Iranian Heart Journal
Volume:23 Issue: 4, Fall 2022

Partial anomalous pulmonary venous connection (PAPVC) is prevalently right-sided. The Warden procedure (WP) is performed for the repair of PAPVC when the anomalous right-sided pulmonary veins (PVs) connect to the superior vena cava (SVC) far from the SVC-right atrium (RA) junction. We aimed to describe the mid-term outcomes in the WP. Moreover, we compared the outcomes in double-SVC cases with those without left-sided superior vena cava (LSVC).
 
In this retrospective study, the medical records of 25 (52% female) patients who underwent the WP between 2009 and 2019 were evaluated. Baseline, perioperative, and follow-up data, including mortality, SVC and PV obstruction, the presence of single right-sided or double SVC, and sinoatrial (SA) node dysfunction, were recorded.
 
The mean (± SD) follow-up time was 5.08 years (±2.59 y). No mortality, SVC or PV obstruction, and SA node dysfunction were noted. SVC-RA anastomotic site mild stenosis occurred in 2 patients. Fourteen of the 25 patients (56%) had double SVC. Subgroup analysis of 2 groups of LSVC positive and LSVC negative revealed mild SVC anastomosis site stenosis in 1/14 (7%) of LSVC-positive and 1/11 (9%) of LSVC-negative patients (P=1.00). SVC anastomotic site patch augmentation was necessary in 3 of the 14 (21%) cases of the LSVC-positive group and none of the LSVC-negative patients (P=0.23).
 
The WP was associated with satisfactory outcomes. This method is excellent in patients who have concurrent LSVC. Coincident double SVC anatomy could be a new indication for performing the WP in relatively high PAPVC. (Iranian Heart Journal 2022; 23(4): 6-12)

Despite the recent experiences and technical advances in the repair of congenital ventricular septal defects (VSDs), there is still the possibility of postoperative complications and even death among patients undergoing treatment. This study aimed to determine and compare the short-term complications of congenital anomaly (VSDs) repair using the pericardial patch and GORE-TEX patch.
 

This cohort study evaluated 100 patients undergoing VSD repair surgery in 2 repair groups of the pericardial patch (50 patients) and the GORE-TEX patch (50 patients) in Rajaie Cardiovascular Medical and Research Center between 2019 and 2020. All the patients’ information was recorded in a checklist and analyzed using the SPSS software via the Mann–Whitney and χ2 tests.
 

There was a significant difference in the duration of aortic clamping between the pericardial patch and GORE-TEX patch groups (P=0.03). The rate of complications in the GORE-TEX patch group was significantly higher than that in the pericardial patch group (34% vs 14%; P=0.01). The cost of treatment was significantly higher in the GORE-TEX patch group than in the pericardial patch group (P=0.0001).
 

The lengths of surgery, cardiopulmonary bypass, and aortic clamping, as well as short-term complications and treatment costs, were lower in the pericardial patch group than in the GORE-TEX patch group. (Iranian Heart Journal 2022; 23(4): 13-19)

We sought to compare diastolic values in cardiac magnetic resonance imaging (CMR) compared with echocardiography in assessing left ventricular diastolic function in patients with thalassemia.
Left ventricular assessment by CMR is mainly limited to the evaluation of the systolic function of the heart and is widely used in clinical practice. On the other hand, the gold standard for diastolic function assessment is echocardiography. The role of CMR in diastolic function assessment is less well-established clinically, despite the importance of the early diagnosis of diastolic dysfunction, which precedes systolic dysfunction.
 
Forty-five subjects (mean age =27.8±10.9 y) who underwent CMR and echocardiography on the same day were evaluated. Diastolic function parameters using the technique of the transmitral flow (the E wave, the A wave, the E/A ratio, and the deceleration time) of the left ventricle were evaluated via both CMR and echocardiography.
 
The E/A ratio of the transmitral flow to assess diastolic parameters in CMR correlated well with echocardiography (r=0.745*, P<0.001), while the E and A values had weak correlations between the 2 modalities (r=0.301, P<0.05 and r=0.343, P<0.05). The measurement of the deceleration time in CMR had no statistically significant correlation with that of echocardiography (r=0.219, P=0.152). A weak correlation existed between the diastolic index measured using the technique of the fractional area change of the left ventricle and the E/A ratio measured in echocardiography (r=0.325, P<0.05).
 
