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

Background: Obstructive prosthetic valve thrombosis is a life-threatening complication associated with high morbidity and mortality. Evaluation of outcomes of surgical management and identification of the perioperative variables associated with poor prognosis are necessary to provide appropriate interventions.

Results: We conducted a retrospective analysis of 39 patients who underwent redo surgery for obstructive prosthetic valve at the Madinah Cardiac Center, Saudi Arabia. Between January 2017 to October 2023 Preoperative, intraoperative, and postoperative factors that influenced the outcome were analyzed. The nature of the obstructed valve was commonly mechanical (32/39, 82.1%) located in the mitral position (30/39, 76.9%) which occurred due to thrombosis, and the size of the thrombus was more than 1 cm in 27 (69.2%) patients. High percentage (25/39, 64.1%) of the patients had a suboptimal INR (less than 2). The major postoperative complications were respiratory failure (6/39, 15.4%) and dysrhythmias (20/39, 51.3%). The 30-day postoperative mortality was 7.7% (3/39). Patients who underwent surgery after failed thrombolysis had significantly higher mortality than those who underwent direct surgery (p = 0.018).

Conclusion: Prosthetic valve thrombosis is primarily associated with suboptimal anticoagulant therapy and can occur years after valve replacement surgery. The prognosis for redo valve replacement is favorable with a 30-day operative mortality rate of 7.7%. For patients with prosthetic valve thrombosis, direct surgical intervention without prior fibrinolysis may be safe and effective for patients with prosthetic valve thrombosis.

Background: Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive cause of diastolic heart failure associated with poor prognosis. Currently available treatment, tafamidis, a TTR stabilizer, is highly effective and tolerable but is not cost-effective. Hence, we aim to evaluate the efficacy and safety of a mechanistically similar but more affordable TTR stabilizer, diflunisal, in patients with ATTR-CA.

Methods: Systematic searching until June 2024 was done on 3 databases to include patients with ATTR-CA of any type (hereditary or wild-type). Efficacy and safety of diflunisal are assessed by baseline to follow-up mean difference of specific clinical parameters and mortality risk reduction comparing intervention to the control group is evaluated by the generic inverse variance model. The proportion of discontinuation rate and adverse effects are evaluated with a single-arm inverse variance model. Statistical analyses are done with a random effect model conducted on RevMan and R software.

Results: Twelve studies comprising 539 ATTR-CA patients with a mean of 70 years old are included. The majority of them are male with NYHA I-II severity and are being followed up for approximately 12 months. For diflunisal efficacy outcomes, we found no statistically significant changes in BNP, troponin I, LVEF, GLS, IVSD, PWD, and E wave from baseline to diflunisal posttreatment, however, we found a statistically significant posttreatment increase of transthyretin level (MD 9.34 mg/dL; CI 1.54-17.14; I² 0%; p 0.02). We also found a statistically significant 77% (CI 58-87%; I² 34%; p < 0.001) risk reduction of mortality in the diflunisal group compared to the control group. For diflunisal safety outcomes, we found a statistically significant reduction of eGFR, hemoglobin, and platelet count (MD - 5.55, - 0.32, - 11.61, respectively, p < 0.01) but no statistically significant change in creatinine level. Pooled proportions of discontinuation rate of diflunisal therapy is 24% (CI 15-36%; I² 72%; p < 0.01) and adverse events causing therapy discontinuation are renal impairment (21%), GI impairment (13%), bleeding (6%), and fluid retention (6%).

Conclusion: Diflunisal therapy is beneficial in treating ATTR-CA patients but is associated with adverse effects that require therapy discontinuation. Hence, careful monitoring during diflunisal therapy is necessary.

