Iranian Heart Journal
Volume:23 Issue: 2, Spring 2022

The relationship between mitral valve area (MVA) and different hemodynamic and echocardiographic parameters is not well defined. This study aimed to assess whether hemodynamic and echocardiographic parameters correlated with MVA in patients with rheumatic mitral stenosis.
This cross-sectional study assessed 600 patients with rheumatic heart disease who underwent transthoracic echocardiography in a tertiary care center between August 2018 and March 2020. Among them, 265 cases of predominant mitral stenosis were enrolled. Demographic data, as well as hemodynamic and echocardiographic variables, were recorded.
Out of the 265 patients, 29.1% were males, and 71.9% were females at a mean age of 44.80±13.54 years. MVA ranged between 0.5 cm2 and 2.0 cm2, with a mean mitral valve gradient of 10.02±3.43 mm Hg. Atrial fibrillation was present in 44.2%. There were positive correlations between MVA and body mass index (r=0.19, P=0.002), systolic blood pressure (r=0.14, P=0.011), diastolic blood pressure (r=0.16, P=0.006), and mean blood pressure (r=0.18, P=0.003). Negative correlations were found between MVA and heart rate (r= −0.20, P=0.001), left atrial size (r= −0.16, P=0.007), mean mitral valve gradient (r= −0.67, P<0.001), and pulmonary artery systolic pressure (r= −0.17, P=0.004).
MVA correlated significantly with body mass index, blood pressure, heart rate, left atrial size, mean mitral valve gradient, and pulmonary artery systolic pressure. This study helps to understand the influence of different clinical parameters and transthoracic echocardiographic findings to accurately assess rheumatic mitral stenosis severity. (Iranian Heart Journal 2022; 23(2): 6-15)

We aimed to study the effects of right ventricular systolic dysfunction on the outcome of patients after coronary artery bypass graft surgery (CABG).

This study enrolled 106 patients (age=60.1±10.8 y, 58.5% male) who underwent pure CABG in Tehran Heart Center and had right ventricular systolic dysfunction (RVSD) with tricuspid annular plane systolic excursion (TAPSE)<16. As a control group, 424 patients (age=61.4±9.7 y, 55.7% male) with a history of isolated CABG and preoperative normal right ventricular systolic function (NRVSF) (TAPSE≥16) were selected.  The median follow-up time was 12 months. Death, ICU stay, intubation time, hospital stay, postoperative blood transfusion, pleural effusion, and tamponade were considered adverse outcomes. TAPSE≤14 was considered more severe RVSD.

In-hospital mortality was significantly higher in the RVSD group than in the NRVSF group (3.8% vs 0.7%; P=0.032). No significant effect of RVSD on ventilation time, hospital length of stay, ICU length of stay, postoperative blood transfusion, tamponade, and pleural effusion was found. The effect of RVSD on overall survival was not significant (P=0.096); however, there was a significantly higher rate of cardiac death in the RVSD group (P=0.017).  Overall survival was better in the NRVSF group than in the group with more severe RVSD as a trend (P=0.076).  The mean values of ventilation time, hospital length of stay, and ICU length of stay were significantly higher among patients with TAPSE≤14 than those with TAPSE≥16.

Preoperative RVSD was associated with increased in-hospital and cardiac mortality in patients undergoing pure CABG, and higher RVSD is a potent risk factor for adverse outcomes following CABG. (Iranian Heart Journal 2022; 23(2): 16-25)

T-wave inversion, which develops shortly after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI), is related to reperfusion or myocardial viability. We aimed to evaluate the clinical outcome according to changes in T-wave inversion in patients with STEMI.

We categorized patients into 3 groups according to T-wave morphology after primary PCI: no newly developed T-wave inversion, newly developed T-wave inversion but resolved within 6 months (recovered T-wave), and newly developed T-wave inversion and persistent over 6 months (persistent T-wave). Newly developed T-wave inversion was defined as new-onset T-wave inversion within 48 hours after primary PCI. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), comprising cardiac death, myocardial infarction, target vessel revascularization, stroke, and re-hospitalization for heart failure.

