The Egyptian heart journal : (EHJ) : official bulletin of the Egyptian Society of Cardiology最新文献

Background: This case report is significant due to its illustration of how infectious endocarditis on a prosthetic mitral valve revealed an underlying metastatic colorectal cancer. Although uncommon, associations between cardiac infection and advanced malignancy, particularly with malignancy serving as the source of infection, have been documented in the literature, making this case clinically significant and complex.

Case presentation: A 54-year-old postmenopausal woman with insulin-dependent diabetes and poorly managed hypertension, who had previously undergone mitral valve replacement with a mechanical prosthesis and tricuspid valve repair for rheumatic mitral stenosis, was admitted for atrial fibrillation with rapid ventricular response. On admission, she presented with normochromic normocytic anaemia (7.7 g/dL), elevated inflammatory markers (CRP 250 mg/L), and leukocytosis (14,000/µL, neutrophils 10,000/µL). Transthoracic and transesophageal echocardiography identified vegetation on the mitral prosthesis with elevated gradients. Blood cultures were positive for Escherichia coli. A thoraco-abdominopelvic CT scan revealed a rectal tumor, confirmed by FDG-PET, with features consistent with metastatic colorectal cancer, considered the entry point for the infectious endocarditis. Tumor markers including ACE, CA 19 - 9, and CA 72 - 4 were elevated. The patient was treated with dual antibiotic therapy and showed initial clinical improvement but later died due to ventricular tachycardia.

Conclusions: This case highlights the importance of considering atypical sources, such as metastatic cancer, in unresolved cases of endocarditis. It underscores the need for comprehensive diagnostic assessment, including oncologic evaluation, in patients with prosthetic valve endocarditis caused by atypical pathogens like E. coli. It also stresses the importance of multidisciplinary collaboration between cardiology and oncology teams. This case report is significant due to its illustration of how infectious endocarditis on a prosthetic mitral valve revealed an underlying metastatic colorectal cancer (CRC).

Background: Complex cardiac arrest cases may require concurrent veno-arterial extracorporeal membrane oxygenation (VA-ECMO), left-ventricular unloading using Impella, and urgent percutaneous coronary intervention (PCI), vascular access sometimes becomes a procedural bottleneck. Conventional single-access Impella-PCI via a 14 Fr peel-away sheath expedites workflow but increases femoral bleeding risk; conversely, the lower-bleeding 16 Fr Medikit sheath used in Japan typically precludes true single-access PCI. We report a rescue strategy employing a coaxial 16 Fr/14 Fr peel-away/6 Fr sheath configuration to achieve single-access Impella-supported PCI when radial access was unobtainable. A 53-year-old man in refractory ventricular fibrillation received VA-ECMO via right femoral cannulation; coronary angiography through the left femoral artery revealed subtotal proximal right-coronary-artery occlusion. Radial access was unobtainable. An Impella CP was implanted through a 14 Fr peel-away sheath coaxially inserted into a 16 Fr Medikit sheath placed in the left common femoral artery. A 6 Fr sheath was advanced through the same peel-away sheath, permitting single-access PCI and successful stent deployment. After revascularization the 6 Fr and 14 Fr sheaths were removed, leaving the Impella supported by the 16 Fr sheath without bleeding complications.

Conclusion: A coaxial 16 Fr/14 Fr/6 Fr femoral strategy enables safe single-access Impella-supported PCI, combining procedural efficiency with a lower bleeding risk when radial routes are not feasible.

Background: The burden of premature atherosclerotic cardiovascular disease (ASCVD) in Egypt remains disproportionately high, and current international dyslipidemia guidelines have proven insufficient in achieving target lipid levels in the local population. This underscores the necessity for a context-specific national guideline. The 2025 Egyptian Guidelines for the Management of Dyslipidemia were developed through a structured consensus process led by an expert panel of cardiologists, endocrinologists, and representatives from national medical societies.

Main text: The methodology included two rounds of blind voting followed by a consensus meeting to ensure rigorous evaluation. The guidelines emphasize the importance of early detection of dyslipidemia through systematic screening programs and prioritize lifestyle interventions as the cornerstone of management. A novel "extreme-risk" category was introduced to identify patients requiring intensified lipid-lowering strategies, including early initiation of combination pharmacotherapy. Additionally, the recommendations highlight the critical role of ongoing monitoring and follow-up to sustain long-term lipid control and reduce cardiovascular risk.

Conclusion: The current guidelines provide a simplified, yet evidence-based framework tailored to the Egyptian population, aiming to optimize dyslipidemia management, reduce ASCVD-related complications, and improve overall cardiovascular outcomes.