CMR evaluation of diastolic function using the transmitral flow correlated well with echocardiography. (Iranian Heart Journal 2022; 23(4): 20-28)

The most common subgroup of premature ventricular contractions (PVCs) is the idiopathic outflow tract premature ventricular contraction (IOT-PVC). The radiofrequency catheter ablation of PVCs is the choice of treatment in drug-resistant or intolerant patients. There are many different ways to localize PVC origins, some of which pose a challenge. We hypothesized that changing limb electrode locations can help us localize IOT-PVCs.
 
This cross-sectional study was done in Rajaie Cardiovascular Medical and Research Center, Tehran, Iran, from 2019 through 2020. In all patients, in addition to surface electrography, 3 limb electrodes were placed at 3 spaces: right parasternal at the second intercostal space, left parasternal at the second intercostal space, and the tip of the left scapula. Three new vectors were achieved, which were then compared with the same-named limb vectors.
 
The study population consisted of 102 patients. The voltage of the R and S waves of PVCs were compared in modified and conventional leads. All the formulas used had a statistically significant relationship (P<0.007) with the origin of PVCs other than IMR/ICR and IMR-S/ICR-S.
 
Comparison of the R and S waves of PVCs in modified lead II and III with the same-named conventional leads can yield the best results to estimate the origin of PVCs. The most useful formulas concerning sensitivity and specificity are IIMR/IICR and IIIMR/IIICR. The absence of notching at modified lead II can be a predictor of successful PVC ablation. (Iranian Heart Journal 2022; 23(4): 29-37)

Anabolic-androgenic steroids (AASs) misuse for improving exercise ability and muscle mass in bodybuilders is ever-increasing and it is suggested to be responsible for destructive cardiovascular effects. In this study, we sought to assess all structural and functional aspects of left ventricular (LV) and right ventricular (RV) functions in male bodybuilding athletes who consume long-term AASs.
 
The present study was conducted in Kerman in 2016. Based on a cross-sectional study, 52 bodybuilders were selected and divided into 2 groups (26 cases in each group). As a control group, 20 healthy sedentary volunteers with the same age and body mass index (BMI) as the previous 2 groups were selected.
 
Except for LV end-systolic diameter, LV end-systolic volume, and A/E in the Doppler assessment, there were significant differences between all the parameters of LV structure and function, consisting of LV end-diastolic diameter, interventricular septal diameter, LV posterior wall diameter, LV end-diastolic volume, LV mass, LV mass index, deceleration time in mitral inflow Doppler evaluation, and tissue Doppler imaging (TDI) parameters between AAS users, nonusers, and control groups (all Ps<0.05). Additionally, RV size, fractional area change, tricuspid annular plane systolic excursion, and TDI evaluation of the lateral point of the tricuspid annulus as parameters of RV function were significantly different between the mentioned groups (all Ps<0.05).
 
Our study showed that multiple courses of AAS abuse by young male bodybuilders could lead to detrimental effects on LV and RV morphology and systolic and diastolic functions over time. Therefore, it is essential to raise awareness among young athletes regarding the chronic side effects of these compounds. (Iranian Heart Journal 2022; 23(4): 38-45)

Soluble ST2 (sST2) is a member of the interleukin-1 receptor family and is considered a novel biomarker of inflammation, fibrosis, and cardiac stress. Additionally, sST2 is accepted by guidelines as a measure of risk stratification in patients with heart failure.
 
Our study enrolled 53 subjects: 23 patients who were followed up for pulmonary arterial hypertension (PAH) and were prescribed different medications and 30 healthy children admitted to the pediatric cardiology outpatient clinic with chest pain or innocent murmurs as the control group. The plasma concentration of NT-proBNP was analyzed via the electrochemiluminescence method, and the sST2 level was analyzed via the ELISA method.
 
The mean age was 13.9 years (5.5–18 y) in the case group and 9.6 years (3–17 y) in the control group. The mean NT-proBNP level was significantly higher in the patient group than in the control group (763.73±2432.67 pg/mL vs 51.71± 30.08 pg/mL; P<0.01). The mean sST2 level was 1469.26±510.9 pg/mL in the patient group and 1151.30±655.99 pg/mL in the control group (P>0.05).
 
