Iranian Heart Journal
Volume:15 Issue: 3, Fall 2014

We compared QT dispersion alterations between the two methods of thrombolytic therapy and primary percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction (STEMI). Methods and In this cohort, STEMI in patients who underwent thrombolytic therapy (n=63) and those who underwent primary PCI (n=63) was assessed and QT dispersion was recorded at admission and after two days for a comparison of the total reduction. The mean QT dispersion reduction was 0.0092 and 0.0049 in the thrombolytic therapy and PCI groups, respectively, showing a significant difference (P = 0.001). The mean change in QT dispersion in women was significantly higher than that in men (P = 0.01). Patients with anterior MI had a significantly longer QT dispersion (P = 0.02). There was a significant linear reverse association between QT dispersion and ejection fraction (P < 0.05). In our STEMI patients, QT dispersion after PCI and thrombolytic therapy was significantly decreased. The reduction was more significant in PCI, demonstrating the higher efficacy of PCI for reperfusion. (Iranian Heart Journal 2014; 15(3): 6-11)

Atrial tachyarrhythmias, especially in association with thromboembolism, may have catastrophic consequences in paroxysmal supraventricular tachycardia (PSVT). This study was performed to evaluate the prevalence of tachyarrhythmias in patients seen for PSVT. One hundred patients were selected randomly from patients undergoing PSVT ablation with no inducible second arrhythmias during electrophysiological study (EPS). Patients with hypertrophic cardiomyopathy were excluded. Age, sex, coronary artery disease, valvular heart disease, systemic hypertension, left ventricular ejection fraction (LVEF), and patient symptoms before EPS were noted. Among 1743 patients who had undergone successful PSVT ablation, 105 patients with induced tachyarrhythmias during EPS (mean age = 41.5 ± 15.27, 52 [49.5%] males) were enrolled. The overall induction of tachyarrhythmia was 6%. The patient's symptoms before EPS were in 70.5% paroxysmal palpitation (P = 0.46) and in less than 1% syncope (P 0.08) in comparison with the controls; 75% palpitation and 5% syncope, respectively. Induced tachyarrhythmias in 55 (52.4%) patients were atrial tachyarrhythmia, in 23 (21.9%) atrial flutter, and in 3 (2.9%) atrioventricular nodal re-entrant tachycardia (AVNRT). The mean age in the patients with AVNRT and those with arrhythmias was 24.66 ± 5.77 and 47.57±9, respectively (P=0.008). Isuprel induction method was associated with more frequent atrial tachycardia (67.6% vs. 44.4% of total induced tachyarrhythmias [P=0.03]) (P>0.05). Atrial tachycardia was more frequent in the females (66% vs. 38.5% of total induced tachyarrhythmias, P=0.005), and atrial fibrillation was induced more frequently in the males (11.5% vs. 1.9%, P=0.04). LV dysfunction was accompanied with more frequent premature ventricular contraction induction (P=0.04). Also, 5.2% of the total induced tachyarrhythmias were in the patients with LVEF ≥ 50%, most of whom (33.3%) had EF<35%. Totally, 3 (69.1%) cases of all the induced atrial tachycardia were ablated and 17 (30.9%) were followed up, but the method of induction did not affect the asymptomatic patients on twomonth follow-up (P=0.97) in the ablated tachyarrhythmias and in the followed up tachyarrhythmias (P=0.46). The prevalence of AF in our population was only 5%, which is almost similar to that in previous studies. Atrial tachyarrhythmias are frequently induced in patients undergoing PSVT ablation. As routine ablation is time-consuming and costly, results carry risks to the patients and without effect on the patient’s symptoms during follow-up. It would be more beneficial to follow up tachyarrhythmias than perform early ablation.

