Iranian Heart Journal
Volume:24 Issue: 4, Autumn 2023

Radiofrequency catheter ablation (RFCA) is an effective and successful approach to the treatment of symptomatic, idiopathic premature ventricular contractions (PVCs); however, some patients experience the delayed disappearance of the arrhythmia.
 
The current prospective cohort study was conducted on 28 patients who suffered from idiopathic PVCs whose RFCA was primarily unsuccessful and who were followed up on for 6 months. Forty-six patients were examined, and 18 of them were lost to follow-up. Characteristics, including age, sex, arrhythmic foci, and left ventricular ejection fraction (LVEF) at the end of RFCA, were recorded. Additionally, 24-hour cardiac Holter monitoring was performed for the patients within 6 months after the intervention.
 
Fifteen patients (53.57%) did not respond to the treatment, while among the others, PVCs ceased within 3 and 6 months after the intervention in 11 (84.61%) and 2 (15.39%). Most PVCs originated from the LV summit (35.71%), followed by the septal part of the right ventricle (RV) (21.42%), the right ventricular outflow tract (RVOT) (14.28%), and the LVOT (7.14%). The success rate assessment revealed the best outcomes in patients with PVCs originating from the septal part of the RV (83.3%) and the RVOT (75%). There were insignificant associations between the age, sex, and the mean LVEF of patients with unsuccessful ablation therapy.
 
Ventricular arrhythmias with left-sided origins had a worse response to RFCA considering unresponsiveness or delayed arrhythmia elimination. We found no association between the age, sex, and LVEF of the patients who never experienced successful arrhythmia cessation compared with those with delayed idiopathic PVC cessation. (Iranian Heart Journal 2023; 24(4): 6-13)

Even when epicardial blood flow is restored, achieving adequate perfusion to the microvascular level is the goal. The generous utilization of antithrombotics may facilitate bleeding. We aimed to compare the efficacy in preventing no-reflow between ticagrelor and traditional loading with clopidogrel in diabetic patients presenting with ST-segment-elevation myocardial infarction (STEMI) and to assess the safety of ticagrelor administration regarding the short-term bleeding risk.
 
The present single-center prospective randomized trial consecutively randomized 300 diabetic patients admitted to the emergency department with STEMI into 2 groups: ticagrelor and clopidogrel. All the patients underwent primary percutaneous coronary intervention (PCI), during which the thrombolysis in myocardial infarction (TIMI) flow grade and the myocardial blush grade (MBG) were recorded. We followed up on the patients for 3 months to detect short-term major adverse cardiovascular events (MACE) and bleeding events.
 
The mean age of the studied population was 56 years, with a male predominance (70%). The median pain-to-door time was 8 hours. The no-reflow phenomenon was encountered more frequently in the clopidogrel group than in the ticagrelor group (37.3% vs 14%). Higher TIMI flow grades and MBGs were achieved in the ticagrelor group, and the difference was statistically significant. No significant differences, however, existed between the groups concerning MACE, stent thrombosis, and mortality. More bleeding episodes were recorded in the ticagrelor group but with no statistical significance.
 
Ticagrelor should be the first choice among P2Y12 inhibitors in the setting of primary PCI, especially in diabetic patients, due to its high efficacy and safety profile, even in elderly patients. (Iranian Heart Journal 2023; 24(4): 14-25)

Cellular damage is inevitable during cardiac surgery due to cardioplegic solutions and subsequent ischemia-reperfusion injury. There are controversies regarding the cardioprotective impact of adenosine addition to cardioplegic solutions in patients undergoing coronary artery bypass graft surgery (CABG). We aimed to assess the impact of adding adenosine to antegrade cardioplegia and before aortic declamping to the aortic root on the clinical outcomes of patients undergoing CABG.
 
The present single-blinded randomized clinical trial was performed on 99 patients of both sexes undergoing isolated CABG. The patients were randomly allocated to 2 trial groups and 1 control group: Group A, adenosine injection with antegrade cardioplegia (n=30); Group B, adenosine injection before aortic declamping by the surgeon at the aortic root (n=26); and Group C, control (n=30). In the course of the study, 13 participants lost their eligibility according to exclusion criteria. The patients’ plasma creatine kinase (CK-MB), troponin T, lactate, and clinical outcomes were measured as trial outcomes.
 
The frequency of patients with antiarrhythmic drug usage was significantly lower in trial groups A and B than in the control group (P = 0.001). The cardiac rhythm resumption time was significantly longer in the control group (344.37 ± 260.45) than in Group A (193.43 ± 297.73) and Group B (170.12 ± 103.58) (P = 0.02). Adenosine injection before aortic declamping (Group B) had the lowest time of cardiac rhythm resumption between the trial groups.
 