A total of 299 patients were analyzed and followed up for a mean of 25 months. Among them, 70, 158, and 71 had no newly developed T-wave inversion, recovered inversion, and persistent inversion, respectively. The cumulative MACCE rate was significantly lower in patients with recovered inversion than in those with no or persistent inversion (10.1% vs 21.4% vs 18.3%, respectively; P=0.04). In multivariate Cox regression analysis, the no T-wave inversion group (hazard ratio [HR], 2.05; 95% confidence interval [CI], 1.0 to 4.39; P=0.05) and the persistent T-wave inversion group (HR, 1.98; 95% CI, 0.93 to 4.18; P=0.07) were associated with more frequent MACCE.

Newly developed T-wave inversion that disappears within 6 months was associated with a favorable long-term outcome compared with no newly developed or persistent T-wave inversion. (Iranian Heart Journal 2022; 23(2): 26-33)

Management of severe functional tricuspid regurgitation (TR) at the time of pulmonary valve replacement in the setting of severe pulmonary regurgitation in adult congenital heart diseases has not been examined clearly.

Thirty-five patients with severe functional TR who were candidates for pulmonary valve replacement with congenital heart diseases were chosen. Baseline features and echocardiographic and clinical findings were compared between isolated pulmonary valve replacement, tricuspid valve repair, and pulmonary valve replacement groups.

In the tricuspid valve repair group, TR was significantly improved compared with the isolated pulmonary valve replacement group in the early postoperative (P<0.001), short-term (P=0.009), and mid-term (P=0.035) follow-up periods. Functional capacity was improved in the tricuspid valve repair group (P=0.009) compared with the isolated pulmonary valve replacement group.

Our study has introduced the concomitant tricuspid valve repair as a safe approach in patients with severe functional TR at the time of pulmonary valve replacement. It can efficiently reduce TR severity in mid-term follow-up and improve the long-term functional capacity. However, there were no significant effects on mortality during the follow-up period. (Iranian Heart Journal 2022; 23(2): 34-41)

The right ventricle (RV) is a major determinant of clinical outcomes in different cardiopulmonary disorders. Quantification of the RV with 2D echocardiography is challenging because of its complex asymmetrical geometry.1,2 Three-dimensional echocardiography is becoming more prevalent in children because of good acoustic windows and the noninvasive nature of the technique. Three-dimensional echocardiography allows the measurement of RV volumes, thereby overcoming the limitations of 2D echocardiography.3
A prospective observational cross-sectional study was performed on 450 normal Egyptian children randomly chosen including both sexes. The subjects were divided into 2 age groups. ECG-gated 2D and 3D transthoracic echocardiography was done to evaluate RV parameters.
The feasibility of 3D echocardiography was 96%. Mean indexed RVEDV was 40.5±5.4 mL/m2 in boys and 40.1±5.8 mL/m2 in girls, mean indexed RVESV was 18.8±3.7 mL/m2 in boys and 18.7±3.7 mL/m2 in girls, mean indexed stroke volume was 21.6±3.1 mL/m2 in boys and 21.3±3.6 mL/m2 in girls, and mean RVEF was 53.7±5.1% in boys and 53.5±5.4% in girls. A significant negative correlation existed between 3DE RVEF and ESV. A strong positive correlation was observed between mean 3DE RVESV and mean 3DE RVEDV. Further, 2DE and 3DE RVESV and EDV mean indexed and absolute values showed significant differences. Additionally, 2DE and 3DE FAC mean values showed positive significant correlations, and 3DE FAC and RVEF showed modest positive correlations.
Three-dimensional echocardiography provides RV volume quantification and functional assessment without any geometric assumptions. Reference values and percentile curves were established for RV parameters by 3DE for the first time in the Egyptian children population. (Iranian Heart Journal 2022; 23(2): 42-52)

