Iranian Heart Journal
Volume:25 Issue: 1, Winter 2024

Clinically, heart failure due to cardiac ischemia or myocardial infarction is associated with different reflex responses, including bradycardia, hypotension, and the urge to urinate or defecate. Stimulation of the cardiac nociceptors of the left ventricle initiates cardiogenic reflexes, such as the mass rectal contraction, which may be responsible for defecation urge. We aimed to study the afferent and efferent pathways responsible for this cardiogenic rectal response.
 
Experiments were performed on artificially ventilated anesthetized cats of either sex. Myocardial ischemia was induced by occluding the main left anterior descending coronary artery (LAD), and rectal movement was recorded. The effects of LAD occlusion on intact and sectioned left inferior cardiac sympathetic, cardiac vagus, gastric vagus, splanchnic, inferior mesenteric ganglion, and pelvic nerves on the rectal response were studied.
 
LAD occlusion induced a biphasic rectal response, which was abolished after sectioning the left inferior cardiac sympathetic nerve but not by cardiac vagotomy. The same response was also abolished by pelvic nerve sectioning. Moreover, the relaxation and contractile phase was abolished by nitric oxide and cholinergic inhibitors.
 
The defecatory urge associated with cardiac ischemia was due to the reflexogenic contraction of the rectal muscle. The afferent and efferent pathways for this reflex were the cardiac sympathetic nerve and the pelvic nerve, respectively. Additionally, nitric oxide and cholinergic pathways were associated with this reflex (Iranian Heart Journal 2024; 25(1): 6-18)

Multiple investigations have reported cardiac involvement in the early and late phases of COVID-19 infection. It is associated with notable morbidity and mortality. Early detection of cardiac involvement may render timely intervention, reducing residual myocardial injuries. We evaluated cardiac magnetic resonance imaging (MRI)-derived functional and inflammatory findings 3 to 6 months after acute COVID-19 infection in a healthy population recovered from the disease and compared them with normal controls.
 
Twenty cases with a definite history of respiratory COVID-19 infection, in the preceding 3 to 6 months and 28 age- and sex-matched healthy subjects were assessed. The non-contrast cardiac MRI findings of the 2 groups were compared. Moreover, pulmonary parenchymal involvement in the acute phase and its correlation with cardiac MRI findings were evaluated. Data analysis was performed with SPSS, version 22, and a P value of less than 0.05 was considered significant.
 
Twenty subjects (mean ± SD of age = 35.30 ± 5.27 y; 55% female) with a definite history of COVID-19 infection and 28 healthy controls (mean ± SD of age = 31.07 ± 4.35 y; 50% female) were included. Biventricular ejection fraction, biventricular global longitudinal strain, right ventricular global circumferential strain, and right ventricular global radial strain were significantly different between the 2 groups. Six patients (30%) in the COVID-19 group exhibited regional myocardial edema. No significant linear correlations existed between the severity of pulmonary involvement and cardiac MRI parameters.
 
In the midterm follow-up of healthy patients after COVID-19 infection, a significant reduction was observed in myocardial strain and function, independent of the severity of lung disease. (Iranian Heart Journal 2024; 25(1): 19-26)

Nonischemic functional mitral regurgitation (FMR) is accompanied by dire long-term consequences. The treatment revolves around correcting the underlying left ventricular dysfunction. This study reports the long-term adverse outcomes of nonischemic FMR.

We enrolled 200 patients with at-least-moderate nonischemic FMR undergoing medical treatment and/or cardiac resynchronization therapy between 2003 and 2019. MR severity and left ventricular dysfunction parameters were obtained. The endpoint outcomes were all-cause mortality, stroke, all-cause rehospitalization, and the need for heart transplantation. 