Background: Heart failure (HF) is a significant global health issue. Appropriate and timely treatment at target doses significantly reduces mortality and enhances quality of life. However, studies indicate suboptimal pharmacotherapy among patients. This study aims to assess the medical treatment of patients with heart failure and reduced ejection fraction (HFrEF) and their adherence to the American Heart Association (AHA) guidelines. The study was designed as a cross-sectional analysis in the cardiac department of Razi Hospital in Birjand from March 20, 2020, to March 11, 2023, focusing on patients with left ventricular ejection fraction less than or equal to 40%. Data were extracted from patients' medical records. Medications were classified according to the four-pillar therapy recommended by the AHA, including β-blockers, ARNI, ACE inhibitors/ARBs, SGLT2, and MRAs. Patients were grouped based on their treatment regimens. The percentage of achieved target doses for each medication was categorized as follows: 0-25%, 25-50%, 50-99%, and 100%. Statistical analysis was conducted using SPSS version 22.

Results: The study included patients with a mean age of 66 ± 13.7 years, of whom 278 (69%) were male. The mean ejection fraction was 26.8 ± 9.6%, and the most prevalent comorbidity was coronary artery disease (CAD) observed in 68.0% of patients. The in-hospital mortality rate was 5%. The results revealed that only 20% were on quadruple therapy, while 10% received none of the recommended medications. The prescription rates for key medications were as follows: β-blockers 76.4%, ACE inhibitors/ARBs 71.6%, MRA 63.3%, SGLT2I 33.5%, and ARNI 0%. Notably, 94.8% of prescribed SGLT2I doses met the target dose, while 84.4% of β-blocker prescriptions and 61.8% of ACEI/ARB prescriptions were below 75% of the target dose.

Conclusion: The findings reveal significant gaps in the prescription of essential therapies, including MRAs and ARNIs, which are crucial for managing myocardial dysfunction. Addressing these gaps underscores the necessity for ongoing education and training for healthcare providers in heart failure management.

Background: Cardiomyopathy is a heterogeneous group of myocardial disorders characterized by structural and functional abnormalities of the heart muscle. It is classified into primary (genetic, mixed, or acquired) and secondary categories, resulting in various phenotypes including dilated, hypertrophic, and restrictive patterns. Hypertrophic cardiomyopathy, the most common primary form, can cause exertional dyspnea, presyncope, and sudden cardiac death. Dilated cardiomyopathy typically presents with heart failure symptoms, while restrictive cardiomyopathy is rarer and often associated with systemic diseases. Diagnosis involves a comprehensive evaluation including history, physical examination, electrocardiography, and echocardiography. Treatment options range from pharmacotherapy and lifestyle modifications to implantable cardioverter-defibrillators and heart transplantation in refractory cases.

Main body: Anthracyclines, particularly doxorubicin, have emerged as crucial components in cancer treatment, demonstrating significant antitumor activity across various malignancies. These drugs have become standard in numerous chemotherapy regimens, improving patient outcomes. However, their use is associated with severe cardiotoxicity, including cardiomyopathy and heart failure. The mechanisms of anthracycline action and toxicity are complex, involving DNA damage, iron-mediated free radical production, and disruption of cardiovascular homeostasis. Doxorubicin-induced cardiomyopathy (DIC) is a severe complication of cancer treatment with a poor prognosis and limited effective treatments. The pathophysiology of DIC involves multiple mechanisms, including oxidative stress, inflammation, mitochondrial damage, and calcium homeostasis disorder. Despite extensive research, no effective treatment for established DIC is currently available. Dexrazoxane is the only FDA-approved protective agent, but it has limitations. Recent studies have explored various potential therapeutic approaches, including natural drugs, endogenous substances, new dosage forms, and herbal medicines. However, the lack of experimental models incorporating pre-existing cancer limits the understanding of DIC pathophysiology and treatment efficacy.

Conclusion: Cardiomyopathy, whether primary or secondary, poses a significant clinical challenge due to its varying etiologies and poor prognosis in advanced stages. Anthracycline-induced cardiomyopathy is a severe complication of chemotherapy, with doxorubicin being a notable contributor. Despite advancements in cancer therapies, the cardiotoxic effects of anthracyclines necessitate further investigation into effective preventive strategies and therapeutic interventions to improve patient outcomes.

Background: While hypertensive heart disease (HHD) has been widely studied, this study uniquely examines the impact of the COVID-19 pandemic on HHD mortality trends, which has not been thoroughly explored in the current literature. The pandemic's effects on healthcare access, economic instability, and social isolation present new challenges and opportunities for understanding HHD mortality among the elderly.