Atrial fibrillation (AF) is the most common cardiac arrhythmia, with a significant rise in prevalence during recent decades. Considering its remarkable morbidity and mortality rates, AF has become a significant concern worldwide. To our knowledge, this is the first study to assess the prevalence of AF in Iran.
The current cross-sectional study is a part of the Isfahan Cohort Study (ICS), which has evaluated 6504 adults aged over 35 years and followed them up since 2001. An echocardiogram was taken from all the participants and interpreted by 2 skilled residents of cardiology. AF diagnosis was made based on the ICD-10-CM codes (I480-I484, I489), and its prevalence was determined.
Thirteen out of 6504 study participants (prevalence=0.19%) at a mean age of 61.8± 9.5 years were diagnosed with AF. AF was slightly predominant among males (53.8% vs 46.2%). Diabetes mellitus, ischemic heart disease, and peripheral vascular disease were present in 1 (7.7%), 2 (15.4%), and 1 (7.7%) cases with AF, respectively.
The remarkably low rate of AF in this study compared with other investigations may be due to the lower age of the assessed population, less alcohol consumption in Iranian society, and failure to find cases with paroxysmal and transient AF. (Iranian Heart Journal 2022; 23(2): 53-60)

Anemia is considered an independent predictor of death in patients with heart failure (HF). The main objective of this study was to determine the prevalence and patterns of anemia among patients with HF in Mogadishu, Somalia.
This is a retrospective assessment of patients with HF admitted to the cardiology outpatient and emergency departments of Mogadishu Somali Turkish Training and Research Hospital between January 2021 and March 2021.
The study population consisted of 200 patients at a mean age of 62.26 years (SD= ±14 y). Male was the predominant sex with 114 patients (57%). Fifty-nine patients (29.5%) had anemia. Iron-deficiency anemia was reported in 37 patients (18.5%), vitamin B12 deficiency anemia in 9 (4.5%), anemia of chronic disease in 9 (4.5%), folic acid deficiency anemia in 2 (1%), both iron deficiency and folic acid deficiency in 1 (0.5%), and a combination of iron, folic acid, and B12 deficiency in 1 (0.5%). The majority of the studied patients (n=141, 70.5%) were non-anemic. No association existed between anemia and age, sex, and HF type (P<0.776, P<0.605, and P<0.553, respectively).
The prevalence rate of anemia among patients with HF in Mogadishu was 29.5%. Anemia was more prevalent in the older population, and iron-deficiency anemia was the most common type of anemia. (Iranian Heart Journal 2022; 23(2): 61-67)

For several years now, primary percutaneous coronary intervention (PPCI) has been considered an effective treatment for ST-elevation myocardial infarction (STEMI). Efforts have been made to reduce the time interval between the patient’s admission to the hospital and PPCI. We evaluated the effect of the time interval between patients’ admission to the emergency department and PPCI on left ventricular ejection fraction (LVEF) in patients with STEMI.
The target population comprised patients who were admitted to the Emergency Department of Shahid Mohammadi Hospital with acute STEMI and scheduled for PPCI between 2017 and 2018. Eventually, 174 patients, who met the inclusion criteria, were investigated using a questionnaire, and the data were analyzed by SPSS20.
From the 174 patients diagnosed with acute STEMI, 72% were male and 28% were female. The mean age of the patients was 57.2 years (SD= ±13). A statistically significant linear relationship existed between symptom-to-balloon time and LVEF (P≤0.05), but no statistically significant linear relationship existed between the door-to-balloon time (DBT) and LVEF (P≤0.05).
Reducing symptom-to-balloon time in PPCI for patients with acute STEMI could preserve LVEF and improve prognosis. (Iranian Heart Journal 2022; 23(2): 68-74)

