was statistically significant only in Group 1 (OR: 5.5, 95% CI: 1.32 - 22.8; P = 0.01).

In patients with lower NiMR values, LV systolic function recovery (defined by improvement in GLS) was significantly higher one month after STEMI. Thus, NiMR can be used as an early marker of LV performance recovery after acute STEMI.