This study was a retrospective assessment at Rajaie Cardiovascular, Medical and Research Center, Tehran, Iran, between April 2005 and March 2011, comparing the immediate and late results of initial percutaneous mitral balloon valvuloplasty (PMBV) with repeat PMBV. Totally, 204 patients (mean age= 46±11 years, 85% women) (Group A) who had undergone MBV as an initial procedure were compared with 162 patients (mean age= 43±10 years, 94% women) (Group B) who had undergone repeat MBV due to symptomatic mitral restenosis following previous balloon commissurotomy. The mean follow-up was 47 ± 19 months. The Inoue technique was used in all the patients. Patients in Group B were younger (43.8±10.7 vs. 46.08±11.8 years; P 0.05) and had higher MES (9.09 ± 0.89 vs. 8.54 ± 1; P<0.001) with more subvalvular thickening (2.40 ± 0.49 vs. 2.21±0.44; P<0.001), indicating unfavorable valve anatomy being more pronounced in this group. The immediate outcome regarding hemodynamic results (≥50% decrease of mean transmitral gradient) was satisfactory in both Group A (98%) and Group B (96.3%) (P=0.310). However, the immediate outcome with regard to postprocedural MVA (≥40% increase in preprocedural MVA and mitral regurgitation ≤2/4) was suboptimal in both groups compared to previous studies, especially in Group B which was significantly inferior to Group A (55.6% vs. 76.5%; P=0.001). This difference was still observed when patients with favorable valve morphology (MES≤8) in both groups were compared (56.8% vs. 81.2%; P =0.003). The following are proposed as reasons for the unsatisfactory final MVAs in both groups, especially Group B: 1) greater extent of valve pathology, including leaflet and/or sub-valvular rigidity as the mechanism of restenosis instead of commissural fusion; 2) effect of “commissural calcification grade” on final MVA in mitral valves with an echo score of ≤8; 3) increase in MVA improving leaflet mobility only within limits; 4) not having calculated MVA via Gorlin’s Formula alongside planimetry (which would have been more accurate, especially in those with a history of commissurotomy); 5) occasional inadequacy of the conventional balloon sizing method based on height; and 6) diversity of MBV operators and echocardiography fellows, with different levels of experience. No baseline variables were found to be the independent predictors of the immediate outcome of PMBV. There were no in-hospital deaths, and the incidence in periprocedural and postprocedural complications was low in both groups with insignificant difference. Late clinical outcome (FC<3), although significantly better in Group A (95.1% vs. 88.9%; P=0.027), was favorable in both groups. Loss of valve area, compared with postprocedural MVA, was greater in Group B than in Group A, but the difference was not significant (0.16±0.21 vs. 0.11 ± 0.19 cm2; P=0.1). Late echocardiographic outcome (≤50% decrease of the initial increase in MVA by valvuloplasty) was relatively satisfactory in Group A (77.9%) and just acceptable in Group B (67.3%). Restenosis (a loss of > 50% of the original increase in MVA) was significantly less frequent in Group A (22.1% vs. 32.7%; P=0.022). Logistic regression analysis identified preprocedural mitral echo score (P =0.004), postprocedural mitral valve area (P =0.003), and age (P =0.003) as the independent predictors of restenosis. The patients having undergone re intervention (repeat MBV or MVR) were significantly more in Group B (36.4% vs. 18.6%; P=0.001); however, an acceptable proportion of the patients in this group showed no significant symptomatic deterioration. This study supports repeat PMBV as a feasible procedure in patients with symptomatic restenosis after a first balloon commissurotomy, which can be performed with low risk and can produce acceptable immediate results, mainly a significant decrease in the mean transmitral gradient. It can provide favorable functional improvement and acceptable freedom from restenosis on follow-up in patients with low echo scores and satisfactory postprocedural MVAs and, thus, defer operation (MVR). Considering that repeat MBV is low risk, it can be suggested as a palliative procedure in patients with high risk for surgery.

Malignant melanomas have a heart metastasis rate of 50-71%, which seems to be the highest among other malignancies. When a patient presents with cardiac metastases of a melanoma, the disease has already spread through the body and is, therefore, hardly curable. This brief review tries to introduce this important condition and discuss its frequency, presentation, diagnosis, histologic findings, and treatments.

The aim of this study was to assess the impact of integrated nutritional counseling in the setting of comprehensive cardiac rehabilitation on the cardiovascular risk factor profile of patients with the metabolic syndrome and underlying heart disease. Totally, 42 patients who fulfilled the criteria for the diagnosis of the metabolic syndrome and accomplished a standard and comprehensive cardiac rehabilitation program over a 3- month period were evaluated prospectively for improvements in dietary habits and baseline cardiovascular risk factors. At the end of the comprehensive rehabilitation program, there was a significant improvement in the consumption of vegetables and low-fat white meat and avoidance of high-fat and fast foods. Mean triglyceride, fasting blood sugar, and waist circumference fell significantly after 36 sessions of rehabilitation protocol. Systolic blood pressure dropped by a nonsignificant 3 mmHg, but diastolic levels showed a statistically significant reduction from 80±8.4 to 77±4.4 mmHg. Focused lifestyle counseling offered during cardiac rehabilitation programs provides a valuable opportunity for risk reduction, especially in high-risk groups affected by the metabolic syndrome, and could become a practical and readily available target in primary and secondary prevention agendas.

Endovascular intervention is an interesting alternative to conventional open surgical repair for a penetrated peripheral artery that has suitable anatomic criteria for percutaneous device treatment. Carotid and subclavian artery injury, especially at the base of the artery in proximity to the aortic arch, is a challenging anatomic position for surgical exposure. This is a situation where the use of endovascular intervention seems to be a good option. Endovascular treatment decreases the time of surgery, estimated bleeding, and iatrogenic complications, especially peripheral nerve injury, when compared with similar surgical modalities by limiting surgical dissection in the traumatized operative field. We describe a young man with a traumatic stab wound injury to the junction of the left subclavian artery and the carotid artery that was successfully managed with a converted stent.

Heparin induced thrombocytopenia (HIT)is a complication of heparin which happens less frequently in low molecular weight heparin. In HIT cases, parenteral direct thrombin inhibitors are used in place of heparin. Dabigatran is an oral direct thrombin inhibitor approved for prevention of stroke in nonvalvular atrial fibrillation. We use Dabigatran in place of heparin in two cases of venous thromboemloism and heparin induced thrombocytopemia. In conclusion, we suggest that Dabigatran may be used in cases of heparin induced thrombocytopenia in place of heparin.