Our findings showed that adenosine injection enhanced the efficacy of cardioplegic arrest and myocardial protection during CABG. (Iranian Heart Journal 2023; 24(4): 26-33)

Chronic ischemic heart disease is the primary cause of acute and chronic heart failure. Cardiac failure due to exacerbated coronary heart disease occurs in 1 of every 4 cases. Variable degrees of heart failure are present in two-thirds of coronary patients who undergo conventional percutaneous coronary intervention (PCI). In an attempt to lower the occurrence of acute kidney injury and contrast-induced nephropathy, the current study aimed to evaluate the effects of PCI using the new dynamic coronary roadmap (DCR) system on the contrast medium volume.
 
This observational study enrolled 80 patients undergoing PCI for chronic coronary syndromes. Patients were assigned to 2 equal groups. Group I consisted of patients who underwent the DCR technique (the DCR group), and Group II was composed of patients who underwent the normal PCI technique without DCR (the normal group). The patients had detailed history taking, comprehensive clinical examinations, the DCR system, and PCI.
 
Group II demonstrated significantly higher contrast medium volume (179  ± 62 vs 37 ± 11 mL; P < 0.001), fluoroscopy time (12 ± 3 vs 6 ± 2 min; P < 0.001), air kerma (744 ± 85 vs 285 ± 60 mGy; P < 0.001), and dose area product (47 ± 5 vs 36 ± 7 Gy/cm2). In contrast, Group I had a significantly higher estimated glomerular filtration rate post-PCI (P = 0.015).
 
Contrast volume and fluoroscopy time can be reduced by using DCR during PCI. (Iranian Heart Journal 2023; 24(4): 34-41)

Suppression of tumorigenicity 2 (ST2) is a biomarker of myocardial fibrosis and remodeling proven to predict outcomes in patients with acute decompensated heart failure (ADHF), especially when measured serially. We aimed to evaluate right ventricular (RV) dynamic changes in ADHF patients using serum soluble ST2 (sST2) and speckle-tracking echocardiography imaging (STE).
 
We enrolled 61 ADHF patients with left ventricular ejection fractions below 50% and serum NT-proBNP levels exceeding 900 pg/mL. Serum sST2 levels were measured on hospital admission and discharge. The patients underwent serial conventional and STE examinations on admission, at 48 hours, and on discharge. RV STE analysis was done using 2D cardiac performance analysis.
 
Serum sST2 had a significant positive correlation with serum NT-proBNP on admission (r = 0.84, P < 0.0001) and showed a significant reduction from 2.47 (1.27–4.05) ng/mL on admission to 1.86 (1.06–3.24) ng/mL at discharge (P < 0.0001), denoting successful decongestion. Significant decreases were observed in the inferior vena cava diameter (P < 0.0001) and the estimated pulmonary artery systolic pressure (P = 0.002); however, the changes were not associated with a significant change in RV dimensions (P > 0.05) or contractility assessed by trans-annular plane systolic excursion (P = 0.09) and tricuspid S-wave velocity (P = 0.9). There was a significant improvement in RV free wall strain (RVFWS) (P = 0.005) assessed by STE, primarily noticed after the first 48 hours until discharge, but the RV 4-chamber strain did not change significantly (P = 0.06).
 
RVFWS assessed by STE can detect improvements in RV systolic function not detected by conventional echocardiographic parameters in ADHF patients. Together with declines in serum sST2 levels, it can be used as a marker of improved cardiac mechanics and successful decongestion. (Iranian Heart Journal 2023; 24(4): 42-53)

Acute coronary syndrome (ACS) is one of the main causes of mortality worldwide, and dyslipidemia is one of its important risk factors. Studies have shown that treatment with high-intensity statins protects against cardiovascular events; other investigations have noted that despite the potential effects of statins, 80% of patients with ACS fail to lower cholesterol levels. We conducted the present study to determine the association between medical compliance to clinical practice guidelines (CPG) and changes in low-density lipoprotein cholesterol (LDL-C) at follow-up among patients with ACS.
 
We performed a prospective cohort study on patients diagnosed with ACS. We enrolled 79 adult patients from August 2019 through March 2020. Data on patient characteristics at presentation, hospitalization, and 8 months of follow-up were collected. Adherence was established as a high-intensity statin prescription at discharge according to Peruvian, European Society of Cardiology (ESC) 2019, and American Heart Association (AHA) 2018 guidelines.
 
Adherence to AHA and ESC guidelines showed a reduction in mean LDL-C values of 44.2 mg/dL (P = 0.14). In patients with dyslipidemia, mean LDL-C values were reduced by 60.6 mg/dL (P < 0.001). Only 27.8% of the patients did not achieve any goal in their LDL-C levels following the AHA or ESC guideline recommendations.
 
Due to the high prevalence of dyslipidemia, adequate primary prevention before an acute event occurs is essential. Compliance with CPG by healthcare personnel is related to a reduction in LDL-C levels at follow-up, and patient adherence is essential to achieve LDL-C targets. (Iranian Heart Journal 2023; 24(4): 54-62)

Heart disease manifestation due to plaque disruption in the coronary arteries is acute coronary syndrome (ACS). Apolipoprotein-E (Apo-E) is a multifunctional protein with central roles in lipid transportation and metabolism. We analyzed the correlation between the Apo-E blood concentration and recurrent ACS.
 