Acute coronary syndrome (ACS) caused by unstable plaque remains the leading cause of mortality and morbidity. The majority of acute coronary occlusion cases are attributed primarily to either plaque rupture or plaque erosion. This study aimed to investigate the effect of unstable plaque morphology on procedural outcomes among patients presenting with ACS.
This retrospective study enrolled 100 patients with ACS managed by optical coherence tomography (OCT)-guided percutaneous coronary intervention (PCI) in our tertiary center. The demographic and clinical characteristics, as well as angiographic and procedural data, of the study population were recorded. OCT was done before PCI and was repeated after PCI. The patients were thoroughly followed up for 180 days postprocedurally to detect 3 and 6 months’ adverse outcomes.
The study population consisted of 100 patients. Men comprised 87% of the studied patients (mean age=53.3 y). Sixty-six patients had ST-segment-elevation myocardial infarction (STEMI), and the left anterior descending was the culprit vessel in 70% of the cases. Plaque rupture was more frequently associated with STEMI presentation, younger age, and white occlusive thrombi. Post-intervention OCT showed a mean minimum stent area of 8 mm2 and a mean stent expansion of 93.2%. No significant difference was observed between plaque erosion and plaque rupture regarding edge dissection and tissue protrusion. The no-reflow phenomenon was encountered solely among patients with plaque rupture.
OCT is safe and feasible in the setting of ACS. Stent malapposition could be easily missed in angiography. Plaque rupture was associated with more adverse angiographic outcomes in terms of the no-reflow phenomenon. (Iranian Heart Journal 2022; 23(2): 75-86)

The frequency of organ transplantation is increasing, leading to increased stress in patients and families. Family performance assessment can express psychological and health consequences for children and their families and provide an opportunity for targeted interventions.
After necessary permits were obtained, the cases were randomly divided into experimental and control groups. Fifty parents of children who underwent heart transplantation participated in the research. Then, after the identification of the subjects in the experimental and control groups, the experimental group was subjected to the family-centered model. Following the completion of the training and 1 month later, anxiety and care-burden questionnaires were distributed to the experimental and control groups. Finally, the data obtained from the questionnaires were collected and analyzed.
Fifty individuals participated in this study. The results of the independent t test showed no significant difference concerning anxiety among parents before and after the intervention between the 2 study groups (P=0.217). Care burden was less in the intervention group than in the controls (P=0.039).
After training, anxiety and care burden in the intervention group improved compared with the control group. Information support of patients’ families will help them better adapt to stressful situations. Educating patients and their families can increase their information and reduce their anxiety. (Iranian Heart Journal 2022; 23(2): 87-95)

Acute coronary syndrome (ACS) is a rapidly growing concern, especially among younger urban communities. We aimed to study age-based differences in clinical and angiographic profiles and outcomes in an urban population.
This study recruited 2 independent, equal-sized cohorts of consecutive patients with ACS undergoing coronary angiography: younger and older cohorts (based on an age cutoff point of 35 years). Clinical and angiographic profiles were compared as primary endpoints, and in-hospital and 3-month major adverse cardiovascular events (MACE) were compared between the 2 cohorts as secondary endpoints.
Each cohort was composed of 103 patients. The younger cohort, compared with the older cohort, revealed higher overweight (69.9% vs 51.5%), positive family history (12.6% vs 4.9%; P=0.048),  use of gutka (smokeless tobacco) (56.3% vs 14.3%; P=0.017), smoking (41.7% vs 33%; P=0.195), total cholesterol (155.05±46.6 mg/dL vs 140.40±35.6 mg/dL; P=0.012), low-density lipoprotein cholesterol (96.74±41.23 mg/dL vs 84.14±27.25 mg/dL; P=0.010), normal/nonobstructive coronaries (15.5% vs 1.9%; P<0.001), single-vessel disease (60.2% vs 35.0%), type A lesions (36.8% vs 17.8%), left ventricular ejection fraction exceeding 40% (57.3% vs 42.7%; P=0.037), medical treatment only as the management strategy (16.5% vs 2.9%), in-hospital MACE (8.7% vs 12.6%; P=0.0367), and 3-month MACE (4.9% vs 12.6%; P=0.048), respectively.
Our younger subjects tended to have higher weight, gutka use, and positive family history than traditional risk factors with a greater frequency of single-vessel disease with type A lesions and normal or nonobstructive disease amenable to medical treatment only. (Iranian Heart Journal 2022; 23(2): 96-105)

