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

Background: Brugada syndrome is a rare, inherited cardiac disorder that predisposes individuals to life-threatening ventricular arrhythmias, often leading to sudden cardiac arrest. In many cases, the characteristic electrocardiographic (ECG) findings of Brugada syndrome are not present at baseline but can be unmasked using sodium channel blockers. While intravenous ajmaline is the preferred agent, its limited availability has led to the increased use of oral flecainide for provocation testing. Previous studies have used 300-400 mg doses, but the efficacy and safety of a lower dose, such as 200 mg, have not been systematically evaluated. This report presents three cases demonstrating that a 200 mg oral flecainide dose may be sufficient to unmask the diagnostic Type 1 Brugada ECG pattern in selected patients.

Case presentation: Three male patients (aged 44, 48, and 60 years) with suspected Brugada syndrome based on Type 2 ECG patterns underwent flecainide challenge testing. One patient received a 400 mg oral dose, while the other two received 200 mg doses. ECG changes were monitored continuously for 24 h. All three patients developed coved-type ST-segment elevation in the right precordial leads (Type 1 Brugada ECG pattern), confirming the diagnosis. The time to onset of diagnostic ECG changes ranged from 15 to 60 min, with peak changes occurring between 90 min and 5 h. No patients experienced syncope, ventricular arrhythmias, or conduction disturbances during or after testing.

Conclusions: This case series suggests that a 200 mg oral flecainide challenge can effectively and safely unmask the diagnostic Type 1 Brugada ECG pattern in selected patients. However, given the small sample size and absence of serum drug concentration data, caution is warranted in interpreting these findings. A lower dose may be a practical alternative to the conventional 400 mg, maintaining diagnostic sensitivity while potentially reducing adverse event risk. Further prospective studies with larger cohorts and longer follow-up are essential to validate the diagnostic performance, safety, and clinical implications of low-dose oral flecainide provocation testing.

Background: The current STEMI criteria fail to detect roughly one-third of occlusive MI (OMI). STEMI criteria demonstrated only a sensitivity of around 21% for OMI. Compared to STEMI, patients with NSTEMI-OMI have higher short-term and long-term all-cause mortality and longer reperfusion delays. This case series presents three NSTEMI patients with OMI and a delayed reperfusion strategy.

Case presentation: We present three cases of patients initially diagnosed with NSTEMI who were later found to have occlusive myocardial infarction (OMI) based on angiographic findings, all of whom underwent delayed reperfusion strategies. The first two cases shared similar clinical profiles, presenting with typical infarct angina, elevated cardiac enzymes, and regional wall motion abnormalities on echocardiography. Their electrocardiograms showed bifascicular blocks, right bundle branch block (RBBB) with left posterior fascicular block (LPFB) in the first case, and RBBB with left anterior fascicular block (LAFB) in the second. Both were classified as high-risk NSTEMI and scheduled for an early invasive approach. Angiography revealed total occlusions in the OM1 and left main arteries, respectively. In the third case, the patient presented with new-onset angina and elevated cardiac biomarkers, but without ECG features fulfilling STEMI or high-risk OMI criteria. However, due to persistent chest pain despite initial treatment in the emergency department, an immediate invasive strategy was pursued. Coronary angiography revealed a total occlusion in the proximal left anterior descending (LAD) artery.

Conclusions: These three cases underscore the diagnostic challenge of identifying occlusive myocardial infarction (OMI) in patients presenting with acute coronary syndrome (ACS) when relying exclusively on traditional STEMI criteria. They emphasize the need to recognize alternative ECG markers indicative of acute coronary occlusion, as failure to do so may result in delayed reperfusion and subsequently worse clinical outcomes compared to patients who receive timely intervention based on prompt STEMI recognition.

Background: Infective endocarditis (IE) remains a serious and potentially life-threatening condition. Fungal infective endocarditis is a rare form of endocarditis that occur in immunodeficient patients. Atrial myxoma are a common cause of cardiac tumors in the left atrium. However, infective endocarditis is a differential diagnosis of cardiac masses in general and atrial myxoma particularly. A 49-year-old male with subacute infective endocarditis presentation underwent an echocardiogram examination that showed a left atrial mass with features of atrial myxoma. However, the histological examination after surgical removal of the mass showed a fungal mass.