Our results suggest that sST2 could be a significant indicator of right heart failure and cardiovascular mortality in children, as well as a novel biomarker of PAH. However, we found that the serum sST2 level was not as useful as the serum NT-proBNP level in this regard. Further studies with larger patient series are needed to evaluate sST2 as a biomarker in patients with PAH. (Iranian Heart Journal 2022; 23(4): 46-51)

Substance use disorders (SUDs) constitute a serious medical problem. Information is scarce regarding the connection between SUDs and cardiovascular complications. We sought to examine the types of SUDs and their relationships with complications in patients with cardiovascular diseases.  The present descriptive cross-sectional study evaluated 406 adult cardiovascular patients with 1 of the different types of SUDs according to eligibility criteria. Required data were extracted, recorded, and analyzed using the SPSS software, version 16.  The mean and standard deviation of the age of the participants was 59.7±11.92 years. Ninety percent of the participants used opium. Substance use had a significant relationship with age range, marital status, education level, and income (P<0.05). Opium use was more frequent in patients with hypertension than other illegal substances (73.8% vs 57.1%; P=0.035).  Opium was the most frequent substance used by patients with cardiovascular disease. Moreover, our participants had little knowledge about the cardiovascular risks and complications related to SUDs. Therefore, stringent measures are recommended to prevent illegal substance use and raise public awareness in the country. (Iranian Heart Journal 2022; 23(4): 52-59)

Cardiac involvement due to iron deposition in β-thalassemia major remains the main cause of mortality. We assessed the effects of cardiac iron overload on the incidence of arrhythmias in β-thalassemia major.

The present cross-sectional study enrolled patients with β-thalassemia major referred to a tertiary cardiovascular care center in Tehran, Iran, between January 2019 and January 2020. The patients’ characteristics were collected using hospital records. Cardiac iron overload status was assessed using cardiac T2* magnetic resonance (severe ≤10 ms, moderate =10–20 ms, and mild =20 ms).

The present study recruited 81 β-thalassemia major cases with a mean age (SD) of 30.69 (11.12) years. Mild, moderate, and severe iron overload statuses were reported in 44.4%, 22.2%, and 33.3% of the stud population, respectively. Of 44 patients (54.3%) with arrhythmias, supraventricular tachyarrhythmias were seen in 24.7%, ventricular tachycardias in 19.8%, and atrioventricular blocks in 9.9%. A significant association was reported between iron overload status and the presence of arrhythmias (P<0.001). There was a significant association between iron overload and dilated atria (P=0.004). The left ventricular ejection fraction (LVEF) was not associated with cardiac iron status, but it was associated with the presence of arrhythmias (P<0.001). Desferal therapy was considerably associated with cardiac iron status (P=0.04).

According to iron chelation therapy, patients with more severe iron overload had a higher incidence rate of arrhythmias. Additionally, patients with lower LVEF values had a higher incidence rate of arrhythmias. There was no statistically significant association between LVEF and cardiac iron overload status. (Iranian Heart Journal 2022; 23(4): 60-68)

Well-timed primary percutaneous coronary intervention (PCI) is known to improve survival, limit infarct size, and improve left ventricular ejection fraction (LVEF) in patients with ST-elevation myocardial infarction (STEMI). Nonetheless, many patients do not recover their LV contractile function after primary PCI and eventually progress to heart failure. This study aimed to assess the predictors of improvement in LVEF after successful primary PCI among patients presenting with STEMI within 12 hours of symptom onset.
 
Our single-center, prospective, observational study enrolled 246 consecutive STEMI patients presenting within 12 hours of symptom onset. All the patients underwent echocardiography at presentation and at a 3-month follow-up. Multivariate analysis was used to identify the predictors of improvement in LVEF in the course of the convalescent phase.
 
