Negar Salehi

Immediate results of percutaneous trans-luminal mitral commissurotomy in pregnant women with severe mitral stenosis.

Background Valvular heart diseases and mainly rheumatic heart diseases complicate about 1% of pregnancies. During pregnancy physiological hemodynamic changes of the circulation are the main cause of mitral stenosis (MS) decompensation. Prior to introduction of percutaneous mitral balloon commissuroplasty (PTMC), surgical comissurotomy was the preferred method of treatment in patients with refractory symptoms. PTMC is an established non-surgical treatment of rheumatic mitral stenosis. The study aimed to assess the safety and efficacy of PTMC in pregnant women with severs mitral stenosis. Material and Method Thirty three consecutive patients undergoing PTMC during pregnancy enrolled in this prospective study. Mitral valve area (MVA), transmitral valve gradient (MVG), and severity of mitral regurgitation (MR) were assessed before and 24 hour after the procedure by transthoracic and transesophageal echocardiography. Mitral valve morphology was evaluated before the procedure using Wilkins criteria. Patient followed for one month and neonates monitored for weight and height and adverse effect of radiation. Result Mitral valve area increased from 0.83 ± 0.13 cm2 to 1.38 ± 0.29 cm2 (P = 0.007). Mean gradient of mitral valve decreased from 15.5 ± 7.4 mmHg to 2.3 ± 2.3 mmHg (P = <0.001). Pulmonary artery pressure decreased from 65.24 ± 17.9 to 50.45 ± 15.33 (P = 0.012). No maternal death, abortion, intrauterine growth restriction was observed and only one stillbirth occurred. Conclusion PTMC in pregnant women has favorable outcome and no harmful effect on children noted.

Thrombosis on implanted device for atrial septal defect closure or echocardiographic beam width artifact? a diagnostic enigma!

A 29 year old woman with NYHA functional class II and large secundum type atrial septal defect (ASD) underwent successfully percutaneous ASD closure with Figula ASD occluder (no. 30) without any peri-procedural complication. After 2 days she underwent transthoracic echocardiography and a large hypo-echoic mass was seen on left atrial side of implanted device in multiple views, suggestive of thrombosis or echocardiographic beam width artifact? A diagnostic enigma!

Changes of High Sensitivity C-Reactive Protein During Clopidogrel Therapy in Patients Undergoing Percutaneous Coronary Intervention

Background: The crucial role of inflammation in the development and progression of atherosclerosis has been previously described. However, there is insufficient data available to demonstrate the changes in high sensitivity C-reactive protein (hs-CRP) during clopidogrel therapy. Objectives: In the present study, we aimed to assess the changes in the inflammatory marker of coronary heart disease, i.e., hs-CRP during clopidogrel therapy, in patients undergoing percutaneous coronary intervention (PCI). We also evaluated the anti-inflammatory effects of clopidogrel, if any, in different groups of patients. Patients and Methods: The study population included 650 consecutive patients who underwent elective, urgent, or emergent PCI. Patients received a 300-mg loading dose of clopidogrel (Plavix®) and aspirin either 24 hours before the planned PCI, or immediately before the procedure in patients with urgent or emergent PCI, followed by a 75-mg daily maintenance dose for up to 12 weeks. At the end of the 12th week, hs-CRP was re-assessed. Results: Six hundred-fifty patients including 386 (59.4%) male and 264 (40.6%) female subjects were enrolled in the study. The mean hs-CRP level was 15.36 ± 9.83 mg/L with a median of 14 mg/L (interquartile range 8 to 19.6 mg/L). Female, hypertensive, diabetic, and non-smoking patients had higher reductions in hs-CRP in response to clopidogrel therapy compared to male, non-hypertensive, non-diabetic and smoker patients, respectively (all P < 0.005). The changes in the hs-CRP levels were also statistically different in patients with various index events before PCI (P < 0.001). No significant differences were observed in the mean reduction of hs-CRP between the patients without stent implantation and those with bare metal or drug-eluting stents (P = 0.07), respectively. Conclusions: We found that the use of clopidogrel in patients undergoing PCI had favorable effects on the suppression of hs-CRP. This effect appears to be heightened and more apparent in some group of patients with co-morbidities such as diabetes and hypertension.

Giant aneurysmal fistula of the left main coronary artery to the right atrium.

A 42-year-old woman presented to our outpatient department with complaints of atypical chest pain and palpitation. On physical examination, the patients blood pressure was 140/95 mm Hg, and there was a systolic cardiac murmur on the left sternal border. A transthoracic echocardiography examination was performed, and a left-to-right shunt ratio (Qp/Qs) of approximately 1.5 was detected. Computed tomography angiography and coronary angiography examinations confirmed the presence of a large fistula between the left main coronary artery and the right atrium, with giant aneurysm formation and an intact right coronary artery. Surgical closure of the shunt was performed with a good final result.