Conclusion: This case shows that a fungal infective endocarditis may present with a cardiac mass sharing typical features with left atrial myxoma. It also shows the importance of histological examination for the final diagnosis and a prompt treatment.

Background: Atrial fibrillation (AF) is the most common sustained cardiac rhythm disorder, significantly impacting global health and healthcare costs. Pulmonary vein isolation (PVI) is the preferred method for catheter-based AF ablation, reducing arrhythmia recurrence. However, vascular access complications remain a concern. This systematic review and meta-analysis aimed to compare the efficacy and safety of venous closure systems (VCSs), like Perclose™ ProGlide™, with traditional manual compression (MC) techniques, focusing on time to hemostasis (TTH), time to ambulation in hours (TTA), time to discharge (TTD), and complication rates.

Method: A comprehensive search was conducted in PubMed, Medline, Scopus, and Embase, adhering to PRISMA guidelines. Five studies met the inclusion criteria, comprising randomized controlled trials (RCTs) and observational studies. Data were analyzed using OpenMeta, applying a random-effects model to calculate standardized mean differences (SMDs) and odds ratios (ORs). Heterogeneity was assessed using the I² statistic, and funnel plots evaluated publication bias.

Result: The meta-analysis included 5 studies with a total of 240 patients. VCSs significantly reduced TTA (SMD - 2.029, 95% CI - 3.097 to - 0.962, p = 0.001) and TTD (SMD - 2.081, 95% CI - 3.870 to - 0.292, p = 0.023) compared to MC, but showed no significant reduction in TTH (SMD - 1.109, 95% CI - 2.524 to 0.307, p = 0.125). No significant differences were observed in bleeding complications (OR 1.35, 95% CI 0.413 to 4.125, p = 0.604) or hematoma rates (OR 4.665, 95% CI 0.768 to 28.345, p = 0.094).

Conclusion: VCSs demonstrated faster ambulation and discharge times compared to MC techniques, suggesting potential benefits in improving patient flow and satisfaction. However, the slight increase in hematoma risk warrants further investigation. These findings could guide clinical decision-making in vascular access management post-AF ablation.

Background: Emerging evidence supports drug-coated balloons (DCBs) as a compelling alternative to stent-based interventions in acute coronary syndrome (ACS), particularly in diabetic populations where lesion complexity and metabolic dysfunction often undermine long-term outcomes. This study explores real-world safety and efficacy of DCB-only angioplasty in ACS patients, with focused analysis of diabetic subgroups.

Methods: A single-center, retrospective cross-sectional analysis was conducted at King Abdullah Medical City between 2019 and 2023. The study enrolled patients presenting with ACS who underwent DCB treatment during this period.

Results: Of 212 patients, 55% had diabetes mellitus. Diabetic individuals exhibited significantly higher comorbid burden-hypertension, dyslipidemia, and prior coronary interventions. Non-ST-elevation myocardial infarction (NSTEMI) predominated among diabetics, and in-stent restenosis (ISR) was more frequently observed than de novo lesions. At one-month follow-up, diabetic patients experienced marginally fewer major adverse cardiovascular events (MACE) than non-diabetics; however, parity was observed at one year. Within the diabetic group, insulin therapy and suboptimal glycemic control (HbA1c > 8.0%) were strongly associated with increased 12-month cardiovascular risk, particularly due to repeat revascularization. Importantly, neither clinical presentation nor angiographic features predicted these risks. Instead, elevated HbA1c and reduced left ventricular ejection fraction (LVEF) independently forecasted adverse outcomes post-DCB.

Conclusion: In the context of ACS, diabetic patients remain uniquely vulnerable. Metabolic control and cardiac function-not anatomy alone-emerge as decisive prognostic factors after DCB therapy. Despite inherent challenges, DCB offers a targeted and promising revascularization approach when patient-specific risk modifiers are proactively addressed.

Background: Cardiac tamponade is an extreme cardiological emergency, fatal in the absence of rapid intervention. This case report highlights a noteworthy and rare correlation between post-polycythemia vera myelofibrosis and extramedullary hematopoiesis affecting the pericardium, leading to tamponade or pericardial effusion.