Results: Age-adjusted mortality rates (AAMRs) increased overall between 1999 and 2020, from 36.7 to 133.9 per 100,000 people, according to analysis. The data on AAMRs indicated a consistent rise from 1999 to 2017, with a notable uptick from 2017 to 2020. An investigation based on gender revealed that older men had a consistently higher AAMR than older women. The biggest AAMRs were found among the non-Hispanic (NH) Black or African-American population, according to variations in AAMR based on race and ethnicity. Geographic differences between states revealed that compared to Nebraska, Oregon, North Dakota, Maine, and Minnesota, the District of Columbia, Oklahoma, Nevada, Vermont, and Mississippi had substantially higher AAMRs. The West, Northeast, and Midwest were in second place with a continuously higher AAMR, followed by the South. Furthermore, compared to non-metropolitan areas, metropolitan areas had a higher AAMR.

Conclusion: The importance of including demographic and geographic factors in public health planning and interventions is highlighted by these findings, which provide insightful information on mortality trends associated with HHD in the elderly.

Background: Small vessel coronary artery disease presents challenges in percutaneous coronary intervention due to higher restenosis rates with traditional treatments. Drug-coated balloons (DCBs) offer a potential alternative, but their efficacy compared to drug-eluting stents (DES) remains debated. This meta-analysis aims to provide updated insights into the comparative outcomes of DCBs versus DES in small coronary artery disease.

Main text: Following PRISMA guidelines, a systematic review identified seven randomized controlled trials (RCTs) comparing DCBs with DES for small vessel CAD. Data were extracted and pooled for analysis, assessing outcomes including target lesion revascularization (TLR), target vessel revascularization (TVR), mortality, myocardial infarction (MI), stent/vessel thrombosis, and major adverse cardiovascular events (MACE). Statistical analysis was performed using RevMan version 5.4, employing random-effects models and forest plots with odds ratios (OR) and 95% confidence intervals (CI). Among 1,808 patients across seven RCTs, no significant difference was found in TVR between DCB and DES over 3 years (OR = 0.95, 95% CI [0.58, 1.54], p = 0.82). While initial analyses favoured higher TLR incidence in DES, the trend shifted towards DCB over time, with a non-significant association favouring DCB at 3 years (OR = 0.51, 95% CI [0.26, 1.00], p = 0.05). DCB use was associated with significantly higher rates of MACE and MI at the 3-year mark (MACE: OR = 0.55, 95% CI [0.38, 0.79], p = 0.001; MI: OR = 0.35, 95% CI [0.17, 0.7], p = 0.003), while mortality rates converged between the two interventions over time. Vessel thrombosis rates were similar between DCB and DES.

Conclusions: While DCBs may offer comparable efficacy to DES in terms of TVR and TLR over shorter durations, there is a concerning trend towards higher rates of MACE and MI associated with DCB use at the 3-year mark. Further research with larger sample sizes, longer follow-up durations, and consistent inclusion criteria is needed to elucidate the optimal treatment strategy for small vessel CAD. Until then, DES may be considered a safer option for managing small vessel CAD.

Background: Cardiac implantable electronic device (CIED) implantation is on the rise, accompanied by an increase in its inevitable complications such as different types of CIED infections that require further therapy and potential device extraction. Ensuring efficacy and safety remains paramount in transvenous lead extraction (TLE), given the complex nature of the procedure. The purpose of this study is to assess the outcomes of relatively low-cost mechanical TLE, including mid-term clinical follow-up, and to develop a predictive model for post-TLE survival. This study included all consecutive patients admitted for TLE at two tertiary medical centers between 2016 and 2021. Baseline characteristics, TLE procedure details complications occurring during and/or after the procedure and follow-up outcomes were collected.

Results: During the 5-year period, 100 consecutive patients underwent TLE. The mean age of the subjects was 61 ± 3 years. The average time from lead implantation to TLE was 69.34 ± 9.36 months, with a total of 216 leads extracted. The most common indication for TLE was infection observed in 87% of subjects with pocket infection seen in the majority (84%). Complete clinical success was achieved in 98% of patients, with major complications occurred in 5% of cases and only one case of peri-procedural death. Proposed experimental model showed that near 50% of the patients will live less than 73.29 months.