This cross-sectional study recruited 90 patients who visited the outpatient cardiology clinic at Airlangga University Hospital. The patients were divided into 3 groups: without ACS, single ACS, and recurrent ACS. The Apo-E blood concentration was measured using the enzyme-linked immunosorbent assay in the Tropical Disease Center of the Airlangga University Laboratory.
 
The median Apo-E concentration was 3.6 (1.32-14.9) µg/mL in the recurrent ACS group, 4.01 (2.61-18.54) µg/mL in the single ACS group, and 3.95 (1.19-43.51) µg/mL in the group without ACS. The Kruskal-Wallis test showed no differences in Apo-E between the groups. The χ2 test demonstrated no correlation concerning Apo-E between the single ACS and recurrent ACS groups. The Fisher exact analysis showed no correlation between the Apo-E concentration and dyslipidemia.
 
Our results showed no correlation between the Apo-E concentration and recurrent ACS. (Iranian Heart Journal 2023; 24(4): 63-69)

Percutaneous transmitral commissurotomy (PTMC) for treating severe mitral valve stenosis with the Inoue balloon is an interventional procedure performed worldwide. Percutaneous transvenous mitral commissurotomy is the preferred treatment for rheumatic valvular mitral stenosis if the valve has a suitable anatomy. Following trans-septal puncture, entry into the left ventricle is challenging, particularly in patients with large atria. We herein describe a 61-year-old woman with mitral stenosis. Having failed to cross the mitral valve with the standard technique, we utilized a novel over-the-curved spring wire simultaneously with the reverse-loop entry technique to cross the mitral valve. We succeeded in performing a valvotomy with no complications. PTMC, still the preferred treatment for isolated mitral stenosis, consists of 2 steps: trans-septal puncture and balloon crossing into the left ventricle. Nonetheless, an altered left atrial and septal anatomy can make the latter step challenging. High operator experience and various maneuvers and techniques can increase the procedural success rate, even in difficult cases. (Iranian Heart Journal 2023; 24(4): 76-78)

Atrioventricular (AV) block is a rare but severe complication of the catheter ablation of cardiac arrhythmias. It usually occurs during ablation in the right atrium close to the His bundle and the peri-AV nodal area or the left ventricle in the septal basal area. AV block occurring during the deployment of radiofrequency (RF) energy in the left atrium is much rarer and has only exceptionally been described. We present the case of a subacute transient first-degree AV block occurring late (24 h) after the catheter ablation of a symptomatic incessant focal atrial tachycardia originating from the left atrium. Spontaneous resolution of the AV block with the recovery of normal AV conduction was observed 7 days after the procedure. This case report highlights the fact that care must be exercised while performing RF ablation on the left atrial septum since AV block can occur during the ablation of areas close to the AV node. (Iranian Heart Journal 2023; 24(4): 79-84)

Arterial tortuosity syndrome (ATS) is a rare, autosomal, and recessive disorder. The genetic defect in this disease is caused by loss-of-function mutations in the SLC2A10 gene, which encodes facilitative glucose GLUT 10. ATS is characterized by the widespread elongation and tortuosity of the aorta and the mid-sized arteries and focal stenosis in segments of the pulmonary arteries and/or the aorta combined with findings of a generalized connective tissue disorder. About 12% of all affected individuals are admitted to the neonatal intensive care unit because of primary presentation with infant respiratory distress syndrome. Most affected patients are identified in early childhood with cardiac murmurs or cyanosis. Here, we describe a 6-year-old boy with repeat hospitalizations due to respiratory symptoms and a history of unilateral hernioplasty. Physical examinations showed an increased range of motion in the joints and a decreased lower limb pulse, raising the suspicion of aortic coarctation. Frontal chest radiography, echocardiography, and computed tomography angiography demonstrated elongation and tortuosity in most of the patient’s arteries and veins. (Iranian Heart Journal 2023; 24(4): 85-89)

Arterial tortuosity syndrome (ATS) is a rare, autosomal, and recessive disorder. The genetic defect in this disease is caused by loss-of-function mutations in the SLC2A10 gene, which encodes facilitative glucose GLUT 10. ATS is characterized by the widespread elongation and tortuosity of the aorta and the mid-sized arteries and focal stenosis in segments of the pulmonary arteries and/or the aorta combined with findings of a generalized connective tissue disorder. About 12% of all affected individuals are admitted to the neonatal intensive care unit because of primary presentation with infant respiratory distress syndrome. Most affected patients are identified in early childhood with cardiac murmurs or cyanosis. Here, we describe a 6-year-old boy with repeat hospitalizations due to respiratory symptoms and a history of unilateral hernioplasty. Physical examinations showed an increased range of motion in the joints and a decreased lower limb pulse, raising the suspicion of aortic coarctation. Frontal chest radiography, echocardiography, and computed tomography angiography demonstrated elongation and tortuosity in most of the patient’s arteries and veins. (Iranian Heart Journal 2023; 24(4): 85-89)