Case presentation: A 69-year-old female with a history of polycythemia vera presented with worsening dyspnea, fever, and altered condition. Examination revealed low blood pressure, tachycardia, jugular vein distention, and muffled heart sounds, leading to a diagnosis of cardiac tamponade due to a large pericardial effusion. Emergency pericardiocentesis was performed, revealing serosanguineous fluid with signs of clonally proliferative hematopoietic cells, indicating possible progression to myelofibrosis. Bone marrow biopsy confirmed post-polycythemia vera myelofibrosis. The patient's condition improved, and she was referred back to her hematologist for further management.

Conclusion: Increased awareness may improve early diagnosis and treatment, ultimately enhancing patient outcomes.

Background: Long-term outcomes of transcatheter mitral valve edge-to-edge repair (TEER) are compared with medical therapy remain under investigation. This study evaluated the 3-year effects of MitraClip on mitral regurgitation (MR) severity, ventricular remodeling, and clinical outcomes in high surgical-risk patients.

Methods: A single-center retrospective cohort included 31 MitraClip patients (2016-2023) and 30 contemporaneous controls on maximally tolerated guideline-directed medical therapy. Anatomical suitability was based on EVEREST criteria. Echocardiography was performed at baseline, 1, 2, and 3 years. Outcomes included MR severity, left ventricular ejection fraction (LVEF), right-sided parameters, biomarkers, NYHA class, 6-min walk test, heart failure (HF) hospitalizations, and all-cause mortality.

Results: Mean age was 63.2 ± 14.5 MitraClip vs. 72.1 ± 8.9 years controls, with secondary MR in 61.3% vs. 56.7%. Severe pulmonary hypertension (SPAP > 50 mmHg) was present in 25% of primary and 55% of secondary MR patients. No procedural mortality occurred. MR improved significantly with MitraClip (93.0% mild to moderate at 1st year, 83.9% at 3rd year) while controls remained severe (p < 0.001). LVEF remained stable (~ 33-35%, p = 0.412) without correlation to MR reduction. HF hospitalizations were lower with MitraClip (58.1%, 2.1 ± 1.8 admissions) vs. controls (7.6 ± 3.2, p < 0.001). Within MitraClip, secondary MR patients had higher rates (68.4% vs. 41.7%, p = 0.042). SPAP decreased after MitraClip but rose in controls (p = 0.015). BNP declined with MitraClip but increased in controls (p = 0.01). At 3 years, more MitraClip patients were in NYHA I/II (41.9% vs. 15%), 6MWT improved while controls declined, and mortality was lower (12.9% vs. 45%, p < 0.01).

Conclusion: TEER provides durable MR reduction, BNP stabilization, improved functional capacity, and survival benefits compared with medical therapy in high-risk surgical patients. Primary MR patients might derive greater benefit than those with secondary MR. Larger multicenter studies are warranted.

Background: Congenital heart disease (CHD) is a significant health concern affecting approximately 1% of live births. Among these anomalies, bicuspid aortic valve (BAV) is the most prevalent, while bicuspid pulmonary valve (BPV) remains exceptionally rare. This case report presents a unique instance of a 10-year-old girl diagnosed with the combination of BAV and BPV alongside a ventricular septal defect (VSD) and infundibular stenosis, referred to as the Gasul phenomenon.

Case presentation: The patient, initially identified with a heart murmur during infancy, exhibited dyspnea classified as New York Heart Association (NYHA) class II but showed no cyanosis or other acute symptoms. Echocardiographic evaluation revealed a small restrictive VSD with significant left-to-right shunting, severe infundibular stenosis, and the coexistence of both BAV and BPV. Surgical intervention involved closing the VSD and resecting the hypertrophied infundibular muscle, leading to improved hemodynamics and symptomatic relief postoperatively.