Coronavirus disease 2019 (COVID-19) was declared as a pandemic by the World Health Organization (WHO) on March 11, 2020.  Apart from respiratory findings, cardiac involvement has been highlighted by some studies. COVID-19 is increasing rapidly among young adults. The present study was designed to evaluate left ventricular function using speckle-tracking echocardiography in young adult COVID-19 patients who underwent home recovery.
The study assessed 40 patients aged between 18 and 39 years who recovered at home from COVID-19 and 20 healthy control subjects. All the participants underwent evaluations of left and right ventricular function via the conventional and global longitudinal strain (GLS) technique measured by speckle-tracking echocardiography.
Heart rate was significantly higher in the post–COVID-19 group (P=0.024). The patients were assessed for a mean period of 38.8 days (standard deviation=10.9 d) after negative COVID-19 testing. In the post–COVID-19 group, 19 patients (47%) reported ongoing dyspnea: 13 had dyspnea during ordinary daily activities and 6 had dyspnea during less-than-ordinary daily activities. Nine patients (23%) had chest pain, 8 (20%) had palpitations, 22 (55%) had fatigue, and 4 (10%) had joint pain. The left ventricular GLS value for the post–COVID-19 group was significantly impaired compared with the control group (P=0.006).
Among our young adult patients, who had recovered from COVID-19 at home, left ventricular GLS was affected, which may indicate the subclinical impairment of left ventricular systolic function. (Iranian Heart Journal 2022; 23(2): 106-115)

Coexistence of an atrial septal defect (ASD) and acquired rheumatic mitral valve disease is uncommon. Transseptal puncture during percutaneous transvenous mitral commissurotomy (PTMC) can be technically difficult and challenging in patients with the pericardial or synthetic patch at the interatrial septum following ASD repair. We describe a middle-aged woman who had pericardial patch repair of ASD during childhood and now presented with severe, symptomatic rheumatic mitral stenosis. She had successful PTMC through a transseptal approach, following the puncture of the pericardial patch. The technical details about the transseptal approach following the surgical patch repair of the ASD are discussed in the article. (Iranian Heart Journal 2022; 23(2): 116-119)

Systemic AA amyloidosis is a rare infiltrative disease representing a complication of chronic inflammatory disorders. Cardiac involvement is extremely rare and is associated with a poor prognosis. Early recognition is imperative as appropriate measures and treatment of the underlying disease may prevent death from refractory heart failure and fatal arrhythmias.

A 53-year-old male patient with psoriatic arthritis presented with heart failure and nephrotic syndrome. Electrocardiography revealed a first-degree atrioventricular block, low-voltage QRS complexes, and a prolonged QT interval. Echocardiography revealed a hypertrophic left ventricle with normal systolic function and signs of diastolic dysfunction, as well as right ventricular dysfunction and mild pericardial effusion. An abdominal fat pad punch biopsy confirmed amyloidosis deposition. A 24-hour Holter study recorded self-terminated polymorphic ventricular arrhythmias. Immunosuppressive, anti-inflammatory, antiarrhythmic, and heart failure agents were promptly instituted, which proved ineffective.