Data of 239 patients were analyzed for the study. The mean age of the patients was 54.2±11.3 years, and 90% of the patients were male. Diabetes and hypertension were prevalent at 44.8% and 38.9%. The average total ischemic and door-to-balloon time was 260 (175–440) and 60 (40–65) minutes, respectively. LVEF showed improvement in more than half of the patients (57.7%) at 3 months’ follow-up. The binomial regression analysis of various variables, predicting LVEF improvement at 3 months, showed that the most significant predictor of LVEF improvement was a shorter total ischemic time (P<0.001; OR, 1.01; 95% CI, 1.00 to 1.01), followed by LVEF of 40% or higher at presentation (P<0.02; OR,1.01; 95% CI, 0.95 to 1.01).
 
In patients with STEMI, the total ischemic time and LV systolic function at presentation can help predict EF recovery after successful primary PCI. Patients at risk can be treated with aggressive medical management. (Iranian Heart Journal 2022; 23(4): 69-79)

The transcatheter device closure of secundum type atrial septal defects (ASDs) has now become the first-line strategy in patients with suitable anatomies. Device closure has remarkable effects on the hemodynamics and function of the heart. Precise diagnosis of these changes is significant in determining patients’ outcomes and prognoses. In the current study, we evaluated volumetric, functional, strain, and strain rate changes in the cardiac chambers following successful device closure.
 
The present prospective cohort study was conducted on 45 patients eligible for ASD device closure. The patients were evaluated for volumetric, functional, Doppler, strain, and strain rate data regarding the left and right atria and ventricles preprocedurally and 48 hours postprocedurally.
 
Significant changes were found in the left ventricular (LV) end-diastolic volume index (P=0.03), the right ventricular (RV) diameter (P≤0.001), the left atrial (LA) volume index (P=0.05), the right atrial (RA) volume index (P=0.001), and the right and left-sided E/e’ ratio (P=0.001 and P=0.004, respectively). Our findings also showed significant reductions in the strain values of all 3 phases of the RA and the LA and the RV free wall after ASD device closure. The LV global longitudinal strain decreased after the procedure but did not reach statistical significance.
 
The LA, RA and RV strain values showed significant reductions after device closure. The decline in LA function following closure was greater in those with larger ASDs. In adult patients undergoing the procedure, abnormal LA function is a clinically relevant issue demanding pre and postprocedural precautions and treatments. (Iranian Heart Journal 2022; 23(4): 80-87)

Both preeclampsia and coronary artery calcification (CAC) are associated with an increased cardiovascular risk. As CAC is race and ethnicity-dependent, we test it in a sample of Iraqi population. We compared the presence of CAC in a cohort of middle-aged women with and without previous preeclampsia.
 
This retrospective cohort study on middle-aged Iraqi women used logistic regression models to compare 100 women with and 100 women without a history of preeclampsia. Other cardiovascular risk factors were assessed as potential covariates. Between September 2020 and January 2022, the women underwent a multidetector computed tomography for the assessment of the presence of CAC.
 
CAC was found in 22% of patients with previous preeclampsia compared with 11% in those without previous preeclampsia. Body mass index, systolic and diastolic blood pressures, lipid indices, glucose levels, and hypertension were significantly related to previous preeclampsia. Age, waist circumference, diastolic blood pressure, glucose levels, hypertension, and diabetes were significantly associated with the presence of CAC. Women with previous preeclampsia had a 128% greater risk of CAC than women without this condition (OR, 2.28; 95% CI, 1.04 to 5). Age adjustments had no discernible effect on the relationship (OR, 2.39; 95% CI, 1.07 to 5.31).
 
Women with previous preeclampsia were more likely to have CAC than women with normotensive pregnancies in their middle age even after adjustments for age. Cardiovascular screening may be beneficial for women with a history of preeclampsia. (Iranian Heart Journal 2022; 23(4): 88-96)

Several studies have shown that during ischemia, repolarization indices such as QTC are prolonged. We describe a typical case with left main disease and prolonged QTC recovering to the normal range after angioplasty. (Iranian Heart Journal 2022; 23(4): 97-101)

The COVID-19 pandemic, together with its complications and management, has been a significant issue worldwide since March 2020. Concomitant infections in vulnerable patients with preexisting cardiovascular diseases are not uncommon. Sharing information about the diagnostic management and treatment of these comorbidities has a prominent role in unveiling some of this pandemic’s challenges. We herein describe a young adult with a history of implantable cardioverter-defibrillator implantation diagnosed with COVID-19 infection and infective endocarditis. (Iranian Heart Journal 2022; 23(4): 102-108)