Background: This cross-sectional study with limited prospective cohort follow-up aimed to determine the prevalence of Brugada-type ECG patterns (BTEPs) among asymptomatic Upper Egyptians using standard and high precordial leads, and to assess the short-term arrhythmic outcomes of positive cases.

Methods: A total of 318 participants without arrhythmic symptoms were enrolled between June 2022 and June 2023. Standard 12-lead and high precordial ECGs (V1-V2 at 2nd intercostal space) were recorded. BTEPs were identified based on β-angle ≥ 58°, base length ≥ 1.5 mm at isoelectric line, and base width ≥ 4 mm at 0.5 mV. Positive cases underwent clinical follow up, echocardiography and Holter monitoring every 6 months for 12 months. Data was analyzed using McNemar's test for paired proportions and logistic regression for confounder adjustment.

Results: Two cases (0.63%; 95%CI: 0.17-2.26%) exhibited BTEPs on standard ECGs versus eight (2.52%; 95% CI:1.28-4.88%) on high precordial ECGs (p = 0.041). All positive cases were males. During follow-up, arrhythmias were documented in 7/8 cases (87.5%), including supraventricular tachycardia (n = 4), non-sustained VT (n = 1), and Mobitz I AV block (n = 1). No patient had family history of sudden cardiac death. The observed prevalence and arrhythmic rates were consistent with prior international data.

Conclusion: Routine use of High precordial leads ECG in upper Egyptians showed comparable benefit of detecting Brugada patterns as reported globally. In addition to type I, the follow up of originally asymptomatic type II and III Brugada patterns may show variable arrhythmic presentations. However, due to small sample size and short-term follow-up, results should be considered preliminary pending larger confirmatory studies. Trial Registration Our study has been registered as a clinical trial, clinicalTrial.gov ID: NCT05116488 at 10th November 2021.

Background: In-stent restenosis (ISR) remains a clinical challenge in the drug-eluting stent (DES) era. Neoatherosclerosis is a recognized mechanism, but tissue responses after drug-coated balloon (DCB) therapy may present with atypical morphologies.

Case presentation: We report a 55-year-old man with recurrent angina and ISR nine years after DES implantation and one year after DCB angioplasty. Optical coherence tomography (OCT) revealed a distinctive striped, low-attenuation plaque protruding into the lumen from outside the stent struts. This lesion lacked lipid, calcification, or macrophages, making it difficult to classify as typical neoatherosclerosis. The morphology suggested layered neointimal remodeling with possible thrombus organization after DCB treatment. The lesion was successfully treated with excimer laser coronary angioplasty, scoring balloon dilatation, and DCB angioplasty.

Conclusion: This case illustrates an atypical OCT morphology observed in recurrent ISR after DCB angioplasty. Recognition of such atypical ISR morphologies may enhance understanding of neointimal healing after DCB treatment and guide interventional strategies.

Background: Only a limited number of studies have reported on TOF with absent pulmonary valve (APV). Similarly, while cases of TOF with absent pulmonary artery (PA) have been documented, case reports describing TOF with both APV and absent PA are extremely rare.

Case presentation: The present study investiged the case of a 1-year-old girl born at term with no initial clinical or physical signs of cyanosis. A subtle additional heart murmur detected during routine examination prompted referral to a cardiologist. Subsequent echocardiography and computed tomography (CT) angiography confirmed TOF with APV and absence of the left pulmonary artery (LPA). The patient later underwent corrective surgery, including pulmonary valve reconstruction and pulmonary artery plication.

Conclusion: Although TOF is a common cyanotic congenital heart disease, certain variants of TOF, such as TOF with APV and absent LPA, may present without the typical cyanotic or respiratory symptoms. Therefore, even the slightest additional heart murmur should be thoroughly investigated. While clinical examination, arterial oxygenation, and echocardiography are essential, definitive diagnosis and precise anatomical characterization ultimately require CT angiography.

Background: Cardiac amyloidosis is an underrecognized etiology of heart failure with preserved ejection fraction (HFpEF), particularly in elderly patients. Light-chain (AL) amyloidosis, when associated with multiple myeloma, is highly aggressive and portends a poor prognosis, especially in advanced cardiac stages.

Case presentation: We report the case of a 79-year-old male with type 2 diabetes, hypertension, and a history of pacemaker implantation for complete atrioventricular block in the context of atrial fibrillation. He was admitted with progressive exertional dyspnea and an episode of syncope. Clinical examination revealed fine basal crackles and signs of decompensated heart failure. ECG demonstrated a paced rhythm. Echocardiography and cardiac MRI revealed concentric left ventricular hypertrophy with a sparkling myocardial texture, biatrial dilation, restrictive filling pattern, and diffuse subendocardial late gadolinium enhancement-features highly suggestive of cardiac amyloidosis. Laboratory tests revealed anemia, nephrotic syndrome, elevated troponin and NT-proBNP, and a monoclonal IgG lambda spike. Renal biopsy demonstrated amyloid deposits with Congo red positivity and light-chain (lambda) restriction, confirming the diagnosis of AL amyloidosis. Bone marrow biopsy confirmed the diagnosis of multiple myeloma with plasma cell infiltration. Based on clinical and laboratory findings, the patient was classified as Mayo stage IIIB AL cardiac amyloidosis and ISS stage I multiple myeloma. He received bortezomib-cyclophosphamide-based chemotherapy and supportive care, but unfortunately died five months after diagnosis.