Two hundred participants, 104 men (52%) and 96 women (48%), with a median age of 61 years (interquartile range [IQR], 50-70) at diagnosis and a median follow-up of 2 years (IQR, 1-4), were enrolled. All-cause mortality, all-cause rehospitalization, and need for heart transplantation were significantly associated with lower left ventricular ejection fraction and tricuspid annular plane systolic excursion (TAPSE) at diagnosis (P < 0.05). Baseline MR severity was significantly associated with stroke (P = 0.026) and all-cause rehospitalization (P < 0.001).MR severity, New York Heart Association (NYHA) classification, left ventricular end-diastolic diameter, and TAPSE improved at follow-up (P < 0.001). ACEi/ARB (P = 0.008), nitrate (P = 0.001), and hydralazine (P = 0.006) were associated with MR severity improvement. A significant difference was observed between survival free of all-cause mortality according to left ventricular ejection fraction (P = 0.041).

We reported freedom from all-cause mortality, cardiac mortality, and composite endpoints (all-cause mortality, heart transplantation, and stroke) in nonischemic FMR patients. We detected a significant decline in MR severity and NYHA classification during follow-up. Overall, the FMR-associated mortality risk can be significantly reduced by adhering to treatment guidelines in a tertiary heart center. (Iranian Heart Journal 2024; 25(1): 27-41)

The duration of antiplatelet therapy in patients with lower extremity artery disease (LEAD) has not been well established. This study aimed to evaluate the clinical outcome according to the duration of dual-antiplatelet therapy (DAPT).
 
From April 2009 through June 2019, 376 patients with LEAD underwent successful endovascular revascularization. After the procedure, the received single-antiplatelet therapy (SAPT) or DAPT of various durations were classified into 2 groups (SAPT or DAPT < 6 months vs DAPT ≥ 6 months). The primary outcomes were major adverse cardiovascular events (MACE) and major adverse limb events (MALE). The safety outcome was moderate-to-severe bleeding according to the Global Use of Strategies to Open Occluded Arteries (GUSTO) criteria.
 
Over the 40-month follow-up period, MACE occurred less frequently in the DAPT ≥ 6-month group than in the SAPT or DAPT < 6-month group (12.4% vs 23.8%; hazard ratio [HR], 0.56; 95% confidence interval [CI], 0.35 to 0.89; P = 0.014) after inverse probability-weighted adjustment and propensity-score matching analysis (HR, 0.55, 95% CI, 0.30 to 0.99, P = 0.048). MALE showed no significant differences between the 2 groups (DAPT ≥ 6-month group: 17.1% vs SAPT or DAPT < 6-month group: 13.1%; HR, 1.05; 95% CI, 0.62 to 1.78; P = 0.846). A significant difference between the DAPT ≥ 6-month group and the SAPT or DAPT < 6-month group was not observed regarding the incidence of moderate-to-severe GUSTO bleeding.
 
In patients with LEAD, DAPT for ≥ 6 months after endovascular revascularization was associated with a lower incidence of MACE. (Iranian Heart Journal 2024; 25(1): 42-55)

Transradial coronary catheterization has already become popular in clinical practice. Radial artery occlusion (RAO) is an infrequent but discouraging complication of transradial access. Anterograde flow in the artery during hemostasis (patent hemostasis) may prevent arterial occlusion. This study aimed to compare conventional vs patent hemostasis after transradial coronary angiography regarding access site complications, especially RAO.
 
A prospective randomized, parallel, open-label clinical trial was conducted on consecutively adult patients scheduled to undergo a diagnostic or therapeutic transradial coronary procedure at Bu-Ali Sina and Mehregan hospitals (Qazvin, Iran) during a 3-month period between March 2021 and May 2021. Two hundred patients were divided randomly into conventional hemostasis and patent hemostasis groups. The incidence of RAO at discharge was evaluated in both groups as the primary endpoint, and other access site complications were considered the secondary endpoints.
 
The mean age of the patients was 61.60 ± 10.45 (range = 34-86) years, and the sex distribution (male/female) of the patients was 119/76. The baseline characteristics were similar in the 2 study groups. RAO at discharge was significantly less frequent in the patent hemostasis group (2 patients [2.02%]) than in the conventional hemostasis group (9 patients [9.37%]) (P = 0.02). Furthermore, demographic, clinical, and procedural variables were not associated with RAO.
 