Significant cardiac involvement in systemic AA amyloidosis is infrequent and complicated by fatal arrhythmias not described before. This report highlights the significance of the early recognition and aggressive control of the inflammatory response. (Iranian Heart Journal 2022; 23(2): 120-129)

A 38-year-old man presented to the emergency department with ongoing chest pain. The patient had a sudden onset of central, crushing chest pain for 7 hours, with severity increasing in the last 2 hours. The symptoms were associated with sweating. He was a known case of hypertension and was on medication for the preceding 2 years. The patient was also prediabetic. His mother had hypertension and diabetes mellitus. There was no history of hypertension, diabetes mellitus, or cardiovascular disease in his siblings. On general examination, the patient had an O2 saturation level of 95%, a pulse rate of 110 beats per minute, and a blood pressure of 110/90 mm Hg. On systemic examination, no abnormality was detected. Additionally, the complete blood count, renal function tests, blood sugar random test, and electrolytes were within normal limits. Electrocardiography demonstrated an ST elevation in the inferolateral leads. He also had a CPK-MB level of 82 IU/L and a troponin level of 11.6 IU/L. Echocardiography revealed a hypokinetic left ventricular inferior wall. With a diagnosis of acute inferolateral wall myocardial infarction (MI), the patient was taken to the catheterization laboratory, where coronary angiography revealed normal coronary arteries. He was admitted to the CCU and was treated with aspirin, clopidogrel, low-molecular-weight heparin, atorvastatin, beta-blockers, anxiolytics, proton-pump inhibitors, and stool softeners. On the following day, cardiac magnetic resonance revealed curvilinear, confluent, and patchy subendocardial enhancement in the inferoposterior wall of the left ventricle. The features were compatible with MI. He was conservatively managed and was discharged on the fifth post-MI day.

Vascular rings compress the trachea, the esophagus, or both, causing severe obstructive esophageal and airway symptoms. Its treatment is surgery. However, a second surgical intervention is required in patients with persistent symptoms after surgery. Sometimes, the reason for this may be that the initial surgery was insufficient. In the presented herein, we applied the extra-anatomic bypass and simultaneous ligamentum arteriosum division approach in a patient with a diagnosis of double aortic arch subjected to isolated arch division. (Iranian Heart Journal 2022; 23(2): 136-141)

Langerhans cell histiocytosis (LCH) is a rare disorder of the reticuloendothelial system with an unknown etiology. We herein present an LCH case with cardiac tamponade and the oral cavity involvement to raise awareness of the distinguishing features of this diagnostically challenging entity.

This study describes a 52-year-old man who presented with dyspnea (NYHA functional class II) and bilateral pedal edema of 4 days’ duration. A clinical examination revealed a large pericardial effusion with cardiac tamponade. A positron emission tomography-computed tomography scan showed a heterogeneously enhancing soft tissue lesion, 2.6×1.7×1.6 cm in size, in the right mid-submandibular region. An intraoral examination confirmed the right submandibular mass. The biopsy of the submandibular gland mass confirmed the diagnosis of LCH.

LCH is often diagnosed in childhood but may manifest in any age group, from infancy to adulthood. Pericardial effusion is a rare finding in this case of LCH. The rarity and the variable system involvement of LCH necessitate a multidisciplinary approach for accurate diagnosis and effective treatment. (Iranian Heart Journal 2022; 23(2): 142-149)

Cardiovascular diseases show high incidence and prevalence in Iran. However, participation in Cardiac Rehabilitation is limited and has been poorly investigated in the country. The aim of study was reasons for not following the cardiac rehabilitation programs by the patients in a Tehran city hospital.

It is a quantitative and qualitative research in which information was collected through interviews with three groups of patients-physicians. In order to collect information from the patients, the questionnaire presented by Gabria et al. (2012) (33) on the reasons for not referring to the rehabilitation ward was used. Data were collected through a Cardiac Rehabilitation Barriers Scale. The collected data were analyzed by SPSS (version 18) software.

The mean age of patients in this study was 41-60 years old. Over all, 25patiens (84%) were male and (16%) were female. The most common reasons for not following the cardiac rehabilitation programs were, “Cardiac rehabilitation center is so far from my home “and “high cost the rehabilitation services”.

This study showed that the reasons for not following the rehabilitation programs were different and two of the most important reasons were the far distance and the high cost sessions.; Therefore, it is necessary to emphasize and encourage cardiac rehabilitation by education to patient. (Iranian Heart Journal 2022; 23(2): 150-157)