Discussion: This case highlights the importance of early recognition of cardiac amyloidosis in elderly patients with unexplained heart failure and monoclonal gammopathy. Echocardiography plays a pivotal role in early disease suspicion, particularly in resource-limited settings, while cardiac MRI serves as a complementary tool for assessing myocardial involvement. Despite advances in treatment, outcomes remain poor in advanced cardiac involvement. Early intervention may improve prognosis, underscoring the need for heightened clinical awareness.

Conclusion: Infiltrative cardiomyopathies like AL amyloidosis should be considered in elderly patients with heart failure and systemic red flags. Timely diagnosis and multidisciplinary management are essential but often insufficient in advanced stages.

Background: Transcatheter aortic valve replacement (TAVR) is a minimally invasive procedure with associated risks that are influenced by the choice of secondary vascular access used. The impact of transradial secondary access (TRSA) compared to transfemoral secondary access (TFSA) on adverse events remains uncertain. Therefore, we conducted an updated meta-analysis to compare procedural complications between TRSA and TFSA in TAVR.

Methods: We systematically searched PubMed, Scopus, and the Cochrane Library for studies comparing TRSA and TFSA in patients undergoing TAVR. The primary endpoints were 30-day rates of each of the following: access-related bleeding, access-related vascular complications, stroke/transient ischemic attack (TIA), myocardial infarction (MI), acute kidney injury (AKI stage III or higher), and all-cause mortality. Leave-one-out sensitivity analyses and subgroup analyses stratified by primary access route were performed to assess the consistency of the findings.

Results: Seven studies with 6327 patients were included, comprising of six observational studies and one randomized controlled trial TRSA was associated with significantly lower odds of mortality (OR 0.55, 95% CI [0.39, 0.78], p = 0.0007), stroke/TIA (OR 0.58, 95% CI [0.39, 0.87], p = 0.009), major/life-threatening bleeding (OR 0.50, 95% CI [0.30, 0.83], p = 0.008), and major vascular complications (OR 0.59, 95% CI [0.41, 0.85], p = 0.004). Additionally, we stratified outcomes for patients undergoing transfemoral primary access (TFPA) to determine whether the primary access route influences results. The transradial group demonstrated significantly lower odds of 30-day all-cause mortality (OR 0.49, 95% CI [0.28, 0.87], p = 0.01), and 30-day minor bleeding (OR 0.48, 95% CI [0.27, 0.86], p = 0.01).

Conclusions: Key limitations included predominance of non-randomized studies and high heterogeneity in some outcomes. In patients undergoing TAVR, TRSA is associated with significantly lower complications compared to TFSA, suggesting it may be a superior alternative.

Background: Hypertension (HTN) remains a major global health problem, and inadequate blood pressure (BP) control contributes substantially to cardiovascular risk. The endothelial activation and stress index (EASIX), derived from routine laboratory parameters, has been proposed as a marker of vascular stress. Existing studies in hypertensive populations relied on office BP measurements and included patients with multiple comorbidities. This study evaluated the association between EASIX and 24-h ambulatory BP monitoring (ABPM) in a homogeneous cohort with isolated primary HTN.

Methods: This retrospective cross-sectional study included 192 adults aged 18-70 years diagnosed with HTN and undergoing 24-h ABPM. Patients were categorized into controlled and uncontrolled BP groups according to 24-h, daytime, and nighttime ABPM thresholds defined by the 2024 European Society of Cardiology guideline. The EASIX score was calculated as [lactate dehydrogenase × creatinine]/platelets and log₂-transformed for analysis. Group comparisons, correlation analyses, multivariable logistic regression, and ROC analyses were performed.

Results: The EASIX score was significantly higher in the uncontrolled BP group than in the controlled BP group. Logistic regression identified ascending aortic diameter, serum sodium, serum albumin, and log₂ (EASIX) as independent factors associated with BP control status. EASIX demonstrated good discriminative performance in identifying hypertensive patients with inadequate BP control on 24-h ABPM.

Conclusions: EASIX demonstrated good discriminative performance for identifying hypertensive patients with inadequate BP control on ABPM. These findings suggest its potential role in risk stratification, warranting validation in prospective studies.