Our study clearly demonstrated that patent hemostasis was highly effective in reducing RAO after transradial coronary catheterization. (Iranian Heart Journal 2024; 25(1): 56-65)

We assessed the relationship between postoperative cognitive impairment and cerebral oximetry (INVOS) and mixed venous oxygen saturation (SvO2) during cardiopulmonary bypass (CPB).
 
This observational cohort study enrolled 110 patients and divided them into 2 groups of 55 subjects. After the exclusion of 5 patients in the SvO2 group and 3 in the INVOS group, the final analysis was conducted on 50 and 52 patients in the former and latter groups, respectively. The Mini-Mental State ‎Examination (MMSE) score was used to assess cognitive impairment in the patients on the second and third postoperative days. SPSS software, version 24, was used for statistical analysis. ‎
 
On the second postoperative day, the frequency of cognitive dysfunction was 4% in the SvO2 group and 3.8% in the INVOS group ‎‎ (P = 0.73). Three days after surgery, the incidence of cognitive ‎dysfunction in the SvO2 and INVOS groups was 2% and 1.9% (P = 0.49), respectively. No statistically significant difference was observed between the 2 groups concerning the incidence of cognitive dysfunction after surgery with CPB.
 
Our results indicated that cerebral tissue perfusion monitoring by INVOS could be replaced with the SvO2 approach ‏without increasing the incidence of cognitive dysfunction ‏compared with INVOS in adult cardiac surgery using CPB. (Iranian Heart Journal 2024; 25(1): 66-73)

The COVID-19 pandemic has rapidly expanded telemedicine in healthcare. We designed and implemented a telemedicine program at Rajaie Cardiovascular Medical and Research Institute.
 
This sequential mixed-methods study was conducted at Rajaie Cardiovascular Medical and Research Institute from April through December 2021 in 3 stages: 1) Findings obtained from a literature review were discussed in expert panel sessions, and a telemedicine program was designed. 2) based on a quasi-experimental method, patients were non-randomly assigned to the experimental and control groups, with the former receiving the telemedicine program for 3 months. 3) The groups were compared concerning the number of hospitalizations, the length of hospital stay, and emergency department visits 3 months after the implementation of the program. Data analysis was performed using SPSS, version 24. The χ2 test was used for qualitative data analysis, and the t and paired samples t tests were employed for quantitative data analysis. ‎
 
The results showed no statistically significant differences between the experimental and control groups regarding the number of hospitalizations, the length of hospital stay, and the number of emergency visits after the implementation of the telemedicine program (P > 0.05).
 
The number of hospitalizations, the number of emergency visits, and the length of hospital stay did not significantly differ between the experimental and control groups after the telemedicine program. (Iranian Heart Journal 2024; 25(1): 74-81)

Data indicate the predictive role of abnormal right ventricular (RV) strain values in postoperative outcomes after coronary artery bypass grafting (CABG). Hence, we aimed to investigate the impact of RV strain assessment by 2D speckle-tracking echocardiography in predicting post-CABG complications.
 

This study analyzed 149 consecutive low-risk patients with preserved left ventricular (LV) and normal RV function concerning echo parameters, including LV ejection fraction and right ventricular free wall longitudinal strain (RVFWLS), undergoing isolated CABG. RVFWLS was assessed with 2D speckle-tracking echocardiography before surgery. Abnormal RVFWLS was defined as absolute RVFWLS < 19%. The adjusted effects of absolute RVFWLS strain and abnormal RVFWLS on the risk of ICU complications were assessed.
 

Of 149 patients, 90 (60.4%) had abnormal preoperative RVFWLS (−16.5 ± 1.98). There were no significant associations between abnormal RVFWLS and postoperative serum creatinine rise, atrial fibrillation, ventilation time, inotrope use, cumulative dose, on-pump CABG, cardiopulmonary bypass duration, and length of ICU stay (all Ps > 0.05). Postoperative ICU complications were not correlated with absolute RV strain values, except for ventilation time, which had a statistically significant but clinically negligible association with absolute RV strain values (regression coefficient = 1.035; P = 0.016). Since ventilation time is short (< 2 min), despite the positive statistical correlation, it had no clinical value.
 