Relationship between Distribution of Coronary Artery Lesions and Renal Artery Stenosis in Patients Undergoing Simultaneous Coronary and Renal Angiography

Aims We evaluated the relationship between distribution of lesions in coronary tree and atherosclerotic renal artery stenosis (RAS). Methods and Results Data collected prospectively on 500 consecutive patients who underwent simultaneous renal angiography following coronary angiography. Overall prevalence of RAS was 26.2% (131 patients). Significant (≥ 50% luminal diameter stenosis) RAS was present in 70 patients (14%). In 346 individuals of the study population, significant CAD was present (69.2%). Significant RAS was more common (18.4%) in this group. Older age, higher intra-arterial systolic blood pressure (SBP) and pulse pressure (PP) at the time of catheterization, and 3-vessel coronary artery disease (CAD) were associated with significant RAS in univariate analysis. Relationship between involved locations of coronary arteries [Left anterior descending (LAD), left circumflex (LCX), Right Coronary Artery (RCA), and their ostioproximal portions] and RAS were significant except for left main (LM) disease. In multivariate model, age more than 62 years, SBP greater than 150 mmHg, PP in excess of 60 mmHg and RCA involvement were independent predictors of significant RAS. Conclusion Simultaneous renal angiography following coronary angiography might be justified in patients with significant RCA disease who are older with increased levels of intra-arterial SBP and PP.

Prasugrel Results in Higher Decrease in High-Sensitivity C-Reactive Protein Level in Patients Undergoing Percutaneous Coronary Intervention Comparing to Clopidogrel

Objectives A growing body of clinical and laboratory evidence indicates that inflammation plays a crucial role in atherosclerosis. In the present study, we compared the effects of clopidogrel and prasugrel on high-sensitivity C-reactive protein (hs-CRP) in patients undergoing percutaneous coronary intervention (PCI). Methods The present randomized, double-blind clinical trial included 120 patients who underwent PCI. Eligible patients were randomly assigned 2:1 to one of the two groups: 80 patients in the first group received clopidogrel (Plavix®; loading dose and maintenance dose of 300 and 75 mg daily, respectively) and 40 patients in the second group received prasugrel (Effient®; loading dose and maintenance dose of 60 and 10 mg, respectively) for 12 weeks. The hs-CRP levels between baseline and 12th week were compared. Results Of the 120 patients, 69 patients (57.5%) were male. Pretreatment hs-CRP level was statistically comparable in clopidogrel (median, 15.10 mg/dL; interquartile range [IQR], 9.62-23.75 mg/dL) and prasugrel groups (median, 18 mg/dL; IQR, 14.25-22 mg/dL; P = 0.06). Patients taking clopidogrel showed a significant reduction in hs-CRP level compared with the baseline values (P < 0.001). Prasugrel administration also resulted in a significant reduction in hs-CRP level (P < 0.001). A significant 73% overall reduction in the hs-CRP level was seen with prasugrel compared with 39% overall reduction in hs-CRP level with clopidogrel (P 0.002). Conclusion Prasugrel seems to be superior to clopidogrel in the reduction of hs-CRP in patients undergoing PCI.

Coronary Flow Assessment in Unstable Angina/non ST-segment Elevation Myocardial Infarction Patients via Thrombolysis in Myocardial Infarction Frame Count in Angiography

Background: TIMI Frame Count (TFC) is one of the methods to estimate the coronary blood flow velocity. This is a simple, inexpensive, quantitative, reproducible, and continuous variable method. Many studies have been conducted on TFC assessment in ST elevation myocardial infarction (STEMI) patients. Objectives: The present study is aimed to measure the TFC in the coronary arteries of UA/NSTEMI patients to find abnormalities in diseased or patent vessels and compare with the normal values. Patients and Methods: The participants were 105 consecutive UA/NSTEMI patients who underwent coronary angiography in Shahid Rajaie Cardiovascular Medical and Research Center, Tehran, Iran in 2009. Exclusion criteria were history of CABG, PCI, or STEMI or presence of occluded arteries in angiography. We measured the coronary TFC in these patients. We examined also 55 stable patients without coronary lesions and with TIMI 3 flow to have an estimation of normal TFCs. Results: From a total of 105 patients, 25 (23.8%) had no significant coronary lesion (> 60%); 35 (33.3%) were diagnosed with single vessel disease; 22 (21%) were 2VD; and 23 (21.9%) were 3 VD.). In overall, mean TFC in UA/NSTEMI group was 28.7 (± 14) frames compared to 23.8 (± 7.8) frames in the normal group (P < 0.05). In the vessels with significant lesions, TFC was significantly higher than normal (30.84 vs. 23.8; P < 0.001) and also significantly higher than patent vessels of the same patients (30.84 vs. 26.10; P = 0.029). In these patients, patent vessels had higher TFC values compared to normal coronaries (26.10 vs. 23.8), but the difference was not significant (P = 0.12). In the patients with significant lesions, mean TFC was higher than the same value in acute coronary patients without significant lesions (29.3 vs. 27.2), but the difference was not significant (P = 0.114). In the patients who underwent PCI and stenting, TFC changed significantly after PCI toward the normal value (P = 0.001). In the patients with elevated cardiac enzymes, TFC was higher but the difference was not significant (P = 0.35). Conclusions: Patent coronaries of UA/NSTEMI patients have a trend to higher TFCs compared to normal values. Presence of significant coronary lesions in these patients significantly increases TFC.

Right Atrium Clot Formation following Percutaneous Transmitral Valvuloplasty

This case report describes a rare complication of percutaneous transmitral commissurotomy (PTMC). A patient with severe mitral stenosis developed a clot in the right atrium after an unsuccessful PTMC procedure. Because of the high risk of thromboembolism, the patient underwent urgent surgery to remove the clot and to replace the mitral valve with a mechanical prosthesis.