Conclusion: TLE demonstrated a high level of safety with low mortality and morbidity rates. Using low cost widely available mechanical tools is useful for treating CIED-related infections.

Background: Ewing's sarcoma (ES) is a common malignant bone tumor in adolescents and young adults. Its pelvic location is associated with a worse prognosis. Our case represents one of the rare instances in the literature involving an adult patient in whom the disease progressed fatally due to cardiac extension.

Case presentation: We report the case of a 31-year-old female patient who initially presented with swelling in her right lower extremity, which was found to be caused by deep venous thrombosis (DVT) extending from the iliac vein to the inferior vena cava. A thoracic-abdominal CT scan, performed as part of the etiological workup, revealed a tumor in the right hip bone with a malignant appearance, exhibiting both endo and exopelvic extension, and extending to the inferior vena cava (IVC) and right heart chambers. An echo-guided biopsy of the tumor mass confirmed Ewing's sarcoma. The patient's condition rapidly deteriorated, leading to death due to the inoperability of the extensive tumor.

Conclusions: Ewing's sarcoma can affect adults, presenting with late-onset or rapidly metastatic forms. In its extensive form, ES requires multimodal imaging to assess operability and is associated with a poor prognosis. This case report represents one of the rare instances in the literature of Ewing's sarcoma metastasizing to the heart.

Background: Contrast-induced nephropathy (CIN) remains a serious complication following percutaneous coronary intervention (PCI), often leading to poor outcomes. Although the overall incidence of CIN is low, the risk can be significantly higher in certain susceptible cohorts.

Results: This prospective observational analytic study enrolled 174 consecutive eligible patients. The study selectively included diabetic patients with heart failure who are receiving regular diuretic therapy, being scheduled for elective coronary angiography (CAG) and/or PCI. CIN occurred in 24.7% of the study participants. CIN patients had significantly higher baseline osmolarity compared to those who did not develop CIN. After adjusting for other factors, pre-procedure osmolarity ≥ 302.3 mOsm/L, higher CHA₂DS₂VA score, and larger contrast volume proved to be independent predictors for CIN with an odds ratio and 95% confidence interval of 7.07 (2.47-20.26), 3.99 (2.02-7.9), and 1.01 (1.0-1.014), respectively.

Conclusions: In patients at high risk for CIN, serum osmolarity can serve as a practical stratification tool for CIN risk before elective CAG or PCI. Future studies should evaluate whether targeting a specific pre-procedural osmolarity threshold can reduce the risk of post-PCI CIN.

Background: Patients with obstructed infra-cardiac total anomalous pulmonary venous connection (TAPVC) require urgent intervention to relieve the obstruction, with or without restoration of anatomical continuity between the pulmonary veins and the left atrium. In cases of infra-cardiac TAPVC draining into the inferior vena cava (IVC) or hepatic vein, the obstructed channel can be accessed via the systemic venous approach for endovascular palliation. However, in cases of infra-cardiac TAPVC draining into the portal venous system, an endovascular approach to the obstructed channel is not possible via the transfemoral route and may require direct percutaneous puncture of the splenoportal axis.

Case presentation: A 45-day-old boy presented with acute respiratory distress and cyanosis. CT angiography demonstrated infra-cardiac TAPVC with a focal critical stenosis in the descending channel, just proximal to its confluence with the portal vein. Incidentally, a vascular channel connecting the left branch of the main portal vein and the intra-hepatic IVC suggestive of a patent ductus venosus was noted. The patent ductus venosus would allow access to the site of obstruction (transfemoral venous approach → IVC → patent ductus venosus → left portal vein → main portal vein → obstructed descending common channel) to achieve emergency palliation by dilating the obstructed segment and subsequently, stenting the ductus venosus to circumvent the distal obstruction at the portal venous sinusoids.

Conclusion: The present case highlights the role of CT angiography in delineating cardiovascular anatomy and demonstrating alternate vascular pathways that may be utilized for performing palliative endovascular procedures.