RV strain measurements by 2D speckle-tracking echocardiography added no benefits to the prediction of ICU complications in low-risk patients undergoing CABG who had preserved or mildly impaired systolic LV function. (Iranian Heart Journal 2024; 25(1): 82-92)

Rare congenital abnormalities known as “coronary artery abnormalities (CAAs)” have various pathophysiological causes and clinical manifestations. We describe a 50-year-old man who complained of recurrent shortness of breath. The patient had a 3-day history of the condition, which worsened with exertion. A coronary angiography, followed by a coronary computed tomography angiography, showed that the ostium of the left main coronary artery (LMCA) originated from the proximal right coronary artery. Our elderly patient with an uncommon CAA also had significant aortic stenosis. Coronary angiography and coronary computed tomography angiography are crucial procedures in these patients to confirm the diagnosis and choose the appropriate course of action. Despite its debatable effectiveness, coronary artery bypass grafting may be an option for young patients suffering from CAAs with interarterial courses, such as the left major coronary artery originating from the right coronary artery. (Iranian Heart Journal 2024; 25(1): 93-97)

Tetralogy of Fallot (TOF) is one of the most common congenital heart diseases. Family recurrence provides strong evidence for the involvement of a genetic component in the susceptibility to TOF. The role of genetic factors is supported by the increased risk of first-degree relatives of patients with TOF. The clinical course of this disease is unclear and unpredictable. We herein describe 2 siblings suffering from TOF with left ventricular noncompaction cardiomyopathy (LVNC) and their clinical course and treatment. LVNC is a rare disease known by prominent trabeculation of the ventricles and reduced systolic function. LVNC can manifest itself in a wide spectrum of symptoms overlapping with other cardiac diagnoses. Familial patterns of disease development and coexistence of cardiac abnormalities are also reported. (Iranian Heart Journal 2024; 25(1): 98-105)

Infective endocarditis (IE) involving both the aortic and pulmonary valves is uncommon. A young man presented to our department with fatigue, chest pain, and intermittent fevers. His echocardiogram showed multiple large vegetation pieces in the aortic and pulmonary valves, a perimembranous ventricular septal defect (VSD) with a left-to-right shunt, and a double-chamber right ventricle (DCRV). After 3 weeks of antibiotic therapy, surgery was indicated since there was no change in the vegetation size and high risk of embolism. Postoperative echocardiography showed post-repair DCRV with insignificant residual obstruction in mid-RV, no residual VSD shunt, and no residual vegetation. Multiple valvular involvement in IE is rare and is associated with a more complicated clinical course and a higher risk of complications. In this case, perimembranous VSD is a known predisposing factor for IE in the aortic valve, while DCRV is associated with IE development in the pulmonary valve. This case report also emphasizes the importance of early diagnosis, timely antibiotic treatment, and surgery in complicated cases. (Iranian Heart Journal 2024; 25(1): 106-111)

Marfan syndrome is an autosomal dominant genetic disorder owing to insufficient fibrillin-1 that involves connective tissue, with an incidence rate of approximately 2–3/10000 in most populations. Almost 25% of cases are caused by new mutations and are sporadic. Marfan syndrome leads to not only skeletal and ocular complications (eg, ectopia lentis and retinal detachment) but also cardiac complications, which are the most significant. Critical cardiovascular complications that can occur include mitral valve prolapse, mitral regurgitation, aortic regurgitation, aortic aneurysms, dilation of the sinus of Valsalva, aortic dissection, and rupture. The diagnosis of Marfan syndrome is based on the Ghent nosology. Since cardiac manifestations are life-threatening, they need to be diagnosed and treated promptly. The treatment of cardiac complications comprises surgical and pharmacological therapy. Here, we introduce an asymptomatic case of Marfan syndrome with blurred vision and severe cardiac manifestations discovered during cardiac assessments before eye surgery. (Iranian Heart Journal 2024; 25(1): 112-117)