Conclusions: This case emphasizes the rarity and complexity of having both bicuspid valves in a single patient and the clinical challenges associated with the Gasul phenomenon. It highlights the importance of comprehensive echocardiographic assessment and timely surgical intervention in managing such congenital anomalies, ultimately improving long-term outcomes. The report contributes to the limited literature on simultaneous BAV and BPV diagnoses and underscores the need for heightened clinical awareness and diagnostic scrutiny in pediatric patients with congenital heart defects. Further studies are warranted to explore the natural history and management strategies for patients with this unusual combination of cardiac anomalies.

Background: ST-elevation myocardial infarction (STEMI) is a major cardiac event that requires rapid reperfusion therapy. The same reperfusion mechanism that minimizes infarct size and mortality may paradoxically exacerbate further cardiac damage-a condition known as reperfusion injury. Oxidative stress, calcium excess, mitochondrial malfunction, and programmed cell death mechanisms make myocardial dysfunction worse. Even with the best revascularization techniques, reperfusion damage still jeopardizes the long-term prognosis and myocardial healing.

Methods: A thorough narrative review was carried out using some of the most well-known scientific databases, including ScienceDirect, PubMed, and Google Scholar. With an emphasis on pathophysiological causes, clinical manifestations, innovative biomarkers, imaging modalities, artificial intelligence applications, and developing treatment methods related to reperfusion injury, peer-reviewed publications published between 2015 and 2025 were highlighted.

Main body: The review focuses on the molecular processes that underlie cardiac reperfusion injury, such as reactive oxygen species, calcium dysregulation, opening of the mitochondrial permeability transition pore, and several types of programmed cell death. Clinical syndromes such as myocardial stunning, coronary no-reflow, and intramyocardial hemorrhage are thoroughly studied-all of which lead to negative consequences like heart failure and left ventricular dysfunction. Cardiac magnetic resonance imaging along with coronary angiography and significant biomarkers like N-terminal proBNP and soluble ST2 aid in risk stratification and prognosis. In addition to mechanical techniques like ischemia postconditioning and remote ischemic conditioning, pharmacological treatments are also examined. Despite promising research findings, the majority of therapies have not yet proven consistently effective in extensive clinical studies. Consideration of sex-specific risk factors, medicines that target the mitochondria, tailored therapies, and the use of artificial intelligence for risk assessment and early diagnosis are some potential future avenues.

Conclusion: Reperfusion damage continues to be a significant obstacle to the best possible recovery after STEMI, even with improvements in revascularization. The management of STEMI still relies heavily on early reperfusion, although adjuvant medicines that target reperfusion injury specifically are desperately needed. Molecular-targeted approaches, AI-driven risk assessment, and precision medicine advancements have the potential to reduce cardiac damage and enhance long-term outcomes for patients with STEMI.

Background: Hypertension, a significant risk factor for cardiovascular diseases, has increased dramatically over the decades. It can be mitigated with proper medication utilization and lifestyle modifications. Adherence to antihypertensive medication plays a significant role in reducing severe complications and improving the overall quality of life of people living with hypertension. This study was conducted to assess the global research output and trends in antihypertensive medication adherence.

Methods: The study utilized the Scopus database for bibliometric analysis. The keywords related to antihypertensive medication adherence were searched from the database's inception to 21st December 2024. The retrieved data were analysed using VOSviewer, Biblioshiny and QGIS 3.30.1. The bibliometric maps and indicators were presented based on publication and funding source, most contributed countries and authors, keyword co-occurrence, and other relevant and important indicators.

Results: In total, 3497 documents specifically related to antihypertensive medication adherence were utilized and they were identified from 1975 to 2024. The publication's annual growth rate was identified as 8.65%. The USA (1144, 33%), the UK (269, 8%), and Germany (246, 7%) are the leading contributors to antihypertensives adherence research. Schmieder R.E was found to be the top published author in this domain. The Journal of Hypertension was identified as the most published source, while National Institute of Health (NIH) revealed as the top funding body supporting antihypertensives adherence research.

Conclusions: Research on antihypertensive medication adherence was largely contributed by developed countries, especially dominated by the USA in most of the indicators. As the contribution from developing countries is limited, LMICs must be prioritized with collaborative research and capacity building to strengthen this adherence research. These efforts gradually help countries to generate context-specific evidence to improve adherence to antihypertensive medications thereby reducing the global burden of hypertension.