Pericardial cysts are a scarce cause of mediastinal masses. They are usually asymptomatic, even in large sizes. Accurate diagnosis of pericardial cysts is possible with multiple diagnostic imaging modalities. A 41-year-old woman complaining of bilateral lower limb edema, exertional dyspnea, and recurrent palpitations was admitted to our emergency department. She had experienced a syncope state. Echocardiography showed a reduced right-side heart function due to a large cystic-like mass at the supradiaphragmatic right paracardiac region with a compressive effect on the right heart. A computed tomography scan confirmed the presence of a giant pericardial cyst. The patient underwent cardiac surgery to excise the mass, 15×13.5×3.5 cm in size. This case report shows that huge right-sided pericardial cysts must be considered in the differential diagnosis of right-sided heart failure. The preferable and reasonable approach to a patient with a huge pericardial cyst is surgical excision for symptom alleviation, early identification, and removal. (Iranian Heart Journal 2022; 23(4): 109-114)

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)

Cardiac hemangiomas are quite rare. They present with vascular lesions that are usually benign and detectable by echocardiography, computerized tomography scan, and cardiac magnetic resonance imaging. We present a rare case of hemangioma in the right atrium. A 48-year-old woman presented to the emergency department with sinus bradycardia and syncope. After workup, the final diagnosis was cardiac mass. According to pathology findings, hemangioma was diagnosed. (Iranian Heart Journal 2022; 23(4): 120-124)

Unilateral absence of the pulmonary artery (UAPA) is a rare congenital cardiovascular anomaly with a wide array of symptoms. An 18-year-old man was referred to our hospital with dyspnea on exertion and central cyanosis. Transthoracic and transesophageal echocardiographic examinations revealed severe right ventricular enlargement, large main and left pulmonary arteries, severe pulmonary hypertension, and a large patent ductus arteriosus (PDA). The right pulmonary artery could not be seen; consequently, UAPA was considered. Computed tomography angiography confirmed the diagnosis. Our case is a rare condition with UAPA associated with patent ductus arteriosus, diagnosed in adulthood. It underscores the need for awareness of this anomaly for early diagnosis and treatment. (Iranian Heart Journal 2022; 23(4): 125-130)

Bundle branch reentrant tachycardia (BBRT) is an uncommon ventricular tachycardia (VT) and is presented with a long His-ventricular (H-V) interval as a reentry between the bundle branches. This arrhythmia is frequently seen in patients with a significant conduction system disorder. QRS morphology during VT is usually the left bundle branch block (LBBB) type and may be similar to that in sinus rhythm. While BBRT usually has LBBB-like morphology, in rare cases it can be seen with the right bundle branch block (RBBB) form. Most patients have prolonged H-V intervals during sinus rhythm, consistent with His–Purkinje disease; however, some patients may have normal H-V intervals. The ablation of RBBB can cure it, but up to 30% of patients may need pacemaker implantation after ablation. BBRT is responsible for about 6% of induced VTs during the electrophysiology study. We herein present an uncommon form of BBRT (the RBBB type) in a patient who had hypertrophic cardiomyopathy with a normal left ventricular function. (Iranian Heart Journal 2022; 23(4): 131-134)

Endovascular interventions are being increasingly used around the world. They are accepted as the primary approach to aortoiliac occlusive disease in most cases. Mainly, balloon-expandable stents are utilized to treat lesions, and some patients may develop complications. Stents may thrombose or migrate due to the force of the bloodstream or their inappropriate dimensions. Sometimes, the operator is to blame. We herein describe a 67-year-old patient with a history of multiple endovascular interventions presenting to the emergency department with right foot pain. The patient underwent repeated angiography and endovascular intervention. In the last approach, diagnostic angiography revealed a crushed and migrated balloon-expandable stent in the abdominal aorta. The stent was removed surgically, and aorta-femoral bypass grafting was performed. Endovascular maneuvers could lead to these complications; hence, the operator should exercise caution when working on previously implanted stents. Optimal stent expansion and awareness of this very uncommon complication are essential. (Iranian Heart Journal 2022; 23(4): 135-140)